suPAR及PCT对脓毒症患者病情严重程度及预后的评判价值

目的 探讨血浆可溶性尿激酶型纤溶酶原激活物受体(suPAR)及降钙素原(PCT)对脓毒症患者病情严重程度及预后的评判价值.方法 采用前瞻性研究方法,将上海交通大学附属新华医院收治的77例脓毒症患者按照病情严重程度分为脓毒症组、严重脓毒症组和脓毒性休克组,测定患者入院后24 h内PCT、suPAR水平,并进行APACHEⅡ评分及SOFA评分,比较suPAR、PCT和APACHEⅡ、SOFA评分的差异.后再根据28 d的结局比较suPAR、PCT和APACHEⅡ、SOFA评分的差异.结果 脓毒症组患者血浆suPAR为(7.9 ±6.5) ng/mL,低于严重脓毒症组[(8.4±4.5) ng/mL]和脓毒性休克组[(13.9±8.0) ng/mL],但脓毒症组和严重脓毒症组之间的差异没有统计学意义,而严重脓毒症组低于脓毒性休克组,差异具有统计学意义.脓毒症组患者血浆PCT为(6.3±3.5) ng/mL,低于严重脓毒症组[(23.7±3.9) ng/mL]和脓毒性休克组[(25.7±4.3) ng/mL],差异具有统计学意义,但是严重脓毒症组和脓毒性休克组之间的差异无统计学意义.死亡组患者血浆suPAR水平及APACHEⅡ、SOFA评分高于生存组,差异具有统计学意义,而PCT水平在生存组和死亡组之间的差异没有统计学意义.根据受试者工作特征曲线(ROC曲线)分析,PCT的ROC曲线下面积(AUC)为0.61 (P ＞0.05),suPAR的AUC为0.803 (P＜0.05),APACHEⅡ评分的AUC为0.832 (P ＜0.05),SOFA评分的AUC为0.767 (P ＜0.05).其截断值suPAR为9.905 ng/mL.结论 监测脓毒症患者入院当天血浆suPAR及APACHEⅡ评分有助于早期对脓毒症患者进行预后评估和病情严重程度的判断.     

血清降钙素原和常用炎症指标结合SOFA评分对脓毒症早期诊断和预后价值的评价

目的 结合感染相关器官功能衰竭评分(SOFA)评价血清降钙素原(PCT)和临床常用炎症指标对脓毒症的早期诊断和预后价值.方法 采用前瞻性、临床病例观察及诊断试验研究.根据美国胸科医师协会/危重病医学会(ACCP/SCCM)共识会议,严格将入选病例分为全身炎症反应综合征(SIRS)组、脓毒症组、严重脓毒症组、脓毒性休克组、非SIRS对照组.测定24 h内的炎症指标、SOFA评分及PCT浓度并进行相关分析.结果 208例患者入选,其中对照组59例,SIRS组57例,脓毒症组52例,严重脓毒症组28例,脓毒性休克组12例.血清PCT浓度与脓毒症严重程度呈正相关,Spearman相关系数为0.909(P=0.000).根据受试者工作特征曲线(ROC曲线)分析,PCT的ROC曲线下面积(AUC)为0.936±0.020,SOFA评分的AUC为0.973±0.011(P均=0.000).判断最佳诊断界值PCT为＞0.375 μg/L,SOFA评分为＞3.5分,其约登(Youden)指数分别为0.808和0.801.二分类Logistic回归分析显示,在排除了年龄、CRP混杂因素后PCT和SOFA评分与脓毒症发病明显相关,相对危险度(OR值)分别为84.794和10.761(P均=0.000),并且可以预测脓毒症的发病概率.SOFA评分是脓毒症疾病预后的最显著因子,OR值为2.084(P=0.000 2).结论 传统炎症指标和C-反应蛋白(CRP)是鉴别SIRS和非SIRS的有用指标,但不是早期诊断脓毒症的可靠指标.PCT是早期诊断脓毒症并能与SIRS鉴别的特异性较高的炎症指标;结合SOFA评分和PCT可以预测脓度症的发病概率;根据PCT值的变化,再结合SOFA评分可以客观判断脓毒症病情的严重性.SOFA评分与脓毒症预后明显相关.     

