有剖宫产史孕妇再次妊娠分娩方式的探讨

目的：探讨剖宫产术后再次妊娠分娩的最佳方式。方法：回顾分析上海交通大学医学院附属瑞金医院2004年1月—2012年9月剖宫产术后再次妊娠的286例孕妇的分娩方式,其中剖宫产234例,阴道试产52例,并随机抽取同期首次行剖宫产术300例孕妇为对照组。结果：286例孕妇中258例（90.2%）再次行剖宫产术,28例阴道分娩,试产成功率53.9%。阴道分娩组无大出血发生,再次剖宫产组发生10例（3.88%）,对照组发生2例（0.67%）,差异有统计学意义（P〈0.05）。再次剖宫产组术中出血量（325.4±12.5）mL,高于对照组（225.6±26.8）mL及阴道分娩组（148.4±15.7）mL,差异有统计学意义（P〈0.05）。再次剖宫产组平均手术时间（59.2±20.5）min,高于对照组（30.9±14.6）min;腹腔粘连146例（56.59%）,高于对照组0例,差异均有统计学意义（P〈0.05和0.01）。再次剖宫产组住院时间（7.2±0.9）d,与对照组（6.8±1.2）d和阴道分娩组（3.5±1.8）d比较,差异有统计学意义（P〈0.05）。结论：瘢痕子宫再次妊娠不是剖宫产的绝对指征。有剖宫产史孕妇再次妊娠后,若无剖宫产指征,应增加阴道试产机会;而提高剖宫产手术水平,是降低剖宫产史孕妇再次剖宫产并发症的关键。     

Comparison of HLA-DR1-restricted T cell response induced in HLA-DR1 transgenic mice deficient for murine MHC class II and HLA-DR1 transgenic mice expressing endogenous murine MHC class II molecules

Transgenic mice expressing human HLA class II molecules provide a useful model for identifying HLA-restricted CD4+ epitopes. However, the influence of endogenous murine H-2-restricted T cell responses on HLA-restricted responses is not known. In the present study, we show that HLA-DR1 transgenic mice deficient for H-2 class II expression (HLA-DR1+/+/IAbeta0/0) exhibit an equivalent expression level of the transgene HLA-DR1 and a similar diversity in the TCR repertoire, but a slightly different number of CD4+ peripheral T cells, when compared to HLA-DR1 transgenic mice in which H-2 class II molecules were retained (HLA-DR1+/+/IAbeta+/+). More importantly, a strong antigen-specific HLA-DR1-restricted response was observed in nearly all HLA-DR1+/+/IAbeta0/0 mice immunized with HBV envelope protein (HBs) or capsid protein (HBc), whereas weak HBs- or HBc-specific HLA-DR1-restricted responses were detected in half of the immunized HLA-DR1+/+/IAbeta+/+ mice. Conversely, strong HBs- or HBc-specific H-2-restricted T cell responses were detected in HLA-DR1+/+/IAbeta+/+ mice but not in HLA-DR1+/+/IAbeta0/0 mice. Our results indicate that the coexpression of endogenous H-2 class II molecules reduces the intensity of HLA-DR1-restricted antigen-specific responses in transgenic mice, by favoring murine over human MHC recognition and education. Thus, HLA-DR1+/+/IAbeta0/0 mice represent a better model for identifying and characterizing HLA-DR1-restricted epitopes relevant for human disease.     

Successful endoscopic ultrasound-guided overstenting biliary drainage through a pre-existing proximal migrated metal biliary stent

Biliary endoscopic drainage using metallic self-expanded stents has become a well-established method for palliative treatment of malignant biliary obstruction. However, its occlusion, mainly by tumor overgrowth, is still the main complication without a standard treatment. We here describe a new method of treatment for biliary metallic stent occlusion, through the echo guided biliary drainage. We present a 68-year-old patient with metastatic pancreatic cancer previously treated for jaundice with ERCP and self-expandable metallic stent insertion. Four weeks later, the patient developed jaundice and symptoms of gastric outlet obstruction. A new ERCP confirmed obstruction of the second portion of the duodenum, due to diffuse tumor growth. EUS was performed, and the previous metal biliary stent was seen occluded at the distal portion in the common bile duct. A EUS-guided choledocododenostomy was performed and then, an overlapping self-expanding metal enteral stent was placed through the malignant obstruction. There were no early complications and the procedure was also clinically effective in relieving jaundice and gastric outlet obstruction symptoms. If ERCP fails in the management of occluded biliary metallic stents, EUS biliary drain can provide effective biliary decompression and should be considered an alternative to other endoscopic techniques.     

