肝脏移植术后移植物抗宿主病的诊断和治疗

【目的】 探讨肝脏移植术后移植物抗宿主病（GVHD）的诊断和治疗。【方法】 分析我院2003年10月至2009年6月完成的772例肝脏移植的临床资料,总结肝脏移植术后GVHD的诊断和治疗经验。【结果】 772例肝脏移植术后5例病人发生GVHD,发病率为0.65%（5/772）,5例患者均在肝脏移植后2～5周出现发热、皮疹、腹泻和全血细胞减少,肝功能均接近正常,经皮肤活检和骨髓穿刺检查证实,并排除巨细胞病毒（CMV）和EB病毒感染。经过调整免疫抑制剂,加用IL-2受体单克隆抗体,积极抗感染和支持对症治疗,2例患者痊愈,3例患者死于严重感染、消化道出血和多器官功能衰竭。【结论】 肝脏移植术后GVHD死亡率高,早期诊断,及时调整免疫抑制剂方案,积极抗感染和营养支持是治疗的关键。     

雄激素剥夺条件下阻断自噬增加LNCaP细胞凋亡

目的 探讨雄激素剥夺条件下阻断自噬后LNCaP细胞凋亡变化与半胱天冬酶(caspase)激活的关系.方法 应用激光共聚焦显微镜、RT-PCR方法观察雄激素剥夺致细胞自噬增加后,利用DAPI染色观察细胞凋亡变化及药物抑制caspase后对凋亡的影响.结果 ①雄激素去除后LNCaP细胞自噬体增加,标准培养基(CM)培养下LNCaP细胞自噬体数量为1.90分;无血清培养基(SF)中细胞自噬体数量增高为2.64分;加入双氧睾酮(SFA组)后细胞自噬体下降至1.85分(P<0.01).CM中LNCaP细胞LC3 mRNA表达率为23%,血清饥饿12 h后,LC3表达量上调至100%,而SFA组LC3 mRNA表达量为86%;血清饥饿24 h后,SF组LC3 mRNA表达量为62%,SFA组为35%.②SF组和SFA组LNCaP细胞基础凋亡率分别为(3.19±1.09)0A和(3.01±0.33)%,加入3-甲基腺嘌呤(3-MA)阻断自噬24 h后,SF组凋亡率为(10.90±2.91)%,SFA组为(4.63±1.69)%.SF+3-MA组中加入Z-VAD-FMK后,细胞凋亡减至(1.16±0.52)%.组间差异有统计学意义(P<0.01).结论 剥夺雄激素后LNCaP细胞中自噬明显增加,阻断自噬后凋亡发生率增加.     

颅外段椎动脉先天发育异常的超声诊断价值

目的探讨彩色多普勒超声对颅外段椎动脉发育异常的诊断价值及其临床意义。方法对2012年1月至2013年3月来我院疑诊为椎动脉型颈椎病患者进行颅外段椎动脉超声检查,观测椎动脉管腔结构、血管走行、血流信号等变化。其中152例颅外段椎动脉发育异常患者同时进行磁共振血管成像（MRA）或血管造影检查。结果发现236例患者椎动脉发育异常,其中椎动脉发育不良者为114例,椎动脉走行变异者为75例,椎动脉发育不良合并椎动脉走行变异者为47例。其中152例患者同时进行磁共振血管成像（MRA）或血管造影检查,其多普勒超声与MRA或血管造影的诊断结果完全符合。结论彩色多普勒超声能准确、快捷的诊断颅外段椎动脉发育异常,且无创、检查费用较低,具有很高的临床应用价值。     

Low serum magnesium levels are associated with increased risk of fractures: a long-term prospective cohort study

