口服避孕药预处理对促性腺激素释放激素激动剂长方案妊娠结局的影响

目的评价口服避孕药(OC)妈富隆预处理对体外受精-胚胎移植(IVF-ET)中促性腺激素释放激素激动剂(GnRH-a)降调节长方案妊娠结局的影响。方法回顾性分析我中心2011年10月至2012年12月IVF患者450例,其中OC组193例服用妈富隆,于月经周期第21天开始GnRH-a降调节治疗,对照组257例自发排卵后一周同法治疗,比较两组促排卵过程及第一次胚胎移植(鲜胚或冻融胚胎)结局。结果 OC组与对照组在降调节时间、促性腺激素(Gn)用药天数、Gn用药量、获卵数、2PN受精率、优胚率、平均移植胚胎数、宫外孕率、流产率、卵巢囊肿及OHSS发生率方面均无统计学差异(P0.05),OC组HCG日血清LH水平、移植日子宫内膜厚度低于对照组(P0.05),临床妊娠率、种植率、活产率低于对照组(P0.05)。冻融胚胎移植周期OC组与对照组在移植日子宫内膜厚度、平均移植胚胎数、临床妊娠率、种植率、宫外孕率、流产率、活产率均无统计学差异(P0.05)。结论 GnRH-a降调节长方案使用OC预处理可能通过影响子宫内膜厚度降低鲜胚移植周期临床妊娠率及活产率,似乎不影响冻融胚胎移植周期的妊娠结局。     

长效长方案垂体降调节后促性腺激素启动时机对助孕结局的影响

目的探讨长方案中长效促性腺激素释放激素激动剂(GnRH-a)垂体降调节后促性腺激素(Gn)的启动时间对体外受精/卵胞浆内单精子注射-胚胎移植(IVF/ICSI-ET)助孕结局的影响。方法回顾性分析2015年1~12月在深圳武警医院生殖中心接受IVF/ICSI-ET(达菲林1.25mg长方案)治疗的3 853例患者资料,根据Gn启动前垂体降调节时间分成4组:A组≤14d;B组15~18d;C组19~23d;D组≥24d。比较各组的临床结局。结果四组患者间MⅡ卵率(ICSI周期)、卵裂率无统计学差异(P0.05);从A组到C组,总Gn用量逐渐减少,D组Gn用量再次增加,A组与C组差异有统计学意义(P0.05);A组获卵数、可利用胚胎数及着床率均显著低于其它组(P0.05);C、D组优胚率显著低于B组(P0.05);从A组到C组,临床妊娠率及活产率逐渐提高,D组略下降,A组与B、C组差异有统计学意义(P0.05);B、C组流产率低于A、D组,但无统计学差异(P0.05)。结论在长效GnRH-a长方案控制性促排卵周期中,适当延长Gn启动时间(15~23d)可能改善卵母细胞的质量和内膜容受性,从而提高临床妊娠率,降低胚胎早期流产率,同时可减少Gn用量,从而减轻患者经济负担。     

促性腺激素释放激素激动剂降调节的个体化与促性腺激素启动日时机选择

促性腺激素释放激素激动剂(GnRH-a)已经广泛地应用于体外受精(IVF)垂体降调节中.GnRH-a分长效和短效两种剂型,长效剂型患者接受性和依从性高,但有卵巢过度抑制倾向,会造成促性腺激素(Gn)用量增加、使用时间延长,因而增加经济负担,而短效者可接受性和依从性较差.两者临床效果无显著差异.临床上常用的GnRH-a降调节方案有长、超长、短、超短等方案,各种方案的临床效果总体上并无显著差异但各有优缺点,通常卵巢功能减退的患者建议给予短方案,甚至超短方案,而卵巢储备功能正常患者常用长方案.超长方案对于合并子宫内膜异位症或多囊卵巢综合征患者等能提高临床妊娠率.降调标准存在争议,因此文献报道对于Gn的启动时间亦有不同,需要根据患者个体及不同的降调节方案而定.适当延迟启动时间可能改善卵母细胞的质量和内膜接受性,从而提高临床妊娠率,而且适当推迟Gn启动时间对于减少Gn的用量,降低患者的经济负担也是十分有益的.     

