笑气吸入清醒镇静在胃镜检查中的作用

目的 探讨笑气( N2O)吸入清醒镇静对胃镜检查者的镇静效果.方法 2007年7月～2010年6月行笑气镇静下胃镜检查者285例,随机选取300例常规胃镜检查者作为对照,观察吸入笑气的镇静镇痛效果及不良反应.结果 笑气镇静组相对于常规胃镜检查组可减轻胃镜检查中的不适症状,且对生命体征无影响(P＞0.05),医师满意率高达95.2％,患者满意率为97.6％.结论 笑气吸入镇静起效迅速、可控性好,安全性高,值得推广.     

笑气吸入与异丙酚静脉麻醉镇痛技术在结肠镜检查中的临床对比研究

目的 对比研究笑气吸入与异丙酚静脉麻醉镇痛技术在结肠镜检查中的临床应用价值.方法 接受结肠镜检查的180例患者,随机分为两组:其中自愿接受笑气吸入镇痛的90例为A组(笑气组),通过面罩吸入笑氧混合气(笑气浓度为45％～50％),自愿接受静脉麻醉的90例为B组(异丙酚组),选用手背静脉推注异丙酚2mg/kg.观察两组患者的镇痛效果、不良反应发生情况,监测检查前后不同时点的血压、心率和血氧饱和度,记录操作时间、离院时间,检查结束后问卷调查患者的主观意见反应.结果 A、B两组的镇痛效果、不良反应发生率、操作时间、满意率和愿意再接受检查率比较,差异均无显著性(P＞0.05).B组患者检查中血压、心率和血氧饱和度均较检查前下降(P＜0.05),A组患者离院时间明显短于B组(P＜0.01).结论 笑气吸入与异丙酚静脉麻醉应用于结肠镜检查均有良好的镇痛效果,笑气吸入镇痛技术操作简便、恢复迅速、安全可靠,而异丙酚静脉麻醉对呼吸、循环系统有一定的抑制作用.     

笑气清醒镇静用于无痛胃镜检查的观察与护理

目的:探讨笑气吸入清醒镇静用于无痛胃镜检查的效果及护理。方法:总结观察组528例笑气吸入清醒镇静用于无痛胃镜检查的临床资料和护理方法,并与常规胃镜检查对照组530例进行对比分析。结果:(1)观察组528例全部完成检查,对照组523例顺利完成检查。两组患者检查中及检查后均未发生呕血、黑便、胃食管反流等严重并发症。(2)观察组咽部不适、恶心、呕吐、躁动、心律失常的发生明显低于对照组(P0.05);头晕、嗜睡、幻觉的发生高于对照组(P0.05)。(3)两组患者均未严重神志意识障碍,血压、心率异常波动以及呼吸抑制、低氧血症等并发症。检查中和检查后对照组血压、心率和呼吸频率明显高于观察组(P0.05),差异有统计学意义。血氧饱和度两组比较无统计学差异(P0.05)。结论:笑气吸入清醒镇静用于无痛胃镜检查安全方便,不良反应少,各观察指标和检测指标均优于常规胃镜检查。护理安全管理和插镜配合是笑气吸入清醒镇静用于无痛胃镜检查护理的关键环节。     

腕踝针在老年无痛胃镜检查中对丙泊酚用量的影响*

目的探讨腕踝针灸法对老年患者无痛胃镜检查中丙泊酚用量的影响。方法收集胃镜检查患者120例,年龄70～85岁,美国麻醉医师协会(ASA)分级Ⅱ级或病情稳定Ⅲ级,按随机数字表法分为对照组和腕踝针组,各60例。腕踝针组入室前在相应区域穿刺留针,入室后两组静脉给予纳布啡0.1 mg/kg,静脉靶控输注丙泊酚,待睫毛反应消失、呼之不应时进行胃镜操作,根据术中体动情况,酌情追加丙泊酚。记录丙泊酚总用量、胃镜操作时间、唤醒时间、离室时间、呼吸抑制、低血压和恶心呕吐等不良反应情况。结果腕踝针组丙泊酚用量、唤醒时间和离室时间明显低于对照组(P 0.05),呼吸抑制、低血压和术后恶心呕吐的发生率低于对照组(P 0.05)。结论腕踝针在丙泊酚无痛胃镜检查中,可有效减少丙泊酚用量,降低不良反应,缩短恢复时间。     

