女性患者，52岁。反复出现发热，关节肿痛，全身水肿，蛋白尿，约4年余，入院时体温38.5℃，四肢关节疼痛，脾肋下3cm，肝肋下2cm，双手掌指关节、双膝关节肿胀、压痛。BUN26.8mmol/L，血钾6.0mmol/L，血沉98mm/h，CRP升高，C3降低，尿蛋白（+++），血压20/12kPa，X线示心影向两侧扩大，右侧肋膈角变钝。采用青霉素、链霉素治疗效果不佳。
如果ANA滴度为1：20000，应优先做哪些实验室检查用以明确诊断（）。
A.抗角蛋白抗体
B.抗ds-DNA抗体
C.抗Sm抗体
D.抗核周因子抗体
E.抗CCP抗体
F.抗SSA、SSB抗体
G.狼疮抗凝物
参考答案：B, C, F, G
解析：
1.女性患者，58岁，反复出现发热，关节肿痛，全身水肿，蛋白尿，约4年余，首先排除急性肾炎的诊断。BUN26.8mmol/L，血钾6.0mmol/L，血沉98mm/h，CRP升高，C3降低，尿蛋白强阳性，血压20/12kPa。支持慢性肾衰竭的诊断。可能的原因是慢性肾炎和系统性红斑狼疮
2.系统性红斑狼疮患者，ANA、抗Sm抗体可出现阳性，而类风湿关节炎患者抗CCP抗体可出现阳性，急性肾炎患者血清ASO水平显著升高，肾脏B超，肾穿刺活检可用于诊断与鉴别诊断
3.高滴度ANA主要见于系统性红斑狼疮，因此应优先做抗ds-DNA抗体、抗Sm抗体、抗SSA、SSB抗体和狼疮抗凝物检验，用以明确系统性红斑狼疮的诊断。抗核周因子抗体、抗CCP抗体和抗角蛋白抗体主要用于类风湿关节炎的辅助诊断
4.系统性红斑狼疮患者抗ds-DNA抗体、抗Sm抗体阳性，尤其抗ds-DNA抗体是判断系统性红斑狼疮是否活动的重要标志
5.抗ds-DNA抗体是判断系统性红斑狼疮是否活动的重要标志。系统性红斑狼疮处于活动期，血清补体大量消耗，因此血清补体水平显著降低。另外血清CRP水平和ESR是非特异性的活动性指标
s he was carrying, along with two sweaters, a basketball and a walkman（随身听）. Mark stopped and helped the boy pick up these things. Since they were going the same way, he helped to carry some of his things. As they walked, Mark knew that the boy’s name was Bill, that he loved computer games, basketball and history, and that he was having lots of troubles with his other subjects and that he had just broken up with his girlfriend.
understand that if I killed myself, I would have missed that time and so many others that might follow. So you see, Mark, when you picked up those books that day, you did a lot more. You saved my life.”