肢体枪弹伤所致眼间接损伤的超声显像评价

目的应用超声技术评价肢体枪弹伤所致眼间接损伤,为枪弹伤合并症的诊治提供影像学依据.方法采用高速弹射击10只猪(20只眼)后肢.致伤前及伤后不同时相点眼部均接受高频二维超声和视网膜中央动脉(CRA)彩色多普勒血流成像检测,并作眼组织病理检查.结果以致伤后眼组织出现组织学改变为眼间接伤发生标准,有11只眼发生损伤(列为效应组),另外9只无损伤发生(列为非效应组).二维超声显示部分效应组伤后前房及玻璃体内透声差,有细弱光点漂浮,2只眼见不全的网脱回声.彩色多普勒显示效应组CRA伤后血流速度显著减慢(P＜0.01),6h后收缩期流速(PSV)逐渐回升,至伤后24h基本接近伤前水平.而舒张期流速(EDV)伤后始终维持较低水平.阻力指数(RI)伤后即刻至24h内均维持高水平(P＜0.01).非效应组CRA血流动力学参数致伤后各时相点与伤前均无差异.效应组和非效应组比较,效应组EDV、RI在伤后各个时相点均与非效应组伤后相应时相点存在明显差异(P＜0.05或P＜0.01),EDV较非效应组低,RI较非效应组高.而效应组PSV在伤后即刻和6h也显著低于非效应组致伤后相应时相点(P＜0.05).眼间接伤的超声表现与其病理改变相一致.结论眼间接伤后眼底血管血流动力学表现为低速度、高阻力、低灌注特点,部分眼的二维超声显像也有显著改变.综合超声显像技术可客观评价枪弹伤所致眼间接损伤,对眼间接伤的诊断、严重度评估、疗效观察有重要价值.     

超声显像对枪弹伤失活组织区域判定的价值

目的：探讨应用超声显像技术判定枪弹伤失活组织区域的价值。方法：应用高频二维超声和能量多普勒成像技术检测猪后肢软组织枪弹伤创伤弹道及其周围组织成像特点，并结合病理检查分析其声学基础。结果：（1）枪弹伤失活组织区之一的原发伤道伛在二维超声下有显著的特点，呈一走行清晰，内径不一，内部回声随时间延长而呈动态变化的管道状回声。（2）伤道周围组织超声显像特点与距伤道远近密切相关。距伤道较近区域（挫伤区，为失活组织）二维超声下组织纹理明显紊乱，能量多普勒模式下血流信号稀少，而距伤道较远区域（震荡区，为变性组织）血流信号丰富，表现为血管内径扩张，血流速度加快，并多以静脉信号为主，结论：综合应用超声显像技术可对枪弹伤失活组织区域俾一基本判定，促进枪弹伤救治水平的提高。     

猪肢体枪弹伤失活组织区域超声造影显像的实验研究

目的 探讨超声造影技术对猪肢体枪弹伤失活组织区域判定的价值.方法 利用53式滑膛枪建立猪肢体软组织枪击伤模型,应用常规超声及超声造影技术观测猪伤肢原发伤道及其周围软组织声像图表现,并与病理结果对比分析.结果 常规超声显像猪肢体枪击伤原发伤道呈走行较清晰的管道状回声,伤道内部回声可随时间延长而发生变化.致伤区超声造影后除原发伤道显示为充盈缺损区外,紧邻伤道周围的部分组织也可呈充盈缺损表现,病理显示充盈缺损区均为失活坏死组织,而造影后伤道周围组织的不均质低增强表现以及最外围的环状高增强表现病理提示分别为以变性组织改变为主和小血管扩张充血改变为主.结论 常规超声可判断猪肢体枪弹伤致伤区原发伤道的走行,而超声造影技术则可以精细识别致伤区域失活组织,两者联合应用有助于促进枪弹伤救治水平的提高.     

