基于标准化患者法评价四川农村基层医生两种慢性病诊断准确性及其影响因素

目的 运用标准化患者法评估四川农村地区基层医生不稳定型心绞痛和2型糖尿病两种慢性病诊断准确性现状,探讨基层医生两种慢性病诊断准确性的主要影响因素,为提升基层医生两种慢性病诊断准确性提供科学依据。方法 采用多阶段随机整群抽样方法,抽取四川省自贡市5个区/县50个乡镇100个村为研究现场,以调查当日在岗的全科及内科医生作为研究对象。共进行两轮数据采集,第1轮采集样本乡镇卫生院和村卫生室医生的基本信息;第1轮调查完成1个月后,运用标准化患者法开展第2轮调查,收集农村基层医生对不稳定型心绞痛和2型糖尿病诊断结果信息。运用Logistic回归分析农村基层医生不稳定型心绞痛和2型糖尿病诊断准确性的影响因素。结果 共纳入172名农村基层医生,完成186次标准化患者访问,正确诊断率为48.39%。其中不稳定型心绞痛的正确诊断率为18.68%(17/91),2型糖尿病的正确诊断率为76.84%(73/95)。Logistic回归分析显示,具有执业医师资质的农村基层医生更有可能做出正确诊断(OR=4.857,95%CI=1.076~21.933,P=0.040)。农村基层医生在诊断过程中涉及的必要问诊和检查条目越多,做出正确诊断的概率越高(OR=1.627,95%CI=1.065~2.485,P=0.024)。与不稳定型心绞痛相比,农村基层医生对2型糖尿病做出正确诊断的可能性更高(OR=6.306,95%CI=3.611~11.013,P<0.001)。结论 四川农村基层医生不稳定型心绞痛和2型糖尿病诊断准确性整体较差,建议以基层医生慢性病诊断过程质量改善为突破口,提升基层医生执业水平,进而提高慢性病诊断准确性。     

Epidemiologic and socioeconomic factors impacting hepatitis B virus and related hepatocellular carcinoma

Chronic Hepatitis B is a highly prevalent disease worldwide and is estimated to cause more than 800000 annual deaths from complications such as cirrhosis and hepatocellular carcinoma (HCC). Although universal hepatitis B vaccination programs may have reduced the incidence and prevalence of chronic hepatitis B and related HCC, the disease still imposes a significant healthcare burden in many endemic regions such as Africa and the Asia-Pacific region. This is especially concerning given the global underdiagnosis of hepatitis B and the limited availability of vaccination, screening, and treatment in low-resource regions. Demographics including male gender, older age, ethnicity, and geographic location as well as low socioeconomic status are more heavily impacted by chronic hepatitis B and related HCC. Methods to mitigate this impact include increasing screening in high-risk groups according to national guidelines, increasing awareness and health literacy in vulnerable populations, and developing more robust vaccination programs in under-served regions.     

氯雷他定联合阿伐斯汀治疗慢性难治性荨麻疹的效果及安全性分析

目的 探讨氯雷他定联合阿伐斯汀治疗慢性难治性荨麻疹的效果及安全性。方法 选择2019年1月至2020年6月本院接收的慢性难治性荨麻疹患者85例,采用随机数字表法将其分为对照组(42例)和观察组(43例)。对照组采用阿伐斯汀胶囊口服治疗,在对照组基础上,观察组采用氯雷他定片口服治疗,治疗4周后,比较两组临床疗效、实验室相关指标[白细胞(WBC)、5-羟色胺(5-HT)、血清免疫球蛋白(IgE)]、安全性。结果 观察组临床总有效率(95.35%)高于对照组(78.57%),差异有统计学意义(χ2=5.308,P=0.021);治疗4周后,观察组5-HT水平(127.65±8.61)μg/L高于对照组的(104.52±9.32)μg/L,IgE水平(57.41±7.53)IU/mL、WBC水平(9.20±1.95)g/L低于对照组的(72.26±8.40)IU/mL、(11.31±2.04)g/L,差异有统计学意义(t=11.889、8.587、4.875,P均=0.000);观察组不良反应发生率(11.63%)与对照组(7.14%)对比,差异无统计学意义(χ2=0.501,P=0.713)。结论 予以慢性难治性荨麻疹患者氯雷他定联合阿伐斯汀治疗效果确切,可改善患者实验室相关指标,且未明显增加不良反应,安全性较高。     

