内镜下钛夹治疗十二指肠乳头括约肌切开并发中重度迟发性出血的临床应用价值

目的在改良内镜负压装置下,探讨钛夹治疗十二指肠乳头括约肌切开并发中重度迟发性出血的临床价值。方法选择10例十二指肠乳头括约肌切开并发中重度迟发性出血的患者,采取在全麻气管插管下行胃镜探查,确定出血部位为十二指肠乳头切口处,更换十二指肠镜予以钛夹夹闭止血。结果 10例患者均一次止血成功,胃镜下探查平均耗时(48.93±3.24)min,钛夹夹闭平均耗时(14.55±2.21) min,使用钛夹数量平均(2.70±1.22)个。10例患者内镜下止血前与止血后12和24 h血清淀粉酶、总胆红素和直接胆红素比较,差异均无统计学意义(P0.05),内镜下止血前与止血后12和24 h血红蛋白比较,差异有统计学意义(P 0.01)。结论在保证内镜视野的前提下,内镜下钛夹治疗十二指肠乳头括约肌切开并发中重度迟发性出血安全、有效,具有十分重要临床意义。     

超声内镜下经胃、十二指肠乳头引流治疗胰腺假性囊肿的效果评价*

目的探究超声内镜(EUS)下经胃或十二指肠乳头置管引流治疗胰腺假性囊肿(PPC)的临床疗效。方法选取2012年3月-2015年3月该院收治的100例PPC患者,按临床治疗指标对其中的80例进行EUS下经胃穿刺置管引流,20例行EUS下经十二指肠乳头穿刺置管引流。记录所有患者的治疗效果以及并发症的发生情况。结果 100例患者的手术中成功率为95.00%,其中囊肿完全消失率为84.00%。100例患者中共有10例发生术中出血,3例发生支架移位堵塞,另有7例术后出现囊肿内部感染,并发症的发生率为20.00%。结论对PPC患者进行EUS下经胃、十二指肠乳头穿刺置管引流治疗可以提高临床疗效,减少并发症,值得在临床上推广应用。     

重症急性胆管炎治疗体会(附79例报告)

目的探讨内镜与手术联合治疗重症急性胆管炎(ACST)的临床效果。方法ACST患者79例,无休克患者首先观察治疗,症状无改善或加重者行内镜下逆行胰胆管造影(ERCP)、十二指肠乳头括约肌切开(EST)及鼻胆管引流(ENBD),急诊内镜失败患者手术治疗。结果61例无休克患者经观察治疗,症状缓解28例(45.9%);急诊内镜治疗51例中,ENBD成功引流40例(78.4%),其中并发轻型胰腺炎6例,EST并发十二指肠乳头出血3例,引流成功后行内镜下胆汁内引流术(ERBD)并发胆道出血死亡1例;急诊手术11例,术后并发多脏器功能衰竭死亡2例。全组病死率3.8%。结论ACST应尽可能采取安全有效的方法,急诊内镜与手术相结合治疗ACST可以明显降低病死率。     

腹腔镜胆囊切除术后Oddi括约肌功能障碍的内镜治疗体会(附26例报告)

目的：探讨内镜乳头括约肌切开术对腹腔镜胆囊切除(laparcscopic cholecystectomy,LC)术后Oddi括约肌功能障碍在外科临床治疗中的应用价值。方法：腹腔镜胆囊切除术后综合征患者行B超、经内镜逆行胰胆管造影检查，测定Oddi括约肌基础压，排除胆管残留或再生结石、胆管狭窄及胆道肿瘤等病变，对最后诊断为Oddi括约肌功能障碍的26例腹腔镜胆囊切除术后患者行内镜下乳头括约肌切开术。并发急性胆道感染者给予ENBD治疗。结果：20例患者术后症状基本消失，2例症状明显缓解，2例2次行内镜下乳头括约肌切开术后症状得到缓解，2例术后症状无缓解，手术有效率达92．3％(24／26)，治疗后恢复快，并发症极少。结论：ERCP对腹腔镜胆囊切除术后Oddi括约肌功能障碍的诊断价值高，内镜下乳头括约肌切开术对腹腔镜胆囊切除术Oddi括约肌功能障碍是一种微创、安全、有效的治疗手段，约76．9％可治愈。缩短了住院时间，病人痛苦少，恢复快。     

