超声心动图诊断胎儿完全型肺静脉异位引流

目的 探讨胎儿完全型肺静脉异位引流(TAPVC)产前诊断线索及超声心动图特征.方法 回顾性分析于我院经超声诊断并经尸体检查或出生后超声心动图证实的14胎TAPVC胎儿的二维及多普勒图像的特征.结果 产前诊断12胎TAPVC,其中心上型9胎,心内型2胎,心下型1胎.TAPVC的产前诊断线索及超声心动图特征:二维超声四腔心切面未显示肺静脉角,左心房后壁光滑;左心房后壁与降主动脉间距离增大;可见共同肺静脉腔和垂直静脉.产前超声心动图漏诊2胎,经出生后超声心动图证实均为心内型TAPVC.14胎TAPVC中,4胎伴肺静脉引流途径梗阻.结论 胎儿超声心动图可诊断TAPVC并准确分型;脉冲和彩色多普勒超声可显示肺静脉回流途径梗阻.     

超声二维斑点跟踪技术测量三尖瓣环位移评价右心室收缩功能

目的 探讨彩色多普勒超声心动图对完全性肺静脉异位连接(TAPVC)的诊断价值。方法 回顾分析19例经手术证实的TAPVC患者的超声心动图诊断情况。结果 首次彩色多普勒超声心动图检查诊断TAPVC与手术诊断的符合率为89.47%(17/19),其中心上型11例,心内型5例,心下型1例。首次超声检查漏诊2例(10.53%),其中包含1例心下型TAPVC以及将1例混合型TAPVC(心上型+心内型)诊断为部分性肺静脉异位连接心内型。这2例患者术前再次复查超声心动图,均正确诊断。19例TAPVC均伴继发孔房间隔缺损及中至重度肺动脉高压。19例TAPVC超声心动图表现共同特点:右心系统扩大,以右心房为主,肺动脉增宽,右心房和(或)左心房增大,左心系统缩小,以左心房缩小显著;彩色多普勒血流显示均为房水平右向左蓝色分流束;不同分型的特征性改变:左心房内不能探及肺静脉的入口部位,左心房缩小,左心房后方可探及一管状无回声结构,即共同静脉干。心上型TAPVC者胸骨上窝主动脉弓长轴切面可显示于主动脉弓前方并环绕主动脉弓的异常“静脉弓”,即共同静脉干经垂直静脉、无名静脉汇入上腔静脉;心内型TAPVC者大多数经冠状静脉窦汇入右心房,此时,在胸骨旁左心室长轴及四腔心切面可显示扩张的冠状静脉窦及其与共同静脉干沟通;心下型TAPVC者剑下主动脉短轴切面显示三条大血管,异常连接的共同静脉干位于下腔静脉左前、腹主动脉的前方,血流呈红色与腹主动脉相同,长轴追踪该共同静脉干于肝右叶后方汇入门静脉。混合型TAPVC(心上型合并心内型)者,胸骨上窝主动脉弓长轴切面显示左上肺静脉与垂直静脉(相对较细)相连,在胸骨旁左心室长轴及四腔心切面可显示右肺静脉及左下肺静脉经冠状静脉窦汇入右心房。合并心内畸形:19例TAPVC患儿中,2例合并心内膜垫缺损,1例合并大动脉转位,1例合并肺动脉瓣狭窄,2例合并动脉导管未闭。结论 二维彩色多普勒超声心动图经多部位、多切面、多方向的探查,对TAPVC能明确诊断及分型,为外科治疗方案提供重要依据,且检查简便易行、无创、可重复,是诊断TAPVC的首选方法。     

