急性高容血液稀释中晶体液和胶体液的血液稀释效果比较

目的探讨急性高容血液稀释中两类不同的液体的血液稀释效果.方法开腹手术全麻患者80例,随机分为对照组,晶体液组,佳乐施组,贺斯组四组.麻醉平稳和各项监测完成10min后,在30min内按15m1/kg匀速输入容量扩充剂.记录稀释扩容前(T0)、扩容15min(T1)、扩容30min(T2)和稀释结束后10min(T3)的各项监测数据.结果佳乐施组T1、T2、T3后Hct分别比术前下降了7.5%、15.8%、17.6%.贺斯组分别下降了7.8%、16.3%、19.7%.晶体液组分别下降了6.5%,12.6%,12.7%.在T3后贺斯组、佳乐施组Hct与晶体液组组间比较,有显著性差异(P＜0.05).结论胶体液佳乐施和贺斯以15ml/kg行急性高容血液稀释均能取得满意的稀释效果.     

腰硬联合麻醉下剖宫产输注不同液体对母体血压的影响

目的探讨腰硬联合麻醉下剖宫产输注不同液体对母体血压的影响。方法选择300例住院行剖宫产产妇,ASAI级,年龄23—35岁,体重60—90kg,无妊娠合并症。随机将300例病人分为3组,即林格氏液组（I组）、羟乙基淀粉130／0．4氯化钠组（Ⅱ组）、羟乙基淀粉130／0．4高渗氯化钠组（BI组）,3组病人均行腰硬联合麻醉,麻醉平面控制于S3～T6之间,麻醉即刻输入3种液体,观察3组产妇收缩压、胸闷、恶心、呕吐情况,血压下降后低于基础值30％或绝对值~90mmHg使用麻黄碱的量,如出现新生儿窒息进行心肺复苏例数。结果3组产妇腰麻后血压均有不同程度的下降,应用扩容（I组）血压下降程度较Ⅱ、Ⅲ组明显,应用麻黄碱的剂量也明显多于Ⅱ、Ⅲ组;工组中有36人发生不同程度的胸闷、恶心、呕吐,占36％;而Ⅱ组、Ⅲ组中分别有13％、11％,明显低于I组。结论腰硬联合麻醉下剖宫产输注胶体液较晶体液更好地维持母体血流动力学稳定,保证母体胎盘有效灌注流量,减少术中仰卧位低血压综合征的发生几率。     

13个重点监测药品使用趋势及频度分析

目的:了解我院13个重点监测药品使用趋势及频度,强化临床医师合理用药意识,避免不良反应发生。方法:对2009年10月1日—2011年9月30日13个重点监测药品使用数量、用药频度(DDDs)、科室分布等进行回顾性分析。结果:重点监控的13个药品中,我院有10个品种23个不同生产厂家及品规;脑蛋白水解物片、参麦注射液、丹参注射液、香丹注射液、细辛脑注射液、喜炎平注射液总消耗数量及金额较高;脑蛋白水解物片的DDDs综合排序最高,丹参注射液DDDs排序居第2位,参麦注射液2年中的DDDs始终居第3位;重点监测药品使用率呈现下降趋势。结论:我院重点监测药品使用趋势、DDDs、科室分布总体较为合理,个别品种科室分布的合理性有待商榷。     

Renal Toxicity and Carcinogenicity of Trichloroethylene: Key Results,Mechanisms, and Controversies

