声通道上的肋骨对高强度聚焦超声在羊肝内形成凝固性坏死的影响

目的从有效性、安全性和剂量学的角度探讨声通道上的肋骨对高强度聚焦超声（HIFU）损伤山羊肝的影响。方法HIFU分别辐照声通道上有肋骨（对照组）和声通道上肋骨被手术切除（实验组）的羊肝。辐照结束后2d处死动物，观察靶区凝固性坏死形成情况，测量凝固性坏死的体积并计算能效因子（energy efficiency factor，EEF）。结果实验组的凝固性坏死形成率明显高于对照组，EEF远远小于对照组。结论声通道上的肋骨明显影响凝固性坏死的形成率和EEF，提高HIFU治疗受肋骨阻挡的肝癌的治疗效率非常重要。     

HIFU联合氟碳乳剂损伤兔肝脏的实验研究

目的　探讨氟碳乳剂对高强度聚焦超声 (HIFU )损伤效率的影响。方法　使用同一聚焦超声换能器 ,辐照深度、功率一致条件下 ,静脉注射等量氟碳乳剂 (实验组 )或生理盐水 (对照组 )后 ,用 HIFU辐照兔肝脏 ,测量凝固性坏死体积 ,计算能效因子。结果　静脉注射生理盐水后 HIFU辐照兔肝脏所产生的凝固性坏死体积和灰度值小于注射实验组 ,能效因子和辐照时间大于实验组。结论　氟碳乳剂增强了 HIFU的损伤效率 ,使损伤后靶区的灰度值明显提高 ,有利于深部肿瘤的治疗和 HIFU治疗的实时监控。     

碘化油增强HIFU损伤离体子宫肌瘤效果的实验研究

目的 探讨碘化油有否增强HIFU损伤离体子宫肌瘤组织的效果及靶区灰度特点.方法 40枚肌瘤标本随机均分成实验组和对照组,实验组向瘤体中心注入1 ml碘化油,30 min后,在一定参数下行HIFU辐照,辐照后即刻、2、4、5 min观测靶区B超灰度值、面积;实验后1 h切开肿瘤组织行氯化三苯基四氮唑(TTC)染色,测量TTC不着色区最大切面面积.对照组以生理盐水代替碘化油,余同实验组.结果 实验组靶区B超灰度值高于对照组,辐照后4~5 min,两组间差异有显著性(P<0.05);靶区强回声面积及TTC未染色区最大切面积均大于对照组(P<0.05).结论 碘化油具有增强HIFU破坏离体子宫肌瘤组织、延缓靶区灰度衰减的效果.     

HIFU联合HL-1损伤正常兔肝脏组织的体内实验研究

目的　探讨一种脂质体 (HIFU L iposomes- 1,HL - 1)增强兔肝高强度聚焦超声 (high intensity focused ultrasound,HIFU )能量沉积和灰阶超声实时监控的效果。方法　将兔随机分为 A,B两组 ,A组右肝为实验侧 (HL - 1侧 ) ,左肝为生理盐水侧 ,B组相反。输入生理盐水后以一定参数行 A组左肝或 B组右肝 HIFU损伤 ;然后输入 HL - 1以相同参数行对侧组织 HIFU损伤 ;记录 HIFU靶区 B超灰度值。实验后 2 4h解剖 ,测量凝固性坏死组织大小、计算能效因子 (energy efficiency factor,EEF)并行组织病理检查。结果　灰度增强出现率在 A、 B两组的 HL - 1侧均有所增加 ,但差异无显著性 (P>0 .0 5 ) ;A,B两组 HL - 1侧的 EEF均明显低于对照侧 (P<0 .0 1) ;损伤组织大体观及病理检查两组两侧均为典型的凝固性坏死。结论　 HL - 1联合 HIFU能导致靶区组织发生凝固性坏死 ,并有增强正常兔肝脏组织 HIFU能量沉积的作用 ,灰阶超声对靶区组织凝固性坏死的实时监控作用有待进一步研究。     

高强度聚焦超声治疗对乳腺癌细胞生物学行为的影响

目的：研究高强度聚焦超声（HIFU）治疗后乳腺癌细胞代谢及生物学行为的变化。方法：23例乳腺癌患者改良根治术前1－2周接受HIFU治疗。术后对乳腺癌组织行：（1）NDAH－黄递酶（nicotinamide adenine dnucleotide-diaphorase)组织化学染色；（2）用单克隆抗体PCNA，CD44v6，MMP－9行免疫组织化学染色，（SP）法；（3）癌基因C－erbB-2mRNA原位杂交；（4）端粒酶TRAP－ELISA法行端粒酶活性进行测定。结果：（1）HIFU治疗靶区内NADH0－黄递酶阴性，但靶区外未损伤区酶染色为阳性；（2）对照组乳腺癌组织PCNA指数、CD44v6、MMP－9阳性率分别为44％、56％和60％，而HIFU治疗组其靶区内细胞无1例阳性；（3）对照组乳腺癌组织C－erbB-2mRNA阳性率为36％，而HIRU治疗组其靶区内细胞无1例阳性；（4）对照组乳腺癌组织端粒酶活性为1．87，HIFU治疗组其靶区内组织端粒酶活性为0．17， 接近阴性对照（P＜0．001）。结论：HIFU治疗靶区乳腺癌组织生长能力、侵袭转移能力丧失，端粒酶失活，癌基因C－erbB－2破坏或 转录下降,经HIFU治疗后乳腺癌组织是一团无任何功能的组织。     

