输尿管软镜下钬激光内切开引流术治疗肾盂旁囊肿11例报告

目的探讨经尿道输尿管软镜钬激光内切开引流术在治疗肾盂旁囊肿疾病中的适用性与可行性。方法回顾性分析2016年1月-2018年1月该院收治的11例肾盂旁囊肿患者的病史资料,男5例,女6例,年龄45～73岁,平均58.8岁,囊肿位于左侧3例,右侧5例,双侧3例,直径3.9～7.8 cm,平均5.2 cm。7例并发单侧或双侧肾结石,2例合并肾功能不全,另分别各1例合并右肾积水、左输尿管结石、膀胱结石或多囊肾。11例均在全麻下行经尿道输尿管软镜下肾盂旁囊肿钬激光内切开引流术,部分合并尿石症者均一并行钬激光碎石取石术。术中先留置斑马导丝,沿斑马导丝插入Cook输尿管软镜鞘管至肾盂管连接处,沿输尿管软镜鞘插入Olympus电子输尿管软镜,顺利通过肾盂管连接处进入肾盂,接着用200μm钬激光光纤于囊肿挤压明显且肾盂壁薄处汽化切开,保证局部引流通畅,最后经输尿管软镜置入斑马导丝至切开囊内,拔除鞘管,并留置双J管引流。结果 11例患者均顺利完成手术,术中及术后无重大并发症。术后随访3～24个月,4例有腰痛症状者症状逐渐好转,2例血尿患者最终血尿消失;影像学检查结果示8例囊肿消失,3例囊肿相比术前CT直径明显减小;2例伴肾功能不全患者血肌酐水平稳中有降,1例合并肾积水患者积水明显减少。结论经尿道输尿管软镜钬激光切开内引流术在治疗肾盂旁囊肿微创、有效和安全可靠。     

腔内输尿管口钬激光切开术并碎石术治疗输尿管壁段结石35例分析

目的：探讨腔内输尿管钬激光切开术在治疗输尿管壁段或输尿管膀胱壁段结石中的应用价值。方法：对35例输尿管壁段结石，经尿道途径行钬激光切开输尿管壁段黏膜，暴露结石，然后行输尿管镜下钬激光碎石术，术后留置双J管，4～6周拔除，0．5a后复查B超、KVP和尿常规。结果：28例成功碎石，排石；3例输尿管穿孔，留置双J管后自愈；3例结石上移到肾脏，行ESWL术，成功；1例输尿管横断，行开放手术治疗，术后4～6周拔除双J管，0．5a后复查B超，KVP和尿常规未见患侧积水或积水明显增加和尿路感染。结论：腔内输尿管口钬激光切开术是提高输尿管壁段结石治疗成功率的有效措施。     

钬激光腔内治疗输尿管肾盂连接处狭窄

目的探讨钬激光腔内治疗肾盂输尿管交界处狭窄（UPJO）的方法及疗效。方法对14例UPJO患者采用钬激光腔内治疗，于狭窄段后外侧全层切开输尿管壁直至肾周脂肪，术后留置双J管6～8周。全部患者获得随访，平均随访10．5个月（4～27个月）。结果手术时间30～60min，术后平均住院3d（2～6d）。临床症状改善明显，影像学显示内切开段造影剂通过良好12例，2例治疗失败者再次给予钬激光腔内切开．1例随访8个月显示治疗成功，1例随访4个月，目前临床症状改善。结论钬激光腔内切开治疗UPJO具有微创、住院时间短、疗效可靠、可重复进行等特点，可作为对部分UPJO病人进行微创治疗的首选。     