超声心动图评估完全型肺静脉异位连接中肺静脉病变

目的 探讨超声心动图评估完全型肺静脉异位连接（TAPVC）中肺静脉病变的价值。方法 收集55例TAPVC患儿的超声心动图资料,并与CTA及术中所见进行对比。结果 应用超声心动图根据肺静脉引流部位对55例TAPVC患儿进行分类,分为心上型24例、心内型20例、心下型7例及混合型4例。15例垂直肺静脉梗阻中,心上型的梗阻多出现在垂直静脉与无名静脉或上腔静脉之间,心下型的梗阻均出现在垂直静脉与肝静脉或门静脉之间。肺静脉狭窄4例,其中3例局限性狭窄均为心内型,出现在分支肺静脉与共同肺静脉腔或右心房之间,1例弥漫性狭窄为心下型。分支肺静脉异常9例,其中超声心动图仅检出1例,而CTA检出8例。结论 超声心动图能对TAPVC中的肺静脉的引流、梗阻和分支肺静脉近端的狭窄做出更为全面的评价。CTA评估分支肺静脉的汇入和数目异常及远端肺静脉的成像方面优于超声心动图。     

彩色多普勒超声心动图对完全性肺静脉异位连接的诊断价值

目的探讨彩色多普勒超声心动图对完全性肺静脉异位连接(TAPVC)的诊断价值。方法回顾分析19例经手术证实的完全性肺静脉异位连接患者的超声心动图诊断情况。结果 19例TAPVC患儿首次彩色多普勒超声心动图检查诊断与手术诊断的符合率为89.5%(17/19),其中心上型11例,心内型5例,心下型1例。首次超声检查漏诊2例(2/19),其中包含1例心下型TAPVC以及将1例混合型TAPVC(心上型+心内型)诊断为部分性肺静脉异位连接(心内型)。这两例患者术前再次复查超声心动图检查均做出了正确诊断。19例TAPVC均伴有继发孔房间隔缺损及中至重度肺动脉高压。结论彩色多普勒超声心动图对TAPVC能明确诊断及分型,为制定外科治疗方案提供重要依据。     

超声心动图诊断肺静脉异位引流

目的 探讨超声心动图诊断肺静脉异位引流(APVC)的准确性.方法 分析38例术前肺静脉异位引流患者的二维超声图像,并与心脏CT及手术结果 对比分析,总结其诊断要点.结果 38例患者中33例为TAPVC,5例为PAPVC.其中TAPVC中的心上型22例,心内型10例,心下型1例,混合型0例;PAPVC中2例为右肺静脉汇入右心房;1例为右上肺静脉汇入上腔静脉;1例为右下肺静脉汇入右心房;1例有肺静脉及左下肺静脉汇入右心房.完全性肺静脉异位引流超声特异表现为:右心扩大,左心房、左心室明显缩小.左心房内无肺静脉开口,左心房后方可见共同肺静脉腔,共同静脉腔回流的人口处及相应部位的内径扩张,房间隔缺损为右向左分流.部分性肺静脉异位引流有1支或1支以上的肺静脉未与左心房相连.本组患者除2例术前超声诊断与CT及术中探查不符外,其余均与心脏CT及手术结果 相符.结论超声心动图诊断APVC具有较高的准确性,对于APVC患者中的少数较难诊断的完全性及部分性病例的鉴别,应结合CT等辅助检查综合判断.     

胎儿超声心动图在产前诊断完全型肺静脉异位引流中的应用

目的探讨完全型肺静脉异位引流（TAPVC）胎儿超声心动图特征及产前诊断临床意义。方法对2010年1月至2013年1月在南京医科大学附属苏州医院超声中心经产前及产后超声心动图或引产后尸检确诊的13例TAPVC胎儿超声心动图特征及产前诊断的临床意义进行总结分析。结果产前超声诊断12例TAPVC,其中心上型7例,心下型3例,心内型2例。超声表现为：胎儿左心稍小于右心,卵圆孔较大,心房水平右向左分流丰富,左心房与降主动脉距离增宽,左心房顶部光滑,无肺静脉开口,其后方可见共同肺静脉干,追踪共同肺静脉干走行可显示引流部位,相应引流部位血管内径扩张。产前超声漏诊1例,经产后超声心动图确诊为心内型TAPVC。13例TAPVC胎儿中3例为单发畸形（3/13）,10例合并其他心内或心外畸形（10/13）。结论 TAPVC有特征性胎儿超声心动图表现,胎儿超声心动图是诊断TAPVC的可靠方法;产前诊断TAPVC有利于孕妇作出优生优育选择,使胎儿出生后得到及时治疗。     

