Outcome after traumatic frontal intracerebral haemorrhage: a comparison of unilateral and bilateral haematomas

Frontal intracerebral haemorrhage (ICH) is a common result of cranial trauma. Outcome differences between bilateral and unilateral frontal ICH are not well studied but would be valuable to predict prognosis in clinical practice. Two aims are proposed in this study: first to compare the risk of developing delayed ICH after bilateral or unilateral frontal ICH, and second to determine the variables helpful to predict outcome according to the Glasgow Outcome Scale (GOS). Between January 1993 and December 1997, 694 consecutive patients with traumatic ICH were admitted to the Chang Gung Medical Center within 24 h of the trauma. Patients with ICH in sites other than the frontal lobes were excluded. A total of 161 cases (mean age 46.3+/-20.3 years), including 57 bilateral (mean age 52.5+/-18.7 years) and 104 unilateral (mean age 42.9+/-20.5 years) traumatic frontal ICH were studied. Twenty-eight of 57 patients (49%) with bifrontal ICH versus 17 of 104 patients (16%) with unilateral frontal ICH had a further, delayed ICH. In 42 of 45 patients (93%) with delayed ICH, this occurred within 5 days of the initial trauma. Multivariate logistic regression was used to select significant predictors of outcome. We found that delayed ICH (p<0.001), age (p=0.004) and mechanism of injury (p=0.001) explained the worse outcome in patients with bifrontal ICH. The best-fitting logistic regression model included three variables: delayed ICH (p=0.011), initial GCS (p=0.023), and a sum score of clinical and radiological variables (p=0.003). Bifrontal ICH tended to occur in older patients after a fall and was associated with a higher risk of developing delayed ICH or brain stem compression compared to unilateral ICH damage. Using these three variables - delayed ICH, initial GCS, and the sum score - in a logistical regression model is useful to predict outcome in patients with traumatic frontal ICH and may aid patient management.     

Prevalence of silent myocardial ischemia in asymptomatic individuals with subclinical atherosclerosis detected by electron beam tomography

BACKGROUND: Electron beam tomography coronary calcium imaging is an evolving technique for the early detection of coronary atherosclerosis, and recent studies have established its prognostic value in asymptomatic individuals. The relationship of coronary artery calcium scores (CAC) to obstructive coronary artery disease (CAD) has been poorly studied but is clinically relevant because it determines which individuals are likely to benefit from revascularization procedures. Hence, we prospectively evaluated the prevalence of myocardial ischemia in asymptomatic patients with cardiovascular risk factors and subclinical atherosclerosis. METHODS AND RESULTS: We studied 864 asymptomatic patients with no previous CAD but with cardiovascular risk factors, referred for electron beam tomography coronary calcium imaging to our institution over an 18-month period. From this group, 220 consecutive patients (85% men; mean age, 61 +/- 9 years; age range, 31-84 years) with moderate to severe atherosclerotic disease (coronary calcium score > or =100 Agatston units) were prospectively evaluated by technetium 99m sestamibi single photon emission computed tomography (SPECT). Patients were followed up (mean follow-up, 14 months) and data regarding their subsequent clinical management recorded. Of the 220 patients, 119 had moderate atherosclerosis (CAC score of 100-400 Agatston units) and 101 had severe atherosclerosis (CAC score > or =400 Agatston units). Abnormal SPECT findings were seen in 18% of patients with moderate atherosclerosis (n = 21) and 45% of patients with severe atherosclerosis (n = 45). Increasing severity of atherosclerosis was related to increasing ischemic burden (summed difference score = 1 +/- 0.2 for CAC score of 100-400 Agatston units and 3.2 +/- 0.5 for CAC score > or =400 Agatston units). In a multivariate linear regression model incorporating risk factors, CAC was the only predictor of silent ischemia. CONCLUSION: In comparison to previously published data, we detected a higher prevalence of silent ischemia even in patients with moderate coronary atherosclerosis (18%). This may reflect the differing risk factor profile of our patient population. When coronary calcium screening is used to preselect asymptomatic patients with cardiovascular risk factors for myocardial perfusion imaging, the optimum coronary calcium score threshold will depend on the population prevalence of risk factors and asymptomatic obstructive CAD.     

