颈动脉内膜中层厚度、脑白质病变与认知功能障碍的相关性分析

目的:探讨颈动脉内膜中层厚度(IMT)、脑白质病变(WML)与认知功能障碍的相关性。方法:收集老年WML患者185例,采用蒙特利尔认知评估量表(Mo CA)评估认知功能,颈动脉超声测量颈动脉IMT,并根据影像学检查WML分级将患者分为无病变组74例、轻度组58例、中度组41例、重度组12例。结果:轻度组与无病变组比较,Mo CA评分及IMT厚度差异均无明显统计学意义(P0.05);中度、重度组的Mo CA评分及IMT厚度均高于无病变组,差异有统计学意义(P0.05)。WML评分与Mo CA评分呈负相关(r=-0.836,P=0.013),与IMT呈正相关(r=0.579,P=0.022);IMT与Mo CA评分呈负相关(r=-0.277,P=0.024)。结论:颈动脉IMT增厚、WML是老年人认知功能障碍发生的独立危险因素。     

老年高血压患者超敏C反应蛋白和糖化血红蛋白水平与颈动脉粥样硬化之间的关系

目的探讨老年高血压患者超敏C反应蛋白(hs-CRP)及糖化血红蛋白(HbA1c)水平与颈动脉粥样硬化的关系。方法采用超声检测159例老年高血压患者的颈动脉内膜中层厚度(IMT),0.8 mm≤IMT1.0 mm为内膜正常组;1.0 mm≤IMT1.2 mm为内膜增厚组;IMT≥1.2 mm为斑块形成组。比较三组间多项临床资料及生化指标水平,并进一步分析颈动脉斑块特点。通过分析各指标与IMT的相关性,评价颈动脉粥样硬化斑块形成的相关因素。结果三组间性别、年龄、体质指数(BMI)、高血压病程、血尿酸(UA)、空腹血糖(FPG)、总胆固醇(TC)对比,差异无统计学意义(P0.05);三酰甘油(TG)在斑块形成组高于内膜正常组(P0.05),高密度脂蛋白胆固醇(HDL-C)在内膜增厚组和斑块形成组均低于内膜正常组(P0.05),低密度脂蛋白胆固醇(LDL-C)、hs-CRP、HbA1c水平三组间差异有统计学意义,斑块组三个指标均最高,内膜正常组最低(P0.01);IMT与LDL-C(r=0.57,P0.01)、hs-CRP(r=0.55,P0.01)、HbA1c(r=0.53,P0.01)呈正相关,与HDL-C呈负相关(r=-0.35,P0.01),与病程、UA、FPG、TC、TG无相关性;hs-CRP、HbA1c、IMT为颈动脉粥样硬化斑块形成的独立危险因素(P0.05);hs-CRP及HbA1c水平不稳定斑块患者明显高于稳定斑块患者(P0.05)。结论老年高血压患者血清hs-CRP、HbA1c水平升高是颈动脉粥样硬化病变发生的危险因素。     

糖尿病患者颈动脉内-中膜厚度与踝臂指数的关联研究

目的 探讨2型糖尿病患者颈动脉内-中膜厚度(IMT)与踝臂指数(ABI)的关系.方法 对31例健康人及62例2型糖尿病患者进行颈动脉IMT及四肢血压的检测.结果 糖尿病组与正常对照组比较,IMT明显增厚(P<0.01),ABI明显降低(P<0.01),糖尿病组颈动脉粥样硬化及ABI<0.90的患者的比例均明显增加(P<0.01);IMT与ABI之间呈负相关(r＝-0.521,P<0.01).与无颈动脉粥样硬化组相比,有颈动脉粥样硬化组的糖尿病患者其ABI下降 (P<0.05),ABI<0.90的患者的比例增加 ( P< 0.05).结论 糖尿病可导致颈动脉IMT增厚和ABI下降,ABI随IMT的增厚而下降;ABI减低与颈动脉粥样硬化相关;IMT及ABI的检测对糖尿病及颈动脉粥样硬化的发生发展有重要提示作用.     

