维持性血液透析患者不同血管通路临床常见并发症分析

目的分析维持性血液透析患者不同类型血管通路常见并发症的发生情况,为临床护理干预提供依据。方法选择血液净化中心401例维持性血液透析患者,随访12个月,观察自体动静脉内瘘、聚四氟乙烯人造血管、长期静脉置管、临时静脉置管、直接动静脉穿刺5种不同类型血管通路常见并发症的发生情况。结果 401例维持性血液透析患者中以聚四氟乙烯人造血管栓塞并发症的发生率最高(42.86%),临时静脉置管感染并发症的发生率最高(19.77%),自体动静脉内瘘常见并发症的发生率低。结论在维持性血液透析患者中,自体动静脉内瘘透析患者常见并发症发生率低,是建立长期血管通路的首选。但在自体动静脉内瘘无法建立时,其他4种仍为维持性血液透析患者选择的重要血管通路。     

血液透析患者血管通路选择和使用情况调查

目的回顾性分析血液透析患者血管通路的使用情况。方法记录自2012年1月1日至2012月12月31日全年新入血液透析患者及维持性血液透析患者的基本资料、原发病、血管通路的选择、变更次数、血管通路并发症的发生情况。结果全年血液透析患者157例。新入患者36例,新入患者开始透析时血管通路分别为:临时导管26例(72.2%),长期管2例(5.6%),自体动静脉内瘘6例(16.7%);维持性血液透析患者121例,其中应用自体动静脉内瘘109例(90.08%),长期管9例(7.4%),临时导管2例(1.65%),人造血管内瘘1例(0.83%)。自体动静脉内瘘并发症主要是血栓形成,肿胀手、肢体缺血,感染,并发症发生率为29.7%。中心静脉导管并发症主要为血流不足,深静脉血栓,感染;只有3例未出现并发症,并发症发生率为72.7%。本组患者原发病前三位依次为慢性肾炎(32.48%)、糖尿病肾病(28.66%)、慢性间质性肾炎(16.56%)。死亡前两位原因心血管疾病和脑出血,共占71.4%。结论研究资料中维持性血液透析患者的血管通路以自体动静脉内瘘为主,新入患者动静脉内瘘使用率低,中心静脉导管并发症明显高于内瘘,影响血管通路选择主要原因为糖尿病、高龄和透析时机过晚。     

钝针扣眼穿刺法降低动静脉内瘘并发症的效果观察

目的观察钝针扣眼穿刺法降低血液透析患者动静脉内瘘并发症的效果。方法选择维持性血液透析治疗利用自体动静脉内瘘建立血管通路的患者70例,按住院床号数分为A组40例、B组30例,A组采用钝针扣眼穿刺,B组采用绳梯穿刺,观察比较两组患者血管瘤、血管狭窄、血栓形成、内瘘感染的发生率以及拔针后的止血时间和疼痛程度。结果 A组血管瘤的发生率、拔针后的止血时间和对穿刺的疼痛评分明显低于B组,组间比较差异具有统计学意义。结论钝针扣眼穿刺法是维持性血液透析患者动静脉内瘘较为理想的穿刺方法。     

长期透析患者标准内瘘失效后血管通路的选择策略

自体动静脉内瘘（autogenous arteriovenous fistulas,autogenousAVF）因长期开放率高和并发症发生率低而成为终末期肾脏病维持性血液透析患者首选血管通路。腕部桡动脉头静脉内瘘（标准内瘘）仍然是首选。由于较好的医疗措施,透析患者寿命显著延长,大多数需更长时间依赖维持性透析,他们的血管通路需要维护及防治相关并发症。     

