剪切波弹性成像及超声造影定量评估慢性肾脏病

目的 观察剪切波弹性成像(SWE)及超声造影(CEUS)定量评估慢性肾脏病(CKD)的价值。方法 纳入168例CKD患者(CKD组,包括CKD1期48例、CKD2期46例、CKD3期38例、CKD4~5期36例)和50名肾脏正常受试者(对照组),行常规超声、SWE及CEUS,比较组间及不同分期CKD之间各超声参数的差异。采用Pearson相关性分析观察CKD患者SWE、CEUS参数与肾功能指标的相关性。绘制受试者工作特征曲线,评估SWE和CEUS参数单独及联合诊断CKD的效能。结果 CKD组肾脏最大长径、最大宽径、皮质厚度、时间-强度曲线(TIC)绝对峰值强度(ΔPI)及TIC下面积(Area)均小于对照组(P均<0.05),平均(E_mean)、最大(E_max)及最小弹性模量(E_min)均高于对照组(P均<0.05)。CKD组内,随CKD分期增高,肾脏E_mean、E_max及E_min增高,TIC的ΔPI及Area缩小(P均<0.05)。CKD组肾脏E_mean、E_max、E_min与肌酐、尿酸、尿素氮均呈正相关(r:0.12~0.44,P均<0.05);Area与肌酐、尿酸、尿素氮均呈负相关(r=-0.44、-0.31、-0.43,P均<0.05),ΔPI与肌酐、尿酸均呈负相关(r=-0.15、-0.18,P均<0.05)。以肾脏E_mean、E_max、E_min、Area及ΔPI诊断CKD的曲线下面积(AUC)为0.776~0.882,尤以Area及E_mean诊断价值更高,其联合诊断CKD的AUC达0.949,敏感度为92.63%,特异度为90.71%。结论 SWE及CEUS均可有效诊断CKD;二者联合可进一步提高诊断价值。     

超声观察高原日光照射对正常人皮肤厚度及硬度的影响

目的 探讨高频超声及剪切波弹性成像（SWE）评估高原日光照射对皮肤厚度及硬度的影响。方法 招募30名高原地区（高原组）、48名非高原地区（非高原组）志愿者,以高频超声及SWE测量右侧中指、右侧前臂、前胸壁及腹壁4个部位皮肤厚度及皮肤硬度。比较2组间4个部位皮肤厚度及硬度差异;选取皮肤厚度及弹性值差异有统计学意义的参数,行诊断性试验,并绘制ROC曲线。结果 高原组右侧中指皮肤厚度、最大弹性值（E_max）、平均弹性值（E_mean）、最小弹性值（E_min）及弹性值标准差（Esd）,右侧前臂及前胸壁皮肤E_max、E_mean、E_min,腹壁皮肤E_max、E_mean、E_min、Esd均大于非高原组（P均<0.05）;前胸壁及腹壁皮肤厚度小于非高原组（P均<0.05）。根据腹壁皮肤E_max、E_mean及E_min诊断高原地区皮肤的ROC曲线AUC均>0.95。以腹壁皮肤E_max=13.30 kPa、E_mean=12.45 kPa、E_min=11.50 kPa为界值,诊断高原地区皮肤的敏感度均为100%,特异度分别为85.40%、87.50%及85.40%。结论 高原日光照射会导致皮肤厚度改变和皮肤硬度增加;腹壁皮肤弹性值E_max、E_mean及E_min的诊断效能最高。     

