共病致大肠癌漏诊情况分析55例

目的:总结共病状态下大肠癌漏诊的具体原因.方法:回顾性分析55例漏诊大肠癌的临床资料,对率的比较采用卡方检验.结果:被漏诊的疾病中,大肠癌合并痔疮18例,合并消化性溃疡10例,合并结直肠息肉7例,合并急性阑尾炎5例,合并缺铁性贫血5例,合并慢性胆囊炎4例,合并溃疡性结肠炎3例,合并慢性盆腔炎2例,合并阑尾周围脓肿1例.结论:不少临床医师拘泥于“一因论”的思维模式而忽视了共病的存在,这是导致共病状态下大肠癌漏诊的主要原因.     

Assessing patients' priorities and perceptions of the quality of health care: the development of the QUOTE-Rheumatic-Patients instrument

Patient views on the quality of care have always been assessed by means of patient satisfaction questionnaires. The objectives of this study were to develop an instrument that would: (1) produce more specific data on health care services; (2) produce data that are related to the needs and expectations of individual clients; (3) contain items that had been formulated in collaboration with patients; (4) measure quality of health care services from the perspective of customers; (5) produce data on generic items and on disease-specific items of health care services. The instrument, developed for measuring the quality of care from the perspective of non-institutionalized rheumatic patients (QUOTE- Rheumatic-Patients), was evaluated in 425 non-institutionalized patients suffering from rheumatic diseases. The internal consistency of the subscales, the presumed factor structure and the feasibility of the instrument were evaluated. The development of this instrument resulted in a self-administered questionnaire on the quality of health care from the perspective of non-institutionalized rheumatic patients, which contains proper scientific characteristics and provides specific information for practical quality assurance policies.      

Cytoplasmic expression of the CD3 antigen as a diagnostic marker for immature T-cell malignancies

The expression of cytoplasmic CD3 (CyCD3) was analyzed in 45 leukemias, five thymus cell samples, five peripheral blood (PB) samples, and ten cell lines. All T cell acute lymphoblastic leukemias (T-ALL) that did not express surface membrane CD3 (SmCD3) appeared to express CyCD3. Furthermore, the majority of SmCD3+ T-ALL also expressed CyCD3. Analogous results were obtained with thymus cell samples in that about 95% of the thymocytes expressed CyCD3 whereas 60% to 75% of the thymocytes also expressed SmCD3. In normal peripheral blood only prominent SmCD3 expression was found. These data indicate that immature T cells express CyCD3 only, that the combined expression of CyCD3 and SmCD3 is characteristic for intermediate differentiation stages, and that mature T cells express prominent SmCD3. All (precursor) B cell leukemias, acute myeloid leukemias, and non-T cell lines tested did not express CyCD3. On the basis of these data, we conclude that CyCD3 expression is restricted to the T cell lineage and can be used as a diagnostic marker for immature SmCD3- T cell malignancies. Therefore, we evaluated which fixative is optimal for CyCD3 staining, and we determined by immunofluorescence staining and Western blotting which anti-CD3 monoclonal antibody (MoAb) can be used for the detection of CyCD3. In our opinion, acid ethanol was the best fixative for the cytocentrifuge preparations. Furthermore, we demonstrated that CyCD3 can be easily detected by use of MoAbs raised against denaturated CD3 chains such as those of the SP series (SP-6, SP-10, SP-64, and SP-78). In addition we tested 22 anti-CD3 MoAbs of the Oxford CD3 panel that were raised against native SmCD3, and it appeared that only four (UCHT1, VIT-3b, G19-41 and SK7/Leu-4) of them were able to detect CyCD3. In Western blot analysis all four MoAbs recognized the CD3- epsilon chain only.     

Does food intolerance play a role in juvenile chronic arthritis?

Sixty children with juvenile chronic arthritis (JCA) have been examined at the paediatric rheumatology out-patient clinic in Maastricht, of whom three ultimately appeared to have a food intolerance. In one of these three patients, there appeared to be a relationship with joint complaints. In the course of the elimination/challenge tests which were conducted, severe painful swelling of the knee occurred rapidly after each challenge. Three challenges were carried out with the same result each time. Since the symptoms did not disappear entirely following elimination of milk, it was concluded that milk intolerance in this case was an aggravating factor in a seronegative monoarticular JCA. In the second and third patients, a strict diet had no positive effect on the joint problems. In conclusion, the existence of such a connection between food and chronic joint complaints has been made clear, it only plays a role in incidental cases.      

