2014 Vol. 5, No. 3

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Original Contributions
Abstract:
  Objective  To investigate the antimicrobial susceptibilities of nosocomial multi-drug resistantAcinetobacter baumannii(MDR-AB) and multi-drug resistant Pseudomonas aeruginosa(MDR-PA) isolates.  Methods  MDR-AB and MDR-PA isolates were collected between August 2011 and July 2012 from 27 hospitals in China. All isolates were collected from high quality samples with definite infection diagnoses, whilst isolates from sputum and screen samples were strictly excluded. Minimum inhibitory concentrations (MICs) of 12 commonly used antimicrobial agents were tested by broth microdilution method in a microbiology laboratory. CLSI clinical breakpoints(CBPs) of pre- and post-revision were applied and compared in determination of MDR.  Results  A total of 664 MDR-AB and 268 MDR-PA isolates were collected. Pan-drug resistant (PDR) was detected in four Pseudomonas aeruginosa but not in Acinetobacter baumannii. The majority of isolates were collected from ICUs and surgical wards. Colistin and tigecycline were the most active agents against MDR-AB (96.8% and 72.6% susceptible, respectively), while no other drug exhibited activity of > 55% susceptible. Only 72.4% of MDR-PA isolates remained susceptible to colistin, but amikacin was more active to MDR-PA (64.2%) than MDR-AB (16.7%). By applying revised CBPs, the susceptibility of MDR-AB isolates to imipenem and meropenem decreased by 1.3% and 0.6%, respectively, whereas the susceptibility of MDR-PA to these two drugs decreased by 5.5% and 8.6%, respectively. The carbapenems susceptible rate of isolates collected from ICUs was lower than surgical and other wards. Isolates collected from different geographic regions showed varied resistant profiles.  Conclusions  Colistin and tigecycline are the most active drugs against MDR-AB, while colistin and amikacin have comparably good performance to MDR-PA.
Abstract:
  Objective  To investigate the clinical significance and influencing factors of serum levels of pro-gastrin-releasing peptide (ProGRP) and neuron-specific enolase (NSE) in the diagnosis of small cell lung cancer (SCLC).  Methods  The levels of serum ProGRP and NSE in 93 SCLC patients (SCLC group), 120 non-small cell lung cancer (NSCLC) patients (NSCLC group), 120 benign pulmonary disease patients (benign disease group), and 90 healthy people (healthy control group) were determined using enzyme-linked immunosorbent assay (ELISA). The potential impacts of the hemolysis in samples and impaired renal function on ProGRP and NSE were tested via electroluminescent and chemiluminescent immunoassay, respectively.  Results  The serum ProGRP and NSE concentrations were 90.61(11.75-20 020.90)ng/L and 13.18(3.05-201.88)μg/L, respectively, in SCLC group; 13.26(8.54-526.23)ng/L and 5.86(1.80-100.90)μg/L in NSCLC group; 24.65(1.32-802.93)ng/L and 7.22(1.36-174.62)μg/L in benign disease group; and 14.74(4.59-100.86)ng/L and 4.95(1.31-10.58)μg/L in healthy control group. The levels in the SCLC group were significantly different from those in the other three groups (all P < 0.01).The area under the receiver operating characteristic curve of ProGRP was (0.856±0.023) (95% CI: 0.811-0.901). When the cutoff value of ProGRP was set at 46 ng/L, the diagnostic sensitivity, specificity, positive predictive value, negative predictive value, and Youden's index were 64.5%(60/93), 94.2% (311/330), 75.9% (60/79), 90.4% (311/344), and 58.7%, respectively, showing good detection performance. Sample hemolysis seriously improved the detection results of NSE. Patients with impaired renal function had higher ProGRP levels.  Conclusions  The serum ProGRP and NSE levels are valuable tumor markers for the diagnosis of SCLC. Detection of both markers are particularly useful for the monitoring of SCLC.Sample hemolysis may seriously increase the detected NSE level, whereas impaired renal function may increase the detected ProGRP level.
