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      39. 首頁 > 技術文章 > 醫學檢驗不能丟了顯微鏡

        醫學檢驗不能丟了顯微鏡

         時下,醫院檢驗科的各種自動化檢驗設備可謂日新月異,檢測速度和準確性不斷提高,傳統的人工顯微鏡檢查還有用武之地嗎?在近日舉行的2012年全國血液體液形態檢驗診斷學學術會議上,不少專家大聲疾呼,在充分發揮現代自動化檢驗技術優勢的同時,不應忽視以傳統人工顯微鏡檢查為主要手段的細胞形態學檢查的重要價值。
        發布日期:2012-11-20  來源:健康報
        一張小涂片解決了大問題
        “一張小小的痰涂片,解決了困擾我一年多的慢性咳嗽。”會上,北京大學第一醫院檢驗科王建中教授與大家分享了自己的經歷, 
        一年前,王建中因受涼患了肺炎,此后一直斷斷續續地咳嗽,夜里常常咳得無法入睡。痰培養、胸透、肺功能、CT,該做的檢查全做了,就是找不到原因,各種對癥治療也效果不佳。家人和同事甚至開始擔心他得了肺癌
        直到有一天,王建中為自己做了一張痰涂片,顯微鏡下發現其中有大量嗜酸性粒細胞,表明咳嗽很可能是由過敏導致的。根據這一檢驗結果,在醫生指導下服用相應抗過敏藥物后,王建中終于治愈了病痛。
        “形態學檢驗對疾病的診斷具有獨到之處。”他深有感觸地說。
        據專家介紹,作為臨床檢驗的核心和基礎,形態學檢驗主要是在顯微鏡下對血液體液標本中的細胞或有形成分進行觀察,是臨床診斷、療效觀察、預后判斷等的重要依據。
        人工鏡檢結果還是一些疾病診斷的“金標準”。如在白血病的血液與骨髓標本中髓系原始細胞計數時,血液或骨髓涂片的顯微鏡下形態學檢查和流式細胞儀分析兩者均可用,但世衛組織最新的造血與淋巴組織腫瘤分類方案仍要求以形態學檢查為準。
        “即使是在臨床檢驗技術自動化大發展的背景下,人工鏡檢依然是醫學檢驗中不可缺少的重要手段。”王建中說,比如臨床最常用的血尿常規檢查,自動化儀器目前仍只能作為篩選手段,需要按照一定比例進行人工鏡檢的復檢。
        南方醫科大學附屬中山博愛醫院檢驗科主任技師黃道連說,自動化儀器都是按照正常細胞的相關參數進行設定的,而病變細胞的結構和形態往往會發生改變,病得越重,變化越大,此時,自動化儀器就難以分辨,甚至張冠李戴,造成誤診、漏診。
        對于人工顯微鏡檢查的重要性,很多專家不約而同地提到了曾在社會上引起軒然大波的“茶水發炎”事件。2007年和2012年,兩度有記者用茶水代替尿液送到醫院化驗,結果被檢測出炎癥。雖然這一做法有違科學原理,但也從另一側面向檢驗界敲響了警鐘:顯微鏡檢查的環節必不可少。“倘若檢驗人員能夠對出現白細胞陽性的標本進行顯微鏡復檢,也許就可以發現這一明顯的謬誤。”北京協和醫院檢驗科張時民教授說。
        河北醫科大學第二醫院檢驗科李順義教授也舉例說,抗凝劑在全自動血細胞分析儀上的使用,有可能造成假性血小板減少,如果不進行進一步鏡檢就直接發出檢驗報告,會導致患者接受不必要的輔助檢查。
        被忽視只因費時費力還不掙錢
        讓與會者感到的擔憂的是,人工顯微鏡檢查這一不可或缺的重要檢驗方式正在被嚴重忽視和弱化,成為許多醫院檢驗科的“短板”。 
        這種忽視和弱化首先體現在人工鏡檢的比例大幅縮水,甚至被取消。“不少醫院基本就不做了。”張時民說。
        據了解,即使全血細胞分析儀判定為正常的標本中,也有5%是假陰性。2005年,世衛組織涂片復檢協作組調查復檢結果發現,每天有25%~30%的標本需要進行顯微鏡復檢。但目前不少醫院的復檢率低于5%,甚至為0。
