The kidney is vulnerable to ischemia and reperfusion (I/R) injury that can be fatal after major surgery. Currently, there are no effective treatments for I/R-induced kidney injury. Trimethylamine N-oxide (TMAO) is a gut-derived metabolite linked to many diseases, but its role in I/R-induced kidney injury remains unclear. Here, our clinical data reveals an association between preoperative systemic TMAO levels and postoperative kidney injury in patients after post-cardiopulmonary bypass surgery. By genetic deletion of TMAO-producing enzyme flavin-containing monooxygenase 3 (FMO3) and dietary supplementation of choline to modulate TMAO levels, we found that TMAO aggravated acute kidney injury through the triggering of endoplasmic reticulum (ER) stress and worsened subsequent renal fibrosis through TGFβ/Smad signaling activation. Together, our study underscores the negative role of TMAO in I/R-induced kidney injury and highlights the therapeutic potential through the modulation of TMAO levels by targeting FMO3, thereby mitigating acute kidney injury and preventing subsequent renal fibrosis. This study elucidates the potential of targeting FMO3 to modulate TMAO levels as a therapeutic approach for mitigating acute kidney injury and subsequent renal fibrosis.

Objective To assess sound source recognition benefits in the horizontal plane in patients with bimodal fitting and daily use settings. Methods A total of 24 patients with bimodal fitting were enrolled in the study and performed sound source recognition tasks in the horizontal plane presented via 37 loudspeakers in a semicircular array in front of the participant at 5° intervals. Stimuli were 0.25, 0.5, 1, 2, 4 and 8 kHz warbles 30 dB above the aided thresholds. Root-mean-square error（RMSE） was used as the assessment index. Results Average performance score was81.95±11.33° when using unilateral cochlear implant（CI） and 78.98±8.12° for bimodal fitting, respectively（t=1.232, P=0.230）. Fourteen subjects performed better when using bimodal fitting, while the other 10 subjects performed worse, as compared to using CI only. Their aided interaural threshold differences were not significantly different（z=0.147, P=0.886）. Age, duration of deafness and duration of bimodal use showed no correlation with sound localization performance（r=-0.102, P=0.636; r=-0.312, P=0.137; r=0.360, P=0.867; repectively）. Conclusion Bimodal fitting did not significantly improve sound source localization ability in these patients. Aided interaural threshold difference, age, duration of deafness and duration of bimodal use do not appear to affect sound localization ability. Sound source localization may depend more on matching the bimodal devices used.

患者 女性,54岁,大学文化.因进行性记忆力减退6年,于2020年8月12日入院.患者6年前因"工作变动压力大"出现记忆力减退,表现为近事记忆减退,忘记物品放置位置,日常工作需工作日程提醒.4年前近事记忆减退加重,常忘记刚说过的话,工作能力下降,睡眠差,当地医院考虑"焦虑",予舍曲林50 mg/d 口服.

目的 分析足月儿颅内出血的发生情况及危险因素,并探讨其对患儿远期生命质量的影响.方法 纳入152例颅内出血足月儿(观察组),以及304例同期无颅内出血的健康足月儿(对照组).收集两组新生儿及其母亲的临床资料.以电话随访的方式,采用儿童生命质量测定量表4.0中文版普适性核心量表对两组儿童的远期生命质量进行评定.分析足月儿发生脑室周围-脑室内出血(PV-IVH)或硬膜下出血(SDH)的危险因素.结果 足月儿颅内出血的发生率为1.3％(152/12089),以PV-IVH为主要类型(占48.0％),SDH占35.5％.小于胎龄儿、宫内窘迫、产钳助产是足月儿发生PV-IVH的独立危险因素(均P<0.05);阴道分娩、产钳助产是足月儿发生SDH的独立危险因素(均P<0.05).新生儿期合并颅内出血的儿童生命质量测定量表总均分、生理功能维度均分、情感功能维度均分及社交功能维度均分均低于正常儿童(均P<0.05).结论 足月儿颅内出血的发生率为1.3％,以PV-IVH为主要类型.小于胎龄儿、阴道分娩、产钳助产与宫内窘迫可增加足月儿颅内出血的发生风险.新生儿期合并颅内出血的儿童的远期生命质量差于正常儿童,生理功能、情感功能和社交功能均有受损.

