血管回声跟踪技术对颈动脉斑块危险分层的探讨

目的 分析应用320排容积CT心电图编辑技术前后心律不齐患者冠状动脉成像图像的质量差别,评估心电图编辑技术的临床应用价值。方法 回顾性分析我院接受320排容积CT冠状动脉因扫描过程中出现心律不齐而导致伪影的29例患者,冠状动脉节段划分根据美国心脏病协会建议的树状结构模型,观察的节段为右侧冠状动脉(分为近段、中段、远段)、左主干、前降支(分为近段、中段、远段)、对角支、回旋支(分为近段、远段),每例患者共10段。由两位高年资医师以双盲法对冠状动脉图像质量进行评价及诊断。图像质量分为4级:Ⅰ级:图像显示清晰,所有血管充盈良好、连续、无伪影;Ⅱ级:图像质量基本满意,仅1段血管边缘轻度模糊,无错层或阶梯状伪影;可以进行分析;Ⅲ级:图像质量不满意,有2段血管管壁出现模糊,无错层、阶梯状伪影;影响分析;Ⅳ级:图像质量差,多段血管管壁模糊,部分血管出现错层伪影;无法分析。把图像质量≤Ⅱ级定义为可以进行评价,无需再心电编辑。把图像≥Ⅲ级定义为不能进行评价,需要进行心电编辑或重新扫描。对比心电编辑前后图像质量,并进行统计学分析。结果 心电编辑前后图像质量≤Ⅱ级有172个节段,心电编辑前≥Ⅲ级而编辑后≤Ⅱ级的有84个节段,心电编辑前≤Ⅱ级而编辑后≥Ⅲ级的有5个节段,心电编辑前后图像质量均≥Ⅲ级有29个节段。统计分析表明,心电编辑对图像质量有提高作用(P<0.05)。结论 心电编辑技术可以明显地减轻或消除大部分心律失常或心电图异常导致的冠状动脉CTA伪影,明显提高图像的质量及检查的成功率。大大减少了心率失常患者的顾虑,为临床提供了更为可靠的诊断指标。     

心电图编辑在心律失常患者CT冠状动脉血管造影数据重建中的应用

目的探讨在心律失常患者冠状动脉CTA数据后处理重建过程中,ECG编辑功能对修正相位的应用价值。方法69例心律失常的患者在我院接受了冠状动脉CTA检查,所有患者的扫描数据均因心律不齐而采用了ECG编辑软件进行处理,比较处理前、后的图像质量,评价ECG编辑功能对修正不同类型心律失常相位重建的应用价值。结果69例患者中,偶发房早24例,偶发室早33例,缓慢型房颤5例,快速率房颤3例,频发室早3例,Ⅱ度Ⅰ型窦房阻滞1例。经ECG编辑处理后,图像质量达到优者26例,占38%;良者32例,占46%;中者5例,占7%。图像质量差者6例,占9%。结论ECG编辑功能对改善偶发早搏（房早、室早）、较慢心率下（≤70次/分）房颤患者的CTA图像质量有较大帮助,但对频发早搏、较快心率下的房颤无明显作用。     

心电编辑在64层螺旋CT冠状动脉成像中的价值

目的探讨心电编辑在64层螺旋CT冠状动脉成像（CTA）中的价值。方法应用心电编辑功能,对23例CTA检查过程中出现心律失常者的图像进行重建,比较心电编辑前后图像质量。结果心电编辑前图像评分1-4级者分别有82、93、36、19节段;心电编辑后图像1-4级分别分别有111、80、25、14节段。心电编辑后图像质量显著改善（Z=6.787,P=0.000 1）。结论心电编辑可改善多数心律失常患者CT冠状动脉成像的图像质量。     

心电编辑结合不规则边界矫正技术在64排螺旋CT冠脉成像中的应用

目的:探讨心电编辑技术结合不规则边界矫正技术在64排螺旋CT冠状动脉成像(CTA)中的运用价值。方法:采集2015年6月-2018年10月来我院进行冠脉CTA检查的387例患者,筛选出93例检查过程中出现心律失常者,对其CT图像进行心电编辑结合不规则边界矫正技术重建后,与重建前的图像进行比较。结果:93例患者图像按I、Ⅱ、Ⅲ级评分,达I级者27例,达Ⅱ级者48例,Ⅲ级者18例。结论:心电编辑技术结合不规则边界矫正技术的联合运用,使图像质量得到显著提高,极大的增加了冠脉CTA检查的成功率,即临床对于冠脉CTA检查的使用范围得到推广和扩大。     

心电图编辑功能在64层螺旋CT冠状动脉成像中的初步应用

目的探讨64层螺旋CT冠状动脉造影心电图编辑功能对于改善心律失常或心电图信号不明原因故障中冠脉成像质量的作用。方法收集22例在检查前已知心律失常或仅在检查过程中出现心律失常或检查过程中出现同步记录的心电图信号部分缺失的64层螺旋CT冠状动脉造影资料,使用心电图编辑功能,对原始心电图进行编辑,比较编辑前后重建的冠状动脉图像质量。结果22例中,检查前已知的心律失常有：4例为房室传导阻滞,4例为房颤,4例为房性早搏,2例为偶发室性早搏,共14例;检查前未知仅在检查过程中出现心律失常的有：2例房性早搏,4例房颤,1例病态窦房结综合征,共7例;检查过程中未明原因的心电图信号部分缺失1例。心电编辑前,由于心律失常,造成重建的冠脉图像模糊、缺失、显著的阶梯状伪影,可评估的冠脉节段为53%,心电编辑后图像质量改善,可评估的冠脉节段达到96%（χ^2=161.4826,P〈0.001）。结论在检查前或者检查过程中出现的心律失常或者不明原因出现的心电信号的异常,使用心电图编辑功能,能显著提高冠脉成像质量。     

