超声弹性成像技术在腮腺良恶性占位性病变鉴别诊断中的应用价值

目的 探讨实时超声弹性成像技术在腮腺良恶性占位性病变鉴别诊断中的应用价值.方法 对48例52个腮腺占位性病变首先行二维超声检查,观察病灶的位置、大小、形态、边界、内部回声、后方回声等,然后切换到实时超声弹性成像模式进行实时超声弹性成像检查,将弹性图像分为0～Ⅳ级,并与手术病理结果进行比较.结果 良性病变组81.8%(36/44)占位性病变弹性分级为0～Ⅱ级,而恶性病变组87.5%(7/8)占位性病变弹性分级为Ⅲ～Ⅳ级,两组病变的弹性分级情况比较差异有统计学意义(P=0.039).以弹性分级Ⅲ～Ⅳ级为恶性预测指标,其敏感度、特异度、准确性、阳性预测值、阴性预测值分别为87.5%(7/8)、81.8%(36/44)、82.7%(43/52)、46.7%(7/15)、97.3%(36/37).结论 实时超声弹性成像提供了组织软硬度的信息,有助于腮腺良恶性占位性病变的鉴别.但部分多形性腺瘤和恶性病变在弹性图上存在一定重叠,需结合二维超声、彩色多普勒超声等常规超声及临床资料进行综合评价,帮助鉴别诊断.     

实时超声弹性成像在甲状腺占位性病变中的初步应用

目的探讨实时超声弹性成像在甲状腺疾病诊断中的应用价值。方法分析40例(44个病灶)甲状腺占位性病变的超声弹性图表现,将图像分为0～IV级,并与病理结果作对比。结果良性病变以0～II级多见,而恶性病变以III～IV级多见。以III级以上(含III级)作为判断恶性的标准,则其敏感性为100%,特异性为77.1%,准确性81.8%。结论超声弹性成像对甲状腺结节的诊断提供较大帮助。     

超声弹性应变率值在甲状腺良恶性结节诊断中的应用

目的探讨超声实时弹性成像及超声弹性应变率值在甲状腺良恶性结节诊断中的最佳诊断界点及其在甲状腺良恶性结节鉴别诊断中的应用价值。方法对64例患者二维超声检出的91个甲状腺结节行超声弹性成像检查及应变率值测量;依据病理诊断结果对良性与恶性甲状腺结节予以弹性分级与分组;以Ⅲ级为界:0～Ⅱ级诊断为良性,Ⅲ～Ⅳ级诊断为恶性。结果 (1)超声弹性分级诊断:64例91个甲状腺结节术前超声弹性分级诊断为0～Ⅱ级45个结节(良性组),弹性分级诊断与病理诊断符合43个结节(43/64,67.2%);弹性分级诊断为Ⅲ、Ⅳ级46个结节,弹性分级诊断与病理诊断符合25个结节(25/27,92.6%);(2)超声应变率值测量:91个结节中67个结节应变率值5.525,24个结节应变率值≥5.525;恶性组结节应变率值均值(7.38±3.72),高于良性组(2.64±1.32,P0.05);(3)应变率值最佳临界点:通过ROC曲线确定的弹性应变率值最佳诊断界点为5.525,约登指数0.78,以超声弹性应变率值5.525为最佳诊断界点,检出良性组中62个结节(62/64)与病理诊断符合;以超声弹性应变率值≥5.525为最佳诊断界点,检出恶性组中22个结节(22/27)与病理诊断符合,对应的敏感性为81.5%,特异性为96.8%;(4)甲状腺结节良恶性鉴别:应变率值ROC曲线下面积0.892大于弹性分级法0.799,应变率值准确性92.3%高于弹性分级法的74.7%。结论超声弹性成像应变率值可用于甲状腺结节良恶性的判断,为甲状腺弹性成像检查提供了一项新的诊断指标。     

计算机辅助超声医师诊断甲状腺TI-RADS 3～4级占位病变的价值

目的评价甲状腺超声图像分析软件(AmCAD-UT Detection)辅助超声医师诊断甲状腺TI-RADS 3～4级占位病变性质的作用及可行性。方法本试验入组病例超声诊断为TI-RADS 3级50例,诊断为TI-RADS 4级174例占位病变;病理证实154例甲状腺恶性病灶及80例甲状腺良性病灶,将符合AmCAD-UT Detection分析系统读片要求的术前超声图像输入系统,该系统通过对甲状腺结节超声图像中表现的主要良、恶性鉴别特征进行处理、量化,并通过诊断系统进行诊断,同时术前超声诊断医师结合软件处理后图像及诊断结论重新进行诊断。对比同一医师在使用该软件前、结合软件后及软件本身独立诊断三者对甲状腺占位病例诊断的灵敏度、特异度及准确率差异。结果对比超声医师术前独立诊断、AmCAD-UT Detection软件读图诊断及超声医师结合软件后诊断三者对甲状腺占位性病变的灵敏度、特异度及准确率。医师术前独立诊断甲状腺占位病变准确率:CUT OFF值设定为TI-RADS 4a、4b及4c级分别为82.1%、54.6%、76.6%;甲状腺CAD诊断甲状腺占位病变准确率:CUT OFF值设定为TI-RADS 4a、4b及4c级分别为86.8%、89.3%、88%;超声医师结合甲状腺CAD诊断甲状腺占位病变准确率:CUT OFF值设定为TI-RADS 4a、4b及4c级分别为91.5%、91.0%、88%。ROC曲线下面积:超声医师、CAD及超声医师+CAD分别为82.3、93.1、96.3;比较三者诊断能力:医师结合CADCAD医师独立诊断,AmCAD-UT Detection辅助超声医师提高诊断甲状腺TI-RADS 3～4级占位病变性质的能力。结论 AmCAD-UT Detection可辅助超声医师提高诊断甲状腺TI-RADS 3～4级占位病变的诊断能力,提高超声医师诊断结节恶性或良性倾向性百分比,为临床医师下一步治疗方案提供更明确依据。     

