中孕期大畸形筛查漏诊完全性肺静脉异位引流一例

胎儿期间,因胎儿心脏较小,心率较快,产前常规超声对TAPVC的诊断非常困难,只有在左房后方形成较为明显的肺总静脉,产前超声才较容易发现[3],所以一般产前常规超声容易漏诊。特别是最为重要的中孕大畸形筛查期间,假如超声检查图像不规范,也比较容易漏诊。 总结分析漏诊TAPVC原因可能有以下几种：1.胎儿期间因特殊的血流动力学影响,左右心房及心室基本对称,没有出现明显的右心房扩大,左心房缩小等较为明显的间接心脏改变。2.左房后方肺静脉与左心房存在空间的重叠,容易误认为肺静脉角存在,而认为肺静脉血流引流至左房,导致对TAPVC的漏诊。3.彩色多普勒技术应用不规范,通常情况下,将彩色血流速度标尺下降至 20 cm/s 左右,以便能更好地观察肺静脉血流。假如标尺过高,容易屏蔽低速肺静脉血流,而导致漏诊的发生。4.超声筛查时,技术不规范,切面不标准,左心房后方明显光滑,未仔寻找其明确原因,而导致漏诊的发生[4]。本例胎儿中孕期筛查图像,心脏图像较小,未进行充分放大,彩色标尺过高,未显示明显肺静脉血流,也未明显看到明显的肺静脉角,所得导致漏诊,误诊的发生。随着产前超声图像的标准化管理,完全性肺静脉异位引流得到了越来越多的关注,检出率也有了明显的提高。     

急性百草枯中毒的治疗进展

百草枯（paraquat，1，1-二甲基-4，4-联吡啶阳离子盐），是目前应用最广泛的触灭型除草剂之一，动物属中等毒性，但对人的毒性却较高，成人估计致死量40mg／kg。百草枯中毒后可造成多个系统或器官损害，肺部最为严重，病死率极高，致病机制复杂且尚未完全明确，     

胃肠胰神经内分泌瘤的诊断与治疗

神经内分泌瘤(NET)是起源于神经内分泌细胞的恶性实体肿瘤,发病率在过去30年内增加了5倍。消化道是NET最常见原发部位,胃肠胰神经内分泌瘤(GEP-NET)发病率在消化道肿瘤中排名第二,是胰腺癌的2倍。GEP-NET是一个进展性疾病,发生转移者中位生存时间仅33个月。GEP-NET可分为功能性和无功能性两类,早期症状不典型,从起病到明确诊断的时间为5⁷年。早期诊断对GEP-NET的治疗至关重要。嗜铬粒蛋白A(Cg A)是目前诊断NET最敏感和最特异的标志物。生长抑素受体成像也是重要诊断方法。GEP-NET目前尚无统一的治疗规范,手术切除是唯一能达到根治的手段。化疗是晚期GEP-NET一线选择,常用药物有卡培他滨、替莫唑胺等。生长抑素类似物如长效奥曲肽对控制症状效果显著。近年来靶向药物舒尼替尼和雷帕霉素在GEP-NET的临床研究中显示出很好的疗效。     

Incremental value of compression ultrasound sonography in the emergency department

The quick evaluation of venous thromboembolism is a key point of modern medicine since the delayed diagnosis is associated with a worse prognosis. Venous ultrasound (VU) is a sensitive and rapidly performed test in cases of suspected deep venous thrombosis. Various protocols have been proposed for its execution, such as the study of the whole deep venous circulation of the lower limb or the analysis of the femoral-popliteal area. The aim is to detect a vessel thrombus and the most sensitive element is the non-compressibility with the probe. Initially, the thrombus is hypoechogenic and adherent to the vessel; later, it tends to organize and recanalize. Usually, in the early stages, the risk of embolism is higher. The role of studying the iliac axis and calf veins is still uncertain. VU is not useful for assessing response to anticoagulation therapy and it is unclear whether the persistence of thrombotic abnormalities can guide on a possible prolongation of therapy.     

