大剂量丙种球蛋白联合地塞米松治疗急重型ITP疗效观察

目的：评价大剂量静脉丙种球蛋白联合地塞米松、单独大剂量静脉丙种球蛋白及单独大剂量地塞米松3种方法治疗急重型儿童ITP的疗效。方法：对入院时血小板计数≤25×10^0／L、出血倾向明显的45例患儿随机分为三组，每组15例。联合组：丙种球蛋白400mg／（kg·d）联合地塞米松1.5mg／（kg·d）静脉滴注，连用5d，于治疗第6d起口服强的松2mg／（kg·d）；丙种球蛋白组：静脉滴注丙种球蛋白；地塞米松组：静脉滴注地塞米松。连续监测血小板计数。结果：联合组、丙种球蛋白组、地塞米松组血小板计数≥50×10^9／L时间分别为（2．1±0．6）d，（2．7±0．6）d，（3．9±0．8）d，血小板数达峰值时间分别为（10．1±1．2）d，（11．2±1．3）d，（13．5±1．9）d，两两相比差异均有统计学意义（P〈0．05）。结论：大剂量静脉丙种球蛋白联合地塞米松静脉滴注治疗急重型儿童ITP比单独使用其中任一种药物升高血小板的作用更迅速。     

甲泼尼龙序贯治疗特发性血小板减少性紫癜

目的观察甲泼尼龙静脉滴注及口服序贯治疗特发性血小板减少性紫癜(ITP)的临床疗效。方法治疗组22例ITP应用甲泼尼龙静脉滴注后口服序贯治疗,对照组19例使用地塞米松静脉滴注后口服泼尼松,对比观察两组疗效及安全性。结果治疗组总有效率87％,对照组总有效率72％,两组差异无统计学意义(P＞0．05)。治疗组血小板最低值持续时间及血小板升高时间均较对照组缩短(P＜0．05)。输注单采血小板次数治疗组少于对照组(P＜0．05)。治疗组治疗前后血清PAIgG水平下降幅度大于对照组(P＜0．05)。结论甲泼尼龙序贯治疗ITP见效快,持续时间长,不良反应少。     

小剂量甲泼尼龙与甘露醇早期干预手足口病重症化的临床研究——附100例报告

目的：探讨早期联合应用小剂量甲泼尼龙与甘露醇干预对防止伴发热症状的手足口病普通病例进展至重症化的临床疗效。方法：选择200例伴发热症状的手足口病普通病例,随机分为A组（治疗组）100例和B组（对照组）100例。两组均给予常规治疗,在此基础上治疗组加用20％甘露醇0．5g／kg快速静脉滴注,每8h1次,甲泼尼龙2mg／（kg·d）加入10％葡萄糖溶液50ml静脉滴注;若无重症发生,两药联合应用3d后停药。观察两组患者的病情进展。结果：治疗组100例患儿无一例进展至重症,均治愈;对照组有6例进展到神经系统受累期,两组进展至重症的发生率比较差异有统计学意义（P〈0．05）;未发生重症的两组患儿比较,治疗组在退热、口腔溃疡愈合、皮疹消退及住院时间均短于对照组（P〈0．05）。结论：早期联合应用小剂量甲泼尼龙与甘露醇可干预有发热症状的手足口病普通病例病情进展、防止重症发生,明显提高手足口病的救治成功率。     

大剂量甲基维生素B12治疗多发性硬化急性期的疗效观察

目的探讨大剂量甲基维生素B12对复发缓解型多发性硬化（MS）急性期的疗效。方法72例随机分为甲泼尼龙加大剂量甲基维生素B12组36例（观察组）及甲泼尼龙组36例（对照组），比较2组的有效率、治疗前后扩充致残量表（EDSS）平均评分及神经电生理包括体感诱发电位（SEP）、脑干听觉诱发电位（BAEP）、视觉诱发电位（VEP）的变化。结果治疗7d时2组治疗前后EDSS评分均显著降低（均P〈0．001），有效率对照组为69．4％、观察组为75．0%，比较2组有效率和治疗后EDSS评分均无显著性差异（均P〉0．05）。治疗30d时观察组有效率为97．2%，明显高于对照组的77．7％（P〈O．05）；观察组EDSS评分也较对照组明显降低（P〈O．05）。诱发电位在治疗7d时2组总的改善率无差别（P〉0．05），在治疗30d时2组有显著性差异（P〈O．05），尤其在VEP、BAEP改善明显（P〈O．01）。结论甲泼尼龙加用大剂量甲基维生素B12治疗急性期多发性硬化，能提高有效率，促进神经功能的恢复，且长程使用效果可能更佳。大剂量甲基维生素B12可以作为免疫抑制治疗急性期多发性硬化的辅助治疗。     

