超声造影评价兔肝炎性假瘤及VX2肝癌血流灌注的实验对照研究

目的 应用实时超声造影成像技术及时间-强度曲线,观察兔肝炎性假瘤和转移性VX2肝癌的血流灌注方式.方法 荷炎性假瘤和荷VX2肝癌实验兔各10只,经耳缘静脉团注法注射超声造影剂SonoVue后,应用CnTI低机械指数实时灰阶成像技术和定量时间-强度曲线(Wash in-Wash out Curve)软件,观察分析各时相肿瘤结节及周围正常肝组织的动态增强过程.结果 与正常肝实质相比较,炎性假瘤造影增强与肝实质同步,二者造影始增时间、峰值时间、增强时间、始消时间无显著性差别(P>0.05).VX2肝癌强化呈典型的"快进快出"型,早期动脉相快速增强,门脉相与延迟相肿瘤结节内造影剂迅速廓清,表现为负性显影,VX2肝癌始增时间、峰值时间、增强时间、始消时间显著早于正常肝实质(P<0.05).VX2肝癌与炎性假瘤比较,VX2肝癌造影始增时间、峰值时间、始消时间显著早于炎性假瘤(P<0.05).结论 低机械指数实时超声造影成像,可提供肝脏局灶性结节的动态血流灌注信息,结合时间-强度曲线定量分析,对肝肿瘤的诊断和鉴别诊断具有较佳的实用价值.     

兔肝炎性假瘤的实时超声造影检查与病理对照研究

目的 应用超声造影技术观察兔肝炎性假瘤的血流灌注情况,探讨其对肝炎性假瘤的诊断价值.方法 10只肝内接种炎性假瘤的实验兔,经耳缘静脉注射声学造影剂SonoVue后,应用低机械指数实时成像技术和定量时间-强度曲线分析(Wash-in/Wash-out)软件,分析各时相肿瘤及周围正常肝组织的动态增强过程.结果 炎性假瘤结节于动脉期未见明显强化,门脉期与周边的肝实质同步增强;延迟后期无明显的负性显影.时间-强度曲线定量分析:与肝实质相比较,炎性假瘤造影增强与肝实质同步,两者的造影始增时间、达峰时间、信号开始增强至峰值时间(上升时间)、开始消退时间等各时间定量指标间均无显著性差异(P＞0.05),与其病理结果相吻合.结论 实时超声造影成像可提供肝脏炎性假瘤结节的动态血流灌注信息,结合时间-强度曲线定量分析,对肝炎性假瘤的诊断具有重要价值,确诊只能依靠病理检查.     

不同肝实质背景超声造影时相变化的实验研究

目的 观察兔不同肝背景模型超声造影时相变化,探讨不同肝实质背景对超声造影时相的影响.方法 取雄性新西兰兔45只,随机分为A、B、C三组,每组15只.分别建立正常肝实质背景、脂肪肝背景、脂肪性肝硬化背景模型.对比各模型组二维超声表现及超声造影肝实质造影剂始增时间、峰值强度、峰值强度减半时间等.结果 B、C两组肝实质造影剂始增时间均长于A组,峰值强度C组低于A、B两组,峰值强度减半时间B组最长,C组最短.病理结果显示:A组为正常肝组织,B组呈脂肪肝表现,C组呈肝硬化表现.结论 实验兔肝超声造影不同肝实质背景造影增强时相不同.因此,超声造影诊断肝脏疾病时,应充分考虑肝实质背景不同引起的造影时相变化对病灶造影模式的影响.     

肝脏炎性假瘤的超声造影表现

目的 观察肝脏炎性假瘤超声造影的表现，探讨超声造影对肝炎性假瘤的诊断价值。方法 经外周静脉团注声诺维，使用对比脉冲序列（CPS）技术对2例经超声引导下活检证实的肝脏炎性假瘤行超声造影检查，观察注射造影剂后病灶的增强情况。结果 2例炎性假瘤均表现为动脉期迅速增强并快速廓清，门脉期与实质期回声显著低于周边肝实质。结论 肝脏炎性假瘤的超声造影灌注特征可以与肝脏恶性肿瘤相类似，造影诊断为恶性的病灶并不能完全除外炎性假瘤的可能，应行超声引导下活检以明确病理诊断。     

肝硬化超声造影时相变化的实验性研究

目的观察兔肝硬化模型超声造影时相变化,探讨超声造影评价肝硬化血流动力学变化的应用价值。方法选择雄性新西兰兔30只,分为实验组和对照组,实验组建立肝硬化动物模型,采用团注法注射声学造影剂声诺维,应用低机械指数实时双幅超声造影及时间-强度曲线,定量分析两组超声造影肝实质造影剂始增时间、峰值强度、峰值强度减半时间。结果病理显示:实验组呈肝硬化改变,对照组为正常肝组织。超声造影时间-强度曲线显示:肝实质造影剂开始增强时间两组分别为:(6.79±1.08)s、(3.46±1.27)s,实验组明显长于对照组;造影剂峰值强度两组分别为:(73.91±10.31)dB、(159.12±12.24)dB,实验组明显小于对照组;造影剂峰值强度减半时间明两组分别为:(15.97±9.48)s、(56.58±13.85)s,实验组明显小于对照组,差异均有统计学意义(t分别=7.47、19.92、8.96,P均<0.05)。结论肝硬化时肝实质与正常肝实质超声造影时相有显著差异,超声造影对评定肝硬化血流动力学变化有重要参考价值。     

