陳佩文 陳欣林 趙勝 楊小紅

(湖北省婦幼保健院超聲診斷科，湖北武漢 430070)

1 原文摘要

ObjectiveThe goal of this study was to examine the intra-operator and inter-operator differences of the manual and semiautomated nuchal translucency(NT)measurements and to evaluate if these differences alter women's risk status．

Methods A cross sectional study was performed．Two operators obtained manual and semiautomated NT measurements of 153 NT images．The maximal acceptable difference in NT measurements within and between operators was 0．15?mm．Intra and interoperator differenceswere analyzed by the paired Student'st-test and homogeneity of variances by the Levene's test．Intra-operator and inter-operator agreement were quantified with Bland and Altman's limits of agreement，and changes in women's risk status were tested with the binomial test．

ResultsIntra-operator agreement was high for each of the measurement methods．Operator 1 had lower SDS for manual measurements．Conversely，operator 2 had lower SDS of the differences for semiautomated measurements，although the SD never reached the same level as operator 1．Inter-operator agreement was highest for the semiautomated measurements．Changes in risk status occurred between the manual and innermiddle method resulting in different clinical policies in up to 1 out of 20 cases．

Conclusion Well-trained operators do not seem to benefit from the use of the semiautomated measurement methods．

2 論文核心內(nèi)容及點(diǎn)評

該文章2013年12月發(fā)表于《Prenatal Diagnosis》雜志上。在該研究中，作者通過觀察手動和半自動兩種方法測量胎兒頸項(xiàng)皮膚厚度(NT)，不同的方法及檢查者自身和檢查者之間的測量差異，評估這些差異是否影響或改變孕婦胎兒染色體異常風(fēng)險(xiǎn)的判定。主要內(nèi)容如下：

這是一項(xiàng)交叉性的研究。2位檢查者對153幅已經(jīng)獲得的NT圖像進(jìn)行手動和半自動NT測量。檢查者自身及兩位檢查者之間的最大可接受的差值為0．15毫米。應(yīng)用成對t檢驗(yàn)對檢查者自身及兩位檢查者之間差異進(jìn)行配對分析，應(yīng)用Levene檢驗(yàn)方差齊性，應(yīng)用Bland and Altman's置信區(qū)間對檢查者自身及兩位檢查者之間一致性進(jìn)行量化，應(yīng)用二項(xiàng)式檢驗(yàn)評估差值是否改變婦女的風(fēng)險(xiǎn)狀況。

檢查者本人應(yīng)用每一種方法進(jìn)行NT值的測量具有高度的一致性。檢查者1應(yīng)用手動測量時(shí)，其標(biāo)準(zhǔn)差差值較低。反之，檢查者2應(yīng)用半自動測量，其標(biāo)準(zhǔn)差差值較低，雖然標(biāo)準(zhǔn)差未達(dá)到檢查者1的水平，但半自動測量時(shí)檢查者間的一致性達(dá)到最高。由于手動測量和內(nèi)-中線的測量差異導(dǎo)致高達(dá)有1/20的病例風(fēng)險(xiǎn)狀態(tài)發(fā)生變化。由此作者認(rèn)為，富有經(jīng)驗(yàn)的超聲檢查者似乎并不能從NT的半自動測量方法中獲益。

NT值的測量是篩查染色體異常及胎兒結(jié)構(gòu)缺陷最有效的標(biāo)志，為使不同操作者的結(jié)果達(dá)到一致性，必須堅(jiān)持標(biāo)準(zhǔn)的測量技術(shù)。在NT的測量中，有胎兒圖像的質(zhì)量及測量鍵放置能導(dǎo)致操作者的偏差，增加了測量的變異性。有研究表明對給定的圖像進(jìn)行NT值測量的過程中，半自動測量能潛在的消除絕大多數(shù)操作者間的變異并實(shí)質(zhì)性地減少操作者自身的測量變異。本研究不僅將兩種方法及不同測量者進(jìn)行交叉性比較，從而得出半自動測量更適宜NT的初學(xué)者或是經(jīng)驗(yàn)不足的超聲檢查者。對于指導(dǎo)我們臨床有一定的實(shí)用價(jià)值。同時(shí)，由于新的方法所導(dǎo)致孕婦風(fēng)險(xiǎn)狀態(tài)的改變，是否提示我們應(yīng)制定半自動測量相應(yīng)風(fēng)險(xiǎn)值，這是值得我們進(jìn)一步關(guān)注的。