输尿管镜联合肾筋膜扩张器在女性输尿管下段狭窄并结石治疗中的应用

[目的]探讨输尿管镜联合肾筋膜扩张器在女性输尿管下段狭窄并结石治疗中的效果.[方法]6例女性输尿管狭窄患者于硬膜外麻醉下用F8/9输尿管镜经尿道、膀胱及输尿管口置入输尿管,检查输尿管狭窄情况,直视下将斑马导丝通过狭窄段输尿管置入肾盂,退镜保留导丝,在导丝引导下将肾筋膜扩张器从F8开始依次递增扩张输尿管到F16,每次扩张5 min,拔出F16肾筋膜扩张器,重新置入输尿管镜通过狭窄部输尿管,气压弹道将结石击碎,取石钳将碎结石取出,沿斑马导丝置入F7 D-J管做支架内引流,F18双腔导尿管留置导尿.[结果]本组6例患者5d后拔尿管出院,2个月后拔除D-J管,拔管后腰痛症状消失,术后6个月复查B超肾积水较术前均明显改善.[结论]输尿管镜联合肾筋膜扩张器治疗女性输尿管下段狭窄并结石具有操作简单、安全、实用、复发率低等特点,值得临床上推广使用.     

经皮肾穿刺顺行输尿管支架管置入治疗输尿管梗阻疗效观察

目的探讨采用经皮肾穿刺顺行置入输尿管支架管治疗输尿管梗阻的临床疗效与安全性。方法回顾性分析2009年2月至2013年4月收治的输尿管梗阻患者47例,54患侧,均在逆行插管失败后采用超声引导下经皮肾穿刺会师技术尝试置入输尿管支架管,结合文献复习,从疗效及并发症等方面进行归纳总结。结果47例患者,54患侧均一次穿刺成功并建立经皮肾通道,45患侧在输尿管硬或软镜下顺利留置输尿管支架管,成功率83．3％。9例患者因导丝不能通过狭窄段仅行经皮肾造瘘术。21例术前肌酐高的患者术后15例恢复正常,另有6例肌酐水平也有不同程度下降,患者的造瘘管均可于1周内拔除,所有患者均无严重并发症,需长期留置支架的患者可采用膀胱镜定期更换输尿管支架。结论经皮肾穿刺会师留置支架管操作安全简便,效果较好,是输尿管支架逆行置入失败患者的较佳选择。     

膀胱镜引导下置双J管在后腹腔镜输尿管切开取石中的应用

目的 推介一种简单易行的后腹腔镜输尿管切开取石中双J管置入方法.方法 利用膀胱镜逆行插管原理,在后腹腔镜输尿管切开取石术中,经10 mm Trocar膀胱镜引导下置入带超滑导丝双J管,在监视器下合理运用膀胱镜远端转向杠杆,使双J管头端对准输尿管切口缓慢送入输尿管下端,抽出导丝,换两把分离钳将双J管尾端置入输尿管上段.结果 采用此方法在后腹腔镜输尿管切开取石术中放置双J管共36例,平均置管时间4min,平均手术时间60 min,均顺利完成手术.结论 后腹腔镜输尿管切开取石术是一种安全有效的微创技术,但术中双J管置入是手术难点之一.经10 mm Trocar膀胱镜引导下置入双J管操作更方便,耗时明显减少,也便于训练及推广.     

输尿管阴道瘘15例诊治体会

【目的】探讨榆尿管阴道瘘的诊断、治疗方法与手术时机。【方法】回顾性分析2002～2008年本院诊治的15例输尿管阴道瘘患者的临床资料。诊断手段包括B超、静脉尿路造影（IVU）、美兰试验、膀胱镜及逆行肾孟插管造影;其中,13例早期行输尿管镜下放置双J管术,6例（包括输尿管镜下放置双J管术失败的4例）行输尿管膀胱再植术。【结果】15例患者中13例早期行输尿管镜下放置双J管术后有9例（69．2％）获得治愈,4例输尿管镜下放置双J管术失败后改为输尿管膀胱再植术获得治愈,另外2例病程3个月以上者直接行输尿管膀胱再植术获得治愈,随访6～31个月（平均10．3个月）,所有患者均无阴道流尿。【结论】输尿管镜下置入双J管术是早期处理输尿管阴道瘘的首选治疗方法,失败后可再选择输尿管膀胱再植术。     

