皮肤结外鼻型血管内NK/T细胞淋巴瘤临床病理探讨

目的 探讨皮肤结外鼻型血管内NK/T细胞淋巴瘤的临床病理特征、诊断和鉴别诊断、治疗及预后.方法 回顾性分析1例皮肤结外鼻型血管内NK/T细胞淋巴瘤患者的临床资料、组织病理形态、免疫组化染色及原位杂交染色.结果 光镜下皮肤附属器周围、血管周围和血管内可见中等大小的异型淋巴样细胞,肿瘤细胞胞质比较丰富、淡染,细胞核圆形、卵圆形或不规则,染色质深染,部分血管内可见纤维素样渗出物.免疫组化显示肿瘤细胞CD3和粒酶B(+),CD56部分(+),CD5和CD8散在(+),CD4、CD20和MPO(-);CD31显示大部分肿瘤细胞位于血管内;Ki-67阳性率＞50％.EBER分子原位杂交(+).结论 皮肤结外鼻型血管内NK/T细胞淋巴瘤是一种罕见的血管内淋巴瘤,临床和病理均易与皮肤血管炎性病变混淆,因此掌握其临床病理特征对该病的诊断和鉴别诊断具有重要意义.     

老年人EBV阳性的弥漫性大B细胞性淋巴瘤临床病理观察

目的探讨EB病毒阳性的老年人弥漫性大B细胞性淋巴瘤(DLBCL)的组织形态特征、免疫组化、诊断与鉴别诊断,观察治疗及预后情况。方法对2例老年人EBV阳性的DLBCL行HE和免疫组化染色观察,收集临床资料并随访。结果患者年龄分别为58岁和72岁,无免疫缺陷及淋巴瘤病史。病理改变主要为大小差别较大的异型淋巴细胞弥漫浸润,散在少数R-S样细胞,可见广泛的地图样肿瘤性坏死及血管中心性浸润。免疫组化显示异型肿瘤细胞CD20弥漫强(+),80%～90%肿瘤细胞胞核EBV原位杂交呈中～强(+)。随访3～6个月,1例死亡。结论老年人EBV阳性的DLBCL罕见,是最近正在被逐渐认识的新淋巴瘤类型,其临床和病理特征独特,诊断需与淋巴瘤样肉芽肿和EBV阳性的霍奇金淋巴瘤鉴别。     

宫颈淋巴瘤样病变7例临床病理分析

目的探讨子宫颈淋巴瘤样病变的临床病理特征及诊断和鉴别诊断要点。方法采用光镜、免疫组化、EBER原位杂交和TCR及IgH基因重排等多项技术对7例宫颈淋巴瘤样病变进行病理分析,并结合临床资料进行探讨。结果7例患者中5例为育龄期女性,临床表现为接触性出血或不规则阴道出血6例,伴白带增多2例;1例为体检发现。妇检见宫颈1枚或数枚息肉样新生物,常伴宫颈糜烂。光镜示新生物内弥漫性淋巴组织浸润,见多量免疫母细胞或滤泡中心母细胞样细胞,易见核分裂象。致密的大淋巴细胞间常混杂不等量的小淋巴细胞和浆细胞。免疫组化:CD20常弥漫( ),小淋巴细胞CD3( ),CD30散在或灶性( ),κ与λ阳性无显著差异。6例基因重排未见单克隆条带。6例EBER原位杂交未见阳性表达。随访6例患者均健在。结论子宫颈淋巴瘤样病变是一类伴多量大淋巴细胞且显示活跃核分裂象的淋巴组织高度增生性病变,临床常表现为息肉样新生物,免疫组化及基因重排显示多克隆性表达有助于确诊。     

肝血管内大B细胞性淋巴瘤2例临床病理观察

目的探讨肝血管内大B细胞性淋巴瘤的临床病理特征、诊断与鉴别诊断、治疗及预后。方法回顾性分析2例肝血管内大B细胞性淋巴瘤患者的临床资料、组织病理学形态和免疫组化结果。结果光镜下肝窦内和小血管内可见较多具有明显异型性的淋巴样细胞浸润,汇管区可见慢性炎细胞浸润,亦可见少许异型淋巴细胞样细胞,未见明确纤维化。免疫组化示CD20、PAX5弥漫(+),CD3散在少许(+),Ki-67阳性率为70%,AE1/AE3、CD117和CD56均(-);其中例1 CD5弥漫(+)。结论血管内大B细胞性淋巴瘤是一种具有高度侵袭性的结外弥漫性大B细胞性淋巴瘤的亚型,由于该病临床表现多样及不典型性,造成了部分患者的诊断困难,因此,掌握临床病理及免疫组化特征对该病的诊断和鉴别诊断具有重要意义。     