胫骨高位截骨对胫骨近端解剖形态的影响

[目的]测量胫骨高位截骨术后胫骨近端解剖形态,并与术前比较,探讨其变化的临床意义.[方法]2001～2005年,35例(59膝)因膝关节内侧室骨性关节炎接受胫骨高位截骨术患者的完整影像学资料,在术前、术后标准正侧位X线片中测量胫骨角;胫骨后倾角度;胫骨近端关节面外移;关节线高度.所得资料采用配对t检验进行统计学分析,以P＜0.01为差异有显著性意义.[结果]胫骨角术前平均为99.1°±4.3°,术后平均为91.1°±3.8°;胫骨后倾角度术前平均为8.9°±2.6°,术后平均为5.0°±2.3°;胫骨近端关节面外移术前平均为(46.2±3.6)%,术后平均为(53.1±3.9)%;关节线高度术前平均(41.2±3.6)mm,术后平均(38.0±3.2)mm.手术前后差异均有显著性意义(P＜0.01).[结论]胫骨近端解剖形态在胫骨高位截骨术后会发生明显变化,如胫骨角变小,后倾角度变小,胫骨近端关节面外移,关节线高度相对下降等,将对转行全膝关节置换术产生不良影响.     

New sonographic techniques for the diagnosis and treatment of hepatocellular carcinoma

Ultrasound (US) contrast agents such as Levovist and Sonazoid are now commercially available in Japan. Innovative contrast agents and ultrasound technologies have dramatically changed both diagnostic and treatment strategies for hepatocellular carcinoma (HCC). Contrast-enhanced US is extremely useful in the differential diagnosis of hepatic tumors as well as in evaluation of post-treatment response of HCC after lipiodol transarterial chemoembolization and radio frequency ablation. Harmonic US sensitively detects residual cancer cells in HCC patients after treatment, to facilitate accurate guidance for needle insertion for US monitoring; no other imaging modalities, including computed tomography (CT) or magnetic resonance imaging (MRI), have such capability. In 2005, the breakthrough technology of pure arterial phase imaging, which depicts only intranodular arterial accumulated maximum intensity projection images, was developed from advanced raw data storing and accumulation technologies. This technique can clearly identify whether blood supplyin the tumor is of arterial or portal origin, to facilitate the non-invasive characterization of nodular lesions associated with liver cirrhosis. Again, CT or MRI do not have such capabilities. This innovative technique can help differentiate premalignant lesions from overt HCC. Concurrent real-time imaging of multi-detector CT and US, known as real-time virtual sonography, has recently become available. This technique greatly facilitates the treatment guidance for HCC. These newly introduced sonographic techniques are dramatically changing the diagnostic and therapeutic strategies for HCC, which are expected to improve the prognosis of HCC patients.     

Computerised and technical navigation in total knee-arthroplasty

Abstract The objective of the study was to evaluate the precision, concordance, practicability and the early clinical outcome of the use of a computerised navigation system in a comparative study with a group of 100 patients. Two groups of 50 patients each underwent implantation of a bicondylar knee prosthesis either by means of the freehand navigation system or by means of technical instrumentation. We found that the computerised navigation system provided a higher precision than the technically instrumented implantation: 94% of the prostheses implanted with the navigation system have an alignment within a range of -3° to 3° on of the Mikulicz line. Only 46% of the patients operated by means of the technical instrumentation reached this aspired result. Furthermore, the navigation system showed smaller ranges in the deviation of the aspired alignment. The radiological and computer-modeled alignment values differed both pre- and postoperatively, but to a larger extent before surgery. The varus or valgus deviations of the axis were more distinct radiologically under the weight of the patient’s body than in the computer model. The clinical outcome examined by the use of the HSS score after a mean followup of 7 months is good in both groups, and without significant differences. On average, the duration of surgery was 13 minutes longer in the computerised navigation group. We conclude that the benefit of the computerised navigation system is represented by the high improvement of precision. Achieving early clinical results identical to those in the technical instrumentation group, we expect a reduction of aseptic loosening in the computerised navigation group.     

