无创产前基因检测在血清学筛查结果为高风险的非高龄孕妇中的应用

目的探讨用无创产前基因检测(NIPT)对血清学标志物筛查结果为高风险的非高龄孕妇(18~34岁)进行产前诊断的意义。方法选取4 168例血清学标志物筛查结果为高风险的非高龄孕妇,用高通量测序技术检测孕妇血浆中胎儿游离DNA(cff DNA),对检测结果为高危的孕妇进行胎儿染色体核型分析,个别病例用微阵列比较基因组杂交技术(array-CGH)验证。结果 NIPT结果显示共有41例孕妇为高风险,阳性率为0.98%,包括32例21-三体综合征(T21),4例18-三体综合征(T18),1例13-三体综合征(T13),4例性染色体异常;经胎儿核型分析证实为30例T21,2例核型正常;另外9例NIPT检测其他染色体非整体结果为高风险者经胎儿核型分析证实为3例T18,1例T13,2例性染色体异常;1例经NIPT检测为45,XO,而胎儿核型分析为46,XX,del(X)(q23→q25),array-CGH验证缺失片段大小为11.6×106bp。结论 NIPT用于血清学筛查结果为高风险的非高龄孕妇检测可减少侵入性的产前诊断,但存在一定的假阳性,仍需有创检查进行确诊。     

产前无创基因检测在诊断胎儿染色体非整倍体疾病中的临床价值

目的研究产前无创基因检测(NIPT)在诊断胎儿染色体非整倍体疾病中的临床价值。方法选取2013年9月至2017年8月在重庆华西妇产医院产科门诊行NIPT的孕妇3 685例作为研究对象,利用高通量基因组测序平台及生物信息分析技术,对母体静脉血中的游离DNA进行深度测序,获取胎儿染色体信息。对NIPT结果高风险的孕妇行羊膜腔穿刺及胎儿染色体核型分析,对NIPT结果阴性的孕妇进行电话随访。结果 3 685例孕妇行NIPT结果高风险孕妇有42例,检测报告显示,21-三体高风险31例,18-三体高风险6例,性染色体异常5例,阳性检出率为1.14%(42/3 685)。将纳入研究的3 685例孕妇按年龄分组,40岁以上患染色体非整倍体疾病高风险的阳性率为4.17%。染色体非整倍体疾病高风险孕妇42例,有5例NIPT结果高风险孕妇未做羊膜腔穿刺液细胞染色体核型分析,直接引产终止妊娠,对37例高风险的孕妇行羊膜腔穿刺液细胞染色体核型分析,其中21-三体27例,18-三体5例,性染色体异常5例。把NIPT高风险结果与羊膜腔穿刺液细胞染色体核型分析作为金标准进行比较,其中21-三体细胞染色体非整倍体异常高风险结果与羊膜腔穿刺液细胞染色体核型结果进行分析显示,符合率为96.30%(26/27),有1例假阳性结果,假阳性率为3.70%(1/27);18-三体细胞染色体非整倍体异常高风险结果与羊膜腔穿刺液细胞染色体核型结果分析显示,符合率为100.00%(5/5);性染色体异常非整倍体异常高风险结果与羊膜腔穿刺液细胞染色体核型结果分析显示,符合率为80.00%(4/5),有1例假阳性结果,假阳性率为20.00%(1/5)。NIPT诊断胎儿染色体非整倍体疾病的敏感度为100.00%(3 643/3 643),总特异度为94.59%(35/37),总假阳性率为0.05%(2/3 680),假阴性率为0.00%(0/0)。结论高通量基因组测序平台及生物信息分析技术具有较高的敏感度和特异度;重庆地区NIPT胎儿染色体非整倍体疾病的阳性检出率为1.14%,主要以21-三体检出为主,占73.81%;40岁高龄孕妇NIPT阳性率较其他年龄组高,达4.17%;NIPT在产前诊断胎儿染色体非整倍体疾病中有较高的临床应用价值,对预防出生缺陷有重要意义。     