依托咪酯与丙泊酚在无痛胃镜检查中的比较

目的比较依托咪酯与丙泊酚两种方法在无痛胃镜检查中的镇痛效果。方法选择200例无痛胃镜患者,随机分依托咪酚复合芬太尼组（E组）和丙泊酚复合芬太尼组（P组）,每组100例,观察各自的镇痛效果及安全性。结果两组镇痛效果明显、安全,组间比较差异无统计学意义（P〉0.05）。结论依托咪酯复合芬太尼和丙泊酚复合芬太尼在无痛胃镜检查中,均安全有效。     

无痛胃镜在内镜下黏膜切除术中的应用及护理配合

目的:探讨无痛胃镜在内镜下黏膜切除术(EMR)中应用效果及护理配合方法。方法:将102例EMR患者随机分为观察组57例和对照组45例。对照组应用常规胃镜检查法完成EMR,观察组在无痛胃镜下完成EMR。比较两组患者完成操作所用时间;患者对医生、护士及治疗过程的满意率;医生护士对无痛胃镜下EMR操作效果的满意率。结果:观察组EMR治疗时间少于对照组(P<0.01),观察组患者对医生、护士和治疗过程的满意率、医生护士对EMR治疗效果的满意率都优于对照组(P<0.05)。结论:无痛胃镜下进行EMR,有助于提高患者满意率。     

笑气与异丙酚在胃肠镜检查中应用的临床分析和护理

摘要：目的 探讨笑气(Nitrous Oxide,N2O)吸入与丙泊酚（Propofol,Pro）静脉注射用于无痛胃肠镜检查时的镇静镇痛效果比较及护理。方法 将2012年5月至2013年10月我院笑气吸入内镜受检者317例（I组,其中胃镜为Ia组,肠镜为Ib组)和丙泊酚静脉注射内镜受检者463例（II组,其中胃镜为IIa组,肠镜为IIb组)进行对照分析。笑气组给予吸入笑氧混合气体至患者有头晕或睡意后开始镜检。异丙酚组静脉推注异丙酚至患者睫毛反射消失后开始镜检。观察记录两组受检者检查前、中、后的血压（BP）、心率（HR）、指脉血氧饱和度（SPO2）,术中的不适反应,胃肠镜操作时间,麻醉药物起效时间、清醒时间,并进行术后问卷调查。结果II组与I组相比,术中BP、SPO2均有明显下降,两组术中与术前BP、SPO2的差值比较差异有统计学意义(p <0.05),其中II组有77例受检者出现收缩压（Systolic Blood Pressure,SBP）<80mmHg,86例受检者出现SPO2低于95%,而I组仅有1例受检者出现SBP<80mmHg,所有受检者术中SPO2>95%,差异有统计学意义(p<0.05);Ia组HR上升幅度高于IIa组(p<0.05),Ib组HR变化与IIb组比较差异无统计学意义(p>0.05);II组胃肠镜操作时间均较I组缩短(p<0.05),术中不适反应少(p<0.05),术后复检接受度高于I组(p<0.01);但II组恢复清醒时间长,与I组比较差异有统计学意义(p<0.05)。结论 与异丙酚静脉麻醉比较,笑气吸入血流动力学更稳定,对呼吸无抑制作用,术后恢复时间短;术中舒适程度和术后复检接受度静脉麻醉较笑气吸入高;对静脉麻醉有禁忌症的患者来说,笑气吸入是镇静镇痛较好的选择,规范的护理有助于提高其有效性和安全性。     

