股骨干骨折--扩髓和不扩髓髓内钉比较

治疗股骨干骨折，采用不扩髓髓内钉比扩髓髓内钉手术时间明显缩短，而且失血也少。但是，扩髓钉的骨愈合更快，延迟愈合更少。两者都没有显著增加包括肺损害等其它并发症的风险。功能结果不能确定。     

扩髓与不扩髓交锁髓内钉治疗胫骨骨折的比较

目的比较交锁髓内钉扩髓与不扩髓治疗闭合性胫骨骨折的临床疗效。方法对72例闭合性胫骨骨折患者随机采用扩髓与不扩髓交锁髓内钉固定，扩髓与不扩髓组均为36例患者，根据术前术中术后的临床数据来比较其治疗结果。结果两组患者在性别、年龄以及骨折类型方面均有可比性。扩髓组手术时间平均51min，明显长于不扩髓组的40min。扩髓组17周愈合，不扩髓组25周愈合。两组间差异有显著性，P〈0．05。扩髓组有1例出现术后锁钉断裂，不扩髓组为6例，P〈0．05，两组差异有显著性。两组均没有感染病例。扩髓组延迟愈合3例，畸形愈合2例；不扩髓组延迟愈合5例，畸形愈合3例，两组无显著性差异。结论治疗闭合性胫骨骨折，扩髓交锁髓内钉在疗效上要优于不扩髓。     

扩髓与非扩髓带锁髓内钉治疗开放性胫骨骨折的疗效比较

目的 比较扩髓与非扩髓带锁髓内钉治疗开放性胫骨骨折的临床疗效。方法 对64例共67侧开放性胫骨骨折采用带锁髓内钉治疗，其中非扩髓组36侧，扩髓组31侧。伤口愈合拆线后扶拐下地活动，术后定期随访6个月-1年。结果 非扩髓组与扩髓组局部感染率分别是13．9％和12．9％(P＞0．05)，无全身感染；非扩髓组5例锁钉断裂，扩髓组无断钉；非扩髓组与扩髓组平均骨折愈合时间分别为22．5周和17．2周(P＜0．05)。延迟愈合分别为5例、3例，非扩髓组有1例骨折不愈合。结论 与非扩髓组比较，扩髓带锁髓内钉具有骨折固定强度大、骨折愈合快、延迟愈合或不愈合少，感染率没有明显升高。     

扩髓与非扩髓髓内钉术中小腿后深间室压力观察

目的：通过扩髓与非扩髓髓内钉术中小腿后深间室压力观察。比较两者对小腿筋膜间室压力的影响。方法：闭合复交锁髓内钉治疗胫骨骨折33例。扩髓组17例，非扩髓组16例，记录麻醉后牵引前，牵引后，术前，进钉，锁钉，锁钉，手术后小腿后深间室压力，扩髓组记录插导针、依次扩髓时的压力。健肢在麻醉后，术后测压对比，结果：受伤后肢体的后深间深室压力均大于健侧肢体（P＜0．05），扩髓时小腿后深间室夺力急剧升高（33－109mmHg）。扩髓后压力有所下降，但进钉时由升高至最高峰（31－114mmHg)。非扩髓组进钉时小腿后深间压力相比较小，髓内钉进入髓腔后锁钉时，扩髓组压力比扩髓组压力低（无统计学差异），术后小腿后深间室压力都下降至接近术前，结论：虽然闭合复合 内钉插入，扩髓时会导致小腿筋膜间室压力增高，但是短暂的，同时扩髓与非扩髓对小腿筋膜间室压力的影响基本一致，无统计学差异。     

扩髓与非扩髓带锁髓内钉治疗开放性胫骨骨折的疗效比较

目的　比较扩髓与非扩髓带锁髓内钉治疗开放性胫骨骨折的临床疗效。方法　对 6 4例共 6 7侧开放性胫骨骨折采用带锁髓内钉治疗 ,其中非扩髓组 36侧 ,扩髓组 31侧。伤口愈合拆线后扶拐下地活动 ,术后定期随访 6个月～ 1年。结果　非扩髓组与扩髓组局部感染率分别是 13 9%和 12 9% (P >0 0 5 ) ,无全身感染 ;非扩髓组 5例锁钉断裂 ,扩髓组无断钉 ;非扩髓组与扩髓组平均骨折愈合时间分别为 2 2 5周和 17 2周 (P <0 0 5 )。延迟愈合分别为 5例、 3例 ,非扩髓组有 1例骨折不愈合。结论　与非扩髓组比较 ,扩髓带锁髓内钉具有骨折固定强度大、骨折愈合快、延迟愈合或不愈合少 ,感染率没有明显升高     

