早期机械通气配合亚低温治疗在重型颅脑损伤中的应用

目的 探讨早期机械通气配合亚低温治疗在重型颅脑损伤治疗中的作用及临床意义。方法 对2001年6月～2004年12月间收治的49例重型颅脑损伤患者伤后或术后即给予机械通气辅助氧供并同时冰毯降温，观察治疗前、后PaO2，GCS评分，lung injury score（LIS评分），acute lung injury（ALI）指数，颅内朦（ICP）变化。结果 49例患者经治疗后，上述指标均明显改善，血气分析指标基本恢复正常水平。全组死产8例，自动出院2例，死亡率（包括自动出院）20．41％。出院病人39例获随诊半年。恢复良好31例，中残3例。重残2例，植物状态3例。结论 早期气管切开、机械通气，配合亚低温治疗，可控制和预防低氧血症，改善脑缺血，减轻脑水肿和颅内高压。对疾病预后有重要意义。     

早期机械通气与常规机械通气对重型颅脑损伤救治效果的比较

目的比较早期机械通气与常规机械通气对重型颅脑损伤患者的救治效果。方法将74例格拉斯哥昏迷评分（GCS）3～8分的重型颅脑损伤患者随机分为对照组和观察组。除常规治疗及相应手术治疗外．对照组35例先予鼻导管持续吸氧．出现呼吸衰竭时使用机械通气；观察组39例伤后即刻应用机械通气。比较两组通气前后动脉血氧分压（PaO2）、二氧化碳分压（PaCO2）、氧饱和度（SaO2）等血气指标变化及伤后6个月格拉斯哥预后评分（GOS）。结果两组患者机械通气后PaO2、PaCO2、SaO2等血气指标均有显著改善，但观察组通气效果更好，通气时间更短。结论早期机械通气较常规机械通气能更有效改善重型颅脑损伤患者的缺氧状态，缩短机械通气时间。     

早期机械通气对重型颅脑损伤预后的影响

目的 探讨早期机械通气对重型颅脑损伤患者临床转归及预后的影响. 方法 将251例GCS评分5-8分的重型颅脑损伤患者依有否进行早期机械通气分为治疗组128例与对照组123例,对治疗前后两组患者的氧饱和度(SaO2)、氧分压(PaO2)、二氧化碳分压(PaCO2)、血压(BP)、心率(HR)、GCS评分和预后进行评估. 结果 治疗组与对照组治疗前SaO2、PaO2、PaCO2、BP、HR、GCS评分比较差异无统计学意义(P>0.05);治疗后1,7,14 d时两组间SaO2、PaO2.PaCO2比较差异有统计学意义(P<0.05).随访6个月.治疗组GOS评分、死亡率、预后较对照组明显改善,差异有统计学意义(P<0.05).结论 早期机械通气可改善重型颅脑损伤患者脑细胞缺氧状况,促进脑功能恢复,降低死亡率.     

纳洛酮治疗新生儿缺氧缺血性脑病临床疗效观察

目的探讨纳洛酮干预治疗缺氧缺血性脑病新生儿的临床效果。方法选择2013-01—2015-06我院收治的缺氧缺血性脑病新生儿90例,随机分为2组各组45例。对照组采用常规治疗措施,包括抗生素预防应用,降低颅内压,持续吸氧、营养支持及脑循环改善等;研究组在对照组治疗基础上加用纳洛酮静脉泵注。比较2组患儿治疗前后的临床症状评分、意识恢复时间、原始反射与肌张力恢复时间及住院时间。结果 2组治疗前临床症状评分差异无统计学意义(P0.05),治疗后各时间段评分均低于治疗前,研究组低于对照组,差异有统计学意义(P0.05)。研究组意识恢复、原始反射与肌张力恢复时间及住院时间等均明显短于对照组,差异有统计学意义(P0.05)。结论纳洛酮可改善缺氧缺血性脑病新生儿的预后,值得推广应用。     

早期机械通气治疗脑卒中并发呼吸衰竭临床观察

目的评价早期机械通气治疗脑卒中并发呼吸衰竭患者的临床效果及其预后情况。方法选择驻马店市中心医院收治的68例脑卒中并发呼吸衰竭患者,按照随机数字表法分为A、B组,均采取降压、吸氧、预防感染及降低颅内压、调节水电解质紊乱等对症治疗。在以上治疗的基础上,A组采取常规机械通气治疗,B组根据患者的呼吸频率及动脉血氧饱和度情况采取早期机械通气治疗,对2组治疗前后血气分析指标及病情程度进行比较,随访6个月,对2组治疗前和随访6个月后的神经功能预后情况进行评价。结果 2组治疗后血气分析指标(PaO2、PaCO2、SaO2)水平、APACHⅡ评分及随访后6个月的神经功能预后指标(NDS、BI、FCA)各项评分均显著优于治疗前(P0.05),且B组治疗后及随访6个月后的上述指标监测水平均显著优于A组(P0.05)。结论早期机械通气治疗脑卒中并发呼吸衰竭较常规机械通气治疗的临床疗效显著,能够显著提高患者的血氧饱和度,减轻其低氧血症,有效改善神经功能预后情况。     