兔肝炎性假瘤的超声显像及其病理基础

目的探讨兔肝炎性假瘤声像图特征及其病理基础。 方法10只肝内接种炎性假瘤的实验兔,应用超声显像观察兔肝炎性假瘤的二维声像图特点、彩色多普勒血流显像,并与病理结果相对照。 结果15个炎性假瘤结节在B超上均表现为等回声或不均匀高回声区,边界尚清晰,其后方无明显增强或衰减表现,个别有弱声晕。彩色多普勒检查,9个结节周边可见点状血流信号,4个结节周围有较明显血流信号并测及静脉频谱,2个结节周边和内部均未见明显血流信号。这些表现均与其病理显示相吻合。 结论超声显像仅可作为肝炎性假瘤提示诊断的初步手段,确诊只能依靠病理检查。     

肝局灶性病变超声造影诊断指标初探

目的 探讨适宜中国肝局灶性病变的超声造影诊断指标。方法 以注射造影剂后肝动脉开始显影作为动脉相的起始时间，以门静脉开始显影作为门脉相起始时间，以肝实质增强达峰值为实质相起始时间；分析682例肝局灶性病变超声造影肝动脉、门静脉的始增时间及肝实质的增强峰值时间、肝内病灶的开始减退时间，分析增强模式。结果 肝硬化与非肝硬化组肝动脉、门静脉及肝实质始增时间有显著差异，肝内良恶性病灶增强退出时间有显著差异。85％的原发性肝癌及99％肝转移癌在注射造影剂后180s内退出，故以180s作为延迟相起始时间及与实质相的划分点，由此将超声造影分为四个时相。结论 由于肝背景不同造成血流动力学差异，病灶增强时相以自身背景对比更为适宜；根据新的时相定义及病灶增强退出特征，总结出中国人肝癌及其他肝局灶性病变的超声造影诊断标准。     

兔肝VX2肿瘤超声造影时相划分:与多排螺旋CT增强扫描对照实验研究

目的 探讨灰阶实时超声造影(CEUS)和多排螺旋CT(MDCT)增强扫描兔肝VX2肿瘤的增强显像特征及兔肝超声造影时相的划分标准.方法 运用超声造影剂SonoVue对33只荷肝VX2瘤兔行CEUS和64排螺旋CT增强扫描,以团注造影剂后肝动脉开始增强作为动脉期的起始时间,以VX2肿瘤增强达峰时间作为门脉期的起始时间,以肝实质增强达峰值强度时间作为实质期的起始时间,观察其增强特征,比较CEUS中肿瘤和瘤周同水平肝实质的时间强度曲线和MDCT中腹主动脉、门静脉、肝实质和肿瘤的时间密度曲线形态特征,制定划分各期时相的标准.结果 CEUS和MDCT对VX2肿瘤动脉期、门脉期、实质期起始时间的划定分别为(6.82±1.36)s、(11.64±2.03)s、(20.24±4.17)s和(9.43±2.23)s、(13.77±2.01)s、(22.71±4.58)s,CEUS较MDCT各相起始时间均提早(P<0.01),二者对兔肝VX2肿瘤增强显像特征一致,均表现为"快进快退".结论 CEUS可以对兔肝VX2肿瘤的灌注情况进行实时高分辨率显像,CEUS和MDCT时相标准可为相关的影像学评估研究提供基本的理论依据.     

不同声压与正常兔肝脏造影增强效果关系研究

目的探讨不同声压与自制脂质类超声造影剂对正常兔肝实质造影增强效果的相互关系.方法 5只健康新西兰大白兔经耳缘静脉团注0.1 ml/kg自制脂质类超声造影剂,使用声压范围1～609 kPa,分为9个水平,每个水平均造影10次(每只兔2次),观察肝实质的增强效果,并对峰值视频强度及增强时间进行量化分析.结果声压低于56 kPa时,肝实质峰值视频强度无差异;声压继续升高,峰值视频强度则逐渐降低;声压达609 kPa时,肝实质无增强效果.增强时间随声压的升高而逐渐降低.结论声压在1～56 kPa范围内变化不影响自制脂质类超声造影剂的造影效果,超过76 kPa则造影效果明显降低.     

灰阶超声造影对正常肝实质及VX2肿瘤血流动力学的对照研究

目的 应用低机械指数灰阶超声造影定量研究肝恶性肿瘤及其周围肝实质血流动力学特点及其诊断价值。方法 分别经耳缘静脉对8只荷VX2肿瘤新西兰大白兔团注超声造影剂SonoVue（0．1ml／kg），应用低机械指数实时灰阶造影匹配成像技术和声学定量时间一强度曲线分析软件，定量分析兔VX2瘤及其周围肝实质血流动力学特点及造影增强效应。结果低机械指数灰阶超声造影可动态显示肝实质与肿瘤内造影剂的增强过程，其时间一信号强度曲线客观反映造影剂的渡越过程。与肝实质相比，VX2瘤造影剂开始增强时间和达到峰值时间均明显提前，分别为10．13s和17．48S，峰值强度较低，渡越时间明显缩短。VX2瘤与肝实质各造影定量参数间差异具有统计学意义（P〈0．01）。结论 低机械指数灰阶超声造影能很好地反映肝恶性肿瘤血流动力学变化，超声造影定量分析对肝恶性肿瘤的诊断有重要价值。     

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.