脊髓栓系综合征儿童术前肛门直肠动力学测定评估

目的：探讨脊髓栓系综合征儿童肛门直肠动力学测定的特点,其测定结果与大便失禁的严重度之间的关系,以供临床参考。方法：40例经CT及MRI证实患有脊髓栓系综合征的患儿,行肛门直肠测压,与30例正常儿童的测压结果相比较。测压内容包括直肠静止压、直肠敏感性、高压区压力大小、内括约肌松弛反射、松弛反射中压力下降程度与高压区的压力差、松弛反射恢复时间。大便失禁评分按Kelly′s评分法。结果：与正常儿童相比较,40例脊髓栓系儿童中,38例儿童存在内括约肌松弛反射,2例患儿无内括约肌松弛反射,无明显高压区,肛周呈松弛状态。38例患儿在直肠敏感性、压力下降程度、松弛反射恢复时间方面与正常儿童存在明显的差异。结论：在肛门直肠动力学测定上脊髓栓系综合征患儿与正常儿童存在差异,脊髓栓系综合征患儿,由于腰骶部神经受到牵拉,盆底肌、外括约肌、会阴部皮肤敏感性和肛直肠黏膜功能受损,反射下降程度较正常人低,由于神经传导速度延迟,以致反射恢复时间延长,故形成测压上的上述特点。对此类病人须尽早手术。[著者文摘]     

小儿直肠肛管测压的护理体会

直肠肛管测压是通过气囊法或灌注法来了解肛门直肠动态的一种新的检测方法。可以检查直肠感觉功能、直肠顺应性和肛门内外括约肌压力、直肠肛管松弛反射、肛管高压区压力及长度等 ,提供反映直肠和肛门内外括约肌功能的客观指标 ,为判定便秘程度和类型提供可靠依据。目前 ,据国内外报道对诊断先天性巨结肠症的阳性率已达到 90 %以上[1] ,已经成为先天性巨结肠症的特异性诊断方法。 2 0 0 2年我院对 2 0 0例便秘患儿进行了肛门直肠测压 ,现将具体检测方法和护理体会介绍如下。1　临床资料1 .1　一般资料　 2 0 0 2年 3月～ 2 0 0 3年 3月我院…     

便秘主导型肠易激综合征患者结、直肠肛门动力学的临床研究--附50例检测分析

目的:研究便秘主导型肠易激综合征患者的结肠、直肠动力和直肠感觉功能.方法:用不透X线法的结肠传输试验检测50例便秘主导型肠易激综合征(constipation predominant irritable bowel syndrom,C-IBS)患者及42名正常受试者(对照组)的结肠传输时间(colonic transit time,CTT)和结肠传输指数(transit index,TI),并用结肠传输指数分型;同时用肛门直肠测压方法测定C-IBS患者和对照组的肛门直肠压力、直肠感觉阈值和直肠顺应性.结果:C-IBS患者的全结肠及各节段结肠传输时间均高于对照组,C-IBS患者的肛管静息压、直肠静息压与对照组比较差异均无统计学意义(P＞0.05),肛门括约肌最大收缩压低于对照组,最大耐受容量及直肠顺应性均明显高于对照组(P＜0.01),且发现不同传输类型的C-IBS患者的肛门直肠测压的结果不尽相同.结论:C-IBS患者存在结肠、肛门直肠动力及直肠感觉功能异常,结肠传输试验与肛门直肠测压相结合,更有助于明确便秘的类型.     

