高频超声在胃镜下幽门肌切开术治疗CHPS的应用价值

目的　旨在通过运用高频超声观察行胃镜下幽门环肌切开术治疗先天性肥厚性幽门狭窄(CHPS)前后肥厚狭窄的幽门管组织各层粘膜改变以及胃内液体通过幽门管情况,以探讨高频超声在此新型微创术式的应用价值和临床意义。方法　对65例CHPS的患儿进行超声检查,观察CHPS患儿术前与术后1天、术后1周、术后1个月、术后6个月幽门管各粘膜层厚度的改变以及幽门管内径变化。结果　手术后1天黏膜及黏膜下层厚度较手术前增加;术后1周及术后1个月幽门管长径、直径、幽门肌层厚度较手术前减小,黏膜及黏膜下层厚度无变化;手术后6个月幽门管长径、直径、幽门肌层厚度、黏膜及黏膜下层厚度均较手术前减少。术后胃内液体通过幽门管的次数较术前明显增多,幽门管开放程度增大。结论　根据高频超声所测得的胃镜下幽门肌切开术治疗CHPS前后的数据发现,幽门肌层和黏膜及黏膜下层厚度的变薄以及幽门管的狭窄程度改善,得出该微创术式是有效的手术方法,超声对其手术的疗效评估有重要的意义。     

彩色多普勒超声在内镜下幽门括约肌切开术治疗先天性肥厚性幽门狭窄中的应用

目的:探讨彩色多普勒超声在一种新型手术疗法--内镜下幽门括约肌切开术治疗先天性肥厚性幽门狭窄(CHPS)中的应用.方法:行胃镜下幽门括约肌切开术的CHPS患儿20例,手术前后应用彩色多普勒超声观察正常组婴幼儿及CHPS组患儿术前肌层及黏膜层血流分级.现察CHPS患儿术前、术后1周、术后1个月肌层及黏膜层血流分级变化趋势.结果:正常纽婴幼儿与CHPS纽患儿肌层及黏膜层血流分级差异有明显统计学意义.CHPS组患儿术前与术后1周、术后1个月肌层及黏膜层血流分级无统计学意义.结论:彩色多普勒超声能很好地观察正常婴幼儿及CHPS患儿术前、术后肌层及黏膜层血流状况,对于诊断CHPS有较大的帮助.     

超声在胃镜下幽门环肌切开术治疗先天性肥厚性幽门狭窄中的应用价值

目的应用超声观察行胃镜下幽门环肌切开术治疗先天性肥厚性幽门狭窄(CHPS)前后幽门管组织各层黏膜的改变,以及胃内液体通过幽门管的情况。方法对65例CHPS患儿行超声检查,观察其术前、术后1 d、术后1周、术后1个月和术后6个月幽门管各层黏膜厚度的改变,以及幽门管内径变化。经胃管向胃内注入浓稠奶液作为胃肠对比造影剂,观察造影剂通过幽门管的情况。结果 65例CHPS患儿术前肌层厚度为(4.85±0.82)mm,黏膜层及黏膜下层厚度为(2.14±0.33)mm,幽门管长径为(18.53±0.91)mm,幽门直径为(15.82±0.66)mm。经胃镜下幽门环肌切开术后1 d,黏膜及黏膜下层厚度与术前比较差异有统计学意义(P0.05),余参数差异均无统计学意义;术后1周和术后1个月幽门管长径、直径、内径及幽门肌层厚度均较术前减小(均P0.05),黏膜及黏膜下层厚度差异无统计学意义;术后6个月幽门管长径、直径、内径、幽门肌层厚度、黏膜及黏膜下层厚度均较术前减小(均P0.05)。术后1周,38例患儿幽门呈现瞬时全开放状态;术后1个月,48例患儿幽门呈现瞬时全开放状态;术后6个月,56例患儿幽门可呈现瞬时全开放状态。结论超声在评估胃镜下幽门环肌切开术治疗CHPS后幽门肌层、黏膜及黏膜下层厚度变化及幽门管狭窄程度的改善方面有重要临床应用价值。     

彩色多普勒超声技术在诊断及评估先天性肥厚性幽门狭窄的新应用价值

目的:旨在通过运用彩色多普勒超声的血流显像技术(CDFI)及脉冲多普勒(PW)频谱分析技术观察先天性肥厚性幽门狭窄(CHPS)患儿的幽门管组织的血流分布、血流速度等情况,以探讨彩色多普勒超声在诊断CHPS并评估其肥厚程度的应用价值。方法:选取2006—2015年广州市第一人民医院新生儿科经超声检查及X线造影检查确诊的65例CHPS患儿,以50例各项生命体征均正常且无临床症状的婴儿作为对照组,对65例CHPS患儿及对照组婴幼儿进行超声检查,记录受检者的幽门形态结构并分别测量幽门肌层厚度、幽门管长径、直径和幽门管内径,通过CDFI检查观察肥厚幽门黏膜各层的彩色血流分布特点并对幽门肌层进行血流分级;通过PW技术进行血流速度测量和频谱分析;另外将CHPS组肌层按厚度分为3组,比较肌层厚度与上述参数间的关系。结果:肥厚的幽门管各层黏膜组织的血流具有分布特征;肌层血流分级为2.83±0.38;最大血流速度(Vmax)为(16.96±0.91)cm/s;阻力指数(RI)为0.68±0.33。65例CHPS患儿的肌层厚度与年龄、体质量、幽门管直径、Vmax、RI均呈正相关(r=0.63、0.48、0.68、0.48、0.42,P均<0.05),与幽门管长度无相关性(r=0.13,P>0.05)。以肌层厚度分为3组的病例中第1组与第2组的血流分级、Vmax及RI无显著差别,血流均较丰富,第3组的血流分级较低,且Vmax加快,RI增大。结论:通过彩色多普勒超声技术检查,可准确掌握幽门管的黏膜各层的血流分布情况和肌层血流分级,并通过测量Vmax及RI以估计幽门狭窄的轻重程度,为临床选择治疗方式乃至为手术治疗方案提供宝贵的客观资料,且简便易行,具有较大的临床应用价值。     

