经胸超声心动图对室间隔缺损封堵术的选择标准和方法学研究

目的 :探讨室间隔缺损 (VSD)封堵术的选择标准和超声的方法学。方法 :室缺患者 90例 ,其中膜部 (膜周 ) 86例 ,嵴内及肌型各 2例。采用非标准左室长轴、大血管短轴及五腔心切面 ,术前测量 VSD的大小、离主动脉瓣、三尖瓣的距离以及彩色分流的宽度 ,术中指导释放封堵器。结果 :左室长轴、大血管短轴及五腔心切面二维超声测量室缺大小分别为 :(5 .2± 2 .3) mm、 (7.0± 2 .9) mm、 (7.0± 3.2 ) mm;彩色多普勒在上述切面测量的室缺分流宽度分别为 :(5 .3± 2 .0 ) mm、 (7.1± 3.4 ) mm和 (6 .3± 2 .7) mm,相同切面二维与彩色测值无显著性差异。二维超声心动图测量室间隔缺损距主动脉瓣为 :左室长轴 (2 .3± 0 .7) mm,五腔心切面 (3.0± 1.0 ) mm;大血管短轴切面所测室缺与三尖瓣的距离为 (3.3± 1.3) mm (1.5～ 7mm)。左室造影测室缺为 (7.4± 2 .9) mm ,与二维和彩色超声最大测量值无显著性差异。结论 :经胸超声心动图可用于选择室缺封堵术适应征、指导封堵器的释放及术中评价封堵疗效。封堵术选择标准为 :1.左室面室缺大小 2 .5～ 15 mm;右室侧为多孔时 ,右室侧最大缺损口应≥2 mm;2 .距主动脉瓣距离≥ 1mm,并无主动脉瓣脱垂 ;3.距三尖瓣距离≥ 1.5 mm,无明显的三尖瓣发育异常及中度以上的三尖瓣返流     

超声心动图在室间隔膜周部缺损经导管封堵术中筛选病例的作用

目的　探讨超声心动图为经导管封堵术筛选室间隔膜周部缺损 (VSD)病例的作用。方法2 6例室间隔膜周部缺损患者实施经导管封堵术。封堵器为国产镍钛合金制成的双盘片结构封堵器。经胸壁超声心动图获取图像。结果　 2 4例成功放置封堵器。VSD的大小平均为 6.4mm ,最大为 10mm ,最小为 4mm。放置封堵器的型号较相应VSD大 2mm ,最大为 12mm。VSD具体分型包括单纯膜部 5例 ,嵴下型 6例 ,隔瓣后型 13例 ,其中嵴下型缺损上缘距主动脉瓣环下缘最小距离为 2mm ;隔瓣后型缺损下缘距三尖瓣隔瓣最小距离为 3mm。单纯膜部缺损易于封堵。 2 1例患者封堵术后即刻观察 ,穿隔血流消失 ,术后 1周超声复查 ,封堵器位置良好、稳定、无残余分流。 3例隔瓣后VSD在封堵术后即刻存在少量分流。术后 1月超声复查 ,封堵器位置良好、稳定 ,1例残余分流消失 ,2例残余分流减少。 2例VSD封堵术中因为引起主动脉反流而放弃封堵。结论　超声心动图选择合适的病例是保证VSD封堵术成功的前提     

超声心动图与心血管造影在室缺封堵术中的互补价值

目的探讨超声心动图及心血管造影在室间隔缺损(VSD)封堵术中的应用价值。方法VSD封堵术成功患者221例,其中单纯膜部或膜周型209例,嵴内型9例,肌型3例。超声心动图及心血管造影于封堵术前确定VSD类型、大小,缺损残端距瓣膜距离、彩色分流宽度。术后测定封堵器腰大小。结果(1)VSD大小不同切面超声测定VSD大小及彩宽可有差别,心血管造影可测量膜部型VSD大小,对嵴内VSD显示欠佳;(2)VSD残端与瓣膜间距离超声所测VSD残端距主动脉瓣距离与心血管造影测值比较,五腔心切面(5CV)差异无显著性意义(P>0.05);(3)VSD大小与封堵器型号大小及封堵器腰关系超声不同切面VSD大小、彩宽及心血管造影测值与封堵器型号大小比较差异均有显著性意义(P<0.05);大血管短轴切面(AOS)、5CV及心血管造影各测值与封堵器腰之间无显著性差异(P>0.05)。结论X-线透视及心血管造影不能取代超声心动图在封堵介入治疗中的作用;同时,超声心动图尚不能完全替代X-线透视及心血管造影的作用,两者在封堵介入治疗中的作用是相互弥补。     

