干燥综合征肾脏受累合并代谢性碱中毒1例

患者,女,56岁,因眼干5年、双下肢无力2年余于2011年8月18日入院。2006年8月双眼干涩,无口干。2007年3月外院诊为"双干眼症"。2008年底出现双下肢无力,查血钾(K)2.4mmol/L,口服氯化钾缓释片症状好转,后仍间断出现血钾偏低,对症补钾治疗。2009年11月自觉尿中泡沫增多,查24小时尿蛋白定量(24hUPro)1.32g,尿pH值7.5,K 2.9mmol/L,红细胞沉降率(ESR)100mm/1h,免疫球蛋白G(IgG)20.20g/L,抗核抗体(ANA)(+)1:640,抗干燥综合征抗原A(SSA)抗体(+)1:64;口腔科行唇腺活检提示灶性淋     

异基因骨髓间质干细胞移植治疗难治性红斑狼疮

目的探索异基因骨髓间质干细胞移植(MSCT)对难治性红斑狼疮(SLE)的疗效及安全性。方法取相关供体(母亲)的骨髓,体外扩增,输注细胞数(MSC)≥1×106/kg。选择难治性SLE患者进行MSCT,比较移植前后临床表现的改善及实验室指标如24 h尿蛋白定量、抗核抗体(ANA)、抗ds-DNA、血清补体C3、血清白蛋白、肾小球滤过率、血像的变化,评价MSCT的疗效。结果2例女性难治性SLE患者在行MSCT后,随访3月。例1患者血清肌酐(Cr)、尿蛋白和ANA滴度下降,血红蛋白、补体C3和肾小球滤过率上升;例2患者血清白蛋白、补体C3上升,尿蛋白下降,高血压得到改善。2例均无移植相关并发症。结论MSCT治疗难治性SLE安全有效,远期疗效有待进一步观察。     

异基因造血干细胞移植后白血病复发伴活动性移植物抗宿主病患者的临床研究

目的 探讨异基因造血干细胞移植(allo-HSCT)后白血病复发伴活动性移植物抗宿主病(GVHD)患者GVHD与GVL效应的分离.方法 分析11例接受allo-HSCT后在白血病复发时存在活动性GVHD的患者其原发病、疾病状态、复发时GVHD类型、供者淋巴细胞输注(DLI)疗效及转归等对GVL效应的影响.结果 11例患者包括急性淋巴细胞白血病5例,急性髓系白血病6例,其中5例曾行预防性DLI,复发时伴有活动性DLI后GVHD,包括2例Ⅱ度急性GVHD(aGVHD),1例原局限型慢性GVHD(cGVHD)加重+新发Ⅱ度aGVHD,2例广泛型cGVHD;这5例患者复发后,2例行化疗+治疗性DLI,DLI后在广泛型cGVHD反复加重情况下,1例达完全缓解(CR)后再次复发,1例未达CR.另6例患者复发前未行预防性DLI,白血病复发时亦均存在活动性GVHD,包括3例广泛型cGVHD、1例Ⅰ度aGVHD及2例Ⅲ～Ⅳ度aGVHD,复发后行化疗+治疗性DLI,之后2例达CR后再次复发,4例未达CR.结论 allo-HSCT后活动性GVHD不一定伴随可抑制白血病复发的有效GVL效应.     

误用小剂量甲氨喋呤致急性造血功能停滞1例

1 病例介绍 患者,女,61岁,4个月前出现口干、眼干,反复发作腮腺肿大,在我院经腮腺ECT检查示:腮腺摄取及排泄功能均延迟.血ANA( ),抗SSA抗体( ),抗SSB抗体( ),RF 129 U/mL,诊断为干燥综合征.     

狼疮性肾炎62例分析

对我院1997-03～2006-03收治的狼疮性肾炎(LN)62例分析如下. 1 临床资料 1.1 一般资料本组男6例,女56例,年龄12～72(29.3±8.57)岁.起病至入院时间12 d～5 a (平均1.9个月). 1.2 实验室检查包括血常规、尿常规、肝肾功能、血沉、24 h尿蛋白定量、血浆蛋白电泳.免疫学检查包括血免疫球蛋白、抗核抗体(ANA)、抗ds-DNA抗体、抗Sm抗体、抗RNP抗体、抗SSA、SSB抗体、血清补体C3、C4.     

