经阴道超声对妊娠早期胎心血流动力学变化的检测

目的　运用经阴道超声对妊娠早期胎儿心脏进行血流动力学检测 ,了解胎心血流的时相变化。方法　采用经阴道多普勒超声技术对 12 0例胎龄为 7～ 12周正常孕妇的胎儿心脏进行研究。结果　妊娠早期胎心血流存在时相变化 :①妊娠第 9周起 ,胎心流入道波形由单峰转变为双峰 ,e峰出现。②e/a值随胎龄增大而增大 ,提示心脏顺应性的改善。e峰的逐渐增大是e/a值增大的原因 ,a峰在妊娠 8周后增加不显著。③胎心率早期随胎龄增加而增快 ,第 10周时最快 ,之后则有所减慢。④等容收缩期 (ICT)和等容舒张期 (IRT)随胎龄增大而减小 ,ICT的减小较显著。⑤流出道血流速度随胎龄增加而增大。结论　妊娠早期胎儿心脏可用经阴道超声进行无创和连续的观测 ,其血流动力学变化存在时相性特征。本研究为连续监测正常孕期胎心的发育及血流动力学变化提供了重要依据     

Tei指数在评估孤立性心包积液胎儿心功能中的价值

目的测量妊娠中晚期孤立性心包积液胎儿心脏的Tei指数,观察与胎龄的关系,初步评估其临床应用价值。方法经超声检查诊断为孤立性心包积液的胎儿51例。应用组织多普勒技术分别测量左、右心室的等容收缩时间(ICT)、等容舒张时间(IRT)、射血时间(ET),根据公式计算Tei指数,并与对照组进行比较,同时分析Tei指数与胎龄之间的关系。结果正常中晚期妊娠胎儿的Tei指数随胎龄增大而减小,少量心包积液胎儿Tei指数与对照组比较差异无统计学意义,中量及大量心包积液胎儿Tei指数与对照组比较有明显统计学差异。结论正常妊娠中晚期胎儿心脏的心肌做功指数随胎龄的增大明显改善,妊娠中晚期有少量心包积液的胎儿心脏心肌做功指数正常,而中量及大量心包积液胎儿的心脏心肌做功指数减低;Tei指数测量方法简单、快捷、可靠,是评价妊娠期心包积液胎儿心功能和预后的理想指标。     

超声心动图评估双胎妊娠并发症孕妇左心结构和功能的研究

目的应用超声心动图评估双胎妊娠并发症孕妇左心结构和功能随孕周增长的变化规律。方法选取经我院定期产前检查诊断的双胎妊娠并发症孕妇20例(病例组)和正常双胎妊娠孕妇50例(对照组),均于妊娠早中期(孕11～14周)、妊娠中期(孕21～26周)及妊娠晚期(孕28～34周)行常规产前超声检查和成人超声心动图检查,对病例组孕妇的左心结构和功能进行纵向研究,并与对照组各相关参数进行比较。结果两组孕妇左房舒张末期内径均随孕周增加而增大,其中病例组左房收缩末期内径在妊娠中晚期显著增加,两组比较差异有统计学意义(P0.05);两组二尖瓣舒张早期血流峰值速度与二尖瓣环舒张早期运动峰值速度比值(E/e’)均随孕周增长而升高,但病例组心输出量、心脏指数、心率及左室射血分数(LVEF)随孕周增加无明显变化;与对照组比较,病例组妊娠早中期LVEF低,妊娠中期Tei指数高,差异均有统计学意义(均P0.05)。结论双胎妊娠并发症孕妇左房舒张、收缩末期内径随孕周增大而增加,心输出量、心脏指数、心率随孕周增大未出现正常适应性改变,妊娠早中期即表现为左室收缩末期内径增高、LVEF降低,妊娠中期心脏整体功能较差。     