APACHE II和SOFA评分对不同原因休克预后评估的临床意义

目的探讨在由不同原因导致的休克患者中APACHE II评分和SOFA评分之间的差异,同时评估SOFA评分变化趋势和不同原因休克患者死亡率之间的关系。方法收集2016年1月1日至2017年12月31日收治于北京大学人民医院呼吸与危重症医学科的58例休克患者的临床资料并行APACHE II和SOFA评分。将休克患者分为脓毒症休克和非脓毒症休克两组,并追踪患者30天生存率,比较存活患者和死亡患者在第1天APACHE II评分、SOFA评分及第3天SOFA评分以及两次SOFA差值间有无统计学意义。结果 (1)共入组脓毒症休克组患者36例,非脓毒症休克组患者22例,在这两组中第1天APACHE II评分、SOFA评分及第3天SOFA评分之间均无统计学差异(P0.05)。(2)除脓毒症休克组存活患者与死亡患者第3天SOFA评分之间的差异有统计学意义(P0.05)外,脓毒症休克组和非脓毒症休克组存活与死亡患者在第1天内APACHE II和SOFA评分间无统计学差异,脓毒症组存活与死亡患者在第3天SOFA评分无统计学差异。(3)两组休克患者在存活和死亡分组之间第1天和第3天SOFA变化值均存在统计学意义(P0.05)。结论和APACHE II与单次SOFA评分相比,SOFA的变化程度更能提示患者病情转归情况,在临床中应予以充分重视以及时调整治疗方案,改善患者预后。     

儿科急诊危重患儿状况调查及分析

目的 调查分析儿科急诊危重患者状况,以期对诊治提出改进意见.方法 入急诊监护室374例危重患儿,记录来院方式、途中治疗、急诊停留时间,检测血气、生化,评估小儿/新生儿危重病例评分(PCIS/NCIS)、格拉斯哥昏迷评分(GCS),判断是否符合全身炎症反应综合征(SIRS)、脓毒症、感染性休克.结果 在374例患儿中,新生儿占29.9％,其余患儿平均年龄37.4个月.急诊停留时间4.7 h (0.42～96 h),感染性疾病47.6％.出租车、救护车、私家车为主要来院工具,分别占38.3％、28.4％、21.5％.病死率12.3％,住院病死率10.3％,急诊病死率15.6％,差异具有统计学意义(P＜0.01).PCIS/NCIS评分(81.92±9.66),危重评分≤80占44.4％、≤90占81％.172例患儿接受GCS评估,GCS≤8、9～12、13～15分别占35.5％、21.5％、43.0％.病死率为26.23％、10.81％、5.41％,差异具有统计学意义(P＜0.01).GCS≤8与13～15、GCS 9～12与13～15患儿PCIS差异具有统计学意义(P＜0.01);GCS≤8与9～12间PCIS差异无统计学意义(P＞0.05).PCIS与GCS二者正相关(r=0.454,P=0.01),能建立直线回归(R2 =0.183,回归系数t检验P＜0.01).374例,SIRS 41.7％,脓毒症25.7％.262例非新生儿病例,休克占43.5％,61.4％为感染性休克.374例中,低血钠37.2％,高血钾22.0％.新生儿低血糖20.91％,高血糖29.1％;非新生儿低血糖9％,高血糖66.7％.pH ＜7.35的酸中毒67.8％,pH＜7.2的严重酸中毒33.1％.结论 (1)新生儿、婴幼儿占急诊危重患儿绝大部分;(2)急诊停留时间相对较短(4.7 h).急诊病死率高于住院病死率( 15.6％ vs.10.3％,P＜0.01),应积极缩短急诊停留时间,尽早住院;(3)不同交通工具来院,危重评分差异无统计学意义,使用救护车者不到1/3 (28.4％),应提高社会使用院前急救服务的意识并提高院前急救的便利性;(4)急诊PCIS/NCIS可有效评估病情与预后;重度脑功能障碍(GCS≤8)、中度脑功能障碍(GCS 8～12)共57％,非创伤性脑功能损伤在儿科急诊重患中占重要地位;(5) GCS≤8、9～12与13～15患儿的PCIS差异有统计学意义,GCS＜ 13应予重视,患儿可能处于危重状态;(6)SIRS 41.7％,脓毒症25.7％;休克占43.5％,感染性休克为主(61.4％),应重视急诊危重患儿循环、器官组织灌注状态观察与评估,以早期识别休克;(7)电解质紊乱以低血钠(37.2％)、高血钾(22.0％)最常见;高血糖(66.7％)常见,新生儿也应注意低血糖(20.91％);酸碱平衡紊乱以酸中毒为主(67.8％),应注意相关检测及监测.     

