长程经颅磁刺激对脑梗死大鼠皮质脑源性神经营养因子表达及神经功能恢复的影响

目的探索长程经颅磁刺激（TMS）对脑梗死大鼠梗死灶周围皮质脑源性神经营养因子（BD-NF）表达和脑损伤体积、神经功能恢复的影响及作用机制，为经颅磁刺激在脑梗死治疗及康复中的应用提供理论依据。方法TMS组与假刺激组大鼠各48只，于大脑中动脉阻塞／再灌注（MCAO／R）90min后的3周内每日接受1次TMS（200脉冲）与假刺激治疗。检测2组大鼠神经功能恢复情况、梗死灶周围皮质BDNF免疫阳性细胞表达及脑损伤体积，对所得资料进行统计学分析。结果在治疗2周和3周时，TMS组神经功能缺损评分与假刺激组相比均明显降低（P〈0．01）。TMS组在治疗3d、7d、14d、21d时梗死灶周围皮质BDNF阳性细胞计数与假刺激组各对应时间点相比，差异均有统计学意义（P〈0．01），且2组治疗21d时梗死灶周围皮质BDNF阳性细胞计数与大鼠神经功能缺损评分呈显著负相关（r=-0．877，P〈0．01）。治疗3周后，TMS组脑损伤体积明显小于假刺激组（P〈0．05），2组脑损伤体积与最终神经功能缺损评分明显相关（r=0．859，P〈0．01）。结论长程TMS有促进脑梗死大鼠神经功能缺损恢复的作用，其作用通过持续上调梗死灶周围皮质BDNF阳性细胞表达、减小梗死后脑损伤体积等作用而实现。     

自制复方中药对局灶性脑缺血大鼠脑组织一氧化氮含量的影响

目的：动态观察自制复方中药对局灶性脑缺血大鼠脑梗死体积和脑组织一氧化氮含量的影响，并与步长脑心通药物进行对照。方法：实验于20014-09／12在河北医科大学中医学院完成。将176只SD大鼠随机分为5组，①假手术组：只分离、暴露血管，不结扎颈总动脉及颈外动脉，不插入尼龙鱼线，5g／L羧甲基纤维素钠液灌胃。②模型组：采用线栓法复制局灶性脑缺血大鼠模型，5g／L羧甲基纤维素钠液灌胃。⑨中风康1．88g／mL组：制备局灶性脑缺血大鼠模型，18．8g／kg中风康灌胃（由枸杞子、怀牛膝、川芎、水蛭、地龙、橘络、胆南星、石菖蒲、冰片等药物组成）。④中风康0．94g／mL组：制备局灶性脑缺血大鼠模型，0．94g／kg中风康灌胃。⑤步长脑心通组：制备局灶性脑缺血大鼠模型，0．33g／kg步长脑心通灌胃。假手术组每时间点取8只太鼠，其余各组每时间点取9只大鼠，于脑缺血6，12，24，48h动态观察各组大鼠脑梗死体积和脑组织一氧化氮含量。结果：模型组，中风康1．88g／mL组，步长脑心通组，中风康0．94g／mL组分别死亡1，2，2，3只，造模失败3，2，2，1只，进入结果分析数量为每组大鼠32只，每时间点各8只。①各组大鼠脑梗死体积：局灶性脑缺血6h模型组梗死灶体积迅速扩大，随缺血时间延长，梗死灶体积缓慢进展，24h达到高峰，至48h梗死灶略有缩小；各治疗组梗死灶体积均有不同程度缩小，以中风康1．88g/mL组效果最为显著（P〈0.05或P〈0．01），且缺血6h中风康1．88g／mL组梗死灶体积明显小于步长脑心通组[（88&;#177;31），（136&;#177;35）mnt（P〈n01）]。②各组大鼠脑组织一氧化氮含量：局灶性脑缺血6h，模型组脑组织一氧化氮含量开始升高，24h达到高峰；局灶性脑缺血24h和48h，中风康1．88g/mL组一氧化氮含量明显低于模型组[（20．69&;#177;3．52），（24．89&;#177;3．13）μmol/g；（17．15&;#177;4．07），（22.37&;#177;3．04]μmol/g，（P〈0.05或P〈0.01）]，局灶性脑缺血48h，步长脑心通组一氧化氮含量亦明显低于模型组[（1827&;#177;335），（2237&;#177;3D4）μmol/g，（P〈0．05）]。结论：中风康可通过降低脑组织一氧化氮含量，减轻细胞毒作用，缩小梗死灶体积，能有效的减轻局灶性脑梗死引起的缺血性损伤，其疗效优于步长脑心通。     

