肠道恶性梗阻内镜水囊扩张和支架治疗

目的：探讨经内镜水囊扩张和金属支架置入术治疗肠道恶性梗阻的临床运用价值。方法：经内镜水囊扩张和金属支架置入术共治疗18例肠道恶性梗阻的病人，其中十二指肠恶性狭窄7例，直肠恶性狭窄8例，乙状结肠恶性狭窄3例。结果：7例十二指肠恶性梗阻经内镜水囊扩张后放置支架成功；11例结直肠恶性梗阻中，8例扩张后放置金属支架作姑息治疗．2例经内镜水囊扩张和支架治疗解除梗阻后接受手术治疗，1例直肠癌术后狭窄伴盆腔广泛转移者扩张治疗失败。结论：经内镜水囊扩张和金属支架置入术治疗肠道恶性狭窄梗阻是一种操作简单、经济有效、并发症少的方法，可以显著降低病人的创伤和痛苦，提高病人的生活质量。     

经内镜球囊扩张治疗大肠良性狭窄的临床价值

目的：探讨经内镜球囊扩张治疗大肠良性狭窄的临床价值。方法：对15例不同病因所致的大肠良性狭窄，采用电子肠镜下球囊导管扩张治疗，其中9例吻合口狭窄、2例克罗恩病、2例PPH(吻合器痔疮切除术)术后狭窄、1例溃疡性结肠炎、1例梅毒性狭窄。结果：15例良性狭窄病变经过2～5次球囊扩张治疗后，均解除梗阻症状，无一例需手术治疗。结论：经内镜球囊扩张治疗大肠良性狭窄是一种简单、安全、有效的方法。     

经内镜金属支架植入治疗结直肠癌合并梗阻病人的护理

[目的]总结经内镜金属支架植入治疗结直肠癌合并梗阻病人的护理。[方法]对9例结直肠癌合并梗阻病人行经内镜金属支架植入治疗,同时加强护理。[结果]9例病人均成功放置支架,支架放置成功后可见较多肠内容物流出,5例病人放置2d~3d 后梗阻症状得到缓解,解除梗阻和肠道准备后6d~9d接受结直肠肿瘤切除术;术后恢复良好,无手术切口感染、吻合口漏等并发症发生。[结论]加强经内镜金属支架植入治疗结直肠癌合并梗阻病人的护理是手术成功的保证。     

食管胃吻合口良性狭窄的内镜治疗

[目的]探讨食管胃吻合口良性狭窄的两种内镜治疗的效果与经验.[方法]将48例食管癌术后吻合口良性狭窄的患者分别进行内镜下治疗,其中有22例单纯予以球囊扩张术,8例经球囊扩张术后放置食管镍钛记忆金属支架,18例经球囊扩张术后放置全覆膜可取出金属支架(Sigma支架),评价近期厦远期疗效.[结果]单纯球囊扩张术治疗的22例中,吞咽困难改善总有效率为90.9%,其中9例发生再狭窄;8例经球囊扩张术后放置食管镍钛记忆金属支架,其中2例再次出现狭窄;18例经球囊扩张术后放置Sigma支架,无1例出现再狭窄.[结论]全覆膜可取出金属支架是治疗食管胃吻合口术后良性狭窄的较佳方案.     

经内镜放置金属支架及肠梗阻导管治疗低位大肠癌性梗阻的对比分析

目的 探讨经内镜放置金属支架及肠梗阻导管治疗左侧大肠癌性梗阻的临床应用价值.方法 在X线辅助下经内镜放置金属支架及肠梗阻导管治疗左侧大肠癌性梗阻患者40例,随机分为2组.金属支架组梗阻部位分别为直肠10例,乙状结肠6例,降结肠4例.肠梗阻导管组,直肠12例,乙状结肠5例,降结肠3例.结果 大肠癌性梗阻患者中行金属支架置入术20例,18例放置支架成功,成功率为90%,行肠梗阻导管放置术20例均成功,成功率100%.所有患者术后1、2d梗阻症状均得到缓解,解除梗阻后6～10d接受外科手术治疗,术后均恢复顺利,无感粢及吻合口漏等并发症发生.结论 经内镜放置金属支架及肠梗阻导管治疗左侧大肠癌性梗阻.均能有效缓解患者的梗阻症状,但肠梗阻导管方法 操作简单、经济、术后对患者的创伤和痛苦轻,提高患者的生活质量,值得推广应用.     

