<第一孕期母血唐氏症篩檢>

這項檢查也稱做"初期唐氏症篩檢"，針對懷孕藉於11週~13週又6天的孕婦來做檢查，內容包含了超音波(大家常聽到的頸部透明帶)和抽血生化檢驗(free ß-hCG和PAPP-A)。

大家普遍有的觀念是唐氏症和高齡產婦相關，所以年紀大的人有可能需要做羊膜穿刺檢查染色體。那年輕女性懷孕是不是就可以仗著年紀小，就都不做檢查??

當然不是，對於我們來說，唐氏症篩檢很重要!!!唐氏症篩檢很重要!!!唐氏症篩檢很重要!!!

#因此不管是任何年齡的女性懷孕我們都會建議要做唐氏症篩檢

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今天主要是來講解所謂第一孕期唐氏症篩檢的"超音波"部分。雖然說俗稱為"頸部透明帶"，但是我們要看的可不只是這一樣。

英國倫敦大學國王學院附設醫院暨胎兒醫學協會(英國Fetal Medicine Foundation)對於這個時期的超音波要做哪些檢查有嚴格的定義與規範，主要就是讓超音波影像可以標準化，放諸四海皆準。畢竟唐氏症篩檢不是小事，所以能夠執行第一孕期母血唐氏症篩檢的醫療人員，都是經過協會考試通過，且每年都還要重新考試與影像認證的!👓🎓

♠️先舉列最重要的會影響唐氏症計算風險的幾項♠️

✔️頸部透明帶(Nuchal translucency, NT)
這時期的寶寶在脖子後面有一層皮下積水，用超音波看的時候會呈現一條黑色的空隙。我們會希望寶寶正躺，且可以看到鼻骨的正切面這時候最為標準。一般來說NT會小於2.5或3mm，過厚則有可能與染色體異常有關。但是單憑NT過厚，在唐氏症的靈敏度大概只有七成多；如果合併抽血數據再去計算風險，靈敏度則可高達八九成。
急著想要知道染色體是否有問題的孕婦，此時可以考慮直接絨毛膜穿刺，省去焦慮等待的時間；也可以等到篩檢正式報告出來，或是16週之後再做羊膜穿刺來做染色體檢查確認。

✔️鼻骨(Nasal bone)
單純只看鼻骨有沒有發育，靈敏度只有三成。而且東方人很多只有半邊鼻骨，所以沒有看到寶寶的鼻骨先不要太緊張唷!👃🏼👃🏽👃

✔️三尖瓣逆流(Tricuspid regurgitation, TR)
蝦米!😮三個月的胎兒也可以看得到三尖瓣逆流?是滴，這時期的三尖瓣逆流會增加一些唐氏症風險，但是通常早期的三尖瓣逆流，到中後期會慢慢消失，在高層次超音波追蹤時都看不太到了~

✏️補充: 近幾年來的趨勢，其實將第一孕期唐氏症篩檢的超音波當作早期胎兒異常篩檢的工具，因此心臟❤️的部分也會看得更加仔細! 像是心房心室發育不對稱，心臟位置不正確等都可以給我們一些提示，可以更早期發現嚴重的先天性心臟異常。

✔️靜脈導管血流(Ductus venosus regurgitation, DV doppler)
這條短小又很細的血管是胎兒循環重要的一條血管，外接部分臍靜脈的血液直接連到胎兒的下腔靜脈，供應充氧血。這時期如果有逆流，或是阻力過高，也會間接影響到唐氏症的風險。

✏️補充: 靜脈導管血流並不是只有在這個階段重要喔! 大週數的寶寶如果有懷疑子宮內胎兒生長遲滯，也會量測這段血流阻力來判斷寶寶的狀況~

♠️其他一樣很重要的篩檢項目♠️
#胎兒部分基本上是從頭到腳看過一遍

✔️腦部: 這個時期寶寶的頭殼都有發育了，一些重大腦部畸形如無腦症，或是頭型不對懷疑神經管缺損，都可以在此時看出

✔️胃: 確認胃有沒有發育，以及胃的位置是否正確

✔️膀胱: 如果此時膀胱非常明顯的過大，縱徑大於7mm，則有可能罹患巨大膀胱症

✔️臍帶: 兩動脈一靜脈，可早期檢查是否有單一臍動脈的情形

✔️四肢: 手腳各12根長骨還有手掌腳掌在此時都已經發育，雖然手指腳趾可能沒有辦法像高層次超音波時看得那麼清楚，但如果有先天重大肢體缺損是可以看出來的

✏️補充: 超音波儀器越是發達，大家就越想把第二孕期的胎兒異常篩檢項目拉到第一孕期來做。進階版的超音波高手們也可以經由所謂鼻骨後三角👃🏼(retronasal triangle)來判斷是否有明顯的唇顎裂~(此並非常規篩檢項目，在此僅供參考~要先聲明以免被同業撻伐啊⋯⋯）

