梗阻性黄疸病人手术并发症和死亡原因分析

目的:通过对梗阻性黄疸手术病例的统计,分析引起手术并发症及死亡的原因。方法:回顾性分析1995~2010年150例梗阻性黄疸手术病例,对其手术并发症发生率及术后死亡因素进行分析统计。结果:梗阻性黄疸病人手术并发症发生率为34.7%、死亡率为13.3%,死亡率与其胆红素水平关系密切,术前胆红素≥342μmol/L时,死亡率达47.4%,急性肾功能衰竭是其主要死亡原因。结论:术前纠正营养不良,保护肝、肾功能,预防和控制感染,监测尿量及肾功能,对降低梗阻性黄疸病人手术并发症和死亡率有重要意义。     

内镜逆行胰胆管造影术与经皮肝穿刺胆道引流术治疗肝外胆管梗阻性黄疸的对比研究

目的探讨内镜逆行胰胆管造影术(ERCP)与经皮肝穿刺胆道引流术(PTCD)在治疗良、恶性肝外胆管梗阻性黄疸方面各自的优劣。方法回顾性分析2013年5月至2014年7月期间兰州大学第二医院普外四科收治的肝外胆管梗阻性黄疸患者并分别采用ERCP与PTCD治疗的临床资料,比较2种方法的手术成功率、5 d血清胆红素下降水平及术后常见并发症的发生率等。结果与PTCD相比,ERCP在治疗良性肝外胆管梗阻性黄疸时,术后5 d血清总胆红素水平下降速度较快[(94.9±11.58)μmol/L vs.(84.3±15.50)μmol/L,t=2.946,P=0.005],术后并发症发生率较低(3.3%vs.21.4%,χ2=4.469,P=0.035),但手术成功率(96.7%vs.92.9%,χ2=0.429,P=0.513)二者无统计学差异。在治疗恶性肝外胆管梗阻性黄疸时,两种方法术后常见并发症的发生率(9.5%vs.18.5%,χ2=0.767,P=0.381)虽无明显差异,但相比ERCP,在手术成功率(95.2%vs.70.4%,χ2=4.795,P=0.029)和术后5 d血清总胆红素水平下降速度[(206.3±13.26)μmol/L vs.(186.8±20.59)μmol/L,t=-2.516,P=0.015]方面PTCD组效果较为显著。结论对于良性肝外胆管梗阻性黄疸患者ERCP不仅具有创伤小、并发症少、起效快、疗效好的优点,而且可以从根本上解除梗阻;而对于恶性肝外胆管梗阻性黄疸,由于PTCD手术成功率高,可以有效缓解梗阻症状,快速降低血清胆红素水平,改善肝功能,提高患者生活质量,因此成为首选方法。     

梗阻性黄疸及术前内镜下胆道引流对胰十二指肠切除术疗效的影响

目的:探讨梗阻性黄疸和术前减黄对胰十二指肠切除术(PD)疗效的影响.方法:对2000～2006年166侧PD病例资料进行回顾性分析,根据有无黄疸及是否行胆道引流(PBD)分为PBD组、非PBD组和非黄疸组,统计分析3组胆红素水平、手术时间、术中出血量、并发症发生率、围术期病死率.结果:PBD组与非PBD组术前平均胆红素水平比较差异无统计学意义(P＞0.05),3组平均手术时间、术中平均失血量、单一并发症发生率、围术期死亡率比较差异无统计学意义(P＞0.05);PBD组减黄前、后胆红素水平差异有统计学意义(P＜0.05);并发症总发生率组间比较,非PBD组明显高于非黄疸组(P＜0.05),PBD组与非PBD组、非黄疸组之间比较差异无统计学意义(P＞0.05).结论:梗阻性黄疸是进行PD的危险因素之一,术前减黄治疗虽然减黄效果确切,但是并不能明显降低术后并发症发生率和病死率,故早期手术对改善患者预后更有意义.     

新生儿病理性黄疸与TORCH感染关系的研究

目的探讨新生儿病理性黄疸与TORCH感染的关系。方法采用酶联免疫吸附试验（ELISA）法，检测TORCH—IgM抗体、血清胆红素检查。结果感染致新生儿病理性黄疸160例中，TORCH感染率高达42．5％，CMV、HSVⅡ、TOX、RV感染阳性率分别为23．75％、11．88％、8．75％、4．38％，血清胆红素在221～342μmol／L（早产儿257μmol／L）者58例，大于3421μmol／L者10例。结论新生儿病理性黄疸中，TORCH感染不应忽视，黄疸重，合并症多，治疗困难，重在预防。     

