内侧间室膝骨性关节的下肢关节生物力学变化

目的：了解内侧间室膝骨性关节炎患者与正常人群在行走过程中的下肢生物力学参数的差异,以便准确客观的对患者下肢功能进行评定。方法：通过三维步态分析系统和测力板分别对正常人群（正常组）25例和内侧间室膝骨性关节炎患者（患病组）25例进行时间空间以及髋、膝、踝关节的运动学和动力学参数采集,并进行比较。结果：与正常组比较,患病组在行走过程中的最大膝关节曲,踝关节跖/背屈,髋关节曲/伸角度以及关节活动范围均明显降低,髋关节内收力矩明显减小,膝关节内收力矩明显增加（均P〈0.05）。结论：内侧间室膝骨性关节炎患者下肢关节生物力学发生变化,步行过程中的膝关节所受的压力明显高于正常人群,为其康复评定及治疗提供客观评价依据。     

全膝关节置换后三维步态分析:病例-对照的随访观察

背景：长期以来，针对步行运动中神经肌肉骨骼系统与运动功能客观精确的评估方式较缺乏。三维步态分析技术可将骨科和康复治疗中沿用已久的定性分析和直观描述转换为客观、精确的定量评定。 目的：基于三维步态分析，以12个月的随访资料为背景，评价全膝关节置换后患者步态模式改变。 设计、时间及地点：前后对比，病例一对照，随访观察于2007—01／2008—05在上海第六人民医院康复医学科步态分析室完成。 对象：选取单侧膝关节骨性关节炎行全膝关节置换的患者10例纳入治疗组，同时选择基线资料比之匹配的无神经、肌肉、骨骼系统及平衡问题者10例为对照组。 方法：治疗组患者行康复训练，并于膝关节置换后3，6，12个月应用三维步态分析系统对时间-空间参数、膝关节运动学参数、膝关节力学参数进行测量，并与对照组进行对比。 主要观察指标：时间一空间参数，膝关节运动学参数，膝关节力学参数，膝关节功能评分。 结果：治疗组步幅、步频、步速、患侧单腿支撑时间均较对照组明显减低；健侧单腿支撑时间、步态周期持续时间较对照组明显延长（P〈0．05）。治疗组支撑相最大伸膝、足尖离地屈膝及摆动相最大屈膝角度均较对照组明显减小（P〈0．05）。治疗组第1次、第2次外部伸膝力矩以及第1次最大膝内收力矩峰值均较对照组明显下降（P〈0．01）。 结论：行关节置换患者步态模式以步速减慢并伴有步幅减小、负重反应期及摆动相屈膝角度减小为主要特征，步态参数未达到正常人群标准。     

以屈膝肌群训练为主的康复训练对膝骨性关节炎的疗效

目的：探讨针对膝关节屈肌群训练为主的综合康复治疗对膝骨性关节炎（KOA ）的临床效果。方法：KOA患者97例,分为屈膝组33例、伸膝组33例和药物组31例。屈膝组、伸膝组均给予肌力训练、针刺、中频等综合康复治疗,屈膝组治疗以屈膝肌群部位为主,伸膝组治疗以伸膝肌群部位为主;药物组给予双氯酚钠缓释片口服及双氯酚酸二乙胺乳胶剂外用。结果：治疗1个疗程后,3组患者西部安大略湖与麦克马斯特骨性关节炎指数（W O M-AC）中3项评分、体征检查及综合评价评分均较治疗前明显下降（P＜0．01）,且屈膝组与伸膝组评分均更低于药物组（P＜0．01,0．05）,屈膝组WOMAC中的疼痛、身体功能评分较伸膝组降低更显著（P＜0．05）。屈膝组、伸膝组总有效率均高于药物组（P＜0．05）,复发率低于药物组（P＜0．05）,屈膝组与伸膝组比较差异无统计学意义。结论：膝关节屈肌群在膝关节功能中有重要作用,在治疗时可给予一定程度重视,加强膝关节功能的整体性治疗。     