胎儿染色体非整倍体无创产前基因检测技术在周口市的临床应用分析

目的探讨胎儿染色体非整倍体无创产前基因检测(non-invasive prenatal testing,NIPT)技术在周口市胎儿染色体非整倍体疾病筛查中的临床应用。方法选取2014年1月-2015年11月间,在周口市中心医院进行唐氏综合征筛查结果提示高风险(RISK1/275)、高龄孕妇(孕龄≥35岁)、有既往不良孕产史以及超声检查提示胎儿异常的共计829例孕妇,进行胎儿染色体非整倍体无创产前基因高通量测序分析,结果提示高风险的孕妇手术抽取羊水后核型分析。结果 612例唐氏筛查高风险孕妇组经外周血胎儿游离DNA检测结果提示高风险者共计7例(6例21-三体、1例18-三体);169例高龄孕妇组共检出1例18-三体结果高风险者;7例既往不良孕产史孕妇组检出1例21-三体结果高风险者;41例超声检查提示胎儿异常孕妇组共检出2例结果高风险(1例21-三体、1例13-三体)。NIPT结果提示21、18、13-三体异常高风险孕妇分别为8例、2例、1例,进一步行染色体核型分析的确诊例数分别为:8例、2例、1例,结果证实NIPT用于检测胎儿21-三体、18-三体、13-三体的敏感度为100%,特异度为100%,准确率100%,与染色体核型分析结果一致。结论周口市孕妇外周血游离胎儿DNA高通量测序分析可用于胎儿常见染色体非整倍体疾病的筛查,敏感度高、特异度强、准确率高应推广临床应用。     

高龄孕妇唐氏筛查-产前诊断序贯方案的选择与评估

目的探讨适宜高龄孕妇唐氏综合征(DS)筛查-产前诊断的序贯方案。方法选取2013年1月至2016年9月于佛山市南海区妇幼保健院妇产科接受早期、中孕期DS血清学筛查以及无创DNA产前检测的3012例高龄孕妇为研究对象。在不同的孕周分别进行早期、中孕期DS血清学筛查以及无创DNA产前检测,对血清学筛查风险值≥l/270或者无创DNA结果高风险的孕妇,均建议行羊膜腔穿刺染色体检查,以确诊胎儿是否为DS;对未接受羊膜腔穿刺染色体检查的孕妇,采用电话随访方式随访其妊娠结局。将这3012例孕妇的筛查结果按照两种序贯方案进行模拟筛查(早期血清学筛查-无创DNA产前检测-染色体核型分析;(2)中期血清学筛查-无创DNA产前检测-染色体核型分析)。分别计算两种方案的假阳性率和筛查效率并进行统计学比较。结果当选择方案(1)时,3012例高龄孕妇中,产前筛查高风险孕妇256例,18例最终被确诊为DS,筛查的假阳性率和筛查效率分别为7.90%和7.03%;而当选择方案(2)时,筛查的假阳性率和筛查效率分别为15.10%和3.81%,两种方案相比较,差异有统计学意义(P0.01)。结论相比中期血清学筛查-无创DNA产前检测方法,采用早期血清学筛查-无创DNA产前检测的序贯筛查方案,具有更高的筛查效率,有较高的临床应用价值。     

无创产前检测与血清生化筛查在染色体异常产前筛查的应用效果对比分析

目的 探讨无创产前检测(NIPT)与血清生化筛查在染色体异常产前筛查的应用效果。方法 回顾性分析2019年1月至2020年12月于我院进行产前筛查的孕妇782例,入选者均进行血清学、NIPT筛查,所有高风险病例孕妇进行羊水或脐带血染色体核型检查。以羊水或脐带血染色体核型分析作为诊断金标准,分析血清学筛查、NIPT诊断染色体异常的效能。结果 NIPT筛查出的高风险占比为4.09%,低于血清学筛查的12.28%,差异有统计学意义(P<0.05);所有高风险病例孕妇进行羊水或脐带血染色体核型检查后,检出染色体异常阳性17例,确诊率为2.17%;NIPT诊断染色体异常特异度98.04%(750/765)、准确度98.08%(767/782)、阳性预测值53.13%(17/32)均高于血清学筛查的89.67%(686/765)、89.90%(703/782)、17.71%(17/96),差异有统计学意义(P<0.05)。结论 染色体异常产前筛查中使用NIPT特异性、准确性均高于血清生化筛查,可减少漏诊误诊情况,值得临床广泛应用。     

无创产前基因检测技术在胎儿染色体非整倍体检测中的临床应用

目的 评价无创产前基因检测技术(NIPT)在产前胎儿染色体非整倍体筛查中的应用价值.方法 收集2017年10月至2021年6月在清远市人民医院行NIPT检测的6535例孕妇的临床资料,高风险孕妇行羊水穿刺术进行核型确诊,低风险孕妇进行产前产后电话随访.结果 6535例样本中共检出胎儿染色体非整倍体异常高风险88例,检出...     

