乳腺癌内分泌治疗发展与未来

乳腺癌是激素依赖性肿瘤,内分泌药物的选择除了根据患者的年龄、病灶部位、手术到复发的间隔时间以及受体测定等因素外,还要根据不同药物的作用机制以及副反应而定。随着对内分泌治疗药物作用机制的深入研究和大规模临床研究的证实,激素受体阳性乳腺癌的内分泌治疗疗效将不断提高。     

腘静脉肌袢代瓣术治疗重度原发性下肢深静脉瓣膜功能不全的疗效分析

目的研究腘静脉肌袢代瓣术进行深静脉瓣膜重建对重度原发性下肢深静脉瓣膜功能不全(PDVI)的疗效。方法选取106例CEAP分级4级以上患者,随机分为肌袢代瓣联合浅静脉手术组和单纯浅静脉手术组,对比两组术前、术后14 d及术后2年的静脉疾病临床严重度评分(VCSS)。结果两组术后14 d VCSS总分及疼痛、静脉曲张、炎症及溃疡评分均较术前明显下降(P<0.05),但组间比较差异无统计学意义(P>0.05)。术后2年VCSS总分[(3.5±1.8)vs.(4.7±3.1),P=0.039]、静脉曲张(P=0.026)与水肿(P=0.021)评分肌袢组较单纯浅静脉组显著下降。结论对CEAP分级4级以上,且合并严重静脉水肿的PDVI患者,肌袢代瓣术联合浅静脉剥脱术远期疗效优于单纯浅静脉手术。     

骨髓移植诱导临床心脏移植后供者特异性免疫耐受方案的探讨

目的 探讨骨髓移植诱导临床心脏移植后供者特异性免疫耐受的可行性.方法 采取供心的同时采用改良"灌流法"获取供者的骨髓350 ml,经过滤及离心处理后,加入细胞冷冻保护液共80ml,分装于低温冻存袋,经程序降温,置于-80℃冰箱中保存.在常规原位心脏移植术后40 d,取冻存骨髓快速复温,穿刺受者双侧髂后上嵴,立即行骨髓腔内骨髓细胞输注(IBM-BMT),共输注单核细胞1.2×107/kg,CD34+细胞2.38×105/kg.骨髓输注前3 d行预处理,包括应用氟达拉滨、抗胸腺细胞球蛋白及全身淋巴结照射.骨髓移植后静脉应用他克莫司(Tac),维持血Tac浓度谷值在10～20μg/L;3周后改为口服Tac+吗替麦考酚酯(MMF);6周后改为环孢素A及MMF.分别于心脏移植后2、4、8和12周采集受者外周血,分别于术后4、8和12周采集受者的骨髓,应用短串联重复序列-聚合酶链反应法检测供者嵌合体.心脏移植后每周行心肌内心电图检查,每月行心肌活检1次.术后3个月,取受者及第三者外周血单核细胞,行混合淋巴细胞反应(MLR).结果心脏移植后1、2及3个月时受者的外周血及髂骨内骨髓细胞中供者来源的细胞比例分别为26.3%、19.1%、4.8%和46.3%、24.4%、7.6%.IBM-BMT后心肌内心电图监测显示心肌阻抗及R波波幅无明显变化.术后3个月行心内膜心肌活检,未见排斥反应征象.术后3个月时行超声心动图检查,提示心脏舒张、收缩功能良好.MLR提示受者对供者特异性刺激呈现低反应性,而对第三者仍保持良好的免疫活性(P＜0.01).结论 采取分期骨髓移植免疫耐受诱导方案可安全、有效地建立嵌合体,成功诱导心脏移植后供者特异性免疫耐受,但远期效果有待进一步研究.

Abstract：

Objective To investigate a new strategy of bone marrow transplantation (BMT) for donor-specific tolerance induction after heart transplantation. Methods Donor bone marrow cells (BMCs)were harvested simultaneously with donor cardiac graft using modified perfusion method (PM) ,then stored in a -80 ℃ refrigerator after filtration and centrifugation. Whole BMCs (IBM-BMT) (monocytes 1.2 ×107/kg,CD34+ cells 2.38× 105/kg) in host iliac bones were injected into the bone marrow cavity 40 days after heart transplantation. Preconditoning regimens that consisted of fludarabine, antithymoctye globin and total lymphoid irradiation were performed 3 days before BMT. Tacrolimus (Tac) was administrated intravenously after BMT or orally in conjunction with mycophenolate mofetil (MMF) 3 weeks later.Cyclosporine and MMF were orally administrated 6 weeks later. Donor chimerism was detected using short tandem repeats-polymerase chain reaction in monocytes from peripheral blood at the 2nd,4th, 8th or 12th week after BMT or BMCs at the 4th, 8th or 12th week after BMT. Intramyocardium electrocardiography examination or endomyocardial biopsy was performed weekly or monthly respectively. Mixed lymphocyte reactions (MLR) were performed 3 months after BMT. Results Donor chimerism in monocytes in peripheral blood or BMCs in iliac bones measured at the 1 st,2nd and 3rd month after BMT was 26.3%, 19.1%,4.8% ,and 46.3%, 24.4%, 7.6%, respectively. After 3-month follow-up, there was no rejection confirmed by endomyocardial biopsy or intramyocardium electrocardiography. Echocardiography revealed that the diastolic and systolic function of the cardiac graft was maintained well 3 months after BMT. MLR revealed donor-specific hyporesponsiveness while immunocompetence was preserved to third-party antigens. Conclusion These findings indicate that the two-stage BMT strategy is a safe and feasible method for the induction of donor-specific tolerance via stable mixed chimerism and needs to be further confirmed after a long-term observation.     