应用生物反馈训练无肛术后患儿的排便功能

背景先天性无肛术后患儿大便失禁常常会引起心理、生理和社会交往能力的障碍.目的采用生物反馈训练方法对先天性无肛术后大便失禁的患儿进行排便训练,以期改善患儿术后的排便功能.设计自身对照实验.单位中国医科大学第二临床学院小儿外科.对象纳入中国医科大学第二临床学院小儿外科1998-01/2004-10收治的无肛术后有大便失禁的患儿20例,其中完全大便失禁4例,稀便失禁7例,污便9例,均为随访病例.中低位无肛畸形9例;高位无肛畸形11例.方法利用直肠肛管向量测压与肛门外括约肌肌电等客观检测手段,对无肛术后大便失禁的患儿经自行收缩肛门和排便习惯训练1个月后,再选择适宜的矫治大便失禁的方法,进行针对性的生物反馈训练.①加强肛周肌肉力量的生物反馈训练2次/d,待3周后患儿能正确进行肛周肌肉收缩训练,可使用便携式生物反馈训练仪回家继续训练.②改善直肠感觉性与肛门外括约肌协调性生物反馈训练,要反复进行扩张气囊的训练,建立一种正常的排便反射,只要直肠扩张,肛门外括约肌就会出现反射性收缩,防止大便失禁.③每日三餐后30min内进行排便习惯的训练.④电刺激结合生物反馈训练每次持续10min,2次/d,连续三四周.主要观察指标①患儿的最大肛管压、肛管的向量容积和肛门外括约肌肌电的振幅变化.②训练前后患儿直肠肛管反射的阳性率.结果按实际处理分析,20例患儿均进入结果分析.①肛管的最大压力值中低位畸形和高位畸形组训练后比训练前增加[(24.88±16.58)和(18.18±13.71)kPa,(11.87±5.61)和(5.76±3.84)kPa,P＜0.05].②肛管内的向量容积中低位畸形和高位畸形组训练后比训练前增加[(608.10±131.06)和(452.17±69.43)cm(cmHg)2,(139.17±130.02)和(117.01±74.35)cm(cmHg)2,P＜0.05].③肛门外括约肌肌电振幅中低位畸形和高位畸形组训练后比训练前增加[(324.12±67.78)和(266.18±49.38)μV,(152.20±37.42)和(114.08±51.41)μV,P＜0.05].④直肠肛管收缩反射的阳性率训练后高于训练前[90%(18/20),55%(11/20)].结论经生物反馈训练后无肛术后各组肛周肌肉力量、直肠感觉性与肛门外括约肌协调性、排便习惯、肛门外括约肌能力均有明显提高,尤以中低位畸形最明显,最大限度的改善了肛门外括约肌功能,起到了治疗大便失禁的作用.     

功能性慢通过型便秘患者直肠肛管动力研究

目的　探讨功能性慢通过型便秘患者直肠肛管动力的改变与大便结肠通过缓慢的因果关系。方法　对 32例功能性慢通过型便秘患者进行肛管直肠压力测定 ,并与对照组比较。结果　观察组肛门内、外括约肌静息压降低 (P <0 .0 5 ) ;直肠感知阈值升高 (P <0 .0 1或P <0 .0 5 ) ;直肠肛门抑制反射直肠扩张最小充气量升高 (P <0 .0 5 )。结论　肛管直肠动力的变化是长期的通过缓慢性便秘的结果。     

应用生物反馈训练无肛术后患儿的排便功能

背景：先天性无肛术后患儿大便失禁常常会引起心理、生理和社会交往能力的障碍。目的：采用生物反馈训练方法对先天性无肛术后大便失禁的患儿进行排便训练，以期改善患儿术后的排便功能。设计：自身对照实验。单位：中国医科大学第二临床学院小儿外科。对象：纳入中国医科大学第二临床学院小儿外科1998-01／2004-10收治的无肛术后有大便失禁的患儿20例，其中完全大便失禁4例，稀便失禁7例，污便9例，均为随访病例。中低位无肛畸形9例；高位无肛畸形11例。方法：利用直肠肛管向量测压与肛门外括约肌肌电等客观检测手段，对无肛术后大便失禁的患儿经自行收缩肛门和排便习惯训练1个月后，再选择适宜的矫治大便失禁的方法，进行针对性的生物反馈训练。①加强肛周肌肉力量的生物反馈训练2次／d，待3周后患儿能正确进行肛周肌肉收缩训练，可使用便携式生物反馈训练仪回家继续训练。②改善直肠感觉性与肛门外括约肌协调性生物反馈训练，要反复进行扩张气囊的训练，建立一种正常的排便反射，只要直肠扩张，肛门外括约肌就会出现反射性收缩，防止大便失禁。③每日三餐后30min内进行排便习惯的训练。④电刺激结合生物反馈训练每次持续10min，2次／d，连续三四周。主要观察指标：①患儿的最大肛管压．肛管的向量容积和肛门外括约肌肌电的振幅变化。②训练前后患儿直肠肛管反射的阳性率。结果：按实际处理分析，20例患儿均进入结果分析。①肛管的最大压力值：中低位畸形和高位畸形组训练后比训练前增加[(24．88&;#177;16．58)和(18．18&;#177;13．71)kPa，(11．87&;#177;5．61)和(5．16&;#177;3．84)kPa，P&;lt;0．05]。②肛管内的向量容积：中低位畸形和高位畸形组训练后比训练前增加[(608．10&;#177;131．06)和(452．1769．43)cm(cmHg)^2，(139．17&;#177;130．02)和(117．01&;#177;74．35)cm(cmHg)^2，P&;lt;0．05]。③肛门外括约肌肌电振幅：中低位畸形和高位畸形组训练后比训练前增加[(324．12&;#177;67．78)和(266．18&;#177;49．38)μV，(152．20&;#177;37．42)和(114．08&;#177;51．41)μV，P&;lt;0．05]。④直肠肛管收缩反射的阳性率：训练后高于训练前[90％(18／20)，55％(11／20)]。结论：经生物反馈训练后无肛术后各组肛周肌肉力量．直肠感觉性与肛门外括约肌协调性．排便习惯、肛门外括约肌能力均有明显提高，尤以中低位畸形最明显，最大限度的改善了肛门外括约肌功能，起到了治疗大便失禁的作用。     

