盐酸戊乙奎醚用于烧伤患儿麻醉前用药的临床研究

目的对盐酸戊乙奎醚作为烧伤患儿手术麻醉前用药进行随机观察比较。方法将40例烧伤手术患儿随机分成两组,盐酸戊乙奎醚组（A组）和阿托品组（B组）,每组20例。分别于入室后静注盐酸戊乙奎醚0．01mg／kg或阿托品0．01mg／kg,行咪唑安定、氯胺酮静脉复合麻醉,记录用药前、用药后10、20、30min及输注氯胺酮后5、15min的HR、MAP、SpOz、体温的变化,并观察40min内口腔、颜面潮红和镇静程度。结果与B组比较A组HR较稳定,B组（92．2±16．0）次／分、A组（77．3±11．4）次／分（P〈0．05）。A组患儿体温轻度变化,B组患儿体温升高明显（P〈0．01）。两组间比较口干、颜面潮红和镇静程度差异均无统计学意义。结论盐酸戊乙奎醚具有显著的HR稳定、体温变化小的作用特点,对避免增快HR、体温升高的是烧伤患儿较理想的麻醉前用药。     

患儿口服可乐定术前用药的效果

目的评价患儿口服可乐定术前用药的效果。方法择期行脑室腹腔分流术患儿45例，年龄2～8岁，体重10～27kg，随机分为3组，每组15例，D组、C2组和C4组分别于麻醉前90min口服安定0．2mg／kg、可乐定2、4μg／kg。记录患儿术前镇静评分、与父母分开接受程度评分、面罩接受程度评分、术后镇痛、镇静情况及围术期不良反应的发生情况。结果与D组相比，C2组和C4组术前镇静、与父母分开接受程度、面罩接受程度的评分较高，术后镇痛补救率、寒颤发生率较低（P〈0．05）；与C2组相比，C4组术前镇静评分较高（P〈0．05）。结论患儿麻醉前90min口服可乐定2μg／kg术前用药可产生良好的镇静、抗焦虑和术后镇痛的效果，且副作用小。     

艾司氯胺酮用于患儿术前镇静的半数有效剂量

目的 应用改良序贯法研究艾司氯胺酮在患儿术前镇静的半数有效剂量（ED50）。
方法 选择2021年1—2月择期全麻下行短小手术（＜1 h）的患儿23例,男12例,女11例,年龄2～6岁,ASA Ⅰ或Ⅱ级。术前于手术准备间内静脉注射艾司氯胺酮,待起效后与家属分离,行麻醉诱导,评估用药后镇静效果。采用改良序贯法测定其用于患儿术前有效镇静的剂量,起始剂量为0.5 mg/kg,剂量梯度设定为0.05 mg/kg,当患儿Ramsay镇静评分≥2分、Funk神经行为评分≥3分且麻醉诱导评分为4分时为镇静成功（阳性）,则下一例患儿在上一例患儿给药剂量基础上降低0.05 mg/kg,反之任一指标达不到相应评分时则为镇静失败（阴性）,下一例患儿在上一例患儿给药剂量基础上升高0.05 mg/kg,直至出现连续7个阳性和阴性拐点交替之后研究结束。采用概率单位回归分析法计算其术前用药的ED50、95%有效剂量（ED95）和95%可信区间（CI）。记录患儿术后苏醒时间和麻醉期间恶心呕吐、喉痉挛、支气管痉挛、呼吸道梗阻、呼吸抑制等不良反应的发生情况。
结果 艾司氯胺酮用于患儿术前有效镇静的ED50为0.580 mg/kg（95%CI 0.559～0.602 mg/kg）,ED95为0.618 mg/kg（95%CI 0.598～0.678 mg/kg）。患儿无一例发生恶心呕吐、喉痉挛、支气管痉挛、呼吸道梗阻、呼吸抑制等不良反应。
结论 艾司氯胺酮静注用于2~6岁患儿入手术室前镇静的ED50为0.580 mg/kg（95%CI 0.559～0.602 mg/kg）。     

