肺灌注SPECT-CT显像对肺栓塞诊断和早期疗效评价的应用价值研究

目的探讨肺灌注SPECT-CT显像对肺栓塞(PE)的诊断效能及其在PE早期溶栓治疗疗效评价中的价值。方法回顾性收集临床确诊或可疑肺动脉栓塞患者76例,均接受了肺通气/灌注(V/Q)平面显像及肺灌注SPECT-CT显像,以临床综合资料来判定为确诊PE或排除PE。其中20例确诊为PE者,溶栓治疗后重复以上检查,盲法分析肺V/Q显像、肺灌注SPECT-CT显像对急性肺栓塞的诊断效能,通过肺段表观指数法评价治疗后灌注改善效果。结果肺栓塞患者50/76例(114个受累肺段,17个亚肺段),肺灌注SPECT-CT显像诊断肺栓塞患者47例(99个肺段,15个亚肺段)诊断PE的灵敏度、特异性、准确性分别为83.9%、90.9%,88.2%,明显高于肺V/Q平面显像(73.6%,78.2%和76%),肺灌注SPECT-CT显像对PE溶栓治疗后早期,27/41个肺段及10/12个亚肺段PE病灶可见完全恢复。结论肺灌注SPECT-CT显像在亚肺段PE及PE排除诊断方面具有一定优势,并能有效进行肺栓塞治疗疗效的评价。     

SPECT肺灌注/低剂量CT融合显像技术在肺栓塞中的诊断价值

目的 探讨SPECT肺灌注与低剂量螺旋CT融合显像(SPECT/CT)技术在肺栓塞(pulmonary embolism,PE)诊断中的临床应用价值.方法 对42例疑似PE患者进行检查,其D-二聚体升高＞0.5mmol/mL或者临床Wells评分＞2,行肺灌注平面显像,采集8个体位.再进行SPECT肺灌注显像与同机低剂量螺旋CT检查,并进行后处理融合,由2位有经验的核医学科医师共同完成图像分析.结果 SPECT/CT的灵敏度、特异性,阳性预测值,阴性预测值及准确性分别为96.43％、92.86％、96.43％、92.86％ 、95.24％,无不确定性结果.结论 SPECT/CT融合显像优于传统的核医学显像方法,灵敏度高,特异性强,有效、简便、准确、无创,可作为诊断PE的一种新的常规影像检查方法.     

血清D-二聚体在不同类型主动脉夹层诊断中的应用

目的 探讨不同类型主动脉夹层患者血清D-二聚体(D-dimer)水平及其诊断价值.方法 选取2018年1月至2020年1月在我院就诊且临床确诊为主动脉夹层的患者62例,根据检查分型结果分为Stanford A型30例(A组)和Stanford B型32例(B组).分别于患者入院后1、6、12、24、72 h及14 d检测患者血清D-dimer水平,分析其与不同类型主动脉夹层的相关性.结果 A组患者在入院后1、6、12、24、72h及14 d时检测血清D-二聚体水平均显著高于B组患者,差异均具有统计学意义(P＜0.05).A组治疗后11例死亡,19例生存;B组治疗后12例死亡,20例生存.A组死亡及生存患者血清D-二聚体水平均显著高于B组,且A组、B组死亡患者血清D-二聚体水平均显著高于生存患者,差异均具有统计学意义(P＜0.05).血清D-二聚体对Stanford A型主动脉夹层诊断的截断值为1 258.4μg/L,ROC曲线下面积AUC为0.92,灵敏度为73.46％,特异性为89.68％.D-二聚体对Stanford B型主动脉夹层诊断的截断值为989.7μg/L,ROC曲线下面积AUC为0.89,灵敏度为70.27％,特异性为88.47％.结论 D-二聚体在Stanford A型和Stanford B型主动脉夹层患者不同时期血清水平均不同,整体呈现Stanford A型高于Stanford B型.通过检测患者血清D-二聚体水平可辅助判断主动脉夹层分型,对临床诊疗具有重要应用价值.     

