脑卒中患者急性期血脂水平与病情严重程度的关系

目的探讨脑卒中患者急性期血脂水平与病情严重程度的关系。方法采用前瞻性队列研究的方法,检测2002年12月~2004年8月所有入院时病程<24h的脑卒中患者548例(其中出血性卒中214例,缺血性卒中334例)的血脂水平;采用斯堪的纳维亚卒中评分(SSS)量表评价患者入院时神经功能缺损程度;比较不同卒中类型患者的血脂水平及其与病情严重程度的关系。结果出血性卒中患者入院时血清胆固醇(TC)为(4.30±1.16)mmol/L,三酰甘油(TG)为(1.37±0.72)mmol/L,明显低于缺血性卒中患者TC和TG水平[(4.90±1.15)mmol/L,(1.52±0.94)mmol/L](均P<0.001);入院时TC<6.0mmol/L的患者443例,TG<2.0mmol/L的患者356例,SSS分别为(32.76±18.63)分和(29.21±18.25)分,明显低于TC>6.0mmol/L和TG>2.0mmol/L患者的SSS[(44.83±14.13)分和(45.95±13.21)分](均P<0.001)。结论出血性卒中患者急性期血清TC和TG水平明显低于缺血性卒中患者;急性期血脂水平较低的脑卒中患者病情较严重。     

欧洲卒中研究动向——第七届欧洲卒中年会及其卫星会议简介

欧洲卒中研究动向———第七届欧洲卒中年会及其卫星会议简介华西医科大学附属第一医院神经内科（６１００４１）刘鸣第七届欧洲卒中年会于１９９８年５月２７日～３０日在英国爱丁堡举行。大会前后有至少六个与卒中有关的卫星会议。下面将作者参加的三个会议依时间顺序作...     

循证医学在临床实践中的应用(一)循证医学简介

1 循证医学的概念 循证医学(evidence-based medicine,EBM)即遵循证据的医学.指医生对病人的诊断、治疗、预防、康复和其他决策应建立在当前最佳临床研究证据、临床专业知识技能及病人的需求三者结合的基础之上.     

靶向特异基因小干扰RNA预防乙醇性股骨头坏死的研究

目的 观察靶向PPARγ基因小干扰RNA(siRNA)预防灌胃法家兔乙醇性股骨头坏死的效果.方法 将96只家兔随机分为4组,每组24只.N组:灌胃法给予生理盐水10ml/(kg·d).M组:灌胃法给予烈性酒(含乙醇度46%,V/V)10 ml/(kg·d);S组:实验1、3、5个月第1天,随机选择侧别手术,穿刺注入股骨头内25 μl siRNA重组腺病毒,同M组灌酒;CO组:同S组手术,同M组灌酒,不注入siRNA重组腺病毒.于2、4、6个月末分批处死家兔,观察血清学和股骨头组织病理学变化.结果　实验6个月时,N、M、CO、S组血清甘油三酯含量分别为(1.21±0.12)、(4.59±1.58)、(4.63±1.17)、(4.32±1.20)mmol/L;总胆固醇含量分别为(2.35±0.33)、(19.59±1.58)、(20.13±1.17)、(18.32±1.20)mmol/L;脂肪细胞平均直径分别为(40.89±2.41)、(48.65±2.93)、(49.45±2.63)、(42.52±2.57)μm;骨小梁面积分数分别为(41.80±2.47)%、(30.70±2.86)%、(29.80±2.69)%、(41.60±2.87)%;空骨陷窝计数分别为(12.30±1.73)%、(22.40±1.52)%、(23.10±1.62)%、(11.70±1.46)%;PPARγ表达量分别为(0.29±0.05)、(0.66±0.12)、(0.61±0.15)、(0.33±0.05);骨钙素mRNA表达量分别为(0.92±0.07)、(0.19±0.11)、(0.23±0.08)、(0.88±0.11);PPARγ蛋白表达量分别为(0.75±0.08)、(1.60±0.11)、(1.55±0.12)、(0.65±0.05).M、CO组病理变化明显,髓内造血组织减少,脂肪细胞增殖肥大,骨小梁变细、稀疏、部分断裂;S组股骨头内最大脂肪细胞平均直径、空骨陷窝计数、骨坏死发生率、PPARγ基因与蛋白表达量均明显低于M、CO组(P＜0.01,P＜0.05),S组与N组差异无统计学意义(P＞0.05).结论　靶向PPARγ基因siRNA腺病毒载体能够有效阻断乙醇诱导的家兔股骨头内MSCs中PPARγ基因表达及成脂分化,预防乙醇性ONFH的发生.