Abstract:
  Objective  To evaluate the alteration of cholesterol ester fatty acids and related serum biochemicalparameters in elderly patients with type 2 diabetes mellitus(T2DM).  Methods  Totally 73 T2DM patients(T2DM group) and 72 healthy subjects(control group) (aged ≥60 years) who received health check-ups in Beijing Hospital from August to December in 2012 were recruited and blood samples were collected. Eleven main cholesterol ester fatty acids in serum were determined with liquid chromatography tandem mass spectrometry, and endogenous conversions by desaturases and elongases were estimated from product-to-precursor ratios. Fasting plasma glucose(FPG), total cholesterol(TC), triglyceride(TG), high-density lipoprotein cholesterol(HDL-C), low-density lipoprotein cholesterol(LDL-C), apolipoprotein(Apo) AI(ApoAI), ApoB, and high sensitivity C-reactive protein(hsCRP) were analyzed with an automatic biochemistry analyzer and the results were statistically analyzed.  Results  CE14:0, CE16:1 and CE22:6 in T2DM group were significantly lower than those in the control group(P < 0.05), while no significant difference existed between other fatty acid compositions. Δ9-desaturase activity was lower in T2DM group compared with that in control group(P=0.001). After adjusting for age, gender, body mass index(BMI), TC, TG, and FPG, Logistic analysis showed the quartiles of CE22:6 and Δ9-desaturase activity were associated with risk of type 2 DM, and the odds ratios were 0.27(95%CI: 0.08-0.86, Wald: 4.93, P < 0.05)and 0.06(95%CI: 0.01-0.22, Wald:17.39, P < 0.01), respectively, for comparison of the top to bottom quartile. Both CE14:0 and CE20:3 negatively correlated with FPG(r=-0.18, -0.17, P < 0.05); CE18:0 positively correlated with BMI and TG(r= 0.25, 0.24, P < 0.01) and negatively correlated with HDL-C and ApoAI(r=-0.39, -0.35, P < 0.01); CE20:3 positively correlated with BMI, with a correlation coefficient of 0.42(P < 0.01).  Conclusions  Several cholesterol ester fatty acids decrease in elderly T2DM patients. CE22:6 and Δ9-desaturase may protect against T2DM. An appropriately balanced intake of fatty acids is helpful for the prevention of T2DM in the elderly population.
Abstract:
  Objective  To study the short-term biological variation of glycated hemoglobin-A1c (HbA1c).  Methods  Blood samples from 30 healthy volunteers [17 men and 13 women; aged 23-34 years (median, 24 years)] were drawn at 8:00 am, 12:00 pm, and 4:00 pm each day for 3 days (days 1, 3 and 5), and HbA1c values were measured in duplicate by high performance liquid chromatography (Variant Ⅱ Yurbo Analyser, Bio-Rad).  Results  The within-subject coefficient of variations (CVI) of total, male, and female subjects in this study were 1.39%, 1.49%, and 1.32%, respectively. The between-subject coefficient of variations (CVG) of the three groups mentioned above were 2.65%, 2.33%, and 2.90%, respectively. The analytical coefficient of variations (CVA) of these three groups were all 0.6%. The index of individuality (II) of the three groups were 0.5, 0.6, and 0.5, respectively. The 95% probabilities of reference change value (RCV) of the three groups were 4.22%, 4.45%, and 4.02%, respectively. The 99% probabilities of RCV were 5.19%, 5.86%, and 5.29%, respectively. Furthermore, intra- and inter-day biological variations of HbA1c were fairly constant among the population examined(P=0.28, 0.31), and no significant difference was observed between the male and female participants(P=0.18).  Conclusions  The short-term CVI and CVG of HbA1c in healthy individuals are minimal. The laboratory findings are quite constant and homogeneous for HbA1c in short term and between genders.