碘化油与高功率聚焦超声破坏肝组织的协同升温效应研究

本实验首次研究生物组织因素（媒质）对高轼率聚焦超声（HIFU）破坏肝组织的影响。采用国产HIFU样机（1．1MHz）．体外观察其靶区在碘化油或蓖麻油不同媒质存在的温度变化。结果显示：不论在高功率（500W/cm2）和低功率（136W/cm2）超声照射下，碘化油使靶区温度升高显著高于无碘的蓖麻油（P=0．0008和P=0．0004）．提示碘比油与HIFU治疗有协同升温作用。用HIFU（1．1MHz，500W/cm2，20s）照射离体肝组织．发现肝内注射碘化油组靶区温度显著高于注射蓖麻油组（P=0．0239），且前者破坏程度和范围均明显大于后者，提示碘化油配合HIFU治疗肝肿瘤具有潜在的增效、定位和导向作用。     

高强度聚焦超声定位损伤幼猪肌肉组织的即时和延迟反应

目的 观察高强度聚焦超声损伤幼猪肌肉组织后即时和延迟的超声影像学改变和病理学改变，为临床应用提供依据。方法 实验幼猪后肢皮下肌内层高强度聚焦超声照射后即刻和存养2周后，观察照射靶区超声影像学改变和病理改变，结果高强度聚焦超声（HIFU）照射后靶区灰度明显增加，与正常组织界限清晰。光镜下靶区组织呈凝固性坏死。HIFU照射2周后凝固灶回声较前减弱，靶区灰度强弱不等，凝固灶体积较前有缩小。与正常组织的界限清晰度较前下降。光镜下发现靶区肉芽组织生成。结论高强度聚焦超声能有效地损伤幼猪肌肉组织，使之发生凝固性坏死，治疗2周后靶区肉芽组织生成。为HIFU治疗软组织肿瘤提供了实验依据。     

超声造影剂增强HIFU消融作用的病理学研究

目的探讨超声造影剂增强高强度聚焦超声（HIFU）消融生物组织作用的病理学改变。 方法24只新西兰大白兔按体质量配对分为两组，A组肝脏接受单纯HIFU辐照，B组动物接受辐照前经静脉注射超声造影剂SonoVue。辐照后测量组织凝固体积并观察光电镜下组织学及细胞超微结构改变。 结果A组与B组组织凝固体积分别为（0．07±0．02）cm^3和（0．21±0．06）cm^3（P＜0．05）。光镜下两组辐照区肝组织未见凝固性坏死，B组可见部分细胞膜及胞核破坏。电镜下两组辐照区细胞内均未见完整细胞器，均呈现不可逆凝固性坏死，A组辐照区细胞结构较B组清楚。 结论超声造影剂增加HIFU焦域体积并进一步破坏细胞结构，从而增强HIFU消融作用。     

高强度聚焦超声辐照离体组织靶区无灰度变化有坏死现象的研究

目的研究高强度聚焦超声(HIFU)辐照离体组织靶区时声像图无灰度变化而有坏死的现象。方法应用HIFU辐照新鲜离体牛肝组织,辐照剂量分别为2500,3000,3750,4200J,每个剂量又分为10个辐照功率时间组。超声实时监控HIFU辐照全过程,辐照结束后即刻采集靶区声像图,运用灰度测量软件读取靶区灰度值;重复实验5次。计算灰度增强出现几率。结果总剂量为2500J时,所有的功率时间组均未出现灰度增强;总剂量为3000J时,声功率≥200W出现灰度增强;总剂量为3750J时,声功率≥150W出现灰度增强;总剂量为4200J时,声功率≥120W出现灰度增强。经病理检查证实,各剂量组中,除2500J组辐照参数50W/50s和60W/41s未出现损伤外,其余均出现凝固性坏死。结论组织凝固性坏死后,声像图上多数有灰度增加,但部分没有灰度变化;声像图上显示的HIFU辐照后即刻的灰度增加并不是组织凝固性坏死的直接表现,提示在临床应用时,不要过分依赖声像图变化判断治疗效果。     

高强度聚焦超声联合碘油栓塞损伤肝脏的病理转归及肝、肾功能的变化

目的探讨肝脏局部碘油栓塞联合高强度聚焦超声(HIFU)热切除术后,坏死组织的病理转归及肝、肾功能的变化,阐明联合治疗的安全性。方法10只山羊,肝左叶动脉碘油栓塞和局部HIFU热切除后,分为A、B二组,各5只。A组动物定期观察坏死组织的动态病理变化,而B组则动态观察术后的肝、肾功能变化。结果肝脏碘油栓塞和HIFU治疗后可形成明显的凝固性坏死灶并引起肝、肾功能的明显变化。但随着时间延长,坏死灶逐渐溶解吸收、纤维化,肝肾功能也逐渐恢复正常。结论局部肝脏碘油栓塞联合高强度聚焦超声热切除术是安全的。     

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.