改良超长方案的应用

目的 比较改良降调节超长方案结合人绝经期促性腺激素(HMG)和常规降调节长方案在特殊不孕患者行体外受精/卵胞浆内单精子注射-胚胎移植术(IVF/ICSI-ET)助孕中的疗效. 方法 回顾分析我院2009年1月～2010年12月因子宫内膜异位症、多囊卵巢综合征及一次降调节不全的不育患者,接受IVF/ICSI-ET的治疗情况,其中5,727例采用改良降调节超长方案,9,259例采用常规降调节长方案,对2组受精率、卵裂率、临床妊娠率,着床率,流产率及官外孕发生率等重要指标进行比较分析. 结果 与同期常规降调节长方案相比,改良降调节超长方案组患者的临床妊娠率显著上升(P＜0.001),官外孕发生率下降(P＜0.05),同时用药天数缩短且患者治疗费用减少(P＜0.05),用药量及卵巢过度刺激综合征(OHSS)风险及冻胚成功率对比无差异,注射人绒毛膜促性腺激素(hCG)日孕酮(P)水平显著降低(P＜0.05). 结论 对子宫内膜异位症、多囊卵巢综合征及一次降调节不全行体外受精的不育患者,采用促性腺激素释放激素激动剂(GnRH-a)超长方案加人绝经期促性腺激素(H MG)是一种节约费用且成功率高的超排卵方案.     

长方案中有关垂体降调节问题的讨论

自1984年Porter等[1]首次将促性腺激素释放激素激动剂(GnRH-a)用于体外受精(IVF)临床以来,GnRH-a已广泛应用于IVF的垂体降调节方案中.然而,关于长方案中GnRH-a的使用,目前仍然存在诸多问题尚需讨论,包括:GnRH-a使用的持续时间、GnRH-a的使用剂量、降调标准、Gn的启动时间等.     

进一步认识垂体降调节

控制性超排卵(COH)过程中使用促性腺激素释放激素激动剂(GnRH-a)进行垂体降调节可以有效地预防早发黄体生成素(LH)峰,降低了周期取消率,同时还可以改善卵泡发育的同步化,但垂体降调节也可能由于垂体抑制过度而出现促性腺激素(Gn)使用量增加、卵巢反应不良增加。因此适度地降调节对COH的顺利进行提供了保障。用于垂体降调节的GnRH-a分长效和短效两种剂型,不同的剂量和剂型的垂体抑制程度不同,保留的垂体反应性也不同。而GnRH-a是否通过调节卵巢旁分泌和自分泌影响卵泡的同步化发育尚未有定论。本文就垂体降调节的优缺点及降调节程度的研究发展进行总结。     

低剂量长效GnRH-a在控制性超排卵方案中的临床应用

目的比较短效促性腺激素释放激素激动剂(GnRH-a)和低剂量GnRH-a长效制剂在控制性超排卵长方案中的应用效果,探讨低剂量长效GnRH-a在控制性超排卵中的应用价值。方法回顾性分析284个卵巢储备功能正常的长方案促排卵周期,其中低剂量长效组134个周期,短效GnRH-a组150个周期。对两组间垂体降调节效果、促性腺激素(Gn)使用剂量、时间、促排卵治疗中性激素的水平及IVF-ET结局进行比较。结果低剂量长效组降调节后血清黄体生成素(LH)水平[(0.95±1.58)U/L]、HCG日LH水平[(1.58±2.21)U/L]、HCG日雌二醇(E2)水平[(11 649.78±2 137.92)pmol/L]较短效组均低[分别为(1.25±1.58)U/L、(2.72±2.08)U/L)和(14 698.23±2 380.35)pmol/L],差异均有统计学意义(P0.05);Gn总量[(34.06±8.12)支]和Gn天数[(10.43±1.25)d]较短效组[分别为(27.91±7.54)支和(9.43±1.01)d]明显升高,差异均有统计学意义(P0.05)。两组获卵数[(10.96±2.01)vs.(11.28±2.08)枚]、MII卵数[(9.97±1.25)vs.(10.56±1.78)枚]、优胚数[(4.31±1.02)vs.(4.81±1.54)枚]、可利用胚胎率(64.81%vs.59.81%)、胚胎着床率(38.46%vs.35.34%)、临床妊娠率(55.05%vs.49.22%)、持续妊娠率(53.21%vs.47.66%)、周期取消率(2.24%vs.2.00%)以及重度卵巢过度刺激综合症(OHSS)发生率(0%vs.1.33%)等指标比较,均无统计学差异(P0.05)。结论在控制性超排卵中,低剂量长效GnRH-a单剂量可达到与短效促性腺激素释放激素激动剂相同程度的垂体降调节状态,临床结局满意。     

