非手术疗法治疗不同TNM分期肝癌的疗效对比研究

目的对比观察非手术疗法治疗不同TNM分期肝癌的疗效。方法716例肝癌患者按非手术疗法[经皮无水酒精瘤内注射（PEI）、射频消融术（RFA）、电化学治疗（ECT）、微波治疗（PMCT）、经导管肝动脉化疗栓塞（TACE）]分5组进行治疗，对比观察TNM不同分期患者非手术疗法的1、2、3、5年生存率。结果5类非手术疗法的1、2、3、5年生存率组间比较显示：TNMⅠ～Ⅱ期病例1年生存率组间差异无统计学意义（P〉0．05），2、3、5年生存率组间差异有统计学意义（P〈0．05），其中TACE组低于其他组。TNMⅢ期病例1、2、3、5年生存率差异无统计学意义（P〉0．05）。TNMⅣ期病例1、2年生存率差异尤统计学意义（P〉0．05）。结论PEI、RFA、ECT、PMCT、TACE等非手术疗法是肝癌治疗的有效手段，在临床治疗巾要根据肿瘤分期、病灶大小、肝功能情况合理的选择非手术治疗方法。     

原发性肝癌伴失代偿肝硬化的射频毁损治疗

目的 评价射频毁损（Radiofrequency Ablation，RFA）治疗伴失代偿肝硬化原发性肝癌患者的疗效。方法 采用RFA治疗41例（RFA组），以肝动脉栓塞化疗（Transarterial Chemoemboliation，TACE）治疗38例（TACE组）作为对照。结果RFA组总缓解率为48．78％（17／41），中位生存率为10．1个月，累计生存率：0．5a为58．38％，1a为33．33％，2a为9．52％；TACE组总缓解率为14．17％，中位生存期为5．1个月，累计生存率0．5a为21．43％，1a为3．57％，2a为0。两组比较差异有统计学意义（P〈0．05）。肝功能损害加重发生率相比：RFA组总胆红素（SB）为36．59％（15／41），谷丙转氨酶（ALT）为48．78％（20／41）和谷草转氨酶（AST）为68．29％（28／41）；TACE组分别为78．95％（30／38），92．11％（35／38），84．21％（32／38），两组比较差异明显（P〈0．05）。结论 RFA治疗伴失代偿肝硬化原发性肝癌疗效好，毒副反应小，肝功能损害轻，是值得推广应用的介入治疗方法。     

射频消融术联合肝动脉灌注化疗栓塞术治疗中晚期原发性肝细胞癌的疗效分析

目的探讨射频消融术（ RFA）联合肝动脉灌注化疗栓塞术（ TACE）治疗中晚期原发性肝细胞癌（HCC）的疗效。方法133例中晚期HCC患者分为两组：单纯RFA组（72例）,行RFA治疗115次;联合治疗组（61例）,RFA治疗后再行TACE治疗,其中RFA 93次,TACE 134次。两组治疗结束后第3、6个月复查CT、AFP进行疗效评价,并随访1、2、3年生存率。结果单纯组和联合组术后3、6个月的有效率分别为73.61％、90.16％（ P＜0.05）和63.88％、85.25％（ P＜0.05）。单纯组和联合组术后3、6个月的AFP分别为（953.36±251.77）μg/L、（537.75±102.52）μg/L （ P＜0.05）和（591.20±106.81）μg/L、（317.75±62.69）μg/L（ P＜0.05）。单纯组和联合组1、2、3年生存率分别为80.56％、66.67％、48.61％和95.08％、77.05％、57.38％。常见不良反应主要是发热、疼痛、转氨酶升高等,经对症处理后均能缓解。结论 RFA联合TACE治疗中晚期原发性肝细胞癌是一种有效的治疗方法,可以有效地控制病灶,延长患者的生存期。     

