参附注射液对体外循环期间胃肠道及全身炎性反应的影响

目的:观察参附注射液(SF)对体外循环心脏手术患者胃肠道及全身炎性反应的影响,并初步探讨其作用机制。方法:择期心内直视手术患者30例,随机分为对照组和SF组。SF组于切皮时静注SF0.5ml·kg-1,再取1.0ml·kg-1用0.9%氯化钠稀释成100ml,用Grasby泵以SF0.004ml·kg-1·min-1速度持续注入;对照组则用同样方法输入等容量0.9%氯化钠。分别于切皮前(S0)、主动脉开放1h(R1)、2h(R2)测定胃黏膜pH(pHi)、血浆二胺氧化酶(DAO)、血浆内毒素(LPS)、血清IL-6水平。结果:S0时两组患者胃pHi、DAO、LPS、IL-6水平比较无显著差异(P<0.05);R1和R2时,两组患者胃pHi值显著低于S0值(P<0.01),DAO、LPS及IL-6水平显著高于S0值(P<0.01),SF组pHi值显著高于对照组(P<0.01),DAO、LPS及IL-6水平则显著低于对照组(P<0.01)。血浆DAO、LPS及IL-6水平与pHi呈显著相关(P<0.01),血浆LPS和IL-6水平呈显著正相关(P<0.01)。结论:SF对心脏手术体外循环期间患者胃肠道具有保护作用,并可抑制全身炎性反应。其机制可能与SF可改善胃肠道黏膜的灌注和氧合、保护肠黏膜细胞结构和功能、阻止内毒素移位及炎性介质释放有关。     

内毒素诱导一氧化氮升高小鼠模型的研究

目的探索通过腹腔注射不同剂量的细菌内毒素标准品(LPS),建立内毒素诱导一氧化氮(NO)升高的小鼠模型。方法50只小鼠,雌雄各半,分为5组,每组10只,分别腹腔注射生理盐水或不同浓度的内毒素标准品(LPS)溶液:Ⅰ组:每只小鼠注射0.2ml0.9%生理盐水;Ⅱ组:每只小鼠给予LPS2.5mg/kg;Ⅲ组:每只小鼠给予LPS5mg/kg;Ⅳ组:每只小鼠给予LPS10mg/kg;Ⅴ组:每只小鼠给予LPS5mg/(kg·d),共给药3d;观察给药后各组小鼠血浆、肝组织、脑组织中NO浓度并做统计学分析。结果Ⅰ-Ⅴ组小鼠血浆中NO浓度分别为(μmol/L):84.58±9.82;160.46±62.21;320.26±180.03;261.44±189.34;79.08±39.70;其中Ⅱ、Ⅲ、Ⅳ组与Ⅰ组有统计学差异;Ⅰ-Ⅴ组小鼠肝组织中NO浓度分别为(μmolo/gprot):16.39±1.06;15.25±0.09;20.41±2.06;22.12±1.59;20.29±1.59;其中Ⅰ、Ⅱ组与Ⅳ、Ⅴ组、与Ⅲ组间均有统计学差异;Ⅰ-Ⅴ组小鼠脑组织中NO浓度(x-±s)分别为(μmologprot-1):7.21±2.86;5.80±1.93;13.47±4.64;13.84±2.63;16.40±5.27;其中Ⅰ、Ⅱ组与Ⅲ、Ⅳ、Ⅴ组间有统计学差异。结论腹腔注射LPS标准品5mg/kg以上,可以建立内毒素诱导的NO升高的小鼠模型。     

联用山莨菪碱及地塞米松治疗MODS大鼠胃粘膜内pH值的变化

目的 :制作失血创伤 内毒素 (LPS)感染致多器官功能障碍综合征 (MODS)的大鼠模型 ,以研究大鼠的胃粘膜内pH (pHi)值在联合应用山莨菪碱 ( 6 5 4- 2 )及地塞米松(DM)治疗MODS过程中的变化。方法 :Wistar大鼠 40只 ,制成失血创伤 LPS感染的动物模型之后 ,随机分为 2组 :①治疗组 ( 15只 )联用 6 5 4- 2 ( 8mg/kg)及DM ( 10mg/kg)进行救治 ;②模型 (MODS)组 ( 15只 )仅应用相应剂量生理盐水 (NS) ;其他大鼠做正常对照组。三组动物于 2 4h后抽取动脉血 ,剖腹抽取胃液。利用Herderson -Hasseelbalch方程计算出pHi。结果 :MODS组大鼠pHi=6 9± 0 10 ,治疗组大鼠的pHi=7 3± 0 10。结论 :治疗组大鼠的pHi逆转并趋于正常值可能是山莨菪碱及地塞米松能够减轻MODS大鼠胃粘膜损伤的重要原因     

