恶性血液病合并侵袭性真菌感染73例治疗分析

目的探讨恶性血液病患者合并侵袭性真菌感染(IFI)应用氟康唑、伊曲康唑和两性霉素B治疗的结果及其影响因素。方法选择南方医科大学附属南方医院1992-01~2004-10收治的恶性血液病合并IFI患者73例,单用常规剂量的氟康唑33例、伊曲康唑26例、两性霉素B14例;氟康唑治疗无效者改用伊曲康唑9例和两性霉素B6例,伊曲康唑治疗无效改用两性霉素B和脂质体两性霉素B16例,47例同时应用了粒细胞集落细胞刺激因子(G-CSF)治疗至白细胞正常,37例联合静脉注射丙种球蛋白。结果73例IFI总的治愈率和有效率分别为53·4%和63·0%,在各诊断组间差异无显著性意义(P>0·05)。单用氟康唑治疗组的有效率显著低于伊曲康唑和两性霉素B治疗组,分别为39·4%、53·9%和57·1%(P<0·05);用氟康唑治疗无效改用伊曲康唑或两性霉素B治疗的有效率分别为77·8%和83·4%。结论伊曲康唑和两性霉素B治疗IFI的疗效相似,明显高于氟康唑;两性霉素B的副反应多。抗真菌的有效率在确诊组、临床诊断组和拟诊组之间差异无显著性意义。     

不同方案对激素无效或复发的原发免疫性血小板减少症的疗效分析

目的:探讨不同方案对激素无效或复发的原发免疫性血小板减少症(ITP)患者的临床疗效。方法:回顾性分析376例初始采用糖皮质激素治疗的成人ITP患者,其中对激素治疗无效或复发者88例,此88例患者中66例患者数据资料齐全可供分析,评估进一步治疗的疗效,并比较不同治疗方案的疗效。结果:进一步治疗的总有效率为56.1%(37/66)。按照不同的治疗方案分为6组,各组有效率分别为:激素58.3%(14/24),重组人血小板生成素12.5%(1/8),利妥昔单抗37.5%(3/8),脾切除90.9%(10/11),免疫抑制剂0(0/3),联合治疗75.0%(9/12)。比较6组不同治疗方案的有效率,差异有统计学意义(P=0.003)。结论:对于激素治疗无效或复发的ITP,各种不同治疗方案中脾切除疗效可靠,激素仍有较好的效果,但要注意其风险,此外联合治疗也有不错的疗效。     

CTPA联合CTBA一次性造影对咯血诊断价值的研究

目的分析16排螺旋CT肺动脉(PA)联合支气管动脉(BA)一次性造影对咯血的诊断意义。方法对31例咯血患者一次性注射照影剂,采用16排螺旋CT机先行CT肺动脉造影(CTPA),后行CT支气管造影(CTBA),处理图像后,阅读薄层轴位与重组图像判断PA与BA的变化,将CTPA联合CTBA扫描结果与DSA及活检结果比较。结果 31例患者中CTPA检出PA异常8例,4例肺栓塞、2例右下肺PA阻塞、PA畸形与PA平滑肌肉瘤各1例。CTBA共检出异常动脉72支,其中33支右侧异常,36支左侧异常,3支非支气管体循环动脉异常。CTBA诊断出11例BA增粗,10例支气管扩张,2例炎性病灶伴空洞。CTPA联合CTBA检出的异常血管、异常血管起源、病因与DSA、病理诊断符合率分别为96.39%、100.00%、90.32%。结论 CTPA联合CTBA一次性造影可清晰显示PA及BA病变、起源、走形等,可准确判断出咯血病变动脉及病因。     

基层医院慢性咳嗽经验性治疗的程序

目的探讨在基层医院建立慢性咳嗽经验性治疗的程序。方法从146例门诊就诊的慢性咳嗽患者中筛选出102例原因不明者,依据不同的疑诊病因划分为四组,按照既定程序分别实施经验性治疗,统计治疗后总有效率,并依据有效的治疗方案推断相应病因,初略了解病因分布情况。结果门诊就诊的146例慢性咳嗽患者中有44例患者经筛选明确了病因;102例不明原因慢性咳嗽患者接受了经验性治疗,73例(71.6%)患者治疗有效;推断为咳嗽变异性哮喘-嗜酸细胞性支气管炎-变应性咳嗽(CVA-EB-AC)者38例(37.3%),推断为上气道咳嗽综合征(UACS)者27例(26.5%),推断为胃食管反流性咳嗽(GERC)者8例(7.8%);治疗无效者判定为无法推断,共计29例(28.4%)。结论经验性治疗是一种简单有效的慢性咳嗽治疗方法,易于在基层医院推广,但治疗前应尽可能完善鉴别诊断,治疗方案需规范。     

