目的 探讨及比较CURB-65、PSI、SMART-COP及APACHEⅡ 4种临床评分对重症社区获得性肺炎(SCAP)患者的早期诊断价值。方法 采用前瞻性研究方法,收集2011年10月—2014年2月广州市第一人民医院呼吸内科收治的67例SCAP及同期33例普通CAP患者的临床资料,记录入组后24小时内CURB-65、PSI、SMART-COP及APACHEⅡ评分的最差值,比较4种临床评分系统对SCAP的早期诊断价值。结果 SCAP组CURB-65、PSI、SMART-COP及APACHEⅡ评分均高于普通CAP组患者[CURB-65(分):3.06±1.10 比0.85±0.79,P<0.001;PSI(分):144.93±36.48比73.94±27.17,P<0.001; SMART-COP(分):6.54±1.41比 1.67±1.02,P<0.001; APACHEⅡ(分):20.79±5.69比7.94±3.87,P<0.001]。CURB-65≥3分、PSI≥130分、SMART-COP≥3分及APACHEⅡ≥15分诊断SCAP的受试者工作特征曲线(ROC)下面积(AUC)分别为0.940[95% CI:0.89~0.98, P<0.001],0.933[95%CI:0.88~0.97,P<0.001],0.999[95%CI:0.99~1.0,P<0.001],0.976[95%CI:0.95~0.99,P<0.001],敏感度分别为65.6%、71.6%、100%、88.1%,特异度分别为100%、100%、78.7%、93.9%。结论 CURB-65及PSI评分特异度好,但敏感度低,易漏诊,SMART-COP和APACHE Ⅱ评分诊断效能更佳。

Objective To evaluate and compare the early diagnosis value of CURB-65,PSI,SMART-COP and APACHEⅡin patients with severe community-acquired pneumonia. Methods This was a prospective study conducted in department of respiratory in Guangzhou First People's Hospital. We included 67 SCAP patients and 33 CAP patients between October of 2011and February of 2014. The lowest scores within 24 hours of CURB-65 score,PSI score,SMART-COP score,APACHE Ⅱ score,respectively,for each patients were recorded. Prediction of SCAP as made in four scoring systems was compared. Results CURB-65 score,PSI score,SMART-COP score,APACHE Ⅱ score were higher in SCAP as compared with that of CAP(CURB-65:3.0±1.1 vs 0.9±0.8,P<0.001;PSI:144.6±36.4 vs 73.9±27.1,P<0.001; SMART-COP:6.5±1.4 vs 1.6±1.0,P<0.001; APACHEⅡ:20.6±5.6 vs 7.9±3.8,P<0.001). ROC curve for CURB-65 score≥ 3 scores,PSI score≥ 130 scores,SMART-COP score≥3 scores and APACHE Ⅱ score ≥ 15 scores in the early diagnosis SCAP were 0.940[95%CI:0.89~0.98,P<0.001],0.933[95%CI:0.88~0.97,P<0.001],0.999[95%CI:0.99~1.0,P<0.001],0.976[95%CI:0.95~0.99,P<0.001]. Sensitivity of four kinds of scoring system was 65.6%,71.6%,100%,88.1%, with specificity of 100%,100%,78.7%,93.9% respectively. Conclusion The specificity of diagnosis was better in the CURB-65 and PSI score,but the sensitivity was low and easy to miss diagnosis. SMART-COP and APACHEⅡscore systems had a better diagnostic value on SCAP.

