Abstract:

隐球菌脑膜炎（Cryptococcal meningitis）简称隐脑，是由隐球菌属中某些种或变种侵犯中枢神经系统（central nervous system，CNS）引起的一种深部真菌病，为CNS最常见的真菌感染。隐脑为机会性感染，是人免疫缺陷病毒（human immunodeficiency virus，HIV）感染后CNS重要的并发症之一。在过去30年里，由于广谱抗菌药物、糖皮质激素及化学治疗药物的广泛应用，特别是获得性免疫缺陷综合征（acquired immune deficiency syndrome, AIDS）的流行，使得隐脑的发病率显著增加［1］。在撒哈拉以南地区，由于HIV的严重流行，使得隐脑已经超越肺炎链球菌及脑膜炎球菌性脑膜炎，成为最主要的社区获得性脑膜炎。据估计，全世界每年约有100万HIV相关性隐脑患者［2］，目前国内多以散发、非AIDS人群为主。隐脑死亡率及致残率均高，在免疫缺陷患者中表现更为突出，即使联合高效抗逆转录病毒疗法（highlyactive antiretroviral therapy, HAART），HIV相关性隐脑患者3个月内的死亡率仍然高达20%左右［3-4］。如何做到早期、迅速、准确诊断及给予有效的治疗措施，仍然是临床工作者面临的重大挑战。近年来，由于两性霉素B、氟胞嘧啶等抗真菌药物的有效、合理使用及新的抗真菌药物的不断推出，使得隐脑的治疗现状有所改善。现就隐脑的诊断与治疗进展作一介绍。

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ObjectiveTo investigate the effect of suppressive oligodeoxynucleotide (Sup ODN) on pSTAT4, pSTAT6 and Tbet expression of concanavalin A induced liver injury in mice.MethodsForty Balb/C mice were randomly divided into 4 groups, normal saline group (NS, blank control group), cyclosporin A group (CsA group, positive control group) ,control oligodeoxynucleotide group (control ODN group), and Sup ODN group (trial group). Mice in each group were injected with ConA(20mg/kg) via the tail vein to make liver injury model. Sup ODN, Con ODN, CsA or NS was injected intraperitoneally at the same time of ConA injection. The expression of pSTAT4 ,pSTAT6 and Tbet in spleen at the 8th or 24th hour after intraperitoneal injection was examined by Westernblotting.ResultspSTAT4 and Tbet in Sup ODN group were significantly lower compared with NS，Con ODN or CsA group respectively ( all P< 0.01); pSTAT6 had no difference between Sup ODN group and other groups ( all P< 0.01).ConclusionSup ODN attained protective effect on ConAinduced mice liver injury by supressing expression of  pSTAT4 and Tbet.

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 Objective   To understand the colonization and resistance characteristics of multidrugresistant bacteria  isolated from ICU patients. Methods  Nasal vestibular  and rectal swabs of 82 patients  admitted in a hospital ICU from November, 2008 to April, 2009 were screened by bacteriological surveillance method, and antimicrobial susceptibility were performed. Data were analyzed by WHONET5.4 software. Results  Multidrugresistant strains were detected among 38 patients , the colonization rate was 46.34%, which including 62 strains of extendedspectrum β lactamases (ESBLs) producing Enterobacteriaceae bacteria and 4 strains of methicillinresistant Staphylococcus aureus(MRSA),  and multidrugresistant Acinetobacter baumannii and Pseudomonas aeruginosa was not detected. 62  strains of ESBLsproducing strains had lower drugresistant rates (4.84%)  to imipenem and meropenem,but had high sensitive rates to the other antimicrobial agents, resistant rates varied with different  bacteria; 4  MRSA strains were all sensitive to vancomycin, teicoplanin and linezolid, some were sensitive to clindamycin, fosfomycin and gentamicin, and all were resistant to other antimicrobials.Conclusion  Colonization rate of multidrugresistant bacteria is high in patients in  ICU, and drugresistance is serious, which should be paid attention by clinicians , surveillance should be intensified , so as to avoid the outbreak of multidrugresistant bacteria infection in hospital.

