老年脑卒中恢复期吞咽障碍的康复治疗

目的:观察老年脑卒中恢复期吞咽功能训练对吞咽障碍的疗效.方法:20例老年脑卒中恢复期吞咽障碍患者在接受吞咽功能训练后进行才藤吞咽障碍7级评定.结果:老年脑卒中恢复期吞咽障碍患者在接受吞咽功能训练后功能明显改善,治疗前、后比较有差异(P<0.01).结论:老年吞咽障碍患者经吞咽功能训练能明显提高吞咽功能,恢复了经口摄食,促进自立能力,达到援助患者生活的目的.     

Sphingosine-mediated phosphatidylinositol metabolism and calcium mobilization

The cytokine-mediated stimulation of sphingomyelin (SM) metabolism is emerging as an important signal transduction pathway via the generation of ceramide and sphingosine, products which have been shown to affect a wide variety of biological processes. Because SM-mediated signal transduction is initiated via the hydrolysis of an integral membrane phospholipid by a phospholipase C-like enzyme (sphingomyelinase) to yield lipids which modulate protein kinase C activity, the SM and phosphatidylinositol (PI) signaling pathways share certain similarities. The present study was undertaken to examine the potential for interplay between SM and PI turnover by testing the effects of sphingosine, sphingosine-1-phosphate, and ceramide on PI turnover. In dermal fibroblasts, sphingosine stimulated a rapid dose-dependent hydrolysis of PI, yielding inositol 1,4,5-triphosphate, followed by increased levels of intracellular calcium. Sphingosine-induced inositol phosphate (IP) accumulation was observed between 5 and 30 microM sphingosine with a maximal accumulation of 2.7-fold over control levels. Enhanced IP formation was measured as early as 5 s following sphingosine treatment and IP levels remained elevated for more than 60 min. Intracellular calcium mobilization accompanied the dose-dependent accumulation of IPs in response to sphingosine, although this effect was not apparent until after a 30-40-s lag period. Interestingly, sphingosine-1-phosphate stimulated a more rapid release of intracellular Ca2+ than sphingosine, but it had no effect on PI turnover. DL-threo-Dihydrosphingosine, a competitive inhibitor of sphingosine kinase, stimulates both PI turnover and Ca2+ flux, but does not block the action of sphingosine relative to those two processes. Ceramide (added as C2-ceramide), N-stearylamine, and stearoyl-D-sphingosine did not affect PI turnover or Ca2+ mobilization. Pretreatment of intact cells with pertussis toxin partially inhibited sphingosine-mediated IP accumulation, suggesting a role for guanine nucleotide binding protein(s) (G protein) in sphingosine-stimulated PI turnover. Furthermore, guanosine 5'-O-(3-thiotriphosphate) stimulated, whereas guanosine 5'-O-(2-thiodiphosphate) inhibited, sphingosine-induced IP accumulation in permeabilized cells. Collectively, these data suggest that sphingosine enhances PI turnover by stimulating phospholipase C activity, and the activation of this process may be modulated by G protein interactions. Thus, the regulation of PI turnover and Ca2+ mobilization by sphingosine may represent another mechanism by which sphingosine modulates cell function and that these effects can be distinguished from those of ceramide.     

Warfarin anticoagulation in the perioperative period: is it safe?

A useful correlation between maximum thyroid uptake and radioiodine urine levels at different times after exposure was developed in order to determine when the intervention with an adequate blocking agent might still be effective. In an animal model (dog), six different doses were administered in the range of 100-600 kBq. The best correlation was found between the 125I uptake after 48 h (T-48) and urine radioactivity 4-6 h (U-4, U-5, U-6) after exposure. For the case of U-4, the equation Y(T-48) = 0.790 X(U-4) + 2.973 (r = 0.974 with a level of significance of p < 0.001) was obtained. An analogous study, carried out in humans (n = 20) to whom 1311 was administered, showed a similar correlation and level of significance: Y(T-24) = 1.162 X(U-4)+3.263 (r = 0.926; p < 0.001). The validity of this correlation was confirmed in four volunteers who received small doses of 125I(25-100 kBq), with good agreement between measured and extrapolated thyroid uptake and a mean difference of less than 10% (CV = 16.2%). Three different blocking agents were then tested in the same dog: potassium iodide, potassium perchlorate, and a thionamide (Tapazole). The blocking action of the first two compounds was about 90%, as opposed to only 48% for the third compound. Potassium iodide was chosen for its limited side effects and more universal utilization. The final study, carried out with four different doses, indicated that 25 mg of KI is the ideal amount to be administered to the dog. This corresponds to approximately 100 mg for a 70 kg human being (i.e., 1.4 mg kg(-1)). This dose, when administered to a volunteer 4 h after exposure, provided a thyroid blocking of 68%.     