♠️子宮結構部分♠️
✔️子宮頸長度: 統計上來說，第一孕期的子宮頸長度如果超過四公分，早產的機率就比較低。萬一此時意外發現子宮頸過短，也可以及早處理

✔️子宮動脈血流: 子宮動脈血流如果阻力過高，會增加孕婦發生子癲前症的風險。一般來說量測到兩邊阻力PI平均大於2.5，或是血流波型出現勾狀(notch)，日後發生子癲前症的風險都會增加。(子癲前症篩檢又是一個大課題...)

在門診無法如此詳細解釋第一孕期超音波的重要性，在此給大家參考～～

#初期唐氏症篩檢
#頸部透明帶
#fetalmaternalfoundation
#早期胎兒異常篩檢

《和屍體說話的人》

Do you believe in past life, and its strong invisible influence over your present life?

He was the Sherlocks Holmes of Taiwan.

The modern day Justice Pao (現代包青天), known to bring justice to murdered victims.

楊青天大人, he was nicknamed by his countrymen.

I had never heard of 楊日松博士, Dr Yang Jih-sung.

Till I read the story written by my Grandmaster, Living Buddha Lian-Sheng, which I posted two days ago.

That was donkey years back.

In my decade long of mastering Chinese Metaphysics, I have amassed hundreds, if not thousands, of Bazi in my crumpled dog-eared notebooks.

One continuous homework that I have been doing since 2006, is to study the Bazi, faces, bodies and lives of not just famous people, people featured in the newspapers (hit-and-run victims, suicide victims, criminals, scholars, helpful people etc.) but as well as people around me.

Shifu said, the more we study, the better and faster we get at dissecting a person's Bazi and people reading.

The goal is to train our eyes and brain so well that we can see a person naked (figuratively, of course) within one split second.

And when a person walks past, without turning our heads to look, we must be able to tell Shifu the current financial state and luck of the person. #aurareading

Such training was very strenuous in the beginning. When I didn't pass the impromptu tests given by Shifu, I was meted harsh punishment and disallowed further learning, till I passed with flying colours.

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I got curious about Dr Yang about a month ago. He had a very fascinating career history.

What does he have in his Bazi, that determines him to be a righteous and dedicated forensic expert with such top-notch crime-solving skills?

What had he done to be bestowed the divine title of 城隍爺 (City God), after his death?

I read that he allegedly handled more than 30,000 bodies over the course of his 62-year career. I took out my calculator. That worked out to 484 bodies every year. 40.3 bodies every month, which is about 1.34 bodies every day.

While all his classmates went off to become doctors, Dr Yang was the only one from his class to take up forensics. It was a decision he made after his brother was forcefully coerced into a confession by the Japanese that he was a spy and wrongfully jailed, and another friend was unfairly charged of being a thief.

Dr Yang learnt early in his life, that eye witnesses were insufficient to solve a case. There was a pressing need for strong scientific evidence.

What caught my eye about Dr Yang was his utmost respect to the dead bodies.

He would always take a bow to the victim before starting work on the dead body.

Through the decades, he had never wore any protective gear like masks and gloves during autopsies.

In his biography:

"A forensic expert’s job is more than just studying and dissecting the bodies. If necessary, we need to taste the contents of their stomachs and determine the time of death from the acidity. We can also tell from the bitterness whether there was poisoning involved.”
He cites a case where three charred bodies were brought in from the same incident.
“They smelled the same, so I could tell that they were burned at the same time. If I wore a mask, I would not be able to observe this subtle detail,” he says. “And, I believe that wearing a mask is disrespectful toward the deceased.”
Finally, he explains that he “cannot feel the elasticity of the skin” if he has gloves on.

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I don't know if you have ever smelt a corpse. But it is known to be extremely foul.

Especially when the bodies have been thrown into the sea, or buried deep in the soil, before digging out much later.

