胶质瘤的CT灌注成像研究

目的:探讨CT灌注成像对胶质瘤术前分级的价值.方法:30例胶质瘤患者,低级别组11例,高级别组19例.在常规CT扫描的基础上行CT灌注成像检查.分析灌注图像.测量肿瘤实质部分的脑血流量(CBF)、脑血容量(CBV)、对比剂平均通过时间(MTT)及表面通透性(PS)的绝对值和相对值,并对两组进行比较.结果:低级别胶质瘤的r CBF、r CBV、r MTT、r PS均值分别为1.41±0.16、2.31±0.28、1.69±0.83、6.67±2.28;高级别胶质瘤的r CBF、r CBV、r MTT、r PS均值分别为4.96±2.17、4.69±1.65、1.29±0.55、19.19±8.65.两组r CBF、r CBV、r PS间差异具有显著意义.结论:CT灌注成像对胶质瘤术前分级具有临床实用价值.     

CT灌注成像对高血压性脑出血患者亚急性期血肿量的评估价值

目的探讨CT灌注成像参数对高血压性脑出血(hypertensive cerebral hemorrhage,HCH)患者亚急性期血肿量的相关性。方法 HCH亚急性期患者100例,均行CT灌注成像检测血肿区及对称健侧区血流量、平均通过时间、血容量、表面通透性等灌注参数,并依据血肿量分为低量组(5～30mL)40例和中量组(31～60mL)60例,比较2组CT灌注参数;采用Pearson相关性分析CT灌注参数与血肿量的关系。结果 HCH亚急性期患者血肿区血流量[(9.62±1.58)mL/(min·100g)]、血容量[(1.06±0.12)L/g]明显低于对称健侧区[(26.34±3.12)mL/(min·100g)、(1.88±0.20)L/g],平均通过时间[(11.27±1.24)s]、表面通透性[(2.14±0.22)mL/(min·100g)]明显高于对称健侧区[(5.42±0.56)s、(1.19±0.14)mL/(min·100g)](P0.05);中量组血肿区血流量[(8.60±0.94)mL/(min·100g)]、血容量[(0.86±0.10)L/g]明显低于低量组[(11.14±1.26)mL/(min·100g)、(1.35±0.16)L/g],血肿区平均通过时间[(12.26±1.38)s]、表面通透性[(2.33±0.26)mL/(min·100g)]明显高于低量组[(9.78±1.04)s、(1.85±0.20)mL/(min·100g)](P0.05);血流量、血容量与血肿量呈负相关(r=-0.821,P0.001;r=-0.836,P0.001),平均通过时间、表面通透性与血肿量呈正相关(r=0.811,P0.001;r=0.842,P0.001)。结论 CT灌注成像中血流量、血容量、平均通过时间、表面通透性与HCH亚急性期患者血肿量有关,可作为评估患者病情的重要指标。     

CT灌注成像评价急性自发性高血压脑出血患者的近期预后

目的 应用CT灌注成像(CTP),对急性自发性高血压出血性脑卒中(shICH)血肿周围脑血流动力学变化进行定量测量,评价脑血肿周围组织灌注参数改变与近期预后的相关性.方法 对26例临床及CT确诊的幕上shICH患者行CTP检查,自发病到灌注扫描的时间为8～19 h.以血肿最大层面为参照,测量血肿周围1 cm内及对侧镜像区脑血流量(CBF)、脑血容量(CBV)、平均通过时间(MTT),获得相对灌注参数值rCBF、rCBV、rMTT(患侧/健侧).电话随访患者脑出血后1个月生活表现,并记录日常生活活动能力量表(BI)分值.结果 shlCH血肿周围带CBV值为(1.61±1.53)ml/100 g、CBF值为(16.48±12.58)ml/(100 g·min),明显低于对侧镜像区(Z=-2.603、-4.178,P＜均0.05);MTT值为(9.12±2.57)s,较对侧镜像区明显延长(t=4.747,P＜0.05).血肿周围CBV、CBF值与BI相关(Z=-3.40、-2.98,P均＜0.01),参数MTT、rCBF、rCBV、rMTT与近期预后无关(P＞0.05);ROC曲线下面积分别为0.897、0.848,且CBV界限值为1.24 ml/100 g时,敏感度66.67％,特异度为100％;CBF界限值为8.44 ml/(100 g·min)时,敏感度100％,特异度为72.70％.结论 CTP可预测shICH血肿患者近期预后,在一定范围内,血肿周围CBV、CBF值越大,提示预后越差.     

