急诊应用瑞替普酶尿激酶对急性心肌梗死溶栓的随机对照研究

目的 在急诊科观察瑞替普酶(r-PA)、尿激酶(UK)用于急性心肌梗死(AMI)溶栓治疗的疗效和不良反应.方法 对符合入选标准的87例AMI患者随机分为r-PA组和UK组,在急诊科分别给予r-PA和UK溶栓治疗,其中r-PA组41例,UK组46例,观察两组溶栓后相关冠状动脉再通率,急性期35 d内的死亡率、并发症和不良反应发生率.结果 2 h内溶栓再通率r-PA组36例(87.8%),UK组30例(65.2%),两组比较差异有统计学意义(P<0.05);两组在急性期35 d内死亡率、缺血再发生和并发症比较差异无统计学意义(P>0.05);r-PA组出血不良反应少于UK组,两组比较差异有统计学意义(P<0.05).结论 与UK相比,在急诊室给予AMI患者r-PA溶栓治疗,梗死相关动脉再通率更高,出血不良反应较少.     

去纤维蛋白原酶对急性心肌梗死尿激酶溶栓效增强作用的研究

目的观察联合应用去纤维蛋白原酶(DEF)和小剂量尿激酶(UK)对急性心肌梗死(AMI)溶栓治疗的临床疗效及安全性.方法对6 h内的AMI患者分为联合用药组和单独用药组.联合用药组UK剂量为单独用药组的一半,静脉滴注UK前先静脉注射DEF 5 U,之后分别加用3次DEF 5 U静脉滴注.所有患者入院后均接受阿斯匹林治疗.观察判断冠状动脉再通率;记录出血并发症.溶栓治疗前及溶栓治疗后6 h分别测定血浆纤维蛋白原(Fg)及D-二聚体含量.结果两组患者的年龄、体质量、发病时间、再通率、再梗死率、次要出血并发症发生率和病死率相似(P均>0.05),均无严重出血并发症发生.UK+DEF组和UK组再通率分别为69.56%和68.18%(P>0.05);但联合用药组再通时间比单独用药组明显缩短,分别为(62.08±32.40)min和(80.00±39.14)min.两组溶栓治疗后D-二聚体水平相似(P>0.05),且均较溶栓前明显升高(P均<0.05).UK+DEF组溶栓后Fg含量下降58.46%,其程度明显大于UK组(16.78%),P<0.01.结论联合应用DEF可以增强小剂量UK的溶栓效力,加速血栓溶解,疗效相当于单独应用全剂量UK,且不增加出血并发症.     

急性心肌梗死6 h内溶栓与延迟溶栓的疗效评价

目的　观察发病后不同时间溶栓对急性心肌梗死 (acute m yocardial infarction,AMI)的疗效。方法　 95例 AMI患者按发病时间分成 <6 h(46例 )和 6～ 12 h(延迟溶栓 4 9例 )两组 ,观察两组患者的血管再通率、病死率及不良反应发生率。结果　 <6 h溶栓组血管再通率为 76 % ,病死率为 4 % ;延迟溶栓组血管再通率为 4 9% ,病死率为 12 % ,两组比较均有统计学差异 (P均 <0 .0 1)。两组不良反应发生率 (15 %比 16 % )无统计学差异 (P>0 .0 5 )。结论　 6 h内溶栓者再通率高 ,病死率低。延迟溶栓仍有较高的血管再通率 ,对有溶栓适应证者也应积极进行溶栓治疗。     

急性心肌梗死6小时内溶栓与延迟溶栓的疗效对比--附95例报告

目的观察发病后不同时间溶栓对急性心肌梗死(acute myocardial infarction,AMI)的疗效.方法95例AMI患者按发病时间分成6小时内溶栓组(46例)、延迟溶栓组(6～12小时,49例)两组,进行溶栓治疗.结果6小时内溶栓组的血管再通率为85%,病死率为4%;延迟溶栓组则分别为57%、12%,两组比较差异有统计学意义(P＜0.01).两组不良反应发生率则无统计学差异(P＞0.05).结论AMI患者发病6小时内溶栓的血管再通率高,病死率低;延迟溶栓亦有治疗价值,也应积极予以溶栓治疗.     

瑞替普酶急诊溶栓治疗急性心肌梗死的临床研究

目的观察瑞替普酶(r-PA)急诊静脉溶栓治疗急性心肌梗死(AMI)不同时间窗溶栓治疗的血管再通率及安全性。方法符合入选标准的57例无溶栓禁忌证患者在常规治疗的基础上给予r-PA18mg+0.9%氯化钠50ml快速静脉溶栓治疗,30min后再给予r-PA18mg治疗。计算发病0.5～2h、>2～4h、>4～6h及>6～12h内溶栓再通率,并将6h内溶栓病例与将>6～12h溶栓病例进行再通率比较。结果 6h内溶栓再通率为86.67%,>6～12h溶栓再通率为41.67%,2者比较差异有统计学意义(P<0.05)。结论临床上应用r-PA急诊溶栓治疗AMI疗效好,再通率高,AMI溶栓时间越早再通率越高,且安全,副作用少。     

