实时动态三维超声造影技术在肝肾肿瘤诊断中的应用

目的探讨动态三维超声造影(3D-CEUS)在诊断肝肾肿瘤中的应用价值。方法对39例肝肿瘤、35例肾肿瘤患者行实时3D-CEUS,并与二维超声造影(2D-CEUS)检查和手术及病理结果对照分析。对比观察肝肾肿瘤的3D-CEUS、2D-CEUS增强方式,肿瘤血管清晰度及立体感情况。结果 3D-CEUS对肝肾肿瘤的增强方式与2D-CEUS比较差异无统计学意义;对肿瘤动脉期血管的清晰度显示较2D-CEUS具有明显优势;显示肿瘤的占位立体感较2D-CEUS为好。结论 3D-CEUS是一种无创、省时、高效、安全的新技术,可以重复进行,对肝肾肿瘤的供血动脉可以立体实时动态显示,并能立体显示肿瘤的构架,为疾病的诊断提供了更多的信息。     

三维超声造影对动脉相肝癌血管空间信息显示的临床应用价值

目的探讨动态三维超声造影(3D-CEUS)显示动脉相肝癌血管增强方式及特点的应用价值。方法选取33例肝癌患者,均行常规超声、二维超声造影(2D-CEUS)及动态3D-CEUS检查,观察并比较2D-CEUS和动态3D-CEUS的病灶增强方式、动态灌注过程及肿瘤血管的空间分布情况。结果 2D-CEUS与动态3D-CEUS在肝癌造影增强时相和增强方式方面表现相同,其中30例原发性肝癌动脉相增强方式均表现为快进快出,3例转移性肝癌表现分别为动脉相快速整体增强、不均匀增强及环状增强。动态3D-CEUS在显示肝癌血管起源、分布及数目方面均明显优于2D-CEUS,差异均有统计学意义(均P0.05)。结论动态3D-CEUS能更直观地显示肝癌血管的空间立体关系,以及病灶周边及内部血管的分布方式,具有较好的临床应用价值。     

肝肿瘤动态三维超声造影与二维超声造影的比较研究

目的 通过与二维超声造影(2D-CEUS)比较,探讨动态三维超声造影(3D-CEUS)在评价肝肿瘤血流灌注方面的价值.方法 对65例肝占位患者(共67个病灶)分别进行2D-CEUS和动态3D-CEUS检查,观察两种造影模式下不同肝肿瘤的动脉期增强方式、不同时相的清晰度或立体感、动脉期血管清晰度以及肿瘤血管的空间关系等方面的差异,并比较两种成像方法诊断肝肿瘤良恶性的价值.结果 动态3D-CEUS显示肝肿瘤的动脉期增强方式、动脉期和门脉期病灶的清晰度或立体感方面与2D-CEUS相似(P＞0.05);3D-CEUS鉴别诊断肝肿瘤良恶性的敏感度、特异度、阳性预测值和阴性预测值分别为98.0％、81.3％、94.3％和92.9％,2DCEUS分别为96.1％、81.3％、94.2％和86.7％;两种方法之间鉴别诊断肝肿瘤良恶性差异无统计学意义(P ＞0.05).动态3D-CEUS在显示动脉期血管清晰度及肿瘤血管空间关系上优于2D-CEUS(P＜0.05).结论 动态3D-CEUS和2DCEUS一样可以准确地鉴别肝肿瘤的良恶性,且动态31D-CEUS可更直观和有效地显示肝肿瘤血管的空间立体关系,为肝肿瘤的诊断和治疗提供更丰富的空间信息.     

肝动脉三维灰阶超声造影在肝移植中的临床应用

目的 探讨肝动脉三维灰阶超声造影(3D-CEUS)在肝移植中的临床应用价值.方法 26例肝移植供体或怀疑肝动脉并发症的肝移植受体行二维灰阶超声造影(2D-CEUS)和3D-CEUS检查,评价3D-CEUS图像重建成功率、图像质量和对肝动脉并发症的诊断准确性,并与2D-CEUS相比较.结果 26例患者3D-CEUS可显示21条肝动脉,图像重建成功率80.8%,重建图像血管连续性好,可显示冠状面上的分支或属支,能帮助判定段动脉起源,能明确显示血管空间关系.5例确诊肝动脉并发症者,2D-CEUS和3D-CEUS能明确诊断并与结果 相符者均为4例,2D-CEUS将1例肝动脉迂曲误诊为动脉狭窄,3D-CEUS予以纠正.结论 肝动脉3D-CEUS可获得直观、立体、清晰的肝动脉重建图.在评价肝移植术后肝动脉并发症方面,当血管走行迂曲、有复杂的解剖空间关系时,3D-CEUS能提供更丰富的诊断信息,可对2D-CEUS发现的一些病变作进一步的证实或纠正.     

超声造影诊断兔闭合性肾外伤肾动脉闭塞的价值

目的 研究超声造影诊断闭合性肾外伤肾动脉闭塞的价值.方法 健康新西兰兔10只,雌雄各半.采用SMS型撞击器自肾外侧向肾门处撞击,建立闭合性肾外伤动物模型.撞击前及撞击后10 min内,分别依次完成灰阶超声、彩色多普勒(CDFI)和超声造影(CEUS)检查.撞击后3h,采用剖腹探查和病理检查进行验证.结果 6只兔肾主动脉发生闭塞,4只段动脉发生闭塞.灰阶超声见肾包膜下可见不同程度的积液,肾实质局部回声增强.CDFI显示6只伤肾血流灌注完全消失,另4只仅见部分肾的血流灌注信息.CEUS显示6只肾全期均无增强,4只呈较大范围的楔形无增强,小部分呈高增强.以上结果经剖腹探查和病理检查证实.结论 CEUS显示整个肾实质无增强是肾主动脉闭塞的重要指标,肾实质呈较大范围的楔形无增强是段动脉闭塞的重要特征.     

