超声造影增强模式分析对甲状腺实性结节良恶性鉴别诊断的价值

目的 探讨超声造影(CEUS)增强模式对甲状腺实性结节良恶性鉴别诊断的价值.方法 回顾性分析39个甲状腺实性结节的常规超声声像图特点及超声造影过程,观察病灶超声造影增强模式和造影前后结节大小的变化.结果 甲状腺良恶性结节增强模式间存在显著性差异(P＜0.05),甲状腺恶性结节造影增强模式多为不均匀增强,占85.71％ (18/21),利用不均匀增强诊断甲状腺恶性结节,敏感度85.71％,特异度88.89％;而良性结节多为周边环状增强,占77.78％ (14/18),利用结节周边环状增强诊断甲状腺良性结节,敏感度77.78％,特异度95.24％.结论 超声造影增强模式分析对甲状腺实性结节良恶性鉴别诊断具有重要的价值.     

前瞻性观察甲状腺结节的SonoVue超声造影增强模式

目的 探讨甲状腺结节实时灰阶超声造影(CEUS)的增强模式及其对甲状腺结节的鉴别诊断价值.方法 对常规超声检测出的95例患者104个甲状腺结节行CEUS检查,其中良性病灶53个,恶性病灶51个;囊性结节1个,囊实性结节41个,实性结节62个.采用低机械指数灰阶脉冲反相谐波成像,静脉团注SonoVue 1.2 ml,观察时间≥3 min(MI 0.05～0.08).观察甲状腺良恶性结节的灰阶内部回声结构和CEUS增强模式.结果 注入造影剂后,甲状腺结节呈现均匀增强、不均匀增强、环状增强和无增强4种表现.甲状腺良恶性结节的增强模式总体上有差别(P<0.01).环状增强提示良性可能性大,敏感度83.02%,特异度94.12%,阳性预测值93.62%,阴性预测值84.21%,准确率88.46%.不均匀增强提示恶性可能大,敏感度88.24%,特异度92.45%,阳性预测值91.84%,阴性预测值89.09%,准确率90.38%.1个囊性结节为良性结节,表现为环状增强.对于囊实性结节和实性结节,环状增强诊断良性结节的阳性预测值分别为93.10%和94.12%,不均匀增强诊断恶性结节的阳性预测值分别为88.89%和92.50%.结论 CEUS在甲状腺结节良恶性鉴别诊断中具有重要应用价值.     

超声弹性成像鉴别诊断甲状腺实性小结节

目的 探讨超声弹性成像对甲状腺实性小结节的鉴别诊断价值.方法 对468例患者共562个甲状腺实性结节行超声弹性成像检查,根据结节长径将其分为两组(组I:长径≤1 cm,组Ⅱ:长径＞1 cm).采用4分法(1～4分)评价甲状腺结节的弹性,≤2分判断为良性结节,≥3分判断为恶性结节.以病理结果为诊断金标准,分别计算两组的诊断敏感度、特异度、准确率、阳性预测值及阴性预测值.结果 弹性成像对于2组甲状腺实性结节的诊断敏感度、准确率、阳性预测值差异均有统计学意义,特异度、阴性预测值之间差异无统计学意义.结论 超声弹性成像对甲状腺小结节(长径≤1 cm)的鉴别诊断价值更高.     

超声造影对甲状腺实质性结节良恶性诊断价值的研究

目的 探讨甲状腺结节实时超声造影(CEUS)的增强模式及其对甲状腺实质性结节的鉴别诊断价值.方法 对常规超声检测出且定性诊断困难的55例患者80个甲状腺实质性结节行超声造影检查,分析总结其增强模式,做出良、恶性判断,并与手术病理结果对照.分析超声造影各项指标包括造影剂进入结节时间、方式、增强强度、造影剂分布是否均匀、以及结节内造影剂消退快慢.结果 术后病理结果甲状腺实性结节良性病灶34个,恶性病灶46个.大于1 cm的良、恶性结节上述超声造影表现均有显著性差异(P＜0.05).其中造影剂早期消退对于诊断甲状腺乳头状癌的灵敏度最高(82.6％),不均匀性增强的特异度最高(89.5％).小于等于1 cm的良、恶性结节造影模式无明显差异(P＞0.05).结论 对于大于1 cm的甲状腺实性结节,造影剂晚进、向心性增强、不均匀增强及造影剂早期消退有助于对甲状腺乳头状癌的诊断.     

