食管穿孔83例分析

８３例不同原因引起的食管穿孔，保守治疗５７例；手术２６例，行单纯食管修补术２０例、开胸行纵隔和／或胸腔引流２例、切除贲门肿物行胃食管吻合１例、颈部食管外置２例（其中１例并行二期结肠代食管手术）、１例开胸取异物形成食管瘘后，行二期修补瘘术。全组死亡８例，其中死于纵隔胸腔感染和主动脉破裂出血各４例。总治愈率８５％。并指出异物假牙造成食管穿孔的重要性，对严重的腐蚀性食管灼伤应早期行食管镜检，并针对食管穿孔部位、种类、间隔期、纵隔与胸腔的感染程度及病人具体情况采取相应的治疗措施。     

不同方法重建指尖离断静脉回流的疗效分析

目的：探讨不同方法重建指尖离断静脉回流的疗效。方法：2008年3月-2013年2月收治指尖离断患者80例,38例吻合指侧方静脉重建回流,术中吻合动静脉比例1：1或1：2或2：2,平均1：2;22例吻合指腹静脉重建回流,术中吻合动静脉比例1：1;20例未吻合静脉,术中仅吻合1条动脉,行侧切口或甲床放血。观察各组治疗效果。结果：吻合指侧方静脉组手指全部成活,无一例发生回流障碍;吻合指腹静脉组19例发生静脉危象,其中4例手指坏死;未吻合静脉组20例均发生回流障碍,其中6例手指坏死。58例获随访,随访时间6~28个月。吻合指侧方静脉组32例,指尖外形佳、指腹饱满;吻合指腹静脉组14例,指体轻度萎缩,指甲生长不平整;未吻合静脉组12例,指体萎缩明显。吻合指侧方静脉组指甲生长近平整,长度长于其他两组[（14.4±3.2）mm比（12.5±2.3）mm和（12.2±2.2）mm],远侧指间关节活动度大于其他两组[（63±5）°比（48±3）°和（45±7）°],两点分辨觉小于其他两组[（4.6±0.4）mm比（7.1±1.2）mm和（7.3±0.6）mm],感觉级别高于其他两组[S（3.45±0.39）级比S（2.57±0.42）级和S（2.55±0.49）级],差异均具有显著性（P〈0.05）。吻合指腹静脉组和未吻合静脉组在指甲长度、运动和感觉方面差异无统计学意义（P〉0.05）。结论：吻合指侧方静脉能有效解决指尖再植静脉回流问题,可避免回流障碍,成活率高,促进指甲生长,可恢复 DIPJ 活动度及感觉。     

Clinico-morphological basis of selection of the methods of treatment of echinococcosis of the abdominal organs and retro- peritoneal space

The work is based on the analysis of surgical treatment of 2,985 patients with hydatid diseases of the organs of the abdominal cavity and retroperitoneal space. The character of the operative intervention is determined by the period of hydatid vital activity, its size, and the features of its localization within the organ. The authors identified the following periods of hydatid vital activity: living parasite, dead parasite; complicated echinococcosis. Organ preserving operations are indicated in subcortical localization of the hydatid in the liver, in one of the poles of the spleen and in the kidney when the fibrous capsule is well preserved. Splenectomy or nephrectomy must be carried out in large and giant hydatids of the spleen and kidney localized in the organ or in its hilus and in irreversible changes in the organ. Open echinococcectomy is indicated in suppuration of large hydatids in the subdiaphragmatic space in occasional cases.     

《护理学基础》全英语教学实施效果评价

目的探讨护理专业基础课《护理学基础》全英语教学的效果,为临床护理课程全英语教学或双语教学打下基础。方法对2001级英语护理专业本科生31人实施《护理学基础》课程的全英语教学,包括理论课教学、实验操作训练辅导,同时作业、实验报告、测验考试等全部使用英语。结果学生理论考试成绩均分为73.9,技能考核均分为88.7,学生综合平均成绩81.3分。结论通过护理学基础的全英语教学,既可使学生掌握护理学的基本理论、基本知识与基本技能,又能提高专业英语的应用能力,同时也为后阶段临床护理的全英语教学工作的开展提供实践的经验。     

Results of operative treatment of fractures of the posterior wall of the acetabulum

