Distal radius volar rim plate: Technical and radiographic considerations

AIM To determine technical considerations and radiographic outcomes of the Synthes volar rim distal radius plate to treat complex intra-articular fractures. METHODS This review highlights technical considerations learnt using this implant since it was introduced in a major trauma unit in November 2011, including anatomical reduction and whether this was maintained radiographically. RESULTS Twenty-six of the 382 internally fixed distal radial fractures at our unit(6.8%) were deemed to require this plate in order to achieve optimal fracture fixation between November 2011 and May 2014. A further dorsal and/or radial plate was necessary in 35% and variable angle screws were used in 54% of cases. Postoperatively, mean radial height, inclination, volar tilt and ulnar variance restored were 11.7 mm, 21o, 4.3o and-1.2 mm respectively. There were no cases of non-union or flexor/extensor tendon rupture; one case of loss of fracture reduction. Overall incidence of plate removal was 15% with one plate removed for flexor and one for extensor tendon irritation CONCLUSION The use of a rim plate enables control of challenging fardistal fracture patterns. However, additional plates were required to improve and maintain reduction. Variable angle screws were necessary in half the cases to avoid intra-articular screw penetration. If used judiciously, this implant can achieve stable fixation despite the complexity of the fracture pattern.

Sirolimus-related pulmonary toxicity mimicking 'asthma like' symptoms

Sirolimus is an immunosuppressant with expanding use in pediatric organ transplantation, dermatology and rheumatology. We report two cases of children who developed asthma like symptoms and were diagnosed with interstitial lung disease, which responded to discontinuation of sirolimus. Pediatricians should be aware about the pulmonary side effects of sirolimus.

CD36 expression and lipid metabolism following an oral glucose challenge in South Asians

AIM:To investigate lipid metabolism and the relationship with monocyte expression of the fatty acid translocase CD36 in South Asians.METHODS:An observational study of South Asians whom as an ethnic group have-a higher risk of developing diabetes.The susceptibility to diabetes is coupled with an earlier and more rapid progression of micro-,and macro-vascular complications.Twentynine healthy South Asian participants [mean age 34.6(8.9) years,76.2% male,mean body-mass index 25.0(5.2) kg/m2] were recruited from an urban residential area of central Birmingham(United Kingdom).The main outcomes measured were post prandial(30 min) and post absorptive(120 min) changes from fasting(0 min) in circulating lipoproteins,lipds and hormones,andmonocyte expression of CD36 post injection of a 75 g oral glucose challenge.The inducements of variations of monocyte CD36 expression were analysed.RESULTS:Our results showed evident changes in monocyte CD36 expression following the glucose challenge(P < 0.001).Non-esterified fatty acids(NEFA) levels decreased progressively during the challenge(P < 0.001),in contrast to increased cholesterol(but not triglyceride) concentrations within very low density lipoprotein(VLDL) and low density lipoprotein subfractions(P < 0.01).Levels of,glucose,serum triglycerides and high density lipoprotein cholesterol remained largely unchanged.Variations of monocyte CD36 were negatively(r =-0.47,P = 0.04) associated to fat from the diet and positively to carbohydrate from the diet(r = 0.65,P < 0.001).CONCLUSION:These data suggest that the initiation of VLDL genesis follows the consumption of glucose within this population,inferring that the sequestration of NEFA from these particles happens due to the increased availability of CD36 receptors.While these are preliminary results,it would appear that lifestyle exposures have a role in moderating the expression of CD36.

Meta-analysis of transanal vs laparoscopic total mesorectal excision of low rectal cancer:Importance of appropriate patient selection

