Prehospital hypertonic saline resuscitation of patients with hypotension and severe traumatic brain injury: a randomized controlled trial

Context  Prehospital hypertonic saline (HTS) resuscitation of patients with traumatic brain injury (TBI) may increase survival but whether HTS improves neurological outcomes is unknown. Objective  To determine whether prehospital resuscitation with intravenous HTS improves long-term neurological outcome in patients with severe TBI compared with resuscitation with conventional fluids. Design, Setting, and Patients  Double-blind, randomized controlled trial of 229 patients with TBI who were comatose (Glasgow Coma Scale score, <9) and hypotensive (systolic blood pressure, <100 mm Hg). The patients were enrolled between December 14, 1998, and April 9, 2002, in Melbourne, Australia. Interventions  Patients were randomly assigned to receive a rapid intravenous infusion of either 250 mL of 7.5% saline (n = 114) or 250 mL of Ringer's lactate solution (n = 115; controls) in addition to conventional intravenous fluid and resuscitation protocols administered by paramedics. Treatment allocation was concealed. Main Outcome Measure  Neurological function at 6 months, measured by the extended Glasgow Outcome Score (GOSE). Results  Primary outcomes were obtained in 226 (99%) of 229 patients enrolled. Baseline characteristics of the groups were equivalent. At hospital admission, the mean serum sodium level was 149 mEq/L for HTS patients vs 141 mEq/L for controls (P<.001). The proportion of patients surviving to hospital discharge was similar in both groups (n = 63 [55%] for HTS group and n = 57 [50%] for controls; P = .32); at 6 months, survival rates were n = 62 (55%) in the HTS group and n = 53 (47%) in the control group (P = .23). At 6 months, the median (interquartile range) GOSE was 5 (3-6) in the HTS group vs 5 (5-6) in the control group (P = .45). There was no significant difference between the groups in favorable outcomes (moderate disability and good outcome survivors [GOSE of 5-8]) (risk ratio, 0.99; 95% confidence interval, 0.76-1.30; P = .96) or in any other measure of postinjury neurological function. Conclusion  In this study, patients with hypotension and severe TBI who received prehospital resuscitation with HTS had almost identical neurological function 6 months after injury as patients who received conventional fluid.      

高压氧对颅脑外伤昏迷患者的康复效果及护理探讨

目的观察高压氧对颅脑外伤昏迷患者的康复效果。方法选择颅脑外伤昏迷患者50例,随机划分为对照组和治疗组各25例,对照组采取常规治疗,治疗组采取高压氧治疗,比较两组的治疗效果。结果治疗组的平均苏醒时间为（15±1．5）d,明显少于对照组的（20±1．2）d,差异具有统计学意义（P〈0．05）。治疗组的总有效率为88％,显著高于对照组的68％,差异具有统计学意义（P〈0．05）。结论颅脑外伤昏迷患者早期采取高压氧治疗。并做好人舱前的护理以及加压、稳压、减压过程的护理,不但可有效减轻或消除患者的后遗症．并能挽救更多患者的生命。     

Pramipexole vs levodopa as initial treatment for Parkinson disease: A randomized controlled trial. Parkinson Study Group

