老年急性髓系白血病诱导缓解化疗的疗效及预后分析

目的探讨老年急性髓系白血病（AML）诱导缓解化疗的疗效及预后。方法选择78例年龄65～88岁的AML患者,分为化疗组54例,姑息治疗组24例,收集两组临床资料并随访比较两组的预后。结果化疗组患者共有27例完全缓解（CR）,7例部分缓解（PR）,总有效率62．96％,而姑息治疗患者未有一例CR;化疗组早期病死率显著低于姑息治疗组,平均总生存时间、1年生存率显著高于姑息治疗组（P均〈0．05）,但2年生存率两组间比较无显著差异（P〉0．05）,两组生存曲线比较具有统计学差异（Log—rank）（x^2=4．589,P=0．031）;COX回归模型发现是否接受化疗与CCI评分〉2分是影响预后的独立因素。结论老年AML患者仍应选择化疗为主要治疗方案,以提升中位生存期和短期生存率。     

原发性急性髓系白血病预后相关因素分析

目的:探讨原发性急性髓系白血病(AML)患者预后的影响因素,为改善患者预后,延长生存期提供临床依据。方法:回顾性分析2006年6月至2010年12月在我院就诊的原发性急性髓系白血病(除外AML-M3)109例,采用Kaplan-Meier生存分析法分析患者性别、年龄、初诊时外周血白细胞计数、血红蛋白浓度、血小板计数、骨髓涂片原始细胞百分数、细胞遗传学、首次诱导是否缓解与总生存时间(OS)及无复发生存期(RFS)的关系,log-rank检验对其可能的预后影响因素进行单因素分析,多元比例危险率COX回归模型进行多因素分析。结果:患者完全缓解(CR)率为56.88%,中位OS为9.5个月,中位RFS为5.5个月。年龄大于60岁、细胞遗传学高危组和首次诱导化疗未获得CR的患者OS及RFS较短(P<0.05),为预后不利因素,且对预后具有独立影响。结论:根据急性髓系白血病预后相关因素可对其进行预后判断,从而为个体化分层治疗提供临床依据,对延长患者总生存时间及无病生存期具有重要意义。     

高三尖杉酯碱、阿糖胞苷、去甲氧柔红霉素联合诱导治疗初治急性髓系白血病临床研究

本研究探讨高三尖杉酯碱(homoharringtonine)、阿糖胞苷(Ara-C)、去甲氧柔红霉素(idambin)组成的联合化疗方案(HAI)治疗初治急性髓系白血病(AML)(除外急性早幼粒细胞白血病)的疗效和安全性.31例初治AML患者接受HAI诱导化疗,统计1个疗程的缓解率、长期生存率及无复发生存率,比较WHO亚型、遗传学及初始白细胞计数等不同预后分组患者疗效,按照WHO抗癌药物不良反应评估标准进行安全性评价.结果表明,26例患者1个疗程后获完全缓解(CR),CR率为84％.染色体核型预后良好组(n=10)、预后中等组(n=16)、预后不良组(n=5)患者1个疗程的CR率分别为90％、88％、60％,组间差异无统计学意义(p=0.28).7例高白细胞数(白细胞计数≥100×109/L)患者均获CR,24例非高白细胞数组患者19例获CR.中位随访期15(2 -56)个月,全部患者3年累积生存率44％.26例CR患者3年累积生存率52％,3年无复发生存率为51％.所有31例患者均完成HAI诱导化疗,无化疗相关死亡病例.在诱导治疗期间所有患者均发生严重骨髓抑制,中性粒细胞绝对值＜0.2×109/L持续的中位时间为16(6 -24)天.31例患者均发生Ⅲ-Ⅳ级严重感染,抑制期中位发热持续时间为6(1 -36)天.败血症发生率为19.4％ (6/31);侵袭性真菌病发生率45.2％( 14/31),Ⅲ-Ⅳ级非血液学毒性反应以发热(非感染性)、谷丙转氨酶升高、腹泻、胆红素升高、口腔炎等最为常见,发生率分别为6.5％、6.5％、3.2％、3.2％、3.2％.结论:HAI方案治疗初治AML疗效肯定,特别是1个疗程的缓解率明显高于DA标准诱导方案.HAI方案安全性较好,除非发生严重感染.     

急性髓系白血病合并阵发性睡眠性血红蛋白尿患者的临床特征及预后分析

目的:探讨成人急性髓系白血病(AML)合并阵发性睡眠性血红蛋白尿(PNH)患者的临床特征及预后价值。方法:收集和回顾性分析2017年1月至2019年5月就诊于本院血液内科并接受规律化疗的13例PNH克隆阳性的AML患者的临床资料。分析诱导化疗后完全缓解(CR)率;使用配对t检验对化疗前后PNH病态细胞水平进行检验;采用Kaplan-Meier法及多因素Cox回归模型分析影响预后的因素。结果:13例患者中,11例初次诱导化疗后达CR,CR率为84.6%。中位总生存期(OS)为17(0-30)个月,中位无进展生存期(PFS)为16(2-26)个月。13例患者治疗前后PNH病态细胞变化无统计学差异(P 0.05)。多因素Cox回归分析显示,患者的年龄、性别、初诊时血红蛋白、血小板数与OS无关(P 0.05);初诊时白细胞水平、乳酸脱氢酶水平及危险度分层对OS存在影响(P 0.05)。Kaplan-Meier生存分析显示,初诊时白细胞水平小于10×109/L的AML合并PNH患者OS率明显高于白细胞大于10×109/L (P=0.0261)的患者。低、中危较高危患者生存率高(P=0.0010)。结论:AML合并PNH患者初次诱导化疗后疗效较好,初诊时白细胞数量及乳酸脱氢酶水平对AML合并PNH患者OS有影响,初诊时白细胞低于10×109/L及低、中危患者OS率更高。     

