桥小脑角非特异性肉芽肿1例

患者女,45岁,2年前无明显诱因出现头痛,加重半个月,无恶心、呕吐,无意识障碍,神经系统检查未见阳性体征,实验室检查未见异常。头颅MRI:右侧桥小脑角区类圆形异常信号,T1WI呈稍低信号,其内见斑点状更低信号(图1);T2WI呈稍高信号,其内见斑点状高信号,周围见环状低信号(图2);FLAIR呈等信号;增强后病灶明显均匀强化(图3),直径约为1.5cm。考虑为桥小脑角区脑膜瘤,遂行脑膜瘤切除术,术中     

腰椎管内硬脊膜下神经束膜瘤1例

患者男,76岁,左下肢疼痛、麻木2个月;既往无特殊病史.查体:左下肢远端肌力2级、近端肌力5级,痛温觉减退.实验室检查未见明显异常.腰椎 M RI:L4 椎管内见 1. 9 cm × 1.3 cm × 1.0 cm结节状肿物,边界较清,呈 T1WI等、T2WI高信号,其内可见不规则T2WI低信号(图1A );增强扫描肿...     

MRI诊断胫骨血管瘤1例

患者女,43岁。左小腿反复胀痛1个月。1个月前无明显诱因左小腿胀痛,与行走无关,无夜间痛、无活动障碍,且反复发作。曾有左踝扭伤史。体检及专科检查未见异常。X线平片:左胫骨中段骨髓腔见长椭圆形稍低密度区,边缘锐利,未见硬化缘。CT检查:左胫骨中段骨髓腔见一3.0cm×1.5cm大小软组织密度影,密度均匀,边界光整,邻近骨皮质受压变薄,呈弧形压迹(图1)。MR检查:左胫骨中段骨髓腔内见1.2cm×1.2cm×3.5cm大小异常信号,T1WI呈与肌肉类似低信号(图2),T2WI呈明显高信号,其内见不规则线状低信号(图3),边界清楚;增强T1WI病变明显持续不均匀强化(…     

咽旁间隙海绵状血管瘤一例

病例资料患者,女,46岁,因颈背部疼入院。体格检查:双侧扁桃体Ⅰ°大,右侧软腭较左侧膨隆低垂,无明显疼痛。口咽部MRI平扫加增强示右咽旁间隙内团块状T1WI等信号(图1a)、压脂T2WI高信号(图1b),其内信号不均,见多发条状T1WI及压脂T2WI低信号影,病灶周围见环形压脂T2WI低信号影,DWI(b=800)呈高信号。     

颅内孤立性纤维瘤2例

病例1:女,30岁,右侧面耳部持续性麻木2月余,可忍受,偶感头痛;CT:右侧额顶部可见4.2 cm×6.3 cm×5.5 cm分叶状肿块.病例2:女,35岁,头昏、头痛,左眼视力模糊,伴呕吐4天;CT:右侧颞部见4.0 cm×3.6 cm×3.0 cm形态不规则肿块.2例肿块T2WI均呈不均匀信号,以稍高信号为主,其内可见小条片状稍低信号,并多发点片状高信号,T1WI以等信号为主,其内多发点片状低信号,周围见大片水肿信号;增强后肿块实性部分明显强化(图1),囊变部分未见强化.     

脊髓圆椎内畸胎瘤1例

病例男,26岁,于2年前无明显诱因出现右下肢无力.近1月来患者右下肢无力、麻木加重,肌肉萎缩.脊髓MRI检查:T12～L1椎体平面局部椎管轻度膨大,脊髓圆椎内见约1.3cmx3.1cm大小椭圆形混杂信号病灶,边缘有包膜,病灶上部分呈蘑菇状,T1WI及T2WI均呈明显高信号,T2脂肪抑制序列呈明显低信号,下部分T1WI呈不均匀稍高信号,T2WI及T2脂肪抑制序列呈不均匀高信号(图1～3),增强后包膜有强化,包膜内未见明显强化(图4).MRI诊断:髓内畸胎瘤.     

子宫直肠陷凹恶性外周神经鞘瘤1例

患者女,46岁,下腹隐痛伴尿频、尿急及肛门坠胀感10天。查体:子宫后方触及直径6.0 cm包块,表面结节感,压痛明显,活动度差。经阴道超声:阴道与直肠肛管间5.8 cm×4.8 cm囊实性肿物,紧邻宫颈后壁及阴道后壁,以实性中等回声为主;CDFI见其内星点状血流信号(图1A)。腹部MRI:直肠右前方5.6 cm×6.8 cm×5.7 cm囊实性肿物,以囊性为主,与子宫颈后壁分界不清,内见条状分隔及斑片状实性成分,T1WI以低信号为主,T2WI呈等-高混杂信号,DWI呈高信号,增强后实性成分明显强化,囊性成分未见明显强化(图1B、1C);考虑子宫颈后壁肿瘤。     

脑桥毛细血管扩张症一例

正病例资料男,48岁,因体检头部MRI检查发现脑桥异常信号3个月余,无异常临床表现。MRI检查:初次头部MRI示(图1)脑桥斑片状T1WI稍低、T2WI稍高信号影,于FLAIR上呈等信号,增强扫描后病灶呈轻度强化,DWI上呈低信号,ADC上呈稍高信号,病灶边缘尚清晰,其内信号较均匀,直径约1.0 cm。3个月后复查头部MRI示(图2a～e)脑桥斑片状T1WI稍低信号、T2WI稍高信号影,于FLAIR上呈等信号,于SWI上呈低信号,病灶边缘尚清晰,直径约1.0 cm,MRA示颅内大血管形态及走行未见明显异常。     

胰腺韧带样纤维瘤病1例

患者男,37岁,因"肝右叶血管瘤切除术后3年"来我院复查。实验室检查:CEA及CA199均正常。彩色超声示胰尾明显增大,可见5.0cm×4.4cm实性低回声区,边界不清,主胰管无扩张。MRI:胰尾部5cm×4cm类圆形实性占位,T1WI呈低信号,边界欠清(图1A),T2WI呈不均匀稍高信号,内见散在     

脾脏错构瘤1例

病例女,41岁,体检B超发现脾下极混合性肿块入院.查体:一般情况可,心肺听诊无特殊,腹软,左上腹可触及一肿块,无压痛,边界清,大小约7cmx8cm,双下肢无浮肿.化验:血常规、肝功能无异常.CT平扫:脾脏增大,脾下极见较大类圆形肿块,大小约7cmx8cm,边界欠清,内部密度尚均匀(图1a);增强动脉期病灶周边强化,中问部分见迂曲血管(图1b),静脉期病灶中间部分强化(图1c).CT诊断脾脏血管瘤可能.MRI示脾下缘见约8.4cmx7.0cm肿块,边界光整,T1WI以低信号为主,中间部分高信号,T2WI病灶边缘部分呈稍低信号,中间部分呈稍高信号.     

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.