用循证医学指导临床组合检验项目的应用

按照循证医学的理念对检验项目临床应用进行评价，包括技术性能、诊断性能、患者结果、经济性能等严格评价，根据不同的诊断目的和不同的疾病，制定检验项目组合的临床应用指南，为临床医生提供最佳临床实验室诊断服务，以保证患者得到最大受益。     

加强与临床的联系,促进检验医学的发展

21世纪的医学是以科学依据为基础的循证医学 ,加强检验医学与临床医学的联系是循证医学的基本要求。检验医学通过与临床的联系与沟通 ,可促进临床标本的正确采集以及检验结果的正确解释和应用 ,从而把单方面 (实验室 )的质量控制发展为全面质量保证 ,同时实验室也可从临床上获得许多宝贵的返馈信息 ,借此可进一步综合评价检验项目的方法学 (特别是标本采集送检方法 )及其临床价值 ,以不断完善操作程序并推进新方法和新项目的开展。临床医学通过加强与检验医学的联系 ,亦可从检验医学中获得许多有价值的临床证据和信息 ,提高诊断水平 ,指导治…     

循证医学的定义、发展、基础及实践

循证医学是结合医生的个人专业技能和临床经验，考虑患的愿望，对患作出医疗决策而发展起来的新兴临床学科。高质量的证据是指尽可能保证结果真实性的、以患为中心的临床研究数据。证据及其质量是循证医学的关键。研究人员应该尽量提供高质量的证据，临床医生尽可能使用现有的最佳证据。循证医学在进行诊断和治疗决策时，考虑患的愿望，从而体现以患为中心的医疗服务宗旨。高素质的临床医生、最佳的研究证据、临床流行病学的基本方法和知识及患的参与是循证医学的基础。循证医学实践包括提出问题，检索证据，评价证据，结合临床经验与最好证据对患进行处理和效果评价5个步骤。     

临床检验学教学的思路与方法

检验医学是一门将临床医学和实验技术相结合，在实验室内通过对各种项目的检验，对疾病的预防、诊断、疗效和预后判断提供重要依据的学科，其本身是一门与多学科相关的交叉性、边缘性医学学科。因此，学习的目的就应该具备两个方面的要求：一方面要积累丰富的基础理论、掌握多专业的实验医学技术能力和循证医学知识；另一方面则要培养学生建立良好的临床检验诊断思维方法，以便进入工作岗位就能承担起临床检验诊断的角色。教师在教学过程中针对以上两个方面，认真研究教学方法就显得更加重要。本文就合理的临床检验学教学提出一点思路与方法。     

循证检验医学能为临床医学提供决策和证据

实验诊断 (laboratorydiagnosis)属于临床学科 ,与检验医学 (laboratorymedicine)比较 ,两者的相同之处是 :均以临床实验室检验项目作为研究的基础 ;两者的相异之处是 :实验诊断着重于检测项目的疾病诊断、病情观察和预后判断 ,检验医学则强调检测方法的优化和发展。近年来 ,由于循证检验医学的兴起和发展 ,使两者有更多的交叉和融合 ,两者的目标是一个 :为临床医学诊断提供最佳的决策证据。现代临床实验检测具有众多特点 :微量标本、多参数分析、自动化、智能化、高质量控制、床边检测、流水线检测、简便快速 ,等等。但现代临床实验诊断也…     

实验诊断学教学改革之思考

实验诊断学是连接基础医学与临床医学的桥梁,是一门将临床医学和实验技术相结合,为疾病的预防、诊断、疗效、预后判断和健康评估提供重要信息的学科。当今,循证医学的理念日益受到认同,“举证倒置”要求临床工作越来越重视客观证据,检验在临床医学中的重要性也与日俱增。但随着检验技术的发展,检验项目越来越多,教学任务也越来越重,其教学弊端也日益突现,教学改革势在必行。     

加强检验与临床的沟通是检验质量管理的关键

检验医学是现代实验室科学技术与临床在高层次的结合,是一门学科交叉,相互渗透的新兴学科。随着检验新技术的应用和检验仪器智能化的发展,使检验质量和水平显著提高,特别是在当今循证医学时代,临床对疾病的诊断和治疗越来越依赖实验室检查,检验质量直接影响着临床的诊断和治疗效果。检验科应加强质量管理,检验质量需要全程的控制和管理,即：实验前（分析前）、实验中（分析中）、实验后（分析后）三个阶段,只有这样才能达到标准化、规范化、科学化管理,当然这个过程也需要与临床沟通,需要得到临床的支持。因此,检验与临床的沟通十分重要。     

循证医学在康复临床中的应用

在康复医学领域如何开展循证医学？循证医学证据的分级，实践循证医学的步骤，以及怎样才能够通过临床医师参与和利用Cochrane协作网、阅读和应用循证医学文献来寻找到目前最好的证据，以解决患者的实际问题；循证医学应用于心肺疾患、神经系统疾患、骨关节疾患等已取得较好的经济效益和社会效益；而目前的部分系统评价所收集的原始文献尚不充分，大部分缺乏大型、多中心随机对照试验的支持，有的系统评价无法得出对临床有帮助的结论。文章综述了康复科主要相关疾病的循证医学研究概况，为临床康复医师如何实践循证医学和进行康复医学科研提供参考。     

循证实验诊断医学--实验诊断医学发展的新思路

循证医学是近十多年来在临床医学领域中迅速兴起的一门朝阳学科,它的迅猛发展给传统医学带来极大的冲击,也为临床各级人员带来深刻思考.近年来,随着医学检验的迅速发展,对其自身提出了巨大挑战,如硬件系统(技术和仪器等)已大大更新,而软件系统(研究和人员素质)相差甚远、学科建设如何发展等问题. 循证医学与实验诊断医学两个学科的交叉,为医学检验的发展提供了新的思路.本文仅就实验诊断医学的发展与现状、国际循证实验诊断医学的概念及展望两个方面进行简要阐述.     

循证医学与中医现代化

1　循证医学的产生与概念循证医学 (Ｅｖｉｄｅｎｃｅ -ＢａｓｅｄＭｅｄｉｃｉｎｅ)的观念产生于二十世纪八十年代。当时 ,国际上发表的临床试验越来越多 ,临床医生已难于从大量的信息海洋中获取所需信息 ,指导临床决策。因此 ,迫切需要对这些信息进行收集、分类、整理、评价 ,形成疗效数据库 ,供临床医疗决策使用。循证医学由此而生。其概念是临床医疗实践 (包括诊断、治疗、预防 )以及医疗卫生决策均应以现有的、可获得的最佳科学研究证据为依据。它并不排斥医生的专业技能和实践经验 ,而是强调二者的结合。由于循证医学的科学理念和在实…     

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.