肝硬化腹水并发自发性细菌性腹膜炎危险因素的探讨

自发性细菌性腹膜炎（SBP）是肝硬化患者并发症中较常见的一种，也是导致病人死亡的原因之一。作者通过对93例肝硬化腹水患者分析，比较并发SBP与未并发SBP患者临床、肝功能及腹水检查特点，探讨肝硬化腹水发生SBP的危险因素，便于早期预防，及时治疗，从而降低其发生率及病死率。     

肝硬化合并自发性腹膜炎患者降钙素原和C反应蛋白检测的临床意义

目的 探讨肝硬化患者血清、腹水降钙素原(PCT)和血清C反应蛋白(CRP)水平对肝硬化合并自发性细菌性腹膜炎(SBP)诊断的临床意义.方法 选择肝硬化腹水患者73例,单纯腹水39例(无SBP组),肝硬化合并SBP 34例(SBP组),进行腹水和血清的PCT以及血清的CRP水平检测.结果 SBP组和无SBP组血清CRP水平分别为(76.00±60.75)mg/L和(16.00±43.00)mg/L(P<0.01);以PCT≥2μg/L为阳性标准,SBP组血清和腹水PCT阳性率高于无SBP组(血清79.4%VS 10.3 %,腹水29.4%vs 5.1%,P<0.01);SBP组患者治疗好转后血清和腹水的PCT阳性率较治疗前明显下降(16.7%vs 3.3%,P<0.01).血清CRP及PCT联合检查有助于提高SBP诊断的敏感度、特异度和准确度.结论 血清和腹水PCT及血清CRP检测对肝硬化合并SBP早期诊断具有一定的临床意义.     

肝硬化患者并发自发性细菌性腹膜炎的诊治进展

自发性细菌性腹膜炎(spontaneous bacterial peritonitis SBP)是指腹腔内或邻近组织没有感染灶的腹水细菌感染。肝硬化是发生SBP的最常见的基础病。1964年，Coma最先于肝硬化腹水的患者中认识了这一疾病。后来，人们逐渐发现SBP也发生于急性肝衰竭及肾病综合征的患者。     

肝硬化合并自发性细菌性腹膜炎患者腹水中TNF-α和sICAM-1表达的研究

目的探讨肝硬化患者腹水中TNF-α和sICAM-1水平与肝硬化患者并发细菌性腹膜炎（SBP）的关系及其临床意义。方法采集肝炎肝硬化腹水患者91例,经确诊结果分为两组：SBP组（45例）,无SBP组（46例）。分别用ELISA发检测各组腹水中TNF-α和sICAM-1的水平。结果SBP组患者腹水TNF-α和sICAM-1水平明显高于无SBP组,差异有显著性（P〈0.01）。诊断SBP以TNF-α的参考值96.54 ng/ml为临界值时,灵敏性88.9%,特异性82.6%,准确率为85.7%;以sICAM-1的参考值234.62ng/ml为临界点时,灵敏性91.1%,特异性78.3%,准确率为84.6%;两种指标联合检测可明显提高SBP的检出率。结论SBP腹水TNF-α和sICAM-1的水平显著增高,对肝炎肝硬化腹水患者有无合并SBP有明显的鉴别诊断意义。     

肝硬化自发性细菌性腹膜炎64例临床分析

自发性细菌性腹膜炎（spontaneous bacterial peritonitis．SBP）是指无腹腔脏器穿孔而发生的腹腔急性细菌感染，最常发生于肝硬化失代偿期患者，也可见于其他严重肝脏疾患，如重症肝炎、肝癌等。早期诊断并有效治疗是改善肝硬化患者预后的重要因素。我们对64例肝硬化合并SBP患者的临床表现、腹水细菌培养及药敏结果进行总结，现报告如下。     

肝硬化腹水并发自发性细菌性腹膜炎治疗进展

肝硬化腹水患者并发自发性细菌性腹膜炎(SBP)已成为一个严峻的临床问题。SBP是肝硬化腹水患者的严重并发症,SBP在失代偿期肝硬化腹水患者中发生率超过15％,占所有肝硬化并发感染的5％～30％,占所     