Context  Pramipexole and levodopa both ameliorate the motor symptoms of early Parkinson disease (PD), but no controlled studies have compared long-term outcomes after initiating dopaminergic therapy with pramipexole vs levodopa. Objective  To compare the development of dopaminergic motor complications after initial treatment of early PD with pramipexole vs levodopa. Design  Multicenter, parallel-group, double-blind, randomized controlled trial. Setting  Academic movement disorders clinics at 22 sites in the United States and Canada. Patients  Three hundred one patients with early PD who required dopaminergic therapy to treat emerging disability, enrolled between October 1996 and August 1997. Interventions  Subjects were randomly assigned to receive pramipexole, 0.5 mg 3 times per day, with levodopa placebo (n = 151); or carbidopa/levodopa, 25/100 mg 3 times per day, with pramipexole placebo (n = 150). For patients with residual disability, the dosage was escalated during the first 10 weeks. From week 11 to month 23.5, investigators were permitted to add open-label levodopa to treat continuing or emerging disability. Main Outcome Measures  Time to the first occurrence of any of 3 dopaminergic complications: wearing off, dyskinesias, or on-off motor fluctuations; changes in scores on the Unified Parkinson's Disease Rating Scale (UPDRS), assessed at baseline and follow-up evaluations; and, in a subgroup of 82 subjects evaluated at baseline and 23.5 months, ratio of specific to nondisplaceable striatal iodine 123 2--carboxymethoxy-3--(4-iodophenyl)tropane (-CIT) uptake on single photon emission computed tomography imaging of the dopamine transporter. Results  Initial pramipexole treatment resulted in significantly less development of wearing off, dyskinesias, or on-off motor fluctuations (28%) compared with levodopa (51%) (hazard ratio, 0.45; 95% confidence interval [CI], 0.30-0.66; P<.001). The mean improvement in total UPDRS score from baseline to 23.5 months was greater in the levodopa group than in the pramipexole group (9.2 vs 4.5 points; P<.001). Somnolence was more common in pramipexole-treated patients than in levodopa-treated patients (32.4% vs 17.3%; P = .003), and the difference was seen during the escalation phase of treatment. In the subgroup study, patients treated initially with pramipexole (n = 39) showed a mean (SD) decline of 20.0% (14.2%) in striatal -CIT uptake compared with a 24.8% (14.4%) decline in subjects treated initially with levodopa (n = 39; P = .15). Conclusions  Fewer patients receiving initial treatment for PD with pramipexole developed dopaminergic motor complications than with levodopa therapy. Despite supplementation with open-label levodopa in both groups, the levodopa-treated group had a greater improvement in total UPDRS compared with the pramipexole group.      

盐酸多奈哌齐改善重型颅脑外伤康复期认知功能2例报告

1　病例介绍例 1,男性 ,2 3岁。因车祸致头部外伤后不省人事 1天就诊我院。入院时昏迷量表 (GCS)评分 7分 ,压眶呈去皮层状态 ,左侧巴氏征阳性。 CT示 :脑干损伤、脑挫裂伤、弥漫性轴索损伤、外伤性蛛网膜下腔出血 (SAH )、右额硬膜下积液、脑挫裂伤、右侧脑室出血。临床诊断 :重型颅脑外伤、脑干损伤、脑挫裂伤、弥漫性轴索损伤。入院后予常规抗炎、脱水、营养支持及神经营养药物等治疗 ,其间昏迷近 3个半月。经过康复治疗患者意识恢复 ,能以单音示意 ,能服从简单命令 ,但认知功能差 ,继续常规治疗 1个半月 ,记忆及认识能力改善已停滞…     

Correlation between cerebral co-oximetry (rSO2) and outcomes in traumatic brain injury cases: A prospective,observational study

BackgroundTraumatic brain injury (TBI) is known to be an important reason for the increase in disabilities and deaths worldwide. Studies have demonstrated that brain tissue oxygen (PO2) monitoring reduces mortality significantly but is a invasive method of monitoring. Therefore, there is a need to monitor cerebral ischemia in TBI by noninvasive methods. The study aims to correlate cerebral co-oximetry and possible outcomes in patients with TBI.MethodsThe study included 78 patients with TBI admitted in intensive care unit (ICU) with glascow coma scale (GCS) of 8 or less than 8. Near-infrared spectroscopy monitor is applied to the patients immediately after admission to ICU; readings are noted every 4 hours up to first 48 hours, and outcomes studied as survival or neurological deficit are noted at 28 days.ResultsA total of 12 (15.4%) deaths were seen in this study. Survived patients were further divided into good recovery 33 (42.3%), moderate disability 21(26.9%), major disability 8 (10.3%), and persistent vegetative state 4 (5.1%). The rSO2 values in surviving patients were ranging from mean of 60.74% (standard deviation [SD] 4.38) to a mean of 64.98% (SD 5.01), and the mean rSO2 values in patients who died were ranging from a mean of 52.17% (SD 4.11) to a mean of 37.17% (SD 12.48). Lower rSO2 values were correlating significantly with worse neurological outcome or death by using two independent sample t-test (p < 0.001).ConclusionCerebral co-oximetry is a simple noninvasive method for predicting the outcomes in TBI and can be used to guide the management of these patients.     

