支气管结核支气管镜下治疗76例临床分析

目的探讨支气管结核镜下的治疗方法及临床效果。方法总结76例支气管结核患者的临床特征,所有病例经抗结核及支气管镜下治疗,17例支气管腔狭窄严重者行支气管镜下高压球囊扩张治疗,分析评价其临床效果。结果76例中溃疡型49例,瘢痕型25例,肉芽增殖型2例,治疗总有效率92．11％。结论支气管镜下治疗溃疡型支气管内膜结核疗效确切,高压球囊扩张治疗是治疗和预防支气管狭窄的有效方法。     

支气管镜下电凝加冷冻及球囊扩张序贯治疗支气管狭窄与闭锁56例疗效评价

目的 回顾分析2007年1月至2008年12月住院和门诊收治的确诊支气管内膜结核引发气管、支气管狭窄或闭塞患者56例,通过支气管镜下氩气刀电凝、冷冻、高压球囊扩张有机序贯治疗,评价疗效.方法 随访观察56例患者应用支气管镜下氩气刀电凝、专用冷冻治疗仪冷冻、高压球囊扩张等有机序贯结合治疗后,定时气管镜及胸部CT观察随访狭窄或闭塞气管、支气管开放愈合情况,并做结果 分析.结果 56例狭窄部位中53个狭窄部位均不同程度恢复,有效率为94.6%;15个闭塞支气管13例得到重新开放,不张肺组织大部分复张,有效率占86.7%.临床症状均缓解.结论 支气管镜下氩气刀电凝、冷冻、高压球囊扩张序贯治疗内膜结核引发的支气管狭窄、闭塞效果良好,疗效显著,避免了肺叶切除,恢复肺不张,使大多数支气管内膜结核患者支气管狭窄或闭塞获得了良好治疗效果.     

支气管镜介入治疗在支气管结核治疗中的价值

目的探讨支气管镜介入治疗在支气管结核治疗中的价值。方法回顾性分析152例经支气管镜检查确诊后通过支气管镜介入治疗的支气管结核(EBTB)患者的临床资料。结果 152例患者经支气管镜检查确诊为支气管结核,通过全身抗结核药物治疗联合支气管镜下气道病变部位灌注抗结核药物、球囊扩张气道成形术、腔内冷冻等治疗后病情明显改善。结论通过支气管镜介入下局部灌注抗结核药物、球囊扩张气道成形术、腔内冷冻等治疗在支气管结核治疗中具有重要的价值。     

纤维支气管镜下冷冻联合高压球囊扩张治疗瘢痕狭窄型气管支气管结核的效果观察

目的观察纤维支气管镜下冷冻联合高压球囊扩张治疗瘢痕狭窄型气管支气管结核(tracheobronchial tuberculosis,TBTB)的效果及安全性。方法选择2012年1月—2015年8月确诊的瘢痕狭窄型TBTB患者90例,随机分为3组,每组30例。3组均在常规抗结核治疗基础上行支气管镜下介入治疗:冷冻治疗(冷冻组)、高压球囊扩张治疗(球囊组)和冷冻联合高压球囊扩张治疗(联合组),每2周治疗1次,共治疗4次。1疗程结束后1个月评价疗效,比较治疗前后主要症状分级、第1秒用力呼气容积(FEV1)及气道直径变化,以及并发症发生情况。结果联合组临床总有效率为90.0%高于冷冻组的60.0%和球囊组的70.0%,差异有统计学意义(P0.05)。3组治疗后主要症状分级、FEV1、气道直径较治疗前均有所改善(P0.05),且治疗后上述指标联合组较其他两组改善更为明显(P0.05)。3组治疗后均无严重并发症发生。结论相较单一支气管镜下介入治疗,冷冻联合高压球囊扩张治疗瘢痕狭窄型TBTB效果更佳。     

良性大气道狭窄的支气管镜介入治疗

目的 介绍该院支气管镜下治疗良性大气道狭窄的临床经验。方法 28例良性气道狭窄病例，根据狭窄的病变性质、部位和程度采取支气管镜下介入治疗方法，对治疗后疗效评价、肺功能改善和并发症以及综合治疗方法的采用进行分析。结果 28例病人共进行支气管镜介入治疗72次。其中行高压球囊扩张治疗16例，病因中以气管、支气管内膜结核为主；高频电治疗8例，以气管切开后肉芽组织增生和腔内息肉、良性肿瘤为主；气道内支架置入9例，病因以气管切开后气管狭窄和复发性多软骨炎气道累及为主。部分病人合用了多种治疗方法。治疗后24例病人呼吸困难迅速缓解，部分病人肺功能明显改善。高频电治疗病例中大出血1例，球囊扩张治疗以轻度胸痛和少量出血为主。支架置入后1例出现明显肉芽增生，需要介入治疗。结论 支气管镜下介入技术治疗良性气道狭窄可以迅速解除气道梗阻，呼吸困难迅速改善，肺功能改善明显，并发症较少。     

