短时程脊髓电刺激治疗爆发痛合并触诱发痛的急性期带状疱疹的临床研究

目的探讨短时程脊髓电刺激(temporary spinal cord stimulation, tSCS)治疗爆发痛合并触诱发痛的急性期带状疱疹的临床疗效。方法回顾性地分析同济大学附属第十人民医院疼痛科2020年1月—2020年12月收治的52例接受tSCS治疗的爆发痛合并触诱发痛的急性期带状疱疹患者的临床资料，评估在治疗前、治疗后3d、7d、14d、3个月、6个月的总体疼痛情况(numerical rating scale, NRS)评分、(simple McGill scores, McGill)评分、爆发痛情况(发生率、NRS评分、次数以及持续时间)、触诱发痛情况(发生率、分级)、术后不良反应等；评估在治疗前、治疗后7d、3个月、6个月的睡眠时长、睡眠中醒来次数、疼痛障碍指数(pain disorder index, PDI)、功能状态评分(Karnofsky score, KPS)、抑郁症筛查量表(patient health questionnaire depression module scale, PHQ-9)和焦虑症筛查量表(generalized anxiety disorder-7 scale, GAD-7)等。结果与治疗前相比，治疗后3d、7d、14d、3个月、6个月的总体疼痛NRS评分、总体疼痛MCGILL评分、静息痛NRS评分明显降低(均P<0.001)；与治疗前相比，治疗后3d、7d、14d、3个月、6个月的的爆发痛NRS评分明显降低(均P<0.05)，治疗后14d、3个月、6个月时的爆发痛次数以及持续时间都明显降低(均P<0.05)；与治疗前比较，患者治疗后7d、14d、3个月、6个月时的触诱发痛的分级都明显降低，差异均有统计学意义(均P<0.05)；与治疗前相比，治疗后14d、3个月、6个月的PDI评分明显降低(P<0.05)；与治疗前相比，治疗后14d、3个月、6个月的PHQ-9评分和GAD-7评分都明显减少(P<0.05)，与术前的药物使用情况相比，治疗后各镇痛药使用人数普遍呈下降趋势；术中及整个随访期间未观察到严重不良事件。结论短时程脊髓电刺激对爆发痛合并触诱发痛的急性期带状疱疹具有较好的临床疗效。     

Higher Preimplantation Opioid Doses Associated With Long‐Term Spinal Cord Stimulation Failure in 211 Patients With Failed Back Surgery Syndrome

ObjectiveSpinal cord stimulation (SCS) is an effective treatment in failed back surgery syndrome (FBSS). We studied the effect of preimplantation opioid use on SCS outcome and the effect of SCS on opioid use during a two-year follow-up period.Materials and methodsThe study cohort included 211 consecutive FBSS patients who underwent an SCS trial from January 1997 to March 2014. Participants were divided into groups, which were as follows: 1) SCS trial only (n = 47), 2) successful SCS (implanted and in use throughout the two-year follow-up period, n = 131), and 3) unsuccessful SCS (implanted but later explanted or revised due to inadequate pain relief, n = 29). Patients who underwent explantation for other reasons (n = 4) were excluded. Opioid purchase data from January 1995 to March 2016 were retrieved from national registries.ResultsHigher preimplantation opioid doses associated with unsuccessful SCS (ROC: AUC = 0.66, p = 0.009), with 35 morphine milligram equivalents (MME)/day as the optimal cutoff value. All opioids were discontinued in 23% of patients with successful SCS, but in none of the patients with unsuccessful SCS (p = 0.004). Strong opioids were discontinued in 39% of patients with successful SCS, but in none of the patients with unsuccessful SCS (p = 0.04). Mean opioid dose escalated from 18 ± 4 MME/day to 36 ± 6 MME/day with successful SCS and from 22 ± 8 MME/day to 82 ± 21 MME/day with unsuccessful SCS (p < 0.001).ConclusionsHigher preimplantation opioid doses were associated with SCS failure, suggesting the need for opioid tapering before implantation. With continuous SCS therapy and no explantation or revision due to inadequate pain relief, 39% of FBSS patients discontinued strong opioids, and 23% discontinued all opioids. This indicates that SCS should be considered before detrimental dose escalation.     

