氯胺酮辅助吗啡硬膜外持续缓慢注射治疗晚期癌痛的临床研究

硬膜外腔持续缓慢注射（PCEA）小剂量吗啡是治疗晚期癌痛的常用方法之一，具有简便、有效、镇痛时间长等优点，但随时间延长镇痛效果减弱并易产生耐药。氯胺酮作为非选择性N-甲基-D-天冬氨酸（NMDA）受体拮抗剂在临床上已广泛应用，小剂量氯胺酮对非NMDA受体并非传统意义上的镇痛作用，而是抗过敏、抗异常疼痛及抗耐受。本研究旨在观察顽固性晚期癌痛患者硬膜外小剂量氯胺酮辅助吗啡与对照组硬膜外单纯吗啡的镇痛效果，探索一种较理想的镇痛方案。     

中枢去甲肾上腺素和强啡肽A（1—17）在痛觉调制中的相互作用

大鼠以辐射热甩尾法测痛。应用脊髓蛛网膜下腔（ｉ．ｔ．）连续累加注射法观察药物的镇痛作用。（１）ｉ．ｔ．单独注射强啡肽Ａ（１－１７）２．５μｇ本身无镇痛作用，但与去甲肾上腺素（ＮＥ）合用时却能产生协同镇痛作用；该作用即能被ｉ．ｔ．注射α受体拮抗剂酚妥拉明３０μｇ所对抗，也能被κ阿片受体拮抗剂Ｎｏｒ－ＢＮＩＯ９μｇ所对抗。（２）强啡肽Ａ和ＮＥ的协同镇痛揭示在两种受体激动剂协同作用时，阻断其中一种受体，     

竞争性及非竞争性NMDA拮抗剂选择性防止小鼠吗啡耐受

通常在临床药物疗法中，吗啡主要作为μ受体激动剂来发挥作用，在运动实验中，发现吗啡与μ阿片受体具有相当高的亲和力并具有相当的选择性。但吗啡与δ及κ阿片受体也中等度亲和力。有实验表明，NMDA受体桔抗剂可以防止动物对吗啡镇痛效应产生耐受，但是NMDA受体桔抗剂是否可以防止动物对μ及δ受体激动剂的镇痛效应产生耐受则未见报道。本实验采用热水甩尾试验作为测痛方法分别观察了NMDA选择性拈抗剂MK801及非选择性桔抗剂LY235959对高选择性μ及δ阿片受体阿片激动剂DAMGO，PL017（μ受体）及［D－Ala2，Glu4］deltorphin（…     

小鼠低频和高频电针镇痛阿片机制的探讨

探讨小鼠低频和高频电针镇痛的阿片机制。方法：采用交叉耐受和受体药理学方法,以甩尾潜伏期增加的百发数作为评判电针镇痛效果的指标。结果：（１）吗啡镇痛与２Ｈｚ电针镇痛之间存在交叉耐受。（２）２／１００Ｈｚ电针镇痛分别与２Ｈｚ、１００Ｈｚ电针镇痛存在交叉耐受;而２Ｈｚ电针镇痛与１００Ｈｚ电针镇痛不存在交叉耐受。（３）ＣＣＫ受体拮抗剂Ｌ３６５,２６０可显著加强１００Ｈｚ电针镇痛效应,对２Ｈｚ电针镇痛无明显     

布托啡诺 吗啡用于剖宫产术后硬膜外镇痛对比观察

硬膜外腔注入小剂量吗啡是目前临床上广泛使用的术后镇痛方法，它简易、安全、效果确切，但其较高的恶心、呕吐发生率，增加了患者的不适感，影响术后镇痛的质量和水平。布托啡诺（Butorphanol）为阿片受体激动拮抗药，通过对脊髓κ受体的激动作用而产生脊髓镇痛，而作为μ受体拮抗药，对μ受体兴奋引起的恶心、呕吐有抑制作用。本研究拟通过对比布托啡诺、吗啡在剖宫产术后硬膜外镇痛的效果与副作用，为临床选择提供依据。     

