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。     

胎儿心轴异常——先天性心脏病和胸腹病变的诊断线索

目的探讨胎儿心轴异常在先心病和胸腹病变超声诊断中的意义。方法中孕期经超声检查的173例正常胎儿和54例先心病、10例胸腹病变胎儿,分为三组,在四腔心切面上进行心轴角度的测量和分析。结果正常胎儿的平均心轴角度为(41.1±8.2)°,先心病组为(51.4±18.3)°,与正常组相比有显著性差异(P<0.0001),其中左心发育不良综合征、心内膜垫缺损、右室双出口等病种合并心轴异常的比例较高。胸腹病变组平均心轴角度为(59.7±15.9)°,与正常组相比有显著性差异(P<0.001),导致心轴异常的病种主要为膈疝和腹腔内脏外翻。按超过正常胎儿99%正常值范围(20.3°～61.9°)为异常心轴统计,心轴左偏(>62°)在三组中分别为1/173(0.6%),16/54(29.6%)和1/10(10.0%);心轴右偏(<20°)在三组中分别为0,6/54(11.1%)和3/10(30.0%)。结论中孕期胎儿心轴角度的测定简单易行,当其<20°或>62°时提示可能存在心脏畸形或胸腹腔病变,应进一步检查确诊。     

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。     

丁丙诺啡联合关节松动术治疗肩周炎的疗效观察

目的观察丁丙诺啡联合关节松动术治疗肩周炎的临床疗效。 方法采用随机数字表法将103例肩周炎患者分为A、B、C共3组。A组患者给予丁丙诺啡及关节松动术联合治疗,B组患者给予非甾体抗炎镇痛药洛索洛芬钠及关节松动术治疗,C组患者则单纯给予关节松动术治疗。于治疗1周、3周及治疗后3个月时观察3组患者疼痛、Constant-Murley肩关节评分（CMS）以及肩关节活动度变化,并比较3组患者治疗过程中关节松动术手法力度间差异。 结果治疗后3组患者疼痛评分、CMS评分以及肩关节活动度均较治疗前明显改善（均P<0.05）。进一步分析发现,在治疗1周时A组患者疼痛评分［（2.8±1.0）分］较B组及C组［分别为（3.8±1.0）分和（4.5±1.3）分］均显著降低,A组患者CMS评分［（60.1±10.7）分］较B组及C组［分别为（48.8±11.0）分和（44.9±9.7）分］均显著提高（均P<0.05）,A组患者肩关节后伸、90°外旋位外展、内旋、外旋角度［分别为（41.3±7.8）°,（68.8±12.4）°,（38.5±4.5）°和（36.6±5.9）°］均显著优于B组［分别为（34.2±4.5）°,（62.0±11.7）°,（34.0±3.5）°和（32.9±5.1）°］及C组水平［分别为（32.4±7.2）°,（60.7±12.9）°,（31.6±6.9）°和（32.4±5.6）°］,且上述差异一直持续到治疗后3个月时。另外在治疗1周时发现A组患者行关节松动术的力度［（2.5±0.5）级］均显著高于B组及C组水平［分别为（1.7±0.6）级和（1.3±0.5）级］,并且这种差异一直持续到治疗后3个月时。 结论丁丙诺啡联合关节松动术治疗肩周炎的临床疗效显著,同时还具有操作简单、安全性高、患者依从性好等优点,值得在肩周炎患者中推广、应用。     

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。     

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。     

速度向量成像技术对正常人左室扭转运动特征的分析

目的探讨速度向量成像(velocityvectorimaging,VVI)技术测量正常人左室扭转运动的方法,分析正常人左室扭转运动特征。方法采用Siemens公司Sequoia512超声诊断仪,在VVI模式下对32例健康志愿者取心底部短轴切面和心尖部短轴切面,勾画心内膜,应用VVI软件自动跟踪分析左室扭转角度。规定从心尖向心底部观察逆时针旋转为正方向,反之为负。左心室扭转角度等于心底部与心尖部旋转角度绝对值之和。结果32例健康志愿者左室扭转角度为6.10°±2.93°,男性左室扭转角度为5.45°±2.46°,女性左室扭转角度为7.04°±3.31°,男女之间差异无统计学意义(P>0.05)。左室扭转方向分为4种类型:心底、心尖均为正方向;心底、心尖均为负方向;心底正方向、心尖负方向和心底负方向、心尖正方向;各组例数分别占总观察例数的34%、13%、25%、28%,但无显著性差异(P>0.05)。结论VVI技术是一种方便、无创的测量心脏扭转的方法。这一新技术还可进行各种心脏病的心脏扭转方面的研究。     

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。     

多层螺旋CT多平面重组测量肩胛盂扭转角的方法

目的探讨多层螺旋CT(MSCT)多平面重组(MPR)重建测量肩胛盂扭转角的方法.方法收集成人肩胛骨干标本22侧,肩关节防腐湿标本24侧,用16层螺旋CT扫描仪扫描,多平面重组轴位重建肩胛盂从上到下共11层,肩胛盂取第2～第10层共9个不同测量层面测量肩胛盂扭转角(即第2层为第一测量层面,第10层为第9测量层面),进行统计学处理.结果从上到下9个不同测量层面肩胛盂扭转角数据分别为-17.13°±11.22°,-7.42°±7.32°,-1.99°±5.37°,-1.65°±4.84°,-2.27°±4.83°,-1.82°±4.93°,-1.71°±5.10°,-2.05°±5.11°,-2.20°±5.77°.第一测量层面肩胛盂扭转角变异最大,肩胛盂扭转角-34.60°～17.50°(向后扭转为负值,向前扭转为正值),第1、2测量层面间肩胛盂扭转角统计学上差异有显著性,第1和2测量层面与其他7个测量层面间扭转角差异有显著性(P＜0.05),第3到9测量层面间肩胛盂扭转角无统计学差异.结论多层螺旋CT多平面重组轴位重建肩胛骨测量肩胛盂扭转角是简单、快捷、准确的方法;肩胛盂窝在轴位(水平)平面呈后倾改变及螺旋性扭曲改变,在肩关节假体设计中应考虑此解剖特点.     

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。     

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.