Con: antiarrhythmic drugs should not be used to suppress ventricular ectopy in the perioperative period

The alterations in autonomic tone imposed by the conduct of anesthesia and surgery predispose patients to ventricular ectopy. It is important to initially view any ectopy as a warning sign and promptly check the adequacy of ventilation and oxygenation. Most commonly an inadequate depth of anesthesia, surgical manipulation or electrolyte abnormality will be causative. Treatment of this underlying problem will usually suffice to terminate the ectopy. Importantly, many patients have preexisting, chronic, complex ventricular ectopy that gets revealed because of perioperative electrocardiographic monitoring. All available pharmacologic agents have significant adverse side effects. To date, all investigations examining outcome of suppression of ventricular ectopy show that successful suppression of ventricular ectopy was associated with an increased mortality. Although the prognosis for patients is worse when complex ventricular ectopy is associated with cardiac structural abnormalities, the optimal therapeutic approach to such patients remains undefined. Unless new data supporting the use of antiarrhythmic drugs in the perioperative setting become available, the risk to benefit ratio is considered unfavorable.     

Continuous measurements of cardiac output in the perioperative period

Management of critically ill patients is based on knowledge of fundamental physiological variables. Automatized and continuous measurement of these variables is preferable. A new system based upon the thermodilution method has been developed to measure cardiac output automatically and continuously. We evaluated the system in the potentially unstable perioperative period with possible great and rapid changes in cardiac output. Twenty patients, scheduled for open heart or abdominal aortic aneurysm surgery, were included into the study, which was approved by the local ethical committee. The patients were monitored for up to 30 hours. At random intervals five iced bolus thermodilution cardiac output (BCO) determinations were made and compared to the continuous measurements (CCO). Two hundred and thirty-one pairs of data were obtained. The cardiac outputs ranged from 2.5-14.9 l/min. The absolute bias was 0.31 l/min (95% limits of agreement -1.4 l/min to 2.0 l/min). The mean relative error was 4.7% with a standard deviation of the relative error of 15.4%. The linear regression was represented by: CCO = 11.352 x BCO - 0.36. The correlation coefficient R was 0.90 (p < 0.001). In conclusion, the CCO measurement technique is a promising clinical method. The method is straightforward, requires no calibration, is independent of vascular geometry and measures with its limitations volumetric flow. Finally automatic and continuous patient monitoring provides more information and has potential to reveal previously undetected haemodynamic events.     

Management of specific medical conditions in the perioperative period

BACKGROUND: Reversal of ischemia after myocardial infarction by revascularization is worthwhile only if viability exists in a sufficiently large portion of the left ventricle. METHODS AND RESULTS: To determine myocardial hypoperfusion reversibility and its influence on segmental and global function, we studied 50 patients after myocardial infarction. Three technetium 99m-tetrofosmin scintigraphies were performed: 1 at rest, 1 after 0.6 mg sublingual nitroglycerin (NTG), and 1 after injection at peak stress. First-pass multigated radionuclide angiography was obtained at rest and after NTG. Each patient also underwent a stress redistribution-reinjection thallium-201 scintigraphy. During stress 99mTc-tetrofosmin, 104 segments had normal uptake, 51 showed moderately reduced uptake, and 186 had severely reduced uptake. Of these 186 segments, 33 (18%) improved at rest, and 41 (22%) improved only after NTG. Fifty-nine (79%) of these segments with improved uptake were also found to have reversible defects on 201TI imaging. In the 26 patients with ventricular dysfunction, a 73% agreement was found between the functional and 99mTc-tetrofosmin uptake post-NTG improvement, whereas a 69% agreement was found with thallium reinjection. No significant differences were seen between 99mTc-tetrofosmin and 201T1 imaging. CONCLUSION: Nitroglycerin administration during 99mTc-tetrofosmin scintigraphy improves the detection of myocardium with reversible hypoperfusion in patients with a previous myocardial infarction.     

