The Use of Clinical Reasoning Skills in the Setting of Uncertainty: A Case of Trial Femoral Head Migration

Clinical skills and medical knowledge enable physicians to overcome the uncertainty of emergent and rare clinical scenarios. Recently, a growing emphasis on evidence-based medicine (EBM) has flooded medical curricula of universities across the globe with guideline-based material, and while it has given teachers and students new tools to improve medical education, clinical reasoning must be reaffirmed in its capacity to provide physicians with the ability to solve unexpected clinical scenarios. Anatomical education in medical school should have two main objectives: to acquire anatomical knowledge and to develop the skill of applying that knowledge in clinical scenarios. The authors present a clinical scenario in which an unexpected and rare complication occurred during a routine elective hip replacement surgery. The general surgeon presiding over the case, also an anatomy professor, solved the problem using clinical reasoning and anatomical knowledge. It was a clear example of how clinical reasoning is key in approaching unprecedented, rare, or unknown complications. The intention of this scenario is to remind colleagues and medical schools that, although EBM is the standard, educators must uphold sound clinical reasoning to best prepare health care providers for their careers.     

动眼、面、听神经显微血管供应与术后神经功能保留关系的研究

目的:研究动眼神经海面窦段及面听神经桥脑小脑角段显微血管供应。方法:采用大体解剖法显露并观测了40侧动眼、面听神经动脉来源。结果:80%的脑膜垂体干及海面窦下动脉发出滋养动脉至动眼神经;面神经桥小脑角段主要由小脑下前动脉发出的迷路动脉、回返穿通动脉供应。结论:动眼、面听神经毗邻结构复杂,滋养血管细小,手术时应特别注意辨认和保护动眼和面听神经的显微血管。     

LP(a) phenotypes and levels in angiographically proven coronary heart disease patients and controls

Lipoprotein Lp(a) excess has been identified as a powerful predictor of premature atherosclerotic vascular diseases. To evaluate this in a North-Indian population, 130 CAD patients and 130 controls were analyzed. The size of the apo(a) phenotypic isoforms was inversely proportional to Lp(a) concentrations. The mean concentration of Lp(a) in the CAD patients was 42±34 mg/dl whereas in the normal subjects it was much lower, 27±27 mg/dl. 157 subjects out of the total 260 subjects showed plasma levels of >20mg/dl. The frequency of high Lp(a) levels was much higher in patients(73%) than controls (43%). These data suggest (1) that there is heterogeneity of the Lp(a) polymorphism, (2) Higher Lp(a) levels were found in patients than in the controls, (3) Patients showed 1.5 fold increase in Lp(a) levels as compared to the controls. We conclude that low molecular weight apo(a) isoforms are significantly associated with increased risk of CAD in the North-Indian population.     

彩色多普勒超声心动图对冠心病的诊断价值138例分析

目的探讨彩色多普勒超声心动图(CDE)诊断冠心病的价值。方法选择年龄在55～85岁之间的138例初诊为冠心病的病人,进行CDE检查及冠状动脉造影(CAG)检查,并进行对照,以CAG诊断结果为标准来评价CDE对冠心病的诊断价值。结果138例临床初诊为冠心病的患者,经CAG检查明确了105例冠心病的诊断,其中74例经CDE检出室壁运动异常,且主要出现在室间隔和左室前壁,而左室下壁及后壁出现较少;CDE诊断冠心病的敏感性和特异性分别为64.76%、81.82%。结论CDE对诊断冠心病有较高的特异性和敏感性,尤其是当病变累及左前降支及其分支时,但对左旋支及右冠状动脉病变的诊断尚存在一定的局限性。     

小儿川崎病并发冠状动脉病变高危因素探讨

目的：探讨川崎病并发冠状动脉病变的相关因素。方法：对86例确诊为川崎病患儿的临床表现、超声心动图、急性期C-反应蛋白、胆固酵、血沉、血小板、血红蛋白、白细胞等资料进行计量资料￡检验和计数资料Y0检验。结果：86例川崎病并发冠状动脉病变26例（30％）。相关因素分析显示：发病年龄、发热天数、血小板、C-反应蛋白、胆固醇与冠状动脉病变发生率有密切关系。用静脉丙种球蛋白（IVIG）治疗的冠状动脉病变发生率23．6％，仅用阿司匹林治疗的冠状动脉病变发生率57．1％，7d内使用IVIG治疗的冠状动脉病变发生率6．4％（P〈0．01）。结论：对川崎病进行综合分析，可对该病作出及时的预后判断，予早期干预，促进冠状动脉病变的恢复；早期足量使用IVIG可减少KD并发冠状动脉病变的发生。     

