膝关节周围恶性肿瘤患者不同保肢治疗术后康复效果观察

目的 探讨不同保肢方法治疗膝关节周围恶性骨肿瘤术后的康复效果.方法 收集1994年1月-2004年10月收治的膝关节周围恶性骨肿瘤患者39例.按照Enneking分期:ⅠB期13例,ⅡA期3例,ⅡB期23例.39肢均行肿瘤节段截除、肢体重建手术.其中人工关节置换16例、复合骨移植16例、旋转成形7例.对不同的患者术后采用不同的康复方法、时间和强度,比较3种保肢手术后局部复发率、并发症和膝关节功能MSTS评分.结果 人工关节置换术后局部复发率为12.5%,复合骨移植术后局部复发率为12.5%,旋转成形术后无局部复发;术后平均膝关节功能MSTS评分:人工关节置换术88.0%,复合骨移植术88.7%,旋转成形术68.0%,3种术式比较差异有统计学意义.结论 人工关节置换术和复合骨移植术应用于相对局限、无转移的膝关节周围恶性肿瘤,配合适当的康复训练,具有并发症少、恢复快、功能好等优点,但仍有一定的转移率和局部复发率.旋转成形术局部复发率低,但术后功能较差.     

人工关节在骨肿瘤治疗中的应用

目的：探讨人工关节在骨肿瘤治疗中的应用价值。方法：分析30例骨肿瘤（恶性20例,良性10例）患者进行人工关节置换术后的效果、生存情况、功能、并发症及处理。结果：20例恶性骨肿瘤局部复发率为5％,5年生存率为15％,最终保肢率95％,未见假体松动;8例骨巨细胞瘤复发率及病死率为37．4％,并发症发生率为74．7％,最终保肢率100％;2例股骨头颈区纤维结构不良术后7年功能良好。在所有人工关节中,4年内各种假体均未见松动,下沉及断裂,但4年后铰链式人工膝关节逐渐出现传动、下沉、5年后人工股骨头出现髋臼侧较严重的骨质磨损;人工全肩钾骨肩关节虽然术后患者功能较差,但未见假体并发症;人工全髋关节置换术后7年未见假体松动。结论：人工假体置换术可用于恶性及侵袭性肿瘤的保肢治疗,早期有较好的临床效果,合理选择,及改进假体能降低并发症,提高疗效。     

绞链式人工全膝置换在股骨下段恶性骨肿瘤保肢治疗中的应用

目的探讨对股骨下段恶性骨肿瘤切除后，采用绞链式人工全膝关节置换保肢后的疗效。方法2005—2008年共收治股骨下段恶性骨肿瘤患者9例，年龄54～75岁，其中恶性骨巨细胞瘤4例，骨肉瘤2例，成骨肉瘤2例，纤维肉瘤1例。肢体功能重建方法为特制的绞链式人工全膝关节置换术。结果本组9例经2～5年随访，5例无瘤存活，4例带瘤存活。术后肢体功能按Enneking评分系统评分，平均为22．3分，总优良率72．7％。结论采用特制的绞链式人工全膝关节置换术，能有效治疗股骨下段恶性骨肿瘤，达到良好保肢效果。     

铰链式人工全膝关节置换术治疗膝部肿瘤的围手术期康复训练

膝部骨肿瘤切除后藉助人工膝关节来弥补切除的骨肿瘤的空缺，并重建膝关节功能，成为骨肿瘤保肢手术的主流术式。骨肿瘤切除后骨缺损的替代修复和患肢功能的重建，目前在世界范围内以人工关节置换疗效最为理想。2003年4月-2006年3月，我院采用铰链式人工全膝关节置换术治疗膝部肿瘤11例，取得了满意的疗效，现报道如下。     