扩髓与非扩髓带锁髓内钉治疗开放性胫骨骨折

目的比较扩髓与非扩髓型带锁髓内钉治疗开放性胫骨骨折的临床疗效。方法对86例共92侧开放性胫骨骨折采用带锁髓内钉治疗,其中扩髓组54侧,非扩髓组38侧。伤口拆线后扶拐下地活动,术后定期随访6个月～2年。结果扩髓组与非扩髓组局部感染率分别是20．3％和5．3％（P〈0．05）;扩髓组与非扩髓组平均骨折愈合时间分别为22．5周和19周（P〉0．05）;延迟愈合分别为8例,3例。结论与扩髓组比较,非扩髓带锁髓内钉延迟愈合或不愈合少,感染率低,两组平均骨折愈合时间无明显差异。     

股骨干骨折扩髓与不扩髓固定对肺气体交换功能的影响

目的 :探讨股骨干骨折髓内钉固定过程中扩髓与不扩髓对肺气体交换功能的影响。方法 :38例股骨干骨折分别采用扩髓和不扩髓交锁钉内固定 ,术中不同时间段进行动脉血气分析 ,计算肺泡死腔分数 (Vd/Vt)、氧合指数(PaO2 /FiO2 )。结果 :扩髓组 ,髓腔扩大后Vd/Vt增加 (p <0 .0 5 ) ;PaO2 /FiO2 降低 (p <0 .0 1) ;不扩髓组 ,插入髓钉后30minVd/Vt增加 ( p <0 .0 5 ) ,PaO2 /FiO2 降低 ( p <0 .0 1) ,髓内钉插入后 6 0min时二者在 2组间均恢复正常 ;扩髓后 2组间Vd/Vt、PaO2 /FiO2 差异具有显著性 ,其它时间段 2组间无差异 ;动脉血气分析 ,各时间段和组间差异无显著性。结论 :扩大髓腔的髓内钉固定 ,并不影响肺气体交换功能 ,股骨干骨折患者血流动力学稳定时 ,能耐受扩髓髓内钉固定手术。     

扩髓和不扩髓交锁髓内钉治疗胫骨干闭合性骨折

用交锁钉作髓内固定是治疗胫骨干闭合性骨折的常用方法。有人认为打入不扩髓、直径小的髓内钉,骨骼的血供保留得好、恢复得快。与扩髓相比,不扩髓能促进骨折愈合,不容易发生感染,打钉简便快捷,很少发生脂肪栓塞。但是直径小的髓内钉也有缺点:髓内钉或螺钉较易发生断裂或固定不牢靠而妨碍骨折愈合。本     

髓内钉治疗股骨干骨折扩髓与不扩髓的比较研究

目的探讨非扩髓钉是否比扩髓钉操作简单、迅速、安全。方法用前瞻性随机研究方法将100例单纯股骨干骨折随机分为扩髓组与非扩髓组,比较二组的手术时间、失血量、手术中意外情况的发生。结果扩髓组37例手术时间138min,失血量278ml,6例术中发生意外情况。非扩髓组63例,手术时间108min(P=0．012),失血量186ml(P=0．034)。17例术中发生意外情况,2例需二次手术。结论非扩髓钉操作步骤少,手术时间及失血量少于扩髓组,但非扩髓组手术中意外情况发生较多,虽然统计学差异不显著。     

不扩髓带锁髓内钉治疗胫骨开放性骨折

目的总结胫骨开放性骨折应用不扩髓带锁髓内钉内固定治疗的经验及体会。方法对52例胫骨开放性骨折行清创复位不扩髓带锁髓内钉内固定。结果50例患者取得随访半年以上，骨折全部愈合，膝踝关节功能完全恢复正常。结论不扩髓带锁髓内钉内固定治疗胫骨开放性骨折固定坚强，操作简单，并发症少，功能恢复良好，疗效确切，结果令人满意。     

Tibial fractures Reamed versus unreamed intramedullary nailing

AMEDLINEsearchwasperformedtoidentifystudiespublishedfromJanuary1997toNovember2003com-paringreamedintramedullary(IM)nailingwithun-reamedIMnailingfortibialfractures.Fromalistof16articles,threerandomizedclinicaltrialscomparingreamedIMnailingtounreamedIMnailingwereidentified.Weincludedstudiesexaminingbothopenandclosedtibialfractures.Weexcludedanalysesofnonrandomizedtrials.StudiesStudy1KeatingJF,OBrienPJ,BlachutPA,etal(1997)Lockingintramedullarynailingwithandwithoutreamingforopenfractur…     

