异位性错构瘤性胸腺瘤的临床病理观察

目的 结合文献探讨异位性错构瘤性胸腺瘤（EHT）的临床病理特征。方法 对患者的左锁骨上区肿物组织标本进行HE染色，并采用免疫组化LSAB法检测瘤细胞的CK、EMA、vimentin、SMA、myoglobin、desmin、S-100、CD99和CD34的表达情况。结果 肿瘤有完整包膜，由梭形细胞、脂肪细胞灶和上皮细胞巢构成。上皮细胞呈网格状，实体性或腺管样排列；梭形细胞是肿瘤的主要成分，呈编织状、车辐状分布，细胞具有较长的梭形细胞核及较空亮的胞质，少数梭形细胞呈肌细胞样具有嗜酸性胞质，类似纤维细胞或平滑肌细胞；脂肪细胞分化良好，呈灶状分布于梭形细胞和上皮细胞岛之间。梭形细胞和上皮细胞均无明显异型性，未见核分裂象。免疫组化示梭形细胞和上皮细胞CK弥漫强（＋），大部分梭形细胞SMA（＋）、myoglobin弱（＋），少数梭形细胞vimentin（＋），上皮细胞vimentin、desmin、S-100、CD34和CD99（-）。结论 异位性错构瘤性胸腺瘤是非常罕见的良性肿瘤，应与双向性滑膜肉瘤、恶性神经鞘瘤、皮肤附件或涎腺起源的混合瘤、胸腺脂肪瘤以及梭形细胞胸腺瘤相鉴别。     

伴有多向分化成分的食管息肉样癌3例并文献复习

目的 探讨伴神经内分泌癌、腺癌的食管息肉样癌的病理特点和来源。方法 应用常规病理，免疫组化研究1例伴神经内分泌癌分化和2例伴腺癌分化的食管息肉样癌并复习相关文献。结果 肿瘤大体呈息肉状。镜检1例见大量巢团状排列的小圆形细胞，神经内分泌癌成分位于肉瘤样癌之间，神经内分泌癌成分chromogranin、NSE（ ），鳞状上皮黏膜间可见角化的鳞状细胞癌；2例伴腺癌成分的食管息肉样癌，局部呈腺管状排列，鳞状细胞癌和腺癌CK（ ），肉瘤样成分见多形性梭形细胞，核分裂及异型明显，α-SMA（ ），CK（-）。结论 伴神经内分泌癌，腺癌的食管息肉样癌突起见，它所含的多向分化成分可能起源于多能干细胞的肿瘤化生。     

肾脏黏液样小管状和梭形细胞癌的临床病理讨论

目的探讨肾脏黏液样小管状和梭形细胞癌的临床病理学特征、免疫表型及鉴别诊断。方法对1例肾脏黏液样小管状和梭形细胞癌进行光镜观察及免疫组化标记并复习相关文献。结果本例光学显微镜下见肿瘤无包膜,但与肾组织之间存在纤维组织分隔,瘤细胞呈大小不等的巢片状,巢内细胞排列成管状、梁状、索状和实性,管状结构互相连接或沟通,漂浮于黏液样基质中,部分小管管腔塌陷或不明显,逐渐移行为梭形细胞,肿瘤细胞胞质嗜酸性,部分胞质透明,间质富于淋巴细胞,浆细胞部分区域可见出血钙化。免疫表型:小管状和梭形细胞显示CK阳性,Viminten阳性,CD34、CD56、AFP均阴性。病理诊断为肾脏黏液样小管状和梭形细胞癌。结论肾脏黏液样小管状和梭形细胞癌是一类罕见的低度恶性肾上皮性肿瘤,预后较好,需注意与集合管癌、乳头状腺癌、透明细胞癌、后肾腺瘤等多种肾脏肿瘤进行鉴别诊断。     

原发性肺动脉内膜肉瘤的临床病理观察

目的 探讨内膜肉瘤（IS）的临床病理学特点、免疫表型、超微结构以及预后等。方法 结合相关文献，对1例原发于肺动脉的IS的临床资料、病理切片、免疫组化标记、电镜检测结果进行分析。结果 镜下见肿瘤由丰富的梭形细胞组成，呈束状、编织状和不规则状，细胞异型性明显，局部呈上皮样，瘤巨细胞及核分裂象多见。免疫组化标记示肿瘤细胞vimentin和osteopotin弥漫强（＋），SMA弥漫（＋），CD34及myogenin均灶性区域（＋）；而MyoD1、myosin、myoglobin、S-100、Des、CK、EMA、CD68以及CD117均（-）。电镜示某些梭形细胞的胞质内可见密体、微肌丝；某些细胞的细胞核周围见大量粗面内质网。结论 IS是一种非常罕见的发生于大动脉壁的低分化恶性间叶肿瘤，一般具有纤维母细胞或肌纤维母细胞分化特征，多与染色体基因扩增或获得有关，预后差。     

原发性心横纹肌肉瘤临床病理观察

目的探讨心横纹肌肉瘤的临床病理学特征及诊断、鉴别诊断要点。方法对1例心横纹肌肉瘤进行临床病理分析及免疫组化研究,并复习相关文献。结果镜下见瘤细胞弥漫生长,疏密不等,部分区域有黏液样基质,部分区域为红染基质。瘤细胞大部分为大圆形、短梭形,核深染,不均匀成块状。部分细胞分化较好,核分裂象易见,可见少量瘤巨细胞。肿瘤组织结节样突向心肌内。免疫组化：PAS和CD68（＋）、desmin、vimentin、CD68和CD117（＋＋＋）,MyoD1（＋＋）,CK、PCNA68%（＋）,myoglobin、S-100、p53和Ki-67（-）。结论原发性心横纹肌肉瘤罕见,恶性程度高、侵袭性强,组织形态学及临床表现有较大差异,免疫组化检测能增加诊断的正确性。     

