合并支原体感染的大叶性肺炎患儿肺泡灌洗液中常规细胞学检测及意义*

目的研究大叶性肺炎患儿支气管肺泡灌洗液(BALF)中常规细胞学形态学检测、肺炎支原体-DNA(MP-DNA)及细胞因子白细胞介素-17(IL-17)水平,探讨其临床意义及相互关系。方法选取确诊为大叶性肺炎并行支气管肺泡灌洗术(BAL)的患儿87例,行BAL当天对患儿行临床肺部感染评分(CPIS)分为:重症组27例,轻症组60例;根据BALF免疫荧光定量MP-DNA结果,分为支原体感染73例:中拷贝组32例、高拷贝组41例,无支原体感染14例;ELISA法检测BALF中IL-17水平,对BALF中细胞HE染色后放大100倍计数,比较各组间常规细胞学计数百分比差异。结果 BALF中中性粒细胞百分比(NE%)、淋巴细胞百分比(LY%)与血清中NE%和LY%无相关性(P0.05);轻症组患儿BALF中柱状上皮细胞计数百分比高于重症组,并且重症组患儿BALF中巨噬细胞百分比高于轻症组(P0.05);高拷贝组NE%高于中拷贝组(P0.05),且NE%与BALF中IL-17水平及MP-DNA拷贝均呈正相关(r1=0.49,P=0.000,r2=0.48,P=0.000)。结论大叶性肺炎肺泡灌洗液中成分更能反应大叶性肺炎局部炎症情况;大叶性肺炎发生时柱状上皮细胞受损脱落,同时巨噬细胞趋化聚集参与炎症反应;肺炎支原体感染时,IL-17通过中性粒细胞募集作用发挥抗感染能力,BALF中NE%可间接反映患儿局部感染支原体拷贝数。     

RT-PCR检测在疑似肺炎支原体感染患者中的应用研究

目的探讨实时荧光定量聚合酶链反应(PCR)检测肺炎支原体(MP)DNA在疑似MP感染患者中的应用价值。方法采用RT-PCR对疑似MP感染患者血清、痰、胸腔积液、鼻咽拭子、肺泡灌洗液、支气管灌洗液标本进行MP-DNA检测。结果 1 402例标本MP-DNA检测总阳性率为12.20%,血清标本检测阳性率最低,仅为2.36%,痰、肺泡灌洗液及支气管灌洗液检测阳性率较高,依次为62.96%、77.08%和88.71%。结论 RT-PCR法适用于多种类型标本MP-DNA检测,是诊断MP感染的有效方法之一。     

小儿肺炎支原体感染肺泡灌洗液内MP-DNA阳性表达的临床意义分析

目的分析小儿肺炎支原体感染肺泡灌洗液内MP-DNA阳性表达的临床意义。方法选取我院2017年2月～2018年1月收治的小儿肺炎支原体感染(MPP)患儿60例,患者均接受支气管肺泡灌洗液和纤维支气管镜检查,用荧光实时定量PCR测定肺泡灌洗液(BALF)中MP-DNA基因,按照肺泡灌洗液MP-DNA检查结果分为阳性组和阴性组各30例。对比2组患儿临床特征。结果阳性组0～3岁发病率13.33%,低于阴性组的60%,6岁发病率43.33%高于阴性组16.67%,差异有统计学意义(P0.05),两组患儿3～6岁阶段发病率比较,差异无统计学意义(P0.05)。阳性组患儿高热率41.67%、CRP升高率66.67%,分别高于阴性组的33.33%和20%,差异有统计学意义(P0.05)。两组BALF细胞学分类比较,差异无统计学意义(P0.05)。结论肺泡灌洗液内MP-DNA阳性患儿CRP升高、高热、年龄均高于肺泡灌洗液内MP-DNA阴性患儿。     

肺泡灌洗液社区获得性呼吸窘迫综合征毒素表达与难治性肺炎支原体肺炎发生风险的相关性

目的 观察肺炎支原体肺炎患儿支气管肺泡灌洗液社区获得性呼吸窘迫综合征毒素(community-acquired respiratory distress syndrome toxin, CARDS Tx)表达变化,探讨其与难治性肺炎支原体肺炎(refractory Mycoplasma pneumoniae pneumonia, RMPP)发生的关系。方法 186例肺炎支原体肺炎患儿均给予规范治疗,治疗后进展至RMPP者59例为RMPP组,余127例为对照组。比较2组胸腔积液、肺门淋巴结肿大等CT影像特征及入院次日血清C反应蛋白、降钙素原、乳酸脱氢酶等生化指标;采用实时荧光定量PCR法检测入院次日支气管肺泡灌洗液CARDS Tx相对表达量;采用多因素logistic回归分析肺炎支原体肺炎患儿进展至RMPP的影响因素;绘制限制性立方样条图,分析CARDS Tx表达与肺炎支原体肺炎患儿进展至RMPP的关系。结果 RMPP组肺部病变影≥2/3肺(44.07%)、中大量胸腔积液比率(22.03%)均高于对照组(24.41%、9.45%)(χ²=7.325,P=0.007;...     