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ObjectiveTo explore the risk factors for nosocomial methicillinresistant Staphylococcus aureus (MRSA) infection, so as  to provide a scientific basis for  taking effective measures to reduce nosocomial MRSA infection rates.Methods1:1 casecontrol study was performed, 108 pairs of research subjects were included in the research. Questionnaires were designed to study the history of case and control data. Multivariate nonconditional Logistic regression and chisquare test were used to analyze the data.ResultsAnalysis showed that the following factors were associated with nosocomial MRSA infection:  old age (≥ 65 years old, P= 0.013), length of stay in hospital (P<0.001), the types of underlying disease (P<0.001), the number of invasive procedures (P<0.001), broadspectrum antimicrobial  use(P<0.001), types of antimicrobial agents (P= 0.004) and duration use of antimicrobial agents (P<0.001). Multivariate analysis showed that the main risk factors related to nosocomial MRSA infection included length of stay in hospital (P<0.001), the number of invasive procedures (P= 0.001), types of used antimicrobial  (P= 0.001) and duration use of antimicrobials  (P<0.001).Conclusion Risk factors for nosocomial MRSA infections are long length of stay in hospital , frequent invasive operations , and longterm  as well as multiple use of broadspectrum antimicrobial agents.

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ObjectiveTo investigate the application value of serum procalcitonin(PCT) and cerebrospinal fluid adenosine deaminase(CSFADA) detection in the diagnosis of meningitis in children.  MethodsSolidphase immune chromatography and enzymatic rate assay were used to determine the level of serum PCT and the activity of CSFADA in children with purulent meningitis (PM group, 33 cases), tubercular meningitis (TM group, 24 cases),  viral meningitis (VM group, 38 cases), and control group (children with epilepsy during the same hospitalization period) respectively.  ResultsSerum PCT of PM group were all positive, and the positive rate (100.00%) was significantly higher than those in the other groups（P＜0.001）; The positive rate of serum PCT in VM group was only 2.63%(1/38); Serum PCT were all negative in TM and control group. The levels of CSFADA in PM and TM group were significantly higher than those in VM and control group (P＜0.001); The difference of CSFADA level between TM and PM group was significant（P＜0.001）, and the positive rate of CSFADA in TM group was 83.33%(20/24), the CSFADA levels in PM group were all in normal range. ConclusionThe simultaneous detection of serum PCT and CSFADA can be helpful for the clinical diagnosis of meningitis in children.

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ObjectiveTo explore the pathogenic distribution and drug resistance  of  ventilatorassociated pneumonia(VAP) in ICU.MethodsEtiological data of 106 patients who were diagnosed as VAP from January,2006 to January, 2009 in a hospital  were analyzed retrospectively.ResultsA total of 247 pathogens were isolated, 162 ( 65.59%) were gramnegative bacteria, the main bacteria of which were Pseudomonas aeruginosa (55 strains) and Acinetobacter baumannii (34 strains); 35 strains (14.17%) were  grampositive bacteria, the main bacteria of which were Staphylococcus aureus (31 strains),  22（70.97%） of  which were methicillinresistant; 50 (20.24%) fungi strains  were isolated. Drug resistant rates of Pseudomonas aeruginosa to imipenem/cilastatin, tobramycin, piperacillin/tazobactam, and ceftazidime were all<30%; Staphylococcus aureus, especially methicillinresistant Staphylococcus aureus were sensitive to vancomycin and teicoplain, but resistant rates to clindamycin, penicillin, erythromycin and amikacin were all >80%.ConclusionVAP in ICU is mainly induced by gramnegative bacteria, and drug resistance are common.

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ObjectiveTo study the  effect of anticommon cold broth on the prevention and remission of  handfootmouth disease(HFMD).MethodsUsing on the spot trial, secondary infection rate and  incidence rate of clinical symptoms were compared between trial group (anticommon cold broth on the basis of standard prevention and control)  and control group (standard prevention and control ) , and  results were analysed with Logistics regression analysis.ResultsThe secondary infection rate in  trial group and control group was 21.90%（23/105）and 51.09%（47/92）respetively, the former was significantly lower than the latter（p＜0.001，OR=0.27，95%CI:0.15～0.50）. Conditional Logistic regression fitted by COX model revealed that the adjusted odds ratio was 0.31（P=0.00，95% CI:0.20～0.48）. There were 17 cases(constitutional ratio:73.91%, 17/23) in trial group and 21 cases(constitutional ratio:44.68%, 21/47) in control group had latent infection , the constitutional ratio of latent infection in trial group was higher than the control group（P=0.02,OR=3.51，95%CI:1.18～10.48）.Logistic regression was used to adjust the contributions of the types of virus, age and gender, the results reveal that the odds ratio of latent infection of the trial group by the control group was 3.17(P=0.01，95% CI: 1.30～9.75）.ConclusionAnticommon cold broth can prevent the secondary infection of HFMD, and relieve its symptoms .

