Optimisation of X-ray examinations: General principles and an Irish perspective

In Ireland, the European Medical Exposures Directive [Council Directive 97/43] was enacted into national law in Statutory Instrument 478 of 2002. This series of three review articles discusses the status of justification and optimisation of X-ray examinations nationally, and progress with the establishment of Irish diagnostic reference levels.In this second article, literature relating to optimisation issues arising in SI 478 of 2002 is reviewed. Optimisation associated with X-ray equipment and optimisation during day-to-day practice are considered. Optimisation proposals found in published research are summarised, and indicate the complex nature of optimisation. A paucity of current, research-based guidance documentation is identified. This is needed in order to support a range of professional staff in their practical implementation of optimisation.     

潜艇艇员健康等级判别模型的研究

根据一组潜艇艇员体格检查资料中的１４项指标，应用Ｂａｙｅｓ逐步判别分析法，选择其中６项指标建立了潜艇艇员健康等级的判别模型，用所建立的判别模型对原数据进行回代考核，总回代符合率为７４．１％。表明：应用该判别模型，可对艇员的健康等级进行定量分析，减少人为因素影响，此法应用方便，可在基层卫生单位推广使用。     

Diagnostic imaging in the management of craniosynostoses

Craniosynostoses are the most frequent craniofacial malformations. However, with a prevalence of 3–6 cases per 10,000 live births they are amongst the rarely seen diseases and their definite diagnosis thus poses a challenge to the physician. When an abnormal calvarial configuration is detected, a radiological evaluation is necessary to characterize the deformity and to guide the corrective surgical procedure. The demand for clear diagnostic criteria is justified by the severity of the disease and the possible consequences of delayed diagnosis. In addition to the clinical signs (deformation of the head), conventional skull X-rays show typical radiological alterations and are used for basic diagnostics. Diagnostic tests that may be performed to confirm the diagnosis and assess the extent of the problem, include computed tomography (CT), 3D-CT, magnetic resonance imaging (MRI) scans, and ultrasonography. In the present review we will describe the most important clinical and radiological characteristics of craniosynostosis by means of clinical, radiological and operative situs examples.     

ACR Appropriateness Criteria Imaging in the Diagnosis of Thoracic Outlet Syndrome

Thoracic outlet syndrome is a clinical entity characterized by compression of the neurovascular bundle, and may be associated with additional findings such as venous thrombosis, arterial stenosis, or neurologic symptoms. The goal of imaging is to localize the site of compression, the compressing structure, and the compressed organ or vessel, while excluding common mimics. A literature review is provided of current indications for diagnostic imaging, with discussion of potential limitations and benefits of the respective modalities.The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment. In this document, we provided guidelines for use of various imaging modalities for assessment of thoracic outlet syndrome.     

高海拔地区急性呼吸窘迫综合征诊断标准参数的评判

目的:评判兰州会议制定的高海拔地区急性呼吸窘迫综合征(H-ARDS)诊断标准.方法:调查西宁地区(海拔2 261m)符合平原地区ARDS诊断标准的71例胸外伤及以胸部损伤为主的多发伤,按机械通气与否分为两组,与平原标准与兰州标准进行对比,并将机械通气组的血气指标与兰州及上海同类报道进行对比.结果:无机械通气组血气指标达到平原标准,机械通气组的血气指标与H-ARDS诊断标准相近.结论:海拔2 002m～2 500m H-ARDS诊断标准基本适合于西宁地区该类病人的诊断.     

放射性心脏损伤诊断标准解读

国家职业卫生标准——《放射性心脏损伤诊断标准》已经卫生部批准并发布.此标准是在广泛调研国内外文献、系统学习相关法律法规,进一步明确了制定此标准的依据和原则的基础上制定的.此标准主要用于事故性照射所致心脏损伤的诊断,对医疗照射引起心脏损伤的诊断也有指导意义.为更好地贯彻执行这一标准,也为了能正确诊断和及时治疗放射性心脏损伤患者,该文对标准的相关内容进行解读.     