小儿术前不同用药方法对围术期应激反应的影响

目的探讨术前不同用药方法对患儿围术期镇静抗焦虑程度的影响。方法48例下腹部手术患儿,术前用药按苯巴比妥钠2mg/kg(对照组)、咪唑安定0.08mg/kg(研究Ⅰ组)肌注及咪唑安定0.5mg/kg加50%葡萄糖容积为0.2ml/kg(研究Ⅱ组)口服,随机分组对比分析,测定三组给药前后平均动脉压(MAP)和心率(HR)的变化、患儿接受率、镇静催眠效果满意度以及血清皮质醇(Cs)、血糖(BS)浓度变化。结果三组给药前后MAP、HR的变化无显著性差异。研究Ⅱ组患儿接受率为87.50%,镇静催眠效果满意度为81.25%,以及血清Cs、BS浓度下降程度均明显高于其他两组(P<0.05,P<0.01)。结论口服咪唑安定易于接受,镇静作用佳,可作为良好的小儿术前镇静用药。     

术前美托洛尔或咪唑安定对全麻诱导丙泊酚用量和血流动力学的影响

目的观察术前口服美托洛尔和肌注咪唑安定对麻醉诱导丙泊酚用量及血流动力学的影响。方法拟全麻行择期手术病人（ASAI-Ⅱ级）60例,随机分为美托洛尔组（Met组）、咪唑安定组（Mid组）和苯巴比妥钠组（Phe组）各20例,三组分别口服美托洛尔50mg、肌注咪唑安定0．04mg／kg、肌注苯巴比妥钠0．1g。以30mg·kg^-1·h^-1恒速推注丙泊酚直至病人入睡,随后静注芬太尼3μg／k,维库溴铵0．1mg／kg,辅助通气3min后进行气管插管。记录丙泊酚用量、入室、诱导前后、插管前后平均动脉压（MAP）和心率（HR）。结果Met组、Mid组、Phe组丙泊酚用量分别为1．36mg／kg±0．22mg／kg、1．40mg／kg±0．08mg／kg、1．61mg／kg±0．23mg／kg,与Phe组相比,Met组和Mid组丙泊酚用量减少（P〈0．01）。血流动力学变化：插管后组间对比Met组和Mid组MAP较Phe组低（P〈0．01）;插管后Mid组和Phe组HR基础值明显升高（P〈0．01或P〈0．05）,而Met组无明显差异（P〉0．05）;插管后组间对比Met组和Mid组HR均比Phe组慢（P〈0．01）。结论术前口服美托洛尔或肌注咪唑安定与肌注苯巴比妥钠相比,均能减少丙泊酚诱导用量,但美托洛尔能更有效抑制血流动力学波动。     

小儿心脏手术前口服咪唑安定和氯胺酮混合液的临床观察

选择先天性心脏病小儿３５例，随机分为观察组（２０例）和吗啡组（１５例），观察组术前口服咪唑安定（０．５ｍｇ／ｋｇ）和氯胺酮（１２ｍｇ／ｋｇ）混合液，吗啡组肌肉注射吗啡（０．２ｍｇ／ｋｇ）。结果显示：观察组９０％的小儿易于与父母分离，与吗啡组（６６．７％）无明显差异（Ｐ＞０．０５）。达Ａ、Ｂ两级镇静者，观察组为８０％，吗啡组为４６．７％，两组差异非常显著（Ｐ＜０．０１）。观察组有８５％小儿静脉穿刺时合作或无反应，吗啡组仅４０％，两组差异显著（Ｐ＜０．０５）。两组麻醉诱导前和诱导时脉搏氧饱和度均正常，也未发生喉痉挛、缺氧、恶心和呕吐等井发症。术中血流动力学稳定，心脏自动复跳率、术后清醒时间、气管拔管时间和术后麻醉有关并发症，两组也无明显差异（Ｐ＞０．０５）。表明小儿心脏手术前口服咪唑安定和氯胺酮混合液，镇痛和镇静效果良好，血流动力学稳定，不增加围术期并发症，证明了术前口服咪唑安定和氯胺酮混合液在先天性心脏病小儿的安全性和可靠性。     

