超声诊断胎儿巨大脐膨出并肌部室间隔缺损1例

孕妇,29岁.孕31周,孕1产0,无家族病史,来我院行产前检查.超声显示:宫内单活胎,胎儿双顶径7.8 cm,股骨长6.1 cm,胎儿颅骨完整,脊柱排列规整,腹部膨隆,腹前壁相当于胃泡水平腹壁向外膨出物约7.5 cm×7.8 cm,膨出部基底宽约6.2 cm,腹壁内膨出物大部分为肝组织,并见部分肠管疝出,彩色多普勒见肝静脉血流信号,突出的肝及肠管外有一薄膜包裹(图1).胎儿四腔心可见肌部室间隔回声失落7.2mm,可见过隔血流信号(图2).超声诊断:①宫内孕单活胎;②巨大脐膨出;③胎儿先心病(肌部室间隔缺损).胎儿引产后见脐膨出大小约7 cm×7 cm×6 cm,膨出物外表无皮肤覆盖,表面覆盖一层薄膜.经家属同意行心脏切开术,见肌部室间隔中断约7 mm.     

胎儿甲状舌管囊肿超声表现1例

患者女,28岁.孕2产1,孕34周行常规超声检查.超声显示:宫内单活胎,双顶径9.3 cm,腹径9.4 cmx9.4 cm,股骨长6.1cm,胎儿左颈部颌下见5.2 cm×4.6 cm无回声区,内见少许分隔(图1),彩色多普勒血流显像示其内未见血流信号.完超声诊断:①晚孕,单活胎,头位;②胎儿左颈部囊性块影.询问患者非近亲结婚,孕期无不良用药史,无毒物及放射线接触史,引产一女死婴,婴儿左侧颈部包块约7 cm×5 cm×4 cm大小,囊性,活动可,左侧边缘达左枕后,右侧缘达气管与气管粘连,切开内见分隔.病理结果:颈部甲状舌管囊肿.     

超声诊断胎儿肢体-体壁综合征1例

<正>孕妇,18岁,孕1产0,孕12+5周,既往身体健康,无感染史及放射接触史,无畸形分娩家族史。患者于孕12周在外院行超声检查提示胎儿腹部包块,后来我院复查,超声表现:宫内单活胎,可见胎头光环,双顶径2.1 cm,胎盘后壁厚1.5 cm,羊水深度3.5 cm,胎心150次/min。胎儿腹部见向外凸出的混合性包块,     

产前超声诊断胎儿骶尾部海绵状血管瘤1例

孕妇,25岁.孕1产0,孕29周.既往身体健康,家族中无遗传病史,孕20周时曾来我院做产前常规超声检查,胎儿未见明显异常.孕29周超声检查发现:胎儿骶尾部软组织内见大小约2.8 cm×2.4 cm×1.4 cm团状低回声(图1),边界较清楚,内部回声不均匀.     

胎儿先天性皮肤缺损超声表现1例

正孕妇,35岁,孕2产0,人流1次。孕期无致畸药物接触史,无有毒有害、放射性物质接触史,否认遗传病史及家族病史。羊水穿刺染色体检测未见异常。孕28周常规超声检查:胎儿大小与孕周相符;胎儿腹壁显示欠清晰,以前腹壁为甚;胎儿胃泡大小约3.8cm×1.5cm,双肾、膀胱可见;孕妇子宫腔内偏左下另见4.4cm×1.6cm混合性回声,内可见骨骼回声,未见明显血流信号。胎儿腹部MRI检查:     

双胎之一胎儿脐静脉腹内段瘤样扩张超声表现1例

正孕妇,26岁,孕1产0,血型AB,平素健康,孕早期无明显患病史,无服药史及X线接触史;孕前血常规、尿常规、肝功、TORCH等检查均未见异常。孕12+1周超声诊断:双绒毛膜双羊膜囊双胎。孕24+4周行胎儿四维及系统超声检查:宫内见双绒毛膜双羊膜囊双胎,胎儿1脐带入腹壁后可探及一大小为1.8 cm×1.8 cm囊性无回声区,入腹壁处宽度1.2 mm;CDFI示其内可见     

