双叶皮瓣修复拇指脱套伤

目的：介绍食指尺侧及中指桡侧带血管神经双叶皮瓣瓦合修复拇指脱套伤的应用价值。方法：运用食指尺侧及中指桡侧带血管神经双叶皮瓣转位瓦合后修复拇指脱套伤5例。结果：5例双叶皮瓣的全部成活,术后随访3－6个月,拇指外观及功能恢复良好,疗效满意。供皮区植皮安全成活,食、中指活动正常。结论：食指尺侧及中指桡侧带血管神经双叶皮瓣,为修复 拇指脱套伤提供了又一种有效方法,外观和感觉良好。     

示指尺侧、中指桡侧双叶皮瓣瓦合急诊修复拇指脱套伤

手是人体重要的运动及感觉器官,而拇指功能占手的40%,因此拇指损伤后的修复极为重要[1].2006年1月起,浙江大学医学院附属第二医院应用示指尺侧、中指桡侧共蒂的双叶皮瓣瓦合修复拇指套脱伤9例,术后全部皮瓣成活,效果满意.     

组合皮瓣修复全手脱套伤9例分析

目的探讨全手脱套伤的治疗方法。方法利用游离拇甲瓣联合足背皮瓣皮瓣修复拇指及手部桡侧创面、前臂骨间背岛状皮瓣修复手部尺侧创面,游离皮片修复虎口部创面。结果皮瓣均成活。随访9~18个月,患手能完成握持动作,拇指感觉恢复,两点辨别觉7~8 mm。结论利用一组游离皮瓣加骨间背岛状皮瓣修复全手脱套伤有效,创伤相对较小且外形尚满意,是全手脱套伤的一种有效治疗方法 。     

游离股前外侧皮瓣修复下肢毁损伤17例临床护理

目的:探讨应用游离股前外侧皮瓣修复下肢毁损伤术后的护理经验,提高该病的临床护理效果。方法:应用游离股前外侧皮瓣移植结合持续冲洗加VSD、外固定架固定等技术对17例濒临截肢的下肢毁损伤患者积极进行修复治疗,术后给予精心的护理。结果:17例移植皮瓣全部成活,1例皮瓣边缘部分坏死,经换药后愈合。经过8个月以上的随访,17例患者骨折均愈合,创面闭合,15例患者受区皮瓣外形良好,2例患者皮瓣经过整形后,外观达到满意效果,15例患者下肢功能基本恢复,2例患者最大限度地保留了功能,可行走(跛行)。结论:应用游离股前外侧皮瓣修复下肢毁损伤术后规范、有效的护理,是手术成功和患者下肢功能恢复的重要保证。     

上臂外侧骨皮瓣游离移植修复手部复合伤的手术配合

目的总结上臂外侧骨皮瓣游离移植修复手部复合伤的手术期的护理经验。方法对10例上臂外侧骨皮瓣游离移植修复手部复合伤患者的临床资料及手术配合过程进行回顾性分析,总结该手术配合的要点。结果本组10例手术配合顺利,术后均未发生感染,组织瓣均成活,手功能恢复良好。结论术前物品准备齐全,熟悉手术步骤,术中配合熟练,严格执行无菌操作,是确保手术成功的关键。     

一例左手脱套伤双侧胸脐皮瓣瓦合术的护理

手部脱套伤是一种严重的手外伤,临床处理较为困难。目前,大多采用袋状皮瓣插兜[1],腹部S形皮瓣修复创面,但这两种皮瓣均有手术次数多、时间长等缺点。2005年3月我科采用双侧胸脐皮瓣瓦合修复手部脱套伤1例,经过术前做好心理护理、健康教育及供、受区皮肤准备;术后保持正确体位,     

非计划性气管拔管的紧急处理及预防措施

2003年1月～2006年12月,我们为50例患者采用其自体组织移植修复手部缺损,经精心护理,效果满意.现将围术期护理体会报告如下. 1 临床资料 本组50例,男45例,女5例,18～50岁,平均34岁.机器挤压伤27例,绞车绞伤10例,炮炸伤5例,车祸碾挫伤4例,电击伤4例.均为手复合组织缺损,经急诊清创,择期修复,均采用游离第2足趾及股前外皮瓣组合组织移植修复,移植组织均成活.有1例于术后6h出现血管危象,经对症处理,危象缓解.1例皮瓣边缘出现坏死,经手术清创及合理处理后成活.对指对掌功能恢复优38例、良10例、可2例.     

