超声诊断胎儿埃伯斯坦畸形1例

孕妇，26岁，孕34周。二维超声检查：胎儿双顶径8.2cm，股骨长6.9cm，腹围31．0cm，胎盘成熟度I级，羊水液性暗区最大深径2．2cm，脊柱排列规整，胎心搏动规律，心率154次。右房扩大，径线3．1cm×2．8cm，三尖瓣前瓣和膈瓣增厚，关闭点下移，关闭时两瓣膜呈"漏斗"状（图1），卵圆孔0．4cm，室间隔连续完好，多普勒检查：右房内探及分布广泛的三尖瓣返流束（图2），CW测最大返流压差61mmHg。超声诊断：①宫内单活胎；②胎儿先心病：Ebstein畸形；③羊水过少。尸检证实三尖瓣下移。超声诊断胎儿埃伯斯坦畸形1例@扈长旭$山东省平邑县人民医…     

超声心动图诊断胎儿永存左上腔静脉1例

孕妇妊娠39周,胎儿超声心动图检查见四腔心清晰显示,右心房、右心室略大,左心房侧探及活瓣甩动,长约1.00 cm,房间隔中部可见卵圆孔无回声区,宽约0.57 cm,冠状静脉窦扩张,宽约0.80 cm(图1、2);CDFI:收缩期三尖瓣可见少量反流.超声提示:①胎儿永存左上腔静脉(persistent left superior vena cava, PLSVC);②三尖瓣轻度关闭不全.     

产前超声诊断胎儿三尖瓣下移畸形的应用价值

目的 探讨产前超声诊断胎儿三尖瓣下移畸形的临床价值。方法 回顾性分析6例经胎儿超声心动图诊断为三尖瓣下移畸形的超声诊断资料与随诊结果，总结其异常声像图特点。结果6例胎儿均经尸体解剖证实为三尖瓣下移畸形，其中三尖瓣隔叶下移2例，隔叶及后叶下移3例，隔叶、后叶及前叶下移1例。6例三尖瓣下移畸形中4例伴有功能右室缩小，合并房间隔缺损1例，肺动脉狭窄1例；4例伴有胸、腹腔及心包积液。胎儿三尖瓣下移畸形主要声像图表现为右心扩大，三尖瓣叶附着点下移，心尖到二尖瓣前叶附着点的距离与到三尖瓣隔叶附着点的距离比值≥1．8，形成典型房化右室特征；彩色血流显示三尖瓣重度反流，其反流起源点低，反流面积大，但反流速度低，平均反流速度217．0cm／s。结论 胎儿三尖瓣下移畸形具有特征性声像图表现，产前超声诊断胎儿三尖瓣下移畸形具有重要临床价值。     

胎儿房颤合并胸、腹水及心包积液超声表现一例

患者女,30岁,孕1产0,孕39周,无遗传病史.产前常规超声检查显示:宫内单胎,头位,胎儿双顶径9.7 cm,胎儿胸腔、腹腔及鞘膜腔内均探及少量液性无回声区,深度分别为0.4 cm,0.5 cm,0.5 cm.胎儿超声心动图心尖四腔心切面显示:十字交叉存在,右房室腔明显扩大,右心房横径22 mm,右心室横径23 mm,左心房横径13 mm,左心室横径16 mm,房间隔中部可见卵圆瓣回声,室间隔回声无明显中断,肺动脉较主动脉增宽,心包腔内可见深4 mm的液性无回声区,胎儿心律明显不齐.彩色多普勒显示:三尖瓣中至大量反流.     

超声诊断胎儿三尖瓣发育不良一例

患者女，30岁，孕2产0，孕32周来我院行孕期检查。超声检查：胎儿心脏位于胸腔左侧，心轴严重左偏，近横位，心胸比例明显增大（大于50％），各心腔内径比例严重失调，右心扩大，以右心房扩大显著，左心房宽径1．0cm，左心室宽径1．2cm，右心房宽径3．6cm，右心室宽径2．0cm；三尖瓣前叶冗长、增厚、回声增强，隔叶短小，与室间隔粘连，活动度差，附着点未见明显下移，距二尖瓣前叶室间隔附着点约0．5cm（图1），CDFI显示三尖瓣收缩期重度反流，最大流速280cm／s（图2，3）；     

