Isolated Donor Specific Alloantibody-Mediated Rejection after ABO Compatible Liver Transplantation

Antibody-mediated rejection (AMR) after liver transplantation is recognized in ABO incompatible and xeno-transplantation, but its role after ABO compatible liver transplantation is controversial. We report a case of ABO compatible liver transplantation that demonstrated clinical, serological and histological signs of AMR without evidence of concurrent acute cellular rejection. AMR with persistently high titers of circulating donor specific antibodies resulted in graft injury with initial centrilobular hepatocyte necrosis, fibroedematous portal expansion mimicking biliary tract outflow obstruction, ultimately resulting in extensive bridging fibrosis. Immunofluorescence microscopy demonstrated persistent, diffuse linear C4d deposits along sinusoids and central veins. Despite intense therapeutic intervention including plasmapheresis, IVIG and rituximab, AMR led to graft failure. We present evidence that an antibody-mediated alloresponse to an ABO compatible liver graft can cause significant graft injury independent of acute cellular rejection. AMR shows distinct histologic changes including a characteristic staining profile for C4d.     

Lumbar Spinal Cord Stimulation Can Improve Muscle Strength and Gait Independently of the Analgesic Effect: A Case Report

Spinal cord stimulation (SCS) is widely used for pain relief in patients with failed back surgery syndrome (FBSS), and muscle weakness is a common finding in patients with chronic pain. We present here a single case report of a 47‐year‐old woman, who, after SCS for FBSS, had continuous improvement in lower leg muscle strength and gait, but only transient and minimal pain relief. To the authors’ knowledge, this is only the second published case report of significant improvement in “motor” function, independent of the analgesic effect following SCS in FBSS. If SCS, in fact, does improve muscle strength, new strategies for the management of patients with chronic pain might be opened up. Further studies are needed to verify this hypothesis.     

hs-CRP、TAS联合血脂检测在早老性痴呆症诊断中的应用研究

[目的]研究超敏C反应蛋白（hs-CRP）、总抗氧化状态（TAS）联合血脂检测在早老性痴呆症诊断中的应用价值：[方法]选择浦东新区精神卫生中心早老性痴呆专科门诊患者54例，作超敏C反应蛋白、总抗氧化状态与血脂检测。[结果]与对照组比较，实验组hs-CRP、TAS差异非常显著，t1=4．55，t2=2．79，P1〈0．001，P2〈0．01；血脂中甘油三酯、低密度脂蛋白胆固醇、载脂蛋白B、Lp（a）差异显著；t1=3.01，P1〈0．01，t2=2．21，P2〈0．05，t3=2．64，P3〈0．01，t4=1．91，P4〈0．05。[结论]超敏C反应蛋白、总抗氧化状态联合血脂（甘油三酯、低密度脂蛋白胆固醇、载脂蛋白B、Lp（a））检测对实验室诊断早老性痴呆症具有较好敏感性和特异性，临床应用前景乐观。     

严重慢性阻塞性肺疾病患者食管切除术围手术期并发症及处理

目的 探讨重度慢性阻塞性肺疾病简称慢阻肺病人食管切除术围手术期常见并发症及其处理。方法 45例重度慢阻肺的病人在全麻联合硬膜外阻滞下进行开胸食管切除手术，围手术期处理包括术前戒烟、胸部理疗、预防和控制呼吸道感染、解痉化痰、呼吸功能锻炼、营养支持和氧疗；术后硬膜外镇痛、早期锻炼、保持呼吸道通畅，部分病人予以呼吸支持。结果 术中3例出现低氧血症。术后所有病人PaO2均有不同程度的下降，6例出现肺部感染，6例行纤维支气管镜吸痰，2例通过气管插管给予呼吸机支持，2例行气管切开术，1例酸碱平衡紊乱使用盐酸精氨酸治疗。所有病人均痊愈出院。结论 重度慢阻肺病人并非开胸食管切除手术的绝对禁忌证，积极的术前准备和严格的术后管理可减少和控制术后急性发作，有助于确保此类病人的围手术期安全和康复。     

慢性肺心病哮喘持续状态218例临床分析

目的探索治疗慢性肺心病哮喘持续状态的方法。方法回顾性分析1983年10月～2005年3月收治的218例慢性肺心病哮喘持续状态患者的临床资料。结果哮喘持续状态在48h以内被控制的62例（28．4％）；在72h以内控制的56例（25．7％）；在120h以内控制的25例（11．5％）；在168h以内控制的34例（15．6％）；痊愈出院177例（81．2％）；死亡41例（18．8％）。结论（1）治疗慢性肺心病哮喘持续状态．根据患者的病理变化．综合治疗．效果显著。（2）在治疗过程中．要恰当选择抗生素和平喘药；对那些血液黏滞度增高的患者．要加用血液稀释疗法。（3）测定血液黏滞度和氧饱和度．可以指导治疗、估计预后．应当列为常规检查。     

Intrathecal Ziconotide in the Treatment of Chronic Nonmalignant Pain: A Randomized,Double‐Blind,Placebo‐Controlled Clinical Trial

