跨步或不跨步下的前弓步和侧弓步动作中的髌股关节压力与应力(一)

背景:在髌股关节康复训练中经常进行负重的弓步动作,但这种动作下的髌股关节压力和应力状况尚不明确.方法 :18名受试者在负重下做跨步和不跨步的前弓步和侧弓步动作,负重承量为口J进行12次重复动作的最大负荷.将肌电学、测力平台以及运动学数据输入生物力学模型中,计算不同膝关节屈曲角度下的髌股关节压力和应力.结果 :髌股关节的压力和应力随膝关节屈曲角度增加而增高,随膝关节屈曲角度减小而降低.膝关节屈曲80°～90°时,侧弓步下的髌股关节压力和应力大于前弓步;膝关节屈曲10°～50°时,跨步下的髌股关节压力和应力大于不跨步.弓步和跨步之间无明显的相互作用.膝关节屈曲0°～50°时髌股关节压力和应力小于膝关节屈曲60°～90°时的压力和应力,因此在髌股关节康复训练早期应限制膝关节屈曲在50°以内.解释:为了尽量减小髌股关节的压力和应力,应当在不跨步下进行前弓步和侧弓步练习,尤其是膝关节屈曲0°～50°时.了解不同弓步间髌股关节压力和应力的差异,可能有助于临床医生制定更加安全有效的康复训练方法.     

Alan Stone and the ethics of forensic psychiatry: an overview

In 1982, Alan Stone presented a keynote speech at the Annual Meeting of the American Academy of Psychiatry and the Law (AAPL) on the ethics of forensic psychiatry. That speech was sharply critical of the prevailing ethics standards and led forensic psychiatrists to study his ideas carefully. A quarter-century later, he returned to the AAPL's Annual Meeting to present his current thinking. This overview outlines the development of Stone's thought over 25 years and the dialectic among Stone and three critics: Paul Appelbaum, Ezra Griffith, and Stephen Morse. Stone is now more optimistic about the possibility of developing an ethic for forensic psychiatry.     

Outcome of electroconvulsive therapy by race in the Consortium for Research on Electroconvulsive Therapy multisite study

OBJECTIVE: The authors examine the differences in outcome between black and white patients receiving electroconvulsive therapy (ECT) as a part of the Consortium for Research on Electroconvulsive Therapy multisite study. METHODS: A total of 624 patients were enrolled in an National Institute of Mental Health (NIMH)-funded, randomized, controlled ECT trial comparing the efficacy of continuation ECT versus continuation pharmacotherapy between 1997 and 2004. This analysis focuses on the 32 black and 483 white patients who participated in phase I of the study. The authors compared baseline demographic and clinical variables and acute outcomes of these 2 groups. RESULTS: Compared with whites, far fewer blacks participated in the study. Those who did were less likely to have failed adequate medication trials and were more likely to have psychotic features. Their initial 24-item Hamilton Rating Scale for Depression scores were higher than those of the whites, and they showed a greater reduction in these 24-item Hamilton Rating Scale for Depression scores by the end of the treatment period. Although sample size limited the statistical significance of the findings, black patients also showed a higher rate of remission after an acute phase of ECT. CONCLUSIONS: This study found that black and white patients with major depressive disorder had comparable outcomes. We also found that fewer black patients received ECT than whites, a difference that has been reported in other samples.     

"Psychometric intelligence" is not equivalent to "crystallized intelligence," nor is it insensitive to presence of brain damage: a reply to Russell

Whether Halstead's (1947) distinction between biologic and psychometric intelligence and Cattell's (1963) theory of fluid and crystallized intelligence reflect the same underlying constructs is an interesting question and has heuristic value. To address that question experimentally, however, requires factor-analytic and other higher-order correlative analysis with careful clinical syndrome characterization. We argue that Halstead's and Cattell's characterizations of test attributes into distinct domains are not equivalent, and that the proposal of their equivalence cannot be properly evaluated based solely on test battery sensitivity to brain damage.     