神经生长因子对急性脑梗死大鼠神经功能和一氧化氮合酶含量的影响

目的 观察神经生长因子（NGF）对实验性急性脑梗死大鼠的疗效，初步探讨可能的机制。方法 将24只制备成的脑梗死模型大鼠随机分为3组，分别用神经生长因子（NGF）、胞磷胆碱钠（CS）和生理盐水（NS）治疗，于治疗前后检查动物的神经病学评分改变；再将55只大鼠随机分为实验组（25只）、对照组（25只）和正常组（5只），实验组急性脑梗死后即刻肌肉注射NGF，对照组注射等量NS。对照组和实验组大鼠分别在脑梗死后1h、3h、6h、12h、24h断头取脑，检测脑组织中一氧化氮合酶（NOS）含量。结果 与治疗前比较，NGF组和CS组大鼠治疗后神经病学评分均低于NS组（P〈0．05）；脑梗死大鼠梗死区脑组织中NOS活性在梗死后1h、3h较正常组明显升高（P〈0．01）；实验组大鼠NOS含量在脑梗死后1h、3h、6h较对照组明显下降（P〈0．01）。结论 NGF可明显促进急性脑梗死大鼠神经功能的恢复，机制之一可能是通过抑制急性脑梗死后NOS的活性起到保护损伤脑神经元的作用。     

急性脑梗死患者血浆D-二聚体水平的临床研究

目的探讨血浆D-二聚体在急性脑梗死发病过程中的变化。方法采用免疫比浊法检测30例健康对照者及46例急性脑梗死患者（入院后第1、7、14天）血浆D-二聚体的变化，分析其与梗死体积大小、神经功能缺损程度的相关性。结果急性脑梗死组患者血浆中D-二聚体含量与健康对照组相比明显增高（P〈0．01），大、中体积梗死组及神经功能缺损重、中型组的D-二聚体水平明显高于小体积梗死组及神经功能缺损轻型组（P〈0．01）。结论急性脑梗死患者血浆D-二聚体水平可作为判断病情的客观指标。     

丹奥与尿激酶联合治疗进展性脑梗死的疗效观察

目的 观察丹奥与尿激酶治疗进展性脑梗死的疗效。方法 将60例进展性脑梗死患者随机分为治疗组和对照组各30例。治疗组给以丹奥80mg，2次／d，静脉滴注，尿激酶10万U，1次／d；对照组丹奥80mg，2次／d，疗程为15d。观察2组患者治疗前后临床神经功能缺损程度评分、血小板聚集率的变化及凝血酶原时间的变化，并进行比较。结果 治疗组总有效率为93．3％，明显高于对照组（76．7％）（P〈0．01）。治疗组凝血酶原时间优于对照组（P〈0．05），2组血小板聚集率于治疗前后均有明显变化（P〈0．01）。结论 丹奥合并尿激酶为治疗进展性脑梗死的安全有效的治疗方法。     

高压氧早期治疗脑梗死的临床疗效观察

目的 探讨高压氧（HBO）在脑梗死早期治疗中的临床疗效。方法 将104例发病6h以内的脑梗死患者随机分为治疗组和对照组。治疗组患者于巴曲酶快速静脉滴注后即给予HBO治疗，对照组于用药（巴曲酶）7d后才开始HBO治疗；HBO治疗每日1次，共治疗10次。治疗结束后对所有患者进行神经功能缺损评分（N1S），并通过MRI测定、比较各组患者的脑梗死灶最大截面积。结果 2组患者N1S评分均较治疗前明显下降（P〈0．01），而且治疗组疗效明显优于对照组（P〈0.05），其梗死灶最大截面积亦显著小于对照组（P〈0．01）。结论 对早期脑梗死患者联合应用药物及HBO治疗，可有效促进其神经细胞功能恢复，缩小梗死灶体积。     

急性脑梗死患者血清超敏C反应蛋白水平的相关研究

目的研究急性脑梗死（ACI）患者血清超敏C反应蛋白（hs-CRP）水平的变化及其与梗死体积及神经功能缺损程度的关系。方法测定147例急性脑梗死患者及80名健康对照者的血清hs-CRP含量,分析比较急性脑梗死患者在不同梗死体积、不同病情时血清hs-CRP含量的变化。结果急性脑梗死患者血清hs-CRP的水平明显高于对照组（p〈0．01）,且血清hs-CRP含量越高,脑梗死灶越大,神经功能缺损程度越重,血清hs-CRP水平与病灶体积、病情轻重程度呈正相关（P〈0．01）。结论急性脑梗死与血清hs-CRP水平关系密切,hs-CRP不仅是脑梗死的危险因子,也可作为一个判断病情严重程度的客观指标。     