无降调节促排卵

20世纪80年代中期促性腺激素释放激素激动剂(GnRH-a)和促性腺激素(Gn)的联合应用,即垂体降调节后的促排卵,或称控制性卵巢刺激(COS),避免或减少了因促排卵后雌激素水平升高而诱发的早发黄体生成素(LH)峰的出现,减少了取消周期,促进了卵泡的同步发育,对提高体外受精/卵胞浆内单精子注射-胚胎移植(IVF/ICSI-ET)的妊娠率起着重要作用,经过20余年的临床资料分析、总结经验,该方案越来越趋于个体化,如减少GnRH-a及Gn的剂量,进周期前口服避孕药(OCP,oral contraceptive pills)或黄体期雌激素的应用,以及重组卵泡刺激素(rFSH)、重组黄体生成素(rLH)的应用等,以达到获得理想的发育卵泡数目、提高获得的卵子质量、改善子宫内膜接受性,进一步提高IVF/IC-SI-ET妊娠率、最大限度减少并发症--卵巢过度刺激综合征(OHSS),在不断的探索中已获得许多成熟的经验.     

体外受精周期中避孕药的应用

卵巢高反应患者在IVF周期中降调节前使用避孕药是利用其对卵巢的双重抑制作用,减低卵巢敏感性,减少获卵数和卵巢过度刺激综合征(OHSS)发生率;卵巢低反应患者在拮抗剂周期前应用口服避孕药(oral contraceptive pill,OCP)意在增加卵巢敏感性,增加获卵数;正常反应者应用OCP,不改变IVF妊娠结局。一I、VF周期应用OCP的目的IVF周期应用OCP的主要目的是对性腺轴的负反馈 促性腺激素释放激素激动剂(GnRH-a)降调节,具有双重抑制作用;对性腺轴的负反馈 直接大量促性腺激素(Gn) GnRH拮抗剂(思则凯),增加卵巢对Gn的敏感性;降低GnRH-a应…     

两种促性腺激素释放激素激动剂降调节方案对体外受精结局的影响

目的比较体外受精-胚胎移植（IVF-ET）中应用不同方案小剂量促性腺激素释放激素激动剂（GnRH—a）降调节,对临床结局的影响。方法回顾性分析本中心行控制性卵巢刺激降调节方案的1,478个周期,根据GnRH—a用药方案不同分成2组,A组（nA=895）：常规方案组于黄体中期给予短效GnRH—a0．1mg／d,14d后减至半量,使用至人绒毛膜促性腺激素（hCG）注射日;B组（nB=583）：新方案组于黄体中期给予短效GnRH-a0．1mg／d,10d后减至半量,使用至hCG注射日。根据使用GnRH—a14d后是否达到降调标准又分为两组：a组：正常启动组（na=1,189,其中nAa=720,nBa=469）;b组：延迟启动组（nb=289,其中nAb=175,nBb=114）。所有降调达标准后立即启动Gn,若未达标准则继续使用GnRH—a直至达标后再启动Gn。比较各组间实验室及临床结局之间的差异。结果（1）各组间相比,以常规方案延迟启动组（Ab组）Gn使用量最多,新方案正常启动组（Ba组）使用量最少（P〈0.05）;（2）各组间平均获卵数、2PN受精率、2PN卵裂率、总优质胚胎率、中重度卵巢过度刺激综合征率无差异（P〉0．05）。结论（1）在保证降调达标准前提下,适当降低GnRH—a剂量,可在不影响临床妊娠结局的情况下减少Gn使用天数和总量;2．降调未达标时继续应用GnRH—a至达标后,仅增加Gn使用量而不会影响临床结局。     

Association between heart rate variability and manual pulse rate

Introduction:

One model for neurological assessment in chiropractic pertains to autonomic variability, tested commonly with heart rate variability (HRV). Since HRV may not be convenient to use on all patient visits, more user-friendly methods may help fill-in the gaps. Accordingly, this study tests the association between manual pulse rate and heart rate variability. The manual rates were also compared to the heart rate derived from HRV.

