单剂赛尼哌联合低剂量普乐可复预防肾移植急性排斥反应的临床观察

目的 :观察单剂赛尼哌联合低剂量普乐可复 (FK5 0 6)对肾移植急性排斥反应 (AR)的预防作用及其安全性。方法 :将同期首次肾移植受者随机分成两组 ,每组 2 0例。 (1)观察组 (单剂赛尼哌联合低剂量FK 5 0 6+MMF+Pred) ;(2 )对照组 (常规剂量FK5 0 6+MMF +Pred)。两组受者HLA错配≤ 3 ,CDC及PRA试验均阴性 ,且两组间性别、年龄、原发病、冷热缺血时间、血透时间、HBsAg阳性率均无统计学差异。应用微粒子酶免疫分析法测定所有受者口服FK5 0 6后 12h的血药谷浓度 ,观察组和对照组谷浓度的控制范围分别为 5～ 10 μg/L和 10～ 15 μg/L。观察术后 60d排斥反应的发生、药物的肾毒性和肝功能异常情况。结果 :观察组和对照组谷浓度均值分别为 (7 2±2 6) μg/L和 (12 1± 3 8) μg/L ,两组全血FK5 0 6谷浓度均值差异具有显著性 (P <0 0 5 )。术后发生急性排斥反应 ,观察组 1例次 ,对照组 2例次 (P >0 0 5 ) ;肾毒性 ,观察组 0例次 ,对照组 5例次 (P <0 0 5 ) ;肝功能异常 ,观察组4例次 ,对照组 6例次 (P >0 0 5 )。结论 :术前使用单剂赛尼哌 ,术后FK5 0 6谷浓度维持在 5～ 10 μg/L水平 ,既能有效预防AR发生 ,又能减少FK5 0 6的肾毒性     

肾移植术后早期肝功能不良的免疫抑制治疗对策

目的探讨肾移植术后早期肝功能不良患者免疫抑制方案的策略。方法将肾移植术后早期(术后两周以内)发生肝功能不良的36例患者,依据免疫抑制方案分为:①FK506 MMF组(A组):21例术后即刻采用,FK506起始量为0.15~0.2mg/(kg·d),血药浓度谷值(Co)控制在6~10μg/L,3个月后降为5~8μg/L,MMF1.0~2.0g/d;3例因初始使用CsA Aza发生肝功能损害而切换;②CsA MMF组(B组):12例,CsA起始剂量5~7mg/(kg·d),术后3个月内Co控制在200~300μg/L。所有病例常规使用保肝利胆治疗。结果A组24例术后肾功能早期恢复,未发生急性排斥反应,治疗3周内高胆红素血症均消失,4周后ALT全部恢复正常。随访3~6个月,肝功能全部保持正常,人/肾存活率100%。B组发生急性排斥反应1例,而肝功能不良易反复发作。结论肾移植术后早期肝功能不良患者联合使用低剂量FK506 MMF,既不加重肝功能损害,也不增加急性排斥反应的发生,是合并慢性肝炎或潜在肝功能异常高危因素移植受者的较理想的免疫抑制方案。     

环孢素血药浓度水平对重型再生障碍性贫血患者免疫抑制治疗近期疗效的影响

目的 研究环孢素(CsA)血药浓度水平是否影响重型和(或)极重型再生障碍性贫血(SAA/VSAA)患者免疫抑制治疗(IST)早期疗效,探讨CsA的合理使用方法.方法 回顾性分析兔源抗胸腺细胞球蛋白(r-ATG)联合CsA方案初始治疗的90例SAA/VSAA患者临床资料,分别比较IST后6个月获得治疗反应和未获治疗反应患者间CsA血药浓度水平的差异,以及不同CsA血药浓度对SAA/VSAA患者获得治疗反应的影响.结果 ①初始CsA血药浓度对SAA/VSAA患者近期IST疗效无影响,但与SAA患者更早获得治疗反应相关;②获得治疗反应组患者IST第3个月CsA谷值血药浓度(C0)和峰值血药浓度(C2)均较未获治疗反应组患者明显增高(P值分别为0.024和0.009),IST其他时间段CsA血药浓度平均水平两组间差异无统计学意义(P＞0.05).③IST第3个月C0≥200 μg/L组患者治疗反应率为82.4％,明显高于C0 150～200μg/L组的55.6％ (P =0.023)和C0＜150 μg/L组的59.3％ (P =0.046);IST第3个月C2≥700 μg/L组患者治疗反应率为80.5％,明显高于C2 ＜700 μg/L组的55.3％ (P =0.012).结论 CsA血药浓度水平影响SAA/VSAA患者近期疗效;IST第3个月CsA血药浓度水平对患者获得早期疗效尤为重要,维持CsA血药浓度C0≥200 μg/L、G2≥700 μg/L或可进一步提高SAA/VSAA患者IST治疗反应率.     

