妊娠期间亚临床甲状腺功能减退的诊断与治疗

妊娠期亚临床甲状腺功能减退(SCH)是指妊娠期间血清促甲状腺激素(TSH)高于妊娠特异性参考值上限,而血清游离甲状腺素(FT4)在妊娠特异性参考值范围内。妊娠SCH特别是合并甲状腺自身抗体阳性者可以增加妊娠不良结局和围产期并发症的风险,并可能影响后代的智力和运动发育。建议对妊娠早期妇女开展SCH的筛查,筛查最佳时间是妊娠8周之内,筛查内容包括FT4、TSH和甲状腺过氧化物酶抗体(TPOAb)。建议孕前或妊娠期出现的SCH患者使用左旋甲状腺素(L-T4)治疗,治疗目标是将TSH恢复到妊娠特异参考值范围内。妊娠期间需碘量增加约50%,需适量补碘,建议每天额外补碘150 μg,以碘化钾最佳。     

左旋甲状腺素(L-T4)治疗亚临床甲减的临床疗效研究

目的 研究左甲状腺素(L-T4)治疗亚临床甲减的临床疗效,并探讨在L-T4治疗期间达到期望的促甲状腺激素(TSH)水平所需的时间长度对妊娠结局的影响.方法 纳入了2016-2019年该院妇产科就诊的457例经甲状腺功能筛查初步确诊的亚临床甲状腺功能减退症(SCH)妊娠期女性,分为治疗组(184例)和对照组(273例).在治疗组中分析达到目标TSH水平所需的时间长度.基于达到目标TSH水平所需的时间(≤4周和>4周)将治疗组进一步分为两个亚组,比较各亚组的妊娠结局.结果 对照组并发症的总体风险明显高于治疗组(P<0.05).L-T4治疗后,治疗持续时间≤4周的患者胎膜过早破(PROM)、妊娠期糖尿病、巨大儿发生率明显低于治疗持续时间>4周患者(P<0.05).结论 L-T4治疗可以明显降低SCH妊娠期女性不良妊娠结局的风险.达到目标TSH水平所需的治疗持续时间越短,并发症发生率越低.     

1例流产后甲状腺炎合并妊娠的护理

流产后甲状腺炎是产后由于甲状腺滤泡细胞被自身免疫性炎症破坏引起的甲状腺功能异常,属于自身免疫性甲状腺炎的一种类型[1,2].临床型自身免疫性甲状腺炎表现为临床型甲状腺功能减退症,亚临床型则表现为亚临床甲状腺功能减退症,或者甲状腺功能正常,仅表现为甲状腺自身抗体阳性.甲状腺激素是胎儿神经发育的必需激素,胎儿甲状腺激素缺乏可以导致神经系统发育障碍,严重者可发生呆小症.孕妇甲状腺功能减退,生殖能力降低,但也有怀孕可能,一旦怀孕,母体及胎儿可出现多种并发症,如:妊娠期高血压疾病发生率增加,引起流产、先天畸形、发育缓慢,小儿智力不同程度受损,但是总的胎儿先天异常发生率与普通人群比较没有明显增加[3].笔者对1例产后甲状腺炎合并妊娠的病例实施了精心的治疗护理,病人及其子健康出院.现将护理体会介绍如下.     

L-T4治疗妊娠亚甲状腺功能减退对孕妇甲状腺功能及妊娠结局的影响

目的探讨左旋甲状腺素片(L-T4)治疗妊娠亚甲状腺功能减退(SCH)对孕妇甲状腺功能和妊娠结局的影响。方法回顾性分析2017年1月至2018年1月92例SCH患者的临床资料,根据其治疗方式分为对照组与治疗组,每组46例,对照组给予常规补充碘、蛋白质等治疗,治疗组给予L-T4治疗,比较两组疗效、甲状腺功能变化与不良母婴结局。结果经治疗,治疗组总有效率显著高于对照组(P0.05);治疗后,两组游离甲状腺激素水平显著提高(P0.05),血清促甲状腺激素水平显著降低(P0.05),且治疗组变化幅度更大(P0.05);治疗组不良妊娠结局(早产、剖宫产与流产)例数与不良新生儿结局(死胎、低体重儿、新生儿窒息、新生儿畸形)例数均显著少于对照组(P0.05)。结论应用L-T4治疗妊娠期SCH,可改善甲状腺功能与妊娠结局,值得临床推广。     

