长效纳曲酮缓释剂植入治疗阿片依赖渴求的线索诱发事件相关电位评价

目的：在前期成功研制出长效纳曲酮缓释剂植入剂型的基础上，应用线索诱发事什相关电位观察长效纳曲酮缓释剂植入治疗阿片依赖者心理渴求的神经心理学作用。方法：①对象和分组：阿片依赖综合征患者自湖北、湖南和广东等地，包括两个不同戒毒方式的组，即长效纳曲酮缓释剂治疗组和强制戒毒组，同时设计一个未戒毒的阿片依赖对照组和一个健康对照组。②方法：采用事件相关电位记录被试由图片的情绪内涵激发的脑内电活动，无需被试对所观察的图片作出外显反应，现场采集记录其观看药物相关情景线索图片和中性图片时产生的脑电事件相关电位波形。结果：①长效纳曲酮缓释剂治疗组各波形的潜伏期和波幅已接近健康对照组（P〉0．05）；而强制戒毒组和阿片依赖对照组的P200潜伏期与健康对照组差异非常显著（P〈0.01）；而且，与未治疗的阿片依赖对照组比较，强制戒毒组没有表现出显著的P200正常化的效应。②源定位分布表明，观察药物相关线索图片P200的源发生点健康对照组在中脑导水管周围灰质，长效纳曲酮缓释剂治疗组在扣带回后部，强制戒毒者在内侧前额叶皮质，阿片依赖对照组在大脑前额叶皮质。结论：①与强制戒毒比较，长效纳曲酮缓释剂植入能降低心理渴求，使患者的心理状况更好。②长效纳曲酮缓释剂治疗能有效改善阿片药物依赖者的神经系统功能，抑制其心理渴求的高级神经活动。     

长效纳曲酮缓释剂植入治疗阿片依赖渴求的线索诱发事件相关电位评价

目的:在前期成功研制出长效纳曲酮缓释剂植入剂型的基础上,应用线索诱发事件相关电位观察长效纳曲酮缓释剂植入治疗阿片依赖者心理渴求的神经心理学作用.方法:①对象和分组:阿片依赖综合征患者自湖北、湖南和广东等地,包括两个不同戒毒方式的组,即长效纳曲酮缓释剂治疗组和强制戒毒组,同时设计一个未戒毒的阿片依赖对照组和一个健康对照组.②方法:采用事件相关电位记录被试由图片的情绪内涵激发的脑内电活动,无需被试对所观察的图片作出外显反应,现场采集记录其观看药物相关情景线索图片和中性图片时产生的脑电事件相关电位波形.结果:①长效纳曲酮缓释剂治疗组各波形的潜伏期和波幅已接近健康对照组(P > 0.05);而强制戒毒组和阿片依赖对照组的P200潜伏期与健康对照组差异非常显著(P < 0.01);而且,与未治疗的阿片依赖对照组比较,强制戒毒组没有表现出显著的P200正常化的效应.②源定位分布表明,观察药物相关线索图片P200的源发生点健康对照组在中脑导水管周围灰质,长效纳曲酮缓释剂治疗组在扣带回后部,强制戒毒者在内侧前额叶皮质,阿片依赖对照组在大脑前额叶皮质.结论:①与强制戒毒比较,长效纳曲酮缓释剂植入能降低心理渴求,使患者的心理状况更好.②长效纳曲酮缓释剂治疗能有效改善阿片药物依赖者的神经系统功能,抑制其心理渴求的高级神经活动.     

