2008年 · 第121卷第18期

During the past 50 years, intensive studies into the characteristics of hematopoietic stem cell transplantation immunology and the emergence of new immunosuppressant and anti-infective drugs have significantly improved the clinical result of hematopoietic stem cell transplantation (HSCT)。

Abstract：Background The pathophysiology of late-onset hemorrhagic cystitis (LOHC) is currently not well understood.The aim of this study was to analyze the ailoimmune aetiology in the pathogenesis of LOHC post allogeneic hematopoietic stem cell transplantation (HSCT).Methods A retrospective study was performed on the medical records of 11 patients with immune-related LOHC post allogeneic HSCT. The clinical characteristics, therapy, and outcomes of these patients were analyzed.Results The median time of onset was 42 days after HSCT (range 16-150 days) and the median duration of HC was 43 days (range 29-47 days).All patients presented with prolonged HC for more than 35 days. Nine patients with evidence of cytomegalovirus (CMV) reactivation did not respond to anti-viral therapy even with CMV clearance in the urine post-therapy.Eleven patients with refractory HC received a low dose of corticosteroids and all patients went into complete remission.Conclusion Our data suggest that alloimmune injury is involved in the pathogenesis of HC in at least some patients and that specific therapy might improve the clinical outcome of hemorrhagic cystitis。

Abstract：Background Relapse remains an obstacle to successful allogeneic haematopoietic stem cell transplantation (alIo-HSCT) for patients with acute leukaemia and no standard treatment is available. We assessed fludarabine and cytarabine with transfusion of donor haematopoietic stem cell in treating the relapse of acute leukaemia after alIo-HSCT.Methods Seven patients, median age 34 years, with relapse of acute leukaemia after alIo-HSCT received combination chemotherapy of fludarabine with cytarabine for 5 days. Five patients suffered from acute myeloid leukaemia (2 refractory) and 2 refractory acute lymphoblastic leukaemia. After the transplantation, the median relapse time was 110 days (range,38-185 days). Two days after chemotherapy, 5 patients received infusion of donor's peripheral blood stem cells, mobilized by granulocyte colony stimulating factor. No prophylactic agents of graft versus host diseases were administered.Results Six patients achieved haematopoietic reconstitution. DNA sequence analysis at day 30 after treatment identified all as full donor chimera type. The median observation time was 189 days. After the treatment, the median time for neutrophilic granulocyte value ≥0.5x109/L and for platelet value >20x109/L were 13 days (range, 10-18 days) and 15 days (range, 11-24 days), respectively. Graft versus host disease occurred in 2 patients (acute) and 3 (chronic). Five patients suffered from pulmonary fungal infection (2 died), 3 haemorrhagic cystitis and 2 cytomegalovirus viraemia. The other patients died of leukaemia related deaths. Three patients with chronic graft versus host disease who had received donor peripheral blood stem cells reinfusion have survived for 375 days, 232 days and 195 days, respectively.Conclusions Fludarabine with cytarabine plus the donor haematopoietic stem cell should be considered as an effective therapeutic regimen for relapse of acute leukaemia after alIo-HSCT. The disease free state of patients may increase, thou.gh with hi qh risk of secondary fungal infection。

Abstract：Background Cisplatin based chemotherapy is a well recognized risk factor for coagulation disordrs and thrombosis.The pathophysiological mechanisms by which cisplatin promote thrombosis are not well understood.Methods Red blood cells (RBCs) were separated from peripheral blood of patients with breast cancer (n=10) and healthy adults (n=6) and treated with cisplatin. Coagulation time of RBCs was assessed by one step recalcification time and the productions of thrombin, intrinsic and extrinsic factor Xa were measured in the presence or absence of various concentrations of lactadherin. Exposed phosphatidylserine was stained with lactadherin and observed by confocal microscopy and flow cytometry.Results Neither fresh RBCs nor RBCs treated without cisplatin had potent procoagulant activity. Cisplatin treatment increased procoagulant activity of RBCs in a cell number- and concentration-dependent manner. Exposed phosphatidylserine was stained with lactadherin and after cisplatin treatment, strong fluorescence was revealed by confocal microscopy. Lactadherin bound RBCs from patients with breast cancer increased from (1.9±0.5)% on control RBCs to (68.0±3.5)% on RBCs treated with 10 pmol/L cisplatin for 24 hours.Conclusions Cisplatin treatment increases procoagulant activity of RBCs, which have a strong association with exposure of phosphatidylserine. The increased procoagulant activity may contribute to the pathogenesis of thrombophilia during cisplatin based chemotherapy in breast cancer patients。

