尿道内口漏斗各参数诊断女性压力性尿失禁

目的 观察尿道内口漏斗形成后各参数对女性压力性尿失禁（SI）的诊断价值。方法 回顾性分析681例接受经会阴实时三维盆底超声检查的女性,根据尿流动力学检查分为SI组（n=145）与对照组（n=536）。观察并比较2组最大瓦尔萨尔瓦动作时尿道内口漏斗形成率,测量其开放长度、宽度、深度、面积、周长及角度,并计算开放长度占尿道长度的比例;绘制受试者工作特征（ROC）曲线,计算曲线下面积（AUC）,评价各参数对SI的诊断效能。结果 最大瓦尔萨尔瓦动作下,SI组尿道内口漏斗各参数值均高于对照组（P均<0.05）。尿道内口漏斗形成后各参数对诊断SI均有一定价值,以开放角度的诊断效能最高,截断值取5.33°时,AUC为0.78,敏感度、特异度和准确率分别为53.10%、83.21%和76.80%。结论 尿道内口漏斗各参数对于诊断SI均有一定价值,以尿道内口漏斗开放角度的诊断效能最高。     

超声观察不同妊娠时期和分娩方式所致盆底组织功能变化

目的 以超声观察不同妊娠时期及分娩方式所致盆底组织结构及功能改变。方法 选取50名接受规律产前检查的单胎初产妇,根据分娩方式分为阴道分娩组（n=26）和剖宫产组（n=24）,以经会阴超声观察其孕早期（孕6~8周）、孕中期（孕24~28周）、孕晚期（孕37周~分娩前）及产后6~8周和12~14周盆底结构,测量静息态和最大瓦尔萨尔瓦动作时膀胱颈距离耻骨联合后下缘距离（BSD）、尿道倾斜角及膀胱尿道后角,观察尿道内口漏斗是否形成及有无膀胱脱垂,并进行比较、分析。结果 孕早、中及晚期,BSD、尿道倾斜角、膀胱尿道后角差异均有统计学意义（P均<0.05）;孕晚期BSD、尿道倾斜角、膀胱尿道后角与孕早、中期比较差异均有统计学意义（P均<0.05）。最大瓦尔萨尔瓦动作下,孕早期无尿道内口漏斗形成及膀胱脱垂,孕中期尿道内口漏斗形成6例、膀胱脱垂1例,孕晚期尿道内口漏斗形成21例、膀胱脱垂19例。组间比较,产后6~8周,静息态下,BSD、尿道倾斜角及膀胱尿道后角差异均无统计学意义（P均>0.05）,而最大瓦尔萨尔瓦动作下上述参数差异均有统计学意义（P均<0.05）;产后12~14周,静息态下及最大瓦尔萨尔瓦动作下BSD、尿道倾斜角及膀胱尿道后角差异均无统计学意义（P均>0.05）;产后6~8周和12~14周,压力性尿失禁和膀胱脱垂发生率差异均无统计学意义（P均>0.05）。结论 孕晚期盆底组织损伤较严重;不同分娩方式所致盆底组织损伤存在差异;随时间延长,产后盆底结构损伤可逐渐修复。     

经会阴盆底超声用于督导盆底功能障碍患者盆底肌训练并定量评估疗效

目的 观察经会阴盆底超声用于督导盆底功能障碍(PFD)患者盆底肌训练(PFMT)并定量评估其疗效的价值。方法 前瞻性纳入158例PFD患者,并将其随机分为研究组(n=69)和对照组(n=89),嘱患者完成12周PFMT,且对研究组额外增加超声督导、健康宣教及跟踪反馈;采用盆底超声评估患者PFMT前、后盆底功能,包括静息态及最大瓦尔萨尔瓦动作下膀胱颈位置及肛提肌裂孔面积,并分析其价值。结果 PFMT前、后,静息态及最大瓦尔萨尔瓦动作下2组膀胱颈位置及肛提肌裂孔面积差异均有统计学意义(P均＜0.05);且PFMT后,2组膀胱颈位置及肛提肌裂孔面积差异亦有统计学意义(P均＜0.05)。研究组患者PFMT依从性优于对照组(P＜0.05)。结论 经会阴盆底超声可用于督导PFD患者PFMT并定量评估其疗效。     

