原发性肝癌实时超声造影时间窗的临床研究

目的 探讨原发性肝癌（HCC）超声造影（CEUS）时间窗及影响因素。 方法 经左肘静脉团注造影剂SonoVue 2．4ml后，分别以肝动脉、门脉主干或二、三级分支显影作为动脉相（AP）、门脉相（PVP）的开始，肝实质回声增强达峰值视为实质相（PP）的开始，2min后为延迟相（DP）。 结果 肝癌CEUS各时相出现的早晚及持续时间的长短，主要与HCC血供性质有关，血管间短路亦有一定影响。HCC血供分2种形式，第一型最多见，呈动态变化过程。初期以门静脉供血为主，动脉呈低血供，而后二者均减少，随着瘤体的增大，动脉供血逐渐增加呈等血供，直至高血供。第二型则主要以门静脉供血为主。以动脉供血为主的HCC，AP快速强化，PVP消退，该表现见于大多数HCC。以门静脉供血为主者，AP、PVP均强化，至PP方消退，该现象见于小肝癌（sHCC）。动门瘘时可使AP缩短，PVP提前显影。 结论 以相关血管显影作为时相的起始及时段，能较全面反映肿瘤特征，有助于定性诊断。主供血管的性质将影响时相的起始及长短。     

肝局灶性病变超声造影诊断指标初探

目的 探讨适宜中国肝局灶性病变的超声造影诊断指标。方法 以注射造影剂后肝动脉开始显影作为动脉相的起始时间，以门静脉开始显影作为门脉相起始时间，以肝实质增强达峰值为实质相起始时间；分析682例肝局灶性病变超声造影肝动脉、门静脉的始增时间及肝实质的增强峰值时间、肝内病灶的开始减退时间，分析增强模式。结果 肝硬化与非肝硬化组肝动脉、门静脉及肝实质始增时间有显著差异，肝内良恶性病灶增强退出时间有显著差异。85％的原发性肝癌及99％肝转移癌在注射造影剂后180s内退出，故以180s作为延迟相起始时间及与实质相的划分点，由此将超声造影分为四个时相。结论 由于肝背景不同造成血流动力学差异，病灶增强时相以自身背景对比更为适宜；根据新的时相定义及病灶增强退出特征，总结出中国人肝癌及其他肝局灶性病变的超声造影诊断标准。     

肝肿瘤的动态灰阶超声造影时相分析

目的:应用动态灰阶超声造影技术研究肝脏占位性病变造影增强的时相变化,评价其在肝肿瘤鉴别诊断中的价值。方法:对54例共58个肝占位性病变进行动态灰阶超声造影检查。肝占位病变包括:原发性肝癌29个,转移性肝癌4个,肝血管瘤8个,肝局灶性结节性增生12个,炎性假瘤2个和血管平滑肌脂肪瘤3个。造影剂选用浓度为400mg?蛐ml的Levovist,经肘部浅静脉快速注射。结果:超声显示注射造影剂后,肝血管瘤开始增强时间[(48±12)s]明显晚于其它病变(P<0.01)。肝恶性肿瘤的增强持续时间[(68±32)s]明显短于肝良性肿瘤(P<0.01)。肝恶性肿瘤的造影特征是肿块在动脉相增强而门脉相消退;有血供的肝良性肿瘤的造影表现为增强持续时间较长,可持续整个门脉相或延迟相。结论:动态灰阶超声造影可动态显示肝肿瘤不同时相的增强情况,有助于肝肿瘤的鉴别诊断。     

超声造影对肝癌的诊断价值

目的 探讨超声造影诊断肝癌的临床应用价值.方法 对经临床病理确诊的105例肝癌患者114个癌灶进行常规彩超和实时超声造影检查,分析病灶二维声像图的特点,造影后分析病灶和周围肝实质的增强方式及增强时相.结果 实时超声造影:在114灶中,105灶(92.1%)于动脉相快速均匀增强,100灶(87.7%)门脉相快速退出,5灶(4.4%)实质相退出;6灶(5.2%)于动脉相环状增强,门脉相退出明显早于周围肝实质;3灶(2.6%)为动脉相与肝实质同步非均匀增强或稍晚,门脉相退出早于周围肝实质;将造影时病灶动脉相快速增强早于肝实质和门脉相快速消退的表现作为超声造影诊断肝癌的标准,则本组定性诊断肝癌的敏感性为92.9%(106/114).常规彩超诊断65灶(57.0%),超声造影对肝癌的诊断率明显高于常规彩超(χ2=36.998,P<0.05).结论 超声造影成像可以较清晰地动态显示肝癌各时相血流灌注全过程,具有安全、方便和确诊率高等特点.     