自发性细菌性腹膜炎患者腹水LPS、TNFα、PCT测定的临床意义

目的探讨肝炎肝硬化并发自发性细菌性腹膜炎（SBP）患者腹水中内毒素（LPS）、肿瘤坏死因子（TNFα）、降钙素原（PCT）水平的变化及其临床意义。方法所有肝炎肝硬化并发腹水患者作腹水LPS、TNFα和PCT水平检测,所有SBP患者腹水均作细菌培养。结果97例SBP患者腹水LPS、TNFα、PCT水平明显高于86例无SBP患者（P均〈0.01）,G-菌SBP腹水中的LPS、TNFα水平明显高于G＋菌SBP腹水（P均〈0.01）。结论腹水LPS、TNFα、PCT水平的检测有助于SBP的诊断,并且腹水LPS、TNFα水平的检测还有助于SBP病原菌的鉴别。     

肝硬化患者合并自发性细菌性腹膜炎的防治

自发性细菌性腹膜炎（spontaneous bacterial peritonitis,SBP）是指腹腔内无原发感染病灶和脏器损伤而出现的急性或亚急性细菌性腹膜炎。它是肝硬化的严重并发症之一,也是肝功能失代偿的重要标志。SBP多见于肝硬化腹水的患者,也可见于重症肝炎或其他原因致终末期肝病的患者。     

影响肝硬化腹水并发腹膜炎病人预后的因素及护理

自发性细菌性腹膜炎（SBP）是肝硬化腹水病人的严重并发症，病死率高达60％以上。本文研究肝硬化腹水并发SBP病人的临床特点与实验室指标，旨在探讨影响病人预后的危险因素，提出相应的护理措施，以提高病人的生存率及生活质量。     

肝硬化失代偿期并发自发性细菌性腹膜炎的临床分析

目的:探讨肝硬化失代偿期并发自发性细菌性腹膜炎(SBP)的危险因素及影响因素,以便及早预防,改善预后.方法:对259例肝硬化腹水患者(其中并发SBP者25例)的临床资料进行回顾性研究.包括了SBP的临床表现、实验室检查、危险因素分析、预后及影响因素分析.结果:统计显示腹水总蛋白≤10 g/L和曾发生SBP是并发SBP的独立影响因素(Logistic回归分析P＜0.05),血小板减少、凝血酶原活动度减小、Child-Pugh评分也与肝硬化腹水并发SBP相关(χ2检验P＜0.05),在众多因素中Child评分和血钠降低对预后的影响较有意义.结论:尽可能减少或控制肝硬化患者易惠SBP的危险因素,监控已发生SBP患者的预后影响因紊,易改善肝硬化腹水患者生存质量.     

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.     

Guns and Knives in New Mexico: Patterns of Penetrating Trauma, 1978–1993

Objective: To identify patterns of nonfatal and fatal penetrating trauma among children and adults in New Mexico using ED and medical examiner data.
Methods: The authors retrospectively sampled in 5-year intervals all victims of penetrating trauma who presented to either the state Level-1 trauma center or the state medical examiner from a 16-year period (1978–1993). Rates of nonfatal and fatal firearm and stabbing injury were compared for children and adults.
Results: Rates of nonfatal injury were similar (firearm, 34.3 per 100,000 person-years; stabbing, 35.1). However, rates of fatal injury were significantly different (firearm, 21.9; stabbing, 2.7; relative risk: 8.2; 95% confidence interval: 5.4, 12.5). From 1978 to 1993, nonfatal injury rates increased for children (p = 0.0043) and adults (p < 0.0001), while fatal penetrating injury remained constant. The increase in nonfatal injury in children resulted from increased firearm injury rates. In adults, both stabbing and firearm nonfatal injury rates increased.
Conclusions: Nonfatal injury data suggest that nonfatal violence has increased; fatal injury data suggest that violent death rates have remained constant. Injury patterns vary by age, mechanism of trauma, and data source. These results suggest that ED and medical examiner data differ and that both are needed to guide injury prevention programs.     

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.