维持性血液透析患者人体成分分析评估营养状况

目的分析维持性血液透析(maintenance hemodialysis,MHD)患者人体成分,评估营养状况。方法选择MHD患者57例,应用人体成分分析仪(Body composition monitor,BCM)测量人体成分,检测患者透析前血清总胆固醇、三酰甘油、白蛋白、血红蛋白、血肌酐等生化指标,以体质量指数(body mass index,BMI)、单位体表面积脂肪含量、瘦组织含量的均值分组进行比较及相关分析。结果BMI高组(BMI≥21.68kg/m~2)与BMI低组(BMI21.68 kg/m~2)比较,前者单位面积脂肪组织含量较高(t=4.327,P0.001),BMI与单位面积脂肪含量呈正相关(r=0.588,P0.001)。2组单位面积瘦组织含量差异无统计学意义(t=0.892,P=0.376),BMI与单位面积瘦组织含量不存在直线相关(r=-0.109,P=0.419)。单位面积脂肪含量高组(≥12.29 kg/m~2)与单位面积脂肪含量低组(12.29 kg/m~2)比较,前者胆固醇(t=2.882,P=0.006)、三酰甘油(t=2.040,P=0.047)、血红蛋白(t=3.857,P0.001)均高于后者;单位面积脂肪含量与胆固醇(r=0.370,P=0.010)、三酰甘油(r=0.403,P=0.005)、血红蛋白(r=0.405,P=0.002)呈正相关。单位面积瘦组织含量高组(≥22.80 kg/m~2)与单位面积瘦组织含量低组(22.80 kg/m~2)比较,前者血肌酐(t=2.515,P=0.015)、血清白蛋白(t=2.189,P=0.033)均高于后者;单位面积瘦组织含量与血肌酐(r=0.416,P=0.001)、白蛋白(r=0.315,P=0.018)呈正相关。结论 BCM能简便、准确、无创地评估MHD患者人体成分,有效评估营养状况。     

慢性肾衰竭维持性血液透析患者血清瘦素水平及其意义

目的：探讨慢性肾衰竭维持性血液透析患者的血清瘦素水平及其与残余肾功能、人体构成和营养状况的关系.方法：分别采用放射免疫分析技术、生物电阻抗技术和常规生化方法测定68例慢性肾衰竭维持性血透患者的血清瘦素水平、残余肾功能、人体构成和营养相关指标.结果：慢性肾衰竭维持性血透患者血清瘦素水平显著高于对照组（P〈0.01）;瘦素水平与体重指数和脂肪百分比呈正相关,与去脂体重呈负相关（P均〈0.01）,与内生肌酐清除率、血清肌酐、尿素氮、白蛋白、胆固醇、血红蛋白相关性无统计学意义（P均〉0.05）.结论：慢性肾衰竭维持性血透患者存在高瘦素血症, 血清瘦素水平可以作为评价机体脂肪含量的营养指标,其在终末期慢性肾衰竭血透患者蛋白质营养不良中未发挥显著作用.     

人体成分分析仪评估干体重对维持性血透患者容量控制的影响

目的 探讨人体成分分析仪(BCM)评估干体重对维持性血液透析患者容量控制的影响。方法 选取在南昌大学第一附属医院血液净化中心进行血液透析患者255例。采用自身对照,分别采取传统方式与BCM评估患者干体重,1个月内逐渐将患者体重调整至目标干体重水平。在两种方式评估1个月后,比较患者容量控制情况及相关指标。采用Pearson相关性分析法分析BCM测量容量控制的影响因素,并进行多元线性回归分析。结果Pearson相关分析结果显示,容量负荷相关的干体重与舒张压(r=0.752,P<0.001)、细胞内水分(r=0.492,P<0.001)、身体水分比(r=0.455,P<0.001)、前白蛋白(r=0.453,P<0.001)均呈正相关,与收缩压(r=-0.159,P<0.001)、透析期间体重增长(r=-0.089,P=0.046)、白蛋白(r=-0.156,P<0.001)、血钠(r=-0.124,P=0.005)呈负相关。多元线性回归分析显示容量负荷有关的干体重与BMI(t=83.219,P<0.001)、血红蛋白(t=2.822,P=0.005...     

慢性肾功能衰竭患者低瘦素基因表达与高瘦素血症的相关病因研究

目的探讨慢性肾衰竭患者高瘦素血症与瘦素基因的表达、肾小球滤过率、体质指数及炎症之间的相关性。方法150例患者处于不同的慢性肾功能衰竭阶段,对其进行血清瘦素水平、肾小球滤过率、同型半胱氨酸、C-反应蛋白检测,并计算其体质指数。RT-PCR法检测15例终末期肾功能衰竭患者腹部脂肪的瘦素基因表达。结果137例肾功能损伤患者的血清平均瘦素水平为(20.8±1.9)μg/L,明显高于健康对照组的(9.0±1.0)μg/L(P<0.001)。肾衰竭患者的血清瘦素水平与体质指数之间呈显著正相关(r=0.47,P<0.001),血清瘦素水平与肾小球滤过率呈负相关(r=-0.26,P<0.001)。相关性分析发现血清瘦素与CRP、tHcy之间呈正相关(r分别为0.60、0.57,均P<0.05)。终末期肾功能衰竭患者瘦素mRNA表达水平显著低于健康对照组(P<0.01)。这些患者的血清瘦素水平与瘦素基因表达水平呈负相关(r=-0.55,P<0.05)。结论慢性肾衰竭患者血清瘦素水平的升高与肾小球滤过率下降所导致的瘦素清除减少有关;体质指数的增加及全身微炎症反应可引起高瘦素血症;高瘦素血症可通过反馈抑制使患者瘦素基因表达下降。     