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。     

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。     

母细胞性浆细胞样树突细胞肿瘤4例临床病理分析

目的 探讨母细胞性浆细胞样树突细胞肿瘤(BPDCN)的临床病理学特征及诊断与鉴别诊断.方法 对4例BPDCN的临床病理学特征、免疫表型以及治疗和预后情况进行分析,并复习相关文献.结果 4例患者均为男性,发病年龄20 ～70岁;2例表现为淋巴结肿大,2例示多发性皮肤斑块或结节.活检组织形态学显示,淋巴结及真皮和皮下由弥漫浸润的小～中等大小幼稚肿瘤细胞浸润,细胞质稀少,核形不规则,染色质细腻,核仁不明显.免疫组化示肿瘤细胞CD4、CD56、CD123、TCL-1和S-100(+).结论 BPDCN是一种罕见的高度恶性的淋巴造血系统肿瘤,多数病例发生于老年患者,常见皮肤累及;少量病例也可发生于年轻患者或无皮肤受累者.即使给予高强度化疗和同种异体骨髓移植,预后仍很差.     

母细胞性浆细胞样树状突细胞肿瘤1例报告并文献复习

目的:探讨母细胞性浆细胞样树状突细胞肿瘤的临床、组织病理学及免疫表型特征。方法:报道1例母细胞性浆细胞样树状突细胞肿瘤,并结合文献分析其临床病理特点。结果:该例以皮肤最先受累,后很快累及骨髓、淋巴结、外周血。组织学特点为真皮内肿瘤细胞弥漫性浸润。骨髓肿瘤细胞表达CD4和CD56。EB病毒阴性,T细胞受体基因重排阴性。结论:该病是一种罕见的侵袭性淋巴瘤,进展快,病死率高,易误诊。诊断依据临床和组织学特点,结合免疫组化标记、EB病毒和TCR克隆性重排检测等综合分析。     

皮下脂膜炎样T细胞淋巴瘤1例

1 病历要 女，54岁。以足部为首发症状，渐进性身体紫斑伴皮下硬结，曾在当地治疗病情未见好转，近来有低热而收入我院。查体除体表体征外无明显其他症状，住院期间全血渐进性减少，血小板减少。为进一步明确诊断，活检送病理。镜检示：脂肪组织中大量淋巴样细胞浸润，其间杂有中性白细胞及组织细胞。肿瘤细胞大小不一，形态不规则，核仁不清，核裂易见。肿瘤细胞围绕单个脂肪细胞，并见少量浆细胞，表皮未见累及。免疫组化：CD20（-）、CD45RO（＋＋）、CD3（＋）、CD79（-）、CD68（局灶＋）。结合临床、组织学形态及免疫组化结果，病理诊断：脂膜炎样T细胞淋巴瘤。     

卵巢霍奇金淋巴瘤临床病理观察

目的 探讨卵巢霍奇金淋巴瘤的临床病理特征、免疫表型、诊断与鉴别诊断要点.方法 对1例卵巢霍奇金淋巴瘤的临床病理资料进行光镜观察及免疫组化检测,并复习相关文献.结果 患者女性,31岁.肿瘤位于卵巢.肿瘤切面灰白、灰黄色,局部质地稍嫩.镜下见纤维带包绕肿瘤呈大小不一结节组织,广泛纤维化;部分肿瘤细胞梭形,部分呈上皮样,细胞核大、深染,中～重度异型;内见“爆米花”样大细胞、嗜酸性胞质及致密浓染核的“干尸”样大细胞.肿瘤细胞巢中央见坏死,伴多量中性粒细胞、嗜酸性粒细胞和淋巴细胞浸润.免疫组化显示肿瘤细胞CD15、CD30和Pax5(+).结论 卵巢霍奇金淋巴瘤非常少见,病理组织学检查与卵巢其他恶性肿瘤难鉴别.免疫组化标记检测有助于鉴别诊断.     

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.     

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.