肝硬化失代偿期肾动脉血流参数的多普勒超声分析

目的：探讨肝硬化失代偿期各级肾动脉血流参数特点。方法：应用Acuson-128XP10超声仪检测94例肝硬化失代偿期患及正常对照85例的肾主动脉（MRA）、段动脉（SRA）、叶间动脉（IRA）的血流参数。结果：患组的各级肾动脉的阻力指数（RI）、搏动指数（PI）、舒张末期最低血流速度（Vdmin）平均血流速度（Vm）、肾动脉主干内径D、肾流量（Q）与正常组有高度显性差异（P＜0.01）；收缩期最大血流速度（Vsmax）与正常组无显性差异（P＞0.05）。     

糖尿病肾病各级肾动脉血流参数的多普勒超声分析

目的 探讨糖尿病肾病（DN）不同阶段各级肾动脉血流参数特点。方法 应用Acuson 128XP/10超声仪检测83例DN患者及正常对照组72例的肾主动脉（MRA）、段动脉（SRA）、叶间动脉（IRA）的血流参数。结果 I组各级肾动脉血流参数与正常组无统计学差异（P＞0．05）。Ⅱ及Ⅲ组的各级肾动脉的阻力指数（RI）搏动指数（PI）、舒张末期最低血流速度（Vdmin)、平均血流速度（Vm)与正常组有高度显著性差异（P＜0．01）。Ⅱ-Ⅲ组肾血流量（Q）与正常组高度显著性差异（P＜0．01）。     

能量多普勒应用于肝硬化进程中肾脏血流动力学观测的价值

目的：探讨能量多普勒显像（PDI）应用于肝硬化病理中肾脏血流动力学观测的价值。方法：应用PDI技术检测不同病程肝硬化患者肾脏血流动力学变化，并与正常人对照。结果：肝硬化代偿组，PDI示肾脏血流丰富，各级动脉呈现完整的血管树分布，肾血流量（V）和阻力指数（RI）与对照组差异不显著（P＞0．05）。肝硬化失代偿期，PDI示肾内血流减少，外层皮质血流缺失，弓形动脉血流断续出现，叶间动脉变细。V较代偿期及正常组显著减少（P＜0．01），而RI显著升高（P＜0．01）。肝肾综合征（HRS）期，PDI示肾内血流明显减少，皮质血流极少显示，叶间动脉及段动脉变细，边缘缺损，叶间动脉可呈片状缺失。V较其它三组均显著减少（P＜0．05或P＜0．01），RI则显著升高（P＜0．05或P＜0．01）。结论；PDI技术结合肾动脉血流参数测定能客观反映肝硬化患者肾脏血流动力学紊乱程度，对其病情监测，HRS的预测和诊断均有重要价值。     

彩色多普勒血流显像对高度近视眼的血流动力学研究

为研究高度近视眼的眼血流动力学变化，对２３例高度近视眼组，２０例轻中度近视眼组及１８例正常对照组进行眼动脉、后睫状动脉、视网膜中央动脉血流的彩色多普勒超声测定。结果表明：高度近视眼组与正常组及轻中度近视眼组血流参数比较：眼动脉血流参数无显著性差异（Ｐ＞０．０５）；后睫状动脉舒张末期血流速度低于其它两组，有显著性差异（Ｐ＜０．０５），余参数差异无显著性（Ｐ＞０．０５）；视网膜中央动脉收缩期血流峰值速度、平均血流速度、舒张末期血流速度均降低，有显著性差异（Ｐ＜０．０５），轻中度近视组与正常组比较无显著性差异（Ｐ＞０．０５）。研究结果表明：高度近视眼视网膜中央动脉血流速度与后睫状动脉舒张末期血流速度均明显降低，彩色多普勒超声有可能应用于研究其病理改变的形成机制。     

糖尿病患者肾脏动脉血流改变与糖尿病肾病的关系

目的探讨糖尿病患者肾内动脉血流动力学变化对糖尿病肾病(DN)诊断的临床价值。方法以24小时尿蛋白排泄率(UAER)作为DN的诊断指标,应用彩色多普勒血流显像技术对2型糖尿病患者54例行肾脏动脉血管超声检查,以20例同期健康体检者为正常对照,对其收缩期最大血流速度、舒张期末最低血流速度和阻力指数进行统计学分析。结果糖尿病组舒张末血流速度下降及血流阻力指数增高程度与正常对照组之间差异均有统计学意义(P<0.01);其中肾内各级动脉血流阻力指数增高与肾功能损害程度相关。结论彩色多普勒超声检测糖尿病患者肾血流动力学变化有助早期DN诊断及肾功能不全的判断。     

彩色多普勒超声对移植肾排斥反应肾动脉血流动力学变化的研究

目的：探讨移植肾排斥反应肾动脉血流动力学变化规律及临床意义。方法：应用超声对98例移植肾患者和53例正常人的肾脏各级肾动脉血流参数进行对比研究。结果：（1）肾功能稳定期，四级肾动脉血流参数与正常人相似（P＞0．5）；（2）急性排斥反应期，各级肾动脉收缩期峰值血流速度（Vp)变化不大（P＞0．05），而舒张期最小血流速度（Vmin)和平均血流速度（Vmean)减低，阻力指数（RI）及脉动指数（PI）增高（P＜0．05）；（3）慢性排斥反应期，主肾动脉和段动脉V,Vmin,Mmean，RI及PI增高（P＜0．05），叶间动脉舒张期血流频谱很低甚至无频谱信号，弓型动脉几乎没有频谱或仅见少许脉冲样频谱，叶间动脉和能测到的弓型动脉血流速度均较降低（P＜0．01），RI，PI显著增高（P＜0．05）；（4）急性排斥及慢性排斥反应期，给予有效治疗后，各级肾动脉血流参数均有所改善。结论：超声测定移植肾各级肾动脉血流参数，对早期诊断排斥反应很有价值，对临床治疗和监测排斥具有指导意义。     

