手法治疗椎动脉型颈椎病的TCD和BAEP观察

目的 观察手法治疗椎动脉型颈椎病的经颅多普勒超声（TCD）和脑干听觉诱发电位（BAEP）变化，从血流速度及神经电生理角度探讨手法治疗的作用机理。方法 将60例椎动脉型颈椎病患者分为手法治疗组30例和常规治疗组30例，治疗前及治疗2周后检查TCD和BAEP，观察手法治疗对椎动脉型颈椎病患者血流速度及脑电生理的影响。结果 （1）2组治疗后总有效率分别为96．6％和90％，其中手法组临床治愈率为46．6％，常规组临床治愈率为33．3％，2组间疗效及平均治疗时间无统计学差异。（2）治疗前疾病组椎基底动脉（VBA）流速明显低于对照组（P＜0．05）。TCD异常率为76．7％（46／60例），以VBA流速降低为主要特点。BAEP异常率为80％（48／60例），以脑干型异常为主。（3）治疗后2组VBA血流速度均有改善，手法治疗组比常规治疗组椎动脉流速改善更显著（P＜0．05）。治疗后2组神经传导功能均有改善，与常规治疗组相比，手法治疗组V波PL，Ⅲ-Ⅴ和Ⅰ-ⅤIPL改善更显著（P＜0．05）。结论 手法治疗可改善椎动脉型颈椎病椎基循环的血流速度及脑干神经传导功能。     

经皮电刺激双侧耳后乳突对缺血性脑卒中TCD和BAEP的影响

目的观察经皮电刺激双侧耳后乳突对缺血性卒中患者经颅多普勒超声（TCD）和脑干听觉诱发电位（BAEP）的影响。方法将40例缺血性脑卒中患者分为观察组和对照组（每组各20例）。两组均给予常规药物治疗,而观察组给予电刺激双耳后乳突部治疗。治疗前及治疗2周结束时均应用TCD和BAEP分别监测大脑前、中、后动脉（ACA、MCA、PCA）及椎动脉（VA）、基底动脉（BA）的血流速度和Ⅰ波、Ⅲ波、Ⅴ波潜伏期、Ⅰ～Ⅲ间期和Ⅲ～Ⅴ间期波峰间潜伏期的变化。结果与治疗前相比,治疗后两组TCD各项血流峰速度指标均有改善（P〈0.05）,而观察组显著优于对照组（P〈0.001）;观察组BAEP各指标也优于对照组（P〈0.05）。结论电刺激双耳后乳突对缺血性脑卒中患者的血流速度及脑干神经传导功能改善有加强作用。     

针刺治疗椎动脉型颈椎病的TCD和BAEP观察

目的　观察针刺治疗椎动脉型颈椎病患者的经颅多普勒超声(TCD)情况和脑干听觉诱发电位(BAEP)变化,从血流速度及神经电生理角度探讨针刺治疗的作用机制。方法　将40例椎动脉型颈椎病患者分为针刺组20例和常规组20例,治疗前及治疗2周后检查TCD及BAEP,观察针刺治疗对椎动脉型颈椎病患者血流速度及脑电生理的影响。结果　①两组治疗后总有效率分别为90%和85%,其中针刺组临床治愈率为45%,常规组临床治愈率为35%,两组间疗效及平均治疗时间无统计学差异。②治疗前针刺组椎基底动脉(VBA)流速明显低于对照组(P<0. 05)。TCD异常率为77. 5% (31 /40例),以VBA流速降低为主要特点。BA EP异常率为75% (30 /40例),以脑干型异常为主。③治疗后两组VBA血流速度均有改善,与常规组比较,针刺组椎动脉流速改善更显著(P<0. 05)。治疗后两组神经传导功能均有改善,与常规组相比,针刺组V波的峰潜伏期(PL)、III V和I V波的峰间潜伏期(IPL)改善更显著(P<0. 05)。④基底动脉低流速与III V及I VIPL之间存在负直线相关关系。结论　针刺治疗可改善椎动脉型颈椎病椎基循环的血流速度及脑干神经传导功能。     

