肾(肝)移植的治疗方案

免疫抑制剂在临床器官移植的发展中占有非常重要的地位,它对器官移植患者的长期存活,移植物保持良好功能起着重要作用.免疫抑制剂极大地推动了临床器官移植的发展和进步,可以看到免疫抑制剂不断的发展与应用对临床器官移植的发展起着决定作用.

僵人综合征1例报告并复习文献

僵人综合征（stiff-man syndrome，SMS）为慢性、进行性加重、持续性全身肌肉僵硬，在某种诱因下发作性出现有痛性肌肉痉挛为主征的临床综合征。本病罕见,现将近年来我们诊断的1例病人。现报告如下：

印度患者的Sweet综合征:4例报道及文献回顾

Background:Sweet’s syndrome or acute Febrile neutrophilic dermatosis is not frequently reported from India.Four patients fulfilling clinico-pathologic criteria for Sweet’s syndrome seen during May-August 2002 pompted us to review reports on Indian patients from the indexed literature.Methods:A PubMed and IndMed search for Sweet’s syndrome revealed 11 reports appearing between 1985-2002 documenting 12 patients.The clinico-pathologic features,clinical course and treatment of all these 16 patients(including four new cases)were studied.Results:The study comprised 12 females and four males between 35 days to 57 years of age.There were four children of < 12 years.Ulcerated,crusted lesions in one and typical,erythematous,tender,papulo-nodulo-plaques and targetoid lesions with pseudo vesiculation were observed in 13 other patients particularly involving head,neck and upper limbs.Extracutaneous Sweet’s syndrome manifesting as gingival hyperplasia And myositis was seen in one patient each.All had simultaneous onset of cutaneous lesions,fever,headache and malaise.Ocular involvement was observed in four patients only.Associated hematoligic disorders recorded were myelodysplasia in three,polycythemia vera in one and leukemia in three patients respectively.Two of these patients had treatment with all-transretinoic acid and low-dose cytosine-Abinoside before onset of Sweet’s syndrome.One patient each had symptoms of upper respiratory tract infection and history of minor injury prior to cutaneous lesions.Another patient had pregnancy induced self-limiting Sweet’s syndrome.Leukocytosis was present in 11 patients.Three of four new patients had positive tests for antistreptolysin-O and C-reactive protein.Characteristics histologic features were recorded in specimens of all patients.Eleven patients responded to systemic corticosteroids.Colchicin or potassium iodide were effective in one patient each.Conclusion:The overall clinico-pathologic and therapeutic spectrum of Sweet’s syndrome in Indian patients does not appear to be different from its established picture.

1例肺部受累的Sweet综合征病例报道及文献回顾

Pulmonary involvement in Sweet’s syndrome(SS)is rare.We report a case of SS with severe respiratory involvement responding to corticosteroid therapy.A 82-year-old man presented fever of 39 °C associated with cough and dyspnea,and crackles in the left lung.The infection work-up was negative.Chest X-ray showed cardiomegaly and left lower lobe pulmonary infiltrates.Pulmonary signs did not improve on treatment with antibiotics,and after 1 week maculopapular lesions appeared,localized on the knees,the periombilical area and the back.The antibiotics were changed without improvement.A skin biopsy revealed infiltration by neutrophilic granulocytes and marked edema in the dermis,consistent with SS.The patient’s condition progressively worsened,requiring high oxygenotherapy,and he was transferred to an intensive care unit.Chest X-ray revealed an important alveolar and interstitial syndrome.Bronchoalveolar lavage found 170 leukocytes with 30%neutrophils(N < 5%),7%lymphocytesand 63%macrophages.A search for bacteria,virusesor parasites in bronchoalveolar lavage was negative.The patientwas treated with antibiotics,a high dose of furosemide and steroids for 4 days.Because the patient improved dramatically within 5 days,with a negative infection work-up and a dramatic decrease of C-reactive protein,the antibioticswere stopped.Steroids were secondarily tapered very slowly.A chest computed tomography(CT)scan showed a substantial improvement of pulmonary lesions.We also review the 22 cases of pulmonary involvement of SS reported in the literature.

