超声诊断左小腿滑膜肉瘤1例

患者女,19岁,因左小腿肿胀疼痛6个月,加重并发现包块3个月入院.查体见左小腿前外侧及后侧明显肿胀,皮肤不红,皮缘略高;可触及大小为10.0 cm×8.0 cm的实质性包块,边界不清,与周围组织粘连紧密,活动性差,质韧,压痛明显,无明显分叶及波动感;踝关节活动轻度受限.     

小腿腓肠肌外侧头肌内血管脂肪瘤超声表现一例

患者男,6岁,发现左小腿包块4年。查体:左小腿后部腓侧明显外凸,可触及一大小为10.0cm×10.0cm×6.0cm的皮下包块,质软,边界不清,活动尚可,表面皮肤正常,未见红肿,局部轻度压痛,左小腿活动无受限,小腿下段后外侧及足背、小趾外侧缘皮肤时有疼麻感。左膝关节及踝关节活动自如,右小腿未见明显异常。超声检查示:左侧小腿腓肠肌外侧头肌丝走行明显紊乱,其内可见大小为11.6cm×1.5cm×5.7cm略强回声团块,边界尚清,似有包膜,团块内可见迂     

胫后动脉穿支筋膜蒂皮瓣移植修复小腿皮肤软组织缺损

选择 2003-02/2007-02于福州总医院骨科应用胫后动脉穿支筋膜蒂皮瓣移植修复小腿皮肤软组织缺损的患者16例,在解剖学基础上,设计胫后动脉穿支筋膜蒂皮瓣,轴线在胫骨内侧髁后与内踝、跟腱间中点的连线,旋转点在最邻近创面、其蒂部在有胫后动脉穿支的轴线上.根据术前超声多普勒血流仪穿支探测,要求皮瓣、蒂部及穿支表面有良好的皮肤.顺行设计皮瓣修复小腿上段,逆行设计修复小腿中下段,其中小腿下段9例,小腿中段3例,小腿上段4例.皮肤软组织缺损范围为2.0 cm×1.5 cm～12.5 cm×7.5 cm,胫后动脉穿支筋膜蒂皮瓣最大面积为15.0 cm×10.0 cm,最小为4.0 cm×2.5 cm.观察其修复效果.术后皮瓣均成活.有2例远端部分皮肤坏死,但其皮下有肉芽生长,其中1例经换药愈合,1例用中厚皮植皮愈合.所有病例均随访半年以上,患肢正常步态行走,有痛觉.应用胫后动脉穿支筋膜蒂皮瓣移植修复小腿皮肤软组织缺损,供区在小腿内后侧,损伤后蒂部保存良好,切取便利,不损伤主要血管,血供可靠,成活率高,是修复小腿皮肤软组织缺损的首选术式之一.     

乳腺及下肢多发性肉芽肿误诊一例

【病例】女,25岁,已婚已育。因周期性月经前乳房疼痛并左乳包块3个月,两侧小腿多发性结节状无痛性包块1周来诊。病程中无发热、贫血、消瘦,否认结核病史,未服用避孕药物。查体:左乳皮肤轻度橘皮样变,左乳外下象限可触及6 cm×6 cm×4 cm包块,界限不清,表面尚光滑,轻度压痛,活动度小,与皮肤及皮下组织轻度粘连,胸肌无固定;左腋下可触及2枚增大淋巴结,活动,无压痛;右乳及右腋下未触及包块。双下肢膝以下尤其后侧触及多发性结节状包块,色青紫,不活动,与皮肤及皮下组织粘连,轻压痛。乳腺钼靶X线片示:双乳头无内陷,皮肤增厚,左乳下限密度增高,其…     

1例婴儿横纹肌样瘤易感综合征超声表现

<正>患儿男,1个月,监护人发现其左大腿后侧根部肿物1周;否认家族史。查体：左大腿后侧根部隆起,触及4 cm×3 cm×4 cm质硬肿物,活动度欠佳,边界不清;局部皮肤无明显异常。实验室检查：神经元特异性烯醇化酶66.68 ng/ml; 糖类抗原CA-153 11.14 ng/ml, 糖类抗原CA-125 5.57 ng/ml, 糖类抗原CA-199 14.32 ng/ml。     

