踝部开放性骨折的急症手术治疗

目的探讨踝部开放性骨折的损伤特点及相关的急症手术技术特点。方法2001年8月至2006年4月，急症手术治疗踝部开放性骨折51例，男39例，女12例；年龄18-72岁，平均36岁。伤口Gustilo分度，Ⅰ度3例，Ⅱ度37例，ⅢA度7例，ⅢB度3例，ⅢC度1例。急诊给予有效抗生素治疗，尽早开始手术。冲洗及彻底清创后，根据骨折类型、粉碎程度及伤口情况制定骨折处理的顺序，依次完成骨折复位、固定。结果48例患者获得随访，随访时间8-48个月，平均26个月。无一例发生深部感染。12例伤口发生浅表皮缘坏死，2例伤口延迟愈合，2例伤口发生浅表感染。踝部骨折在10-18周（平均13周）愈合。采用AOFAS踝后足功能评分标准，48例评分在76-100分，平均90分。结论踝部开放性骨折在急症手术时应彻底清创，注意保护皮肤活力。在处理后踝骨折时，可采用胫骨远端脱出法。多数手术应先精确复位、固定外踝骨折，对旋后内收型、外踝严重粉碎的踝部骨折应先进行内踝骨折的复位、固定。对严重的下胫腓联合分离，应直视下复位且常规使用下胫腓螺钉固定。     

National Alliance for Oral Health Consensus Conference on Medically Necessary Oral Health Care: Legal issues

This paper examines medical malpractice law as it applies to medically necessary oral health care. The basic legal concepts and reported cases involving medically necessary oral health care are reviewed. It is concluded that dental professionals and consumer advocates must advance their educational and legislative advocacy efforts so that health professional colleagues and the public will become aware of the importance of these services and insurers will routinely include coverage of medically necessary oral health care in their medical and dental policies. While failure to provide medically necessary oral health care can be violative of patient rights and legally actionable, medical malpractice litigation should always be the behavior modifier of last resort.     

The relationship of life adversity, social support, and coping to hospitalization with major depression.

We evaluated the relationship between life events, social support, coping, and depression in 27 male inpatients meeting the requirements for Research Diagnostic Criteria major depressive disorder and in 35 age- and sex-matched nonpatients. Overall, the hospitalized depressed patients reported significantly more events and difficulties than did the controls, but this difference in statistical significance disappeared after excluding from analysis "non-independent" happenings which could have been brought on by depression. More hospitalized depressed patients (23 of 27, or 85%) than controls (8 of 35, or 22.9%) experienced markedly threatening events and difficulties ("marked adversities") in the 6 months before their interview. The depressed group also reported having significantly fewer social supports, being less satisfied with the emotional component of this support, and using more emotion-focused coping than the controls. A discriminant analysis predicted depressive status from a combination of marked adversities, reduced number of social supports, and greater use of emotion-focused coping. The results indicate that the relationship of life events to depression is complex. The excess number of events might be partly a product of dysfunctional behavior that "produces" depression-related events which might, in turn, exacerbate depression; simultaneously, patients are more likely to experience highly adverse events which might precipitate the depression in the first place. Reduced social supports and the use of emotion-focused coping appear to also be associated with hospitalization for major depression.     

Semantic dementia with category specificity:acomparative case-series study

Patients with semantic dementia, the temporal variant of frontotemporal dementia, are relevant to both the neuroanatomical and neuropsychological debates in the category-specific literature. These patients present with a selective and progressive semantic deficit consequent on circumscribed atrophy of the inferolateral polar temporal lobes bilaterally, including the inferotemporal gyrus. In this study, a patient KH with a significant advantage for artefacts over living things was compared to five other semantic dementia patients with commensurate levels of semantic impairment. KH demonstrated a consistent category difference in favour of artefacts across all the expressive and receptive semantic tests. This difference was reliable even when familiarity, frequency, and other potential confounding factors were controlled. While KH demonstrated an association between poor knowledge of sensory attributes and a consistently greater impairment on living things than artefacts, the other patients did not. As observed in a number of previous studies, all five of the patients, contrasted to KH, exhibited an advantage for functional/associative over sensory attributes but without demonstrating the category-specific deficit that the sensory-functional theory (and the locus of their atrophy) might predict. The results of this and other studies are discussed in relation to four accounts of category specificity: the sensory-functional theory, domain-specific knowledge systems, intercorrelated features, and individual differences.     