脓毒症患儿血RDW水平与PCIS评分及血乳酸的相关性研究

目的探讨脓毒症患儿红细胞分布宽度(red blood cell distribution width,RDW)、小儿危重症评分(pediatric critical illness score,PCIS)和血乳酸的变化及与预后的关系。方法收集某医院重症监护室(intensive care unit,ICU)脓毒症患儿204例,入院后进行小儿危重症评分,并检测24 h内血RDW和乳酸水平。根据临床转归及病情严重程度分组,比较各组血RDW、乳酸的水平及PCIS评分,对血RDW和乳酸及PCIS评分进行相关性研究。结果存活组PCIS评分、RDW(%)、LAC(mmol/L)分别为76.84±3.79,14.12%±0.10%和1.24±1.01 mmol/L,死亡组为71.13±5.55,16.21%±0.32%和4.38±4.27 mmol/L,死亡组较存活组PCIS评分降低,RDW及乳酸水平升高,差异均有统计学意义(t=-8.29,8.06,8.33,均P0.05)。三项指标与PCIS 71～80组(14.44%±1.69%,1.70±2.37 mmol/L和18.3%)相比,PCIS≤70组(15.73%±2.25%,3.76±3.61 mmol/L和62.9%)RDW及乳酸水平均升高,死亡率增加,差异均有统计学意义(t=3.87,4.22,χ~2=13.08,均P0.05)。三项指标与非严重脓毒症组(77.09±3.65,14.26%±1.57%,1.18±1.42 mmol/L和8.18%)相比,严重脓毒症组(73.34±5.56,15.13%±2.06%,3.08±2.99 mmol/L和46.8%)PCIS评分降低,RDW、乳酸水平及死亡率均升高,差异均有统计学意义(t=5.77,3.4,5.28,χ~2=21.63,均P0.05)。与RDW≤14.0组(76.54±4.47,1.57±2.12 mmol/L和12%)相比,RDW14.0组(74.53±5.17,2.40±3.04 mmol/L和36%)PCIS评分降低,乳酸水平和死亡率升高,差异均有统计学意义(t=-2.89,2.18,χ~2=8.09,均P0.05);RDW水平与PCIS评分呈正态分布,两者呈负相关(r=-0.305 7,P0.05),RDW水平与乳酸水平呈正相关(r=0.195 4,P0.05)。结论严重脓毒症患儿及死亡患儿入院24 h内RDW水平明显升高,RDW水平与PCIS评分及乳酸水平具有相关性,RDW水平与脓毒症患儿疾病严重程度和死亡率相关,RDW适用于评价脓毒症患儿危重程度和预后。     

脓毒症EGDT后早期血乳酸清除率与器官功能障碍评分及预后的关系

[目的]探讨严重脓毒症及脓毒症休克患者经早期目标导向治疗(EGDT)后,早期(6 h内)乳酸清除率与器官功能障碍评分的变化与病死率的关系.[方法]选择2008年5月至2010年3月本院急诊科严重脓毒症和脓毒症休克患者64例,应用EGDT,计算早期(6 h)血乳酸清除率,按乳酸清除率四分位数由低到高分为四组,统计治疗至 72 h患者各种器官功能障碍评分:①急性生理和慢性健康评分(APACHEⅡ),②简化急性生理评分(SAPSⅡ),③多器官功能障碍评分(MODS),④序贯器官衰竭评分(SOFA).并统计住院30 d、60 d死亡率.[结果]治疗最初6 h,乳酸清除率较高组在72 h各器官功能障碍评分均较低,差异有统计学意义(P<0.01);乳酸清除率较高组住院d30、d60的病死率也显著低于乳酸清除率较低组,差异有统计学意义(P<0.01).[结论]早期乳酸清除率与严重脓毒症和脓毒性休克患者各器官功能障碍程度以及住院死亡率存在相关.这可能为临床医师判断严重脓毒症及脓毒症休克治疗效果、预后提供参考.     

