胆管细胞癌与不同分化程度肝细胞癌CEUS特征的对比研究

目的 比较肝内胆管细胞癌（ICC）和不同分化程度肝细胞癌（HCC）CEUS表现对ICC和不同分化程度HCC的鉴别诊断价值。方法 回顾性分析经病理证实的34例ICC（ICC组）和136例不同分化程度的HCC患者高、中、低分化（HCC组）的常规超声及CEUS表现,并评价CEUS始退时间对ICC的诊断效能。结果 ICC组在门静脉早期开始消退的比例（24/34,70.59%）均高于各HCC组,在门静脉中期开始消退的比例（0/34）和在门静脉晚期/延迟期开始消退的比例（4/34,11.76%）均低于中、高分化HCC组,差异均有统计学意义（P均<0.008）。低分化HCC组在门静脉中期开始消退的比例（16/41,39.02%）高于高分化HCC组（P<0.008）。CEUS诊断ICC的敏感度、特异度、阳性预测值、阴性预测值、准确率、阳性似然比及阴性似然比分别为82.35%（28/34）、91.18%（124/136）、70.00%（28/40）、95.38%（124/130）、89.41%（152/170）、9.4、0.2。ICC及低、中、高分化HCC组病灶CEUS始增时间分别为（13.03±3.49）s、（13.80±3.04）s、（14.89±4.12）s、（16.00±3.38）s,差异有统计学意义（F=4.369,P<0.05）,ICC组始增时间早于高分化HCC组（P<0.05）。结论 不同分化程度HCC和ICC的CEUS表现存在差异,CEUS对其鉴别诊断有一定的参考价值。     

经皮超声引导下射频消融治疗结直肠癌肝转移疗效分析

目的 探讨经皮超声引导下射频消融(RFA)治疗结直肠癌肝转移(CRLM)的疗效及预后因素。方法 回顾性分析192例接受经皮超声引导下RFA治疗的CRLM患者临床及影像资料,其中原发肿瘤为结肠癌者105例,直肠癌者87例。结果 192例患者共接受RFA治疗302例次,肝转移灶共437个。首次RFA治疗后1个月肿瘤总体灭活率93.59%(409/437)。肿瘤局部复发率为11.21%(49/437),平均复发时间为RFA治疗后(9.34±7.25)个月(2~34个月)。治疗后肝内新生转移灶发生率48.96%(94/192)。患者1、3、5年总体生存率分别为87.0%、40.8%、16.5%。单因素分析结果显示,肿瘤数目(P=0.003)、最大径(P=0.001)、肝内分布(P=0.001)及治疗后1个月肿瘤灭活情况(P=0.007)是影响患者生存率的潜在危险因素。多因素分析结果显示,肿瘤数目(P=0.001)及最大径(P=0.001)为患者生存率的独立影响因素。RFA治疗后较严重并发症发生率为3.31%(10/302),未发生治疗相关性死亡。结论 RFA是一种安全、有效的CRLM治疗方法,肿瘤最大径≤3 cm及单发肝转移灶患者预后较好。     

剪切波弹性成像联合CEUS校正乳腺影像报告和数据系统3~5类乳腺病变

目的 探讨剪切波弹性成像（SWE）联合CEUS在校正乳腺影像报告和数据系统（BI-RADS）3~5类乳腺肿瘤中的应用价值。方法 收集50例乳腺病变患者（57个病灶）,其中良性病灶28个,恶性29个。对所有病灶术前行常规超声、SWE和CEUS检查,以常规超声进行BI-RADS分类,并采用SWE、CEUS及SWE联合CEUS对BI-RADS分类进行校正。以病理结果为金标准,计算常规超声、SWE、CEUS及SWE联合CEUS诊断乳腺良恶性病灶的敏感度、特异度和诊断正确率。结果 SWE参数最大杨氏模量值（E_max）诊断乳腺良恶性病灶的临界值为87.2 kPa,CEUS的临界值为8.5分,SWE联合CEUS的多因素Logistic回归模型为Y（P）=-18.785+0.161X₁+11.822X₂,X₁为E_max,X₂为增强后病灶大小改变。SWE联合CEUS将11个病灶正确降为3级,4个病灶误诊;SWE联合CEUS诊断乳腺良恶性病灶的敏感度、特异度和诊断正确率分别为100%（29/29）、85.71%（24/28）和92.98%（53/57）。结论 SWE联合CEUS对BI-RADS 3~5类乳腺病灶具有良好的校正作用,可提高超声诊断正确率。     