益气生血法联合FOLFOX化疗对胃癌肿瘤标志物和免疫调控的影响

[目的]观察益气生血法联合FOLFOX化疗对胃癌肿瘤标志物和免疫调控的影响。[方法]选取我院68例中晚期胃癌患者作为研究对象,分为观察组、对照组(各34例)。对照组采用FOLFOX化疗方案进行治疗,观察组采用益气生血法联合FOLFOX化疗进行治疗,比较2组的疗效、肿瘤标志物癌胚抗原(CEA)、糖类抗原(CA12-5、CA15-3、CA19-9)、血细胞簇分化抗原(CD3~+、CD4~+、CD8~+、CD4~+/CD8~+)及自然杀伤细胞(NK)的水平。[结果]观察组总有效率为76.5%(26/34)显著高于对照组的50.0%(17/34)(P0.05)。治疗前2组CEA、CA12-5、CA15-3、CA19-9比较,差异无统计学意义;治疗后2组CEA、CA12-5、CA15-3、CA19-9均下降(P0.05);治疗后观察组CEA、CA12-5、CA15-3、CA19-9均低于对照组(P0.05)。治疗前2组CD3~+、CD4~+、CD8~+、CD4~+/CD8~+及NK细胞比较差异无统计学意义,治疗后观察组CD3~+、CD4~+、CD4~+/CD8~+及NK细胞均增高,CD8~+下降;对照组CD3~+、CD4~+、CD4~+/CD8~+及NK细胞均下降,CD8~+增高(P0.05);治疗后观察组免疫调控指标均优于对照组(P0.05)。[结论]益气生血法联合FOLFOX化疗改善胃癌的疗效,降低血清中肿瘤标志物的表达,提高机体的免疫功能。     

射频消融治疗肝癌的近期疗效观察

目的探讨射频消融治疗肝癌的近期疗效及安全性。方法回顾性分析我科射频治疗的27例肝癌患者的资料。结果27例肝癌患者经射频消融治疗,一月后考核疗效发现达到显效者10例,有效13例(总有效率为85%)。其中肿瘤直径小于3cm的小肝癌4例,治疗后肿瘤均消失;肿瘤直径在3cm～5cm之间者9例,术后达到显效者4例(其中1例通过2次治疗后肿瘤消失),有效5例(有效率100%);在肿瘤直径5cm～10cm的患者中达到显效的1例,有效6例(有效率87.5%,7/8),无效1例;肿瘤直径大于10cm的患者中,达到显效的1例,有效2例(有效率为50%,3/6),无效3例。结论射频消融治疗肝脏肿瘤是一种疗效可靠、安全性较高的微创治疗技术,值得进一步推广应用。     

射频热疗配合热灌注化疗治疗老年恶性腹腔积液的临床疗效

目的探讨射频热疗配合热灌注化疗治疗老年恶性腹腔积液的临床疗效。方法选取老年恶性腹腔积液患者57例行射频热疗配合热灌注化疗治疗。结果治疗后,显效36.84%(21/57),有效50.88%(29/57),总有效率87.72%。老年患者腹水量由治疗前的中、大水平(分别为35和22例)转变为无34例、少18例、中4例以及大1例。治疗后CR、PR、SD、PD患者所占比例分别为49.1%(28/57)、40.4%(23/57)、10.5%(6/57)和0%。显效组6例出现副作用,有效组有9例患者出现副作用,无效组有1例患者出现副作用。患者出现白细胞下降、血小板下降、恶心呕吐、腹泻、BUN、Cr升高、肝损害、肾损害、手足综合征、脱发以及腹痛等副反应的比例分别为19.3%(11/57)、10.5%(6/57)、21.1%(12/57)、7.0%(4/57)、8.8%(5/57)、12.3%(7/57)、10.5%(6/57)、12.3%(7/57)、7.0%(4/57)以及15.8%(9/57)。结论射频热疗配合热灌注化疗治疗老年恶性腹腔积液疗效好,副作用的发生率较低。     

