整形外科研究的循证医学证据水平

目的 近年来,医学、外科类文献有向循证医学方向发展的趋势.本研究旨在检测已发表的整形外科类文章的证据水平.方法 回顾性分析<整形再造外科杂志(Plastic and Reconstructive Surgery,PRS)><整形外科年鉴(Annals of Plastic Surgery,Annals)><整形再造与美容外科杂志(Journal of Plastic,Reconstructive,and Aesthetic Surgery,JPRAS)><美国美容外科杂志(American Journal of Aesthetic Surgery,Aesthetic)>4本主要的整形外科类杂志2009年1～12月刊载论文利用证据的水平.结果 在1759篇文献中,共有726篇(41%)纳入本研究标准(排除动物实验、尸体研究、基础医学、文献复习、继续教育和信函等方面文献).将选中的文献根据其证据水平进行分级(Ⅰ～Ⅳ级;Ⅰ级,证据水平最高,如随机对照研究;Ⅳ级,证据水平最低,如病例报告).4本杂志的平均证据水平分别为:PRS=3.05,Aesthetic=3.11,JPRAS=3.35,Annals=3.31.4本杂志的平均证据水平,除了JPRAS与Aesthetic的差异无统计学意义外,余者差异均有统计学意义(P<0.05).本研究纳入标准的文献,只有2.2%的证据水平为Ⅰ级.结论 4本杂志的平均证据水平为3.2(Ⅲ级水平).为了使整形外科专业加入到高水平循证医学行列,我们应当在今后的工作中着重强调随机对照研究的应用.     

Spontaneous closure of pseudoaneurysm after transapical aortic valve implantation

Transcatheter aortic valve implantation by an apical approach has been developed as an alternative to conventional aortic valve replacement. Complications with these relatively new procedures are being reported. We report a case of transapical transcatheter aortic valve implantation, in which a pseudoaneurysm at the apex of the left ventricle as a complication of the procedure developed in the patient and was treated without surgery. The defect spontaneously closed.     

Pain after percutaneous radiofrequency ablation of renal tumors

BACKGROUND AND PURPOSE: Most patients have minimal pain after percutaneous radiofrequency ablation (RFA) of a renal tumor. However, anecdotally, there is some variation in the amount of patient discomfort. Our goal was to identify relevant patient factors and characteristics of their renal tumors that may influence pain after percutaneous RF ablation. PATIENTS AND METHODS: We performed a retrospective chart review of 59 sequential patients who received percutaneous RFA between 2001 and 2005 at a single institution. Data on patient age, sex, body mass index (BMI), and narcotic administration in the periprocedural period were available for 46 patients. Preoperative imaging (CT or MRI) was reviewed to determine tumor size and location, as well as the shortest distance of the mass to the body-wall musculature. RESULTS: The distance from the renal mass to the body-wall musculature was significantly correlated with the total narcotics received in the periprocedural period. This measured distance did not correlate with the patient's BMI. No other relations between patient factors or tumor characteristics and peri-procedural narcotic usage were identified. CONCLUSION: Patients whose tumors lie close to their body-wall musculature have greater narcotic requirements in the periprocedural period. Knowledge of this correlation should result in better patient counseling and help anticipate periprocedural analgesia requirements.     

Fractured neck of femur in a child after femoral fracture fixation by intramedullary flexible nails: a case report

Since the introduction of flexible intramedullary nails, the treatment of femoral shaft fractures in adolescents has been revolutionized and this has become the routine treatment in most units, with minimal complications. We report a rare complication of an ipsilateral fractured neck of femur in a fit and healthy 12-year-old girl 6 months after treatment of a traumatic fractured femoral shaft; this was treated effectively with cannulated screws and the patient was successfully discharged without any further complication.     

Persistant dysphonia following endotracheal intubation

Voice production is a complex process that involves more than one system, yet most causes of dysphonia are attributed to disturbances in the laryngeal structures and little attention is paid to extralaryngeal factors. Persistent dysphonia after general anesthesia is a challenge to both anesthesiologists and otolaryngologists. The etiology is often multivariable and necessitates a team approach for proper diagnosis. Laryngeal symptoms are subdivided into phonatory disturbances and airway related complaints. When they become persistent for more than 72 hours or are coupled with airway symptoms such as hemoptysis, stridor, dyspnea or aspiration, the anesthesiologist should suspect injury to the vocal folds or cricoarytenoid joints. Here-below, the laryngeal manifestations of endotracheal intubation and the pathophysiology of vocal fold scarring are discussed.     

Control of the vertebral artery from a posterior approach: a technical report

Background contextVertebral artery (VA) injury is a rare but potentially devastating complication of cervical spinal fusion. The Magerl and Harms techniques are associated with a rate between 0% to 8% and 0% to 5%, respectively. Most of reported VA injuries are related to surgical exposure or screw placement, which in turn is likely due to variability in VA anatomy.PurposeThe purpose of this report was to present the case of a 77-year-old woman, with a history of right VA occlusion, who sustained an intraoperative left VA injury during posterior cervical spine fusion and the subsequent intraoperative and postoperative management strategies.Study designThis is a single-patient case report.MethodsThe patient was placed prone and into Mayfield tongs. A midline incision was made, and dissection was carried down to the lamina and facet joints from occiput to T2. During dissection, she sustained a left-sided VA injury, which was subsequently controlled.ResultsThe patient was doing well at her 1-year postoperative visit without any residual neurologic deficits. Her severe neck pain had resolved.ConclusionA detailed understanding of VA anatomy of each individual patient is paramount. There are four types of anomalies: intraforaminal; extraforaminal; arterial; and anomalies of the surrounding bony and soft-tissue architecture. In the event of a posterior intraoperative VA injury, we outlined an algorithm to deal with this complication: control bleeding temporarily to gain visualization of the arterial injury; remove lateral masses and tissue to adequately visualize the arterial injury; once visualized, control the bleeding and see if there are any neuromonitoring changes as a result of the VA occlusion; and proceed with definitive control of the artery by either repair or ligation.     