正常肝脏间歇二次谐波声学造影的初步研究

目的探讨正常肝组织间歇二次谐波声学造影显像特点.方法20例正常自愿者接受肝脏间歇二次谐波声学造影检查,间歇成像由心电图R波触发,触发间隔为1～5个心动周期.声学造影剂经左前臂浅静脉"弹丸式"注射.结果注射造影剂后15～18 s[平均(16.8±1.5)s]肝动脉显影,实质回声增强.肝动脉血管呈"亮线"状强回声,似"枯树枝状"形态.肝动脉显影后6～10 s[平均(7.9±1.7)s]门静脉显影,肝实质回声再次增强,门脉血管呈"条带"状强回声.显影全过程持续95～126 s[平均(108±7)s].注射造影剂后延迟3min再触发成像,肝实质呈均匀增强回声.结论间歇二次谐波声学造影是检测组织血流的敏感方法,不仅能清楚显示较大血管结构,还能反映微循环血供状况,为临床提供极为丰富的血流信息.     

实时超声造影在肝脏占位性病变定性诊断中的应用

目的探讨不同性质肝占位性病变在超声造影实时双模式灰阶成像中的增强特征.方法对48例肝占位性病变患者应用新型超声造影剂SonoVue行实时双模式灰阶成像超声造影检查,其中原发性肝细胞癌20例,转移性肝癌6例,肝血管瘤13例,肝局灶性结节增生9例,病变均经手术或超声引导下穿刺活检病理证实.结果48例病变均表现不同程度的增强.18例原发性肝细胞癌在动脉相显著增强,门脉相快速消退,其中15例病变在早期延迟相即呈明显低于肝实质的低回声结节或团块,2例仅在早期动脉相可见周边增强的血管影,其后均为低回声至无回声团块;13例肝血管瘤平均31.4s开始增强,其中8例病变早期呈典型的边框样和块状增强,随后增强呈向心性逐渐充填,增强可持续整个门脉相和大部分延迟相,增强的持续时间明显长于肝脏恶性病变;肝局灶性结节增生平均17.7s开始增强,其中6例早期动脉相可见自中心向外周放射分布的轮辐状增强血管影,增强的持续时间也明显长于肝脏恶性病变;4例转移性肝癌早期动脉相明显增强,门脉相开始减退,至延迟相回声明显低于正常肝组织,另2例增强不显著.结论不同性质肝占位性病变在超声造影中形成不同的增强方式,从而为肝肿瘤的诊断和鉴别诊断提供依据.超声造影双模式灰阶成像技术便于准确定位,使病变造影剂充盈时相尤其以早期动脉相显示更清晰准确,也使病变的造影增强过程由于双实时图像对照而显示更清晰,有较好的临床应用前景.     

超声造影在肝脏HCC诊断及鉴别诊断中的应用价值

目的:探讨超声造影(CEUS)在肝细胞性肝癌(HCC)诊断和鉴别诊断中的应用价值。方法:对58例肝脏局灶性病变进行超声增强造影检查并观察动脉相、门脉相和实质相的动态造影变化,对不同性质的病变的造影特点进行了分析总结。结果:造影结果诊断34例HCC中34例均经病理或AFP证实,33例具有造影剂的快进快出及动脉相均匀性或非均匀性增强的特点。超声造影在HCC中的快进快出即动脉相快速增强,门脉相和实质相快速消退的特点并具有较高诊断敏感性(97%)和特异性(99%)。结论:超声造影在肝脏局灶性异常回声的筛选诊断及鉴别诊断中具有重要的临床意义和应用价值。     

