急性淋巴细胞白血病患儿早期治疗反应与预后关系

目的:分析急性淋巴细胞白血病(ALL)患儿早期治疗反应与预后的关系。方法:选取2013年3月-2017年3月期间在海南省人民医院进行诊治的278例ALL患儿。所有患者接受CCLg-ALL-2008治疗方案治疗,从对患儿早期治疗反应的第8天泼尼松敏感试验、第15天骨髓缓解状态(D15-BM)、第33天骨髓缓解状态(D33-BMR)和第33天微小残留病(D33-MRD)4个指标分析不同分组患儿3年无事件生存率(3年EFS),将这4个指标和其他可能影响患儿预后的指标纳入Cox回归模型分析及其独立影响因素。结果:共269例患儿参与了第8天泼尼松敏感试验,结果显示激素反应良好(PGR)者240例(89.22%)、高于激素反应不良(PPR)者29例(10.78%),其中PGR患者3年EFS明显大于PPR患者(P0.05)。262例患儿D15-BM试验显示,骨髓缓解状态为M1者230例(87.79%),M2组20例(7.63%),M3组12例(4.58%);3年EFS M1组明显高于M2组、而M2组明显高于M3组(P0.05)。257例患儿D33-BMR试验显示,骨髓缓解状态为M1者227例(88.33%),明显高于M2组21例(8.17%)和M3组9例(3.51%);M1组的3年EFS高于M2组,M2组高于M3组,组间差异有统计学意义(P0.05)。185例患儿D33-MRD试验显示,MRD10~(-4)组128例(69.19%),MRD≥10~(-4)-10~(-2)组43例(23.24%),≥10~(-2)组14例(7.57%);10~(-4)组的3年EFS高于MRD≥10~(-4)-10~(-2)组,而MRD≥10~(-4)-10~(-2)组高于≥10~(-2)组,组间差异有统计学意义(P0.05)。Cox模型分析显示,D8泼尼松敏感试验中PPR、D15和D33-BMR中M2和M3、D33-MRD中≥10~(-2)和T-ALL分型为影响ALL患者预后的独立风险因素。结论:早期治疗反应指标可预测ALL患儿预后情况,为ALL患儿预后的独立影响因素。     

急性淋巴细胞白血病儿童骨髓单个核细胞CRLF2高表达的临床意义

目的:检测初诊急性淋巴细胞白血病(ALL)儿童的骨髓单个核细胞CRLF2表达水平,并探讨其在儿童ALL中的临床意义。方法:对第一疗程化疗获得完全缓解且有完整随访信息的218例初诊ALL儿童,采用实时荧光定量PCR方法检测骨髓单个核细胞CRLF2表达水平;分析CRLF2表达水平在ALL儿童临床预后中的意义。结果:有完整资料的218例儿童ALL中有28例CRLF2高表达。CRLF2高表达组累计复发率明显高于低表达组(53.6%vs 12.6%)(P 0.01),CRLF2高表达组预计5年无复发生存率明显高于低表达组(P 0.01)。标危组中的CRLF2高表达和低表达患儿预计5年无复发生存率的差异无统计学意义(P 0.05),中危组和高危组中CRLF2低表达的患儿预计5年无复发生存率均高于高表达组的儿童(P 0.05)。Cox法分析显示,CRLF2高表达是影响ALL儿童复发的独立危险因素。结论:CRLF2高表达的ALL儿童复发率高,CRLF2高表达是中高危ALL儿童复发高风险的重要预后因素。有必要将CRLF2表达水平作为ALL儿童的危险分层的指标。     