经会阴盆底超声联合剪切波弹性成像测量肛提肌诊断女性压力性尿失禁

目的 观察经会阴盆底超声联合肛提肌（LAM）剪切波弹性成像（SWE）诊断女性压力性尿失禁（SI）的价值。方法 对32例SI患者（SI组）和34名已育健康女性（对照组）行经会阴盆底常规超声及SWE检查,获取静息状态及最大瓦尔萨尔瓦动作下LAM弹性模量最大值（E_max）和平均值（E_mean）及其最大值的差值（△E_max）和平均值的差值（△E_mean）;行Logistic回归分析,绘制受试者工作特征（ROC）曲线,观察LAM各弹性模量值诊断SI的效能。结果 SI组与对照组间月经状况、尿道漏斗形成情况、BND及LAM厚度差异均有统计学意义（P均<0.05）。SI组LAM的△E_max和△E_mean均小于对照组（P均<0.05）。静息状态下,SI组与对照组LAM的E_max和E_mean差异均无统计学意义（P均>0.05）;最大瓦尔萨尔瓦动作下,SI组LAM的E_max和E_mean均小于对照组（P均<0.05）,且SI组及对照组LAM的E_max和E_mean均大于静息状态下（P均<0.05）。以21.40 kPa为截断值,△E_max诊断SI的敏感度和特异度分别为80.40%和71.90%;以18.80 kPa为截断值,△E_mean的敏感度和特异度分别为85.60%和85.00%,均大于△E_max（P均<0.05）。尿道漏斗形成情况、BND和△E_mean是SI的独立危险因素（P均<0.05）。结论 经会阴盆底超声联合SWE 测量LAM有助于诊断女性SI;△E_mean<18.80 kPa可提示SI。     

分娩镇痛对足月初产女性产后盆底结构的近期影响

目的 观察分娩镇痛对足月初产女性产后盆底结构的近期影响。方法 回顾性分析230名于产后6~8周接受经会阴实时三维盆底超声检查的足月初产女性,根据是否接受分娩镇痛将其分为分娩镇痛组（n=70）和对照组（n=160）;对比观察组间一般资料、产程、静息态、最大瓦尔萨尔瓦动作及盆底肌收缩状态下盆底超声参数,分析分娩镇痛对其盆底结构的影响。结果 分娩镇痛组与对照组受试者年龄、孕次、体质量指数（BMI）、新生儿体质量及产程差异均无统计学意义（P均>0.05）。静息态及最大瓦尔萨尔瓦动作下,组间膀胱颈位置、膀胱位置、子宫位置及直肠壶腹部位置差异均无统计学意义（P均>0.05）;最大瓦尔萨尔瓦动作下,组间膀胱颈移动度及肛提肌裂孔面积差异亦无统计学意义（P均>0.05）。2组受试者肛提肌撕脱发生率及肛门内/外括约肌损伤率差异均无统计学意义（P均>0.05）。结论 分娩镇痛对足月初产女性产后早期盆底结构无明显影响。     

经会阴四维超声评估单切口吊带悬吊术治疗压力性尿失禁

目的采用会阴四维超声观察单切口吊带悬吊术(SIS)治疗压力性尿失禁(SI)术后转归,分析导致治疗失败的可能因素。方法回顾性分析33例SIS术后6~12个月SI患者盆底超声声像图,以压力诱发实验评估治疗效果,并据此将其分为治疗有效组(n=20)和无效组(n=13),比较2组在静息状态及瓦尔萨尔瓦动作下吊带形态及其相对于尿道的位置等。结果静息状态下所有患者吊带均位于尿道后方,无效组2例出现吊带折叠。静息及瓦尔萨尔瓦动作下,有效组吊带相对于尿道的位置均保持一致,无效组中仅3例保持一致,且此3例于瓦尔萨尔瓦式动作下吊带双侧臂不对称(P<0.05);2组吊带中点与尿道中点最短距离以及吊带成角差异均无统计学意义(P均>0.05)。结论经会阴超声可动态观察SI患者SIS悬吊术术后转归,并有助于了解手术失败原因。     