血清D-二聚体、NT-proBNP联合检测在小儿肺炎支原体感染心肌损害诊断中价值分析

目的 探讨血清D-二聚体(D-dimer)、N-末端脑钠素原(NT-proBNP)联合检测对小儿肺炎支原体感染并心肌损害的临床诊断价值.方法 选取2018年1月至2020年1月我院收治的肺炎支原体感染并心肌损害患儿108例为研究对象,按照纽约心脏病协会制定心脏功能分级(NYHA)分为I级(28例)、II级(26例)、III级(27例)、IV级(27例).检测并比较患儿血清D-dimer、NT-proBNP及肌酸激酶同工酶(CK-MB)、心肌肌钙蛋白I(cTnI)的差异.结果 IV级、III级患儿血清D-二聚体、NT-proBNP及CK-MB、cTnI水平均显著高于I、II级(P<0.05);II级患儿血清D-二聚体、NT-proBNP及CK-MB、cTnI水平显著高于I级(P<0.05).Pearson相关性分析显示,血清D-二聚体水平与CK-MB、cTnI水平均呈显著正相关(r分别为0.524、0.602,P<0.05);血清NT-proBNP与CK-MB、cTnI水平均呈显著正相关(r分别为0.573、0.621,P<0.05);血清D-二聚体水平与NT-proBNP水平呈显著正相关(r=0.619,P<0.05).ROC曲线显示,D-二聚体、NT-proBNP、CK-MB、cTnI及D-二聚体+NT-proBNP联合检测对肺炎支原体肺炎并心肌损害诊断的AUC分别为0.728、0.905、0.847、0.743、0.923;灵敏度分别为66.73％、89.47％、71.36％、67.24％、95.03％;特异性分别为73.49％、92.44％、66.28％、72.14％、96.53％.D-二聚体+NT-proBNP联合检测显著高于单一D-二聚体、NT-proBNP的诊断效能(P<0.05).结论 血清D-二聚体、NT-proBNP联合检测有助于肺炎支原体感染并心肌损害患儿的临床诊断及病情判断,对患儿的临床诊疗具有重要应用价值.     

ROC曲线评价D-二聚体诊断肺动脉栓塞的应用

目的:采用ROC曲线评价D-二聚体在肺动脉栓塞诊断中的准确性及阴性、阳性预测值。方法:选择112例经多层螺旋CT肺血管造影(MSCTPA)确诊为肺动脉栓塞患者(肺动脉栓塞组)和100例年龄和性别相匹配的体检健康人员(正常对照组)进行D-二聚体浓度定量测定。检测结果采用MedCalc软件绘制ROC曲线,计算AUC面积得出肺动脉栓塞诊断及排除诊断的最佳临界值,并据此评价D-二聚体在肺动脉栓塞排除诊断中的准确性和阴性、阳性预测值。结果:与正常对照组相比,肺动脉栓塞组D-二聚体浓度明显升高(P<0.01)。以0.61μg/ml作为肺动脉栓塞的诊断临界值的AUC面积为0.87,以0.20μg/ml作为肺动脉栓塞排除诊断临界值时的灵敏度为96.20%,阴性预测值为95.20%。结论:诊断肺动脉栓塞的D-二聚体检测最佳临界值为0.61μg/ml,排除诊断最佳临界值为0.20μg/ml。     

血浆D-二聚体、FDP、和尿ALB/Cr联合检测对早期糖尿病肾病临床诊断的价值

目的 探究血浆D-二聚体、FDP和尿ALB/Cr联合检测对早期糖尿病肾病临床诊断的价值.方法 选取我院2019年1月至2020年10月收治的113例早期糖尿病肾病患者作为EDN组,另选取50例单纯2型糖尿病患者作为T2DM组,并选取50例健康体检者作为健康对照组,检测三组受试者血浆D-二聚体、FDP的水平和尿ALB/Cr比值,并比较单个指标检测与联合检测对早期糖尿病肾病诊断的价值.结果 EDN组血浆D-二聚体和FDP均高于T2DM组和健康对照组,尿ALB/Cr比值低于T2DM组和健康对照组,差异有统计学意义(P<0.05),血浆D-二聚体、FDP和尿ALB/Cr联合检测诊断早期糖尿病肾病的特异性与灵敏度分别为95.38％和96.21％,较单个指标检测高.结论 血浆D-二聚体、FDP和尿ALB/Cr联合检测对早期糖尿病肾病的临床诊断具有一定的参考价值.     