血管回声跟踪技术评价动脉血管弹性变化的动物实验

目的 应用血管回声跟踪(ET)技术评价兔腹主动脉粥样硬化动脉弹性变化,探讨其评价动脉硬化弹性变化的病理基础及应用价值.方法 雄性新西兰兔30只,随机分为三组,A组为对照组;B、C组为实验组,分别高脂喂养8周、12周.A、B两组于喂养8周,A、C两组于喂养12周时应用ET技术检测兔腹主动脉弹性参数(Ep)、僵硬化系数(β)、脉搏波传导速度(PwVp)、增大指数(AI)、顺应性(AC)等参数,同时对比观察腹主动脉二维超声及病理变化.结果 各组二维超声均未见明显腹主动脉管壁增厚及斑块形成.ET检测指标显示:C组Ep、β、PWVβ较A、B组高,AC低于A、B两组,差异有统计学意义(均P<0.05);AI各组间差异无统计学意义(P>0.05).病理检查B组腹主动脉内膜泡沫细胞形成,动脉弹力层及平滑肌层未见明显破坏.C组腹主动脉内膜大量胆固醇结晶形成,动脉弹力层及平滑肌层破坏断裂.结论 ET技术可早于二维超声发现腹主动脉粥样硬化时动脉弹性改变.当动脉粥样硬化引起其管壁弹力层、平滑肌层破坏时,ET即能检测到相关参数变化,因此弹力层、平滑肌层损伤可能是动脉弹性改变的病理基础.     

两种动脉重建方式彩超对移植肾远期影响的比较

目的 通过对5年以上供肾动脉与髂外动脉行端侧吻合（EEA）或与髂内动脉行端端吻合（ESA）的移植肾进行二维超声、多普勒血流参数及血肌酐(SCr)的比较，评价两种动脉重建方式的远期效果。方法 根据供肾动脉的不同吻合方式将64名肾移植患者分为髂内动脉端端吻合组和髂外动脉端侧吻合组，采用彩色多普勒超声进行监测，观察移植肾的大小、结构、血流灌注情况、血流动力学参数，进行对比分析。结果 两组移植肾患者的血肌酐(SCr)、移植肾体积、椎体大小、肾皮质厚度、肾动脉内径、移植肾段动脉、叶间动脉、弓形动脉血流及阻力指数差异均无统计学意义(P>0．05)。结论 供肾动脉与髂内动脉端端吻合或与髂外动脉端侧吻合5年以上的移植肾患者在肾功能、二维超声、多普勒血流上没有明显差异。     

常规超声和超声造影对移植肾两种动脉重建方式的评价

目的 应用常规超声及超声造影(CEUS)评价肾移植患者供肾动脉与髂内动脉行端端吻合(EEA)或与髂外动脉行端侧吻合(ESA)两种方式的远期效果.方法 根据供肾动脉吻合方式将60名移植肾患者分为EEA组和ESA组,进行二维超声、彩色多普勒超声以及CEUS定量分析的比较.结果 两种动脉重建方式在二维超声和彩色多普勒超声的指标上差异无统计学意义;CEUS定量分析指标上,ESA组略优于EEA组.结论 两种动脉重建方式的血流灌注ESA略优于EEA.     

实时超声剪切成像定量评价肢体挤压伤后局部肌肉损伤

目的 探讨实时超声剪切成像(supersonic shear imaging,SSI)的定量超声弹性图在肢体挤压伤所致局部肌肉损伤中的价值.方法 健康新西兰白兔23只,使用袖带气囊加压法于兔后腿制作肌肉挤压伤动物模型.于解压后30 min、2h、6h、24 h、72 h分别进行实时超声组织弹性成像,获取肌肉组织的弹性值,分析使用组织弹性值评价肌肉损伤程度的准确性.结果 23只兔全部建模成功.左后腿挤压伤面积占体表面积的2.6％～3.0％.灰阶超声显示左后腿肌肉的挤压部分与非挤压部分分界清晰.解压后30 min、2h、6h、24 h、72 h的最大弹性值分别为(19.51±6.74)kPa、(21.47±5.54)kPa、(11.36±5.35)kPa、(15.09±3.31)kPa、(13.72±3.74)kPa,平均弹性值分别为(12.44±3.77)kPa、(13.20±3.60)kPa、(6.80±2.86)kPa、(10.04±2.95)kPa、(6.94±0.97)kPa,均显著高于非挤压区的最大弹性值和平均弹性值(P＜0.001).ROC曲线显示,使用最大弹性值和平均弹性值能够诊断肢体肌肉挤压区,且弹性值越大,诊断价值越大.结论 肢体肌肉挤压伤的弹性平均值与弹性最大值可以定量测定挤压区组织弹性变化,反映组织的硬度和压力变化,在诊断肢体肌肉挤压伤中是常规超声有价值的补充.     