Abstract：Background Regulatory T cells (Treg) have been shown to play an important role in the regulation of hematopoietic activity. However, there is no information about the effect of Treg cells in the pathogenesis of polycythaemia vera (PV).Methods In this study, we investigated the percentage and function of Treg cells in the peripheral blood of 21 PV patients and 25 healthy donors. Treg cells were identified and characterized as CD4+CD25+FOXP3+ by flow cytometry.The suppressive activity of CD4+CD25+ Treg cells was assessed by the proliferation and cytokine secretion of the co-cultured CD4+CD25- fractions.Results The results showed that the percentage of Treg cells in the peripheral blood of PV patients significantly increased compared to healthy controls ((10.93±4.02)% vs (5.86±1.99)%, P <0.05). Moreover, the mRNA and protein expression of FOXP3 was higher in CD4+CD25+ Treg cells. Coordinately, when co-cultured with the activated CD4+CD25-cells, the CD4+CD25+ Treg cells showed enhanced suppressive function in PV. Yet, the underlying mechanism for the increased frequency and function of CD4+CD25+ Treg cells is still to be clarified.Conclusion Treg cells expansion might account for the abnormal T cell immunity in PV patients and thus contribute to the pathogenesis of PV。

Abstract：Background Patients with myelodysplastic syndrome (MDS) display a very diverse pattem. In this study, we investigated prognostic factors and survival rate in adult patients with MDS refractory anaemia (MDS-RA) diagnosed according to French-American-British classification and evaluated the International Prognostic Scoring System (IPSS) for Chinese patients.Methods A multi-center study on diagnosis of MDS-RA was conducted to charactedze the clinical features of Chinese MDS patients. The morphological criteria for the diagnosis of MDS-RA were first standardized. Clinical data of 307 MDS-RA patients collected from Shanghai, Suzhou and Beijing from 1995 to 2006 were analyzed using Kaplan-Meier curve, log rank and Cox regression model.Results The median age of 307 MDS-RA cases was 52 years. The frequency of 2 or 3 lineage cytopenias was 85.6%. Abnormal karyotype occurred in 35.7% of 235 patients. There were 165 cases (70.2%) in the good IPSS cytogenetic subgroup, 44 cases (18.7%) intermediate and 26 cases (11.1%) poor. IPSS showed 20 (8.5%) categodzed as low dsk,195 cases (83.0%) as intermediate-I risk and 20 cases (8.5%) as intermediate-ll dsk. The 1-, 2-, 3-, 4- and 5-year survival rates were 90.8%, 85.7%, 82.9%, 74.9% and 71.2% respectively. Fifteen cases (4.9%) transformed to acute myeloid leukaemia (median time 15.9 months, range 3-102 months). Lower white blood ceil count (<1.5x109/L), platelet count (<30x109/L) and cytogenetic abnormalities were independent prognostic factors by multivariate analysis, but age (≥65 years), IPSS cytogenetic subgroup and IPSS risk subgroup were not independent prognostic factors associated with survival time.Conclusions Chinese patients were younger, and had lower incidence of cytogenetic abnormalities, more severe cytopenias but a more favourable prognosis than Western patients. The major prognostic factors were lower white blood cell count, lower platelet count and fewer abnormal karyotypes. The intemational prognostic scodng system dsk group was not an independent prognostic factor for Chinese myelodysplastic syndrome patients with refractory anaemia patients。

Abstract：Background Hyperostosis is a common pathological change among people more than 50 years old; it is connected with many risk factors, which are all indefinite. The aim of this study was to prospectively investigate the correlation between obesity and female hyperostosis.Methods Totally 4326 females were included in this study and their basic information including their age, stature, body weight, course of disease, symptoms, medical complications, frequency of exercise and smoking, and X-ray and bone mineral density (BMD) examination results, was carefully collected for a statistical analysis. The ttest or x2 test was used to evaluate the differences between two groups; an analysis of variance (ANOVA) was used to evaluate the differences among several groups; the relationship between hyperostosis and body mass index (BMI), age, medical complications,exercise, average BMD was analyzed using Logistic regression.Results The incidence rate of hyperostosis in obese patients was higher than that in patients with normal weight (P=0.000). Obesity was relevant to hyperostotic sites (P=0.000), and the incidence of hyperostosis in one or several sites of the lumbar vertebrae, knee joints, and other sites was higher in obese patients than in patients with normal weight.There was also a difference in the extent of hyperostosis between these two groups. BMI had positive effects on the incidence and degree of hyperostosis, which were also relative to the sites of hyperostosis, and the BMI of patients without hyperostosis were much lower than those of the patients with hyperostosis in their lumbar vertebrae, knee joints,or multiple sites. Obesity, age, and exercise had positive effects on the incidence of hyperostosis (P=0.002, 0.000,0.018).Conclusions Obesity is a significant potential stimulant of hyperostosis, especially hyperostosis in knee joints and multiple sites; keeping fit might be an important way to prevent it。

