电针结合重复经颅磁刺激对局灶性脑缺血大鼠蛋白激酶表达的影响

目的:探讨电针(EA)结合重复经颅磁刺激(rTMS)对局灶性脑缺血大鼠蛋白激酶A(PKA)表达的影响及其治疗缺血性脑损伤的机制。方法:Wistar大鼠75只,采用线栓法制备大鼠大脑中动脉闭塞模型,随机分为正常组、模型组、EA组、rTMS组和EA+rTMS组,通过Western印迹检测脑缺血后第7天、第14天与第28天三个不同时间点大鼠海马胞核内PKA表达的变化,并观测其神经功能评分。结果:脑缺血后不同时间点缺血侧海马PKA灰度值,模型组在第7天时高于正常组,第28天时低于正常组(P0.05),第14天时与正常组相比P0.05;EA组、rTMS组和EA+rTMS组3个时相均高于模型组,第7天、第14天时高于正常组,差异具有显著性意义(P0.05),第28天时与正常组相比P0.05,其中,EA+rTMS组第7天、第14天时高于EA组、rTMS组P0.05,EA组和rTMS组各时间点均无显著性差异(P0.05)。EA组、rTMS组和EA+rTMS组各时间点神经功能评分均较模型组改善(P0.01),尤以EA+rTMS组为明显。结论:EA结合rTMS对脑卒中后神经功能的恢复具有显著的促进作用,PKA蛋白的表达增强可能是其治疗缺血性脑卒中的机制之一。     

电针结合重复经颅磁刺激对局灶性脑缺血大鼠蛋白激酶A-环磷腺苷反应元件结合蛋白信号转导通路的影响

目的探讨电针结合重复经颅磁刺激(rTMS)对局灶性脑缺血大鼠蛋白激酶A-环磷腺苷反应元件结合蛋白（PKA-CREB）信号转导通路的影响及其治疗缺血性脑损伤的机制。 方法取雄性Wistar大鼠75只,采用线栓法制备大鼠大脑中动脉闭塞模型,分为正常组、模型组、电针组、rTMS组和电针+rTMS组, 每组大鼠15只,通过蛋白印迹法检测正常组入组后及其它各组脑缺血后第7,14,28天3个时间点大鼠海马胞核内蛋白激酶A（PKA）、磷酸化环磷腺苷反应元件结合蛋白(pCREB)表达的变化,并观测其神经功能评分。 结果脑缺血后不同时间点缺血侧海马PKA及pCREB灰度值比较,模型组在造模后第7天时高于正常组,造模后第28天时低于正常组,差异均有统计学意义(P<0.05),造模后第14天时与正常组相比差异无统计学意义 (P&rt;0.05);电针组、rTMS组和电针+rTMS组3个时间点均高于模型组,造模后第7,14天时高于正常组,差异具有统计学意义(P<0.05),造模后第28天时与正常组相比差异无统计学意义(P&rt;0.05),其中,电针+rTMS组第7,14天时高于电针组、rTMS组,差异有统计学意义(P<0.05),电针组和rTMS组各时间点差异均无统计学意义(P&rt;0.05)。电针组、rTMS组和电针+rTMS组各时间点神经功能评分均较模型组改善(P<0.01),其中以电针+rTMS组神经功能评分改善最为明显。 结论电针结合rTMS对脑卒中后神经功能的恢复具有显著的促进作用, 蛋白激酶A-环磷腺苷反应元件结合蛋白信号转导通路蛋白的表达增强可能是其治疗缺血性脑卒中的机制之一。     

