实施心肺复苏期间患者血栓素A2和前列环素动态变化的临床研究

目的：探讨血管活性物质血栓素A2（TXA2）和前列环素（PGI2）在心肺复苏过程中的意义。方法：20例心脏骤停行心肺复苏术患者，根据复苏后有无自主循环分组，缺血组（8例）和再灌流组（12例），缺血组于复苏前，复苏开始即刻，15，30分钟时；再灌流组于复苏前，复苏后即 刻，15，30分钟时，分别测定血浆中血栓素B2（TXB2）和6－酮－前列腺素F1a的浓度，比较两组患者上述指标的动态变化，并设正常对照组，结果：再灌流组；TXB2浓度在恢复自主循环即刻明显增高，随后逐渐下降，但与缺血组无显著差异，6－酮－前列腺素F1α浓度在恢复自主循环后明显增高，且明显高于缺血组，结论：TXA2，PGI2参与了心肺复苏期间的再灌注，动态监测血中TXA2，PGI2浓度对估计心肺复苏患者的预后有参考价值。     

山莨菪碱对急性完全性脑缺血再灌流后脑组织Ca2+、MDA含量、SOD活性及超微结构的影响

40只家兔随机分为假手术组（A组）、缺血组（B组）、缺血再灌流组（C组）、治疗组（D组）。采用闭塞双侧颈总动脉和椎动脉及体循环低血压法建立急性完全性脑缺血再灌流损伤模型，缺血时限20min，再灌流2h，观察了脑组织Ca2＋、脂质过氧化产物一丙二醛（MDA）含量、超氧歧化酶（SOD）活性及脑组织超微结构改变。结果发现：治疗组于再灌流前1min注射山莨菪碱10mg／kg体重，并以5mg／h维持2h，脑组织Ca2＋、MDA含量较缺血组及缺血再灌流组明显降低，（P＜0．05，P＜0．01），SOD活性较缺血再灌流组明显增加（P＜0．05）同时脑组织超微结构损伤明显减轻。结果表明；再灌流早期给予山莨菪碱治疗对完全性脑缺血再灌注损伤具有明显保护作用。膜稳定作用、Ca2＋拮抗作用、抗脂质过氧化是其重要的作用环节。     

心肺复苏中血浆内皮素和超氧化物歧化酶水平的动态观察与分析

目的　探讨血浆内皮素 (endothelin ,ET)及超氧化物歧化酶 (superoxidedismutase,SOD)水平与心肺复苏 (cardiopulmonayresuscitation ,CPR)患者预后的关系。方法　 2 5例心搏骤停和心肺复苏患者 ,依复苏效果分为A组 (9例 ) ,心肺复苏 30min无效死亡 ;B组 (11例 ) ,复苏成功 ,自主循环建立 >2h ,但经抢救 2 4h后死亡 ;C组 (5例 ) ,复苏成功存活出院。三组患者于复苏即刻、 30min、 2h、 4h分别测定血中ET、SOD的浓度 ,比较三组患者上述指标的动态变化。结果　B、C两组随着CPR的进展ET、SOD的浓度逐渐降低 ,于CPR 2 4h差异具有显著性意义。C组ET水平下降速度比B组慢 ,而SOD水平下降速度比B组快。结论　在CPR过程中 ,ET功能衰竭是预后不良的指标 ,ET下降速度快提示预后较差。动态监测血中SOD浓度对评估心肺复苏期间患者再灌流损伤程度及代偿能力有参考价值 ,对预测抢救效果有一定的临床意义     

β七叶皂甙对家兔脑缺血再灌流损害的保护作用

目的：研究β－七叶皂甙对家兔前脑缺血、再灌流损害的保护作用。方法：在建立家兔前脑缺血、再灌流动物模型的基础之上，将动物分为四组：缺血组、再灌流组、缺血治疗组和再灌流治疗组。前两组静脉注射生理盐水，后两组注射5mg／kg的β－七叶皂甙。观察脑皮质组织水含量、脑组织皮质匀桨MDA浓度和SOD活性，以及脑皮质和海马组织超微病理结构的改变。结果，治疗组脑水肿程度明显轻于未治疗组（P＜0．05），MDA含量低于未治疗组（P＜0.01），而SOD活性较未治疗组明显升高（P＜0．01）。且超微病理结构的改变较未治疗组损害程度所有减轻。结论：说明β－七叶皂甙可以减轻家兔脑缺血、再灌流性损害，具有神经保护作用。该作用与β－七叶皂甙的抗氧自由基活性有关。     