Dr Yang never feared infection by the bacteria in the corpses.

Those were the days when CSI kind of science did not exist.

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楊日松法醫：「你沒有良心，做不了。」

Dr Yang solved his first case when he was just an intern and still a student at Taipei Medical University in 1949. A pair of university lovers supposedly hung themselves by the Tamsui River, but the man survived. Later on, Dr Yang quickly proved that the noose was too small for two persons to be hung together. The man had murdered his girlfriend and staged a suicide attempt, complete with a forged suicide note, to cover up.

Dr Yang was only 21 years old then. (Jeez...what was I doing at 21?)

He went on to solve many difficult cases, which shocked Taiwan's society. Here are just 3 of them:

1. September 1977. It was Taiwan's 1st dismemberment murder case.

Two plastic bags containing about 6 pieces of body parts were found along the Dahan River.

DNA tests were non-existent then.

Dr Yang was called in, and his examination showed that the body parts belonged to the same person. He also provided the victim's age and possible identity at a reporters' conference, where he displayed the body parts on a table, and listed 10 areas of identification.

Including, the mammary glands were not enlarged, proof that the woman had never been pregnant.

And how the woman was possibly murdered and mutilated.

The police soon tracked the murderer to a ex-convict, who put up a false hiring notice, to trick young ladies.

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2. 1990. The murder of a young Japanese undergraduate.

The body could not be found till a year later.

The young lady came to Taiwan for solo free and easy travel. She got onto a taxi, with a friendly driver who showed her around Taiwan. Iguchi Mariko agreed to staying at the driver's home for the night, when she could not find accommodation.

Her body was mutilated into 100+ parts and buried under a big tree. Her head was thrown into a rubbish bin.

When the police caught the taxi driver, Dr Yang provided scientific evidence that the taxi driver washed his home walls with strong chemicals and the water usage during the month of murder was 5 times the usual amount.

While the bones were too damaged to be tested for DNA, Dr Yang could piece them together that they belonged to the same person.

This case shocked both Taiwan and Japan.

3. 1993. The dead Marine Captain Yin Ching-feng (尹清楓)
The Captain was discovered dead along the coast of Yilan. The military claimed it was suicide by drowning. Dr Yang examined the corpse and discovered many wounds. There was no ocean debris in the lungs or other drowning symptoms.
Dr Yang announced that the Captain was murdered before being disposed into the ocean.
His honest words unscrambled a huge military scandal in Taiwan and caused many high-ranking officials to lose their jobs.
.
楊日松法醫：「法醫學是人權保障醫學。」

Dr Yang was also involved in the examination of 17-year-old Bai Hsiao Yen's mauled body. During the examination, Bai Bing Bing, the famous Taiwanese actress, mother of the victim, requested to be present.
Calling Dr Yang a Bodhisattva to the family of the victims, Bai Bing Bing was deeply moved by Dr Yang's comforting words to her:
我只能幫你瞭解真相。我沒有辦法再騰出我的手，再來救一個萬一昏倒的人。妳放心，妳信任我，我等一下一定會給妳最清楚的答案。
(I can only help you find out the truth. I am unable to lend another hand, to save a person who might faint. Don't worry. Trust me. Later I will definitely give you the clearest answer.)

Due to the nature of his work, Dr Yang contracted a skin disease, which caused great itchiness. Two months of seeing the doctor and injections did not help. Eventually, Dr Yang learnt of using rice water to wash his skin. Neighbours and Taiwanese who knew of Dr Yang's condition would bring rice water all the way to his home. It took 6 months before Dr Yang's skin ailment was under control.

#好人有好報

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楊日松法醫：「對屍體要誠實。沒有誠實的人，不要來當。」

There were many cases that Dr Yang solved, with supernatural help.

Once, when he was on a car together with his friends, he spotted a lady sitting beside him. He kept quiet as he assumed she was the friend of one friend. Later on, the car was stopped at a roadblock, where the officer told Dr Yang that he was needed at a crime scene. By then, the lady had mysteriously disappeared.

When Dr Yang reached the scene, he saw that the corpse looked exactly like the lady in the car. He knew immediately it wasn't a suicide case, as seen from the surface.

Another time, Dr Yang was at home when there was a knock on his door. He opened the door and saw a lady in a tracksuit with her head down. The lady sought Dr Yang's help to examine her injury. Dr Yang replied that he didn't have his equipment right now and asked the lady to go to the police station tomorrow. The next morning, during an autopsy, Dr Yang saw a body which didn't have clear facial features, as the body was rescued from the river.

