药物联合内镜治疗与经颈静脉肝内门体分流术对肝硬化食管胃静脉曲张出血的疗效分析

目的比较药物联合内镜治疗及经颈静脉肝内门体分流术(TIPS)对急性肝硬化食管胃静脉曲张出血(EGVB)的近期及远期疗效。方法收集2010年1月-2014年12月住院行药物联合内镜下治疗或行TIPS术的肝硬化EGVB患者资料120例,根据治疗方式分为联合治疗组77例,TIPS治疗组43例,比较两组急性期止血情况、远期再出血情况、生存情况及并发症发生情况。结果联合治疗组及TIPS治疗组的急性期止血率无明显差异,分别为96.1%及97.7%,联合治疗组2年未再出血率低于TIPS治疗组(59.7%vs 81.4%,P0.05),且两组间免于再出血函数比较差异有统计学意义(P=0.031)。两组间死亡率无明显差异(10.4%vs 4.7%,P=0.444),联合治疗组肝性脑病发生率低于TIPS治疗组(13.2%vs 27.9%,P0.05)。结论药物联合内镜治疗及TIPS术均能较好地控制EGVB,TIPS术可以更好地防止再出血的发生但会导致更高的肝性脑病发生率。     

个体化饮食营养干预在肝硬化食管胃静脉曲张破裂出血患者EVL术后护理中的应用

目的：探讨个体化饮食营养干预在肝硬化食管胃静脉曲张破裂出血(EGVB)患者内镜下静脉曲张套扎术(EVL)术后护理中的采用效果。方法：选取2019年1月1日～2021年10月31日行EVL手术治疗的130例肝硬化EGVB患者,采用随机数字表法分为观察组和对照组各65例,对照组实施常规护理和饮食干预,观察组在对照组基础上实施个体化饮食营养干预。比较两组饮食依从性、机体营养标志物与肝功能指标水平、术后再出血发生情况。结果：观察组饮食依从性高于对照组(P<0.05);干预后,两组营养标志物及肝功能指标水平均优于干预前(P<0.05),且观察组血清前白蛋白(PA)、视黄醇结合蛋白(RBP)、铁蛋白(SF)水平均高于对照组(P<0.01),丙氨酸氨酶(ALT)与血清总胆红素(TBIL)水平低于对照组(P<0.05);干预后,观察组大便隐血试验阳性、黑便、呕血发生率均低于对照组(P<0.05)。结论：个体化饮食营养干预可有效提升EVL术后肝硬化EGVB患者饮食依从性,改善营养状况,降低术后再出血发生风险。     

内镜下套扎术联合药物注射对肝硬化合并上消化道出血患者止血效果及血流动力学指标的影响

目的探讨内镜下套扎术联合药物注射对肝硬化合并上消化道出血患者止血效果及血流动力学指标的影响。方法选取2016年3月至2018年3月渭南市第一医院60例肝硬化合并上消化道出血患者作为研究对象,根据随机化原则进行分组,其中对照组30例患者接受内镜下套扎术治疗,研究组30例患者在对照组治疗的基础上联合药物注射治疗,比较两组患者止血效果及治疗前后血流动力学指标的变化情况。结果研究组患者总有效率为93.33%,对照组为73.33%,两组患者总有效率比较差异有统计学意义(P0.05);研究组患者输血量、止血时间、症状改善时间、住院时间、再出血发生率均明显少于对照组,差异均有统计学意义(P0.05);治疗后两组患者门静脉及脾静脉血流量较治疗前均明显降低,且研究组低于对照组,差异均有统计学意义(P0.05)。结论内镜下套扎术联合药物注射治疗可有效改善肝硬化合并上消化道出血患者的血流动力学指标,止血效果明显,再出血发生率较低,治疗中有极高的临床应用价值。     