多微脑回畸形胎儿超声表现1例

孕妇,31岁.孕1产0.停经37+周,因孕30周时产前超声检查异常入院.家族无畸胎史.以往产科检查和超声检查无异常发现.孕30周超声检查显示:双顶径6.6 cm,头围23.9 cm,股骨长5.3 cm,腹围24.3 cm,胎盘位于右前壁Gr Ⅰ级,羊水3 cm,脐动脉S/D值2.65.胎儿左肾集合系统分离0.4 cm.宫腔左上方见宽1.0 cm条状低回声,连接子宫前后壁.住院后38周行超声检查:胎儿双顶径7.7 cm,头围28.6cm(图1),股骨长6.6 cm,腹围31.4 cm,胎盘位于右前壁GrⅡ+级,羊水3 cm,脐动脉S/D值1.9.胎儿颈部见脐带压迹.超声提示:宫内孕单活胎,胎儿宫内生长受限,小头畸形不排除,脐带绕颈(3圈),子宫不全纵隔.孕妇与家属要求引产,并出具计划生育引产证明.     

超声诊断胎儿并腿畸形综合征1例

正孕妇,27岁,孕2产0。于孕前3个月行人绝经期促性腺激素联合人绒毛膜促性腺激素促排卵治疗,并予以黄体酮口服黄体功能支持;无化学毒物、放射性接触史,无家族遗传病史和病毒感染史。孕12+1周行超声检查:胎盘位于子宫后壁,厚度1.1 cm,钙化0级,羊水最大无回声区3.3 cm,顶臀径5.19 cm,超声孕周11+6周,颈项透明层厚度1.5 mm,胎儿仅见单一下肢(图1)。2周后要求终止妊娠,复查超声示:胎盘位于子宫后壁,厚度2.0 cm,钙化0级,羊水最大无回声区3.7 cm,顶臀径7.27 cm,颈项透明层厚度2.3 mm,超声孕周13+3周;胎儿下肢呈融合状,小腿可见两     

产前超声诊断喉-气管闭锁1例

孕妇31岁,孕1产0,孕20周,因羊水过多行产前超声检查。超声显示胎儿双肺轮廓明显增大,回声增强,气管及左右支气管明显扩张(图1),气管宽约0.4cm,气管上段与咽喉部连接显示不清。胎儿心脏受压,但心脏结构未见异常声像,腹腔内见大量游离无回声区,肠管漂浮其中。其他结构未见异常。超声诊断:喉-气管闭锁可能,腹腔大量积液,羊水过多。因孕妇及家属要求终止妊娠,引产一死男婴。病理解剖证实为胎儿水肿,大量腹腔积液,喉尾端及气管上段闭锁,呈盲端,两肺明显增大,图肺1组织学正常。喉-支气管闭锁声像图(R-LU:右肺;RB:右支气管;T:气管;LB:左支气管;…     

产前超声可疑胎儿小肠闭锁生后确诊为全结肠型巨结肠1例

<正>病例女，27岁，孕36周⁺⁵，此前在当地医院分别于孕24周和孕32周行产前超声检查，均未发现异常；孕36周产前超声检查时提示肠管内径较宽处约1.3 cm，羊水深度4.0 cm，逐转诊于我院。此次产前超声示：胎儿双顶径9.0 cm，头围32.0 cm，腹围35.1 cm，股骨长度7.3 cm，胎心率141次/分。胃泡大小约4.9 cm×2.6 cm。下腹部肠管扩张，内径较宽处约1.8 cm(图1,2)。胎儿右下腹、右肾下方见约3.6 cm×2.5 cm稍强回声，似迂曲萎瘪的肠管影像(图3)。胎儿子宫后方直肠萎瘪(图4)，肛门靶环征可见。羊水深度4.3cm，羊水指数12.6cm。胎盘位于子宫前壁，成熟度Ⅱ级，厚度约4.2 cm。超声提示：     

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.     

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.     

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.     

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.     

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.