CHARACTERISTIC MAGNETIC RESONANCE ENHANCEMENT PATTERN IN CEREBRAL SCHISTOSOMIASIS

Objective To describe the characteristic magnetic resonance imaging （MRI） appearance of cerebral schistosomiasis. Methods Twenty-five patients whose diagnosis of central nervous system （CNS） schistosomiasis had been pathologically （n = 8 ） and clinically （n = 17） confLrmed were randomly selected. MRI was performed on a Signal 1.5T MRI scanner before and after the intravenous administration of gadopentetate dimeghimine constrast medium. We reviewed the MRI studies obtained at the time of initial presentation, as well as follow-up studies obtained during and after medical treatment Results ImmunoLogicaL tests in L5 patients indicated schistosomiasis haematobium. Contrast-enhanced TL-weighted images in 22 cases showed central linear enhancement surrounded by multiple enhancing punctate nodules, which ap- peared “arborized”. Through operation and pathological examination, 8 cases had the granuloma formation of schistoso- mal eggs extensive surrounded by inflammation and venous congestion. And 17 cases were treated with praziquantel and corticosteroid therapy. And they were followed up for 2 months by taking MRI, which turned out to be complete resolution of the enhancing structure and edema. At follow-up, all the patients＇ initial symptoms also resolved. Conclnsion The specified MRI enhancement pattern of cerebral schistosomiasis is common in most cases of CNS schistosomiasis, so it should be taken account into the diagnosis of cerebral schistosomiasis.

Plasmapheresis and corticosteroid treatment for persistent jaundice after successful drainage of common bile duct stones by endoscopic retrograde cholangiography

Prolonged cholestasis is a very rare complication of endoscopic retrograde cholangiography (ERC). Only few cases with this complication are reported in the English literature. We report persisting cholestatic jaundice in a 73-year old man after successful therapeutic ERC for choledocholithiasis. Serologic tests for viral and autoimmune hepatitis were all negative. A second-look ERC was normal also. He denied any medication except for prophylaxis given intravenous 1 g ceftriaxon prior to the ERC procedure. After an unsuccessful trial with ursodeoxycholic acid and cholestyramine for 2 wk, this case was efficiently treated with corticosteroids and plasmapheresis. His cholestatic enzymes became normal and intense pruritis quickly resolved after this treatment which lasted during his follow- up period. We discussed the possible mechanisms and treatment alternatives of intrahepatic cholestasis associated with the ERC procedure.

Clinical heterogeneity in autoimmune acute liver failure

AIM: To describe the outcome and prognosis in a cohort of patients with acute liver failure due to autoimmune hepatitis without liver transplantation. METHODS: A retrospective trial was conducted in 11 patients with acute liver failure due to autoimmune hepatitis who attended the Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubiran. Demographic, biochemical and severity indexes, and treatment and outcome were assessed. RESULTS: Among the 11 patients, with a median age of 31 years, 72% had inflammatory response syndrome, and six patients received corticosteroids. The mortality rate within four weeks was 56%, and the one-year survival was 27%. In the survivors, severity indexes were lower and 83% received corticosteroids. CONCLUSION: We observed a relatively high survival rate in patients with acute liver failure due to autoimmune hepatitis. This survival rate could be influenced by severity of the disease and/or use of corticosteroids.