重度颅脑创伤后应用(S)-4C3HPG减轻小鼠颅脑损伤的作用

目的探讨重度颅脑创伤(severe traumatic brain injury,sTBI)后不同时间点使用谷氨酸释放调节剂(S)-4C3HPG对颅脑创伤急性期伤情的影响,以明确调节谷氨酸释放获得有效脑保护作用的最佳时间点。方法以自由落体撞击方法制作重度小鼠颅脑损伤模型,分别在小鼠致伤后15 min、1、3、6 h 4个时间点腹腔注射(S)-4C3HPG 5 mg/kg,观察了其对颅脑创伤后24 h时神经功能缺损评分、脑含水量、脑脊液中谷氨酸浓度及炎症因子TNF-α、IL-1βmRNA表达的影响。结果致伤后24 h检测(S)-4C3HPG药物处理15 min组和1 h组神经功能缺损[分别为(1.70±0.48)、(1.90±0.56)]显著低于对照组[(2.80±0.42),P<0.01],脑含水量[分别为(80.14±0.28)%、(80.17±0.52)%]显著低于对照组[(82.55±0.34)%,P<0.01],脑脊液中谷氨酸浓度[分别为(4.24±0.28)、(6.12±0.23)μmol/L]显著低于对照组[(9.03±0.32)μmol/L,P<0.01],炎症因子TNF-αmRNA的表达[分别为(0.722±0.160)、(0.793±0.122)]显著低于对照组[(1.006±0.125),P<0.01],IL-1βmRNA的表达[分别为(0.594±0.128)、(0.651±0.111)]显著低于对照组[(1.012±0.088),P<0.01],证明于致伤后15 min和1 h给予(S)-4C3HPG能明显减轻重度颅脑损伤,而于致伤后3 h和6 h给予(S)-4C3HPG与对照组比较,神经功能缺损、脑含水量、脑脊液中谷氨酸浓度及炎症因子TNF-α、IL-1βmRNA的表达无统计学差异,说明神经功能保护作用不明显。结论重度颅脑创伤后,尽早使用(s)-4C3HPG控制谷氨酸释放将有效减轻急性期的脑损伤。     

Effect of (S)-4C3HPG on alleviating brain injury in severe traumatic brain injury and the underlying mechanisms

目的 探讨重度颅脑创伤(severe traumatic brain injury,sTBI)后不同时间点使用谷氨酸释放调节剂(S)-4C3HPG对颅脑创伤急性期伤情的影响,以明确调节谷氨酸释放获得有效脑保护作用的最佳时间点.方法 以自由落体撞击方法制作重度小鼠颅脑损伤模型,分别在小鼠致伤后15 min、1、3、6h4个时间点腹腔注射(S)-4C3HPG 5 mg/kg,观察了其对颅脑创伤后24h时神经功能缺损评分、脑含水量、脑脊液中谷氨酸浓度及炎症因子TNF-α、IL-1β mRNA表达的影响.结果 致伤后24h检测(S) -4C3 HPG药物处理15 min组和1h组神经功能缺损[分别为(1.70 ±0.48)、(1.90±0.56)]显著低于对照组[(2.80±0.42),P＜0.01],脑含水量[分别为(80.14±0.28)％、(80.17±0.52)％]显著低于对照组[ (82.55 ±0.34)％,P＜0.01],脑脊液中谷氨酸浓度[分别为(4.24 ±0.28)、(6.12 ±0.23) μmol/L]显著低于对照组[ (9.03 ±0.32) μmol/L,P＜0.01],炎症因子TNF-α mRNA的表达[分别为(0.722 ±0.160)、(0.793 ±0.122)]显著低于对照组[(1.006±0.125),P＜0.01],IL-1β mRNA的表达[分别为(0.594±0.128)、(0.651 ±0.111)]显著低于对照组[( 1.012 ±0.088),P＜0.01],证明于致伤后15 min和1h给予(S) -4C3HPG能明显减轻重度颅脑损伤,而于致伤后3h和6h给予(S) -4C3 HPG与对照组比较,神经功能缺损、脑含水量、脑脊液中谷氨酸浓度及炎症因子TNF-α、IL-13 mRNA的表达无统计学差异,说明神经功能保护作用不明显.结论 重度颅脑创伤后,尽早使用(s) -4C3HPG控制谷氨酸释放将有效减轻急性期的脑损伤.     