The patella and tibial condyle position after combined and after closing wedge high tibial osteotomy

High tibial osteotomy changes the patella and tibial condyle position, which makes the subsequent total knee replacement technically demanding. From 1 January 1993 to 31 December 2000, combined osteotomy [After the first osteotomy made 2 cm distally to the joint line, a bone wedge is removed based laterally. Its tip ends at the center of the tibial condyle (half bone wedge). The distal part of the tibia is placed into the valgus position and the half bone wedge is placed into the gap opened medially.] was performed on 103 knees and closing wedge osteotomy was performed on 47 consecutive knees. Eighty combined (group A) and 41 closing wedge (group B) osteotomy were studied. All knees were assessed radiologically before surgery, in the 10th postoperative week, in the 12th postoperative month and at the time of the final follow-up (in group A—66.15 months, in group B—66.61 months). We examined the change of the femorotibial angle, of the patellar height according to the method of Insall and Salvati, of the tibial slope angle according to the method of Bonnin, of the tibial condylar offset according to the method of Yoshida and of the distance between the lateral tibial plateau and the top of the fibular head. In group A and B, the recurrence of the varus deformity was not noted and valgus alignment did not increase in any case. In group-A, the Insall–Salvati ratio remained unchanged in 65% of knees. The tibial slope angle decreased in both groups. There was correlation between the change of the tibial condylar offset and the angle of the correction in both groups. There was correlation between the change of the distance between the lateral tibial plateau and the top of the fibular head. After combined osteotomy, the transposition of the tibial condyle and the decrease of the distance between the lateral tibial plateau and the top of the fibular head was less than after closing wedge osteotomy, although the average angle of correction was more after combined osteotomy (11.835°), than after closing wedge osteotomy (9.465°). Theoretically, the recurrence of the varus deformity, the increase of the valgus alignment and (in majority of cases) the shortening of the patellar tendon do not compromise the likelihood of successful conversion to the subsequent total knee replacement, either after combined or after closing wedge osteotomy. The combined osteotomy does not lead to considerable transposition of the tibial condyle and to considerable lateral tibial bone loss; therefore, theoretically, the combined osteotomy does not impair the subsequent total knee replacement.     

早期扩髓髓内钉固定治疗合并胸部损伤的股骨干骨折

目的探讨合并胸部损伤的股骨干骨折早期扩髓及髓内钉固定是否增加并发症及死亡率. 方法采用回顾性对比分析,依据下列标准选择病例(1) 年龄在17～65岁;(2) 必须有胸部损伤[简明损伤定级(AIS)≥2], 且损伤严重度评分(ISS)≥16;(3) 住院时间≥48 h;(4) 病史中无明显影响全身状况的疾病, 如糖尿病, 慢性心、肺、肾功能不全等;(5) 有股骨干骨折, 且进行了扩髓髓内钉固定, 不含钢板、外固定支架或牵引及石膏固定者.并按受伤至手术时间划分为两组, A组为<24 h手术者(早期扩髓组), B组为≥24 h手术者(延期扩髓组),将两组间合并伤情况、ISS、住院时间、ICU时间、并发症、死亡及合并休克情况进行比较. 结果有96例符合上述标准, 其中A组57例, B组39例,经统计学处理, 两组间仅在股骨开放性骨折发生率(A组53%,B组31%,χ2=4.496, P<0.05)、合并休克率(A组51%, B组28%,χ2=4.895, P<0.05 )及住院时间[A组为(17.5±6.5)d, B组为(31.5±9.5)d,t=8.599, P<0.001]上差异有显著性意义和非常显著性意义, 而两组并发症发生率和死亡率等方面比较, 差异无显著性意义(P>0.05). 结论在合并胸部损伤的股骨干骨折中,只要能控制休克,保证生命体征平稳,对股骨干骨折行早期扩髓髓内钉固定不增加患者的并发症发生率及死亡率,并可促进患者早日康复,缩短住院时间.