目的 探讨黏附因子E-钙粘蛋白(E-cadherin)和Toll样受体9(TLR9)在系统性红斑狼疮(SLE)发病机制中的作用。方法 随机选取SLE患者41例,健康对照组18例,采用酶联免疫吸附试验(ELISA)法检测血清中sE-cadherin的表达,采用流式细胞技术(FCM)检测外周血单核细胞上TLR9的表达。分析 sE-cadherin,TLR9与系统性红斑狼疮患者病情的活动性。结果 SLE组血清中sE-cadherin的表达水平高于正常组(P=0.00),差异有统计学意义;SLE活动组血清中sE-cadherin表达水平高于稳定组(P=0.06),但差异无统计学意义;SLE组TLR9表达高于健康组(P=0.00),活动组高于稳定期组(P=0.00),差异均有统计学意义;SLE患者TLR9表达与SLEDI呈正相关(r=0.727,P=0.00),差异有统计学意义。结论 血清中sE-cadherin和外周血单核细胞内TLR9均参与了SLE患者病情发展的过程,并且二者在SLE发病机制中可能具有协调作用。

Objective To explore the effect of adhesion molecule E-cadherin and Toll-like receptor-9(TLR9) in the pathogenesis of systemic lupus erythematosus(SLE). Methods 41 patients with SLE and 18 healthy controls were selected randomly.Expression of TLR9 in peripheral blood mononuclear cells determined by FCM. SE-cadherin levels were measured in the serum by ELISA analysis. The correlation between sE-cadherin、TLR9 and the patient's condition of SLE was analyzed. Results Compared with healthy subjects,the expression of sE-cadherin in serum was higher among SLE patients(P=0.00),there was statistically significant between two groups;activity group was higher than inactivity group and healthy controls(P=0.06),but there was no statistically significant between activity group and inactivity group. Compared with healthy subjects,the expression of TLR9 in peripherql blood mononuclear cells was higher among SLE patients(P=0.00);activity group was higher than inactivity group(P=0.00),there was all statistically significant between two groups.The positive correlation was observed between TLR9 expression levels and clinical measure of the SLEDAI(r=0.727,P=0.00),there was statistically significant between two groups. Conclusion SE-cadherin and TLR9 may play an important role in SLE,and may interact with each other which needed further study.

目的 探讨自体心包膜组织对急性心肌梗死大鼠心脏功能的影响。方法 筛选合格的模型动物随机分为三组:心包去除组:仅去除心包膜;心梗组:前降支结扎法建立大鼠心肌梗死模型3周后仅开胸;移植组:前降支结扎法建立大鼠心肌梗死模型,3周后将心包膜移植于心肌梗死及周边区。实验4周后,通过心动图评价实验动物心脏功能,使用Masson染色检测动物心肌梗死大小,通过免疫荧光评价动物心肌存活率、观察血管新生状况,Western blot检测Caspase-3蛋白/Bcl-2基因表达情况。结果 4周后,心包去除组大鼠的心电图监测结果未见有室性颤动;而心梗组、心梗+移植组均有非致死性室性颤动。相比心梗组,心梗+移植组改善了心功能,降低了心肌凋亡指数,免疫Bcl-2蛋白表达升高,而Caspase-3蛋白表达降低。结论 提示自体心包膜移植不会导致恶性室性心律失常,相对有较高的安全性;并能促进心肌梗死细胞恢复心功能,其改善机制可能与通过修补心室重构途径同时抑制缺血区域细胞凋亡有关。

Objective To explore the effect of autologous pericardial transplantation for treating the myocardial infarction (MI) in experimental rats. Methods 30 SD rats were randomly divided in to three equal parts: Pericardial removal group (PR group): only pericardium tissue was removed; Myocardial infarction group (MI group): the anterior descending branch ligation method established a rat model of myocardial infarction and only opened the chest after 3 weeks. Autologous pericardium transplantation (APT group): After established the MI model of SD rats, 3 weeks later, the autologous pericardial patch was harvested and transplanted to infarcted zone. Four weeks after the surgery, the cardiac function and serum biochemistry were analyzed for all the experimental rats. The cardiac function was evaluated by echocardiography, which the size of the infarction were examined by Masson staining, the survival time of transplanted autologous pericardial and angiogenesis were measured by immunohistochemistry, the protein expressions of Caspase and the gene expressions of Bcl were examined by Western blot analysis. Results 4 week after the 2^nd operation, no ventricular fibrillation was detected in the ECG of PR group. Fatal ventricular fibrillation wasn't detected in the ECG of MI group and APT group. Compared with MI group, APT group improved cardiac function and decreased myocardial apoptosis index(P<0.05),which similar to PR group. APT group has the higher density of angiogenesis at infracted area to MI group but less than that of PR group. PT group had decreased protein expressions of Caspase-3 and the expressions of Bcl-2 were decreased. Conclusion Autologous pericardial transplantation could recover myocardial infarction cells, which will improve the cardiac function in experimental rats with MI.