多层螺旋CT灌注对脑胶质瘤分级的初步研究

目的:探讨CT灌注在胶质瘤术前分级中的作用。方法:19例经手术病理证实的脑胶质瘤病例术前接受CT灌注检查。根据病理,将病例分为低级别(n=9)和高级别(n=10)两组进行分析。获得肿瘤血流灌注的时间-密度曲线及灌注参数并进行相关性统计学分析。结果:低、高级别胶质瘤的脑血容量(CBV)、血管表面通透性(PS)均数±标准差分别为4.00±2.30、8.30±6.44、0.42±0.26和13.65±6.21,组间差异有统计学意义(P<0.05)。结论:脑CT灌注测量可以反映不同级别胶质瘤的血流灌注状况,从而为胶质瘤术前分级提供有价值的信息。     

多参数磁共振成像在脑胶质瘤中的应用研究

目的探讨多参数磁共振成像(MRI)在脑胶质瘤中的临床应用价值。方法 80例脑胶质瘤患者,均进行颅脑MRI平扫、弥散加权成像(DWI)、磁共振灌注成像(PWI)、定量动态对比加强磁共振(DCE-MRI)、多体素共振波谱(MRS)、扩散张量成像(DTI)。按照不同恶化情况分为低级别组(n=36)及高级别组(n=44),①统计两组各向异性分数(FA)、平均扩散系数(DCavg)、表观扩散系数(ADC)、胆碱(Cho)/N-乙酰天门冬氨酸(NAA)及胆碱(Cho)/肌酸(Cr);②统计两组渗透性参数(K~(trans))、血液回流常数(k_(ep))、血浆容积(v_p)、脑血流量(CBF)、脑血容量(CBV)及平均通过时间(MTT);③统计两组患者肿瘤实质部分相对脑血容量(rCBVt)、相对脑血流(rCBFt),肿瘤周围水肿部分rCBVe、rCBFe;(4)统计上述指标诊断阈值及多种参数MRI联合诊断效能。结果①高级别组Cho/NAA、Cho/Cr水平高于低级别组,ADC水平低于低级别组(P0. 05),ADC诊断阈值为1. 02×10~(-3)mm~2/s,ROC下面积0. 905; Cho/NAA诊断阈值为2. 03,ROC下面积0. 787; Cho/Cr诊断阈值为2. 10,ROC下面积0. 810。②高级别组K~(trans)、CBF、CBV高于低级别组(P0. 05),K~(trans)诊断阈值为0. 25 mm~2/s,ROC下面积0. 782; CBF诊断阈值为1. 51 ml/(g·min),ROC下面积0. 870; CBV诊断阈值为0. 19 ml/g,ROC下面积0. 742。③高级别组rCBVt、rCBFt、rCBVe、rCBFe水平高于低水平组(P0. 05),rCBVt诊断阈值为2. 33 ml/g,ROC下面积0. 833; rCBFt诊断阈值为2. 08 ml/(g·min),ROC下面积0. 843; rCBVe诊断阈值为1. 04 ml/g,ROC下面积0. 784; rCBFe诊断阈值为0. 96 ml/(g·min),ROC下面积0. 813。④多种参数MRI联合诊断效能准确率为92. 50%,灵敏度94. 44%,特异度90. 91%。结论多参数MRI可对脑胶质瘤进行有效分级。     

