有效利用课前谈话 构建和谐高效课堂

课前谈话,是指教师利用课前的几分钟时间为沟通师生之间的情感、活跃课堂气氛而设计的即兴式谈话。叶圣陶先生曾经说过：＂文章的开头,犹如一幕戏剧开幕的一刹那,情景选择得恰当,足以奠定全剧的情调,笼罩全幕的气氛,使大家立刻把纷乱的杂念放下,专心致志看那下文的发展。＂俗话说得好,良好的开端是成功的一半,写文章如此,授课亦是如此。虽然课前谈话只有短短的几分钟,但却能充分体现教师的课堂机智以及教师平时的知识储备和所具备的独特的人格魅力。

Efficacy and safety of thalidomide in patients with hepatocellular carcinoma

AIM: To evaluate which patients with hepatocellular carcinoma (HCC) are most likely to respond to thalidomide treatment. METHODS: From July 2002 to July 2004, patients with HCC who received thalidomide treatment, were enrolled. We extracted relevant data from the patients’ medical records, including history and type of hepatitis, comorbidity, serum α-fetoprotein (α-FP) level, volumetric changes in tumor, length of survival, and the dose, duration, side effects of thalidomide treatment. The tumor response was evaluated. On the basis of these data, the patients were divided into two groups: those with either partial response or stable disease (PR + SD group) and those with progressive disease (PD group). RESULTS: Two of 42 (5%) patients had a partial tumor response after treatment with thalidomide, 200 mg/d, and 9 (21%) had stable disease. Patients in the PR + SD group all had cirrhosis. Comparing patients with and without cirrhosis, the former were more likely to respond to thalidomide therapy (PR + SD: 100% vs PD: 64.5%, P = 0.041 < 0.05). Thalidomide was significantly more likely to be effective in tumors smaller than 5 cm (PR + SD: 63.6% vs PD: 25.8%, P = 0.034 < 0.05). Compared with patients with progressive disease (PD), patients in the PR + SD group had a higher total dose of thalidomide (13 669.4 ± 8446.0 mg vs 22 022.7 ± 11 461.4 mg, P = 0.023 < 0.05) and a longer survival (181.0 ± 107.1 d vs 304.4 ± 167.1 d, P = 0.047 < 0.05). Patients with comorbid disease had a significantly greater incidence of adverse reactions than those without (93.8% vs 60.0%, P = 0.021 < 0.05). The average number of adverse reactions in each person with a comorbid condition was twice as high as in those without other diseases (2.2 ± 1.3 vs 1.1 ± 1.2; P = 0.022 < 0.05). CONCLUSION: Thalidomide therapy is most likely to beeffective in patients with early stage small HCC, espe- cially in those with other underlying diseases. A low dose (200 mg/d) of thalidomide is recommended to continue the treatment long enough to make it more effective.

Superiority of split dose midazolam as conscious sedation for outpatient colonoscopy

AIM: To elucidate the efficacy and safety of a split dose of midazolam in combination with meperidine for colonoscopy. METHODS: Eighty subjects undergoing outpatient colonoscopy were randomly assigned to group A or B. Group A (n = 40) received a split dose of midazolam in combination with meperidine. Group B (n = 40) received a single dose of midazolam in combination with meperidine. Outcome measurements were level of sedation, duration of sedation and recovery, degree of pain and satisfaction, procedure-related memory, controllability, and adverse events. RESULTS: Group A had a lower frequency of significant hypoxemia (P = 0.043) and a higher sedation score on withdrawal of the endoscope from the descending colon than group B (P = 0.043). Group B recovered from sedation slightly sooner than group A (P < 0.002). Scores for pain and memory, except insertion-related memory, were lower in group A one week after colonoscopic examination (P = 0.018 and P < 0.030, respectively). Poor patient controllability was noted by the endoscopist and nurse in group B (P = 0.038 and P = 0.032, respectively). CONCLUSION: Split dose midazolam in combination with meperidine resulted in a safer, more equable sedation status during colonoscopic examination and a reduction in procedure-related pain and memory, but resulted in longer recovery time.

