女性尿直肠隔畸形序列征产前超声表现

目的总结分析胎儿尿直肠隔畸形序列征产前超声声像图及引产胎儿尸检特征。方法对2003年1月至2012年12月在南方医科大学附属深圳市妇幼保健院产前超声诊断的11例尿直肠隔畸形序列征胎儿超声图像表现和产后尸检特点进行总结分析。结果 11例尿直肠隔畸形序列征胎儿产前超声均显示腹腔内巨大囊性包块（双房或单房囊性结构2例,三房囊性结构9例,囊内透声清亮3例,囊内透声浑浊8例）和肛门闭锁,其中7例肾脏异常,6例伴腹腔积液;3例可见肠石症;伴发其他系统畸形包括脊髓栓系2例、单脐动脉2例、脐带囊肿2例、骶尾部发育不良1例、心肌致密化不全1例。染色体检查发现21-三体1例。引产胎儿标本尸检证实11例均为女性,有单个会阴开口,外生殖器性别不清楚,阴蒂肥大及阴唇融合;内生殖器异常包括双阴道或阴道纵隔9例,双子宫或双角子宫10例,阴道发育不良1例。结论尿直肠隔畸形序列征是一种包括泌尿系统、生殖系统、胃肠道异常的复杂先天畸形,腹腔内囊性包块是女性尿直肠隔畸形序列征的特征改变,具有重要诊断价值,产前超声发现肾脏异常及外生殖器性别不清楚有助于诊断尿直肠隔畸形序列征。     

尿直肠隔畸形序列征的产前超声诊断及文献复习

目的探讨尿直肠隔畸形序列征(URSMS)的产前超声表现和解剖特点。方法对我院产前超声诊断的5例URSMS胎儿的产前超声表现和引产后尸体解剖结构进行总结分析。结果 URSMS特征性超前超声表现包括肛门闭锁、肠管扩张及肠石症、腹腔囊性团块和泌尿生殖系统畸形;同时可伴发脊柱、心脏及其他异常。引产后解剖结果证实5例均为部分型URSMS,其中4例男性,1例性别不定,染色体证实为女性。5例中3例外生殖器形态异常。5例URSMS中4例胎儿腹腔均见泄殖腔,1例男性胎儿未见泄殖腔,但后尿道壁与直肠壁融合。结论产前超声发现肛门闭锁、肾脏异常以及外生殖器异常有助于诊断URSMS,腹腔内囊性团块是女性URSMS的特征性产前超声改变,肠管扩张及肠石症是男性URSMS的特征性产前超声改变,具有重要诊断价值。     

B超诊断胎儿直肠闭锁1例

孕妇,25岁,孕1产0。现孕24周行常规B超检查。B超所见:胎儿颅骨光环完整,双顶径6.2cm,四肢可见,胎心搏动正常,羊水最大暗区前后径9.8cm。胎儿腹部显膨隆,胎腹下方见一较大“双叶征”无回声区(图1),中央有一不完全隔,胎腹较高平面可见大小肠扩张,更高平面可见大小肠均扩张,且小肠蠕动活跃,其中一段扩张大肠直径2.5cm。同时于两大腿间,阴囊根部系带后方肛门区见“靶环征”低回声肛门声像(图2)。超声诊断:1.宫内中孕,单活胎;2.胎儿畸形:考虑直肠闭锁。入院后引产下一死男婴,其外观除腹部显膨隆外未见明显异图1　胎儿下腹部见“双叶征”无回声区…     

三维超声断层成像技术评价胎儿肛门直肠发育的价值

目的应用三维超声断层成像技术（TUI）评价产前超声对胎儿肛门直肠发育的诊断价值,从而为产前超声诊断肛门闭锁提供更加丰富的诊断信息。 方法选取2017年6月至2018年7月首都医科大学附属北京天坛医院315例正常单胎孕妇,年龄23~40岁,平均年龄（29±3）岁,孕周为19~40周。应用TUI技术分别测量胎儿肛门括约肌直径（ASD）、肛管直径（ACD）及肛管长径（ACL）。各测量值与孕周之间的关系采用Pearson相关分析,取得ASD、ACD及ACL与孕周的相关性,建立回归方程及曲线。采用组内相关系数（ICC）及其95%可信区间（95% CI）观察对ASD、ACD及ACL测量的可重复性,以此评价测量的可靠性。 结果所有胎儿应用TUI技术胎儿肛门直肠部位显示率为97.8%（308/315）,Pearson相关分析结果表明,正常胎儿ASD、ACD及ACL与胎儿孕周呈正相关。回归方程分别为：ASD：Y=-0.001X²＋0.421X-1.726（r=0.83,P<0.01）;ACD：Y=0.418X-4.207（r=0.89,P<0.01）;ACL：Y=0.526X-1.062（r=0.87,P<0.01）。 结论TUI技术评价胎儿肛门直肠结构的发育可作为产前观察胎儿肛门直肠结构的一种方法,应用该方法可以提高胎儿肛门直肠结构的显示率。     

胎儿消化道闭锁产前超声声像特征分析

目的 探讨胎儿消化道闭锁的产前超声声像特征及其相关临床价值.方法 2010年7月至2012年7月期间驻马店市中心医院诊断20例消化道闭锁胎儿,将产前超声诊断与引产尸检结果相对比,对其影像学资料进行回顾性分析.结果 20例确诊的消化道闭锁胎儿中产前超声检查检出11例,其检出率为55.0％,其中包括3例食管闭锁,3例十二指肠闭锁,3例空回肠闭锁,2例肛门闭锁;漏诊9例,其中3例存在气管-食管瘘,无食管扩张征的食管闭锁,6例结肠、直肠无扩张征的肛门闭锁.结论 产前超声诊断胎儿消化道闭锁具有操作简便、检出率高等特点,加强孕晚期的复查,明显降低了漏诊率,值得临床推广.     

