2011年美国骨髓移植会议临床热点荟萃

2011年2月17—21日美国骨髓移植会议（Bone Marrow Transplant Tandem Meeting）在美国夏威夷举行,来自世界各地的4000余名造血干细胞移植（hematopoietic stem cell transplantation,HSCT）专家和代表参与,650余份论文交流,其中口头报告100余份。大会主题涉及造血干细胞及移植免疫的基础研究、HSCT后过继细胞免疫治疗、非清髓预处理在脐血及单倍体相合HSCT中的应用、杀伤细胞免疫球蛋白样受体（killer cell immunoglobulin—like receptor,KIR）对移植预后的影响以及异基因HSCT后复发的治疗等。本文就部分临床热点内容作一简介。     

胸腺五肽联合抗生素治疗复发性尿路感染疗效分析

 目的 观察胸腺五肽联合抗生素治疗复发性尿路感染的疗效.方法 将40例复发性尿路感染患者随机分为单纯抗生素治疗组和胸腺五肽联合抗生素治疗组,观察两组治疗前后患者症状、体征、尿常规、中段尿培养的改善情况以及尿路感染复发的情况.结果 与单纯抗生素治疗组相比,胸腺五肽联合抗生素治疗可以明显缩短复发性尿路感染的疗程,减少复发率(P＜0.05).结论 胸腺五肽联合抗生素可以有效治疗复发性尿路感染.     

Level of operant training rather than cocaine intake predicts level of reinstatement

Rationale Extended cocaine self-administration has been shown to potentiate reinstatement. This increased vulnerability to relapse could be attributed not only to extended cocaine exposure but also to extended operant training. Objective This study was aimed at determining the influence of different operant training histories on cocaine-induced reinstatement when cocaine intake is kept constant. Materials and methods Cocaine intake and operant training were dissociated by using experimental procedures generating different histories of operant training but almost identical histories of cocaine intake. Rats were first trained to self-administer cocaine at a classical unit dose (250 μg/inf, FR1), then in independent groups, the level of operant response was changed for the next 20 sessions by changing either the unit dose available (83, 250, or 750 μg/inf, Experiment 1) or the fixed ratio required (FR-1, FR-3, or FR-10, Experiment 2). Then, all rats were tested for reinstatement with different priming doses of cocaine (0, 5, 10, and 15 mg/kg; i.p.) at an early and late stage of an extinction period. Results Level of responding during training predicts the level of reinstatement later on, independently of the amount of cocaine consumed. High FR requirement and low unit dose access led to higher level of reinstatement at early and late stage of the extinction period, respectively. Conclusions This study shows that the level of operant responding required to maintain optimal cocaine intake directly influences later levels of reinstatement. This finding suggests that environmental constrains that make drug-taking demanding and effortful may increase the vulnerability to relapse.     

消化性溃疡复发的常见因素分析

目的探讨分析消化性溃疡复发常见的因素,总结防治措施。方法对该院2008年1月—2011年12月收治的326例消化性溃疡的病例患者愈后定期随访或复诊,依据胃镜检查及病理结果分为复发组和未复发组,对两组患者进行相关因素(性别、年龄、职业、文化程度、不良饮食习惯、精神因素、药物因素、吸烟、维持用药、经济收入)回顾分析。结果复发114例,占34.97%,未复发212例,占65.03%。消化性溃疡的复发与性别、年龄、文化程度、不良饮食习惯、精神因素、药物因素、吸烟、维持用药、经济收入、季节等因素有关。结论消化性溃疡的复发是多因素综合作用的结果,应对针对上述因素采取防治措施,比如:健康教育、指导饮食、心理疏导、指导用药等等。     

