三维超声容积自动测量技术评价胎儿小脑蚓部发育

目的 应用三维超声容积自动测量技术检测胎儿小脑蚓部的发育,为产前筛查胎儿小脑发育异常提供理论依据.方法 选择20～36孕周正常胎儿387例,应用经腹三维容积自动测量技术(VOCAL)测量小脑蚓部体积,观察胎儿小脑蚓部发育规律.结果 应用VOCAL软件测量胎儿小脑蚓部体积成功率为98%.胎儿小脑蚓部体积与孕周及小脑横径呈正相关,r分别为0.98、0.98(P<0.0001).以孕周为自变量X,小脑蚓部体积测量值为因变量Y,直线回归分析认为X与Y之间有直线关系,方程为Y=-2.17 0.12X.以小脑横径为自变量,小脑蚓部体积测量值为因变量,直线回归分析认为X与Y之间有直线关系,方程为Y=-0.94 0.06X.结论 三维超声容积自动测量技术测量胎儿小脑蚓部体积有助于评价胎儿小脑蚓部的发育.     

三维超声对胎儿肺体积的研究

目的 应用三维超声建立不同孕周胎儿左肺、右肺及总肺体积的正常参考值范围.方法 对正常单胎妊娠16～37周324例胎儿进行肺三维超声体积扫查,采用VOCAL分析软件30°旋转法分别测定左肺及右肺体积,应用相关回归分析拟合左肺、右肺及总肺体积随孕周增长的回归方程.结果 正常妊娠胎儿左肺、右肺及总肺体积三维超声测量值均与孕周高度相关(左肺:r=0.966,P＜0.001;右肺:r=0.973,P＜0.001;总肺:r=0.990,P＜0.001).左肺、右肺及总肺体积随孕周增长的最适方程均为指数曲线回归方程(左肺:y=0.207exp~(0.143X),右肺:y=0.301exp~(0.14X),总肺:y=0.508exp~(0.142X)).结论 三维超声测量16～37周胎儿肺体积的正常参考值为产前诊断肺发育不良提供有价值的参考指标.     

妊娠中晚期正常胎儿颅后窝生长发育规律

目的 观察妊娠中晚期正常胎儿颅后窝的生长发育规律。方法 回顾性纳入493胎妊娠25~36周正常胎儿,于图像存储与传输系统(PACS)工作站测量其MRI所示小脑横径及体积、颅后窝宽度及体积,并计算小脑体积/颅后窝体积,分析颅后窝随孕周变化的规律。结果 正常胎儿小脑横径与孕周呈直线相关,直线方程为y=－21.15+1.90x(R²=0.85,P＜0.01);小脑体积随孕周增加呈指数增长,曲线方程为y=150.52e^(0.13x)(R²=0.73,P＜0.01)。胎儿颅后窝宽度与孕周无明显相关(R²＜0.01,P=0.30),而颅后窝体积及小脑体积/颅后窝体积均随孕周增加而呈指数增长,曲线方程分别为y=1 098.50e^(0.10x)(R²=0.60,P＜0.01)及y=0.14e^(0.04x)(R²=0.30,P＜0.01)。结论 妊娠中晚期正常胎儿小脑及颅后窝体积均随孕周增加而呈指数增长,且小脑生长速度快于颅后窝。     

三维超声计算机辅助虚拟脏器分析技术评价胎儿胆囊发育

目的 探讨三维超声计算机辅助虚拟脏器分析(VOCAL)技术测量不同孕龄胎儿胆囊体积,建立胆囊体积的正常参考值范围,并评价其与孕周的相关性。方法 选择19~40孕周正常胎儿230胎作为研究对象,采用二维超声和三维超声测量胎儿胆囊体积,并观察其重复性和一致性,分析胆囊体积与孕周的相关性。结果 同一操作者和不同操作者应用三维超声的重复性和一致性均优于二维超声。胎儿胆囊体积随孕周增加而增大,回归方程为Y=-0.027+0.104X-0.005X²(r=0.774,P=0.0001)。结论 三维超声VOCAL技术在胎儿胆囊体积测量方面的重复性和一致性优于二维超声,有助于评价胎儿胆囊发育。     

三维容积超声成像评估胎儿胸腺发育的研究

目的利用三维超声建立胎儿胸腺体积的正常参考值并探讨胸腺发育与胎儿异常的相关性。方法产前超声检测340例正常胎儿和42例异常胎儿(心脏异常23例,其他异常19例)的胸腺三维体积。线性回归分析正常胎儿胸腺体积和孕周的相关性,并建立正常参考值,胸腺体积低于同孕周正常值第5百分点定为胸腺发育不良,P0.05为差异有统计学意义。结果 (1)正常胎儿三维胸腺体积与孕周呈直线相关,回归方程Y=-13.023+0.659X,P0.05。(2)42例异常胎儿中发现2例胸腺缺如,23例胸腺发育不良,17例胸腺发育正常。胸腺发育异常胎儿中合并心脏异常占17例,2例胸腺缺如均证实为22q11.2微缺失。结论 (1)正常胎儿胸腺体积随孕周增加呈线性增长。(2)胎儿异常与胸腺发育不良或缺如具有一定相关性,尤其先天性心脏病和22q11.2微缺失。     

