Volume 128 · Issue 05 · 2015

磁共振成像（MRI）在临床应用和实验研究中都被用作一种有前途的方法。MRI表现出研究各种组织和器官的解剖、代谢、灌注、功能和分子特征的卓越能力，而没有辐射损伤或侵入性；因此，它已被用于各种疾病的检测、诊断、分期、分级和治疗。

为实现全民医疗保险覆盖，中国已启动了三个阶段的医疗体系改革。第一轮改革始于20世纪80年代中期，引入了市场激励措施。第二轮始于1997年，推出了城市雇员基本医疗保险计划，该计划除了为政府工作人员提供长期/历史计划外，还向所有城市工作人员提供医疗保险。政府和UBMI计划都仅限于个人注册；然而，配偶或子女等家属不在承保范围内。第三阶段改革始于2003年新型农村合作医疗制度（NRCMS）的启动。这一制度覆盖了家庭一级的农村居民。2007年，城镇居民基本医疗保险（URBMI）计划出台，进一步将保险覆盖范围扩大到失业的城镇居民。^[1]UBMI、URBMI和NRCM被认为是基本医疗保险（BMI），所有计划都需要支付参保费。

Mild hypoxic-ischemic encephalopathy (HIE) injury is becoming the major type in neonatal brain diseases. The aim of this study was to assess brain maturation in mild HIE neonatal brains using total maturation score (TMS) based on conventional magnetic resonance imaging (MRI).

Totally, 45 neonates with clinically mild HIE and 45 matched control neonates were enrolled. Gestated age, birth weight, age after birth and postmenstrual age at magnetic resonance (MR) scan were homogenous in the two groups. According to MR findings, mild HIE neonates were divided into three subgroups: Pattern I, neonates with normal MR appearance; Pattern II, preterm neonates with abnormal MR appearance; Pattern III, full-term neonates with abnormal MR appearance. TMS and its parameters, progressive myelination (M), cortical infolding (C), involution of germinal matrix tissue (G), and glial cell migration bands (B), were employed to assess brain maturation and compare difference between HIE and control groups.

The mean of TMS was significantly lower in mild HIE group than it in the control group (mean ± standard deviation [SD] 11.62 ± 1.53 vs. 12.36 ± 1.26, P < 0.001). In four parameters of TMS scores, the M and C scores were significantly lower in mild HIE group. Of the three patterns of mild HIE, Pattern I (10 cases) showed no significant difference of TMS compared with control neonates, while Pattern II (22 cases), III (13 cases) all had significantly decreased TMS than control neonates (mean ± SD 10.56 ± 0.93 vs. 11.48 ± 0.55, P < 0.05; 12.59 ± 1.28 vs. 13.25 ± 1.29, P < 0.05). It was M, C, and GM scores that significantly decreased in Pattern II, while for Pattern III, only C score significantly decreased.

The TMS system, based on conventional MRI, is an effective method to detect delayed brain maturation in clinically mild HIE. The conventional MRI can reveal the different retardations in subtle structures and development processes among the different patterns of mild HIE.

A comprehensive assessment of various vascular anomalies and variants associated with venous pulsatile tinnitus (PT) by radiography is essential for therapeutic planning and improving the clinical outcome. This study evaluated the incidence of various vascular anomalies and variants on the PT side and determined whether these lesions occurred as multiple or single entities.

The dual-phase contrast-enhanced computed tomography images of 242 patients with unilateral venous PT were retrospectively reviewed. The vascular anomalies and variants on the symptomatic and asymptomatic sides were analyzed, and the incidences of anomalies or variants on each side were compared. The number of anomalies and variants on the symptomatic side in each patient was calculated.

