膀胱炎性肌纤维母细胞瘤1例

患者女,62岁,因"间歇性、无痛性肉眼血尿10天"入院.超声检查:膀胱内见实质不均匀性回声团块,大小约4.6 cm× 5.0 cm,边界清晰,内部及周边见彩色血流信号,提示膀胱占位性病变,肌纤维母细胞瘤可能.CT:膀胱内见不规则软组织密度影(图1),大小约4.5 cm×4.0 cm,平扫30 HU,增强后不均匀强化(图2),动脉期58 HU,延迟期73 HU,静脉期71 HU,提示膀胱占位.     

膀胱原发性B细胞恶性淋巴瘤1例

患者女,80岁,因"排尿不畅伴下腹部酸胀不适2月余"就诊.患者自发病以来无尿频、尿急、尿痛,无明显肉眼血尿,无肾区叩击痛.实验室检查:潜血(++++).CT:膀胱前壁见一类圆形软组织密度影,边缘光整,大小约3.0 cm×4.0 cm×2.5 cm,密度均匀(图1),增强后呈明显均匀性强化(图2),后腹膜、盆腔及腹股沟未见明显肿大淋巴结,考虑膀胱占位.     

多发性内分泌腺瘤综合征-Ⅳ型1例

病例男,24岁.体检时发现胰腺及双肾上腺肿块1周入院.既往十二指肠球部溃疡史4年余,发病时饥饿痛明显,偶有心慌、出汗.查体:双肾区未触及明显包块,无叩击痛,血压162～120/96～75mmHg.实验室检查:CEA 5.32ng/mL,空腹血糖5.68mmol/L,尿香草苦杏仁酸14.3mg/24h.CT示胰头部类圆形稍低密度肿物,大小约2.7cm×2.4cm,CT值为35HU,边界较清,突出于胰腺边缘,增强早期明显均匀强化,程度与主动脉类似,而后强化程度逐渐减低,延迟期仍稍高于周围胰腺实质(图1,2);双肾上腺椭圆形稍低密度肿物,右侧大小约6.7cm×4.4cm,左侧约3.0cm×2.8cm,二者内部均可见液性密度区,边界欠清,皮质期实性成分明显强化,周围似有包膜,中心液化区未见强化(图3,4).     

脐尿管癌1例

病例男,53岁.间断血尿1个月,近10d全程无痛血尿.查体:全腹未触及明显包块.B超:膀胱顶部占位性病变.CT扫描:平扫示膀胱右前壁见大小约2.5cm×2.5cm×3.5cm类圆形囊实性肿块,边界清楚.其内密度欠均匀,CT值为21～29HU,病灶周边见弧形带状高密度钙化灶,增强后,病变未见明显强化.CT诊断:膀胱前壁占位性病变,多考虑为膀胱肿瘤,不除外脐尿管癌.     

脾硬化性血管瘤样结节性转化一例

正患者女,51岁。因"发现脾脏占位1个月余"入院。查体:全身浅表淋巴结未触及肿大,心肺未见阳性体征,腹平软,无异常发现。实验室检查未见明显异常。CT平扫示脾脏内见一类圆形稍低密度灶,CT值约47 HU,边界欠清(图1);MRI示脾脏内见一类圆形占位,其大小约6.3 cm×5.6 cm×6.3 cm,T1WI呈稍低信     

