地西他滨治疗骨髓增生异常综合征10例疗效观察

目的:观察地西他滨治疗骨髓增生异常综合征(MDS)的疗效及不良反应.方法:对10例MDS患者采用地西他滨治疗,25 mg/d,连用5d,休息23 d,28 d为1疗程.国际预后评分0.5分4例、1分1例、1.5分2例、2分1例、2.5分2例.结果:其中3例患者使用1疗程,3例患者使用2疗程,4例患者使用4疗程.10例患者中3例患者因粒细胞缺乏时间长,严重的肺部感染导致呼吸及循环衰竭于治疗2个月内死亡.2例患者因骨髓抑制期血小板极低,出现消化道出血,积极抢救于1个月内无效死亡.随访另外5例患者,其中1例难治性血细胞减少伴多系发育异常(RCMD)患者治疗4个疗程后完全缓解,5个月后进展为急性白血病,于第7个月后死亡;1例环形铁粒幼细胞难治性贫血患者使用地西他滨1个疗程获完全缓解后未坚持巩固治疗,7个月后死亡;1例由MDS转变为急性白血病患者治疗2个疗程获完全缓解,目前仍存活;1例难治性贫血伴原始细胞增多(RAEB)治疗3个疗程后获血液学改善;1例RAEB患者治疗4个疗程后情况稳定.结论:地西他滨用于治疗中危-2及高危MDS患者,疗效尚可.     

地西他滨治疗低中危骨髓增生异常综合征的疗效及患者生存预后因素分析

目的:探讨地西他滨治疗低中危骨髓增生异常综合征(MDS)的疗效,分析患者生存预后因素。方法:回顾性研究47例在我院接受地西他滨治疗的低中危MDS患者治疗资料,地西他滨皮下注射20 mg/(m~2·d)×5 d,28 d为1个疗程。患者接受地西他滨治疗3-4个疗程后评价其治疗反应,分析生存预后因素。结果:根据修订的国际工作组标准(IWG),18例(38.3%)患者达到CR,13例(27.7%)患者达到PR,血液学改善7例(14.9%),7例(14.9%)死于肺部感染或骨髓抑制,2例转变为急性髓系白血病,中位生存时间为26个月。地西他滨方案治疗的整体有效率为80.9%(38/47)。患者的独立的不良预后因素为:IPSS分级高、MDS病程长、早期曾有MDS治疗、老年。结论:地西他滨治疗低中危MDS的长期疗效确切,治疗前的临床因素或许可以预测地西他滨治疗MDS的疗效结果。     

地西他滨联合IAG方案治疗老年MDS转化为急性髓系白血病患者的疗效观察

目的:观察地西他滨联合IAG方案治疗老年骨髓增生异常综合征(MDS)转化为急性髓系白血病患者的疗效和安全性。方法:2例老年MDS转化为急性髓系白血病患者应用地西他滨+IAG方案(地西他滨25 mg/d,1/d,静脉滴注,d 1-5;去甲氧柔红霉素10 mg/d,1/d,静脉滴注,d6;阿糖胞苷10 mg/m~2,1/12 h,皮下注射,d 6-19;G-CSF 300μg,1/d,皮下注射,d 6-19)。观察患者的疗效和不良反应。结果:1例使用2个疗程,另1例使用1个疗程,2例获完全缓解;化疗的不良反应主要表现为骨髓抑制和粒细胞缺乏所致的感染,未见肝肾毒性反应及其他严重的胃肠等非造血系统不良反应。结论:地西他滨联合IAG方案治疗老年骨髓增生异常综合征转化为急性髓系白血病的患者,其效果良好。     