BACKGROUND: The purpose of this study was to determine the clinical outcome in patients in whom a displaced fracture of the posterior wall of the acetabulum had been treated by open reduction and internal fixation. METHODS: One hundred patients who had had open reduction and internal fixation of an unstable unilateral fracture of the posterior wall of the acetabulum were studied. Ninety-four patients were assessed at a mean of five years (range, two to fourteen years) after the injury. Six patients with a poor result were followed for less than two years. The functional outcome was evaluated with use of the clinical grading system adopted by Letournel and Judet with incorporation of modifications by Matta. Patient, fracture, and radiographic variables were analyzed to identify possible associations with functional outcome. RESULTS: The reduction of the fracture, as determined with plain radiography, was graded as anatomic in ninety-seven patients and as imperfect in three. The clinical outcome at the time of final follow-up was graded as excellent in fifty-five patients, very good in twenty-five, good in nine, fair in one, and poor in ten. The radiographic result was excellent in eighty-one patients, good in five, fair in four, and poor in ten. There was a strong association between the clinical outcome and the final radiographic grade. Variables identified as risk factors for an unsatisfactory clinical result included a delay of greater than twelve hours before reduction of an associated hip dislocation, an age of fifty-five years or older at the time of injury, intra-articular comminution, and osteonecrosis. CONCLUSIONS: The uncomplicated radiographic appearance and relatively simple operative approach for fractures of the posterior acetabular wall belie the risk of poor results. Prompt reduction of an associated hip dislocation is imperative. Fractures in elderly patients and those with extensive comminution are more likely to have a poor clinical result. However, a high likelihood of a long-term good-to-excellent result can be expected following anatomic reduction and internal fixation of these fractures.     

Complications of operative treatment of injuries of peripheral arteries

In 1991 and 1992, a total of 97 patients with 106 peripherial arterial injuries underwent surgery at the Institute for Cardiovascular Diseases, Clinical Centre of Serbia. Civilian injuries accounted for 53 (54.6%) patients (94.3% males, age range: 16-63 yr, mean: 35.2), and 44 patients had war injuries (93.2% males, age range: 19-61 yr, mean: 34.8). The injuries affected the superfitial femoral artery in 31 (29.24%); the popliteal artery in 28 (26.41%); the brachial artery in 17 (16.04%); the posterior tibial artery in 6 (5.66%); the axillary artery in 5 (4.72%); the anterior tibial artery in 5 (4.72%); the tibioperoneal trunk in 4 (3. 77%); the common femoral artery in 4 (3.77%); the external iliac artery in 2 (1.89%); the profound femoral artery in 2 (1.89%); the radial artery in 1 (0.94%); and ulnar artery in 1 (0.94%).A total of 98 reconstructive procedures were used to treat these patients. Graft interposition carried out in 50 (51.02%); by pass in 25 (25. 51%); end-to-end anastomosis in 9 (9.18%); suture in 8 (8.16%); ligation in 4 (4.08%); and patch-angioplasty in 2 (2.04%). Primary reconstruction of injured arteries was performed in 72.2% and secondary repair in 27.8% cases.Infection developed in 51 (52.57%) patients, and it was significantly (P<0.05) more common in the war injuries (70.45%) and in secondary repairs (88.89%). The presence of associated lesions (69.56%) was also correlated with a greater rate of infection.Amputation was necessary in 21 (21.65%) of our patients, and was significantly (P<0.05) more often performed after secondary (44.44%) than primary operations (12.86%) and in the presence of associated injuries (32.61%).     

Role of imaging in diagnosis of carcinoma of breast

Imaging plays an important role in the diagnosis of breast diseases. With the advancement in technology new diagnostic modalities have been added in the armamentarium of investigation protocols for breast diseases, especially carcinoma of breast, which is showing a rising trend in the recent years. This includes MRI of breast, color doppler ultrasound, contrast ultrasound, digital mammography etc. This article briefly describes the role of imaging in the diagnosis of carcinoma breast.     

Assessment of methods of placement of polypropylene meshes in alloplasty of ventral hernias

Alloplasty with polypropylene meshes was fulfilled in 153 patients with ventral hernias. Most frequently the prosthesis was placed in the preperitoneal fatty tissue under the sutured muscular-aponeurotic margins of the hernia hilus (61 patients) or in sheathes of the rectus muscle of the abdomen (48 patients). Best results were obtained after implantation of the mesh in sheathes of the rectus muscle of the abdomen. The greatest number of complications and recurrences was obtained in alloplasty above aponeurosis.     