超声弹性成像鉴别良恶性甲状腺结节

目的 探讨超声实时弹性成像在甲状腺良恶性结节鉴别诊断中的应用价值.方法 术前采用超声弹性成像技术对87例(135个结节)患者的甲状腺结节进行检查,予以弹性分级.结果 结节性甲状腺肿弹性分级以≤Ⅱ级为主,甲状腺乳头状癌弹性分级以≥Ⅲ级为主.良性结节的弹性分级以0～Ⅱ级为主,恶性结节的弹性分级以Ⅲ～Ⅳ级为主,甲状腺良恶性结节弹性分级的差异有统计学意义(P<0.05).弹性分级Ⅲ级时,良恶性结节差异有统计学意义(P<0.05).对于甲状腺结节良恶性的鉴别,超声弹性分级诊断的敏感度、特异度和准确率分别为90.91%、76.47%、80.00%. 结论超声弹性成像有助于甲状腺结节良恶性的判断.     

声触诊组织弹性成像鉴别诊断甲状腺结节良恶性的价值

目的 探讨声脉冲辐射力声触诊组织弹性成像(virtual touch tissue imaging,VTI)定性诊断甲状腺结节良恶性的价值.方法 观察经病理证实的74例患者共77个甲状腺结节的VTI图像特征,并将图像分为6级,级数越高代表组织硬度越大.应用ROC曲线分析VTI分级诊断甲状腺结节良恶性的最佳诊断点,并计算其敏感度、特异性及准确率.结果 77个甲状腺结节病理证实良性病变61个,恶性病变16个.恶性病变中VTI图像分别为Ⅰ级0个,Ⅱ级1个,Ⅲ级1个,Ⅳ级9个,Ⅴ级3个及Ⅵ级2个;良性病变中VTI图像分别为Ⅰ级18个,Ⅱ级28个,Ⅲ级10个,Ⅳ级1个,Ⅴ级2个及Ⅵ级2个.VTI弹性分级最佳诊断点为Ⅳ级,Ⅳ级及Ⅳ级以上诊断恶性甲状腺结节的敏感度、特异性及准确率分别为87.5％、91.8％、90.9％.结论 VTI可帮助判断甲状腺结节的良恶性.     

实时超声弹性成像在甲状腺弥漫性病变中的初步应用

目的 探讨实时超声弹性成像对甲状腺炎性病变的诊断价值.方法 对照各甲状腺炎性疾病的病理基础,分析各种甲状腺炎性病变的超声弹性成像的图像特征.结果 单纯性甲状腺肿8人与甲状腺功能亢进7人的弹性图像主要表现为Ⅱ级;甲状腺功能减低6人、亚急性甲状腺炎5人、桥本氏甲状腺炎12人的弹性图像主要表现为Ⅲ级;对照组15人弹性图像主要表现为Ⅰ级.结论 弹性图像可鉴别甲状腺炎性疾病组与正常组,具有一定的临床参考价值.     

三维声弹性成像在甲状腺结节诊断中的初步应用

目的探讨三维声弹性成像在甲状腺结节诊断中的应用价值。方法选取于复旦大学附属中山医院诊治的34例甲状腺结节患者,依次进行灰阶超声、彩色多普勒超声、二维声弹性成像和三维声弹性成像检查。根据三维声弹性图表现,将病灶的弹性分级分为Ⅰ~Ⅳ级,并与病理结果对比。结果良性病变以Ⅰ~Ⅱ级多见,恶性病变以Ⅲ~Ⅳ级多见,良性病变与恶性病变声弹性图的分布差异具有统计学意义（P〈0.05）。以Ⅲ级以上（含Ⅲ级）作为判断恶性的标准,灵敏度为94.4%,特异度为81.3%,准确率为88.2%。结论三维声弹性成像对甲状腺结节的诊断能提供一定帮助。     

超声弹性成像在乳腺疾病中的初步应用

目的探讨超声弹性成像对乳腺疾病的诊断价值。方法分析28例(31个病灶)乳腺疾病的超声弹性图表现,将图像分为0~V级,并与病理结果作对比。结果良性病变以0～II级多见,而恶性病变以III~V级多见。结论超声弹性成像对乳腺疾病的诊断提供另一种新指标。     

彩超联合超声弹性成像对Graves病和桥本氏甲状腺炎的诊断价值分析

目的探讨彩超联合超声弹性成像对弥漫性甲状腺肿(Graves病,GD)和桥本氏甲状腺炎(HT)的诊断价值。方法选取20例GD患者和20例HT患者,采用彩超联合超声弹性成像进行检查,观察甲状腺的大小、形态、血运、回声及弹性情况。结果两组患者甲状腺均明显增大,Graves组低回声分布分级以2级为主,HT组以3级为主(P<0.05);HT组85%呈网格样强回声分布,Graves组较少见(P<0.05)。Graves组收缩期峰值流速、舒张末期流速均较HT组快(P<0.05)。Graves组弹性图像分级以2级为主,占85%(17/20);HT组弹性图像分级以3级为主,占80%(16/20)。Graves组MEAN明显大于HT组,AREA%则较HT组小(P<0.05)。结论彩超联合超声弹性成像能为Graves病和桥本氏甲状腺炎的诊断提供更多信息,有效提高诊断准确率。     

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.     

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.     

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.     

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.