超声引导下髋关节穿刺注药的临床应用研究

目的 研究超声引导下髋关节穿刺注药的准确性、有效性及副作用,探讨临床应用价值.方法 选择确诊为强直性脊柱炎(AS)或骨性关节炎(OA) 43例进行超声引导下髋关节穿刺注药82次.记录穿刺次数、穿刺深度、所用时间、副作用、并发症及治疗前、后髋关节疼痛程度的视觉模拟法(VAS)评分,并对治疗前、后VAS评分进行比较.结果 所有髋关节腔均能在超声上清晰显示,95.1％的关节穿刺1次成功,穿刺成功率为100％.患者自觉疼痛缓解率为97.7％,两组患者治疗前、后VAS评分差异均有统计学意义(P＜0.01).术后未发现与操作相关的并发症.结论 髋关节穿刺注药短期内可有效缓解关节疼痛,超声是一种准确、安全的引导方法.     

超声引导下关节腔穿刺注射术治疗风湿免疫性关节炎的效果分析

目的探讨实时超声引导下关节腔穿刺注射术在风湿免疫性关节炎中的应用价值。方法选取在超声科进行关节腔穿刺注药的102例患者,术前均行超声检查,观察拟行穿刺关节的骨表面、软骨、滑膜、关节腔是否有积液,以及关节周围肌腱、腱鞘及滑囊情况。采用视觉模拟评分法(VAS)进行拟穿刺关节疼痛的评估,穿刺1 d后再次以VAS法对穿刺注药关节进行疼痛评估,1周后复查关节超声,尤其注意观察滑膜厚度及滑膜血供情况是否改善。结果 102例超声引导下的关节腔穿刺注药术均1次成功,术中可清晰显示针尖及药物注入关节腔全过程,术后未出现出血、感染、神经损伤等并发症。96例患者感觉药物注射后疼痛程度降低;术前平均VAS评分(3. 8±2. 1)分,术后(2. 4±0. 7)分;术后滑膜血供评级下降者88例;术前滑膜厚度(4. 2±1. 7) mm,术后(2. 8±1. 5) mm;术后的疼痛程度、滑膜血供、VAS评分、滑膜厚度与术前比较,差异均有统计学意义(P 0. 05或P 0. 01)。结论超声引导下关节腔穿刺术成功率高,安全可靠,局部关节腔穿刺注药术后可有效缓解局部疼痛,减轻关节炎性改变。     

超声波在成人股骨头缺血性坏死中的应用

目的 研究成人股骨头缺血性坏死的超声图像表现.方法 选择经CK和CT证实的96例股骨头缺血性坏死患者,应用超声波进行双侧髋关节的冠状面、横断面及纵断面扫查.结果 96例中,超声发现82例有关节面毛糙,70例有关节面回声断裂现象,30例有关节腔间隙增宽、积液,60例有关节间隙变窄或消失.结论 超声能早期发现关节腔增宽、积液及股骨头关节面毛糙,为临床早期诊断提供了可靠依据,是其他影像学检查的有益补充.     

超声引导下经骶部行后盆腔包裹性积液置管引流的临床价值

目的 探讨超声引导下经骶部行后盆腔包裹性积液置管引流的临床价值。方法 回顾性分析行超声引导经骶部后盆腔包裹性积液置管引流的患者43例,分析其穿刺成功率及其引流效果。其中腹腔术后者32例,原发性后盆腔脓肿11例。结果 包裹性积液直径8.6～16.8 cm,平均直径(13.7±2.4)cm。其中含气有31例,不含气有12例。术后经影像学随访复查,所有患者脓腔均完全消失,平均置管时长为(12.7±1.7)d。后盆腔包裹性积液穿刺成功率为100%,出现1例穿刺并发症,穿刺并发症发生率为2.3%(1/43)。37例患者细菌培养阳性,降钙素原下降时间为(7.3±0.8)d。结论 经骶部行置管路径上血管及器官较多。超声引导下经骶部行后盆腔脓肿置管引流是一项较安全、有效、微创的操作方式。     

