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1.

Background

Stroke is a primary cause of death and disability in upper-middle–income countries such as Colombia. Given the lack of comprehensive rehabilitation for stroke patients in Colombia, there is a need to assess longitudinal mental health problems poststroke in this region.

Objective

To compare the course of mental health in stroke patients to healthy controls over the first year poststroke in Ibague, Colombia.

Design

Cross-sectional study.

Setting

The Psychological Attention Center of Antonio Nariño University in Ibague, Colombia.

Participants

Stroke patients (n = 50) and age- and gender-matched healthy controls (n = 50).

Methods

Patients and controls completed self-report Spanish versions of demographic information, injury-related characteristics, and mental health questionnaires

Main Outcome Measurements

Outcomes assessed included mental health (depression, anxiety, and stress) at 3, 6, and 12 months poststroke.

Results

Hierarchical linear models suggested that stroke patients had worse depression and anxiety over time than controls (P < .001). Among patients, depression and anxiety decreased over time (P < .001), whereas stress increased over time (P < .01). The findings suggest that although anxiety and depression improved over time in stroke patients, their mental health remained significantly lower than that of controls.

Conclusions

This is the first study to examine the course of mental health over the first year poststroke in Latin America, specifically in Ibague, Colombia. Despite the improvements in anxiety and depression over the first year poststroke, patient anxiety and depression were still worse in comparison to those in healthy controls. The current findings indicate a need for rehabilitation services in Colombia, especially targeting mental health issues.

Level of Evidence

I  相似文献   

2.

Background

Ideally, high-stakes examinations assess 1 dimension of medical knowledge to produce precise estimates of a candidate’s performance. It has not been reported whether the American Board of Physical Medicine and Rehabilitation Part 1 Certification Examination (ABPMR-CE-1) is unidimensional or not.

Objective

To examine the ABPMR-CE-1 to measure how many dimensions it assesses.

Design

Retrospective observational study.

Setting

We assessed examination results from the 2015 ABPMR-CE-1.

Participants

A total of 489 deidentified candidates taking the 2015 ABPMR-CE-1.

Methods

A 1-parameter Item Response Theory (IRT) measurement model was utilized. A Principal Components Analysis (PCA) of standardized residual correlations was used to detect multidimensionality.

Main Outcome Measure

Number of primary dimensions reflected in the 325 test questions.

Results

The results of the dimensionality analysis indicated that the ABPMR-CE-1 examination is highly unidimensional from a psychometric perspective. Expert content review of the substantive content of small contrasting clusters of questions provided additional assurance of the unidimensional nature of the examination.

Conclusions

The ABPMR-CE-1 appears indeed to measure a single construct, which suggests a sound structure of the examination. It closely approximates the assumption of statistical unidimensionality.

Level of Evidence

Not applicable.  相似文献   

3.

Background

A significant proportion of burn injury patients are admitted to inpatient rehabilitation facilities (IRFs). There is increasing interest in the use of functional variables, such as cognition, in predicting IRF outcomes. Cognitive impairment is an important cause of disability in the burn injury population, yet its relationship to IRF outcomes has not been studied.

Objective

To assess how cognitive function affects rehabilitation outcomes in the burn injury population.

Design

Retrospective study.

Setting

Inpatient rehabilitation facilities in the United States.

Participants

A total of 5347 adults admitted to an IRF with burn injury between 2002 and 2011.

Methods or Interventions

Multivariable regression was used to model rehabilitation outcome measures, using the cognitive domain of the Functional Independence Measure (FIM) instrument as the independent variable and controlling for demographic, medical, and facility covariates.

Main Outcome Measurements

FIM total gain, readmission to an acute care setting at any time during inpatient rehabilitation, readmission to an acute care setting in the first 3 days of IRF admission, rate of discharge to the community setting, and length of stay efficiency.

Results

Cognitive FIM total at admission was a significant predictor of FIM total gain, length of stay efficiency, and acute readmission at 3 days (P < .05). Cognitive FIM total scores did not have an impact on acute care readmission rate or discharge to the community setting.

Conclusions

Cognitive status may be an important predictor of rehabilitation outcomes in the burn injury population. Future work is needed to further examine the impact of specific cognitive interventions on rehabilitation outcomes in this population.

Level of Evidence

II  相似文献   

4.

