基层医院高血压脑出血个性化微创治疗的临床研究

目的 探讨基层医院高血压脑出血各种微创手术方式的临床效果。方法 选择符合微创手术适应证的56例高血压脑出血患者,根据不同患者采取个性化手术方式（软通道穿刺、硬通道穿刺、锁孔显微镜下血肿清除、小骨窗内镜下血肿清除、立体定向血肿穿刺抽吸引流术等）进行微创手术,观察疗效。结果 56例患者术后再出血4例,再出血率7.14%。随访3～6个月,采用日常生活能力（ADL）评定：Ⅰ级8例、Ⅱ级17例、Ⅲ级24例、Ⅳ级2例、V级1例、死亡4例（包括3例因经济及对预后不良难以接受原因放弃治疗）,恢复良好率87.50%,死亡率7.14%。结论 基层医院高血压脑出血患者因发病时间短等情况有其特殊性,对符合手术适应证的不同患者采取个性化的微创手术方式进行干预,使得取得良好预后成为可能。     

超早期锁孔开颅经外侧裂显微手术治疗基底节区高血压性脑出血的疗效观察

目的 探讨超早期锁孔小骨窗经外侧裂入路显微手术治疗基底节区高血压性脑出血(HICH)的效果.方法 对85例基底节区HICH患者在超早期(发病后6h内)实施锁孔小骨窗开颅经外侧裂手术.术毕及术后48 h内复查头颅CT,了解血肿清除情况.随访6个月时,采用日常生活能力(ADL)分级评估预后.结果 血肿清除量＞80％者64例(75.3％).术后随访6个月,ADL分级包括Ⅰ级13例(15.3％),Ⅱ级37例(43.5％),Ⅲ级25例(29.4％),Ⅳ级5例(5.9％),V级3例(3.5％).术后因并发症死亡2例(2.3％).结论 超早期锁孔小骨窗开颅经外侧裂人路行显微镜下血肿清除术具有创伤小、术中显露好、止血彻底等优点,尤其适用于基底节区中等量出血者,可促进患者后期的神经功能恢复.     

微球囊辅助脑造通器在神经内镜下手术治疗基底节区脑出血中的应用*

目的探讨微球囊辅助脑造通器在神经内镜下手术治疗自发性基底节区脑出血中的临床应用效果。方法选取该院2017年8月-2018年7月收治的自发性基底节区脑出血患者97例为研究对象,随机分为治疗组和对照组。治疗组46例,行微球囊辅助脑造通器在神经内镜下清除血肿;对照组51例,行传统骨瓣(或骨窗)开颅显微镜下清除血肿。观察两组手术情况,术后随访6个月观察两组预后效果。结果治疗组手术时间和术中失血量均明显低于对照组(P 0.05),所有患者术后1 d行常规CT检查以了解血肿清除情况。治疗组平均清除率为(90.5±5.3)%,对照组平均血肿清除率为(78.7±11.3)%,治疗组明显高于对照组(P 0.05)。所有患者术后随访6个月,以患者的日常生活能力(ADL)作为疗效评价指标。治疗组ADLⅠ级4例,Ⅱ级15例,Ⅲ级14例,Ⅳ级13例,死亡0例;对照组ADLⅠ级5例,Ⅱ级10例,Ⅲ级11例,Ⅳ级25例,死亡0例。治疗组ADL效果良好33例(Ⅰ～Ⅲ级),效果不良13例(Ⅳ～Ⅴ级)。对照组ADL效果良好26例(Ⅰ～Ⅲ级),效果不良25例(Ⅳ～Ⅴ级);两组恢复良好率分别为71.7%(33/46)和51.0%(26/51),治疗组预后ADL优于对照组(P 0.05)。结论神经内镜手术相比于显微镜手术治疗自发性基底节区脑出血,临床疗效显著,手术时间缩短,术中出血量减少,血肿清除率提高,再出血发生率低,并发症发生率降低,能改善患者预后,安全性较高。微球囊辅助脑造通器提高了神经内镜手术的可视性及安全性,在保证降低手术人为创伤的条件下,达到了微侵袭神经外科所要求的以最小创伤取得最佳手术效果的目的,进一步扩大了神经内镜在神经外科领域的应用范围,具有较高的临床应用价值。     

不同手术方式对超早期高血压脑出血患者术后再出血的影响

目的探讨不同手术方式对超早期高血压脑出血患者术后再出血的影响。方法选择2014年12月至2016年8月在该院接受手术治疗的超早期高血压脑出血患者112例作为研究对象,随机分为观察组与对照组各56例,观察组患者行微创穿刺血肿引流术,对照组行小骨瓣开颅血肿清除术,对比两组患者术后再出血发生情况、术后并发症发生率及术后日常生活能力分级等。结果观察组与对照组患者术后再出血率及病死率对比差异无统计学意义(P0.05);观察组与对照组患者颅内感染、肺部感染及应激性溃疡发生率对比差异无统计学意义(P0.05);与对照组对比较,观察组患者生活能力等级为Ⅰ级所占比例显著升高,Ⅴ级所占比例明显降低,差异有统计学意义(P0.05),两组Ⅱ级、Ⅳ级患者所占比例对比差异无统计学意义(P0.05)。结论微创穿刺血肿引流术与小骨瓣开颅血肿清除术治疗超早期高血压脑出血患者术后再出血发生情况相近,具体手术方式应根据患者具体病情选择。     

高血压脑出血小骨窗血肿清除术后再出血的高危因素及防治

目的:探讨高血压脑出血小骨窗血肿清除术后再出血的高危因素和防治对策.方法:选取我院2012年2月-2014年2月收治的80例高血压脑出血经小骨窗血肿清除术后患者作为研究对象,对其临床资料进行回顾性分析,观察其术后再出血因素,并探讨防治办法.结果:21例再出血患者中,有17例患者行第二次手术,其中5例患者行三次手术,保守治疗3例,放弃治疗1例.所有患者预后效果按ADL分级分别为Ⅱ级2例、Ⅲ级6例、Ⅳ级5例、V级4例、死亡4例.结论:术中操作技巧不到位、手术时间把握不准确、抗凝药物的应用、血压失控等原因都可能导致高血压脑出血患者小骨窗血肿清除术术后再出血,针对以上原因采取相应的措施,可减少患者再出血,改善预后.     