Usefulness of bispectral monitoring of conscious sedation during endoscopic mucosal dissection

AIM: To assess the usefulness of bispectral index (BIS) monitoring in order to carry out endoscopic submucosal dissection (ESD) safely and with patients' satisfaction. METHODS: Three hundred sixty-six patients with an early-stage neoplasm of the digestive tract were enrolled. The BIS monitor (A-1050: Aspect medical systems/NIHON KOHDEN, Tokyo, Japan) was used. The appropriate sedative condition was set at 55 to 75 BIS levels (BIS value) during the endoscopic procedures. RESULTS: Among 366 cases, 13 were accompanied by adverse events during and/or after ESD. All episodes occurred in cases with BIS value between 56 and 65. Hypotension was observed in four cases, and bradycardia in six. Respiratory distress was observed in two cases with chronic pulmonary obstructive disease. All patients with adverse events were able to leave the hospital without extension of the hospitalization. CONCLUSION: BIS monitoring is useful to safely perform ESD. A BIS value of 70 to 75 is suitable for ESD.

Sedation-associated hiccups in adults undergoing gastrointestinal endoscopy and colonoscopy

AIM:To investigate whether the incidence of hiccups in patients undergoing esophagogastroduodenoscopy (EGD) or same-day bidirectional endoscopy (EGD and colonoscopy;BDE) with sedation is different from those without sedation in terms of quantity,duration and typical onset time.METHODS:Consecutive patients scheduled for elective EGD or same-day BDE at the gastrointestinal endoscopy unit or the health examination center were allocated to two groups:EGD without sedation (Group A) and BDE with sedation (Group B).The use of sedation was based on the patients' request.Anesthesiologists participated in this study by administrating sedative drugs as usual.A single experienced gastroenterologist performed both the EGD and the colonoscopic examinations for all the patients.The incidence,duration and onset time of hiccups were measured in both groups.In addition,the association between clinical variables and hiccups were analyzed.RESULTS:A total of 435 patients were enrolled in the study.The incidences of hiccups in the patients with and without sedation were significantly different (20.5% and 5.1%,respectively).The use of sedation for patients undergoing endoscopy was still significantly associated with an increased risk of hiccups (adjusted odds ratio:8.79,P < 0.001) after adjustment.The incidence of hiccups in males under sedation was high (67.4%).The sedated patients who received 2 mg midazolam developed hiccups more frequently compared to those receiving 1 mg midazolam (P = 0.0028).The patients with the diagnosis of gastroesophageal reflux disease (GERD) were prone to develop hiccups (P = 0.018).CONCLUSION:Male patients undergoing EGD or BDE with sedation are significantly more likely to suffer from hiccups compared to those without sedation.Midazolam was significantly associated with an increased risk of hiccups.Furthermore,patients with GERD are prone to develop hiccups.

Effects of thalidomide on angiogenesis and tumor growth and metastasis of human hepatocellular carcinoma in nude mice

AIM: To investigate the effects of thalidomide on angiogenesis, tumor growth and metastasis of hepatocellular carcinoma in nude mice.METHODS: Twenty-four nude mice were randomly divided into therapy group and control group, 12 mice in each group. Thalidomide dissolved in 0.5% sodium carboxyl methyl cellulose (CMC) suspension was administered intraperitoneally once a day at the dose of 200 mg/kg in therapy group, and an equivalent volume of 0.5% CMC in control group. Mice were sacrificed on the 30th d, tumor size and weight and metastases in liver and lungs were measured. CD34 and VEGF mRNA in tumor tissue were detected by immunohistochemistry and semi-quantitative RT-PCR respectively and microvessel density (MVD) was counted. Serum concentrations of TNF-α and ALT and AFP were also tested.RESULTS: MVD and VEGF mRNA in therapy group were less than those in control group (31.08±16.23 vessels/HP vs 80.00±26.27 vessels/HP, 0.0538±0.0165 vs 0.7373±0.1297,respectively, P＜0.05). No statistical difference was observed in tumor size and weight and metastases in liver and lungs.TNF-α was significantly lower in therapy group than in control group (28.64±4.64 ng/L vs42.69±6.99 ng/L, P＜0.05). No statistical difference in ALT and AFP was observed between groups.CONCLUSION: Thalidomide can significantly inhibitangiogenesis and metastasis of hepatocellular carcinoma.Italso has inhibitory effects on circulating TNF-α.