咪唑安定对氯胺酮麻醉诱导的影响

目的　观察咪唑安定对氯胺酮麻醉诱导的影响。方法　 2 4只健康家兔随机分为三组 :咪唑安定组 (M组 ) ,咪唑安定 1mg/kg ,静注 ;氯胺酮组 (K组 ) ,氯胺酮 5mg/kg ,静注 ;咪唑安定加氯胺酮组 (MK组 ) ,咪唑安定 1mg/kg加氯胺酮 5mg/kg ,静注。注药前后监测EEG频谱边界频率(SEF)、双频指数 (BIS)、中位频率 (MF)、δ比值 [δ/ (α +β) ]、心率 (HR)、平均动脉压 (MAP)和精神症状。采颈动脉血分析血气。结果　给药后三组的SEF、MF和BIS均下降。δ比值升高 (P <0 0 1) ,且MK组的改变与其他两组比有显著性差异 (P <0 0 1)。K组给药后MAP从 (14 2± 1 3)kPa上升到 (16 4± 0 8)kPa(P <0 0 1) ,HR从 (2 2 8± 17)次 /分上升到 (2 35± 11)次 /分 (P <0 0 5 ) ;M组给药后MAP从 (14 3± 1 6 )kPa下降至 (10 5± 1 5 )kPa(P <0 0 1) ;MK组无明显改变。K组与MK组用药后PaO2 均明显下降 (P <0 0 1) ;但两组间无显著性差异。MK组精神症状较K组明显减轻(P <0 0 1)。结论　咪唑安定可加强氯胺酮的中枢抑制作用 ,减轻精神症状 ,且不增强氯胺酮的呼吸抑制作用。氯胺酮与咪唑安定复合应用于麻醉诱导是合理的     

咪唑安定复合氯胺酮用于小儿基础麻醉的临床研究

目的　研究咪唑安定复合氯胺酮肌注或口服用于小儿基础麻醉的可能性。方法　 80例 1～ 8岁、ASAⅠ～Ⅱ级的患儿随机等分成四组 :A组 ,肌注氯胺酮 6mg/kg ;B组 ,肌注氯胺酮 4mg/kg +口服咪唑安定 0 2mg/kg ;C组 ,口服氯胺酮 5mg/kg +咪唑安定 0 5mg/kg ;D组 ,口服咪唑安定0 7mg/kg。观察各组麻醉诱导效果、循环呼吸变化及不良反应。 结果　 (1)B组与A组相比 ,起效更快 ,术中不良反应发生率更低 (P <0 0 5 ) ,而麻醉诱导效果无明显差异 (P >0 0 5 ) ;(2 )C组与A组相比 ,小儿更为合作 (P <0 0 1) ,HR增加不明显 (P >0 0 5 ) ,但起效更慢 (P <0 0 5 ) ,镇静程度不如后者 (P <0 0 5 ) ,但 80 %的患儿尚能与父母分离。结论　咪唑安定复合氯胺酮肌注用于小儿麻醉诱导要优于单纯肌注氯胺酮 ,而咪唑安定复合氯胺酮口服仍不失为一种可行的诱导方法。     

