正电子发射断层显像中感兴趣区选取及标准摄取值分界点的优化

目的探讨PET图像中勾画感兴趣区(ROI)的最佳方法及标准摄取值(SUV)最佳诊断分界点.方法以PETFDG 126例肺部肿瘤图像为例说明,由SUVmax的百分比(50%～100%)为等高线值勾画ROI,得各SUV均值;由受试者工作特性(ROC)曲线分析确定ROI最佳画法;由准确率最大值、Y0uden's指数最大值及敏感性与特异性交点确定分界点.结果①最优ROI:70%等高线所画ROI的SUV具有最大ROC曲线下面积.其3个典型SUV分界点值分别为:2.075、2.825、2.919.②3个典型分界点的准确率、Youden's指数和阳性概率比/阴性概率比均在70%等高线出现较大值.结论提出一套客观画取ROI、确定最佳等高线值、及最佳分界点的方法,可用于各种示踪剂PET图像中的各种定量指标.     

影像学诊断评价中的参数法ROC曲线分析

目的 探讨采用ROC曲线参数分析法对影像学分类诊断结果进行评价的价值,并介绍ROC曲线参数分析软件ROCKIT。 方法 2名医师分别对60幅肺部CT图像进行肺结节良恶性5级分类诊断。分别用ROCKIT软件和SPSS软件对他们的诊断结果进行参数法和非参数法ROC曲线分析。 结果 对2名医师的诊断结果利用ROCKIT进行参数法ROC分析时,ROC曲线下面积分别为0.940±0.039和0.785±0.075(Z=2.056, P=0.040),利用SPSS进行非参数估计时结果分别为0.913±0.042和0.771±0.075。通过ROCKIT软件可绘制光滑的拟合ROC曲线,SPSS软件可绘制不光滑的经验ROC曲线。 结论 当有序分类资料样本量适中时,参数估计一般均无偏倚,非参数估计的结果可能小于真实值;ROCKIT软件是双正态参数法ROC曲线分析的有力工具。     

超声造影对桥本甲状腺炎背景下良恶性结节鉴别诊断价值研究

目的 评价超声造影对桥本甲状腺炎背景下良恶性结节的鉴别诊断价值.方法 对93例经手术病理证实的桥本甲状腺炎背景下的单发性结节行超声造影检查,应用TomTec软件绘制超声造影时间-强度曲线,比较良恶性结节超声造影参数的差异,并应用ROC曲线进行分析.结果 93例桥本甲状腺炎背景下的单发性结节中,良性56个,恶性37个.①良性结节注射造影剂后多同时于周围腺体增强,廓清时间及增强程度亦与周围腺体基本一致.恶性结节始增时间多晚于周边甲状腺组织,廓清时间早于周边甲状腺,增强程度低于周边甲状腺组织.②恶性结节与良性结节造影参数相比,平均渡越时间缩短,峰值强度降低,差异具有统计学意义(P＞0.05);始增时间、达峰时间差异均无统计学意义(P＜0.05).③通过ROC曲线确定良恶性结节的临界诊断点分别为平均渡越时间21.70 s、峰值强度86.41％.平均渡越时间、峰值强度、两者联合诊断桥本甲状腺炎伴恶性结节的敏感性分别为86.5％、83.8％、97.3％,特异性分别为69.6％、75.0％、48.2％.结论 超声造影对桥本甲状腺炎背景下良恶性结节的鉴别诊断有一定价值.     

