4D CT成像辅助引导经动脉精准化疗栓塞治疗原发性肝癌

目的 描述四维(4D)CT成像方法 ,并探究经动脉化疗栓塞(TACE)术前应用四维CT成像引导肝癌的化学栓塞治疗的价值。方法利用容积螺旋动态穿梭技术,前瞻性完成拟行TACE治疗的原发性肝细胞癌患者的增强CT扫描。扫描范围覆盖全肝,从动脉前期至静脉期动态研究肿瘤病灶。针对目标病灶的4D CT重组图与数字减影血管造影(DSA)图在肝动脉解剖、肿瘤供血血管、肿瘤血管显示以及肿瘤染色方面进行比较。栓塞效果经CT随访进行评价。结果本研究纳入了39位患者的46个孤立肝癌病灶。根据Michels分型,25位(64.1%)具备正常的肝动脉解剖,其余存在解剖变异。该信息为肝动脉插管造影提供了很好的依据,并经过DSA证实。4D CT成像无创性显示了病灶的肿瘤供血动脉(41/46),肿瘤血管(36/46),肿瘤染色(42/46)。因4D CT成像可以引导超选择性置入微导管,使得化学栓塞治疗成功完成。结论 四维CT成像可以有效地评价肝动脉解剖,定位肿瘤供血动脉,为肝癌介入化学栓塞提供影像引导。     

原发性肝癌异常血供临床价值的探讨

目的 探讨原发性肝癌异常血供的发生率、来源、形式及对提高经肝动脉化疗栓塞(TACE)疗效的价值。方法 选择2000年行TACE治疗的149例原发性肝癌患者，采用Seldinger技术经股动脉穿刺插管成功后，进行数字减影血管造影(DSA)以寻找肿瘤的供血血管，对存在异常血供的病例进行分析。结果 发现异常血供24例(16．1％)；异常血供的来源有：肠系膜上动脉、膈下动脉、右肋间动脉、胃左动脉、胃十二肠动脉、副肝动脉及腹主动脉的直接分支血管；供血形式有：(1)迷走肝动脉；(2)多重血供；(3)介入后血供异常；(4)副肝动脉。结论 原发性肝癌存在异常血供比较常见，其来源及供血形式多样、复杂，肠系膜上动脉的参与率较高。TACE时应注意多方寻找，只有尽可能对所有供血血管进行化疗灌注和／或栓塞，才能提高介入治疗的临床效果。     

超声造影评估肝癌经动脉内化疗栓塞疗效的临床研究

目的探讨超声造影评估肝癌经动脉内化疗栓塞(TACE)疗效的敏感性。方法选取我院行TACE治疗的原发性肝癌患者52例,均为单发病灶,动态观察超声造影各时相病灶血供特点,比较TACE治疗前及治疗后1个月肝癌患者的超声造影特点和数字减影血管造影(DSA)图像及病理随访结果,并对其治疗效果进行判断。结果 TACE治疗前所有病灶超声造影均提示血供丰富,增强模式均为"快进快出"型;治疗后1个月超声造影评估残存病灶血供与DSA检查结果一致性较好,Kappa值=0.83。结论超声造影能敏感显示治疗前后病灶血供情况,在随访肝癌TACE后肝动脉栓塞效果具有非常重要的意义。     

肝段动脉化疗栓塞治疗肝癌

经导管肝动脉栓塞术(TAE)巳广泛地用于肝癌的非手术治疗,常规TAE不能造成肿瘤组织的完全坏死,反复TAE治疗也会给肝功能带来损害。肝段动脉化疗栓塞是在TAE基础上发展起来的新技术.众所周知,肝癌除主要地接受肝动脉分支供血外,部分地接受门静脉分支和胆管周围血管丛的供养,肝段动脉化疗栓塞的目的就是同时封闭肿瘤组织周围各种供养血管。我们报告了12例肝癌患者接受肝段动脉化疗栓塞的初步经验,重点地对插管技术、适应症和应用理论进行了讨论。     

彩超观察肝癌经肝动脉栓塞化疗前后门静脉血供的动态变化

目的:应用彩色多普勒超声观察肝细胞性肝癌(HCC)患者经肝动脉栓塞化疗(TACE)前后门静脉作为肿瘤引流血管及供血血管的动态变化并探讨其临床意义。方法:HCC患者42例,行2次TACE治疗,分别于2次TACE术前及术后7d行彩超检查,分析不同时间段肿瘤血供方式的变化。结果:首次TACE术前肝癌均有动脉参与供血,以动脉供血并门静脉引流者所占比例最大占50%,其次是单纯动脉供血方式占35.7%,动脉与门静脉双重供血者较少占14.3%,但无单纯门静脉供血者;而TACE术后7d出现5例完全由门静脉供血的肿瘤,占11.9%;双重供血的肿瘤数也显著增加,占47.6%;单纯动脉供血及动脉供血门静脉引流的肿瘤数则显著减少,分别占19.0%、21.4%,差异有统计学意义(P<0.05)。第二次TACE前后肝癌血供的变化趋势与首次TACE相似,但变化无统计学意义(P>0.05)。结论:经TACE治疗后部分肿瘤内门静脉由TACE术前的引流血管转变为术后的供血血管,门静脉作为HCC供血血管的比例增加。     