经会阴盆底超声联合剪切波弹性成像测量肛提肌诊断女性压力性尿失禁

目的 观察经会阴盆底超声联合肛提肌（LAM）剪切波弹性成像（SWE）诊断女性压力性尿失禁（SI）的价值。方法 对32例SI患者（SI组）和34名已育健康女性（对照组）行经会阴盆底常规超声及SWE检查,获取静息状态及最大瓦尔萨尔瓦动作下LAM弹性模量最大值（E_max）和平均值（E_mean）及其最大值的差值（△E_max）和平均值的差值（△E_mean）;行Logistic回归分析,绘制受试者工作特征（ROC）曲线,观察LAM各弹性模量值诊断SI的效能。结果 SI组与对照组间月经状况、尿道漏斗形成情况、BND及LAM厚度差异均有统计学意义（P均<0.05）。SI组LAM的△E_max和△E_mean均小于对照组（P均<0.05）。静息状态下,SI组与对照组LAM的E_max和E_mean差异均无统计学意义（P均>0.05）;最大瓦尔萨尔瓦动作下,SI组LAM的E_max和E_mean均小于对照组（P均<0.05）,且SI组及对照组LAM的E_max和E_mean均大于静息状态下（P均<0.05）。以21.40 kPa为截断值,△E_max诊断SI的敏感度和特异度分别为80.40%和71.90%;以18.80 kPa为截断值,△E_mean的敏感度和特异度分别为85.60%和85.00%,均大于△E_max（P均<0.05）。尿道漏斗形成情况、BND和△E_mean是SI的独立危险因素（P均<0.05）。结论 经会阴盆底超声联合SWE 测量LAM有助于诊断女性SI;△E_mean<18.80 kPa可提示SI。     

中国版甲状腺影像报告和数据系统(C-TIRADS)联合结节内部及周围腺体硬度鉴别甲状腺良、恶性结节

目的 评估中国版甲状腺影像报告和数据系统（C-TIRADS）联合结节内部及周围腺体硬度鉴别甲状腺良、恶性结节的价值。方法 回顾性分析117例经细针抽吸细胞学检查（FNAC）和/或手术病理确诊甲状腺结节患者的常规超声及超声剪切波弹性成像（SWE）资料,按照C-TIRADS对结节进行分类;基于SWE技术测量结节及其周围2 mm腺体的SWE参数,包括甲状腺结节（E）及结节周围腺体（Eshell）杨氏模量值[最大值（E_max/Eshell_max）、平均值（E_mean/Eshell_mean）、最小值（E_min/Eshell_min）及标准差（E_SD/Eshell_SD）]。绘制受试者工作特征（ROC）曲线,计算曲线下面积（AUC）,评估C-TIRADS、SWE及二者联合鉴别甲状腺良、恶性结节的效能。结果 共纳入117例共117个甲状腺结节,包括良性结节50个、恶性结节67个。甲状腺恶性结节各SWE参数均高于良性结节（P均<0.001）。C-TIRADS鉴别甲状腺良、恶性结节的AUC为0.736,敏感度为79.10%、特异度为68.00%、准确率为74.36%;E_max、E_mean、E_min及E_SD的AUC分别是0.816、0.752、0.664及0.705,以E_max的AUC最高;Eshell_max、Eshell_mean、Eshell_min及Eshell_SD的AUC分别为0.834、0.804、0.693及0.697,以Eshell_max的AUC最高,而与E_max差异无统计学意义（Z=1.044,P=0.297）。C-TIRADS+E_max和C-TIRADS+Eshell_max的AUC分别为0.835和0.843,其间差异无统计学意义（Z=0.574,P=0.566）但均高于C-TIRADS（AUC=0.736,Z=2.510、2.230,P均<0.05）,二者诊断特异度及准确率均高于C-TIRADS（P均<0.05）。结论 C-TIRADS联合结节内部及其周围腺体硬度可有效鉴别良、恶性甲状腺结节,显著提高C-TIRDAS诊断效能。     

