创伤患者输血与供者白细胞微嵌合的相关性

输血是挽救创伤患者生命而普遍使用的治疗方法,但其又存在着明显和潜在的危险性。当今,经血液传播传染病和输血反应很少发生,但仍然存在。尽管在临床治疗中试图控制创伤患者休克的发展及损伤的严重度,但其输血后细菌感染、多脏器功能衰竭、死亡的发生率仍较高。     

Ordered recombination of immunoglobulin light chain genes occurs at the IGK locus but seems less strict at the IGL locus

Regulation of allelic and isotypic exclusion of human immunoglobulin (Ig) light-chain genes was studied in 113 chronic B-cell leukemias as a "single-cell" model that allowed complete analysis of each light chain allele. Our data show that monospecific Ig light chain expression is in about 90% of cases determined by ordered recombination: Igkappa gene (IGK) rearrangements, followed by IGK deletions and Iglambda gene (IGL) rearrangements, resulting in the presence of only one functional Ig light chain rearrangement. In about 10% (10 cases), 2 functional Ig light chain rearrangements (IGK/IGL or IGL/IGL, but not IGK/IGK) were identified. This might be explained by the fact that regulation of the ordered recombination process is not fully strict, particularly when the IGL locus is involved. Unfavorable somatic mutations followed by receptor editing might have contributed to this finding. Eight of these 10 cases indeed contained somatic mutations. In cases with 2 functional Ig light chain rearrangements, both alleles were transcribed, but monospecific Ig expression was still maintained. This suggests that in these cases allelelic exclusion is not regulated at the messenger RNA level but either at the level of translation or protein stability or via preferential pairing of Ig light and Ig heavy chains. Nevertheless, ordered rearrangement processes are the main determinant for monospecific Ig light chain expression.     

Gallstone disease. Management of common bile-duct stones and associated gallbladder stones: Surgical aspects

For many years, open exploration of the common bile duct has been the treatment of choice for patients with common bile-duct stones. During recent decades endoscopic sphincterotomy has gained wide acceptance as an effective and less invasive alternative. After sphincterotomy, subsequent (laparoscopic) cholecystectomy is warranted in patients with gallbladder stones. This chapter will discuss whether sphincterotomy should be performed prior to, during or after cholecystectomy, and will also address the question of whether single-stage treatment by laparoscopic cholecystectomy and laparoscopic bile-duct exploration is in fact preferable. The rate of recurrent choledocholithiasis after endoscopic biliary sphincterotomy can reach more than 20%. This review focuses on the risk factors--delayed bile-duct clearance and bactobilia--that may lead to recurrent primary bile-duct stone formation. Underlying altered bile composition (relative phospholipid deficiency) should be recognised in a subgroup of patients. Identification of these risk factors may significantly affect treatment policy.     

Intravenous glucose intake independently related to intensive care unit and hospital mortality: an argument for glucose toxicity in critically ill patients

OBJECTIVE: It is assumed that the toxic effects of glucose play a role in the outcome of critically ill patients. We studied the impact of the amount of infused glucose as a determinant of mortality. DESIGN: A retrospective cohort study design was used as blood glucose levels in critically ill patients are nowadays tightly controlled. PATIENTS: Long-stay critically ill patients (7-30 days). MEASUREMENTS: The association between the mean amount of glucose infusion and both intensive care unit (ICU) and hospital mortality was determined. We corrected for the mean glucose serum concentration, the mean dosage of insulin and for severity of illness, using the acute physiology and chronic health evaluation (APACHE II) score. RESULTS: Of the 2,042 admitted patients, 273 met the inclusion criteria. The mean length of stay was 14.4 days [interquartile range (IQR) 9-18]. Hospital mortality was significantly lower for patients with a mean glucose level below 8 mmol/l (30/79; 38%) compared to patients with a level above 8 mmol/l (104/194; 54%, P=0.023). Logistic stepwise multivariate regression analysis for both ICU and hospital mortality as dependent variables showed that APACHE II score and the mean daily amount of infused glucose were associated with mortality. CONCLUSION: In long-stay ICU patients without blood glucose level control, the ICU and hospital mortality was independently related to the mean amount of infused glucose. In addition, mortality in patients with a mean glucose level above 8.0 mmol/l was higher. Both these determinants of mortality can exert their effects by insulin-independent uptake of glucose with subsequent toxic intracellular effects.     

Socio—cultural factors influencing insecticide treated bed net utilization in a malaria endemic city in north—central Nigeria

ObjectiveTo ascertain the socio-cultural factors influencing the rate of utilization of insecticide treated bed nets (ITNs) in a malaria endemic city of Makurdi, north central Nigeria.MethodsThe study was cross-sectional in nature using systematic sampling method to identify households. Both quantitative and qualitative data was generated from adult women using structured and semi structured questionnaires, and focused group discussions (FGDs) to obtain information on rate and patterns of utilization of ITNs. Information such as age, educational level, marital status, awareness or otherwise of the existence of malaria, and factors influencing rate of ownership and utilization of ITNs were obtained. FGDs were used to obtain qualitative information on rate of utilization of ITNs not captured in the questionnaires. Data obtained was analysed using Epi Info 6 statistical software.ResultsAmong the respondents interviewed, 97.0% (2 013/2 075) were aware of existence of malaria and 87.0% of these (1 751/2 013) would associate it with mosquitoes. The rate of ownership of any bed net, ITNs and untreated bed nets (UTNs) was 25.1%, 17.0% and 8.3%, respectively. Utilization of ITNs among children was 30.0% (112/373) and UTNs 12.9% (48/373). Positive contributors to ITNs utilization were literacy, enhanced economy, experience of marriage, and being gainfully employed (P<0.05); while negative contributors were ignorance, poverty and some cultural beliefs and values.ConclusionsA more synchronized advocacy should be carried out on the potential benefits of ITNs utilization and sustained. Also ITNs should be made available to the people of the community at minimal or no cost.     

Opportunistic infections and organ‐specific diseases in HIV‐1‐infected children: a cohort study (1990–2006)

Objectives

Highly active antiretroviral therapy (HAART) has dramatically changed the natural history of HIV infection in children, but there are few studies in the literature about the incidence of clinical manifestations after HAART in this population, compared with adults. The aim of this study was to describe the influence of the widespread use of HAART on the development of opportunistic infections and organ‐specific diseases in HIV‐infected children.

Methods

An observational study of a cohort of 366 vertically HIV‐infected children followed from 1990 to 2006 was carried out. According to the main antiretroviral protocol used, three calendar periods (CPs) were defined and compared: CP1 (1990–1996: no patients on HAART), CP2 (1997–1999: <60% on HAART) and CP3 (2000–2006: >60% on HAART).

Results

Children experienced a progressive increase in CD4 T cell count (P<0.05) and a decrease in HIV viral load from 1996 onwards (P<0.05). Similarly, rates of death, AIDS, opportunistic infections (bacteraemia, candidosis, cryptosporidiosis and bacterial pneumonia) and organ‐specific diseases (wasting syndrome, thrombocytopenia, cardiomyopathy, lymphoid interstitial pneumonia and HIV‐associated encephalopathy) were lower in CP2 and CP3 than in CP1.

Conclusions

This study provides evidence of improved clinical outcomes in HIV‐infected children over time and shows that mortality, AIDS, opportunistic infections and organ‐specific diseases declined as HAART was progressively instituted in this population.