577 nm激光光凝联合玻璃体内注射康柏西普治疗糖尿病性黄斑水肿的效果观察

目的　探讨577 nm激光光凝联合玻璃体内注射康柏西普治疗糖尿病性黄斑水肿的效果。方法　选取2016年1月至2017年3月在我院治疗的糖尿病性黄斑水肿患者81例81眼，根据患者最终选取的治疗方案分为观察组43例43眼和对照组38例38眼，观察组给予577 nm激光光凝联合玻璃体内注射康柏西普治疗，对照组仅给予577 nm激光光凝，观察两组治疗前后最佳矫正视力（best corrected visual acuity，BCVA）和黄斑中心凹厚度（central fovea of macula thickness，CMT），分析观察组BCVA和CMT变化值与初始因素的相关性。结果　随治疗时间延长，观察组和对照组BCVA、CMT相应改善（均为P＜0.05）；观察组治疗后1个月、3个月和6个月BCVA分别为0.37±0.09、0.44±0.10和0.52±0.13，均明显高于对照组（均为P＜0.05）；观察组治疗后1个月、3个月和6个月CMT分别为（351.03±41.43）μm、（270.32±40.03）μm和（220.01±32.91）μm，均明显低于对照组（均为P＜0.05）；BCVA变化值与糖尿病性黄斑水肿病程、治疗前BCVA呈负相关（r=-0.422、-0.410，均为P＜0.05）；CMT变化值与糖尿病性黄斑水肿病程、治疗前CMT呈负相关（r=-0.430、-0.415，均为P＜0.05）。结论　577 nm激光光凝联合玻璃体内注射康柏西普治疗糖尿病性黄斑水肿效果较好，其效果与患者基线BCVA、糖尿病性黄斑水肿病程有一定相关性。     

糖尿病黄斑水肿患者病变程度与脉络膜厚度的关系

目的　利用频域光学相干断层扫描深度增强（enhanced depth imaging spectral domain optical coherence tomography，EDI SD-OCT）观察糖尿病黄斑水肿（diabetic macular edema，DME）患者脉络膜厚度（choroidal thickness，CT）的变化及结构特点，探讨DME病变程度与CT的关系。方法　纳入2型糖尿病患者共123例204眼，其中69眼诊断为DME（DME组），135眼无黄斑水肿为对照组。DME眼依据OCT形态学特点进一步分为视网膜弥漫性增厚（diffuse retinal thickness，DRT）型（34眼）、黄斑囊样水肿（cystoid macular edema，CME）型（19眼）和浆液性视网膜脱离（serous retinal detachment，SRD）型（16眼），利用EDI-OCT分别测量黄斑中心凹下CT和以黄斑为中心上、下、鼻、颞500 μm、1000 μm、1500 μm、2000 μm处CT。结果　DME组黄斑中心凹下CT为（326.72±90.15）μm，对照组为（320.17±106.46）μm，两组之间无统计学差异，但黄斑中心凹下CT与视网膜厚度间具有明显正相关关系（r=0.270，P=0.025）。DME亚型CT分别为:DRT型（303.94±81.47）μm、CME型（304.42±73.98）μm和SRD型（401.63±88.80）μm，SRD型CT明显高于其他亚型（P<0.05），此外，SRD型的周边CT同样呈现均匀一致的增厚；鼻侧CT从500 μm至2000 μm呈距离敏感性降低（P<0.05），但SRD型鼻侧CT降低幅度明显变缓（P=0.195）。结论　SRD型黄斑水肿患者CT在中心凹下及周边部均显著增厚，CT与DME病变程度之间有一定相关性。     

Advancing primary and community care for persons with spinal cord injury: Key findings from a Canadian summit

Context: Persons with spinal cord injury (SCI) experience significant challenges when they access primary care and community services.

Design: A provincial summit was held to direct research, education, and innovation for primary and community care for SCI.

Setting: Toronto, Ontario, Canada.

Participants: Key stakeholders (N?=?95) including persons with SCI and caregivers, clinicians from primary care, rehabilitation, and specialized care, researchers, advocacy groups, and policy makers.

Methods: A one-day facilitated meeting that included guest speakers, panel discussions and small group discussions was held to generate potential solutions to current issues related to SCI care and to foster collaborative relationships to advance care for SCI. Perspectives on SCI management were shared by primary care, neurosurgery, rehabilitation, and members of the SCI community

Outcome Measures: Discussions were focused on five domains: knowledge translation and dissemination, application of best practices, communication, research, and patient service accessibility.

