神经电图-肌电图检测对多灶性运动神经病的评估作用

目的：探讨神经电图(ENG)和肌电图(EMG)检查对多灶性运动神经病(multifoeal motor neuropathy，MMN)的诊断价值及康复干预的评估作用。方法：对16例诊断为MMN的患进行电生理检查，受试为MMN组16例和正常组16例，分别进行运动神经传导速度(MCV)和感觉神经传导速度(SCV)检查，记录刺激引出的复合肌肉动作电位(compound muscle action potentials，CMAP)的波幅、波宽、面积、位相、时限进行对比分析，判定是否有运动神经传导阻滞(conduction block，CB)或暂时性离散(temporal dispersion，TD)。并有选择性地进行常规肌电图检查。结果：16例患中均见有一根以上运动神经或至少一根运动神经的一个以上部位出现CB或TD。其中13例双上肢正中神经，尺神经出现CB，3例首发为正中神经尺神经的远端出现CB，随病情进展出现下肢腓深神经CB。仅有两例感觉神经传导速度稍有减慢，波幅略有降低。16例患神经受累区域以下所支配肌肉肌电图检查见有运动神经源性受损改变。     

神经电图-肌电图检测对多灶性运动神经病的评估作用

目的:探讨神经电图(ENG)和肌电图(EMG)检查对多灶性运动神经病(multifocalmotorneuropathy,MMN)的诊断价值及康复干预的评估作用。方法:对16例诊断为MMN的患者进行电生理检查,受试者为MMN组16例和正常组16例,分别进行运动神经传导速度(MCV)和感觉神经传导速度(SCV)检查,记录刺激引出的复合肌肉动作电位(compoundmus-cleactionpotentials,CMAP)的波幅、波宽、面积、位相、时限进行对比分析,判定是否有运动神经传导阻滞(conductionblock,CB)或暂时性离散(temporaldispersion,TD)。并有选择性地进行常规肌电图检查。结果:16例患者中均见有一根以上运动神经或至少一根运动神经的一个以上部位出现CB或TD。其中13例双上肢正中神经,尺神经出现CB,3例首发为正中神经尺神经的远端出现CB,随病情进展出现下肢腓深神经CB。仅有两例感觉神经传导速度稍有减慢,波幅略有降低。16例患者神经受累区域以下所支配肌肉肌电图检查见有运动神经源性受损改变。结论:MMN病是一种以远端神经受累为主的不对称性周围神经病,神经电生理检查对诊断和鉴别诊断MMN起重要作用,CB是MMN特征性表现。     

尺神经共同刺激影响腕管综合征正中神经远端潜伏期：避免误差的定量测定

目的研究尺神经-大鱼际复合肌肉动作电位(CMAP)潜伏期正常值,以定量分析尺神经共同刺激所致腕管综合征(CTS)患者正中神经-大鱼际潜伏期的误差。 方法正常组112例,记录224侧正中神经-拇短展肌（APB）和224侧尺神经-大鱼际的CMAP潜伏期和波幅。另对其中10例20侧正中神经,分别记录以正中神经-APB最大波幅之刺激强度的30%、50%、70%、100%刺激时的CMAP潜伏期和波幅。其中4例分别予以120%、150%和200%的超强刺激,记录CMAP潜伏期和波幅。CTS组16例,记录到正中神经-APB的CMAP最大波幅后,继续增大刺激强度,记录尺神经共同刺激效应后的正中神经-大鱼际CMAP。 结果①正常组：尺神经-大鱼际远端潜伏期为（3.17±0.25）ms,波幅为（6.60±1.07）mV;正中神经-APB远端潜伏期为(3.45±0.31)ms,波幅为(6.47±1.08)mV。当正中神经刺激强度从引出最大CMAP波幅之强度的30%、50%、70%增加至100%,正中神经远端潜伏期相应缩短0.1~0.3ms;达到最大波幅后继续增加刺激强度至120%、150%和200%的超强刺激,则潜伏期不再继续缩短。②CTS组：尺神经共同刺激所引起的正中神经-大鱼际CMAP潜伏期缩短范围为0.5~8.7ms,导致正中神经-APB的错误潜伏期范围为(2.9~4.1)ms。 结论CTS患者正中神经检测时,若正中神经-APB CMAP潜伏期随刺激强度增大而缩短超过0.3ms,并且达到2.9~4.1ms的范围,则提示可能发生了尺神经共同刺激。     

