重症患者贫血的研究进展

贫血是重症患者的常见问题,其病因是多因素的,主要包括各种原因导致的急性、非急性血液丢失;此外,炎症也会导致机体红细胞寿命缩短、红细胞生成减少。针对重症患者贫血的治疗,如各种止血药物(抗纤溶剂、去氨加压素、重组Ⅶa因子等)、红细胞生成素、血液替代品(全氟化碳、改良血红蛋白等)已被应用于临床或处于临床试验阶段,相关的血液保护策略的提出也为重症患者贫血提供了一个新的防治措施,是目前广大临床医师较为关注的问题。     

宫颈癌术野血经辐射后回输的临床前实验研究

目的　了解有效去除血中污染的宫颈癌细胞所需的辐射剂量。方法　对人类宫颈癌HeLa系细胞给予不同剂量梯度的γ线辐射,测定细胞生长抑制率及克隆形成抑制率,从而确定完全抑制HeLa细胞增生的最低有效辐射剂量。为了模拟临床实际情况,在体外将HeLa细胞与洗涤红细胞混合后给予有效剂量辐射,经密度梯度分离HeLa细胞并接种培养,用细胞集落形成检测其增生能力。取40份妇科恶性肿瘤病人的静脉全血,分别测定其在无辐射及予以有效剂量辐射后红细胞携氧功能指标2,3 DPG值。结果　12 Gy的辐射剂量能够完全抑制肿瘤细胞的增生(细胞生长抑制率及克隆形成抑制率均为100%,P<0.01),且不影响红细胞的携氧功能(不辐射与辐射后的2,3 DPG值无显著性差异,P>0.05)。结论　12 Gy的辐射剂量是彻底去除血中污染的宫颈癌细胞的最低有效辐射剂量,且不影响红细胞的携氧功能;为在宫颈癌手术中回收式自体输血(IAT)的临床应用提供了实验依据。     

Malawi Health News

Current literature suggests that therapeutic misconception - a belief by participants in a clinical trial that they are in fact simply being given clinical care - is common, especially among illiterate populations in developing countries. Therapeutic misconception reflects problems in informed consent, as people agree to participate in clinical trials without being aware that the trial procedures and test products may not in fact benefit them.In this study of Malawian adults who had participated in research projects of various kinds during the preceding years, we found that the majority participated in research for the sake of obtaining better quality treatment made available through the clinical trials as ancillary care. Their consent to participate was not due to a belief that the actual procedures of the trial would directly benefit their health. Respondents indicated that, government hospitals being crowded and commonly lacking drugs, they agreed to take part in research projects in the hope of obtaining access to ancillary care provided by clinical trials.We conclude that in this environment, possibly owing to inadequacy of routine health services, people make rational decisions to participate in research. We question whether the term ‘therapeutic misconception’ accurately describes participants'' motivation under conditions of limited resources. We also discuss the relevance of these findings for understanding undue inducement in clinical trials.     

灵芝对鼠的外周血象和耗氧量的影响

选取大鼠22只,随机均分两组。实验组大鼠每日按2克/100克体重连续灌给灵芝浸膏72天,对照组灌给等量的蒸溜水。于给药第45天后测定两组的红细胞总数和血红蛋白等指标,实验组不仅显著地增加了红细胞和血红蛋白,而且于72天后其血氧含量亦有增加的趋势。取小鼠54只,采取自身对照的方法,按0.3克/100克体重由腹腔注入灵芝的总提取物后,结果能明显地降低其整体的耗氧量。上述实验结果表明,灵芝能增加红细胞和血红蛋白并能降低整体的耗氧量。     

Blood conservation strategies to reduce the need for red blood cell transfusion in critically ill patients

Anemia commonly affects critically ill patients. The causes are multifactorial and include acute blood loss, blood loss from diagnostic testing and blunted red blood cell production. Blood transfusions are frequently given to patients in intensive care units to treat low hemoglobin levels due to either acute blood loss or subacute anemia associated with critical illness. Although blood transfusion is a life-saving therapy, evidence suggests that it may be associated with an increased risk of morbidity and mortality. A number of blood conservation strategies exist that may mitigate anemia in hospital patients and limit the need for transfusion. These strategies include the use of hemostatic agents, hemoglobin substitutes and blood salvage techniques, the reduction of blood loss associated with diagnostic testing, the use of erythropoietin and the use of restrictive blood transfusion triggers. Strategies to reduce blood loss associated with diagnostic testing and the use of hemostatic agents and erythropoietin result in higher hemoglobin levels, but they have not been shown to reduce the need for blood transfusions or to improve clinical outcomes. Lowering the hemoglobin threshold at which blood is transfused will reduce the need for transfusions and is not associated with increased morbidity or mortality among most critically ill patients without active cardiac disease. Further research is needed to determine the potential roles for other blood conservation strategies.     

