兔胫神经阻滞中乙醇扩散的影响因素

目的：探讨乙醇推注速度、浓度和容量对乙醇在组织中扩散特征的影响,为溶神经技术的临床应用提供依据。方法：27只新西兰大白兔,54条胫神经干,分为3组。在神经电刺激仪引导下准确定位胫神经干后,注射用非离子型碘造影剂标记的乙醇。第Ⅰ组（推注速度组）胫神经18条,分成3个亚组（Ⅰa、Ⅰb、Ⅰc）,分别接受以不同推注速度（0.004ml/s;0.01ml/s;0.1ml/s）注射0.3ml无水乙醇。第Ⅱ组（浓度组）胫神经干12条,分成2个亚组（Ⅱa,Ⅱb）,分别接受以0.01ml/s推注速度注射0.3ml 50%乙醇和无水乙醇。第Ⅲ组胫神经24条,分成4个亚组（Ⅲa、Ⅲb、Ⅲc、Ⅲd）,分别接受以0.01ml/s推注速度注射无水乙醇0.1ml、0.3ml、0.5ml、1.0ml。注射后第10min行16排螺旋CT扫描,计算乙醇扩散体积,并将图像行三维重建观察乙醇扩散方式。结果：Ⅰc亚组乙醇扩散体积明显高于Ⅰa、Ⅰb亚组(P<0.05).乙醇浓度对乙醇扩散体积没有影响（P>0.05）。容量组各亚组间比较发现各亚组间乙醇扩散体积均有显著性差异（P<0.05）。结论：乙醇扩散的形态为纵向,推注速度以及容量显著影响乙醇扩散体积,但是乙醇浓度对扩散体积无影响。     

80例糖尿病患者的胫神经电生理分析

目的:探讨糖尿病性神经病的电生理改变特征。方法:在80例Ⅱ型糖尿病患者中,有神经病学症状或体征的39例为A组,无神经病学症状或体征的41例为B组。C组为正常对照。在三组中测定胫神经运动神经传导速度(MCV),远端潜伏期(DPL),复合肌肉动作电位(CMAP)的波幅、时限,检测数据进行t检验。结果:A组与B、C组分别对比,A组MCV减慢(69%),DPL延长(53.8%),cMAP波幅降低(35.9%),时限延长(51.2%),有显著差异(P<0.01)。B组与C组对比,B组CMAP波幅降低,有显著差异(P<0.05),B组17%DPL延长,7.3%CMAP时限延长。各组内远端与近端刺激引出的CMAP波幅、时限对比均无显著差异(P>0.05)。A组电生理异常率为100%,B组为26.8%。A组病程长但血糖水平同B组相近。结论:了解胫神经的电生理改变有助于评价糖尿病性远端神经病与临床病程、进展的关系。     

尺神经共同刺激影响腕管综合征正中神经远端潜伏期：避免误差的定量测定

目的研究尺神经-大鱼际复合肌肉动作电位(CMAP)潜伏期正常值,以定量分析尺神经共同刺激所致腕管综合征(CTS)患者正中神经-大鱼际潜伏期的误差。 方法正常组112例,记录224侧正中神经-拇短展肌（APB）和224侧尺神经-大鱼际的CMAP潜伏期和波幅。另对其中10例20侧正中神经,分别记录以正中神经-APB最大波幅之刺激强度的30%、50%、70%、100%刺激时的CMAP潜伏期和波幅。其中4例分别予以120%、150%和200%的超强刺激,记录CMAP潜伏期和波幅。CTS组16例,记录到正中神经-APB的CMAP最大波幅后,继续增大刺激强度,记录尺神经共同刺激效应后的正中神经-大鱼际CMAP。 结果①正常组：尺神经-大鱼际远端潜伏期为（3.17±0.25）ms,波幅为（6.60±1.07）mV;正中神经-APB远端潜伏期为(3.45±0.31)ms,波幅为(6.47±1.08)mV。当正中神经刺激强度从引出最大CMAP波幅之强度的30%、50%、70%增加至100%,正中神经远端潜伏期相应缩短0.1~0.3ms;达到最大波幅后继续增加刺激强度至120%、150%和200%的超强刺激,则潜伏期不再继续缩短。②CTS组：尺神经共同刺激所引起的正中神经-大鱼际CMAP潜伏期缩短范围为0.5~8.7ms,导致正中神经-APB的错误潜伏期范围为(2.9~4.1)ms。 结论CTS患者正中神经检测时,若正中神经-APB CMAP潜伏期随刺激强度增大而缩短超过0.3ms,并且达到2.9~4.1ms的范围,则提示可能发生了尺神经共同刺激。     