儿童T系急性淋巴细胞白血病的临床特点及预后分析

本研究旨在探讨儿童T系急性淋巴细胞白血病(T-ALL)的临床特征与预后。回顾性分析2005年1月到2010年8月我院血液科收治的初诊T-ALL 38例患儿的临床资料,并随机抽取B系ALL中危组、高危组患儿共78例作为对照,比较两者泼尼松试验敏感率、诱导化疗第33天完全缓解(CR)率、复发率及3年无事件生存(EFS)率。结果表明,T-ALL与B-ALL两者在年龄、肝脾淋巴结肿大、中枢神经系统浸润及染色体异常、融合基因比例等方面的差异无统计学意义(p>0.05);与B系ALL患儿比较,T系ALL患儿在性别构成、白细胞计数≥50×109/L比例的差异均有统计学意义(p<0.05)。T-ALL、B-ALL患儿对泼尼松预处理敏感率分别为51.9%和89.3%,差异有统计学意义(p<0.05),而两组患儿诱导化疗未缓解率分别为15.4%、8.1%,差异无统计学意义(p>0.05)。26例T系ALL患儿中有8例(30.8%)复发,74例B-ALL患儿中有11例(14.9%)复发。T系和B系ALL患儿CR至复发时间分别为(9.78±3.48)个月和(21.28±14.32)个月(p<0.05)。中、高危组B-ALL和中、高危组T-ALL患儿Kaplan-Meier生存曲线分析显示,3年EFS率分别为(66.7±7)%、(37.5±17.1)%、(51.7±9.3)%、(22.2±9.8)%(p<0.05)。结论:与B-ALL患儿相比T-ALL男性比例和初诊白细胞数均较高,且早期泼尼松反应和3年EFS率均较B-ALL差。     

门冬酰胺合成酶表达水平与儿童急性淋巴细胞白血病预后的相关性研究

目的 探讨儿童急性淋巴细胞白血病(ALL)肿瘤细胞中门冬酰胺合成酶(AS)基因表达水平是否与ALL的治疗反应和预后相关.方法 用实时荧光定量PCR(Real-time Quantitative PCR,RQ-PCR)测定53例初发ALL患儿骨髓单个核细胞(BMMNC)AS mRNA水平,结合其临床资料,统计分析不同预后组患儿初诊时BMMNC中AS表达水平差异及其与预后的关系.结果 未缓解组患儿AS表达水平最高,表达水平中位值为17.25(2.48～46.82),复发组其次,为14.28(3.20～54.47),持续完全缓解组患儿AS表达水平最低,为5.08(0.84～54.92),三组比较差异有统计学意义(P＜0.05).合并未缓解和复发两组患儿,其中位AS mRNA水平为14.93(2.48～54.47),显著高于持续完全缓解组患JL(P＜0.01).AS低表达组患儿白血病持续完全缓解率为84.6%,而AS高表达组患儿持续完全缓解率仅为53.8%(P＜0.05).AS高表达组患儿的2年预计无病生存率为51.6%,显著低于AS低表达组患儿(84.6%)(P＜0.05).结论 AS高表达与患儿预后不良相关.     

吡柔比星、长春新碱、环磷酰胺、泼尼松联合治疗复发与难治性急性淋巴细胞白血病的效果分析

目的探讨吡柔比星(THP)、长春新碱(VCR)、环磷酰胺(CTX)、泼尼松(Pred)联合治疗复发与难治性急性淋巴细胞白血病(ALL)的效果。方法回顾分析2017年11月至2018年11月32例复发与难治性急性淋巴细胞白血病患者的临床资料,对照组15例患者采取TVLP方案治疗,观察组17例患者给予TCVP方案治疗。比较两组的总缓解率与不良反应发生率。结果观察组患者的总缓解率(70.59%,12/17)高于对照组(53.33%,8/15),差异有统计学意义(P0.05);观察组患者的不良发应发生率(29.41%,5/17)低于对照组(33.33%,5/15),差异未见统计学意义(P0.05),两组均无因毒副作用而终止治疗病例。结论对复发与难治性急性淋巴细胞白血病患者采取THP、VCR、CTX、Pred联合治疗能促进疾病缓解,改善患者的预后质量,且未出现严重的不良反应,值得广泛推广。     

