病态窦房结综合征伴房室传导延迟患者心房按需起搏与房室同步起搏模式左心功能的超声评价

目的 运用多普勒超声心动图及组织多普勒(TDI)技术评价病态窦房结综合征(SSS)伴房室传导延迟患者分别在心房按需起搏(AAI)与房室同步起搏(DDD)模式下的心脏功能,并探讨其起搏模式的选择.方法 选择植入DDD起搏器的SSS伴Ⅰ度房室传导阻滞的患者24例,分别置于AAI模式和房室间期优化的DDD模式,应用多普勒超声心动图和TDI技术评价这两种起搏模式下心脏的收缩和舒张功能.结果 多普勒超声心动图评价心脏收缩功能(EF,主动脉VTI)和舒张功能(E/A)参数在AAI组和DDD组之间差异无统计学意义.TDI显示收缩峰值速度(Sm)在AAI组为(10.88±2.92)cm/s,DDD组为(9.06±2.49)cm/s;舒张早期峰值速度(Em)、舒张早期峰值速度/舒张晚期峰值速度(Em/Am)在AAI组和DDD组分别为[(9.25±2.89)cm/s 对 (8.37±2.31)cm/s、0.96±0.35 对 0.80±0.25];Tei指数在AAI组为 0.56±0.12,DDD组为 0.80±0.40.这些参数在两组间差异有统计学意义(P《0.05).结论 ①SSS伴房室传导延迟(PR》200 ms且《260 ms)患者采用AAI起搏模式心脏收缩和舒张功能的改善优于DDD起搏模式;②TDI技术较多普勒超声心动图能更敏感地反映心脏收缩和舒张功能的变化.     

应用组织多普勒显像技术评价冠状动脉支架植入术后左心室舒张功能变化

目的应用超声心动图组织多普勒显像技术(tissue Doppler imaging,TDI)监测冠心病(coronary heart disease,CAD)患者冠状动脉支架植入术前、后左心室舒张功能的变化,探讨冠状动脉支架植入术对左心室舒张功能的影响。方法冠心病患者108例,分别于术前、术后3～7天、术后6～9个月应用TDI测量左心室舒张功能各项指标,二尖瓣环舒张早期速度峰值(Em),二尖瓣环舒张晚期速度峰值(Am),两者比值(Em/Am),并分析其变化。正常对照组80例,应用TDI测量左心室舒张功能各项指标。结果冠心病组术前Em(6.81±1.19)cm/s,Em/Am 0.84±0.35,正常对照组Em(10.72±1.41)cm/s,Em/Am 1.32±0.43(P<0.05)。与冠心病组术前比较,术后3～7天各项指标无明显变化,术后6～9个月Em(9.87±1.33)cm/s,Em/Am 1.19±0.25,较术前改善明显(P<0.05)。结论冠心病患者冠状动脉直架植入术后短期内左心室舒张功能无明显改善,随着术后时间的延长,左心室舒张功能会逐步得到恢复。     

脉冲波组织多普勒超声心动图评价单次血液透析治疗对终末期肾病患者左室功能的急性影响

目的 评价单次血液透析(HD)治疗对终末期肾病(ESRD)患者左室功能的急性影响.方法 57例既往无心血管疾病病史,且正处于维持性HD治疗中的ESRD患者入选本研究.所有患者于单次HD治疗前及治疗后1 h内接受超声心动图检查.常规超声心动图测量并分析左室形态及功能指标.脉冲波组织多普勒成像(PW-TDI)测量二尖瓣环运动速度.结果 单次HD治疗后,左室内径明显减小(P<0.05);PW-TDI及常规超声心动图左室收缩功能指标,包括二尖瓣环等容收缩期峰值速度(IVS)、收缩期峰值速度(Sm)及左室射血分数(LVEF)均较治疗前显著升高(P<0.05).常规超声心动图左室舒张功能指标,包括二尖瓣血流舒张早期峰值流速(E)、舒张晚期峰值流速(A)及E/A比值,较单次HD治疗前均明显减低(P<0.05);而PW-TDI左室舒张功能指标,包括二尖瓣环舒张早期峰值速度(Em)、舒张晚期峰值速度(Am)及Em/Am比值则未见显著变化.左室充盈压相关指标E/Em比值在单次HD治疗后显著降低(P<0.05).结论 单次HD治疗可以改善ESRD患者左室收缩功能;PW-TDI技术可以在不同的前负荷状态下准确地评价左室舒张功能.     