基于dot-probe的电针干预海洛因戒断者 注意偏向的 fMRI研究

摘要 目的：研究脱毒后海洛因依赖者的注意偏向、情绪及针刺对这种注意偏向、情绪的影响。 方法：利用3.0T磁共振成像技术,采用基于“注意偏向”的dot-probe刺激模式,选取海洛因依赖者与正常对照,在电针干预前后对正性情绪、负性情绪、海洛因相关三类注意线索执行认知任务时进行血氧水平依赖性-功能性磁共振成像(BOLD-fMRI)技术扫描成像比较,选取相关脑部激活区研究激活体积与激活强度的变化。 结果：实验组对吸毒线索激活额叶背外侧区、前扣带回、顶上/顶下小叶、梭状回、右侧颞叶,电针后,左侧额叶背外侧区、左侧顶上小叶的激活体积明显减小,右侧颞叶的激活强度减弱;对正性线索电针后,背侧丘脑、左侧颞叶、额下回的激活体积明显减小;对负性线索电针后,左侧额叶背外侧区背激活体积明显减小,右侧顶下小叶激活强度增强;对照组对吸毒线索主要激活额叶背外侧区、左侧额叶腹内侧区、前扣带回、顶上/顶下小叶、梭状回、右侧纹状体、左侧背侧丘脑、颞叶,电针后,额叶背外侧区激活强度减弱;对正性线索电针后,背侧丘脑、右侧额叶背外侧区的激活强度明显减弱;对负性线索电针后,右侧额下回、右侧顶下小叶激活体积减小,额叶背外侧区、额下回激活强度明显减弱。 结论：电针干预能明显降低海洛因戒断者对吸毒线索的注意水平,明显抑制海洛因戒断者对负性情绪的感受度,提高对正性情绪的感受度,表明电针能够有效抑制戒断者对毒品线索的注意偏向,同时具有改善海洛因患者戒断后情绪状态持续低迷的作用,具有降低复吸率的潜力。     

安非他明成瘾患者情绪损伤的脑功能磁共振成像研究

目的 探讨安非他明成瘾患者情绪损伤特殊脑区的激活.方法 通过功能磁共振成像,采用统计参数图软件(SPM2)处理,t检验进行统计学分析,以像素强度阈值[T=3.11,P<0.001(uncorrected)]的像素构成统计参数图,探讨12例安非他明成瘾患者和12例健康受试者观看安非他明、悲哀、喜悦线索图片时的脑区的激活情况.结果 安非他明成瘾患者在观看安非他明线索图片时,前扣带回表现出显著激活(tmax = 11.7,P<0.001),观看高兴、悲哀线索图片时前扣带回无显著激活(P＞0.05);健康受试者在观看各类线索图片时,前扣带回均无显著激活(P＞0.05).在观看高兴、悲哀图片时,安非他明成瘾患者额叶的部分区域激活弱于健康受试者 (P＞0.05).结论 安非他明成瘾患者有较广泛的情绪损伤.     

强迫症患者fMRI Stroop试验脑功能异常

目的 应用fMRI观察强迫症(OCD)患者的脑功能异常区域。 方法 OCD患者13例(OCD组),正常对照者15名(正常对照组),按年龄、性别、受教育程度相匹配。对全部受试者行fMRI,刺激采用Stroop任务,运用SPM8软件对两组平均后的脑功能图像的激活区域进行比较分析。 结果 OCD患者需要激活更多脑区(左侧海马旁回、中央旁小叶、丘脑、距状回等)以完成相对简单的色字无干扰任务,激活减低的脑区主要有左侧前扣带回和左侧尾状核。在相对复杂的色字干扰任务时,OCD组并未出现激活高于正常对照组的脑区,激活减低的脑区主要有双侧眶额叶、左侧前扣带回以及左侧尾状核。 结论 OCD患者可能存在眶额叶、前扣带回、尾状核等区域的功能异常,这些脑区功能异常可能在OCD发病机制方面发挥作用。     

fMRI观察美沙酮维持治疗时间对海洛因依赖者毒品线索反应的影响

目的 探讨美沙酮维持治疗（MMT）时间对海洛因依赖者在毒品线索下主观渴求及大脑反应的影响。方法 收集15例接受连续MMT≤1年的海洛因依赖者（≤1年组）与11例人口学特征相匹配且连续接受MMT 2~3年的海洛因依赖者（2~3年组）,采用3.0T MR仪采集功能数据,试验设计采用事件相关的毒品线索诱导渴求设计,应用SPM 8及SPSS 16.0软件进行数据处理。结果 在毒品线索下,两组被试渴求变化程度差异无统计学意义（t=2.9,P>0.05）。与2~3年组相比,≤1年组双侧尾状核激活明显增强。控制年龄、受教育程度、每日吸烟量和海洛因使用情况,右侧尾状核激活程度与美沙酮使用总剂量和总时间分别呈负相关（r=-0.54,P=0.01;r=-0.51,P=0.01）,左侧尾状核激活程度与美沙酮使用总剂量呈负相关（r=-0.60,P=0.003）。结论 在海洛因渴求明显改善之前,接受MMT 2~3年的海洛因依赖者可能通过调节尾状核功能来改善其大脑渴求反应。     

