膝关节内骨折围手术期的系统康复

目的:探讨膝关节内骨折患者围手术期系统康复的临床疗效。方法:选择住院治疗的膝关节内骨折患者64例作为治疗组,其中股骨髁间骨折20例、胫骨平台骨折44例,于伤后7—10天实施骨折切开复位内固定手术治疗,患者入院后即开始围手术期系统康复治疗;随机选择门诊患者56例为对照组(术后自行锻炼者)。结果:治疗组:平均随访时间为6个月(3—10个月),康复疗程平均7.2±4.6周,膝关节平均屈曲115.9°±10.4°、伸直5°±6.1°,GEPI:3.1%±1.6%,HHS评分:87±17.6,全部恢复伤前工作,与对照组比较差异有显著性意义(P<0.001),无一例因术后早期康复而致骨折不愈合、内固定物松动的发生。结论:膝关节内骨折患者伤后实行围手术期、个性化、系统性康复治疗,能够促进骨折愈合、使伤肢功能障碍降低到最低程度。     

肘关节创伤术后围手术期系统康复的临床研究

目的:前瞻性地研究严重肘关节创伤患者,术后围手术期系统康复治疗。方法:选择2002年8月—2003年5月间在我院创伤骨科住院治疗的肘关节创伤患者26例为研究对象,所有入选病例均为肘部关节内骨折的患者;并于伤后7—10天实施骨折切开复位内固定手术治疗。术后第1—5天开始康复治疗;随机选择对照组30例(术后自行锻炼)。结果:治疗组患者术后康复治疗时间为4—16周、平均(8.2±4.6)周;治疗结束时患者肘关节活动范围均达到正常,Mayo肘关节评分,20例为优(总分≥90分),6例为良(总分80—89分),优良率为100%。GEPI评分:2%—10%、平均5.9%±1.9%;无一例出现内固定物松动、骨折不愈合、废用性骨质疏松的征象。结论:肘关节严重创伤术后实行围手术期、个性化、系统性康复治疗,能够促进骨折愈合、伤肢功能障碍降低到最低的程度,从而提高了严重创伤患者的生活质量,康复治疗是骨关节损伤治疗过程中必不可少的重要环节。     

关节镜监视下微创内固定治疗胫骨平台骨折的护理

目的:探讨在关节镜监视下,微创内固定治疗胫骨平台骨折的围手术期护理措施及疗效。方法:对32例各种类型胫骨平台骨折病人,术前进行心理辅导,术后严密观察病情,积极预防并发症发生,配合早期系统的康复锻炼。结果:32例病人全部获得随访,平均随访时间15.8个月,骨折均获愈合。结论:关节镜监视下微创内固定治疗胫骨平台骨折手术创伤小,固定可靠,骨折愈合率高,同时,可处理关节内合并伤,配合优质围手术期护理,术后膝关节功能恢复快。     

快速康复外科理念指导围手术期护理对四肢骨折患者术后生活质量的影响

目的 探讨以快速康复外科理念指导围手术期护理,对四肢骨折患者预后影响。方法 回顾分析2015年1月至2016年12月在甘肃省民勤县医院手术治疗的361例四肢骨折患者的临床护理资料,其中204例患者应用了快速康复理念指导围手术期护理,为观察组。另157例患者给予常规护理为对照组。比较两组患者术后并发症、不良反应、疼痛评分、住院时间,随访比较两组骨折愈合时间及生活质量。结果 观察组术后并发症及不良反应发生率均低于对照组（P<0.05）,术后住院时间及骨折愈合时间也短于对照组（P<0.05）。两组术后VAS评分均逐渐下降,但观察组低于对照组（P<0.05）。术后1、3个月观察组的生理职能、社会功能、情感职能、精神健康评分均高于对照组（P<0.05）。结论 应用围手术期快速康复外科理念指导围手术期护理可减少四肢骨折手术患者术后并发症发生率,缩短住院时间及骨折愈合时间,改善患者术后生活质量。     

股骨粗隆间骨折的手术治疗

目的：探讨手术治疗股骨粗隆间骨折临床疗效及应用价值。方法：本科自2000年1月～2005年12月采用动力髋螺钉（DHS）、股骨近端髓内钉（PFN）、动力髁螺钉（DCS）、单边外固定架治疗股骨粗隆间骨折113例，分别对每组患者的一般资料、手术方法、术后处理及并发症情况进行评估分析。结果：113例随访时间6～24个月，平均9个月。复位及内固定满意率91．0％（100／113），愈合率为95．0％（108／113），关节功能优良率96.5％（109／113）。并发髋内翻为6．0％（7／113），其中2例为髋螺钉钉位不正、1例复位不良，骨不连为4．4％（5／113），单边外固定架针道感染2例。结论：正确掌握股骨粗隆间骨折手术指征、规范手术操作、各种内固定物适应范围及完善围手术期处理，是提高治疗效果的关键。     