B超参数法预测巨大胎儿的准确性评估

目的:评测常用的几种B超参数法公式用于预测巨大胎儿体重的准确性.方法:选择2002-2007年在我院出生的巨大胎儿584例,产前B超测量,以9种方法分别估算胎儿体重,筛选巨大胎儿,并与其实际出生体重相比较,计算符合率,对几种方法预测巨大胎儿体重的准确性进行比较.结果:仅3种方法的预测准确率超过50%,其中腹围法②的预测符合率最高(95.0%),其次为简易法(71.2%),张方林法②(65.O%),而双顶径法②、股骨长径法和张方林法①符合率最低.预测符合率最高的3种方法中,腹围法②和简易法的假阳性率较高,均＞20%,而张方林法②的假阳性率仅为6.7%.腹围法①、腹围法②、张方林法②等3种方法用于预测巨大胎儿与正常体重胎儿的偏差相近,而其他几种方法分别用于预测正常体重及巨大胎儿的偏差距离较大.其中腹围法①和张方林法②的预测偏差最小,精确性最高.结论:张方林法②是较为理想的应用B超测量参数预测巨大胎儿体重的公式,其次为腹围法②,在条件不允许的情况下可考虑采用简易法预估,但该方法假阳性较高.     

女性冠心病患病风险评价数学模型的建立与验证

目的尝试建立综合多个生理生化指标的评价数学模型,提高女性冠心病（CHD）的诊断效能。方法通过相关性及ROC曲线分析,明确与女性CHD密切关联的指标,尝试建立评价数学模型,通过ROC曲线确定诊断效能,并在患者中进行重复性验证。结果①建模对照组与建模病例组除低密度脂蛋白胆固醇（LDL C）、载脂蛋白B（APOB）和脂蛋白a［Lp（a）］外,其余各指标差异均有统计学意义;②年龄、甘油三酯（TG）、同型半胱氨酸（Hcy）、γ 谷氨酰转移酶（GGT）、高密度脂蛋白胆固醇（HDL C）和载脂蛋白A（APOA）与CHD具有很强的相关性;③年龄、Hcy、GGT、HDL C、APOA 5个指标ROC曲线下面积大于0.75;④建立了6个数学评价模型,其中模型6的ROC曲线下面积达到了0.955;⑤数学模型能在验证人群中被重复。结论通过建立包含了多个指标的数学评价模型,能显著提升女性判断是否患CHD的诊断效能。     

三维能量多普勒血管成像及其定量参数在甲状腺结节诊断中的应用

目的探讨三维能量多普勒血管成像(3D-CPA)及其定量参数在甲状腺结节诊断中的应用。方法应用内置VOCAL分析软件对85个结节进行观察,获得灰阶直方图及定量参数:平均灰阶(MG),血流血管指数(VFI),平均能量(MP),血管指数(R),绘制受试者操作特性(ROC)曲线,确定适于诊断的临界值,分析两种方法的敏感度及特异度,并用z检验,比较两种方法在甲状腺良恶性结节诊断中的差异。结果甲状腺良恶性结节在3D-CPA及其参数的差异有统计学意义(P0.05);以MG、MP及两者综合鉴别结节良恶性,ROC曲线下面积分别为0.845、0.725、0.848,两者综合诊断价值最高。结论 3D-CPA定量分析MG和MP在鉴别低回声实性结节良恶性的差别有统计学意义,可提高诊断甲状腺结节的准确度。     

声脉冲辐射力成像技术3种弹性参数单独及联合诊断在鉴别乳腺肿块中的应用

目的:评价声脉冲辐射力成像(acoustic radiation force impulse imaging,ARFI)技术中3个主要诊断参数面积比(area ratio,AR)、应变率(strain ratio,SR)和剪切波速度(shear wave velocity,SWV)单独诊断及联合诊断在临床鉴别乳腺肿块良恶性中的意义。方法:对113例患者132个实性乳腺肿块的ARFI特征进行分析,回归分析3个诊断指标,拟合出联合诊断方法预测概率的新变量PRE-1。以病理结果为金标准,用受试者工作特征(receiver operating characteristic,ROC)曲线对3个参数单独诊断及联合诊断的效能进行评估。结果:132个乳腺肿块的病理诊断结果显示,良性肿块69个,恶性肿块63个。良性病灶的AR、SR、SWV值分别为2.82±1.03、1.26±0.40、(3.10±0.99)m/s,均低于恶性组的4.32±1.58、2.09±0.91、(5.05±1.65)m/s,差异有统计学意义(P0.05)。AR、SR、SWV值ROC曲线的曲线下面积分别为0.812、0.807和0.843,3个参数联合诊断ROC曲线的曲线下面积为0.954。结论:3个参数联合诊断乳腺肿块良恶性的效能最好,从而为临床诊断乳腺肿块良恶性提供了更多的参考方法。     