新生儿血清胆红素增高67例临床分析

目的 分析新生儿血清胆红素增高的常见病因和临床特点.方法 本文就我院2007年6月～2010年10月收治血清胆红素增高新生儿67例的临床资料进行分析.结果 本组血清胆红素增高病因母乳性黄疽28例,婴儿肝炎综合征25例,生理性黄疸5例,ABO溶血4例,头皮血肿、颅内出血各2例,新生儿窒息1例.出生<24 h内出现黄疸6例,1～5d出现53例,5～14 d出现黄疸4例,>14d出现黄疸4例.血清胆红素<205μmol/L 34例,205～342μmol/L30例,>342μmol/L 3例.本组经综合治疗66例痊愈,1例需换血治疗转上级医院.结论 新生儿血清胆红素升高以非感染性因素为主,感染因素次之;非感染性因素中母乳性黄疸最为常见.     

梗阻性黄疸病人危险因素分析及护理对策

梗阻性黄疸是肝、胆、胰外科临床常见病症。1998年1月～2004年7月，我科收治103例总胆红素在156～550μmol／L的梗阻性黄疸病人。本文回顾性分析梗阻性黄疸病人住院期间发生的危险因素，进行分析及护理，取得较好的临床效果，现报道如下。     

恶性梗阻性黄疸介入治疗172例分析

目的分析恶性梗阻性黄疸行胆管引流术或支架置人术的疗效及并发症。方法回顾性分析恶性梗阻性黄疸172例,根据胆管梗阻情况,施行胆管引流术或胆管支架置入术。观察近期疗效和生存时间,记录、分析并发症。结果全部病例均经皮肝穿刺胆管引流或胆管支架置入成功。术后血清胆红素由（392±121）μmol／L降至（122±97）μmol／L,差异有统计学意义（P〈0．01）;ALT由术前（165．2±102．3）U／L（62．5±26．1）U／L（P〈0．01）。全组中位生存时间256d,1、3、6和12个月生存率分别为95．3％,89．4％,49．7％和20．6％。并发症：腹腔出血2例,胆汁瘤1例;胆系感染42例;急性胰腺炎12例;胆道出血13例。结论介入治疗恶性梗阻性黄疸能有效改善临床症状,延长患者生存期,但要有效防治并发症。     

102例新生儿ABO血型不合溶血病临床分析

目的探讨新生儿ABO血型不合溶血病的临床表现。方法2005年1月至2007年6月对收治的102例新生儿ABO溶血病进行回顾性分析。结果102例中第1胎45例（44．1％），黄疸出现时间：24小时内59例（57．8％），36小时内81例（79．4％），48小时内98例（96．08％），72小时内102例（100％）。胆红素峰值：≤220．6μmol／L 15例（14．71％），～256．5μmol／L18例（17．65％），～342μmol／L59例（57．84％）；～427．5μmol／L10例（9．8％）。溶血三项试验：改良直接抗人球蛋白试验仅5例阳性，抗体释放试验全部阳性。结论新生儿ABO溶血病第1胎可以发病，临床以黄疸为主要表现，黄疸出现时间多数在出生36小时内，胆红素峰值多数在220．6～342μmol／L，并以间接胆红素增高为主，可以为生理性黄疸，贫血不重。溶血三项试验以抗体释放试验阳性率最高。早发现、早治疗可以降低胆红素峰值浓度，从而减轻胆红素的损害，减少胆红素脑病的发生。     

新生儿游泳对黄疸影响的研究

黄疸为新生儿早期最常见的症状，健康足月儿均可发生。一般出生后2d或3d血清胆红素〉85μmol／L时皮肤出现黄染；〉136．8μmol／L时可有轻度嗜睡或食欲不振，4d或5d为高峰，7d-10d消退，但正常足月新生儿血清胆红素不超过205．2μmol／L〉220．5μmol／L称为高胆红素血症。由于新生儿血-脑脊液屏障不成熟，通透性较大，胆红素易于透过而易发生胆红素脑病，     

母乳性黄疸患儿T细胞亚群的变化

目的探讨母乳性黄疸患儿T细胞亚群的变化特点,并分析血清胆红素水平与T细胞亚群各指标的相互关系。方法观察组选择母乳性黄疸患儿38例,按血清胆红素水平分为A组(血清胆红素<205μmol／L),B组(血清胆红素≥205μmol／ L);对照组选择健康儿40例为C组,采用流式细胞术检测T细胞亚群CD3 、CD4 、CD8 及CD40L。结果 B组CD3 、CD4 、 CD8 、CD4 ／CD8 、CD40L明显低于A组及C组,A组与C组相比无显著差异。结论母乳性黄疸患儿血清胆红素≥205μ mol／ L时可降低患儿的细胞免疫功能。     

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.