三种方法治疗基底节区高血压脑出血的效果对比

目的探讨锁孔颅内血肿清除术、传统开颅术和内科保守治疗三种方法治疗基底节区高血压脑出血的效果。方法将基底节区高血压脑出血患者147例分为三组。治疗组56例采用锁孔颅内血肿清除术治疗,对照组A采用传统开颅术,对照组B为内科保守治疗。比较三组临床疗效、血肿清除率、再出血率、病死率和神经功能缺损评分。结果治疗组的总有效率达76.79%,对照组A的为57.78%,对照组B的为21.74%,三组比较,治疗组明显优于对照组A(P0.05)和对照组B(P0.01)。治疗组与对照组A再出血率分别为8.93%和24.44%,差异有统计学意义(P0.05)。对照组B无一例再出血。治疗组的病死率明显低于对照组A、B,差异有统计学意义(P0.05)。治疗后治疗组的神经功能恢复明显优于对照组A、B(P0.01)。结论采用锁孔颅内血肿清除术治疗基底节区高血压脑出血患者,创伤小,恢复快,生存质量好,能明显提高临床效果。     

侧脑室三角区锁孔开颅血肿清除术与双侧侧脑室钻孔引流术治疗高血压丘脑出血破入脑室疗效比较

目的探究侧脑室三角区锁孔开颅血肿清除术与双侧侧脑室钻孔引流术应用于高血压丘脑出血破入脑室的价值。方法选取2016年3月～2018年10月我院收治的高血压丘脑出血破入脑室患者130例,根据手术方案不同分为清除组和引流组各65例。引流组行双侧侧脑室钻孔引流术,清除组行侧脑室三角区锁孔开颅血肿清除术,比较两组术后相关指标(意识恢复时间、拔管时间、ICU住院时间)、格拉斯哥预后(GOS)评分、术后并发症发生率。结果清除组意识恢复时间、拔管时间、ICU住院时间均显著短于引流组(P0.05);清除组预后良好率为56.92%,显著高于引流组的36.92%(P0.05);清除组术后并发症发生率为6.15%,显著低于引流组的18.46%(P0.05)。结论与双侧侧脑室钻孔引流术对比,脑室三角区锁孔开颅血肿清除术应用于高血压丘脑出血破入脑室可缩短康复进程,改善预后,降低术后并发症发生率,临床应用价值高。     

高血压脑出血微创颅内血肿清除术后并发症的预防性护理

目的：探讨微创颅内血肿清除术治疗高血压脑出血术后并发症的预防性护理方法。方法：将入院编号为单号的31例患者设为预防组,针对术后可能发生的并发症采取预防性护理;将入院编号为双号的31例患者设为对照组,行常规护理。结果：两组病死率比较无显著性差异（P〉0．05）。两组致残率及再出血、肺部感染、消化道溃疡的发生率比较均有极显著性差异（P〈0．01）。结论：预防性护理措施可有效降低高血压脑出血行微创颅内血肿清除术患者的并发症发生率和致残率。     

利用锁孔技术行幕下硬膜外血肿清除术的意义

目的探讨锁孔技术在幕下硬膜外血肿清除术中的作用。方法将60例创伤性幕下硬膜外血肿患者随机分成两组各30例（分别称为观察组及对照组，简称A组及B组），A组利用锁孔技术清除硬膜外血肿（必要时使用神经内镜辅助），B组使用传统后颅窝开颅术清除硬膜外血肿，比较两组在手术时间、手术出血量及疗效方面的差别。结果平均手术时间A组为46min，B组为113min（P〈0．01）；平均手术出血量A组为81ml，B组为425ml（P〈0．01）；两组硬膜外血肿均完全清除，无复发。结论在幕下硬膜外血肿清除术中，利用锁孔技术比传统后颅窝开颅术具有手术时间短、出血量少、疗效确切等优点，值得推广应用。     

显微镜下锁孔手术治疗高血压基底节出血疗效分析

目的探讨显微镜下锁孔手术治疗高血压基底节出血的临床疗效。方法对162例具有手术指征的高血压基底节出血患者行显微镜下锁孔手术治疗,并对患者临床资料进行回顾性分析,以格拉斯哥预后评分（GOS）标准进行预后评价,并随访调查患者术后生存质量。结果162例患者行显微镜下锁孔手术治疗高血压基底节出血,治疗效果理想。颅内血肿彻底清除和清除90％以上的患者分别为68例（41．98％）和62例（38．27％）,所占比例比较差异无统计学意义（P〉0．05）;清除60％～90％的患者为28例（17．28％）,与清除90％以上的患者所占比例比较,差异有统计学意义（P〈0．05）。术后随访3～6个月,GOS评分恢复良好88例（54．32％）,与轻度残疾、重度残疾、植物生存及死亡患者所占比例比较,差异有统计学意义（P〈0．05）。术后随访1年内,89．33％的患者生活质量优良。结论显微镜下锁孔手术治疗高血压基底节出血具有损伤小、安全、有效的优点。     

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.