379例重型病毒性肝炎的临床观察与护理

目的分析重型病毒性肝炎（SVH）预后的影响因素，提出护理对策。方法分析379例SVH的预后与病原分型、谷丙转氨酶（ALT）、谷丙转氨酶与谷草转氨酶比值（ALT／AST），总胆红素（Tbil），胆固醇（Teh01），凝血酶原活动度（PTA），以及各种并发症的关系。结果SVH的预后与重叠感染其他肝炎病毒、PTA及并发症有极显著的相关性（P〈0．01），与ALT／AST、Tbil、Tchol显著相关（P〈0．05）。结论了解SVH预后的相关因素，进行预防性的护理，对降低患者的死亡率具有非常重要的意义。     

重型病毒性肝炎62例治疗及预后的影响因素

就我院 2 0 0 0 - 0 1～ 2 0 0 4 - 0 1重型病毒性肝炎 (SVH) 6 2例治疗及预后的有关影响因素分析如下。1　对象和方法1 .1　对象　本组男 4 6例 ,女 1 6例 ,年龄 1 4～ 6 8岁 ,平均 4 0 .3岁。符合 1 995年第 5次全国传染病和寄生虫病学术会议修订的诊断标准 [1 ] 。入院后均给予促肝细胞再生、免疫调节、防治并发症、支持等综合治疗。1 .2　方法　根据患者预后不同 ,分为存活组 2 8例 ,死亡组 4 3例 ,分别观察临床分型、病原学类型、凝血酶原活动度 (PTA)、血清总胆红素 (TBil)、胆固醇 (Ch)、甘油三酯 (TG)、周围血象等 ,分析各因素…     

肝病患者血脂水平的变化

目的探讨肝病患者血清总胆固醇（TC）、三酰甘油（TG）、高密度脂蛋白胆固醇（HDL-C）、低密度脂蛋白胆固醇（LDL-C）的变化情况及其临床意义。方法测定235例肝病患者（其中急性肝炎55例、慢性肝炎59例、肝硬化50例、重型肝炎71例）血清TC、TG、HDL-C、LDL-C水平，并与75名健康人进行比较，同时测定血清总胆红素（TBil）、白蛋白（Alb）、血浆凝血酶原活动度（PTA）。对重型肝炎患者血清TC、TG、HDL-C、LDL-C浓度与其TBil、Alb、PTA进行相关性分析。结果各型肝病患者血清TC、TG、HDL-C、LDL-C水平和对照组比较均有所降低，其中肝硬化和重型肝炎患者以上指标与对照组比较明显下降（P〈0．01或P〈0．05）。重型肝炎组血清TC、TG、HDL-C、LDL-C与TBil呈负相关[P〈0．01]，与Alb呈正相关（P〈0．01），与PTA呈正相关（P〈0．01或P〈0．05）；血清TC与LDL-C呈正相关（P〈0．05）。重型肝炎组中39例死亡患者与32例存活患者的血清TC、TG、HDL-C、LDL—C水平差异均具有统计学意义（P〈0．05）。结论对肝病患者进行定期的血脂水平测定能及时反映体内的脂类代谢状况，对了解肝病患者的肝脏损伤程度、病程进展情况以及重型肝炎的预后判断都有重要价值。     

影响重型肝炎预后的危险因素分析

目的分析影响重型肝炎患者预后的危险因素。方法随机选择重型肝炎患者84例,分存活组和死亡组。统计年龄、性别、并发症、肝脏生化等指标,进行统计学分析。结果年龄、消化道、并发症、凝血酶原活动度（PTA）、血清总胆红素（TB）、总胆固醇（TC）、血清钠（Na）、PTA、TB、TC、Na、BS、AFP是判断重型肝炎预后的指标。结论明确影响重型肝炎患者预后的重要因素,早诊断,早期采取综合治疗措施有重要临床意义。     

重症肾综合征出血热202例预后影响因素分析

目的对影响重症肾综合征出血热（HFRS）的因素进行分析和评估，为HFRS患者预后进行科学的预则。方法2003年1月至2012年12月本溪市传染病医院收治的HFRS患者202例，其中死亡31例（死亡组）和生存171例（生存组），比较两组在年龄、性别、职业、病程、病期重叠、血常规、生化指标、并发症上的差异。结果单因素分析显示年龄、病期重叠、血小板、总蛋白、白蛋白、肌酸磷酸肌酶、凝血酶原时间、钾离子、继发感染、ARDS、脑水肿、颅内出血、中毒性脑病、心力衰竭、DIC、抽搐与重症HFRS的预后有相关性（P〈0．05或P〈0．01）。多因素分析显示年龄、凝血酶原时间、中毒性脑病、颅内出血、ARDS是影响其预后的独立因素（P〈0．05或P〈0．01）。结论年龄、凝血酶原时间、中毒性脑病、颅内出血、ARDS是影响重症肾综合征出血热预后的独立因素，重视相关指标的动态监测，及时掌握病情变化及调整治疗，对改善患者预后、提高生存率具有重要意义。     

379例重型病毒性肝炎的临床观察与护理

目的 分析重型病毒性肝炎(SVH)预后的影响因素,提出护理对策.方法 分析379例SVH的预后与病原分型、谷丙转氨酶(ALT)、谷丙转氨酶与谷草转氨酶比值(ALT/AST),总胆红素(Tbil),胆固醇(Tchol),凝血酶原活动度(PTA),以及各种并发症的关系.结果 SVH的预后与重叠感染其他肝炎病毒、PTA及并发症有极显著的相关性(P＜0.01),与ALT/AST、Tbil、Tchol显著相关(P＜0.05).结论 了解SVH预后的相关因素,进行预防性的护理,对降低患者的死亡率具有非常重要的意义.     

