肺复张对急性呼吸窘迫综合征的疗效观察

目的 观察肺复张对急性呼吸窘迫综合征(ARDS)患者的治疗效果.方法 观察7例符合美国/欧洲危重症学会诊断标准ARDS早期患者,应用压力控制型呼吸机,在吸氧体积分数为100％条件下,监测血流动力学参数及血管外肺水指数(EVLWI).肺复张开始时将呼吸机模式调整为压力控制,吸气压力(Pi) =24 cm H2O(1cmH2O=0.0981 kPa),呼气末正压(PEEP)10cm H2O,f=50,吸呼比为5∶1.此后,先将PEEP上调至24 cm H2O,Pi上调至45 cm H2O,维持3次吸气再将Pi下调至30 cm H2O,立即查动脉血气.如果PaO2＜450mmHg (1mmHg=0.133kPa),在上次压力的基础上增加5 cm H2O,直到PaO2＞ 450 mm Hg,认为复张成功.随后,逐渐以2 cm H2O下调PEEP,每次下调后再重复上述步骤,直到PEEP到达某数值时PaO2＜ 350 mm Hg,在此PEEP上增加2 cm H2O则认为是最佳PEEP.保持气道压力不少于4h,监测复张前后血气指标以及血液动力学指标并进行比较.如果复张过程中血液动力学不稳定则立即停止复张.结果 方差分析结果表明:6位患者复张后4 h PaO2较基础明显增加(P＜0.01),PEEP比基础状态明显升高(P＜0.01),EVLWI则显著降低(P＜0.01).1位患者因血液动力学不稳而终止复张.7位患者均未出现复张相关并发症,并且6位患者治愈.结论 应用肺复张治疗ARDS是安全有效的.     

约翰·霍普金斯大学医学院医学博士培养模式特点及其启示

约翰·霍普金斯大学医学院是世界一流的医学院,21世纪初实施医学博士培养模式改革,通过高远而具体的目标定位、优越的教学条件、合理的学程安排、整合的课程体系、能力培养为本的教学内容和方法、科学合理的学生评价体系,培养优秀的医学人才,充分体现了生物—心理—社会医学模式的要求,其成功经验值得学习和借鉴.     

中医理论对德育工作的启发

中医理论思想中富含古代的唯物论和辩证法的哲学思想。其中的阴阳学说、辨证施治、中和思维能给学生的教育工作提供借鉴和启发。阴阳学说,阴阳相互对立、相互依存、相互转化、消长平衡,可以体现教师与学生之间的一种动态变化关系;辨证施治,提示教师用“望、闻、问、切”全面的去分析学生,最终采取合适的教育方法;中和思维,对于很难教育的学生,采用中和的思想,与学生之间形成一种平衡,达到教育目的。     

认真走好青春期的每一步——试论《爱弥儿》中的性教育

法国著名启蒙思想家卢梭,是西方教育史上第一个精辟论述性教育的教育家。在他的巨著《爱弥儿》中,他深刻批判了当时扼杀人性的旧教育,以"遵循自然"为指导原则,以爱弥儿为载体,详细论述了他的性教育思想,成为西方性教育史上的里程碑式的人物。他的性教育思想为在我国家庭教育中实施性教育提供了诸多启示。     

协同教学对制药化工原理课程教学组织的启示

教学组织形式是教学论中的一个重要问题,一直以来,在教学组织形式研究上,主要关注学生的组织形式,而对教师的组织形式有所忽略。本文从教师组织形态变革着手,详细介绍协同教学的基本情况及其在制药化工原理课程教学中的实施构想,以期对当前教学组织形式的变革有所启发。     

“正确处理人民内部矛盾”理念对构建和谐医患关系的启示

近年来,医患关系紧张成为困扰中国社会和普通民众的热点问题。毛泽东《关于正确处理人民内部矛盾的问题》一文的“正确处理人民内部矛盾”理念,对当前构建和谐社会有着重要参考价值。医患之间的矛盾是在人民利益根本一致基础上的矛盾,是人民内部矛盾。医患双方应该互相尊重、互相理解、互相信任,本着“团结-批评-团结”的原则来化解医患矛盾。构建和谐医患关系建议:建立健全完善的医疗保障制度和法律法规,医生终身学习、对患者加强人文关怀,加强对群众的教育和正向引导,完善医疗风险分担机制等,逐步构建起良好的医患关系,促进社会和谐健康发展。     

Developmental effects of ketamine on inspiratory hypoglossal nerve activity studied in vivo and in vitro