MRI评估宫颈癌子宫根治术后患者肛提肌长期变化

目的 采用MRI评估宫颈癌子宫根治术(RH)后1、5年患者肛提肌变化。方法 前瞻性纳入30例接受RH的宫颈癌患者,分别于术前、术后1年及5年采集静息态及最大瓦尔萨尔瓦动作下盆底MRI,重建骨盆及肛提肌三维模型;测量并比较不同时间点肛提肌裂孔横径(LH-W)、前后径(LH-L)、肛提肌板角度(LPA)、肛提肌体积(LVOL),双侧肛提肌与耻骨联合下缘间距(LSG)、髂尾肌角度(ICA)及厚度(ICT)、耻骨直肠肌厚度、M线及H线长度的差异。结果 静息态及最大瓦尔萨尔瓦动作下,双侧ICT及耻骨直肠肌厚度逐渐变薄、M线逐渐延长,各时间点差异均有统计学意义(P均＜0.05)。术后1年,静息态下LVOL较术前减小(P＜0.05);最大瓦尔萨尔瓦动作下,双侧ICA及LPA均较术前增大而LVOL减小(P均＜0.05)。结论 宫颈癌RH术后患者髂尾肌、耻骨直肠肌逐渐萎缩变薄,盆底支持能力逐渐减弱。     

实时三维超声评估产后女性盆底器官运动及肛提肌裂孔

目的 采用经会阴实时三维超声动态观察和评估产后女性盆底三腔室器官的位置及肛提肌裂孔面积。方法 选取年龄、体质量指数匹配的60名产妇（产后组）和35名未育女性（对照组）,采用经会阴超声分别在静息状态及瓦氏动作下测量膀胱、子宫颈、直肠壶腹部的最低点与参考线（耻骨联合后下缘的水平线）之间的距离,采用实时三维超声测量瓦氏动作下肛提肌裂孔面积,并进行统计学分析。结果 产后组在静息状态和瓦氏动作下膀胱及子宫颈的最低点位置均低于对照组（P均<0.05）,直肠壶腹部位置在静息状态下两组差异无统计学意义（t=0.405,P=0.398）,在瓦氏动作下产后组低于对照组（t=17.378,P<0.001）。产后组在静息状态和瓦氏动作下肛提肌裂孔面积均大于对照组（t=11.253、9.625,P均<0.001）。结论 经会阴实时三维超声可动态观察女性盆底三腔室器官的位置、运动情况及肛提肌裂孔面积,从而评价妊娠和分娩对盆底支持组织的影响。     

盆腔器官活动度和肛提肌裂孔面积用于诊断盆腔器官脱垂

目的 观察盆腔器官活动度和肛提肌裂孔面积诊断盆腔器官脱垂(POP)的价值。方法 收集疑诊盆底肌功能障碍的343例女性患者,根据POP定量系统(POP-Q)将其分为POP组(n=247)及对照组(n=96);记录其静息态至最大瓦尔萨尔瓦动作时的膀胱颈移动度(BNM)、宫颈移动度(CM)、直肠壶腹移动度(RAM)及最大瓦尔萨尔瓦动作下肛提肌裂孔面积(vHA);比较组间上述指标差异,评价其诊断POP的价值。结果 POP组前腔BNM、中腔BNM和CM、后腔RAM与对照组各指标差异均有统计学意义(P均＜0.05);其中,POP组中腔CM与对照组的差异较组间BNM差异更为显著(P=0.001 vs. P=0.01)。以BNM诊断前腔POP、以CM诊断中腔POP、以RAM诊断后腔POP的敏感度分别为85.60%、78.10%、88.60%,以vHA诊断前、中及后腔POP的敏感度分别为79.10%、85.60%及75.60%;以BNM+vHA诊断前腔POP的敏感度为94.96%,以CM+vHA诊断中腔POP的敏感度为97.10%,以RAM+vHA诊断后腔POP的敏感度为95.60%。结论 盆腔器官活动度联合肛提肌裂孔面积有助于诊断POP。     