海水浸泡火器伤失活肌组织的外科判定标准

目的　探讨外科标准“4C”(颜色、致密度、收缩性、出血 )在判定海水浸泡肢体火器伤失活肌组织的可靠性。方法　以滑膛枪发射质量为 0 .2 5 g、速度为 6 0 0～ 80 0 m/ s钢球击中兔后肢 ,将致伤兔浸泡于人工海水中 30～ 6 0 min后出水。伤后 6～ 8h以“4C”标准分级判定肌组织活力 ,并运用图象分析技术 ,观察损伤组织显微病理改变与“4C”标准之间的关系。结果　 χ2 检验显示“4C”标准中与失活组织的密切程度依次为 :收缩性、出血、致密度 ,而颜色与肌组织活力无关。病理观察显示肌组织变性、坏死 ,尤以肌间隙肿胀明显。结论　判定海水浸泡火器伤失活组织主要依据肌组织的收缩性、出血与致密度的变化。     

《外照射放射性骨损伤诊断标准》解读

国家职业卫生标准——《外照射放射性骨损伤诊断标准》已经卫生部批准并发布.此标准是在广泛调研国内外文献、系统学习相关法律法规,进一步明确了制定此标准的依据和原则的基础上制定的.此标准主要用于事故性照射以及职业性慢性外照射所致骨骼损伤的诊断,对医疗照射引起骨骼损伤的诊断也有指导意义.为更好地贯彻执行这一标准,也为了能正确诊断和及时治疗外照射放射性骨损伤患者,该文对标准的相关内容进行解读.     

《放射性肿瘤病因判断标准》解读

《放射性肿瘤病因判断标准》是《放射性肿瘤诊断标准》的修订版本,主要修改点有两方面:在判断标准上,一是可用于估算病因概率(PC)的癌症的数量由5种扩大到10种,二是已发生的癌症与辐射相关联的病因判断标准由原标准中的PC≥50％改为取95％可信限上限的PC≥50％;在估算方法上,除了基于超额相对危险外,还增加了基于超额绝对危险来估算PC.这些改进旨在在结合中国国情的基础上,符合国际发展趋势,尽可能保护索赔者的权益.     

基于RIFLF标准的中老年开腹手术后急性肾损伤危险因素分析

目的 分析外科相关急性肾损伤影响因素.方法 纳入2006年4月～ 2011年1月开腹手术合并术后急性肾损伤(AKI)患者46例,均符合RIFLF标准,记录患者各项临床资料.以同期开腹腔手术未合并AKI患者为对照,分析术后AKI患者发生的危险因素.通过生存曲线分析术后AKI病死率与AKI分期关系.结果 (1)纳入开腹手术合并AKI患者46例,平均年龄(52.56±8.28)岁,其中既往有肾脏病史患者9例.按RIFLF分期示AKI Ⅰ期患者24例;AKIⅡ期患者15例,AKIⅢ期患者7例;(2)单因素分析结果显示两组病例间术前肌酐、蛋白尿、营养不良、血容量不足、肾脏病史例数有显著性差异(P＜0.05);(3)多因素分析结果显示急诊手术相对危险度(OR)为3.19,肾脏病史的OR为6.28;围手术期血容量不足OR为14.78;蛋白尿OR为2.21;术中失血超过1000 ml的OR为3.71,纳入方程有意义;(4)术后AKI生存曲线分析显示,AKI Ⅰ期、AKIⅡ、AKIⅢ期患者间病死率有显著性差异(P＜0.05).结论 外科开腹手术后AKI与多种因素相关,早期干预AKI发生是改善其预后的关键.     

Role of combined grey scale US and US tissue elastography in differentiating solid thyroid nodules

Background

Ultrasonographic (US) examination is an accurate method for detecting thyroid nodules, but its use in differentiating between benign and malignant thyroid nodules is relatively low. US elastography has been applied to study the hardness/elasticity of nodules to differentiate malignant from benign lesions thus deviating a significant group of patients from unnecessary FNAB.

Objectives

The aim of the study is to evaluate the validity of combined grey scale US and tissue elastography in differentiating benign form malignant solid thyroid nodules.

Methods

The study included 46 selected patients with solid thyroid nodules according to our inclusion and exclusion criteria. The patients underwent surgery for compressive symptoms or suspicion of malignancy on FNA cytology. US features and tissue elastography were scored according to the Rago criteria (1).

