超声诊断孕早期联体双胎畸形的价值

目的:分析联体双胎的超声图像特点,提高超声诊断联体双胎的准确率。方法:回顾性分析西北妇女儿童医院经超声诊断并随访确诊的16例联体双胎的超声资料,经二维超声观察联体胎儿的连接部位、共用脏器、融合程度,并用彩色多普勒超声观察脐血流以及合并畸形的胎儿心血管情况。结果:16例联体双胎畸形中,双头联合11例(68.75%),其中7例胸腹腔联合、2例胸腹腔+骶尾部脊柱联合、2例仅腹腔联合;并头联合4例(25.00%),其中2例合并胸腹腔联合、2例仅头部联合;臀部联合1例(6.25%)。5例合并其他畸形:2例合并颈部水囊瘤(其中1例双胎儿均合并心脏畸形),1例合并无叶全前脑,1例合并上肢桡骨缺如,1例合并小下颌。结论:对于联体双胎应做到尽早诊断并终止妊娠,彩色多普勒超声能直接显示羊膜腔内联体胎儿的连接部位、共用脏器、融合程度及合并畸形,对判断预后具有重要意义。     

Optimal timing of joint replacement using mathematical programming and stochastic programming models

The optimal timing for performing radical medical procedures as joint (e.g., hip) replacement must be seriously considered. In this paper we show that under deterministic assumptions the optimal timing for joint replacement is a solution of a mathematical programming problem, and under stochastic assumptions the optimal timing can be formulated as a stochastic programming problem. We formulate deterministic and stochastic models that can serve as decision support tools. The results show that the benefit from joint replacement surgery is heavily dependent on timing. Moreover, for a special case where the patient's remaining life is normally distributed along with a normally distributed survival of the new joint, the expected benefit function from surgery is completely solved. This enables practitioners to draw the expected benefit graph, to find the optimal timing, to evaluate the benefit for each patient, to set priorities among patients and to decide if joint replacement should be performed and when.     

Joint Longitudinal Models for Dealing With Missing at Random Data in Trial-Based Economic Evaluations

ObjectivesIn trial-based economic evaluation, some individuals are typically associated with missing data at some time point, so that their corresponding aggregated outcomes (eg, quality-adjusted life-years) cannot be evaluated. Restricting the analysis to the complete cases is inefficient and can result in biased estimates, while imputation methods are often implemented under a missing at random (MAR) assumption. We propose the use of joint longitudinal models to extend standard approaches by taking into account the longitudinal structure to improve the estimation of the targeted quantities under MAR.MethodsWe compare the results from methods that handle missingness at an aggregated (case deletion, baseline imputation, and joint aggregated models) and disaggregated (joint longitudinal models) level under MAR. The methods are compared using a simulation study and applied to data from 2 real case studies.ResultsSimulations show that, according to which data affect the missingness process, aggregated methods may lead to biased results, while joint longitudinal models lead to valid inferences under MAR. The analysis of the 2 case studies support these results as both parameter estimates and cost-effectiveness results vary based on the amount of data incorporated into the model.ConclusionsOur analyses suggest that methods implemented at the aggregated level are potentially biased under MAR as they ignore the information from the partially observed follow-up data. This limitation can be overcome by extending the analysis to a longitudinal framework using joint models, which can incorporate all the available evidence.     

回旋扣压法治疗肩关节脱位

目的:探讨肩关节脱位的简易复位方法。方法:对1990～2002年门诊治疗的27例肩关节脱位行回旋扣压法复位进行回顾性分析。结果:27例新鲜或习惯性肩关节脱位经回旋扣压法复位,非麻醉下复位成功19例,首次复位失败经臂丛麻醉后复位成功6例。结论:应用回旋扣压法对肩关节脱位进行复位方法简单,可单人非麻醉下进行,动作温柔,能减少患者的紧张情绪,特别适用于新鲜或习惯性肩关节脱位。操作中不使用暴力,有四两拨千斤之功效。     

一起人感染H5N6禽流感疫情处置探讨传染病联防联控合作机制

目的 探讨传染病联防联控合作机制在突发公共卫生事件处置中的作用,为区域性联防联控合作机制提供参考。方法 对江西省赣州市1起输入性人感染H5N6禽流感疫情进行回顾性分析,总结赣粤两省传染病联防联控机制在病例感染来源调查、密切接触者追踪排查、信息沟通和风险监测等方面经验。结果 以传染病联防联控合作机制为依托,赣粤两省共同完成了本起疫情的流行病学调查,实现了突发公共卫生事件联防联控和风险沟通机制的高效畅通。本次事件为偶发个案,感染来源可能与活禽市场暴露有关,密切接触者未出现H5N6禽流感病毒感染。结论 在赣粤区域性联防联控合作机制基础上,实现传染病防控合作常态化运作,不断完善突发公共卫生事件联防联控和风险沟通机制,务实赣粤两地联合应对突发公共卫生事件基础。     