神经传导速度及交感皮肤反应检测在糖尿病性周围神经病诊断中的价值

目的 探讨神经传导速度及交感皮肤反应（SSR）在糖尿病性周围神经病（DPN）诊断中的价值。方法 对36例DPN患者进行神经电图检查，包括运动神经传导速度（MCV）、感觉神经传导速度（SCV）及交感皮肤反应（SSR）检测。结果 共检查36例患者216条神经，其中MCV检测108条神经，MCV减慢32条，MCV减慢合并远端潜伏期延长8条，复合肌肉动作电位（CMAP）波幅下降4条，异常率40．7％；SCV检测108条神经，SCV减慢42条，未引出电位7条，SCV减慢伴波幅下降6条，异常率50．9％：SSR检测36例72侧肢体，其中有4例上、下肢均未引出SSR，22例38肢SSR潜伏期延长：波幅下降，异常率63．8％，10例无自主神经症状患者中有3例SSR异常，异常率30％。结论 NCV及SSR检测为DPN自主神经及周围神经早期病变，尤其是为亚临床病变提供了客观依据，多个参数相结合有助于提高早期病变的阳性检出率。     

神经传导速度差异规律量化评估肌萎缩侧索硬化症

背景：肌电图的神经传导速度异常是肌萎缩侧索硬化(amyotrophic lat-eral sclerosis，ALS)的诊断标准之一，可否以其变化差异规律来量化患者病情变化和评估预后?目的：研究肌萎缩侧索硬化(ammyotrophic lateral sclerosis，ALS)患者中神经传导速度的改变，建立量化评定肌萎缩侧索硬化病情及其预后的神经生理指数。设计：回顾性分析。地点和对象：本研究的地点为北京大学第三医院神经科，研究对象为北京大学第三医院神经内科1997—02／1999—03住院患者。方法：对21名ALS患者的30条尺神经、32条正中神经及24名健康对照组的38条尺神经、40条正中神经进行运动传导速度(motor conduc-tion velocity，MCV)及感觉传导速度(sensory conduction velocity，SCV)和F波进行检测。两组间数据进行统计学分析。主要观察指标：两组正中神经神经传导速度与F波，ALS组患者小指暖肌的肌力与CMAP波幅／DML&;#215;F出现率数值的相关性。结果：ALS组正中神经、尺神经运动传导速度的远端潜伏期(distal molor latency，DML)、肌肉动作电位(compound muscle action potential，CMAP)波幅及面积、F波的出现率较对照组有显著性差异。而两组MCV、SCV、F波的潜伏期差异无显著性。ALS组中10名小指展肌的肌力与CMAP波幅／DML&;#215;F出现率的数值有显著的相关性（r=0．89，P&;lt;0．01）。结论：CMAP波幅／DML&;#215;F波的出现率是一种有效的客观的电生理指数，可对ALS病情及其预后进行量化评估。     

复合肌肉动作电位波幅和肌力的相关性在危重病瘫痪诊断中的价值

  目的  探讨复合肌肉动作电位(compound muscle action potential, CMAP)波幅和肌力的相关性在协助重症患者肢体瘫痪定位中的价值。  方法  采用床旁肌电图测定, 对30例伴有肢体无力的重症患者进行运动神经传导测定, 同时收集测定神经所支配肌肉的肌力, 与CMAP波幅进行比较。  结果  5例患者神经传导测定CMAP波幅和速度均正常, 其中3例为明显无力, 符合中枢神经系统病变的诊断。6例肢体明显无力的患者, 发现有运动神经传导阻滞和传导速度减慢, CMAP波幅下降, 符合脱髓鞘性周围神经病的诊断。19例表现为CMAP波幅下降, 其中8例波幅明显下降(3例未引出波形), 无潜伏期延长或传导速度减慢, 临床查体可见8例明显无力, 10例轻度无力, 1例肌力正常, 支持神经肌肉病变的诊断。  结论  将CMAP波幅和肌力结合进行分析有助于重症患者肢体瘫痪的定位, 尤其在明显无力的肢体测定时价值更大。     