川芎嗪注射液抗脑缺血—再灌注损伤作用机制的实验研究

目的：探讨川芎嗪注射液（LGTI）对脑缺血－再灌注损伤（CIRI）的防治作用及其机制。方法：制备家兔CIRI模型,随机分为假手术对照组、缺血－再灌流组和LGTI组,动态观察浆及脑组织一氧化氮（NO）水平,内皮素（ET）含量,丙二醛（MDA）浓度,超氧化物歧化酶（SOD）尖性及脑超微结构伯变化。结果：脑缺血－再灌注期间,血浆和脑组织NO水平及SOD活性与缺血前比较明显下降（P＜005和P＜0．01）,ET及MDA含量与缺血前比较显著升高（P＜0．05和P＜0．01）,超微结构发 生异常改变;使用LGTI后,上述各指标的异常变化明显减轻,与缺血－再灌注相相比差异有显著意义,（P＜0．01）。结论LGTI具有良好的防护作用,其机制与提高机体NO水平、降低ET水平及减轻氧自由的基损伤等有关。     

缺血预处理对离体大鼠肺缺血再灌注氧化损伤的影响

目的：研究缺血预处理（IP）对离体大鼠肺缺血再灌注氧化损伤的影响。方法：建立离体大鼠肺缺血再灌注损伤模型。18只SD大鼠随机分为3组，每组6只。对照组（Con)持续平衡灌注通气60min，无缺血；缺血再灌注组（IR）缺血45min，再灌注30min；缺血预处理组（IP）先给予连续2次的5min缺血、5min再灌注的预处理，再行缺血45min和再灌注30min。测定缺血前和再灌注末灌注液中丙二醛（MDA）、超氧化物歧化酶（SOD）和白细胞数量，测定再灌注末肺组织髓过氧化物酶（MPO）活性、黄嘌呤氧化酶（XOD）活性和湿／干比（W／D）。结果：IR组再灌末MDA含量、MPO活性、XOD活性和W／D较Con组明显升高（P＜0．01），而SOD活性则显著下降（P＜0．01）。IP能明显减少再灌后MDA、MPO、XOD和W／D的增加，提高SOD的活性（P＜0．01）。结论：IP能明显抑制离体大鼠肺缺血再灌注导致的氧化损伤。     

极化液对肢体缺血/再灌注脂质过氧化反应影响的临床观察

目的 临床观察极化液对肢体缺血／再灌注脂质过氧化反应的效果。方法 选择20例下肢手术需充气带加压下肢止血的患者，随机分为对照组（n=10）和治疗组（n=10）。治疗组病人术前10min静脉滴入极化液（300mL），对照组病人给等量平衡液。肢体缺血前、再灌注后30、90、180min分别检测血MDA、CPK和SOD。结果 肢体缺血／再灌注30、90、180min与缺血前比较，血MDA和CPK含量升高，SOD含量下降。治疗组缺血／再灌注同时间血MDA含量明显低于对照组（P〈0.01）；CPK值低于对照组（P〈0．05）；SOD活性逐渐上升，180min高于对照组（P〈0.05）。结论 极化液有抗脂质过氧化作用，降低CPK值，提高SOD活性，能有效防止肢体缺血／再灌注损伤。     

