High-dose therapy and peripheral blood progenitor cell transplantation: effects of recombinant human granulocyte-macrophage colony-stimulating factor on the autograft

Between June 1989 and June 1992, 144 patients participated in sequential clinical trials using peripheral blood progenitor cells (PBC) as their sole source of hematopoietic rescue following high-dose chemotherapy. All patients had received prior extensive combination chemotherapy and had marrow defects that precluded autologous bone marrow transplantation (ABMT). PBC were collected according to a single apheresis protocol. The initial 86 patients (group 1) had PBC collected without mobilization. Beginning in April 1991, PBC were mobilized solely with recombinant human granulocyte-macrophage colony-stimulating factor (rHuGM-CSF). Thirty-four patients (group 2) received rHuGM-CSF at a dose of 125 micrograms/m2/d by continuous intravenous infusion, and 24 patients (group 3) received rHuGM-CSF at a dose of 250 micrograms/m2/d by continuous intravenous infusion. Patients underwent at least six aphereses and had a minimum of 6.5 x 10(8) mononuclear cells (MNC)/kg collected. Cytokines were not routinely administered immediately after transplantation. A median of nine aphereses were required to collect PBC in group 1 and seven aphereses for groups 2 and 3 (P = .03). The time required to recover 0.5 x 10(9)/L granulocytes after transplant was significantly shorter (P = .0004) for the mobilized groups; the median time to recovery was 26 days for group 1, 23 days for group 2, and 18 days for group 3. Transplantation of PBC mobilized with rHuGM-CSF resulted in a shorter time to platelet (P = .04) and red blood cell (P = .01) transfusion independence. Mobilization with rHuGM-CSF alone resulted in efficient collection of PBC, that provided rapid and sustained restoration of hematopoietic function following high-dose chemotherapy. Mobilization of PBC with rHuGM-CSF alone is an effective method for patients who have received prior chemotherapy and have bone marrow abnormalities.     

The next step from high-flux dialysis: application of sorbent technology.

The current foci of renal replacement therapy with dialysis are middle molecular weight toxins, consisting of small proteins, polypeptides and products of glycosylation and lipoxygenation. Conventional high-flux dialysis is not efficient at removing these molecules, explaining the increased interest in using sorbents to supplement dialysis techniques. Prototype biocompatible sorbents have been developed and investigated for middle molecule removal; these have been shown, in man, to remove beta(2)-microglobulin, angiogenin, leptin, cytokines and other molecules, without reducing platelets and leukocytes. Extensive clinical studies are underway to demonstrate the clinical utility and safety of adding routinely a sorbent hemoperfusion device to hemodialysis.     

Reuniting overnutrition and undernutrition,macronutrients, and micronutrients

Over‐nutrition and its late consequences are a dominant theme in medicine today. In addition to the health hazards brought on by over‐nutrition, the medical community has recently accumulated a roster of health benefits with obesity, grouped under “obesity paradox.” Throughout the world and throughout history until the 20^th century, under‐nutrition was a dominant evolutionary force. Under‐nutrition brings with it a mix of benefits and detriments that are opposite to and continuous with those of over‐nutrition. This continuum yields J‐shaped or U‐shaped curves relating body mass index to mortality. The overweight have an elevated risk of dying in middle age of degenerative diseases while the underweight are at increased risk of premature death from infectious conditions. Micronutrient deficiencies, major concerns of nutritional science in the 20^th century, are being neglected. This “hidden hunger” is now surprisingly prevalent in all weight groups, even among the overweight. Because micronutrient replacement is safe, inexpensive, and predictably effective, it is now an exceptionally attractive target for therapy across the spectrum of weight and age. Nutrition‐related conditions worthy of special attention from caregivers include excess vitamin A, excess vitamin D, and deficiency of magnesium.     

Increasing incidence of HIV‐ associated tuberculosis in Romanian injecting drug users

Background

A high prevalence of tuberculosis (TB) among HIV‐positive injecting drug users (IDUs) may fuel the TB epidemic in the general population of Romania. We determined the frequency and characteristics of TB in HIV‐infected IDUs referred to a national centre.

Methods

Prospective observational cohort study of all newly‐diagnosed HIV‐positive IDUs admitted to Victor Babes Hospital, Bucharest, between January 2009 and December 2014. Socio‐demographics, clinical characteristics and outcomes of HIV/TB co‐infected IDUs were compared to HIV‐positive IDUs without TB.

Results

170/598 (28.5%) HIV‐infected IDUs were diagnosed with TB. The prevalence increased from 12.5% in 2009 to 32.1% in 2014 (P < 0.001). HIV/TB co‐infected individuals had lower median CD4 cell counts 75 (vs. 450/mm³, P < 0.0001) and higher median HIV viral loads 5.6 log₁₀ (vs. 4.9 log₁₀, P < 0.0001) when presenting to healthcare services. 103/170 (60.6%) HIV/TB co‐infected IDUs were diagnosed with pulmonary TB. Resistant Mycobacterium tuberculosis strains were common, with 18/105 (17.1%) of patients having Multi‐Drug Resistant (MDR) disease. Higher mortality rate was associated with TB co‐infection (P < 0.0001), extra‐pulmonary TB (P = 0.0026) and extensively drug resistant TB (P = 0.024).

