三维超声对胎儿躯干骨骼系统解剖结构的检测

目的:探讨三维超声立体直观检测胎儿躯干骨骼的解剖形态和结构的方法。方法:采用静态最大透明回声成像模式,对206例胎儿躯干骨骼的外表形态和解剖结构进行三维重建,以直接显示胎儿躯干骨骼的外表结构特征和相互解剖关系。结果:在妊娠14~28周中,完全可以建立完整的不同角度的躯干三维图像,在妊娠29周后,可以循序分段建立胎儿躯干的部分三维图像,三维成像率达100%。以孕24~32周为合适的胎儿躯干骨骼系统完整三维重建成像时机。重建的胎儿躯干各骨骼形态直观、清晰、层次分明;重建的脊柱、肋骨及其紧邻的锁骨、肩胛骨的连接关系、定位走向明朗清晰。206例孕妇中,无一例躯干骨骼的异常记录。结论:三维超声能全面直观、形象生动地显示胎儿躯干及其毗邻骨骼的生长发育状况、解剖形态和相互关系,对躯干骨骼疾病的形态表达和空间定位诊断优于二维超声。     

三维超声骨骼成像模式对胎儿上颌骨检测的应用研究

目的探讨不同孕期胎儿上颌骨三维超声成像特点。方法对我院261例经常规超声检查颜面部发育无异常胎儿的上颌骨形态进行静态三维超声成像,并比较各孕期三维超声成像的成功率;同时对3例非颜面部畸形引产后胎儿上颌骨标本进行解剖及体外三维超声成像,对8例腭裂畸形胎儿进行上颌骨三维重建。结果孕12～27+6周胎儿上颌骨三维成像的成功率均≥96%,孕36～40周成像成功率为27.5%;8例腭裂畸形胎儿均成功显像。孕12～15周胎儿上颌骨三维立体图像显示似平放的直角三角形;孕16周时可清晰显示鼻切迹及鼻前棘,胎儿上颌骨与成人相似。结论三维超声骨骼成像模式在显示胎儿上颌骨解剖结构和形态特征方面具有明显的优势,可作为二维常规超声检查的重要补充。     

中晚期妊娠胎儿脸面部的三维超声成像

目的 探讨胎儿脸面部三维超声成像的方法及其临床应用。方法 采用表面成像方法对92例中晚期妊娠胎儿的脸面部进行三维超声成像。结果 92例孕妇中,90例均清楚显示胎儿脸面部的表面特征。立体形态及各结构间的位置关系。2例因前方羊水较少显示不满意。结论 胎儿脸面部的三维图像可提供更丰富的诊断信息。可作为二维超声诊断的补充,提高对胎儿脸面部畸形的产前诊断率。同时使孕妇及其他非超声工作人员更直观地观察胎儿面部结构,使准妈妈们提前与腹中宝宝见面。     

实时三维超声在产前胎儿超声检查中的初步应用

目的探讨实时三维超声在产前胎儿超声成像中应用的临床价值。方法对26例孕龄16～41周的正常适龄胎儿进行实时三维超声检查。观察胎儿的心脏、颜面部、头颅、胸腹部各重要解剖结构。实时显示三维图像,或者在检查结束后脱机分析图像。结果26例胎儿均获得满意的实时三维图像,包括心脏、颜面部、头颅、胸腹部结构。其中26例观察了心脏,14例观察了颜面部,12例观察了头颅,6例观察了胸腹部。结论实时三维超声能够实时直观地显示胎儿各部位解剖结构的三维立体图像,比传统的二维超声提供更直观的图像信息,其在胎儿先天性畸形显像及筛查中具有重要的应用价值。     

三维超声能量多普勒血管成像检测胎儿脐带绕颈

目的探讨三维超声能量多普勒血管成像(3D-CPA)技术立体直观检测胎儿脐带绕颈(NEUC)的临床实用价值。方法以3D-CPA模式，对215例单胎孕妇进行NEUC的三维超声图像重建。结果3D-CPA检测出脐带缠绕46例，其中脐带搭颈26．09％，NEUC一周58．70％，NEUC二周15．22％，分娩验证符合率100％。重建的胎儿脐带血管解剖结构直观清晰、螺旋层次分明，脐带的宏观形态定位、空间走向明朗；重建的NEUC及其周数、来源和去路一目了然；3D-CPA显示脐带在官腔内的空间运行轨迹的立体效果优于三维彩色多普勒血流显像(3D-CDFI)模式。结论3D-CPA能直观、形象和层次分明地显示脐带血流解剖形态、走势关系、空间运行轨迹，诊断NEUC的符合率高于3D-CDFI模式。     