胎儿胃泡超声形态学改变与消化道异常相关性分析

目的 探讨产前超声所示胎儿胃泡形态学变化在不同类型消化道畸形中的声像图特征及其临床价值.方法 应用彩色多普勒超声检查妊娠13～42周胎儿,测量胃泡最长径、前后径、L/W比值,认真观察幽门部蠕动,节律性幽门管显示及有无幽门扩张等形态学变化,并与分娩后新生儿检查或胎儿尸体检查结果进行对照.结果 产前超声共发现消化道畸形27例,其中先天性隔疝8例,十二指肠闭锁13例,空回肠闭锁4例,结肠闭锁2例.合并其他复杂畸形7例,羊水过多19例.结论 胎儿胃泡形态学变化,特别是L/W比值、幽门部蠕动、节律性幽门管显示及有无幽门扩张,在消化道畸形中具有一定的特征性表现,有助于指导产科医生下一步处理.     

超声观察胎儿肛门对诊断肛门闭锁的意义

目的：探讨产前应用超声观察胎儿肛门结构的存在诊断胎儿肛门闭锁的临床价值.方法：选择16～38周单胎孕妇42496例为研究对象,观察胎儿肛门声像图,其表现为周边环绕低回声、中央呈圆点样强回声“靶环征”.若无法探及“靶环征”声像图则认定为肛门闭锁.结果：所有胎儿中未探及肛门“靶环征”声像图的有13例,引产、流产或生后均证实为肛门闭锁.1例为单纯闭锁,12例合并其他畸形及异常,7例出现了肠管扩张,2例肠管内可见强回声的胎粪.结论：正常情况下肛门声像图是可以显示的,它可以用来提示肛门闭锁的可能性.     

VACTERL联合征的产前超声诊断分析

目的：探讨VACTERL联合征胎儿产前超声声像图特征及妊娠结局。方法对2003年1月至2013年9月深圳市妇幼保健院产前超声诊断为VACTERL联合征的55例胎儿超声声像图特征及产后随访结果进行总结分析。结果55例胎儿6种VACTERL联合征畸形产前超声检出率分别为：脊柱异常45.5%（25/55）、肛门闭锁30.9%（17/55）、心脏畸形81.8%（45/55）、气管食管瘘和（或）食管闭锁32.7%（18/55）、肾脏畸形60.0%（33/55）、肢体畸形83.6%（46/55）。55例胎儿均伴3种及3种以上VACTERL联合征畸形,产前超声表现及畸形特征：（1）55例胎儿中合并3种联合征畸形39例（70.9%,39/55）,其中以肢体畸形（33/39）、心脏畸形（31/39）和肾脏畸形居多（21/39）。（2）55例胎儿中合并4种联合征畸形13例（23.6%,13/55）,其中以心脏畸形（11/13）、肢体畸形（10/13）、肾脏畸形（9/13）和气管食管畸形居多（8/13）。（3）55例胎儿中合并5种联合征畸形3例（5.5%,3/55）,均合并肛门闭锁、心脏、肾脏和肢体畸形（3/3）;其中2例合并脊柱异常（2/3）。（4）55例胎儿中未检出合并6种畸形的胎儿（0/55）。（5）55例VACTERL联合征胎儿中合并其他畸形29例（52.7%,29/55）,以单脐动脉居多（38.2%,21/55）。55例胎儿超声检查后均引产,引产胎儿大体标本外观检查（55例）及胎儿标本解剖（9例）所见与产前超声检查结果均符合。结论 VACTERL联合征胎儿产前超声有典型声像图特征,胎儿均伴多发畸形,以肢体畸形、心脏畸形和肾脏畸形多见。超声检查时由畸形发生率高的部位向畸形发生率低的部位顺序扫查,有助于提高超声诊断符合率。产前超声诊断VACTERL联合征有助于指导产科处理。     

高频超声在先天性肛门直肠畸形诊治中的应用

目的探讨超声检查在先天性肛门直肠畸形诊治中的应用价值。方法应用高频超声和X-线对18例肛门直肠畸形患儿进行检查。结果肛门闭锁和直肠阴道瘘有较典型的声像图表现，同时可以发现合并症，本组7例合并症，超声发现6例。肛门闭锁直肠盲端和直肠阴道瘘定位准确性，超声为89％(16／18)，X-线为72％(13／18)。结论超声对肛门直肠畸形的诊断符合率和定位准确率均高于X-线，对常见合并症如先天性心脏病、泌尿生殖系畸形等易检出，是首选的辅助诊断方法，为外科手术方式的选择提供重要依据。     

胎儿食道闭锁产前超声诊断分析

目的探讨胎儿食道闭锁(EA)产前声像图特征,以提高胎儿食道闭锁产前超声诊断符合率。方法收集产前超声诊断、尸检或产后检查证实为胎儿食道闭锁病例共9例,分析其主要超声表现。结果 9例胎儿中3例孕周≤24周时检出,其中2例超声表现为胃泡不显示,伴有其他结构明显异常,染色体检查异常,尸检结果为单纯食道闭锁;1例超声表现为小胃泡、羊水过多伴右心室双出口、单脐动脉,尸检结果为食道闭锁伴食管气管瘘;其余6例胎儿孕周>28周时检出,其中3例超声表现为小胃泡、3例胃泡不显示;4例胎儿可见近端食道囊状扩张;3例羊水过多;3例胎儿宫内生长受限。此6例胎儿产后证实为食道闭锁合并气管食管瘘。结论胎儿食道闭锁有其特征性超声表现,产前超声对诊断胎儿食道闭锁有重要意义。     

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.     

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.     

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.     

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.