重症肝炎患者凝血功能检测分析

目的探讨利用血凝仪检测凝血四项功能对准确反映病毒性肝炎患者凝血功能状况及预后判断的价值。方法选择正常人和慢性肝炎重度（慢肝重度）、重型肝炎（重肝）、肝炎后肝硬化（肝硬化）患者，血凝仪检测凝血酶原时间（PT）、部分凝血活酶时间（APTT）、凝血酶时间（TT）以及纤维蛋白原（Fbg）含量。结果除慢性肝炎严重肝损害患者外的所有患者上述四项指标的均值均明显高于正常组（P〈0．001）；其中慢肝重度和肝硬化患者Fbg含量的异常率明显高于其它二项或三项指标（P〈0．01或0．05）；重型肝炎死亡患者PT均数及APTT异常率均明显高于存活者（P〈0．05）。结论利用血凝仪检测凝血四项功能可以从多个角度更客观、准确地反映严重肝损害的肝炎患者凝血功能状况及其预后。     

血浆置换治疗对重型病毒性肝炎血清内毒素和炎性介质的影响

目的：应用血浆置换技术，探讨其对重型病毒性肝炎患者体内内毒素和炎性因子水平的影响。方法：50例例重型病毒性肝炎患者和血浆置换治疗，于血浆置换治疗前，治疗结束时，治疗后24小时，48小时分别抽血测血清内毒素（ET）、TNFα及IL－6的水平。结果：重型生地炎患者血清内毒素、TNFα、IL－6的水平明显升高，血浆置换治疗结束时血清内毒素、TNFα、IL－6的水平明显低于治疗前水平（P＜0．05）。治疗后48小时内毒素、TNFα、IL－6的水平有所上升，但存活组较治疗前明显下降（P＜0．05），而死亡组与治疗前无明显变化（P＞0．05）。结论：血浆置换治疗能有效清除重型病毒性肝炎血清内毒素和炎性介质，治疗后血清内毒性和炎性介质的水平动态变化可能是判断血浆置换治疗重型病毒性肝炎预后的一个指标。     

病毒性肝炎患者血清胆碱酯酶、凝血酶原活动度检测的临床意义

目的　研究血清胆碱酯酶 (CHE)、凝血酶原活动度 (PTA)与病毒性肝炎临床分型、病情及预后之间的关系。方法　分别采用酶速率法和比浊法测定 16 0例急性病毒性肝炎、慢性病毒性肝炎 (轻度、中度、重度 )、肝炎肝硬化患者血CHE和PTA ,其中 2 3例行肝穿病理诊断。结果　急性病毒性肝炎组CHE和PTA下降率分别为 0 .0 0 %和8.82 % ,急性病毒性肝炎组、慢性病毒性肝炎组、肝炎肝硬化组中CHE和PTA依次降低 (P <0 .0 1) ,且二者之间相关系数为 0 .75 2 (P <0 .0 1) ;12例血清CHE低于 1kU/L和PTA低于 2 0 %的肝硬化患者中 10例死亡 ,病死率为83.33% ,明显增高 (P<0 .0 1)。结论　血清CHE和PTA不能作为急性肝损伤指标 ,却是反映肝脏疾病慢性化、肝脏储备功能和再生功能的良好指标 ,与病情及预后有关     

血脂、载脂蛋白与慢性病毒性肝炎肝损害关系——附178例报告

目的：探讨慢性乙型病毒性肝炎（慢乙肝）各临床分型之间，血脂、载脂蛋白的变化规律，及其与总胆红素和凝血酶原活动度（PTA）之间的相关性，以指导诊断、治疗及判断预后。方法：将178例慢乙肝按轻度慢性肝炎、中度慢性肝炎、重度慢性肝炎、肝炎后肝硬化慢性重型肝炎分为5个亚组，检测血清总胆固醇、甘油三酯、HDL－C、载脂蛋白A1、载脂蛋白B100、总胆红素、PTA，并与正常对照组作比较。结果：慢乙肝病人随着病情的加重，肝储备能力下降，血脂、载脂蛋白水平相应降低，其中血清总胆固醇、甘油三酯、HDL－‘脂蛋白A1、载脂蛋白B100与总胆红素，PTA有显著的相关性（均为P＜0．01）。结论：慢乙肝病人血脂和载脂蛋白水平的变化可间接表现其肝细胞功能的状态，可作为临床诊断、鉴别诊断及判断预后的参考依据。     

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.