术中心外膜超声心动图引导和评价一种新型肺动脉支架瓣膜植入的实验研究

目的 应用术中心外膜超声心动图来引导和评价一种新型肺动脉支架瓣膜的植入.方法 10只羊接受新型肺动脉支架瓣膜植入术.术中心外膜超声心动图测量并选择新型肺动脉支架瓣膜的型号,术中采用经心外膜超声心动图的方法引导植入,术后应用术中心外膜超声心动图来评价这种新型肺动脉支架瓣膜植入后的位置和血流动力学功能情况.结果 1只羊术中即出现了支架脱落至右室,余9只羊的支架瓣膜位置固定且功能良好,1只羊出现少中量中心性反流,2只羊提示有少量的中心性反流,均未出现瓣膜狭窄或瓣周漏等并发症.结论 术中心外膜超声心动图在这种新型肺动脉支架瓣膜的植入术中发挥了不可或缺的作用.     

三维经食管超声心动图在经导管主动脉瓣植入术中的应用研究

目的探讨三维经食管超声心动图在经导管主动脉瓣植入术中的应用价值。方法对16例严重主动脉瓣病变患者分别经由两种不同手术入径行经导管主动脉瓣植入术(transcatheter aortic valve implantation,TAVI),其中7例重度主动脉瓣狭窄(主动脉瓣狭窄面积1.0 cm2,主动脉瓣口最大流速≥4 m/s,平均跨瓣压差≥40 mm Hg)和1例人工生物主动脉瓣中重度反流患者行经股动脉TAVI,另外4例重度主动脉瓣狭窄和4例重度主动脉瓣反流患者行经心尖TAVI,术前均行常规经胸超声心动图检查及三维经食管超声心动图检查,术中三维经食管超声心动图监测,术后常规经胸超声心动图随访。结果经股动脉TAVI组:所有患者均成功经导管植入人工生物主动脉瓣,其中1例患者术中发现心包填塞合并升主动脉夹层分离。经心尖TAVI组:所有患者均成功植入人工生物主动脉瓣,无并发症发生。CT和经食管三维超声心动图测量主动脉瓣环最大径、最小径、瓣环面积及狭窄瓣口数据的比较,二者相关性良好,r值分别为0.99(瓣环最大径)、0.97(瓣环最小径)、0.98(瓣环面积)、0.99(狭窄瓣口面积);术前连续性方程测量的狭窄瓣口面积与CT及3D-TEE比较,二者相关性良好,r值均为0.99。结论三维经食管超声心动图能快速、准确地测量主动脉瓣环的大小及评价主动脉的解剖结构,并且能实时引导、监测经导管人工生物主动脉瓣的植入。     

超声心动图用于心尖入路经导管主动脉瓣植入术

目的 评价超声心动图用于心尖入路经导管主动脉瓣植入术(TAVI)的价值.方法 纳入23例接受J-Valve TAVI的主动脉瓣疾病患者,根据主要疾病,将其中20例非重度主动脉瓣狭窄(AS)合并中度以上主动脉瓣反流(AR)者分为AS组(n=10)及AR组(n=10).术前行经胸超声心动图(TTE),术中全程以经食管超声心...     

经心尖途径经导管主动脉瓣置换术救治单纯性主动脉瓣重度反流1例

目的 探讨经心尖途径经导管主动脉瓣置换术治疗单纯性主动脉瓣关闭不全的可行性.方法 回顾性分析2016年9月8日浙江大学医学院附属第二医院心脏中心开展的浙江省首例经心尖途径经导管主动脉瓣置换术的术前评估、术中操作以及患者术后情况.结果 患者严格进行术前评估,术中行全身麻醉、气管插管,透视下定位后第五肋间小切口进胸,打开心包,选择心尖裸区预置荷包,穿刺后导入超滑泥鳅导丝跨过主动脉瓣到达降主动脉,导入J-Valve输送系统逐步释放,经食道超声心动图评估主动脉瓣反流从术前的大量到瓣膜释放后无反流,撤出瓣膜输送系统,手术成功结束.术后患者症状明显缓解,出现Ⅰ度房室传导阻滞,未发生死亡、心肌梗死、心包填塞、动脉夹层等并发症.结论 经心尖途径经导管主动脉瓣置换术是安全可行的,患者的远期预后还有待进一步观察.     

动态三维超声灰阶成像在犬心脏起搏电极置放中的初步应用

目的探讨动态三维超声灰阶成像引导犬心脏起搏电极精确定位的可行性.方法采用动态三维超声心动图(3-DE)为主要影像学监测技术,引导6例犬心包吊床模型右心室室间隔、右心室心尖、左心室室间隔及左心室心尖起搏电极置放.结果3-DE在较短时间内引导电极到达目标位置,减少了X线曝光的幅射时间和剂量.3-DE能清晰显示起搏电极与心脏特定结构及心内膜之间的空间位置关系.结论3-DE有助于心脏起搏电极的置放,具有潜在的临床应用前景.     

