肾闭合性损伤的治疗:附78例报告

目的:探讨肾闭合性损伤的治疗策略。方法:回顾分析2006年1月—2010年12月收治的78例肾闭合性损伤患者的临床资料,其中男性59例,女性19例;平均年龄36岁;58例伴有合并伤;肉眼血尿61例、镜下血尿14例;根据美国创伤外科协会的肾损伤分级标准,Ⅰ级35例,Ⅱ级17例,Ⅲ级13例,Ⅳ级10例,Ⅴ级3例。结果:保守治疗的23例患者随访3～12月,肾周/后腹膜血肿均吸收,无患者出现继发性高血压以及患肾萎缩。肾切除14例患者中,IV-V级肾损伤9例,Ⅱ～Ⅲ级肾损伤4例;Ⅰ级肾损伤1例。行肾修补或肾部份切除16例患者中,IV～V级损伤4例;Ⅱ～Ⅲ级肾损伤11例;Ⅰ级肾损伤1例;21例腹部探查手术中未打开后腹膜血肿的患者,术后3个月复查发现肾周/后腹膜血肿均完全吸收,未发生相关并发症。结论:对于肾损伤必须在术前根据CT检查进行仔细的分级和评估,Ⅲ级以下肾损伤不需打开后腹膜血肿进行处理;IV级以上肾损伤患者行保留肾脏手术需慎重,必要时需果断行肾切除手术而避免发生二次出血。     

超声造影在可吸收网脾包裹术中的应用价值

目的探讨超声造影在可吸收网脾包裹术中的应用价值。方法32例Ⅲ-Ⅳ级脾外伤患者行可吸收网脾包裹术治疗,应用常规超声结合超声造影对其术前及术后进行评价。结果32例脾外伤患者,术前常规超声检出28例,漏诊4例,脾外伤程度分级诊断为：阴性4例,Ⅰ级3例,Ⅱ级5例,Ⅲ级12例,Ⅳ级8例;而超声造影检出所有病灶,脾外伤程度分级诊断为：Ⅲ级19例,Ⅳ级13例,与术后探查结果一致;5例可见造影剂外溢,提示活动性出血。所有病例均行可吸收网脾包裹术。术后3d内复查,其中29例手术治疗成功,患者腹腔积液消失,脾周显示有强回声膜状物包绕,膜状物内可见片状无增强区,脾脏呈不规则增强。3例手术失败：1例于术后发生感染,超声造影显示脾脏仅下极增强,中上极未见增强;1例于注入造影剂后,造影剂于脾门处突然中断,脾脏实质未见增强,提示脾动脉主干受压;1例术后出现腹腔积液进行性增加,提示仍存在活动性出血,此3例均行再次手术切除脾脏。结论常规超声通过腹腔积液量的动态变化,判断患者是否存在活动性出血;而超声造影可通过显示组织的微循环灌注,对脾外伤进行术前准确分级及术后评估,两者结合可互为补充。     

超声造影在脾外伤保脾手术中的应用价值

目的：探讨超声造影在脾外伤保脾手术中的应用价值。方法：46例脾外伤患者行保脾手术治疗,应用常规超声与超声造影对其术前及术后进行监测。结果：46例脾外伤手术分级,Ⅱ级5例,Ⅲ级32例,Ⅳ级9例;常规超声共检出42例,漏诊4例;超声造影对46例损伤均作出诊断,其中9例可见造影剂外溢。术后常规超声发现1例腹腔积液进行性增加;超声造影发现2例并发症,1例脾动脉主干受压,1例患者术后发生感染难以控制,其脾脏术后增强体积小于原来体积的1/5。结论：超声造影能够为脾外伤保脾手术术前提供选择依据,术后进行监测和随访,对于发现并发症、伤情变化以及预后有重要作用。     

超声造影结合Bosniak分级在肾脏囊性病变诊断中的应用价值

目的探讨超声造影（CEUS）结合Bosniak分级在肾脏囊性病变诊断中的应用价值。 方法选取2010年8月至2016年8月在上海交通大学附属第一人民医院确诊的75个肾脏囊性病灶的超声造影声像图特征，并结合Bosniak分级标准对75个病灶进行分类，手术病例以术后病理结果为"金标准"，非手术病例临床随访2年以上（超声造影、增强CT等）。采用四格表计算用超声造影结合Bosniak分级标准对是否需要手术判断的准确性、敏感度、特异度、阳性预测值、阴性预测值。采用配对资料的χ²检验对Bosniak阳性诊断率和手术病理结果阳性诊断率进行比较。 结果75个肾脏囊性病灶中，超声造影结合Bosniak分级标准诊断为Ⅰ级2个，Ⅱ级33个，ⅡF级8个，Ⅲ级19个，Ⅳ级13个。超声造影结合Bosniak分级检查阳性率与手术病理检查阳性率，差异无统计学意义（χ²=0.243，P=0.622）。对是否需要手术治疗的判断的敏感度为85.71%、特异度为95.00%、准确性为90.67%、阳性预测值为93.75%、阴性预测值为88.37%。 结论超声造影结合Bosniak分级标准在肾脏囊性病变良恶性鉴别诊断中有较高的应用价值，有助于临床医师制订准确的临床治疗方案。     

