骨髓涂片常规检验的基本实践和体会

目的 根据多年的实践和体会采用全新的概念,对确诊血液病及其疗效、预后和骨髓移植造血功能的恢复判断具有重要意义的骨髓涂片常规检验作了开拓性探索,使该项检验能为临床提供更准确可靠、更直观定量和更新更多的信息.方法 采用理论与实践、经验与体会、具体方法与实验数椐相比较的手段.结果 骨髓液取材部位以髂后上棘为好;骨髓液取材量以真正抽到骨髓液、满足检验的需要为原则,以往规定以0.2 ml左右为佳,而根据作者抽取不同骨髓液量的三组标本统计,抽取0.04～0.20 ml组、0.2～1.00 ml组及1.00～3.00 ml组比较,三组有核细胞定量计数,均值分别为67.6,94.6和119.4,A组与B组,A组与C组均值间差异有显著性意义.所以抽取骨髓液的量以0.5～1.0 ml(0.5 ml左右)为佳;为了涂到数量足够、细胞分布均匀的涂片,提出以EDTA-K2抗凝骨髓液(2～4 mg/ ml);以定量(5 μl)抗凝骨髓液涂成2 cm×3.5 cm能区别头、体、尾的簿片,这样既比较规范又可对巨核细胞进行定量计数,根据38份骨髓液涂片标本实验,采用单位面积法、每张涂片法和定量计数法比较,其变异系数(CV%)分别为65.8,27.6和26.4,显然,定量计数法最好;采用批量(每次50～100张)垂直染色可使涂片之间染色结果相对一致,还可避免沉渣附着影响镜下观察;用血细胞计数池直接计数抗凝骨髓液内的有核细胞,高、中、低值标本结果变异系数(CV)分别可达到6.1,6.1和9.6,准确性和重复性十分理想,大大提高了对骨髓增生程度判断的准确性和重复性,而且便于动态观察和回顾性比较;以往采用低倍镜或油镜视野计数成熟红细胞与有核细胞数的比例来判断骨髓增生程度,重复性和准确性差,而且各种型号显微镜的视野面积也有很大的差异. 结论 文中提出了一些全新的观点,例如:骨髓液的抗凝,定量涂片,批量垂直染色,骨髓有核细胞定量计数和巨核细胞定量计数,各型显微镜视野面积不同等,具有很强的实用性和针对性.     

巨核细胞定量计数及分类的临床意义探讨

目的提高巨核细胞计数的准确性和对正常人巨核细胞分类结果的重新认识和评价.方法用5μl定量抗凝骨髓液涂片、染色后计数全涂片巨核细胞,并逐个对巨核细胞进行分类.结果 16例正常人巨核细胞定量计数结果为16.80±8.41个/μl(x±s),参考范围5～33个/μl.分类结果(x±s,%)为原巨1.00±1.26,幼巨3.62±2.94,颗粒巨50.50±5.48,产板巨42.50±6.38,裸核巨2.36±2.32;参考范围分别为0～4%、0～14%、44%～60%、30%～52%、0～8%.69例血小板数正常组(≥150×109/L)巨核细胞计数结果为21.16个/μl(x),巨核细胞分类结果为(x)原巨2.90%,幼巨5.00%,颗粒巨60.20%,产板巨23.40%±6.50%,裸核巨8.50%.巨核细胞定量计数(μl)两结果采用泊松分布的统计量来表示(分别为9～25/μl、12～30/(μl),差异无显著意义;巨核细胞分类结果采用两样本率差别u检验,原巨、幼巨、颗粒巨、产板巨和裸核巨,u值分别为0.99,0.61,0.29,1.49和1.92,差异均无显著意义.结论定量计数巨核细胞较传统单位面积法或以每张涂片表示法准确可靠,可为临床提供可资动态比较的更确切数据;两组巨核细胞分类结果显示正常人巨核细胞以颗粒巨为主,产板巨只要大于10%即可视为产血小板功能正常.     

