高龄支气管内膜结核患者临床特点分析

目的 探讨高龄支气管内膜结核患者的临床特点、确诊手段及治疗.方法 回顾性分析112例年龄70岁以上,经纤维支气管镜检查确诊为支气管内膜结核患者的临床表现、胸部X线、胸部CT、纤维支气管镜镜下表现及治疗、预后情况.结果 高龄患者临床表现主要为咳嗽、咳痰、咯血、发热等症状,平均确诊时间9.2个月;痰集抗酸杆菌阳性仅14例(12.5％),纤维支气管镜刷检抗酸杆菌阳性51例(45.5％),内膜活检组织病理学检查为结核表现61例(54.5％),其中在组织中找到抗酸杆菌21例(34.4％);误诊为呼吸道感染27例(24.2％),误诊为肺癌19例(16.9％);绝大多数患者能够耐受规律的抗结核治疗,有32例还进行了经纤支镜局部注药治疗,预后较好.结论 高龄支气管内膜结核患者缺乏特异性临床表现,误诊率较高;纤维支气管镜下行常规刷检找抗酸杆菌及组织学活检阳性率高;绝大部分患者还应进行规律治疗.     

经纤维支气管镜诊断老年慢性阻塞性肺疾病合并单纯性支气管结核的临床分析

目的探讨纤维支气管镜对老年慢性阻塞性肺疾病(COPD)合并单纯性支气管结核的诊断价值。方法回顾性分析11例经纤维支气管镜确诊的老年COPD合并单纯支气管结核患者的临床资料、镜下表现及病理类型。结果11例老年患者男女比例1:0.375,临床症状及体征无特异性。镜下检查均有异常改变,其中浸润型3例,溃疡型2例,增殖型1例,淋巴支气管瘘(穿孔后期)2例,非特异性支气管炎型4例。镜下活检6例,阳性4例;刷检11例,阳性6例,支气管灌洗9例,阳性5例。结论老年COPD合并支气管结核患者临床无特异性,仅靠痰细胞学及胸部X线检查难免造成误诊。纤维支气管检查对老年COPD合并支气管结核诊断有重要作用,活检联合刷检、灌洗液找抗酸杆菌,可以相互补充,提高阳性率。     

纤维支气管镜诊断支气管内膜结核的临床分析

目的 探讨纤维支气管镜(简称纤支镜)对支气管内膜结核的诊断价值.方法 回顾性分析该院2006-2007年经纤支镜等检查确诊为支气管内膜结核的118例患者的临床资料.结果 支气管内膜结核男女比例为1.0:1.6.发病年龄为16-78岁,60岁以上者占11%.临床症状无特异性.胸部CT显示支气管异常仅36%.细菌学检查阳性率为54%.100%病例纤支镜下均可见不同程度的异常表现,部分病例同时合并两种以上的病理改变.结论 支气管内膜结核女性发病近年仍在继续升高,发病年龄趋向老年化.临床仅靠细茼学和胸部CT检查难免造成漏诊.纤支镜检查对该病是一个极重要的诊断手段,一方面能留取标本行细菌学检查;另一方面能对支气管黏膜有一个直观的了解.主张对已确诊的肺结棱患者常规行纤支镜检查.     

比较纤维支气管镜与螺旋CT诊断支气管内膜结核的价值

目的 比较螺旋CT和纤维支气管镜对支气管内膜结核(EBTB)的诊断价值.方法 采用美国通用公司GE HiSpeed CT/e扫描机对38例拟诊为EBTB的患者行胸部CT扫描,所有患者均经纤维支气管镜活检或手术病理证实.结果 38例患者中,螺旋CT表现:8例管腔向心性狭窄,22例管腔不规则狭窄,2例管腔内结节,6例支气管完全堵塞;纤维支气管镜检查示:浸润型2例,溃疡型8例,增生型12例,瘢痕狭窄型22例;螺旋CT和纤维支气管镜诊断EBTB的准确率分别为94.7%、97.4%,两者比较差异无统计学意义(P>0.05).结论 螺旋CT作为无创性检查是纤维支气管镜的有益补充,可为纤维支气管镜检查提供准确的导航,已经成为临床随访EBTB的重要检查方法之一.     

纤支镜对41例支气管结核的诊断意义

目的：探索气管-支气管结核的临床特征，分析纤维支气管镜（FB）对支气管结核的检出率及镜下特征，探讨其诊断价值。方法：分析41例经纤维支气管镜确诊的气管-支气管结核的纤维支气管镜下表现、临床症状、胸部X线及实验室检查情况。结果：纤支镜检查显示：Ⅰ型11例，占26．83％；Ⅱ型8例，占19．51％；Ⅲ型17例，占41．46％；Ⅳ型5例，占12．20％。镜下所见管腔内各种类型病变互有重迭，其病变表现具有一定特征。31例镜检前后进行痰菌涂片检查2～6次／例，仅6例阳性。41例经FB刷片行抗酸杆菌检查，有12例阳性（阳性率29．3％）。41例行活组织检查证实为结核36例（87．80％）。结论：气管-支气管结核缺乏特异性临床表现，胸部X线表现正常并不能排除支气管结核，确诊主要依靠纤支镜下活检病理、刷检涂片及痰结核菌检查。对不明原因低热和呼吸道症状经积极抗炎治疗无效者，应怀疑支气管结核及早行纤支镜检查。     

