甲板甲床部分切除联合苯酚烧灼术治疗嵌甲症的临床研究

目的:探讨甲板甲床部分切除联合苯酚烧灼术治疗嵌甲症的临床疗效。方法:选择武汉市中心医院2004年10月至2013年5月收治的115例148趾拇趾嵌甲进行研究。以2004年10月至2007年12月的患者53例(67趾)作为对照组行单纯甲板甲床部分切除术治疗,2008年1月至2013年5月的患者62例(81趾)作为观察组行甲板甲床部分切除联合苯酚烧灼术治疗。对比两组患者的出血、疼痛缓解和康复时间,了解一年后患者复发情况及满意度。结果:148趾手术伤口均一期愈合,观察组病例术后出血时间、疼痛缓解时间(1.85±0.42天、13.25±2.17小时)较对照组(2.69±0.53天、21.54±2.56小时)低,但术后恢复时间(11.32±2.37天)较对照组(8.93±2.06天)长,差异均有统计学意义(P0.05),观察组和对照组的复发率及总体满意率分别为6.15%、12.5%及97.06%、91.07%,两组差异并无统计学意义(P0.05)。结论:甲板甲床部分切除联合苯酚烧灼术治疗嵌甲症与单纯甲板甲床部分切除术的疗效相当,但可显著减少患者痛苦。     

Short term treatment of dermatophyte onychomycosis with terbinafine.

OBJECTIVE--To evaluate the effect of short term treatment with terbinafine on dermatophytosis. DESIGN--Multicentre, randomised, double blind placebo controlled trial of 250 mg/day terbinafine for 12 weeks in dermatophyte onychomycosis. SETTING--Eight dermatology centres in the United Kingdom. PATIENTS--112 patients (mean age 44, range 19-78), 99 with mycologically proved toenail infections and 13 with fingernail infections, of whom eight were subsequently excluded and 19 failed to complete the study. INTERVENTION--Terbinafine 250 mg daily or placebo for 12 weeks. Follow up for 36 weeks after stopping treatment. MAIN OUTCOME MEASURES--Mycological cure (negative results on microscopy and culture) and clinical cure at the end of follow up, adverse events, and biochemical and haematological variables at monthly intervals during treatment. RESULTS--After follow up 82% (37/45) (95% confidence interval 68% to 92%) mycological cure and 69% clinical cure were recorded for evaluable patients treated with terbinafine for toenail infection and 71% (5/7) (30% to 96%) mycological cure and clinical cure for those treated for fingernail infection. The corresponding values for those treated with placebo were 12% (3% to 31%) mycological cure and no clinical cure for toenail infections and 33% (1% to 91%) mycological cure and no clinical cure for fingernail infections. On an intention to treat basis for toenail infections the figures were 73% (38/52) (58% to 85%) mycological cure for terbinafine compared with 6% (0% to 30%) for placebo (p less than 0.007). Two withdrawals were related to adverse events with terbinafine, and there were no significant abnormal laboratory test results. CONCLUSION--12 weeks'' terbinafine is effective and safe treatment for nail dermatophytosis.     

Medical cost of curing childhood acute lymphoblastic leukaemia

Between 1970 and 1979 acute lymphoblastic leukaemia was diagnosed in 378 children at this hospital. The outcome for the 181 survivors was examined six or more years after diagnosis to assess morbidity in an unselected group of long term survivors. One hundred and thirty seven of the survivors were in first remission and probably cured (group I). Forty four (group II) had had one or more relapses, some of whom, who had isolated extramedullary relapses, also have a good chance of cure.In group I 136 patients had prophylactic cranial or craniospinal irradiation, while patients in group II, in addition to having that treatment, received local testicular (17) or craniospinal radiation (seven) for testicular or central nervous system relapse. Eight had additional prophylactic cranial radiotherapy after bone marrow relapse, and six had total body irradiation before bone marrow transplantation. The incidence of clinically important growth and endocrine morbidity was 20% in group I and 68% in group II. The morbidity in patients in group I was mainly attributable to early pubertal maturation. In group II 30 patients had growth failure, of whom 19 had gonadal failure from testicular or total body irradiation, 14 had growth hormone deficiency after doses of cranial irradiation of over 2400 cGy, and 10 had spinal growth impairment after craniospinal irradiation. Two also had early pubertal maturation. Five out of six patients who received total body irradiation had multiple endocrine deficiency. Neuropsychological sequelae of treatment were seen in 40 (42%) of 96 schoolchildren in group I and in 12 (38%) of 32 schoolchildren in group II. Postinfective sequelae of treatment were found in patients in both groups.These results show that the survivors who were in their first remission had a 42% residual morbidity related to treatment compared with an 82% morbidity in the survivors of one or more relapses who had multiple treatments.     

