Therapeutic hypothermia and frostbite injury: a preventable source

Frostbite injury from cold exposure is not uncommon. The application of ice pack is well known in clinical practice; however, its improper use can pose danger to the patient. We report a case of frostbite injury due to prolonged use of ice packs in a ventilated patient.     

东北地区风寒指数日极值的分布及冻伤预防

风寒指数是最为广泛采用的冷应激指标。人体短时间对风寒指数极值的暴露易发生冻伤。为了探讨寒区风寒指数日极值和冻伤预防措施，根据东北和内蒙古４７个气象站１０年的逐日平均气温、最低气温、平均风速和平均总云量资料，计算出各站区的风寒指数日最大值，分析发生冻伤的关键期、警戒期及可能发生冻伤的天数。本结果有助于部队科学地安排军事训练和耐寒锻炼，预防冻伤，提高寒区部队战斗力。     

Considerations in fluids and electrolytes after traumatic brain injury.

Appropriate fluid management of patients with traumatic brain injury (TBI) presents a challenge for many clinicians. Many of these patients may receive osmotic diuretics for the treatment of increased intracranial pressure or develop sodium disturbances, which act to alter fluid balance. However, establishment of fluid balance is extremely important for improving patient outcomes after neurologic injury. The use of hyperosmolar fluids, such as hypertonic saline, has gained significant interest because they are devoid of dehydrating properties and may have other beneficial properties for patients with TBI. Electrolyte derangements are also common after neurologic injury, with many having neurologic manifestations. In addition, the role of electrolyte abnormalities in the secondary neurologic injury cascade is being delineated and may offer a potential future therapeutic intervention.     

Consent for the secondary use of human residual tissue: the patient is best served by an 'opting-out' procedure

In medical scientific research much use is made of human bodily material (residual tissue) which remains after treatment or diagnosis. Using this, relevant research questions can be answered. The way in which patients can consent to the secondary use of residual tissue is now formalised in a code of conduct, which allows such use unless the patient has objected to this use ('opting-out' procedure). A law is being formulated which will probably require the explicit permission of the patient for secondary use of residual tissue. It is expected that this requirement will lead to a lesser and more selective availability of residual tissue for research. Requesting explicit permission also means additional health care work. Patients demonstrate a preference for the 'opting-out' procedure, on condition that they are well informed about the use of the residual tissue. It is concluded that the interests of the patient are best served by the 'opting-out' procedure, provided that patients are well informed.     

Medical malpractice as an epidemiological problem

The notion that the tort liability system deters negligence in health care has been invoked to make the "business case for patient safety." However, existing data on the relationship between hospital adverse events and malpractice claims typically are interpreted as evidence that the tort system does not deter negligence because of the poor fit between those who are negligently injured and those who sue. Using a familiar analogy from epidemiology--the problem of false positives in screening tests for rare diseases--and data from two large studies of medical injuries and malpractice claims in the United States, this paper presents an argument that the standard interpretation overlooks a complexity in the data. Although most malpractice claims do not actually involve a negligent injury, a patient who suffers a negligent injury is more than 20 times more likely, on average, to file a claim than a patient who does not. However, because malpractice claiming is a rare event with many false positives, for the average hospital or group practice, even substantial improvements in rates of negligent injury will not lead to a large reduction in claims rates. These findings suggest that the strength of the business case for patient safety depends on the perspective from which one views the data.     

Plasma amino acid levels with a note on membrane transport: characteristics,regulation, and metabolic significance

The plasma concentration of an amino acid (AA) is the result of its rates of appearance (Ra) in and disappearance (Rd) from plasma. As for most nutrients, AA Ra and Rd are tightly regulated and at the postabsorptive state Ra equals Rd. Factors controlling Ra are protein intake and tissue release; those controlling Rd are tissue uptake and body losses (urine, sweat, etc.). Regulation of plasma AA concentrations involves hormones, in particular insulin and glucagon, both of which induce hypoaminoacidemia (but for quite different reasons), and cortisol, which induces hyperaminoacidemia. In addition, in pathologic states, catecholamines, thyroid hormones, and cytokines modulate plasma AA levels. Peripheral availability of AAs after protein ingestion is controlled by the liver, with an activation of ureagenesis in hyperprotein feeding and repression during a hypoprotein diet. The arginine-to-citrulline pathway in the intestine plays a key role in this adaptative process. In some circumstances tissue uptake of AAs and further metabolism depend on plasma AA concentrations. Plasma glutamine level may be the driving force controlling the flux of this AA at the muscle level. Also, channeling of the arginine cellular pathways means that plasma arginine is a major controlling component of nitric oxide synthesis in endothelial and immune cells. All these features explain the excessive increase in glutamine and arginine demands, in particular for energy expenditure, leading to morbidity (e.g., gut atrophy, muscle wasting, and immune dysfunction) in stressed patients. Normoaminoacidemia is not synonymous with health because this state is observed in level 2 starvation (Ra and Rd decrease) or after minor injury (Ra and Rd increase). Hyperaminoacidemia may be the consequence of organ failure (Rd decreases) or excessive AA intake during parenteral nutrition (Ra increases). Hypoaminoacidemia is observed after organ removal (Ra decreases, e.g., decrease in citrulline concentration in short bowel syndrome) or in stress situations (Rd increases). Mere determinations of plasma AA concentrations at the basal state (i.e., postabsorptive) provide rather limited information. Their usefulness can be improved by measuring arteriovenous differences or performing time course measurements, but techniques based on stable isotopes are necessary to obtain more precise information on the behavior of a particular AA or group of AAs.     

