老年慢性心力衰竭患者的胰岛素抵抗状态及运动训练对其的影响——附60例报告

目的:观察老年慢性心力衰竭(chronic heart failure, CHF)患者胰岛素抵抗(insulin resistance,IR) 状态及运动训练对其的影响.方法:110例NYHA心功能Ⅱ～Ⅲ级的老年CHF患者为CHF组,随机分为训练组(60例)和常规治疗组(50例),2组患者均接受常规的抗心力衰竭药物治疗,训练组还接受每日2次,每次6 min,长达20周的运动训练.选同期32名老年健康体检者为正常对照组.比较训练组和常规治疗组患者治疗前后用稳态模式评估法计算的胰岛素抵抗指数(insulin resistance index, IR),即HOMA-IR,胰岛素敏感指数(insulin sensitivity index, ISI),LVEF,左心室的短轴缩短率(fraction shortening,FS),6 min步行试验(6-minute walking test, 6-MWT),心率及平均动脉压的变化.结果:与正常对照组比较,CHF患者ISI 降低,HOMA-IR增加(P<0.01).治疗后训练组与常规治疗组比较,训练组的LVEF与FS值、6-MWT行走距离及ISI增加,而心率、平均动脉压及HOMA-IR降低,2组比较差异有统计学意义(P<0.05～0.01).结论:老年CHF患者存在胰岛素抵抗,运动训练在改善其心功能及运动功能的同时,亦能增强胰岛素敏感性、改善胰岛素抵抗状态.     

慢性心力衰竭患者运动训练后血浆NT-proBNP浓度的变化

目的 旨在探讨运动训练对不同程度慢性心力衰竭（chronic heart failure，CHF）患者血浆脑钠肽前体N末段（N-terminal pro-brain natriuretic peptide，NT-proBNP）的影响。方法 80例心功能Ⅱ～Ⅲ级的CHF患者随机分为训练组（n=42）和对照组（n=38），入院后24 h内行6分钟步行运动试验，记录其行走距离，检测血浆NT-proBNP浓度，两组均常规给予抗心衰药物治疗，但训练组每天行2次6分钟步行运动训练。8周后复查血浆NT-proBNP浓度及6分钟步行运动试验。结果 运动训练可显著降低CHF患者的血浆NT-proBNP浓度（P＜0．05），增加CHF患者的6min步行距离（P＜0．05）。结论 运动训练可显著降低血浆NT-proBNP浓度，并改善运动功能，因此，有益于延缓CHF病程进展。     

氯沙坦联合卡托普利治疗充血性心力衰竭疗效观察

目的：探讨氯沙坦联合卡托普利治疗慢性充血性心力衰竭（CHF）的临床疗效。方法：60例CHF患者随机分成治疗组和对照组。两组基础治疗类同，治疗组32例给予氯沙坦50mg/d，卡托普利37.5mg/d；对照组28例给予托普利37.5mg/d及安慰剂治疗。疗程6个月。观察治疗前后两组患者的临床症状、超声心动图心功能指标、6min步行距离的变化。结果：治疗后，治疗组临床总有效率为93.7%，对照组总有效率为67.6%；两组治疗前后相比左室射血分数（LVEF）、心脏指数（CI）、6min步行距离均有显著改善（P＜0.01），治疗组LVEF、CI及6min步行距离的改善优于对照组。结论：氯沙坦联合卡托普利治疗CHF可以增强疗效。     

运动训练对老年慢性心力衰竭患者心功能及血清CysC浓度的影响

【目的】探讨运动训练对老年慢性心力衰竭（CHF）患者心功能和血清胱抑素C（CysC）浓度的影响。方法 172例心功能Ⅱ～Ⅲ级老年CHF患者随机分为训练组（n=36）和对照组（n=36）,入选后即行6分钟步行试验（6MwT）、检测CysC浓度、超声多普勒检测心功能。对照组常规给予抗心衰药物治疗,在此基础上训练组每天行2次6MWT运动强度的步行训练。8周后复查6MWT、血清CysC浓度、行超声多普勒检测心功能。【结果】两组患者6MWT距离心功能Ⅲ级患者均显著短于Ⅱ级患者（P〈O．05）,CysC水平Ⅲ级患者均显著高于Ⅱ患者（P〈O．05）。治疗8周后两组患者血清CysC浓度均有显著下降（P〈0．05）,6MWT距离明显增加（P〈0．01,P〈O．05）,心功能客观指标明显提高（P〈0．05）,但训练组改善程度显著优于对照组（P〈0．01）。【结论】运动训练可以显著提高老年CHF患者的运动能力并降低血清CysC浓度,改善心功能。     