肾脏外伤的超声造影分级与预后分析

目的 探讨超声造影技术在肾脏外伤分级与预后中的应用价值.方法 对59例血流动力学稳定的肾脏外伤患者进行常规超声与超声造影结合监测随访.结果 59例肾脏外伤患者,8例接受手术治疗,51例接受非手术治疗;其中50例完全愈合,9例不完全愈合;超声造影发现并发症4例.均为Ⅳ级损伤.结论 超声造影可在肾脏外伤的动态随访中及时发现并发症,了解预后情况,可成为肾脏外伤诊断及追踪随访的主要检查方法.     

超声造影引导肝脾脏外伤的微创止血治疗

目的 探讨超声造影引导肝脾脏外伤止血剂联合注射微创止血治疗的价值及临床疗效.方法 根据超声造影及CT的诊断结果,依据AAST分级标准,对损伤程度为Ⅲ～Ⅳ级,生命体征平稳的患者,行超声造影引导下微创止血治疗.结果 10例外伤病人,脾外伤6例,肝外伤4例(合并肾损伤2例);10例病人均成功在超声造影引导下进行了肝脾脏的微创止血治疗.结论 超声造影引导肝脾脏的微创止血治疗对生命体征平稳的患者可实现安全、有效的止血,无严重并发症发生.本文初步探讨了肝脾脏外伤微创治疗的新方法.     

闭合性肾损伤动物模型的建立及超声造影对肾损伤早期的分级诊断价值

目的 构建闭合性肾损伤动物模型并探讨超声造影(contrast-enhanced ultrasonography,CEUS)在肾损伤早期分级诊断中的应用价值.方法 采用钢球自由落体垂直撞击20只新西兰兔,36例肾脏造成不同程度的闭合性损伤,分别使用常规超声及CEUS观察肾损伤情况,并与病理分级对照分析.结果 CEUS肾损伤分级与病理分级的符合率明显高于常规超声(P＜0.05),且CEUS肾损伤分级与病理分级具有很好的一致性(Kappa=0.841,P＜0.001).结论本实验动物模型具有撞击设备操作简便、物理参数易控制、撞击部位准确及可重复性好等优点,肾损伤的病理类型、伤情特点与临床较为接近.CEUS能清晰地显示肾损伤的部位、范围及程度,可提高超声诊断肾损伤及判断损伤程度的敏感性.     

常规超声和超声造影在腹部实质脏器创伤快速诊断中的价值

目的 探讨常规超声与超声造影在腹部实质脏器创伤快速诊断中的作用.方法 因腹部外伤在我院急诊科就诊的患者1030例,所有患者均行常规超声和CEUS检查.结果 1030例患者依常规超声结果将其分为4组:Ⅰ组脏器实质脏器回声不均匀伴腹腔积液472例;Ⅱ组脏器实质回声均匀但腹腔有积液424例;Ⅲ组脏器实质脏器不均匀,无腹腔积液,37例;Ⅳ组未见明显异常97例.Ⅰ、Ⅱ组腹部实质脏器创伤的CEUS阳性率分别为91.1%(430/472)及90.8%(385/424),显著高于Ⅲ、Ⅳ组的18.9% (7/37)及12.4%(12/97)(P＜0.01),Ⅰ组与Ⅱ组CEUS阳性率之间的差异无统计学意义(P＞0.05).Ⅲ级以上的严重创伤仅分布在Ⅰ组和Ⅱ组.结论 腹部创伤后常规超声显示腹腔积液是腹部实质脏器创伤的重要提示,对常规超声有腹腔积液表现的患者无论有无实质脏器不均匀回声表现,均应积极行CEUS.常规超声对腹腔积液的动态观察是对CEUS的必要补充.     