经内镜乳头气囊扩张术治疗胆胰疾病

目的 探讨经内镜乳头气囊扩张术(EPBD)在治疗胆胰疾病中的应用价值,并对影响疗效的因素进行分析.方法 应用国产乳头柱状扩张气囊对88例胆胰疾病患者行EPBD治疗,如有胆管结石,行胆管结石取石术或碎石术,常规放置鼻胆管引流,随访观察疗效及并发症情况.结果 88例患者行乳头气囊扩张均获成功.61例胆管结石患者中55例采用网篮或取石气囊取出结石,4例采用机械碎石篮碎石后取出;1例2次内镜取尽结石;另2例患者改行EST后成功取出结石.胆总管下段良性狭窄扩张后有效率达94.11%(16/17),未发生出血、穿孔等急重并发症.结论 EPBD对胆总管结石的取出以及胆总管下端良性狭窄的治疗效果明显,尤其适用于需要保留乳头括约肌功能的年轻患者及经内镜乳头括约肌切开(EST)禁忌的患者.     

内镜技术治疗良性胆管狭窄的应用价值

目的 探讨内镜技术在治疗良性胆管狭窄中的应用价值.方法 对23例具有临床症状的良性胆管狭窄患者采用内镜下乳头括约肌切开术(EST)、狭窄部扩张术联合多支架内支撑术进行治疗.结果 23例患者均完成首次治疗,临床症状有效缓解.1例Mirizzi综合征患者经鼻-胆管引流后转外科手术治疗；2例(腹腔镜胆囊切除术后Oddi括约肌功能障碍、十二指肠乳头炎性狭窄者)仅行EST; 20例接受狭窄部扩张+多支架内支撑术治疗,其中18例治愈,2例仍处于治疗观察期；总的治愈率87％,并发症发生率10.6％.结论 经内镜治疗胆管良性狭窄具有微创、安全、有效、可反复治疗的优点,应该作为首选方法在临床上推广应用.     

支架胆管引流在内镜下逆行胰胆管造影术治疗胆总管结石中的应用

目的:探讨单猪尾胰管塑料支架胆管引流在内镜下逆行胰胆管造影术(endoscopic retrograde cholangiopancreatography,ERCP)治疗胆总管结石中的应用效果。方法:回顾性分析同济大学附属东方医院2014年10月至2016年10月ERCP治疗的胆总管结石患者105例的临床资料。根据胆管引流方式的不同分为支架组(n=38)和常规组(n=67)。支架组患者采用ERCP+十二指肠乳头括约肌切开术(endoscopic sphincterotomy,EST)/内镜下十二指肠乳头气囊扩张术(endoscopic papillary balloon dilatation,EPBD)+取石+单猪尾胰管支架胆管内引流;常规组患者采用ERCP+EST/EPBD+取石+ENBD。比较两组患者术后急性胰腺炎(post-ERCP acute pancreatitis,PEP)的发生情况;观察支架组胰管支架脱落、内镜下支架取出等情况。结果:支架组患者PEP发生率为13.1%(5/38),常规组患者PEP发生率为14.9%(10/67),差异无统计学意义。支架组中有3例患者术后第1天支架从胆道脱落,1例因上腹部不适于术后3d拔除支架,8例术后2周仍未脱落,遂经内镜成功取出;其余26例患者于术后2周内支架脱落并经消化道自行排出体外,未发生消化道梗阻、出血及穿孔等严重并发症。结论:胆总管结石行ERCP治疗后,可应用单猪尾胰管塑料支架行胆管内引流以预防PEP的发生,降低PEP的严重程度。胰管支架多可自行脱落,安全排出,无严重并发症。     