BACKGROUND Achieving a clear resection margins for low rectal cancer is technically challenging.Transanal approach to total mesorectal excision(TME)was introduced in order to address the challenges associated with the laparoscopic approach in treating low rectal cancers.However,previous meta-analyses have included mixed population with mid and low rectal tumours when comparing both approaches which has made the interpretation of the real differences between two approaches in treating low rectal cancer difficult.AIM To investigate the outcomes of transanal TME(TaTME)and laparoscopic TME(LaTME)in patients with low rectal cancer.METHODS A comprehensive systematic review of comparative studies was performed in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses standards.Intraoperative and postoperative complications,anastomotic leak,R0 resection,completeness of mesorectal excision,circumferential resection margin(CRM),distal resection margin(DRM),harvested lymph nodes,and operation time were the investigated outcome measures.RESULTS We included twelve comparative studies enrolling 969 patients comparing TaTME(n=969)and LaTME(n=476)in patients with low rectal tumours.TaTME was associated with significantly lower risk of postoperative complications(OR:0.74,P=0.04),anastomotic leak(OR:0.59,P=0.02),and conversion to an open procedure(OR:0.29,P=0.002)in comparison with LaTME.Moreover,the rate of R0 resection was significantly higher in the TaTME group(OR:1.96,P=0.03).Nevertheless,TaTME and LaTME were comparable in terms of rate of intraoperative complications(OR:1.87;P=0.23),completeness of mesoractal excision(OR:1.57,P=0.15),harvested lymph nodes(MD:-0.05,P=0.96),DRM(MD:-0.94;P=0.17),CRM(MD:1.08,P=0.17),positive CRM(OR:0.64,P=0.11)and procedure time(MD:-6.99 min,P=0.45).CONCLUSION Our findings indicated that for low rectal tumours,TaTME is associated with better clinical and short term oncological outcomes compared to LaTME.More randomised controlled trials are required to confirm these findings and to evaluate long term oncological and functional outcomes.

Tipping the balance:Haemoglobinopathies and the risk ofdiabetes

AIM: To establish a link between the risk of diabetes with haemoglobinopathies by examining available evidence of the effects of iron and blood glucose homeostasis from molecular to epidemiological perspectives.METHODS: A systematic literature search was performed using electronic literature databases using various search terms. The International Diabetes Federation World Atlas was used to generate a list of populations with high rates of diabetes. Pub Med, Scopus and Google Scholar were used to identify which of these populations also had a reported prevalence of haemoglobin abnormalities.RESULTS: Abnormalities in iron homeostasis leads to increases in reactive oxygen species in the blood. This promotes oxidative stress which contributes to peripheral resistance to insulin in two ways:(1) reduced insulin/insulin receptor interaction; and(2) β-cell dysfunction. Hepcidin is crucial in terms of maintaining appropriate amounts of iron in the body and is in turn affected by haemoglobinopathies. Hepcidin also has other metabolic effects in places such as the liver but so far the extent of these is not well understood. It does however directly control the levels of serum ferritin. High serum ferritin is found in obese patients and those with diabetes and a meta-analysis of the various studies shows that high serum ferritin does indeed increase diabetes risk.CONCLUSION: From an epidemiological standpoint, it is plausible that the well-documented protective effects of haemoglobinopathies with regard to malaria may have also offered other evolutionary advantages. By contributing to peripheral insulin resistance, haemoglobinopathies may have helped to sculpt the so-called "thrifty genotype", which hypothetically is advantageous in times of famine. The prevalence data however is not extensive enough to provide concrete associations between diabetes and haemoglobinopathies- more precise studies are required.

Dehydration and volume depletion:How to handle the misconceptions

Dehydration and volume depletion describe two distinct body fluid deficit disorders with differing pathophysiology,clinical manifestations and treatment approaches.However,the two are often confused or equated with each other.Here,we address a number of commonly encountered misconceptions about body-fluid deficit disorders,analyse their origins and propose approaches to overcome them.

Ethnic differences in inflammatory bowel disease: Results from the United Kingdom inception cohort epidemiology study

