小肠移植后急性排斥反应的早期监测指标

小肠移植术后急性排斥反应是小肠移植成功的主要障碍.近年来虽有一些新型免疫抑制剂的应用使小肠移植成为可能,但其发生急性排斥反应的概率远高于肝或肾等器官移植.故如何尽早发现排斥反应并加以干预治疗,则成为提高小肠移植成功率的保证.现就小肠移植术后急性排斥反应的早期检测指标进行综述.     

大鼠同基因单纯胰腺移植动物模型

目的研究建立大鼠同基因单纯胰腺移植(PTA)的方法及观测移植物内分泌功能。方法64只SD大鼠为供受体，血管吻合采用供胰腺腹主动脉绊(含腹腔动脉及脾动脉)及门静脉绊(含脾静脉)与受体腹主动脉及左肾静脉分别行端侧和端端吻合(袖套式)；胰腺断端与小肠行Roux-y吻合。监测受体体重、饮食量、饮水量和空腹血糖。结果在32只单纯胰腺移植中，前10只为预实验，其余22只除5例于1周内死亡外，均成活1个月以上，平均手术时间供体为32±12min，受体为63±15min；移植物均无热缺血时间，冷缺血时间为58±18min只移植后死亡，8只死于胰漏(75%)，2只死于继发性胰腺炎(17%)，1只死于血管栓塞(9%)，1只死于出血(9%)，成功的胰腺移植后第1天血糖即下降；饮水、食量、尿量均减少，一周以后开始稳定。结论PTA是治疗Ⅰ型糖尿病患者(IDDM)的有效方法；如何防治术后继发性胰腺炎及胰漏是手术成功的关键。     

细胞间黏附分子-1及热休克蛋白70与猪同种异体胰腺移植排斥反应的关系

目的 探讨细胞间黏附分子-1（ICAM-1）及热休克蛋白70（HSP70）与猪同种异体胰腺移植排斥反应发生的关系。方法 建立小型猪胰腺移植动物模型，通过移植胰腺穿刺活检组织学检查将标本分为Ⅰ（无排斥反应）、Ⅱ（轻度排斥反应）、Ⅲ（中度排斥反应）及Ⅳ（重度急性排斥反应）组。进一步行ICAM-1及HSP70免疫组织化学检查和图像分析。结果 当移植胰腺发生排斥反应时，ICAM-1及HSP70的表达均升高，并随着排斥反应的加重而呈进行性升高。结论 ICAM-1及HSP70均参与了胰腺排斥反应的发生过程，通过胰腺穿刺活检行ICAM-1及HSP70免疫组织化学检查可早期诊断排斥反应并判断排斥反应的严重程度。     

彩色多普勒血流与肾穿刺活检在移植肾排斥反应中的临床应用

目的 探讨彩色多普勒血流(CDFI)与肾穿刺活检在移植肾排斥反应中的临床意义.方法 对73例肾移植术后患者行CDFI检查,对移植肾的二维超声、血流阻力指数(RI)、动脉搏动指数(PI)与穿刺活检病理结果 进行分析.结果 73例肾移植患者超声引导下经皮肾穿刺活检显示:稳定期37例,急性排斥反应15例,慢性排斥反应11例,肾小管坏死7例,环孢素中毒3例.二维超声检测急、慢性排斥反应的移植肾体积及皮质厚度均明显高于稳定期(P＜0.01).肾动脉CDFI示急性排斥反应、慢性排斥反应、肾小管坏死、环孢素中毒的RI、PI均较稳定期增高(P＜0.01).结论 CDFI对移植肾术后功能的评估起到重要的作用,移植肾穿刺活检病理结果 是最准确的金标准,能够及时准确地对排斥反应进行诊断和疗效判断.     

移植肾超急性排斥反应三例

移植肾超急性排斥反应 (HAR)是一种反应最急剧 ,后果最严重的排斥反应[1 ] 。我院 1998-12～ 2 0 0 3 -0 3共施行同种异体肾移植术 164例 ,发生移植肾HAR 3例均为首次尸肾移植(发生率 1 83 %) ,现报告如下。例 1　男性 ,3 2岁。供受者血型均为A型 ,HLA -A、B、DR6抗原 1个错配 ,群体反应性抗体 (PRA) <10 %,淋巴细胞毒交叉配合试验 (CDC) 0 0 3。首先利用供者左侧肾动、静脉分别与受者右侧髂外动、静脉端侧吻合 ,开放血流约 2min移植肾出现紫斑 ,继之全肾呈紫黑色 ,泌尿停止 ,排除肾动脉血栓形成及痉挛等情况后临床诊断为HAR ,立…     

心脏和心肺移植术后彩超观察排斥反应心包积液变化的研究(附4例报道)