Magnesium, which is an essential trace element that plays a key role in several cellular processes, is a major component of bone; however, its relationship with risk of major bone fractures is uncertain. We aimed to investigate the association of baseline serum magnesium concentrations with risk of incident fractures. We analyzed data on 2245 men aged 42–61 years in the Kuopio Ischemic Heart Disease prospective cohort study, with the assessment of serum magnesium measurements and dietary intakes made at baseline. Hazard ratios [95% confidence intervals (CI)] for incident total (femoral, humeral, and forearm) and femoral fractures were assessed. During a median follow-up of 25.6 years, 123 total fractures were recorded. Serum magnesium was non-linearly associated with risk of total fractures. In age-adjusted Cox regression analysis, the hazard ratio (HR) (95% CIs) for total fractures in a comparison of the bottom quartile versus top quartile of magnesium concentrations was 2.10 (1.30–3.41), which persisted on adjustment for several established risk factors 1.99 (1.23–3.24). The association remained consistent on further adjustment for renal function, socioeconomic status, total energy intake, and several trace elements 1.80 (1.10–2.94). The corresponding adjusted HRs for femoral fractures were 2.56 (1.38–4.76), 2.43 (1.30–4.53) and 2.13 (1.13–3.99) respectively. There was no evidence of an association of dietary magnesium intake with risk of any fractures. In middle-aged Caucasian men, low serum magnesium is strongly and independently associated with an increased risk of fractures. Further research is needed to assess the potential relevance of serum magnesium in the prevention of fractures.     

One- and two-stage surgical revision of peri-prosthetic joint infection of the hip: a pooled individual participant data analysis of 44 cohort studies

One-stage and two-stage revision strategies are the two main options for treating established chronic peri-prosthetic joint infection (PJI) of the hip; however, there is uncertainty regarding which is the best treatment option. We aimed to compare the risk of re-infection between the two revision strategies using pooled individual participant data (IPD). Observational cohort studies with PJI of the hip treated exclusively by one- or two-stage revision and reporting re-infection outcomes were retrieved by searching MEDLINE, EMBASE, Web of Science, The Cochrane Library, and the WHO International Clinical Trials Registry Platform; as well as email contact with investigators. We analysed IPD of 1856 participants with PJI of the hip from 44 cohorts across four continents. The primary outcome was re-infection (recurrence of infection by the same organism(s) and/or re-infection with a new organism(s)). Hazard ratios (HRs) for re-infection were calculated using Cox proportional frailty hazards models. After a median follow-up of 3.7 years, 222 re-infections were recorded. Re-infection rates per 1000 person-years of follow-up were 16.8 (95% CI 13.6–20.7) and 32.3 (95% CI 27.3–38.3) for one-stage and two-stage strategies respectively. The age- and sex-adjusted HR of re-infection for two-stage revision was 1.70 (0.58–5.00) when compared with one-stage revision. The association remained consistently absent after further adjustment for potential confounders. The HRs did not vary importantly in clinically relevant subgroups. Analysis of pooled individual patient data suggest that a one-stage revision strategy may be as effective as a two-stage revision strategy in treating PJI of the hip.     

家庭群居爆发型新型冠状病毒肺炎的临床与胸部HRCT表现

目的 探讨家庭群居爆发型新型冠状病毒肺炎（简称"新冠肺炎"）（novel coronavirus pneumonia，NCP）的临床与胸部HRCT表现特点。方法 收集2020年2月3所医院经核酸检测阳性确诊的新冠肺炎患者10例（4个家庭），其中男性6例（中位年龄60.5岁），女性4例（中位年龄59岁）。所有患者均接受胸部CT扫描并行薄层HRCT重建，由两名10年以上工作经验放射科医生共同阅片分析新冠肺炎HRCT病变发生部位、形态、分布、密度等特点，以及治疗前后HRCT征象变化。并收集临床和实验室指标进行分析和总结。结果 本组4个家庭中首例确诊病例均有武汉确诊病例或武汉疫区接触史，4例为输入型病例（占40%），平均潜伏期5 d。实验室检查中5例（50%）外周血白细胞总数降低，4例（40%）淋巴细胞明显降低；8例（80%）C-反应蛋白增高，10例（100%）乳酸脱氢酶增高。10例（100%）患者胸部CT均有阳性表现，其中7例（70%）表现为双肺散在分布磨玻璃密度影（ground glass opacity，GGO），病变界限大多清楚。8例（80%）累及多个肺叶，2例（20%）为单肺叶病变。绝大多数病灶位于胸膜下和肺外周处，以双肺下叶为著。5例患者（50%）病变内可见细支气管充气征，9例患者（90%）病变内可见增粗细小血管影。7例患者（70%）治疗后复查胸部CT，3例（30%）原肺内胸膜下病变出现不同程度实变及纤维化，2例（20%）实变影转变为GGO，1例（10%）原肺内GGO消失，又出现新发GGO，1例（10%）病变范围有增大。结论 新冠肺炎具有家庭群居爆发的特点，均可有输入性病例，潜伏期较短，其胸部HRCT表现具有一定特征性，且有助于治疗后患者病变动态观察；结合流行病学和实验室检查有助于对NCP做出临床诊断和提供疫情防控的可靠依据。     