不同穿刺方法对维持性血液透析患者自体动静脉内瘘影响的研究

目的对比3种不同穿刺方法对维持性血液透析患者自体动静脉内瘘的影响。方法接受维持性血液透析的120例终末期肾病患者,根据动静脉内瘘穿刺方向的不同分为向心组、交替组、离心组,每组40例。3组观察时间均为1年,比较3种方法对患者透析效果及内瘘并发症发生率的影响。结果3组动静脉内瘘血流量和透析充分性指标(尿素下降率、尿素清除指数)比较,差异无统计学意义(P>0.05)。向心组发生1(2.50%)例内瘘闭塞、8(20.00%)例内瘘狭窄和1(2.50%)例动脉瘤;交替组发生2(5.00%)例内瘘狭窄和2(5.00%)例动脉瘤;离心组发生6(15.00%)例内瘘闭塞、1(2.50%)例内瘘狭窄和10(25.00%)例动脉瘤。结论向心与离心交替穿刺可以减少维持性血液透析患者动静脉内瘘闭塞、狭窄的发生率,降低血管瘤的形成风险,对提高患者的生活质量具有积极意义。     

不用止血带穿刺在血液透析患者动静脉内瘘早期穿刺中的应用研究

正维持性血液透析是维持终末期肾脏病患者生命的一种有效治疗手段,而血管通路则是患者的生命通道[1]。随着临床研究的深入,目前认为自体动静脉内瘘是维持性血液透析患者血管通路的首选,具有寿命长、并发症少等优点[2]。早期失用是自体动静脉内瘘术后较为常见的情况,发生率5%~24%[3],导致内瘘早期失用的主要原因在于内瘘尚未成熟,直接影响到内瘘的使用寿命[4]。本研究对部分血液透析患者动静脉内瘘     

肘部改良自体动静脉内瘘手术与肘部传统内瘘手术的评价研究

目的评价维持性血液透析患者肘部改良自体动静脉内瘘手术与传统肘部动静脉内瘘术的应用效果;方法对84例行肘部改良内瘘术患者及79例传统内瘘术患者进行4年的随访研究。比较各组透析期间血管直径、可用血管长度、平均血流量及内瘘通畅率情况。并统计2组患者血栓、动脉瘤、前臂水肿、心力衰竭等并发症的发生率,以此来判定2种术式的优缺点;结果 2组患者内瘘成熟后均可满足血液透析需求。术后3月传统内瘘术组内瘘平均血流量高于改良内瘘术组(1101.66±189.66ml/min比1199.46±197.23ml/min,P=0.002),改良内瘘术组可用血管长度明显高于传统内瘘术组(15.24±1.17cm比20.59±1.63cm,P0.001),2组术式血管直径无显著差异(6.30±0.59mm比6.20±0.62mm,P=0.284)。2组前2年内瘘通畅率无明显差异(P0.05),第3年改良内瘘术组内瘘通畅率高于传统内瘘术组(P=0.045)。在并发症方面传统内瘘术组血栓发生率高于改良内瘘术组(P=0.047),改良内瘘术组前臂水肿发生率高于传统内瘘术组(P=0.037),两组患者在心力衰竭、动脉瘤等并发症发生率无显著差异(P0.05);结论 2组动静脉内瘘术式血流量均较好且通畅率高,肘部改良自体动静脉内瘘术较传统肘部动静脉内瘘术可显著延长穿刺用血管长度,但前臂水肿发生率高于传统内瘘术组,有待于进一步对术式进行改良。     

精准化护理在降低血液透析病人自体动静脉内瘘并发症发生率中的应用效果

目的:分析精准化护理在降低血液透析病人自体动静脉内瘘并发症发生率中的应用效果.方法:选取2017年1月—2017年12月医院收治的294例自体动静脉内瘘的血液透析病人作为对照组;选取2018年1月—2018年12月收治的329例自体动静脉内瘘的血液透析病人作为观察组.对照组实施常规内瘘护理,观察组实施精准化护理,比较实施不同护理措施的两组血液透析病人自体动静脉内瘘并发症(包括内瘘闭塞、血管狭窄、血栓形成、渗血、血肿、动脉瘤形成)发生率及病人对自体动静脉内瘘使用现状的满意度.结果:观察组血液透析病人自体动静脉内瘘闭塞、血管狭窄、血栓形成、渗血、血肿及动脉瘤形成的发生率明显低于对照组(P<0.05),观察组病人对自体动静脉内瘘使用现状的满意度明显高于对照组(P<0.05).结论:精准化护理的临床实施能有效减少血液透析病人自体动静脉内瘘并发症发生,延长病人自体动静脉内瘘的穿刺长度,充分利用病人的血管资源,延长自体动静脉内瘘的使用寿命,为血液透析治疗提供有效的通路,同时提高了血液透析病人对内瘘使用的满意度,有利于发展和谐的护患关系.     

