支气管黏膜脂肪瘤1例

患者男性，49岁。活动后胸闷气促1个月伴干咳，休息后可缓解。胸部CT示两肺纹理紊乱，右肺上叶近肺门见细条状密度略高影，并见小点状结节影，右肺上叶见肺大泡，右主支气管内见结节影，CT值约28Hv，内见钙化；右主支气管腔狭窄；纵隔内未见肿大淋巴结。病理诊断：①慢性支气管炎；②右肺上叶肺大泡；③右肺上叶感染、纤维化；④右主支气管占位（隆突下2cm左右）肿瘤？异物？建议支气管镜检查。支气管镜示右主支气管外侧壁见一息肉样隆起，阻塞上叶支气管口，基底窄，周围黏膜有浸润征象，表面尚光滑。     

肺黏液表皮样癌1例诊治及预后分析

患者,男,55岁,因反复刺激性咳嗽3个月于2009年3月13日入院,2个月前查胸部X线片未见明显异常,考虑支气管炎给予抗感染治疗,症状无明显好转,2天前胸部CT见右主支气管类圆形肿物,大小2cm×1cm×1cm,部分阻塞管腔,右上肺阻塞性炎症,1天前查气管镜见右肺上叶开口淡红色表面光滑息肉样肿物,部分阻塞右主支气管(图1),病理考虑肺黏液表皮样癌(图2)。手术可见右上叶支气管开口处     

肺毛霉菌病咳出小块支气管组织1例

患者男性 ,5 2岁。因旅途中突然昏厥急送我院。患者高热不退 ,轻咳 ,胸部Ｘ线示 :右肺部有一 4ｃｍ× 3ｃｍ× 3ｃｍ大小阴影。ＣＴ示 :右肺占位性病变 ,考虑肺癌可能性大。支气管镜见右肺支气管分段处有一肉芽组织阻塞支气管腔 ,取其送病理检查。病理诊断 :肺毛霉菌感染。用抗霉菌药物治疗 2天后热退 ,咳嗽加重 ,随痰咳出一块状物 ,约黄豆粒大小 ,灰红色 ,急送病理。镜检 :大片坏死组织中可见大块支气管软骨及平滑肌组织 ,证实为一肺的亚段支气管管壁。在其血管管腔中有成团的毛霉菌 ,菌丝粗大无分隔 ,呈直角分支(图 1,2 )。病理诊断 :肺段…     

支气管粘液表皮样癌1例

患者男性，21岁。因咳嗽、发热、右脚钝痛40余天，外院CT诊断为“肺癌，右胸腔积液”，纤维支气管镜检病理报告“小细胞癌”入我院。X线胸片示右中叶不张，右侧胸腔积液。临床诊断：右肺癌，右胸腔积液性质待查。纤维支气管镜检查：右中叶支气管口被“息肉样”肿物完全堵塞。病理活俭示粘液表皮样癌。手术见右中叶不张，中叶支气管开口处有一0．5cm×1．0cm×0.5cm“息肉状”肿物，行右肺中叶切除术。病理检查右肺中叶、胸膜部分粘连，体积10cm×7cm×2cm。气管一段，长2cm，横径1．5cm，气管内查见一类圆形息肉样肿物突入气管腔，直径1cm…     

肺原发性恶性淋巴瘤

肺原发性恶性淋巴瘤是较少见的肺恶性肿瘤，现报告1例，并结合文献复习分析如下。1病例介绍患者男，42岁。咳嗽，血丝痰，胸闷4月余。全身浅表淋巴结未见肿大，胸部X线照片示右中肺叶致密影，累及下叶内基底段，中间支气管远段变窄，考虑为中央型肺癌伴肺不张、实变。痰徐片查癌细胞5次为阴性，支纤镜检查见右中叶支气管粘膜水肿、充血、管腔狭窄，未见新生物。于1994年9月行探查术，术中见肿瘤位于右中叶，约12cm×10cm×8cm，不规则，灰白色，质韧，侵犯右上肺和右下肺，行右中下肺叶切除及上叶楔行切除术，术后经过顺利。病理检查镜下见…     