Abstract：

Objective To observe the effect of small interfering RNA (siRNA) adenovirus vectors targeting PPARγto prevent the alcohol-induced osteonecrosis of the femoral head (ONFH) in rabbits.Methods Ninety-six rabbits were randomly divided into four groups. In group N, normal saline ( 10 ml/kg every day) was poured into stomach. In group M, the strong wine (the volume fraction was 46% alcohol,10 ml/kg every day) was poured into stomach. In group S, under the randomly selected side and anesthesia, the animals were injected with 25 μl siRNA adenovirus drip into the femoral head and then the puncture hole was closed on the 1st day at the 1st, 3rd and 5th month of the experiment, and at the same time the strong wine (the volume fraction was 46% alcohol, 10 ml/kg every day) was poured into stomach. In group CO, animals were treated with the same method as the group S, but not injected with siRNA adenovirus drip. The animals were sacrificed in batches at 2nd, 4th and 6th month after the experiment. The serology and pathological changes of the femoral head were studied. Results At the 6th month, the triglyceride (TG, mmol/L) contents in groups N, M, CO and S were (1.21 ±0. 12), (4.59 ± 1.58), (4.63 ±1.17) and (4. 32 ± 1.20), the cholesterol levels ( CHO, mmol/L) were (2. 35 ± 0. 33), ( 19. 59 ±1.58), (20. 13 ± 1. 17) and ( 18.32 ± 1.20), the average diameter of the max adipocyte (μm) was (40. 89 ± 2. 41 ), (48.65 ± 2.93 ), (49. 45 ± 2. 63 ) and ( 42. 52 ± 2. 57 ), the trabeculace area fraction was (41.80 ±2. 47)%, (30. 70 ±2. 86)%, (29. 80 ±2. 69)% and (41.60 ±2. 87)%, the percentage of empty osteocyte lacunae was (12.30 ± 1.73)%, (22.40 ± 1.52)%, (23. 10 ± 1.62)% and (11.70 ±1.46)%, the expreasion levels of PPARγ mRNA were (0.29 ±0.05), (0.66±0. 12), (0.61±0.15) and (0. 33 ± 0. 05 ), the expression levels of osteocalcin mRNA were (0. 92 ± 0. 07 ), (0. 19 ± 0. 11 ), (0. 23 ±0. 08) and (0. 88 ± 0. 11 ), the expression levels of PPARγprotein were ( 0. 75 ± 0. 08 ), ( 1.60 ± 0. 11 ),(1.55 ±0. 12) and (0.65 ±0.05), respectively. In groups M and CO, the pathological changes were obvious; there was decreased hematopoietic tissue, proliferation and hypertrophy of the adipocytes, increased fatty tissue, and thinned, sparse or breoken bone trabeculae in the femoral head; the area fraction of the trabeculae was reduced. In group S, the average diameter of the max adipocyte, percentage of empty osteocyte lacunae, incidence of ONFH, the expressions of PPARγmRNA and protein were obviously reduced as compared with groups M and CO (P ＜0. 01,P ＜0. 05). There was no statistically significant difference between group S and group N (P ＞ 0. 05). Conclusion siRNA adenovirus vectors targeting PPARγcan efficaciously suppress the expression of PPARγ gene and adipogenic differentiation of the MSCs in the femoral head induced by alcohol, which may prevent the development of the alcohol-induced ONFH in rabbits.     

2例起源于右房的房性心动过速体表心电图鉴别

例1 患者男性,65岁.因阵发性心悸5年,"阵发性室上性心动过速"入院.查体:体温36.5℃,心率76次/分,脉搏20次/分,血压140/80mmHg,心界无扩大,心率76次/分,律齐,各瓣膜听诊区未闻及杂音.心电图(图1A)示:窦性心律,频率61次/分.     

