胰岛素抵抗中诸多因素与冠状动脉再狭窄的相关性

目的:探讨胰岛素抵抗与冠状动脉再狭窄的关系,研究后者的相关因素,寻求实施康复介入的可能性。 方法:对191(男163例,女28例)成功行冠状动脉支架术(coronarystent,CS)并完成冠脉造影随访的患者选择年龄、糖尿病、空腹胰岛素等11项作为观察指标,以有无再狭窄和高胰岛素血症进行分组。单因素 分析上述的各种临床因素与再狭窄的关系及高胰岛素血症与CS术后狭窄程度的关系。用Kaplan-Meier法分析高胰岛素血症对CS术后无再狭窄发生率(生存率)的影响。 结果:入选的191例患者的217支血管中,共置入263枚支架。有54例患者的68处原支架发生再狭窄,靶病变的再狭窄率为25.9％(68/263)。空腹胰岛素>15 mU/L患者为36.1％(69/191)。在再狭窄组高胰岛紊血症的患者比率明显高于无再狭窄组(48.1％,31.4％)(X~2=4.7,P<0.05)。Kaplan-Meier法分析结果高胰岛素血症组患者未发生再狭窄的比率(生存率)明显低于正常血清胰岛素组患者(62.3％,77％)(X~2=4.7,P<0.05)。 结论:高胰岛素血症可能是CS术后再狭窄的危险因素。高浓度胰岛素促进CS术后再狭窄的形成。     

冠心病患者的餐后高血糖、胰岛素抵抗情况调查

目的:调查冠状动脉粥样硬化性心脏病(冠心病)患者餐后高血糖、胰岛素抵抗的发生情况。方法:收集既往无糖尿病史的可疑冠心病患者268例,根据冠状动脉造影检查结果分为冠心病组177例和非冠心病组91例。通过口服葡萄糖耐量试验,测定两组空腹、餐后1、2 h的血糖和胰岛素水平,观察两组糖耐量异常及胰岛素抵抗情况。结果:冠心病组中糖耐量减低(IGT)和糖尿病者的比例(76.3%)明显高于非冠心病组(37.3%),P<0.01。冠心病组餐后1、2 h血糖及胰岛素均高于空腹时(P<0.01);非冠心病组餐后1 h血糖、餐后1、2 h胰岛素均高于空腹时,但餐后2 h血糖与空腹时比较差异无统计学意义(P<0.05)。两组空腹血糖、餐后1 h血糖、空腹胰岛素、餐后1 h胰岛素水平比较差异无统计学意义(P>0.05),但冠心病组餐后2 h血糖及胰岛素水平均明显高于非冠心病组(P<0.05或0.01)。冠心病组、非冠心病组的HOMA-IR及胰岛素抵抗患者比例比较差异均无统计学意义(P均>0.05),冠心病组高胰岛素血症者比例明显高于非冠心病组(P<0.01)。结论:冠心病患者的餐后高血糖及胰岛素抵抗情况比非冠心病患者严重。     

胰岛素抵抗中诸多因素与冠状动脉再狭窄的相关性

目的：探讨胰岛素抵抗与冠状动脉再狭窄的关系，研究后者的相关因素，寻求实施康复介入的可能性。方法：对191(男163例，女28例)成功行冠状动脉支架术(coronary stent，CS)并完成冠脉造影随访的患者选择年龄、糖尿病、空腹胰岛素等11项作为观察指标，以有无再狭窄和高胰岛素血症进行分组。单因素分析上述的各种临床因素与再狭窄的关系及高胰岛素血症与CS术后狭窄程度的关系。用Kaplan-Meier法分析高胰岛素血症对CS术后无再狭窄发生率(生存率)的影响。结果：入选的191例患者的217支血管中，共置入263枚支架。有54例患者的68处原支架发生再狭窄，靶病变的再狭窄率为25．9％(68／263)。空腹胰岛素&;gt;15mU／L患者为36．1％(69／191)。在再狭窄组高胰岛素血症的患者比率明显高于无再狭窄组(48．1％．31.4％)(χ^2=4．7，P&;lt;0．05)。Kaplan-Meier法分析结果高胰岛素血症组患者未发生再狭窄的比率(生存率)明显低于正常血清胰岛素组患者(62，3％,77％)(χ^2=4．7，P&;lt;0．05)。结论：高胰岛素血症可能是CS术后再狭窄的危险因素。高浓度胰岛素促进CS术后再狭窄的形成。     