肾功无改变肝硬化患者肾血流动力学的超声检测价值

目的通过对肾功尚无改变肝硬化患者的肾血流动力学的超声研究，探讨超声检测对肝硬化患者发生肾脏损害的早期诊断及预后判断的价值。方法应用多普勒检测技术，分别检测肾功尚无改变的肝硬化Child分级A、B、C级三组患者的各级肾动脉，包括肾动脉主干（MRA）、段动脉（SRA）、叶间动脉（IRA）和弓形动脉（ARA）的峰值流速（Vmax）、舒张末流速（Vmin）、平均流速（Vmean）、阻力指数（RI）及主肾动脉血流量（V），并与健康对照组比较。结果肝硬化Child A级组与对照组之间各级肾动脉的血流参数均无显著性差异；肝硬化Child B级组肾叶间动脉和弓形动脉血流的阻力指数（RI）增加（P〈0．01）；肝硬化Child C级组各级肾动脉的RI均增加（P〈0．001），且主肾动脉血流量（V）减少。结论肝硬化患者在肾功尚无改变时，肾动脉的血流动力学已发生变化，其程度与肝硬化进程密切相关。     

彩色多普勒超声检测肾内动脉对早期高血压肾病的诊断价值

目的探讨彩色多普勒超声检测肾内动脉血流参数对早期高血压肾病的诊断价值。方法利用HP sonos4500超声仪检测41例原发性高血压患者和43例正常人肾内段动脉、叶间动脉的血流参数:收缩期峰值最高速度(Vmax),舒张期最低速度(Vmin),阻力指数(RI)。并对41例原发性高血压患者同时进行尿微量蛋白检测,根据尿微量蛋白,将41例高血压患者分为A、B两组(A组:高血压伴尿微量蛋白增高;B组:高血压伴尿微量蛋白正常),分别与正常健康组(C组)对照,分析早期高血压肾病肾内动脉血流的变化。结果B组肾段动脉和叶间动脉Vmax与C组比较无明显差异(P>0.05),B组RI轻度升高,Vmin轻度下降,但与C组比较无明显差异(P>0.05)。A组段动脉和叶间动脉RI明显高于B组和C组(P均<0.01),Vmax、Vmin均明显低于B组和C组(P均<0.01),A组RI均>0.70,而C组和B组RI均<0.70。结论肾内动脉血流参数的检测有利于早期高血压肾病的诊断,阻力指数(RI)可丰富早期高血压肾病的诊断。     

高度近视眼彩色多普勒血流显像检测价值

目的　研究高度近视眼的眼血流动力学变化。方法　采用ＨＰＳｏｎｏｓ１０００ 型彩色多普勒血流显像仪, 对２３例高度近视眼患者、２０例轻中度近视眼患者及１８例正常对照者的眼动脉、后睫状短动脉、视网膜中央动脉血流进行彩色多普勒超声测定。结果　高度近视眼组与正常组及轻中度近视眼组血流参数比较： 眼动脉血流参数无显著性差异（Ｐ＞ ０．０５）; 后睫状短动脉舒张末期血流速度低于其它两组, 有显著性差异（Ｐ＜ ０．０５）; 视网膜中央动脉收缩期血流峰值速度、平均血流速度、舒张末期血流速度均降低,有显著性差异（Ｐ＜ ０．０５）, 轻中度近视组与正常组比较无显著性差异（Ｐ＞ ０．０５）。结论　高度近视眼视网膜中央动脉血流速度与后睫状短动脉舒张末期血流速度均明显降低, 彩色多普勒超声有可能应用于研究其病理改变的形成机制。     

彩色多普勒能量图对多囊肾的血流动力学观察

目的　探讨多囊肾患者肾脏的彩色多普勒能量图 (CDE)表现及临床意义。方法　用二维超声显像和CDE技术对 76例多囊肾患者和 45例健康成人的肾脏进行检查 ,对比分析其肾脏体积、皮质厚度、主肾动脉血流动力学变化及肾内血流灌注情况。结果　多囊肾肾功能正常期 :肾体积不大或略大 ,皮质厚度正常 ,CDE显示肾内血流丰富 ,主肾动脉血流速度、阻力指数 (RI)和搏动指数 (PI)与对照组差异无显著性意义 (P >0 .0 5 ) ;多囊肾肾功能不全代偿期 :肾体积增大 ,皮质减薄 ,与对照组差异有显著性意义 (P <0 .0 0 1) ,CDE显示肾内血流仍较丰富 ,主肾动脉血流速度、RI、PI与对照组差异无显著性意义 ;多囊肾肾功能不全失代偿期 :肾体积增大 ,皮质变薄 ,肾内血流减少 ,主肾动脉血流速度减低 ,舒张期较明显 ,RI、PI增高 ,与对照组差异有显著性意义 (P <0 .0 0 1) ;多囊肾肾衰竭 (尿毒症 )期 :肾体积明显增大 ,皮质菲薄 ,CDE显示肾内血流进一步减少 ,主肾动脉血流速度在收缩期、舒张期均降低 ,RI、PI增高 ,与对照组差异有显著性意义 (P <0 .0 0 1)。多囊肾各期之间比较 ,大多数参数间差异具有显著性意义 (P <0 .0 0 1、0 .0 0 5或 0 .0 1)。结论　多囊肾患者的CDE表现反映了肾脏的血流灌注情况 ,对其诊断、分期、治疗监测等都     

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.