Monitoring aminoglycoside use in patients with severely impaired renal function.

Twenty patients with severely impaired renal function, 17 of wnom had recently transplanted kidneys, were treated with aminoglycosides for severe infections acquired in hospital. Serum aminoglycoside concentrations were closely monitored and dosages adjusted individually to obtain peak and trough concentrations that ensured adequate treatment while avoiding toxicity. Causative organisms were susceptible to treatment in 21 out of 26 episodes of infection (81%), and 12 of the 17 patients (71%) in whom organisms were isolated were cured. Nephrotoxicity attributable to aminoglycosides alone was not observed during the 35 courses of treatment. Ototoxicity occurred in only one patient, who had excessively high serum concentrations of amikacin. Serum aminoglycoside concentrations were directly affected by carbenicillin and flucytosine. The concurrent administration of cephradine and cephalexin with gentamicin may have produced nephrotoxicity. We conclude that aminoglycosides, when carefully monitored, are effective and safe in patients with severely impaired renal function.     

Survey of 3765 cardiopulmonary resuscitations in British hospitals (the BRESUS Study): methods and overall results.

OBJECTIVE--To determine the circumstances, incidence, and outcome of cardiopulmonary resuscitation in British hospitals. DESIGN--Hospitals registered all cardiopulmonary resuscitation attempts for 12 months or longer and followed survival to one year. SETTING--12 metropolitan, provincial, teaching, and non-teaching hospitals across Britain. SUBJECTS--3765 patients in whom a resuscitation attempt was performed, including 927 in whom the onset of arrest was outside the hospital. MAIN OUTCOME MEASURE--Survival after initial resuscitation, at 24 hours, at discharge from hospital, and at one year, calculated by the life table method. RESULTS--There were 417 known survivors at one year, with 214 lost to follow up. By life table analysis for every eight attempted resuscitations there were three immediate survivors, two at 24 hours, 1.5 leaving hospital alive, and one alive at one year. Survival at one year was 12.5% including out of hospital cases and 15.0% not including these cases. Each hospital year averaged 30 survivors at one year: three who had an arrest outside hospital, seven who had one in the accident and emergency department, seven in the cardiac care unit, 10 in the general wards, and three in other, non-ward areas. Within the hospitals survival rates were best in those who had an arrest in the accident and emergency department, the cardiac care unit, or other specialised units. Outcome varied 12-fold in subgroups defined by age, type of arrest, and place of arrest. CONCLUSION--71% of the mortality at one year in patients undergoing attempted resuscitation occurred during the initial arrest. Hospital resuscitation is life saving and cost effective and warrants appropriate attention, training, coordination, and equipment.     

Intermittent treatment of duodenal ulcer with cimetidine.

Intermittent treatment with short courses of cimetidine given only when symptoms recurred was assessed in patients with duodenal ulcer as an alternative to maintenance treatment. Their progress was followed up for up to 22 months. Gastroscopy was carried out in most attacks to confirm recurrence of the ulcer and subsequent healing. Out of 125 patients treated, 83 relapsed, of whom 21 defaulted. After retreatment 36 patients relapsed again. The pattern of relapse and remission for the group as a whole was similar after both courses of treatment, indicating an unchanged natural history. Nevertheless, wide variation occurred in individual patients, so that the pattern of relapse could not be predicted by the duration of the initial remission. Most patients had one or two or rarely three symptomatic relapses a year, which were rapidly treated successfully with cimetidine. Therefore, unless the necessity for long-term maintenance treatment is established, intermittent treatment provides an adequate alternative in most patients with duodenal ulcer.     