F4输尿管导管配合低压灌注在输尿管镜碎石取石术中的应用

目的探讨F4号输尿管导管配合低压灌注对输尿管镜碎石取石术成功率、术中及术后并发症的影响。方法将96例输尿管结石患者,按手术方法的不同分为:F4输尿管导管配合低压灌注组(F4组)、使用斑马导丝配合常压灌注组(斑马导丝组),各48例。结果 F4组与斑马导丝组手术均成功进行,未行开放手术。F4组手术结石上移至肾盂的发生率以及术后肾区严重疼痛、术后发热等早期并发症的发生率明显低于斑马导丝组(P<0.05)。结论 F4号输尿管导管配合低压灌注可以提高输尿管镜碎石取石术的成功率,并有效降低术中、术后的并发症。更多还原     

输尿管阴道瘘8例临床诊治分析

目的探讨妇科手术致输尿管阴道瘘的病因及处理方式。方法回顾性分析本院收治的8例妇科手术导致输尿管阴道瘘患者的病因、诊断及治疗。结果病因中剖宫产术2例,子宫全切术4例,广泛性子宫切除术2例;患者输尿管损伤左侧5例,右侧3例;2例行膀胱镜下逆行置输尿管支架管,6例行输尿管阴道瘘修补术,术后均留置输尿管支架管和导尿管。所有患者均一次修补成功,输尿管支架管留置时间15～90d,未发现严重并发症。结论输尿管损伤重在预防,提高妇科操作技能是预防本病的关键。治疗措施以手术为主,手术时间及方式的选择要取决于患者的就诊时间、一般情况和输尿管梗阻的程度。     

双镜顺逆结合法输尿管支架置入治疗医源性输尿管瘘13例

目的：探讨双镜顺逆结合法输尿管支架置入术治疗医源性输尿管瘘的临床效果。方法对2006年5月—2013年1月我院收治的13例医源性输尿管瘘行双镜顺逆结合法输尿管支架置入术,手术方法：先经皮肾穿刺微造瘘,留置可撕开鞘,置入输尿管镜寻及肾盂输尿管出口后顺行置入泥鳅导丝,导丝引导下置入肾造瘘管;改截石位,输尿管镜逆行进入梗阻段输尿管,将导丝拉出体外并留置输尿管支架。结果13例均成功置入输尿管支架,平均手术时间76(49~132)min,术中失血量<25 ml,术后6~72 h 漏尿停止。术后3个月更换输尿管支架并拔出肾造瘘管,12个月拔出输尿管支架复查静脉肾盂造影,患侧肾显影良好,输尿管通畅。1例造影示输尿管狭窄经输尿管镜下扩张术恢复正常。随访15~36个月,无并发症发生。结论盆腹腔手术尤其是腹腔镜或输尿管镜手术易造成医源性输尿管瘘,双镜顺逆结合法输尿管支架置入术治疗输尿管瘘操作简单、微创、安全性好、成功率高,并可避免二次开放手术。     

一种新的输尿管口扩张术在内镜治疗中的应用

目的探讨在斑马导丝引导下扩张输尿管口的安全性和有效性，提高腔镜下治疗输尿管结石的成功率。方法对输尿管镜常规入镜法失败的27例临床资料进行回顾性分析。结果27例顺利入镜，其中25例腔镜手术成功，2例改开放手术。结论在斑马导丝引导下扩张输尿管口是一种安全、有效的方法，能明显地提高腔镜下治疗的成功率。     

