右大腿颗粒细胞瘤超声表现1例

正患者女,40岁,因右大腿内侧无痛性肿块10年余,进行性增大伴间歇性疼痛2个月入院。体格检查:右大腿中下段内侧扪及4 cm×4 cm×3 cm肿块,质硬,边界欠清,活动度差,伴有轻压痛。超声检查:右大腿中下段内侧皮下软组织内见一大小约44 mm×43 mm×31 mm低回声包块,距体表约5 mm,边界不清,呈毛刺状,形态不规则,内部呈极低回声,后方回声衰减;CDFI:包块周边见稀疏点状血流信号,内部未见明显血流信号(图1)。     

右前上臂恶性上皮样神经鞘瘤1例

患者女 ,2 6岁 ,发现右肘部无痛性包块 2d入院。体格检查 :右前臂上段内侧可见一约 4cm× 6cm包块 ,质偏硬 ,无压痛及触痛 ,无波动感 ,可活动 ,局部皮肤无发红 ,无色素沉着 ,未见静脉曲张 ,肘关节功能无障碍。肝肾功能及血生化检查均无异常。CT示 :右前上臂囊性包块 ,邻近各骨质未见明显变化。超声所见 :右肘部尺侧内后方肌肉内 (间 )见一椭圆形混合回声肿块 ,大小约 5 .2cm× 3 .2cm ,包膜完整连续 ,内部可见多个不规则无回声区 ,其间有高回声结构相隔 ,肿块内血流丰富 ,呈动脉性 (图 1)。超声诊断 :右前上臂尺侧混合性肿块 ,血流异常。术…     

乳腺横纹肌肉瘤超声误诊为乳腺癌1例

患者女,37岁.发现右乳肿块伴疼痛1个月入院.查体:双乳发育正常,皮肤乳头无异常.右乳下方可触及一个2.5 cm×2.0 cm的肿块,质中、硬,边界欠清,表面欠光滑,基底有粘连,活动度差,轻触痛.右腋下可触及直径1.0 cm的淋巴结.超声检查:右乳下方探及2.5 cm×2.0 cm×2.0 cm的低回声包块,边界清,形态尚规则,包块后方深筋膜下可见另一个大小约3.5 cm×3.8 cm×3.0 cm低回声包块,边界清,形态不规则,包块内回声欠均匀,内血流丰富,包块向胸肌凸起(图1).右腋下可见多个低回声结节,最大的约0.8 cm×0.6 cm.超声诊断:1.右乳腺实性占位病变(乳腺纤维瘤);2.乳腺实性包块向胸肌浸润(乳腺癌);3.右腋下淋巴节肿大.手术所见:右乳腺内有一2.5 cm×2.0 cm×2.0 cm肿块,包膜完整.肿块下有另一不均匀肿块无包膜,其内为灰白色似烂鱼肉状组织极脆,侵犯肌层达骨膜.     

上肢软组织嗜酸性淋巴肉芽肿超声表现1例

患者男,50岁,因右上臂无痛性包块3年余,逐渐长大入院。体格检查：血压14／9kPa,心律齐,约65次／min。触诊：右前臂内侧皮下可触及大小约9cm×6cm×4cm的隆起性包块,活动度差,边界欠清,中等硬度,无压痛及色素沉着,肩、肘关节活动无障碍。     

下肢平滑肌肉瘤超声误诊为神经鞘瘤1例

患者男,83岁,发现左大腿内侧无痛性肿物半年.查体:左大腿中段内侧触及4 cm×3 cm椭圆形肿块,质硬,边界清,同定,无压痛,左下肢无浮肿.超声:左大腿内侧肌肉层探及椭圆形实性低回声团(图1),大小4.38 cm×2.06cm,边界清,形态规则,内部回声均匀,与股动、静脉紧贴,股浅动脉局部受压,血流信号不丰富.术前诊断:神经鞘瘤.行左大腿包块切除术,术中见肿块质脆、较硬、色白.术后病理:肿瘤细胞呈浸润性生长,核可见异型性,有瘤巨细胞,低度恶性(图2).病理诊断:高分化平滑肌肉瘤.临床诊断:左大腿平滑肌肉瘤.术后半个月行放疗,随访期间无复发.     

乳腺浸润性导管癌骨骼肌转移超声表现1例

正患者女,55岁。因发现右肘部包块1个月余就诊。查体:右肘部外上方皮下触及4cm×1cm肿块,质韧,有压痛,活动度好。超声检查(PHILIPS EPIQ7彩色超声诊断仪,L12-5线阵探头):右肘关节外上方肌层探及低回声包块,大小约3.2cm×1.2cm,形态不规则,呈分叶状,边界欠清晰,内回声不均匀(图1a);CDFI:包块内未见明显血流信号(图1b)。超声提示:右上臂肌层内实性占位。既往史:患者1年前在我院行"左乳癌改良根治术、前哨     

阑尾嵌顿疝超声表现1例

患者女,60岁.因右腹股沟肿块,渐大就诊.查体于右腹股沟内侧可见大小约3 cm×4 cm肿物,中等硬度,表面光滑,位置固定,挤压有坠胀感,大小无变化.超声检查:先用7.5 MHz高频探头探测,右腹股沟内侧探及一2.8 cm×1.8 cm混合回声包块,以实性为主,有包膜,周围探及2～3个淋巴结回声,包块壁深侧缺损(图1),可见一实性低回声通向外后方.     