咪唑安定对氯胺酮诱导的c-fos基因在大鼠后扣带回皮质区表达的影响

目的 观察咪唑安定对氯胺酮诱导的c-fos基因在大鼠后扣带回皮质区表达的影响，探讨咪唑安定预防或减轻氯胺酮所致精神症状及神经损害的机制。方法 雄性Wistar大鼠30只，随机分为生理盐水5ml组、咪唑安定15mg／kg组、氯胺酮100mg／kg组、咪唑安定15mg／kg加氯胺酮100mg／kg组、氯胺酮100mg／kg加咪唑安定15mg／kg组。咪唑安定与氯胺酮两药间隔15min给药，所用药物均由腹腔注射。各组动物于用药后2h开胸经心脏灌流脑固定，用免疫组织化学方法检测后扣带回皮质区c-fos蛋白的表达，用彩色病理图像分析系统测定c-fos阳性细胞的百分率和阳性细胞的密度。结果氯胺酮可明显诱导c-fos蛋白在大鼠后扣带回皮质区的表达；咪唑安定自身不能诱导c-fos的表达；咪唑安定预处理可显著抑制氯胺酮诱导的c-fos在这一区域的表达；先用氯胺酮后给予咪唑安定仅能部分抑制c-fos的表达。结论 咪唑安定预处理可抑制氯胺酮诱导的c-fos基因在大鼠后扣带回皮质区的表达，这可能是其预防或减轻氯胺酮所致精神症状和神经损害的机制之一。     

小儿术前口服或肌注盐酸戊乙奎醚和咪唑安定混合液的比较

目的观察盐酸戊乙奎醚（长托宁）和咪唑安定混合液作为小儿麻醉前用药口服给药和肌肉注射给药的优缺点。方法选择小儿择期手术60例,随机均分为观察组和对照组。观察组术前口服盐酸戊乙奎醚0.03mg/kg、咪唑安定0.5mg/kg和500g/L葡萄糖混合液,对照组肌肉注射盐酸戊乙奎醚0.01mg/kg和咪唑安定0.1mg/kg混合液。观察给药时反应,入手术室时的镇静情况,用药前后各时段患儿的BP、HR、RR、SpO2变化及术后精神状态和有无并发症。结果观察组93%的患儿给药时合作,对照组仅10%（P〈0.01）。观察组62%患儿给药30min后入睡,对照组为87%（P〈0.05）。术后随访产生恐惧和抵触情绪的患儿观察组为10%,对照组为53%（P〈0.05）。结论口服盐酸戊乙奎醚和咪唑安定混合液作为小儿麻醉前用药安全可靠,比肌注盐酸戊乙奎醚和咪唑安定混合液更易被患儿接受。     

Presenteeism and Absenteeism Before and After Total Hip and Knee Arthroplasty

BackgroundAbsenteeism is costly, yet evidence suggests that presenteeism—illness-related reduced productivity at work—is costlier. We quantified employed patients’ presenteeism and absenteeism before and after total joint arthroplasty (TJA).MethodsWe measured presenteeism (0-100 scale, 100 full performance) and absenteeism using the World Health Organization’s Health and Work Performance Questionnaire before and after TJA among a convenience sample of employed patients. We captured detailed information about employment and job characteristics and evaluated how and among whom presenteeism and absenteeism improved.ResultsIn total, 636 primary, unilateral TJA patients responded to an enrollment email, confirmed employment, and completed a preoperative survey (mean age: 62.1 years, 55.3% women). Full at-work performance was reported by 19.7%. Among 520 (81.8%) who responded to a 1-year follow-up, 473 (91.0%) were still employed, and 461 (88.7%) had resumed working. Among patients reporting at baseline and 1 year, average at-work performance improved from 80.7 to 89.4. A Wilcoxon signed-rank test indicated that postoperative performance was significantly higher than preoperative performance (P < .0001). The percentage of patients who reported full at-work performance increased from 20.9% to 36.8% (delta = 15.9%, 95% confidence interval = [10.0%, 21.9%], P < .0001). Presenteeism gains were concentrated among patients who reported declining work performance leading up to surgery. Average changes in absences were relatively small. Combined, the average monthly value lost by employers to presenteeism declined from 15.3% to 8.3% and to absenteeism from 16.9% to 15.5% (ie, mitigated loss of 8.4% of monthly value).ConclusionAmong employed patients before TJA, presenteeism and absenteeism were similarly costly. After, employed patients reported increased performance, concentrated among those with declining performance leading up to surgery.     

