外伤性脾破裂保脾方法的选择(附46例报告)

目的 探讨外伤性脾破裂保脾方法的选择。方法 回顾性分析进行保脾治疗的46例外伤性脾破裂患者的临床资料。结果 非手术治疗成功率79．3％(23／29)，非手术治疗占同期脾外伤的20％。手术保脾治疗17例，其中单纯修补缝合3例，脾修补缝合加大网膜填塞3例，脾部分切除加大网膜填塞修补3例，全脾切除加脾组织大网膜移植8例。血管介入脾动脉栓塞治疗6例，均一次脾动脉栓塞成功。46例均无并发症发生。痊愈45例，1例因合并颅脑损伤呈植物状态。结论 脾脏Ⅰ级损伤以非手术治疗为主，Ⅱ级损伤以脾动脉栓塞或手术修补保脾为主，Ⅲ级以上的损伤只能手术保脾，同时结合实际情况进行个体化和综合治疗。     

延迟性脾破裂25例临床诊治分析

目的探讨延迟性脾破裂（DRS）的诊断和治疗方法。方法回顾性分析25例DRS患者的临床资料。结果我院收治的DRS患者约占脾外伤的12％（25／217）。手术治疗24例，行脾切除术17例，脾切除加自体脾片网膜内移植术5例。脾部分切除术1例，脾修补术1例；非手术治疗1例。24例治愈，1例死于脑疝。手术治疗平均住院时间12d。结论接诊医生对DRS应有足够的认识，及时做出正确诊断；发病经历对诊断很重要，诊断性腹腔穿刺、B超和CT是重要的辅助检查手段；治疗以挽救生命为主，同时要兼顾脾脏的功能。     

腹腔镜脾切除术脾蒂处理方法探讨

目的探计腹腔镜脾切除术(laproscopic splenectomy,LS)中处理脾蒂的方法。方法回顾性分析36例腹腔镜脾切除手术病例(包括16例腹腔镜下脾切除联合断流手术)的临床资料。了解脾蒂处理的方法及技巧。结果36例病人中有1例中转开腹,35例均顺利完成腹腔镜脾切除术或腹腔镜脾切除联合断流手术,19例腹腔镜脾切除平均手术时间为165min,术中平均失血87mL,术后平均禁食时间1.5d,术后平均住院时间6d。16例腹腔镜脾切除联合断流手术平均手术时间268min,术中平均失血800mL,手术后平均禁食时间为2.5d,手术后平均住院时间8d。结论腹腔镜脾切除及腹腔镜脾切除联合断流手术是安全且效果良好的手术,手术成功的关键是术中仔细操作,控制脾蒂,防止大出血。     

腹腔镜脾切除(附20例报告)

目的探讨腹腔镜脾切除及腹腔镜脾切除联合断流手术的方法、临床效果及优缺点。方法回顾性分析20例腹腔镜脾切除手术病例（包括6例腹腔镜下脾切除联合断流手术）的临床资料。结果20例病人中有1例中转开腹，19例均顺利完成腹腔镜脾切除术或腹腔镜脾切除联合断流手术，13例腹腔镜脾切除平均手术165．0min。术中平均失血87mL，术后平均禁食1．5d，术后平均住院6d。6例腹腔镜脾切除联合断流手术平均手术268min，术中平均失血800mL，手术后禁食2．5d，手术后平均住院8d。结论腹腔镜脾切除及腹腔镜脾切除联合断流手术是安全且效果良好的手术，手术成功的关键是术中仔细操作，控制脾蒂，防止大出血。     

可吸收脾网治疗小儿严重脾外伤的观察与护理

脾外伤是小儿腹部外伤中最常见的一种，严重脾外伤常用的脾实质修补术，脾缝合大网膜填塞术及脾包膜缝合止血术等均不能使严重伤牌得以保存，故多采用牌切除术治疗。由于脾切除术后，机体丧失了脾脏的生理功能，特别是术后由于机体免疫功能下降易发生暴发性感染，死亡率很高，故近年来许多学者主张对伤脾作保留性治疗。我院自1989年以来采用可吸收脾网术治疗小儿严重脾外伤6例，均获满意疗效，现将观察和护理总结如下。1临床资料1．16例患儿年龄4～13岁，男性5例，女性1例；病因：摔伤4例，车祸2例，均为闭合性肿外伤；病理类型：星状粉碎性…     