A comparison of two recently developed health status instruments for patients with arthritis: Dutch-AIMS2 and IRGL. Arthritis Impact Measurement Scales. Impact of Rheumatic diseases on General health and Lifestyle

Two multidimensional health status instruments of rheumatic diseases, the Dutch-AIMS2 and the IRGL (Impact of Rheumatic diseases on General health and Lifestyle), were compared in a sample of 284 rheumatoid arthritis patients with regard to their measurement properties and usefulness for research purposes. Both questionnaires showed an excellent reliability (Cronbach's alpha), and were highly comparable with regard to their construct and convergent validity. Second-order factor analysis confirmed the physical, psychological and social health dimensions for both questionnaires. The comparability between the instruments was established by high intercorrelations between the physical and psychological health dimensions. Sufficient convergent validity was indicated by the strong correlations between the physical functioning scales and clinical and laboratory measures. The main differences between both questionnaires relate to their length and emphasis on health aspects. The Dutch-AIMS2 is characterized by a more extensive assessment of the physical dimension and the additional measurement of general health aspects. The shorter IRGL exclusively assesses the main health dimensions with a more comprehensive measurement of the psychological and social dimensions. The instrument that reflects the subject in question most adequately should be chosen.      

Fractionated total body irradiation and high-dose VP 16-213 followed by allogeneic bone marrow transplantation in advanced leukemias

Thirty-eight patients (median age, 21 years) with acute nonlymphoblastic leukemia (ANLL) (17 patients), acute lymphoblastic leukemia/lymphoma (ALL) (18 patients), chronic myelogenous leukemia (two patients), and refractory anemia received allogeneic bone marrow transplants from HLA-identical sibling donors or a one-antigen- mismatched brother (one patient) after a preparatory regimen consisting of fractionated total body irradiation and high-dose VP 16-213 (60 to 70 mg/kg body weight). Of the 33 patients with acute leukemia who received grafts from HLA-identical donors, three patients with ANLL received transplants in first remission and one patient with standard- risk ALL received a graft while in second remission. All other patients were in more advanced stages of their disease or exhibited other high- risk features. At the time of analysis, 20 of the 33 patients were alive, with 19 of them remaining in continued complete remission for 6 to 35 months (median, 18 months). The 3-year actuarial disease-free survival rate of 56.6% +/- 9.7% (SE) and the actuarial relapse rate of 11.9% +/- 6.8% (SE) demonstrate that the combination of fractionated total body irradiation and high-dose VP 16 is an effective mode of therapy in patients with advanced leukemias. Preliminary experience cautions against the use of VP 16 instead of cyclophosphamide in any clinical situation carrying an increased risk of graft rejection because the immunosuppressive potency of VP 16 is largely untested but may be inferior to that of cyclophosphamide.     

Large paraesophageal varices on endosonography predict recurrence of esophageal varices and rebleeding

BACKGROUND & AIMS: Recurrence of varices and rebleeding after endoscopic therapy is very common. Data on the prediction of recurrent varices after initial obliteration by endoscopic therapy are few. The aim of this study was to correlate the presence and the size of paraesophageal varices (PEVs) in patients after endoscopic variceal ligation with recurrent varices and rebleeding. METHODS: Forty patients who underwent endoscopic banding ligation for esophageal variceal bleeding were studied by endosonography within 4 weeks after obliteration of varices. PEVs were classified as none, small, or large (maximum diameter, > or =0.5 cm). Esophagoscopy and endosonography were then repeated every 6 months for up to 1 year. RESULTS: Two patients (5%) were not detected to have PEVs. Small and large PEVs were identified in 24 (60%) and 14 (35%) patients, respectively. During the follow-up period of 1-year, recurrent submucosal esophageal varices were detected in 24 patients, including 13 patients (93%) with large PEVs and 11 patients (46%) with no or small PEVs (P = 0.0019). Recurrent bleeding occurred in 6 patients (43%) with large PEVs and in 3 patients (12%) with small PEVs (P = 0.044). CONCLUSIONS: Patients with large PEVs have a higher risk of developing recurrent varices and rebleeding. (Gastroenterology 1997 Jun;112(6):1811-6)     

Requirements of von Willebrand factor to protect factor VIII from inactivation by activated protein C

