扩散峰度成像在胶质瘤分级和预测细胞增殖中的诊断效能

目的 探讨MR扩散峰度成像（DKI）在胶质瘤分级的价值,及其与Ki-67标记指数的相关性。方法 收集经手术病理证实的脑胶质瘤患者32例,根据病理结果分为高级别胶质瘤组（HGG组,n=18）和低级别胶质瘤组（LGG组,n=14）,术前行常规MR、DWI及DKI扫描,测定肿瘤实质区的平均扩散峰度（MK）、轴向扩散峰度（Ka）、径向扩散峰度（Kr）、平均扩散系数（MD）、部分各向异性（FA）和ADC值,比较高低级别胶质瘤各参数值的差异和诊断效能、肿瘤区各参数与Ki-67标记指数的相关性。结果 高低级别胶质瘤各参数值差异均有统计学意义（P均<0.01）。HGG组的MK、Ka、Kr、FA值高于LGG组,而MD、ADC值低于LGG组。MK在鉴别高低级别胶质瘤的ROC曲线下面积最大（0.82,P<0.01）,特异度最高（90.40%）;ADC值敏感度最高（80.20%）。MK、Ka、Kr、MD和ADC值与Ki-67标记指数均有相关性,MK值与Ki-67标记指数相关性最大（r_s=0.61,P<0.01）。结论 DKI参数对鉴别高低级别胶质瘤有一定的价值,其诊断效能总体高于传统扩散参数。DKI参数值对预测肿瘤细胞增殖有潜在价值。     

合成MRI联合弥散加权成像评估胶质瘤级别及肿瘤细胞增殖活性

目的 观察合成MRI联合弥散加权成像（DWI）鉴别高、低级别胶质瘤及评估肿瘤细胞增殖活性的价值。方法 回顾性分析69例经病理学证实的胶质瘤患者资料，包括低级别胶质瘤（LGG）27例、高级别胶质瘤（HGG）42例，术前均接受颅脑MRI、合成MRI和DWI。检测肿瘤实质T1值、T2值、质子密度（PD）和表观弥散系数（ADC），比较LGG与HGG间各参数差异。采用受试者工作特征（ROC）曲线评价各参数单独及联合鉴别LGG与HGG的效能，分析各参数与Ki-67标记指数（Ki-67 LI）的相关性。结果 LGG T1值及PD低于HGG （P均<0.001），而ADC高于HGG （P<0.001），二者T2值差异无统计学意义（P=0.328）。单一参数中，以ADC鉴别LGG与HGG的曲线下面积（AUC）为0.901，高于T1值（AUC=0.862）和PD （AUC=0.848）（P均>0.05）；T1值＋PD＋ADC的AUC （0.988）高于任一单一参数（P均<0.05），其敏感度和特异度分别为92.86%和100%。肿瘤ADC与其Ki-67 LI呈中等负相关（r=-0.617，P<0.001），T1值和PD与Ki-67 LI呈中等正相关（r=0.441、0.437，P均<0.001），T2值与Ki-67 LI无明显相关性（r=-0.044，P=0.719）。结论 合成MRI联合DWI可无创评估胶质瘤级别及细胞增殖活性。     

DWI评价乳腺浸润性导管癌生物学特征

目的 探讨DWI评估乳腺浸润性导管癌（IDC）生物学特征的价值。方法 回顾性分析经手术病理证实的87个乳腺浸润性导管癌的DWI数据,测量ADC值,评价并比较ADC值在不同腋窝淋巴结状态、组织学级别及分子学分型间的差异,并分析ADC值与腋窝淋巴结状态、组织学级别及分子学分型的相关性。结果 淋巴结阳性病灶ADC值低于淋巴结阴性病灶（P=0.035）,高级别乳腺癌ADC值低于中级别、低级别乳腺癌（P=0.021、0.002）,ADC值在不同分子分型间差异无统计学意义。ADC值与组织学分级呈低度负相关（r_s=-0.357,P=0.001）,与腋窝淋巴结转移及分子分型呈弱的负相关（r_s=-0.227,P=0.034;r_s=-0.093,P<0.001）。结论 DWI能够反映乳腺浸润性导管癌的生物学特征。     

