经皮微波消融子宫肌层良性病变围消融期灰阶声像图表现及其临床意义

目的探讨二维灰阶超声在经皮微波消融(PMA)子宫肌层良性病变围消融期声像图特点及其临床意义。方法选择19例接受PMA治疗的患者,共21个病灶(13个子宫肌瘤,8个子宫腺肌病)。消融前常规观察病变位置、回声及血供特点,消融中以灰阶超声监测消融区高回声范围,消融后即刻测量、计算高回声体积,并与CEUS测量无增强区体积进行比较。结果灰阶超声显示消融前病变均为偏低回声。微波辐射开始约3s,辐射点周围组织回声即增高,并随时间延长而呈球形或类球形增大,子宫肌瘤以高回声达到肌瘤被膜时停止微波辐射,子宫腺肌病以高回声达到病灶内缘0.3cm时停止消融,高回声范围不再增大。消融后即刻灰阶超声高回声范围[(97.94±72.88)cm3]与CEUS无增强区范围[(88.82±70.06)cm3]差异无统计学意义,且二者呈正相关(r=0.859,P<0.01)。结论PMA子宫肌层良性病变围手术期灰阶声像图变化特点鲜明;高回声范围可粗略代表凝固坏死区范围。     

超声造影在经皮微波消融治疗子宫肌层良性病变围手术期中的作用

目的 探讨超声造影在经皮微波消融治疗子宫肌层良性病变围手术期中的应用价值.方法 采用微波消融治疗仪对22例患者24个子宫肌层良性病灶(子宫肌壁间、黏膜下和浆膜下肌瘤16个、弥漫性和局限性腺肌病病灶8个)进行微波消融治疗.微波治疗前、治疗后即刻和治疗后12~24 h均行超声造影,观察消融灶增强表现,并对无造影剂灌注区体积进行测量.结果 22例患者微波治疗前后超声造影图像特征:微波治疗前,14例子宫肌瘤16个病灶呈周边强化方式,8例腺肌病8个病灶快速优先增强,峰值时病灶与周围肌层分界不清晰.微波消融后即刻,超声造影显示24个消融灶呈边缘毛糙的类球形或不规则形无增强区,内可见线状、片状热场未消散所致的高增强.微波消融后12~24 h内再次造影,19个消融灶显示为边界较锐利、均匀一致的无增强.微波消融后即刻超声造影显示无造影剂灌注区体积为(83.41±72.83)cm3,小于微波消融后12~24 h的(94.73±80.37)cm3,但差异无统计学意义(t=1.138,P=0.267).结论 在子宫肌瘤和子宫腺肌病经皮微波消融治疗术前及术后超声造影显示微波消融区图像变化特点鲜明,消融治疗后12~24 h内再次超声造影检查可较准确判断治疗后消融灶坏死范围.     

实时超声弹性成像评估微波消融肌组织凝固范围可行性研究

目的 探讨实时超声弹性成像(real-time ultrasound elastography,RTE)定量评估微波消融(microwave ablation,MWA)肌组织消融范围的可行性及准确性.方法 单导水冷2 450 MHz微波,作用功率50 W,作用时间200 s,消融离体猪臀部肌组织,消融前及消融后行RTE,测量消融后弹性成像图蓝色+绿色区,并与大体标本消融区实测值相比较,分析RTE测值与消融后大体标本测值的相关性.结果 MWA后RTE显示消融灶呈椭圆形,中心为较均匀蓝色,周边呈宽度较均匀一致绿色,与周围混杂颜色的正常组织分界清楚.RTE测值与消融灶大体标本测值相关系数r=0.78 (P=0.000).结论 RTE可望较准确评估MWA肌组织消融范围.     

超声造影在高强度聚焦超声治疗子宫肌瘤中的作用评价

目的 通过与磁共振成像(MRI)结果比较,评价超声造影(CEUS)在高强度聚焦超声(HIFU)治疗子宫肌瘤过程中实时判断消融效果的价值.方法 对72例子宫肌瘤患者92个肌瘤行HIFU治疗的同时行CEUS和MRI检查.结果 CEUS与MRI检查结果比较,治疗前肌瘤最大径,肌瘤体积,非灌注区体积,肌瘤消融率分别为(4.87±2.12) cm比(4.85±2.11) cm,(71.1±89.1) cm3比(74.1±91.7) cm3,(59.1±83.4) cm3比(59.2±89.6) cm3,(83.8±26.5)％比(83.1±21.6)％;2种检查方法所测定各指标间无统计学差异(P＞0.05).CEUS与术后MRI检查的各指标分别具有高度相关性.术中出现的所有副反应与CEUS无关.结论 CEUS是一种准确评价HIFU消融效果的方法,可安全用于HIFU术中实时评价子宫肌瘤消融效果.     

