口服多潘立酮片提高术前超声检查对腹腔胆囊切除术第一戳孔部位选择的探讨

目的探讨口服多潘立酮片提高术前超声检查对腹腔胆囊切除术第一戳孔部位选择的临床应用价值。 方法患者晨空腹，在实施超声检查前30min，口服多潘立酮片10mg，于30min后饮水300～400ml，待15min，患者取平卧位，嗣后实施超声检查，探头置于脐孔周围边缘，嘱患者深呼运动，观察肠管与腹壁层、腹膜间有无滑动征，确定有无粘连。 结果310例腹腔镜胆囊切除术（laparoscopic cholecystectomy，LC），术前经超声检查与LC进镜手术对照，腹腔粘连第一戳孔位置，超声检出率98．7％（306／310）。310例中轻度粘连169例（54．5％），中度粘连129例（41．6％），重度粘连12例（3．9％）。 结论术前超声检查腹腔粘连，可为正确选择第一戳孔位置提供粘连部位、大小、形态、范围及程度等信息，图像清晰，具有推广应用价值。     

超声检查在急性胆囊炎腹腔镜胆囊切除术前的应用价值

目的 评价术前超声检查对预测腹腔镜胆囊切除术(LC)治疗急性胆囊炎难度的价值。方法 对180例因急性胆囊炎接受LC的患者,术前超声检查综合分析胆囊轮廓、胆囊颈部、囊壁厚度、囊壁回声、囊内回声情况,评估胆囊周围、Calot三角区的粘连程度,并与手术病理进行对照。结果 超声检查综合性评估胆囊与周围组织粘连程度的敏感度为92.78%(90/97),特异度为93.98%(78/83),准确率为93.33%(168/180)。结论 术前超声检查对预测LC治疗急性胆囊炎的难度有重要价值。     

超声在肝外胆管结石定位诊断中的临床应用

目的探讨超声在肝外胆管结石定位诊断中的临床应用价值。 方法以胰头上下为界，应用超声对132例肝外胆管结石进行分段定位诊断，并与手术结果对照分析。 结果132例肝外胆管结石全部经手术证实。梗阻型112例，占84．85％（112／132），非梗阻型20例，占15．15％（20／132）。术前超声检出127例，检出率96．21％（127／132），未检出5例，占3．79％（5／132）。术前超声定位127例，术后符合119例，符合率93．70％（119／127）；其中术前超声检出肝外胆管上段结石88例，术后诊断79例；胰腺段26例，术后诊断29例；壶腹部13例，术后诊断19例。 结论超声对肝外胆管结石定位诊断准确率较高，具有重要的临床应用价值。     

十二指肠乳头区肿瘤71例超声诊断价值

目的 总结十二指肠乳头区肿瘤的超声特点,探讨超声对十二指肠乳头区肿瘤的诊断价值。方法 回顾性分析了1991－2001年经手术和病理证实的71例十二指肠乳头区肿瘤。结果 术前超声诊断为十二指肠乳头肿瘤51例（71．8％）,误诊胰头癌4例,误诊胆管末端癌5例,误诊为胆总管结石2例,误诊为壶腹部结石1例,诊断胃扩张2例,提示胰胆管扩张,胆囊增大6例。超声在十二指肠乳头区肿瘤定位诊断中的准确性与检查的手法及经验密切相关,本组超声定位准确率88．7％,高于CT（84％）,低于ERCP（96％）。超声为目前诊断十二指肠乳头区肿瘤首选的最佳方法。结论 超声和ERCP联合检查可提高十二指肠乳头区肿瘤检出率。     

CDFI超声对肾细胞癌的诊断价值

目的探讨CDFI超声在肾细胞癌诊断中的价值。方法采用二维及CDFI超声检查并与手术病理对照回顾性分析、比较。结果38例肾肿瘤，超声确诊肾细胞癌34例，超声符合率89．5（34／38），其中Ⅰ期3例，占8．8％（3／34）；Ⅱ期5例，占14．7％（5／34）；Ⅲ期11例，占32．4％（11／34）；Ⅳ期15例，占44．1％（15／34），全部病例经手术、病理证实。结论超声检查肾细胞癌，可为临床提供重要依据，具有重要诊断价值。     

经阴道超声与宫腔镜评价不孕者宫腔因素的比较

目的 以宫腔镜为金标准，评估经阴道超声在诊断不孕患者宫腔异常中的意义。 方法 对在我院不孕门诊进行阴道超声、宫腔镜检查的171例患者资料进行回顾性分析。 结果 经宫腔镜检查发现异常宫腔99例（99／171，57．9％），包括：子宫内膜息肉42例（42．4％），宫腔粘连18例（18．2％），子宫内膜薄13例（13．1％），子宫内膜增生12例（12．1％），子宫内膜炎症8例（8．1％），子宫内膜息肉样增生6例（6．1％）。以宫腔镜为金标准，经阴道超声检查的敏感度及特异度分别为81．8％（81／99）、88．9oA（64／72）。其中超声诊断子宫内膜息肉的敏感度及特异度为83．3％（35／42）、98．4％（127／129）；诊断宫腔粘连的敏感度及特异度为66．7％（12／18）、100％；诊断子宫内膜增生、子宫内膜炎症敏感度及特异度分别为75％（8／12）、100％；87．5％（7／8）、100％。 结论 经阴道超声可作为是否行官腔镜检查的初筛方法，对有特殊病史如自然流产史、体外受精胚胎移植（in vitro fertilization，IVF-ET）失败的患者提倡常规官腔镜检查，二者的有机结合有益于发现潜在的不孕病因。     