超声检查诊断成人非特异性髋关节滑膜炎的应用价值

目的探讨超声在成人非特异性髋关节滑膜炎中的应用价值。方法对150例临床怀疑为髋关节滑膜炎患者行超声检查,同时注意双侧对比扫查,观察股骨颈前间隙宽度,前隐窝积液情况等。结果 150例患者共183个髋关节经超声检查诊断为髋关节滑膜炎,均表现为股骨颈前间隙增宽,其中101个髋关节仅表现为股骨颈前间隙增宽,未见液性无回声区。82个髋关节表现为股骨颈前间隙增宽,同时伴有厚度不一液性无回声区。结论超声检查可准确反映髋关节滑膜炎患者股骨颈前间隙增宽及积液情况,为临床诊断及治疗提供可靠的影像学依据,可作为成人髋关节滑膜炎的首选检查方法。     

三维矩阵探头实时双平面成像在超声引导介入诊疗中的应用

目的 探讨三维矩阵探头实时双平面成像在超声引导介入诊疗中的应用价值.方法 采用三维超声实时双平面成像模式(RT 3Dxplane)引导下对36例患者进行穿刺组织学活检及穿刺抽液介入治疗,同期对40例患者采用常规超声引导进行穿刺组织学活检.比较双平面成像与常规超声引导下,两组在穿刺时间、穿刺并发症、组织标本长度等方面有无差异.结果 全部双平面超声引导介入操作中,调节交互平面的不同部位,可确定针尖的位置及其与靶目标的相互关系.对于肾病肾穿刺患者,双平面引导组与对照组两者之间在穿刺时间及穿刺标本长度上均无统计学差异[分别为(440±10)s与(442±12)s,以及(1.0±0.20) cm与(0.9±0.26) cm],所有标本均完整并获得病理组织学诊断.对于穿刺并发症,双平面组少于对照组.结论 三维双平面成像技术引导超声介入操作可实时、清晰、直观地观察穿刺针与病变的空间位置关系,降低操作难度,增加操作医师的信心.     

超声检查对小儿髋关节一过性滑膜炎的诊断价值

目的：探讨B超检查对小儿髋关节一过性滑膜炎的诊断价值及诊断标准。方法：对临床上已确诊的82例单侧髋关节一过性滑膜炎病例,采用髋关节前侧切面进行双髋关节超声对比检查,随机抽取与病例组年龄范围相同的33例健康儿童进行双髋关节超声检查,以进行正常对照,将病例组双髋股骨颈颈前间隙差值与正常对照组双髋股骨颈颈前间隙差值作两样本均数比较的t检验。结果：病例组患髋均存在股骨颈颈前间隙增宽,部分病例关节腔尚存在积液,超声图像上表现为关节囊肿胀型25例,关节腔积液型57例,结论：超声检查可以清晰地显示髋关节一过性滑膜炎健髋的组织层次及患髋的结构变化,有利于该病的客观诊断及病情估计。     

高频超声引导穿刺抽液及注射药物治疗膝关节滑膜炎60例分析

目的探讨高频超声检查在膝关节滑膜炎诊断及引导穿刺抽液和穴位注射药物的应用价值。方法应用高频超声对60例诊断为膝关节滑膜炎的患者进行膝关节腔检查,观察超声声像改变并与X线检查进行比较,根据膝关节积液和滑膜增厚程度制定不同治疗方案。结果 60例患者经过高频超声检查均发现不同程度的积液和滑膜增厚,X线检查无一例发现关节积液和滑膜增厚。10例单纯膝关节积液且深度小于5 mm的患者,注射玻璃酸钠后疗效显著;其余50例在超声引导穿刺抽液+局部封闭和注射玻璃酸钠后症状得到明显改善。结论应用高频超声检查观察膝关节腔积液及滑膜形态改变明显优于X线检查,且还可以动态观察,根据积液量的多少及滑膜增厚程度,为临床制定治疗方案提供依据。     

