伤口呈色显影用于预测重症肢体缺血患者血管腔内治疗后溃疡愈合的价值初探

目的 探讨伤口呈色显影预测重症肢体缺血患者血运重建术后溃疡愈合的价值.方法 回顾性分析上海交通大学医学院附属仁济医院血管外科2011年6月1日-2014年6月30日收治成功实施Angiosome概念指导腔内血运重建的重症肢体缺血的缺血性溃疡患者临床资料.根据血管腔内血运重建术后伤口呈色显影情况分组,其中伤口呈色(+)组109例,伤口呈色(-)组64例,分别比较患者保肢率,溃疡愈合时间的差异,试分析其作为重症肢体缺血的缺血性溃疡愈合预测因子的价值.采用SPSS 19.0软件进行统计学分析.正态分布计量资料以均数±标准差(x±s)表示,两组比较采用t检验.计数资料以频数和百分比表示,两组比较采用Pearson x2检验或Fisher确切概率法.结果 纳入研究患者共173例(173条患肢),两组患者年龄、性别比例、吸烟史、冠心病、糖尿病、慢性肾功能不全、术前踝肱指数、术后踝肱指数差异均无统计学意义,溃疡愈合时间:伤口呈色(+)组(3.9±1.9)个月低于伤口呈色(-)组(7.9±2.6)个月,差异有统计学意义(P＜0.05).累积保肢率:伤口呈色(+)组(90.2％)高于伤口呈色(-)组(78.0％),差异有统计学意义(P＜0.05).通过Logistic回归分析,校正年龄、性别、吸烟史、高血压异常等因素后,伤口呈色(-)(OR=4.5,P＜0.05)、IRc(间接血供有侧支)血运重建(OR =2.6,P＜0.05)均是溃疡难愈合的独立危险因素.结论 伤口呈色显影阳性显示足部循环较好,可以作为重症肢体缺血的缺血性溃疡愈合的预测因子,而伤口呈色显影阴性是溃疡难愈合的独立危险因素.     

成年癌症患者生育力保存决策体验质性研究的Meta整合

目的 系统整合癌症患者生育力保存决策体验的质性研究,为辅助癌症患者做决策及改进现有决策支持体系提供循证依据。方法 计算机检索PubMed、EMbase、The Cochrane Library、CINAHL、Web of Science、PsycINFO、Scopus、中国知网、万方数据库、维普数据库关于癌症患者生育力保存决策的质性研究,检索时限为建库至2022年8月。采用JBI循证卫生保健中心质性研究质量评价标准对文献进行质量评价,采用Meta整合中汇集性整合方法对结果进行整合。结果 共纳入18篇文献,提炼出67个研究结果,将相似结果归纳成7个新的类别,并综合成3个整合结果：对生育力保存风险-收益的艰难权衡,紧迫决策下复杂的心理变化过程,决策过程的干扰。结论 医护人员及相关卫生机构应重视癌症患者生育力保存决策的心理体验和信息需求,优化决策程序、开发决策辅助方案,促进患者尽快完成决策。     

Who needs a fine-needle biopsy? A comparison of the ATA and ACR TI-RADS guidelines in a single-centre retrospective study

The 2015 American Thyroid Association (ATA) and 2017 American College of Radiology: Thyroid Imaging, Reporting and Data System (ACR TI-RADS) guidelines are two popular guidelines adopted to stratify sonographic risk of malignancy for thyroid nodules, and to select cases for fine-needle aspiration (FNA). To understand the test performance of the two systems in predicting thyroid malignancy, 164 thyroidectomy cases performed in a regional hospital in Hong Kong between January 2021 and June 2022 were reviewed. Sonographic images of the index nodule in each case were retrospectively classified into different risk categories using the ATA and ACR TI-RADS guidelines, respectively, followed by retrieval of cytological and pathological results, for comparison. The index nodule was proven malignant in 26.8% of cases in the final pathology. There was a strong and positive correlation between the ATA and ACR TI-RADS risk categories assignment (r_s = .931, p < .001). Recommending FNA according to the ATA had a better sensitivity for malignancy than using the ACR TI-RADS (81.8% vs 72.7%), at the expense of a lower specificity (10.8% vs 40.8%). The sensitivity for malignancy of both systems could be further improved if all fluorodeoxyglucose (FDG)-avid nodules were investigated with FNA regardless of sonographic features and size. There was a statistically significant association between “nodules with FDG avidity and nodules recommended for FNA by the ACR TI-RADS guideline” and an eventual malignant thyroid nodule (p = .002).     