剖宫产术后经静脉镇痛对母婴的影响

目的观察剖宫产术后经静脉镇痛对宫缩、泌乳及胎儿体重的影响。方法选择 3 0例健康足月无妊娠合并症 ,并发症在硬膜外麻下行剖宫产产妇 ,术后自愿接受静脉镇痛为镇痛组 ,选择同期条件相同未行静脉镇痛的产妇3 0例为对照组。镇痛组在剖宫产术后 ,采用病人自控静脉镇痛 (PCIA)给予芬太尼 ,芬太尼持续剂量 2 0～ 2 5 μg/h ,镇痛时间 48h ,采用放射免疫法测血浆催乳素 (PRL)浓度。结果镇痛组术后第 1天PRL增高 ,显著高于对照组(P <0 .0 5 ) ,镇痛组初乳时间较对照组提前(P <0 .0 5 ) ,两组产后流血、宫缩、肠蠕动恢复时间 ,婴儿体重增减无显著性差异 (P >0 .0 5 ) ,但镇痛组术后出现呕吐的产妇高于对照组 (P <0 .0 1)。结论剖宫产术后采用芬太尼PCIA ,能使初乳时间及PRL分泌提前 ,不影响宫缩 ,对婴儿亦无不良影响     

芬太尼加异丙酚与氯胺酮加羟丁酸钠用于小儿手术的麻醉效果比效

目的比较芬太尼加异丙酚与氯胺酮加羟丁酸钠用于小儿各类手术的麻醉效果。方法患儿 6 0例 ,随机分为两组 ,A组 (n =31 )用芬太尼 2 μg/kg、阿曲库铵 0 .5mg/kg、异丙酚 2～ 3mg/kg静注诱导插管 ,然后微泵持续注射异丙酚 1 0～ 1 2mg/ (kg·h)维持 ,30～ 4 5min间断静注阿曲库铵 0 .2 5～ 0 .5mg/kg ,根据患儿的麻醉深度作调整。B组 (n =2 9)静注氯胺酮 1～ 1 .5mg/kg、羟丁酸钠 80mg/kg、阿曲库铵 0 .5mg/kg作诱导插管 ,用微泵 0 .36～ 0 .6mg/ (kg·h)速率输注氯胺酮维持 ,酌情追加羟丁酸钠 ,间断给予肌松剂。分别记录两组病例在用药前后的心率 (HR)、收缩压 (SBP)、舒张压 (DBP)、血氧饱和度、麻醉效果、停药后苏醒时间、手术结束至导管拔除时间、苏醒后再入睡等情况。结果A组病例麻醉效果良好 ,但诱导后SBP、DBP、HR降低 ;B组用药后HR增快 ,术中肢体有不自主的躁动现象 ,苏醒时间及拔管时间明显延长。结论芬太尼加异丙酚用于小儿各类手术 ,麻醉效果好 ,与氯胺酮加羟丁酸钠相比 ,麻醉效果确切 ,可控性强 ,苏醒迅速     

特重烧伤病人血清蛋白变化与败血症的关系

目的探讨烧伤病人血清蛋白水平变化与败血症的发生、发展和预后的关系。方法回顾性分析 40例特重烧伤病人的血清蛋白值。结果2 2例并发败血症的病人血清蛋白水平低于未发生败血症组 (18例 ) ,其中因败血症而死亡的 8例病人低蛋白血症未得到纠正 ;血清白蛋白降低值与其败血症的发生密切相关 (P <0 .0 1) ,血清球蛋白和总蛋白水平也与之相关 (P <0 .0 5 )。结论严重烧伤病人烧伤后应尽早纠正低蛋白血症 ,以保证白蛋白在 30 g/L以上 ,总蛋白在 5 0g/L以上为宜 ;在整个病程中 ,应积极给予营养支持治疗 ,维持正常血清蛋白水平。     