早期2型糖尿病血清内脂素与颈动脉内膜-中膜厚度的相关性研究

目的 探讨早期2型糖尿病(T2DM)血清内脂素(Visfatin)与颈动脉内膜-中膜厚度(IMT)的关系.方法 70例早期T2DM患者,高分辨超声检测颈动脉IMT,分为IMT增厚组(36例)、IMT非增厚组(34例),对照组为同期健康体检人员30例.三组均检测常规临床指标,采用ELISA法测空腹血清Visfatin.各组间进行统计学分析,探讨Visfatin与早期T2DM颈动脉IMT的关系.结果 T2DM患者Visfatin明显高于对照组(14.32±0.76 μg/L vs 6.34±0.91 μg/L,11.54±0.83μg/L vs 6.34±0.91μg/L,t1=2.41,t2=1.841;P1=0.009,P2=0.029),IMT增厚组Visfatin高于IMT非增厚组(14.32±0.76μg/L vs 11.54±0.83 μg/L,t3=0.901,P3=0.031);简单相关分析显示Visfatin与BMI,IMT,LDL-C,WHR,ln(FINS),ln(HOMA-IR),ln (FBG)呈正相关(r=0.201～0.331,P=0.007～0.047),但多元线性回归分析发现Visfatin仅与HOMA-IR(t=4.123,P=0.0071),IMT(t=3.573,P=0.0084)呈独立相关.结论 血清Visfatin与T2DM发病密切相关,可能参与早期T2DM动脉粥样硬化的发生发展.     

2型糖尿病患者高敏C反应蛋白与颈动脉内膜中层厚度的相关研究

目的研究2型糖尿病(T2DM)患者高敏C反应蛋白(hsCRP)与颈动脉内膜中层厚度(IMT)的关系。方法选取62例T2DM患者和30例正常对照者,用免疫透射比浊法测定hsCRP及用高分辨彩色多普勒测定颈动脉IMT,根据所测的hsCRP水平将T2DM患者分为低hsCRP组(0.05~3 mg/L)30例,高hsCRP组(>3~10 mg/L)32例;T2DM患者给予降糖、调脂等综合性治疗1年,再测定治疗后hsCRP和颈动脉IMT,分析hsCRP与颈动脉IMT变化的关系。结果T2DM患者综合治疗1年后,高hsCRP组颈动脉IMT的增厚明显高于低hsCRP组[(1.05±0.15)mm vs(0.84±0.12)mm(P<0.05)];相关分析中,T2DM患者高hsCRP组在治疗前、后颈动脉IMT与hsCRP呈正相关(r=0.882,r=0.905,均P<0.05)。结论在T2DM中,hsCRP水平的增高与颈动脉IMT的增厚有关,提示血清hsCRP增高可能是T2DM患者合并早期动脉粥样硬化的危险因素之一。     

血尿酸与T2DM及颈动脉内-中膜厚度的关系及意义

目的探讨血尿酸(BUA)与2型糖尿病(T2DM)及颈动脉内-中膜厚度(cIMT)的关系及意义。方法选取2017年10月至2018年6月我院收治并完成颈动脉超声检查的T2DM 100例作为研究对象,按照颈动脉超声测量结果将患者分为正常组(cIMT<0.9mm,48例),增厚组(cIMT≥0.9mm,52例),选择相同时间到我院体检健康者50例作为对照组,比较两组患者的生化指标与BUA水平变化,并分析BUA与各生化指标间的相关性,并采用logistics回归分析影响cIMT的独立危险因素。结果正常组、增厚组的SBP、DBP、TC、TG、LDL-C及FPG、cIMT等指标均高于对照组(P<0.05;增厚组、正常组HDL-C低于对照组(P<0.05),而增厚组SBP、DBP、TC、TG、LDL-C及FPG、cIMT等指标均高于对照组(P<0.05),增厚组HDL-C低于对照组(P<0.05);BUA水平、HbA1c、LDL-C、cIMT呈正相关(P<0.05),BUA水平与HDL-C呈负相关(P<0.05);LDL-C(OR=2.638,P=0.020)、HbA1c(OR=1.618,P=0.003)、TC(OR=1.011,P=0.003)是c IMT增厚的独立危险因素,HDL-C为cIMT增厚的保护因素(RO=0.612,P=0.027)。结论 LDL-C、HbA1c、TC是cIMT增厚的独立危险因素,BUA水平与颈动脉内-中膜厚度呈正相关。     

老年男性2型糖尿病患者血清25-(OH)D3与颈动脉粥样硬化相关性研究

目的探讨老年男性2型糖尿病(T2DM)患者血清25-羟维生素D3(25-OHD3)与糖尿病大血管病变的关系。方法入组老年男性T2DM患者126例,平均年龄56±12.4岁,根据颈动脉彩超测定结果,分为颈动脉内膜中层正常组(IMT1.0mm)47例和IMT增厚组(IMT1.0mm)79例,对每位患者进行临床资料收集及常规生化指标检测,采用电化学发光法检测所有受试者血清25-(OH)D3水平。结果 IMT增厚组血清25-OHD3浓度明显低于正常组,差异均有统计学意义(P0.05)。Pearson相关分析显示,IMT与病程、吸烟率、SBP、2h PG、Hb A1c、TC、LDL-C、CRP呈正相关,与25-OHD3呈负相关。结论低水平血清25-OHD3增加老年男性糖尿病患者发生动脉粥样硬化的风险,是2型糖尿病患者发生颈动脉粥样硬化的独立危险因素。     