Methods:

Forty-eight chiropractic students were examined with heart rate variability (SDNN and mean heart rate) and two manual radial pulse rate measurements. Inclusion criteria consisted of participants being chiropractic students. Exclusion criteria for 46 of the participants consisted of a body mass index being greater than 30, age greater than 35, and history of: a) dizziness upon standing, b) treatment of psychiatric disorders, and c) diabetes. No exclusion criteria were applied to the remaining two participants who were also convenience sample volunteers. Linear associations between the manual pulse rate methods and the two heart rate variability measures (SDNN and mean heart) were tested with Pearson’s correlation and simple linear regression.

Results:

Moderate strength inverse (expected) correlations were observed between both manual pulse rate methods and SDNN (r = −0.640, 95% CI −0.781, −0.435; r = −0.632, 95% CI −0.776, −0.425). Strong direct (expected) relationships were observed between the manual pulse rate methods and heart rate derived from HRV technology (r = 0.934, 95% CI 0.885, 0.962; r = 0.941, 95% CI 0.897, 0.966).

Conclusion:

Manual pulse rates may be a useful option for assessing autonomic variability. Furthermore, this study showed a strong relationship between manual pulse rates and heart rate derived from HRV technology.     

正常人心率减速力和心率变异性的变化及相关性

目的 测定不同年龄正常人心率减速力与心率变异性并分析其相关性,探讨其临床意义。方法 选取正常人90例,根据年龄将受试者分为青年组和老年组,进行24h动态心电图检查,离线计算DC、HRV时域指标及相关系数。结果 老年组DC和HRV值与青年组比较均降低,差异有统计学意义（P〈0.05）,且DC和HRV显著相关。结论 DC和HRV时域指标随着年龄的增加而减小,这些无创指标可以反映自主神经功能。     

精子CMA3阳性率与IVF受精率的相关性研究

目的探讨精子色素酶A3(CMA3)阳性率与IVF受精率之间的相关性。方法收集2015年4月至2016年7月因单纯输卵管性不孕在我院生殖医学科行常规IVF助孕的156个周期,以受精率<25%为低受精,根据受精率不同分为正常受精组(134个周期)和低受精组(22个周期)。取卵日,将授精后剩余的洗涤精液行精子浓度和活动率分析,并将精子进行CMA3染色。比较两组优选后的精子参数,分析IVF受精率与精子参数及CMA3阳性率的关系。结果与正常受精组比较,低受精组精子CMA3阳性率显著升高[(20.0±4.2)%vs.(30.7±2.3)%],优选后前向运动精子的百分率显著降低[(90.4±4.8)%vs.(74.3±3.4)%](P<0.05);两组精子浓度比较无显著性差异(P>0.05)。IVF受精率与优选后的前向运动精子百分率呈正相关(r=0.76,P<0.01)。精子CMA3阳性率与优选后前向运动精子百分率(r=-0.82,P<0.01)及IVF受精率(r=-0.83,P<0.01)呈显著负相关,与精子浓度则无显著相关性(P>0.05)。结论精子CMA3阳性率与IVF受精率负相关,但其具体机制尚需进一步研究探讨。     

Effect of alcohol consumption on estimated glomerular filtration rate and creatinine clearance rate.

