心肺复苏后脑功能障碍与高压氧治疗

Neumar等[1]2008年提出的心脏骤停后综合症(post cardiac arrest syndrome,PCAS)是一个独特而复杂的病理生理学过程,它包括:(1)心脏骤停后脑损伤,(2)心脏骤停后心肌功能障碍,(3)全身性缺血/再灌注反应,(4)持续诱因性病变(引起心脏骤停的未解除的病理过程).日渐增多的研究表明,心脏骤停后综合征的每个组份均具有潜在的可治疗性. 一、心脏骤停后脑功能障碍 心脏骤停(cardiac arrest,CA)后脑功能障碍是死亡的常见原因.CA复苏后脑血流动力学变化是影响脑复苏的重要因素,脑灌流不全影响CA复苏后脑功能恢复.正常血压下CA(≥10 min)复苏后脑灌流不全的再灌流过程分为4期[2]:(1)多灶性无再灌流:CA复苏后即刻发生,它与脑微循环改变和低灌流压有关,通过升高血压而提高脑灌流压,此期是可以逆转的;(2)短暂全脑反应性充血:持续15 ～ 30 min,可能与脑血管麻痹有关,同时颅内压(intracranial pressure,ICP)轻微短暂升高;(3)延迟性、持续全脑多灶低灌流:CA后2～12 h明显,此期ICP维持正常.     

不同深低温停循环方法对脑组织ATP酶的影响

目的：观察深低温停循环对脑组织ATP酶活力及结构的影响。方法：18只实验犬随机分为3组，深低温停循环（DHCA）组，DHCA＋逆行脑灌注（RCP）组，DHCA＋顺行间断脑灌注（IACP）组。降温至18℃后停循环90min，在停循环前、后及再循环后留取血液标本作ATP酶活力和乳酸含量测定。手术结束时取海马组织作透射电镜检查。结果：停循环后，DHCA和RCP组ATP酶活力值显著降低，乳酸含量显著升高；IACP组ATP酶活力值无显著差异，乳酸含量仅在停循环后45min时显著升高。结论：DHCA时间较长时，脑组织会发生缺血缺氧性损伤；RCP对脑组织有保护作用，但易发生神经细胞水肿；IACP的脑保护效果较为理想。     

异氟烷不同时间干预对大鼠不同程度全脑缺血的保护作用及其神经递质机制的探讨

目的评价异氟烷3种干预方式的脑保护效能,为临床提供脑缺血保护依据。方法雄性SD大鼠随机分为假手术组、对照组、预处理组、保护组、复苏组,后4组按缺血时间再分为缺血10min、15min及20min3个亚组。建立清醒全脑缺血模型。观察清醒、缺血及再灌注后海马谷氨酸递质浓度及BIS改变,记录翻正反射恢复的时间及运动功能评分。记数海马CA1区锥体细胞数和TUNEL阳性细胞的百分率。结果保护组在缺血15min翻正反射恢复时间短于预处理组(P<0.05)。保护组缺血10min和15min期间谷氨酸浓度低于预处理组和复苏组(P<0.01)。全脑缺血10min及15min,保护组海马CA1区神经细胞计数高于预处理组及复苏组(P<0.05)。缺血10min及15min保护组的细胞凋亡率明显低于预处理组和复苏组(P<0.05)。结论异氟烷麻醉下的脑保护效应要好于预处理及复苏;异氟烷预处理与复苏的脑保护效应相同。     

气管内吸引术对脑内血肿致颅内高压兔脑氧代谢的影响

目的　研究气管内吸引术 (endotrachealsuctioning ,ETS)对兔急性脑内血肿致颅内高压状态下脑氧代谢的影响及其意义。　方法　利用微泵注射自体血法建立兔急性脑内血肿致颅内高压模型 ( 10只 ) ,并设对照组 ( 10只 ) ,进行开放式气管内吸引术。动态监测颅内压 (ICP)、平均动脉压 (MAP)、脑灌注压 (CPP)、胸内压 (ITP)变化。同时 ,运用颈内静脉插管技术及外周血气 ,分析观察颈静脉氧饱和度 (SjvO2 )、脑氧摄取率 (CEO2 )、脑动静脉血氧差 (AVDO2 )变化。　结果　两组兔气管内吸引后ICP均有短暂升高 (P <0 .0 5 ) ,而MAP基本不变。颅内高压组吸引后即时SjvO2 下降至 0 .769± 0 .0 5 3 (P <0 .0 1) ,CEO2 、AVDO2 明显上升 (P <0 .0 1) ,CPP下降 (P <0 .0 5 )。　结论　颅内高压状态下进行开放式ETS可引起脑缺血、缺氧反应。SjvO2 监测有助于早期发现继发性脑缺血、缺氧损害     