Management of asthma in hospital: a prospective audit

In a prospective study of management of asthma in hospital patients with acute asthma admitted to a single hospital over a calendar year were surveyed. Altogether 157 out of 194 admissions (81%) were studied. The patients (16 of whom had been admitted twice and one three times) were interviewed at home about two weeks after discharge, and their hospital records were reviewed. When interviewed an appreciable proportion of patients said that their asthma had been poorly controlled after their discharge from the hospital: 54 reported regular sleep disturbance due to wheeze, 78 tightness of the chest in the morning, and 77 wheeze after climbing one flight of stairs. Patients had been described on admission as having had symptoms of deteriorating asthma for a median of three days. Closer questioning of 71 patients, however, elicited that 50 had had regular symptoms indicating poor control for weeks or months. Most patients did not know how their drugs worked, and many did not have an appropriate plan of action in the event of a further attack. In all the cases studied 114 patients were treated with oral corticosteroids, only 70 had had their previous maintenance treatment increased at the time of discharge, and 107 had a follow up appointment booked for an average of three and a half weeks after discharge.These findings show that undersupervision and undertreatment of patients with asthma are common and not confined to those dying of the condition.     

Ingrowing toenails: an evaluation of two treatments.

Most of the procedures used for treating ingrowing toenails cause considerable discomfort and have high failure rates. This study evaluated two methods of treatment: (a) a simple procedure, and (b) angular phenolisation. Patients were seen in a special toenail clinic and were assessed for severity and duration of symptoms. Those with no permanent deformity of the nail fold and with only minor infection were treated by the simple procedure. The nail was nicked and torn down to expose the infected nail fold. The patients were then taught to clean the area, spray it with povidone-iodine dry powder, and pack the nail fold with a twist of cotton-wool. Patients with recurrent or severe ingrowing toenails were treated by angular phenolisation. One hundred patients were treated by the simple procedure and 61 of these had had no recurrence after six months. A total of 280 phenolisations were carried out over 18 months and 272 were successful. The treatments described are simple, effective, and well tolerated and should be considered as alternatives to traditional treatment.     

Evaluation of the efficacy and acceptability to patients of a physiotherapist working in a health centre.

The records of the first 805 patients who had been referred by general practitioners at this health centre to the attached physiotherapist were examined in November 1985, three years after the physiotherapy department was opened. Seventy per cent (549) of the patients had been treated within one week, treatment having started on the same day for 8.5% (67) of the patients. This compares with a mean of six weeks for direct access to a district general hospital that is eight miles away and between six and 13 months for the three nearest orthopaedic consultants who are 13 miles away. The most common conditions treated were knee injuries (16.5%), followed by cervical (15.5%) and shoulder (13.8%) injuries. Surprisingly, only 9% were back injuries. The non-attendance rate was 2.2% and only 7% of patients failed to complete treatment. Nearly all the patients were able to attend the clinic, only 4% requiring home treatment. By March 1986, 90 treatments a week were being carried out at a cost of 6.11 pounds per patient. Compared with official hospital figures, this represents a savings of 21,500 pounds a year for a practice of 12,000 patients.     

Fifty six continence advisers,one peripatetic teacher.

The increasing demand for the services of a continence nurse led to a novel plan to combat such demand in Leicestershire. The district nursing service seconded a nurse to be trained as an adviser and then to return to the community to set up continence clinics in each health centre. The adviser selected nurses to run these clinics and taught them the skills required to do so. She also carried her own caseload. One hundred and one patients were seen in the clinics in the first year, of whom 30 were cured. In a further one third continence was greatly improved, and the remainder benefited from advice and consultation. The adviser has worked in only six health centres but has had a greater impact on dealing with incontinence than a series of lectures and seminars for district nurses over many years had had.     

Pyorrhoea as cause of pyrexia.

Three patients with fever and malaise, one of whom also had joint pains, were extensively investigated before their condition was attributed to dental sepsis. Each patient recovered fully after appropriate dental treatment. Dental sepsis should be added to the list of possible causes of pyrexia of undetermined origin, and a routine dental examination should be carried out in each case.     

Prevalence of advanced renal failure in Northern Ireland.