阿米洛利同系物对老龄大鼠心肌缺血再灌注损伤的保护作用

目的：通过建立老龄大鼠心肌缺血再灌注模型，研究5-N-乙基-N-异丙基-阿米洛利（EIPA）对心肌缺血再灌注损伤的保护作用。方法：取心电图正常的老龄雄性SD大鼠32只，随机分为假手术组、缺血-再灌注组、缺血前给药组和再灌注前给药组，每组8只。假手术组只开胸，不结扎冠脉。其余各组均结扎冠状动脉左前降支20min。假手术组及缺血-再灌注组分别于开胸后及冠脉结扎前10min给予生理盐水2mL／kg．其余2组分别于缺血前10min及再灌注前10min给予EIPA2rag（2mL）／kg。观察各组于再灌注后10min、2h、24h3个时间点血清中肌酸磷酸激酶同工酶（CK-MB）、乳酸脱氢酶（LDH）水平及术后24h心肌组织中丙二醛（MDA）含量及超氧化物歧化酶（SOD）活性。使用光学及电子显微镜观察心肌组织超微结构的变化。结果：缺血再灌注可造成明显的心肌细胞损伤。再灌注后各时间点血清心肌酶谱水平较术前明显升高；心肌组织中MDA含量明显增高，SOD活性下降。缺血前及再灌注前给予EIPA预处理的两组大鼠，心肌细胞损伤均较缺血-再灌注组有明显减轻。差异有显著性。其中，缺血前给药组的心肌细胞保护作用较再灌注前给药组更为明显。结论：使用阿米洛利同系物——EIPA作为心肌缺血再灌注损伤的预处理手段可减轻心肌细胞损伤和坏死。对心肌细胞具有明显的保护作用。关键词心肌缺血再灌注损伤EIPA钠氢交换器抑制剂     

牛磺酸对家兔肾上腹主动脉阻断所致急性肾缺血/再灌注损伤保护作用的实验研究

目的 探讨牛磺酸对家兔肾上腹主动脉阻断所致急性肾缺血／再灌注损伤（ARIRI）的保护作用及可能机制。方法 将24只家兔随机等分为3组（每组n＝8）：假手术组（I组）、缺血再灌注组（Ⅱ组）和牛磺酸治疗组（Ⅲ组）。Ⅱ、Ⅲ两组建立肾上腹主动脉阻断所致ARIRI的动物模型，I组不阻断主动脉血流。Ⅲ组于阻断主动脉前5min静注牛磺酸150mg/kg。Ⅰ、Ⅱ组以等容积生理盐水取代牛磺酸。动态检测中BUN、Cr、SOD、MDA、AT－Ⅱ、尿β2－MG的变化，以及肾皮质中SOD、MDA的浓度。结果 Ⅲ组在灌注期血BUN、Cr、AT－Ⅱ及尿中β2－MG含量明显低于Ⅱ组（P＜0．05或P＜0．01），血和肾皮质MDA浓度明显低于Ⅱ组（P＜0．01），SOD活性显著高于Ⅱ组（P＜0．01）。Ⅱ组电镜下见明显肾小管损伤及坏死，而Ⅲ组肾小管损伤轻微。结论 牛磺酸对家兔肾上腹主动脉所致ARIRI具有良好的保护作用，作用机制与其抗氧化作用及抑制AT－Ⅱ的生成有关。     

脊髓缺血再灌注损伤中热休克蛋白表达的研究

目的：研究脊髓缺血再灌注损伤（SCⅡ）后热休克蛋白（HSP70）表达的变化。方法：制作SCⅡ动物模型，采用光镜，激光多普勒超声，免疫组化等技术，研究SCⅡ后HSP70表达的变化。结果：（1）缺血30min，血灌流量平均下降85．37％，再灌流即刻血灌流量迅速升高，再灌流10min左右达到最高点，再灌流30min，血灌流量基本恢复到缺血前的基线水平，以后逐渐降低。（2）缺血后部分大鼠再灌注后出现“二次瘫痪”现象。（3）脊髓缺血30min再灌注60min后即有HSP70的表达增强，随着再灌注时间的延长，HSP70表达逐渐增多，在再灌注240min达到高峰，此后，HSP70表达逐渐减少，在再灌注24h基本消失，结论：（1）脊髓缺血一定时间后恢复血液供应，可以发生再灌注损伤。（2）脊髓缺血灌注后HSP70的表达增加。     

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.