超声与射频导管消融下腔静脉口的实验研究

目的 观察超声与射频导管消融下腔静脉口对其消融终点、狭窄的影响及组织学改变，探讨超声消融的临床应用价值。方法 健康成年杂种犬11只，随机分成2组：5只行下腔静脉口超声消融，6只行下腔静脉口射频导管消融（在同一个环状面上分别消融5－15个点，力求达到环状消融）。消融3个月后行下腔静脉造影，观察消融处管腔直径的变化，然后行电生理检查，观察消融终点（电隔离）情况，将狗处死，取消融处组织制成切片，行Masson三色染色法染色，在光镜下观察其组织学改变。结果 下腔静脉造影显示：行超声消融的5个下腔静脉口有1个出现轻度狭窄，行射频导管消融的6个下腔静脉口均出现程度不等的狭窄。电生理检查发现：超声消融易达到消融终点，且在3个月时仍保持电隔离状态；而射频消融不易达到电隔离，30min及3个月时均不存在电隔离。大体标本显示射频消融术后静脉管壁形成局限、僵硬、形状不规则的瘢痕，且瘢痕间有存活的心肌；而超声消融组在静脉壁形成光滑、均匀、连续的环状损伤。组织学证实射频消融与超声消融后均有不同程度的内膜损伤及增生，全层肌组织破坏并被纤维组织取代，管壁挛缩，但射频消融组更明显。结论 超声消融下腔静脉口成功率高，狭窄发生率低，且损作简单，是临床上行肺静脉口消融治疗局灶性心房颤动较射频消融更为理想的方法。     

超声影像在经皮射频治疗肾VX2肿瘤中应用体会

目的探讨超声影像在经皮集束电极射频消融肾肿瘤模型中的引导方法及应用价值。方法将27只新西兰大白兔在超声引导下经皮穿刺组织块悬液注射法建立肾VX2肿瘤模型，成模后超声影像观测肿瘤结节并确定穿刺点，行超声引导下经皮射频消融肿瘤结节，于治疗后观察肿瘤的生长情况和消融灶的位置、大小及声像图变化。结果27只兔形成31个肿瘤灶接受射频治疗。超声影像引导穿刺成功率1DO％；二维声像图显示19个消融灶电极针放置合理，病灶消融完全，12个病灶消融不完全，出现残余灶，均经病理解剖证实。4只兔出现周围脏器灼伤，3只兔出现针道转移。结论超声影像引导经皮射频消融肾脏肿瘤安全、有效，超声准确的术前定位、精确的术中引导和医师熟练的配合是操作成功的关键。     

超声引导下射频子宫内膜消融治疗功血的研究

目的：探讨超声引导下射频消融在治疗绝经期顽固性功血中的应用价值。方法：在B超实时动态监测下，以射频为治疗源，将子宫内膜消融器经阴道介入到内膜，治疗后定期B超复查，观察疗效。结果：25例患者经治疗后，子宫体积均不同程度缩小，无1例出现再流血现象。结论：超声射频子宫内膜消融是一项安全、经济、痛苦小的微创介入治疗新技术，值得推广应用。     

超声引导下经皮心肌内室间隔冷冻消融离体猪心的可行性研究

目的:探讨超声引导下经皮心肌内室间隔冷冻消融离体猪心的可行性,观察经皮心肌内室间隔射频消融与冷冻消融的效果。方法:实验一：将6只离体猪心按照冷冻消融时间分为1 min组、3 min组和5 min组(各2只),均以100%功率进行超声引导下经皮心肌内室间隔冷冻消融,冷冻消融结束后测量超声图像、实体解剖的冰球大小及冷冻冰球...     

后位峡部线性消融法治疗典型心房扑动

目的：采用右心房后位峡部线性消融治疗典型心房扑动。方法：典型心房扑动（AFL）23例。对三尖瓣环至下腔静脉口之间的后位峡部为靶点行线性消融术，以峡部双向阳滞和异丙肾上腺素或阿托品激发后程序刺激和burst刺激不能诱发临床AFL为消融终点。结果：本组患者均为逆钟典型房扑，消融后均达到峡部安全性双向阻滞，即刻消融成功率为100%，未出现并发症，随访6-34周有1例复发，再次行射频消融术成功，结论：采用后位峡部线形消融典型心房扑动是一种高成功率和安全性，低并发症和复发率的根治性手术，安全性峡部双向阻滞是手术成功的良好指标和消融终点，异丙肾上腺素或阿托品激发下心房程序和burst刺激不能诱发AFL是双向阻滞的有益补充。     

超声造影、磁共振评价肾射频消融短期效果的实验研究

目的 应用超声造影(CEUS)、磁共振(MRI)观察正常兔肾射频消融灶的影像表现,并与大体病理进行对照,探讨超声造影、MRI在正常肾射频消融效果评估中的价值.方法 10只新西兰大白兔行肾经皮射频消融术,分别在射频术后1d、1周行超声造影及MRI检查,并与大体标本消融灶的测量结果进行比较.结果 在射频消融术后较短时间内(术后1d和1周),超声造影和增强MRI可以清晰地显示肾消融灶的部位、形态及范围,影像表现与大体标本、超声造影与增强MRI测量结果比较,差异均无统计学意义(P＞0.05).结论 超声造影和增强MRI均适用于肾射频消融灶短期情况的观察评价,超声造影可以实时动态地显示消融灶血流灌注的变化.     

