CT诊断脾脏血管肉瘤1例

患者女,49岁,因“上腹部不适1个月”就诊.2007年曾接受血管瘤栓塞治疗术.患者一般状态可,左上腹压痛明显,脾脏增大,达肋下2.0 cm,质略硬.实验室检查未见异常.CT平扫示肝内多个类圆形不均匀低密度影,边缘尚清晰;胆囊内可见结石影;脾脏增大,密度不均,实质大部呈囊状改变,囊内可见不规则斑片、结节状软组织影(图1).腹膜后区未见明显肿大淋巴结.增强扫描肝脏内低密度影呈不均匀渐进性强化,由边缘向中央区填充;脾脏囊性病灶内斑片、结节影呈轻度强化改变,并随强化时间延长,密度增加(图2).影像诊断:肝脏多发血管瘤;脾脏恶性占位病变,源于脉管可能性大.行脾脏切除术,术后病理:脾脏血管肉瘤,浸透脾脏全层(图3).     

精索侵袭性血管黏液瘤合并高分化脂肪肉瘤1例

正患者男性,79岁。于2年前发现左阴囊有一突出肿块,开始较小,后来逐渐增大,有轻度坠胀感、质软、无压痛。既往无手术史。实验室检查:癌胚抗原(CEA) 6.47 ng/ml(0.00~5.00 ng/ml),前列腺特异抗原(PSA) 6.95 ng/ml(0.00-4.00 ng/ml),其余未见明显异常。CT检查示:左侧阴囊明显增大,精索增粗,内侧见囊样低密度影,大小约4.8 cm×5.3 cm(平均CT值约24 Hu),外侧见“月牙形”脂肪样低密度影(平均CT值约-72 Hu),其内密度不均,见结节样软组织密度影(平均CT值约31 Hu),内侧囊样病变与外侧软组织结节分界不清(图1),其余脏器未见占位性病变。     

胃癌多发钙化性转移1例

患者男,57岁.上腹胀痛不适伴食欲差1个月.既往无肝炎、结核、手术及疫区接触史.入院CT检查:平扫见胃窦壁不均匀增厚并见点状钙化,腹腔见多发结节状高密度影(图1A),肝内见大小不等的沙粒状、结节状及团块状高密度影,CT值91~192 HU;左肺底见一钙化结节(图1B);增强扫描示增厚的胃壁明显强化,肝内及腹腔病灶不均匀轻中度强化,肝内另见多个类圆形低密度灶.     

后腹膜炎性肌纤维母细胞瘤1例

患者男,57岁.发现左中上腹部包块一周.查体:左中上腹部扪及一包块,约15 cm×12 cm大小,质硬,动度差,无压痛、反跳痛.CT:左侧腹膜后见一巨大分叶状软组织肿块影,边界较清,大小13.35 cm×11.05 cm×15.0 cm.腹腔干被包绕,肠系膜上动脉被推挤.平扫密度均匀(图1),CT值为26.45 Hu,增强后病变被逐渐轻中度强化,强化不均(图2).左肾上极可见一圆形低密度灶,边缘光滑无强化.     

肺巨大淋巴结增生症1例

患者女,14岁,因鼻衄1个月就诊,时有发热,无胸闷、胸痛、咳嗽等表现. 影像学检查:胸部CT示右肺门见约4.5 cm×4.0 cm肿块影,无明显分叶及毛刺,密度较均匀,CT值 49 Hu,右肺下叶支气管受压变窄(图1),纵隔上腔静脉后见一枚肿大淋巴结.手术中见肿块位于右肺中叶及下叶之间,实性,包膜完整.病理诊断:巨大淋巴结增生症(图2).免疫组化:Keratin(-).     

肝脏多发性上皮样血管内皮细胞瘤1例

1 病例报告 患者女,39岁,2007年4月18日在我院行肝脏CT检查：肝脏CT平扫（图1）,肝脏大小形态正常,边缘欠光滑,肝实质内可见多个大小不等的类圆形低密度区,边缘欠锐利,CT值37．06～42．59Hu。意见：肝脏多发低密度影,建议增强扫描,进一步排除转移。肝脏CT增强扫描（图2）：肝脏体积可,边缘欠光滑,肝实质内可见多个类圆形低密度区,边缘欠锐利,大小不等,增强后,肝实质内类圆形不均匀低密度区,在动脉期轻度强化,门静脉期及平衡期呈高密度。意见：肝脏多发占位,考虑转移瘤,建议进一步检查。     

巨大脾单纯性囊肿1例

患者男,8岁,左上腹钝性胀痛 2个月,查体:左肋缘下可触及增大的脾脏.B超检查见脾区巨大囊状液性回声,边界清晰,包膜完整,腔内透声好,无分隔. CT:平扫见脾区直径约11cm的圆形低密度区,CT值为 5Hu,轮廓清,密度均匀.右内侧缘可见挤压变薄的正常脾实质(如图 1),增强后病灶无强化.结论:脾单纯性囊肿.     

腹腔Castleman病CT误诊1例

患者,女,31岁。因健康体检时发现甲胎蛋白（AFP）升高而行腹部CT检查。临床无明显症状,体格检查无异常发现。CT：肝肾间隙见一33mm×31mm大小的类圆形等密度影,密度均匀,边缘光整,平扫CT值45.96Hu,三期增强扫描CT平均值分别为：80.07Hu、95.69Hu、71.98Hu,呈均匀并延迟强化,境界清楚,与结肠肝曲相连（图1）。CT拟诊：肠壁或系膜间质瘤可能性大。     

彩超诊断肝肾多发性血管平滑肌脂肪瘤1例

患者女,56岁。因“右上腹部闷胀不适10年余,加重1周”入院。查体:心肺(-),皮肤巩膜无黄染,肝脾未触及。CT扫描肝肾内见多发性的低密度影,密度尚均匀,CT值-39Hu。提示:肝肾脂肪瘤可能。彩色多普勒超声检查:肝形态增大,左叶大小约8.7cm×5.6cm,右叶斜径约15.0cm,肝内见弥漫分布的     

腹膜后恶性外周神经鞘瘤1例

患者女,41岁,于2个月前出现右侧腰部疼痛,近1个月来进行性加重,伴尿频、尿急、腹胀、乏力、纳差,无发热、呕吐.CT平扫于肝脏与右肾间见不规则混杂密度肿块影,约12.6 cm×8.7 cm×18.3 cm,其内可见片状低密度区、斑片索条状软组织密度影及钙化影;增强扫描肿块不均匀强化,斑片索条状影强化明显(CT值由41 HU强化为108 HU),片状低密度区无强化(CT值约为13 HU);肿物推挤肝脏、右肾及右侧肾上腺,与周围组织边界尚清,下腔静脉受压向左移位,内可见小的充盈缺损(图1、2).     

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.