溃疡性结肠炎的中西医治疗

溃疡性结肠炎是一种具体病因尚未明确的结肠黏膜及黏膜下炎症性疾病,其治疗仍是一个难题。西医治疗一般采用氨基水杨酸类、皮质类固醇、免疫调节剂和抗菌药物,效果较确切,但不良反应较大、患者耐受性较差、容易复发。中医则采用中药复方口服、灌肠、外敷离子导入多途径联合治疗,多管齐下,标本兼顾,气血同治,有一定疗效,在一定程度上减少了西药治疗所带来的不良反应,且费用低廉,患者依从性好,但对重症溃疡性结肠炎的疗效不确切。该文就西医及中医的治疗观点作一介绍。     

门诊肠道寄生虫病感染状况的纵向观察

本文对 1981-2 0 0 0年门诊病人肠道寄生虫感染资料进行统计分析 ,总感染率为 30.89% ( 33607/ 10 8795 ) ;其中肠道蠕虫感染占 78.14% ,肠道原虫感染占 21.86 %。主要感染虫种为蛔虫、蓝氏贾第鞭毛虫、钩虫、肠滴虫、猪带绦虫和阿米巴。 2 0年间肠道寄生虫感染率呈明显下降趋势 ,由 1981年的 46.61%下降到 2000年的 12.82 % ;但近年来肠道蠕虫感染率下降速度变缓 ,而肠道原虫感染率呈现上升趋势 ,优势虫种亦由蛔虫、钩虫为主转为蓝氏贾第鞭毛虫、蛔虫居前。虽然肠道寄生虫感染 2 0年间变化较大 ,但每年的季节分布仍未打破 ,感染率以第三季度最高 ,第一季度最低。结果表明 ,目前人体肠道寄生虫病感染率还比较高 ,尤其是肠道原虫。因此 ,仍需根据季节、虫种、人群等具体情况 ,搞好肠道寄生虫病的防治工作.     

距骨骨折及其并发症的治疗进展

距骨骨折是一种比较少见的损伤,手术治疗距骨骨折的指征是距骨颈或距骨体骨折移位明显,其目的是使骨折部位达到解剖复位。距骨解剖结构特殊,表面大部分被关节面所覆盖,所以损伤常累及关节面,因此治疗难度较高且骨折术后并发症发生率高,容易发生缺血性坏死及创伤性关节炎。我们以距骨的解剖结构为基础,综述了目前距骨骨折及其并发症最新的治疗方法、不同治疗方法的优缺点及存在的问题。     

Limiting factors for exercise at extreme altitudes

Summary. Man can only survive and do work in the severe oxygen deprivation of great altitudes by an enormous increase in ventilation which has the advantage of defending the alveolar Po₂ against the reduced inspired Po₂. Nevertheless the arterial Po₂ on the summit of Mt Everest at rest is less than 30 Torr, and it decreases with exercise because of diffusion limitation within the lung. One of the consequences of the hyperventilation is that the marked respiratory alkalosis increases the oxygen affinity of the haemoglobin and assists in loading of oxygen by the pulmonary capillary. Although ventilation is greatly increased, it is a paradox that cardiac output for a given work level is the same in acclimatized subjects at high altitude as at sea level. Stroke volume is reduced but not because of impaired myocardial contractility because this is preserved up to extreme altitudes. Indeed the normal myocardium is one of the few tissues whose function is unimpaired by the very severe hypoxia. There is evidence that oxygen delivery to exercising muscle is diffusion limited along the pathway between the peripheral capillary and the mitochondria. At the altitude of Mt Everest, maximal oxygen uptake is reduced to 20–25% of its sea level value, and it is exquisitely sensitive to barometric pressure. Seasonal variations of barometric pressure affect the ability of man to reach the summit without supplementary oxygen. In spite of the greatly reduced aerobic capacity, anaerobiosis is greatly curtailed, and it is predicted that above 7500 m, there is no rise in blood lactate on exercise. The paradoxically low lactate is possibly related to plasma bicarbonate depletion.     