维吾尔族女性三阴性乳腺癌MRI表现及其与Ki-67指数的相关性

目的 探讨维吾尔族女性三阴性乳腺癌（TNBC）的MRI表现及其与Ki-67指数的相关性。方法 收集97例经病理证实的TNBC患者,其中维吾尔族28例（维吾尔族组;28个病灶）,汉族69例（汉族组;70个病灶）,比较两组MRI特征;分析维吾尔族组TNBC的MRI特征与Ki-67指数的相关性。结果 维吾尔族及汉族患者TNBC均以浸润性导管癌（3级）为主,两组间Ki-67指数及ADC值差异均无统计学意义（P均> 0.05）。维吾尔族患者年龄小于汉族患者（P<0.05）,肿瘤最大径和早期强化率均大于汉族患者（P均< 0.05）;两组间TNBC病灶边缘、强化特征差异均有统计学意义（P均< 0.05）;维吾尔族组时间-信号强度曲线（TIC）类型以流出型为主,汉族组以平台型为主（P < 0.001）。维吾尔族组Ki-67指数与肿块形态及TIC类型呈正相关（r=0.464、0.606,P均< 0.05）。结论 维吾尔族女性TNBC的MRI特征与汉族女性有一定差异,且部分特征与Ki-67指数相关。     

DWI评估宫颈鳞状细胞癌增殖和侵袭性

目的 探讨DWI不同ADC值预测宫颈鳞状细胞癌（CSCC）增殖和侵袭性的价值。方法 对96例CSCC患者术前行盆腔常规MRI和DWI,测量肿瘤最小ADC值、平均ADC值和最小ADC率（最小ADC值/平均ADC值）,比较不同Ki-67表达及临床病理特征患者间的差异。结果 与低侵袭性宫颈癌相比,最小ADC值在Ki-67高表达、肿瘤最长径 ≥ 4 cm、高FIGO分期、低分化、宫颈间质浸润深度 ≥ 1/2、宫旁受累、LVI、淋巴结转移和PNI阳性的高侵袭性宫颈癌患者中显著降低（P均<0.05）。与平均ADC值和最小ADC率相比,最小ADC值预测CSCC不同临床病理特性的ROC曲线下面积和效能较高,且与Ki-67指数呈负相关（r=-0.48,P<0.001）,与其他临床病理特征如肿块大小、FIGO分期、病理分级、间质浸润深度、宫旁受累、LVI、淋巴结转移和PNI呈负相关（r=-0.36、-0.34、-0.27、-0.40、-0.33、-0.60、-0.61、-0.41,P均<0.05）。结论 最小ADC值可有效反映CSCC的增殖和侵袭性。     

不同年龄阿尔茨海默病患者脑核团ADC值与年龄的相关性

目的 探讨不同年龄阿尔茨海默病（AD）患者ADC值与年龄的相关性。方法 选取30例AD患者（AD组）和年龄与之相匹配的30名志愿者（对照组），按年龄段各分为6个亚组[55~59岁（n=3）、60~64岁（n=4）、65~70岁（n=9）、71~74岁（n=5）、75~80岁（n=6）、>80岁（n=3）]，测量双侧海马、红核、尾状核、杏仁体、壳核ADC值，并进行配对t检验、独立样本t检验、单因素方差分析及Pearson相关分析。结果 AD组红核左、右侧ADC值有统计学差异（P=0.022）。AD组不同年龄亚组右侧海马、双侧尾状核、右侧壳核ADC值差异有统计学意义（P均<0.05）；2组不同年龄亚组双侧海马、壳核、尾状核ADC值差异有统计学意义（P均<0.05）。AD组右侧海马（r=0.615，P<0.001）、右侧壳核（r=0.653，P=0.001）及双侧尾状核（左侧：r=0.397，P=0.030；右侧：r=0.429，P=0.020）ADC值与年龄呈正相关。结论 AD患者右侧海马和壳核、双侧尾状核ADC值随年龄增加而增大。ADC值可为临床预测和早期诊断AD脑内右侧海马和壳核、双侧尾状核神经退行性病变提供参考。     

