重型颅脑损伤的监护

重型颅脑损伤患者常伴有颅内压 (ICP)增高 ,在临床上属于一种较为复杂的病理生理过程 ,如不能及时发现和解除 ,常导致严重的脑代谢障碍、脑灌注压 (CPP)下降或脑疝形成 ,这是该类患者致残或死亡的主要原因之一 .在临床开展的监护研究 ,能及时、准确地掌握患者的 ICP和 CPP变化 ,并采取有效的治疗措施 ,可明显地降低这类患者的并发症和死亡率 .     

Relevance of neuroimaging for neurocognitive and behavioral outcome after pediatric traumatic brain injury

This study aims to (1) investigate the neuropathology of mild to severe pediatric TBI and (2) elucidate the predictive value of conventional and innovative neuroimaging for functional outcome. Children aged 8–14 years with trauma control (TC) injury (n = 27) were compared to children with mild TBI and risk factors for complicated TBI (mild^RF+, n = 20) or moderate/severe TBI (n = 17) at 2.8 years post-injury. Neuroimaging measures included: acute computed tomography (CT), volumetric analysis on post-acute conventional T1-weighted magnetic resonance imaging (MRI) and post-acute diffusion tensor imaging (DTI, analyzed using tract-based spatial statistics and voxel-wise regression). Functional outcome was measured using Common Data Elements for neurocognitive and behavioral functioning. The results show that intracranial pathology on acute CT-scans was more prevalent after moderate/severe TBI (65%) than after mild^RF+ TBI (35%; p = .035), while both groups had decreased white matter volume on conventional MRI (ps ≤ .029, ds ≥ ?0.74). The moderate/severe TBI group further showed decreased fractional anisotropy (FA) in a widespread cluster affecting all white matter tracts, in which regional associations with neurocognitive functioning were observed (FSIQ, Digit Span and RAVLT Encoding) that consistently involved the corpus callosum. FA had superior predictive value for functional outcome (i.e. intelligence, attention and working memory, encoding in verbal memory and internalizing problems) relative to acute CT-scanning (i.e. internalizing problems) and conventional MRI (no predictive value). We conclude that children with mild^RF+ TBI and moderate/severe TBI are at risk of persistent white matter abnormality. Furthermore, DTI has superior predictive value for neurocognitive out-come relative to conventional neuroimaging.     

建立胫骨癌痛模型的理论与实践

目的:骨癌痛动物模型已有报道,但还没有可接受的与人类骨癌痛相一致的模型。综述胫骨癌痛模型的研究进展及相关治疗前景。资料来源:应用计算机检索Medline1996-01/2006-03相关胫骨、癌痛和治疗的文献,检索词“tibial,cancerpain,therapy”,并限定文献语言种类为English。同时检索万方数据库1996-01/2006-05文献,检索词为“胫骨癌痛”,并限定语言种类为中文。资料选择:对资料进行初审,选取包括胫骨、癌痛和治疗的文献,开始查找全文。纳入标准:①胫骨和癌痛。②癌痛和治疗。排除标准:综述文献、重复研究、Meta分析类文章。资料提炼:共收集到51篇关于胫骨、癌痛和治疗的文献,纳入30篇关于胫骨和癌痛,癌痛和治疗的文献。资料综合:①目前认为,胫骨癌痛动物模型的疼痛表现与临床上所见的骨转移症状相似,可视为转移性骨癌痛模型。②恶性肿瘤骨损害的特征性变化是溶骨性骨吸收和恶性肿瘤疼痛本身,随骨质破坏的加剧,疼痛逐渐增强,移动或轻触可以引发急性痛,在到达极度痛之前,常因运动、负重或自发地间断发生突破痛,其发生的程度和频率与骨质破坏和溶骨活性成正相关。③目前从胫骨癌痛的实验研究中发现可供选择的药物主要有阿片类药、5-羟色胺受体阻断剂、抗惊厥药物加巴喷丁、环氧化酶2抑制剂表皮生长因子阻断剂。结论:利用动物胫骨癌痛模型来研究人类骨癌痛是可行的,但其研究有待进一步深入。从胫骨癌痛的实验研究中发现有许多药物可供选择,这展示了药物治疗骨癌痛的应用前景。     