目的 探讨p27^Kip1蛋白的表达与梅州地区客家人食管鳞癌的关系。方法 收集我院病理科2003年1月—2008年12月的61例经手术切除的中国梅州地区客家人食管鳞癌组织及32例食管良性肿瘤组织为研究对象并包埋成蜡块。采用免疫组织化学技术检测组织中p27^Kip1蛋白的表达,结合患者的临床病理资料和随访资料,进行回顾性分析,并作出评价。结果 P27^Kip1蛋白在食管鳞癌细胞核和/或细胞浆都有表达。胞核表达阳性率为27.87%,低于食管良性肿瘤组织胞核表达（50.0%）（P<0.05）;而胞浆表达阳性率为49.18%,高于食管良性肿瘤组织胞浆表达（12.5%）（P<0.05）。无淋巴结转移的食管鳞癌p27^Kip1蛋白胞核表达阳性率为42.41%,高于有淋巴结转移者的阳性率（10.7%）,差异有统计学意义（P<0.05）;而无淋巴结转移的食管鳞癌p27^Kip1蛋白胞浆表达阳性率为42.4%,比有淋巴结转移者（57.12%）的阳性率有降低的趋势（P>0.05）。Ⅱ期（ⅡA+ⅡB）和Ⅲ期p27Kip1蛋白胞核表达阳性率分别为42.41%和10.71%,差异有统计学意义（P<0.05）;p27^Kip1蛋白胞浆表达阳性率有随着TNM分期的增高而增高的趋势（P>0.05）。结论 P27^Kip1蛋白作为肿瘤抑制因子,其在食管鳞癌的胞核和胞浆表达阳性呈相反趋势,随食管鳞癌TNM分期越高,胞核阳性率越低,胞浆阳性率越高,其可作为食管肿瘤恶性程度及进展的预测指标。

目的 分析无创产前基因检测(NIPT)在胎儿染色体非整倍体疾病诊断中的检出效率及临床应用价值。方法 选取2016年4月—2018年3月在我院接受无创产前基因检测的3 759例孕妇作为研究对象,利用二代测序AR550平台结合生物信息学进行无创产前基因检测,NIPT 的检测范围包括21、18、13 及性染色体非整倍体。对 NIPT 高风险的孕妇,建议行羊水或脐血穿刺染色体核型分析,比较两者结果的一致性,并随访妊娠结局。结果 3759例孕妇中NIPT提示高风险27例,阳性率为0.71%。其中24例孕妇行染色体核型分析,确诊为 21-三体14例、18-三体1例、13-三体1例和性染色体数目异常4例,阳性预测值分别为100%、50%、100%和66.7%。其中NT增厚中无创孕妇99例,检出高风险为5例,检出率为5.05%（5/99）,明显高于总体检出率。结论 NIPT 对 21-三体和 18-三体具有较高的敏感性和特异性,能提高产前筛查和诊断效率,具有较好的临床应用价值.