甲泼尼龙静脉滴注及鼻塞正压呼吸支持治疗小儿重症毛细支气管炎疗效观察

目的：观察甲泼尼龙静脉滴注及鼻塞正压（NCPAP）呼吸支持治疗重症毛细支气管炎的疗效。方法：将60例重症毛细支气管炎患儿随机分为治疗组35例,给予NCPAP呼吸支持及甲泼尼龙静脉滴注,雾化吸入喘乐宁加布地奈德混悬液,每日2次。对照组25例,给予喘乐宁加布地奈德混悬液、爱全乐雾化吸入,每日2次,对比观察两组用药前、用药后患儿症状体征改善情况进行比较。结果：治疗组三凹征、喘息、喘鸣音、咳嗽。消失时间分别为03d,0．8d,1．5,4．3,对照组分别为1．1d．2．2d,3．3d,5．5d。治疗组较对照组病程明显缩短（P〈0．05）。结论：重症毛细支气管炎患儿应用静脉滴注甲泼尼龙及NCPAP呼吸支持,对改善症状、缩短病程疗效显著。     

米卡芬净单药及联合两性霉素B对小鼠侵袭性肺曲霉病的治疗作用

目的评价米卡芬净单药及联合两性霉素B对小鼠侵袭性肺曲霉病（IPA）的治疗作用。方法采用环磷酰胺骨髓抑制、烟曲霉孢子滴鼻接种构建中性粒细胞减少小鼠IPA模型。实验动物随机分为为4组：模型对照组（NS＋5％GS，A组）、米卡芬净治疗组[5mg／（k·d），B组]、两性霉素B治疗组[1mg／（kg·d），C组]和米卡芬净[5mg／（kg·d）]加两性霉素B[1mg／（kg·d）]治疗组（D组），治疗从接种第2天开始，每天1次，共7d。①动物生存期观察：每组15～16只小鼠，接种后每天观察1次至第21天。共进行2批次实验，分别给予2×10^5和6×10^6个孢子／小鼠。②肺的真菌负荷：每组9只小鼠，给予1．5×10^4个孢子／小鼠。治疗结束后取肺，匀浆后梯度稀释培养，记取菌落数并计算肺的真菌负荷量。结果①生存分析：第1批次，米卡芬净、两性霉素B单药及联合用药治疗均能延长小鼠生存期，但3种治疗方案在延长生存期方面差异无显著性（B组、C组分别与A组比较均有P〈0．05，D组与A组比较P〈0．01）。第2批次，联合用药组生存期长于其它各组，米卡芬净及两性霉素B单药治疗组与模型组比较差异无显著性（D组与A组比较P〈0．01；D组分别与B组及C组比较均有P〈0．05）。②肺的真菌负荷：两性霉素B单药及联合用药均能降低肺的真菌负荷，米卡芬净单药不降低肺的真菌负荷（C组与A组比较P〈0．01；D组与A组比较P〈0．05；B组与C组比较P〈0．05；B组与D组比较P〈0．01）。结论单独应用米卡芬净或两性霉素B及联合用药均能够延长中性粒细胞减少IPA小鼠生存期，当孢子接种量为6×10^6／小鼠时，联合用药优于单独应用米卡芬净或两性霉素B。单独应用米卡芬净不降低肺的真菌负荷，联合用药或两性霉素B单药在降低肺的真菌负荷方面均优于对照组及米卡芬净组。     

经面罩机械通气在重症急性左心衰竭中的应用

目的：研究经面罩机械通气（FMMV）对重症急性左心衰竭患者的治疗效果。方法：回顾分析56例重症急性左心衰竭患者FMMV后的效果（治疗组），并与传统药物治疗方法（对照组）56例比较，观察患者心率、呼吸频率、动脉血气等变化。结果：治疗组患者均能教好地耐受FMMV。2h后49例呼吸困难等临床症状明显改善，心率由（136±14）次·min^-1降至（89±10）次·min^-1（P〈0．05），呼吸频率由（38±4）次·min^-1降至（26±3）次·min^-1（P〈0．05），PaO2由（50．10±8．70）mmHg上升至（92．50±10．20）mmHg（P〈0．05），而对照组治疗前后临床症状与动脉血气变化不明显，两组比较均有统计学差异（P〈0．05）。结论：与用传统药物治疗方法相比，FMMV可迅速纠正低氧血症，改善重症急性左心衰竭患者的循环和呼吸功能。     

