磁共振成像对胆管癌的诊断价值

目的 探讨胆管癌的MRI和MRCP表现，评价MRI结合MRCP对胆管癌的诊断价值。方法 对62例经手术病理证实的胆管癌，回顾性分析其MRI和MRCP表现。结果 肝内胆管癌11例表现为肝内不规则长T1、长T2浸润性信号，增强后呈中度环形强化。肝门胆管癌16例，MRI主要表现为肝内胆管扩张，在肝门部胆管突然截断、中断或充盈缺损，肝门部软组织肿块。肝外胆管癌35例，MRI表现为肝内胆管软藤样扩张，胆总管不同部位完全性梗阻。MRCP可显示扩张的肝内外胆管及梗阻部位的狭窄、中断、截断和管腔内的充盈缺损。结论 MRI和MRCP联合应用能较好地对胆管癌进行诊断，并能准确描述和评价胆管癌扩散及浸润范围。     

MRCP结合MRI对不同病理类型恶性肿瘤性胆道梗阻的诊断分析

目的：研究MRI、MRCP对胆道梗阻恶性肿瘤的诊断价值，并与病理类型对照。方法：46例胆道梗阻恶性肿瘤患者，常规T1WI、T2WI及脂肪抑制T2WI检查后，行MRCP检查。分析不同部位胆道梗阻恶性肿瘤的MRI、MRCP表现与病理类型对照。结果：46例患者，4例MRCP仅肝内胆管扩张，肿块T2WI高信号，病理均为肝内胆管细胞癌；10例MRCP肝门“空虚征”、肝内胆管枯树枝状扩张，肿块T2WI高信号7例，病理为胆管癌6例，胆囊癌4例；16例胆总管中段截断，近段胆管、肝内胆管扩张，肿块T2WI稍高信号6例，病理为胆管癌9例、胆囊癌3例、胰头癌2例、十二指肠腺癌2例；16例胆管末段截断或狭窄，T2WI稍高信号8例，病理改变为胰头癌4例、十二指肠乳头腺癌4例、胆管癌3例、壶腹癌5例。结论：恶性肿瘤性胆道梗阻有不同的MRI和MRCP表现，反映其病理类型。常规MRI和MRCP联合应用有利于恶性肿瘤性胆道梗阻的定位、定性诊断。     

Gd-EOB-DTPA增强磁共振成像在胆管癌诊断的应用

目的探讨不同类型胆管癌Gd-EOB-DTPA增强磁共振影像表现。方法回顾性分析25例经手术或穿刺病理证实的胆管癌的影像征象。每位患者均行T1WI、T2WI平扫、Gd-EOB-DTPA动态增强扫描、肝细胞期及胆管期扫描（CE-MRC）。从肿瘤形态、位置、胆管扩张程度、管壁增厚程度、信号强度、强化方式等各方面分析图像,并记录患者的血清总胆红素水平。结果①外生型胆管癌10例,表现为边界清楚的类圆形肿块,T1WI呈低信号,T2WI呈不均匀高信号,Gd-EOB-DTPA动态增强扫描呈渐进性强化,肝细胞期及胆管期呈不均匀低信号,CE-MRC可清晰显示胆道系统;②浸润型胆管癌10例,表现为胆管内浸润生长的肿块,T1WI呈低或等信号,T2WI呈不均匀稍高信号,Gd-EOB-DTPA动态增强扫描呈渐进性强化,肝细胞期及胆管期呈不均匀低信号,CE-MRC不能显示胆管系统;③息肉型胆管癌2例,表现为胆管内单发或多发息肉状肿块,T1wI呈低信号,T2WI呈稍高信号,Gd-EOB-DTPA动态增强扫描呈全瘤较均匀强化,肝细胞期及胆管期呈均匀低信号,CE-MRC延迟显影;④混合型胆管癌3例,同时具有2种或2种以上前述类型的表现。结论Gd-EOB-DTPA增强磁共振可用于不同类型胆管癌的诊断与鉴别诊断,CE-MRC的成像效果受总胆红素水平影响,并与胆管癌类型存在一定关联。     

