慢性阻塞性肺疾病的新定义及临床诊疗建议——基于2022年《柳叶刀》文件解读

慢性阻塞性肺疾病(以下简称慢阻肺)是一种常见的慢性气道异质性疾病。近年来,尽管国内外慢阻肺相关研究不断深入,管理日趋完善,但仍有许多难点亟待解决。2022年9月,《柳叶刀》杂志发布《消除慢阻肺之路》,该文件针对慢阻肺的认识、诊断、评估和个体化治疗等方面提出了新理念并提供临床诊疗指导。本文重点对该文件中慢阻肺的分类、诊断标准及诊断建议、慢阻肺的急性加重和迈向消除慢阻肺5个方面进行介绍和解读,以期为我国临床工作者开展慢阻肺相关研究和管理提供一定的参考及启示。     

The shell region of the nucleus ovoidalis: a subdivision of the avian auditory thalamus.

The connectivity of a region surrounding the established thalamic auditory nuclei, n. ovoidalis (Ov) and n. semilunaris parovoidalis (SPO), was explored in the ring dove by using the anterograde tracers, Phaseolus vulgaris leucoagglutinin (PHAL) and biocytin, and the retrograde tracer, fluorogold. The Ov-SPO surround received a projection from a cell group along the interface of the auditory midbrain and the n. intercollicularis, as revealed with PHAL and biocytin, and was composed of neurons exhibiting a common morphology. These features and the presence of overlapping projections from different portions of the Ov-SPO surround suggest that this region comprises a functionally discrete area, which we term the Ov shell. Single unit recording within the shell established the existence of acoustically responsive units. Both PHAL and fluorogold labeling revealed a robust projection from the Ov shell to the caudomedial hypothalamus. Major telencephalic projections of the shell terminated within the ventral paleostriatal complex, "end-zones" of the field L, the caudomedial hyperstriatum ventrale, and regions immediately dorsal and lateral to the auditory neostriatum. Except for a portion of the shell bordering medial ovoidalis, PHAL injections into the shell also labeled fibers within the caudolateral neostriatum and along the lateral neostriatal rim. The connectivity of the Ov shell suggests that this region may integrate auditory pathways with brain regions associated with endocrine mediated behavior. In addition, the shell may constitute a source of converging input to several levels of central auditory pathways.     

A Study of Early Pregnancy Factor Activity in Preimplantation

PROBLEM and METHOD: Early pregnancy factor (EPF), an Immunosuppressive substance, which appears in pregnant women's sera 48 h after fertilization, is a kind of pregnancy-specific protein. To determine whether the EPF activity could be a super early indicator of pregnancy, we used rosette inhibition assay to detect EPF activity in the sera, collected from 70 women 2–7 days after ovulation intending to conceive monitored by ultrasonography. Simultaneously we selected 40 non-pregnant sera and 12 early-pregnant sera as negative control and positive control, respectively. RESULTS: The results of this study demonstrated that EPF activity is detected in 35 women's sera out of 70 women within 2–7 days after ovulation, and 28 women out of the 35 were pregnant, which was known by follow-up, and 7 were not pregnant, possibly due to either false positive results or embryo loss because of preimplantation failure, thus causing no pregnancy. The other 35 out of 70 had no EPF activity and 34 of them were not pregnant, which was known by follow-up, but one case became pregnant, which was false negative result. Our study showed that diagnosis of the super early pregnancy could be made by detecting EPF activity in maternal serum within the time of preimplantation. The accuracy of pregnancy diagnosis by this method is 88.6%, with a false negative rate of 3.4% and a false positive rate of 17.1%. The β-HCG level was measured from the above 70 women's sera in order to contrast EPF activity. All of the sera collected 2–6 days following ovulation indicated that there were lower β-HCG values in very early pregnancy (≥a5 mIU/ml). On the seventh day after ovulation, EPF activity was detected in 11 out of 15 sera with only 2 of them with a b-HCG level that reached or slightly surpassed that of the early pregnancy diagnosis (5 mIU/ml and 5.4 mIU/ml, respectively). This demonstrated that β-HCG is not the earliest signal of pregnancy; otherwise the EPF activity is one that appears 2–6 days earlier than β-HCG appears. We measured the progesterone level of the 48 sera from the 70 collected above within 2–7 days postovulation and found most of them reached the level of progesterone in the luteal phase (7.5–98.3 nmol/L). This indicated that ovulation had taken place in these women, which was in accordance with observations by ultrasonography. CONCLUSIONS: Our study showed that diagnosis (of 88.6%) of super early pregnancy could be made with an accuracy of 88.6% by detecting EPF activity in maternal serum within 2-days after ovulation. This offers a basis for pregnancy diagnosis for the women who attempt to terminate their pregnancy safely or who conceive unexpectedly, and it contributes to family-planning.     

An epidemiologic approach to computerized medical diagnosis—AEDMI program

A program called “An Epidemiological Approach to Computerized Medical Diagnosis” (AEDMI) is presented. Using an interactive questionnaire, physician-patient interviews are conducted and a summary of the relevant clinical data is provided. Standard items, obained on a multi-centre basis, form a large-scale data base. Simultaneously, the reasoning of clinical experts in each real case is analyzed to obtain a knowledge-rules data base. The methodology of the program combines Bayesian systems, expert systems, and other new lines of researcg such as neural networks or case-based reasoning. The general concepts of clinical decision making aid systems are reviewed. This publication is aimed at obtaining international cooperation.     