电针结合经颅磁刺激对局灶性脑缺血大鼠pCREB表达的影响

目的：探讨电针结合经颅磁刺激（rTMS）对局灶性脑缺血大鼠磷酸化环腺苷酸反应元件结合蛋白（pCREB）表达的影响及其治疗缺血性脑损伤的机制。方法：Wistar大鼠75只,随机分为A、B、C、D及E组各15只,A组为正常对照,B、C、D及E组大鼠采用线栓法制备局灶性脑缺血模型,术后A、B组不实施处理,C组进行电针治疗,D组给予rTMS治疗,E组给予电针及rTMS联合治疗。通过Western blot检测脑缺血后第7、14及28d3个不同时相大鼠海马胞核内pCREB的表达,并观测神经功能缺损程度评分的变化。结果：脑缺血后不同时相点缺血侧海马pCREB阳性表达和灰度值,B组在7d时高于A组,28d时低于A组（P〈0．05）,14d时与A组比较差异无显著性意义;C、D组和E组各时相点均高于B组,7及14d时高于A组（均P〈0．05）,28d时与A组比较无差异;E组7及14d时相点均高于C及D组（P〈0．05）;C与D组各时相点均无差异。各时相点神经功能缺损评分C、D组和E组均较B组下降（P〈0．01）,尤以E组为明显。结论：电针结合rTMS对脑卒中后神经功能的恢复有显著的促进作用,pCREB的表达增强可能是其治疗缺血性脑卒中的机制之一。     

电针结合重复经颅磁刺激对脑缺血大鼠海马突触后致密物-95的影响

目的探讨电针结合重复经颅磁刺激对脑缺血大鼠海马突触后致密物-95（PSD-95）的影响。 方法60只Wistar大鼠随机分为正常组、模型组、电针组（EA组）、重复经颅磁刺激组（rTMS组）和电针结合重复经颅磁刺激组（EA+rTMS组）,每组又根据观察时间点分为7 d、14 d和28 d 3个亚组,每个亚组4只大鼠。大鼠复制大脑中动脉栓塞模型后,分别给予电针、重复经颅磁刺激和电针结合重复经颅磁刺激干预,免疫组织化学法检测缺血侧海马齿状回和CA3区的PSD-95蛋白表达变化。 结果观察第7天,模型组、EA组、rTMS组和EA+rTMS组大鼠海马的PSD-95表达均下降;治疗14 d后,各治疗组PSD-95表达上调;至28 d时各治疗组与模型组比较差异有统计学意义,尤其是EA+rTMS组PSD-95在海马CA3区表达增加更明显,与EA组和rTMS组比较差异有统计学意义。 结论电针结合重复经颅磁刺激能明显增强脑缺血大鼠海马PSD-95的表达,这可能是其改善脑缺血大鼠学习记忆功能的机制之一。     

电针神庭、百会对脑缺血再灌注大鼠学习记忆能力和海马CA1区环磷酸腺苷效应元件结合蛋白及其磷酸化水平的影响

目的探讨电针神庭、百会治疗脑卒中后认知功能障碍的机制。方法 45只Sprague-Dawley大鼠随机分为假手术组、模型组和电针组,每组15只。后两组线栓法复制大鼠大脑中动脉缺血2 h再灌注模型。电针组于造模后24 h开始电针神庭和百会,共7 d。每天电针后行Morris水迷宫测试。治疗后,取大鼠脑组织TTC染色测量脑梗死体积,免疫组化检测海马CA1区环磷酸腺苷效应元件结合蛋白(CREB)及其磷酸化水平(p-CREB)的表达。结果从第4天开始,与模型组相比,电针组大鼠逃避潜伏期及游泳路程缩短(P0.05);穿越平台次数增多(P0.05)。电针组大鼠脑梗死体积小于模型组(P0.05);海马CA1区CREB、p-CREB表达量较模型组增加(P0.05)。结论电针神庭、百会后,脑缺血再灌注大鼠海马CA1区CREB、p-CREB表达量增加,从而保护神经元,改善学习记忆功能。     

脉冲磁针仪对脑缺血模型大鼠神经生长因子的影响

目的 研究脉冲磁针仪对脑缺血模型大鼠神经生长因子的影响。方法 健康Wistar大鼠70只，雌雄各半，随机分为7组：正常组、假手术组、模型组、静磁组、针刺组、电针组、脉冲磁组。线栓法制备大鼠脑缺血模型，神经功能评分评定术后各组大鼠的神经功能，运用免疫组化方法检测各组神经生长因子变化情况。结果 术后15d与术后6h组内神经功能评分比较，模型组无显著性差异(P＞0．05)，静磁组有显著性差异(P＜0．05)，其余各治疗组组内有高度显著性差异(P＜0．01)；组间15d时神经功能评分比较，脉冲磁组、电针组和针刺组疗效相仿。在第15d时神经生长因子表达比较，脉冲磁组、针刺组高于静磁组、电针组(P＜0．05)，静磁组、电针组高于模型组(P＜0．05)，针刺组与脉冲磁组无显著性差异(P＞0．05)。结论 脉冲磁针仪可促进神经生长因子产生并延长神经生长因子产生时限，促进脑缺血损伤后肢体功能恢复。     