应用扣眼穿刺法预防内瘘血管瘤样扩张的效果观察

目的探讨内瘘扣眼穿刺法的正确使用及其预防动静脉内瘘血管瘤样扩张的效果。方法方便性抽样选择2007年1月至2011年12月在浙江省人民医院血液净化中心采用自体动静脉内瘘穿刺进行维持性血液透析的患者120例,分别采用扣眼法（试验组60例）及传统区域法（对照组60例）穿刺内瘘,比较两组患者内瘘血管瘤样扩张发生情况。结果试验组患者均未发生穿刺局部血管呈圆瘤样扩张膨大,有5例患者内瘘穿刺点前方血管呈粗条状扩张。对照组患者出现穿刺部位血管呈圆瘤状扩张49例,粗条状扩张6例。两组比较,差异具有统计学意义（P〈0．01）。结论对维持性血液透析患者采用扣眼法穿刺内瘘可有效预防内瘘血管瘤样扩张,且穿刺成功率高,疼痛感轻,提高了患者的透析依从性,尤其适合于血管条件差无法进行绳梯法穿刺的患者。     

动静脉内瘘顺血流方向穿刺的临床观察

[目的]探讨不同动静脉内瘘穿刺方法对维持性血液透析病人内瘘并发症发生率的影响.[方法]选择糖尿病肾病维持性血液透析病人42例,随机分为观察组和对照组,分别采用顺血流方向和逆血流方向两种不同的穿刺方法,观察两组内瘘并发症发生及创面延期愈合情况.[结果]观察组血管瘤、内瘘狭窄、创面延期愈合发生率明显低于对照组(P<0.05).[结论]对糖尿病肾病维持性血液透析病人采用顺血流方向穿刺动静脉内瘘,可有效保护动静脉内瘘,促进穿刺处创面愈合,减少并发症发生.     

基于腕关节功能、肘关节功能和影像学参数探讨不同术式治疗创伤性桡骨远端骨折的疗效

目的  探讨基于腕关节功能、肘关节功能和影像学参数探讨不同术式治疗创伤性桡骨远端骨折的疗效。方法  选择2015年1月~2022年1月我科收治的80例创伤性桡骨远端骨折患者作为研究对象,所有患者均因间接暴力受伤,为单侧闭合性骨折,根据骨折分型和程度,按不同术式将患者分为两组,其中A组38例采用背侧入路切开复位钢板内固定术;B组42例采用掌侧入路切开复位钢板内固定术,对比分析两组患者的腕关节功能评分、肘关节功能评分,采用我院医学影像信息处理系统测量并记录两组术后骨折端复位情况相关的影像学参数（桡骨远端高度、掌倾角、尺偏角）,采用Logistic回归模型分析创伤性桡骨远端骨折固定术后关节功能恢复不良的影响因素。结果  两组术后疼痛、功能、活动度评分均高于术前（P < 0.05）,且B组术后上述腕关节功能评分均高于A组（P < 0.05）;两组术后关节活动范围、疼痛、稳定性、功能评分均高于术前（P < 0.05）,且B组术后上述肘关节功能评分均高于对照组（P < 0.05）;两组术后桡骨远端高度、掌倾角、尺偏角均高于术前（P < 0.05）,且研究组术后掌倾角高于对照组（P < 0.05）;本研究共80例患者,根据术后腕关节功能评分和肘关节功能评分结合影像学复查,术后恢复良好58例,恢复不良22例,单因素分析结果显示,年龄、末次复查掌倾角、手术方式与创伤性桡骨远端骨折固定术后关节功能恢复不良有关（P < 0.05）,性别、骨折分型与创伤性桡骨远端骨折固定术后关节功能恢复不良无关（P>0.05）;Logistic回归分析结果显示年龄、末次复查掌倾角、手术方式均是创伤性桡骨远端骨折固定术后关节功能恢复不良的独立影响因素（P < 0.05）。结论  通过掌侧入路切开复位钢板内固定术治疗创伤性桡骨远端骨折的疗效更佳,促进腕关节功能和肘关节功能恢复,改善与术后骨折端复位情况有关的影像学参数,可有效改善患者的预后。     