肾黏液性管状梭形细胞癌的临床病理特点

目的 探讨肾黏液性管状梭形细胞癌的临床病理特点。方法 应用常规病理、免疫组化和电镜观察2例肾黏液性管状梭形细胞癌并复习相关文献。结果 2例肿瘤均为男性，年龄37岁和82岁。肿瘤界限清楚，切面灰白色。镜下见嗜酸性胞质的低立方细胞单层排列，呈长管状或交织吻合的细管状，有的呈巢状；部分肿瘤细胞梭形，排列成束状，类似于平滑肌瘤。肿瘤间质黏液样，胞核居中，有皱折，核分裂罕见。瘤细胞间可见淋巴浆细胞及泡沫细胞。免疫组化示肿瘤细胞vimentin、EMA和AE1／AE3（＋），34β3E12、SMA、S-100、HMB45、CD15、CD20、UEA-1、CK7和CAM5．2（-）。电镜示管腔内可见短的微绒毛，有连接复合体。结论 肾黏液性管状梭形细胞癌是低度恶性的肾肿瘤，可能来源于远端肾单位。     

膀胱平滑肌肉瘤3例报告并文献复习

目的探讨膀胱平滑肌肉瘤的临床病理和诊治方法。方法患者3例,肉眼血尿,膀胱镜检见肿瘤分别发生于膀胱左侧壁、左前壁和右后壁,直径2.0～3.5cm,以菜花样和乳头样为主,基底较宽,瘤体表面光滑。结果 3例均行全膀胱切除术,病理表现为上皮下间质富于黏液,黏液中可见散在或束状分布的细长梭形瘤细胞,其胞质淡染,核呈长梭形,有轻度异型,核分裂象易见。免疫组化SMA（＋）3例、MSA（＋）3例、Des（＋）2例、S-100（-）2例、CD34（-）3例,均诊断为膀胱低级别平滑肌肉瘤。随访6个月～8年,1例术后2.5年死亡,2例存活。结论膀胱平滑肌肉瘤临床罕见,确诊依赖病理及免疫组化检查,应与平滑肌瘤、横纹肌肉瘤、癌肉瘤、炎性肌纤维母细胞瘤等鉴别,治疗以手术为主,需根据肿瘤分级、分期决定手术方案及术后是否需行辅助治疗。     

炎症性肌纤维母细胞肿瘤4例临床病理分析

目的 探讨特殊类型炎症性肌纤维母细胞肿瘤（IMFT）的临床病理特点和鉴别诊断。方法 分析4例特殊类型IMFT的临床病理和超微结构并进行免疫组化CK、SMA、结蛋白、CD31、CD34、S-100和ALK等检测。结果 4例IMFT中男性1例，女性3例，年龄14～65岁；肿块位于膀胱、大腿、足趾及髌骨，1例为多灶性。肿瘤无包膜，肿瘤细胞梭形，呈束状、编织状排列，细胞质丰富，背景为大量炎症细胞；其中3例出现片状坏死和出血，1例出现肿瘤血管内凸人，1例细胞异型较明显，核分裂象5个／10HPF。肿瘤细胞vimentin和SMA均（＋），2例CK（＋），而CD31、CD34、S-100和ALK均（-）。电镜示梭形细胞有肌丝及致密体、吞饮小泡及不完整的基膜。结论 炎症性肌纤维母细胞肿瘤是由梭形细胞和炎症细胞组成的肿瘤，需与其他梭形细胞肌纤维母细胞肉瘤鉴别。     

肾孤立性纤维瘤临床病理观察

目的探讨肾孤立性纤维瘤的临床病理特征、诊断和鉴别诊断，提高对该肿瘤的诊断水平。方法对1例肾孤立性纤维瘤进行光镜、免疫组化观察，并结合文献讨论。结果患者女性，47岁。临床、放射学诊断为肾盂癌。肿瘤边界清楚，切面灰白色。镜下梭形细胞呈束状、旋涡状或不规则状排列，部分与胶原纤维混杂，部分呈血管外皮瘤样结构。细胞无明显异型，核分裂象偶见。免疫组化示肿瘤细胞vimentin、CD34和皿199（＋），bel-2部分（＋），desmin、SMA、MAS、HMB45、carponin、S-100蛋白、CD117、CD31、FVⅢ、CK（AE1/AE3）、ENA、Ki-67和p53均（-）。结论肾孤立性纤维瘤是一种非常罕见的肿瘤，诊断主要依靠病理形态学及免疫组化，并应与肾的其他梭形细胞肿瘤鉴别。     

淋巴结指突状树突细胞肉瘤临床病理观察

目的探讨淋巴结原发性指突状树突细胞肉瘤的临床病理特点及鉴别诊断,提高对该肿瘤的诊断水平。方法对2例指突细胞肉瘤进行组织病理学、免疫组化及电镜观察。结果2例肿瘤均位于颈部淋巴结,光镜检查肿瘤组织呈席纹状、旋涡状或杂乱排列,瘤细胞卵圆形、梭形,胞质少,核卵圆形或短梭形,染色质细,少数有核仁,分裂象多见。瘤细胞S-100、CD68及vimentin( ),CD21、CD34、CK、CD45、SMA及HMB45均(-)。电镜下瘤细胞胞质有大量长指状突起,无桥粒连接及Birbeck颗粒。结论指突状树突细胞肉瘤是一种罕见的恶性肿瘤,预后差。诊断主要依靠电镜及免疫组化,并应与滤泡树突细胞肉瘤、朗格汉斯细胞肉瘤、恶性纤维组织细胞瘤、黑色素瘤、梭形细胞癌及其他肉瘤鉴别。     

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.