颈动脉连续波多普勒超声评估颅内侧支循环

目的探讨颈动脉连续波多普勒超声评估颅内侧支循环。方法对80例无脑供血动脉狭窄性病变患者,在行颈总动脉压迫试验时采用4 MHz连续波探头检测对侧颈内动脉起始段和同侧椎动脉寰枢段血流速度变化。并对连续波多普勒超声与经颅多普勒超声检测的侧支循环方式结果进行比较。结果颈动脉连续波多普勒超声检出前交通动脉侧支开放76例(95%),经颅多普勒超声检出前交通动脉侧支开放76例(95%)。在受检的160个后交通动脉侧支中,颈动脉连续波多普勒超声检出后交通动脉侧支开放140个(88%),经颅多普勒超声检出132个(83%)。结论颅外动脉连续波多普勒超声结合颈总动脉压迫试验检测颅内侧支循环既安全又方便,其准确率与经颅多普勒超声一致。     

经颅彩色多普勒超声对颈内动脉闭塞患者颅内侧支循环及血供的研究

目的 探讨颈内动脉闭塞时颅内动脉侧支循环血流代偿的途径及血供状况。方法 选择单侧颈内动脉闭塞患者29例，应用经颅彩色多普勒超声显像（TCCD）、能量多普勒（CDE）及超声造影检测双侧眼动脉（OA）及颅内动脉；分别根据患侧OA反向血流、患侧大脑前动脉（ACA）的A1段反向血流或压迫健侧颈总动脉（CCA）患侧大脑中动脉（MCA）血流速度降低、压迫患侧CCA同侧大脑后动脉（PCA）的P1段血流速度增高，判断OA、willis环前交通动脉（ACoA）、willis环后交通动脉（PCoA）侧支循环途径代偿。结果 29例患者经TCCD和CDE检查OA均显示清楚，MCA、ACA、PCA完全显示16例（55．2％），另13例（44．8％）行超声造影后均能完全显示。经OA、ACoA、PCoA侧支循环代偿分别29例（100％）、24例（82．7％）、2例（6．8％）。患侧OA血流速度较健侧增高，搏动指数、阻力指数减小（P〈0．05）；而患侧MCA、ACA流速较健侧降低（P〈0．05），搏动指数、阻力指数无明显变化（P〉0．05）。结论 TCCD、CDE、超声造影能实时观察颅内动脉侧支循环及血供，为脑血管检查的有效方法。     

急性颈内动脉闭塞颅内循环的变化及临床意义

目的 分析急性颈内动脉闭塞后颅内血流动力学的变化及临床意义.方法 对68例经影像学检查证实急性单侧颈内动脉颅外段闭塞患者,采用经颅多普勒超声(TCD)检测颅内主要动脉的血流动力学变化.结果 患侧大脑中动脉峰值流速和搏动指数均显著低于健侧(P<0.001).在侧支循环开放中,前交通动脉开放占48.53%(33/68),后交通动脉开放为42.65%(29/68),眼动脉参与的侧支循环占32.35%(22/68),无交通支开放14.71%(10/68).患者颅内侧支循环开放,侧支途径两支以上者、患侧大脑中动脉峰值流速>60 cm/s者,临床预后相对较好.结论 TCD检测颅内主要动脉的血流状况,可以快速方便地评价颅内侧支循环状态,对急性颈内动脉闭塞患者治疗方法选择和预后判断具有重要的临床价值.     

椎动脉颅内段血流速度及频谱波形异常的分析与诊断

目的探讨椎动脉颅内段血流异常的类型、病变部位及产生原因。方法对299例经磁共振血管成像和／或数字减影血管造影证实的颅内外动脉严重狭窄或闭塞患者，采用经颅多普勒超声（11CD）和颈动脉连续波多普勒超声（CWD）评估椎动脉颅内段血流异常。结果299例患者共检测598支椎动脉颅内段，其中508支血流异常：狭窄血流（32支）、无血流（17支）、低流速低阻力（58支）、低流速高阻力（42支）、代偿血流（287支）和窃血频谱（72支）。狭窄血流或无血流均在病变部位直接检出，其他4种类型血流异常则是病变部位近端或远端动脉的间接血流改变。结论采用TCD和CWD评估椎动脉颅内段血流异常可为临床寻找后循环缺血的原因和更深入研究缺血性脑血管病的发病机制提供重要的客观依据。     