超声-中频电经颅刺激小脑区对大鼠局灶性脑缺血再灌注的保护作用

目的观察超声-中频电经颅刺激小脑区对大鼠局灶性脑缺血再灌注损伤的保护作用，并探讨其作用机制。方法将实验大鼠随机分为假手术组、对照组及治疗组。用线栓法制备一侧大脑中动脉闭塞再灌注（MCA-OR）模型，造成大鼠左脑缺血2h再灌注24h，采用5级评分法评定神经功能缺损程度并筛选大鼠。采用干重湿重法测定脑含水量，用TTC染色-图像分析仪测定梗死灶体积，并分析缺血侧脑组织超氧化物歧化酶（SOD）和丙二醛（MDA）含量的变化。结果与对照组相比，治疗组大鼠（即刻组除外）的脑水肿程度明显减轻（P〈0．05）；治疗组脑梗死体积缩小（P〈0．05），脑组织中SOD含量增加，而MDA值下降（P〈0．05）。结论超声-中频电经颅刺激小脑区对脑缺血再灌注损伤具有神经保护作用，其作用可能与减轻脑水肿、提高SOD活性、降低MDA含量及缩小梗死体积有关。     

康复训练对脑梗死大鼠血管内皮生长因子的表达及血管生成的影响

目的研究康复训练对脑梗死大鼠梗死灶周围新生血管情况、血管内皮生长因子（VEGF）和其受体（FLK-1）表达的影响。方法60只Wistar大鼠制备脑梗死模型后，随机分为康复训练组和造模对照组。康复训练组大鼠每天进行1h滚筒、平衡木、转棒及网屏训练，造模对照组置于普通笼中自由活动。每组分别于造模后3，7，14，21和28d采用免疫组织化学法检测梗死灶周围微血管数量（CD34标记）及VEGF和FLK-1的表达。结果（1）康复训练组术后14，21和28d行为学评分明显低于造模对照组（P〈0．05）；（2）康复训练组大鼠脑梗死灶周围CD34阳性微血管数量在脑梗死后21和28d较造模对照组明显增加（P〈0.05）；（3）康复训练组大鼠各时间点梗死灶周围VEGF表达均较对照组明显增加（P〈0．05）；（4）康复训练组大鼠各时间点梗死灶周围FLK-1表达均较造模对照组明显增加（P〈0．05）。结论康复训练可能通过诱导VEGF及其受体的表达，保护神经细胞，并促进血管新生，改善梗死灶周围血液供应，从而促进脑梗死后神经功能的恢复。     

阿司匹林、盐酸氟桂利嗪联合预处理对高血糖SD大鼠局部脑缺血再灌注损伤的保护作用

目的采用高血糖条件下Sprague-Dawley（SD）大鼠局灶性脑缺血再灌注模型,观察神经功能缺损评分、脑梗死体积及脑组织病理形态改变,探讨阿司匹林联合盐酸氟桂利嗪预处理对高血糖SD大鼠局灶性脑缺血再灌注损伤是否有保护作用。方法36只雄性健康SD大鼠,建立高血糖模型后随机分为2组：对照组（n=18）、阿司匹林＋盐酸氟桂利嗪组（治疗组,n=18）,各组按脑缺血90min再灌注3h（n=6）、6h（n=6）、24h（n=6）分为3个亚组。比较两组在相同再灌注各时间点神经功能缺损评分、脑梗死体积和脑组织病理形态的改变。结果治疗组相同再灌注各时间点神经功能缺损评分好于对照组（P〈0．05）;治疗组脑梗死体积明显小于对照组（P〈0．01）;治疗组与对照组相比,变性、坏死的神经元减少,空泡化改变减轻,组织间水肿减轻。结论阿司匹林联合盐酸氟桂利嗪预处理能减轻高血糖条件下的局灶陛脑缺血再灌注损伤,减轻神经功能缺损症状,缩小梗死体积,减轻神经细胞变性、坏死及组织水肿。     

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.     