组织浓度的意义

过去几十年至今,人们普遍以组织药物浓度来推测抗生素的活性和MIC,将组织匀浆液中测得的药物浓度与相应血浆中的药物浓度的比值来指导药物的临床应用。然而从药动学和药效学角度看这种方法并不合理,并最终可能对病人产生潜在危害。全组织药物浓度通常是通过测定碾碎或溶解后的匀浆组织的药物浓度而得到,这种测定方法忽略了组织的内部结构(如间质液、细胞及亚细胞结构等),药物不一定是均匀分布于组织中,并且,组织匀浆的药物浓度不能完全反映药物的有效活性。所以全组织药物浓度不能真实反应抗生素在感染部位的浓度。比如:多数细菌的感染部位在细胞外,故细胞外药物浓度才是关注的焦点。对于主要分布于胞外的药物,组织碾碎后使细胞内外液混合,则测得的药物浓度会低于实际感染部位的浓度;相反,对于主要分布于胞内的药物,测得的全组织浓度会大大高于细胞外浓度。对于胞内菌感染也可得相应结论。给药后抗生素会分布到全身不同部位,大多数药动学可以用二室或三室模型模拟。由于室间不能瞬间达到平衡,所以各室的药-时曲线也可能出现很大差异。在某时刻采集全组织样本就可获得该时间点组织浓度与血药浓度的比值。为了减少干扰,应在同一病人上采集达稳态的样品,但这并不可行且存在伦理学问...     

Optimal gantry angles and field sizes in kilovoltage cone-beam tomosynthesis for set-up of women with breast cancer undergoing radiotherapy treatment

Optimal beam geometry for kilovoltage cone-beam tomosynthesis (CB-TS) imaging for the set-up of 20 patients with breast cancer was analyzed and presented for prone and supine scenarios. Gantry angles and field sizes that allow maximum clearance and minimum dose to normal organs from kilovoltage imaging were determined for medial and lateral arcs. Optimal CB-TS arc span may vary depending on patient geometry, particularly on the separation between the cavity and the chest wall. CB-TS arc angles ?40° were found to be optimal for the cavity to chest wall separation d > 3 cm for supine set-up and d > 7 cm for prone set-up. Maximum required jaw openings were 20 × 14 cm². Recommendations are provided for clinical implementation of CB-TS imaging for breast cancer patients.     

Development and Implementation of National Practice Guidelines: A Prospect for Continuous Quality Improvement in Physiotherapy: Introduction to the method of guideline development

The development of national practice guidelines (NPGs) is an issue of much concern in healthcare policies world-wide to guarantee and to improve the quality and efficiency of care. The development and implementation of NPGs constitutes an important part of the quality of care policy of the Royal Dutch Physiotherapy Association (KNGF). This interest is due to pressure from society (policy-makers, healthcare managers, financiers and patients) on physiotherapists to ensure quality of care and to justify our position in the healthcare system. The development of NPGs can also be seen as a logical step in the process of professionalisation and quality assurance by physiotherapists.An NPG is described as a systematically developed statement, drafted by experts and directed at one aspect of the treatment of a health problem belonging to the domain of the profession. NPGs are based on the different stages of the physiotherapy care process, the available clinical evidence and expert consensus. Priority is given to a cost-effective approach and multidisciplinary consensus on diagnosis, treatment and primary or secondary prevention. Recommendations are based on the results of new or recorded systematic reviews or meta-analysis.NPGs are important state-of-the-art documents, which can guide professionals in their daily practice and make explicit to other relevant people what professionals can do in a certain situation or with a specific condition, and why they do it. NPGs have important functions, including supporting physiotherapists in their decision-making process; they are a frame of reference for orientation and educational purposes, they provide criteria for self-evaluation and peer review, and can initiate changes in established practice patterns.This paper describes the process and development of NPGs for physiotherapists in the Netherlands. In a companion paper the method and strategies for the implementation of NPGs and the need for evaluation of their outcome will be discussed.     

The neuroimaging findings in Sotos syndrome

We reviewed the neuroimaging studies of 40 patients with classic Sotos syndrome. The studies consisted of CT scans only in 4 patients and one or more MRI scans in 36 patients. The diagnosis of Sotos syndrome was made using well-established clinical criteria. The neuroimaging studies of each patient were evaluated subjectively by visual inspection and the chief findings were tabulated and grouped into five categories: 1) ventricular abnormalities, 2) extracerebral fluid spaces, 3) midline abnormalities, 4) migrational abnormalities, and 5) others. The most common abnormality of the cerebral ventricles was prominence of the trigone (90%), followed by prominence of the occipital horns (75%) and ventriculomegaly (63%). The supratentorial extracerebral fluid spaces were increased for age in 70% of the patients and the fluid spaces in the posterior fossa were increased in 70% also. A variety of midline abnormalities were noted but anomalies of the corpus callosum were almost universal. Gray matter heterotopias occurred in only 3 (8%) of 36 patients. Periventricular leukomalacia, presumably the result of prenatal or perinatal difficulties and unrelated to the basic condition, was the most common of the miscellaneous other abnormalities noted. The neuroimaging findings of Sotos syndrome are distinct enough to allow differentiation of this syndrome from other mental retardation syndromes with macrocephaly. Am. J. Med. Genet. 68:462–465, 1997. © 1997 Wiley-Liss, Inc.