Effect of exogenous surfactant (calfactant) in pediatric acute lung injury: a randomized controlled trial

Context  Despite evidence that patients with acute lung injury (ALI) have pulmonary surfactant dysfunction, trials of several surfactant preparations to treat adults with ALI have not been successful. Preliminary studies in children with ALI have shown that instillation of a natural lung surfactant (calfactant) containing high levels of surfactant-specific protein B may be beneficial. Objective  To determine if endotracheal instillation of calfactant in infants, children, and adolescents with ALI would shorten the course of respiratory failure. Design, Setting, and Patients  A multicenter, randomized, blinded trial of calfactant compared with placebo in 153 infants, children, and adolescents with respiratory failure from ALI conducted from July 2000 to July 2003. Twenty-one tertiary care pediatric intensive care units participated. Entry criteria included age 1 week to 21 years, enrollment within 48 hours of endotracheal intubation, radiological evidence of bilateral lung disease, and an oxygenation index higher than 7. Premature infants and children with preexisting lung, cardiac, or central nervous system disease were excluded. Intervention  Treatment with intratracheal instillation of 2 doses of 80 mL/m² calfactant or an equal volume of air placebo administered 12 hours apart. Main Outcome Measures  Ventilator-free days and mortality; secondary outcome measures were hospital course, adverse events, and failure of conventional mechanical ventilation. Results  The calfactant group experienced an acute mean (SD) decrease in oxygenation index from 20 (12.9) to 13.9 (9.6) after 12 hours compared with the placebo group’s decrease from 20.5 (14.7) to 15.1 (9.0) (P = .01). Mortality was significantly greater in the placebo group compared with the calfactant group (27/75 vs 15/77; odds ratio, 2.32; 95% confidence interval, 1.15-4.85), although ventilator-free days were not different. More patients in the placebo group did not respond to conventional mechanical ventilation. There were no differences in long-term complications. Conclusions  Calfactant acutely improved oxygenation and significantly decreased mortality in infants, children, and adolescents with ALI although no significant decrease in the course of respiratory failure measured by duration of ventilator therapy, intensive care unit, or hospital stay was observed.      

内科疾病伴脑损伤的高压氧治疗(附93例报告)

目的:探讨高压氧治疗内科疾病伴脑损伤的疗效。方法:常规采用压力0.25MPa,吸氧60min,每日1次;急性期采用0.22MPa,吸氧60min,每日2次。结果:治愈54例(58.1％),显效21例(22.5％),有效11例(11.8％),总有效率93.5％。结论:高压氧治疗内科疾病伴脑损伤疗效显著,选择最佳治疗时机及合理治疗方案能够提高疗效。     

Diaspirin cross-linked hemoglobin (DCLHb) in the treatment of severe traumatic hemorrhagic shock: a randomized controlled efficacy trial

CONTEXT: Severe, uncompensated, traumatic hemorrhagic shock causes significant morbidity and mortality, but resuscitation with an oxygen-carrying fluid might improve patient outcomes. OBJECTIVE: To determine if the infusion of up to 1000 mL of diaspirin cross-linked hemoglobin (DCLHb) during the initial hospital resuscitation could reduce 28-day mortality in traumatic hemorrhagic shock patients. DESIGN AND SETTING: Multicenter, randomized, controlled, single-blinded efficacy trial conducted between February 1997 and January 1998 at 18 US trauma centers selected for their high volume of critically injured trauma patients, but 1 did not enroll patients. PATIENTS: A total of 112 patients with traumatic hemorrhagic shock and unstable vital signs or a critical base deficit, who had a mean (SD) patient age of 39 (20) years. Of the infused patients, 79% were male and 56% were white. An exception to informed consent was used when necessary. INTERVENTION: All patients were to be infused with 500 mL of DCLHb or saline solution. Critically ill patients who still met entry criteria could have received up to an additional 500 mL during the 1-hour infusion period. MAIN OUTCOME MEASURES: Twenty-eight day mortality, 28-day morbidity, 48-hour mortality, and 24-hour lactate levels. RESULTS: Of the 112 patients, 98 (88%) were infused with DCLHb or saline solution. At 28 days, 24 (46%) of the 52 patients infused with DCLHb died, and 8 (17%) of the 46 patients infused with the saline solution died (P = .003). At 48 hours, 20 (38%) of the 52 patients infused with DCLHb died and 7 (15%) of the 46 patients infused with the saline solution died (P = .01). The 28-day morbidity rate, as measured by the multiple organ dysfunction score, was 72% higher in the DCLHb group (P = .03). There was no difference in adverse event rates or the 24-hour lactate levels. CONCLUSIONS: Mortality was higher for patients treated with DCLHb. Although further analysis should investigate whether the mortality difference was solely due to a direct treatment effect or to other factors, DCLHb does not appear to be an effective resuscitation fluid.     