精囊镜检诊治顽固性血精

目的探讨经尿道精囊镜检诊治顽固性血精的临床应用价值。方法回顾性分析我院自2008年9月以来开展经尿道精囊镜检诊治8例顽固性血精患者的临床资料,结合文献复习顽固性血精的治疗方法。年龄26～55岁,平均42岁,血精病程6～48个月,平均12个月,药物和物理治疗无效。采用7F输尿管硬镜行经尿道精囊镜检。结果 8例精囊镜检手术均成功,手术时间分别为20～75min,平均35min。精囊镜检示慢性炎症5例,精囊结石2例,射精管梗阻扩张1例。无尿道和精囊损伤等并发症。术后随访时间3～24个月,7例患者血精症状消失,1例术后9个月再发血精。结论经尿道精囊镜检操作简单,创伤小,可作为顽固性血精的有效诊治方法之一。     

广西HIV感染者呼吸道非结核分枝杆菌定植情况和临床特点分析

目的呼吸道非结核分枝杆菌定植是HIV感染者发生播散性非结核分枝杆菌感染的危险因素,并可能对肺结核的诊断造成干扰。我国HIV感染者中非结核分枝杆菌呼吸道定植情况和临床特点目前尚无较大样本的研究报道。本文分析HIV感染者痰培养中非结核分枝杆菌的阳性率和相关因素,从而总结其临床特点。方法 2006年8月至2008年7月,对广西省4个诊疗机构中CD4〈350的HIV感染者进行临床症状、胸片、痰涂片,痰分枝杆菌培养和血液分枝杆菌培养在内的结核筛查。结果 1073例HIV感染者在结核筛查时进行了痰分枝杆菌培养,检出非结核分枝杆菌87例（8.1%）,129例（12.0%）为结核分枝杆菌。在痰培养阳性的标本中,43%为非结核分枝杆菌。非结核分枝杆菌在呼吸道的定植率随着患者CD4水平降低而逐渐升高,在CD4计数〉200/μl、100～200/μl、50～100/μl和〈50/μl的患者组中分别为2.8%、6.4%、7.1%和9.8%。痰涂片抗酸杆菌阳性的患者中12.0%为非结核分枝杆菌,非结核分枝杆菌呼吸道定植的患者中8.5%痰涂片结果为抗酸杆菌阳性。与痰培养阴性的患者相比,有呼吸道非结核分枝杆菌定植的患者CD4水平较低,除体重下降更多见外,其他临床症状如发热、咳嗽、盗汗、乏力等,以及胸片异常表现均未增加。结论我国HIV感染者中痰培养非结核分枝杆菌的阳性率较高,尤其是在CD4〈200的患者中,需要加强临床观察。在未有进行细菌培养的情况下,非结核分枝杆菌在呼吸道的定植可能造成结核的误诊,应给予重视。     

RNA干扰靶向抑制磷脂酰肌醇3-激酶P85α蛋白表达对结直肠癌细胞周期和细胞凋亡的影响

目的探讨RNA干扰靶向抑制磷脂酰肌醇3-激酶（P13K）P85α蛋白表达对结直肠癌细胞周期与细胞凋亡的影响。方法设计4条shRNA干扰载体及1条阴性对照载体．分别稳定转染结直肠癌SW480细胞。采用Western blot筛选出对P13K P85α蛋白抑制效率最高的shRNA干扰片段．然后通过PI标记法和Annexin V—FITC标记法分别检测干扰后SW480细胞周期和细胞凋亡情况。结果转染shRNA／324后．SW480细胞P13K P85α蛋白降低最为显著．抑制率为90％。选择该干扰片段进行后续实验。干扰组与对照组SW480细胞的G1期细胞数量分别占（62．4±2．7）％和（51．2±3．5）％;S期细胞数量占（23．9±1．7）％和（34．1±3．4）％;氟尿嘧啶所诱导的细胞凋亡率为（11．1±3．7）％和（1．4±0．6）％;上述差异均有统计学意义（P〈0．05）。结论P13K P85α蛋白表达下降可引起结直肠癌SW480细胞周期阻滞,细胞凋亡增加：PI3K P85α可能成为结直肠癌基因治疗的新靶点。     