对比干燥综合征干眼病与普通干眼病泪腺超声表现

目的 对比干燥综合征(SS)干眼病与普通干眼病泪腺超声表现。方法 对33例SS干眼病(66眼,SS干眼组)、30例普通干眼病患者(60眼,普通干眼组)及35名健康人(70眼,对照组)行泪腺二维超声、多普勒超声及超声弹性成像,比较3组泪腺长径、短径和基于泪腺回声的风湿病临床试验结果指标(OMERACT)评分,以及泪腺动脉收缩期峰值流速(PSV)、舒张末期流速(EDV)、阻力指数(RI)、血流评分和应变比(SR)及杨氏模量平均值(E_mean)的差异。结果 SS干眼组泪腺长径和短径均长于、OMERACT评分均高于普通干眼组及对照组(P均＜0.05);普通干眼组泪腺长径和短径与对照组差异均无统计学意义(P均＞0.05),OMERACT评分则高于对照组(P＜0.05)。SS干眼组泪腺动脉PSV、RI及血流评分均高于普通干眼组及对照组,其EDV高于普通干眼组而低于对照组(P均＜0.05);普通干眼组泪腺动脉PSV及EDV均低于对照组而RI高于对照组(P均＜0.05)。SS干眼组泪腺SR及E_mean均高于普通干眼组及对照组,普通干眼组泪腺SR及E_mean高于对照组(P均＜0.05)。结论 SS干眼病与普通干眼病泪腺超声表现有所差异,有助于诊断和鉴别诊断。     

xSPECT Quant联合唾液腺显像评估分化型甲状腺癌甲状腺全切术后131I治疗前患者腮腺和残留甲状腺功能

目的 观察xSPECT Quant联合唾液腺显像(SGS)评估分化型甲状腺癌(DTC)甲状腺全切术后¹³¹I治疗前患者腮腺和残留甲状腺功能的价值。方法 前瞻性纳入60例拟接受¹³¹I治疗的甲状腺全切术后DTC患者,于¹³¹I治疗前日行头颈部xSPECT Quant断层融合显像及SGS,计算左、右侧及整体腮腺摄取指数(UI)、最大排泌率(MSR)、最大标准摄取值(SUV_max)、平均标准摄取值(SUV_mean)及残留甲状腺SUV_max、SUV_mean;根据xSPECT Quant断层图像中颈部存在残留甲状腺组织与否将患者分为残留组(n=32)和无残留组(n=28),依照参数分析法评估腮腺功能结果而分为功能正常组(n=43)和功能受损组(n=17);观察xSPECT Quant联合SGS评估腮腺和残留甲状腺功能的价值。结果 功能正常组与功能受损组左、右侧腮腺UI及SUV_mean差异均有统计学意义(P均＜0.05),腮腺整体UI与SUV_max,MSR与SUV_max、SUV_mean均呈低度相关(r=0.356、0.327、0.380,P均＜0.01),而UI与SUV_mean呈中度相关(r=0.531,P＜0.01)。残留组与无残留组24 h摄碘率差异有统计学意义(P＜0.05),且残留甲状腺SUV_max与24 h摄碘率呈低度相关(r=0.381,P＜0.05)。结论 xSPECT Quant联合SGS对评估DTC甲状腺全切术后¹³¹I治疗前患者腮腺和残留甲状腺功能具有一定价值,可初步筛查腮腺功能障碍并评估残留甲状腺的摄碘能力。     

实时剪切波弹性成像技术鉴别诊断肺良恶性周围型肿块

目的 探讨实时剪切波弹性成像（SWE）技术鉴别诊断肺部良恶性周围型肿块的价值。方法 采用SWE技术测量112例周围型肺部肿块患者的杨氏模量值,分析良恶性组及恶性病变不同病理类型亚组间的杨氏模量最大值（E_max）和平均值（E_mean）的差异。以病理结果为金标准,绘制ROC曲线获得其鉴别诊断良恶性肿块的效能。结果 周围型肺部肿块良恶性组间E_max及E_mean差异均有统计学意义（t=－2.78、－3.28,P均<0.01）,恶性组不同病理类型亚组间E_max及E_mean差异均无统计学意义（P均>0.05）。E_max和E_mean鉴别诊断肺良恶性肿块的阈值分别为10.35 kPa和5.85 kPa,AUC分别为0.74（P=0.003）、0.81（P=0.001）,敏感度、特异度、阳性预测值、阴性预测值分别为74.36%、72.22%、85.29%、57.52%和81.58%、80.78%、89.57%和67.67%。结论 SWE技术可用于评估周围型肺部肿块的弹性特征,为鉴别肺部良恶性周围型肿块提供了重要的影像学手段。     