中医综合康复疗法治疗不完全性脊髓损伤后神经源性膀胱尿潴留的多中心临床随机对照试验

目的：探讨采用中医综合康复疗法治疗不完全性脊髓损伤后神经源性膀胱尿潴留的临床疗效,为该方案的临床推广提供依据。方法：采用中央区组随机方法将符合纳入标准的184例患者分为试验组（89例）和对照组（95例）。2组患者均予以间歇性导尿和膀胱功能训练,试验组患者同时予以电针（20 min/次,每天1次,每周6 d）和推拿（20 min/次,每天1次,每周6 d）治疗,2周1个疗程,共治疗4个疗程。检测2组患者治疗前后膀胱残余尿量、膀胱安全容量和膀胱内压,并进行疗效评估。结果：与治疗前比较,试验组患者治疗后膀胱残余尿量明显降低（P<0.01）,膀胱安全容量明显升高（P<0.01）,膀胱内压无明显变化（P>0.05）;对照组患者治疗后膀胱残余尿量明显降低（P<0.01）,但膀胱安全容量和膀胱内压均无明显变化（P>0.05）。治疗后组间比较,试验组患者膀胱残余尿量明显少于对照组（P<0.01）,2组患者膀胱安全容量和膀胱内压比较差异无统计学意义（P>0.05）。结论：中医综合康复治疗可有效减少不完全性脊髓损伤后神经源性膀胱尿潴留患者的膀胱残余尿量,且疗效明显优于间歇性导尿和膀胱功能训练的现代康复治疗。     

Stratified care vs step care strategies for migraine: the Disability in Strategies of Care (DISC) Study: A randomized trial

CONTEXT: Various guidelines recommend different strategies for selecting and sequencing acute treatments for migraine. In step care, treatment is escalated after first-line medications fail. In stratified care, initial treatment is based on measurement of the severity of illness or other factors. These strategies for migraine have not been rigorously evaluated. OBJECTIVE: To compare the clinical benefits of 3 strategies: stratified care, step care within attacks, and step care across attacks, among patients with migraine. DESIGN AND SETTING: Randomized, controlled, parallel-group clinical trial conducted by the Disability in Strategies Study group from December 1997 to March 1999 in 88 clinical centers in 13 countries. PATIENTS: A total of 835 adult migraine patients with a Migraine Disability Assessment Scale (MIDAS) grade of II, III, or IV were analyzed as the efficacy population; the safety analysis included 930 patients. INTERVENTIONS: Patients were randomly assigned to receive (1) stratified care (n = 279), in which patients with MIDAS grade II treated up to 6 attacks with aspirin, 800 to 1000 mg, plus metoclopramide, 10 mg, and patients with MIDAS grade III and IV treated up to 6 attacks with zolmitriptan, 2.5 mg; (2) step care across attacks (n = 271), in which initial treatment was with aspirin, 800 to 1000 mg, plus metoclopramide, 10 mg. Patients not responding in at least 2 of the first 3 attacks switched to zolmitriptan, 2.5 mg, to treat the remaining 3 attacks; and (3) step care within attacks (n = 285), in which initial treatment for all attacks was with aspirin, 800 to 1000 mg, plus metoclopramide, 20 mg. Patients not responding to treatment after 2 hours in each attack escalated treatment to zolmitriptan, 2.5 mg. MAIN OUTCOME MEASURES: Headache response, achieved if pain intensity was reduced from severe or moderate at baseline to mild or no pain at 2 hours; and disability time per treated attack at 4 hours for all 6 attacks, compared among the 3 groups. RESULTS: Headache response at 2 hours was significantly greater across 6 attacks in the stratified care treatment group (52.7%) than in either the step care across attacks group (40.6%; P<.001) or the step care within attacks group (36.4%; P<.001). Disability time (6 attacks) was significantly lower in the stratified care group (mean area under the curve [AUC], 185.0 mm. h) than in the step care across attacks group (mean AUC, 209.4 mm. h; P<.001) or the step care within attacks group (mean AUC, 199.7 mm. h; P<.001). The incidence of adverse events was higher in the stratified care group (321 events) vs both step care groups (159 events in across-attack group; 217 in within-attack group), although most events were of mild-to-moderate intensity. CONCLUSION: Our results indicate that as a treatment strategy, stratified care provides significantly better clinical outcomes than step care strategies within or across attacks as measured by headache response and disability time. JAMA. 2000;284:2599-2605.     