三维超声容积断层成像对中孕早期胎儿筛查的意义

目的探讨三维超声容积断层成像对中孕早期胎儿产前筛查的意义。方法对181例13～16孕周的胎儿进行二维超声和三维超声容积断层成像检查。比较两种检查方法在检查时间、对胎儿主要解剖结构的显示和生长指标测量的一致性。结果完成二维超声检查的平均时间为（13．2±4．1）min,三维超声容积断层成像检查平均时间为（7．8±1．3）min,每例平均节省时间约5min。三维超声容积断层成像对胎儿侧脑室、脊柱、胸廓、腹部、上肢及下肢的显示率均为100％,对颅骨的显示率小于二维超声,但差异无统计学意义（P=0．25）,对双眼球、心脏及胃泡的显示率小于二维超声,P〈0．01。与二维超声比较,三维超声对双顶径、头围、腹围、股骨径的测量,85％的测值差异〈1mm,95％的测值差异〈2mm。结论三维超声容积断层成像具有省时,对操作者依赖性小等优点,可以显示中孕早期胎儿主要解剖结构,对主要生长指标的测量与二维超声比较无明显差异。     

胎儿面部三维超声成像研究

目的：评价三维超声在胎儿面部成像中的应用价值。方法：应用Medison Krez Voluson530D三维超声系统对我院门诊及住院孕16-39周高危孕妇67例进行检查，该系统可完成常规二维超声检查及三维超声成像。结果：63例胎儿面部正常，孕16-24周胎儿面部瘦削。图像质量稍差，孕25-39周胎儿面部逐渐丰满，解剖结构越来越清晰，4例唇裂胎儿均经三维超声检出。结论：三维超声提供了直观立体的胎儿面部图像，对二维图像具有重要的补充作用。     

三维超声表面模式重建在胆囊疾病中的应用

目的探讨三维超声表面模式重建在胆囊疾病中的实用价值。方法采用三维超声成像技术系统对30例胆囊结石，12例胆囊息肉，10例胆囊壁水肿，3例胆囊癌进行三维超声表面模式成像重建。结果三维超声可显示胆囊内壁结构，胆囊壁的完整性和连续性，直观显示病灶的数目，立体形态及与胆囊壁的关系。结论表面模式适用于胆囊疾病的三维重建，为胆囊疾病诊断提供直观信息。     

11～13~(+6)孕周胎儿三维超声容积回顾分析质量控制体系的可行性研究

目的探讨11~13~(+6)孕周胎儿三维超声容积数据应用于胎儿质量控制体系的可行性。方法回顾分析200例胎儿的三维超声容积数据,应用4Dview软件采用超声断层成像(TUI)技术,通过矢状面与横断面结合,显示检查所需的切面及结构。结果胎儿各解剖结构的显示率,除心脏、膀胱、胃泡及颅内透明层的显示率60%,颅骨、大脑镰、脉络丛、鼻后三角、耳朵、眼睛、鼻骨、颈项透明层、胸腹壁、四肢的显示率均60%。经Logistic回归分析,当胎盘位于后壁时图像质量较好;孕妇的腹壁脂肪层越厚对图像质量的影响越大。结论通过三维超声提取和重建系统筛查所需的标准切面,对11~13~(+6)孕周胎儿畸形筛查的质量控制具有一定的临床意义。     

二维及三维超声检测正常胎儿颅缝及前囟

目的 观察二维和三维超声对胎儿颅缝和前囟的显像价值.方法 对80名16～35孕周的孕妇进行二维和三维超声检测,观察胎儿颅缝和前囟,比较两种方法的显示率.结果 二维与三维超声对胎儿额缝、人字缝、冠状缝、前囟显示率差异无统计学意义, 三维超声对矢状缝的显示率明显高于二维超声.三维超声对颅缝和前囟的完全显示率在孕30周之前与二维超声显示率差异有统计学意义,30孕周之后显像率随孕期增加而下降.结论 三维超声能直观、形象地显示胎儿颅缝和前囟的立体形态,对矢状缝的显示率优于二维超声,在30孕周前对胎儿颅缝和前囟的完全显像优于二维超声.     

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.     

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.     

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.     

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.