动作观察疗法对亚急性期脑卒中患者上肢运动功能的影响

目的:探讨动作观察疗法对亚急性期脑卒中患者上肢运动功能的影响。方法:将31例脑卒中患者按随机数字表法分为观察组(16例)和对照组(15例)。对照组采用常规康复治疗,观察组在对照组基础上辅以动作观察疗法,每周6次,每次20min,共治疗4周。分别于治疗前、治疗4周后对两组患者采用上肢Fugl-Meyer运动功能评分法(FMA)并使用量角器对肩关节前屈、肘关节伸展和腕背伸主动活动度进行测量,以评定患者的上肢运动功能;并分别检测治疗前后FMA与肩关节前屈、肘关节伸展和腕背伸主动活动度之间的相关性。结果:治疗前,两组患者的FMA评分及肩关节前屈、肘关节伸展和腕背伸主动活动度评定差异无显著性意义(P0.05);治疗4周后,两组患者上述指标较治疗前均有所改善(P0.05),且与对照组相比,观察组的FMA评分(44.81±8.86)、肩关节前屈(150.88°±21.32°)、肘关节伸展(135.56°±17.22°)主动活动度的改善程度显著(P0.05);两组患者,除治疗后的对照组FMA评分与肩关节主动前屈活动度、FMA评分与肘关节主动伸展活动度不相关(P0.05)外,其余FMA评分均与肩关节主动前屈活动度、肘关节主动伸展活动度及腕主动背伸活动度之间存在正相关性(P0.05)。结论:基于镜像神经元理论的动作观察疗法可改善亚急性期脑卒中患者的上肢运动功能,且FMA与肩关节前屈、肘关节伸展和腕背伸主动活动度存在相关性。     

夹腕端正法治疗肱骨外上髁炎20例的即刻疗效

目的观察夹腕端正法治疗肱骨外上髁炎患者的即刻疗效。方法选取2018年8月至2020年8月北京大学首钢医院收治的肱骨外上髁炎患者40例,采用随机数字表法将其分为治疗组(夹腕端正法治疗)和对照组(常规肘关节周围理筋法),每组20例。比较两组治疗前、后的肘关节VAS评分及肘关节活动度。结果治疗前,两组VAS评分比较,差异不具有统计学意义(P>0.05);治疗后,两组VAS评分均较治疗前降低,且治疗组低于对照组,差异具有统计学意义(P<0.05)。治疗前,两组肘关节伸、屈活动度比较,差异不具有统计学意义(P>0.05);治疗后,两组肘关节伸、屈活动度均较治疗前改善,且治疗组优于对照组,差异具有统计学意义(P<0.05)。结论夹腕端正法可减轻肱骨外上髁炎患者肘关节疼痛程度,改善肘关节活动度,效果优于常规肘关节周围理筋法。     

肘部内瘘与腕部内瘘对维持性血液透析患者左心结构的影响

目的 比较肘部内瘘与腕部内瘘对维持性血液透析患者左心结构的影响.方法 选择上海交通大学附属第一人民医院肾内科2007年10月至2011年1月维持性血液透析患者46例.分为肘部内瘘组(14例);腕部内瘘组(32例).比较2组左心室射血分数(EF)、短轴缩短率(FS)、左心房内径(LAD)、主动脉根部内径(AAo)、左心室...     

