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。     

胎儿完全性肺静脉异位引流的产前超声诊断价值

目的分析总结胎儿完全性肺静脉异位引流(TAPVC)的超声心动图表现;探讨产前超声诊断胎儿TAPVC的临床意义。方法回顾性分析总结15例我院产前及产后超声心动图或引产后尸检确诊为TAPVC的胎儿超声心动图表现,并将产前超声心动图与产后超声心动图或引产后尸解结果对照。结果产前超声诊断14例TAPVC中,12例TAPVC均伴复杂型先心病(均为右侧异构综合征),其中心内型3例,心上型5例,心下型4例;1例混合型(心内型+心上型)TAPVC;1例心内型TAPVC;产前超声漏诊1例,产后行超声心动图证实为心内型TAPVC。结论胎儿TAPVC超声心动图有特征性表现;产前超声对胎儿TAPVC有重要的诊断意义。     

产前超声心动图与解剖铸型观察胎儿完全性肺静脉异位引流

目的 采用产前超声心动图与解剖铸型观察胎儿完全性肺静脉异位引流（TAPVC）。方法 纳入9胎经产前超声心动图诊断为TAPVC的胎儿,对引产后3胎标本进行解剖、6胎标本制作胎儿心脏铸型,观察胎儿静脉回流特点及合并心内外畸形。结果 9胎TAPVC中,66.67%（6/9）为心上型,33.33%（3/9）为心下型。胎儿超声四腔心切面见左心房缩小,未见静脉与左心房相连;三血管气管切面见左心房后方赘余血管;6胎心上型TAPVC中,4胎肺静脉汇入右上腔静脉、2胎肺静脉汇入左上腔静脉;3胎心下型TAPVC肺静脉均汇入门静脉。9胎均合并心房异构综合征,8胎（8/9,88.89%）合并单心室,7胎（7/9,77.78%）合并肺动脉狭窄,合并单心房及完全型心内膜垫缺损各4胎（4/9,44.44%）;5胎（5/9,55.56%）合并永存左上腔静脉,合并双下腔静脉及左头臂静脉主动脉弓下走行各1胎（1/9,11.11%）;1胎（1/9,11.11%）合并膈疝。结论 TAPVC胎儿多合并心内外畸形及体静脉异常。产前超声具有重要诊断价值,解剖铸型有助于认识TAPVC胎儿血管走行及静脉引流途径。     

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.     

胎儿超声心动图在产前检测完全型肺静脉异位引流中的价值研究

本研究以2013年7月~2014年7月在我院超声中心经产前检测胎儿超声心动图的资料和引产后尸检后确诊为完全型肺静脉异位引流的胎儿共20例为研究对象,采用回顾性分析的方法,分析胎儿超声心动图在产前检测完全型肺静脉异位引流的特征及准确性。20例引产后尸检后确诊为完全型肺静脉异位的胎儿中,产前超声漏诊1例。产前超声心动检测诊断为完全型肺静脉异位的胎儿的例数为19例,其中,心上型9例,心下型6例,心内型4例。仅合并房间隔缺损和动脉导管未闭归为单发畸形共8例。11例合并其他心内畸形或心外畸形。胎儿超声心动图在产前检测完全型肺静脉异位引流的准确性为95%(P>0.05),以上差异具有统计学意义。胎儿超声心动图在产前检测完全型肺静脉异位引流具有很高的准确性。胎儿超声心功图是诊断完全型肺静脉异位引流的可靠性临床方法,具有无创、简便便捷,重复性强的优点,有利于产妇做出优生优育选择,提高生育质量。值得临床推广应用。     

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.     

彩色多普勒超声心动图诊断完全性肺静脉异位连接的方法和价值

目的:探讨完全性肺静脉异位连接(TAPVC)的彩色多普勒超声心动图(CDE)图像特征及超声心动图诊断TAPVC的价值。方法:对16例手术证实的TAPVC患儿进行回顾性分析。结果:TAPVC的CDE具有明显的图像特征:①肺静脉未与左房直接连接;②心上型TAPVC可见肺静脉共腔-垂直静脉-左无名静脉-上腔静脉-右心房或肺静脉共腔-上腔静脉近心端;心内型TAPVC可见四根肺静脉引流入扩张的冠状静脉窦-右心房;心下型TAPVC可见肺静脉共腔-降垂直静脉-肝内门静脉相连;混合型TAPVC以心内型+心上型常见;③均有心房水平(经ASD或PFO)右向左分流。根据TAPVC的CDE图像特征该16例作出正确诊断,诊断准确率100%,引流部位正确率94%。结论:彩色多普勒超声心动图对TAPVC的诊断有很高的临床价值。     

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.     

完全性肺静脉畸形引流的超声心动图诊断

目的：评价超声心动图对完全性肺静脉畸形引流（TAPVC）的诊断价值。方法：回顾分析16例超声诊断为TAPVC的超声心图特征，其中11例超声结果与手术结果相对照，超声检查内容包括二维及彩色多普勒显像，分别经胸骨旁、胸骨上窝，剑突下等部位多切面观详细观察肺静开口部位，引流途径，共同肺静脉干形态及存在的合并畸形等。结果：按Darling等的分型，16例TAPVC患者中超声诊断分型为：心上型（Ⅰ型）11例，其中ⅠA型10例，ⅠB型1例，心内型（Ⅱ型）5例，其中ⅡA型2例，ⅡB型3例。11例经手术证实的TAPVC患者超声诊断及分型与手术结果一致，同时超声心动图还可以估计肺动脉压力，发现合并存在的其他畸形等。结论：超声心动图是TAPVC患者术前首选检查方法，如能多部位多切面仔细观察，则可对TAPVC作出准确的定性及分型诊断。     

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.     

Dissociable correlates of two classes of retrieval processing in prefrontal cortex

Although substantial evidence suggests that the prefrontal cortex (PFC) implements processes that are critical for accurate episodic memory judgments, the specific roles of different PFC subregions remain unclear. Here, we used event-related functional magnetic resonance imaging to distinguish between prefrontal activity related to operations that (1) influence processing of retrieval cues based on current task demands, or (2) are involved in monitoring the outputs of retrieval. Fourteen participants studied auditory words spoken by a male or female speaker and completed memory tests in which the stimuli were unstudied foil words and studied words spoken by either the same speaker at study, or the alternate speaker. On "general" test trials, participants were to determine whether each word was studied, regardless of the voice of the speaker, whereas on "specific" test trials, participants were to additionally distinguish between studied words that were spoken in the same voice or a different voice at study. Thus, on specific test trials, participants were explicitly required to attend to voice information in order to evaluate each test item. Anterior (right BA 10), dorsolateral prefrontal (right BA 46), and inferior frontal (bilateral BA 47/12) regions were more active during specific than during general trials. Activation in anterior and dorsolateral PFC was enhanced during specific test trials even in response to unstudied items, suggesting that activation in these regions was related to the differential processing of retrieval cues in the two tasks. In contrast, differences between specific and general test trials in inferior frontal regions (bilateral BA 47/12) were seen only for studied items, suggesting a role for these regions in post-retrieval monitoring processes. Results from this study are consistent with the idea that different PFC subregions implement distinct, but complementary processes that collectively support accurate episodic memory judgments.     

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.