老年人大肠癌诊断及随访中肿瘤标记物联合检测的价值

目的　评价血清学肿瘤标记物对老年人大肠癌诊断和随访的价值。　方法　采用微粒酶免疫法检测 16 3例老年人大肠癌患者和 2 9例老年大肠良性疾病患者血清糖类抗原CA19 9、CA5 0、CA2 4 2及癌胚抗原的表达 ,对 4 2例行根治术的大肠癌患者进行随访。　结果　大肠癌患者血清糖类抗原CA19 9、CA5 0、CA2 4 2及癌胚抗原水平分别为 (45 2± 2 1 3)、(2 9 7± 17 6 )、(43 2± 37 6 ) μg/L和 (18 7± 12 4 ) μg/L ,均高于大肠良性疾病患者〔分别为 (8 4± 11 5 )、(7 7± 5 2 )、(9 1± 6 3) μg/L和 (2 5± 1 8) μg/L〕 ,并随病程进展逐渐增高 ;4种肿瘤标记物对诊断的敏感性与大肠癌的分期有关 ;平行联合检测可使诊断的敏感性提高至 83 5 % ,系列联合检测可使特异性提高至 88 7% ;肿瘤根治术后 ,肿瘤标记物显著下降 ;术后肿瘤标记物未降至正常者复发或转移率为 73 3% ,而术后再升高者复发或转移率为 85 2 %。　结论　上述 4种肿瘤标记物对老年人大肠癌的诊断和随访及监测肿瘤复发和转移有一定的价值。肿瘤标记物的联合检测有助于大肠癌早期诊断 ,可增加诊断的敏感性和特异性     

吉西他滨联合奥沙利铂或氟尿嘧啶治疗晚期胰腺癌临床观察

目的观察吉西他滨联合奥沙利铂(GEMOX方案)与吉西他滨联合氟尿嘧啶(GF方案)治疗晚期胰腺癌的近期疗效和不良反应。方法经病理组织学或细胞学证实的40例胰腺癌患者,随机对照分为GEMOX组和GF组,各20例。可评价疗效分别为15例和14例。GEMOX组给予吉西他滨1000mg/m2加生理盐水100ml,静脉滴注30min,第1,8,15d;奥沙利铂50mg/m2,静脉滴注,第1,8,15d。GF组给予吉西他滨1000mg/m2加生理盐水100ml,静脉滴注30min,第1,8,15d,氟尿嘧啶500mg/m2加5%葡萄糖液(GS)500ml,静脉滴注6h以上,第1~5d。结果两组患者性别、肿瘤病理类型及TNM分期具可比性。GEMOX组部分缓解(PR)2例,微效(MR)3例,稳定(D)6例,进展(PD)4例,治疗有效率达33.3%,中位生存期8.7个月,临床受益率(CBR)50.0%,肿瘤标志物CA19-9下降>50%占47.1%。GF组PR2例,MR3例,SD5例,PD4例,治疗有效率达35.7%,中位生存期10.1个月,CBR38.9%,CA19-9下降>50%占38.9%。经统计学比较,两组CBR差异有显著性(P<0.05)。主要不良反应为白细胞减少和血小板减少。结论吉西他滨联合奥沙利铂或联合氟尿嘧啶的治疗有效率、CBR较高,中位生存期较长,不良反应小。GEMOX的CBR较GF更高。     

单克隆抗体CD4及CD8联合环孢素A治疗重型再生障碍性贫血临床研究

目的探寻降低重型再生障碍性贫血(SAA)患者早期死亡率以及提高疗效的安全方案。方法采用单克隆抗体CD4、CD8联合环孢素A(CSA)(治疗组)治疗SAA21例,并与抗淋巴细胞球蛋白(ALG)联合CSA(对照组)治疗SAA20例进行比较。结果两组总有效率分别为76·2%与65·0%相近(P>0·05),但早期血象的恢复快于对照组(P<0·05),早期感染率低于对照组(P<0·05)。而发热反应、血清病反应等副作用则显著少于对照组(P<0·01)。结论单克隆抗体CD4、CD8联合CSA是安全方便有效的治疗SAA方案。     

A comparison of imipenem to ceftazidime with or without amikacin as empiric therapy in febrile neutropenic patients.

