罗哌卡因和布比卡因分别复合芬太尼应用于术后硬膜外镇痛的比较研究

目的比较罗哌卡因和布比卡因分别复合芬太尼用于术后持续硬膜外镇痛(CEA)的临床效果。方法硬膜外麻醉行下腹部手术、美国麻醉医师学会(American Society of Anesthesiologists，ASA)分级Ⅰ～Ⅱ级的50例患者，随机分为罗哌卡因复合芬太尼(RF、)组和布比卡因复合芬太尼(BF)组，每组25例。手术结束前5rain硬膜外腔注入负荷剂量，Rt?组为O．2％罗哌卡因 5μg／ml芬太尼5ml，BF组为O．2％布比卡因 5μg／m1芬太尼5ml。术毕，经硬膜外管持续泵入药物2ml／h，RF组为O．2％罗哌卡因 2μg／ml芬太尼，BF组为O．2％布比卡因 2μg／ml芬太尼。记录启用止痛泵后1h、4h、8h、24h、48h的视觉模拟评分法(VAS)评分、改良Bromage分级。结果50例患者启用止痛泵后48h内生命体征平稳。各时段的VAS评分两组间无显著性差异(P＞O，05)；但改良Bromage分级RF组低于BF组(P＜O．05)。结论罗哌卡因和布比卡因分别复合芬太尼用于术后持续硬膜外镇痛均可取得良好的镇痛效果，而罗哌卡因对运动神经的阻滞较轻，效果更理想。     

不同浓度罗哌卡因在老年病人术后自控镇痛的应用研究

目的 探讨不同浓度的罗哌卡因在老年病术后自控镇痛的效果、安全性及合适的使用浓度。方法 选择ASAⅠ-Ⅱ级的老年病人（年龄大于65岁），腹部择期手术216例，随机分为N、M、G三组，每组72例，所有病例术毕经镇痛泵注入该组镇痛液。N组：0．125％罗哌卡因＋2μg／ml芬太尼；M组：0．16％罗哌卡因＋3μg／ml芬太尼；G组：0．2％罗哌卡因＋3μg／ml芬太尼。术后4、8、12、24、48h进行镇痛、镇静评分，观察不良反应。结果 术后4、8、12、24、48h静息状态下N、M、G三组病人视觉模拟评分（VAS）评分无显著差异（P〉0．05），但N组术后咳嗽、起床活动VAS评分较高，与M、G组相比，有显著差异（P〈0．05），不良反应在G组中的发生率较高，但三组间无显著差异（P〉0．05）。结论 N、M、G三组不同浓度罗哌卡因术后镇痛对老年病人都安全、效果均较好。但以M组0．16％罗哌卡因复合芬太尼对老年病人术后镇痛更为合理。     

肾上腺素对剖宫产患者硬膜外术后镇痛效果的影响

目的观察肾上腺素对小剂量罗哌卡因复合吗啡用于剖宫产术后镇痛作用的影响。方法30例剖宫产手术患者，随机均分为A组及B组，手术均在腰硬联合麻醉下进行。术毕A组硬膜外持续输注1mg／ml罗哌卡因＋20μg／ml吗啡＋2μg／ml肾上腺素混合液，输注速度4ml／h；B组则不加肾上腺素，余相同。术后24h把镇痛泵持续流速调为0ml／h，观测记录两组患者试验开始至结束后5h咳嗽和下床活动时视觉模拟评分（VAS）、自控按键次数、不良反应。结果B组的VAS、自控按键次数均显著增高（P〈0．05），恶心呕吐发生率增加（P〈0．05）。结论肾上腺素能增强罗哌卡因复合吗啡硬膜外术后镇痛作用。     

高龄产妇术后左旋布比卡因与罗哌卡因复合芬太尼硬膜外镇痛的临床观察

目的：比较左旋布比卡因和罗哌卡因复合芬太尼用于高龄产妇剖宫产术后硬膜外镇痛的效果和副作用。方法：将40例择期行剖宫产术的足月、单胎高龄产妇分为左旋布比卡因组（L组）和罗哌卡因组（R组）。每组20例。术后分别采用0．125％左旋布比卡因和0．2％的罗哌卡因复合小剂量芬太尼（2μg／mL）行病人自控硬膜外镇痛（PCEA）。观察各组术后48h内的镇痛效果、运动阻滞程度变化及恶心呕吐、尿潴留等副作用的发生率。结果：两组产妇术后视觉模拟评分比较差异均无显著性（P〉0．05）。两组产妇对PCEA的非常满意率差异无显著性（L组为87．6％。R组为77．9％．P〉0．05）。左旋布比卡因组稍高于罗哌卡因组。两组不良反应发生率及排气时间差异无显著性（P〉0．05）。结论：用0．125％左旋布比卡因与罗哌卡因复合小剂量芬太尼（2μg／mL）用于高龄产妇术后硬膜外镇痛均可获得满意的镇痛效果．且无明显副作用。     

