肝单形性上皮样血管平滑肌脂肪瘤2例临床病理分析

目的 探讨肝单形上皮样血管平滑肌脂肪瘤（MEA）的临床病理学特征及诊断、鉴别诊断要点。方法 对2例MEA进行临床病理学分析、免疫组织化学及电镜研究。结果 患者临床无症状。肿瘤由形态多样的上皮样细胞构成，胞质透亮或嗜酸，无脂肪细胞及异常血管；HMB45（ ），SMA和Vim部分（ ），Des少烤（ ），S-100弱（ ），CK和AFP（-），CD34血管内皮细胞（ ）。电镜下瘤细胞胞质中微丝束上有高电子致密度的凝集物显示，可见黑色素样小体。结论 肝MEA是极为罕见的间叶性肿瘤，组织起源有争议，其诊断及鉴别诊断主要依靠组织病理学、免疫组织化学及电镜检查。     

皮下软组织上皮样血管肉瘤2例临床病理观察

目的探讨上皮样血管肉瘤(EAS)的临床病理特点、诊断和鉴别诊断。方法对2例上皮样血管肉瘤的组织病理学、免疫组化结果进行分析,结合文献进行讨论。结果镜下肿瘤由细胞体积大、胞质丰富、具有上皮样特征的瘤细胞构成。瘤细胞呈弥漫片状、腺管状、单排条索状排列。免疫组化:肿瘤细胞CD34和FⅧAg(+),AE1/AE3和EMA部分(+)。结论上皮样血管肉瘤是一种罕见的高度恶性肿瘤,诊断和鉴别诊断主要依赖其病理形态学特点结合免疫表型。     

伴神经鞘膜分化的硬化性上皮样纤维肉瘤临床病理观察

目的探讨伴神经鞘膜分化的硬化性上皮样纤维肉瘤的临床病理特征。方法对1例伴神经鞘膜分化的硬化性上皮样纤维肉瘤进行组织病理学观察及免疫组化标记,并复习相关文献。结果肿瘤位于左腹壁浅筋膜下,与神经解剖关系密切。光镜下,肿瘤细胞呈上皮样,单个或巢状埋藏于广泛胶原变性的基质中。胞质透亮或呈弱嗜酸性,胞核卵圆形点彩状或空泡状,核仁明显。大部分区域瘤细胞核异型性较小。电镜下瘤细胞质内可见丰富的粗面内质网及中间丝,部分细胞见细长的胞质突起及外板结构,显示神经鞘膜分化。瘤细胞vimentin（＋）,S-100蛋白、NSE和desmin灶性（＋）,CD117弱（＋）,EMA、CK、CD34、SMA、actin、HMB45、LCA和CD68均（-）。结论伴神经鞘膜分化的硬化性上皮样纤维肉瘤具有典型硬化性上皮样纤维肉瘤的光镜特点,但在临床表现、超微结构及免疫组化上有其特异性。     

原发性脾上皮样血管肉瘤临床病理观察

目的探讨脾上皮样血管肉瘤(SEAS)的临床病理特点、免疫组化、诊断及鉴别诊断。方法回顾性分析1例脾上皮样血管肉瘤的临床表现、组织学形态特征及免疫组化,并复习相关文献。结果正常的脾组织被增生的上皮样肿瘤细胞所代替,并且向周围脾组织浸润生长,瘤细胞呈圆形、卵圆形,胞质丰富,细胞核呈空泡状,可见大核仁,核分裂易见(20个/50HPF)。肿瘤细胞排列呈巢片状,局灶可呈乳头状或不规则裂隙状排列,裂隙内见红细胞,提示血管来源。肿瘤细胞CD31、CK、vimentin、ERG(+),CgA及Syn散在(+),Ki-67阳性指数30%;CD34、S-100、EMA、FⅧ、CK7、CK20、CD30、CD68、Lys、ALK、FIL-1、D2-40和p63均为(-)。患者于脾切除术后1个月死亡。结论原发于脾的上皮样血管肉瘤是起源于血管的恶性肿瘤,临床主要表现为急腹症,预后较差;诊断主要依赖于组织学形态及免疫组化。     

上皮样肉瘤样血管内皮细胞瘤临床病理观察CSCD

目的分析上皮样肉瘤样血管内皮细胞瘤(ES-H)的临床病理学特点及诊断要点。方法通过HE切片、免疫组化观察1例上皮样肉瘤样血管内皮细胞瘤,并结合文献讨论。结果主要病理学形态表现为瘤细胞呈实性片状或巢状分布,瘤细胞圆形或略呈梭形、多角形,胞质嗜酸性,胞质内可见空泡或血管腔形成。免疫组化示CK、vimentin、FLI-1和CD31均(+),而CD34和FⅧ(-)。结论 ES-H是一种罕见的肿瘤,生物学行为属于低度恶性,具有复发及远处转移的潜能,诊断需要依赖免疫组化,治疗及预后尚待观察。     

上皮样肉瘤样血管内皮细胞瘤临床病理观察

目的分析上皮样肉瘤样血管内皮细胞瘤(ES-H)的临床病理学特点及诊断要点。方法通过HE切片、免疫组化观察1例上皮样肉瘤样血管内皮细胞瘤,并结合文献讨论。结果主要病理学形态表现为瘤细胞呈实性片状或巢状分布,瘤细胞圆形或略呈梭形、多角形,胞质嗜酸性,胞质内可见空泡或血管腔形成。免疫组化示CK、vimentin、FLI-1和CD31均(+),而CD34和FⅧ(-)。结论 ES-H是一种罕见的肿瘤,生物学行为属于低度恶性,具有复发及远处转移的潜能,诊断需要依赖免疫组化,治疗及预后尚待观察。     

