异体肢体移植术后手功能重建3例

目的 探讨异体肢体移植术后手功能康复的临床效果。方法 在应用免疫抑制剂条件下，采用术前、术中、术后一体化康复计划，对3例(5个肢体)异体移植患进行康复治疗。结果 手外形好，感觉基本正常，两点辨别觉2．5—4．0cm，前2例手指总屈伸度均为优良，生活完全自理，心理健康。第3例手功能部分已恢复。结论 异体肢体移植术后手功能康复效果良好。     

异体肢体移植术后手功能重建3例

目的探讨异体肢体移植术后手功能康复的临床效果。方法在应用免疫抑制剂条件下,采用术前、术中、术后一体化康复计划,对3例(5个肢体)异体移植患者进行康复治疗。结果手外形好,感觉基本正常,两点辨别觉2.5～4.0cm,前2例手指总屈伸度均为优良,生活完全自理,心理健康。第3例手功能部分已恢复。结论异体肢体移植术后手功能康复效果良好。     

同种异体肢体移植的一体化康复护理

目的 总结异体肢体移植一体化功能康复护理。方法 对4例(6个肢体)同种异体肢体移植患者在手术前、后开展“一体化”的功能康复护理,对移植肢体的术前、术中、术后的功能康复分别做出详细而周密的计划,由专人负责并予以实施。结果 4例(6个肢体)患者移植肢体功能评分均在良好以上;日常生活基本自理,其中1例已回归工作岗位。结论 对同种异体肢体移植患者的功能康复必须建立一个整体的、系列的、全程的康复观念。     

异体双手移植后的神经再生问题：1例探讨

同种异体双手移植世界上开展不多，该病例为世界第4例异体双手移植。目的：探讨异体手移植免疫抑制状态下的神经再生特点。设计：病例分析。地点和对象：手术在哈尔滨医科大学附属第一医院完成。2001-01收治的1例双手腕上4cm截肢患者，男。18岁。干预：1例双手缺失患者行异体手移植，手术过程基本同自体断腕再植，术中吻合正中神经、尺神经、尺神经腕背支和桡神经浅支。术后联合应用普乐可复(FK506)等免疫抑制剂抗免疫排斥反应。主要观察指标：通过Tinnel征观察神经恢复情况。结果：术后患者移植手存活良好，无免疫排斥反应发生。术后1个月Tirmel征示神经生长&;gt;50mm，2个月&;gt;100mm，3个月达200mm左右，神经再生速度均&;gt;2mm／d。4个月痛、温觉、触觉拇指已恢复至指腹，其他4指至近指间关节水平，手主动运动可抓持物品、纸张；与Tinel氏征检查相符。结论 异体手移植免疫抑制状态下神经再生迅速，在较短时间内恢复手部感觉与手内在肌神经再支配，快于同平面的自体断肢再植，值得进一步探讨。     

异体双手移植后的神经再生问题:1例探讨

背景同种异体双手移植世界上开展不多,该病例为世界第4例异体双手移植.目的探讨异体手移植免疫抑制状态下的神经再生特点.设计病例分析.地点和对象手术在哈尔滨医科大学附属第一医院完成.2001-01收治的1例双手腕上4 cm截肢患者,男,18岁.干预1例双手缺失患者行异体手移植,手术过程基本同自体断腕再植,术中吻合正中神经、尺神经、尺神经腕背支和桡神经浅支.术后联合应用普乐可复(FK506)等免疫抑制剂抗免疫排斥反应.主要观察指标通过Tinnel征观察神经恢复情况.结果术后患者移植手存活良好,无免疫排斥反应发生.术后1个月Tinnel征示神经生长＞50 mm,2个月＞100 mm,3个月达200 mm左右,神经再生速度均＞2 mm/d.4个月痛、温觉、触觉拇指已恢复至指腹,其他4指至近指间关节水平,手主动运动可抓持物品、纸张;与Tinel氏征检查相符.结论异体手移植免疫抑制状态下神经再生迅速,在较短时间内恢复手部感觉与手内在肌神经再支配,快于同平面的自体断肢再植,值得进一步探讨.     

膝关节周围恶性骨肿瘤保肢术后的肢体功能康复

目的总结股骨下端、胫骨上端恶性骨肿瘤患者保肢手术后膝关节功能康复方法。方法64例恶性骨肿瘤患者接受不同方式的保肢手术治疗,平均随访36.8个月。结果(1)术后早期系统的康复治疗有利于膝关节功能恢复和减少术后并发症。因恶性骨肿瘤保肢手术创伤大,膝关节屈伸锻炼最早在手术1周后进行,而异体半关节移植的患者手术3周内需用支架固定。（2）术后感染、皮肤坏死、关节退变和不稳是导致肢体功能不良的主要因素。（3）异体半关节移植、保留自体髁部关节面的异体骨段移植、人工全膝关节置换的术后肢体功能优良率分别为48.6％、81.3％、90.9％。结论保肢手术方法选择应注重恢复肢体功能,术后早期进行康复训练有利于膝关节功能康复。     

同种异体手移植患者术后黏附分子的动态变化及意义

目的：探讨同种异体手移植患者术后外周血黏附分子的动态变化及意义。方法：用流式细胞仪对3例同种异体手移植术前患者和术后1～180d外周血黏附分子水平进行动态观察。结果：患者外周血黏附分子CD4，CD8，CD28，CD54，CD11a的水平于术后第1天开始降低，至术后第6天为最低。术后第7天始，上述黏附分子水平逐渐回升，至180d，CD4，CD28，CD54水平一直低于术前水平，CD11a于术后20d回升到术前水平，而CD8则持续升高，于术后30d，明显超过术前水平(t=4．1，P&;lt;0．05)。结论：免疫抑制剂对黏附分子具有明显抑制作用。同种异体手移植术后患者无明显排斥反应与临床观察相符，提示黏附分子可作为排斥反应的监测指标，对提高移植手的存活率及其远期功能恢复具有重要意义。     

异体手移植术后慢性排斥反应的观察及护理

由于创伤、肿瘤切除或先天性原因所导致肢体缺失，往往使患者丧失劳动能力，甚至丧失生活自理能力。给家庭和社会带来沉重负担。而患者对上肢佩带的假肢要求高。即使是三维电子手也只能完成手部粗大的动作，难以适应生活与工作需要，现阶段解决手缺损最直接的方法，仍是异体手移植。至今国内外已完成20余例同种异体手移植，其中我院完成4例同种异体手移植（6个肢体）。3例术后曾发生过慢性排斥反应（CR），现报道如下。     

手部深度烧伤手术治疗临床分析

目的:提高手部深度烧伤的愈合速度和功能康复.方法:在伤后1～5 d对伤手分区早期切削痂移植皮片或带蒂皮瓣或异体真皮复合移植.结果:380例伤手功能基本恢复314例,占82.6%;功能部分恢复66例,占17.4%.结论:手部深度烧伤在没有肌腱、骨质及关节损害的情况下行皮片移植;在有肌腱、骨质和关节等损伤的情况下可行皮瓣移植.     

健康教育在手功能康复中的应用

目的 :提高手外伤修复术后患者参与康复的积极性 ,帮助患者掌握康复训练的知识和技巧 ,实现自我康复 ,最大程度地恢复手功能。方法 :对 173例患者采用病房、康复室、门诊一体化的教育方式 ,由专人负责制定、实施、评价健康教育计划。结果 :健康教育效果评价优良率为 88.1% ,康复计划完成率为 6 0 .7%。结论 :手功能康复过程中应用健康教育 ,可提高患者参与康复的积极性 ,有利于患者手功能的恢复。     

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.