颈段胸导管的高频超声检测及其临床意义

目的 探讨高频超声检测正常成人颈段胸导管的检查方法及其正常值,为诊断颈段胸导管疾病提供参考依据.方法 对278例健康志愿者沿左颈静脉处进行高频超声观察,观察颈段胸导管的超声影像学特征,依次于3个位点(弓部、干部、末端)测量内径,并对各部位内径与身高、体质量的相关性进行分析.结果 左颈段胸导管高频超声显示率为96％ (269/278);颈段胸导管呈管状无回声,其内可见间断乳糜流,并于颈静脉角汇入静脉.其弓部、干部、末端内径分别为(2.29±1.10)、(2.32±1.06)、(2.61±0.98) mm,末端内径较弓部及干部增宽,内径差异有统计学意义(P＜0.05);不同年龄组间、男女间各段内径差异均无统计学意义(P＞0.05);各段内径与身高、体质量有相关性.结论 高频超声可有效检出颈段胸导管,正常值可供临床诊断参考.     

高频超声对健康志愿者及肝硬化患者颈段胸导管的评价

目的：探讨超声显示颈段胸导管结构的方法,并监测肝硬化对患者胸导管的影响。方法：利用高频超声对90例受检者（其中健康志愿者组45例,肝硬化患者组45例）,于左侧椎静脉与颈内静脉夹角水平观察颈段胸导管形态、管腔结构及淋巴回流情况,并对胸导管的内径进行测量,对比两组间数值的差异。结果：成功显示颈段胸导管82例（显示率92%）,其中正常对照组39例（显示率86%）,肝硬化组43例（显示率95%）。颈部胸导管于左颈部颈内静脉与椎静脉之间注入左静脉角55例（71%）或注入左侧锁骨下静脉27例（29%）,显示为管状或梭形。超声可显示胸导管的管腔结构及淋巴回流情况。正常对照组及肝硬化组胸导管内径分别为（2.51±0.5）mm、（4.6±2.5）mm。淋巴回流次数：健康志愿者组4~6次/分,肝硬化患者组0~1次/分,两组间对比有统计学差异（P＜0.05）。结论：高频超声可较清晰的显示颈段胸导管的管腔结构及淋巴回流情况,具有可信、无创、方便等优越性,值得在临床中应用。肝硬化患者胸导管异常超声影像表现为内径较正常对照组增宽,淋巴回流次数减少。     

影像学检查在胸导管末端探查术治疗淋巴管肌瘤病合并乳糜胸术式选择中的价值

目的 探讨影像学检查在胸导管末端探查术治疗淋巴管肌瘤病（LAM）合并乳糜胸术式选择中的诊断价值。方法 回顾性分析经临床和/或病理证实的34例LAM合并乳糜胸患者的临床和影像学资料。所有患者均接受放射性核素⁹⁹Tc^m-右旋糖酐（DX）淋巴显像和CT淋巴管造影（CTL）检查。根据⁹⁹Tc^m-DX淋巴显像对胸导管分型：Ⅰ型为异常浓聚型;Ⅱ型为异位引流型;Ⅲ型为未显影或一过性显影型,Ⅰ型和Ⅱ型为胸导管异常。根据CTL对胸导管分型：Ⅰ型为扩张型;Ⅱ型为末端梗阻型;Ⅲ型为主干缩窄型;Ⅳ型为异位引流型;Ⅴ型为未显示型。以Ⅰ~Ⅳ型为胸导管异常。评价2种方法显示胸导管病变的一致性。结果 ⁹⁹Tc^m-DX淋巴显像显示Ⅰ型17例,Ⅱ型3例,Ⅲ型14例。58.82%（20/34）的LAM合并乳糜胸病例存在胸导管病变。CTL显示Ⅰ型15例,Ⅱ型3例,Ⅲ型5例,Ⅳ型2例,Ⅴ型9例,73.53%（25/34）的LAM合并乳糜胸病例存在胸导管病变。2种方法显示胸导管是否存在病变的一致性较好（Kappa=0.679）。CTL胸导管分型中,Ⅰ型和Ⅱ型多采用胸导管—静脉吻合术或胸导管末端松解术解除梗阻,Ⅲ型多采用胸导管末端压迫带/粘连松解术解除梗阻,Ⅳ型根据胸导管异常回流路径来选择手术入路和手术方式,Ⅴ型多采取保守治疗。结论 CTL优于⁹⁹Tc^m-DX淋巴显像,能准确显示胸导管的病变情况,为胸导管末端探查术治疗LAM合并乳糜胸的术式选择提供影像学依据。     

