右旋美托咪啶用于椎管内麻醉随机对照试验的Meta分析

目的系统评价右旋美托咪啶用于椎管内麻醉的有效性和安全性。方法计算机检索PubMed、EBSCO、Springer、Ovid、CNKI和万方数据库,并辅以手工和机检查找相关文献的参考文献,查找右旋美托咪啶用于椎管内麻醉的随机对照试验(RCT),文献检索起止时间均从建库至2011年2月。在按纳入与排除标准进行资料提取和文献质量评价后,采用RevMan 5.0软件进行Meta分析。结果纳入13个RCT,共计672例患者。Meta分析结果显示:与生理盐水相比,右旋美托咪啶能明显缩短椎管内麻醉感觉达到T10的平均时间[WMD=–2.39,95%CI(–4.40,–0.39)]和运动阻滞达到Bromage 3的平均时间[WMD=–5.30,95%CI(–7.18,–3.43)],并延长感觉阻滞消退两个节段的平均时间[WMD=51.14,95%CI(44.96,57.32)]和运动阻滞消退至Bromage 0的平均时间[WMD=68.46,95%CI(38.56,98.35)],同时明显增加心动过缓发生率[RR=3.03,95%CI(1.64,5.59)],减少寒战发生[RR=0.47,95%CI(0.28,0.80)];但在低血压以及术后恶心呕吐的发生率方面两者差异无统计学意义。结论现有研究表明,右旋美托咪啶可明显缩短椎管内麻醉的阻滞起效时间并延长其作用时间,同时可以降低寒战发生率,但也会明显增加心动过缓的发生率。     

自动压力模式与固定压力模式持续气道正压通气治疗阻塞性睡眠呼吸暂停综合征疗效的系统评价

目的系统评价自动压力模式持续气道正压通气(Auto-CPAP)与固定压力模式持续气道正压通气(Fixed-CPAP)治疗阻塞性睡眠呼吸暂停综合征(OSAS)的疗效。方法计算机检索PubMed(1990～2010)、Springer Link(1995～2010)、CNKI(1990～2010)、万方数据库(1995～2010)和学术搜索引擎(1994～2010),查找公开发表的Auto-CPAP与Fixed-CPAP比较治疗OSAS的随机对照试验(RCT),并查找相关会议文献及询问本领域专家获取相关资料。由两名评价者按纳入排除标准独立筛选试验、提取资料和评价方法学质量,而后采用RevMan 5.0软件进行Meta分析。结果共纳入11个RCT,合计327例患者。Meta分析结果显示:与Fixed-CPAP组相比,Auto-CPAP组平均有效治疗压力更低[WMD=–1.79,95%CI(–3.39,–0.20)],治疗依从性更好[WMD=0.43,95%CI(0.30,0.56)],但AHI值[WMD=1.17,95%CI(0.25,2.08)]和ESS值[WMD=0.88,95%CI(0.42,1.33)]更高;在病人主观喜好上,两组差异无统计学意义[OR=2.06,95%CI(0.46,9.10)]。结论 Auto-CPAP能明显降低OSAS患者平均治疗压力,提高其治疗依从性,但在降低AHI值与ESS方面却不及Fixed-CPAP。因研究质量和研究样本的局限性,上述结论有待设计严谨的大样本随机对照试验加以验证。     

腹腔镜胆总管探查取石术后胆管一期缝合与T管引流比较的系统评价

目的系统评价腹腔镜下胆总管探查取石后胆管一期缝合(LBEPS)与腹腔镜下胆总管探查取石后T管引流(LCHTD)治疗胆总管结石的效果,为医患双方合理选择术式提供证据。方法计算机检索Cochrane图书馆临床对照试验数据库(2010年第2期)、PubMed(1978～2010)、EMbase(1966～2010)、CBM(1978～2010)、CNKI(1979～2010)和中华医学会数字化期刊系统(1990～2010),并手工检索中、英文已发表的资料和会议论文并追索纳入文献的参考文献,查找比较LBEPS与LCHTD治疗胆总管结石的随机或半随机对照试验。在对纳入研究进行方法学质量评价后,采用RevMan 5.0软件进行Meta分析。结果共纳入3个随机对照试验和1个半随机对照试验,合计274例患者。Meta分析结果表明:与LCHTD相比,LBEPS能缩短手术时间[WMD=–17.11,95%CI(–25.86,–8.36)]、腹腔引流时间[WMD=–0.74,95%CI(–1.39,–0.10)]、术后住院天数[WMD=–3.30,95%CI(–3.67,–2.92)]和减少住院费用[WMD=–2998.75,95%CI(–4396.24,–1601.26)],而且还能降低由放置T管引起的脱管及拔管后胆漏、胆汁性腹膜炎等并发症的发生[RR=0.56,95%CI(0.29,1.09)]。结论 LBEPS治疗胆总管结石总体疗效优于与LCHTD,其前提是需严格掌握手术适应症。由于纳入研究质量普遍较低,上述结论尚需开展更多设计合理、执行严格的多中心大样本且随访时间足够的随机对照试验加以验证。     