Background

Epistaxis is a common emergency department (ED) complaint; however, this entity is rare among children younger than 2 years of age. In this age group, epistaxis may be a presenting sign of a bleeding disorder or nonaccidental trauma.

Case Report

We present a case of a 2-month-old infant who was evaluated in the pediatric ED for epistaxis and discharged home. The infant returned 2 days later with facial swelling and irritability, and was found to have significant head trauma. In this article we review the epidemiology and differential diagnoses for epistaxis among infants, as well as the initial approach to the evaluation of this uncommon clinical entity in this age group.

Why Should an Emergency Physician Be Aware of This?

Potential etiologies for epistaxis among infants and young children include severe systemic disease and nonaccidental trauma. Given its rarity and possible clinical significance, the approach to epistaxis differs in this age group. Emergency physicians should screen for and exclude a bleeding disorder while also having a very low threshold for a nonaccidental trauma evaluation.  相似文献   

5.

Background

Thoracic injuries are a major cause of death associated with blunt trauma in children. Screening for injury with chest x-ray study, compared with chest computed tomography (CT) scan, has been controversial, weighing the benefits of specificity with the detriment of radiation exposure.

Objective

To identify predictors of thoracic injury in children presenting as trauma activations to a Level I trauma center after blunt torso trauma, and to compare these predictors with those previously reported in the literature.

Methods

We performed a retrospective chart review of pediatric patients (<18 years of age) who presented to the Emergency Department of a Level I trauma center between June 2010 and June 2013 as a trauma activation after sustaining a blunt torso trauma and who received diagnostic imaging of the chest as part of their initial evaluation.

Results

Data analysis was performed on 166 patients. There were 33 patients (20%) with 45 abnormalities detected on diagnostic imaging of the chest, with the most common abnormalities being lung contusion (36%), pneumothorax (22%), and rib fracture (13%). Statistically significant predictors of abnormal diagnostic imaging of the chest included Glasgow Coma Scale score (GCS) < 15 (27% with abnormality vs. 13% without abnormality), hypoxia (22% vs. 5%), syncope/loss of consciousness (55% vs. 35%), cervical spine tenderness (12% vs. 3%), thoraco-lumbar-sacral spine tenderness (41% vs. 17%), and abdominal/pelvic tenderness (12% vs. 3%).

Conclusions

Based on our data, predictors of thoracic injury in children after blunt torso trauma include GCS < 15, hypoxia, syncope/dizziness, cervical spine tenderness, thoraco-lumbar-sacral spine tenderness, and abdominal/pelvic tenderness.  相似文献   

6.

Background

Left ventricular assist devices (LVADs) have become an increasingly popular and effective means for treating advanced heart failure. LVAD implantation requires extensive surgery and postoperative rehabilitation. The Functional Independence Measure (FIM) has been used to quantify functional gains in numerous patient populations, including those with stroke and spinal cord injury. This study investigated functional improvements in patients undergoing LVAD implantation using the FIM score.

Objective

To assess functional improvements in patients with advanced heart failure who underwent LVAD implantation.

Design

Retrospective.

Setting

Inpatient rehabilitation unit.

Subjects

Ninety consecutive patients who received acute inpatient rehabilitation after continuous flow LVAD implantation.

Methods

Demographic, laboratory, and functional outcomes data including inpatient rehabilitation unit (IRU) length of stay (LOS), discharge disposition, and FIM score were collected for all patients. Paired t-tests were used to assess change in functional measures and laboratory data.

Main Outcome Measures

Primary outcome measures included FIM gain, FIM efficiency, discharge disposition, rates of readmission after discharge from rehabilitation, and LOS in the rehabilitation unit.

Results

The FIM gain was statistically significant at 28.4 ± 12.3 (P < .001) and compared favorably with benchmarks for mean FIM gains at our facility (26.4), regionally (21.5), and nationally (22.7) for patients admitted to IRUs with a cardiac diagnosis. FIM efficiency (FIM gain/IRU LOS) was 1.9 ± 1.0 compared with the mean FIM efficiency at our facility (2.2), regionally (2.1), and nationally (2.2). Seventy-four percent (n = 67) of patients were discharged directly home after inpatient rehabilitation, 17% (n = 16) were readmitted to the acute hospital service, and 8% (n = 7) required additional rehabilitation at a subacute rehabilitation facility. The IRU LOS was 16.2 ± 6.9 days.

