放射性肠炎的非手术治疗进展

随着放射治疗病例的增多,放射性肠炎的发病率亦逐渐增加。急性放射性肠炎以对症治疗为主。慢性放射性肠炎的腹泻和腹痛以对症治疗为主;治疗主要为口服药物、局部肠道内给药、内镜下及高压氧治疗等,在临床治疗中需根据患者具体情况选择合适的方案。     

兔肘关节尺侧副韧带急性损伤手术与非手术治疗后负载和强度的比较

目的 比较兔急性肘关节尺侧副韧带损伤后手术修复与非手术治疗的差异.方法 新西兰兔81只按随机数学表法分为三组(n=27),正常对照组(A组):暴露右尺侧副韧带后,但不切断;韧带缝合组(B组):切断右尺侧副韧带后随即缝合韧带;韧带不缝合组(C组):切断右尺侧副韧带后不缝合.分别于术后3、6、12周三个阶段取材,进行生物力学检测.结果 术后12周B组断裂时的最大载荷[(68.23±5.64)N]与C组[(42.45±3.66)N]比较,差异有统计学意义(P<0.05);B组与A组[(72.86±2.99)N]比较,差异无统计学意义(P>0.05).B组应力强度[(3.84±0.47)N/mm2]与C组[(2.84±0.17)N/mm2]比较,差异有统计学意义(P<0.05);B组与A组[(4.09±0.15)N/mm2]比较,差异尤统计学意义(P>0.05).结论 肘关节尺侧副韧带急性损伤后手术治疗明显优于非手术治疗.     

Management and outcome of pneumatosis intestinalis

BACKGROUND: Pneumatosis intestinalis (PI), infiltration of gas into the bowel wall, has traditionally been associated with immediate operative intervention and a high mortality rate. METHODS: We retrospectively reviewed the diagnosis and management of pneumatosis in an attempt to characterize the disease, and examined management strategies. RESULTS: Ninety-seven patients had a computed tomography (CT) diagnosis of pneumatosis. The location of pneumatosis was as follows: 46% colon, 27% small bowel, 5% stomach, and 7% both small and large bowel. Fourteen patients also had portal venous gas and 6 (43%) of these patients died. Management strategy was non-operative in 52%, operative in 33%, and futile care in 15%. The overall mortality rate was 22% (16% operative, 6% non-operative, and 87% futile). Patients who died had a higher mean APACHE II score (25 vs 11, P <.001). CONCLUSIONS: Approximately 50% of patients with pneumatosis can be successfully managed non-operatively. The combination of PI and portal venous gas may confer a higher mortality rate.     

Regional differences in prolonged non-operative therapy utilization prior to primary ACDF surgery

There is a paucity of data characterizing regional variations in the utilization and costs of conservative management in patients suffering from cervical stenosis prior to anterior cervical discectomy and fusion (ACDF) surgery. An understating of these regional trends becomes critical as outcomes-based reimbursement strategies become standard. The objective of this investigation was to evaluate for regional differences in the utilization and overall costs of maximal non-operative therapy (MNT) prior to ACDF surgery. Medical records from patients with symptomatic cervical stenosis undergoing a ≤3-level index ACDF procedure between 2007 and 2016 were accessed from a large insurance database. Geographic regions (Midwest, Northeast, South, and West) reflected U.S. Census Bureau definitions. MNT utilization within 2-years prior to ACDF surgery was analyzed. An index ACDF surgery was performed in 15,825 patients. Patient regional breakdown was as follows: South (67.6% of patients), Midwest (21.8% of patients), West (8.9% of patients), Northeast (1.6% of patients). Regional variations were identified in the number of patients utilizing NSAIDs (p < 0.001), opioids (p < 0.001), muscle relaxants (p < 0.001), cervical epidural steroid injections (p = 0.001), physical therapy/occupational therapy treatments (p < 0.001), and chiropractor visits (p < 0.001). The West (64.5%) and South (63.5%) had the greatest proportion of patients utilizing narcotics. When normalized by the number of opioid using-patients however, the Northeast (691.4 pills/patient) and South (674.4 pills/patient) billed for the most opioid pills. The total direct cost associated with all MNT prior to index ACDF was $17,255,828. The Midwest ($1,277.72 per patient) and South ($1,047.86 per patient) had the greatest average dollars billed.     