经会阴超声评估盆底康复治疗近期疗效

目的 探讨经会阴超声评估盆底康复治疗近期疗效的临床价值。方法 对前盆腔器官脱垂或盆底肌力<4级的50例初产妇行盆底康复治疗1个疗程（约6周）。对比治疗前后压力性尿失禁自主症状、前盆腔超声表现、盆底肌力的变化,并进行统计学分析。结果 与治疗前比较,压力性尿失禁自主症状者由12例（12/50,24.00%）减少至3例（3/50,6.00%,P<0.05）;静息状态及最大瓦氏动作时膀胱颈位于经耻骨联合下缘参考线的位置升高;最大瓦氏动作时,Ⅱ～Ⅲ级前盆腔脏器脱垂者由46例（46/50,92.00%）减少为34例（34/50,68.00%,χ²=11.97,P<0.05）;双侧耻骨直肠肌厚度、耻骨直肠肌增厚率均增加（P均<0.05）;Ⅰ类肌纤维肌力≥4级者由4例（4/50,8.00%）增加至24例（24/50,48.00%）,Ⅱ类肌纤维肌力≥4级者由9例（9/50,18.00%）增加至25例（25/50,50.00%）,差异均有统计学意义（P均<0.05）。结论 经会阴超声在评估盆底康复治疗近期疗效中具有重要的临床价值。     

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.     

Dissociable correlates of two classes of retrieval processing in prefrontal cortex

Although substantial evidence suggests that the prefrontal cortex (PFC) implements processes that are critical for accurate episodic memory judgments, the specific roles of different PFC subregions remain unclear. Here, we used event-related functional magnetic resonance imaging to distinguish between prefrontal activity related to operations that (1) influence processing of retrieval cues based on current task demands, or (2) are involved in monitoring the outputs of retrieval. Fourteen participants studied auditory words spoken by a male or female speaker and completed memory tests in which the stimuli were unstudied foil words and studied words spoken by either the same speaker at study, or the alternate speaker. On "general" test trials, participants were to determine whether each word was studied, regardless of the voice of the speaker, whereas on "specific" test trials, participants were to additionally distinguish between studied words that were spoken in the same voice or a different voice at study. Thus, on specific test trials, participants were explicitly required to attend to voice information in order to evaluate each test item. Anterior (right BA 10), dorsolateral prefrontal (right BA 46), and inferior frontal (bilateral BA 47/12) regions were more active during specific than during general trials. Activation in anterior and dorsolateral PFC was enhanced during specific test trials even in response to unstudied items, suggesting that activation in these regions was related to the differential processing of retrieval cues in the two tasks. In contrast, differences between specific and general test trials in inferior frontal regions (bilateral BA 47/12) were seen only for studied items, suggesting a role for these regions in post-retrieval monitoring processes. Results from this study are consistent with the idea that different PFC subregions implement distinct, but complementary processes that collectively support accurate episodic memory judgments.     

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.     

Modified micro-superior percutaneously-assisted total hip: early experiences & case reports

Because of the extensile nature and familiarity of the standard posterior-lateral approach to the hip, a family of "micro-posterior" approaches has been developed. This family includes the Percutaneously-Assisted Total Hip (PATH) approach, the Supercapsular (SuperCap) approach and a newer hybrid approach, the Supercapsular Percutaneously-Assisted Total Hip (SuperPATH) approach. Such approaches should ideally provide a continuum for the surgeon: from a "micro" (external rotator sparing) posterior approach, to a "mini" (external rotator sacrificing) posterior approach, to a standard posterior approach. This could keep a surgeon within his comfort zone during the learning curve of the procedure, while leaving options for complicated reconstructions for the more practiced micro-posterior surgeons. This paper details one author's experiences utilizing this combined approach, as well as permutations of this entire micro-posterior family of approaches as applied to more complex hip reconstructions.     

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.     

Structure and function of "metalloantibiotics"

Although most antibiotics do not need metal ions for their biological activities, there are a number of antibiotics that require metal ions to function properly, such as bleomycin (BLM), streptonigrin (SN), and bacitracin. The coordinated metal ions in these antibiotics play an important role in maintaining proper structure and/or function of these antibiotics. Removal of the metal ions from these antibiotics can cause changes in structure and/or function of these antibiotics. Similar to the case of "metalloproteins," these antibiotics are dubbed "metalloantibiotics" which are the title subjects of this review. Metalloantibiotics can interact with several different kinds of biomolecules, including DNA, RNA, proteins, receptors, and lipids, rendering their unique and specific bioactivities. In addition to the microbial-originated metalloantibiotics, many metalloantibiotic derivatives and metal complexes of synthetic ligands also show antibacterial, antiviral, and anti-neoplastic activities which are also briefly discussed to provide a broad sense of the term "metalloantibiotics."