甲状腺癌诊断及复发因素分析

目的探讨甲状腺癌的诊断及与术后复发有关的因素。方法回顾性分析1999年3月至2006年2月期间上海市第一人民医院宝山分院收治的256例经手术及病理检查证实的甲状腺癌患者的临床资料。结果甲状腺乳头状癌235例(91.8%),滤泡状癌11例(4.3%),髓样癌7例(2.7%),未分化癌3例(1.2%)。所有病例均行手术治疗,手术方式包括:患侧腺叶+峡部+对侧甲状腺腺叶大部切除+病变侧中央区颈淋巴结清扫术;明确颈淋巴结转移或肿块明显外侵者,则行功能性颈淋巴结清扫术;对多灶癌或双腺叶癌者则施行双侧甲状腺全或近全切除,单或双侧Ⅵ区颈淋巴结清扫或一侧功能性颈淋巴结清扫+对侧Ⅵ区颈淋巴结清扫术。228例患者有完整的术后随访资料,随访3～9年,平均随访(6.5±1.3)年。随访期间14例发生复发或转移,其中6例死亡,死亡原因均为术后复发或远处转移。结论影像学检查是诊断甲状腺癌最主要的检查方法,肿块细针穿刺细胞学检查对肿块性质的判断准确率高,可靠性强。淋巴结转移率与原发病灶直径有关,肿瘤病理类型、分期、肿瘤外侵程度、淋巴结转移度、年龄及初次手术方式的选择与术后复发有关。     

Healthcare Utilization is High in Adult Patients Relapsing after Allogeneic Hematopoietic Cell Transplantation

Disease relapse is the leading cause of death for patients with acute leukemia (AL) and myelodysplastic syndrome (MDS) who undergo allogeneic hematopoietic cell transplantation (HCT). Relapse post-HCT is associated with poor prognosis; however, inpatient healthcare utilization of this population is unknown. Here we describe survival, intensity of healthcare utilization, and characteristics associated with high resource use at the end of life (EOL). Adult patients with AL/MDS who underwent HCT at a large regional referral center with subsequent relapse between 2005 and 2015 were included in this retrospective study. We compared the distribution of demographic and clinical characteristics of patients as well as healthcare utilization over 2 years postrelapse and at EOL by postrelapse disease-directed therapeutic interventions. We created a composite score for EOL healthcare utilization intensity by summing the presence of any of the following criteria: death in the hospital, use of chemotherapy, emergency department, hospitalization, intensive care unit, intubation, cardiopulmonary resuscitation, or hemodialysis in the last month of life. Higher scores indicate more intense healthcare use at EOL. Multivariable linear regression analysis was used to determine variables (demographic characteristics, postrelapse treatment group, advance directives documentation, palliative care referral, time to relapse) associated with EOL healthcare utilization intensity. One hundred fifty-four patients were included; median age at relapse was 56 years (interquartile range [IQR], 39 to 63), 55% were men, 79% had AL, and median time from HCT to relapse was 6 months (IQR, 3 to 10). After relapse, 28% received supportive care only, 50% received chemotherapy only, and 22% received chemotherapy plus cell therapy (either donor lymphocyte infusion, second HCT, or donor lymphocyte infusion plus second HCT). With the exception of time until relapse and Karnofsky Performance Status, baseline characteristics (gender, age, race, graft-versus-host disease, year of treatment) did not significantly differ by postrelapse treatment group. One hundred thirty-six patients (88%) died within 2 years of relapse; survival differed significantly by postrelapse treatment group, with those receiving disease-directed treatment showing lower risk of death. Healthcare use in AL/MDS patients after post-HCT relapse was high overall, with 44% visiting the emergency department at least once (22% at least 2 times), 93% hospitalized (55% at least 2 times, 16% at least 5 times), and 38% using the intensive care unit (median length of stay 5, days; IQR, 3 to 10). Use was high even among those receiving only supportive care. For those patients who died, the mean intensity score for EOL healthcare use was 1.8 (standard deviation, 1.8). Most patients (70%) had a marker of high-intensity healthcare utilization at the EOL or died in hospital. In multivariable analysis, an increase in age (estimate -.03 (95% CI, -.06 to -.003) and having AL versus MDS were significantly associated with a decreased EOL healthcare intensity score; no other variables were associated with intensity of EOL healthcare use. Healthcare utilization after post-HCT relapse is associated with receipt of disease-directed therapy but remains high across all groups despite known poor prognosis. Interventions are needed to minimize nonbeneficial treatments and promote goal-concordant EOL care in this seriously ill patient population.     

