超声在脊髓肿瘤手术中的应用价值

目的 探讨术中超声应用于脊髓肿瘤的可行性及临床应用价值.方法 40例脊髓肿瘤患者术中行超声检查,了解肿瘤的声像图特点,进行术中定位,确定病变边界,判断肿瘤的切除情况.结果 术中超声均清晰显示40例脊髓肿瘤,不同肿瘤有其特征性的声像图表现.所有肿瘤均准确定位,并准确评价了手术切除程度.结论 术中超声可帮助术者进行术中肿瘤定位,有助于确认脊髓肿瘤边界及判断肿瘤切除情况,提高了脊髓肿瘤的准确诊断率和全切除率.     

术中超声在活体肝移植受体手术中的应用价值

目的 探讨术中超声在活体肝移植受体手术中的应用价值.方法应用Mylab 30超声诊断仪对45例活体肝移植受者在血管吻合完毕后行术中超声检查.结果术中超声诊断肝动脉栓塞3例,流出道梗阻2例,门静脉血流速度及血流量异常增高4例,门静脉吻合口狭窄1例.结论术中超声在活体肝移植受体手术中具有重要的应用价值.     

不同子宫全切术方案对患者免疫细胞的影响

目的:研究腹腔镜子宫全切术(LH)和开腹子宫全切术(AH)对TH1/TH2细胞(辅助性T细胞)平衡的影响.方法:2008年6月至2009年6月子宫肌瘤患者100例,试验组(L组)行LH,对照组(A组)开腹手术,各50例.术前24 h、术后3,6,9,12,15,18,24及48 h分别抽取肘静脉血测定TH1、TH2细胞含量.结果:A组术后TH1明显减少,而TH2明显增加.TH1/TH2比值降低.L组术后各指标均无明显变化,与A组差异有显著性.结论:LH可明显降低术后TH1/TH2细胞的偏移程度,对术后免疫功能干小.     

腹腔镜治疗粘连性肠梗阻32例

目的:探讨腹腔镜松解粘连性肠梗阻的效果.方法:回顾性分析我院自2000-2008年32例因粘连性肠梗阻行腹腔镜松解术患者的临床资料.结果:患者均治愈.术中平均出血量10 mL,术后平均住院时间4 d,术后无并发症,随访至今无复发.结论:腹腔镜肠粘连松解术创口小、腹膜创面少、操作轻柔、腹腔干扰少,能较大限度地减少术后腹腔内再粘连,为粘连性肠梗阻的外科治疗提供了一种新方法.     

术中超声在脑血管疾病的应用

目的 采用术中超声观察不同颅内血管性病变的显示情况,探讨术中超声实时定位病灶、指导手术切除的价值.方法 对204例颅内血管性疾病患者行术中超声检查,对动静脉畸形患者寻找供血动脉和引流静脉.对海绵状血管瘤患者剪开硬脑膜切除病变前(术前)、经大脑皮层造瘘到达病灶时(术中)以及病灶切除术后(术后)均行术中导航及术中超声检查,并比较二者定位的准确性.结果 ①术中超声对颅内血管性疾病的显示率为98%,其中对颅内动静脉畸形和海绵状血管瘤的显示率均为100%,动脉瘤的显示率为81%,血管母细胞瘤的显示率为91%.②术中超声对颅内动静脉畸形患者供血动脉及引流静脉的显示率为71%.③术中超声与术中导航在海绵状血管瘤切除术前定位的准确率差异无统计学意义(100%对95%,P=0.244).术中超声在海绵状血管瘤切除术中、术后定位的准确率明显高于术中导航,差异有统计学意义(100%对74%,x2=19.513,P＜0.0001,100%对68%,x2=24.973,P＜0.0001).结论 术中超声对颅内血管性疾病具有较高的显示率,并可准确定位病变,指导手术,缩短手术时间,减少损伤,提高手术的精确性.     

冠状动脉造影术后右冠状动脉梭样扩张1例

患者男,70岁.2003年3月以冠状动脉硬化性心脏病,于外院行冠脉造影及左旋支15～17段Cordis支架安置术.2003年4月于我院局麻下行永久心脏起搏器置入术,术中术后顺利.     

无痛胃镜检查术的护理

通过总结了250例行无痛胃镜检查术患者的护理,包括术前、术后的护理及术中的配合,认为系统的护理有利于减少无痛胃镜检查术患者的不良反应.     

腹腔镜手术治疗小儿卵巢囊肿疗效观察

目的 探讨腹腔镜手术治疗小儿卵巢囊肿的临床可行性.方法 26例小儿卵巢囊肿在腹腔镜下进行剥除术与24例小儿开腹卵巢囊肿剥除术进行比较,比较两组之间手术时间、术中出血量、术后住院时间、术后肛门排气时间、切口疼痛、术中术后并发症、抗生素使用及术后复发率等.结果 两组患者的手术时间差异无统计学意义(P＞0.05),腹腔镜组患者术中出血量明显减少、术后肛门排气时间明显缩短、切口疼痛明显减轻、术后住院时间及抗生素使用时间缩短、无手术并发症发生,囊肿复发率及大小无差异.结论 腹腔镜下小儿卵巢囊肿剥除术是一种安全、可靠、适合于临床上广泛开展应用的手术方式.     

超声实时监视在宫腔疑难手术中的应用

目的探讨超声在宫腔疑难取环术及宫腔残留组织清除术中的作用.方法超声监视引导下行26例疑难取环术及71例宫腔残留物钳刮手术.结果26例疑难取环术及70例宫腔残留组织清除术均一次性完成手术,采用本法仅1例宫腔憩室手术失败.结论超声可清晰显示宫内环或宫内残留组织确切位置,在宫腔疑难取环术及宫腔残留组织清除术中实时动态观察和指导手术全过程,有效减少和避免并发症的发生,在计划生育手术中具有重要的实用价值.     

结肠镜单双人操作的应用对比

我院从2009-07-2010-07对196例患者进行单双人操作,并进行了一项对比性研究.结果表明结肠镜操作过程中单人术比双人术可以通过保持直线化状态,提高患者忍受程度,减轻痛苦,缩短检查时间,现总结如下.     

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.     

Guns and Knives in New Mexico: Patterns of Penetrating Trauma, 1978–1993

Objective: To identify patterns of nonfatal and fatal penetrating trauma among children and adults in New Mexico using ED and medical examiner data.
Methods: The authors retrospectively sampled in 5-year intervals all victims of penetrating trauma who presented to either the state Level-1 trauma center or the state medical examiner from a 16-year period (1978–1993). Rates of nonfatal and fatal firearm and stabbing injury were compared for children and adults.
Results: Rates of nonfatal injury were similar (firearm, 34.3 per 100,000 person-years; stabbing, 35.1). However, rates of fatal injury were significantly different (firearm, 21.9; stabbing, 2.7; relative risk: 8.2; 95% confidence interval: 5.4, 12.5). From 1978 to 1993, nonfatal injury rates increased for children (p = 0.0043) and adults (p < 0.0001), while fatal penetrating injury remained constant. The increase in nonfatal injury in children resulted from increased firearm injury rates. In adults, both stabbing and firearm nonfatal injury rates increased.
Conclusions: Nonfatal injury data suggest that nonfatal violence has increased; fatal injury data suggest that violent death rates have remained constant. Injury patterns vary by age, mechanism of trauma, and data source. These results suggest that ED and medical examiner data differ and that both are needed to guide injury prevention programs.     

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.