急性血液稀释自体输血在颅脑手术中的应用

目的：评价急性血液稀释自身输血应用于颅脑手术患者的安全性和可行性。方法：142例无内科合并症的颅脑手术患者随机分为同种异体输血组（对照组71例）及自身输血组（治疗组,71例）,治疗组麻醉后采血至150ml时快速静脉滴注采血量2倍量的稀释液,输液毕立即手术,治疗组患者在手术临近结束或出血超过300ml时回输自体血;对照组在出血超过300ml时输同种异体血。观察生命体征及测定输血前及术后24h红细胞（RBC）、血红蛋白（HGB）、血小板（Plt）、血球比积（Hct）、网织红细胞、血红细胞沉降率（ESR）、纤维蛋白原（Fb）、凝血酶原时间（PT）、部分凝血活酶时间（APTT）、血黏度、血浆电解质（K^＋、Na^＋、Cl^-）、动脉氧分压（PaO2）、动脉血氧饱和度（SaO2）及C反应蛋白（CRP）。结果采血及回输血过程无不良反应,生命体征监测参数稳定,对照组及治疗组在麻醉前、术后24h及术后24两组间血压、心率、RBC、HGB、Plt、Hct、Fb、PT、APTT、网织红细胞、血黏度、血电解质（K^＋、Na^＋、Cl^-）、PaO2及SpO2变化无统计学意义（P〉0.05）,对照组及治疗组术后24h ESR及CRP均比输血前升高（P〈0．01）,对照组术后24hESR及CRP比治疗组显著升高（P〈0．01）。结论：急性血液稀释自身输血应用于颅脑手术安全、可行,可降低颅脑手术病人对同种异体血的需求,且急性血液稀释自身输血比同种异体输血炎症反应轻。     

Current status of erythrocyte substitutes.

During the last two decades the search for alternatives to whole blood transfusions has led to promising developments in the field of erythrocyte substitutes. Hemoglobin solutions free of fragments of erythrocyte stroma and fluorocarbon emulsions are not blood-type-specific and appear likely to satisfy some proportion of our blood requirements. Both must be modified before becoming clinically useful. The oxygen affinity of the hemoglobin solution must be reduced and its intravascular persistence improved. Fluorocarbons cannot yet contribute significantly to the oxygen supply unless the patient breathes hyperbaric oxygen. Recent advances are leading to solutions for these problems.     

负氧离子和低分子右旋糖苷对血沉及血粘度的影响

本文报告16例病员全血在负氧离子和低分子右旋糖苷（低右）体外处理前后血沉和血比粘度的变化。结果表明：加入血标本量1/9的低右，血沉和血比粘度的下降极为显著（血沉t=4.518 p＜0.01，比粘度t=5.419 P＜0.01）。经负氧离子处理后，上述检测指标的下降也极为显著（血沉t=3.145 p＜0.01，比粘度t=3.326 p＜0.01）。且血沉和血粘度的变化呈正相关。提示低右和负氧离子能够改善红细胞的分散态，降低血粘度。     

外周血异常红细胞形态学检验与诊断的意义

红细胞形态学检查在临床检验中易被忽视。观察红细胞形态一般以外周血涂片较为可靠。由于各类型血液细胞分析仪尚不具备识别红细胞、白细胞和血小板形态的能力,只能用作健康人血液一般检验的筛查,其结果可为是否需要进一步镜检提供筛检信息,尚不能完全代替显微镜对各类血细胞的识别和分类检查。现从红细胞大小、形态、数量、红细胞内血红蛋白含量改变、自身抗体引起红细胞凝集现象以及红细胞结构异常等几个方面进行总结,主要介绍外周血涂片中成熟红细胞的各种形态特征和临床意义,目的是要重视外周血红细胞形态特点,提高诊断水平。     

Evolution of the role of army transfusion services in the management of trauma patients and battle casualties with massive hemorrhage