Postmastectomy reconstruction with extended latissimus dorsi myocutaneous flap for Hong Kong Chinese

Objective: Because of the smaller breast size of Chinese women, postmastectomy reconstruction without prosthesis by extended latissimus dorsi (LD) flap is potentially more applicable in the Chinese population. Methods: Patients who had undergone immediate postmastectomy breast reconstruction by extended latissimus dorsi flap without prosthesis were retrospectively studied. Surgical complications, aesthetic result and patient satisfaction were evaluated. Results: Ten Asian patients (nine Chinese and one Filipino) underwent extended LD flap for breast reconstruction after mastectomy. There was no total or partial flap failure. Operative complications included seroma in one patient and minor wound edge slough at back wounds in two patients. Simultaneous seroma and minor donor wound slough occurred in another patient. Aesthetic outcome was excellent (n = 5), good (n = 4) and poor (n = 1). Patient satisfaction with the procedure was very satisfied in four, satisfied in four and dissatisfied in two, respectively. All but two patients would recommend the same procedure to their friends or relatives. Conclusion: Extended LD flap can reliably achieve pleasing results with low morbidity. It has more potential to become a competitive alternative to transverse abdominis myocutaneous flap in most Chinese women for postmastectomy reconstruction.     

Bilirubin appears to be the only independent variable affecting mortality on liver transplant waiting list if waiting time exceeds 1 year

BACKGROUND: The Model for End-Stage Liver Disease (MELD) score has been shown to be the best predictor of short-term mortality on the liver transplant waiting list in the United States but waiting time often exceeds 1 year in many countries. We wanted to identify the factors affecting mortality on the liver transplant waiting list in Singapore where waiting time for liver transplant exceeds 1 year. PATIENTS AND METHODS: All patients who were listed on the liver transplant waiting list in Singapore from January 1997 to December 2003 excluding those who were transplanted were analyzed. MELD was calculated according to the United Network for Organ Sharing formula. Univariate analysis was performed to identify factors affecting mortality on the waiting list and multivariate analysis by logistic regression. Categorical and continuous variables were compared with the chi-square and Mann-Whitney U tests. RESULTS: There were 48 patients in the study. We found that on univariate analysis, bilirubin, INR, MELD score, and Child's score significantly influenced mortality on the waiting list but on multivariate analysis, bilirubin was the only independent prognostic indicator of mortality on the waiting list (LR = 1.97; 95% confidence interval = 1.08 to 3.61). INR was found to be significantly correlated to bilirubin with Pearson correlation (R = 0.63, P < .001). CONCLUSION: Bilirubin is the only independent factor affecting mortality on the liver transplant waiting list where waiting time exceeds 1 year.     

Outcomes following parotidectomy for metastatic squamous cell carcinoma with microscopic residual disease: implications for facial nerve preservation

Background.

Metastatic cutaneous squamous cell carcinoma (SCC) of the parotid is an aggressive disease, requiring combined modality treatment of surgery and adjuvant radiotherapy to achieve cure. This study aims to determine whether facial nerve preservation followed by radiotherapy is a reasonable option in patients with microscopic residual disease involving the facial nerve.

Methods.

One hundred seventy‐six patients with metastatic cutaneous SCC involving the parotid were analyzed.

Results.

In this cohort, 15 patients who underwent nerve‐sparing surgery and adjuvant radiotherapy were found to have involved margins adjacent to the facial nerve. Comparing this group to patients with clear margins showed no difference in local recurrence or survival. Only 3 patients in this group developed local recurrence, and all successfully salvaged by further surgery.

Conclusion.

This study suggests that patients with metastatic cutaneous SCC to the parotid with microscopic residual disease involving the facial nerve and normal function can be successfully treated with a facial nerve–sparing approach and timely postoperative radiotherapy. © 2008 Wiley Periodicals, Inc. Head Neck, 2009     

The reliability of determining “leg dominant pain”

Background contextPatients with back dominant pain generally have a worse prognosis after spine surgery when compared with patients with leg dominant pain. Despite the importance of determining whether patients with lumbar spine pain have back or leg dominant pain as a predictor for success after decompression surgery, there are limited data on the reliability of methods for doing so.PurposeTo assess the test-retest reliability of a patient's ability to describe whether their lumbar spine pain is leg or back dominant using standardized questions.Study design/settingProspective, blinded, test-retest cohort study performed in an academic spinal surgery clinic.Patient sampleConsecutive patients presenting for consultation to one of three spinal surgeons for lumbar spine pain were enrolled.Outcome measuresEight questions to ascertain a patient's dominant location of pain, either back dominant or leg dominant, were identified from the literature and local experts.MethodsThese eight questions were administered in a test-retest format over two weeks. The test-retest reliability of these questions were assessed in a self-administered questionnaire format for one group of patients and by a trained interviewer in a second group.ResultsThe test-retest reliability of each question ranged from substantial (eg, interviewer-administered percent question, weighted kappa=0.77) to slight (eg, self-administered pain diagram, weighted kappa=0.09). The Percent question was the most reliable in both groups (self-administered, interviewer). All questions in the interviewer-administered group were significantly (p<.001) more reliable than the self-administered group. Depending on the question, between 0% and 32% of patients provided a completely opposite response on test-retest. There was variability in prevalence of leg dominant pain, depending on which question was asked and there was no single question that identified all patients with leg dominant pain.ConclusionA patient's ability to identify whether his or her lumbar spine pain is leg or back dominant may be unreliable and depends on which questions are asked, and also how they are asked. The Percent question is the most reliable method to determine the dominant location of pain. However, given the variability of responses and the generally poorer reliability of many specific questions, it is recommended that multiple methods be used to assess a patient's dominant location of pain.     

