垂体相关临床及MRI影像组学特征联合列线图鉴别特发性中枢性性早熟与单纯乳房早发育

目的 观察垂体相关临床及MRI影像组学特征联合列线图鉴别特发性中枢性性早熟(ICPP)与单纯乳房早发育(PT)的价值。方法 纳入67例ICPP及51例PT共118例患儿,按照7 ∶ 3比例随机分为训练集(n=83)和验证集(n=35),记录其垂体相关临床资料,以多因素logistic回归分析筛选并建立临床模型。采集垂体MRI,基于矢状位T1WI提取垂体影像组学特征,以最大相关最小冗余、最小绝对收缩和选择算子及多因素logistic回归筛选最佳影像组学特征,构建影像组学模型。联合应用临床、MRI及影像组学特征构建列线图模型。绘制受试者工作特征曲线,评估模型鉴别诊断效能;以决策曲线分析(DCA)观察临床获益度。结果 训练集ICPP与PT患儿年龄、骨龄、体质量、黄体生成素(LH)基础值、卵泡刺激素基础值及垂体高度差异均有统计学意义(P均＜0.05)。骨龄及LH基础值是鉴别ICPP与PT的独立因素(OR=1.807、1.422,P均＜0.05),以之建立的临床模型鉴别训练集、验证集ICPP与PT的曲线下面积(AUC)分别为0.849和0.812。共提取垂体1 781个影像组学特征,于其中筛选出1个形态特征、1个一阶特征及1个灰度区域大小矩阵特征建立影像组学模型,其鉴别训练集和验证集ICPP与PT的AUC分别为0.956和0.947。基于最终得出的2个临床及3个垂体MRI影像组学特征构建的列线图模型鉴别训练集、验证集ICPP与PT的AUC分别为0.981、0.977,均优于临床模型(P均＜0.05),而与影像组学模型差异无统计学意义(P均＞0.05)。一定危险阈值范围内,列线图模型净收益最大。结论 基于垂体相关临床及MRI影像组学特征建立的联合列线图模型用于鉴别ICPP与PT具有较高价值。     

特发性性早熟女孩骨龄评价的诊断性试验研究

目的探讨骨龄测定对诊断特发性性早熟(idiopathic precocious puberty)的诊断价值和实用性.方法参照"金标准"选择特发性性早熟患儿55例,正常对照83例.回顾性分析初诊时第一张左手腕部X线照片,由专人用TW2法盲法分期,骨龄结果分为RUS(Radius Ulna and Short bones)(13骨)骨龄、腕骨(7骨)骨龄和20骨骨龄3个系统,每个系统又分为＞P97、＞P90、＞P75、＞P50和≤P505个工作点,并对该诊断性试验进行评价,比较TW2法骨龄的3个系统对性早熟患儿的诊断价值,并帮助选择正常临界点.结果①敏感度和特异度都高的有13骨骨龄的＞P90点(敏感度0.836,特异度0.916),7骨骨龄的＞P90点(敏感度0.746,特异度0.916)以及20骨骨龄的＞P90点(敏感度0.746,特异度0.964)和＞P75点(敏感度0.982,特异度0.783)4个工作点;② 3条ROC曲线的曲线下面积(A)分别为:13骨骨龄A13 0.939±0.019[95%CI(0.902,0.977)],7骨骨龄A7 0.899±0.028[95%CI(0.845,0.954)],20骨骨龄A20 0.958±0.014[95%CI(0.930,0.986)].3条曲线下面积无统计学差异(F=2.03,P=0.13);③骨骺核分期重复性为89.28%,可比性为80.3%,骨龄测定Kappa值为0.68(u=6.87,P＜0.01).结论 13骨骨龄和20骨骨龄诊断性早熟有高度准确性;"13骨骨龄＞P90"工作点为综合考虑了敏感度和特异度之后的最佳工作点,故建议将此点作为骨龄诊断性早熟的正常值临界点.     

