内镜治疗胆总管结石合并胆总管十二指肠乳头旁瘘的疗效及安全性分析

目的 探讨内镜逆行胰胆管造影术（ERCP）经瘘口或原始乳头治疗胆总管结石合并胆总管十二指肠乳头旁瘘（PCDF）的临床疗效及安全性。方法 回顾性分析2008年1月－2019年12月该院收治的259例胆总管结石合并PCDF患者的临床资料,根据不同取石方式,分为乳头组（n = 141）和瘘口组（n = 118）,比较两组患者一次性取石成功率、总取石成功率、机械碎石率、操作时间、术中扩张或切开使用率和术后并发症发生率。结果 共9 390例患者行ERCP下胆总管结石取石。其中,259例（2.8%）胆总管结石合并PCDF。经瘘口胆管造影成功率为100.0%,145例因各种原因经十二指肠乳头胆总管插管造影,成功率为97.2%（141/145）。两组患者一次性取石成功率［77.1%（91/118）和79.4%（112/141）,P = 0.652］、取石总成功率［86.4%（102/118）和87.9%（124/141）,P = 0.718］、机械碎石率［9.3%（11/118）和8.5%（12/141）,P = 0.819］和操作时间［（19.83±12.24）和（18.52±11.90）min,P = 0.500］比较,差异均无统计学意义。瘘口组术中使用切开或扩张的比例明显低于乳头组［44.9%（53/118）和88.7%（125/141）,P < 0.05］,瘘口组术后急性胰腺炎［0.0%（0/118）和9.2%（13/141）］和并发症总发生率［5.1%（6/118）和22.0%（31/141）］低于乳头组,差异均有统计学意义（P < 0.05）。结论 胆总管结石合并PCDF,经瘘口行ERCP取石,可达到经原始乳头取石的同等疗效,且可降低术后急性胰腺炎发生率,操作更简单。对于胆总管结石合并PCDF患者,行ERCP应优先考虑经瘘口取石。     

腰肋悬空半截石位和俯卧位经皮肾镜取石术对主观感觉的影响

目的 探讨腰肋悬空半截石位和俯卧位经皮肾镜取石术（PCNL）对主观感觉的影响。方法 选取2018年6月－2020年12月于长江航运总医院泌尿外科行PCNL的患者100例,通过入院顺序将患者分为治疗组（腰肋悬空半截石位组）和对照组（俯卧位组）,每组50例。比较两组患者体位舒适度、呼吸困难感、术后24 h疼痛感、术者舒适度、麻醉师舒适度、手术时间和结石清除率。结果 治疗组手术时间明显较对照组短［（86.0±9.7）和（108.1±11.2）min］,患者体位舒适度［（5.8±0.6）和（3.7±0.6）分］和呼吸困难感［（3.3±0.7）和（5.7±0.7）分］优于对照组,差异有统计学意义（t = -10.92,t = 16.33,t = -18.44;均P < 0.01）。术后24 h伤口疼痛感［（3.8±0.6）和（3.6±0.6）分］和结石清除率［86.0%（43/50）和90.0%（45/50）］比较,差异均无统计学意义（t = 1.48,P = 0.146;χ² = 0.38,P = 0.538）。治疗组术者舒适度［（6.2±1.4）和（5.4±1.6）分;t = 2.31,P = 0.025］和麻醉师舒适度［（7.4±1.3）和（6.7±1.4）分;t = 2.51,P = 0.015］均明显优于对照组。结论 采用腰肋悬空半截石位行PCNL手术,患者拥有较好的体位舒适度,呼吸困难感轻微,手术安全有效,适合于高龄高危、极度肥胖和慢性心肺功能不全的患者。     

