磁共振扩散加权成像评价TACE联合血管生成抑制剂内皮抑素治疗兔VX2肝移植瘤

目的 应用DWI观察经导管肝动脉化疗栓塞术(TACE)联合血管生成抑制剂内皮抑素(ES)对兔VX2肝移植瘤增殖细胞核抗原(PCNA)表达的影响.方法 建立兔VX2肝移植瘤模型,随机分为对照组、TACE组和抗血管生成组,分别给予不同治疗.DWI观察治疗前后肿瘤的磁共振信号和表观扩散系数(ADC值)变化情况,b值选择350、550和1000 s/mm2.免疫组织化学染色检测肿瘤PCNA的表达.结果 肿瘤的接种成功率为100%,两周后可监测到肿瘤.b值为350、550和1000 s/mm2时,与对照组相比,TACE组和抗血管生成组术后ADC值差异均有统计学意义(P<0.05).b值为350和550 s/mm2时,TACE组和抗血管生成组术后ADC值间差异有统计学意义(P<0.05).TACE组、抗血管生成组和对照组瘤灶PCNA增值指数PI分别为0.69±0.11,0.41±0.07和0.72±0.15,组间比较差异均有统计学意义(P<0.05).结论 PCNA对肿瘤的生物学行为有显著影响,TACE联合抗血管生成治疗可明显抑制肿瘤细胞增殖活性.     

磁共振弥散加权成像和动态增强成像对肝癌经导管动脉化疗栓塞的疗效评价

目的 探讨DWI和动态增强成像(DCEI)在评价经导管动脉化疗栓塞术(TACE)治疗肝细胞癌(HCC)疗效中的作用。方法 收集TACE前及TACE后4~6周接受常规MR、DWI及DCEI检查的HCC患者20例(39个病灶),比较TACE前后各病灶大小、ADC值、动脉期和门脉期相对强化率(rER)的差异,分析TACE后ADC值下降/升高与动脉期或门脉期rER升高/下降之间的一致性。结果 TACE后病灶的直径 较TACE前 增大(P<0.001),ADC值 较TACE前 升高(P=0.003)。动脉期rER(0.69±0.38)与TACE前(0.73±0.48)差异无统计学意义(P=0.655),门脉期rER(1.21±0.36)与TACE前(1.27±0.37)的差异无统计学意义(P=0.451)。TACE后病灶ADC值的下降/升高与动脉期rER的升高/下降不一致(P=0.001),与门脉期rER的升高/下降保持一致(P=0.118)。TACE后门脉期rER升高病灶的ADC值 与TACE前 差异无统计学意义(P=0.255); TACE后门脉期rER下降病灶的ADC值 较TACE前 升高(P=0.004)。结论 HCC病灶的ADC值与其门脉期血流灌注存在一定的关系,可用于评价TACE治疗HCC的疗效。     

肝脏恶性肿瘤扩散加权成像与T2加权成像对比研究

目的比较肝脏扩散加权成像(DWI)和T2WI反映肝脏恶性肿瘤扩散特征、病理特征及肿瘤范围的价值.方法回顾性研究肝脏恶性肿瘤44例48灶(肝细胞癌30例30灶,肝转移瘤10例14灶,胆管细胞癌4例4灶),比较DWI与T2WI图像液体(脑脊液,胆囊胆汁)和肝脏恶性肿瘤的信号,肿瘤/肝脏信号强度比(SIR),对比噪声比(CNR)以及肿瘤范围,测量肿瘤表观扩散系数(ADC)值.结果在b=600 s/mm2的图像中,所有病例的脑脊液均显示为低信号.肝脏恶性肿瘤多表现为高信号,其信号分布特征与T2WI不同;肿瘤的信号强度和瘤/肝SIR,DWI与T2WI不相关;DWI信号强度与ADC值呈负相关.DWI的病灶对比噪声比高于T2WI,二者差异有显著性.DWI显示病灶范围与T2WI差异无显著性.结论b=600 s/mm2的肝脏DWI图像受T2穿透效应影响较小,能够较好地反映肝脏恶性肿瘤的扩散特征.DWI肿瘤对比噪声比更高,有助于病灶边界的确定.DWI反映的肝脏恶性肿瘤的扩散特征,可作为其影像学特征之一.     

