山东省胶东半岛多中心人群骨密度分析研究

目的探讨山东省胶东半岛沿海地区健康人群骨密度正常参考值、骨密度变化规律和骨质疏松的患病率。方法采用双能X线骨密度仪(DEXA)对胶东半岛沿海地区多中心多阶段整群抽样调查3879名21～89岁居民进行骨密度测量。结果确定了胶东半岛沿海地区21～89岁人群不同性别、年龄别腰椎L2～L4和股骨近端的骨密度正常参考值、骨峰值和患病率。男性腰椎L2～L4骨密度峰值在30～39岁,女性腰椎骨密度峰值在21～29岁;男性股骨近端骨密度峰值在21～29岁,女性股骨近端(Neck和Ward’s)骨密度峰值在31～39岁,Troch区骨密度峰值在21～29岁。随着年龄的增加(40岁以上),男女性各部位BMD逐渐下降,女性更为明显,男性腰椎BMD下降程度较轻。男性腰椎50～岁组与60～岁组比较和60～岁组与70～岁组比较、女性腰椎60～岁组与70～岁组比较,差异无统计学意义(P>0.05),其余各组比较差异有显著性意义。腰椎的OP患病率最高,40～岁组和50～岁组男女患病率差异无显著性,60岁以后女性明显高于男性(P<0.001)。50～89岁人群腰椎和股骨骨质疏松症发病率男性为13.37%和2.87%,女性为28.03%和7.0%,男女比较差异有非常显著性(P<0.001)。结论获得胶东半岛健康人群骨质疏松症诊断和治疗的骨密度参考值,为骨质疏松纵向流行病学研究奠定基础。     

骨硬化蛋白水平与绝经后妇女体脂含量及骨密度的相关性研究

目的 探讨绝经后妇女血清骨硬化蛋白水平与体脂含量及骨密度(bone mineral density, BMD)之间的相关性。方法 对230名年龄在50~75岁之间健康的绝经后妇女进行横断面研究。通过双能X射线吸收仪测量受试者全身、腰椎、左侧股骨BMD及全身脂肪和肌肉含量。通过定量夹心酶联免疫吸附法测量受试者血清骨硬化蛋白水平。结果 与非骨质疏松症的女性相比,骨质疏松女性血清硬化蛋白水平显著降低(P <0.05)。血清骨硬化蛋白水平与体重和脂肪量呈正相关(P <0.05)。即使在校正年龄、绝经年龄、身高和体重之后,骨硬化蛋白水平与全身及各个部位的BMD均呈正相关(P <0.05)。多元线性逐步回归分析显示,与年龄、绝经年龄、脂肪量和肌肉量相比,血清骨硬化蛋白水平是全身和腰椎BMD最重要的决定因素(P <0.05)。年龄与血清硬化蛋白对髋部BMD的影响相似。结论 在绝经后妇女中,骨质疏松症患者的血清硬化蛋白水平低于非骨质疏松症患者。血清硬化蛋白与全身、腰椎、髋部的BMD和体脂含量呈正相关。     

佛山地区中老年人骨密度测定及骨质疏松患病率分析

目的了解佛山地区中老年人群骨密度（BMD）变化规律及骨质疏松（OP）患病率,为本地区骨质疏松症的防治提供参考。方法使用美国Hologic公司双能X线骨密度仪对839例广东省佛山地区40～85岁中老年人正位腰椎和股骨近端进行骨密度测定。结果随着年龄的增加（40岁以上）,男女性各部位BMD逐渐下降,女性更为明显,男性腰椎BMD下降程度较轻。男性腰椎50～岁组与60～岁组比较和60～岁组与70～岁组比较、女性腰椎60～岁组与70～岁组比较,差异无统计学意义（P〉0.05）,其余各组比较差异有显著性意义。腰椎的OP患病率最高,40~59岁男女患病率差异无显著性,60岁以后女性明显高于男性（P〈0.001）。40～84岁人群腰椎和股骨骨质疏松症发病率男性为27.1%和2.2%,女性为46.4%和11.8%,男女比较差异有非常显著性（P〈0.001）。结论佛山地区中老年人群BMD逐年下降,腰椎骨质疏松的患病率最高,研究的重点在中老年妇女。中老年人应坚持适当的体育活动,并注意防止跌倒导致的骨折发生。     