The effects of the anesthetic ketamine on properties of inspiratory bursts (I-bursts) in mouse hypoglossal nerve activity were studied in vivo and in vitro. In urethane anesthetized mice we observed rhythmic I-phase activity in only one of eight pups at P9 days. In contrast in older mice rhythmic I-phase hypoglossal activity was almost always observed. Ketamine caused a reduction in I-burst frequency and an increase in peak integrated hypoglossal nerve activity in all three age groups studied (P10-P13, P15-P20 and adult mice). In these mice I-phase oscillations, due to hypoglossal motoneurons firing clusters of action potentials at a particular frequency, were observed in control and after ketamine. Ketamine did not change the frequency of the dominant spectral peak determined from power spectra examined from 0 to 200 Hz. The effects of ketamine were also studied in vitro in the mouse rhythmic medullary slice preparation. Ketamine reduced hypoglossal I-burst frequency and I-burst peak integrated amplitude. Oscillations were observed in I-phase activity, and as in the in vivo studies ketamine did not shift the dominant spectral peak frequency. These results demonstrate that in vivo and in vitro ketamine results in significant changes in I-burst frequency and peak integrated hypoglossal nerve activity, but changes in the oscillation frequency are minimal.     

Inhalation characteristics and their effects on in vitro drug delivery from dry powder inhalers Part 1. Inhalation characteristics, work of breathing and volunteers'' preference in dependence of the inhaler resistance

A test inhaler with exchangeable air flow resistances encompassing the range of commercial DPIs has been used to study the inspiratory flow curves of 39 healthy adult volunteers. A strong increase in mean Peak Inspiratory Flow Rate (PIFR) has been obtained with decreasing inhaler resistance, varying between 160 1/min for a resistance equivalent to the Rotahaler and 50 1/min for the simulated Inhalator Ingelheim at maximum inspiratory effort. The volunteers experienced on average 55% of maximum effort as comfortable (expressed in PIFR) and gave preference (82%) to relative high air flow resistances in the range of 0.4-0.9 × 10⁵ (N^0.5·s·m⁻⁴). It has been calculated that the real amount of work of breathing does not increase with increasing air flow resistance at comfortable inspiration mode. At maximum inspiration, the amount of work performed through a high resistance inhaler (1.5 × 10⁵) is approx. 70% of that through a low resistance device (0.4 × 10⁵). The calculated mean PIFR of 62 1/min at maximum effort through an air flow resistance of 0.9 × 10⁵, equivalent to the Turbuhaler, is in good agreement with PIFR-values of 68.5 vs. 59 1/min from two other studies with asthmatic patients through this device. It has, therefore, been concluded that the flow curves of healthy volunteers may be used to predict the range of PIFRs for asthmatics through the same air flow resistances.     

Relationship among cardiac index, inspiration/expiration ratio, and perfluorocarbon dose during partial liquid ventilation in an oleic acid model of acute lung injury in sheep

Background

The aim of this study was to demonstrate the influence of different inspiration/expiration (I/E) ratios on cardiac index (CI) and hemodynamics during partial liquid ventilation (PLV) using a large animal model of acute respiratory failure in a prospective, randomized controlled animal laboratory trial.

Methods

After induction of respiratory failure by right atrial injection of 0.09 mL/kg oleic acid, (1) determination of agreement between reversed Fick and pulmonary artery thermodilution (Q_TD) techniques with progressive doses of perflubron (LiquiVent, Alliance Pharmaceutical Corp, San Diego, Calif) (n = 7 sheep) and (2) comparison of 4 groups with I/E ratios of 3.4:1, 2:1, 1:1, and 1:2 were performed, applying identical ventilatory patterns in all I/E groups (n = 28 sheep). PLV was established with intratracheal instillation of 25 mL/kg perflubron. Cardiac index was assessed at 15-minute intervals for a 120-minute experimental period by Q_TD.

Results

During progressive doses of PLV, the correlation (r) between Fick and Q_TD techniques was 0.82. Thermodilution deteriorated after induction of lung injury and recovered after PLV start. Regarding Q_TD, no significant changes after PLV onset (within-group comparison) and between I/E groups were observed (P < .05).

Conclusion

The QTD technique is a satisfactory reflector of CI during PLV, and I/E ratio has no significant influence on CI, even using extreme inverse ratio ventilation.     

美国NN/LM医学图书馆网的分析和启示

从背景、宗旨、任务、现状、信息服务等方面全面分析美国NN/LM,并提出对我国医学图书馆发展的启示和建议。