定量组织速度成像及脑钠肽评价增龄对左心功能的影响

目的 应用定量组织速度成像(QTVI)技术及脑钠肽(BNP)的测定,评价增龄对左心室收缩及舒张功能的影响.方法 将60例年龄36～82岁的正常健康人分为<60岁组(32例)与≥60岁组(28例),对比2组传统心脏超声、QTVI、BNP指标,分析增龄与传统超声参数、QTVI参数及BNP之间的关系.结果 年龄≥60岁组与年龄<60岁组比较,二尖瓣口舒张早期与舒张晚期血流速度比(E/A)(0.92±0.18、1.28±0.18)、二尖瓣环6个位点平均收缩期峰值速度(Sm)[(6.04±0.77)、(6.89±1.03)cm/s]、平均舒张早期峰值速度(Em)[(5.67±0.99)、(7.29±1.11)cm/s]、平均舒张早期与舒张晚期峰值速度比(Em/Am)[(0.79±0.13)、(1.18±0.33)]明显减低(t值分别为5.396、2.478、4.075、3.535,P均<0.05),平均舒张晚期峰值速度(Am)[(7.67±0.80)、(6.80±1.16)cm/s]、二尖瓣口舒张早期血流速度与二尖瓣环平均舒张早期峰值速度比(E/Em)[(14.83±4.43)、(10.68±2.85)]、BNP[(51.25±12.21)、(14.15±6.68)ng/L]明显升高(t值分别为-2.268、-2.995、-3.523,P均<0.05).年龄与平均Sm、平均Em、平均Em/Am、E/A呈负相关(r值分别为-0.411、-0.631、-0.622、-0.614,P均<0.05),与平均Am、平均E/Em、BNP呈正相关(r值分别0.481、0.614、0.684,P均<0.05).结论 增龄使左心室收缩及舒张功能均受损,QTVI及BNP检查评价心室功能敏感而简便易行.

Abstract：

Objective To evaluate the influence of aging on left ventricular systolic and diastolic function by quantitative tissue velocity image(QTVI) and B-type natriuretic peptide (BNP). Methods Sixty healthy participants aged from 36 to 82 years old were divided into age <60 years group (32 cases) and age≥60 years old group (28 cases). Compared traditional echocardiography,QTVI and BNP between the two groups, and analysised the correlation between age and the abovementioned measurements. Results Compared age ≥60 years group with age <60 years group, the ratio of early to late mitral annulus flow velocity(E/A) (0. 92 ±0. 18 vs. 1. 28 ± 0. 18), mean of systolic mitral annulus velocity (Sm) ([6. 04 ± 0.77] cm/s vs.[6. 89 ± 1. 03] cm/s) ,mean of early diastolic mitral annulus velocity (Em) ([5. 67 ±0.99]cm/s vs. [7.29 ± 1. 11]cm/s),the ratio of Em to Am(Em/Am) (0. 79 ± 0. 13 vs. 1.18 ± 0. 33) were significantly decreased (t =5. 396,2.478,4.075,3. 535, respectively, Ps < 0. 05), whereas mean of late diastolic mitral annulus velocity (Am) ([7. 67 ±0. 80]cm/s vs. [6. 80 ± 1. 16] cm/s),the ratio of E to Em(E/Em) (14. 83 ±4.43 vs. 10. 68 ±2. 85), BNP ([51. 25 ± 12. 21] ng/L vs. [14. 15 ± 6. 68] ng/L) were significantly increased (t =-2. 268,-2.995 and-3. 523, Ps < 0.05) . Age was negatively correlated with Sm, Em, Em/Am, E/A (r =-0.411,-0. 631,-0.622,-0. 614,Ps<0.05),and age was positively correlated with Am,E/Em and BNP (r = 0.481,0.614 and 0. 684,Ps <0. 05). Conclusion Left ventricular systolic and diastolic function decreased with aging. QTVI and BNP could evaluate left ventricular function sensitively and easily.     