TM、PIC、D-二聚体联合诊断骨外伤术后静脉血栓的价值分析

目的 探讨TM、PIC、D-二聚体在诊断骨外伤术后患者静脉血栓形成中的价值分析.方法 选择2016年2月1日至2017年2月1日我院收治的创伤性四肢骨折患者96例作为研究对象,所有患者均接受骨折内固定手术.术后4～5d进行彩色多普勒结合静脉造影检查,诊断出术后静脉血栓形成患者48例,作为观察组,术后未出现静脉血栓形成患者48例,作为对照组.观察两组患者术后的血栓调节蛋白(TM)、纤溶酶-抗纤溶酶复合物(PIC)和D-二聚体.结果 术后观察组患者的TM(9.12 ±2.09 IU/mL)、PIC(1.21 ±0.71 μg/mL)和D-二聚体(5.37±2.14 ng/mL)含量均显著高于对照组TM(7.21±1.68IU/mL)、PIC(0.92 ±0.24 μg/mL)和D-二聚体(2.34 ±0.66ng/mL),差异具有统计学意义(P＜0.05).回归分析显示D-二聚体、TM、PIC均与术后血栓的形成具有相关性(P均＜0.05);三者联合诊断对静脉血栓诊断受试者工作曲线下面积为0.903,诊断灵敏度为87.31％,特异性也高达85.05％.三者联合检测的灵敏度87.31％高于TM、PIC和D-二聚体单一检测(22.96％、35.85％、49.79％) (P ＜0.05);三者联合检测的准确度86.39％高于TM、PIC和D-二聚体单一检测(49.38％、58.38％、72.27％) (P ＜0.05).结论 检测骨外伤患者术后TM、PIC、D-二聚体指标含量的变化,联合检测有助于早期诊断静脉血栓形成,对预警静脉血栓形成有重要价值.     

CA125、HE4及D-二聚体血清表达水平对卵巢癌临床诊断和预后评估价值分析

目的 探究血清糖类抗原125(CA125)、人附睾分泌蛋白4(HE4)和D-二聚体表达水平对卵巢癌临床诊断及预后评估价值.方法 选取2016年1月至2018年6月我院收治确诊为卵巢癌患者80例为观察组;收治确诊良性卵巢肿瘤80例为良性对照组;同期体检的80例健康女性为健康对照组.检测三组受试者血清CA125、HE4及D-二聚体水平.另对观察组患者进行为期2年随访,汇总患者临床资料,Kaplan-Meier生存曲线分析随访期患者生存情况,以ROC曲线分析血清CA125、HE4及D-二聚体对卵巢癌预后评估价值.结果 观察组血清CA125、HE4及D-二聚体水平均显著高于良性对照组和健康对照组(P<0.05);良性对照组血清CA125水平显著高于健康对照组(P<0.05).CA125、HE4及D-二聚体对卵巢癌检测特异性分别为71.4％、69.1％、60.2％,灵敏度分别为69.8％、74.1％、73.7％;联合检测特异性为91.3％,灵敏度为94.8％,联合检测的特异性与灵敏度均显著高于单一指标检测(P<0.05).观察组80例患者随访2年期间复发19例,淋巴转移14例,TNM分期上升16例,死亡8例,总不良预后发生率为47.5％.患者Kaplan-Meier生存曲线可见术后时间延长而不良预后发生率逐渐增加.CA125、HE4及D-二聚体对卵巢癌预后的AUC分别为0.89、0.76、0.64;截断值分别为701.44U/mL、261.56pmol/L、2.97μg/mL;灵敏度分别为65.47％、61.59％、59.21％;特异性分别为89.69％、82.77％、82.89％.联合检测的AUC为0.94,灵敏度为84.26％,特异性为94.26％.结论 血清CA125、HE4及D-二聚体用于卵巢癌检测有助于临床诊断,而且对卵巢癌预后具有一定评估价值,尤以三者联合检测更能提高卵巢癌预后评价的准确性.     

