小剂量芬太尼对地氟醚交感兴奋作用的影响

临床研究表明 ,快速增加呼气末地氟醚浓度超过 1 0MAC时 ,可产生交感兴奋作用[1～ 3] ,给麻醉管理带来困难。如何预防其交感兴奋作用 ,国内外尚无定论 ,本文旨在探讨芬太尼对地氟醚交感兴奋作用的影响。1　资料与方法1 1　临床资料　 3 0例 2 1～ 5 9岁 ,体格分级为Ⅰ～Ⅱ级 ,择期行胸及上腹部手术的患者 ,未用激素类药物。随机分为地氟醚 (A组 )和地氟醚 +芬太尼 (B组 ) 2组 ,每组 15例。 2组患者的年龄、性别、身高和体重无显著性差异 (P >0 0 5 )。1 2　麻醉方法　不用术前药。患者入手术室后均取仰卧位 ,先安静 10min后记录生命体征…     

地氟醚和异氟醚对血液动力学和儿茶酚胺的影响

目的　比较地氟醚对血液动力学和儿茶酚胺的影响。方法　择期手术病人３０ 例（ＡＳＡⅠ～Ⅱ） ，随机分为地氟醚（１５ 例）、异氟醚（１５ 例）两组。不用术前药。气管插管后观察不同ＭＡＣ时地氟醚和异氟醚对ＭＡＰ、ＨＲ和血中儿茶酚胺浓度的影响。结果　在地氟醚组达１－５ ＭＡＣ后呈现２～４ ｍｉｎ 的血压增高和心率增快，且儿茶酚胺增高。结论　快速增加地氟醚浓度至１－５ＭＡＣ可出现交感兴奋作用，而异氟醚没有此作用。     

针刺镇痛的效能观察

目的通过测定对比针刺－异氟醚复合麻醉（AIA）与单纯异氟醚吸入麻醉（IA）作用,探测针刺的效能。方法随机分为AIA(40例)和IA(20例)两组。上腹部手术针刺内关和足三里,下腹部手术针刺足三里和三阴交,均为双侧并用电针机持续刺激至术毕。以序贯法测定切皮时半数患者体动的肺泡气最低有效浓度（MAC－SI50）,以平均法测定术中抑制交感肾上腺反应吸入麻醉药量MAC（MAC－BAR）。结果切皮时的MAC－SI50,IA组为1.11,AIA组为0.78,两组之差0.33MAC。术中抑制交感肾上腺反应的MAC－BAR,IA组为1.64±0.24,AIA组为1.35±0.23,两组之差为0.29MAC。结论针刺确有一定的镇痛作用,其效能约为0.3MAC异氟醚左右。     

右美托咪定对支撑喉镜手术心率变异性的影响

目的研究右美托咪定对支撑喉镜手术心率变异性的影响。方法选择ASA分级Ⅰ~Ⅱ支撑喉镜手术患者60例,随机分成两组,D组在全麻诱导前15 min给予右美托咪定0.6μg/kg,C组以等容量的0.9%氯化钠溶液输注,两组采用相同的麻醉诱导维持用药、复苏方法。分别记录两组诱导前15 min(T0)、插管时(T1)、手术操作时(T2)、拔除气管导管时(T3)、拔除气管导管5 min后(T4)的心率变异性(HRV)频域分析指标低频功率(LF)和高频功率(HF),计算低频功率与高频功率的比值(LF/HF)。结果与T0比较,D组T2~T4时点HF值明显升高(P0.05),LF变化不明显,LF/HF明显降低(P0.05),与C组比较T2~T4时点HF值明显升高(P0.05),LF变化不明显,LF/HF明显降低(P0.05)。结论支撑喉镜手术中,单次应用右美托咪定能改变HRV,达到交感与迷走调节的均衡性,稳定心血管反应。     