BACKGROUND--Neutropenic patients with cancer are traditionally treated with empiric antibiotic combinations when they become febrile. The availability of broad-spectrum antibiotics such as ceftazidime and imipenem has made it possible to initiate therapy with a single agent (monotherapy). The objectives of this trial were to compare ceftazidime and imipenem as single agents for the therapy of febrile episodes in neutropenic patients and to ascertain whether the addition of an aminoglycoside (amikacin) to either of these agents would provide an advantage. METHODS--A prospective clinical trial was conducted in which eligible neutropenic patients with cancer were randomized to one of four treatment arms: ceftazidime alone; imipenem alone; ceftazidime plus amikacin; and imipenem plus amikacin. Efficacy analysis was done for 750 assessable episodes. A multivariate logistic-regression analysis was also performed to examine the unique contribution of various prognostic factors. RESULTS--The overall response rates were 76% with imipenem plus amikacin, 72% with imipenem, 71% with ceftazidime plus amikacin, and 59% with ceftazidime alone. Single-organism gram-positive infections occurred in 101 of 750 episodes. Without a change in antibiotics, the response rates were 50% with imipenem, 40% with imipenem plus amikacin, 39% with ceftazidime plus amikacin, and 38% with ceftazidime. Most responded to vancomycin or other antibiotics, and the mortality associated with gram-positive infections was only 5%. Regardless of the antibiotic regimen, the majority of uncomplicated gram-negative infections responded to therapy and the majority of complicated gram-negative infections failed to respond. Multivariate logistic-regression analysis showed that recovery of the neutrophil count was the most favorable prognostic factor in a patient's response to infection, whereas the presence of gram-positive infection, acute leukemia, pulmonary or enteric infection, and therapy with ceftazidime were unfavorable factors. CONCLUSIONS--Single-agent therapy with imipenem is as effective as more conventional combination antibiotic therapy for the empirical treatment of febrile episodes in neutropenic patients with cancer.     

Piperacillin plus amikacin vs. piperacillin plus amikacin plus teicoplanin for empirical treatment of febrile episodes in neutropenic patients receiving quinolone prophylaxis.

A prospective, randomized trial was initiated to evaluate the efficacy of two antibiotic regimens, differing in the agent included with activity against gram-positive bacteria, for the empirical treatment of febrile episodes in neutropenic patients with hematologic malignancies (group 1, piperacillin plus amikacin; group 2, piperacillin plus amikacin plus teicoplanin). After 72 hours of therapy, patients in group 1 who were still febrile were administered teicoplanin and those in group 2 were administered amphotericin B. A total of 158 evaluable episodes were observed within 8 months. The success rate was 50.6% in group 1 and 60% in group 2. The response rate among patients who did not respond to the original regimen increased to 86.7% with the addition of teicoplanin (group 1) and to 90% with the addition of amphotericin B (group 2). There were 86 unexplained febrile episodes and 56 documented episodes of bacteremia (34 caused by gram-positive organisms). Our results indicate that teicoplanin is safe, well tolerated, and effective for the treatment of documented episodes of gram-positive bacteremia and as an empirical agent. The inclusion of teicoplanin in the initial empirical regimen appears unnecessary if a combination of antibiotics active against gram-positive organisms is used, unless infections are due to oxacillin-resistant staphylococci.     

Empiric therapy with aztreonam for febrile neutropenic patients with hematological malignancies

Combination of aztreonam/amikacin/ticarcillin (AAT) and latamoxef/amikacin/ticarcillin (LAT) were compared in a prospective randomized trial of empiric therapy for febrile neutropenic patients with hematological malignancies. Low dose amphotericin B was also added to each regimen from the beginning. Of 45 evaluable episodes, 23 were treated with AAT and 22 with LAT. The response rates were 61 percent for AAT and 50 percent for LAT, statistically not significant. There was one infection-related death among patients assigned to AAT therapy and also one among those assigned to LAT therapy. Dose escalation of amphotericin B seemed to be effective for those patients who did not improve with initial therapy.     