超声、D-二聚体和AFP-L3对原发性肝癌诊断的对比研究

目的 探讨超声造影法和D-二聚体、AFP-L3水平的检测对原发性肝癌诊断准确性的差异,对比三种诊断方法,以提高对原发性肝癌的早期诊断的准确性.方法 对50例原发性肝癌患者分别进行超声造影检查,D-二聚体和AFP-L3水平的测定,比较三种诊断方式的真阳性率.结果 超声、D-二聚体和AFP-L3对原发性肝癌的确诊率分别为76％、54％、74％;超声和AFP-L3的确诊率较高,D-二聚体的漏误诊率较高,三者之间的待定率无显著性差异.超声和AFP-L3两项联合检测的敏感性及特异性与三项联合检测无显著性差异(P＞0.05).三项联合检测的敏感性与超声、D-二聚体单独检测有显著性差异(P＜0.05),联合检测的特异性与单独检测也有显著性差异(P＜0.05).结论 在临床上可优先选择超声或AFP-L3进行检测,必要时候两者进行联合检测,或再联合检测D-二聚体,提高对原发性肝癌的早期确诊率,降低漏误诊率.     

D-二聚体和肌钙蛋白I在急性心肌梗死与主动脉夹层早期鉴别中的应用

目的 探讨D-二聚体、肌钙蛋白I(cTnI)在急性心肌梗死(acute myocardial infarction,AMI)与主动脉夹层(aortic dissection,AD)早期鉴别中的诊断价值.方法 选取2019年1月至2020年12月来我院住院治疗的相关病例进行回顾性分析,比较2组患者一般资料、入院后首次D-二聚体及cTnI的检测水平;绘制ROC曲线分析D-二聚体、cTnI及二者联合检测对AMI与AD早期鉴别的诊断价值.结果(1)2组患者年龄、高血压、高血脂、糖尿病病史比较,差异具有统计学意义(P<0.05),男性比例比较,差异无统计学意义(P>0.05);(2)AD组患者血浆D-二聚体水平显著高于AMI组患者,AMI组患者血浆cTnI水平显著高于AD组患者,差异均具有统计学意义(P<0.05);(3)ROC曲线显示,D-二聚体鉴别诊断AMI和AD的AUC为0.955,95％CI在0.930～0.981之间,最佳界点值为1.40μg/mL,灵敏度、特异性为0.877、0.934;cTnI鉴别诊断AMI和AD的AUC为0.843,95％CI在0.801～0.885之间,最佳界点值为0.07ng/mL,灵敏度、特异性为0.886、0.705;D-二聚体联合cTnI鉴别诊断AMI和AD的AUC为0.982,95％CI在0.969～0.994之间,灵敏度、特异性为0.930、0.958,差异具有统计学意义(P<0.05).结论 D-二聚体、cTnI联合检测对急性心肌梗死与主动脉夹层的早期鉴别有较高的诊断价值.     

肺巨噬细胞在小鼠肺纤维化发生中的作用

本文以博莱霉素注入小鼠气管内诱发肺泡炎导致肺纤维化。对肺泡灌洗液（ＢＡＬ）内细胞进行分类，检测了ＢＡＬ中及肺泡巨噬细胞（ＰＭ）培养上清液内酸性酶活性，并检测了ＰＭ培养上清液对成纤维增殖的影响。结果表明，实验组ＢＡＬ中ＰＭ数增加，酸性酸酶活性上升，并与肺胶原蛋白含量相关，ＰＭ培养上清使肺成纤维细胞＾３Ｈ－Ｔdisplay status     