缺血性脑卒中患者颈动脉超声与颅底大动脉经颅多普勒的改变

目的：研究颈动脉及颅内血管的功能状况，为缺血性脑卒中预防及治疗提供依据。方法：110例缺血性脑卒中患者行颈动脉彩色多普勒超声、颅底大动脉经颅多普勒超声检查。结果：颈动脉超声异常率达84．5％，颅底大动脉经颅多普勒超声异常率达71．8％。结论：对颈动脉和颅内动脉的联合检查有助于评价患者侧支循环状况，是缺血性脑卒中病情轻重、预后的关键因素。     

颈动脉狭窄闭塞性病变时侧支循环的开放特征

目的：以数字减影血管造影为检测手段，观察颈动脉重度狭窄闭塞性病变时开放侧支循环的特征。 方法：选择2003-10／2004—12首都医科大学附属北京天坛医院神经内科经数字减影血管造影证实的颈动脉重度狭窄（70％）闭塞患者150例，均由放射介入科医师行主动脉弓＋双侧颈总动脉＋双侧椎动脉全脑血管造影，至少正侧位两个方向投照，全面展示颅外、颅内动脉病变及侧支代偿情况。确定颈动脉及合并其他动脉病变情况，确定前交通动脉、后交通动脉、眼动脉、前／后软脑膜吻合各侧支开通情况，分析侧支循环开放和颈动脉病变的关系。 结果：150例患者中侧支出现102例（68％），前交通动脉、后交通动脉、眼动脉、后软脑膜吻合、前软脑膜吻合出现率分别为58．8％。47.1％。45．1％，41．2％，7．8％。随单侧颈动脉病变狭窄程度的加重，侧支出现增加（r=0．673，P〈0．001）、开放侧支途径≥2条（和1条相比）增加（r=0.273，P=0．014）、前交通动脉开放增加（r=0．31l，P=0．005）、眼动脉侧支出现增加（r=0．237，P=0．033）；合并颅内动脉严重狭窄时，不利于前交通动脉的开放（χ^2=6．575，P=0．010）；双侧颈动脉病变后软脑膜吻形成增加（χ^2=7．094，P=0．008）。 结论：单侧颈动脉病变时前交通动脉是主要的代偿侧支，合并颅内动脉病变前交通动脉开放减少；血液动力学受损严重时，次级侧支出现增多。     

经颅多普勒超声评估Willis环动脉变异

目的探讨经颅多普勒超声评估Willis环动脉变异的价值。方法152例无脑血管病患者,在行颈总动脉压迫试验时采用经颅多普勒超声(TCD)检测大脑前动脉交通前段和大脑后动脉交通前段的血流速度。结果30%患者的前交通动脉和两侧后交通动脉均开放,构成一个血流动力学完整的Willis环;95%患者的Willis环前部动脉开放,另3%前交通动脉及2%大脑前动脉交通前段缺如导致Willis环前部动脉不开放;44%Willis环后部动脉发育异常,阻碍了侧支血流从基底动脉到颈内动脉.其中36%后交通动脉缺如.8%大脑后动脉起源于颈内动脉。结论经颅多普勒超声结合颈总动脉压迫试验检测Willis环动脉变异既安全又方便,其检出率与解剖学研究一致。     

颈动脉严重狭窄或闭塞对颅内循环的影响

目的分析严重的颅外段颈动脉狭窄或闭塞对颅内循环的影响.方法采用彩色多普勒超声(CDFI)筛查单侧严重颈动脉狭窄或闭塞的患者,用经颅多普勒超声(TCD)评价颅内动脉的血流动力学变化.结果①严重颈动脉狭窄或闭塞病变同侧的大脑中动脉峰值流速和搏动指数均显著低于对侧(P＜0.01).②在各侧支循环开放组中,中风和TIA发病率分别为:无交通支开放(A组)77.4%;单支开放(B组)69.6%;双支开放(C组)65.4%;三支开放(D组)46.4%.③前交通支的开放与中风发生呈负相关(P=0.009).结论严重的颅外段颈动脉狭窄或闭塞使同侧半球血流量下降,侧支循环建立.侧支循环的开放数量与中风及TIA的发生呈负相关.     