钆塞酸二钠增强MRI评估全肝及各肝段肝功能

目的 评价采用乳腺CEUS预测模型诊断乳腺恶性病灶的观察者一致性。方法 收集多中心共953例接受超声和CEUS检查的乳腺单发结节患者。本课题组由初始组（各医院1名低年资医师）、检查者组（各医院1~2名具有2年以上CEUS检查经验的医师）、研究组（四川省医学科学院四川省人民医院2名高年资医师）及交叉盲读组（各医院1~2名副主任医师或主任医师）构成。首先由初始组及检查者组根据乳腺影像报告和数据系统（BI-RADS）对病灶进行分类,其次由交叉盲读组和研究组采用乳腺CEUS预测模型再次进行BI-RADS分类。以病理结果为金标准,计算4组诊断乳腺恶性病灶的效能;分析观察者间诊断乳腺恶性病灶的一致性。结果 953例中,病理证实良性病灶451例（451/953,47.32%）,恶性病灶435例（435/953,45.65%）,癌前病变67例（67/953,7.03%）。初始组、检查者组、研究组及交叉盲读组诊断乳腺恶性病灶的准确率分别为71.67%（683/953）、74.92%（714/953）、80.17%（764/953）及83.42%（795/953）。初始组与检查者组诊断乳腺恶性病灶的一致性较好（Kappa=0.82,P<0.001）,与研究组及交叉盲读组的一致性中等（Kappa=0.56、0.41,P均<0.001）;检查者组与研究组、交叉盲读组的一致性均为中等（Kappa=0.68、0.51,P均<0.001）;研究组与交叉盲读组的一致性中等（Kappa=0.74,P<0.001）。结论 不同观察者采用乳腺CEUS预测模型诊断乳腺恶性病灶的一致性一般。     

颈动脉斑块超声造影增强特征与其病理特征及易损性的相关性

目的 采用超声造影（CEUS）评价颈动脉粥样硬化斑块增强特征与斑块中新生血管及弹性蛋白形态等病理特征及其易损性的相关性。方法 纳入124例颈动脉粥样硬化斑块患者,根据6个月内有无短暂性脑缺血发作（TIA）或非致死性脑卒中将其分为症状组（n=40）和非症状组（n=84）,比较组间CEUS增强等级差异;其中60例接受颈动脉内膜剥脱术（CEA）并获得病理学结果,评价CEUS增强等级与斑块内新生血管、弹性蛋白形态的相关性;以Ⅱ级增强为标准判断斑块易损性,并与病理结果对照,评价CEUS判断斑块易损性的效能。结果 症状组颈动脉斑块CEUS增强等级高于非症状组（P<0.05）。斑块CEUS表现为0级增强时,其内弹性蛋白以波浪状为主;Ⅱ级增强时,以平直或断裂状为主;不同增强等级斑块弹性蛋白形态差异具有统计学意义（P<0.05）。斑块CEUS增强等级与其微血管密度（MVD）呈正相关（r=0.62,P<0.01）。CEUS判断斑块易损性的敏感度、特异度、阳性预测值和阴性预测值分别为74.36%、61.91%、78.00%和57.00%。结论 症状性颈动脉斑块新生血管较多,其CEUS增强等级与新生血管数量及弹性蛋白形态有关;CEUS评价颈动脉粥样硬化斑块的效能较高。     

