化疗患者锁骨下静脉置管感染的相关因素研究

目的 :探讨应用锁骨下静脉置管化疗患者导管感染的相关因素。方法 :对适合锁骨下静脉穿刺置管肿瘤化疗患者 40 0例进行置管化疗 ,拔管后常规给以穿刺点、导管尖端细菌培养。同时 ,拟对 1 2个感染相关因素进行临床观察和单因素、多因素非条件logistic回归分析。结果 :发生导管性感染 36例 ,感染率 9.0 %。导管感染主要危险因素是留置天数、病情、合用激素与否和有无伴有糖尿病。结论 :锁骨下静脉穿刺置管化疗患者导管感染的高危险因素为留置天数、病情、合用激素与否和有无伴有糖尿病。因而 ,对有感染高危险因素存在的导管留置者要定期监测各项感染指标 ,避免导管感染发生     

化疗患者锁骨下静脉置管留置时间与感染关系的探讨

目的:探讨肿瘤化疗患者经皮穿刺锁骨下静脉置管留置时间与感染发生的关系。方法:通过400例肿瘤化疗患者经皮穿刺锁骨下静脉置管术后感染的监测,按留置时间长短分4组:A组:<20 d、B组:20～39 d、C组:40～59 d、D组:≥60 d。4组感染率之间用X2检验。结果:共发生导管性感染36例,感染率9.0％。A、B、C、D组感染率分别为3.2％、4.5％、13.6％、15.0％。4组之间经X2检验结果:A与B、c、D的P值分别为P>0.05、P<0.05、P<0.01;B与c、D的P值分别为P<0.05、P<0.01;C与D的P值>0.05。除A与B、C与D之间值差异无显著性外,其他均有非常显著性。结论:导管留置时间在39d内,感染率发生较低,相对较安全;超过40 d,感染率明显增高。即留置时间越长、感染率越高。     

多种体位锁骨下静脉穿刺中心静脉置管术的应用

目的　探讨多种体位经锁骨下静脉穿刺中心静脉置管术临床应用的可行性及安全性。方法　 12 6 0例恶性肿瘤患者按耐受程度及穿刺部位分为A组 (833例平卧位右侧穿刺置管 )、B组 (4 0 6例平卧位左侧穿刺置管 )、C组 (15例 30°～ 6 0°卧位穿刺置管 )和D组 (6例 6 0°以上卧位穿刺置管 ) ,穿刺点在锁骨中下 1～ 2cm偏内 1～ 2cm范围内 ,半卧位以上的穿刺点要离锁骨稍远一些 (1 5～ 2 5cm) ,穿刺时紧贴锁骨背面朝胸骨上窝方向水平进针 ,置管深度右侧 13～ 15cm ,左侧 15～ 17cm。结果　A、B组置管成功率均达 99%以上 ,C、D组全部成功 ,失败原因主要是误刺动脉和局部血肿。早期并发症A组 11例 (气胸3例 )、B组 6例 (气胸 2例 ) ,全部经对症治疗后痊愈 ,C、D组无一例并发症发生。结论　锁骨下静脉穿刺置管是患者易接受的一种方便、安全、有效的治疗途径 ,且穿刺置管术可在从平卧到坐位的多种体位下完成。     

洛汀新和波依定治疗糖尿病高血压129例临床观察

目的　观察洛汀新联合波依定治疗糖尿病高血压的降压疗效。方法　 12 9例糖尿病高血压患者随机分为A、B、C 3组。A组口服洛汀新 10～ 2 0mg ,1次 /d ;B组口服波依定片 10mg ,1次 /d ;C组口服洛汀新 5～ 10mg ,波依定 5mg ,1次 /d。治疗 6周。 结果　 3组患者收缩压、舒张压明显降低 ,与治疗前比较差异显著 (P <0 .0 1) ,但C组降压疗效更明显 ,与A、B组比较差异显著 (P <0 .0 5 )。结论　洛汀新联合波依定治疗糖尿病高血压疗效更好     

儿童分泌性中耳炎112例临床治疗体会

目的 探讨行鼻内镜电视监视下腺样体切除联合鼓膜置管术治疗儿童分泌性中耳炎(SOM)的临床疗效.方法 回顾性分析2010年1月至12月收治的112例伴有腺样体肥大的SOM患儿的临床资料,A组32例行鼓膜置管术,B组33例行腺样体切除术,C组47例行腺样体切除联合鼓膜置管术,比较3组临床疗效及并发症情况.结果 C组总有效率(100.0％)明显高于A组(75 0％)、B组(72.7％)(P均＜0.05).C组并发症发生率低于B组(4.3％vs21.2％,P＜0.05),虽低于A组但差异无统计学意义(4.3％ vs 18.8％,P＞0.05).结论 鼻内镜电视监视下行腺样体切除联合鼓膜置管术治疗SOM并发症少,临床疗效显著.     