可弯曲支气管镜在支气管结核诊断及治疗中的意义

目的 探讨可弯曲支气管镜(纤维支气管镜/电子支气管镜,简称支气管镜)在支气管结核诊断及治疗中的意义.方法 回顾性的分析92例经可弯曲支气管镜检查确诊和治疗的支气管结核(EBTB)患者的临床资料.结果 92例患者均经可弯曲支气管镜检查确诊为支气管结核(EBTB),并通过全身抗结核药物化疗联合可弯曲支气管镜下气道病变部位灌注药物和球囊扩张气道成形术等治疗后病情明显好转.结论 支气管结核临床上容易漏诊和误诊,确诊依赖于支气管镜检查;支气管镜下抗结核药灌注联合球囊扩张等介入治疗在支气管结核的治疗中具有重要的意义.     

支气管结核的诊断和介入治疗的现状与思考

经支气管镜介入治疗已逐渐成为治疗支气管结核的新手段.为使该项技术在我国规范化开展,呼吸科医生必须严格掌握其治疗适应证,明确治疗目的并正确选择治疗方法.支气管结核的支气管镜下分型分为5型,即炎症浸润型、溃疡坏死型、肉芽增殖型、疤痕狭窄型、管壁软化型.在支气管结核的治疗中,应根据不同的类型,采用包括高频电刀、氩气刀、激光、冷冻、球囊扩张、支架置入以及腔内注射抗结核药物等综合介入技术进行治疗.     

无痛支气管镜下球囊扩张与冷冻术联合治疗支气管结核安全性及其影响因素的评价

目的探讨无痛支气管镜下球囊扩张与冷冻术联合治疗支气管结核安全性及其影响因素。方法在无痛支气管镜条件下,先用XP60型超细支气管镜观察支气管结核病变情况,结合术前高分辨率计算机体层X线摄影(HRCT)三维重建的方法详细了解此狭窄处远端支气管功能情况。再更换IT260型治疗纤维支气管镜,选择与狭窄部位相应的(略小于正常支气管管径)型号的球囊扩张导管进行扩张,球囊扩张后用气管镜清除血迹分泌物和坏死脱落的组织。视病灶大小采取多点多处的冻融治疗。每周行扩张冷冻治疗术一次,视病灶情况行扩张冷冻治疗平均2～4次。结果 25例患者术后完全有效12例,明显有效8例,基本有效3例,完全无效2例,25例患者球囊扩张冷冻治疗总有效率为92%。并发症:15例血丝痰,23例支气管黏膜撕裂伤,10例出现咽喉痛,1例发生左侧气胸,无发热、头痛、大咯血及肺内出现新的结核播散病灶。结论无痛支气管镜下高压球囊扩张与冷冻联合治疗支气管结核瘢痕狭窄型对患者基础状态要求低,创伤小,操作简单,可以反复进行,值得有条件医院推广应用。     

电子气管镜引导下支气管球囊扩张的护理配合

电子气管镜引导下支气管球囊扩张术已经广泛应用于治疗气道狭窄,是指单纯用气管镜引导球囊导管到狭窄段支气管,可借助导丝或不借助导丝。众所厨知,支气管内膜结核造成的支气管狭窄单靠药物治疗不能取得良好的效果,药物治疗与物理治疗相结合才能取得令人满意的疗效。物理治疗包括支气管球囊扩张、冷冻、激光、微波、氩气刀等。我科在电子气管镜引导下支气管球囊扩张与冷冻及镜下药物注射相结合治疗支气管内膜结核所致的支气管狭窄患者69例,经精心的治疗及护理,取得了满意效果,现报道如下。     

高压球囊扩张气道成形术治疗气道狭窄患者的护理

良性气道狭窄多由支气管内膜结核、外伤、支气管异物等引起 ,患者常由于气道阻塞而反复发生肺部感染 ,表现为活动后胸闷、气急、呼吸困难。近年来我科采用纤维支气管镜 (以下简称纤支镜 )介导下高压球囊扩张气道成形术对 4 6例良性近端气道狭窄的患者进行治疗 ,患者狭窄段气管、支气管管径明显增大 ,收到了良好的效果。1　临床资料4 6例患者均为 1999年 5月至 2 0 0 2年 1月在我科治疗的患者 ,分别接受球囊扩张 1～ 6次 ,其中男 17例 ,女 2 9例 ,年龄在 13～ 6 2岁。其中结核性支气管瘢痕狭窄 2 7例 ,气管插管或切开后的损伤性瘢痕狭窄 5例 …     

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.