胎儿小肠闭锁超声表现1例

孕妇29岁,孕1产0,孕33+5周.本人及家族无特殊病史,其夫有烟酒嗜好.常规围产期超声检查:胎儿上腹部可见2个囊性无回声区,呈典型的"双泡"征,由较细的管道(幽门管)相连(图1A);"双泡"由扩张的胃泡和十二指肠组成,实时观察可见内容物在胃泡和十二指肠之间流动.胎儿中下腹部横切面探测显示小肠多处扩张并且相通,最宽处达3.3 cm(图1B);同时胃肠蠕动较活跃.羊水过多,羊水厚径10.5 cm.超声提示:①宫内孕单活胎;②胎儿消化道畸形-小肠闭锁?羊水过多.引产后胎儿尸体解剖证实为小肠闭锁.     

彩色多普勒诊断先天性心脏病三尖瓣下移畸形1例

患者男,年龄22岁,自幼活动后心慌、气短,近几年渐加重,于1995年8月19日来我院就诊.超声所见(如图):右房明显增大,内径为6.1cm,三尖瓣隔叶和后叶的基底部明显下移,较正常低8cm,且瓣叶粗短,回声增强,关闭时可见缝隙0.5cm,右心室明显减小,形成房化右心室,房壁增厚,回声增强.CDFI:三尖瓣口收缩期以蓝色为主的多彩反流束达右房顶.CW:三尖瓣口收缩期探及负向充填频谱.诊断:先天性心脏病;三尖瓣下移畸形并关闭不全.     

B超诊断胎儿十二指肠闭锁合并多囊肾1例

患者,女性,26岁。停经26周,G1P0,常规产前检查来诊。超声检查:胎儿为臀位,双顶径6.7cm,胸径8.1cm,腹径7.5cm,股骨长5.0cm,胸径明显大于双顶径。于胎儿上腹部探及两个较大液性暗区,二者相通,上方较大一个为胃(ST),下方较小一个为十二指肠(DU)。转动探头为横切,显示为“双泡征”(图1);探头不动,可见上方较大暗区有蠕动。于胎儿腰椎旁探查,可见双肾明显增大,均可见难以计数的大小不等小暗区,使肾失去正常形态(图2)。羊水最深处仅为2.7cm。超声诊断:1.胎儿先天性发育畸形(十二指肠远端闭锁,双肾多囊肾);2.羊水少。引产后胎儿行B超检查亦为多囊肾,十二指肠远端闭锁,经病理证实与超声诊断符合。     

胎儿三尖瓣下移畸形的典型及罕见超声表现

目的探讨胎儿三尖瓣下移畸形的典型及罕见超声表现,提高其产前诊断率。方法分析13例胎儿三尖瓣下移畸形的超声心动图图像,与产后超声心动图或引产后心脏解剖结果对照分析,总结其典型及罕见表现。结果 13例三尖瓣下移畸形中10表现典型,3例较为罕见。典型的三尖瓣下移畸形超声心动图表现为三尖瓣隔瓣和后瓣附着点下移,下移的瓣叶短小,前瓣冗长。罕见病例除上述典型病变外,还可表现为腱索和乳头肌缺如、瓣膜增厚或合并心肌致密化不全。结论三尖瓣下移畸形是涉及三尖瓣、腱索、乳头肌和心肌的一组广泛性病变,超声表现多样化,掌握不同类型三尖瓣下移畸形声像图特点,可提高超声对三尖瓣下移畸形的诊断能力。     

超声诊断胎儿三尖瓣发育畸形1例

孕妇 2 4岁 ,第一胎孕 40周。产前 B超检查 :胎儿双顶径10 cm ,股骨长 7.1cm,胎心 138次 /分 ,律齐。羊水最深径 7.1cm,混浊。胎儿右房呈球形增大 ,右室增大。左房、室大小正常。右室壁增厚约 5 mm。房间隔明显凸向左房 ,三尖瓣位置正常 ,瓣叶增厚 ,回声增强 ,舒张期开放尚可 ,收缩期关闭可见裂隙约3mm(图 1)。余各瓣膜形态、结构及运动未见异常。多普勒检测 :三尖瓣上探及大量返流 ,Vmax=2 .2 m/ s。超声诊断 :1、宫内孕 ,单活胎 ,羊水过多 ,混浊 ;2、胎儿先天性心脏病 ,三尖瓣发育不良伴重度返流 ,巨大右房 ,右室肥厚。引产后尸检查所见 …     

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.