肝硬化患者门静脉系压力与其B超下宽度对比观察及临床意义

本文对38例门脉性肝硬化患者门脉系统血管直径进行了超声探测,肝硬化手术组18例,术前门静脉直径16.11±0.96mm((?)±SD),脾静脉11.02±2.04mm,肠系膜上静脉10.30±1.47mm,行脾切除手术时测肠系膜上静脉压力均值为35.52±3.99cmH_2O,肠系膜上静脉压力与其管径宽度的关系分析,两者呈直线线形正相关(r=0.8073,P<0.01),术后测量门静脉宽度降低。本资料提示脾切除可降低门静脉压力。     

门脉流速与内径比值在门脉高压诊断中的意义

目的探讨门静脉流速与内径比值在门静脉高压诊断中的价值。方法随机选取30例肝硬化门静脉高压患者,15例门体分流术后患者,30例慢性肝炎患者;50例正常人,测量门静脉流速v(cm/s)及内径d(mm),计算比值(v/d)对比分析。结果肝硬化门静脉高压组v/d为0.91±0.18;肝硬化门体分流术后组为1.07±0.21;慢肝组为1.25±0.27;正常组为1.65±0.21。肝硬化门静脉高压组v/d比值与其它三组有显著差异(P值<0.05,P值<0.001,P值<0.01),用d及v值比较门脉静脉高压组与其它组部分差异不大。结论v/d比值可作为肝硬化尤其是早期肝硬化门静脉高压的一项诊断标准。可观察门体分流术后疗效。     

氯沙坦治疗肝硬化门脉高压的临床观察

目的　观察血管紧张素Ⅱ受体拮抗剂氯沙坦 (商品名科素亚 )降低肝硬化门脉高压的作用。方法　 2 5例肝硬化门脉高压患者每天口服氯沙坦 2 5～ 5 0mg,历时 2～ 4周 ,应用多普勒超声分别测定治疗前后门静脉、脾静脉、肠系膜上静脉内径 ,并计算门静脉、脾静脉的血流量。结果　治疗后门静脉内径明显缩小 ,从 (14 11± 2 11)mm降到 (12 11± 1 87)mm(P <0 0 1) ,血流量从 (1185 5 2± 812 6 0 )mL/min降到 (6 4 1 91± 390 30 )mL/min(P <0 0 1) ;脾静脉、肠系膜上静脉内径及其血流量也有所降低 ,无显著性意义。结论　氯沙坦具有一定程度的降门脉压力作用。     

腹壁浅静脉留置针穿刺在门静脉高压症中的可行性评价

目的 对40例门静脉高压患者行腹壁残静脉留置针穿刺从不同侧面评价留置效果。方法 以第四代“Y”型留置套管针,根据被选静脉血流方向,依靠左食、拇指的辅助作用,以10°～15°进针见血后妥然固定。结果观察组的腹壁浅静脉充盈度、可穿刺静脉数目非常明显优于对照组(P<0.01);其自然回血率、再次置管率明显高于对照组(P<0.05);以生理盐水对封管结果无明显影响(P>0.05)。结论 门静脉高压有广泛腹壁浅静脉侧支循环的建立与开放的病理基础,为浅静脉留置针穿刺提供了穿刺途径。     

VIP对肝硬化患者门脉侧枝循环血流的作用

目的:探讨肝硬化患者血浆血管活性肠肽(VIP)对门脉侧枝循环血流的影响。方法:对37例肝硬化患者,20例健康人(HS)采用多谱勒超声测定门静脉、脾静脉及肠系膜上静脉血流参数;用放免法(RIA)测定血浆VIP含量。结果:肝硬化组血浆VIP显著高于HS组(57.34±19.62pg/ml vs 15.12±7.03 pg/ml,P<0.01);肝硬化组门静脉血流量显著低于HS组(494±286ml/min vs811±186ml/min,P<0.01);肝硬化组脾静脉与肠系膜上静脉血流量之和显著高于HS组(1257±326ml/min vs 801±197ml/min,P<0.01);肝硬化组血浆VIP与脾静脉及肠系膜上静脉血流量之和呈正相关(γ=0.87,P<0.05)。结论:血浆VIP升高可能是引起肝硬化患者内脏高动力状态的因素之一。     

肝动脉搏动指数在肝硬化门静脉高压中的应用价值

目的 探讨肝动脉搏动指数(HA-PI)在肝硬化门静脉高压中的应用价值。方法 对50例肝硬化门静脉高压患者和30例健康患者作肝动脉搏动指数检测。结果 病例组HA-PI为1.47±0.19,健康组为1.08±0.13,病例组HA-PI明显高于健康组(P<0.001)。结论 HA-PI在肝硬化门静脉高压中将有重要临床应用价值。     

