静脉吸毒人群中血浆抗-HCVEIA法、WB法与HCVRNA荧光定量PCR法比较

目的了解吸毒人群中抗-HCV EIA法、WB法与HCV RNA检测分析的符合性,选取适合高危人群的HCV实验室诊断策略。方法使用2种EIA试剂进行筛查试验,初检阳性者用另一种抗体试剂复检和用FQ-PCR(荧光定量PCR)法检测HCV RNA,抗体复检阳性的样品用HCV WB检测试剂进行确认。结果血清学试验115份样本初检结果阳性108份,阴性7份;对初检阳性者进行复检,结果阳性90份,阴性18份。复检阳性者使用WB确认,89份阳性,1份不确定;EIA抗-HCV结果S/CO≥3.8有71份,与WB阳性符合率为98.6%。EIA复检阳性样本中HCV-RNA检出率为82.22%,复检阴性样本中有HCV RNA的检出率为77.78%(14/18)。结论抗-HCV并不与HCV RNA同时出现。吸毒人员HCV感染的检测,在EIA筛查基础上,对阴性样本检测HCV-RNA,阳性样本用WB试验进行确认,确保检测的准确性。     

丙型肝炎病毒抗体诊断试剂盒(EIAgen HCV Ab Kit)的可信度分析

目的 分析丙型肝炎病毒(HCV)抗体酶联免疫吸附试验(ELISA)诊断试剂盒(EIAgen HCV Ab Kit)的可信度.方法 应用考核试剂EIAgen HCV Ab Kit和参比试剂Ortho HCV 3.0 ELISA对2 881例样本进行检测,检测结果不一致时,应用重组免疫印迹试验(RIBA)确证.所用试剂为RIBA(R)HCV 3.0 SIA或核酸试验(NAT),并对结果进行综合分析.结果 2 881例样本中,阳性样本333例,阴性样本2 539例,9例不确定的样本被剔除.考核试剂检测真阳性333例,无假阴性结果,真阴性2 527例,假阳性12例.考核试剂灵敏度为100.00%,高于参比试剂;特异性为99.53%,略低于参比试剂.考核试剂对部分国内常见HCV基因型的灵敏度为100.00%,对于非HCV感染的病毒性肝炎、自身免疫性疾病及妊娠样本具有良好的特异性,特异性均为100.00%.溶血、脂血样本对考核试剂检测结果无影响.考核试剂阳性预测值为96.52%,阴性预测值为100.00%,符合率为99.58%.考核试剂S/CO≥5.9的样本301例,其中用参比试剂检测S/CO≥3.8占88.70%;考核试剂S/CO＜5.9的样本32例,其中用参比试剂检测S/CO＜3.8占87.50%.结论 试剂EIAgen HCV Ab Kit灵敏度100.00%,特异性较好,是一种优质的抗-HCVELISA试剂,尤其适用于阳性样本的筛选.采用EIAgen HCV Ab Kit试剂检测样本,当S/CO≥5.9时,样本的阳性预测值比较高.     

国产抗丙型肝炎抗体检测试剂盒灰区范围的设置

目的设置上海地区临床实验室常用的4种国产抗丙型肝炎病毒(HCV)抗体(简称抗HCV)检测试剂的灰区范围。方法收集抗HCV临床初检阳性样本656例,分别用荣盛、新波、科华和科美4家国产抗HCV检测试剂进行复检,分别计算初检不同S/CO值范围的复检率;选择抗HCV初、复检结果不一致的弱阳性样本338例,采用确认试验[重组免疫印迹法(RIBA)]进行确认,对RIBA结果为不确定的样本采用实时荧光定量聚合酶链反应(PCR)检测HCV RNA。以RIBA和HCV RNA结果作为金标准,绘制受试者工作特征(ROC)曲线,探讨其最佳临界S/CO值。以95%真阳性和95%真阴性S/CO值确定4种国产抗HCV检测试剂阴、阳性灰区范围。结果 4种国产抗HCV检测试剂的阴性复检符合率均90%,S/CO值均12.01;阳性复检符合率均95%。荣盛、新波、科华及科美4种国产试剂检测抗HCV的最佳临界S/CO值分别为1.31、2.48、3.22和4.32。分别以95%真阳性率和95%真阴性率确定4种国产抗HCV检测试剂的阳性和阴性临界值,得出荣盛、新波、科华及科美4种国产抗HCV检测试剂S/CO值的灰区范围分别为0.6~1.3、0.7~2.5、0.7~4.0和0.7~4.3。结论确认了上海地区4种常用国产抗HCV检测试剂的最佳临界S/CO值,为临床提供了4种抗HCV检测试剂的灰区范围。     