超薄游离股前外侧皮瓣修复手部大面积皮肤缺损的护理

报告了42例超薄游离股前外侧皮瓣修复手部大面积皮肤缺损的护理。术前加强心理护理、进行有效的床上排便训练、注重术野皮肤准备是手术成功的关键,术后安置正确的体位、加强皮瓣血液循环的观察、帮助患者进行有效的功能锻炼是促进肢体功能恢复的重要措施。本组42例42块皮瓣全部成活,经过2个月~5年随访,患者手功能和外形恢复满意。     

手部重度热压伤的皮瓣移植修复22例

目的:重度热压伤者深层组织暴露,断层或全厚皮片移植不能覆盖神经、肌腱、皮质骨,临床常采用早期皮瓣移植修复,本组观察22例手部重度热压伤患者的治疗效果,进行了重复性的经验验证。方法:选择2001-01/2006-06解放军第八五医院烧伤整形外科收治的皮瓣移植修复治疗手部重度热压伤患者22例,对治疗方案均知情同意。其中选择手部局部皮瓣4例,上臂管型皮瓣3例,腹部随意带蒂皮瓣10例,腹部轴型皮瓣5例。术后进行康复治疗,定期随访,根据伤情和手功能恢复情况评估疗效。结果:①术后各种皮瓣全部成活,随访6￣12个月,皮瓣颜色质地均佳,手外形和功能恢复满意。②22例患者治疗效果优、良、差者分别为10,7,5例。③伤后急诊手术及1周内手术者17例,愈合优良率为82%;2周内手术者5例,愈合优良率为60%。结论:根据不同的热压伤创面选用相应的皮瓣进行早期移植修复,术后同时进行康复治疗,可最大限度地恢复手的外形和功能。     

自体组织移植修复手部缺损50例围术期护理

2003年1月～2006年12月,我们为50例患者采用其自体组织移植修复手部缺损,经精心护理,效果满意.现将围术期护理体会报告如下. 1 临床资料 本组50例,男45例,女5例,18～50岁,平均34岁.机器挤压伤27例,绞车绞伤10例,炮炸伤5例,车祸碾挫伤4例,电击伤4例.均为手复合组织缺损,经急诊清创,择期修复,均采用游离第2足趾及股前外皮瓣组合组织移植修复,移植组织均成活.有1例于术后6h出现血管危象,经对症处理,危象缓解.1例皮瓣边缘出现坏死,经手术清创及合理处理后成活.对指对掌功能恢复优38例、良10例、可2例.     

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.     

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.     

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.     

Clinical Pharmacokinetics of Morphine

Morphine, the most widely used mu-opioid analgesic for acute and chronic pain, is the standard against which new analgesics are measured. A thorough understanding of the pharmacokinetics of morphine is required in order to safely and effectively use this analgesic in a wide variety of patients with different levels of organ function. A MEDLINE search was conducted to identify literature published between 1966 and January 2002 relevant to the pharmacokinetics of morphine. These publications were reviewed and the literature summarized regarding unique and clinically important elements of morphine disposition relative to its parenteral administration (including intravenous, intramuscular, subcutaneous, epidural and intrathecal administration), absorption profile (immediate release, controlled release, and sublingual/buccal, and rectal administration), distribution, and its metabolism/ excretion. Special populations, including infants, elderly, and those with renal/liver failure, have a unique morphine pharmacokinetic profile that must be taken into account in order to maximize analgesic efficacy and reduce the risk of adverse events.     

手转胎头术失败的原因与分娩结局临床分析

目的 探讨手转胎头术失败的原因与分娩结局.方法 选择2008年1月至2010年12月于我院住院分娩的持续性枕横位、枕后位产妇198例,根据行手转胎头术后结果分为成功组126例、失败组72例.比较两组分娩结局,对比分析失败原因.结果 失败组胎儿体质量≥3500 g的发生率[76.4％(55/72)]明显高于成功组[31.7％(40/126)],差异有统计学意义(x2=30.177,P=0.001)、失败组宫缩乏力发生率[58.3％(42/72)]高于成功组[38.1％ (48/126)],差异有统计学意义(x2=7.569,P=0.006)、失败组骨盆临界或轻度狭窄发生率[38.9％ (28/72)]高于成功组[23.8％(30/126)],差异有统计学意义(x2 =5.030,P=0.002)、失败组手转胎头时机不当(宫口开大＜6 cm、胎头位于坐骨棘上及宫口开大8～10 cm、胎头位于坐骨棘下≥2 cm)发生率[61.1％(44/72)]高于成功组[38.9％(49/126)],差异有统计学意义(x2=9.084,P=0.003).失败组母儿并发症(产后出血、产褥病率、胎儿窘迫、新生儿窒息)发生率高于成功组(x2 =9.586,P=0.002、x2=9.334,P=0.002、x2=5.910,P=0.015、x2=5.240,P=0.022)、失败组剖宫产发生率[72.2％(52/72)]明显高于成功组[34.1 ％(43/126),x2=26.641,P=0.001)].结论 手转胎头术能使难产变顺产,降低剖宫产率,减少母儿并发症,但须积极预防、处理导致手转胎头术失败的原因,对矫正失败后继续矫正及试产应慎重.     

Evidence-Based Pain Management and Palliative Care in Issue Four for 2009 of The Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly. Issue 4 for 2009 contains 4027 complete reviews, 1906 protocols for reviews in production, and 11447 one-page summaries of systematic reviews published in the general medical literature. In addition, there are citations of 600,000 randomized controlled trials, and 12,200 cited papers in the Cochrane methodology register. The health technology assessment database contains over 7500 citations. This edition of the Library contains 90 new reviews, of which 19 have potential relevance for practitioners in pain and palliative medicine.