胸腔镜下内脏大小神经切断术的临床应用

目的 :研究胸腔镜下内脏大小神经切断术的临床应用。材料与方法 :报告 2例胰腺癌并剧烈顽固性腹痛的患者接受胸腔镜下内脏大小神经切断术 ,并就其疗效、适应征等方面进行文献复习。结果 :2例 (1例接受左侧 ,1例接受两侧内脏大小神经切断 )患者术后即起效 ,1例随访 3个月仍有效 ,无并发症 ,顺利出院。结论 :对于顽固性上腹部剧痛患者 ,该手术不失为一安全、微创、有效的方法     

全胸腔镜下成人房间隔缺损修补手术20例临床分析

目的回顾性分析全胸腔镜下行20例成人房间隔缺损修补手术的临床效果,总结全胸腔镜下心脏手术经验。方法该院自2014年3月-2016年8月,采用右侧股动脉、股静脉插管建立周围体外循环,主动脉根部顺行灌注冷血停跳液保护心肌,在右侧胸壁打3孔完成成人房间隔缺损修补心脏手术20例,分析手术时间、主动脉阻断时间、体外循环时间、呼吸机辅助时间、胸腔引流情况、住院天数和并发症等临床资料。结果全组患者手术时间为3.5~5.0 h,平均(3.8±0.5)h;升主动脉阻断时间为28~46 min,平均(29.8±8.2)min;体外循环时间为86~108 min,平均(80.6±11.5)min;呼吸机辅助时间5~8 h,平均(6.0±0.8)h;胸腔引流量100~260 ml,平均(150.0±35.0)ml;术后住院时间6~9 d,平均(6.5±1.2)d。全组患者无手术死亡,术后无残余分流发生,有1例患者腹股沟伤口脂肪液化,予以加强伤口换药处理;1例患者胸腔积气,予以穿刺后好转;1例患者因右侧胸腔粘连改为胸腔镜辅助,患者恢复顺利,全组无严重并发症发生。术后3~5天超声心动图示手术效果满意,患者顺利出院。随访1~28个月,无残余分流,无下肢静脉血栓形成,心功能均为Ⅰ级。结论全胸腔镜下成人房间隔缺损修补心脏手术安全可行,手术创伤小,切口美观,术后引流少,患者恢复快。     

Ligasure血管闭合系统在胸腔镜肺叶切除术中的应用

目的探讨Ligasure血管闭合系统在胸腔镜肺叶切除术中的应用。方法选择周围型肺癌的患者共47例,采用胸腔镜肺叶切除术,术中选用Ligasure血管闭合系统离断小血管。结果全部纳入对象均手术顺利,平均手术时间为178±87 min,平均出血量为115±45 ml,术后平均胸腔引流时间为3.9±1.5 d,术后平均住院时间6.9±1.9 d。共采用Ligasure血管闭合系统处理肺血管分支145支,其中直径3 mm者42支(28.97%),3~5 mm者71支(48.97%),5~7 mm者32支(22.06%)。2例患者出现术中出血,另外有1例闭合后切割不完全,均紧急处理止血成功。结论 Ligasure血管闭合系统能成为胸腔镜肺叶切除中处理血管时方便、安全、可靠的技术手段,值得临床应用。     

单孔法胸腔镜下T3/T4胸交感神经链切断术治疗原发性手汗症27例的效果观察

目的探讨单孔法胸腔镜下T_3/T_4胸交感神经链切断术治疗原发性手汗症的效果。方法选取单孔法胸腔镜下行T_3或T_4胸交感神经链切断术治疗原发性手汗症27例。分别记录患者交感神经链切断术前、术后掌温变化情况及治疗情况。结果 27例患者手术均获得成功,无1例中转开胸。术后随访1～12月,平均6月,无复发病例。手术时间(50. 0±9. 1) min,术中出血量(5. 0±2. 5) m L,术后掌温升高(1. 3±0. 2)℃,住院时间(5. 7±2. 3) d。平均住院费用9 800元。1例患者术后出现气胸,3例患者术后5～6 d出现颜面部、前胸部代偿性多汗,7～14 d后均能缓解。无血胸、心脏骤停、Horner综合征等并发症发生。手术治疗有效率100. 0%,腋窝和足底多汗症状得到改善。结论单孔法胸腔镜下T_3/T_4胸交感神经链切断术治疗原发性手汗症安全、有效。     

两种不同入路单孔胸腔镜T3交感神经链切断术的应用对比研究

目的对比两种不同入路(经剑突下入路与经两侧腋下入路)单孔胸腔镜双侧T3交感神经链切断术治疗原发性手汗症的可行性及安全性。方法从2011年10月-2015年9月,该科共完成单孔胸腔镜双侧T3交感神经链切断术治疗手汗症47例,其中经剑突下单孔胸腔镜行双侧T3交感神经链切断术11例(A组),经双侧腋下单孔胸腔镜行T3交感神经链切断术36例(B组),通过观察术后疼痛、术后并发症、症状好转程度、远期有无复发及代偿性多汗等指标,对比两种不同入路单孔胸腔镜手术的疗效及安全性。结果两组患者均顺利完成手术,A组平均手术时间为(74.00±12.00)min,术后平均住院时间为(2.00±0.70)d,术后1周使用镇痛药物氨酚双氢可待因平均剂量(26.30±9.20)mg,B组平均手术时间为(56.00±16.00)min,术后平均住院时间为(2.30±1.00)d,术后1周使用镇痛药物氨酚双氢可待因平均剂量(48.30±12.00)mg。近期均无血胸、气胸、Hornor综合征等并发症,随访两组均无复发,两组患者对比围手术期数据,经剑突下入路手术平均时间较经双侧腋下入路手术长,术后各项并发症及治疗效果差异无统计学意义,但术后疼痛程度明显减轻。结论与传统的经双侧腋下切口单孔胸腔镜T3胸交感神经链切断术相比,经剑突下单孔胸腔镜治疗手汗症具有更微创的优势,减轻了术后出现的肋间神经疼痛症状,疗效及安全性确切,值得进一步推广。     

