Application of ultrasound in diagnosis, treatment, epidemiology, public health and control of Echinococcus granulosus and E-multilocularis
Application of ultrasound in diagnosis, treatment, epidemiology, public health and control of Echinococcus granulosus and E-multilocularis
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DOI：
10.1017/s0031182003003676
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发表时间：
2003-01-01
期刊：
影响因子：
2.4
通讯作者：
Frider, B
中科院分区：
文献类型：
--
作者：
Macpherson, CNL;Bartholomot, B;Frider, B
在过去的30年里，超声检查（US）在兽医和临床医学的许多领域得到了令人瞩目的应用，并且该技术正越来越多地应用于多种寄生虫感染，包括绦虫人畜共患病细粒棘球绦虫和多房棘球绦虫。超声检查能提供实时结果，具有高分辨率和诊断准确性，且可永久记录。这些特性，加上所获图像的临床价值以及该检测的无创性（安全，无需患者特殊准备时间，操作简便），使得超声检查成为囊性（CE）和泡性（AE）棘球蚴病的首选诊断技术。无电离辐射和副作用意味着检查时间不受限制。手持式探头便于进行快速、无血的无创剖腹探查，能够从无数个角度搜索病变，提供有关囊肿数量、大小、类型、位置及其临床影响的信息。此类临床信息促进了针对不同囊肿类型治疗方案的制定。诸如在超声引导下进行的穿刺、抽吸、注射、再抽吸（PAIR）、PAIR加引流（PAIRD）或经皮穿刺引流刮除术（PPDC）等侵入性较小的手术技术也是可行的。纵向超声研究有助于监测治疗和化疗结果的效果。如今，由电池或发电机供电、重量仅几磅的便携式超声扫描仪促进了该技术在基于社区的大规模筛查研究中的应用。这些研究大多在偏远、社会经济水平较低的地区进行，那里医院、兽医设施、学校或受过培训的人员即便有也很少。这些调查发现，在流行地区的无症状个体中，尤其是在世界各地的游牧或迁徙牧民中，CE和AE的患病率出乎意料地高。对CE和AE进行筛查是合理的，因为早期诊断可使治疗后的预后更好。超声在现场和临床环境中的应用使人们更好地了解了CE和AE的自然史，并制定了世界卫生组织关于CE囊肿类型的标准化分类。这种分类可用于帮助确定在调查中发现的不同囊肿的治疗方案，进而也可用于计算在流行社区治疗该疾病的公共卫生成本。所揭示的病例组合也会影响超声作为特定环境下诊断测试的特异性（特别是囊肿类型CE4和CE5以及囊性病变 - CL的比例）。基于社区的超声调查为不同流行环境中CE和AE的公共卫生重要性提供了新的见解。通过对整个人群进行筛查，它们揭示了疾病的真实范围，并揭示了特定的年龄和性别风险因素。通过对大规模筛查调查中发现的所有感染病例进行治疗和随访，可以大幅降低该疾病在流行社区的公共卫生影响。此类调查在国家、社区和个人层面上对专业人员和非专业人员的教育影响开始受到重视。将所获信息转化为积极的控制方案仍有待实现。在绵羊和山羊等中间宿主未大量屠宰的地区，已证明进行大规模超声筛查调查以确定家畜中CE的患病率是可能的。对这些中间宿主进行纵向研究将揭示患病率随时间的变化，这在其他项目中已被用作控制成功的标志。在阿根廷正在进行的一项控制项目中进行的大规模超声筛查调查显示了控制措施对人群的早期影响，并确定了该控制项目中的突破。大规模超声筛查调查必须遵循最高的道德标准，调查结果应导致针对不同囊肿类型应用世界卫生组织推荐的适当治疗方案。在实施此类调查之前，必须为所有不需要治疗的感染个体以及所有在调查中发现的疑似但未确诊的病例制定随访策略。在社区筛查调查中使用超声揭示了道德问题的复杂性（知情同意、保密、随访、检测并非研究重点的病变等），也为CE和AE的早期检测和治疗提供了最符合道德的指导方针。
The last 30 years have seen an impressive use of ultrasonography (US) in many fields of veterinary and clinical medicine and the technique is being increasingly applied to a wide variety of parasitic infections including the cestode zoonoses Echinococcus granulosus and E. multilocularis. US provides real-time results which are permanently recordable with a high resolution and diagnostic accuracy. These properties, coupled with the clinical value of the images obtained and the noninvasive nature of the test which is safe, require no special patient preparation time; it is easy to operate and this has resulted in the establishment of US as the diagnostic technique of choice for cystic (CE) and alveolar (AE) echinococcosis. The lack of ionizing radiation and side-effects mean that examination times are not restricted. The hand-held probes facilitate what amounts to a rapid, bloodless non-invasive laparotomy, enabling a search from an infinite number of angles for lesions producing information on their number, size and type of cysts, their location and clinical implications. Such clinical information has facilitated the development of treatment protocols for different cyst types. Less invasive surgical techniques, such as US guidance for PAIR (Puncture, Aspiration, Injection, Re-aspiration), PAIRD (PAIR plus Drainage) or PPDC (Percutaneous Puncture with Drainage and Curettage) are also possible. Longitudinal US studies have facilitated monitoring the effects of the outcome of treatment and chemotherapy. Portable ultrasound scanners which today weigh as little as a few pounds, powered by battery or generators have facilitated the use of the technique in mass community-based screening studies. The majority of these studies have been conducted in remote, low socio-economic areas where there were few, if any, hospitals, veterinary facilities, schools or trained personnel. The surveys led to the discovery of unexpectedly high prevalences of CE and AE in asymptomatic individuals of endemic areas and especially amongst transhumant or nomadic pastoralists living in various parts of the world. Screening for CE and AE is justified as an early diagnosis leads to a better prognosis following treatment. The application of US in field and clinical settings has led to a better understanding of the natural history of CE and AE and to the development of a WHO standardized classification of cyst types for CE. This classification can be used in helping define the treatment options for the different cysts found during the surveys, which in turn can also be used to calculate the public health cost of treating the disease in an endemic community. The case mix revealed can also influence the specificity (particularly proportions of cyst types CE4 and CE5 and cystic lesions-CL) of US as a diagnostic test in a particular setting. Community based US surveys have provided new insights into the public health importance of CE and AE in different endemic settings. By screening whole populations they disclose the true extent of the disease and reveal particular age and sex risk factors. Through the treatment and follow-up of all infected cases found during the mass screening surveys a drastic reduction in the public health impact of the disease in endemic communities can be achieved. Educational impacts of such surveys at the national, community and individual levels for both professional and lay people are beginning to be appreciated. The translation of the information gained into active control programmes remains to be realized.In areas where intermediate hosts, such as sheep and goats, are not slaughtered in large numbers mass US screening surveys to determine the prevalence of CE in livestock has proved possible. Longitudinal studies in such intermediate hosts would reveal changes in prevalence over time, which has been used as a marker for control success in other programmes. Mass US screening surveys in an ongoing control programme in Argentina has demonstrated the early impact of control in the human population and identified breakthroughs in that control programme. Mass US screening surveys must adhere to the highest ethical standards and the outcome of surveys should result in the application of appropriate WHO recommended treatment options for different cyst types. Follow-up strategies have to be in place prior to the implementation of such surveys for all infected individuals who do not require treatment and for all suspected, but not confirmed, cases found during the surveys. The use of US in community screening surveys has revealed the complexity of ethical issues (informed consent, confidentiality, follow-up, detection of lesions that are not the focus of the study etc) and also provided real solutions to providing the most ethical guidelines for the early detection and treatment of CE and AE.