脑血流灌注断层显像对精神分裂症的诊断价值研究

目的 探讨精神分裂症脑血流灌注断层显像的特点及其临床价值。方法 对22例未经治疗的精神分裂症患者进行^99Tc^m-ECD SPECT脑血流灌注显像,同时测定各区与同侧小脑的放射性摄取比值。8例于治疗后进行复查。结果 22例未经治疗精神分裂症患者脑血流减低发生率为82％（18／22）。精神分裂症组右额叶、右顶叶、右颞叶及扣带回放射性摄取比值显著低于正常对照组（P＜0．01或P＜0．05）。8例精神分裂症患者治疗前共有16处放射性减低区,治疗后仅有8处。结论 脑血流灌注断层显像对精神分裂症的辅助诊断和疗效监测有临床价值。     

单光子计算机断层扫描仪局部脑血流灌注显像用于抑郁症氟西汀治疗前后的对比观察

目的探讨单光子计算机断层扫描仪（SPECT）对抑郁症的疗效评估价值。方法 2006年5月2007年12月,选取32例未经治疗的原发性中、重度抑郁症患者,给予氟西汀治疗10周。治疗后根据临床疗效总评量表和汉密尔顿抑郁量表（HAMD）减分率作为疗效评定指标,将患者分为有效组21例,无效组11例。对所有患者于治疗前和治疗后分别进行99m锝-双半胱乙酯（99mTc-ECD）脑灌注显像。静脉注射99mTC-ECD1 110MBq,30min后行脑断层显像,对显像结果分别进行目测及半定量分析两种方法进行判断。结果抑郁症患者出现的脑血流灌注减低区主要集中在前额叶、扣带回,经过治疗后好转的抑郁症患者脑血流灌注明显改善。可通过脑血流灌注显像评估抗抑郁治疗的疗效,左前额叶血流灌注越低,对氟西汀治疗效果越好。结论 SPECT显像技术可视性较好,可用于评估抗抑郁治疗的疗效。     

认知行为疗法与西酞普兰对抑郁症患者局部脑血流的影响

目的探讨认知行为疗法与喜酞普兰对抑郁症患者局部脑血流的影响。方法38例抑郁症患者分为认知行为治疗组18例和西酞普兰药物治疗20例。采用99Tcm-双半胱乙酯局部脑血流灌注单光子发射计算机断层扫描（SPECT）显像结合感兴趣区（ROI）技术,对两组患者治疗前后的局部脑血流变化和汉密尔顿抑郁量表（HAMD）评分进行比较。结果治疗后,两组患者的抑郁症状均有改善,但西酞普兰组早于认知行为治疗组;两种治疗方法均可增加右基底节血流量,认知行为治疗组亦有右边缘系统扣带回后部局部血流量增加,西酞普兰组亦有右颞叶后部局部脑血流量增加。结论两种治疗方法对抑郁症均有效,但改善脑血流的部位不同。     

抑郁症与焦虑症脑血流灌注SPECT显像对照研究

目的：探讨抑郁症、焦虑症患者局部脑血流量（rCBF）的特点及脑单光子计算机断层扫描（SPECT）对抑郁症的诊断价值。方法：对21例抑郁症患者、17例焦虑症患者和20例正常对照者进行脑SPECT显像,并比较检查结果。结果：抑郁症组与正常对照组比较,双侧前额叶、颞叶前部、双侧扣带回前部、双侧顶叶、枕叶以及尾状核rCBF明显低于正常对照组（P＜0.05或0.01）。焦虑症组与正常对照组比较,额叶、部分颞叶和丘脑的rCBF明显低于正常对照组（P＜0.05或0.01）。抑郁症组与焦虑症组相比较,抑郁症组在双侧扣带回前部、右顶叶及尾状核的rCBF明显低于焦虑症组（P＜0.05或0.01）。结论：抑郁症和焦虑症对脑血流灌注均有重要影响,抑郁症患者在双侧扣带回前部、右顶叶及尾状核的脑血流灌注明显低于焦虑症组。SPECT脑灌注显像在抑郁症和焦虑症的诊断与鉴别诊断中具有重要价值。     

