CTA与MRA对颅内动脉瘤的诊断价值对比

目的分析数字减影血管造影(DSA)、CT血管造影(CTA)、MR血管造影(MRA)检查颅内动脉瘤(IA)图像并比较CTA与MRA临床诊断价值。方法回顾性分析198例疑似IA患者DSA、CTA和MRA结果,比较CTA和MRA对颅内动脉瘤的诊断价值。结果经DSA检查,198例患者中共164例确诊为IA患者,动脉瘤共339个;CTA确诊161例,检出动脉瘤332个,其中假阳性7个,实际检出332个,漏诊21个;MRA确诊142例,检出动脉瘤329个,其中假阳性4个,实际检出304个,漏诊39个;CTA与MRA检出率比较,差异有统计学意义(P0.05);CTA所测瘤体直径以及不同大小瘤体检出率与DSA比较,差异未见统计学意义(P0.05),MRA所测瘤体直径与CTA、DSA比较,差异有统计学意义(P0.05),且直径3 mm瘤体检出率明显低于CTA(P0.05);CTA和MRA诊断IA患者敏度分别为92.07%和86.59%(P0.05),特异度分别为73.53%和91.18%(P0.05),准确度分别为88.89%和81.81%(P0.05)。结论 CTA检查IA患者对较小体积动脉瘤检出率更高,所测瘤体大小更精确,综合诊断价值更高;MRA虽然准确率欠佳,但安全性更高,且费用较低。     

颅内动脉瘤的多层螺旋CT血管成像评估（附62例报道）

目的探讨多层螺旋CT血管成像（multi-slice computed tomography angiography, MSCTA）诊断颅内动脉瘤的价值：方法对62例临床怀疑为颅内动脉瘤患者的进行MSCTA检查,并与DSA和手术结果进行对照和分析。结果在62例患者中,MSCTA检出动脉瘤其66个,7例未检见动脉瘤,其中9例为多发动脉瘤,2个瘤灶者7例,3个瘤灶者2例。动脉瘤位于前交通动脉者26个,大脑中动脉15个,颈内动脉12个,大脑前动脉4个,后交通动脉4个,小脑后下动脉3个,基底动脉2个。最大瘤体直径为18mm,最小瘤体直径2mm。经DSA和手术对照,MSCTA诊断准确55例,漏诊3例,动脉瘤位置判断不准3例,假阳性1例。MSCTA诊断动脉瘤敏感性883％,特异性100％,准确率91．7％,阳性预测值97.0％,阴性预测值71．4％。结论MSCTA可安全、快捷、无创性血管成像,能清晰显示颅内动脉瘤瘤体（形态、大小、指向、轮廓）、瘤颈宽度、载瘤动脉及与颅骨之间的关系,推荐作为颅内动脉瘤检查的主要方法之一。     

小动脉瘤CTA与DSA的动物实验对比研究

目的通过CTA的容积再现法(VR)、表面阴影遮盖法(SSD)、仿真内镜(VE)等重建图像与DSA血管造影所见对照分析,探讨CTA对小动脉瘤的诊断价值.方法用外科手术方法建立了20只新西兰大白兔颈总动脉囊状侧壁型小动脉瘤模型,直径小于4 mm.分别进行CTA多种方法重建和DSA造影,测量动脉瘤的长、宽、瘤颈、顶/颈的比值、动脉瘤与载瘤动脉的夹角及对比剂用量,观察有无血栓形成、血管痉挛等征象,将DSA与CTA的结果进行统计学配对t检验.结果 CTA的VR对动脉瘤纵径、瘤体宽度、瘤颈宽度、动脉瘤顶/颈的比值、动脉瘤与载瘤动脉夹角的测量数据,与DSA测量的结果无显著统计学差异(P＞0.05),提示CTA的VR与DSA效果相同.CTA的SSD测得的动脉瘤瘤体、瘤颈数据较DSA测得的数据偏大(P<0.05),CTA的SSD对动脉瘤顶/颈的比值、与载瘤动脉夹角,与DSA比较无显著统计学差异(P＞0.05),CTA的SSD与DSA效果相同.DSA比CTA所用的对比剂量更多(P<0.05).结论 CTA能准确显示小动脉瘤的部位、形态、大小、起源、与载瘤动脉的夹角、载瘤动脉的通畅性等重要信息,可提示DSA的最佳投照角度、与周围血管组织的关系,造影剂的用量更少,可为选择治疗方案提供详实的影像信息.     

