超声对类风湿性膝关节炎滑膜血管翳的定量研究及动态监测

目的 探讨多排螺旋CT在诊断视神经管骨折中的价值。方法 采用64排螺旋CT,应用软组织算法及骨算法薄层扫描对19例视神经管骨折患者进行检查,获取层厚为0.625mm 轴位图像,利用容积重建(VR)、多平面重建(MPR)技术并结合轴位图像综合分析视神经管骨折患者的CT 表现。结果 本组19例患者中,单纯视神经管骨折3例,其余16例均合并眼眶或颌面部多发骨折;单纯视神经管管壁骨折5例,内侧壁骨折3例,上壁骨折2例;多发视神经管管壁骨折14例,内侧壁受累者12例,上壁受累者9例,2例为视神经管全段骨折;本组中未见单纯下壁或外侧壁骨折的病例。CT表现:①直接征象:骨质连续性中断为最直接的骨折征象,本组19例均可见此征象。其又细分为线性骨折5例,仅见骨质连续性中断,骨折端没有任何移位,对位对线良好;错位骨折5例,其中3例骨折断端朝向内侧,骨折断端向内可能刺伤视神经;撕脱骨折4例,视神经管内可见游离碎骨片影;粉碎性骨折5例,多处骨质连续性中断。②间接征象:视神经管内积气3例,蝶窦积血9例,视神经增粗、扭曲4例。结论 采用MDCT多种算法薄层扫描,通过VR、MPR等图像后处理技术可清晰显示视神经管骨折的类型、范围,为临床提供准确、可靠的参考信息,对该病的临床治疗具有重要的指导意义。     

HRCT诊断外伤性颞骨内耳损伤

目的 探讨HRCT诊断外伤性颞骨内耳损伤的价值。方法 对106例颞骨外伤患者进行HRCT轴位扫描,收集其中内耳损伤患者12例。应用Philips工作站,行颞骨（耳蜗、前庭、水平半规管、前半规管、后半规管） MPR并观察内耳损伤位置、类型及其相邻结构受累的情况。结果 12例内耳损伤患者中,内耳骨折8例,气迷路3例,耳蜗异物1例;3例合并外伤性迷路骨化。结论 HRCT扫描及MPR重建技术可清晰显示内耳受损情况,是诊断内耳损伤的有效方法。     

急性脑外伤合并视神经损伤手术治疗11例分析

目的探讨颅脑损伤合并视神经损伤的有效治疗方法。方法手术治疗 11例颅脑损伤合并视神经损伤患者 ,9例行额部冠状切开头皮 ,一侧额部开颅清除眶骨骨折片或出血 ,矫正额眶骨折错位畸形。有视神经管骨折者 ,用微钻磨开视神经管 ,剪开视神经鞘进行神经减压。 2例眶尖综合征者行额颞切口 ,经眶尖外侧壁磨开眶上裂和视神经管神经减压。结果 8例有效 ,其中 2例眼球突出、1例眼球内陷均得到矫正。结论经额部或额颞入路手术行视神经减压 ,对颅脑损伤合并视神经损伤的患者可取得良好效果     

外科治疗颅底骨折并视神经损伤18例

目的:探讨颅底骨折并视神经损伤的外科治疗方法.方法:总结18例经手术治疗的颅底骨折并视神经损伤的患者资料,其中10例行额部冠状切开减压,5例行额颞部开颅清除眶骨骨折片或血肿,矫正额眶骨折错位畸形;时存在视神经管骨折者,用微钻磨开视神经管,切开视神经鞘进行减压.3例眶尖综合征者行额颞切口,经眶尖外侧壁磨开眶上裂和视神经管减压.随访6个月以上,分析临床治疗效果.结果:本组手术治疗18例,其中显效8例,占44.4%;有效7例,占38.9%;无效3例,占16.7%.结论:颅底骨折并视神经损伤外科治疗的疗效与视神经损伤程度和手术时间等因素有关;外伤后早期经额部或额颞入路手术行视神经减压,结合术后高压氧治疗对颅脑损伤合并视神经损伤的患者可取得良好效果.     

视神经管骨折CT分型诊断

目的：探讨视神经管骨折CT分型诊断,方法：对19例外伤性视神经管骨折进行CT分型诊断,结果将视神经管骨折分为3型：（1）管内型（10）例）,（2）管外型（7例）,双分颅口型和眶口型两个亚型;（3）混合型（2例）,结论：视神经管骨折CT分型诊断有助于临床确定适庆证和制定手术入路。     

上半规管裂发生率及其HRCT特征

目的 基于颞骨HRCT图像统计我国3岁以上人群中上半规管裂的发生率,观察上半规管裂的HRCT特征。方法 回顾性分析接受颞骨HRCT检查的3 904例（7 216侧）受检者的CT图像,以64排螺旋CT行颞骨容积扫描,并对原始图像进行标准化处理,在斜矢状位重建图像中评估有无上半规管裂,并记录上半规管裂的发生部位及宽度。结果 3 904例中,共发现上半规管裂16例（18侧）,总发生率为4.10‰（16/3 904）,其中男性和女性发生率分别约3.69‰（7/1 897）和4.48‰（9/2 007）,不同年龄组间和同一年龄组男女性别间上半规管裂的发生率差异均无统计学意义（P均>0.05）。上半规管裂多发生于上半规管顶壁中部（n=13）,其次为后部（n=2）和前部（n=1）;裂隙宽度为0.4~4.8 mm,平均（2.79±1.37）mm。结论 在我国上半规管裂的总发生率约为4.10‰,其发生率与年龄及性别无关,裂隙较窄,且多位于上半规管顶壁中部。     