肝动脉化疗栓塞联合射频消融治疗直径≥5 cm肝细胞癌患者10年疗效及预后分析

目的探讨经导管肝动脉化疗栓塞（TACE）联合射频消融（RFA）治疗直径≥5 cm肝细胞癌（HCC）患者的远期疗效及预后影响因素。 方法选择2006年1月至2015年12月天津第三中心医院收治并接受RFA治疗或RFA联合TACE治疗的HCC患者79例。其中36例HCC患者行单纯RFA治疗（RFA组）,43例HCC患者行TACE联合RFA治疗（TACE联合组）。TACE联合组患者在TACE术后2周内进行RFA治疗。采用χ²检验比较TACE联合组与RFA组患者肿瘤首次完全消融率差异;采用Kaplan-Meier法对2组患者进行生存分析,并采用Log-rank检验比较2组患者的生存率。采用Cox回归分析直径≥5 cm的HCC患者预后的影响因素。 结果TACE联合组患者肿瘤首次完全消融率93.0%（40/43）,RFA组患者肿瘤首次完全消融率为91.7%（33/36）,两者比较差异无统计学意义（χ²=0.051,P=0.821）。TACE联合组及RFA组患者1、3、5、7、10年肿瘤无进展生存率分别为78.8%、56.1%、38.4%、25.2%、16.8%及69.0%、40.0%、20.1%、13.4%、13.4%,两者差异无统计学意义（χ²=3.561,P=0.059）;TACE组患者1、3、5、7、10年总生存率分别为83.4%、57.6%、45.9%、41.3%、31.0%,高于RFA组患者的68.8%、40.2%、24.1%、16.2%、16.2%,且差异有统计学意义（χ²=4.681,P=0.030）。单因素分析结果显示,合并门脉分支瘤栓、肿瘤无假包膜以及甲胎蛋白（AFP）浓度升高是影响直径≥5 cm的HCC患者总生存时间的因素;进一步多因素分析结果显示,合并门脉分支瘤栓及AFP浓度升高是影响直径≥5 cm的HCC患者总生存时间的独立危险因素。 结论TACE联合RFA治疗能延长直径≥5 cm HCC患者的生存时间,改善患者预后;合并门脉分支瘤栓及AFP浓度是影响直径≥5 cm HCC患者预后的独立危险因素。     

介入治疗联合适形放射治疗原发性肝细胞癌的疗效分析

目的：探讨经导管肝动脉灌注化疗栓塞（TACE）与TACE联合三维适形放射治疗（TACE＋3DCRT）原发性肝细胞癌（HCC）的疗效。方法：随机分成两组的HCC患者,均不能手术、门脉无癌栓、无远处脏器转移。50例患者行单纯TACE2次（TACE组）。40例患者在TACE2次后第四周再行三维适形放射治疗（TACE＋3DCRT组）,放疗采用6MV-X射线,4～6Gy／次,隔日一次,3次／周,总剂量45～60Gy。TACE采用碘化油、顺铂、5-氟尿嘧啶、表阿霉素及明胶海绵。结果：TACE组与TACE＋3DCRT组近期疗效有效率（完全缓解＋部分缓解）分别为68．0％（34／50）、87．5％（35／40）,1年生存率分别为78．0％（39／50）、95．0％（38／40）,两组差异均有统计学意义（P〈0．05）。TACE的治疗反应主要为栓塞综合征,3DCRT有7．5％（3／40）发生急性放射性肝炎,经对症、保肝处理后缓解。两组患者均能耐受。结论：TACE＋3DCRT治疗不能手术、门脉无癌栓、无远处脏器转移的HCC的疗效较单纯TACE治疗HCC的疗效好。     

经导管肝动脉化疗栓塞联合局部注射无水乙醇治疗中晚期原发性肝癌

目的探讨经导管肝动脉化疗栓塞（TACE）联合经皮注射无水乙醇（PEI）治疗中晚期原发性肝癌的治疗效果。方法非随机对照研究，纳入90例中晚期原发性肝癌。41例接受TACE联合PEI治疗（治疗组），另49例仅接受TACE治疗（对照组）。全部患者随访12个月，观察安全性、局部治疗效果及生存时间。结果治疗组患者共接受99次TACE、131次PEI治疗，对照组共接受116次TACE治疗。全部患者均无严重并发症出现，治疗组总有效率（CR＋PR）高于对照组，分别是58．5％和28．6％（P〈0．05）。治疗组3、6、12个月生存率及生存曲线均高于对照组（P=0．0002），两组生存率分别为88．19％、75．03％、44．30％和62．12％、36．48％、21．02％，两组差异有显著性（P〈0．05）。结论本文研究结果提示经导管肝动脉化疗栓塞联合经皮注射无水乙醇治疗安全有效，提高了中晚期原发性肝癌的局部治疗效果，延长了患者的生存时间。     

