Immunoadsorption for coagulation factor inhibitors

Inhibitors to coagulation factors are among the most difficult problems in the management of coagulation disorders. Most presently available therapy does not assure hemostasis. An extracorporeal immunoadsorption system, which selectively binds IgG, was used to lower inhibitor levels in eight patients on 10 occasions. In this system, separated plasma is delivered to two staphylococcal protein A-Sepharose columns, which are coupled to an elution monitor. Columns are eluted sequentially and regenerated to maximize IgG removal. Successful removal of the inhibitor was accomplished in all six hemophiliacs on seven occasions, as well as in a patient with acquired von Willebrand disease. All patients whose inhibitors were lowered to less than 10 Bethesda units achieved measurable factor levels when factor concentrate replacement was given. Immunoadsorption facilitates efficient removal of inhibitors, which allows factor replacement therapy.     

BACTERIAL VAGINOSIS

SUMMARY Bacterial vaginosis (BV) is an alteration of the vaginal flora, where the normally predominant lactobacilli are replaced by a cocktail of organisms including Gardnerella vaginalis and anaerobes. It presents with a grey, homogenous, offensive vaginal discharge that has a raised pH. However, around half the women with this condition are asymptomatic. Diagnosis is best made by microscopic examination of a Gram-stained smear of vaginal secretions. Treatment is with metronidazole or clindamycin. The indications for treatment of asymptomatic BV are not clear, but women should probably be treated before any invasive gynaecological procedure, including intrauterine contraceptive device (IUCD) insertion. BV during pregnancy is associated with preterm labour, although a causal effect is not proven; studies are in progress to determine whether treatment of BV will improve the outcome of these pregnancies.     

Treatment of compulsive behaviour in eating disorders with intermittent ketamine infusions

We have previously shown that eating disorders are a compulsive behaviour disease, characterized by frequent recall of anorexic thoughts. Evidence suggests that memory is a neocortical neuronal network, excitation of which involves the hippocampus, with recall occurring by re-excitement of the same specific network. Excitement of the hippocampus by glutamate-NMDA receptors, leading to long-term potentiation (LTP), can be blocked by ketamine. Continuous block of LTP prevents new memory formation but does not affect previous memories. Opioid antagonists prevent loss of consciousness with ketamine but do not prevent the block of LTP. We used infusions of 20 mg per hour ketamine for 10 h with 20 mg twice daily nalmefene as opioid antagonist to treat 15 patients with a long history of eating disorder, all of whom were chronic and resistant to several other forms of treatment. Nine (responders) showed prolonged remission when treated with two to nine ketamine infusions at intervals of 5 days to 3 weeks. Clinical response was associated with a significant decrease in Compulsion score: before ketamine, mean +/- SE was 44.0 +/- 2.5; after ketamine, 27.0 +/- 3.5 (t test, p = 0.0016). In six patients (non-responders) the score was: before ketamine, 42.8 +/- 3.7; after ketamine, 44.8 +/- 3.1. There was no significant response to at least five ketamine treatments, perhaps because the compulsive drive was re-established too soon after the infusion, or because the dose of opioid antagonist, nalmefene, was too low.      

造血干细胞移植与临床感染的防治

学术背景:造血干细胞移植技术在临床上已得到广泛应用,移植后感染是关系到移植成败的重要因素。目的:探讨造血干细胞移植后各阶段的感染的特点、预防及治疗,以进一步减低造血干细胞移植后感染的发生率及死亡率。检索策略:由作者应用计算机检Medline 1994-01/2007-05关于造血干细胞移植及移植后感染的文章,检索词为"hematopoietic stem cell transplantation,infection",限定语言种类为"English";同时检索中国期刊全文数据库1994-01/2007-05相关文章,检索词"造血干细胞移植,感染,防治",限定语言种类为中文。纳入标准:随机对照研究;实验或临床研究包含平行对照组。排除标准:重复性研究文献评价:初检得到212篇文献,初审后选取与造血干细胞移植后感染有关的文章126篇,删除明显无关及相关性不强的文章,进一步查找全文,29个实验符合标准,予以纳入。29个研究包括324例患者和140个实验动物,分别阐述了造血干细胞移植后感染的原因、途径、特点、种类及各种感染的预防及治疗措施。资料综合:造血干细胞移植后感染发病隐匿,由于患者免疫力低下,感染不易控制,在不同阶段致病菌的种类有所不同,细菌感染普遍,在移植后各个时期均可出现,真菌感染和病毒感染致死性强,故预防和治疗感染至关重要,其治疗分为预防治疗、抢先治疗、经验性治疗和针对治疗。结论:造血干细胞移植后感染的治疗已成为影响移植疗效的一个重要原因,及早的诊断及正确的治疗将成为移植后感染治疗成功的关键。     

