腹腔镜下多脏器联合手术的临床体会

目的应用腹腔镜技术行腹腔内多脏器联合手术。方法分析10余年来由肝胆外科、妇产科、泌尿外科等联合完成腹腔镜下多脏器联合手术，其中行LC＋肠粘连松解术23例，LC＋阑尾切除术10例，LC＋肝囊肿开窗引流术12例，LC＋肝活检术13例，LC＋子宫附件手术6例，LC＋右肾囊肿去顶术2例，肝囊肿开窗引流＋肠粘连松解术3例。结果69例手术均顺利完成，无不可控制的出血，无中转开腹，无术后并发症发生。平均手术时间为100min，单病灶LC为45min；术后平均住院天数为5．2d，LC3．8d。所有患者均在术后36h内下床活动，术后第2天恢复饮食。结论腹腔镜下多脏器联合手术不增加患者痛苦，一次手术同时完成两个病灶，缩短了麻醉、手术和住院时间，从而减轻了患者的经济负担，兼有微创美容的效果。     

腹腔镜在腹部多脏器联合手术中的应用

目的 探讨腹腔镜联合手术治疗胆囊疾病合并非寄生虫性肝囊肿或／和阑尾炎的临床价值。方法 21例胆囊炎合并肝囊肿，11例胆囊炎合并阑尾炎，11例胆囊炎合并肝囊肿，阑尾炎。9例胆囊息内合并肝囊肿。均在腹腔镜下切除胆囊，肝囊肿囊壁电凝开窗，吸尽囊液，切除阑尾。结果 平均手术时间增加20～30min，全组术后恢复良好，不增加住院时间，无并发症。结论 腹腔镜联合手术治疗腹腔内多种疾病，更能体现微创优势。     

腹腔镜联合多脏器手术18例报告

随着腹腔镜手术应用范围的拓宽,腹腔镜下联合多脏器手术已被广泛采用。我院于1998年1月～1999年8月共完成腹腔镜联合多脏器手术18例,报告如下。1　临床资料本组腹腔镜联合多脏器手术18例,男4例,女14例,年龄22～67岁,平均41岁。均采用连续硬膜外阻滞麻醉加强化。其疾病种类及手术方法见附表。附表　疾病种类及手术方法疾病种类手术方法例数胆囊结石 肝囊肿ＬＣ 肝囊肿开窗术4胆囊结石 慢性阑尾炎ＬＣ 阑尾切除术5胆囊结石 胆总管结石ＬＣ 胆总管切开取石术2胆囊结石 卵巢囊肿ＬＣ 卵巢囊肿切除术3胆囊结石 肝血管瘤ＬＣ 无水酒精注射1胆囊结…     

腹腔镜联合手术治疗肠粘连合并阑尾炎45例临床分析

目的明确腹腔镜联合手术治疗肠粘连合并阑尾炎的临床疗效。方法选取我院2010年1月～2012年6月收治的肠粘连合并阑尾炎患者87例,随机分为观察组45例和对照组42例,观察组施行腹腔镜阑尾切除术联合肠粘连松解术,对照组施行常规开腹手术,观察两组手术情况、临床效果及并发症情况。结果观察组手术时间、术中出血量、肠蠕动恢复时间、平均住院时间和并发症率均显著少于对照组,差异具有统计学意义(P<0.05)。结论腹腔镜联合手术治疗肠粘连合并阑尾炎疗效显著,手术创伤小,安全性高,术后胃肠功能恢复快,肠粘连复发等并发症率低,值得临床推广应用。     

腹腔镜胆囊切除联合术中内镜下乳突肌切开术治疗胆总管结石的手术配合

目的:总结腹腔镜胆囊切除联合术中内镜下乳突肌切开术(EST)治疗胆总管结石手术的护理配合方法。方法:对14例胆囊结石合并胆总管继发结石患者的临床资料进行回顾分析,术前做好患者准备和物品准备,手术体位的正确摆放术中配合顺序以及术后正确处理。结果:14例手术患者均顺利完成,无术中并发症及术后并发症的发生,效果满意。结论:腹腔镜胆囊切除联合术中EST治疗胆总管结石,可以部分取代开腹手术,且具有创伤小、恢复快、痛苦少等优点。     