经导管肝动脉化疗栓塞治疗肝细胞癌前后磁共振灌注成像观察

目的 观察肝细胞癌(HCC)患者经导管动脉化疗栓塞(TACE)治疗前后磁共振灌注加权成像(MR PWI)灌注值改变.方法 对22例HCC患者在TACE术前和术后3～10天分别进行MR PWI,得出术前及术后平均强化时间(MTE)、负增强积分(NEI)、病灶达峰值时间(TTP)、最大信号下降斜率 (MSD),比较TACE术前与术后上述各指标的差异.结果 HCC瘤区时间信号曲线(TIC)TACE术前呈快速下降,TACE术后趋向平缓;MTE与TTP值术后较术前降低,NEI值术后较术前升高,差异均有统计学意义(P<0.05);MSD值术后较术前降低,但差异无统计学意义(P>0.05).结论 MR PWI能够敏感地观察到HCC TACE术前后的血流变化,可用于评价TACE疗效.     

氩氦刀联合经肝动脉化疗栓塞术治疗肝癌疗效的MRI评价

目的探讨氩氦刀联合经肝动脉化疗栓塞术(TACE)治疗原发性肝癌的MRI诊断价值。方法对49例肝癌患者行氩氦刀联合TACE治疗共56个病灶的MRI图像进行回顾性分析,评价其疗效,探讨肿瘤残留的MRI特点。结果 56个病灶先TACE后氩氦刀治疗病灶24个,肿瘤完全坏死21个(87.5%),先氩氦刀后TACE治疗病灶32个,肿瘤完全坏死11个(34.3%);5cm以下病灶完全坏死率为78.8%(26/33),5cm以上病灶完全坏死率为26.1%(6/23);全部病灶完全坏死率为57.1%(32/56)。肿瘤消融完全的MRI表现为消融范围覆盖全部肿瘤、肿瘤区无强化;T2WI肿瘤边缘高信号,增强扫描肿瘤不规则强化是肿瘤残留的可靠征象。结论 MRI评价氩氦刀联合TACE治疗肝癌的疗效准确、及时,特异性高,T2WI及增强扫描仍是评价疗效的关键。     

磁共振扩散加权成像早期评估热消融肝癌疗效的价值

目的：探讨磁共振扩散加权成像（DWI）早期评估热消融肝癌疗效的价值。方法：21个肝细胞癌于热消融前、消融完成后24 h内行不同b值下的DWI检查。比较相同b值下病灶消融前后ADC值的差异。用受试者工作特征（ROC）曲线分析活性肿瘤与坏死组织的ADC值。结果：相同b值下肿瘤消融后的ADC值均较消融前升高,差异均具有统计学意义（P＜0.01）。ROC曲线显示b值为800、1 000 s/mm2时,ADC值鉴别二者有意义。b值为1 000 s/mm2时,ADC值阈值为1.09×10-3 mm2/s时诊断肿瘤坏死的灵敏度为89.5%,特异度为63.2%;选择阈值为1.26×10-3 mm2/s时诊断肿瘤坏死的灵敏度为52.6%,特异度为89.5%。结论：DWI在早期评价热消融肝癌疗效中有一定价值。     