肺炎支原体肺炎患儿外周血和肺泡灌洗液中T细胞及细胞因子变化研究

目的探讨肺炎支原体肺炎(MPP)患儿外周血和肺泡灌洗液(BALF)中T细胞亚群及细胞因子变化情况,以探讨该病可能的免疫损伤机制。方法选择43例MPP患儿(MPP组)为研究对象,并选取同期40例普通肺炎患儿(普通肺炎组),以及因异物入院行软式支气管镜术的25例患儿(对照组)作为对照。流式细胞仪检测外周血和BALF中T细胞亚群构成比,ELISA法检测白细胞介素(IL)-6、IL-10水平,并进行统计学分析。结果 MPP组患儿外周血及BALF中CD3~+CD8~+T细胞水平显著高于普通肺炎组及对照组(P0.05);MPP组外周血及BALF中CD3~+CD4~+T细胞、CD3~+CD4~+CD25~+T细胞水平显著低于普通肺炎组及对照组(P0.05);MPP组患儿血清及BALF中IL-6水平显著高于普通肺炎组及对照组(P0.05),IL-10水平显著高于对照组(P0.05);MPP患儿血清与BALF中IL-6(r=0.635,P=0.000)、IL-10(r=0.396,P=0.009)水平呈显著性正相关。结论肺炎支原体肺炎患儿外周血及BALF中T细胞失衡表达,细胞因子IL-6、IL-10显著升高。     

实时荧光定量PCR检测肺炎支原体DNA在小儿肺炎诊断中的应用价值

目的探讨实时荧光定量聚合酶链反应（FQ-PCR）检测肺炎支原体（MP）DNA在小儿肺炎诊断中的应用价值。方法采用FQ-PCR对该院742例儿科住院患儿的血清、痰液、胸腔积液、支气管灌洗液、肺泡灌洗液临床标本进行MPDNA的定量检测。结果742例患儿中MPDNA检测总阳性率为40．3％（299／742）;男、女性患儿MPDNA阳性率的差异无统计学意义（P〉0．05）;4～〈7岁、7～〈10岁、10～〈13岁、13～16岁组,MPDNA阳性率均高于0～〈4岁组（P〈O．05）;不同种类标本的阳性率不同,由高到低依次为支气管灌洗液（96．5％）、肺泡灌洗液（83．7％）、痰液（71．7％）、胸腔积液（38．9％）、血清（6．1％）。结论4岁及4岁以上儿童易感染肺炎支原体,且随着年龄增长感染率逐渐增高;支气管灌洗液标本的MPDNA阳性率较高;FQ-PCR法检测MP DNA用于肺炎支原体感染的诊断有一定价值。     

实时荧光定量PCR在儿童肺炎支原体感染中的诊断价值

目的探讨实时荧光定量PCR(RTFQ-PCR)在儿童肺炎支原体(MP)感染中的诊断价值。方法选取106例肺炎患儿,采集静脉血,以间接荧光免疫法(IFA)检测MP-Ig M表达;采集咽拭子标本,以RTFQ-PCR检测MP DNA拷贝数。以血清学检测结果为诊断标准,观察RTFQ-PCR诊断MP的灵敏度、特异度、阳性预测值和阴性预测值,及其在检测不同年龄段患儿MP感染中的准确性;比较MP-Ig M阳性和阴性患儿的MP-DNA拷贝数差异。结果 1 RTFQ-PCR诊断灵敏度、特异度、阳性预测值和阴性预测值分别为90.48%、93.02%、95.00%、89.96%。绘制受试者工作曲线(ROC曲线),曲线下面积为0.740;2 RTFQ-PCR诊断6岁以上患儿MP感染的灵敏度和准确率高于1岁以下患儿(P0.01);3 MP-Ig M阳性组DNA拷贝数对数显著高于阴性组拷贝数对数(P0.01)。结论 RTFQ-PCR诊断儿童MP感染具有较好的准确性,其荧光拷贝数越大越支持MP感染的诊断,对发病早期及年龄较大的患儿可能具有更高的诊断价值。     

肺泡灌洗液高迁移率族蛋白B1水平在难治性肺炎支原体肺炎患儿预后中的意义

目的 探讨肺炎支原体肺炎(mycoplasmal pneumonia,MPP)患儿肺泡灌洗液中高迁移率族蛋白B1(high mobility group box 1,HMGB1)在病情进展和肺外损伤中的意义.方法 收集66例MPP患儿为研究对象,同时收集同期行支气管异物取出术的患儿18例为对照组.根据MP P患儿治疗7...     