化脓性骶髂关节炎CT表现（附5例报告）

目的探讨化脓性骶髂关节炎的CT表现。方法回顾性分析经临床、CT确诊的5例化脓性骶髂关节炎的临床资料和CT表现。结果5例化脓性骶髂关节炎均为单侧发病，3例病变位于右侧骶髂关节，2例位于左侧。CT表现为荚节面模糊、骨质破坏、骨质增生硬化、关节间隙增宽。其中3例可见斑点状、短条状死骨，5例均可见关节囊肿胀，1例可见周围软组织脓肿形成。结论CT可清楚显示骶髂关节及其周围结构，对化脓性骶髂关节炎的诊断可提供可靠的信息。     

Summary of the practice guideline 'Rheumatoid arthritis' (first revision) from the Dutch College of General Practitioners

The guideline covers the evaluation of patients with one or more painful joints without previous injury and focuses on the distinction between rheumatoid arthritis and other joint complaints. In the case of rheumatoid arthritis, the arthritis is based on aseptic synovitis and is nearly always associated with tenderness, warmth, swelling, and impaired function. Redness is not present in most cases. The diagnosis is primarily made on the basis of the case history and physical examination. Laboratory tests and X-ray are only of secondary importance. NSAIDs are recommended as the initial treatment for patients with rheumatoid arthritis or serious indications for this. If the arthritis does not settle within a period of 6 to 12 weeks after the onset of the complaints, the patient should be referred to a rheumatologist to start treatment with one or more disease-modifying antirheumatic drugs (DMARDs). DMARDs suppress the activity of the disease and can prevent joint damage. However, which combination of DMARDs gives the best results is still unclear.     

A conceptual framework for evaluating joint venture opportunities between hospitals and physicians.

This paper reviews the changes in the competitive and regulatory environment and examines the impact of those changes on the relationships between hospitals and physicians. Transaction cost economics (TCE) provides a conceptual framework for examining the emergence of closer linkages between hospitals and physicians than the traditional independent hospital and medical staff organisations. TCE predicts that as investments in support of transactions become more specialised, closer linkages are more efficient. To illustrate, two case studies of successful hospital-physician joint ventures are presented. The first case study describes a joint venture between hospitals and physicians to purchase durable medical equipment. The second case describes the breakdown of an informal arrangement and the subsequent formation of a joint venture to organise a clinical programme. The discussion reports the rationale for choosing these structural arrangements and their key features, pointing out how TCE would account for the decision to establish a joint venture. The conclusion discusses the implications of this argument for the strategic decisions of health care managers.     

腹腔镜联合胆道镜在胆囊结石合并胆总管结石治疗中的应用

目的：总结腹腔镜联合胆道镜治疗胆囊结石合并胆总管结石的经验。方法：回顾性分析2006年6月-2012年5月本院收治的采用腹腔镜联合胆道镜治疗的56例胆囊结石合并胆总管结石患者的临床资料。结果：Ⅰ期缝合胆总管20例,术后发生胆漏1例;放置T管引流36例,术后发生水肿性胰腺炎和胆漏各1例,均经保守治疗痊愈。结论：腹腔镜联合胆道镜治疗胆囊结石合并胆总管结石对患者创伤小,效果好,且安全可靠,值得临床推广。     

Joint modeling of medical cost and survival in complex sample surveys

Medical cost data are typically highly skewed to the right with a large proportion of zero costs. It is also common for these data to be censored because of incomplete follow‐up and death. In the case of censoring due to death, it is important to consider the potential dependence between cost and survival. This association can occur because patients who incur a greater amount of medical cost tend to be frailer and hence are more likely to die. To handle this informative censoring issue, joint modeling of cost and survival with shared random effects has been proposed. In this paper, we extend this joint modeling approach to handle a final feature of many medical cost data sets, i.e., Specifically, the fact that data were obtained via a complex survey design. Specifically, we extend the joint model by incorporating the sample weights when estimating the parameters and using the Taylor series linearization approach when calculating the standard errors. We use a simulation study to compare the joint modeling approach with and without these adjustments. The simulation study shows that parameter estimates can be seriously biased when information about the complex survey design is ignored. It also shows that standard errors based on the Taylor series linearization approach provide satisfactory confidence interval coverage. The proposed joint model is applied to monthly hospital costs obtained from the 2004 National Long Term Care Survey. Copyright © 2012 John Wiley & Sons, Ltd.     

Monoarticular pseudogout of the hip: a case report

Monoarticular pseudogout is a rare cause of acute hip pain, and may mimic hip joint infection. We present a case of monoarticular pseudogout in an 85-year-old woman. Diagnosis was confirmed with hip joint aspiration and crystal analysis. The patient was treated with intra-articular corticosteroids, and her symptoms resolved.     

Osteochondromatosis of the hip joint. Report of a cast.

Osteochondrmatosis of the hip is a rare disease in which segments of synovial membrane become cartilaginous. These may calcify or ossify forming osteocartilaginous masses as loose bodies. It occurs most often in young or middle-aged adults and the etiology of the condition is unknown. The diagnosis can be apparent with due consideration on clinical history and proper X-ray examination of the joint. One case of such disease with typical X-ray findings is reported.     