L-T4治疗妊娠期亚临床甲状腺功能减退患者疗效的影响因素

【目的】探讨左旋甲状腺素(L-T4)治疗妊娠期亚临床甲状腺功能减退(SCH)患者疗效的影响因素。【方法】选取2019年10月至2021年8月本院收治的365例妊娠期SCH患者,依据L-T4治疗效果分为L-T4治疗有效组(有效组,n=278)和L-T4治疗无效组(无效组,n=87)。收集两组研究对象的相关病史、甲状腺功能指标、脂代谢指标、微量元素及彩色多普勒超声血流指标;采用多因素Logistic回归分析L-T4治疗妊娠期SCH患者疗效的影响因素。【结果】L-T4治疗妊娠期SCH患者的总有效率为76.16%。单因素分析结果显示:检测促甲状腺激素(TSH)时间、TSH水平、合并糖尿病、合并胃肠道疾病、铁元素(Fe)、锌元素(Zn)、甲状腺过氧化物酶抗体(TPO-Ab)阳性、甲状腺球蛋白抗体(TG-Ab)阳性、收缩期峰值流速(PSV)、舒张末期血流速度(EDV)是L-T4治疗妊娠期SCH患者疗效的影响因素。多因素分析结果显示:检测TSH时间、Fe、TSH水平、TG-Ab阳性、TPO-Ab阳性、合并胃肠道疾病、合并糖尿病、PSV是L-T4治疗妊娠期SCH患者疗效的影响因素(P<0.05)。【结论】L-T4治疗妊娠期SCH患者有效率有待提高,影响L-T4治疗效果的因素众多,应加强对妊娠期SCH治疗的重视,避免影响治疗的不利因素,提高L-T4的治疗效果。     

左甲状腺素钠对妊娠早期甲状腺过氧化物酶抗体阴性的亚临床甲状腺功能减退患者围产结局的影响

目的 探讨左甲状腺素钠(L-T4)对妊娠早期伴甲状腺过氧化物酶抗体(TPoAb)阴性的亚临床甲状腺功能减退(甲减)患者围产结局的影响。方法 选择就诊的妊娠早期亚临床甲减伴TPoAb阴性患者1 140例,随机分为L-T4组(n=570)和对照组(n=570),L-T4组给予L-T4治疗并达到目标值[促甲状腺素(TSH)<2.5 mU/L],对照组不进行相应治疗。观察两组患者妊娠高血压、贫血、流产、早产及新生儿体质量等相关指标。结果 对照组妊娠高血压、贫血、流产率及早产率等指标显著高于L-T4组(P＜0.05),顺产率显著低于L-T4组,并且L-T4组患者治疗达目标值所需L-T4剂量与患者的TSH水平呈明显正相关(r=0.763,P＜0.05)。结论 L-T4可以明显改善妊娠早期伴TPoAb抗体阴性的亚临床甲状腺功能减退患者的围产结局。     

妊娠前甲状腺自身抗体阳性甲状腺功能正常妇女五例临床观察

自身免疫性甲状腺疾病为妊娠期常见疾病,甲状腺球蛋白抗体(TGAb)、甲状腺过氧化物酶抗体(TPOAb)是甲状腺自身免疫功能紊乱的重要标志。不同的报道显示,育龄期妇女甲状腺自身抗体(anti-thyroid antibody,ATA)阳性率为5.4%～31%[1]。有研究显示ATA阳性的妇女在妊娠期发生甲状腺功能异常、产后甲状腺炎(postpartum thyroiditis,PPT)以及自然流产、早产、妊娠期高血压、胎盘早剥等妊娠不良结局的风险可能增高[2-3]。本研究追踪随访5例孕前血清TSH<2.5mIU/L,总T4(TT4)和游离T4(FT4)水平正常,TGAb和(或)TPOAb阳性妇女,观察其妊娠期及产后1年间甲状腺功能、TGAb、TPOAb水平、妊娠不良结局及PPT的发生情况,报道如下。一、病例资料例1,37岁,因"婚后不孕5年,拟行辅助生殖技术,术前检     