腹腔镜下复杂性肾盂输尿管连接部梗阻术式途径选择

目的 探讨腹腔镜下复杂性肾孟输尿管连接部梗阻(UPJO)的术式途径.方法 回顾性分析该院2000～2007年收治的48例复杂性UPJO患者腹腔镜下手术方式及途径,其中22例经腹腔途径行肾盂输尿管离断成型术,3例为输尿管镜下内切开术后的双侧UPJO患者,12例曾行开放性肾孟或输尿管切开取石术,7例为较肥胖者;26例为经后腹腔途径肾盂输尿管离断成型术中,17例曾行输尿管镜下内切开术,5例为血管压迫,4例为纤维条素压迫,均无同侧开放性手术史.术后留置单条或双条双J管,1～3个月更换,输尿管镜检观察肾盂输尿管吻合口愈合情况,必要时行镜体扩张或内切开术.结果 42例1次治愈,更换双J管1～3次,6例经输尿管镜下扩张或内切开、更换双J管共3～6次治愈.肾积水明显减轻,IVU及输尿管镜检UPI通畅.随访6个月～18个月,平均12个月,IVU及输尿管镜检无明显再狭窄.结论 对于双侧、曾行开放或腔内手术、长段狭窄、较肥胖者、外部压迫等复杂性UPJO患者,腹腔镜下选择合适的径路,术后留置合适的双J管,定时更换,是复杂性UPJO患者微创治疗的较好选择.     

超声引导下输尿管软镜钬激光肾盂旁囊肿切开内引流术的临床分析

目的探讨超声引导下经尿道输尿管软镜钬激光切开内引流术治疗肾盂旁囊肿的安全性和有效性。方法收集2014年11月-2019年3月民航总医院收治的肾盂旁囊肿患者的临床资料。该组共23例,男12例,女11例,年龄33～75岁,平均58.3岁。腰痛6例,余为体检发现。合并同侧肾结石5例,合并同侧肾盂肾盏积水16例,合并患侧肾功能受损者1例。术前超声、泌尿系CT增强提示肾盂旁囊肿,直径4.0～8.5 cm,平均5.9 cm。23例全麻下行输尿管软镜钬激光肾盂旁囊肿切开内引流术。术中电子输尿管软镜观察集合系统与囊肿的解剖关系,在超声引导下用200μm钬激光光纤向凸起的囊壁"十字"切开1.5～2.0 cm,囊腔内留置双J管内引流。记录手术成功例数以及术后症状缓解、囊肿变化和并发症情况。结果 23例手术均成功。手术时间17～50 min,平均28.0 min。腰痛者症状缓解,合并结石者术后复查无残留,肾功能减退者手术后肾小球滤过率(GFR)有所改善。1例术中出现肾被膜下积液,保留双J管引流24 h后消失。随访12～64个月,平均28.0个月。15例囊肿消失,8例直径较术前缩小 1/2。23例均未出现囊肿感染、血肿、复发和癌变等。结论超声引导下经尿道输尿管软镜钬激光切开内引流术治疗肾盂旁囊肿是安全、有效的,且微创、并发症少,值得临床推广。     

钬激光内切开术治疗输尿管狭窄的临床分析

目的探讨输尿管镜下钬激光内切开加留置7-12F外套式双J管治疗输尿管狭窄的效果。方法2001年3月-2004年10月采用经输尿管镜钬激光内切开治疗56例62次输尿管狭窄，术中留置7-12F外套式双J管，术后2、3个月拔除双J管，拔管后4周、12周、0．5a进行超声、排泄性尿路造影及肾图检查。结果术后56例共随访了50例，随访率89．2％，随访3-40个月；42例／50例治愈（治愈率84．0％），36例／50例一次内切开治愈（1次切开治愈率72．0％），6例／50例行2次以上内切开治愈（占12．0％）。IVP检查提示：输尿管狭窄段消失。B超示：肾孟集合系统分离从术前平均31mm缩小到术后平均16mm（P〈0．01）。2例因肾脏无功能伴感染行肾切除术；1例术后出现大出血；1例行输尿管膀胱移植。结论输尿管镜下钬激光内切开加留置7-12F外套式双J管治疗原发性和继发性输尿管狭窄具有创伤小，疗效较佳的优点。     

