黄韧带退变与腰椎管狭窄症椎管形态的变化

背景：目前研究发现Ⅰ型及Ⅱ型胶原在结缔组织的增殖与分化、软骨的形成和吸收等过程中起十分重要的作用。目的：探讨腰椎黄韧带退变与腰椎管狭窄症椎管形态变化的相关性。方法：收集中央型腰椎管狭窄症36例和外伤性腰椎骨折20例患者的黄韧带标本分别为实验组和对照组,采用酶联免疫吸附法测定Ⅰ型和Ⅱ型胶原;CT测量腰椎硬膜横截面积;黄韧带行苏木精-伊红和Masson染色,观察组织病理学变化。结果与结论：实验组黄韧带厚度、Ⅰ型及Ⅱ型胶原含量高于对照组,腰椎硬膜横截面积和Ⅰ型/Ⅱ型比值低于对照组（P〈0.05）;病理学显示实验组黄韧带弹性纤维排列紊乱,数量减少,胶原纤维增生。提示腰椎黄韧带Ⅰ型、Ⅱ型胶原含量及Ⅰ型/Ⅱ型比值发生改变,可能引起黄韧带厚度增加,导致椎管横截面积减小,参与腰椎管狭窄症的发生。     

脊柱损伤的CT诊断(附100分析)

目的：探讨脊柱损伤的CT诊断价值；局限性以及临床意义。材料与方法：对100例脊柱损伤进行回顾性分析。其中男性68例，女性32例，平均年龄35．5岁。结果：损伤部位，颈椎25例，胸椎32例，腰椎43例。骨折类型：屈曲压缩型42例（42％）、爆裂型35例（35％）、骨折脱位型14例（14％）、安全带型9例（9％）。椎管狭窄程度；I度狭窄42例，Ⅱ度狭窄11例，Ⅲ度狭窄2例，无椎管狭窄45例。结论：CT能正确的评价脊柱损伤的类型，了解椎管内受损程度，判定脊柱稳定与否，是指导临床手术治疗和预后评估的一种较好的方法。     

壶腹癌的超声诊断分型在外科治疗中的意义

目的 探讨壶腹癌超声诊断分型在外科治疗中的临床意义。方法 将３１例手术病理证实的得癌根据超声表现分为３型∶Ⅰ型、胆总管下段无肿块型;Ⅱ型,胆总管下段小肿块型;Ⅲ型,胆总管下段明显肿块型。各型均与手术方式对照。结果 ３１例中Ⅰ型５例（１６．１％）,Ⅱ型１１例（３５．５％）,Ⅲ型１５例（４８．４％）。Ⅰ型与Ⅱ型合并手术切除率（１００％）与Ⅲ型的手术切除率（６０．０％）比较差异有显著性意义（Ｐ〈０．０１）。结论 壶腹癌超声诊断分型对术前制定手术方案、进一步提高手术切除率以及估计得癌的预后有重要的临床意义。     

肥厚腰椎黄韧带中成纤维细胞生长因子、转化生长因子及结缔组织生长因子的表达

背景：腰椎黄韧带肥厚是临床上引起腰椎管狭窄的主要因素之一,但其分子机制仍不是非常清楚。目的：分析纤维化相关细胞因子碱性成纤维细胞生长因子、转化生长因子β1和结缔组织生长因子在腰椎黄韧带肥厚过程中的作用。方法：取临床手术所取黄韧带,对照组6例（椎管内占位且无腰椎不稳患者黄韧带）、突出组（单纯腰椎间盘突出症患者黄韧带）6例、腰椎管狭窄症组6例。采用实时定量RT-PCR的方法检测各组黄韧带中碱性成纤维细胞生长因子、转化生长因子β1、结缔组织生长因子及Ⅰ、Ⅲ、Ⅴ型胶原蛋白的mRNA含量,分析3个细胞因子在黄韧带肥厚过程中的作用。结果与结论：腰椎管狭窄症组碱性成纤维细胞生长因子mRNA表达均明显高于突出组和对照组（均P 〈0.05）;腰椎管狭窄症组转化生长因子β1mRNA在3组中的表达明显高于对照组和突出组（均P 〈0.01）;结缔组织生长因子 mRNA 3组间差异无显著性意义（P 〉0.05）。腰椎管狭窄症组Ⅰ型胶原蛋白mRNA表达明显高于突出组和对照组（均P 〈0.05）;Ⅲ型胶原蛋白、Ⅴ型胶原蛋白mRNA表达3组之间差异无显著性意义（P 〉0.05）。结果说明碱性成纤维细胞生长因子、转化生长因子β1在腰椎黄韧带肥厚形成过程中有重要作用,引起黄韧带肥厚的主要胶原产物为Ⅰ型胶原蛋白。     

棘突基底部截骨全椎板切除椎管成形术治疗腰椎管狭窄症600例分析

目的：探讨棘突基底部截骨全椎板切除椎管成形术治疗腰椎管狭窄症的疗效及手术适应证。方法：1999—12／2005—12笔者采用该术式对腰椎管狭窄症单节段485例、两节段115例进行椎管扩大减压、椎管成形。结果：疗效评分采用北美脊柱外科学会的腰椎功能障碍指数进行评定。术后1～6a 600例均得到随访，其中507例改善率为53％～84％，优良率为84．5％（507／600）。结论：该术式具有创伤小，出血少，手术时间短，疗效确实等优点，绝对手术适应证为腰椎管狭窄症需要全椎板切除减压者。     

