胆囊结石的内镜微创治疗与开放式胆囊切除术的比较观察

目的：探讨胆囊结石的内镜微创治疗与开放式胆囊切除术的疗效差异。方法：回顾性分析本院近年来收治的80例胆囊结石患者的临床资料。结果：治疗组患者的手术时间、术中出血量、住院时间等指标均要明显小于对照组,经统计学比较分析,差异具有统计学意义,P〈0.05,而两组患者的并发症发生率比较,差异无统计学意义,P〉0.05。结论：与开放式胆囊切除术比较,内镜微创治疗胆囊结石有创伤小、痛苦少、恢复快的优点,值得临床推广使用。     

乙肝病毒外膜大蛋白检测及在病毒复制诊断中的临床应用

目的探讨乙肝外膜大蛋白(HBV-LP)检测用于乙肝患者的临床诊断意义。方法采用酶联免疫吸附实验(ELISA)检测HBV-LP、电化学发光发检测病毒血清标志物,荧光定量聚合酶链式反应(PCR)方法对患者HBV DNA进行检测。结果乙肝病毒血清标志物相同模式患者血清中HBV-LP与HBV DNA检出率无显著差异(P>0.05);110例小三阳乙肝患者血清中HBV-LP HBeAg阳性检出率与HBV DNA阳性率差异无统计学意义,二者的检出一致率为78.18%;HBV-LP吸光度(OD值)与HBV DNA呈正相关关系(r=0.986)。结论在HBeAg阴性的乙肝患者中HBV-LP与HBV DNA有较高检出一致率,与HBV DNA有良好的正相关关系,HBV-LP可反映乙肝病毒复制水平。     

Outcome of non-surgical treatment of proximal femur fractures in the fragile elderly population

IntroductionWith the aging of the population the rate of fragility hip fractures increases. While medical recommendations are for hasten surgical treatment, for some older patients burdened with severe comorbidities, this might be risky.AimsTo compare the outcomes of patients treated non-surgically to those of the most fragile patients treated surgically.Patients and methodsA retrospective cohort study, of individuals aged ≥65 yearswho presented with fragility hip fractures between 01.01.2011-30.06.2016, to a primary trauma center. Patients treated surgically were stratified according to their age-adjusted Charlsons' comorbidity index (ACCI) score. Patients in the upper third of ACCI score, representing the more fragile population, were compared to patients treated non-surgically.Results847 patients presented with fragility fractures. 94 (11%) were treated non-surgically and 753 (89%) underwent surgery. Medical reasons were the leading cause for non-surgical treatment (61.7%). Surgically-treated patients were stratified according to their ACCI and 114 patients with ACCI > 9 were chosen for comparison. While both groups were comparable in terms of age, the non-surgical treatment group had more female patients (p. = 0.026) and a smaller proportion of independent walkers (p < 0.001). The ACCI was higher for the surgical treatment group (p < 0.001). In-hospital mortality was similar (14.9% and 18.1% for the operative and non-surgical groups respectively, P. = 0.575). However, one-year mortality was significantly higher for the non-surgical group (48.2% vs. 67.0%, P. = 0.005). The rates of in-hospital complications and 1-year readmissions were similar.ConclusionsOperative treatment for fragility hip fracture reduces long-term mortality rates even in the more fragile patients, compared to non-surgical treatment.     

Short-term morbidity factors associated with length of hospital stay (LOS): Development and validation of a Hip Fracture specific postoperative morbidity survey (HF-POMS)