Efficacy,immunogenicity, and safety of available vaccines in children on biologics: A systematic review and meta-analysis

Vaccinations are essential for preventing infectious diseases in children with chronic diseases as they have increased risk of infection from frequent use of biologics. Response to immunizations in this group is not well known.ObjectiveA systematic review was performed to evaluate three primary outcomes: efficacy; immunogenicity; and safety of vaccines in children with chronic conditions treated with biologics.MethodsThe protocol for our systematic review and meta-analysis was registered and published with PROSPERO. We searched electronic bibliographic databases for studies published from 2009 to 2019, focusing on vaccinations in children with chronic conditions treated with biologics.ResultsWe retrieved 532 records. Thirty-one full-text articles were selected, and 14 were included in the meta-analysis. No significant publication bias was found. Efficacy: limited data are available regarding the efficacy of vaccination, as most studies have focused on immunogenicity as surrogate outcome for efficacy. Immunogenicity: patients receiving anti-TNF-alpha therapy had a statistically significant risk of poor seroconversion (p = 0.028) and seroprotection by the serotype B influenza vaccine [inflammatory bowel disease (IBD) p = 0.013; juvenile idiopathic arthritis (JIA) p = 0.004]. We found adequate responses with H1N1 and H3N2 serotypes. Few studies existed for pneumococcal, hepatitis A virus, hepatitis B virus, varicella-zoster virus, Measles Mumps Rubella virus, and multiple vaccine administration. Safety: vaccine administration was not associated with serious side effects, but JIA patients on anti-TNF alpha therapy had a statistically significant risk of presenting with myalgia or arthralgia postinfluenza vaccine (p = 0.014).ConclusionsMore evidence concerning efficacy, immunogenicity, and safety of vaccinations is needed to guide physicians in the vaccine decision process for this pediatric population.     

Dual-Energy Computed Tomography as an Adjunct in the Evaluation of Peripheral Chronic Total Occlusions: A Feasibility Study

This study investigated the role of dual-energy computed tomography (CT) for lesion characterization in patients with peripheral arterial disease manifesting with chronic total occlusions (CTOs). Forty-one symptomatic patients with CTOs underwent dual-energy CT angiography before endovascular treatment. The lesions were subsequently analyzed in a dedicated workstation, and 2 indexes—dual-energy index (DEI) and effective Z (Z_eff)—were calculated, ranging from 0.0027 to 0.321 and from 6.89 to 13.02, respectively. Statistical analysis showed a significant correlation between the DEI and Z_eff values (P < .001). The interobserver intraclass correlation coefficient was 0.91 for the mean Z_eff values and 0.86 for the mean DEI values. This technique could potentially provide useful information regarding the composition of a CTO.     

慢阻肺急性加重期患者延迟就医与家庭动力学的相关性研究

目的研究慢阻肺急性加重期患者延迟就医与家庭动力学的相关性,希望能够为慢阻肺急性加重期患者拟定护理措施提供科学依据。方法选取2017年1月-2019年12月我院240例诊断为慢阻肺急性加重期的患者为研究对象。根据患者入院就医的时间进行分组,时间≥24h的延迟就医的患者为观察组,时间<24h的及时就医患者为对照组。结果两组患者在文化水平、家庭年收入、在职状态、医疗保险和婚姻状况和APACHEⅡ评分比较(P<0.05)。观察组患者疾病观念、个性化、系统逻辑和家庭氛围得分比对照组高(P<0.05)。Pearman的相关性分析结果显示:慢阻肺急性加重期患者延迟就医时间与各个层面分数以及家庭动力总分呈现负相关性(P<0.05)。应变量为延迟就医为应变量,患者的一般资料为自变量,经Logistic回归分析结果表明:延迟就医的影响因素为文化水平、家庭动力评分、职业状态、家庭收入、婚姻状况和APACHEⅡ评分。结论慢阻肺急性加重期患者家庭动力总分与疾病观念、个性化、系统逻辑和家庭氛围得分与延迟就医时间呈现负相关性,患者延迟就医的影响因素是家庭动力学评分。     