Luteinized thecomas (thecomatosis) of the type typically associated with sclerosing peritonitis: a clinical, histopathologic, and immunohistochemical analysis of 27 cases

The nature of the distinctive ovarian lesion often associated with sclerosing peritonitis, initially considered a variant of luteinized thecoma in the paper describing this phenomenon, remains uncertain, as does its long-term prognosis. We describe the features of 27 cases, including immunohistochemical analysis of 13 cases. Sclerosing peritonitis was documented in 25 cases. Patients ranged in age from 10 months to 85 years, and typically presented with abdominal distension and pain with ascites and sometimes bowel obstruction. The ovarian lesions, clinically bilateral in 24 cases, ranged from 2 to 31 cm and often had a striking cerebriform aspect. Microscopically, mitotically active spindle cells with weakly luteinized cells, variable edema, and entrapped follicles were typical. The spindle cells were focally positive with calretinin in 2 cases, CD56 in 2, AE1/3 in 4, smooth muscle actin in 12, and desmin in 8 cases, and negative with alpha-inhibin, epithelial membrane antigen, beta-catenin, CD34, and transforming growth factor-beta, with focal nuclear positivity for estrogen receptor in 5 and progesterone receptor in 11 cases. Luteinized cells were positive with alpha-inhibin, calretinin, and/or CD56. The peritoneal lesions were strongly positive with AE1/3 and exhibited focal weak or moderate positivity with estrogen receptor or progesterone receptor in 4 of 8 cases each. Follow-up in 20 cases (mean: 5.9 y) disclosed no evidence of spread of the ovarian lesion, but 3 patients died of sclerosing peritonitis. The findings fail to allow definitive classification of the ovarian lesions, and we prefer at present to retain their current designation as a subtype of luteinized thecoma, but to allow for the possibility of a non-neoplastic nature, feel it reasonable to have the designation "thecomatosis" as a parenthetical alternative. We have documented for the first time that sclerosing peritonitis is not invariably associated with the distinctive ovarian pathology present in these cases.     

An 18-year experience in the management of congenital nevomelanocytic nevi

BACKGROUND: Children with giant congenital nevomelanocytic nevi (CNN) are referred to our pediatric burn center for the surgical management of this disfiguring and potentially malignant skin disorder. Use of tissue expanders has contributed significantly in limiting donor site morbidity associated with treatment of giant CNN. Cultured skin substitutes (CSS) have also shown promise as an alternative wound coverage. With recent controversy regarding the effectiveness of excision in preventing melanoma risk, we wished to review our surgical management of giant CNN and to determine the incidence of malignancy in these patients. METHODS: A retrospective chart review of patients with giant CNN was performed from 1985 to 2003. Charts were reviewed for age, sex, percentage total body surface area (TBSA) involved, age at initiation and completion of treatment, surgical treatment, complications, histopathology, and length of follow-up. RESULTS: Of the 40 patients treated at our facility, the mean extent of skin involvement was 10% TBSA (range: 0.5%-75%). The mean age at initial operation was 5.1 years, and the majority of surgical interventions were completed within a mean of 1.3 years. Twenty-two patients (55%) required more than 1 surgical procedure. Excision and split-thickness skin grafting was the most common surgical procedure (n = 22) followed by excision with primary closure (n = 18). Ten patients were treated with tissue expansion, while 4 received cultured skin replacements. One patient died of extracutaneous melanoma during the course of surgical treatment. Three patients demonstrated histopathologic evidence of cytoatypia but remained clinically free of malignancy during a mean follow-up of 11 years. CONCLUSIONS: Giant CNN are both important cosmetic and medical problems. With an associated lifetime risk of melanoma in 4%-10% of patients, excision of CNN is recommended despite the fact that 50% of melanomas arise extracutaneously. Depending on the extent of body surface area involvement, wound closure can be obtained with conventional split- or full-thickness skin grafts, tissue expansion, and/or cultured autologous cultured skin substitutes. The latter 2 modalities provide improved cosmetic results, with minimal donor site morbidity.     

Cost-effectiveness of frequent in-center hemodialysis

Published evidence suggests that frequent hemodialysis (more than three times per week) for patients with ESRD may improve health-related quality of life and has the potential to increase longevity and reduce hospitalization and other complications. Here, a Monte Carlo simulation model was used to compare varying combinations of in-center hemodialysis frequency (three to six treatments per week) and session length (2 to 4.5 h per session) with regard to unadjusted and quality-adjusted life-years and total lifetime costs for a cohort of 200,000 patients, representing the prevalent ESRD population. The incremental cost-effectiveness ratio was calculated for the various regimens relative to a conventional hemodialysis regimen (three treatments per week, 3.5 h per session). Using conservative assumptions of the potential effects of more frequent hemodialysis on outcomes, most strategies achieved a cost-effectiveness ratio of <$125,000, although all had a cost-effectiveness ratio of >$75,000. The cost-effectiveness ratio increased with the frequency of hemodialysis. More frequent in-center hemodialysis strategies could become cost-neutral if the cost per hemodialysis session could be reduced by 32 to 43%. No other change in model assumptions achieved cost neutrality. In conclusion, given the extraordinarily high costs of the ESRD program, the viability of more frequent hemodialysis strategies depends on significant improvements in the economic model underlying the delivery of hemodialysis.