实时三维超声引导经皮微创切除乳腺良性肿物的应用

目的探讨三维超声引导麦默通旋切系统经皮负压切除乳腺良性肿物的应用价值。方法三维超声引导对83例患者161个乳腺良性肿物行麦默通微创抽吸切除。结节最长径0．6～3．5cm，平均（1．7±O．5）cm。结果全部结节均成功引导切除，实时三维模式下穿刺旋切刀显示清晰，定位准确，但图像实时性较差。全部病例术后随访1～18个月无复发。结论实时三维超声引导麦默通旋切系统适于乳腺良性肿物（最长径≤3．5cm）的微创切除，安全、有效，短期随访无复发。有助于手术计划制订，但实时性有待进一步提高。     

超声引导下Mammotome微创旋切系统在乳腺良性病变切除术中的应用

目的探讨超声引导下Marnmotome微创旋切系统往切除乳腺良性病变中的应州价值。方法86例乳腺肿瘤患者,115个乳腺肿块,经超声或X线钼靶检查,结合临床初步诊断为良性病变,在超声引导下应用Mammotome微创旋切系统治疗,同时行病理检查。结果乳腺病灶在超声引导下均被完全切除,每个肿块手术时间（20±10）min,平均旋切次数15次,皮肤切口0．25～0．4cm。1例出现切口下血肿,2个月后完全吸收,5例出现皮下淤血癍,术见感染．结论超声引导下Mammotome微创旋切乳腺良性病变,具有创伤小、并发症少、恢复快、乳房表面不留疤痕等优点,是一种值得推广的乳腺病变微创治疗方法。     

超声引导Mammotome旋切真空抽吸系统切除乳腺包块的临床价值

目的探讨超声引导Mammnotome旋切抽吸微创系统在乳腺包块切除及活检中的临床价值。方法临床触征和超声检查发现乳腺包块患者100例（共135个包块）,包块直径0．4～3．5cm,超声引导Mammotome旋切抽吸系统行包块切除术,切除的组织条行病理检查。结果超声引导Mmmnotome真空旋切抽吸系统对135个病灶准确定位,所有病灶均取得组织,病理结果乳腺癌9例,其中4例为浸润性导管癌,其余均为良性病灶。结论Mammnotome旋切抽吸系统适用于实性肿块活组织检查和良性肿块切除,术后并发症少,超声定位准确,操作简单,有较高的临床实用价值。     

超声引导下Mammotome8G和11G旋切刀在乳腺肿块诊治中的对比研究

目的比较超声引导下Mammotome系统8G、11G旋切刀在乳腺良性肿块取材活检及肿块切除中的价值。方法120例139个乳腺病灶随机分成两组,第一组60例72个病灶,使用8G旋切刀进行旋切治疗;第二组60例67个病灶,使用11G旋切刀进行旋切治疗。比较二者取材成功率、切除每个病灶的平均时间,并在术后1周及6个月比较分析并发症的发生情况。结果第一组和第二组取材成功率均为100％,切除每个病灶平均所需时间分别为（13．84±3．9）min和（15．8±3．2）min,两组比较P〈0．05;术后1周并发症发生比分别为18．3％（11／60）和5．0％（3／60）,P〈0．05;6个月后两组并发症均消失。结论8G和11G旋切刀在乳腺纤肿块取材活检时具有同样价值;但在完全切除肿块时,两者各有优缺点,临床医师应根据患者情况进行灵活选择。     

辅助旋切系统的选择对乳腺良性病灶切除效果及乳房美观的影响

目的探讨不同辅助旋切系统对乳腺良性病灶的切除效果及乳房美观的影响。方法对716例乳腺良性病灶患者采用Mammotome、Vacora及EnCor三种辅助旋切设备进行微创治疗,比较三组的切除效果、乳房美观情况及手术时间。结果三组在最大直径1.5 cm的病灶中,完全切除率差异无统计学意义(P0.05),在最大直径≥1.5 cm的病灶中,Vacora组完全切除率显著低于其余两组(P0.05);Vacora组血肿发生率明显低于其余两组(P0.05)。三组乳房美观方面差异无统计学意义(P0.05)。Vacora组手术时间长于其余两组(P0.05)。结论 Mammotome和EnCor切除效果好,手术时间短,但血肿发生率高;Vacora组切除效果虽不如EnCor、Mammotome,但并发症发生率低。     