腹腔镜胆囊切除术对患者术后粘连的疗效与安全性分析

目的 探讨腹腔镜胆囊切除术对患者术后粘连的疗效与安全性。方法 回顾性分析2015年3月－2020年7月该院63例行胆囊切除术的患者的临床资料，根据手术方式不同分为对照组（n = 32）和观察组（n = 31）。对照组行开腹胆囊切除术，观察组行腹腔镜胆囊切除术。比较两组患者临床指标、炎症因子水平、并发症及肠粘连发生率。应用Pearson相关系数分析炎症因子与术后粘连的相关性。结果 观察组手术时间、肛门排气时间和肠鸣音恢复时间均短于对照组［（56.7±8.3）和（82.6±9.4）min、（22.5±2.3）和（35.6±4.3）h、（13.2±5.7）和（19.1±6.8）h］，术后疼痛评分低于对照组［（7.6±0.3）和（9.2±0.5）分］（P < 0.05）。术后2 d，观察组血清C反应蛋白（CRP）和降钙素原（PCT）明显低于对照组［（11.3±3.6）和（26.7±6.5）mg/L，（5.5±1.3）和（6.4±2.5）μg/L］（P < 0.05）。观察组并发症发生率明显低于对照组（6.5%和25.0%，P < 0.05）。术后3个月，观察组肠粘连发生率明显低于对照组（12.9%和28.1%，P < 0.05）。术后CRP和PCT水平与肠粘连发生率存在明显正相关。结论 腹腔镜胆囊切除术可明显改善患者临床指标，降低患者炎症因子水平、并发症和肠粘连发生率。     

胸腔镜辅助小切口手术在胸外伤治疗中的经验总结

目的 探讨胸腔镜辅助小切口手术在胸外伤治疗中的效果及经验总结。方法 回顾性分析2017年10月－2021年6月该院80例胸外伤患者的临床资料,根据患者治疗方式不同,分为观察组（n = 40）和对照组（n = 40）,对照组给予开胸术,观察组给予胸腔镜辅助小切口术。比较两组患者手术效果。结果 观察组手术时间、住院时间、胸管留置时间和下床活动时间均明显较对照组短［（61.25±9.43）和（95.29±12.04）min,（6.51±1.42）和（12.94±1.85）d,（4.34±1.85）和（7.28±2.17）d,（9.23±1.78）和（14.26±2.38）d］,出血量和术后24 h胸腔引流量均明显较对照组少［（122.62±48.16）和（257.83±72.36）mL,（107.31±10.26）和（386.14±28.64）mL］,切口长度明显较对照组短［（7.74±0.76）和（16.31±0.68）cm］,术后切口疼痛程度明显较对照组轻［（3.65±1.27）和（5.94±1.41）分］。术前,两组患者焦虑自评量表（SAS）和抑郁自评量表（SDS）评分比较［（57.18±4.85）和（56.62±4.95）分,（55.28±4.92）和（55.31±4.75）分］,差异无统计学意义（P > 0.05）;术后1周,观察组SAS和SDS明显低于对照组［（37.26±2.75）和（48.53±4.42）分,（35.27±3.02）和（47.13±4.08）分］,两组患者比较,差异有统计学意义（P < 0.05）。观察组并发症发生率为5.00%,明显低于对照组的25.00%,两组患者比较,差异有统计学意义（P < 0.05）。观察组术中无死亡病例,对照组有3例死亡,两组患者比较,差异无统计学意义（χ² = 3.12,P = 0.077）。结论 胸腔镜辅助小切口手术对胸外伤患者创伤小,能够改善患者手术指标及心理状态,降低患者并发症发生率及术中死亡率,在胸外伤治疗中具有明显优势。     