急性结直肠癌性梗阻内镜治疗的操作配合与护理

目的探讨经内镜放置金属支架和肠梗阻导管治疗急性结直肠癌性梗阻的护理配合要点，总结护理经验。方法在X线辅助下经内镜放置金属支架或肠梗阻导管治疗27例急性结直肠癌性梗阻的病人，其梗阻的部位分别为直肠14例，乙状结肠9例，降结肠3例，横结肠1例。结果27例姑直肠癌性梗阻患者，因术前准备充分，术中操作配合到位，术后护理措施细致得当，总的操作成功率达92．6％（25／27），临床有效率为88．9％（24／27）。其中13例为永久性姑息治疗，10例经内镜治疗解除梗阻后7～10d行Ⅰ期肿瘤切除术，术后均恢复顺利，无感染及吻合口漏等并发症发生。结论经内镜放置金属支架或肠梗阻导管治疗急性结直肠癌性梗阻，是一种操作简单、安全、有效的新方法，其术前准备、术中操作配合及术后护理措施是十分重要的。     

内镜下支架治疗结直肠恶性梗阻临床价值分析

目的 探讨支架在结直肠恶性梗阻治疗中的应用价值.方法 对我院2007年5月至2013年6月收治的28例结直肠恶性梗阻患者采用内镜联合X线下临时性或姑息性支架治疗,观察肠梗阻缓解情况和并发症.结果 28例患者接受支架治疗,仅1例失败.21例经内镜治疗解除梗阻后7～10 d行肿瘤一期切除,术后恢复顺利,支架放置后未发生支架移位及结肠穿孔.结论 经内镜放置支架治疗结直肠恶性梗阻是一种临时过渡性或姑息性治疗手段,避免了结肠造瘘术,提高了生活质量,安全可靠,值得推广应用.     

经内镜球囊扩张治疗食管狭窄

目的：探讨经内镜球囊扩张治疗食管狭窄的应用价值。方法：对27例不同病因所致的食管狭窄,采用球囊（CRE长80mm,直径12～18mm）扩张治疗,其中食管癌7例经球囊扩张后放置内支架,吻合口狭窄8例,食管化学性烧伤后严重全食管狭窄9例,硬化剂治疗后狭窄3例。结果：27例病人经58例次扩张,所有病人均能恢复正常通道进食,其中2／58例次出现颈部和胸部皮下气肿,经保守治疗好转。结论：采用内镜球囊扩张治疗食管狭窄是一种安全有效的新方法。     

食管贲门癌支架置入术的全程护理

目的 探讨食管贲门癌支架置入术的全程护理.方法 对22例失去手术治疗机会或拒绝手术的中晚期食管癌或食管贲门癌狭窄患者,采用胃镜直视下食管金属支架置入术治疗.结果 22例患者均一次性放置成功.8例有不同程度胸骨后疼痛,7例咽部不适及异物感,2例出现黑便,5例胃食管返流,均给予对症处理.结论 胃镜直视下放置金属支架方便快捷,可避免X线照射,对解除恶性食管梗阻是一种安全、有效的姑息性治疗方法,可改善患者的生存质量,延长其生存时间.     

食管贲门及直肠狭窄的内镜下扩张治疗体会

目的：探讨内镜下应用气囊扩张器或聚乙烯探条扩张器治疗食管贲门部狭窄138例及7例直肠狭窄的应用体会和临床疗效分析。方法：应用气囊扩张器，在内镜直视下对120例食管贲门部狭窄病人进行了249次扩张治疗；并对7例直肠术后吻合口狭窄病人进行了17次扩张治疗；应用探条扩张器对18例食管狭窄病人进行了35次扩张治疗。扩张前常规先行内镜检查，明确狭窄的部位、特点和病因，选择直径适悬空的扩张器。结果：扩张后食管狭窄137例、直肠狭窄6例效果均很显著，该组食管狭窄117例、直肠5例首次扩张后内镜即可顺利通过，既直径大于1．0cm，20例经几次扩张后内镜可以通过，扩张后当日既可进普食。为巩固疗效，患者应进行多次扩张，扩张2、3次为佳。顽固性食管狭窄2例扩张3次后效果不佳置入一食道支架，2个月后取出，胃镜可通过。结论：采用气囊或探条扩张器对良性食管及直肠狭窄扩张是在内镜直视下进行，能准确放置扩张器，其成功率高，疗效显著。     

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.     

Dissociable correlates of two classes of retrieval processing in prefrontal cortex

Although substantial evidence suggests that the prefrontal cortex (PFC) implements processes that are critical for accurate episodic memory judgments, the specific roles of different PFC subregions remain unclear. Here, we used event-related functional magnetic resonance imaging to distinguish between prefrontal activity related to operations that (1) influence processing of retrieval cues based on current task demands, or (2) are involved in monitoring the outputs of retrieval. Fourteen participants studied auditory words spoken by a male or female speaker and completed memory tests in which the stimuli were unstudied foil words and studied words spoken by either the same speaker at study, or the alternate speaker. On "general" test trials, participants were to determine whether each word was studied, regardless of the voice of the speaker, whereas on "specific" test trials, participants were to additionally distinguish between studied words that were spoken in the same voice or a different voice at study. Thus, on specific test trials, participants were explicitly required to attend to voice information in order to evaluate each test item. Anterior (right BA 10), dorsolateral prefrontal (right BA 46), and inferior frontal (bilateral BA 47/12) regions were more active during specific than during general trials. Activation in anterior and dorsolateral PFC was enhanced during specific test trials even in response to unstudied items, suggesting that activation in these regions was related to the differential processing of retrieval cues in the two tasks. In contrast, differences between specific and general test trials in inferior frontal regions (bilateral BA 47/12) were seen only for studied items, suggesting a role for these regions in post-retrieval monitoring processes. Results from this study are consistent with the idea that different PFC subregions implement distinct, but complementary processes that collectively support accurate episodic memory judgments.     

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.