首发及复发精神分裂症的性激素水平比较

目的:比较首发与复发精神分裂症的性激素水平,探讨精神分裂症与性激素的关系。方法:选取符合条件的首发及复发精神分裂症患者95例,使用利培酮治疗,疗程6周,分别于治疗前和治疗后进行雌二醇(E2)、孕酮(Prog)、睾酮(T)、催乳素(PRL)、促卵泡激素(FSH)、黄体生成素(LH)检测和BPRS评定。结果:与首发男性患者相比,复发男性患者的基线Prog水平较高,T水平较低,治疗后T水平仍低于首发患者;与首发女性患者相比,复发女性患者的基线E2、T水平较低,PRL水平较高,治疗后E2、Prog、LH水平低于首发患者,PRL水平仍高于首发患者。上述差异均有显著性(P<0.05)。结论:无论治疗前还是治疗后,首发与复发精神分裂症的性激素水平均有差异,影响因素较多。     

Perceived support to stay quit: What happens after delivery?

Objective

To assess whether perceived changes in postpartum support were associated with postpartum return to smoking.

Study design

This is a prospective repeated measures, mixed methods observational study. Sixty-five women who smoked prior to pregnancy were recruited at delivery and surveyed at 2, 6, 12, and 24 weeks postpartum; in-depth interviews were conducted when participants reported smoking.

Results

Fifty-two percent self identified as White, non-Hispanic. Forty-seven percent resumed smoking by 24 weeks postpartum. Women who had returned to smoking by 24 weeks had a significantly larger decrease in perceived smoking-specific support than women who remained abstinent (p < 0.001). By 24-week postpartum follow-up, only 24% of women reported that an obstetric clinician had discussed how to quit/stay quit. When qualitatively interviewed, more than half of women reported having no one to support them to stay quit or quit smoking.

Conclusion

Following delivery, women lack needed smoking-specific support. Decline in perceived smoking-specific support from family and friends is associated with postpartum smoking resumption.     

Hawley联合舌侧保持器和压膜式保持器的临床正畸保持效果比较

目的:比较Hawley联合舌侧固定保持器和压膜式保持器的临床效果,为选择合适的正畸保持方式提供参考。方法:选择正畸治疗刚结束的患者45例,随机给下颌戴用压膜式保持器(压膜式保持器组,25例)或联合保持器,即舌侧固定保持器配合夜间Hawley保持器(联合保持器组,20例)。每隔3个月复诊1次,记录矫治前、矫治结束时以及保持6个月和保持1年后的覆、覆盖及牙石指数。在模型上测量下颌牙扭转度、尖牙间和磨牙间宽度以及下前牙不齐指数。采用SAS 6.12软件包对数据进行方差分析、卡方检验和Fisher确切检验,比较2组之间的差异。结果:压膜式保持器组各测量项目在矫治后、保持6个月和保持1年后均无显著差异(P>0.05)。联合保持器组除牙石指数在保持6个月和1年后变化显著大于压膜式保持器组外(P<0.05),其余各项指标2组间均无显著差异。1年内的损坏率,压膜式保持器和联合保持器分别是24%和20%,即成功率76%和80%,两者无显著差异。结论:压膜式保持器保持和舌侧固定保持器配合夜间Hawley保持器保持的1年随访效果均良好,但综合考虑患者依从性和保持器的可靠性,后者是较好的保持方式。     

儿童自身免疫性溶血性贫血和Evans综合征复发及其相关因素分析

目的研究和探讨儿童自身免疫性溶血性贫血(AIHA)和Evans综合征复发率及其相关因素。方法采用同期病例对照法,比较不同因素与复发的相关性。结果40例患者中有7例复发,复发率为17·5%,Coombs阴性患者复发率为66·66%,Coombs阳性患者复发率为13·51%。复发发生在首次发病的2个月到2年7个月之间,4例在停药后,2例在激素减量中。复发诱因中感染因素占4例(57·14%),主要为呼吸道和消化道感染;无诱因者3例(42·86%)。复发组和未复发组患儿的性别、抗体的类型、是否存在其他自身免疫性疾病、患病时的血红蛋白水平和网织红细胞计数等均与复发无关(P>0·05)。细胞免疫功能的检查结果显示复发组CD3增高、CD8降低,经统计学分析两组存在显著差异(P<0·05)。结论儿童AIHA和Evans综合征的复发率远低于成人,复发患者免疫功能异常较未复发患者显著。