Clinical outcomes of non-operative management and clinical observation in non-angioembolised hepatic trauma: A systematic review of the literature

PurposeLiver is the most frequently injured organ in abdominal trauma. Today non-operative management (NOM) is considered as the standard of care in hemodynamically stable patients, with or without the adjunct of angioembolisation (AE). This systematic review assesses the incidence of complications in patients who sustained liver injuries and were treated with simple clinical observation. Given the differences in indications of treatment and severity of liver trauma and acknowledging the limitations of this study, an analysis of the results has been done in reference to the complications in patients who were treated with AE.MethodsA systematic literature review searched “liver trauma”, “hepatic trauma”, “conservative management”, “non operative management” on MEDLINE (via PubMed), Cochrane Central Register of Controlled Trials databases, EMBASE, and Google Scholar, to identify studies published on the conservative management of traumatic liver injuries between January 1990 and June 2020. Patients with traumatic liver injuries (blunt and penetrating) treated by NOM, described at least one outcome of interests and provided morbidity outcomes from NOM were included in this study. Studies reported the outcome of NOM without separating liver from other solid organs; studies reported NOM complications together with those post-intervention; case reports; studies including less than 5 cases; studies not written in English; and studies including patients who had NOM with AE as primary management were excluded. Efficacy of NOM and overall morbidity and mortality were assessed, the specific causes of morbidity were investigated, and the American Association for the Surgery of Trauma classification was used in all the studies analysed. Statistical significance has been calculated using the Chi-square test.ResultsA total of 19 studies qualified for inclusion criteria were in this review. The NOM success rate ranged from 85% to 99%. The most commonly reported complications were hepatic collection (3.1%), followed by bile leak (1.5%), with variability between the studies. Other complications included hepatic haematoma, bleeding, fistula, pseudoaneurysm, compartment syndrome, peritonitis, and gallbladder ischemia, all with an incidence below 1%.ConclusionNOM with simple clinical observation showed an overall low incidence of complications, but higher for bile leak and collections. In patients with grade III and above injuries, the incidence of bile leak, collections and compartment syndrome did not show a statistically significant difference with the AE group. However, the latter result is limited by the small number of studies available and it requires further investigations.     

Musculo skeletal trauma in an East African public hospital

The contribution of musculo skeletal trauma to morbidity and disability in developing countries is often underestimated. As Head of Department of Surgery and Orthopaedics for 3 years at a non-paying hospital in Malawi/East Africa (one of the least developed countries according to UNDP), I analysed my operation log book of 658 cases. Although there are many specific and local factors influencing the picture, the main problems of trauma care in rural Africa become evident. Based on personal experience views on non-operative versus operative fracture treatment, indications, quality control and training are presented. First world standards, equipment and implants of yesterday are often the only ones available but they scarcely meet the demands of clinical practice in developing countries. Contemporary state-of-the-art knowledge lacks most of its material basis to be successfully introduced. However, transforming it into "appropriate technologies" is most rewarding not only for the individual trauma surgeon, but for the wider community within orthopaedics.     

无骨折脱位型颈髓损伤手术与非手术治疗疗效对比观察

目的　比较无骨折脱位型颈髓损伤非手术与手术治疗后 ,脊髓功能恢复程度的差异。　方法　回顾性分析 2 4例无骨折脱位型颈髓损伤患者 ,其中 13例行手术治疗 ,11例行非手术治疗 ,根据损伤时日本骨科学会 (JOA)评分、治疗后随访JOA评分 ,比较治疗前后JOA评分增加幅度。　结果　治疗后 3个月JOA评分增加幅度 :非手术组为 1.6 4± 0 .5 8,手术组为 3.2 9±0 .90 ;治疗后 12个月JOA评分增加幅度 :非手术组为 2 .0 0± 0 .73,手术组为 4 .93± 0 .96。经t检验 ,两组差异均有非常显著性意义 (P <0 .0 1)。　结论　无骨折脱位型颈髓损伤手术治疗效果明显优于非手术治疗 ,无骨折脱位型颈髓损伤一旦确诊 ,应当积极争取早期手术。     

Non-operative treatment of common finger injuries

Finger fractures are common injuries with a wide spectrum of presentation. Although a vast majority of these injuries may be treated non-operatively with gentle reduction, appropriate splinting, and careful follow-up, health care providers must recognize injury patterns that require more specialized care. Injuries involving unstable fracture patterns, intra-articular extension, or tendon function tend to have suboptimal outcomes with non-operative treatment. Other injuries including terminal extensor tendon injuries (mallet finger), stable non-articular fractures, and distal phalanx tuft fractures are readily treated by conservative means, and in general do quite well. Appropriate understanding of finger fracture patterns, treatment modalities, and injuries requiring referral is critical for optimal patient outcomes.