MSCTA在颅内动脉瘤诊断中的应用及质量控制

目的探讨多层螺旋CT血管成像（MSCTA）对颅内动脉瘤的诊断价值以及其质量控制。方法收集经数字减影血管造影（DSA）和手术证实的颅内动脉瘤27例,所有的病例均行多层螺旋CT血管成像。采用容积再现（VR）、最大密度投影（MIP）和曲面重建（CPR）等方法进行图像重建。19例行手术治疗,8例行DSA检查。结果27例患者均单发,MSCTA发现动脉瘤24个,其中大脑中动脉10个,大脑前动脉7个,大脑后动脉4个,颈内动脉2个,椎动脉1个。3例颈内动脉瘤漏诊。MSCTA上动脉瘤显示直径5—22mm。手术及DSA所见与CT动脉造影CTA所显示动脉瘤位置、大小、形态基本一致。结论MSCTA能清楚显示颅内动脉瘤的形态、位置及其与周围的解剖关系,为手术或介入治疗动脉瘤提供非常有价值的信息。     

CTA与DSA诊断脑动脉瘤的价值分析

目的分析CT血管造影(CTA)与数字减影血管造影(DSA)诊断脑动脉瘤的价值。方法回顾性分析接受检查的62例高度疑似脑动脉瘤患者的临床资料,所有患者均接受CTA与DSA检查,以手术病理结果为“金标准”,分析CTA与DSA诊断脑动脉瘤的价值。结果62例患者中确诊为脑动脉瘤52例(83.87%),动脉瘤数量58个,其中大脑前动脉瘤12个,前交通动脉瘤17个,后交通动脉瘤20个,脑中动脉瘤9个。CTA、DSA及联合诊断脑动脉瘤与金标准一致性分别为0.487、0.652、0.881。联合诊断的敏感度及准确度高于CTA与DSA单一诊断,3种诊断方式以联合诊断效能最高,其次分别为DSA、CTA,差异有统计学意义(P<0.05)。结论CTA与DSA在脑动脉瘤的诊断中均具有一定价值,但单一DSA的诊断效能比CTA的高,通过联合诊断可提高诊断效能,临床可根据实际情况合理选择诊断方式。     

64排螺旋CT血管造影与3D DSA对颅内小动脉瘤诊断的比较分析

目的通过64排螺旋CT血管造影（CTA）与三维旋转数字减影血管造影（3D DSA）对颅内小动脉瘤检测的对照研究,评价64排CTA对颅内小动脉瘤的诊断价值。方法 2007年6月—2010年12月疑似颅内动脉瘤患者73例,回顾性分析其64排CTA及3D DSA图像资料,以3D DSA为诊断标准,采用双盲法对比分析64排CTA对颅内小动脉瘤的诊断价值。结果 3D DSA共检出47例,合计52个小动脉瘤。颅内小动脉瘤组（直径3～5 mm）32个,其中CTA检出32个,CTA的诊断灵敏度、特异度均为100%;颅内微小动脉瘤组（直径〈3 mm）20个,其中CTA检出19个,假阴性1例和假阳性4例。CTA的诊断灵敏度、特异度和准确性分别为91.8%、86.0%和91.5%。64排CTA对颅内小及微小动脉瘤诊断与DSA比较两组间差异无统计学意义（P〉0.05）。结论 64排螺旋CTA的应用,提高了对颅内小动脉瘤的检出能力,CTA可作为颅内小动脉瘤筛选检测的首选方法。     

磁共振血管造影、CT血管造影及数字减影血管造影对颅内动脉瘤诊断价值的对照研究

目的 对照研究磁共振血管造影(MRA)、CT血管造影(CTA)及数字减影血管造影(DSA)对颅内动脉瘤的诊断价值.方法 34例经DSA检查和(或)临床证实的颅内动脉瘤患者,均行DSA检查,并同时行CTA和(或)MRA检查.分析MRA、CTA及DSA对颅内动脉瘤的检出率,并观察分析动脉瘤的形态特征,测量动脉瘤瘤体直径及囊状动脉瘤瘤颈宽度.结果 34例患者共检出动脉瘤41个,DSA、MRA及CTA的检出率分别为97.6%(40/41)、86.4%(19/22)和75.0%(15/20).以DSA为诊断金标准,CTA与MRA检出率差异无统计学意义(P＞0.05).CTA与DSA、MRA与DSA所测瘤体直径及瘤颈宽度差异均无统计学意义(P＞0.05).结论 DSA仍为检出颅内动脉瘤最敏感的方法,但MRA和CTA对于动脉瘤形态特征的显示可达到与DSA相同的水平,且MRA和CTA因无创、经济、快捷方便应作为首选检查方法,尤其MRA无需注入对比剂,使得检查更安全.     