Prospects for the control of neglected tropical diseases by mass drug administration

The prospects for the control of neglected tropical diseases, including soil-transmitted helminthiasis, shistosomiasis, lymphatic filariasis, onchocerciasis and trachoma, through mass drug administration, are exemplified by the elimination of the trachoma as a public-health problem in Morocco. In spite of this and other striking successes, mass drug administration programs are faced with major challenges resulting from suboptimal coverage and lack of efficacy. At current suboptimal coverage rates, programs may need prolongation for an extended period, increasing costs and undermining sustainability. Community participation through health education and information appears to be crucial to improve coverage and to achieve sustainability. Implementation of complementary measures, such as vector control, improved hygiene and environmental sanitation, are important to further control transmission and to prevent re-emergence of the infection and, again, may only be achieved effectively through community-based initiatives. To reduce costs and to relieve pressure on the health system, combining neglected tropical disease programs in areas where diseases coexist and integration with existing control programs for malaria, tuberculosis and HIV/AIDS is advocated. The risk of developing drug resistance is of particular concern in view of the lack of alternative drugs, and reduced treatment efficacy due to emerging resistance is evident for the soil-transmitted helminths and onchocerciasis. Given the risk for the development of drug resistance and the need for a high degree of participation, close attention should be paid to the monitoring of the coverage and efficacy of the different program components.     

Bacterial meningitis: an update of new treatment options

The outcome of bacterial meningitis critically depends on the rapid initiation of bactericidal antibiotic therapy and adequate management of septic shock. In community-acquired meningitis, the choice of an optimum initial empirical antibiotic regimen depends on the regional resistance patterns. Pathogens resistant to antibacterials prevail in nosocomial bacterial meningitis. Dexamethasone is recommended as adjunctive therapy for community-acquired meningitis in developed countries. In comatose patients, aggressive measures to lower intracranial pressure <20 mmHg (in particular, external ventriculostomy, osmotherapy and temporary hyperventilation) were effective in a case–control study. Although many experimental approaches were protective in animal models, none of them has been proven effective in patients. Antibiotics, which are bactericidal but do not lyse bacteria, and inhibitors of matrix metalloproteinases or complement factor C5 appear the most promising therapeutic options. At present, vaccination is the most efficient method to reduce disease burden. Palmitoylethanolamide appears promising to enhance the resistance of the brain to infections.     

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.     

Imaging choices in occult hip fracture

Background: Hip fracture is a common injury, with an incidence rate of > 250,000 per year in the United States. Diagnosis is particularly important due to the high dependence on the integrity of the hip in the daily life of most people. Objectives: In this article we review the literature focused on hip fracture detection and discuss advantages and limitations of each major imaging modality. Discussion: Plain radiographs are usually sufficient for diagnosis as they are at least 90% sensitive for hip fracture. However, in the 3–4% of Emergency Department (ED) patients having hip X-ray studies who harbor an occult hip fracture, the Emergency Physician must choose among several methods, each with intrinsic limitations, for further evaluation. These methods include computed tomography, scintigraphy, and magnetic resonance imaging. Conclusion: We present an evidence-based algorithm for the evaluation of a patient suspected to have an occult hip fracture in the ED. Also outlined are future directions for research to distinguish more effective techniques for identifying occult hip fractures.     

Systematic Reviews Published in the April 2012 Issue of the Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly as a DVD but monthly online. The April 2012 issue (second DVD for 2012) contains 5045 complete reviews, 2182 protocols for reviews in production, and 17,084 short summaries of systematic reviews published in the general medical literature. In addition, there are citations of 674,000 randomized controlled trials, and 15,400 cited papers in the Cochrane methodology register. The health technology assessment database contains just over 11,000 citations. One hundred and seventeen new reviews have been published in the last 3 months of which 12 have potential relevance for practitioners in pain and palliative medicine. The impact factor of the Cochrane Library stands at 6.186. Readers are encouraged to access the full report for any articles of interest as only a brief commentary is provided.     

Platelets,thrombosis, coagulation,and atherosclerosis

When I first got the invitation to join a medical delegation going to Moldova, I thought for a moment that our destination was the fictional country in the old Marx Brothers movie Duck Soup. On further checking, it turns out that entertaining place was called Freedonia. I now know that Moldova is indeed a real country, bordered on the west by Romania and on the other three sides by the Ukraine. It is a proud country, rich with traditions, and its people are warm, giving, eager to learn ways to improve their healthcare system, and deeply appreciative of our attempts to help them in the task.