Claims for damages due to bile-duct injury following laparoscopic cholecystectomy: some legal remarks

Of 278 patients who were referred to a tertiary centre because of a bile-duct injury incurred during a laparoscopic cholecystectomy, 19% had sued the doctor or hospital involved. This percentage is relatively low compared with data from the US, and also if compared with the much larger group of patients who believe that their injury was due to medical negligence. When patients perceive their injury in this way, malpractice litigation is not the only option available to them; they can also lodge a complaint with the hospital's complaint committee or with the medical disciplinary board. If such complaints are found justified, this increases the chance of a settlement without court proceedings. Patients should be informed about the possibility of bile-duct injury during laparoscopic cholecystectomy. Apart from the legal obligation to do so, an informed patient will be less inclined to attribute the injury automatically to a medical error. Finally, the high number of complications and claims justifies further debate on whether a no-fault compensation system is to be preferred over the present system of compensation based on medical negligence.     

Malpractice liability in private practice of nutrition

To date, no dietitian has been successfully sued in a malpractice case. However, as the number of dietitians in private practice increases, the risk of such suits increases proportionally. What is malpractice law and how does it apply to dietitians? What tests do the courts apply to determine whether injuries a patient has suffered were the fault of the health professional caring for that patient? What circumstances might ameliorate the patient's claims and limit the liability of the dietitian? Even though each case will be decided independently on the basis of the evidence presented in court, general principles and guidelines govern the courts' decision-making process. Among the elements that must be proved by a patient seeking legal redress are actual injury, a relationship of duty between the parties, breach of that duty, and a cause-and-effect relationship between the breach of duty and the injury suffered. Awareness of those principles can assist dietitians in conforming their conduct to practices that minimize their risk of liability.     

The practice guideline 'Dermatomyositis, polymyositis and sporadic inclusion body myositis'

This guideline presents recommendations for the diagnosis and treatment of dermatomyositis, polymyositis and sporadic inclusion body myositis (sIBM) according to the best available evidence. Characteristic skin abnormalities can be sufficient for the diagnosis of dermatomyositis. In case of doubt, a skin biopsy is advisable. A muscle biopsy is indicated when other examinations are inconclusive and the musculature is involved. The working group considers screening for cancer to be required in adults with dermatomyositis and presents recommendations for the way that this should be done. At least one-third of all patients with polymyositis has, or will develop, an associated inflammatory connective tissue disease. If a patient with a connective tissue disease develops symmetrical, proximal muscle weakness in the course of weeks or months, this may be assumed to be due to polymyositis. In the absence ofpre-existing connective tissue disease, demonstration of a mononuclear cell infiltrate in muscle tissue is a prerequisite for the diagnosis ofpolymyositis. The histopathology of muscle tissue is used as the gold standard for the diagnosis of sIBM. The practice guideline presents criteria for the concept 'activity' of myositis. Disease activity serves as a guideline for the treatment of polymyositis and dermatomyositis. The treatment of choice for dermatomyositis and polymyositis is high-dose prednisone. Physical activity does not have a negative effect on the course of these diseases. The long-term prognosis ofdermatomyositis and polymyositis is not well known. The clinical course of sIBM is slowly progressive.     

Determination of nutritional status in critical care

The application of the standard battery of nutritional assessment tests, measurements, and calculations is of limited value in the immediate nutritional diagnosis of the critically ill patient. Many of these tests are affected by stress, making it impossible to distinguish the etiology of abnormalities during the early postinjury period. Altered test results because of stress or injury include: increased excretion of creatinine; increased white blood cell (WBC) counts; increased anergy to skin tests; and decreased serum albumin, transferrin, thyroxin-binding prealbumin, and retinol-binding protein concentrations. Therefore, in assessing the nutritional status of the critically ill patient, it is important to focus on indexes that are realistic relative to the patient's metabolic status. Timing of data collection is of keen importance; data collected after fluid resuscitation and the peak metabolic response to injury on postinjury days 5 through 10 are usually more meaningful than those collected immediately after hospital admission. Admission assessment is necessary only to identify the high-risk patient in need of immediate nutrition intervention, to estimate energy/nutrition and fluid requirements, and to provide guidelines for planning nutrition care. This article presents recommendations for initial assessment, postcatabolism assessment, and serial assessment of the critically ill patient. Guidelines for estimating energy/nutrient requirements and timing data collection are also presented.     

