纤维支气管镜下微波联合局部注药治疗在支气管结核中的应用

目的：探讨应用纤维支气管镜（纤支镜）介入微波并局部注药治疗支气管结核的疗效。方法：将46例支气管结核患者随机分为治疗组和对照组；治疗组22例强化期采用纤支镜介入微波并局部注药加全身化疗，对照组24例只进行全身化疗。结果：22例共进行136人次治疗，治疗成功率100％，症状改善率为95．4％，痰菌阴转率83．3％，纤支镜下病灶吸收率86．4％，胸部CT所见病灶吸收率85．7％，与对照组相比有显著性差异（P＜0．01）；无1例发生气胸、出血、结核播散、肺部继发性感染等并发症；治疗组远期疗效也较对照组有显著性差异（P＜0．05）。结论：该疗法效果显著，明显优于单纯全身化疗组，另一种安全、有效、易行的治疗支气管结核的综合性方法，能减少手术及各种并发症的发生。     

经纤维支气管镜治疗气管支气管内膜结核

目的：研究经纤维支气管镜给药气管支气管内结核的疗效，方法：全身化疗加强化期经纤维支气管镜给药治疗结核，与单纯全身化疗１６例对照，结果：治疗组肺安全复张率为９４．４４％，病灶吸收率为９６．３０％，较对照组４０．００％，５６．２５％高（Ｐ〈０．０１）；治疗组瘢痕狭窄率为６．６７％，较对照组５５．５６％低（Ｐ〈０．０５）。无明显毒副反应及并发症，结论：经纤维支气管镜给药加全身化治疗气管支气管内膜结核疗效     

气管支气管结核的螺旋CT诊断

目的探讨螺旋啊在气管支气管结核诊断中的价值。方法对12例经手术病理和纤维支气管镜活检证实的气管支气管结核进行回顾性分析。以层厚10mm，螺距为1进行胸部螺旋CT扫描．．并对局部支气管加扫连续2～3mm薄层，在工作站进行MPR重建。结果12例中，16支病变支气管表现为支气管擘不同程度向心性增厚，管壁厚度约3～9mm．内壁呈浅波浪状。其中12支受累支气管范围较长，长度达30mm，占75％（12／16）。4支病变支气管壁出现钙化，12例均合并肺内结核，肺内结核病灶多数分布于病变支气管所属肺组织。结论螺旋CT可以有效显示气管支气管结核的病变特征，结合MPR可以更加直观显示病变范围，有助于病变的诊断。     

纤支镜对41例支气管结核的诊断意义

目的：探索气管-支气管结核的临床特征，分析纤维支气管镜（FB）对支气管结核的检出率及镜下特征，探讨其诊断价值。方法：分析41例经纤维支气管镜确诊的气管-支气管结核的纤维支气管镜下表现、临床症状、胸部X线及实验室检查情况。结果：纤支镜检查显示：Ⅰ型11例，占26．83％；Ⅱ型8例，占19．51％；Ⅲ型17例，占41．46％；Ⅳ型5例，占12．20％。镜下所见管腔内各种类型病变互有重迭，其病变表现具有一定特征。31例镜检前后进行痰菌涂片检查2～6次／例，仅6例阳性。41例经FB刷片行抗酸杆菌检查，有12例阳性（阳性率29．3％）。41例行活组织检查证实为结核36例（87．80％）。结论：气管-支气管结核缺乏特异性临床表现，胸部X线表现正常并不能排除支气管结核，确诊主要依靠纤支镜下活检病理、刷检涂片及痰结核菌检查。对不明原因低热和呼吸道症状经积极抗炎治疗无效者，应怀疑支气管结核及早行纤支镜检查。     

支气管结核在纤维支气管镜下治疗方法的探讨

目的 :探讨支气管结核在纤维支气管镜下治疗的方法及价值。方法 :对 2 5例支气管结核病人 ,在全身抗结核治疗的同时分别实施镜下注药治疗、微波接触式辐射治疗和球囊扩张术 局部注药治疗。结果 :在全身抗结核治疗的同时运用上述几种镜下治疗方法 ,支气管局部病灶较镜下治疗前均有明显好转。结论 :利用纤维支气管镜对支气管结核病人进行局部治疗 ,可加快病灶的吸收和症状的改善 ,值得推广应用     