膝关节腔穿刺术的技术改进

目的探讨改进后膝关节腔穿刺（玻璃酸钠或其他药物注射、关节腔积液抽吸）技术的优越性。方法将100例需要进行膝关节腔穿刺的患者按穿刺方式的不同分为传统组和改进组,每组50例。改进组采用推注药液阻力突然明显减低从而判断针尖已人关节腔的方法来进行膝关节腔穿刺：传统组采用穿刺针刺破滑膜的突破感来判断针尖已进入关节腔的方法来进行膝关：帝腔穿刺。对2组患者的膝关节腔穿刺术一次性成功率及并发症（关节穿刺损伤出血、药物注入软组织内、穿刺失败）的发生率进行比较。结果改进组穿刺术一次性成功率及并发症的发生率分别为90．0％及10．0％,传统组穿刺术一次性成功率及并发症的发生率分别为46％及38．0％。2组比较差异有统计学意义（均P〈0．05）。结论改进后的膝关节腔穿刺技术是一种适宜在临床推广的好方法,尤其适用于无关节积液患者的穿刺。     

小儿一过性髋关节滑膜炎的超声诊断及预后评价

目的探讨一过性髋关节滑膜炎(TSH)股骨颈颈前间隙的厚度和积液程度,以确立髋关节滑膜炎的诊断、评价其转归及预后。方法选取髋关节滑膜炎的患儿109例,采用髋关节前侧切面,测量股骨颈颈前间隙,并随机抽查70例健康儿童双髋对照。结果TSH的图像表现为患髋股骨颈颈前间隙增宽,统计学处理有显著意义(P<0.001)。TSH超声声像分为关节囊肿胀型和关节腔积液型。且有积液的病例症状重、病程长,积液越多恢复越慢。结论超声声像能够准确反映正常髋关节组织结构和TSH病变变化,可客观诊断该病,并预测其预后。     

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.     

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.     

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.     

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.     

俯卧位通气对高海拔地区肺复张治疗无效急性呼吸窘迫综合征患者氧合的影响

目的 探讨俯卧位通气对高海拔地区肺复张术(RM)治疗无效急性呼吸窘迫综合征(ARDS)患者的治疗作用.方法 从海拔2260m的地区医院筛选RM治疗无效的41例ARDS患者[平均氧合指数( PaO2/FiO2)较RM前升高＜20％视为RM无效],依不同病因分为肺内源性ARDS组(ARDSp组)和肺外源性ARDS组(ARDSexp组),每组再按信封法随机分为俯卧位组和仰卧位组,即ARDSp俯卧位组(11例)、ARDSp仰卧位组(9例)、ARDSexp俯卧位组(10例)、ARDSexp仰卧位组(11例).在通气前及通气1、2、3、4h监测动脉血氧分压( PaO2)、PaO2/FiO2、静态顺应性(Cst)、气道阻力(Raw)的变化.结果 通气lh时,ARDSexp俯卧位组PaO2/FiO2( mm Hg,l mm Hg=0.133 kPa)即较通气前显著升高(157.4±40.6比129.3±48.7,P＜0.05),并随通气时间延长呈持续增高趋势,4h达峰值(219.1 ±41.1);且ARDSexp俯卧位组通气3h内PaO2/FiO2较其他3组显著增高,另3组间则差异无统计学意义.ARDSp俯卧位组、ARDSexp俯卧位组通气4h时PaO2/FiO2均较相应仰卧位组显著增高(208.8±39.7比127.4±47.1,219.1±41.1比124.9±50.8,均P＜0.05).4组通气前后Cst无显著改变,各组间差异也无统计学意义.ARDSp俯卧位组通气4h时Raw(cmH2O·L-1·s-1)较通气前显著降低(6.8±1.7比10.7±1.8,P＜0.05),且明显低于其他3组;其他3组各时间点Raw组内及组间比较差异均无统计学意义.结论 俯卧位通气作为ARDS机械通气重要策略之一,可以改善RM无效高原ARDS患者的氧合,为抢救患者赢得宝贵的时间.     