3D-CTA与DSA诊断颅内动脉瘤对比分析

目的：探讨三维CT血管成像（3D-CTA）与DSA（数字减影血管造影检查）检查诊断颅内动脉瘤的对比情况。方法：对32例动脉瘤患者经3D-CTA与DSA检查出的36个动脉瘤予以比较研究,评估出3D-CTA对颅内动脉瘤的诊断价值。结果：32例患者的36个动脉瘤,3D-CTA准确检出34个,DSA检出36个,两者检出率差异无统计学意义（P〉0.05）,但是在小动脉瘤的诊断上3D-CTA不及DSA,而3D-CTA在载瘤动脉的显示、瘤壁钙化及瘤周解剖标志等方面,明显优于DSA（P〈0.05）。结论：3D-CTA可以作为颅内动脉瘤诊断和治疗的首选。     

急性动脉瘤性蛛网膜下腔出血患者三维CT血管造影的临床意义

目的 评价三维CT血管造影(3D-CTA)在急性动脉瘤性蛛网膜下腔出血(SAH)患者诊治中的应用价值。方法 回顾性分析29例急性动脉瘤性蛛网膜下腔出血患者3D-CTA、数字减影血管造影(DSA)和手术资料。CTA图像采用遮盖容积重建(SVR)、最大密度投影(MIP)、彩色表面阴影显示法(SSD)和CT仿真内窥镜(VE)4种处理技术。所得图像分别由两位神经外科医生、两位放射科医生、两位介入科医生评价。结果 3D-CTA检出动脉瘤31个，显示瘤体、瘤颈、载瘤动脉和周围血管及颅骨的关系清晰、确切。DSA检出动脉瘤28个，漏检1个大脑前动脉瘤、1个前交通动脉瘤和1个后交通动脉瘤。CTA的检出率为100％，DSA的检出率为90％。两者检出率经χ^2检验无显著性差异(χ^2=1．61，P=0．42)。29例患者中，17例接受手术治疗，12例接受血管内栓塞治疗。3D-CTA测得瘤体最大直径19．7mm。最小直径1．2mm，与DSA测量结果比较，无显著性差异(t=1．52，P=0．33)。结论 对急性动脉瘤性蛛网膜下腔出血患者3D-CTA检出动脉瘤敏感性高、快速、无创，可以作为首选的影像学诊断方法。     

三维CT血管造影在颅内动脉瘤诊治中的临床应用

目的研究三维CT血管造影（3D-CTA）在诊断和治疗颅内动脉瘤过程中的可靠性。方法对240例CT检查怀疑为动脉瘤破裂出血的自发性蛛网膜下腔出血（SAH）患者行3D—CTA检查,发现颅内动脉瘤者直接进行显微手术,未发现动脉瘤者进行重复造影与数字减影血管造影技术（DSA）检查,并将CTA图像与术中所见及DSA图像进行对比。结果240例患者检出动脉瘤者227例,发现动脉瘤239个;首次检出率为94．6％（227／240）;8例重复CTA与DSA检查发现动脉瘤,5例两种检查均未发现动脉瘤;CTA诊断敏感度和特异度为100％,诊断符合率为100％[（235＋5）／240&#215;100％]。假阴性率和假阳性率均为0％（0／235）。术中所见动脉瘤的部位、数量、大小、瘤体指向、瘤体上有无穿支血管、与栽瘤动脉及周围骨性结构的关系均与CTA影像相一致。结论多层螺旋CT结合CTA可以替代DSA作为颅内动脉瘤的早期诊断可靠方法,CTA能为手术计划提供详实的影像学资料,对颅内动脉瘤的术后效果评价、随访复查以及流行病学调查具有重要价值。     

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.