3种方法检测儿童肺炎支原体感染的临床评估

目的比较3种检测肺炎支原体(MP)感染的方法[被动凝集法、多重聚合酶链反应(PCR)及荧光定量PCR]的差异,探讨不同方法在不同年龄段及不同病程肺炎患儿中的应用价值。方法选取接受纤维支气管镜灌洗治疗的MP肺炎患儿213例。采用被动凝集法、多重PCR及荧光定量PCR分别检测血清MP抗体、痰液MP DNA及肺泡灌洗液(BALF)中的MP DNA。以荧光定量PCR在BALF中检出MP DNA为病原学判断标准,比较3种方法的一致性。将所有患儿按年龄分为1岁组(8例)、1～3岁组(29例)、4～6岁组(97例)、6岁组(79例),按病程分为≤7 d组和7 d组。比较各组3种方法的阳性检出率。结果 213例MP肺炎患儿中,被动凝集法、多重PCR及荧光定量PCR的阳性检出率分别为98.12%、76.06%和89.20%。以荧光定量PCR在BALF中检出MPDNA为病原学判断标准,多重PCR与荧光定量PCR的Kappa值为0.301,优于被动凝集法与荧光定量PCR的Kappa值(0.043)。按年龄分组,3种方法的阳性检出率均与年龄有关(P0.05)。病程7 d组荧光定量PCR阳性率高于≤7 d组(P=0.003),而被动凝集法和多重PCR的阳性检出率2个组之间差异无统计学意义(P0.05)。结论在使用纤维支气管镜灌洗治疗的MP肺炎患儿中,荧光定量PCR与多重PCR的一致性优于被动凝集法,荧光定量PCR的阳性检出率与患儿病程相关。     

儿童肺炎支原体肺炎与肺炎支原体合并链球菌感染肺炎的胸部CT表现及其鉴别

目的探讨肺炎支原体肺炎(MP)和肺炎支原体合并链球菌感染肺炎(MP+SP)的影像学表现差异,为临床早期鉴别单纯MP及MP+SP提供帮助。方法回顾性分析经血清学及血培养证实的23例单纯MP和23例MP+SP患儿的胸部CT图像,分别对病变分布、病变形态及合并症(如肺气肿、胸腔积液、淋巴结肿大等)进行比较及统计学分析。结果与MP+SP比较,单纯MP多表现为肺间质病变,包括支气管壁增厚、磨玻璃影、网状影及支气管血管束增厚(P<0.05);而MP+SP则以肺实变影为主,且胸腔积液量及肿大淋巴结直径均大于单纯MP患儿(P<0.05)。从病变形态上看,单纯MP的肺内阴影多为自内向外,呈扇形分布的薄片影;MP+SP则多为无分布规律的大片实变影。结论单纯MP表现为在较少肺实变基础上合并较明显的肺间质改变;而MP+SP的肺泡炎症程度较重,片状阴影密度高、范围大,但肺间质表现不突出,同时易伴有中-大量胸腔积液及淋巴结显著增大。     

Guns and Knives in New Mexico: Patterns of Penetrating Trauma, 1978–1993

Objective: To identify patterns of nonfatal and fatal penetrating trauma among children and adults in New Mexico using ED and medical examiner data.
Methods: The authors retrospectively sampled in 5-year intervals all victims of penetrating trauma who presented to either the state Level-1 trauma center or the state medical examiner from a 16-year period (1978–1993). Rates of nonfatal and fatal firearm and stabbing injury were compared for children and adults.
Results: Rates of nonfatal injury were similar (firearm, 34.3 per 100,000 person-years; stabbing, 35.1). However, rates of fatal injury were significantly different (firearm, 21.9; stabbing, 2.7; relative risk: 8.2; 95% confidence interval: 5.4, 12.5). From 1978 to 1993, nonfatal injury rates increased for children (p = 0.0043) and adults (p < 0.0001), while fatal penetrating injury remained constant. The increase in nonfatal injury in children resulted from increased firearm injury rates. In adults, both stabbing and firearm nonfatal injury rates increased.
Conclusions: Nonfatal injury data suggest that nonfatal violence has increased; fatal injury data suggest that violent death rates have remained constant. Injury patterns vary by age, mechanism of trauma, and data source. These results suggest that ED and medical examiner data differ and that both are needed to guide injury prevention programs.     