右美托咪定对预防无痛胃镜检查中引起呛咳的临床观察

观察通过预输注右美托咪定是否能预防无痛胃镜检查中呛咳的发生。选择无痛胃镜患者400例,ASAⅠ~Ⅱ级,随机均分为2组,分别为右美托咪定复合丙泊酚组(Ⅰ组)和单纯丙泊酚组(Ⅱ组)。Ⅰ组静脉泵注右美托咪定10min后行无痛胃镜检查,Ⅱ组常规行无痛胃镜检查。观察记录患者胃镜检查中丙泊酚的总用量;胃镜检查中、麻醉恢复期发生低氧血症的例数;在入镜时、检查中、麻醉苏醒期发生呛咳的例数,并进行统计学分析。胃镜检查中丙泊酚的总用量Ⅰ组较Ⅱ组明显减少(P0.01);Ⅰ组的总呛咳率低于Ⅱ组(P0.05),有统计学差异;入镜时Ⅰ组呛咳率比Ⅱ组低(P0.05),有统计学差异;检查中Ⅰ组呛咳率比Ⅱ组低(P0.05)认为有统计学差异;麻醉苏醒期Ⅰ组较Ⅱ组呛咳率(P0.05)无统计学差异。无痛胃镜前静脉泵注右美托咪定能够减少胃镜导管引起的呛咳反应。     

丙泊酚复合芬太尼用于老年患者无痛胃镜检查术1000例效果观察

目的观察丙泊酚复合小剂量芬太尼用于老年患者无痛胃镜检查术的效果及方法。方法回顾性分析1000例丙泊酚复合小剂量芬太尼用于老年患者无痛胃镜检查术的麻醉效果、副作用、麻醉用药量、手术时间、术毕清醒时间、离室时间等情况。结果麻醉镇痛效果优良率99.81%;患者满意率100%;副作用发生率4.3%,主要是呛咳及呼吸抑制;麻醉药平均用量丙泊酚(75±15)mg、芬太尼30μg;手术时间(6.5±3.3)min,术毕(2.5±0.4)min清醒,术后0.5～1 h离院或送返病房。结论丙泊酚复合小剂量芬太尼用于老年患者无痛胃镜的镇痛确切,安全,副作用发生率低,性价比好,是目前较好的无痛胃镜麻醉方法。     

宫腔镜检查时使用笑气的护理及镇痛效果评价

目的 观察笑气吸入用于宫腔镜检查者的镇痛效果并总结护理要点。 方法 对 104例拟行宫腔镜检查患者按手术日单双号分为笑气吸入组(笑气组,53例)及对照组(51例),观察两组检查前与检查中的收缩压、呼吸、血氧饱和度及检查时间和镇痛效果。 结果 检查中收缩压、呼吸与检查前比较两组均明显升高(P＜0.05 ), 但笑气组升高幅度明显低于对照组 (P＜0.05);两组检查前及检查中血氧饱和度均无明显变化(P＞0.05);笑气组手术时间明显短于对照组(P＜0.05);笑气组患者疼痛明显较对照组轻(P＜0.01)。 结论 笑气吸入应用于宫腔镜检查有良好的镇痛效果 ,可减轻患者检查时紧张、焦虑情绪,有利于检查操作,缩短检查时间。     

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.     

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。     

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。     

Acetaminophen and acetylcysteine dose and duration: Past,present and future

Abstract

Acetylcysteine has been utilized successfully in the treatment of acetaminophen overdose since the 1970s. Although prospective trials as to efficacy and safety of acetylcysteine were conducted, there were no randomized controlled trials. This commentary addresses the reasons for this, and the background to choice of dose of acetylcysteine utilized in the oral and IV dosing regimens. Nomograms to predict possible hepatotoxicity based upon time of ingestion of acetaminophen were developed from a relatively arbitrary definition of toxicity as an aspartate aminotransferase/alanine aminotransferase (ALT/AST) greater than 1000 IU/L. While these have proved generally useful, patients still continue to develop hepatic damage after acetaminophen overdose, particularly if they present late after ingestion. The optimum management of these patients remains unclear, and one area of uncertainty is the dose and duration of acetylcysteine in various circumstances. This article discusses the issues that need to be elucidated to better target changes in acetylcysteine dose. The potential for measurements of other markers to improve treatment selection is the subject of further research.     

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.