实时灰阶超声造影评价肾动脉狭窄血流灌注的实验研究

目的探讨兔肾动脉狭窄模型的超声造影肾脏血流灌注模式。方法对10只实验兔递进性钳夹左肾动脉主干,钳夹程度分四级:0级-正常;Ⅰ级-钳夹动脉主干1/3;Ⅱ级-钳夹动脉主干2/3;Ⅲ级-完全钳夹。应用实时超声造影匹配成像技术行超声造影检查,动态观察各钳夹级别狭窄侧肾脏血流灌注。对各钳夹级别肾脏皮质及段间动脉部位进行量化分析,提供以下指标:曲线下面积、峰值强度、开始增强时间、曲线上升斜率。分析上述指标在不同程度肾动脉狭窄模型中的变化规律。结果①肾脏血流灌注增强模式:肾段间动脉、叶间动脉、肾皮质、肾髓质依次增强。随钳夹程度递进,肾脏开始增强时间逐渐延迟,增强程度逐渐减弱。肾动脉完全闭塞时,注射造影剂前后肾脏回声无明显改变。②超声造影时间-强度定量分析:随钳夹级别的递进,皮质和段间动脉取样,开始增强时间逐渐延迟,曲线下面积、峰值强度呈递减趋势。曲线上升斜率Ⅱ级组低于0、Ⅰ级组,0级组与Ⅰ级组无差异。结论超声造影增强模式对筛查肾动脉狭窄有一定价值;超声造影定量分析有助于评价不同程度肾动脉狭窄时缺血肾血流灌注。     

超声造影对肾脏良、恶性病变鉴别诊断的价值

目的：探讨超声造影在肾脏良、恶性病变鉴别诊断中的应用价值。方法：对31例肾脏占位性病变患者进行常规超声及实时超声造影检查,比较病变区造影剂灌注的变化规律,并与病理结果对照分析。结果：所有患者中恶性肿瘤17例,良性病变14例。分析超声造影特征后发现肾恶性肿瘤中11例表现为皮质期快速增强,廓清时间早于周围肾皮质,为快进快退型。良性病变超声造影特点为造影剂廓清过程与周围肾皮质一致或晚于肾皮质,囊肿造影全程均无增强。结论：超声造影可以清晰显示肾脏病变的血流灌注特征,对鉴别诊断肾脏病变的良、恶性有重要的实用价值。     

Gd-DTPA作为肾脏CT血流灌注对比剂的动物实验研究

目的探讨Gd-DTPA作为肾脏CT增强对比剂用于肾脏血流灌注研究的可行性.方法 12只新西兰白兔,分组注射Gd-DTPA或碘对比剂,CT动态扫描获得主动脉和肾脏的时间-密度曲线,计算血流灌注数值.结果静脉注射0.5 mmol/(kg*ml) Gd-DTPA后,肾皮质增强(33.2±11.9) Hu.Gd-DTPA和碘对比剂获得的肾脏皮质、髓质血流灌注数值无明显差异.结论 Gd-DTPA能够作为X线对比剂用于肾脏增强CT检查,并用于研究肾脏血流灌注.     

64排螺旋CT三维重建在肾脏移植中的价值

背景:目前应用相对无创的多排螺旋CT来替代有创的数字减影血管造影进行评价肾脏移植手术中肾脏解剖及功能情况,主要集中在16排螺旋CT及以下机型,鲜有关于64排螺旋CT应用在肾脏移植中的报道.目的:探讨64排螺旋CT三维重建技术在肾脏移植手术中供者肾脏及受者肾脏的检查价值.方法:对7例拟自愿捐献一侧肾脏给其亲属进行活体肾脏移植的供者肾脏及6例接受了肾脏移植的受者肾脏进行了CT平扫、动脉期、静脉期及延迟期增强扫描,并对增强扫描各期进行多平面重建、容积再现技术、最大密度投影及曲面重建等三维后处理.结果与结论:7例供者CT血管造影显示左右肾均为1条肾动脉者4例;左肾2条肾动脉,右肾1条肾动脉者1例;左肾3条肾动脉,右肾两条肾动脉者2例;所有供者左右肾均见1条肾静脉及1套肾盂输尿管.MPR重建显示左肾囊肿1例,CT尿路造影显示双肾功能均未见异常,与手术对照,符合率100%.6例受者中CT血管造影显示6例移植肾动脉、静脉及输尿管吻合口均未见狭窄及内瘘,其中4例移植肾大小形态及密度正常,增强扫描动脉期皮质髓质分界清晰,皮质CT值均在150 HU以上,静脉期肾脏实质强化均匀,CT尿路造影显示肾脏泌尿功能正常;2例移植肾增强扫描动脉期皮质髓质分界不清,皮质CT值均小于100 HU,静脉期肾脏实质强化较弱,延迟10 min扫描仅见少量对比剂排泄,经过肾脏穿刺确诊为排斥反应.结果表明,64排螺旋CT三维重建技术能完成对肾实质、肾血管以及泌尿系统的综合评价,可作为肾脏移植前后评价肾脏解剖及功能的较好方法.     

超声造影监测兔肾缺血再灌注前后肾皮质、髓质血流灌注

目的 探讨兔肾缺血再灌注损伤(IRI)前后肾皮质、髓质血流灌注变化的CEUS特征.方法 建立12只兔肾IRI模型,分别于缺血前及再灌注24 h后行CEUS检查,并对造影的时间—强度曲线(TIC)各参数进行分析.结果 肾皮质缺血前TIC上升支斜率(Grad)明显高于再灌注24 h后(P＜0.05),开始增强时间(AT)、...     

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.