电针周围性面瘫患者穴位的功能磁共振成像研究

目的 探讨功能磁共振成像(fMRI)研究电针周围性面瘫患者不同穴位时脑功能区变化.方法 将18例左侧周围性面瘫患者随机分为3组,分别电针左侧地仓穴(6例)、左侧合谷穴(6例)、左侧后溪穴(6例),同时行全脑fMRI 扫描.以SPM 软件进行图像后处理,t检验(P<0.05)分析得出电针不同穴位的脑功能图像. 结果电针左侧地仓穴、左侧合谷穴信号降低区:双侧额中回,左扣带回;信号升高区:右侧中央前回,双侧中央后回,左侧颞上回,右侧脑岛.电针左侧后溪信号降低区:双侧额下回,左侧豆状核,右侧颞中回,右侧小脑扁桃体;信号升高区:右侧尾状核头,右侧扣带回,脑干,小脑蚓,右侧海马回. 结论 电针周围性面瘫患者合谷穴和地仓穴可引起大脑相应的功能区激活,而电针后溪穴未见和前两者有相似的激活区域,推测穴位与大脑的联系与其所属的经脉有密切联系.     

指揉合谷穴的功能磁共振研究

目的:探讨指揉合谷穴对脑功能的影响.方法:通过血氧水平依赖性磁共振脑功能成像技术,研究12例健康志愿者指揉左侧合谷穴的脑激活情况.应用统计参数图5进行图像处理及统计学分析.结果:指揉健康志愿者左侧合谷穴信号升高区:双侧小脑,双侧豆状核,右侧尾状核,右侧颞叶,左侧额下回,右侧中央后回,右侧中央前回,左侧顶叶,左侧额中回等脑区.结论:穴位刺激与脑区的激活密切相关,指揉合谷穴可激活头面及肢体的相关运功、感觉中枢.     

基于局部一致性算法的周围性面瘫针刺治疗静息态功能MRI研究

目的：研究在静息状态下周围性面瘫患者临床针刺治疗不同病程状态下的脑区局部一致性(regional homogeneity,ReHo)变化特点,探讨针刺治疗周围性面瘫的可能中枢整合机制。材料与方法采用静息态fMRI技术,采集32例健康志愿者及47例面瘫患者临床针刺治疗不同病程状态下(面瘫早期组、后期组及治愈组)的BOLD数据,采用ReHo的数据后处理方法进行分析,将面瘫早期组、后期组及治愈组分别与健康志愿者ReHo值比较,获取有统计学意义的差异脑区。结果(1)面瘫早期组ReHo增高的脑区有右侧额上回、额中回、额下回,左侧楔前叶、后扣带回和颞上回,ReHo值减低脑区有右侧颞下回、楔叶和楔前叶;(2)面瘫后期组ReHo增高的脑区有左侧SII、颞上回、额上回、中央旁小叶、楔叶、楔前叶和右侧额下回;(3)面瘫治愈组ReHo增高的脑区有左侧中央旁小叶、梭状回和颞上回。结论大脑皮层运动前区(PMA)、辅助运动区(SMA)是周围性面瘫患者脑功能重组及代偿的关键区域,也是针刺治疗周围性面瘫患者重要的调制和关键代偿区域。     

电针通里、悬钟穴对1例皮质下失语症患者语言功能和fMRI改变的作用

目的：通过对1例皮质下失语症患者针刺通里、悬钟前后的语言学评估，观察此穴位配伍的语言学疗效及探索语言功能的改善与皮质激活效应的关系和意义。方法：试验1：对1例皮质下失语症志愿者在针刺通里、悬钟前后用汉语标准失语症检查表进行语言学评价。试验2：分别电针左、右通里、悬钟，试验采用组块设计模式，静息阶段与刺激阶段交替；运用fMRI中的BOLD技术及SPM2软件分析方法来显示脑皮质功能区的激活情况。结果：电针左侧通里、悬钟后出现右侧颞上回、颞横回、额下回、岛叶、海马旁回、中央前后回、小脑扁桃体等部位的激活．电针右侧通里、悬钟后左侧颞上回、颞下回、海马旁回、角回、岛叶、顶上小叶、顶下小叶、中央后回等脑区出现激活：其中电针左侧的通里、悬钟后出现双侧颞叶的皮质激活效应。结论：针刺通里、悬钟可以激活脑语言功能区，从而证实针刺此组穴位可以改善失语症患者的语言功能。通过观察针刺单侧穴位后的侧别交叉激活和双侧皮质激活推测语言功能的双侧性。     

针刺合谷穴脑功能磁共振成像研究

目的观察针刺合谷穴引发脑内相关区域的变化情况.方法对6名健康右利手年轻被试进行右手合谷穴针刺,同时进行全脑fMRI,对脑内活动区域进行定位.结果针刺合谷时引起双侧感觉/运动区,额中回,颞上回前部,丘脑,额上内侧回,双侧小脑,双侧枕颞交界区,对侧岛叶,扣带回前部,中央后回上部以及同侧顶盖区激活,而降低的区域则分别表现在双侧颞极部,内颞叶区,额下内侧回,额叶眶部,双侧颞中回,双侧扣带回后部,枕叶,双侧中央前回中部,同侧中央前回上部.结论针刺合谷能够引发脑内相关区域的激活和降低,说明fMRI能够为针灸机制的探讨提供帮助.     