内镜下乳头括约肌小中切开术联合球囊扩张术治疗肝外胆管结石的探讨

目的探讨内镜下乳头括约肌小中切开术(SMEST)联合球囊扩张术(EPBD)治疗肝外胆管结石的有效性和安全性。方法入选的181例肝外胆管结石患者,特殊十二指肠乳头38例(憩室内乳头14例、憩室旁乳头17例、细小乳头7例)、正常十二指肠乳头143例,前者行乳头括约肌小切开术(SEST)联合EPBD取石、碎石,后者行乳头括约肌中切开术(MEST)联合EPBD取石、碎石。结果 SMEST联合EPBD治疗181例,最大结石≥10 mm而15 mm的患者136例、最大结石≥15 mm而25 mm的患者45例,前者采用取石网篮直接取石成功115例、不成功21例,这21例患者行碎石后取石均一次成功,后者先碎石后取石,一次成功31例、二次成功14例,所有181例患者取石均获成功,成功率为100.00%。181例患者中,并发轻症急性胰腺炎8例(4.42%,8/181)、出血9例(4.97%,9/181)、穿孔0例,近期三大并发症发生率为9.93%(17/181),经内科治疗均治愈。结论 SMEST联合EPBD治疗肝外胆管结石安全、有效,且保留了十二指肠乳头括约肌功能,对于特殊十二指肠乳头患者尤为适用。     

Oddi括约肌压力测定及内镜下十二指肠乳头括约肌切开术对Oddi括约肌功能紊乱诊治的意义

目的针对反复右上腹痛的患者进行Oddi括约肌测压,以评价Oddi括约肌测压术(SOM)在慢性胆胰疾病诊治中的应用价值,并探讨内镜下十二指肠乳头切开术(EST)对Oddi括约肌基础压升高患者的疗效。方法回顾分析该院2012年10月-2014年9月30例慢性上腹痛疑似Oddi括约肌功能紊乱(SOD)的患者在内镜逆行胰胆管造影术(ERCP)检查时接受SOM的临床资料,观察Oddi括约肌基础压、收缩幅度、频率和传播方式。对Oddi括约肌基础压40.0 mm Hg者及30.0 mm Hg并存在血淀粉酶、脂肪酶、谷丙转氨酶(ALT)、谷草转氨酶(AST)、碱性磷酸酶(AKP)升高超过正常值2倍以上和(或)胆总管、胰管管增宽者行EST治疗,并随访其疗效。结果 30例患者SOM均存在不同程度的异常,Oddi括约肌基础压力为(36.6±21.1)mm Hg,收缩幅度为(210.6±25.7)mm Hg,收缩频率为(10.1±3.1)次/min,逆向收缩率为(55.0±8.0)%。30例患者均接受EST治疗,术后随访,其中27例(90.0%)有效。结论 SOM助于评价Oddi括约肌功能,对诊断SOD具有较大价值,测压发现Oddi括约肌基础压升高患者EST治疗可获得满意疗效。     

sEST术联合EPBD术治疗直径≤1.5 cm胆总管结石临床研究

目的:研究经内镜乳头括约肌小切开术联合经内镜乳头球囊扩张术治疗直径≤1.5 cm胆总管结石的临床效果。方法:选取我院2015年1月～2018年10月收治的直径≤1.5 cm胆总管结石患者650例,用随机数字表法分为对照组和研究组,各325例。对照组采用内镜下乳头括约肌切开术治疗,研究组采用经内镜乳头括约肌小切开术联合经内镜乳头球囊扩张术治疗。对比两组结石一次性取净率、机械碎石率、并发症发生率及术后恢复情况。结果:研究组结石一次性取净率96.62%,高于对照组的85.54%,机械碎石率8.62%低于对照组24.31%(P0.05);研究组术后鼻胆管引流时间、住院时间均短于对照组(P0.05);研究组并发症总发生率9.23%低于对照组19.69%(P0.05)。结论:采用经内镜乳头括约肌小切开术联合经内镜乳头球囊扩张术治疗直径≤1.5 cm胆总管结石患者,能显著提高结石一次性取净率,降低机械碎石率,减少术后并发症发生,缩短术后恢复时间。     

创伤高血糖与感染和MODS早期诊断和干预

本文详细介绍了创伤后血糖应激适度理论,以及高血糖与感染和多器官功能不全综合征的关系;提出涉及胰岛B细胞功能不全的MODS实验诊断新方案和极化液个体化干预新措施,可早期发现创伤MODS、降低感染率及MODS发生率和病死率。     