经皮冠状动脉介入治疗术后再狭窄相关危险因素分析

目的分析经皮冠状动脉介入治疗(PCI)术后发生再狭窄的相关危险因素。方法选择18例行PCI术后发生再狭窄的患者做为观察组,选择同期手术治疗术后未发生狭窄的160例患者为对照组。对两组患者的年龄、性别、术前空腹血糖、收缩压、胆固醇、超敏C-反应蛋白(hs-CRP)及体质指数进行统计学分析。结果两组患者术前空腹血糖、收缩压、胆固醇、hs-CRP及体质指数具有显著差异(P<0.05),而年龄及性别构成比无显著差别(P>0.05);logistic回归分析结果显示:空腹血糖、hs-CRP及胆固醇为PCI术后再狭窄的独立风险因素。结论临床上对PCI术前,术后应强化抗炎、降脂和控制血糖治疗,以降低术后再狭窄的发生率。     

血清sortilin、occludin水平与急性冠状动脉综合征患者PCI术后支架内再狭窄的关系

目的 探讨血清分拣蛋白(sortilin)、闭合蛋白(occludin)与急性冠状动脉综合征(ACS)患者经皮冠状动脉介入术(PCI)后支架内再狭窄的关系。方法 选取2019年5月至2021年5月在安阳市中医院行PCI术治疗的126例ACS患者为研究对象，采用酶联免疫吸附法检测患者血清sortilin、occludin水平。根据术后连续随访12个月是否发生支架内再狭窄分为狭窄组(n=34)与未狭窄组(n=92)。应用受试者工作特征(ROC)曲线分析血清sortilin、occludin对ACS患者PCI术后支架内再狭窄的预测价值，多因素Logistic回归分析探讨影响ACS患者PCI术后支架内再狭窄的相关因素。结果 两组糖尿病史、冠状动脉病变支数、冠状动脉病变长度、术前Gensini评分、支架置入个数、LDL-C比较，差异有统计学意义(P<0.05)。狭窄组血清sortilin、occludin水平高于未狭窄组，差异有统计学意义(P<0.05)。ROC曲线分析结果显示，血清sortilin、occludin预测再狭窄的AUC(95%CI)为0.791(0.741～0.841...     

冠心病患者支架术后再狭窄的多因素回归分析

目的探讨经皮冠状动脉介入治疗（PCI）前后血管性血友病因子（vWF）、血小板膜糖蛋白GPⅡb／Ⅲa（CIMl）受体、血管内皮生长因子（VEGF）水平与术后再狭窄的关系。方法不稳定型心绞痛患者52例（UAP组），稳定型心绞痛患者46例（SAP组）。同时选取40例冠状动脉造影正常患者作对照。采用酶联免疫吸附双抗夹心法测定vWF、VEGF；流式细胞仪测定CD41活性。结果经多变量Logistic回归分析，术后vWF峰值（RR=3．892，95％CI=3．113～5．665，P=0．002）、VEGF峰值（RR=2．763，95％CI=1．897-4．229，P=0.001）和支架长度（RR=1．295，95％CI=1．112～1．867，P=0．024）是PCI术后再狭窄的独立预测因素。结论经皮冠状动脉介入治疗术后vWF、VEGF峰值水平对再狭窄的发生具有独立预测价值。     