腹腔镜胆囊切开取石术中圈套器套扎胆囊壁切口法与丝线缝合胆囊壁切口法的临床疗效对比

目的 比较腹腔镜胆囊切开取石术中圈套器套扎胆囊壁切口法与丝线缝合胆囊壁切口法的临床疗效。方法 回顾性分析同济大学附属东方医院胆石中心2020年1月－2022年1月收治的206例胆石病患者的临床资料,按照手术方式分为圈套组（n = 86）和缝合组（n = 120）,对比两组患者手术情况、手术并发症情况和术后胆囊恢复情况。结果 所有患者顺利完成手术,圈套组手术时间较缝合组短［（19.98±2.31）和（34.97±2.21）min］,差异有统计学意义（P < 0.01）。圈套组术中出血量较缝合组少［（5.29±1.00）和（16.98±2.17）mL］,差异有统计学意义（P < 0.01）;两组患者住院时间［（2.28±0.75）和（3.46±0.66）d］比较,差异有统计学意义（P < 0.01）。两组患者手术并发症比较,差异无统计学意义（P > 0.05）,圈套组术后无胆囊内血凝块形成和胆囊急性炎症发生。两组患者术后胆囊结石复发率比较,差异无统计学意义（P > 0.05）。圈套组术前与术后的胆囊排空率和胆囊壁厚度比较,差异无统计学意义（P > 0.05）。结论 圈套器套扎胆囊壁切口法安全可行,可明显缩短手术时间和住院时间,减少术中出血量,避免胆囊切开取石术后胆囊内血凝块形成及急性炎症的发生,值得临床推广。     

18F-FDG PET/CT联合MR胰胆管造影多模态显像诊断良恶性梗阻性黄疸

目的 探讨¹⁸F-FDG PET/CT联合MR胰胆管造影（MRCP）多模态显像对良恶性梗阻性黄疸的诊断价值。方法 回顾性分析57例梗阻性黄疸患者的PET/CT与MRCP资料,根据最终诊断分为恶性梗阻组（n=31）和良性梗阻组（n=26）,分析¹⁸F-FDG PET/CT与MRCP特征及多模态联合显像的诊断效能。结果 恶性梗阻组中,胰胆管中重度扩张13例（13/31,41.94%）,良性梗阻组中,胰胆管中重度扩张1例（1/26,3.85%）,差异有统计学意义（P=0.047）。恶性梗阻组病灶最大标准摄取值（SUV_max）为10.54±6.69,高于良性组（3.78±1.68;P<0.001）。¹⁸F-FDG PET/CT和MRCP诊断恶性梗阻性黄疸的灵敏度为90.32%（28/31）和61.29%（19/31）,差异有统计学意义（P=0.046）;特异度为84.62%（22/26）和76.92%（20/26）,差异无统计学意义（P=0.725）;准确率为87.72%（50/57）和68.42%（39/57）,差异有统计学意义（P=0.013）。¹⁸F-FDG PET/CT联合MRCP多模态显像诊断恶性梗阻性黄疸的灵敏度、特异度和准确率分别为96.77%（30/31）、88.46%（23/26）和92.98%（53/57）,与¹⁸F-FDG PET/CT比较差异均无统计学意义（P均>0.05）,与MRCP比较,灵敏度、准确率差异有统计学意义（P=0.002、0.002）,特异度差异无统计学意义（P=0.463）。¹⁸F-FDG PET/CT联合MRCP、¹⁸F-FDG PET/CT、MRCP诊断良恶性梗阻性黄疸与最终诊断结果的一致性Kappa值分别为0.858、0.752及0.375。结论 ¹⁸F-FDG PET/CT联合MRCP多模态显像有利于提高梗阻性黄疸的诊断准确率,对诊断与临床治疗决策具有重要指导意义。     

