氟西汀联合重复经颅磁刺激治疗对抑郁症患者疗效及认知功能的影响

目的：探讨氟西汀联合重复经颅磁刺激治疗对抑郁症患者疗效及认知功能的影响。方法将60例抑郁症患者随机分两组,每组30例。研究组口服氟西汀联合重复经颅磁刺激治疗,对照组口服氟西汀联合假经颅磁刺激治疗,观察6周。于治疗前后采用汉密顿抑郁量表评定临床疗效,威斯康星卡片分类测验评估认知功能,副反应量表评定不良反应。结果治疗第2周末研究组有效率显著高于对照组（P＜0．01）,治疗第4周、6周末两组比较差异无显著性（P＞0．05）。治疗后研究组威斯康星卡片分类测验的正确反应数及完成分类数均较治疗前显著升高（P＜0．01）,且研究组显著高于对照组（P＜0．05）;两组汉密顿抑郁量表评分较治疗前显著降低（P＜0．01）,治疗第2周、4周末研究组显著低于对照组（P＜0．05）。治疗过程中,两组均未出现严重不良反应。结论氟西汀联合重复经颅磁刺激治疗抑郁症疗效显著,起效快,安全性高,且能显著改善患者的认知功能,优于单用氟西汀治疗。     

抗抑郁剂联合认知疗法治疗门诊抑郁症对照研究

目的：探讨抗抑郁剂联合认知疗法治疗门诊抑郁症的临床效果。方法将76例门诊抑郁症患者随机分为两组,均给予常规抗抑郁剂治疗,研究组联合认知疗法,观察10周,随访12个月。采用汉密顿抑郁量表、临床疗效总评量表评定临床疗效,生活质量综合评定问卷评定生活质量,统计患者服药依从性和复发率。结果治疗后两组汉密顿抑郁量表、临床疗效总评量表评分均较治疗前显著下降（P＜0．01）,生活质量综合评定问卷总分及躯体健康、心理健康、社会功能维度评分均较治疗前显著升高（ P＜0．05或0．01）。治疗10周末两组总有效率比较差异无显著性（χ2＝0．00,P＞0．05）。随访第12个月研究组服药依从性显著高于对照组,复发率显著低于对照组（χ2＝8．89、10．83,P＜0．01）。结论抗抑郁剂联合认知疗法能快速缓解门诊抑郁症患者的抑郁症状,提高服药依从性及生活质量,降低复发率。     

米氮平联合低频重复经颅磁刺激治疗激越性抑郁症对照研究

目的：探讨米氮平联合低频重复经颅磁刺激治疗激越性抑郁症的临床疗效和安全性。方法将60例激越性抑郁症患者随机分为两组,每组30例,两组均口服米氮平治疗,研究组联合低频重复经颅磁刺激治疗,观察4周。采用汉密顿抑郁量表及大体评定量表评定临床疗效,副反应量表评定不良反应。结果研究组治疗第1周、2周末汉密顿抑郁量表及大体评定量表评分均显著低于对照组（ P＜0．05或0．01）;治疗第4周末研究组显效率86．7％、有效率96．7％,对照组分别为90．0％、93．3％,两组比较差异无显著性（χ^2＝0．16、0．35,P＞0．05）。两组不良反应较轻微,发生率比较差异无显著性（P＞0．05）。结论米氮平联合低频重复经颅磁刺激治疗激越性抑郁症疗效显著,起效快,安全性高,有利于提高患者的治疗依从性,优于单用米氮平治疗。     

帕罗西汀联合重复经颅磁刺激治疗广泛性焦虑症对照研究

目的：探讨帕罗西汀联合重复经颅磁刺激治疗广泛性焦虑症的疗效和安全性。方法将60例广泛性焦虑症患者随机分为两组,研究组口服帕罗西汀联合重复经颅磁刺激治疗,对照组口服帕罗西汀治疗,观察6周。于治疗前后采用汉密顿焦虑量表及临床疗效总评量表‐病情严重程度分量表评定临床疗效,副反应量表评定不良反应。结果治疗后两组汉密顿焦虑量表及临床疗效总评量表‐病情严重程度分量表评分均较治疗前显著下降（P＜0．01）,研究组治疗6周末各量表评分均显著低于对照组（ P＜0．01）,显效率显著高于对照组（χ2＝4．44,P＜0．05）。两组均未出现严重不良反应。结论帕罗西汀联合重复经颅磁刺激治疗广泛性焦虑症患者起效快,疗效更显著,安全性高,优于单用帕罗西汀治疗。     