三维经食管超声心动图在心尖入路经导管主动脉瓣置换术中的应用价值

目的 探讨三维经食管超声心动图（3D-TEE）在经心尖入路的经导管主动脉瓣置换术（TA-TAVR）中的应用价值。方法 连续选取行TA-TAVR植入J-Valve瓣膜的患者44例，所有患者均于全身麻醉下，应用3D-TEE评估主动脉根部结构及瓣叶病变，引导J-Valve输送系统进入左室并释放人工瓣膜，术后即刻评价手术效果及术后并发症。结果 在3D-TEE实时监测引导下，42例患者成功植入J-Valve瓣膜，成功率95.45%。3D-TEE预测人工瓣膜型号与实际植入瓣膜型号的符合率为72.72%，术后即刻瓣周反流的发生率为33.33%，左室射血分数无明显变化。结论 3D-TEE可在TA-TAVR中提供重要的引导作用，并即刻评价手术效果及并发症，具有重要的临床价值。     

超声心动图在经导管主动脉瓣置换术中的应用价值

目的 探讨超声心动图在主动脉瓣膜病变患者经导管主动脉瓣置换术（TAVR）的术前评估、术中监测及术后随访中的应用价值。方法 回顾性分析我院收治的32例行TAVR的主动脉瓣膜病变患者的临床资料，分为单纯主动脉狭窄患者13例（Ⅰ组），单纯主动脉瓣反流患者6例（Ⅱ组），主动脉瓣狭窄合并反流患者13例（Ⅲ组）。分析各组术前多层计算机断层扫描（MSCT）对主动脉根部结构测值、术前及术后1个月超声心动图参数的差异，以及术中情况、术后并发症发生情况。结果 32例患者术中均经股动脉植入瓣膜，并应用经食管超声心动图（TEE）监测，其中2例于TEE引导下行房间隔穿刺逆行跨主动脉瓣，4例采用瓣中瓣手术。术前实时三维经食管超声心动图（RT-3D TEE）与MSCT测得的主动脉瓣环最大径、最小径、面积、周长，以及左、右冠状动脉开口高度比较，差异均无统计学意义。术后即刻TEE评估：少至中量瓣周漏4例，少量瓣周漏9例，微量瓣周漏5例，无瓣周漏14例。经胸超声心动图结果显示，与术前比较，Ⅰ组术后1个月主动脉瓣峰值流速（AV Vmax）、主动脉瓣平均跨瓣压差（AVPGmean）、室间隔厚度（IVST）、左室后壁厚度（PW...     

超声心动图诊断主动脉瓣四瓣化畸形

目的 观察超声心动图诊断主动脉瓣四瓣化畸形(QAV)的价值.方法 纳入63例QAV患者,将其分为轻度主动脉瓣反流(AR)组(n=20)、中度AR组(n=35)及重度AR组(n=8);回顾性分析超声声像图及临床资料,观察临床因素及瓣膜超声征象对于QAV的诊断效能.结果 经胸超声心动图(TTE)和/或经食管超声心动图(TE...     

超声引导下腔静脉滤器植入术的安全性评估及个体化原则

目的：探讨超声引导与X线引导在下腔静脉滤器（IVCF）植入术中的应用价值.方法：2012-2013年我院因下肢深静脉血栓置放IVCF患者共计42例,其中超声引导下23例,X线引导下19例.对两种方式在技术成功率、植入时间、术后并发症等进行比较.结果：两组释放均取得成功,超声组在股静脉穿刺、手术时间,穿刺点血肿、X线辐射等明显好于X线组,同时远期并发症两组无明显差别.但在滤器释放位置上X线组好于超声组.结论：超声引导下IVCF置入术具有操作时间短、适应证范围广、费用低廉、无辐射等优点,与X线引导具有一定的互补性,是一种简便、安全、可靠的引导方法,具有较高的临床应用价值.     

二维、三维经食管超声心动图在经导管主动脉瓣植入术中的应用价值

目的探讨二维、三维经食管超声心动图在经导管主动脉瓣植入术（TAVI）中的应用价值。 方法对2010年5月至2015年10月在复旦大学附属中山医院行TAVI的11例重度主动脉瓣狭窄[主动脉瓣狭窄口面积<1.0 cm²,主动脉瓣口最大流速>4 m/s,平均跨瓣压差>40 mmHg（1 mmHg=0.133 kPa）]和1例人工生物主动脉瓣中重度反流患者术前均行常规经胸超声心动图检查及二维、三维经食管超声心动图检查（2DTEE、3DTEE）,术中二维、三维经食管超声心动图监测,术后常规经胸超声心动图随访。采用Pearson相关分析分析3DTEE与计算机断层扫描（MDCT）评价主动脉瓣环最大值、最小值、瓣环面积以及狭窄口面积的相关性及3DTEE、MDCT与连续性方程评价狭窄口面积的相关性。 结果所有患者均成功植入人工生物主动脉瓣,其中1例患者术中发现心脏压塞合并升主动脉夹层分离,经心包穿刺以及升主动脉夹层分离保守治疗3 d后突发心脏压塞死亡。所有患者MDCT与3DTEE评价主动脉瓣环最大径、最小径、瓣环面积及狭窄口面积的相关性均较好（r=0.98、0.97、0.97、0.99,P均<0.01）;术前连续性方程测量的主动脉狭窄口面积与MDCT及3DTEE评价结果的相关性均很好（r值均为0.99,P均<0.01）。 结论2DTEE、3DTEE能快速、准确地定量主动脉瓣环的大小及评价主动脉的解剖结构,能实时引导和监测经导管主动脉瓣植入及其并发症。     

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.     

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.     

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.     

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.     

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.