高脂肪饮食对颈段胸导管超声成像效果的影响

目的探讨高脂肪饮食对正常成人颈段胸导管超声成像效果的影响,为诊断淋巴管疾病提供依据。方法对29例健康志愿者空腹及高脂肪餐后3 h行颈段胸导管超声成像,观察进食前后胸导管内径的变化,对成像效果进行量化评分,并观察右位胸导管检出情况。结果空腹状态下28例志愿者左颈静脉角区探及胸导管结构,内径(2.20±0.98)mm,评分为2分构成比为55%(16/29)。脂肪餐后3 h左侧胸导管内径增加至(3.04±1.53)mm,与餐前比差异有显著差异(P0.01);评分为2分构成比达83%(24/29),与餐前两者差异有统计学意义(χ~2=5.516,P=0.023)。1例志愿者高脂肪餐后3 h可由静脉角乳糜回流追踪到右位胸导管,并经同位素淋巴显像证实。结论高脂饮食可以促进乳糜的生成及转运,从而提高了颈段胸导管的超声显示效果,可为临床诊断淋巴管疾病提供影像依据。     

99Tcm-右旋糖酐淋巴显像诊断乳糜胸

目的 探讨⁹⁹Tc^m-右旋糖酐(DX)淋巴显像诊断乳糜胸的价值。方法 回顾性分析95例实验室检查证实单侧胸腔积液甘油三酯含量高于1.24 mmol/L而临床诊断乳糜胸患者的⁹⁹Tc^m-DX淋巴显像资料，观察双下肢淋巴引流、胸导管及静脉角区放射性分布及患侧胸腔有无异常放射性分布。结果 95例中，43例(43/95,45.26%)下肢淋巴回流正常，36例(36/95,37.89%)淋巴回流缓慢，16例(16/95,16.84%)肢体淋巴水肿；41例(41/95,43.16%)胸导管出口梗阻，表现为左静脉角持续或增宽显影、显像剂异常反流或双侧静脉角显影；89例(89/95,93.68%)患侧胸腔内放射性异常增高，其中2例(2/95,2.11%)见可疑乳糜漏出点，6例(6/95,6.32%)胸腔内未见明显异常放射性分布。结论 ⁹⁹Tc^m-DX淋巴显像有助于诊断乳糜胸。     

99Tcm-右旋糖酐淋巴显像评价Klippel-Trenaunay综合征淋巴管畸形及淋巴水肿

目的 观察⁹⁹Tc^m-右旋糖酐（⁹⁹Tc^m-DX）淋巴显像评价Klippel-Trenaunay综合征（KTS）患者淋巴管畸形及淋巴水肿的应用价值。方法 回顾性分析36例临床确诊为KTS患者的临床及核素淋巴显像资料。经双足趾间皮下注射⁹⁹Tc^m-DX后,分别于给药后10 min、1 h、3 h及6 h行全身淋巴显像,观察患者双下肢淋巴管、双腹股沟及髂、腰淋巴结、胸导管及静脉角区的显影情况以及全身其他部位有无显像剂异常分布。结果 36例KTS患者中,35例淋巴显像提示淋巴管、淋巴结显影异常并伴淋巴水肿,其中31例为单侧下肢淋巴水肿、4例为双下肢淋巴水肿。20例出现颈部静脉角区域异常显影,其中15例为左静脉角区域显像剂滞留,2例为右静脉角区域显像剂滞留,3例为双静脉角区域显像剂滞留。12例伴会阴部淋巴水肿。8例出现身体其他部位的异常淋巴管显影。结论 ⁹⁹Tc^m-DX淋巴显像可以评价KTS患者淋巴管与淋巴结发育异常以及胸导管回流状况。     

骨外组织摄取骨显像剂的所见及临床意义探讨(附497例报告)

目的:探讨骨外组织摄取99Tcm-MDP的临床意义。材料和方法:回顾性分析6602例99Tcm-MDP骨显像并识别骨外组织显影。结果:骨外组织显影497例。弥漫性摄取见于四肢、胸、腹部(淋巴和/或静脉回流障碍120例,恶性胸、腹腔积液各146及44例,甲状旁腺功能亢进3例,肝脏转移瘤20例);局灶性摄取见于不同部位多种类型的肿瘤(107例,除1例良性外其余均为恶性),心肌炎及脑梗死灶各1例、横纹肌炎症1例、近期骨折或手术后局部软组织各16及18例,术后瘢痕7例、术后造瘘13例。上述显影的骨外组织良性病变占33%,恶性病变占67%。结论:正确识别核素骨显像的骨外组织显影有助于对骨显像的正确分析并可提供有价值的信息。     

