脑梗死患者血浆ICAM-1、CD62p、CD63的动态变化及其临床意义

目的 探讨脑梗死患者血浆细胞间黏附分子（ICAM-1）、血小板表面P选择素（CD62p）、溶酶体颗粒糖蛋白53（CD63）的动态变化及其临床意义。方法 用流式细胞仪观察60例脑梗死患者发病3d、7d、14d外周血中ICAM-1、CD621，CD63的变化，并与20名健康者进行比较。结果 脑梗死3d、7d上述3项指标明显高于14d及正常对照组（均P〈0．05），而3d与7d间则差异不显著（P〉0．05）；ICAM-1与CD62p、CD63间无相关关系（r=0．1385、0．1632，均P〉0.05）；CD62p与CD63呈显著正相关（r=0.746，P〈0．05）；3项指标与临床神经功能缺损程度评分无相关性（r=0.1462、0.2145、0．368，均P〉0．05）。结论 脑梗死后ICAM-1表达增强，介导了粒细胞与脑血管内皮发细胞间的黏附，同时血小板表面CD62p、CD63表达增强，反映了血小板的活化程度与功能状态，评介导了血小板与中性粒细胞及内皮细胞间的黏附，促进了脑梗死的发生和发展，加重了脑组织的损伤。     

急性脑梗死及并发肺部感染患者血清C反应蛋白水平的变化

目的 探讨急性脑梗死及其并发肺部感染患者血清C反应蛋白（CRP）水平的变化及其意义。方法 采用免疫散射比浊法测定20例健康体检者（对照组）和55例脑梗死患者（按梗死面积分为大、中、小3组）血清CRP含量，中等面积梗死患者据是否合并肺部感染分组，于入院7d后复测CRP。结果 CRP含量为大面积梗死组〉中面积梗死组〉小面积梗死组〉对照组，组间差异均具显著性（P〈0．05～0．01）。中面积梗死组，1周后并发感染者较入院1d时CRP含量增高，未并发感染者降低（均为P〈O．01）；中面积梗死者，入院时CRP含量虽无显著性差异（P〉0．05），1周后感染者较未感染者CRP含量显著升高（P〈0．01）。结论 血清CRP含量反映脑梗死严重程度，动态观察对了解有无合并感染的病情变化有帮助。     

脑梗塞患者血小板数目,体积和功能的变化

目的研究脑梗塞患者血小板数目，体积和功能变化。方法随机选择９７例脑梗塞患者测定急性期和恢复期血小板数目，体积，粘附和聚集功能，３０例健康人作为正常对照组。结果脑梗塞急性期血小板体积，粘附率和聚集率均高于对照组（Ｐ＜０．０１）；而血小板数目和解聚率均低于对照组（Ｐ＜０．０１）。恢复期血小板体积，粘附率，５分钟聚集率虽比急性期降低，但仍高于对照组（Ｐ＜０．０１），而血小板数目及解聚率与对照组相似。大面积梗塞血小板，粘附率和最大聚集率均高于小面积梗塞（Ｐ＜０．０１）；多元逐步回归分析血小板体积，最大聚集率与脑梗塞容积呈正相关。结论脑梗塞患者血小板消耗，体积增大，功能亢进，血小板体积与最大聚集率和梗塞面积有关     

脑缺血对大鼠循环铁的影响

目的 探讨脑缺血对大鼠循环铁的影响。方法 雄性Wistar大鼠随机分为脑缺血1、3、7、28d和假手术组；脑缺血组结扎双侧颈总动脉造成大鼠脑缺血，假手术组仅分离出双侧颈总动脉但不结扎；采用比色法测定大鼠血清铁含量；用放射免疫法测定血清铁蛋白含量。结果脑缺血1d大鼠血清铁含量低于假手术组（P〈0．05）；缺血3d血清铁含量虽低于假手术组，但无统计学意义（P〉0．05）；之后随着缺血时间的延长血清铁含量呈增高趋势，缺血28d时显著高于假手术组（P〈0．01）。脑缺血1d大鼠血清铁蛋白含量与假手术组比较无明显差别（P〉0．05）；缺血3d组低于假手术组（P〈0．05）；之后随着缺血时间的延长血清铁蛋白含量呈增高趋势，在缺血7、28d时均高于假手术组（P〈0．05）。结论脑缺血早期引起大鼠循环铁降低，晚期升高；循环铁的改变可能参与了脑铁含量升高和神经元铁沉积过程。     