Systematic Reviews Published in the January 2011 Issue of The Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly as a DVD and monthly online. The January 2011 issue (first quarterly DVD for 2011) contains 4515 complete reviews, 1985 protocols for reviews in production, and 13,521 one-page summaries of systematic reviews published in the general medical literature. In addition, there are citations of 641,000 randomized controlled trials, and 14,018 cited papers in the Cochrane methodology register. The health technology assessment database contains over 9300 citations. One hundred and seven new reviews have been published in the last 3 months, of which five have potential relevance for practitioners in pain and palliative medicine.     

Interprofessional approaches to creating safe,high quality health care

Three supplementary perspectives are presented arguing that interprofessional collaboration is both necessary and desirable. Nonetheless, there are often too many serious intra-professional barriers and obstacles to interprofessional collaboration to make it successful. Some of these barriers, it is argued and illustrated, are found in the multiple ways in which professional identity is tacitly acquired and embodied in the practitioners' habitual, everyday practice. The paper then explores ways in which reflection, especially Second order reflection, can help to elucidate and overcome these obstacles, as well as increasing professional adaptability and competence.     

Prise en charge des entorses externes de cheville : étude clinique préliminaire sur l’efficacité du dispositif Myolux™

Ankle sprains are the most common injury of the musculoskeletal system and are associated with significant societal and economic impacts. It has been proven that classical therapeutic strategies may not be effective in preventing recurrent injuries: the recurrence rates reported in the literature can reach 73%. In order to provide an effective rehabilitation solution, a destabilizing orthosis was developed. This device is equipped with a mechanical articulator reproducing the subtalar mechanics and placed under the heel. In this paper, we present the main results of a preliminary clinical study conducted between 2004 and 2007. All subjects included in this study were treated with the abovementioned orthosis during 10 rehabilitation sessions of 30 minutes each. Data show a relatively low recurrence rate of 12% for the overall population. Moreover, it's of primary importance to note that this satisfactory ratio is largely reduced (3% of recurrence rate) for the 29 patients who performed one training session per month after the 10th initial rehabilitation sessions. Hence, the destabilizing orthosis appears to be an effective solution to prevent recurrent ankle sprains. However, joint protection requires long-term and regular training sessions. This result has motivated the development of a similar device allowing patients to perform training sessions at home. Finally, data obtained in this study are promising awaiting the final results of the comparative, multicentric and independent clinical trials currently managed by the Hospices Civils de Lyon.     

Determination of creatine kinase isoenzyme MB activity in serum using immunological inhibition of creatine kinase M subunit activity. Activity kinetics and diagnostic significance in myocardial infarction.

This is a new method for the determination of creatine kinase isoenzyme MB activity in serum. The method uses direct activity measurement of creatine kinase B subunit activity after blocking of CK-M subunit activity by inhibiting antibodies. The test takes no longer than 15 min. The method yields an intra-serial C.V. of 2.0-12.9%, and a C.V. from day to day of 5.5%. The detection limit is 3.4 U/l creatine kinase MB. In the 95 cases with proven myocardial infarction several types of creatine kinase MB activity kinetics could be determined. The percentage of creatine kinase MB of peak CK-total is 6-25%, with a mean of 11.1%. The amount of creatine kinase MB with respect to total CK activity after reinfarction is higher than the amount after initial infarction.     

俯卧位通气对高海拔地区肺复张治疗无效急性呼吸窘迫综合征患者氧合的影响

目的 探讨俯卧位通气对高海拔地区肺复张术(RM)治疗无效急性呼吸窘迫综合征(ARDS)患者的治疗作用.方法 从海拔2260m的地区医院筛选RM治疗无效的41例ARDS患者[平均氧合指数( PaO2/FiO2)较RM前升高＜20％视为RM无效],依不同病因分为肺内源性ARDS组(ARDSp组)和肺外源性ARDS组(ARDSexp组),每组再按信封法随机分为俯卧位组和仰卧位组,即ARDSp俯卧位组(11例)、ARDSp仰卧位组(9例)、ARDSexp俯卧位组(10例)、ARDSexp仰卧位组(11例).在通气前及通气1、2、3、4h监测动脉血氧分压( PaO2)、PaO2/FiO2、静态顺应性(Cst)、气道阻力(Raw)的变化.结果 通气lh时,ARDSexp俯卧位组PaO2/FiO2( mm Hg,l mm Hg=0.133 kPa)即较通气前显著升高(157.4±40.6比129.3±48.7,P＜0.05),并随通气时间延长呈持续增高趋势,4h达峰值(219.1 ±41.1);且ARDSexp俯卧位组通气3h内PaO2/FiO2较其他3组显著增高,另3组间则差异无统计学意义.ARDSp俯卧位组、ARDSexp俯卧位组通气4h时PaO2/FiO2均较相应仰卧位组显著增高(208.8±39.7比127.4±47.1,219.1±41.1比124.9±50.8,均P＜0.05).4组通气前后Cst无显著改变,各组间差异也无统计学意义.ARDSp俯卧位组通气4h时Raw(cmH2O·L-1·s-1)较通气前显著降低(6.8±1.7比10.7±1.8,P＜0.05),且明显低于其他3组;其他3组各时间点Raw组内及组间比较差异均无统计学意义.结论 俯卧位通气作为ARDS机械通气重要策略之一,可以改善RM无效高原ARDS患者的氧合,为抢救患者赢得宝贵的时间.     