用SPM分析焦虑症患者99mTc-ECD局部脑血流变化

目的：用统计参数地图（statistical parametric mapping,SPM)软件包分析焦虑症患者局部脑血流（regional cerebral blood,flow,rCBF）灌注的变化。方法：选择经CCMD－2或ICD－10诊断为焦虑症患者19例，进行脑^99mTc-ECD显像，并与23例年龄匹配的健康人作比较。用SPM软件包对脑血流图像进行组间比较，分析焦虑症患者大脑血流变化情况。结果：焦虑症患者的局部脑血流双侧颞叶，额上回，扣带回明显降低。而在中央前回，额叶眶部，左基底节血流明显升高。结论：焦虑症患者的局部脑血流有明显的变化，且与其发病机理相关。     

孤独症儿童的脑血流变化分析

目的：分析孤独症患儿脑血流灌注变化的特点。方法：采用单光子发射断层扫描（SPECT）对23例孤独症与28例其他疾病患儿进行脑血流灌注显像,以半定量方法分析脑内局部血流量的变化。结果：研究组中,83％存在脑血流灌注降低,其中78％的病灶位于海马回、颞叶、顶枕叶、扣带回等边缘系统,与对照组存在统计学差异（P〈0．05）。结论：孤独症患儿大多存在脑边缘系统血流灌注降低,SPECT有助于儿童孤独症的诊断。     

应用SPECT探索抑郁症局部脑血流变化规律

目的探讨抑郁症患者和正常对照组在认知与基础状态下局部脑血流(rCBF)变化规律。方法选取9例确定为抑郁症患者和9例年龄相匹配的健康被试为对照组,利用隔日显像法,分别对两组被试在认知和基础状态下进行SPECT脑血流灌注显像。利用StatisticalParametricMapping(SPM2)软件分析。结果认知相对于基础状态:①正常被试额上回、前额右侧和BA(Brodmannarea)6脑血流显著升高;颞叶、颞上回区血流降低。②抑郁症患者右扣带回和尾状核左侧脑血流显著升高;海马旁回右侧、中央后回血流显著降低。结论两组被试在基础和认知状态下的SPECT脑激活,在抑郁症治疗诊断中具有重要的临床参考价值。     

脑血流灌注半定量法显像评价高压氧联合药物治疗一氧化碳中毒迟发性脑病疗效

目的对比研究一氧化碳中毒后迟发性脑病（DEACMP）患者在高压氧（HBO）联合药物治疗前、后单光子发射计算机断层成像（SPECT）脑血流灌注显像结果,并对其优越性及临床意义进行评价。 方法34例DEACMP患者接受20～40次HBO联合药物治疗,并在治疗前、后用双半胱乙酯（99mTc-ECD）脑SPECT血流灌注扫描半定量法进行疗效监测和对比分析。 结果HBO治疗后,DEACMP患者脑血流灌注减低区有明显改善,脑SPECT血流灌注半定量值与治疗前比较,差异有统计学意义（P<0.05）,而治疗前、后脑磁共振显像无明显差异。 结论脑SPECT血流灌注半定量法显像在DEACMP的诊断和HBO治疗的疗效监测中可起重要作用。     

单光子发射型CT检测抑郁症患者局部脑血流的变化

背景：抑郁症患者存在着不同程度的脑血流灌注减低区，但范围不尽相同，涉及不同的大脑皮质及皮质下结构区域。 目的：观察抑郁症患者局部大脑皮质血流灌注异常类型。 设计：以诊断为依据的病例一对照分析。 单位：上海交通大学医学院附属瑞金医院核医学科，上海交通大学医学院生物医学工程教研室，上海市普陀区精神卫生中心。 对象：于1999—01／2000—12选择在普陀区精神卫生中心门诊就诊未治疗的经CCMD-2-R诊断为抑郁症12例患者为观察对象。正常对照者为与之年龄匹配的医院内工作人员19名。 方法：采用SPECT检查抑郁症患者和健康人，进行双半胱乙酯脑显像，使用统计参数图对图像进行分析。首先将所有的SPECT图像转换成DICOM格式或anlysis7格式，以Talairach图谱为模版对图像进行标准化及平滑，用高斯随机理论进行统计分析与推断以评价有显著差异的区域。 主要观察指标：抑郁症组与正常对照组大脑特定区域血流灌注的区别和平均局部脑血流图像的变化。 结果：抑郁症者12例和正常健康人19名均完成检测，进人结果分析。统计参数图分析显示抑郁症患者的双侧额叶、左侧颡上回、左侧边缘叶钩回（Brodmannarea 20）、左侧丘脑乳头体、右侧扣带回、右侧壳核血流灌注下降。抑郁症患者的右侧中间额回，右侧上颡回，右侧枕叶，左侧中间额回血流灌注升高。 结论：抑郁症患者额叶、颡叶及边缘系统局部脑血流发生了明显的变化。     

