超声检查软指标在早孕期胎儿心脏畸形筛查中的应用

目的:探讨超声检查软指标在早孕期胎儿心脏畸形筛查中的应用。方法:本次回顾性分析研究对象的选择为7150例行产前超声检查的孕11~13+6周孕妇,病例收集时间为2017年1月至2022年1月,对所有孕妇行经腹部或联合阴道超声检查,记录颈项透明层厚度(NT)、静脉导管(DV)血流频谱以及三尖瓣反流(TR)情况。计算不同的超声软指标诊断标准对于胎儿心脏畸形的筛查结果和诊断价值。结果:7150例孕妇中共80例胎儿发生心脏畸形,其中超声软指标异常的胎儿中共有396例NT增厚胎儿,222例DV频谱异常胎儿,178例三尖瓣反流胎儿;胎儿心脏畸形发生率随着NT厚度的增长而显著升高(χ2=256.31,P<0.05),DV频谱是否异常对于胎儿心脏畸形发生率具有显著差异(χ2=689.77,P<0.05),是否三尖瓣反流对于胎儿心脏畸形发生率具有显著差异(χ2=208.48,P<0.05);NT增厚、DV频谱异常且三尖瓣反流的诊断标准胎儿心脏畸形发生率显著高于NT增厚且DV频谱异常或三尖瓣反流诊断标准和DV频谱异常且三尖瓣反流诊断标准(P<0.05);NT增厚、DV频谱异常且三尖瓣反流筛查胎儿心脏畸形的敏感度47.50%,特异度为99.52%,阳性预测值为52.78%,阴性预测值为99.41%,准确度为98.41%,NT增厚、DV频谱异常且三尖瓣反流的诊断标准阳性预测值显著高于其他诊断标准(P<0.05),差异有统计学意义。结论:NT增厚、DV频谱异常且三尖瓣反流的超声软指标诊断标准对于筛查孕早期胎儿心脏畸形有较好的诊断价值。     

孕早期超声软指标在胎儿复杂先天性心脏畸形筛查中的应用价值

目的探讨孕早期超声软指标颈项透明层(NT)厚度、静脉导管(DV)频谱及三尖瓣反流(TR)在胎儿复杂先天性心脏畸形(CHD)筛查中的临床价值。方法回顾性分析在我院行孕早期(孕11~13+6周)产前超声检查的孕妇9100例,记录NT厚度、DV频谱和TR情况,并与随访结果对照分析。结果孕早期共检出NT增厚342例,DV频谱异常181例,TR 163例,NT增厚+DV频谱异常或TR 168例,DV频谱异常+TR 124例,三项指标均为阳性92例。胎儿复杂CHD发生率随着NT厚度增加显著增长(P0.01),DV频谱异常胎儿、TR胎儿复杂CHD的发生率均高于DV频谱正常胎儿和无TR胎儿,差异均有统计学意义(均P0.01)。NT增厚+DV频谱异常或TR、三项指标联合筛查胎儿复杂CHD的敏感性和阳性预测值均高于DV频谱异常+TR及各项指标单独应用,差异均有统计学意义(均P0.05)。结论 NT增厚、DV频谱异常及TR是筛查胎儿复杂CHD的有效超声软指标,具有较好的临床应用价值。     

超声心动图诊断以三尖瓣反流为首发征象的胎儿心血管异常

目的 探讨超声心动图诊断以三尖瓣反流为首发征象的胎儿心血管异常的价值。方法 收集产前超声诊断心血管异常合并三尖瓣反流胎儿128胎,分析超声心动图检查对胎儿心血管异常的检出率及病因特点。结果 128胎中,三尖瓣结构异常组18胎、压力负荷增加组74胎,容量负荷增加组36胎,三组间胎儿三尖瓣反流严重程度的差异有统计学意义(χ²=11.157,P=0.025),与三尖瓣结构异常组(χ²=4.425,P=0.109)及容量负荷增加组(χ²=10.495,P=0.005)相比,压力负荷增加组更易产生重度反流。三尖瓣结构异常组中,与Ebstein畸形相比,三尖瓣发育不良更易发生重度三尖瓣反流(P=0.015);压力负荷增加组中,动脉导管提前收缩多表现为三尖瓣轻度反流,与之相比,肺动脉狭窄(P=0.001)、肺动脉闭锁(P<0.001)更易发生重度反流。结论 对于以三尖瓣反流为首发征象的胎儿,详细有序的超声心动图检查,能有效降低胎儿心血管异常的误诊及漏诊。     