判断骨髓有核细胞增生程度几种方法的比较

目的探讨和比较判断骨髓有核细胞增生程度几种方法的准确性。方法对临床206份抗凝骨髓标本采用直接定量计数法和涂片染色后高倍镜视野观察有核细胞数;比较低倍镜法、成熟红细胞与有核细胞比值法、高倍镜视野法和直接定量计数法,对骨髓有核细胞高、中、低值标本的测试精度。结果206份EDTA-K2抗凝的骨髓标本有核细胞直接定量计数,结果介于(5.0~770.0)×109/L之间,x-83.86×109/L;其中男性骨髓标本120例,有核细胞介于(5.0~388)×109/L之间,x-79.4×109/L,女性患者86例有核细胞介于(8.0~770)×109/L之间,x-94.2×109/L;高、中、低值骨髓标本有核细胞直接定量计数法,变异系数(CV)分别为0.061,0.061和0.096(平均CV 0.073)。4种方法,除方法1只能按五级增生法大体估计外,其它二种方法高、中、低值骨髓标本的平均CV分别为0.424,0.186。结论选用EDTA-K2抗凝骨髓并进行骨髓有核细胞直接定量计数是必要的也是可行的,该法较目前国内传统方法准确性高、重复性好、便于操作,能满足现代临床血液学诊断、治疗和预后的需要。     

巨核细胞定量计数及分类的临床应用

目的 提高巨核细胞计数的准确性与对传统方法的计数及分类结果的重新认识和评价.方法 常规计数1.5 cm×3.0 cm髓膜并分类与用5 μl定量抗凝骨髓液涂片,染色后计数全片巨核细胞数,并逐个对巨核细胞进行分类.结果 巨核细胞定量计数平均数(36.8±14.6)只/微升、常规计数法骨髓巨核细胞计数平均数(96.3±62.5)只/片;两种方法对巨核细胞分类差异无统计学意义.结论 定量计数巨核细胞较传统单位面积表示法精确可靠,可为临床提供可资动态比较的更确切数据;两组巨核细胞分类结果显示健康人巨核细胞以颗粒型巨核细胞为主.     

骨髓有核细胞直接定量计数的实验研究

目的探讨骨髓有核细胞直接定量计数的准确方法。方法选用EDTA-K2抗凝骨髓,稀释20倍后,以血细胞计数池准确计数有核细胞;同时对有核细胞增生程度以高倍镜法进行比较。结果123份EDTA-K2抗凝的骨髓标本有核细胞进行直接定量计数,结果介于6.0～456.0×109/L之间,平均95.3×109/L。低、中、高3份骨髓标本有核细胞直接定量计数法,CV分别为0.096、0.061和0.061;高倍视野法CV分别为0.348、0.136和0.075。123份骨髓有核细胞增生经高倍视野法观察:极度活跃5份、明显活跃33份、活跃52份、减低26份、极度减低7份,各增生梯度之间,采用t检验:t值分别为7.28、3.41、2.56和4.30,差异均具有显著意义。结论选用EDTA-K2抗凝骨髓并进行骨髓有核细胞直接定量计数是必要的也是可行的,该法较目前国内常规方法准确性高、重复性好,便于操作。     

骨髓有核细胞直接定量计数的实验研究

目的探讨骨髓有核细胞直接定量计数的准确方法.方法选用EDTA-K2抗凝骨髓,稀释20倍后,以血细胞计数池准确计数有核细胞;同时对有核细胞增生程度以高倍镜法进行比较.结果 123份EDTAK2抗凝的骨髓标本有核细胞进行直接定量计数,结果介于6.0～456.0×109/L之间,平均95.3×109/L.低、中、高3份骨髓标本有核细胞直接定量计数法,CV分别为0.096、0.061和0.061:高倍视野法CV分别为0.348、0.136和0.075.123份骨髓有核细胞增生经高倍视野法观察:极度活跃5份、明显活跃33份、活跃52份、减低26份、极度减低7份,各增生梯度之间,采用t检验:t值分别为7.28、3.41、2.56和4.30,差异均具有显著意义.结论 选用EDTA-K2抗凝骨髓并进行骨髓有核细胞直接定量计数是必要的也是可行的,该法较目前国内常规方法准确性高、重复性好,便于操作.     

