老年乳腺癌102例治疗体会

目的分析老年人乳腺癌的特殊性和治疗体会。方法回顾性总结2005年2月至2010年12月收治的102例老年乳腺癌患者的临床资料。结果 102例术前均经针吸活检或快速冰冻切片明确病理诊断。86例行乳腺癌改良根治术,12例行乳腺单纯切除术,4例行乳腺区域切除术。术后TNM分期:II期47例,III期54例,IV期1例。术后同时接受放、化疗16例(15.69%),接受化疗46例(45.10%);单纯放疗9例(8.82%),单纯内分泌治疗31例(30.39%)。术后内分泌治疗各87例(85.29%),除单纯内分泌治疗者,余56例(54.90%)为术后放疗或化疗、或放疗+化疗并接受内分泌治疗。全组术后接受随访最长5年,5年内死亡21例,非肿瘤原因死亡19例,2例因转移、复发死亡。结论老年人乳腺癌有其特殊的生理特点和肿瘤生物学特点。老年人乳腺癌非手术禁忌证,术后应根据老年人的具体身体情况决定辅助治疗。     

隐匿性乳腺癌的诊断和治疗

目的：探讨隐匿性乳腺癌诊断和治疗方法，提高诊断准确率和生存率。方法：回顾性分析14例隐匿性乳腺癌的诊断和治疗经过及随访结果。结果：所有病例均为女性，占同期乳癌的0．82％（14／1707），14例均行钼靶x线摄片、8例发现异常，12例行腋下肿块穿刺活检，一例行锁骨上肿块穿刺活检，准确率为100％。12例患者直接行乳腺癌改良根治术；1例患者行乳腺癌改良根治术前行4周期化疗，1例行双侧乳腺癌根治术，本组术后均辅助放、化疗和内分泌治疗。生存率83．33％（10／12），1例于术后2年死于肺、纵膈转移。1例双侧乳腺癌改良根治术患者术后3年死于脑转移。结论：临床上对腋窝肿块或锁骨上肿块应高度警惕隐匿性乳腺癌的可能，提高认识和适宜的影像学检查、肿块切取活检能提高诊断准确率。乳癌改良根治术加术后辅助治疗是适宜的治疗方式。对疑有远处转移或锁骨上淋巴结转移者术前给予适当化疗。     

隐匿性乳腺癌临床诊治分析

目的：分析隐匿性乳腺癌的诊断和治疗经过及其预后结果，总结其诊断和治疗经验和方法。方法：回顾性分析9例隐匿性乳腺癌诊断治疗方法以及各种治疗的效果。结果：9例隐匿性乳腺癌患者均经腋窝淋巴结切除行病理检查明确诊断，其中7例行根治或改良根治术，所有患者均行进一步化疗，4例行放疗。出院后随访，肿瘤转移导致死亡3例。结论：腋窝淋巴结切除活检和免疫组化检查对隐匿性乳腺癌诊断有重要意义，治疗宜选择根治术或改良根治术，并辅以化疗、放疗等综合治疗。     

Ⅰ、Ⅱ期乳腺癌的手术治疗

目的 总结Ⅰ、Ⅱ期乳腺癌的外科治疗经验。方法 136例Ⅰ、Ⅱ期乳腺癌患者均采用改良根治术行手术切除及CAF或CMF联合方案化疗，部分患者加用放疗或内分泌治疗。结果 死亡1例，复发1例，皮瓣下积液24例，部分皮瓣或皮缘坏死12例，5年生存率98．46％。结论 采用改良根治术治疗Ⅰ、II期乳腺癌，严格无瘤操作技术、严防并发症，辅以化、放疗及内分泌治疗，可取得较好的远期效果。     

乳腺癌保乳治疗16例体会

目的探讨乳腺癌保乳手术治疗的临床经验。方法对16例乳腺癌患者实施肿块象限切除及腋窝淋巴结清扫，术后辅助放疗、化疗及内分泌治疗。结果16例保乳手术均获成功，术后恢复良好。随访6个月至5年，1、3、5年生存率分别为100％，93．8％和81、4％。结论乳腺癌行保乳手术治疗，术后应结合辅助放疗和化疗以及内分泌治疗，似可收到与改良根治术相同的治疗效果，患者生活质量提高。     

改良根治术及术后辅助治疗乳腺癌中远期疗效分析

目的总结分析改良根治术及术后辅助治疗Ⅰ、Ⅱ期乳腺癌的疗效。方法1994年4月至1999年4月共实行改良根治术35例期间，分别采用改良根治术Ⅰ式和Ⅱ式。术后再分别给予6个疗程辅助联合化疗，根据病情分别采用了CMF方案、CAF方案、辅助放疗及三苯氧胺治疗。结果35例术后随访，生存8年以上11例，占31．4％；生存5年以上18例，占51．4％；生存3年以上5例，占14．2％；另1未化疗病例术后15个月因肝肺转移死亡，占2．8％。结论采用改良根治术治疗Ⅰ、Ⅱ期乳腺癌，对腋淋巴结有转移较明显的宜采用改良根治术Ⅱ式。术后辅助治疗可以提高病人的长期生存率，延长生存时间。     