经腹三维超声建立正常胎儿小脑蚓部参考值研究

目的应用经腹三维超声探讨胎儿小脑蚓部生长发育与孕周的关系,并建立相关参考值,评估胎儿的小脑蚓部发育情况。方法选取在我院行产前检查并正常分娩的孕产妇345例,自孕18~40周每个孕周随机选取15例,应用经腹三维超声对每个孕周的正常胎儿小脑蚓部矢状面上下径、前后径及总面积进行测量,分析其与孕周的关系,并建立上述参数每个孕周的相关参考值。结果正常胎儿小脑蚓部矢状面上下径、前后径及总面积均随着孕周的增加而增长(P0.05),线性回归方程为:小脑蚓部上下径(mm)=(0.888×孕周)-10.384,小脑蚓部前后径(mm)=(0.979×孕周)-9.977,小脑蚓部总面积(cm)=(0.196×孕周)-3.433。胎儿小脑蚓部上下径、前后径及总面积呈偏态分布,并建立了95%参考值上限和5%的参考值下限。结论通过建立不同孕周胎儿小脑蚓部的参考值,对临床评估胎儿小脑生长发育过程中小脑异常的诊断有一定的临床价值。     

三维超声测量胎儿胼胝体体积

目的：应用三维超声体积自动测量技术建立不同孕周胎儿胼胝体的正常范围参考值。方法：对筛选出的21~36周正常胎儿共160例进行颅脑三维超声容积扫查,采用VOCAL技术测量胎儿胼胝体体积,并分析其与孕周的关系。结果：应用VOCAL技术可以测量胎儿胼胝体的体积,正常胎儿胼胝体体积与孕周高度相关（r＝0.956,P<0.001）。结论：建立孕周胼胝体体积正常参考值将有利于评价正常神经系统发育以及协助诊断胼胝体发育不全。     

三维超声测量胎儿肝体积与孕龄相关性的研究

目的　探讨三维超声测量胎儿肝体积与孕龄的相关关系及其临床意义。方法　应用三维超声平面体积测量法测量 173例孕龄 2 2～ 39周正常胎儿肝体积。结果　①三维超声测量胎儿肝体积可重复性好 ;②胎儿肝体积与孕龄呈直线相关 (r =0 .93,P <0 .0 5 ) ,以孕龄为自变量 ,胎儿肝体积为因变量的直线回归公式为Y =4.832X -89.0 5 4(R2 =0 .87,P <0 .0 5 )。结论　三维超声平面体积测量法能够无创性地测量不规则形状的胎儿肝体积 ,具有很大的临床实用价值     

三维超声容积自动测量技术评价胎儿胃泡发育

目的应用三维超声体积自动测量(VOCAL)技术检测胎儿胃泡的发育,建立不同孕周胎儿最大、最小胃泡容积正常范围参考值,并评价其与孕周的关系。方法对筛选出的16～38周正常胎儿共345胎,应用经腹三维超声VO-CAL技术估测胎儿最大、最小胃泡容积,并分析其与孕周的关系。结果应用VOCAL技术可近似测量胎儿最大、最小胃泡容积。正常胎儿最大、最小胃泡容积与孕周呈曲线相关(R2max=0.98、0.96,P均<0.001)。结论三维超声VOCAL技术测量胎儿胃容积有助于评价胎儿胃泡的发育。     

三维超声测量胎儿肺体积及其在常见胎儿肺病变随访中的应用

目的利用三维超声技术测量胎儿肺体积,建立肺体积正常值范围,评价胎儿肺发育。方法选择显示满意的300胎18～36周正常胎儿肺三维容积图像,利用VOCAL技术测量其左、右肺体积,并对肺总体积(TLV)与孕周(GA)进行回归分析。随机抽取20胎正常胎儿TLV测值进行可信度分析。对4胎超声诊断为肺囊性腺瘤样畸形或隔离肺胎儿进行随访,测量其TLV,与正常胎儿TLV行散点图比较,观察其变化趋势。结果胎儿肺三维图像满意者占91.74%(300/327)。正常胎儿TLV随GA增加而增大,最适回归方程为:TLV=1.139-1.418GA+0.093GA2(r=0.99,P<0.01)。三维超声测量胎儿TLV的可信度很高(内部一致性系数为0.99,组内相关系数为0.99)。4胎肺病变胎儿TLV均随GA增加而增大,但变化趋势各不相同。结论三维超声能够很好地测量胎儿肺体积,在评价胎儿肺发育中具有重要作用。     

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.     

Guns and Knives in New Mexico: Patterns of Penetrating Trauma, 1978–1993

Objective: To identify patterns of nonfatal and fatal penetrating trauma among children and adults in New Mexico using ED and medical examiner data.
Methods: The authors retrospectively sampled in 5-year intervals all victims of penetrating trauma who presented to either the state Level-1 trauma center or the state medical examiner from a 16-year period (1978–1993). Rates of nonfatal and fatal firearm and stabbing injury were compared for children and adults.
Results: Rates of nonfatal injury were similar (firearm, 34.3 per 100,000 person-years; stabbing, 35.1). However, rates of fatal injury were significantly different (firearm, 21.9; stabbing, 2.7; relative risk: 8.2; 95% confidence interval: 5.4, 12.5). From 1978 to 1993, nonfatal injury rates increased for children (p = 0.0043) and adults (p < 0.0001), while fatal penetrating injury remained constant. The increase in nonfatal injury in children resulted from increased firearm injury rates. In adults, both stabbing and firearm nonfatal injury rates increased.
Conclusions: Nonfatal injury data suggest that nonfatal violence has increased; fatal injury data suggest that violent death rates have remained constant. Injury patterns vary by age, mechanism of trauma, and data source. These results suggest that ED and medical examiner data differ and that both are needed to guide injury prevention programs.     

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.