膜部室间隔缺损形态、大小与封堵器的选择

目的探讨膜部型室间隔缺损(VSD)各种形态的超声心动图特征,缺损形态、大小与封堵器选择的关系.方法 VSD封堵成功的209例膜部型VSD患者.超声心动图术前测量VSD大小、观察缺损口形态及判断缺损右室侧粘连情况.结果 209例VSD中有184例缺损口呈局限性向右室侧突出,形成不同形态,其中不规则形66例,漏斗形56例,瘤形38例,管形24例.不同形态的VSD大小不同,以管形较小,不规则形较大,差异有显著性意义(P＜0.05).184例中有140例呈多孔,平均最大孔径(3.6±1.1)mm.结论超声心动图在术前准确的测量VSD的大小,观察缺损口形态、缺损右室侧分流口多少及周缘粘连的牢固性等,以筛选VSD封堵术的适应证及合适封堵器大小,保证VSD封堵术的远期疗效.     

彩色多普勒超声心动图在膜周部室间隔缺损介入治疗中的应用

目的评估彩色超声心动图在膜周部室间隔缺损(VSD)介入治疗中的应用价值.方法在经胸彩色多普勒超声心动图引导下,对158例膜周部VSD患者实施经导管封堵术,封堵器为国产镍钛合金双盘片封堵器,并行超声随访治疗效果.结果153例患者成功实施了VSD封堵术,成功率为96.8%.未成功的5例中,3例因导管未能通过缺损处,2例因封堵器放置后影响主动脉瓣关闭而放弃封堵术.153例封堵成功的VSD超声定位准确,包括膜部VSD 35例,嵴下型VSD 72例,隔瓣后型VSD 46例.其中嵴下型VSD的缺损上缘距主动脉瓣瓣环下缘最小距离为1.5 mm,隔瓣后型VSD缺损下缘距三尖瓣隔瓣最小距离为3 mm.121例患者封堵术后即刻观察,穿隔血流消失,术后1周超声复查,封堵器位置良好、稳定,无残余分流.32例封堵术后即刻观察存在少量分流,术后1个月超声复查,封堵器位置良好、稳定,28例残余分流消失,4例残余分流明显减少.4例术前存在三尖瓣口中量反流的患者,封堵术后2例反流消失,2例反流明显减少.结论彩色多普勒超声心动图在膜周部VSD介入治疗中对病例选择及术后随访具有重要辅助作用.     

经胸超声心动图在国产双盘伞封堵室间隔缺损的应用价值

目的　探讨经胸超声心动图在国产双盘伞封堵室间隔缺损 (VSD)中的应用价值及封堵术后近期疗效。方法　 VSD患者 4 4例 ,男性 18例 ,女性 2 6例。超声心动图术前观测 VSD类型、大小、形态 ;术中监测封堵器释放 ;术后观察封堵术疗效。结果　 1.VSD大小 2 .5～ 15 mm ,平均 (8.9± 5 .3) mm;4 4例 VSD中 30例缺损右室侧呈不同形态 ,其中漏斗形 13例 ,瘤形 8例 ,不规则 6例 ,管形 3例 ;缺损口距主动脉瓣距离 >2 mm,距三尖瓣距离≥ 1mm,选择封堵器型号 5～ 16 mm,平均 (9.3± 3.6 ) mm;2 .4 4例 VSD均成功封堵 ,其中 8例封堵器未释放前存在微量或微量至少量残余分流 ,释放后 4例消失 ,4例有改善。三尖瓣和主动脉瓣少量返流 (TR、 AR)各 1例 ;3.术后 2 4 h及 72 h超声心动图检查 ,4例残余分流消失 ,TR、 AR较术中无加重 ;1例术中无并发症者 ,于术后 2 4 h封堵器后上缘及腰部出现残余分流 ,同时伴有溶血 ,1个月后残余分流量明显减少 ,2个月残留分流完全消失 ;1例于术后 3d出现间歇性 °房室传导阻滞 ,治疗 1周后消失。结论　经胸超声心动图可准确观测 VSD大小、形态及与周边结构的关系 ,指导选择国产双盘伞封堵器的大小及术中释放 ,评价封堵术后疗效。     

超声心动图在室间隔缺损封堵术中的应用价值

目的探讨超声心动图在室间隔缺损(VSD)封堵术前筛选、术中监视引导及术后随访的应用价值.方法采用超声心动图对11例VSD,1例心肌梗死室间隔肌部穿孔患者,术前测量VSD形状与大小,术中监测封堵过程,术后随诊封堵效果.结果 VSD膜周部5例、隔瓣后型3例、膜周嵴下型2例、嵴内漏斗部1例、心肌梗死室间隔肌部穿孔1例,共安置13个封堵器,其中1例患者有两个相距较远的缺损,安置了2个封堵器,被封堵的VSD直径为3～8 mm,平均(5.2±0.8)mm,选用封堵器直径应比VSD测值大2 mm,最大封堵器直径为10 mm.10例患者封堵术后即刻观察,穿隔分流消失,术后1周复查,封堵器位置良好、稳定,无经封堵器残余分流;1例有微量残余分流,术后24 h超声心动图复查分流消失;1例少量残余分流,术后即刻复查最大分流速度为1.2 m/s(低于险值2 m/s),于6个月后复查仅见微量残余分流.结论超声心动图在VSD封堵术适应证的筛选,封堵器释放时间的确定,释放时即刻疗效的评价及术后随访中具有重要价值.     

