自体造血干细胞移植治疗难治性恶性淋巴瘤疗效观察

目的探讨自体外周血造血干细胞移植(APBSCT)治疗难治性恶性淋巴瘤的临床疗效。方法APBSCT治疗难治性恶性淋巴瘤46例,采用环磷酰胺 阿霉素 长春新硷 泼尼松(CHOP)方案化疗加粒细胞集落刺激因子(G-CSF)动员外周血造血干细胞。结果43例获造血重建,完全缓解(CR)26例,占56.52%,部分缓解(PR)17例,占36.95%,1例死于肝静脉闭塞,2例死于严重感染,移植相关死亡率6.52%。结论APBSCT治疗难治性恶性淋巴瘤具有较好疗效。     

自体外周血造血干细胞移植治疗恶性淋巴瘤30例分析

1994至2003年我们用超大剂量化疗联合外周血造血干细胞移植(APBSCT)治疗恶性淋巴瘤30例。现报告如下。     

自体外周血干细胞移植联合大剂量化疗治疗恶性淋巴瘤31例分析

【目的】分析自体外周血造血干细胞移植(autologous peripheral blood stem cell transplantation,APB-SCT)治疗恶性淋巴瘤的临床疗效及安全性。【方法】采用APBSCT联合大剂量化疗治疗恶性淋巴瘤31例。平均4周期常规诱导化疗后行APBSC动员及采集。动员方案:非霍奇金淋巴瘤(NHL)患者采用常规剂量CHOP方案,其中环磷酰胺(CTX)增至2.5 g/m2;霍奇金淋巴瘤(HD)患者采用高剂量单药CTX 4 g/m2。化疗后给予粒细胞集落刺激因子(G-CSF)3.5~5μg/kg。当外周血白细胞(WBC)计数达(2~5)×109/L,单核细胞(MNC)计数达20%~30%时分离外周血造血干细胞。预处理方案:异环磷酰胺(IFO)12 g/m2或CTX 4 g/m2,阿糖胞苷(Ara-c)4.5 g/m2,足叶乙甙(Vp-16)0.75 g/m2。移植后对原发灶直径大于4 cm或有肿瘤残留的病灶给予局部补量放疗。【结果】31例患者移植后缓解时间为1~108个月,中位缓解期43个月。其中1年无病生存26例(83.9%),2年23例(74.1%),3年21例(67.7%)。最长存活108个月。全组无移植相关死亡。【结论】APB-SCT联合大剂量化疗治疗恶性淋巴瘤的疗效明显优于常规化疗且安全性高值得推广。     

自体外周血造血干细胞移植的护理

目的:探讨自体外周血造血干细胞移植(APBSCT)治疗复发难治性淋巴瘤过程中护理方法。方法:我科对9例非霍奇金淋巴瘤患者实施自体外周血造血干细胞移植,并进行超大剂量化疗(HDCT),为此,我们开展全环境保护、层流病房护理、超大剂量化疗护理、干细胞回输护理及移植心理护理。结果:9例患者都恢复造血,全部移植成功,均未发生严重感染,效果显著。结论:自体外周血造血干细胞移植难度和风险较大,通过针对移植的心理、预处理化疗、移植后的抗感染、出血进行护理,可提高移植的成功率,层流病房全环境保护性护理是自体造血干细胞移植成功的关键。     

FLAG联合改良BUCY预处理方案的异基因造血干细胞移植治疗难治复发恶性血液病疗效分析

本研究旨在观察应用FLAG联合改良的BUCY预处理方案行异基因造血干细胞移植治疗难治复发或高危恶性血液病的疗效。对10例难治复发或高危恶性血液病患者自愿接受FLAG联合改良的BUCY预处理的异基因造血干细胞移植的疗效进行分析。10例中复发2例(早期复发1例,淋巴瘤进展1例),难治7例(2例CR2,1例CR3,2例PR,2例NR),1例CR1但为高危病例。10例患者中包括急性髓性白血病8例(M11例,M25例,M61例,恶性骨髓增生异常综合征伴骨髓纤维化1例),前T淋巴母细胞淋巴瘤/白血病1例,脾边缘带淋巴瘤IVB1例。结果表明,10例全部顺利植入,10例患者除2例死亡(1例死于肺部感染,1例死于真菌肺炎、渗漏综合征、多脏器功能衰竭),其余8例无复发,中位生存时间为164天(57-442天)。结论:应用FLAG联合改良的BUCY预处理方案(清肿瘤性方案)的异基因造血干细胞移植治疗难治复发或高危的恶性血液病可取得良好的疗效。     

