新型人工肝--分子吸附再循环系统及其临床应用

到目前为止,急慢性重型肝炎的治疗仍强调基础护理和一般的支持对症处理,缺乏清除肝脏毒素和促进肝细胞再生的有效手段。虽然血液透析、灌流和血浆置换已被用于重型肝炎的治疗,但其临床疗效尚未被公认。与上述血液净化方法不同的是,新型人工肝——分子吸附再循环系统在有效清除水溶性中小毒素分子的同时,还可以选择性清除亲脂性及与血浆白蛋白相结合的毒素分子,并保留血液中有用的重要营养物质和蛋白质。本文对这一新型人工肝支持系统的基本原理、使用方法、不良反应及临床应用研究进展作了综述。     

TREC-Rio trial: a randomised controlled trial for rapid tranquillisation for agitated patients in emergency psychiatric rooms [ISRCTN44153243]

Background  

Agitated or violent patients constitute 10% of all emergency psychiatric treatment. Management guidelines, the preferred treatment of clinicians and clinical practice all differ. Systematic reviews show that all relevant studies are small and none are likely to have adequate power to show true differences between treatments. Worldwide, current treatment is not based on evidence from randomised trials. In Brazil, the combination haloperidol-promethazine is frequently used, but no studies involving this mix exist.     

Hypothermia-induced reversible platelet dysfunction.

Baboons that were subjected to systemic hypothermia at 32 C had an arm skin temperature of 27.3 C and bleeding time of 5.8 minutes. With local warming of the arm skin to 34 C, the bleeding time was 2.4 minutes. In normothermic baboons with arm skin temperature of 34.6 C, the bleeding time was 3.1 minutes. Local cooling of the arm skin to 27.6 C produced a bleeding time of 6.9 minutes. Increasing the skin temperature of the arm in hypothermic baboons to 38.9 C and in normothermic baboons to 40.1 C reduced bleeding times to 2.1 and 2.3 minutes, respectively. In both hypothermic and normothermic baboons there was a negative and significant correlation between the bleeding time and the arm skin temperature and the thromboxane B2 level in the shed blood obtained at the template bleeding time site. There was a significant positive correlation between the thromboxane B2 level in the shed blood and the arm skin temperature. Both in-vivo and in-vitro studies have shown that the production of thromboxane B2 by platelets is temperature-dependent, and that a cooling of skin temperature produces a reversible platelet dysfunction. Data also suggest that when a hypothermic patient bleeds without surgical cause, skin and wound temperature should be restored to normal before the administration of blood products that are not only expensive but may also transmit disease.     

肺源性心脏病急性发作期免疫功能的改变

目的:观察肺源性心脏病(简称肺心病)急性发作期患者免疫功能的变化。方法:选择南华大学附属第一医院2004-11/2006-01收治慢性肺心病急性发作期患者60例为肺心病组,于急性加重期入院第2天7:00,空腹抽取静脉血,采用流式细胞仪检测T细胞亚群CD3 、CD4 、CD8 及自然杀伤细胞活性,免疫浊度法检测体液免疫指标(IgG,IgM,IgA及补体C3)。以同期60例健康体检者为对照。结果:120例是否受试者均进入结果分析。①T细胞亚群:肺心病组CD3 ,CD4 水平低于对照组(0.52±0.06,0.62±0.04;0.32±0.06,0.41±0.06;P均<0.05),CD4 /CD8 高于对照组(1.96±0.26,1.84±0.78,P<0.05)。②免疫血清指标:肺心病组IgA、补体C3及自然杀伤细胞活性低于对照组[(1.26±0.74),(2.45±0.85)g/L;(6200±217),(9960±302)mg/L;0.34±0.08,0.57±0.07;P均<0.05]。结论:肺源性心脏病急性发作期患者的细胞免疫和体液免疫功能均受损,尤以细胞免疫功能受损更突出,且与病情呈平行关系。     

Granulocyte transfusion therapy in a child with chronic granulomatous disease and multiple red cell alloantibodies

A 7-year-old, 17-kg child with chronic granulomatous disease and nocardial pneumonia and osteomyelitis did not respond to antibiotic therapy and developed multiple red cell (RBC) alloantibodies (anti-c, -E, and -Jka). To provide daily granulocyte concentrates, a method was devised to reduce the number of incompatible RBCs per transfusion. Leukapheresis was done with hydroxyethyl starch, and the apheresis product was allowed to sediment by gravity in a plasma expressor for 90 minutes. The leukocyte-rich plasma was separated from the sedimented RBCs by transfer to a satellite bag, and the volume of the product was reduced by centrifugation to approximately 80 ml. RBC content was reduced from 29 +/- 7 to 2.5 +/- 1.0 ml (n = 22, p less than 0.01) and was accompanied by a 70 percent recovery of white cells (range, 49-90%). The final product contained 1.6 +/- 1.0 X 10(10) granulocytes. There were no clinical or laboratory signs of hemolysis during the course of 46 granulocyte transfusions, 37 of which were derived from c-, E-, or Jka-positive donors. The size of most apheresis donor pools is insufficient to provide phenotypically matched granulocyte concentrates daily for patients with RBC alloimmunization. The rapid, simple method described here may allow daily therapy with mismatched concentrates to be administered safely to such patients.     

