胎儿左心室流出道占位并梗阻狭窄产前超声表现1例

孕妇,26岁.孕1产0,孕38周,既往体健,无家族遗传病史,在外地发现胎儿心脏异常来我院会诊.我院胎儿超声心动图检查显示:胎儿心脏位置正常,位于左侧胸腔,心尖指向左前方.心房正位,心室右襻,房室连接一致.主动脉及肺动脉起源和位置正常,各房室腔径线测值正常.于左室流出道内可见9.4 mm×6.1 mm×7.4 mm中等回声实质性团块(图1),边界清晰,内回声均质,团块基底部与室间隔上段相连接,由于团块影响左室流出道内径变窄,彩色多普勒示左室流出道内可见花色血流信号(图2).超声提示:胎儿心脏占位(位于左室流出道内并梗阻狭窄,考虑横纹肌瘤可能).引产后病理解剖,标本肉眼观左心室室间隔上段见一结节状肿块,大小约7.0 mm×6.0mm×6.9 mm,突向左室流出道,边界清晰,无包膜、表面光滑.     

彩超发现婴儿双心室肿瘤1例

患儿男 ,3月。父母健康状况良好 ,母亲孕 4 0周 ,顺产 ,怀孕期间无感冒 ,无放射线接触史。因肺部感染住院 ,体检时发现心脏杂音 ,申请彩超检查。彩超所见 :心脏各房、室内径正常 ,房、室间隔连续 ,未见分流。左右心室内分别中等回声团块 ,附着于室间隔左室面及右室前壁 ,大小分别为 18mm× 11mm、17mm× 12 mm (图 1～ 3)。右室流出道狭窄 ,内径约 4mm,CDFI示右室流出道血流呈多彩样 ,最大流速 2 30cm/s (图 4、 5 )。彩超提示 :1.左、右心室内实质性肿瘤 (粘液瘤可能 ) ;2 .右室流出道狭窄。由于家庭困难自动出院 ,未能经病理证实。MAS…     

超声诊断胎儿心脏横纹肌瘤1例

病例孕妇,28岁,第一胎妊娠,孕40+4周,产前常规超声检查:胎儿头位,舣顶径9.9cm,脊柱排列整齐,股骨长7.3cm,胎盘位于宫底,厚约3.1cm,可见半环状强回声,羊水最大深度8.1cm,羊水指数26.0cm.二维超声胎儿四腔心切面显示清楚,室间隔明显增厚,内可见一大小约29.0mm×21.1mm×18.2mm的实质性强同声团块,边界清楚,回声均匀(图1),团块膨向左室流出道,致左室流出道变窄,内径约8.5mm.CDFI:左室流出道见五彩镶嵌血流;CW:左室流出道探及收缩期湍流频谱.峰值流速2.85m/s,压差32.4mmHg.     

超声诊断破裂口位于左心室流出道的心脏巨大血肿1例

患者女,64岁。因头晕、乏力就诊。查体:血压17.3/12.0kPa,心脏可闻及杂音。心脏超声检查:升主动脉与左房前壁之间可见一96mm×83mm薄壁不均匀回声区,与左室流出道相通,破裂口起于左室流出道左后壁,位于主动脉瓣左冠瓣下二尖瓣前叶基底部,>12mm(图1)。CDFI示该处局部有收缩期双向血流,可见彩色血流信号填充破口周围,未见穿行血流。超声诊断:①主动脉、左房及右房之间囊实性占位,考虑血肿;②主动脉瓣反流(少量);③二尖瓣反流(中量);建议进一步检查。磁共振考虑:左心房内占位。冠状动脉造影示该肿物与冠状动脉不通。手术证实:破裂口位于左室…     

超声诊断先天性肺动脉瓣缺如伴法洛四联症1例

患儿女,5岁,入我院行先心病矫治手术.超声检查:左室长轴观显示室间隔连续中断约15 mm,主动脉增宽,内径16mm,骑跨于左、右心室,右室前壁增厚,为8 mm,右室流出道及大动脉短轴观示右室漏斗部肌性肥厚,形成管状狭窄,内径6mm,主肺动脉及左、右肺动脉明显扩张(图1),内径分别为26mm、25 mm.、24 mm,肺动脉瓣环狭窄,约6 mm,仅见极短小的肺动脉瓣残迹,瓣叶缺如,彩色多普勒及频谱多普勒于右室流出道及肺动脉瓣口测及收缩期高速湍流及重度舒张期反流(图2),前向血流速度最大6.0 m/s,反流速度3.6 m/s.     

