牛珀至宝丹对内毒素休克大鼠溶酶体的保护作用

目的：探讨中药制剂牛珀至宝丹对内毒素休克大鼠溶酶体的保护作用。方法：用ＳＤ大鼠制作休克模型并同期对大鼠肝溶酶体进行体内外稳膜实验，以溶酶体标志酶——酸性磷酸酶（ＡＣＰ）的活性、酶比活性、溶酶体膜通透率等反应肝溶酶体的变化，以观察牛珀至宝丹对肝细胞溶酶体的影响。结果：模型组游离ＡＣＰ活性为（１１０．１９±４．３３）ｎｍｏｌ·ｓ－１／ｇ，膜通透率为０．８４±０．０３；而牛珀至宝丹组分别为（８３．５２±８．１７）ｎｍｏｌ·ｓ－１／ｇ和０．６４±０．０８，２组比较均有显著性差异（Ｐ均＜０．０１）。结论：内毒素休克大鼠肝溶酶体膜明显受损，膜通透率增加，ＡＣＰ外逸；牛珀至宝丹可阻止上述变化，对溶酶体具有保护作用。     

“717复方”制剂对内毒素损伤大鼠肝细胞线粒体的保护作用

目的：观察“７１７复方”制剂对内毒素休克大鼠肝细胞线粒体的保护作用。方法：采用静脉注射内毒素制备大鼠内毒素休克模型，观察“７１７复方”对休克大鼠肝细胞线粒体功能的影响。结果：模型组大鼠肝细胞线粒体呼吸控制率（ＲＣＲ）明显下降，与正常对照组比较（４．５８±０．３１比５．７３±０．３５）有显著性差异（Ｐ＜０．０５）；电镜下，内毒素休克模型线粒体明显肿胀，嵴减少、模糊不清。“７１７复方”制剂组大鼠肝细胞线粒体ＲＣＲ（５．６８±０．４１）则接近正常，与模型组比较有极显著性差异（Ｐ＜０．０１）；其电镜下超微结构病变也较轻。体外实验测定肝细胞线粒体膜通透性（膜吸光度下降百分比），“７１７复方”制剂组明显低于内毒素组（Ｐ＜０．０１）。结论：“７１７复方”制剂具有拮抗内毒素损伤线粒体的作用     

清除血液中内毒素、肿瘤坏死因子和白细胞介素-1对实验性内毒素休克时肺损伤的保护作用

目的：了解内毒素（ＬＰＳ）、肿瘤坏死因子（ＴＮＦ）和白细胞介素１（ＩＬ１）对实验性内毒素休克时肺损伤的保护作用。方法：实验分３组：Ⅰ组为假灌流组，Ⅱ组、Ⅲ组大鼠在内毒素休克早期开始分别给予活性炭（Ⅱ组）、大孔树脂ＡｍｂｅｒｌｉｔｅＸＡＤ７（Ⅲ组）血液灌流，结果与Ⅰ组作比较。结果：Ⅱ组ＬＰＳ、ＩＬ１水平明显降低，而Ⅲ组ＴＮＦ水平明显降低。Ⅱ组、Ⅲ组外周血白细胞数分别为（４．０±０．４）×１０９／Ｌ和（３．９±０．４）×１０９／Ｌ，均明显高于Ⅰ组〔（３．１±０．２）×１０９／Ｌ〕，Ｐ均＜０．０１；支气管肺泡灌洗液（ＢＡＬＦ）中的白细胞数〔（８．５±０．１）×１０９／Ｌ，（８．９±０．１）×１０９／Ｌ〕、肺系数（０．６４±０．０６，０．６６±０．０６）以及肺组织浸润的中性分叶核粒细胞数（２９．６±７．９／ＨＰ，３４．５±４．１／ＨＰ）均明显低于Ⅰ组〔（１２．３±１．８）×１０９／Ｌ，０．７５±０．０７，４８．６±６．６／ＨＰ〕，Ｐ均＜０．０１或＜０．０５。Ⅱ组、Ⅲ组的肺组织学改变亦较Ⅰ组明显减轻。结论：清除血液中致病介质可能对内毒素休克时的肺损伤产生保护作用。     