急性心肌梗死院前溶栓治疗临床观察

目的:探讨急性心肌梗死(AMI)院前溶栓治疗临床疗效。方法:将116例胸痛、18导联心电图显示ST段抬高的AMI且无溶栓禁忌症的患者,即时应用尿激酶(UK)150～200万u溶于生理盐水100mL中静脉滴注,30min滴完。观察用药后胸痛缓解程度、再通情况及不良反应。结果:ST段抬高的AMI患者给药越早,胸痛缓解率、再通率越高,呈线性关系,存在显著性差异,P<0.001,死亡率明显降低。结论:对ST段抬高的AMI患者,应尽早进行院前溶栓治疗以挽救生命。     

去纤维蛋白原酶对急性心肌梗死尿激酶溶栓疗效增强作用的研究

目的 :观察联合应用去纤维蛋白原酶 (DEF)和小剂量尿激酶 (UK)对急性心肌梗死 (AMI)溶栓治疗的临床疗效及安全性。方法 :对 6 h内的 AMI患者分为联合用药组和单独用药组。联合用药组 U K剂量为单独用药组的一半 ,静脉滴注 U K前先静脉注射 DEF 5 U ,之后分别加用 3次 DEF 5 U静脉滴注。所有患者入院后均接受阿斯匹林治疗。观察判断冠状动脉再通率 ;记录出血并发症。溶栓治疗前及溶栓治疗后 6 h分别测定血浆纤维蛋白原 (Fg)及 D二聚体含量。结果 :两组患者的年龄、体质量、发病时间、再通率、再梗死率、次要出血并发症发生率和病死率相似 (P均 >0 .0 5 ) ,均无严重出血并发症发生。 U K+DEF组和 U K组再通率分别为6 9.5 6 %和 6 8.18% (P>0 .0 5 ) ;但联合用药组再通时间比单独用药组明显缩短 ,分别为 (6 2 .0 8± 32 .4 0 ) m in和(80 .0 0± 39.14 ) min。两组溶栓治疗后 D 二聚体水平相似 (P>0 .0 5 ) ,且均较溶栓前明显升高 (P均 <0 .0 5 )。UK+DEF组溶栓后 Fg含量下降 5 8.4 6 % ,其程度明显大于 U K组 (16 .78% ) ,P<0 .0 1。结论 :联合应用 DEF可以增强小剂量 UK的溶栓效力 ,加速血栓溶解 ,疗效相当于单独应用全剂量 UK,且不增加出血并发症。     

院前与冠心病监护病房联合应用重组组织型纤溶酶原激活剂与尿激酶溶栓治疗急性心肌梗死的对比分析

目的 探讨院前与院内联合快速处理急性心肌梗死(AMI)的方法.方法 在院前与院内密切配合的情况下,由"120"急诊医师将AMI患者以最快捷的方式直接送入冠心病监护病房(CCU),应用重组组织型纤溶酶原激活剂(rt-PA)与尿激酶(UK)静脉溶栓治疗,对比分析rt-PA和UK治疗AMI的疗效.结果 rt-PA组冠状动脉(冠脉)总再通率明显高于UK组[80.0%(48/60)比59.0%(36/61),P<0.01];在发病＜3 h溶栓治疗中,rt-PA组冠脉再通率也明显高于UK组[88.9%(32/36)比68.4%(26/38),P＜0.05].rt-PA组4周住院病死率明显低于UK组[6.7%(4/60)比13.1%(8/61),P＜0.05].结论 rt-PA溶栓疗效优于UK,尤其是在患者发病3 h内进行溶栓治疗效果更佳,住院病死率低.     

影响老年急性心肌梗死溶栓疗效因素分析

目的:分析老年人急性心肌梗塞(AMI)溶栓疗效的影响因素.方法:106例AMI患者分为≥70岁组(31例)、＜70岁组(75例)均在发病6小时内接受尿激酶150万单位静脉溶栓治疗.结果:≥70岁组与＜70岁组血管再通率无差异(P＞0.05),血管再通与血管未通者比较病死率有差异(P＜0.05),溶栓开始越晚病死率越高.结论:AMI的溶栓疗效与年龄无关,与血管是否再通密切相关,疗效与溶栓时间呈显著依赖关系.     

重组组织型纤溶酶原激活剂与尿激酶溶栓治疗急性心肌梗死的疗效比较

目的：观察小剂量（50mg)重组织型纤维酶原激活剂（rt-PA)与尿激酶（UK）溶栓治疗急性心肌梗死（AMI）的疗效及安全性,方法：将116例AMI患随机分为rt-PA组和UK组,分别应用rt-PA和UK溶栓治疗,结果：冠状动脉（冠脉）总再通率分别rt-PA组80．65％和UK组为51．85％,患在发病后6h内治疗,冠脉再通率分别为rt-PA组91．18％和UK组67．86％,前明显高于后,两组比较均有显差异（P＜0．01）,5wk住院病死率分别为rt-PA组6．5％和UK组11．1％,结论：小剂量（50mg)rt-PA用于AMI溶栓治疗的临床疗效明显优于UK,血管再通率高,尤其在发病后6h内进行治疗效果更佳.rt-PA溶栓并发症少,可降低闰 率,是一种安全有效的溶栓剂.     

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.     

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.     

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.