Objective To analyze the efficiency and clinical value of noninvasive prenatal gene test (NIPT) in the diagnosis of fetal chromosomal aneuploidy. Methods From April 2016 to March 2018, 3 759 pregnant women who underwent noninvasive prenatal gene testing in our hospital were selected as subjects. The second generation sequencing AR550 platform combined with bioinformatics was used for noninvasive prenatal gene testing. The NIPT detection ranged from 21, 18, 13 to sex chromosome aneuploidy. For pregnant women at high risk of NIPT, amniotic fluid or umbilical cord blood puncture karyotype analysis was recommended to compare the consistency of the two results, and follow-up pregnancy outcomes. Results Among 3 759 pregnant women, NIPT showed 27 cases of high risk, with a positive rate of 0.71%. Twenty-four pregnant women were diagnosed as 21-trisomy in 14 cases, 18-trisomy in 1 case, 13-trisomy in 1 case and abnormal sex chromosome number in 4 cases. The positive predictive values were 100%, 50%, 100% and 66.7% respectively. Among them, 99 cases were non-invasive pregnant women with NT thickening, and 5 cases were at high risk of detection. The detection rate was 5.05% (5/99), which was higher than the overall detection rate. Conclusion NIPT has high sensitivity and specificity to 21-trisomy and 18-trisomy, can improve the efficiency of prenatal screening and diagnosis, and has good clinical application value.

目的 研究新辅助化疗联合保肢手术治疗骨肉瘤的临床效果。方法 根据既往治疗骨肉瘤方法的不同,将56例患者分为对传统保肢组（A组）和现代保肢组（B组）,各28例。A组用采用传统保肢方案,即保肢手术+术后化疗方案进行;B组采用现代保肢方案,即新辅助化疗+保肢手术+术后化疗方案进行。化疗方案均采用CTX + VCR +MTX+ ADM方案,比较两组转移/复发率、术后1 年、2年及 3 年生存率、肢体功能、临床疗效情况。结果 比较两组的转移/复发率及3年后的死亡率,B组低于A组(P<0.05);肢体功能优良率及临床疗效,B组高于A组(P<0.05)。结论 新辅助化疗联合保肢手术能够降低骨肉瘤患者转移/复发率、死亡率,改善肢体功能,提高临床疗效。

Objective To study the clinical effect of neoadjuvant chemotherapy combined with limb salvage surgery for osteosarcoma. Methods Based on the previous methods of treating osteosarcoma, 56 patients were divided into the traditional limb salvage group (A group) and the modern limb salvage group (B group), 28 cases for each. The traditional limb salvage surgery + postoperative chemotherapy regimen were used in group A, and modern limb salvage regimen was performed in group B, ie neoadjuvant chemotherapy + limb salvage surgery + postoperative chemotherapy. The CTX + VCR +MTX+ ADM protocol was used in the chemotherapy regimens. The metastasis/recurrence rate, the 1-year, 2-year and 3-year survival rates, limb function, and clinical efficacy were compared between the two groups. Results The metastasis/recurrence rate and the mortality rate after 3 years in the two groups were compared. The B group was lower than that of the group A (P<0.05). The excellent rate of limb function and clinical efficacy were higher in the B group than that of in the group A (P<0.05). Conclusion Neoadjuvant chemotherapy combined with limb salvage surgery may reduce the metastasis/recurrence rate and mortality of osteosarcoma patients, improve limb function and increase clinical efficacy.

目的 分析针对乳腺不可触及肿物实施超声引导下微创旋切活检术治疗的临床效果。方法 选择我院收治的乳腺肿物患者200例进行观察（2012年1月—2017年12月）,针对200例乳腺肿物患者存在的305个乳腺不可触及肿物进行活检检查,采用随机分组的方式将其分成两组后针对常规组100例乳腺肿物患者实施传统手术治疗,针对治疗组100例乳腺肿物患者实施超声引导下微创旋切活检术治疗,对比两组的治疗效果。结果 两组乳腺肿物患者之间对比的术中出血量、术后愈合时间、术后并发症发生率、治疗显效率存在差异（P<0.05）,统计学有意义;且超声引导下微创旋切活检术对于乳腺癌的诊断检出率较高。结论 针对乳腺不可触及肿物实施超声引导下微创旋切活检术治疗的疗效显著,促进患者预后。