21例慢性主动脉夹层的CT诊断

目的：探讨主动脉夹层的CT表现及其临床意义。方法：回顾性分析21例主动脉夹层的CT表现。结果：按De-Bakey分型，Ⅰ型6例（28％），Ⅱ型8例（38％），Ⅲ型7例（33％）。所有患者均由CT诊断。结论：CT诊断主动脉夹层有重要价值。     

脊柱显微内镜在治疗腰椎管狭窄症的临床应用 (附129例报告)

目的 探讨脊柱显微内镜（microendoscopic discectomy，MED）治疗腰椎管狭窄症（1umbar spinalstenosis，LSS）的临床应用价值。方法 应用脊柱显微内镜手术治疗LSS患者129例，其中中央型34例，神经根型35例，侧隐窝型50例，混合型10例。按不同类型分别行椎管减压、神经根管扩大及侧隐窝减压术。结果 术后129例各型腰椎管狭窄症患者，平均随访6．9个月。按NAKAI分级，优：87例，良：38例，可：4例，优良率96．9％。中央椎管型、侧隐窝型、神经根型椎管狭窄3者疗效差异无显著性。3者与混合型椎管狭窄疗效有统计学差异。结论 该术式清晰地显露神经根受压情况，从减压的范围、对脊柱的稳定性及临床疗效上看都是可行的，但对混合型椎管狭窄患者的选择上要慎重。     

内窥镜鼻窦清理术疗效分析

目的：探讨内窥镜鼻窦手术后影响预后因素和清理术的对策。方法：对１９９５年１月～１９９７年１０月手术随访１年以上的１６０例完整临床资料,按海口ＦＥＳＳ—９７疗效评估指标进行分析。结果：治愈率：Ⅰ型２期１００％（３７／３７）,３期１００％（１１／１１）;Ⅱ型２期９７％（６４／６６）,３期３１．３％（１３／１６）;Ⅲ型８０％（２４／３０）,Ⅰ型与Ⅱ型３期、Ⅲ型疗效对比,经Ｘ方检验（Ｐ＜０．０５）有显著差异。鼻窦炎分型、期、筛窦分型、鼻息肉分型与鼻窦清理次数有显著相关性。结论：长期、多次鼻窦清理手术是提高ＦＥＳＳ术治愈率的重要手段。     

交叉开窗潜行式椎管扩大术治疗腰椎管狭窄症临床分析

目的：探讨交叉开窗潜行式椎管扩大术治疗腰椎管狭窄症的手术方法和疗效。方法：交叉开窗潜行式椎管扩大术治疗腰椎管狭窄症23例,与用传统方法治疗30例进行疗效比较。结果：交叉开窗组疗效优良率96.61%,传统手术组93.33%,两组比较疗效无统计学差异（P〉0.05）。结论：交叉开窗潜行式椎管扩大术既可充分减压,又不破坏脊柱稳定性,是治疗腰椎管狭窄症的有效方法。     

鼻骨骨折CT分型及其与临床分型关系的探讨

目的 探讨鼻骨骨折CT分型及其与临床分型的关系,为临床治疗和法医学鉴定提供依据.方法 110例鼻外伤患者经MSCT诊断为鼻骨骨折.根据骨折线的侧别、骨折线形态及骨折断端错位成角程度,以及合并鼻中隔骨折及相邻部位骨折分为四型.Ⅰ型：单侧和（或）双侧鼻骨线性骨折,无或轻度错位成角.Ⅱ型：分两个亚型,Ⅰ型的基础上出现骨折线明显错位成角为Ⅱa型,单侧和（或）双侧鼻骨粉碎性骨折为Ⅱb型.Ⅲ型：Ⅰ、Ⅱ型伴鼻中隔骨折,分两个亚型,不伴发周围骨折为Ⅲa,伴发周围骨折为Ⅲb.Ⅳ型：Ⅰ、Ⅱ型伴有鼻骨周围骨折但不伴鼻中隔骨折.明显错位成角定义为断端移位〉1/2、塌陷或上翘≥45°.将CT分型与临床分型进行比较,采用配对计数资料的加权Kappa统计量检验,P〈0.05为差异具有统计学意义.结果 CT分型由高到低依次为Ⅳ型、Ⅰ型、Ⅲ型及Ⅱ型,形态和部位：（1）单侧39例,双侧71例;（2）鼻骨线性骨折71例,无明显移位成角52例,有明显移位成角19例;其中单侧35例,双侧36例;（3）粉碎性骨折39例;单侧4例,双侧20例;一侧线性另一侧粉碎性15例;（4）伴鼻中隔骨折 29例;（5）合并其他骨折57例.CT分型：Ⅰ型24例;Ⅱ型14例,其中Ⅱa型11例,Ⅱb型3例;Ⅲ型29例,其中Ⅲa型11例,Ⅲb型18例;Ⅳ型43例.将Ⅱ型和Ⅲ型中的两个亚型合并后与临床分型比较,经配对计数资料的加权Kappa统计量检验,Kappa=0.740,P=0.000,CT分型与临床分型一致性较好.结论 通过CT分型,能够准确描述鼻骨骨折的复杂情况,对骨折的临床处理和法医学鉴定具有重要意义.     

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.