骨龄评价方法TW3-RUS、TW3-Ccarpal、RUS-CHN对比及可重复性分析

目的:探讨TW3-RUS、TW3-C carpal、RUS-CHN三种骨龄评价方法的差异性及可重复性。材料与方法:应用TW3-RUS、TW3-C carpal、RUS-CHN三种方法,由2名有骨龄评价培训经历的医师,阅读时间年龄为12岁的正常男性儿童的手腕部X线平片,独立盲法进行骨龄评价。结果:2名医师的骨龄评价结果差别无统计学差异(P>0.05);3种方法对骨龄评价结果的差别有统计学意义(P<0.05);2人组内3种方法两两比较,TW3-C carpal与TW3-RUS及RUS-CHN骨龄评价结果的差别有统计学意义(P<0.05),TW3-RUS与RUS-CHN骨龄评价结果的差别无统计学意义(P>0.05)。结论:2名医师应用3种方法对12岁男童骨龄评价结果的可重复性高。对12岁男童骨龄评价,TW3-RUS与RUS-CHN法无明显差别,TW3-C carpal与TW3-RUS及RUS-CHN差别较大,推测TW3-C carpal可能不适合12岁男童骨龄评价。     

血浆长链非编码RNA HOTTIP与ROR联合高尔基体蛋白73对甲胎蛋白阴性肝癌的诊断与预后评估价值

目的探讨长链非编码RNA(long non-coding RNAs,lncRNAs)HOTTIP与ROR联合高尔基体蛋白73(Golgi protein 73,GP73)在甲胎蛋白(alpha-fetoprotein,AFP)阴性肝癌(AFP-negative hepatocellular carcinoma,AFP-NHCC)中的临床价值。方法 AFP-NHCC患者100例为AFP-NHCC组,肝脏良性疾病患者100例为肝脏良性疾病组,体检健康者110例为健康对照组。采用实时荧光定量PCR法检测3组血浆lncRNA HOTTIP、ROR,采用ELISA法检测3组血浆GP73,并进行组间比较;分析血浆lncRNA HOTTIP、ROR、GP73与AFP-NHCC临床特征的关系;绘制ROC曲线,分析血浆lncRNA HOTTIP、ROR与GP73对AFP-NHCC的诊断价值;多元logistic回归分析AFP-NHCC的危险因素。结果 AFP-NHCC组患者血浆lncRNA HOTTIP[12.8±0.6(-log)]、ROR表达[3.9±0.2(-log)]及GP73水平[(93.4±8.5)μg/L]高于肝脏良性疾病组[5.8±0.3(-log)、2.6±0.2(-log)、(30.8±3.7)μg/L]和健康对照组[5.7±0.2(-log)、2.5±0.2(-log)、(27.2±1.6)μg/L](P0.05);血浆lncRNA HOTTIP、ROR和GP73表达水平与AFP-NHCC患者的淋巴结转移(HOTTIP:r=0.567,P=0.002;ROR:r=0.552,P=0.006;GP73:r=0.535,P=0.011)及TNM分级(HOTTIP:r=0.559,P=0.001;ROR:r=0.539,P=0.007;GP73:r=0.538,P=0.017)呈线性关联;ROC曲线分析显示,血浆GP73、lncRNA HOTTIP、ROR诊断AFP-NHCC的灵敏度/特异度分别为80.4%/76.9%、86.1%/74.5%和69.3%/63.2%,而联合三者诊断AFP-NHCC的特异度为92.9%;logistic回归多因素分析显示,在校正年龄、性别、吸烟史、饮酒史等因素影响后,血浆高GP73、lncRNA HOTTIP和ROR水平仍是AFP-NHCC发病的独立危险因素(OR=3.51,95%CI:1.53～5.72,P0.001;OR=1.12,95%CI:1.03～1.34 P=0.032;OR=2.77,95%CI:1.47～5.08,P0.001)。结论血浆lncRNA HOTTIP、ROR和GP73在AFP-NHCC的诊断以及评估AFP-NHCC患者发生肿瘤远处转移中有重要临床意义。     