罗哌卡因复合曲马多或芬太尼应用于子宫切除术后硬膜外镇痛的临床观察

目的：比较罗哌卡因复合曲马多或芬太尼对子宫切除术后硬膜外镇痛作用，为临床安全合理用药提供依据。方法：选择ASAⅠ-Ⅱ级经腹子宫切除患者120例，随机分为三组：R组：0．125％罗哌卡因（n=40）；F组：0．125％罗哌卡因＋0．0004％芬太尼（n=40）；T组：0．125％罗哌卡因＋0．5％曲马多（n=40）。三组术后均应用首剂镇痛药0．5％罗哌卡因5ml硬膜外注入，连接一次性微量泵进行硬膜外镇痛，监测术后不同时间的VAS疼痛评分；观察恶心呕吐等不良反应以及肛门排气时间；总体满意度评分。结果：R组VAS评分明显高于F组和T组，有显著性差异（P〈0．05）；F组和T组VAS评分无明显差异（P〉0．05）；F组恶心呕吐发生率高于R组和T组（P〈0．05）；F组和T组镇痛总体满意度优良率明显高于R组（P〈0．05）。结论：罗哌卡因复合曲马多或芬太尼均可达到有效术后硬膜外镇痛效果，罗哌卡因与曲马多配伍副作用发生率较低，是一种更为安全有效的硬膜外术后阵痛配方。     

芬太尼、吗啡分别联合罗哌卡因用于术后硬膜外镇痛的比较

目的：比较芬太尼、吗啡分别联合罗哌卡因用于术后硬膜外镇痛的效果及不良反应的发生率。方法：择期肿瘤手术患者150例随机分为Ⅰ组、Ⅱ组、Ⅲ组各50例。Ⅰ组给予吗啡60—80μg／mL复合0．125％罗哌卡因100mL硬外镇痛；Ⅱ组给予芬太尼5-6μg／mL复合0．125％罗哌卡因100mL硬外镇痛；Ⅲ组单纯给予芬太尼20μg／kg静脉镇痛。比较三组术后不同时点VAS评分、Ramsay评分以及不良反应的发生率。结果：VAS评分三组间比较差异无统计学意义（P〉0．05）；Ⅲ组在术后12h、24h、48h的Ramsay评分显著高于其他组（P〈0．05）；恶心、呕吐、皮肤瘙痒的发生率Ⅱ组、Ⅲ组均显著小于Ⅰ组（P〈0．05）；头晕、嗜睡的发生率Ⅰ、Ⅱ组显著低于Ⅲ组（P〈0．05）。结论：芬太尼联合低浓度罗哌卡因用于术后硬膜外镇痛效果确切、不良反应发生率少。     

罗哌卡因和布比卡因分娩镇痛中胎儿α-酸性糖蛋白浓度的比较

目的：通过测定脐血中α-酸性糖蛋白（alpha-1-acid glycoprotein，AAG）浓度，来比较罗哌卡因和布比卡因分娩镇痛中对胎儿的毒性作用。方法：选择42例产前检查估计能从阴道自然分娩的头位、单胎足月初产妇。随机分为三组，A组为罗哌卡因．芬太尼组；B组为布比卡因。芬太尼组；C组为未行分娩镇痛对照组，每组各14例。分娩镇痛采用病人自控硬膜外镇痛（patient-controlled epidural analgesia，PCEA），PCEA剂量为基础注药速率为6ml／h，冲击量均为2ml，锁定时间均为10min。采用“速率散射比浊法”测定脐血中α-酸性糖蛋白浓度，进行脐血血气分析，进行胎儿的Apgar评分和SpO2检测，视觉模拟镇痛评分法（VAS）评定产妇疼痛程度，用下肢运动神经阻滞评分法（MBS）评定产妇运动神经阻滞程度。结果：两组产妇的镇痛效果无显著差异。罗哌卡因组脐血α-酸性糖蛋白浓度和pH值明显高于布比卡因组（P〈0．05）。罗哌卡因组1分钟胎儿Apgar评分和胎儿血氧饱和度明显高于布比卡因组（P〈0．05）。布比卡因组对运动神经阻滞大于罗哌卡因组。结论：在分娩镇痛时，罗哌卡因对胎儿毒性低于布比卡因。     

舒芬太尼及芬太尼与吗啡用于子宫切除术后硬膜外镇痛的比较

目的：比较舒芬太尼、芬太尼与吗啡用于子宫切除术后持续硬膜外镇痛的临床镇痛效果和不良反应。方法：选择ASAⅠ或Ⅱ级,在连续硬膜外麻醉下行子宫切除术,术后行硬膜外镇痛的患者120例,随机分为4组,S1组（舒芬太尼0．5μg／mL复合甲磺酸罗哌卡因0．237mg／mL）、S2组（舒芬太尼0．75μg／mL复合甲磺酸罗哌卡因0．237mg／mL）、F组（芬太尼5μg／mL复合甲磺酸罗哌卡因0．237mg／mL）、M组（吗啡0．06mg／mL复合甲磺酸罗哌卡因0．237mg／mL）;负荷剂量5mL,速度2mL／h,单次给药0．5mL,锁定时间15min。观察患者术后疼痛视觉模拟评分（VAS）、不良反应以及Ramsay评分。结果：4组患者术后4hVAS评分差异无统计学意义（P〉0．05）,S2,M组术后8h,16h评分低于S1组（P〈0．05）,S2,M组镇痛满意率更高（P〈0．05）。M组恶心、呕吐、瘙痒发生率高（P〈0．05）。结论：舒芬太尼0．75μg／mL复合甲磺酸罗哌卡因0．237mg／kg用于子宫切除术后镇痛效果满意,不良反应发生率低。     