李遇春临证特色与学术思想研究

作者从四个方面介绍了李遇春教授的临证特色,即:处方精炼、用药平和;针对主症、用方灵活;阐释病情,通俗易懂;思路广阔,善用单方。将李遇春教授的学术思想总结为三个方面:一是主张治疗脾胃病用药当以平和为主,时时顾护胃气,养后天之本;二是发挥了守方思想,守方的前提是辨证准确,守方守的是治疗方向,而不是死守方剂;三是对方剂学组方思想的贡献,提出“针对主要症状+次要症状,用基本对路的方子,加入对症的药物”这一重要思想。     

生活饮用水氯化消毒副产物分布的研究

目的研究饮用水中氯化消毒副产物的形成及其分布规律。方法采用仪器法和化学分析法,对不同采样点水源水、出厂水和管网水进行氯化消毒副产物检测。结果水源水、出厂水和管网末梢水中三卤甲烷检出率60.20%、有13.40%超标;卤乙酸的检出率50.05%,超标率为2.10%。丰水期的水中消毒副产物浓度高于枯水期,市县级水厂与乡镇水厂污染程度无差别。结论某市氯化消毒的饮用水中三氯甲烷副产物检出率达50%以上,部分水中毒副产物含量超标,应改进水消毒工艺,加强水源保护。     

孟氏骨折脱位（儿童）愈合后畸形的早期手术矫治探讨

目的探讨早期手术矫形治疗儿童孟氏骨折愈合后畸形的临床效果。方法本组17例,全部采用肘后外侧切口。方法一：切断尺骨并作相应延长及植骨,使肱桡关节复位;方法二：切断桡骨,复位肱桡关节后作相应短缩。重建环状韧带,并用克氏针暂时固定肱桡关节,石膏托外固定前臂于屈肘100。中立位。结果随访13—27个月,本组17例均基本获得桡骨头复位,肘关节稳定而无明显疼痛。功能恢复情况较为良好,大致接近于肢体的正常活动范围。结论对儿童孟氏骨折后畸形早期采取积极的矫形治疗措施,使桡骨头复位,矫正尺骨畸形,恢复正常的关节组合,对患儿的正常发育是有利的。即使骨与关节已有变形,在成长期也可获得重新塑型的机会。因此积极矫形较等待观望的态度更有价值。     

Caring in nursing: a different interpretation

AIM: To apply Habermas' (1995) Theory of Moral Consciousness and Communicative Action to the nurse-patient relationship, offering a different interpretation to the nurse-patient relationship that is caring in nursing. RATIONALE: Many authors have described the nurse-patient relationship, but Habermas' theory synthesizes the components into a complex matrix that is caring in nursing. FINDINGS: The theory offers three claims to normative validity: the claim to truth which is the factual objective knowledge; the claim to truthfulness which refers to the intrasubjective self; and the claim to right which is the intersubjective interaction. The validity claims explain the patient's personal and illness self, the nurse's personal and professional self, and the interaction/discourse. The interaction is situation specific, and is identified as moral because dialogue/discourse requires a 'considerateness' of each for the other. 'Considerateness' in discourse requires certain rules, including that each participant has an equal voice, be followed in order for the Principle of Universalization to occur. Habermas draws on Kohlberg's (1981), and Selman's (1980) work to develop three levels of moral maturity of communication. These are preconventional, conventional, and postconventional. Initial moral maturity is egocentric, subjective, and obedient to authority. Maturity develops with recognition of other and reciprocity. At the postconventional level there is mutuality and the ability for abstract reasoning. There is a third person objectivity combining speaker and addressee/listener perspectives. Norms are not just accepted, they are reasoned through. This leads to justification of the norm, which is then accepted as valid. When the three validity claims are met and there is genuine 'considerateness' in the interaction there is communicative action. The reverse is strategic action, where the communication is coercive. When there is communicative action both patient and nurse are validated with a sense of fulfillment or . CONCLUSION: Habermas' (1995) theory offers a new paradigm for caring in nursing.     

Impedance to Defibrillation Countershock: Does an Optimal Impedance Exist?