超声造影和超声弹性成像对甲状腺良恶性结节的鉴别诊断价值

目的 评价超声造影和超声弹性成像在甲状腺良恶性结节中的鉴别诊断价值.方法 对82个经手术病理证实的甲状腺良恶性结节的超声造影和弹性成像特征进行对比分析,评估各诊断方法的灵敏度、特异度、阳性预测值、阴性预测值及诊断符合率.结果 82个甲状腺结节中,良性病灶48个,恶性病灶34个.良性结节在注射造影剂后均早于周围腺体增强,晚于周围腺体廓清,多数结节表现为周边环状增强;恶性结节大多以低增强为主,增强回声不均匀,早于周边甲状腺组织消退.超声造影的灵敏度、特异度、阳性预测值及阴性预测值分别为91.18%、93.75%、91.18%及93.75%,弹性成像的灵敏度、特异度、阳性预测值及阴性预测值分别为88.24%、91.67%、88.24%及91.67%,超声造影联合超声弹性成像的灵敏度、特异度、阳性预测值及阴性预测值分别为97.06%、85.42%、82.50%及97.62%.结论 超声造影和弹性成像对甲状腺良恶性结节有较高的鉴别诊断价值,两者结合可提高该病的诊断率.     

超声造影在甲状腺结节鉴别诊断中的价值

目的探讨超声造影对甲状腺影像报告和数据系统(TI-RADS)分类的甲状腺结节进一步鉴别诊断的价值。 方法对295例387个常规超声TI-RADS分类的甲状腺结节行超声造影检查,观察造影后甲状腺结节的微循环灌注特征和应用SonoLiver CAP软件获得的时间-强度曲线各定量参数分析,综合进行两次TI-RADS分类评估,并与术后病理结果进行对照,计算常规超声TI-RADS、超声造影后TI-RADS分类诊断甲状腺恶性结节的敏感度、特异度、准确度、阳性预测值、阴性预测值,并绘制常规超声TI-RADS、超声造影后二次TI-RADS分类诊断甲状腺恶性结节的受试者操作特性(ROC)曲线,计算ROC曲线下面积。 结果295例387个常规超声TI-RADS分类2～5类的甲状腺结节,术后病理结果为恶性82例121个、良性213例266个。常规超声TI-RADS分类诊断恶性结节的敏感度63.64 %(77/121)、特异度73.87%(229/310)、准确度79.07%(306/387)、阳性预测值45.83%(77/168)、阴性预测值83.88%(229/273),而超声造影后二次TI-RADS分类诊断恶性结节的敏感度85.95%(104/121)、特异度92.93%(263/283)、准确度94.83%(263/387)、阳性预测值83.87%(104/124)、阴性预测值93.93%(263/280),超声造影后二次TI-RADS分类诊断甲状腺恶性结节的敏感度、特异度、准确度、阳性预测值、阴性预测值均高于常规超声TI-RADS分类诊断,差异有统计学意义(χ² ＝5.92,4.38,7.31,7.45,3.13;P<0.05)。常规超声TI-RADS、超声造影后二次TI-RADS分类诊断甲状腺恶性结节的ROC曲线下面积分别为0.753,0.834。二次TI-RADS分类评估后甲状腺结节恶性组的超声造影增强模式：≥1 cm实性结节早期快速不均匀增强伴灌注缺损区,<1 cm实性结节呈不均匀低增强;实性结节良性组增强模式表现为均匀高或等增强以及结节周边环状高增强,两者比较差异有统计学意义(χ² ＝43.86,12.54;P<0.05);良恶性组间在增强水平、增强边界、始退特点、相对平均渡越时间、峰值强度、平均强度均具有统计学意义(χ² ＝51.48,17.91,47.25,8.92,3.37,4.05;P<0.05);而增强范围、平均强度、峰值强度在良恶性组间均无统计学意义(χ² ＝2.87,0.95,0.88;P>0.05)。 结论超声造影对常规超声TI-RADS分类的甲状腺结节可以做进一步良恶性鉴别,提高术前诊断准确率。     