Infrared spectroscopy: A new diagnostic tool in Alzheimer disease

Biological markers play an evolving role in the diagnosis of Alzheimer disease (AD). We compare conventional measurements of cerebrospinal fluid (CSF) tau and β-amyloid_1–42 proteins to a novel approach – Fourier transformed infrared (FT-IR) spectroscopy – a simple technique derived from chemical and physical sciences that characterizes intramolecular bonds. For automatic diagnostic analysis, we developed an artificial neural network (ANN). We examined 71 patients with a clinical diagnosis of AD and 66 controls. β-Amyloid_1–42 was decreased (sensitivity 80% and specificity 78%); tau was elevated (sensitivity 76% and specificity 88%) in CSF of AD patients. The combined tau/β-amyloid_1–42 quotient was able to distinguish healthy from diseased subjects with 99% sensitivity and 86% specificity. The ANN could separate FT-IR spectroscopy data with 88.5% sensitivity and 80% specificity. FT-IR spectroscopy proved to be cost-effective and simple to perform. Diagnostic sensitivity and specificity is in the range of CSF tau and β-amyloid_1–42 protein analysis. Larger sample numbers for ANN training and validation could increase diagnostic accuracy and thus prove to be a useful screening tool.     

Die klinische Relevanz der Sonographie in der Akutdiagnostik perforierter Gastroduodenalulcera

Zusammenfassung Anhand einer prospektiven, auslesefreien Serie von 22 Patienten mit perforierten Ulcera im Gastroduodenalbereich verweisen wir auf die begrenzte diagnostische Aussagekraft einfacher anamnestischer, klinischer und radiologischer Daten. Lediglich bei acht Patienten (36%) ergaben sich wesentliche Indizien aus Krankengeschichte und Aufnahmebefund. Bei 16 Patienten (73%) verriet die Thoraxübersichtsaufnahme durch Nachweis einer subphrenischen Luftsichel eine Perforation im Magen-Darm-Trakt. Die Ultraschalluntersuchung wird als bedeutungsvolle Ergänzungsmethode vor allem in der diagnostischen Abklärung radiologisch negativer Ulcusperforationen vorgestellt und diskutiert. Dabei werden die sonographisch faßbare flüssigkeitsbedingte Magendistension sowie das Magenwandödem als unspezifische Kriterien gewertet. Der Objektivierung einer pathologischen Magenkokarde kommt bei gleichzeitigem Nachweis freier Luft und/oder extraluminärer Ingesta sowie freier echoloser Transsudatflüssigkeit pathognomonische Beweiskraft zu. Selbige Ultraschallkriterien erlaubten im einschlägigen Krankengut bei 16 Patienten (73%) eine definitive Diagnose und erfaßte 4 Patienten mit negativem Röntgen. Die kombinierte Analyse radiologischer und sonographischer Befunde führte somit bei 20 Patienten (91 %) unverzüglich zur korrekten Diagnose.

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Perforated peptic ulcer: Diagnosis and assessment by sonography

Summary In a prospective unselected series of 22 patients with perforated gastroduodenal ulcers the diagnostic efficacy of clinical and radiologic data was modest. In eight patients only (36%), clinical data yielded sufficient evidence; in 16 patients (73%), plain X-ray demonstrated subphrenic gas. Sonography was proven to be a major advance, especially rewarding in the diagnosis of perforations with negative plain X-ray. Gastric distention and stomach wall edema are unspecifc sonographic criteria, whereas objectivation of a pathologic stomach cockade in the presence of free gas, extraluminary ingesta or echofree fluid in the peritoneal cavity are pathognomonic data. These criteria yielded a definite diagnosis in 16 patients (73%) including four patients with negative X-ray. The combined analysis of radiologic and sonographic findings yielded an immediate correct diagnosis in 20 patients (91%).

     

病例组合指数的内涵及应用探讨

国内普遍认为病例组合指数(CMI)属于医疗服务能力维度,体现收治疾病的疑难复杂程度和医疗服务的整体技术难度。通过结构方程模型分析发现,CMI与时间消耗指数、费用消耗指数等服务效率维度指标联系更紧密,与DRG组数、入组病例数及总权重等服务能力维度指标联系相对较弱,故应归属医疗服务效率维度。CMI的直接应用主要是对平均住院费用的预测控制及对科室绩效的评价;CMI的间接应用主要是对管理指标的调整/校正。医院管理者应准确把握CMI内涵,恰当应用CMI对不同层级及不同类别住院费用进行预测、评价与控制,并对其他管理指标进行调整后再评价。     

基于分级诊疗的“互联网+护理服务”模式探索

“互联网+护理服务”是满足居家患者服务需求的主要形式之一。以分级诊疗为基础,依托“互联网医院”平台,初步探索构建了医联体内“互联网+护理服务”模式。认为基于分级诊疗的“互联网+护理服务”模式能够满足患者延续性护理服务需求,保障患者享受同质化护理服务,促使护理资源合理分配和有效利用。     

选择性动脉造影在不明原因的下消化道出血诊断中的价值探讨

目的 探讨选择性动脉造影和造影时机选择在不时原因下消化道出血诊断中的价值。方法 运用Seldinger技术对32例患者进行选择性肠系膜上、下动脉及其分支造影,其中少量出血患者17例,中至大量15例。首次出血3例,2次以上反复出血29例。结果 32例中28例发现病变（87.5%）,其中肿瘤性病变（n=15）非肿瘤性病变（n=13）,少理出血未见造影剂外溢征,中至大量出血中造影剂外溢征占33％。结论 选择性动脉造影检查下消化道出血是一种安全、有效的方法,在少量出血和出血间歇期仍有很大价值;造影显示病变部位更重要于显示出血征象。