Abstract:
  Objective  To detect the effects of CA125 on cellular immune function of the ovarian cancer (OC) patients in vitro.  Methods  Totally 58 patients with confirmed OC in our hospital from May 2012 to June 2013 were divided into three groups based on the CA125 levels. Meanwhile, 20 healthy subjects(control group) and 20 patients with benign gynecological diseases (benign diseases group) were also included. The in vitro ability of healthy human lymphocytes in secreting interferon-γ (IFN-γ) under the stimulation of phytohemagglutinin(PHA) was observed by cell culture, enzyme-linked immunosorbent assay (ELISA) and enzyme-linked immunospot (ELISPOT).  Results  In OC patients, the count and percentage of lymphocytes decreased gradually with elevated levels of CA125. The concentration of IFN-γ in the supernatant of cultured lymphocytes from healthy individuals decreased significantly under the stimulation of PHA and high concentration of CA125[(36.16±16.89)ng/ml]compared with that of PHA alone [(45.68±18.01)ng/ml] or PHA and low concentration of CA125 [(46.22±19.30)ng/ml](both P < 0.05). Compared with the control group(spots number 573.0) and the benign diseases group(spots number 523.0), the high(spots number 108.2) and intermediate(spots number 371.6) concentration of CA125 had significant inhibitory effect on the cellular immune system, as detected by ELISPOT (P < 0.01, P < 0.05, respectively). After removal of CA125 from the serum by antibody, the inhibitory effect was weakened significantly.  Conclusions  The concentration of CA125 in OC patient is negatively correlated with the number and activity of lymphocytes, in particular their abilities in releasing cytokines. CA125 is not only a biomarker of OC but also may serve as an immunosuppressive factor.
Abstract:
  Objective  To conduct a comprehensive performance evaluation of fully automated coagulation analyzer in testing coagulation factors, protein S(PS), protein C(PC), anti-thrombin Ⅲ (AT-Ⅲ), and von Willebrand factor antigen (vWF:Ag).  Methods  According to the Clinical and Laboratory Standards Institute (CLSI) EP5-A2, EP9-A2, and WS/T 406-2012 specifications, coagulation factors(FⅡ, FⅤ, FⅦ, FⅧ, FⅨ, FⅩ, FⅪ, and FⅫ), PS, PC, AT-Ⅲ, and vWF:Ag were detected in the apparatus to evaluate the accuracy, within-run and between-run imprecisions, linear range, carryover rate, method comparisons, and reference range of the ACL TOP 700 coagulation analyzer.  Results  The instrument had high accuracy and precision, a good linear range, and low carryover rate (0-2.63%, < 3%). The biases of the 12 College of American Pathologists (CAP) controls compared with the target value were all less than 15%, excepting the low value of PC. The within-run imprecisions of 8 coagulation factors were 1.7%-4.4%, and the between-run imprecisions were 2.2%-7.5%. The within-run imprecisions of 3 thrombophilia screen tests and vWF:Ag were 1.0%-7.0% and 2.2%-3.1%, and he between-run imprecisions were 1.5%-10.5% and 2.1%-4.1%, respectively. The carryover rates of the 12 items ranged from 0 to 2.63%. Results of liner verification test showed the correlation coefficients of PS, PC, AT-Ⅲ, and vWF:Ag were 0.982-0.988. Results of method comprisons showed the correlation coefficients of ACL TOP 700 and other coagulation analyzer were more than 0.975, and the recommended reference ranges of all the 12 items were appropriate for our laboratory.  Conclusions  ACL TOP 700 coagulation analyzer has a good performance in accuracy, imprecision, carryover rate, linear range, and method comparison. It is suitable for detection of clinical specimens.
