Biomechanical stress analysis of the main soft tissues associated with the development of adult acquired flatfoot deformity

BackgroundAdult acquired flatfoot deformity (AAFD) is traditionally related to a tibialis posterior tendon deficiency. In the intermediate stages, treatments are commonly focused on reinforcing this tissue, but sometimes the deformation appears again over time, necessitating the use of more aggressive options. Tissue stress cannot be consistently evaluated through traditional experimental trials. Computational foot modeling extends knowledge of the disease and could help guide the clinical decisions. This study analyzes the biomechanical stress of the main tissues related to AAFD and their capacity to support the plantar arch.MethodsA FE foot model was reconstructed. All the bones, cartilages and tissues related to AAFD were included, respecting their biomechanical characteristics. The biomechanical tissue stress was quantified. The capacity of each soft tissue to support the plantar arch was measured, following clinical criteria.FindingsBiomechanical stress of the tibialis posterior tendon is considerably superior to both the plantar fascia and spring ligament stress. However, it cannot maintain the plantar arch by itself. Both the tibialis posterior tendon and spring ligament act in reducing the hindfoot pronation, while the plantar fascia is the main tissue that prevents arch elongation. The Achilles tendon action increases the plantar tissue stress.InterpretationThe tibialis posterior tendon stress increases when the spring ligament or the fascia plantar fails. These findings are consistent with the theory that regards the tibialis posterior tendon as a secondary actor because it cannot support the plantar arch and claudicates when the hindfoot has rotated around the talonavicular joint.     

自体脂肪颗粒移植治疗面部凹陷畸形的效果及安全性

目的 探讨自体脂肪颗粒移植治疗面部凹陷畸形的效果及安全性.方法 回顾性选取2018年10月至2020年10月本院收治的100例面部凹陷畸形患者,依据移植治疗方法将其分为硅胶移植治疗组、自体脂肪颗粒组,各50例.硅胶移植治疗组采用硅胶移植治疗,自体脂肪颗粒组采用自体脂肪颗粒移植治疗.比较两组患者的临床疗效、并发症发生情况...     

继发不孕腹腔镜治疗及预后

目的探讨腹腔镜在诊治继发不孕中的价值。方法回顾分析108例继发不孕患者在腹腔镜下进行诊治和经宫腔输卵管美蓝通液的情况。结果盆腔粘连、输卵管梗阻为继发不孕的主要原因；108例继发不孕患者经腹腔镜诊治后，47例再次妊娠，复孕率为43．52％。结论应用腹腔镜对继发不孕的诊治具有损伤小、恢复快、兼诊断与治疗于一体等优点；直视下通液，观察输卵管形态及功能，对预后可做出初步判断。     

Finite element analysis of the foot: Model validation and comparison between two common treatments of the clawed hallux deformity

Background

Clawed hallux is defined by first metatarsophalangeal joint extension and first interphalangeal joint flexion; it can increase plantar pressures and ulceration risk. We investigated two corrective surgical techniques, the modified Jones and flexor hallucis longus tendon transfer.

Methods

A finite element foot model was modified to generate muscle overpulls, including extensor hallucis longus, flexor hallucis longus and peroneus longus. Both corrective procedures were simulated, predicting joint angle and plantar pressure changes.

Findings

The clawed hallux deformity was generated by overpulling: 1) extensor hallucis longus, 2) peroneus longus + extensor hallucis longus, 3) extensor hallucis longus + flexor hallucis longus and 4) all three together. The modified Jones reduced metatarsophalangeal joint angles, but acceptable hallux pressure was found only when there was no flexor hallucis longus overpull. The flexor hallucis longus tendon transfer reduced deformity at the metatarsophalangeal and interphalangeal joints but may extended the hallux due to the unopposed extensor hallucis longus. Additionally, metatarsal head pressure increased with overpulling of the extensor hallucis longus + flexor hallucis longus, and all three muscles together.

Interpretation

The modified Jones was effective in correcting clawed hallux deformity involving extensor hallucis longus overpull without flexor hallucis longus overpull. The flexor hallucis longus tendon transfer was effective in correcting clawed hallux deformity resulting from the combined overpull of both extensor and flexor hallucis longus, but not with isolated extensor hallucis longus overpull. An additional procedure to reduce the metatarsal head pressure may be required concomitant to the flexor hallucis longus tendon transfer. However this procedure avoids interphalangeal joint fusion.     