超声心动图在婴幼儿完全性肺静脉异位引流中的应用价值

目的 探讨超声心动图在婴幼儿完全性肺静脉异位引流(TAPVC)诊断中的临床应用价值.方法 回顾分析41例TAPVC患儿的超声心动图资料,与手术结果或尸体解剖相对照.结果 41例TAPVC的超声心动图特征:右房、右室增大,左房、左室较小.左房未及肺静脉开口,于左房后上方可见肺静脉共腔,伴有心房水平右向左分流.41例婴幼儿TAPVC心上型23例,心内型13例,心下型3例,混合型2例.结论 多部位、多切面仔细观察,超声心动图可以诊断TAPVC,并准确分型.     

胎儿心脏解剖横切面数据库在产前精准诊断完全性肺静脉异位连接中的应用价值

目的 利用常见类型胎儿完全性肺静脉异位连接(TAPVC)解剖横切面数据库,建立常见TAPVC切面特征及诊断思路,指导产前精准诊断。方法 利用已建立的TAPVC解剖横切面数据库,建立常见胎儿TAPVC的切面特征及诊断思路。结果 经无名静脉引流的心上型TAPVC切面特征：共同静脉腔/垂直静脉(CPV/VV)位于四腔心后方和导管弓横弓的左侧;经门静脉引流的心下型TAPVC切面特征：CPV/VV位于四腔心后方、腹腔横切面的降主动脉和下腔静脉之间。对四腔心切面可疑TAPVC的病例,分别通过三血管(气管)切面和腹腔横切面,快速判断TAPVC的类型。研究期间共诊断18例TAPVC,其中12例心上型、6例心下型,均被出生后超声心动图或引产后解剖验证。结论 通过解剖数据库重建,可以建立不同类型TAPVC的解剖特征及快速诊断方法,有助于提高TAPVC产前诊断率和精准度,方便产前咨询和预后评估。     

完全性肺静脉畸形引流的彩色多普勒超声诊断

目的：探讨彩色多普勒超声诊断完全性肺静脉畸形引流（TAPVC）的价值。方法：应用HP2500、Angilet5500型彩色多普勒超声诊断仪检查7例TAPVC患者，常规行二维超声心动图及彩色多普勒血流显像检查，主要观察心腔大小、肺静脉左房开口、房间隔缺损部位、大小及分流方向，跟踪扫查共同静脉干的走行及开口部位。结果：7例TAPVC患者中，心上型5例（IA1例，IB1例），心内型2例（ⅡA1例，ⅡB1例），检查发现本组患者均有右房、右室明显增大，左房、左室较小；继发孔型房间隔缺损；左房内不能探及肺静脉开口，在心脏后方探及一粗大管道（CPV），其结果与手术完全一致，彩色多普勒超声正确显示TAPVC部位。结论：应用彩色多普勒超声可确定TAPVC的诊断和分型，为制定手术方案提供重要依据。     