基于规律成簇的间隔短回文重复序列及其相关蛋白技术检测乙型肝炎病毒共价闭合环状DNA方法的建立

目的建立一种基于规律成簇的间隔短回文重复序列及其相关蛋白(CRISPR/Cas13a)的乙型肝炎病毒(HBV)共价闭合环状DNA(HBV cccDNA)检测方法。方法提取2017年6月至2020年10月于首都医科大学附属北京佑安医院就诊的4例乙型肝炎患者肝脏总DNA后,使用HindⅢ内切酶和质粒安全性ATP依赖DNA酶(PSAD)分别进行酶切;根据松弛环状DNA(rcDNA)和cccDNA的结构差异,设计特异性扩增HBV cccDNA的引物,对酶切后的产物进行滚环扩增(RCA)和PCR扩增;并筛选crRNA,建立基于CRISPR/Cas13a技术的HBV cccDNA检测新方法。结果利用α-1-抗胰蛋白酶(A1AT)和HBV表面抗原(HBsAg)引物对双重酶切后的产物进行扩增,验证产物中HBV基因组的存在;利用HBV cccDNA和HBV rcDNA引物对PSDA酶切后的产物扩增,验证了产物中只存在HBV cccDNA;利用RCA后的阳性样本作为模板梯度稀释,然后进行PCR扩增转录后使用CRISPR/Cas13a检测,计算出检测下限为10拷贝/μl。结论本研究建立了RCA-PCR-CRISPR-Cas13a的新型检测方法,可对HBV cccDNA进行高灵敏度和高特异性检测,为乙型肝炎患者抗病毒治疗评估、治疗终点的确定以及调整治疗方案提供了有效的监测手段。     

CD19+CD24hiCD38hi B细胞比例预测肝移植术后急性细胞性排斥反应发生的临床研究

目的分析肝移植术后受者外周血CD19⁺CD24^hiCD38^hi B细胞占单个核细胞比例变化情况及其与急性细胞性排斥反应(ACR)之间的关系。 方法回顾性分析2013年12月至2015年12月在浙江大学医学院附属第一医院接受心脏死亡器官捐献肝移植的80例成人受者临床资料，根据术后是否发生ACR，将受者分为ACR组(25例)和非ACR组(55例)。术前、术后各个时间点抽取参加研究者静脉血并分离外周血单个核细胞，加入异硫氰酸荧光素-单克隆鼠抗人CD19抗体、藻红蛋白-单克隆鼠抗人CD24抗体和别藻蓝蛋白-单克隆鼠抗人CD38抗体，流式细胞仪检测各组CD19⁺CD24^hiCD38^hi B细胞百分比。采用t检验和单因素方差分析比较正态分布计量资料，采用χ²检验比较计数资料，采用Kaplan-Meier法绘制受试者工作特征曲线(ROC曲线)。P<0.05为差异有统计学意义。 结果ACR组、非ACR组受者术前外周血平均CD19⁺CD24^hiCD38^hi B细胞比例分别为(3.13±0.91)%、(3.49±0.83)%，差异无统计学意义(t＝1.636，P>0.05)。ACR组术后发生ACR前外周血平均CD19⁺CD24^hiCD38^hi B细胞比例为(1.87±0.70)%。非ACR组受者术后3个月、6个月和1年外周血平均CD19⁺CD24^hiCD38^hi B细胞比例分别为(1.64±0.52)%、(1.63±0.56)%和(2.04±1.24)%，术后3、6个月平均值均低于术前和术后1年，差异均有统计学意义(P均<0.05)。ACR组受者发生ACR时外周血平均CD19⁺CD24^hiCD38^hi B细胞比例为(0.8±0.5)%，低于发生ACR前的平均水平(t＝5.752，P<0.05)，且低于非ACR组术后3个月、6个月和1年的平均水平(P<0.05)。ACR组受者接受抗排斥反应治疗后，CD19⁺CD24^hiCD38^hi B细胞比例也逐渐增加，ACR发生后7 d为(0.84±0.08)%，与ACR发生时相比差异无统计学意义(P>0.05)；而发生30 d后达(1.65±0.18)%，与ACR发生时相比差异有统计学意义(P<0.05)。当截断值为1.015%时，CD19⁺CD24^hiCD38^hi B细胞比例预测ACR发生的敏感度和特异度分别为0.786和0.702，ROC曲线下面积为0.775(95%CI: 0.671~0.879，P<0.05)。 结论CD19⁺CD24^hiCD38^hi B细胞比例下降与肝移植术后ACR反应发生有关，并可作为预测ACR发生的细胞标志物。