Listening to Turkish classical music decreases patients’anxiety,pain,dissatisfaction and the dose of sedative and analgesic drugs during colonoscopy:A prospective randomized controlled trial

AIM： To determine whether listening to music decreases the requirement for dosages of sedative drugs, patients＇ anxiety, pain and dissatisfaction feelings during colonoscopy and makes the procedure more comfortable and acceptable. METHODS： Patients undergoing elective colonoscopy between October 2005 and February 2006 were randomized into either listening to music （Group 1, n = 30） or not listening to music （Group 2, n = 30）. Anxiolytic and analgesic drugs （intravenous midazolam and meperidine） were given according to the patients＇ demand. Administered medications were monitored. We determined their levels of anxiety using the State-Trait Anxiety Inventory Test form. Patients＇ satisfaction, pain, and willingness to undergo a repeated procedure were self-assessed using a visual analog scale. RESULTS： The mean dose of sedative and analgesic drugs used in group 1 （midazolam： 2.1 ± 1.4, meperidine： 18.1 ± 11.7） was smaller than group 2 （midazolam： 2.4 ± 1.0, meperidine： 20.6 ± 11.5）, but without a significant difference （P 〉 0.05）. The mean anxiety level in group 1 was lower than group 2 （36.7 ± 2.2 vs 251.0 ± 1.9, P 〈 0.001）. The mean satisfaction score was higher in group 1 compared to group 2 （87.8 ± 3.1 vs 58.1 ± 3.4, P 〈 0.001）. The mean pain score in group i was lower than group 2 （74.1 ± 4.7 vs 39.0 ± 3.9, P 〈 0.001）. CONCLUSION： Listening to music during colonoscopy helps reduce the dose of sedative medications, as well as patients＇ anxiety, pain, dissatisfaction during the procedure. Therefore, we believe that listening to music can play an adjunctive role to sedation in colonoscopy. It is a simple, inexpensive way to improve patients＇ comfort during the procedure.

Unsedated ultrathin upper endoscopy is better than conventional endoscopy in routine outpatient gastroenterology practice:A randomized trial

AIM： to compare the feasibility and patients＇ tolerance of esophagogastroduodenoscopy （EGD） using a thin endoscope with those of conventional oral EGD and to determine the optimal route of introduction of smallcaliber endoscopes. METHODS： One hundred and sixty outpatients referred for diagnostic EGD were randomly allocated to 3 groups： conventional （C）-EGD （9.8 mm in diameter）, transnasal （TN）-EGD and transoral （TO）-EGD （5.9 mm in diameter）. Pre-EGD anxiety was measured using a 100-mm visual analogue scale （VAS）. After EGD, patients and endoscopists completed a questionnaire on the pain, nausea, choking, overall discomfort, and quality of the examination either using VAS or answering some questions. The duration of EGD was timed. Blood oxygen saturation （SaO2） and heart rate （HR） were monitored during EGD. RESULTS： Twenty-one patients refused to participate in the study. The 3 groups were well-matched for age, gender, experience with EGD, and anxiety. EGD was completed in 91.1% （41/45）, 97.5% （40/41）, and 96.2% （51/53） of cases in TN-EGD, TO-EGD, and C-EGD groups, respectively. TN-EGD lasted longer （3.11 ± 1.60 min） than TO-EGD （2.25 ± 1.45 min） and C-EGD （2.49 ± 1.64 rain） （P 〈 0.05）. The overall tolerance was higher （P 〈 0.05） and the overall discomfort was lower （P 〈 0.05） in TN-EGD group than in C-EGD group. EGD was tolerated ＂better than expected＂ in 73.2% of patients in TN-EGD group and 55% and 39.2% of patients in TO-EGD and C-EGD groups, respectively （P 〈 0.05）. Endoscopy was tolerated ＂worst than expected＂ in 4.9% of patients in TN-EGD group and 17.5% and 23.5% of patients in TO- EGD and C-EGD groups, respectively （P 〈 0.05）. TN-EGD caused mild epistaxis in one case, The ability to insuffiate air, wash the lens, and suction of the thin endoscope were lower than those of conventional instrument （P 〈 0,001）, All biopsies performed were adequate for histological assessment. CONCLUSION： Diagnostic TN-EGD is better tolerated than C-EGD, Narrow-diameter endoscope has a level of diagnostic accuracy comparable to that of conventional gastroscope, even though some technical characteristics of these instruments should be improved, Transnasal EGD with narrow-diameter endoscope should be proposed to all patients undergoing diagnostic EGD.