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ObjectiveTo understand the pathogenic characteristics and drug sensitivity of 8 strains of Neisseria meningitidis isolated in Hunan province between 2007—2008.MethodsNeisseria meningitidis strains were identified and clustered by serology and PCR test, drug sensitivity test was carried by minimum inhibitory concentration (MIC) agar dilution method.ResultsAmong  8 strains of Neisseria meningitidis, 5 strains were in serogroup C, 1 in serogroup B, 1 in serogroup Y and 1 was unidentified. All 8 strains were sensitive to penicillin, ampicillin, minocycline, ceftriaxone, cefotaxime, meropenem, rifampicin, but resistant to sulfamethoxazole/trimethoprim,  4 strains were resistant to ciprofloxacin and levofloxacin respectively, and 1 strain was resistant to chloramphenicol and azithromycin respectively.ConclusionEight epidemic strains of Neisseria meningitidis are mainly in serogroup C; penicillin, ceftriaxone, cefotaxime and meropenem should be used as the firstline drugs for the treatment of epidemic cerebrospinal meningitis, the resistance to quinolones and macrolides should be paid attention.

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ObjectiveTo realize the characteristics of nosocomial infection management of mine disaster miners during medical rescue.MethodsOn the spot investigation were performed  in the hospitals where the mine disaster miners were cured,  infection control measures were put forward , the effect of these measures was evaluated  and adjusted timely according to the patients’ condition.ResultsThere was no nosocomial  infection occurring in the mine disaster miners,  successful medical rescue was ensured. ConclusionThe enforcement of infection control measures are appropriate and  effective.

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ObjectiveTo study the causes of death among HIV/AIDS patients coinfected with HCV and/or HBV，and analyse the impact of coinfection on the prognosis of HIV/ AIDS patients. MethodsThe main complications and causes of death among  36 HIV/ AIDS patients(including 26 HCV and/or HBV coinfected patients )hospitalized in a hospital were analysed.ResultsAmong simple HIV infected patients , 50.00%(5/10) died of respiratory failure,30.00%（3/10）died of central nervous system diseases, among patients coinfected with HCV and/or HBV,50%(13/26) died of respiratory failure, 23.08%(6/26) died of central nervous system diseases,there was  no  significant difference between  two groups. No one died of liver function failure among simple HIV patients;6 patients coinfected with  HCV and/or HBV died of endstage liver disease ,which accounting for 23.08% of HCV and/or HBV coinfected patients.ConclusionPulmonary infection and central nervous system diseases are the main causes of death in AIDS patients, and is the same causes of death in  HIV/AIDS patients coinfected with HCV and/or HBV. 

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ObjectiveTo compare the epidemiological and clinical characteristics of bacillary dysentery and other infective diarrhea for better nonbacteriological diagnosis and differential diagnosis .MethodsEpidemiology and clinical manifestations of 140 bacillary dysentery and 349 other infective diarrhea cases were retrospectively studied, Logistic regression analysis was used to screen the related factors for differentiating bacillary dysentery from other infective diarrhea. ResultsPeak seasonal difference was found statistically significant in the occurrence rate of bacillary dysentery and other infective diarrhea（P＜0.05）,  the former  was in summer time and the latter in autum. Fever, tenesmus, mucous stool, pus and blood stool and tenderness on left lower quadrant were found more frequent in bacillary dysentery cases than in other infective diarrhea, but nausea, vomiting, watery stool and loose stools were the main clinical characteristics of the latter（all P＜0.05）. Logistic regression analysis showed that  attacked season, tenesmus, fever, mucous stool and tenderness on left lower quadrant were proved to have significant correlation with clinical diagnosis of bacillary dysentery.ConclusionFever, tenesmus, mucous stool, and tenderness on left lower quadrant are the main differential points  between clinically diagnosed bacillary dysentery and other infective diarrhea.