Objective. The safety and efficacy of intrathecal (IT) ziconotide was studied in a randomized, double‐blind, placebo‐controlled trial. Materials and Methods. Patients (169 ziconotide, 86 placebo) with severe chronic nonmalignant pain unresponsive to conventional therapy and a visual analog scale of pain intensity (VASPI score) ≥ 50 mm were treated over a 6‐day period in an inpatient hospital setting. Initial starting dose was 0.4 µg/hour and was titrated to analgesia or intolerance (maximum dose 7.0 µg/hour). The starting and maximum doses were reduced to 0.1 µg/hour and 2.4 µg/hour, respectively, due to adverse events (AEs). Results. The mean percent reduction in VASPI score from baseline was 31.2% and 6.0% for ziconotide‐ and placebo‐treated patients, respectively (p ≤ 0.001). During the initial titration phase, a significantly greater percentage of patients in the ziconotide group compared to the placebo group reported AEs, including abnormal gait, amblyopia, dizziness, nausea, nystagmus, pain, urinary retention, and vomiting. Conclusion. Ziconotide provided significant analgesia in patients for whom conventional therapy failed. However, there was a considerable incidence of ziconotide‐associated AEs due to the rapid titration and high doses administered.     

社区干预对老年慢性支气管炎独居患者生活质量的影响

目的提高社区老年慢性支气管炎独居患者的生活质量.方法将70例老年慢性支气管炎独居患者随机分为对照组和干预组各35例.干预组采取社区健康干预,如疾病防治知识讲解、自我保健训练及干预人员(志愿者)与患者结对提供帮助与督促等;对照组未采取社区健康干预.于6个月后采用生活质量(QOL)测评表进行评估.结果干预组日常生活能力、社会活动能力、抑郁心理状态、焦虑心理状态及QOL总分显著优于对照组(均P<0.01).结论通过充分利用社区卫生资源为老年慢性支气管炎独居患者进行疾病防治的健康教育,可提高其生活质量.     

Emerging Issues in Hepatitis C Virus-Positive Liver and Kidney Transplant Recipients

Hepatitis C virus (HCV) infection is a major health care issue in liver and kidney transplantation. Besides negatively affecting both patient and graft survival, HCV is associated with a heightened risk for new onset diabetes mellitus (NODM). The mechanisms underlying the diabetogenicity of HCV are complex but are likely to involve insulin resistance caused by inhibitory actions of the virus on insulin regulatory pathways in the liver. The resultant glucose dysregulation is an important determinant of increased morbidity and mortality in liver and kidney recipients. This review highlights the concerns for outcomes in HCV-positive liver and kidney transplant patients with particular focus on the interrelationship between hepatitis C and diabetes. Data about the potential role of calcineurin inhibitors, corticosteroids and mycophenolate mofetil in HCV infection and HCV-associated NODM will also be discussed.     

Preservation of Bile Ductules Mitigates Bile Duct Loss

The finer branches of the biliary tree (FBBT) contain a regenerative compartment. We hypothesized that preservation of the FBBT together with its microvasculature will lead to recovery of biliary damage and prolonged preservation of bile ductules during the development of chronic liver allograft rejection. The interlobular bile ducts, portal bile ductules and extraportal biliary cells with and without microvessels were studied in sequential biopsies in five patients who fulfilled the Banff criteria of early chronic rejection (CR) (imminence group). Biopsies of CR patients (n = 12) served as controls. Biopsies were double immunostained with CD34 (microvessels) and cytokeratin 7 (biliary structures). Proliferation and proangiogenic activity were assessed with Ki67 and VEGF-A immunostaining. Severe damage of bile ducts in the imminence group did not progress to significant bile duct loss. This was associated with a high proliferative activity in all biliary structures and preservation of the microvascular compartment. VEGF-A expression was increased in all but the reperfusion biopsies. In conclusion, both regenerative activity of the FBBT and an intact microvascular compartment are associated with less damage of the biliary tree and could therefore be prerequisites for biliary regeneration.     

92例重型肝炎并发自发性细菌性腹膜炎的诊断与治疗

目的探讨重型肝炎并发自发性细菌性腹膜炎(SBP)的诊断和抗生素使用。方法回顾性分析2002年7月~2005年6月间收治的92例并发SBP的重型肝炎患者的临床资料。结果92例患者中,发热72例(78.26%),腹胀85例(92.39%),腹痛38例(41.30%),反跳痛35例(38.04%),83例(90.21%)外周血中性粒细胞(PMN)分类≥0.75,40例(45.98%)腹水PMN计数≥250个/mm3,79例(90.80%)腹水PMN比值≥0.50,11例(12.00%)腹水细菌培养阳性,共分离出细菌17株,G-杆菌占52.9%(9/17),其对头孢曲松、头孢哌酮、头孢他啶、左旋氧氟沙星及泰能敏感,对丁胺卡那、氧哌嗪青霉素敏感性较低。临床治疗显示,联合使用头孢他啶和甲硝唑效果较好,并较少出现继发真菌感染。结论重型肝炎并发SBP患者的临床表现不典型,腹水培养阳性率低,外周血和腹水PMN比值是诊断SBP比较可靠的参数。治疗SBP,可首选二联使用头孢他啶与甲硝唑,疗程约10~14日。