摘要：目的以单纯补充叶酸为对照，评价孕期补充多种微营养素或铁／叶酸对出生体重、分娩孕周和孕晚期血红蛋白的影响。设计采用整群随机双盲对照试验设计。地点中国陕西省的两个贫困县（长武县和彬县）。研究对象5828名孕妇及其分娩的4697名活产新生儿。干预措施以村为单位整群随机化，同一个村的孕妇孕期每天补充叶酸（对照组）、铁／叶酸或多微营养素。多微营养素含15种推荐量的维生素和矿物质。主要结局指标测量出生体重、身长、头围在产后72小时内测量。通过产后42天访视收集新生儿生存情况。结果与单纯补充叶酸比较，多微营养素可显著提高出生体重42g（95％CI7—78g）；孕期补充多微营养素和铁／叶酸均可显著增加分娩孕周（铁／叶酸：0．23周，95％CI0．10～0．36周；多微营养素：0．19周，95％CI0．06～0．32周）。铁／叶酸可显著减少34周以内的早产（RR0．50，95％CI0．27～0．94，P=0．031）。相对于纯叶酸组，多微营养素和铁／叶酸均可显著增加孕妇孕晚期的血红蛋白水平（铁／叶酸：5．0g／L，95％CI2．0～8．0g／L，P=0．001；多微营养素：6．9g／L，95％CI4．1～9．6g／L，P〈0．001）。孕期营养素补充对围产儿死亡没有明显影响，但铁／叶酸可减少54％（RR0．46，95％CI0．21～0．98）的7天内新生儿死亡。结论与对照组（叶酸）比较，在中国贫困农村孕期补充铁／叶酸可延长分娩孕周从而减少早期新生儿死亡；多微营养素可适当增加出生体重，尽管如此，对早期新生儿死亡并无明显影响。在孕期微营养素干预中，剂量充足的铁对于降低发展中国家的新生儿死亡是最关键的。

摘要：Objective: To conduct a randomized prospective trial of immune globulin treatment for 105 Rh+ children with newly diagnosed immune thrombocytopenic purpura and a platelet count 20,000/μ L (P = 0.03). By day 7, hemoglobin concentrations decreased by 1.6 g/dL, 2 g/dL, and 0.3 g/dL in the anti- D50, anti- D75, and IVIg groups, respectively. Headache, fever, or chills occurred least often in the anti- D50 group. Conclusions: A single 75μ g/kg dose of Anti- D raised the platelet count in children with newly diagnosed immune thrombocytopenic purpura more rapidly than standard- dose anti- D and as effectively as IVIg, with an acceptable safety profile.

摘要：Objective: This study was undertaken to investigate the impact of incorporating assessment of the nasal bone into first-trimester combined screening by fetal nuchal translucency(NT) thickness and maternal serum biochemistry. Study design: In this prospective combined screening study for trisomy 21, the fetal nasal bone was also examined and classified as present or absent. A multivariate approach was used to calculate patient-specific risks for trisomy 21 and the detection rate(DR) and false-positive rate(FPR) were estimated. We examined 2 screening strategies; first, integrated first-trimester screening in all patients and second, first-stage screening of all patients using fetal NT and maternal serum free fl-hCG and PAPP-A, followed by second-stage assessment of nasal bone only in those with an intermediate risk of 1 in 101 to 1 in 1000 after the firststage. Results: The nasal bone was absent in 113(0.6%) of the 20,165 chromosomally or phenotypically normal fetuses and in 87(62.1%) of the 140 fetuses with trisomy 21. With combined first-trimester NT and serum screening, the DR of 90%was achieved at a FPR of 5%. Inclusion of the nasal bone, either in all cases or in about 10%of the total in the 2-stage approach, halved the FPR to 2.5%. Conclusion: Inclusion of the nasal bone in first-trimester combined screening for trisomy 21 achieves a DR of 90%for a FPR of 2.5%.