经导管动脉灌注栓塞化疗联合射频消融和无水乙醇化学消融治疗原发性肝癌近期疗效观察

目的观察经导管动脉灌注栓塞化疗联合射频消融和无水乙醇化学消融术治疗原发性肝癌的近期疗效。方法60例病例，其中男性47例，女性13例，平均年龄为49岁。均采用经肝动脉灌注化疗栓塞（transcatheter arterial chemoembolization，TACE），治疗次数2～5次；19例（31．67％，19／60）病灶碘油沉积良好，经CT或MRI证实无肿瘤存活，进行追踪观察；41例（68．33％，41／60）影像学检查示病灶碘油沉积不良，联合射频消融术（radiofrequency ablation，RFA）治疗1—3次，部分病例在RFA治疗同时瘤内注射无水酒精。术后增强CT或MRI随访，检测血AFP值。同时观察1，3，6个月生存率。结果本组60例病人随访6个月影像检查59例显示肿瘤均有不同程度的缩小；联合RFA和PEI治疗的癌灶坏死更为彻底。49例（81．67％，49／60）A清AFP值下降率〉50％，11例〈50％（18．33％，11／60），其中3例（5．0％，3／60）〈20％，1例Child C级晚期肝癌病人因多器官功能衰竭3个月后死亡。1，3，6个月生存率分别为100％，100％，98．33％。结论肝动脉灌注栓塞化疗结合射频消融和无水乙醇化学消融术是治疗肝癌的有效方法。     

三种微创治疗方法序贯联合治疗块状型肝细胞癌

【目的】探讨序贯联合肝动脉化疗栓塞（TACE）与经皮瘤内注药、射频消融（RFA）治疗块状型肝细胞癌（HCC）的临床疗效。【方法】对26例块状型HCC患者,共计39个瘤灶,先行TACE术,根据术后复查情况序贯联合TACE、经皮瘤内注药和RFA继续治疗。观察患者术前、术后6个月各相关指标的变化。【结果]26例患者,共行TACE术59人次,经皮穿刺瘤内注药术31人次,RFA术28人次。术后6个月甲胎蛋白（AFP）较术前明显下降（P〈O．01）。术后3个月、6个月的肿瘤体积分别较术前明显缩小（P〈0．01）。术后3个月肿瘤完全坏死率为89．7％。术前、术后3个月、6个月的肝、肾功能和血常规均在正常范围。1、2、3年患者生存率分别为76．92％、61．54％、34．62％。【结论】序贯联合TACE与经皮瘤内注药、RFA是一种对块状型HCC有效和可行的治疗方法。     

TACE＋PEI治疗原发性肝癌的临床研究

目的探讨肝动脉化疗栓塞术（TACE）结合经皮肝穿刺无水酒精注射术（PEI）治疗原发性肝癌的临床疗效。方法将82例肝癌患者分为对照组和治疗组,对照组单纯行TACE治疗,治疗组给予TACE＋PEI治疗,比较两组的治疗效果。结果治疗组与对照组相比,AFP下降率为88．2％和42．5％,肿瘤体积缩小有效率为83．5％和45％。半年、1年、2年生存率分别为100％、78．04％、53．65％和73．17％、52．22％、24．39％,差异有统计学意义（P〈0．05）。结论肝动脉化疗栓塞术（TACE）结合经皮肝穿刺无水酒精注射术（PEI）治疗原发性肝癌的临床疗效明显优于单纯肝动脉化疗栓塞组。     

肝动脉化疗栓塞联合射频消融术治疗原发性肝癌的疗效分析

目的探讨肝动脉化疗栓塞(TACE)联合射频消融术(RFA)治疗原发性肝癌的临床疗效及安全性。方法根据意愿不同,将70例中晚期原发性肝细胞癌(HCC)患者分为TACE+RFA组37例和TACE组33例。TACE+RFA组采用TACE联合RFA治疗,TACE组采用TACE,观察2组血清甲胎蛋白(AFP)水平的变化,比较治疗3个月后的临床疗效及半年、1年、2年生存率,并记录并发症的发生情况。结果 TACE+RFA组血清AFP水平下降率明显大于TACE组(P0.05),且总有效率显著高于TACE组(P0.05)。TACE+RFA组1、2年生存率明显优于TACE组,差异均有统计学意义(P0.05或P0.01)。治疗期间,2组均未见严重并发症发生。结论 TACE联合RFA能有效治疗HCC,延长患者生存期,其疗效优于TACE单纯治疗。     

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。