右美托咪定混合罗哌卡因用于缓解上肢长时间手术中止血带反应的效果观察

目的：探讨右美托咪定混合罗哌卡因在肌间沟复合腋路臂丛神经阻滞应用于上肢长时间手术中的疗效观察。方法60例急诊断指（多指）、断腕或断臂手术患者,ASAⅠ~Ⅱ级,手术时间8~10 h,随机分配为2组（n =30）：罗哌卡因组（R 组）采用1%罗哌卡因15 mL +2%利多卡因10 mL 加生理盐水至40 mL;右美托咪定混合罗哌卡因组（DR 组）采用1%罗哌卡因15 mL+2%利多卡因10 mL +盐酸右美托咪定1μg/ kg 加生理盐水至40 mL。以神经刺激器定位肌间沟臂丛神经分支（腋神经）及腋路臂丛神经主分支（尺神经、桡神经、正中神经和肌皮神经）,止血带充气压力200~250 mmHg,压迫时间90 min。观察并记录入室时（T0）、阻滞后1.5 h（T1）、3 h（T2）、4.5 h（T3）、6 h（T4）、7.5 h（T5）、9 h（T6）及术毕（T7）患者的一般生命体征（MAP、HR）,同时以VAS 评分法评估患者止血带反应的程度,若无法忍受止血带反应,臂丛加药后试验结束。记录患者止血带耐受情况,并以 Ramsay评分评价 R 组及 DR 组的镇静程度,记录术中出现的不良反应。结果与 R 组相比,DR 组患者对止血带耐受率明显升高,且差异有统计学意义（P ﹤0.05）,止血带疼痛时间出现延迟（P ﹤0.05）;与 R 组比较,DR 组 T1~ T5时 HR 减慢（P ﹤0.05）,DR 组有7例出现窦性心动过缓,两组均未出现止血带严重并发症。结论1μg/ kg 右美托咪定混合1%罗哌卡因对减轻上肢长时间手术带来的止血带疼痛安全、有效,并可延迟止血带疼痛出现的时间。     

Congenital midline sinus of the upper lip

A congenital lip sinus is a rare condition that has been reported to occur in both the upper and lower lips, either in isolation or in association with congenital deformities such as a cleft lip and palate in Van der Woude syndrome. The prevalence of lower lip sinuses has been estimated to be about 0.00001% of the white population. Upper lip sinuses are even more uncommon. To date, there have been several case reports of upper lip sinuses and fistulas, but no similar cases have been described in Singapore. We herein report a case of congenital upper lip sinus presenting as a recurring upper lip abscess and review the current literature on this condition.     

Control of hospital acquired infections in the ICU: A?service perspective

Background

The service setting has some unique strengths and weaknesses that must be kept in mind when organizing Hospital acquired infections (HAI) prevention interventions.

Methods

Following an initial study to gather data regarding HAI in the Surgical intensive care unit (ICU) we put into place various infection control interventions. The present study was carried out to analyse the effect of these interventions on the incidence of HAI in the ICU.

Results

The total admissions to the ICU were 253 patients. Eighty eight patients (34.78%) were admitted for more than 48 hr, 165 patients stayed for less than 48 h. The frequency of HAI was 7.95% (95% CI 3.54, 15). Hospital acquired pneumonia was observed in 2 of the 88 patients (2.27%) (95% CI 0.38, 7.30) which amounted to 9.70 infections per 1000 ventilator days. Bloodstream infection was detected in 3 out of 88 patients (3.4%) (95% CI 0.87, 8.99) amounting to 6.54 fresh infections per 1000 Central Venous Catheter days. Urinary tract infection was observed in 2 (2.27%) (95% CI 0.38, 7.30) at 2.86 fresh infections per 1000 catheter days. As compared to the previous study we found that there was a decline of HAI ranging from 60 to 70%.

Conclusion

Our study demonstrated that by meticulously following infection control protocols especially tailored to the service setting the incidence of HAI''s can be reduced. However, the challenge is in maintaining the gains achieved since there is a rapid turnover of manpower in the ICU and a lack of a structured ICU design model.     

应用磁共振弥散张量成像评价急性前循环脑梗死锥体束损伤

目的：通过分析急性前循环脑梗死患者起病后MRI、弥散张量成像技术（DTI）图像,探讨DTI在急性前循环脑梗死的应用价值。方法选自急性期3 d前循环脑梗死、符合WHO制定的缺血性脑卒中诊断标准的患者为研究组,测量患者梗死灶和健侧相应部位的分数各向异性（fractional anisotropy ,FA）值,观察患者皮质脊髓束（CST ）的损伤程度并分级。同时选择10名年龄性别与研究组匹配的正常健康人为对照组,对照组在相应位置选择与研究组梗死部位同样大小的感应区进行测量FA值。应用日常生活活动能力量表（ADL量表）对研究组患者入院时和治疗后3个月进行评分。结果急性期前循环脑梗死患者病灶的FA值低于健侧,差别有统计学意义。梗死灶FA值降低百分比和皮质脊髓束的损伤程度、ADL相关,有统计学意义。DTI所示皮质脊髓束的损伤程度与ADL评分相关。结论梗死病灶区FA值下降越明显,皮质脊髓束损伤程度越重,临床症状越重,它可以作为判断预后的客观指标之一。通过DT T 分级评价脑梗死患者的预后和神经功能康复有重要的临床价值。     

Inhaled corticosteroid for persistent cough following upper respiratory tract infection