不同ROI和弹性模量值对剪切波弹性成像诊断颈部良恶性淋巴结效能的影响

目的 探讨剪切波弹性成像（SWE）中,不同ROI和弹性模量值的选择对诊断颈部良恶性淋巴结的影响。方法 选取经穿刺活检或手术病理证实的143枚颈部肿大淋巴结,于术前行常规超声及SWE检查,设置3种不同ROI：直径2 mm的小圆形ROI（ROI-1）、不超出淋巴结边缘的最大切圆ROI（ROI-2）及手动勾勒整个淋巴结边缘的ROI（ROI-3）,均包含淋巴结的最硬区域,分别测量最大弹性值（E_max）、平均弹性值（E_mean）和弹性标准差（SD）并进行对比分析,构建ROC曲线获得各弹性值诊断颈部良恶性淋巴结的AUC,并进行比较。结果 恶性淋巴结3种ROI测量的E_max、E_mean和SD均高于良性淋巴结（P均<0.001）。3种ROI测量的良性淋巴结、恶性淋巴结及总淋巴结E_max总体差异无统计学意义（P均>0.05）,E_mean和SD总体差异均有统计学意义（P均<0.001）。ROC曲线结果显示,3种ROI测量的E_max诊断良恶性淋巴结的AUC差异均无统计学意义（P均>0.05）,ROI-1测量的E_mean的AUC高于ROI-2和ROI-3（P均<0.05）,SD低于ROI-2和ROI-3（P均<0.05）,而后两者比较差异无统计学意义（P均>0.05）。结论 SWE能够对颈部良恶性淋巴结进行鉴别,但其诊断效能随ROI及弹性模量值的选择而不同。选择较小ROI时,建议使用E_max和E_mean;选择较大ROI时,建议使用E_max和SD。     

PET/CT超级迭代技术诊断孤立性肺结节

目的 观察PET/CT超级迭代技术诊断良、恶性孤立性肺结节(SPN)、评估肿瘤侵袭程度及Ki-67表达的价值。方法 纳入53例经病理确诊并接受PET/CT检查的恶性SPN患者(恶性组)及53例良性SPN患者(良性组),采用超级迭代技术获取病灶最大标准摄取值(SUV_max)及平均标准摄取值(SUV_mean),以受试者工作特征曲线分析PET/CT参数判断良、恶性SPN的价值;比较不同侵袭程度及表达Ki-67情况的恶性SPN PET/CT参数差异,以Spearman相关性分析评价PET/CT参数与恶性SPN侵袭程度及Ki-67表达的相关性。结果 PET/CT超级迭代技术显示恶性组SUV_max、SUV_mean均高于良性组(P均＜0.05)。以SUV_max、SUV_mean判断良恶性SPN的曲线下面积分别为0.738、0.847。随着肿瘤侵袭程度增加,恶性SPN的SUV_max、SUV_mean均呈升高趋势(P均＜0.001)。Ki-67阳性SPN的SUV_max、SUV_mean均高于阴性者(P均＜0.05)。恶性SPN的SUV_max、SUV_mean与其侵袭程度、Ki-67表达均呈正相关(r=0.340~0.452,P均＜0.001)。结论 PET/CT超级迭代技术所获SUV_max、SUV_mean与恶性SPN侵袭程度及Ki-67表达具有一定相关性,可用于判断良、恶性SPN。     

