A web-based Delphi study on the indications of chest radiographs for patients in ICUs

BACKGROUND: Strategies for ordering bedside chest radiographs (CXRs) have substantial logistic and financial consequences in the ICU. Many of the indications for CXRs in the ICU are controversial, such as the ordering of daily routine CXRs for intubated patients. The opinions of intensivists about ordering CXRs have not been reported. Comparing these opinions to established guidelines and identifying situations where opinions diverge in the absence of guidelines are of considerable interest. METHODS: We asked 190 intensivists from 34 ICUs in the area of Paris, France, to anonymously complete a 29-item questionnaire about their opinions regarding the ordering of CXRs; each item described a clinical scenario. Of the 29 scenarios, 10 dealt with the placement of medical devices, 8 with the presence of medical devices, and 11 with other clinical situations. The study was based on a Delphi process deployed over the Internet through an original software application. Three Delphi rounds were run between January and March 2006, using the same questionnaire. Detailed feedback for the answers given during the previous round was supplied to each intensivist solicited for updating his answers. RESULTS: Eighty-two intensivists from 32 ICUs completed the study. A consensus emerged that routine CXRs were necessary for eight scenarios and unnecessary for two scenarios. The study also shed light on items without a consensus. In particular, 75% of intensivists (58% on the first round) did not support obtaining daily routine CXRs in intubated patients. CONCLUSION: The study underlines situations in which intensivists do not support the guidelines and outlines recommendations likely to be followed in clinical practice.     

CD40 activation in human pancreatic islets and ductal cells

AIMS/HYPOTHESIS: CD40 expression on non-haematopoietic cells is linked to inflammation. We previously reported that CD40 is expressed on isolated human and non-human primate islets and its activation results in secretion of IL-8, macrophage inflammatory protein 1-beta (MIP-1beta) and monocyte chemoattractant protein-1 (MCP-1) through nuclear factor-kappaB and extracellularly regulated kinases 1/2 pathways. The objective of this study was to identify the pattern of gene expression, and to study viability and functionality affected by CD40-CD40 ligand (CD40L) interaction in human islets. Furthermore, we have studied the CD40-mediated cytokine/chemokine profile in pancreatic ductal cells, as they are always present in human islet transplant preparations and express CD40 constitutively. METHODS: CD40-CD40L gene expression modulation was studied by microarray on islet cells depleted of ductal cells. Selected genes were validated by quantitative RT-PCR. The cytokine profile in purified ductal cells was evaluated by Luminex technology, based on the use of fluorescent-coated beads, known as microspheres, and capable of multiplex detection of proteins from a single sample. Glucose-stimulated insulin secretion and islet viability were assessed by perifusion and 7-aminoactinomycin D membrane exclusion, respectively. RESULTS: Statistical analysis of microarrays identified 30 genes exhibiting at least a 2.5-fold increase across all replicate arrays. The majority of them were related to oxidative stress/inflammation. Prominently upregulated were chemokine C-X-C motif ligand 1 (CXCL1), CXCL2 and CXCL3 belonging to the CXC family of chemokines related to IL-8. CD40-mediated CXCL1 secretion was confirmed by ELISA. The viability or in vitro function was not affected by CD40 activation. In addition to previously reported IL-8, MIP-1beta and MCP-1, CD40 stimulation in ductal cells produced IL-1beta, IFN-gamma, TNF-alpha, granulocyte colony-stimulating factor and granulocyte-macrophage colony-stimulating factor. CONCLUSIONS/INTERPRETATION: CD40 activation in islets and ductal cells produces cytokines/chemokines with a broad-spectrum range of biological functions.     

Oral disopyramide for the acute treatment of severe outflow obstruction in hypertrophic cardiomyopathy in the ICU setting

When severe COPD and obstructive hypertrophic cardiomyopathy (HCM) coexist, management is challenging and complex. Drug contraindications limit pharmacologic options. Patients may not be candidates for surgical septal myectomy due to severe pulmonary disease. We describe a case of an elderly woman with severe reactive COPD who presented with an infectious exacerbation and dyspnea that progressed to near intubation due to heart failure from coexistent obstructive HCM. Transthoracic echocardiography revealed massive asymmetric septal hypertrophy and a diffusely hyperkinetic left ventricle with a left ventricular outflow tract (LVOT) gradient of 92 mm Hg. Two and a half hours after oral administration of disopyramide, LVOT gradient had decreased to 25 mm Hg with a corresponding immediate improvement in symptoms.     

定量动态增强磁共振技术的影响因素分析

动态增强磁共振成像(dynamic contrast-enhanced MRI,DCE-MRI)基于快速T1WI,行多期动态增强扫描,获取感兴趣区时间-信号强度曲线,再通过药代动力学模型分析,得到反映组织灌注及血管渗透性的定量参数,已应用于肿瘤诊断、疗效评价、预后评估。作者针对影响DCE-MRI结果的主要因素:扫描方案、动脉输入函数(arterial input functions,AIF)、运动位移、药代动力学模型,进行系统评价,通过提高DCE-MRI参数的可重复性和准确性,为临床应用提供帮助。     