PET/CT对非小细胞肺癌患者胸腔积液性质的鉴别诊断价值

目的:探讨~(18)F-FDG PET/CT鉴别初诊非小细胞肺癌(non-small cell lung cancer,NSCLC)患者中胸腔积液性质的临床价值。方法:回顾性分析合并胸腔积液的病理学确诊的初诊NSCLC患者,胸腔积液的良恶性诊断以胸腔穿刺及胸膜活检为标准。分别以胸膜标准化摄取值(standard uptake value,SUV)大于2.5、胸膜SUV大于动脉SUV为PET/CT诊断恶性胸腔积液的标准,计算其灵敏度、特异度、阳性预测值、阴性预测值和准确率。结果:共纳入46例患者,其中恶性胸腔积液患者39例。以胸膜SUV2.5为诊断标准,灵敏度、特异度、阳性预测值、阴性预测值和准确率分别为76.9%、100.0%、100.0%、43.8%和80.4%;以胸膜SUV动脉SUV为标准,分别为89.7%、100.0%、100.0%、63.6%和91.3%;二者受试者工作特征(receiver operating characteristic,ROC)曲线的曲线下面积分别为0.961和0.976。结论:18F-FDG PET/CT对初诊NSCLC患者中胸腔积液的良恶性鉴别具有较高的临床价值。以胸膜核素浓聚程度高于纵隔为标准,可提高其诊断效能。     

乳腺X线片直方图分析鉴别乳腺BI-RADS 3~5类良恶性肿块

目的 探讨基于乳腺X线片直方图分析鉴别乳腺影像报告和数据系统（BI-RADS）3~5类良恶性肿块的价值。方法 回顾性分析经手术病理证实的114例BI-RADS 3~5类乳腺肿块患者，包括61例良性病变（良性组，68个肿块）和53例恶性病变（恶性组，55个肿块）。分析2组图像的直方图，比较组间直方图参数差异，包括平均值、方差、偏斜度、峰度及第1、10、50、90、99百分位数；分别绘制差异有统计学意义的参数鉴别诊断BI-RADS 3~5类乳腺良恶性肿块的受试者工作特征（ROC）曲线，计算曲线下面积（AUC），分析其诊断效能。结果 2组平均值、方差及第1、10、50、90、99百分位数差异均有统计学意义（t=－5.49、－3.14、－3.01、－3.97、－5.49、－5.84、－6.45，P均<0.05）。ROC曲线分析结果显示第99百分位数诊断效能最佳，其AUC为0.81，最佳阈值为0.50时，特异度为88.20%，敏感度为61.80%。结论 乳腺X线片直方图分析可用于鉴别诊断乳腺BI-RADS 3~5类良恶性肿块。     

甲状腺实性结节的超声弹性成像定量参数分析

目的 探讨实时超声弹性成像定量参数分析在诊断甲状腺实性结节性质中的价值.方法分析112例(157个病灶)甲状腺实性结节患者的超声弹性图像,计算病灶与周围组织的应变率比值及其平均值,并通过受试者操作特点(ROC)曲线分析取得最合适的诊断甲状腺良恶性病灶临界值.所有病例均经手术及病理证实.结果 157个病灶中良性结节79个,应变率比值平均值为1.93±1.29;恶性病灶78个,应变率比值平均值为5.07±4.21,两者间差异有统计学意义(t=6.319,P<0.01).根据良恶性结节的应变率比值绘制ROC曲线,曲线下面积为0.861±0.031.通过ROC 曲线分析得出良恶性结节的弹性应变率比值临界点为2.96,其敏感度、特异度和准确性分别为73.1%(57/78)、88.6%(70/79)和80.9%(127/157).结论 实时超声弹性成像定量参数分析为甲状腺实性结节的良恶性鉴别诊断提供了一种新方法.     

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.     

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.     

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.