超声造影与动态增强磁共振成像观察局限性子宫腺肌病微波消融治疗效果及分析

目的应用超声造影与动态增强磁共振成像(DCE-MRI)观察经皮穿刺微波消融治疗局限性子宫腺肌病消融治疗的效果并进行分析。方法选取2013年1月至2016年7月于山东省聊城市肿瘤防治院行经皮微波消融治疗的单发局限性子宫腺肌病患者42例,术前及术后1~2 d分别进行静脉超声造影和DCE-MRI检查,观察及子宫腺肌病及病灶消融治疗的效果。结果微波消融治疗后,超声造影及DCE-MRI显示42例局限性子宫腺肌病消融灶无造影剂增强,且平均消融率均达90%以上。其中超声造影显示微波消融病灶内无造影剂灌注,消融体积及病灶消融率分别为(49.0±29.5)cm~3、(91.6±7.1)%;DCE-MRI显示消融灶内无增强区,消融体积及病灶消融率分别为(49.4±29.9)cm~3、(91.9±6.7)%。结果显示微波治疗局限性子宫腺肌病效果好,且超声造影与DCE-MRI观察的消融率一致性相近。结论超声造影对微波消融治疗局限性子宫腺肌病消融率的评价较准确,与DCE-MRI评价消融率一致性较好,对造影显示消融不完全的病灶可即刻补充消融。     

卵巢囊性病变MRI诊断与鉴别诊断

目的 探讨助力式静态弹性成像技术和声压式动态弹性成像技术即声触诊组织量化技术(VTQ)在子宫肌层病变微波消融治疗中的应用价值。方法 对在本院接受子宫肌瘤和超声引导经皮穿刺微波消融治疗的患者,术前、术中、术后24h及1个月应用助力式静态弹性成像技术和VTQ测定病灶和正常子宫肌壁剪切波速度,彩色能量三维显像获得整体子宫的容积,并采用任意切面和多层剖析观察血管架构;对比脉冲序列(CPS)造影,观察并记录病灶的灌注,用ContrastDynamic分析软件分析峰值速度、达峰时间、曲线下面积、通过时间等参数并进行比较,以观察病灶质地和消融效果及热效能间的关系,了解弹性成像参数与靶目标血流灌注的关系。所有病例均通过消融术前穿刺取样送检获得病理诊断,且均在术前及术后第2天接受MR检查以作为评估疗效的金标准。结果 8例患者获得完整资料,子宫肌瘤6例,子宫腺疾病2例。助力式静态弹性成像模式示病灶的质地明显不同于正常子宫肌壁,经灰阶或彩色编码可见病灶与正常子宫肌壁间有明显色差,可完整地勾画出病灶范围,部份病灶呈现明显不同的色差度,提示质地不均匀,消融后的病灶色差表现为最硬的级别,并可清晰勾画出消融区轮廓。VTQ反映出正常子宫肌壁、子宫肌瘤、子宫腺肌病灶内不同的剪切波值,病灶与正常组织有明显的差异,病灶内可较一致或很不一致,反映出病灶的质地是否均匀,有效消融后的病灶VTQ 值为0。三维彩色能量模式反映出病灶的血管架构与正常子宫肌壁不同,子宫肌瘤与子宫腺肌病不同,前者具有明显的包绕血管,后者为插入式血管,消融术后病灶的架构血管被破坏。CPS超声造影获得了正常子宫肌壁和病灶的灌注图像,二者明显不同,ContrastDynamic分析软件更进一步以曲线和数据显现峰值强度、达峰时间、曲线下面积、通过时间的差异。消融后再造影和分析显示消融灶与正常肌壁交界处的充血带峰值强度明显提高、有效消融的病灶区域灌注缺失。结论 助力式静态弹性成像的模式可用于消融前病灶范围和质地的确定及消融后有效消融范围的评估;VTQ 可反映子宫正常肌壁与病灶的剪切波速度,在消融术后可精确评估消融灶是否发生凝固性坏死,有助于消融术后定期评价靶目标的临床转归。     

超声引导经皮微波消融子宫肌瘤及腺肌病治疗中及远期超声声像图表现

目的研究灰阶超声在经皮微波消融（PMWA）治疗子宫肌层良性病变消融过程中及消融后期消融区声像图表现及其临床意义。 方法选择2007年8月至2015年6月于解放军总医院行经皮微波消融治疗的患者588例,其中子宫肌瘤患者255例,子宫腺肌病患者333例,消融过程中及消融后3、6、9、12及24个月,灰阶超声观察消融区声像图表现,并与磁共振成像表现对比。 结果消融过程中588例子宫肌层病变灰阶超声声像图表现为以微波辐射点为中心动态扩散的高回声,随微波辐射时间延长高回声范围逐渐增大,直至消融停止。消融结束后即刻所有病例消融区仍呈高回声,但无血流信号,静脉造影无血流灌注。随着随访时间延长所有病例消融区病变回声逐渐减低,呈不均质回声,但整体回声仍高于周围正常子宫肌层。3个月后开始消融区病变出现灶状无回声区,12个月后无回声区逐渐缩小或消失,消融针道呈条状高回声,24个月时消融针道高回声仍清晰可见。超声表现提示患者消融效果较好,治疗病灶逐渐吸收。 结论经皮微波消融治疗子宫肌层病变过程中及治疗后灰阶超声声像图特点鲜明,可实时监测消融过程,也可后期评估病灶转归。     