脑梗塞患者颈内静脉血和肘静脉血的血小板聚集功能比较

我们比较了１０例大面积脑梗塞（Ａ组）和１０例小面积脑梗塞（Ｂ组）的颈内静脉血和时静脉血的血小板聚集功能。（１）两组颈内静脉血和时静脉血的血小板聚集功能均较正常人增强；（２）Ａ组颈内静脉血的血小板聚集功能较时静脉血的血小板聚集功能明显增强，而Ｂ组则无此规律；（３）二组颈内静脉血的血小板聚集功能比较发现Ａ组更为亢进，而二组时静血的血小板聚集功能相比显著差异。本文认为血小板聚集功能异常可能与大面积梗塞的发生发展有一定关系。     

颅脑损伤急性期血小板参数的变化及其与继发性脑损害的关系

目的探讨颅脑损伤后患者血小板（PLT）参数的变化及其与继发性脑损害的关系。方法伤后24h内入院的非手术治疗的颅脑损伤患者163例，分别于伤后1d、3d及14d三个时间段采血测定外周血PLT数量、PLT平均体积（MPV）、PLT体积分布宽度（PDW）；于入院时、伤后1d、伤后7d进行GCS评分，并通过CT计算脑出血量及脑水肿体积；伤后6个月进行GOS预后评分。分析上述指标与PLT计数、MPV和PDW之间的关系。同时测定40例健康体检者外周血的PLT计数、MPV和PDW作为对照。结果伤后1d及3dPLT计数较对照组明显下降，MPV和PDW值明显增加（P〈0．05）；伤后14dPLT计数、MPV和PDW值均恢复正常；GCS〈8分者PLT计数明显低于GCS≥8分者，而MPV和PDW则明显高于GCS≥8分者（P〈0．05）；脑水肿体积伤后逐渐扩大，至伤后7d时水肿体积最大（P〈0．05）；脑水肿体积与PLT计数呈负相关关系（r＝-0．238，P〈0．05），与MPV和PDW的值呈正相关关系（r＝642、0．593，P〈0．05）；GOS评分与外周血PLIT计数呈正相关（r=0．883，P〈0．05），而与MPV和PDW值呈负相关（r=-0．235、－0．267，P〈0．05）。结论本结果提示，颅脑损伤后PLT参数的变化可能与伤后继发性脑损害有关；检测其变化有助于对颅脑损伤伤情、预后的判断，并为颅脑损伤治疗提供新思路。     

急性脑梗死患者活化血小板表达血小板内皮细胞黏附分子-1、P-选择素的动态变化

目的观察急性脑梗死患者血小板表达血小板内皮细胞黏附分子-1(PECAM-1)、P-选择素的动态变化。方法采用全血流式细胞术测定35例急性脑梗死患者不同时间血小板PECAM-1、P-选择素的表达水平,并与30名健康对照比较。结果脑梗死患者24h内血小板表达PECAM-1、P-选择素(分别为78.35±10.48,7.75±3.04)明显高于健康对照组(分别为48.89±10.84,2.18±0.83,均P<0.01);P-选择素于24h、PECAM-1于48h达高峰,后缓慢下降,至14d仍高于健康对照组(分别为P<0.05,P<0.01)。48h内血小板PECAM-1与梗死体积大小呈正相关,与NIHSS评分无关;P-选择素与梗死体积大小和NIHSS评分呈正相关。14dNIHSS评分与血小板PECAM-1有负相关,与P-选择素无关。结论血小板表达的PECAM-1、P-选择素参与了脑梗死急性期的不同病理生理过程。     