后扩张对冠心病弥漫性长病变患者冠状动脉支架术（PCI）后支架再狭窄的效果影响分析

目的:分析后扩张对冠心病弥漫性长病变患者冠状动脉支架术(PCI)后支架再狭窄的效果影响。方法:选取2015年2月~2016年3月我院收治的96例冠心病弥漫性长病变患者临床资料,根据治疗方式不同分为对照组与研究组各48例。研究组在完成PCI术后予以支架后扩张,对照组未予以后扩张,比较两组PCI术式置入支架的参数与病变特征以及术后再狭窄与不良心血管事件发生情况。结果:两组PCI术式置入支架的参数与病变特征比较无显著性差异(P>0.05);研究组术后再狭窄与不良心血管事件发生率显著低于对照组(P<0.05)。结论:PCI术后予以患者后扩张可降低术后再狭窄与不良心血管事件发生率,值得临床推广应用。     

高脂蛋白a血症对冠状动脉支架术后再狭窄的影响

目的 探讨高血清脂蛋白(a)[LP(a)]血症与冠状动脉支架植入术后支架内再狭窄的关系.方法 对152例成功在我院行经皮冠状动脉成形术(PTCA)+支架植入术并于术后行冠状动脉造影随访的患者进行回顾性分析.分为再狭窄组(29例)和无再狭窄组(123例),检测患者血LP(a)水平,对其一般临床资料也进行调查分析.统计学采用Logistic多因素逐步回归分析.结果 2组患者在高LP(a)血症、吸烟、糖尿病比例方面差异均有统计学意义(P均<0.05).Logistic多因素逐步回归分析显示:LP(a)水平是支架术后支架内再狭窄发生的独立危险因素,RR为2.648,95%CI为1.066～6.575,P<0.05.其他因素如吸烟(P=0.023)、糖尿病(P=0.036)、支架类型(P=0.011)也与支架内再狭窄发生有关(P均<0.05).结论 高LP(a)血症是发生冠状动脉支架术后再狭窄的独立危险预测因素.     

红细胞分布宽度与冠心病患者经皮冠状动脉介入治疗术后支架内再狭窄的相关性研究

目的 探讨红细胞分布宽度(RDW)与冠心病患者经皮冠状动脉介入治疗(PCI)术后支架内再狭窄(ISR)的相关性.方法 选取2015年3月至2016年3月在我科行冠状动脉造影确诊为冠心病并行药物洗脱支架(DES)置入术的患者978例,其中493例患者(50.41%)在术后6~12个月在我院复查了冠状动脉造影.根据复查造影结果分为再狭窄组和非再狭窄组.收集患者的基础资料、各项实验室指标及冠状动脉介入术手术记录,分析两组间可能导致支架内再狭窄的因素.结果 再狭窄组51例(10.34%),非再狭窄组442例(89.66%).两组患者基线特征相似,在性别、年龄、体质量指数、合并高血压、冠心病家族史、术后长期服用他汀类药物情况及随访间期方面差异均无统计学意义(P均>0.05).再狭窄组合并糖尿病患者比例高于非再狭窄组(37.3%比22.6%,P=0.021));再狭窄组患者吸烟率更高(52.9%比35.7%,P=0.016).实验室检查方面,两组患者血脂水平及全血细胞分析中的白细胞、红细胞、血红蛋白、血小板计数差异均无统计学意义(P均>0.05).再狭窄组患者血清RDW[13.4(13.00, 13.80)比12.7(12.40,13.10),P<0.01]及hs-CRP[3.15(2.32,4.63)比1.33(0.63,3.16),P<0.01]水平显著升高.再狭窄组患者置入的支架更长[(21.87±5.20)mm比(19.14±4.87)mm,P<0.01)],支架直径更小[(2.87 ± 0.38)mm 比(3.09 ± 0.36)mm,P<0.01)],串联支架例数更多(45.1%比30.8%,P=0.038).多因素 Logistic 回归分析结果显示,校正年龄、性别后,RDW(OR=2.396,95%CI:1.655~3.471;P<0.01),hs-CRP(OR=1.052,95%CI:1.001~1.105;P=0.044),糖尿病(OR=2.029,95%CI:1.004~4.100;P=0.049),吸烟(OR=2.252,95%CI:1.060~4.783;P=0.035),支架长度(OR=1.149, 95%CI:1.072-1.230;P<0.01),支架直径(OR=0.210,95%CI:0.079~0.558;P=0.002)和串联支架(OR=2.306,95%CI:1.162~4.575;P=0.017)是支架内再狭窄发生的独立危险因素.结论 红细胞分布宽度为冠心病患者PCI术后支架内再狭窄的独立预测因子,而慢性炎症及氧化应激反应可能为RDW升高导致ISR发生的最主要机制.     