瑞芬太尼复合七氟醚控制性降压在神经外科手术中对内脏灌注的影响

目的:探讨瑞芬太尼复合七氟醚控制性降压在神经外科手术中对内脏灌注的影响。方法:20例行择期神经外科手术的患者,ASA分级Ⅰ～Ⅱ,麻醉诱导后吸入1MAC七氟醚维持麻醉,开始降压时通过调节瑞芬太尼的剂量0.2～0.5μg/(kg.min),直至收缩压较基础值降低30%或MAP不低于60mmHg。记录降压前即刻(T0)、降压后1h(T1)、降压后2h(T2)、降压后3h(T3)、术后1h(T4)的MAP、HR、胃黏膜二氧化碳分压(PgCO2),同时测血气计算胃黏膜pH值(pHi)。结果:与T0相比,MAP、HR、pHi在T1、T2、T3下降(P<0.05),PgCO2在T1、T2、T3升高(P<0.05),其余各指标在各时间点差异均无显著性(P>0.05)。结论:在神经外科手术中,用瑞芬太尼复合七氟醚行控制性降压后,可引起胃黏膜pHi可逆性改变,降压后3h内的内脏灌注均在正常范围内。     

内毒素耐受大鼠肺部iNOS和NO表达的动态变化和意义

目的 研究内毒素血症时内毒素耐受大鼠肺部诱导型一氧化氮合酶(iNOS)、一氧化氮(NO)的动态变化.方法 72只SD大鼠随机分为对照组(NC组)和内毒素耐受组(ET组).腹腔注射小剂量内毒素(LPS),第1天0.1 mg/只;第2～5天0.5 mg/只,建立内毒素耐受模型.NC组腹腔注射同等剂量生理盐水.最后一次注射LPS 72 h后,两组均腹腔注射大剂量LPS(10 mg/kg).各组按注射LPS前(0 h),注射后2、4、6、12、24 h分为六小组(n=6).通过比色法(即Griess法)测量肺组织iNOS、NO、丙二醛(MDA)及髓过氧化物酶(MPO)含量.同时在第6、12 h取大鼠左下肺组织行组织病理形态学观察.用SPSS13.0统计软件进行统计分析.结果 NC组大鼠在大剂量LPS刺激后肺组织iNOS和NO在4 h开始升高,6～12 h达到高峰(P＜0.05);MDA和MPO含量在2 h即开始升高,4～12 h达到高峰(P＜0.05).ET组大鼠在大剂量LPS刺激前肺组织iNOS、NO、MDA和MPO即有微量升高(P＞0.05),大剂量LPS刺激后肺组织iNOS、NO、MDA和MPO亦有升高,但与NC组相比明显降低(P＜0.05).病理学检查显示,ET组肺组织损伤明显较NC组减轻.结论 内毒素耐受时,大剂量内毒素血症引起的大鼠肺部损伤减轻与肺部iNOS、NO低表达有关.     

淋巴液对内毒素休克大鼠的干预作用及其机制

目的　观察外源性正常淋巴液对脂多糖 (LPS)所致大鼠内毒素休克的干预作用 ,初步探讨其作用机制。方法　Wistar雄性大鼠 4 0只 ,随机分为内毒素组、淋巴液组、血浆组、正常组。前 3组复制内毒素休克模型 (LPS ,5mg/kg·bw ,iv) ,正常组以等量生理盐水代替LPS。 15min后 ,淋巴液组输入仅占全血量 1/ 15的无细胞淋巴液。血浆组以血浆代替淋巴液 ,内毒素组和正常组以生理盐水代替淋巴液。给予LPS后 4h,取血浆及心、肝、肾、肺组织匀浆 ,对比观察血浆及组织中肿瘤坏死因子 -α(TNF -α)、一氧化氮 (NO)、一氧化氮合酶 (NOS)、诱导型一氧化氮合酶 (iNOS)、超氧化物歧化酶 (SOD)及丙二醛 (MDA)含量的变化。结果　淋巴液干预后 ,淋巴液组血浆TNF -α水平为 18.81± 3.70fmol/mL、NO含量为 4 6 .0 2± 9.2 9μmol/L、NOS活性为 2 5 .16± 4 .2 0U/mL、SOD活性为 10 2 .15± 17.88NU/mL、MDA水平 8.19± 1.6 4nmol/mL ,与其余 3组相比 ,各项指标差异均有统计学意义 (P <0 .0 5～ 0 .0 1)。结论　外源性正常淋巴液对内毒素休克具有干预作用 ,其机制可能与减少细胞因子及自由基损伤有关。     