甲状腺功能异常对男性骨密度影响的研究

目的探讨甲状腺功能异常对50～80岁男性骨密度的影响,为这类患者的骨质疏松症防治提供理论基础。方法纳入162名50～80岁男性,根据甲状腺功能分为正常对照组(90名),甲亢组(38例),甲减组(34例)。检测记录三组受试者血清FT3、FT4、TSH、Ca、P、1,25-(OH)_2D_3、ALP以及BGP水平。测量三组受试者正位腰椎1～4与左侧髋关节骨密度。结果甲减组血清FT3、FT4、ALP、BGP水平低于对照组(P0.05),而甲亢组高于对照组(P0.05);甲减组血清TSH高于对照组(P0.05),而甲亢组低于对照组(P0.05);甲亢及甲减组腰椎和髋关节BMD低于对照组(P0.05)。三组受试者血清Ca、P、1,25-(OH)_2D_3差异无统计学意义(P0.05)。相关性结果表明血清BGP和ALP与FT3、FT4间存在统计学正相关,与TSH呈负相关(P0.05);骨密度T值评分与FT3、FT4间存在统计学负相关(P0.05)。Logistic回归结果显示甲减和甲亢均对骨密度有负向影响(P0.05)。结论甲状腺功能异常对50～80岁男性骨密度有负面影响,应重视甲状腺功能异常患者骨密度的改变,这对于骨质疏松症的防治具有重要意义。     

中老年女性乳腺癌患者骨丢失的临床研究

目的观察中老年女性乳腺癌患者骨密度(bone mineral density,BMD)变化及影响因素。方法选取40岁以上乳腺癌患者339例为乳腺癌组,同时选择1 356名健康女性为对照组。通过美国GE LUNAR公司生产的Prodigy advance双能X线骨密度仪测量受试者腰椎(L_(1～4))、左股骨BMD。对比乳腺癌组、对照组BMD及骨质疏松(osteoporosis,OP)患病率。结果①随着增龄,乳腺癌与对照组腰椎、股骨BMD逐渐降低。乳腺癌组腰椎、左侧股骨干、全髋BMD 40～49岁年龄段低于对照组,50～80岁年龄段高于对照组。乳腺癌组左侧股骨颈、大转子BMD 40～59岁年龄段低于对照组,60～80岁年龄段高于对照组;②体质量指数(body mass index,BMI)与腰椎、股骨BMD呈正相关(r=0. 101～0. 283,P0. 01)。亚洲骨质疏松自我评价工具(osteoporosis self-assessment tool for asians,OSTA)与BMD呈正相关(r=0. 382～0. 592,P0. 01);③随着增龄,乳腺癌与对照组OP检出率逐渐增加。对照组腰椎OP检出率高于乳腺癌组。50～80岁年龄段股骨OP检出率高于乳腺癌组。结论中老年女性乳腺癌患者与健康人群均有较高骨丢失率。50岁以后健康人群OP患病率高于乳腺癌患者。OSTA对乳腺癌OP风险有较好预测价值。     

绝经后女性不同空腹血糖水平和体质量指数与骨密度 的相关性研究

目的探讨绝经后女性不同空腹血糖水平和体质量指数(bone mass index, BMI)与骨密度的相关性。方法纳入202名绝经后妇女作为受试者,其中42例为2型糖尿病(type 2 diabetes mellitus,T2DM)患者(即T2DM组),160名为非2型糖尿病患者(即健康对照组)。通过双能X射线吸收测定法(DXA)获得其腰椎和股骨颈的骨密度(bone mineral density, BMD)数据,并记录其他相关的临床和实验室数据,分析相关变量之间的相关性。结果 T2DM组的BMD显著高于对照组(P0.05);通过空腹血糖和HbA1c水平比较受试者骨质疏松症的患病率时,发现骨质疏松症的患病率随血糖和HbA1c升高而显著降低;此外,T2DM组腰椎和股骨颈的BMD明显高于对照组(P0.05);同时发现骨质疏松症与糖尿病、BMI和饮酒呈负相关,但与年龄、既往骨折史以及肌肉骨骼系统和结缔组织的其他疾病呈正相关;在调整上述因素后,糖尿病与骨质疏松症之间的关联仍然具有统计学意义(P0.05);T2DM与骨质疏松症发病率相关且与BMI不相关(P0.05)。结论与健康对照组相比,T2DM患者腰椎和股骨颈的BMD均较高且不受BMI影响。此外,骨质疏松症的患病率随血糖和HbA1c升高而显著降低。     