骨髓标本质量与骨髓液抽取量相关性实验报告

目的探讨细胞形态学检查抽取骨髓液量多少与骨髓标本质量之间的关系。方法对抽取不同骨髓液量之间的骨髓标本,用骨髓有核细胞直接计数法计数有核细胞,定量骨髓涂片定量计数巨核细胞,同时记录骨髓小粒的有无,比较不同骨髓液间的差异。结果328份骨髓标本按抽取骨髓液量的多少分为:A(0.04~0.2m l)、B(>0.2~1.0m l)、C(>1.0~3.0m l)三组。A组129份,平均抽取的骨髓液为0.15 m l;B组167份,平均抽取的骨髓液为0.50 m l;C组32份,平均抽取的骨髓液为1.68 m l。有核细胞直接计数:A组与B组、A组与C组间,均值间差异均有显著意义;B组与C组均值间无显著性差异。巨核细胞定量计数:A组与B组间差异有显著意义;A组与C组间、B组与C组间差异无显著意义。统计了100例抽取骨髓液量在0.04~0.2 m l和95例>0.2~3.0 m l的骨髓标本,两组间有骨髓小粒的比例分别为0.580和0.747,差异非常显著。结论以骨髓有核细胞直接计数数量、巨核细胞定量计数和骨髓小粒的有无,作为骨髓涂片细胞形态学检查的质量要求是切实可行的,结果显示抽取量在0.04~0.2 m l组不如第二组好,说明抽取量应控制在>0.2m l~1.0m l(约0.5m l)为宜。     

慢性特发性血小板减少性紫癜患者巨核系祖细胞体外生长及成熟的研究

为研究慢性特发性血小板减少性紫癜(CITP)患者骨髓巨核系祖细胞体外生长及成熟状态,采用血浆凝块法进行培养,经SZ-21单抗和免疫组化染色后计数33例患者骨髓巨核祖细胞(CFU-Meg与BFU-Meg)集落数,用图像分析仪测定巨核祖细胞直径和面积.结果发现,CITP患者CFU-Meg为39.27±21.44,BFU-Meg为5.62±3.93,与对照组无明显差异,但GPⅢa+细胞面积为(134.90±6.08)μm2,直径为(12.89±3.66)μm,均低于对照组.骨髓涂片巨核细胞数正常组的患者CFU-Meg为19.43±7.28和BFU-Meg为4.67±1.53,均低于对照组.巨核系祖细胞总集落数与骨髓涂片巨核细胞数呈正相关,r=0.6503,而与外周血血小板计数和病程长短无相关.结果提示CITP患者巨核祖细胞存在成熟障碍,部分患者存在增殖障碍.     

特发性血小板减少性紫癜病人外周血像及骨髓巨核细胞数与预后关系

为了探讨特发性血小板减少性紫癜 (ITP)病人初诊时血像及骨髓涂片巨核细胞计数的预后价值 ,作者回顾性分析了 2 2 9例ITP病人外周血白细胞计数、血小板计数、治疗过程中血小板上升速度及骨髓涂片巨核细胞计数与治疗结果之间的关系。结果显示 ,ITP病人初诊时外周血白细胞计数及血小板计数与疗效无关 ,治疗 2周内血小板达到 10 0× 10 9/L以上的病人 ,其基本治愈率较高 (94 .9% ) ;初诊时骨髓涂片巨核细胞计数越多 ,病人的预后越好 ,每单位涂片 (1.5× 3cm)巨核细胞计数大于 10 0个的病人治愈率达 86 .1%。结论 :ITP病人初诊时进行骨髓检查 ,并计数巨核细胞数 ,对诊断及预后的判定均是必要的。在治疗过程中及时复查血像 ,观察血小板上升速度 ,对预后的判定亦有重要价值     

骨髓有核细胞直接定量计数实验设计的理论探讨

作者曾报道了骨髓有核细胞直接定量计数与传统方法的实验比较及操作程序[1~3],其中仅对方法学作了简单评价,但方法学设计原理未作分析,现就此问题探讨如下,为了便于叙述,将直接计数方法一并简述如下。1骨髓有核细胞直接定量计数法1.1骨髓液的抗凝按常规方法抽取骨髓液0.2~0.5ml     

量化考评在口腔科医院感染管理中的应用

目的评价综合性教学医院口腔科医院感染量化管理,以便进行量化考评,加强口腔科医院感染管理。方法根据口腔科特点,把口腔科医院感染管理考核指标进行量化,纳入医疗质量检查体系,实施考评。结果经对该医院口腔科医院感染管理质量连续3年考评,2005年平均得分为81.5分,2006年平均得分为87分,2007年平均得分为94分。实行量化考评3年来,口腔科内环境卫生质量得到改善,口腔科专用设备和消毒与灭菌设备均有增加,无医院感染事故发生。结论口腔科医院感染管理量化考评得分逐年提高,实现了口腔科医院感染管理的持续质量改进,量化考评措施效果明显。     