尾型同源盒基因在成人急性淋巴细胞白血病中表达及临床意义

本研究旨在探讨同源盒基因CDX1,CDX2和CDX4在成人急性淋巴细胞白血病(ALL)中的表达及其临床意义.急性淋巴细胞白血病骨髓或外周血标本51份,采用逆转录聚合酶链反应(RT-PCR)检测CDX1,CDX2和CDX4在成人急性淋巴细胞白血病患者和14例正常对照组中的表达情况.结果表明,在14例健康成人中未见CDX1,CDX2和CDX4表达,15例缓解期急性淋巴细胞白血病患者中未见CDX1,CDX2和CDX4表达,在初治ALL患者中CDX2的表达率为60.8%,而在治疗缓解后其表达率明显下降(p<0.05);在复发组患者中CDX2表达率又升高(81.8%);CDX2表达与疾病危险分组相关,高危组CDX2阳性率为91.7%,高于标危组45.7%(p<0.05);CDX1和CDX4在初治及复发成人ALL中皆无表达.在初治和复发的成人ALL患者中CDX2表达阳性患者的完全缓解率(CR)低于表达阴性的患者(p<0.05);CDX2表达阳性患者的中位生存时间短于阴性表达的患者.结论:CDX2表达和成人ALL的发病、复发相关,CDX1和CDX4表达与成人ALL发病及复发无相关性;CDX2表达阳性的患者完全缓解率低,预后不良;CDX2可作为成人急性淋巴细胞白血病的发病、复发及预后判断的指标之一.     

急性淋巴细胞白血病高危组患儿临床特点和预后因素分析

目的:探讨急性淋巴细胞白血病(ALL)高危组患儿的临床特点和预后因素。方法:2008年8月至2013年3月在苏州大学附属儿童医院就诊的初诊ALL患儿共421例,均采用中国儿童白血病协作组(CCLG)-2008-ALL方案危险分层并治疗,其中标危组148例,中危组191例,回顾性分析高危组82例患儿的临床特点、预期5年概率无事件生存(pEFS)率及总生存(pOS)率。结果:82例病人中位随访时间64(3.0-76.3)个月;诱导化疗1个疗程后达完全缓解55例(缓解率67.1%),复发25例(30.5%)[以早中期复发为主,与标危组差异有统计学意义(P=0.013)],死亡27例(32.9%);5年pEFS率及pOS率分别为57.20%和58.50%。单因素分析显示,Ph~+或BCR/ABL~+和第33天MRD10~(-2)两项因素对EFS和OS影响均有统计学意义(P0.05);多因素COX回归分析显示,Ph~+或BCR/ABL~+具有独立预后意义,第33天MRD因素差异无统计学意义。结论:ALL高危组患儿具有诱导缓解率低、复发率高和5年pEFS率低的临床特点;存在有Ph~+或BCR/ABL~+是其预后差的独立因素。     

吡柔比星、长春新碱、环磷酰胺、泼尼松联合治疗复发与难治性急性淋巴细胞白血病的效果

目的探讨吡柔比星、长春新碱、环磷酰胺、泼尼松(VTCP方案)联合治疗复发与难治性急性淋巴细胞白血病(ALL)的效果。方法选取2015年2月至2018年6月焦作市第二人民医院14例复发与难治性急性淋巴细胞白血病患者为研究对象,14例复发与难治性急性淋巴细胞白血病患者均接受VTCP方案治疗,记录其疗效、治疗前后实验室指标变化情况、治疗期间毒副反应发生情况。结果 14例复发与难治性ALL患者经相应方案治疗后总有效率为78.57%(11/14);治疗期间14例患者存在不同程度的恶心呕吐、脱发、骨髓抑制等毒副反应,未见心肝肾损害;14例患者治疗后白细胞计数、幼稚细胞比例显著低于治疗前,治疗后血红蛋白、血小板计数显著高于治疗前(P0.05)。结论应用吡柔比星+长春新碱+环磷酰胺+泼尼松联合方案对复发与难治性ALL患者治疗有效性、安全性均较优。     

儿童急性淋巴细胞白血病分层诊断及相关因素研究

目的通过收集骨髓融合基因、微小残留病（MRD）结合早期治疗反应等危险因素,对急性淋巴细胞白血病（ALL）患儿进行分层诊断和治疗,并比较各组治疗效果,评价疗效。方法收集2007年5月～2008年9月在本院初诊并接受正规化疗的ALL患儿资料,统计分析．评价相关因素与预后的关系。结果临床资料初步显示BCR—ABL阳性ALL患儿易复发,TEL-AML1阳性患者的治疗反应较好。泼尼松诱导试验不良、第19天骨髓象为M2／M3患者复发率高于诱导试验良好、骨髓象为M1患儿组。诱导治疗结束时骨髓MRD水平〉1％组较〈1％组复发率高。结论临床资料结合骨髓形态学检查、MRD和融合基因定期监测,对急性淋巴细胞性白血病患儿分层诊断和个体化治疗、提高治疗效果具有重要价值。     