京城区居民骨密度随年龄变化的特点--3285例骨密度测定结果分析

目的 了解北京城区居民骨密度(BMD)的变化规律和骨质疏松症(OP)的患病率.方法 应用法国MEDILINK公司牛产的OSTEOCORE1型双能X线骨密度仪对北京市城区3285名20～89岁人群进行股骨近端及腰L2-L4椎的BMD测定.结果 北京市城区男、女性人群的股骨近端及腰椎的BMD峰值均出现在20～29岁年龄组,峰值后随着年龄的增长骨密度BMD降低,女性在50～59岁BMD下降明显加速,男性没有出现下降加速现象.北京市城区中国人40岁以后OP患病率男性23.19%,女性OP患病率28.7%.结论 通过对北京市城区中国人群的BMD变化规律及患病率研究,为北京市城区中国人群的骨质疏松症预防、诊断及治疗提供客观有效的依据.     

乌鲁木齐地区2711例骨密度调查研究

目的了解新疆乌鲁木齐地区正常汉族人群骨密度(BMD)的变化规律和骨质疏松症(OP) 的患病率。方法应用法国DMS公司生产的CHALLENGER型双能X线骨密度仪对乌鲁木齐地区汉族人群共2711名20～80岁居民进行腰椎2～4及股骨近端的骨密度测定。结果乌鲁木齐地区汉族人群男性、女性的腰椎及股骨近端的BMD峰值均出现在20～29岁年龄组,峰值后随着年龄的增长,而骨密度BMD降低,女性在50～59岁明显加速下降,男性没有加速下降现象。乌鲁木齐地区40岁以后OP患病率男性28．3％,女性OP患病率45．2％。男女性50～59岁以上,组间患病率有显著差异(P<0．05)。结论通过对乌鲁木齐地区汉族人群的骨密度变化规律及患病率研究, 为乌鲁木齐地区汉族人群的骨质疏松症诊断及治疗提供客观有效的依据。     

老年男性骨密度与身体成分相关性的研究

目的分析老年男性骨密度(bone mineral density,BMD)与身体成分的关系。方法记录166名80~94岁老年男性的年龄、身高、体重、BMI,检测L1-4、左侧股骨颈、Wards三角、大粗隆、左侧股骨上端的BMD及总肌肉含量(total lean mass,TLM)和总脂肪含量(total fat mass,TFM),根据BMD水平将受试者分为骨量正常组(n=50)、骨量低下组(n=91)和骨质疏松组(n=25)。结果 (1)骨量低下组及骨质疏松组的BMD均明显低于正常骨量组(P0.01),骨质疏松组又明显低于骨量低下组(P0.01);(2)骨质疏松组体重、TLM、TFM及BMI均明显低于正常骨量组(P0.01);(3)TLM与左侧股骨颈、Wards三角、左侧股骨上端的BMD相关系数分别为0.227、0.203及0.193(P0.05),TFM与腰椎1-4、左侧股骨颈、Wards三角、大粗隆、左侧股骨上端的BMD相关系数为0.269、0.222、0.206、0.246及0.242(P0.01)。结论大部分老年男性BMD与年龄呈显著负相关;与体重、BMI及TFM、TLM呈显著正相关,适当的运动和适度的肥胖,增强肌肉量和维持一定的脂肪量,保持健康的体重,可能有利于预防老年性骨质疏松症。     