血液检测实验室ELISA试剂的选择评价

目的　综合评价抗 HCV、抗 HIV国产ELISA试剂在血液筛查实验室的应用效果。方法　将参考品试验与常规中试试验相结合 ,参考品试验 :将抗 HCV试剂、双抗原夹心法抗 HIV试剂在 37℃恒温箱中放置 72h后 ,检测参考品的符合率 ,计算每种试剂的阳性符合率、阴性符合率、总符合率、约登指数、阳性预测值、阴性预测值 ,比较差别 ;常规中试试验 :用抗 HIV试剂、抗 HCV试剂分别检测常规标本 ,绘制每种试剂阴性结果S/CO分布图 ,观察每种试剂反应模式的均一性。结果　在参考品试验中 ,5种符合国家标准的抗 HCV国产试剂存在差异 ;常规中试试验中 ,抗 HCV、抗 HIV阴性结果S/CO分布图显示了不同试剂本底均一性的差别。结论　血液筛查实验室ELISA试剂的选择 ,在依照参考品的考核结果的同时 ,还应结合常规应用情况 ,就试剂盒本底均一性、功能性、适应性、成分稳定性综合判定。     

抗HCV抗体灰区样本的处置方案和产生原因分析及临床提示

目的探讨抗丙型肝炎病毒(HCV)抗体灰区样本产生的原因和处置方案及临床提示。方法采用5种国产试剂[4种试剂为间接酶联免疫吸附试验(ELISA)、1种试剂为双抗原夹心法]和1种进口试剂(化学发光法)检测血清中抗HCV抗体,结果不一致且在灰区范围内的样本再用重组免疫印迹法(RIBA)检测确认,并对RIBA测定结果为不确定的样本用实时荧光定量聚合酶链反应(PCR)测定HCV RNA。对12例处于窗口期的特殊样本分析HCV RNA的拷贝数和基因型。结果除F试剂外,其他5种抗HCV抗体检测试剂的复检阴性符合率均≥90%;复检阳性符合率随着初检S/CO值的增大而增高,当S/CO值15.01时,6种抗HCV抗体检测试剂的复检阳性符合率均95%。采用6种抗HCV抗体检测试剂分别检测36例灰区样本,单种试剂检测的假阴性率为27.8%~94.4%;2种国产试剂随机组合后检测的假阴性率为8.3%~61.1%;2种国产试剂加进口试剂组合后假阴性率降至5.6%~22.2%;2种国产试剂加国产双抗原夹心法试剂组合后假阴性率降至2.2%~13.9%。6种试剂检测12例特殊样本抗HCV抗体的结果为阴性或部分处于厂家规定的灰区范围内,RIBA确认结果为阴性或不确定,而HCV RNA为弱阳性。12例特殊样本中有8例RNA基因分型为1b型,4例为无分型。结论对于抗HCV抗体检测试剂灰区结果,建议至少采用2种不同的初筛试剂组合对样本进行复检;必要时可引入双抗原夹心法或进口试剂作为复检的补充。为减少窗口期样本的漏检,建议将HCV RNA检测作为补充试验。     

两种抗HCV试剂检测献血者结果不符追踪观察

目的 探讨两种抗HCV试剂检测结果不符标本在抗HCV分片段试剂不同区抗原的反应性，随访和跟踪该类人员在抗HCV和抗HCV分片段试剂中的反应变化。方法 利用抗HCV分片段试剂对国家抗HCV参考品及抗HCV试剂检测不符的标本进行测试，并对可跟踪的献血者在6个月后再进行抗HCV及抗HCV分片段试剂检测。结果 国家抗HCV参考品中，29份阳性标本均出现二片段或二片段以上阳性，阴性标本全部阴性；103份抗HCV试剂结果不符标本中有6例为二片段阳性，26例为单片段阳性，以NS3、C区为主；6个月后对可以跟踪的86例献血员进行检测，37例两种抗HCV试剂转阴，16例两种试剂均转为阳性，6例抗HCV分片段阴性者己转为一个或二个片段阳性。结论 对抗HCV试剂阳性结果不符标本同时应用HCV分片段试剂检测有利于降低HCV阳性血清漏检率，跟踪和复检有助于了解阳性结果不符标本在抗HCV及抗HCV分片段试剂中的反应变化，排除假阳性。     