药物洗脱球囊在冠状动脉支架术后再狭窄治疗中的应用效果

目的分析药物洗脱球囊(DEB)用于冠状动脉支架术后再狭窄治疗中的效果。方法选取济源市第二人民医院2017年6月至2018年6月收治的40例冠状动脉支架术后再狭窄患者为研究对象,随机分为对照组与研究组,每组20例。对照组给予紫杉醇药物洗脱支架治疗,研究组给予药物洗脱球囊(DEB)治疗。比较分析研究组与对照组患者术后心血管不良事件发生情况、管腔狭窄率及最小管腔长径等临床指标。结果术后12个月,研究组与对照组最小管腔长径分别为(2.60±0.43)mm与(2.57±0.42)mm,差异未见统计学意义(P>0.05)。两组患者术后心血管事件发生率、管腔狭窄率及冠状动脉支架术后再狭窄率比较,差异未见统计学意义(P>0.05)。结论DEB用于冠状动脉支架术后再狭窄治疗中的效果理想,安全性高,与药物洗脱支架治疗相比疗效并无显著差异,具有临床推广意义。     

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.     

Determination of creatine kinase isoenzyme MB activity in serum using immunological inhibition of creatine kinase M subunit activity. Activity kinetics and diagnostic significance in myocardial infarction.

This is a new method for the determination of creatine kinase isoenzyme MB activity in serum. The method uses direct activity measurement of creatine kinase B subunit activity after blocking of CK-M subunit activity by inhibiting antibodies. The test takes no longer than 15 min. The method yields an intra-serial C.V. of 2.0-12.9%, and a C.V. from day to day of 5.5%. The detection limit is 3.4 U/l creatine kinase MB. In the 95 cases with proven myocardial infarction several types of creatine kinase MB activity kinetics could be determined. The percentage of creatine kinase MB of peak CK-total is 6-25%, with a mean of 11.1%. The amount of creatine kinase MB with respect to total CK activity after reinfarction is higher than the amount after initial infarction.     

俯卧位通气对高海拔地区肺复张治疗无效急性呼吸窘迫综合征患者氧合的影响

目的 探讨俯卧位通气对高海拔地区肺复张术(RM)治疗无效急性呼吸窘迫综合征(ARDS)患者的治疗作用.方法 从海拔2260m的地区医院筛选RM治疗无效的41例ARDS患者[平均氧合指数( PaO2/FiO2)较RM前升高＜20％视为RM无效],依不同病因分为肺内源性ARDS组(ARDSp组)和肺外源性ARDS组(ARDSexp组),每组再按信封法随机分为俯卧位组和仰卧位组,即ARDSp俯卧位组(11例)、ARDSp仰卧位组(9例)、ARDSexp俯卧位组(10例)、ARDSexp仰卧位组(11例).在通气前及通气1、2、3、4h监测动脉血氧分压( PaO2)、PaO2/FiO2、静态顺应性(Cst)、气道阻力(Raw)的变化.结果 通气lh时,ARDSexp俯卧位组PaO2/FiO2( mm Hg,l mm Hg=0.133 kPa)即较通气前显著升高(157.4±40.6比129.3±48.7,P＜0.05),并随通气时间延长呈持续增高趋势,4h达峰值(219.1 ±41.1);且ARDSexp俯卧位组通气3h内PaO2/FiO2较其他3组显著增高,另3组间则差异无统计学意义.ARDSp俯卧位组、ARDSexp俯卧位组通气4h时PaO2/FiO2均较相应仰卧位组显著增高(208.8±39.7比127.4±47.1,219.1±41.1比124.9±50.8,均P＜0.05).4组通气前后Cst无显著改变,各组间差异也无统计学意义.ARDSp俯卧位组通气4h时Raw(cmH2O·L-1·s-1)较通气前显著降低(6.8±1.7比10.7±1.8,P＜0.05),且明显低于其他3组;其他3组各时间点Raw组内及组间比较差异均无统计学意义.结论 俯卧位通气作为ARDS机械通气重要策略之一,可以改善RM无效高原ARDS患者的氧合,为抢救患者赢得宝贵的时间.     

