Ⅴ型斜视的手术治疗

目的探討Ⅴ型斜視不同術式的治療效果.方法采用直肌符着點垂直移位及下斜肌部分切除兩種方法治療Ⅴ型斜視.結果V型斜視采用下斜肌部分切除術和直肌符着點移位術均取得較好治療效果,但下斜肌部分切除效果更為明顯.結論采用直肌符着點垂直移位及下斜肌部分切除術矯正Ⅴ型斜視不但可矯正眼位,而且可重建視功能.     

Contractile speed and fatigue of adductor pollicis muscle in multiple sclerosis

The purpose of the study was to investigate differences in contractile speed, force, and fatigability of the adductor pollicis muscle between 12 patients with multiple sclerosis (MS) and 8 sedentary control subjects matched for age and gender. There were no differences between the patients with MS and control subjects with respect to the percentage of maximal muscle force that could be recruited during voluntary effort (95.5 +/- 3.9% and 98.2 +/- 2.0%, respectively, P = 0.10), the stimulation frequency/force and force/velocity relationships, the rates of force development and relaxation, fatigue resistance, and the recovery rate of adductor pollicis muscle. However, previous results from the same group of MS patients showed that quadriceps femoris muscle force and resistance to fatigue were reduced. Therefore, our data support the clinical experience that, in patients with MS, lower limb muscle function is more or earlier affected than upper limb muscle function.     

Obtaining force-frequency curves with a single 3-second train of stimuli

We devised a method to assess the force-frequency relationship (FFR) in human skeletal muscle that involved delivery of a single 2.8-s train of shocks directly to the femoral nerve. This increasing-frequency train (IFT) was based on a power function, with a range of stimulation frequencies beginning at 5 Hz and rising to 100 Hz. We compared the IFT to a standard series of constant-frequency trains (CFT) under two conditions. Force-frequency curves were examined, first in response to altered muscle length and second, following fatigue. There was no leftward shift in the curve when the knee extensors were shortened, although maximal force increased. In contrast, we observed a rightward shift in the curve after fatigue with both protocols; the frequency required to develop 50% of maximal force increased by 48% (P <.01) with CFT and 58% (P <.001) with an IFT. The CFT produced an irregular pattern of low-frequency fatigue recovery. In the IFT, low-frequency fatigue was greatest at the onset of recovery and decreased linearly until 120 s. These experiments show that the IFT protocol reveals alterations in muscle performance similar to the more traditional CFT. However, it requires only 2.8 s to administer and was judged more tolerable by 70% of our subjects. This suggests that the IFT may be an effective alternative for determining the FFR in human muscle for clinical and experimental purposes.     

Flexor digitorum longus accessorius in the club foot of an infant with Nager syndrome

The case of a male infant is reported who had club foot on the right side and pes adductus on the left side in combination with acrofacial dysostosis; he also demonstrated preaxial anomalies of the upper limbs indicative of Nager syndrome. In addition, an unusual aberrant muscle was discovered during surgical correction of the right club foot. Received: 22 March 1999     

Patients' perceptions of medical care in chronic fatigue syndrome

This study investigated perceptions of medical care among patients with chronic fatigue syndrome (CFS) referred to a specialist clinic. Sixty-eight patients completed a questionnaire survey on their overall satisfaction with medical care received since the onset of their illness, and their views on specific aspects of care. Two-thirds of patients were dissatisfied with the quality of medical care received. Dissatisfied patients were significantly more likely to describe delay, dispute or confusion over diagnosis; to have received and rejected a psychiatric diagnosis; to perceive doctors as dismissive, skeptical or not knowledgeable about CFS and to feel that the advice given was inadequate or conflicting. Satisfied patients were significantly more likely to perceive doctors as caring, supportive and interested in their illness; to state that they did not expect their doctors to cure CFS and to perceive their GP or hospital doctor as the source of greatest help during their illness. Many patients were critical of the paucity of treatment, but this was not associated with overall satisfaction. The findings suggest that medical care was evaluated less on the ability of doctors to treat CFS, and more on their interpersonal and informational skills. Dissatisfaction with these factors is likely to impede the development of a therapeutic doctor-patient alliance, which is central to the effective management of CFS. The findings suggest a need for better communication and better education of doctors in the diagnosis and management of CFS.     

Endocannabinoids protect cerebral cortical neurons from in vitro ischemia in rats

Activation of the ventrolateral periaqueductal gray (vlPAG) evokes a reaction of quiescence, immobility, hypotension and bradycardia. Pain of deep somatic or visceral origin also often triggers a reaction of quiescence, immobility, hypotension and bradycardia and further, evokes a selective increase in immediate-early-gene (c-Fos) expression within the vlPAG. Vasodepression evoked from the vlPAG is thought to be mediated by an inhibition of presympathetic neurons within the rostral ventrolateral medulla (RVLM). In this study the prior injection of retrograde tracer into the RVLM was combined with the use of Fos expression as a marker of neuronal activation, to determine if deep (muscle) pain-evoked vasodepression could be mediated by a direct vlPAG-RVLM pathway. It was revealed that intramuscular injection of formalin, in the anaesthetised rat, evoked a significant increase in Fos expression within the caudal vlPAG, and that approximately 25% of the Fos-immunoreactive neurons projected to the RVLM.     