特发性膜性肾病患者血清抗M型磷脂酶A2受体抗体阳性率与肾间质损伤的关系

目的观察特发性膜性肾病(idiopathic membranous nephropathy,IMN)患者血清抗M型磷脂酶A₂受体(phospholipase A₂receptor,PLA₂R)抗体阳性率变化,探讨其对IMN患者发生肾间质损伤的预测价值。方法268例IMN患者,发生肾间质损伤219例为损伤组,未发生肾间质损伤49例为未损伤组。比较2组一般资料及24h尿蛋白定量、血肌酐、血尿酸、估算肾小球滤过率、血清白蛋白水平等;比较2组血清抗M型PLA₂R抗体阳性率;多因素logistic回归分析IMN患者发生肾间质损伤的影响因素;绘制ROC曲线,评估血清抗M型PLA₂R抗体阳性联合血肌酐、血清白蛋白、24h尿蛋白定量预测IMN患者发生肾间质损伤的价值。结果损伤组年龄[(46.32±13.20)岁]大于未损伤组[(35.16±9.53)岁](P<0.05),24h尿蛋白定量[(6.58±3.50)g]、血肌酐[(72.53±32.62)mmol/L]、血尿酸(352.26±96.48)mmol/L]水平均高于未损伤组[(4.04±1.78)g、(60.21±17.36)mmol/L、(309.05±72.64)mmol/L](P<0.05),估算肾小球滤过率[(92.83±18.71)mL/(min·1.73m²)]、血清白蛋白水平[(21.76±4.80)g/L]低于未损伤组[(122.03±32.05)mL/(min·1.73m²)、(28.91±6.18)g/L](P<0.05);2组性别比例、民族、体质量指数及血清三酰甘油、总胆固醇、低密度脂蛋白胆固醇、高密度脂蛋白胆固醇水平比较差异均无统计学意义(P>0.05)。损伤组血清抗M型PLA₂R抗体阳性(1∶10)率、血清抗M型PLA₂R抗体阳性(1∶100)率(49.8%、35.6%)均高于未损伤组(24.5%、12.2%)(P<0.05)。多因素logistic回归分析结果显示,24h尿蛋白定量(OR=1.503,95%CI:1.164~1.940,P=0.002)、血肌酐(OR=0.971,95%CI:0.944~1.000,P=0.047)、估算肾小球滤过率(OR=0.911,95%CI:0.867~0.958,P<0.001)、血尿酸(OR=1.011,95%CI:1.003~1.018,P=0.005)、血清白蛋白(OR=0.804,95%CI:0.720~0.898,P<0.001)、血清抗M型PLA₂R抗体(OR=19.939,95%CI:5.558~71.530,P<0.001)是IMN患者发生肾间质损伤的影响因素。ROC曲线分析结果显示,血清抗M型PLA₂R抗体阳性预测IMN患者发生肾间质损伤的AUC为0.813(95%CI:0.736~0.889,P<0.001),灵敏度为89.0%,特异度为73.5%;血肌酐、血清白蛋白、24h尿蛋白定量分别以79.5mmol/L、23.01g/L、6.45g/L为最佳截断值,联合血清抗M型PLA₂R抗体阳性预测IMN患者发生肾间质损伤的AUC分别为0.859(95%CI:0.802~0.916,P<0.001)、0.907(95%CI:0.861~0.952,P<0.001)、0.923(95%CI:0.886~0.960,P<0.001),灵敏度分别为89.0%、88.6%、79.0%,特异度分别为73.5%、83.7%、91.8%。结论24h尿蛋白定量、血肌酐、估算肾小球滤过率、血尿酸、血清白蛋白、血清抗M型PLA₂R抗体是IMN患者发生肾间质损伤的影响因素,血清抗M型PLA₂R抗体阳性联合24h尿蛋白定量检测对IMN患者肾间质损伤有较高的预测价值。     

系统性红斑狼疮致蛋白丢失性肠病1例

患者,女性,34岁。主因颜面、眼睑水肿1年余,腹胀、双下肢水肿8个月于2006年3月10日入院。患者于1年前无明显诱因出现颜面、眼睑水肿。7月前出现腹胀、双下肢水肿,病情逐渐加重,并停经。3月前在四川华西医院化验:抗核抗体(ANA)( ),滴度1∶100(均质型),抗干燥综合征抗原A抗体(SSA)、抗干燥综合征抗原B抗体(SSB)( ),抗核黄素抗体(Rib)( ),余抗体阴性;IgG、IgA低于正常,IgE高于正常,补体C3、C4均低于正常,类风湿因子(RF)阴性;血白蛋白9.5 g/L,胆固醇、甘油三酯升高,24小时尿蛋白定量0.16 g/L。X线片示右侧胸膜下增厚粘连,右侧少量胸腔…     

慢性移植物抗宿主病与T淋巴细胞免疫重建的关系

慢性移植物抗宿主病(cGVHD)为一组以自身抗体产生与纤维化形成为主要临床表现的自身免疫性疾病.cGVHD疾病发生与自身免疫形成及胸腺功能受损密切相关.异基因造血干细胞移植(allo-HSCT)过程中胸腺功能严重受损,T淋巴细胞免疫重建迟缓,并可导致allo-HSCT后受者体内产生自身反应性T淋巴细胞.在allo-HSCT中胸腺功能受损为cGVHD疾病发生的潜在重要诱因,保护胸腺功能并促进其功能恢复有助于预防cGVHD发生并减轻其严重程度.笔者拟就cGVHD与T淋巴细胞免疫重建间的关系进行综述.     