Tei指数联合静脉导管相关参数及三尖瓣环位移评价孕晚期羊水过少胎儿右心功能

目的探讨右心室Tei指数联合静脉导管(DV)相关参数及三尖瓣环位移(TAD)综合评价孕晚期羊水过少胎儿右心功能。方法选取257例足月妊娠孕妇,对照组羊水量正常183例,实验组羊水量过少74例,运用组织多普勒技术(TDI)获得三尖瓣前叶与三尖瓣环连接处组织多普勒频谱,测量并计算所有胎儿右心室Tei指数,用PW获得DV血流频谱,计算阻力指数(RI)、搏动指数(PI)及S/A值,用M型超声获得所有胎儿TAD。结果实验组胎儿右心室Tei指数、DV相关参数均较对照组升高,实验组TAD低于对照组,差异有统计学意义(P0.05),实验组胎儿右心室Tei指数与TAD呈负相关,与DV相关参数呈正相关。结论右心室Tei指数联合DV相关参数及TAD可以全面评价孕晚期羊水过少胎儿右心功能。     

颈部透明层厚度、心脏三尖瓣反流和静脉导管血流联合Z评分对胎儿先天性心脏病的诊断效能分析

目的研究颈部透明层厚度（NT）、心脏三尖瓣反流（TR）和静脉导管血流（DV）联合胎儿心脏测量参数Z评分对胎儿先天性心脏病的诊断效能。 方法采用2015年1月至2020年2月在内蒙古医学院附属医院进行孕早期新生儿筛查的6 217例孕妇作为研究对象,根据引产与分娩共确证胎儿患有先心病分为观察组和对照组,分别对两组胎儿的NT、TR、DV以及心脏测量参数Z评分进行比较。分析NT、TR、DV与Z评分的联合对胎儿先天性心脏病的诊断效能。 结果观察组胎儿的NT、TR、DV异常率均高于对照组（χ²=1 953.577、1 805.085、1 339.066,均P＜0.001）。在以双顶径的预测中,观察组胎儿的主动脉Z评分低于对照组（0.012±0.001 vs 0.023±0.002,t=84.259,P＜0.001）,肺动脉Z评分高于对照组（0.035±0.002 vs 0.025±0.003,t=38.623,P=0.000）;在以股骨长的预测中,观察组胎儿的主动脉Z评分（0.022±0.003 vs 0.037±0.004,t=38.172,P＜0.001）以及肺动脉Z评分（0.031±0.005 vs 0.039±0.003,t=12.474,P＜0.001）低于对照组;在以实际孕周的预测中,观察组胎儿的主动脉Z评分（0.013±0.001 vs 0.022±0.002,t=68.939,P＜0.001）以及肺动脉Z评分（0.014±0.002 vs 0.019±0.003,t=19.312,P＜0.001）低于对照组。NT、TR、DV与Z评分联合诊断胎儿先天性心脏病的灵敏度为93.44%,显著优于单独诊断;NT、TR、DV与Z评分联合诊断胎儿先天性心脏病的受试者工作特征曲线下面积为0.892,显著高于单独检测（95%CI：0.654~0.912,P＜0.001）。 结论NT、TR、DV联合胎儿心脏测量参数Z评分对胎儿先天性心脏病具有积极的诊断意义。     

胎儿十字交叉心产前超声表现二例

例1孕妇,26岁,孕1产0,孕25周,停经后无毒物、无放射性物质接触史,无上呼吸道感染病史,外院产前超声筛查发现胎儿畸形转诊入本院。超声检查:上腹部横切面扫查示:胎儿内脏正位,肝、胆囊位于腹中线右侧,胃泡位于腹腔左侧,腹主动脉位于脊柱左前方,下腔静脉位于腹主动脉右前方。胎儿心脏扫查示:心脏大部分位于右侧心腔,心尖指向右侧,横切面不能显示正常四腔心,心房正位、房室连接一致,右心房通过三尖瓣连于左侧心室(形态学右心室),左心房通过二尖瓣连于右侧心室(形态学左心室);胸腔矢状切面显示心室呈上下排列,右心在上左心在下,实时动态扫查右心室流入道位于左心室流入道上方,两者呈上下交叉排列,室间隔上部连续性回声中断;左、右心室流出道:主动脉发自形态学的左心室,肺动脉发自形态学的右心室,心室与大动脉连接关系一致。主动脉弓内径明显较肺动脉内径小。产前检查彩色多普勒血流成像示:三尖瓣少量反流,室水平双向分流,主动脉弓血流束变窄。胎儿双肺可见,回声均匀。     