The German emergency and disaster medicine and management systemdhistory and present

As well for optimized emergency management in individual cases as for optimized mass medicine in disaster management, the principle of the medical doctors approaching the patient directly and timely, even close to the site of the incident, is a long-standing marker for quality of care and patient survival in Germany. Professional rescue and emergency forces, including medical services, are the “Golden Standard” of emergency management systems. Regulative laws, proper organization of resources, equipment, training and adequate delivery of medical measures are key factors in systematic approaches to manage emergencies and disasters alike and thus save lives. During disasters command, communication, coordination and cooperation are essential to cope with extreme situations, even more so in a globalized world. In this article, we describe the major historical milestones, the current state of the German system in emergency and disaster management and its integration into the broader European approach.     

Differences in Osteocyte Density and Bone Histomorphometry Between Men and Women and Between Healthy and Osteoporotic Subjects

Bone defects related to osteoporosis develop with increasing age and differ between males and females. It is currently thought that the bone remodeling process is supervised by osteocytes in a strain-dependent manner. We have shown an altered response of osteocytes from osteoporotic patients to mechanical loading, and osteocyte density is reduced in osteoporotic patients, which might relate to imperfect bone remodeling, leading to lack of bone mass and strength. Hence, information on osteocyte density will contribute to a better understanding of bone biology in males and females and to the assessment of osteoporosis. Osteocyte density as well as conventional histomorphometric parameters of trabecular bone were determined in cancellous iliac crest bone of healthy postmenopausal women and men and of osteoporotic women and men. Osteocyte density was higher in healthy females than in healthy males and lower in osteoporotic females than in healthy females. Bone mass was reduced in osteoporotic patients, both male and female. In females, trabecular number was reduced, whereas in males, trabecular thickness was reduced and eroded surface was increased. There were no correlations between the parameter groups bone architecture, bone formation, bone resorption, and osteocyte density. These results are consistent with impaired osteoblast function in osteoporotic patients and with a different mechanism of bone loss between men and women, in which osteocyte density might play a role. The reduced osteocyte numbers in female osteoporotic patients might relate to imperfect bone remodeling leading to lack of bone mass and strength. M. G. Mullender and S. D. Tan contributed equally to this work.     

肝内胆管囊腺瘤和囊腺癌的CT、MRI及病理表现

目的探讨肝内胆管囊腺瘤和囊腺癌的CT、MRI和病理特点。方法回顾性分析经手术病理证实的6例肝内胆管囊腺瘤和2例肝内胆管囊腺癌的影像及临床病理资料，将病变的影像表现与其病理大体形态及组织学表现作对照分析。结果6例肝内胆管囊腺瘤，女4例、男2例；2例肝内胆管囊腺癌均为女性病人；8例病人平均年龄55岁。所有病灶均表现为多房囊性肿块，肿瘤囊腔各分房内常为多种液体成分，在CT上可表现为不同密度、在MRI上可表现为不同信号强度。囊内出现多发大小不等的壁结节在胆管囊腺癌内更常见，囊内有分隔但无壁结节只见于胆管囊腺瘤。在7例CT扫描中，4例胆管囊腺瘤和1例胆管囊腺癌可见囊壁或分隔上钙化，囊壁、囊内分隔及囊内结节均为轻、中度延迟增强。肿瘤中出现卵巢样间质见于3例胆管囊腺瘤和1例胆管囊腺癌，且均为女性病人。结论肝内胆管囊腺瘤和囊腺癌是肝脏不常见的囊性肿瘤，影像上多房、囊内有分隔且各分房囊内密度或信号不一致，高度提示肝内胆管囊腺瘤或囊腺癌的诊断，如囊内伴有多发大小不等的结节，则进一步提示囊腺癌的可能。但影像学表现不能区分肿瘤中有无卵巢样间质。