纤维支气管镜对气管、支气管内膜结核诊断与治疗的再评价

目的探讨纤维支气管镜在气管、支气管内膜结核诊断、治疗中的价值。方法回顾性分析 83例气管、支气管内膜结核患者的纤维支气管镜的诊断与治疗。结果发现新生物样或肉芽样改变 38例 ( 4 5 .8% ) ,管腔狭窄或闭塞 30例 ( 36 .1% ) ,局部充血、水肿 15例( 18.1% )。经粘膜活检病理确诊 74例 ( 89.2 % ) ,刷检细菌学证实 9例 ( 10 .8% )。 6例予病变支气管内滴注或 (及 )支气管粘膜下注射抗结核药治疗。结论纤维支气管镜在气管、支气管内膜结核的诊断治疗中具有重要地位 ;要建立支气管内“正常区”与“病变区”的相对概念及遵循“先正常后病变”的检查顺序     

纤维支气管镜下支气管内膜结核形态改变的临床研究

目的回顾性地总结了支气管内膜结核病人纤维支气管镜(以下简称纤支镜)下形态学表现。方法选择近5年来临床确诊的支气管内膜结核(EBTB)患者42例。其中男16例,女26例,对其纤支镜下形态改变进行归纳、分类。结果对所有研究对象纤支镜下形态学改变进行综合分析后归纳为以下7种类型:即干酪样坏死型6例、充血水肿型10例、疤痕狭窄型4例、肿瘤型4例、粟粒型8例、溃疡型4例和非特异性支气管炎型6例。结论纤支镜下支气管内膜结核7种类型的表现反映了该病自然病程中不同发展阶段的形态学改变,纤支镜检查对支气管内膜结核具有较大诊断价值。临床上出现反复咳嗽、咯血或痰中带血、胸痛等症状2周以上,而痰菌检查阴性,怀疑支气管内膜结核时应及时行纤支镜检查。     

胸片正常的支气管内膜结核12例临床分析

目的 探讨胸片正常支气管内膜结核(EBTB)的临床特点及确诊手段.方法 分析12例经纤支镜(FB)确诊的胸片正常的支气管内膜结核患者的临床表现、胸部CT、纤支镜检查结果.结果 全部病例均有咳嗽,发热4例,咯血或血丝痰3例.胸闷2例,消瘦2例.喘鸣l例,伴乏力、午后潮热、盗汗6例.血沉正常5例.结核菌素纯蛋白衍化物(PPD)试验仅1例呈阳性.CT检查:3例未见明显异常,肺内结节2例,支气管不同程度受累6例.FB镜下异常者11例,均经活检或刷检涂片抗酸染色细菌学确诊.结论 EBTB缺乏特异性临床表现,痰检、CT、血沉、PPD试验已不能作为主要诊断手段,胸片正常的不明原因长期呼吸道症状存在者应及时行FB检查,以早期确诊.     

支气管结核48例临床诊断分析

目的探讨提高支气管结核患者临床诊断水平的方法。方法回顾性分析我院2004年至2009年收治的48例支气管结核患者的临床资料。结果所有患者均有咳嗽、咳痰病史;X线检查有2例考虑为结核病,确诊率为4.17%(2/48);有30例患者行CT检查,12例确诊,确诊率为40%(12/30);48例行纤维支气管镜检,32例确诊,确诊率为66.67%(32/48);常规痰抗酸染色涂片有12例发现结核杆菌,阳性率为25%(12/48),结合支气管镜取材39例抗酸染色涂片阳性,阳性率为81.25%(39/48);确诊率为81.25%(39/48);病理检查38例确诊,确诊率为79.17%(38/48)。结论 X线、胸部CT、PPD检查、常规痰涂片检查及纤维支气管镜检查对支气管结核的诊断都存在盲区,但纤维支气管镜镜检联合镜下取材行痰抗酸杆菌培养及涂片检查或者联合病理学检查能大大提高诊断水平。     

支气管内膜结核的纤维支气管镜下微波治疗

目的：探讨应用纤维支气管镜(纤支镜)引手段波治疗气管—支气管内膜结核的疗效。方法：52例支气管内膜结核患者，Ⅱ型支气管内膜结核(溃疡、干酪坏死型)8例，Ⅲ型支气管内膜结核(肉芽增殖型)27例，Ⅱ型、Ⅲ型支气管内膜结核(混合存在)17例，按纤维支气管镜介入治疗常规准备井插镜，将微波导线探出镜端2-30n，接触欲行微波治疗的病灶表面，调节微波功率为45—60w，时间为每次3—6S，共计25—30min结果：52例急者治疗均取得成功，40例经3—4次镜下微波治疗和镜下给药，病变得到治愈。8例病变经6—8次微波治疗和镜下给药，其中4例病情较重治疗后仍狭窄，建议球食扩张和支架置入。结论：内镜下微波治疗支气管内膜结核，能使病灶迅速缩小、治愈；咳漱、呼吸困难、肺不张明显改善，避免部分患者最终手术治疗。     

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.