BACKGROUND The current epidemiology of inflammatory bowel disease(IBD)in the multiethnic United Kingdom is unknown.The last incidence study in the United Kingdom was carried out over 20 years ago.AIM To describe the incidence and phenotype of IBD and distribution within ethnic groups.METHODS Adult patients(>16 years)with newly diagnosed IBD(fulfilling Copenhagen diagnostic criteria)were prospectively recruited over one year in 5 urban catchment areas with high South Asian population.Patient demographics,ethnic codes,disease phenotype(Montreal classification),disease activity and treatment within 3 months of diagnosis were recorded onto the Epicom database.RESULTS Across a population of 2271406 adults,339 adult patients were diagnosed with IBD over one year:218 with ulcerative colitis(UC,64.3%),115 with Crohn's disease(CD,33.9%)and 6 with IBD unclassified(1.8%).The crude incidence of IBD,UC and CD was 17.0/100000,11.3/100000 and 5.3/100000 respectively.The age adjusted incidence of IBD and UC were significantly higher in the Indian group(25.2/100000 and 20.5/100000)compared to White European(14.9/100000,P=0.009 and 8.2/100000,P<0.001)and Pakistani groups(14.9/100000,P=0.001 and 11.2/100000,P=0.007).The Indian group were significantly more likely to have extensive disease than White Europeans(52.7%vs 41.7%,P=0.031).There was no significant difference in time to diagnosis,disease activity and treatment.CONCLUSION This is the only prospective study to report the incidence of IBD in an ethnically diverse United Kingdom population.The Indian ethnic group showed the highest age-adjusted incidence of UC(20.5/100000).Further studies on dietary,microbial and metabolic factors that might explain these findings in UC are underway.

小儿肝移植后进行性肝组织损伤

The long-term histological outcome after pediatric liver transplantation (OLT) is not yet fully understood. De novo autoimmune hepatitis, consisting of histological chronic hepatitis associated with autoantibody formation and allograft dysfunction, is increasingly recognized as an important complication of liver transplantation, particularly in the pediatric population. In this study, 158 asymptomatic children with 5-year graft survival underwent protocol liver biopsies(113, 135, and 64 at 1, 5, and 10 years after OLT, respectively). Histological changes were correlated with clinical, biochemical, and serological findings. All patients received cyclosporine A as primary immunosuppression with withdrawal of corticosteroids at 3 months post OLT. Normal or near-normal histology was reported in 77 of 113 (68%), 61 of 135 (45%), and 20 of 64 (31%) at 1, 5, and 10 years, respectively. The commonest histological abnormality was chronic hepatitis (CH), the incidence of which increased with time[25/113 (22%), 58/135 (43%), and 41/64 (64%) at 1, 5, and 10 years, respectively) (P< .0001)]. The incidence of fibrosis associated with CH increased with time [13/25 (52%), 47/58 (81%), and 37/41 (91%) at 1, 5, and 10 years, respectively)(P < .0001)]. The severity of fibr- osis associated with CH also increased with time, such that by 10 years 15%had progressed to cirrhosis. Aspartate aminotransferase(AST) levels were slightly elevated in children with CH (median levels 52 IU/L, 63 IU/L, and 48 IU/L at 1, 5, and 10 years, respectively), but this did not reach statistical significance compared with those with normal histology. On multivariate analysis, the only factor predictive of chronic hepatitis was autoantibody positivity (present in 13%and 10%of children with normal biopsies at 5 and 10 years, respectively, and 72%and 80%of those with CH at 5 and 10 years, respectively)(P < .0001). Four children with CH and autoantibodies, who also had raised immunoglobulin G (IgG) levels and AST greater than 1.5x normal fulfilled the diagnostic criteria for de novo autoimmune hepatitis(AIH). Another two were found to be hepatitis C positive. No definite cause for CH could be identified in the other cases. In conclusion, chronic hepatitis is a common finding in children after liver transplantation and is associated with a high risk of developing progressive fibrosis, leading to cirrhosis. Standard liver biochemical tests cannot be relied on either in the diagnosis or in the monitoring of progress of chronic allograft hepatitis. In contrast, the presence of autoantibodies is strongly associated with the presence of CH. The cause of chronic hepatitis in transplanted allografts is uncertain butmay be immunemediated, representing a hepatitic form of chronic rejection.