Differences in multi-joint kinematic patterns of repetitive hammering in healthy, fatigued and shoulder-injured individuals

BACKGROUND: Work-related musculo-skeletal disorders have been previously related to movement repetition, inadequate postures, non-ergonomic environments, muscular imbalance and fatigue. However, no direct link between fatigue and injury has been experimentally shown. To address this problem, we compared the effects of fatigue and injury on the kinematics of repetitive hammering. METHODS: Healthy subjects (n=30) hammered repetitively both before and after fatigue. Fatigue was induced by a combination of static and dynamic procedures. Shoulder-injured subjects (n=15) hammered for 30s without fatigue. Kinematics of motion was recorded. FINDINGS: The movement time and shoulder range of motion during hammering were not affected by either fatigue or shoulder injury. When fatigued, the healthy subjects displayed decreased range of joint motion, peak velocity and peak acceleration of elbow motion during hammering as well as reduced grip strength. Shoulder-injured individuals had a smaller hammer trajectory amplitude than healthy controls with or without fatigue. They also had lower wrist range of motion, elbow peak velocity, and peak wrist and elbow acceleration compared to healthy subjects hammering without fatigue but only lower wrist peak acceleration compared to healthy subjects hammering with fatigue. INTERPRETATION: Results showed that fatigue affects elbow motion while shoulder injury affects both wrist and elbow motions during hammering. However, shoulder kinematics were not changed by either fatigue or shoulder injury. These changes at the wrist and elbow may reflect strategies used by individuals with shoulder injury to maintain constant movement duration and shoulder kinematics during movement.     

Ulnar nerve conduction velocity as function of wrist position

Ulnar nerve conduction velocity (CV) calculated across the elbow has been shown to be significantly influenced by the position of the elbow. This study investigated the effect of wrist position on ulnar nerve CV in 19 control subjects. Ulnar nerve CV was determined with the elbow flexed at 90 degrees at two different wrist positions. The below-elbow-to-wrist CV was not significantly different between the wrist extended and the wrist flexed. Similarly, the mean across-elbow CV with wrist extended was not significantly different from the CV with the wrist flexed. The authors conclude that wrist position does not affect the calculated ulnar nerve CV across the elbow.     

Botulinum toxin type B in upper-limb poststroke spasticity: a double-blind, placebo-controlled trial

OBJECTIVE: To determine whether botulinum toxin type B (BTX-B) is effective in controlling upper-limb spasticity. DESIGN: A single-site, double-blind, placebo-controlled, randomized trial and open-label study. SETTING: Outpatient. PARTICIPANTS: Subjects with an Ashworth Scale score of 2 or more at the elbow, wrist, and fingers. INTERVENTIONS: Subjects were injected with 10000 U of BTX-B or placebo at the elbow, wrist, and finger flexors.Main outcome measures Measures recorded at weeks 0, 2, 4, 8, 12, and 16, with a 12-week open-label study. Ashworth Scale score, a global assessment of change (GAC), adverse events and mouse neutralization antibody testing. RESULTS: BTX-B did not decrease muscle tone in the elbow, wrist, or finger flexors at 10000 U over the 16-week period. A decrease in Ashworth Scale score for the BTX-B patient group was present at the wrist at week 2 of the double-blind study (P=.003) but was not statistically significant at other visits. In the open-label study, improvement was noted at week 4 for the elbow (P=.039), wrist (P=.002), finger (P=.001), and thumb flexors (P=.002). In the double-blind study, the Physician GAC did not reach significance. Dry mouth was reported by 8 of 9 BTX-B subjects in the double-blind study. Mouse neutralization antibodies were negative. CONCLUSIONS: Our study does not show a significant decrease in tone from 10000 U of BTX-B. Dry mouth was common.     