Objective:To investigate the effect of dapagliflozin on aldosterone to renin ratio (ARR) in patients with type 2 diabetes mellitus (T2DM) complicated with hypertension.Methods:Patients with T2DM and hypertension who were admitted to the Department of Endocrinology, Beijing Huairou Hospital from September 2019 to December 2020 were enrolled. Body weight, fasting blood glucose (FPG), glycosylated hemoglobin (HbA 1c), uric acid, plasma renin concentration, aldosterone level and other indicators were measured and recorded before treatment, and ARR was calculated. Patients were treated with dapagliflozin for 12 weeks, and hematologic indicators were collected again while ARR was also calculated. Paired t test or Mann-Whitney U test were used to compare the ARR and related indexes before and after treatment of dapagliflozin. Results:A total of 20 patients were enrolled. ARR before and after treatment were 0.86 (0.73, 1.20) and 0.95 (0.72, 1.32), respectively. However, there was no significant difference between them ( Z=1.12, P=0.263). After 12 weeks of dapagliflozin, FPG ( Z=-3.62, P<0.001), HbA 1c ( Z=-3.76, P<0.001), body weight ( Z=-3.19, P=0.001) and uric acid ( Z=-2.71, P=0.014) decreased significantly compared with baseline. Conclusions:Dapagliflozin has no effect on ARR in patients with T2DM complicated with hypertension, but it has good effects on reducing FPG, uric acid and weight loss.

阿尔茨海默病(AD)是痴呆的主要原因之一,是一种以进行性认知功能损伤为主要症状的神经退行性疾病,多发生于老年前期、老年期,病理改变以脑内β-淀粉样蛋白(Aβ)沉积、过度磷酸化微管相关蛋白异常缠结为特征[1].2020年一项研究显示,我国AD发病率居高不下,在中国60岁以上人群中患病率为3.9％ [2].AD的症状可以分为A、B、C三大类:A(activity)——生活功能改变,B(behavior)——行为精神症状,C(cognition)——认知功能损害[3].

血液净化技术是终末期肾病患者肾脏替代治疗的重要方式.良好的血管通路是血液净化技术的先决条件.目前,临床中主要使用的血管通路类型有自体动静脉内瘘(native arteriovenous fistulas,AVF)、人造血管(synthetic arteriovenous grafts,AVG)和中心静脉导管(central venous catheter,CVC)[1].虽然,在肾脏病预后质量指南(kidney disease outcome quality initiative,K-DOQI)指南中认为自体动静脉内瘘是透析患者的优先选择,但是中心静脉导管在临床中仍具有不可替代的地位[2].因此,中心静脉导管的安全与通畅尤为重要,封管液的合理应用是保证中心静脉导管正常使用的保障.肝素是目前临床中应用最为广泛的一种封管液,它具有带强负电荷的理化特性,能干扰血凝过程的许多环节,在体内外都有抗凝作用[3].本文针对不同种类肝素封管液对中心静脉置管患者凝血功能的影响研究进行综述.

Objective:To explore the effects and safety of intraoperative application of peripheral venous indwelling needles of different parts in aged patients with acoustic neuroma.Methods:Totally 260 aged patients undergoing acoustic neuroma surgery in Beijing Tiantan Hospital, Capital Medical University from January 2017 to October 2019 were selected and divided into the observation group and the control group according to the random number table, with 130 cases in each group. Patients in the observation group had a 20G indwelling needle in the saphenous vein of the lower extremities, while patients in the control group had a 20G indwelling needle in the vein of the upper extremities. The operation time of intravenous indwelling needle and the success rate of single puncture were compared between the two groups of patients. The incidence of phlebitis, local exudation and microthrombosis within 48 hours after operation was observed.Results:The operation time of the intravenous indwelling needle in the observation group was (3.58±0.06) min, while that in the control group was (5.42±0.05) min, and the difference between the two groups was statistically significant ( t=2.35, P< 0.05) . The success rate of single puncture in the observation group was 93.8% (122/130) , while that in the control group was 81.5% (106/130) , and the difference between the two groups was statistically significant (χ 2=9.12, P< 0.05) . At 48 hours after catheterization, 17 cases of local exudation and 20 cases of phlebitis occurred in the observation group, and 14 cases of microthrombus were found by color doppler ultrasonic diagnosis apparatus, which were less than those in the control group, but the differences between the two groups were not statistically significant (χ 2=1.82, 2.04, 0.54; P>0.05) . Conclusions:The intraoperative application of peripheral venous indwelling needles in lower limbs in aged patients with acoustic neuroma shows better effects than that of peripheral venous catheters in upper limbs. It is clinically easy to operate, safe and practical.