Biomechanical analysis of the load on the intercondylar surface of the knee joint in frontal projection

The article is intended for experts on biomechanics, traumatologists, and orthopedists working in the field of the large joint pathology treatment. The method for analysis of the load on the knee joint presented in this article makes it possible to predict development of local necrosis of the joint surface caused by abnormal biomechanical axis of the lower extremity. The method also allows the necrosis center location to be determined with sufficient accuracy. Besides, the article provides a theoretical basis for preoperative design in the case of operative correction of the biomechanical axis of the leg intended to optimize the intense-deformed condition of the knee joint.     

案例分析教学联合病房见习提高临床示教质量与效果研究

目的：探讨案例分析教学联合病房见习在提高临床示教质量的应用效果。方法将案例分析法应用于外科教学见习课中,经老师授课、见习讨论的模式将病例讨论引入见习教学中,通过临床能力测评及问卷调查表学生意见反馈探讨该方法应用的教学效果。结果实验组理论考试成绩和案例诊断技能考试成绩均好于对照组（P〈0.01）,问卷调查结果显示：大多数学生支持典型案例教学法。结论案例分析教学联合病房见习在提高临床示教质量与效果上具有较好的成效,值得推广。     

自体骨-髌腱移植重建膝关节交叉韧带恢复本体感觉的术后护理

目的探讨膝关节前交叉韧带重建后,本体感觉恢复的护理。方法通过关节镜下膝关节自体骨-髌腱移植重建损伤前交叉韧带,探讨本体感觉恢复及术后康复的护理。结果本组20例均得到6～18个月随访,术后膝关节功能活动恢复正常,平均恢复时间5周。2例剧烈活动后膝部有酸胀感;12例患者自诉膝关节不稳消失;1例患者抽屉试验阳性,但无膝关节不稳,可能与术后被动活动有关。结论术后积极的护理干预和康复指导可早日恢复损伤的前交叉韧带功能,促进膝关节本体感觉的恢复。     

高频彩超诊断腱鞘囊肿的应用

目的探讨高频彩超诊断腱鞘囊肿的应用价值。方法对彩超诊断腱鞘囊肿86例患者在本院手术并经过病理证实的声像图资料进行回顾分析。结果腱鞘囊肿83例,符合率为96．5％;其中手腕部54例,踝关节周围20例,手指关节6例,膝关节3例。另有腱鞘巨细胞瘤2例,神经鞘瘤1例,共3例误诊为腱鞘囊肿,误诊率占3．4％。结论彩超诊断腱鞘囊肿无创伤、无放射、操作片便、符合率高,为临床确定治疗方案提供有利依据。     

Analysis of case-crossover designs

The case-crossover design provides a means to study the effects of transient exposures on the risk of acute illness, for example, the effects of drinking alcohol on the immediate risk of a heart attack. Only cases are required by the design, since each case is effectively its own control; what a case was doing at the time of an acute event is compared with what the case would have been doing usually. Maclure has described an approach based on the Mantel–Haenszel method of analysis. It is shown here how the analysis of case-crossover designs can be achieved by a method of maximum likelihood. The method is quite general and, in principle, can be used to analyse the joint effects of many transient exposures. For binary exposures the Mantel–Haenszel approach is an approximate solution to the likelihood equations. In practice, case-crossover designs are limited by the information available on each case's ‘usual’ behaviour. Extracting such information requires in-depth questioning, but, in principle, it can be obtained. To do so requires careful questionnaire design. The approach is illustrated by analysis of 24 hour alcohol consumption and the risk of myocardial infarction. The problem with this analysis is how to estimate the probability of what a case would ‘usually’ have been doing from information on drinking frequency.     

关节镜下腘绳肌腱移植重建前交叉韧带的疗效分析

目的探讨关节镜下腘绳肌腱移植重建前交叉韧带术后对膝关节稳定性和运动功能的影响。方法对45例前交叉韧带胫损伤的患者分别进行关节镜下腘绳肌腱移植重建,术后定期随访,按Ly-sholm膝关节功能评分和IKDC膝关节功能评分对术后膝关节功能进行评估,判断患肢整体功能恢复情况。结果IKDC膝关节损伤功能评分结果表明,关节镜下腘绳肌腱移植重建前交叉韧带取得了较好的膝关节稳定性和运动功能,膝关节活动范围正常,关节功能良好;关节镜下重建术后6个月Lysholm膝关节功能评分为(91.2±3.4)分,术后1年Lysholm膝关节功能评分(93.1±4.7)分。结论关节镜下腘绳肌腱移植重建前交叉韧带是前交叉韧带损伤的重要治疗手段,术后可获得良好的膝关节功能和稳定性。     

Patients as partners in a health research agenda setting: the feasibility of a participatory methodology

This article deals with the participation of patients in setting the agenda of health research that potentially directly affects their lives. The focus is on the communication problems encountered between lay people and medical professionals in developing a joint research agenda. The author argues that a participatory methodology can address these problems and thereby give patients "a say" in the types of health research that have the greatest chance of affecting them personally. The article uses a case example of people with spinal cord injuries participating in research to support the importance and value of patient participation. The case example also helps to rethink appropriate methodologies or at least to modify existing approaches by paying more attention to required social conditions, diversity, and the life world of patients to foster meaningful participation.