血压正常的2型糖尿病患者动态血压的改变

目的：观察血压正常的2型糖尿病患者动态血压的改变及其与尿白蛋白排泄率和自主神经病变的关系。方法：对偶测3次血压正常的36例2型糖尿病患者进行24h动态血压监测，同时测定尿白蛋白排泄率（UARE），并与39例健康人（对照组）进行比较。结果：2型糖尿病患者24h平均收缩压、夜间收缩压均较对照组明显增高（P＜0．01）；夜间收缩压负荷值增高（P＜0．01）；夜间收缩压下降百分率降低（P＜0．05）。有神经病变的2型糖尿病患者夜间收缩压下降百分率及昼夜蛋白排泄率差值均低于无神经病变患者（P＜0．01），有非常显著性差异。结论：2 型糖尿病患者在血压增高之前已出现昼夜血压节律异常，与交感、副交感神经受损程度有关。在出现昼夜节律异常时进行干预，有助于早期发现和针对性地治疗高血压。     

2型糖尿病患者微量白蛋白尿与动态血压,胰岛素水平关系的研究

目的 :研究 2型糖尿病患者微量白蛋白尿与动态血压、胰岛素水平之间的关系。方法 :5 0例 2型糖尿病患者分成微量蛋白尿组 ( 2 3例 ) ,正常蛋白尿组 ( 2 7例 ) ,分别测 2 4小时动态血压、糖基化血红蛋白、胆固醇、甘油三酯、血浆胰岛素水平。结果 :①微量白蛋白尿组患者的夜间收缩压、平均动脉压分别为 ( 14 1.8± 6.8)mmHg( 1mmHg =0 .13 3kPa)和( 97.1± 0 .9)mmHg ,较正常组 ( 12 2 .3± 6.1)mmHg和 ( 88.7± 5 .2 )mmHg明显升高 ,并存在显著差异 ( P均 <0 .0 5 )。②微量白蛋白尿组血浆胰岛素水平明显高于正常组 (P <0 .0 5 )。而血脂血糖、糖基化血红蛋白两组无显著差别 (P均 >0 .0 5 )。结论 :2型糖尿病患者微量白蛋白尿与夜间收缩压、平均动脉压及胰岛素水平有显著相关关系。     

急性缺血性脑卒中动态血压变化临床研究

目的 :探讨急性缺血性脑卒中患者的血压昼夜变化规律。方法 :采用 2 4小时无创伤性全自动动态血压记录仪 ,对 4 6例急性缺血性脑卒中合并高血压患者及 3 0例正常人进行动态血压测量。结果 :急性缺血性脑卒中患者 2 4小时平均收缩压和舒张压、白天平均收缩压和舒张压、夜间平均收缩压和舒张压都比对照组明显增高 ( P<0 .0 1) ,而且血压夜间下降率收缩压为 6% ,舒张压为 7% ,均小于 10 % ,夜间 /白天收缩压为 0 .95 ,夜间 /白天舒张压为 0 .94 ,比正常值增高。结论 :高血压合并脑梗死患者血压昼夜波动减少 ,为“非杓型”改变。     

高原地区Ⅱ型糖尿病微白蛋白尿患者的动态血压和心率的关系

目的：观察高原地区Ⅱ型糖尿病微白蛋白患者动态血压水平及昼夜节律改变和心率的关系。方法：对各组共１０６例行２４小时动态血压和心率的监测。结果：Ⅱ型糖现微白蛋白尿患者２４小时血压和心率、白天血压、夜间血压和和心率均显著增高,夜间血压下降幅度减少。结论：高原地区Ⅱ型糖尿病患者尿白蛋白发展和昼夜血压节律异常与心率变化有关,同时发现夜间血压以舒张压增高为主。     

氯沙坦对糖尿病微血管病变的影响

目的观察氯沙坦对糖尿病肾病合并高血压患者降低尿白蛋白排泄率及降压疗效。方法 6 0例早期糖尿病肾病患者 ,其中 30例伴高血压 ,30例不伴有高血压 ,原糖尿病治疗不变 ,经洗脱期 (停用所有扩血管药物 2周 )后 ,给氯沙坦5 0～ 10 0mg/d口服干预 ,8周后观察 2 4小时动态血压、尿白蛋白排泄率 (UAER)、血肌酐 (Cr)、尿素氮 (BUN)水平的变化。结果治疗后 2 4小时UAER明显下降 (P <0 .0 5 ) ,伴高血压的患者 2 4小时血压下降有显著性 (P <0 .0 5 ) ,血压昼夜下降幅度无显著性 (P >0 .0 5 ) ;不伴高血压的糖尿病肾病患者血压下降无显著性。 2 4小时UAER的下降与血压下降无相关性 (P >0 .0 5 )。结论氯沙坦可降低糖尿病肾病伴高血压患者的尿白蛋白 ,同时降低血压 ,但不能改变糖尿病高血压患者的血压昼夜节律异常 ,氯沙坦有独立于降压之外的降低糖尿病伴高血压患者的尿白蛋白 ,同时降低血压 ,但不能改变糖尿病高血压患者的血压昼夜节律异常 ,对不伴有高血压的糖尿病肾病患者能有效降低尿蛋白 ,而不降低血压。     