Metabolic consequences of different perioperative fluid therapies in the neonatal period

The rat CNS has been previously shown to synthesize pregnenolone (PREG) and to convert it into progesterone (PROG) and some of its 5 alpha-reduced metabolites. However, the brain cell types involved in the metabolic conversions of PREG are poorly known. Selective conditions were used to obtain purified cultures of neurons and astrocytes from mouse or rat fetal striatum and cerebral cortex. Neurons converted PREG to only one identified metabolite, 20 alpha-dihydro PREG, whereas astrocytes converted PREG also to PROG, 5 alpha-dihydro PROG, and 3 alpha (3 beta)-5 alpha-tetrahydro PROG. Therefore, astrocytes can convert the neurosteroid PREG into the steroid hormone PROG and the neuromodulatory steroid 3 alpha, 5 alpha-tetrahydro PROG, whereas neurons lack the delta 5-3 beta-hydroxysteroid dehydrogenase isomerase activity (and cholesterol side-chain cleavage activity), necessary for the biosynthesis of PROG. Provision of steroid substrates is another example of cross-talk between glial cells and neurons.     

Gait pattern in the early recovery period after stroke

The gait patterns of eighteen patients who had had a single infarct due to obstruction of the middle cerebral artery were evaluated within one week after the patients had resumed independent walking and before a gait rehabilitation program had been initiated. Gait was analyzed with use of motion analysis, force-plate recordings, and dynamic surface electromyographic studies of the muscles of the lower extremities. The patterns of motion of the lower extremity on the hemiplegic side had a stronger association with the clinical severity of muscle weakness than with the degree of spasticity, balance control, or phasic muscle activity. There was a delay in the initiation of flexion of the hip during the pre-swing phase, and flexion of the hip and knee as well as dorsiflexion of the ankle progressed only slightly during the swing phase. During the stance phase, there was decreased extension of the hip that was related to decreased muscle effort and a coupling between flexion of the knee and dorsiflexion of the ankle. The abnormal patterns of motion altered the velocity, the length of the stride, the cadence, and all phases of the gait cycle. The duration of the pre-swing phase was prolonged for the patients who had the slowest gait velocities. There also were abnormal movements of the upper extremity, the trunk, the pelvis, and the lower extremity on the unaffected side in an effort to compensate for the decreased velocity on the hemiplegic side. As velocity improved, these abnormal movements decreased. Therefore, the goal of therapy should be to improve muscle strength and coordination on the hemiplegic side, especially during the pre-swing phase.     

Methylprednisolone and cortisol metabolism during the early post-renal transplant period

Despite the widespread use of methylprednisolone and the well-appreciated effects of this drug on HPA suppression, little data is available which describes individual patient exposure to both methylprednisolone and cortisol following renal allograft placement. The clinical utilization of methylprednisolone during the early post-transplant period is based upon standardized dosing protocols that do not consider factors which may influence the pharmacokinetics of this drug during the post-transplant period. Therefore, this study was designed to examine the pharmacokinetics of methylprednisolone (mean dose: 28 mg) and cortisol pharmacodynamics in 9 renal transplant recipients (4 females; 5 males) who were studied during the early post-transplant period (5 to 12 days after surgery). All patients (mean serum creatinine: 1.4 +/- 0.3 mg/dl) had serial blood samples collected over a 12- to 24-hour period (depending upon the dosing schedule) which were analyzed concurrently for methylprednisolone and cortisol. A three-fold variation in drug clearance ranging from 174 to 638 ml/h/kg with a range in the volume of distribution of 0.83 to 2.24 l/kg and resultant half-lives ranging from 1.20 to 3.02 hours was noted. The cortisol response was quantitated by a 12-hour cortisol area under the curve (C-AUC12) to examine the interpatient cortisol patterns during the early post-transplant period. C-AUC12 ranged from 44.0 to 636 ng.h/ml. Significant correlations were noted between the cortisol plasma concentration at 12 hours and methylprednisolone clearance and area under the concentration versus time curve (AUC). Interpatient variability in the disposition of methylprednisolone and cortisol response noted during the early post-transplant period contradict the clinical assumptions which underlie the fixed dosing protocols currently utilized for methylprednisolone.     

Differential recovery from impairment to the phonological lexicon

Word production was examined in four aphasics diagnosed acutely with neologistic jargon and who displayed impairment to the lexical stage of phonological production (Kohn & Smith, 1993, 1994a). To investigate the major source of their nonword errors (i.e., neologisms, phonemic paraphasias), single word production was tested at three different times over the first 6 months postonset, with one subject receiving additional testing at 14 months postonset. Two subjects showed signs of recovery to the phonological output system with respect to: (1) improved word production scores, (2) increased frequency of phonemic paraphasias versus neologisms, and (3) increased production of target phonemes. These subjects also displayed above-chance production of target phonemes and no significant tendency to perseverate phonemes across picture-naming trials. It was argued that this pattern reflects a resolving disturbance in retrieving entries from the phonological lexicon. The other two subjects showed no improvement in word production. They also consistently produced target phonemes at chance levels and had a tendency to perseverate phonemes across picture-naming trials. This static pattern of performance was considered to reflect loss of information from the phonological lexicon. The neuroanatomical damage sustained by each case was consistent with these two recovery patterns.     