64层螺旋CT冠状动脉成像时心率对成像质量的影响

目的评价患者的心率对64层螺旋CT冠状动脉成像时图像质量的影响。方法100名患者因怀疑有冠心病或冠心病治疗后复查进行了冠状动脉CTA检查。所有患者没有服用控制心率的药物。扫描用飞利浦64层CT进行,扫描后常规75%时相重建,有运动伪影时增加其他重建时相。冠状动脉的血管分段按AHA的15段分类法进行。对每例患者的2mm以上的血管段进行分析。血管的成像质量按Ⅰ:无伪影;Ⅱ轻度伪影和Ⅲ严重伪影分类。用多元回归分析方法和Fisher's exact检验进行分析。结果100例患者共有1353个血管段大于2mm。冠状动脉CTA的质量主要受患者的心率影响(P=0.000),当心率小于60次/min时,无任何伪影;心率为60~70次/min时,11.2%的患者图像在一些血管段有Ⅱ级伪影,但不影响诊断;心率大于70次/min时,58.6%的患者图像有Ⅱ级伪影,其中一个血管段为Ⅲ级伪影。并且随着患者心率的增加,重建的时相增多,后处理时间延长。结论64层CT冠状动脉成像的质量有了明显的提高,但心率的快慢仍然是影响图像质量的主要因素,较快的心率出现伪影的机会增多,后处理的时间延长。     

320排CT心电编辑功能在冠脉支架置入术后的初步应用

目的 探讨320排螺旋CT心电编辑功能在冠心病冠脉支架成像的应用价值.方法 利用320排螺旋CT对14例有冠心病冠脉内支架置入术后的患者行冠脉血管成像,使用回顾性心电门控结合心电编辑软件对原始心电图进行编辑并重建,比较心电编辑前后重建的冠脉内支架显像质量.结果 14例患者冠脉内支架图像在心电编辑前图像模糊、出现伪影或分支血管缺失,其中编辑前诊断狭窄10例,1例无法显示冠脉支架及其远端分支而不能判断,仅3例诊断为支架通畅;心电编辑后冠脉内支架图像质量较前明显提高,诊断支架再狭窄4例,10例支架通畅;其中1例无法显示支架结构的病例支架近端狭窄.心电编辑前血管评分总均值为2.14±0.86,编辑后评分总均值为3.07±0.73,两者之间的差异有统计学意义（t =-13,P＜0.001）.结论 320排CT回顾性心电门控结合心电编辑技术能明显减轻或消除心律不齐及支架摆动、伪影而造成的图像失真,清楚显示支架形态及远端分支血管的变化,提高冠脉内支架的成像质量.     

64层螺旋CT冠状动脉成像质量的研究

目的探讨64层螺旋CT冠状动脉成像质量的影响因素,评估心电图编辑软件对提高冠状动脉成像质量的价值。方法收集我院2005年8月-2006年4月行64层螺旋CT冠状动脉成像的981位患者的影像资料,分析成像质量及其影响因素。结果心率、心率波动幅度及呼吸运动与冠状动脉成像质量负相关。结论64层螺旋CT冠状动脉成像质量受到患者心率、心率波动幅度、呼吸运动伪影及重建时相的影响。     

心电编辑功能在心律不齐患者双源CT冠状动脉造影中的作用

冠状动脉CTA作为无创性检测冠状动脉病变的方法已经广泛被临床所接受.虽然心率快慢已不再是影响图像质量的重要因素,但心律不齐仍被视为该项榆查的禁忌症[1-2],日前尚无对于心律不齐状况下冠状动脉CTA成像质量方面的报道.本研究收集我院进行冠状动脉CTA检查中出现心律不齐患者共45例,通过对扫描实时心电图的观察及心电编辑方法的分析与总结,以达到使心律不齐患者的图像质量能得到明显改善的目的.     

心房颤动患者64层CT冠脉成像的扫描方法及后处理技术探讨

目的探讨心房颤动(房颤)患者64层螺旋CT冠状动脉成像的扫描方法及后处理技术的应用价值。方法所有31例房颤心律患者均进行64层螺旋CT扫描并采用绝对值时间法重组心脏容积数据,对其中12例患者心电信号进行编辑,再结合回顾性心电门控技术和后处理工作站进行冠状动脉成像。分析31例心房纤颤患者的冠状动脉CT血管成像(CTA)图像质量,利用血管分析软件判断血管有无狭窄并测量狭窄程度,其中10例患者的冠状动脉CTA结果与冠状动脉导管造影(CAG)进行了对照分析。结果 31例患者中364段血管节段成像质量分析结果:质量优、良、中和差分别为194段(53.3%)、82段(22.5%)、41段(11.3%)和47段(12.9%);成像质量优良率为276段(75.8%)。10例与CAG进行对照,共分析冠状动脉血管125段,CTA诊断血管狭窄程度≥50%的敏感度为85.0%(17/20),特异度为95.2%(100/105)。结论 64层螺旋CT能够对房颤患者进行冠状动脉CTA检查,结合心电编辑、回顾性心电门控和工作站后处理技术,可以重建出较高质量的冠状动脉图像。     

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.     

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.     

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.