超声造影诊断右室黏液瘤1例

患者男,80岁,自述平素有胸闷、气短症状,卧位时明显,现加重1个月入院。体格检查:脉搏60次/min,血压133/57 mm Hg(1 mm Hg=0.133 kPa),胸骨左缘第三四肋间可闻及收缩期喷射性杂音。超声心动图检查:房室及大动脉水平均未见明显异常分流,各室壁收缩幅度正常,右室腔内及右室流出道内可见一混合附加回声(图1),边界尚清,形态欠规则,呈分叶状,其内回声欠均匀,未探及明显血流信号,活动度较大,附着点显示欠佳,收缩期进入肺动脉,致右室流出道狭窄及肺动脉瓣血流速度加快;CDFI:右室流出道及肺动脉瓣收缩期见五色血流束;频谱多普勒:静息状态下右室流出道收缩期血流速度339 cm/s,收缩期峰值压差46 mm Hg,肺动脉瓣口收缩期血流速度224 cm/s。超声心动图提示:右室腔及右室流出道内占位,性质待定,致右室流出道狭窄及肺动脉瓣狭窄。后行左心腔声学造影检查:右室腔内见一大小约60.2 mm×20.8 mm混合附加回声(图2),密度略低于心肌,低血供,考虑黏液瘤可能。     

超声心动图诊断法洛四联症合并主-肺动脉窗1例

患儿女,3个月.青紫3个月伴呼吸急促2 d入院,胸骨左缘2～3肋间3/6级收缩期杂音.超声心动图示:心脏位置与连接正常,右室壁增厚,右室流出道狭窄,最窄处7 mm,肺动脉瓣增厚开放受限,肺动脉瓣环内径8 mm,过瓣血流流速2.85 m/s,压差4.26 kPa,肺动脉主干内径8 mm,左右肺动脉狭窄;室间隔与主动脉前壁连续中断8 mm,主动脉增宽前移骑跨室间隔,骑跨率30%.     

主肺动脉间隔缺损1例

患儿，女，43天，外院诊断为肺炎转入我院。超声心动图示：全心长大，以右心明显；心室壁增厚。右室流出道及肺动脉增宽；距肺动脉瓣环约5mm处，升主动脉左侧壁与主肺动脉右侧壁之间的间隔连续性中断约11mm（图1）；实时三维超声心动图采集全容积图像并进行旋转切割，显示主肺动脉间隔缺损（APSD）的主动脉面和肺动脉面均呈圆形（图2）。     

超声诊断主动脉右后窦右室瘘1例

患者,男,30岁,因胸闷数年,心前区隐痛、心悸、气急、发绀1月来我附属医院就诊。检体:心率88次/分,律齐,胸骨左缘2、3肋间闻及连续性杂音,毛细血管搏动及周围动脉枪击音(+)。心电图示左室肥厚伴劳损,临床拟诊心肌病,动脉导管未闭?超声检查:室间隔舒张期厚25mm,左室后壁舒张期厚15mm,左室收缩期内径为23mm,舒张期内径为39mm,收缩中期二尖瓣前叶前向运动明显,左室长轴切面和心尖四腔心切面均可见主动脉右后窦侧壁连续性中断,缺损最大径线为5mm,断端稍突向右室流出道,脉冲多普勒于右室流出道瘘口为收缩期异常血流频谱。彩色多普勒显示右室流出道…     