MRI定量参数评估肠道克罗恩病病变活动性

目的 探讨MRI定量参数ADC与容积转运常数（K^trans）评估肠道克罗恩病（CD）病变活动性的应用价值。方法 收集50例回盲部单发病灶的CD患者,依次行常规MR、DWI和动态增强MRI（DCE-MRI）扫描,测量ADC和K^trans值,同时评估患者Harvey-Bradshow指数（HBI）和血清C反应蛋白（CRP）浓度。根据HBI将50例患者分为重度活动组、轻中度活动组及静止组,比较3组间K^trans、ADC值的差异;对K^trans、ADC值与对应的HBI、CRP行相关性分析。结果 50例CD患者中,静止组16例、轻中度活动组21例、重度活动组13例。3组K^trans、ADC值的差异均有统计学意义（P均<0.05）,组间两两比较差异均有统计学意义（P均<0.05）。病变肠壁K^trans值与HBI呈正相关（r=0.635,P<0.001）,与CRP呈正相关（r=0.764,P<0.001）;ADC值与HBI呈负相关（r=-0.614,P<0.001）,与CRP呈负相关（r=-0.490,P<0.001）。病变肠壁HBI与CRP呈正相关（r=0.755,P<0.001）,K^trans与ADC值呈负相关（r=-0.348,P=0.013）。结论 MRI定量参数K^trans和ADC可反映CD活动状态,且K^trans的稳定性和敏感性优于ADC。     

直肠癌磁共振体素内不相干运动成像定量参数与Ki-67表达水平的相关性分析

目的 探讨直肠癌体素内不相干运动成像（IVIM）定量参数值与Ki-67表达水平的相关性。方法 86例未接受新辅助治疗而直接经手术证实的直肠腺癌患者接受直肠多b值DWI检查（b=0、20、50、100、200、400、600、800、1 000、1 200、1 400、1 600 s/mm²）,测量病灶相应的D、D^*、f值。按Ki-67水平将其分为低表达组（Ki-67<50%）和高表达组（Ki-67≥50%）,比较两组多b值定量参数有无差异并分析其与Ki-67表达水平的相关性,并采用多因素回归分析Ki-67指数增殖程度与临床病理结果和MR参数的关系。结果 直肠癌低表达组与高表达组的平均D、f值分别为,差异有统计学意义（P<0.01;P=0.01）,两组间D^*值差异无统计学意义。D值与Ki-67表达水平呈负相关（r=-0.40,P<0.01）。多因素回归分析提示仅D值是高Ki-67表达的独立危险因子。结论 直肠癌D值与Ki-67表达相关,可间接评估直肠肿瘤细胞增殖情况及预后,反映直肠癌的侵袭性和生物学特性。     

酰胺质子转移成像和扩散加权成像鉴别诊断乳腺良恶性病变

目的 观察MR酰胺质子转移成像（APTWI）和扩散加权成像（DWI）鉴别诊断乳腺良恶性病变的价值，并分析不同参数间的相关性。方法 对65例乳腺病变患者行APTWI及DWI，测量并比较乳腺良恶性病变间平均ADC（ADC_mean）、最小ADC（ADC_min）及非对称磁化转移率[MTRasym（3.5 ppm）]值的差异；采用ROC曲线评估各参数鉴别乳腺良恶性病变的诊断效能，并分析良恶性病变中各参数间的相关性。结果 共70个病灶纳入研究，包括32个良性（良性组）和38个恶性病灶（恶性组）。良性组ADC_mean、ADC_min及MTRasym（3.5 ppm）值均高于恶性组（t=－5.63、－5.94、－0.24，P均<0.05）；ADC_min、ADC_mean及MTRasym（3.5 ppm）鉴别乳腺良恶性病变的AUC分别为0.850、0.827及0.729（P均<0.01）；ADC_min的AUC大于MTRasym（3.5 ppm）值（Z=1.990，P=0.046），其余各参数AUC差异均无统计学意义（P均>0.05）。恶性组MTRasym（3.5 ppm）值与ADC_mean（r=－0.325，P=0.046）和ADC_min值（r=－0.384，P=0.017）均呈负相关；良性组MTRasym（3.5 ppm）值与ADC_min值呈负相关（r=－0.357，P=0.045）。结论 APTWI及DWI均可用于鉴别诊断乳腺良恶性病变；相比DWI，APTWI的诊断效能有待进一步提高。     