CT淋巴管造影对乳糜尿的诊断价值

目的 探讨CT淋巴管造影对直接淋巴管造影术后乳糜尿的诊断价值.方法 回顾性分析11例乳糜尿患者的核素淋巴显像、直接淋巴管造影、CT淋巴管造影并经手术证实的所有资料.结果 11例乳糜尿患者中,核素淋巴显像发现胸导管扩张8例,腰干增宽5例,肾盂显影7例;直接淋巴管造影发现胸导管扩张10例,腰干淋巴管纡曲、扩张11例,对侧腰干、腹膜后淋巴管反流4例,向肾盂反流10例;CT淋巴管造影发现胸导管扩张9例,右淋巴管扩张1例,腰干、腹膜后、髂、盆腔淋巴管纡曲、扩张11例,对侧腰干、腹膜后淋巴管反流10例,肾盂、肾窦反流11例.结论 CT淋巴管造影可以发现更多病变淋巴管,并清晰显示其周围解剖关系,对核素淋巴显像和直接淋巴管造影的低空间分辨力起到补充作用.     

伤寒患者回盲部的B型超声显像

目的探讨伤寒患者回盲部的Ｂ型超声显像特点。方法以伤寒病回肠末端淋巴组织病变最为显著的病理特点为依据，对发热４天以上患者，首先应用高频Ｂ超进行检查。结果最终确诊的１０９例成人伤寒病患者中，回肠末端肠壁增厚、规则、肠壁回声减弱，伴有周围淋巴结肿大者１０６例，敏感性达９７．２５％。同时对２００例非伤寒病患者进行对比检查，无假阳性。结论超声显像对伤寒病的早期诊断价值很大，可作为首选检查项目     

肝硬化患者颈段胸导管的超声影像学特征

目的应用超声测量肝硬化患者颈段胸导管内径,评估不同类型肝硬化患者胸导管内径的差异及意义。方法选取我院临床确诊为慢性肝病肝硬化患者163例,其中慢性乙型肝炎肝硬化(CHB)患者61例,慢性丙型肝炎肝硬化(CHC)患者32例,酒精性肝硬化(AC)患者42例,自身免疫性肝炎肝硬化(AHC)患者28例。同期选取65例健康志愿者作为对照组。应用高频超声测量颈段胸导管内径(CTDd),比较各组CTDd的差异。结果 CHB、CHC、AC、AHC组颈段胸导管超声显示率分别为97%、100%、100%、89%,健康对照组显示率为89%,显示率差异无统计学意义(P0.05)。健康对照组的CTDd测值最小,为(2.11±0.58)mm;AHC组、CHB组、CHC组AC组CTDd测值分别为(3.96±1.31)mm、(4.49±1.31)mm、(4.62±1.56)mm、(6.07±2.60)mm,较对照组均明显增宽,差异有统计学意义(P0.000);AHC组、CHB组、CHC组各组间差异无统计学意义(P0.05);AC组CTDd测值较AHC组、CHB组、CHC组增宽,差异有统计学意义(P0.01)。结论肝硬化患者胸导管内径较正常人明显增宽,不同病因导致增宽程度有所差别。     

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.     

Guns and Knives in New Mexico: Patterns of Penetrating Trauma, 1978–1993

Objective: To identify patterns of nonfatal and fatal penetrating trauma among children and adults in New Mexico using ED and medical examiner data.
Methods: The authors retrospectively sampled in 5-year intervals all victims of penetrating trauma who presented to either the state Level-1 trauma center or the state medical examiner from a 16-year period (1978–1993). Rates of nonfatal and fatal firearm and stabbing injury were compared for children and adults.
Results: Rates of nonfatal injury were similar (firearm, 34.3 per 100,000 person-years; stabbing, 35.1). However, rates of fatal injury were significantly different (firearm, 21.9; stabbing, 2.7; relative risk: 8.2; 95% confidence interval: 5.4, 12.5). From 1978 to 1993, nonfatal injury rates increased for children (p = 0.0043) and adults (p < 0.0001), while fatal penetrating injury remained constant. The increase in nonfatal injury in children resulted from increased firearm injury rates. In adults, both stabbing and firearm nonfatal injury rates increased.
Conclusions: Nonfatal injury data suggest that nonfatal violence has increased; fatal injury data suggest that violent death rates have remained constant. Injury patterns vary by age, mechanism of trauma, and data source. These results suggest that ED and medical examiner data differ and that both are needed to guide injury prevention programs.     

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.