(1) A total 170 patients (170/242) had more than one anomaly or variant on the symptomatic side, and 58 patients (58/242) had a single lesion on tomography. (2) There was a statistically significant difference in the incidence of dehiscent sigmoid plate (P = 0.000), lateral sinus stenosis (P = 0.014), high jugular bulb (P = 0.000), sigmoid sinus diverticulum (P = 0.000), jugular bulb diverticulum (P = 0.000), dehiscent jugular bulb (P = 0.000), and a large emissary vein (P = 0.006) between the symptomatic and asymptomatic sides. (3) Dehiscent sigmoid plate (86.4%) was the most frequent lesion on the symptomatic side, followed by lateral sinus stenosis (55.8%), high jugular bulb (47.1%), sigmoid sinus diverticulum (34.3%), jugular bulb diverticulum (13.6%), dehiscent jugular bulb (13.6%), large emissary vein (4.1%), sinus thrombosis (1.2%), and petrosquamosal sinus (0.8%).

Various vascular anomalies and variants occur more frequently on the venous PT side. Preliminary findings suggest that venous PT patients may have multiple vascular anomalies or variants on the symptomatic side.

Differentiating benign from malignant sinonsal lesions is essential for treatment planning as well as determining the patient’s prognosis, but the differentiation is often difficult in clinical practice. The study aimed to determine whether the combination of diffusion-weighted (DW) and dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) can improve the performance in differentiating benign from malignant sinonasal tumors.

This retrospective study included 197 consecutive patients with sinonasal tumors (116 malignant tumors and 81 benign tumors). All patients underwent both DW and DCE-MRI in a 3-T magnetic resonance scanner. Two different settings of b values (0,700 and 0,1000 s/mm²) and two different strategies of region of interest (ROI) including whole slice (WS) and partial slice (PS) were used to calculate apparent diffusion coefficients (ADCs). A DW parameter with WS ADCs_b0,1000 and two DCE-MRI parameters (time intensity curve [TIC] and time to peak enhancement [Tpeak]) were finally combined to use in differentiating the benign from the malignant tumors in this study.

The mean ADCs of malignant sinonasal tumors (WS ADCs_b0,1000 = 1.084 × 10⁻³ mm²/s) were significantly lower than those of benign tumors (WS ADCs_b0,1000 = 1.617 × 10⁻³ mm²/s, P < 0.001). The accuracy using WS ADCs_b0,1000 alone was 83.7% in differentiating the benign from the malignant tumors (85.3% sensitivity, 81.2% specificity, 86.4% positive predictive value [PPV], and 79.5% negative predictive value [NPV]). The accuracy using DCE with Tpeak and TIC alone was 72.1% (69.1% sensitivity, 74.1% specificity, 77.5% PPV, and 65.1% NPV). Using DW-MRI parameter was superior than using DCE parameters in differentiation between benign and malignant sinonasal tumors (P < 0.001). The accuracy was 87.3% (90.5% sensitivity, 82.7% specificity, 88.2% PPV, and 85.9% NPV) using DW-MRI combined with DCE-MRI, which was superior than that using DCE-MRI alone or using DW-MRI alone (both P < 0.001) in differentiating the benign from the malignant tumors.

Diffusion-weighted combined with DCE-MRI can improve imaging performance in differentiating benign from malignant sinonasal tumors, which has the potential to improve diagnostic accuracy and to provide added value in the management for these tumors.

Neuroimaging studies have found that functional changes exist in patients with Parkinson’s disease (PD). However, the majority of functional magnetic resonance imaging (fMRI) studies in patients with PD are task-related and cross-sectional. This study investigated the functional changes observed in patients with PD, at both baseline and after 2 years, using resting-state fMRI. It further investigated the relationship between whole-brain spontaneous neural activity of patients with PD and their clinical characteristics.

Seventeen patients with PD underwent an MRI procedure at both baseline and after 2 years using resting-state fMRI that was derived from the same 3T MRI. In addition, 20 age- and sex-matched, healthy controls were examined using resting-state fMRI. The fractional amplitude of low-frequency fluctuation (fALFF) approach was used to analyze the fMRI data. Nonlinear registration was used to model within-subject changes over the scanning interval, as well as changes between the patients with PD and the healthy controls. A correlative analysis between the fALFF values and clinical characteristics was performed in the regions showing fALFF differences.