Results

On US elastography: all the 31 cases with a final diagnosis of benign nodule had a score of 1–3, while 14 of 15 (94.1%) with a final diagnosis of carcinoma had a score of 4–5, with a sensitivity of 93.3%, a specificity of 100% and an accuracy of 97.8%. Combined US and elastography reveals that hypoechogenicity/score 4–5 was most predictive of malignancy with sensitivity 80% and specificity 100%; and accuracy 93.4%.

Conclusions

US elastography seems to have great potential as a new tool for differentiating solid thyroid nodules and for recommending FNAC. Combined grey scale US features and US elastography added no significant value when compared with US elastography alone. Further prospective studies are needed.     

肿瘤免疫治疗疗效评价标准—iRECIST解读

近年来,肿瘤免疫治疗迅猛发展,而现有世界卫生组织标准或实体瘤疗效评价标准(response evaluation criteria in solid tumor,RECIST)无法对免疫治疗疗效进行准确的解读和确切的评估,尤其是反映肿瘤缓解或进展的关键问题—肿瘤负荷的变化。基于此,RECIST工作组结合临床肿瘤免疫治疗实践改良的实体肿瘤疗效评价标准（RECIST版本1.1）制定了一个新的肿瘤免疫治疗疗效评价标准—实体瘤免疫治疗疗效评价标准（immune response evaluation criteria in solid tumor,iRECIST）,并在2017年第18期的The Lancet Oncology上发表。该标准详细定义了实体瘤测量及肿瘤大小评价的标准方法,以期在后续肿瘤免疫治疗临床试验中得以验证。作者对这一新的标准作一介绍。     

《放射性肝病诊断标准》解读

国家职业卫生标准——《放射性肝病诊断标准》已经放射性疾病诊断标准委员会通过,并报送卫生部待批准发布.此标准是在广泛调研国内外文献的基础上、依据相关法律法规制定的.此标准主要用于事故性照射所致肝病的诊断,对医疗照射引起肝病的诊断也有指导意义.为更好地贯彻执行这一标准,并能正确诊断和及时治疗放射性肝病患者,该文对标准的相关内容进行了解读.     

Evaluation of the American College of Cardiology Foundation/American Society of Nuclear Cardiology appropriateness criteria for SPECT myocardial perfusion imaging

Background. The American College of Cardiology Foundation/American Society of Nuclear Cardiology appropriateness criteria (AC) were created to guide responsible use of single photon emission computed tomography (SPECT). Clinical applicability of the AC has not been evaluated. Methods and Results. Indications for testing were determined in 1209 patients and categorized as having appropriate, uncertain, or inappropriate indications; the specialty of the ordering physician was noted. There were 940 (80%) appropriate, 154 (13%) inappropriate, and 79 (7%) uncertain tests; 36 tests were labeled “no category,” as these were ordered for indications not clearly addressed in the AC. Inappropriate studies had more normal and lower summed stress scores, although there remained a high proportion of abnormal SPECT studies in this group (26% of women and 50% of men). Women had lower summed stress scores and more normal tests in the appropriate and inappropriate groups. Studies ordered by anesthesiologists for preoperative evaluation were more likely to be deemed inappropriate than other specialty groups. Conclusion. In evaluating the AC in a single-center academic setting, the majority of studies are appropriate, but a large proportion of ordered SPECT studies were categorized as uncertain, inappropriate, or no category. Although the inappropriate studies showed less ischemia than other groups, especially in women, a substantial portion of these studies (32%) were abnormal.     

脑囊虫病72例MRI表现分析

目的　重点逐灶分析大宗脑囊虫病MRI表现 ,并初步探讨脑囊虫病的诊断标准。方法　回顾性阅读已确诊的脑囊虫病例的MRI片 ,并于横断面、矢状面、冠状面的立体结构上对全部病灶进行定位、定数及MRI解剖分析。结果　脑囊虫病以涉及脑实质最为常见 (97 2 % ) ,且绝大多数寄生于双侧大脑半球皮髓质交界处 (83 1% ) ,95 7%的病人系多发病灶。脑实质囊虫病MRI表现有 9种之多。同一患者同时出现 2种或 2种以上表现者占 5 4 3 %。对其头节、囊泡、周边水肿、钙化状态等征象 ,MRI都有其特征性表现 ,一般诊断不难。脑室内及蛛网膜下腔囊虫病表现为小圆形活囊虫灶及葡萄丛状 2种 ,以T1加权显示病灶较好。脑囊虫病MRI表现复杂多样 ,其主要取决于囊虫感染的不同阶段及部位。结论　脑囊虫病MRI表现复杂多样MRI可予以定性、定位、定量诊断以及明确其病理阶段     