单侧小腿截肢患者穿假肢后的步态运动学参数研究

目的 采用计算机辅助康复环境(CAREN)步态评估系统分析单侧小腿截肢患者穿假肢后的步态运动学参数,并分析其产生差异的原因。 方法 选取单侧小腿中段截肢但均装配假肢的受试者9例设为假肢组,同期选择健全受试者11例设为标准组,通过CAREN步态评估系统对2组受试者的步态运动学参数进行收集、处理、分析,并根据分析报告阐明产生差异原因。 结果 假肢组步态时相性指数为(0.88±0.04),其假肢侧的步长、支撑期百分比、髋关节支撑期最大伸展角度、膝关节支撑期最大屈曲角度、踝关节足跟着地背屈角度、踝关节支撑期最大背屈角度、踝关节支撑期最大跖屈角度与健侧比较,差异均有统计学意义(P<0.05）。假肢组假肢侧的步行速度、步态周期、跨步长、支撑期百分比、髋关节足跟落地屈髋角度、髋关节支撑期最大伸展角度、髋关节支撑期最大屈曲角度、膝关节足跟着地屈膝角度、踝关节足跟着地背屈角度、踝关节支撑期最大跖屈角度、踝关节支撑期最大背屈角度与标准组双侧均值比较,差异均有统计学意义(P<0.05）。 结论 单侧小腿截肢者穿戴假肢后步态时相对称性为（0.88±0.04）,假肢侧踝关节运动学参数显著弱于自身健侧,其时空与运动学参数也显著弱于健全人。     

综合康复治疗膝关节骨性关节炎的疗效观察

目的：观察综合康复治疗膝关节骨性关节炎（KOA）的疗效。方法：KOA患者48例随机分为观察组和对照组各24例,2组均给予负压动态干扰电疗法和中西药物治疗,观察组在此基础上增加放射状冲击波治疗。结果：治疗30d后,2组膝关节损伤患者疗效评分均较治疗前明显提高（P〈0.05）;且观察组更高于对照组（P〈0.05）;治疗后2组膝关节分级疗效及关节积液疗效比较,观察组总有效率均更高于对照组（P〈0.05）。结论：综合康复治疗KOA配合中西药物对膝关节疼痛和活动度具有显著的疗效。     

基于经筋理论的理筋手法治疗膝骨性关节炎的疗效观察

目的 观察理筋手法对膝骨性关节炎（KOA）患者关节疼痛、活动功能及步态的影响。 方法 采用随机数字表法将61例KOA患者分为观察组（31例）及对照组（30例）。2组患者均给予超声波理疗及运动训练（包括股四头肌训练及提踵训练）,观察组患者在此基础上辅以理筋手法治疗。2组患者均每天治疗1次,每周治疗5 d,连续治疗3周。于治疗前、治疗3周后分别采用视觉模拟评分法（VAS）、西安大略和麦克马斯特大学(WOMAC)骨关节炎指数量表及三维步态分析设备对2组患者膝关节疼痛、运动功能及步态时空参数（如步长、步速、双支撑相占比）进行评测。 结果 与治疗前比较,治疗后2组患者疼痛VAS评分、WOMAC量表关节疼痛、僵硬、功能障碍维度评分及总分均明显降低（P＜0.05）;观察组步长、步速及双支撑相占比均明显改善（P＜0.05）,对照组仅有步速、双支撑相占比明显改善（P＜0.05）。通过组间对比发现,治疗后观察组患者疼痛VAS评分、WOMAC量表各维度评分、总分及步态时空参数（如步长、步速、双支撑相占比）均显著优于同期对照组水平（P＜0.05）。 结论 在常规康复干预基础上辅以理筋手法能进一步缓解KOA患者疼痛,减轻膝关节功能障碍程度,提高步行效率,从而改善患者生活质量。     

