超声软指标在胎儿染色体异常筛查中的应用价值

目的探讨各项超声软指标在胎儿染色体异常筛查中的临床应用价值。方法回顾性分析513例超声检查发现软指标阳性但未合并明确结构畸形的单胎妊娠孕妇资料,应用二元Logistic回归分析超声软指标与胎儿染色体异常的相关性,绘制受试者工作特征(ROC)曲线分析各项超声软指标对染色体异常的筛查价值。结果513例胎儿中,单项超声软指标阳性胎儿457例,两项及以上超声软指标阳性胎儿56例;染色体异常总体发生率为17.74%(91/513),其中两项及以上超声软指标阳性胎儿染色体异常发生率为28.57%(16/56),高于单项超声软指标阳性胎儿(16.41%,75/457),差异有统计学意义(P<0.05)。二元Logistic回归分析显示颈项透明层增厚、鼻骨发育异常、单脐动脉对染色体异常的筛查价值明显高于其他超声软指标(均P<0.05),敏感性分别为46.2%、20.9%、17.6%,特异性分别为86.5%、90.8%、88.2%,曲线下面积分别为0.663、0.558、0.529;颈项透明层增厚、鼻骨发育异常、单脐动脉联合应用的曲线下面积为0.751,与单项超声软指标比较差异均有统计学意义(均P<0.05)。结论超声软指标中颈项透明层增厚、鼻骨发育异常、单脐动脉筛查染色体异常的价值较高,三者联合应用可提高其诊断效能。     

孕15~20＋6周产前超声筛查联合孕妇血清学筛查提高胎儿染色体异常检出率的临床研究

目的：评价产前超声筛查联合孕妇血清学筛查对提高胎儿染色体异常检出率的临床价值。方法选择于孕15~20＋6周已行孕妇血清学筛查且结果提示有21-三体和（或）18-三体临界风险的628例胎儿行超声筛查,采用经腹部超声对胎儿鼻骨（NB）和颈部皮肤皱褶（NF,中孕期超声软指标）进行检测,观察有无鼻骨发育不良、有无颈部皮肤皱褶增厚（＞6 mm为增厚）及有无其他超声软指标异常,对鼻骨发育不良及颈部皱褶增厚者进行羊水穿刺染色体核型分析。结果产前超声筛查的628例胎儿中发现鼻骨皱发育不良6例（0.96%,6/628）,其中1例合并颈部皮肤皱褶增厚,2例合并肠道回声增强,1例合并脉络膜囊肿,1例合并左心室内高回声;6例胎儿均行羊水穿刺染色体核型分析,2例为21-三体（33.3%,2/6）,余4例染色体未见明显异常。结论产前超声筛查联合孕妇血清学筛查可提高染色体临界风险胎儿染色体异常的检出率。     

中孕期超声软指标在胎儿染色体筛查中的价值

目的 探讨中孕期超声软指标在胎儿染色体异常筛查中的应用价值。方法 对757例单胎妊娠高危孕妇行中孕期超声检查,观察以下超声软指标:胎儿颈部软组织有无增厚、胎儿鼻骨存在与否、有无脉络丛囊肿、有无轻度侧脑室增宽、有无心室强回声点、有无肠管强回声、有无肾盂轻度扩张及单脐动脉。之后所有孕妇均接受羊水穿刺行胎儿染色体核型分析。结合胎儿软指标及染色体核型结果,统计分析超声软指标与胎儿染色体异常的关系。结果 757胎胎儿中,软指标阳性200胎(200/757, 26.42%),阴性557胎(557/757,73.58%);染色体异常56胎。其中软指标阳性胎儿中,染色体异常39胎。颈部软组织增厚及鼻骨缺失是与胎儿染色体异常关系最密切的两项软指标(P均<0.01)。结论 高危孕妇中,软指标阳性胎儿染色体异常发生率高于软指标阴性胎儿。不同超声软指标在预测胎儿染色体异常中价值不同,其中颈部软组织增厚及鼻骨缺失意义最大。     

基于logistic回归模型及CHAID决策树模型的胎儿染色体异常预测研究

目的 使用logistic回归模型及CHAID决策树模型分析胎儿染色体异常的影响因素,并比较两种模型的优劣。方法 回顾性分析超声软指标（ultrasound soft marker,USM）阳性并具有羊水穿刺结果的642例单胎孕妇资料,以胎儿染色体结果为因变量,USM为自变量建立logistic回归模型及决策树模型筛选影响胎儿染色体结果的因素,绘制ROC曲线比较两种模型的效果。结果 单因素logistic回归模型显示NT增厚、鼻骨缺失、侧脑室增宽为胎儿染色体异常的危险因素;多因素logistic回归分析筛选NT增厚（OR=7.511,P<0.05）、鼻骨缺失（OR=4.819,P<0.05）、侧脑室增宽（OR=4.789,P<0.05）3个因素用于回归模型的拟合;CHAID决策树模型显示NT增厚、鼻骨缺失是胎儿染色体异常的影响因素;logistic回归模型ROC曲线下面积大于CHAID决策树模型（0.712vs 0.675,Z=2.267,P<0.05）。结论 logistic回归模型及决策树模型对胎儿染色体结果有一定的预测价值,且logistic回归模型优于决策树模型。 关键词：logistic回归模型;CHAID决策树模型;胎儿染色体异常;超声软指标     