口饲乳果糖对失血性休克大鼠预后的影响

为了进一步阐明失血性休克预后与继发性内源性内毒素血症的直接关系，作者探讨了用口饲乳果糖清除肠道内毒素对大鼠失血性休克的保护作用。造成休克前，首先给大鼠口腔管饲２０％乳果糖（５ｍｌ／ｄ）或等容量生理盐水７天，每天给药２次。结果：休克后４８ｈ，乳果糖组大鼠存活率要明显高于盐水组（１０／１０与４／９，Ｐ＜０．０１）。休克后９０ｍｉｎ和１２０ｍｉｎ，乳果糖组大鼠血浆内毒素、ＴＮＦ水平均显著低于盐水组。提示：继发于失血性休克的内源性内毒素血症及肿瘤坏死因子在促使休克向不可逆性发展中可能起重要作用。作者认为，临床上对严重的失血性休克患者，除作复苏外，还应针对感染，尤其是内毒素血症尽早采取防护措施。     

中药热毒清对内毒素攻击半乳糖胺敏化大鼠的保护作用

观察中药热毒清对半乳糖胺敏化大鼠受内毒素致死性攻击后的保护作用。方法：模型组用半乳糖胺（０．３ｇｋｇ－１／只）和内毒素（１０μｇ／只）给大鼠作腹腔内注射，在此基础上，热毒清组和地塞米松组分别静注热毒清和地塞米松。结果：５小时后动物血中肿瘤坏死因子α、白细胞三烯Ｃ４、谷丙转氨酶和总胆红素水平均明显上升（Ｐ均＜０．０５）；在５～２０小时内大鼠全部死亡，死亡率为１００．００％。热毒清处理组的上述血液生化指标均明显低于模型组（Ｐ均＜０．０５），死亡率也低于模型组（５０．００％，Ｐ均＜０．０５）。结论：热毒清与地塞米松相似，具有良好的预防内毒素血症并发症的作用。     

牛珀至宝丹对内毒素休克大鼠血液流变学的影响

目的：探讨牛珀至宝丹抗内毒素休克的作用机制。方法：采用静注致死量灭活大肠杆菌内毒素造成大鼠重症感染性休克模型，以牛珀至宝丹预先处理动物（实验组），并与正常组、内毒素体克组进行对照观察。结果：实验组血压下降幅度显著低于休克组；血液流变学指标中全血粘度、血浆比粘度、红细胞聚集指数、红细胞刚性指数和红细胞压积实验组较休克组均明显降低，红细胞电泳时间缩短；与正常组比较无显著性差异（Ｐ＞０．０５），但与休克组比较有显著性差异（Ｐ＜０．０５或＜０．０１）。结论：牛珀至宝丹能明显改善内毒素休克大鼠血液流变性，并对内毒素休克大鼠有一定的升压作用。     