MRCP结合常规MRI诊断恶性肿瘤性胆道梗阻的临床应用

目的研究MRCP结合MRI对胆道梗阻恶性肿瘤的诊断价值。方法46例胆道梗阻恶性肿瘤患者,常规T1WI、T2WI及脂肪抑制T2WI检查后,行MRCP检查。分析不同部位胆管梗阻恶性肿瘤的MRI、MRCP表现,与病理诊断对照。结果46例患者,4例MRCP仅肝内胆管扩张,肿块T2WI高信号,病理诊断肝内胆管细胞癌;10例MRCP肝门"空虚征"、肝内胆管枯树枝状扩张,肿块T2WI高信号7例,病理诊断胆管癌6例,胆囊癌4例;32例胆总管截断或狭窄,近段胆管、肝内胆管扩张,肿块T2WI稍高信号14例,病理诊断胆管癌12例、胆囊癌3例、胰头癌6例、壶腹癌5例、十二指肠腺癌及乳头腺癌6例。结论常规MRI和MRCP联合应用有利于恶性肿瘤性胆道梗阻的定位、定性诊断。     

肝门区胆管癌CT/MRI诊断对比分析

目的：探讨肝门区胆管癌的MSCT和MRI诊断价值。方法：回顾性分析36例经手术病理证实的肝门部胆管癌患者的CT／MRI影像特点。结果：36例中,MSCT检查,16例显示肝门部可见低密度软组织肿块,10例见胆管壁不规则增厚,管腔狭窄;增强扫描可见轻度强化,门脉期强化明显;MRI检查25例显示肝门区不规则软组织肿快,肿块影在T1WI为低于肝脏实质的信号,T2WI为略高于肝脏实质的信号,增强扫描5例早期显示轻度强化,23例可见延时强化;MSCT、T1WI、T2WI及MRCP全部清晰的显示了肝内胆管扩张及扩张的程度,扩张的胆管呈“软藤状”,病变区域胆管可见狭窄、闭塞或充盈缺损。结论：肝门区胆管癌典型的MSCT和MRI影像改变,结合病史、临床体征及肿瘤标志物检查多数可做出正确诊断。     

肝门部胆管癌MRI诊断价值分析(附64例报告)

目的探讨MRI对肝门部胆管癌的诊断价值。方法对经手术病理证实的肝门部胆管癌64例,采用MRI平扫、MRCP及动态增强扫描。结果 64例肝门部胆管癌均表现为肝内胆管不同程度"软藤样扩张"(MRCP),肝门区胆管狭窄、中断或腔内充盈缺损;42例MRI肝门区可见稍长T_1、稍长T_2的肿块影,22例未发现明确肿块;增强扫描42例可见肿块延迟期缓慢持续强化,22例表现为管壁增厚强化,管腔狭窄。结论增强前后MRI可以显示肝门胆管癌的特征性改变,如联合应用MRCP则有助于提高其定位、定性诊断准确率。     

肝内胆管囊腺瘤的MR影像诊断

目的：探讨肝内胆管囊腺瘤的MR检查影像表现的特征及其诊断价值。方法：经手术病理证实的肝内胆管囊腺瘤3例，2例局部可见癌变。3例均为女性，年龄39～72岁，平均52岁。常规扫描横轴位GR-T1WI、抑脂T2WI，其中1例行MRCP检查，采用3D LAVA或FAME序列动态增强扫描，3例均行三期及延迟期扫描。结果：3例肝内胆管囊腺瘤中1例呈囊实性结构，可见囊壁及乳头状实性肿块；1例为多个大小不等的多房囊状结构，囊壁及分隔光滑，囊壁局部明显增厚，有壁结节，周围见轻度的肝内胆管扩张；1例为巨大的多房囊状结构，囊壁及分隔光滑，局部均匀增厚；3例中的囊壁、分隔、壁结节及实性部分均呈T2WI稍高信号、T1WI稍低信号，囊内液性部分均呈T2WI高信号、T1WI低信号；肿瘤瘤体大小径线范围3.4~13.5cm。3例肝内胆管囊腺瘤中囊壁、分隔、实性肿块和壁结节动脉期均明显强化，门脉期、平衡期及延迟期强化程度略减低，强化程度均高于同期肝实质。MRCP示1例左肝内胆管分支进入到囊实性结构的瘤体内，肝内胆管均未见明显的扩张。结论：MR能明确显示肝内胆管囊腺瘤的整体影像的特征性表现，若囊壁上有结节或乳头状肿块提示局部有癌变，MR常规扫描结合动态增强及MRCP成像对肝内胆管囊腺瘤具有很高的诊断价值。     