膜性肾病合并抗中性粒细胞胞质抗体阴性血管炎一例报告及文献复习

病例:患者,男,84岁,因"双下肢浮肿伴泡沫尿2个月,肾功能异常1个月"入我院诊治。入我院前2个月,患者自觉双下肢胫前区轻度浮肿,同时有尿中泡沫增多,遂至外院就诊。外院查尿常规示,尿蛋白(+++),红细胞(RBC)(-),尿蛋白定量1 130 mg/24 h;血清白蛋白(ALB)40 g/L,血肌酐(Scr)83μmol/L,抗中性粒细胞胞质抗体(ANCA)(-)。外院予缬沙坦(代文)治疗后,患者症     

慢性肾脏病基础上的急性肾衰误诊35例分析

我院1999-10~2006-10共收治慢性肾脏病基础上的急性肾衰(A/C)76例,其中误诊35例(46.05%),分析如下。1临床资料1.1一般资料本组男20例,女15例,年龄17~82(33.2±11.21)岁。A/C的基础肾脏病分别为:慢性肾小球肾炎11例,原发性肾病综合征(PN S)6例,高血压病肾损害5例,狼疮性肾炎(LN)9例,乙肝相关性肾炎(HBV-GN)4例。1.2实验室检查包括血常规、尿常规、肝肾功能、血沉、24 h尿蛋白定量、血浆蛋白电泳。免疫学检查包括血免疫球蛋白、抗核抗体(ANA)、抗ds-DNA抗体、抗Sm抗体、抗RNP抗体、抗SSA、SSB抗体、血清补体C3、C4。采用固相放射…     

Guns and Knives in New Mexico: Patterns of Penetrating Trauma, 1978–1993

Objective: To identify patterns of nonfatal and fatal penetrating trauma among children and adults in New Mexico using ED and medical examiner data.
Methods: The authors retrospectively sampled in 5-year intervals all victims of penetrating trauma who presented to either the state Level-1 trauma center or the state medical examiner from a 16-year period (1978–1993). Rates of nonfatal and fatal firearm and stabbing injury were compared for children and adults.
Results: Rates of nonfatal injury were similar (firearm, 34.3 per 100,000 person-years; stabbing, 35.1). However, rates of fatal injury were significantly different (firearm, 21.9; stabbing, 2.7; relative risk: 8.2; 95% confidence interval: 5.4, 12.5). From 1978 to 1993, nonfatal injury rates increased for children (p = 0.0043) and adults (p < 0.0001), while fatal penetrating injury remained constant. The increase in nonfatal injury in children resulted from increased firearm injury rates. In adults, both stabbing and firearm nonfatal injury rates increased.
Conclusions: Nonfatal injury data suggest that nonfatal violence has increased; fatal injury data suggest that violent death rates have remained constant. Injury patterns vary by age, mechanism of trauma, and data source. These results suggest that ED and medical examiner data differ and that both are needed to guide injury prevention programs.     

Dissociable correlates of two classes of retrieval processing in prefrontal cortex

Although substantial evidence suggests that the prefrontal cortex (PFC) implements processes that are critical for accurate episodic memory judgments, the specific roles of different PFC subregions remain unclear. Here, we used event-related functional magnetic resonance imaging to distinguish between prefrontal activity related to operations that (1) influence processing of retrieval cues based on current task demands, or (2) are involved in monitoring the outputs of retrieval. Fourteen participants studied auditory words spoken by a male or female speaker and completed memory tests in which the stimuli were unstudied foil words and studied words spoken by either the same speaker at study, or the alternate speaker. On "general" test trials, participants were to determine whether each word was studied, regardless of the voice of the speaker, whereas on "specific" test trials, participants were to additionally distinguish between studied words that were spoken in the same voice or a different voice at study. Thus, on specific test trials, participants were explicitly required to attend to voice information in order to evaluate each test item. Anterior (right BA 10), dorsolateral prefrontal (right BA 46), and inferior frontal (bilateral BA 47/12) regions were more active during specific than during general trials. Activation in anterior and dorsolateral PFC was enhanced during specific test trials even in response to unstudied items, suggesting that activation in these regions was related to the differential processing of retrieval cues in the two tasks. In contrast, differences between specific and general test trials in inferior frontal regions (bilateral BA 47/12) were seen only for studied items, suggesting a role for these regions in post-retrieval monitoring processes. Results from this study are consistent with the idea that different PFC subregions implement distinct, but complementary processes that collectively support accurate episodic memory judgments.     