医院获得性肺炎诊治进展

医院获得性肺炎（HAP）死亡率较高。本文重点从HAP的概念、诊断和抗生素治疗三个方面进行介绍。     

Sistrunk术治疗小儿甲状舌管残留畸形的临床分析

目的探讨小儿甲状舌管残留畸形的临床诊治方法及减少术后复发的措施。方法回顾性分析徐州医学院附属医院2010年1月至2012年12月收治的50例小儿甲状舌管残留畸形患儿的临床资料、手术治疗及术后疗效。所有患儿均行手术治疗,其中在全身麻醉下行Sistrunk术治疗48例,行扩大切除术2例。结果本研究患儿在全身麻醉下手术,术后切口一期愈合,无手术并发症,手术标本均经病理学确诊,未发现恶变;随访0．5～2年均无一例复发。结论完善术前检查,充分认知甲状舌管残留畸形的解剖学特点,正确的术前诊断,选择合适的手术时机,规范的Sistrunk术式和良好的手术技巧才能保障彻底切除甲状舌管残留畸形,这是预防和降低术后复发的关键。     

大面积Ⅲ°烧伤早期大片自体皮移植与畸形的预防

目的 :探讨大片自体皮移植治疗大面积Ⅲ°烧伤患者及其畸形的预防。方法 :在患者全身情况允许时 (伤后10d左右 )行切痂或削痂 ,做大片自体皮移植。采用同一供皮区和Ⅱ°烧伤初愈区重复大片供皮的技术 ,扩大自体皮源。结果 :12 2例烧伤总面积 5 0 %— 80 %、Ⅲ°烧伤 2 0 %— 5 0 %的患者 ,采用上述治疗 ,皮片存活率为 90 %— 10 0 %。随访 84例植皮区外形接近正常 ,功能良好 ;14例患者留有轻度畸形 ,但采用小手术治疗后畸形得以矫正。结论 :改进取皮技术 ,扩大皮源 ,采用大片自体皮移植 ,皮片存活率高 ,明显缩短了疗程 ,功能与外形好 ,提高了患者的生存质量     

A biomechanical analysis of posterior tibial tendon dysfunction,medial displacement calcaneal osteotomy and flexor digitorum longus transfer in adult acquired flat foot

Background

Biomechanical models have been used to study stress in the metatarsals, subtalar motion, lateral column lengthening and subtalar arthroereisis. Posterior tibial tendon dysfunction has been associated with increased loads in the arch of the acquired flat foot. We examine whether a 10 millimeter (mm) medial displacement calcaneal osteotomy and flexor digitorum longus transfer to the navicular reduces these increased loads in the flat foot.

Methods

The response of a normal foot, a foot with posterior tibial tendon dysfunction, and a flat foot to an applied load of 683 Newton was analyzed using a multi-segment biomechanical model. The distribution of load on the metatarsals, the moment about each joint, the force on each of the plantar ligaments and the muscle forces were computed.

Findings

Posterior tibial tendon dysfunction results in increased load on the medial arch, which may cause the foot to flatten. A 10 mm medial displacement calcaneal osteotomy substantially decreases the load on the first metatarsal and the moment at the talo-navicular joint and increases the load on the fifth metatarsal and the calcaneal-cuboid joint. Adding the flexor digitorum longus transfer to the medial displacement calcaneal osteotomy has only a small effect on the flattened foot.

Interpretation

Our biomechanical analysis illustrates that when the foot becomes flat, the force on the talo-navicular joint increases substantially from its value for the normal foot, and that medial displacement calcaneal osteotomy can reduce this increased force back toward the value occurring in the normal foot. This study provides a biomechanical rationale for medial displacement calcaneal osteotomy treatments for posterior tibial tendon dysfunction.     

成人牙周病前牙扇形移位的牙周-正畸联合治疗

目的总结运用牙周-正畸联合治疗术对成人牙周病前牙扇形移位的治疗过程及疗效。方法临床选取19例成人牙周病前牙扇形移位的患者,年龄24~42岁,在牙周基础治疗控制牙周炎症的基础上,采用直丝弓矫治器按细丝轻力的原则进行治疗。结果疗效明显,前牙排列整齐,咬合良好,牙齿松动度降低,面部美观和口腔功能得到改善。结论在系统的牙周治疗基础上,合理地使用矫治器和矫治力,成人牙周病前牙扇形移位的患者可以得到较好的治疗。     

人工全膝关节表面置换治疗膝关节骨性关节炎伴重度膝内翻畸形的临床效果

目的探究人工全膝关节表面置换(TKA)治疗膝关节骨性关节炎(KOA)伴重度膝内翻畸形的临床效果。方法根据治疗方式的不同将本院收治的60例KOA伴重度膝内翻畸形患者分为对照组(23例,胫骨高位截骨术)和观察组(37例,TKA)。比较两组的手术效果。结果术后1年,两组的ROM、BBS及Lysholm评分均高于术前,且观察组的ROM高于观察组(P<0.05)。术后1年,两组的SF-36各项评分均高于术前(P<0.05)。观察组的并发症总发生率低于对照组(P<0.05)。结论TKA治疗KOA伴重度膝内翻畸形的临床效果显著,可提高ROM,且患者无需经历二次手术。     