经尿道钬激光治疗浅表性膀胱肿瘤效果的Meta分析

目的比较经尿道钬激光膀胱肿瘤切除术(holmium laser resection of bladder tumors,HOLBT)与经尿道膀胱肿瘤电切术(electrocautery transurethral resection for bladder tumors,TURBT)治疗浅表性膀胱肿瘤的疗效差别,为临床决策提供依据。方法计算机检索MEDLINE、EMbase、CBM、CNKI及Cochrane图书馆,并辅以手工及其它检索,查找所有比较钬激光与电切术治疗膀胱肿瘤的随机对照试验。按照纳入与排除标准选择文献、提取资料和评价质量后,采用RevMan 5.0软件进行Meta分析。结果共纳入9个RCT,合计1323例患者。Meta分析结果显示:①与经尿道电切治疗浅表性膀胱肿瘤术相比,钬激光手术的术中出血少[WMD=–6.04,95%CI(–6.90,–5.19)]、术后膀胱冲洗时间短[WMD=–14.99,95%CI(–17.58,–12.40)]、导尿管留置时间短[WMD=–2.46,95%CI(–3.59,–1.34)]、术后并发症如闭孔神经反射少[OR=0.03,95%CI(0.01,0.09)]、膀胱穿孔少[OR=0.12,95%CI(0.05,0.31)],且术后短期复发率低[OR=0.70,95%CI(0.52,0.96)]。结论当前证据表明,钬激光治疗对膀胱组织损伤小,术中出血少,是一种疗效可靠、并发症少的治疗浅表性膀胱肿瘤的微创术式。     

连花清瘟胶囊治疗流行性感冒疗效和安全性的系统评价

目的系统评价中成药连花清瘟胶囊治疗流行性感冒的临床疗效和安全性。方法计算机检索MEDLINE(Ovid)、The Cochrane Libary、PubMed、VIP、WanFang Data、CNKI和CBM,收集连花清瘟胶囊治疗流行性感冒的随机对照试验(RCT),检索时限均为2000～2011年。按纳入和排除标准筛选试验、提取资料并评价研究质量后,采用RevMan 5.0软件进行统计分析。结果共纳入12个RCT,其中中文11篇,英文1篇,按治疗策略分层进行Meta分析,结果显示:①连花清瘟胶囊组与其他中药治疗组比较共纳入5个RCT,连花清瘟胶囊与羚羊感冒胶囊比较,临床疗效愈显率[RR=1.32,95%CI(1.15,1.52)]、体温疗效愈显率[RR=1.31,95%CI(1.10,1.55)]及退热时间[WMD=–3.98,95%CI(–4.81,–3.15)]差异均有统计学意义;与苦甘颗粒比较,临床疗效愈显率[RR=1.33,95%CI(1.08,1.64)]及体温疗效愈显率[RR=1.58,95%CI(1.20,2.09)]差异均有统计学意义;与中药汤剂比较,退热时间差异也有统计学意义[WMD=5.52,95%CI(0.32,10.72)]。②连花清瘟胶囊组与西药治疗组比较共纳入9个RCT,其中与利巴韦林比较,临床疗效愈显率差异有统计学意义[RR=1.52,95%CI(1.15,2.02)];与磷酸奥司他韦比较,临床疗效愈显率差异无统计学意义[RR=0.96,95%CI(0.77,1.18)],而除病毒核酸转阴时间差异无统计学意义外,在退热,咳嗽、咽痛、周身酸痛、咳痰及头痛等流感样症状缓解方面均有统计学意义。所有纳入研究均未报道与连花清瘟胶囊有关的严重不良反应。结论在流行性感冒的治疗中,连花清瘟胶囊较其他中药及西药更能缓解流感样症状。由于纳入研究数量限制,上述结论尚需进一步开展更多高质量、大样本RCT加以验证。     