儿童T系急性淋巴细胞白血病的临床研究

目的 研究T系急性淋巴细胞白血病(ALL)患儿的临床与预后特征.方法 对1999年1月至2005年4月采用ALL-XH-99方案治疗的305例ALL患儿进行细胞形态学、免疫学、细胞遗传学和分子遗传学分型,并按型分层治疗.结果 在305例ALL患儿中T系ALL患儿43例,其中男34例(79.1%),平均年龄7.8(2.2～16.4)岁,大于10岁的患儿29例(67.4%),中危和高危组患儿分别为11例和32例,WBC≥50×109/L 27例(62.8%),骨髓形态学分型L2 32例,22例患儿出现纵隔增宽.与B系ALL患儿比较,T系ALL患儿在骨髓形态学分型L2比例、大于10岁患儿的比例和WBC≥50×109/L的比例差异均有统计学意义(P<0.05).在诱导缓解治疗中,T系ALL患儿泼尼松窗口试验反应好和第19天骨髓未达缓解的比例分别为62.9%和57.9%,与B系ALL患儿比较,差异均有统计学意义(P值均<0.01).有14例T系ALL患儿复发,完全缓解至复发时间为(1.2±1.5)年.T系ALL患儿的8年无事件生存(EFS)率、无复发生存(RFS)率和总生存(OS)率分别为(40.2±10.1)%、(51.4±11.6)%和(49.8±9.9)%,而B系ALL患儿的8年EFS率、RFS率和OS率分别为(72.1±3.0)%、(83.2±2.7)%和(76.6±2.9)%(P值均<0.01).结论 T系ALL患儿在年龄、白细胞计数和骨髓形态学分型上和B系ALL患儿存在差异,早期治疗反应以及远期疗效较B系ALL患儿差.     

Determination of creatine kinase isoenzyme MB activity in serum using immunological inhibition of creatine kinase M subunit activity. Activity kinetics and diagnostic significance in myocardial infarction.

This is a new method for the determination of creatine kinase isoenzyme MB activity in serum. The method uses direct activity measurement of creatine kinase B subunit activity after blocking of CK-M subunit activity by inhibiting antibodies. The test takes no longer than 15 min. The method yields an intra-serial C.V. of 2.0-12.9%, and a C.V. from day to day of 5.5%. The detection limit is 3.4 U/l creatine kinase MB. In the 95 cases with proven myocardial infarction several types of creatine kinase MB activity kinetics could be determined. The percentage of creatine kinase MB of peak CK-total is 6-25%, with a mean of 11.1%. The amount of creatine kinase MB with respect to total CK activity after reinfarction is higher than the amount after initial infarction.     