《放射性神经系统疾病诊断标准》解读

国家职业卫生标准——《放射性神经系统疾病诊断标准》已经由卫生部发布并实施.此标准原为放射性脑、脊髓、外周神经损伤3个独立的标准,但在临床工作中3者的损伤往往相伴出现,为了实现标准的整体性及可操作性,因此将3个诊断标准合并为《放射性神经系统疾病诊断标准》,此标准是在广泛调研国内外相关文献、总结临床实践经验,并参考国外相关出版物的基础上制定的.此标准主要适用于职业性放射性神经系统疾病的诊疗,医疗照射引起的神经系统疾病的诊疗也可参照使用.为了更好地执行此标准,也为了能正确处理放射性神经系统损伤,该文对标准的主要内容包括剂量阈值、临床表现、分度标准、治疗原则等进行解读.     

双相迟发多器官功能不全综合征（MODS）动物模型的研究

目的：复制符合ＭＯＤＳ发病因素，病理过程和临床特征的标准化动物模型。方法：在提出符合临床实际的ＭＯＤＳ模型标准和建立动物ＩＣＵ的基础上，用创伤失血性休克后门静脉持续输入内毒素的方法；复制出山羊ＭＯＤＳ模型。结果和结论：该模型的致伤因素、发病过程、临床特征及诊断标准都与临床典型的双相迟发ＭＯＤＳ相似，是目前比较理想的和适用于临床防治研究的ＭＯＤＳ动物模型。     

The Beighton score as a predictor of Brighton criteria in sport and dance

ObjectivesTo determine the efficacy of using the Beighton joint hypermobility score as a predictor of Brighton criteria components, considering the influence of gender and sports participation.DesignCross sectional study design. Setting: A University.ParticipantsSixty-five female rugby players, 38 male rugby players, 61 netball players, 42 female dancers, 40 male controls and 40 female controls.Main outcome measuresThe Beighton score was assessed using the Beighton and Horan Joint Mobility Index. The Brighton criteria was used to assess joint hypermobility syndrome. A binary logistic regression was performed for a pooled sample (n = 286), and subsequently for gender and sport to assess the Beighton score as a predictor of Brighton criteria.ResultsBeighton scores were found to be a predictor of arthralgia (P = 0.002), dislocation and subluxation (P = 0.048) in the pooled analysis; a predictor of dislocation and subluxation (P = 0.047) in males and arthralgia (P = 0.001) in females. Beighton scores were a predictor of arthralgia in female rugby (P = 0.003) and in female controls (P = 0.012).ConclusionsThe potential of the Beighton score to predict joint arthralgia and dislocation/subluxation may allow clinicians to implement effective injury prevention strategies.     

Emergence of the verification phase procedure for confirming 'true'O2max

Traditional V?O_2max criteria are typically based on attainment of a V?O₂ plateau, and threshold values for the respiratory exchange ratio, heart rate and blood lactate concentration. Despite long‐standing criticisms directed at these criteria, their use remains widespread. This article discusses an alternative procedure, termed the verification phase, for confirming the attainment of true V?O_2max. Following a continuous incremental exercise test to the limit of tolerance and appropriate recovery period, the verification phase is performed and is characterized by a supramaximal square wave exercise bout. Consistent peak V?O₂ values in the incremental and verification phases, confirms that a true V?O_2max has been attained. Six recent studies investigated the utility of the verification phase for evaluating true V?O_2max. These studies consistently found small insignificant mean differences between the maximal V?O₂ attained in the incremental and verification phases. However, this group mean approach does not identify individual subjects who may not have attained a true V?O_2max. Notably, only one of the six studies reported a criterion threshold to verify the V?O_2max of individual subjects. Further research is required to investigate the utility of different verification phase procedures and to establish a suitable verification criterion threshold for confirming true V?O_2max.