基于临床联合CT影像组学特征列线图预测急性胰腺炎预后

目的 观察基于临床联合CT影像组学特征构建的联合模型列线图预测急性胰腺炎（AP）预后的价值。方法 回顾性分析203例临床首诊AP患者的临床及上腹部CT资料,按7 ： 3比例将其分为训练集（n=142）和验证集（n=61）,基于增强静脉期CT提取并筛选最优影像组学特征,计算影像组学评分Radscore;根据预后分为预后良好组（n=114）与预后不良组（n=89）。将临床变量（包括临床及CT表现）及Radscore纳入单因素和多因素逻辑回归分析,筛选影响AP预后的独立危险因素;构建临床、影像组学和联合模型,以受试者工作特征（ROC）曲线评价其预测AP预后的效能;以联合模型预测指标构建列线图,结合校准曲线评估其校准度。结果 共筛选出7个最优影像组学特征用于计算Radscore,其中C反应蛋白、糖尿病史和Radscore为影响AP预后的独立危险因素。联合模型预测训练集及验证集AP预后的AUC （0.84、0.82）均高于临床模型（0.71、0.66,Z=3.12、2.71,P均<0.05）;其预测训练集的AUC （0.84）高于影像组学模型（0.76,Z=2.39,P=0.02）,预测验证集的AUC （0.82）与影像组学模型（0.81）差异无统计学意义（Z=0.08,P>0.05）。校正曲线显示联合模型列线图的校准度良好。结论 基于临床联合CT影像组学特征列线图可有效预测AP预后。     

基于非小细胞肺癌双能CT表现及影像组学列线图模型预测其血管生成拟态

目的 基于非小细胞肺癌(NSCLC)双能CT (DECT)表现及影像组学构建联合列线图模型,分析其预测NSCLC血管生成拟态(VM)的价值。方法 回顾性分析137例经手术病理证实的单发NSCLC患者,以7 ∶ 3比例将其分为训练集和验证集。基于肺窗CT提取及筛选最优影像组学特征,计算影像组学评分。以单因素分析及多因素logistic回归分析筛选NSCLC表达VM的独立预测因素,分别以之构建临床、能谱及影像组学模型;基于独立预测因素构建联合列线图模型。采用受试者工作特征曲线评估各模型预测NSCLC VM的效能,以校准曲线分析模型的拟合度,以决策曲线分析评估模型的临床获益。结果 最终筛选出6个最优影像组学特征。病灶最大径、毛刺征、CT_{140 keV}及影像组学评分为NSCLC VM的独立预测因素(OR=2.25、9.69、0.99、-14.44,P均＜0.05)。临床、能谱及影像组学模型预测验证集NSCLC VM的曲线下面积(AUC)分别为0.83、0.85、0.87,均低于联合列线图模型(AUC=0.95,Z=2.14、2.10、2.07,P均＜0.05)。联合列线图模型预测结果与实际结果的一致性较好,且其临床获益较高。结论 基于DECT及影像组学构建的联合列线图模型能可有效预测NSCLC VM。     

基于T2WI影像组学模型产前预测胎盘植入性病变

目的 评估基于MR T2WI影像组学模型产前预测胎盘植入性病变（PAS）的价值。方法 回顾性分析241例孕妇及胎儿MRI,其中116例PAS、125例无PAS。按7：3比例将其分为训练集（n=168）和验证集（n=73）,于训练集提取并筛选半傅立叶采集单次激发快速自旋回波（HASTE）及真实稳态进动快速成像（TrueFISP）序列图像的影像组学特征,构建预测PAS的影像组学模型,并以回归分析方法构建临床模型、影像组学模型及临床-影像组学模型。采用校准曲线和受试者工作特征（ROC）曲线分析模型的效能,以决策曲线分析（DCA）评估其临床实用性。结果 对各序列图像分别提取1 130个影像组学特征,经LASSO回归等处理后,各筛选出9个影像组学特征,用于构建预测PAS的HASTE及TrueFISP影像组学模型。ROC曲线显示,临床模型、HASTE影像组学模型及TrueFISP影像组学模型在验证集中诊断PAS的曲线下面积（AUC）分别为0.882、0.968和0.930（P均>0.05）;HASTE联合TrueFISP影像组学模型的AUC为0.990,高于临床（Z=-2.36,P=0.02）、HASTE影像组学（Z=-2.48,P=0.02）及TrueFISP影像组学模型（Z=-2.43,P=0.02）;临床-HASTE-TrueFISP影像组学模型的AUC为0.995,与HASTE联合TrueFISP影像组学模型差异无统计学意义（Z=-0.85,P=0.40）,高于HASTE或TrueFISP影像组学模型（Z=-2.64、-2.47,P均<0.05）。临床模型之外,各模型在验证集数据中的校准度均较好;阈值取0~0.6时,其在验证集的临床净获益均大于临床模型。结论 基于产前HASTE及TrueFISP序列图像的联合影像组学模型有助于准确预测PAS。     