OBJECTIVE: The aim of this study was to determine the clinical effect of inhaled corticosteroid treatment for persistent cough, post upper respiratory tract infection (URTI) in previously healthy individuals, and on bronchial hyperresponsiveness (BHR). METHODOLOGY: This was a prospective, randomized, double-blinded, placebo-controlled study conducted at a university hospital. A total of 30 non-asthmatic, non-smoking patients who were >15 years old and who had persistent post-URTI cough for >3 weeks were assessed by a physical examination, CXR and spirometry, and were allocated to receive inhaled budesonide (400 microg/puff, twice daily) or placebo for 4 weeks. If a patient suffered from sinusitis, it was a requirement that it had been well treated. A symptom score (frequency of cough, frequency of coughing bouts, symptoms associated with cough, night-time cough, frequency of taking medications to relieve cough, and number of medications) was recorded at entry, and after 2 and 4 weeks of treatment. A methacholine challenge test was performed at entry and after 4 weeks of treatment. RESULTS: The mean symptom scores for the treatment group (9.4) and the placebo group (9.8) at baseline were not significantly different (P=0.79), and no differences were found between the groups after week 2 and week 4 of treatment (3.93 and 4.27 vs 2.26 and 2.66, P=0.29). The mean change in symptom scores from baseline to week 2 and to week 4 of treatment were also not different between groups (5.93 and 5.6 vs 7.00 and 7.58, P=0.23). No difference between groups was found in the mean changes in FEV(1), FVC, and FEF(25--75%) after 4 weeks of treatment. A positive bronchial provocation test occurred in three patients (10%) but these were borderline. CONCLUSION: Inhaled corticosteroid is ineffective in treating persistent post-URTI cough in previously healthy individuals.     

Necrotizing small-vessel vasculitis confined to the uterine cervix

OBJECTIVES: To report our experience with five cases of apparently isolated small-vessel vasculitis of the uterine cervix. METHODS: Case study of five patients with necrotizing vasculitis discovered incidentally in surgical specimens of the female genital tract, and a review of the pertinent literature on this subject. RESULTS: All patients lacked clinical and serological features of the well-delineated vasculitic syndromes. Comprehensive workup failed to yield any evidence of an underlying disorder. All patients were managed expectantly and did not develop systemic vasculitis during follow-up ranging from 6 months to 5 years. CONCLUSIONS: Isolated vasculitis of the female genital tract can be encountered as an innocuous finding in otherwise healthy individuals. The cause and pathogenesis of this disorder remain obscure. Rheumatologists should be familiar with this rare and vexing form of vasculitis and with its benign prognosis.     

国产法莫替丁治疗上消化道出血效果观察

对156名上消化道出血病人,根据性别、年龄及出血量随机分成法莫替丁试验组(20mg,静注,每日两次)和西米替丁对照组(400mg,静注,每日两次)。用药后三天内的显效率法莫替丁为65.4％,西米替丁为26.9％;用药后五天内总有效率分别为97.4％及84.6％,无论三天内的显效率还是五天内的总有效率法莫替丁组均高于西米替丁组。     

Diffuse esophageal spasm: not diffuse but distal esophageal spasm (DES)

Diffuse esophageal spasm is an uncommon motility disorder that is found in less than 5% of patients undergoing esophageal motility testing for dysphagia. It is defined manometrically by the presence of 20% or more simultaneous contractions in the distal esophageal body with normal peristalsis. This motility abnormality has been traditionally identified as occurring primarily in the smooth muscle portion of the distal esophagus yet, the term diffuse persists in the medical literature to identify DES. The aim of our study was to assess the diffuse or limited nature of this entity by evaluating the prevalence of simultaneous contractions in both proximal and distal esophagus in patients with DES. We reviewed esophageal motility tracings of 53 consecutive patients (32 F, 21 M) with DES and compared them with 53 age-matched patients with manometric normal studies. In the distal esophagus we found 195 simultaneous contractions (37% of swallows) with a median of 3 and range of 2–7 per patient. Of the 53 patients with DES a total of 13 simultaneous contractions (2% of swallows) occurred in the proximal esophagus with only 3 (5.6%) of the 53 patients having 2 or more simultaneous contractions in 10 swallows. None of the patients with normal manometry showed more than one simultaneous contraction in either proximal or distal esophagus. In conclusion, these findings suggest that the term diffuse esophageal spasm is a misnomer and the DES is more appropriately described as distal esophageal spasm.     

High-resolution manometry and impedance-pH/manometry: valuable tools in clinical and investigational esophagology

Both high-resolution manometry (HRM) and impedance-pH/manometry monitoring have established themselves as research tools and both are now emerging in the clinical arena. Solid-state HRM capable of simultaneously monitoring the entire pressure profile from the pharynx to the stomach along with pressure topography plotting represents an evolution in esophageal manometry. Two strengths of HRM with pressure topography plots compared with conventional manometric recordings are (1) accurately delineating and tracking the movement of functionally defined contractile elements of the esophagus and its sphincters, and (2) easily distinguishing between luminal pressurization attributable to spastic contractions and that resultant from a trapped bolus in a dysfunctional esophagus. Making these distinctions objectifies the identification of achalasia, distal esophageal spasm, functional obstruction, and subtypes thereof. Ambulatory intraluminal impedance pH monitoring has opened our eyes to the trafficking of much more than acid reflux through the esophageal lumen. It is clear that acid reflux as identified by a conventional pH electrode represents only a subset of reflux events with many more reflux episodes being composed of less acidic and gaseous mixtures. This has prompted many investigations into the genesis of refractory reflux symptoms. However, with both technologies, the challenge has been to make sense of the vastly expanded datasets. At the very least, HRM is a major technological tweak on conventional manometry, and impedance pH monitoring yields information above and beyond that gained from conventional pH monitoring studies. Ultimately, however, both technologies will be strengthened as outcome studies evaluating their utilization become available.