支架置入术治疗颈动脉粥样硬化狭窄临床研究

目的观察血管内支架置入术治疗颈动脉狭窄的疗效和安全性。方法选择北京航天总医院住院的经颈部超声检查及全脑血管造影提示颈内动脉狭窄患者16例，全部病例行经皮腔内血管成形和支架植入术治疗。结果16例患者成功置入支架17枚，术后1例患者出现心率减慢和血压下降；短期随访6个月未出现新发脑卒中和短暂性脑缺血发作，TCD检查未发现明显颈内动脉支架部位再狭窄，支架形态无改变。结论颈内动脉自膨式支架置入术治疗颈内动脉粥样硬化狭窄安全有效，但仍需随机对照研究进行长期疗效观察。     

锁骨下动脉狭窄或闭塞的血管内支架治疗

目的 探讨应用血管内支架治疗锁骨下动脉狭窄或闭塞性疾病的临床疗效。方法 11例锁骨下动脉狭窄或闭塞的患者进行了血管内支架成形术治疗，分别置入国产内支架6枚，进口内支架5枚，进口血管内支架选用Wallstent、Memotherm及Symphony，国产血管内支架类似Wallstent。结果 11例患者中10例成功地完成了血管内支架成形术，其中5例患者中的6条病变血管中置入6枚国产血管内支架，5例患者中的5条病变血管中置入5枚进口血管内支架，病变血管开放获得满意，上肢脉搏血压恢复正常，1例锁骨下动脉闭塞的患者，因导丝穿破血管进入纵隔而放弃治疗。术后随访时间为6～39个月，其中1例置入血管内支架在5个月复查时出现再狭窄，经球囊扩张后16个月复查血管开放良好。结论 血管内支架可有效地治疗锁骨下动脉狭窄或闭塞性疾病，有望成为最主要的治疗手段。     

髂动脉支架置入术治疗髂动脉狭窄性疾病

目的探讨髂动脉支架置入术治疗髂动脉狭窄性疾病的适应证和并发症。方法结合文献回顾分析采用髂动脉支架置入术治疗髂动脉狭窄性疾病15例(17条肢体)的诊治经验。结果、15例均行髂动脉经皮球囊扩张血管成形术 髂动脉支架置入术，其中4例同时行股-Guo动脉人造血管旁路术。术后患者均有不同程度的症状改善。踝肱指数增加0．13～0．35，平均0．21。随访6～32个月，近期通畅率(术后6个月以内)。100％，远期通畅率93．3％(14／15)，再狭窄率6．7％(1／15)，均未发生闭塞和移位。结论髂动脉支架置入术治疗下肢动脉狭窄性疾病是微创、安全的，掌握其适应证可得到良好的效果。     

31例颈内动脉狭窄支架成型术的护理

[目的]探讨血管内支架置入术的护理措施。[方法]对31例行颈内动脉狭窄血管内支架置入的病人进行严密监测和护理。[结果]所有病人治疗效果明显。[结论]合理有效的护理是颅内外动脉狭窄支架植入术治疗成功的重要保障。     

血管内超声对Radius支架近期及远期效果的研究

目的 探讨血管内超声评价Radius支架的近期及远期效果的价值。方法 147例冠心病患者186处病变择期置入自扩张Radius支架，在支架置入前、置入后即刻及置入后6个月进行冠状动脉造影及血管内超声检查，同时进行临床随访，观察Radius支架的近期及远期效果。结果 对147例患者186处病变，Radius支架的置入成功率为99．5％，临床成功率为98．9％，6．4个月后复查再狭窄率为10．8％；血管内超声显示，治疗前血管内腔面积平均为2．7mm^2，在支架留置后即刻面积扩大为5．3mm^2，约6．4个月后复查支架面积扩大至7．6mm^2，但因支架内新增生的内膜面积为2．6mm^2，最终血管内腔面积为5．Omm^2，比支架留置后即刻略小。结论 Radius支架再狭窄发生率低，血管内超声对观察Radius支架再狭窄发生有一定的应用价值。     