空心钉内固定治疗老年股骨颈骨折疗效观察

目的：评价老年股骨颈骨折空心钉内固定预后的影响因素，内固定治疗老年股骨颈骨折的可行性。方法：空心钉经皮手术内固定治疗老年股骨颈骨折62例，男25例，女37例，年龄60—85岁，平均68．65岁。无移位骨折（GardenⅠ、Ⅱ型）28例，移位骨折（GardenⅢ、Ⅳ型）34例，随访时间8—74个月，平均36．4个月。观察内容包括受伤至手术的时间、移位程度、术后早期负重及与年龄的关系。结果：无移位股骨颈骨折，骨折不愈合及股骨头缺血坏死发生率为0，移位骨折，不愈合及股骨头缺血坏死分别占8．82％（3／34）和14．71％（5／34）。伤后至手术时间超过3周，骨折不愈合的发生率增高至50％（1／2）。结论：如术前能掌握好适应证，术后给予正确的康复指导，内固定治疗老年人股骨颈骨折大多数效果良好。     

颈前路螺钉内固定术治疗齿状突骨折24例围术期护理

目的:探讨颈前路螺钉内固定术治疗齿状突骨折患者围术期护理方法.方法:对24例齿状突骨折患者行颈前路螺钉内固定术,围术期给予预见性护理及康复指导.结果:本组术后恢复顺利,手术切口一期愈合;脑脊液漏2例,喉返神经损伤1例,经对症治疗,均好转出院.结论:正确实施围术期护理是颈前路螺钉内固定术治疗齿状突骨折手术成功及术后康复的重要保证.     

动力骼螺钉治疗高龄股骨粗隆间骨折78例临床分析

目的 评估动力髋螺钉（DHS）治疗高龄股骨粗隆间骨折的临床疗效。方法 78例高龄患者使用DHS内固定，对围手术期、手术操作、术后治疗及结果进行分析。结果 患者均获随访，随访时间6～24月，骨折均愈合，优42例，良31例，可5例，髋关节优良率93，6％。结论 DHS内固定治疗高龄股骨粗隆间骨折疗效满意，只要围手术期处理得当、操作规范，可减少并发症。     

关节内跖骨头骨折的诊断及治疗分析

目的总结关节内跖骨头骨折的诊断、治疗方法及临床效果。方法2004年2月至2009年2月,收治此类女性患者11例,伤后至手术时间16h～6d,平均3d,均采用1．5舢直径AO微型自攻螺钉固定。结果术后切口均I期愈合。11例均获随访,随访时间12．5个月～5．2年,术后患侧足趾无明显疼痛,跖趾关节活动范围恢复正常。x线片检查骨折愈合良好,愈合时间为4—7周,平均5周。采用美国足与踝关节协会（American Orthopedic Foot＆Ankle Society,AOFAS）前足评分系统：获优9例,良1例,可1例,优良率占90．9％。结论1．5mm直径AO微型自攻螺钉治疗特殊型关节内跖骨头骨折方便、实用,值得推广。     

切开复位内固定治疗骨盆骨折54例临床疗效观察

目的观察切开复位固定治疗骨盆骨折的临床疗效。方法选择本院2007年4月至2009年4月收治的AO分型为B、c的不稳定骨盆骨折患者54例，以上患者均采用切开复位内固定治疗。结果本组手术平均时间（2．4±1．5）h。术中平均出血（750±150）ml。原始骨折移位为8～40mm，平均（22．5±8．7）mm。患者术后随访时间平均（12．4±6．3）月，术后骨折复位质量按Matta评分标准进行评定：优16例；良38例。功能评定按Iowa骨盆评分法评定：本组患者中，51例患者可以做以前的工作，患者家庭生活均满意；1例患者术后出现异位骨化，口服消炎痛以及局部放射治疗，异位骨化没有出现加重，不影响患者负重行走；2例股外侧皮神经损伤，术中神经吻合后6个月基本恢复。本组无骨不愈合、深部血肿及深静脉血栓发生。结论早期手术内固定治疗骨盆骨折可以尽早恢复骨盆稳定度，明显降低死亡率和致残率，提高后期功能。同时，稳固的内固定使并发伤治疗问题更易解决，更利于多发伤的治疗。     

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.     

Dissociable correlates of two classes of retrieval processing in prefrontal cortex

Although substantial evidence suggests that the prefrontal cortex (PFC) implements processes that are critical for accurate episodic memory judgments, the specific roles of different PFC subregions remain unclear. Here, we used event-related functional magnetic resonance imaging to distinguish between prefrontal activity related to operations that (1) influence processing of retrieval cues based on current task demands, or (2) are involved in monitoring the outputs of retrieval. Fourteen participants studied auditory words spoken by a male or female speaker and completed memory tests in which the stimuli were unstudied foil words and studied words spoken by either the same speaker at study, or the alternate speaker. On "general" test trials, participants were to determine whether each word was studied, regardless of the voice of the speaker, whereas on "specific" test trials, participants were to additionally distinguish between studied words that were spoken in the same voice or a different voice at study. Thus, on specific test trials, participants were explicitly required to attend to voice information in order to evaluate each test item. Anterior (right BA 10), dorsolateral prefrontal (right BA 46), and inferior frontal (bilateral BA 47/12) regions were more active during specific than during general trials. Activation in anterior and dorsolateral PFC was enhanced during specific test trials even in response to unstudied items, suggesting that activation in these regions was related to the differential processing of retrieval cues in the two tasks. In contrast, differences between specific and general test trials in inferior frontal regions (bilateral BA 47/12) were seen only for studied items, suggesting a role for these regions in post-retrieval monitoring processes. Results from this study are consistent with the idea that different PFC subregions implement distinct, but complementary processes that collectively support accurate episodic memory judgments.     

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.     

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.