成人前列腺胚胎性横纹肌肉瘤并肺转移1例

患者男,36岁,主诉右大腿内侧痛伴会阴部下坠感20余天.肛门直肠指诊:前列腺Ⅲ度增大,质韧,中央沟消失,活动度差,精囊腺未触及,直肠内未及肿物,指套退出时无血迹.影像学检查:盆腔CT平扫示前列腺区类圆形软组织密度肿块,最大径9 cm,密度不均,内见片状低密度区;膀胱受压变形,后壁增厚,与肿块界限不清;后缘与精囊腺、直肠相连,右侧闭孔内肌肿胀,右耻骨局限性溶骨性骨质破坏(图1).诊断:前列腺恶性肿瘤性病变:①前列腺肉瘤;②前列腺癌.胸部CT平扫示:双肺见分布于肺外围的多个大小不等的结节影(图2),诊断:肺转移瘤.腹部B超检查:前列腺体积增大,大小为8.1 cm×7.8 cm×8.0 cm,形态不规则,内部回声不均.印象:符合前列腺恶性肿瘤声像图改变.经直肠超声诊断:前列腺周围腺实性占位病变.核素显像:右髋关节局部骨代谢活跃.骨盆X线片显示:右耻骨溶骨性破坏并病理性骨折.MR检查:前列腺实性占位性病变.考虑:①前列腺癌?②前列腺肉瘤?并精囊腺、膀胱后壁、直肠前壁、阴茎海绵体、球海绵体受侵,髂骨、腰5椎体转移.穿刺病理诊断"前列腺胚胎性横纹肌肉瘤".     

原发性肾腺泡状软组织肉瘤1例

患者男,33岁,体检发现左肾占位1周;既往体健.入院查体及实验室检查均未见明显异常.腹部 CT:左肾下极见5.5 cm×6.0 cm×5.5 cm类圆形软组织密度肿块,边界清,密度不均,内见多发钙质影(图1A ) ,增强后呈明显不均匀强化,"快进快出"强化方式(图1B、1C );诊断:左肾占位性病变,考虑肾癌可能性大....     

直肠黑色素瘤1例

患者男,30岁,因"便血1个月"入院.结肠镜检查发现距肛缘约5 cm处直肠前壁有一包块,活检病理诊断直肠黏膜慢性炎症,局部淋巴滤泡增生.CT:直肠前壁见6.50 cm×4.50 cm×4.00 cm软组织肿块,边界清楚,束腰状,肿块跨肠壁向腔内外生长,平扫CT值45 HU,增强后动脉期和静脉期CT值分别为83 HU、78 HU,呈均匀中度强化,邻近右侧精囊腺、膀胱受压移位,直肠腔受压局部扩张,直肠周围脂肪间隙清晰,未见明显肿大淋巴结(图1、2).术中见肿瘤位于腹膜折返处以下直肠前壁,质硬,边界清楚,包膜完整而韧.术后病理诊断:恶性黑色素瘤(图3).免疫组化:HMB45(+)、MelaA(+)、CD10弱(+)、CK20弱(+)、S100(+)、Vim (+).     

B超诊断精囊腺囊肿伴结石1例

患者男,38岁.因小腹不适就诊.超声检查:膀胱充盈一般,于膀胱右后方见一大小约54 mm×16 mm的长梭形液性暗区,边界清楚,其一端为盲端,另一端开口于前列腺尿道,后壁见一直径约12 mm的强回声团伴声影,强回声团可随体位移动(图1).左侧精囊腺未见异常.超声诊断:右侧精囊腺囊肿伴结石.后经手术证实.     

盆腔平滑肌瘤误诊为精囊腺肿瘤1例的超声所见

患者男 ,4 1岁。无痛肉眼血尿 5天来诊 ,无尿路刺激征 ,无血精。查体无阳性体征。尿常规 :RBC2 0～ 30个 /HP。曾在外院抗炎止血治疗 ,症状略缓解。经腹彩超见 :膀胱左后方、左侧精囊腺区域未见正常精囊腺回声 ,可见一大小约为 6 .0 cm× 5 .5 cm的圆形低回声团块 ,边界清晰 ,似有包膜 ,团块内部回声欠均匀 ,CDFI及 CDE示其内有点状、条状血流信号 ,可引出动脉频谱 ,峰值流速为 35 cm/s,RI为 0 .89。膀胱壁受压向前呈弧形 ,局部黏膜不光整 (图 1)。右侧精囊腺及前列腺未见异常。彩超初步诊断 :左侧精囊腺区实性占位性病变 (精囊腺肿瘤…     

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.