BackgroundWe aimed to describe and quantify postoperative complications in the older hip fracture population, develop and validate a hip fracture postoperative morbidity survey tool (HF–POMS).MethodsA prospective clinical observation study of patients (≥ 70 years) admitted for emergency hip fracture surgery, was conducted across three English National Health Service hospitals. Outcome data items were developed from the Postoperative Morbidity Survey (POMS), Cardiac-POMS, hip fracture postoperative literature and orthogeriatric clinical team input. Postoperative outcome data were collected on days 1, 3, 5, 8 and 15; 341 patients participated.ResultsA 12-domain HF-POMS tool was developed with acceptable construct validity on all HF–POMS days. Patients with high perioperative risk scores as measured by the NHFS and ASA grade were more prone to develop HF–POMS defined morbidities. High morbidity rates occurred in the following domains; renal, ambulation assistance, pain and infectious. Presence of any morbidity on postoperative days 8 and 15 was associated with subsequent length of stay of 3.08 days (95% CI 0.90–5.26, p = 0.005) and 15.81 days (95% CI 13.35–18.27, p = 0.001) respectively. Observed average length of stay was 16.9 days. HF–POMS is a reliable and valid tool for measuring early postoperative complications in hip fracture patients. Additional domains are necessary to account for all morbidity aspects in this patient population compared to the original POMS.ConclusionMany patients remained in hospital for non-medical reasons. HF-POMS may be a useful tool to assist in discharge planning and randomised control trial outcome definitions.     

腹腔镜胆囊切除术治疗急性胆囊炎

目的：探讨腹腔镜胆囊切除术治疗急性胆囊炎的方法和经验。方法：回顾分析2008年10月—2010年9月行腹腔镜胆囊手术的54例急性胆囊炎患者的临床资料。结果：在54例急性胆囊炎患者中45例72h内手术,9例72h后手术,其中最长者发病5d手术;成功完成腹腔镜手术53例,中转开腹1例。结论：急性胆囊炎、胆囊结石患者应在72h内行腹腔镜胆囊切除术,病程长、操作困难、高龄和合并有心血管疾病的患者应及时中转开腹手术。     

传统中医理论指导下的老年人养生

《黄帝内经》确立了老年人养生的指导思想,奠定了中医养生学的基础,《内经》中关于老年人养生的理论特征、养生原则、养生方法都具有现实意义。以未病先防为指导,明确慎起居、勤锻炼、适饮食、调情志为具体的养生方法,《黄帝内经》的养生理论重视保养先天真气,主张老年人养生应当顺其自然,体现了自然而然的养生理念。     

锁骨钩钢板治疗肩锁关节脱位术后疼痛原因分析及对策

肩锁关节脱位治疗方法较多,有使用外固定器治疗肩锁关节脱位Ⅲ,也有使用“8”字钢丝加克氏针治疗,临床上取得良好效果。但锁骨钩钢板目前被认为是治疗肩锁关节脱位的最有效方法之一。自2002年2月至2008年5月先后对TossyⅡ、Ⅲ型肩锁关节脱位33例患者行切开复位锁骨钩钢板固定术,术后出现不同程度肩关节疼痛,现报告如下。     

Opioid-related compartment syndrome and associated morbidity

IntroductionOpioid-related compartment syndrome (ORCS) is an understudied complication related to opioid overdose. We hypothesized that ORCS would be associated with worse clinical outcomes, including higher amputation rates, need for multiple surgical procedures, and rhabdomyolysis on admission, compared with nonopioid-related compartment syndrome (NORCS).MethodsWe used Current Procedural Terminology codes for fasciotomy as a proxy marker for cases of compartment syndrome treated at 1 health system from January 1, 2016, to December 21, 2018. We excluded patients younger than 18 years, those treated for exertional compartment syndrome, and those who underwent elective fasciotomies. Seventy-four patients met our inclusion criteria. Data reviewed included patient characteristics, cause of compartment syndrome, time until evaluation for compartment syndrome, peak creatinine kinase levels, number of surgical procedures required, duration of hospital stay, and postoperative inpatient morbidity and death. Patients were categorized as having ORCS (n = 8) or NORCS (n = 66). Alpha = .05.ResultsAll cases of ORCS occurred in men. Opioid use was the third most common cause of compartment syndrome. Two patients underwent amputation, both in the ORCS group (p < 0.01). The median number of debridements was significantly higher for the ORCS group (median, 4; interquartile range [IQR]: 3–6) than for the NORCS group (median, 3; IQR 2–4) (p = 0.03). Duration of hospital stay was longer for the ORCS group (median, 27 days; IQR 16–38) compared with the NORCS group (median, 9 days; IQR: 5–13) (p < 0.001). Mean (± standard deviation) peak creatinine kinase level was significantly higher in the ORCS group (224,000 ± 225,052 U/L) compared with the NORCS group (7550 ± 32,500) (p < 0.001). The proportion of patients who underwent hemodialysis was higher in the ORCS group (88%) than in the NORCS group (35%) (p < 0.001). All ORCS patients presented >8 h after immobilization in a dependent position.ConclusionPatients in the ORCS group had delayed presentations and significantly more morbidity compared with patients in the NORCS group.     