生物性功能重建应用于关节周围恶性骨肿瘤保肢术的作用

目的探讨生物性功能重建方式应用于关节周围骨肿瘤保肢术的作用。方法选取1996—07／2003—03上海市第一人民医院骨科诊疗的四肢关节周围恶性肿瘤(Enneking分期Ⅱa～Ⅱh)患者6例，在瘤段切除或次全切除术后，分别予以自体骨移植、异体骨移植或骨水泥填充，重建关节周围肌腱的止点。结果6例患者随访9个月～8年。①6例Enneking肌骨骼肿瘤术后功能评分为69％～87％。②4例骨移植术后获得满意的骨性愈合，1例骨水泥重建术后见轻度骨吸收。结论生物性重建适用于近关节骨肿瘤恶性程度较低，外科边界与关节面有一定距离的病例，并能获得良好的功能恢复。     

铰链式人工全膝关节置换术治疗膝部肿瘤的围手术期康复训练

膝部骨肿瘤切除后藉助人工膝关节来弥补切除的骨肿瘤的空缺,并重建膝关节功能,成为骨肿瘤保肢手术的主流术式。骨肿瘤切除后骨缺损的替代修复和患肢功能的重建,目前在世界范围内以人工关节置换疗效最为理想[1]。2003年4月-2006年3月,我院采用铰链式人工全膝关节置换术治疗膝部肿瘤11例,取得了满意的疗效,现报道如下。     

大段冷冻同种异体骨移植复合人工关节置换修复股骨远近段骨缺损

目的 :研究大段冷冻异体骨移植复合人工关节置换修复股骨远近段肿瘤切除后骨缺损的疗效。方法 :本组 2 4例 ,行复合股骨上段的全髋关节置换 10例 ,复合股骨下段全膝关节置换 14例。按Enneking分期 ,广泛边缘性切除股骨上下段肿瘤 ,选用长柄人工关节将大小和形态合适的同种异体骨关节与宿主骨经骨水泥髓内固定 ,假体柄插入宿主骨髓内长度与异体骨轴心长度比≥ 0 8～ 1。结果 :2 2例患者随访 6～ 12 8个月 ,平均 4 8个月。 2例分别于术后 9个月和 15个月死亡 ;4例于术后 7个月内局部复发 ;其余均无瘤生存。所有患者均无关节脱位、假体松动和断裂。 6例异体股骨大转子区部分吸收。异体骨和宿主骨间均达骨性愈合 ,平均愈合时间为 8月。 10例复合股骨上段的全髋关节置换者 ,髋关节活动度平均为 87°。 12例复合股骨下段全膝关节置换者 ,膝关节活动度平均为 82°。按ISOLS骨肿瘤术后功能重建评定 ,平均为 2 6 5分。结论 :大段冷冻异体骨移植复合人工关节置换具有异体骨和人工关节两者的优点 ,更适应于生存时间长的良性或恶性骨肿瘤的保肢术     

膝关节周围恶性骨肿瘤保肢术后的肢体功能康复

目的总结股骨下端、胫骨上端恶性骨肿瘤患者保肢手术后膝关节功能康复方法。方法64例恶性骨肿瘤患者接受不同方式的保肢手术治疗,平均随访36.8个月。结果(1)术后早期系统的康复治疗有利于膝关节功能恢复和减少术后并发症。因恶性骨肿瘤保肢手术创伤大,膝关节屈伸锻炼最早在手术1周后进行,而异体半关节移植的患者手术3周内需用支架固定。（2）术后感染、皮肤坏死、关节退变和不稳是导致肢体功能不良的主要因素。（3）异体半关节移植、保留自体髁部关节面的异体骨段移植、人工全膝关节置换的术后肢体功能优良率分别为48.6％、81.3％、90.9％。结论保肢手术方法选择应注重恢复肢体功能,术后早期进行康复训练有利于膝关节功能康复。     