慢性特发性便秘患者肛门直肠的感知阈值和动力学的改变

目的 探讨慢性特发性便秘(CIC)患者肛门直肠动力学特征，便秘的病因和发病机理。方法 采用PC Polygraf高分辨多道胃肠功能测定仪检测24例CIC患者的肛门直肠压力、直肠容量感知、疼痛阈值、耐受闽值及排便功能等指标，并与12例健康人进行对照。结果 CIC组直肠静息压、肛管括约肌静息压、最大缩窄压及肛管长度与对照组无显著性差异，但CIC患者的初始感觉、疼痛、排便等阈值，引起肛门直肠抑制反射的最低支气量和肛管内括约肌松弛压均高于正常对照组。模拟排便时，CIC组33．33％(8／24)的患者在直肠收缩时伴有肛管括约肌矛盾收缩。结论 CIC忠者直肠粘膜对容量刺激的反应性降低和排便时肛管括约肌的反向矛盾收缩可能是形成便秘的原因之一。     

单纯乙状结肠冗长症患儿术前及术后的肛门直肠测压分析

目的分析单纯乙状结肠冗长症患儿术前及术后的肛门直肠测压有关参数,探讨肛门直肠测压检查对小儿单纯乙状结肠冗长症诊断与预后的意义。方法对经过手术治疗的22例单纯乙状结肠冗长症患儿术前及术后进行肛门直肠测压检查,同时测15例正常儿进行对照。结果 22例单纯乙状结肠冗长症患儿术前测压显示波形呈"W"型17例,近似"W"型5例。波幅均深而宽大,时限明显延长。直肠肛门抑制反射存在,直肠静息压为(0.62±0.39)kPa,低于对照组12例;肛管静息压为(18.79±5.36)kPa,高于对照组21例;肛管高压区长度为(30.92±7.06)mm,高于对照组21例。术后半年测压结果:22例波形均恢复正常,直肠肛门抑制反射存在,直肠静息压为(0.84±0.25)kPa,低于对照组1例;肛管静息压为(13.27±3.14)kPa,高于对照组13例;肛管高压区长度为(22.18±2.66)mm,高于对照组16例。结论肛门直肠测压对小儿单纯乙状结肠冗长症的诊断和预后具有指导作用。     

扩肛在先天性巨结肠患儿术后治疗中的应用及效果

目的分析扩肛在婴幼儿先天性巨结肠术后的应用及效果。方法2011年1月-2012年6月,对100例先天性巨结肠术后患儿规范使用扩肛器进行为期6个月的扩肛。结果5例吻合口狭窄患儿,给予加大型号延长扩肛3～6个月后好转;4例腹胀患儿,采取结肠灌洗1周和延长扩肛3个月后好转;3例小肠结肠炎者,经庆大霉素和甲硝唑结肠灌洗1周后好转。100例患儿扩肌前后其肛管静息压、直肠静息压、月T管最大收缩压、收缩持续时间比较,差异有统计学意义（P〈0．001）。扩肛后肠蠕动增加,直肠肛管蠕动加强,压力增加。结论先天性臣结肠患儿术后规范使用扩肛器能减少术后腹胀、小肠结肠炎发生率,增加肠蠕动频率幅度。     

先天性直肠肛门疾病患儿术后肛门的护理干预

直肠肛门先天性疾病是小儿常见的消化道畸形之一,包括先天性巨结肠、先天性直肠肛门畸形等疾病.先天性巨结肠是指由于直肠或结肠远端的肠管持续痉挛,粪便淤滞在近端结肠,使该肠管肥厚、扩张,需要进行根治手术切除无神经节细胞肠段和部分扩张结肠.先天性直肠肛门畸形的发生是由于胚胎第7周～第8周时泄殖腔发育缺陷形成肛门闭锁、狭窄并瘘管,手术是重要的治疗手段,需通过手术建立正常的排便功能[1].而先天性直肠肛门疾病术后肛门的正确护理是减少并发症的重要环节.现采用0.2%甲硝唑棉球代替生理盐水棉球进行肛门皮肤的护理,取得了良好的效果.现将体会介绍如下.     

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.