对硫胺素敏感的巨幼红细胞性贫血综合征:对7家族的长期随访和基因突变分析

Aim:Thiamine-responsive megaloblastic anaemia syndrome(TRMA)is the association of diabetes mellitus,anaemia and deafness,due to mutations in SLC19A2,encoding a thiamine transporter protein.This is a unique monogenic form of vitamin-dependent diabetes for which there is limited long-term data.We aimed to study genotype-phenotype relationships and long-term follow-up in our cohort.Methods:We have studied 13 patients from seven families and have follow-up data for a median of 9 y(2-30 y).Results:All patients originated from Kashmir or Punjab,and presented with non-immune,insulin deficient diabetes mellitus,sensorineural deafness and a variable anaemia in the first 5 y of life,the anaemia progressing to megaloblastic and sideroblastic changes in the bone marrow.The anaemia and diabetes mellitus responded to oral thiamine hydrochloride 25 mg/d,but during puberty thiamine supplements became ineffective,and almost all patients require insulin therapy and regular blood transfusions in adulthood.All patients are homozygous for mutations in the SLC19A2 gene.We have identified a novel missense mutation(T158R)that was excluded in 100 control alleles.Conclusion:Diabetes in this syndrome is due to an insulin insufficiency that initially responds to thiamine supplements;however,most patients become fully insulin dependent after puberty.A mutation screening strategy is feasible and likely to identify mutations in almost all cases.

Folic acid supplementation: The new dawn for postmenopausal women with hot flushes

Hot flushes, experienced by 75% of menopausal women, are associated with estrogen deprivation. Estrogen was shown to ameliorate hot flushes by interacting with monoamine neurotransmitters in the brain; reducing noradrenaline and increasing serotonin. Hormone replacement therapy(HRT), the first treatment option, causes concerns over possible increased risks particularly breast cancer. Folic acid is involved in the biosynthesis of serotonin and nordrenaline, which is responsible for its effects on mood and cognition, and degrees of folate inadequacy, not severe enough to produce megaloblastic anaemia, were found to be associated with depression and cognitive malfunctioning. Also, increased age was observed to relate to reduced serum and cerebrospinal fluid folic acid levels. There is emerging evidence that folic acid supplementation ameliorates hot fl ushes by the same mechanism as estrogen. To explore this hypothesis, a multi-centre, double-blind, placebo-controlled randomized is being set up to compare the effect of 5 mg folic acid vs placebo in reducing the frequency and severity of hot fl ushes in postmenopausal women, and on the blood level of serotonin and noradrenaline. If folic acid supplementation is demonstrated to be effective, this will be a turning point in the clinical practice since it represents a cheap, safe and well-tolerated alternative to HRT.

Subtalar dislocations:Mechanisms,clinical presentation and methods of reduction

Subtalar joint is a complex joint in hindfoot formed by the talus superiorly and the calcaneus and navicular inferiorly.Subtalar dislocations are high-mechanism injuries,which are caused by simultaneous dislocation of both talonavicular and talocalcaneal joints,without major fracture of the talus.They are usually classified as medial(most common),lateral,anterior and posterior dislocations,based on the position of foot in relation to talus and the indirect forces that have been applied to cause this significant injury.They are usually diagnosed by X rays,but computed tomography and magnetic resonance imaging can be used to identify associated intra-articular fractures and peri-talar soft tissue injuries respectively.Majority being closed injuries,can be managed in ED by closed reduction and cast immobilisation,but if they are open,have poor outcomes.Complications that ensue open dislocations are post-traumatic arthritis,instability and avascular necrosis.

Survival analysis in nonagenarian patients with non-hip lower limb fractures

BACKGROUND The United Kingdom has an aging population with nearly 1 in 5 being over the age of 65,and over 0.5 million over the age of 90.The treatment of acute fractures of the lower limb in the nonagenarian cohort of patients poses a technical challenge to orthopaedic surgeons.AIM To report the fracture incidence,survival outcomes of treating acute non-hip lower limb fractures in nonagenarians in Major Trauma Centre.METHODS Thirty Lower limb long bone fractures in patients of age from 90 to 99 years were identified during 12-mo at a Level 1 trauma centre from a computerized database.A retrospective evaluation performed for fracture incidence,treatment,length of hospital duration and mortality at 30-d,1-year and 2-year.RESULTS Thirty fractures(28 patients)were identified,twenty-four fractures were treated with surgery(mean age 93 years SD±2.59)and 6 managed conservatively(mean age 94 years SD±2.07).The mean length of the hospital stay was 18.2 d for both groups.The 30-d,1-year and 2-year mortality risks were 1/23,6/23 and 9/23(4%,26%and 39%)in the surgery group and 0/5,1/5 and 2/5(0%,20%and 40%)in the conservative group,with no evidence for a difference between the two groups at any time point.CONCLUSION Nonagenarians in the surgical group had similar length of hospital stay and mortality risks as those treated conservatively.Patients with fewer comorbidities and admitted from their own home were offered surgery.