输尿管镜下钬激光治疗尿道狭窄8例

目的探讨输尿管镜联合钬激光治疗尿道狭窄的疗效。方法采用经输尿管镜钬激光内切开术治疗尿道狭窄患者8例,术后留置导尿管2～4周。结果病人术后全部随访3—15个月,1次性手术治愈2例,有效6例。结论输尿管镜钬激光内切开术是治疗尿道狭窄的有效方法,效果好,手术创伤小,并发症少。     

后腹腔镜技术治疗肾盂输尿管连接部梗阻疗效分析

目的 探讨后腹腔镜治疗肾盂输尿管连接部(UPJ)梗阻的手术方式及疗效.方法 回顾性分析应用后腹腔镜技术治疗UPJ梗阻23例患者的临床资料.术前行B型超声、静脉尿路造影(IVU)、肾盂输尿管逆行造影或MRI、多层CT泌尿系统成像(CTU)检查.20例为连接部狭窄,其中2例狭窄段<0.5 cm,做狭窄段纵形切开,横向缝合;18例做肾盂成形术;3例迷走血管致梗阻,其中2例移植输尿管后做肾盂成形,1例结扎迷走血管,肾盂造口.23例均置双J管引流.结果 23例均手术成功,平均手术时间160 min(120～210min),术中出血平均80 ml(50～120 ml).术后住院平均7.5 d(6.0～10.0 d).症状消失或明显减轻,术后随访平均13个月(6～24个月).经B型超声、IVU检查,肾积水明显减少,连接部无狭窄.结论 后腹腔镜技术治疗UPJ梗阻安全有效,较开放式手术创伤小,康复时间短.     

离断性肾盂成形术治疗肾盂输尿管连接部狭窄

目的 探讨肾盂输尿管连接部狭窄的手术治疗方法和临床疗效。方法 采用离断性肾盂成形（Anderson-Hynes术）治疗肾盂输尿管连接部狭窄46例，常规采用双J管作支架内引流或贤，输尿管造瘘，术后4-6wk拔除双J管或肾，输尿管造瘘管，3mo行静脉尿路造影复查，结果 1次手术成功45例，2次手术成功1例，经3mo-3a随访，患肾积水好转，吻合口通畅，远期疗效好。结论 肾盂输尿管连接部狭窄，手术方法以离断性肾盂成形术为首选，双J管能起到引流通畅及内支架作用；儿童患仍需采用输尿管内支架及舍肾造瘘引流。     

顺行或逆行输尿管镜下内切开处理肾盂输尿管连接部狭窄

目的 探讨顺、逆行输尿管镜下针状电极内切开方法治疗肾孟-输尿管连接部狭窄(UPJO)的疗效.方法 回顾分析18例UPJO患者,原发性7例,继发性11例,合并患侧肾盏或肾盂结石(直径大于0.8 cm)3例.在C臂X线机的辅助下,通过经皮肾造口顺行或逆行输尿管镜下,采用针状电极内切开技术切开UPJ处狭窄,合并结石患者同期行气压弹道碎石取石术,术中安放双J(5F)管,术后6～8周拔除.平均随访13个月.结果 18例患者手术成功,输尿管狭窄长度小于1.0锄(0.5～1.0 cm),无大出血、肾周感染等并发症.拔除双J管后1及3个月复查B超及静脉肾孟造影(IVP),提示肾积水消失或较术前明显减少,UPJO狭窄段消失.4例原发性LPJO拔除双J管12个月后复查UPJO复发,改行开放手术治愈.结论 选择适合UPJO患者采用针状电极行输尿管镜下顺、逆行内切开治疗有效、损伤小,适合于狭窄长度小于1.0cm的UPJO患者的治疗;当UPJO合并肾结石及其他需顺行入路情况下,首选顺行经皮肾盂内切开的方法.     

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.