Defibrillation is thought to occur because of changes in the transmembrane potential that are caused by current flow through the heart tissue. Impedance to electric countershock is an important parameter because it is determined by the magnitude and distribution of the current that flows for a specific shock voltage. The impedance is comprised of resistive contributions from: (Ij extra-tissue sources, which include the defibrillator, leads, and electrodes; (2) tissue sources, which include intracardiac and extra-cardiac tissue; and (3) the interface between electrode and tissue. Tissue sources dominate the impedance and probably contribute to the wide range of impedance values presented to the defibrillation pulse. Hucause impedance is not constant within or between subjects, defibrillators must be designed to accommodate these differences without compromising patient safety or therapeutic efficacy. Experimental investigations in animals and humans suggest that impedance changes at several different time scales ranging from milliseconds to years. These alterations are believed to be a result of both electrochemical and physiological mechanisms. It is commonly thought that impedance is optimized when it has been decreased to a minimum, since this allows the most current flow for a given voltage shock. However, if the impedance is lowered by changing the location or size of the electrodes in such a way that current flow is decreased in part of the heart even though current flow is increased elsewhere, then the total voltage, current, and energy needed for defibrillation may increase, not decrease, even though impedance is decreased. A simple boundary element computer model suggests that the most even distribution of current flow through the heart is achieved for those electrode locations in which the impedance across the heart is at or near the maximum cardiac impedance for any location of these particular electrodes. Thus, the optimum shock impedance is achieved when impedance is minimized for extra-tissue and extra-cardiac tissue sources and is at or near a maximum for intracardiac tissue sources.     

Peptide-Bound Hydroxylysine and Large Polypeptides related to Collagen Synthesis

About 10% of the urinary hydroxylysine is linked to peptides. There is no significant difference between the excretion of peptide-bound hydroxylysine and hydroxylysine measured in the non-dialysable fraction of the urine. Non-dialysable hydroxylysine is highly glycosylated and contains mainly glucosyl-galactosyl-hydroxylysine. It is concluded that the urinary peptide-bound hydroxylysine is present in the non-dialysable collagen polypeptides. Their unusual carbohydrate composition is discussed.     

Defining ‘competency’ in nursing (part II): an analytical review

? The reason for the present uncertainty in defining nursing competency is analysed. ? The prevailing educational philosophy underpinning nursing preparation for competence is subjected to a critique. ? The effect and outcome of this philosophy on clinical supervision, PREP and the law are considered in relation to nursing competence. ? It is concluded that because nursing competency is only vaguely and broadly defined, preparation and assessment of competency is haphazard and unstructured; and hence a potential safety hazard for both patient and nurse. ? It is suggested that the UKCC needs to assume responsibility for ascertaining nursing competence; and a four-point framework is proposed for setting and testing national standards of nursing competency.     

Manipulativeness and dialogue

The notion of manipulativeness is sometimes invoked both with regard to patients or clients and with regard to the professionals who are charged with caring for them. The paper explores that notion and the idea that what makes an action manipulative is not the end at which it is directed but the way in which that end is sought. Open dialogue is characterized and it is suggested that manipulative interactions are ones that depart from open dialogue. Manipulative persons are characterized as having or being biased towards a restricted social repertoire. While some manipulativeness is inevitable, it is suggested that we need to reflect from time to time on whether we have got the balance right.     

Time for a change to assess and evaluate body temperature in clinical practice

The definition of normal body temperature as 37°C still is considered the norm worldwide, but in practice there is a widespread confusion of the evaluation of body temperature, especially in elderly individuals. In this paper, we discuss the relevance of normal body temperature as 37°C and consequences in clinical practice. Our conclusion is that body temperature should be evaluated in relation to the individual variability and that the best approach is to use the same site, and an unadjusted mode without adjustments to other sites. If the baseline value is not known, it is important to notice that frail elderly individuals are at risk of a low body temperature. In addition, what should be regarded as fever is closely related to what is considered as normal body temperature. That is, as normal body temperature shows individual variations, it is reasonable that the same should hold true for the febrile range.