探讨302例心上型肺静脉异位引流的超声诊断与漏误诊原因

目的 分析302例心上型完全性和部分性肺静脉异位引流(TAPVC和PAPVC)的彩色多普勒超声心动图图像特点,探讨其超声诊断价值及误诊与漏诊原因。方法 回顾性研究204例完全性和98例部分性心上型肺静脉异位引流患者的彩色多普勒超声图像特征,与CT或手术对照,分析漏、误诊原因与鉴别要点。结果(1)204例心上型TAPVC的超声心动图诊断准确率为100.0%。引流部位方面,193例汇入头臂静脉;11例直接开口于右上腔静脉。引流支数方面,202例表现完整的4支肺静脉;仅2例显示3支肺静脉。主要合并的畸形有房间隔缺损165例(80.9%)、卵圆孔未闭34例(16.7%)等。(2)98例心上型PAPVC的超声心动图诊断符合74例、误诊20例(6例超声分型与外科手术不符、9例引流支数误判及5例手术正常)、漏诊4例(3例超声仅提示房缺、1例孤立性肺静脉异位引流),诊断准确率、误诊率、漏诊率分别为75.5%、20.4%和4.1%。引流部位方面,60例引流入头臂静脉、37例汇入右上腔静脉、1例经奇静脉汇入上腔静脉。引流支数方面,单支71例、二支21例及三支6例。合并的常见畸形有房间隔缺损67例(68.4%)、卵圆孔未闭15例(15.3%)等。结论 超声诊断部分性肺静脉异位引流的准确性弱于完全性,通过有意识加强灵活应用胸骨旁、剑突下、右锁骨上窝上腔静脉长轴等非标准切面,全面扫差异常血管走形,关注异位引流的部位、汇入支数及合并畸形,注重伪像及正常或异常心内结构的鉴别诊断,有助于降低心上型肺静脉异位引流的漏误诊率。     

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.     

俯卧位通气对高海拔地区肺复张治疗无效急性呼吸窘迫综合征患者氧合的影响

目的 探讨俯卧位通气对高海拔地区肺复张术(RM)治疗无效急性呼吸窘迫综合征(ARDS)患者的治疗作用.方法 从海拔2260m的地区医院筛选RM治疗无效的41例ARDS患者[平均氧合指数( PaO2/FiO2)较RM前升高＜20％视为RM无效],依不同病因分为肺内源性ARDS组(ARDSp组)和肺外源性ARDS组(ARDSexp组),每组再按信封法随机分为俯卧位组和仰卧位组,即ARDSp俯卧位组(11例)、ARDSp仰卧位组(9例)、ARDSexp俯卧位组(10例)、ARDSexp仰卧位组(11例).在通气前及通气1、2、3、4h监测动脉血氧分压( PaO2)、PaO2/FiO2、静态顺应性(Cst)、气道阻力(Raw)的变化.结果 通气lh时,ARDSexp俯卧位组PaO2/FiO2( mm Hg,l mm Hg=0.133 kPa)即较通气前显著升高(157.4±40.6比129.3±48.7,P＜0.05),并随通气时间延长呈持续增高趋势,4h达峰值(219.1 ±41.1);且ARDSexp俯卧位组通气3h内PaO2/FiO2较其他3组显著增高,另3组间则差异无统计学意义.ARDSp俯卧位组、ARDSexp俯卧位组通气4h时PaO2/FiO2均较相应仰卧位组显著增高(208.8±39.7比127.4±47.1,219.1±41.1比124.9±50.8,均P＜0.05).4组通气前后Cst无显著改变,各组间差异也无统计学意义.ARDSp俯卧位组通气4h时Raw(cmH2O·L-1·s-1)较通气前显著降低(6.8±1.7比10.7±1.8,P＜0.05),且明显低于其他3组;其他3组各时间点Raw组内及组间比较差异均无统计学意义.结论 俯卧位通气作为ARDS机械通气重要策略之一,可以改善RM无效高原ARDS患者的氧合,为抢救患者赢得宝贵的时间.     