针刺神门穴对阿尔茨海默病患者脑功能磁共振成像的影响

目的：应用脑功能磁共振成像技术观察针刺神门穴对阿尔茨海默病(Alzheimer disease，AD)患者脑功能区的激活作用，探讨针刺治疗AD的客观基础。方法：对2004-03／08宣武医院收治的6例轻中度老年性痴呆患者进行的电针刺激神门穴，运用1．5T磁共振成像系统，采集脑部的fMRI数据，通过SPM软件分析，获取脑内不同区域的功能活动图像。结果：针刺神门穴主要引起老年性痴呆患者针刺对侧大脑皮质的功能活动，具体表现为左侧的额中回、颞上回、颞横回及中央前、后回，还有丘脑和壳核；另外，右侧额中回和颞上回也被激活。结论：针刺神门穴引起的脑部功能活动不仅与感觉运动中枢神经系统有关，而且还与认知功能有关，提示应用神门穴治疗老年性痴呆存在一定的客观基础。     

癫痫患者语义加工的功能磁共振成像研究

目的分析颞叶癫痫（TLE）患者语义处理相关功能区的分布。方法左侧TLE患者、右侧TLE患者和健康对照各6例，均为右利手。对所有受试者进行逆序词任务功能性磁共振成像（fMRI）检查，以按键记录受试者反应，使用统计参数图2（SPM2）对fMRI图像进行个体水平的统计分析和组分析。结果右侧TLE患者主要激活左侧的额下回、额中回、颞上回、颞中回以及双侧扣带回、梭状回、基底节区、小脑（右著）等区域，与对照组的差异无显著性意义；左侧TLE患者与对照组相比语言激活区出现不典型化表现，右侧额下回、中央前回和左侧楔叶、楔前叶出现更多激活。结论左侧TLE患者的语义处理相关功能区不典型分布，出现激活区对侧镜像转移。     

低频振幅算法功能磁共振成像观察屈光参差性弱视患者脑活动

目的 应用基于低频振幅(ALFF)算法的功能磁共振成像(fMRI)观察屈光参差性弱视患者脑活动的变化。方法 对9例左眼单眼屈光参差性弱视患者(弱视组)和12名健康志愿者(对照组)在黑白棋盘格刺激下行fMRI,应用t检验对ALFF脑图进行组间和组内统计学分析。结果 1例弱视组患者数据在预处理后被剔除。左眼接受刺激时,弱视组较对照组左侧舌回、右侧枕中回、右侧中央前回、左侧后扣带回、左侧顶上小叶、左侧楔前叶和楔叶等区域ALFF减弱,左侧额中间回、左侧额上回、左侧颞上回、右侧杏仁体和右侧壳核等区域ALFF显著增强;右眼接受刺激时,弱视组较对照组胼胝体和左侧颞中回ALFF减弱,双侧枕叶、右侧额中回和右侧尾状核等区域ALFF显著增强。弱视组中,与右眼接受视觉刺激时比较,左眼接受视觉刺激时右侧额下回、左侧尾状核、丘脑及前扣带回等脑区ALFF显著增强,双侧枕叶ALFF显著减弱。结论 任务状态下基于ALFF算法的fMRI不仅可反映弱视患者视皮层的功能损害,还可反映多脑区神经活动的变化。     

功能磁共振成像观察补法、泻法针刺足三里穴对大脑作用的中枢机制

目的 用功能磁共振成像(fMRI)方法观察补法和泻法针刺足三里穴对大脑作用的中枢机制. 方法 选取32名健康右利手志愿者,对11名受检者用补法电针刺激右侧足三里穴(ST36)、11名用泻法电针刺激ST36、10名电针刺激右侧足三里穴同一水平向外2～3 cm处.同时行全脑fMRI扫描;用SPM2软件进行图像后处理. 结果 电针结束后5 min,泻法组的脑区激活不明显,而补法组平均信号升高的脑区主要有双侧尾状核头部、丘脑、左侧岛叶、扣带回及小脑齿状核.电针结束后20～30 min期间两组脑区的激活最为明显,均激活左侧的丘脑、中央旁小叶、中央前回、颞中回、额中回、岛叶、双侧尾状核头部、小脑半球、前、后扣带回;两组激活区域大致相同,但补法组激活的脑区范围更广、强度更大.针刺假穴组只激活中央旁小叶及小脑半球. 结论 补、泻手法针刺足三里穴均能激活边缘系统、辅助运动区、灰质结构等脑区,而应用补法能更早、更强烈地激活上述脑区.     

静息态fMRI观察遗忘型轻度认知障碍患者长-短程功能连接

目的 分析遗忘型轻度认知障碍（aMCI）患者长、短程功能连接的变化。方法 采集37例aMCI患者（aMCI组）和40名认知功能正常志愿者（对照组）的静息态fMRI数据,以GRETNA软件自动计算完成全脑长程和短程功能连接,比较2组间差异。结果 与对照组比较,aMCI组长程功能连接减低的脑区主要位于双侧楔前叶/中后扣带回、右侧中央沟盖,长程功能连接增强的脑区主要分布于双侧中央前回、左侧颞极/颞中回、左侧直回、右侧眶内额上回、左侧眶内额下回;其短程功能连接减低脑区位于左侧岛叶,短程功能连接增强脑区主要包括左侧颞极/颞上回、左侧颞中回、左侧直回、左侧眶内额下回、右侧海马、右侧颞上回、右侧额中回、右侧辅助运动区及左侧中央后回/楔前叶。结论 aMCI组患者脑长、短程功能连接模式均有所改变,有助于理解aMCI患者脑网络改变的病理生理机制。     

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.     

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.     

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.     

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.