双镜联合治疗胆囊结石合并继发性胆总管结石高龄患者的可行性研究

目的 分析腹腔镜胆囊切除术（LC）联合内镜逆行胰胆管造影术（ERCP）和内镜下乳头括约肌切开术（EST）治疗胆囊结石合并继发性胆总管结石高龄患者的可行性。方法 选取2017年10月－2022年9月该院收治的胆囊结石合并继发性胆总管结石高龄患者78例，均采用LC联合ERCP和EST进行治疗。39例年龄≥80岁的胆囊结石合并继发性胆总管结石患者为高龄组，39例年龄 < 80岁的胆囊结石合并继发性胆总管结石患者为非高龄组。比较两组患者术后3个月结石清除率、手术情况、术后不同时间点疼痛程度［视觉模拟评分法（VAS）］、肝功能指标［总胆红素（TBIL）、碱性磷酸酶（ALP）、谷丙转氨酶（GPT）和直接胆红素（DBIL）］、炎症指标［C反应蛋白（CRP）、白细胞介素-10（IL-10）、肿瘤坏死因子-α（TNF-α）和白细胞（WBC）］和并发症发生率。结果 高龄组结石清除率为97.44%，与非高龄组的100.00%比较，差异无统计学意义（P > 0.05）；高龄组手术相关指标和术后不同时点VAS与非高龄组比较，差异均无统计学意义（P > 0.05）；术后3 d，两组患者TBIL、GPT、ALP和DBIL较术前降低，差异均有统计学意义（P < 0.05），但组间比较，差异均无统计学意义（P > 0.05）；术后1 d，两组患者CRP、IL-10、WBC和TNF-α较术前升高，术后3 d，CRP、IL-10、WBC和TNF-α低于术后1 d，差异均有统计学意义（P < 0.05）；术后1和3 d，两组间CRP、IL-10、WBC和TNF-α比较，差异均无统计学意义（P > 0.05）；高龄组并发症发生率为10.26%（4/39），与非高龄组的5.13%（2/39）比较，差异无统计学意义（P > 0.05）。结论 LC联合ERCP和EST治疗≥80岁的胆囊结石合并继发性胆总管结石患者，结石清除效果确切，并发症发生率低，且不会损伤肝功能，炎症反应轻微，是安全有效的治疗方式。     

后腹腔镜下精准解剖性左侧肾上腺切除术

目的 探讨后腹腔镜下精准解剖性左侧肾上腺切除术的可行性和安全性。方法 回顾性分析2018年1月－2019年3月该院实施后腹腔镜下精准解剖性左侧肾上腺切除术的107例住院患者的临床资料（试验组）,并与2016年1月－2018年12月实施后腹腔镜下解剖性左侧肾上腺切除术的95例住院患者的临床资料进行对比（对照组）。统计分析两组患者手术时间、术中出血量、术后引流量、术后住院时间、术后胃肠功能恢复时间、术后止痛剂用量和术中术后并发症发生率。结果 两组患者均顺利完成手术,无中转开放及输血病例。试验组手术时间较对照组短［（43.6±10.5）和（67.8±15.1）min］,术中出血量较对照组少［（29.3±12.5）和（69.4±25.5）mL］,腹膜损伤率较对照组低（4.7%和14.7%）,差异均有统计学意义（P < 0.05）;试验组和对照组术后引流量［（79.4±22.3）和（81.9±26.9）mL］、术后住院时间［（5.9±0.7）和（5.8±0.7）d］、术后胃肠功能恢复时间［（17.7±4.4）和（16.7±3.6）d］和术后止痛剂用量［（167.3±79.8）和（174.7±77.1）mg］比较,差异均无统计学意义（P > 0.05）。结论 后腹腔镜下精准解剖性左侧肾上腺切除术安全、可行。与经典三层面法比较,其手术时间明显缩短,术中出血量明显减少,术中腹膜损伤发生率明显降低,值得临床推广应用。     