高血压患者腹腔镜手术CO2气腹过程中自主神经功能的变化

目的 探讨高血压患者在腹腔镜手术CO2气腹过程中自主神经功能的变化.方法 应用心率变异性(HRV)分析法对25例择期高血压患者腹腔镜手术(Ⅰ组)和25例无高血压腹腔镜手术患者(Ⅱ组)麻醉前、气管插管结束后15 min、腹腔内CO2充气完成后的心率变异性改变进行分析.结果 麻醉诱导及插管15min后Ⅰ组低频(LF)、高频(HF)、低频与高频的比值(LF/HF)及总功率(TP)显著降低(P＜0.05),Ⅱ组LF、LF/HF、11P亦显著降低(P＜0.05),而HF未见明显改变.腹腔CO2充气完成后两组HRV值均显著升高(P＜0.05).组间比较显示,插管15min后Ⅰ组HF和TP显著低于Ⅱ组,LF和LF/HF组间差异无统计学意义;气腹后Ⅰ组HF和TP亦显著低于Ⅱ组.而LF/HF显著高于Ⅱ组,LF组间差异仍无统计学意义.结论 高血压患者迷走神经活性厦总自主神经张力显著低于非高血压患者,迷走神经对心脏窦房结的调控作用严重受损.     

运动与吸烟对健康青壮年男性心率变异性的影响

目的:探讨每周训练时长与吸烟两个潜在的自主神经功能影响因子对健康青壮年男性心率变异性(HRV)的交互影响,为改善青壮年男性人群自主神经功能、降低心血管疾病发病率提供相应参考。方法:本研究共选取了149例受试者,依据受试者吸烟指数的大小分为不吸烟组(N组,n=66例)、吸烟多组(M组,n=45例)以及吸烟少组(F组,n=38例),其中,N组、M组和F组依据每周训练时间的长短又都分为运动多和运动少两个亚组,分别为:不吸烟运动少组(NF组,n=28例)、不吸烟运动多组(NM组,n=38例)、吸烟多运动多组(MM组,n=22例)、吸烟多运动少组(MF组,n=23例)、吸烟少运动多组(FM组,n=18例)和吸烟少运动少组(FF组,n=20例)。HRV测试包括时域指标有SDNN、RMSSD、SDSD以及PNN50等,频域指标有TP、HF、LF、HFnu、LFnu、LF/HF以及VLF等。结果:(1)不吸烟时,NM和NF组心率变异性的时域及频域各指标相差不大(P0.05);吸烟相对较少时,FM组的TP、HF和LF等指标的值均大于FF组对应指标的值(P0.05);吸烟相对较多时,MM组的LF/HF值大于MF组的LF/HF值(P0.05)。(2)运动相对较少时,NF组的LF值大于MF组的LF值(P0.05);运动相对较多时,NM组和FM组各时域及频域指标中除LF/HF和LFnu以外的其他各项指标的均值均大于MM组对应各指标的均值,其中,FM组的RMSSD和SDSD等的值与MM组对应两指标值的差异具有显著性意义(P0.05)。结论:(1)吸烟和缺乏规律性的健身活动(每周训练时间少于300min)都是影响心率变异性的风险因素。(2)吸烟指数少于200者,规律性的健身活动(每周总时长超过300min)对于心率变异性存在明显的改善作用。(3)吸烟指数大于200者,规律性的健身活动(每周总时长超过300min)未能干预吸烟对心率变异性形成的不良影响,必须戒烟。(4)运动强度作为影响心率变异性的一个重要因子,建议后续研究运动对于心率变异性影响时应作重点具体化考量。(5)吸烟引起心率变异性的变化是个急性效应,建议后续研究吸烟对于心率变异性的影响可以将每日吸烟支数作为影响因子。     

倍他乐克和爱地清联用对高血压病患者心率变异性的疗效分析

目的:观察倍他乐克和爱地清联用对高血压病患者心率变异性的影响。方法:134例患者随机分为两组,治疗组给予倍他乐克和爱地清联合用药,对照组仅给爱地清。治疗6周后评价患者心率变异性。结果:治疗组患者的SDNN、SDANN、LF、HF及LF/HF与对照组之间的差异均有统计学意义(P<0.05)。结论:倍他乐克和爱地清对高血压病患者心率变异性改善疗效显著,倍他乐克和爱地清可作为高血压病患者的主要治疗措施在临床中推广应用。     

