骨髓增殖性疾病MPLW515L点突变研究

为了探讨MPLW515L和JAK2V617F点突变在南京地区骨髓增殖性疾病（MPD）中的突变情况，采用等位基因特异性聚合酶链反应（AS-PCR）及基因测序方法检测190例MPD患者的MPLW515L和JAK2V617F点突变。结果表明：102例原发性血小板增多症（ET）患者有1例存在MPLW515L点突变，突变率为1．0％；43例存在JAK2V617F点突变，突变率为42．2％。13例特发性骨髓纤维化（IMF）患者未检测到MPLW515L点突变；5例存在JAK2V617F点突变，突变率为38．5％。32例真性红细胞增多症（PV）患者未检测到MPLW515L点突变；20例存在JAK2V617F点突变，突变率为62．5％。43例慢性髓系白血病（CML）患者未检测到MPLW515L和JAK2V617F点突变。结论：AS—PCR检测MPLW515L和JAK2V617F点突变简便可靠。ET患者中可存在MPLW515L点突变，JAK2V617F点突变存在于PV、ET、IMF中，而CML患者不存在JAK2V617F点突变。     

原发性血小板增多症及原发性骨髓纤维化患者MPL515突变的筛查

目的 建立一种能够简便、灵敏地检测原发性血小板增多症(ET)及原发性骨髓纤维化(PMF)患者外周血MPL515突变的方法,探讨我国ET和PMF患者的MPL5I5突变频率及JAK2V617F突变情况.方法 选取2008至2010年复旦大学附属华山医院ET患者261例和PMF患者25例,提取患者外周血DNA.使用SYBR Green Ⅰ荧光定量PCR检测标本的JAK2V617F突变.分别采用针对MPL515wt、MPIW515L和MPLW515K这3种基因型设计的Taqman探针,使用荧光定量PCR法检测MPL515突变,并通过T-A克隆挑取纯克隆测序确认.结果 在261例ET患者中,检测到JAK2V617F突变119例(45.6％),MPL515突变7例(2.7％),包括5例MPLW515L突变、1例MPLW515K突变和1例MPLW515L+K突变.25例PMF患者中,JAK2V617F突变为10例(40.0％),M PL515突变为3例(12.0％),包括1例MPLW515L突变和2例MPLW515L+K突变.1例M PLW515K突变的ET患者同时伴有JAK2V617F突变.结论 JAK2V617F是ET和PMF的分子标志物,而在JAK2V617F阴性的病例中,MPL515突变则是一个重要、有益的补充.     

骨髓增殖性肿瘤患者TET2基因SNP rs3733609 C/T与JAK2V617F突变负荷关系的研究

目的:探讨骨髓增殖性肿瘤(myeloproliferative neoplasms,MPN)患者中TET2基因SNP rs3733609 C/T多态性与JAK2V617F基因突变负荷的关系。方法:采用RT-PCR法扩增TET2基因9号外显子,基因测序法分析SNP rs3733609位点碱基序列;应用MGB Taqman探针PCR法定量检测JAK2V617F突变负荷,分析TET2基因SNP rs3733609 C/T与JAK2V617F突变负荷及临床参数之间的相关性。结果:85例JAK2V617F+MPN患者中19例(22.4%)检出TET2基因rs3733609 C/T杂合多态性(正常为T/T),106例健康志愿者中仅有9例检测出,发生率仅为8.5%(9/106)。与阴性组(TET2 rs3733609 T/T)相比,TET2基因SNP rs3733609(CT/TC)+患者在中位年龄、血红蛋白水平、血小板计数无显著差异,而外周血白细胞数、JAK2V617F突变负荷显著增高。JAK2V617F高突变负荷组TET2基因SNP rs3733609(CT/TC)+7例(36.8%,7/19),其比例高于低突变负荷组(18.2%,12/66)。结论:TET2 SNP rs3733609 C/T可能是一个新的MPN易感等位基因,影响MPN患者的临床特点及克隆演化。     

30例早期骨髓增殖性疾病疑似患者JAK2V617F和MPLW515L/K突变基因的表达

目的 探讨BPC及Hb水平轻微升高,但未达真性红细胞增多症(PV)或原发性血小板增多症(ET)诊断标准的患者JAK2V617F及MPLW515L的表达情况与某些临床特征的相关性在早期骨髓增殖性疾病(MPD)中的诊断价值.方法 采用等位基因特异性PCR方法,检测30例BPC或Hb值偏高的早期MPD疑似患者JAK2V617F和MPLW515L/K基因表达,并定期随访其病情进展.结果 30例患者中有14例(46.7%)存在JAK2V617F突变,且此14例患者中有5例(35.7%)曾有血栓史;30例患者中无一例存在MPLW515L表达;有效随访22例,JAK2V617F阳性12例,阴性10例,12例阳性患者经过6至24个月后均发展为典型的MPD,而10例阴性患者只有2例发展成MPD.结论 JAK2V617F阳性表达有可能作为诊断早期MPD的重要依据.     