The Role of Pineal Gland in Regulating Circadian Corticosterone Rhythm and Its Mechanism

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Treatment of severe steroid refractory ulcerative colitis

Although systemic steroids are highly efficacious in ulcerative colitis (UC), failure to respond to steroids still poses an important challenge to the surgeon and physician alike. Even if the life time risk of a fulminant UC flare is only 20%, this condition is potentially life threatening and should be managed in hospital. If patients fail 3 to 5 d of intravenous corticosteroids and optimal supportive care, they should be considered for any of three options: intravenous cyclosporine (2 mg/kg for 7 d, and serum level controlled), infliximab (5 mg/kg Ⅳ, 0-2-6 wk) or total colectomy. The choice between these three options is a medical- surgical decision based on clinical signs, radiological and endoscopic findings and blood analysis (CRP, serum albumin). Between 65 and 85% of patients will initially respond to cyclosporine and avoid colectomy on the short term. Over 5 years only 50% of initial responders avoid colectomy and outcomes are better in patients naive to azathioprine (bridging strategy). The data on infliximab as a medical rescue in fulminant colitis are more limited although the efficacy of this anti tumor necrosis factor (TNF) monoclonal antibody has been demonstrated in a controlled trial. Controlled data on the comparative efficacy of cyclosporine and infliximab are not available at this moment. Both drugs are immunosuppressants and are used in combination with steroids and azathioprine, which infers a risk of serious, even fatal, opportunistic infections. Therefore, patients not responding to these agents within 5-7 d should be considered for colectomy and responders should be closely monitored for infections.

Arctic spring: the arrival biology of migrant birds

On arrival in the Arctic, migrant birds must adjust their physiology and behavior to unpredictable snow cover, weather, food sources and predator pressure. In other words they must be resistant to environmental perturbations (stress) so that they can migrate to their tundra nesting areas and settle on territories as soon as possible. They can then begin breeding as soon as when environmental conditions become favorable. They do this partly by using micro-habitats such as areas where snow depth is low, and patches of tundra that melt out rapidly (especially near willows Salix sp). Ground temperatures increase dramatically within hours after exposure to sun; and invertebrate activity begins simultaneously. Wind speeds are attenuated almost completely within 10 cm of the ground in willows and tussock tundra. The combination of these conditions provides an ideal refuge, especially for passerine migrants in early spring. However, if conditions worsen, the birds can leave. There are adjustments of the adrenocortical responses to stress because arctic conditions in spring are potentially severe, at least compared with wintering grounds to the south. Secretion of corticosterone in response to acute stress is enhanced at arrival in males, accompanied by a decrease in sensitivity to negative feedback and a change in responsiveness of the adrenal cortex cells to adrenocorticotropin. There is also an increase in levels of corticosterone-binding globulin (CBG) so that the actions of corticosterone are buffered according to the severity of environmental conditions. Regulation at the level of genomic receptors, particularly the low affinity glucocorticosteroid-like receptor for corticosterone in brain and liver, may be important; and non-genomic actions of corticosterone may play a major role too. In other words, the hormone-behavior system associated with arrival biology is highly flexible.

A REPORT ON THE TREATMENT OF STEROID RESISTANT ASTHMA WITH ACUPUNCTURE-MOXIBUSTION AND ACUPOINT INJECTION

In the present paper, the authors report their results of treatment of 5 cases of steriod resistant asthma with acupoint-injection, body acupuncture, moxibustion and cupping. Bilateral Zusanli (ST 36) are used for acupoint injection of mixture solution of placenta tissue injectio (2 mL), Danggui (Radix Angelicae Sinesis) injectio (2 mL) and Huangqi (Radix Astragli seu Hedysari) injectio (4 mL), with 4 mL for each acupoint. Acupoints used for puncturing are bilateral Yuji (LU 10), Dingchuan (EX-B 1), Feishu (BL 13), Fengmen (BL 12), Gaohuangshu (BL 43), Taiyuan (LU 9), Fenglong (ST 40), Shenshu (BL 23), Zusanli (ST 36), etc.. Dazhui (GV 14), Tanzhong (CV 17), and Zhongwan (CV 12) are moxibustioned after insertion of acupuncture needles and achieving needling sensations. Cupping is applied to bilateral Dingchuan (EX-B 1) after removing acupuncture needles with a little blood out. Following 3 days’ treatment, these 5 asthma patients who have no apparent response to conventional medication treatment are relieved strikingly in the attack frequency, till the 7th day of the treatment, they have no any asthmatic onset again. One month’s follow-up shows no recurrence. Results indicate that acupuncture with moxibustion and cupping is fairly effective in relieving steriod resistant asthma patients who have no effect in responding to glucocorticoid treatment.