OBJECTIVE--To determine the prevalence of advanced chronic renal failure in Northern Ireland as part of an assessment by the Renal Association of the level of service provision for treatment of such patients. DESIGN--Prospective notification of patients reaching a defined level of advanced chronic renal failure (serum creatinine concentration greater than or equal to 500 mumol/l or blood urea concentration greater than or equal to 25 mmol/l) within one year and follow up for at least three, and, at most, four years after notification. SETTING--Northern Ireland. PATIENTS--122 Patients with a serum creatinine or blood urea concentration higher than the defined level newly detected from 1 March 1985 to 28 February 1986. MAIN OUTCOME MEASURE--Survival after notification. RESULTS--77 Patients of all ages/million population/year had advanced chronic renal failure compared with 67/million/year between the ages of 5 and 80 found in an earlier study of the same population. 62% Of the patients were older than 50 years. Seventeen (14%) of the patients either required dialysis or died within one month of notification, 51 (42%) survived for at least three months, and 23 (19%) for one year or longer. Three patients, all of whom were attending a renal clinic, survived for periods of 43, 45, and 46 months respectively without renal replacement treatment. CONCLUSIONS--The increased number of new patients disclosed in this survey compared with the earlier survey is mainly owing to an increased number of older patients. Such patients often have disabilities other than renal failure, are less likely to be capable of self treatment, may develop complications more often and require more frequent hospital admissions, and may not be suitable for transplantation and consequently have considerable resource implications for the NHS.     

A four-year prospective study of the work of the practice nurse in the treatment room of a South Yorkshire practice.

During a four-year study period 43 985 patients were seen in the treatment room and 61 806 coded procedures carried out. Thirty per cent of these procedures were not part of usual nursing curricula and required initial supervision and assessment or training (or both). Nearly 15% of the patients seen were making a first visit and did not require referral to a doctor. A further 17% were also making a first visit but were referred to a doctor. The treatment room made an important contribution to the work of the practice, but this would not have been possible if the staff concerned had been attached nurses requiring area health authority authorisation for procedures carried out as opposed to practice nurses for whom procedures were authorised on a personal basis.     

How much physical therapy for patients with stroke?

The use of physiotherapy, occupational therapy, and speech therapy for patients with stroke was investigated, and the three treatments were compared. Out of 135 patients with stroke surviving at two weeks, 107 received physiotherapy, but only 35 received occupational therapy and 19 speech therapy. Those who received most physiotherapy were the most severely disabled and had the worst prognosis, and, although almost no recovery occurred after six months, 30 patients continued with treatment beyond this time. Stiff and painful shoulders were present in 21 of the patients by two weeks and had developed in a further 37 by one year. Physiotherapy did not prevent this. The objectives of physiotherapy for patients with stroke need careful definition, with emphasis on treatment in the early months. Alternative treatment, possibly carried out by volunteers or more simply trained personnel, merits further consideration.     

Methotrexate in rheumatoid arthritis is frequently effective, even if re-employed after a previous failure

Effectiveness of therapy with individual disease-modifying antirheumatic drugs (DMARDs) in rheumatoid arthritis (RA) is limited, and the number of available DMARDs is finite. Therefore, at some stage during the lengthy course of RA, institution of traditional DMARDs that have previously been applied may have to be reconsidered. In the present study we investigated the effectiveness of re-employed methotrexate in patients with a history of previous methotrexate failure (original course). A total of 1,490 RA patients (80% female, 59% rheumatoid factor positive) were followed from their first presentation, yielding a total of 6,470 patient-years of observation. We identified patients in whom methotrexate was re-employed after at least one intermittent course of a different DMARD. We compared reasons for discontinuation, improvement in acute phase reactants, and cumulative retention rates of methotrexate therapy between the original course of methotrexate and its re-employment. Similar analyses were peformed for other DMARDs. Methotrexate was re-employed in 86 patients. Compared with the original courses, re-employment was associated with a reduced risk for treatment termination because of ineffectiveness (P = 0.02, by McNemar test), especially if the maximum methotrexate dose of the original course had been low (<12.5 mg/week; P = 0.02, by logistic regression). In a Cox regression model, re-employed MTX was associated with a significantly reduced hazard of treatment termination compared with the original course of methotrexate, adjusting for dose and year of employment (hazard ratio 0.64, 95% confidence interval 0.42-0.97; P = 0.04). These findings were not recapitulated in analyses of re-employment of other DMARDs. Re-employment of MTX despite prior inefficacy, but not re-employment of other DMARDs, is an effective therapeutic option, especially in those patients in whom the methotrexate dose of the original course was low.     

