Stewart-Treves 综合征13例临床病理分析

目的探讨Stewart-Treves综合征的临床病理学特征。方法回顾性分析13例Stewart-Treves综合征的临床病理特征,并复习相关文献。结果 13例Stewart-Treves综合征中,有5例发生于乳腺癌术后,3例发生于宫颈癌术后,5例继发于慢性淋巴水肿而无恶性肿瘤病史;其中6例恶性肿瘤患者术后曾行放疗;所有病例均以肢体水肿为首发症状,病变皮肤出现红斑或破溃。镜下表现为真皮层及皮下组织内可见浸润性生长的不规则脉管,部分区域脉管相互交通;部分区域内衬细胞异型性明显,可见核分裂象,肿瘤细胞排列呈乳头、巢片状,并可见出血、坏死。免疫组化:肿瘤细胞CD34、CD31、ERG、D2-40、c-myc、FⅧ和vimentin (+),Ki-67阳性指数30%～90%。患者随访,12例死亡(5～30个月),1例失访。结论 Stewart-Treves综合征少见,预后差,死亡率高,辅助免疫组化检测能够提高诊断的准确性,以达到早期诊断、早期治疗的目的。     

原发性脾上皮样血管肉瘤临床病理观察

目的探讨脾上皮样血管肉瘤(SEAS)的临床病理特点、免疫组化、诊断及鉴别诊断。方法回顾性分析1例脾上皮样血管肉瘤的临床表现、组织学形态特征及免疫组化,并复习相关文献。结果正常的脾组织被增生的上皮样肿瘤细胞所代替,并且向周围脾组织浸润生长,瘤细胞呈圆形、卵圆形,胞质丰富,细胞核呈空泡状,可见大核仁,核分裂易见(20个/50HPF)。肿瘤细胞排列呈巢片状,局灶可呈乳头状或不规则裂隙状排列,裂隙内见红细胞,提示血管来源。肿瘤细胞CD31、CK、vimentin、ERG(+),CgA及Syn散在(+),Ki-67阳性指数30%;CD34、S-100、EMA、FⅧ、CK7、CK20、CD30、CD68、Lys、ALK、FIL-1、D2-40和p63均为(-)。患者于脾切除术后1个月死亡。结论原发于脾的上皮样血管肉瘤是起源于血管的恶性肿瘤,临床主要表现为急腹症,预后较差;诊断主要依赖于组织学形态及免疫组化。     

肝原发性癌肉瘤临床病理观察

目的分析肝原发性癌肉瘤的临床病理学特点,探讨其诊断和鉴别诊断。方法对1例肝原发性癌肉瘤进行影像学、HE及免疫组化染色分析并复习相关文献。结果肿瘤由上皮性肿瘤细胞和间叶性肿瘤细胞混合构成,包括不同分化程度的肝细胞癌和肉瘤成分。免疫组化瘤细胞EMA、CKpan、CK7、S-100、vimentin、Glypican-3、CD34、CD10、SMA、CD57和CD99均(+),灶性过渡区域瘤细胞EMA和vimentin(+),Ki-67增殖指数20%。患者术后3个月出现肺转移。结论肝原发性癌肉瘤是一种极罕见的恶性肿瘤,确定诊断依靠组织形态学和免疫组化标记物。治疗以手术切除加术后放疗为主,但预后很差。     

腰椎软组织上皮样血管内皮瘤临床病理观察

目的探讨上皮样血管内皮瘤(EHE)的临床病理特点及鉴别诊断。方法观察l例腰椎软组织EHE的病理组织学表现及免疫组化染色,同时复习相关文献。结果患者女性,29岁。4年前无明显诱因出现腰痛,伴有下肢放射痛。MRI示腰4、5椎体水平腹膜后、椎旁异常信号肿块,累及椎体及邻近结构。手术切除肿物及椎体。镜下肿瘤细胞呈上皮样,胞质嗜酸,可见胞质内空泡,内含红细胞。免疫组化:肿瘤细胞vimentin、CD31和laminin(+),CD34、CD68、FⅧRAg、CK、S-100、SMA、Syn和CD56(-),Ki-67阳性指数为10%。随访16个月未复发或转移。结论 EHE是一种少见的血管肿瘤,易误诊为转移癌或肌上皮肿瘤,依据其独特的病理组织学特点及免疫组化可做出正确诊断。     

肺血管肉瘤临床病理观察

目的探讨肺血管肉瘤的临床表现、病理形态学特点及诊断与鉴别诊断。方法通过1例肺血管肉瘤的临床表现、病理学观察及免疫组化染色,对其进行分析。结果肺血管肉瘤临床症状为胸痛、咳嗽、咳血,影像学为多发或单发结节影;病理形态为肿瘤细胞呈弥漫排列,细胞大,异型性明显,肿瘤组织中可见不规则分布的幼稚血管及出血。免疫组化CD31、CD34、FⅧ和vimentin(+)。结论肺血管肉瘤是罕见的肺组织恶性肿瘤,形态需与分化差的非小细胞性肺癌等鉴别。     