内镜下组织黏合剂联合硬化剂对危重食管胃底静脉曲张患者门静脉血流动力学的影响

目的探讨内镜下组织黏合剂联合硬化剂对危重食管胃底静脉曲张患者门静脉血流动力学的影响。方法采用便利抽样法选取该院2012年9月至2016年9月收治的危重食管胃底静脉曲张患者76例作为研究对象,将其随机分为观察组和对照组,每组38例。对照组采用内镜下注射硬化剂治疗,观察组采用内镜下组织黏合剂联合硬化剂治疗,观察对比两组患者的治疗效果和门静脉血流动力学检测指标。结果治疗后,观察组患者吞咽梗塞、胸痛、发热等并发症出现的情况明显少于对照组(P0.05),且急诊止血率高于对照组(P0.05);观察组患者近期、远期再出血发生率明显少于对照组(P0.05);与治疗前比较,治疗后两组患者门静脉内径无明显改变,其血流速度与血流量均明显增加,且观察组明显高于对照组(P0.05);观察组出现脊髓和大脑栓塞各1例,对照组出现脊髓栓塞2例、大脑栓塞3例,两组不良反应发生情况比较差异无统计学意义(P0.05)。结论内镜下组织黏合剂联合硬化剂治疗危重食管胃底静脉曲张,能够提高止血效果,降低近远期再出血发生率,促进肝功能的恢复。     

风险性管理在肝硬化出血行颈静脉肝内门体分流术中的应用

目的:探讨风险性管理在肝硬化食管胃底静脉曲张破裂出血(EGVB)患者行颈静脉肝内门体分流术(TlPS)中的应用效果。方法:将76例肝硬化合并EGVB患者采用随机数字表法分为对照组和观察组各38例,对照组采用常规围术期护理干预,观察组在此基础上实施手术风险管理,比较两组干预效果。结果:观察组手术时间、住院时间短于对照组(P0.05);观察组术中风险事件发生率、TIPS并发症发生率低于对照组(P0.05);观察组患者对护理技术和服务态度满意度评分及患者总体满意率均高于对照组(P0.05)。结论:风险管理用于TIPS,可缩短手术时间,减少术中风险事件,降低术后并发症发生率,提高手术成功率和患者满意度。     

经颈静脉肝内门体分流术与内镜治疗预防食管胃底静脉曲张出血的效果

目的 分析经颈静脉肝内门体分流术（TIPS）与内镜治疗对食管胃底静脉曲张出血（EGVB）的预防效果,为肝硬化患者早期合理选择治疗方案提供参考依据。方法 回顾性分析2018年1月～2020年2月于遂宁市中心医院接受一级预防的肝硬化合并食管胃底静脉曲张的89例患者,根据手术方式不同将患者分为两组,其中进行内镜下套扎治疗（EVL）者纳入EVL组（n=43）,进行TIPS治疗者纳入TIPS组（n=46）,比较两组静脉曲张改善效果,治疗前后门静脉内径、肝功能变化以及治疗后患者EGVB、并发症和死亡发生情况。结果 TIPS组和EVL组静脉曲张改善有效率分别为90.70%和86.96%,差异无统计学意义（P>0.05）;两组治疗后肝功能Child-Pugh分级及评分差异无统计学意义（P>0.05）,TIPS组术后门体循环压力差降低（P<0.05）,且治疗后3、6、12、24月时门静脉内径门静脉内径低于EVL组,差异有统计学意义（P<0.05）;两组治疗后EGVB发生率分别为32.56%和17.39%(P>0.05),其中TIPS组远期出血（治疗3月后）发生率低于EVL组...     

卡维地洛联合内镜下套扎术治疗肝硬化食管静脉曲张临床疗效观察

目的探讨卡维地洛联合内镜下套扎术治疗肝硬化食管静脉曲张的临床疗效。方法我院收治的肝硬化伴食管静脉曲张患者134例,根据数字表法随机分为联合组与对照组各67例,对照组行普萘洛尔联合内镜下套扎术,联合组行卡维地洛与内镜下套扎术治疗。比较两组临床疗效、不良反应和再出血发生率等指标。结果对照组治疗有效率低于联合组(P0.05)。随访期间,联合组再出血率低于对照组,血液流变学指标改变优于对照组(P0.05)。两组不良反应发生率比较,差异无统计学意义(P0.05)。结论卡维地洛联合内镜下套扎术可以有效降低食管静脉曲张患者的再出血率,保证治疗效果,值得临床推荐应用。     