18F-FDG PET/CT诊断梗阻性黄疸的价值

目的 探讨¹⁸F-FDG PET/CT在梗阻性黄疸病因诊断中的价值。方法 28例梗阻性黄疸患者根据梗阻病因分为良性梗阻组（n=11）和恶性梗阻组（n=17）,对比分析两组患者¹⁸F-FDG PET/CT的显像特征、最大标准摄取值（SUV_max）水平;比较PET/CT、MRI诊断梗阻性黄疸的效能。结果 28例患者中,胆道无或轻度扩张15例（15/28,53.57%）,中-重度扩张13例（13/28,46.42%）。恶性梗阻组中,肝门胆管癌2例、胆总管癌5例、胰头癌6例、壶腹癌4例,其中14例¹⁸F-FDG PET/CT显像表现为梗阻部位近端高代谢结节。良性梗阻组中,胆道炎性狭窄7例,其中4例合并胆管结石,¹⁸F-FDG PET/CT显像6例表现为相应梗阻部位条片状或结节状轻度代谢增高;自身免疫性胰腺炎4例,¹⁸F-FDG PET/CT显像表现为胰腺多节段性多发条带状或结节状肿大,代谢普遍性增高。恶性梗阻组SUV_max（6.88±2.81）明显高于良性梗阻组SUV_max（4.20±1.70;t=3.143,P<0.05）。¹⁸F-FDG PET/CT、MRI诊断恶性梗阻性黄疸的敏感度为94.12%（16/17）和58.82%（10/17）,差异有统计学意义（χ²=4.086 5,P=0.043）,特异度为81.82%（9/11）和63.64%（7/11）,差异无统计学意义（χ²=0.229 2,P=0.632）,准确率为89.29%（25/28）和60.71%（17/28）,差异有统计学意义（χ²=4.666 7,P=0.031）。结论 ¹⁸F-FDG PET/CT对梗阻性黄疸的诊断具有重要价值,对临床治疗决策具有重要指导意义。     

静脉利多卡因复合丙泊酚镇静在超声胃镜检查中的应用

目的 探索静脉利多卡因复合丙泊酚镇静在超声胃镜检查中的应用效果。方法 选取2020年3月－2020年7月在雅安市人民医院行超声胃镜检查的患者62例,采用随机数表法分为丙泊酚+利多卡因组（L组）和丙泊酚+生理盐水组（P组）,每组31例。L组镇静前静脉推注利多卡因1.0 mg/kg,然后以1.0 mg/（kg·h）持续泵注,P组以相同方式输注等容量生理盐水。两组患者均给予丙泊酚1.5 mg/kg和舒芬太尼0.1 μg/kg,患者改良警觉 / 镇静评分（MOAA/S） > 3分或尝试内镜进镜失败,根据情况每次追加丙泊酚0.5 mg/kg。记录两组患者诱导前（T₁）、诱导后（T₂）、胃镜插入时（T₃）、退镜时（T₄）的心率（HR）、平均动脉压（MAP）与经皮动脉血氧饱和度（SpO₂）,记录丙泊酚诱导剂量、追加剂量和总量、完全苏醒时间、并发症发生率和内镜医师满意度。结果 两组患者在T₂、T₃和T₄时点的HR较T₁时点慢,MAP较T₁时点低（P < 0.05）。L组各时间点HR、MAP和SpO₂与P组比较,差异无统计学意义（P > 0.05）。L组丙泊酚诱导剂量［（100.08±14.69）和（118.07±27.35）mg］、追加剂量［（73.54±36.34）和（127.52±92.24）mg］、总量［（166.04±27.17）和（244.30±95.05）mg］及平均用量［（5.86±2.67）和（7.44±1.80）mg/（kg·h）］均明显少于P组（P < 0.05）。L组完全苏醒时间明显短于P组［（3.24±1.04）和（4.76±0.99）min］（P < 0.05）。L组低血压、低氧血症、丙泊酚注射痛和呛咳发生率均明显低于P组,内镜医师满意度明显高于P组（P < 0.05）。两组患者心动过缓、咽喉部疼痛和腹痛发生率比较,差异均无统计学意义（P > 0.05）。两组患者均无恶心呕吐发生。结论 超声胃镜检查中静脉推注利多卡因可有效减少术中丙泊酚用量,缩短患者苏醒时间,降低术中并发症发生率,提高内镜医师满意度。     