不同免疫抑制方案对高龄肾移植受者长期存活的临床研究

目的 :回顾分析不同免疫抑制方案对高龄肾移植受者长期人 /肾存活的影响。方法 :5 4例高龄肾移植患者分为两组 :组1术后用药方案为环孢素A(CsA) +硫唑嘌呤 (Aza) +泼尼松 (Pred) 30例 ;组 2术后用药方案为抗淋巴细胞球蛋白 (ALG) +CsA+霉酚酸酯 (MMF) +Pred 2 4例。观察患者 1、3、5年的人 /肾存活率 ,急性排斥发生率 ,移植肾功能 ,病毒感染发生率以及血脂情况。结果 :组 1与组 2相比 ,1、3、5年的人 /肾存活率分别为 86 .7% / 80 %、76 .7% / 6 0 %、6 0 % / 4 3.3%vs 95 .8% / 95 .8%、91.7% / 87.5 %、83.3% / 75 % ,两组病人同一时期人 /肾存活率相比 ,有显著差异 (P <0 .0 5 ) ;急性排斥率分别为 4 0 %vs 2 5 % ,(P <0 .0 5 ) ;1、3、5年时血清肌酐 (SCr)值 92± 15 .3μmmol/L ,118± 2 3.5 μmmol/L ,16 3± 31.9μmmol/Lvs 88±17.4 μmmol/L ,10 2± 2 1.7μmmol/L ,12 4± 2 6 .3μmmol/L ,两组病人分别在第 3、5年时的Cr值有显著差异 (P <0 .0 5 ) ;5年内病毒感染发生率分别为 2 3.3%vs 2 0 .8% ,无显著差异 (P >0 .0 5 ) ;高脂血症发生率 70 %vs 4 5 .8% ,有显著差异 (P <0 .0 5 )。结论 :ALG +CsA +MMF +Pred方案安全、有效 ,优于CsA +Aza +Pred方案     

肾移植术后应用他克莫司对血糖的监测与护理

目的　监测肾移植术后应用免疫抑制药物他克莫司 (FK5 0 6)后对患者血糖的影响及提出相应的护理重点。方法　随机对 162例无糖尿病史的肾移植患者分成两组。第 1组 82例患者 ,术后应用FK5 0 6;第 2组 80例 ,术后应用环孢素 (CsA)。对所有患者进行连续、定时、动态的血糖、尿糖及血药浓度的监测。结果　应用FK5 0 6组有 13例患者出现不同程度的血糖增高 ,其中 2例并发切口感染。应用CsA有 3例出现不同程度的血糖增高。结论　应用FK5 0 6后 ,要严密监测血糖、尿糖值 ;并观察和分析全身症状 ,积极防治感染和指导患者正确服药与饮食。     

经尿道气化加电切术治疗前列腺增生症

目的探讨良性前列腺增生症 (BPH)的有效治疗方法。方法采用经尿道前列腺气化电切 (TU VP)加经尿道前列腺电切术 (TURP)联合治疗BPH患者 2 18例。结果平均手术时间 70 (2 0～ 15 0 )min ,2例术中需输血 2 0 0ml,均为Ⅲ度增生者 ,切除前列腺组织平均重量 5 0 (30～ 15 0 ) g ,未发生电切综合征 ,术后 3～ 5d拔除导尿管 ,排尿均通畅 ,随诊 1～ 6个月 ,国际前列腺症状评分 (IPSS)由术前 (2 8.5± 2 .5 )分下降至术后 (8.5±0 .5 )分 ,最大尿流率由术前平均 (6 .2± 2 .0 )ml/s升至术后 (17.5± 1.5 )ml/s,B超复查约 30例仍有剩余尿 10～ 4 0ml,平均 17.5ml,术后继发性出血 8例 ,尿道狭窄 12例 ,暂时性尿失禁 10例。结论TUVP加TURP联合治疗BPH可综合两者的优点 ,疗效显著 ,并发症少 ,安全性高 ,是治疗BPH的有效方法     

急性间质性肾炎肾间质中淋巴细胞亚型分析

分析急性间质肾炎 (AIN)肾间质中浸润的淋巴细胞亚型的意义。方法19例AIN患者根据肾活检前的血清肌酐值 (SCr)分为SCr >5 0 0 μmol/L组 (A组 )及SCr <5 0 0 μmol/L(B组 ) ;根据病人入院 30d时的血清肌酐分为SCr恢复正常组 (Ⅰ组 )及SCr未恢复正常组 (Ⅱ组 )。所有病人行肾穿刺活检 ,肾间质淋巴细胞亚型的检测采用SABC法。结果病理改变均表现为不同程度的间质炎性细胞浸润 ,以淋巴细胞为主 ,淋巴细胞亚型以CD 4 和CD 8细胞居多 ,CD 2 0 细胞较少 ;A组肾间质中的淋巴细胞明显多于B组 (P<0 .0 5 ) ;Ⅱ组间质中CD 4 及CD 8细胞明显多于Ⅰ组 (P <0 .0 1)。结论间质浸润淋巴细胞越多 ,肾功能越差 ,AIN的预后也越差 ;细胞免疫在AIN发病机制中起着重要作用。     

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.     

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.     

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.