多巴胺对吗啡成瘾大鼠中枢痛觉的调制

目的：观察多巴胺对正常及急性吗啡成瘾大鼠尾核中痛兴奋神经元电活动的影响，从而进一步探讨多巴胺和尾核在吗啡成瘾大鼠痛觉调制中的作用。 方法：实验于2005—05／11在哈尔滨医科大学神经痛觉电生理研究室完成。（1）52只Wistar大鼠随机分为2组：正常对照组26只（叉分为生理盐水组6只、多巴胺组20只）及吗啡成瘾组26只（又分为生理盐水组6只、多巴胺组20只）。（2）模型制备：大鼠背部皮下递增注射吗啡剂量，依次为：5，10，20，40，50mg／kg，3次／d（8：00。12：00，16：00），连续给药5d，建立吗啡成瘾大鼠的模型。正常对照组大鼠背部皮下注射生理盐水，时间、剂量均与吗啡成瘾组相同。第6天8：00观察大鼠的自然戒断症状30min后开始实验。（3）实验以电脉冲刺激大鼠坐骨神经作为伤害性痛刺激，用玻璃微电极记录尾核中痛兴奋神经元的放电，观察侧脑室注入多巴胺对痛兴奋神经元电活动的影响。 结果：52只大鼠均进入结果分析。（1）多巴胺可提高正常大鼠尾核中痛兴奋神经元的兴奋性，即22个痛兴奋神经元平均秒净增值比注射多巴胺前（100％）增加了（131．8&;#177;10．3）％，潜伏期缩短了（55．6&;#177;6.3）％。（2）多巴胺使吗啡成瘾大鼠17个痛兴奋神经元的兴奋性降低，17个痛兴奋神经元的平均秒净增值比注药前（100％）降低了（74．8&;#177;7．6）％，潜伏期延长了（82．1&;#177;8．3）％。 结论：多巴胺可使正常大鼠尾核中痛兴奋神经元对电刺激的兴奋性增强，呈易化疼痛，而对吗啡成瘾大鼠尾核中痛兴奋神经元有抑制作用，表现为镇痛效应。     

大黄抗内毒素性休克大鼠炎性介质作用的实验研究

目的：研究大黄对内毒素性休克大鼠炎性介质作用的机制。方法：选用大鼠内毒素性休克模型。随机分为６组：单纯手术组、内毒素组、大黄预防用药组（１５０ｍｇ／ｋｇ组和７５０ｍｇ／ｋｇ组）和大黄治疗组（１５０ｍｇ／ｋｇ组和７５０ｍｇ／ｋｇ组）。检测磷脂酶Ａ２（ＰＬＡ２）和血小板活化因子（ＰＡＦ）的活性。结果：内毒素注射前６组大鼠平均动脉压（ＭＡＰ）无显著性差异；注射内毒素后４小时ＭＡＰ明显降低；大黄预防用药组和大黄治疗组ＭＡＰ则与注射内毒素前及单纯手术组比较均无明显变化，并均显著高于内毒素组注射内毒素４小时后。注射内毒素后４小时，血清和小肠组织中ＰＬＡ２活性及ＰＡＦ含量均明显增高；与内毒素组注射内毒素后４小时比较，大黄预防组和治疗组则血清和小肠组织中ＰＬＡ２活性和ＰＡＦ含量显著降低。结论：大黄对内毒素性休克所致炎症反应有明显的预防和治疗作用     

孕酮对内毒素休克大鼠的脑保护作用

目的观察孕酮对内毒素休克大鼠脑组织炎性介质的影响,探讨其脑保护作用机制。方法经腹腔注射D-氨基半乳糖（100mg／kg）致敏后腹腔注射内毒素（1．5mg／kg）建立实验模型,将60只大鼠随机分为对照组、内毒素休克组和孕酮干预组,测定脑组织匀浆TNF-α、IL-1β水平。结果内毒素休克组、孕酮干预组大鼠脑组织TNF-α、IL-1β的浓度和对照组有差异。结论孕酮可影响脑组织的炎症介质水平,对内毒素血症大鼠脑组织有保护作用。     