三种健身气功练习对老年女性骨密度的影响

目的探讨定期的健身气功易筋经、五禽戏和八段锦练习对老年女性腰椎和股骨近端骨密度(BMD)的影响。方法年龄、身高和体重相匹配的易筋经组(n=22)、五禽戏组(n=22)、八段锦组(n=21)和对照组(n=25)参与研究,三种健身气功组进行为期24周(5次/周,70 min/次)的健身气功练习。测试4组受试者腰椎L_(2-4)和股骨近端BMD。结果 24周后组内比较:易筋经组和八段锦组腰椎L_(2-4)的BMD分别显著增加12.0%和11.0%(P0.05),五禽戏组腰椎L_(2-4)的BMD虽有增加(5.6%)但无显著变化(P0.05);组间比较:易筋经组和八段锦组腰椎L_(2-4)的BMD分别大于对照组12.0%和9.8%(P0.05)。结论 24周易筋经和八段锦练习增加了老年女性腰椎L_(2-4)的BMD,且效果优于五禽戏。三种健身气功对股骨近端BMD影响均不明显。     

Is the recovery profile of mivacurium independent of the rate of decay of its plasma concentration in patients with normal plasma cholinesterase activity?

Background: The duration of action of muscle relaxants is poorly correlated to the rate of decay of their plasma concentration. The plasma concentration of mivacurium may rapidly decrease below its active concentration because of the extensive hydrolysis of mivacurium. By inflating a tourniquet on one upper limb for 3 min after the administration of atracurium, mivacurium or vecuronium, we studied the influence of the initial decline of their plasma concentration on their effect. Methods: In 50 patients anaesthetised with thiopental, isoflurane and fentanyl, the effect of bolus doses of 0.15 or 0.25 mg . kg^?1 mivacurium (MIV 15, MIV 25), 0.3 or 0.5 mg . kg^?1 atracurium (ATR 30, ATR 50) and 0.06 or 0.1 mg . kg^?1 vecuronium (VEC 06, VEC 10) were measured on both arms (evoked response of the adductor pollicis to train-of-four stimulation every 12 s), a tourniquet being applied on one arm just before and during 3 min after the muscle relaxant bolus. Results: Tourniquet inflation of 3 min almost abolished the neuromuscular effect of mivacurium. In the vecuronium groups and in the ATR 50 group, tourniquet inflation did not modify the maximum degree of depression of the twitch response. Also, the duration of action of vecuronium was unaffected by the tourniquet. In the ATR 30 group, times to return of the twitch response to 25% (duration 25%) and 75% (duration 75%) of control response were significantly shorter in the cuffed arm, 23 min vs 27 min, and 41 min vs 45 min, respectively. In the ATR 50 group, only duration 25% was significantly shorter in the cuffed arm (41 min vs 45 min). Conclusion: The results suggest that the rate of decline of the plasma concentration of mivacurium is so rapid, that a very low and almost clinically ineffective concentration is present as soon as 3 min after its administration. The results also indicate that the recovery from a mivacurium-induced neuromuscular blockade is not influenced by the rate of decay of its plasma concentration in patients with genotypically normal plasma cholinesterase.     

Membranes in Artificial Organs

Abstract: Membrane processes play a pivotal and enabling role in modern replacement therapy for acute and chronic organ failure and in the management of immunologic diseases. In fact, virtually all contemporary extracorporeal blood purification methods employ membrane devices, and the next generation of artificial organs and tissue engineering therapies are almost certain to be similarly grounded in membrane technology. In this short essay, we comment on the similarities and differences among synthetic membranes and their natural counterparts and also provide a critical overview of the demographics and technology of hemodialysis, hemofiltration, apheresis, oxygenation, and emerging membrane technologies and applications.     

Reduction of Plasma Fibrinogen, Immunoglobulin G, and Immunoglobulin M Concentrations by Immunoadsorption Therapy with Tryptophan and Phenylalanine Adsorbents

