胎儿心轴角度异常对心脏畸形诊断的价值

目的 探讨胎儿心轴角度异常在胎儿心脏结构异常的诊断价值。方法 研究对象为2013年至2015年门诊就诊及住院孕妇,胎龄在20～40周的胎儿,单纯随机选取胎儿心脏正常组(A组)与胎儿心脏结构异常组作对照(B组),其中A组231例,B组36例,采用标准四腔心切面进行心轴角度的测量。结果 A组胎儿的平均心轴角度为(37.9±7.6)°,B组为(52.6±19.8)°,两组胎儿平均心轴角度相比,差异有统计学意义(P<0.01)。以超过正常胎儿心轴平均角度的99%正常值范围(20.3°～61.9°)为心轴异常,以<20.0°为心轴角度偏小,心轴角度>62.0°为心轴角度偏大。A组无心轴角度偏大或偏小；B组心轴角度偏大15例(41.7%),心轴角度偏小2例(5.6%),两组患者在心轴角度异常的差异有统计学意义(P<0.01),A组的心轴角度偏大发生率以及心轴角度偏小发生率均低于B组。结论 20～40周胎儿心轴角度的测定简单易行,当其<20.0°或>62.0°时提示可能存在心脏畸形,应进一步检查确诊。     

早孕期胎儿心轴的参考值及其临床意义

目的探讨孕11^＋0~13^＋6周胎儿心轴的正常参考值范围,并评价早孕期测定胎儿心轴的临床应用价值。 方法选取2017年6月至2018年6月于南京医科大学附属苏州医院行早孕期超声检查的孕妇1639例,均为单胎妊娠,于早孕期超声检查时显示标准四腔心切面,于收缩期（房室瓣完全关闭时）测量心轴角度。 结果1631例正常胎儿心轴测量值范围为10.26°~74.02°,平均为（43.79±10.10）°。按照不同孕周将1631例胎儿分为11^＋0~11^＋6周、12^＋0~12^＋6周、13^＋0~13^＋6周3组,其胎儿心轴角度分别为（43.40±10.82）°、（43.91±9.88）°、（43.65±9.96）°,3组胎儿心轴比较差异无统计学意义（F=0.40375,P>0.05）。本研究采用普通人群中胎儿心轴角度的95%可信区间作为正常参考值范围,得出1631例早孕期胎儿心轴角度正常参考值范围为23.99~63.58°。1639例胎儿中,8例于早孕期诊断为先天性心脏病,其中6例心轴角度测量值异常（4例心轴向左侧偏移,1例心轴向右侧偏移,1例心轴无法测量）。 结论早孕期胎儿心轴角度测量及正常参考值范围的建立对于早孕期胎儿心脏超声筛查具有一定的价值,可作为早孕期诊断胎儿心脏畸形的指标之一。     

心轴角度异常在胎儿心脏畸形诊断中的价值

目的探讨心轴角度异常在胎儿心脏结构异常诊断中的意义。方法随机选取胎儿心脏正常孕妇231例(正常组)与胎儿心脏结构异常孕妇36例(异常组),应用超声心动图于标准四腔心切面测量心轴角度并对其进行比较。以20.0°为心轴角度偏小,62.0°为心轴角度偏大,心轴角度偏小或偏大定义为心轴异常。结果正常组和异常组胎儿平均心轴角度分别为(37.9±7.6)°、(52.6±19.8)°,两组比较差异有统计学意义(P0.01);正常组无心轴角度偏大或偏小;异常组心轴角度偏大16例(44.4%),心轴角度偏小2例(5.6%),两组患者心轴角度异常率比较差异有统计学意义(P0.01)。结论当心轴角度偏大或偏小时提示可能存在心脏畸形,应进一步检查确诊。     

三维超声诊断胎儿小下颌畸形的价值

目的 应用三维超声定量检测胎儿下颌骨位置及大小,为产前诊断小下颌畸形提供理论依据。方法 采用经腹三维超声观察且比较188胎20~36孕周正常胎儿(正常组)及7胎小下颌畸形胎儿(异常组)下颌骨发育情况,测量胎儿颜面部角度及下颌骨宽度与上颌骨宽度之比,分析其与孕周的关系,并比较两组测量数据。结果 188胎中,成功测量178胎的全部下颌骨指标。正常胎儿颜面部角度为(62.37±6.23)°,与孕周无相关性(r=0.001,P=0.757),颜面部角度<49.90°诊断为颏后缩;下颌骨宽度与上颌骨宽度之比为0.98±0.09,在观察孕期内无显著变化,下颌骨宽度与上颌骨宽度之比<0.80诊断为下颌骨短小。7胎下颌骨短小且颏后缩,产前超声诊断为小下颌畸形,为产后或尸检结果证实。结论 应用三维超声测量胎儿颜面部角度及下颌骨与上颌骨宽度之比可在产前定量诊断小下颌畸形。     