联合治疗输尿管结石继发严重上尿路感染

目的探讨输尿管结石继发严重上尿路感染的治疗方法与疗效。方法回顾性分析24例输尿管结石梗阻继发急性严重上尿路感染患者的临床治疗方法;在积极抗感染的同时,急诊行膀胱镜下逆行插管引流,或在B超引导下经皮肾穿刺置管引流,其中20例感染控制后二期行输尿管镜下碎石或体外冲击波碎石术(ESWL),3例在抗感染同时行ESWL,1例在抗感染同时行输尿管镜下气压弹道碎石术。结果 14例膀胱镜下逆行插管成功,6例在B超引导下行经皮肾穿刺造瘘术成功,10例行ESWL成功。在抗感染同时一期行ESWL或输尿管镜的4例碎石成功。所有患者无输尿管穿孔、输尿管撕裂、严重出血等并发症。术后1～8周输尿管结石全部排净,平均住院28.5 d。结石排净后随访1～9个月,患者肾功能全部恢复正常。结论膀胱镜下逆行插管引流或经皮肾穿刺造瘘引流联合输尿管镜下碎石或ESWL简便,耐受性好,并发症少,可迅速控制感染,清除结石,二者联合应用是输尿管结石继发急性严重上尿路感染的理想治疗方法。     

输尿管硬镜在拔除输尿管支架管中的应用及患者疼痛耐受性研究

摘要:目的 研究输尿管硬镜在拔除输尿管支架管中的应用价值并对接受输尿管硬镜拔管患者疼痛耐受性情况进行比较分析。方法 120例留置输尿管支架管的男性患者,60例行输尿管硬镜拔管,60例行膀胱硬镜拔管;记录两组的拔管时间及拔管中的疼痛评分,对两组的拔管时间及术中的疼痛评分进行比较分析。结果 比较两组拔除支架管的平均操作时间,差异无统计学意义（P=1.000）;比较两组患者的疼痛评分,输尿管硬镜组轻～中度疼痛患者的比例显著高于膀胱镜组（96.67% vs 36.67%）;输尿管硬镜组平均疼痛评分低于膀胱镜组,差异有统计学意义（P＜0.05）。结论 输尿管硬镜下拔除输尿管支架管可显著减轻患者的疼痛程度,值得临床推广。     

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.     

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.     

Molecular characterization of virulence and antimicrobial resistance profile of Shigella species isolated from children with moderate to severe diarrhea in northeastern Brazil

Molecular characterization of virulence and antimicrobial resistance profiles were determined for Shigella species isolated from children with diarrhea in Fortaleza, Brazil. Fecal specimens were collected along with socioeconomic and clinical data from children with moderate to severe diarrhea requiring emergency care. Shigella spp. were isolated by standard microbiological techniques, and we developed 4 multiplex polymerase chain reaction assays to detect 16 virulence-related genes (VRGs). Antimicrobial susceptibility tests were performed using disk diffusion assays. S. flexneri and S. sonnei were the predominant serogroups. S. flexneri was associated with low monthly incomes; more severe disease; higher number of VRGs; and presence of pic, set, and sepA genes. The SepA gene was associated with more intense abdominal pain. S. flexneri was correlated with resistance to ampicillin and chloramphenicol, whereas S. sonnei was associated with resistance to azithromycin. Strains harboring higher numbers of VRGs were associated with resistance to more antimicrobials. We highlight the correlation between presence of S. flexneri and sepA, and increased virulence and suggest a link to socioeconomic change in northeastern Brazil. Additionally, antimicrobial resistance was associated with serogroup specificity in Shigella spp. and increased bacterial VRGs.     

护理干预对面部中重度寻常型痤疮的临床疗效影响分析

目的研究护理干预对面部中重度寻常型痤疮的临床疗效影响。方法选取本院在2014年4月~2016年7月诊治的136例面部中重度寻常型痤疮患者,随机分为研究组与对照组,每组68例;所有患者均依据其情况给予对应的治疗,其中对照组在治疗期间给予常规护理,研究组在对照组的基础上再给予综合性护理干预,比较两组的治疗效果及护理满意度情况等。结果患者在接受治疗和护理后,研究组中度与重度患者的治疗效果较对照组均明显提高(P0.05),研究组护理满意度较对照组明显增高(P0.05)。结论对面部中重度寻常型痤疮患者在其治疗期间给予综合性护理干预,具有良好的效果。