地西他滨联合CAG方案与单纯CAG方案治疗中、高危骨髓增生异常综合征的疗效比较

本研究比较小剂量地西他滨联合CAG方案（阿克拉霉素、阿糖胞苷、粒细胞集落刺激因子）与单用CAG方案治疗中高危骨髓增生异常综合征的临床疗效及不良反应,探讨前方案作为中高危骨髓增生异常综合征新的治疗方法的可行性及有效性.2011年起小剂量地西他滨联合CAG治疗中高危骨髓增生异常综合征（MDS-RAEB）12例及2005年起既往单纯CAG方案治疗中高危MDS患者10例（治疗1个疗程后评估,至少使用2个疗程）疗效评估.分析接受两种方案的患者1个疗程的完全缓解率、总有效率、无病生存时间及总的生存时间.结果表明：小剂量地西他滨联合CAG方案治疗中高危MDS的12例患者一疗程后有完全缓解9例,2例部分缓解,1例完全无效,缓解率75.0％,总有效率91.7％,中位无病生存时间9（0-27）个月,中位总生存时间16（3-28）个月.治疗后肺部感染发生4例,予以抗感染治疗后均好转.既往2005年起10例中高危MDS患者予以单纯CAG方案治疗,完全缓解5例,部分缓解伴临床症状改善3例,2例无效,骨髓及血液学均无好转.缓解率50％,总有效率80％,中位无病生存时间6（0-18）个月,中位总生存时间13（3-31）个月.治疗后肺部感染3例,肠道感染1例,大肠杆菌败血症1例,予以积极抗感染治疗后均好转.两组患者治疗过程中未发生严重并发症,患者均能耐受,无治疗相关死亡.经统计分析,小剂量地西他滨联合CAG较单用CAG治疗中高危MDS有较长的无病生存时间（P值为0.013）,总体生存时间有延长趋势,但无统计学意义（P值0.087）.结论：小剂量地西他滨联合CAG治疗中高危MDS有较高的治疗效果,不增加治疗风险,可在临床推广.     

地西他滨治疗骨髓增生异常综合征的疗效分析

目的探讨地西他滨治疗骨髓增生异常综合征(MDS)的疗效及危险因素。方法收集65例MDS患者的临床资料,均接受地西他滨治疗,分析年龄、病程、国际预后积分系统(IPSS)分组、血小板计数等与疗效的关系,分析影响地西他滨治疗MDS效果的危险因素。结果所有患者治疗总有效率为78.46%。年龄、病程、IPSS分组、血小板计数与地西他滨治疗MDS的疗效有相关性,差异有统计学意义(P 0.05)。Logistic回归分析显示,年龄大、病程长、IPSS分组高、血小板计数低是影响地西他滨治疗MDS效果的危险因素(OR1,P 0.05)。结论地西他滨治疗MDS效果显著,其效果与年龄、病程、IPSS分组、血小板计数有关。     

地西他滨治疗骨髓增生异常综合征的临床观察及预后因素分析

目的:探索地西他滨治疗骨髓增生异常综合征(MDS)的临床疗效及预后预测因素。方法:回顾性分析87例接受地西他滨治疗的MDS患者的临床资料。分别采用Q-PCR及测序检测MDS患者h ENT1的mRNA表达及TP53基因的突变情况,分析患者临床特征及分子学指标与地西他滨临床反应的关系。结果:地西他滨中位治疗4(2-17)个疗程,51例(58. 6%)治疗有效,其中CR 17例(19. 5%),PR 12例; mCR 9例,HI 13例,36例(41. 4%)无反应。单因素分析显示,复杂核型、单体核型、7号染色体异常以及1个疗程后Plt数倍增的患者可获得更高的CR率; IPSS相对高危组(中危2+高危)、复杂核型及1个疗程后Plt倍增的患者总体有效率更高。治疗有反应组MDS患者的h ENT1 mRNA表达水平明显高于无反应组[1. 78±1. 45 (2-△△Ct) vs 0. 96±0. 97 (2-△△Ct)](P=0. 002)。在51例有反应组中,CR组的h ENT1 mRNA表达水平高于未获得CR者[2. 58±1. 44(2-△△Ct) vs 1. 39±1. 3(2-△△Ct)](P=0. 005)。在52例相对高危组(中危2+高危)中高h ENT1 mRNA表达的患者中位OS时间显著长于低h ENT1表达的患者(31 vs 12个月)(P 0. 001)。在87例接受地西他滨治疗的患者中,TP53突变者11人(12. 6%)。TP53突变患者总体反应率高(P=0. 04),且更容易获得CR(P 0. 001)。多因素Logistic回归模型显示,复杂核型、1个疗程后Plt数倍增、TP53突变及h ENT1 mRNA高表达是预测地西他滨治疗获得CR的独立预后因素。结论:IPSS分期、复杂核型、1个疗程后Plt数倍增及h ENT1表达、TP53基因突变可预测地西他滨治疗的疗效。     