目的彩色多普勒超声心动图（UCG）观察原位心肺联合移植（OHLT）、心脏移植（OHT）术后急性排异期、稳定期心包积液的变化,评价心包积液作为排异指标的临床意义和价值。方法UCG对4例OHLT、OHT患者术后进行最长达五年余不等的长期动态监测急性排异期、稳定期心包积液的变化。结果本组病例发生十几次急性排异反应,出现中到大量心包积液,从未使用过心内膜心肌活检,均由UCG定性、定量观察、评判,明确提出超声诊断。结论UCG是测定心包积液量变化的重要方法,可作为评价OHLT、OHT急性排异期、稳定期反应的重要指标。     

C4d在大鼠慢性排斥反应移植肾组织中的表达及意义

目的探讨大鼠肾移植慢性排斥反应模型移植肾组织中补体裂解产物C4d沉积的表达及意义。方法分别采用封闭群W istar及SD大鼠为供、受体,建立大鼠肾移植慢性排斥反应模型,随机分为试验组(非治疗组)及对照组(霉酚酸酯治疗组),观察移植术后12周各组移植肾组织学变化及C4d在肾小管周围毛细血管的沉积情况。结果术后12周,试验组出现了明显的慢性排斥反应病理改变及广泛的C4d沉积,与对照组比较病理组织学变化及C4d沉积分差异均有统计学意义(P<0.01)。结论移植肾组织中C4d的沉积可作为诊断慢性排斥反应的有效指标。     

小肠移植后急性排斥反应的病理诊断标准

1概述 小肠移植作为治疗不可逆小肠功能衰竭的有效手段,在现代外科中开展越来越广泛,但与其他器官移植相比,小肠移植的长期预后还不令人满意,其中很大的因素是我们还不能完全控制排斥反应的发生,而这也是最终导致小肠移植失败的原因.因此,准确地诊断和治疗急性排斥反应是小肠移植成功的关键之一.     

维生素E对移植器官慢性排斥反应的影响

目前 ,移植领域的一个重要方向就是诱导多机制起作用的免疫耐受 ,防治人体对同种异体器官的慢性排斥反应。作者列举了该方向在免疫因素和非免疫因素方面一些新的发现 ,总结了大剂量维生素E(VE)对免疫系统的调节作用 ,是通过Th/Ts比值的改变和不提高特异性抗体水平来实现的。同时 ,VE强大的抗氧化作用有助于减轻移植组织的氧化压力和血管损伤 ,展望了VE用于防治移植器官慢性排斥反应的意义以及存在问题。     

胰腺、十二指肠、肾一期联合移植围手术期的营养管理

目的：总结胰肾联合移植围手术期的营养管理,提高器官移植的成功率,减少术后并发症,促进康复。方法：行胰腺、十二指肠和肾一期联合移植5例。术前肠内营养支持的原则为高热量、高蛋白、高维生素,同时加大胰岛素用量,以便增加营养,尽快改善全身营养状况,为手术作好准备。术后分阶段给予全静脉营养、肠内营养加静脉营养,直至完全停用静脉营养。结果：2例病人体重、上臂围、肱三头肌皮厚度较入院时增加,4例血清白蛋白、血红蛋白增加,3例血清总蛋白增加。结论：胰肾联合移植围手术期营养管理十分必要,分阶段的营养支持是可行的。提供合适的热量和营养物质是围手术期营养支持成功与否的关键,营养状况的改善与病情及营养支持时间长短有关。     

单剂量赛尼哌诱导治疗对肾移植术后急性排斥反应的预防作用

目的 观察术前使用单剂量赛尼哌对肾移植术后急性排斥反应的预防作用，并对其安全性进行评估。方法 将同期行肾移植的80例病人分为对照组和治疗组各40例，除了治疗组术前使用赛尼哌外，两组病人其余治疗方案均相同。结果 治疗组6个月内急性排斥反应发生率（7．5％）显著低于对照组（25％），在感染及毒副作用方面两组无显著性差别。结论 术前单剂量赛尼哌诱导治疗，能有效预防肾移植术后急性排斥反应发生，是经济安全有效的。     