肝内胆管乳头状瘤的CT及MR表现

目的：探讨肝内胆管乳头状瘤（Intrahepatic biliary papillomatosis,IHBP）的临床病理特征、影像学表现。方法 ：回顾性分析5例经手术病理证实的IHBP患者的临床病理特征及影像学表现,并结合文献进行分析和讨论。结果：5例IHBP患者中2例表现为间歇性黄疸、1例腹痛伴发热、1例左腰背部酸痛,1例体检时发现。影像学特点：5例均发现全胆管树系统扩张,胆总管下段无明确占位或结石,受累肝内胆管相对比另一肝叶胆管或胆总管不成比例的扩张,受累肝内胆管呈＂瘤样＂扩张,扩张的肝内胆管出现乳头状或长条状肿块影,MRCP示扩张胆管内多发乳头状及条状充盈缺损,3例位于右肝内胆管、2例位于左肝内胆管,肿块直径约0.3~2.5 cm,于CT平扫呈等或稍低密度,MR T1WI表现为等或稍低信号,T2WI上多呈等高信号,DWI上呈乳头状及条状高信号,增强扫描肿块呈轻度强化。结论：IHBP的影像学表现有一定的特征性,尤其MRCP、DWI及动态增强检查,熟悉该病的特征性影像学表现有助于对IHBP诊断及鉴别诊断。     

外周型肝内胆管细胞癌8例MRI表现及误诊分析

目的分析外周型肝内胆管细胞癌（PCC）的MRI表现及其误漏诊原因。方法回顾性分析8例MR检查被误漏诊的PCC,均经手术病理证实,所有病例均做了MRI平扫、磁共振胰胆管造影（MRCP）和动脉期、门脉期、延迟期增强扫描。结合手术及病理所见分析其MRI表现及误诊原因。结果 8例PCC磁共振成像均未显示具体肿块影,肝左叶胆管走向僵直、截断及病灶内胆管扩张。平扫T1WI见低信号灶,T2WI信号改变不明显,弥散加权像（DWI）呈高信号;增强扫描动脉期病灶无强化,门脉期、平衡期及延迟期均呈不均匀轻/中度强化。其他表现包括肝内小转移灶3例,腹膜后淋巴结转移者5例,均无门静脉癌栓。结论 MRI检查信号改变、强化特征不明显的PCC极易误诊,需仔细观察胆管扩张的形态改变及动态增强特点,结合DWI像做出诊断。     

MRI多种成像技术在胰腺癌诊断中的价值

目的研究MRI多种成像技术在胰腺癌诊断中的价值.方法收集经手术病理证实的胰腺癌患者26例,采用的MRI技术分别为FLASH T1WI、TSE T2WI、T1WI FS、T2WI FS、Gd-DTPA动态增强扫描和MRCP,分析其MRI表现.结果26例胰腺癌中,在T1WI FS上呈低信号者24例,等信号者2例;T2WI FS上22例呈明显高信号,4例表现为等信号;Gd-DTPA动态增强扫描动脉期25例表现为无强化或强化不明显;MRCP 18例胰头癌均显示胆总管或胰管梗阻性扩张.结论T1WI FS、T2WI FS、Gd-DTPA动态增强扫描和MRCP成像技术对胰腺癌的定位、定性准确率较高,是诊断胰腺癌的理想方法.     

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.