冠状动脉支架置入术后迷走神经反射的观察与护理

近年来，随着心血管医学与影像学的迅猛发展。冠状动脉内支架置入术已经成为心内科治疗冠心病伴动脉狭窄的主要方法。目前临床对支架置入术后常见的并发症，如出血、血管再狭窄、心包填塞、支架脱落等已有充分认识，并总结出一套有效的预防措施，但对于迷走神经反射（vasovagal reflex，VVR）因容易判断与处理。且多数不留后遗症，故常被忽视。2004年4-8月，我院共行冠状动脉内支架置入术22例。发生VVR7例。通过分析，总结教训发现。VVR发生重在预防。术前采取积极预防措施。术后提高警惕，加强护理，可以明显降低VVR的发生率，现报道如下。     

锁骨下动脉盗血综合征行支架置入术患者的护理

总结锁骨下动脉盗血综合征行支架置入术的护理体会。8例患者双侧血压差值达20mmHg（1mmHg=0．133kPa）以上，认为无论是住院期间，还是出院后，一定要测量患者双上肢血压，观察两侧血压的差值变化，以判断治疗效果和预防疾病复发；术前减少患肢运动，以免引起脑缺血症状；支架置入术后，观察是否有出血症状；出院前教会患者及家属测量血压、脉搏的方法；嘱患者戒烟，减少疾病复发几率。8例患者均成功置入支架，临床症状改善，两侧血压相差10mmHg以内，未发生严重并发症。     

持续护理质量改善对脑卒中支架置入术后患者血压管理的作用研究

目的 研究持续护理质量改善对促进脑卒中患者支架置入术后患者血压管理的效果。方法 回顾性分析2018年1-3月我病区61例脑卒中患者支架置入术后发生12例低血压、高血压的原因,跟踪调查2018年4月我病区手术患者术后从导管室返回病室路途中需要的时间,5-8月对我病区支架置入术后患者血压管理进行持续护理质量改善,观察术后患者血管活性药物泵入的持续性情况。结果 转运监护仪使用后,术后患者转运途中血压监测无空窗期；进行持续护理质量改善,保证了支架置入术术后使用活性药物患者药液泵入的持续性,每次更换药液的时间在五秒之内。结论 使用转运监护仪对术后患者生命体征的无缝隙监测十分重要；实行持续护理质量改善,可以避免护理操作过程中的人为因素影响,保证血管活性药物持续泵入,尽量减少患者血压波动,以最大限度促进患者术后的康复。     

脑动脉狭窄血管内支架置入术并发症的预防与护理

目的探讨脑动脉狭窄血管内支架置入术的护理经验。方法通过对15例进行血管内支架置入患者术后可能出现的并发症提出预见性护理措施，总结预防并发症的护理方法。结果15例脑动脉狭窄患者共置支架17枚，手术均成功，临床神经功能缺损明显改善。术后出现穿刺1：3出血1例、尿潴留2例，未发生严重的并发症。结论术前充分准备是手术成功的基础，术中密切观察病情和医护配合是成功置入支架的保证，术后生命体征和神经系统功能的监测是预防并发症的关键。     

Firebird冠状动脉内支架的临床应用

目的：评估Firebird冠状动脉内支架的临床应用效果。方法：回顾性分析51例接受Firebird冠状动脉内支架置入术患者的即刻疗效和临床随访结果。结果：51例患者共置入Firebird冠状动脉内支架117枚。根据ACC／AHA分型，A—B1型病变36处，B2-C型病变81处；原发病变32处，单纯球囊扩张术疗效不满意病变25处，内膜撕裂病变16处。3倒严重钙化病变需辅以高压（16～18atm）球囊才充分扩张，2例支架远端发生内膜撕裂，3例弥漫性痛变支架置入术后TIMI血流2级。51例患者平均随访3～13（7．5±3．0）个月，无心源性死亡和心肌梗死；7例（13．7％）有心绞痛（CCS分类Ⅰ级）发生；5例行冠状动脉造影复查1例显示支架内再狭窄，予再次血管重建术后缓解。结论：Firebird冠状动脉内支架可安全有效地应用于冠心痛的介入治疗。     

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.