单纯性支气管内膜结核66例临床及纤维支气管镜下特点分析

单纯性支气管内膜结核（EBTB）是气管、支气管粘膜或粘膜下层发生的结核病变，无传统的肺部结核病灶。由于其临床症状不典型，胸部X线表现无特征性，常致误诊或漏诊，而延误治疗。近年来本院经纤维支气管镜（纤支镜）检查后诊断66例，回顾性分析报告如下。     

协同护理模式在支气管镜介入冷冻治疗支气管结核中的应用

目的探讨经支气管镜介入冷冻治疗支气管结核的护理方法。方法对22例经支气管镜介入局部冷冻治疗的患者实行术前宣教、术中配合、术后护理的协同护理模式,比较治疗前后患者临床症状、镜下表现及影像学检查,患者术前焦虑发生的情况,患者对支气管镜检查治疗知识的知晓程度及患者对支气管镜冷冻治疗的接受程度。结果22例患者共进行了87次治疗,每例患者平均治疗1．5个月,平均（5±3）次,临床症状改善明显,原气管、支气管内膜病变绝大部分吸收,肺部病变明显吸收,原狭窄的管腔通畅,显效68．18％,有效31．81％,总有效率100％。未见明显不良反应。患者术前平均焦虑评分为（31．45±5．65）分,与常模（29．78±0．46）分比较,差异无统计学意义（t=1．391。P〉0．05）;对支气管镜冷冻治疗知识的知晓情况,比较了解以上的项目达到了96％,全部患者均愿意接受此项治疗。结论协同护理模式在支气管镜介入冷冻治疗支气管结核的应用中起到了一定辅助作用,它也是临床上一种新的护理模式,值得临床有条件的单位推广应用及验证。     

经纤维支气管镜治疗痰菌阳性的支气管内膜结核的疗效分析

目的：探讨经纤支镜局部给药治疗痰菌阳性的支气管内膜结核的疗效。方法：对52例痰菌阳性的支气管内膜结核随机分为治疗组和对照组，治疗组采用纤支镜局部给药＋全身化疗，对照组采用单纯全身化疗。结果：治疗组瘘菌转阴率为100％，病变改善有效率为96．2％，而对照组分别为69．2％，65．3％（P＜0．05）。结论：经纤维支气管镜局部治疗瘘菌阳性的支气管内膜结核疗效显著，副作用少，值得广泛推广。     

经纤维支气管镜球囊扩张术治疗良性气道狭窄

目的探讨经纤维支气管镜球囊扩张术治疗良性气道狭窄的疗效、扩张策略和合适指征选择。方法对12例气管和支气管狭窄病例，其主要原因为支气管结核，气管插管后狭窄，经临床、肺功能评价后，在透视下用气腔成形球囊进行气道扩张术，每周扩张1次，连续3次，评价即刻气道开放，远期疗效和肺功能改善。结果12例病人共扩张42次，平均3．5次，即刻气道开放为91．6％，6月内狭窄率为18％，部分多叶狭窄病例采用分段扩张法，3例病例合用气管支架。无明显并发症。结论球囊扩张术对支气管狭窄病例，以纤维疤痕为主者疗效好，对内芽增生型宜多次扩张。对气管狭窄者宜合用其它介入手段。对气道开放，改善肺功能是较好的介入措施。     

纤维支气管镜在气管切开昏迷病人中的应用

目的：讨论支气管纤维镜在气管切开昏迷病人中应用价值。方法：50例气管切开昏迷病人，表麻后支气管纤维镜对分泌物，痰栓或血凝块进行抽吸，然后分次用生理盐水＋敏感抗菌素灌洗直至清除．观察对比检查前后的X线胸片、临床表现，血氧饱和度等指标．结果：50例患者经支气管纤维镜治疗后，均取得满意疗效，11例肺不张100％复张，25例肺部感染患者23例病灶有吸收，有效率92％，高热患者15例中13例体温下降，有效率88％，血氧饱和度由治疗前的83．2％升至95．6％。结论：气管切开昏迷病人合并肺部感染，肺不张，血氧饱和度下降应用支气管纤维镜治疗，是一种安全简便而有效的方法，具有推广和应用的价值。     

创伤高血糖与感染和MODS早期诊断和干预

本文详细介绍了创伤后血糖应激适度理论,以及高血糖与感染和多器官功能不全综合征的关系;提出涉及胰岛B细胞功能不全的MODS实验诊断新方案和极化液个体化干预新措施,可早期发现创伤MODS、降低感染率及MODS发生率和病死率。     

