三维CT血管造影对颅内前循环动脉瘤诊断价值

目的探讨三维CT血管造影(three-dimensional CT angiography,3D-CTA)指导颅内前循环动脉瘤早期夹闭手术的价值。方法自发性蛛网膜下腔出血患者28例均于出血48h内行3D-CTA检查,明确前循环动脉瘤破裂诊断后,依据3D-CTA提供的影像学资料,于发病72h内完成动脉瘤夹闭手术。结果 28例患者3D-CTA检查均发现前循环动脉瘤,其中单个动脉瘤26例,2个动脉瘤2例;28例均行动脉瘤夹闭术,术中证实3D-CTA诊断;术后格拉斯哥预后评分分级Ⅴ级6例,Ⅳ级10例,Ⅲ级5例,Ⅱ级5例,Ⅰ级2例。结论 3D-CTA是诊断前循环动脉瘤的一种简便、快速、无创的方法,可为破裂动脉瘤的早期夹闭手术提供可靠影像学资料。     

颅内多发动脉瘤破裂危险因素及治疗方法

尽管现在关于颅内多发动脉瘤有许多相关报道,但对于颅内多发动脉瘤的治疗仍然具有争论性。随着CT血管造影(CTA,CT angiography)、磁共振血管成像(MRA,magnetic resonance angiography)及血管造影(DSA,digital subtraction angiography)的广泛应用,颅内多发动脉瘤也越来越多见,颅内多发动脉瘤的主要风险是破裂导致蛛网膜下腔出血,     

容积重建成像三维CT血管造影在急性破裂性颅内动脉瘤诊断中的应用研究

目的 探讨容积重建三维CT血管造影(3D-CTA)技术在急性破裂性颅内动脉瘤诊断中的临床应用价值.方法 回顾性总结分析146例164个急性破裂性颅内动脉瘤的容积重建3D-CTA和数字减影造影术(DSA)影像学资料.影像学分析诊断采用双盲法.结果 146例患者共发现164个动脉瘤,120例患者为单发动脉瘤,8例为2个动脉瘤,5例为3个动脉瘤.3D-CTA容积重建(VR)漏诊10例,DSA漏诊3例.经统计学分析3D-CTA容积重建在诊断颅内动脉瘤的准确性、敏感性为94.5%、95.0%.结论 3D-CTA容积重建技术在急性破裂性颅内动脉瘤的诊断中具有较好的准确性和敏感性,在颅内动脉瘤的诊断中具有重要的筛检价值.     

三维CT血管造影术在破裂颅内动脉瘤的诊断和急诊手术治疗中的作用

三维CT血管造影术(three-dimensional computedtomography angiography,3D-CTA)近年在神经外科脑动脉瘤的诊治运用越来越多.本研究回顾性分析了72例破裂颅内动脉瘤出血患者早期诊断和急诊显微手术治疗的3D-CTA检查资料,以此来探讨3D-CTA的临床应用价值.     

16排螺旋CT三维血管造影对颅内动脉瘤的临床诊断价值

[目的]探讨16排螺旋CT三维血管造影(3D-CTA)对颅内动脉瘤的临床诊断价值.[方法]采用16排螺旋CT对36例患者行CTA检查,应用容积重建(VR)、最大密度投影(MIP)结合多平面重建(MPR),并与手术或数字减影血管造影术(DSA)颅内动脉瘤结果对照.[结果]1例无动脉瘤,35例患者中发现动脉瘤44个,其中单个动脉瘤29例,2个动脉瘤5例(10个),3个以上动脉瘤1例(5个),3D-CTA清晰显示了颅内动脉瘤瘤体的部位、瘤颈、载瘤动脉的关系及与周围邻近结构的空间关系.对动脉瘤的特异性、灵敏性与DSA对比差异无显著性(均P＞0.05).[结论]16排3D-CTA是一种安全、快捷、简便的颅内血管检查方法,且重建图像质量高,能为急诊手术计划提供详实的影像学资料,可作为急诊颅内动脉瘤患者的首选筛查方法.     

3D-CTA诊断颅内多发动脉瘤（含颅内镜像动脉瘤）

目的：探讨3D-CTA诊断颅内多发动脉瘤（含颅内镜像动脉瘤）的临床应用价值。方法47例颅内多发动脉瘤的患者进行3D-CTA检查,层厚0.625mm,后处理技术包括多层面重建、表面遮盖三维重建、容积显示重建、最大密度投影重建,并对照手术及介入栓塞治疗结果评估其诊断价值。结果3D-CTA共发现47例110个动脉瘤,其中2个动脉瘤者35例（含镜像动脉瘤15例）,3个动脉瘤者例9例；4个动脉瘤者2例（含镜像动脉瘤1例）,5个动脉瘤者1例。3D-CTA能清晰显示颅内多发动脉瘤,并能清晰显示每个动脉瘤的瘤体大小、瘤颈、瘤顶指向、载瘤动脉及动脉瘤与临近血管和骨性组织间的空间关系。结论3D-CTA诊断颅内多发动脉瘤有较高的准确性,可作为颅内多发动脉瘤诊断的首选方法,在指导动脉瘤治疗方面可对DSA起到重要补充作用。将颅内镜像动脉瘤分为Ⅰ型和Ⅱ型有助于判断破裂出血的责任动脉瘤。     