The interaction of factor VIII with von Willebrand factor (vWF) was investigated on a quantitative and qualitative level. Binding characteristics were determined using a solid phase binding assay and protection of factor VIII by vWF from inactivation by activated protein C (aPC) was studied using three different assays. Deletion mutants of vWF, a 31-kD N-terminal monomeric tryptic fragment of vWF that contained the factor VIII binding site (T31) and multimers of vWF of different size were compared with vWF purified from plasma. We found that deletion of the A1, A2, or A3 domain of vWF had neither an effect on the binding characteristics nor on the protective effect of vWF on factor VIII. Furthermore, no differences in binding of factor VIII were found between multimers of vWF with different size. Also, the protective effect on factor VIII of vWF was not related to the size of the multimers of vWF. A 20-fold lower binding affinity was observed for the interaction of T31 with factor VIII, and T31 did not protect factor VIII from inactivation by aPC in a fluid-phase assay. Comparable results were found for a mutant of vWF that is monomeric at the N- terminus (vWF-dPRO). The lack of multimerization at the N-terminus may explain the decreased affinity of T31 and vWF-dPRO for factor VIII. Because of this decreased affinity, only a small fraction of factor VIII was bound to T31 and to vWF-dPRO. We hypothesized that this fraction was protected from inactivation by aPC but that this protection was not observed due to the presence of an excess of unbound factor VIII in the fluid phase. Therefore, vWF, T31, and vWF-dPRO were immobilized to separate bound factor VIII from unbound factor VIII in the fluid phase. Subsequently, the protective effect of these forms of vWF on bound factor VIII was studied. In this approach, all forms of vWF were able to protect factor VIII against inactivation by aPC completely. We conclude, in contrast with earlier work, that there is no discrepancy between binding of factor VIII to vWF and protection of factor VIII by vWF from inactivation by aPC. The protective effect of T31 was not recognized in previous studies due to its low affinity for factor VIII. The absence of multimerization observed for T31 and vWF- dPRO may explain the low affinity for factor VIII. No other domains than the binding site located at the D' domain were found to be involved in the protection of factor VIII from inactivation by aPC.     

Hematopoietic potential of cryopreserved and ex vivo manipulated umbilical cord blood progenitor cells evaluated in vitro and in vivo

The hematopoietic potential of cryopreserved and ex vivo manipulated umbilical cord blood (UCB) samples was evaluated in vitro and in vivo. Phenotypic analysis shows that approximately 1% of cord blood mononuclear cells express high levels of CD34 antigen on their surface (CD34hi), but none of a panel of lineage antigens (Lin-), suggesting that they are hematopoietic progenitor cells that have not yet committed to a specific lineage. Approximately 1% of CD34hi/Lin- cells are primitive hematopoietic progenitors that produce B lymphoid and multiple myeloid progeny for up to 7 weeks in stromal cell cultures. Twenty-one percent (+/- 13%) of CD34hi/Lin- cells also express low levels of the Thy-1 antigen and are threefold to fourfold enriched over CD34hi/Lin- cells in primitive hematopoietic potential as measured by long-term culture and phenotypic analysis. One-week liquid cultures of CD34-enriched UCB progenitor cells in the presence of interleukin (IL)- 3, IL-6, and stem cell factor (SCF) results in a two-fold to threefold expansion of progenitors capable of reinitiating long-term stromal cell cultures. Only the CD34hi/Thy-1+/Lin- cell population was capable of maintaining progenitors with secondary transfer potential in long-term stromal cell cultures and is thus postulated to contain all of the primitive hematopoietic stem cells in UCB. The in vivo transplantation potential of UCB was also measured. Ex vivo manipulated UCB progenitor cells were used to engraft irradiated human thymus fragments implanted in severe combined immunodeficiency (SCID) mice. Thymic engraftment with >5% donor-derived cells and a normal CD4/CD8 distribution was observed in 19 of 23 tissues tested. UCB cells from in vitro expansion cultures engrafted with efficiencies comparable to nonexpanded cells. Similar results were obtained for UCB engraftment of human bone fragments implanted in SCID mice. In all cases, engraftment was achieved in competition with endogenous competitor stem cells and across major histocompatibility barriers. Taken together, this data demonstrates that human UCB is a rich source of multipotent hematopoietic progenitors that can be cryopreserved, enriched by physical methods, and expanded in a limited fashion without measurable loss of long-term culture or in vivo engrafting potential as measured in these assays.