135°DHS治疗股骨粗隆间不稳定骨折的疗效评价

目的观察DHS治疗不稳定股骨粗隆间骨折的疗效并做出评价.方法1996年9月～2000年10月采用DHS治疗不稳定股骨粗隆间骨折76例.男47例,女29例,年龄24～87岁,平均67.6岁.改良Evans分型Ⅲ型12例,Ⅳ型42例,Ⅴ型22例.合并颅脑损伤2例,胸部外伤1例,骨盆骨折2例,腰椎骨折3例,同侧股骨下段骨折1例,同侧小腿骨折2例.26例合并内科疾病,24例为60岁以上患者,占60岁以上患者的58.5%,其中高血压17例,冠心病9例,心率失常5例,糖尿病3例,脑梗塞6例,慢性支气管炎3例,慢性胃炎2例,十二指肠球部溃疡1例,60岁以上患者合并骨质疏松28例.结果围手术期本组无一例死亡,平均住院时间16d(12～26d),术前2～10d,平均5.4d,住院期间术后并发症5例,2例心功能衰竭,3例下肢深静脉血栓.58例获得随访,男34例,女24例,其中60岁以上患者32例,随访7～26个月,3～6个月骨折愈合,平均3.5个月.2例颈干角小于术前评价,但大于110°.无螺钉松动及钢板断裂.根据Merle D & A ubigne[1]髋关节功能评价标准优良率91%.结论DHS是结构坚固的可伸缩内固定装置,允许骨折端在装置上滑动以寻求自身的稳定,为骨折端提供了静力及动力性加压,是治疗股骨粗隆间骨折的理想方法,对于合并有内科疾病的高龄患者,只要采取有效内科治疗,该手术同样可获得满意疗效.     

Exercise-related transient abdominal pain secondary to median arcuate ligament syndrome: a case report

Exercise-related transient abdominal pain is a common entity in young athletes. An uncommon aetiology of this type of pain is median arcuate ligament syndrome. This article details an 18-year-old field hockey player who presented with a 1-year history of exercise-related transient abdominal pain. Despite a trial of preventative strategies, the patient’s pain persisted, prompting surgical intervention. Following a laparoscopic median arcuate ligament release, the patient’s symptoms resolved. Therefore, when exercise-related transient abdominal pain persists despite precautionary measures, median arcuate ligament syndrome should be considered.     

Association between TaqIB polymorphism of cholesteryl ester transfer protein and coronary artery disease in the Chinese population

Objective  

To assess whether the TaqIB polymorphism of cholesteryl ester transfer protein (CETP) is associated with coronary artery disease (CAD) in Chinese population, we performed a meta-analysis in this paper.     

Screening for significant atherosclerotic renal artery stenosis with a regression model in patients undergoing transradial coronary angiography/intervention

Objective: Early detection of atherosclerotic renal artery stenosis (ARAS) is clinically important with respect to blood pressure control, prevention of renal insufficiency, and even improving survival. We investigated whether the presence of significant ARAS (luminal diameter narrowing ≥70%) could be predicted using a logistic regression model before coronary angiography/intervention. Methods: Initially, we developed a logistic regression model for detecting significant ARAS based upon clinical and angiographic features and biochemical measurements in a cohort of 1 813 patients undergoing transfemoral coronary and renal angiography. This model was then prospectively applied to an additional 495 patients who received transradial renal angiography to ascertain its predictive accuracy for the presence of significant ARAS. Results: Multivariate regression analysis revealed that older age (≥65 years), resistant hypertension, type 2 diabetes, creatinine clearance (Ccr) ≤60 ml/min, and multivessel coronary disease were independent predictors for significant ARAS. A logistic regression model for detecting ARAS by incorporating conventional risk factors and multivessel coronary disease was generated as: P/(1−P)=exp(−2.618+1.112[age≥65 years]+1.891[resistant hypertension]+0.453[type 2 diabetes]+0.587[Ccr≤60 ml/min]+2.254[multivessel coronary disease]). When this regression model was prospectively applied to the additional 495 patients undergoing transradial coronary and renal angiography, significant ARAS could be detected with a sensitivity of 81.2%, specificity of 88.9%, and positive and negative predictive accuracies of 53.8% and 96.7%, respectively. Conclusions: The logistic regression model generated in this study may be useful for screening for significant ARAS in patients undergoing transradial coronary angiography/intervention.