Systematic Reviews Published in the January 2011 Issue of The Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly as a DVD and monthly online. The January 2011 issue (first quarterly DVD for 2011) contains 4515 complete reviews, 1985 protocols for reviews in production, and 13,521 one-page summaries of systematic reviews published in the general medical literature. In addition, there are citations of 641,000 randomized controlled trials, and 14,018 cited papers in the Cochrane methodology register. The health technology assessment database contains over 9300 citations. One hundred and seven new reviews have been published in the last 3 months, of which five have potential relevance for practitioners in pain and palliative medicine.     

Interprofessional approaches to creating safe,high quality health care

Three supplementary perspectives are presented arguing that interprofessional collaboration is both necessary and desirable. Nonetheless, there are often too many serious intra-professional barriers and obstacles to interprofessional collaboration to make it successful. Some of these barriers, it is argued and illustrated, are found in the multiple ways in which professional identity is tacitly acquired and embodied in the practitioners' habitual, everyday practice. The paper then explores ways in which reflection, especially Second order reflection, can help to elucidate and overcome these obstacles, as well as increasing professional adaptability and competence.     

Determination of creatine kinase isoenzyme MB activity in serum using immunological inhibition of creatine kinase M subunit activity. Activity kinetics and diagnostic significance in myocardial infarction.

This is a new method for the determination of creatine kinase isoenzyme MB activity in serum. The method uses direct activity measurement of creatine kinase B subunit activity after blocking of CK-M subunit activity by inhibiting antibodies. The test takes no longer than 15 min. The method yields an intra-serial C.V. of 2.0-12.9%, and a C.V. from day to day of 5.5%. The detection limit is 3.4 U/l creatine kinase MB. In the 95 cases with proven myocardial infarction several types of creatine kinase MB activity kinetics could be determined. The percentage of creatine kinase MB of peak CK-total is 6-25%, with a mean of 11.1%. The amount of creatine kinase MB with respect to total CK activity after reinfarction is higher than the amount after initial infarction.     

Modified micro-superior percutaneously-assisted total hip: early experiences & case reports

Because of the extensile nature and familiarity of the standard posterior-lateral approach to the hip, a family of "micro-posterior" approaches has been developed. This family includes the Percutaneously-Assisted Total Hip (PATH) approach, the Supercapsular (SuperCap) approach and a newer hybrid approach, the Supercapsular Percutaneously-Assisted Total Hip (SuperPATH) approach. Such approaches should ideally provide a continuum for the surgeon: from a "micro" (external rotator sparing) posterior approach, to a "mini" (external rotator sacrificing) posterior approach, to a standard posterior approach. This could keep a surgeon within his comfort zone during the learning curve of the procedure, while leaving options for complicated reconstructions for the more practiced micro-posterior surgeons. This paper details one author's experiences utilizing this combined approach, as well as permutations of this entire micro-posterior family of approaches as applied to more complex hip reconstructions.     

Prise en charge des entorses externes de cheville : étude clinique préliminaire sur l’efficacité du dispositif Myolux™

Ankle sprains are the most common injury of the musculoskeletal system and are associated with significant societal and economic impacts. It has been proven that classical therapeutic strategies may not be effective in preventing recurrent injuries: the recurrence rates reported in the literature can reach 73%. In order to provide an effective rehabilitation solution, a destabilizing orthosis was developed. This device is equipped with a mechanical articulator reproducing the subtalar mechanics and placed under the heel. In this paper, we present the main results of a preliminary clinical study conducted between 2004 and 2007. All subjects included in this study were treated with the abovementioned orthosis during 10 rehabilitation sessions of 30 minutes each. Data show a relatively low recurrence rate of 12% for the overall population. Moreover, it's of primary importance to note that this satisfactory ratio is largely reduced (3% of recurrence rate) for the 29 patients who performed one training session per month after the 10th initial rehabilitation sessions. Hence, the destabilizing orthosis appears to be an effective solution to prevent recurrent ankle sprains. However, joint protection requires long-term and regular training sessions. This result has motivated the development of a similar device allowing patients to perform training sessions at home. Finally, data obtained in this study are promising awaiting the final results of the comparative, multicentric and independent clinical trials currently managed by the Hospices Civils de Lyon.