多灶性运动神经病电生理诊断的初步研究

目的 探讨多灶性运动神经病（ＭＭＮ）的电生理诊断特点。方法 对６例临床诊断为ＭＭＮ的患者进行电生理检查，ＭＣＶ测定采用自近端至远端分段刺激，记录各段刺激引发ＣＭＡＰ的波幅，时限，面积，并判定ＣＢ和ＴＤ。结果 ６例患者所有受累运动神经至少有一条出现ＣＢ，正中神经和尺神经是易出现，其中腕至肘，腋至Ｅｒｂ’点为好部位，其它脱鞘要电生理表现也常见，部分神经可出现轻度轴索样改变，结论 ＭＭＮ是一种脱鞘为主的     

运动神经元病的磁刺激运动诱发电位分析

目的 探讨磁刺激运动诱发电位(MEP)在运动神经元病(MND)中的应用价值.方法 分别对我科2005年4月至2006年10月确诊的8例MND组及10例正常对照组进行上下肢MEP测定.结果 8例MND患者中MEP总异常率占75%,主要表现为皮层刺激潜伏期延长、波幅降低或未引出、波形呈复合波及中枢运动传导时间延长.结论 MEP结合肌电图、神经传导速度测定可进一步确定MND的诊断,并在分型中起到一定的作用.MEP是诊断MND的一种必要辅助手段.     

腕管综合征的电生理分析及与身体质量指数的相关性

目的:探讨88例腕管综合征(CTS)的电生理特点,明确电生理检查的诊断价值。方法:对88例门诊腕管综合征患者行一侧或双侧正中神经、尺神经的分段运动神经传导速度(MCV)和,Ⅰ、Ⅴ、Ⅳ指刺激感觉神经传导速度(SCV)测定,以及拇短展肌针极肌电图检查;计算每一位患者身体质量指数(BMI)及正中神经与尺神经Ⅳ指刺激感觉神经动作电位(SNAP)波幅比值。结果:Ⅰ、Ⅳ指刺激正中神经SNAP潜伏期延长者的百分比分别为59.1%与65.9%;复合肌肉动作电位(CMAP)波幅降低者中拇短展肌肌电图异常者占87.2%;SNAP各参数正常者中有8例(72.7%)出现Ⅳ指刺激正中神经与尺神经波幅比值的异常,各异常参数患者BMI值无显著性差异。结论:神经电生理检查是诊断CTS的理想检测手段。     

电生理检测中运动神经传导变异对急性炎症性脱髓鞘性多发性神经病的评估意义

目的：了解急性炎症性脱髓鞘性多发性神经病(acute inflammatory demyelinating polyradiculoneuropathy，AIDP)电生理异常和受损程度的分布情况，探讨其发病机制。方法：对26例AIDP患者进行电生理检测，记录肢体两侧、上下肢及远近端运动神经末端潜伏期(DML)、运动传导速度(MCV)、肌肉复合动作电位(CMAP)；感觉神经潜伏期、感觉传导速度(SCV)及肌电图。结果：①MCV异常率(78，2％)高于SCV异常率(64．1％)(x^2=5．310，P&;lt;0．05)。②肢体远端肌肉自发电位出现率(79.2％)，明显高于近端肌肉(50％)(x^2=14．856，P&;lt;0．05)。③远端运动神经末端潜伏期重度受损率(75.6％)，较近端神经(47．4％)高(x^2=14，628，P&;lt;0.01)，远端运动神经CMAP波幅重度受损率(74.4％)，较近端(52.5％)高(x^2=5．168，P&;lt;0．05)。结论：AIDP在电生理上改变为广泛的、多灶、远近端神经、上下肢均受累，运动神经较感觉神经易受累，就损伤程度而言远端神经较近端神经受损程度重。     

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.