自体外周血干细胞移植治疗难治性恶性淋巴瘤的护理

外周血干细胞移植(APBSCT)支持下的超剂量化疗,是目前治疗恶性淋巴瘤等实体瘤最为有效的方法.由于移植前采用超剂量的化疗和致死量的放疗预处理,在尽可能多的杀死肿瘤细胞的同时,造成骨髓造血功能急性衰竭,免疫功能严重受抑制.因而移植是否成功,除移植前患者的病情、预处理方案和合并症的治疗计划外,全环境保护及移植后的病情观察和护理是移植成功的关键.现将江苏省泰州市人民医院2004年9月以来开展的3例难治性恶性淋巴瘤患者APBSCT护理体会报告如下. ……     

造血干细胞／细胞因子支持下高剂量、多循环化疗治疗恶性淋巴瘤16例

目的：探讨造血干细胞及细胞因子支持下高剂量、多循环化疗对中高度恶性淋巴瘤（ML）的疗效。方法：16例ML以1.5倍常规化疗剂量＋粒细胞集落刺激因子（G－CSF）动员后采集外周血造血干细胞,病人分别于第28天、56天接受2倍及2.5倍大剂量化疗后应用G－CSF及回输造血干细胞。结果：治疗组16例中可评价病例15例,其中完全缓解10例（66.67%）,部分缓解3例（20％）,稳定2例(13.33%);无病生存7例（9－38个月,中位生存期26个月）,疗效高于常规化疗组,且免疫损伤少,造血恢复快,并发症少。结论：对中高度恶性的ML,在造血干细胞／细胞因子的支持下,采用常规2－3倍剂量、3次循环的强化治疗,可提高治疗周期内平均剂量强度,疗效高于常规化疗,且该方案可在普通病房实施,治疗风险与费用均较低。     

自体外周血造血干细胞移植治疗高危难治恶性淋巴瘤96例疗效分析

目的探讨恶性淋巴瘤患者接受自体外周血造血干细胞移植的疗效及预后因素。方法收集96例恶性淋巴瘤患者病理资料,常规化疗后均接受自体外周血造血干细胞移植。统计患者的基本临床资料、移植前相关指标及预后情况,采用SPSS19.0统计软件对预后情况进行Kaplan-Meier生存分析,应用Cox比例风险模型进行预后因素分析,回顾性的分析总体疗效及预后因素。结果 96例患者中94例顺利完成造血重建,中性粒细胞重建时间为7~19d,平均9d;血小板重建时间10~37d,平均16d;随访时间0~74个月,平均26个月。3年总体生存(OS)率为86.4%,3年无进展生存(PFS)率为70.3%。单因素分析显示IPI评分大于2分、移植前未能达到完全缓解(CR)、乳酸脱氢酶(LDH)高于正常水平、骨髓浸润等为不良预后因素,多因素分析显示移植前状态及LDH水平为独立影响因素。结论大剂量化学治疗联合自体外周血造血干细胞移植是高危难治恶性淋巴瘤安全、有效的治疗方法。移植前能否达到CR、LDH水平为移植疗效的影响因素。     

儿童自体外周血造血干细胞移植的护理

自体外周血造血干细胞移植(APBSCT)是对患者进行超大剂量化疗或全身放疗预处理后,将正常外周血造血干细胞植入患者体内,使其重建正常造血及免疫功能的治疗方法[1].由于儿童对大剂量化疗和全身照射治疗不良反应敏感性较高,对护理工作提出了更高要求.     

自体造血干细胞移植联合大剂量放化疗治疗中高度恶性非何杰金淋巴瘤5例

自体造血干细胞移植(AHSCT)联合大剂量放化疗治疗非何杰金淋巴瘤(NHL)5例，包括4例第一次完全缓解(CR)中、高度恶性NHE；1例(CR)高度恶性NHL合并淋巴瘤白血病。其中自体骨髓移植(ABMT)4例，自体外周血干细胞移植(APBSCF)1例。所有病例均移植成功。同时部分病人已获得长期生存，4例ABMT患者无病生存124月、122月、113月、77月；1例auto-PBSCT患者无病生存15月。结果显示AHSCT联合大剂量放化疗是治疗中、高度恶性淋巴瘤的有效方法。     

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.     