Similar risk of complete revision for infection with single-dose versus multiple-dose antibiotic prophylaxis in primary arthroplasty of the hip and knee: results of an observational cohort study in the Dutch Arthroplasty Register in 242,179 patients

Background and purpose — The optimal type and duration of antibiotic prophylaxis for primary arthroplasty of the hip and knee are subject to debate. We compared the risk of complete revision (obtained by a 1- or 2-stage procedure) for periprosthetic joint infection (PJI) after primary total hip or knee arthroplasty between patients receiving a single dose of prophylactic antibiotics and patients receiving multiple doses of antibiotics for prevention of PJI.Patients and methods — A cohort of 130,712 primary total hip and 111,467 knee arthroplasties performed between 2011 and 2015 in the Netherlands was analyzed. We linked data from the Dutch arthroplasty register to a survey collected across all Dutch institutions on hospital-level antibiotic prophylaxis policy. We used restricted cubic spline Poisson models adjusted for hospital clustering to compare the risk of revision for infection according to type and duration of antibiotic prophylaxis received.Results — For total hip arthroplasties, the rates of revision for infection were 31/10,000 person-years (95% CI 28–35), 39 (25–59), and 23 (15–34) in the groups that received multiple doses of cefazolin, multiple doses of cefuroxime, and a single dose of cefazolin, respectively. The rates for knee arthroplasties were 27/10,000 person-years (95% CI 24–31), 40 (24–62), and 24 (16–36). Similar risk of complete revision for infection among antibiotic prophylaxis regimens was found when adjusting for confounders.Interpretation — In a large observational cohort we found no apparent association between the type or duration of antibiotic prophylaxis and the risk of complete revision for infection. This does question whether there is any advantage to the use of prolonged antibiotic prophylaxis beyond a single dose.

Annually around 1 million patients receive a total hip or total knee prosthesis in the United States and over 190,000 hip and knee replacements are performed in England and Wales (Maradit et al. 2015, National Joint Registry for England and Wales 2018). The incidences of prosthetic replacement of the hip and knee are expected to increase (Kurtz et al. 2014). Prosthetic joint infection (PJI) following total hip or knee arthroplasty and the treatment thereof are catastrophic for patients and pose tremendous costs to healthcare systems (Poultsides et al. 2010, Zmistowski et al. 2013, Moore et al. 2015). Perioperative antibiotic prophylaxis remains an effective method of reducing the risk of PJI (Illingworth et al. 2013, Thornley et al. 2015). The type and duration of antibiotic prophylaxis are subject to debate.Both single-dose and multiple-dose antibiotic prophylaxis regimens have been advocated with comparable results (Thornley et al. 2015, Tan et al. 2019). The recommendations provided by the Second International Consensus Meeting of the MusculoSkeletal Infection Society (MSIS) and the European Bone and Joint Infection Society (EBJIS) advise that antibiotic prophylaxis should be administered 30–60 minutes before incision and discontinued within 24 hours after surgery (Hansen et al. 2014, Parvizi and Gehrke 2018). Large variation in prophylaxis regimens has been observed in the United Kingdom (Hickson et al. 2015). The Dutch national orthopedic association advises administration of antibiotic prophylaxis using a first- or second-generation cephalosporin starting 30–60 minutes preoperatively and discontinuing the antibiotic prophylaxis within 24 hours (Swierstra et al. 2009, Nederlandse Orthopaedische Vereniging 2018). The World Health Organization and, in the USA, the Centers for Disease Control and Prevention (CDC) recommend against the use of postoperative continuation of antibiotic prophylaxis and advocate for a single dose of antibiotics delivered preoperatively (Berrios-Torres et al. 2017). This recommendation is vehemently challenged by the American Association of Hip and Knee Surgeons and the International Consensus Meeting, which encourage their members to proceed with the current common practice of multiple-dose antibiotic prophylaxis protocols until more evidence is available (Yates 2018).We compared the risk of complete revision for infection in the 1st year following primary hip and knee arthroplasty according to the perioperatively administered antibiotic prophylaxis regimen by using data from the Dutch Arthroplasty Register (LROI).