超声造影在甲状腺微小实性结节良恶性鉴别诊断中的价值

目的探讨超声造影对甲状腺微小实性结节良恶性鉴别诊断的价值。方法回顾分析113例(126个结节)经手术病理证实的甲状腺微小实性结节患者的超声造影特征,评估其诊断的敏感性、特异性、准确性、阳性预测值、阴性预测值及约登指数。结果 126个微小实性结节中,恶性结节74个(58.7%),良性结节52个(41.3%)。74个甲状腺微小恶性结节超声造影特征多表现为:向心性(67.5%)、不均匀性(83.8%)、低增强(82.4%)、慢进同出(66.1%)、周边等增强(93.2%),超声造影诊断甲状腺微小恶性结节的敏感性、特异性、准确性、阳性预测值、阴性预测值、约登指数分别为62.2%、96.2%、76.2%、95.8%、64.1%、58.4%;52个甲状腺微小良性结节超声造影多表现为周边环状高增强(63.5%)。结论超声造影对甲状腺微小实性结节的良恶性鉴别诊断有较高的应用价值。     

超声弹性成像鉴别诊断实性甲状腺良、恶性小结节

目的 探讨超声弹性成像鉴别诊断良、恶性甲状腺实性小结节(最大径≤10 mm)的价值.方法 分析109个甲状腺实性小结节的常规超声及超声弹性成像图像.常规超声采用半定量评分方法判断结节的性质.超声弹性成像采用5级评分法判断结节性质.以术后病理结果为诊断金标准,构建ROC曲线,比较两种方法对良、恶性甲状腺实性小结节的诊断率.结果 超声弹性成像诊断良、恶性甲状腺实性小结节的敏感度、特异度、准确率分别为88.89％(16/18)、84.62％(77/91)、85.32％(93/109).半定量评分法诊断良、恶性甲状腺实性小结节的敏感度、特异度、准确率分别为77.78％(14/18)、81.32％(74/91)、80.73％(88/109).超声弹性诊断准确率高于半定量评分方法(x2=31.25,P＜0.05).超声弹性成像及半定量评分方法诊断甲状腺良、恶性结节的ROC曲线下面积分别为0.88和0.80,差异有统计学意义(Z=4.032,P＜0.01).结论 超声弹性成像有助于鉴别诊断甲状腺良、恶性实性小结节.     

超声造影联合超声实时组织弹性成像在甲状腺良恶性结节诊断中的应用价值

目的：评价超声造影联合超声实时组织弹性成像（RTE ）在甲状腺良恶性结节诊断中的应用价值。方法分析85例甲状腺结节患者的超声造影和RTE的图像信息并与病理活组织检查（活检）相对比,评估单用两种方法及联合使用两种方法诊断的灵敏度、特异度、阳性预测值、阴性预测值及诊断符合率。结果85个甲状腺结节中,病理活检证实恶性病灶48个,良性病灶37个。恶性结节在注射造影剂后以不均匀低增强为主,早于周边甲状腺组织消退。良性结节则以弥散性等增强或高增强为主,晚于周围腺体廓清。超声造影的灵敏度、特异度、阳性预测值、阴性预测值及诊断符合率分别为91.67％、81.08％、91.67％、81.08％、87.06％;RTE 则分别为87.50％、83.78％、87.50％、83.78％、85.89％;两者联合诊断的灵敏度、特异度、阳性预测值、阴性预测值及诊断符合率分别为97.92％、86.49％、90.38％、96.97％、92.94％。超声造影联合 RTE 灵敏度、特异度、阴性预测值及诊断符合率比单用超声造影或RTE高（均P＜0.05）。结论超声造影联合RTE可提高甲状腺良恶性结节诊断的准确性。     

超声造影环状高增强征象诊断肾癌的特异性分析

目的 探讨超声造影环状高增强(PHR)征象对于肾常见肿瘤定性诊断的价值.方法 回顾性分析207例肾常见肿瘤(136个肾细胞癌,84个肾错构瘤)患者的超声造影图像,比较PHR在肾癌与肾错构瘤组间以及肾癌不同亚型组间检出率的差异.结果 肾癌组中,PHR的检出率为36.76％(50/136),肾错构瘤组未检出PHR;采用PHR诊断肾癌,其敏感性、特异性、准确性、阳性预测值、阴性预测值、假阳性率及假阴性率分别为36.76％(50/136)、100％(84/84)、60.91％(134/220)、100％(50/50)、49.41％(84/170)、0(0/50)、50.59％(86/170).PHR在肾透明细胞癌、乳头状肾癌、肾嫌色细胞癌及肾集合管癌四种肾癌亚型间检出率分别为31.03％(36/116)、81.82％(9/11)、62.50％(5/8)、0(0/1).结论 超声造影检出的PHR征象可作为诊断肾癌的特异性指标,且对于鉴别肾肿瘤的良恶性及肾癌病理亚型有一定的参考价值.     

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.     

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.     

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.     

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.