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.     

手转胎头术失败的原因与分娩结局临床分析

目的 探讨手转胎头术失败的原因与分娩结局.方法 选择2008年1月至2010年12月于我院住院分娩的持续性枕横位、枕后位产妇198例,根据行手转胎头术后结果分为成功组126例、失败组72例.比较两组分娩结局,对比分析失败原因.结果 失败组胎儿体质量≥3500 g的发生率[76.4％(55/72)]明显高于成功组[31.7％(40/126)],差异有统计学意义(x2=30.177,P=0.001)、失败组宫缩乏力发生率[58.3％(42/72)]高于成功组[38.1％ (48/126)],差异有统计学意义(x2=7.569,P=0.006)、失败组骨盆临界或轻度狭窄发生率[38.9％ (28/72)]高于成功组[23.8％(30/126)],差异有统计学意义(x2 =5.030,P=0.002)、失败组手转胎头时机不当(宫口开大＜6 cm、胎头位于坐骨棘上及宫口开大8～10 cm、胎头位于坐骨棘下≥2 cm)发生率[61.1％(44/72)]高于成功组[38.9％(49/126)],差异有统计学意义(x2=9.084,P=0.003).失败组母儿并发症(产后出血、产褥病率、胎儿窘迫、新生儿窒息)发生率高于成功组(x2 =9.586,P=0.002、x2=9.334,P=0.002、x2=5.910,P=0.015、x2=5.240,P=0.022)、失败组剖宫产发生率[72.2％(52/72)]明显高于成功组[34.1 ％(43/126),x2=26.641,P=0.001)].结论 手转胎头术能使难产变顺产,降低剖宫产率,减少母儿并发症,但须积极预防、处理导致手转胎头术失败的原因,对矫正失败后继续矫正及试产应慎重.     

Evidence-Based Pain Management and Palliative Care in Issue Four for 2009 of The Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly. Issue 4 for 2009 contains 4027 complete reviews, 1906 protocols for reviews in production, and 11447 one-page summaries of systematic reviews published in the general medical literature. In addition, there are citations of 600,000 randomized controlled trials, and 12,200 cited papers in the Cochrane methodology register. The health technology assessment database contains over 7500 citations. This edition of the Library contains 90 new reviews, of which 19 have potential relevance for practitioners in pain and palliative medicine.     

Wie zuverlässig sind Angaben zu nichtentzündlichen ausgedehnten Schmerzen?

ZusammenfassungFragestellung Es wurde geprüft, wie sich der Differenziertheitsgrad zweier Schmerzmessmethoden auf Angaben zur Ausgedehntheit klinischer Schmerzen auswirkt. Zugleich wurde der Referenzzeitraum variiert, über den die Patienten berichten sollten.Methode Erfasst wurde der Einfluss zu Lasten der Befragungsdifferenziertheit durch den Vergleich zweier Körperschema-Bildvorlagen. Drei Referenzzeiträume (Schmerz aktuell, letzte Woche, letztes halbes Jahr) wurden vorgegeben.Ergebnisse Patienten mit ausgedehnten Schmerzen gaben bei differenzierter Befragung um so mehr Schmerzen an, je weiter die Schmerzen zurück lagen und je größer der Berichtszeitraum war. Patienten mit gelenknahen Schmerzen gaben bei hoch differenzierter Befragung weniger ausgedehnte Schmerzen in der Vergangenheit an als bei globaler Einschätzung. Patienten mit Rückenschmerzen berichteten bei differenzierter Befragung zum aktuellen Schmerz über weniger ausgedehnte Schmerzen als bei globaler Befragung.Schlussfolgerung Die Angaben zur Schmerzausdehnung variieren vor allem bei Patienten mit ausgedehnten Schmerzen in Abhängigkeit von der Differenziertheit der Befragung. In diesen Fällen ist die Wahrscheinlichkeit erhöht, dass sich die Beschwerdesymptomatik zumindest teilweise erst in der Reaktion auf die situativen Befragungsbedingungen konstituiert und daher nicht auf andere Befragungsbedingungen generalisiert werden kann.