Guns and Knives in New Mexico: Patterns of Penetrating Trauma, 1978–1993

Objective: To identify patterns of nonfatal and fatal penetrating trauma among children and adults in New Mexico using ED and medical examiner data.
Methods: The authors retrospectively sampled in 5-year intervals all victims of penetrating trauma who presented to either the state Level-1 trauma center or the state medical examiner from a 16-year period (1978–1993). Rates of nonfatal and fatal firearm and stabbing injury were compared for children and adults.
Results: Rates of nonfatal injury were similar (firearm, 34.3 per 100,000 person-years; stabbing, 35.1). However, rates of fatal injury were significantly different (firearm, 21.9; stabbing, 2.7; relative risk: 8.2; 95% confidence interval: 5.4, 12.5). From 1978 to 1993, nonfatal injury rates increased for children (p = 0.0043) and adults (p < 0.0001), while fatal penetrating injury remained constant. The increase in nonfatal injury in children resulted from increased firearm injury rates. In adults, both stabbing and firearm nonfatal injury rates increased.
Conclusions: Nonfatal injury data suggest that nonfatal violence has increased; fatal injury data suggest that violent death rates have remained constant. Injury patterns vary by age, mechanism of trauma, and data source. These results suggest that ED and medical examiner data differ and that both are needed to guide injury prevention programs.     

Interprofessional approaches to creating safe,high quality health care

Three supplementary perspectives are presented arguing that interprofessional collaboration is both necessary and desirable. Nonetheless, there are often too many serious intra-professional barriers and obstacles to interprofessional collaboration to make it successful. Some of these barriers, it is argued and illustrated, are found in the multiple ways in which professional identity is tacitly acquired and embodied in the practitioners' habitual, everyday practice. The paper then explores ways in which reflection, especially Second order reflection, can help to elucidate and overcome these obstacles, as well as increasing professional adaptability and competence.     

Systematic Reviews Published in the January 2011 Issue of The Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly as a DVD and monthly online. The January 2011 issue (first quarterly DVD for 2011) contains 4515 complete reviews, 1985 protocols for reviews in production, and 13,521 one-page summaries of systematic reviews published in the general medical literature. In addition, there are citations of 641,000 randomized controlled trials, and 14,018 cited papers in the Cochrane methodology register. The health technology assessment database contains over 9300 citations. One hundred and seven new reviews have been published in the last 3 months, of which five have potential relevance for practitioners in pain and palliative medicine.     

Prospects for the control of neglected tropical diseases by mass drug administration

The prospects for the control of neglected tropical diseases, including soil-transmitted helminthiasis, shistosomiasis, lymphatic filariasis, onchocerciasis and trachoma, through mass drug administration, are exemplified by the elimination of the trachoma as a public-health problem in Morocco. In spite of this and other striking successes, mass drug administration programs are faced with major challenges resulting from suboptimal coverage and lack of efficacy. At current suboptimal coverage rates, programs may need prolongation for an extended period, increasing costs and undermining sustainability. Community participation through health education and information appears to be crucial to improve coverage and to achieve sustainability. Implementation of complementary measures, such as vector control, improved hygiene and environmental sanitation, are important to further control transmission and to prevent re-emergence of the infection and, again, may only be achieved effectively through community-based initiatives. To reduce costs and to relieve pressure on the health system, combining neglected tropical disease programs in areas where diseases coexist and integration with existing control programs for malaria, tuberculosis and HIV/AIDS is advocated. The risk of developing drug resistance is of particular concern in view of the lack of alternative drugs, and reduced treatment efficacy due to emerging resistance is evident for the soil-transmitted helminths and onchocerciasis. Given the risk for the development of drug resistance and the need for a high degree of participation, close attention should be paid to the monitoring of the coverage and efficacy of the different program components.     

Bacterial meningitis: an update of new treatment options

The outcome of bacterial meningitis critically depends on the rapid initiation of bactericidal antibiotic therapy and adequate management of septic shock. In community-acquired meningitis, the choice of an optimum initial empirical antibiotic regimen depends on the regional resistance patterns. Pathogens resistant to antibacterials prevail in nosocomial bacterial meningitis. Dexamethasone is recommended as adjunctive therapy for community-acquired meningitis in developed countries. In comatose patients, aggressive measures to lower intracranial pressure <20 mmHg (in particular, external ventriculostomy, osmotherapy and temporary hyperventilation) were effective in a case–control study. Although many experimental approaches were protective in animal models, none of them has been proven effective in patients. Antibiotics, which are bactericidal but do not lyse bacteria, and inhibitors of matrix metalloproteinases or complement factor C5 appear the most promising therapeutic options. At present, vaccination is the most efficient method to reduce disease burden. Palmitoylethanolamide appears promising to enhance the resistance of the brain to infections.     