Compared to the control subjects, the patients with PD showed increased fALFF values in the left inferior temporal gyrus, right inferior parietal lobule (IPL) and right middle frontal gyrus. Compared to the baseline in the 2 years follow-up, the patients with PD presented with increased fALFF values in the right middle temporal gyrus and right middle occipital gyrus while also having decreased fALFF values in the right cerebellum, right thalamus, right striatum, left superior parietal lobule, left IPL, left precentral gyrus, and left postcentral gyrus (P < 0.01, after correction with AlphaSim). In addition, the fALFF values in the right cerebellum were positively correlated with the Unified PD Rating Scale (UPDRS) motor scores (r = 0.51, P < 0.05, uncorrected) and the change in the UPDRS motor score (r = 0.61, P < 0.05, uncorrected).

The baseline and longitudinal changes of the fALFF values in our study suggest that dysfunction in the brain may affect the regions related to cortico-striato-pallido-thalamic loops and cerebello-thalamo-cortical loops as the disease progresses and that alterations to the spontaneous neural activity of the cerebellum may also play an important role in the disease’s progression in patients with PD.

Previous studies have indicated that the cognitive deficits in patients with Alzheimer’s disease (AD) may be due to topological deteriorations of the brain network. However, whether the selection of a specific frequency band could impact the topological properties is still not clear. Our hypothesis is that the topological properties of AD patients are also frequency-specific.

Resting state functional magnetic resonance imaging data from 10 right-handed moderate AD patients (mean age: 64.3 years; mean mini mental state examination [MMSE]: 18.0) and 10 age and gender-matched healthy controls (mean age: 63.6 years; mean MMSE: 28.2) were enrolled in this study. The global efficiency, the clustering coefficient (CC), the characteristic path length (CpL), and "small-world" property were calculated in a wide range of thresholds and averaged within each group, at three different frequency bands (0.01–0.06 Hz, 0.06–0.11 Hz, and 0.11–0.25 Hz).

At lower-frequency bands (0.01–0.06 Hz, 0.06–0.11 Hz), the global efficiency, the CC and the "small-world" properties of AD patients decreased compared to controls. While at higher-frequency bands (0.11–0.25 Hz), the CpL was much longer, and the "small-world" property was disrupted in AD, particularly at a higher threshold. The topological properties changed with different frequency bands, suggesting the existence of disrupted global and local functional organization associated with AD.

This study demonstrates that the topological alterations of large-scale functional brain networks in AD patients are frequency dependent, thus providing fundamental support for optimal frequency selection in future related research.

The objective was to qualitatively and quantitatively evaluate hepatic metastases using computed tomography (CT) virtual noncontrast (VNC) spectral imaging in a retrospective analysis.

Forty hepatic metastases patients underwent CT scans including the conventional true noncontrast (TNC) and the tri-phasic contrast-enhanced dual energy spectral scans in the hepatic arterial, portal venous, and equilibrium phases. The tri-phasic spectral CT images were used to obtain three groups of VNC images including in the arterial (VNCa), venous (VNCv), and equilibrium (VNCe) phase by the material decomposition process using water and iodine as a base material pair. The image quality and the contrast-to-noise ratio (CNR) of metastasis of the four groups were compared with ANOVA analysis. The metastasis detection rates with the four nonenhanced image groups were calculated and compared using the Chi-square test.

There were no significant differences in image quality among TNC, VNCa and VNCv images (P > 0.05). The quality of VNCe images was significantly worse than that of other three groups (P < 0.05). The mean CNR of metastasis in the TNC and VNCs images was 1.86, 2.42, 1.92, and 1.94, respectively; the mean CNR of metastasis in VNCa images was significantly higher than that in other three groups (P < 0.05), while no statistically significant difference was observed among VNCv, VNCe and TNC images (P > 0.05). The metastasis detection rate of the four nonenhanced groups with no statistically significant difference (P > 0.05).

The quality of VNCa and VNCv images is identical to that of TNC images, and the metastasis detection rate in VNC images is similar to that in TNC images. VNC images obtained from arterial phase show metastases more clearly. Thus, VNCa imaging may be a surrogate to TNC imaging in hepatic metastasis diagnosis.