目的 肝淀粉样变性与肝窦阻塞综合征的病理发病部位同为肝窦周隙,影像学表现相似,临床表现又缺乏特异性,临床对其认识不足,容易误诊,本研究通过总结肝淀粉样变性及肝窦阻塞综合征的临床及影像特点,提高对两种疾病的诊断水平.材料与方法 回顾北京佑安医院2009-2019年经病理诊断的11例肝淀粉样变性和20例肝窦阻塞综合征患者的临床及影像资料,比较其差异.结果 (1)肝淀粉样变性的典型临床特征是巨肝、肝功能损害轻微但碱性磷酸酶(alkaline phosphatase,ALP)和谷氨酰转肽酶(γ-glutamyl transpeptadase,GGT)显著升高,国内肝窦阻塞综合征患者多有服用土三七病史,临床多以黄疸伴肝功能受损、凝血功能障碍及糖类抗原125(carbohydrate antigen 125,CA125)增高为主要表现.(2)影像学检查:①超声肝弹性成像检查中肝淀粉样变性肝实质硬度极高(≥75 kPa),显著高于肝窦阻塞综合征患者的肝脏硬度[(44.65±19.01)kPa];②MRI上肝淀粉样变性T2WI像肝实质信号均匀、细腻,肝"纹理"减少;增强扫描肝实质强化程度减低且强化峰值延迟,静脉期肝实质呈"窗凌花"样改变,可同时伴有脾脏或肾脏的低血流灌注征象.而肝窦阻塞综合征T2WI像肝实质信号不均匀增高,可见不规则片状或呈"云絮"状稍高信号影;增强扫描门脉期肝实质可呈现地图样强化及环绕三支肝静脉的"三叶草"样强化,延迟期肝实质强化范围较门脉期进一步增大;③肝淀粉样变性肝动脉及门脉主干管径大于肝窦阻塞综合征患者(P<0.05);两者病例影像的共同点是静脉期三支肝静脉不显影或显影纤细.结论 肝淀粉样变性与肝窦阻塞综合征的病因、临床表现及影像学表现均存在一定的差别,可利用这些差别进行鉴别诊断.

成年人脑白质病变是在成年期起病的脑白质的病理性改变,其鉴别诊断仍是神经内科医生面临的重点和难点之一.本文主要从病因角度对成年人脑白质病变进行了细化分类,并概述了常见成年人脑白质病变的临床及影像学表现、诊断和治疗手段等,强调了细化脑白质病变的分类对临床精准诊疗的重要性,认为颅脑影像学检查是鉴别脑白质病变的重要手段,且结合脑脊液、病理检查、脑代谢检测和二代测序技术等辅助检查手段有助于提高临床诊断效率.

目的 探究T淋巴细胞亚群与结核性腹膜炎(TBP)合并肠梗阻术后并发症的相关性.方法 回顾性分析2005年5月—2013年5月首都医科大学附属北京天坛医院收治的318例TBP合并肠梗阻患者的临床资料.患者均接受手术治疗,根据术后是否发生并发症将患者分为发生组、未发生组,比较发生组与未发生组术前外周血和腹水中CD3+、CD4+、CD8+比率及CD4+/CD8+比值及其他可能导致术后并发症发生的影响因素的差异,并采用Logistic回归分析法明确导致术后并发症的危险因素.结果 318例患者术后发生并发症64例,总发生率为20.13％,其中切口感染发生率最高(5.03％),腹腔感染及肠粘连发生率最低(1.89％).TBP合并肠梗阻患者外周血CD8+比率较腹水升高,CD3+、CD4+比率及CD4+/CD8+比值均较腹水降低(P<0.05).未发生组和发生组外周血CD8+比率较腹水升高,CD3+、CD4+比率及CD4+/CD8+比值均较腹水降低(P<0.05);发生组外周血和腹水中CD4+比率及CD4+/CD8+比值均低于未发生组(P<0.05).发生组贫血、急性生理学及慢性健康状况评分系统Ⅱ(APACHE II)评分≥14分、手术时间≥3 h患者比率高于未发生组(P<0.05).经Logistic回归分析,腹水和外周血中CD4+/CD8+比值、贫血、APACHE II评分、手术时间≥3 h均为TBP合并肠梗阻术后并发症的危险因素(P<0.05).结论 TBP合并肠梗阻患者存在全身性细胞免疫低下、腹腔局部细胞免疫增强现象,且腹水和外周血中CD4+/CD8+比值与术后并发症发生关系密切,对指导临床并发症防治有重要价值.

