十二指肠乳头癌的诊断与外科治疗

目的:探讨十二指肠乳头癌的早期诊断及治疗。 方法:回顾性分析10年间收治的71例经手术及病理证实的十二指肠乳头癌患者的临床资料。 结果:十二指肠乳头癌主要以进行性无痛性黄疸（57例）、上腹部隐痛（10例）及上消化道出血（4例）为首发临床表现。术前纤维十二指肠镜确诊率为96.8%，逆行性胆胰管造影（ERCP）阳性率为100.0%，磁共振胰胆管显像（MRCP）为83.3%，B超为85.9%，CT为72.3%。46例行胰十二指肠切除术（Whipple术），22例行十二指肠乳头癌局部切除术，3例行姑息性胆肠吻合术。Whipple 术及局部切除术术后的3年生存率分别为43.9%和44.4%；5年生存率分别为31.7%和33.3%。结论:纤维十二指肠镜检查和ERCP，MRCP是诊断十二指肠乳头癌的有效方法，早期诊断、早期选择合理的根治性切除手术是治疗的关键。     

甲状腺癌的外科治疗

目的 探讨甲状腺癌的外科手术治疗的方式和效果.方法 回顾性分析1990-2005年间上海市第八人民医院和江苏大学附属医院收治的126例甲状腺癌患者的临床资料.结果 126例甲状腺癌中,乳头状腺癌94例（74.6%）,其中有2例为桥本氏病合并甲瘤和甲状腺乳头状腺癌,1例还合并有甲亢,滤泡状腺癌20例（15.9%）,髓样癌5例（4.0%）,未分化癌4例（3.2%）,恶性淋巴瘤2例（1.6%）,鳞状细胞癌1例.126例中肿瘤直径小于1 cm的甲状腺微小癌（TMC）56例,均为乳头状腺癌.术后随访5年以上78例,1～5年36例,生活质量均为良好.未分化癌4例均于术后3～6个月死亡,2例髓样癌和1例鳞状细胞癌术后1年均因肺转移死于咯血.结论 早期诊断和治疗、规范手术切除范围可避免因漏诊再次手术,术后应早期尽量替代治疗.     

Post-Transplant Lymphoproliferative Disorders Occurring After Renal Transplantation in Adults: Report of 230 Cases From the French Registry

Post-transplant lymphoproliferative disorders (PTLD) are a rare but serious complication after organ transplantation. A French Registry of PTLD was set up in a nationwide population of kidney transplant recipients. We prospectively enrolled all adult kidney recipients developing PTLD between January 1, 1998, and December 31, 2003. We analyzed the incidence, risk and prognostic factors of PTLD by Kaplan-Meier and Cox analyses. Totally 230 cases of PTLD were referred to the French Registry. Cumulative incidence was 1.18% after 5 years. Older age (per year, AHR = 2.19, CI = 1.22-3.94) and recipient Epstein-Barr virus seronegativity (AHR = 3.01, CI = 1.57-5.08) were associated with an increased risk of PTLD. Patients with PTLD had a reduced survival rate (61% at 5 years). Graft PTLD had the best prognosis with an 81% survival rate after 5 years. Infection with hepatitis C or B virus (HCV or HBV), late-onset PTLD, multiple sites involvement and high Ann Arbor staging were risk factors for patient death. Use of azathioprine was associated with a poorer survival rate. PTLD incidence and risk factors in French recipients are in line with the international or American PTLD series. We highlighted the role of HBV or HCV in patient mortality and described the relevant prognosis factors for patients with post-transplant lymphoproliferations.     