脊髓损伤患者双下肢神经肌肉的电生理特征

目的:采用神经传导测定及肌电图观察脊髓损伤(SCI)患者双下肢神经肌肉电生理变化,为脊髓损伤后双下肢神经肌肉功能判断提供依据。方法:19例脊髓损伤患者,采用常规神经传导检测方法测定双胫、腓总神经运动及感觉传导,分析末端潜伏期、动作电位波幅及传导速度。采用同心圆针电极检测双侧胫前肌、腓肠肌、股四头肌及L4—S1脊旁肌自发肌电活动(SA)。结果:①神经传导特征:94.7%患者运动传导异常,表现为单纯复合肌肉动作电位(CMAP)波幅降低、波幅降低伴潜伏期延长、动作电位缺失三种类型;15.8%的患者同时伴有感觉传导异常,表现为波幅降低、传导速度减慢或动作电位缺失;②胫神经:单纯运动传导异常占47.4%,运动与感觉传导均异常占10.5%;运动传导均表现为双侧异常(动作电位缺失、波幅减低和/或潜伏期延长);感觉传导表现为单侧传导速度减慢和/或波幅降低;③腓总神经:单纯运动异常占78.9%,运动与感觉均受累为15.8%;运动传导双侧异常为84.2%(动作电位缺失和/或波幅降低),单侧异常为10.5%(波幅降低和/或潜伏期延长);感觉传导异常为双侧或单侧动作电位缺失、传导速度降低和波幅降低(15.8%);④胸腰段SCI的胫、腓神经运动传导异常显著高于颈段SCI(腓神经为100%:85.7%,胫神经为66.7%:42.9%)。⑤肌肉自发电活动:所有患者双下肢肌肉及脊旁肌均见不同程度的自发电活动,包括纤颤电位、正锐波。结论:脊髓损伤后双下肢电生理主要表现为运动神经轴索性损害及肌肉异常自发电活动,肌肉异常自发电活动与下肢周围神经电生理改变无关;胸腰段脊髓损伤下肢周围神经传导异常比例高于颈段脊髓损伤。     

脑卒中患者周围神经与肌肉神经电生理特征分析

目的:通过神经传导及同心圆针肌电图检测探讨脑卒中患者周围神经、肌肉的神经电生理变化特征,为脑卒中后神经肌肉功能评估和预后判断提供依据。方法:对符合入选标准的41例脑卒中患者进行双侧正中、尺、桡、肌皮、腋、肩胛上、胫、腓神经运动传导及双正中、尺、桡、胫、腓神经感觉传导检测,双拇短展肌、伸指总肌、肱二头肌、三角肌、冈上肌、胫前肌、比目鱼肌行同心圆针肌电图检测。采用Brunnstrom分期评价肢体功能。分析健、患侧肢体神经及肌肉的神经电生理指标差异及其与肢体功能的相关性。结果:(1)运动神经传导:与健侧比较,偏瘫侧正中、尺、桡、腋、肩胛上、胫、腓神经复合肌肉动作电位(compound muscle action potential,CMAP)波幅均显著降低(P0.05),腓总神经末端潜伏期延长及腓骨小头-踝传导速度减慢(P0.05),其他各神经末端潜伏期均无明显差异;病程3—6个月患者正中、尺、桡神经运动传导异常率均高于其他病程组;(2)感觉神经传导:偏瘫侧桡、腓浅神经SNAP波幅较健侧降低,尺、桡神经传导速度较健侧减慢(P0.05),且有9例患者健侧正中神经感觉传导速度减慢;病程3—6个月患者正中神经和腓浅神经感觉传导异常率高于其他病程组;(3)同心圆针肌电图:不同病程均有一定比例脑卒中患者上下肢肌肉可见纤颤电位、正锐波等异常自发电位;肢体远端肌肉,如拇短展肌、伸指总肌在各个病程中出现自发电位的比例均较高;病程6个月以上者,三角肌的自发电位发生率增高,而比目鱼肌在各个病程的患者中自发电位的出现率均较高;无主动收缩功能肌肉自发电位出现率显著高于有主动收缩功能肌肉(P=0.000);(4)患者手Brunnstrom分期与尺神经偏瘫侧/健侧CMAP波幅比呈正相关(r=0.426,P0.05)。结论:脑卒中患者偏瘫侧运动神经轴索变性及脱髓鞘伴部分感觉神经脱髓鞘和轴索变性,且以病程3—6个月患者最为多见;同时手功能Brunnstrom分期与尺神经运动传导CMAP波幅具有相关性;偏瘫侧肢体肌肉失神经支配改变以肢体远端肌肉和无主动收缩功能肌肉为主。     