BACKGROUND: Moderate alcohol consumption is widely recognized as beneficial in the prevention of cardiovascular disease, yet the renal effects of alcohol intake are still controversial. The present study is designed to investigate the influence of alcohol consumption on calculated creatinine clearance rate (CCr) and glomerular filtration rate (GFR) in a Southern Taiwan Pai-Wan aboriginal community with a high prevalence of alcohol consumption. METHODS: This is a cross-sectional community-based study. The 1466 aboriginal subjects, 40-95 years of age, are a stratified random subpopulation identified during an integrative health care programme. They were sampled for drinking patterns. The main outcome measurements were serum creatinine, estimated CCr and GFR. RESULTS: Subjects with alcohol consumption had significantly higher levels of serum triglycerides, high-density lipoprotein cholesterol, uric acid, estimated CCr and GFR values than non-drinkers. Their blood pressure was also significantly higher. They had lower total cholesterol and low-density lipoprotein cholesterol concentrations. Increasing alcohol consumption was independently and significantly associated with a higher level of estimated CCr and GFR when analysed as both a categorical and continuous variable. CONCLUSIONS: The present study shows that chronic alcohol consumption has a negative effect on blood pressure and lipid profile and stimulates the estimated GFR.     

The effect of carbon dioxide, respiratory rate and tidal volume on human heart rate variability

BACKGROUND: Heart rate variability (HRV) has been used for assessment of depth of anesthesia. Alterations in respiratory rate and tidal volume modulate the sympatovagal neural drive to the heart. The changes in PaCO2 that accompany changes in breathing pattern may, through chemoreceptors in the brainstem, independently influence the autonomic control of the heart and modulate HRV. METHODS: We measured the effects of PaCO2, tidal volume and respiratory rate on HRV during spontaneous and mechanical ventilation in 22 healthy volunteers and in 25 mechanically ventilated anesthetized patients. RESULTS: Adding CO2 to the inspiratory gas increased high frequency (HF) and low frequency (LF) components of HRV in awake volunteers both during spontaneous and mechanical ventilation, while this effect of CO2 was abolished in patients during anesthesia. Increase of tidal volume increased HF component of HRV only in volunteers during spontaneous ventilation. On the other hand, when respiratory rate was reduced, the balance of HF and LF power moved toward LF power in all study groups. Breathing frequency altered HRV independent on PaCO2, tidal volume and the level of consciousness. In contrast, the effect of PaCO2 appeared to be related to normal level of consciousness, suggesting that a cortical modulation of the autonomic nervous activity contributes to the effects of PaCO2 on HRV. CONCLUSIONS: PaCO2, tidal volume and respiratory rate should be controlled when HRV power spectrum is measured in conscious patients or volunteers, while in anesthetized patients small changes in end-tidal CO2 or tidal volume do not modulate HRV if respiratory rate remains unchanged.     

Dialysate flow rate and peritoneal clearance

We evaluated the influence of dialysate flow rates upon peritoneal clearance of urea, creatine, protein losses into dialysate, glucose disappearance from dialysate, sodium removal from the patient during dialysis, and ultrafiltration rate in 64 patients undergoing intermittent peritoneal dialysis. We evaluated three dialysate flow rates: 2 L/h, 3 L/h, and 4 L/h. All dialysate contained 1.5% glucose. The clearance of urea in milliliters per minute (2-L series 14.0, 3-L series 15.1, 4-L series 17.6) and creatinine in milliliters per minute (2-L series 9.3, 3-L series 10.6, 4-L series 11.6) determined at a dialysate flow rate of 4 L/h was significantly greater than the clearances determined at 3 and 2 L/h of dialysate flow (P less than 0.05). The clearance of glucose from the peritoneal cavity in milliliters per minute (2-L series 6.9, 3-L series 7.9, 4-L series 8.9) was significantly greater for the 4-L series as compared with the 2-L series (P less than 0.05). There were no other significant differences. Neither sex, race, previous episodes of peritonitis, nor etiology of renal failure influenced the results. Given the high cost of dialysate, we recommend dialysate flows of 2 L/h if a patient has a residual renal clearance of 2.5 mL/min. Although increasing dialysate flow rate may compensate for renal clearances significantly less than this, we believe the patient should be offered hemodialysis, continuous cyclic peritoneal dialysis (CCPD), or continuous ambulatory peritoneal dialysis (CAPD).     