轻度阿尔茨海默病患者脑代谢与脑血流影像变化

目的：观察轻度阿尔茨海默病患者脑^18F-FDG PET影像特征，并与^99Tc^m-ECD SPECT脑血流显像进行对比。方法：选择2003-04／2004-05在首都医科大学附属宣武医院神经内科门诊就诊的阿尔茨海默病患者30例。其中轻度阿尔茨海默病患者15例，男6例，女9例；中重度阿尔茨海默病患者15例，男5例，女10例。选择同期来本院体检的健康体检者7例和阿尔茨海默病患者的配偶3例为正常对照组，全部受检者均行PET脑显像、9例正常人和9例轻度阿尔茨海默病患者于PET检查后1周内行^99Tc^m-ECD SPECT脑血流显像。利用计算机感兴趣区分析程度求出脑代谢比值和脑血流比值结果：按意向处理分析，轻度、中重度阿尔茨海默病患者及正常对照组，均进入结果分析。①轻度阿尔茨海默病患者的脑代谢比值(左顶叶：1．08&;#177;0．02，左颞叶：1．04&;#177;0．06，右顶叶：1．09&;#177;0．06，右颞叶：1．07&;#177;0．07)和中重度阿尔茨海默病患者的脑代谢比值(左顶叶：0．93&;#177;0．05，左颞叶：0．98&;#177;0．05．左额叶：1．15&;#177;0．10．右顶叶：0．95&;#177;0．05，右颞叶：1．01&;#177;0．09，右额叶：1．05&;#177;O．08)均明显低于正常对照组[(左顶叶：1．2l&;#177;0．15．左颞叶：1．19&;#177;0．11．左额叶：1．31&;#177;0．13，右顶叶：1．25&;#177;0．12，右颞叶：1．22&;#177;0.10，右额叶：1．34&;#177;0．14)，(t=2．04-5．71，P&;lt;0．05-0．01)]、②轻度阿尔茨海默病患者的脑血流比值(左顶叶：0．8l&;#177;004，左颞叶：0．79&;#177;0．12，右顶叶：0．86&;#177;0．10，右颞叶：0．83&;#177;008)均明显低于正常对照组[(0．90&;#177;O．06，0．89&;#177;0．09，0．87&;#177;0．07，0．93&;#177;0．08．0．91&;#177;0.07．0．92&;#177;0．08)，(t=2．08-2．82，P&;lt;0.05)].③15例中重度脑血流比值患者的PET显像，12例表现为双侧顶叶或双侧颞顶叶对称性放射性摄取减低[80％(12／50)]，3例表现为单侧颞顶叶放射性减低[20％(3／15)115例轻度阿尔茨海默病患者的PET显像，13例表现为单侧顶叶、单侧颞叶或单侧放射性摄取减低[87％(13／15)]，2例表现为双侧顶叶放射性减低[13％(2／15)]。9例轻度阿尔茨海默病患者的SPECT显像，6例出现单侧放射性摄取减低，3例患者的SPECT显像未见阳性发现。结论：轻度阿尔茨海默病患者既有脑代谢减低也有脑血流减低．脑葡萄糖代谢影像特征是以单侧顶叶、颞叶或颞顶叶小范围的代谢减低为主要表现，这种损害并不累及额叶，SPECT脑血流灌注显像可用于轻度阿尔茨海默病辅助诊断，其主要影像特征是出现单侧顶叶、颞叶或颞顶叶血流灌注减低，损害部位与PET显像发现的代谢减低区基本一致；但是应用sPEcT脑血流灌注显像探测轻度阿尔茨海默病的灵敏度低于PET代谢显像，当sPEcT显像阴性而临床可疑轻度阿尔茨海默病时，应进一步行PET显像。     

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.