超声监测AmPlatzer封堵器经导管治疗室间隔缺损

目的探讨超声心动图在室间隔缺损(VSD)经导管治疗中的应用价值及评价Amplatzer装置的治疗效果。方法28例VSD患者应用经胸超声心动图(TTE)检查确定VSD部位,测量缺损口长径及其边缘至主动脉瓣和三尖瓣的距离。术中依据超声测值选择封堵器型号,观察封堵器位置及有无残余分流和瓣膜反流,其中1例应用心腔内超声心动图(ICE)监测。术前和术后分别测量左心室舒张期末内径(LVDd)、每搏指数(SVI)和心脏指数(CI)。结果TTE检查确定1例为肌部缺损,另27例为膜周部缺损。VSD与主动脉瓣和三尖瓣的距离均>3mm。缺损口直径为4～13mm,平均(6.81±2.65)mm,封堵器型号为4～16mm,平均(8.71±3.58)mm。28例全部封堵成功,24例无残余分流,4例伴膜部瘤者有少量残余分流,无瓣膜反流。术前和术后LVDd、SVI及CI比较差异有显著性意义。结论超声心动图在VSD介入治疗的术前诊断、术中监测和术后疗效评价中均有重要价值。     

经胸超声心动图在室间隔缺损封堵术中的应用研究

目的 :探讨室间隔缺损 (VSD)的形态 ,封堵器大小的选择原则和经胸超声心动图 (TTE)在室缺封堵术 (VSDO)中的应用价值。方法 :室缺患者 90例 ,单纯膜部或膜周型 86例 ,嵴内及肌型各 2例。超声心动图于非标准胸骨旁左室长轴、大血管短轴及五腔心切面观察 VSD的大小、形态和类型 ,并与封堵器的大小相比较。结果 :90例 VSD有 67例突向右室 ,漏斗形 2 9例、瘤形 2 0例、不规则形 12例、管形 (隧道形 ) 6例 ,其中右室面多孔 18例 ,左室面缺口分隔 2例。 2 DE测舒张期 VSD大小 2 .5～ 15mm ,平均 (8.0± 5.4) mm。封堵器大小 5～ 16mm,平均 (9.5± 3 .3 ) mm。结论 :经胸超声心动图可用于观测 VSD的形态 ,指导选择封堵器并于术中释放。 VSD分为四种形态 :1.漏斗形 ;2 .瘤形 ;3 .不规则形 ;4.管道形 (隧道形 )。 VSD最大径 (U)与封堵器大小 (D)的关系为 D=1.0 2 U + 1.75。     

彩色超声心动图评价非对称型封堵器在室间隔缺损封堵术中的应用价值

目的 采用彩色超声心动图评价非对称型封堵器在室间隔缺损（VSD）封堵术中的应用价值。方法 采用彩色超声心动图对58例拟行经导管VSD封堵术的患者，术前取胸骨旁五腔心切面、左心室长轴切面、主动脉短轴切面和心尖四腔心切面行超声扫查，确定VSD部位及周围毗邻关系，并测量VSD边缘距主动脉瓣瓣环的最小距离，测量VSD下缘距三尖瓣隔瓣距离；术后采用彩色超声心动图观察封堵器在心腔内的形状及封堵效果，并随访3～12个月。结果 58例VSD患者选择使用非对称型封堵器，封堵术均获成功，其中嵴下型18例（缺损边缘距主动脉瓣最小距离为0．5mm）、膜部13例、肌部3例、嵴内型3例、隔瓣后型21例（缺损边缘距三尖瓣最小距离为1．5mm）。术后超声显示非对称型封堵器图像清晰，封堵器在心脏内呈现超声图像与体外形态相一致。其中3例囊袋形VSD在放置对称型封堵器后因残余分流多而改用非对称型封堵器，效果良好。术后即刻观察9例存在室间隔少量残余分流，24h后完全消失。57例三尖瓣、主动脉瓣均未出现因封堵引起的明显反流，1例术后出现主动脉瓣反流，瞬时反流量约0．5ml，随访3个月，反流无明显增多。结论 根据VSD部位及形态选择非对称型封堵器能进一步扩大封堵术应用范围及提高其安全性；彩色超声心动图在筛选病例、观察疗效及远期随访中起重要辅助作用。     

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.     

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.     

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.     

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.     

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.