Results: Summit participants identified issues and prioritized solutions to improve primary and community care including the creation of a network of key stakeholders to enable knowledge creation and dissemination; an online repository of SCI resources, integrated health records, and a clinical network for SCI care; development and implementation of strategies to improve care transitions across sectors; implementation of effective care models and improved access to services; and utilization of empowerment frameworks to support self-management.

Conclusions: This summit identified priorities for further collaborative efforts to advance SCI primary and community care and will inform the development of a provincial SCI strategy aimed at improving the system of care for SCI.     

Discordant Electrocardiogram Left Ventricular Wall Thickness and Strain Findings in Influenza Myocarditis

A 42‐year‐old man presented with a viral prodrome and tested positive for influenza A. He rapidly deteriorated developing cardiogenic shock, rhabdomyolysis, and acute kidney injury. Patient improved 1 week later with supportive measures including vasopressors, inotropes, and an intraaortic balloon pump. We report this case as it highlights the discordance between echocardiographic ventricular wall thickening as a result of myocardial edema, and electrocardiographic findings at presentation, with a reversal in findings at time of resolution. Additionally, there was some suggestion of a regional pattern to the reduced longitudinal strain.     

不同手术方案对脊髓型颈椎病合并椎管狭窄症患者术后疗效及颈椎矢状位参数的影响

目的探讨前路椎体次全切除术和后路椎管扩大椎板成形术对脊髓型颈椎病(CSM)合并椎管狭窄症患者术后疗效及颈椎矢状位参数的影响。方法回顾性分析2010年3月—2015年8月收治的147例CSM合并椎管狭窄症患者的临床资料,其中80例行前路椎体次全切除术治疗(A组),67例行后路椎管扩大椎板成形术治疗(B组)。比较2种手术方法治疗前后日本骨科学会(JOA)评分、Cobb角及矢状位垂直距离(SVA)。将2组患者根据T_1倾斜角分别分为高T_1倾斜角(≥25°)亚组和低T_1倾斜角( 25°)亚组,对不同亚组之间的疗效及手术安全性进行比较。结果 2组术后JOA评分和Cobb角均高于术前,差异有统计学意义(P 0.05)。A组术后SVA低于术前,差异有统计学意义(P 0.05),B组术后SVA与术前相比差异无统计学意义(P 0.05)。A组术后JOA评分和Cobb角均高于B组,SVA低于B组,差异均有统计学意义(P 0.05)。A组中,高T_1倾斜角亚组和低T_1倾斜角亚组JOA评分改善效果和后凸畸形发生率比较差异无统计学意义(P 0.05);B组中,低T_1倾斜角亚组JOA评分改善效果和后凸畸形发生率优于高T_1倾斜角亚组,差异均有统计学意义(P 0.05)。结论相较于后路椎管扩大椎板成形术,前路椎体次全切除术治疗CSM合并椎管狭窄症临床疗效更佳,且有助于改善颈椎矢状位平衡;在高T_1倾斜角水平下,应尽可能选择前路椎体次全切除术。     

Étude exploratoire de la santé musculo-squelettique du rachis d’étudiants en ostéopathie

BackgroundDuring their training, students in osteopathy regularly undergo spinal manipulation exercises. This exposes the students’ spine to unskilled gestures performed by their colleagues learning spinal manipulation. Discomfort, muscle soreness or moderate pain following spinal manipulations lasting two or three days are commonly reported. In addition, some students may have ongoing spinal musculoskeletal disease (SMSD) during their studies. The purpose of this study was to evaluate the prevalence of SMSDs and their maximum intensity in a population of osteopathy students and to determine whether individual differences exist.MethodAn exploratory cross-sectional study took place over three years. Data were collected by means of a self-administrated standardised questionnaire screening for MSD: the Nordic questionnaire.ResultsThere were 733 exploitable questionnaires, giving an average response rate of 91.5%. Average prevalence of SMSD was 98.4% during the last 12 months. Average maximum intensity perceived was 6/10 and 45% of students experienced an intense SMSD (scored between 7 and 10/10). Variation of the maximum intensity of SMSD between “before osteopathy studies” and “the last 12 months” was 1.2/10. This variation was influenced by the number of days students were manipulated during a week (p < 0.0001). On average, students underwent manipulation three days a week.ConclusionThis study confirms the important prevalence of SMSD among osteopathy students. This result led us to carry out a qualitative study for exploring students’ conceptions in health and spinal manipulative practices.