亚低温对实验犬复苏后血清及脑脊液中血小板活化因子含量的影响

目的 探讨亚低温治疗的脑保护作用机制。方法 采用犬室颤致心跳骤停动物模型,观察复苏过程中亚低温治疗对血清及脑脊液中血小板活化因子（ＰＡＦ）含量的影响。结果 ①复苏后血清及脑脊液中ＰＡＦ含量较心跳骤停前明显升高（Ｐ〈０．０１）;②亚低温治疗组脑脊液中ＰＡＦ含量明显低于常温对照组（Ｐ〈０．０１）,而血清中ＰＡＦ含量两组间无明显差异。结论 ＰＡＦ在缺血及再灌注脑损害中起重要作用,亚低温抑制复苏后脑组织中     

经右腋动脉选择性脑灌注在主动脉夹层手术中的应用

目的总结右腋动脉插管体外循环(ECC)、选择性顺行脑灌注在主动脉夹层手术中应用的初步经验。方法回顾性分析我院2005年1月—2008年7月采用深低温停循环(DHCA)加右腋动脉插管选择性顺行脑灌注(ASCP)手术治疗I型主动脉夹层10例。男8例,女2例。年龄24~63岁,平均(41.7±12.0)岁。升主动脉+全弓置换+降主动脉术中支架置入术5例,升主动脉+全弓置换2例,升主动脉+右半弓置换3例。结果本组主动脉阻断时间83~258min,平均(132.3±52.8)min。深低温停循环时间8~53min,平均(29.10±18.30)min,选择性脑灌注时间8~58min,平均(33.4±18.5)min。手术死亡2例,1例因术中出血、体外循环时间长不能脱机,1例因术后低心排和多脏器功能衰竭。术后暂时性脑损害2例,均治愈出院,无永久性脑损害发生。结论右腋动脉插管灌注和顺行脑灌注在主动脉夹层手术中可提供有效的脑保护,其操作简便、安全。     

改良猪深低温模型脑保护机制研究

目的 研究猪改良深低温动物模型深低温不停循环(DHNCA)90min期间脑保护作用机制。方法 实验分二组：假手术组6只，37℃不予特殊处理；实验组8只，18～25℃深低温不停循环90min，复温后观察生理指标变化、脑组织形态学和超微结构变化，用逆转录聚合酶链反应(RT～PCR)方法检测即早基因c～fos和c～jun mRNA的表达。结果 实验组光镜下可以观察到少量神经元形态学改变；电镜下线粒体形态基本正常，突触前膜有大量囊泡聚集；c-fos和c-jun mRNA表达上调。结论 猪改良动物模型在深低温脑保护研究中有效简便。深低温不停循环90min对神经组织无明显损害，可作为下一步深低温脑保护液辅助灌注实验的基础。     

心肺复苏后脑复苏的进展

随着医院外心肺复苏术的普及和提高,心跳、呼吸骤停的复苏率明显提高。但即使生命得以挽救,幸存者中约有20%遗留永久性脑损害,约40%意识不能恢复乃至死亡。因此,脑复苏仍是心肺复苏后最棘手的难题。1　早期心肺复苏是脑复苏成功的基础　　脑组织没有氧储存,对缺氧异常敏感。缺氧10s就可意识消失,缺氧15s可有数分钟昏迷,缺氧3min可致数日昏迷。心跳停搏4～6min就可造成大脑细胞不可逆损害。完全无氧的情况下,大脑皮层细胞生命时间不超过8min。心跳骤停经过复苏后,不同器官内氧供应恢复的时间为1～40min。而脑组织在复苏开始数分钟仅有某些部…     