缺陷型及非缺陷型精神分裂症执行功能障碍的fMRI初步研究

目的比较缺陷型、非缺陷型精神分裂症患者与执行控制功能有关的脑区激活情况,探讨精神分裂症执行功能障碍的表现规律与相应脑机制。方法缺陷型、非缺陷型精神分裂症患者各6名及与之匹配的正常对照组,在执行参量设计的倒数n项实验时进行全脑BOLD-fMRI扫描。数据处理时采用单因素方差分析进行差异检测,分离出激活强度随记忆负荷增加而增强的脑区（执行加工相关脑区）。结果正常组执行加工相关脑区主要为左侧前额叶及顶叶后部皮层,两精神分裂症组前额叶激活体积相对较小,而且涉及更多皮层下结构。其中非缺陷型组双侧前额皮层均显著激活,且背外侧前额叶（BA9/46区）激活数目较正常组明显增多。而缺陷型组无论是前额皮层激活的脑区分布范围还是体积均显著减少于其他两组。结论精神分裂症患者存在以前额叶功能失调为基础的执行功能障碍。不同亚型的患者前额叶功能失调的机制不同：缺陷型患者前额叶可能存在特异性损伤,而非缺陷型患者主要表现为前额叶的生理低效能。     

海洛因成瘾者渴求任务对大型脑网络影响的功能磁共振研究

目的探讨海洛因成瘾者在毒品线索任务下主观渴求及大型脑网络特征。材料与方法 21例海洛因成瘾者与33例年龄、性别、教育程度相匹配的健康者,纳入该功能磁共振成像(functional MRI,fMRI)研究。应用Matlab、SPM8、DPABI及SPSS 20.0软件进行数据分析。首先,基于静息态fMRI的数据获取任务负相关网络及任务正相关网络;然后,进行事件相关毒品线索下的任务态fMRI,并对其大脑网络的差异行组间比较,继而与其心理行为学行相关性分析。结果海洛因成瘾者在毒品线索刺激任务后渴求程度显著性大于任务前(t=1.19,P=0.00);正常对照组此项对比无显著性差异(t=0.031,P=0.75)。与正常组相比,海洛因成瘾在毒品线索任务下,任务负相关网络(默认网络)及任务正相网络(突显网络、执行控制网络、高级视觉网络、视觉空间网络、基底核团)激活强度均显著增强(P<0.05,AphaSim校正),而任务正相关网络的初级视觉网络激活程度显著降低(P<0.05,AphaSim校正)。控制头动因素,海洛因成瘾者大脑基底核团激活强度与观看毒品相关线索后的渴求程度成正相关关系(r=0.56,P=0.01)。结论海洛因成瘾者心理渴求及在毒品线索条件下任务相关正、负大型脑网络功能均存在明显异常。     

轻度认知障碍患者记忆力的功能磁共振研究

目的为探索早期诊断阿尔茨海默病 (AD)的方法 ,将神经心理测定和功能磁共振 (fMRI)检查相结合 ,了解轻度认知障碍 (MCI)患者在记忆方面的脑功能情况。方法 9例MCI患者和 9名正常对照在进行无意义图形记忆和再认时行fMRI检查 ,对反应时间、正确率和fMRI的脑激活图进行比较。结果患者的反应时间比正常对照明显延长 (P <0 0 1) ,正确率显著降低 (P <0 0 0 1)。脑激活图显示 ,与对照相比 ,在记忆编码时 ,患者主要在左侧前额叶背外侧和海马旁回、以及以右侧为主的后部脑区激活减弱 ,记忆提取时 ,在双侧前额叶背外侧 ,左侧海马旁回和前扣带回 ,以及后部脑区激活减弱。结论MCI患者的记忆功能已有损害。记忆功能的fMRI检查与认知神经心理学的联合研究能为早期诊断AD提供有力的参考依据。     

慢性腰背痛患者的脑静息态功能磁共振成像

目的 观察慢性腰背痛患者静息状态下的脑功能活动特点。方法 对15例慢性腰背痛患者及16名健康对照组受试者进行静息态脑功能磁共振成像,应用局部一致性(ReHo)方法处理fMRI数据,观察脑功能成像的差异。 结果 与健康对照组相比,慢性腰背痛患者双侧额叶、右侧枕叶、双侧前扣带回等脑区的ReHo值升高;中脑导水管周围灰质、臂旁核、脑桥、左侧顶叶后部、双侧扣带回后部及邻近楔前叶的ReHo值减低。结论 静息状态下慢性腰背痛患者多个脑区的功能活动存在异常,可能与机体对持续疼痛刺激的适应性增加、内源性镇痛系统活动减低等有关。     

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.