        “自動化儀器主要看細胞數量的變化,而人工鏡檢則重點關注細胞‘質’的改變,兩者本應是左右手的關系,但現在普遍是‘一手硬、一手軟’。”黃道連說,他所在的檢驗科形態學檢查做得不錯,臨床醫生從中嘗到了甜頭,醫院也因此非常重視人工鏡檢,“我們醫院要求每一位住院病人在檢查血常規時必須同時做血涂片。但據我了解,很少有醫院這樣要求”。  (下轉第2版)(上接第1版)
        其次,檢驗人員對各種細胞的識別能力有限,難以為臨床診斷提供有價值的信息。“認得出就認,認不出就當作沒看見。”張時民說。
        人工鏡檢被忽視的另一個突出表現是愿意干的人少,干著的人培訓進修機會少,專業從事形態學檢驗的人員嚴重不足,不少醫院采用輪崗、兼職的辦法來安排人手。
        “青黃不接是普遍現象。”黃道連曾對中山市4家三級醫院的檢驗科人員進行問卷調查,僅有17%的人表示愿意從事形態學檢查工作,約12%的人員接受過為期1個月以上的形態學檢驗診斷培訓,而免疫、生化等其他檢驗項目的檢驗人員接受培訓的比例則為25%~30%。
        中國中醫科學院廣安門醫院檢驗科劉貴建教授指出,過度倚重自動化設備,對儀器的局限性以及人工鏡檢的重要性認識不足,認為機器檢查可以取代人工鏡檢,加之臨床工作量激增,面對每天成百上千份的血尿標本,且要在1小時甚至半小時內出檢驗結果,檢驗人員超負荷工作,無暇完成進一步鏡檢,是人工鏡檢在檢驗科被忽視的主要原因。
        另一個原因則是收費問題。目前,醫院檢驗項目的收費標準主要按照耗費的物力成本計算,人工鏡檢所需試劑少、儀器簡單,因而這一檢驗項目基本不收費或收費很低。在目前的醫院運行機制下,對于“費時費力還不掙錢”的人工鏡檢,醫院普遍缺乏關注熱情。
        張時民舉例說,在該院做一套肝腎功能血脂檢查的收費在300元左右,1小時自動化檢驗設備大約可以處理上百個標本,而一名檢驗醫師1小時僅能處理約10個普通標本,復雜的標本甚至只能處理兩三個。
        “有時一張涂片看不到病變細胞,但根據經驗判斷覺得有問題,為了找到證據,就得多看幾張甚至十幾張片子,可能花費一天時間就為了找到一個惡性細胞。”黃道連說,“在美國,形態學檢查被視為技術含量極高的檢驗項目,費用也相應較高,屬于醫保的限檢項目。一套骨髓涂片的形態學檢查收費為400美元~500美元,而我們的收費只有50元~60元。”
        張時民指出,一名成熟的形態學檢驗技師需要至少10年的經驗積累,而現在愿意待在顯微鏡前的人越來越少,非常不利于我國形態學檢驗診斷領域的發展。
        形態學檢查有廣闊發展空間
        “形態學檢查是一門古老的學科,也有著廣闊的發展空間,絕不應該是檢驗科的弱項。”上海交通大學醫學院附屬瑞金醫院王鴻利教授說,在形態學檢驗的基礎上發展起來許多新的檢驗方法,流式細胞儀就是典型代表。同時,細胞生物學、分子生物學等新興技術領域都與形態學有關。“放棄了形態學,就放棄了臨床檢驗學的基礎。”

        王建中表示,近年來逐漸發展成熟的全自動血細胞數字圖像分析等現代技術,將為形態學檢查的未來發展帶來“革命性”的變化。“標本制備的全自動化、儀器自動獲取細胞圖像,可以減少人工制備標本時間,檢驗者可以在電腦屏幕上看到標本的顯微圖像,同時通過網絡實現資料共享,同行間可以相互交流,這有助于提高檢驗診斷的效率和準確性。”

        張時民認為,當前應著力加強形態學檢驗技術骨干的培養和基本技能的培訓。在政策允許的情況下,提高形態學檢查項目的收費,適當提高從事形態學檢驗人員的待遇。黃道連建議,應該在崗位安排、人才培養、進修培訓、崗位津貼等方面實行政策傾斜,“讓從事形態學檢驗的人員能夠安心本職工作,不斷提高業務水平,為臨床醫生提供更有價值的診斷信息”。

        添加日期:2015-06-25
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