脓毒血症患者高敏肌钙蛋白T水平及预后判断的价值研究

目的探讨脓毒血症患者高敏心肌肌钙蛋白T水平及预后判断的价值。方法选取我院2014年1月至2014年12月脓毒血症住院患者156例为研究对象,选取同期健康体检者323例为健康对照,统计患者的年龄、性别、住院天数,检测患者入院时(day0)及第5天(day5)降钙素原(PCT)和高敏心肌肌钙蛋白T(hs-cTnT)水平,健康对照组仅检测纳入时PCT和hs-cTnT水平。研究对象按入院时和第5天PCT的变化分为PCT升高组(29例)和PCT降低组(127例),比较患者年龄、性别及不同时间点hs-cTnT水平和PCT水平。结果脓毒血症患者hs-cTnT水平为28.3(12.9,86.2)ng/L高于健康对照人群3.0(3.0,3.8)ng/L(P0.05);脓毒血症患者入院时PCT水平为5.24(2.93,19.35)ng/ml,hs-cTnT水平为28.25(12.92,83.55)ng/L,两者相关性为r=0.332(P0.05),第5天PCT水平为1.34(0.56,4.69)ng/ml,hs-cTnT水平为22.60(11.15,56.35)ng/L,两者相关性为r=0.439(P0.05);PCT升高组第5天hs-cTnT水平为60.7(26.8,187.4)ng/L,明显高于入院时hs-cTnT水平27.5(11.8,123.4)ng/L(P0.05),PCT降低组第5天hs-cTnT水平为18.7(8.9,43.2)ng/L低于入院时hs-cTnT水平29.0(13.0,83.4)ng/L(P0.05);PCT升高组病情恶化率达72.4%,高于PCT降低组34.6%(P0.05)。结论脓毒血症对心肌细胞产生损伤,脓毒血症严重程度和心肌细胞损伤程度密切相关,hs-cTnT水平对脓毒血症患者的预后具有指导意义。     

荧光定量PCR测定HBV DNA室内质控方法的探讨

目的探讨实时荧光定量聚合酶链反应(PCR)测定乙型肝炎病毒核酸(HBV DNA)的室内质控方法。方法统计上海地区PCR实验室HBV DNA常规条件下前20次室内质控数据的不精密度(CV),以测出的均值(x珋±s)绘制质控图,分别采用13s/22s的多规则质控方法和Levey-Jennings单规则质控方法,判断前20次室内质控数据CV分别为≥10%、5%~10%和1%~5%范围内A、B和C 3家实验室的室内质控数据,分别分析其失控检出能力。结果分别采用13s/22s多规则和Levey-Jennings单规则质控方法。当HBV DNA室内质控品低、高两个浓度分别为5×104和5×106IU/mL时,CV为14.96%和12.15%的A实验室均未正确检出失控数据;CV为6.49%和5.00%的B实验室检出2个随机误差引起的失控数据;其CV为4.36%和2.43的C实验室,采用13s/22s多规则质控方法检出3个系统误差引起的失控数据,采用单规则质控方法未检出失控。结论 PCR检测HBV DNA当实验室前20次室内质控数据CV≥10%时,无论采用单规则还是多规则质控方法均不能正确检出失控;实验室应设定自己实验室最低要求的CV,并采用多规则质控方法,以提高系统误差的失控检出率。     

临床实验室定量检测项目应选择自己的室内质控方法

[目的]对临床实验室定量检测项目选择自己的室内质控方法。[方法]设计的质量控制方法应与每一分析系统的准确度、精密度和误差发生率相匹配。不同的质控规则将检出不同的大小和不同类型的误差。通过增加检测质控物个数来改进误差检出。根据性能的质量控制设计系统能使我们改变质控规则、质控物个数、质控的频率和其它的质控策略来匹配当前的分析性能和误差发生率。[结果]高的临界系统误差表明方法能耐受大的均值偏移和要求相对地宽松的质量控制策略。低的临界系统误差表明方法能耐受均值小的偏移，并要求相对严格的质量控制策略。[结论]质量控制设计表为质控规则、控制频率(或质控物个数)、检查质控图的频率，以及需要纠正措施提供了建议。     