Amide proton transfer (APT) imaging has recently emerged as an important contrast mechanism for magnetic resonance imaging (MRI) in the field of molecular and cellular imaging. The aim of this study was to evaluate the feasibility of APT imaging to detect cerebral abnormality in patients with Alzheimer’s disease (AD) at 3.0 Tesla.

Twenty AD patients (9 men and 11 women; age range, 67–83 years) and 20 age-matched normal controls (11 men and 9 women; age range, 63–82 years) underwent APT and traditional MRI examination on a 3.0 Tesla MRI system. The magnetic resonance ratio asymmetry (MTR_asym) values at 3.5 ppm of bilateral hippocampi (Hc), temporal white matter regions, occipital white matter regions, and cerebral peduncles were measured on oblique axial APT images. MTR_asym (3.5 ppm) values of the cerebral structures between AD patients and control subjects were compared with independent samples t-test. Controlling for age, partial correlation analysis was used to investigate the associations between mini-mental state examination (MMSE) and the various MRI measures among AD patients.

Compared with normal controls, MTR_asym (3.5 ppm) values of bilateral Hc were significantly increased in AD patients (right 1.24% ± 0.21% vs. 0.83% ± 0.19%, left 1.18% ± 0.18% vs. 0.80%± 0.17%, t= 3.039, 3.328, P = 0.004, 0.002, respectively). MTR_asym (3.5 ppm) values of bilateral Hc were significantly negatively correlated with MMSE (right r = −0.559, P = 0.013; left r = −0.461, P = 0.047).

Increased MTR_asym (3.5 ppm) values of bilateral Hc in AD patients and its strong correlations with MMSE suggest that APT imaging could potentially provide imaging biomarkers for the noninvasive molecular diagnosis of AD.

To compare the diagnostic values of magnetic resonance elastography (MRE) and diffusion-weighted imaging (DWI) in staging hepatic fibrosis (HF) in an animal model.

This study consisted of 44 rabbits served as HF group and 9 normal rabbits. HF group was divided into two subgroups: Group A (n = 32) and Group B (n = 12). Rabbits in Group B were served as a complementary group when rabbits in Group A suddenly died during the study. Rabbits from control and Group A underwent abdominal MR imaging (MRI), MRE, and DWI. In Group A, random eight rabbits underwent MRI examinations at 4, 5, 6, 10 weeks after carbon tetrachloride oil subcutaneous injection. Liver stiffness (LS) and apparent diffusion coefficient (ADC) values of liver parenchyma were measured. The diagnostic performance of MRE and DWI for staging HF was compared using the receiver operating characteristic curve analysis on the basis of the histopathological analysis of HF.

Significant differences of LS and DWI values were present among HF stages (P < 0.005). The LS values measured on MRE (r = 0.838, P < 0.001) were more strongly correlated with the HF stages than with ADC values (r = −0.527, P < 0.001). The area under the receiver operating characteristic curve values of LS were significantly larger than those of DWI were for discriminating two stages of HF (0.979 vs. 0.712 for ≥ S1, 0.922 vs. 0.699 for ≥ S2). MRE showed higher specificity for predicting all stages of HF compared to DWI.

MRE more strongly correlated with the HF stages than DWI and is more specific in predicting all HF stages.

Diffusion weighted imaging (DWI), with the applying of intravoxel incoherent motion model, has showed promising results in obtaining additional information about microperfusion and tubular flow associated with morphologic changes in chronic kidney diseases. The study aims to evaluate the potential of T2-weighted signal intensity (SI) and DWI with mono- and bi-exponential models to reflect the serial changes on cisplatin (CP) induced rat renal fibrosis models.

Magnetic resonance exams were performed prior to and 2^nd day, 4^th day, 6^th day, 8^th day, 2^nd week, 3^rd week and 4^th week after CP injection at a 3.0T with an animal coil. Besides T2-weighted images (T2WI), DWI of 13 b values from 0 to 1500 s/mm² was acquired. Apparent diffusion coefficient (ADC), fluid fraction f, pure diffusivity D and pseudodiffusivity D* values were calculated. The regions of interest were placed on cortex (CO), outer stripe of the outer medulla (OM) and inner stripe of the outer medulla (OM), parameters were measured and compared among different time points. Five rats were scarified at each time point for pathological examination.