俯卧位通气对高海拔地区肺复张治疗无效急性呼吸窘迫综合征患者氧合的影响

目的 探讨俯卧位通气对高海拔地区肺复张术(RM)治疗无效急性呼吸窘迫综合征(ARDS)患者的治疗作用.方法 从海拔2260m的地区医院筛选RM治疗无效的41例ARDS患者[平均氧合指数( PaO2/FiO2)较RM前升高＜20％视为RM无效],依不同病因分为肺内源性ARDS组(ARDSp组)和肺外源性ARDS组(ARDSexp组),每组再按信封法随机分为俯卧位组和仰卧位组,即ARDSp俯卧位组(11例)、ARDSp仰卧位组(9例)、ARDSexp俯卧位组(10例)、ARDSexp仰卧位组(11例).在通气前及通气1、2、3、4h监测动脉血氧分压( PaO2)、PaO2/FiO2、静态顺应性(Cst)、气道阻力(Raw)的变化.结果 通气lh时,ARDSexp俯卧位组PaO2/FiO2( mm Hg,l mm Hg=0.133 kPa)即较通气前显著升高(157.4±40.6比129.3±48.7,P＜0.05),并随通气时间延长呈持续增高趋势,4h达峰值(219.1 ±41.1);且ARDSexp俯卧位组通气3h内PaO2/FiO2较其他3组显著增高,另3组间则差异无统计学意义.ARDSp俯卧位组、ARDSexp俯卧位组通气4h时PaO2/FiO2均较相应仰卧位组显著增高(208.8±39.7比127.4±47.1,219.1±41.1比124.9±50.8,均P＜0.05).4组通气前后Cst无显著改变,各组间差异也无统计学意义.ARDSp俯卧位组通气4h时Raw(cmH2O·L-1·s-1)较通气前显著降低(6.8±1.7比10.7±1.8,P＜0.05),且明显低于其他3组;其他3组各时间点Raw组内及组间比较差异均无统计学意义.结论 俯卧位通气作为ARDS机械通气重要策略之一,可以改善RM无效高原ARDS患者的氧合,为抢救患者赢得宝贵的时间.     

Digital imaging among medical facilities

The Department of Veterans Affairs (VA) in the USA operates a network of 172 medical centres which all utilize a hospital information system (HIS) which has been developed and is currently maintained by the VA. During the past several years, an image management and communication module has been developed, installed and clinically utilized at the Washington DC and Maryland VA Medical Centres. This image management and communication system, referred to as the decentralized hospital computer program (DHCP) imaging system, is fully integrated with a commercial picture archiving and communication system (PACS). The system is utilized to capture, archive, and display all images generated within the hospital including radiology, nuclear medicine, pathology, endoscopy, bronchoscopy, and dermatology, intraoperative photographs, ECG data, and a limited number of paper documents. The ultimate goal of the project is to have all patient text and image data available at any clinical workstation to any authorized user anywhere within the network of medical centres. Clinical requirements for an imaging workstation include ease of use, rapid and reliable access to the complete set of patient information, and images which are of acceptable quality to meet the requirements of the user and the subspecialty. Patient confidentiality and data security must be safeguarded at all times. Integration of the images with the remainder of the patient's database was found to be critical to the success of the project. The experience at the Washington and Maryland facilities suggests that an imaging system that is successfully integrated with a hospital information system can provide substantial clinical and economic benefits both within and among medical centres. Clinical acceptance and utilization of the system has been excellent, particularly in diagnostic radiology where DHCP Imaging has been interfaced to a commercial PAC system. Based upon this initial experience, the VA has begun to deploy the system throughout its large network of medical centres.     

Myocardial elastography at both high temporal and spatial resolution for the detection of infarcts

Myocardial elastography is a novel method for noninvasively assessing regional myocardial function, with the advantages of high spatial and temporal resolution and high signal-to-noise ratio (SNR). In this paper, in-vivo experiments were performed in anesthetized normal and infarcted mice (one day after left anterior descending coronary artery [LAD] ligation) using a high-resolution (30 MHz) ultrasound system (Vevo 770, VisualSonics Inc., Toronto, ON, Canada). Radiofrequency (RF) signals of the left ventricle (LV) in longitudinal (long-axis) view and the associated electrocardiogram (ECG) were simultaneously acquired. Using a retrospective ECG gating technique, 2-D full field-of-view RF frames were acquired at an extremely high frame rate (8 kHz) that resulted in high-quality incremental displacement and strain estimation of the myocardium. The incremental results were further accumulated to obtain the cumulative displacements and strains. Two-dimensional and M-mode displacement images and strain images (elastograms), as well as displacement and strain profiles as a function of time, were compared between normal and infarcted mice. Incremental results clearly depicted cardiac events including LV contraction, LV relaxation and isovolumetric phases in both normal and infarcted mice, and also evidently indicated reduced motion and deformation in the infarcted myocardium. The elastograms indicated that the infarcted regions underwent thinning during systole rather than thickening, as in the normal case. The cumulative elastograms were found to have higher elastographic SNR (SNR(e)) than the incremental elastograms (e.g., 10.6 vs. 4.7 in a normal myocardium, and 6.0 vs. 2.4 in an infarcted myocardium). Finally, preliminary statistical results from nine normal (m = 9) and seven infarcted (n = 7) mice indicated the capability of the cumulative strain in differentiating infracted from normal myocardia. In conclusion, myocardial elastography could provide regional strain information at simultaneously high temporal (>/=0.125 ms) and spatial ( approximately 55 microm) resolution as well as high precision ( approximately 0.05 microm displacement). This technique was thus capable of accurately characterizing normal myocardial function throughout an entire cardiac cycle, at the same high resolution, and detecting and localizing myocardial infarction in vivo.     