动脉自旋标记及体素内不相干运动成像在胶质瘤分级中的应用

目的评价动脉自旋标记联合体素内不相干运动(intravoxel incoherent motion,IVIM)成像在胶质瘤分级中的诊断价值。材料与方法纳入32例经病理证实的胶质瘤患者,进行3D动脉自旋标记技术(artery spin labeling,ASL)及多b值(分别为0 s/mm~2、20 s/mm~2、50 s/mm~2、100 s/mm~2、150 s/mm~2、200 s/mm~2、400 s/mm~2、800 s/mm~2、1000 s/mm~2、1200 s/mm~2)IVIM成像,测量所有患者脑血流量(cerebral blood flow,CBF)值及IVIM双指数模型扩散系数D值,灌注相关扩散系数D*及灌注分数f值,比较高、低级别胶质瘤的CBF及IVIM模型参数。结果高级别胶质瘤CBF值显著高于低级别胶质瘤[分别为(75.6±12.3)ml/(100g·min)和(55.8±8.9)ml/(100g·min),P0.001]。在IVIM参数中,高级别胶质瘤的D*值亦高于低级别胶质瘤[分别为(40.3±23.5)×10~(-3) mm~2/s和(19.2±7.5)×10~(-3) mm~2/s,P0.01],而D值[分别为(0.59±0.15)×10~(-3) mm~2/s和(0.73±0.26)×10~(-3) mm~2/s,P0.05]与f值(分别为11.1±6.9和7.2±4.1,P0.05)差异无统计学意义。联合CBF及D*值对胶质瘤分级的曲线下面积(area under curve,AUC)为0.935,其敏感性和特异性分别为91.5%及89.6%。结论通过3D ASL及IVIM多参数联合分析,进一步提高了术前肿瘤分级评估的敏感性和特异性,为临床提供一种无创的更准确的胶质瘤分级方法。     

多层螺旋CT灌注成像在脑星形细胞肿瘤术前分级中的价值

目的评价多层螺旋CT(MSCT)灌注成像在脑星形细胞肿瘤中的应用价值.方法经手术及病理证实的脑星形细胞肿瘤共24例,行常规CT及MSCT灌注成像检查.原始图像经ADW 4.0工作站Perfusion 2软件处理,构建分析脑血容量(CBV)及表面通透性(PS)图像,计算平均CBV及PS值.结果低级别星形细胞瘤组、间变性星形细胞瘤组及胶质母细胞瘤组最大CBV值分别为2.733±0.8274,4.755±0.4367,6.654±0.529;三组的PS值分别为16.668±0.5237,27.3524±0.8975,38.7452±0.328.三组间的CBF及PS值均有显著性差异,PS与CBF有明显正相关(r=0.832,P<0.01).结论 MSCT灌注成像技术及灌注成像参数PS与CBV在术前评价星形细胞肿瘤的病理级别上有实用价值.     

高、低级别脑星形细胞瘤瘤周区CTP研究

目的：探讨高、低级别星形细胞瘤瘤周区CT灌注成像（CTP）参数的差异及其病理基础。方法：对30例手术与病理证实的脑星形细胞瘤（低级别星形细胞瘤10例、高级别星形细胞瘤20例）行术前CT平扫、增强及CTP检查,测量强化区近侧1cm处或低强化区距边缘1cm处的脑血流量（CBF）、脑血容量（CBV）、平均通过时间（MTT）及脑血管表面通透性（PS）值。比较高、低级别脑星形细胞瘤瘤周区CTP参数差异。对照影像学,采用肿瘤切除前活检的方法取得标本,观察瘤周区病理表现。结果：高级别星形细胞瘤瘤周区CBF、CBV、MTT及PS值高于低级别星形细胞瘤瘤周区。CBF、CBV、MTT及PS值,高级别星形细胞瘤瘤周区分别为（50.05±14.05）ml?蛐（min·100g）、（3.50±1.79）ml?蛐100g、（5.84±2.95）s及（1.23±1.75）ml?蛐（min·100g）,低级别星形细胞瘤瘤周区分别为（25.20±8.67）ml?蛐（min·100g）、（1.61±0.68）ml?蛐100g、（4.83±1.63）s及（0.33±0.27）ml?蛐（min·100g）,二组间CBF、CBV差异有统计学意义（P<0.05）。组织学上,高级别与低级别星形细胞瘤瘤周区均可见散在肿瘤细胞,前者肿瘤细胞密度较大、血管较多。结论：高级别与低级别脑星形细胞瘤瘤周区CBF、CBV有明显差别,其病理基础不同。     