The recovery of vanadium from ash obtained during the combustion of fuel oil at thermal power stations

The recovery modes of vanadium from the vanadium-containing ashes of foreign thermal power stations (the Fiomo Santo station (Italy) (sample 1) and stations in Leina, Germany, (sample 2) and Cagliari, Italy (sample 3)) are established. It is shown that there is no single approach to directly recovering vanadium from various ashes. Each ash needs its own leaching mode depending on its chemical and phase compositions, namely, for samples 1 and 2, this is leaching with water and 9% sulfuric acid at S: L = 1: 4 and t = 60–80°C for 30 min; for sample 3, this is leaching with 5% sulfuric acid in the presence of hydrogen peroxide at S: L = 1: 4 and t = 20°C for 30 min and then for 60 min at 60°C. The conditions for the hydrolytic precipitation of vanadium from the leaching solutions are selected. It is shown that, in order to isolate it from solutions at the stage of hydrolytic precipitation most completely, it is necessary to change the degree of oxidation of vanadium to +5 using hydrogen pentoxide at t = 20°C for 30 min and then precipitate vanadium peroxide at pH = 1.8–2.0 and t = 95°C for 2 h.     

Changes in psychological features in patients for anesthesia and operation during perioperative period

In patients with previous myocardial infarction (MI), depressed heart rate variability (HRV) may reflect a reduction in vagal activity and lead to cardiac electrical instability. Interventions designed to increase HRV may be of clinical interest. Data on the effects of calcium antagonists on HRV in post-MI patients are very limited. The aim of our study was to assess the effects of verapamil on HRV and on the sympathovagal balance after MI. Fifty consecutive patients with a first MI, stable sinus rhythm, and left ventricular ejection fraction >0.40 were studied. Each patient underwent two 24-hour Holter recordings, 1 at baseline and another after 4 days of treatment with verapamil retard (180 mg 2 times daily). Time and frequency domain parameters of HRV were analyzed. All time domain measurements increased significantly after verapamil: the standard deviation of all NN intervals (SDNN) from 87.1 +/- 31.4 to 98.1 +/- 30.3 ms (p <0.05) and the log-transformed percentage of pairs of adjacent NN intervals that differ >50 ms (pNN50) from 0.57 +/- 0.42 to 0.76 +/- 0.45 (p <0.01). The standard deviation of the averages of RR interevals (SDANN) (75.9 +/- 30.1 vs 86.3 +/- 29.4 ms, p <0.05), root-mean-square of successive differences between RR intervals (rMSSD) (23.0 +/- 11.7 and 28.1 +/- 13.1 ms, p <0.01), and the triangular HRV index (28.3 +/- 9.6 vs 23.4 +/- 8.6, p <0.001) also increased. A significant inverse correlation was found between improvement in HRV indexes induced by verapamil and baseline values. Spectral analysis showed a significant increase in high-frequency power of 58.5% without changes in low and very low components. With normalized units, significant reductions in low-frequency power and low- to high-frequency ratio were observed. Diabetic patients did not show any significant changes in HRV on administration of verapamil. These findings indicate that verapamil, administered during the subacute phase of MI, improves both global and short-period indexes of HRV and induces a shift in the sympathetic-parasympathetic interaction toward vagal predominance. This effect may contribute to an explanation of the beneficial effects of verapamil that have been reported in post-MI patients.     

Energy metabolism in sedentary and active 49- to 70-yr-old women

This study examined differences between long-term exercising (LE) and long-term nonexercising (LNE) women [n = 24; age 56.4 +/- 6.2 (SD) yr] for resting metabolic rate (RMR) and energy expenditure in the free-living state by using doubly labeled water (DLW). There was a statistically significant difference (P = 0.0002) between the 12 LE (94.85 +/- 8.44 kJ . kg-1 . day-1) and 12 LNE (81.16 +/- 6.62 kJ . kg-1 . day-1) for RMR, but this difference was only marginally significant (P = 0.06) when the data (MJ/day) were subjected to an analysis of covariance with fat-free mass as the covariate. The DLW data indicated that the eight most active LE (12.99 +/- 3.58 MJ/day) expended significantly (P = 0.01) more energy than did the eight least active LNE (9.30 +/- 1.15 MJ/day). Energy expenditures ranged from 7.64 to 18.15 MJ/day, but there was no difference (P = 0.96) between the LE and LNE in energy expenditure during activity that was not designed to either improve or maintain fitness. These cross-sectional data on 49- to 70-yr-old women therefore suggest that 1) aerobic-type training results in a greater RMR per unit of body mass and also when statistical control is exerted for the effect of the metabolically active fat-free mass, 2) there is a large range in the energy intake necessary to maintain energy balance, and 3) aerobic training does not result in a compensatory reduction in energy expenditure during the remainder of the day.     