颅内动脉瘤诊疗策略探讨

目的 探讨颅内动脉瘤诊断方法 的选择以及开颅直接手术或采取血管内介入手术的取向等问题.方法 190例颅内动脉瘤患者中术前均行颅脑CT检查,MRI检查37例、MRA31例,通过重建CT血管成像技术(CTA)及三维CTA(3D-CTA)确诊134例;数字减影血管造影(DSA)/3D-DSA确诊142例;直接手术96例,其中因血管内手术失败而开颅4例;采用血管内介入治疗92例,其中ONYX胶栓塞2例,其余均采用GDC栓塞手术.另6例因再次出血,病情恶化等原因家属放弃治疗.结果 死亡9例,死因:2例再出血、3例严重血管痉挛,肺炎等并发症死亡4例;其余均痊愈出院.结论 CT为蛛网膜下腔出血的首诊选择,MRA可作为无出血史患者的检查,但不宜以此直接手术;CTA/3D-CTA在相当患者中可以确定动脉瘤的大小、部位、供血动脉及破裂点,并依此直接手术;DSA尤其3D-DSA对复杂性的动脉瘤的血供情况可清晰提示并指导手术.血管内栓塞治疗和直接开颅夹闭手术各有优点,我们主张急性期脑肿胀患者应首先行急诊介入治疗,但血管痉挛明显的患者应果断早期手术,其中多发性动脉瘤的重点是判断责任动脉瘤.     

3D-CTA与DSA诊断颅内动脉瘤对比分析

目的：探讨三维CT血管成像（3D-CTA）与DSA（数字减影血管造影检查）检查诊断颅内动脉瘤的对比情况。方法：对32例动脉瘤患者经3D-CTA与DSA检查出的36个动脉瘤予以比较研究,评估出3D-CTA对颅内动脉瘤的诊断价值。结果：32例患者的36个动脉瘤,3D-CTA准确检出34个,DSA检出36个,两者检出率差异无统计学意义（P〉0.05）,但是在小动脉瘤的诊断上3D-CTA不及DSA,而3D-CTA在载瘤动脉的显示、瘤壁钙化及瘤周解剖标志等方面,明显优于DSA（P〈0.05）。结论：3D-CTA可以作为颅内动脉瘤诊断和治疗的首选。     

三维CT血管重建成像在急性蛛网膜下腔出血的应用分析

目的：探讨三维CT血管重建成像在急性蛛网膜下腔出血的应用及局限性分析。方法：对147例CT表现为急性蛛网膜下腔出血患者进行CTA检查,由神经和放射两名医生对结果分析,对CTA阴性以及诊断有争议患者进行DSA检查。结果：在147例急性蛛网膜下腔出血患者中,109例患者3D-CTA结合出血CT图像确诊动脉瘤,瘤体直径2-12mm,均在手术或者介入治疗中证实;其余病例中,7例CT图像有明显的责任灶的蛛网膜下腔出血,3D-CTA阴性,通过DSA发现并经手术证实为动脉瘤,23例普通CT表现为中脑周围出血以及均匀弥漫蛛网膜下腔出血病例CTA提示阴性患者DSA检查也为阴性;3例CTA可疑动脉瘤均被DSA证实为动脉起始的壶腹,CTA在诊断颅内动脉瘤的敏感性和特异性分别为94％和100％。结论：对急性蛛网膜下腔出血患者使用CTA筛查是相对快捷、低风险检查方式,但结果的分析需结合CT图像出血形式以及放射和神经外科医生共同阅片可以完成CTA的诊断效能。     

三维螺旋CT血管造影诊断颅内动脉瘤与数字减影血管造影的一致性研究

目的 研究三维螺旋CT血管造影（3D-CTA）诊断颅内动脉瘤与数字减影血管造影（DSA）的一致性。方法 回顾性分析2021年1月至2022年7月曹县人民医院接收的106例疑似为颅内动脉瘤患者的临床资料。106例患者均接受3D-CTA、DSA检查,统计患者的检查结果,并对比3D-CTA、DSA检查的瘤体最大径、瘤颈径;以DSA为“金标准”,分析3D-CTA诊断颅内动脉瘤的诊断效能及其与DSA之间的一致性。结果 在106例患者中,DSA共检出83例颅内动脉瘤,3D-CTA共检出84例颅内动脉瘤。以DSA为“金标准”进行分析,发现3D-CTA诊断颅内动脉瘤的诊断敏感度为97.59%、特异度为86.96%、准确度为95.28%、漏诊率为2.41%、误诊率为13.04%。3D-CTA检查的瘤体最大径、瘤颈径与DSA对比,差异无统计学意义（均P>0.05）。对于颅内动脉瘤检出及测量的判读,3D-CTA与DSA之间判读一致性为优。结论 在颅内动脉瘤诊断中,3D-CTA具有较高的敏感度、特异度和准确度,且3D-CTA诊断与DSA诊断具有较高的一致性。     

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.