胸腔镜房间隔缺损修补术初步经

目的：总结胸腔镜房间隔缺损修补术的经验。方法：采用右侧胸壁打孔、电视胸腔镜下行房间隔缺损修补手术34例，其中男性16例，女性18例，年龄3～46岁，体重12-62kg。房间隔缺损直接缝合24例，涤纶补片修补10例，同时行三尖瓣成形3例。结果：术后右侧气胸2例，手术时间1．8～3．6h，平均2．6h；体外循环时间36-92min，平均是77min；升主动脉阻闭时间8～52min，平均28min。术后患者恢复顺利，治疗效果满意。结论：胸腔镜下房间隔缺损修补术安全可行。     

经胸小切口房间隔缺损封堵术治疗房间隔缺损的效果分析

目的:探讨房间隔缺损患者采用经胸小切口房间隔缺损封堵术治疗的临床效果。方法:回顾性分析2017年1月～2018年12月收治的88例房间隔缺损患者的临床资料,按治疗方法不同分为封堵组和修补组,各44例。封堵组采用经胸小切口房间隔缺损封堵术治疗,修补组采用传统外科修补术治疗,对比两组手术效果。结果:封堵组手术时间、ICU时间、停用呼吸机时间及术后住院时间均短于修补组,切口长度小于修补组,术后左室舒张末内径、左房前后径小于修补组,左室射血分数高于修补组,差异有统计学意义(P0.05)。两组患者术后无特殊不适感,随访期间无死亡病例,术后复查超声心动图,无残余分流等并发症发生。结论:采用经胸小切口房间隔缺损封堵术治疗房间隔缺损,手术时间短,患者恢复快,术后心功能改善明显,并发症发生率低。     

继发孔房间隔缺损手术治疗原则与方法

目的 总结外科治疗继发孔房间隔缺损的不同手术方式及应用原则。方法 对我科1996年1月～2002年12月经手术治疗的375例继发孔房间隔缺损的临床资料进行回顾分析。其中：传统体外循环心内直视修补153例(40．8％)，体外循环心脏不停跳修补145例(38．7％)，闭式修补77例(20.5％)。对该病症的手术适应征、治疗方式及主要并发症进行讨论。结果 全组除1例(0．3％)死于严重鱼精蛋白过敏外，均治愈出院，术后心功能NYHA评级改善，尤以术前Ⅳ级者最为明显。术后发生心律失常58例(15．5％)、左心功能不全6例(1．6％)、肺高压危象4例(1．1％)及呼吸功能不全3例(0．8％)，均治愈。术后残余分流6例(1．6％)，其中4例(66．7％)为治疗性分流，未做特殊处理。结论 根据患者病情，选择合适的手术方法，可以提高房间隔缺损修补安全性，扩大手术适应症，降低术后并发症。     

继发孔房间隔缺损三种手术方式的临床应用

目的：总结继发孔房间隔缺损三种不同术式的治疗经验。方法：对我科1996年1月至2002年12月经手术治疗的375例继发孔房间隔缺损的临床资料进行回顾分析。包括传统体外循环心内直视修补153例(40．8％)，体外循环心脏不停跳修补145例(38．7％)，闭式修补77例(20．5％)。对手术适应证、治疗方式及主要并发症进行讨论。结果：全组除1例(0．3％)死于严重鱼精蛋白过敏外，均治愈出院，术后心功能NYHA评级改善，尤以术前Ⅳ级者最为明显。术后发生心律失常58例(15．5％)、左心功能不全6例(1．6％)、肺高压危象4例(1．1％)及呼吸功能不全3例(0．8％)，均治愈。术后残余分流6例(1．6％)，其中4例(66．7％)为治疗性分流，未做特殊处理。结论：根据病情选择适宜的手术方法，可以有效提高房间隔缺损修补的安全度，扩大治疗范围，减少并发症。     