丙泊酚和七氟醚对乳腺癌手术后生存率和复发率影响的Meta分析

目的 评价丙泊酚和七氟醚对乳腺癌手术后五年生存率和复发率的影响。方法 计算机检索PubMed、Embase、Cochrane Library、Web of Science、维普、万方和知网数据库,收集关于丙泊酚和七氟醚对乳腺癌手术预后影响的随机对照试验和回顾性研究,检索时间为建库至2021年5月28日。按照纳入和排除标准进行文献筛选、数据提取和质量评价,采用RevMan 5.4统计软件进行Meta分析。结果 共纳入8篇研究,患者10 662例,其中丙泊酚组4 210例,七氟醚组6 452例。Meta分析结果显示,与七氟醚组比较,丙泊酚组乳腺癌术后五年生存率明显升高(OR=1.82,95%CI 1.08～3.04,P=0.02)。两组术后的乳腺癌复发率(OR=0.71,95%CI 0.47～1.06,P=0.10)差异无统计学意义。结论 与七氟醚麻醉比较,丙泊酚麻醉明显升高乳腺癌术后五年生存率,但对乳腺癌术后复发率的影响无明显差异。因受诸多因素影响,上述结论仍需更多大样本双盲随机对照试验予以验证。     

Effects of glycopyrrolate and atropine on heart rate variability

Analysis of heart rate variability, combined with physiological tests (deep breathing and tilt tests) was used to characterise the effects of atropine and glycopyrrolate on the parasympathetic nervous tone of the heart in healthy male volunteers. The low dose of atropine (120 micrograms) administered as a continuous infusion in 15 min was associated with parasympatomimetic effects estimated by the slowing of the heart rate and an increase of the mean and beat-to-beat heart rate variability. The bradycardia and increase of heart rate variability following infusion of glycopyrrolate (50 micrograms) was less marked and did not differ significantly from that of placebo. The higher doses of atropine (720 micrograms) and glycopyrrolate (300 micrograms) administered as a continuous infusion in 15 min produced an equal vagal cardiac blockade characterised by significant tachycardia and a decrease in overall and beat-to-beat heart rate variability. It is concluded that at low doses the parasympatomimetic action of glycopyrrolate is less marked than that of atropine; and at higher doses only small differences exist between these two muscarinic antagonists in their effects on cardiac vagal outflow, assessed by heart rate and heart rate variability.     

显微授精穿刺方式与胚胎受精率及闭锁率相关性研究

目的探讨显微授精时由于卵膜弹性不同产生的不同破膜方式对卵母细胞受精率及卵母细胞闭锁率的影响。方法回顾性分析在本中心行显微授精治疗的患者共1589个卵母细胞，根据显微注射针穿刺卵膜的方式分为两组：一组1250例为卵膜弹性正常组，另一组339例为卵膜无弹性组，比较不同分组间的受精率差异，及穿刺后卵母细胞闭锁率。结果根据卵膜弹性分成的两组受精率无差异，卵膜有弹性组受精率为88．2％，卵膜无弹性组受精率87、3％，P〉0.05；穿刺后卵细胞闭锁的比率在卵膜无弹性组为17.1％，而在卵膜有弹性组的此比率为5.4％，两者有明显的统计学差异，P〈0.001。结论显微授精的受精率与穿刺时卵子的质量密切相关，所以选择恰当的取卵时机获取成熟度适当的卵子是提高显微授精受精率的关键。     

长托宁术前用药对心率及维库溴铵肌松作用的影响

Objective To investigate the effects of penehyclidine hydrochloride on heart rate (HR) and veeuronium-induced relaxation.Methods Sixty female patients were randomly assigned to three groups (n=20):0.01 mg/kg penehyclidine hydrochloride (group C),0.01 mg/kg atropine (group A) and 1ml normal saline (group N).These drugs were injected intramuscularly 20 minutes before anesthesia induction.Midazolam,fentanyl,propofol and vecuronium were given intravenously for induction.Muscle relaxation was monitored.Results HR increased in group A at 15 min and 20 min after injection(P＜0.05),and was faster than that in group C and group N at 10,15,20 min after injection,and 1 min after induction (P＜0.05).There were no differences in onset time,noresponse period,clinical relaxation duration and recovery time of vecuronium-induced relaxation among three groups.Conclusion 0.01 mg/kg penehyclidine hydrochloride is able to stabilize heart rate,and does not affect vecuronium-induced relaxation.