性早熟女童血清ghrelin水平研究

目的 探讨性早熟女童血清ghrelin水平变化.方法 将87例5～9 岁性早熟女童根据第二性征发育情况、骨龄、子宫、卵巢容积及促性腺激素释放激素(GnRH)激发试验的结果分为特发性中枢性早熟(ICPP)组和单纯乳房早发育(PT)组,选择34例年龄相当的健康女童作为对照组,采用夹心法酶联免疫吸附试验测定空腹血清ghrelin水平.结果 ICPP组血清ghrelin水平为Log(2.728±0.304)ng/L,明显高于对照组[Log(2.567±0.304)ng/L],差异有统计学意义(P<0.05);PT组血清ghrelin水平为Log(2.613±0.300)ng/L,与ICPP组和对照组比较,差异均无统计学意义(P>0.05).结论 ICPP组血清ghrelin水平明显高于对照组,推测ICPP女童血清ghrelin变化可能与性激素升高有关.     

促性腺激素释放激素类似物停药后特发性中枢性性早熟女童月经来潮年龄及其相关因素分析

目的分析促性腺激素释放激素类似物(Gn RHa)停药后特发性中枢性性早熟(ICPP)女童月经来潮的情况,了解Gn RHa长期治疗对性腺功能的影响及其影响因素。方法回顾性收集45例ICPP患儿的临床资料,随访患儿停药后月经初潮(或复潮)情况,Pearson相关性分析了解影响月经初潮的相关因素。结果 Gn RHa治疗月经初潮(或复潮)的平均年龄为(11.9±0.9)岁,距离停药时间(14.1±6.8)个月,月经初潮(或复潮)的年龄与治疗前身高(r=-0.305,P=0.042)、体质量(r=-0.380,P=0.010)、子宫容积(r=-0.380,P=0.013)、促黄体生成素(LH)峰值(r=-0.308,P=0.039)以及骨龄与实际年龄的差值(r=-0.333,P=0.025)呈负相关;与停药时骨龄与实际年龄差值(r=-0.595,P=0.000)及平均治疗剂量(r=-0.295,P=0.049)呈负相关,而与疗程(r=0.384,P=0.009)、停药年龄(r=0.781,P=0.000)、停药时预测成年身高与靶身高差值(r=0.338,P=0.023)呈正相关。月经来潮距离停药的时间长短除与治疗前有无月经初潮有关(r=-0.305,P=0.042)外,与其他所有因素均不相关。结论经Gn RHa正规治疗后的女童月经来潮的时间与普通人群相仿,治疗前性发育进展的情况及疗程是影响月经初潮年龄的主要因素。     

深度学习模型在儿童TW3法骨龄评估的临床效能分析

目的 探讨深度学习模型在儿童应用TW3法进行骨龄评估的临床效能。方法 回顾性收集180例儿童左手X线片。评估基于Tanner-WhitehouseⅢ(TW3)法的掌指骨和腕骨骨龄。以3位高年资主任医师的评估均值为金标准组,计算并比较深度学习模型(模型组)及2位低年资医师(医师组,分别记作医师1、医师2)与金标准组评估时间差异,掌指骨骨龄、腕骨骨龄的均方误差(MSE)及平均绝对误差(MAE);采用组内相关系数(ICC)分析模型组和医师组与金标准组结果一致性。结果 骨龄评估所用时间模型组明显少于医师组(P<0.05)。掌指骨骨龄评估,模型组和医师1、医师2与金标准组相比MSE、MAE差异有统计学意义(P<0.05)。腕骨骨龄评估,模型组和医师1、医师2与金标准组相比MSE、MAE差异有统计学意义(P<0.05)。掌指骨骨龄评估,模型组与金标准组ICC为0.988,医师1、医师2与金标准组的ICC分别为0.986、0.977。腕骨骨龄评估,模型组与金标准组ICC为0.971,医师1、医师2与金标准组ICC分别为0.970、0.953。结论对于儿童,应用TW3法深度学习模型在...     