Development of quality indicators: lessons learned in bariatric surgery

Quality indicators will likely be used in comprehensive surgical quality assessment and improvement programs. Quality indicators are the actions equated with good quality of care. As a case example, bariatric surgery quality indicators were developed using evidence in the literature combined with formal expert opinion validation. Qualitative analysis was performed to identify the critical thematic issues surrounding development of these surgical quality indicators. Researchers identified five major thematic categories during the development process. These included feasibility in medical records (availability, ease of abstraction, and cost), the number of indicators developed (optimal number), the lack of evidence in the literature (weight on expert opinion), structural versus process indicators, and linkage to outcomes (need to demonstrate that adherence to indicators is associated with better outcomes). This project, using bariatric surgery as an example, uncovered important issues that need to be addressed when developing quality assessment and quality improvement programs for evaluating surgical quality. As quality indicators will likely be developed and used increasingly, future projects in this regard will benefit from these lessons.     

Improving quality of recovery: what anaesthetic techniques make a difference?

Practising evidence-based medicine in anaesthesia can be difficult. Minor, transient complications are common after anaesthesia and surgery and these may or may not have a significant effect on patient outcome, including overall quality of recovery. Most anaesthesia research does not provide reliable information about effective interventions. Nevertheless, good quality evidence from randomized trials and systematic reviews is available, and their uptake into clinical practice should reduce serious or permanent complications. Most patients do not suffer major complications and so their quality of recovery needs to be defined in other ways and this should be assessed from the patient's perspective. Thus, a good outcome can be defined by avoidance of major complications and the experience of a good quality recovery. Changes in clinical practice should be evidence-based and this requires the conduct of good quality clinical research, including large trials. This paper identifies some anaesthetic techniques that do make a difference; these should be part of routine practice.     

Clinical audit,quality improvement and data quality

Clinical audit and quality improvement are essential processes that help to ensure that patients receive safe, effective, and high-quality care. By participating in clinical audit and quality improvement initiatives, anaesthetists can gain a deeper understanding of the care provided to patients and identify areas for improvement. Ensuring good data quality is crucial for these processes, and can be achieved by following a systematic approach to data management, including training on data collection and management techniques, strict data validation procedures and regular data quality checks. Additionally, involving patients, staff, and other stakeholders in the process can help to ensure that changes are well received and implemented effectively. By participating in these processes, we can contribute to the ongoing efforts to improve the quality of care provided by the NHS, and develop the skills and knowledge necessary for continuing professional development.     

Surgical prophylaxis and other complication avoidance care bundles

Individual health care quality measures that have been shown to improve outcome can be combined together into what are called care bundles, with the expectation that this set of practices produces further improvements in outcome. Prevention of surgical site infection is the focus of several quality measures put forward by the Surgical Care Improvement Project; these can collectively be considered a bundle as well. Whether these process measures, which include several components related to the administration of antibiotic prophylaxis, are effective in decreasing rates of surgical site infection has come under considerable debate recently.     

Novel Raman Spectroscopic Biomarkers Indicate That Postyield Damage Denatures Bone's Collagen

Raman spectroscopy has become a powerful tool in the assessment of bone quality. However, the use of Raman spectroscopy to assess collagen quality in bone is less established than mineral quality. Because postyield mechanical properties of bone are mostly determined by collagen rather than the mineral phase, it is essential to identify new spectroscopic biomarkers that help infer the status of collagen quality. Amide I and amide III bands are uniquely useful for collagen conformational analysis. Thus, the first aim of this work was to identify the regions of amide bands that are sensitive to thermally induced denaturation. Collagen sheets and bone were thermally denatured to identify spectral measures that change significantly following denaturation. The second aim was to assess whether mechanical damage denatures the collagen phase of bone, as reflected by the molecular spectroscopic biomarkers identified in the first aim. The third aim was to assess the correlation between these new spectroscopic biomarkers and postyield mechanical properties of cortical bone. Our results revealed five peaks whose intensities were sensitive to thermal and mechanical denaturation: ～1245, ～1270, and ～1320 cm^–1 in the amide III band, and ～1640 and ～1670 cm^–1 in the amide I band. Four peak intensity ratios derived from these peaks were found to be sensitive to denaturation: 1670/1640, 1320/1454, 1245/1270, and 1245/1454. Among these four spectral biomarkers, only 1670/1640 displayed significant correlation with all postyield mechanical properties. The overall results showed that these peak intensity ratios can be used as novel spectroscopic biomarkers to assess collagen quality and integrity. The changes in these ratios with denaturation may reflect alterations in the collagen secondary structure, specifically a transition from ordered to less‐ordered structure. The overall results clearly demonstrate that this new spectral information, specifically the ratio of 1670/1640, can be used to understand the involvement of collagen quality in the fragility of bone. © 2015 American Society for Bone and Mineral Research.     