双向交替牵引手法配合低频电刺激治疗椎动脉型颈椎病的疗效观察

目的评价双向交替牵引手法配合低频电刺激治疗椎动脉型颈椎病的临床疗效，并探讨其作用机制。方法椎动脉型颈椎病患者83例，随机分为观察组和对照组。观察组患者43例，采用双向交替牵引手法和低频电刺激治疗；对照组患者40例，采用颈椎牵引和低频电刺激治疗。治疗前、后均行经颅多普勒超声（TCD）检查，观察2组患者收缩期血流速度的变化。结果①2组治疗后总有效率分别为95.3％和75％，其中观察组治愈率为65．1％，对照组为25％，2组间总有效率及治愈率差异均有统计学意义（P〈0．01）。②治疗后2组椎基底动脉（VBA）血流速度均有改善（P〈0．05），与对照组比较，观察组VBA血流速度的改善更为明显（P〈0．05）。结论双向交替牵引手法配合低频电刺激是更为有效的治疗椎动脉型颈椎病的方法。     

经颅多普勒超声在老年人椎动脉型颈椎病的诊断及治疗中的价值

目的 探讨经颅多普勒超声（TCD）对老年人椎动脉型颈椎病的诊断及疗效评定价值。方法 按临床诊断标准收集椎动脉型颈椎病患者36例,平均年龄53.6岁,对照组为年龄相近的健康人28例。采用MT－1000型彩色经颅多普勒超声仪于治疗前后对基底动脉（BA）、椎动脉（VA）、大脑后动脉（PCA）、大脑前动脉（ACA）和大脑中动脉（MCA）的血流峰速度（Vp）、血流平均速度（Vm）及血流频谱图像进行检测分析。结果 疾病组椎基底动脉（VBA）流速明显低于对照组（P＜0.05）。疾病组TCD异常率为80.6％（29例／36例）,以VBA流速降低为主要特点。治疗后椎基底动脉系统血流速度明显改善（P＜0.05）。结论 TCD可作为老年人椎动脉型颈椎病患者诊断及疗效评定的参考依据。     

红花黄色素加低频电刺激治疗老年椎动脉型颈椎病

目的：观察红花黄色素配合低频电刺激治疗老年椎动脉型颈椎病的疗效。方法：老年椎动脉型颈椎病患者90例,随机分为3组各30例。药物组给予静脉滴注红花黄色素150mg;电刺激组进行低频电刺激治疗20min;综合组联合上述2种方法治疗,均每日1次。结果：治疗2周后,3组患者双侧椎动脉和基底动脉平均峰流速均较治疗前明显下降,综合组更低于药物组及电刺激组（P〈0.05）。临床疗效比较,综合组总有效率明显高于药物组及电刺激组（P〈0.05）。电刺激组与药物组比较,各项指标比较均差异无统计学意义。结论：综合2种有效方法治疗椎动脉型颈椎病可促进疗效的提高。     

脑电仿生电刺激结合针刺治疗椎动脉型颈椎病眩晕临床观察

目的:观察脑电仿生电刺激结合针刺治疗椎动脉型颈椎病眩晕的眩晕量表评估和经颅多普勒超声(TCD)的变化,探讨其作用机制。方法:将102例椎动脉型颈椎病眩晕患者,随机分为2组,2组均在针灸治疗基础上,分别加脑仿生电刺激和牵引。治疗前及治疗2个疗程后采用经颅多普勒超声(TCD)、《颈性眩晕症状与功能评估量表》(ESCV)进行评估,观察脑仿生电刺激结合针刺治疗对椎动脉型颈椎病眩晕患者血流速度及眩晕症状的影响。结果:治疗组总有效率为92.6%,对照组总有效率为80%。2组总效率比较,差异有统计学意义(P0.05);治疗后较治疗前,2组患者ESCV、椎动脉血流动力比较均有提高,且治疗组ESCV评估量评分明显优于对照组(P0.05);同时,TCD指标显示治疗组较对照组的RVA、LVA、BA血流速度明显加快(P0.05)。结论;脑电仿生电刺激结合针刺治疗椎动脉型颈椎病可改善脑血流量,从而缓解其眩晕症状。     

电刺激小脑顶核治疗椎动脉型颈椎病

目的：观察电刺激小脑顶核治疗椎动脉型颈椎病临床效果。方法：前瞻性随机对照研究，观察比较脑循环治疗仪电刺激小脑顶核与其他物理因子治疗椎动脉型颈椎病的临床治疗效果。结果：脑循环治疗组38例，显效28例，有效9例，头晕加重1例，显效率74％，总有效率97％，常规治疗组36例，显效17例，有效11例，无效8例，显效率47％，总有效率74％。结论：脑循环治疗能显改善椎动脉型颈椎病患头晕等症状。     