大段冷冻异体骨移植后人工关节置换保肢术后护理与康复

目的 为了保留骨肿瘤病人的肢体功能，提高生活质量。方法 对33例骨肿瘤病人进行了大段冷冻异体骨移植复合人工关节置换保肢术，病人术前进行辅助化疗，入院时强化健康教育，预防或减轻化疗药物的毒副作用；加强生命体征监护、惠肢护理、实施了分阶段的功能康复。出院时加强指导，预防骨折，坚持随访。结果 33例病人出院时，病情稳定，切口愈合好，胸片正常，患肢摄片示：患肢位置良好，无脱位、假体松动和断裂现象。随访平均46个月，3例分别于术后4．6和7个月时局部软组织复发，经广泛切除后治愈，2例分别于9个月和15个月死亡，其余患者均无瘤生存，其生活质量得到了提高。结论 此保肢术具有异体骨和人工关节两者的优点，同时又降低或减少了两者的缺点，更适用于生活时间长的良性或恶性肿瘤保肢。     

持续被动活动在微波诱导高温原位灭活治疗膝关节周围骨肿瘤术后关节功能康复中的意义

目的：探讨持续被动活动（CPM）在微波诱导高温原位灭活保肢手术治疗膝关节周围恶性或侵袭性骨肿瘤术后关节功能康复中的意义。方法：微波诱导高温原位灭活保肢手术治疗膝关节周围恶性或侵袭性骨肿瘤，灭活处骨缺损应用脱钙骨基质颗粒加骨水泥修复，局部用钢板或异体皮质骨板内固定，不用外固定。将75例患者随机分为A、B两组。A组40例，术后24h开始使用CPM对患肢进行持续被动功能锻炼，连续3周。B组35例术后进行常规功能锻炼。结果：75例均获随访，平均随访时间13个月，骨缺损处无骨折和骨不连，内固定良好。至3个月时，A组膝关节活动度110&;#176;－160&;#176;，平均141&;#176;，B组膝关节活动度90&;#176;－140&;#176;，平均126&;#176;，统计学差异有显著性意义，P＜0．01。结论：微波诱导高温原位灭活治疗膝关节周围骨肿瘤保持手术，能最大程度地保留膝关节功能，术后CPM能进一步改善膝关节的活动度。     

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.     

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.     

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.     

Wie zuverlässig sind Angaben zu nichtentzündlichen ausgedehnten Schmerzen?

ZusammenfassungFragestellung Es wurde geprüft, wie sich der Differenziertheitsgrad zweier Schmerzmessmethoden auf Angaben zur Ausgedehntheit klinischer Schmerzen auswirkt. Zugleich wurde der Referenzzeitraum variiert, über den die Patienten berichten sollten.Methode Erfasst wurde der Einfluss zu Lasten der Befragungsdifferenziertheit durch den Vergleich zweier Körperschema-Bildvorlagen. Drei Referenzzeiträume (Schmerz aktuell, letzte Woche, letztes halbes Jahr) wurden vorgegeben.Ergebnisse Patienten mit ausgedehnten Schmerzen gaben bei differenzierter Befragung um so mehr Schmerzen an, je weiter die Schmerzen zurück lagen und je größer der Berichtszeitraum war. Patienten mit gelenknahen Schmerzen gaben bei hoch differenzierter Befragung weniger ausgedehnte Schmerzen in der Vergangenheit an als bei globaler Einschätzung. Patienten mit Rückenschmerzen berichteten bei differenzierter Befragung zum aktuellen Schmerz über weniger ausgedehnte Schmerzen als bei globaler Befragung.Schlussfolgerung Die Angaben zur Schmerzausdehnung variieren vor allem bei Patienten mit ausgedehnten Schmerzen in Abhängigkeit von der Differenziertheit der Befragung. In diesen Fällen ist die Wahrscheinlichkeit erhöht, dass sich die Beschwerdesymptomatik zumindest teilweise erst in der Reaktion auf die situativen Befragungsbedingungen konstituiert und daher nicht auf andere Befragungsbedingungen generalisiert werden kann.