Conclusions

Tuberculosis (TB) is an increasing problem in HIV‐infected IDUs in Romania. Presentation is often with advanced HIV, significant TB drug resistance and consequent outcomes are poor.

     

A Composite of Functional Status and Pneumonia Severity Index Improves the Prediction of Pneumonia Mortality in Older Patients

Background

The baseline health status may be a determinant of interest in the evolution of pneumonia.

Objective

Our objective was to assess the predictive ability of community-acquired pneumonia (CAP) mortality by combining the Barthel Index (BI) and Pneumonia Severity Index (PSI) in patients aged ≥ 65 years.

Design, patients and main measures

In this prospective, observational, multicenter analysis of comorbidities, the clinical data, additional examinations and severity of CAP were measured by the PSI and functional status by the BI. Two multivariable models were generated: Model 1 including the PSI and BI and model 2 with PSI plus BI stratified categorically.

Key results

The total population was 1919 patients, of whom 61% had severe pneumonia (PSI IV–V) and 40.4% had some degree of dependence (BI ≤ 90 points). Mortality in the PSI V–IV group was 12.5%. Some degree of dependence was associated with increased mortality in both the mild (7.2% vs. 3.2%; p = 0.016) and severe (14% vs. 3.3%; p < 0.001) pneumonia groups. The combination of PSI IV–V and BI ≤ 90 was the greatest risk factor for mortality (aOR 4.17; 95% CI 2.48 to 7.02) in our series.

Conclusions

The use of a bimodal model to assess CAP mortality (PSI + BI) provides more accurate prognostic information than the use of each index separately.

     

我国初级职称护理人员规范化培训现状

初级职称护理人员规范化培训是护理专业学生毕业后继续教育的重要阶段,是护理人才梯队培养的重要环节,起到衔接院校基础教育与继续医学教育的重要作用。随着医药卫生体制改革的不断深化,护理事业发展取得突破性进展。护士队伍数量大幅度增加。截至＂十一五＂末,我国注册护士总数达到205万,较2005年增长了52%,是历史上护士数量增长最快的时期[1]。     

调任通督治疗失眠症实施护理干预的临床观察

目的 探讨调任通督治疗并实施护理干预对失眠患者睡眠的影响.方法 将57例失眠患者随机分为对照组28例和干预组29例,对照组给予调任通督针剌治疗,干预组在调任通督治疗基础上实施护理干预,观察两组心理健康状况、睡眠质量、临床疗效及治疗依从性,并进行比较.结果 干预组治愈率明显高于对照组,心理健康状况、睡眠质量指标及对治疗的依从性亦明显优于对照组.结论 调任通督针刺并实施护理干预是治疗失眠症的有效方法.     

Weight loss and incretin responsiveness improve glucose control independently after gastric bypass surgery

Background: The aim of the present study was to determine the mechanisms underlying Type 2 diabetes remission after gastric bypass (GBP) surgery by characterizing the short‐ and long‐term changes in hormonal determinants of blood glucose. Methods: Eleven morbidly obese women with diabetes were studied before and 1, 6, and 12 months after GBP; eight non‐diabetic morbidly obese women were used as controls. The incretin effect was measured as the difference in insulin levels in response to oral glucose and to an isoglycemic intravenous challenge. Outcome measures were glucose, insulin, C‐peptide, proinsulin, amylin, glucagon, glucose‐dependent insulinotropic polypeptide (GIP), glucagon‐like peptide‐1 (GLP‐1) levels and the incretin effect on insulin secretion. Results: The decrease in fasting glucose (r = 0.724) and insulin (r = 0.576) was associated with weight loss up to 12 months after GBP. In contrast, the blunted incretin effect (calculated at 22%) that improved at 1 month remained unchanged with further weight loss at 6 (52%) and 12 (52%) months. The blunted incretin (GLP‐1 and GIP) levels, early phase insulin secretion, and other parameters of β‐cell function (amylin, proinsulin/insulin) followed the same pattern, with rapid improvement at 1 month that remained unchanged at 1 year. Conclusions: The data suggest that weight loss and incretins may contribute independently to improved glucose levels in the first year after GBP surgery.     

不同吸痰方式对急性呼吸窘迫综合征血流动力学影响的实验研究

目的研究更适宜急性呼吸窘迫综合征(ARDS)机械通气气管内吸痰的方式。方法采用静脉注射油酸制备动物ARDS模型;每只犬随机选择使用开放式气管内吸痰(OS)和密闭式气管内吸痰(CS)2种吸痰方式。于吸痰前后记录血流动力学等监测指标的数据。结果OS和CS后,犬平均肺动脉压(MPAP)与吸痰前比较均明显升高(P<0.05);OS后平均动脉压(MAP)显著升高(P<0.05)。结论OS、CS均可影响血流动力学的稳定。本研究提示,在护理工作中,对ARDS机械通气者应重视吸痰引起的继发性损害,加强吸痰前后血流动力学等监测。