乙酰半胱氨酸与氨溴索治疗小儿社区获得性肺炎的临床效果比较

目的比较乙酰半胱氨酸与氨溴索治疗小儿社区获得性肺炎的临床效果。方法选取2016年12月至2019年12月我院收治的152例社区获得性肺炎患儿作为研究对象,将其随机分为研究组和对照组,各76例。两组均给予常规抗感染、对症支持处理,研究组给予乙酰半胱氨酸雾化吸入,对照组给予氨溴索静脉注射。比较两组的治疗效果。结果研究组的治疗总有效率为94.74%,高于对照组的78.95%,差异具有统计学意义(P<0.05)。研究组的发热、咳嗽、肺部啰音改善时间均短于对照组,差异具有统计学意义(P<0.05)。两组的不良反应总发生率比较,差异无统计学意义(P>0.05)。治疗后,研究组的IgA、IgG水平高于对照组,差异具有统计学意义(P<0.05)。结论乙酰半胱氨酸雾化吸入治疗社区性肺炎患儿的效果优于氨溴索静脉注射,可有效改善患儿的临床症状、体征及体液免疫功能,且不良反应较少。     

Doxycycline vs. levofloxacin in the treatment of community‐acquired pneumonia

Background: Community‐acquired pneumonia (CAP) affects 5–10 million adults annually in the United States with approximately 1·1 million hospitalizations. Current guidelines recommend fluoroquinolones as monotherapy for treatment of CAP in general medical wards and doxycycline monotherapy for outpatient therapy only. Fluoroquinolones are expensive and development of bacterial resistance to them has become a concern. Therefore, we studied whether doxycycline is as efficacious as levofloxacin in treatment of CAP in general medical wards. Methods: In this prospective double‐blinded trial, non‐pregnant adults with clinical and radiological evidence of pneumonia requiring hospitalization were enrolled. Patients who were septic, hypoxic requiring intubations, nursing home residents, diagnosed with severe hepatic or renal dysfunction, recently hospitalized or immunocompromised were excluded from the study. Subjects were randomly assigned to either i.v. levofloxacin 500 mg daily or doxycycline 100 mg twice daily. After discharge, patients were followed for 2 months. Results: There were 30 patients in the levofloxacin group and 35 patients in the doxycycline group. Groups were comparable in both clinical and laboratory profiles. Additionally, efficacy of treatment was not significantly different between the two groups (P = 0·844). Length of stay was 5·7 ± 2·05 days in the levofloxacin group and 4·0 ± 1·82 days in the doxycycline group (P < 0·0012). Failure rate was similar in both groups (P = 0·893). Total antibiotic cost was $122·07 ± 15·84 for levofloxacin and $64·98 ± 24·4 for doxycycline (P < 0·0001). Conclusions: Our study supports doxycycline as an effective and economical alternative therapy for levofloxacin in the empirical treatment of CAP in general medical wards.     

痰热清注射液联合头孢哌酮-舒巴坦治疗老年社区获得性肺炎的疗效评价

目的观察痰热清注射液联合头孢哌酮-舒巴坦治疗老年社区获得性肺炎（CAP）的临床效果和安全性。方法78例CAP患者随机分为治疗组（40例）和对照组（38例）。对照组采用头孢哌酮-舒巴坦治疗,治疗组在对照组治疗的基础上加用痰热清注射液静脉滴注治疗,共治疗10d。治疗结束后评价临床疗效、细菌学疗效和安全性。结果治疗组临床疗效有效率为92．5％,高于对照组（81．6％）,相比较差异有显著性（P〈0．05）;治疗组细菌清除率为93．9％,高于对照组（80．6％）,相比较差异有显著性（P〈0．05）;治疗组不良反应发生率为12．5％,低于对照组（76．3％）,相比较有显著性差异（P〈0．05）。结论痰热清注射液联合头孢哌酮-舒巴坦治疗CAP安全、有效,值得临床推广应用。     

Exploring predictors of treatment outcome in cognitive behavior therapy for sleep disturbance following acquired brain injury

Purpose: To identify predictors of treatment response to cognitive behavior therapy (CBT) for sleep disturbance following acquired brain injury (ABI).

Methods: Classification and regression tree (CART) analysis was conducted on individual patient data from two pilot randomized controlled trials (RCTs): one in traumatic brain injury (TBI), the other in stroke. The combined sample comprised 32 participants; 15 receiving CBT and 17 allocated to treatment as usual (TAU). The outcome was reliable improvement on the Pittsburgh Sleep Quality Index (PSQI).