Objective To analysis of the clinical effect of ultrasound guided minimally invasive rotary biopsy for untouchable breast masses. Methods A total of 200 patients with breast masses were selected for observation （January 2012 to December 2017）, and 305 untouchable breast masses in 200 patients were examined by biopsy. It was divided into two groups randomly and then treated with traditional surgical treatment for 100 patients with breast masses in the routine group and 100 patients with breast masses in the treatment group with minimally invasive biopsy under the guidance of ultrasound. The therapeutic effects of the two groups were compared. Results There were differences between the two groups in the amount of intraoperative bleeding, postoperative healing time, the incidence of postoperative complications and the effective rate of treatment （P < 0.05）, and the differences were statistically significant （P < 0.05）. The diagnostic rate of breast cancer was higher with minimally invasive rotary biopsy guided by ultrasound. Conclusion The effect of ultrasound-guided minimally invasive rotary biopsy on untouchable breast masses is significant and promotes the prognosis of the patients.

目的 分析15例腹腔妊娠患者的临床病例特点,为临床工作提供参考依据,进一步减少漏诊及误诊的情况。方法 收集我院2002年1月—2018年6月期间住院治疗的腹腔妊娠患者的临床病例资料。回顾性分析并总结患者的临床诊治特点。通过t检验,进一步比较腹腔镜与腹式手术患者围手术期情况是否存在统计学差异。结果 1例B超检查提示大网膜妊娠可能;另1例入院前外院B超提示腹腔妊娠,孕8⁺周单活胎;其余13例患者术前B超提示宫内未见孕囊,子宫旁有包块,提示异位妊娠可能,术前未能明确腹腔妊娠。14例患者行手术治疗,另1例行介入穿刺保守治疗。术中探查发现腹腔妊娠病灶种植部位：位于大网膜5例,位于盆腔9例（膀胱区右下方盆壁1例,子宫直肠窝右侧直肠表面1例,右侧宫骶韧带2例,子宫下段前壁瘢痕处右缘1例,偏左侧肠管与子宫粘连之间1例、右侧盆壁1例、子宫直肠窝1例、子宫左侧圆韧带起始端1例）,位于腹腔1例（腰3椎体前方、腹主动脉与下腔静脉之间）。结论 腹腔妊娠的异位妊娠病灶种植部位非常广泛,超声检查需进一步扩大检查范围。必要时可选择MRI或CT检查准确定位,减少漏诊及误诊的情况。

Objective To analysis and summary clinical characteristics of 15 patients who were diagnosed with abdominal pregnancy,which supply reference for clinical work. Methods 15 cases who were diagnosed with abdominal pregnancy and admitted to Guangdong Women and Children hospital between January 2002 and June 2018 were identified. Retrospective analysis was used to summarize the clinical characteristics of diagnosis and treatment in 15 patients. Test statistics used Student's t test to find if there was statistical difference between laparoscopic and abdominal surgery patients in perioperative period. Results One case was likely diagnosed with greater omentum pregnancy by type B ultrasound. Another one patient was diagnosed with abdominal pregnancy which has 8+ weeks pregnant single live fetus by type B ultrasound in other hospital prior to hospitalization.The B ultrasound tests of the other 13 patients showed there were no sac in uterus and enclosed mass beside uterus which were diagnosed with ectopic pregnancy, but not positive diagnosis with abdominal pregnancy.Surgery was performed for 14 patients.We found more different sites where gestational sacs plant in abdominal pregnancy patients in operation, 5 cases sacs planted in greater omentum, 9 cases sacs planted in pelvic cavity including 1 case sac planted in pelvic wall bottom-right bladder,1 case sac planted in rectum outside right-hand of Douglas pouch,2 cases sacs planted in right utero-sacral ligament,1 case sac planted in right-side of scar in lower uterus segment,1 case sac planted in adhesive tissue between the lift intestinal canal and uterus,1 case sac planted in right pelvic cavity,1 case sac planted in Douglas pouch,1 case sac planted in initiating terminal of the lift round ligament of uterus. The inteventional puncture with medical treatment was supply for only 1 patient,CT test showed the sac planted in abdominal: ahead of third lumbar vertebra between abdominal aorta and inferior vena cava. Conclusion There are more sites where gestational sacs can plant in abdominal pregnancy patients. Ultrasound is first choice for patient who was considered ectopic pregnancy and better to expansion the inspection range. MRI or CT may find sacs plant site who was considered abdominal pregnancy which may reduce missed diagnosis and misdiagnosis. Surgery is first performed who was diagnosed with abdominal pregnancy. Medical treatment for patients who vital signs are stable.