两种动脉重建方式对移植肾远期影响的彩色多普勒超声观察

目的:通过对5年以上供肾动脉与髂外动脉端侧吻合或与髂内动脉端端吻合的移植肾进行二维超声、多普勒血流参数及血肌酐(SCr)的比较,评价两种动脉重建方式的远期效果。方法:根据供肾动脉的不同吻合方式将64例肾移植患者分为ESA组和EEA组,采用彩色多普勒超声进行监测,观察移植肾的大小、结构、血流灌注情况、血流动力学参数,进行对比分析。结果:两组移植肾患者的SCr、移植肾体积、锥体大小、肾皮质厚度、肾动脉内径、移植肾段动脉、叶间动脉、弓形动脉血流及阻力指数差异均无统计学意义(P>0.05)。结论:供肾动脉与髂外动脉端侧吻合或与髂内动脉端端吻合5年以上的移植肾患者在肾功能、二维超声、多普勒血流上没有明显差异。     

血管回声跟踪技术对2型糖尿病患者下肢血管弹性功能的检测

目的 探讨血管回声跟踪技术(echo-racking,ET)对2型糖尿病患者下肢血管病变的诊断价值.方法 筛选30例正常人和68例2型糖尿病患者,在ET模式下采集股总动脉、腘动脉的二维超声图像,应用ET技术检测其动脉弹性指标:僵硬度指数(β),血管压力-应变弹性系数(Eρ),顺应性(AC),增大指数(AI),脉搏波传导速度(PWVβ).结果 糖尿病组股总动脉、腘动脉的β、Eρ、PWVβ较对照组显著增高(P<0.05),AC值显著降低(P<0.05),AI值与对照组相比差异无统计学意义(P>0.05).结论 糖尿病患者的股动脉存在动脉硬化,腘动脉作为肌性动脉也存在动脉硬化,且与弹性大动脉股动脉改变一致,有良好的相关性.ET技术为2型糖尿病患者下肢动脉的弹性检测提供了一种快速、无创的评价方法 .     

超声诊断腹主动脉、髂动脉发育异常1例

患者女, 49岁, 以"双手掌指关节间断疼痛伴脚后跟疼痛并行走受限"为主诉入院。无胸闷、胸痛、腹痛、腹胀等其他不适。体格检查见双下肢水肿, 无压痛、肌肉萎缩或肢体畸形表现。既往曾行"阑尾切除术", 余病史无特殊。入院后血常规、血沉、尿常规、粪常规、甲状腺功能三项、血脂六项、肝功能、心肌酶谱、肾功能、电解质、凝血四项、D-二聚体、CCP、ANA、ENA、免疫全套等检验结果均无明显异常。行下肢动脉血管超声检查示双下肢动脉频谱呈低流速、低搏动改变(图1, 2), 为进一步明确原因, 遂继续行双侧髂动脉、腹主动脉扫查, 超声提示:腹主动脉下段、右侧髂总动脉未测及(考虑:先天缺如, 图3, 4);左侧髂总、双侧髂外动脉近心端管样狭窄(考虑:先天发育异常, 双侧髂内动脉向髂外动脉逆向供血, 图3～7);腹主动脉残端、腹腔干、肠系膜上动脉与盆腔动脉间侧支循环形成;腹主动脉残端-左侧髂总动脉-右侧髂总动脉残端间侧支循环形成。后行腹主动脉CTA提示:腹主动脉下段(平肾动脉以下层面)、肠系膜下动脉、右侧髂总动脉未见明确显影, 左侧髂总动脉仅见一纤细残端, 腹盆腔内可见多支侧支血管;脾动脉走形迂曲;肠系膜上...     