Digital imaging among medical facilities

The Department of Veterans Affairs (VA) in the USA operates a network of 172 medical centres which all utilize a hospital information system (HIS) which has been developed and is currently maintained by the VA. During the past several years, an image management and communication module has been developed, installed and clinically utilized at the Washington DC and Maryland VA Medical Centres. This image management and communication system, referred to as the decentralized hospital computer program (DHCP) imaging system, is fully integrated with a commercial picture archiving and communication system (PACS). The system is utilized to capture, archive, and display all images generated within the hospital including radiology, nuclear medicine, pathology, endoscopy, bronchoscopy, and dermatology, intraoperative photographs, ECG data, and a limited number of paper documents. The ultimate goal of the project is to have all patient text and image data available at any clinical workstation to any authorized user anywhere within the network of medical centres. Clinical requirements for an imaging workstation include ease of use, rapid and reliable access to the complete set of patient information, and images which are of acceptable quality to meet the requirements of the user and the subspecialty. Patient confidentiality and data security must be safeguarded at all times. Integration of the images with the remainder of the patient's database was found to be critical to the success of the project. The experience at the Washington and Maryland facilities suggests that an imaging system that is successfully integrated with a hospital information system can provide substantial clinical and economic benefits both within and among medical centres. Clinical acceptance and utilization of the system has been excellent, particularly in diagnostic radiology where DHCP Imaging has been interfaced to a commercial PAC system. Based upon this initial experience, the VA has begun to deploy the system throughout its large network of medical centres.     

Myocardial elastography at both high temporal and spatial resolution for the detection of infarcts

Myocardial elastography is a novel method for noninvasively assessing regional myocardial function, with the advantages of high spatial and temporal resolution and high signal-to-noise ratio (SNR). In this paper, in-vivo experiments were performed in anesthetized normal and infarcted mice (one day after left anterior descending coronary artery [LAD] ligation) using a high-resolution (30 MHz) ultrasound system (Vevo 770, VisualSonics Inc., Toronto, ON, Canada). Radiofrequency (RF) signals of the left ventricle (LV) in longitudinal (long-axis) view and the associated electrocardiogram (ECG) were simultaneously acquired. Using a retrospective ECG gating technique, 2-D full field-of-view RF frames were acquired at an extremely high frame rate (8 kHz) that resulted in high-quality incremental displacement and strain estimation of the myocardium. The incremental results were further accumulated to obtain the cumulative displacements and strains. Two-dimensional and M-mode displacement images and strain images (elastograms), as well as displacement and strain profiles as a function of time, were compared between normal and infarcted mice. Incremental results clearly depicted cardiac events including LV contraction, LV relaxation and isovolumetric phases in both normal and infarcted mice, and also evidently indicated reduced motion and deformation in the infarcted myocardium. The elastograms indicated that the infarcted regions underwent thinning during systole rather than thickening, as in the normal case. The cumulative elastograms were found to have higher elastographic SNR (SNR(e)) than the incremental elastograms (e.g., 10.6 vs. 4.7 in a normal myocardium, and 6.0 vs. 2.4 in an infarcted myocardium). Finally, preliminary statistical results from nine normal (m = 9) and seven infarcted (n = 7) mice indicated the capability of the cumulative strain in differentiating infracted from normal myocardia. In conclusion, myocardial elastography could provide regional strain information at simultaneously high temporal (>/=0.125 ms) and spatial ( approximately 55 microm) resolution as well as high precision ( approximately 0.05 microm displacement). This technique was thus capable of accurately characterizing normal myocardial function throughout an entire cardiac cycle, at the same high resolution, and detecting and localizing myocardial infarction in vivo.     

手转胎头术失败的原因与分娩结局临床分析

目的 探讨手转胎头术失败的原因与分娩结局.方法 选择2008年1月至2010年12月于我院住院分娩的持续性枕横位、枕后位产妇198例,根据行手转胎头术后结果分为成功组126例、失败组72例.比较两组分娩结局,对比分析失败原因.结果 失败组胎儿体质量≥3500 g的发生率[76.4％(55/72)]明显高于成功组[31.7％(40/126)],差异有统计学意义(x2=30.177,P=0.001)、失败组宫缩乏力发生率[58.3％(42/72)]高于成功组[38.1％ (48/126)],差异有统计学意义(x2=7.569,P=0.006)、失败组骨盆临界或轻度狭窄发生率[38.9％ (28/72)]高于成功组[23.8％(30/126)],差异有统计学意义(x2 =5.030,P=0.002)、失败组手转胎头时机不当(宫口开大＜6 cm、胎头位于坐骨棘上及宫口开大8～10 cm、胎头位于坐骨棘下≥2 cm)发生率[61.1％(44/72)]高于成功组[38.9％(49/126)],差异有统计学意义(x2=9.084,P=0.003).失败组母儿并发症(产后出血、产褥病率、胎儿窘迫、新生儿窒息)发生率高于成功组(x2 =9.586,P=0.002、x2=9.334,P=0.002、x2=5.910,P=0.015、x2=5.240,P=0.022)、失败组剖宫产发生率[72.2％(52/72)]明显高于成功组[34.1 ％(43/126),x2=26.641,P=0.001)].结论 手转胎头术能使难产变顺产,降低剖宫产率,减少母儿并发症,但须积极预防、处理导致手转胎头术失败的原因,对矫正失败后继续矫正及试产应慎重.     