地西他滨联合减量FLAG方案治疗老年高危急性髓系白血病患者的临床疗效观察

目的:探究地西他滨联合减量FLAG方案治疗老年高危AML患者的疗效及不良反应。方法:对12例老年高危AML患者采用地西他滨联合减量FLAG方案(地西他滨20 mg/m~2,qd,d 1-5;氟达拉滨50 mg/d,d 3-6;阿糖胞苷1 g/m~2,qd,d 3-6; G-CSF 300μg,qd,自d 2起至中性粒细胞达最低值后恢复 1.0×109/L)进行诱导化疗,观察临床疗效及其不良反应。结果:12例患者经1个疗程化疗后,9例获得完全缓解,2例获得部分缓解,1例病情稳定,总有效率为92%。中位随访时间7.4(3-12)个月,中位生存期6.4个月。化疗的不良反应主要有骨髓抑制和粒细胞缺乏所致的感染,无严重的非血液学不良反应,无治疗相关死亡。结论:地西他滨联合减量FLAG方案作为诱导缓解方案对老年高危AML疗效确切,能显著提高CR率并降低不良反应,可作为老年高危AML首选诱导缓解方案之一。     

第一次巩固治疗前淋巴细胞计数是急性髓系白血病无复发生存期的预测因素

目的:分析第一次巩固治疗前淋巴细胞计数对急性髓系白血病患者(AML)无复发生存期的影响,探索预测AML复发简单易行的检测方法。方法:回顾性分析132例AML(均为非急性早幼粒细胞白血病)患者的临床资料。根据第1次巩固治疗前淋巴细胞计数分为高淋巴细胞组(H-Lym≥1.2×10~9/L)和低淋巴细胞组(L-Lym1.2×10~9/L),分析2组患者在复发率、无复发生存期(RFS)之间的差异。结果:132例AML患者中可评估的患者有65例。H-Lym组40例,在诱导治疗前患者的白细胞绝对值、年龄、染色体核型与L-Lym组(25例)不存在统计学差异。单因素分析显示,L-Lym计数和不良的染色体核型是无复发生存期的不良预后因素,二者存在明显统计学差异(P=0.001,P=0.008),L-Lym组患者复发的风险明显增加,风险比(hazard ratio,HR)=3.01,(95%CI1.55-5.86,P=0.001)。在含有不良预后核型的多因素分析中,这种趋势仍然存在(HR=2.52,95%CI 1.28-4.98,P=0.008)。结论:第一次巩固治疗前高淋巴细胞的AML患者具有较长的无复发生存期,第一次巩固治疗前的淋巴细胞计数可能是AML患者无复发生存期的预后因素。     

24例伴8号染色体三体原发性急性髓系白血病发病的特点及预后

目的:探讨伴8号染色体三体("8三体")的原发性急性髓系白血病(AML)的发病特点及预后。方法:收集24例伴8三体的原发性AML患者的临床资料,分析初诊时血常规指标、FAB分型、染色体、基因与缓解率和疾病转归的相关性。结果:除1例未予以化疗外,余23例均接受1-2个疗程的标准诱导化疗方案。3例M3达到CR1,至今均无病存活,5年存活率100%。在20例非M3中12例达CR1(60%),4例部分缓解(PR,20%),4例未缓解(NR);3年内5例复发(RL)(41.7%),经再诱导化疗后3例达CR2,2例NR。除1例CR1后失访外,其余19例非M3平均随访26.2(1.5-84)月,9例死亡(均系未缓解或CR1后复发患者),3年无病生存(DFS)率及总生存(OS)率分别为21%和31.5%;2例CR1后行同胞HLA全相合异基因外周血造血干细胞移植(allo-HSCT),至今仍无病存活(58和66个月)。除M3、移植及未化疗患者外,余18例初诊白细胞计数(WBC)10×109/L者较WBC≥10×109/L者OS长(P=0.03),DFS也较长(P=0.002);经1-2诱导化疗达CR1患者OS较长(P=0.002)。结论:8三体在原发性M5中发病率高于其它亚型,而且预后不良。发病时WBC≥10×109/L为高危因素。8三体合并RARA+的M3患者生存期长。伴8三体原发性AML达CR后尽可能行allo-HSCT。8三体可能增加非M3的预后风险,合并FLT3、MLL、HOX11、C-kit和NPM1等对预后有重要影响。     