多沙普仑联合无创通气治疗对慢性阻塞性肺疾病肺性脑病肺功能及预后的影响

目的探讨多沙普仑联合无创通气治疗对慢性阻塞性肺疾病肺性脑病肺功能及预后的影响。方法回顾性分析110例慢性阻塞性肺疾病肺性脑病患者临床资料,按照不同治疗方式分为2组各55例,对照组予无创通气治疗,研究组予多沙普仑联合无创通气治疗,对比2组临床疗效及预后情况。结果研究组神智恢复时间、机械通气时间及住院时间均短于对照组,生活质量评分高于对照组(P0.01);研究组血气指标及肺功能指标均较治疗前显著改善,优于对照组(P0.01)。结论多沙普仑联合无创通气治疗对慢性阻塞性肺疾病肺性脑病疗效显著,可改善动脉血气功能及肺功能,且可改善预后。     

机械通气在脑出血术后呼吸衰竭患者治疗中的应用效果

目的探讨机械通气在脑出血术后并呼吸衰竭患者中的应用效果。方法选择我院2012-08-2013-12收治的46例脑出血术后呼吸衰竭患者,在常规治疗的基础上均给予机械通气,分析治疗前后动脉血气指标、平均动脉压、APACHEⅡ评分、Glasgow评分的变化情况。结果机械通气治疗后平均动脉压、APACHEⅡ评分值、Glasgow评分与治疗前相比均有明显改善,动脉血气指标均恢复正常水平,差异有统计学意义(P0.05)。结论机械通气治疗对脑出血术后并发呼吸衰竭患者具有较好的治疗效果,可明显改善机体供氧状态,值得临床推广。     

早期支气管镜配合机械通气治疗重型颅脑损伤致呼吸衰竭并气道误吸的应用

目的探讨纤维支气管镜（纤支镜）配合有创机械通气治疗在重型颅脑损伤致呼吸衰竭（呼衰）并气道误吸治疗中的价值及安全性。方法对32例重型颅脑损伤致呼衰并气道误吸的患者于伤后3h内实施有创机械通气支持下经纤支镜作支气管肺泡灌洗术，观察术前、中、后心率（HR）、血压（BP）、动脉血氧分压（PaO2）、氧合指数（OI）、吸气峰压（PIP）、吸氧浓度（FiO2）变化。结果32例患者均术程顺利，未发生并发症。术中HR、BP、PaO2、OI较术前无改变（P〉0.05），术后FiO2较术前显著减少，HR、PaO2、OI明显好转（P〈0.01）。经治疗无一例出现吸入性肺炎及阻塞性肺不张。结论经纤支镜支气管肺泡灌洗配合机械通气治疗，对防止吸入性肺炎及阻塞性肺不张的发生，预防和纠正低氧血症，保证脑供氧，提高救治成功率及改善预后有重要价值，并具有良好的安全性。     

机械通气联合氨溴索对老年脑卒中后重症肺炎的影响

目的探究有创机械通气联合盐酸氨溴索静滴对老年脑卒中后重症肺炎患者机械通气时间及神经功能的影响。方法选取2014-02—2017-02我院68例老年脑卒中后重症肺炎患者,随机数字表法分为2组,每组34例。2组均采取常规治疗,对照组在此基础上予以有创机械通气治疗,观察组予以有创机械通气联合盐酸氨溴索静滴治疗,2组均持续治疗1周。对比2组治疗前、治疗1周后血气指标[动脉血二氧化碳分压(PaCO_2)、血氧分压(PaO_2)]与血清炎症指标[降钙素原(PCT)、C反应蛋白(CRP)]水平及肺炎严重程度评分(CURB-65)、神经功能缺损评分(NIHSS),统计2组症状缓解时间、机械通气时间、ICU入住时间。结果观察组治疗1周后PaCO_2与血清PCT、CRP、WBC水平较对照组降低,PaO_2水平较对照组提高,差异有统计学意义(P0.05);观察组治疗1周后CURB-65、NIHSS评分较对照组降低,差异有统计学意义(P0.05);经治疗,观察组症状缓解时间、机械通气时间、ICU入住时间均较对照组缩短,差异有统计学意义(P0.05)。结论联合采用有创机械通气与盐酸氨溴索静滴治疗老年脑卒中后重症肺炎患者效果显著,可明显减轻机体炎症反应,改善血气指标情况,降低患者肺炎严重程度,缩短患者机械通气时间,促进患者神经功能恢复。     