NK受体KIR及其HLA配体对肾移植急性排斥反应的作用

目的探讨杀伤细胞免疫球蛋白样受体（KIR）及其配体人类白细胞抗原（HLA）对肾移植患者术后发生急性排斥反应（AR）的作用。方法随机采集2009年3月-2012年3月实行肾移植的45对供受者,采用PCR-SSP方法进行HLA-Cw和KIR基因分型,然后依据受者移植后移植肾功能恢复状态分为AR组（16例）和非AR组（29例）,分析供受者HLA-Cw和KIR基因型、受者KIR/供者HLA-Cw组合型与受者术后肾移植发生AR反应的相关性,籍此研究KIR及配体HLA-Cw对肾移植急性排斥反应的作用。结果在AR组中受者表达KIR2DL2/2DS2明显低于非AR组（P〈0.05）;非AR组中供受者KIR2DL2/HLA-Cw1、2DL3/HLA-Cw1和2DS2/HLA-Cw1组合型的匹配几率明显高于AR组（P〈0.05）。结论特定的KIR基因（2DL2/2DS2）以及供受者KIR2DL2/HLA-Cw1、2DL3/HLA-Cw1和2DS2/HLA-Cw1组合型在异基因移植免疫应答中具有传导抑制信号的作用。     

大鼠胰岛移植后血管重建和排斥反应的实验研究

目的通过不同移植前和移植后处理,观察移植胰岛的血管重建及功能变化。方法随机将SD大鼠分成3组,未处理组:移植前后均未作处理,只作单纯胰岛移植;抗树突状细胞单克隆抗体处理组:胰岛移植前先将供体胰岛细胞用抗树突状细胞单克隆抗体和补体在体外37℃下共育45min,再移植给受体大鼠;雷帕霉素处理组:胰岛移植后给予受体大鼠1mg/kg/d的雷帕霉素。胰岛的血管密度通过Lecti nFrom Bandeiraea Simplicifolia的荧光染色来评估,胰岛功能通过测定血糖水平来评估。结果3组胰岛在移植后2d时结构松散,均未见毛细血管再生。移植后4、8、10d胰岛呈团块状和条索状,均可见微血管再生。移植后8、10d时雷帕霉素处理组的微血管密度大于抗树突状细胞单克隆抗体处理组和未处理组(P<0.05),而移植后4d时3组之间均无明显差异(P>0.05)。抗树突状细胞单克隆抗体处理组的高血糖缓解时间比未处理组延长2d。雷帕霉素处理组移植后血糖水平一直维持在低水平。结论雷帕霉素在胰岛移植早期对血管重建有着重要的临床意义,并能有效地保护胰岛细胞免受排斥反应的影响。去除供体胰岛中的树突状细胞对防止胰岛移植早期的免疫排斥有一定的...     

在猪肝-肠联合移植中瓜氨酸是移植肠急性排斥反应的血清学指标

目的:研究在猪肝-小肠联合移植实验中,移植肠的急性排斥反应对血清瓜氨酸浓度的影响.方法:共进行肝-小肠联合移植15次,术后给予免疫抑制剂治疗,存活时间超过7天的受者猪在研究范围之内.术后按计划对肝-小肠联合移植实验后,测定受者猪的血清瓜氨酸浓度.在取血的同时采集移植肠黏膜作移植肠的急性排斥反应的病理评分,并作瓜氨酸浓度-急性排斥反应病理评分的线性回归分析.结果:15头猪中有11头存活时间超过7天.在受者猪肾功能正常的情况下,随着排斥反应逐级增强,血清瓜氨酸水平逐渐减低,而且具有显著性差异(P＜0.05).瓜氨酸浓度-急性排斥反应病理评分的线性回归分析结果为:瓜氨酸浓度=36.02-8.26×病理评分,相关系数为r=0.91.结论:在猪肝-小肠联合移植中瓜氨酸是一种移植肠急性排斥反应的血清学指标.     

ECHO-AGE: An Innovative Model of Geriatric Care for Long-Term Care Residents With Dementia and Behavioral Issues

ObjectivesTo design, implement, and assess the pilot phase of an innovative, remote case-based video-consultation program called ECHO-AGE that links experts in the management of behavior disorders in patients with dementia to nursing home care providers.DesignPilot study involving surveying of participating long-term care sites regarding utility of recommendations and resident outcomes.SettingEleven long-term care sites in Massachusetts and Maine.ParticipantsAn interprofessional specialty team at a tertiary care center and staff from 11 long-term care sites.InterventionLong-term care sites presented challenging cases regarding residents with dementia and/or delirium related behavioral issues to specialists via video-conferencing.MethodsBaseline resident characteristics and follow-up data regarding compliance with ECHO-AGE recommendations, resident improvement, hospitalization, and mortality were collected from the long-term care sites.ResultsForty-seven residents, with a mean age of 82 years, were presented during the ECHO-AGE pilot period. Eighty-three percent of residents had a history of dementia and 44% were taking antipsychotic medications. The most common reasons for presentation were agitation, intrusiveness, and paranoia. Behavioral plans were recommended in 72.3% of patients. Suggestions for medication adjustments were also frequent. ECHO-AGE recommendations were completely or partially followed in 88.6% of residents. When recommendations were followed, sites were much more likely to report clinical improvement (74% vs 20%, P < .03). Hospitalization was also less common among residents for whom recommendations were followed.ConclusionsThe results suggest that a case-based video-consultation program can be successful in improving the care of elders with dementia and/or delirium related behavioral issues by linking specialists with long-term care providers.     

