Long-term clinical performance of flapless implant surgery compared to the conventional approach with flap elevation: A systematic review and meta-analysis

BACKGROUND The conventional implant approach involves flap elevation,which may result in increased soft tissue and bone loss and postoperative morbidity.The flapless surgical technique,aided by three-dimensional medical imaging equipment,is regarded as a possible alternative to the conventional approach to alleviate the above issues.Several studies have been performed regarding the role of flapless implant surgery.However,the results are inconsistent and there is no robust synthesis of long-term evidence to better inform surgeons regarding which type of surgical technique is more beneficial to the long-term prognosis of patients in need of implant insertion.AIM To compare the long-term clinical performance after flapless implant surgery to that after the conventional approach with flap elevation.METHODS PubMed,EMBASE,Cochrane Central Register of Controlled Trials,and grey literature databases were searched from inception to 23 September 2019.Randomised controlled trials(RCTs)and cohort studies comparing the long-term clinical performance after flapless implant surgery to that after the conventional approach over a follow-up of three years or more were included.Meta-analyses were conducted to estimate the odds ratios(ORs)or mean differences(MDs)and their 95%confidence intervals(CIs)between the long-term implant survival rate,marginal bone loss,and complication rate of the flapless and conventional groups.Subgroup analyses were carried out to account for the possible effects of the guided or free-hand method during flapless surgery.RESULTS Ten articles,including four RCTs and six cohort studies,satisfied the eligibility criteria and nine of them were included in the meta-analysis.There was no significant difference between the long-term implant survival rate[OR=1.30,95%CI(0.37,4.54),P=0.68],marginal bone loss[MD=0.01,95%CI(-0.42,0.44),P=0.97],and complication rate[OR=1.44,95%CI(0.77,2.68),P=0.25]after flapless implant surgery and the conventional approach.Moreover,subgroup analyses revealed that there was no statistically significant difference between the implant survival rate[guided:OR=1.52,95%CI(0.19,12.35),P=0.70];free-hand:n=1,could not be estimated,marginal bone loss[guided:MD=0.22,95%CI(-0.14,0.59),P=0.23;free-hand:MD=-0.27,95%CI(-1.10,0.57),P=0.53],or complication rate[guided:OR=1.16,95%CI(0.52,2.63),P=0.71;free-hand:OR=1.75,95%CI(0.66,4.63),P=0.26]in the flapless and conventional groups either with use of the surgical guide or by the free-hand method.CONCLUSION The flapless surgery and conventional approach had comparable clinical performance over three years or more.The guided or free-hand technique does not significantly affect the long-term outcomes of flapless surgery.     

运用心理知识做好门诊医患纠纷协调工作

随着人们对医疗服务需求的日益增长以及法律意识和维权观念的不断增强,医患纠纷呈不断上升趋势.门诊是医院的一个"大窗口",人员流动性大,病人需经过挂号、看病、划价、取药、检查等许多过程,身心极易疲惫,情绪会变得烦躁、易怒,很容易与医务人员发生冲突,因此门诊是医患纠纷易发场所.所以运用心理知识做好门诊医患纠纷协调工作显得尤为重要.     

泌尿系结石患者的饮食管理

泌尿系结石的形成与食物的组成有关。根据文献报道，能影响泌尿系结石形成的食物成分有蛋白质、脂肪（胆固醇、鱼油、多不饱和脂肪酸）、糖类、嘌呤、草酸、矿物质（钙、镁、钠等）、维生素（A、B6、D、C、K）、蔬菜（菠菜）、磁化水、乳制品、液体、微量元素等。改变饮食习惯或进行饮食控制，有助于预防结石复发。     

迟缓青霉素过敏反应高热休克1例

患者,女,38岁,教师。既往健康,因患上呼吸道感染1周,来院就诊,青霉素皮试(-),加入5%葡萄糖注射液500m l静脉滴注。上午11时静脉滴注结束,当日无不良反应及不适,下午正常生活。第2日上午继续静脉点滴青霉素800万U。批号、方法同前。11∶30静脉滴注结束,身体无不适。未用其他任何药物。13∶30在家中出现心悸、气短、胸闷、寒战、高热、脉搏细数。查体:体温40.3℃,心率124次/分,呼吸12次/分,血压测不清。急性痛苦病容,神志恍惚,烦躁不安,强迫体位,寒战,高热,张口呼吸,呼吸极度困难,带有喘鸣音,语音微弱,吐字不清,全身皮肤苍白,双眼球上翻,颈静…     