Spontanous Remission of PAN

Polyarteritis nodosa (PAN) affects mostly medium-sized arteries and sometimes small ones as well. The primary methods used to make the diagnosis are through physical examinations, biopsies of organs that are affected, and/or angiographic studies. Immunosuppressants like glucocorticoids and cyclophosphamide are usually started as soon as possible after a diagnosis. So, it’s not clear if sudden remission of PAN happens or not. Here we present a 42-year-old male who presented with right upper quadrant, right flank pain and fever. CT angiogram Aorta revealed soft tissue rind around the small to medium sized vessel in the abdomen and bilateral cortical renal infarcts of variable age in the right more than the left. A diagnosis of polyarteritis nodosa was made and the patient achieved spontaneous remission with no need for corticosteroids or immunosuppressive therapy.

未登记的视力损害现状:登记系统是否正在失去作用

Background/aims: To assess the current level of under-registration of blindne ss and partial sight among patients attending a large teaching hospital, and to determine any risk factors for under-registration. Methods: Medical records of all patients attending general ophthalmology outpatient clinics over a 3 month p eriod were included in a retrospective analysis of registration rates; questionn aire survey assessing the level of knowledge of registration practices among 35 ophthalmologists working in theWest Midlands. Results: 146/2161 (7%) patients w ere eligible for blind or partial sight registration, or were in possession of a completed BD8 form. Of these 146 patients, 65 (45%) were unregistered with 18 fulfilling the criteria for blind and 47 for partially sight. In addition, 32/81 (40%) registered patients appeared to have been inappropriately registered. Pa rtially sighted patients were more likely to be unregistered than blind patients (OR 2.31, 95%CI 1.15 to 4.63, p=0187), and patients from ethnic minorities wer e more than three times more likely to be unregistered than white patients (OR 3 .23, 95%CI 1.56 to 6.65, p=0.0015). A patient with a treatable condition was mo re likely to be unregistered than a patient with an unbeatable condition (OR 4.8 7, 95%CI 2.10 to 11.33, p=0.0002). The overall level of knowledge of registrati on practices among doctors was found to be low and there was no indication of in creasing knowledge with increasing experience. Conclusions: There has been littl e improvement in registration rates of visually impaired patients over the past decade. Ophthalmologists lack the necessary knowledge to cater for visually impa ired patients’needs.

成年先天性心脏病患者心脏手术的变化

Objectives: To review 13 years’data from a unit for grown ups with congenital heart disease(GUCH) to understand the change in surgical practice. Methods: Records were reviewed or patients over 16 years of age undergoing surgery between 1 January 1990 and 31 December 2002 in a dedicated GUCH unit. Patients with atrial septal defects were included but not those with Marfan’s syndrome or undergoing a first procedure for bicuspid aortic valves. Three equal time periods of 52 months were analysed. Results: Of 474 operations performed, 162(34.2%)were repeat operations. The percentage of repeat operations increased from 24.8%(41 of 165) in January 1990-April 1994 to 49.7%(74 of 149) in September 1998-December 2002. Mortality was 6.3%(n=30). The median age decreased from 25.4 years(interquartile range 18.7) in January 1990-April 1994 to 23.9(interquartile range 17.3) in September 1998-December 2002(p=0.04). The proportion of patients with a “simple”diagnosis decreased from 45.4%(74 or 165) in January 1990-April 1994 to 27.5%(41 of 149) in September 1998-December 2002(p=0.013). Pulmonary valve replacements in operated tetralogy of Fallot increased from one case in January 1990-April 1994 to 23 cases in September 1998-December 2002 and conduit replacement increased from five cases to 17. However, secundum atrial septal defect closures decreased from 35 cases to 14(p< 0.0001). The estimated cost(not including salaries and prosthetics) incurred by an adult patient with congenital heart disease was ￡2290 compared with ￡2641 for a patient undergoing coronary artery bypass grafting. Conclusion: Despite the impact of interventional cardiology, the total number of surgical procedures remained unchanged. The complexity of the cases increased particularly with repeat surgery. Nevertheless, the patients do well with low mortality and the inpatient costs remain comparable with costs of surgery for acquired disease.