Digital imaging among medical facilities

The Department of Veterans Affairs (VA) in the USA operates a network of 172 medical centres which all utilize a hospital information system (HIS) which has been developed and is currently maintained by the VA. During the past several years, an image management and communication module has been developed, installed and clinically utilized at the Washington DC and Maryland VA Medical Centres. This image management and communication system, referred to as the decentralized hospital computer program (DHCP) imaging system, is fully integrated with a commercial picture archiving and communication system (PACS). The system is utilized to capture, archive, and display all images generated within the hospital including radiology, nuclear medicine, pathology, endoscopy, bronchoscopy, and dermatology, intraoperative photographs, ECG data, and a limited number of paper documents. The ultimate goal of the project is to have all patient text and image data available at any clinical workstation to any authorized user anywhere within the network of medical centres. Clinical requirements for an imaging workstation include ease of use, rapid and reliable access to the complete set of patient information, and images which are of acceptable quality to meet the requirements of the user and the subspecialty. Patient confidentiality and data security must be safeguarded at all times. Integration of the images with the remainder of the patient's database was found to be critical to the success of the project. The experience at the Washington and Maryland facilities suggests that an imaging system that is successfully integrated with a hospital information system can provide substantial clinical and economic benefits both within and among medical centres. Clinical acceptance and utilization of the system has been excellent, particularly in diagnostic radiology where DHCP Imaging has been interfaced to a commercial PAC system. Based upon this initial experience, the VA has begun to deploy the system throughout its large network of medical centres.     

Myocardial elastography at both high temporal and spatial resolution for the detection of infarcts

Myocardial elastography is a novel method for noninvasively assessing regional myocardial function, with the advantages of high spatial and temporal resolution and high signal-to-noise ratio (SNR). In this paper, in-vivo experiments were performed in anesthetized normal and infarcted mice (one day after left anterior descending coronary artery [LAD] ligation) using a high-resolution (30 MHz) ultrasound system (Vevo 770, VisualSonics Inc., Toronto, ON, Canada). Radiofrequency (RF) signals of the left ventricle (LV) in longitudinal (long-axis) view and the associated electrocardiogram (ECG) were simultaneously acquired. Using a retrospective ECG gating technique, 2-D full field-of-view RF frames were acquired at an extremely high frame rate (8 kHz) that resulted in high-quality incremental displacement and strain estimation of the myocardium. The incremental results were further accumulated to obtain the cumulative displacements and strains. Two-dimensional and M-mode displacement images and strain images (elastograms), as well as displacement and strain profiles as a function of time, were compared between normal and infarcted mice. Incremental results clearly depicted cardiac events including LV contraction, LV relaxation and isovolumetric phases in both normal and infarcted mice, and also evidently indicated reduced motion and deformation in the infarcted myocardium. The elastograms indicated that the infarcted regions underwent thinning during systole rather than thickening, as in the normal case. The cumulative elastograms were found to have higher elastographic SNR (SNR(e)) than the incremental elastograms (e.g., 10.6 vs. 4.7 in a normal myocardium, and 6.0 vs. 2.4 in an infarcted myocardium). Finally, preliminary statistical results from nine normal (m = 9) and seven infarcted (n = 7) mice indicated the capability of the cumulative strain in differentiating infracted from normal myocardia. In conclusion, myocardial elastography could provide regional strain information at simultaneously high temporal (>/=0.125 ms) and spatial ( approximately 55 microm) resolution as well as high precision ( approximately 0.05 microm displacement). This technique was thus capable of accurately characterizing normal myocardial function throughout an entire cardiac cycle, at the same high resolution, and detecting and localizing myocardial infarction in vivo.     

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.