腹膜后纤维化与肾积水发生关系的临床研究

目的：探讨腹膜后纤维化（RPF）导致肾积水的原因及诊治经验。方法：回顾分析2004年1月—2010年12月24例腹膜后纤维化致肾积水患者的诊治资料。结果：（1）RPF患者常见首发症状为腰背痛或腹痛（69.2%）;（2）红细胞沉降率（ESR）增快和血清IgG4升高最常见。超声检查仅提示上尿路积水。RPF的静脉肾盂造影（IVP）和CT尿路成像（CTU）表现具有特征性。IVP肾盂输尿管显影不良时,CTU能较清晰的显示上尿路影像。CT扫描发现腹膜后软组织肿块9例（37.5%）,优于超声检查;（3）输尿管松解和腹腔化手术治疗22例;行肾切除术1例;行输尿管置双J管术1例。最终确诊为继发性RPF8例,其中4例为术前诊断,3例为术中腹膜后软组织肿块冷冻活检证实,1例为术后病理证实;（4）特发性RPF手术后肾积水均获长期缓解,而继发性RPF的预后取决于原发疾病及其治疗方案。结论：影像学检查是诊断RPF的重要手段,CTU优于超声检查和IVP。输尿管松解和腹腔化手术可以使特发性RPF输尿管梗阻得到长期的缓解,术中对肿块进行冷冻活检有助于鉴别特发性和继发性RPF,及时调整治疗方案。     

Fibrinogen and fibrin structure and functions

Fibrinogen molecules are comprised of two sets of disulfide-bridged Aalpha-, Bbeta-, and gamma-chains. Each molecule contains two outer D domains connected to a central E domain by a coiled-coil segment. Fibrin is formed after thrombin cleavage of fibrinopeptide A (FPA) from fibrinogen Aalpha-chains, thus initiating fibrin polymerization. Double-stranded fibrils form through end-to-middle domain (D:E) associations, and concomitant lateral fibril associations and branching create a clot network. Fibrin assembly facilitates intermolecular antiparallel C-terminal alignment of gamma-chain pairs, which are then covalently 'cross-linked' by factor XIII ('plasma protransglutaminase') or XIIIa to form 'gamma-dimers'. In addition to its primary role of providing scaffolding for the intravascular thrombus and also accounting for important clot viscoelastic properties, fibrin(ogen) participates in other biologic functions involving unique binding sites, some of which become exposed as a consequence of fibrin formation. This review provides details about fibrinogen and fibrin structure, and correlates this information with biological functions that include: (i) suppression of plasma factor XIII-mediated cross-linking activity in blood by binding the factor XIII A2B2 complex. (ii) Non-substrate thrombin binding to fibrin, termed antithrombin I (AT-I), which down-regulates thrombin generation in clotting blood. (iii) Tissue-type plasminogen activator (tPA)-stimulated plasminogen activation by fibrin that results from formation of a ternary tPA-plasminogen-fibrin complex. Binding of inhibitors such as alpha2-antiplasmin, plasminogen activator inhibitor-2, lipoprotein(a), or histidine-rich glycoprotein, impairs plasminogen activation. (iv) Enhanced interactions with the extracellular matrix by binding of fibronectin to fibrin(ogen). (v) Molecular and cellular interactions of fibrin beta15-42. This sequence binds to heparin and mediates platelet and endothelial cell spreading, fibroblast proliferation, and capillary tube formation. Interactions between beta15-42 and vascular endothelial (VE)-cadherin, an endothelial cell receptor, also promote capillary tube formation and angiogenesis. These activities are enhanced by binding of growth factors like fibroblast growth factor-2 (FGF-2) and vascular endothelial growth factor (VEGF), and cytokines like interleukin (IL)-1. (vi) Fibrinogen binding to the platelet alpha(IIb)beta3 receptor, which is important for incorporating platelets into a developing thrombus. (vii) Leukocyte binding to fibrin(ogen) via integrin alpha(M)beta2 (Mac-1), which is a high affinity receptor on stimulated monocytes and neutrophils.     

