失血性休克复苏时心肌损伤和一氧化氮的变化及灵芝多糖的干预作用

目的 :探讨失血性休克和复苏再灌注过程中心肌损伤和一氧化氮 (NO)浓度的变化及灵芝多糖的干预作用。方法 :复制家兔失血性休克再灌注模型 ,随机分成假手术组、生理盐水再灌注组和质量分数为 1%的灵芝多糖再灌注组 ;观察 3组动物平均动脉血压 (MAP)、心功能、血浆 NO浓度及心肌 NO含量和一氧化氮合酶(NOS)活性的变化。结果 :两个再灌注组动物在失血性休克 4 0 m in时左心室舒张末压 (L VEDP)比休克前及假手术组略有升高 ,但差异不显著 (P均 >0 .0 5 ) ,左心室内压最大变化速率 (± dp/dt max)则明显降低 (P均 <0 .0 5 ) ,血浆 NO浓度则显著升高 (P均 <0 .0 5 )。生理盐水再灌注组动物再灌注 4 0 min时 ,心功能较休克 4 0 m in时进一步降低 (P<0 .0 5 ) ,血浆 NO浓度进一步升高 ,心肌 NOS活性和 NO含量明显高于假手术组 (P均 <0 .0 5 )。灵芝多糖组再灌注 4 0 min时较生理盐水再灌注组、心功能明显改善 ,血浆 NO浓度、心肌 NO含量和心肌 NOS活性均明显降低 (P均 <0 .0 5 )。结论 :失血性休克再灌注过程中心肌 NOS活性、血浆 NO浓度、心肌NO含量均升高 ,而心功能降低 ,提示 NO在失血性休克再灌注心肌损伤中起重要作用 ;而灵芝多糖可通过抑制 NOS活性、降低 NO浓度对失血性休克再灌注心肌损伤起保护作用。     

川芎嗪注射液抗脑缺血-再灌流损伤作用机制的实验研究

目的　探讨川芎嗪注射液 (LGTI)对脑缺血 再灌流损伤 (CIRI)的防治作用及其机制。方法　制备家兔CIRI模型 ,随机分为假手术对照组、缺血 再灌流组和LGTI组 ,动态观察血浆及脑组织一氧化氮 (NO)水平、内皮素 (ET)含量、丙二醛 (MDA)浓度、超氧化物歧化酶 (SOD)活性及脑超微结构的变化。结果　脑缺血 再灌流期间 ,血浆和脑组织NO水平及SOD活性与缺血前比较明显下降 (P <0 0 5和 P <0 0 1) ,ET及MDA含量与缺血前比较显著升高 (P <0 0 5和 P <0 0 1) ,超微结构发生异常改变 ;使用LGTI后 ,上述各指标的异常变化明显减轻 ,与缺血 再灌注组相比差异有显著意义 (P <0 0 1)。结论　LGTI对CIRI具有良好的防护作用 ,其机制与提高机体NO水平、降低ET水平及减轻氧自由基损伤等有关     

葛根素对脑缺血-再灌流时大鼠肿瘤坏死因子-α和白细胞介素-1β表达的影响

目的　探讨全脑缺血 再灌流时葛根素的脑保护作用机制。方法　将实验大鼠随机分为空白对照 (S)组、全脑缺血 再灌流 (IR)组、葛根素 (P)组。采用Pulsinelli法制备大鼠全脑缺血 再灌流损伤模型 ,以原位杂交法分别测定全脑缺血 再灌流 2 ,6 ,12 ,2 4 ,4 8h各时点海马CA1 区肿瘤坏死因子 α (TNF α)mRNA、白介素 1β (IL β)mRNA的表达 ,HE染色光镜下计数存活神经元数的变化。 结果　与IR组相比 ,P组各对应时点TNF αmRNA、IL 1βmRNA的表达均有显著下降 (P <0 0 5 ) ,而存活神经元数目均有明显增加 (P <0 0 1或P <0 0 5 )。结论　葛根素通过下调TNF αmRNA、IL 1βmRNA的表达 ,抑制脑缺血再灌流炎症反应而对脑有保护作用     