外周血游离胎儿DNA检测在产前唐氏筛查中的应用价值研究

目的 探讨外周血游离胎儿DNA检测（NIPT）在产前唐氏筛查中的应用价值。方法 回顾性分析2020年8月至2022年8月于我院行DS产前筛查的1580例DS高风险孕妇的临床资料，所有孕妇均行外周血游离胎儿DNA、唐氏筛查及羊水穿刺-核型检查。结果 外周血游离胎儿DNA在DS诊断中的灵敏度、特异度、准确度、阳性预测值、阴性预测值均高于唐氏筛查，差异有统计学意义（P<0.05）。Kappa检验显示：唐氏筛查与“金标准”一致性尚可（kappa值=0.600,P=0.000）；外周血游离胎儿DNA与“金标准”一致性良好（kappa值=0.887,P=0.000）;24例NIPT阳性孕妇中，15例确诊为染色体异常，胎儿染色体异常发生率为0.95%(15/1580)，确诊13-三体综合体2例，18-三体综合体4例，21-三体综合体9例，与“金标准”符合率均为100.00%。结论 NIPT在产前唐氏筛查中具有较高的应用价值，可减少产前有创性诊断数量，增加诊断的准确性，降低新生儿出生缺陷，提高出生人口质量，减少不必要的胎儿流失。     

无创DNA检测技术在常州市产前筛查中的应用

目的探讨无创DNA产前检查(NIPT)在胎儿染色体非整倍体疾病诊断中的应用价值。方法选取2 237例接受唐氏筛查的孕妇,对其外周血中游离胎儿DNA进行测序分析,阳性者进行羊水穿刺及染色体核型分析;阴性者行电话随访。结果 (1)无创DNA检测结果为阳性者共23例,包括21-三体15例、18-三体4例、13-三体1例,性染色体异常3例。(2)23例结果异常的孕妇,22例进行了羊水穿刺及染色体核型分析。结果显示无创DNA检测技术的检出率为100%,准确率86.4%。结论 NIPT对孕妇外周血中游离胎儿DNA的检测准确率达86.4%,其高准确性、无创伤性等优点将使其成为未来产前筛查的主力手段。     

无创产前检测高风险胎儿的染色体核型及CMA结果分析

目的探讨无创产前检测(NIPT)技术在产前筛查中的应用价值。方法对189例NIPT高风险的孕妇在知情同意原则下行介入性手术,采集羊水或脐血标本进行染色体核型分析,对9例NIPT提示染色体结构异常者同时行染色体微阵列分析(CMA)。结果 189例NIPT高风险孕妇中,21-三体综合征高风险63例,18-三体综合征高风险25例,13-三体综合征高风险18例,提示性染色体异常62例,其他染色体数目异常14例,结构异常9例。其中1例既提示9号染色体数目增加也提示X染色体数目偏多,1例既提示18-三体综合征高风险也提示18号染色体存在4.5Mb重复。通过胎儿染色体核型分析和CMA检测,结果发现21-三体综合征高风险、18-三体综合征高风险、13-三体综合征高风险、性染色体数目异常、其他染色体数目异常及结构异常的阳性预测值分别为87.30%、84.00%、61.11%、59.68%、7.14%、44.44%。结论 NIPT具有较高的灵敏度和特异度,但仍存在一定的假阳性和假阴性,对NIPT提示高风险的孕妇仍需进一步行有创的产前诊断来进行验证。     

限制性胎盘嵌合对无创产前基因检测的影响

目的探讨限制性胎盘嵌合(CPM)对无创产前基因检测(NIPT)的影响。方法对16例经NIPT检测后结果提示高风险的孕妇进行产前诊断,采用羊膜腔穿刺术、脐血穿刺及荧光原位杂交技术(FISH)对胎儿进行产前诊断核型分析,并于引产或生产后对胎盘进行FISH或染色体微阵列分析(CMA)检测。结果经产前诊断14例标本与NIPT检测结果一致,且引产后胎盘组织检测结果与NIPT结果一致;2例产前诊断结果与NIPT结果不一致,其中1例经羊水细胞诊断核型正常,胎盘CMA检测存在21-三体嵌合,1例NIPT检测6号染色体三体高风险,经羊水细胞CMA诊断结果为arr[GRCh37]16p13.11(14892975_16528123)×1,胎盘CMA检测结果显示存在6号三体嵌合及16p13.11区域中1.36M缺失。经统计,NIPT结果与胎盘检测结果的一致率为93.8%(15/16),与产前诊断结果的一致率为87.5%(14/16)。结论 CPM的存在是引起NIPT结果与产前诊断结果不一致的重要原因,建议NIPT高风险的孕妇通过侵入性诊断来进一步明确诊断,检测结果高度提示为CPM的孕妇应加强胎儿宫内发育情况的监控,并留取胎盘标本,以进一步明确异常来源。     

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.     