超声造影对颈动脉斑块增强类型与脑梗死关系的研究

目的 超声造影评价颈动脉软斑块增强类型与脑梗死的关系.方法 运用实时超声造影技术分别对81例腩梗死患者和95例非脑梗死患者颈动脉粥样软斑块进行检测,根据斑块造影增强特点进行分级:Ⅰ级,斑块无增强;Ⅱ级,斑块基底部增强;Ⅲ级,斑块基底部和肩部增强;Ⅳ级,斑块基底部、肩部及内部增强.并进行两组间比较.结果 脑梗死组增强类型Ⅰ级7例,Ⅱ级14例,Ⅲ级26例,Ⅳ级34例;非梗死组增型类型Ⅰ级26例3,Ⅱ级7例,Ⅲ级17例,Ⅳ级15例.脑梗死在Ⅰ级中所占比率为21.2%(7/33),Ⅱ级为27.5%(14/51),Ⅲ级为60.5%(26/43),Ⅳ级为69.4%(34/49).脑梗死组Ⅲ级比率明显高于Ⅰ级和Ⅱ级(P=0.001,P=0.001),但与Ⅳ级比较差异无统计学意义(P=0.370).以斑块造影分级大于Ⅱ　级为标准,评价脑梗死的敏感性和特异性分别为74.1%和66.3%.结论 颈动脉斑块超声造影增强级别是预测脑梗死的一个有效指标,增强级别越高,脑梗死的风险越大.     

超声造影在腹部实质脏器外伤治疗中的作用

目的探讨超声造影在腹部脏器外伤治疗方法的选择以及超声引导局部注射治疗中的作用。方法81例腹部外伤患者经超声造影检查明确脏器损伤分级,不同级别外伤患者结合生命体征情况采取相应的处理措施,包括保守治疗组（Ⅰ组）、超声造影引导注射治疗组（Ⅱ组）和手术治疗组（Ⅲ组）。在Ⅱ组中,由超声造影引导下,经皮穿刺对血肿和活动性出血部位分别注射蛇毒凝血酶和可吸收性氰基丙烯酸酯。结果81例患者中肝损伤35例,脾损伤28例,肾损伤17例,肝肾复合伤1例。Ⅰ组患者55例,经保守治疗50例痊愈,3例发生再出血,2例发生动脉瘤;Ⅱ组8例,超声引导下经皮局部注射治疗,止血效果明确,无并发症;Ⅲ组18例,经手术治疗。结论超声造影能够为腹部实质脏器外伤治疗方案的选择提供可靠依据,同时还可用于引导局部注射治疗,实现腹部脏器外伤的超声介入治疗。     

Guns and Knives in New Mexico: Patterns of Penetrating Trauma, 1978–1993

Objective: To identify patterns of nonfatal and fatal penetrating trauma among children and adults in New Mexico using ED and medical examiner data.
Methods: The authors retrospectively sampled in 5-year intervals all victims of penetrating trauma who presented to either the state Level-1 trauma center or the state medical examiner from a 16-year period (1978–1993). Rates of nonfatal and fatal firearm and stabbing injury were compared for children and adults.
Results: Rates of nonfatal injury were similar (firearm, 34.3 per 100,000 person-years; stabbing, 35.1). However, rates of fatal injury were significantly different (firearm, 21.9; stabbing, 2.7; relative risk: 8.2; 95% confidence interval: 5.4, 12.5). From 1978 to 1993, nonfatal injury rates increased for children (p = 0.0043) and adults (p < 0.0001), while fatal penetrating injury remained constant. The increase in nonfatal injury in children resulted from increased firearm injury rates. In adults, both stabbing and firearm nonfatal injury rates increased.
Conclusions: Nonfatal injury data suggest that nonfatal violence has increased; fatal injury data suggest that violent death rates have remained constant. Injury patterns vary by age, mechanism of trauma, and data source. These results suggest that ED and medical examiner data differ and that both are needed to guide injury prevention programs.     

Dissociable correlates of two classes of retrieval processing in prefrontal cortex

Although substantial evidence suggests that the prefrontal cortex (PFC) implements processes that are critical for accurate episodic memory judgments, the specific roles of different PFC subregions remain unclear. Here, we used event-related functional magnetic resonance imaging to distinguish between prefrontal activity related to operations that (1) influence processing of retrieval cues based on current task demands, or (2) are involved in monitoring the outputs of retrieval. Fourteen participants studied auditory words spoken by a male or female speaker and completed memory tests in which the stimuli were unstudied foil words and studied words spoken by either the same speaker at study, or the alternate speaker. On "general" test trials, participants were to determine whether each word was studied, regardless of the voice of the speaker, whereas on "specific" test trials, participants were to additionally distinguish between studied words that were spoken in the same voice or a different voice at study. Thus, on specific test trials, participants were explicitly required to attend to voice information in order to evaluate each test item. Anterior (right BA 10), dorsolateral prefrontal (right BA 46), and inferior frontal (bilateral BA 47/12) regions were more active during specific than during general trials. Activation in anterior and dorsolateral PFC was enhanced during specific test trials even in response to unstudied items, suggesting that activation in these regions was related to the differential processing of retrieval cues in the two tasks. In contrast, differences between specific and general test trials in inferior frontal regions (bilateral BA 47/12) were seen only for studied items, suggesting a role for these regions in post-retrieval monitoring processes. Results from this study are consistent with the idea that different PFC subregions implement distinct, but complementary processes that collectively support accurate episodic memory judgments.     