骨髓干细胞移植治疗扩张性心肌病疗效及安全性的系统评价

目的系统评价骨髓干细胞移植治疗原发性扩张型心肌病的临床疗效和安全性。方法计算机检索Pub Med、CENTRAL、EMbase、Web of Knowledge、VIP、CNKI、CBM和Wan Fang Data数据库,查找所有骨髓干细胞移植治疗扩张性心肌病的随机对照试验(RCT),检索时限均为建库至2014年3月31日。由2位研究者按照纳入与排除标准筛选文献、提取资料和评价纳入研究的方法学质量,而后采用Rev Man 5.2.0软件进行Meta分析。结果共纳入10个RCT,包括374例患者。Meta分析结果显示:1安全性:与常规治疗相比,骨髓干细胞移植3个月后患者恶性心律失常事件发生率差异无统计学意义[RR=0.81,95%CI(0.38,1.72),P=0.58]。2疗效:与对照组相比,骨髓干细胞移植3个月后患者左室射血分数增加[WMD=3.86,95%CI(2.53,5.20),P<0.000 01]、6个月后左室射血分数增加[WMD=5.54,95%CI(3.02,8.06),P<0.000 1],3个月后6 min步行距离增加[WMD=22.12,95%CI(7.78,36.46),P=0.003],6个月后6 min步行距离增加[WMD=102.79,95%CI(50.16,155.41),P=0.000 1],3个月的心肌灌注缺损面积百分比减小[WMD=–4.00,95%CI(–5.87,–2.13),P<0.000 1];但在3个月后左室舒张末期内径[WMD=–0.37,95%CI(–1.67,0.93),P=0.57]和6个月后左室舒张末期内径[WMD=–0.70,95%CI(–2.76,1.36),P=0.51]方面,差异无统计学意义。结论骨髓干细胞移植治疗扩张性心肌病可明显改善患者心功能且安全性较好。受纳入研究数量和质量的限制,上述结果仍需要更多高质量、大样本的RCT予以验证。     

环磷腺苷葡胺治疗慢性心力衰竭的系统评价

目的系统评价环磷腺苷葡胺(MAC)治疗慢性心力衰竭的疗效和安全性。方法计算机检索Cochrane图书馆临床对照试验资料库(2011年第3期)、MEDLINE(1950～2011.3)、EMbase(1980～2011.3)、中国期刊全文数据库(1995～2011.3)、中国科技期刊全文数据库(1989～2011.3),并手工检索相关会议论文集及药厂资料等。按纳入与排除标准选择试验、提取资料并评价方法学质量后,采用RevMan 5.0软件对数据进行Meta分析。结果共纳入17个RCT,合计1?281例患者,均为低质量研究。Meta分析结果显示:环磷腺苷葡胺+常规治疗组在升高左室射血分数[5.75,95%CI(3.61,7.89)]、提高每搏输出量[WMD=5.55,95%CI(3.71,7.38)]、提高E/A峰值[WMD=0.09,95%CI(0.05,0.14)]及改善6分钟步行距离[WMD=43.52,95%CI(21.00,66.04)]方面均优于常规治疗组,而在提高心输出量[WMD=0.20,95%CI(–0.31,0.71)]和改善心率[WMD=0.64,95%CI(–7.49,8.77)]方面与常规治疗组比较差异无统计学意义。治疗期间环磷腺苷葡胺组未见明显不良反应或过敏反应的报道。结论现有临床研究表明,环磷腺苷葡胺能有效改善慢性心力衰竭患者的射血分数、每搏输出量、E/A峰值和6分钟步行距离,但由于纳入研究存在选择性偏倚和测量偏倚的高度可能性,势必影响结果的论证强度,因此期待更多高质量的随机双盲对照试验提供更高质量的证据。     