CT CARE kV低管电压扫描联合CPR技术术前评估面神经管骨折

目的 探讨智能最佳管电压(CARE kV)低剂量CT扫描及CPR技术在术前评估面神经管骨折中的价值。方法 收集头部外伤伴单侧面瘫患者,采用CARE kV技术进行颞骨HRCT扫描,按就诊先后分4组:A组108例(CARE kV On),管电压120 kVp,B~D组分别为114、105、109例(CARE kV Semi),管电压分别为120 kVp、100 kVp、80 kVp;观察CPR图像面神经管,比较4组患者面神经管骨折发生率、发生部位并与手术结果对照;比较4组间图像质量客观评价指标,包括CT值、噪声(SD)、SNR、CNR及辐射剂量参数[容积CT剂量指数(CTDIvol)、剂量长度乘积(DLP)、有效剂量(ED)]。结果 共纳入436例患者,面神经管骨折174例(174/436,39.91%)。A~D组骨折发生率分别为43.52%(47/108)、39.47%(45/114)、37.14%(39/105)、39.45%(43/109);术前HRCT诊断面神经管骨折与手术结果具有较好的一致性(Kappa>0.5);膝状窝骨折发生率最高(100/174,57.47%),迷路段最低(5/174,2.87%)。A~D组SD、SNR、CNR差异有统计学意义(P<0.05),两两比较除A、B组外余各组间比较差异均有统计学意义(P均<0.05);A~D组CTDIvol、DLP、ED、有效电流差异有统计学意义(P<0.05),经两两比较除A、B组外余各组间比较差异均有统计学意义(P均<0.05)。结论 CARE kV联合CPR术前能够准确评估面神经管骨折情况,并可在满足诊断的前提下降低辐射剂量。     

螺旋CT及MRI在外伤性视神经病变诊断中的价值

目的:分析外伤性视神经病变的螺旋CT/MRI影像表现特征,探讨螺旋CT/MRI在该病临床诊断中的价值。材料与方法:回顾性分析2012年1月至2016年6月住院手术治疗的外伤性视神经病变患者40例,观察患者外伤性视神经病变的临床及CT/MRI影像学表现,对比两种检查方法的临床诊断价值。结果:对患者行视神经管的减压手术病理确诊,40例患者均为外伤性视神经病变,研究显示,螺旋CT检查确诊37例,诊断符合率92.5%,MRI检查确诊35例,诊断符合率87.5%,两组结果对比不具有显著差异,不具有统计学意义;CT检查显示患者视神经管骨折部位包括蝶鞍型骨折、管前型骨折、半管型骨折和全管型骨折,MRI检查显示患者视神经损伤包括移位、水肿、出血和萎缩。结论:CT/MRI检查对了解外伤性视神经病变的性质、范围及程度有重要意义,能够准确判断患者视神经病变的情况,分辨率高,联合诊断可为临床诊断、治疗及评估预后提供可靠的依据。     

Flash双源CT智能最佳管电压技术在小儿中耳胆脂瘤面神经管裸露中的应用

目的 评价高分辨率CT(HRCT)智能最佳管电压技术(CARE kV技术)在中耳炎患儿颞骨检查中对降低辐射剂量和显示面神经管裸露的应用价值。方法 收集中耳炎患儿(2~4岁)176例;按就诊先后顺序分为A组88例,采用CARE kV技术行颞骨HRCT扫描,B组88例,常规颞骨HRCT扫描。比较两组中耳胆脂瘤、面神经管裸露、HRCT图像质量及辐射剂量情况,并进行统计学分析。结果 A、B两组中耳胆脂瘤发生率[59.09%(52/88)vs 64.77%(57/88)]差异无统计学意义(χ²=0.020,P=0.887)。术前HRCT诊断中耳胆脂瘤的准确率两组间差异无统计学意义[96.15%(50/52) vs 96.49%(55/57),χ²=0.199,P=0.639]。A、B两组术前HRCT诊断面神经管裸露发生率分别为29.54%(26/88)和31.82%(28/88),术中观察面神经管裸露发生率分别为27.27%(24/88)和28.41%(25/88),两组间术前HRCT诊断及术中观察面神经管裸露发生率差异均无统计学意义(χ²=0.978、χ²=0.440,P均>0.05)。鼓室段面神经管裸露发生率最高(25/49,51.02%),迷路段最低(5/49,10.20%)。两组中,前膝段面神经管裸露长度术前HRCT与术中测量值差异有统计学意义(P均<0.05),其余各段差异均无统计学意义(P均>0.05)。两组间CT平均值、噪声(SD)、SNR、CNR差异无统计学意义(P均>0.05)。两组间剂量长度乘积(DLP)、有效剂量(ED)差异均有统计学意义(P=0.039、0.028)。结论 小儿颞骨HRCT智能最佳管电压技术能准确诊断面神经裸露,同时保证图像质量并有效降低辐射剂量。     

MRI与CT对比分析颈动脉狭窄和粥样硬化斑块特征

目的 探讨MRI和CT对颈动脉狭窄和粥样硬化斑块病变影像学特征的评估能力。 方法 10例缺血性脑血管疾病患者,超声检查发现颈动脉斑块后,分别接受颈动脉CTA和MR检查。观察颈动脉分叉处管腔的狭窄程度和斑块纤维帽状态、斑块内出血和钙化等。比较两种检查方法判断血管狭窄程度的差异。 结果 CT和MRI显示血管平均狭窄程度均为24%(t=0.461,P>0.05)。CT发现18支血管46处钙化,MRI发现17支血管39处钙化。MRI发现2支血管斑块内有小灶出血,CT无法显示斑块内出血。MRI发现4支血管的不稳定纤维帽,CT发现3支血管的不稳定纤维帽。 结论 CT与MRI均可较好地判断病变血管的管腔狭窄程度,但MRI更适于对颈动脉粥样硬化斑块特征进行分析。     

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.