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.     

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.     

Clinical Trial Updates and Hotline Sessions presented at the European Society of Cardiology Congress 2007

This article provides information and commentaries on trials which were presented at the Hotline and Clinical Trial Update Sessions at the European Society of Cardiology Congress 2007 in Vienna. The key presentations were performed by leading experts in the field with relevant positions in the trials or registries. It is important to note that unpublished reports should be considered as preliminary data, as the analysis may change in the final publications. The comprehensive summaries have been generated from the oral presentation and the webcasts of the European Society of Cardiology and should provide the readers with the most comprehensive information of relevant publications.     

Prospects for the control of neglected tropical diseases by mass drug administration

The prospects for the control of neglected tropical diseases, including soil-transmitted helminthiasis, shistosomiasis, lymphatic filariasis, onchocerciasis and trachoma, through mass drug administration, are exemplified by the elimination of the trachoma as a public-health problem in Morocco. In spite of this and other striking successes, mass drug administration programs are faced with major challenges resulting from suboptimal coverage and lack of efficacy. At current suboptimal coverage rates, programs may need prolongation for an extended period, increasing costs and undermining sustainability. Community participation through health education and information appears to be crucial to improve coverage and to achieve sustainability. Implementation of complementary measures, such as vector control, improved hygiene and environmental sanitation, are important to further control transmission and to prevent re-emergence of the infection and, again, may only be achieved effectively through community-based initiatives. To reduce costs and to relieve pressure on the health system, combining neglected tropical disease programs in areas where diseases coexist and integration with existing control programs for malaria, tuberculosis and HIV/AIDS is advocated. The risk of developing drug resistance is of particular concern in view of the lack of alternative drugs, and reduced treatment efficacy due to emerging resistance is evident for the soil-transmitted helminths and onchocerciasis. Given the risk for the development of drug resistance and the need for a high degree of participation, close attention should be paid to the monitoring of the coverage and efficacy of the different program components.     

Balance and Boundaries in Grief Counseling: An Intervention Framework for Volunteer Training

Volunteers or paraprofessional counselors are commonly used to provide supportive care to the bereaved. These counselors generally are trained in basic listening skills, providing a generic, nonspecific approach to intervention that remains to be proven effective. The present paper outlines a framework that provides paraprofessionals with a broader model for intervention with the bereaved. Attention to boundaries as a helper and balance in the grief recovery are central to the model. Interventions are described that provide the paraprofessional counselor with more options for tailoring their counseling strategy to the individual. These include techniques that are presumed to be more specific to the enhancement of grief recovery.     

A new method for the simultaneous analysis of unmodified and modified urinary nucleosides and nucleobases by high performance liquid chromatography

Details are given of a new, rapid and simple pre-fractionation method and an isocratic high performance liquid chromatography system suitable for parallel analysis of nucleosides and nucleobases from urine and other biological fluids. The quantitative recovery and excellent reproducibility of the method is demonstrated by analysis of representative standard RNA catabolites. The advantage of this new method for application to biological samples is discussed.     

Bacterial meningitis: an update of new treatment options

The outcome of bacterial meningitis critically depends on the rapid initiation of bactericidal antibiotic therapy and adequate management of septic shock. In community-acquired meningitis, the choice of an optimum initial empirical antibiotic regimen depends on the regional resistance patterns. Pathogens resistant to antibacterials prevail in nosocomial bacterial meningitis. Dexamethasone is recommended as adjunctive therapy for community-acquired meningitis in developed countries. In comatose patients, aggressive measures to lower intracranial pressure <20 mmHg (in particular, external ventriculostomy, osmotherapy and temporary hyperventilation) were effective in a case–control study. Although many experimental approaches were protective in animal models, none of them has been proven effective in patients. Antibiotics, which are bactericidal but do not lyse bacteria, and inhibitors of matrix metalloproteinases or complement factor C5 appear the most promising therapeutic options. At present, vaccination is the most efficient method to reduce disease burden. Palmitoylethanolamide appears promising to enhance the resistance of the brain to infections.