内镜下套扎联合硬化剂注射治疗乙肝肝硬化并食管胃底静脉曲张出血的效果

目的分析内镜下套扎联合硬化剂注射治疗乙肝肝硬化合并食管胃底静脉曲张出血(EGVB)的疗效。方法选择2015年3月至2018年10月86例EGVB患者为研究对象,随机分为两组,每组43例。观察组予以硬化剂注射配合内镜下套扎治疗,对照组予以内镜下套扎治疗。比较两组的止血成功率及静脉曲张消失率,并随访6个月,统计两组静脉曲张治疗疗效及并发症。结果观察组食管静脉曲张及胃底静脉曲张治疗效果均优于对照组(P0.05)。治疗后,观察组静脉曲张消失率显著高于对照组(76.7%比41.9%,33/43比18/43,P0.05),但两组止血成功率比较差异未见统计学意义(95.3%比83.7%,41/43比36/43,P0.05)。两组随访结果比较,观察组静脉曲张复发率显著低于对照组(9.3%比27.9%,4/43比12/43,P0.05),但两组再出血率比较差异未见统计学意义(11.6%比18.6%,5/43比8/43,P0.05)。两组并发症总发生率比较差异未见统计学意义(16.3%比18.6%,7/43比8/43,P0.05)。结论内镜下套扎联合硬化剂注射治疗能显著提高乙肝肝硬化合并EGVB的治疗效果,改善静脉曲张情况,且患者预后良好。     

经颈静脉肝内门体分流术治疗门静脉高压症急性上消化道出血的临床研究

目的:探讨急诊行经颈静脉肝内门体分流术(TIPS)治疗门静脉高压症急性上消化道出血的可行性、有效性及安全性,评估其临床应用价值。方法:选择2015-04—2017-03期间潍坊市人民医院收治的肝硬化门脉高压症合并上消化道出血的患者共78例,使用随机数字表法将病例随机分为观察组及对照组,每组39例。观察组接受TIPS手术治疗,对照组行脾切除、贲门周围血管离断术。随访1年,观察并比较两组手术前后的血流动力学指标、肝功能、凝血功能指标,比较两组患者术后1年内再出血率、围手术期及术后并发症发生率。结果:两组患者均顺利接受相应手术,观察组无围手术期死亡病例,对照组围手术期死亡1例,为术后门静脉血栓形成导致小肠大面积坏死;观察组患者较对照组术后门静脉内径(PVD)显著变细,门静脉压力(PVP)明显下降,门静脉血流量(PVF)明显减少,而门静脉流速(PVV)较对照组明显加快,差异均具有统计学意义(P0.05);观察组术后AST、ALT、TBIL水平均低于对照组(P0.05),而PT、APTT指标较对照组差异无统计学意义(P0.05)。观察组术后1年内再出血病例3例,分别为术后第4、6、11个月出现再出血,其中1例行内镜下套扎术,另2例行内科保守治疗后治愈;6例患者术后1年内出现Ⅱ级以上的肝性脑病,2例患者出现肝功能衰竭而死亡,分别为术后第3、8个月。对照组术后1年内再出血病例2例,分别为术后2、5个月,均行内镜下套扎术后治愈;5例患者术后1年内出现Ⅱ级以上的肝性脑病,1例患者出现肝功能衰竭而死亡,为术后第5个月。两组在术后1年内再出血率、围手术期及术后并发症发生率比较,差异均无统计学意义(P0.05)。结论:TIPS可明显改善患者的血流动力学指标及肝功能,治疗门静脉高压症上消化道出血与传统手术方式相比,创伤小,效果显著,安全性高,值得临床进一步推广应用。     

PTVE联合PSE治疗肝硬化门脉高压并上消化道出血的观察

目的:评价经皮肝穿刺胃冠状静脉栓塞术联合脾动脉部分栓塞术治疗肝硬化门脉高压并上消化道出血的临床效果。方法:选取我院消化内科2016年12月～2018年12月收治的72例肝硬化门脉高压并上消化道出血患者,按随机数字表法分为对照组和观察组,每组36例。对照组采用经皮肝穿刺胃冠状静脉栓塞术治疗,观察组采用经皮肝穿刺胃冠状静脉栓塞术联合脾动脉部分栓塞术治疗,比较两组治疗效果。结果:观察组术后门脉血流动力学较对照组改善明显,白蛋白高于对照组,再出血率2.78%,低于对照组的22.22%,差异均有统计学意义(P0.05);两组止血成功率及直接胆红素比较无显著性差异(P0.05)。结论:经皮肝穿刺胃冠状静脉栓塞术联合脾动脉部分栓塞术治疗肝硬化门脉高压并上消化道出血操作简单,安全性高,适用于难以耐受外科手术患者。     