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ObjectiveTo explore the impact of diabetes mellitus (DM) on characteristics of nosocomial infection (NI)．MethodsPatients with NI in a hospital between July， 2006 and June, 2008 were selected as studied subjects, and patients were divided into studied group (patients with DM) and control group (patients without DM), the similarities and differences in underlying diseases, infection sites, susceptible factors, invasive factors and pathogenic distribution between two groups were analysed.ResultsIn studied group, fewer patients  complicated with  tumor (P=0.00) ,more with urinary tract infection (P=0.00， OR=1.61), the use of chemotherapy (P=0.01),  glucocorticoid (P=0.00) and immunosupressive agents (P=0.01) were infrequent, more patients received  blood dialysis (P=0.00, OR=2.82) and developed Enterococcus infections (P=0.01, OR=2.06). ConclusionThere are certain impact of DM on characteristics of NI. The management of blood dialysis in patients with DM should be intensified and prevention of urinary tract Enterococcus infection should be paid attention.

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目的探讨重症肝病患者医院真菌感染的临床特点。方法采用回顾性调查方法对 60例重症肝病合并医院真菌感染患者的临床资料及相关因素进行分析。结果同期住院重症肝病患者485例，其中60例(12.37%)发生医院真菌感染83例次(17.11%)。感染部位以肠道为主，占50.60%；其次为口腔(25.30%)、下呼吸道(9.64%)、腹腔(7.23%)、泌尿道(4.82%)和血液(2.41%)。 感染菌种以白假丝酵母菌为主，占61.67%；其次为近平滑假丝酵母菌，占16.67% 。60例重症肝病合并医院真菌感染者中死亡34例(56.67%)，与真菌感染直接相关2例(3.33%)；而未发生真菌感染的60例对照者中死亡19例(31.67%)，两组病死率差异有高度显著性(χ2＝7.60，Ｐ<0.01)。结论重症肝病患者发生医院真菌感染预后差，病死率极高。预防和治疗医院真菌感染需采取综合措施。

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ObjectiveTo analyze the distribution and drug sensitivity of nonfermentative bacteria in lower respiratory tract infection. MethodsSixty hundred and fortyeight cases with nonfermentative bacterial lower respiratory tract infection between January , 2006 and December , 2008 were analysed .ResultsThe first four isolated  nonfermentative bacteria were  Pseudomonas aeruginosa (277 strains, 42.75%), Acinetobacter baumannii (158 strains, 24.38%), Stenotrophomonas maltophilia (59 strains,9.10%) and Burkholderia cepacia (47 strains, 7.25%). Infection cases   mainly distributed in  local officials wards (261 strains, 40.28%) and military cadres wards (120 strains,18.52%) with the older average age of patients,  department of respiratory medicine (111 strains, 17.13%) and intensive care unit (96 strains, 14.81%) also had a higher isolation rates.  Pseudomonas aeruginosa was sensitive to amikacin and imipenem ; Acinetobacter baumannii was sensitive to imipenem, ciprofloxacin, amikacin and antimicrobial agents with βlactamas inhibitors ; Stenotrophomonas maltophilia was strongly resistant to multiple antimicrobial agents ,but sensitive to sulfamethoxazole/trimethoprim only. Burkholderia cepacia had higher drugresistant rate,but was sensitive to piperacillin/tazobactam and cefoperazone/sulbactam.ConclusionNonfermentative bacteria  are important pathogen in  nosocomial lower respiratory tract infection, and most of them are serious drug resistant, drug sensitivity varies with different types of strains, clinical treatment should be based on antimicrobial susceptibility tests  and  mechanisms of drug resistance.

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ObjectiveTo study the distribution and change of microbial population of clinical isolated bacteria from a hospital in recent 10 years. MethodsBacterial culture results of  60 846 clinical samples (blood, urine ,throat swab,sputum,stool , vagina swab,and sterile body fluid) from  inpatients and outpatients between January,1999 and December,2008 were analysed retrospectively.ResultsThese isolates included 67 genus 207 species 18 674  strains of bacteria, the isolation rate was 30.69%(18 674/60 846), the ratio of gramnegative bacillus to grampositive coccus and fungus was 54.42∶32.21∶11.56. The major bacteria were Salmonella paratyhi A, Viridans streptococci, Escherichia coli, yeastlike fungi ,coagulase negative Staphylococcus and Staphylococcus aureus. The proportion of gramnegative bacillus rose obviously, so did the opportunistic pathogens.  The isolation rates of Viridans streptococcus and enteric pathogens and Salmonella paratyhi A  decreased (P<0.01). ConclusionChange in  floral  is in accordance with fundamental characteristics  of presentday infection; The increase of opportunistic pathogens  is disadvantageous to the prevention and treatment of multiple  infectious diseases.