全膝人工关节股骨假体屈曲对疗效的影响:1年随访结果

背景:对于全膝人工关节置换术的股骨假体屈曲问题,多数人认为不能或不太影响膝关节术后功能,仅仅是术后X射线片令人不甚满意,因此尚未引起人们足够的重视.目的:回顾分78例123膝全膝人工关节置换术股骨假体屈曲对随访疗效的影响.设计:分组对比观察.单位:中国中医科学院望京医院骨关节一科.对象:选择2001-10/2004-06在中国中医科学院望京医院关节一科行全膝人工关节置换者78例123膝,其中发生股骨假体不同程度屈曲15例17膝(13.8%),男5例,女10例,年龄47～81岁:未发生屈曲63例106膝(86.2%),男22例,女41例,年龄47～79岁.方法:回顾性分析方法比较股骨假体屈曲组和非屈曲组手术前后HSS(HSS knee rating score)评分、膝关节活动范围和屈曲挛缩畸形,并测量屈曲角和屈曲距离,股骨假体屈曲对置换效果的影响.主要观察指标:①股骨假体屈曲的测量结果.②患者膝关节HSS评分和活动度.③患者屈曲挛缩畸形例数及角度.④不良事件及副反应.结果:患者获随访1年以上.①17膝股骨假体屈曲角为7°～19°,平均为11.3°;股骨假体屈曲距离为2～4 mm,平均为2.6 mm.②术前屈曲组与非屈曲组患者HSS评分和膝关节活动范围差异均无显著性(P＞0.05),但术后屈曲组低于非屈曲组(P≤0.01);术后均高于术前(P=0.02或P＜0.01).③屈曲组术后屈曲挛缩例数和角度多于和大于非屈曲组(P＜0.01),两组术后屈曲挛缩均有改善(屈曲组P＜0.05,非屈曲组P＜0.01).④非屈曲组并发右股深静脉血栓1例,骨化性肌炎1例;屈曲组并发髌骨假体撞击征1膝.结论:本组资料证明,股骨假体屈曲对全膝人工关节置换效果的影响是增加术后膝关节屈曲挛缩的发生率,造成伸膝功能障碍.     

Laparoscopic repair of complete intrathoracic stomach with iron deficiency anemia:A case report

BACKGROUND Giant paraesophageal hiatal hernias(HH)are very infrequent,and their spectrum of clinical manifestations is large.Giant HH mainly occurs in elderly patients,and its relationship with anemia has been reported.For the surgical treatment of large HH,Nissen fundoplication is the most common antireflux procedure,and the reinforcement of HH repair with a patch(either synthetic or biologic)is still debatable.CASE SUMMARY We report on a case of giant paraesophageal HH in a middle-aged male patient with reflux symptoms and severe anemia.After performing a series of tests and diagnostic approaches,results showed a complete intrathoracic stomach associated with severe iron deficiency anemia.The patient underwent successful laparoscopic hernia repair with mesh reinforcement and Nissen fundoplication.Postoperatively,reflux symptoms were markedly relieved,and the imaging study showed complete reduction of the hernia sac.More importantly,anemia was resolved,and hemoglobin,serum iron and ferritin level were returned to the normal range.The patient kept regular follow-up appointments and remained in a satisfactory condition.CONCLUSION This case report highlights the relationship between large HH and iron deficiency anemia.For the surgical treatment of large HH,laparoscopic repair of large HH combined with antireflux procedure and mesh reinforcement is recommended.     