超声诊断胎儿法洛四联症伴肺动脉瓣缺如1例

孕妇,30岁.孕1产0,孕28周.胎儿超声心动图示:四腔心不对称,右心室轻度增大,室间隔上段缺损6 mm,主动脉与肺动脉位置关系正常,主动脉内径6 mm,骑跨于室间隔上,肺动脉呈瘤样扩张,内径约11 mm,右室流出道切面显示右室流出道无狭窄,肺动脉瓣环明显狭窄,无肺动脉瓣叶回声及启闭活动,彩色多普勒血流显像示肺动脉瓣口呈全收缩期湍流频谱及全舒张期反流血流,连续多普勒显示肺动脉瓣口呈连续双向射流与反流频谱,三尖瓣口显示少量反流血流,未能显示动脉导管血流.     

胎儿超声心动图诊断埃布斯坦综合征

目的 探讨胎儿超声心动图诊断埃布斯坦综合征及其并发症的价值。方法 2450胎接受胎儿超声心动图检查;对其中的14胎埃布斯坦综合征胎儿的超声心动图进行分析,并与大体病理结果进行对照分析。结果 14胎埃布斯坦综合征胎儿中,超声均显示三尖瓣反流,其中重度11胎(11/14,78.57%);7胎(7/14,50.00%)合并肺动脉瓣狭窄;3胎(3/14,21.43%)肺动脉内径与主动脉内径比>1.1;1胎合并心脏其他畸形;7胎伴胸腔、腹腔及心包积液共。结论 埃布斯坦综合征胎儿易并发重度三尖瓣反流、肺动脉瓣狭窄、肺动脉与主动脉比例变小、胸腔/腹腔/心包积液;胎儿超声心动图对埃布斯坦综合征胎儿的细化诊断是判断预后的重要依据。     

彩色多普勒超声检测12～14孕周胎儿三尖瓣反流的应用价值

目的探讨彩色多普勒超声检测孕12—14周胎儿三尖瓣反流的临床价值。方法52例孕12-14周发现三尖瓣反流的胎儿为反流组,根据反流程度分为轻度反流和中重度反流;50例孕12-14周未见三尖瓣反流的胎儿为对照组。两组均于孕中晚期行彩色多普勒系统畸形筛查。结果反流组胎儿轻度反流46例,中重度反流6例;检出胎儿异常10例,检出率为19．2％。对照组检出胎儿异常2例,检出率为4．0％;反流组胎儿异常检出率高于对照组（P〈0．05）。结论孕12-14周三尖瓣反流的胎儿发生异常的风险高于正常胎儿,彩色多普勒超声检测孕早期胎儿三尖瓣反流有重要的临床价值。     

胎儿期三尖瓣生理性反流与心脏微小异常的超声研究

目的：通过对胎儿期心脏微小异常以及三尖瓣生理性反流的超声观察,分析二者发生的相互关系以及胎儿期三尖瓣生理性反流的多普勒参数特点。方法胎儿超声心动图检测非选择性人群300例,经产前检查及产后随访除外胎儿及婴儿心脏疾病,胎儿期动脉导管提前收缩,胎儿心律失常以及孕妇妊娠糖尿病、妊高症等疾病。统计胎儿三尖瓣生理性反流和心脏微小异常的发生情况。彩色和脉冲多普勒检测胎儿期三尖瓣反流的面积、持续时间以及峰值流速。结果300例胎儿中,胎儿期三尖瓣生理性反流136例,心脏微小异常者27例（包括心包腔少量积液6例,升主动脉宽于肺动脉主干6例,永存左上腔静脉4例,二尖瓣少量反流3例,肺动脉瓣少量反流7例,右心房内Chiari＇s网1例）,心脏微小异常的病例中合并三尖瓣生理性反流者17例,统计分析发现微小异常组和非微小异常组之间,胎儿期三尖瓣生理性反流的发生率无明显差异（χ2＝3.721,P＝0.054）,并且反流的面积、持续时间以及峰值流速亦无明显差异（P 值分别为0.639、0.930和0.185）。结论胎儿期心脏微小异常存在与否,对胎儿期三尖瓣生理性反流的发生率无明显影响。胎儿期三尖瓣生理性反流的特点为反流面积较小,峰值流速较低且持续时间短暂,对胎儿心脏血流动力学无明显影响。     

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.