International Headache Society classification: interobserver reliability in the diagnosis of primary headaches

We assessed interobserver reliability of the International Headache Society (IBIS) classification for diagnosis of primary headaches. The study was performed on 103 patients consecutively seen at two Headache Centres. Each patient was given a structured interview recorded on videotape. Four experienced clinicians then reviewed the interviews separately and made a diagnosis of headache according to IHS criteria at the one- and two-digit levels. At both the one- and the two-digit level the agreement was substantial (Kappa = 0.74 and 0.65, respectively). The analysis of reliability for each of nine items necessary for diagnosis showed an agreement ranging from substantial (Kappa = 0.69) to almost perfect (Kappa = 0.89). Our results indicate that the IHS classification has a good reliability for the diagnosis of primary headaches at the one- and two-digit levels.     

不同处理方法对经尿道前列腺电切术患者寒战反应的预防效果分析

目的比较不同的处理方法对减少经尿道前列腺电切术中患者寒战的效果。方法收集320例择期行经尿道前列腺电切术患者，随机分成Ⅰ组、Ⅱ组、Ⅲ组、Ⅳ组各80例，全部采用蛛网膜下隙阻滞硬膜外联合麻醉，经尿道行前列腺电切术，对4组患者分别采用不同的预防和护理方法，观察4组患者寒战发生情况。结果寒战的发生率Ⅰ组和Ⅲ组较Ⅳ组显著降低，差异有统计学意义。结论物理升温及曲马多静脉注射可降低经尿道前列腺电切术中患者寒战的发生率。     

双清平化方对代谢综合征大鼠骨骼肌自噬通路蛋白表达的影响

目的 观察双清平化方对代谢综合征大鼠Lee''s指数、血糖、血脂及骨骼肌哺乳动物雷帕霉素靶蛋白(mammalian target of rapamycin,mTOR)、自噬效应蛋白1(Beclin1)、微管相关蛋白1轻链3(microtubule-associated protein1 light chain 3,LC3)蛋白表达的影响,探讨其改善糖脂代谢的作用机制。方法 大鼠给予高脂饲料加10%果糖水溶液喂养,并联合应用N-硝基-L-精氨酸甲酯(N-nitro-L-arginine methyl ester,L-NAME)及链脲佐菌素(streptozotocin,STZ)诱导代谢综合征模型。代谢综合征大鼠给予双清平化方或二甲双胍干预8周,实验前后定期测量大鼠体质量、体长、腹围、血压、糖耐量、糖化血红蛋白(glycated hemoglobin,GHb)、胰岛素(insulin,INS)、总胆固醇(total cholesterol,TC)、三酰甘油(triglyceride,TG)、低密度脂蛋白胆固醇(low-density lipoprotein cholesterol,LDL-C)、高密度脂蛋白胆固醇(high-density lipoprotein cholesterol,HDL-C),计算葡萄糖曲线下面积(OGTT-AUC)和胰岛素抵抗指数(HOMA-IR);采用苏木素-伊红(HE)染色观察骨骼肌组织病理形态学变化;采用Masson染色观察骨骼肌纤维形态变化;采用免疫组化法检测骨骼肌组织中LC3蛋白表达;采用Western blotting检测骨骼肌组织中mTOR、Beclin1和LC3蛋白表达。结果 与对照组比较,模型组大鼠空腹血糖(fasting blood glucose,FBG)、餐后2 h血糖(2 h postprandial glucose,PG2h)、OGTT-AUC、HOMA-IR、INS、GHb、TC、TG及LDL-C水平均显著升高(P<0.01),HDL-C水平显著降低(P<0.01);骨骼肌组织中mTOR蛋白表达显著上调(P<0.01),Beclin1、LC3蛋白表达显著下调(P<0.01)。与模型组比较,双清平化方组FBG、PG2h、OGTT-AUC、HOMA-IR、INS、GHb、TC、TG及LDL-C水平均显著降低(P<0.05、0.01),HDL-C水平显著升高(P<0.01);骨骼肌组织中mTOR蛋白表达水平显著上调(P<0.01),Beclin1和LC3蛋白表达显著下调(P<0.01)。结论 双清平化方可以改善代谢综合征大鼠胰岛素抵抗,改善糖脂代谢水平,抑制骨骼肌病理变化,其作用机制可能与调节骨骼肌自噬,激活骨骼肌组织自噬通路中mTOR、Beclin1、LC3蛋白表达有关。     

Baroreflex Sensitivity as a Cardiac and Arrhythmia Mortality Risk Stratifier

The last two decades have provided clear evidence for the tight and casual relation existing between arrhythmic mortality and the autonomic nervous system, particularly with imbalances characterized by decreases in vagal and/or increases in sympathetic activity. A series of compelling experimental results has represented the driving force for the clinical evaluation of the potential prognostic value of baroreflex sensitivity (BBS), a measure that can provide information on the capability to augment vagal activity. This article reviews the methodology more commonly used to quantify the clinical evaluation of this parameter, and then focuses on the key clinical studies highlighting those performed in postmyocardial infarction patients. Among them the most informative is ATRAMI, a multicenter prospective study involving almost 1300 patients. The main conclusion is that both heart rate variability and BRS are strong and independent risk factors for post-infarction mortality, thus demonstrating the clinical usefulness of autonomic markers.