The discussion on renal carcinogenicity of trichloroethylene adresses epidemiological, mechanistic, and metabolic aspects. After trichloroethylene exposure of rats, renal cell tumors were found increased in males, and an increased incidence of interstitial cell tumors of the testes was reported. Studies on the metabolism of trichloroethylene in rodents and in humans support the role of bioactivation reactions for the development of tumors following exposure to trichloroethylene. Epidemiological cohort studies addressing the carcinogenicity of trichloroethylene with respect to the renal or urothelial target sites have been conducted, and no clear evidence for an elevated renal or urinary tract cancer risk in trichloroethylene-exposed groups was visible in exposed populations. However, a cohort study of 169 male workers having been exposed to unusually high levels of trichloroethylene in Germany within the period between 1956 and 1975 supported a nephrocarcinogenic effect of trichloroethylene in humans. The results of this study were discussed in the literature with considerable reserve; criticism was based mainly on the choice of the study group, which had been recruited from personnel of a company in which a cluster of four renal tumors was observed previously. Hence, a further case-control study was conducted in the same region. This study confirmed the results of the previous cohort study, supporting the concept of involvement of prolonged and high-dose trichloroethylene exposures in the development of renal cell cancer. Further investigations on patients with renal cell carcinoma and with histories of high trichloroethylene exposures, on the basis of excretion of marker proteins in the urine, pointed to toxic damage to the proximal renal tubules by trichloroethylene. The hypothesis of implication of a glutathione transferase-dependent bioactivating pathway of trichloroethylene, established in experimental animals, seems at least also plausible for humans. Apparently, the occurrence of renal cell carcinomas in man follows high-dose exposures to trichloroethylene that are also accompanied by damage to tubular renal cells. Development of renal cell carcinomas has been related to mutations in the vonHippel-Lindau (VHL) tumor suppressor gene. Renal cell carcinoma tissues of persons with histories of prolonged high-dose exposure to trichloroethylene were investigated for the occurrence of mutations of the vonHippel-Lindau (VHL) tumor suppressor gene. VHL gene mutations were found in the majority of renal cell tumors associated with high-level exposure to trichloroethylene. A specific mutational hot spot at the VHL nucleotide 454 was addressed as a unique mutation pattern of the VHL tumor suppressor gene. A synopsis of all experimental, clinical, and epidemiological data suggests that reactive metabolites of trichloroethylene, with likely involvement of dichlorovinyl-cysteine (DCVC), exert a genotoxic effect on the proximal tubule of the human kidney. This constitutes a tumor-initiating process of genotoxic nature, the initial genotoxic effect apparently being linked with mutational changes in the VHL tumor suppressor gene. However, there is compelling evidence that the full development of a malignant tumor requires continued promotional stimuli. Repetitive episodes of high peak exposures to trichloroethylene over a prolonged period of time apparently led to nephrotoxicity, visualized by the excretion of tubular marker proteins in the urine. This critical process of development of tubular damage by trichloroethylene must follow a “conventional” dose-dependence, implying a practical threshold. This view is much corroborated by the fact that the occurrence of human renal cell cancer is obviously confined to cases of unusually high trichloroethylene exposures in the past, with special characteristics of very high and repetitive peak exposures. Current instruments of regulation should be adjusted to allow adequate consideration of such carcinogenic effects of chemicals that are practically relevant at very high doses only.     

Controversies in Alcoholism and Substance Abuse

No abstract available for this article.     

Controversies in fumonisin mycotoxicology and risk assessment

Fusarium verticillioides causes several animal diseases and the contamination maize suggests that it could adversely affect human health. The fumonisin B mycotoxins were characterized from the fungal culture material and shown to be the causative principle responsible for the major mycotoxicological effects of the fungus in experimental and farm animals. The main focus was on the toxicological effects in rats and mice, the outcome of which played an important role in setting risk assessment parameters for exposure of the fumonisins to humans. The International Agency for Research on Cancer characterized the fumonisins as Group 2B carcinogens. Several controversial findings regarding the toxicological effects of the culture material of the fungus, the genotoxicity and carcinogenicity of pure fumonisin B(1) (FB(1)) in rats have been reported that should be clarified prior to assessing the risk in humans. The underlying differences between the diets with the high protein levels are likely to sensitize the kidneys to FB(1)-induced toxic and carcinogenic effects. Several other dietary factors, such as plant extracts (antioxidants) and dietary Fe, could either stimulate or inhibit cancer induction of FB(1), which complicates the comparison of toxicological effects in experimental animals. Cognisance should be taken of the modulating role of dietary constituents as it will determine the outcome of toxicological assays and determine the threshold of an adverse effect in a specific target organ to be used in determining risk assessment parameters.     

Controversies in antibiotic prophylaxis in urology

Antibiotic prophylaxis in urologic surgery remains controversial. However, progress has been made and some of the controversies have been answered. Firstly, it is important to underline that urologic diagnostic and therapeutic procedures can induce surgical site infections (SSIs), bacteriuria, pyelonephritis and septicaemia in a substantial number of patients, too great to be neglected. Secondly, as patients are different and have various risk factors, a careful assessment of the patient and its individual risk is crucial. Thirdly, the same procedure may be totally different from one individual to another and they can rarely be grouped as standard procedures. A floating level of invasiveness is followed by a variation of the risk of infection. Fourthly, the pathogens and their susceptibility pattern vary extensively in Europe so that no clear-cut recommendations as for the choice of antibiotics can be given. Basic principles of antibiotic prophylaxis in terms of timing, mode of administration and length of regiment apply for urologic interventions. Thus, clean operations will usually not require antimicrobial prophylaxis except for those including the implant of a prosthetic device, while clean-contaminated will benefit from preventive antimicrobials. It is the task of the urologists to carefully assess each individual patient and procedure to opt for an optimal prophylaxis.     

Colloid milium: a review and update

Colloid milium (CM) is a rare cutaneous deposition disease with at least 3 distinct subtypes. The exact histogenesis of the condition is still unresolved and awaits definitive elucidation. Electron microscopy and immunohistochemical analysis have allowed the distinction of CM from clinically similar conditions such as amyloidosis. Successful treatment has been achieved with dermabrasion and, more recently, with ablative and fractional laser resurfacing of affected skin.     