桥本甲状腺炎伴甲状腺激素抵抗综合征并1型糖尿病酮症酸中毒

目的 提高对甲状腺激素抵抗综合征及甲状腺功能减退与糖尿病相关性及大剂量外源性甲状腺激素对血糖影响的认识.方法 对我院经治1例甲状腺功能减退并甲状腺激素抵抗综合征患者在长期大剂量外源性甲状腺激素替代时诱发糖尿病酮症酸中毒的临床资料进行回顾性分析.结果 本例因生长发育迟缓7年,体重减轻1月余,嗜睡、阵发腹痛4d,昏迷1d入院.此次发病前曾在省级医院先后确诊为甲状腺功能减退症、甲状腺激素抵抗,予大剂量甲状腺激素替代,后出现体重减轻、多饮多尿、嗜睡、乏力、昏迷入院,经检查诊为糖尿病酮症酸中毒,治疗后好转.出院后在北京某医院确诊为桥本甲状腺炎(甲状腺功能减退)伴甲状腺激素抵抗综合征、1型糖尿病酮症酸中毒.结论 甲状腺激素抵抗综合征是一种临床表现复杂、多变、极易漏诊误诊的疾病,并桥本甲状腺炎所致甲状腺功能减退,长期大剂量外源性激素替代治疗可升高血糖诱发糖尿病酮症酸中毒,治疗过程中应注意监测血糖.以减少漏误诊所致并发症.     

原发性甲状腺功能减退患者甲状腺激素治疗前后血清心肌酶及同型半胱氨酸变化分析

目的探讨原发性甲状腺功能减退患者经甲状腺激素治疗前后血清心肌酶及同型半胱氨酸(Hcy)的浓度变化,寻找原发性甲状腺功能减退与其之间的关系。方法研究对象为原发性甲状腺功能减退者51例。分别在初诊和激素替代治疗4周后观察甲状腺激素浓度、心肌酶及同型半胱氨酸的变化。采用速率法检测心肌酶;用化学发光法检测游离三碘甲状腺原氨酸(FT3)、游离甲状腺素(FT4)、促甲状腺素(TSH)和Hcy。结果原发性甲状腺功能减退患者初诊时的甲状腺激素、心肌酶和Hcy与经4周甲状腺激素治疗后比较有差异有统计学意义(除CK-MB外)。治疗后FT3、FT4浓度分别为(1.48±0.61)pmol/L、(0.75±0.46)pmol/L,较治疗前显著上升(P<0.05);治疗后TSH、Hcy、CK、LDH浓度分别为(14.81±7.60)μU/L、(15.80±2.50)μmol/L、(141.57±140.58)U/L、(98.54±38.58)U/L,较治疗前显著下降(P<0.01);治疗后AST、HDBH浓度分别为(17.58±12.54)U/L、(128.00±48.01)U/L,较治疗前下降(P<0.05)。CK-MB浓度变化差异无统计学意义(P>0.05)。结论甲状腺功能减退时肌酶水平随甲状腺功能减退程度加重而升高,经激素替代治疗后心肌酶和Hcy浓度逐渐恢复。     

妊娠期甲状腺功能减退患者胰岛素抵抗水平及与甲状腺激素水平、妊娠结局的相关性

目的 研究妊娠期甲状腺功能减退患者胰岛素抵抗水平及与甲状腺激素水平、妊娠结局的相关性。方法 回顾性选取2020年5月至2022年5月于运城市中心医院进行产检并住院分娩的92例妊娠期甲状腺功能减退患者为研究对象,根据胰岛素抵抗指数(HOMA-IR)将患者分为A(HOMA-IR<4.00)、B(4.00≤HOMA-IR<5.00)、C(HOMA-IR≥5.00)3组。检测并比较各组患者促甲状腺激素(TSH)、游离三碘甲状腺原氨酸(FT3)、甲状腺过氧化物酶抗体(TPOAb)、游离甲状腺素(FT4)的表达水平。根据妊娠结局,将患者分为妊娠结局良好组和不良妊娠结局组。采用Spearman法分析妊娠期甲状腺功能减退患者HOMA-IR与TSH、FT3、TPOAb、FT4及妊娠结局的相关性。结果 A组、B组、C组患者HOMA-IR及TSH、TPOAb表达水平逐渐增加,FT3、FT4表达水平逐渐降低,差异均有统计学意义(P<0.05)。妊娠期甲状腺功能减退患者HOMA-IR与TSH、TPOAb呈正相关(r=0.740、0.596,P<0.05),而与FT3、FT4呈负相关(r=...     

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.