乳腺浸润性导管癌时间-信号强度曲线及ADC值与病理学分级的相关性

目的 探讨浸润性导管癌(IDC)时间-信号强度曲线(TIC)及ADC值与组织学分级的相关性。方法 回顾性分析43例(共45个病灶)经病理学证实为IDC的动态增强MRI及DWI表现,测量肿块的早期强化率、ADC值,描绘时间-信号强度曲线(TIC),对不同病理学分级IDC的早期强化率、TIC曲线分型及ADC值进行组间比较,并分析其与病理组织分级的相关性。结果 43例IDC中,Ⅰ级8例,Ⅱ级24例,Ⅲ级11例。不同级别IDC两两比较,早期强化率的差异均无统计学意义(P均>0.05),而TIC曲线分型、ADC值的差异均有统计学意义(P均<0.05),IDC的TIC曲线分型与病理组织学分级呈正相关关系(r=0.40,P<0.01),与ADC值呈负相关(r=-0.79,P<0.01)。正常乳腺组织与不同病理组织分级IDC的ADC值差异均有统计学意义(P均<0.05)。结论 乳腺动态增强MRI的TIC曲线结合ADC值可在一定程度上预测IDC的组织学分级。     

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.     

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.     

Molecular characterization of virulence and antimicrobial resistance profile of Shigella species isolated from children with moderate to severe diarrhea in northeastern Brazil

Molecular characterization of virulence and antimicrobial resistance profiles were determined for Shigella species isolated from children with diarrhea in Fortaleza, Brazil. Fecal specimens were collected along with socioeconomic and clinical data from children with moderate to severe diarrhea requiring emergency care. Shigella spp. were isolated by standard microbiological techniques, and we developed 4 multiplex polymerase chain reaction assays to detect 16 virulence-related genes (VRGs). Antimicrobial susceptibility tests were performed using disk diffusion assays. S. flexneri and S. sonnei were the predominant serogroups. S. flexneri was associated with low monthly incomes; more severe disease; higher number of VRGs; and presence of pic, set, and sepA genes. The SepA gene was associated with more intense abdominal pain. S. flexneri was correlated with resistance to ampicillin and chloramphenicol, whereas S. sonnei was associated with resistance to azithromycin. Strains harboring higher numbers of VRGs were associated with resistance to more antimicrobials. We highlight the correlation between presence of S. flexneri and sepA, and increased virulence and suggest a link to socioeconomic change in northeastern Brazil. Additionally, antimicrobial resistance was associated with serogroup specificity in Shigella spp. and increased bacterial VRGs.     

护理干预对面部中重度寻常型痤疮的临床疗效影响分析

目的研究护理干预对面部中重度寻常型痤疮的临床疗效影响。方法选取本院在2014年4月~2016年7月诊治的136例面部中重度寻常型痤疮患者,随机分为研究组与对照组,每组68例;所有患者均依据其情况给予对应的治疗,其中对照组在治疗期间给予常规护理,研究组在对照组的基础上再给予综合性护理干预,比较两组的治疗效果及护理满意度情况等。结果患者在接受治疗和护理后,研究组中度与重度患者的治疗效果较对照组均明显提高(P0.05),研究组护理满意度较对照组明显增高(P0.05)。结论对面部中重度寻常型痤疮患者在其治疗期间给予综合性护理干预,具有良好的效果。