Abstract Immunoadsorption (1A) therapy with tryptophan (TR-350) or phenylalanine (PH-350) adsorbents has been used to reduce the concentration of serum antibodies in human lymphocyte antigen (HLA)-immunized patients. Other forms of plasma purification have been reported to reduce the level of fibrinogen, which affects the blood properties. In this study we investigated the effects of IA therapy using both adsorbents on plasma fibrinogen and immunoglobulins G and M in 13 patients (8 patients were treated with TR-350, and 5 patients were treated with PH-350). During each session 1 plasma volume (2.8 ± 0.4 L of plasma) was processed through the immunocolumn and then returned to the patient together with the blood cells. Compared with the pretreatment values, the plasma fibrinogen, IgG, and IgM concentrations were significantly reduced after IA therapy (p < 0.01 for TR-350; p < 0.04 for PH-350). There was a positive correlation between the degree of reduction of plasma proteins and the number of IA treatments given. A nonpara-metric test (Wilcoxon's signed-rank test or the Mann-Whitney test) was used for statistical analysis. We conclude from our study that IA therapy effectively lowers the plasma levels of fibrinogen, IgG, and IgM and thus can be considered a valuable alternative to other blood purification methods.     

Dilemma of Membrane Biocompatibility and Reuse

Abstract: Numerous articles have been published on the multiple use of dialyzers and on the effect of different reprocessing chemicals and techniques on the dialyzer biocompatibility and performance. The results often appear contradictory, especially those comparing standard biocompatibility parameters. Despite this confusion, a discerning review of the published works allows certain limited conclusions to be drawn. Reprocessing of used hemodialyzers changes the biocompatibility profile of a dialyzer as defined by the parameters complement activation. leukopenia, and cytokine release. The effect of reprocessing depends on the chemicals and reprocessing technique applied and also on the type of membrane polymer being subjected to the reprocessing procedure. Reports of pyrogenic reactions indicate that the flux of the membrane also influences how suitable it is for safe reuse. An increased risk of allergic and pyrogenic reactions appears to be associated with dialyzer reuse. Furthermore, there has been a lack of investigations into the immunologic effect of the layer of adsorbed and chemically altered proteins that remains on the inner surface of reprocessed dialyzers. We conclude that the clinical benefit of dialyzer reuse cannot be generally accepted from a biocompatibility point of view.     

The analgesic effect of racemic ketamine in patients with chronic ischemic pain due to lower extremity arteriosclerosis obliterans

Background : Ketamine in sub-dissociative doses has been shown to have analgesic and phantom-Limb pain, where conventional treatment has often failed. Chronic ischemic pain due to lower extremity arteriosclerosis obliterans often responds poorly to analgesics, and the pain-generating mechanisms are not well understood.
Methods : Eight patients with rest pain in the lower extremity due to arteriosclerosis obliterans were given sub-dissociative doses of 0.15, 0.30, or 0.45 mg/kg racemic ketamine and morphine 10 mg as a 5-min infusion on four separate days in a cross-over, double-blind, randomised protocol. Plasma levels of (S)- and (R)-ketamine and their nor-metabolites were analysed with an enantioselective high-performance liquid chromatography (HPLC) method. Pain levels were evaluated with a visual analogue scale (VAS).
Results : Individual pain levels were highly variable during and after all the infusions but the pooled pain levels showed a dose-dependent analgesic effect of ketamine with a transient but complete pain relief in all patients at the highest dose (0.45 mg/ kg). Side-effects, mainly disturbed cognition and perception, were pronounced and dose-dependent. Morphine 10 mg had an analgesic peak at 20 min and 5/8 patients had complete pain relief. The remaining 3 patients also had high baseline pain scores, indicating a higher analgesic potency for the 0.30 and 0.45 mg/ kg ketamine doses than for morphine 10 mg.
Conclusion : We have demonstrated a potent dose-dependent analgesic effect of racemic ketamine in clinical ischemic pain. Due to a narrow therapeutic window, this analgesic effect is probably best utilised in combination with other analgesics.     