OM revealed remarkable hyperintense and broadened before it became an obscure thread, while CO demonstrated moderate hyperintense and IM didn’t show significant change on T2WI. On all three stripes, ADC values decreased firstly then kept increasing since the 4^th day; f values decreased on all stripes; D values had a tendency to increase with fluctuations but the changes didn’t achieve statistical significance; D* values increased at the 2^nd day then tended to be steady thereafter. Pathological findings revealed tubules epitheliums swelling followed by inflammation cells infiltration, interstitial fibrosis was observed since the 2^nd week.

All of T2-weighted SI, ADC, and biexponential models parameters vary during fibrotic process; biexponential model is superior to monoexponential model in separating changes of microperfusion together with tubular flow from pure diffusion.

China has achieved universal health insurance coverage. This study examined how patients and hospitals react to the different designs of the plans and to monitoring of patients by the local authority in the Chinese multiple health security schemes.

The sample for analysis consisted of 1006 orthopedic inpatients who were admitted between January and December 2011 at a tertiary teaching hospital located in Beijing. We conducted general linear regression analyses to investigate whether medical expenditure and length of stay differed according to the different incentives.

Patients under plans with lower copayment rates consumed significantly more medication compared with those under plans with higher copayment rates. Under plans with an annual ceiling for insurance coverage, patients spent significantly more in the second half of the year than in the first half of the year. The length of stay was shorter among patients when there were government monitoring and a penalty to the hospital service provider.

Our results indicate that the different designs and monitoring of the health security systems in China cause opportunistic behavior by patients and providers. Reformation is necessary to reduce those incentives, and improve equity and efficiency in healthcare use.

抑郁症是最普遍的精神疾病之一，对患者的生产力、生活质量和认知功能有显著的负面影响。^[1]根据世界卫生组织最近的一项调查，据估计，抑郁症目前在残疾调整生命年方面排名第三，到2030年将成为疾病和伤害负担的主要原因，超过癌症以及心血管和呼吸系统疾病。^[2]这种令人不安的情况引起了国际精神病学领域的关注，挑战着世界各地的研究人员调查抑郁症的预防和控制，并确定支持这项研究的必要资金。鉴于生物医学的广阔和跨学科性质，没有一个研究人员或机构能够跟上抑郁症研究的所有发展。因此，科学合作对于生物医学的进步变得不可或缺，因为它加强了交流，鼓励了能力共享，并促进了新科学知识的发现。尽管如此，迄今为止很少有关于抑郁症研究领域合作研究的科学出版物。因此，本文旨在衡量三个层面的科学合作——作者、机构和国家。通过检查科学合作，本文还确定了抑郁症研究中的热门话题，这些话题代表了许多研究人员认为具有预防和治疗这种普遍疾病的巨大潜力的重点领域。

尽管术后并发症的发生率较高，但脾切除术是脾占位性病变的常用手术。回顾性分析2796例脾切除术患者，119例（4.25%）发生术后细菌感染，71例（60%）死于感染。^[1]因此，已经提出了对保存脾功能的重视，即必须保留至少25%的脾重量以维持脾免疫功能，前提是充足的动脉血供应。继80年代首次施行脾部分切除术后，90年代文献报道了首例腹腔镜脾部分切除术。^[2]腹腔镜脾部分切除术目前已成为许多脾脏疾病的常见选择。然而，专门针对出血风险高的实体血管瘤的腹腔镜脾部分切除术在文献中并不常见。本研究回顾了6例腹腔镜脾部分切除术治疗脾血管瘤的病例，以评估该手术是否可行和安全。

马蹄肾是胚胎发生过程中由下极异常引起的一种肾融合。由于基因突变导致多囊蛋白1(ADPKD1)和多囊蛋白2(ADPKD2)表达，发生在成人中的多囊肾是一种常染色体显性疾病。这两种肾脏疾病分别是常见的先天性疾病，但一名患者同时患有这两种异常非常罕见，发病率为1/134,000-1/8,000,000。^[1,2]