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ObjectiveTo get information about pathogenic distribution and bacterial resistance .MethodsData about bacteria isolated from inpatients who were hospitalized  between January 1st, 2006 to  December 31st, 2008 were collected and analysed with WHONET 5.4 software.Results5 697 pathogenic bacteria were isolated within 3 years,  which included 3 627 (63.67%) gramnegative and 1 536（26.96%）grampositive strains. Escherichia coli (895 strains,15.71%), Pseudomonas aeruginosa (873 strains, 15.32%), Klebsiella pneumoniae (446 strains,7.83%), Acinetobacter baumannii(366 strains, 6.43%) were the most common gramnegative isolates; Staphylococcus aureus(648 strains,11.37%), Enterococcus spp.(373 strains, 6.55%), and coagulasenegative Staphylococcus(349 strains,6.13%) were the top three grampositive isolates. The prevalence of extended spectrum βlactamases ( ESBLs) producing bacteria, methicillinresistant Staphylococcus aureus (MRSA) and methicillinresistant coagulasenegative Staphylococcus(MRCNS)  increased year by year. Bacteria were isolated from various specimens, the top three were  sputum (45.97%), secretion (16.54%) and urine (10.65%). Resistant rates of Escherichia coli, Klebsiella pneumoniae to carbapenems were all 0.00%, but 23.85%~31.76% of Pseudomonas aeruginosa isolates were carbapenemsresistant. Less than 15.52% of the above four kinds of bacteria were resistant to cefoperazone/ sulbactam, but they were highly resistant to other antimicrobial agents; more than 70% of Escherichia coli were quinoloneresistant. No Staphylococcus were detected to be resistant to glycopeptides, such as vancomycin and linezoid , but the resistant rates to the other commonly used  antimicrobial agents were relatively high, more than 78.57% Staphylococcus were clindamycinresistant. ConclusionPathogenic bacteria are mainly isolated from sputum, secretion and urine， the main pathogens are gramnegative bacteria； Antimicrobial resistance is very severe in hospitalized patients. Surveillance of antimicrobial resistance is important and valuable for rational antimicrobial therapy.

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目的了解某院重症监护室（ICU）和非ICU送检痰标本中鲍曼不动杆菌与嗜麦芽窄食单胞菌在革兰阴性（G-）菌中的构成比及耐药情况。方法回顾性比较2005年6月—2007年6月ICU和非ICU送检痰标本中分离的上述2种细菌的相关资料。结果 2005—2007年，鲍曼不动杆菌在ICU 痰标本分离的G-菌中占7.00%～22.41%，非ICU为7.14%～16.84%，两两比较，差异均无显著性（P＞0.05）；嗜麦芽窄食单胞菌在ICU 痰标本分离的G-菌中占5.70%～12.07%，非ICU为3.06%～5.05%，2006年两者差异有显著性 (P=0.00)。鲍曼不动杆菌对亚胺培南敏感率（97.50%～97.65%）最高,对其他抗菌药物耐药率均＞50%,ICU与非ICU差异无显著性（P＞0.05）；嗜麦芽窄食单胞菌对头孢他啶、复方磺胺甲口恶唑、替卡西林敏感率＞50%，仅对头孢他啶的耐药率ICU高于非ICU(P=0.03)。结论鲍曼不动杆菌与嗜麦芽窄食单胞菌在ICU与非ICU送检痰标本G-菌中的构成比多无差异，其耐药性均较严重；医务人员需根据本院用药习惯及细菌的耐药变化合理选择抗菌药物。