Digital imaging among medical facilities

The Department of Veterans Affairs (VA) in the USA operates a network of 172 medical centres which all utilize a hospital information system (HIS) which has been developed and is currently maintained by the VA. During the past several years, an image management and communication module has been developed, installed and clinically utilized at the Washington DC and Maryland VA Medical Centres. This image management and communication system, referred to as the decentralized hospital computer program (DHCP) imaging system, is fully integrated with a commercial picture archiving and communication system (PACS). The system is utilized to capture, archive, and display all images generated within the hospital including radiology, nuclear medicine, pathology, endoscopy, bronchoscopy, and dermatology, intraoperative photographs, ECG data, and a limited number of paper documents. The ultimate goal of the project is to have all patient text and image data available at any clinical workstation to any authorized user anywhere within the network of medical centres. Clinical requirements for an imaging workstation include ease of use, rapid and reliable access to the complete set of patient information, and images which are of acceptable quality to meet the requirements of the user and the subspecialty. Patient confidentiality and data security must be safeguarded at all times. Integration of the images with the remainder of the patient's database was found to be critical to the success of the project. The experience at the Washington and Maryland facilities suggests that an imaging system that is successfully integrated with a hospital information system can provide substantial clinical and economic benefits both within and among medical centres. Clinical acceptance and utilization of the system has been excellent, particularly in diagnostic radiology where DHCP Imaging has been interfaced to a commercial PAC system. Based upon this initial experience, the VA has begun to deploy the system throughout its large network of medical centres.     

Myocardial elastography at both high temporal and spatial resolution for the detection of infarcts

Myocardial elastography is a novel method for noninvasively assessing regional myocardial function, with the advantages of high spatial and temporal resolution and high signal-to-noise ratio (SNR). In this paper, in-vivo experiments were performed in anesthetized normal and infarcted mice (one day after left anterior descending coronary artery [LAD] ligation) using a high-resolution (30 MHz) ultrasound system (Vevo 770, VisualSonics Inc., Toronto, ON, Canada). Radiofrequency (RF) signals of the left ventricle (LV) in longitudinal (long-axis) view and the associated electrocardiogram (ECG) were simultaneously acquired. Using a retrospective ECG gating technique, 2-D full field-of-view RF frames were acquired at an extremely high frame rate (8 kHz) that resulted in high-quality incremental displacement and strain estimation of the myocardium. The incremental results were further accumulated to obtain the cumulative displacements and strains. Two-dimensional and M-mode displacement images and strain images (elastograms), as well as displacement and strain profiles as a function of time, were compared between normal and infarcted mice. Incremental results clearly depicted cardiac events including LV contraction, LV relaxation and isovolumetric phases in both normal and infarcted mice, and also evidently indicated reduced motion and deformation in the infarcted myocardium. The elastograms indicated that the infarcted regions underwent thinning during systole rather than thickening, as in the normal case. The cumulative elastograms were found to have higher elastographic SNR (SNR(e)) than the incremental elastograms (e.g., 10.6 vs. 4.7 in a normal myocardium, and 6.0 vs. 2.4 in an infarcted myocardium). Finally, preliminary statistical results from nine normal (m = 9) and seven infarcted (n = 7) mice indicated the capability of the cumulative strain in differentiating infracted from normal myocardia. In conclusion, myocardial elastography could provide regional strain information at simultaneously high temporal (>/=0.125 ms) and spatial ( approximately 55 microm) resolution as well as high precision ( approximately 0.05 microm displacement). This technique was thus capable of accurately characterizing normal myocardial function throughout an entire cardiac cycle, at the same high resolution, and detecting and localizing myocardial infarction in vivo.