Muscle involvement in rheumatoid arthritis: an ultrastructural study

An electron microscopic investigation has been carried out on muscle bioptic samples from patients affected by rheumatoid arthritis (RA). This study was undertaken to seek further ultrastructural alterations affecting striated muscles in RA pathology. Bioptic samples were collected on a total of 30 surgical interventions of hip (10), knee(8), and foot (12). This yielded three muscle types: gluteus maximus, vastus lateralis, and extensor digitorum communis. Muscle samples from 12 patients with no RA stigmata, selected to match RA patients by age and gender, constituted the control group. Tissue samples were prepared both for conventional histochemical methods and according to conventional electron microscopic procedures, including morphometric analysis. Although to a different extent in each sample, in muscles from RA vs. controls the authors observed the simultaneous presence of discrete muscular alterations such as wider separation of myofibrils, myelin figures, dilated sarcotubular system, pleomorphic mitochondria, myofibril flaking, and lipofuscin deposition in the subsarcolemmal region. In addition to a progressive atrophy, the above findings are suggestive of rheumatoid myositis and lend further support to the still poorly documented presence of an idiopathic inflammatory myopathy and inclusion body myositis associated with RA.     

Medical Student Competence in Eliciting a History for “Chronic Fatigue”

Purpose: We report an observational study of medical students abilities in taking a complex history for which sleep disorders is one of several possible conditions. Methods: Students are observed taking a focused history from a simulated patient whose chief complaint is I am tired. I cannot get anything done. Nine groups of students (n = 360) completing the internal medicine core-clerkship were evaluated by one of three examiners. Students received full, partial, or no credit for each item on a uniform behavioral checklist, which included prompts for common medical and psychiatric disorders associated with chronic fatigue. Results: Observed means were lowest for items pertaining to sleep behaviors and head trauma. Fewer than half of the students inquired about whether or not the person had difficulty falling asleep at night, family history of sleep apnea, and frequency and length of naps. In contrast, the majority of students inquired about heart disease, metabolic disorders, the use of illicit drugs, alcohol consumption, and the taking of medications. Examiners accounted for a significant source of variance in scores; yet the station discriminated among top and bottom students as measured by the Objective Structured Clinical Examination (OSCE) overall. No statistically significant differences were observed on the basis of clerkship site, primary care versus traditional-track students, time of year, or gender. Conclusion: A majority of students do not adequately cover issues relevant to sleep in contrast to other associated disorders when taking a focused history for chronic fatigue.     

A definition-based analysis of symptoms in a large cohort of patients with chronic fatigue syndrome

OBJECTIVE: The Holmes and Fukuda criteria are widely used criteria all over the world, yet a specific European study regarding chronic fatigue syndrome (CFS) patient symptomatology has not been conducted so far. This study was performed to answer the need to assess the homogeneity of a large CFS population in relationship to the Fukuda or Holmes definitions and to assess the importance of a symptom severity scale. DESIGN: Multivariate analyses were performed to assess the symptom presentation within a fatigued population and the differences between the Fukuda and Holmes definitions compared with an excluded chronic fatigued group in a large cohort of fatigued patients. SETTING: An outpatient tertiary care setting fatigue clinic in Brussels. MAIN OUTCOME MEASURES: Prevalence and severity of symptoms and signs in a CFS population and in a chronic fatigued population. SUBJECTS AND METHODS: A total of 2073 consecutive patients with major complaints of prolonged fatigue participated in this study. Multivariate analyses were performed to assess the symptom presentation and severity and the differences between the Fukuda and Holmes definitions. RESULTS: Of the 2073 patients complaining of chronic fatigue (CF), 1578 CFS patients fulfilled the Fukuda criteria (100% of CFS group) and 951 (60.3% of the CFS group) fulfilled the Holmes criteria. Discriminant function analysis revealed that the Fukuda and Holmes definitions can be differentiated by symptom severity and prevalence. The Holmes definition was more strongly associated than the Fukuda definition with the symptoms that differentiated the CFS patients from the patients that did not comply with the CFS definitions. The inclusion of 10 additional symptoms was found to improve the sensitivity/specificity and accuracy for selection of CFS patients. CONCLUSIONS: The CFS patients fulfilling the Holmes criteria have an increased symptom prevalence and severity of many symptoms. Patients fulfilling the Fukuda criteria were less severely affected patients which leads to an increase in clinical heterogeneity. Addition of certain symptoms and removal of others would strengthen the ability to select CFS patients.     

Orthostatic intolerance: different abnormalities in the neural sympathetic response to a gravitational stimulus

In this paper we shall focus on the different abnormalities in the neural sympathetic response to a gravitational stimulus, characterising syndromes with symptoms of orthostatic intolerance. In Vaso vagal Syncope, an increase or a reduction of cardiac and vascular sympathetic modulation have been described in occasional and habitual fainters, respectively. Pure Autonomic Failure (PAF) is characterized by a global cardiovascular denervation. Accordingly, the spectral markers of cardiac and vascular sympathetic modulation are absent or reduced. However, a concomitant vagal diminished activity is present. In Chronic Orthostatic Intolerance (COI), the most common form of dysautonomia in young female, an abnormal regional distribution of sympathetic discharge has been hypothesized during standing. Indeed, an overall increased sympathetic activity is present in recumbent position; during tilt a blunted vascular sympathetic discharge, with a concomitant exaggerated cardiac sympathetic modulation, is evident. Baroreflex Failure is a syndrome that may result from neck surgery or irradiation due to different forms of regional cancer. It is characterized by a volatility of blood pressure and heart rate, without habitual orthostatic hypotension. In the present paper, we describe a case of Baroreflex Failure with marked orthostatic hypotension in spite of a huge muscle sympathetic nerve activity (MSNA) and high levels of plasma cathecolamines. The most relevant finding was the absence of any coordinate rythmicity in blood pressure, heart rate and MSNA, both at rest and during tilt, particularly in the frequency band likely to be related with sympathetic modulation, i.e. at 0.1 Hz. We hypothesize that the absence of 0.1 Hz spontaneous fluctuations might play a role in sustaining orthostatic hypotension.