超声与磁共振血管成像在急性颈内动脉闭塞中的应用

目的：探讨超声、磁共振血管成像（MRA）对急性颈内动脉闭塞的诊断价值。方法：采用彩色多普勒（CDFI）、经颅多普勒（TCD）结合MRA筛查急性单侧颈内动脉闭塞56例患者,用TCD、MRA评价颅内动脉的脑血流动力学变化并与DSA进行比较。结果：颈内动脉闭塞发生在颅外段46例,颅内段10例。后交通动脉显示率MRA高于TCD（P＜0.05）;眼动脉参与的侧支循环显示率TCD高于MRA（P＜0.01）;TCD联合MRA显示侧支动脉与DSA之间无显著性差异。患侧大脑中动脉峰值流速和搏动指数均明显低于健侧（P＜0.001）。结论：超声与MRA能够很好显示急性ICA闭塞后颅内血流动力学变化和侧支循环状态。超声检查方便快捷,可作为首选方法。超声联合MRA可替代或减少有创的DSA。     

经颅多普勒超声评估分水岭梗死患者的Willis环侧支循环能力

目的探讨分水岭梗死患者的Willis环侧支循环能力。方法对100例一侧颈内动脉闭塞患者，采用经颅多普勒超声检测Willis环的侧支循环通路。结果48例分水岭梗死患者，27％未发现Willis环侧支循环通路，13％出现后交通动脉侧支血流。52例无分水岭梗死患者，4％未发现Willis环侧支循环通路，后交通动脉侧支开放的比率增高至52％（P〈0．01）。前交通动脉侧支开放的比率两组大致相同，分别为60％和63％。结论一侧颈内动脉闭塞患者，无Willis环侧支循环和低比率的后交通动脉侧支开放与发生分水岭梗死相关。     

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.     

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.     

Molecular characterization of virulence and antimicrobial resistance profile of Shigella species isolated from children with moderate to severe diarrhea in northeastern Brazil

Molecular characterization of virulence and antimicrobial resistance profiles were determined for Shigella species isolated from children with diarrhea in Fortaleza, Brazil. Fecal specimens were collected along with socioeconomic and clinical data from children with moderate to severe diarrhea requiring emergency care. Shigella spp. were isolated by standard microbiological techniques, and we developed 4 multiplex polymerase chain reaction assays to detect 16 virulence-related genes (VRGs). Antimicrobial susceptibility tests were performed using disk diffusion assays. S. flexneri and S. sonnei were the predominant serogroups. S. flexneri was associated with low monthly incomes; more severe disease; higher number of VRGs; and presence of pic, set, and sepA genes. The SepA gene was associated with more intense abdominal pain. S. flexneri was correlated with resistance to ampicillin and chloramphenicol, whereas S. sonnei was associated with resistance to azithromycin. Strains harboring higher numbers of VRGs were associated with resistance to more antimicrobials. We highlight the correlation between presence of S. flexneri and sepA, and increased virulence and suggest a link to socioeconomic change in northeastern Brazil. Additionally, antimicrobial resistance was associated with serogroup specificity in Shigella spp. and increased bacterial VRGs.     

护理干预对面部中重度寻常型痤疮的临床疗效影响分析

目的研究护理干预对面部中重度寻常型痤疮的临床疗效影响。方法选取本院在2014年4月~2016年7月诊治的136例面部中重度寻常型痤疮患者,随机分为研究组与对照组,每组68例;所有患者均依据其情况给予对应的治疗,其中对照组在治疗期间给予常规护理,研究组在对照组的基础上再给予综合性护理干预,比较两组的治疗效果及护理满意度情况等。结果患者在接受治疗和护理后,研究组中度与重度患者的治疗效果较对照组均明显提高(P0.05),研究组护理满意度较对照组明显增高(P0.05)。结论对面部中重度寻常型痤疮患者在其治疗期间给予综合性护理干预,具有良好的效果。