脑卒中偏瘫患者膝过伸步态运动学特点分析

目的:探讨脑卒中偏瘫患者膝过伸步态的三维运动学特点及其与步行速度的相关性,从运动学角度探讨影响膝过伸患者步行速度的主要因素。方法:利用三维步态分析系统对15例伴有膝过伸步态的脑卒中偏瘫患者和15例健康老年人进行运动学定量比较,并将其与步行速度进行相关性分析。结果:与正常对照组相比,膝过伸患者的步长、步频减小,步速减慢,支撑期百分比延长(均P0.05);膝过伸患者髋、膝、踝关节活动范围减小,最大伸髋、屈膝、踝背屈角度减小,最大伸膝角度增加(均P0.05)。步行速度与步频、支撑相百分比、膝踝关节活动范围、最大屈膝角度和最大踝跖屈角度均相关(均P0.05)。结论:脑卒中偏瘫膝过伸患者下肢关节活动不同程度受限,步行速度下降,其中屈膝和踝跖屈异常是影响膝过伸患者步行速度的主要因素。     

老年双膝骨性关节炎患者膝关节屈伸肌力与静态平衡的变化特征

目的探讨老年双膝骨性关节炎（KOA）患者膝关节屈伸肌力与静态平衡功能的变化特征。方法采用等速肌力测试仪和静态平衡测定仪对59例老年KOA患者（KOA组）和50例非KOA患者（对照组）进行膝关节肌力和静态平衡功能定量测定。结果与对照组比较,在低速向心模式下,KOA组屈伸肌群的峰力矩、总功、平均功率、力矩加速能均降低（P〈0.05）,而腘绳肌与股四头肌峰力矩比值升高（P〈0.05）;在闭眼模式下与对照组相比,KOA组轨迹长度、轨迹面积、单位面积轨迹长均显著升高（P〈0.01）;在KOA组,与睁眼模式相比,闭眼模式下轨迹长度、轨迹面积、单位面积轨迹长均明显升高（P〈0.05）;KOA组腘绳肌与股四头肌峰力矩比和单位面积轨迹长升高有较显著的相关关系（P〈0.01）。结论KOA患者膝屈伸肌群肌力下降,静态平衡功能也随之下降,其中屈伸肌力不同步性降低影响尤为明显。     

双膝骨性关节炎患者步态特征的研究

目的:比较双侧膝骨性关节炎(knee osteoarthritis,KOA)患者与健康成年人步态特征的差异。方法:应用现代步态测试系统对双侧KOA患者及健康成年人(各50例)进行步态检测,比较并分析受试者足底各区域受力时间参数、步角、单足支撑时间。结果:双侧KOA患者足底受力时间百分比M1值明显低于健康成年人,而M2、M3值则明显高于健康成年人(均P0.05);双侧KOA患者与健康成年人步角差异无统计学意义(P0.05);双侧KOA患者单足支撑时间明显大于健康成年人(P0.05)。结论:双侧KOA患者与健康成年人的步态特征存在差异。     

膝骨关节炎患者步态中膝关节三维运动特征

目的:观察中老年膝关节骨关节炎(KOA)患者步态中膝关节的三维运动特征,为膝关节骨关节炎患者设计康复训练提供研究依据.方法:纳入符合标准的KOA患者29例为观察组;15例无KOA者纳入对照组.2组的年龄、身高、体重和身体质量指数(BMI)相匹配.2组受试者均使用KneeKG系统进行测量,对比自重状态下步行时两组受试者膝...     

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.     

Clinical Pharmacokinetics of Morphine

Morphine, the most widely used mu-opioid analgesic for acute and chronic pain, is the standard against which new analgesics are measured. A thorough understanding of the pharmacokinetics of morphine is required in order to safely and effectively use this analgesic in a wide variety of patients with different levels of organ function. A MEDLINE search was conducted to identify literature published between 1966 and January 2002 relevant to the pharmacokinetics of morphine. These publications were reviewed and the literature summarized regarding unique and clinically important elements of morphine disposition relative to its parenteral administration (including intravenous, intramuscular, subcutaneous, epidural and intrathecal administration), absorption profile (immediate release, controlled release, and sublingual/buccal, and rectal administration), distribution, and its metabolism/ excretion. Special populations, including infants, elderly, and those with renal/liver failure, have a unique morphine pharmacokinetic profile that must be taken into account in order to maximize analgesic efficacy and reduce the risk of adverse events.     