急性冠脉综合征中妊娠相关蛋白-A与斑块不稳定性

目的探讨妊娠相关蛋白-A(PAPP-A)在急性冠脉综合征(ACS)中的变化及其与斑块不稳定性的关系。方法26例冠脉正常者作为对照组,稳定性心绞痛(SA)组22例,ACS组40例,包括不稳定性心绞痛(UA)20例、急性心肌梗死(AMI)20例。定量检测外周血PAPP-A、C-反应蛋白(CRP)、肌酸激酶MB同工酶(CK-MB)。对所有冠脉造影显示狭窄≥30%的病变进行影像学分析。结果ACS中PAPP-A含量(13·19±4·04)mIU/L明显高于SA(5·47±3·00)mIU/L(P<0·01)及对照组(5·09±2·19)mIU/L(P<0·01);并且与CRP(r=0·62P<0·01)、复杂性狭窄的数量(r=0·45P<0·05)有显著的正相关。结论PAPP-A在ACS患者外周血中明显升高,可能与斑块的不稳定性有关,对ACS的危险度分层可能具有一定的价值。     

Blastomycosis in solid organ transplant recipients

BACKGROUND: Blastomyces dermatitidis, the etiologic agent of blastomycosis, causes severe disease and substantial mortality in those immunocompromised by acquired immunodeficiency syndrome or malignancy. In solid organ transplant recipients, the epidemiology, clinical features, and outcomes have not been fully described. METHODS: We conducted a retrospective case-series at the University of Wisconsin Hospital and Clinics. Case patients were solid organ transplant recipients with blastomycosis. RESULTS: From 1986 to 2004, we identified 11 cases of post-transplant blastomycosis with 64% occurring between 2000 and 2004. Onset of infection occurred a median of 26 months post transplantation with near equal distribution before and after the first year of transplantation. Rejection did not precede any case of post-transplant blastomycosis. Opportunistic co-infections were common, occurring in 36% of patients. Pneumonia was the most common clinical presentation and was frequently complicated by acute respiratory distress syndrome (ARDS). Extrapulmonary disease predominantly involved the skin and spared the central nervous system. The overall mortality rate was 36%; however, this increased to 67% in those with ARDS. None of the surviving patients relapsed or received routine secondary antifungal prophylaxis. CONCLUSION: Blastomycosis is an uncommon infection following solid organ transplantation that is frequently complicated by ARDS, dissemination, and opportunistic co-infection. After cure, post-transplant blastomycosis may not require lifelong antifungal suppression.     

抗端粒酶核酶抑制肝癌细胞裸鼠移植瘤生长的研究

设计针对端粒酶RNA组分的特异性核酶，研究该核酶对肝癌细胞裸鼠移植瘤生长的影响。构建含针对端粒酶RNA组分锤头状核酶基因的重组真核表达质粒pBBS212-RZ，以及建立人肝癌细胞株HepG2裸鼠移植瘤模型。将不同剂量的pBBS212-RZ用脂质体包裹后进行瘤体内多点注射，对照组注射生理盐水或空质粒载体pBBS212。连续注射2l天后，测量移植瘤体积和重量，检测瘤组织端粒酶活性。抗端粒酶特异性核酶使瘤组织端粒酶活性下降(抑制率为72％)，明显地抑制了肝癌细胞裸鼠移植瘤生长(抑制率为68％)，且存在剂量依赖性。抗端粒酶特异性核酶作为一种有效的端粒酶抑制剂，可抑制肝癌细胞的生长，有望在肝癌基因治疗中发挥作用。     

Intravenous Gammaglobulin (IVIG): A Novel Approach to Improve Transplant Rates and Outcomes in Highly HLA-Sensitized Patients

Intravenous immunoglobulin (IVIG) products are derived from pooled human plasma and have been used for the treatment of primary immunodeficiency disorders for more than 24 years. Shortly after their introduction, IVIG products were also found to be effective in the treatment of autoimmune and inflammatory disorders. Over the past 2 decades, the list of diseases where IVIG has a demonstrable beneficial effect has grown rapidly. These include Kawasaki disease, Guillain-Barre syndrome, myasthenia gravis, dermatomyositis and demyelinating polyneuropathy. Recently, we have described a beneficial effect on the reduction of anti-HLA antibodies with subsequent improvement in transplantation of highly HLA-sensitized patients as well as a potent anti-inflammatory effect that is beneficial in the treatment of antibody-mediated rejection (AMR). These advancements have enabled transplantation of patients previously considered untransplantable. These studies and relevant mechanism(s) of action will be discussed here.     