Abstract:
  Objective  To validate the accuracy of CardioChek PA lipid point-of-care devices in determining total cholesterol (TC), triglyceride (TG), and high-density lipoprotein cholesterol (HDL-C) in whole blood and the comparability with results determined by full-automatic biochemical analyzer.  Methods  We determined the low, medium, and high levels of TG, TC, and HDL-C in whole blood with single reagent lot number 20 times using 3 different CardioChek PA devices to evaluate inter-run and devices' coefficient of variations(CVs), and used single CardioChek PA device with 3 reagent lot number to determine the whole blood 10 times for evaluating inter-run and total CVs. Fifty-four volunteers whose lipid profiles covered up high, medium, and low levels were recruited. Lipids in fasting periphery whole blood and venous serum were collected and determined using 3 different CardioChek PA devices and 4 kinds of full-automatic biochemical analyzers, respectively. Bland-Altman plot was made to analyze the comparability of results from CardioChek PA and the full-automatic biochemical analyzers. Linear regression was analyzed using results of CardioChek PA and full-automatic biochemical analyzers. Bias and percentage bias were determined between CardioChek PA and different automatic biochemical analyzers; meanwhile, whether they satisfied the requirements of medical decision levels was determined.  Results  The total CVs of TC in low, medium, and high levels in 3 different devices were 2.69%, 4.88%, and 3.51%, respectively; for TG, they were 5.51%, 5.27% and 4.96%; and for HDL-C, they were 7.27%, 6.84% and 6.79%. The total CVs of TC, TG, and HDL-C determined with the same device but different reagent lot number were 4.70%, 7.66%, and 8.61%, respectively. Comparison of the results from CardioChek PA devices and the 4 kinds of full-automatic biochemical analyzers showed lowest deviation for TC with -2.21%-2.56%, and for HDL-C with -1.12%-5.57%; the deviation of TG results of BeckmanDxC800 was relatively high with 25.85%, but in other 3 systems were -4.55%-13.34%. Deviation of TC, TG, and HDL-C in different medical decision levels were -3.27%-1.96%, -11.05%-13.06%, and -5.86%-11.56%, respectively, all of which could satisfy the requirements of the National Cholesterol Education Program(NCEP). Compared with reference methods, the biases of TC in medical decision levels were 1.96% and 0.77%; for HDL-C, they were 2.34% and 4.87%.  Conclusion  The accuracy of CardioChek PA lipid point-of-care device can satisfy the clinical requirements, and the device can be used in the screening and monitoring of dyslipidemia.
Abstract:
  Objective  To evaluate the clinical application of a fully-automatic urine sediment analyzer and establish the reference range of urinary formed elements.  Methods  The precision, carryover rate, analytical measurement range, and comparability with manual microscopy method were evaluated, and the reference ranges of red blood cells (RBC), white blood cells (WBC), squamous epithelial cells (EC), and casts by the instrument were analyzed.  Results  The low, medium, and high values of precision were 129.10%, 20.59%, and 7.80% for RBC, and 65.73%, 14.30%, and 13.00% for WBC. The medium and high values of precision for EC were 27.01% and 21.46%. The carryover rate of RBC, WBC, and EC were all 0. The measurement range was 0-83 608/μl for RBC and 0-15 624/μl for WBC. As to the measurement range of bacteria, there were obvious differences according to the different species of bacteria. When compared the instrument results with the manual microscopy, the consistency rates were 82.80% for RBC, 73.82% for WBC, and 57.56% for EC. The reference ranges of urinary formed elements were as follows: the range of urinary RBC was 0-8/μl for males and 0-12/μl for females; the range of urinary WBC was 0-12/μl for males and 0-21/μl for females; the range of urinary EC was 0-13/μl for males and 0-42/μl for females; the range of urinary cast was 0-4/μl for males and 0-4/μl for females; and the range of urinary crystal was 0-34/μl for males and 0-2/μl for females.  Conclusions  This fully-atomatic urine sediment analyzer has better recognition performance for RBC and WBC. We can carry on the manual recognition using audit function by instruments, and manual morphological examination when necessary, to detect crystals, casts, fungi, and irregular cell components which are difficult to identify automatically.