成人房间隔缺损的外科治疗

目的总结成年人房间隔缺损的手术治疗经验。方法48例20岁以上继发性房间隔缺损病人，年龄20～71岁，其中，男17例。女31例，合并肺动脉高压15例，心律失常23例。房缺修补采用直接连续缝合或补片修补。2例房颤患者同期行右侧迷宫术。结果全组48例无手术死亡。随访一年以上心功能较术前均有明显改善。结论成人房间隔缺损应尽早手术，采用补片修补时，自体心包为首选。同手术期肺动脉高压以及合并症的正确处理是手术成功的关键。     

10kg以下婴幼儿室间隔缺损修补术36例分析

目的：总结10 kg以下婴幼儿室间隔缺损（VSD）的外科治疗经验。方法：全组36例均在体外循环下心停跳行室缺修补术。均采用绦纶或自体心包片修补缺损,无直接缝合。结果：全部治愈出院,术后主要并发症为肺部感染5例,肺不张4例,心律失常2例,残余分流2例。结论：婴幼儿室缺伴反复感染、肺动脉高压或心功能不全宜及早手术治疗,完善和提高手术技巧、加强术后监护是治疗成功的关键。     

小切口心脏不停跳下房间隔缺损修补术的临床研究(附26例报告)

目的总结经胸骨下段小切口,在心脏不停跳下修补房间隔缺损(atrial septal defect,ASD)的手术结果.方法 2000年8月至2003年9月,为26例房间隔缺损的患者经胸骨下段小切口,在心脏不停跳下完成了缺损修补术.平均房间隔缺损直径18mm,直接缝合11例,补片修补15例.结果无死亡和任何并发症,平均切口长度(7.5±1.0)cm.平均体外循环时间(30±7)min,术后平均随诊时间(1.8±1.0)年.所有患者心功能NYHA Ⅰ级.结论胸骨下段小切口心脏不停跳下房间隔缺损修补术,是一种安全、有效、美观、微创的手术方法.     

外科矫治三尖瓣下移畸形13例

目的:总结13例三尖瓣下移畸形手术矫治的方法和疗效.方法:2003年1月至2005年12月,我科对13例三尖瓣下移畸形患者施行了手术矫治,其中三尖瓣成形术10例,三尖瓣置换术3例,同期行双向腔肺分流术2例,房间隔缺损修补术6例,室间隔缺损修补术1例.结果:全组无死亡病例.早期并频发室性早搏1例.术后B超示10例成形术患者中3例有轻度三尖瓣关闭不全.术后随访心功能均达Ⅰ～Ⅱ级.结论:应根据病变情况适期选用最佳方法矫治三尖瓣下移畸形,并同期治疗合并症.     

经胸非体外循环房间隔缺损封堵术的配合及监护

目的探讨经胸非体外循环房间隔缺损封堵术的术中配合及监护。方法对采用经胸非体外循环封堵房间隔缺损的110例患者的术中配合及监护进行回顾性分析。结果全组无手术死亡,3例因房缺大无法牢固放置封堵器,术中延长小切口侧开胸在体外循环下进行房间隔缺损修补。其余107例术后3d复查无残余分流,平均术后住院日期3．2d。结论经胸非体外循环房间隔缺损封堵术创伤小、适应症广、手术安全性高,有推广应用价值,术中良好的护理配合及监护是手术成功的重要保证。     

主动脉窦瘤破裂的外科治疗

目的探讨主动脉窦瘤破裂（RSVA）的临床特点、诊断及外科治疗方法。方法 2004年1月-2009年12月对28例RSVA患者在体外循环下行RSVA修补术,同期行室间隔缺损修补术18例,房间隔缺损修补术4例,主动脉瓣成形术2例,主动脉瓣置换术4例。术后随访3个月～6年,平均32.4个月。结果 28例患者均无手术死亡和残余分流。失访4例。心功能Ⅰ级20例,Ⅱ级4例;复查心脏彩色超声心动图无主动脉窦瘤复发或残余分流,主动脉瓣轻-中度反流2例。结论外科手术是RSVA的最有效治疗方法,窦瘤破口直径〉0.5cm者宜用补片修补。伴有中或重度主动脉瓣关闭不全时需根据主动脉瓣病变程度以及手术者经验决定,必要时需放宽换瓣指征。     

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.