超声造影定量分析在肝脏肿瘤诊断中的应用

目的探讨超声造影定量分析在肝脏肿瘤诊断中的应用价值。方法超声造影检查92例患者,共102个肝脏病灶,其中59个恶性,43个良性;记录病灶增强方式、开始强化时间、消退时间、时间-强度曲线（TIC）达峰时间;应用Logistic多因素回归分析上述指标与肝脏局灶性病变的关系,对开始强化时间、消退时间、TIC达峰时间用ROC曲线分析。结果肝脏恶性病灶与良性病灶在动脉相强化模式、门脉相回声及整体强化的差异有统计学意义（P〈0．05）。动脉相20s强化为病灶良恶性诊断标准,敏感性为85．0％,假阳性为14．1％;以时间强度曲线达峰时间33s为诊断标准,敏感性81．4％,假阳性为10．2％。结论超声造影动脉相早期强化作为肝恶性肿瘤诊断指标有临床价值,结合其他指标有助于提高对肝脏恶性肿瘤的诊断。     

肝脏VX_2肿瘤声学造影的动态变化时相

目的　观察兔肝脏VX2 肿瘤在二次谐波声学造影中的增强效果及动态变化时相。方法　 1 7只接种VX2 肝肿瘤的新西兰白兔经外周静脉注射氟碳声学造影剂FX5 30 ,采用Sequoia5 1 2超声仪的二次谐波显像观察肿瘤造影增强过程 3min。结果　VX2 肿瘤在声学造影中出现了三个特异性的动态变化时相 ,即动脉相、门脉相和延迟相。动脉相 (造影后 5～ 1 0s)中出现肿瘤血管早期增强 ;门脉相 (造影后 1 0～ 30s)中肝实质逐渐增强 ,肿瘤血管影像减弱 ;延迟相 (造影 30s以后 )肝实质强烈增强 ,VX2 肿瘤呈弱回声病灶。结论　新型声学造影方法可以发现VX2 肿瘤特异性的造影动态变化 ,显著提高肿瘤诊断特异性。     

肝癌16层螺旋CT肝动脉三期强化特点分析

目的：探讨肝癌在动脉三期的强化特点及临床应用价值。方法：肝癌27例，分别行动脉三期扫描，动脉早期、中期和晚期的扫描时间是在注射造影剂后的18s、24s、30s。结果：动脉早期无强化13例，强化14例，其中血管样强化9例，肿瘤实质样强化5例。动脉中期无强化3例，强化24例，其中血管样强化16例，肿瘤实质样强化8例。动脉晚期均有不同程度强化，其中血管样强化4例，肿瘤实质样强化23例。结论：动脉三期均能很好反应肝癌的强化特点，动脉中期肿瘤血管显影较佳，动脉晚期肿瘤整体强化较佳。     

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.     

Systematic Reviews Published in the January 2011 Issue of The Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly as a DVD and monthly online. The January 2011 issue (first quarterly DVD for 2011) contains 4515 complete reviews, 1985 protocols for reviews in production, and 13,521 one-page summaries of systematic reviews published in the general medical literature. In addition, there are citations of 641,000 randomized controlled trials, and 14,018 cited papers in the Cochrane methodology register. The health technology assessment database contains over 9300 citations. One hundred and seven new reviews have been published in the last 3 months, of which five have potential relevance for practitioners in pain and palliative medicine.     

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.     

Prise en charge des entorses externes de cheville : étude clinique préliminaire sur l’efficacité du dispositif Myolux™

Ankle sprains are the most common injury of the musculoskeletal system and are associated with significant societal and economic impacts. It has been proven that classical therapeutic strategies may not be effective in preventing recurrent injuries: the recurrence rates reported in the literature can reach 73%. In order to provide an effective rehabilitation solution, a destabilizing orthosis was developed. This device is equipped with a mechanical articulator reproducing the subtalar mechanics and placed under the heel. In this paper, we present the main results of a preliminary clinical study conducted between 2004 and 2007. All subjects included in this study were treated with the abovementioned orthosis during 10 rehabilitation sessions of 30 minutes each. Data show a relatively low recurrence rate of 12% for the overall population. Moreover, it's of primary importance to note that this satisfactory ratio is largely reduced (3% of recurrence rate) for the 29 patients who performed one training session per month after the 10th initial rehabilitation sessions. Hence, the destabilizing orthosis appears to be an effective solution to prevent recurrent ankle sprains. However, joint protection requires long-term and regular training sessions. This result has motivated the development of a similar device allowing patients to perform training sessions at home. Finally, data obtained in this study are promising awaiting the final results of the comparative, multicentric and independent clinical trials currently managed by the Hospices Civils de Lyon.     

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.