急性重型颅脑损伤后急性肺损伤和急性呼吸窘迫综合征的治疗体会

目的探求急性重型颅脑损伤后急性肺损伤（ALI）和急性呼吸窘迫综合征（ARDS）的发病机理、诊断和治疗。方法对39例急性重型颅脑损伤（GLS〈8）后并发ALI／ARDS患者的临床资料进行回顾性分析，及早采用综合治疗方案，气管切开，机械通气，早期大剂量甲基强的松龙，沐舒坦，纳洛酮，脱水，抗感染，消化道去污染，早期肠内营养，合理的容量支持等治疗。结果随访3个月，以GOS分级法评价病人预后：Ⅰ级死亡8例（20％），Ⅱ级植物生存1例（3％），Ⅲ级重残4例（10％），Ⅳ中残3例（7％），Ⅵ级良好23例（60％）。结论ALI／ARDS是重型颅脑损伤后危及生命的严重并发症，系多种因素诱导的一个病理过程。针对器官及功能进行支持治疗，特别是呼吸支持是ARDS治疗的主要手段。     

Epilepsy and anomalies of neuronal migration: MRI and clinical aspects

Neuronal migration disorders are the result of disturbed brain development. In such disorders, neurons are abnormally located. In diagnosing these conditions, magnetic resonance imaging is superior to any other imaging technique. This enables us to improve our knowledge of the clinical correlates of neuronal migration. With reference to migrational disorder, a retrospective study of all 303 patients with epileptic seizures referred for magnetic resonance imaging during a 3-year period was performed, 13 patients (aged 12-41, mean age 27) were identified. They represent 4.3% of the entire study group. Of the patients with known epilepsy, 6.7% and of the mentally retarded, 13.7% had migrational disorders. Four patients had schizencephaly as the dominant finding, one was classified as hemimegalencephaly, 2 had isolated heterotopias, and 6 had localized pachy- and/or poly-microgyria. The clinical pictures are complex. Ectopias of grey matter are recognised foci of epilepsy, but from an epileptological and a clinical viewpoint little attention has been given to these disorders. The present study shows that malmigration is not rare in epilepsy patients, especially not in the mentally retarded.     

Classification of methods in transcranial Electrical Stimulation (tES) and evolving strategy from historical approaches to contemporary innovations

Transcranial Electrical Stimulation (tES) encompasses all methods of non-invasive current application to the brain used in research and clinical practice. We present the first comprehensive and technical review, explaining the evolution of tES in both terminology and dosage over the past 100 years of research to present day. Current transcranial Pulsed Current Stimulation (tPCS) approaches such as Cranial Electrotherapy Stimulation (CES) descended from Electrosleep (ES) through Cranial Electro-stimulation Therapy (CET), Transcerebral Electrotherapy (TCET), and NeuroElectric Therapy (NET) while others like Transcutaneous Cranial Electrical Stimulation (TCES) descended from Electroanesthesia (EA) through Limoge, and Interferential Stimulation. Prior to a contemporary resurgence in interest, variations of transcranial Direct Current Stimulation were explored intermittently, including Polarizing current, Galvanic Vestibular Stimulation (GVS), and Transcranial Micropolarization. The development of these approaches alongside Electroconvulsive Therapy (ECT) and pharmacological developments are considered. Both the roots and unique features of contemporary approaches such as transcranial Alternating Current Stimulation (tACS) and transcranial Random Noise Stimulation (tRNS) are discussed. Trends and incremental developments in electrode montage and waveform spanning decades are presented leading to the present day. Commercial devices, seminal conferences, and regulatory decisions are noted. We conclude with six rules on how increasing medical and technological sophistication may now be leveraged for broader success and adoption of tES.     

Hepatic Considerations in the Use of Antiepileptic Drugs

Summary: Virtually all of the major antiepileptic drugs (AEDs) can cause hepatotoxicity, although fatal hepatic reactions are rare. The mechanisms, incidences, and risk profiles for such reactions differ from drug to drug. With carbamazepine and phenytoin, hepatotoxicity may be due to drug hypersensitivity. Although the profiles of patients at risk have not been well-defined for these two antiepileptic drugs, it would appear from reports in the literature that older adolescents and adults are at higher risk than children of developing serious or fatal hepatotoxicity. Once hepatotoxicity develops, mortality rates are 10–38% with phenytoin and 25% for carbamazepine. The risk profile for valproate fatal hepatotoxicity has been more clearly defined. Those at primary risk of fatal hepatic dysfunction are children under the age of 2 years who are receiving multiple anticonvulsants and also have significant medical problems in addition to severe epilepsy. The risk is considerably lower for patients over the age of 2 years on valproate monotherapy. In contrast to the risk profile with other AEDs, adults receiving valproate as monotherapy have the lowest risk of hepatotoxicity. Fatal hepatic dysfunction coincident with valproate may be the result of aberrant drug metabolism. Concomitant use of AEDs that induce microsomal P450 enzymes (e.g., phenytoin and phenobarbital) may enhance the production of a toxic metabolite, and hence the greater risk of hepatotoxicity with polypharmacy.     