He asked for the police to show him the clothes the body was found in. It was the EXACT same tracksuit as the lady who knocked on his door last night.

One day after work, Dr Yang's car was flagged down by a lady standing by the road. It was pouring heavily. Dr Yang got the chauffeur to stop his car and the lady asked to hitch a ride. Dr Yang agreed. The lady remained silent and kept her head down throughout. Dr Yang found her vaguely familiar.

After she disembarked, for some reason, Dr Yang's chauffeur got lost and could not find his way home. For over an hour, his car kept turning around the same spot.

Feeling something was amiss, Dr Yang headed back to Yilan, and re-examined the corpse. He had initially deduced that the corpse had committed suicide by drinking pesticide. On his 2nd examination, he discovered that the pesticide was found in the lungs. Usually for such suicide case, pesticide would be present in the esophagus. But if one was forced to drink it, the pesticide would leak into the lungs. Dr Yang amended his autopsy conclusion of suicide to murder.

Many supernatural incidents like these had alerted Dr Yang to correcting his initial findings, and solving mysterious cases.

.

Yet, there were times when Dr Yang was unable to reach a conclusive result despite many rounds of autopsy.

Then, Dr Yang would pray to the "Floating Head" in his autopsy laboratory. It belonged to a murdered victim, whose case was also resolved by Dr Yang. For some reason, the family/friend didn't want to claim the head. The head had been preserved in a glass container of formalin for 50 over years and its hair and moustache would grow. It was the Guardian Protector of Dr Yang and his team.

Each time after Dr Yang prayed to it, he would gain new insights into the case on hand.

During the Hungry Ghosts' Festival, Dr Yang would lead his entire team to pray to the "good brothers" and made many offerings. He had never missed a year of prayers.

While most educated people turn their noses up at the talk of ghosts and gods, this is one Doctor who will bow humbly before them and ingrain into his team the importance of respect.

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Dr Yang told my Grandmaster that in his past life, he was the confidential secretary to the King of Hades. Hence in this lifetime, he took on the role of a forensic expert, helping murdered victims to redress the injustice they suffered.

Dr Yang's Bazi was an interesting revelation to his life and character, and why his occupation suited his Bazi to a T.

During his time, there were less than 10 forensic experts in the whole of Taiwan.

His integrity, courage, care to minute details, diligence, quest to find the truth and dedication are qualities I deeply admired. The same qualities my Shifu had been drilling into me for the past 11 years to be a very competent practitioner.

In this era where most people worship the famous and the rich, it is very rare to find a noble character like Dr Yang, who also respected the spiritual world.

Before he passed on due to colon caner, Dr Yang had expressed no regret over his career choice. The only thing he felt bad about was not being to provide more for his children, as public servants in Taiwan earned much less than doctors.

But Dr Yang, your heroic legacy is one that your children and descendants can speak proudly of for decades. The merits you left for them can guarantee them a better life than money ever can buy.

Dr Yang was born on 23 November, 1927. He passed away on the same day, in 2011.

I wanted to post this article yesterday, on his birthday and death anniversary. I took too long to write and am a day late. But I still wish to share Dr Yang's great life story with you.

Congratulations on your promotion to be the righteous City God. You totally earned it. 🙏

城隍境主楊日松法醫，Happy Belated Birthday, Dr Yang. 🙇🏻‍♀️

.....................

Photo credit to Apple Daily, TVBS Taiwan, and respective owners.

You can learn more about Dr Yang and his work on Youtube by searching for "楊日松".

To read my post where I posted my Grandmaster's article on Dr Yang, link in comment.