Migraine and genetic and acquired vasculopathies

It is remarkable that migraine is a prominent part of the phenotype of several genetic vasculopathies, including cerebral autosomal dominant arteriopathy with subcortical infarcts and leucoencephalopathy (CADASIL), retinal vasculopathy with cerebral leukodystrophy (RVCL) and hereditary infantile hemiparessis, retinal arteriolar tortuosity and leukoencephalopahty (HIHRATL). The mechanisms by which these genetic vasculopathies give rise to migraine are still unclear. Common genetic susceptibility, increased susceptibility to cortical spreading depression (CSD) and vascular endothelial dysfunction are among the possible explanations. The relation between migraine and acquired vasculopathies such as ischaemic stroke and coronary heart disease has long been established, further supporting a role of the (cerebral) blood vessels in migraine. This review focuses on genetic and acquired vasculopathies associated with migraine. We speculate how genetic and acquired vascular mechanisms might be involved in migraine.     

Telemedicine and teleradiology technologies and applications

Summary. Telemedicine and teleradiology hold the key for improving future health care delivery. In this paper we first review current communication and computer technologies used in telemedicine and teleradiology. Five examples in teleradiology applications are given including hospital-integrated picture archiving and communication systems, tele-neuro-imaging, telemammography, university consortium teleradiology service, and teleradiology for second opinion. Parameters important to teleradiology applications like costs, image quality, system reliability, and turn around time are considered. Data security is discussed, including patient confidentiality and image authenticity-which will be a major issue in future teleradiology applications.     

Physician and Nurse Practitioner Teamwork and Job Satisfaction: Gender and Profession

Designing interprofessional primary care teams composed of physicians and nurse practitioners (NPs) is a national priority. We assessed how profession and gender affect teamwork and job satisfaction among primary care physicians and NPs by using survey data from 186 physicians and 398 NPs practicing in New York State. Our regression models show profession (NP vs physician) moderates the associations of gender with teamwork and job satisfaction. Among NPs, men had higher job satisfaction than women. Among physicians, women had higher job satisfaction than men. Our results can benefit interprofessional primary care teams to optimize their professional and gender mix.     

Acetaminophen and acetylcysteine dose and duration: Past,present and future

Abstract

Acetylcysteine has been utilized successfully in the treatment of acetaminophen overdose since the 1970s. Although prospective trials as to efficacy and safety of acetylcysteine were conducted, there were no randomized controlled trials. This commentary addresses the reasons for this, and the background to choice of dose of acetylcysteine utilized in the oral and IV dosing regimens. Nomograms to predict possible hepatotoxicity based upon time of ingestion of acetaminophen were developed from a relatively arbitrary definition of toxicity as an aspartate aminotransferase/alanine aminotransferase (ALT/AST) greater than 1000 IU/L. While these have proved generally useful, patients still continue to develop hepatic damage after acetaminophen overdose, particularly if they present late after ingestion. The optimum management of these patients remains unclear, and one area of uncertainty is the dose and duration of acetylcysteine in various circumstances. This article discusses the issues that need to be elucidated to better target changes in acetylcysteine dose. The potential for measurements of other markers to improve treatment selection is the subject of further research.     

Trust and distrust between patient and doctor

To trust someone is to have expectations of their behaviour; distrust often involves disappointed expectations. But healthy trust and distrust require a good understanding of which expectations are reasonable, and which are not. In this paper, I discuss the limits of trustworthiness by drawing on recent studies of trust in the context of defensive medicine, biobanking and cardiopulmonary resuscitation decisions.     

妊娠合并血小板减少症与心、肝、肾脏器损伤

目的探讨妊娠合并血小板减少症伴随重要脏器的损伤情况。方法前瞻性研究我院及北华大学附属医院2004年10月至2005年5月妊娠合并血小板减少症的临床资料，对41例妊娠合并血小板减少症者尿素氮（BUN）、肌酐（CREA）、谷丙转氨酶（ALT）、乳酸脱氢酶（LDH）的测定及妊娠期高血压疾病与血小板计数（PLT），血小板平均体积（MPV）和血小板体积分布宽度（PDW）参数的测定进行对比分析。结果妊娠合并血小板减少症患者心、肝、肾等重要脏器均有不同程度的改变，且随着血小板计数降低，损害程度加剧，差异具有显著性（P〈0．01）。妊娠期高血压疾病，随着疾病程度的加重，血小板计数较正常孕妇明显减少，MPV、PDW明显升高，有显著性差异（P〈0．01）。结论血小板参数是判断疾病的重要参考指标，肝、肾、心脏器损伤程度与血小板计数具有相关性。