Clinical Pharmacokinetics of Morphine

Morphine, the most widely used mu-opioid analgesic for acute and chronic pain, is the standard against which new analgesics are measured. A thorough understanding of the pharmacokinetics of morphine is required in order to safely and effectively use this analgesic in a wide variety of patients with different levels of organ function. A MEDLINE search was conducted to identify literature published between 1966 and January 2002 relevant to the pharmacokinetics of morphine. These publications were reviewed and the literature summarized regarding unique and clinically important elements of morphine disposition relative to its parenteral administration (including intravenous, intramuscular, subcutaneous, epidural and intrathecal administration), absorption profile (immediate release, controlled release, and sublingual/buccal, and rectal administration), distribution, and its metabolism/ excretion. Special populations, including infants, elderly, and those with renal/liver failure, have a unique morphine pharmacokinetic profile that must be taken into account in order to maximize analgesic efficacy and reduce the risk of adverse events.     

Evidence-Based Pain Management and Palliative Care in Issue Four for 2009 of The Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly. Issue 4 for 2009 contains 4027 complete reviews, 1906 protocols for reviews in production, and 11447 one-page summaries of systematic reviews published in the general medical literature. In addition, there are citations of 600,000 randomized controlled trials, and 12,200 cited papers in the Cochrane methodology register. The health technology assessment database contains over 7500 citations. This edition of the Library contains 90 new reviews, of which 19 have potential relevance for practitioners in pain and palliative medicine.     

Wie zuverlässig sind Angaben zu nichtentzündlichen ausgedehnten Schmerzen?

ZusammenfassungFragestellung Es wurde geprüft, wie sich der Differenziertheitsgrad zweier Schmerzmessmethoden auf Angaben zur Ausgedehntheit klinischer Schmerzen auswirkt. Zugleich wurde der Referenzzeitraum variiert, über den die Patienten berichten sollten.Methode Erfasst wurde der Einfluss zu Lasten der Befragungsdifferenziertheit durch den Vergleich zweier Körperschema-Bildvorlagen. Drei Referenzzeiträume (Schmerz aktuell, letzte Woche, letztes halbes Jahr) wurden vorgegeben.Ergebnisse Patienten mit ausgedehnten Schmerzen gaben bei differenzierter Befragung um so mehr Schmerzen an, je weiter die Schmerzen zurück lagen und je größer der Berichtszeitraum war. Patienten mit gelenknahen Schmerzen gaben bei hoch differenzierter Befragung weniger ausgedehnte Schmerzen in der Vergangenheit an als bei globaler Einschätzung. Patienten mit Rückenschmerzen berichteten bei differenzierter Befragung zum aktuellen Schmerz über weniger ausgedehnte Schmerzen als bei globaler Befragung.Schlussfolgerung Die Angaben zur Schmerzausdehnung variieren vor allem bei Patienten mit ausgedehnten Schmerzen in Abhängigkeit von der Differenziertheit der Befragung. In diesen Fällen ist die Wahrscheinlichkeit erhöht, dass sich die Beschwerdesymptomatik zumindest teilweise erst in der Reaktion auf die situativen Befragungsbedingungen konstituiert und daher nicht auf andere Befragungsbedingungen generalisiert werden kann.