正常儿童年龄与胫骨力学轴线的关系在评介正常儿童生理性胫骨旋转中的作用

目的绘制出6个月~15岁儿童正常胫骨旋转解剖轴线的发育曲线图,为诊断儿童胫骨旋转畸形提供理论依据。方法随机抽取门诊体检的正常儿童345例,排除骨骼、肌肉及神经疾病和双侧下肢其他疾病引起的畸形,对每例儿童分别进行双侧下肢胫骨旋转轴线(包括内旋角度、外旋角度)角度测量,并根据年龄进行分组统计:第1组,6个月~2周岁82例,男47例,女35例,平均年龄(1.1±0.5)岁;第2组,25个月~4周岁66例,男32例,女34例,平均年龄(3.3±0.4)岁;第3组,5~12岁112例,男61例,女51例,平均年龄(9.1±0.6)岁;第4组,12~15周岁85例,男36例,女49例,平均年龄(12.9±0.8)岁。结果初始大腿-足轴角从左侧(6±14.2)°、右侧(6±14.3)°,到15岁时的左侧(12±14.0)°、右侧(12±13.9)°,大腿-踝轴角从初始的左侧(6±17.1)°、右侧(6±17.4)°,到15岁时左侧(12±11.8)°、右侧(12±12.7)°,分别绘制出不同年龄段的正常胫骨旋转解剖轴线的发育曲线图。结论儿童胫骨旋转解剖轴线具有随着年龄增加而发生变化的特点,不同的年龄段,标准差大于正常年龄儿童时,即可作为诊断胫骨旋转异常的依据;该曲线同时可作为临床进一步研究的基础。     

小儿His角的超声观测及对胃食管反流的诊断价值

目的 研究小儿His角的大小、生长变化规律及其在胃食管反流诊断中的价值。方法 将729例小儿按年龄分为新生儿（60例）、婴儿（252例）、幼儿（243例）和儿童（174例）4个年龄段,在哺乳或饮水后,超声观察胃食管连接部并测量His角的大小。以临床诊断为标准,将受检小儿分为GER组(156例)和健康组(573例)。对各组数据进行统计学分析,并绘制ROC曲线判断His角诊断GER的价值及最佳截断值（cutoff值）。结果 健康组小儿His角均值为87.2°±7.2°,其中新生儿为93.3°±8.7°,婴儿为90.4°±6.6°,幼儿为86.2°±4.3°,儿童为84.5°±8.8°。GER组小儿His角均值为108.3°±6.7°,明显大于健康组(P<0.01)。其中新生儿107.5°±7.2°,婴儿108.9°±7.2°,幼儿106.8°±3.5°,儿童为106.2°±5.3°,均大于相同年龄段健康组小儿(P<0.01)。His角诊断GER的AUCROC为0.969,最佳截断值为102.2°,其诊断敏感性为94.1%,特异性为97.9%。结论 正常小儿的His角随年龄的增大逐渐变小;胃食管反流小儿的His角明显大于正常小儿,且不同年龄段小儿His角大小无明显差异;His角增大可作为诊断小儿GER的指标之一。     

早孕期超声测量胎儿脉络丛及枕额径诊断开放性脊柱裂

目的 观察早孕期(孕11～13⁺⁶周)超声测量胎儿颅脑脉络丛(CP)及枕额径(OFD)对诊断开放性脊柱裂(OSB)的价值。方法 回顾性收集177胎早孕期超声未见明显异常、经系统产前超声筛查及出生后追踪证实无异常(正常组),以及25胎早孕期超声发现颅脑结构异常并经中期引产证实为OSB(OSB组)的胎儿，比较组间早孕期CP、OFD、脑干(BS)宽度、脑干至枕骨距离(BSOB)、CP/OFD及BS/BSOB值的差异，分析上述指标与胎儿头臀长(CRL)的相关性。结果 早孕期超声对正常组177胎胎儿均清晰显示CP及OFD,对其中150胎清晰显示、27胎无法显示BS及BSOB;对OSB组25胎均清晰显示CP及OFD,对其中18胎清晰显示、7胎无法显示BS及BSOB。相比正常组，OSB组胎儿BS宽度及CP均增大，BSOB及OFD均缩小，BS/BSOB及CP/OFD均增大(P均<0.001)。正常组胎儿BS宽度、BSOB、CP、OFD均与CRL呈正相关(r=0.592、0.794、0.565、0.772,P均<0.05),CP/OFD、BS/BSOB与CRL均呈负相关...     