应用阶段磨矿阶段选别流程提高金回收率实践

通过两段直接磨细后浮选与阶段磨矿阶段浮选工艺的研究厦处理团结沟矿石的生产实践，指出阶段磨矿阶段选别工艺流程对于处理金矿物以细粒、不均匀嵌布为主、含泥大的矿石，是提高浮选回收率、降低精矿产率、提高精矿品拄的有效措施。     

Study of platelet-activating factor acetylhydrolase in the perioperative period of patients undergoing cardiac surgery

This study was conducted to determine whether brief, intermittent exposure to hypoxia with little change in nutrient intake would affect fetal growth. Pregnant rats were exposed to 1 or 2 h of hypoxia (FiO2 = 0.09-0.095) from days 15 to 19 of gestation. Exposure to 1 h of hypoxia decreased fetal body weight and length, liver weight and increased the brain/liver weight ratio (p < 0.05) as compared to controls. Two hours of hypoxia decreased fetal body weight and length, and heart, lung, kidney, gut, brain and liver weights (p < 0.01), but did not affect the brain/liver weight ratio. Two hours of hypoxia decreased maternal food intake and weight gain (p < 0.05), but fetal growth was not significantly altered in pair-fed controls. These data demonstrate that brief, intermittent periods of intrauterine hypoxia have significant effects on fetal growth.     

Perceived side effects and benefits of coronary angioplasty in the early recovery period

BACKGROUND/AIM: Appendicitis and its complications remain a common problem affecting patients of all age groups. Foreign bodies are a rare cause of appendicitis. We tried to define potentially dangerous foreign bodies that may cause appendicitis and summarize general guidelines for their clinical management. METHODS: A 100-year literature review including 256 cases of ingested foreign bodies within the appendix with emphasis on: (1) objects that are more prone to cause appendicitis or appendiceal perforation; (2) foreign bodies that are radiopaque and may be detected during follow-up with plain abdominal films, and (3) guidelines for clinical management. RESULTS: Complications usually occur with sharp, thin, stiff, pointed and long objects. The majority of these objects are radiopaque. An immediate attempt should be made to remove a risky object by gastroscopy. If this fails, clinical follow-up with serial abdominal radiographs should be obtained. If the anatomical position of the object appears not to change and, most commonly, remains in the right lower abdominal quadrant, an attempt at colonoscopic removal is indicated. If this is unsuccessful, laparoscopic exploration with fluoroscopic guidance should be carried out to localize and remove the objects either by ileotomy, colotomy, or by appendectomy. CONCLUSION: Foreign bodies causing appendicitis are rare. However, if stiff or pointed objects get into the appendiceal lumen they have a high risk for appendicitis or perforation. These foreign bodies are almost always radiopaque.     

Changes in plasma dopamine-beta-hydroxylase activity during the perioperative period of cardiac surgery: an index of sympathetic nerve activity

To evaluate the usefulness of plasma dopamine-beta-hydroxylase (DBH) activity as an index of sympathetic nerve activity during cardiac operations, we examined the serial changes in plasma DBH activity, in relation to the plasma noradrenaline (NA) level and hemodynamic parameters, in patients who underwent cardiac surgery. The plasma DBH activity decreased significantly after cardiopulmonary bypass, and remained low during dopamine (DA) infusion until 72 h after the operation. However, recovery of the hemodynamic parameters, being the mean arterial pressure, heart rate and cardiac index, was seen as early as 1-3 h postoperatively. It was therefore assumed that the plasma DBH activity takes a long time to recover after an operation. The time-course changes in the plasma NA level were quite different from the changes in DBH activity, with an apparent negative correlation being observed between them. Thus, there is a possibility that exogenously administered DA, as well as increased plasma NA, might inhibit DBH activity during cardiac surgery. Moreover, since catecholamines are often administered upon completion of cardiac surgery, measurement of the plasma catecholamine level would be inappropriate for evaluating real sympathetic nerve activity. From the results of this study, it is surmised that measurement of the plasma DBH activity could be useful for estimating the intrinsic sympathetic nerve activity of patients who have undergone cardiac surgery.