Prise en charge des entorses externes de cheville : étude clinique préliminaire sur l’efficacité du dispositif Myolux™

Ankle sprains are the most common injury of the musculoskeletal system and are associated with significant societal and economic impacts. It has been proven that classical therapeutic strategies may not be effective in preventing recurrent injuries: the recurrence rates reported in the literature can reach 73%. In order to provide an effective rehabilitation solution, a destabilizing orthosis was developed. This device is equipped with a mechanical articulator reproducing the subtalar mechanics and placed under the heel. In this paper, we present the main results of a preliminary clinical study conducted between 2004 and 2007. All subjects included in this study were treated with the abovementioned orthosis during 10 rehabilitation sessions of 30 minutes each. Data show a relatively low recurrence rate of 12% for the overall population. Moreover, it's of primary importance to note that this satisfactory ratio is largely reduced (3% of recurrence rate) for the 29 patients who performed one training session per month after the 10th initial rehabilitation sessions. Hence, the destabilizing orthosis appears to be an effective solution to prevent recurrent ankle sprains. However, joint protection requires long-term and regular training sessions. This result has motivated the development of a similar device allowing patients to perform training sessions at home. Finally, data obtained in this study are promising awaiting the final results of the comparative, multicentric and independent clinical trials currently managed by the Hospices Civils de Lyon.     

Imaging choices in occult hip fracture

Background: Hip fracture is a common injury, with an incidence rate of > 250,000 per year in the United States. Diagnosis is particularly important due to the high dependence on the integrity of the hip in the daily life of most people. Objectives: In this article we review the literature focused on hip fracture detection and discuss advantages and limitations of each major imaging modality. Discussion: Plain radiographs are usually sufficient for diagnosis as they are at least 90% sensitive for hip fracture. However, in the 3–4% of Emergency Department (ED) patients having hip X-ray studies who harbor an occult hip fracture, the Emergency Physician must choose among several methods, each with intrinsic limitations, for further evaluation. These methods include computed tomography, scintigraphy, and magnetic resonance imaging. Conclusion: We present an evidence-based algorithm for the evaluation of a patient suspected to have an occult hip fracture in the ED. Also outlined are future directions for research to distinguish more effective techniques for identifying occult hip fractures.     

Systematic Reviews Published in the April 2012 Issue of the Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly as a DVD but monthly online. The April 2012 issue (second DVD for 2012) contains 5045 complete reviews, 2182 protocols for reviews in production, and 17,084 short summaries of systematic reviews published in the general medical literature. In addition, there are citations of 674,000 randomized controlled trials, and 15,400 cited papers in the Cochrane methodology register. The health technology assessment database contains just over 11,000 citations. One hundred and seventeen new reviews have been published in the last 3 months of which 12 have potential relevance for practitioners in pain and palliative medicine. The impact factor of the Cochrane Library stands at 6.186. Readers are encouraged to access the full report for any articles of interest as only a brief commentary is provided.     

Platelets,thrombosis, coagulation,and atherosclerosis

When I first got the invitation to join a medical delegation going to Moldova, I thought for a moment that our destination was the fictional country in the old Marx Brothers movie Duck Soup. On further checking, it turns out that entertaining place was called Freedonia. I now know that Moldova is indeed a real country, bordered on the west by Romania and on the other three sides by the Ukraine. It is a proud country, rich with traditions, and its people are warm, giving, eager to learn ways to improve their healthcare system, and deeply appreciative of our attempts to help them in the task.