早期胃癌25例误诊原因分析

目的:探讨早期胃癌误诊原因,提高本病诊断水平.方法:回顾分析2000年1月～2007年6月我院收治的25例早期胃癌误诊病例资料.结果:本组占我院同期收治胃癌的20.3%,误诊时间最短1个月,最长达6个月余,其中20例误诊2个月以上.误诊为胃溃疡13例,慢性胃炎11例,神经症1例.19例再次行纤维胃镜并取活组织病理检查确诊,6例因长期慢性溃疡行胃大部切除术经术中冷冻切片病理检查确诊.临床分型:T1N0M0 21例,T1N1M0 4例.结论:早期胃癌起病隐匿,症状轻,需对高危人群加以警惕,提高胃镜、X线诊断水平,以降低早期胃癌误诊率.     

进行性核上性麻痹临床特征及误诊分析

目的探讨进行性核上性麻痹(PSP)的临床特征及误诊原因、防范措施。方法对2015年1月—2019年12月收治的曾误诊的PSP 15例的临床资料进行回顾性分析。结果本组误诊率为57.69%,以步态不稳和运动迟缓起病10例,以静止性震颤和垂直性核上性眼肌麻痹起病各2例,以认知功能障碍起病1例。15例均出现垂直性核上性眼肌麻痹,11例出现帕金森病症状。曾误诊为帕金森病11例,动眼神经麻痹2例,路易体痴呆和多系统萎缩各1例。误诊时间0.5～5.0年。本组均依据临床表现、头颅MRI检查结合相关诊断标准确诊PSP,予相应治疗,3例运动障碍稍有改善,但1个月后病情再次进展;12例症状无明显改善。结论 PSP起病隐匿,临床表现复杂多样,早期缺乏相关诊断指标,极易误诊。临床医生应提高对其认识,详细询问病史和仔细查体,重视头颅影像学检查,并长期随访,以减少或避免该病误诊误治。     

小儿肝豆状核变性误诊5例分析

目的：分析我院肝豆状核变性误诊的原因。方法：将我院近年来发现的以神经系统症状为主要表现的肝豆状核变性5例情况分别从临床症状、体征及辅助检查方面及以分析,从而找出误诊原因。结果：所有5例患者最后均确诊为肝豆状核变性,经相应的药物治疗后症状大为改观。结论：提高对肝豆状核变性的认识,减少本病的误诊率。     

误诊为类风湿关节炎的原发性干燥综合征八例分析

目的分析原发性干燥综合征误诊为类风湿关节炎的原因。方法回顾分析2014年3月—2018年10月我院就诊的54例原发性干燥综合征中8例误诊为类风湿关节炎的临床资料。结果本组误诊率14.81%。8例中4例以双下肢肿痛并活动受限3～15年,加重1～7 d入院;4例以滑膜炎、下肢疼痛伴皮疹反复发作1～10年,加重1～5 d入院。8例均误诊为类风湿关节炎,误诊时间5个月～8年。给予甲氨蝶呤、柳氮磺吡啶、糖皮质激素、非甾体类消炎药等常规治疗,口干、眼干症状无明显改善,后经抗SSB抗体和(或)抗SSA抗体检查、角膜染色和(或)Schirmer试验、唾液腺动态显像、腮腺检查等确诊为原发性干燥综合征。8例确诊后给予相应治疗,患者症状明显缓解后出院。结论原发性干燥综合征主要表现为关节疼痛时和类风湿关节炎表现相似,若接诊医生诊断思维片面,易引起误诊。临床医生应加强对原发性干燥综合征的认识,综合分析病情,及时行自身抗体等相关检查,可减少或避免误诊。     

6例以急性腹痛起病的糖尿病酮症酸中毒的误诊分析

[目的]探讨糖尿病酮症酸中毒(DKA)引起急性腹痛的机制、与急腹症的鉴别要点及误诊原因.[方法]对6例以急性腹痛起病的糖尿病酮症酸中毒误诊病人的临床资料进行分析.[结果]本组6例病例院外误诊5例,本院误诊1例.6例患者确诊后经抢救10～36 h症状好转,酮症消失.[结论]以急性腹痛起病的糖尿病酮症酸中毒易与外科急腹症误诊,临床医生应加强对DKA以患者急性腹痛为首发症状的认识,以降低误诊率.     