无步行能力脑卒中偏瘫患者踏车有氧训练有效性的初步研究

目的研究无辅助步行和独立步行能力的脑卒中偏瘫患者进行低强度踏车有氧训练的有效性。 方法将无辅助步行和独立步行能力的脑卒中偏瘫患者30例分为对照组和有氧训练组。2组患者均接受常规康复治疗,有氧训练组患者在常规康复治疗的基础上进行每周3次、每次30 min、共6周的低强度踏车有氧训练。2组患者总康复治疗时程和时间均相等。治疗前、后2组患者均采用Fugle-Meyer运动功能评分法（FMA）和Rivermead运动指数评定肢体功能,运用Barthel指数（BI）评定日常生活活动（ADL）能力,并进行运动试验终止心率、耐受时间及实验室检查［空腹血糖、血胰岛素、血脂、血胆固醇、高敏C反应蛋白、口服葡萄糖耐量试验（OGTT）2 h血糖和胰岛素等,并计算稳态模型胰岛素抵抗指数（HOMA-IR）］。 结果24例患者完成观察程序（每组12例）。2组患者治疗前、后肢体运动功能、运动试验耐受时间、空腹胰岛素、OGTT 2 h血糖、HOMA-IR等指标明显改善（P＜0.05）,治疗后2组间FMA、Rivermead指数、BI、运动试验耐受时间、空腹胰岛素及OGTT 2 h血糖等差异均有统计学意义(P<0.05)。 结论低强度踏车有氧训练可以有效应用于无步行能力的脑卒中偏瘫患者。     

老年充血性心力衰竭对卡维地洛的耐受性研究

目的：研究卡维地洛治疗慢性老年充血性心力衰竭（CHF）的临床疗效及耐受性。方法：60例老年（＞65岁）CHF患者随机分为2组，对照组：采用常规治疗方法（ACEI／ARb、利尿剂、地戈辛）；治疗组：在对照组治疗的基础上，加用卡维地洛，治疗4月。治疗前后检查超声心动图，测定左心室射血分数（LVEF），并行6分钟步行试验，记录心率、血压。结果：治疗组显示心功能改善、LVEF、6min步行距离、心率均有显著改善（p＜0．01），对照组的LVEF、6min步行距离较治疗前虽有明显改善（p＜0．05），但与治疗组相比仍有显著差异（p＜0．01）。结论：在常规治疗老年CHF患者的基础上加用目标剂量的卡维地洛，对CHF患者安全有效的。     

步行运动训练对慢性充血性心衰患者左室结构和血浆B型脑利钠肽水平的影响

目的 观察步行运动训练对慢性充血性心衰(CHF)患者左心室结构和血浆B型脑利钠肽(BNP)水平的影响,探寻运动训练的意义.方法 将223例心功能分级Ⅱ～Ⅲ级的CHF患者分为处方康复组、非处方康复组和对照组,均给予基础药物治疗,处方康复组和非处方康复组按不同的要求进行康复训练.入选时及6个月随访时对各组进行血压测量、6 min步行距离测量和血浆BNP水平测定,并进行心脏超声检查观察左室射血分数(LVEF)和左室舒张末期内径(LVEDd)的变化.结果 入选时,各组血压、6 min步行距离、左室功能及血浆BNP水平比较,差异均无统计学意义.6个月随访时,处方康复组再次住院例次和其中因心功能恶化再次住院比率明显低于非处方康复组和对照组(P<0.05);与运动训练前及其他2组比较,血浆BNP水平明显下降,6 min步行距离和LVEF明显提高(P<0.01),LVEDd则无明显变化.结论 步行运动训练可改善CHF患者的运动耐力,降低血浆BNP水平,且安全性好,但短期内对左室的重构尚无积极影响.     