腹膜后纤维化与肾积水发生关系的临床研究

目的：探讨腹膜后纤维化（RPF）导致肾积水的原因及诊治经验。方法：回顾分析2004年1月—2010年12月24例腹膜后纤维化致肾积水患者的诊治资料。结果：（1）RPF患者常见首发症状为腰背痛或腹痛（69.2%）;（2）红细胞沉降率（ESR）增快和血清IgG4升高最常见。超声检查仅提示上尿路积水。RPF的静脉肾盂造影（IVP）和CT尿路成像（CTU）表现具有特征性。IVP肾盂输尿管显影不良时,CTU能较清晰的显示上尿路影像。CT扫描发现腹膜后软组织肿块9例（37.5%）,优于超声检查;（3）输尿管松解和腹腔化手术治疗22例;行肾切除术1例;行输尿管置双J管术1例。最终确诊为继发性RPF8例,其中4例为术前诊断,3例为术中腹膜后软组织肿块冷冻活检证实,1例为术后病理证实;（4）特发性RPF手术后肾积水均获长期缓解,而继发性RPF的预后取决于原发疾病及其治疗方案。结论：影像学检查是诊断RPF的重要手段,CTU优于超声检查和IVP。输尿管松解和腹腔化手术可以使特发性RPF输尿管梗阻得到长期的缓解,术中对肿块进行冷冻活检有助于鉴别特发性和继发性RPF,及时调整治疗方案。     

Migraine and genetic and acquired vasculopathies

It is remarkable that migraine is a prominent part of the phenotype of several genetic vasculopathies, including cerebral autosomal dominant arteriopathy with subcortical infarcts and leucoencephalopathy (CADASIL), retinal vasculopathy with cerebral leukodystrophy (RVCL) and hereditary infantile hemiparessis, retinal arteriolar tortuosity and leukoencephalopahty (HIHRATL). The mechanisms by which these genetic vasculopathies give rise to migraine are still unclear. Common genetic susceptibility, increased susceptibility to cortical spreading depression (CSD) and vascular endothelial dysfunction are among the possible explanations. The relation between migraine and acquired vasculopathies such as ischaemic stroke and coronary heart disease has long been established, further supporting a role of the (cerebral) blood vessels in migraine. This review focuses on genetic and acquired vasculopathies associated with migraine. We speculate how genetic and acquired vascular mechanisms might be involved in migraine.     

Fibrinogen and fibrin structure and functions

Fibrinogen molecules are comprised of two sets of disulfide-bridged Aalpha-, Bbeta-, and gamma-chains. Each molecule contains two outer D domains connected to a central E domain by a coiled-coil segment. Fibrin is formed after thrombin cleavage of fibrinopeptide A (FPA) from fibrinogen Aalpha-chains, thus initiating fibrin polymerization. Double-stranded fibrils form through end-to-middle domain (D:E) associations, and concomitant lateral fibril associations and branching create a clot network. Fibrin assembly facilitates intermolecular antiparallel C-terminal alignment of gamma-chain pairs, which are then covalently 'cross-linked' by factor XIII ('plasma protransglutaminase') or XIIIa to form 'gamma-dimers'. In addition to its primary role of providing scaffolding for the intravascular thrombus and also accounting for important clot viscoelastic properties, fibrin(ogen) participates in other biologic functions involving unique binding sites, some of which become exposed as a consequence of fibrin formation. This review provides details about fibrinogen and fibrin structure, and correlates this information with biological functions that include: (i) suppression of plasma factor XIII-mediated cross-linking activity in blood by binding the factor XIII A2B2 complex. (ii) Non-substrate thrombin binding to fibrin, termed antithrombin I (AT-I), which down-regulates thrombin generation in clotting blood. (iii) Tissue-type plasminogen activator (tPA)-stimulated plasminogen activation by fibrin that results from formation of a ternary tPA-plasminogen-fibrin complex. Binding of inhibitors such as alpha2-antiplasmin, plasminogen activator inhibitor-2, lipoprotein(a), or histidine-rich glycoprotein, impairs plasminogen activation. (iv) Enhanced interactions with the extracellular matrix by binding of fibronectin to fibrin(ogen). (v) Molecular and cellular interactions of fibrin beta15-42. This sequence binds to heparin and mediates platelet and endothelial cell spreading, fibroblast proliferation, and capillary tube formation. Interactions between beta15-42 and vascular endothelial (VE)-cadherin, an endothelial cell receptor, also promote capillary tube formation and angiogenesis. These activities are enhanced by binding of growth factors like fibroblast growth factor-2 (FGF-2) and vascular endothelial growth factor (VEGF), and cytokines like interleukin (IL)-1. (vi) Fibrinogen binding to the platelet alpha(IIb)beta3 receptor, which is important for incorporating platelets into a developing thrombus. (vii) Leukocyte binding to fibrin(ogen) via integrin alpha(M)beta2 (Mac-1), which is a high affinity receptor on stimulated monocytes and neutrophils.     