常规超声联合超声造影鉴别诊断甲状腺恶性与炎性病灶

目的 观察常规超声联合超声造影（CEUS）鉴别诊断甲状腺恶性与炎性病灶的价值。方法 纳入78例甲状腺疾病患者,根据病理结果将其分为恶性组（n=61）及炎性组（n=17）;对比2组病灶常规超声及CEUS特点,并将组间差异有统计学意义的因素纳入回归分析,观察常规超声联合CEUS鉴别诊断甲状腺恶性与炎性病灶的价值。结果 恶性组与炎性组病灶最大径、钙化情况、纵横比、造影剂到达时间、病灶增强模式及程度差异均有统计学意义（P均<0.05）。回归分析结果显示,病灶最大径<10 mm（OR=130.319,P<0.001）、慢进型增强（OR=6.177,P=0.013）、微钙化（OR=10.886,P=0.001）及向心性增强（OR=12.922,P<0.001）为甲状腺恶性病灶的预测因子,其曲线下面积分别为0.828[95%CI（0.740,0.916）]、0.703[95%CI（0.575,0.832）]、0.638[95%CI（0.501,0.775）]及0.630[95%CI（0.491,0.768）]。结论 常规超声联合CEUS有助于鉴别诊断甲状腺恶性与炎性病灶;病灶伴微钙化、慢进型增强及向心性增强为恶性病灶的预测因子。     

肝血管平滑肌脂肪瘤的临床及超声造影特点分析:与肝血管瘤及肝细胞癌对比

目的 对比分析肝血管平滑肌脂肪瘤（HAML）与肝血管瘤（HCH）及肝细胞癌（HCC）的临床及超声特点。方法 回顾性分析经病理证实的40例HAML患者（HAML组），并与同时期随机检索的40例HCH患者（HCH组）及40例HCC患者（HCC组），比较其临床特点、二维超声和超声造影表现。结果 HAML好发于女性（70.00%，28/40），平均发病年龄（39.8±10.6）岁，在患者性别、年龄、肝炎病毒感染方面均与HCC差异有统计学意义（P均<0.001），而与HCH差异无统计学意义（P均>0.05）。HAML二维超声多表现为边界清楚的高回声病灶。HAML组与HCC组间回声（χ²=8.93，P=0.008）、边界（χ²=2.03，P=0.013）差异均有统计学差异，病灶数目、大小、形态及血供差异均无统计学意义（P均>0.05）；与HCH组间病灶数目、大小、边界、回声、形态及血供差异均无统计学意义（P均>0.05）。62.50%（25/40）的HAML病灶CEUS表现为"快进快退"模式，但与HCC组相比在强化消退为等增强（t=-2.46，P=0.016）及低增强的时间（t=-5.35，P<0.001）方面差异均有统计学意义。HAML组与HCH组间、HAML组与HCC组间门脉期及延迟期增强表现差异均有统计学意义（P均<0.05），而动脉期增强表现差异均无统计学意义（P均>0.05）。结论 结合临床特点、二维超声和超声造影表现，有助于诊断HAML，并与HCH、HCC相鉴别。     

放射性粒子定位与金属丝定位引导切除隐匿性乳腺病变

目的 对比分析放射性粒子定位（RSL）与金属丝定位（WL）引导切除隐匿性乳腺病变的效果,探讨RSL的应用价值。方法 收集72例女性隐匿性乳腺病变患者,对其中34例行RSL（于术前5天内进行定位,RSL组）、38例行WL（于手术当日完成定位,WL组）,而后均以手术切除病灶。对比2组定位准确率、首次切缘阴性率、病灶再切除率及定位相关并发症发生情况。结果 2组均定位准确,乳腺X线片示病灶均完整切除。RSL组首次切缘阴性率为91.18%（31/34）,病灶再切除率为5.88%（2/34）;WL组分别为65.79%（25/38）和28.95%（11/38）;2组间差异均有统计学意义（P均<0.01）。WL组术中出现金属丝移位2例、迷走神经反应1例,RSL组未出现明显并发症。结论 RSL、WL均可准确定位并引导切除隐匿性乳腺病变;与WL比较,RSL不受手术时间影响,不易移位,切缘阴性率低,定位相关并发症少。     