Carbon dioxide insufflation during colonoscopy in deeply sedated patients

AIM:To compare the impact of carbon dioxide(CO2) and air insufflation on patient tolerance/safety in deeply sedated patients undergoing colonoscopy.METHODS:Patients referred for colonoscopy were randomized to receive either CO2 or air insufflation during the procedure.Both the colonoscopist and patient were blinded to the type of gas used.During the procedure,insertion and withdrawal times,caecal intubationrates,total sedation given and capnography readings were recorded.The level of sedation and magnitude of patient discomfort during the procedure was assessed by a nurse using a visual analogue scale(VAS)(0-3).Patients then graded their level of discomfort and abdominal bloating using a similar VAS.Complications during and after the procedure were recorded.RESULTS:A total of 142 patients were randomized with 72 in the air arm and 70 in the CO2 arm.Mean age between the two study groups were similar.Insertion time to the caecum was quicker in the CO2 group at 7.3 min vs 9.9 min with air(P = 0.0083).The average withdrawal times were not significantly different between the two groups.Caecal intubation rates were 94.4% and 100% in the air and CO2 groups respectively(P = 0.012).The level of discomfort assessed by the nurse was 0.69(air) and 0.39(CO2)(P = 0.0155) and by the patient 0.82(air) and 0.46(CO2)(P = 0.0228).The level of abdominal bloating was 0.97(air) and 0.36(CO2)(P = 0.001).Capnography readings trended to be higher in the CO2 group at the commencement,caecal intubation,and conclusion of the procedure,even though this was not significantly different when compared to readings obtained during air insufflation.There were no complications in both arms.CONCLUSION:CO2 insufflation during colonoscopy is more efficacious than air,allowing quicker and better cecal intubation rates.Abdominal discomfort and bloating were significantly less with CO2 insufflation.

Luminal oxidants selectively modulate electrogenic ion transport in rat colon

AIM： To investigate the effects of luminal exposure to H2O2 and two related thiol oxidizing agents on basal and stimulated chloride secretion in native colon using electrophysiological and pharmacological approaches. METHODS： Unstripped rat distal colon segments were mounted in Ussing chambers. Potential difference, calculated resistance and short-circuit current across unstripped colon segments were monitored with a dual voltage/current clamp. Paracellular permeability was assessed by measuring the mucosa-to-serosa flux of a fluorescent probe （FITC）. RESULTS： Luminal exposure to hydrogen peroxide transitorily stimulated chloride secretion without altering barrier function. This stimulatory effect could be blocked by basolateral atropine but not indomethacin. The cysteine and methionine oxidizing compounds, phenylarsine oxide and chloramine T respectively, mimicked the effect of H2O2, except for a drop in transcolonic resistance after 30 min. In contrast to the observed stimulatory effect on basal secretion, cAMP-stimulated electrogenic ion transport was blunted by luminal H2O2. However, the Ca^2＋- activated response remained unchanged. CONCLUSION： H2O2 may be an important selective modulator of intestinal ion and water secretion in certain pathologic conditions such as inflammation or ischemiareperfusion by multiple mechanisms.

Balanced propofol sedation administered by nonanesthesiologists:The first Italian experience

AIM:To assess the efficacy and safety of a balanced approach using midazolam in combination with propofol,administered by nonanesthesiologists,in a large series of diagnostic colonoscopies.METHODS:Consecutive patients undergoing diagnostic colonoscopy were sedated with a single dose of midazolam(0.05 mg/kg)and lowdose propofol(starter bolus of 0.5 mg/kg and repeated boluses of 10 to 20 mg).Induction time and deepest level of sedation,adverse and serious adverse events,as well as recovery times,were prospectively assessed.Cecal intubation and adenoma detection rates were also collected.RESULTS:Overall,1593 eligible patients were included.The median dose of propofol administered was 70 mg(range:40120 mg),and the median dose of midazolam was 2.3 mg(range:24 mg).Median induction time of sedation was 3 min(range:14 min),and median recovery time was 23 min(range:1040 min).A moderate level of sedation was achieved in 1561(98%) patients,whilst a deep sedation occurred in 32(2%) cases.Transient oxygen desaturation requiring further oxygen supplementation occurred in 8(0.46%;95% CI:0.2%0.8%)patients.No serious adverse event was observed.Cecal intubation and adenoma detection rates were 93.5%and 23.4%(27.8%for male and 18.5%for female,subjects),respectively.CONCLUSION:A balanced sedation protocol provided a minimalization of the dose of propofol needed to target a moderate sedation for colonoscopy,resulting in a high safety profile for nonanesthesiologist propofol sedation.

