经皮肝穿刺胆道梗阻引流术

目的 探讨恶性梗阻性黄疸经皮胆道引流的方法及临床效果。方法 对21例恶性胆道梗阻患者采用经皮肝穿刺胆道引流术(PTC)治疗，术中PIC后能通过梗阻段者，采用内支架引流或置入内外引流管作内外引流，不能通过梗阻段则直接外引流。结果 用金属内支架作内引流者5例，内外引流者6例，外引流者10例，其中1例肝门区高位梗阻患者作外引流位置欠佳，疗效不好，另20例患者胆道引流充分，术后总胆红素、碱性磷酸酶、丙氮酸转氮酶均明显下降，症状消失明显。结论 经皮肝穿刺胆道引流术是对恶性梗阻性黄疸的一种安全、有效的姑息性治疗方法，可明显缓解黄疸，减轻痛苦，提高生存质量，并为进一步手术治疗创造条件。     

胆道支架在恶性肿瘤所致梗阻性黄疸治疗中的应用

在DSA下为15例梗阻性黄疸患者行胆道支架植入术,梗阻部位分别为高位梗阻6例,低位梗阻9例。15位患者均住院行胆道支架治疗,术前血清总胆红素23.6±10.7mg/dl(2.5～47.8 mg/dl),引流3～7d后血清总胆红素为17.9±10.1mg/dl(1.5～39.8mg/dl)。术后8～14d胆红素14.0±11.4mg/dl(0.8～38mg/dl)。植入支架患者平均生存期为197d,较其它治疗生存期明显延长。梗阻性黄疸进展迅速,死亡率高,积极采取支架植入减轻黄疸、改善肝功能,能有效延长患者生成期、提高生活质量,为进一步治疗创造条件。     

纤维十二指肠镜逆行胆胰管造影治疗恶性胆道梗阻33例

目的探讨纤维十二指肠镜逆行胆胰管造影（ERCP）置放胆道内支架姑息治疗恶性胆道梗阻的临床疗效。方法通过ERCP将导丝插入33例恶性肿瘤引起的梗阻性黄疸患者的胆道并超过梗阻部位,扩张狭窄,然后用推送导管将引流支架推送至胆道狭窄部位,其两端均超过狭窄段1 cm以上,从而解除33例恶性肿瘤引起的梗阻性黄疸。结果 33例患者中插管成功29例,不成功4例,成功率为87.88%（29/33）。术后黄疸逐渐消退,皮肤瘙痒等症状消失或减轻。术后2周内血清总胆红素均下降50%以上,血清总胆红素均退至40μmol/L,肝功能较术前显著改善（P〈0.05）。结论通过ERCP内镜下胆道内置放支架,解除恶性梗阻性黄疸,对缓解症状、提高患者生存质量具有满意疗效。     

恶性梗阻性黄疸病人行经皮经肝胆道穿刺引流术的观察与护理

[目的]探讨恶性梗阻性黄疸病人行经皮经肝胆道穿刺引流术（PTCD）的护理。[方法]对12例恶性梗阻性黄疸病人行PTCD术,同时加强围术期护理。[结果]12例病人均穿刺引流成功,症状改善,4周内8例血清总胆红素恢复正常,3例血清总胆红素下降50%,1例轻度好转。[结论]恶性梗阻性黄疸病人行PTCD术可明显缓解症状,加强围术期护理是手术成功的保证。     

内镜下置入金属支架对恶性胆道梗阻的姑息治疗

目的评估内镜下置放金属胆道支架对恶性胆道梗阻患者姑息治疗的疗效。方法纳入病例为恶性疾病所致的梗阻性黄疸不能外科手术者。自2000年5月-2003年11月共有21例患者接受了胆道金属支架放置术及随访观察。结果放置成功率与临床有效率分别是100％和95％，没有出现与手术相关的严重并发症。术后7d血清总胆红素平均下降70．8％，60d内的病死率为4．7％。支架置入后存活时间最短32d。有3例(14.3％)分别于术后90、168、850d发生支架阻塞，经ERCP确定为支架阻塞的3例患者均行塑料支架置入术，最长存活者已超过3年。结论对恶性胆道梗阻的姑息治疗，置入金属胆道支架较经皮经肝和外科手术引流创伤性小，并发症发生率低，可持久引流胆汁、改善临床症状，提高患者的生活质量，延长生存期，是一种安全、有效的选择。     