微型胸腔镜下T2交感神经电切断术治疗手汗症

目的 探讨微型胸腔镜T2交感神经电切断术治疗手汗症的效果.方法 双腔气管插管全麻,侧卧位,二孔法5mm微镜,3mm微型电钩进入胸腔手术,行T2双侧交感神经电切断术.结果 手术时间50～85min,平均(65±5)min,术后手汗消失,双手温暖,住院3～7d,平均4 d.无严重并发症.结论 微型胸腔镜T2交感神经电切断术治疗手汗症安全有效.比常规胸腔镜手术伤口更小,创伤更小,术后恢复快,值得推广.     

急诊单操作孔胸腔镜手术治疗自发性血气胸58例临床分析

目的探讨急诊单操作孔胸腔镜手术治疗自发性血气胸的可行性、优点及疗效。方法58例血气胸患者入院行胸腔闭式引流观察6-48h后即行急诊单操作孔胸腔镜手术治疗。结果所有患者术后无严重并发症,无再次手术,皆治愈出院。平均手术时间（60±5）min,术后留置胸管引流24～48h,平均胸腔液引流量（80±10）ml。术后住院日平均（4±1）d。随访时间12个月,无复发病例。结论该法具有创伤极小,手术视野好,诊治确实,疼痛小,恢复快,复发少等优点,是治疗自发性血气胸的优选术式。     

21例单操作孔电视胸腔镜肺叶切除术后护理分析

目的探讨"单操作孔"电视胸腔镜(VATS)肺叶切除患者术后的围手术期护理。方法回顾性分析我院21例"单操作孔"VATS肺叶切除患者的临床病理资料,总结其术后生命体征、疼痛、胸腔闭式引流管、并发症、住院时间,分析其术后护理特点。结果患者术后疼痛轻,术后第2~3天下床活动,胸腔引流管拔出时间(2.1±1.3)d,术后平均住院时间(5.2±3.2)d。全部患者后恢复顺利,无严重并发症,无围手术期死亡。结论"单操作孔"VATS肺叶切除患者疼痛轻、恢复快,针对性护理措施有利于防止术后并发症,加快康复、早期出院。     

胸腔镜治疗肺大泡病人的护理

我院心胸外科于2004年9月-2009年8月经电视胸腔镜治疗肺大泡病人18例,效果良好,现将老年胸腔镜治疗肺大泡的护理体会总结如下. 1 临床资料 本组病人同时进行肺大泡切除18例,其中男12例,女6例;年龄25岁～75岁,平均53岁;病人均为自发性气胸入院,入院后经CT检查均显示为双侧肺大泡,其中左侧肺大泡致气胸7例,右侧肺大泡致气胸8例,双侧气胸3例.术前双侧胸腔闭式引流8例,左侧胸腔闭式引流6例,右侧胸腔闭式引流4例.术前引流10 d～25 d,术后平均引流4.5 d,住院14 d～20 d,所有病人均治愈出院.术后随访3个月至3年,术后复发2例,经内科保守治疗痊愈.     

电视胸腔镜手术治疗肺结核合并自发性气胸

目的：探讨电视胸腔镜手术治疗肺结核合并自发性气胸的效果。方法：采用胸腔镜或配合小切13＇的手术方法对肺结核合并自发性气胸患者肺大疱或肺漏气进行修补,并与单纯行胸腔闭式引流治疗患者进行比较。结果：本组手术均一次成功,无死亡及术后1年内复发病例。术后平均闭式引流时间和住院天数分别为3．4d和10．7d。结论：胸腔镜微创手术治疗肺结核合并自发性气胸是一种安全有效地治疗方法,可降低病死率,减少复发。     

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.     

Dissociable correlates of two classes of retrieval processing in prefrontal cortex

Although substantial evidence suggests that the prefrontal cortex (PFC) implements processes that are critical for accurate episodic memory judgments, the specific roles of different PFC subregions remain unclear. Here, we used event-related functional magnetic resonance imaging to distinguish between prefrontal activity related to operations that (1) influence processing of retrieval cues based on current task demands, or (2) are involved in monitoring the outputs of retrieval. Fourteen participants studied auditory words spoken by a male or female speaker and completed memory tests in which the stimuli were unstudied foil words and studied words spoken by either the same speaker at study, or the alternate speaker. On "general" test trials, participants were to determine whether each word was studied, regardless of the voice of the speaker, whereas on "specific" test trials, participants were to additionally distinguish between studied words that were spoken in the same voice or a different voice at study. Thus, on specific test trials, participants were explicitly required to attend to voice information in order to evaluate each test item. Anterior (right BA 10), dorsolateral prefrontal (right BA 46), and inferior frontal (bilateral BA 47/12) regions were more active during specific than during general trials. Activation in anterior and dorsolateral PFC was enhanced during specific test trials even in response to unstudied items, suggesting that activation in these regions was related to the differential processing of retrieval cues in the two tasks. In contrast, differences between specific and general test trials in inferior frontal regions (bilateral BA 47/12) were seen only for studied items, suggesting a role for these regions in post-retrieval monitoring processes. Results from this study are consistent with the idea that different PFC subregions implement distinct, but complementary processes that collectively support accurate episodic memory judgments.     

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.