组织多普勒超声对急性心肌梗死患者急诊PCI后二尖瓣环舒张早期速度与心室重构关系的研究

目的 观察急性ST段抬高心肌梗死(STEMI)患者急诊经皮冠状动脉介入(PCI)后二尖瓣环舒张早期峰值速度(Em)与心室重构关系.方法 随机选取79例急诊PCI治疗的STEMI患者,应用超声心动图及组织多普勒超声测定患者入院第7天及发病6个月时左室舒张末期容积(LVEDV)、左室收缩末期容积(LVESV)、左室射血分数(LVEF)、左室舒张末期容积指数(LVEDVI)及二尖瓣环收缩期运动速度(Sm)、舒张期早期运动速度(Em)、舒张晚期运动速度(Am).按6个月时LVEDVI较第7天增加20%为标准分为重构组(18例)与未重构组(61例).结果 重构组患者发病第7天及6个月时Em均显著低于未重构组,P值<0.05.6个月LVEDVI与第7天Em呈负相关,r=-0.426,P<0.001.第7天Em ≤3 cm/s的患者6个月时LVEF显著减低,心室重构率显著增加(P<0.05).结论 急诊PCI治疗的STEMI患者发病第7天Em降低与半年后心室重构密切相关.     

接受和未接受高效抗逆转录病毒疗法的艾滋病患者左心功能超声心动图研究

目的利用超声心动图技术对照评价接受高效抗逆转录病毒治疗(HAART)的艾滋病(AIDS)患者和未接受HAART治疗者的左心功能,分析评价目前国内AIDS治疗所采用的HAART方案是否对AIDS患者左心功能造成影响。方法对59例未接受HAART治疗的AIDS患者及56例接受HAART治疗的AIDS患者行超声心动图检查,测量各项常规超声心动图参数,采集二尖瓣环前间隔、前壁、侧壁、后壁、下壁及后间隔六个位点组织多普勒(TDI)运动频谱,测量各位点的收缩期峰值速度(Vs)、舒张早期峰值速度(Ve)、舒张晚期峰值速度(Va),计算各位点Ve/Va值及左心平均Vs、Ve、Va和Ve/Va值,同时测量二尖瓣环瓣叶附着点处侧壁位点“a”波结束至下一心动周期“e”波开始的时间间期(a线)及“s”波开始至结束的时间间期(b线),按照公式Tei=(a-b)/b计算右室Tei指数。两组间进行对照分析。结果未治疗组和治疗组间常规超声心动图检查指标及二尖瓣环各位点TDI测值包括Vs、Ve、Va、Ve/Va、Vs[(9.06±1.69)cm/s,(8.98±1.41)cm/s]、Ve[(11.19±2.04)cm/s,(11.05±2.30)cm/s]、Va[(8.47±1.50)cm/s,(8.08±1.64)cm/s]、Ve/Va(1.37±0.38,1.30±0.37)及Tei指数(0.41±0.14,0.42±0.13)比较,差异无统计学意义(P>0.05)。结论短期看,目前国内AIDS治疗采用的HAART方案对AIDS患者左心功能暂未见明显影响。     

重度阻塞性睡眠呼吸暂停低通气综合征患者心脏结构及左心室功能变化研究

目的 探讨重度阻塞性睡眠呼吸暂停低通气综合征(OSAHS)患者心脏结构及左心室功能变化,为临床诊断及治疗提供参考依据。方法 选择2014年1月至2015年1月收治的53例重度OSAHS患者作为病例组,并选择同时期门诊健康体检者50例作为对照组,分别接受常规超声心动图、组织多普勒(TDI)检查。比较两组对象心脏结构、左心室收缩功能及左心室舒张功能。结果 病例组各心脏结构指标均显著高于对照组(P0.05);病例组E峰、E/A峰、室间隔舒张早期峰值运动速度(Em)、舒张早期峰值运动速度/室间隔舒张晚期峰值运动速度(Em/Am)、二尖瓣环Em、二尖瓣环Em/Am、左室后壁Em、左室后壁Em/Am均低于对照组,室间隔Am、左室后壁Am均高于对照组(P0.05);病例组左室射血分数(EF)、左室短轴缩短率(FS)、室间隔收缩期峰值运动速度(Sm)、左室后壁Sm、二尖瓣环Sm均低于对照组,Tei指数高于对照组(P0.05)。结论 重度OSAHS患者的心脏结构出现明显改变,且左心室收缩功能及舒张功能明显减退,值得临床重视。     