Conclusions

Our study indicates that most patients with an LVAD achieve clinically meaningful functional gains from acute inpatient rehabilitation, with the majority of patients being discharged home. Further studies need to be performed to analyze clinical outcomes after acute inpatient rehabilitation.

Level of Evidence

IV  相似文献   

7.

Background

The oculocardiac reflex is a decrease in heart rate caused by ocular compression or traction upon the extraocular musculature. Multiple instances of this phenomenon have been described in anesthesia, trauma, craniofacial, and ophthalmology literature, but there is a sparsity of documentation in the emergency medicine literature.

Case Report

We describe the observation and management of the oculocardiac reflex in a 26-year-old man with retrobulbar hematoma and intraocular trauma caused by a self-inflicted gunshot wound.

Why Should an Emergency Physician Be Aware of This?

Prompt recognition of the oculocardiac reflex is important for the emergency physician given the common occurrence of craniofacial trauma and the potentially devastating consequences if not recognized and addressed.  相似文献   

8.

Background

Impaired postural stability places individuals with Parkinson's disease (PD) at an increased risk for falls.

Objective

We evaluated the effectiveness of 10 vs. 15 sessions of Nintendo Wii Fit for balance recovery for outpatients PD.

Methods

Twenty-seven patients, 48.1% female (66 ± 8 years), with PD. Patients with PD were consecutively assigned to one of two groups receiving either 10 or 15 sessions (low dose or high dose group, respectively) with Nintendo Wii Fit in recovering balancing ability. All outcome measures were collected at baseline, immediately following the intervention period, and 1-month following the end of the intervention. Main outcome measure: Falls risk test (FRT), Stability index (PST), Berg balance scale (BBS) and Tinetti scale.

Results

The patients undergoing the 10 sessions demonstrated significantly improvement on the balance performances (Tinetti balance and gait scales, BBS and BSF) (all, P < 0.05) as those undergoing 15 treatment with Nintendo Wii Fit, but no significant group effect or group-by-time interaction was detected for any of them, which suggests that both groups improved in the same way.

Conclusions

The results suggest that functional improvement can be made in fewer visits during outpatient rehabilitation sessions with Nintendo Wii Fit improving the efficiency of intervention.  相似文献   

9.

Background

Although subcutaneous emphysema resulting from maxillofacial surgery is well described in the literature, the association with maxillofacial trauma is less firm. Clinically evident subcutaneous emphysema from facial injury is uncommon and extension into the cervical and mediastinal tissues is exceedingly rare, with few reported cases.

Case Report

An unusual case of extensive subcutaneous emphysema after facial trauma is presented. The case posed a diagnostic dilemma in our emergency department.

Why Should Emergency Physicians Be Aware of This?

Facial fractures are a rare but important cause of surgical emphysema. Emergency physicians need to be aware of the diagnostic possibility and the need to avoid factors that may precipitate secondary injury.  相似文献   

10.

Background

Serious isolated laryngeal injuries are uncommon in children.

Case Report

We describe the case of an 8-year-old boy with laryngeal injury and pneumomediastinum due to minor blunt neck trauma. He presented to the emergency department complaining of odynophagia and hoarseness, but without respiratory distress. Emphysema was seen between the trachea and vertebral body on initial cervical spine x-ray study, and flexible laryngoscopy revealed erythema and mild edema of both the right vocal cord and the arytenoid region. He recovered with conservative management only.

Why Should an Emergency Physician Be Aware of This?

We conclude that it is important to recognize subtle evidence of laryngeal injury secondary to blunt neck trauma to ensure early diagnosis. Initial cervical spine x-ray assessment should exclude both cervical spine fracture and local emphysema after blunt neck trauma. If patients with blunt neck trauma have evidence of a pneumomediastinum, the clinician should consider the possibility of aerodigestive injury.  相似文献   

11.

Background

Spilled gallstones are common during laparoscopic cholecystectomy; however, they rarely lead to postoperative complications. Perihepatic abscesses develop in < 0.1% of patients with spilled gallstones and are typically contained within the peritoneal cavity.