Vascular Malformations and Epilepsy: Clinical Considerations and Basic Mechanisms

Summary: Vascular malformations (VMs) are associated with epilepsy. The natural history of the various VMs, clinical presentation, and tendency to provoke epilepsy determine treatment strategies. Investigations have probed the mechanisms of epileptogenesis associated with these lesions. Electrophysiologic changes are associated with epileptogenic cortex adjacent to VMs. Putative pathophysiologic mechanisms of epileptogenesis include neuronal cell loss, glial proliferation and abnormal glial physiology, altered neurotransmitter levels, free radical formation, and aberrant second messenger physiology.     

Neonatal Seizures: Problems in Diagnosis and Classification

Summary: The clinical identification of neonatal seizures is critical for the recognition of brain dysfunction; however, diagnosis is often difficult because of the poorly organized and varied nature of these behaviors. Current classification systems are limited in their ability to communicate motor, autonomic, and electroencephalo-graphic features of seizures precisely and to provide a basis for uniform effective diagnosis, therapy, and determination of prognosis. Recent investigations of neonates, utilizing bedside electroencephalographic/polygraphic/ video monitoring techniques, have provided the basis for improved diagnosis and classification of seizures in the newborn. These studies have demonstrated that not all clinical phenomena currently considered to be seizures require electrocortical epileptiform activity for their initiation or elaboration. In addition, the specific clinical character of the phenomena considered to be seizures, the clinical state of the infant, and the character of the EEG indicate the probable pathophysiological mechanisms involved and suggest probable etiologies, prognosis, and therapy. Similarities between animal models that demonstrate reflex physiology and neonates with motor automatisms and tonic posturing suggest that these clinical behaviors may not be epileptic in origin but, rather, primitive movements of progression and posture mediated by brainstem mechanisms. Although not all clinical behaviors currently considered to be neonatal seizures may have similar pathophysiological mechanisms, they are clinically significant because they all indicate brain dysfunction.     

Valproate Monotherapy in the Management of Generalized and Partial Seizures

Summary: For decades, therapeutic tradition has promoted the concept of polypharmacy in the management of epilepsy. In recent years, however, studies have shown that, for most patients, monotherapy can provide comparable or better seizure control than administration of multiple anticonvulsants, while diminishing the potential for adverse reactions, drug interactions, and poor compliance. Valproate is an important monotherapeutic agent that is highly effective in the control of idiopathic primary and secondarily generalized epilepsies, and partial seizures that do not generalize. Comparative studies have found that valproate is at least as effective as phenytoin and carbamazepine in the treatment of generalized and partial seizures. Given the similar efficacy, other factors such as pharmacokinetics and side effects may therefore determine anticonvulsant selection for monotherapy.     

Carbamazepine Efficacy and Utilization in Children

Summary: Carbamazepine is effective for preventing partial and generalized tonic-clonic seizures in children. Although absence epilepsies are more common in children than adults, an estimated 80% of children with epilepsy have seizure types or epilepsies that are potentially responsive to carbamazepine. The differential diagnosis of ictal staring is an especially important issue in children because absence and atypical absence seizures are more prevalent in children than adults. Age-related pharmacokinetic differences and drug interactions are major considerations in children. On average, children have higher clearance rates of carbamazepine, shorter half-lives, and higher ratios of carbamazepine-10, 11-epoxide to carbamazepine than adults. In addition, children with severe epilepsy are more likely to require multiple-drug therapy, which can lead to complex drug interactions. When carbamazepine is administered along with valproate, drug protein binding interactions can cause intermittent side effects.     

Un nouveau cadre conceptuel de travail pour la psychiatrie

In an attempt to place psychiatric thinking and the training of future psychiatrists more centrally into the context of modern biology, the author outlines the beginnings of a new intellectual framework for psychiatry that derives from current biological thinking about the relationship of mind to brain. The purpose of this framework is twofold. First, it is designed to emphasize that the professional requirements for future psychiatrists will demand a greater knowledge of the structure and functioning of the brain than is currently available in most training programs. Second, it is designed to illustrate that the unique domain which psychiatry occupies within academic medicine, the analysis of the interaction between social and biological determinants of behavior, can best be studied by also having a full understanding of the biological components of behavior.