New laboratory tools in the assessment of bone quality

Bone quality is a complex set of intricated and interdependent factors that influence bone strength. A number of methods have emerged to measure bone quality, taking into account the organic or the mineral phase of the bone matrix, in the laboratory. Bone quality is a complex set of different factors that are interdependent. The bone matrix organization can be described at five different levels of anatomical organization: nature (organic and mineral), texture (woven or lamellar), structure (osteons in the cortices and arch-like packets in trabecular bone), microarchitecture, and macroarchitecture. Any change in one of these levels can alter bone quality. An altered bone remodeling can affect bone quality by influencing one or more of these factors. We have reviewed here the main methods that can be used in the laboratory to explore bone quality on bone samples. Bone remodeling can be evaluated by histomorphometry; microarchitecture is explored in 2D on histological sections and in 3D by microCT or synchrotron. Microradiography and scanning electron microscopy in the backscattered electron mode can measure the mineral distribution; Raman and Fourier-transformed infra-red spectroscopy and imaging can simultaneously explore the organic and mineral phase of the matrix on multispectral images; scanning acoustic microscopy and nanoindentation provide biomechanical information on individual trabeculae. Finally, some histological methods (polarization, surface staining, fluorescence, osteocyte staining) may also be of interest in the understanding of quality as a component of bone fragility. A growing number of laboratory techniques are now available. Some of them have been described many years ago and can find a new youth; others having benefited from improvements in physical and computer techniques are now available.     

Quality of life in end-stage renal disease: a reexamination

A self-administered questionnaire assessing both objective and subjective quality of life was completed by 489 end-stage renal disease (ESRD) patients in a representative sample of an entire network. Patients differed in both objective and subjective quality of life when examined as a function of treatment modality. The quality of life is similar for successful transplant and home hemodialysis patients; these patients appear to fare better than other treatment groups on both objective and subjective measures. Patients receiving staff-assisted center hemodialysis and continuous ambulatory peritoneal dialysis (CAPD) report markedly diminished quality of life; these decrements remained after statistically controlling for nontreatment variables. Diminished quality of life was most pronounced in dialysis patients who had experienced failed transplants. All treatment groups showed some objective losses, especially loss of employment, but patients in the best rehabilitated treatment groups showed near-normal subjective quality of life. The results confirm previous reports that the subjective quality of life of ESRD patients can be nearly normal despite objective losses, but demonstrate that inadequate definition of treatment groups has led to misperceptions about the impact of transplant failure.     

Utility of Ecological Risk Factors for Evaluation of Transplant Center Performance

There is substantial evidence across different healthcare contexts that social determinants of health are strongly associated with morbidity and mortality in the United States. These factors, including socioeconomic status, behavior and environmental risks, education, social support, healthy food, and access to healthcare also vary widely by region and individual communities. One of the implications of heterogeneity in these risks is the potential impact on measured quality of healthcare providers. In particular, there is concern that providers treating disproportionally vulnerable communities may be disadvantaged by lack of risk adjustment for these factors that affect health but not indicators of quality of care. Recently, the National Quality Forum has endorsed risk adjustment for sociodemographic characteristics based on these concerns. These issues are salient to transplant programs since social determinants of health impact transplant patient outcomes and vary by region. In this viewpoint, we argue that integration of ecological (area‐level) factors in risk adjustment models used to assess transplant center quality should be strongly considered. We believe this reform could be accomplished rapidly, would attenuate disparities in access to care by reducing disincentives to treat patients from vulnerable communities, and improve risk adjustment and calibration of models used for center evaluations.     

Quality of life following prostate cancer treatments

Quality of life is of major concern to patients when choosing a treatment for prostate cancer. Health-related quality of life (HRQOL) is a patient-centered variable from the field of health services research that can be assessed in a valid and reliable manner. Using standardized questionnaires specifically designed to measure HRQOL in men with prostate cancer, we can now study the effect of various treatments on patients’ quality of life. Treatments for metastatic prostate cancer can have significant effects in all areas of patients’ quality of life. Patients with localized disease undergoing radical prostatectomy (RP) tend to have more sexual and urinary dysfunction than do men undergoing external beam radiation therapy (EBRT), although both groups have worse quality of life in these areas than age-matched controls. Men undergoing EBRT have worse bowel function than age-matched controls or men undergoing RP. Recent studies of men undergoing interstitial brachytherapy indicate that these patients have less urinary leakage than those who undergo RP, but experience considerably more irritative voiding symptoms, which can profoundly affect quality of life. Patients need to be informed of the possible impact of therapy on quality of life when choosing treatment.