血小板活化因子拮抗剂对急性出血坏死型胰腺炎大鼠内毒素血症的防治作用

目的：观察血小板活化因子（ＰＡＦ）拮抗剂对急性出血坏死型胰腺炎（ＡＨＮＰ）大鼠内毒素血症的防治作用。方法：１４０只ＳＤ大鼠随机分为３组：急性胰腺炎组（ＡＰ组）：采用去氧胆酸钠逆行胰管内注射法复制；治疗组（ＢＮ组）：制备模型后经腹腔注射ＰＡＦ特异性受体拮抗剂ＢＮ５２０２１（５ｍｇ／ｋｇ）；假手术组（ＳＯ组）：开腹后仅轻轻翻动胰腺即关腹。结果：ＢＮ组与ＡＰ组比较，１小时后血清淀粉酶值明显下降〔（１４９７０±２５００）Ｕ／Ｌ，（１６１７０±２３８０）Ｕ／Ｌ，Ｐ＜０．０５〕，６小时和１２小时后更为明显（Ｐ均＜０．０１）；血中ＰＡＦ含量１小时后明显降低〔（２．２０±０．２５）μｇ／Ｌ与（１．１０±０．２１）μｇ／Ｌ，Ｐ＜０．０５〕，３小时后更为明显（Ｐ＜０．０１）。血浆内毒素含量ＢＮ组比ＡＰ组明显下降（Ｐ＜０．０１）。ＢＮ组术后大鼠平均存活时间为（４５．０±２５．１）小时，存活率为４０％；ＡＰ组术后大鼠在２４小时内全部死亡，平均存活时间为（１１．５±４．８）小时，存活率为０（Ｐ均＜０．０１）。结论：ＰＡＦ参与了ＡＨＮＰ的发病过程；应用ＰＡＦ受体拮抗剂对实验性ＡＨＮＰ有良好的防治作用。     

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.     

俯卧位通气对高海拔地区肺复张治疗无效急性呼吸窘迫综合征患者氧合的影响

目的 探讨俯卧位通气对高海拔地区肺复张术(RM)治疗无效急性呼吸窘迫综合征(ARDS)患者的治疗作用.方法 从海拔2260m的地区医院筛选RM治疗无效的41例ARDS患者[平均氧合指数( PaO2/FiO2)较RM前升高＜20％视为RM无效],依不同病因分为肺内源性ARDS组(ARDSp组)和肺外源性ARDS组(ARDSexp组),每组再按信封法随机分为俯卧位组和仰卧位组,即ARDSp俯卧位组(11例)、ARDSp仰卧位组(9例)、ARDSexp俯卧位组(10例)、ARDSexp仰卧位组(11例).在通气前及通气1、2、3、4h监测动脉血氧分压( PaO2)、PaO2/FiO2、静态顺应性(Cst)、气道阻力(Raw)的变化.结果 通气lh时,ARDSexp俯卧位组PaO2/FiO2( mm Hg,l mm Hg=0.133 kPa)即较通气前显著升高(157.4±40.6比129.3±48.7,P＜0.05),并随通气时间延长呈持续增高趋势,4h达峰值(219.1 ±41.1);且ARDSexp俯卧位组通气3h内PaO2/FiO2较其他3组显著增高,另3组间则差异无统计学意义.ARDSp俯卧位组、ARDSexp俯卧位组通气4h时PaO2/FiO2均较相应仰卧位组显著增高(208.8±39.7比127.4±47.1,219.1±41.1比124.9±50.8,均P＜0.05).4组通气前后Cst无显著改变,各组间差异也无统计学意义.ARDSp俯卧位组通气4h时Raw(cmH2O·L-1·s-1)较通气前显著降低(6.8±1.7比10.7±1.8,P＜0.05),且明显低于其他3组;其他3组各时间点Raw组内及组间比较差异均无统计学意义.结论 俯卧位通气作为ARDS机械通气重要策略之一,可以改善RM无效高原ARDS患者的氧合,为抢救患者赢得宝贵的时间.     