贝前列素钠治疗肺源性心脏病肺动脉高压的临床研究

目的:观察贝前列素钠治疗肺源性心脏病(肺心病)肺动脉高压的临床疗效。方法:将68例肺心病急性发作期患者随机分为对照组(n=31)和贝前列素钠组(n=37)。两组患者均给予抗感染、止咳、化痰、平喘、强心利尿等常规治疗,贝前列素钠组在上述治疗的基础上加口服贝前列素钠治疗。比较两组疗效和外周动脉压(PABP)、肺动脉压(PAP)、左室射血分数(LVEF)、血脑钠肽(BNP)、血气[酸碱度(pH),氧分压(PaO2)、二氧化碳分压(PaCO2)、血氧饱和度(SaO2)]及血清C反应蛋白(CRP)、内皮素-1(ET-1)、一氧化氮(NO)水平变化。结果:贝前列素钠组总有效率明显高于对照组(94.59%vs 77.42%,P0.05),显效率也显著高于对照组(48.65%vs 16.12%,P0.01)。治疗后两组PAP、CRP、ET-1、NO、BNP、血气指标较治疗前均明显改善(P0.05或P0.01);贝前列素钠组较对照组PAP、PaCO2、ET-1、BNP降低更明显(P0.01),PaO2、SaO2、NO升高更显著(P0.01)。结论:贝前列素钠可以明显降低肺心病肺动脉高压患者肺动脉压,改善心功能,这可能与其降低ET-1和提高NO水平有关。     

Pulmonary sarcoidosis

Sarcoidosis is a multisystemic disease of unknown aetiology characterized by the formation of immune granulomas in involved organs. It is a worldwide disease that mainly affects 25-40 years old people with a lifetime incidence rate of 0.85-2.4%. Multiple clinical phenotypes are observed according to presentation, involved organs, disease duration and severity. Sarcoidosis primarily affects the lungs and the lymphatic system. The prevailing pathogenic hypothesis is that various antigens could promote sarcoidosis in genetically susceptible hosts, both these factors modulating the incidence and the clinical phenotype of sarcoidosis. So far, environmental agents have been suspected, including possible mycobacteria and propionibacteria. Interferon-gamma, tumour necrosis factor (TNF)-alpha, interleukin (IL)-12 and IL-18 play a critical role in driving the Th1 commitment in the course of granulomatous process. Evolution of sarcoidosis is often marked by spontaneous resolution within 12-36 months, but can be severe because of chronic cases with pulmonary fibrosis or involving other organs, including heart, central nervous system and eyes. Mortality, ranging between 0.5 and 5%, is most often related to pulmonary fibrosis. Corticosteroids can reverse the granulomatous process, but are only suspensive, and their long-term benefit remains under question. Corticosteroids are recommended when sarcoidosis shows unfavourable clinical tolerance and evolution. Alternative and corticosteroid-sparing therapies are of increased interest in difficult cases, while targeted new drugs such as anti-TNF-alpha are still under investigation.     

Pulmonary Blastoma

Three cases of pulmonary blastoma exhibiting biphasic epithelial and stromal patterns, and a case of fetal lung type adenocarcinoma, were examined by immunohisto-chemistry and electron microscopy (EM) and compared with fetal bronchial epithelium in order to explore the multidirectional differentiation of their epithelial components. The glandular cells of all four tumors resembled fetal bronchial epithelial cells in the pseudoglandular stage. Neuroendocrine (NE) cells were also present: they were argyrophilic and expressed pan NE markers, neurose-cretory granules and peptide hormones. The neural cell adhesion molecule (NCAM) was strongly expressed on the cell membranes of glandular cells, as in the case of proximal bronchial epithelial cells at the pseudoglandular stage in fetal lung. Sialosylated Lewis^X was also expressed, indicating that the epithelial cells were possibly of endodermal origin. Two of the four cases showed considerable immunoreactivity for alpha fetoprotein (AFP). The epithelial cells of pulmonary blastomas may occasionally de-differentiate into cells functionally resembling fetal hepatic, foregut and yolk sac cells expressing AFP. Tumor examination by immunohistochemistry and EM suggested that the glandular cells of the tumors may differentiate to some extent like those of fetal large bronchi at the pseudoglandular stage, but there was concordance and discordance in the expression of neuroendocrine and oncofetal markers between blastomatous tumors and fetal bronchial epithelium. Acta Pathol Jpn 42: 884–892, 1992.     