脑梗塞患者血小板活化部位的探讨

采用ＦＣＭ检测脑梗塞患者（１６例腔梗，１８例大面积梗塞）颈内静脉（Ａ）和肘静脉（Ｂ）的血小板ＧＭＰ－１４０，ＧＰ５３和ＧＰⅡｂ／Ⅲａ。结果：脑梗塞组Ａ和Ｂ血中三种ＧＰ阳性表达率均明显高于非脑血管疾病（ＣＶＤ）组和健康组Ｂ血（Ｐ＜０．０１～０．００１）；脑梗塞组Ａ血明显高于同组Ｂ血（Ｐ＜０．０５～０．００５），Ａ／Ｂ比值为１．２４～２．５２，而非ＣＶＤ组Ａ与Ｂ血之间阳性率无显著差异，Ａ／Ｂ比值≤１．０６；大面积梗塞组Ａ血阳性率高于腔梗组Ａ血（Ｐ＜０．０５），但两组Ｂ血无显著差异。提示脑梗塞急性期血小板主要在脑循环中活化，测定Ａ血指标较测定Ｂ血更能敏感地反映脑梗塞时血小板的活化程度和功能状态。     

脑梗死患者血小板计数与体积的变化

目的　脑梗死患者血小板计数与体积的变化。方法　随机选择 10 0例脑梗死患者测定血小板数目与体积 ,2 1例健康人作为正常对照组。结果　脑梗死患者的MPV均普遍大于正常对照组 (P <0 0 1) ,而PLT低于正常对照组 (P <0 0 5 )。大面积脑梗死MPV大于小面积及腔隙性梗死 (P <0 0 1)。腔隙性梗死PLT高于小面积及大面积梗死 (P <0 0 1)。结论　在脑梗死患者中 ,血小板计数与体积的变化具有显著性意义 ,值得进一步研究。     

奥扎格雷对进展性脑血栓形成患者血小板活化功能变化的影响

目的：探讨奥扎格雷对进展性脑血栓形成患者血小板活化功能变化的影响。方法：68例颈内动脉系统进展性脑血栓形成患者随机分为奥扎格雷治疗组和丹参治疗组。应用流式细胞仪和单克隆抗体动态测定CD62p、CD63，行血小板活化指标和临床疗效对照观察。结果：进展性脑血栓形成患者发病早期（24h内）CD62p、CD63值较对照组显著增高（P〈0．001）。患者经丹参治疗后，血小板表达CD62p、CD63缓慢下降，14d时其值仍高于健康对照组（P〈0．05）。经奥扎格雷治疗后血小板表达CD62p、CD63快速下降，至14d时已接近健康对照组（P〉0．05）。奥扎格雷组临床疗效明显优于丹参组。结论：进展性脑血栓形成患者中血小板表达CD62p、CD63明显增加，并与病情转归相关。奥扎格雷治疗后可使CD62p、CD63快速下降、提高临床疗效。     

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.     

Special Pharmacokinetic Considerations in Children

Summary: Pediatric patients have greater degrees of pharmacokinetic variability and unpredictability than adults. This variability results from the effects of pharmacogenetics, age and growth, prior and current comedication, and disease. Newborns with seizures have the least predictable dosage requirements, and their needs change as drug-eliminating mechanisms mature in the neonatal period. Infants have the highest relative capacities to eliminate antiepileptics of any age group and require the largest relative doses. In addition to age-related trends, children demonstrate the same drug-specific, pharmacokinetic phenomena that adults do, including nonlinear phenytoin elimination, nonlinear valproate binding, and autoinduction of carbamazepine. Intercurrent illness and drug interactions further modify the age-related pharmacokinetic patterns in children and make dosage requirements even more unpredictable. Recent studies have shown that febrile illness can affect drug elimination, sometimes decreasing drug levels by 50% or more. Intermittent treatment with benzodiazepines administered either orally or rectally can be an important adjunct and help minimize this type of problem for children with marginally controlled epilepsy. Intermittent benzodiazepines are also helpful for children who have febrile seizures and who need only occasional antiepileptic protection.