高敏心肌肌钙蛋白T检测在急性心肌梗死诊断中的应用

目的:评价高敏心肌肌钙蛋白T(hs-cTnT)在急性心肌梗死(acute myocardial infarction,AMI)诊断中的临床应用价值。方法:比较了18例AMI、21例不稳定型心绞痛(UA)、20例稳定型心绞痛(SA)患者入院即刻样本hs-cTnT、肌酸激酶同工酶(CK-MB)及超敏C-反应蛋白(hs-CRP)检出阳性率,检测了18例确诊为AMI患者入院5个不同时间点(入院即刻和入院后6、24、48h及5d)hs-cTnT、CK-MB、hs-CRP浓度,动态监测比较AMI组、UA组、SA组入院6h内hs-cTnT浓度变化率。结果:确诊为AMI患者入院即刻hs-cTnT、CK-MB、hs-CRP的检出阳性率分别为88.9%、72.2%、77.8%,明显高于UA组的47.6%、9.5%、4.8%和SA组的40.0%、0.0%、5.0%。入院各时间点不同指标(hs-cTnT、CK-MB、hs-CRP)检测中,hs-cTnT在6h检测浓度达高峰,CK-MB在24h检测浓度达到高峰,hs-CRP在48h检测浓度达高峰,5d时hs-cTnT依然持续处于高值,CK-MB、hs-CRP基本恢复正常。动态检测hs-cTnT在AMI组、UA组、SA组的浓度变化率,AMI组与其他两组差异有显著性(P<0.05)。结论:hs-cTnT检测能够为AMI的更早期诊断提供可靠依据,结合动态监测hs-cTnT浓度的变化率更能鉴别诊断疑似AMI患者。     

NT-proBNP对慢性肾功能不全合并慢性心力衰竭患者危险分层价值的研究

目的:探讨血浆中氨基末端脑钠肽前体(NT-proBNP)对慢性肾功能不全(chronic renal insufficiency,CRI)合并慢性心力衰竭(chronic heart failure,CHF)患者的危险分层价值。方法:以CRI合并CHF的97例患者为研究对象,根据血浆NT-proBNP水平将患者分为高危组53例、非高危组44例(中危组25例,低危组19例),以同期体检健康的41例为对照组。比较各组高敏肌钙蛋白T(hs-cTnT)及经多普勒超声心动图检测的左心室射血分数(LVEF)。结果:高危组NT-proBNP和hs-cTnT均明显高于非高危组[(5611.40±1790.28)ng/L vs(1302.75±195.57)ng/L,P0.01]和[(131.22±40.98)ng/L vs(46.56±13.80)ng/L,P0.01],而高危组明显LVEF明显低于非高危组[(31.81±9.02)%vs(65.32±10.73)%,P0.05];非高危组NT-proBNP和hs-cTnT明显高于对照组[(1302.75±195.57)ng/L vs(187.68±39.61)ng/L,P0.05]和[(46.56±13.80)ng/L vs(16.11±4.53)ng/L,P0.05],而非高危组LVEF与对照组无明显差异[(65.32±0.73)%vs(68.32±0.51)%,P0.05]. Pearson直线相关分析示:高危组NT-proBNP水平与hs-cTnT水平呈正相关(r=0.93,P0.01),而与LVEF呈负相关(r=-0.45,P0.05),非高危组NT-proBNP水平与hs-cTnT水平呈正相关(r=0.82,P0.01),而与LVEF亦呈负相关(r=-0.41,P0.05).制订NTproBNP危险分层指数为4400 ng/L,是诊断CRI合并CHF的最佳截点,具有较好的敏感性(82.1%)、特异性(84.6%)及准确度(86.3%)。结论 CRI合并CHF患者血浆中NT-proBNP水平显著升高,hs-cTnT,LVEF发生相应改变,制订出NT-proBNP危险分层指数对CRI合并CHF患者危重程度的诊治具有一定的临床价值。     

重组人癌胚抗原的原核表达及其在质控品中的应用

目的原核表达人癌胚抗原(CEA),并将重组蛋白作为原材料应用在质控品的开发中。方法利用基因工程方法构建原核表达载体p Cold1-cea,通过大肠埃希菌BL21(DE3)进行原核表达得到重组人癌胚抗原(rh CEA)。结果得到了rh CEA的包涵体,经纯化及透析复性后得到可溶的、具有免疫活性形式的重组蛋白,并将其利用在质控品的研制中。研制出的质控品在Abbott平台上的检测结果为:高值235.35 ng/m L,中值68.04 ng/m L,低值11.97 ng/m L;在Roche平台上的检测结果为:高值32.27 ng/m L,中值7.99 ng/m L,低值1.35 ng/m L;在Wondfo平台上的检测结果为:高值5 ng/m L,中值和低值未能检出。结论原核表达的rh CEA在不同检测平台上的检测结果相差较大。rh CEA质控品更适用于Abbott平台,而不适合于其他2种平台。     