Gamma-Ray Induction of Malignant Tumors in Rats

Sources of protracted gamma radiation adjacent to bone were found to induceosteogenic sarcoma in half of the exposed males. Osteogenic sarcomas appeared in 3 males remote from the radioactive sources and may not have been radiation induced. Some tumors were small enough so that the site of origin could be determined accurately: some arose from endosteum, others from periosteum. Although portions of the skeleton in the female rats incidentally received doses of over 20,000 rads, no osteogenic sarcomas developed in them. Parauterine sources induced adenocarcinoma of the endometrium in 14 of 32 rats (44%). The incidence of carcinoma of the ovary (12%) was lower than expected. Carcinomas of the breast were frequent, but often distant from the source. Increased total dose, which was usually related to length of time of exposure, produced an increased incidence of cancer and a shortening of the latent period. However, extremely high doses (over a million rads to bone and hundreds of thousands to the uterus) at times failed to induce cancers.     

A study of post traumatic stress disorder in Vietnam veterans

Three groups of Vietnam-era veterans were compared on the frequency of symptoms typical of the diagnostic criteria for Post Traumatic Stress Disorder (PTSD), a diagnostic category introduced in DSM III (N = 90). The three groups consisted of veterans who had experienced (a) a war-related traumatic event; (b) a non-war-related traumatic event; or (c) no traumatic event. The results indicated that the two groups who experienced a traumatic event reported significantly more symptoms than the group who never experienced a traumatic event. Furthermore, the group who experienced a war-related traumatic event reported more symptoms than the group who experienced a non-war-related traumatic event. These results support the validity of PTSD.     

Replacement of Candida albicans with C. dubliniensis in human immunodeficiency virus-infected patients with oropharyngeal candidiasis treated with fluconazole

Candida dubliniensis is an opportunistic yeast that has been increasingly implicated in oropharyngeal candidiasis (OPC) in human immunodeficiency virus (HIV)-infected patients but may be underreported due to its similarity with Candida albicans. Although most C. dubliniensis isolates are susceptible to fluconazole, the inducibility of azole resistance in vitro has been reported. Thus, the use of fluconazole prophylaxis in the treatment of these patients may have contributed to the increasing rates of isolation of C. dubliniensis. In this study, yeast strains were collected from the oral cavities of HIV-infected patients enrolled in a longitudinal study of OPC. Patients received fluconazole for the suppression or treatment of OPC, and isolates collected at both study entry and end of study were chosen for analysis. Samples were plated on CHROMagar Candida medium for initial isolation and further identified by Southern blot analysis with the species-specific probes Ca3 (for C. albicans) and Cd25 (for C. dubliniensis). Fluconazole MICs were determined by using NCCLS methods. At study entry, susceptible C. albicans isolates were recovered from oral samples in 42 patients who were followed longitudinally (1 to 36 months). C. albicans strains from 12 of these patients developed fluconazole resistance (fluconazole MIC, >/=64 micro g/ml). C. dubliniensis was not detected at end of study in any of these patients. Of the remaining 30 patients, eight (27%) demonstrated a replacement of C. albicans by C. dubliniensis when a comparison of isolates obtained at baseline and those from the last culture was done. For the 22 of these 30 patients in whom no switch in species was detected, the fluconazole MICs for initial and end-of-study C. albicans isolates ranged from 0.125 to 2.0 micro g/ml. For the eight patients in whom a switch to C. dubliniensis was detected, the fluconazole MICs for C. dubliniensis isolates at end of study ranged from 0.25 to 64 micro g/ml: the fluconazole MICs for isolates from six patients were 0.25 to 2.0 micro g/ml and those for the other two were 32 and 64 micro g/ml, respectively. In conclusion, a considerable number of patients initially infected with C. albicans strains that failed to develop fluconazole resistance demonstrated a switch to C. dubliniensis. C. dubliniensis in this setting may be underestimated due to lack of identification and may occur due to the impact of fluconazole on the ecology of oral yeast species.