Providing blood at the times of national emergencies and war-like scenarios is a challenge to the blood transfusion services. The dictum should be adequate bleeding, minimum storage time, quick transportation and maximum utilization of blood as soon as possible. For the successful implementation of its role, forward transfusion services should be fully mobile with integral transportation and communication systems. Supplementation of blood supplies has to be prompt, & for this adequate air transport facilities will have to be established. A rational approach to using blood products in patients with bleeding, requires an understanding of the principles of managing hemorrhagic shock. The main priorities are controlling hemorrhage and restoring adequate oxygen delivery to the tissues. Surgical control and treatment of coagulopathy are required to stop hemorrhage in these patients. Resuscitation with fluids and red cells are necessary to improve perfusion and oxygen delivery to tissues. Once patients are resuscitated and further bleeding is stopped, use of conservative transfusion triggers is recommended to avoid excessive transfusion and adverse outcomes. A host of new technologies are being developed that have the potential of reducing blood loss. These will help in reducing the transfusion requirements in trauma patients with massive hemorrhage.     

红细胞输注对早产儿脑氧代谢及生命体征的影响

目的 探讨红细胞输注对早产儿脑氧代谢及生命体征的影响.方法 选取160例早产儿,按照随机数表法分为研究组与对照组各80例,对照组患儿予以常规治疗,研究组在对照组基础上联合红细胞输注.比较治疗前及治疗后2h时,两组患儿脑氧代谢[脑组织氧饱和度(CrSO2)、氧摄取分数(CFOE)]水平变化;比较输血前及治疗后2h时,两组...     

多发伤患者红细胞输注后的效果评价

目的评价多发伤患者输注红细胞后的临床效果。方法115例多发伤输注红细胞患学按照性别分为两组,研究两组的输血反应、ALT、TP、CR、K＋、BUN以及Hb在治疗前后的差异。结果71％的患者输注后血压等指标恢复良好。输血前和输血后48h相比：男性和女性的TP、CR、BUN以及Hb之间的差异具有统计学意义;男性输血前后K＋差异无统计学意义,女性输血前后K＋差异具有统计学意义;而ALT的差异无统计学意义。结论多发伤患者进行红细胞输注,有效地改善了患者的循环,且对血钾和ALT的改变不大,起到了良好的治疗效果。     

New treatments for patients with type 2 diabetes mellitus.

In subjects with type 2 diabetes, both defects of insulin secretion and insulin resistance contribute to the development of hyperglycaemia. The major goals of treatment are to optimise blood glucose control, and normalise the associated lipid disturbances and elevated blood pressure. Pharmacologic treatment is often necessary. This paper discusses new forms of oral treatment for subjects with type 2 diabetes. These include a new sulphonylurea compound glimepiride (Amaryl), which binds to a different protein of the putative sulphonylurea receptor than glibenclamide, and seems to have a lower risk of hypoglycaemia. A new class of drugs with insulin secretory capacity, of which repaglinide (NovoNorm) is the leading compound, is now in phase III clinical trials. Alpha-glucosidase inhibitors reversibly inhibit alpha-glucosidase enzymes in the small intestine, which delays cleavage of oligo- and disaccharides to monosaccharides. This leads to a delayed and reduced blood glucose rise after a meal. Two compounds are in development or have been marketed, ie, miglitol and acarbose (Glucobay). Another new class of drugs is the thiazolidine-diones, which seem to work by enhancing insulin action. The ''insulin sensitising'' effects of the leading compounds, troglitazone and BRL 49653C, do not involve any effect on insulin secretion. These drugs also seem to beneficially influence serum cholesterol and triglyceride levels. Oral antihyperglycaemic agents can be used only during a limited period of time in most patients, after which the diabetic state ''worsens'' and insulin therapy has to be started. In this light, two new forms of treatment which require subcutaneous injections are also discussed: the synthetic human amylin analogue AC137 (pramlintide) and glucagon-like peptide-1 (7-36)-amide, a strong glucose-dependent stimulator of insulin secretion. It remains to be seen whether these compounds can be developed further for clinical use in patients with diabetes.     