应用多普勒超声在妊娠11+0～14+6周筛查先天性心脏畸形的初步研究

目的 在妊娠早期末和妊娠中期初联合应用二维超声和多普勒超声观察胎儿心脏结构、心内 和心外血流,探索在此阶段多普勒超声在筛查胎儿先天性心脏发育异常中的价值.方法 在妊娠11 +0 ～ 14 +6周进行常规胎儿产前超声检查,结合颈项透明层厚度(NT)和颈部软组织厚度(NF)测量,观察胎儿心脏 大体结构,应用脉冲多普勒超声获取胎儿二尖瓣、三尖瓣和静脉导管血流频谱,并进行相应的血流频谱分析.所有胎儿在妊娠中期进行胎儿超声心动图检查或在出生后进行新生儿超声心动图检查.结果 正常胎儿 335 例,NT 或NF 增厚者9 例,其中1 例在妊娠13 周诊断心脏永存动脉干畸形,引产后病理证实,2 例选择14 周前终止妊娠,2 例妊娠中期超声筛查胎儿其他结构异常选择中期引产,无心脏结构异常,4 例足月分娩,无 心脏结构异常.正常胎儿舒张早期时间(EADT)较舒张晚期时间(ENDT)短,左右心室之间无统计学差异.NT 增厚不伴心脏畸形胎儿仅部分胎儿静脉导管搏动指数(PI)、阻力指数(RI)、收缩期峰值流速与舒张期最 低流速比值(S/D)增高.永存动脉干胎儿左右心室E/A 比值较正常胎儿异常增高或下降,EADT 缩短,ENDT 延长,EADT/ENDT 比值缩小,静脉导管血流波形异常.结论 妊娠13 周后,随着胎儿心脏各个切面的显示 率不断增高,可有针对性地对特殊群体进行早期的胎儿超声心动图检查,筛查严重的先天性心脏畸形.分析 二尖瓣和三尖瓣的血流频谱,判断左右心室的血流动力学变化,并结合观察静脉导管的血流波形,可以辅助 筛查胎儿先天性心脏畸形.如果仅二维超声怀疑心脏结构异常,而心内和心外血流动力学未发生改变者,应 慎重诊断先天性心脏畸形,避免误诊.     

妊娠期高血压疾病对晚期妊娠胎儿心脏Tei指数的影响

目的 研究妊娠期高血压疾病(HDCP)对晚期妊娠胎儿心脏Tei指数的影响.方法 应用超声心动图测量41例HDCP患者的胎儿(28～36孕周)和41例与其胎龄匹配的正常胎儿的心脏多普勒时间间期,计算左、右心室Tei指数范围,分析两者之间差异.结果 41例HDCP患者的胎儿左心室Tei指数为0.35±0.01.右心室Tei指数为0.36±0.01,与正常胎儿左、右心室Tei指数(0.33±0.04与0.32±0.05)比较,差异有统计学意义(P均＜0.01);不同程度HDCP组胎儿和对照组胎儿左、右心室Tei指数比较,只有重度子痫前期组(0.36±0.03与0.37±0.04)与对照组Tei指数差异有统计学意义(P均＜0.01).结论 HD-CP患者晚孕期胎儿心脏Tei指数增高,提示其胎儿可能存在心功能异常;胎儿心脏Tei指数改变与HDCP患者病情发展程度有关.     

妊娠晚期妊娠高血压综合征胎儿右心室Tei指数与静脉导管指数的对比研究

目的 检测胎儿右心室Tei指数与静脉导管指数,探讨二者对右心功能评价的敏感性.方法 用多普勒超声心动图测量30例孕龄28～40周的妊娠高血压综合征(妊高征)胎儿及55例孕龄28～40周正常胎儿右心室等容收缩和舒张时间间期,获得右心室Tei指数;用多普勒静脉导管血流流速曲线法获得前负荷指数、峰值流速指数.比较妊高征组与正常对照组Tei指数差异有无统计学意义.用ROC曲线比较右心室Tei指数与静脉导管指数监测胎儿心功能变化的敏感性.结果 妊高征组右心室Tei指数与正常对照组有差别,静脉导管指数与正常对照组差异无统计学意义(P＞0.05).ROC曲线比较,右心室Tei指数曲线下面积为0.77±0.07,静脉导管指数曲线下面积＜0.5.结论 Tei指数评估胎儿右心室功能的变化比静脉导管指数更敏感,有利于尽早发现胎儿心功能异常.     