联合含瘤周肿瘤全体积CT影像组学特征及临床相关独立预测因子列线图预测肺腺癌淋巴血管侵犯

目的 观察基于含瘤周的肿瘤全体积(GPTV) CT影像组学特征及临床相关独立预测因子构建的联合模型列线图预测肺腺癌淋巴血管侵犯(LVI)的价值。方法 回顾性分析142例经病理证实的肺腺癌患者,以7 ∶ 3比例将其随机分为训练集(n=100,40例LVI阳性、60例LVI阴性)和验证集(n=42,17例LVI阳性、25例LVI阴性)。以单因素分析及多因素logistic回归分析筛选肺腺癌LVI的临床相关独立预测因子,以之构建临床模型。分别基于肿瘤全体积(GTV)及含瘤周3 mm、6 mm、9 mm的GPTV (GPTV₃、GPTV₆和GPTV₉)的增强动脉期CT图提取并筛选最佳影像组学特征,构建影像组学模型,即GTV、GPTV₃、GPTV₆和GPTV₉模型并筛选最佳者;基于后者的影像组学评分和临床相关独立预测因子构建联合模型,绘制列线图进行可视化。以受试者工作特征(ROC)曲线评估各模型预测肺腺癌LVI的效能,以决策曲线分析(DCA)评价联合模型列线图的价值。结果 性别、吸烟和毛刺征均为肺腺癌LVI的临床相关独立预测因子(P均＜0.05)。分别基于GTV、GPTV₃、GPTV₆及GPTV₉筛选出7、16、10及8个最佳影像组学特征,用于构建GTV、GPTV₃、GPTV₆及GPTV₉模型。GPTV₃模型预测训练集、验证集肺腺癌LVI的曲线下面积(AUC)分别为0.82、0.77,均高于GTV (0.79、0.72,Z=3.74、2.62,P均＜0.01)、GPTV₆(0.80、0.72,Z=2.40、2.06,P均＜0.05)及GPTV₉(0.77,0.72,Z=3.03、2.59,P均＜0.01),为最佳影像组学模型。联合模型列线图(0.86、0.73,Z=2.66、2.31,P均＜0.05)及GPTV₃模型(0.82、0.77,Z=2.23、2.54,P均＜0.05)于训练集和验证集的AUC均高于临床模型(0.73、0.61),而联合模型列线图与GPTV₃模型的AUC差异均无统计学意义(Z=1.57、0.88,P均＞0.05)。阈值取0.20~0.50时,联合模型列线图与GPTV₃模型的净获益相当,且均大于临床模型。结论 基于GPTV₃影像组学特征及临床相关独立预测因子的列线图可有效预测肺腺癌LVI。     

基于超声影像组学特征列线图模型术前鉴别早期与中晚期宫颈鳞癌

目的 观察基于经阴道超声影像组学特征建立的列线图模型术前鉴别早期与中晚期宫颈鳞癌的价值。方法 回顾性收集经术后病理证实的227例宫颈鳞癌患者,利用3D-Slicer软件于术前经阴道声像图中勾画ROI,提取并经冗余性分析、最小绝对收缩和选择算子(LASSO)和10折交叉验证筛选影像组学特征,构建影像组学模型并得到Radscore评分;利用多因素logistic回归纳入Radscore及临床资料构建列线图模型。比较2个模型术前鉴别早期与中晚期宫颈鳞癌的受试者工作特征曲线下面积(AUC);评估列线图模型的校准度及临床收益。结果 最终纳入18个超声影像组学特征;以之构建术前鉴别早期与中晚期宫颈鳞癌的影像组学模型在训练集和验证集的AUC分别为0.839和0.744;联合年龄、流产次数及Radscore评分构建的列线图模型在训练集和验证集的AUC分别为0.882和0.773。DeLong检验结果显示,上述2模型在训练集的AUC差异有统计学意义(P＜0.05)。Hosmer-Lemeshow检验显示,列线图模型在训练集和验证集的校准度均佳(χ²=5.053、7.063,P均＞0.05);决策曲线分析(DCA)显示其在0.01~1.00阈值区间净收益相对较大。结论 基于经阴道超声影像组学特征的列线图模型可于术前较好地鉴别早期与中晚期宫颈鳞癌。     