东芝64排螺旋CT冠状动脉血管造影检查中心率对冠脉图像质量的影响

研究背景 门静脉期在肝硬化患者是否伴发肝癌的检查中具有重要地位;同时门静脉期可以更好地显示门静脉及肝静脉的侵犯,为进一步治疗措施的选择提供必要的参考信息。因而,获取高质量的门静脉期图像并得到较高的肝实质-血管浓度差是门脉期检查的主要目标。然而,针对肝硬化患者扫描方法的探讨却鲜见报道,本研究拟通过对比剂剂量和门脉期扫描时间的对比研究探讨肝硬化患者门脉期的合适检查方法。目的 探讨对比剂剂量及扫描时间对肝硬化患者门脉期图像质量的影响。方法 60例临床确诊的肝硬化患者随机分为3组:常规剂量常规扫描组(A组)、大剂量常规扫描组(B组)和大剂量延迟扫描组(C组),每组20例;另选20名年龄相匹配的非肝硬化患者为对照组。A组、对照组对比剂剂量为1.5ml/kg体质量,B组、C组剂量为2.5ml/kg体质量,注射速度均为3.5ml/s,A、B组及对照组门脉期扫描时间为60s,C组70s。测量门静脉、肝实质及肝静脉的CT值,并对图像质量进行双盲目测评分。结果 A、B、C组及对照组门静脉CT值分别为(142.16±15.25)HU、(168.29±14.63)HU、(151.42±11.96)HU 和(187.73±9.45)HU;肝实质CT值分别为(87.91±11.16)HU、(98.75 ± 10.86)HU、(93.43 ± 11.48)HU 和(109.20 ± 5.79)HU;肝静脉CT 值分别为(121.09±16.78)HU、(130.54±15.31)HU、(136.92±17.53)HU 和(160.55±14.27)HU。肝硬化患者的门静脉、肝实质、肝静脉CT值及门静脉、肝静脉与肝实质之间的CT值差值均低于对照组(P均<0.05);B组门静脉密度高于A 组和C组(P均<0.05),B组肝实质密度高于A、C组,但与C组间差异无统计学意义(P>0.05)。C组相对于A 组肝静脉CT 值显著增加,同时肝实质密度轻度降低,差异有统计学意义(P<0.05),C组图像质量评分高于A 组及B组(P<0.05)。结论肝硬化患者多期增强扫描应增大对比剂剂量,门脉期扫描时间应适当延迟。     

二维快速平衡稳态进动序列和肝脏容积加速采集序列对门静脉系统成像技术的比较

目的:比较二维快速平衡稳态进动序列(2D-FIESTA)和肝脏容积加速采集序列(LAVA)对门静脉系统成像的临床应用价值。方法:对23例肝硬化门静脉高压患者(肝硬化组)和25例无肝疾病及相关疾病患者(正常组)行2D-FIESTA扫描及LAVA扫描,分别测量门静脉主干、肠系膜上静脉和脾静脉的直径,比较两种检查方法的符合情况。结果:2D-FIESTA和LAVA对门静脉系统各组血管直径的测量差异无统计学意义,对门静脉系统的癌栓及解剖变异都能很好地显示。肝硬化组中门静脉主干、肠系膜上静脉和脾静脉直径明显大于正常组。结论:2D-FIESTA和LAVA可以比较满意地评价门静脉系统的情况,两者各有优势。     

肝硬化伴门静脉血栓形成5例报告

门静脉血栓 (portalveinthrombosis,PVT)形成是肝硬化较少见的并发症之一 ,其发病机制尚未明确。PVT多形成于门静脉主干及其属支脾静脉 ,少数也可发生在肠系膜静脉 ,易引起肝外门静脉高压[1] ,预后较差。近年来 ,我们收治 5例 ,报告如下。1　病历摘要男 3例 ,女 2例 ;年龄分别为 19、2 1、2 5、4 3及 6 8岁。均因腹胀、少尿等肝硬化失代偿期症状而住院。查体均有腹壁静脉曲张、脾大、腹部移动性浊音阳性 ,其中 2例合并右侧胸腔积液 ;经超声、CT等影像学检查发现门静脉主干内有血栓形成 ,且除外恶性肿瘤。经对症治疗后 ,仅 2例患者病情缓…     

多层螺旋CT门静脉造影诊断肝硬化门静脉高压

目的评价门静脉CT血管造影对肝硬化门脉高压患者的诊断价值.方法对43例经临床、肝功能和影像学检查诊断的肝硬化门脉高压患者进行门静脉CT血管成像(CTPV),对门静脉主干、主要属支和侧支循环血管进行显示和测量.结果 43例患者均成功地实施了门静脉CTPV,门静脉主干显示率100%,胃左静脉97.6%,胃短静脉44.2%,食管胃底静脉曲张90.7%,脾/胃肾分流28.7%,脐静脉、腹壁静脉曲张分别为46.5%、44.4%.其中门静脉主干宽度为(13.94±2.47) mm,胃左静脉主干宽度为(5.62±2.40) mm.结论 CTPV可显示肝硬化门脉高压患者的门-体静脉之间侧支循环血管,有助于对门脉高压合并消化道出血患者选择合理治疗方案及进行疗效随访.     

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.