褪黑素对大鼠急性脊髓损伤的保护作用

目的：探讨褪黑素对大鼠急性脊髓损伤的作用。方法：将72只Wistar成熟健康大鼠随机分为褪黑素组、甲泼尼龙琥珀酸钠组、生理盐水组、无水乙醇组，采用改良Allen’s技术（5g×10cm）以1、9为中心制作急性脊髓损伤模型：损伤后10min分别予以褪黑素（100mg／kg）、甲泼尼龙琥珀酸钠（30mg／kg）、生理盐水及5％无水乙醇腹腔内注射，伤后2h、24h、72h分别观察各组BBB评分变化，取T8、T9、T10 3个脊髓节段，应用免疫组化对脊髓组织及P53阳性细胞进行标记，探讨褪黑素对急性脊髓损伤有无保护作用。结果：在急性脊髓损伤后，各观测时间点褪黑素组与甲泼尼龙琥珀酸钠组BBB评分均较生理盐水组及无水乙醇组明显升高（P〈0．01），褪黑素组与甲泼尼龙琥珀酸钠组之间差异无显著性（P〉0.05）；P53阳性细胞的表达在脊髓损伤后各组均呈逐渐增高趋势，但褪黑素组与甲泼尼龙琥珀酸钠组较生理盐水组及无水乙醇组P53阳性细胞表达降低（P〈0．01），褪黑素组与甲泼尼龙琥珀酸钠组之间P53阳性细胞表达差异无显著性（P〉0．05），无水乙醇组与生理盐水组差异无显著性（P〉0．05）。结论：褪黑素对大鼠急性脊髓损伤具有保护性治疗作用，其作用效果与甲泼尼龙琥珀酸钠相似。     

甲泼尼龙冲击治疗急性脊髓炎的临床分析

目的观察甲泼尼龙冲击治疗急性脊髓炎的临床效果。方法选取本院收治的急性脊髓炎患者36例,随机分为2组：观察组24例给予甲泼尼龙静滴5 d,随后口服泼尼松并逐渐减量直至停药;对照组12例给予地塞米松静滴10 d,随后口服强的松并逐渐减量直至停药,比较2组脊髓神经功能恢复所需时间及总体疗效。结果观察组总有效率（83.3%）显著高于对照组（50.0%）,并发症发生率（8.3%）低于对照组（33.3%）,差异有统计学意义（P〈0.05）,观察组患者自行下地行走、排尿恢复以及肌力改善2级以上所需时间均短于对照组,差异有统计学意义（P〈0.05或P〈0.01）。结论在临床上采用甲泼尼龙冲击治疗急性脊髓炎的疗效更好,也更安全,值得临床大力推广。     

肝衰竭患者外周血CD4+ CD25+调节性T淋巴细胞水平变化与疗效的相关性研究

目的动态观察肝衰竭患者外周血Treg细胞在人工肝治疗和内科治疗前后的水平变化规律，探讨其与疗效及预后的相关性。方法63例肝衰竭患者按治疗方式不同分为两组，29例为人工肝结合内科治疗组，34例为内科治疗组，依据肝功能、临床症状等指标判定人工肝治疗有效组17例、无效组12例，内科治疗有效组11例、无效组23例，23例健康献血员为健康对照组。流式细胞仪检测外周血Treg细胞水平，动态观察Treg细胞水平变化规律并分析与疗效的相关性。结果健康对照组Treg细胞水平（2．46±0．56）％，有效患者治疗前Treg细胞水平低于健康对照组，其中人工肝有效组（1．92±0．78）％，内科有效组（2．10±0．56）％，两组之间比较差异无统计学意义（P〉0．05），与健康对照组比较差异均有统计学意义（均P〈0．05）；治疗后人工肝组（2．62±0．67）％，内科组（2．89±0．72）％，两组之间比较差异无统计学意义（P〉0．05），与健康对照组比较差异均无统计学意义（均P〉0．05）；两组有效患者治疗前与治疗后比较差异均有统计学意义（均P〈0．05）；无效患者治疗前Treg细胞水平高于健康对照组水平，其中人工肝组（4．64±1．31）％，内科组（4．87±2．86）％，两组之间比较差异无统计学意义（P〉0．05），与健康对照组比较差异均有统计学意义（均P〈0．05）；治疗后人工肝组（5．44±2．13）％，内科组（5．91±2．78）％，两组之间比较差异无统计学意义（P〉0．05），与健康对照组比较差异均有统计学意义（均P〈0．05），两组无效患者治疗前与治疗后比较差异均有统计学意义（均P〈0．05）。Treg细胞水平变化在有效患者呈现低→高→低的“峰”形曲线，且人工肝组较内科组Treg细胞水平较早恢复至正常水平；而在无效患者呈现高→低→高的“谷”形曲线。结论外周血Treg细胞水平与疗效相关，可作为肝衰竭疗效评估及预后判定的指标。     

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.