目的 探究主观认知下降(SCD)人群的多模态MRI变化情况.方法 SCD人群与资料匹配的正常人群各30例,行认知功能及常规MRI、全脑灰质体积(GMV)、静息态低频振幅(ALFF)检查,比较其变化规律.结果 全脑GMV比较显示SCD组在前扣带回(左)、后扣带回(右)、前额叶(右)、颞上回(左、右)、尾状核(左、右)、颞中回(左、右)、舌回(左、右)以及丘脑(右)、小脑(左、右)、枕叶(右)等皮层或灰质结构中表达量下降.ALFF比较显示SCD组在前扣带回(左、右)、前额叶(右)、眶回(右)、颞上回(左)、颞中回(右)、颞极(右)ALFF降低,在小脑(左)、小脑蚓以及尾状核区(左)ALFF升高.结论 对比正常组,SCD人群已存在脑结构与脑功能的改变.

Objective: To evaluate the safety and efficacy of catheter ablation in patients with new-onset atrial arrhythmia after surgical excision of left atrial myxoma. Methods: Nine patients with new onset atrial arrhythmia and a prior history of left atrial myxoma, who received surgical myxoma excision and catheter ablation between September 2014 and November 2019, were included in the present study. Baseline characteristics, procedural parameters during catheter ablation, severe perioperative adverse events, recurrence rate of arrhythmia and clinical prognosis were analyzed. Kaplan Meier survival analysis was used to define the maintenance rate of sinus rhythm after catheter ablation in this patient cohort. Results: Nine patients were included. The average age was (55.8 ± 9.1) years old (3 male), there were 3 patients (3/9) with paroxysmal atrial fibrillation (PAF) and 6 patients (6/9) with atrial flutter or atrial tachycardia (AFL or AT). Ablation was successful in all patients, there were no perioperative complications such as stroke, pericardial effusion, cardiac tamponade, vascular complications or massive hemorrhage. During a mean follow-up time of 40.0 (27.5, 55.5) months, sinus rhythm was maintained in six patients (6/9) after the initial catheter ablation. The overall sinus rhythm maintenance rate was 2/3. In addition, 1 out of the 3 AF patients (1/3) developed recurrence of AF at 3 month after ablation, and 2 out of the 6 AFL or AT patients (2/6) developed late recurrence of AF or AFL (19 months and 29 months after ablation), two out of three patients with recurrent AFs or AFL received repeated catheter ablation and one patient remained sinus rhythm post repeat ablation. Meanwhile, there was no recurrence of atrial myxoma, no death, stroke, acute myocardial infarction and other events during the entire follow-up period. Conclusions: Catheter ablation is a safe and feasible therapeutic option for patients with new-onset atrial arrhythmia after surgical excision of left atrial myxoma.

目的:探讨酸味饮方配合耳穴压贴法治疗糖尿病前期人群的临床疗效.方法:选取社区糖尿病前期人群200例,随机分为两组,各100例.对照组运用耳穴压贴法治疗;试验组在耳穴压贴基础上给予酸味饮方治疗.比较两组临床疗效、血糖及血脂水平.结果:试验组干预后餐后2 h血糖(2 hPG)、糖化血红蛋白(HbA1c)、总肝固醇(TC)水平明显均低于对照组,差异有统计学意义(P<0.05);试验组治疗总有效率高于对照组,差异有统计学意义(P<0.05).结论:在对糖尿病前期人群的干预中,酸味饮方能发挥调肝健脾、清热滋阴作用,较好地调节血糖及血脂水平,且疗效确切,接受度高.