乙型肝炎肝硬化与肝癌患者HBV DNA、AFP-L3、GP73的差异及HBV DNA与AFP-L3、GP73相关性分析

目的探讨乙型肝炎肝硬化与肝癌患者乙型肝炎病毒DNA(HBV DNA)、血清甲胎蛋白异质体L3(AFP-L3)、高尔基蛋白73(GP73)的差异及HBV DNA与AFP-L3、GP73相关性。方法回顾该院2015年10月至2017年10月收治的乙型肝炎肝硬化患者和肝癌患者的临床资料,其中80例乙型肝炎肝硬化患者设为对照组,68例肝癌患者设为观察组。所有患者均采用PCR法检测血清HBV DNA,采用酶联免疫吸附法检测血清AFP-L3、GP73水平。比较两组患者血清HBV DNA、AFP-L3、GP73表达水平及阳性率的差异,采用Pearson相关对HBV DNA、AFP-L3、GP73相关性进行分析,并采用ROC曲线分析HBV DNA与AFP-L3、GP73在肝癌诊断中的价值。结果观察组患者HBV DNA、GP73表达阳性率高于对照组,但差异无统计学意义(P>0.05);观察组患者AFP-L3表达阳性率明显高于对照组,差异有统计学意义(χ2=55.01,P<0.001)。观察组患者血清HBV DNA、AFP-L3、GP73水平明显高于对照组,差异均有统计学意义(P<0.05)。分别将患者HBV DNA水平与AFP-L3、GP73水平作Pearson相关性分析,结果显示,HBV DNA与AFP-L3无相关性(r=0.214,P=0.079);HBV DNA与GP73表达无相关性(r=0.155,P=0.208)。采用ROC曲线对两组患者3种指标的鉴别诊断价值进行分析,3种指标均有一定的临床诊断价值(AUC>0.5),且AFP-L3在鉴别诊断中的应用价值最高(AUC=0.971,95%CI:0.943~0.999)。结论乙型肝炎肝硬化与肝癌患者HBV DNA、AFP-L3、GP73的水平存在明显差异,且肝癌患者血清HBV DNA与AFP-L3、GP73水平无明显相关性,AFP-L3在乙型肝炎肝硬化与肝癌的鉴别诊断中价值最高,值得在临床推广应用。     

疑特发性中枢性性早熟患儿应用戈那瑞林激发试验的护理

戈那瑞林是促性腺激素释放激素（LH-RH）受体拮抗剂，临床主要用作药物激发试验，对乳房提前发育（女孩8岁以前），骨龄≥实际年龄1年的患儿应用该药激发以测定血液中黄体生成素（LH）、促卵泡刺激素（FSH）的峰值，从而达到对特发性中枢性性早熟（ICPP）、单纯乳房发育（PT）及周围性性早熟（PPP）的患儿进行鉴别诊断的目的。我科应用此药对61例患儿作激发试验，现将护理体会总结如下。     

外周血高尔基体糖蛋白-73表达水平对肝细胞癌的诊断与鉴别诊断价值

目的定量分析肝病患者血清高尔基体糖蛋白-73(GP73)水平,探讨其对肝细胞肝癌(HCC)的诊断与鉴别诊断价值。方法收集不同肝病患者外周血标本,以酶联免疫吸附法(ELISA)检测GP73浓度,并分析与甲胎蛋白(AFP)的相互关系。结果血GP73表达水平,正常对照组为(28.83±21.00)ng/ml,慢性肝炎组为(49.86±40.46)ng/ml,肝硬化组为(62.30±56.30)ng/ml,肝癌组为(66.75±69.97)ng/ml;GP73水平随着肝病的进展呈进行性增加,肝癌组明显高于对照组和慢性肝炎及肝硬化组(P<0.05)。肝癌患者血GP73表达水平在HBV感染(HBsAg阳性/阴性)、肝外转移与否组间对比,差异有统计学意义(P<0.05)。且GP73与AFP表达改变呈显著正相关(r=0.961,P=0.039),血AFP的ROC曲线下面积为0.877,GP73为0.931,GP73与AFP联合检测对肝癌有互补诊断价值。结论血GP73表达异常与肝癌发展密切相关,定量检测有助于肝癌的诊断和鉴别。     

Migraine and genetic and acquired vasculopathies

It is remarkable that migraine is a prominent part of the phenotype of several genetic vasculopathies, including cerebral autosomal dominant arteriopathy with subcortical infarcts and leucoencephalopathy (CADASIL), retinal vasculopathy with cerebral leukodystrophy (RVCL) and hereditary infantile hemiparessis, retinal arteriolar tortuosity and leukoencephalopahty (HIHRATL). The mechanisms by which these genetic vasculopathies give rise to migraine are still unclear. Common genetic susceptibility, increased susceptibility to cortical spreading depression (CSD) and vascular endothelial dysfunction are among the possible explanations. The relation between migraine and acquired vasculopathies such as ischaemic stroke and coronary heart disease has long been established, further supporting a role of the (cerebral) blood vessels in migraine. This review focuses on genetic and acquired vasculopathies associated with migraine. We speculate how genetic and acquired vascular mechanisms might be involved in migraine.     

