下颈椎椎弓根入口处皮质厚度的影像学测量

目的：对下颈椎椎弓根四壁及入口毗邻结构的皮质厚度行影像学测量，为临床椎弓根钉植入提供参考。方法：对8例新鲜颈椎进行DR摄片和螺旋CT扫描重建。在AutoCAD软件中测量CT图像显示的椎弓根四壁及入口处毗邻结构（包括上关节突前壁（ACS）、椎板前壁（ACL）、下关节突前壁（ACI）和横突孔后壁（PCT））的皮质厚度，并行统计学分析。结果：双斜位DR片示颈椎椎弓根内壁（MCP）、上壁（SCP）、下壁（ICP）皮质较厚，而外壁（LCP）菲薄。统计学分析发现同一颈椎的MCP、SCP、ICP、ACL、ACS和ACI之间的厚度无差别，LCP和PCT皮质菲薄，明显薄于前6项指标。MCP、SCP、ICP、ACS和PCT在C3-7间的厚度无差别，PCTc明显小于其它4项指标。结论：同一颈椎PCT和LCP明显薄于其它各项指标，提示PCT和LCP抵抗外力强度最小，MCP、SCP、ICP和ACS在C3-7间厚度无差别，提示其在不同颈椎间抵抗外力可能一致。颈椎椎弓根钉固定时应该避免靠近PCT和LCP。     

多层螺旋CT三维重建国人下颈椎椎弓根的临床解剖学意义

背景：因颈椎解剖结构复杂以及个体化差异较大,导致颈椎弓根钉置入内固定技术应用受到很大限制。目的：应用螺旋CT三维重建国人的下颈椎椎弓根,并对重建图像进行测量评估。方法：对60例需行颈椎CT扫描的患者C3～C7进行颈椎CT扫描,使用Syngo应用软件对原始CT图像进行所需面的重建,测量CT重建后的椎弓根各项指标。结果与结论：颈椎绝大部分椎弓根峡部的宽度小于高度,男性高度和宽度C4～C7逐渐增大,女性则从C3开始逐渐增大。C3～C7椎弓根侧块投射点到上关节突下缘的距离并无规律性,而到侧块外缘的距离从头端到尾端是不断增大的。男性与女性的椎弓根水平角在C7均最小。结果提示,国人女性患者的C3及C4椎体行经颈椎椎弓根内固定应谨慎,大部分国人的C5到C7椎体是适合行椎弓根内固定的,但考虑到颈椎弓根个体的差异较大,内固定前颈椎弓根的CT扫描及重建后的评估是必要的。     

多层螺旋CT三维重建国人下颈椎椎弓根的临床解剖学意义

背景:因颈椎解剖结构复杂以及个体化差异较大,导致颈椎弓根钉置入内固定技术应用受到很大限制。目的:应用螺旋CT三维重建国人的下颈椎椎弓根,并对重建图像进行测量评估。方法:对60例需行颈椎CT扫描的患者C3～C7进行颈椎CT扫描,使用Syngo应用软件对原始CT图像进行所需面的重建,测量CT重建后的椎弓根各项指标。结果与结论:颈椎绝大部分椎弓根峡部的宽度小于高度,男性高度和宽度C4～C7逐渐增大,女性则从C3开始逐渐增大。C3～C7椎弓根侧块投射点到上关节突下缘的距离并无规律性,而到侧块外缘的距离从头端到尾端是不断增大的。男性与女性的椎弓根水平角在C7均最小。结果提示,国人女性患者的C3及C4椎体行经颈椎椎弓根内固定应谨慎,大部分国人的C5到C7椎体是适合行椎弓根内固定的,但考虑到颈椎弓根个体的差异较大,内固定前颈椎弓根的CT扫描及重建后的评估是必要的。     

CT三维重建与颈椎弓根测量

背景：三维重建技术能够提供人体内部结构的数字化三维模型,并利用相关软件在模型上进行手术设计和生物力学分析,为椎弓根螺钉的安全有效置入提供可靠数据。目的：综述CT三维重建在颈椎弓根测量中的应用。方法：应用计算机检索1990/2011PubMed数据库、维普数据库及万方数据库中有关CT三维重建在颈椎弓根测量中应用的文献,英文检索词为＂thre edimensional reformation sofmulti-slicespiral CT;cervical pedicle＂;中文检索词为＂颈椎弓根;三维CT;计算机辅助设计;脊柱外科;数字骨科;医学图像＂。结果与结论：应用CT三维重建技术可以获得清晰颈椎三维图像。颈椎椎弓根螺钉置入技术因颈椎椎弓根变异较大,临近解剖结构复杂,目前国内仅少数医院得以成功开展。而利用三维CT重建测量颈椎弓根可以模拟椎弓根螺钉置入技术,能够真实准确地观察和测量椎弓根螺钉在椎体内的情况,获取个体化解剖数据,为临床应用椎弓根螺钉置入技术提供指导。     

利用CT多平面重建进行颅内血肿定位

我院近3年来用西门子sensation 16层螺旋CT对67例高血压性脑出血患者进行CT多平面重建定位法指导微创血肿穿刺清除术，基本步骤为以下几点：①扫描：对于高度怀疑高血压性脑出血者，适当加大扫描范围，包住颅底，因为定位时需有外耳孔作参照点。②重建：把扫描好的图像进行薄层重建，然后在3D区进行多平面重建。③调正：通过调整多平面轴线将横断面、矢状面、冠状面调正，重点是将横断面定在外耳孔中心层面，     