血乳酸水平和SOFA评分对急诊严重脓毒症患者的评估作用

目的 探讨SOFA评分和动脉血乳酸在急诊严重脓毒症患者中的变化及其与预后的关系.方法 检测我院急诊重症观察室中的28例严重脓毒症患者入院时和正规治疗6h的动脉血气分析、血常规、血肝肾功能,监测入院时和正规治疗6h后平均动脉压、心率、体温和尿量变化.比较两组SOFA评分、血乳酸和6h乳酸清除率.结果 治疗前血乳酸水平死亡组(7.98±4.24) mmol/L明显高于存活组(3.99 ±4.09) mmol/L,差异有统计学意义(P＜0.05).治疗前死亡组SOFA评分(7.55 ±2.67)分明显高于存活组(4.94±3.49)分,差异有统计学意义(P＜0.05).应用治疗前SOFA评分判断严重脓毒症患者预后的ROC曲线下面积(AUC)是0.798,治疗前血乳酸的AUC是0.847.结论 严重脓毒症患者的初始血乳酸水平和SOFA评分越高,患者预后越差.早期监测患者血乳酸水平,进行SOFA评分是急诊判断严重脓毒症患者病情严重程度和预后的良好方法.     

脓毒症患者血液激活素 a，CRP，HMGB1和 vWF表达水平及临床意义

目的　探讨脓毒症患者血液激活素 a(Activin-A)、C反应蛋白 (C-reactive protein, CRP)、高迁移率族蛋白 B1(high mobility group protein B1, HMGB1)和血管性血友病因子 (von willebrand factor, vWF)水平变化及临床意义。方法　选取 2019年 1月～ 2020年 5月鄂东医疗集团黄石市中心医院收治的 87例脓毒症患者,根据病情严重程度分为脓毒症组 (n=29)和脓毒性休克组 (n=58),根据 28天预后情况分为死亡组 (n=36)和存活组 (n=51)。另选取同期 53例健康体检者为对照组。比较各组血清 Activin-A,CRP,HMGB1和 vWF水平,分析血清 Activin-A,CRP,HMGB1和 vWF水平与脓毒症患者病情严重程度和不良预后的关系。结果　脓毒性休克组血清 Activin-A,CRP,HMGB-1和 vWF水平明显高于脓毒症组和对照组（ Z=-8.935~-3.558, 均 P<0.001）,脓毒症组明显高于对照组 (Z=-7.347~-5.950,均 P＜ 0.05),差异具有统计学意义。 Spearman相关性分析显示,脓毒症患者血清 Activin-A,CRP,HMGB1,vWF水平与急性生理与慢性健康评分系统Ⅱ (APACHE Ⅱ )评分、脓毒症相关的序贯器官衰竭评估 (SOFA)呈正相关,差异具有统计学意义 (rAPACHEⅡ=0.396~0.450,均 P<0.000;rSOFA=0.381~0.442,均 P<0.05)。多因素 Logistics回归分析显示, APACHE Ⅱ评分、 SOFA评分、 Activin-A,CRP,HMGB1,vWF为脓毒症患者不良预后独立影响因素 (P＜ 0.05)。Activin-A+CRP+HMGB1+vWF预测不良预后的 AUC明显大于 APACHEⅡ评分、 SOFA评分以及 Activin-A,CRP,HMGB1和 vWF单独与两两预测,差异具有统计学意义 (均 P＜ 0.05)。结论　脓毒症患者血清 Activin-A,CRP,HMGB1,vWF水平明显提升,与病情严重程度和不良预后相关,联合检测可提升不良预后预测价值。     