Results: Study group was a statistically significant predictor of outcome, with CBT participants more likely to achieve reliable improvements than TAU (OR?=?4.88, p?=?0.042). Study group (CBT vs. TAU) exhibited an area under the ROC curve (AUROC) of 69%. In separate CART analyzes, verbal memory (CVLT-II >45.5), age (<47.5) and baseline depression (HADS-D?>?6) predicted positive outcomes in CBT recipients. Each of these variables added a small (～5%) but not statistically significant amount to AUROC over study group.

Conclusions: In this ABI sample, better memory, younger age, and higher baseline depression were associated with positive treatment response to CBT although individually these variables were not better than group alone in predicting outcomes. The present findings generate hypotheses for further investigation in future studies.

• Implications for rehabilitation

• Cognitive behavior therapy improves sleep quality over treatment as usual in persons with acquired brain injury.

• Individuals who are younger in age with better memory and co-morbid symptoms of depression are more likely to respond to the treatment.

• These findings are based on a small sample and can be considered hypothesis generating for future clinical studies.

     

莫西沙星与左氧氟沙星治疗社区获得性肺炎的对比分析

目的对比观察莫西沙星与左氧氟沙星治疗社区获得性肺炎的临床疗效。方法分析收治的社区获得性肺炎患者临床资料,依据治疗方式不同分为莫西沙星组30例和左氧氟沙星组30例。结果莫西沙星组咳嗽消失时间、体温恢复正常时间、血常规恢复时间、胸部阴影明显吸收>50%时间均低于左氧氟沙星组,莫西沙星组细菌清除率和临床治疗总有效率均明显优于左氧氟沙星组,差异均有统计学意义(P<0.05)。结论莫西沙星治疗社区获得性肺炎临床症状改善明显,效果优于左氧左氧氟沙星,值得临床推广应用。     

支气管镜在治疗重型颅脑外伤患者院内获得性肺炎中的应用

目的 探讨支气管镜治疗重型颅脑外伤患者院内获得性肺炎的应用及护理效果. 方法 选取2013年1月至2014年5月在我院住院的重型颅脑外伤患者院内获得性肺炎( Hospital acquired pneumonia,HAP)患者100例,随机分为对照组和观察组各50例,其中对照组接受常规治疗,观察组在常规治疗的基础上接受支气管镜气道灌洗,分析比较两组治疗前后的症状、血气分析及血液化验变化情况. 结果 治疗后两组患者的HR、RR、PaCO2 及PCT均下降,PaO2 及SpO2 均上升,观察组改善缺氧及感染控制情况明显优于对照组( P<0. 05 ) ,同时观察组疗效优于对照组( P<0. 05 ) ,差异有统计学意义( P<0. 05 ). 结论 对颅脑外伤HAP患者采用支气管镜气道灌洗,并给予有针对性的护理干预,可明显改善患者缺氧状况,及时控制感染.     

Staging headache cases: reconciling the complexity of a case with the required intensity of treatment

To stage a chronic illness is to place the case along a continuum of illness progression and complexity. Staging can also identify key clinical variables and treatment targets in order to assure the most effective treatment, as well as providing the basis for measuring illness progression and improvement. Underlying an effective staging concept is the principle that to achieve clinically effective outcomes and maximal cost effectiveness, the severity and complexity of a case must be matched to the most appropriate level and intensity of care. With the growing appreciation that the primary headache disorders represent a major public health problem and the increasing need to assure the most cost effective and clinically effective care, the authors believe that the time to implement a formal staging concept for primary headaches is now upon us.     

Demographic and clinical data in acquired hemophilia A: results from the European Acquired Haemophilia Registry (EACH2)

Summary. Background: Acquired hemophilia A (AHA) is a rare autoimmune disease caused by autoantibodies against coagulation factor VIII and characterized by spontaneous hemorrhage in patients with no previous family or personal history of bleeding. Although data on several AHA cohorts have been collected, limited information is available on the optimal management of AHA. Objectives: The European Acquired Hemophilia Registry (EACH2) was established to generate a prospective, large‐scale, pan‐European database on demographics, diagnosis, underlying disorders, bleeding characteristics, treatment and outcome of AHA patients. Results: Five hundred and one (266 male, 235 female) patients from 117 centers and 13 European countries were included in the registry between 2003 and 2008. In 467 cases, hemostasis investigations and AHA diagnosis were triggered by a bleeding event. At diagnosis, patients were a median of 73.9 years. AHA was idiopathic in 51.9%; malignancy or autoimmune diseases were associated with 11.8% and 11.6% of cases. Fifty‐seven per cent of the non‐pregnancy‐related cases were male. Four hundred and seventy‐four bleeding episodes were reported at presentation, and hemostatic therapy initiated in 70.5% of patients. Delayed diagnosis significantly impacted treatment initiation in 33.5%. Four hundred and seventy‐seven patients underwent immunosuppression, and 72.6% achieved complete remission. Conclusions: Representing the largest collection of consecutive AHA cases to date, EACH2 facilitates the analysis of a variety of open questions in AHA.