艾司氯胺酮在无痛人工流产术中的临床应用

目的 采用改良序贯测定艾司氯胺酮抑制无痛人工流产术体动反应的半数有效剂量(ED50),并观察艾司氯胺酮在无痛人工流产术中的临床应用效果和不良反应。方法 选取2021年9月至2021年11月在延安市人民医院择期行无痛人工流产术且ASA I～Ⅱ级的26例患者。采用改良序贯法操作,艾司氯胺酮的初始剂量为0.3 mg/kg,相邻患者剂量差0.05 mg/kg,若上一例患者术中发生体动反应(扭臀、抬手、动腿)影响手术操作为阳性,则下一例患者增加0.05 mg/kg,反之减少0.05 mg/kg,直至出现7个拐点结束研究。计算艾司氯胺酮抑制体动反应的ED50、ED95及95%可信区间(CI),记录苏醒时间、苏醒后5 min视觉模拟评分法(VAS)疼痛评分,记录低血压、呼吸抑制(SpO₂<90%)、术后谵妄、恶心呕吐、分泌物增加等不良反应发生情况。结果 艾司氯胺酮抑制人工流产手术体动反应的ED50为0.294(95%CI:0.256～0.332)mg/kg, ED95为0.370(95%CI:0.332～0.590)mg/kg,苏醒时间(11.3±1.2)min,苏醒后5...     

手部烧伤后不同时间行外科整形修复治疗的临床效果及对关节活动度的影响

分析在手部烧伤后不同时间采取外科整形修复治疗的效果及对患者关节活动度的影响。方法 选取2022年1月-2023年4月我院收治的60例手部烧伤后瘢痕挛缩畸形患者为研究对象,根据整形修复时间不同分为对照组和观察组,每组30例。对照组于烧伤10 d后行外科整形修复,观察组于烧伤10 d内行外科整形修复,比较两组关节活动度、临床疗效、生活质量及并发症发生情况。结果 观察组治疗后ROM评分高于对照组（P ＜0.05）;观察组治疗总有效率为96.67%,高于对照组的80.00%（P ＜0.05）;观察组治疗后生活质量各项评分均高于对照组（P ＜0.05）;观察组并发症发生率为6.67%,低于对照组的26.67%（P＜0.05）。结论 针对手部烧伤后出现瘢痕挛缩畸形的患者,在烧伤后10 d内给予外科整形修复,可有效改善患者的关节活动度,有利于降低术后感染、植皮坏死等并发症发生几率,对于提升患者的预后生活质量具有积极意义。     

Implementing an internal audit to change practice: Current evidence and review of patient outcomes enabled transition to the relative motion extension approach in the postoperative management of zones IV-VI extensor tendon repairs

BackgroundEvidence supports use of the relative motion extension (RME) approach following extensor tendon repairs in zones V-VI yielding good or excellent outcomes.PurposeTo demonstrate how a 3-year internal audit and regular review of emerging evidence guided our change in practice from our longstanding use of the Norwich Regimen to the RME approach using implementation research methods. We compared the outcomes of both approaches prior to the formal adoption of the RME approach.Study DesignProspective clinical audit.MethodsA prospective audit of all consecutive adult finger extensor tendon repairs in zones IV-VII rehabilitated in our tertiary public health hand centre was undertaken between November 2014 and December 2017. Each audit year, outcomes were reviewed regarding the Norwich regimen and the RME early active motion approaches. As new evidence emerged, adjustments were made to our audit protocol for the RME approach. Discharge measurements of the range of motion of the affected and contralateral fingers and complications were recorded.ResultsDuring the 3-year audit, data was available on 79 patients (56 RME group including 59 fingers with 71 tendon repairs; 23 Norwich group including 28 fingers with 34 tendon repairs) with simple (n = 68) and complex (n = 11) finger extensor tendon zones IV-VI repairs (no zone VII presented during this time). Over time, the practice pattern shifted from the Norwich Regimen approach to the RME approach (and with the use of the RME plus [n = 33] and RME only [n = 23] approaches utilized). All approaches yielded similar good to excellent outcomes per total active motion and Miller’s classification, with no tendon ruptures or need for secondary surgery.ConclusionsAn internal audit of practice provided the necessary information regarding implementation to support a shift in hand therapy practice and to gain therapist or surgeon confidence in adopting the RME approach as another option for the rehabilitation of zone IV-VI finger extensor tendon repairs.     

Does temporary bridge plate fixation preserve joint motion after an unstable Lisfranc injury?

BackgroundRecently, temporary bridge plate fixation has gained popularity in the treatment of unstable Lisfranc injuries. The technique aims to reduce the risk of posttraumatic osteoarthritis, and after plate removal, the goal is to regain joint mobility. Here we explore marker-based radiostereometric analysis (RSA) to measure motion in the 1st tarsometatarsal (TMT) joint and asses the radiological outcome in patients treated with this surgical technique.MethodTen patients with an unstable Lisfranc injury were included. All were treated with a dorsal bridge plate over the 1st TMT joint and primary arthrodesis of the 2nd and 3rd TMT joints. The plate was removed four months postoperatively. Non- and weight-bearing RSA images were obtained one and five years postinjury to assess joint mobility and signs of osteoarthritis.ResultsDetectable 1st TMT joint motion was observed in 2/10 patients after one year, and 6/9 patients after five years. At the final follow-up, mean 1st TMT dorsiflexion was 2.0°. Radiologically, the incidence of posttraumatic osteoarthritis was present in 4/10 patients after one year, and 5/9 patients after five years. All patients had observed TMT joint stability throughout the follow-up period.ConclusionPreservation of joint motion can be achieved with a temporary bridge plate fixation over the 1st TMT joint.Type of study/level of evidenceProspective cohort study/Therapeutically level IV.     