Cognitive behavioral therapy and aerobic exercise for Gulf War veterans' illnesses: a randomized controlled trial

Context  Gulf War veterans' illnesses (GWVI), multisymptom illnesses characterized by persistent pain, fatigue, and cognitive symptoms, have been reported by many Gulf War veterans. There are currently no effective therapies available to treat GWVI. Objective  To compare the effectiveness of cognitive behavioral therapy (CBT), exercise, and the combination of both for improving physical functioning and reducing the symptoms of GWVI. Design, Setting, and Patients  Randomized controlled 2 x 2 factorial trial conducted from April 1999 to September 2001 among 1092 Gulf War veterans who reported at least 2 of 3 symptom types (fatigue, pain, and cognitive) for more than 6 months and at the time of screening. Treatment assignment was unmasked except for a masked assessor of study outcomes at each clinical site (18 Department of Veterans Affairs [VA] and 2 Department of Defense [DOD] medical centers). Interventions  Veterans were randomly assigned to receive usual care (n = 271), consisting of any and all care received from inside or outside the VA or DOD health care systems; CBT plus usual care (n = 286); exercise plus usual care (n = 269); or CBT plus exercise plus usual care (n = 266). Exercise sessions were 60 minutes and CBT sessions were 60 to 90 minutes; both met weekly for 12 weeks. Main Outcome Measures  The primary end point was a 7-point or greater increase (improvement) on the Physical Component Summary scale of the Veterans Short Form 36-Item Health Survey at 12 months. Secondary outcomes were standardized measures of pain, fatigue, cognitive symptoms, distress, and mental health functioning. Participants were evaluated at baseline and at 3, 6, and 12 months. Results  The percentage of veterans with improvement in physical function at 1 year was 11.5% for usual care, 11.7% for exercise alone, 18.4% for CBT plus exercise, and 18.5% for CBT alone. The adjusted odds ratios (OR) for improvement in exercise, CBT, and exercise plus CBT vs usual care were 1.07 (95% confidence interval [CI], 0.63-1.82), 1.72 (95% CI, 0.91-3.23), and 1.84 (95% CI, 0.95-3.55), respectively. The OR for the overall (marginal) effect of receiving CBT (n = 552) vs no CBT (n = 535) was 1.71 (95% CI, 1.15-2.53) and for exercise (n = 531) vs no exercise (n = 556) was 1.07 (95% CI, 0.76-1.50). For secondary outcomes, exercise alone or in combination with CBT significantly improved fatigue, distress, cognitive symptoms, and mental health functioning, while CBT alone significantly improved cognitive symptoms and mental health functioning. Neither treatment had a significant impact on pain. Conclusion  Our results suggest that CBT and/or exercise can provide modest relief for some of the symptoms of chronic multisymptom illnesses such as GWVI.      

Effects of risedronate treatment on vertebral and nonvertebral fractures in women with postmenopausal osteoporosis: a randomized controlled trial. Vertebral Efficacy With Risedronate Therapy (VERT) Study Group.