手转胎头术失败的原因与分娩结局临床分析

目的 探讨手转胎头术失败的原因与分娩结局.方法 选择2008年1月至2010年12月于我院住院分娩的持续性枕横位、枕后位产妇198例,根据行手转胎头术后结果分为成功组126例、失败组72例.比较两组分娩结局,对比分析失败原因.结果 失败组胎儿体质量≥3500 g的发生率[76.4％(55/72)]明显高于成功组[31.7％(40/126)],差异有统计学意义(x2=30.177,P=0.001)、失败组宫缩乏力发生率[58.3％(42/72)]高于成功组[38.1％ (48/126)],差异有统计学意义(x2=7.569,P=0.006)、失败组骨盆临界或轻度狭窄发生率[38.9％ (28/72)]高于成功组[23.8％(30/126)],差异有统计学意义(x2 =5.030,P=0.002)、失败组手转胎头时机不当(宫口开大＜6 cm、胎头位于坐骨棘上及宫口开大8～10 cm、胎头位于坐骨棘下≥2 cm)发生率[61.1％(44/72)]高于成功组[38.9％(49/126)],差异有统计学意义(x2=9.084,P=0.003).失败组母儿并发症(产后出血、产褥病率、胎儿窘迫、新生儿窒息)发生率高于成功组(x2 =9.586,P=0.002、x2=9.334,P=0.002、x2=5.910,P=0.015、x2=5.240,P=0.022)、失败组剖宫产发生率[72.2％(52/72)]明显高于成功组[34.1 ％(43/126),x2=26.641,P=0.001)].结论 手转胎头术能使难产变顺产,降低剖宫产率,减少母儿并发症,但须积极预防、处理导致手转胎头术失败的原因,对矫正失败后继续矫正及试产应慎重.     

Clinical Pharmacokinetics of Morphine

Morphine, the most widely used mu-opioid analgesic for acute and chronic pain, is the standard against which new analgesics are measured. A thorough understanding of the pharmacokinetics of morphine is required in order to safely and effectively use this analgesic in a wide variety of patients with different levels of organ function. A MEDLINE search was conducted to identify literature published between 1966 and January 2002 relevant to the pharmacokinetics of morphine. These publications were reviewed and the literature summarized regarding unique and clinically important elements of morphine disposition relative to its parenteral administration (including intravenous, intramuscular, subcutaneous, epidural and intrathecal administration), absorption profile (immediate release, controlled release, and sublingual/buccal, and rectal administration), distribution, and its metabolism/ excretion. Special populations, including infants, elderly, and those with renal/liver failure, have a unique morphine pharmacokinetic profile that must be taken into account in order to maximize analgesic efficacy and reduce the risk of adverse events.     

Evidence-Based Pain Management and Palliative Care in Issue Four for 2009 of The Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly. Issue 4 for 2009 contains 4027 complete reviews, 1906 protocols for reviews in production, and 11447 one-page summaries of systematic reviews published in the general medical literature. In addition, there are citations of 600,000 randomized controlled trials, and 12,200 cited papers in the Cochrane methodology register. The health technology assessment database contains over 7500 citations. This edition of the Library contains 90 new reviews, of which 19 have potential relevance for practitioners in pain and palliative medicine.     

Wie zuverlässig sind Angaben zu nichtentzündlichen ausgedehnten Schmerzen?

ZusammenfassungFragestellung Es wurde geprüft, wie sich der Differenziertheitsgrad zweier Schmerzmessmethoden auf Angaben zur Ausgedehntheit klinischer Schmerzen auswirkt. Zugleich wurde der Referenzzeitraum variiert, über den die Patienten berichten sollten.Methode Erfasst wurde der Einfluss zu Lasten der Befragungsdifferenziertheit durch den Vergleich zweier Körperschema-Bildvorlagen. Drei Referenzzeiträume (Schmerz aktuell, letzte Woche, letztes halbes Jahr) wurden vorgegeben.Ergebnisse Patienten mit ausgedehnten Schmerzen gaben bei differenzierter Befragung um so mehr Schmerzen an, je weiter die Schmerzen zurück lagen und je größer der Berichtszeitraum war. Patienten mit gelenknahen Schmerzen gaben bei hoch differenzierter Befragung weniger ausgedehnte Schmerzen in der Vergangenheit an als bei globaler Einschätzung. Patienten mit Rückenschmerzen berichteten bei differenzierter Befragung zum aktuellen Schmerz über weniger ausgedehnte Schmerzen als bei globaler Befragung.Schlussfolgerung Die Angaben zur Schmerzausdehnung variieren vor allem bei Patienten mit ausgedehnten Schmerzen in Abhängigkeit von der Differenziertheit der Befragung. In diesen Fällen ist die Wahrscheinlichkeit erhöht, dass sich die Beschwerdesymptomatik zumindest teilweise erst in der Reaktion auf die situativen Befragungsbedingungen konstituiert und daher nicht auf andere Befragungsbedingungen generalisiert werden kann.