肠管强回声胎儿伴发结构异常及染色体异常超声图像分析

目的探讨肠管强回声合并染色体异常胎儿的产前超声声像图特征。方法选取2009年9月至2013年6月在南京医科大学附属苏州医院产前超声检出的80例肠管强回声胎儿行染色体核型分析并随访至产后,产前超声与产后检查结果对照分析。结果 80例肠管强回声胎儿产前超声及染色体检查结果：（1）单纯肠管强回声胎儿58例（72.5%,58/80,均无染色体异常）,产前超声筛查无其他异常发现。（2）合并超声软指标异常11例（13.8%,11/80,均无染色体异常）,超声显示脉络丛囊肿8例,单脐动脉1例,鼻骨偏短1例,心室点状强回声1例。（3）合并严重结构异常或复合结构畸形但无染色体异常5例,超声显示心脏结构畸形3例,心衰1例,中枢神经系统畸形2例。其中1例为复合畸形,表现为右心室发育不良综合征伴发小脑发育不良及单脐动脉,其余4例均为单发畸形,且无其他软指标异常。（4）合并染色体异常6例（7.5%,6/80）,3例染色体结构异常,3例染色体数目异常（21-三体1例,18-三体1例,双胎之一三倍体1例）,均合并严重结构畸形及软指标异常;超声显示严重心脏畸形2例,中枢神经系统畸形2例,心包腔积液合并腹腔积液1例,胎盘绒毛膜多发性血管瘤1例。其中1例双胎输血综合征胎儿合并全前脑（输血儿）宫内死亡;伴发的软指标异常包括颈项软组织层（NF）增厚、脉络丛囊肿,脐带囊肿,单脐动脉,胎盘绒毛膜血管瘤等。结论单纯肠管强回声胎儿预后良好,临床随访过程中部分肠管强回声可消失;合并严重结构畸形和染色体异常的胎儿预后差,产前超声检出肠管强回声应行系统超声检查并提示临床对胎儿行染色体核型分析。     

超声软指标联合母体血清甲胎蛋白和人绒毛膜促性腺激素筛查胎儿染色体异常

目的 观察孕中期超声软指标联合检测血清甲胎蛋白（AFP）和人绒毛膜促性腺激素（HCG）用于筛查胎儿染色体异常的价值。方法 对1 625名接受孕中期产前检查孕妇以常规腹部超声检测胎儿超声软指标，采用免疫层析法检测母体血清AFP和HCG。将胎儿多个超声软指标（≥2个）阳性者归为高危孕妇（高危组），行羊膜腔穿刺术及羊水细胞染色体核型检查；对低危孕妇进行产后随访，与筛查结果进行对比。结果 共检出64胎胎儿染色体异常，包括染色体数目异常35胎、结构异常29胎。于高危组167名中发现40胎胎儿染色体异常，包括染色体数目异常23胎、结构异常17胎。母体血清AFP及HCG水平筛查胎儿染色体异常的敏感度分别为64.60%和98.50%，特异度分别为66.00%和14.40%，曲线下面积（AUC）分别为0.701和0.788，截断值分别为56.24 ng/ml和19.36 ng/ml；母体血清AFP联合HCG筛查胎儿染色体异常的敏感度为71.88%，特异度为93.66%，AUC为0.796。超声软指标联合检测母体血清AFP、HCG诊断胎儿染色体异常的敏感度均高于单项指标（P均<0.05）。结论 孕中期超声软指标联合母体血清AFP、HCG检测可提高检出胎儿染色体异常的敏感度，有效筛选胎儿染色体异常的高危孕妇。     

NT与NF筛查染色体异常的意义

目的：探讨早孕期测量颈项透明层（NT）值及中孕期测量颈后皮肤皱褶（NF）值对筛查染色体异常的意义及其相互关系。方法：对3 963名单胎孕妇分别于孕早期（11～14周）测量NT值,在孕中期（16～22周）测量NF值,并对孕妇随诊观察。结果：3 963名孕妇中共发现染色体异常胎儿39胎,13胎表现为孕早期NT增厚（33.3%）,12胎表现为NF增厚（30.8%）,其中NT及NF均增厚5胎。超声检查共发现44胎NT增厚病例及55胎NF增厚病例,其中包括14胎NT及NF均增厚病例。NT增厚对染色体异常的检出率为29.5%, NF增厚对染色体异常的检出率为21.8%,NT及NF均增厚对染色体异常的检出率为35.7%。结论：NT及NF是筛查染色体异常的两个独立、有效的软指标,NT及NF均增厚的胎儿出现染色体异常的风险性明显增加。     