中性粒细胞明胶酶相关脂质运载蛋白在重症肺炎合并脓毒症患儿中的表达及临床价值

目的探讨中性粒细胞明胶酶相关脂质运载蛋白(NGAL)在重症肺炎合并脓毒症患儿中的表达及临床价值。方法选取该院106例重症肺炎合并脓毒症患儿,根据严重程度分为脓毒症组、严重脓毒症组和脓毒症休克组,根据出院时转归分为预后良好组和预后不良组,根据是否合并肾功能障碍分为肾功能障碍组和无肾功能障碍组。分析患儿的NGAL、降钙素原(PCT)、白细胞介素-6(IL-6)、C-反应蛋白(CRP)及小儿危重病例评分(PCIS),采用Spearman秩相关及受试者工作特征曲线(ROC曲线)对各指标进行分析与评价。结果肾功能障碍组NGAL水平明显高于无肾功能障碍组,两组比较差异有统计学意义(P<0.05);NGAL、CRP、PCT、IL-6水平和PCIS在脓毒症组、严重脓毒症组和脓毒症休克组中的差异均有统计学意义(均P<0.05),其中NGAL、PCT、IL-6水平在3组中依次升高,PCIS在3组中依次降低,组间两两比较差异均有统计学意义(均P<0.05);与预后良好组比较,预后不良组的NGAL、CRP、PCT、IL-6水平明显升高,PCIS明显降低,差异均有统计学意义(均P<0.05);Spearman相关分析显示NGAL与CRP、PCT、IL-6呈正相关,与PCIS呈负相关(均P<0.05);NGAL用于预测预后不良的曲线下面积(AUC)为0.915,仅次于PCIS的0.949。结论NGAL在重症肺炎合并脓毒症患儿病情严重程度及预后预测中可能具有一定的临床价值。     

早期心肌肌钙蛋白Ⅰ及乳酸水平联合检测对急诊老年严重脓毒症及脓毒症休克患者预后的评估价值

目的研究早期血浆心肌肌钙蛋白Ⅰ(cTnI)及动脉血乳酸水平联合检测对老年严重脓毒症及脓毒性休克患者病情和预后的评估价值。方法收集急诊老年严重脓毒症和脓毒性休克患者98例。随访28 d,根据患者预后分为死亡组和存活组,比较死亡组和存活组cTnI、乳酸、APACHEⅡ评分及SOFA评分。比较脓毒性休克和严重脓毒症组的cTnI、乳酸、APACHEⅡ评分及SOFA评分。进行cTnI,乳酸与APACHEⅡ评分、SOFA评分的相关性分析。结果脓毒性休克组患者cTnI、乳酸、APACHEⅡ评分和SOFA评分大于严重脓毒症组,死亡组cTnI和乳酸均大于存活组(P0.05)。cTnI、乳酸水平与APACHEⅡ评分、SOFA评分具有显著相关性(P0.05),cTnI、乳酸预测死亡ROC曲线下面积分别为0.846、0.809(P0.05)。结论 cTnI和动脉血乳酸联合检测对急诊老年严重脓毒症和脓毒性休克患者的病情和预后具有重要的评估价值。     

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.     

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.     

Clinical Pharmacokinetics of Morphine

Morphine, the most widely used mu-opioid analgesic for acute and chronic pain, is the standard against which new analgesics are measured. A thorough understanding of the pharmacokinetics of morphine is required in order to safely and effectively use this analgesic in a wide variety of patients with different levels of organ function. A MEDLINE search was conducted to identify literature published between 1966 and January 2002 relevant to the pharmacokinetics of morphine. These publications were reviewed and the literature summarized regarding unique and clinically important elements of morphine disposition relative to its parenteral administration (including intravenous, intramuscular, subcutaneous, epidural and intrathecal administration), absorption profile (immediate release, controlled release, and sublingual/buccal, and rectal administration), distribution, and its metabolism/ excretion. Special populations, including infants, elderly, and those with renal/liver failure, have a unique morphine pharmacokinetic profile that must be taken into account in order to maximize analgesic efficacy and reduce the risk of adverse events.     