两种抗HCV试剂检测献血者结果不符追踪观察

目的探讨两种抗HCV试剂检测结果不符标本在抗HCV分片段试剂不同区抗原的反应性,随访和跟踪该类人员在抗HCV和抗HCV分片段试剂中的反应变化.方法利用抗HCV分片段试剂对国家抗HCV参考品及抗HCV试剂检测不符的标本进行测试,并对可跟踪的献血者在6个月后再进行抗HCV及抗HCV分片段试剂检测.结果国家抗HCV参考品中,29份阳性标本均出现二片段或二片段以上阳性,阴性标本全部阴性;103份抗HCV试剂结果不符标本中有6例为二片段阳性,26例为单片段阳性,以NS3、C区为主;6个月后对可以跟踪的86例献血员进行检测,37例两种抗HCV试剂转阴,16例两种试剂均转为阳性,6例抗HCV分片段阴性者己转为一个或二个片段阳性.结论对抗HCV试剂阳性结果不符标本同时应用HCV分片段试剂检测有利于降低HCV阳性血清漏检率,跟踪和复检有助于了解阳性结果不符标本在抗HCV及抗HCV分片段试剂中的反应变化,排除假阳性.     

用不同厂家ELISA试剂检测抗HCV结果的差异性分析

目的探讨不同厂家酶联免疫吸附试验（ELISA）试剂检测丙型肝炎病毒抗体（抗HCV）结果的差异性。方法用4种不同厂家生产的第3代ELISA抗HCV试剂检测经上海科华公司生产的ELISA抗HCV试剂检测为阳性的出入境体检人员的血清标本62例,结果不一致的标本再用MP HCV BLOT3.0检测确认。结果A、B、C、D 4种试剂阳性反应数分别为59、50、43和53份,其中试剂B和C、B和D比较差异无统计学意义（P〉0.05）;试剂C和D比较差异有统计学意义（P〈0.05）。4种试剂反应都阳性标本37份,结果不一致的标本25份,经确认有9份标本阳性。结论不同厂家抗HCV试剂检测结果的阳性率有较大差异,提示选择灵敏度较高的试剂进行初筛,并且要有另一种灵敏度和特异性高的试剂作为复检方法,当2种试剂检测都为阳性,且标本吸光度值与阳性判定值（cut off）的比值（S/CO）≥3.8时,则可判定为抗HCV阳性;当检测结果为阳性但其S/CO值≤3.8或其中1种检测方法结果为阴性,建议用免疫重组印迹（RIBA）试验确认。     

用不同厂家ELISA试剂检测抗HCV结果的差异性分析

目的探讨不同厂家酶联免疫吸附试验(ELISA)试剂检测丙型肝炎病毒抗体(抗HCV)结果的差异性。方法用4种不同厂家生产的第3代ELISA抗HCV试剂检测经上海科华公司生产的ELISA抗HCV试剂检测为阳性的出入境体检人员的血清标本62例,结果不一致的标本再用MP HCV BLOT3.0检测确认。结果A、B、C、D 4种试剂阳性反应数分别为59、50、43和53份,其中试剂B和C、B和D比较差异无统计学意义(P>0.05);试剂C和D比较差异有统计学意义(P<0.05)。4种试剂反应都阳性标本37份,结果不一致的标本25份,经确认有9份标本阳性。结论不同厂家抗HCV试剂检测结果的阳性率有较大差异,提示选择灵敏度较高的试剂进行初筛,并且要有另一种灵敏度和特异性高的试剂作为复检方法,当2种试剂检测都为阳性,且标本吸光度值与阳性判定值(cut off)的比值(S/CO)≥3.8时,则可判定为抗HCV阳性;当检测结果为阳性但其S/CO值≤3.8或其中1种检测方法结果为阴性,建议用免疫重组印迹(RIBA)试验确认。     

16例抗-HIV国产ELISA试剂检测假阳性报告

笔者在用国产ELISA间接法试剂对原料血浆进行抗-HIV复检时,曾检出16份"阳性"样品,再用进口ELISA双抗原直接法试剂复检为阴性,最后用蛋白印迹法试剂检测,证实为假阳性,现将结果报告如下.     

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.     

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.     

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.     

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.