国内奥曲肽与乌司他丁联用治疗急性胰腺炎效果的Meta分析

目的系统评价国内奥曲肽与乌司他丁联用治疗急性胰腺炎的疗效和安全性。方法计算机检索CBM、VIP、CNKI和WanFang Data,查找有关应用奥曲肽与乌司他丁联用治疗急性胰腺炎的随机对照试验(RCT),并追索纳入文献的参考文献,检索时限均为建库至2011年2月。由2名评价者独立选择试验、提取资料和评估方法学质量后,采用RevMan 5.1软件进行Meta分析。结果最终纳入12个研究,共1 023例受试者。Meta分析结果显示:奥曲肽与乌司他丁联用在以下方面均优于常规治疗或单用二者之一,且差异有统计学意义:总有效率[RR=0.34,95%CI(0.23,0.52)],腹痛和腹胀缓解时间[SMD=–0.89,95%CI(–1.09,–0.70)],体征(主要为腹部压痛)缓解时间[SMD=–0.95,95%CI(–1.48,–0.42)],平均住院时间[SMD=–1.10,95%CI(–1.58,–0.63)],血淀粉酶恢复正常时间[SMD=–1.14,95%CI(–2.10,–0.17)],疗程结束时阳性例数[RR=0.20,95%CI(0.08,0.51)],尿淀粉酶恢复正常时间[SMD=–0.86,95%CI(–1.04,–0.68)]和治疗结束时阳性例数[RR=0.27,95%CI(0.12,0.63)],治疗结束时IL-6水平[SMD=–2.25,95%CI(–4.39,–0.11)],并发症的发生率[RR=0.39,95%CI(0.28,0.55)],转手术率[RR=0.41,95%CI(0.24,0.69)],病死率[RR=0.43,95%CI(0.29,0.64)];而在血钙恢复正常时间上稍长于常规治疗或单用二者之一,但差异无统计学意义[MD=0.15,95%CI(0.05,0.26)]。结论本Meta分析结果提示,奥曲肽与乌司他丁联用优于常规治疗或二者之一单用,从而为当前国内急性胰腺炎的治疗提供了一种新的治疗选择,在临床上具有良好的应用前景。但由于纳入研究样本量小且质量较低,上述结论尚需要高质量、大样本的随机盲法对照试验加以证实。     

中药冲洗治疗对慢性鼻窦炎鼻内镜术后术腔恢复效果的系统评价

目的系统评价中药液冲洗治疗对慢性鼻窦炎鼻内镜术后术腔恢复的临床疗效和安全性。方法计算机检索PubMed(1980.1～2009.1)、MEDLINE(1980～2009)、EBSCOhost(1975.1～2009.1)、CALIS外文期刊网(1984～2009)、CNKI(1979～2007)、VIP(1989～2009)、CBM(1978～2009),并手工检索《中华耳鼻咽喉头颈科杂志》(1990～2008)、《临床耳鼻咽喉头颈外科杂志》(1988～2008)、《耳鼻咽喉头颈外科》(1990～2008)、《中国中西医结合耳鼻咽喉科杂志》(1996～2008)等,收集慢性鼻窦炎鼻内镜术后使用中药冲洗治疗的随机对照试验(RCT)。按纳入与排除标准筛选试验、提取资料和评价质量,而后采用RevMan 4.2.10软件进行统计分析。结果 3个亚组共纳入32篇中文文献,合计6272例患者进行Meta分析。结果显示,各试验组治愈率[OR=1.99,95%CI(1.78,2.23)],总有效率[OR=2.66,95%CI(2.20,3.22)],术后症状Ⅰ级改善率[OR=2.22,95%CI(1.60,3.06)],术后症状总改善率[OR=8.77,95%CI(1.09,70.64)],术腔清洁时间[OR=2.54,95%CI(1.70,3.79)],术腔上皮化时间[OR=–29.46,95%CI(–37.73,–21.18)],鼻腔纤毛运动速率(mucociliary transport rate,MTR)[OR=1.14,95%CI(0.22,2.06)]均优于对照组。安全性评价共纳入4篇文献进行Meta分析,结果显示试验组胃肠道反应与对照组相比差异无统计学意义[OR=0.25,95%CI(0.00,33.78)],而局部反应与对照组相比差异有统计学意义[OR=0.03,95%CI(0.01,0.12)]。结论在慢性鼻窦炎鼻内镜术后的治疗中,采用中药液冲洗治疗可提高临床疗效、加快愈合时间,不良反应发生率较小,但由于纳入试验方法学质量普遍较低,评价指标较完善的文献较少,尚需进一步开展设计科学、指标合理的随机对照试验。经过筛选,本课题组建议使用如下中药组成冲洗液:黄芩、薄荷、鱼腥草、金银花、辛夷、白芷、黄芪、当归、荆芥。     