骨嗜酸性肉芽肿放射治疗临床分析

目的：探讨骨嗜酸性肉芽肿的治疗方法。方法：对近5年来我院收治经病理证实的12例骨嗜酸性肉芽肿的治疗进行临床回顾性研究。结果：随访1．5a～6a,其中11例患者行局部肿块刮除和放射治疗30Cy后治愈,1例复发,行再程治疗后治愈,总有效率为100％。结论：骨嗜酸性内芽肿治疗采用手术局部肿块刮除和放射治疗,可取得良好效果。     

Influence of intrinsic sympathomimetic activity on respiratory function during chronic beta blockade: comparison of propranolol and pindolol.

The long term effect of beta blockers and the influence of intrinsic sympathomimetic activity on respiratory function were assessed in patients with chronic stable angina pectoris randomised to receive treatment with propranolol (n = 21) or pindolol (n = 19) for one year. Forced expiratory volume in one second (FEV1) had fallen by a mean of 240 ml after one year (p less than 0.001) in those treated with propranolol compared with 120 ml in those treated with pindolol (p less than 0.05). The difference between the groups was significant (p less than 0.01). Vital capacity fell significantly only in those treated with propranolol (p less than 0.05 at one year). In those in whom the basal ratio of FEV1 to forced vital capacity was low (less than 70%) propranolol, but not pindolol, caused a significant (p less than 0.05) fall in FEV1 throughout treatment. Long term administration of pindolol has a less adverse effect on respiratory function than propranolol, which results in a progressive deterioration in respiratory function over one year.     

Ablative radioiodine therapy for hyperthyroidism: long term follow up study.

A total of 225 patients were treated for hyperthyroidism with 555 MBq (15 mCi) radioiodine to ablate the thyroid and induce early hypothyroidism. The efficacy of this treatment in eradicating hyperthyroidism and problems of follow up were assessed one to six years later from case records and questionnaires. Information was received from 197 out of 219 live patients (90%) and from 160 doctors concerning 207 patients (92%). Only three patients were not traced and six had died since treatment. The modal time to hypothyroidism was three months, and 64% of patients were hypothyroid at one year; 5.6% had failed to become euthyroid within one year. Ninety five per cent of patients had been seen by the doctor and 82% had had a thyroid test done within the past two years. Most doctors preferred patients to be returned to their care once thyroxine treatment was stabilised. An ablative dose of 131I is recommended as an effective means of treatment which has clear advantages over conventional methods. Good communications and effective follow up should ensure success.     

Renal Artery Surgery in Patients with Presumptive Renovascular Hypertension

The authors review their experience with 29 patients who were operated upon for renal artery stenosis and had been followed up for longer than one year postoperatively. The preoperative assessment should include an aortogram and split-function test. A bypass prosthesis was the most useful operative technique. One year following surgery 40% were cured, 40% significantly improved and 20% unchanged. The results in patients with a longer follow-up (to seven years) were similar.A plea is made for more frequent preoperative renal biopsies and a greater willingness to perform bilateral repairs at the time of the initial operation.     

CONGENITAL DISLOCATION OF THE HIP—A Study of Open Reduction After Failure of Conservative Treatment

In a study of 42 cases in which open reduction of congenital dislocation of the hip was carried out after conservative treatment had failed, the following observations were made (in a relatively short period of follow-up observation):No one pathological change, as observed at operation, was inordinately associated with failure of closed reduction.By far the highest incidence of successful results of open reduction was obtained in cases in which the operation was done in the second and third year of life.The highest incidence of successful operation, as appraised immediately after the procedure, was in patients more than one year and less than six years of age.Results as determined roentgenographically were in close agreement with results observed clinically.