全膝关节置换术围手术期康复管理及其疗效评定

目的:探讨围手术期康复管理对人工全膝关节置换术(TKR)后患者关节功能恢复的影响。方法:170例膝TKR患者分为康复组和对照组各85例,均接受TKR手术及常规的治疗与护理,术后CPM机功能训练。康复组患者在围手术期制定管理程度:术前健康教育;术后分期康复治疗,主要为呼吸、肌力及关节活动度(ROM)训练,平衡功能、本体感觉、步态和独立转移能力训练。2组治疗前后均采用美国HSS膝关节功能评分和ROM测定。结果:术后7及14d时,2组HSS膝关节功能评分和ROM测评均明显高于治疗前(P0.05,0.01)康复组均明显高于对照组(均P0.05,0.01)。结论:TKR围手术期康复管理对患者的功能恢复有十分重要的意义。     

早期阶梯式康复锻炼在全膝关节表面置换术后中的应用

目的:探讨全膝关节表面置换术后(TKR)早期行阶梯式康复锻炼方案与常规康复锻炼对膝关节功能评分(HSS)与膝关节活动度(ROM)的影响。方法:将44例骨性关节炎(OA)患者按手术顺序随机分为康复组和对照组各22例,两组患者均行TKR手术,术后进行常规治疗与护理,治疗组患者严格按制定的阶梯式康复锻炼方案进行训练。两组在治疗前后均采用HSS评分和ROM测定。结果:两组患者术后第4天、第1、2、6、12、24周HSS评分和ROM测定比较差异有统计学意义(P<0.05)。结论:TKR术后患者早期进行阶梯式康复锻炼可有效改善膝关节的功能和关节活动度,减少卧床时间,对患者整体功能恢复有非常重要的临床意义。     

早期阶段性康复干预对老年膝关节骨性关节炎患者全关节置换术后下肢疼痛及功能的影响

目的:测试阶段性康复干预方案在缓解TKR术后膝关节疼痛和改善膝关节主体功能方面的安全性和可行性,并评估测量身体功能的变化。方法:本研究共纳入了46例受试者,被随机分进对照组和康复干预组。对照组(n=22)接受关节置换术后临床常规治疗和康复指导;康复干预组(n=24)在接受临床常规治疗同时,将在术后第一天开始接受每天1次(第1阶段)或每周3次(第2、3阶段),为期12周的"全膝关节置换术后康复干预方案"。所有患者在术前、术后4周、术后12周接受全身状态、疼痛及膝关节相关功能评估。结果:在干预组,患者在术后第4—12周,下肢功能逐步得到显著改善,减轻疼痛表现为WOMAC、VAS、肌力、主被动ROM、患肢维度、BBS、FAC、FIM评分与术前存在显著性差异(P0.05)。与对照组相比,干预组患者的疼痛和功能恢复速度更快、幅度更大。术前、术后VAS疼痛评分与病程、BMI、WOMAC呈显著正相关(P0.05),与伸膝肌力、主动ROM、BBS、FIM、FAC呈显著负相关(P0.05)。结论:持续12周的分阶段TKR术后康复方案,对改善TKR术后患者的疼痛缓解和功能恢复有明显效果,其训练计划是安全可行的。疼痛控制是康复干预关键因素。     

股骨髁上骨折术后早期康复治疗对患膝关节功能恢复的影响

目的:观察股骨髁上骨折术后早期康复治疗对膝关节功能的影响。方法:股骨髁上骨折术后患者65例,随机分为康复组32例与对照组33例,2组均行膝关节逆行交锁髓内钉术,术后常规抗感染、消肿止痛、促进骨折愈合等药物治疗。对照组以卧床休息为主,康复组术前后均进行关节功能训练、肌力训练;并于术后配合物理因子等治疗。结果:治疗3个月后,康复组Lysholm膝关节评分和关节活动范围(ROM)均明显高于对照组(P0.01)。结论:股骨髁上骨折术后早期的综合康复治疗对膝关节功能恢复有显著促进作用。     

人工膝关节置换术早期康复的卫生经济学评价

目的:探讨早期康复治疗对人工膝关节置换术(TKA)的卫生经济学影响。方法:TKA患者64例,随机分为对照组与康复组各32例,对照组给予常规骨科治疗、骨科康复知识宣教与连续被动运动(CPM)机训练等;康复组此基础上加入早期康复介入治疗。术后第2天与出院前采用关节活动度(ROM)、肢体周径、日常生活活动能力(ADL)评分、美国特种外科医院评分系统(HSS)等指标评定2组患者功能恢复效果;采用平均住院日、住院各项费用等指标评估2组患者经济效果。结果:2组患者出院时与术后第2天比较,ROM、ADL、HSS均有显著改善(P0.05),且康复组以上指标均优于对照组(P0.05)。康复组平均住院日明显低于对照组(P0.05),2组住院费用差别无统计学意义。结论:早期康复治疗可有效改善TKA患者功能状态,缩短患者住院周期,增加床位周转率,是值得临床推广的有效、经济、合理的治疗方法。     