重复经颅磁刺激结合穿梭箱训练对脑梗死恢复期大鼠认知功能的影响

目的:比较重复经颅磁刺激(repetitive transcranial magnetic stimulation, rTMS)单独或与穿梭箱训练结合对短暂性大脑中动脉闭塞(transient middle cerebral artery occlusion,tMCAO)大鼠恢复期认知功能的影响。方法:60只雄性SD大鼠经tMCAO术后,根据神经功能评分分为5组:rTMS刺激组(n=7)、训练组(n=8)、rTMS结合训练组(n=7)、对照组(n=7)、假手术组(n=6),于术后7天开始进行20Hz rTMS和/或穿梭箱训练,术后第1、7、14、21、28天进行改良神经功能缺陷程度评分(mNSS),术后第28天进行Morris水迷宫实验。结果:第28天时rTMS结合训练组(P0.001)与rTMS刺激组(P0.05)的mNSS评分均低于对照组。水迷宫实验第1—5天训练组及对照组平均逃避潜伏期较假手术长(P0.05),第3天rTMS结合训练组的平均逃避潜伏期较rTMS组及训练组短(P0.05)。对照组穿越平台次数较假手术组少(P0.05),rTMS结合训练组穿越平台次数较rTMS组、训练组及对照组多(P0.05)。结论:rTMS结合穿梭箱训练可以改善脑梗死恢复期大鼠的认知功能,效果优于单一的rTMS刺激或训练。     

电针结合减重步行训练对急性脊髓损伤大鼠巢蛋白和神经生长因子表达的影响

摘要 目的：通过检测脊髓损伤后运动功能恢复情况和巢蛋白（nestin）、神经生长因子（NGF）的蛋白表达来探讨电针（EA）结合减重步行训练疗法（BWSTT）干预脊髓损伤（SCI）的作用。 方法：选用健康成年清洁级雄性SD大鼠72只,随机分为假手术对照组（假手术组）、模型对照组(模型组)、电针治疗组(电针组)、电针结合减重步行训练治疗组（电针+训练组）。用美国NYU脊椎冲击损伤仪致大鼠T9—T10段脊髓急性中度损伤模型。BBB运动功能评分对大鼠后肢运动功能的恢复情况进行评估;免疫组织化学技术检测各时间点损伤段脊髓NGF和nestin的表达。 结果：与模型组相比,两治疗组BBB评分显著增加,电针结合减重步行训练组在术后第14天和第28天显著增加,与电针组比较具有显著性差异（P＜0.05）。两治疗组脊髓损伤术后第14天和第28天NGF和Nestin的表达显著增加,但二者没有显著性差异（P＞0.05）。 结论：①电针能够促进脊髓损伤大鼠内源性NGF和nestin的大量表达来促进神经再生。②电针结合减重步行训练对大鼠运动功能的恢复更为有效。     