Influence of the method of measurement of muscle force on results of isolated resections of the head of the radius in the adult

A statistical study of a group of 50 patients determined the mean difference in grip strength between the dominant and non-dominant hands. For every position of the wrist a mean non-dominant/dominant ratio was calculated. This ratio, 87% in the neutral position, was then used to assess grip strength in relation to the dominance of the injured limb in 15 patients who had undergone 16 radial head excisions, a mean time of 74.4 months earlier. Using this method as a correction factor, results vary considerably according to the functional scoring system used. Loss of grip strength was more frequent and more pronounced in men who had been operated on and in those whom a statistical increase in distal radio-ulnar variance was noted. Loss of grip strength was also greatest when the dominant hand had undergone surgery. Excision of the radial head is still indicated in isolated and comminuted fractures when internal fixation is not possible, especially in less active patients when the non-dominant side is affected.     

Non-surgical method of treatment of dislocation of the acromial end of the clavicle

An apparatus for reposition and fixation of the clavicle in case of the dislocation, in the acromioclavicular joint is described. The method was used in the treatment of 60 patients. There were 57 good results, and in 3 cases the results were fair.     

Comparative evaluation of the methods of treatment of dislocations of the clavicle

An analysis of treatment was made in 93 patients divided into three groups: conservative treatment (11 patients), operations by traditional methods (28 patients), surgery using constructions of titanium nickelide (54 operations). It was found that the conservative treatment of complete acromioclavicular end dislocation was followed by a repeated displacement, development of deforming arthrosis and deformity of the area of injury. Transcapticular fixation of acromioclavicular end dislocation resulted in the development of deforming arthrosis (68%), the incidence of this complication depending on the kind of operation. The greatest inclination of the construction to migration was noted after fixation with wires. After the application of a titanium nickelide construction the most frequent process was resorption of the bone around the construction in the shape of a hook (36%) which resulted in some patients in subluxation (11%) and development of deforming arthrosis (4.5%).     

Method of extrafocal osteosynthesis of compound fractures of the lower end of the radius

The Ilizarov device was used for extrafocal osteosynthesis in complex fractures of the distal end of radius. With the aid of the device the bone fragments can be joined and kept in a correct position till a callus is formed. The mean time of fixation in the apparatus is equal to 21 days. In 114 patients 117 operations were performed. Good remote results were obtained in 73 of 99 patients (73,7%), satisfactory results in 25 (25,3%).     

Dynamics of indices of the natural resistance of patients with cancer of the stomach

The complement titer, bactericidal serum activity and cation protein content of the peripheral blood granulocytes in gastric cancer, polyps and gastric ulcer disease were studied in dynamics. The most decrease in the indices listed was noted in patients with stage IV gastric cancer. The results of the tests mentioned permit to judge about the state of the non-specific resistance of the body of patients with gastric cancer, and in the complex with the other clinico-laboratory findings are of prognostic value.     

Assessment of efficacy of endarterectomy of coronary arteries

Results of coronary artery bypass grafting (CABG) with coronary endarterectomy (CE) are analyzed. The study group consisted of 97 patients who has undergone ACB with CE, control group--102 patients after ACB without CE. There were no differences in clinical state of the patients early (30 days) and late (1-2 years) after surgery. Computed tomography was used for detection of coronary bypass patency. In long-term period of follow-up (60 patients) autoarterial shunts were occluded in 3% cases in the study group and in 5% cases in the control one. Autovenous shunts were occluded in 36 and 27% cases respectively. These results demonstrate necessity of CE in CABG.     

Results of treatment of fracture-dislocations of the elbow

Twenty-four patients with ulnohumeral dislocation associated with radial head fracture were studied two to 35 years after injury. On the basis of an objective functional grading score that included elements of pain, motion, strength, and stability, results were excellent in three (12%), good in 15 (62%), and fair in six (25%). The best results were obtained in patients with Mason Type 2 injuries treated by closed reduction without fracture excision and with early complete radial head excision for a Type 3 fracture. Late instability was not observed in any of the 24 patients. Prolonged immobilization (greater than four weeks) was associated with poor results. Ectopic ossification occurred in only one patient who had surgical treatment at eight days after injury; the grading score was only fair. These observations demonstrate that the injury should be treated with early reduction of the ulnohumeral joint and treatment of the radial head fracture according to its type. Immobilization for more than four weeks should be avoided. The prognosis is better than what has been thought previously.     

