贲门失弛缓症内镜下扩张治疗的临床研究

目的探讨内镜直视下气囊扩张术治疗贲门失弛缓症的临床价值。方法1997年1月～2005年3月,对56例贲门失弛缓症患者采用内镜直视下气囊扩张术治疗,观察扩张前和扩张后4周患者的症状评分、钡餐造影显示的食管最大宽度(MWE)、下食管括约肌静息压(LESP)、下食管括约肌松弛率(LESRR)及食管体部蠕动情况,并对部分病人进行随访。结果①56例患者中,扩张后4周症状缓解率为89.3%,扩张后4周症状评分明显低于扩张前(P<0.01);②52例患者扩张前钡餐食管的最大宽度为(3.77±0.29)cm,扩张后4周为(2.84±0.33)cm,P<0.05;③49例患者扩张前LESP为(43.08±11.41)mmHg,扩张后4周LESP为(15.20±5.39)mmHg,P<0.01;扩张前LESRR为(14.19±7.47)%,扩张后4周LESRR为(88.45±11.46)%,P<0.001;食管体部均未恢复推进性蠕动波;④所有患者均有贲门黏膜撕裂等,未见出血等并发症;⑤随访6、12、24个月及以上分别有86.3%(44/51)、84.4%(38/45)和82.1%(23/28)的病人无症状复发。结论内镜直视下气囊扩张术治疗贲门失弛缓症近期及远期疗效满意;临床疗效可能与治疗后食管动力学变化有关。     

肉毒素注射与气囊扩张治疗贲门失弛缓症的对照研究

目的比较肉毒素注射及气囊扩张治疗贲门失弛缓症的近期、远期疗效。方法56例贲门失弛缓症患者随机分为2组。气囊扩张组30例，肉毒素注射组26例；随访9—14个月，对2组患者治疗前后的症状、X线钡餐检查、食管下端括约肌静息压（LESP）和食管下端括约肌松弛率（LESRR）进行比较分析。结果治疗前肉毒素注射组食管压力测定结果[LESP（45．2±11．7）mmHg，LESRR（53±7．3）％]与气囊扩张组[LESP（46．3±8．9）mmHg，LESRR（83．6±7．7）％]比较差异无统计学意义（P〉0．05），治疗后1个月2组指标与治疗前比较明显好转（P〈0．05），但2组间比较差异无统计学意义。治疗后12个月肉毒素注射组LESP高于气囊扩张组、LESRR低于扩张组，2组比较差异有统计学意义（P〈0．05）。结论肉毒素注射和气囊扩张为治疗贲门失弛缓症有效方法，肉毒素注射法并发症少，但远期缓解率低于气囊扩张组。     

肉毒杆菌毒素局部注射联合小气囊扩张治疗贲门失弛缓症

目的：探讨肉毒杆菌毒素（BT）联合小气囊扩张治疗贲门失弛缓症的疗效及食管动力学变化.方法：29例贲门失弛缓症患者, 在内镜直视下行食管下部括约肌（LES）内注射 BT联合小气囊扩张治疗,进行症状评分及食管测压检查.结果：29例患者临床症状较治疗前明显改善（P＜0.05）;食管下部括约肌压力（LESP）,松弛率（LESRR）明显降低（P＜0.01）;治疗前后食管体部均为非推进性蠕动波.结论：经内镜注射BT联合小气囊扩张治疗贲门失弛缓症可明显缓解患者的临床症状,改善食管动力,是一种简单、安全、有效的治疗方法.     

贲门失弛缓症的动力研究和胃镜直视下气囊扩张治疗

目的 :研究贲门失弛缓症患者扩张治疗前后食管动力学特征及气囊扩张治疗贲门失弛缓症的可行性。方法 :35例患者 ,均在非透视胃镜直视引导下行扩张治疗。其中 17例扩张治疗前、治疗后 3d以内、治疗后 3月、10例治疗后 1年行食管测压 ,观察下食管括约肌压力 (LESP)、松弛率 (LESR)及食管体部蠕动收缩的压力波幅和时限。结果 :35例患者扩张治疗全部有效。扩张后从症状积分看出 ,扩张后患者的临床症状明显改善 ,且持续一年 (P <0 .0 0 1)。扩张治疗后LESP ,LESR明显改善 ,以LESP下降尤为明显。结论 :气囊扩张法治疗贲门失弛缓症的近远期疗效均好 ,气囊扩张治疗疗效肯定 ,应予推荐。     

贲门失弛缓症两种治疗方式的临床疗效观察

目的　寻找贲门失弛缓症的最佳治疗方式.方法　对比分析行球囊扩张和手术治疗的39例贲门失弛缓症患者的临床疗效.16例患者应用Rigiflex扩张器行球囊扩张治疗,23例患者行Heller手术治疗.结果　16例扩张术患者1例发生扩张性穿孔,其余15例食管体横径平均降低(20±6.7)mm;贲门入口直径增宽(2.4±0.7)mm;下食管括约肌压力(LESP)降低(1.9±0.6)kPa;治疗后Eckardt症状分的优良率为93.3%.23例手术患者食管体横径降低(26±0.8)mm;贲门口直径增宽(2.9±1.0)mm;LESP降低(2.5±0.5)kPa;术后Eckardt症状分的优良率为91.3%.结论　两种贲门失弛缓症的治疗方式均有效,组间比较均无统计学差异(P>0.05).     