Digital imaging among medical facilities

The Department of Veterans Affairs (VA) in the USA operates a network of 172 medical centres which all utilize a hospital information system (HIS) which has been developed and is currently maintained by the VA. During the past several years, an image management and communication module has been developed, installed and clinically utilized at the Washington DC and Maryland VA Medical Centres. This image management and communication system, referred to as the decentralized hospital computer program (DHCP) imaging system, is fully integrated with a commercial picture archiving and communication system (PACS). The system is utilized to capture, archive, and display all images generated within the hospital including radiology, nuclear medicine, pathology, endoscopy, bronchoscopy, and dermatology, intraoperative photographs, ECG data, and a limited number of paper documents. The ultimate goal of the project is to have all patient text and image data available at any clinical workstation to any authorized user anywhere within the network of medical centres. Clinical requirements for an imaging workstation include ease of use, rapid and reliable access to the complete set of patient information, and images which are of acceptable quality to meet the requirements of the user and the subspecialty. Patient confidentiality and data security must be safeguarded at all times. Integration of the images with the remainder of the patient's database was found to be critical to the success of the project. The experience at the Washington and Maryland facilities suggests that an imaging system that is successfully integrated with a hospital information system can provide substantial clinical and economic benefits both within and among medical centres. Clinical acceptance and utilization of the system has been excellent, particularly in diagnostic radiology where DHCP Imaging has been interfaced to a commercial PAC system. Based upon this initial experience, the VA has begun to deploy the system throughout its large network of medical centres.     

Myocardial elastography at both high temporal and spatial resolution for the detection of infarcts

Myocardial elastography is a novel method for noninvasively assessing regional myocardial function, with the advantages of high spatial and temporal resolution and high signal-to-noise ratio (SNR). In this paper, in-vivo experiments were performed in anesthetized normal and infarcted mice (one day after left anterior descending coronary artery [LAD] ligation) using a high-resolution (30 MHz) ultrasound system (Vevo 770, VisualSonics Inc., Toronto, ON, Canada). Radiofrequency (RF) signals of the left ventricle (LV) in longitudinal (long-axis) view and the associated electrocardiogram (ECG) were simultaneously acquired. Using a retrospective ECG gating technique, 2-D full field-of-view RF frames were acquired at an extremely high frame rate (8 kHz) that resulted in high-quality incremental displacement and strain estimation of the myocardium. The incremental results were further accumulated to obtain the cumulative displacements and strains. Two-dimensional and M-mode displacement images and strain images (elastograms), as well as displacement and strain profiles as a function of time, were compared between normal and infarcted mice. Incremental results clearly depicted cardiac events including LV contraction, LV relaxation and isovolumetric phases in both normal and infarcted mice, and also evidently indicated reduced motion and deformation in the infarcted myocardium. The elastograms indicated that the infarcted regions underwent thinning during systole rather than thickening, as in the normal case. The cumulative elastograms were found to have higher elastographic SNR (SNR(e)) than the incremental elastograms (e.g., 10.6 vs. 4.7 in a normal myocardium, and 6.0 vs. 2.4 in an infarcted myocardium). Finally, preliminary statistical results from nine normal (m = 9) and seven infarcted (n = 7) mice indicated the capability of the cumulative strain in differentiating infracted from normal myocardia. In conclusion, myocardial elastography could provide regional strain information at simultaneously high temporal (>/=0.125 ms) and spatial ( approximately 55 microm) resolution as well as high precision ( approximately 0.05 microm displacement). This technique was thus capable of accurately characterizing normal myocardial function throughout an entire cardiac cycle, at the same high resolution, and detecting and localizing myocardial infarction in vivo.     

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.