糖尿病患者血清尿酸水平检测及其价值

目的　通过检测糖尿病 (diabetesmellitus,DM )患者血尿酸 (UA)水平 ,探讨其与并发血管疾病的关系及价值。方法　血UA采用尿酸酶法测定。对 6 8例DM患者 (36例并发血管疾病 ,其中 2 1例发生微血管并发症 ,15例发生大血管病变 )和 5 0例健康成人取肘静脉血检测UA水平。结果　DM各组血清UA水平显著高于健康成人组(P<0 .0 1) ;大、微血管病变组与无并发症DM患者血清UA水平差异有统计学意义 (P <0 .0 1) ;微血管病变组血清UA水平与大血管病变组比较 ,差异无统计学意义 (P >0 .0 5 ) ;以大于正常 x± 2s值为阳性判定标准 ,大、微血管病变组阳性率为 80 .5 6 % (2 9/ 36 ) ,无并发症组阳性率为 6 .2 5 % (2 / 32 ) ,有、无并发症组阳性率差异有统计学意义 (χ2 =2 9.6 70 ,P <0 .0 1)。阳性预测值 93.5 5 % (2 9/ 31) ,阴性预测值 81.0 8% (30 / 37) ,敏感性 80 .5 6 % (2 9/ 36 ) ,特异性93.75 % (30 / 32 )。结论　DM患者病情与血清UA水平相关 ,UA定量测定对DM患者并发血管疾病有判断价值     

基层医院对肺栓塞的认识

肺栓塞 (PE)是由于肺动脉或其某一分支被血栓堵塞而引起的严重并发症。由于过去对该病识别不够 ,检出率极低 ,反过来又加重了PE是少见病的概念。实际PE绝非少见病 ,近年来PE的发生率逐年提高 ,病死率位于死因的第 3位。未经治疗的PE病死率为 2 5 %～ 3 0 %,而得到及时诊断与治疗后 ,病死率可降至 2 %～ 8%[1 ] 。由此可见 ,早期正确诊断PE非常关键 ,然而许多基层医院缺乏必要的检查设备和技术 ,加上各级大夫对PE认识肤浅 ,漏诊率极高。结合我院近三年及作者在外院进修期间诊治的 12例PE患者资料 ,现将基层医院对PE的诊治体会总结报…     

妇科肿瘤术后并发深静脉血栓的预防和护理16例

深静脉血栓 (deepvenousthrombosis,DVT)是外科手术常见的早期并发症之一 ,国内报道外科术后DVT的发生率为 2 6 % ,而在妇科肿瘤术后血栓形成发生率达 7%～4 5 % [1] 。由于下肢DVT可影响下肢活动 ,甚至使患者丧失劳动能力 ,栓子脱落还可造成肺栓塞 (PE)导致患者猝死。1986年 1月～ 2 0 0 2年 6月 ,我院行妇科肿瘤盆腔手术32 4例 ,术后并发DVT 16例 ,故对妇科肿瘤患者围手术期DVT的预防和护理十分重要。1　临床资料1.1　一般资料。我院 1986年 1月～ 2 0 0 2年 6月行妇科肿瘤盆腔手术 32 4例 ,术后并发DVT患者共 16例 ,发生率为4 .9…     

尿激酶静脉溶栓治疗脑梗死研究

目的探讨尿激酶静脉溶栓治疗急性脑梗死的疗效。方法对发病 12小时内的 2 0 0例急性脑梗死患者 ,随机分溶栓组和丹参等常规治疗组 ,溶栓组尿激酶剂量为 10 0～ 15 0 U,静脉滴注。结果基本痊愈率为 6 0 .0 % ( 6 3/10 5 ) ,总显效率为 88.6 % ( 93/10 5 ) ,病死率为2 .9% ( 3/10 5 ) ,脑内出血性并发症为 8.6 % ( 9/10 5 ) ,常规治疗组基本痊愈率为 6 .3% ( 11/95 ) ,总显效率为 35 .8% ( 34/95 ) ,病死率为11.6 % ( 11/95 ) ,脑内出血性并发症为 1.1% ( 1/95 )。结论溶栓组疗效显著高于常规治疗组 ( P<0 .0 5 ) ,但脑出血并发症也显著高于常规治疗组 ( P<0 .0 1)     

重症胆源性胰腺炎手术时机的探讨

目的为提高重症胆源性胰腺炎 (SGP)的治疗效果 ,探讨SGP早期手术适应证和最佳手术时间。方法采用统计学方法回顾性分析 5 2例SGP的手术时机与并发症及死亡情况。结果早期手术 (住院 48h内 ) 2 2例和延期手术 (病情稳定 6～ 8周后 )3 0例的并发症的发生率分别为 3 1.8%和 3 .3 % (P<0 .0 2 5 ) ,病死率分别为 13 .6%和 0 (P <0 .0 5 ) ;胆总管探查率分别为 90 .9%和 5 6.7% (P <0 .0 1)。结论SGP的手术时机应采用延期与个体化相结合的处理原则 ,即首先应积极系统的非手术治疗 ,在临床症状控制 6～ 8周后延期手术 ,能够降低SGP的病死率、并发症和胆总管探查率。在出现以胆道梗阻为主 ,胰腺炎进行加重或有重症急性胆管炎表现或并发弥漫性腹膜炎时应早期手术治疗为宜     