气管切开患者不同部位中心静脉导管置管护理观察

目的：探讨气管切开患者不同部位中心静脉置管差异及临床意义。方法收集苏州大学附属第一医院2012年02月-2014年02月收治的75例气管切开患者临床资料,随机分为锁骨下静脉置管组（A组）、颈内静脉置管组（B组）、股静脉置管组（C组）,每组25例。分别对穿刺成功率、并发症、穿刺部位血肿、渗液、导管堵管、脱出、导管相关感染、敷料更换频率等指标进行观察,比较各组之间差异。结果各组患者穿刺成功率及并发症差异无统计学意义（P＞0.05）,其余各指标A组显著低于B、C两组,具有统计学意义（P＜0.05）。其中B组患者导管更易脱出,与A、C两组差异有统计学意义（P＜0.05）。结论气管切开患者选择锁骨下静脉置管具有较低的导管相关感染发生率,且便于护理治疗,应作为首选置管途径。     

PICC插管与锁骨下静脉插管在血液病患者中的应用比较

目的 :比较经外周静脉穿刺的中心静脉置管 (PICC)和锁骨下静脉插管在血液病治疗中的应用范围及利弊。方法 :30例经肘窝外周静脉穿刺的中心静脉置管组为A组 ,30例经右侧锁骨下静脉穿刺的中心静脉置管组为B组 ,记录置管成功率、操作时间、留管时间、液体流速及并发症。结果 :A组一次置管成功率为 93 .3 % ,B组为 76 .7% ,P <0 .0 1;A组平均操作时间12min ,B组为 2 4min ,P <0 .0 1;A组平均留管时间为 6 6d ,B组为 39d ,P <0 .0 1;A组并发症 6 .7% ,B组并发症为 2 3 .3 % ,P <0 .0 1;A组的液体流速最大为 2 75ml/h ,B组为 5 5 8ml/h ,P <0 .0 1;PICC导管的价格是锁骨下静脉导管的 3～ 4倍。结论 :PICC组较锁骨下静脉组一次置管成功率高 ,节省时间和人力 ,留管时间长 ,并发症低 ,病人痛苦时间短 ,在临床上值得推广应用 ,但锁骨下静脉双腔导管在异基因骨髓移植的治疗中具有不可替代的作用。     

谷氨酸脱羧酶抗体和血尿C肽在糖尿病中的临床意义

目的　探讨糖尿病患者谷氨酸脱羧酶抗体和血、尿C肽测定的临床价值。方法　观察 2型糖尿病、成人隐匿型自身免疫性糖尿病、1型糖尿病患者及正常人的谷氨酸脱羧酶、馒头餐前后血C肽和 2 4h尿C肽浓度的变化 ,并进行对比分析。结果　谷氨酸脱羧酶检测 :2型糖尿病组均为阴性 ,成人隐匿型自身免疫性糖尿病组均为阳性 ,1型糖尿病组 7例阳性 ,5例阴性 ,正常对照组均为阴性。 2 4h尿C肽分泌总量 :2型糖尿病组显著高于成人隐匿型自身免疫性糖尿病组和 1型糖尿病组 (P <0 .0 1) ,与正常对照组比较无显著差异 (P >0 .0 5 ) ;成人隐匿型自身免疫性糖尿病组高于 1型糖尿病组 (P <0 .0 5 ) ;成人隐匿型自身免疫性糖尿病组和 1型糖尿病组明显低于正常对照组 (P <0 .0 1)。馒头餐试验各时相血C肽浓度 :与正常对照组相比 ,2型糖尿病组空腹血C肽浓度无显著差异 ,餐后血C肽升高缓慢 ,下降也缓慢 ,成人隐匿型自身免疫性糖尿病组和 1型糖尿病组空腹及餐后各时相血C肽浓度明显降低 (P <0 .0 1) ;且 1型糖尿病组降低更明显(P <0 .0 5 )。结论　谷氨酸脱羧酶抗体是反映 1型糖尿病胰岛B细胞自身抗体的免疫学指标 ,血、尿C肽是反映糖尿病胰岛B细胞功能的可靠指标 ,二者联合检测有重要临床意义。     

激素性股骨头坏死动物模型中血栓前状态的检测及其诊断学意义

目的　探讨激素性股骨头坏死过程中血栓前状态的出现及其诊断学意义。方法　 4 0只兔随机分成 4组 ,每组 10只。A组 :间隔 2 4h耳缘静脉内两次注射大肠杆菌内毒素 ,每次 4 0 μg kg。B组 :注射方法同A组 ,第二次注射内毒素后立即注射一次醋酸强地松龙 2 0mg kg。C组 :一次耳缘静脉内注射醋酸强地松龙 2 0mg kg。D组 :空白对照组。各组分别在注射后 2 4h、7d及 2 1d ,进行血小板、血脂和血浆粘度测定 ,2 1d取股骨头行病理组织学观察。结果　 1、A及B组用药后 2 4h血小板计数减少 (P <0 0 1) ,血浆粘度、血脂升高 (P <0 0 1) ,用药后 7d、2 1d ,A组各项指标逐渐恢复 ,B组持续异常 ,与A组相比差异显著 (P <0 0 1)。C组用药后 7d及 2 1d血小板降低 (P <0 0 1)、血浆粘度和血脂水平明显升高 (P <0 0 1)。B组 2 1d股骨头病理切片见骨细胞变性、坏死 ,较A、C组为重。结论　激素通过增强由内毒素引起的血栓前状态 ,形成血栓导致骨坏死 ,血栓前状态的检测对于激素性股骨头坏死的诊治有重要的参考价值     

经皮扩张气管置管术的疗效观察及护理对策

目的　探讨经皮气管置管术 (PDT)的临床疗效及护理对策。方法　 12 8例需气管切开的危重患者随机分为PDT组 (观察组 )和气管切开组 (对照组 ) ,观察组行经皮气管置管术 ,对照组行气管切开插管。比较两组的操作时间、切口大小、观察伤口愈合时间及并发症的发生率。结果　观察组的手术操作时间、切口长度和气管导管拔除后切口的愈合时间均显著低于对照组P <0 .0 0 0 1。观察组有 2例皮下气肿和 1例操作中出血。对照组有 6例出血、1例感染 ,两组并发症发生率无统计学意义 (χ2 =1.0 81,P >0 .0 5 )。结论　经皮气管置管术创伤小 ,手术过程简单、方便 ,良好护理能提高疗效 ,具有临床推广应用价值。     

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.