旋转式DSA对肝癌多支和侧支供血的应用

经导管肝动脉化疗栓塞术(TACE)是治疗中晚期肝癌的首选方法,肝动脉的解剖变异及肝肿瘤双重供血和多支供血对肝动脉栓塞效果及预后影响已引起临床关注,肝癌多支供血和栓塞后侧支供血是直接影响TACE疗效的重要因素。我们应用DSA技术诊断肝癌多支供血及栓塞后侧支供血的有利因素,给介入治疗中如何正确处理以进一步提高疗效提供更有效手段,现报道如下。 材料和方法 65例中晚期肝癌,原发性51例,转移或原发合并转移14例;男47例、女18例;年龄26～75岁,平均46.2岁,均经临床、化验、AFP、B超、CT或MRI检查符合肝癌诊断,介入治疗前均作腹腔动脉,肝总或肠系膜上动脉DSA确诊,38例分别作2～5次TACE治疗,共作101     

肝外动脉为主要供血的肝细胞性肝癌的DSA表现及栓塞治疗探讨

目的 探讨肝外动脉供血肝细胞癌的DSA表现及栓塞治疗.方法 同颐性分析本中心2002年8月～2008年9月3例肝外动脉供血肝细胞肝癌患者的临床资料,包括患者的供血动脉形态、手术方式及时间、肝癌DSA表现及预后.结果 DSA显示3例患者肝癌动脉均存在解剖变异：1例患者肝外动脉直接开口于腹主动脉较高部位;2例患者肝外动脉与肾上腺中动脉共干开口于主动脉弓右外侧壁;3例患者肝外动脉均供血肝S6肿瘤,栓塞治疗后,无并发症,3例患者均存活6个月以上.结论 生理变异的肝外动脉可供血肝细胞性肝癌,其影像学诊断可靠,栓塞治疗疗效较好.     

64层螺旋CT肝血管成像的临床研究

目的探讨64层螺旋CT肝脏多期血管成像不同后处理技术显示肝脏血管的能力及其临床应用价值。方法对209例肝脏多期增强扫描患者行肝动脉期、门静脉期双期血管成像,采用最大密度投影(MIP)、容积再现技术(VR)和多平面重组技术(MPR)三种重组方式,分析三种重组方法对肝动脉、门静脉系统、肝静脉以及肝肿瘤血管性病变的显示情况;同期30例患者行肝动脉DSA血管造影,并进行对照观察。结果本组肝动脉变异率为32%;VR与MIP对肝动脉2级以下分支及肿瘤供血动脉的显示无统计学意义(P>0.05),在显示3级以上肝动脉分支及肿瘤血管上有明显差异(P<0.05),MIP优于VR;30例同期行DSA检查的肝癌患者中,MIP与DSA在供血动脉及肿瘤血管的显示上完全一致,对3级以下肝动脉的显示无统计学意义,在4级以上肝动脉的显示上有差异(P<0.05),DSA优于MIP;VR与MIP在显示门静脉及肝静脉分支方面无统计学意义。门静脉有5种变异类型,变异率为27.8%。正常组肝静脉Ⅰ型80例(95%),Ⅱ型4例(5%),7例(8.3%)可见右后下肝静脉。结论64层螺旋CT肝血管成像能更准确、全方位地显示肝血管、肝血管性病变及富血管性肿瘤性病变,可为外科手术及介入术前提供准确信息。VR、MIP与MPR三种重组技术结合使用在肝血管性病变的诊断方面并不亚于DSA。     

旋转DSA三维重建技术在肝脏肿瘤介入治疗中的应用

目的探讨旋转DSA三维重建技术在肝脏肿瘤介入治疗中的应用价值。方法应用Philips Allura Xper FD20数字减影血管造影(DSA)系统对47例肝脏肿瘤患者行常规DSA及旋转DSA检查,并将旋转DSA图像传至3DRA工作站进行图像三维重建,运用多种后处理软件显示血管及病灶。结果 47例患者中,旋转DSA三维重建技术均能较好的显示肿瘤供血血管与肿瘤之间的关系,在3DRA工作站上能清楚看到供血动脉的角度;有8例肝癌患者常规DSA无法清晰显示肿瘤供血动脉,行旋转DSA三维重建后,肿瘤供血动脉全部清晰显示;2例肝癌患者在大的主病灶周围有较小的子病灶,其供血动脉常规DSA观察不清,旋转DSA三维重建后显示清楚。结论旋转DSA三维重建技术在肝脏肿瘤介入治疗中有较大优势,在显示肿瘤与供血动脉关系上优于常规DSA,是对常规DSA的重要补充。     

原发性肝癌的迷走肝外营养血供与介入治疗（附23例报告）

目的 探讨原发性肝癌的迷走肝外营养血供及其对肝癌介入治疗的意义。方法 本组23例原发性肝癌患者行常规腹腔动脉造影及肝外营养血管探查，并对其行超选择性插管及化疗栓塞治疗（TACE）。结果 23例患者共见24条肝外营养血管，其中肠系膜上动脉（8／24）和膈动脉（7／24）占多数。4条肝外营养血管因未能成功行超选择性插管而只予化疗药灌注治疗，其余20条肝外营养血管均行超选性插管和化疗栓塞治疗。结论 原发性肝癌的迷走肝外营养血供较为常见和多变，对肝癌的经导管介入治疗具有重要的意义。     

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.