荧光定量RT-PCR检测白血病多药耐药基因及其临床意义

目的　在Light-CyclePCR仪上对多药耐药基因 (MDR1)定量的技术方法和临床应用进行探讨。方法　应用荧光定量逆转录 -多聚酶链反应 (RT -PCR)检测了 30例急性白血病患者和 8例正常人外周血MDR1基因的表达。结果　该实验方法标准曲线线性良好 (r=1.0 ) ,耐药组MDR1基因拷贝数与非耐药组有显著性差异 (P <0 .0 1) ,正常人亦有低水平MDR1基因的表达。结论　荧光逆转录 -多聚酶链反应 (RT -PCR)是一种可靠的定量方法 ,能快速、特异地检测临床肿瘤标本中MDR1,为临床医生用药、预防MDR发生、考核逆转MDR效果等方面提供了有价值的量化指标。     

体育与非体育专业大学生静态平衡定量对比分析

目的：在定量分析体育与非体育专业大学生静态平衡的基础上，探讨运动训练、性别对大学生静态平衡功能的影响。方法：采用意大利PosturalEqua平衡分析系统，对78名体育专业与非体育专业在校大学生，分别在睁、闭眼状态下测试其静态平衡的各项指标。结果：两专业之间的横向对比在睁、闭眼状态下，均无显著性差别。但纵向对比显示，两专业分别在X轴与Y轴、前后之间存在极显著性差异（P〈0．01）；同性别的静态平衡各参数之间，除男大学生在闭眼状态下，LFS和额状面存在差异（P〈0．05）外，其他情况均无显著性差异。不同性别之间，除了非体育专业在闭眼状态下，无性别差异外，在其他情况的不同状态下，某些指标均存在性别差异。结论：运动训练对大学生静态平衡影响不大，但对男性大学生的某些平衡指标却有显著影响；性别对体育与非体育专业大学生的静态平衡均产生影响，而且体育专业男、女性差别更大。     

Evaluating a nurse-led model for providing neonatal care

Aims. The paper presents an overview of a multi‐dimensional, prospective, comparative 5‐year audit of the quality of the neonatal care provided by a maternity unit in the UK delivering 2000 babies a year, where all neonatal care after 1995 was provided by advanced neonatal nurse practitioners, in relation to that provided by a range of other medically staffed comparator units. Methods. The audit includes 11 separate comparative studies supervised by a panel of independent external advisors. Data on intrapartum and neonatal mortality is reported. A review of resuscitation at birth, and a two‐tier confidential inquiry into sentinel events in six units were carried out. The reliability of the routine predischarge neonatal examination was studied and, in particular, the recognition of congenital heart disease. A review of the quality of postdischarge letters was undertaken alongside an interview survey to elicit parental views on care provision. An audit of all hospital readmissions within 28 days of birth is reported. Other areas of study include management of staff stress, perceived adequacy of the training of nurse practitioners coming into post, and an assessment of unit costs. Results. Intrapartum and neonatal death among women with a singleton pregnancy originally booked for delivery in Ashington fell 39% between 1991–1995 and 1996–2000 (5·12 vs. 3·11 deaths per 1000 births); the decline for the whole region was 27% (4·10 vs. 2·99). By all other indicators the quality of care in the nurse‐managed unit was as good as, or better than, that in the medically staffed comparator units. Conclusion. An appropriately trained, stable team with a store of experience can deliver cot‐side care of a higher quality than staff rostered to this task for a few months to gain experience, and this is probably more important than their medical or nursing background. Factors limiting the on‐site availability of medical staff with paediatric expertise do not need to dictate the future disposition of maternity services.     

急性心肌梗死证候诊断标准规范化研究

目的:以基于熵的复杂系统分划方法结合诊断性试验受试工作者曲线(ROC)分析建立急性心肌梗死(AMI)证候量化诊断标准,并分析其证候组合规律。方法:根据文献研究、专家咨询、临床流行病学调查获得AMI四诊资料,将410例临床AMI患者随机分为运算组(308例)和考核组(102例),以基于熵的复杂系统分划方法提取308例AMI患者症状信息,分析基本证候之间组合规律,确立症状对证候贡献度,以诊断性试验ROC分析建立各基本证候诊断阈值。结果:AMI存在气滞、气虚、痰浊、血瘀、痰热、阴虚、阳虚等基本证候,确立了不同症状对证候诊断的贡献度及诊断阈值,建立以基本证型为诊断单元的AMI证候量化诊断标准,经回顾性检验和102例患者前瞻性检验,具有良好的灵敏度和特异度。结论:所建立AMI证候量化诊断标准具有良好的诊断效能,为中医药干预AMI治疗提供了辨证依据。     

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.