中枢去甲肾上腺素与E－2078和盐酸二氢埃托啡在痛觉调制中的相互作用

给大鼠脊髓蛛网膜下腔（ｉ．ｔ．）单独注射去甲肾上腺素（ＮＥ）２．μｇ或强啡肽Ａ（１～８）衍生物（Ｋ激动剂）Ｅ－２０７８８０ｎｇ可产生轻度但显著的镇痛效应。同时ｉ．ｔ．注射１／２量ＮＥ和１／２量Ｅ－２０７８所产生的镇痛效应显著高于单独ＮＥ或Ｅ－２０７８的效应。将Ｅ－２０７８的剂量增加到９６和１１５ｎｇ（依次递增２０％），也得到与上述类似的结果，提示Ｅ－２０７８与ＮＥ在脊髓产生协同镇痛作用。用同样的方法观察皮下注射（ｓ．ｃ．）μ激动剂盐酸二氢埃托啡（ＤＨＥ）对ｉ．ｔ．注射ＮＥ镇痛的影响，发现ｓ．ｃ．ＤＨＥ在２６８，３７５，５２５ｎｇ三个剂量水平（依次递增４０％）下，１／２量ＮＥ和１／２量ＤＨＥ联合注药组产生的镇痛效应与单纯ＮＥ或ＤＨＥ组相比均无显著性差异。以上结果提示，脊髓内的ＮＥ与。阿片激动剂Ｅ－２０７８有协同镇痛作用，而与μ阿片激动剂ＤＨＥ仅有加和作用。     

100Hz电针和脊髓鞘内注射强啡肽A引起大鼠镇痛作用的性别差异

目的：比较１００Ｈｚ电针对雌性与雄性大鼠的镇痛作用,以及脊髓蛛网膜下腔（ｉ．ｔ．）注射阿片κ受体激动剂强啡肽Ａ１１７（ＤｙｎＡ）对雌、雄大鼠镇痛的差异性。方法：用辐射热甩尾法测痛。为避免强啡肽的致瘫作用,本实验采用小剂量（５μｇ或２．３ｎｍｏｌ,１０μｌ）ｉ．ｔ．注射,并以斜板试验观察大鼠运动功能的变化。结果：雌性大鼠１００Ｈｚ电针的镇痛作用强于雄性大鼠,这种差异以电针２０ｍｉｎ时最为显著。ｉ．ｔ．注射ＤｙｎＡ２．３ｎｍｏｌ后１０ｍｉｎ雌鼠有镇痛作用,而雄鼠在给药后６０ｍｉｎ内均未表现镇痛作用。结论：１００Ｈｚ电针对雌性大鼠的镇痛作用强于雄性,这种性别差异可能与脊髓水平强啡肽镇痛的性别差异有关。     

外周镇痛的机制及临床研究

外周感觉神经末梢存在阿片受体，炎症能使其密度和活性增加，但临床局部应用阿片类药物尚未能取得满意的效果，如何能使阿片类药物局部应用达到临床镇痛效果尚需进一步研究。不能通过血脑屏障的阿片类药物和阿片肽代谢酶抑制剂也仅限于动物实验，临床实验尚未进行。免疫细胞是内源性阿片肽的一个重要来源，在外周炎症疼痛控制中有重要的作用，这对于免疫抑制的状态如癌症、糖尿病、AIDS疼痛的解释以及炎症性疾病治疗策略的设计都是非常重要的，Mrg是一类新近发现的、位于外周神经组织的阿片受体。NMDA（N-甲酰-D天门冬氮酸）受体是一种离子型谷氨酸受体，广泛存在于外周躯体或内脏的痛觉传导通路上，外周NMDA受体的活化或表达的改变与疼痛发生发展密切相关。总之，阿片类药物的外周镇痛作用，可避免全身阿片类药物应用产生的呼吸抑制、成瘾、耐受等中枢副作用，又为阿片类药物的应用开辟了新途径，但仍有许多问题需进一步研究。     

人参茎叶甙对吗啡耐受性的影响

本文研究了人参茎叶皂甙对吗啡耐受性产生的影响。实验结果表明，人参茎叶皂甙５０ｍｇ／ｋｇ灌胃给药能够明显对抗吗啡引起的小鼠自主活动增强现象，并抑制吗啡镇痛（小鼠对夹尾压痛）的耐受作用。长期应用吗啡对小鼠体重增长抑制的作用逐渐减弱。人参茎叶皂甙能够加强吗啡抑制体重增长的作用。上述结果提示，人参茎叶皂甙对吗啡耐受性的产生一定的抑制作用。     