Intravenous endotoxin does not increase tissue extravasation of albumin in rats

Background : It is unclear whether activation of the inducible nitric oxide synthase (iNOS) increases or decreases the extravasation of plasma.
Methods : Chloralose anaesthetised male Wistar rats received E. coli lipopolysacharide (LPS), 3 mg kg^-1 i.v., or the corresponding volume of saline, 3 or 5 h before the end of the experiment. Mean arterial pressure (MAP) and heart rate (HR) were recorded. Tissue clearance of radio-labelled albumin, during the last 2 h of each experiment, was determined by a double-isotope method. In separate animals, the serum concentration of nitrite and nitrate was determined, 5 h after LPS or the solvent.
Main Results : LPS initially decreased MAP and lastingly increased HR. In the 3-h LPS animals (n=8), tissue plasma clearance was lower in the heart and calf muscle and increased only in diaphragm, compared to corresponding control animals (n=8). In the 5-h LPS rats, clearance was lowered (n=8) in the entire gastrointestinal tract and in testes, compared to controls (n=8). The serum nitrite/nitrate concentration was higher in animals given LPS (n=6) than in controls (n=6).
Conclusion : After LPS, tissue clearance of albumin was not increased in any major tissue, in spite of increased serum levels of NO end products. Apparently, after activation of iNOS, the augmented release of NO is not necessarily associated with increased albumin extravasation.     

The multiply injured child

Blunt trauma is the principal cause of childhood death in many developed countries. This review outlines the differences between adults and children with respect to resuscitation and treatment of orthopaedic injuries in a child with polytrauma. Recent advances in techniques of fracture stabilization are reported.     

Adrenaline markedly improves thoracic epidural analgesia produced by a low-dose infusion of bupivacaine, fentanyl and adrenaline after major surgery: A randomised, double-blind, cross-over study with and without adrenaline

Background: Basic pharmacological research indicates that there are synergistic antinociceptive effects at the spinal cord level between adrenaline, fentanyl and bupivacaine. Our clinical experience with such a mixture in a thoracic epidural infusion after major surgery confirms this. The objectives of the present study were to evaluate the effects on postoperative pain intensity, pain relief and side effects when removing adrenaline from this triple epidural mixture. Methods: A prospective, randomised, double-blind, cross-over study was carried out in 24 patients after major thoracic or abdominal surgery. Patients with only mild pain when coughing during a titrated thoracic epidural infusion of about 10 ml · h^?1 of bupivacaine 1 mg · ml^?1, fentanyl 2 μg · ml^?1, and adrenaline 2 μg · ml^?1 were included. On the 1^st and 2^nd postoperative days each patient was given a double-blind epidural infusion, at the same rate, with or without adrenaline. The effect was observed for 4 h or until pain when coughing became unacceptable in spite of a rescue analgesic procedure. Rescue analgesia consisted of up to two epidural bolus injections per hour and i.v. morphine if necessary. All patients received rectal paracetamol 1 g, every 8 h. Fentanyl serum concentrations were measured with a radioimmunoassay technique at the start and end of each study period. Main outcome measures were extent of sensory blockade and pain intensity at rest and when coughing, evaluated by a visual analogue scale, a verbal categorical rating scale, the Prince Henry Hospital pain score, and an overall quality of pain relief score. Results: The number of hypaesthetic dermatomal segments decreased (P <0.001) and pain intensity at rest and when coughing increased (P <0.001) when adrenaline was omitted from the triple epidural mixture. This change started within the first hour after removing adrenaline. After 3 h pain intensity when coughing had increased to unacceptable levels in spite of rescue analgesia (epidural bolus injections and i.v. morphine). Within 15–20 min after restarting the triple epidural mixture with adrenaline, pain intensity was again reduced to mild pain when coughing. Serum concentration of fentanyl doubled from 0.22 to 0.45 ng · ml^?1 (P <0.01), and there was more sedation during the period without adrenaline. Conclusions: Adrenaline increases sensory block and improves the pain-relieving effect of a mixture of bupivacaine and fentanyl infused epidurally at a thoracic level after major thoracic or abdominal surgery. Serum fentanyl concentrations doubled and sedation increased when adrenaline was removed from the epidural infusion, indicating more rapid vascular absorption and systemic effects of fentanyl.     

Utilisation des médicaments prokinétiques en réanimation : indications et limites ?

Enteral feeding is often limited by gastric and intestinal motility disturbances in critically ill patients, particularly in patients with shock. So, promotility agents are frequently used to improve tolerance to enteral nutrition. This review summaries the pathophysiology, presents the available pharmacological strategies, the clinical data, the counter-indications and the principal limits. The clinical data are poor. No study demonstrates a positive effect on clinical outcomes. Metoclopramide and erythromycin seems to be the more effective. Considering the risk of antibiotic resistance, the first line use of erythromycin should be avoided in favor of metoclopramide.