Motion‐compensated b‐tensor encoding for in vivo cardiac diffusion‐weighted imaging

Motion is a major confound in diffusion‐weighted imaging (DWI) in the body, and it is a common cause of image artefacts. The effects are particularly severe in cardiac applications, due to the nonrigid cyclical deformation of the myocardium. Spin echo‐based DWI commonly employs gradient moment‐nulling techniques to desensitise the acquisition to velocity and acceleration, ie, nulling gradient moments up to the 2nd order (M2‐nulled). However, current M2‐nulled DWI scans are limited to encode diffusion along a single direction at a time. We propose a method for designing b‐tensors of arbitrary shapes, including planar, spherical, prolate and oblate tensors, while nulling gradient moments up to the 2nd order and beyond. The design strategy comprises initialising the diffusion encoding gradients in two encoding blocks about the refocusing pulse, followed by appropriate scaling and rotation, which further enables nulling undesired effects of concomitant gradients. Proof‐of‐concept assessment of in vivo mean diffusivity (MD) was performed using linear and spherical tensor encoding (LTE and STE, respectively) in the hearts of five healthy volunteers. The results of the M2‐nulled STE showed that (a) the sequence was robust to cardiac motion, and (b) MD was higher than that acquired using standard M2‐nulled LTE, where diffusion‐weighting was applied in three orthogonal directions, which may be attributed to the presence of restricted diffusion and microscopic diffusion anisotropy. Provided adequate signal‐to‐noise ratio, STE could significantly shorten estimation of MD compared with the conventional LTE approach. Importantly, our theoretical analysis and the proposed gradient waveform design may be useful in microstructure imaging beyond diffusion tensor imaging where the effects of motion must be suppressed.     

Cyclic Fatigue Resistance of Rotary and Reciprocating Nickel-Titanium Instruments Subjected to Static and Dynamic Tests

IntroductionThis study compared the static and dynamic cyclic fatigue resistance of contemporary nickel-titanium instruments with different kinematic, metallurgic, and design features to establish whether the fatigue-reducing effect of the pecking motion differs among different nickel-titanium instruments.MethodsProTaper Gold (PTG), Hyflex EDM (EDM), Reciproc Blue (RPB), and WaveOne Gold (WOG) files were divided into 2 groups of 10 for the static and dynamic cyclic fatigue resistance tests. A stainless steel artificial canal with 1.5-mm inner diameter, 60° angulation, and 3-mm radius of curvature was used. In the dynamic cyclic fatigue resistance test, speeds were set at 100 and 200 mm/min for the descending and ascending motion, respectively. The number of cycles to fracture (NCF) was calculated, the fractured lengths were recorded, and fractographic analysis of the fractured surfaces was carried out by scanning electron microscopy. Data were analyzed statistically with the Kruskal-Wallis test with Bonferroni correction (alpha = 0.05).ResultsThe RPB and EDM showed significantly higher NCF in the static and dynamic cyclic fatigue resistance tests (P < .05). The dynamic cyclic fatigue resistance test showed significantly higher NCF than the static cyclic fatigue resistance test in the PTG and EDM (P < .05). There was no significant difference between the RPB and WOG (P > .05).ConclusionsIn the experimental condition where the ascending speed was higher than the descending speed, the dynamic cyclic fatigue resistance was significantly higher than the static cyclic fatigue resistance in continuous rotary instruments, but not in reciprocating instruments.     

The continuum of hip range of motion: From soft-tissue restriction to bony impingement

Traditional studies of hip kinematics have not identified which anatomic structures limit the range of motion (ROM) when the hip is placed in different maneuvers. In this study, we attempted to answer two questions: (a) During which maneuvers is the motion of the hip limited by bony impingement between the femur and pelvis? (b) When is hip ROM determined by the constraint of soft tissues and to what extent? ROM of eight cadaveric hips was measured in 17 maneuvers using a motion capture system. The maneuvers were recreated in silico using 3D CT models of each specimen to detect the occurrence of bony impingement. If bony impingement was not detected, the variable component of 3D hip motion was increased until a collision was detected. The difference between the virtual ROM at the point of bony impingement and the initial ROM measured experimentally was termed as the soft-tissue restriction. The results showed that bony impingement was present in normal hips during maneuvers consisting of high abduction with flexion, and high flexion combined with adduction and internal rotation. At impingement-free maneuvers, the degree of soft tissue restriction varies remarkably, ranging from 4.9° ± 3.8° (internal rotation) at 90° of flexion to 80.0° ± 12.5° (internal rotation) at maximum extension. The findings shed light on the relative contributions of osseous and soft tissues to the motion of the hip in different maneuvers and allow for a better understanding of physical exams of different purposes in diagnosing bone- or soft tissue-related diseases.