动态磁敏感对比增强灌注加权成像评估胶质瘤病理分级的价值

目的评估磁共振动态磁敏感对比增强灌注加权成像(DSC-PWI)对术前胶质瘤病理分级的价值。方法分析经手术病理证实的76例胶质瘤患者,其中低级别(Ⅰ~Ⅱ级)胶质瘤36例,含I级4例、Ⅱ级32例;高级别(Ⅲ~Ⅳ级)胶质瘤40例,含Ⅲ级25例、Ⅳ级15例。所有病例均于术前进行常规MRI平扫和增强检查及DSC-PWI检查,经工作站后处理软件检测肿瘤实性部分最大r CBV值(患侧与对侧正常脑实质CBV的比值),分析高、低级别胶质瘤实性部分最大r CBV值,采用t检验分析法。绘制ROC曲线,确定鉴别高级别与低级别胶质瘤实性部分最大r CBV值的理想阈值。结果胶质瘤实性部分最大r CBV值与其病理级别呈正相关(相关系数r=0.51),低级别和高级别胶质瘤最大r CBV值分别为(0.87±0.93)、(2.04±1.53)(CI±Se),两者之间差异有统计学意义(P=0.002)。以胶质瘤实性部分最大r CBV值鉴别低级别与高级别胶质瘤时,所获得的ROC曲线下面积AUC值为0.73;以1.35作为理想阈值时,其灵敏度为66.7﹪,特异度为73.0﹪。结论胶质瘤DSC-PWI检查所获得的肿瘤实性部分最大相对血容量r CBV值的检测对术前评估胶质瘤的病理级别具有很高价值。     

CT灌注成像结合CT血管造影在缺血性肾脏病诊断中的价值

目的探讨CT灌注成像结合CT血管造影(CT angiography,CTA)早期诊断缺血性肾脏病变及鉴别病变良、恶性质的价值。方法 72例缺血性肾脏病患者,其中恶性病变22例(恶性组),良性病变50例(良性组),均行CT灌注成像及CTA检查。评定2组图像显示情况;记录病灶感兴趣区内血流量、血容量、渗透率、平均转运时间;与组织病理结果进行对照,计算CT灌注成像结合CTA诊断缺血性肾脏病的准确性、灵敏度与特异度。结果恶性组图像显示良好率(81.8%)与良性组(84.0%)比较差异无统计学意义(P0.05);恶性组病灶部位血容量[(11.98±6.28)mL/100g]、血流量[(84.67±23.10)mL/(100g·min)]、渗透率[(28.48±11.91)mL/(100g·min)]均低于良性组[(22.46±4.22)mL/100g、(322.10±54.20)mL/(100g·min)、(57.20±6.67)mL/(100g·min)](P0.05),平均转运时间[(7.46±3.10)s]较良性组[(4.78±1.20)s]长(P0.05);CT灌注成像结合CTA诊断恶性病变20例,良性病变52例,与组织病理结果进行对照,诊断准确率为97.2%,灵敏度为90.0%,特异度为100.0%。结论 CT灌注成像结合CTA可用于缺血性肾脏病的早期诊断,根据病灶检查参数可对病变良、恶性质作出鉴别诊断。     

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.