手转胎头术失败的原因与分娩结局临床分析

目的 探讨手转胎头术失败的原因与分娩结局.方法 选择2008年1月至2010年12月于我院住院分娩的持续性枕横位、枕后位产妇198例,根据行手转胎头术后结果分为成功组126例、失败组72例.比较两组分娩结局,对比分析失败原因.结果 失败组胎儿体质量≥3500 g的发生率[76.4％(55/72)]明显高于成功组[31.7％(40/126)],差异有统计学意义(x2=30.177,P=0.001)、失败组宫缩乏力发生率[58.3％(42/72)]高于成功组[38.1％ (48/126)],差异有统计学意义(x2=7.569,P=0.006)、失败组骨盆临界或轻度狭窄发生率[38.9％ (28/72)]高于成功组[23.8％(30/126)],差异有统计学意义(x2 =5.030,P=0.002)、失败组手转胎头时机不当(宫口开大＜6 cm、胎头位于坐骨棘上及宫口开大8～10 cm、胎头位于坐骨棘下≥2 cm)发生率[61.1％(44/72)]高于成功组[38.9％(49/126)],差异有统计学意义(x2=9.084,P=0.003).失败组母儿并发症(产后出血、产褥病率、胎儿窘迫、新生儿窒息)发生率高于成功组(x2 =9.586,P=0.002、x2=9.334,P=0.002、x2=5.910,P=0.015、x2=5.240,P=0.022)、失败组剖宫产发生率[72.2％(52/72)]明显高于成功组[34.1 ％(43/126),x2=26.641,P=0.001)].结论 手转胎头术能使难产变顺产,降低剖宫产率,减少母儿并发症,但须积极预防、处理导致手转胎头术失败的原因,对矫正失败后继续矫正及试产应慎重.     

Evidence-Based Pain Management and Palliative Care in Issue Four for 2009 of The Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly. Issue 4 for 2009 contains 4027 complete reviews, 1906 protocols for reviews in production, and 11447 one-page summaries of systematic reviews published in the general medical literature. In addition, there are citations of 600,000 randomized controlled trials, and 12,200 cited papers in the Cochrane methodology register. The health technology assessment database contains over 7500 citations. This edition of the Library contains 90 new reviews, of which 19 have potential relevance for practitioners in pain and palliative medicine.     

Wie zuverlässig sind Angaben zu nichtentzündlichen ausgedehnten Schmerzen?

ZusammenfassungFragestellung Es wurde geprüft, wie sich der Differenziertheitsgrad zweier Schmerzmessmethoden auf Angaben zur Ausgedehntheit klinischer Schmerzen auswirkt. Zugleich wurde der Referenzzeitraum variiert, über den die Patienten berichten sollten.Methode Erfasst wurde der Einfluss zu Lasten der Befragungsdifferenziertheit durch den Vergleich zweier Körperschema-Bildvorlagen. Drei Referenzzeiträume (Schmerz aktuell, letzte Woche, letztes halbes Jahr) wurden vorgegeben.Ergebnisse Patienten mit ausgedehnten Schmerzen gaben bei differenzierter Befragung um so mehr Schmerzen an, je weiter die Schmerzen zurück lagen und je größer der Berichtszeitraum war. Patienten mit gelenknahen Schmerzen gaben bei hoch differenzierter Befragung weniger ausgedehnte Schmerzen in der Vergangenheit an als bei globaler Einschätzung. Patienten mit Rückenschmerzen berichteten bei differenzierter Befragung zum aktuellen Schmerz über weniger ausgedehnte Schmerzen als bei globaler Befragung.Schlussfolgerung Die Angaben zur Schmerzausdehnung variieren vor allem bei Patienten mit ausgedehnten Schmerzen in Abhängigkeit von der Differenziertheit der Befragung. In diesen Fällen ist die Wahrscheinlichkeit erhöht, dass sich die Beschwerdesymptomatik zumindest teilweise erst in der Reaktion auf die situativen Befragungsbedingungen konstituiert und daher nicht auf andere Befragungsbedingungen generalisiert werden kann.