Case Report

We present a 57-year-old man with history of cholecystectomy 2 years prior who presented with cough and flank pain and was discovered to have a perihepatic abscess invading his lung and kidney secondary to a spilled gallstone.

Why Should Emergency Physicians Be Aware of This?

Although most perihepatic abscesses can be treated with percutaneous drainage and antibiotics, abscesses secondary to spilled gallstones usually require open or laparoscopic surgery to drain the abscess and retrieve the gallstone. Prompt identification of spilled gallstones in patients with intra-abdominal and intrathoracic abscesses can thereby guide disposition and decrease morbidity and mortality.  相似文献   

12.

Background

Theoretically, patients with only one functional arm secondary to contralateral amputation or paralysis will subject their only functional upper extremity to increased loads. This could become an issue after reverse shoulder arthroplasty (RSA). However, there are no reported data on the implant survival or function for patients with a nonfunctional contralateral upper extremity.

Objective

To report the outcomes of RSA in patients with contralateral upper extremity amputation or paralysis.

Design

Retrospective case series.

Setting

Tertiary university hospital.

Patients

All patients who underwent RSA between January 2004 and December 2013.

Methods

Of 1335 RSA procedures performed, 5 patients had a minimum 2-year follow-up and nonfunctional contralateral upper extremity. There were 3 men and 2 women, with a mean (standard deviation) age and length of follow-up of 72.4 (7.5) years and 56.4 (24-132) months. Two of the patients had a contralateral upper extremity amputation, and the other 3 had contralateral upper extremity paralysis as a result of stroke, traumatic brain injury, and traumatic brachial plexus injury at birth.

Main Outcomes

Pain, range of motion, functional scores (Simple Shoulder Test, American Shoulder and Elbow Society and Quick-Disability of the Arm, Shoulder and Hand), satisfaction, complications/reoperations, and radiographic loosening.

Results

RSA resulted in substantial improvement in pain (P = .008), forward flexion (P = .02), and external range of motion (P = .01). The mean (standard deviation) Simple Shoulder Test, American Shoulder and Elbow Society, and Quick-Disability of the Arm, Shoulder, and Hand scores were 9.8 (1.3), 82 (13), and 17.8 (13.4), respectively. The results were excellent in 3, satisfactory in 1, and unsatisfactory in 1 patient (due only to external rotation limited to 10°). Subjectively, all 5 patients felt greatly improved and stated they would undergo RSA again. There were no complications or reoperations. There were no shoulders with component loosening.

Conclusions

RSA seems to be a safe, effective, and successful surgical procedure for patients with a nonfunctional contralateral upper extremity. Studies with larger sample sizes and longer follow-up will hopefully validate the present findings.

Level of Evidence

IV  相似文献   

13.

Background

Pyogenic liver abscesses have become common in emergency departments (EDs) in recent years in Shanghai, China due to a variety of risk factors contributory to the disease.

Objective

To review our experience in managing pyogenic liver abscesses to aid in the current management of this complex condition.

Methods

This retrospective study was conducted to collect and analyze information from adult patients diagnosed with liver hepatic abscesses who were admitted to Ren Ji Hospital during the period from January 1, 2010 to December 31, 2015. The demographic data, etiology, underlying diseases, clinical presentation, imaging features, laboratory examinations, microbiological tests, treatment, and clinical outcomes were analyzed.

Results

The data of a total 105 patients were retrospectively analyzed. The mean age of the patients was 62.0 ± 13.5 years. The etiology was predominantly hepatobiliary disease (43/105, 40.1%) or diabetes mellitus (42/105, 40.0%). During hospitalization, 12 patients (11.4%) with septic shock required intensive care. One patient died, yielding a 0.9% fatality rate. In addition to empiric antimicrobial therapy, 66/105 (62.9%) patients underwent ultrasound-guided percutaneous drainage of the liver abscess at diagnosis. Only 3 patients required surgical intervention. Bacterial culture of pyogenic fluids revealed 25 positive results of 66 cases (37.9%). Among them, Klebsiella pneumoniae was the primary pathogen detected in 15 cases (60.0%).

Conclusions

Pyogenic liver abscesses have become common in EDs in Shanghai, China. The early recognition of the disease, prompt use of empirical antimicrobial therapy, initiation of drainage in the appropriate patients, and controlling the underlying conditions were crucial for preventing severe sepsis and improving the outcome.  相似文献   

14.