膝关节巨大滑膜囊肿1例

患者女,50岁,因"发现左小腿后内侧肿物1个月、双下肢水肿6个月"就诊.既往类风湿关节炎病史10年,接受口服药物治疗.无重大外伤史.查体:左小腿后内侧可扪及包块,与皮肤及周围组织无明显粘连,无触痛和压痛.双侧足背动脉搏动正常.双膝关节正侧位X线片:双膝关节退行性改变,余未见明确异常.MRI:平扫于双小腿内后方软组织内可见多发不规则囊状长T2异常信号,最大者位于左小腿内侧肌群间(图1);增强扫描见左小腿巨大囊性病变约20.36 cm×4.56 cm×4.21 cm;右小腿囊性病变18.85 cm×3.45 cm×4.81 cm,囊壁明显强化,但厚薄欠均匀,囊内可见分隔,腘窝内见多个大小不一的环状强化病变(图2);双膝关节滑膜增厚及异常强化(图3),滑膜最厚处1.21 cm.     

左股下段后侧赘生性脂肪瘤一例

患者男,79岁.因发现左大腿后侧赘生性包块72年伴红肿热痛皮肤溃破十余天于2011年2月入院.患者6岁时发现大腿后侧长出一小赘生物,约花生米大小,缓慢生长,遂未作任何处治.近年来因包块长大后遂行中草药外敷治疗,敷后出现包块溃破并伴周围皮肤红肿热痛及行走困难来诊.入院查体:一般情况可,左股下段后侧腘窝上见长径约8 cm鸡蛋形有蒂的赘生性包块(图1),周围见中草药残渣,包块顶端溃破并形成直径约为3 cm的圆形溃疡,溃疡底见脂肪样组织外露,溃疡周围包括肿块的表皮完整,但包块及蒂周红肿热痛炎性症状明显,包块触之质软有弹性.外院及我院超声示:左腘窝上突出性包块,血管瘤可能.     

小腿软组织纤维肉瘤一例

男49岁,农民。三年前发现左小腿中段内侧一蚕豆大小硬结,不痛不痒未引起注意,一年前包块稍有增大,轻度压痛,曾在当地医院取活检诊为慢性炎症。活检后包块增大迅速,两个月后成倍增大,表面凹凸不平,溃烂,有腥臭分泌物流出。体查左小腿软组织肿块约20cm×15cm×9cm,中央凹陷约6cm×6cm,肿块与皮肤界线清楚,表面有奇臭分泌物及散在出血点,周围皮肤正常。化验检查,白细胞7.9×10~9/L,中性71％,淋巴29％,AKP17.5金氏单位。 X线片(附图)见小腿中下段巨大软组织肿块,约18cm×17cm×13cm,分叶状,密度高于周围软组织,未见钙化,肿块中部直径6cm大小透光区,如车轮状,胫腓骨内后侧骨皮质受压变薄,局部骨干略变细,未见骨膜反应及骨质破坏。左踝躁关节及跗骨明显骨质稀疏,尤     

高频彩色多普勒超声诊断肌疝一例

1病例介绍患者男,33岁。因"发现左小腿可复性包块20余年,加重伴酸痛1个月余"于2011年9月就诊,数天前有左小腿外伤史。检查:左侧膝关节外下方扪及一个大小约5 cm×3 cm的包块,边界不清,质软,轻压痛,无波动感及搏动。周围皮肤无红、肿、热,下蹲或小腿外翻时包块增大,平卧后消失。临床诊断:左小腿肌层肿瘤。高频彩色多普勒超     

肿瘤样色素沉着绒毛结节性滑膜炎

[病例]男,38岁.因左膝外下包块5年,左小腿前外侧包块3年、左腘窝包块1年入院.包块呈进行性生长,伴左小腿轻微胀痛.查体:左小腿周径明显增粗,腓骨小头前侧、小腿前外侧及后侧、胭窝及髌上囊部均发现包块,边缘不清,质硬,无波动感及压痛:膝关节滑膜增厚,浮髌征阳性,膝、踝、足运动及感觉正常.     

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.