项九针结合高压氧对椎动脉型颈椎病患者治疗前后血流动力学的影响

目的：观察项九针结合高压氧（HBO）治疗对椎动脉型颈椎病患者血流动力学的影响。方法：120例椎动脉型颈椎病患者随机分为2组各60例,观察组采用项九针结合HBO治疗;对照组采用丁咯地尔注射液静脉滴注治疗。结果：治疗30次后,与治疗前比较,经颅多普勒超声（TCD）检测椎动脉收缩峰流速（Vs）、舒张末期血流速度（Vd）及平均血流速度（Vm）值显著上升,搏动指数（PI）及阻力指数（RI）值显著下降（P〈0.01）;对照组仅Vs及Vm值明显上升（P〈0.05）。与对照组比较,血流参数值观察组改善更明显（P〈0.05-0.01）。结论：项九针结合HBO治疗能显著改善椎动脉型颈椎病患者椎基底动脉供血不足,消除临床症状,疗效明显。     

针刺治疗对椎动脉型颈椎病患者血流速度的影响

目的：观察针刺治疗椎动脉型颈椎病的经颅多普勒超声(TED)检查，探讨针刺治疗对椎动脉型颈椎病血流速度的作用。方法：将40例椎动脉型颈椎病患者分为针刺治疗组20例和常规治疗组20例，治疗前及治疗2周后检查TCD，观察针刺治疗对椎动脉型颈椎病患者血流速度的影响。结果：两组治疗后总有效率分别为90％和85％，其中针刺组临床治愈率为45％，常规组临床治愈率为35％，两组间疗效及平均治疗时间差异无显著性意义。治疗前疾病组椎基动脉流速明显低于对照组(P&;lt;0．05)。TCD异常率为77．5％(31／40)，以椎基动脉流速降低为主要特点。治疗后两组椎基动脉血流速度均有改善，与常规治疗组比较，针刺治疗组椎动脉流速改善更显著(P&;lt;0．05)。结论：针刺治疗可改善椎动脉型颈椎病椎基循环的血流速度。     

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.     

Prospects for the control of neglected tropical diseases by mass drug administration

The prospects for the control of neglected tropical diseases, including soil-transmitted helminthiasis, shistosomiasis, lymphatic filariasis, onchocerciasis and trachoma, through mass drug administration, are exemplified by the elimination of the trachoma as a public-health problem in Morocco. In spite of this and other striking successes, mass drug administration programs are faced with major challenges resulting from suboptimal coverage and lack of efficacy. At current suboptimal coverage rates, programs may need prolongation for an extended period, increasing costs and undermining sustainability. Community participation through health education and information appears to be crucial to improve coverage and to achieve sustainability. Implementation of complementary measures, such as vector control, improved hygiene and environmental sanitation, are important to further control transmission and to prevent re-emergence of the infection and, again, may only be achieved effectively through community-based initiatives. To reduce costs and to relieve pressure on the health system, combining neglected tropical disease programs in areas where diseases coexist and integration with existing control programs for malaria, tuberculosis and HIV/AIDS is advocated. The risk of developing drug resistance is of particular concern in view of the lack of alternative drugs, and reduced treatment efficacy due to emerging resistance is evident for the soil-transmitted helminths and onchocerciasis. Given the risk for the development of drug resistance and the need for a high degree of participation, close attention should be paid to the monitoring of the coverage and efficacy of the different program components.     

Bacterial meningitis: an update of new treatment options

The outcome of bacterial meningitis critically depends on the rapid initiation of bactericidal antibiotic therapy and adequate management of septic shock. In community-acquired meningitis, the choice of an optimum initial empirical antibiotic regimen depends on the regional resistance patterns. Pathogens resistant to antibacterials prevail in nosocomial bacterial meningitis. Dexamethasone is recommended as adjunctive therapy for community-acquired meningitis in developed countries. In comatose patients, aggressive measures to lower intracranial pressure <20 mmHg (in particular, external ventriculostomy, osmotherapy and temporary hyperventilation) were effective in a case–control study. Although many experimental approaches were protective in animal models, none of them has been proven effective in patients. Antibiotics, which are bactericidal but do not lyse bacteria, and inhibitors of matrix metalloproteinases or complement factor C5 appear the most promising therapeutic options. At present, vaccination is the most efficient method to reduce disease burden. Palmitoylethanolamide appears promising to enhance the resistance of the brain to infections.     