Prevention of delayed recovery and disability of work-related upper extremity disorders

There is always a psychological component to any illness or injury, and unless it is appropriately addressed, such factors can complicate or delay the recovery from a work-related illness or injury. When a worker experiences delayed recovery and unexpected disability, significant contributing psychosocial factors must be assessed for and managed appropriately. A maladaptive belief or understanding about the condition and disability by a patient presents an obstacle to successful treatment. Using cognitive behavioral therapy techniques may be an effective means of managing this challenge for the clinician.     

Recovery from an eighty-percent total body surface area burn injury sustained at work

This article presents a case of severe burn injury at work involving 80 % of body surface area and patient treatment and rehabilitation, which resulted in preserved working ability. The worker was injured by hot water and steam. After initial treatment in the intensive care unit, he underwent comprehensive clinical and outpatient rehabilitation that took 92 weeks, after which he returned to work. His working disability was 100 % after the initial treatment in the intensive care unit, but rehabilitation improved it to 50 %. It should always be kept in mind that even patients with serious or life-threatening injuries can be reintegrated into the workforce if patients, physicians, occupational physicians, and employers all work together.     

Cholestatic icterus after intake of ovulation inhibitors

Clinical and biopsic aspects of cholestatic icterus in 9 women treat ed with Ovosiston and Non-ovlon are reported. Clinical symptoms disappeared rapidly in 7 patients after medication was discontinued, but the course was protracted in 2 patients. Icterus could be observed in the liver tissue for some time after its clinical disappearance. The steroid component of the oral contraceptive is regarded as the releasing factor in the temporary liver cell damage. Ovulation inhibitors are contraindicated in women with a history of hepatitis, liver cirrhosis, pregnancy icterus, familiar liver disease, and toxic injury to liver cell. Oral contraceptives should be suspected in the etiology of any ic terus in a female patient.     

妊娠期患者腹部CT检查所致胎儿辐射风险分析

目的：对妊娠患者进行常规腹部螺旋CT扫描所致胎儿辐射风险进行评估。方法：曝光条件由临床CT检查选择病例的统计数据确定。CT扫描仪包括3个生产厂商的双排、16排和64排CT。胎儿受照剂量由患者子宫的器官剂量代替。子宫器官剂量由SR250软件估算。结果：对于所有机型的常规腹部螺旋CT扫描,胎儿受照剂量范围为14～26mGy,平均值和方差为（18.5±4.7）mGy。结论：根据ICRP建议书,分别从3个角度评价胎儿辐射效应：①常规腹部螺旋CT扫描不会引起胎儿组织损伤及功能障碍;②不会造成胎儿智力发育障碍;③胎儿时期的X射线照射会提高幼儿时期癌症的发生率。然而,由于实际情况的复杂性,很难确定这个癌症发生率提高的程度有多大。因此,根据本次实验所估计的胎儿受照剂量,妊娠患者进行常规腹部螺旋CT扫描导致胎儿发生辐射效应的概率极低。     

The role of oxidative stress and arterial blood supply in the transplanted liver function

INTRODUCTION: Reperfusion injury and hepatic artery thrombosis are major causes of graft failure after liver transplantation. The magnitude of oxidative stress increases after reperfusion and the appearance of an arterial thrombosis presents a higher risk for the graft and patient survival. AIM OF THE STUDY: The aim of the study was to detect the level of oxidative stress in the perioperative period of transplantation. METHODS: Clinical documentations of 32 patients were investigated and the level of myeloperoxidase (MPO) was measured for the monitoring of the oxidative stress. RESULTS: The mean age of the patients was 43 years and hepatitis C cirrhosis was the most common indication (14 cases, 43%). Two retransplantations were done. In 24 cases (75%) the primary graft functions and patient survival were good. Eight patients died, in two cases because of acute liver failure, in two cases due to primary non function and in four cases due to late complications. The incidence of hepatic artery thrombosis was 11% (4 cases) and the incidence of acute rejection was 35% (12 cases). The level of MPO was higher (65 ng/ml) in all patients before operation. After the first 48 hours this level increased significantly (p < 0.0001) up to the mean level of 123 ng/ml and decreased after one week. In the cases with acute liver failure and hepatic artery thrombosis high levels of MPO were measured. CONCLUSION: This study provides evidence of increased oxidative stress before liver transplantation. The magnitude of these changes increased after operation, mostly in cases with acute liver failure and hepatic artery thrombosis. Reducing the reperfusion injury and performing an "ideal" arterial supply for the liver-graft present better survival.     

