Diagnostic Performance of CT Angiography in Patients Visiting Emergency Department with Overt Gastrointestinal Bleeding

Objective

To investigate the diagnostic performance of computed tomography angiography (CTA) in identifying the cause of bleeding and to determine the clinical features associated with a positive test result of CTA in patients visiting emergency department with overt gastrointestinal (GI) bleeding.

Materials and Methods

We included 111 consecutive patients (61 men and 50 women; mean age: 63.4 years; range: 28-89 years) who visited emergency department with overt GI bleeding. They underwent CTA as a first-line diagnostic modality from July through December 2010. Two radiologists retrospectively reviewed the CTA images and determined the presence of any definite or potential bleeding focus by consensus. An independent assessor determined the cause of bleeding based on other diagnostic studies and/or clinical follow-up. The diagnostic performance of CTA and clinical characteristics associated with positive CTA results were analyzed.

Results

To identify a definite or potential bleeding focus, the diagnostic yield of CTA was 61.3% (68 of 111). The overall sensitivity, specificity, positive predictive value (PPV), and negative predictive value were 84.8% (67 of 79), 96.9% (31 of 32), 98.5% (67 of 68), and 72.1% (31 of 43), respectively. Positive CTA results were associated with the presence of massive bleeding (p = 0.001, odds ratio: 11.506).

Conclusion

Computed tomography angiography as a first-line diagnostic modality in patients presenting with overt GI bleeding showed a fairly high accuracy. It could identify definite or potential bleeding focus with a moderate diagnostic yield and a high PPV. CTA is particularly useful in patients with massive bleeding.     

根据本底半自动化确定肿瘤内靶区:模型实验

目的根据本底标准化摄取值(SUV)计算肺肿瘤内靶区(ITV)SUV阈值,并评价其可行性。材料与方法 3个空心插件固定在圆桶底部,空心插件与圆桶分别充满55.06 k Bq/ml和5.37 k Bq/ml 18F-FDG溶液以模拟肿瘤与肺组织。以三维运动滑台驱动该模型模拟呼吸运动,最大位移10.9 mm、21.8 mm、43.7 mm。采集模型二维PET/CT图像。记肺本底SUV为±SD,以+3SD作为确定ITV的阈值,以真实ITV和测量ITV的Dice相似系数(DSC)和容积恢复系数(VRC)为评价指标,并与SUV2.5、35%SUVmax、41%SUVmax、a×m SUV70+b×、0.42×(SUVmax+)及Riegel等根据肿瘤体积、靶本底比及肿瘤运动幅度确定SUV阈值的方法进行比较,分析各方法的ITV、DSC和VRC。结果 3个肿瘤模型共9个ITV真实值分别为134.3 ml、166.1 ml、223.5 ml、86.6 ml、108.5 ml、150.7 ml、32.3 ml、43.8 ml、63.6 ml。采用Riegel等的方法测得ITV与真实值差异无统计学意义(t=-0.48,P>0.05)。其他6种SUV阈值法测量ITV与真实值差异有统计学意义(t=-5.11~2.76,P<0.05)。+3SD和Riegel等的方法制订的ITV的DSC和VRC分别为0.75~0.92、0.69~0.93和0.82~0.97、0.74~0.96,差异无统计学意义(t=-0.73,P>0.05),但大于其他5种方法所得值。结论根据本底确定的SUV阈值(+3SD)具有描绘肺癌ITV的潜力,可以为放射治疗提供ITV的参考范围。     

蕈样霉菌病临床病理观察

目的探讨蕈样霉菌病(MF)的临床及病理学特点。方法对2例蕈样霉菌病进行临床病理及免疫组化观察,并复习近期的相关文献。结果蕈样霉菌病组织学特征为真皮内具有脑回状细胞核的异型T淋巴细胞呈灶性、片状或弥漫性浸润,可累及皮下脂肪组织,可见亲表皮性及Pautrier微脓肿。免疫组化肿瘤细胞表达CD3、CD45RO、CD4。结论 MF是皮肤T细胞淋巴瘤,诊断主要依赖临床特点及病理组织学检查结果。     

Synthetic Mesh Improves Shoulder Function After Intraarticular Resection and Prosthetic Replacement of Proximal Humerus