认知矫正治疗对慢性精神分裂症患者临床症状和社会功能的影响

目的:观察认知矫正治疗对慢性精神分裂症患者临床症状和社会功能的改善作用。方法:选择2003-01/08在北京回龙观医院住院的慢性精神分裂症患者104例。均符合CCMD-Ⅲ及DSM-Ⅳ关于精神分裂症诊断标准;年龄25～55岁;病程≥2年;病情稳定,处于迁延、残留或部分缓解状态;药物治疗状况稳定,近期无换药打算;纳入对象或家属同意入组并签署知情同意书。应用随机数字表法将患者分认知矫正治疗组和对照组,每组52例。在相近药物治疗的基础上,认知矫正治疗组以Ann Delahunty和Rodney Morice等制定的神经认知矫正手册(汉化)为治疗工具,在治疗师的指导下进行认知作业练习,内容包括认知灵活性、工作记忆、计划执行功能3大功能模块。对照组予以相同时间的工娱治疗,主要包括有治疗师指导的操作性音乐治疗和舞蹈治疗。治疗前后两组患者分别进行PANSS、住院精神患者社会功能缺陷量表和护士观察量表的评定。结果:实验共纳入慢性精神分裂症患者104例,认知矫正治疗组44例,对照组46例进入结果分析,14例脱落。①治疗前后两组患者PANSS量表总分以及阴性症状量表、复合量表、一般精神病理量表、反应缺乏量表4个分量表的评分均有下降,组内比较差异有显著性意义(t=2.12～4.59,P<0.05);减分情况在两组间差异不明显(P>0.05)。②两组患者的社会功能缺陷量表总分在治疗后均有下降,与治疗前比较,差异有显著性意义(t=3.89,2.04,P<0.05);两组间比较,差异无显著性意义(P>0.05)。认知矫正治疗组治疗后护士观察量表的总病情以及总消极、迟滞2个分量表评分下降,与治疗前比较差异有显著性意义(t=1.49,1.19,2.81,P<0.05);其中迟滞项的减分在两组间比较,差异具有显著性意义(F=4.97,P<0.05)。③社会功能量表的改善与词语流畅性的改善呈正相关(R2=0.36,P<0.05),护士观察量表中总病情与积极两项评分的改善也与言语流畅性测验的改善正相关(R2=0.37,0.34,P<0.05)。结论:认知矫正治疗能在一定程度上改善精神分裂症患者的社会功能,并与部分认知功能的改善相关,但对临床症状无明显改善作用。     

The systemic inflammatory response syndrome as a predictor of bacteraemia and outcome from sepsis

Criteria defining the <it>systemic inflammatory response syndrome</it> (SIRS) were used to assess prospectively 270 clinical episodes in which blood cultures were taken from patients in general medicine. SIRS, severe sepsis and septic shock occurred in 149 (55%), 13 (5%) and 9 (3%) episodes, respectively. However, evidence of organ hypoperfusion indicating severe sepsis was recorded as sought in only 26% of episodes of SIRS. Crude mortality at 28 days increased sequentially as more SIRS criteria were met, rising from 12% in non-SIRS blood culture episodes, to 36% when all four criteria were met. Mortality from severe sepsis and septic shock was 38% and 56%, respectively. In 61/64 (95%) episodes of clinically important bacteraemia, patients fulfilled SIRS criteria when the blood culture was taken. However, the positive predictive value of SIRS for predicting bacteraemia was only 7%. Patients who did not fulfill SIRS criteria when blood cultures were taken were at low risk of bacteraemia and comprised 45% (121/270) of the study population. Three patients in this low-risk group had bacteraemia. Mortality in bacteraemic patients with severe sepsis or septic shock who were initially treated with ineffective antibiotics for up to 48 h was 80%, compared to 42% in those always treated appropriately.      

Surgical bacterial infections and antimicrobial susceptibility patterns at Lilongwe Central Hospital

A cross sectional study was done between October 1999 and February 2000 to determine antimicrobial susceptibility patterns of consecutive bacterial isolates of 102 clinical samples among surgical in-patients at Lilongwe Central Hospital (LCH), Malawi. Antimicrobial susceptibility was determined using comparative disc diffusion techniques. 83 (81.4%) samples were culture positive for bacterial growth while 19 (18.6%) grew nothing. Of the 93 culture positive specimens, Staphylococcus aureus was the predominant organism 43(51.8%) followed by Proteus species 8(9.6%) and E. coli 7(8.4%). Overall, 98.6% of all isolates tested against ciprofloxacin were susceptible, and against gentamicin and flucloxacin were 84.8% and 66.7% respectively. 59.3% of isolates tested against chloramphenicol were resistant. We recommend a review on the use of chloramphenicol as first-line antimicrobial therapy among surgical in-patients at Lilongwe Central Hospital. We also recommend restricted use of antimicrobials so as to minimise development of drug resistance. Periodic susceptibility studies are necessary to guide judicious use of antibiotics.