随着人口老龄化进程加剧,近年来我国痴呆患者数量呈现快速增多趋势,但目前我国痴呆诊治相关医疗资源主要集中在大型综合医院,远不能满足广大痴呆患者需求.目前仍存在基层医务工作者由于缺乏痴呆识别和诊治经验、不能区分痴呆与正常老化而导致多数痴呆患者得不到及时救治,进而贻误病情、导致患者错过早期治疗的最佳时间等问题.提高广大基层医务工作者对痴呆的识别和诊治能力、建立基层医务工作者与三甲医院记忆门诊的上下联动机制并进行连续性管理是中国痴呆防控的必要措施.本文主要就我国痴呆流行病学特征、诊治现状及困境、提高痴呆规范化管理水平的有效改进措施等进行了分析.

目的:初步探讨既往心房颤动导管消融术中心包压塞患者再次接受导管消融治疗的可行与有效性.方法:回顾分析北京安贞医院自2016年4月至2019年8月间,既往心房颤动导管消融术中心包压塞并再次接受导管消融治疗的患者10例.收集患者临床基线数据、消融参数,随访临床事件与窦律维持情况.结果:10例患者平均年龄为(63.6±11.4)岁,男6例,3例复发为阵发性心房颤动、心房扑动,7例复发为持续性心房颤动;围术期8例应用华法林桥接抗凝,2例应用不间断达比加群酯抗凝.所有患者顺利完成再次导管消融治疗,1例患者术后因继发肺部感染死亡,其余患者围术期均未发生心脏压塞、其他出血及死亡事件.随访期间(30.0± 14.4)个月,6例(6/10)患者维持窦性心律.结论:既往心房颤动导管消融术中心包压塞患者再次行导管消融治疗安全及可行.

目的:初步探讨心房颤动合并帕金森病(PD)患者导管消融治疗可行性、潜在获益.方法:纳入北京安贞医院自2017年3月至2019年9月,接受导管消融的心房颤动合并PD患者8例.记录患者基线数据,术中消融情况、围术期并发症,随访患者术后心房颤动复发情况、症状改善、临床事件、抗心律失常与抗凝性药物停药情况.结果:患者中男性居多(7例,87.5％),平均年龄(68.3±9.0)岁,其中阵发性心房颤动/心房扑动(PAF/AFL)4例,持续性心房颤动(PeAF)4例,心房颤动平均病史为(5.2±4.7)年.8例患者共计完成9次导管消融治疗(其中1例2次消融),围术期均未发生卒中、心脏压塞、血管并发症和大出血事件.随访期间(9～ 39个月)患者总体窦律维持率为75％(PAF/AFL,100％;PeAF,50％)、症状较术前明显改善,1例(12.5％)死亡.术后6例(75％)暂停抗心律失常药物,7例(87.5％)暂停抗凝药物治疗.结论:心房颤动合并帕金森病患者行导管消融治疗安全、可行,术后多数患者症状改善明显,维持窦律(尤其PAF患者).

目的:探讨心房颤动家族史与年轻(≤50岁)心房颤动患者导管消融术后复发的关系.方法:中国心房颤动注册研究从2011年8月至2018年12月前瞻性纳入25512例心房颤动患者.在排除瓣膜性心房颤动、既往行导管消融、术后随访<3个月的患者后,2919例接受导管消融治疗且首次心电图诊断心房颤动时年龄≤50岁的患者纳入本研究.根据患者有无心房颤动家族史,将患者分为无心房颤动家族史组和有心房颤动家族史组.术后第3、6、12个月及其后每6个月进行随访,收集患者心房颤动复发信息.心房颤动家族史定义为:一级亲属(父母或兄弟姐妹)在65岁之前诊断心房颤动,且诊断时间早于该患者.采用Cox多因素回归分析校正其他已知的影响心房颤动复发的因素,评估心房颤动家族史与患者导管消融术后复发的关系.结果:2919例入选患者中,289例(9.9％)有心房颤动家族史,2630例(90.1％)无心房颤动家族史.术后平均随访(24.05±19.38)个月,共有1272例(43.6％)患者心房颤动复发.有心房颤动家族史的患者导管消融术后复发率显著高于无心房颤动家族史者(26.70/100人年vs.21.19/100人年,P=0.0033).多因素Cox回归分析显示,与无心房颤动家族史者相比,有心房颤动家族史者术后复发风险升高27％(HR=1.27,95％CI:1.07～1.50,P=0.0056).结论:在年轻心房颤动患者中,心房颤动家族史与患者导管消融术后复发率高显著相关.