右肩胛骨骨软骨瘤1例

1　病例报告男 ,6 4岁 ,右肩部骨性包块 10 a余。查体 :右肩关节前上方骨性包块、质硬 ,略凹凸不整 ,无压痛。 X线示右肩胛颈上缘重叠处出现类圆形、鸡蛋大小向上突起的骨性肿块 ,呈蘑菇状 ,周边不规则钙化 (见图 1)。 X线诊断右肩胛骨骨软骨瘤不除外。CT示右肩胛颈前缘不规则骨性突起 ,边缘呈波浪状钙化并连续 ,其内散在点状、环状致密影 ,未见软组织肿块 (见图 2 )。 CT诊断右肩胛骨骨软骨瘤。术后病理证实 :(肩胛骨 )骨软骨瘤。图 1　右肩胛颈上缘蘑菇状骨性突起 ,周边有钙化。图 2　右肩胛颈骨性突起 ,边缘清楚呈波浪状 ,其内分布点…     

肺良性肿块的X线诊断（附73例报告）

作者报告经手术、病理证实的肺良性肿瘤和肿瘤样病变73例。本病临床X线表现:1.肺内孤立性圆形或椭圆形块状影,密度高而均匀,边缘光整,2.15％肿物密度不均匀,当中见斑点状、结节状或“爆玉米花样”钙化:3.肿物位于大支气管内者胸部平片见阻塞性肺炎、肺不张。体层摄影或支气管造影于大支气管内见软组织块影,阻塞端呈杯口状。     

巨大肺错构瘤1例报告

1 病例报告 患者，男性，42岁，因胸闷、咳嗽3个月就诊。既往19年前体检时发现右肺下叶结节病灶约2cm×2cm，诊断肺良性肿瘤，未予治疗。每间隔几年行X线胸片检查，病灶进行性增大。本次住院后螺旋CT显示右下病灶11cm×10cm，增强后病灶不强化，CT值-2．9～64．9Hu，病灶内可见明显的“爆米花”样钙化灶。于2006年5月19日全麻下行开胸手术。术中见右胸腔广泛模样粘连，肿瘤位于右下叶背段肺表面，包膜完整，顺利地从肺组织中将其剥离，重量为360g。术后病理报告：肿瘤组织中由软骨、纤维、脂肪及支气管纤毛柱状上皮构成。病理诊断：软骨型错构瘤。     

临床罕见的肺前肠囊肿病例报告

目的分析肺前肠囊肿的临床病理特点及影像学表现,提高诊断水平。方法对我院收治1例肺前肠囊肿临床资料进行分析总结。结果患儿因右胸疼痛并间断咯血查X线胸片及CT扫描示:右肺上叶可见大片高密度影,内有空洞影;纤维支气管镜检查示:右肺上叶开口有一息肉样物,软骨环破坏。活检病理报告:支气管黏膜呈慢性炎,另见胃黏膜。临床诊断:肺内囊性病变,胃黏膜异位。行右肺上叶切除术,术后病理检查诊断:支气管胃混合性前肠囊肿伴肺组织急慢性炎。结论前肠囊肿临床表现多与囊肿大小、周围器官受压程度有关,诊断主要依据CT和MR I检查,确诊需依靠手术病理检查。     

成人前列腺胚胎性横纹肌肉瘤并肺转移1例

患者男,36岁,主诉右大腿内侧痛伴会阴部下坠感20余天.肛门直肠指诊:前列腺Ⅲ度增大,质韧,中央沟消失,活动度差,精囊腺未触及,直肠内未及肿物,指套退出时无血迹.影像学检查:盆腔CT平扫示前列腺区类圆形软组织密度肿块,最大径9 cm,密度不均,内见片状低密度区;膀胱受压变形,后壁增厚,与肿块界限不清;后缘与精囊腺、直肠相连,右侧闭孔内肌肿胀,右耻骨局限性溶骨性骨质破坏(图1).诊断:前列腺恶性肿瘤性病变:①前列腺肉瘤;②前列腺癌.胸部CT平扫示:双肺见分布于肺外围的多个大小不等的结节影(图2),诊断:肺转移瘤.腹部B超检查:前列腺体积增大,大小为8.1 cm×7.8 cm×8.0 cm,形态不规则,内部回声不均.印象:符合前列腺恶性肿瘤声像图改变.经直肠超声诊断:前列腺周围腺实性占位病变.核素显像:右髋关节局部骨代谢活跃.骨盆X线片显示:右耻骨溶骨性破坏并病理性骨折.MR检查:前列腺实性占位性病变.考虑:①前列腺癌?②前列腺肉瘤?并精囊腺、膀胱后壁、直肠前壁、阴茎海绵体、球海绵体受侵,髂骨、腰5椎体转移.穿刺病理诊断"前列腺胚胎性横纹肌肉瘤".     

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.