腹腔镜胆囊切除联合术中内镜下乳突肌切开术治疗胆总管结石的手术配合

目的：总结腹腔镜胆囊切除联合术中内镜下乳突肌切开术（EST）治疗胆总管结石手术的护理配合方法。方法：对14例胆囊结石合并胆总管继发结石患者的临床资料进行回顾分析，术前做好患者准备和物品准备，手术体位的正确摆放术中配合顺序以及术后正确处理。结果：14例手术患者均顺利完成，无术中并发症及术后并发症的发生，效果满意。结论：腹腔镜胆囊切除联合术中EST治疗胆总管结石，可以部分取代开腹手术，且具有创伤小、恢复快、痛苦少等优点     

胆囊合并肝外胆管结石的微创治疗探讨

目的 探讨胆囊结石合并肝外胆管结石的微创治疗方法、适应证和安全性.方法 选择胆囊结石合并肝外胆管结石患者90例,分别行腹腔镜、胆道镜、十二指肠镜三镜联合和腹腔镜、胆道镜两镜联合手术,并观察术后临床表现.结果 三镜组34例,中转开腹1例(2.94％);腹腔镜手术平均历时92 min;术后发生胆漏2例,无其他并发症,无死亡;术后平均住院日8d.两镜组56例,中转开腹3例(5.36％);手术平均历时73 min;残余结石2例,未发生胆漏,无其他并发症,无死亡;术后平均住院日6.5 d.结论 三镜联合或两镜联合治疗胆囊结石合并肝外胆管结石具有微创、安全的优点;三镜联合分期治疗更适合于合并急性梗阻性化脓性胆管炎患者;两镜联合治疗对于非急性炎症期患者更经济、更安全,患者更易接受.     

后腹腔镜直视下肾穿刺经皮肾镜治疗肾囊肿并上尿路结石(附16例报告)

目的:探讨同期后腹腔镜下肾囊肿去顶减压术联合MPCNL术治疗肾囊肿合并上尿路结石的临床应用价值。方法:回顾性分析我院近年收治的16例肾囊肿合并上尿路结石患者,实施同期后腹腔镜下肾囊肿去顶减压术联合MPCNL术的临床效果,观察手术成败、手术时间、术中出血量、结石清除率及囊肿复发情况。结果:16例手术均顺利完成,术后无发热、感染、高血压等并发症。手术平均时间125 min;术中平均出血量82 ml;平均住院8.5 d;随访6~12个月,未见囊肿复发;其中首次结石清除13例(81.25%),二期手术结石清除3例(18.75%),结石总清除率100%。结论:同期后腹腔镜下囊肿去顶减压术联合MPCNL术治疗肾囊肿合并上尿路结石效果明显,兼备了微创手术创口小、恢复快、住院时间少等优点,同时具有结石清除率高的优点,但同时存在一定局限,受研究样本限制,研究仅供参考。     

十二指肠镜联合腹腔镜治疗胆囊结石并胆总管结石80例的护理

目的探讨护理在十二指肠镜联合腹腔镜治疗胆囊结石合并胆总管结石中的作用。方法分析徐州医学院附属淮安医院2005-06-2010-01间采用十二指肠镜联合腹腔镜治疗胆囊结石合并胆总管结石患者80例。结果 77例患者均成功实施十二指肠镜联合腹腔镜治疗,术后恢复快,护理效果满意。结论十二指肠镜联合腹腔镜治疗胆囊结石合并胆总管结石创伤小、恢复快、并发症少,加强围术期护理可为治疗的成功提供重要保证。     

子宫附件肿块合并慢性阑尾炎腹腔镜联合手术

目的 探讨子宫附件肿块合并慢性阑尾炎腹腔镜联合手术的可行性及临床意义.方法 对该院1999年6月～2005年6月实施的22例子宫附件肿块合并慢性阑尾炎腹腔镜联合手术进行回顾性分析.结果 22例全部腹腔镜下顺利完成手术,无中转开腹手术,无手术并发症.结论 子宫附件肿块合并慢性阑尾炎腹腔镜联合手术是安全可行的,符合联合手术的原则,体现了微创的优越性,并可以明确慢性阑尾炎的诊断.     

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。