Clinical Pharmacokinetics of Morphine

Morphine, the most widely used mu-opioid analgesic for acute and chronic pain, is the standard against which new analgesics are measured. A thorough understanding of the pharmacokinetics of morphine is required in order to safely and effectively use this analgesic in a wide variety of patients with different levels of organ function. A MEDLINE search was conducted to identify literature published between 1966 and January 2002 relevant to the pharmacokinetics of morphine. These publications were reviewed and the literature summarized regarding unique and clinically important elements of morphine disposition relative to its parenteral administration (including intravenous, intramuscular, subcutaneous, epidural and intrathecal administration), absorption profile (immediate release, controlled release, and sublingual/buccal, and rectal administration), distribution, and its metabolism/ excretion. Special populations, including infants, elderly, and those with renal/liver failure, have a unique morphine pharmacokinetic profile that must be taken into account in order to maximize analgesic efficacy and reduce the risk of adverse events.     

Evidence-Based Pain Management and Palliative Care in Issue Four for 2009 of The Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly. Issue 4 for 2009 contains 4027 complete reviews, 1906 protocols for reviews in production, and 11447 one-page summaries of systematic reviews published in the general medical literature. In addition, there are citations of 600,000 randomized controlled trials, and 12,200 cited papers in the Cochrane methodology register. The health technology assessment database contains over 7500 citations. This edition of the Library contains 90 new reviews, of which 19 have potential relevance for practitioners in pain and palliative medicine.     

Molecular characterization of virulence and antimicrobial resistance profile of Shigella species isolated from children with moderate to severe diarrhea in northeastern Brazil

Molecular characterization of virulence and antimicrobial resistance profiles were determined for Shigella species isolated from children with diarrhea in Fortaleza, Brazil. Fecal specimens were collected along with socioeconomic and clinical data from children with moderate to severe diarrhea requiring emergency care. Shigella spp. were isolated by standard microbiological techniques, and we developed 4 multiplex polymerase chain reaction assays to detect 16 virulence-related genes (VRGs). Antimicrobial susceptibility tests were performed using disk diffusion assays. S. flexneri and S. sonnei were the predominant serogroups. S. flexneri was associated with low monthly incomes; more severe disease; higher number of VRGs; and presence of pic, set, and sepA genes. The SepA gene was associated with more intense abdominal pain. S. flexneri was correlated with resistance to ampicillin and chloramphenicol, whereas S. sonnei was associated with resistance to azithromycin. Strains harboring higher numbers of VRGs were associated with resistance to more antimicrobials. We highlight the correlation between presence of S. flexneri and sepA, and increased virulence and suggest a link to socioeconomic change in northeastern Brazil. Additionally, antimicrobial resistance was associated with serogroup specificity in Shigella spp. and increased bacterial VRGs.     

护理干预对面部中重度寻常型痤疮的临床疗效影响分析

目的研究护理干预对面部中重度寻常型痤疮的临床疗效影响。方法选取本院在2014年4月~2016年7月诊治的136例面部中重度寻常型痤疮患者,随机分为研究组与对照组,每组68例;所有患者均依据其情况给予对应的治疗,其中对照组在治疗期间给予常规护理,研究组在对照组的基础上再给予综合性护理干预,比较两组的治疗效果及护理满意度情况等。结果患者在接受治疗和护理后,研究组中度与重度患者的治疗效果较对照组均明显提高(P0.05),研究组护理满意度较对照组明显增高(P0.05)。结论对面部中重度寻常型痤疮患者在其治疗期间给予综合性护理干预,具有良好的效果。