ABO血型次侧不相合肝移植术后发生过客淋巴细胞综合征的研究(附2例报告)

目的 研究ABO血型次侧不相合肝移植后发生过客淋巴综合征(passenger lymphocyte syndrome,PLS)的机制及过客淋巴综合征血型血清学诊断标准和输血策略.方法 对2例ABO血型次侧不相合肝移植患者,进行ABO、RhD血型鉴定,直抗分型、抗体筛选和抗体鉴定试验,同时患者红细胞进行放散试验.结果 患者1:血型为AB型、RhD阳性,肝供者为O型、RhD阳性,患者血浆中存在抗-A、抗B,红细胞放散液中存在抗A、抗B;患者2:血型为A型、RhD阳性,肝供者为O型、RhD阳性,患者血浆中存在抗A,红细胞放散液中存在抗A.两位患者直抗均强阳性,抗体筛选阴性.结论 2例患者肝移植术后,均发生PLS.血红蛋白进行性下降,由于移植肝中的淋巴细胞产生了相应的ABO血型抗体,破坏受者的红细胞.患者与O型洗涤红细胞配血相合,输注后无不良输血反应,Hb上升.     

COVID-19 trial graph: a linked graph for COVID-19 clinical trials

ObjectiveClinical trials are an essential part of the effort to find safe and effective prevention and treatment for COVID-19. Given the rapid growth of COVID-19 clinical trials, there is an urgent need for a better clinical trial information retrieval tool that supports searching by specifying criteria, including both eligibility criteria and structured trial information.Materials and MethodsWe built a linked graph for registered COVID-19 clinical trials: the COVID-19 Trial Graph, to facilitate retrieval of clinical trials. Natural language processing tools were leveraged to extract and normalize the clinical trial information from both their eligibility criteria free texts and structured information from ClinicalTrials.gov. We linked the extracted data using the COVID-19 Trial Graph and imported it to a graph database, which supports both querying and visualization. We evaluated trial graph using case queries and graph embedding.ResultsThe graph currently (as of October 5, 2020) contains 3392 registered COVID-19 clinical trials, with 17 480 nodes and 65 236 relationships. Manual evaluation of case queries found high precision and recall scores on retrieving relevant clinical trials searching from both eligibility criteria and trial-structured information. We observed clustering in clinical trials via graph embedding, which also showed superiority over the baseline (0.870 vs 0.820) in evaluating whether a trial can complete its recruitment successfully.ConclusionsThe COVID-19 Trial Graph is a novel representation of clinical trials that allows diverse search queries and provides a graph-based visualization of COVID-19 clinical trials. High-dimensional vectors mapped by graph embedding for clinical trials would be potentially beneficial for many downstream applications, such as trial end recruitment status prediction and trial similarity comparison. Our methodology also is generalizable to other clinical trials.     

不同输血方法在自身免疫性溶血性贫血患者中的效果分析

目的探讨自身免疫性溶血性贫血患者采用不同的输血方法的治疗效果。方法79例自身免疫性溶血性贫血患者均为来我院就诊的患者,其分组的依据为采用不同的输血方法,其中Ⅰ组（n=31）、Ⅱ组（n=28）、Ⅲ组（n=20）的输血方法分别为洗涤红细胞输注、悬浮红细胞输注、洗涤红细胞输注联合血液置换。比较三组患者的治疗总有效率、输血反应发生率及输血前后的Hb、RBC、网织红细胞及血清胆红素的变化。结果（1）与Ⅰ组及Ⅱ组比较,Ⅲ组患者的治疗的总有效率明显的较高（P〈0．05）;（2）三组间的输血反应差异无统计学意义（P〉0．05）;（3）输血后三组患者的Hb、RBC均显著升高,胆红素及网织红细胞均显著降低（P〈0．05）;而与Ⅰ组比较．Ⅲ组的Hb、RBC、胆红素及网织红细胞均改善的幅度更大（P〈0．05）。结论自身免疫性溶血性贫血患者在条件允许时选择红细胞制剂输注联合应用血液置换,能够使其临床治疗效果得到显著的提升。     