胃原发性上皮样血管肉瘤1例报道并文献复习

目的探讨胃上皮样血管肉瘤的临床病理特征、治疗及预后。方法对1例原发于胃的上皮样血管肉瘤进行组织形态学、免疫组织化学分析，并复习相关文献。结果临床表现及大体病理无特征性；镜下瘤细胞呈上皮样特征，异型性明显，表达CD31、CD34、Vim。结合文献，消化道原发性上皮样血管肉瘤男性多于女性，平均发病年龄为60．4岁。结论消化道上皮样血管肉瘤是一种罕见的高度恶性肿瘤，术前确诊困难，预后差，转移率高，平均生存时间为7个月，主要与上皮样血管内皮瘤、恶性黑色素瘤、转移癌等鉴别。     

骨原发性恶性上皮样血管肿瘤临床病理分析

目的探讨骨原发性恶性上皮样血管肿瘤的临床病理特征、诊断及鉴别诊断。方法对4例骨原发性上皮样血管内皮细胞瘤(EHE)和2例上皮样血管肉瘤(EA)进行临床、光镜及免疫组化分析。结果 4例EHE中3例行刮除术,1例行化学治疗,均存活。2例EA分别行单纯化疗和手术治疗,1例失访,1例2个月后死亡。镜检:EHE的肿瘤细胞呈巢状、片状或条索状排列,间质常黏液样变性或透明变性,瘤细胞轻度异型,常见胞质内空泡。EA主要由呈实性片状、巢状排列的上皮样肿瘤细胞组成,瘤细胞异型性大,核呈空泡状,核仁显著,核分裂易见。免疫组化:瘤细胞CD31和vimentin(+)。结论 EHE低度恶性,EA高度恶性,两者鉴别主要依靠病理学特征,治疗和预后均差异较大,准确诊断是正确治疗的前提。     

硬化性上皮样纤维肉瘤3例临床病理观察

目的探讨硬化性上皮样纤维肉瘤(SEF)的临床病理特征、诊断与鉴别诊断。方法对3例SEF的临床资料、组织学、免疫组化进行观察分析并随访,结合文献进行讨论。结果 3例SEF均为男性,中位年龄为44岁,分别位于右腰部、左足底及左股内侧。临床主要表现为局部肿块及压痛。镜下见上皮样细胞排列成巢状、条索状和腺泡状,胞质透明或嗜酸,细胞有轻~中度异型性;1例核分裂象易见(1个/10HPF),2例核分裂象少见(1个/10HPF)。局部区域瘤细胞呈梭形、短梭形;间质含有大量玻璃样变的胶原纤维。免疫组化:瘤细胞vimentin、MUC4弥漫强(+),EMA(+),AE1/AE3、melan-A、TFE-3、HMB45、S-100、desmin、CD34、bcl-2、LCA、CD30、myogenin和MyoD1(-)。3例均获得随访,均在2年内复发或转移。结论硬化性上皮样纤维肉瘤是一种少见的软组织肿瘤,可局部复发及远处转移,其诊断需与一些具有上皮样形态和硬化性间质的良、恶性肿瘤鉴别。     

肾嫌色细胞癌25例临床病理分析

目的探讨肾嫌色细胞癌的临床病理学特点及预后。方法对25例肿瘤组织进行光镜、免疫组化及组织化学观察，其中3例进行电镜研究。结果25例肾嫌色细胞癌的肿瘤细胞多呈巢状，周围细胞较大，胞质呈空泡网状，中央细胞较小，胞质红染，细胞分布不均，中央密，外周疏，常可见双核细胞；免疫组化AEI／AE3和CK7（＋），vimentin（-）；电镜可见瘤细胞内有多少不等的胞质微囊泡。25例中3例伴肉瘤样癌成分。22例存活，3例死亡。结论肾嫌色细胞癌病理学特征明确，临床预后好，伴肉瘤样癌成分者预后较差。     

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.     

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.     

Wie zuverlässig sind Angaben zu nichtentzündlichen ausgedehnten Schmerzen?

ZusammenfassungFragestellung Es wurde geprüft, wie sich der Differenziertheitsgrad zweier Schmerzmessmethoden auf Angaben zur Ausgedehntheit klinischer Schmerzen auswirkt. Zugleich wurde der Referenzzeitraum variiert, über den die Patienten berichten sollten.Methode Erfasst wurde der Einfluss zu Lasten der Befragungsdifferenziertheit durch den Vergleich zweier Körperschema-Bildvorlagen. Drei Referenzzeiträume (Schmerz aktuell, letzte Woche, letztes halbes Jahr) wurden vorgegeben.Ergebnisse Patienten mit ausgedehnten Schmerzen gaben bei differenzierter Befragung um so mehr Schmerzen an, je weiter die Schmerzen zurück lagen und je größer der Berichtszeitraum war. Patienten mit gelenknahen Schmerzen gaben bei hoch differenzierter Befragung weniger ausgedehnte Schmerzen in der Vergangenheit an als bei globaler Einschätzung. Patienten mit Rückenschmerzen berichteten bei differenzierter Befragung zum aktuellen Schmerz über weniger ausgedehnte Schmerzen als bei globaler Befragung.Schlussfolgerung Die Angaben zur Schmerzausdehnung variieren vor allem bei Patienten mit ausgedehnten Schmerzen in Abhängigkeit von der Differenziertheit der Befragung. In diesen Fällen ist die Wahrscheinlichkeit erhöht, dass sich die Beschwerdesymptomatik zumindest teilweise erst in der Reaktion auf die situativen Befragungsbedingungen konstituiert und daher nicht auf andere Befragungsbedingungen generalisiert werden kann.