循證醫(yī)學(xué)診斷案例分析_圖文

1、循證醫(yī)學(xué)實(shí)踐教學(xué)案例分析 2014年2月18日修訂科別:口腔頜面外科住院號:38871入院日期:2014.3.6報告者姓名:職務(wù): 住院醫(yī)師 基地醫(yī)師 實(shí)習(xí)醫(yī)師 完成時間:2014.4.11病例摘要患者，女，31歲。因“右上腭腫塊2年余，伴脹痛3個月”之主訴于2014年3月16日收住我科。查體：患者一般情況良好，右眶下隆起，鼻道無異常分泌物，開口度：30cm，牙列完整無叩痛，右上腭部明顯隆起，內(nèi)界接近中線，后界達(dá)軟腭前部，黏膜光滑無潰瘍，觸之中等硬度，無明顯壓痛，上頜瓦氏位片示，右上頜竇內(nèi)有一半球形軟組織陰影。MRI與CT掃描見右上頜竇內(nèi)有一半球形軟組織陰影，上頜竇底骨質(zhì)無規(guī)則破壞。腫塊穿刺液

2、涂片發(fā)現(xiàn)異形細(xì)胞，血尿常規(guī)、生化檢驗(yàn)無異常。初步診斷右上頜骨惡性腫瘤，侵犯上頜竇。于2014年3月13日在經(jīng)鼻氣管插管全麻下。行右上頜骨次全切除術(shù)。手術(shù)進(jìn)行順利，術(shù)后恢復(fù)良好。術(shù)后病理報告：腺樣囊性癌。由修復(fù)科行上頜贗復(fù)體修復(fù)，恢復(fù)上頜形態(tài)及咀嚼功能，于2014年4月7日出院。提出可回答的臨床問題(AskingP:唾液腺腺樣囊性癌患者I:CT或者M(jìn)RI診斷C:病理診斷O:診斷正確率的評價檢索最有用的證據(jù)(Acquire關(guān)鍵詞( Key word ：oral adenoid cystic carcinoma，CT or MRI數(shù)據(jù)庫來源 ( Database ：PubMed Clinical Q

3、ueries主要內(nèi)容：Perineural spread of adenoid cystic carcinoma in the oral and maxillofacial regions: evaluation with contrast-enhanced CT and MRIObjectives: The objective of this study was to compare the accuracy of contrast-enhanced CT (CECT and contrast-enhanced MRI (CEMRI in the detection of perineura

4、l spread (PNS of adenoid cystic carcinoma (ACC in the oral and maxillofacial regions.Methods: This study consisted of 13 ACCs from 13 patients, all of which were histopathologically diagnosed. Both CECT and CEMRI were performed in all patients before the treatment. The images of each patient were re

5、trospectively evaluated for the detection of PNS. The definitions of PNS included abnormal density/signal intensity, contrast enhancement or widening of the pterygopalatine fossa, palatine foramen, incisive canal, mandibular foramen and mandibular canal, and enlargement or excessive contrast enhance

6、ment of a nerve.Results: 11 out of 13 cases were proven to exhibit PNS histopathologically. 8 of the 11 cases for which PNS was histopathologically proven exhibited PNS on MR images. Six of the eight cases for which PNS was exhibited on MR images also exhibited PNS on CT images. The sensitivity, spe

7、cificity and accuracy for the detection of PNS were 55%, 100% and 62% on CT images and 73%, 100% and 77% on MR images, respectively. Although the accuracy of PNS on MR images was slightly superior to that on CT images, there were no statistically significant differences between the detection of PNS

8、on CT images and on MR images.Conclusions: CT and MR images are equally useful for the detection of PNS of ACC in the oral and maxillofacial regions.證據(jù)評價 (Appraisal 證據(jù)等級：DWorksheet：一、標(biāo)準(zhǔn)診斷方法的確定：組織病理學(xué)檢查的神經(jīng)侵犯（the presence of PNS by the histopathological diagnosis）二、診斷對象的選擇：The study sample was derived

9、from the population of patients who presented to Osaka University Dental Hospital, and were histopathologically diagnosed with ACC between June 2000 and December 2007.此研究中病例組指的是患有腺樣囊性癌有神經(jīng)侵犯的病例。病例組和對照組的確定是根據(jù)標(biāo)準(zhǔn)診斷方法，即組織病理學(xué)檢查的神經(jīng)侵犯（the presence of PNS by the histopathological diagnosis）的陰陽性來決定的。陽性為病例組，陰性