糖耐量减低患者颈动脉内膜中层厚度与血同型半胱氨酸及超敏C-反应蛋白的关系

目的 观察糖耐量减低(IGT)患者的血同型半胱氨酸(Hcy)、超敏C-反应蛋白(hs-CRP)与颈动脉内膜中层厚度(IMT)的关系,以探讨其在并发动脉粥样硬化(AS)的临床意义.方法 选择IGT患者70例,根据颈动脉IMT,分为IMT正常组(IMT≤0.9 mm)、IMT增厚组(IMT>0.9 mm),分别进行血脂、hs-CRP、Hey及收缩压(SBP)、舒张压(DBP)、体重指数(BMI)等参数测定,并选择60名为健康对照组进行比较和相关性分析.结果 IMT增厚组hs-CRP、Hcy水平高于IMT正常组和正常对照组[hs-CRP:(48.8±4.9)、(34.8±2.2)、(21.2±3.5)mg/L,P<0.05、P<0.01;HCY:(12.88±0.96)、(10.12±0.54)、(7.86±0.25)μmol/L,P<0.050.01],1GT者SBP、TG、TC及颈动脉IMT也均高于正常对照组(P均<0.05).颈动脉IMT与hs-CRP、Hcy、TC、SBP呈正相关(r值分别为0.616、0.557、0.351、0.252,P值分别为<0.01、<0.01、<0.05、<0.05).颈动脉IMT增厚组的Hcy水平与hs-CRP呈正相关(r=0.364,P<0.05).结论 IGT者颈动脉IMT较正常者已有所升高,已有早期的AS.而血Hcy和CRP对预测IGT者早期的AS有重要意义,高Hcy可能使CRP水平升高,进而引起早期的AS.     

代谢综合征患者颈动脉内中膜厚度与PAI-1的关系

目的观察代谢综合征(MS)患者颈动脉内中膜厚度(IMT)与血浆纤溶酶原激活物抑制物-1(PAI-1)的关系。方法根据NCEP-ATPⅢ的MS诊断标准,323例住院患者分为MS组(160例)和非MS组(163例),采用ELISA法测定血浆PAI-1水平,应用高频多普勒超声检测颈动脉IMT及颈动脉粥样硬化斑块。结果MS组的PAI-1水平为(30.52±11.02)ng/ml,颈动脉IMT为(0.92±0.21)mm,粥样斑块发生率为63.1%,而非MS组分别为(26.57±11.09)ng/ml、(0.86±0.20)mm和49.1%,两组间差异有显著性意义(P<0.05～0.01),其中颈动脉IMT及粥样斑块发生率随着MS诊断条件数的增加而逐渐增加,差异有显著性意义(P<0.05)。多元逐步回归分析显示,PAI-1与颈动脉IMT独立相关(标准化回归系数β=0.105,P<0.05)。结论MS患者易引起颈动脉粥样硬化,PAI-1可能与动脉粥样硬化密切相关。     

高频超声评价2型糖尿病合并微量白蛋白尿患者颈动脉粥样硬化

目的 评价高频超声对2型糖尿病(T2DM)合并微量白蛋白尿(MA)患者颈动脉粥样硬化的诊断价值.方法 将91例T2DM患者根据尿白蛋白排泄率(UAER)分为T2DM未合并MA患者组(T2DM1组)49例;T2DM合并MA患者组(T2DM2组)42例,利高频超声检测T2DM患者颈动脉内-中膜厚度(IMT)及粥样硬化斑块形成情况.同时获得血清总胆固醇(TC)、甘油三酯(TG)、低密度脂蛋白(LDL)、高密度脂蛋白(HDL)、糖化血红蛋白(HbAlc)、尿酸(URIC)、血肌酐(CREA)、超敏C反应蛋白(HSCRP)、空腹血糖(FPG)、餐后2 h血糖(2hPG)、尿白蛋白排泄率(UAER)、体质指数(BMI)等指标.结果 T2DM2组2hPG、BMI、TC、CREA、UAER、HbAlc、IMT均高于T2DM1组,差异均有统计学意义(P<0.05).Pearson相关分析显示两组中IMT与CREA、UAER、HbAlc及病程呈正相关(r=0.311、P<0.05,r=0.309、P<0.05,r=0.441、P<0.05,r=0.350、P<0.05).在多元线性回归分析中,两组中UAER、HbAlc、病程是IMT的独立预测因子.两组组内斑块检出率:软斑>混合斑>硬斑,差异有统计学意义(P<0.05).结论 T2DM合并MA患者的颈动脉IMT增厚,UAER、HbAlc及病程与IMT密切相关.高频超声能够准确、快捷地检测T2DM合并MA患者颈动脉粥样硬化.     

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.