Primary mucinous adenocarcinoma of the renal pelvis with elevated CEA and CA19-9

Primary adenocarcinoma of the renal pelvis is rarely reported in the literature. Here we present a case of primary mucinous adenocarcinoma of the renal pelvis with elevated serum carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA19-9) levels. A 56-year-old woman was referred to our center with intermittent fever and left-sided back pain for 1 month. Computed tomography showed bilateral nephrolithiasis, mild right hydronephrosis and left pyonephrosis accompanied with ambiguous soft tissues. A radionucleorenogram showed that the glomerular filtration rate of the left and right kidney was 0 and 79 ml/min, respectively. Left nephrectomy was performed without lymph node dissection. Histopathology revealed mucinous adenocarcinoma and elevated serum CEA and CA19-9 levels were found. She died of multiorgan metastasis after 5 months. A review of the literature is also reported.     

Seroma is an expected consequence and not a complication of MammoSite brachytherapy

Seroma has long been listed as a complication of MammoSite brachytherapy. Palpable abnormalities are clinically apparent months after treatment and a vast majority of patients demonstrate seroma formation in radiologic studies. We embarked on this study to evaluate the actual sonographic incidence and eventual sonographic resolution, possible contributing factors, cosmesis, pain, and local control associated with seroma formation after MammoSite partial breast irradiation (PBI). We investigated 160 patients who underwent MammoSite PBI from 2002 to 2006 of whom 100 patients had serial sonographic information. Clinical and tumor variables, infection, pain, and cosmesis were investigated. Dosimetric data including volume of balloon, dose at balloon surface, and at skin were analyzed. After a median follow-up of 36 months, the incidence of sonographically confirmed post-radiation seroma was 78% within the first 1 year following radiation and steadily decreased with time. The average size of a seroma cavity was 2.3 cm (range 0.6-6 cm) with a decline to an average of 1.4 cm after 1 year, with complete resolution in 65% of patients at 2 years. No statistically significant correlation was found between patient characteristics, tumor variables, and volumetric or dosimetric data for seroma formation. Excellent/good cosmetic scores were achieved in 94% of women with and 92% without seroma. Local control was equivalent between patients with and without seroma. Consecutive sonographic imaging reveals a high rate of seroma formation after MammoSite PBI, with resolution in 65% of patients by 2 years without intervention. Seroma formation does not prevent an excellent cosmetic result or alter local control.     

Factors associated with early mortality after cervical spinal cord injury

Background

A relatively high early mortality rate (<30 days post-injury) for cervical spinal cord injury (SCI) has been observed.

Objective

To investigate this early mortality rate observed after cervical SCI and analyze the associated influential factors.

Methods

Medical records for 1163 patients with cervical SCI were reviewed, and the number of patients with early mortality was documented. Through logistic regression analysis, the effects of age, gender, occupation, cause of injury, severity of injury, highest involved spinal cord segment, nutritional condition during hospitalization, surgical treatment, tracheotomy, etc., on early mortality were assessed. Implementation of early treatment (i.e. surgery, tracheotomy, and nutritional support) and its effect on patient prognosis were also analyzed.

Results

Early mortality occurred in 109 of 1163 patients (9.4%). Four factors affected the early mortality rate, including level and severity of SCI, whether or not surgery was performed, the time interval between SCI and surgery, malnutrition, and tracheotomy. Patients with an American Spinal Injury Association grade of A, a high cervical SCI (C1–C3), and/or no surgical intervention were statistically more likely to have early mortality (P < 0.001).

Conclusion

Severe cervical SCI, upper-level cervical cord injury, malnutrition, and inappropriate tracheotomy are risk factors for early mortality in patients with cervical SCI. Surgery can reduce early mortality. Early tracheotomy should be performed in patients with complete upper-level cervical SCI, but patients with incomplete cervical SCI or complete low-level cervical SCI should initially be treated surgically to maintain smooth airway flow.     

Functional pectoralis minor muscle flap transplantation for reconstruction of thumb opposition: an anatomic study and clinical applications

In this report, we present the results of an anatomic study on the dimensions of the pectoralis minor muscle and its neurovascular supply in 10 adult human cadavers, in attempt to evaluate the feasibility of microsurgical transplantation of a part of the muscle for thumb opposition reconstruction. A series of five patients consequently underwent thenar reconstruction with the pectoralis minor muscle flap from December 2004 to October 2006. The transferred muscle was reinnervated with the third lumbrical branch of the ulnar nerve. Follow-up assessment showed that the patients recovered functional opposition of carpometacarpal joint with 24 degrees of pronation, and a muscle power with M4 to M5. All patients were satisfied with the appearance of reconstructed thenar eminence. We recommend this new technique for thenar and opposition reconstruction in patients who have severe loss of thenar muscles, injury to the median nerve, and wish to improve the appearance of thenar eminence.