Background

Lower rib fractures are considered as a marker of intra-abdominal organ injury. Abdominal computed tomography (CT) is the “gold standard” examination for patients with lower rib fractures. However, the reported incidence of concomitant intra-abdominal injuries (IAI) is 20%–40%.

Objective

The purpose of this study was to evaluate the incidence of intra-abdominal organ injuries in blunt trauma patients with lower rib fractures.

Methods

Medical charts and radiology reports of patients with lower rib (from the 8th to 12th rib) fractures admitted to our center during a 6-year period were retrospectively reviewed. Patients were divided into two groups. Group I included patients with intra-abdominal injury (IAI) diagnosed either by CT or on urgent laparotomy, and Group II included those with normal abdominal CT scans. Data included demographics, mechanism of injury, laboratory tests, radiology results including number and location of fractured ribs, and incidence of IAI.

Results

Overall 318 patients were included in the study. Fifty-seven patients (17.9%) had 71 IAIs compared with 265 (82.1%) patients with no IAI. Logistic regression identified age younger than 55 years (relative risk [RR] = 7.2; 95% confidence interval [CI] 3.1–16.8; p = 0.001), bilateral rib fractures (RR = 3.9; 95% CI 1.1–13.5; p = 0.03) and decreased levels of hematocrit (RR = 2.4; 95% CI 1.2–4.8; p = 0.016) as independent risk factors for the presence of IAI.

Conclusions

Abdominal CT should be considered in blunt trauma patients with lower rib fractures who are younger than 55 years of age and have bilateral rib fractures and decreased levels of hematocrit on admission.  相似文献   

15.
16.

Background

Pediatric foreign-body ingestions are commonly managed by emergency physicians. Risk assessment and specific intervention are dependent on the nature and location of the foreign body. Radiographic evaluation is usually necessary to help define the clinical situation.

Case Report

We present an interesting case of presumed ingestion of several disk batteries by a toddler with an unexpected outcome, reviewing aspects of this clinical problem and highlighting potential pitfalls in medical decision making.

Why Should an Emergency Physician Be Aware of This?

Pediatric foreign-body ingestions are commonly managed in the emergency department, and timely and accurate intervention is dependent on correct defining and localization of the foreign body. This case illustrates potential pitfalls in this evaluation.  相似文献   

17.

Objective

To assess the effectiveness of bracing in adult with scoliosis.

Design

Retrospective cohort study.

Setting

Outpatients followed in 2 tertiary care hospitals.

Participants

Adults (N=38) with nonoperated progressive idiopathic or degenerative scoliosis treated by custom-molded lumbar-sacral orthoses, with a minimum follow-up time of 10 years before bracing and 5 years after bracing. Progression was defined as a variation in Cobb angle ≥10° between the first and the last radiograph before bracing. The brace was prescribed to be worn for a minimum of 6h/d.

Interventions

Not applicable.

Main Outcome Measure

Rate of progression of the Cobb angle before and after bracing measured on upright 3-ft full-spine radiographs.

Results

At the moment of bracing, the mean age was 61.3±8.2 years, and the mean Cobb angle was 49.6°±17.7°. The mean follow-up time was 22.0±11.1 years before bracing and 8.7±3.3 years after bracing. For both types of scoliosis, the rate of progression decreased from 1.28°±.79°/y before to .21°±.43°/y after bracing (P<.0001). For degenerative and idiopathic scoliosis, it dropped from 1.47°±.83°/y before to .24°±.43°/y after bracing (P<.0001) and .70°±.06°/y before to .24°±.43°/y after bracing (P=.03), respectively.

Conclusions

For the first time, to our knowledge, this study suggests that underarm bracing may be effective in slowing down the rate of progression in adult scoliosis. Further prospective studies are needed to confirm these results.  相似文献   

18.

Background

Emergency Department (ED) overcrowding mainly due to the lack of access to inpatient beds negatively affects safety and quality of care. Implementation of ED short-stay units (EDSSUs) may help to mitigate this situation.

Objectives

To describe the general characteristics and evaluate the activity of EDSSUs in Spanish hospitals.