超声心动图评估双胎妊娠并发症孕妇左心结构、功能的研究

目的 探讨双胎妊娠并发症孕妇左心结构、功能随孕周的变化规律。 方法 选取我院定期产前检查诊断的双胎妊娠并发症孕妇20例（病例组）和正常双胎妊娠孕妇50例（对照组）,均已于妊娠早中期（11~14周）、妊娠中期（21~26周）及妊娠晚期（28~34周）行常规产前超声检查和成人超声心动图检查,对双胎妊娠并发子痫前期、胎儿生长受限孕妇的左心结构和功能进行纵向研究,并与正常双胎孕妇各相关参数进行比较。结果 两组孕妇左房舒张末期内径均随孕周增加而增长,其中病例组左房收缩末期内径在妊娠中晚期间显著增加,两组比较病例组妊娠早中期左室收缩末期内径高,差异有统计学意义（P＜0.05）;两组二尖瓣舒张早期血流峰值速度与二尖瓣环舒张早期运动峰值速度比值（E/e''）均随孕周增长而升高,但病例组心输出量（CO）、心脏指数（CI）、心率（HR）及左室射血分数（LVEF）随孕周增加无明显变化;与对照组比较,病例组妊娠早中期LVEF低,妊娠中期Tei指数高,两组比较差异有统计学意义（P＜0.05）。结论 双胎妊娠并发症孕妇左房舒张、收缩末期内径随孕周增大而增加,CO、CI及HR随孕周增加未出现正常适应性改变,妊娠早中期即可表现为左室收缩末期内径高、LVEF低,妊娠中期心脏整体功能较差。     

孕11～14周正常胎儿心脏经阴道与腹部超声检查的对比研究

目的探讨经阴道超声检查观察孕11～14周胎儿心脏的方法及其诊断价值。方法对158例有高危妊娠病史及胎儿颈项透明层增厚且胎儿心脏正常的孕妇,于孕11～14周采用经阴道超声检查及腹部超声检查进行胎儿心脏检查。结果经阴道超声检查对孕12+0～12+6周、孕13+0～13+6周、孕14+0～14+3周胎儿心脏四腔心、左心室流出道及右心室流出道切面的显示明显优于腹部超声检查,两者相比差异有统计学意义(P0.01,P0.05)。而经阴道超声检查对孕11+0～11+6周胎儿心脏各切面的显示与腹部超声检查相比差异无统计学意义(P0.05)。结论对早孕晚期及中孕早期的高危孕妇行经阴道超声检查有临床应用价值。     

组织多普勒纵向评估正常胎儿及新生儿Tei指数

目的采用组织多普勒成像(TDI)纵向评估正常中晚孕同一胎儿不同孕周及新生儿期左、右室Tei指数的范围,并探讨Tei指数与孕周的关系。方法应用TDI测量100例同一正常孕妇的正常胎儿在不同孕周(22~24周、32~34周、36~38周)及新生儿期二、三尖瓣环的运动频谱,测量等容收缩时间(ICT)、等容舒张时间(IRT)、射血时间(ET),计算Tei指数,将同一胎儿不同孕周及新生儿期左、右心室Tei指数进行统计分析。结果正常胎儿不同孕周(22~24周、32~34周、36~38周)及新生儿期左、右心室Tei指数分别为0.452±0.054、0.452±0.057、0.418±0.065、0.368±0.061,0.453±0.045,0.453±0.054、0.399±0.056、0.316±0.069;左、右心室Tei指数不同时期间差别有统计学意义(P0.05),34周前Tei指数随孕周增加无变化,34周后随孕周增加而下降,新生儿期进一步降低。结论 TDI测量Tei指数是一种简单、可靠、无创的定量综合评价心脏收缩和舒张功能的方法,同一正常孕妇的正常胎儿在不同孕周及新生儿期Tei指数测量值范围为未来研究各种病理状态下的胎儿、新生儿心功能异常提供可靠的常规对照指标。     