G6P／6PG比值法用于筛查G6PD缺乏症的比对分析

目的：评价手工操作和全自动生化仪两种检测方法,对于改良葡萄糖6-磷酸脱氢酶定量比值法筛查G6PD缺乏症的一致性。方法收集患者样本,分别用手工操作法和全自动生化分析仪检测G6P／6PG比值,参照EP9-A2文件,进行方法学比对和偏倚评估。结果两种方法检测结果相关性分析 r2为0．83,在医学决定水平0．95、1、1．05处,其偏倚为31．6％、29％、27．6％。两个方法间结果的偏倚不能接受。结论使用全自动生化分析仪上机检测G6P／6PG比值,可以提高G6PD缺乏症的检出率。采用手工法,必须做好方法间比对,建立自己实验室的参考区间。     

应用Logistic回归模型筛选剪切波弹性成像评估颈部淋巴结的定量参数

目的 采用Logistic回归模型探讨剪切波弹性成像(SWE)评估颈部淋巴结良恶性的价值和筛选SWE的定量参数.方法 对59例患者共95个疑似恶性颈部淋巴结在颈部淋巴结清扫前进行常规超声检查及剪切波弹性成像检查,分别比较颈部良性与恶性淋巴结的弹性值比值(E-ratio)、病灶的平均弹性值(E-mean)、病灶的最大弹性值(E-max)和标准差(SD);以病理结果为金标准,建立二分类逻辑回归模型,绘制模型预测概率的ROC曲线并计算曲线下面积,确定诊断界值,计算敏感度、特异度、准确度、阳性预测值、阴性预测值和约登指数.结果 Logistic回归模型为logitic(p)=-3.653+1.760X₁+0.235X₂-0.207X₃+0.168X₄,X₁为E-ratio,X₂为E-mean,X₃为E-max,X₄为SD.模型预测概率ROC曲线的曲线下面积为0.865,以55.66%为模型预测概率的诊断界值时,准确率最高为84.21%,对应的敏感度为80.00%,特异度88.89%,阳性预测值为88.89%,阴性预测值为80.00%,约登指数为68.89%.结论 运用SWE的4个定量参数建立的逻辑回归模型对颈部良恶性淋巴结的鉴别具有中等诊断价值,4个定量参数均可为良恶性淋巴结的鉴别诊断提供依据,而诊断价值最高的定量参数是E-ratio.     

定量组织速度成像技术评价PTCA支架置入后 心肌功能改变的研究

目的探讨超声定量组织速度成像(QTVI)技术评价冠心病患者PTCA支架置入前后局部心肌运动速度的临床应用价值.方法研究对象包括因冠状动脉左前降支(LAD)狭窄接受PTCA支架置入治疗的冠心病患者27例,分别于治疗前1天、治疗后1周及1个月测量左前降支供血区各节段心肌收缩期峰值速度(PSMV)、舒张早期峰值速度(PDMV).另外测量20例正常人左前降支供血区各节段心肌收缩期峰值速度(PSMV)、舒张早期峰值速度(PDMV)作为对照.结果①与正常对照组比较,冠心病组治疗前1天左前降支供血区各节段心肌PSMV、PDMV明显减低(心尖段除外);治疗后1个月室壁运动速度减低节段除前壁中段及前间隔中段 PSMV及PDMV达到正常值,其余节段仍低于正常对照组;②冠心病组治疗前后比较:上述速度减低节段治疗后1周, PSMV及PDMV明显增快;治疗后1个月继续增快.结论 QTVI技术能定量分析PTCA支架置入治疗前后左室壁局部心肌运动速度的变化.     

定量磁化率成像的基本原理及方法概述

定量磁化率成像(quantitative susceptibility mapping,QSM)是磁共振成像(magnetic resonance imaging,MRI)中一项新兴的用于定量测量组织磁化特性的技术。利用定量磁化率成像,可以对组织的铁含量、钙化、血氧饱和度等进行有效的定量分析,对脑出血、多发性硬化症及帕金森综合症等脑神经疾病的研究和诊断也具有重要意义。定量磁化率图像的重建是一个复杂的过程,包括几个不同的步骤,因此其准确性受到很多因素的影响。本文主要概述定量磁化率成像的基本原理和重建流程,并对重建过程中每个步骤的主要方法进行介绍。同时,也将对当前定量磁化率成像的几种主要临床应用进行介绍。     

肝癌特异性GGT的发生及其定量分析的临床价值

目的探讨肝癌特异性ＧＧＴ的动态变化及其定量分析的临床价值。方法以化学致癌剂２－ＦＡＡ（００５％）制备鼠肝癌模型，观察肝癌ＧＧＴ的产生及其肝组织内分布，并对不同肝病患者血清肝癌特异性ＧＧＴ区带（ＨＳＢ）进行定量分析研究。结果在实验性鼠的诱癌过程中，鼠肝脏癌变组织中ＧＧＴ大量表达，出现早并具有胎肝ＧＧＴ的特点；人血清中ＨＳＢ的定量检测发现：肝癌组明显高于其他肝病组，肝外肿瘤及正常对照组（Ｐ＜０００１）；ＨＳＢ在小肝癌中的阳性率为７５％，在ＡＦＰ阴性肝癌中为７８３％。结论研究资料提示ＨＳＢ的定量检测其临床价值优于ＨＳＢ的定性分析，且有助于小肝癌和ＡＦＰ阴性肝癌的早期诊断。