胶乳增强免疫比浊法两种定量试剂检测D-二聚体的评价

目的应用胶乳增强免疫比浊法对两种定量试剂(西门子,九强)检测D-二聚体(D-D)的准确度、精密度及检测结果的一致性进行评价。方法收集新鲜凝血标本50份,应用两种不同试剂在sysmex CA-7000全自动凝血分析仪进行D-二聚体检测,比较其检测结果的一致性,通过对质控品的测定来比较两种试剂的精密度和准确度。结果准确度通过检测自身质控品和对方质控品进行评价,西门子试剂检测D-二聚体的相对偏差分别为-2.0%和-8.7%,九强试剂检测D-二聚体的相对偏差分别为-2.2%和26%;精密度通过20次室内质控结果进行评价,西门子试剂的检测均值为4.9±0.19 mg/L,CV为3.88%,差异无统计学意义(t=0.117,P>0.05),九强试剂检测的均值为4.5±0.17 mg/L,CV为3.69%,差异无统计学意义(t=0.132,P>0.05);检测结果一致性的对比显示:在D-D<0.5　mg/L时,两种定量试剂差异无统计学意义(P>0.05);在0.5　mg/L0.05);但在D-D>5　mg/L时,九强试剂显著高于西门子试剂,差异具有统计学意义(P<0.01)。结论两种试剂的精密度良好,准确度在检测对方质控品时结果不令人满意,九强试剂在D-D>5 mg/L时的准确度尚需进一步论证。     

降钙素原室内质控品的制备与应用

目的评价降钙素原(PCT)室内质控品的制备方法与应用价值。方法收集该院检验科日常工作中PCT检测水平正常和较高患者的血清标本,根据0.5 ng/L和2.0 ng/L两个医学决定水平,自制PCT高、低两水平室内质控品,每天与罗氏质控品共同进行检测,以评价自制PCT室内质控品的均匀性和稳定性。结果自制PCT室内质控品的瓶间不精密度分别为1.04%和0.96%,满足≤1/3室内不精密度要求。自制PCT室内质控品复融后稳定性评价结果均在控制范围内。长期稳定性评价结果显示,自制PCT室内质控品12个月的室内不精密度分别为4.36%和3.89%,均≤1/3允许总误差(TEa)(TEa=25%);根据12个月的质控图和Westgard规则判断,自制PCT室内质控品与罗氏质控品的相关性良好,无偏离现象,与罗氏质控品同步出现7次质控失控现象,均与试剂有关,校准后重新检测即在控。结论自制PCT室内质控品的均匀性、稳定性良好,在-20℃条件下保存时,稳定时间可达12个月,适用于实验室PCT检测系统的室内质量控制。     

流式细胞术检测P选择素的方法学性能评价

目的对流式细胞术(FCM)检测P选择素进行方法学性能评价。方法参考美国临床和实验室标准化协会(CLSI)系列文件,结合工作实际,设计验证方案,对BD Aria流式细胞仪检测系统测定血浆P选择素的精密度、准确度、分析灵敏度、分析测量范围和生物可参考区间五大分析性能进行验证和评价,并将实验结果与厂家(美国BD公司)提供的分析性能或公认的质量指标进行比较。结果 P选择素含量在39.06和10 000 ng/L时,批内变异系数分别为4.23%和9.00%,批间变异系数分别为4.63%和11.00%,准确度相对偏倚分别为2.71%和5.28%;检测灵敏度为7.88 ng/L,分析测量范围为7.88~103 928.00 ng/L,生物参考区间验证为4 512.20~10 250.00 ng/L。结论 BD Aria流式细胞仪检测系统检测血浆P选择素的分析性能符合厂家提供的性能指标和公认的质量指标。     

高敏肌钙蛋白T和普通肌钙蛋白I在急性心肌梗死早期诊断中的临床应用价值

目的通过对高敏肌钙蛋白T(hs-cTnT)和普通肌钙蛋白I(cTnI)的检测,探讨hs-cTnT、cTnI在急性心肌梗死(AMI)早期诊断中的应用价值。方法选取2015年10月至2016年3月北京大学深圳医院心血管内科已确诊AMI患者100例作为观察组(AMI组),同时选取100例健康体检成年人作为对照组,采用化学发光免疫法检测hs-cTnT和cTnI水平,并比较AMI组hs-cTnT和cTnI对AMI早期诊断的阳性率、敏感度和特异度。结果 AMI组hs-cTnT水平为(4.89±1.83)ng/mL高于健康人群第99百分位值的0.014ng/mL,cTnI水平为(28.82±12.32)ng/mL高于健康人群正常参考值上限0.4ng/mL,两者水平均明显高于对照组(P0.05),hs-cTnT的阳性率和敏感度均为92.0%,明显高于cTnI的79.0%(均P0.05),cTnI的特异度为96.0%显著高于hs-cTnT的76.0%(P0.05)。结论 hs-cTnT的阳性率和敏感性高,cTnI的特异性高,两者联合检测对于AMI的早期诊断具有重要意义。     

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.     

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.     

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.     

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.