前列地尔、硫辛酸联合西洛他唑治疗糖尿病周围神经病变疗效观察

目的:观察前列地尔、硫辛酸和西洛他唑3药联合使用对糖尿病周围神经病变(DPN)的疗效。方法:DPN患者76例,随机分为对照组和治疗组各38例,在糖尿病基础治疗基础上,对照组给予前列地尔和硫辛酸治疗,治疗组给予前列地尔、硫辛酸和西洛他唑3药联用。于治疗前和治疗4周后,检测并分析2组运动神经传导速度(MCV)、感觉神经传导速度(SCV)、运动神经复合肌动作电位(CMAP)波幅、CMAP潜伏期和感觉神经动作电位(SNAP)波幅的变化和神经病变主觉症状问卷(TSS)评分。结果:治疗前,2组TSS评分、神经传导速度、CMAP波幅、CMAP潜伏期和SNAP波幅无统计学差异(P>0.05);治疗后,2组TSS评分和CMAP潜伏期均低于治疗前,且治疗组低于对照组(P<0.01);2组MCV、CMAP波幅、SNAP波幅和SCV均较治疗前提高(P<0.01),且治疗组优于对照组(P<0.05)。结论:前列地尔、硫辛酸和西洛他唑3药联用治疗DPN疗效好于前列地尔、硫辛酸2药联用。     

无水乙醇神经内及神经周围阻滞对大鼠坐骨神经运动功能与形态学的影响

目的:研究无水乙醇神经内及神经周围阻滞对大鼠坐骨神经运动功能与形态学的影响并对两种阻滞效果的差异进行比较。方法:72只雌性健康SD大鼠,体重(200±20)g,随机分成神经内和神经周围无水乙醇阻滞两大组,每组36只。每大组又分为阻滞前、阻滞后24h、72h、1周、4周、12周六个观察组,每组6只,分别在阻滞前及阻滞后五个时间点评估各组大鼠的运动功能,测试其坐骨神经运动传导速度(MCV),以及神经肌肉组织形态学的变化,并进行组间和组内比较,以评估神经损伤程度及其修复情况。结果:①神经内阻滞组大鼠各时间点运动功能学指标和坐骨神经MCV均较神经周围阻滞组低(P<0.01);②两组大鼠均于阻滞后24h出现运动功能显著下降(P<0.05)和MCV减慢(P<0.01),72h损伤最重,1周后可见恢复,并延续至第12周;③阻滞后12周时,两组大鼠坐骨神经运动功能和运动传导速度均未恢复到阻滞前的水平(P<0.01);④两组大鼠于阻滞后早期局部肌肉均有不同程度的变性,阻滞后12周,周围阻滞组可见阻滞局部瘢痕形成,内阻滞组可见阻滞局部肌纤维萎缩;⑤阻滞后72h,神经组织结构损伤达高峰;阻滞后1周,出现修复反应,并持续至12周;内阻滞组神经结构在阻滞后12周仍难以恢复正常。结论:①坐骨神经内阻滞较周围阻滞造成的神经结构损害更加难以修复,运动功能下降更加显著;②无水乙醇阻滞造成的神经损伤持续时间达12周以上。     

快速恢复与缓慢恢复的急性运动轴索性神经病 临床比较分析

目的：比较分析快速恢复与缓慢恢复的急性运动轴索性神经病（AMAN）的临床及神经电生理学特点。方法：收集我院收治的AMAN患者50例的临床资料,根据发病高峰期的Hughes评分,将得分≥3分者纳入缓慢恢复组,得分<3分者纳入快速恢复组;回顾性分析比较2组的临床及电生理特点。结果：纳入缓慢恢复组27例,纳入快速恢复组23例。缓慢恢复组在发病高峰时Hughes评分4～6分,发病年龄大,前驱感染以腹泻多见,伴有延髓受累,肢体瘫痪完全,可累及呼吸肌,需机械辅助通气。快速恢复组发病高峰时Hughes评分2～4分,发病年龄小,临床症状轻,肢体瘫痪轻,多伴肢体麻木。AMAN肌电图特点：感觉神经的感觉神经动作电位波幅（SNAP）和感觉神经传导速度（SCV）正常。正中神经、尺神经、胫神经的复合肌肉动作电位运动末端潜伏期（DML）和运动神经传导速度（MCV）均在正常值范围内;腓总神经DML高于正常值（P<0.05）,而MCV低于正常值（P<0.05）,但2组间差异无统计学意义。复合肌肉动作电位（CMAP）波幅第1周内就开始下降,且除胫神经外,缓慢恢复组的正中神经、尺神经及腓总神经的CMAP...     

