儿童昏迷评分量表的研制及信效度检验

目的研制中文版儿童昏迷评分量表,为更好地评估昏迷儿童神经系统提供测评工具。方法引进简化全面无反应性量表(FOUR),通过翻译、回译,结合本院儿科重症监护室患儿及我国儿童生理特征进行修订、文化调适,形成儿童昏迷评分量表,抽取119例儿科重症监护室(PICU)患儿进行测评,对量表进行信度、效度及可行性评价。结果方差贡献率为78.031%,总体Cronbach′sα系数为0.905;内容效度指数(CVI)为1.00,量表各维度间相关系数为0.641~0.819。结论儿童昏迷评分量表具有良好的信效度和一定的可行性,可初步用于PICU患儿神经系统状况测定。     

The Edinburgh-2 coma scale: a new scale for assessing impaired consciousness

In the management of patients with acute cerebral disturbances, it is essential to determine precisely the degree of impaired consciousness. However, a coma scale for assessing impaired levels of consciousness has not yet been standardized internationally. The Edinburgh-2 coma scale (E2 CS) is introduced and compared with the Glasgow coma scale (GCS). The reliability of the E2 CS was tested by comparing levels of the E2 CS with the outcome of patients who underwent neurosurgical operations. A good correlation was observed between the levels of the E2 CS and the outcome. A change of two levels suggests that some change influencing the outcome has occurred or exists within the cranium of the patient. A correlation between the E2 CS and the GCS was proven to exist. The merits and drawbacks of both scales are discussed. One advantage of the E2 CS is that it has removed ambiguous terms, which are still present in the GCS. Also it is easier to grasp changes in a patient's condition shown on a chart because the levels of the E2 CS are arranged first-dimensionally. Use of the GCS should not preclude the use of other scales, such as the E2 CS; the E2 CS could be used together with the GCS. The accumulation of data on both scales would provide information useful in improving the existing coma scales.     

Intraoperative irradiation: a new technique in pediatric oncology

Adverse effects on normal tissue are the principal limiting factor in the use of radiation therapy. Maturing tissues are most susceptible to these side effects, so high-dose applications can be a particularly difficult challenge in children. Intraoperative radiation therapy (IORT) enables the radiation oncologist to displace or shield dose-limiting organs or structures. These first two cases of children treated with IORT suggest that IORT, used alone or in conjunction with external beam irradiation, may be useful in the pediatric age group.     

Sub-urethral tape treatment of female urinary incontinence--morbidity assessment of the trans-obturator route and a new tape (I-STOP): a multi-centre experiment involving 604 cases

PURPOSE: To make an assessment of the morbidity related to using the trans-obturator route (TOT); findings after one year for the 140 first cases and preliminary results of short term morbidity after 604 implants. PATIENTS AND METHOD: This retrospective, multi-centre study involves the 604 first procedures with a 1-3 month follow-up. The mean patient age was 57 years. 92% of the patients underwent an isolated urinary incontinence cure and 8% had associated surgery. 47.3% of the cases had pure stress urinary incontinence and 52.7% had mixed incontinence. A 12-month minimum follow-up period was applied to the first 140 cases operated between September 2002 and January 2003. Patient assessment was made by a clinical examination in the first three months and their satisfaction rate expressed after 1 year. RESULTS: Operative complications were very few: 0.5% vesical perforations, 0.3% vaginal perforations, no urethral wounds, 0.8% 200-300 ml haemorrhages, two perineal haematomas (0.33%). The post-operative period was marked by: 1.5% transient retentions, 2.3% transient pain, 2.5% urinary infections, 1.3% transient dysuria. The 1-3 month follow-up of 572 patients shows a 5.2% rate of de novo symptoms. Patient assessment of 131 subjects after one year revealed an encouraging satisfaction rate of 85.5% with a 1.5% rate of de novo dysuria and urgency. To date there have been no serious or specific complications attributable to the surgical route adopted. The morbidity is not affected by associated surgery. CONCLUSION: The trans-obturator route combines low morbidity with a low rate of de novo symptoms on a large series. These results will have to be corroborated by further studies.     