直肠癌弥散峰度成像与D2-40、CD31、S-100及肿瘤细胞增殖指数的相关性研究

目的探讨弥散峰度DKI参数(diffusion-kurtosis image,DKI)参数与直肠癌免疫组化D2-40、CD31及Ki-67之间的关系。能够在术前评估其表达程度,从而能够间接反映肿瘤细胞的增殖指数等,为临床提供直肠癌术前恶性程度评估的依据。材料与方法搜集2016年1月至9月经病理证实的直肠癌患者69例,所有病例经常规扫描加DKI,得到DKI与扩散张量成像(diffusion tensor imaging,DTI)参数:各向异性指数(fractional anisotropy,FA),垂直扩散张量(radial diffusivity,D⊥)、平均扩散系数(mean diffusivity,MD)、轴向扩散张量(axial diffusivity,D//),平均峰度(mean kurtosis,MK)、径向峰度(radial kurtosis,K⊥)、轴向峰度(axial kurtosis,K//)。免疫组化D2-40、CD31、S-100及Ki-67由Ultra View-DAB染色进行处理得到。D2-40、CD31根据表达分为阴性与阳性组,采用独立样本t检验进行各参数间的对比。用ROC曲线评判各参数对两组的诊断效度,分析各MK等值与Ki-67的关系采用Pearson相关分析法。结果 MK、K⊥在D2-40、CD31阳性组参数值高于阴性对照组,MD在阳性参数组低于阴性参数组,差异有统计学意义(P0.05)。Pearson相关分析法得出Ki-67与D⊥、D//、MD之间呈负相关,而与MK、K⊥、K//之间呈正相关性。应用ROC曲线分析各参数对直肠癌D2-40、CD31表达阴性与阳性的诊断鉴别能力。结论 DKI成像可反映直肠癌组织的复杂程度,可在术前无创地评估免疫组化D2-40、CD31、S-100及Ki-67的表达水平,从而可间接反映肿瘤细胞增殖程度。     

淋巴管癌栓检测及与乳腺癌临床病理特征的关系

目的比较淋巴管内皮标记物D2-40和HE染色对乳腺癌淋巴管癌栓的检出率以及D2-40阳性的淋巴管癌栓与乳腺癌临床病理特征的关系。方法选取110例浸润性乳腺癌,分别进行HE染色及免疫组化D2-40、CD31、CD34、p63染色;应用SPSS17.0统计软件进行分析。结果 HE染色的淋巴管癌栓检出率为15.5%,假阳性率为2.8%,假阴性率为23.6%;而应用D2-40标记的淋巴管癌栓检出率为36.5%,两者比较差异显著(P<0.05)。淋巴管癌栓与患者的年龄、肿瘤大小、组织学分级、淋巴结转移、ER低表达具有显著的统计学意义,与PR、HER-2表达无统计学意义。结论单克隆抗体D2-40是可靠的淋巴管内皮标记物,与HE染色相比能显著提高淋巴管癌栓的检出率。     

脾窦岸细胞血管瘤3例临床病理分析

目的探讨脾窦岸细胞血管瘤(LCA)的临床病理特征、诊断与鉴别诊断要点。方法对3例脾窦岸细胞血管瘤进行常规病理检查、组织化学染色、免疫组化标记及电镜观察,并复习临床资料和相关文献。结果3例LCA患者均为中老年男性,组织学上肿瘤由大小不等的、互相吻合的血管性腔隙组成,腔隙被覆低柱状或立方形内皮细胞,无明显异型性。免疫表型:肿瘤细胞CD31、CD8、CD68、Ⅷ因子和lysozyme(+),CD34和D2-40(-)。结论LCA是很少见的、仅发生在脾的血管肿瘤,CT和B超检查可以发现病变,确诊还需依靠病理学及免疫组化检查。该肿瘤常伴有其他内脏疾病。     

皮肤假血管瘤样鳞状细胞癌临床病理观察

目的探讨皮肤假血管瘤样鳞状细胞癌的临床病理特点。方法对1例发生于皮肤的假血管瘤样鳞状细胞癌的临床表现、组织形态、组织化学、免疫组化及电镜进行分析,并复习相关文献。结果患者女性,85岁。临床表现为右下腹皮肤暗红色包块。镜下肿瘤细胞轻度异型,呈血管瘤样结构排列。免疫组化显示肿瘤细胞CK(AE1/AE3)和CK14强(+),CD34、CD31和FⅧ(-)。Gomori氏网织纤维染色显示单个肿瘤细胞周边(-)。电镜下肿瘤细胞间桥粒连接,细胞质内可见张力丝。结论免疫组化、电镜及临床表现是正确诊断皮肤假血管瘤样鳞状细胞癌的重要依据。     

10例肝脏上皮样血管内皮细胞瘤临床病理分析及特征总结

目的 探讨原发性肝脏上皮样血管内皮细胞瘤(HEHE)的临床病理学特征、免疫组化、分子病理特征及鉴别诊断。方法 回顾性分析10例HEHE患者的临床资料、组织病理学与免疫组化特征以及基因检测结果。结果 10例HEHE患者中，男性5例，女性5例，其中大部分临床表现为腹部隐痛不适、腹胀、恶心伴疲倦乏力，少数病例为体检时发现肝脏占位。7例为肝内多发结节，3例为单发结节，其中2例伴肺部转移。镜下肿瘤细胞呈梭形或上皮样，排列呈条索状、巢片状，高倍镜下观察肿瘤细胞具有嗜酸性胞质，胞质内可见特征性空泡形成，肿瘤间质常伴黏液样变性，细胞核具有轻至中度异型性，偶见核分裂象和坏死。免疫组化结果：肿瘤细胞表达CD31、CD34、ERG、FⅧ等血管源性标志物，Ki-67增殖活性较低。其中1例行荧光原位杂交(FISH)结果检测到TFE 3基因断裂阳性。结论 HEHE为少见的血管源性恶性肿瘤，临床表现及辅助检查通常无特异性，需结合组织学、免疫组化及基因检测等诊断。     

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.