Abstract:
  Objective  To explore the different expressions of bcl-2 and vascular endothelial growth factor receptor-3 (VEGFR-3) in intravenous leiomyomatosis (IVL) and classical leiomyoma (LM).  Methods  We retrospectively reviewed the pathology of 20 cases of IVL, matching with 10 cases of LM. The bcl-2 and VEGFR-3 immunohistochemical staining was performed in the slides from all cases, and the results were compared between the IVL group and LM group.  Results  In the IVL group, all the 20 cases showed moderate to strong bcl-2 immunohistochemical staining. Meanwhile, 19 cases showed moderate to strong VEGFR-3 immunohistochemical staining, while 1 case was negative. In the LM group, all 10 cases showed weak to moderate bcl-2 immunohistochemical staining and negative VEGFR-3 staining.  Conclusions  Both bcl-2 and VEGFR-3 are highly expressed in IVL; in particular, the expression of VEGFR-3 is dramatically different between IVL and LM. This indicates IVL and LM have different molecular alterations, which may play important roles in the pathogenesis and development of IVL.
Abstract:
  Objective  To analyze the clinical features and genetic background of mitochondrial neurogastrointestinal encephalomyopathy (MNGIE).  Methods  The clinical data of an adult patient with MNGIE were retrospectively reviewed. Meanwhile, the mitochondrial disease-related gene of the patient and his families were detected by target area capture sequencing with NimbleGen solid phase chip.  Results  This patient presented with progressive pseudo-gastrointestinal obstruction, leukoencephalopathy, cachexia, peripheral neuropathy, extraocular muscle weakness, and multiple metabolic disorders. A homozygous mutation (TYMP gene c.217G>A) was identified. The patient's parents and sister were heterozygous for this novel mutation.  Conclusion  A novel TYMP gene mutation that caused MNGIE in a Chinese adult patient was confirmed by gene detection.
Abstract:
  Objective  To investigate the demographic characteristics, disease spectrum, and clinical features of inpatients from foreign countries and those from Hong Kong and Taiwan of China.  Methods  The general information and clinical data of foreign inpatients as well as inpatients from Hong Kong and Taiwan who had been admitted to the Department of International Medical Services at Peking Union Medical College Hospital from January 2011 to December 2013 were retrospectively collected and analyzed.  Results  A total of 557 patients were enrolled in this study. Among them there were 216 males and 341 females, with an average age of 45.5 years old.The age of 379 patients (68.0%) were between 30 and 59 years old. These 557 patients were from 76 countries and 2 regions of China (Hong Kong and Taiwan). The top three foreign countries were the United States (n=123, 22.1%), Canada (n=66, 11.8%), and Australia (n=45, 8.1%).Diseases during pregnancy, delivery, and puerperium (n=124, 22.3%), tumors(n=78, 14.0%), and digestive system diseases(n=65, 11.7%) were the top three causes of hospitalization. Of all these 557 patients, 187(33.6%) were admitted from emergency department, 103(18.5%) were severe or difficult cases, and 29(5.2%) were once transferred from or to intensive care unit. The average hospital stay was 7.1 days. On discharge, 50.5%(n=281) of these patients were cured, 49.0%(n=273) improved, and 0.5%(n=3) died.  Conclusions  Inpatients from foreign countries as well as Hong Kong and Taiwan admitted to the Department of International Medical Services at Peking Union Medical College Hospital have a large age span, big regional difference, broad spectra of diseases, and high proportions of severe and difficult diseases. Besides favorable hospitalization environment and patient-centered services, fluent communication in foreign languages, rich clinical experiences, ability to quickly identify severe cases, and coordination among different departments are also needed to offer high-quality and effective medical services for these patients.