左旋四氢巴马汀在脑缺血再灌注损伤中作用的实验研究

目的 :探讨左旋四氢巴马汀 (L tetrahydropalmatine,L THP)对脑缺血再灌注损伤的保护作用。方法 :采用小鼠和大鼠脑缺血模型 ,并术前 30min分别腹腔内注射生理盐水 (10ml/kg)、L THP(5 ,10 ,2 0mg/kg)和尼莫地平(0 0 4mg/kg) ,观察小鼠存活时间、大鼠神经功能缺损评分、脑梗死范围、超氧化物歧化酶 (SOD)活性、丙二醛 (MDA)和一氧化氮 (NO)含量的改变。结果 :与生理盐水组比较 ,L THP组可显著延长脑缺血小鼠的存活时间 ,改善脑缺血2h再灌注不同时间大鼠的神经功能缺损 ,缩小脑梗死范围 ,增加SOD活性、降低MDA和NO含量 (P <0 0 5 ) ;10、2 0mg/kgL THP作用与尼莫地平差异无显著性 (P >0 0 5 )。结论 :L THP可通过抗自由基与减轻NO介导的神经毒性机制发挥对脑缺血再灌注损伤的神经保护作用。     

山莨菪碱对家兔急性完全性脑缺血及再灌流后脑组织[Ca2+]i和超微结构影响

目的　研究山莨菪碱对急性完全性脑缺血及再灌注后脑组织游离Ca2 ([Ca2 ]i)及超微结构的影响。方法　采用闭塞双侧颈总动脉和椎动脉及体循环低血压法建立家兔急性完全性脑缺血及再灌流损伤模型 ,缺血 2 0min ,再灌流 2h。40只家兔随机分为假手术组、缺血组、缺血再灌流组、治疗组 ,观察了脑组织 [Ca2 ]i和超微结构及山莨菪碱对其变化的影响。结果　缺血组及缺血再灌流组脑组织 [Ca2 ]i 浓度明显高于假手术组 (P <0 0 1) ,而且缺血再灌流组 [Ca2 ]i 明显高于缺血组(P <0 0 1) ,随着 [Ca2 ]i 增加 ,脑组织超微结构损伤明显加重。治疗组 [Ca2 ]i 浓度较缺血组及缺血再灌流组明显降低 (P <0 0 1) ,同时脑组织超微结构损伤明显减轻。结论　山莨菪碱通过阻断Ca2 内流对完全性脑缺血及再灌损伤具有保护作用。     

通脑精对大鼠局灶脑缺血一氧化氮和自由基的影响

目的 :探讨通脑精对大鼠局灶脑缺血的保护作用及其机制。方法 :采用电凝阻断大脑中动脉造成大鼠局灶脑缺血模型 ,测定血浆中一氧化氮 (NO)、丙二醛 (MDA)含量和超氧化物歧化酶 (SOD)活性 ,及脑组织中一氧化氮(NO)、丙二醛 (MDA)含量和超氧化物歧化酶 (SOD)、一氧化氮合酶 (NOS)活性的变化。结果 :通脑精 (2 g/kg)能显著增加血浆和组织中超氧化物歧化酶 (SOD)活性 ,P <0 .0 1 ,降低血浆中NO、MDA含量和脑组织中NOS活性 ,P <0 .0 1。结论 :通脑精对大鼠局灶脑缺血损伤有保护作用 ,其机理与降低血浆中NO、MDA含量和脑组织中NOS活性及增加脑组织中SOD活性作用有关。     

硫酸镁对离体大鼠缺血-再灌流心脏的保护作用

目的　研究硫酸镁对缺血 再灌流心肌损伤的治疗作用 ,探讨更有效减轻再灌流心肌损伤的治疗措施。方法　采用Langendorff离体大鼠心脏灌流模型 ,心脏缺血 (停灌 ) 30min、再灌流 12 0min ,2 4只大鼠随机分成 3组 ,A组 :给Krebs-Henseleix (NKH)灌注液为对照组 ;B组 :再灌流开始至结束给予硫酸镁 ( 1 5mM)治疗 ;C组 :缺血前 5min及再灌流全程给予硫酸镁( 1 5mM)治疗。结果　B组、C组心脏功能 (LV +dp/dtmax,LV -dp/dtmax,LVDP)恢复显著优于A组 (P <0 0 5 ) ;C组再灌流后 2h心肌梗死范围减小 ,C组为 ( 2 8 75± 5 0 1) %、A组为( 38 98± 9 0 8) % ,P <0 0 5 ;C组肌酸激酶 (CK)活性增加 ,C组为 ( 1 0 1± 0 31)IU/mg蛋白、A组为 ( 0 75± 0 0 9)IU/mg蛋白 ,P <0 0 5 ;此外心律失常发生C组亦明显减少 ,C组 ( 0 81±0 5 3)次、A组 ( 2 31± 1 5 5 )次 ,P <0 0 5。结论　硫酸镁对缺血 再灌流损伤有保护作用 ,并与给药时间密切相关     