垂体相关临床及MRI影像组学特征联合列线图鉴别特发性中枢性性早熟与单纯乳房早发育

目的 观察垂体相关临床及MRI影像组学特征联合列线图鉴别特发性中枢性性早熟(ICPP)与单纯乳房早发育(PT)的价值。方法 纳入67例ICPP及51例PT共118例患儿,按照7 ∶ 3比例随机分为训练集(n=83)和验证集(n=35),记录其垂体相关临床资料,以多因素logistic回归分析筛选并建立临床模型。采集垂体MRI,基于矢状位T1WI提取垂体影像组学特征,以最大相关最小冗余、最小绝对收缩和选择算子及多因素logistic回归筛选最佳影像组学特征,构建影像组学模型。联合应用临床、MRI及影像组学特征构建列线图模型。绘制受试者工作特征曲线,评估模型鉴别诊断效能;以决策曲线分析(DCA)观察临床获益度。结果 训练集ICPP与PT患儿年龄、骨龄、体质量、黄体生成素(LH)基础值、卵泡刺激素基础值及垂体高度差异均有统计学意义(P均＜0.05)。骨龄及LH基础值是鉴别ICPP与PT的独立因素(OR=1.807、1.422,P均＜0.05),以之建立的临床模型鉴别训练集、验证集ICPP与PT的曲线下面积(AUC)分别为0.849和0.812。共提取垂体1 781个影像组学特征,于其中筛选出1个形态特征、1个一阶特征及1个灰度区域大小矩阵特征建立影像组学模型,其鉴别训练集和验证集ICPP与PT的AUC分别为0.956和0.947。基于最终得出的2个临床及3个垂体MRI影像组学特征构建的列线图模型鉴别训练集、验证集ICPP与PT的AUC分别为0.981、0.977,均优于临床模型(P均＜0.05),而与影像组学模型差异无统计学意义(P均＞0.05)。一定危险阈值范围内,列线图模型净收益最大。结论 基于垂体相关临床及MRI影像组学特征建立的联合列线图模型用于鉴别ICPP与PT具有较高价值。     

基于临床病理及常规和功能MRI影像组学模型预测乳腺癌腋窝淋巴结转移

目的 评估基于临床病理及常规和功能MRI（fMRI）影像组学模型预测乳腺癌腋窝淋巴结（ALN）转移的价值。方法 回顾性分析140例浸润性乳腺癌,按7∶3比例将其分为训练集（n=99）和验证集（n=41）。采用多因素Logistic回归分析分别建立基于临床病理及MRI特征的临床模型及各序列图像影像组学、联合序列影像组学以及临床病理及常规和fMRI影像组学的个体化模型,以受试者工作特征（ROC）曲线评价其诊断效能;比较个体化模型与临床模型曲线下面积（AUC）的差异,应用决策曲线分析（DCA）评估模型的临床获益。结果 临床模型预测训练集和验证集ALN转移的AUC分别为0.95和0.88;T2WI、DWI、DCE-MRI模型及联合序列模型在验证集中的AUC分别为0.67、0.71、0.72及0.76。个体化模型在训练集和验证集中的AUC为0.98和0.93,与临床模型差异均无统计学意义（Z=1.56、1.34,P=0.12、0.18）。DCA结果显示阈值>0.25时,个体化模型的净受益高于临床模型。结论 基于临床病理及常规和功能MRI的个体化模型预测乳腺癌ALN转移的效能与临床模型相当,其净受益高于后者,且均优于单一序列模型。     