Hip precautions not meaningful after hemiarthroplasty due to hip fracture. Cluster-randomized study of 394 patients operated with direct anterolateral approach

AimsWe aimed to compare two treatment regimes, one with and one without postoperative precautions in hemiarthroplasty patients, in terms of dislocation rate and patient-reported outcome. Direct lateral approach was used.Patients and Methods394 patients were included in a cluster-randomized study 2010−2014. Depending on which ward they were admitted to, they were allotted to free rehabilitation (non-precaution group, NPG, n = 226) or our conventional regime with precautions and mandatory assistive equipment (precaution group, PG, n = 168). Patients were followed during hospital stay, at 6 weeks (postal questionnaire), 3 month (visit) and 6 months (reading of medical records) by means of function tests, health-related quality of life (EQ-5D) and other patient-reported outcome measures (PROM).ResultsOne patient in each group had dislocation(s). We found no statistically significant differences regarding in-hospital-mortality, severe adverse events, EQ5D index or other PROM. In the NPG, rehabilitation personnel had significantly shorter work effort during hospital stay (p < 0.001). 7 in the NPG and 13 of the PG had reoperations (p = 0.038), 4 and 8 had deep infections, 3 and 5 periprosthetic fractures.ConclusionRehabilitation precautions are not needed for preventing dislocation when direct lateral approach is used. Without precautions, rehabilitation personnel implement significantly shorter work effort during hospital. We found no statistically significant differences regarding PROM and complications except for somewhat more reoperations in total in the precaution group.     

A comparison of the bipedicled nerve flap with the Littler flap for reconstructing a neurocutaneous defect of digits

BackgroundComplex digital injuries involving soft-tissue loss and digital nerve defect continues to pose a reconstructive challenge. This study reports the repair of such neurocutaneous defect with the bipedicled nerve flap or the Littler flap and compares the results of the two techniques.MethodsA retrospective study was conducted in 59 patients who had a neurocutaneous defect in the single digit treated with the bipedicled nerve flap or the Littler flap from Jul 2008 to May 2016. The patients were divided into two groups based on which flap was chosen. At the final follow-up, the two groups were compared for static two-point discrimination and Semmes-Weinstein monofilament scores on both flap and pulp, and pain, cold intolerance and patient satisfaction of the reconstructed digit.ResultsSignificant differences were found in static two-point discrimination, pain, cold intolerance, and patient satisfaction (p < 0.05). In comparison with the bipedicled flap group, the Littler flap group presented better discriminatory sensation in the flap and pulp, but exhibited higher incidence of pain and cold intolerance in the reconstructed digit. In the donor digits, the bipedicled flap group achieved lower pain incidence. Finally, the bipedicled flap group attained a larger degree of satisfaction than the Littler flap group.ConclusionsWhen reconstructing a complex neurocutaneous defect in the digit, choosing the bipedicled nerve flap rather than the Littler flap attains lower incidence of pain and cold intolerance, and higher patient satisfaction. Our results suggest that repair of the transected digital nerves can reduce neuroma incidence.