慢性肾功能衰竭患者血Leptin水平的变化

目的探讨慢性肾功能衰竭患者血清Leptin水平的变化;方法对68例慢性肾功能衰竭患者,用放射免疫分析法测定血Leptin水平,并测定患者内生肌酐清除率、体重指数等指标;结果CRF患者Leptin总体水平明显增高,与正常人比较、差异极显著(P<0.01)。肾功能不全代偿期Leptin水平与正常人无明显差异(P>0.05),随病情发展,Leptin水平逐渐升高,与CCr呈负相关(r=-0.364,P<0.01)。尿毒症期最高(P<0.01)。患者BMI各期均值均<24kg/m2,其Leptin/BMI值CRF患者为0.1402±0.0485,明显高于正常人(P<0.01),与CCr值呈负相关(r=-0.342,P<0.01)。结论CRF患者血Leptin水平随着肾功能损伤、CCr下降的程度而增高,在体内积聚,对机体造成影响。用Leptin或Leptin/BMI两指标均可反映其水平。     

2型糖尿病患者瘦体重与骨矿含量和骨密度的相关性分析

目的 探讨超重肥胖的2型糖尿病患者瘦体重与骨矿含量(BMC)及骨密度的相关性.方法 选取2014年6月到2016年8月在我院内分泌科住院治疗且符合入选条件的76例2型糖尿病患者,根据体质量指数(BMI)不同分为正常糖尿病组(BMI<24 kg/m2)和超重肥胖糖尿病组(BMI≥24 kg/m2).入院后符合观察条件的入组患者测量收集其收缩压(SBP)、舒张压(DBP)、腰围(WC)、体质量指数(BMI)、空腹血糖(FBG)、糖化血红蛋白(HbA1c)、血脂(TC、TG、HDL-C、LDL-C)、丙氨酶氨基转移酶(ALT)、血肌酐(SCr)、血钙(Ca)、血磷(P)、血25羟维生素D(25OHD).采用双能X线测定患者骨密度、骨矿含量(BMC)、体脂百分比(BF%)、瘦体重(LBM)、脂肪量(FM)、男性脂肪和女性脂肪的比率(A/G).对上述相关指标进行统计学处理分析.结果 25OHD在超重肥胖糖尿病组(17.1±12.6)μg/L低于正常糖尿病组(23.8±8.2)μg/L(P<0.05),而BMI、腰围、骨密度、BMC、脂肪和脂肪含量百分比在超重肥胖糖尿病组[BMI(27.8 ± 2.1)kg/m2、腰围(96.8 ± 7.9)cm、骨密度(1.12 ± 0.14)g/cm2、BMC (2.47±0.38)kg、脂肪和脂肪含量百分比(1.18±0.23)]高于正常糖尿病组[BMI(22.3±1.7)kg/m2、腰围(84.5±7.9)cm、骨密度(0.93 ± 0.13)g/cm2、BMC(2.02 ± 0.28)kg、脂肪和脂肪含量百分比(2.02 ±0.28)](P均<0.05).瘦体重和机体不同部位的BMC,骨密度存在明显的正相关(r值分别为0.37、0.37、0.35、0.43,P<0.05或P<0.001).BMI、A/G比率也和不同位点的BMC和骨密度存在正相关[BMI (r值分别为0.38、0.31、0.28、0.33,0.27、0.25、0.23、0.37,P<0.05或P<0.001)].机体脂肪百分比和BMC、骨密度呈负相关[r值分别为-0.30、-0.27、-0.25、-0.33,P<0.05或P<0.001)].在矫正了年龄,性别,BMI和25OHD后,使用多元线性回归分析提示瘦体重是 BMC 的强烈预测因子(回归系数为0.210,P=0.001).结论 在2型糖尿病患者中BMI升高患者的 BMC、骨密度明显升高,且瘦体重是BMC的强烈影响因素.     