乳腺癌80例疗效分析

目的 探讨不同分期乳腺癌的手术治疗方法及综合治疗效果。方法 80例乳腺癌患者依据其临床分期、肿瘤大小等采用不同手术方式治疗,其中4例Ⅰ期乳腺癌患者行保乳乳腺癌切除术,20例Ⅱ~Ⅲ期乳腺癌伴腋窝1、2组淋巴结肿大者行乳腺癌改良根治术,49例伴腋窝1、2、3组淋巴结肿大者行乳腺癌根治术,1例Ⅲc期及6例Ⅳ期患者行姑息性全乳房切除术。术后除Ⅰ期4例外,均行化、放疗等辅助治疗。随访5a观察存活率。结果 4例行保乳乳腺癌切除术者均存活;20例行乳腺癌改良根治术者存活10例,生存率50.00%;49例行乳腺癌根治术者存活41例,生存率83.67%;7例行姑息性全乳房切除术者存活2例,生存率28.57%。60例肿瘤直径〈3cm者术后5a生存率（86.67%）高于20例直径〉3cm者（25.00%）（P〈0.05）。结论 Ⅱ期以上乳腺癌患者行乳腺癌根治术和改良乳腺癌根治术,术后辅助放、化疗,可提高患者5a生存率。     

乳腺癌86例综合治疗临床分析

目的 介绍我院乳腺癌的综合治疗方法。方法 86例乳腺癌的诊断及治疗进行回顾性分析，对术前局部晚期患者，术前采用经动脉灌注化疗，待临床降期后再手术治疗，对HER2强阳性患者采用赫赛汀基因联合希罗达或紫衫醇类联合蒽环类或cMF方案治疗。结果 保乳根治术26例，改良根治术50例，根治术10例死亡1例。结论 动脉灌注化疗在局部晚期患者的治疗具有非常重要价值，HER2强阳性的患者应采用赫赛汀基因联合希罗达治疗，术后转移晚期患者应联合紫衫醇类和蒽环类化疗。     

乳腺癌改良根治术Ⅰ式325例治疗体会

目的探讨乳腺癌改良根治术Ⅰ式的临床疗效。方法回顾性分析325例乳腺癌改良根治术Ⅰ式的临床资料。结果术中淋巴结清扫数目为7～18枚,平均13.6枚。术后皮下积液35例(10.8%),皮瓣坏死49例(15.1%)。术后行放、化疗和内分泌治疗等285例,占87.7%(放化疗97例,单纯化疗167例,单纯放疗13例,单纯内分泌治疗8例);术后未行正规综合治疗40例。手术及综合治疗组3年生存率84.2%(240/285),5年生存率66.3%(189/285);未行正规综合治疗组3年生存率72.5%(29/40),5年生存率35.0%(14/40),2组3、5年生存率及3、5年复发率差异均有统计学意义(P均<0.05)。结论乳腺癌改良根治术(Ⅰ式)术中适时变换体位,注意操作技巧,可以保证清扫范围,降低术后皮下积液等并发症的发生,术后进行综合治疗,可以降低患者的医疗风险,提高患者的生存率。     

保留皮肤或保留乳头、乳晕的乳腺癌改良根治术后扩展型背阔肌肌皮瓣即时乳房再造

目的探讨行保留皮肤或乳头、乳晕的乳腺癌改良根治术后应用扩展型背阔肌肌皮瓣即时乳房再造的疗效。方法30例乳腺癌患者中16例行保留皮肤乳腺癌改良根治术，14例行保留乳头乳晕乳腺癌改良根治术，术后即时切取包括背阔肌及其表面的脂肪和岛状皮肤、髂嵴上方脂肪、背阔肌前沿侧胸部脂肪和肩胛区脂肪构成扩展型背阔肌肌皮瓣，转移至胸壁再造乳房。结果30例即时乳房再造全部获得成功。切除乳房的组织量180～350ml（平均245ml），移植再造乳房的扩展型背阔肌肌皮瓣组织量210～440ml（平均265ml）。28例术后辅助化疗，5例辅助放疗。随访6～34个月（平均22个月），均生存，其中1例术后8个月骨转移，1例术后19个月腋窝胸壁局部复发。美容效果：优14例，良11例，一般3例，差2例。结论乳腺癌患者行保留皮肤或乳头乳晕改良根治术后应用扩展型背阔肌肌皮瓣即时乳房再造可获得足够的组织量，再造乳房形态良好，不影响乳腺癌的术后辅助治疗和远期疗效。     

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.     

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.     

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.     

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.     

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.