超声联合检测胎儿颈项透明层增厚及鼻骨缺失在胎儿异常中的临床价值

目的探讨采用彩色多普勒超声进行胎儿颈项透明层(NT)增厚及鼻骨缺失联合检测在胎儿异常中的临床应用价值。方法从2010年10月至2014年10月孕11~13+6周进行产前检查的8 056例孕妇病例资料中选择单胎妊娠,有效进行胎儿NT及鼻骨检测,并获随访的有效病例5 945例;其中4 368例NT≥3.0 mm和或鼻骨缺失者在孕18周后于上级医院行羊膜囊穿刺或抽脐带静脉血检查胎儿染色体核型;所有病例在孕24~28周时超声筛查胎儿畸形;出生后随访。对是否NT增厚、是否鼻骨缺失者的染色体、超声检查及出生后结果进行比较分析。结果5 945例中,5 347例(89.94%)NT测值在正常范围,598例(10.06%)NT测值增厚。NT正常组染色体异常率0.09%(5/5 347),结构异常率0.17%(9/5 347);NT增厚组染色体异常率1.67%(10/598),结构异常率1.67%(10/598);胎儿不良后果的发生率NT增厚胎儿为3.34%,远高于NT正常范围胎儿的发生率0.26%(P<0.01)。5 945例中,5 940例(99.92%)鼻骨存在;5例(0.08%)鼻骨缺失。两种检查只有2例(0.03%)鼻骨缺失同时合并NT增厚。鼻骨存在组染色体异常率0.19%(11/5 940),结构异常率0.32%(19/5 940),鼻骨缺失组染色体异常率80.00%(4/5),结构异常率0,两组比较有统计学差异(P<0.01);胎儿不良后果的发生率鼻骨缺失胎儿为80.00%,远高于鼻骨存在胎儿的发生率0.51%(P<0.01)。结论早孕期胎儿NT及鼻骨的观察可以为胎儿早期染色体异常及结构异常的筛查提供重要的线索,具有较高的临床价值。     

早中孕胎儿超声软指标筛查的意义

目的：探讨早中孕胎儿超声软指标筛查的意义。方法对15～20＋6周孕妇行血清学产前筛查,其中染色体异常低风险共有713例,对713例行胎儿超声软指标筛查。结果713例中发现鼻骨发育不良7例,其中1例伴颈部皮肤皱褶增厚,3例伴有肠管强回声,3例伴有左心室高回声;1例有短长骨。8例均行羊水穿刺,发现21-三体2例,未发现18-三体。结论孕妇血清学产前筛查提示患染色体异常低风险的胎儿,联合超声筛查可以提高染色体异常的检出率。但再行侵入性检查仍需慎重。     

介入性产前诊断2285例指征分析

目的 回顾性分析2285例介入性产前诊断指征,探讨联合筛查对于胎儿染色体核型介入性诊断的指导意义,以期提高筛查指标的特异性.方法 按照年龄≥35岁（高龄）、血清学筛查高风险、超声软指标阳性、其他指征（包括不良孕史、夫妻一方染色体核型异常等）分组,以x2分析各组胎儿异常染色体核型检出率,分析2个以上穿刺指征（联合筛查阳性）存在时,胎儿异常染色体核型的发生率.结果 超声软指标阳性组异常核型检出率11.1％,与其他指征组相比较,统计学差异有显著性意义（P=0.000）,其中妊娠11～14周胎儿颈项透明层增厚者,染色体异常检出率为25.0％,与其他超声软指标阳性组相比统计学差异有显著性意义（P=0.028）.联合筛查指征阳性时,胎儿异常核型检出率为8.3％,与单一指征组相比较,统计学差异存在显著性（P =0.026）,但差异主要体现在高龄组,当孕妇年龄达到或超过35岁,并同时具有超声软指标阳性或血清学筛查高风险时,异常核型检出率（8.0％）高于单纯高风险组（3.1％）,统计学差异有显著性（P=0.016）.结论 超声对于介入性产前诊断具有重要意义,对于高龄孕妇组超声作为联合筛查指标可显著提高胎儿异常核型检出率,特别是胎儿颈项透明层厚度,应列入产前筛查序列.高龄是否作为独立的介入性产前诊断指征尚需进一步探讨.     

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.     

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.     

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.     