吸氧前后乳腺浸润性导管癌BOLD-fMRI成像的特征及意义

目的观察与比较乳腺浸润性导管癌患者吸氧前后基于血氧合水平依赖效应的功能磁共振成像(BOLD-fMRI)信号的特征及变化,探讨乳腺癌BOLD-fMRI成像特征及临床价值。方法纳入2011年1～12月我院病理证实乳腺浸润性导管癌患者21例,所有患者均于术前知情同意后于面罩吸氧前及吸氧15min后采用3.0T核磁共振仪行BOLD-fMRI及扩散加权成像(DWI)检查,测定肿瘤BOLD-fMRI的R2*值及DWI的ADC值,比较吸氧前后乳腺癌组织R2及ADC值关系及变化。结果 21例患者平均年龄为(47.1±9.2)岁,其中术后病理证实9例为浸润性导管癌Ⅱ级,12例为浸润性癌Ⅲ级。21例患者吸氧前肿瘤组织BOLD-fMRI呈高信号,R2*值为(51.8±16.7)Hz,吸氧后BOLD-fMRI显示病灶信号减低,R2*值为(49.1±16.9)Hz,Wilcoxon秩和检验比较吸氧前后R2变化,显示Z=-3.425,P=0.001。21例患者吸氧前瘤灶ADC为低信号,ADC平均值为(0.866±0.195)×10-3mm2/s,吸氧后ADC信号无明显变化,ADC值为(0.866±0.194)×10-3mm2/s,Wilcoxon秩和检验比较吸氧前后ADC值,显示Z=-1.651,P=0.099。Pearson相关分析显示吸氧前R2*值与ADC值无统计学相关(r=0.334,P=0.139),吸氧后R2*值与ADC值无统计学相关(r=0.363,P=0.106)。结论吸氧后乳腺浸润性导管癌组织总体BOLD信号减低,DWI无明显变化,吸氧前后后BOLD-fMRI成像R2*值变化可能用于评价乳腺癌乏氧状态及变化的方法,为肿瘤治疗评价提供一条新思路。     

TACE对肝癌细胞凋亡和增殖的影响

目的探讨经动脉化疗栓塞术(TACE)对肝细胞癌细胞凋亡指数(AI)和细胞增殖指数(PCNA-LI)的影响,以及AI和PCNA-LI的相关性.方法经病理证实的肝细胞癌病例63例,包括单纯手术组42例,TACE组21例.采用TUNEL法和免疫组织化学SP法分别检测各标本的AI和PCNA-LI. 结果 TACE组AI高于单纯手术组,PCNA-LI低于单纯手术组(P<0.01),AI和PCNA-LI呈高度负相关(P<0.01).TACE组术后血清AFP值较术前下降(P< 0.05),肿瘤缩小,坏死率增高(P<0.01).结论 TACE可以明显增加HCC细胞凋亡率,降低细胞增殖率,从而促使肿瘤缩小,促进肿瘤坏死,达到治疗目的.     

磁共振ADC值定量评价原发性肝癌TACE术后疗效的应用价值

目的:研究磁共振表观扩散系数(ADC)值在原发性肝癌TACE术后疗效评价中的应用价值。方法:收集某院60例行TACE治疗的原发性肝癌患者,共87个病灶,均于术前、术后行常规MRI扫描及DWI序列扫描,分析原发性肝癌TACE术后病灶在DWI成像序列的信号特点,测量并记录术区瘤灶及新发病灶区的ADC值,分析ADC值在鉴别肿瘤残存组织和坏死组织中的价值。结果:(1)术前病灶(Ⅰ组)平均ADC值为(0.937±0.08)×10~(-3)mm~2/s;(2)完全栓塞病灶(Ⅱ组)平均ADC值为(1.481±0.15)×10~(-3)mm~2/s;(3)不完全栓塞病灶(Ⅲ组)平均ADC值为(1.226±0.18)×10~(-3)mm~2/s;(4)肿瘤再发病灶(Ⅳ组)平均ADC值为(0.965±0.06)×10~(-3)mm~2/s。结论:磁共振表观扩散系数值可以对瘤灶进行定量测量,有效区分瘤灶的活性组织和坏死组织成分,可对原发性肝癌TACE术后疗效起到较好的评价作用,从而为临床上进一步治疗提供可靠的影像依据。     