剪切波弹性成像观察糖尿病周围神经病变患者胫神经

目的 探讨剪切波弹性成像（SWE）技术评价糖尿病周围神经病变（DPN）患者胫神经改变的价值。方法 选取30例临床诊断为2型糖尿病伴周围神经病变患者、30例2型糖尿病不伴周围神经病变患者及30名健康志愿者（对照组），应用二维超声及SWE测量并比较3组双下肢远端胫神经横截面积（CSA）及弹性模量均值（E_mean）。分析2型糖尿病患者胫神经CSA、运动神经传导速度（MCV）及DPN （+）组患者疼痛视觉模拟量表（VAS）评分与E_mean的相关性。绘制E_mean诊断DPN的ROC曲线。结果 3组间胫神经CSA、E_mean总体差异有统计学意义（P均<0.01），两两比较差异均有统计学意义（P均<0.01）。2型糖尿病患者胫神经CSA与E_mean呈正相关（r=0.64，P<0.05），胫神经MCV与E_mean呈负相关（r=－0.70，P<0.05）；DPN （+）组患者VAS与E_mean呈正相关（r=0.82，P<0.05）。胫神经E_mean诊断2型糖尿病患者DPN最佳截断值为47.4 kPa，敏感度为94.2%，特异度为80.0%。结论 2型糖尿病患者胫神经硬度增加；弹性模量值可作为诊断DPN的参考指标。     

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.     

Dissociable correlates of two classes of retrieval processing in prefrontal cortex

Although substantial evidence suggests that the prefrontal cortex (PFC) implements processes that are critical for accurate episodic memory judgments, the specific roles of different PFC subregions remain unclear. Here, we used event-related functional magnetic resonance imaging to distinguish between prefrontal activity related to operations that (1) influence processing of retrieval cues based on current task demands, or (2) are involved in monitoring the outputs of retrieval. Fourteen participants studied auditory words spoken by a male or female speaker and completed memory tests in which the stimuli were unstudied foil words and studied words spoken by either the same speaker at study, or the alternate speaker. On "general" test trials, participants were to determine whether each word was studied, regardless of the voice of the speaker, whereas on "specific" test trials, participants were to additionally distinguish between studied words that were spoken in the same voice or a different voice at study. Thus, on specific test trials, participants were explicitly required to attend to voice information in order to evaluate each test item. Anterior (right BA 10), dorsolateral prefrontal (right BA 46), and inferior frontal (bilateral BA 47/12) regions were more active during specific than during general trials. Activation in anterior and dorsolateral PFC was enhanced during specific test trials even in response to unstudied items, suggesting that activation in these regions was related to the differential processing of retrieval cues in the two tasks. In contrast, differences between specific and general test trials in inferior frontal regions (bilateral BA 47/12) were seen only for studied items, suggesting a role for these regions in post-retrieval monitoring processes. Results from this study are consistent with the idea that different PFC subregions implement distinct, but complementary processes that collectively support accurate episodic memory judgments.     

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.     

Modified micro-superior percutaneously-assisted total hip: early experiences & case reports

Because of the extensile nature and familiarity of the standard posterior-lateral approach to the hip, a family of "micro-posterior" approaches has been developed. This family includes the Percutaneously-Assisted Total Hip (PATH) approach, the Supercapsular (SuperCap) approach and a newer hybrid approach, the Supercapsular Percutaneously-Assisted Total Hip (SuperPATH) approach. Such approaches should ideally provide a continuum for the surgeon: from a "micro" (external rotator sparing) posterior approach, to a "mini" (external rotator sacrificing) posterior approach, to a standard posterior approach. This could keep a surgeon within his comfort zone during the learning curve of the procedure, while leaving options for complicated reconstructions for the more practiced micro-posterior surgeons. This paper details one author's experiences utilizing this combined approach, as well as permutations of this entire micro-posterior family of approaches as applied to more complex hip reconstructions.     

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.