The effect of prestorage irradiation on posttransfusion red cell survival

Transfusion-associated graft-versus-host disease (TA-GVHD) may occur whenever immunologically competent allogeneic lymphocytes are transfused to an immunocompromised recipient. Irradiation of blood components eliminates the risk of TA-GVHD but may damage the cellular elements in the transfused component, particularly if the cells are stored for prolonged periods in the irradiated state. To study the effect of irradiation on long-term storage of red cells, AS-1 red cells from eight normal subjects were prepared on two occasions. On one occasion, the units were stored as standard AS-1 red cells for 42 days at 4 degrees C; on the other, they were exposed to 3000 cGy radiation within 4 hours of collection and then were stored as AS-1 red cells for 42 days at 4 degrees C. The donations were at least 12 weeks apart. Irradiated units demonstrated significant elevations in poststorage plasma hemoglobin (Hb) (623 +/- 206 vs. 429 +/- 194 g/dL [6230 +/- 2060 vs. 4290 +/- 1940 g/L], p less than 0.02) and plasma potassium (78 +/- 4 vs. 43 +/- 9 mEq/L [78 +/- 4 vs. 43 +/- 9 mmol/L], p less than 0.01) and significant decreases in red cell ATP (1.9 +/- 0.2 vs. 2.1 +/- 0.3 microM/g Hb, p less than 0.04) and 24-hour posttransfusion red cell recovery (68.5 vs. 78.4%, p less than 0.02), as compared to nonirradiated units. It can be concluded that irradiation with 3000 cGy damages red cells and that long-term storage in the irradiated state may enhance this damage. Red cells should not be stored for 42 days after irradiation with 3000 cGy.     

复合富血小板血浆的酶处理异种骨修复兔桡骨缺损

目的:自源性的富血小板血浆可促进骨组织及软组织的修复,又不存在疾病传播及免疫排斥的可能。实验拟验证应用复合富血小板血浆的酶处理异种骨修复节段性骨缺损的可行性。方法:实验于2006-07/12在解放军昆明总医院实验动物中心完成。①实验分组:选用新西兰大耳白兔20只,体质量2.0～2.5kg,共40只前肢,随机分为复合酶组,单纯酶组,脱蛋白骨组,空白组。每组共10个标本。②实验方法:制作富血小板血浆及酶处理的异种骨并制备桡骨中段15mm的节段性骨缺损模型,将上述骨材料植入兔桡骨缺损处,其中复合酶组:植入复合富血小板血浆的酶处理异种骨;单纯酶组:植入酶处理异种骨;脱蛋白骨组:植入部分脱蛋白骨;空白组:不植入任何材料。③实验评估:分别于术后4,8,12周取材,X线片及苏木精-伊红染色分别观察骨缺损区的新骨形成情况。同时对各组骨密度进行测定。结果:纳入新西兰大耳白兔20只,均进入结果分析,所有手术无术后感染,无动物死亡,植入骨无脱落。①所有动物麻醉苏醒后均恢复进食,2周伤口愈合,未出现感染及渗液等。富血小板血浆中的血小板含量均为全血的4倍以上。②在同一时间点,酶处理后异种骨与部分脱蛋白骨在成骨能力方面差异无显著性意义,而复合富血小板血浆的酶处理异种骨在8周时骨缺损部分修复;12周时完全修复。空白组骨缺损未修复。③8,12周时复合酶组骨密度较单纯酶组、脱蛋白骨组高,差异有显著性意义(P<0.05);单纯酶组与脱蛋白骨组比较无明显差异(P>0.05)。结论:经酶处理后异种骨可用于节段性骨缺损的修复,复合富血小板血浆后有明显加速骨愈合的作用。     

Seasonal variation in surgical outcomes as measured by the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP)

OBJECTIVE: We hypothesize that the systems of care within academic medical centers are sufficiently disrupted with the beginning of a new academic year to affect patient outcomes. METHODS: This observational multiinstitutional cohort study was conducted by analysis of the National Surgical Quality Improvement Program-Patient Safety in Surgery Study database. The 30-day morbidity and mortality rates were compared between 2 periods of care: (early group: July 1 to August 30) and late group (April 15 to June 15). Patient baseline characteristics were first compared between the early and late periods. A prediction model was then constructed, via stepwise logistic regression model with a significance level for entry and a significance level for selection of 0.05. RESULTS: There was 18% higher risk of postoperative morbidity in the early (n = 9941) versus the late group (n = 10313) (OR 1.18, 95%, CI 1.07-1.29, P = 0.0005, c-index 0.794). There was a 41% higher risk for mortality in the early group compared with the late group (OR 1.41, CI 1.11-1.80, P = 0.005, c-index 0.938). No significant trends in patient risk over time were noted. CONCLUSION: Our data suggests higher rates of postsurgical morbidity and mortality related to the time of the year. Further study is needed to fully describe the etiologies of the seasonal variation in outcomes.