Pulmonary Eosinophilia

Eosinophils may infiltrate the lung tissue, thus impairing gas exchange and causing several symptoms as dyspnea, fever, and cough. This process may be secondary to several factors, including drugs or parasite migration, or primary (idiopathic). Acute eosinophilic pneumonia is life-threatening and presents frequently in young smokers as an acute hypoxemic respiratory failure of generally less than a week with bilateral lung infiltrates, frequently misdiagnosed as severe community-acquired pneumonia. This patients present without peripheral eosinophilia but usually have more than 25% eosinophils on bronchoalveolar fluid. Chronic eosinophilic pneumonia is a protracted disease of usually more than a month before presentation, with a predilection for middle aged asthmatic patients. Hypoxemia is mild-moderate, and there are usually more than 1,000 eosinophils/mm3 of peripheral blood. Bronchoalveolar fluid has high eosinophil levels (usually more than 25%). Migratory peripheral infiltrates are seen in the chest x-ray film. Both acute and chronic eosinophilic pneumonia are treated by glucocorticoids and respiratory support as well as avoidance of any recognized trigger.     

Pulmonary blastoma

Summary A primary pulmonary tumour in a four year old boy arising from the subpleural zone of the lung is described. It contains both stromal and epithelial elements at the primary site and in the bony metastases. The combination of the age of the patient, the site of the tumour, the stromal and epithelial elements present in the tumour suggest that this is a true pulmonary blastoma. Electronmicroscopy showed the presence of intranuclear viral particles.     

Pulmonary fibrosis

Diffuse interstitial pulmonary fibrosis is the end result of alveolar damage which may occur as a sudden acute incident or as a slowly developing process. Potentiating factors include release of enzymes and generation of oxygen radicals by granulocytes. Evidence from studies on broncho-alveolar lavage fluid and from immunocytochemistry indicate that an autoimmune process has an important but, as yet, not clearly defined role in initiating the disease. The fibrosis is probably due to proliferation of small clones of fast growing fibroblasts of a specific phenotype. Bronchiolitis obliterans, organizing pneumonia, idiopathic pulmonary fibrosis, usual interstitial pneumonia and desquamative interstitial pneumonia represent different aspects of the same condition. Their varied morphological appearances probably reflect the fact that tissue has been taken at different stages in the development of the disease.     

Pulmonary cryptococcosis

Observation of an unusual pulmonary distribution of cryptococci in a patient at autopsy prompted a review of 36 patients with pulmonary cryptococcosis listed in the autopsy files of The Johns Hopkins Hospital. The patients ranged in age from 2 to 89 years (mean, 49 years), 19 were female, and 18 were black. All but three patients had underlying debilitating diseases, and 23 patients had received steroids and/or chemotherapy. In 25 patients (69 per cent) cryptococcosis was a major factor contributing to death, through pulmonary disease in ten, systemic involvement in seven, and central nervous system disease in eight. In 15 patients (42 per cent) cryptococcosis was diagnosed clinically. Four basic morphologic patterns were observed: 1) Seven patients (19 per cent) had one or more peripheral pulmonary granulomas. In three of these patients the granulomas were apparently quiescent, and no other lesions were found. 2) Nineteen patients (53 per cent) had what has been called granulomatous pneumonia, with intra-alveolar proliferating organisms and varying degrees of inflammatory response, which, when present, ranged from acute inflammation to diffuse intra-alveolar granulomas with giant cells. 3) In seven patients (19 per cent) organisms were present diffusely within alveolar capillaries and interstitial tissues, and reactions ranged from little or no inflammation with numerous organisms to few organisms with miliary granulomas. 4) In three patients (8 per cent) both intra-alveolar and intravascular organisms were present in massive numbers, and the primary route of infection was uncertain. Fatalities from pulmonary and generalized infection occurred in patients in each histologic group. The results show marked variability both in pathologic reaction to cryptococci and in the clinical appreciation and significance of pulmonary cryptococcosis.     

Pulmonary tuberculosis

We present a case of previously undiagnosed and unsuspected pulmonary tuberculosis (TB) identified on post mortem histology. The presentation of TB in the mortuary is reviewed and we present the key learning points regarding dealing with this infection in the post mortem patient.Trainees should appreciate that although a rare occurrence, pulmonary TB may go undiagnosed until after death, and given its ability to survive in the post mortem patient, the use of personal protective equipment is paramount.