10、為非病例組。1. 病例組包括該病的各種類型：神經(jīng)侵犯（PNS）有一個標(biāo)準(zhǔn)（the basis of Ginsbergs criteria of PNS）,包括不正常牙的密度，翼腭窩的增強(qiáng)，腭孔、切牙管上頜管和孔神經(jīng)侵犯性（abnormal density/signal intensity, contrast enhancement or widening of the pterygopalatine fossa, palatine foramen, incisive canal, mandibular foramen and mandibular canal, and enlargement

11、or excessive contrast enhancement of a nerve），其多樣性體現(xiàn)了病例組的多樣性。2. 對照組是未表現(xiàn)為神經(jīng)侵犯的病例，由于此研究重點(diǎn)對CT和MRI的診斷比較，沒有包括易與該病混淆的其他病例。CT和MRI相互對比。三、列出評價診斷試驗(yàn)的四格表：標(biāo)準(zhǔn)診斷病例組非病例組病例組非病例組診斷試驗(yàn)CT+606診斷試驗(yàn)MRI+8085273251121311213四、計算各項診斷試驗(yàn)的評價指標(biāo)：1. CT靈敏度（真陽性率）55%，漏診率（假陰性率）45%特異性（真陰性率）100%，誤診率（假陽性率）0%預(yù)測值，陽性100%，陰性29%似然比LR，試驗(yàn)陽性無窮大，實(shí)驗(yàn)

12、陰性45%神經(jīng)侵犯疾病概率85%神經(jīng)侵犯疾病比率550%驗(yàn)前比550%驗(yàn)后比，陽性無窮大，陰性278%驗(yàn)后概率，陽性27%，陰性74%2. MRI靈敏度（真陽性率）73%，漏診率（假陰性率）27%特異性（真陰性率）100%，誤診率（假陽性率）0%預(yù)測值，陽性100%，陰性40%似然比LR，試驗(yàn)陽性無窮大，實(shí)驗(yàn)陰性72%神經(jīng)侵犯疾病概率85%神經(jīng)侵犯疾病比率550%驗(yàn)前比550%驗(yàn)后比，陽性無窮大，陰性396%驗(yàn)后概率，陽性20%，陰性80%3. 處理綜合實(shí)驗(yàn)結(jié)果陰性驗(yàn)后比=178%五、診斷試驗(yàn)的評估：1. 真實(shí)性：采用盲法：Thesefindings were independently ev

13、aluated on the CT and MR images by two radiologists who did not know the results of the histopathological examination and then consensus readings for interpretation discrepancies was performed.診斷試驗(yàn)包含適當(dāng)?shù)牟∽V診斷試驗(yàn)的檢測結(jié)果不會影響參考標(biāo)準(zhǔn)的運(yùn)用存在相同真實(shí)性由于樣本量不夠大，對于其數(shù)值的真實(shí)性存在質(zhì)疑2. 重要性：特異性較強(qiáng)，能夠診斷疾病，但是敏感性不夠沒有進(jìn)行分層似然比3. 實(shí)用性由于樣本量

14、不夠大，對于其數(shù)值的可能存在偏倚但是實(shí)用性必須得到重視。由于腺樣囊性癌具有極強(qiáng)的神經(jīng)侵犯性，其相較于其他唾液腺腫瘤比較保守的方法，手術(shù)范圍必須擴(kuò)大，并且果斷犧牲各種神經(jīng)。所以術(shù)前診斷室非常重要的，有利于手術(shù)方案的確定。可以在本單位開展，因?yàn)镃T和MRI的運(yùn)用。驗(yàn)前概率估計該病發(fā)生神經(jīng)侵犯的概率，可以作為估算驗(yàn)后概率得到相對可靠的神經(jīng)侵犯的概率，為手術(shù)方案的確定作指導(dǎo)。證據(jù)解讀及證據(jù)應(yīng)用( Apply 由于腺樣囊性癌具有極強(qiáng)的神經(jīng)侵犯性，其相較于其他唾液腺腫瘤比較保守的方法，手術(shù)范圍必須擴(kuò)大，并且果斷犧牲各種神經(jīng)。所以術(shù)前診斷室非常重要的，有利于手術(shù)方案的確定。病人在追求治愈疾病的同時，也注重術(shù)后的生活質(zhì)量。基于可能犧牲神經(jīng)，導(dǎo)致病人許多感覺運(yùn)動功能喪失，例如面癱等嚴(yán)重影響其生存治療。病人的志