彩色多普勒超声诊断DeBaKeyⅢ型主动脉夹层分离1例

患者男,66岁,高血压病史15年。因突发心前区剧痛、胸闷、气短入院。查体：主动脉 瓣区闻及舒张期杂音,血压29.3/14.6kPa。心电图：窦性心律,左室高电压。心向量图： 左房大,左室肥厚劳损。 　　应用美国Acuson ASPEN彩色多普勒超声仪(探头频率3.5MHz),于胸骨上窝降主动脉长轴切 面及主动脉弓长轴切面扫查,见主动脉弓内径30mm,降主动脉内径36mm,自左锁骨下动脉开 口处远端可见降主动脉内膜分离(图1),形成降主动脉真假腔,内膜片游离飘动,假腔最宽 处达31.2mm,真腔受压变形,最窄处仅12.6mm。CDFI见真假腔血流同时显示,其血流界面 清晰,真腔彩色鲜明,血流速度1.56m/s,假腔血流缓慢。内膜破口位于左锁骨下动脉开口 处远端,连续扫查内膜分离至腹主动脉。胸骨旁左室长轴切面可见左室肥厚扩大,主动脉瓣 中度关闭不全,升主动脉未见夹层分离。右室及右室流出道前方可见不规则液性暗区,范围 约81mm×41mm(图2),左侧胸腔内可见胸腔积液。超声诊断DeBaKeyⅢ型主动脉夹层分离,夹 层血肿破入前纵隔、左胸腔。     

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.     

Systematic Reviews Published in the January 2011 Issue of The Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly as a DVD and monthly online. The January 2011 issue (first quarterly DVD for 2011) contains 4515 complete reviews, 1985 protocols for reviews in production, and 13,521 one-page summaries of systematic reviews published in the general medical literature. In addition, there are citations of 641,000 randomized controlled trials, and 14,018 cited papers in the Cochrane methodology register. The health technology assessment database contains over 9300 citations. One hundred and seven new reviews have been published in the last 3 months, of which five have potential relevance for practitioners in pain and palliative medicine.     

Interprofessional approaches to creating safe,high quality health care

Three supplementary perspectives are presented arguing that interprofessional collaboration is both necessary and desirable. Nonetheless, there are often too many serious intra-professional barriers and obstacles to interprofessional collaboration to make it successful. Some of these barriers, it is argued and illustrated, are found in the multiple ways in which professional identity is tacitly acquired and embodied in the practitioners' habitual, everyday practice. The paper then explores ways in which reflection, especially Second order reflection, can help to elucidate and overcome these obstacles, as well as increasing professional adaptability and competence.     

Prise en charge des entorses externes de cheville : étude clinique préliminaire sur l’efficacité du dispositif Myolux™

Ankle sprains are the most common injury of the musculoskeletal system and are associated with significant societal and economic impacts. It has been proven that classical therapeutic strategies may not be effective in preventing recurrent injuries: the recurrence rates reported in the literature can reach 73%. In order to provide an effective rehabilitation solution, a destabilizing orthosis was developed. This device is equipped with a mechanical articulator reproducing the subtalar mechanics and placed under the heel. In this paper, we present the main results of a preliminary clinical study conducted between 2004 and 2007. All subjects included in this study were treated with the abovementioned orthosis during 10 rehabilitation sessions of 30 minutes each. Data show a relatively low recurrence rate of 12% for the overall population. Moreover, it's of primary importance to note that this satisfactory ratio is largely reduced (3% of recurrence rate) for the 29 patients who performed one training session per month after the 10th initial rehabilitation sessions. Hence, the destabilizing orthosis appears to be an effective solution to prevent recurrent ankle sprains. However, joint protection requires long-term and regular training sessions. This result has motivated the development of a similar device allowing patients to perform training sessions at home. Finally, data obtained in this study are promising awaiting the final results of the comparative, multicentric and independent clinical trials currently managed by the Hospices Civils de Lyon.     

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.