“女性”隐睾伴精原细胞瘤超声表现1例

患者女,28岁,已婚,有性生活史,未产。既往于院外诊断"原发性闭经",染色体异常,为"XY"。半年前,扪及右侧腹股沟区一鸡蛋大小包块,表面光滑,时有隐痛,近日包块逐渐增大,约鹅蛋大小。超声检查:右侧腹股内侧皮下探及大小约8.0cm×5.7cm×5.4cm的卵圆形肿块,边界清晰,规则,可见包膜。内呈低回声局部伴散在点状及斑片状强回声(图1)。彩色多普勒血流成像示其内可见少许血流信号。左侧腹股内侧皮下探及大小约3.4cm×1.5cm×1.4cm的条形肿块,边界清晰,未显示包膜,内     

非典型性脂肪瘤样肿瘤声像图表现1例

患者女,56岁.因左上臂渐大性无痛包块约40年入院.患者约40年前无意中发现左上臂一鸡蛋黄样大小质软包块,无明显不适感,包块渐大,无消瘦,无左上肢运动障碍.查体:左前臂上段背侧、左上臂下段外侧及中段背侧分别可触及约9.0 cm×8.0cm×2.0cm、6.0cm×3.0cm×1.5cm及9.0 cm×7.0 cm×4.0 cm的多个质软包块,界清,活动度可,无触痛,未及波动感,表皮无红肿及破溃.其中左前臂上段背侧包块表面不光滑,触及有膨胀感和压缩感,表面可见蜿蜒增粗的血管.彩超检查:左前臂上段背侧及同侧上臂下段外侧皮下软组织内探及低回声包块,大小分别为9.0 cm×8.0 cm×2.2 cm、6.0cm×3.2 cm×1.4 cm,边界清楚,形态规则,内部回声不均,内呈扭曲的管状结构.     

超声诊断颈部节细胞神经瘤1例CSCD

患者女,28岁,体检发现右侧颈部肿块1个月余。超声检查:甲状腺右叶后方、锁骨上窝及胸骨后方见一大小约8.6 cm×5.0 cm×2.8 cm团块状较低回声(图1),边界清晰,形态规则,回声欠均匀,上缘达颈中段,下缘至胸骨后,内侧位于甲状腺右叶后方气管右后部,外侧达胸锁乳突肌前缘。CDFI:包块内探及条状血流信号(图2)。超声提示:甲状腺右叶后方至胸骨后方及锁骨上窝不均质包块,考虑良性病变可能性大。颈部增强CT提示:右颈部占位,考虑血管源性或神经源性肿瘤可能。患者于全身麻醉下行右颈侧进路颈部肿物切除术,术中见肿物表面呈灰红色,边界清晰,大小约6.8 cm×5.8 cm×4.5 cm,包膜尚完整,质韧,沿被膜将肿物分离切除。术后病理诊断:(右颈部)神经源性肿瘤,见成束神经纤维及较多神经节细胞,考虑节细胞神经瘤。免疫组化:Vim(+),S100(+),Syn(神经节细胞+),NSE(神经节细胞+),GFAP(-),CKpan(-),EMA(-),Ki67(<1%+),SOX-10(部分+),NF(+)。     

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.     

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.     

Dissociable correlates of two classes of retrieval processing in prefrontal cortex

Although substantial evidence suggests that the prefrontal cortex (PFC) implements processes that are critical for accurate episodic memory judgments, the specific roles of different PFC subregions remain unclear. Here, we used event-related functional magnetic resonance imaging to distinguish between prefrontal activity related to operations that (1) influence processing of retrieval cues based on current task demands, or (2) are involved in monitoring the outputs of retrieval. Fourteen participants studied auditory words spoken by a male or female speaker and completed memory tests in which the stimuli were unstudied foil words and studied words spoken by either the same speaker at study, or the alternate speaker. On "general" test trials, participants were to determine whether each word was studied, regardless of the voice of the speaker, whereas on "specific" test trials, participants were to additionally distinguish between studied words that were spoken in the same voice or a different voice at study. Thus, on specific test trials, participants were explicitly required to attend to voice information in order to evaluate each test item. Anterior (right BA 10), dorsolateral prefrontal (right BA 46), and inferior frontal (bilateral BA 47/12) regions were more active during specific than during general trials. Activation in anterior and dorsolateral PFC was enhanced during specific test trials even in response to unstudied items, suggesting that activation in these regions was related to the differential processing of retrieval cues in the two tasks. In contrast, differences between specific and general test trials in inferior frontal regions (bilateral BA 47/12) were seen only for studied items, suggesting a role for these regions in post-retrieval monitoring processes. Results from this study are consistent with the idea that different PFC subregions implement distinct, but complementary processes that collectively support accurate episodic memory judgments.     

Molecular characterization of virulence and antimicrobial resistance profile of Shigella species isolated from children with moderate to severe diarrhea in northeastern Brazil

Molecular characterization of virulence and antimicrobial resistance profiles were determined for Shigella species isolated from children with diarrhea in Fortaleza, Brazil. Fecal specimens were collected along with socioeconomic and clinical data from children with moderate to severe diarrhea requiring emergency care. Shigella spp. were isolated by standard microbiological techniques, and we developed 4 multiplex polymerase chain reaction assays to detect 16 virulence-related genes (VRGs). Antimicrobial susceptibility tests were performed using disk diffusion assays. S. flexneri and S. sonnei were the predominant serogroups. S. flexneri was associated with low monthly incomes; more severe disease; higher number of VRGs; and presence of pic, set, and sepA genes. The SepA gene was associated with more intense abdominal pain. S. flexneri was correlated with resistance to ampicillin and chloramphenicol, whereas S. sonnei was associated with resistance to azithromycin. Strains harboring higher numbers of VRGs were associated with resistance to more antimicrobials. We highlight the correlation between presence of S. flexneri and sepA, and increased virulence and suggest a link to socioeconomic change in northeastern Brazil. Additionally, antimicrobial resistance was associated with serogroup specificity in Shigella spp. and increased bacterial VRGs.