脊柱手术患者吸入七氟醚和异氟醚麻醉恢复的比较

目的:比较脊柱手术患者吸入七氟醚和异氟醚麻醉的恢复情况。方法:将40例在全麻下行脊柱手术患者分为七氟醚组(S组)和异氟醚(I组),每组20例。麻醉诱导行气管插管后机械通气,麻醉维持两组分别吸入1.0MAC七氟醚和1.0MAC异氟醚,间断注射芬太尼、维库溴铵和异丙酚,维持血压和心率波动不超过基础值25%。记录停止吸入麻醉药到睁眼时间、拔除气管导管时间及术后苏醒评分到达9分时间。结果:S组患者的睁眼时间、拔除气管导管时间及术后苏醒评分到达9分时间均较I组缩短(P<0.05)。结论:吸入七氟醚患者麻醉恢复时间明显短于吸入异氟醚者,但是全麻苏醒期躁动发生率较吸入异氟醚者高。     

年龄对围术期心率变异性的影响及其临床意义

目的 :探讨年龄对围术期心率变异性的影响及其临床意义。方法 :选择 15 0例择期手术患者 ,以动态心电图 (DCG)监测围术期心率变异性 (HRV)的变化。于术前 1d内监测至少 12h ,术后监测 48h。患者按年龄分为 5组 :A组 :<5 5岁 ,2 3例 ;B组 :5 5～ 64岁 ,2 2例 ;C组 :65～ 69岁 ,41例 ;D组 :70～ 74岁 ,3 6例 ;E组 :≥ 75岁 ,2 8例。结果 :术前TP、LF随年龄的增长呈明显下降趋势 ,B、C、D、E组TP、LF显著低于A组 ,E组HF、D组LF/HF低于A组 ;术后 1d各组HRV各项指标均明显降低 ,B、D、E组TP和B、C、E组HF显著低于A组 ,D、E组LF/HF低于A组 ;术后 2d ,各组HF ,D、E组TP、LF进一步降低 ,D、E组TP、LF/HF显著低于A组。结论 :围术期自主神经功能受损的程度与年龄有一定的关系 ,表现为 :( 1)年龄愈大 ,术前自主神经功能愈低下 ;( 2 )术后高龄患者迷走神经功能降低幅度相对较大 ,迷走 /交感张力失衡相对更为严重且持续时间长     

利多卡因联合阿托品对全麻下择期手术的老年患者心率变异性的影响

目的探讨静脉注射利多卡因联合阿托品对全麻下择期手术的老年患者心率变异性的影响。方法将60例美国麻醉医师协会(ASA)Ⅱ～Ⅲ级的患者随机分为利多卡因联合阿托品组(LA组)、阿托品组(A组)和生理盐水对照组(S组),每组20例。LA组在诱导前先静脉注射2%利多卡因1.5 mg/kg,A组和S组注射等量生理盐水。插入喉罩5 min后,LA组、A组注射阿托品0.5 mg,S组注射等量生理盐水。记录各组患者麻醉诱导前(T_0)、诱导后1 min(T_1)、3 min(T_2)、静脉注射阿托品或生理盐水后1 min(T_3)、3 min(T_4)心率变异性(HRV)的变化。结果与T_0时点比较,3组T_1及T_2时点低频段(LF)、高频段(HF)及总功率频段(TP)均显著下降(P 0.05),A组和S组低频段与高频段比值(LF/HF)显著下降(P 0.05); LA组HF高于A组和S组,LF/HF低于A组和S组,差异均有统计学意义(P 0.05)。与T_2时点比较,3组T_3、T_4时点LF、TP均显著升高(P 0.05); LA组和S组T_3、T_4时点LF/HF与T_2时点比较,差异无统计学意义(P0.05),A组T_3、T_4时点LF/HF较T_2时点显著升高(P 0.05)。与T_2时点比较,LA组T_3、T_4时点LF、TP升高程度及HF下降程度低于A组,但高于S组,差异有统计学意义(P 0.05)。结论静脉注射利多卡因能显著抑制交感神经兴奋,联合使用阿托品后能减弱对老年患者心率变异性的影响,维持老年患者自主神经调节的平衡状态。     

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.     

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.     

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.