重症急性胰腺炎诊治探讨（附75病例）

重症急性胰腺炎是极严重的外科急腹症 ,起病急、病情进展迅速、并发症多、病死率相当高。本文根据我院资料对重症急性胰腺炎的诊治作出探讨。1　临床资料我院由 1971年～ 1995年间共收治经手术和病理检查证实的重症急性胰腺炎 75例。男 39例 ,女 36例。年龄 2 0～ 81岁 ,平均 49岁。患者住院前和住院后的临床表现和实验室检查结果见表 (1)。表 1　 75例的临床表现和实验室检查情况项　　目例数 %腹　痛 75 10 0消化道症状 75 10 0体温≥ 38℃ 415 5全腹压痛及肌紧张 6 992血白细胞 >15× 10 9/Ｌ 6 890血淀粉酶 >2 5 0Ｕ 42 5 6血糖 >6 .6ｍ…     

结肠癌并发急性肠梗阻的外科处理

目的　探讨结肠癌并发急性肠梗阻的外科处理。方法　分析 1995～ 2 0 0 3年间 5 3例结肠癌致急性肠梗阻的外科治疗资料。结果　 5 3例患者中Ⅰ期切除吻合 4 7例 (88 6 8% ) ,其中右半结肠 8例。横结肠 4例 ,左半结肠 12例 ,乙状结肠 2 3例。 4例Ⅰ期肿瘤切除 ,结肠造瘘 ,Ⅱ期肠吻合术。 2例行永久性结肠双腔造口术。术后并发症发生率 13 2 % (7/5 3) ,围手术期病死率 1 9% (1/5 3)。结论　重视对结肠癌致肠梗阻的认识 ,及时诊断 ,做好围术期处理 ,合理选择手术方式是减少并发症和提高疗效的关键。     

重症急性胰腺炎患者早期或晚期手术时外周血有核细胞Toll样受体表达差异及意义

目的　探讨重症急性胰腺炎患者早期或晚期手术时外周血单核细胞Toll样受体 2、 4mRNA的表达差异 ,及其与患者并发症发生率和预后的相关性。方法　随机选取重症急性胰腺炎患者 2 9例 ,分成早期或晚期手术组 ,于手术后第 5天分离外周血有核细胞 ,利用逆转录聚合酶联反应 (RT PCR)法检测TLR2、TLR4基因的变化 ,同时测量血浆内毒素水平的变化 ,并与并发症发生率和病死率的差别作相关性分析。结果　早期手术组与晚期组的病死率分别为 2 5 % (3/12 )和 5 % (1/17) ,χ2 =15 2 1,P <0 0 1;并发症发生率分别为 10 0 %和 35 % ,χ2 =5 34,P <0 0 5 ;TLR2mRNA的表达水平分别为 (119 82± 11 13)和(75 15± 6 34) (t =12 5 4 ,P <0 0 1) ;TLR4mRNA的表达水平为 (98 11± 5 16 )和 (6 5 5 4± 5 11) ,t =16 83,P <0 0 1;两组间内毒素水平分别为 (1 16± 0 10 )pg/L和 (1 0 9± 0 0 8)pg L ,t =1 83,P >0 0 5。结论　与晚期手术者比较 ,早期手术者外周血白细胞TLR4及TLR2mRNA表达水平增加 ,术后病死率和并发症发生率增加 ,说明早期手术可能通过再次炎症反应打击而加重了系统性器官损伤     

有机磷农药中毒并发中间综合征的早期防治

目的 :探讨有机磷农药中毒后并发中间综合征 (IMS)的早期防治措施。方法 :将中、重度有机磷农药中毒的 30 5例患者随机开放式分为治疗组 15 8例和对照组 14 7例 ,治疗组采用早期、突击剂量应用胆碱酯酶复活剂的治疗方法 (第 1个 2 4h氯磷啶平均用量 8.4± 1.1g) ,对照组采用传统的治疗方法 (第 1个 2 4h氯磷啶平均用量 3.2 5± 0 .5 g) ,观察两组胆碱酯酶恢复的时间 ,IMS的发生率及病死率 ,胆碱酯酶活力与IMS发生的关系。结果 :治疗组胆碱酯酶平均恢复的时间 (5 .8± 1.5d)较对照组(19.3± 3.5d)明显缩短 (P <0 .0 1) ;治疗组IMS的发生率 (5 .6 6 % )及病死率 (1.89% )较对照组 (2 5 .0 9%和 10 .2 7% )明显降低 (P <0 .0 1) ;并发IMS患者的胆碱酯酶活力均在 6 0 %以下。结论 :早期 (中毒 2h内 )足量 (第 1个 2 4h氯磷啶用量 8～ 10 g)应用胆碱酯酶复活剂是减少有机磷中毒后并发IMS及降低其病死率的有效措施。     

非酮症高渗性糖尿病昏迷病人的护理探讨

非酮症高渗性糖尿病昏迷 (NHDC)是糖尿病的急性严重并发症。本症病死率极高 ,国外早期报道高达 40 %～ 70 % ,近年由于提高了对本症的认识 ,病死率虽已显著下降 ,但仍高达15 %～ 2 0 % [1] 。我院内分泌科自 1999年～ 2 0 0 2年收治NHDC病人 19例 ,经积极救治和护理 ,无 1例死亡。现将护理体会报道如下。1　临床资料1 1　一般资料 :我院内分泌科于 1999年～ 2 0 0 2年收治NHDC病人 19例 ,男 9例 ,女 10例 ,年龄 48～ 89岁。有糖尿病史者 9例 ,血糖 2 7 0～ 66 83mmol/L ,尿糖均为 ,血钠13 0～ 176mmol/L ,血钾 2 5～ 5 4mmol/L …     

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.     

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.     

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.     

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.