Abstract：Background The aim of this study was to prospectively study the changes in neutrophil elastase (NE), flbroblast growth factor 9 (Fgf9), matrix metalloproteinase-9 (MMP-9), tissue inhibitor of metalloproteinase 1 (TIMP-1) in sputum induced during the early period after lung volume reduction surgery (LVRS).Methods From April to October 2005, ten consecutive patients with chronic obstructive pulmonary disease (COPD) underwent LVRS. Ten non-small cell lung cancer patients (stage II-Illa) received Iobectomy as a control group. The induced sputum was collected from beth groups at six different times (two weeks before operation and postoperatively at 1, 2, 4, 6 and 10 days). The level of NE, Fgf9, MMP-9 and TIMP-1 were measured using enzyme-linked immunosorbent assay.Results The pulmonary function (FEV1%) and arterial blood gases (PaO2 and PaCO2) were significantly different between the groups. There were no significant differences in age, ejection fraction (EF), and operation duration, but hemoglobin in the LVRS group was statistically higher than in the controls. At certain times, there were significant differences in NE, MMP-9, TIMP-1 and MMP-9/I"IMP-1 (P <0.05) but not in Fgf9 between the two groups. The levels of NE and TIMP-1 were maximal at 2 days postoperatively and that of MMP-9 and MMP-9/IIMP-1 at 4 clays postoperatively in the LVRS group. In the control group, maximal levels of NE and TIMP-1 occurred at 2 days postoperatively and that of MMP-9 and MMP-9/TIMP-1 at 1 day postoperatively. Ten days after surgery, all values of the control group were not significantly different from the baseline. In the LVRS group, the levels were significantly different from the pre-operative values (P <0.05) apart from TIMP-1.Conclusion The levels of NE, MMP-9, TIMP-1 and MMP-9/TIMP-1 of the LVRS group were different from those of the control group. The time course of these changes may be related to LVRS and the underlying process of COPD。

Abstract：Background Successful treatment of gliomas in or adjacent to language areas constitutes a major challenge to neurosurgery. The present study was performed to evaluate the procedure of language mapping via intraoperative direct cortical electrical stimulation under awake anaesthesia when performed prior to resective glioma surgery.Methods Thirty patients with gliomas and left-hemisphere dominance and, who underwent language mapping via intraoperative direct cortical electrical stimulation under awake anaesthesia before resective glioma surgery, were analyzed retrospectively. All patients had tumors in or adjacent to cortical language areas. The brain lesions were removed according to anatomic-functional boundaries with preservation of areas of language function. Both preoperative and postoperative functional findings were evaluated.Results Intraoperative language areas were detected in 20 patients but not in four patients. Language mapping failure for reasons attributable to the anaesthesia or to an intraoperative increase in intracranial pressure occurred in six cases.Seven patients presented with moderate or severe language deficits after six months of follow-up. Total resection was achieved in 14 cases, near-total resection in 12 cases and subtotal resection in four cases.Conclusions Intraoperative cortical electrical stimulation is an accurate and safe approach to identification of the language cortex. Awake craniotomy intraoperative cortical electrical stimulation, in combination with presurgical neurological functional imaging to identify the anatomic-functional boundaries of tumor resection, permits extensive tumor excision while preserving normal language function and minimizing the risk of postoperative language deficits。

Abstract：Background Ossification of the posterior longitudinal ligament (OPLL) has a strong genetic background. Previous studies have shown that bone morphogenetic protein-2 (BMP2) and BMP2 mRNA are expressed in ossifying matrix and chondrocytes adjacent to cartilaginous areas of OPLL tissues and mesenchymal cells with fibroblastic features in the immediate vicinity of the cartilaginous areas. It is suggested that BMP2 plays different roles in the different stages of development of OPLL. However, it remains unknown which factors induce ligament cells to produce BMP2.Methods OPLL patients (n=192) and non-OPLL controls (n=304) were studied. Radiographs of the cervical spine were analyzed for extent of OPLL. We investigated whether single nucleotide polymorphisms of exons 3(-726) TIC and 3(-583) A/G in the BMP2 gene are statistically associated with genetic susceptibility to OPLL in Chinese Han subjects.Results There was no statistical difference between the occurrence of exons 3(-726) TIC and 3(-583) A/G and the occurrence of OPLL in the cervical spine. However, there was a significant association between occurrence of exon 3(-726) TIC polymorphism and occurrence of OPLL in males of cases and controls in the cervical spine. In addition, no significant association was found between the exons 3(-726) TIC and 3(-583) A/G with number of ossified cervical vertebrae in OPLL patients.Conclusions Exon 3(-583) A/G polymorphism in BMP2 gene is not associated with the occurrence and the extent of OPLL in the cervical spine. Chinese Han male patients with TC and CC genotypes in exon 3(-726) T/C have genetic susceptibility to OPLL but not to more extensive OPLL in the cervical spine。