中高危骨髓增生异常综合征转化为急性髓系白血病的高危因素

目的:探讨以地西他滨为主治疗中高危骨髓增生异常综合征(MDS)患者转化为急性髓系白血病(AML)的高危因素。方法:回顾性分析60例中高危MDS患者的临床特点及其转化为AML的高危因素。结果:以地西他滨为主治疗的中高危MDS患者总有效率(ORR)为65.0%(39/60),其中达完全缓解(CR)患者17例(28.3%),骨髓缓解(m CR)患者5例(8.3%);部分缓解(PR)患者4例(6.7%);血液学缓解(HI)患者13例(21.7%)。60例以地西他滨为主治疗的中高危MDS患者转化为AML 21例(35.0%),中位转化时间为10.0(1.5月-32.0)个月。χ^2或Fisher精确检验显示,中高危MDS转化为AML与2016年WHO诊断分型、骨髓增生明显活跃、地西他滨用药间隔延长相关(χ^2=9.878,P=0.031;χ^2=4.319,P=0.038;χ^2=6.406,P=0.011);Kaplan-Meier检验单因素分析显示,中高危MDS转化为AML与2016年WHO诊断分型、骨髓原始细胞数、骨髓病态造血系数、地西他滨疗程间隔延长相关(P=0.015,P=0.008,P=0.012,P=0.032);COX多因素分析显示,骨髓原始细胞数、骨髓病态造血系数为中高危MDS患者转化为AML的独立危险因素(P=0.022,P=0.018)。结论:骨髓原始细胞数、骨髓病态造血系数是以地西他滨为主治疗中高危MDS患者转化为AML的独立危险因素;地西他滨用药间隔规律有利于维持病情稳定。     

低剂量地西他滨单药治疗骨髓增生异常综合征的疗效分析

目的:探讨低剂量地西他滨单药治疗骨髓增生异常综合征(MDS)的疗效及安全性。方法:选取51例中高危MDS患者,根据用药方案将他们分为A、B和C 3组:A组——地西他滨10 mg/(m~2·d)×7 d,28 d为1个疗程;B组——地西他滨20 mg/(m~2·d)×5 d,28 d为1个疗程;C组——地西他滨+CAG地西他滨10mg/(m~2·d)d 1-5,阿糖胞苷10 mg/m~2皮下注射q12h d 1-7,阿克拉霉素10 mg/d静滴d 1-4,重组人粒细胞刺激因子200μg/(m~2·d)d 1-7, 28 d为1个疗程。3组患者均给予治疗4个疗程,比较3组的疗效及治疗反应。结果:3组患者的完全缓解率(CR%)分别为18.75%、22.22%和23.53%,总有效率(ORR%)分别为56.25%、61.11%和58.82%,3组比较均无明显差异(P0.05)。随访1年,3组患者生存率无统计学差异,血细胞均较基础值上升。1个化疗疗程之后,3组患者Ⅲ-Ⅳ级骨髓抑制率比较有统计学差异,A组骨髓抑制发生率较B和C组明显降低。3组感染发生率比较也有统计学差异,A组感染发生率较B和C组均明显降低。4个月治疗期间人均成分血输注量,A组较B和C组低,但3组比较无统计学差异。结论:低剂量地西他滨单药治疗MDS与常规剂量地西他滨及联合CAG方案治疗MDS疗效相当,但严重骨髓抑制及感染发生率均较低,患者耐受性更好。     