目的 探讨临床全程导师制结合OSCE考试法对实习护生评判性思维的影响。方法 将176名在我院实习的本科实习护生随机分为两组,每组88人。对照组采用传统的临床带教和考核方式进行带教,实验组采用临床全程导师制结合OSCE考试法进行带教。记录两组理论考试成绩、实践技能成绩及护理病历成绩,比较两组实习护生教学前后评判性思维能力,比较两组实习护生干预后对临床带教模式的整体评价。结果 实验组理论考试成绩、实践技能成绩、护理病历成绩得分均高于对照组（P<0.05）。开展教学后两组评判性思维能力量表（CTDI-CV）各维度评分及总分均升高,实验组各维度评分及总分均高于对照组（P<0.05）。开展教学后实验组对临床带教模式的整体评价均高于对照组（P<0.05）。结论 临床全程导师制结合OSCE考试法,有助于提高本科实习护生的评判性思维能力。

Objective To explore the application and influence of the whole course mentor system combined with OSCE on the critical thinking ability of undergraduate clinical student nurses. Methods 176 undergraduate clinical student nurses were divided to control group and experimental group,88 for a group respectively. Control group used traditional clinical teaching method while the experimental group used whole course mentor system combined with OSCE. The theory and practice assessment scores ,medical record writing scores and critical thinking scores of clinical student nurses before and after the implementation of the two teaching modes were compared. Results The theory and practice assessment scores and medical record writing scores of the students in the experimental group were better than those of students in the control group（P<0.05）. The score of CTDI-CV was increased in both two groups after intervention. The score of all dimensions in CTDI-CV was better improved in the experimental group than that of controls （P<0.05）. And the evaluation of teaching mode of the experimental group was better than the control group（P<0.05）. Conclusion The teaching method of the whole course mentor system combined with OSCE is helpful to improve undergraduate clinical student nurses'ability of critical thinking.

目的 探讨运用巴林特沟通模式对老年住院患者满意度的影响。方法 选取我院2016年1月—2016年12月老年科收治的120名患者作为对照组,实施常规护理;另选取2017年1月—2017年12月间老年科接收的120名患者作为观察组,在对照组的护理基础上运用巴林特沟通模式,对比两组患者满意度评价。结果 运用巴林特培训后临床护士的沟通能力（包括困难情景沟通能力、情感感知能力、情感支持能力、基本语言沟通能力、基本非语言沟通能力、团队沟通能力）得分较培训前有提高,且观察组患者对护理人员的工作态度、疑问解答、业务指导以及沟通反馈等方面的满意度评价均优于对照组,差异有统计学意义（P<0.05）。结论 运用巴林特沟通模式不仅能够显著提升老年患者对住院医疗服务的满意度评价,同时能够提高护士的沟通能力,为提升医院医疗服务水平和良好的社会形象奠定有利基础,值得推广。

Objective To study Communication mode of Balint group in elderly inpatient's satisfaction. Methods 120 patients undergoing the conventional nursing care from January 2016 to December 2016 in our geriatric department were selected as control group;120 patients undergoing the conventional nursing care plus Balint communication mode from January 2017 to December 2017 were selected as observation group. The clinical satisfaction was evaluated. Results After the Balint training,the communication abilities including communication ability at the difficult scenes,emotional perception ability,emotional support ability,basic verbal communication ability,basic non-verbal communication ability,team communication ability were higher than before;the clinical satisfaction on the nurse's working attitude,frequently asked question,professional guidance,and communication and feedbacks in the observation group was higher than that of control group （P<0.05）. Conclusion The Balint communication mode may remarkably improve the patient's satisfaction on the nursing services and the nurse's communication abilities. It is of great importance to increase the hospital's medical service and establish a good social image. It is worthy of promotion.