心脏再同步化治疗对慢性充血性心力衰竭患者左心室舒张功能的影响

目的应用超声心动图评价左心室舒张功能,探讨心脏再同步化治疗对左心室舒张功能的影响。方法对组织多普勒提示有左心室非同步的慢性充血性心力衰竭患者12例进行心脏再同步化治疗,起搏前和起搏后1周行超声心动图检查,测量左室射血分数、Tei指数,同时测量二尖瓣血流E、A峰,E/A,左室舒张充盈时间占心动周期的比例,E峰减速时间,肺静脉血流S波、D波,二尖瓣环Em/Am。根据以上参数将舒张功能减退分为3期,应用组织多普勒测量心室机械不同步,比较起搏前后各参数的变化。结果起搏前,11例患者E峰和A峰融合,形似单峰,无法测量E、A峰值及E峰减速时间,所有患者左室舒张充盈时间缩短。起搏后1周,所有患者E峰和A峰分离,5例患者为第2期的舒张功能降低,7例患者为第1期的舒张功能降低。左室舒张充盈时间占整个心动周期的比例由起搏前的(34.5±2.9)%提高到(46.4±5.7)%(P<0.01)。左室射血分数由起搏前的(26.8±7.6)%提高到(37.7±10.1)%。左房内径在起搏后1周明显缩小(P<0.05),左室收缩非同步指数由起搏前的179.2±48.3下降到103.4±58.2(P<0.05)。结论在充血性心力衰竭患者中,由于心脏收缩的不同步,二尖瓣血流E、A峰融合较为常见。心脏再同步化治疗后,左室舒张充盈改善,体现了左室舒张功能的改善。     

组织多普勒成像评价肥厚型心肌病患者心脏舒张功能

目的 探讨组织多普勒成像评价肥厚型心肌病舒张功能的价值.方法 回顾性对比分析肥厚型心肌病组(60例)及正常对照组(30例)超声心动图检查结果,比较组织多普勒参数与常规超声参数评估左室舒张功能的价值.结果 肥厚型心肌病组左心房前后径、面积、室间隔厚度、室间隔与左室后壁厚度比值(IVS/LVPW)、二尖瓣E峰速度与二尖瓣环舒张早期峰值速度比值(E/Em)和左心室充盈压均显著高于对照组(P<0.01),E/A在两组差异无统计学意义(P=0.67),Em显著低于对照组E(7.84±2.43)cm/s对(10.87±2.18)cm/s,P<0.01].肥厚型心肌病组E/Em与左房前后径及面积有相关关系(分别r=0.331,P=0.017;r=0.325,P=0.019),而E/A与二者无相关性.结论 组织多普勒参数(Em,E/Em)是评价肥厚型心肌病患者心脏舒张功能的敏感方法.     

脉冲多普勒组织成像及Tei指数评价急性心肌梗死患者左心室功能研究

目的:研究脉冲多普勒组织成像(pulsed-waveDoppler tissue imaging,PW-DTI)及Tei指数评价急性心肌梗死患者左心室功能的临床应用价值.方法:33例左心宣射血分数(ejection fraction,EF)正常急性心肌梗死患者(A组)、25例左心室EF减低急性心肌梗死患者(B纽),30例健康体检者(C组)均行常规超声心动图、PW-DTI和Tei指数检测,比较3组Tei指数、二尖瓣环收缩期运动峰值速度(systolic velocity,Sm)、舒张早期运动峰值速度(early diastolic velocity,Em)、Em与舒张晚期运动峰值速度(late diastolic velocity,Am)比值(Em/Am),二尖瓣口舒张早期血流峰值速度(transmitral early diastolic filling velocity,E)与Em比值(E/Em).结果:(1)A,B组Tei指教高于C组(P<0.01),B组Tei指数高于A组(P<0.01);3组E,A,E/A比较差异无统计学意义(P>0.05);Tei指数与EF呈负相关.(2)A,B组Sm、Em、Em/Am低于C组(P<0.01),E/Em高于C组(P<0.05,或P<0.01),B组Sm、Em、Em/Am低于A组(P<0.01),E/Em 高于A组(P<0.01);Sm 与EF呈正相关.结论:PW-DTI联合Tei指教评价急性心肌梗死患者左心室功能较常规超声心动图准确.     

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.     

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.     

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.