Digital imaging among medical facilities

The Department of Veterans Affairs (VA) in the USA operates a network of 172 medical centres which all utilize a hospital information system (HIS) which has been developed and is currently maintained by the VA. During the past several years, an image management and communication module has been developed, installed and clinically utilized at the Washington DC and Maryland VA Medical Centres. This image management and communication system, referred to as the decentralized hospital computer program (DHCP) imaging system, is fully integrated with a commercial picture archiving and communication system (PACS). The system is utilized to capture, archive, and display all images generated within the hospital including radiology, nuclear medicine, pathology, endoscopy, bronchoscopy, and dermatology, intraoperative photographs, ECG data, and a limited number of paper documents. The ultimate goal of the project is to have all patient text and image data available at any clinical workstation to any authorized user anywhere within the network of medical centres. Clinical requirements for an imaging workstation include ease of use, rapid and reliable access to the complete set of patient information, and images which are of acceptable quality to meet the requirements of the user and the subspecialty. Patient confidentiality and data security must be safeguarded at all times. Integration of the images with the remainder of the patient's database was found to be critical to the success of the project. The experience at the Washington and Maryland facilities suggests that an imaging system that is successfully integrated with a hospital information system can provide substantial clinical and economic benefits both within and among medical centres. Clinical acceptance and utilization of the system has been excellent, particularly in diagnostic radiology where DHCP Imaging has been interfaced to a commercial PAC system. Based upon this initial experience, the VA has begun to deploy the system throughout its large network of medical centres.     

Myocardial elastography at both high temporal and spatial resolution for the detection of infarcts

Myocardial elastography is a novel method for noninvasively assessing regional myocardial function, with the advantages of high spatial and temporal resolution and high signal-to-noise ratio (SNR). In this paper, in-vivo experiments were performed in anesthetized normal and infarcted mice (one day after left anterior descending coronary artery [LAD] ligation) using a high-resolution (30 MHz) ultrasound system (Vevo 770, VisualSonics Inc., Toronto, ON, Canada). Radiofrequency (RF) signals of the left ventricle (LV) in longitudinal (long-axis) view and the associated electrocardiogram (ECG) were simultaneously acquired. Using a retrospective ECG gating technique, 2-D full field-of-view RF frames were acquired at an extremely high frame rate (8 kHz) that resulted in high-quality incremental displacement and strain estimation of the myocardium. The incremental results were further accumulated to obtain the cumulative displacements and strains. Two-dimensional and M-mode displacement images and strain images (elastograms), as well as displacement and strain profiles as a function of time, were compared between normal and infarcted mice. Incremental results clearly depicted cardiac events including LV contraction, LV relaxation and isovolumetric phases in both normal and infarcted mice, and also evidently indicated reduced motion and deformation in the infarcted myocardium. The elastograms indicated that the infarcted regions underwent thinning during systole rather than thickening, as in the normal case. The cumulative elastograms were found to have higher elastographic SNR (SNR(e)) than the incremental elastograms (e.g., 10.6 vs. 4.7 in a normal myocardium, and 6.0 vs. 2.4 in an infarcted myocardium). Finally, preliminary statistical results from nine normal (m = 9) and seven infarcted (n = 7) mice indicated the capability of the cumulative strain in differentiating infracted from normal myocardia. In conclusion, myocardial elastography could provide regional strain information at simultaneously high temporal (>/=0.125 ms) and spatial ( approximately 55 microm) resolution as well as high precision ( approximately 0.05 microm displacement). This technique was thus capable of accurately characterizing normal myocardial function throughout an entire cardiac cycle, at the same high resolution, and detecting and localizing myocardial infarction in vivo.     

Clinical Pharmacokinetics of Morphine

Morphine, the most widely used mu-opioid analgesic for acute and chronic pain, is the standard against which new analgesics are measured. A thorough understanding of the pharmacokinetics of morphine is required in order to safely and effectively use this analgesic in a wide variety of patients with different levels of organ function. A MEDLINE search was conducted to identify literature published between 1966 and January 2002 relevant to the pharmacokinetics of morphine. These publications were reviewed and the literature summarized regarding unique and clinically important elements of morphine disposition relative to its parenteral administration (including intravenous, intramuscular, subcutaneous, epidural and intrathecal administration), absorption profile (immediate release, controlled release, and sublingual/buccal, and rectal administration), distribution, and its metabolism/ excretion. Special populations, including infants, elderly, and those with renal/liver failure, have a unique morphine pharmacokinetic profile that must be taken into account in order to maximize analgesic efficacy and reduce the risk of adverse events.     