低频重复经颅磁刺激对脑卒中后抑郁状态和神经功能缺损的治疗效应

目的：探讨低频重复经颅磁刺激对脑卒中后抑郁患者抑郁状态和神经功能缺损的治疗效应。方法：脑卒中后抑郁患者32例为2002—01／2004—09华中科技大学同济医学院附属协和医院神经内科收治，所有患者脑卒中病程均〉2个月，汉密顿抑郁量表（17项版本）评分均〉17分，并排除既往有精神异常史者。32例患者随机抽签分为重复经颅磁刺激治疗组和对照组各16例，对照组仅给予常规治疗，重复经颅磁刺激治疗组在此基础上予以低频重复经颅磁刺激治疗，以60％最大刺激强度刺激双侧额叶，每侧刺激30次，频率0．5Hz，每日一序列，连续治疗7d。两组治疗期间均停用抗抑郁药物。于治疗前、后观察两组汉密顿抑郁量表评分及临床神经功能缺损程度评分的变化，以及两组患者抑郁症状改善率。结果：按意向处理分析，32例患者均完成了治疗，治疗期间无显著不适应现象。①重复经颅磁刺激治疗组平均汉密顿抑郁量表评分治疗后较治疗前明显降低（25．9&;#177;5．2，15．4&;#177;6．7），较对照组治疗后评分也明显降低（22．4&;#177;7．1），治疗组自身前后比较及治疗组与对照组治疗后比较差异均有显著性意义（t=4．97，3．43，P〈0．01）。②重复经颅磁刺激治疗组临床神经功能缺损程度评分评分治疗后（12．6&;#177;4．6）较治疗前评分（18．3&;#177;4．8）明显降低（t=3．43，P〈0．01），较对照组治疗后评分（16．6&;#177;4．7）也有所降低（t=2．43，P〈0．05）。③重复经颅磁刺激治疗组治疗后抑郁症状改善有效率88％（14／16），对照组为12％（2／16）。两组有效率比较差异意义明显（x^2=-31．64，P〈0．01）。结论：0．5Hz低频重复经颅磁刺激可改善脑卒中后抑郁患者的抑郁症状，减轻患者的神经功能缺损程度，且患者无特殊不适应现象。     

重复经颅磁刺激治疗脑卒中后抑郁对照研究

目的探讨重复经颅磁刺激治疗脑卒中后抑郁患者的临床疗效。方法将120例脑卒中后抑郁患者随机分为两组,每组60例,两组均接受神经内科常规治疗,研究组联合重复经颅磁刺激治疗,连续治疗1个月,观察6个月。治疗前后采用脑卒中患者临床神经功能缺损程度评分标准评定神经功能缺损状况,采用汉密顿抑郁量表评定抑郁状况。结果治疗1个月、6个月末,研究组汉密顿抑郁量表评分显著低于对照组（u=22．91、19．23,P〈0．01）,神经功能恢复效果显著优于对照组（Х^2=6．99、6．92,P〈0．05）。结论重复经颅磁刺激治疗能显著改善脑卒中后抑郁患者的抑郁情绪,有利于神经功能的恢复。     