高压氧预处理对新生大鼠脑缺血损伤的保护作用

目的 观察高压氧预处理后缺氧缺血型脑损伤(hypoxia-ischemia brain damage,HIBD)新生大鼠脑组织神经干细胞增殖变化以及后期脑发育和功能.方法 将6日龄新生大鼠进行0.25 MPa高压氧预处理150 min,24 h后制作HIBD模型,然后暴露于8%氧、92%氮的混合气中90 min.观察皮层和海马神经干细胞的增殖情况、损伤后大鼠体质量增长率和成年后脑形态,水迷宫检测学习记忆功能.结果 高压氧预处理组神经干细胞增殖显著,发育情况、脑形态和学习记忆功能与HIBD组有显著差异.结论 高压氧预处理可能通过促进神经干细胞增殖发挥对新生大鼠HIBD的保护作用并影响后期脑发育.     

治疗性低温及其诱导时机对兔复苏后心肌的影响

目的观察不同时机行轻度低温干预对室颤兔心肌组织能量、超微结构和血清心肌肌钙蛋白(cTNI)、肿瘤坏死因子α(TNF-α)水平以及近期死亡率的影响。方法雄性新西兰兔54只,随机分为5组:常温(39.0±0.5℃)对照组(n=8),低温(33.5±0.5℃)对照组(n=8),常温(39.0±0.5℃)复苏组(n=14),复苏前低温(33.5±0.5℃)组(n=10),复苏后低温(33.5±0.5℃)组(n=14)。采用心外膜电刺激致颤法制备兔心肺复苏模型。复苏后4h采血检测血清cTNI、TNF-α水平;低温各组均持续控温4h后自然复温,观察各组存活情况至复苏后48h,将兔处死后行左室心尖组织电镜检查和三磷腺苷(ATP)、二磷酸腺苷(ADP)、磷酸腺苷(AMP)含量测定,计算心肌能荷(EC)。结果复苏后低温组和两对照组48h存活率均为100%,高于常温复苏组和复苏前低温组(60.0%和44.4%,P<0.05),复苏前低温组48h存活率低于常温复苏组(P<0.05)。各复苏组血清cTNI水平均高于两对照组,复苏前低温组血清cTNI水平低于常温复苏组和复苏后低温组(P<0.05);常温复苏组血清TNF-α水平明显高于其他各组(P<0.05),两低温复苏组间及两对照组间无统计学差异(P>0.05)。复苏前和复苏后低温组心肌组织ATP含量均高于常温复苏组,复苏后低温组和常温复苏组心肌组织ATP含量均较对照组明显减低(P<0.05);常温复苏组EC明显低于两对照组和复苏前低温组(P<0.05);复苏后低温组EC与复苏前低温组及两对照组间无统计学差异(P>0.05)。复苏前和复苏后低温组复苏后48h心肌超微结构损害均较常温复苏组轻(P<0.05)。结论室颤兔自主循环恢复后存在心肌组织损害和能量代谢异常;自主循环恢复后轻度低温干预可减轻心肌组织结构损害,降低48h死亡率,其保护机制与改善心肌细胞能量代谢、抑制炎症反应有关;室颤前轻度低温处理不能降低48h死亡率。     

Knee injury and Osteoarthritis Outcome Score (KOOS) - validation of a Swedish version

The Knee injury and Osteoarthritis Outcome Score (KOOS) is a self-administered instrument measuring outcome after knee injury at impairment, disability, and handicap level in five subscales. Reliability, validity, and responsiveness of a Swedish version was assessed in 142 patients who underwent arthroscopy because of injury to the menisci, anterior cruciate ligament, or cartilage of the knee. The clinimetric properties were found to be good and comparable to the American version of the KOOS. Comparison to the Short Form-36 and the Lysholm knee scoring scale revealed expected correlations and construct validity. Item by item, symptoms and functional limitations were compared between diagnostic groups. High responsiveness was found three months after arthroscopic partial meniscectomy for all subscales but Activities of Daily Living.     