New directions in the understanding and management of pain

Control of pain and the suffering that it causes still eludes us. Despite impressive progress in the prevention and cure of disease and in care of the trauma victim, pain is still a frontier in medical research. It accompanies surgery, various diagnostic procedures and dental care as well as acute injury and disease. For a significant number of patients it persists after injury or illness into a chronic state. Chronic pain is recognized to be the most frequent cause of disability in the United States and many industrialized nations today, and is a major cost to society in both work hours lost and medical expenses. In addition to its social importance, pain is an intimate cause of personal concern for every human being throughout life. The progress, or lack of progress, achieved by medical research in pain control is of interest to us all. Pain disorders may be usefully classified in two categories: acute and chronic. The etiology, physiopathology, symptomatology, diagnosis and therapy of these two types of pain are quite different and require separate consideration. Acute pain is that which arises from an acute injury or disease process and persists only as long as the tissue pathology itself. If acute pain problems are not effectively treated, they may progress to chronic states. Chronic pain is that: (1) associated with chronic tissue pathology; or (2) which persists beyond the normal healing period for an acute injury or disease. There are unique challenges for health care providers associated with each of these two categories of problems, and failure to distinguish between these types of pain has led to a widespread, ongoing mismanagement of patients that can be prevented if strong efforts are made to better educate health care professionals about pain and its therapy. This paper presents an overview of current understanding about the nature of pain and its management. The physiology and psychology of pain are reviewed against a background of the concepts and information taught 25 years ago. Some common acute and chronic pain problems are reviewed and discussed. Finally, several new directions in pain control are described.     

Neuromodulation and neurostimulation in urology

Functional voiding disorders, such as urge incontinence and urine retention, have a high prevalence and often lead to stigmatisation and a diminished quality of life. Patients with idiopathic voiding dysfunctions, for whom conservative treatments are insufficient, can currently be treated with sacral neuromodulation. In sacral neuromodulation a pulse generator is implanted; it is a reversible treatment that can be tested beforehand to evaluate if the patient is eligible for it. After implantation a good result is obtained, on average, in 73% of patients. Patients with spinal cord injury may currently be treated with electrical neurostimulation of the anterior sacral roots, which results in the ability to void without a residue, evacuate stools and obtain an erection or vaginal lubrication. Over 80% of the implanted patients with a spinal cord injury void without residual urine. Furthermore, continence is restored and the bladder capacity increases. In patients with therapy-resistant functional micturition disorders and in patients with spinal cord injury, neuromodulation and neurostimulation must be considered before invasive surgery is carried out.     

The role of flexibility in injury prevention and athletic performance: have we stretched the truth?

The use of stretching to prevent injury, off-set muscle soreness, and improve performance has been widely accepted and promoted in sports. However, little or no scientific evidence supports the practice, and recent research suggests that stretching, which increases flexibility beyond that needed for sport-specific movements, may cause injury. This article presents studies that have looked at the effects of stretching on injury and performance. Many earlier studies that showed benefits of stretching did not look at the effects of stretching alone; they also involved general cardiovascular workouts in the experimental but not control groups. More recent research shows that general fitness, rather than stretching, is a more important risk factor in injury prevention. This article also discusses studies of the relationship between joint laxity and injury and the role that stiffness may play in enhancing performance and preventing injury. Overall, the evidence suggests that increasing range of motion beyond function through stretching is not beneficial and can actually cause injury and decrease performance. These findings should be used to challenge common warm-up practices in athletics.     

Risk factors for psychiatric inpatient assaults on staff

The risk of psychiatric patient assaults on staff members is increasing yearly, with resultant increases in employee victim suffering, medical expense, and lost productivity. Traditionally considered a clinician responsibility, the management of patient violence also has important administrative implications. This article presents a review of the risk factors associated with violence that includes the characteristics of patients who assault but adds the characteristics of employee victims of such assaults as well as contextual variables. Additional data from a two-year study of a peer-help crisis intervention program for employee victims of patient assaults are included. The mental health administrative implications of this approach are outlined.     

Electromyographic Techniques in,the Prognostication of Ischemic Injury

Since it is not possible subjectively to make an accurate early determination of tissue loss in cases of cold injury, a technique was developed wherein electromyographic procedures were used to forecast tissue loss within 24 hours after the cold injury. This technique was tested in 7 dogs in which the hind limb had been immersed in a -40 C freezing solution to the level of the hock. The electrical response of the îibîal nerve was followed into the injured area, and the level at which no positive electrical response from the nerve could be recognized was taken as the level of projected tissue loss. The same general procedure was followed using the muscle action potential of thigh muscle on five rats immersed in freezing solution to mid thigh. In each case, the line of eventual tissue loss coincided with the level where muscle or nerve electrical responses could no longer be recognized.