艾司西酞普兰治疗冠心病支架植入术患者伴发焦虑抑郁情绪对照研究

目的：探讨放松训练联合草酸艾司西酞普兰对冠心病支架植入术后患者伴发焦虑抑郁情绪的临床疗效和安全性以及对生活质量的影响。方法将65例冠心病冠脉支架植入术后伴焦虑抑郁患者随机分为两组,均予以冠心病常规治疗及放松训练,研究组在此基础上联合草酸艾司西酞普兰治疗,观察8周。采用汉密顿焦虑量表、汉密顿抑郁量表评定焦虑抑郁情绪,生活质量量表评定生活质量,副反应量表评定不良反应。结果治疗后两组汉密顿焦虑量表、汉密顿抑郁量表评分较治疗前显著下降（P＜0．01）,研究组较对照组下降更显著（P＜0．01）;研究组生活质量量表的4个领域、对照组1个领域评分较治疗前显著升高（P＜0．01）,研究组5个领域评分显著高于对照组（P＜0．01）。治疗过程中两组不良反应均轻微,各项实验室检查均无异常改变。结论放松训练联合草酸艾司西酞普兰能显著改善冠心病冠脉支架植入术患者伴发的焦虑抑郁情绪,提高患者的生活质量,且安全性高,优于单用放松训练治疗。     

舍曲林联合丁螺环酮治疗抑郁症伴性功能障碍对照研究

目的：探讨舍曲林联合丁螺环酮治疗抑郁症伴性功能障患者的临床疗效。方法将100例抑郁症伴性功能障碍患者随机分为两组,每组50例,两组均口服舍曲林治疗,观察组联合丁螺环酮合治疗,观察8周。采用汉密顿抑郁量表、抑郁自评量表评定抑郁状况,Olson婚姻质量问卷评定婚姻质量,性生活满意度量表评定性生活满意度。结果治疗后两组汉密顿抑郁量表、抑郁自评量表评分均较治疗前显著下降（P＜0．01）,观察组较对照组下降更显著（P＜0．01）;两组Olson婚姻质量问卷评分均较治疗前显著升高（P＜0．01）,观察组较对照组升高更显著（P＜0．01）;观察组性生活总满意率显著高于对照组（χ2＝7．48,P＜0．01）。结论舍曲林联合丁螺环酮治疗抑郁症伴性功能障患者效果显著,能显著提高患者的性生活满意度和婚姻质量,显著优于单用舍曲林治疗。     

齐拉西酮对男性精神分裂症临床疗效及生活质量的影响

目的：探讨齐拉西酮对男性精神分裂症患者临床疗效及生活质量的影响。方法将66例男性精神分裂症患者随机分为两组,每组33例,研究组口服齐拉西酮治疗,对照组口服利培酮治疗,观察10周。于治疗前后采用简明精神病评定量表评定临床疗效,副反应量表评定不良反应,生活质量综合评定问卷评定生活质量。结果治疗后两组简明精神病评定量表评分均较治疗前显著下降（P＜0．01）,两组间评分比较差异均无显著性（P＞0．05）。两组不良反应较轻微,研究组总体不良反应发生率以及锥体外系反应、体质量增加发生率显著低于对照组（P＜0．05）。治疗10周末研究组生活质量综合评定问卷总分及身体健康、心理健康维度分显著高于对照组（ P＜0．05或0．01）。结论齐拉西酮治疗男性精神分裂症疗效显著且与利培酮相当,不良反应发生率低、治疗依从性好,有利于提高患者的生活质量。     

艾司西酞普兰联合团体心理治疗对抑郁症疗效及治疗依从性的影响

目的：探讨艾司西酞普兰联合团体心理治疗对抑郁症患者的疗效及治疗依从性的影响。方法将64例抑郁症患者按随机数字表法分为观察组和对照组,每组32例,均口服艾司西酞普兰治疗,观察组联合团体心理治疗,观察8周。治疗前后采用汉密顿抑郁量表评定抑郁症状,世界卫生组织生存质量测定量表评定生存质量,自知力与治疗态度问卷量表评定患者的自知力及治疗态度。结果治疗后两组汉密顿抑郁量表评分均较治疗前显著下降（P＜0．01）,观察组治疗各时点评分显著低于对照组（ P＜0．05或0．01）;两组世界卫生组织生存质量测定量表各领域评分及自知力与治疗态度问卷量表评分均较治疗前显著升高（ P＜0．05或0．01）,观察组显著高于对照组（ P＜0．05或0．01）。结论艾司西酞普兰联合团体心理治疗对抑郁症具有协同增效作用,起效快,效果显著,有利于提高患者的生存质量及治疗依从性。     

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.     

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.     

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.     

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.