Gastric carditis:Is it a histological response to high concentrations of luminal nitric oxide?

During the last decade, inflammation (carditis) and in- testinal metaplasia localized to immediately below the human gastro-oesophageal junction have received much attention in relation to the rising incidence of cancer at this site. Since these histological findings are frequently observed even among those who are H pylori-negative, the causative factors for such histologic events at the human gastro-oesophageal junction remain obscure. A series of recent studies have demonstrated that a high level of salivary nitrite is sustained over several hours after the ingestion of a high nitrate meal, and that the nitrite in swallowed saliva is rapidly converted to nitric oxide by an acid catalyzed chemical reaction at the gastro-oesophageal junction. Eventually, a substantial amount of nitric oxide diffuses from the lumen into the adjacent tissue. Therefore, the human gastro-oesopha- geal junction is likely to be a region of high nitrosative stress. Considering the life-time exposure of the gastro- oesophageal junction to cytotoxic levels of nitric oxide, this may account for the high prevalence of inflamma- tion, intestinal metaplasia, and subsequent development of neoplasia at this site. Although gastric acid, pepsin, and bile acid have been intensively investigated as a cause of adenocarcinoma at the gastro-oesophageal junction and the distal esophagus, nitric oxide and the related nitrosative stress should also be examined.

Depressant effect and mechanism of atorvastatin on the chronic rejection of aortic allograft in rats

Objective To investigate the depressant effect and mechanism of atorvastatin on the chronic rejection of aortic allograft in rats. Methods： The models of abdominal aorta transplantation were made with micro-surgery in rats. The recipients were divided into three groups： allograft control group, atorvastatin-treated group and isograft control group. Vascular intimal thickness in all of the groups were observed by histological examination. The expression of PCNA and α-SMA were determined by immunohistochemistry. The content of nitric oxide was determined by nitrate reductase chromatometry. Results： The vascular intimal thickness in rats of atorvastatin-treated group （11.60% ± 2.40% ） were lower than those in allograft control group （34.60 % ± 6.40 % ; P 〈 0.05） and higher than those in isograft control group （1.15 % ± 0.65 %; P〈 0.05 ）. The expression level of PCNA was decreased in atorvastatin-treated group （4.80% ± 0.80% ） than allograft control group （18.40% ± 1.80% ; P〈0.05） and higher than isograft group （1.20% ± 0.40% ; P〈0.05）. Conclusion： The expression of PCNA in the transplant aorta could be suppressed by atorvastatin, which resalted in relief of chronic rejection of aortic allograft.

Does deep sedation impact the results of 48 hours catheterless pH testing?

AIM： To study a cohort of patients undergoing 48 h Bravo pH testing receiving deep sedation with propofol. METHODS： We retrospectively reviewed the charts of 197 patients （81 male, 116 female） who underwent Bravo esophageal pH monitoring from July 2003 to January 2008. All patients underwent Bravo pH probe placement via esophagogastroduodenoscopy （EGD） and received propofol for sedation. Patients on a proton pump inhibitor （89 patients） were excluded. Acid reflux variables measured included the total, upright, and supine fractions of time at pH 〈 4 and DeMeester score, and were compared between day I and day 2. RESULTS： Of the 108 patients that were included in the study, the most common indication for Bravo pH monitoring was heartburn, with chest pain being the second most common. A signed rank test revealed no statistically significant difference between day I and day 2 reflux episodes. CONCLUSION： Patients who received propofol for sedation for EGD with Bravo pH capsule placement did not experience any significant difference in reflux episodes from day 1 to day 2.