Ph阴性骨髓增殖性肿瘤患者驱动基因突变的临床分析

目的:探讨费城染色体阴性(Ph~-)骨髓增殖性肿瘤(MPN)患者驱动基因突变与患者临床特征的关系,为疾病诊治提供依据。方法:回顾性分析2013年1月至2016年12月于福建医科大学附属协和医院住院的410例Ph~-经典型MPN患者临床资料,包括真性红细胞增多症(PV)150例,原发性血小板增多症(ET)188例和原发性骨髓纤维化(PMF)72例。JAK2 V617F、JAK2 exon12、CALR和MPL W515L/K突变采用PCR或DNA测序的方法检测,电话或门诊随访更新患者临床资料。结果:在410例Ph~- MPN患者中,136(33.2%)例患者初诊时无症状;389例患者行基因检测发现87.1%(122/140)PV患者检出JAK2 V617F,JAK2 exon12突变1例;64.1%(118/184)ET患者检出JAK2 V617F,MPL W515L/K突变1例,CALR突变18(9.8%)例;64.6%(42/65)PMF患者检出JAK2 V617F,MPL W515L/K突变1例,CALR突变5(7.7%)例。JAK2 V617F突变PV患者在年龄、外周血白细胞、血小板计数和脾肿大发生率方面均高于其野生型患者(P0.05);JAK2 V617F突变ET患者在年龄、白细胞计数及血栓事件发生率方面均高于其野生型及CALR突变患者,血红蛋白水平高于其野生型患者,而血小板计数低于其野生型及CALR突变患者(P0.05);JAK2 V617F或CALR突变PMF患者脾肿大发生率均高于JAK2 V617F野生型患者,JAK2V617F野生型PMF患者白血病转化率高于其突变型患者(P0.05)。结论:在Ph~- MPN患者中,驱动基因突变类型与患者临床特征及预后密切相关。     

联合检测JAK2V617F、MPLW515L/K和CALR基因突变在原发性血小板增多症患者中的意义

目的研究成人原发性血小板增多症(PT)患者外周循环血液中JAK2V617F、MPLW515L/K和CALR基因的突变率,并分析联合检测的诊断价值。方法共纳入342例单纯血小板持续升高(≥300×109/L)的患者,分别行血常规、骨髓活检和基因检测,共确诊PT患者154例(45.03%),继发性血小板增多症188例。采用等位基因特异性-聚合酶链反应(AS-PCR)检测JAK2V617F和MPLW515L/K的点突变,直接测序法检测CALR基因突变。结果 3种基因的突变型有两条电泳条带,野生型仅有一条;JAK2V617F和MPL突变不引起读码框改变,而CALR突变可导致读码框改变。PT组JAK2V617F和CALR基因突变率显著高于继发组,差异有统计学意义(P0.05);MPL阳性突变率为4.55%。采用受试者工作特征(ROC)曲线分析,单独检测JAK2V617F突变诊断PT的曲线下面积(AUC)为0.721,敏感度为72.4%,特异度为79.5%;单独CALR突变的AUC为0.664,敏感度为68.4%,特异度为82.4%;JAK2V617F联合CALR突变的AUC为0.862,敏感度为85.9%,特异度为87.8%。结论 PT中以JAK2V617F和CALR突变率较高,联合二者检测可明显提高PT的诊断价值。     

Ph染色体阴性骨髓增殖性肿瘤患者JAK2基因第12外显子突变研究

目的 探讨Ph染色体阴性骨髓增殖性肿瘤(MPN)患者JAK2基因第12外显子(JAK2 exon 12)突变情况及其与临床特征的关系.方法 采用等位基冈特异性聚合酶链反应(AS-PCR)检测573例Ph染色体阴性MPN患者JAK2 V617F突变,直接测序法检测JAK2 exon 12突变状态,克隆后测序鉴定突变类型.比较JAK2 exon 12突变与JAK2 V617F患者的临床和实验室特征,并研究该突变与表观遗传调节子基因突变及JAK2 46/1单倍型的关系.结果 在原发性血小板增多症(ET)、原发性骨髓纤维化(PMF)、骨髓增殖性肿瘤未分类型(MPN-U)及JAK2 V617F阳性真性红细胞增多症(PV)患者中均未发现JAK2 exon 12突变,在13例JAK2 V617F阴性PV患者中发现2例(15.4%)存在该基因突变,均为N542.E543del,即第542位天冬酰胺和第543位谷氨酸缺失.2例JAK2 exon 12突变的患者以红细胞增多为主要表现,白细胞及血小板计数增高不明显,骨髓以红系增生为主,血清促红细胞生成素(EPO)水平低于正常,造血干/祖细胞体外培养可检测到内源性红系集落(EEC),不伴有表观遗传调节子基因TET2、ASXL1、EZH2突变,其中1例患者46/1单倍型rs12340895和rs10974944位点均为CC基因型,另1例患者上述两个位点均为GC基因型.结论 JAK2 V617F阴性的ET、PMF、MPN-U患者无需再行JAK2 exon 12突变检测;JAK2 exon 12突变的PV患者具有特定的临床和实验室特征.     