磁共振弥散加权成像及磁敏感加权成像对急性静脉性脑梗死的临床应用

目的 评价磁共振弥散加权成像(DWI)及磁敏感加权成像(SWI)对急性静脉性脑梗死的临床应用价值.方法 搜集17例急性静脉性脑梗死患者的核磁共振成像(MRI)资料,MRI序列有T1WI、T2WI、FLAIR、DWI、SWI及磁共振静脉成像(MRV),观察梗死区信号变化特点.结果 10例为出血性静脉脑梗死,7例为非出血性静脉脑梗死,出血灶共15处.所有病例DWI图像上均有异常改变,其中均匀一致高信号有21处,混杂稍高信号5处.16个病灶ADC值降低,10个病灶ADC值升高.出血灶DWI表现为中央低信号,周边不规则高信号,ADC值降低.SWI可以显示所有出血灶(15/15),较T1FFE序列(12/15)、T2FSE序列(9/15)、T2-FLAIR序列(13/15)多.其中15例(15/17)SWI最小密度投影(MinIP)图像梗死区及静脉窦闭塞区可见多发扩张的小静脉,其他序列未见此征象.结论 急性期静脉性脑梗死MRI表现较动脉性脑梗死复杂,DWI图像可以反映静脉性脑梗死的病理过程,SWI可以发现更多的出血灶和扩张的引流小静脉;DWI联合SWI对早期诊断急性静脉性脑梗死、判断静脉性脑梗死患者预后有较高的价值.     

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.     

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.     

Prospects for the control of neglected tropical diseases by mass drug administration

The prospects for the control of neglected tropical diseases, including soil-transmitted helminthiasis, shistosomiasis, lymphatic filariasis, onchocerciasis and trachoma, through mass drug administration, are exemplified by the elimination of the trachoma as a public-health problem in Morocco. In spite of this and other striking successes, mass drug administration programs are faced with major challenges resulting from suboptimal coverage and lack of efficacy. At current suboptimal coverage rates, programs may need prolongation for an extended period, increasing costs and undermining sustainability. Community participation through health education and information appears to be crucial to improve coverage and to achieve sustainability. Implementation of complementary measures, such as vector control, improved hygiene and environmental sanitation, are important to further control transmission and to prevent re-emergence of the infection and, again, may only be achieved effectively through community-based initiatives. To reduce costs and to relieve pressure on the health system, combining neglected tropical disease programs in areas where diseases coexist and integration with existing control programs for malaria, tuberculosis and HIV/AIDS is advocated. The risk of developing drug resistance is of particular concern in view of the lack of alternative drugs, and reduced treatment efficacy due to emerging resistance is evident for the soil-transmitted helminths and onchocerciasis. Given the risk for the development of drug resistance and the need for a high degree of participation, close attention should be paid to the monitoring of the coverage and efficacy of the different program components.     

Bacterial meningitis: an update of new treatment options

The outcome of bacterial meningitis critically depends on the rapid initiation of bactericidal antibiotic therapy and adequate management of septic shock. In community-acquired meningitis, the choice of an optimum initial empirical antibiotic regimen depends on the regional resistance patterns. Pathogens resistant to antibacterials prevail in nosocomial bacterial meningitis. Dexamethasone is recommended as adjunctive therapy for community-acquired meningitis in developed countries. In comatose patients, aggressive measures to lower intracranial pressure <20 mmHg (in particular, external ventriculostomy, osmotherapy and temporary hyperventilation) were effective in a case–control study. Although many experimental approaches were protective in animal models, none of them has been proven effective in patients. Antibiotics, which are bactericidal but do not lyse bacteria, and inhibitors of matrix metalloproteinases or complement factor C5 appear the most promising therapeutic options. At present, vaccination is the most efficient method to reduce disease burden. Palmitoylethanolamide appears promising to enhance the resistance of the brain to infections.     