Fibrinogen and fibrin structure and functions

Fibrinogen molecules are comprised of two sets of disulfide-bridged Aalpha-, Bbeta-, and gamma-chains. Each molecule contains two outer D domains connected to a central E domain by a coiled-coil segment. Fibrin is formed after thrombin cleavage of fibrinopeptide A (FPA) from fibrinogen Aalpha-chains, thus initiating fibrin polymerization. Double-stranded fibrils form through end-to-middle domain (D:E) associations, and concomitant lateral fibril associations and branching create a clot network. Fibrin assembly facilitates intermolecular antiparallel C-terminal alignment of gamma-chain pairs, which are then covalently 'cross-linked' by factor XIII ('plasma protransglutaminase') or XIIIa to form 'gamma-dimers'. In addition to its primary role of providing scaffolding for the intravascular thrombus and also accounting for important clot viscoelastic properties, fibrin(ogen) participates in other biologic functions involving unique binding sites, some of which become exposed as a consequence of fibrin formation. This review provides details about fibrinogen and fibrin structure, and correlates this information with biological functions that include: (i) suppression of plasma factor XIII-mediated cross-linking activity in blood by binding the factor XIII A2B2 complex. (ii) Non-substrate thrombin binding to fibrin, termed antithrombin I (AT-I), which down-regulates thrombin generation in clotting blood. (iii) Tissue-type plasminogen activator (tPA)-stimulated plasminogen activation by fibrin that results from formation of a ternary tPA-plasminogen-fibrin complex. Binding of inhibitors such as alpha2-antiplasmin, plasminogen activator inhibitor-2, lipoprotein(a), or histidine-rich glycoprotein, impairs plasminogen activation. (iv) Enhanced interactions with the extracellular matrix by binding of fibronectin to fibrin(ogen). (v) Molecular and cellular interactions of fibrin beta15-42. This sequence binds to heparin and mediates platelet and endothelial cell spreading, fibroblast proliferation, and capillary tube formation. Interactions between beta15-42 and vascular endothelial (VE)-cadherin, an endothelial cell receptor, also promote capillary tube formation and angiogenesis. These activities are enhanced by binding of growth factors like fibroblast growth factor-2 (FGF-2) and vascular endothelial growth factor (VEGF), and cytokines like interleukin (IL)-1. (vi) Fibrinogen binding to the platelet alpha(IIb)beta3 receptor, which is important for incorporating platelets into a developing thrombus. (vii) Leukocyte binding to fibrin(ogen) via integrin alpha(M)beta2 (Mac-1), which is a high affinity receptor on stimulated monocytes and neutrophils.     

Telemedicine and teleradiology technologies and applications

Summary. Telemedicine and teleradiology hold the key for improving future health care delivery. In this paper we first review current communication and computer technologies used in telemedicine and teleradiology. Five examples in teleradiology applications are given including hospital-integrated picture archiving and communication systems, tele-neuro-imaging, telemammography, university consortium teleradiology service, and teleradiology for second opinion. Parameters important to teleradiology applications like costs, image quality, system reliability, and turn around time are considered. Data security is discussed, including patient confidentiality and image authenticity-which will be a major issue in future teleradiology applications.     