临床表现不典型的慢性阑尾炎19例误诊原因分析

目的总结慢性阑尾炎的误诊原因,以减少误诊误治。方法回顾分析我院2008年3月—2012年3月收治经手术确诊慢性阑尾炎47例的临床资料。结果本组19例误诊,误诊率40.43%。误诊为慢性胃炎7例,盆腔炎5例,慢性结肠炎4例,慢性胆囊炎2例,右肾结石1例。后经手术探查、术后病理检查及相关医技检查确诊,误诊时间1.0~4.3年。经相应治疗,术后切口愈合出院。结论对无典型急性阑尾炎发作史,以反复右下腹痛为主要表现者,临床应警惕慢性阑尾炎的可能。     

多系统萎缩临床特征、诊断时程影响因素及误诊原因分析

目的探讨多系统萎缩(multiple system atrophy, MSA)临床特征、诊断时程影响因素及误诊原因、防范措施。方法对2016年1月—2018年6月于空军军医大学西京医院神经内科住院的52例MSA的临床资料进行回顾性分析。结果本组52例MSA,以帕金森病样症状为突出表现的P型(MSA-P)30例(57.7%),以小脑综合征为突出表现的C型(MSA-C)22例(42.3%)。MSA-P患者接受左旋多巴治疗较MSA-C患者多,且Epworth嗜睡评分量表及汉密顿焦虑量表评分高于MSA-C患者,Hoehn和Yahr帕金森病分级3～5级所占比例较MSA-C患者低,差异均有统计学意义(P0.05)。男性和非运动症状首发患者较女性和运动症状首发患者起病至首诊时程及起病至确诊时程更长,差异均有统计学意义(P0.05)。本组首诊误诊50例,误诊为帕金森病12例,脑梗死9例,泌尿系感染7例,脑供血不足及诊断不明各5例,小脑萎缩4例,颈椎病及前列腺增生各2例,心脏病、腰椎间盘突出、糖尿病周围神经病和胃炎各1例。首诊误诊患者起病至确诊时间40(25,72)个月。7例因误诊行手术治疗。参考2008年Gilman等提出的MSA第2版诊断标准,本组14例符合可能MSA标准,38例符合很可能MSA标准。52例MSA中23例(44.2%)接受过左旋多巴治疗,其中MSA-P中12例(40.0%)以及MSA-C中1例(4.5%)接受左旋多巴治疗有效;29例(55.8%)MSA未接受左旋多巴治疗。结论 MSA首诊误诊率高,确诊时程长。提高对该病认识、详细询问病史及合理进行医技检查可减少该病误诊误治。男性和非运动症状首发可能是影响MSA诊断时程的因素。     

肌萎缩侧索硬化临床分析

目的探讨肌萎缩性侧索硬化（amyotrophic lateral sclerosis,ALS）的临床特点和诊断。方法分析2005年1月-2009年1月收治的57例ALS患者,对其临床特点进行统计分析。结果 ALS以50～60年龄段发病为主,男性多见。患者平均发病年龄52岁,男女发病年龄无差别,男女比例1.7∶1,死亡23例（40.4%）,平均生存时间22个月。结论发病年龄越晚,病后存活时间越短。临床表现隐袭起病,逐渐进展。其诊断主要依据临床表现,肌电图检查对早期诊断有重要的价值。     

成人颅内肿瘤常见误诊类型102例分析

成人颅内肿瘤系神经科常见疾病 ,原发性肿瘤的发病率为7.8～ 12 .5 /10万人 ,平均年发病率约为 10 /10万人 [1 ]。由于颅内结构复杂 ,肿瘤特性及患者个体差异 ,临床表现多样 ,极易误诊。 1997～ 2 0 0 0年经我院神经内外科确诊的原发性颅内肿瘤患者 178例 ,其中 10 2例确诊前曾被院内外误诊 ,误诊率达5 7.3%。现对其临床资料进行分析总结如下。1　临床资料1.1　一般资料　本组男 47例 ,女 5 5例 ,年龄 18～ 82岁。患者的早期表现、误诊类型及影像学结果见表 1。表 1　 10 2例成人颅内肿瘤情况早期症状例数 (% )误诊时间误诊病种 (例 ) CT/ …     