An Easy Assessment of Frailty at Baseline Independently Predicts Prognosis in Very Elderly Patients With Acute Coronary Syndromes

Background

Information about the impact of frailty in patients with acute coronary syndromes (ACS) is scarce. No study has assessed the prognostic impact of frailty as measured by the FRAIL scale in very elderly patients with ACS.

An Integrated Syndromic Surveillance System for Monitoring Scarlet Fever in Taiwan

Objective

To develop an integrated syndromic surveillance system for timely monitoring and early detection of unusual situations of scarlet fever in Taiwan, since Hong Kong, being so close geographically to Taiwan, had an outbreak of scarlet fever in June 2011.

Introduction

Scarlet fever is a bacterial infection caused by group A streptococcus (GAS). The clinical symptoms are usually mild. Before October, 2007, case-based surveillance of scarlet fever was conducted through notifiable infectious diseases in Taiwan, but was removed later from the list of notifiable disease because of improved medical care capacities. In 2011, Hong Kong had encountered an outbreak of scarlet fever (1,2). In response, Taiwan developed an integrated syndromic surveillance system using multiple data sources since July 2011.

Methods

More than 99% of the Taiwan population is covered by National Health Insurance. We first retrospectively evaluated claims data from the Bureau of National Health Insurance (BNHI) by comparing with notifiable diseases reporting data from Taiwan Centers for Disease Control (TCDC). The claims data included information on scarlet fever diagnosis (ICD-9-CM code 034.1), date of visits, location of hospitals and age of patients from outpatient (OPD), emergency room (ER) and hospital admissions. Daily aggregate data of scarlet fever visits or hospitalizations were prospectively collected from BNHI since July 2011. Over 70% of the deaths in Taiwan are reported to the Office of Statistics of Department of Health electronically. We obtained daily data on electronic death certification data and used SAS Enterprise Guide 4.3 (SAS Institute Inc., Cary, NC, USA) for data management and analysis. Deaths associated with scarlet fever or other GAS infections were identified by text mining from causes of death with keywords of traditional Chinese ‘scarlet fever’, ‘group A streptococcus’ or ‘toxic shock syndrome’ (3).

Results

From January 2006 to September 2007, the monthly OPD data with ICD-9-CM code 034.1 from BNHI showed strong correlation with TCDC’s notifiable disease data (r=0.89, p<0.0001). From July 6, 2008 (week 28) through July 28, 2012 (week 30), the average weekly numbers of scarlet fever visits to the OPD, ER and hospital admissions were 37 (range 11–70), 7 (range 0–20) and 3 (range 0–9). Eighty-five percent of the scarlet fever patients were less than 10 years old. In Taiwan, scarlet fever occurred year-round with seasonal peaks between May and July (Fig. 1). From January 2008 to July 2012, we identified 12 potential patients (9 males, age range 0–82 years) who died of GAS infections. No report had listed ‘scarlet fever’ as cause of death during the study period.Open in a separate windowFig. 1.Weekly numbers of nationwide scarlet fever OPD and ER visits, and hospital admissions, with baseline OPD visits and 95% confidence interval calculated by a Serfling’s model, week 28 of 2008 to week 30 of 2012.

Conclusions

Taiwan has established an integrated syndromic surveillance system to timely monitor scarlet fever and GAS infection associated mortalities since July 2011. Syndromic surveillance of scarlet fever through BNHI correlated with number of scarlet fever cases through notifiable disease reporting system. Text mining from cause of death with the used keywords may have low sensitivities to identify patients who died of GAS infection. In Taiwan, syndromic surveillance has also been applied to other diseases such as enterovirus, influenza-like illness, and acute diarrhea. Interagency collaborations add values to existing health data in the government and have strengthened TCDC’s capacity of disease surveillance.     

青海省急性弛缓性麻痹病例主动搜索调查分析

1999年10月青海省循化撒拉族自治县发生1例由输入脊髓灰质炎(脊灰)野病毒引起的病例,其后在全省范围内对15岁以下儿童开展了急性弛缓性麻痹(AFP)病例入户调查,对所有县级及县级以上医院和部分乡级卫生院进行了主动搜索,在1994～2000年4月共发现AFP病例64例,已报告60例,报告率93.75%;漏报4例,漏报率6.25%,1996年、1997年各漏报2例.1998年以后未发现漏报.经过对全省10岁以下儿童进行6轮口服脊灰疫苗“扫荡”式免疫活动,无2代病例发生.