Possibilities of restoration of fresh ligament injuries of the knee

Author briefly summarizes the changes in the aspects and diagnostics of the ligament injuries of the knee. He deals with the methods of treatment used at his Department and with the operative procedures and describes in details the types of injuries of the single parts and the possibilities of reconstruction. His unambigous opinion is that in fresh ligament injuries the best result can be expected from the early complete reconstruction. In spite of the fact that "restitutio and integrum" can be reached only in the minority of the cases, the results are better than in conservative treatment or in ligamentous plasties.     

Organization of Treatment of Patients with Cardiac Insufficiency of Different Origin

Summary: Assisted circulation is now used in the treatment of severe forms of heart failure which complicate the course of many diseases. Application of one method of assisted circulation-intra-aortic counterpulsation by a balloon pump in cardiogenic shock-was successful: prolonged survival (over 1 year) was obtained in 18% of the patients. A further decrease in the mortality rate is dependent on the rational organization of treatment for these patients. This poses two major problems: the organization of treatment of patients in cardiogenic shock and postoperative heart failure in large cardiologic and heart surgery centers, and treatment of heart failure in patients in whom it has occurred secondarily. We developed a method of organizing the treatment of these patients beginning in the prehospital stage and continuing in a specialized hospital. In addition to methods of assisted circulation, various intensive care methods and hemosorption (in poisoning by liver toxins), hemodialysis (in anuria), etc., are used. Although this type of organization complicates therapy, the results are significantly improved.     

Methods of evaluation of the functional results of flexor tendon repair of the fingers

The methods used by Buck-Gramcko, Kleinert and Tsuge in evaluating the functional results of flexor tendon repair were each applied to assess the functional outcome in sixty-seven fingers where both tendons had been severed in "no man's land". The method of Buck-Gramcko gave the highest rating, and the three methods showed evident differences in the results of evaluation after surgery. The study suggests a need for one standard method of measurement and recording, if a comparison of results after flexor tendon repair is to be of value. We found that the method of Buck-Gramcko incorporated the most essential features in the functional evaluation.     

Correction of microcytosis following elimination of an occult source of aluminum contamination of dialysate

A higher prevalence of aluminum-associated microcytic anemia was noted in hemodialysis unit A (n = 67) compared to unit B (n = 39). This finding could not be explained by differences in the aluminum content of reverse osmosis (RO) water or intake of antacids containing aluminum by patients in the two units. An intermittent source of aluminum contamination was suspected when water aluminum and total dissolved solutes (TDS) were measured at several sites in the water treatment facility of unit A. A one-way valve that maintained unidirectional flow in an RO bypass circuit was found missing. Intermittent pressure changes in this circuit altered the direction of water flow causing mixing of partially purified water with RO water. Installation of the valve stopped contamination and resulted in a decrease in plasma aluminum concentration from 183 +/- 12 micrograms/L to 76 +/- 7.3 micrograms/L, erythrocyte aluminum concentration from 210 +/- 31 micrograms/L to 61 +/- 9 micrograms/L and microcytosis from 58% to 8% in patients (n = 48) when measured 6 months later. Because contamination was missed in spite of water testing at the RO site, these findings underscore the importance of measuring water aluminum and TDS content at the dialysis stations. Frequent water testing at dialysis stations, familiarity with the design of water treatment facilities, and recognition of aluminum overload can lead to early detection and correction if similar types of aluminum contamination should occur.     

Evaluation of surgical treatment of spontaneous pneumothorax--assessment of postoperative recurrence and quality of life]

To assess the effect of surgical treatment for spontaneous pneumothorax, including the evaluation of the quality of postoperative life by a questionnaire method, we examined 139 patients with spontaneous pneumothorax who underwent the surgical treatment. The operation was performed 149 times and 154 sides for these patients. Of these, 95 cases (65.2%) were the first episode of the disease, since we often chose surgical treatment even for the first attack of the disease. Postoperative recurrence was seen in only one case (0.6%). Operative complications included 4 cases of empyema (in two of them requiring reoperation) and 18 cases of wound infection. The most common postoperative complaints were post-thoracotomy pain in 12 cases (12.6%), disturbance of sensation in the scar in 9 (9.5%), and limitation of exercise in 9 (9.5%). Four patients (4.2%) suffered from these symptoms and had difficulty in daily life. Forty-seven patients (49.5%) had a fear of recurrence. Quality of postoperative life was almost satisfactory. From the viewpoints of both prevention of the recurrence and postoperative quality of life, the surgical treatment is effective and safe method. We advocate the surgical treatment as the first choice of the treatment even in case of the first episode of the disease, especially in patients with high activities in social life.