中频电理疗联合更昔洛韦治疗带状疱疹疗效观察

目的观察中频电联合更昔洛韦治疗带状疱疹的临床疗效。方法治疗组予中频电流直接作用于带状疱疹皮损区域,同时予更昔洛韦0.25 g静脉注射;有水疱、渗出者外搽炉甘石洗剂,对照组不用中频电流直接作用于带状疱疹皮损区域,余同治疗组。两组均治疗后第7天时观察治疗结果。结果两组痊愈率和有效率比较差异均有统计学意义(P均0.01),两组患者皮损停止渗出、疱疹结痂、止痛、脱痂时间相比差异亦有统计学意义(P均0.01)。结论中频电理疗具有止痛的作用,与更昔洛韦联合应用治疗带状疱疹,疗效明显优于对照组。     

多发性肝内外胆管结石长期取石术1例的护理

胆石病是一种常见疾病,随着人们生活改善和平均年龄的增高,本病有逐年增多的趋势.胆石可以发生在肝内胆管,肝外胆管或胆囊内.也可同时存在于胆囊与胆管内或同时存在于肝内胆管与肝外胆管内.肝外胆管结石可原发于胆管,也可来自胆囊.结石可位于肝总管和胆总管.多数位于胆总管下端.结石多含有胆红质;但来自胆囊者为胆固醇结石或混合性结石.一部分结石比较松软,状似泥沙.胆管结石易于并发感染,且常可累及肝和胰腺.肝内胆管结石中我国比较多见,多数原发于肝内胆管,为胆色素结石.可局限在肝内某个区域的胆管内,亦可广泛分布于肝内肝管.常同时有肝外胆管结石.肝实质易受胆管炎症和淤胆的损害.     

中国临床指南循证制定的方法学现状分析

目的 了解我国当前临床实践指南循证制定的方法学现状.方法 收集中华医学会2010 ～ 2012年公开发表的临床指南,以关键词“临床指南、实践指南”检索CNKI、VIP、WanFang Data及中国临床指南文库网站(www.cgc-chinaebm.org/index.aspx),同时补充检索临床常见大病指南,而后按照纳入与排除标准选择文献,并选取AGREE Ⅱ量表中指南开发严谨性领域相关8个条目对纳入指南进行评分,符合评价指标者计1分,否则计0分.结果 ①共纳入22个国内循证制定的指南,其中13个是首版,9个是更新版,指南平均更新时间为3～5年.②纳入指南涵盖领域包括中风、糖尿病、慢性乙型肝炎、高血压和儿科营养等.③指南参考文献数在10 ～ 218篇不等,有9个指南共引用了24篇Cochrane系统评价,占总参考文献数的2.62％ (24/916),引用Cochrane系统评价最多是急性缺血性脑卒中指南共7篇.④每个指南参与制定的专家人数在2 ～ 95人不等.⑤每个指南总页数在4～150页不等.⑥纳入指南评分在4～7分不等,推荐意见强度与证据质量相对应.但不少指南在检索方法、外部专家审阅和更新程序未清楚描述.结论 循证制定临床实践指南是当前国内临床实践指南发展趋势,但指南开发方法的严谨性和报告规范等有待提高.Cochrane系统评价引用率较低.我们提倡指南推荐意见强度与证据质量水平相对应,同时应考虑国情、配套政策对实际操作性的影响.未来应注重对指南开发方法、报告规范、指南可及性及相关人员的规范化培训.     

延髓梗死23例临床分析

目的:了解延髓梗死的临床表现与影像学改变的特点.方法:对23例延髓梗死患者进行临床症状、体征及影像学改变的分析.结果:表现为典型Wallenberg综合征者16例,不典型者7例,后者临床表现复杂、多变,12例患者进行头部CT检查延髓部位均未见异常,全部病例行头部MRI检查均见延髓部位有长T1、长T2斑片状均匀信号.结论:本组延髓梗死多数(2/3以上)表现为典型的Wallenberg综合征,但不典型病例不少,引起后者的原因可能与小脑后下动脉变异较多、侧支循环的建立、梗死灶向周围延伸、腔隙性梗死等多种因素有关,影像学检查应首选MRI.