Endovascular management of carotid-cavernous fistulas

Objective To investigate endovascular treatment of traumatic direct carotid-cavernous fistulas （CCF） and their complications such as pseudoaneurysms. Methods： Over a five-year period, 22 patients with traumatic direct CCFs were treated endovascularly in our institution. Thirteen patients were treated once with the result of CCF occluded, 8 twice and 1 three times. Treatment modalities included balloon occlusion of the CCF, sacrifice of the ipsilateral internal carotid artery with detachable balloon, coll embolization of the cavernous sinus and secondary pseudoaneurysms, and covered-stem management of the pseudoaneurysms. Results All the direct CCFs were successfully managed endovascularly. Four patients developed a pseudoaneurysm after the occlusion of the CCF with an incidence of pseudoaneurysm formation of 18.2% （4/22）. A total number of 8 patients experienced permanent occlusion of the ICA with a rate of ICA occlusion reaching 36.4% （8/22）. Followed up through telephone consultation from 6 months to 5 years, all did well with no recurrence of CCF symptoms and signs. Conclusion Traumatic direct CCFs can be successfully managed with endovascular means. The pseudoaneurysms secondary to the occlusion of the CCFs can be occluded with stent-assisted coiling and implantation of covered stents.     

The acutely limping child

Acute limping may be the result of multiple pathologies in children. The differential diagnosis varies based on the age of the child. Irrespective of age, the initial imaging work-up includes AP and frog leg radiographs of the pelvis and ultrasound; MRI may sometimes be helpful. In children less than 3 years, infections and trauma are most frequent. MRI is the imaging modality of choice when osteomyelitis is clinically suspected. Between the ages of 3 and 10 years, transient synovitis of the hip and Legg-Calvé-Perthes disease are main considerations but infection, inflammation and focal bony lesions are also considered. In children over 10 years, slipped capital femoral epiphysis also is considered.     

Do Balance Board Training Programs Reduce the Risk of Ankle Sprains in Athletes?

Introduction Ankle sprains are the most common musculo-skeletal injury that occurs in athletes,particularly in sports that require jumping and landing on one foot such as soccer,and basketball(1-4).These injuries often result in significant time loss from participation,long-term disability,and have a major impact on health care costs and resources(5-8).     

High Intensity Interval Training:New Insights

KEY POINTS ·High-intensity interval training(HIT)is characterized by repeated sessions of relatively brief，intermittent exercise.often performed with an“a11 out”effort or at an intensity close to that which elicits peak oxygen uptake(i.e.，≥90%of VO2 peak).     

Developmental validation of the PowerPlex(®) ESI 16 and PowerPlex(®) ESI 17 Systems: STR multiplexes for the new European standard

In response to the ENFSI and EDNAP groups’ call for new STR multiplexes for Europe, Promega^® developed a suite of four new DNA profiling kits. This paper describes the developmental validation study performed on the PowerPlex^® ESI 16 (European Standard Investigator 16) and the PowerPlex^® ESI 17 Systems. The PowerPlex^® ESI 16 System combines the 11 loci compatible with the UK National DNA Database^®, contained within the AmpFlSTR^® SGM Plus^® PCR Amplification Kit, with five additional loci: D2S441, D10S1248, D22S1045, D1S1656 and D12S391. The multiplex was designed to reduce the amplicon size of the loci found in the AmpFlSTR^® SGM Plus^® kit. This design facilitates increased robustness and amplification success for the loci used in the national DNA databases created in many countries, when analyzing degraded DNA samples. The PowerPlex^® ESI 17 System amplifies the same loci as the PowerPlex^® ESI 16 System, but with the addition of a primer pair for the SE33 locus. Tests were designed to address the developmental validation guidelines issued by the Scientific Working Group on DNA Analysis Methods (SWGDAM), and those of the DNA Advisory Board (DAB). Samples processed include DNA mixtures, PCR reactions spiked with inhibitors, a sensitivity series, and 306 United Kingdom donor samples to determine concordance with data generated with the AmpFlSTR^® SGM Plus^® kit. Allele frequencies from 242 white Caucasian samples collected in the United Kingdom are also presented. The PowerPlex^® ESI 16 and ESI 17 Systems are robust and sensitive tools, suitable for the analysis of forensic DNA samples. Full profiles were routinely observed with 62.5 pg of a fully heterozygous single source DNA template. This high level of sensitivity was found to impact on mixture analyses, where 54–86% of unique minor contributor alleles were routinely observed in a 1:19 mixture ratio. Improved sensitivity combined with the robustness afforded by smaller amplicons has substantially improved the quantity of data obtained from degraded samples, and the improved chemistry confers exceptional tolerance to high levels of laboratory prepared inhibitors.