手转胎头术失败的原因与分娩结局临床分析

目的 探讨手转胎头术失败的原因与分娩结局.方法 选择2008年1月至2010年12月于我院住院分娩的持续性枕横位、枕后位产妇198例,根据行手转胎头术后结果分为成功组126例、失败组72例.比较两组分娩结局,对比分析失败原因.结果 失败组胎儿体质量≥3500 g的发生率[76.4％(55/72)]明显高于成功组[31.7％(40/126)],差异有统计学意义(x2=30.177,P=0.001)、失败组宫缩乏力发生率[58.3％(42/72)]高于成功组[38.1％ (48/126)],差异有统计学意义(x2=7.569,P=0.006)、失败组骨盆临界或轻度狭窄发生率[38.9％ (28/72)]高于成功组[23.8％(30/126)],差异有统计学意义(x2 =5.030,P=0.002)、失败组手转胎头时机不当(宫口开大＜6 cm、胎头位于坐骨棘上及宫口开大8～10 cm、胎头位于坐骨棘下≥2 cm)发生率[61.1％(44/72)]高于成功组[38.9％(49/126)],差异有统计学意义(x2=9.084,P=0.003).失败组母儿并发症(产后出血、产褥病率、胎儿窘迫、新生儿窒息)发生率高于成功组(x2 =9.586,P=0.002、x2=9.334,P=0.002、x2=5.910,P=0.015、x2=5.240,P=0.022)、失败组剖宫产发生率[72.2％(52/72)]明显高于成功组[34.1 ％(43/126),x2=26.641,P=0.001)].结论 手转胎头术能使难产变顺产,降低剖宫产率,减少母儿并发症,但须积极预防、处理导致手转胎头术失败的原因,对矫正失败后继续矫正及试产应慎重.     

Evidence-Based Pain Management and Palliative Care in Issue Four for 2009 of The Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly. Issue 4 for 2009 contains 4027 complete reviews, 1906 protocols for reviews in production, and 11447 one-page summaries of systematic reviews published in the general medical literature. In addition, there are citations of 600,000 randomized controlled trials, and 12,200 cited papers in the Cochrane methodology register. The health technology assessment database contains over 7500 citations. This edition of the Library contains 90 new reviews, of which 19 have potential relevance for practitioners in pain and palliative medicine.     

Wie zuverlässig sind Angaben zu nichtentzündlichen ausgedehnten Schmerzen?

ZusammenfassungFragestellung Es wurde geprüft, wie sich der Differenziertheitsgrad zweier Schmerzmessmethoden auf Angaben zur Ausgedehntheit klinischer Schmerzen auswirkt. Zugleich wurde der Referenzzeitraum variiert, über den die Patienten berichten sollten.Methode Erfasst wurde der Einfluss zu Lasten der Befragungsdifferenziertheit durch den Vergleich zweier Körperschema-Bildvorlagen. Drei Referenzzeiträume (Schmerz aktuell, letzte Woche, letztes halbes Jahr) wurden vorgegeben.Ergebnisse Patienten mit ausgedehnten Schmerzen gaben bei differenzierter Befragung um so mehr Schmerzen an, je weiter die Schmerzen zurück lagen und je größer der Berichtszeitraum war. Patienten mit gelenknahen Schmerzen gaben bei hoch differenzierter Befragung weniger ausgedehnte Schmerzen in der Vergangenheit an als bei globaler Einschätzung. Patienten mit Rückenschmerzen berichteten bei differenzierter Befragung zum aktuellen Schmerz über weniger ausgedehnte Schmerzen als bei globaler Befragung.Schlussfolgerung Die Angaben zur Schmerzausdehnung variieren vor allem bei Patienten mit ausgedehnten Schmerzen in Abhängigkeit von der Differenziertheit der Befragung. In diesen Fällen ist die Wahrscheinlichkeit erhöht, dass sich die Beschwerdesymptomatik zumindest teilweise erst in der Reaktion auf die situativen Befragungsbedingungen konstituiert und daher nicht auf andere Befragungsbedingungen generalisiert werden kann.