Migraine and genetic and acquired vasculopathies

It is remarkable that migraine is a prominent part of the phenotype of several genetic vasculopathies, including cerebral autosomal dominant arteriopathy with subcortical infarcts and leucoencephalopathy (CADASIL), retinal vasculopathy with cerebral leukodystrophy (RVCL) and hereditary infantile hemiparessis, retinal arteriolar tortuosity and leukoencephalopahty (HIHRATL). The mechanisms by which these genetic vasculopathies give rise to migraine are still unclear. Common genetic susceptibility, increased susceptibility to cortical spreading depression (CSD) and vascular endothelial dysfunction are among the possible explanations. The relation between migraine and acquired vasculopathies such as ischaemic stroke and coronary heart disease has long been established, further supporting a role of the (cerebral) blood vessels in migraine. This review focuses on genetic and acquired vasculopathies associated with migraine. We speculate how genetic and acquired vascular mechanisms might be involved in migraine.     

Fibrinogen and fibrin structure and functions

Fibrinogen molecules are comprised of two sets of disulfide-bridged Aalpha-, Bbeta-, and gamma-chains. Each molecule contains two outer D domains connected to a central E domain by a coiled-coil segment. Fibrin is formed after thrombin cleavage of fibrinopeptide A (FPA) from fibrinogen Aalpha-chains, thus initiating fibrin polymerization. Double-stranded fibrils form through end-to-middle domain (D:E) associations, and concomitant lateral fibril associations and branching create a clot network. Fibrin assembly facilitates intermolecular antiparallel C-terminal alignment of gamma-chain pairs, which are then covalently 'cross-linked' by factor XIII ('plasma protransglutaminase') or XIIIa to form 'gamma-dimers'. In addition to its primary role of providing scaffolding for the intravascular thrombus and also accounting for important clot viscoelastic properties, fibrin(ogen) participates in other biologic functions involving unique binding sites, some of which become exposed as a consequence of fibrin formation. This review provides details about fibrinogen and fibrin structure, and correlates this information with biological functions that include: (i) suppression of plasma factor XIII-mediated cross-linking activity in blood by binding the factor XIII A2B2 complex. (ii) Non-substrate thrombin binding to fibrin, termed antithrombin I (AT-I), which down-regulates thrombin generation in clotting blood. (iii) Tissue-type plasminogen activator (tPA)-stimulated plasminogen activation by fibrin that results from formation of a ternary tPA-plasminogen-fibrin complex. Binding of inhibitors such as alpha2-antiplasmin, plasminogen activator inhibitor-2, lipoprotein(a), or histidine-rich glycoprotein, impairs plasminogen activation. (iv) Enhanced interactions with the extracellular matrix by binding of fibronectin to fibrin(ogen). (v) Molecular and cellular interactions of fibrin beta15-42. This sequence binds to heparin and mediates platelet and endothelial cell spreading, fibroblast proliferation, and capillary tube formation. Interactions between beta15-42 and vascular endothelial (VE)-cadherin, an endothelial cell receptor, also promote capillary tube formation and angiogenesis. These activities are enhanced by binding of growth factors like fibroblast growth factor-2 (FGF-2) and vascular endothelial growth factor (VEGF), and cytokines like interleukin (IL)-1. (vi) Fibrinogen binding to the platelet alpha(IIb)beta3 receptor, which is important for incorporating platelets into a developing thrombus. (vii) Leukocyte binding to fibrin(ogen) via integrin alpha(M)beta2 (Mac-1), which is a high affinity receptor on stimulated monocytes and neutrophils.     

Telemedicine and teleradiology technologies and applications

Summary. Telemedicine and teleradiology hold the key for improving future health care delivery. In this paper we first review current communication and computer technologies used in telemedicine and teleradiology. Five examples in teleradiology applications are given including hospital-integrated picture archiving and communication systems, tele-neuro-imaging, telemammography, university consortium teleradiology service, and teleradiology for second opinion. Parameters important to teleradiology applications like costs, image quality, system reliability, and turn around time are considered. Data security is discussed, including patient confidentiality and image authenticity-which will be a major issue in future teleradiology applications.     