2型糖尿病合并高血压患者24小时动态血压分析

目的观察2型糖尿病合并高血压患者24h动态血压昼夜节律的变化。方法选取60例住院患者,按诊断标准分为2型糖尿病合并高血压组和单纯高血压组,对所有患者进行24h动态血压监测,比较24h平均收缩压、24h平均舒张压、白天平均收缩压、夜间平均收缩压、白天平均舒张压、夜间平均舒张压、24h平均脉压、白天平均脉压、夜间平均脉压及血压昼夜节律。结果 24h平均舒张压、白天平均收缩压、白天平均舒张压、白天平均脉压2组比较差异无统计学意义(P均>0.05),24h平均收缩压、夜间平均收缩压、24h平均脉压、夜间平均脉压及血压昼夜节律2组比较差异有统计学意义(P均<0.05)。结论 2型糖尿病合并高血压患者建议尽早进行24h动态血压监测,同时降压和降血糖,纠正异常的昼夜血压节律,对于减少心脑血管并发症、防止靶器官的损害具有积极意义。     

胰岛素抵抗和动态血压在2型糖尿病肾病中的作用

目的通过检测尿Ⅳ型胶原探讨胰岛素抵抗和动态血压对2型糖尿病肾病的影响。方法 90例2型糖尿病患者根据尿微量白蛋白排泄量分为3组(各30例):糖尿病无肾病组、糖尿病早期肾病组及糖尿病临床肾病组。另选健康体检者34例作为正常对照组。采用ELISA法测定尿Ⅳ型胶原,免疫比浊法测定尿微量白蛋白;并进行胰岛素敏感指数、相关的肾功能指标和24h动态血压监测。结果胰岛素敏感指数在2型糖尿病各组均低于正常对照组(P均<0.05)。24h平均血压、白天和夜间平均血压在糖尿病临床肾病组高于其他3组(P均<0.05)。尿Ⅳ型胶原与胰岛素敏感指数呈负相关,与24h平均舒张压、夜间血压、尿微量白蛋白排泄量、尿β2-微球蛋白、尿α1-微球蛋白和尿-乙酰-β-D-氨基葡萄糖苷酶呈正相关。结论胰岛素抵抗和动态血压通过Ⅳ型胶原影响2型糖尿病肾病的发展。     

高龄高血压病合并2型糖尿病患者动态血压变化观察

目的观察高龄高血压病合并2型糖尿病患者的动态血压变化。方法选取84例高龄高血压患者,按照是否合并2型糖尿病分为两组,即A组(单纯高血压)和B组(高血压合并糖尿病),监测24 h动态血压。结果高血压合并2型糖尿病患者所测得夜间平均收缩压(nSBP)、夜间平均动脉压(nMBP)较单纯高血压患者均升高;高血压合并2型糖尿病患者非杓型动态血压节律较单纯高血压患者比率增高,两组比较差异显著(P<0.05)。结论高龄高血压病合并2型糖尿病患者昼夜变化节律明显改变,监测高龄高血压病合并2型糖尿病患者动态血压可为治疗提供指导。     

阻塞性睡眠呼吸暂停综合征患者的血压波动特点及护理

目的 :分析阻塞性睡眠呼吸暂停综合征患者血压波动特点。方法 :应用无创性携带式动态血压监测仪进行 2 4h动态血压监测。结果 :阻塞性睡眠呼吸暂停综合症患者的昼夜平均收缩压和平均舒张压均高于正常人 ;夜间血压下降率均小于正常人群 ( <10 % ) ;试验组与对照组的动态血压各均值均有显著性差异 (P <0 .0 5 )。结论 :该组患者夜间发生心血管意外的可能性增大 ,护士应增加夜间血压监测、采取最佳测血压的时间 ,为指导患者采取最佳服用降压药物时间提供了客观依据。     

2型糖尿病视网膜病变危险因素的探讨

目的 对2型糖尿病视网膜病变的相关危险因素进行多因素分析。方法 选择2型糖尿病患者357例，其中糖尿病视网膜病变组(DR组)152例和未合并视网膜病变组(NDR组)205例。比较两组间的临床特征和实验指标包括性别、年龄、体重指数、吸烟情况、糖尿病病程、血压(收缩压和舒张压)、血糖(空腹血糖和餐后2h血糖)、血脂以及尿白蛋白排泄率等。结果 经多因素非条件logistic回归分析显示，糖尿病病程和尿白蛋白排泄率与2型糖尿病视网膜病变显著关联。结论 糖尿病病程和尿白蛋白排泄率是2型糖尿病视网膜病变的独立危险因素。     

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.