小剂量氯胺酮静脉使用和吗啡硬膜外应用超前镇痛的比较

目的：对胃切除手术病人，术前静脉使用小剂量的氯胺酮、硬膜外应用吗啡，或者两者联合应用，通过随机双盲法来评价其镇痛效果。方法：术前硬膜外使用吗啡，或者静脉使用小剂量的氯胺酮对于胃切除病人有效果，但是不明显。硬膜外应用吗啡，和对照组相比，VAS评分在术后24、48小时降低，在术后6、12小时吗啡的使用量减少。静脉使用小剂量的氯胺酮，VAS评分和吗啡的使用量在术后6、12、24、48小时于对照组相比降低。术前联合使用硬膜外注射吗啡和静脉使用小剂量的氯胺酮有较好的镇痛作用，VAS评分和吗啡的使用量在术后6、12、24、48小时明显减少。在活动状态，VAS评分和疼痛评分在组中最低。结论：结果表明对于术前的预镇痛，在上腹部手术如胃切除术，必须阻断阿片和NMDA受体。这两种方法有太后镇痛作用，但是不明显。硬膜外应用吗啡可能只是部分影响脊髓上的受体，静脉使用氯胺酮通过迷走神经阻断脑干的敏感性。     

Guns and Knives in New Mexico: Patterns of Penetrating Trauma, 1978–1993

Objective: To identify patterns of nonfatal and fatal penetrating trauma among children and adults in New Mexico using ED and medical examiner data.
Methods: The authors retrospectively sampled in 5-year intervals all victims of penetrating trauma who presented to either the state Level-1 trauma center or the state medical examiner from a 16-year period (1978–1993). Rates of nonfatal and fatal firearm and stabbing injury were compared for children and adults.
Results: Rates of nonfatal injury were similar (firearm, 34.3 per 100,000 person-years; stabbing, 35.1). However, rates of fatal injury were significantly different (firearm, 21.9; stabbing, 2.7; relative risk: 8.2; 95% confidence interval: 5.4, 12.5). From 1978 to 1993, nonfatal injury rates increased for children (p = 0.0043) and adults (p < 0.0001), while fatal penetrating injury remained constant. The increase in nonfatal injury in children resulted from increased firearm injury rates. In adults, both stabbing and firearm nonfatal injury rates increased.
Conclusions: Nonfatal injury data suggest that nonfatal violence has increased; fatal injury data suggest that violent death rates have remained constant. Injury patterns vary by age, mechanism of trauma, and data source. These results suggest that ED and medical examiner data differ and that both are needed to guide injury prevention programs.     

Systematic Reviews Published in the January 2011 Issue of The Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly as a DVD and monthly online. The January 2011 issue (first quarterly DVD for 2011) contains 4515 complete reviews, 1985 protocols for reviews in production, and 13,521 one-page summaries of systematic reviews published in the general medical literature. In addition, there are citations of 641,000 randomized controlled trials, and 14,018 cited papers in the Cochrane methodology register. The health technology assessment database contains over 9300 citations. One hundred and seven new reviews have been published in the last 3 months, of which five have potential relevance for practitioners in pain and palliative medicine.     

Interprofessional approaches to creating safe,high quality health care

Three supplementary perspectives are presented arguing that interprofessional collaboration is both necessary and desirable. Nonetheless, there are often too many serious intra-professional barriers and obstacles to interprofessional collaboration to make it successful. Some of these barriers, it is argued and illustrated, are found in the multiple ways in which professional identity is tacitly acquired and embodied in the practitioners' habitual, everyday practice. The paper then explores ways in which reflection, especially Second order reflection, can help to elucidate and overcome these obstacles, as well as increasing professional adaptability and competence.     

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.     

Prise en charge des entorses externes de cheville : étude clinique préliminaire sur l’efficacité du dispositif Myolux™

Ankle sprains are the most common injury of the musculoskeletal system and are associated with significant societal and economic impacts. It has been proven that classical therapeutic strategies may not be effective in preventing recurrent injuries: the recurrence rates reported in the literature can reach 73%. In order to provide an effective rehabilitation solution, a destabilizing orthosis was developed. This device is equipped with a mechanical articulator reproducing the subtalar mechanics and placed under the heel. In this paper, we present the main results of a preliminary clinical study conducted between 2004 and 2007. All subjects included in this study were treated with the abovementioned orthosis during 10 rehabilitation sessions of 30 minutes each. Data show a relatively low recurrence rate of 12% for the overall population. Moreover, it's of primary importance to note that this satisfactory ratio is largely reduced (3% of recurrence rate) for the 29 patients who performed one training session per month after the 10th initial rehabilitation sessions. Hence, the destabilizing orthosis appears to be an effective solution to prevent recurrent ankle sprains. However, joint protection requires long-term and regular training sessions. This result has motivated the development of a similar device allowing patients to perform training sessions at home. Finally, data obtained in this study are promising awaiting the final results of the comparative, multicentric and independent clinical trials currently managed by the Hospices Civils de Lyon.     

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.