二级脾蒂离断法在腹腔镜脾切除术中应用价值分析（附32例报告）

目的：探讨腹腔镜脾切除术（LS）中应用二级脾蒂离断法的安全性、可行性及临床疗效。方法：对2006年5月—2009年3月施行腹腔镜二级脾蒂离断法脾切除术32例的临床资料进行回顾分析。其中血吸虫肝硬化致继发性脾功能亢进18例,肝炎肝硬化致继发性脾功能亢进6例,免疫性血小板减少性紫癜（ITP）5例,脾良性肿瘤3例,均在全腹腔镜下行二级脾蒂离断法脾切除术。结果：全组手术均成功,无中转开腹,无严重并发症。术后1例并发胸腔积液、胸膜炎,经积极抗炎治疗及胸腔穿刺后痊愈出院。2例术后出现脾热,对症治疗后治愈出院。平均手术时间125min,术中平均失血120mL,平均住院时间7d。结论：在腹腔镜脾切除术中应用二级脾蒂离断法安全性高、切实可行,并可一定程度降低腹腔镜手术费用,有临床推广价值。     

脾外伤保脾手术治疗47例报告

目的 探讨保脾手术治疗脾外伤的适应证的选择及治疗体会.方法 总结分析1996年1月至2005年10月间精河县人民医院采用保脾手术治疗47例脾外伤病例的临床资料.结果 47例手术均成功,其中明胶海绵填塞止血8例,缝合修补术13例,脾部分切除术23例,全脾切除加自体移植3例.随访6～12个月,所有病人无死亡及并发症发生.结论 选择性保脾治疗脾外伤安全可靠,疗效确切.     

腹腔镜下二级脾蒂离断法原位脾切除术治疗外伤性脾破裂的应用体会

目的探讨腹腔镜二级脾蒂离断法原位全脾或部分脾切除术对外伤性脾破裂（TSR）患者的疗效。 方法收集杭州市第一人民医院肝胆胰外科2012年6月至2015年8月间收治的17例TSR患者,结合术前CT检查和术中腹腔镜探查,并根据2000年第六届全国脾脏外科学术研讨会制订的脾损伤分级标准确定脾损伤等级,再行全脾切除或部分脾切除,并观察术中及术后恢复情况。 结果17例患者中Ⅰ级脾损伤3例,Ⅱ级5例,Ⅲ级7例,Ⅳ级2例。平均手术时间为（78 ± 12）min,平均回输自体血（750 ± 23）ml,平均出血量（220 ± 45）ml。所有病例均在术后3 d内肛门恢复排气并恢复饮食,平均住院（11.7 ± 2.1）d,且术后随访无相关远期并发症发生。 结论腹腔镜二级脾蒂离断法原位全脾或部分脾切除术治疗TSR患者安全有效。     

保脾术治疗外伤性脾破裂36例临床分析

目的总结保脾术治疗外伤性脾破裂的经验。方法对我院2000年5月至2006年8月36例外伤性脾破裂行保脾治疗患者的资料进行回顾性分析。结果本组行非手术治疗4例，单纯脾修补9例，脾部分切除15例，全脾切除自体脾组织片网膜囊内移植术8例；1例因脾部分切除术后残脾血肿迟发性破裂出血，再次手术。所有患者均治愈出院，随访无并发症发生。结论手术是治疗脾损伤的主要方法，非手术治疗应严格掌握适应证，在保证生命安全的同时，尽可能保留脾脏功能。     

腹腔镜脾切除术临床分析

目的探讨腹腔镜脾切除的操作要点、围手术期处理、适应证选择及优、缺点。方法回顾性分析6例腹腔镜脾切除手术患者的临床资料。结果6例顺利完成腹腔镜下脾切除术，无中转开腹，平均手术时间188min，术中平均失血300ml，术后平均禁食3d，术后平均住院7．4d。术后因腹腔出血行腹腔镜止血1例。结论腹腔镜脾切除术是安全且效果良好的手术，掌握适当的手术适应证、注意规范细致的术中操作和合理的围手术期处理是手术成功的关键。     

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.