Aztreonam therapy in neutropenic patients with cancer

Combinations of aztreonam/vancomycin, aztreonam/vancomycin/amikacin, and moxalactam/ticarcillin were compared in a prospective randomized trial as empiric therapy for febrile neutropenic cancer patients. Vancomycin was added to aztreonam to provide coverage against gram-positive organisms. Of 535 febrile episodes included in the study, 455 were evaluable. The aztreonam/vancomycin and aztreonam/vancomycin/amikacin combinations were both more effective than the moxalactam/ticarcillin combination in a total of 244 episodes of documented infection. The difference was due to the fact that both aztreonam-containing combinations were more effective than the moxalactam/ticarcillin combination in documented gram-positive infections. The three regimens were equally effective in 67 documented infections due to a single gram-negative bacterial species. (The response rates were 87, 86 and 94 percent for the aztreonam/vancomycin, aztreonam/vancomycin/amikacin, and moxalactam/ticarcillin combinations, respectively.) Aztreonam was effective as the single active antibiotic in the treatment of gram-negative infections in neutropenic patients; however, it must be used in combination with another antibiotic to provide gram-positive coverage.     

Using teicoplanin for empiric therapy of febrile neutropenic patients with haematological malignancies

S ummary The cumulative experience with teicoplanin in treating febrile neutropenic patients included in three different comparative clinical trials conducted at a single institution during a 3-year period, is presented. 1 52 febrile episodes in 129 neutropenic patients were treated with iv. teicoplanin (6 mg/kg/d) combined with amikacin (15 mg/kg/d) plus ceftazidime (90 mg/kg/d). The study population comprised 75 patients with acute leukaemia and 77 marrow recipients: 53(% (81/152) had a central venous catheter in place and 68%) (103/152) had severe neutropenia (< 100/mm³) at the beginning of the febrile episode.
The overall response rate of the evaluiable febrile episodes was excellent: 88% (107/122) improved. Bacteraemias due to Gram-positive cocci accounted for 75% of the total (42/56) and pathogens in the blood isolates were mostly staphylo-cocci (coagulase-negative 14, coagulase-positive 13) and streptococci (131. The response rate of Gram-positive bacteraemias was good: 88% (37/42) improved and 75% (9/12) of Gram-positive bacteraemias having teicoplanin as the only antibiotic with in vitro activity against the infective strains were cured. Death due to infection accounted for 7% of total febrile episodes (11/152). Side effects were documented in 14(%, of the episodes. In a setting of high prevalence of Grampositive infections caused by strains with a high rate of resistance to aminoglycoside and betalactam antibiotics, there may be an advantage in including teicoplanin in the initial empiric antibiotic regimen for febrile neutropenic cancer patients.     

Combination of Amikacin and either Ampicillin or Cephalotin as Initial Treatment of Febrile Neutropenic Patients

ABSTRACT. A prospective, randomized trial of two antibiotic combinations (amikacin plus either ampicillin or cephalotin) was performed on 39 consecutive episodes of fever in 30 patients with neutropenia and hematological malignancy. Infections were documented as the cause of fever in 37 episodes (95%): in 21 episodes (54%) bacteria or a virus (n=1) were isolated, and in 16 (41% of all episodes) the infection was documented clinically but no pathogen was isolated. The most frequently isolated bacteria were Staph, aureus (38% of all strains), E. coli (13%), and Pseudomonas aeruginosa (13%). Bacteremia occurred in 18% of the febrile episodes. Improvement followed treatment with the combination amikacin plus ampicllin in 73% of 19 cases, and with amikacin plus cephalotin in 55% of 20 cases (p>0.05), giving a total Improvement rate of 64%. Failure of therapy was seen in episodes caused by multiple bacteria or Pseudomonas infections. Mild signs of nephrotoxicity were noted in 13% during both regimens. Audiograms were normal in all but two patients who showed slight high-frequency hearing loss. A second infection occurred in 7 episodes (18%). Thus, the combination of amikacin plus ampidllin was as efficient (but less expensive) as amikacin plus cephalotin in the initial treatment of febrile episodes in neutropenic patients with hematological malignancies.     