角质细胞生长因子在内毒素耐受大鼠肺部表达的变化

目的:研究内毒素血症时内毒素耐受大鼠肺部角质细胞生长因子(KGF)表达的情况。方法:SD大鼠随机分入正常对照组(NC组)和内毒素耐受组(ET组)。腹腔注射脂多糖(LPS),每日0．6 mg／kg连续4d建立内毒素耐受模型。第5天腹腔注射6 mg／kg。各组按注射大剂量LPS前(0 h)．注射后2、6、24 h分为4小组,n=5。用ELISA测定肺组织匀浆中 KGF的浓度。用SPSS 11．5医学统计软件分析数据。结果:反复小剂量LPS注射后,ET组较NC组肺组织KGF蛋白水平上调,分别为(35．6±5．0)pg／ml和(24．2±5．3)pg／ml,P=0．009;给药后两组均下降,然而ET组下降幅度较小,而且各时间点KGF浓度均高于NC组,其中2 h和6 h有显著差异。结论:内毒素耐受有利于减轻大剂量内毒素引起的肺部 KGF蛋白表达抑制,这可能和其肺损伤程度减轻有关。     

丹参对大鼠烫伤后内毒素移位影响的实验研究

目的　探讨丹参对大鼠烫伤后内毒素移位的影响及其机制。方法　采用 30 %TBSA深Ⅱ度烫大鼠模型 ,检测伤前及伤后 3、6、12、2 4、4 8h大鼠血浆内毒素 (LPS)含量、肠黏膜血流量 (IMBF)、肠组织内一氧化氮 (NO)和内皮素 (ET)含量。结果　①伤后血浆LPS含量显著增高 (P <0 0 1) ,但治疗组显著低于烫伤组 (P <0 0 5 ,P <0 0 1) ;②伤后IMBF显著下降 (P <0 0 1) ,但治疗组下降幅度明显小于烫伤组 (P <0 0 5 ,P <0 0 1) ;③伤后肠组织内ET、NO含量均升高 ,尤以ET升高幅度较大 ,ET/NO比值上升 (P <0 0 5 ,P <0 0 1)。但治疗组与烫伤组相比较 ,ET含量降低、NO含量升高 ,ET/NO比值下降 (P <0 0 5 ,P <0 0 1)。结论　丹参能有效防治烫伤后内毒素移位 ,其作用机制可能与影响肠组织内ET、NO含量 ,调节ET/NO比值进而改善肠黏膜血液循环有关。     

高渗盐水对前列腺电切患者胃黏膜灌注和电切综合征的影响

目的观察输注高渗氯化钠溶液对前列腺电切患者胃黏膜灌注的影响和前列腺电切综合征（TURS）的发生率。方法 TURP的患者60例随机分两组,Ⅰ组为实验组输注高渗氯化钠溶液,Ⅱ组为对照组输注氯化钠溶液。监测患者血流动力学、电解质、胃内二氧化碳分压（PgCO2）和胃黏膜pH（pHi）变化,记录两组患者的TURS发生率。结果 T60时点Ⅱ组平均动脉压、血Na^＋、胃黏膜pHi显著低于Ⅰ组（P〈0.05）,而PgCO2显著高于Ⅰ组（P〈0.05）;Ⅱ组出现4例电切综合征（TURS）,而Ⅰ组无一例。结论输注高渗氯化钠溶液能改善胃黏膜灌注,预防TURS的发生。     

内毒素休克时循环血中一氧化氮的动态变化及其发生机制

为探讨内毒素休克时循环血中一氧化氮(NO)的动态变化及其可能的发生机制。方法:给新西兰白兔一次性静注大肠杆菌内毒素(LPS,8.0×10~9cfu/kg.B.w)后,观察平均动脉压(MAP)、血浆肿瘤坏死因子—α(TNF—α)和NO_2~-(NO代谢终产物)水平、组织一氧化氮合酶(NOS)活性及器官功能变化。结果:一次性静注LPS后,MAP呈双相下降;血浆TNF—α活性呈陡直的单峰曲线;NO_2~-含量于30min迅速增高,6h达峰值,24h仍高于注射前;24h心组织中NOS活性明显高于肝、肺和肾组织;肝、肾功能损害进行性加重。结论:内毒素休克时NO的生成不但迅速增加,而且持续时间长,可能是继TNF—α之后生成的其它细胞因子作用的结果。     

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.     

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.     

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.