恶性梗阻性黄疸的介入治疗

目的：探讨经皮肝穿刺胆道引流术（PTCD）和内支架置入术治疗恶性梗阻性黄疸的方法及疗效。方法：38例患者经影像学和血液生化检查诊断为恶性梗阻性黄疸,男22例,女16例,平均年龄65.3岁。所有患者行PTCD和内支架置入术。结果：内支架置入21例23个,其中2例患者左右胆管各置入支架1个, 11例置入支架同时行外引流或内外引流,4例外引流患者经介入化疗后再次置入支架成功。17例为单纯外引流或内外引流。术后患者血清胆红素及肝功能均明显好转,并发症发生率约为10%,其中胆道感染1例,一过性胆道出血2例,一过性胆汁外渗1例,经治疗后症状消失。结论：PTCD术和内支架术治疗恶性梗阻性黄疸,安全,并发症少。[著者文摘]     

经皮经肝胆道内支架置入术在恶性梗阻性黄疸中的应用

目的探讨经皮经肝胆道内支架置入术治疗恶性梗阻性黄疸的疗效。方法对18例恶性梗阻性黄疸患者行经皮、肝穿刺胆内支架置入治疗。结果 18例患者共成功置入支架20枚,术后梗阻胆道的通畅率100%,症状体征明显缓解,术后1周血清总胆红素水平较术前显著下降(P﹤0.05)。结论经皮肝穿刺胆道内支架置入术治疗恶性梗阻性黄疸可延长患者生存期,对失去外科手术机会的部分恶性梗阻性黄疸患者是一种较为理想的非手术方法。     

胆道成形术在恶性梗阻性黄疸治疗中的应用价值

目的 探讨胆道成形术(经皮胆道引流及支架置入)治疗恶性梗阻性黄疸的临床疗效及应用价值.方法 在DSA下对80例梗阻性黄疸患者行经皮肝胆管穿刺置管引流以及胆道内支架置入,观察临床症状和黄疸的改善情况.结果 80例患者穿刺置管引流术均置管成功,其中60例单支架置入,20例双支架置入.术前血清总胆红素(200.67±48)μmol/L,术后1周、2周及3周血清总胆红素分别下降到(140.2 ± 42.8)μmol/L、(90.3±26.5)μmol/L及(60.6±36.5)μmol/L.其中32例患者临床症状改善后行化疗以及放射治疗.结论 胆道成形术可明显改善恶性胆道梗阻的临床症状,提高患者生活质量,为进一步治疗创造条件.     

PTBD技术在胆系疾病中的应用

目的 评价经皮肝胆道引流术(PTBD)在胆系疾病中的应用价值。方法 对13例不能手术的胆道梗阻患者行PTBD术，其中肝门部胆管阻塞4例，胆总管下段梗阻9例。结果 13例共行15例次PTBD，11例(13例次)置管引流成功，手术成功率86．6％(13／15)，成功置管的13例次中1次穿刺成功率84．6％(11／13)。成功手术的11例患者术后1周黄疸明显减退者8例(72．7％)，血浆胆红素下降至5g／L以下，2例血浆胆红素较术前有下降，但仍高于5g／L(2．5％)，1例无明显减退。结论 PTBD能有效地降低不能手术治疗的胆系阻塞患者的血浆胆红素，已被临床证实为阻塞性黄疸患者术前减轻黄疸与姑息性治疗的有效方法。     

经皮胆道内外引流及支架置入治疗梗阻性黄疸

目的 总结经皮肝穿刺放置引流管及金属内支架作胆汁内、外引流的临床应作价值。方法 23例梗阻性黄疸患者经皮肝穿刺胆道置管内外引流后，其中12例行胆道内支架置入术治疗。结果 23例黄疸均消退满意，血清总胆红素由术前147.4-648.7μmol/L降至正常或接近正常。22例恶性梗阻3个月内死亡6例，半年内死亡8例，最长生存25月，中位生存期6个月。结论 经皮肝穿刺胆道置管及内支架引流是姑息性治疗手术不能切除的梗阻性黄疸的有效方法。     

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.     

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.     

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.     

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.