耐酶抑制剂β-内酰胺酶研究进展

耐酶抑制剂β-内酰胺酶（IR-BLs）是一类不被酶抑制剂所抑制的β-内酰胺酶，主要来自TEM型，故又称为耐酶抑制剂TEM（IRT），其特点是对阿莫西林、替卡西林及其酶抑制剂复合制剂耐药，但对窄谱头孢菌素、氧亚氨基头孢菌素和7-α-甲氧基头孢菌素敏感，这类酶不属于超广谱β-内酰胺酶（ESBLs）；值得注意的是，TEM-50、-68、-89、-109、-121、-125型酶不仅具有ESBLs的耐药特征，而且具有IRT耐酶抑制剂的特征，这种复杂的TEM变异体（CMT）的出现，不仅对实验室检测是一个挑战，而且也给临床抗感染治疗带来困难。     

心理应激与下丘脑-垂体-肾上腺-免疫轴功能关系的研究进展

心理应激是由于个体在生活适应过程中．因环境要求与自身应付能力不平衡的认识所引起的一种身心紧张状态。机体在各种应激状态下，多出现以交感神经-肾上腺髓质轴和下丘脑-垂体-肾上腺皮质轴反应为主的变化，使血清儿茶酚胺和肾上腺糖皮质激素含量上升，这常常被视为应激的标志。胸腺是重要的中枢免疫器官，对外周免疫器官的发育起着重要的调节作用，在神经-内分泌-免疫调节网络中，胸腺作为免疫、内分泌器官与神经系统相联结构成了神经-内分泌-胸腺轴，本就心理应激与下丘脑-垂体-肾上腺-免疫轴功能关系的研究进展作一综述。     

脑损伤后内分泌功能的变化及其发生机制

在创伤性颅脑损伤和脑血管病急性期，均可出现下丘脑-垂体．肾上腺皮质轴、下丘脑-垂体-甲状腺轴和下丘脑-垂体-性腺轴功能紊乱，主要是由于下丘脑和垂体原发或继发性损伤所致。脑损伤后急性期的体内大多数激素水平的变化是暂时性的，也可能是可逆的，但部分病例在恢复期合并有垂体功能减退，出现分泌功能不足的表现。激素的缺乏可能会影响到脑损伤患者的预后，目前需要建立一个指南以明确哪部分患者、什么时候以及怎样进行激素替代治疗。     

β-防御素:治疗感染的新希望

天然免疫是抵御病原微生物入侵的最初免疫反应，而内源性抗菌肽是天然免疫的重要介质。近20年来，已发现120余种抗菌肽，防御素是其中的一大家族，在自然界分布广泛，从植物、昆虫到动物均有表达。在人类，防御素按结构分为α-防御素、β-防御素两种亚型，α-防御素主要由中性粒细胞和小肠潘氏细胞产生，而β-防御素广泛表达于多种器官的上皮细胞和粘膜下腺体。β-防御素具有广谱     

注射用阿魏酸钠与维生素B6注射液存在配伍禁忌

阿魏酸钠，化学名称：3-甲氧基-4-羟基桂皮酸钠盐二水合物。维生素B6注射液主要是吡哆醛、吡哆胺和吡哆醇，在自然界广泛分布，其磷酸化形式是氨基酸代谢过程的辅酶。     

医护协作促进整体护理的效果研究

医-护-患之间的关系本应该是和谐、融洽的，然而近些年来，医-护-患关系日趋紧张，医-护-患之间冲突频发导致患者身心利益受到影响，从而医患纠纷层出不断，影响了医院的正常运转和社会稳定，医患间矛盾已成为阻碍医院发展的最不和谐因素。发生医疗纠纷的比例占98例”。整体护理是我国现推行的护理模式，该模式顺应医学模式的发展，是将人视为生理、心理、社会、精神、     

郎格汉斯组织细胞增生症的治疗和影像学研究现状

传统的组织细胞病X(histioeytosis X)，又称网状内皮细胞增生症和组织细胞增生症，包括莱特勒-西韦病(LettererSiwe disease，LSD)，汉-许-克病(Hand-Schtlller-Christian disease，HSC)和嗜酸性肉芽肿(eosinophilic granuloma，EG),它们是一种病变的不同发展阶段，其临床表现和病理变化有所不同，但界限并不十分清楚。是一种病因不明的非肿瘤性肉芽肿病灶，由Jaffe和Licntenstein在1940年首先提出。     

问：什么是DNA甲基化？

答：DNA甲基化是一种表观遗传修饰，它是由DNA甲基转移酶（DNA methyl—transferase，Dnmt）催化S-腺苷甲硫氨酸作为甲基供体，CG二核苷酸是最主要的甲基化位点。DNA甲基化的主要形式为5-甲基胞嘧啶，N6-甲基腺嘌呤和7-甲基鸟嘌呤。在真核生物中，5-甲基胞嘧啶是唯一存在的化学性修饰碱基，主要出现在CpG和CpXpG中，原核生物中CCA／TGG和GATC也常被甲基化。DNA甲基化能关闭某些基因的活性，是后天基因沉默的一种主要决定性因素，而去甲基化则诱导了基因的重新活化和表达。[第一段]     

雷贝拉唑治疗胃溃疡50例临床观察

雷贝拉唑是2-[[[4-（3-甲氧基丙氧基）-3-甲基吡啶基]甲基]亚磺酰基]-1H-苯并咪唑，是苯并咪唑的替代品。作为一种新型的质子泵抑制剂，具有特异性抑制胃壁细胞的H^＋-K^＋ATP酶，从而对胃酸分泌产生强而持久的抑制作用。口服吸收快，能够显著抑制基础和最大胃酸分泌量，为溃疡愈合创造有利的条件。我们采用随机抽取对照分组治疗胃溃疡96例，疗效满意，现报告如下。     

环氧酶-2抑制药的药理研究及临床应用

1引言 环氧酶（cycloxygenase,，COX）于1976年被发现，是前列腺素（prostaglandins，PGs）生物合成的必需酶之一。其主要作用机制为催化花生四烯酸产生前列腺素和白三烯，引起炎症和启动凝血系统。环氧酶分为2种——环氧酶-1和环氧酶-2。环氧酶-1属结构性酶，在生理状态下，在全身大多数组织和细胞中均可测到，且含量稳定，主要和胃肠道反应有关：环氧酶-2是可诱导酶，属炎性介质，生理状态下仅存住于脑、肾皮质等个别器官。     

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.