瘦素水平与性别及残余肾功能关系的对照研究

目的:研究维持性血液透析患者血清瘦素水平与性别、残余肾功能的关系。方法:慢性肾功能衰竭维持性血液透析患者31例(患者组),男16例,女15例;门诊体检健康志愿者38例(对照组),男18例,女20例。采用放射免疫分析法测定所有研究对象的血清瘦素水平,测定血液透析患者的体质量指数(bodymassindex,BMI)、血肌酐、尿素氮、内生肌酐清除率。结果:①慢性肾功能衰竭血液透析患者血清瘦素水平犤(11.820±5.507)μg/L犦显著高于健康对照组犤(6.163±3.230)μg/L犦,差异有非常显著性意义(P<0.001)。②慢性肾功能衰竭血液透析患者女性血瘦素水平犤(15.710±4.969)μg/L犦高于男性犤(8.173±2.879)μg/L犦,差异有非常显著性意义(P<0.001)。③慢性肾功能衰竭血液透析患者血清瘦素水平与内生肌酐清除率、血肌酐、尿素氮无相关性(P>0.05)。结论:①慢性肾功能衰竭血液透析患者存在高瘦素血症。②女性患者血瘦素水平高于男性,性别是影响血瘦素水平的一个独立因素。③慢性终末期肾功能衰竭血液透析患者血瘦素水平与患者的残余肾功能无关。     

老年慢性阻塞性肺疾病患者营养状态与血清瘦素、生长激素的相关性

目的探讨老年慢性阻塞性肺疾病(COPD)患者血清瘦素、生长激素的变化及意义。方法采用放射免疫法测定32例老年COPD患者及15例健康老年人的血清瘦素、生长激素,同时进行营养状况评价。结果COPD组患者各营养指标均明显低于健康对照组(P<0.05),血清瘦素(3.2±2.1)μg/L、生长激素(4.1±1.5)μg/L亦低于健康对照组(P<0.05),瘦素水平与各营养指标犤体重指数(BMI)(r=0.75,P<0.001),理想体质量百分比(IBW%)(r=0.66,P<0.001),三头肌皮褶厚度(TSF)(r=0.57,P<0.01),上臂中部臂围(MAC)(r=0.54,P<0.01)犦呈显著正相关。结论COPD患者存在营养不良,血清瘦素、生长激素水平低于健康老年人,瘦素对COPD营养不良患者有调节意义。     

不同血管通路维持性血液透析患者血红蛋白的差异及相关性

目的比较武汉地区不同血管通路的维持性血液透析(maintenance hemodialysis,MHD)患者之间血红蛋白(hemoglobin,Hb)水平的差异,并分析其相关性。方法以武汉市血液透析质量控制平台中40家透析单位的MHD患者为研究对象,收集患者一般情况及生化指标等资料。筛选出3792例患者纳入研究,根据患者血管通路不同分为动静脉内瘘组(arteriovenous fistula,AVF)和非AVF组,比较2组Hb水平及其他项目的差异,分析血管通路对患者Hb的影响。结果①一般情况比较显示,AVF组单室尿素清除率(spKt/V)中位数明显高于非AVF组(χ~2=3.358,P=0.001);②AVF组血红蛋白、白蛋白、尿素氮、钙平均值较非AVF组高(t值分别为5.522、13.297、11.51,2.895,P值分别为<0.001、<0.001、<0.001、0.004),肌酐、磷、甲状旁腺素对数的平均值较非AVF组低(t值分别为-17.720、-8.309、-3.773,P值分别为<0.001、<0.001、<0.001);③Pearson相关分析结果得出,AVF组HB与白蛋白(r=0.268,P<0.001)、钙(r=0.117,P<0.001)呈正相关,与磷(r=-0.077,P=0.008)、甲状旁腺素对数(r=-0.061,P=0.002)呈负相关;非AVF组HB水平与白蛋白(r=0.301,P<0.001),与肌酐(r=-0.131,P=0.006)呈负相关;④AVF组贫血(HB<100g/L)比例(32.2%)低于非AVF组(39.1%)(χ~2=16.043,P<0.001);⑤在校正各种混杂因素后的Logstic回归模型中显示,AVF的患者发生贫血(Hb<100g/L)的风险较非AVF患者低19.5%(OR=0.805,95%CI:0.752~0.956,P=0.043)。结论血管通路为AVF的患者HB水平较非AVF患者高,且发生贫血的风险更低。     

慢性肾衰竭维持性血液透析患者血清甲状旁腺激素与机体营养的关系

目的探讨慢性肾衰竭维持性血液透析患者血清甲状旁腺激素(PTH)与机体营养的关系。方法选择2014—2015年血透室收治的100例慢性肾功能衰竭维持性血液透析患者,依据患者的营养状态分为3组,对3组患者的生化指标、PTH与各营养指标的关系进行统计学分析。结果 PTH与体重指数(BMI)、肱三头肌皮褶厚度(TSF)、臂肌围(MAMC)、白蛋白(ALB)、血红蛋白(Hb)和血肌酐(SCr)呈负相关,P0.05;与膳食蛋白摄入量(DPI)呈负相关,P0.01;与C-反应蛋白(CRP)呈正相关,P0.01;与转铁蛋白(TF)、血肌酐(SCr)无相关性,P0.05。结论慢性肾衰竭维持性血液透析患者PTH水平与机体营养水平密切相关,临床应充分给予重视。     

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.