Factors for conversion in laparoscopic cholecystectomy for acute cholecystitis: Is timing important?

Aim: Laparoscopic cholecystectomy is regarded as the gold standard treatment for gallstones. Conversion to open cholecystectomy is still common, and preoperative factors to predict conversion are useful in clinical practice. The aim of this study was to evaluate preoperative factors that could predict conversion in acute cholecystitis. Methods: This is a retrospective review of 83 patients with a diagnosis of acute cholecystitis who had laparoscopic cholecystectomy carried out as an emergency operation. Clinical, biochemical, and operative factors were analyzed for association with conversion. Results: A total of 83 patients were recruited to this study. The overall conversion rate was 33.7% (28/83). A longer duration of symptoms before presentation (P = 0.005) and surgery that was carried out over 48 h after admission (P = 0.022) were associated with a higher conversion rate. Emergency operations that began between 20.00 hours and 08.00 hours were also associated with a higher rate of conversion (P = 0.003). Other factors that were associated with conversion included male sex (P = 0.004), low albumin level upon admission (P = 0.024), prolonged prothrombin time (P = 0.040), and a raised serum total bilirubin level (P = 0.024). ASA scores were found to be similar in both groups (P = 0.509). Multivariate analysis by logistic regression showed that the independent risk factors for conversion in emergency laparoscopic cholecystectomy were surgery >48 h after admission (P = 0.028), emergency operation started between 20.00 hours and 08.00 hours (P = 0.026), and longer duration of symptoms before presentation (P = 0.034). Conclusions: Laparoscopic cholecystectomy should be carried out within 48 h of the patient being admitted for acute cholecystitis. The operation should be carried out during the daytime.     

Can cost utility evaluations inform decision making about interventions for low back pain?

Background contextLow back pain (LBP) is associated with high health-care utilization and lost productivity. Numerous interventions are routinely used, although few are supported by strong evidence. Cost utility analyses (CUAs) may be helpful to inform decision makers.PurposeTo conduct a systematic review of CUAs of interventions for LBP.Study designSystematic review.MethodsA search strategy combining medical subject headings and free text related to LBP and health economic evaluations was executed in MEDLINE. Cost utility analyses combined with randomized controlled trials for LBP were included. Studies that were published before 1998, non-English, decision analyses, and duplicate reports were excluded. Search results were evaluated by two reviewers, who extracted data independently related to clinical study design, economic study design, direct cost components, utility results, cost results, and CUA results.ResultsThe search produced 319 citations, and of these 15 met eligibility criteria. Most were from the United Kingdom (n=8), published in the past 3 years (n=12), studied chronic LBP or radiculopathy (n=13), and had a follow-up >12 months (n=13). Combined, there were 33 study groups who received a mean 2.1 interventions, most commonly education (n=17), exercise therapy (n=13), spinal manipulation therapy (n=7), surgery (n=7), and usual care from a general practitioner (n=7). Mean baseline utility was 0.57, improving to 0.67 at follow-up; the mean difference in utility improvement between study groups was 0.04. Based on available data and converted to US dollars, the cost per quality-adjusted life year ranged from $304 to $579,527, with a median of $13,015.ConclusionsFew CUAs were identified for LBP, and there was heterogeneity in the interventions compared, direct cost components measured, indirect costs, other methods, and results. Reporting quality was mixed. Currently published CUAs do not provide sufficient information to assist decision makers. Future CUAs should attempt to measure all known direct cost components relevant to LBP, estimate indirect costs such as lost productivity, have a follow-up period sufficient to capture meaningful changes, and clearly report methods and results to facilitate interpretation and comparison.     

Systematic Review of the Prevalence of Radiographic Primary Hip Osteoarthritis

Hip osteoarthritis is a common cause of musculoskeletal pain in older adults and may result in decreased mobility and quality of life. Although the presentation of hip osteoarthritis varies, surgical management is required when the disease is severe, longstanding, and unresponsive to nonoperative treatments. For stakeholders to plan for the expected increased demand for surgical procedures related to hip osteoarthritis, including arthroplasty, it is important to first understand its prevalence. We conducted a systematic review by searching MEDLINE® and EMBASE to identify recent English language articles reporting on the prevalence of radiographic primary hip osteoarthritis in the general adult population; references including studies and primary studies from previous systematic reviews were also searched. This strategy yielded 23 studies reporting 39 estimates of overall prevalence ranging from 0.9% to 27% with a mean of 8.0% and a standard deviation of 7.0%. Heterogeneity was noted in study populations, eligibility criteria, age and gender distribution, type of radiographs, and method of diagnosis. Although the association between radiographic hip osteoarthritis and the need for eventual surgical management is still unclear, this study supports assertions that hip osteoarthritis is a prevalent condition whose treatment will continue to place important demands on health services.