诊断超声激励微泡对增强临床乳腺癌血流灌注的研究

目的 观察并探讨诊断超声激励超声造影剂微泡对浸润性乳腺癌病灶血流灌注的增强效应。方法 5例经病理证实的浸润性乳腺癌患者,在每次新辅助化疗结束后1h内对病灶进行诊断超声激励造影剂微泡治疗。治疗前后实施常规超声造影动态观察其血流灌注情况,应用时间-强度曲线分析软件分析并获取峰值强度(Peak Intensity, PI)、曲线下面积(Area Under Curve, AUC)及曲线上升斜率(Ascending Slope, AS)。结果 诊断超声激励微泡治疗后乳腺癌病灶的PI、AS及AUC均有所提高,治疗前后PI及AS比较差异均有统计学意义(Z=-2.13,-2.09；P=0.03,0.03),但治疗前后AUC比较差异无统计学意义(t=-1.15；P=0.28)。结论 诊断超声激励造影剂微泡能够增加新辅助化疗乳腺癌病灶的血流灌注量,加快血流灌注速度。     

Chest ultrasonography for the emergency diagnosis of traumatic pneumothorax and haemothorax: A systematic review and meta-analysis

ObjectiveTo assess the accuracy of the chest ultrasonography for the emergency diagnosis of traumatic pneumothorax and haemothorax in adults.Study designSystematic review and meta-analysis.MethodsPubMed, EMBASE, Scopus, Web of Science and LILACS (up to 2016) were systematically searched for prospective studies on the diagnostic accuracy of ultrasonography for pneumothorax and haemothorax in adult trauma patients. The references of other systematic reviews and the included studies were checked for further articles. The characteristics and results of the studies were extracted using a standardised form, and their methodological quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2). Primary analysis was performed considering each hemithorax as an independent unit, while secondary analysis considered each patient. The global diagnostic accuracy of the chest ultrasonography was estimated using the Rutter–Gatsonis hierarchical summary ROC method. Moreover, Reitsma’s bivariate model was used to estimate the sensitivity, specificity, positive likelihood ratio (LR + ) and negative likelihood ratio (LR–) of each sonographic sign. This review was previously registered (PROSPERO CRD42016048085).ResultsNineteen studies were included in the review, 17 assessing pneumothorax and 5 assessing haemothorax. The reference standard was always chest tomography, alone or in parallel with chest radiography and observation of the chest tube. The overall methodological quality of the studies was low. The diagnostic accuracy of chest ultrasonography had an area under the curve (AUC) of 0.979 for pneumothorax (Fig). The absence of lung sliding and comet-tail artefacts was the most reported sonographic sign of pneumothorax, with a sensitivity of 0.81 (95% confidence interval [95%CI], 0.71–0.88), specificity of 0.98 (95%CI, 0.97–0.99), LR+ of 67.9 (95%CI, 26.3–148) and LR– of 0.18 (95%CI, 0.11–0.29). An echo-poor or anechoic area in the pleural space was the only sonographic sign for haemothorax, with a sensitivity of 0.60 (95%CI, 0.31–0.86), specificity of 0.98 (95%CI, 0.94–0.99), LR+ of 37.5 (95%CI, 5.26–207.5), LR– of 0.40 (95%CI, 0.17–0.72) and AUC of 0.953.ConclusionNotwithstanding the limitations of the included studies, this systematic review and meta-analysis suggested that chest ultrasonography is an accurate tool for the diagnostic assessment of traumatic pneumothorax and haemothorax in adults.     

Anna Freud: A New Look at Development

This paper is a summary of Anna Freud's important contribution to our understanding of child development and its deviations. It highlights her concern for the whole child, both his internal and external world and their mutual interactions. An example is given of changes in the law with regard to children in which her views were influential. Vignettes are given showing the evolution of her thinking regarding treatment techniques in the light of the widening range of developmental disturbances and presenting problems.     

A Longitudinal Study of the Yield and Clinical Utility of a Specifically Designed Secondary Hypertension Investigation Protocol

Objective.?It has become common practice to use a day-case based approach to identify from the population of hypertensive patients those with an identifiable cause. We aimed to prospectively identify 96 consecutive hypertensive patients undergoing an algorithmic investigation protocol based around two day case hospital attendances. Methods.?The overall diagnostic yield and associated costs were recorded and the patients were observed for a mean of 2.5 years with ambulatory blood pressure (BP) monitoring every three months. Results.?A secondary cause of hypertension was identified in 18.1% of patients, three quarters of whom had renovascular disease. There was a fall in blood pressure with time (157/97 vs. 140/85) but this was associated with an increase in the amount of medication required (mean medication score 5.99 vs. 7.65). Improvement in BP occurred irrespective of whether or not a secondary cause was identified. Only 3.2% of patients were cured of their hypertension as a result of enrollment in the protocol. The cost of identifying each case of secondary hypertension was Euro 10, 196. Conclusions.?A comprehensive protocol aimed at identifying secondary hypertension had a low yield, the majority of whom had renovascular disease. In light of recent data illustrating the lack of improvement in BP following dilatation or bypass of atherosclerotic renovascular disease, it is debatable whether searching for it is justifiable.     

Pulmonary Ultrasound and Diaphragmatic Shortening Fraction Combined Analysis for Extubation-Failure-Prediction in Critical Care Patients

Introduction

Invasive respiratory support is a cornerstone of Critical Care Medicine, however, protocols for withdrawal of mechanical ventilation are still far from perfect. Failure to extubation occurs in up to 20% of patients, despite a successful spontaneous breathing trial (SBT).

Accessibility of Medical Diagnostic Equipment for Patients With Disability: Observations From Physicians

ObjectiveTo explore attitudes and practices of physicians relating to accessible medical diagnostic equipment in serving patients with mobility disability.DesignOpen-ended individual telephone interviews, which reached data saturation. Interview recordings were transcribed verbatim for qualitative conventional content analysis.SettingMassachusetts, the United States, October 2017-January 2018.ParticipantsPracticing physicians from 5 clinical specialties (N=20).InterventionsNot applicable.Main Outcome MeasuresCommon themes concerning physical accessibility.ResultsMean ± SD time in practice was 27.5±12.5 years; 14 practices had height-adjustable examination tables; and 7 had wheelchair-accessible weight scales. The analysis identified 6 broad themes: height-adjustable examination tables have advantages; height-adjustable examination tables have drawbacks; transferring patients onto examination tables is challenging; rationale for examining patients in their wheelchairs; perceptions of wheelchair-accessible weight scales; and barriers and facilitators to improving physical accessibility. Major barriers identified by participants included costs of equipment, limited space, and inadequate payment for extra time required to care for persons with disability. Even physicians with accessible examination tables sometimes examined patients seated in their wheelchairs.ConclusionsEven if physicians have accessible equipment, they do not always use it in examining patients with disability. Future efforts will need to consider ways to eliminate these access barriers in clinical practice. Given small sample size, results are not generalizable to physicians nationwide and globally.