超声引导腘窝坐骨神经鞘膜下阻滞在足踝手术中的应用效果

目的探讨足踝部手术中应用超声引导腘窝坐骨神经鞘膜下阻滞的临床效果和安全性。方法将60例择期行足踝部手术患者按随机数字表法分为观察组与对照组,每组30例。观察组行超声引导腘窝坐骨神经鞘膜下阻滞,对照组行超声引导腘窝坐骨神经鞘膜外阻滞。比较2组操作时间、神经内注射发生率、注射成功率、麻醉成功率、足踝区域感觉与运动阻滞起效和恢复时间、术中添加芬太尼发生率及术后1周并发症发生情况。结果观察组操作时间、神经内注射发生率、胫神经与腓总神经感觉起效时间、术中添加芬太尼发生率较对照组显著减少(P<0.05或P<0.01),注射成功率、麻醉成功率、胫神经与腓总神经感觉恢复时间较对照组显著增加(P<0.05或P<0.01);2组胫神经与腓总神经运动阻滞起效、恢复时间比较差异无统计学意义(P>0.05),术后1周均无并发症发生。结论超声引导腘窝坐骨神经鞘膜下阻滞相比鞘膜外阻滞,操作时间更短,感觉神经阻滞起效时间更快,能够很好地满足外踝手术所需的镇痛,且较少有术后并发症发生。     

连枷臂综合征的临床及神经电生理特点分析

目的 探讨连枷臂综合征（FAS）的临床及神经电生理特点。 方法 选取13例诊断明确的FAS患者及31例由上肢起病的肌萎缩侧索硬化（UL-ALS）患者,收集上述患者临床查体及神经电生理数据,包括正中神经、尺神经、腋神经复合肌肉动作电位（CMAP）波幅并计算分裂手比值SI值（SI值=正中神经CMAP波幅/尺神经CMAP波幅）。分析入选FAS患者临床特点及分裂手现象,并对比FAS及UL-ALS患者正中神经、尺神经、腋神经CMAP波幅。 结果 与UL-ALS患者比较,入选FAS患者发病年龄［(60.9±7.4)岁］偏大,症状进展至第二区域时间［（24±6）个月］较长;约15% FAS患者上肢腱反射消失,77%减弱,无反射活跃或亢进者,约54% FAS患者下肢反射活跃,38%减弱,上述肢体反射情况与UL-ALS患者组间差异均具有统计学意义（P<0.05）。入选FAS患者正中神经、尺神经CMAP波幅、SI值与UL-ALS患者组间差异均无统计学意义（P>0.05）,两组SI值均<1。伴上运动神经元（UMN）体征的FAS患者SI值（0.41±0.26）较不伴UMN体征患者SI值（0.76±0.18）明显降低（P<0.05）。入选FAS患者尺神经CMAP波幅较大,正中神经次之,腋神经CMAP波幅较小（P<0.05）,而UL-ALS患者尺神经CMAP波幅较正中神经波幅明显增大（P<0.05）,但两者均与腋神经CMAP波幅无显著差异（P>0.05）。 结论 FAS是一种以上肢近端肌肉受累为主的运动神经元疾病,其病程相对缓慢,症状进展至第二区域时间超过1年（平均24个月）,患者上肢反射多减弱或消失,下肢反射活跃或减弱,具有UMN体征,且存在分裂手现象,具有UMN体征的FAS患者更易出现分裂手现象,肌电图检查显示腋神经CMAP波幅明显低平,上述特点有助于临床早期诊断FAS患者。     

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.     

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.     

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.     

Clinical Trial Updates and Hotline Sessions presented at the European Society of Cardiology Congress 2007

This article provides information and commentaries on trials which were presented at the Hotline and Clinical Trial Update Sessions at the European Society of Cardiology Congress 2007 in Vienna. The key presentations were performed by leading experts in the field with relevant positions in the trials or registries. It is important to note that unpublished reports should be considered as preliminary data, as the analysis may change in the final publications. The comprehensive summaries have been generated from the oral presentation and the webcasts of the European Society of Cardiology and should provide the readers with the most comprehensive information of relevant publications.     