Abstract:
  Objective  To investigate the value of gray-scale and color Doppler ultrasound in the diagnosis of brachial cleft cysts and brachial cleft fistulas.  Methods  The sonographic and clinical records of 19 patients with pathologically proven brachial cleft cysts and brachial cleft fistulas between January 2010 and January 2014 were retrospectively reviewed and the sonographic characteristics of the brachial cleft abnormalities were analyzed.  Results  Fourteen cases were diagnosed as brachial cleft cysts (5 were First, 9 were Second), 5 cases were diagnosed as brachial cleft fistulas (1 was First, 2 were Second, 1 was Third, 1 was Fourth). On the ultrasound, the brachial cleft cysts manifested as round or oval in 92.8% (13/14), and 85.7%(12/14) had a sharp border; 50.0%(7/14) were echo-free, and floating echo points could be found in 2 of them. Also, 14.3%(2/14) had solid cysts with small cystic structure, and 28.6% (4/14) had purely heterogeneous solid cysts. Color Doppler flow imaging(CDFI) showed 28.6%(4/14) were peripherally vascularized and 71.4%(10/14) were not vascularized. In the 5 patients with brachial cleft fistulas, 4(80%) had hypo-echoic strips or irregular shape, 2(40%) showed the fistula, 3(60%) were solid, and 2(40%) were mixed solid and cyst. CDFI showed 2(40%) were inner-part vascularized, 1(20%) was peripherally vascularized, and 2(40%) were not vascularized.  Conclusion  Brachial cleft cysts and brachial cleft fistulas have typical ultasound manifestations, which can guide the preoperative diagnosis of these diseases.
Abstract:
  Objective  To summarize the principles, techniques, and effectiveness of the surgical treatment for pulmonary aspergillosis.  Methods  The clinical data of 34 pulmonary aspergillosis patients who had undergone surgical treatment in our department from January 1986 to December 2013 were retrospectively analyzed. Three patients with diffuse lesions manifested by CT image received wedge resection to obtain pathological tissues. Thirty-one patients with localized lesions received complete resection, in whom the surgical procedures included lobectomy (n=26), segmentectomy (n=3), and wedge resection (n=2). Thoracotomy was performed in 27 patients and video-assisted thoracoscopic surgery in 7 patients.  Results  No perioperative death was noted. All the 34 patients were pathologically confirmed as with pulmonary aspergillosis. Five patients (14.7%) suffered from postoperative complications including pulmonary embolism (n=1), acute pulmonary edema (n=1), pleural effusion (n=1), prolonged air leak (n=1), and wound disruption (n=1). All patients were successfully discharged 2-34 days after the surgery, and the average hospital stay was (10.1±6.2) days. No relapse was noted during the 1-16 years of follow-up.  Conclusions  For patients with suspected pulmonary aspergillosis, which may present as diffuse lung lesions, surgical biopsy provides the "golden standard" of pathological and pathogenic diagnosis. For patients with localized pulmonary aspergillosis, surgical treatment can completely remove the lesions, provide definite pathological diagnosis, and effectively relieve the symptoms.
Abstract:
  Objective  To investigate the clinical outcome of bone pate for mastoid obliteration after canal wall down mastoidectomy.  Methods  The clinical data of 12 patients who had undergone canal wall down mastoidectomy followed by bone pate obliteration in Peking Union Medical College Hospital from October 2013 to February 2014 were retrospectively analyzed. The post-operative morphologies of tympanic membranes and mastoid cavities were observed, and the complete reepithelialization time and improvement of hearing were analyzed.  Results  The mastoid cavities were completely reepithelialized in all 12 patients. The morphologies of tympanic membranes were nearly normal. The volumes of mastoid cavities were significantly reduced. The mean time of complete reepithelialization was 29.9 days. The air-bone gap value increased by (11.7±1.8) dB after the operation in 8 patients who had undergone hearing reconstruction.  Conclusions  Mastoid obliteration with bone pate after canal wall down mastoidectomy is a simple and convenient procedure that can easily make the mastoid cavity be well-shaped and reepithelialized, shorten the healing time, and achieve good hearing outcome.
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