脑缺血再灌注损伤大鼠CREB信号通路调控及电针足三里作用机制

目的探讨脑缺血再灌注损伤大鼠环磷腺苷效应元件结合蛋白(c AMP-response element binding protein,CREB)信号通路调控及电针足三里作用机制。方法选择100只健康雄性SPF级Wistar大鼠,随机分为假手术组、模型组、电针组、电针+阻断剂组,每组各25只。电针+阻断剂组造模前注射H-89阻断剂,模型组、电针组、电针+阻断剂组均行脑缺血再灌注损伤模型,假手术组和模型组不予电针干预,电针组、电针+阻断剂组电针足三里干预7 d。评估大鼠神经行为学评分,观察脑梗死体积,检测血管内皮生长因子(vascular endothelial growth factor,VEGF)、CREB和磷酸化CREB(p-CREB)的表达水平,记录CREB和VEGF的基因表达水平。结果与假手术组比较,造模2 h、干预7 d模型组、电针组和电针+阻断剂组大鼠神经行为学评分均明显升高,脑梗死体积均明显增大,差异有统计学意义(P 0. 05);与本组造模2 h比较,干预7 d模型组、电针组和电针+阻断剂组神经行为学评分均明显降低,电针组干预7 d脑梗死体积减小,差异有统计学意义(P 0. 05);与电针组比较,模型组、电针+阻断剂组干预7 d神经行为学评分升高,脑梗死体积增大,差异有统计学意义(P 0. 05)。与电针组比较,假手术组、模型组、电针+阻断剂组VEGF表达量均减少,差异有统计学意义(P 0. 05)。与假手术组比较,模型组、电针组、电针+阻断剂组p-CREB和p-CREB/CREB蛋白表达水平与VEGF基因表达水平升高,差异有统计学意义(P 0. 05);与电针组比较,模型组、电针+阻断剂组p-CREB和p-CREB/CREB蛋白表达水平与VEGF基因表达水平降低,差异有统计学意义(P 0. 05)。结论电针足三里可改善脑缺血神经行为学功能,其机制可能与激活CREB通路,刺激下游VEGF表达,进而促进神经血管再生有关。     

电针结合重复经颅磁刺激对脑缺血大鼠海马突触素的影响

目的：研究电针结合重复经颅磁刺激对脑缺血大鼠海马突触素的影响。方法：120只Wistar大鼠随机分为正常组、模型组、电针组、重复经颅磁刺激组和电针结合重复经颅磁刺激组, 根据不同时间点每个组又细分为7d、14d和28d组3个亚组。复制大脑中动脉栓塞模型,分别给予电针、磁刺激和电针结合磁刺激干预。免疫荧光标记方法观察缺血侧海马CA3区突触素的表达,蛋白印迹技术定量分析不同时间点、不同组别之间缺血侧海马突触素表达的差异。结果：电针、磁刺激和电针结合磁刺激都能显著上调3个时间点海马突触素的表达。从时间上看,随着治疗时间的增加,突触素的表达逐步上调;不同组间比较,第28天时电针结合磁刺激海马突触素的表达最显著。结论：三种干预方法都能促进脑缺血大鼠海马突触素的表达,其中第28天时电针结合磁刺激效果最显著。     

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.     

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.     

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.     

Spiritual Dimensions of Nursing Practice. edited by V. B. Carson

The Cochrane Library of Systematic Reviewsis published quarterly. Issue one for 2004 of the library was published in February 2004. This issue contains 3,329 reviews and protocols of which 1,921 are fully published reviews. The trials database now stands at over 400,000 records with an additional 4,427 one-page summaries of non-Cochrane reviews in the NHS database of reviews of effectiveness (DARE). This version of the library contains the results of an extensive search for RCTs on EMBASE. The latest library contains 84 new reviews, seven are considered relevant to practitioners in pain and palliative care. References are published in the same format as the citation for Cochrane reviews.     

Advance Care Planning

Predictors of patient wishes and influence of family and clinicians are discussed. Research findings on patient decision-making relating to preferences in end-of-life care are described. Advance directives and durable powers of attorney are defined and differentiated. Most patients have not participated in advance care planning and the need for more effective planning is documented. Appropriate times for discussions of such planning are described. Scenarios discussed include terminal cancer, chronic obstructive pulmonary disease, AIDS, stroke, and dementia. Patient satisfaction is discussed, as is a structured process for discussions about patient preferences. Results of patient responses to hypothetical scenarios are described. Invasiveness of interventions, prognosis and other factors that favor or discourage patient preferences for treatment are discussed. Findings resulting from research funded by the Agency for Healthcare Research and Quality (AHRQ) are discussed. This research can help providers offer end-of-life care based on preferences held by the majority of patients under similar circumstances.     

Évaluation,par l’imagerie ultrasonore,du recrutement musculaire,de la force motrice et de la détente verticale du quadriceps après électromyostimulation (cas de 15 étudiants de l’INJS)

The increase of strength seems to be an element of performance in some sports.