Clinical Trial Updates and Hotline Sessions presented at the European Society of Cardiology Congress 2007

This article provides information and commentaries on trials which were presented at the Hotline and Clinical Trial Update Sessions at the European Society of Cardiology Congress 2007 in Vienna. The key presentations were performed by leading experts in the field with relevant positions in the trials or registries. It is important to note that unpublished reports should be considered as preliminary data, as the analysis may change in the final publications. The comprehensive summaries have been generated from the oral presentation and the webcasts of the European Society of Cardiology and should provide the readers with the most comprehensive information of relevant publications.     

Balance and Boundaries in Grief Counseling: An Intervention Framework for Volunteer Training

Volunteers or paraprofessional counselors are commonly used to provide supportive care to the bereaved. These counselors generally are trained in basic listening skills, providing a generic, nonspecific approach to intervention that remains to be proven effective. The present paper outlines a framework that provides paraprofessionals with a broader model for intervention with the bereaved. Attention to boundaries as a helper and balance in the grief recovery are central to the model. Interventions are described that provide the paraprofessional counselor with more options for tailoring their counseling strategy to the individual. These include techniques that are presumed to be more specific to the enhancement of grief recovery.     

A new method for the simultaneous analysis of unmodified and modified urinary nucleosides and nucleobases by high performance liquid chromatography

Details are given of a new, rapid and simple pre-fractionation method and an isocratic high performance liquid chromatography system suitable for parallel analysis of nucleosides and nucleobases from urine and other biological fluids. The quantitative recovery and excellent reproducibility of the method is demonstrated by analysis of representative standard RNA catabolites. The advantage of this new method for application to biological samples is discussed.     

Adsorption of Charged Non-albumin Bound Drugs by Amorphous Silica

We investigated the in vitro drug adsorption of PQ 10150 sodium silicate gel (AIS, Santa Clara, CA) with particle size of 230 um and surface area of 400 nr/g. We observed 99% to 88% adsorption of gentamicin; a mean 91 % of disopyramide; a mean 89% of quinidine at low concentration, falling to 75% at higher concentration. Insulin was 88% adsorbed at low concentrations but less so (65%) at higher concentrations. We observed a mean 83 % adsorption of procainamide, a mean 84% of N-acetyl procainamide, 74% oflidocaine, 73% of amitriptyline; and 44% of desipramine. We found an average 14% reduction of total digoxin concentration when serum containing digoxin (2 to 33 ng/mL) was exposed to sodium silicate, while the reduction in free digoxin concentration was 16%. Five percent ethosuximide was also removed. The adsorption of theophylline, phenobarbital, acetaminophen, phenytoin, ethylene glycol, methotrexate, salicylate, thiocyanate and diazepam was minimal and not significant. We conclude that significant amounts of charged, non-albumin bound drugs can be removed by PQ 10150 sodium silicate gel.     

自动化酸碱平衡图在急诊社区获得性肺炎诊治中的应用

目的 探讨自动化酸碱平衡图在急诊科社区获得性肺炎(CAP)患者诊断中的价值.方法 根据病史、肺功能测定结果、慢性阻塞性肺疾病(COPD)诊断标准,将111例CAP患者分为单纯CAP组(56例)和COPD合并CAP组[即慢性阻塞性肺疾病急性加重(AECOPD)组,55例].询问患者病史后即刻抽取动脉血测血气并进行自动化酸碱平衡图分析.结果 血气分析结果显示,AECOPD组动脉血二氧化碳分压(PaCO2,kPa)、HCO3- (mmol/L)、剩余碱(BE,mmol/L)均显著高于CAP组(PaCO2:7.714±2.414比5.896±1.308,HCO3-:30.767±7.185比25.014±3.043,BE:4.345±5.371比-0.354±3.180,均P＜0.01).自动化酸碱平衡图分析结果显示,AECOPD组患者酸碱平衡紊乱高达89.1％,CAP组为66.1％.将AECOPD组和CAP组患者中正常(10.9％、33.9％)、急性呼吸性酸中毒(急性呼酸,12.7％、14.3％)、慢性呼吸性酸中毒(慢性呼酸,49.1％、10.7％)、呼吸性碱中毒(呼碱,7.3％、14.3％)、代谢性酸中毒(代酸,12.7％、17.9％)、代谢性碱中毒(代碱,12.7％、8.9％)综合进行x2分析,差异有统计学意义(x2=24.421,P=0.001),而将正常、急性呼酸、呼碱、代酸及代碱进行x2分析,差异无统计学意义(x2=5.280,P=0.260),提示AECOPD患者慢性呼酸的发生率较单纯CAP患者显著增加.结论 自动化酸碱平衡图能帮助急诊科医师快速识别CAP患者是否存在多重酸碱平衡紊乱,并可快速识别急、慢性呼吸系统疾病.