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目的了解某院非淋病性泌尿生殖道感染患者标本分离的支原体分布及药敏情况。方法采用支原体药敏试剂盒对872例疑似非淋病性泌尿生殖道感染患者送检的标本进行支原体培养和药敏试验。结果872例非淋病性泌尿生殖道感染患者中，培养支原体阳性434例（49.77%），其中解脲支原体（Uu）感染244例（27.98%），人型支原体（Mh）感染16例（1.83%），混合感染 (Uu+Mh)174例（19.95%）。女性患者感染率为54.45%（306/562），男性患者感染率为41.29%（128/310），两者比较，差异有高度显著性（P＜0.01）。434例阳性患者中，男性128例（29.49%），女性306例（70.51%），后者所占比率明显高于前者（P＜0.05）；21～40岁患者支原体培养阳性率为75.12%，明显高于其他年龄段患者（P＜0.05）。药敏试验中，四环素类药物最敏感，其次为大环内酯类药物中的克拉霉素、交沙霉素，而其他药物的敏感率均＜50.00%。结论该院非淋病性泌尿生殖道感染患者支原体检出以女性为多，年龄以21～40岁多见；支原体对各种抗菌药物已有一定的耐药性，在治疗时，应参考药敏结果。

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目的了解中医医院血液透析室的管理现状，为进一步提升血液透析质量管理提供依据。方法根据《湖南省血液透析室工作质量检查评分表》对29所中医医院的血液透析室进行现场评估，总分100分，≥60分为合格。结果29所受检中医医院血液透析室合格18所，合格率62.07%，其中6所三级医院均合格，合格率100%；23所二级医院合格12所,合格率仅52.17%。结论大多数血液透析室的建设和管理需加强和改进，以杜绝安全隐患。

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目的调查某院消毒灭菌效果与环境卫生学监测情况。方法回顾性分析该院1997—2008年间消毒灭菌及环境卫生学监测资料。结果12年共采集48 497份样本，合格39 161份，合格率80.75%。样本量与其合格率整体呈上升趋势，空气合格率由60.04%升至97.91%；物体表面合格率由85.65%升至98.70%；医务人员手采样合格率由78.75%升至99.62%；使用中消毒液合格率由88.92%升至98.83%；紫外线灯合格率由77.62%升至97.13%；消毒灭菌物品合格率由97.27%升至100.00%（均P＜0.01）。压力蒸汽灭菌器、污水处理在每年的监测中，合格率均为100.00%。结论该院消毒灭菌工作质量及环境卫生质量得到不断提高。

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丙型肝炎病毒（hepatitis C virus, HCV）是1989年由美国学者Choo等首次从受感染的黑猩猩血液标本中分离。HCV呈全球性流行，根据世界卫生组织 (WHO) 的统计，HCV在人群中的感染率约为3%，全球约有1.8亿人感染HCV，每年新发丙型肝炎病例约300~500万例。我国进行的全国HCV血清流行病学调查显示［1］，我国一般人群抗 HCV阳性率为3.2%，约有4 000万人感染HCV；70%以上的感染者将发展成肝纤维化、肝硬化，甚至肝细胞癌。常规的干扰素（IFN）单用或者IFN联合利巴韦林治疗的总体应答率比较低，治疗费用颇高，且具有明显的毒副作用［2］。据分析，在未来的10~20年中，将会出现一个因HCV感染而导致的肝硬化与肝癌高峰期。HCV感染后缺乏有效的保护性免疫，因此，HCV中和抗体一直是近年来的研究热点［3］。近年来HCV体外培养系统的建立为HCV中和抗体相关研究提供了强有力的工具，使人们对HCV的认识提升到新的层次，为从根本上认识HCV和彻底防治丙型肝炎奠定了基础。本文就近年来在丙型肝炎中和抗体及机体抗HCV感染免疫方面的研究作一简要综述。

Abstract:

广泛使用抗菌药物后诱发耐药与多重耐药现象已十分严重。对产超广谱β内酰胺酶（ESBLs）革兰阴性（G-）菌、多重耐药铜绿假单胞菌、耐甲氧西林金黄色葡萄球菌（MRSA）及耐万古霉素肠球菌（VRE）尿路感染的治疗十分困难。在多重耐药病原菌尿路感染高发病区必须掌握本部门耐药动向，及时调整用药方案，既要使临床取得良好的疗效，又要能阻遏耐药菌株扩散。

Abstract:

美国疾病控制与预防中心2008版《医疗机构消毒灭菌指南》已出版，本指南最终目标是通过适当选择消毒灭菌方法，减少医院感染的发生。以下节选关于医疗机构环境表面的清洁与消毒内容，每条建议均根据科学证据、基本原理、实用性和联邦法律制定。其建议分级系统如下。