Abstract：Background Recently, bilateral transpedicular kyphoplasty with a single balloon was performed for osteoporotic vertebral body compression fractures (OVCFs) to reduce the fees of the operation, but the time of operation and radiation exposure are longer. The aim of this study was to determine the safety and effectiveness of a single balloon cross-midline expansion via unipedicular approach in kyphoplasty for OVCFs.Methods Thirty-six patients with painful OVCFs (61 vertebrae) were enrolled in this research. Unilateral transpedicular puncture was performed under the fluoroscopy monitoring of an oblique angle down the pedicle. A single balloon was introduced through unipedicular approach. The final balloon position was in the midline of the vertebral body with the balloon cross-midline expansion and bone cement filled. Clinical outcomes were determined by comparison of the preoperative and postoperative visual analogue scale (VAS) and Oswestry disability index (ODI). Radiographic assessment included restoration of vertebral height and correction of kyphosis. Follow-up was conducted for 6-12 months (mean 9.2 months).Results Thirty-six consecutive patients with 61 vertebrae were successfully operated on with a mean operation time of 37.4 minutes per vertebra. All patients had dramatic pain relief and functional recovery within 96 hours after the procedure with no surgery or device-related complications. VAS score improved from 7.27±1.02 preoperatively to 2.71±0.75 postoperatively (P <0.01). ODI score was decreased from (71.14±10.94)% preoperatively to (26.56±6.35)% postoperatively. The average loss of anterior body height was (14.33e2.76) mm before procedure and (10.03±1.83) mm after procedure (P <0.01), while the average loss of middle body height was (10.15e2.70) mm before procedure and (5.89±1.83) mm after procedure (P <0.01). The kyphotic deformity was corrected from (23.43±5.00) degree to (16.16±2.77) degree (P <0.01). The pain relief and functional recovery were substantial and maintained to the last follow-up without any re-collapse or adjacent level fracture.Conclusions A single-balloon cross-midline expansion via unipedicular approach in kyphoplasty for OVCFs is an effective and safe procedure with less cost, less operation time and less radiation exposure when compared with the conventional kyphoplasty technique。

Myeloproliferative disorders (MPD) are clonal haematopoietic stem cell disorders characterized by proliferation of one or more myeloid cell lineages in the bone marrow and increased numbers of mature and immature cells in the peripheral blood. MPDs are classified into five categories: polycythemia vera (PV),essential thrombocythaemia (ET), idiopathic myelofibrosis (IMF), chronic myelogenous leukaemia(CML) and atypical MPD。

Intestinal ischemia occurs in a wide variety of clinical manifestations.1,2 The gut barrier is broken down by bacterial translocation after small intestinal ischemiareperfusion injury (IIRI), which can result in many clinical consequences, even death.3 The intestinal mucosal mast cells (IMMCs) serve as a unique cellular source of large amounts of vasoactive mediators, and they can influence local tissue reactions.4 We and others have previously shown that IIRI could activate IMMCs, make them degranulate and release a mass of inflammatory mediators, which in turn aggravate IIRI.5,6

Ventricular fibrillation (VF) in myocardial is chemia iscalled "ischemic VF". As a severe morbid state and a leading cause of sudden cardiac attack, ischemic VF induces approximately 3 million deaths in the United States each year. Ischemic VF is caused by "triggers" such as ventricular premature beat or ventricular tachycardia in the presence of a suitable "substrate". The triggers frequently occur at the border zone and thesubstrate is required for the maintenance of ischemic VF。

Lower gastrointestinal hemorrhage is a nonspecific common symptom of both acute promyelocytic leukemia (APL) and gastrointestinal stromal tumors (GIST). The possibility of GISTs is rarely considered in patients with APL when intestinal hemorrhage occurres. We treated a case of GISTs coexisting with APL in July 2006. The diagnosis of GIST was verified through surgery and pathological examination of the resected intestinal mass。

Granulocytic sarcoma or chloroma is a rare tumour derived from myeloid cell precursors. It is generally seen before or after or together with the onset of myelocytic leukaemia. Immunohistochemical staining of myeloperoxidase is necessary for a definite diagnosis of granulocytic sarcoma. Recognition of this entity ensures an early aggressive chemotherapy that causes regression of the tumour。