Imaging choices in occult hip fracture

Background: Hip fracture is a common injury, with an incidence rate of > 250,000 per year in the United States. Diagnosis is particularly important due to the high dependence on the integrity of the hip in the daily life of most people. Objectives: In this article we review the literature focused on hip fracture detection and discuss advantages and limitations of each major imaging modality. Discussion: Plain radiographs are usually sufficient for diagnosis as they are at least 90% sensitive for hip fracture. However, in the 3–4% of Emergency Department (ED) patients having hip X-ray studies who harbor an occult hip fracture, the Emergency Physician must choose among several methods, each with intrinsic limitations, for further evaluation. These methods include computed tomography, scintigraphy, and magnetic resonance imaging. Conclusion: We present an evidence-based algorithm for the evaluation of a patient suspected to have an occult hip fracture in the ED. Also outlined are future directions for research to distinguish more effective techniques for identifying occult hip fractures.     

Systematic Reviews Published in the April 2012 Issue of the Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly as a DVD but monthly online. The April 2012 issue (second DVD for 2012) contains 5045 complete reviews, 2182 protocols for reviews in production, and 17,084 short summaries of systematic reviews published in the general medical literature. In addition, there are citations of 674,000 randomized controlled trials, and 15,400 cited papers in the Cochrane methodology register. The health technology assessment database contains just over 11,000 citations. One hundred and seventeen new reviews have been published in the last 3 months of which 12 have potential relevance for practitioners in pain and palliative medicine. The impact factor of the Cochrane Library stands at 6.186. Readers are encouraged to access the full report for any articles of interest as only a brief commentary is provided.     

Platelets,thrombosis, coagulation,and atherosclerosis

When I first got the invitation to join a medical delegation going to Moldova, I thought for a moment that our destination was the fictional country in the old Marx Brothers movie Duck Soup. On further checking, it turns out that entertaining place was called Freedonia. I now know that Moldova is indeed a real country, bordered on the west by Romania and on the other three sides by the Ukraine. It is a proud country, rich with traditions, and its people are warm, giving, eager to learn ways to improve their healthcare system, and deeply appreciative of our attempts to help them in the task.     

Advance Care Planning

Predictors of patient wishes and influence of family and clinicians are discussed. Research findings on patient decision-making relating to preferences in end-of-life care are described. Advance directives and durable powers of attorney are defined and differentiated. Most patients have not participated in advance care planning and the need for more effective planning is documented. Appropriate times for discussions of such planning are described. Scenarios discussed include terminal cancer, chronic obstructive pulmonary disease, AIDS, stroke, and dementia. Patient satisfaction is discussed, as is a structured process for discussions about patient preferences. Results of patient responses to hypothetical scenarios are described. Invasiveness of interventions, prognosis and other factors that favor or discourage patient preferences for treatment are discussed. Findings resulting from research funded by the Agency for Healthcare Research and Quality (AHRQ) are discussed. This research can help providers offer end-of-life care based on preferences held by the majority of patients under similar circumstances.     

Spiritual Dimensions of Nursing Practice. edited by V. B. Carson

The Cochrane Library of Systematic Reviewsis published quarterly. Issue one for 2004 of the library was published in February 2004. This issue contains 3,329 reviews and protocols of which 1,921 are fully published reviews. The trials database now stands at over 400,000 records with an additional 4,427 one-page summaries of non-Cochrane reviews in the NHS database of reviews of effectiveness (DARE). This version of the library contains the results of an extensive search for RCTs on EMBASE. The latest library contains 84 new reviews, seven are considered relevant to practitioners in pain and palliative care. References are published in the same format as the citation for Cochrane reviews.     

Évaluation,par l’imagerie ultrasonore,du recrutement musculaire,de la force motrice et de la détente verticale du quadriceps après électromyostimulation (cas de 15 étudiants de l’INJS)

The increase of strength seems to be an element of performance in some sports.