THE CLINICAL ANALYSIS OF HYPNOTICS AND SEDATIVES USED IN OUTPATIENT CLINICS IN GENERAL HOSPITAL

Aim. To statistic the usage of hypnotics and sedatives in outpatient and emergency clinics prescriptions in one day. Method. Check all prescriptions on April 29, 1987 and November 13, 1995 in order to know the quantity, kind and distribution of hypnotics and sedatives in different outpatient departments. Result. There were 1 319 prescriptions on April 29, 1987. Among them, hypnotics and sedatives were 122(9. 24%); in comparing with 2 065 prescriptions on November 13, 1995, hypnotics and sedatives were 141 (6. 82%). Benzodiazepine used more than 80% in all prescriptions. Conclusion. The possibility of long-term low-dosage using benzodiazepine is present. It must strengthen the control and education to avoid the drug-abuse.

Sedative and hypnotic effect of freeze-dried paeoniflorin and Sini San freeze-dried powder in pentobarbital sodium-induced mice

OBJECTIVE: To investigate the sedative and hypnotic activity of paeoniflorin and freeze-dried Sini San powder on mice and provide a reliable method for determining the pharmacodynamic material basis of Sini San.METHODS: Male adult mice weighing 20-22 g were used in this study. Three experiments were carried out. Synergism with pentobarbital was used as an index for hypnotic effect. Loss of the righting reflex was used to determine the start of sleep.Sleep latency and sleeping time were recorded in each experiment.RESULTS: The coefficient of variation of the suprathreshold dose(55 mg/kg) was significantly lower than that of the threshold dose. The sleep latency of mice was significantly decreased, and the sleeping time of mice was significantly prolonged. The effects of paeoniflorin and Sini San on prolonging the sleeping time of mice induced by pentobarbital sodium were significantly stronger than those in the control group.CONCLUSION: Paeoniflorin produces significant sedative and hypnotic effects, and there is an obvious dose-effect relationship.

Clinical study of midazolam sequential with dexmedetomidine for agitated patients undergoing weaning to implement light sedation in intensive care unit

Purpose： To evaluate midazolam sequential with dexmedetomidine for agitated patients undergoing weaning to implement light sedation in ICU. Methods： This randomized, prospective study was conducted in Tianjin Third Central Hospital, China. Using a sealed-envelope method, the patients were randomly divided into 2 groups （40 patients per group）. Each patient of group A received an initial loading dose of midazolam at 0.3 3 mg/kg-h 24 h before extubation, followed by an infusion of dexmedetomidine at a rate of 0.2-1 μg/kg-h until extubation. Each patient of group B received midazolam at a dose of 0.3 3 mg/kg.h until extubation. The dose of sedation was regulated according to PASS sedative scores maintaining in the range of-2-1. All patients were continuously monitored for 60 min after extubation. During the course, heart rate （HR）, mean artery pressure （MAP）, extubation time, adverse reactions, ICU stay, and hospital stay were observed and recorded continuously at the following time points： 24 h before extubation （T1）, 12 h before extubation （T2）, extubation （T3）, 30 rain after extubation （T4）, 60 min after extubation （TS）. Results： Both groups reached the goal of sedation needed for ICU patients. Dexmedetomidine was associated with a significant increase in extubation quality compared with midazolam, reflected in the prevalence of delirium after extubation （20% （8/40） vs 45% （18140））, respectively （p=0.017）. There were no clinically significant decreases in HR and MAP after infusing dexmedetomidine or midazolam. In the group A, HR was not significantly increased after extubation; however, in the group B, HR was significantly increased compared with the preextubation values （p 〈 0.05）. HR was significantly higher in the group B compared with the group A at 30 and 60 min after extubation （both, p 〈 0.05）. Compared with preextubation values, MAP was significantly increased at extubation in the group B （p 〈 0.05） and MAP was significantly higher at T3, T4, T5 in the group B than group A （p 〈 0.05）. There was a significant difference in extubation time （（3.0± 1.5） d vs （4.3 ± 2.2） d, p 〈 0.05）, ICU stay （（5.4 ± 2.1 ） d vs （8.0± 1.4） d, p 〈 0.05）, hospital stay （（10.1 ± 3.0） d vs （15.3 ± 2.6） d, p 〈 0.05） between group A and B. Conclusion： Midazolam sequential with dexmedetomidine can reach the goal of sedation for ICU agitated patients, meanwhile it can maintain the respiratory and circulation parameters and reduce adverse reactions.