肾细胞癌常规超声及超声造影特征

目的 观察肾细胞癌（RCC）及其常见病理亚型的常规超声及超声造影（CEUS）特征。方法 纳入94例RCC（恶性组）及34例肾脏良性病变患者（良性组）,将恶性组分为肾透明细胞癌（ccRCC）亚组（n=74）和肾乳头状细胞癌（pRCC）及肾嫌色细胞癌（cRCC）亚组（n=16）;比较良、恶性组及恶性组2亚组病灶常规超声及CEUS特征。结果 恶性组主要表现为低回声（63/94,67.02%）、快进（84/94,89.36%）、快退（58/94,61.70%）及高增强（68/94,72.34%）,良性组主要表现为高回声（20/34,58.82%）、快进（22/34,64.71%）、慢退（16/34,47.06%）及高增强（15/34,44.12%）;组间病灶回声、CEUS增强方式、消退方式及增强强度差异均有统计学意义（P均<0.05）。恶性组内2亚组病灶增强程度差异具有统计学意义（P<0.05）,ccRCC主要表现为高增强（61/74,82.43%）,pRCC及cRCC主要表现为低增强（10/16,62.50%）。结论 RCC,尤其ccRCC超声多表现为低回声、快进、快退及高增强;常规超声及CEUS对术前诊断RCC有一定价值。     

声触诊组织量化成像联合超声造影鉴别诊断TI-RADS 4类良恶性甲状腺结节

目的 探讨声触诊组织量化成像（VTIQ）联合超声造影（CEUS）鉴别诊断TI-RADS 4类甲状腺良恶性结节的价值。方法 对经手术切除及术后病理证实的86例TI-RADS 4类甲状腺结节患者的98个结节（以45个良性结节为良性组，53个恶性结节为恶性组）于术前行VTIQ及CEUS检查，获取结节剪切波速度最大值（SWV_max）、最小值（SWV_min）、平均值（SWV_mean）、病灶最大值与周围正常组织的比值（SWV_ratio）及CEUS特征，建立VTIQ联合CEUS的Logistic回归模型；以AUC比较VTIQ、CEUS及二者联合回归模型对TI-RADS 4类良恶性甲状腺结节的鉴别诊断效能。结果 恶性组SWV_max、SWV_min、SWV_mean、SWV_ratio值均高于良性组（P均<0.05）。CEUS强化程度、强化均匀度、强化方式、环状增强、消退方式组间差异均有统计学意义（P均<0.05）。SWV_mean（>2.96 m/s）、强化程度（低增强）是诊断TI-RADS 4类恶性甲状腺结节的重要指标（P均<0.05）。SWV_mean、CEUS及Logistic回归模型诊断TI-RADS 4类甲状腺良恶性结节的AUC分别为0.862、0.835和0.933。结论 VTIQ及CEUS均可鉴别TI-RADS 4类甲状腺良恶性结节，二者联合可明显提高诊断效能。     

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.     

Dissociable correlates of two classes of retrieval processing in prefrontal cortex

Although substantial evidence suggests that the prefrontal cortex (PFC) implements processes that are critical for accurate episodic memory judgments, the specific roles of different PFC subregions remain unclear. Here, we used event-related functional magnetic resonance imaging to distinguish between prefrontal activity related to operations that (1) influence processing of retrieval cues based on current task demands, or (2) are involved in monitoring the outputs of retrieval. Fourteen participants studied auditory words spoken by a male or female speaker and completed memory tests in which the stimuli were unstudied foil words and studied words spoken by either the same speaker at study, or the alternate speaker. On "general" test trials, participants were to determine whether each word was studied, regardless of the voice of the speaker, whereas on "specific" test trials, participants were to additionally distinguish between studied words that were spoken in the same voice or a different voice at study. Thus, on specific test trials, participants were explicitly required to attend to voice information in order to evaluate each test item. Anterior (right BA 10), dorsolateral prefrontal (right BA 46), and inferior frontal (bilateral BA 47/12) regions were more active during specific than during general trials. Activation in anterior and dorsolateral PFC was enhanced during specific test trials even in response to unstudied items, suggesting that activation in these regions was related to the differential processing of retrieval cues in the two tasks. In contrast, differences between specific and general test trials in inferior frontal regions (bilateral BA 47/12) were seen only for studied items, suggesting a role for these regions in post-retrieval monitoring processes. Results from this study are consistent with the idea that different PFC subregions implement distinct, but complementary processes that collectively support accurate episodic memory judgments.     

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.