Balance and Boundaries in Grief Counseling: An Intervention Framework for Volunteer Training

Volunteers or paraprofessional counselors are commonly used to provide supportive care to the bereaved. These counselors generally are trained in basic listening skills, providing a generic, nonspecific approach to intervention that remains to be proven effective. The present paper outlines a framework that provides paraprofessionals with a broader model for intervention with the bereaved. Attention to boundaries as a helper and balance in the grief recovery are central to the model. Interventions are described that provide the paraprofessional counselor with more options for tailoring their counseling strategy to the individual. These include techniques that are presumed to be more specific to the enhancement of grief recovery.     

A new method for the simultaneous analysis of unmodified and modified urinary nucleosides and nucleobases by high performance liquid chromatography

Details are given of a new, rapid and simple pre-fractionation method and an isocratic high performance liquid chromatography system suitable for parallel analysis of nucleosides and nucleobases from urine and other biological fluids. The quantitative recovery and excellent reproducibility of the method is demonstrated by analysis of representative standard RNA catabolites. The advantage of this new method for application to biological samples is discussed.     

Adsorption of Charged Non-albumin Bound Drugs by Amorphous Silica

We investigated the in vitro drug adsorption of PQ 10150 sodium silicate gel (AIS, Santa Clara, CA) with particle size of 230 um and surface area of 400 nr/g. We observed 99% to 88% adsorption of gentamicin; a mean 91 % of disopyramide; a mean 89% of quinidine at low concentration, falling to 75% at higher concentration. Insulin was 88% adsorbed at low concentrations but less so (65%) at higher concentrations. We observed a mean 83 % adsorption of procainamide, a mean 84% of N-acetyl procainamide, 74% oflidocaine, 73% of amitriptyline; and 44% of desipramine. We found an average 14% reduction of total digoxin concentration when serum containing digoxin (2 to 33 ng/mL) was exposed to sodium silicate, while the reduction in free digoxin concentration was 16%. Five percent ethosuximide was also removed. The adsorption of theophylline, phenobarbital, acetaminophen, phenytoin, ethylene glycol, methotrexate, salicylate, thiocyanate and diazepam was minimal and not significant. We conclude that significant amounts of charged, non-albumin bound drugs can be removed by PQ 10150 sodium silicate gel.     

自动化酸碱平衡图在急诊社区获得性肺炎诊治中的应用

目的 探讨自动化酸碱平衡图在急诊科社区获得性肺炎(CAP)患者诊断中的价值.方法 根据病史、肺功能测定结果、慢性阻塞性肺疾病(COPD)诊断标准,将111例CAP患者分为单纯CAP组(56例)和COPD合并CAP组[即慢性阻塞性肺疾病急性加重(AECOPD)组,55例].询问患者病史后即刻抽取动脉血测血气并进行自动化酸碱平衡图分析.结果 血气分析结果显示,AECOPD组动脉血二氧化碳分压(PaCO2,kPa)、HCO3- (mmol/L)、剩余碱(BE,mmol/L)均显著高于CAP组(PaCO2:7.714±2.414比5.896±1.308,HCO3-:30.767±7.185比25.014±3.043,BE:4.345±5.371比-0.354±3.180,均P＜0.01).自动化酸碱平衡图分析结果显示,AECOPD组患者酸碱平衡紊乱高达89.1％,CAP组为66.1％.将AECOPD组和CAP组患者中正常(10.9％、33.9％)、急性呼吸性酸中毒(急性呼酸,12.7％、14.3％)、慢性呼吸性酸中毒(慢性呼酸,49.1％、10.7％)、呼吸性碱中毒(呼碱,7.3％、14.3％)、代谢性酸中毒(代酸,12.7％、17.9％)、代谢性碱中毒(代碱,12.7％、8.9％)综合进行x2分析,差异有统计学意义(x2=24.421,P=0.001),而将正常、急性呼酸、呼碱、代酸及代碱进行x2分析,差异无统计学意义(x2=5.280,P=0.260),提示AECOPD患者慢性呼酸的发生率较单纯CAP患者显著增加.结论 自动化酸碱平衡图能帮助急诊科医师快速识别CAP患者是否存在多重酸碱平衡紊乱,并可快速识别急、慢性呼吸系统疾病.