彩色多普勒超声在肝内胆汁淤积症致脐动脉血液异常对胎儿宫内缺氧监测的价值

目的探讨妊娠期肝内胆汁淤积症(intrahepatic cholestasis of pregnancy, ICP)患者胎儿脐动脉血流异常对胎儿宫内缺氧的彩色多普勒超声监测价值.方法选择足月妊娠或近足月妊娠的ICP患者31例,正常足月妊娠30例,于剖宫产当天彩色多普勒探测脐动脉血流,剖宫产时检测脐动脉血pH值及脐动脉胆汁酸水平.结果 ICP缺氧组脐动脉血流异常率高于ICP不缺氧组及正常妊娠组(分别为75.0%,15.8%,6.7%,P<0.05);ICP缺氧组脐动脉血流收缩期与舒张期流速比(S/D)值高于ICP不缺氧组及正常妊娠组 (分别为 3.81±0.54,2.28±0.32,2.22±0.35, P<0.05); ICP缺氧组胆汁酸水平高于ICP不缺氧组及正常妊娠组(分别为25.12±9.21,15.66±4.72,8.92±4.32,P<0.05).ICP组脐动脉血流 S/D值与脐动脉pH值呈负相关(r=-0.74, P<0.05), ICP组脐动脉血流S/D值与脐动脉胆汁酸水平呈正相关(r=0.76, P<0.05).结论 ICP患者脐动脉血流异常与ICP胎儿宫内缺氧明显有关,可能因ICP胎盘血流灌注不足以及ICP时高浓度的胆汁酸致脐血管及胎盘绒毛表面血管收缩、胎儿缺氧所致,故脐动脉血流的检测对ICP胎儿宫内缺氧有很好的监测价值.     

Ⅱ型糖尿病患者血小板活化与微血管病变的关系

目的探讨Ⅱ型糖尿病患者血小板活化与微血管病变的关系.方法应用流式细胞术测定51例Ⅱ型糖尿病患者(其中微血管病变者27例,无微血管病变者24例)及29名正常对照组的血小板糖蛋白,包括α颗粒膜糖蛋白(CD62p)、溶酶体颗粒膜糖蛋白(CD63)、血小板膜表面糖蛋白(CD41、CD61、CD42b)、凝血酶敏感蛋白(TSP),同时用放免法检测血浆内皮素和胰岛素.结果糖尿病组血小板CD62P、CD63、TSP阳性的百分率[(1.35±0.70)%、(5.04±2.73)%、(76.5±9.1)%]和CD41、CD61的平均荧光道数(MnX)[(14.22±6.03)%、(6.54±1.73)%]显著高于正常对照组[(0.54±0.34)%、(2.84±1.12)%、(66.3±8.4)%、(10.43±1.70)%、(4.36±0.62)%](P<0.005),有微血管病变组高于无微血管病变组(P<0.05).糖尿病组的血小板CD42b的阳性百分率显著低于正常对照组(P<0.005).但有无微血管病变组间差异无显著意义.血小板CD62P,CD63,CD61,TSP与血浆内皮素呈显著正相关(r分别为0.45,0.47,0.34和0.30,P均<0.05).结论活化血小板测定对于糖尿病微血管病变的早期诊断具有重要的临床应用和研究价值.     

盘状半月板损伤的关节镜手术方法与术后康复

目的探讨关节镜下盘状半月板损伤的手术方法、效果及术后康复。方法关节镜下诊断盘状半月板并损伤54例,39例行半月板成形术,保留半月板边缘6~8 mm,9例行盘状半月板次全切除术,6例行盘状半月板完全切除术,术后即行膝关节功能锻炼,入院与术后1月、1年行膝关节活动范围测量,其中47例获1~4年10个月的随访。结果按照Lkeuchi评价方法,优38例(70.4%),良11例(20.0%),可5例(9.3%),差0例,优良率为90.4%。入院时膝关节活动范围屈曲平均118°±16°,伸直10°±4,°术后1月膝关节活动范围屈曲平均133°±4,°伸直0°±3°,术后1年膝关节活动范围屈曲平均135°±3°,伸直0°±3°,经统计学分析,术后1月、1年与入院时比较均差异有统计学意义。结论关节镜下盘状半月板成形术创伤小,疗效满意。     

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.