多时相CT影像组学模型预测胸腺瘤风险分类

目的 观察多时相CT影像组学模型预测胸腺瘤风险分类的价值。方法 纳入86例经病理确诊的单发胸腺瘤患者,包括32例高风险及54例低风险胸腺瘤,按照7∶3比例将其分为训练集(n=59)和验证集(n=27);采用单因素及多因素logistic回归分析训练集临床及CT特征,筛选胸腺瘤风险分类的独立预测因素,构建临床-CT模型。分别基于平扫、动脉期(AP)、静脉期(VP)、平扫+AP、平扫+VP、AP+VP及平扫+AP+VP提取并筛选最优影像组学特征,计算影像组学评分(Rad-score);采用受试者工作特征(ROC)曲线选取最佳影像组学模型,以之联合临床-CT特征构建联合模型。绘制ROC曲线,计算曲线下面积(AUC),评估各模型预测胸腺瘤风险分类的效能。结果 周围脂肪浸润是胸腺瘤风险分类的独立预测因素(OR=0.029,P=0.004)。ROC曲线显示,模型_AP+VP为最佳影像组学模型,其与联合模型预测训练集胸腺瘤风险分类的AUC分别为0.860及0.877,均高于临床-CT模型的0.736(Z=1.925、-2.464,P均＜0.05),预测验证集的AUC分别为0.835及0.847,亦高于临床-CT模型的0.641(Z=1.840、-2.137,P均＜0.05);模型_AP+VP与联合模型在训练集和验证集的AUC差异均无统计学意义(Z=-1.180、0.291,P均＞0.05)。结论 多时相CT影像组学模型可有效预测胸腺瘤风险分类。     

T2WI、DWI及ADC图多序列影像组学模型评估直肠癌淋巴结转移

目的 观察基于术前MR T2WI、弥散加权成像(DWI)及表观弥散系数(ADC)图多序列影像组学模型评估直肠癌淋巴结转移的价值。方法 回顾性分析74例经术后病理确诊单发直肠癌患者的T2WI、DWI和ADC图,按照7∶3比例将其分为训练集(n=52,21例淋巴结转移、31例无淋巴结转移)和测试集(n=22,9例淋巴结转移、13例无淋巴结转移)。由2名影像科医师以病理结果为标准基于常规MRI评价淋巴结转移,评估其诊断效能;分别基于T2WI、DWI、ADC图及三者联合提取病灶影像组学特征,筛选后构建影像组学模型,包括T2WI模型、DWI模型、ADC模型及多序列模型,并于训练集进行训练,于测试集评估其效能。绘制受试者工作特征(ROC)曲线,计算曲线下面积(AUC),观察各模型诊断直肠癌淋巴结转移的效能。结果 训练集与测试集患者性别、年龄、病灶位置、T分期及N分期差异均无统计学意义(P均＞0.05)。常规MRI评估直肠癌淋巴结转移的准确率为58.11%(43/74),敏感度和特异度分别为76.67%(23/30)和45.45%(20/44)。T2WI、DWI、ADC及多序列模型评估测试集直肠癌淋巴结转移的AUC分别为0.78、0.68、0.77及 0.82,后者的准确率、敏感度及特异度分别为86.36%、88.89%及84.62%。结论 术前基于MR T2WI、DWI及ADC图多序列影像组学模型能有效评估直肠癌淋巴结转移。     

瘤内及瘤周表观弥散系数影像组学特征预测髓母细胞瘤患儿预后

目的 观察瘤内及瘤周表观弥散系数（ADC）影像组学特征预测髓母细胞瘤（MB）患儿预后的价值。方法 回顾性分析74例MB患儿资料,根据术后2年随访结果将其分为进展组（n=29）及无进展组（n=45）,并按6：4比例分为训练集（n=44）或验证集（n=30）。基于ADC图提取并筛选瘤内及瘤周影像组学特征,分别建立瘤内、瘤周及瘤内+瘤周影像组学模型,并以之结合临床及常规影像学特征建立联合模型;比较各模型预测MB患儿预后的效能。结果 训练集中,临床-常规影像-瘤周影像组学模型、临床-常规影像-瘤内+瘤周影像组学模型曲线下面积（AUC）均大于单一瘤周影像组学模型（P均<0.05）;验证集中,临床-常规影像学-瘤内+瘤周影像组学模型的AUC最大,但与其他模型差异均无统计学意义（P均>0.05）。结论 瘤内及瘤周ADC影像组学特征可用于预测MB患儿预后;联合临床及常规影像学特征或有助于提高预测效能。     

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.