Systematic Reviews Published in the January 2011 Issue of The Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly as a DVD and monthly online. The January 2011 issue (first quarterly DVD for 2011) contains 4515 complete reviews, 1985 protocols for reviews in production, and 13,521 one-page summaries of systematic reviews published in the general medical literature. In addition, there are citations of 641,000 randomized controlled trials, and 14,018 cited papers in the Cochrane methodology register. The health technology assessment database contains over 9300 citations. One hundred and seven new reviews have been published in the last 3 months, of which five have potential relevance for practitioners in pain and palliative medicine.     

Interprofessional approaches to creating safe,high quality health care

Three supplementary perspectives are presented arguing that interprofessional collaboration is both necessary and desirable. Nonetheless, there are often too many serious intra-professional barriers and obstacles to interprofessional collaboration to make it successful. Some of these barriers, it is argued and illustrated, are found in the multiple ways in which professional identity is tacitly acquired and embodied in the practitioners' habitual, everyday practice. The paper then explores ways in which reflection, especially Second order reflection, can help to elucidate and overcome these obstacles, as well as increasing professional adaptability and competence.     

Modified micro-superior percutaneously-assisted total hip: early experiences & case reports

Because of the extensile nature and familiarity of the standard posterior-lateral approach to the hip, a family of "micro-posterior" approaches has been developed. This family includes the Percutaneously-Assisted Total Hip (PATH) approach, the Supercapsular (SuperCap) approach and a newer hybrid approach, the Supercapsular Percutaneously-Assisted Total Hip (SuperPATH) approach. Such approaches should ideally provide a continuum for the surgeon: from a "micro" (external rotator sparing) posterior approach, to a "mini" (external rotator sacrificing) posterior approach, to a standard posterior approach. This could keep a surgeon within his comfort zone during the learning curve of the procedure, while leaving options for complicated reconstructions for the more practiced micro-posterior surgeons. This paper details one author's experiences utilizing this combined approach, as well as permutations of this entire micro-posterior family of approaches as applied to more complex hip reconstructions.     

Prise en charge des entorses externes de cheville : étude clinique préliminaire sur l’efficacité du dispositif Myolux™

Ankle sprains are the most common injury of the musculoskeletal system and are associated with significant societal and economic impacts. It has been proven that classical therapeutic strategies may not be effective in preventing recurrent injuries: the recurrence rates reported in the literature can reach 73%. In order to provide an effective rehabilitation solution, a destabilizing orthosis was developed. This device is equipped with a mechanical articulator reproducing the subtalar mechanics and placed under the heel. In this paper, we present the main results of a preliminary clinical study conducted between 2004 and 2007. All subjects included in this study were treated with the abovementioned orthosis during 10 rehabilitation sessions of 30 minutes each. Data show a relatively low recurrence rate of 12% for the overall population. Moreover, it's of primary importance to note that this satisfactory ratio is largely reduced (3% of recurrence rate) for the 29 patients who performed one training session per month after the 10th initial rehabilitation sessions. Hence, the destabilizing orthosis appears to be an effective solution to prevent recurrent ankle sprains. However, joint protection requires long-term and regular training sessions. This result has motivated the development of a similar device allowing patients to perform training sessions at home. Finally, data obtained in this study are promising awaiting the final results of the comparative, multicentric and independent clinical trials currently managed by the Hospices Civils de Lyon.     

Determination of creatine kinase isoenzyme MB activity in serum using immunological inhibition of creatine kinase M subunit activity. Activity kinetics and diagnostic significance in myocardial infarction.

This is a new method for the determination of creatine kinase isoenzyme MB activity in serum. The method uses direct activity measurement of creatine kinase B subunit activity after blocking of CK-M subunit activity by inhibiting antibodies. The test takes no longer than 15 min. The method yields an intra-serial C.V. of 2.0-12.9%, and a C.V. from day to day of 5.5%. The detection limit is 3.4 U/l creatine kinase MB. In the 95 cases with proven myocardial infarction several types of creatine kinase MB activity kinetics could be determined. The percentage of creatine kinase MB of peak CK-total is 6-25%, with a mean of 11.1%. The amount of creatine kinase MB with respect to total CK activity after reinfarction is higher than the amount after initial infarction.