老年急性髓性白血病的临床特点及疗效观察

目的:分析老年急性髓性白血病(AML)的临床特点以及不同化疗方案的疗效。方法:选取132例年龄≥60岁的老年AML患者,其中由骨髓增生异常综合征(MDS)转化而来的AML11例,低增生性AML17例。AML(除M3予以全反式维甲酸治疗外)分别采用HA、AA、DA、IDA、MA、CAG等作为诱导方案。结果:起病时以乏力、头晕、气促、胸闷、发热症状最多见,大多合并基础疾病,FAB分型以M2、M5型常见,颅内出血及重度感染是老年AML早期死亡的最主要原因。老年AML完全缓解率为48.0%,住院化疗期间早期病死率为36.4%。CAG方案对老年低增生AML有较好的疗效,IDA、MA等较强的方案可以提高缓解率,延长无病生存期。结论:老年性AML临床表现不典型,易误诊、漏诊。对老年AML患者应采用个体化的治疗方案,以提高患者的生存质量,减少化疗的毒副作用。     

87例成人Ph染色体阴性ALL预后影响因素分析

目的:探讨影响成人费城(Ph)染色体阴性急性淋巴细胞白血病(ALL)患者总完全缓解(CR)、复发、无病生存(DFS)和总生存(OS)率的因素及后续异基因造血干细胞移植(allo-HSCT)对预后的影响。方法:收集本院收治的87例成人Ph阴性ALL患者的临床资料进行回顾性分析,诱导化疗方案为CHOP、左旋门冬酰胺酶(L-Asp),巩固化疗方案为CHOP+改良Hyper-CVAD或甲氨蝶呤治疗。巩固化疗3-6个疗程后,45例(51.72%)患者采用allo-HSCT治疗,42例(48.28%)患者继续维持巩固化疗。存活患者平均随访时间为40.13(3-60)个月。结果:87例患者中,早期死亡1例(1.15%)。86例可评估患者中,1个疗程结束达CR者为68例(79.07%),总CR达80例(93.02%)。多因素回归分析结果发现,肝脾/淋巴结肿大、白细胞计数≥100×109/L是患者总CR的影响因素(均P0.05)。80例CR患者中,复发27例(33.75%);5年OS为47.50%,DFS为45.00%。多因素回归分析结果还发现,诱导化疗未应用L-Asp、诊断时合并中枢神经系统白血病、未行allo-HSCT、诱导化疗4周后未达CR是患者复发、生存预后不良的影响因素(均P0.05)。以是否合并中枢神经系统白血病、诊断时白细胞计数是否高于100×109/L、是否行L-Asp诱导化疗、诱导化疗4周后是否达CR等4个预后因素对患者进行分组:无不良预后因素为低危组,伴有1个不良预后因素为中危组,伴有2-4个不良预后因素为高危组。统计结果发现,低危组是否行alloHSCT治疗对OS、DFS并无明显影响(均P0.05);中、高危组行allo-HSCT治疗的患者OS、DFS较无alloHSCT治疗者明显升高(均P0.05)。结论:合并中枢神经系统白血病、白细胞计数偏高(≥100×109/L)、未行LAsp诱导化疗、化疗4周后未达CR、后续未行allo-HSCT治疗均是成人Ph阴性ALL患者的影响因素,对伴有上述不良预后因素的患者应积极采取allo-HSCT治疗。     

减半剂量CAG方案治疗高龄老年急性髓细胞白血病临床研究

目的探讨减半剂量的阿克拉霉素、阿糖胞苷和重组人粒细胞集落刺激因子组成的CAG方案治疗老年人急性髓系白血病（AML）的疗效和安全性。方法75岁以上老年AML初治28例,采用减半剂量CAG化疗方案诱导及巩固治疗。结果完全缓解17例,部分缓解6例,未缓解5例,完全缓解率60．7％,总有效率82．1％。治疗相关死亡3例。在染色体核型预后良好和预后中等组近期疗效与标准剂量CAG方案相似,且核型预后良好组疗效优于预后中等组。结论减半剂量CAG方案治疗高龄老年AML缓解率高,不良反应轻,患者耐受性好。     

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.     

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.     

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.     

Clinical Pharmacokinetics of Morphine

Morphine, the most widely used mu-opioid analgesic for acute and chronic pain, is the standard against which new analgesics are measured. A thorough understanding of the pharmacokinetics of morphine is required in order to safely and effectively use this analgesic in a wide variety of patients with different levels of organ function. A MEDLINE search was conducted to identify literature published between 1966 and January 2002 relevant to the pharmacokinetics of morphine. These publications were reviewed and the literature summarized regarding unique and clinically important elements of morphine disposition relative to its parenteral administration (including intravenous, intramuscular, subcutaneous, epidural and intrathecal administration), absorption profile (immediate release, controlled release, and sublingual/buccal, and rectal administration), distribution, and its metabolism/ excretion. Special populations, including infants, elderly, and those with renal/liver failure, have a unique morphine pharmacokinetic profile that must be taken into account in order to maximize analgesic efficacy and reduce the risk of adverse events.