Electric water heaters: a new hazard for pediatric burns

The electric water heater has recently become a popular household appliance replacing the hot water dispensing jug. This device provides hot water and potable cool water directly from the faucets thus removing the need to refill the container or boil water separately in a kettle. Along with the convenience of dispensing hot water immediately has come an increased incidence of pediatric burns. This paper presents a 6-year retrospective study of such pediatric scald burns from 1996 to 2001. Computer database records revealed that the incidence of pediatric scald burns caused by the electric water heater during the past 6 years was 6.4% (66/1028). The age of victims ranged 0-6 years (mean 1.5+/-1.1 years), most of the victims were in the 1-2-year-old group. In most common cases burn location was the trunk. The accidents often occurred during the cold months and in the living room of the house. From this retrospective study, it was seen that the etiology and incidence of scald burns among children have changed as people have modified their household practice for obtaining hot water in our country. This study aims to increase public awareness to the problem and suggest some prevention measures to reduce this type of scald injury.     

Retropubic tension-free vaginal tape and inside-out transobturator tape: a long-term randomized trial

Introduction and hypothesis

The tension-free vaginal tape (TVT) and inside-out transobturator tape (TVT-O) are first-line surgical treatments for stress urinary incontinence (SUI). However, there is a lack of information regarding the long-term comparative safety of these procedures.

Methods

A total of 140 SUI patients were randomized to the TVT or TVT-O procedure and were interviewed by an independent investigator at the follow-up. The primary outcomes were the proportions of patients with long-term postoperative complications. The secondary outcomes included the cure rates, quality of life (QOL) and sexual function based on validated questionnaires.

Results

One hundred and twenty (85.71 %) patients completed the long-term follow-up. More TVT patients experienced perioperative complications (P?<?0.05). However, in a mean follow-up of 95 months, no significant between-group difference was found in the proportions of patients with long-term complications or in the variety of reported complications. The long-term complication rates for TVT and TVT-O were 43.1 % and 27.4 % respectively (P?=?0.07). De novo voiding (15.8 %) and storage symptoms (10.8 %) were the primary long-term complications. Tape exposure was possible up to 7 years after TVT-O. The objective cure rates of TVT and TVT-O procedures were 79.30 and 69.35 % respectively, which were not significantly higher than the subjective rates. The Pelvic Floor Impact Questionnaire (PFIQ-7) scores remained improved (P?<?0.001) after both procedures, even at the 95-month follow-up. No difference was observed in the Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire Short Form (PISQ-12) scores after either procedure.

Conclusions

In the long term, the proportion of patients with complications and the cure rates of the two procedures did not differ significantly. The long-term complication rates were high, but morbidity was low, and the QOL remained improved.

     

Blunt carotid arterial injuries: implications of a new grading scale

BACKGROUND: Blunt carotid arterial injuries (BCI) have the potential for devastating outcomes. A paucity of literature and the absence of a formal BCI grading scale have been major impediments to the formulation of sound practice guidelines. We reviewed our experience with 109 BCI and developed a grading scale with prognostic and therapeutic implications. METHODS: Patients admitted to a Level I trauma center were evaluated with cerebral arteriography if they exhibited signs or symptoms of BCI or met criteria for screening. Patients with BCI were treated with heparin unless they had contraindications, and follow-up arteriography was performed at 7 to 10 days. Endovascular stents were deployed selectively. A prospective database was used to track the patients. RESULTS: A total of 76 patients were diagnosed with 109 BCI. Two-thirds of mild intimal injuries (grade I) healed, regardless of therapy. Dissections or hematomas with luminal stenosis (grade II) progressed, despite heparin therapy in 70% of cases. Only 8% of pseudoaneurysms (grade III) healed with heparin, but 89% resolved after endovascular stent placement. Occlusions (grade IV) did not recanalize in the early postinjury period. Grade V injuries (transections) were lethal and refractory to intervention. Stroke risk increased with injury grade. Severe head injuries (Glasgow Coma Scale score < or =6) were found in 46% of patients and confounded evaluation of neurologic outcomes. CONCLUSION: This BCI grading scale has prognostic and therapeutic implications. Nonoperative treatment options for grade I BCI should be evaluated in prospective, randomized trials. Accessible grade II, III, IV, and V lesions should be surgically repaired. Inaccessible grade II, III, and IV injuries should be treated with systemic anticoagulation. Endovascular techniques may be the only recourse in high grade V injuries and warrant controlled evaluation in the treatment of grade III BCI.     