双侧全膝关节置换术后系统康复的临床研究

目的:前瞻性地进行双侧一次性全膝关节置换术(TKR)患者围手术期系统康复的临床研究。方法:选择2002年3月—2002年8月住院治疗TKR患者21例,所有入选病例均为膝关节骨性关节炎实施双侧一次性TKR的患者,入院后即开始实施系统个性化康复治疗方案,康复治疗分为3个阶段。第一阶段(手术前)、第二阶段(术后0—20天)、第三阶段(出院后),康复治疗内容包括:肌力训练、关节活动度训练、平衡功能、本体感觉及步态训练,术后康复治疗从术后第1天开始。结果:病例随访6—12个月,总共42个膝关节。膝关节活动度:出院时(术后10—20天):膝关节屈曲:100°—120°,平均101°±11.3°;伸直:10°—30°,平均10.4°±8.6°;膝关节周围肌力达到4级以上;术后半年复查,按照HSS膝关节评分标准:优:18例,良:3例,优良率100%,患者能够脱离拐杖行走及上下楼梯,生活完全自理。结论:双侧TKR患者术后早期系统康复治疗可直接影响手术的效果;早期系统的康复训练对于维持关节的稳定性、减少对人工关节的磨损、延长人工关节的使用寿命、提高患者生活质量是必需的,对双侧TKR患者更为重要。     

强化护理干预在人工全膝关节置换翻修术中的应用

目的:探讨强化护理干预对人工全膝关节置换术(TKR)患者中的应用效果,为促进TKR翻修术后关节功能康复患者提供有效护理依据。方法:将拟行TKR术的60例患者随机分为对照组和观察组各30例,对照组予常规护理治疗,观察组术前在对照组基础上予强化护理干预,术后3个月分别评估膝关节活动度(ROM)和膝关节评分标准(Hss)评分情况。结果:观察组ROM度数和Hss评分均高于对照组(P0.05)。结论:强化护理干预能有效促进TKR翻修患者术后关节功能恢复,值得进一步推广应用。     

早期大角度被动关节活动联合常规康复训练对全膝关节置换术后患者膝关节功能的影响

目的观察早期大角度被动关节活动训练对全膝关节置换术（TKR）后患者膝关节功能的影响。 方法TKR术后患者36例,按随机数字表法随机分成大角度被动关节活动训练组（观察组）和常规被动关节活动训练组（对照组）,每组患者18例。对照组患者采用常规活动角度的被动关节活动训练和常规康复训练进行治疗,其中康复医学科病房治疗2周,出院后采用同样的方法治疗10周,观察组采用大角度被动关节活动训练和常规康复训练进行治疗（仅被动关节活动训练的屈膝角度较对照组大20°,其他方法与对照组完全相同）。于康复治疗前和康复治疗1,2,4,6,12周后采用美国纽约特种外科医院（HSS）的膝关节功能评定量表、膝关节主动关节活动范围（ROM）和被动ROM评定2组患者膝关节功能的恢复情况。 结果康复治疗前,2组患者HSS评分和膝关节主动ROM和被动ROM差异均无统计学意义（P&rt;0.05）。康复治疗1,2,4,6,12周后,观察组的HSS评分均高于对照组,其中康复治疗1,2周后组间差异有统计学意义（P<0.05）。康复治疗1,2,4,6,12周后,观察组患者的膝关节主动和被动ROM较对照组均显著改善,差异有统计学意义（P<0.01）。 结论早期大角度被动关节活动可有效地改善TKR后患者膝关节的运动功能。     

基于表面肌电评价术前康复治疗对单膝关节置换术后功能恢复的影响

目的:探讨术前康复治疗对单膝关节置换患者术后股四头肌肌力恢复、步行功能恢复所需治疗时间的影响。方法:40例准备进行单膝关节置换患者,按照随机数字表法分成术前康复组(A组,20例)与术后康复组(B组,20例)。A组术前7天开始股四头肌肌力强化训练与下肢有氧训练,术后2组均采取常规康复治疗,包括关节活动度训练、肌力训练、站立步行训练、空气波压力治疗、股四头肌低频电刺激。术后第3天与第7天分别采用表面肌电图评估患者股四头肌均方根植(RMS),比较患者手术开始至恢复正常步行功能(达到Holden步行功能Ⅴ级)所需治疗天数。结果:2组股直肌及股内侧肌表面RMS比较,术后第3天A组高于B组,肌肉收缩能力增强;术后第7天,2组RMS比较差异无统计学意义(P0.05)。2组股外侧肌表面RMS比较,术后第3天及第7天差异无统计学意义(P0.05)。A组术后达到Holden步行功能Ⅴ级所需平均治疗天数与B组比较,差异有统计学意义(P0.01)。结论:术前康复治疗能有效改善患者术后肌肉抑制现象,有效缩短术后功能恢复时间,减少患者术后住院时间。     

早期系统康复治疗对股骨远端骨折术后效果的影响

目的评价早期系统康复治疗对股骨远端骨折患者术后效果的影响。方法选取58例手术治疗的股骨远端骨折患者,根据术后有无系统的康复治疗将其分为康复组(30例)和对照组(28例)。康复组术后采取早期系统康复治疗和训练,对照组进行常规术后康复治疗。比较2组术后1、3个月后膝关节活动度(ROM)。结果 2组在治疗1、3个月后膝关节ROM较治疗前均得到明显提高(P<0.01,P<0.05),且康复组高于对照组(P<0.01);康复组治疗3个月膝关节ROM较治疗1个月明显提高(P<0.05),而对照组差异无统计学意义(P>0.05)。结论膝关节ROM的恢复在早期1个月内是恢复的关键时期,早期系统康复治疗对恢复膝关节ROM,改善其功能有着重要作用。更多还原     

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.     

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.     

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.     

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.