致编者：2013年8月，一名22岁女性被转诊至精神病院，有6个月的失眠、自杀念头、社交退缩、易怒和被害妄想史。她被诊断为精神分裂症，并开始服用利培酮和氯丙嗪，由于精神状态没有任何改善，1周后突然停用。2天后出现反复发作的全身性强直阵挛发作，在昏迷状态下转入我院。她被紧急插管并开始服用苯巴比妥和丙戊酸。根据家庭，患者还有6个月的头晕、疲劳和月经量少的病史。疑似库欣综合征，但血清皮质醇在800 h为534.6 nmol/L，1600 h为445.5 nmol/L，2400 h为382.7 nmol/L（正常范围：85.3-618.0 nmol/L）；促肾上腺皮质激素在800 h为5.1 ng/L，1600 h≤5 ng/L，2400 h≤5 ng/L（正常范围：0-46.0 ng/L）；24小时尿17-羟基类固醇为15.7µmol（正常范围：5.5-22.2µmol/天）。

致编者：抗结核(TB)治疗可引起各种药物不良反应，包括肝毒性、肾毒性和皮疹。^[1,2]异烟肼（INH）、利福平（RFP）、乙胺丁醇（EMB）等引起的间质性肺病（ILD）已有一些病例报道。^[3,4]永久停用致病药物或在脱敏治疗后重新给药。但短期抗结核药物诱导的肺纤维化非常罕见。我们在此报告了一例可能由INH引起的肺纤维化病例，该病例在抗结核治疗3周后发生。

致编辑：我们报告了一例主动脉手术后30年发生的无症状吻合口假性动脉瘤的治疗策略。

编者按：Mikulicz病（MD）又称良性淋巴上皮病变，是指泪腺、腮腺和颌下腺的特发性、双侧、无痛性、对称性肿胀。MD的并发症包括自身免疫性胰腺炎、腹膜后纤维化、肾小管间质性肾炎、自身免疫性垂体炎和Riedel甲状腺炎，所有这些都显示血清免疫球蛋白G4（IgG4）水平升高和IgG4阳性浆细胞的显著浸润。来自厚生劳动省的两个日本研究小组的成员在2010年金泽的第二次会议上同意使用术语“IgG4相关疾病（IgG4-RD）”来识别这种临床疾病实体。IgG4-RD主要影响中老年男性。常累及一个或多个器官。由于其临床症状相对较轻，通常由于器官肿胀或损伤而引起临床关注。^[1]无症状IgG4相关淋巴结病很常见，有时可以是最初或唯一的表现。^[2]日本于2012年引入了IgG4-RD的综合临床诊断标准（CCD标准）。^[3]在此，我们报告一例IgG4-RD的典型病例，于5年前被误诊。

致编者：一名49岁女性因高血压和糖尿病入院。心电图显示V中T波倒置_1-6血压为180/110 mmHg。总胆固醇为4.82 mmol/L，高密度脂蛋白胆固醇为1.12 mmol/L，低密度脂蛋白胆固醇为3.08 mmol/L。为排除冠心病和肾动脉狭窄，采用5Fr Terumo Optitorque TIG导管经右桡动脉同时行冠状动脉造影(CAG)和肾动脉造影，结果显示冠状动脉和肾动脉均正常。CAG后，还使用多功能导管进行肾动脉造影。但她主诉右肾动脉造影后立即右腰部疼痛逐渐加重，半小时后血压降至90/40mmHg。腹部超声检查显示右肾周围有肾周血肿[图1a].我们最终发现，右肾动脉血管造影只是由于右肾动脉上方的肾包膜动脉意外注射而轻微出现[图1b].然后静脉注射适量鱼精蛋白，早期使用升压药，共输红细胞1600 ml后病情稳定。3周后她出院了。

编者按：大颗粒淋巴细胞白血病（LGLL）是一种罕见的慢性克隆性淋巴增生性疾病，以大颗粒淋巴细胞持续增多为特征，是核质比低、胞浆丰富的大淋巴细胞，有嗜天青颗粒。^[1]在此，我们报告了华西医院用猪抗人胸腺细胞免疫球蛋白（ATG）治疗的两例诊断为难治性LGLL的病例。