Piperacillin plus amikacin therapy v carbenicillin plus amikacin therapy in febrile, granulocytopenic patients

In a prospective randomized trial, febrile, granulocytopenic patients received either piperacillin sodium plus amikacin sulfate or carbenicillin disodium plus amikacin as initial empiric antimicrobial therapy. Although significantly more gram-negative aerobic bacilli isolated from initial cultures were susceptible to piperacillin than to carbenicillin (54 of 58 v 30 of 58), the overall response rates for the two regimens were similar (113 of 143 or 79% for piperacillin plus amikacin and 116 of 154 or 75% for carbenicillin plus amikacin). Piperacillin plus amikacin was associated with less hypokalemia (26 of 143 v 56 of 154). Nephrotoxicity, which was minimal with both regimens, developed less frequently in patients receiving carbenicillin plus amikacin (12 of 143 v two of 154). These results suggest that the overall efficacy of piperacillin plus amikacin is similar to carbenicillin plus amikacin and that piperacillin plus amikacin may be associated with less hypokalemia but more nephrotoxicity.     

Empiric therapy for infections in granulocytopenic cancer patients: continuous infusion of amikacin plus cephalothin.

A combination of amikacin sulfate given by continuous infusion (800 mg/sq m/24 hr) plus cephalothin sodium (2 g every four hours) was used as initial empiric therapy for the treatment of 65 evaluable febrile (greater than 38.5 degrees C) episodes in 54 granulcoytopenic (neutrophils, less than 1,000/microliter) adult cancer patients. Carbenicillin disodium (5 g every four hours) was substituted for cephalothin in patients with Pseudomonas infections and in patients in whom the initial regimen was unsuccessful. Thirty-two of the 38(84%) identifiable infections responded to therapy, including all of the eight septicemias and eight of 11 pneumonias. Three additional infections responded to the substitution of carbenicillin for cephalothin, for a total response rate of 92% (35/38). Nephrotoxicity occurred in five patients (7.1%), most commonly in patients over 60 years of age. Ototoxicity, highly correlated with a duration of greater than 19 days and a total dosage of greater than 25 g of amikacin sulfate, occurred in four patients (5.6%). Amikacin given by continuous infusion plus cephalothin is a safe and efficacious empiric therapy for infections in granulocytopenic cancer patients.     

Vancomycin as part of initial empirical antibiotic therapy for febrile neutropenia in patients with cancer: pros and cons.

Gram-positive organisms predominate as the bacterial pathogens identified in episodes of febrile neutropenia. This has led to increased use of antibiotics with efficacy against gram-positive organisms (often vancomycin) as part of empirical antibiotic regimens for treating febrile neutropenia. Among 101 children randomized to receive amikacin, ticarcillin, and vancomycin or ticarcillin/clavulanate and amikacin along with vancomycin placebo, treatment success in those treated with vancomycin was higher (85% vs. 62%). In 1990, the European Organization for Research and Treatment of Cancer-National Cancer Institute of Canada Clinical Trials Group compared amikacin and ceftazidime with and without vancomycin and concluded that there was no need to include vancomycin in initial empirical antibiotic therapy. Results from another study and a retrospective review of a large clinical trial also support the previous conclusion. In 1999, most experts in the field recommend vancomycin not be part of the initial empirical therapy regimen for treating febrile neutropenia in patients with cancer.     

Empiric therapy for infections in patients with granulocytopenia. Continuous v interrupted infusion of tobramycin plus cefamandole

A combination of tobramycin sulfate and cefamandole nafate was used as initial empiric therapy for the treatment of 71 evaluable febrile (temperature greater than 38.5 degrees C) episodes in 64 (neutrophils, less than 1,000/microL) adult patients with cancer and granulocytopenia. Carbenicillin sodium or ticarcillin disodium was substituted for cefamandole in patients with Pseudomonas infections and in patients in whom the initial regimen was unsuccessful. Twenty-nine episodes were randomized to receive tobramycin by continuous infusion, while 42 were randomized to receive tobramycin by interrupted infusion. Twenty-seven (79%) of the 34 documented infections responded to the initial empiric antibiotic combination, ten (83%) of 12 being given continuous infusion and 17 (77%) of 22 being given interrupted infusion of tobramycin. Nephrotoxic reaction occurred in 7% of patients treated with continuous infusion and 15% treated with interrupted infusion, mostly patients older than 60 years. Tobramycin, by either continuous or interrupted infusion, plus cefamandole is safe and efficacious empiric therapy for infections in patients with cancer and granulocytopenia.