实时剪切波弹性成像评估乳腺良性结节微波消融效果的价值探讨

目的探讨实时剪切波弹性成像(SWE)技术在评估乳腺良性结节微波消融效果的应用价值。方法选取23例乳腺良性结节患者(共25个结节),分别于行微波消融治疗前后行常规超声、超声造影及SWE检查,比较超声造影与SWE显示的有效消融区横切面及纵切面最大径,以及消融前后消融区的杨氏模量值,包括最大弹性值(E_(max))、平均弹性值(E_(mean))、弹性标准差(E_(sd))及病灶与正常脂肪组织弹性比(E_(ratio))。结果微波消融术后,超声造影显示有效消融区无造影剂灌注;SWE显示消融区以红黄相间的不均匀彩色改变为主,与周围组织分界清晰,两种方法获得的消融区横切面及纵切面最大径比较差异均无统计学意义。消融区杨氏模量值(E_(max)、E_(mean)、E_(sd)及E_(ratio))均较术前显著增加,差异均有统计学意义(均P0.01)。结论 SWE可较准确地反映乳腺结节微波消融术后的消融范围,并能够定量分析消融区硬度变化,有望成为无创、有效评价消融效果的方法。     

超声引导经皮微波消融治疗乳腺良性结节

目的 探讨超声引导经皮微波消融(MWA)治疗乳腺良性结节的可行性和疗效。方法 选择经超声引导穿刺活检病理证实的109例共207个乳腺良性结节。MWA治疗前分别行超声和(或)MR检查,后行超声引导经皮MWA治疗,消融后超声和(或)MRI显像判断治疗效果。结果 消融治疗后1 h结节最大径及体积增大,治疗后1、3、6及12个月后结节逐渐缩小。消融治疗前,灰阶超声显示结节呈均匀低回声,边界清楚;CDFI显示结节内血流信号为0~Ⅱ占93.24%(193/207);超声弹性成像评分为1~2分占87.92%(182/207);CEUS和(或)MR增强扫描显示结节内均有不同程度增强。消融治疗后,灰阶超声显示原结节区域呈不均匀高回声,边界不清;治疗后1、3、6及12个月,超声检查显示结节边界逐渐清晰,回声较治疗前轻度增强;CDFI显示血流分级为0级占89.85%(186/207);消融治疗后1 h,超声弹性成像显示结节硬度较治疗前均有所增加;治疗后1、3、6及12个月复查,结节硬度逐渐下降;CEUS和(或)增强MRI显示结节完全消融或大部分消融且消融后可见消融灶周边环状水肿带。穿刺活检见消融区呈凝固样坏死改变。结论 超声引导经皮MWA治疗乳腺良性结节创伤小、恢复快、无瘢痕,具有患者易耐受、可门诊治疗等优势,是治疗乳腺良性结节安全、有效、可行的新方法。     

超声弹性成像在宫颈癌浸润范围评估中的应用研究

目的探讨超声弹性成像评估宫颈癌浸润范围的价值。方法对40例宫颈癌患者分别行经阴道常规二维超声和弹性成像,比较两种方法测量的宫颈癌病灶大小并评估宫颈癌浸润宫颈内口的情况,与病理测量结果进行比较。结果病灶大小的常规超声测值:长径35.35±10.16 mm、横径33.08±13.68 mm、前后径24.49±11.22 mm;弹性成像测值:长径37.86±9.93 mm、横径35.94±14.82 mm、前后径27.15±11.74 mm;病理测值:长径40.00±11.07 mm、横径37.08±14.99 mm、前后径27.50±11.88 mm;弹性成像测值大于常规超声测值,二者比较有统计学差异(P0.05)弹性成像测值与病理测值无差异(P0.05),常规超声测值与病理测值比较有明显差异(P0.01);弹性成像方法病灶大小测值与病理结果间呈显著正相关(r=0.992),常规超声病灶大小测值与病理结果间呈正相关(r=0.890)。在评价宫颈癌是否浸润宫体中,常规超声诊断宫体浸润9例,弹性成像诊断宫体浸润16例,病理诊断宫体浸润17例,弹性成像与常规超声诊断结果间有差异(P0.05)。结论经阴道实时弹性成像对宫颈癌浸润范围的评估优于常规超声。     

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.