彩色多普勒血流成像在恶性肾实质上皮性肿瘤诊断中的价值

目的探讨彩色多普勒血流成像（CDFI）在恶性肾实质上皮性肿瘤（MRPET）诊断中的应用价值。方法将手术病理证实为MRPET的116例患者分为≤4cm（39例）组和〉4cm组（77例），对比两组患者术前彩色多普勒超声检查结果（患侧肾轮廓有无改变、病变边界、内部回声类型、病变边缘、内部血流分布及其血流强度分级情况），并与手术病理结果对照。结果116例MRPET超声图像特征：（1）二维超声：≤4cm组肿瘤内部偏高回声检出率66．7％（26／39）高于〉4cm组5．2％（4／77），而肿瘤内部混合性回声检出率5．1％（2／39）明显低于〉4cm组79．2％（61／77），两组肿瘤内高回声及混合回声检出率比较差异有非常显著性（P均〈0．01）。两组肿瘤病变均显示肾轮廓改变；（2）彩色多普勒超声：116例肿瘤内探及彩色血流信号105例（90．5％，105／116），其中69例（59．5％）肿瘤内部及周边见丰富的Ⅲ级彩色血流信号；≤4cm组肿瘤内部Ⅲ级血流检出率为35．9％（14／39），〉4cm组肿瘤内部Ⅲ级血流检出率为71．4％（55／77），两组比较差异有非常显著性（P〈0．01）。术前超声诊断MRPET与病理诊断符合率93．1％（108／116）。结论CDFI在MRPET术前诊断、分期及临床治疗中有重要的作用。     

CDFI对转移性肝癌的诊断价值

目的 探讨彩色多普勒血流成像（CDFI）对转移性肝癌的诊断价值。方法 采用回顾性分析方法。对86例临床诊断肝肿瘤患者，实施CDFI检查，并与手术病理结果对照。结果 86例肝肿瘤患者，超声诊断转移性肝癌并与手术病理对照，超声诊断符合率98．8％（85／86），其中结节型42例，占48．8％（42／86）；巨块型28例，占32．6％（28／86）；浸润型15例，占17．4％（15／86）；误诊1例，占1．2％（1／86），为肝内血管瘤。结论 CDFI对转移性肝癌能够准确地进行定性、定位诊断，为临床提供一种无创、无痛苦、无放射的有效检查方法，具有重要的临床应用价值。     

腹腔镜胆囊切除即刻中转开腹手术临床分析(附236例报告)

目的：总结腹腔镜胆囊切除术（LC）即刻中转开腹手术的临床经验。方法：回顾分析11436例LC即刻中转开腹的临床资料。结果：LC即刻中转开腹手术的发生率为2.06%，主要原因是急性胆囊炎，近期有急性胆囊炎发作史，胆囊周围粘连，胆囊颈部结石嵌顿，Calot三角解剖不清，难以辨认胆囊管，胆总管损伤。结论：正确掌握中转开腹的时机是降低LC手术并发症的有效措施。提高腹腔镜基本技术，控制手术适应症和必要的辅助检查有利于降低LC中转手术率。     

经阴道超声诊断宫腔粘连的临床应用价值

目的探讨经阴道超声诊断宫腔粘连的临床应用价值。方法对临床疑诊为宫腔粘连的136例患者行经阴道超声检查并与宫腔镜检查结果进行比较,总结宫腔粘连经阴道超声声像图特征。结果136例患者宫腔镜手术后病理检查证实宫腔粘连121例（89．0％,121/136）,宫腔镜下显示：（1）宫腔粘连程度：轻度粘连47例（38．9％,47/121）、中度粘连46例（38．0％,46/121）、重度粘连28例（23．1％,28/121）;（2）宫腔粘连范围：中央型粘连61例（50．4％,61/121）、周围型粘连24例（19．8％,24/121）、混合型粘连36例（29．8％,36/121）。经阴道超声示：（1）宫腔粘连程度：轻度粘连19例（40．4％,19/47）、中度粘连33例（71．7％,33/46）、重度粘连23例（82．1％,23/28）;（2）宫腔粘连范围：中央型粘连39例（63．9％,39/61）、周围型粘连9例（37．5％,9/24）、混合型粘连27例（75．0％,27/36）。宫腔镜检查证实术前经阴道超声正确诊断宫腔粘连75例（62．0％,75/121）,漏诊46例（38．0％,46/121）,误诊3例（3．8％,3/78,将子宫内膜息肉1例、子宫内膜菲薄1例、不全子宫纵隔1例误诊为宫腔粘连）。经阴道超声诊断宫腔粘连的敏感度为62．0％（75/121）、特异度为80．0％（12/15）、准确性为64．0％（87/136）。经阴道超声对不同程度宫腔粘连的检出率间差异有统计学意义（χ2＝15．956,P＝0．000）;对不同类型宫腔粘连的检出率间差异亦有统计学意义（χ2＝8．792,P＝0．012）。结论经阴道超声是诊断宫腔粘连的有效方法,较宫腔镜检查简便且无创。经阴道超声可作为宫腔粘连病变的常规筛查方法,具有较高的临床应用价值。     

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.     

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.