创伤高血糖与感染和MODS早期诊断和干预

本文详细介绍了创伤后血糖应激适度理论,以及高血糖与感染和多器官功能不全综合征的关系;提出涉及胰岛B细胞功能不全的MODS实验诊断新方案和极化液个体化干预新措施,可早期发现创伤MODS、降低感染率及MODS发生率和病死率。     

腹膜后纤维化与肾积水发生关系的临床研究

目的：探讨腹膜后纤维化（RPF）导致肾积水的原因及诊治经验。方法：回顾分析2004年1月—2010年12月24例腹膜后纤维化致肾积水患者的诊治资料。结果：（1）RPF患者常见首发症状为腰背痛或腹痛（69.2%）;（2）红细胞沉降率（ESR）增快和血清IgG4升高最常见。超声检查仅提示上尿路积水。RPF的静脉肾盂造影（IVP）和CT尿路成像（CTU）表现具有特征性。IVP肾盂输尿管显影不良时,CTU能较清晰的显示上尿路影像。CT扫描发现腹膜后软组织肿块9例（37.5%）,优于超声检查;（3）输尿管松解和腹腔化手术治疗22例;行肾切除术1例;行输尿管置双J管术1例。最终确诊为继发性RPF8例,其中4例为术前诊断,3例为术中腹膜后软组织肿块冷冻活检证实,1例为术后病理证实;（4）特发性RPF手术后肾积水均获长期缓解,而继发性RPF的预后取决于原发疾病及其治疗方案。结论：影像学检查是诊断RPF的重要手段,CTU优于超声检查和IVP。输尿管松解和腹腔化手术可以使特发性RPF输尿管梗阻得到长期的缓解,术中对肿块进行冷冻活检有助于鉴别特发性和继发性RPF,及时调整治疗方案。     

探讨儿童慢性顽固性咳嗽与支原体感染的关系及临床治疗观察

目的探讨儿童慢性顽固性咳嗽与肺炎支原体（MP）感染的关系及临床疗效观察。方法采用回顾性研究方法对于现将2005年3月至2008年3月在我院的55例确诊慢性顽固性咳嗽患儿,主要表现为肺炎支原体感染为临床特点进行分析,并进一步临床治疗研究。结果①临床特点：在55例确诊慢性咳嗽的患儿中,以慢性顽固性咳嗽为主要症状。58％（32／55）的病例无肺部体征;②外周血：85％（47／55）的病例外周血变化不大,WBC（4—10）×10 9／L之间,嗜酸性粒细胞增多;③特别检查：47．27％（26／55）肺炎支原体IgM（MP—IgM）抗体阳性,83．64％（46／55）PeR技术检测肺炎支原体特异性DNA;④X光报告为多种形式。结论肺炎支原体（MP）感染是引起儿童慢性顽固性咳嗽的病因之一,对儿童慢性咳嗽,特别是顽固性咳嗽的诊治中应更加重视。     

Acetaminophen and acetylcysteine dose and duration: Past,present and future

Abstract

Acetylcysteine has been utilized successfully in the treatment of acetaminophen overdose since the 1970s. Although prospective trials as to efficacy and safety of acetylcysteine were conducted, there were no randomized controlled trials. This commentary addresses the reasons for this, and the background to choice of dose of acetylcysteine utilized in the oral and IV dosing regimens. Nomograms to predict possible hepatotoxicity based upon time of ingestion of acetaminophen were developed from a relatively arbitrary definition of toxicity as an aspartate aminotransferase/alanine aminotransferase (ALT/AST) greater than 1000 IU/L. While these have proved generally useful, patients still continue to develop hepatic damage after acetaminophen overdose, particularly if they present late after ingestion. The optimum management of these patients remains unclear, and one area of uncertainty is the dose and duration of acetylcysteine in various circumstances. This article discusses the issues that need to be elucidated to better target changes in acetylcysteine dose. The potential for measurements of other markers to improve treatment selection is the subject of further research.     

Physician and Nurse Practitioner Teamwork and Job Satisfaction: Gender and Profession

Designing interprofessional primary care teams composed of physicians and nurse practitioners (NPs) is a national priority. We assessed how profession and gender affect teamwork and job satisfaction among primary care physicians and NPs by using survey data from 186 physicians and 398 NPs practicing in New York State. Our regression models show profession (NP vs physician) moderates the associations of gender with teamwork and job satisfaction. Among NPs, men had higher job satisfaction than women. Among physicians, women had higher job satisfaction than men. Our results can benefit interprofessional primary care teams to optimize their professional and gender mix.