六分钟步行训练对慢性心力衰竭患者运动能力及左室射血分数的影响

目的探讨6min步行运动训练对不同程度慢性心力衰竭(心衰)患者左心室射血分数的影响。方法将62例心功能Ⅱ～Ⅲ级的慢性心衰患者按分层抽样法随机分为训练组(n=33)和对照组(n=29),在入院24h内行左室射血分数及6min步行距离测定,然后两组均行常规抗心衰药物治疗,但训练组每天2次行6min步行运动训练,8周后重复检测上述指标。结果运动训练显著改善慢性心衰症状,训练组步行距离在治疗8周后较对照组更加明显犤能II级为(492±56)m和(386±49)m;心功能III级为(386±49)m和(297±40)m犦,均有显著差异(P<0.05)。治疗8周后,两组患者LVEF均较入院时升高,但训练组升高的程度比对照组更显著犤能II级为(0.56±0.06)和(0.52±0.05);心功能III级为(0.51±0.04)和(0.48±0.06)犦(t=2.10～3.81,P<0.05～0.01)。结论6min步行运动训练可显著提高慢性心衰患者的左心室射血分数。     

步行运动训练对慢性充血性心衰患者左室结构和血浆B型脑利钠肽水平的影响

目的 观察步行运动训练对慢性充血性心衰(CHF)患者左心室结构和血浆B型脑利钠肽(BNP)水平的影响,探寻运动训练的意义.方法 将223例心功能分级Ⅱ～Ⅲ级的CHF患者分为处方康复组、非处方康复组和对照组,均给予基础药物治疗,处方康复组和非处方康复组按不同的要求进行康复训练.入选时及6个月随访时对各组进行血压测量、6 min步行距离测量和血浆BNP水平测定,并进行心脏超声检查观察左室射血分数(LVEF)和左室舒张末期内径(LVEDd)的变化.结果 入选时,各组血压、6 min步行距离、左室功能及血浆BNP水平比较,差异均无统计学意义.6个月随访时,处方康复组再次住院例次和其中因心功能恶化再次住院比率明显低于非处方康复组和对照组(P<0.05);与运动训练前及其他2组比较,血浆BNP水平明显下降,6 min步行距离和LVEF明显提高(P<0.01),LVEDd则无明显变化.结论 步行运动训练可改善CHF患者的运动耐力,降低血浆BNP水平,且安全性好,但短期内对左室的重构尚无积极影响.     

运动训练对左室射血分数保留心力衰竭患者活动耐量及生活质量的影响

目的 观察个体化运动训练对左室射血分数保留心力衰竭患者活动耐量及生活质量的影响。 方法 采用随机数字表法将108例左室射血分数（LVEF）保留心力衰竭患者分为运动训练组（55例）和对照组（53例）。对照组给予常规优化药物治疗,运动训练组在对照组用药基础上辅以个体化运动训练。于入选时及12个月后随访时分别采用LVEF、6分钟步行距离测试（6MWD）及明尼苏达心功能不全生命质量量表（MLHFQ）对2组患者活动耐量、生活质量情况进行评定,同时记录观察期间2组患者不良事件发生情况。 结果 12个月后随访时2组患者LVEF组间差异无统计学意义（P>0.05）;运动训练组6MWD［（409.9±66.9）m］及MLHFQ评分［(37.8±3.6)分］均显著优于对照组（均P<0.05）。12个月后随访时2组患者LVEF均较入选时无明显改善（均P>0.05）;运动训练组6MWD较入选时显著改善（P<0.05）,而对照组无明显改善（P>0.05）;运动训练组及对照组MLHFQ评分均较入选时显著改善（均P<0.05）。观察期间2组患者不良事件发生情况组间差异无统计学意义（P>0.05）。 结论 个体化运动训练可显著改善左室射血分数保留心力衰竭患者活动耐量及生活质量,同时还具有较好的安全性,但对患者射血分数的影响不显著。     

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.