Effect of glucocorticoid on promoter of 11β-hydroxysteroid dehydrogenase I gene

Objective: To study the effect of glucocorticoid on the promoter of the pre-receptor glucocorticoid metabolizing enzyme 11β-hydroxysteroid dehydrogenase type 1 (11β-HSD1) gene. Methods: The 1. 2 kb length sequence upstream to the transcription start site of the 11β-HSD1 gene was amplified with polymerase chain reaction (PCR) and then was cloned into pBLCAT6 plasmid carrying chloramphenicol acetyltransferase ( CAT) reporter gene. The plasmid pBLCAT6 carrying the promoter and reporter gene was used to transfect HeLa cells to study the regulation of 11β-HSD1 gene expression by glucocorticoids in terms of reporter gene expression. Results: PCR showed that there was a complete alignment of the amplified sequence with the sequence 1. 2 kb upstream to the transcription start site of 11β-HSD1 gene. When cloned into pBLCAT6 plasmid carrying the reporter gene, this part of the promoter is functional in terms of regulation of reporter gene expression upon transfection into HeLa cells. The synthetic glucocorticoid-dexamethasone induced the reporter gene expression in the system described above, which was blocked by glucocorticoid receptor antagonist RU486. Conclusion: Glucocorticoids can modulate the expression of 11β-HSD1 through a mechanism involving activation of GR and interaction of the promoter of 11β-HSD1 gene.

Clinical and gene mutation studies on a Chinese pedigree with glucocorticoid-remediable aldosteronism

OBJECTIVE: To report the clinical characteristics, biochemical profiles, diagnosis and treatment of one Chinese pedigree with glucocorticoid-remediable aldosteronism (GRA) and to study its molecular mechanism. METHODS: Plasma and urinary aldosterone, cortisol and plasma renin activities were dynamically tested and diagnostic therapy with dexamethasone was undergone in 3 affected subjects. Long-distance PCR as well as DNA sequencing were applied to detect the fusion gene in this pedigree. RESULTS: In this GRA pedigree, there were 4 affected subjects who had hypertension, hypokalemia and low basic and provoked renin activity. Three patients were given dexamethasone treatment, and had a significant decrease in plasma aldosterone concentrations (PACs) (from 192 +/- 9 ng/L to 87 +/- 7ng/L, P

Effect of corticosteroids on atrial fibrillation after catheter ablation: a meta-analysis

Objective： The purpose of this meta-analysis was to explore the effect of corticosteroids on atrial fibrillation（AF） following catheter ablation. Methods： We searched Pub Med, Embase, and the Cochrane Central Register of Controlled Trials for published articles describing the effect of corticosteroids in preventing AF recurrence after catheter ablation. Data on study and patient were extracted. Risk ratios（RRs） and 95% confidence intervals（CIs） were calculated by use of a random-effect model, and P values of 〈0.05 were considered significant. Results： Two randomized controlled trials（RCTs） and three cohort studies involving 846 patients were included in this meta-analysis. Within one month of catheter ablation, corticosteroid use was associated with a declined risk of recurrence of AF in RCT（RR 0.57, 95% CI 0.39 to 0.85, P=0.005）, but without significant effect in cohort studies（RR 1.01, 95% CI 0.79 to 1.30, P=0.94）. After three months of catheter ablation, corticosteroids did not have a significant effect in the prevention of late recurrence of AF in either RCT（RR 0.78, 95% CI 0.38 to 1.59, P=0.49） or cohort studies（RR 0.96, 95% CI 0.70 to 1.31, P=0.78）. Conclusions： Our meta-analysis suggested that periprocedural administration of corticosteroids of catheter ablation was associated with reduction of early but not late recurrence of AF.