Imaging choices in occult hip fracture

Background: Hip fracture is a common injury, with an incidence rate of > 250,000 per year in the United States. Diagnosis is particularly important due to the high dependence on the integrity of the hip in the daily life of most people. Objectives: In this article we review the literature focused on hip fracture detection and discuss advantages and limitations of each major imaging modality. Discussion: Plain radiographs are usually sufficient for diagnosis as they are at least 90% sensitive for hip fracture. However, in the 3–4% of Emergency Department (ED) patients having hip X-ray studies who harbor an occult hip fracture, the Emergency Physician must choose among several methods, each with intrinsic limitations, for further evaluation. These methods include computed tomography, scintigraphy, and magnetic resonance imaging. Conclusion: We present an evidence-based algorithm for the evaluation of a patient suspected to have an occult hip fracture in the ED. Also outlined are future directions for research to distinguish more effective techniques for identifying occult hip fractures.     

Systematic Reviews Published in the April 2012 Issue of the Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly as a DVD but monthly online. The April 2012 issue (second DVD for 2012) contains 5045 complete reviews, 2182 protocols for reviews in production, and 17,084 short summaries of systematic reviews published in the general medical literature. In addition, there are citations of 674,000 randomized controlled trials, and 15,400 cited papers in the Cochrane methodology register. The health technology assessment database contains just over 11,000 citations. One hundred and seventeen new reviews have been published in the last 3 months of which 12 have potential relevance for practitioners in pain and palliative medicine. The impact factor of the Cochrane Library stands at 6.186. Readers are encouraged to access the full report for any articles of interest as only a brief commentary is provided.     

Platelets,thrombosis, coagulation,and atherosclerosis

When I first got the invitation to join a medical delegation going to Moldova, I thought for a moment that our destination was the fictional country in the old Marx Brothers movie Duck Soup. On further checking, it turns out that entertaining place was called Freedonia. I now know that Moldova is indeed a real country, bordered on the west by Romania and on the other three sides by the Ukraine. It is a proud country, rich with traditions, and its people are warm, giving, eager to learn ways to improve their healthcare system, and deeply appreciative of our attempts to help them in the task.     

Spiritual Dimensions of Nursing Practice. edited by V. B. Carson

The Cochrane Library of Systematic Reviewsis published quarterly. Issue one for 2004 of the library was published in February 2004. This issue contains 3,329 reviews and protocols of which 1,921 are fully published reviews. The trials database now stands at over 400,000 records with an additional 4,427 one-page summaries of non-Cochrane reviews in the NHS database of reviews of effectiveness (DARE). This version of the library contains the results of an extensive search for RCTs on EMBASE. The latest library contains 84 new reviews, seven are considered relevant to practitioners in pain and palliative care. References are published in the same format as the citation for Cochrane reviews.     

Advance Care Planning

Predictors of patient wishes and influence of family and clinicians are discussed. Research findings on patient decision-making relating to preferences in end-of-life care are described. Advance directives and durable powers of attorney are defined and differentiated. Most patients have not participated in advance care planning and the need for more effective planning is documented. Appropriate times for discussions of such planning are described. Scenarios discussed include terminal cancer, chronic obstructive pulmonary disease, AIDS, stroke, and dementia. Patient satisfaction is discussed, as is a structured process for discussions about patient preferences. Results of patient responses to hypothetical scenarios are described. Invasiveness of interventions, prognosis and other factors that favor or discourage patient preferences for treatment are discussed. Findings resulting from research funded by the Agency for Healthcare Research and Quality (AHRQ) are discussed. This research can help providers offer end-of-life care based on preferences held by the majority of patients under similar circumstances.     

Évaluation,par l’imagerie ultrasonore,du recrutement musculaire,de la force motrice et de la détente verticale du quadriceps après électromyostimulation (cas de 15 étudiants de l’INJS)

The increase of strength seems to be an element of performance in some sports.