Controversies in breast cancer: adjuvant and neoadjuvant therapy

Initial randomised studies of chemotherapy and endocrine therapy showed that systemic treatments had a substantial impact on the survival of women with early breast cancer. The original assumption was that the efficacy of these treatments was limited to those patients presenting with more adverse prognostic features. Subsequently, meta-analyses of randomised trials revealed that the benefits of chemotherapy and endocrine therapy are not mutually exclusive and extend to all the prognostic subgroups. However, the absolute benefit varies according to baseline characteristics such as tumour stage and other biological factors. Over the last 10 years, considerable progress has been made with the introduction of new drugs into the adjuvant and neoadjuvant treatment of women with breast cancer. Taxanes and third-generation aromatase inhibitors are providing proof of additional benefits compared with standard reference treatments. In parallel, research on the biology of breast cancer is establishing novel prognostic and predictive factors, which may allow better treatment tailoring. Currently, however, women with early breast cancer and their doctors face the difficult task of making therapeutic decisions often based on early results from positive studies. In a disease where follow up is crucial to fully assess the benefit and long-term toxicities of an intervention, current knowledge leaves unanswered questions that generate debate and controversy. This review will summarise recent results from randomised trials of adjuvant and neoadjuvant therapy in women with early breast cancer and focus on the current controversies.     

Controversies in breast cancer: adjuvant and neoadjuvant therapy

Initial randomised studies of chemotherapy and endocrine therapy showed that systemic treatments had a substantial impact on the survival of women with early breast cancer. The original assumption was that the efficacy of these treatments was limited to those patients presenting with more adverse prognostic features. Subsequently, meta-analyses of randomised trials revealed that the benefits of chemotherapy and endocrine therapy are not mutually exclusive and extend to all the prognostic subgroups. However, the absolute benefit varies according to baseline characteristics such as tumour stage and other biological factors. Over the last 10 years, considerable progress has been made with the introduction of new drugs into the adjuvant and neoadjuvant treatment of women with breast cancer. Taxanes and third-generation aromatase inhibitors are providing proof of additional benefits compared with standard reference treatments. In parallel, research on the biology of breast cancer is establishing novel prognostic and predictive factors, which may allow better treatment tailoring. Currently, however, women with early breast cancer and their doctors face the difficult task of making therapeutic decisions often based on early results from positive studies. In a disease where follow up is crucial to fully assess the benefit and long-term toxicities of an intervention, current knowledge leaves unanswered questions that generate debate and controversy. This review will summarise recent results from randomised trials of adjuvant and neoadjuvant therapy in women with early breast cancer and focus on the current controversies.     

Controversies of anticoagulation reversal in life-threatening bleeds

Therapeutic anticoagulation with heparins, warfarin, and anti-Xa inhibitors carry an inherent risk of complications due to their multifaceted pharmacokinetic and pharmacodynamic properties as well as narrow therapeutic ranges. When an anticoagulated patient presents with a major or life-threatening bleed, immediate and effective therapy may be necessary to reverse the effects of the anticoagulant, minimize blood loss, and reduce patient morbidity and mortality. Optimal agents and strategies for anticoagulant reversal are limited, particularly for newer anticoagulants. The literature describing such strategies available to reverse the effects of anticoagulants in the setting of a bleed is limited, and therefore many controversies exist. Thus, as new anticoagulants become available, without a specific agent for reversal, the concerns and controversies related to this topic must be addressed. The purpose of this review is to discuss the management of major or life-threatening bleeds by addressing the following controversies: (1) the use of recombinant factor VIIa for rapid reversal of warfarin in patients with intracerebral hemorrhage, (2) the role of prothrombin complex concentrate in emergent warfarin reversal, and (3) the optimal approach to reverse newer anticoagulants such as low molecular weight heparins, fondaparinux, and direct thrombin inhibitors.     

Controversies in translational research: drug self-administration

RATIONALE: Laboratory animal and human models of drug self-administration are used to evaluate potential pharmacotherapies for drug abuse, yet the utility of these models in predicting clinically useful medications is variable. OBJECTIVE: The objective of this study was to track how antagonist, agonist, and partial agonist medication approaches influence heroin and cocaine self-administration by rodents, non-human primates, and humans and to compare these results to clinical outcomes. RESULTS: Across species, heroin self-administration was decreased by all three medication approaches, paralleling their demonstrated clinical utility. The heroin data emphasize the importance of assessing a medication's abuse liability preclinically to predict medication abuse and compliance and of considering subject characteristics (e.g., opioid dependence) when interpreting medication effects. For cocaine, the effects of ecopipam, modafinil, and aripiprazole were consistent in the laboratory and clinic, provided that the medications were administered repeatedly before self-administration sessions. Modafinil attenuated cocaine's reinforcing effects in the human laboratory and improved treatment outcome, while ecopipam and aripiprazole increased the reinforcing effects of cocaine and do not appear promising in the clinic. CONCLUSIONS: The self-administration model has reliably identified medications to treat opioid dependence, and the recent data with modafinil suggest that the human laboratory model also identifies medications to treat cocaine dependence. There have been numerous false positives when subjective effects are the primary outcome measure, but not when self-administration is the outcome. Factors relevant to the predictive validity of self-administration procedures include medication maintenance and the concurrent assessment of a range of behaviors to determine abuse liability and the specificity of effect.