创伤高血糖与感染和MODS早期诊断和干预

本文详细介绍了创伤后血糖应激适度理论,以及高血糖与感染和多器官功能不全综合征的关系;提出涉及胰岛B细胞功能不全的MODS实验诊断新方案和极化液个体化干预新措施,可早期发现创伤MODS、降低感染率及MODS发生率和病死率。     

腹膜后纤维化与肾积水发生关系的临床研究

目的：探讨腹膜后纤维化（RPF）导致肾积水的原因及诊治经验。方法：回顾分析2004年1月—2010年12月24例腹膜后纤维化致肾积水患者的诊治资料。结果：（1）RPF患者常见首发症状为腰背痛或腹痛（69.2%）;（2）红细胞沉降率（ESR）增快和血清IgG4升高最常见。超声检查仅提示上尿路积水。RPF的静脉肾盂造影（IVP）和CT尿路成像（CTU）表现具有特征性。IVP肾盂输尿管显影不良时,CTU能较清晰的显示上尿路影像。CT扫描发现腹膜后软组织肿块9例（37.5%）,优于超声检查;（3）输尿管松解和腹腔化手术治疗22例;行肾切除术1例;行输尿管置双J管术1例。最终确诊为继发性RPF8例,其中4例为术前诊断,3例为术中腹膜后软组织肿块冷冻活检证实,1例为术后病理证实;（4）特发性RPF手术后肾积水均获长期缓解,而继发性RPF的预后取决于原发疾病及其治疗方案。结论：影像学检查是诊断RPF的重要手段,CTU优于超声检查和IVP。输尿管松解和腹腔化手术可以使特发性RPF输尿管梗阻得到长期的缓解,术中对肿块进行冷冻活检有助于鉴别特发性和继发性RPF,及时调整治疗方案。     

探讨儿童慢性顽固性咳嗽与支原体感染的关系及临床治疗观察

目的探讨儿童慢性顽固性咳嗽与肺炎支原体（MP）感染的关系及临床疗效观察。方法采用回顾性研究方法对于现将2005年3月至2008年3月在我院的55例确诊慢性顽固性咳嗽患儿,主要表现为肺炎支原体感染为临床特点进行分析,并进一步临床治疗研究。结果①临床特点：在55例确诊慢性咳嗽的患儿中,以慢性顽固性咳嗽为主要症状。58％（32／55）的病例无肺部体征;②外周血：85％（47／55）的病例外周血变化不大,WBC（4—10）×10 9／L之间,嗜酸性粒细胞增多;③特别检查：47．27％（26／55）肺炎支原体IgM（MP—IgM）抗体阳性,83．64％（46／55）PeR技术检测肺炎支原体特异性DNA;④X光报告为多种形式。结论肺炎支原体（MP）感染是引起儿童慢性顽固性咳嗽的病因之一,对儿童慢性咳嗽,特别是顽固性咳嗽的诊治中应更加重视。     

Acetaminophen and acetylcysteine dose and duration: Past,present and future

Abstract

Acetylcysteine has been utilized successfully in the treatment of acetaminophen overdose since the 1970s. Although prospective trials as to efficacy and safety of acetylcysteine were conducted, there were no randomized controlled trials. This commentary addresses the reasons for this, and the background to choice of dose of acetylcysteine utilized in the oral and IV dosing regimens. Nomograms to predict possible hepatotoxicity based upon time of ingestion of acetaminophen were developed from a relatively arbitrary definition of toxicity as an aspartate aminotransferase/alanine aminotransferase (ALT/AST) greater than 1000 IU/L. While these have proved generally useful, patients still continue to develop hepatic damage after acetaminophen overdose, particularly if they present late after ingestion. The optimum management of these patients remains unclear, and one area of uncertainty is the dose and duration of acetylcysteine in various circumstances. This article discusses the issues that need to be elucidated to better target changes in acetylcysteine dose. The potential for measurements of other markers to improve treatment selection is the subject of further research.     

Physician and Nurse Practitioner Teamwork and Job Satisfaction: Gender and Profession

Designing interprofessional primary care teams composed of physicians and nurse practitioners (NPs) is a national priority. We assessed how profession and gender affect teamwork and job satisfaction among primary care physicians and NPs by using survey data from 186 physicians and 398 NPs practicing in New York State. Our regression models show profession (NP vs physician) moderates the associations of gender with teamwork and job satisfaction. Among NPs, men had higher job satisfaction than women. Among physicians, women had higher job satisfaction than men. Our results can benefit interprofessional primary care teams to optimize their professional and gender mix.