胃镜下幽门环肌切开术患儿疼痛的干预

目的观察胃镜下幽门环肌切开术治疗先天性肥厚性幽门狭窄(CHPS)患儿疼痛的预防和处理的效果及安全性。方法:回顾性分析2010年8月至2014年8月我科收治的行胃镜下幽门环肌切开术治疗的CHPS患儿60例的临床资料,术前30 min静脉注射苯巴比妥钠20 mg·kg-1,术前5 min静脉注射咪达唑仑(0.1-0.3)mg·kg-1,予鼻导管低流量吸氧,术后安置舒适的体位,非营养性吸吮,观察术前、术中、术后患儿面部表情、哭闹、呼吸方式、上肢动作、下肢动作、觉醒状态,以新生儿疼痛评分(CRIES)分级标准对患儿进行疼痛程度评级。结果:术前CRIES处于0分、1分、2分者分别为16例、31例、13例,给予苯巴比妥、咪达唑仑后疼痛减轻;术后予护理干预可减轻新生儿行胃镜下幽门环肌切开术的疼痛。结论:胃镜下幽门环肌切开术治疗CHPS,术前联合应用苯巴比妥和咪达唑仑镇静安全可靠,不良反应少;术后适宜个性化护理干预可减轻其疼痛。     

影像学评价胃镜下幽门括约肌切开治疗先天性肥厚性幽门狭窄无效

目的 探讨影像学检查对胃镜下幽门括约肌切开治疗先天性肥厚性幽门狭窄(CHPS)无效的病因诊断价值.方法 回顾性分析9例胃镜下治疗CHPS术后反复呕吐患者的超声检查特点,并与泛影葡胺胃肠造影、胃镜检查结果进行比较.结果超声检查能量化比较术前、术后的改变,动态观察幽门管的功能;泛影葡胺胃肠造影对引起呕吐的其他消化系统疾病诊断准确;胃镜能及早期、准确观察到黏膜的病变,并引导治疗.结论超声检查具有无创、准确性高及价廉等优点,可作为胃镜下幽门括约肌切开术治疗CHPS无效的首选影像学评价手段.     

小儿先天性肥厚性幽门狭窄的彩超诊断及临床价值

目的探讨彩色多普勒超声在诊断先天性肥厚性幽门狭窄(CHPS)的临床价值。材料与方法采用彩色多普勒超声高频探头对临床上怀疑先天性幽门肥厚性狭窄的呕吐患儿进行检查,回顾分析本院2012年10月至2014年10月间经手术证实的21例CHPS患儿的幽门管的超声表现包括形态结构、幽门管长径、直径及幽门肌厚度、胃腔大小、胃蠕动和幽门管的开放情况,并与手术结果对照。结果以幽门肌厚度≥4mm,幽门直径≥1 5mm,幽门管长度≥17mm,且空腹后胃腔扩张,为诊断肥厚性幽门狭窄的标准.所有共21例超声诊断为CHPS的患者均经手术证实。结论彩色多普勒超声诊断CHPS有特异性,而且操作简单、安全、方便,是首选的影像学检查方法,对临床诊断及治疗方案的选择具有重要的应用价值。     

先天性肥厚性幽门狭窄的超声表现分析

目的探讨先天性肥厚性幽门狭窄（Congenital hypertrophic pyloric stenosis CHPS)的声像图特点。方法 分析手术证实的15例CHPS声像特征，与非CHPS患儿组对照。结果14例CHPS有曲型的声像特征。1、胆囊内下方及右肾前方见团块状幽门；2、幽门横轴面呈靶环状，中央为强回声气体及流动液体回声，周围为低回声肌层；3、幽门纵轴面显示前后肌层增厚，近端宽阔，远端狭窄，CHPS患儿幽门肌层长径，幽门管直径，幽门环股厚度明显高于非CHPS患儿组，幽门肌层长径，幽门管直径超声测两组之间有交叉重叠，幽门环肌厚度测值两组之间无重叠，超声符合率达93.3%。结论 超声诊断CHPS有较强的特异性，超声诊断CHPS简单易行，无创伤，无痛苦，我们认为疑有CHPS应首先超声检查，阴性病例应结合X-线检查以避免假阴性。     

先天性肥厚性幽门狭窄的超声诊断价值

目的 通过总结手术证实的57例先天性肥厚性幽门狭窄（CHPS）的超声诊断结果,探讨该病的声像图特点及临床应用价值.方法 测量幽门管长度,直径及幽门肌厚度.结果 57例CHPS的幽门肌厚度均≥3.5 mm,最厚8.5 mm,平均4.7 mm.结论 超声可作为诊断CHPS的首选方法.     

婴幼儿先天性肥厚性幽门狭窄的超声诊断

目的 回顾11例先天性幽门狭窄(CHPS)。探讨该病的声像图特点。方法 观察患儿胃潴留情况。测量幽门管肌层厚度。结果幽门肌厚度明显增厚≥3．6mm，量厚达9．5mm。结论 超声对CHPS诊断有特异性价值。     

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.