Methods

This is a cross-sectional study. A questionnaire was sent to coordinators responsible for the EDSSUs identified among Spanish hospitals appearing on the Ministry of Health Web page. Data regarding structure, caseloads, and clinical management practices were collected.

Results

Among the 591 hospitals surveyed, 35 EDSSUs (5.9%) were identified and 23 participated in the study. Admissions to EDSSUs over different periods in 2011 were assessed: 12-month activity in 17 EDSSUs and between 5 and 10.5 months in six EDSSUs. A total of 25,568 patients with a mean age of 67.2 ± 9.8 years were admitted, representing between 6% and 16.3% of hospital admissions from the ED. The most frequent diagnoses were acute heart failure, chronic obstructive pulmonary disease exacerbation, and urinary and respiratory tract infections. The average length of stay (LOS) was 2.6 ± 1.1 days (range 1.2–5.3), in-hospital mortality 0.59% (range 0–2.68), and the 30-day readmission rate after discharge was 6.7% (range 0–14.6).

Conclusions

To date, only a few Spanish hospitals have implemented EDSSUs. Prevalent infections and exacerbation of chronic conditions are the most frequent causes for admission. Considering LOS, 30-day readmission rate and mortality, EDSSUs appear to be safe and effective and might be considered a tool to alleviate ED overcrowding.  相似文献   

19.

Objective

To determine relationships between pain sites and pain intensity/interference in people with lower limb amputations (LLAs).

Design

Cross-sectional survey.

Setting

Community.

Participants

Lower limb prosthesis users with unilateral or bilateral amputations (N=1296; mean time since amputation, 14.1y).

Interventions

Not applicable.

Main Outcome Measures

Patient-Reported Outcomes Measurement Information System (PROMIS) pain intensity (1 item to assess average pain), PROMIS pain interference (4-item short form to assess the consequences of pain in desired activities), and questions that asked participants to rate the extent to which each of the following were a problem: residual limb pain (RLP), phantom limb pain (PLP), knee pain on the nonamputated side, back pain, and shoulder pain.

Results

Nearly three quarters (72.1%) of participants reported problematic pain in 1 or more of the listed sites. Problematic PLP, back pain, and RLP were reported by 48.1%, 39.2%, and 35.1% of participants, respectively. Knee pain and shoulder pain were less commonly identified as problems (27.9% and 21.7%, respectively). Participants also reported significantly (P<.0001) higher pain interference (T-score ± SD, 54.7±9.0) than the normative sample based on the U.S. population (T-score ± SD, 50.0±10.0). Participants with LLAs rated their pain intensity on average ± SD at 3.3±2.4 on a 0-to-10 scale. Pain interference (ρ=.564, P<.0001) and intensity (ρ=.603, P<.0001) were positively and significantly correlated with number of pain sites reported.

Conclusions

Problematic pain symptoms, especially RLP, PLP, and back pain, affect most prosthetic limb users and have the potential to greatly restrict participation in life activities.  相似文献   

20.

Background

Vertigo is a debilitating disease that is commonly encountered in the emergency department (ED). Diazepam and meclizine are oral medications that are commonly used to alleviate symptoms.

Objectives

We sought to determine whether meclizine or diazepam is superior in the treatment of patients with peripheral vertigo in the ED.

Methods

We performed a double-blind clinical trial at a suburban, teaching ED. We randomized a convenience sample of adult patients with acute peripheral vertigo (APV) to diazepam 5 mg or meclizine 25 mg orally. Demographic and historical features were recorded on a standardized data form. Patients recorded their initial level (t0) of vertigo on a 100-mm visual analog scale (VAS) and after 30 min (t30) and 60 min (t60). The primary outcome parameter was the mean change in VAS score from t0 to t60. Differences between groups and 95% confidence intervals were calculated. Our a priori power calculation estimated that a sample size of 20 patients in each group was required to have an 80% power to detect a difference of 20 mm between treatment groups.

Results

There were 20 patients in the diazepam group and 20 in the meclizine group. The two groups were similar with respect to patient demographics and presenting signs and symptoms. At t60, the mean improvements in the diazepam and meclizine groups were 36 and 40, respectively (difference ?4; 95% confidence interval ?20 to 12; p = 0.60).

Conclusion

We found no difference between oral diazepam and oral meclizine for the treatment of ED patients with acute peripheral vertigo.  相似文献   

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