【長時間久坐 當心梨狀肌症候群】
「梨狀肌症候群」的症狀相似於椎間盤突出(intervertebral discitis)、腰椎神經根病變(lumbar radiculopathy)、大轉子滑囊炎(trochanteric bursitis)等其他常見骨科疾病，因此，也往往誤判梨狀肌症候群。根據統計，大約16%慢性下背痛的病患會造成工作上部分或完全失能，但事實上約有6%病患造成下背痛的原因是梨狀肌症候群。藉由正確認識梨狀肌症候群，往往可以減少許多不必要的治療處置或開刀。
梨狀肌是位於髖關節深處的肌肉，起於薦椎(sacrum)的第二到四節前側，往外背側連接於股骨大轉子(greater trochanter)的上內側。坐骨神經是腰椎及薦椎發出的神經根結合成束，往下穿入骨盆腔，再經由坐骨大切跡(greater sciatic notch)穿出骨盆腔來支配下肢的後側。大部分的人坐骨神經穿出骨盆腔的解剖位置是位於梨狀肌之下；然而，少部分的人會有正常的變異，其坐骨神經會穿入梨狀肌或被梨狀肌分為兩束，甚至兩者情況都有。因此，過度的運動、跑跳或髖關節扭轉可能使梨狀肌痙攣或損傷發炎，造成坐骨神經被擠壓而出現類似坐骨神經痛的症狀。

梨狀肌症候群的症狀
＊坐姿、站姿或躺姿超過15-20分鐘會有疼痛產生
＊疼痛或麻木感會從臀部向下延伸到大腿後側
＊變換姿勢或伸展臀部肌肉時疼痛加劇，如：從坐姿或蹲姿站起
＊患側下肢無力，嚴重時走路會有困難，如：跛腳
＊患側梨狀肌有可觸摸到的腫塊或壓痛點

如何區辨梨狀肌症候群或坐骨神經痛？
梨狀肌症候群患者在仰躺時，患側下肢髖關節外轉可以紓緩疼痛的症狀；然而，主動將患側下肢轉回腳尖向上的姿勢會造成疼痛。
臨床上，醫師或治療師除了會詢問病史之外，另外會配合一些理學檢查來區辨梨狀肌症候群與坐骨神經痛。
＊直抬腿試驗 (Straight Leg Raise Test (SLRT))：病患在仰躺姿勢下，由治療師將患側下肢髖　
　關節彎曲並合併膝關節伸直的動作，如果呈現不疼痛的陰性反應，則懷疑是梨狀肌症候群所
　造成的疼痛；相反地，如果出現疼痛的陽性反應、抬高的角度越高會越痛，則懷疑是椎間盤
　突出，需要配合肌電圖或相關影像的檢查做進一步的確認。

　　　　　　　　　　　　　　　
　 FAIR手法 (FAIR maneuver)：病患在側躺姿勢下，由治療師被動將患側下肢髖關節彎曲60度、膝關節彎曲90度，再加上髖關節內轉、內收的動作，如果有神經症狀出現或是感到臀部疼痛，則測驗結果為陽性，表示有梨狀肌症候群。
治療及處理
梨狀肌症候群臨床的治療方式分為保守治療及開刀治療兩種。在急性疼痛時必須休息，並視病患的嚴重程度來決定休息的時間長短、是否需要服用非類固醇消炎止痛藥或肌肉鬆弛劑，來減緩疼痛並放鬆梨狀肌對坐骨神經的壓迫。透過保守治療的方式，約有八成的患者症狀改善可達70%。如果病患對藥物及物理治療的療效不盡理想，則可以考慮局部注射麻醉劑或類固醇。若對上述治療反應皆不佳的病患，則可以考慮手術治療。
物理治療可藉由儀器治療及牽拉梨狀肌的復健活動來減少對坐骨神經的壓迫，敘述如下：
＊ 儀器治療：
．熱療：使用淺層熱療(如：熱敷)或深層熱療(如：短波、超音波)。
． 電療：包括經皮電刺激、干擾波等。
＊ 復健活動：
． 軟組織徒手治療：病患採俯臥的姿勢，由物理治療師被動地將病患膝關節彎曲90度，並控
　制髖關節內外旋的角度，以手肘沿著梨狀肌肌肉的方式向下施壓，藉以拉長放鬆梨狀肌。
＊牽拉運動(示範圖左腳為患側腳)：病患的非患側腳膝關節彎曲90度，並將患側腳的腳踝架於
　非患側腳的大腿上，呈現翹腳的姿勢，一手抱住非患側腳的腳踝，一手抱住患側腳的膝關節
　後方，將膝蓋往對側肩膀靠近，感到臀部肌肉有拉扯的感覺維持10秒鐘。一天三回，
　每回20次。相同的牽拉方式也可以在坐姿進行。
＊提臀運動：病患採四足跪趴姿，將患側腳抬起維持約10秒鐘，放下時患側腳懸空維持
　10秒鐘(圖六)。一天三回，每回重覆10~15分鐘。

　　　　　　

復健醫學科 物理治療師 俞玉智