成人结核性脑膜炎23例误诊原因分析

结核性脑膜炎(简称结脑)的症状多种多样,与颅内非特异性感染疾病鉴别困难。早期极易误诊或漏诊。为提高诊断正确率,对我院1977年—1987年收住院的98例成人结脑中误诊的23例作一回顾性分析。临床资料一、病例选择,成人结脑均按结脑综合诊断标准选择的住院确诊病人。病人入院首次查房没有考虑到结脑、未按结脑治疗者列为误诊。按此标准,98例中23例误诊,误诊率为23.46％,与文献报导相似①。误诊时间4～150天、平均15天。二、年龄和性别:男性15例,女8例;16～42岁、平均24岁。三、误诊情况和确诊手段:1、以发热、头痛,全身不适起病者误诊为上感8例。数日以后病情加重才出现呕吐及脑膜刺激征。CSF检查符合结脑,按结脑治疗显效。     

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.     

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.     

手转胎头术失败的原因与分娩结局临床分析

目的 探讨手转胎头术失败的原因与分娩结局.方法 选择2008年1月至2010年12月于我院住院分娩的持续性枕横位、枕后位产妇198例,根据行手转胎头术后结果分为成功组126例、失败组72例.比较两组分娩结局,对比分析失败原因.结果 失败组胎儿体质量≥3500 g的发生率[76.4％(55/72)]明显高于成功组[31.7％(40/126)],差异有统计学意义(x2=30.177,P=0.001)、失败组宫缩乏力发生率[58.3％(42/72)]高于成功组[38.1％ (48/126)],差异有统计学意义(x2=7.569,P=0.006)、失败组骨盆临界或轻度狭窄发生率[38.9％ (28/72)]高于成功组[23.8％(30/126)],差异有统计学意义(x2 =5.030,P=0.002)、失败组手转胎头时机不当(宫口开大＜6 cm、胎头位于坐骨棘上及宫口开大8～10 cm、胎头位于坐骨棘下≥2 cm)发生率[61.1％(44/72)]高于成功组[38.9％(49/126)],差异有统计学意义(x2=9.084,P=0.003).失败组母儿并发症(产后出血、产褥病率、胎儿窘迫、新生儿窒息)发生率高于成功组(x2 =9.586,P=0.002、x2=9.334,P=0.002、x2=5.910,P=0.015、x2=5.240,P=0.022)、失败组剖宫产发生率[72.2％(52/72)]明显高于成功组[34.1 ％(43/126),x2=26.641,P=0.001)].结论 手转胎头术能使难产变顺产,降低剖宫产率,减少母儿并发症,但须积极预防、处理导致手转胎头术失败的原因,对矫正失败后继续矫正及试产应慎重.     

Clinical Pharmacokinetics of Morphine

Morphine, the most widely used mu-opioid analgesic for acute and chronic pain, is the standard against which new analgesics are measured. A thorough understanding of the pharmacokinetics of morphine is required in order to safely and effectively use this analgesic in a wide variety of patients with different levels of organ function. A MEDLINE search was conducted to identify literature published between 1966 and January 2002 relevant to the pharmacokinetics of morphine. These publications were reviewed and the literature summarized regarding unique and clinically important elements of morphine disposition relative to its parenteral administration (including intravenous, intramuscular, subcutaneous, epidural and intrathecal administration), absorption profile (immediate release, controlled release, and sublingual/buccal, and rectal administration), distribution, and its metabolism/ excretion. Special populations, including infants, elderly, and those with renal/liver failure, have a unique morphine pharmacokinetic profile that must be taken into account in order to maximize analgesic efficacy and reduce the risk of adverse events.     

Evidence-Based Pain Management and Palliative Care in Issue Four for 2009 of The Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly. Issue 4 for 2009 contains 4027 complete reviews, 1906 protocols for reviews in production, and 11447 one-page summaries of systematic reviews published in the general medical literature. In addition, there are citations of 600,000 randomized controlled trials, and 12,200 cited papers in the Cochrane methodology register. The health technology assessment database contains over 7500 citations. This edition of the Library contains 90 new reviews, of which 19 have potential relevance for practitioners in pain and palliative medicine.