剖宫产术后不同复合液硬膜外镇痛效果观察

剖宫产术后硬膜外镇痛因其镇痛效果良好，有利于术后恢复等优点，现已广泛应用于临床。硬膜外腔所用镇痛液各不相同，本主要探讨剖宫产术后硬膜外腔分别注入同等低浓度(0．2％)罗哌卡因 芬太尼和布比卡因 芬太尼两组不同复合液术后镇痛的效果。     

不同浓度甲磺酸罗哌卡因复合芬太尼硬膜外术后镇痛的观察

目的：比较不同浓度甲磺酸罗哌卡因复合芬太尼术后硬膜外镇痛的效果，为临床用药提供依据。方法：选择90例患者，随机分为3组，每组30例，A组甲磺酸罗哌卡因浓度为0．20％，B组0．237％，C组0．284％，均加入2μg／mL芬太尼，首次剂量5mL，设定持续输注背景剂量2ml，自控镇痛量每次0．5mL，锁定时间15min。监测术后4、8、12、24、48h不同时间的疼痛评分（VAS）、HR、SpO2、MAP、总体满意度评分、恶心等不良反应和下肢运动阻滞情况。结果：三组VAS评分、HR、SpO2、MAP、镇痛总体满意度评分、恶心、呕吐、皮肤瘙痒相比无显著性差异（P〉0．05）；下肢运动阻滞程度A组及B组和C组比较有显著性差异（P〈0．05）；C组低血压、尿潴留的发生和A组及B组比较有显著性差异（P〈0．05）。结论：0．20％～0．237％甲磺酸罗哌卡因复合芬太尼（2μg／mL）术后硬膜外镇痛效果确切，副作用发生率低，适合临床应用。     

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.     

Dissociable correlates of two classes of retrieval processing in prefrontal cortex

Although substantial evidence suggests that the prefrontal cortex (PFC) implements processes that are critical for accurate episodic memory judgments, the specific roles of different PFC subregions remain unclear. Here, we used event-related functional magnetic resonance imaging to distinguish between prefrontal activity related to operations that (1) influence processing of retrieval cues based on current task demands, or (2) are involved in monitoring the outputs of retrieval. Fourteen participants studied auditory words spoken by a male or female speaker and completed memory tests in which the stimuli were unstudied foil words and studied words spoken by either the same speaker at study, or the alternate speaker. On "general" test trials, participants were to determine whether each word was studied, regardless of the voice of the speaker, whereas on "specific" test trials, participants were to additionally distinguish between studied words that were spoken in the same voice or a different voice at study. Thus, on specific test trials, participants were explicitly required to attend to voice information in order to evaluate each test item. Anterior (right BA 10), dorsolateral prefrontal (right BA 46), and inferior frontal (bilateral BA 47/12) regions were more active during specific than during general trials. Activation in anterior and dorsolateral PFC was enhanced during specific test trials even in response to unstudied items, suggesting that activation in these regions was related to the differential processing of retrieval cues in the two tasks. In contrast, differences between specific and general test trials in inferior frontal regions (bilateral BA 47/12) were seen only for studied items, suggesting a role for these regions in post-retrieval monitoring processes. Results from this study are consistent with the idea that different PFC subregions implement distinct, but complementary processes that collectively support accurate episodic memory judgments.     

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.     

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.     

Modified micro-superior percutaneously-assisted total hip: early experiences & case reports

Because of the extensile nature and familiarity of the standard posterior-lateral approach to the hip, a family of "micro-posterior" approaches has been developed. This family includes the Percutaneously-Assisted Total Hip (PATH) approach, the Supercapsular (SuperCap) approach and a newer hybrid approach, the Supercapsular Percutaneously-Assisted Total Hip (SuperPATH) approach. Such approaches should ideally provide a continuum for the surgeon: from a "micro" (external rotator sparing) posterior approach, to a "mini" (external rotator sacrificing) posterior approach, to a standard posterior approach. This could keep a surgeon within his comfort zone during the learning curve of the procedure, while leaving options for complicated reconstructions for the more practiced micro-posterior surgeons. This paper details one author's experiences utilizing this combined approach, as well as permutations of this entire micro-posterior family of approaches as applied to more complex hip reconstructions.     

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.     

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.