蒽环类药物对肿瘤患者心脏Tei指数影响的临床研究

目的探讨利用心肌做功指数(MPI,Tei指数)早期检测和评估蒽环类药物(ATC)对肿瘤患者心脏毒性的临床价值。方法用多普勒法测定46例恶性肿瘤患者ATC化疗前和化疗后3~6个月左心Tei指数,常规超声心动图EF、FS和E/A指标。结果与化疗前比较,Tei指数相关参数中ATC化疗后左心室等容舒张时间(IRT)延长,等容舒张指数(IRT/ET)增大,E/A指标降低(P<0.05)。左心室等容收缩时间(ICT),等容收缩指数(ICT/ET),EF和FS指标较化疗前无显著性差异。结论在早期评价ATC对肿瘤患者心脏功能损害方面,Tei指数、等容舒张指数是敏感的指标,E/A指标虽然在应用上有局限性,但也有一定参考意义。     

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.     

Prospects for the control of neglected tropical diseases by mass drug administration

The prospects for the control of neglected tropical diseases, including soil-transmitted helminthiasis, shistosomiasis, lymphatic filariasis, onchocerciasis and trachoma, through mass drug administration, are exemplified by the elimination of the trachoma as a public-health problem in Morocco. In spite of this and other striking successes, mass drug administration programs are faced with major challenges resulting from suboptimal coverage and lack of efficacy. At current suboptimal coverage rates, programs may need prolongation for an extended period, increasing costs and undermining sustainability. Community participation through health education and information appears to be crucial to improve coverage and to achieve sustainability. Implementation of complementary measures, such as vector control, improved hygiene and environmental sanitation, are important to further control transmission and to prevent re-emergence of the infection and, again, may only be achieved effectively through community-based initiatives. To reduce costs and to relieve pressure on the health system, combining neglected tropical disease programs in areas where diseases coexist and integration with existing control programs for malaria, tuberculosis and HIV/AIDS is advocated. The risk of developing drug resistance is of particular concern in view of the lack of alternative drugs, and reduced treatment efficacy due to emerging resistance is evident for the soil-transmitted helminths and onchocerciasis. Given the risk for the development of drug resistance and the need for a high degree of participation, close attention should be paid to the monitoring of the coverage and efficacy of the different program components.     

Bacterial meningitis: an update of new treatment options

The outcome of bacterial meningitis critically depends on the rapid initiation of bactericidal antibiotic therapy and adequate management of septic shock. In community-acquired meningitis, the choice of an optimum initial empirical antibiotic regimen depends on the regional resistance patterns. Pathogens resistant to antibacterials prevail in nosocomial bacterial meningitis. Dexamethasone is recommended as adjunctive therapy for community-acquired meningitis in developed countries. In comatose patients, aggressive measures to lower intracranial pressure <20 mmHg (in particular, external ventriculostomy, osmotherapy and temporary hyperventilation) were effective in a case–control study. Although many experimental approaches were protective in animal models, none of them has been proven effective in patients. Antibiotics, which are bactericidal but do not lyse bacteria, and inhibitors of matrix metalloproteinases or complement factor C5 appear the most promising therapeutic options. At present, vaccination is the most efficient method to reduce disease burden. Palmitoylethanolamide appears promising to enhance the resistance of the brain to infections.     