股骨近段CT扫描与全髋关节置换的术前计划

背景：做好全髋关节置换前假体型号预测的前提是对股骨近段的充分了解和精确测量,但X射线片仅提供一个平面图像,不能了解股骨近段横断面的情况,而股骨上段CT扫描可以提供更多信息。目的：观察股骨近段CT扫描在全髋关节置换前计划中的作用。方法：对61例进行初次全髋关节置换的患者行股骨近端CT扫描,选取股骨小转子最突出处上方2cm股骨颈平面（T20）、股骨小转子最突出点处的股骨转子区平面（T0）和股骨干髓腔最狭窄处平面（N）的横断面CT影像。测量股骨颈平面髓腔长径、宽径、内侧径;小转子平面髓腔长径、内侧径;股骨峡部平面髓腔长径、宽径、皮质厚度。结果与结论：股骨颈T20长径40.8～63.3mm,平均（49.6±5.1）mm;T20宽径13.3～29.1mm,平均（22.4±3.4）mm;T20内侧径7.2～14.6mm,平均（10.6±1.6）mm。股骨转子区T0长径20.5～40.2mm,平均（28.7±4.4）mm;T0内侧径4.3～13.0mm,平均（8.1±1.7）mm。股骨峡部N长径8.2～22.4mm,平均（14.1±3.1）mm;N宽径6.1～17.9mm,平均（10.2±2.9）mm;N皮质厚度2.7～12.7mm,平均（7.5±1.8）mm。提示股骨近端CT扫描可以提供更多的影像信息和更精确的测量数据,对全髋关节置换前计划有所帮助。     

多层螺旋CT对髌骨关节软骨的形态学研究

目的对髌骨关节软骨进行形态学研究，探讨螺旋CT对关节软骨的最佳成像方法及在关节软骨形态学研究中的应用价值。方法5例新鲜膝关节标本进行螺旋CT容积扫描，将髌骨原始图像行SSD、MPR重建成像后进行关节软骨形态学研究并与解削标本研究测量结果进行对比，应用线性回归和相关分析统计学分析两种测量方法的差异性。结果正常髌软骨在不同区域厚度不同，CT扫描图像经重建后能良好显示出关节软骨，图像中关节软骨形态轮廓与真实软骨相近，在螺旋CT三维重建图像上行关节软骨厚度测量与标本测量结果比较无统计学差异。结论正常髌骨软骨关节面形态与骨性关节面并非完全一致，软骨关节面厚度为非均等性分布；螺旋CT成像是一种快速、有效的无创性影像学技术，可在活体条件下进行关节软骨的形态学研究。     

螺旋CT三维重建在胫骨平台骨折中的应用价值

目的：探讨螺旋CT表面遮盖显示（SSD）和多平面重建（MPR）在胫骨平台骨折中的临床应用价值。方法：78例胫骨平台骨折病例均行X线正、侧位摄片，而后行螺旋CT横断面扫描以及SSD和MPR重建。螺旋CT的扫描参数为层厚2－5mm，床速3－5mm，重建间距1．5－3mm。结果：所有病例CT横断面、SSD或MPR明显地显示了骨折，螺旋CT三维重建在骨折的分型和碎骨的描述上较平片优越。结论：螺旋CT三维重建能够更为精确地显示胫骨平台的骨折情况，为临床医师制定治疗方案提供可靠依据。     

16层螺旋CT图像后处理技术在急性颅脑创伤中的诊断价值

目的:评估16层螺旋CT图像后处理技术诊断急性颅脑外的临床价值。方法:对104例急性颅脑创伤病人作16层螺旋CT颅脑扫描,对原始轴位图像进行图像后处理,包括回顾性薄层重建、多平面重组;分析急性颅脑创伤的CT影像表现、计算颅脑创伤病变的数量,分别就原始轴位图像、回顾性薄层重建、多平面重组图像进行比较。结果:原始轴位图像难以显示隐匿性的颅脑创伤病灶,回顾性薄层重建及多平面重组发现病灶数量要多于原始轴位图像,但回顾性薄层重建与多平面重组发现病灶的数量无明显差别。结论:就16层螺旋CT检查急性颅脑创伤而言,回顾性薄层重建、多平面重组能够明显提高隐匿性病灶的检出率。     

腰椎棘突间区的影像解剖学研究及其临床意义

目的：探讨三维CT重建腰椎棘突间区的方法及其临床意义。方法：GE light speed 16 pro螺旋CT扫描患者46人，扫描条件为层厚0．625mm，层距0．3mm，在图像工作站中ADW4．2软件采用容积再现及多平面重建技术重建T12至S1段脊柱三维图像，对图像进行整倍数放大，并使用图像工作站（Advantage Workstation）软件中的测量工具，对棘突间距，棘突顶距，棘突中央高度，相邻棘突上下缘及中央厚度进行测量，测量过程中可以对腰椎三维图像任意角度旋转，选择最佳测量图像，对测量的图像数据进行正态性检验、t检验。结果：腰椎棘突间距从上到下（L1～5）逐渐减小，L1～2为8．26mm，L4～5，为5．66mm。棘突顶距棘突中央高度中段大于上段和下段，T12～L1的棘突顶距为54．91mm，至L2～3，增大为59．35mm，L4～5减小为47．13mm。L3的棘突高度最大，为21．56mm，上一棘突下缘大于相邻下一棘突上缘厚度。女性棘突较男性棘突短薄矮（P〈0．05～P〈0．01）。结论：本研究可模拟生理状态下腰椎棘突间区解剖，所测指标呈正态分布，能够反映国人腰椎棘突间区解剖，为腰椎棘突间内固定器的设计和临床的应用及计算机导航手术系统的应用提供解剖学基础。     

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.