Transobturator tape (Uratape): a new minimally-invasive procedure to treat female urinary incontinence

OBJECTIVE: Assessment of one-year results of a new technique of transobturator suburethral tape in the treatment of female stress urinary incontinence. METHODS: UraTape, a non-woven, non-elastic polypropylene tape with a 15 mm long central (suburethral) silicone-coated section was inserted via the transobturator route. The tape is inserted tension-free in a horizontal plane underneath the middle of the urethra between the two obturator foramens. The ends of the tape are tunnelled percutaneously with a tunneller. As the retropubic space is preserved intact, cystoscopy is not required.From May 2000 to February 2002, 150 patients with stress urinary incontinence without associated prolapse were operated and a minimum of 1 year follow-up was available for 32 patients (mean follow-up 17 months; range 13-29). The mean age was 64 years (range 50-81). All patients were assessed before surgery by clinical and urodynamic examination: 5 patients presented sphincter incompetence (maximum closure pressure <20 cm H(2)O); 5 patients presented with recurrent urinary incontinence after Burch procedure or TVT; 18 patients presented with mixed incontinence, six of them with detrusor instability confirmed by cystometry. The results were evaluated by two independent investigators (clinical examination, uroflowmetry, cough test). Voiding disorders suggesting bladder outflow obstruction were defined as the presence of the following two criteria: Q(max)<15 ml/s, residual urine volume >20%. RESULTS: 29/32 patients (90.6%) were cured and 3/32 (9.4%) were improved. Mean operating time was 15minutes. No intra-operative complications were recorded. One patient had complete postoperative bladder retention which resolved after 4 weeks of self-catheterization. There were no problems with urethral erosion, residual pain or functional impairment related to the tape. 5/32 patients had voiding disorders suggesting bladder outflow obstruction. Two patients developed de novo urge incontinence. CONCLUSION: Uratape transobturator tape is a simple and effective procedure with follow-up of one year for the treatment of female stress urinary incontinence confirmed after 1 year of follow-up. The transobturator approach avoids the risk of bladder, bowel or vascular injuries. Evaluation of the results after a longer follow-up period is needed to validate this technique.     

儿科急诊预检分诊流程的改良

目的 为提高儿科急诊预检分诊效率,缩短患儿候诊时间、提高患儿家属满意度.方法 对儿科急诊室进行环境、预检工具和仪器配置,并对预检分诊流程进行改良.结果 每例患儿的预检时间由过去的5 min缩短至3 min.改良前（2009年）统计有6例患儿在候诊中发生病情恶化,改良后2010年发生3例、2011年2例、2012年1例.结论 改良后的预检分诊流程有助于患儿合理分流,可缩短患儿候诊时间,提高患儿的救治成功率及其家属满意度.     