新生儿在输血过程中禁食或喂养对肠氧合变化的影响

  目的   探讨新生儿在输血过程中给予禁食或喂养对肠氧合变化的影响。  方法   选取2021年6月至2022年7月以来云南省某三级甲等儿童专科医院新生儿科接受红细胞输注治疗的新生儿,根据输血过程中是否继续喂养,随机数字表法随机分组,分为禁食组及喂养组。使用近红外组织血氧参数无损监测仪对其指标进行检测,新生儿在输注红细胞过程中给予禁食或喂养时的肠道组织氧饱和度（rSO₂）变化。共纳入符合条件的新生儿59例,禁食组21例,喂养组38例。2组患儿在性别、胎龄（早产儿纠正胎龄）、日龄上差异均无统计学意义（P > 0.05）。  结果  在红细胞输注过程中禁食组禁食前、禁食段、禁食后肠道rSO₂ （%）平均值分别是[（54.77±6.49）、（55.18±7.64）、（55.94±6.46）];喂养组喂养前、喂养段、喂养后肠道rSO₂ （%）平均值分别是[（55.35±6.11）、（57.79±6.37）、（58.89±5.55）]。2组禁食/喂养前、禁食/喂养段、禁食/喂养后的分组间比较,差异均无统计学意义（P > 0.05）。  结论   新生儿输注红细胞过程中给予禁食或喂养对比禁食或喂养前后的肠道rSO₂变化范围不大,在原喂养基础上可以考虑在输血过程中继续喂养。     

两种血浆代用品对凝血功能影响的比较

目的：比较血定安与血代两类药物对患凝血功能的影响。方法：选择60例ASA（美国麻醉医师学会）1－2级手术患随机分为两组（血定安组与血代组）。入室后采集静脉血测定凝血酶原时间、纤维蛋白酶定量、血小板计数、血球压积和血钙含量。分别输入血定安与血代1000ml后,再次于非输液侧采集静脉血,监测上述指标。结果：比较两类药物输液前后血球压积P＜0．05,差异显性。其余各项指标均在正常范围内变化。结论：输注血浆代用品后对凝血机制无明显,仅对血液有稀释作用。通过稀释血液,还能提高血液的运氧能力。     

The effects of red blood cell infusion on 10-km race time

The purpose of this study was to investigate the effect of infusion of 400 mL of red blood cells (RBCs) on 10-km track race time, submaximal heart rate, hematocrit, 2,3-diphosphoglycerate, and partial pressure of oxygen at 50% hemoglobin saturation. Six highly trained, male, distance runners twice donated a unit of RBCs, which was frozen for subsequent reinfusion. Eleven weeks after the second donation, they undertook a series of three competitive 10-km races on a standard 400-m track: before infusion, after 100 mL of saline solution, and after 400 mL of autologous, previously frozen deglycerolized RBCs. All subjects took all trials in this double-blind, placebo, crossover, experimental design. Running time was recorded at each 400-m split, and blood was collected prior to each trial. The data were analyzed by analysis of variance. Results following the RBC infusion showed a significantly higher hematocrit concentration, a significantly faster 10-km run, a nonsignificant decrease in submaximal heart rate (10 beats faster 10-km run, a nonsignificant decrease in submaximal heart rate (10 beats per minute), and no significant changes in either 2,3-diphosphoglycerate or partial pressure of oxygen at 50% hemoglobin saturation. Erythrocythemia induced by the infusion of 400 mL of autologous packed RBCs effectively increased performance capacity in a 10-km track race, probably due to an increase in oxygen delivery to the working muscles.     

Association between transfusion of whole blood and recurrence of cancer

Transfusion affects the immune response to renal transplantation and may be associated with recurrence of various human neoplasms. Data from patients with colonic, rectal, cervical, and prostate tumours showed an association between transfusion of any amount of whole blood or larger amounts of red blood cells at the time of surgery and later recurrence of cancer. Recipients of one unit of whole blood had a significantly higher incidence of recurrence (45%) than recipients of a single unit of red cells (12%) (p = 0.03). Recipients of two units of whole blood also had a higher rate of recurrence (52%) than those receiving two units of red cells (23%) (p = 0.03). Recipients of any amount of whole blood had similar recurrence rates (38-52%). Recipients of four or more units of red blood cells had a higher rate of recurrence (55%) than those receiving three or fewer units of red blood cells (20%) (p = 0.005). Mortality due to cancer in patients receiving three or fewer units of red blood cells (2%) was similar to that in patients who did not have transfusions (7%) and significantly lower than that observed in patients receiving three or fewer units of whole blood (20%) (p = 0.003). A proportional hazards risk analysis showed that transfusion of any whole blood or more than three units of red blood cells was significantly associated with earlier recurrence and death due to cancer. These data support an association between transfusion and recurrence of cancer. They also suggest that some factor present in greater amounts in whole blood, such as plasma, may contribute to the increased risk of recurrence in patients who have undergone transfusion. Until the questions raised by retrospective studies of cancer recurrence and transfusion can be answered by prospective interventional trials with washed red blood cells, red blood cells should be transfused to patients with cancer in preference to whole blood when clinically feasible.