手转胎头术失败的原因与分娩结局临床分析

目的 探讨手转胎头术失败的原因与分娩结局.方法 选择2008年1月至2010年12月于我院住院分娩的持续性枕横位、枕后位产妇198例,根据行手转胎头术后结果分为成功组126例、失败组72例.比较两组分娩结局,对比分析失败原因.结果 失败组胎儿体质量≥3500 g的发生率[76.4％(55/72)]明显高于成功组[31.7％(40/126)],差异有统计学意义(x2=30.177,P=0.001)、失败组宫缩乏力发生率[58.3％(42/72)]高于成功组[38.1％ (48/126)],差异有统计学意义(x2=7.569,P=0.006)、失败组骨盆临界或轻度狭窄发生率[38.9％ (28/72)]高于成功组[23.8％(30/126)],差异有统计学意义(x2 =5.030,P=0.002)、失败组手转胎头时机不当(宫口开大＜6 cm、胎头位于坐骨棘上及宫口开大8～10 cm、胎头位于坐骨棘下≥2 cm)发生率[61.1％(44/72)]高于成功组[38.9％(49/126)],差异有统计学意义(x2=9.084,P=0.003).失败组母儿并发症(产后出血、产褥病率、胎儿窘迫、新生儿窒息)发生率高于成功组(x2 =9.586,P=0.002、x2=9.334,P=0.002、x2=5.910,P=0.015、x2=5.240,P=0.022)、失败组剖宫产发生率[72.2％(52/72)]明显高于成功组[34.1 ％(43/126),x2=26.641,P=0.001)].结论 手转胎头术能使难产变顺产,降低剖宫产率,减少母儿并发症,但须积极预防、处理导致手转胎头术失败的原因,对矫正失败后继续矫正及试产应慎重.     

Evidence-Based Pain Management and Palliative Care in Issue Four for 2009 of The Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly. Issue 4 for 2009 contains 4027 complete reviews, 1906 protocols for reviews in production, and 11447 one-page summaries of systematic reviews published in the general medical literature. In addition, there are citations of 600,000 randomized controlled trials, and 12,200 cited papers in the Cochrane methodology register. The health technology assessment database contains over 7500 citations. This edition of the Library contains 90 new reviews, of which 19 have potential relevance for practitioners in pain and palliative medicine.     

Wie zuverlässig sind Angaben zu nichtentzündlichen ausgedehnten Schmerzen?

ZusammenfassungFragestellung Es wurde geprüft, wie sich der Differenziertheitsgrad zweier Schmerzmessmethoden auf Angaben zur Ausgedehntheit klinischer Schmerzen auswirkt. Zugleich wurde der Referenzzeitraum variiert, über den die Patienten berichten sollten.Methode Erfasst wurde der Einfluss zu Lasten der Befragungsdifferenziertheit durch den Vergleich zweier Körperschema-Bildvorlagen. Drei Referenzzeiträume (Schmerz aktuell, letzte Woche, letztes halbes Jahr) wurden vorgegeben.Ergebnisse Patienten mit ausgedehnten Schmerzen gaben bei differenzierter Befragung um so mehr Schmerzen an, je weiter die Schmerzen zurück lagen und je größer der Berichtszeitraum war. Patienten mit gelenknahen Schmerzen gaben bei hoch differenzierter Befragung weniger ausgedehnte Schmerzen in der Vergangenheit an als bei globaler Einschätzung. Patienten mit Rückenschmerzen berichteten bei differenzierter Befragung zum aktuellen Schmerz über weniger ausgedehnte Schmerzen als bei globaler Befragung.Schlussfolgerung Die Angaben zur Schmerzausdehnung variieren vor allem bei Patienten mit ausgedehnten Schmerzen in Abhängigkeit von der Differenziertheit der Befragung. In diesen Fällen ist die Wahrscheinlichkeit erhöht, dass sich die Beschwerdesymptomatik zumindest teilweise erst in der Reaktion auf die situativen Befragungsbedingungen konstituiert und daher nicht auf andere Befragungsbedingungen generalisiert werden kann.