地西他滨联合CAG方案治疗骨髓增生异常综合征-RAEB及难治性急性髓系白血病的临床观察

目的:观察地西他滨联合CAG方案治疗骨髓增生异常综合征-RAEB(MDS-RAEB)及难治性急性髓系白血病(AML)的临床疗效和不良反应。方法:回顾性分析2011年7月至2014年7月解放军总医院第一附属医院收治的21例MDS-RAEB及难治性AML患者临床疗效,给予患者地西他滨+CAG方案治疗:地西他滨20 mg/(m2·d),d 1-5;阿柔比星10 mg/d,d 6-13;阿糖胞苷20 mg/d,d 6-19;重组粒细胞集落刺激因子(G-CSF)300μg/d,d 6-19)。结果:1个疗程后,21例患者中完全缓解8例(42.1%),部分缓解8例(42.1%),血液学改善2例,未缓解1例,死亡2例;1年总生存(OS)率为67.5%。12例年龄≥60岁患者中完全缓解6例(60%,6/10),1年OS率为62.5%。13例高危核型患者中完全缓解6例(54.5%,6/11);1年OS率为61.5%。治疗不良反应主要为骨髓抑制,非血液学不良反应主要为肝功能损害和胃肠道反应。结论:地西他滨联合CAG方案治疗MDS-RAEB及难治性AML安全有效,可延长难治恶性血液病患者生命。     

超低剂量地西他滨和环孢素对低危及中危-1型骨髓增生异常综合征的临床疗效比较

目的:比较地西他滨与环孢素治疗低危及中危-1型骨髓增生异常综合征(MDS)的临床疗效和不良反应的差别。方法:回顾性分析上海市同济医院血液内科在近3年中收治的27例中低危MDS患者临床资料;患者分为两组:地西他滨组(11例)和环孢素组(16例),分别采用超低剂量地西他滨和环孢素治疗对其临床疗效和不良反应进行了评估。结果:接受超低剂量地西他滨(DAC)治疗的11例中、低危MDS患者中,血液学改善4例(36.4%);无效7例(63.6%),总有效率36.4%,无效者包括未缓解6例(54.5%),死亡1例(9.1%);1年内死亡3例,总生存(overall survival,OS)率为72.7%,其死亡的主要原因为骨髓抑制及感染。接受环孢素(CsA)治疗的16例患者中,获得血液学改善10例(62.5%),无效6例(37.5%),总有效率62.5%,无效者全部为未缓解病例;1年内死亡患者0例,1年的OS值为100%。两组患者治疗期间中性粒细胞、血红蛋白、血小板的变化无统计学差异。结论:地西他滨治疗中低危MDS临床疗效未表明优于环孢素(P=0.252),且感染及骨髓抑制副作用明显,1年总生存率低于环孢素(P=0.027),但本研究病例数少,随访时间短,仍需扩大病例长期随访观察。     

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.     

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.     

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.     

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.     

俯卧位通气对高海拔地区肺复张治疗无效急性呼吸窘迫综合征患者氧合的影响

目的 探讨俯卧位通气对高海拔地区肺复张术(RM)治疗无效急性呼吸窘迫综合征(ARDS)患者的治疗作用.方法 从海拔2260m的地区医院筛选RM治疗无效的41例ARDS患者[平均氧合指数( PaO2/FiO2)较RM前升高＜20％视为RM无效],依不同病因分为肺内源性ARDS组(ARDSp组)和肺外源性ARDS组(ARDSexp组),每组再按信封法随机分为俯卧位组和仰卧位组,即ARDSp俯卧位组(11例)、ARDSp仰卧位组(9例)、ARDSexp俯卧位组(10例)、ARDSexp仰卧位组(11例).在通气前及通气1、2、3、4h监测动脉血氧分压( PaO2)、PaO2/FiO2、静态顺应性(Cst)、气道阻力(Raw)的变化.结果 通气lh时,ARDSexp俯卧位组PaO2/FiO2( mm Hg,l mm Hg=0.133 kPa)即较通气前显著升高(157.4±40.6比129.3±48.7,P＜0.05),并随通气时间延长呈持续增高趋势,4h达峰值(219.1 ±41.1);且ARDSexp俯卧位组通气3h内PaO2/FiO2较其他3组显著增高,另3组间则差异无统计学意义.ARDSp俯卧位组、ARDSexp俯卧位组通气4h时PaO2/FiO2均较相应仰卧位组显著增高(208.8±39.7比127.4±47.1,219.1±41.1比124.9±50.8,均P＜0.05).4组通气前后Cst无显著改变,各组间差异也无统计学意义.ARDSp俯卧位组通气4h时Raw(cmH2O·L-1·s-1)较通气前显著降低(6.8±1.7比10.7±1.8,P＜0.05),且明显低于其他3组;其他3组各时间点Raw组内及组间比较差异均无统计学意义.结论 俯卧位通气作为ARDS机械通气重要策略之一,可以改善RM无效高原ARDS患者的氧合,为抢救患者赢得宝贵的时间.     