Telemedicine and teleradiology technologies and applications

Summary. Telemedicine and teleradiology hold the key for improving future health care delivery. In this paper we first review current communication and computer technologies used in telemedicine and teleradiology. Five examples in teleradiology applications are given including hospital-integrated picture archiving and communication systems, tele-neuro-imaging, telemammography, university consortium teleradiology service, and teleradiology for second opinion. Parameters important to teleradiology applications like costs, image quality, system reliability, and turn around time are considered. Data security is discussed, including patient confidentiality and image authenticity-which will be a major issue in future teleradiology applications.     

Physician and Nurse Practitioner Teamwork and Job Satisfaction: Gender and Profession

Designing interprofessional primary care teams composed of physicians and nurse practitioners (NPs) is a national priority. We assessed how profession and gender affect teamwork and job satisfaction among primary care physicians and NPs by using survey data from 186 physicians and 398 NPs practicing in New York State. Our regression models show profession (NP vs physician) moderates the associations of gender with teamwork and job satisfaction. Among NPs, men had higher job satisfaction than women. Among physicians, women had higher job satisfaction than men. Our results can benefit interprofessional primary care teams to optimize their professional and gender mix.     

探讨儿童慢性顽固性咳嗽与支原体感染的关系及临床治疗观察

目的探讨儿童慢性顽固性咳嗽与肺炎支原体（MP）感染的关系及临床疗效观察。方法采用回顾性研究方法对于现将2005年3月至2008年3月在我院的55例确诊慢性顽固性咳嗽患儿,主要表现为肺炎支原体感染为临床特点进行分析,并进一步临床治疗研究。结果①临床特点：在55例确诊慢性咳嗽的患儿中,以慢性顽固性咳嗽为主要症状。58％（32／55）的病例无肺部体征;②外周血：85％（47／55）的病例外周血变化不大,WBC（4—10）×10 9／L之间,嗜酸性粒细胞增多;③特别检查：47．27％（26／55）肺炎支原体IgM（MP—IgM）抗体阳性,83．64％（46／55）PeR技术检测肺炎支原体特异性DNA;④X光报告为多种形式。结论肺炎支原体（MP）感染是引起儿童慢性顽固性咳嗽的病因之一,对儿童慢性咳嗽,特别是顽固性咳嗽的诊治中应更加重视。     

妊娠合并血小板减少症与心、肝、肾脏器损伤

目的探讨妊娠合并血小板减少症伴随重要脏器的损伤情况。方法前瞻性研究我院及北华大学附属医院2004年10月至2005年5月妊娠合并血小板减少症的临床资料，对41例妊娠合并血小板减少症者尿素氮（BUN）、肌酐（CREA）、谷丙转氨酶（ALT）、乳酸脱氢酶（LDH）的测定及妊娠期高血压疾病与血小板计数（PLT），血小板平均体积（MPV）和血小板体积分布宽度（PDW）参数的测定进行对比分析。结果妊娠合并血小板减少症患者心、肝、肾等重要脏器均有不同程度的改变，且随着血小板计数降低，损害程度加剧，差异具有显著性（P〈0．01）。妊娠期高血压疾病，随着疾病程度的加重，血小板计数较正常孕妇明显减少，MPV、PDW明显升高，有显著性差异（P〈0．01）。结论血小板参数是判断疾病的重要参考指标，肝、肾、心脏器损伤程度与血小板计数具有相关性。     

Literature and poetry: Pleasure and practice

The value of a humanities perspective in the initial and continuing education of practising nurses and midwives is discussed briefly. It is suggested that nursing requires a blend of both science and sensitivity and that empirical knowledge alone is insufficient for one who cares for others. The value of literature in relation to the notions of catharsis, vicarious experience and insight into the lives of patients will be discussed. Some examples of literature that may be used to help nurses gain insight into aspects of death and dying, midwifery, physical disability and mental illness are presented.