重症输血量的新计算公式

Background: Published formulae, frequently used to predict the volume of transfused red cells required to achieve a desired rise in haemoglobin (Hb) or haematocrit (Hct), do not appear to have been validated in clinical practice. Aims: To examine the relation between transfusion volume and the resulting rise in Hb and Hct in critically ill children. Methods: Phase 1: Sample of 50%of children admitted during 1997; 237 of these 495 patients received at least one packed red cell transfusion; 82 children were transfused without confounding factors that could influence the Hb/Hct response to transfusion and were analysed further. Actual rise in Hb concentration or haematocrit was compared to that expected from use of existing formulae. A new formula was developed. Phase 2: In 50 children receiving a packed red cell transfusion during 2001, actual rise in Hb concentration was compared to expected rise in Hb with use of the new formula. Results: Phase 1: Existing formulae performed poorly; median ratio of actual/predicted rise in Hb or Hct ranged from 0.61 to 0.85. Using the regression coefficients new formulae were developed for both Hb and Hct. These formulae were applicable across all age and diagnostic groups. Phase 2: Median ratio of actual/predicted rise in Hb improved to 0.95 with use of the new formula. Conclusions: Existing formulae underestimate the volume of packed red cells required to achieve a target Hb or Hct. Adoption of the new formulae could reduce the number of transfusion episodes in PICU, cutting costs and reducing risk.

1998—2003年英国儿童医院甲氧西林耐药性金黄色葡萄球菌(MRSA)的感染情况

Aims: To investigate the epidemiological and clinical aspects of MRSA among inpatients and outpatients presenting to hospital. Methods: Analysis of demographic, epidemiological, and clinical data collected on 385 children first identified as having MRSA between January 1998 and December 2003 in a 250 bed English children’s hospital. Results: There were 267 inpatients and 118 outpatients. The number of new cases of MRSA declined from 72 in 1998 to 52 in 2003, whereas hospital activity increased. Ninety nine (37.1%) inpatients acquired MRSA outside the hospital; a further 90 occurred among 31 clusters of cases. One hundred and seventy eight (66.7%) inpatients were aged < 2 years; cardiac services and paediatric&neonatal surgery accounted for 59.6%of cases. Dermatology and A&E accounted for 51.7%of outpatients; 73.8%of outpatients had recently previously attended the hospital. A total of 13.9%of inpatients with MRSA developed bacteraemia;MRSA accounted for 15%of Staphylococcus aureus bacteraemias. The risk of MRSA bacteraemia in colonised patients, and the proportion of S aureus bacteraemias that were MRSA, varied between specialties. Intravascular devices were the most common source of MRSA bacteraemia (63.4%of cases). The mortality rate was 7.3%. Conclusions: Enhanced surveillance of MRSA can identify at-risk patient groups, thus facilitating targeting of control measures. The absence of a link between numbers of cases of acquisition of MRSA and bacteraemia suggests that the rise in MRSA bacteraemia may not solely reflect an increase in MRSA prevalence in children in the UK. The need for larger epidemiological studies is emphasised.

对乙酰氨基酚引起的肝中毒

Aim:To identify the clinical and biochemical risk factors associated with outcome of paracetamol induced significant hepatotoxicity in children. Methods:Retrospective case notes review of those with paracetamol overdose admitted from 1992 to 2002. Patients were analysed in two groups:group I recovered after conservative treatment and group II developed progressive liver dysfunction and were listed for liver transplantation. Results:Of 51 patients (6 males,45 females,aged 0.8-16.1 years),6 (aged < 7 years) received cumulative multiple doses,and 45 a single large overdose (median 345 mg/kg,range 91-645). The median (range) interval to hospital at presentation post-ingestion was 24 hours (4-65) and 44 hours (24-96) respectively in groups I and II. Patients received standard supportive treatment including N-acetylcysteine. All children in group I survived. In group II,6/11 underwent orthotopic liver transplantation (OLT) and 2/6 survived; 5/11 died awaiting OLT. Cerebral oedema was the main cause of death. Children who presented late to hospital for treatment and those with progressive hepatotoxicity with prothrombin time >100 seconds,hypoglycaemia,serum creatinine > 200 μmol/l,acidosis (pH<7.3),and who developed encephalopathy grade III,had a poor prognosis or died. Although hepatic transaminase levels were markedly raised in both groups,there was no correlation with necessity for liver transplantation or death. Conclusion:Accidental or incidental paracetamol overdose in children may be associated with toxic liver damage leading to fulminant liver failure. Delayed presentation and/or delay in treatment,and hepatic encephalopathy ≥grade III were significant risk factors,implying poor prognosis and need for OLT. Prompt identification of high risk patients,referral to a specialised unit for management,and consideration for liver transplantation is essential.