目的 探讨经颅直流电刺激(tDCS)结合感觉训练对卒中偏身感觉障碍患者感觉功能及手功能的康复疗效.方法 回顾性连续纳入2019年7月至2020年1月在首都医科大学宣武医院康复医学科住院治疗的卒中偏身感觉障碍患者30例,均为初发卒中,病程3个月内.根据治疗方式的不同,将30例患者分为试验组和对照组,各15例.两组患者均接受常规药物治疗、偏瘫运动治疗及感觉功能训练,感觉训练2次/d,30 min/次,5 d/周.在感觉功能训练前,试验组另进行阳极tDCS治疗,对照组患者给予tDCS假刺激,即电刺激仪仅进行正常显示,无刺激电流输出;均2次/d,20 min/次,5 d/周.疗程均为2周.记录两组患者基线资料以及治疗前后的上肢感觉、上肢运动、日常生活能力评分[Fugl-Meyer运动功能(FMA)量表感觉、运动评分,改良Barthel指数(MBI)评分],并进行组间比较.基线资料包括性别、年龄、病程、卒中类型(脑梗死或脑出血)、病变部位(左半球、右半球).结果(1)两组患者性别、年龄、病程、病变性质和病变部位的差异均无统计学意义(均P>0.05).(2)两组患者治疗前后FMA感觉评分比较,组别及时间交互效应的差异有统计学意义(F=235.71,P<0.01).试验组治疗前和治疗后FMA感觉评分分别为(5.9±1.8)、(10.5±1.6)分,对照组治疗前后FMA感觉评分分别为(6.1±1.8)、(8.7±1.6)分.两组患者治疗前FMA感觉评分的差异无统计学意义(P=0.84);治疗2周后,试验组FMA量表上肢感觉评分高于对照组,组间差异有统计学意义(P<0.01).两组患者治疗后FMA感觉评分均高于本组治疗前,治疗前后的差异均有统计学意义(均P<0.01).(3)两组治疗前后FMA运动评分比较,组别及时间交互效应的差异有统计学意义(F=1713.93,P<0.01).试验组治疗前和治疗后FMA运动评分分别为(13±4)、(41±5)分,对照组治疗前后FMA运动评分分别为(14±4)、(36±3)分.两组患者治疗前FMA运动评分的差异无统计学意义(P=0.54);治疗2周后,试验组FMA运动评分优于对照组,组间差异有统计学意义(P<0.01).两组患者治疗后FMA运动评分均高于本组治疗前,治疗前后的差异均有统计学意义(均P<0.01).(4)两组患者治疗前后MBI评分比较,组别及时间交互效应的差异有统计学意义(F=412.33,P<0.01).试验组治疗前和治疗后MBI评分分别为(18±8)、(60±16)分,对照组治疗前后MBI评分分别为(15±6)、(44±8)分.两组患者治疗前MBI评分的差异无统计学意义(P=0.16);治疗后,试验组MBI评分高于对照组,组间差异有统计学意义(P<0.01).两组患者治疗后MBI评分均高于本组治疗前,治疗前后的差异均有统计学意义(均P<0.01).结论 经tDCS结合感觉训练可以改善卒中患者的感觉功能和偏瘫侧手功能,提高日常生活能力,但本研究结果有待于进一步验证.

目的 探讨经颅直流电刺激对脑卒中患者上肢运动功能康复的作用.方法 选取2017年12月至2019年12月本院康复医学科住院的初发脑卒中患者50例,病程<6个月,随机分为对照组(n=25)和试验组(n=25),两组均接受上肢常规康复治疗和上肢康复机器人训练,试验组在对照组基础上给予经颅直流电刺激,共2周.治疗前后采用ReConn上肢康复机器人评价体系、简式Fugl-Meyer运动功能评分-上肢部分(FMA-UE)、Carroll手功能评定法(UEFT)和改良Barthel指数(MBI)进行评定.结果 治疗前两组各项指标无显著性差异(|t|<2.954,P>0.05).治疗后两组各项评分均显著改善(|t|>7.551,P<0.001),试验组各项指标均优于对照组(|t|>2.639,P<0.05).结论 经颅直流电刺激能进一步改善脑卒中患者的上肢运功功能,提高患者日常生活活动能力.