血脂康胶囊治疗高脂血症有效性和安全性的系统评价

目的系统评价血脂康胶囊(简称血脂康)治疗高脂血症的有效性和安全性。方法电子检索MEDLINE、EMBASE、Cochrane图书馆临床对照试验注册库、Cochrane协作网内分泌代谢组资料库、中国生物医学文献数据库、中国医院知识仓库,手工检索已发表与未发表的相关文献(检索至2005年12月)。纳入治疗组服用血脂康,对照组服用他汀类等调脂药治疗高脂血症的随机或半随机对照试验。采用CochraneReviewer’sHandbook4.2.2中的方法进行文献质量评价和资料分析。结果共纳入11个研究,1073例原发性高血脂症患者。纳入研究质量均为B或C级。①血脂康降低TC的作用与他汀类[WMD0.06,95%CI(-0.09,0.20),RR1.02,95%CI(0.93,1.12)]、贝特类药物[WMD0.05,95%CI(-0.22,0.31)]及丙丁酚[WMD0.42,95%CI(-0.01,0.85)]相似,并优于烟酸肌醇酯[WMD0.96,95%CI(0.73,1.18)]。②血脂康降低TG作用与他汀类药物[WMD0.02,95%CI(-0.10,0.14),RR1.17,95%CI(0.92,1.49)]、烟酸肌醇酯[WMD0.28,95%CI(-0.17,0.73)]相似、丙丁酚[WMD0.71,95%CI(0.22,1.20)],但弱于贝特类[WMD-0.81,95%CI(-1.40,-0.23)]。③血脂康升高HDL-C作用与他汀类药物相似[WMD-0.03,95%CI(-0.10,0.04),RR1.03,95%CI(0.80,1.33)],优于烟酸肌醇酯[WMD0.15,95%CI(0.01,0.29)],与贝特类[WMD0.03,95%CI(-0.08,0.15)]、丙丁酚[WMD0.04,95%CI(-0.16,0.24)]相似。④血脂康降低LDL-C作用与他汀类药物比较,差异无统计学意义[WMD-0.23,95%CI(-0.61,0.15),RR1.15,95%CI(0.75,1.77)]。血脂康降低LDL-C作用与贝特类[WMD0.19,95%CI(-0.12,0.50)]、丙丁酚相似[WMD0.35,95%CI(-0.03,0.73)],优于烟酸肌醇酯[WMD0.53,95%CI(0.16,0.90)]。⑤不良反应:短期服用血脂康的不良反应主要为胃肠道反应,较少有肝功能异常改变和肌痛。结论血脂康能降低高脂血症患者的TC、TG和LDL-C水平,升高HDL-C水平,其作用与他汀类药物相似,短期服用血脂康未发现有明显的不良反应。本系统评价纳入研究质量和数量有限,上述结论尚需更多高质量、大样本、长期随访的随机对照试验予以验证。     

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.     

Systematic Reviews Published in the January 2011 Issue of The Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly as a DVD and monthly online. The January 2011 issue (first quarterly DVD for 2011) contains 4515 complete reviews, 1985 protocols for reviews in production, and 13,521 one-page summaries of systematic reviews published in the general medical literature. In addition, there are citations of 641,000 randomized controlled trials, and 14,018 cited papers in the Cochrane methodology register. The health technology assessment database contains over 9300 citations. One hundred and seven new reviews have been published in the last 3 months, of which five have potential relevance for practitioners in pain and palliative medicine.     

Interprofessional approaches to creating safe,high quality health care

Three supplementary perspectives are presented arguing that interprofessional collaboration is both necessary and desirable. Nonetheless, there are often too many serious intra-professional barriers and obstacles to interprofessional collaboration to make it successful. Some of these barriers, it is argued and illustrated, are found in the multiple ways in which professional identity is tacitly acquired and embodied in the practitioners' habitual, everyday practice. The paper then explores ways in which reflection, especially Second order reflection, can help to elucidate and overcome these obstacles, as well as increasing professional adaptability and competence.     

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.     

Prise en charge des entorses externes de cheville : étude clinique préliminaire sur l’efficacité du dispositif Myolux™

Ankle sprains are the most common injury of the musculoskeletal system and are associated with significant societal and economic impacts. It has been proven that classical therapeutic strategies may not be effective in preventing recurrent injuries: the recurrence rates reported in the literature can reach 73%. In order to provide an effective rehabilitation solution, a destabilizing orthosis was developed. This device is equipped with a mechanical articulator reproducing the subtalar mechanics and placed under the heel. In this paper, we present the main results of a preliminary clinical study conducted between 2004 and 2007. All subjects included in this study were treated with the abovementioned orthosis during 10 rehabilitation sessions of 30 minutes each. Data show a relatively low recurrence rate of 12% for the overall population. Moreover, it's of primary importance to note that this satisfactory ratio is largely reduced (3% of recurrence rate) for the 29 patients who performed one training session per month after the 10th initial rehabilitation sessions. Hence, the destabilizing orthosis appears to be an effective solution to prevent recurrent ankle sprains. However, joint protection requires long-term and regular training sessions. This result has motivated the development of a similar device allowing patients to perform training sessions at home. Finally, data obtained in this study are promising awaiting the final results of the comparative, multicentric and independent clinical trials currently managed by the Hospices Civils de Lyon.     

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.