Digital imaging among medical facilities

The Department of Veterans Affairs (VA) in the USA operates a network of 172 medical centres which all utilize a hospital information system (HIS) which has been developed and is currently maintained by the VA. During the past several years, an image management and communication module has been developed, installed and clinically utilized at the Washington DC and Maryland VA Medical Centres. This image management and communication system, referred to as the decentralized hospital computer program (DHCP) imaging system, is fully integrated with a commercial picture archiving and communication system (PACS). The system is utilized to capture, archive, and display all images generated within the hospital including radiology, nuclear medicine, pathology, endoscopy, bronchoscopy, and dermatology, intraoperative photographs, ECG data, and a limited number of paper documents. The ultimate goal of the project is to have all patient text and image data available at any clinical workstation to any authorized user anywhere within the network of medical centres. Clinical requirements for an imaging workstation include ease of use, rapid and reliable access to the complete set of patient information, and images which are of acceptable quality to meet the requirements of the user and the subspecialty. Patient confidentiality and data security must be safeguarded at all times. Integration of the images with the remainder of the patient's database was found to be critical to the success of the project. The experience at the Washington and Maryland facilities suggests that an imaging system that is successfully integrated with a hospital information system can provide substantial clinical and economic benefits both within and among medical centres. Clinical acceptance and utilization of the system has been excellent, particularly in diagnostic radiology where DHCP Imaging has been interfaced to a commercial PAC system. Based upon this initial experience, the VA has begun to deploy the system throughout its large network of medical centres.     

Myocardial elastography at both high temporal and spatial resolution for the detection of infarcts

Myocardial elastography is a novel method for noninvasively assessing regional myocardial function, with the advantages of high spatial and temporal resolution and high signal-to-noise ratio (SNR). In this paper, in-vivo experiments were performed in anesthetized normal and infarcted mice (one day after left anterior descending coronary artery [LAD] ligation) using a high-resolution (30 MHz) ultrasound system (Vevo 770, VisualSonics Inc., Toronto, ON, Canada). Radiofrequency (RF) signals of the left ventricle (LV) in longitudinal (long-axis) view and the associated electrocardiogram (ECG) were simultaneously acquired. Using a retrospective ECG gating technique, 2-D full field-of-view RF frames were acquired at an extremely high frame rate (8 kHz) that resulted in high-quality incremental displacement and strain estimation of the myocardium. The incremental results were further accumulated to obtain the cumulative displacements and strains. Two-dimensional and M-mode displacement images and strain images (elastograms), as well as displacement and strain profiles as a function of time, were compared between normal and infarcted mice. Incremental results clearly depicted cardiac events including LV contraction, LV relaxation and isovolumetric phases in both normal and infarcted mice, and also evidently indicated reduced motion and deformation in the infarcted myocardium. The elastograms indicated that the infarcted regions underwent thinning during systole rather than thickening, as in the normal case. The cumulative elastograms were found to have higher elastographic SNR (SNR(e)) than the incremental elastograms (e.g., 10.6 vs. 4.7 in a normal myocardium, and 6.0 vs. 2.4 in an infarcted myocardium). Finally, preliminary statistical results from nine normal (m = 9) and seven infarcted (n = 7) mice indicated the capability of the cumulative strain in differentiating infracted from normal myocardia. In conclusion, myocardial elastography could provide regional strain information at simultaneously high temporal (>/=0.125 ms) and spatial ( approximately 55 microm) resolution as well as high precision ( approximately 0.05 microm displacement). This technique was thus capable of accurately characterizing normal myocardial function throughout an entire cardiac cycle, at the same high resolution, and detecting and localizing myocardial infarction in vivo.     

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.