超声引导下Mammotome旋切系统在多发性乳腺纤维腺瘤中的应用

目的：探讨在高频超声引导下Mammotome微创旋切术对乳腺纤维腺瘤的应用价值。方法：对37例114个纤维腺瘤进行了超声引导下Mammotome微创旋切术，对114个纤维腺瘤进行了切除，对直径＜１２ｍｍ的乳腺纤维腺瘤均采用１１G的旋切刀，对直径１２~２０ｍｍ的乳腺纤维腺瘤采用８G的旋切刀进行切除，并在术后1年内进行跟踪检查，评价其对乳腺纤维腺瘤的诊治价值。结果：超声引导成功率及显示率为100%，114个直径5~18mm的乳腺纤维腺瘤均被完整切除，除1例有皮下淤血和1例有局部血肿外，无其它并发症。结论：超声引导下的Mammotome旋切术操作方便，对纤维腺瘤切除彻底，是微创治疗纤维腺瘤的一个比较有效和理想的途径。     

超声引导下微创旋切活检系统在乳腺疾病中的应用

目的 探讨高频超声引导下微创旋切系统对乳腺病灶的诊断与治疗的应用价值。方法 对14例26个乳腺病灶进行了高频超声引导下Mammotome微创旋切术，评价其对乳腺病灶的诊治疗效。结果 9例19个病理诊断为乳腺纤维瘤，3例4个为潴留囊肿，2例3个为乳腺病。14例26个乳腺病灶均Mammotome微创旋切切除，平均旋切20次，用时20min，仅1例有轻度皮下淤血现象，余无其它并发症。结论 高频超声为Mammotome微创旋切系统进行乳腺良性病灶的微创切除和明确诊断乳腺可疑病灶提供了不起个有效的引导方法。     

Mammotome旋切术治疗乳腺良性肿瘤76例

【目的】探讨Mammotome旋切系统在乳腺良性疾病诊治中的应用。【方法】2005年9月至2007年12月对76例91处乳腺病灶行超声引导下Mammotome微创旋切术，并进行回顾性分析及评价其在乳腺疾病诊治中的应用价值。【结果】所有病灶均成功切除。76例91处乳腺病灶中，乳腺纤维腺瘤37例（47处），乳腺腺病25例（27处），乳腺腺病伴纤维腺瘤形成11例（14处），乳腺癌3例。【结论】Mammotome微创旋切系统可明确诊断可疑病灶，完整切除乳腺良性病灶，操作简易，创伤小，安全，美容效果好。     

超声在乳腺疾病微创诊疗中的应用

目的使用Mammotome乳腺微创旋切技术对乳腺病灶进行组织学活检和切除，评价超声在此微创诊疗中的作用。方法36例女性患者36处乳腺病灶在超声引导下行微创旋切术，超声动态实时监测切除全过程，所有切除组织均送病理学检查。结果36例36处病灶中，临床诊断33例良性病灶均被Mammotome微创旋切切除，疑为乳腺癌的3例仅行部分切除活检，所有操作无一例失败，均获得明确诊断。除3例疑为乳腺癌患者外，其余病灶在切除后1周、1个月和3个月行超声检查和临床触诊均未在原手术病灶区发现异常。结论超声引导下乳腺病灶微创旋切术是一项简便、安全、有效的技术，具有良好的临床应用前景。     

超声引导微创旋转切割刀乳腺手术的临床应用

超声引导下Mammotome微创旋转切割系统是近年来应用于乳腺良性病变诊断和治疗的新方法，是一种安全有效、创伤小的技术。Mammotome系统的主要优点即美观与微创，在超声实时监控导航下，采用真空吸引和旋切的方法，可连续切除乳腺良性病变的全部组织，满足了现代医学的微创化发展的趋势。本院2004年5月至2005年6月应用超声引导Mammotome微创旋切系统施行乳房手术36例，疗效满意，现报告如下。     

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.     

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.     

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.     

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.