子宫内膜增生的治疗:对现行治疗方法的评价

Objective: To identify current management practices and evaluate subsequent outcomes of treatment for women diagnosed with endometrial hyperplasia. Study design: All women with a histological diagnosis of endometrial hyperplasia at the Birmingham Women s Hospital were identified between October 1998 and September 2000. A retrospective case note review was performed for each woman using a standardised data abstraction sheet. Baseline characteristics including clinical presentation and treatment strategywere obtained. Results of subsequent endometrial tissue examinations were used to assess histological response to treatment and the need and indication for hysterectomy was used to assess clinical response. Results: There were 351 women diagnosed with endometrial hyperplasia during the study period of which 84% presented with symptoms of abnormal uterine bleeding and 54% were postmenopausal. Complex endometrial hyperplasia was the most common diagnosis accounting for 60% of all cases. Eighty percent of women with atypical endometrial hyperplasia were treated by hysterectomy compared with 30% without evidence of cytological atypia (relative hysterectomy rate of 2.6, 95% CI 2.0- 3.3). Hysterectomy was avoided in 138/172 (80% , 95% CI 74- 86% ) women managed conservatively during the study period. Overall 35/108 (36% , 95% CI 27- 46% ) of women managed conservatively had persistent or progressive disease identified (mean follow up 36 months). 20/143 (14% ) women initially diagnosed with endometrial hyperplasia who subsequently underwent hysterectomy were found to have endometrial cancer, the majority of whom had been diagnosed with atypical disease (14/20, 70% ). Conclusion( s): The majority of women with atypical endometrial hyperplasia were managed by hysterectomy and the substantial risk of diagnostic under-call supports this approach to treatment. In contrast, there is no consensus regarding the initial management of women with endometrial hyperplasia without cytological atypia.

腹裂复位术是否需全身麻醉:一项比较性分析

Background: Outcome after gastroschisis repair without general anesthesia is controversial, and published conclusions are variable with no comparative studies. Aim: The aim of this study was to present a comparative study evaluating outcome after gastroschisis repair with and without general anesthesia.Methods: An ambispective nonrandomized study of a cohort of 51 neonates born with gastroschisis between July 1998 and December 2003 was performed. Twenty-four neonates (group1) had conventional reduction under general anesthesia, and 27(group 2) cotside minimal intervention reductions were without general anesthesia. Results: Groups were comparable regarding gestational age, birth weight, and quality of eviscerated bowel. Statistical significance (P < 0.05) was seen between groups 1 and 2 with regard to age at reduction of gastroschisis(5.6 ±2.5 vs 3 ±1 hours) and time taken for completion of gastroschisis reduction (58.1 ±15 vs 49 ±14 minutes). No statistical significance (P > 0.05) was seen with respect to start of feeds (10.4 ±3.6 vs 10.9 ±4.1 days), duration of total parenteral nutrition (21.5 ±7.3 vs 22.4 ±6.8 days), and total hospital(stay 29 ±10 vs 30 ±13 days). Admission to the intensive care unit was required in 92%in group 1 for 1 to 6 days vs 7%in group 2 for 3 to 6 days. There was 1 death in group 1(4%). Total hospital cost in group 1 was ￡12,283 ±￡2438 vs￡6208 ±￡2120 in group 2 (P = 0.013). Conclusions: Neonates with gastroschisis, whose bowel was reduced without general anesthesia, have similar outcomes to those whose bowel was reduced under general anesthesia. Both approaches appear to be safe and effective, but reduction without general anesthesia was cost-effective.