Tissue adhesive and adhesive tape for pediatric wound closure: A systematic review and meta-analysis

BackgroundTissue adhesive (TiA), adhesive tape (AdT), and sutures can be used to close surgical wounds and lacerations in children. However, it is unclear which technique produces the best results.MethodsIn this prospectively registered study, the PubMed, Ovid MEDLINE, Cochrane Library, Centre for Reviews and Dissemination Database, and ScienceDirect databases were searched. English language studies published between January 1980 and August 2017 evaluating TiA and/or AdT for primary skin closure of surgical wounds or lacerations in patients aged ≤ 18 years were included. Study endpoints included clinician-rated wound cosmesis and incidence of wound complications.ResultsThirty-one studies were included in the systematic review and 16 studies in the meta-analysis. Amongst heterogeneous studies, AdT yielded marginally better cosmetic outcomes than TiA (p = 0.04). There was no difference in cosmesis between sutured wounds and those closed with TiA (p = 0.2). No difference in overall risk of wound infection or dehiscence was identified when comparing TiA with AdT (p = 0.3), and TiA with sutures (p = 0.9 and 0.3 respectively).ConclusionsTiA, AdT, and sutures can all be used for wound closure with equivalent risk of wound infection and dehiscence. AdT appears to convey better cosmesis. Further adequately powered studies directly comparing techniques are required.Levels of EvidenceLevel IV.     

The surgical hospitalist: a new model for emergency surgical care

BACKGROUND: Quality of acute surgical care in the US is threatened by a shortage of surgeons performing emergency procedures because of rising costs of uncompensated care, liability concerns, declining reimbursement, and lifestyle considerations. In July 2005, we restructured the general surgery service at our medical center into a hospitalist model to improve patient access to surgical care. STUDY DESIGN: We hypothesized that a surgical hospitalist program could improve timeliness of care, emergency department (ED) efficiency and physician satisfaction, resident supervision, continuity of care, and revenue generation. We reviewed our program after 1 year, including patient demographics, diagnosis, and time to consult. RESULTS: Three surgical hospitalists cared for 853 patients during 1 year. Patients ranged from 17 to 100 years of age and presented with abdominal pain (66%), infection (18%), malignancy (6%), hernia (4%), and trauma (3%). Fifty-seven percent of consults originated from the ED; 8% came from other surgeons. Mean time to consult was 20 minutes. A survey of ED physicians reported shorter ED length of stay, better patient satisfaction, improved professionalism and resident supervision, and better overall quality of care. Average waiting time for patients with acute appendicitis to undergo operation was reduced from 16 +/- 10 hours to 8 +/- 4 hours (p < 0.05). Forty-two percent of consults resulted in an operative procedure, and revenue increased as the number of billable consults rose by 190%. CONCLUSIONS: The surgical hospitalist model provides a cost-effective way for general surgeons to provide timely and high-quality emergency surgical care and enhance patient and referring provider satisfaction.     

Is a full team required for emergency management of pediatric trauma?

Pediatric trauma centers often do not meet the guidelines requiring a trauma team as recommended by the American Academy of Pediatrics (AAP). We reviewed our experience with a team consisting of a pediatric emergency physician, resident, nurse, and respiratory therapist. The surgical and pediatric critical care residents and staff were available within 5 minutes. We conducted a retrospective chart review of 146 patients (aged 8.1 +/- 4.8 years) between 1987 and 1989, with Injury Severity Scores (ISS) greater than or equal to 16 or admitted to the pediatric critical care unit. The time of presentation, surgical services consulted, and the nature of the injury were obtained from chart review. The Pediatric Trauma Score (PTS), the Revised Trauma Score (RTS), the Injury Severity Score (ISS), Glasgow Coma Scale (GCS) score, and Pediatric Risk of Mortality (PRISM) were used to determine the severity of insult and physiologic derangement on admission. The Modified Injury Severity Score (MISS) was determined and the Delta score for Disability Assessment was assigned at discharge. The Delta score was also determined at 3-month intervals up to one year. The probability of survival (Ps) was calculated, using the ISS and RTS. The Z statistic for this group of patients was then determined, using the Major Trauma Outcome Study (MTOS) methodology. The percentages of patients who were normal, disabled, and dead were 61%, 31.5%, and 7.5%, respectively, at 6 months follow-up. Eleven deaths were expected based on PRISM and TRISS analysis. Our mortality and morbidity figures were comparable with those of centers with teams based on AAP guidelines.(ABSTRACT TRUNCATED AT 250 WORDS)