高分辨熔解曲线法检测骨髓增殖性肿瘤患者 JAK2V617F 基因突变简

本研究探讨高分辨率熔解曲线（High resolution melting,HRM）法检测骨髓增殖性肿瘤（MPN）患者JAK2V617F基因突变的可行性.随机抽取29份2008年1月至2011年1月确诊为MPN患者的骨髓标本,应用HRM法检测JAK2V617F基因突变情况,并与等位基因特异性聚合酶链反应（AS-PCR）和测序法的检测结果比较分析.结果表明,经HRM法检测,在29份MPN患者骨髓标本中检出JAK2 V617F突变阳性11例,突变率为37.9％;与基因测序法比较,结果完全一致,符合率100％.而AS-PCR法与测序法比较,Kappa=0.179,P=0.316,一致性强度较差.结论：HRM方法具有简便、快速、特异性高等优点,可作为临床JAK2V617F基因突变的优选方法.     

骨髓增殖性疾病患者JAK2基因V617F突变频率、磷酸化JAK/STAT蛋白表达水平及临床意义

目的 探讨145例骨髓增殖件疾病患者JAK2基因V617F突变率;并分析JAK2基因V617F突变阳性患者的临床特点及意义.方法 应用PCR产物直接测序和等位基因特异性PCR技术检测145例骨髓增殖性疾病患者JAK2基因V617F突变.并应用Western blot方法测定JAK2基因V617F突变阳性患者JAK2蛋白、磷酸化JAK2蛋白及磷酸化STAT5蛋白表达;对JAK2基因V617F突变阳性与突变阴性的骨髓增殖性疾病患者临床资料进行比较,评价JAK2基因V617F突变阳性的临床意义.结果 ①本组病例真性红细胞增多症(PV)、特发性骨髓纤维化(ET)、原发性血小板增多症(IMF)患者JAK2基因V617F突变率分别为92%(64例中59例)、58%(43例中25例)和50%(38例中19例),等位基因特异性PCR检测较PCR产物直接测序有更高的JAK2基因V617F检出率[PV84%(64例中53例)、MIF 44%(43例中19例)、ET 39%(38例中15例)].②JAK2基因V617F突变阳性患者外周血单个核细胞磷酸化JAK2及磷酸化STAT5蛋白表达较突变阴性者明显增高(P<0.05).③JAK2基因V617F突变阳性骨髓增殖性疾病患者发病平均年龄偏大;平均白细胞计数高于突变阴性患者;血小板计数小于突变阴性患者;脾脏较突变阴性患者小;JAK2基因V617F突变阳性PV、ET和IMF患者血栓性事什发生率分别为17%、32%和16%;而突变阴性PV、ET和IMF患者血栓性事件发生率分别为0、16%和5%.结论 骨髓增殖性疾病患者有较高的JAK2基因V617F突变发生率,且JAK2基因V617F突变阳性患者易发生血栓事件.     

血小板明显波动的难治性贫血伴环状铁粒幼细胞增多的临床与生物学特征

为了探讨血小板明显波动的RARS与RARS—T在临床表现、分子生物学特征及预后转归的相关意义，采用骨髓细胞涂片和骨髓活检观察细胞形态学改变，用流式细胞术检测细胞免疫学特征，染色体分析检测细胞遗传学改变，应用AS—PCR、基因测序检测JAK2V617F、MPLW515L点突变。结果表明：本例患者确诊为RARS，多次发生血栓相关并发症，血钾水平与血小板计数呈正相关。血小板计数增高时，外周血及骨髓涂片中发现巨大畸形血小板，血小板大簇易见；骨髓活检示巨核细胞数量显著增多；JAK2V617F、MPLW515L基因突变均阴性。结论：RARS可向RARS—T转化，伴骨髓巨核细胞增殖、巨大畸形血小板、JAK2 V617F可能为阴性。病程中出现巨大血小板、血小板计数明显波动时同样要高度重视相关血栓事件的防治，监测相关基因突变。     

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.     

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.     

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.     

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.     

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.