低频经皮穴位电刺激在社区脑卒中上肢手功能康复中的近期疗效分析

目的：探究低频经皮穴位电刺激（TEAS）作为社区适宜技术在脑卒中患者上肢和手功能康复中的近期疗效。方法：将60例社区脑卒中患者随机分为观察组和对照组各30例,2组患者均接受社区常规康复训练,观察组在此基础上增加TEAS治疗。治疗前后分别采用腕关节徒手肌力测试（MMT）、腕肘部改良Ashworth肌张力评定量表(MAS)、Fugl-Meyer上肢评定（FMA-UE）、美国国立卫生研究院卒中量表（NIHSS）、改良 Barthel指数（MBI）对患者进行评定。结果：治疗6周后,2组掌屈、背伸肌力评分均较治疗前显著提高(均P＜0.05);且观察组优于对照组(均P＜0.05),观察组肘关节肌张力评分均较治疗前和对照组显著降低(均P＜0.05),且观察组腕关节肌张力低于治疗前(P＜0.05)。治疗6周后,2组FMA-UE总分、FMA腕和手及MBI评分较治疗前均显著提高(均P＜0.05),且观察组高于对照组(P＜0.05);2组NIHSS评分均较治疗前显著降低(均P＜0.05);2组间比较差异无统计学意义。结论：低频经皮穴位电刺激适宜技术可以有效改善社区脑卒中患者近期手和上肢功能。     

Application of a volar static splint in poststroke spasticity of the upper limb

OBJECTIVE: To evaluate clinical and neurophysiologic effects of 3-month reflex inhibitory splinting (RIS) for poststroke upper-limb spasticity. DESIGN: Pretest-posttest trial. SETTING: Outpatient rehabilitation center. PARTICIPANTS: Forty consecutive patients with hemiplegia and upper-limb spasticity after stroke that had occurred at least 4 months before. INTERVENTION: Patients wore an immobilizing hand splint custom-fitted in the functional position for at least 90 minutes daily for 3 months. MAIN OUTCOMES MEASURES: Patients underwent measurement of (1) spasticity at the elbow and wrist according to Modified Ashworth Scale; (2) passive range of motion (PROM) at the wrist and elbow; (3) pain at the shoulder, elbow, and wrist using a visual analog scale; (4) spasms; and (5) comfort and time of splint application. The instrumental measure of spasticity was the ratio between the maximum amplitude of the H-reflex and the maximum amplitude of the M response (Hmax/Mmax ratio). RESULTS: A significant improvement of wrist PROM (F=8.92, P=.001) with greater changes in extension than in flexion, and a reduction of elbow spasticity (F=5.39, P=.002), wrist pain (F=2.89, P=.04), and spasms (F=4.33, P=.008) were observed. The flexor carpi radialis Hmax/Mmax ratio decreased significantly (F=4.2, P=.007). RIS was well tolerated. CONCLUSIONS: RIS may be used as an integrative treatment of poststroke upper-limb spasticity. It can be used comfortably at home, in selected patients without functional hand movements, and in cases of poor response or tolerance to antispastic drugs.     

ANALYSIS OF RANGE OF MOTION IN FEMALE RECREATIONAL TENNIS PLAYERS WITH AND WITHOUT LATERAL ELBOW TENDINOPATHY

Background:Intrinsic factors including altered joint motion in the upper extremity may lead to altered biomechanics in tennis players and could result in symptoms of lateral elbow tendinopathy.Purpose:To compare upper extremity passive motion and elbow carrying angle between three groups of women: recreational tennis players with LET, non-symptomatic recreational tennis players, and a control group of non-tennis players.Study Design:Cross-sectional.Methods:A convenience sample of 63 women was recruited and placed into one of the three groups: non-symptomatic tennis players (NSTP), symptomatic tennis players (STP), and a control group. Elbow carrying angle, passive range of motion of the shoulder, elbow, forearm, and wrist were measured during a single session.Results:A significant difference was found between the groups for wrist flexion (p < 0.00), forearm pronation (p = 0.002), elbow flexion (p = 0.020) and extension (p = 0.460), as well as shoulder internal rotation (p < 0.00). No significant differences were found in other motions or carrying angle between the three groups (p =0.059). Post-hoc comparisons indicated that shoulder internal rotation and wrist flexion was less in both STP and NSTP groups compared with the control group. Elbow flexion and forearm pronation were greater in STP than the other two groups.Conclusion:Impairments including loss of shoulder internal rotation and wrist flexion and greater motion at the elbow and forearm were found in the UE of symptomatic tennis players. Evaluation of passive motion and muscle length should be performed prior to establishing a rehabilitation plan for symptomatic tennis players.Levels of Evidence:3