黄芩甙对糖尿病大鼠脑缺血-再灌注损伤的影响

目的 :观察黄芩甙对糖尿病大鼠脑缺血再灌注损伤的影响 ,并探讨其可能的作用途径。方法 :用线栓法制备糖尿病大鼠脑缺血再灌注损伤模型 ,观察不同剂量黄芩甙对缺血区脑梗死体积、髓过氧化物酶 (MPO)活性和细胞间黏附分子 1(ICAM 1) m RNA表达的影响。结果 :1黄芩甙 30 0 m g/ kg及 6 0 0 m g/ kg剂量组均较生理盐水对照组大鼠脑梗死体积显著缩小 (P均 <0 .0 5 ) ;2缺血区 MPO活性及 ICAM 1m RNA表达较生理盐水对照组显著降低 (P均 <0 .0 5 )。结论 :黄芩甙可缩小糖尿病大鼠脑缺血再灌注损伤的脑梗死体积 ,减轻白细胞浸润程度 ,其保护作用是通过抗炎途径来实现的 ,并与抑制 ICAM 1的表达有关。     

左旋四氢巴马汀在大鼠全脑缺血再灌注时对脑组织钙含量及脑细胞凋亡的影响

目的　通过观察脑缺血再灌注时脑组织钙含量及脑细胞凋亡的变化 ,探讨左旋四氢巴马汀在全脑缺血再灌注损伤时的作用机制。方法　本实验在建立大鼠急性全脑缺血再灌注损伤模型的基础上 ,用原子分光光度仪检测脑组织钙含量 ,用流式细胞仪检测脑细胞凋亡。结果　脑缺血再灌注 12h钙含量较假手术组增高 (P <0 0 1) ,脑细胞凋亡数亦增加(P <0 0 1) ;2 4h钙含量进一步增高 (P <0 0 1) ,凋亡细胞数亦进一步增加 (P <0 0 1) ;左旋四氢巴马汀在脑缺血再灌注 12h和 2 4h均能抑制脑组织钙含量的增高 (P <0 0 1)并减少脑细胞凋亡数 (P <0 0 1)。各组脑组织钙含量与脑细胞凋亡数呈正相关 (P <0 0 5 )。结论　左旋四氢巴马汀可减少脑细胞凋亡 ,其机制与抑制缺血再灌注后脑组织钙聚集有关。     

山莨菪碱对急性完全性脑缺血再灌流后脑组织Ca2+、MDA含量、SOD活性及超微结构的影响

40只家兔随机分为假手术组（A组）、缺血组（B组）、缺血再灌流组（C组）、治疗组（D组）。采用闭塞双侧颈总动脉和椎动脉及体循环低血压法建立急性完全性脑缺血再灌流损伤模型，缺血时限20min，再灌流2h，观察了脑组织Ca2＋、脂质过氧化产物一丙二醛（MDA）含量、超氧歧化酶（SOD）活性及脑组织超微结构改变。结果发现：治疗组于再灌流前1min注射山莨菪碱10mg／kg体重，并以5mg／h维持2h，脑组织Ca2＋、MDA含量较缺血组及缺血再灌流组明显降低，（P＜0．05，P＜0．01），SOD活性较缺血再灌流组明显增加（P＜0．05）同时脑组织超微结构损伤明显减轻。结果表明；再灌流早期给予山莨菪碱治疗对完全性脑缺血再灌注损伤具有明显保护作用。膜稳定作用、Ca2＋拮抗作用、抗脂质过氧化是其重要的作用环节。     

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.