BackgroundShoulder function often is limited after tumor resection and endoprosthetic replacement of the proximal humerus. This is partly attributable to the inability to reliably reattach rotator cuff tendons to the prosthesis and achieve adequate shoulder capsule repair with a metallic prosthesis. An option to attain these goals is to use synthetic mesh for the reconstruction, although the value of this method has not been well documented in the literature.Questions/purposesWe asked whether patients who had shoulder reconstruction using synthetic mesh had (1) better shoulder function; (2) improved ROM compared with shoulder reconstructions without mesh; and (3) more stable joints compared with those in patients with similar resections who had reconstructions without synthetic mesh.MethodsDuring a 5-year period, we performed 41 intraarticular resections with endoprosthetic reconstructions for malignancies in the proximal humerus meeting specified criteria to generate similarity in the study groups. Twelve patients (29%) were lost to followup before 24 months, leaving 29 patients available for review at a mean of 45 months (range, 24–70 months). This retrospective study compared 14 patients with soft tissue reconstruction that included synthetic mesh with 15 patients with soft tissue reconstruction without the use of synthetic mesh. The choice was made during consultation between the patient and surgeon, after reviewing the perceived advantages and disadvantages of each approach. A tumor band (ligament advanced reinforcement system) was used as synthetic mesh and wrapped around the prosthesis of the proximal humerus for soft tissue reconstruction in the reconstruction-with-mesh group. Study endpoints included the Musculoskeletal Tumor Society (MSTS) function scores, American Shoulder and Elbow Surgeons (ASES) score, shoulder ROM, and proximal migration of the humeral prosthesis.ResultsThe mean MSTS score for patients without synthetic mesh reconstruction was 20 ± 3 points (66%), whereas for patients with synthetic mesh reconstruction, the mean score was 24 ± 2 points (79%; p = 0.001). Patients with synthetic mesh reconstruction had a higher mean total ASES score (85 ± 1.1 points versus 72 ±1.7 points; p = 0.025), and better function for activities of daily living. They also had better ROM on mean active forward flexion (p = 0.020), abduction (p < 0.001), and external rotation (p < 0.001) than patients without synthetic mesh reconstruction. Proximal migration of the prosthesis was observed in five of 15 of patients in the group without synthetic mesh reconstruction and in none of those treated with synthetic mesh (p = 0.042).ConclusionsPatients with intraarticular resection and endoprosthetic replacement of the proximal humerus with reconstruction that included synthetic mesh had better shoulder function and ROM, and more stable joints than patients who had reconstruction without synthetic mesh. This result supports prior observations by others and it remains to be shown whether use of the ligament advanced reconstruction system is superior to other types of mesh or other types of reconstructions. Further investigation is needed but our results indicate that using mesh should be considered for patients with tumor resection and endoprosthetic replacement of the proximal humerus.

Level of Evidence

Level III, therapeutic study.     

儿童股骨远端骨肉瘤保留骨骺的定制肿瘤型假体重建术

 目的 介绍儿童股骨远端骨肉瘤保留骨骺的定制肿瘤型假体重建术,并探讨其工作原理、手术操作技巧、早期临床疗效以及并发症的防治。方法 2012年8月至2013年7月期间,应用肿瘤瘤段骨切除、保留骨骺的定制肿瘤型假体重建术治疗股骨远端骨肉瘤的儿童患者3例,均为男性,年龄8岁、9岁和15岁。术前给予新辅助化疗1~2周期,化疗结束后根据X线、CT 和MR等检查结果评价化疗疗效,对于化疗效果好且符合保留骨骺手术条件者采用此术式治疗。首先通过CT、MRI确定病变范围,根据影像学检查结果利用计算机辅助定制保留骨骺的肿瘤型假体以及模具,待假体定制完毕后行肿瘤瘤段骨切除、保留骨骺的定制肿瘤型假体重建术,术后指导患者进行功能锻炼,切口愈合1周后给予术后的规范化化疗,并进行长期随访。 结果 3例患者手术时间分别为3 h、4 h和6 h,术中出血量分别为300 ml、500 ml和2 200 ml。对3例患者术后随访时间 为12~24个月,根据美国骨肿瘤学会评分系统（Musculoskeletal Tumor Society,MSTS）,术后3个月功能评分分别为24分、26分和13分,短期随访显示患者肢体功能良好。1例患者出现假体感染,经保守治疗（抗炎补液、切口换药等）无效后行大腿截肢术,余2例患者未出现假体松动等其他并发症。2例患者双下肢长度相差均< 2 cm。结论 通过严格掌握保留骨骺保肢手术的适应证,配合术前及术后的新辅助化疗,保留骨骺的定制肿瘤型假体重建术为儿童股骨远端骨肉瘤的保肢治疗提供了新的选择方案,其疗效安全、可靠,且具有手术操作简单、手术时间短、术后恢复快等优点,但长期疗效尚需进一步观察。