CONTEXT: Risedronate, a potent bisphosphonate, has been shown to be effective in the treatment of Paget disease of bone and other metabolic bone diseases but, to our knowledge, it has not been evaluated in the treatment of established postmenopausal osteoporosis. OBJECTIVE: To test the efficacy and safety of daily treatment with risedronate to reduce the risk of vertebral and other fractures in postmenopausal women with established osteoporosis. DESIGN, SETTING, AND PARTICIPANTS: Randomized, double-blind, placebo-controlled trial of 2458 ambulatory postmenopausal women younger than 85 years with at least 1 vertebral fracture at baseline who were enrolled at 1 of 110 centers in North America conducted between December 1993 and January 1998. INTERVENTIONS: Subjects were randomly assigned to receive oral treatment for 3 years with risedronate (2.5 or 5 mg/d) or placebo. All subjects received calcium, 1000 mg/d. Vitamin D (cholecalciferol, up to 500 IU/d) was provided if baseline levels of 25-hydroxyvitamin D were low. MAIN OUTCOME MEASURES: Incidence of new vertebral fractures as detected by quantitative and semiquantitative assessments of radiographs; incidence of radiographically confirmed nonvertebral fractures and change from baseline in bone mineral density as determined by dual x-ray absorptiometry. RESULTS: The 2.5 mg/d of risedronate arm was discontinued after 1 year; in the placebo and 5 mg/d of risedronate arms, 450 and 489 subjects, respectively, completed all 3 years of the trial. Treatment with 5 mg/d of risedronate, compared with placebo, decreased the cumulative incidence of new vertebral fractures by 41 % (95% confidence interval [CI], 18%-58%) over 3 years (11.3 % vs 16.3%; P= .003). A fracture reduction of 65% (95% CI, 38%-81 %) was observed after the first year (2.4% vs 6.4%; P<.001). The cumulative incidence of nonvertebral fractures over 3 years was reduced by 39% (95% CI, 6%-61 %) (5.2 % vs 8.4%; P = .02). Bone mineral density increased significantly compared with placebo at the lumbar spine (5.4% vs 1.1 %), femoral neck (1.6% vs -1.2%), femoral trochanter (3.3% vs -0.7%), and midshaft of the radius (0.2% vs -1.4%). Bone formed during risedronate treatment was histologically normal. The overall safety profile of risedronate, including gastrointestinal safety, was similar to that of placebo. CONCLUSIONS: These data suggest that risedronate therapy is effective and well tolerated in the treatment of women with established postmenopausal osteoporosis.     

Severe traumatic brain injury in New South Wales: comparable outcomes for rural and urban residents

OBJECTIVE: To compare differences in functional outcomes between urban and rural patients with traumatic brain injury (TBI). DESIGN: A longitudinal, prospective, multicentre study of a 2-year cohort from the Brain Injury Rehabilitation Program (BIRP) for New South Wales, with follow-up at 18 months after injury. PARTICIPANTS: 198 patients (147 urban, 51 rural) with severe TBI from the 11 participating rehabilitation units. MAIN OUTCOME MEASURES: Demographic and injury details collected prospectively using a standardised questionnaire, and measures from five validated instruments (Disability Rating Scale, Mayo-Portland Adaptability Inventory, Sydney Psychosocial Reintegration Scale, Medical Outcomes Study Short Form and the General Health Questionnaire--28-item version) administered at follow-up to document functional, psychosocial, emotional and vocational outcomes. RESULTS: Demographic details, injury severity, lengths of stay in intensive and acute care wards were similar for both rural and urban groups. There were no significant group differences in functional outcomes, including return to work, at follow-up. CONCLUSIONS: Our findings contrast with previous research that has reported poorer outcomes after TBI for rural residents, and suggest that the integrated network of inpatient, outpatient and outreach services provided throughout NSW through the BIRP provides effective rehabilitation for people with severe TBI regardless of where they live.     

颅脑损伤术后颅内压监测的临床作用及意义

目的 探讨颅内压(ICP)监测在颅脑损伤术后患者临床治疗中的作用及意义。方法 回顾性分析108例在我科因颅脑损伤收住院手术治疗的患者,根据患者术后是否行ICP进行分组。其中62例行ICP监测作为监测组,参考ICP监测数据值作为调整治疗方案。常规组中46例根据患者意识、生命体征等临床症状变化情况采取相应的治疗措施。对比两组患者的疗效(GOS评分)、甘露醇的应用情况、术后并发症等差异。结果 监测组患者预后有效率为69.35％(43/62),明显优于常规组(P＜0.05)。监测组术后并发症发生率为12.90％(8/62),明显低于常规组(P＜0.05)。监测组甘露醇使用剂量均值为(758.5±35.9)g,使用时间为(6.4±2.5)d,均明显低于常规组(P＜0.05)。结论 颅内压监测在急性重型颅脑损伤中的临床应用价值确切,对颅脑损伤术后患者应及早动态观察颅内压力变化,有助于指导临床脱水药物的使用,降低术后并发症,合理有效的治疗措施可提高患者术后生存率,减少病残率,并对患者临床预后具有较好的评估价值。