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.     

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.     

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.     

Imaging choices in occult hip fracture

Background: Hip fracture is a common injury, with an incidence rate of > 250,000 per year in the United States. Diagnosis is particularly important due to the high dependence on the integrity of the hip in the daily life of most people. Objectives: In this article we review the literature focused on hip fracture detection and discuss advantages and limitations of each major imaging modality. Discussion: Plain radiographs are usually sufficient for diagnosis as they are at least 90% sensitive for hip fracture. However, in the 3–4% of Emergency Department (ED) patients having hip X-ray studies who harbor an occult hip fracture, the Emergency Physician must choose among several methods, each with intrinsic limitations, for further evaluation. These methods include computed tomography, scintigraphy, and magnetic resonance imaging. Conclusion: We present an evidence-based algorithm for the evaluation of a patient suspected to have an occult hip fracture in the ED. Also outlined are future directions for research to distinguish more effective techniques for identifying occult hip fractures.     

Systematic Reviews Published in the April 2012 Issue of the Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly as a DVD but monthly online. The April 2012 issue (second DVD for 2012) contains 5045 complete reviews, 2182 protocols for reviews in production, and 17,084 short summaries of systematic reviews published in the general medical literature. In addition, there are citations of 674,000 randomized controlled trials, and 15,400 cited papers in the Cochrane methodology register. The health technology assessment database contains just over 11,000 citations. One hundred and seventeen new reviews have been published in the last 3 months of which 12 have potential relevance for practitioners in pain and palliative medicine. The impact factor of the Cochrane Library stands at 6.186. Readers are encouraged to access the full report for any articles of interest as only a brief commentary is provided.     

Platelets,thrombosis, coagulation,and atherosclerosis

When I first got the invitation to join a medical delegation going to Moldova, I thought for a moment that our destination was the fictional country in the old Marx Brothers movie Duck Soup. On further checking, it turns out that entertaining place was called Freedonia. I now know that Moldova is indeed a real country, bordered on the west by Romania and on the other three sides by the Ukraine. It is a proud country, rich with traditions, and its people are warm, giving, eager to learn ways to improve their healthcare system, and deeply appreciative of our attempts to help them in the task.     

Advance Care Planning

Predictors of patient wishes and influence of family and clinicians are discussed. Research findings on patient decision-making relating to preferences in end-of-life care are described. Advance directives and durable powers of attorney are defined and differentiated. Most patients have not participated in advance care planning and the need for more effective planning is documented. Appropriate times for discussions of such planning are described. Scenarios discussed include terminal cancer, chronic obstructive pulmonary disease, AIDS, stroke, and dementia. Patient satisfaction is discussed, as is a structured process for discussions about patient preferences. Results of patient responses to hypothetical scenarios are described. Invasiveness of interventions, prognosis and other factors that favor or discourage patient preferences for treatment are discussed. Findings resulting from research funded by the Agency for Healthcare Research and Quality (AHRQ) are discussed. This research can help providers offer end-of-life care based on preferences held by the majority of patients under similar circumstances.     

Spiritual Dimensions of Nursing Practice. edited by V. B. Carson

The Cochrane Library of Systematic Reviewsis published quarterly. Issue one for 2004 of the library was published in February 2004. This issue contains 3,329 reviews and protocols of which 1,921 are fully published reviews. The trials database now stands at over 400,000 records with an additional 4,427 one-page summaries of non-Cochrane reviews in the NHS database of reviews of effectiveness (DARE). This version of the library contains the results of an extensive search for RCTs on EMBASE. The latest library contains 84 new reviews, seven are considered relevant to practitioners in pain and palliative care. References are published in the same format as the citation for Cochrane reviews.     

Évaluation,par l’imagerie ultrasonore,du recrutement musculaire,de la force motrice et de la détente verticale du quadriceps après électromyostimulation (cas de 15 étudiants de l’INJS)

The increase of strength seems to be an element of performance in some sports.