Survivin在T细胞非霍奇金淋巴瘤组织中的表达及临床意义

【目的】了解生存蛋白Survivin在T细胞非霍奇金淋巴瘤（T—NHL）中的表达，以及Survivin表达与预后的关系。【方法】用免疫组化S-P法检测83例T细胞NHL组织Survivin表达情况，分析Survivin表达与预后的关系。【结果】Survivin表达阴性10例（12％），表达阳性73例（88％），Survivin表达与病理类型、性别、年龄、B症状、结外病变数、PS、分期、LDH水平、IPI等临床特征均无相关性（P〉0．05）。78例接受了化疗，大多数采用CHOP方案化疗，全组CR率45％，有效率86％，Survivin阴性者CR率60％，阳性者43％（P〉0．05）。中位随访22月（1—76月），全组5年生存率31％，Survivin表达阳性的T—NHL患者5年生存率明显低于Survivin表达阴性患者（21％比70％，P〈0．001）。多因素分析显示Survivin表达是T细胞NHL的独立预后指标。【结论】Survivin在T细胞NHL表达上调，Survivin阳性T—NHL患者5年生存率低于Survivin阴性者，Survivin表达可能为T细胞NHL预后的独立指标。     

Recovery and Utilization of Deceased Donor Kidneys from Small Pediatric Donors

The optimal use of kidneys from small pediatric deceased donors remains undetermined. Using data from the Scientific Registry of Transplant Recipients, 2886 small (< 21 kg) pediatric donors between 1993 and 2002 were identified. Donor factors predictive of kidney recovery and transplantation (1343 en bloc; 1600 single) were identified by logistic regression. Multivariable Cox regression was used to assess the risk of graft loss. The rate of kidney recovery from small pediatric donors was significantly higher with increasing age, weight and height. The odds of transplant of recovered small donor kidneys were significantly higher with increasing age, weight, height and en bloc recovery (adjusted odds ratio = 65.8 vs. single; p < 0.0001), and significantly lower with increasing creatinine. Compared to en bloc, solitary transplants had a 78% higher risk of graft loss (p < 0.0001). En bloc transplants had a similar graft survival to ideal donors (p = 0.45) while solitary transplants had an increased risk of graft loss (p < 0.0001). En bloc recovery of kidneys from small pediatric donors may result in the highest probability of transplantation. Although limited by the retrospective nature of the study, kidneys transplanted en bloc had a similar graft survival to ideal donors but may not maximize the number of successfully transplanted recipients.     

Histologic Findings One Year After Positive Crossmatch or ABO Blood Group Incompatible Living Donor Kidney Transplantation

Recent protocols have allowed successful positive crossmatch (+XM) and ABO incompatible (ABOI) kidney transplantation, although their long-term outcome is not clear. To begin to assess this issue we compared protocol biopsies performed 12 months posttransplant in 37 +XM, 24 ABOI and 198 conventional allografts. Although the majority in all three groups had only minimal histologic changes, transplant glomerulopathy (TG) was significantly increased in +XM (22% vs. 13% ABOI vs. 8% conventional, p = 0.015), and correlated with prior humoral rejection (HR) by multivariate analysis (odds ratio 17.5, p < or = 0.0001). Patients with a prior history of HR also had a significant increase in interstitial fibrosis (No HR 54% vs. HR 86%, p = 0.045). In the absence of HR no difference in histologic changes was seen between groups, although all three groups had a demonstrable mild increase in interstitial fibrosis from biopsies performed at the time of transplant. Thus, although HR is associated with an increase in TG, in its absence allograft histology is similar in +XM, ABOI and conventional allografts 1 year posttransplant.