Timing of CMV‐specific effector memory T cells predicts viral replication and survival after allogeneic hematopoietic stem cell transplantation

The aim of this study was to characterize timing, kinetic, and magnitude of CMV‐specific immune response after hematopoietic stem cell transplantation (HSCT) and its ability to predict CMV replication and clinical outcomes. Using cell surface and intracellular cytokine staining by flow cytometry, CMV‐specific T‐cell response was measured in blood, while CMV viral load and chimerism were determined by real‐time PCR. Patients that reconstituted CMV‐specific T‐cell response within 6 weeks after Allo‐SCT showed a more robust immune response (CD8⁺: 0.7 cells/μl vs. 0.3/μl; P‐value = 0.01), less incidence of CMV replication (33% vs. 89.5%; P‐value = 0.007), reduced viral loads (1.81 log copies/ml vs. 0 copies/ml; P‐value = 0.04), and better overall survival (72%; CI: 0.53–0.96 vs. 42% CI: 0.24–0.71; P‐value = 0.07) than patients with a delayed immune reconstitution. Viremic patients had significantly higher transplant‐related mortality than nonviremic patients after 1 year (33% CI: 0.15–0.52 vs. 0% CI: 0.05–0.34; P‐value = 0.01). Risk factors independently associated with viral replication were receptor pretransplant CMV‐positive serostatus (P‐value = 0.02) and acquiring CMV‐specific T‐cell response after 6 weeks post‐transplantation (P‐value = 0.009). In conclusion, timing of acquiring a positive CMV‐specific T‐cell immune response after transplantation may identify patients with different risk for viral replication and different clinical outcomes, including survival.     

The prevalence of anxiety and depression among end-stage renal disease patients on hemodialysis in Saudi Arabia

Depression commonly overlaps with uremic symptoms, but anxiety is less commonly studied among renal patients. The symptoms of medical illness, along with the psychological and social stresses that often accompany a debilitating chronic disease, are thought to produce deleterious psychological consequences. We sought to determine the prevalence and predictors of anxiety and depression among Saudi dialysis patients in Makkah. A cross-sectional study of anxiety and depression among end-stage renal disease (ESRD) patients in Makkah was conducted in November 2011. The Hospital Anxiety and Depression Scale (HADS) was used to screen for anxiety and depression. Participants’ demographic data, possible stressors and past psychiatric history were obtained. All participants were Saudi ESRD patients on maintenance hemodialysis. According to HADS, 57 (21.1%) patients were probable cases of anxiety and 63 (23.3%) were probable cases of depression. Only 32 (11.3%) were diagnosed with depression or anxiety before ESRD onset. Age was a significant predictor of anxiety and depression diagnoses. Major family problems (p?=?0.001) were also a significant predictor of anxiety. Anxiety and depressive symptoms are prevalent among ESRD patients in Makkah, and anxiety can be predicted by family factors. Early detection, management and family support might improve clinical outcomes.     

Outcomes of metastatic breast cancer patients in relationship to disease‐free interval following primary treatment of localized disease; a pooled analysis of two clinical trials

The aim of the current study is to assess the impact of disease‐free interval (DFI) following treatment of primary localized breast cancer on the outcomes of patients with subsequent metastatic breast cancer treated with first‐line docetaxel chemotherapy. This study is a combined analysis of patient‐level raw data of 604 metastatic breast cancer patients referred for docetaxel first‐line chemotherapy in two clinical trials. Overall survival and time to progression were evaluated according to DFI through Kaplan‐Meier analysis. Multivariate analysis of factors affecting overall survival and time to progression was then conducted through Cox regression analysis. For the overall cohort, shorter DFI is associated with worse overall survival (P < 0.0001). When classified by the hormone receptor status, the shorter interval was associated with worse overall survival in both hormone receptor positive and negative patients (P = 0.009; P = 0.018; respectively). Likewise, shorter DFI is associated with shorter time to progression (P < 0.0001) in the overall cohort. When classified by the hormone receptor status, the shorter interval was associated with shorter time to progression for hormone receptor negative but not positive patients (P = 0.001; P = 0.070; respectively). In multivariate Cox regression analysis, the following factors were associated with worse overall survival: shorter DFI (P < 0.0001), poorer ECOG performance score (P = 0.008) and lower body mass index (P = 0.018). Likewise, in multivariate Cox regression analysis, the following factors were associated with shorter time to progression: shorter DFI (P < 0.0001) and hormone receptor negative status (P = 0.025). Shorter DFI was associated with worse overall survival and shorter time to progression among patients receiving first‐line docetaxel chemotherapy.