贲门失弛缓症肉毒毒素注射治疗前后食管动力学的研究

目的探讨贲门失弛缓症患者的食管动力特征及肉毒毒素局部注射治疗后食管动力学的改变。方法28例患者内镜下局部注射肉毒毒素,分别于治疗前、治疗后1周、3个月时测定下食管括约肌的压力(LESP)、松弛率(LESRR)和食管体部的动力。结果治疗前,LESP为(42.68±17.16)mmHg,LESRR(38.69±3.66)%,吞咽时100%患者食管体部为同步收缩,无推进性蠕动波。肉毒毒素注射治疗后1周和3个月时,LESP分别为(23.35±4.86)mmHg和(22.74±4.02)mmHg,LESRR分别为(79.98±4.16)%和(80.48±3.79)%,但吞咽时食管体部的动力无改善。结论内镜下LES内注射肉毒毒素,可减低LESP和提高LESRR。     

气囊扩张和肉毒素注射治疗贲门失弛缓疗效比较

目的：了解内镜下气囊扩张和肉毒素注射两种方法治疗贲门失弛缓的疗效。方法：118例经内镜、钡餐及食管测压确诊为贲门失弛缓病人分注射组56例，扩张组62例，分别采用内镜下气囊扩张和肉毒素注射方法。治疗前、治疗后1周内测定下食管括约肌压力(LESP)、下食管括约肌松弛压(佃BP)以及下食管括约肌松弛率(KESRP)等指标进行测量，并观察病人症状缓解情况。结果：治疗后LESP及LESRP均有明显降低(P＜0．05)，同时两组间降低程度也存在明显差别(P＜0．05)，治疗后两组LESRR均无变化.临床症状的缓解情况，注射组：无效9例(14．52％)，改善38例(61．29％)，显效15例(24．19％)；扩张组：无效0例，改善11例(19．以％)，显效45例(80．36％)。随访2年结果显示，气囊扩张法较肉毒素注射疗效明显要高。结论：气囊扩张方法治疗贲门失弛缓疗效较肉毒素注射方法要好，临床症状的改善同LESP及LESRP的降低，特别是LESRP的降低有非常密切的对应关系，可以针对不同的临床特点给予不同的方法治疗。     

球囊扩张治疗贲门失弛缓症55例食管动力变化分析

目的探讨内镜下球囊扩张治疗贲门失弛缓症前后的食管动力变化。方法应用球囊扩张器对55例确诊为贲门失弛缓症的患者进行扩张治疗,并进行治疗前后食管压力测定。结果治疗后食管下括约肌压力及食管下括约肌松弛压明显降低（P〈0.01）,食管下括约肌松弛率明显升高（P〈0.01）,食管下括约肌长度差异无统计学意义（P〉0.05）。结论球囊扩张治疗贲门失弛缓症疗效较好,食管测压是检查食管动力的最敏感指标。     

胃镜下小剂量注射肉毒毒素A治疗贲门失弛缓症的近期疗效观察

目的探讨注射小剂量肉毒毒素 A治疗贲门失弛缓症的方法与疗效。方法内镜下将小剂量肉毒毒素 A分点注射在 10例贲门失弛缓症患者的贲门处。结果 10例患者贲门口明显松弛和扩张。治疗前后贲门口直径分别为 (1.5± 1.11) mm和 (4 .3± 1.42 ) mm(P<0 .0 1) ;治疗前后食管 5分钟存留钡柱高度分别为 (2 2 9.8± 40 .9) mm和 (163 .9± 40 .3 ) mm(P<0 .0 1)。治疗前后经 Eckardt评分分级 ,治疗后均下降 1～ 3个级差。结论内镜下注射小剂量肉毒毒素 A治疗贲门失弛缓症 ,方法简便 ,近期疗效显著     

气囊扩张与A型肉毒杆菌毒素注射序贯联合治疗贲门失弛缓症38例临床护理

目的:探讨哑铃型气囊扩张器扩张序贯联合A型肉毒杆菌毒素注射治疗贲门失弛缓症(AC)的近、远期疗效和护理方法.方法:对38例AC患者应用哑铃型气囊扩张器扩张1周后注射A型肉毒杆菌毒素100 U,并进行精心护理.结果:本组治疗后1、3、6、12、24个月有效率分别为100.0%、94.7%、89.5%、81.6%、55.3%.治疗后1周食管下端括约肌压力(LESP)、食管下端括约肌松弛率(LESRR)与治疗前比较有极显著性差异(P<0.01),治疗后24个月LESRR与治疗后1周比较有显著性差异(P<0.05).结论:哑铃型气囊扩张器扩张序贯联合肌内注射A型肉毒杆菌毒素治疗技术可靠,安全性高,采取适宜的护理措施,可取得满意的临床疗效,且降低并发症发生率.     

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.     

Guns and Knives in New Mexico: Patterns of Penetrating Trauma, 1978–1993

Objective: To identify patterns of nonfatal and fatal penetrating trauma among children and adults in New Mexico using ED and medical examiner data.
Methods: The authors retrospectively sampled in 5-year intervals all victims of penetrating trauma who presented to either the state Level-1 trauma center or the state medical examiner from a 16-year period (1978–1993). Rates of nonfatal and fatal firearm and stabbing injury were compared for children and adults.
Results: Rates of nonfatal injury were similar (firearm, 34.3 per 100,000 person-years; stabbing, 35.1). However, rates of fatal injury were significantly different (firearm, 21.9; stabbing, 2.7; relative risk: 8.2; 95% confidence interval: 5.4, 12.5). From 1978 to 1993, nonfatal injury rates increased for children (p = 0.0043) and adults (p < 0.0001), while fatal penetrating injury remained constant. The increase in nonfatal injury in children resulted from increased firearm injury rates. In adults, both stabbing and firearm nonfatal injury rates increased.
Conclusions: Nonfatal injury data suggest that nonfatal violence has increased; fatal injury data suggest that violent death rates have remained constant. Injury patterns vary by age, mechanism of trauma, and data source. These results suggest that ED and medical examiner data differ and that both are needed to guide injury prevention programs.