超声造影在肝移植术后血管并发症诊断中的应用

目的探讨超声造影在肝移植术后血管并发症诊断中的价值。方法对200例肝移植术后患者行谐波超声造影,工作站录像并由4名有经验的医师分析作出诊断。结果超声造影准确诊断12例肝移植术后血管并发症患者。其中肝动脉栓塞3例（其中2例显示侧支循环）,门静脉栓塞5例（其中门静脉部分栓塞3例）,门静脉吻合口狭窄2例,下腔静脉吻合口狭窄1例,肝静脉与腔静脉吻合口处狭窄1例。2例常规超声因没取到频谱从而怀疑肝动脉栓塞的患者通过造影排除了栓塞可能,1例患者通过超声造影纠正了常规超声肝动脉狭窄的诊断。结论超声造影对于肝移植术后血管并发症的诊断有较高的价值,其应用有利于减少进一步有创检查的使用。     

经球囊超声消融肺静脉口治疗阵发性心房颤动的临床研究

目的对经球囊超声消融肺静脉口治疗阵发性心房颤动的疗效和安全性进行临床评价。方法阵发性心房颤动患者5例，症状明显且应用抗心律失常药物治疗无效。经球囊超声消融肺静脉的开口，消融终点为肺静脉电学隔离。结果总计消融了19支肺静脉，单纯超声消融肺静脉实现电学隔离15支(73、7％)。早期有1例心房颤动复发，1例频发房性期前收缩，1例偶发房性期前收缩，均经胺碘酮治疗后消失。所有患者的随访时间超过6个月，均可以无需药物而维持窦性心律。并发症包括消融中1例出现心房穿孔，1例出现严重迷走反应，无肺静脉狭窄。结论肺静脉口超声消融是治疗阵发性心房颤动的一种有效手段。     

超声引导下射频消融联合泡沫硬化剂治疗不同管径大隐静脉曲张的临床价值

目的 探讨超声引导下射频消融联合泡沫硬化剂治疗不同管径大隐静脉曲张及超声在术后短期疗效评估的价值。方法 选取我院收治的大隐静脉曲张患者145例（145条患肢）,根据术前超声测量大隐静脉大腿段最大管径分为A组98例（管径＜10 mm）和B组47例（管径≥10 mm）,两组均采用超声引导下腔内射频消融大隐静脉主干和泡沫硬化剂治疗小腿曲张浅静脉。比较两组消融次数和术后即刻、1个月、6个月大隐静脉闭塞率、残余管腔管径,以及术后并发症情况。结果 B组每节段平均消融次数大于A组,差异有统计学意义（P＜0.05）。A组、B组术后即刻大隐静脉闭塞率均为100%,术后1个月大隐静脉闭塞率分别为97.96%、100%,术后6个月大隐静脉闭塞率分别为95.92%、95.74%,两组各时间点大隐静脉闭塞率比较差异均无统计学意义。术后1个月、6个月B组残余管腔管径均大于A组,差异有统计学意义（均P＜0.05）。术后两组患者均未出现深静脉血栓、肺栓塞等严重并发症,两组出现皮下瘀斑和皮肤灼伤占比比较差异无统计学意义;B组出现皮下条索僵硬静脉占比大于A组,差异有统计学意义（P＜0.05）。结论 超声引导下射频消融联合泡沫硬化剂治疗不同管径大隐静脉曲张短期内大隐静脉闭塞率较高,较大管径的大隐静脉消融可能需要更多的消融周期,超声在术中监测、术后随访和疗效评估中均有重要的作用。     

超声引导下经皮冷循环射频消融治疗肾上腺肿瘤的护理

目的探讨超声引导下经皮冷循环射频消融治疗肾上腺肿瘤的护理方法和效果。方法对10例肾上腺肿瘤患者进行超声引导下经皮冷循环射频消融治疗，并对各个阶段进行认真分析、观察。结果10例患者9例病灶在1次消融后完全坏死，1例病灶在2次消融后完全坏死，无严重并发症出现，随访6～12个月，随访期内无肿瘤复发。结论超声引导下经皮冷循环射频消融治疗肾上腺肿瘤安全可靠，关键在于完善术前准备，加强术后观察，而护理是有效减少术后并发症、保证手术成功、确保患者安全的关键。     

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.     

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.