Imaging choices in occult hip fracture

Background: Hip fracture is a common injury, with an incidence rate of > 250,000 per year in the United States. Diagnosis is particularly important due to the high dependence on the integrity of the hip in the daily life of most people. Objectives: In this article we review the literature focused on hip fracture detection and discuss advantages and limitations of each major imaging modality. Discussion: Plain radiographs are usually sufficient for diagnosis as they are at least 90% sensitive for hip fracture. However, in the 3–4% of Emergency Department (ED) patients having hip X-ray studies who harbor an occult hip fracture, the Emergency Physician must choose among several methods, each with intrinsic limitations, for further evaluation. These methods include computed tomography, scintigraphy, and magnetic resonance imaging. Conclusion: We present an evidence-based algorithm for the evaluation of a patient suspected to have an occult hip fracture in the ED. Also outlined are future directions for research to distinguish more effective techniques for identifying occult hip fractures.     

Systematic Reviews Published in the April 2012 Issue of the Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly as a DVD but monthly online. The April 2012 issue (second DVD for 2012) contains 5045 complete reviews, 2182 protocols for reviews in production, and 17,084 short summaries of systematic reviews published in the general medical literature. In addition, there are citations of 674,000 randomized controlled trials, and 15,400 cited papers in the Cochrane methodology register. The health technology assessment database contains just over 11,000 citations. One hundred and seventeen new reviews have been published in the last 3 months of which 12 have potential relevance for practitioners in pain and palliative medicine. The impact factor of the Cochrane Library stands at 6.186. Readers are encouraged to access the full report for any articles of interest as only a brief commentary is provided.     

Platelets,thrombosis, coagulation,and atherosclerosis

When I first got the invitation to join a medical delegation going to Moldova, I thought for a moment that our destination was the fictional country in the old Marx Brothers movie Duck Soup. On further checking, it turns out that entertaining place was called Freedonia. I now know that Moldova is indeed a real country, bordered on the west by Romania and on the other three sides by the Ukraine. It is a proud country, rich with traditions, and its people are warm, giving, eager to learn ways to improve their healthcare system, and deeply appreciative of our attempts to help them in the task.     

Advance Care Planning

Predictors of patient wishes and influence of family and clinicians are discussed. Research findings on patient decision-making relating to preferences in end-of-life care are described. Advance directives and durable powers of attorney are defined and differentiated. Most patients have not participated in advance care planning and the need for more effective planning is documented. Appropriate times for discussions of such planning are described. Scenarios discussed include terminal cancer, chronic obstructive pulmonary disease, AIDS, stroke, and dementia. Patient satisfaction is discussed, as is a structured process for discussions about patient preferences. Results of patient responses to hypothetical scenarios are described. Invasiveness of interventions, prognosis and other factors that favor or discourage patient preferences for treatment are discussed. Findings resulting from research funded by the Agency for Healthcare Research and Quality (AHRQ) are discussed. This research can help providers offer end-of-life care based on preferences held by the majority of patients under similar circumstances.     

Spiritual Dimensions of Nursing Practice. edited by V. B. Carson

The Cochrane Library of Systematic Reviewsis published quarterly. Issue one for 2004 of the library was published in February 2004. This issue contains 3,329 reviews and protocols of which 1,921 are fully published reviews. The trials database now stands at over 400,000 records with an additional 4,427 one-page summaries of non-Cochrane reviews in the NHS database of reviews of effectiveness (DARE). This version of the library contains the results of an extensive search for RCTs on EMBASE. The latest library contains 84 new reviews, seven are considered relevant to practitioners in pain and palliative care. References are published in the same format as the citation for Cochrane reviews.     

Évaluation,par l’imagerie ultrasonore,du recrutement musculaire,de la force motrice et de la détente verticale du quadriceps après électromyostimulation (cas de 15 étudiants de l’INJS)

The increase of strength seems to be an element of performance in some sports.