Rare anaplastic sarcoma of the kidney:A case report

BACKGROUND Anaplastic sarcoma of the kidney(ASK)is a rare and newly recognized renal neoplasm.The tumor usually is extensive and cystic,characterized by pleomorphic spindle cells with marked atypia and associated with multinucleated cells.To date,only 27 cases have been reported in the literature.The authors present an additional case and summarize the relevant knowledge in the literature.CASE SUMMARY A 27-year-old previously healthy woman presented with a palpable mass over the abdomen and right flank soreness for one year.After the computed tomography study,the patient underwent right radical nephrectomy obtaining a 1680-g tumor with a size of 18.4 cm×14.5 cm×11 cm.The tumor is chiefly composed of anaplastic spindle cells with marked nuclear atypia admixed with multinucleated cells.Immunohistochemical evaluation of tumor cells exhibited diffuse positivity for CD56,p53,and vimentin,and focally positive for desmin.The diagnosis of ASK was established.Unfortunately,a local tumor recurrence followed by a distant metastasis developed within months.The patient died 26 months after the initial surgery.Comparing to the previously 27 cases of ASK,the current case had a relatively worse prognosis,which might be potentially associated with older patient age,larger tumor size,and the lack of en-bloc resection of adjacent organs during the initial radical nephrectomy.CONCLUSION This case points out the featured pathological findings for diagnosing ASK and suggests more aggressive management for patients with ASK.     

柳硼酊巧治灰指甲

灰指甲是由皮肤真菌侵犯甲板所致的一类疾病,多表现为甲板失去光泽、增厚变形,因变脆而破裂、缺失,病甲呈灰白、污黄色,临床多见,且顽固难治.笔者用柳硼酊(由本院药剂科配制)治疗该病5例,均治愈.现将此方法介绍如下.     

基于MRI、CT不同层面和位像形态学依据回顾性分析双侧股骨头坏死塌陷的危险因素

背景:MRI、CT对骨组织形态学变化评估为客观金标准.目的:基于MRI、CT不同位像影像学客观依据分析双侧股骨头坏死塌陷的危险因素.设计、时间及地点:自身对照,分类汇总分析,试验于2003-04/2007-06在北京协和医学院研究生院完成.参试者:选择本科收治的双侧股骨头坏死并有完整塌陷前/未塌陷资料的患者48例,男21例,年龄21～48岁;女27例,年龄23～46岁.均为激素性股骨头坏死.股骨头坏死按照国际骨循环学会(ARCO)标准分期,ARCOA-C 4例,ARCOB-C 4例,ARCOB-B 12例,ARCOC-C 28例.方法:对有单/双侧塌陷的双侧股骨头坏死的患者影像资料进行回顾性分析.根据早期MRI T1中低信号带的形态分为开放型和包含型.根据坏死灶的CT变化类型分为:a:坏死灶形成硬化带,并且在软骨下骨下为连续的硬化带;b:在软骨下骨下为不连续的硬化带;c:软骨下骨下硬化带形成不明显:d:没有明显硬化带形成,坏死灶呈均匀中密度影.主要观察指标:坏死灶大小、位置、MRI形态、CT形态及塌陷.结果:单侧塌陷43例(ARCOA-C 4髋.ARCOB-C 4髋,ARCOB-B 12髋,ARCOC-C 23髋),双侧塌陷5例(ARCOC-C 10髋).负重面外侧型(64髋)塌陷49髋(ⅡB 12髋,ⅡC 37髋),负重面中央型(21髋)塌陷4髋(ⅡC 4髋)负重面内侧型(11髋)无塌陷;早期MRI T1中低信号带的形态开放型塌陷51髋,闭合型塌陷2髋.CT示坏死灶形成硬化带,并且在软骨下骨下为连续的硬化带O/23(type-a);有不连续硬化带形成但没有延伸到软骨下骨下者塌陷19/30髋(type-b);CT有硬化带形成,并不连续延伸到软骨下骨下者塌陷28/37髋(type-c);没有硬化带形成,病灶呈均匀中高密度影者塌陷6/6髋(type-d).结论:以MRI、CT评估,坏死灶上负重面外侧型更易早塌陷;对于双侧股骨头坏死的病例,MRI显示相似的面积,T1低信号带包含型者,预后相对较好;CT显示软骨下骨均匀增厚或明显的"焊接"现象是延迟塌陷的因素;但是软骨下骨没有或有不均匀不连续性硬化是危险因素.