89例下肢瘢痕癌的诊治体会

目的：总结下肢瘢痕癌的临床特点及其诊治方法。方法：回顾性分析中南大学湘雅医院烧伤重建外科 1998年1月至2017年12月收治的89例下肢瘢痕癌患者的临床资料,包括人口统计学、致伤因素、癌变潜伏期、病变部 位、溃疡面积、病理类型、骨质侵犯、淋巴结转移情况、手术方式、修复方法与预后等。结果：89例下肢瘢痕癌患 者中,男70例,女19例;最常见致伤因素依次为火焰烧伤(42例)、创伤(19例)、烫伤(12例)。病变最常见于小腿(31 例),其次为大腿(11例)、足跟(11例);溃疡面积为1.5~600.0 cm2 。其中鳞状细胞癌80例、疣状癌8例、肉瘤1例。术前 发现腹股沟淋巴结肿大78例,行腹股沟淋巴结清扫49例,单纯淋巴结活检、切除29例;9例发现淋巴结转移,8例有 骨质侵犯;24例行截肢术,53例行病灶扩大切除皮片移植术,12例行病灶扩大切除皮瓣修复术。65例得到随访,8例 出现复发,其中截肢者2例,扩大切除者6例,且肿瘤复发与手术方式无关(P>0.05)。结论：下肢瘢痕癌复发转移率较 高,需早期发现、早期诊断,应尽早手术治疗并定期随访;腹股沟淋巴结肿大较常见,需行淋巴结活检、切除或清 扫;局部扩大切除、植皮或皮瓣修复是其主要治疗方法,但癌肿较大、侵犯较深且下肢瘢痕广泛、畸形严重者可考 虑截肢。     

Young Men,Masculinities, and Suicide

Young men constitute one of the highest risk groups for suicide in most countries. This gives reason to explore how meanings attached to masculinity can be evoked and handled when a young man takes his life. In-depth interviews with 5 to 8 informants for each of 10 suicides, as well as suicide notes, were analyzed using Interpretative Phenomenological Analysis. The suicides appeared as signature acts of compensatory masculinity with the following themes: When hope is gone, no one must know; weakness was never allowed; and suicide conducted in a way to present oneself as heroic. The handling of masculinity in triggering suicidal plans and in carrying out suicide is intrinsically connected to avoidance of help-seeking behavior.     

Paradoxical brain embolism shadowing massive pulmonary embolism

Patent foramen ovale is frequently observed in the general population. In case of massive pulmonary embolism, the sudden increase in the right heart cavity's pressure may cause a right-to-left shunting across this foramen, which could be associated with conflicting outcomes. Herein, we report a case of reversible cardiac arrest preceded by seizures, and followed by hemodynamic stability without any vasopressor. A brain CT-scan showed a limited ischemic stroke. Initial echocardiographic assessment revealed an acute cor pulmonale and a right-to-left intracardiac shunt across a large patent foramen ovale, suggesting the diagnosis of massive pulmonary embolism that was lately confirmed by a multidetector CT-angiography. Anticoagulation therapy was rapidly complicated by a hemorrhagic transformation of the ischemic stroke leading to a fatal outcome. This case illustrates the double-edged circulatory effect of shunting across a patent foramen ovale in case of massive pulmonary embolism: it may have limited circulatory failure but caused in the meanwhile a fatal paradoxical brain embolism.     

Reducing post-lumbar puncture headaches with small bore atraumatic needles

Lumbar puncture for testing of Alzheimer’s disease pathophysiology for diagnostic confirmation is likely to become more common in the coming years. Minimizing adverse effects from this testing will be essential for clinical practice. Small bore, atraumatic needles reduce the occurrence of post-lumbar puncture headache (PLPH). Our goal was to extend this recommendation specifically to a well-characterized aging population. We assessed PLPH in the Alzheimer’s Disease Neuroimaging Initiative cohort and found that PLPH occurrence was reduced only when using a 24 gauge atraumatic needle. We recommend that lumbar punctures for clinical and research purposes in Alzheimer’s disease be conducted with 24 gauge atraumatic needles.     

Atrial Fibrillation Clinics in Canada: A Nationwide Project Report

The increased prevalence of atrial fibrillation (AF) has led to specialized AF clinics (AFCs) to facilitate management of AF patients. In this article we report on outpatient AFCs in Canada, which is essential to health policies required to standardize the performance of existing AFCs and help design new AFCs. We surveyed 14 clinics in 5 provinces; 100% provided responses to a detailed questionnaire on clinic processes and care practices. Fourteen care maps were analyzed, and 5 models of care were identified; 4 were specific to AFCs. An online survey with 49 questions included items on: (1) process before visit; (2) process at visit; (3) patient education provided; (4) outreach; and (5) specific clinic information. Clinicians’ advice to patients on self-care items such as: (1) amount of alcohol and (2) caffeine intake; (3) exercise activity; (4) stressful events; (5) “when to go to the emergency department”; and (6) lifestyle changes, were evaluated to assess consistency in practice. There were moderate variances in clinicians’ advice to patients in 5 of 6 self-care items. The 1 item that had 100% consistent practice recommendation was when to go to the emergency department. A guideline-based clinical assessment checklist (CAC) was piloted to obtain feedback on its usability in real-world practice; revisions finalized the “simplified CAC” for AF care encompassing 35 data points with rationale. There was 100% positive feedback on its ability to provide baseline elements in AF care. When validated, a “simplified CAC” can facilitate a standardized clinical assessment tool in clinical practice.     

Dental age estimation of Omani children using Demirjian's method

Dental age plays a significant role in forensic dentistry, orthodontics and paediatric dentistry, as well as in general diagnosis and treatment planning. Different methods have been developed to determine dental age. One of the most commonly used methods is Demirjian’s method, which was developed in 1973 from research on a large number of French-Canadian children. It is based on the degree of tooth mineralisation by examining the radiological appearance of the lower mandibular left quadrant. The purpose of this study was to assess the dental age of Omani children using Demirjian's method and evaluate the applicability of the method in dental age estimation for Omani children. The sample consisted of 485 digital panoramic radiographs of children (264 males, 221 females) aged between 4.6?years and 16.5?years, and obtained from the records of the Military Dental Centre in Oman. The data were analysed using SPSS. Paired t-tests, intraclass correlation coefficients (ICC) and difference-against-mean plots were used to compare the dental age calculated by Demirjian's method with chronological age. A single examiner scored the radiographs, and intra-observer reliability was evaluated using Cronbach's alpha on data from rescoring one out of every 20 radiographs. For boys, the mean difference between chronological age and dental age for all age groups was 0.10 (95% CI ?0.03 to 0.24). For girls, the mean difference between chronological age and dental age for all age groups was 0.05 (95% CI ?0.11 to 0.22). Difference-against-mean plots showed no evidence of differential bias by age. For boys, the ICC was 0.896 (95% CI 0.869–0.917); for girls, it was 0.886 (95% CI 0.854–0.911). Difference-against-mean plots for boys (Fig. 1) and girls (Fig. 2) showed some evidence of differential bias by age. In conclusion, the extent of the observed differences was sufficient for doubt to be cast upon the utility of Demirjian’s method for Oman, particularly when it is considered that the method’s most likely application would be in age determination for minors in the workforce.