摘要：目的基于随机对照试验和非随机对照试验产生的证据,在因急慢性疾病住院的儿童和青少年中,评价医院小丑对一系列症状群的干预效果。研究设计基于随机和非随机对照试验的系统综述。数据来源美国国立医学图书馆(MEDLINE).美国科学情报研究所数据库(ISI of Knowledge).考科蓝对照试验注册中心(Cochrane Cental Registerof Controled Trials)、Science Diret全文数据库、Sopus数据库、美国心理协会数据库(American Psychalogical Association PeyeINFO)、护理和健康文献累积指数数据库(Curmulative Index to Nursing and Alied Heauth Literature),以及拉丁美洲和加勒比健康科学文献数据库(Lain Ameriean and Caribbean Health Sciences Literature)。研究筛选经間行评议后筛选随机和非随机对照试脸,纳人标准如下:因急性或慢性疾病人院的儿童和青少年,比较医院小丑与标准护理的研究,此外研究将医院小丑对住院儿童和青少年症状管理的影响作为主要结局指标。数据提取与整合由两名研究者独立完成研究筛选,数据摘录,以及偏倚风险评价。方法学评价也由两名研究者独立进行,评价工具有:Jadnd量表、随机对照试验的偏倚风险评估工具(RoB 2)和非随机对照试验的偏倚风险评估工具(ROBINS-I)。结果24项研究(n=1612)符合纳入标准,对其进行数据摘录和分析。大多数研究是随机对照试验(n=13)。最常分析的症状是焦虑(n=13),其次是疼痛(n=9)、心理和情绪反应以及幸福感(n=4)、压力(n=4)、癌症相关疲劳(n-3)和哭泣(n=2)。5项研究使用生物标志物(主要为皮质醇)来评估医院小丑对压力或疲劳的影响。方法学评价显示,大多数随机对照试验(n=11;85%)存在潜在偏倚风险,2项试验具有高度偏倚风险。ROBINS-I评价结果显示,大多数非随机对照试验(n=6;55%)存在中度偏倚风险。研究表明,无论父母是否在场,医院小丑出现时,儿童和青少年在一系列医疗程序中的焦虑显著降低,心理调节也得到改善(P<0.05)。3项针对慢性病患者的研究显示,医院小丑的干预有明显获益,显著减少了患儿的压力、疲劳、疼痛和痛营(PC0.05)。结论这些研究表明,在医疗程序术前诱导麻醉,以及慢性病常规护理中进行医院小丑干预,可能是症状管理的有效策略。此外,与接受标准护理的患儿相比,医院小丑干预可能有助于改善患有急慢性疾病的儿童和青少年的心理健康状态。

摘要：Background: Although studies have examined the incidence of stroke in heart failure(HF), their findings are inconsistent and difficult to interpret because of heterogeneity in study design and population. Although HF remains a highly fatal disease, the excess mortality imparted from stroke is unknown. Methods: A random sample of cases of HF from 1979 to 1999 was identified and validated according to Framingham criteria. Strokes were identified by screening medical diagnoses and subsequent physician validation. Stroke risk in HF was compared with the risk in the general population with standardized morbidity ratios. Associations between selected characteristics and stroke were examined using proportional hazards regression. Results: The study cohort included 630 persons with incident HF. During a median of 4.3 years of follow-up, 102(16%) experienced an ischemic stroke. Heart failure was associated with a 17.4-fold increased risk for stroke compared with the general population in the first 30 days after HF diagnosis and remained elevated during 5 years of follow-up. Older persons with prior stroke or diabetes were more likely to experience stroke after HF diagnosis. Persons with stroke after HF were 2.31 times more likely to die compared with persons without stroke. Conclusions: In the community, persons with HF have a large increase in the risk for ischemic stroke compared with the general population. Stroke results in a >2-fold increase in mortality. Thus, prevention of stroke has the potential to improve survival among patients with HF, particularly among the elderly and those with diabetes or prior stroke.

摘要：CD8+T细胞主要通过T细胞表面受体(T cell recep tor,TCR)识别并与Ⅰ型主要组织性复合物提呈的抗原(pMHC-Ⅰ)相互作用[1]。TCR对刺激型抗原的识别在CD8+T细胞毒性和适应性免疫中发挥着关键作用。许多证据表明机械力可以延长TCR与刺激性pMHC作用的键合时间(bond lifetime)形成抗原特异性逆锁键(catch bond)[2],并且这种逆锁键对抗原识别非常重要。然而,机械力调控TCR抗原识别的具体结构机制仍不清楚。通过分子动力学模拟、单分子生物膜力学探针、磁镊、T细胞活化实验和动物模型对此问题展开了系统的研究[4]。发现作用在TCR-pMHC-Ⅰ复合体上的拉力可以作用在TCR-pMHC-Ⅰ复合体上的拉力可以打破MHC-I分子内部α1-α2和β2结构域间的相互作用,导致α1-α2结构域旋转并发生构象变化。力诱导的MHC-I构象变化可以进一步别构地调节TCR与刺激性抗原肽及α1-α2结构域的构象及相互作用,诱导产生新的氢键,增强TCR-pMHC-Ⅰ之间的键合时间,但并不能增强TCR与抑制性pMHC-Ⅰ之间的作用。当用点突变阻断这些新形成的氢键,或者α1-α2和β2结构域被二硫键锁住时,最佳力诱导的TCR-pMHC-Ⅰ作用的键合时间明显缩短并且T细胞的活化受到抑制。另外,在人TCR和HLA-A2相互作用中发现了类似机制,并且与肿瘤相关的HLA-A2点突变[3]可以通过限制HLA-A2α1--α2和β2结构域之间的构象打开减弱TCR对肿瘤抗原的识别及T细胞的功能。研究结果表明,机械力诱导的MHC-I构象变化对TCR抗原识别和T细胞活化非常重要,进一步地阐明了机械力调控TCR抗原识别机制,为临床肿瘤的免疫治疗和药物设计提供了新思路和新靶点。

摘要：目的:分析自1991年来,在布里斯托尔及全英国, 小儿心脏直视手术死亡率的变化趋势。设计:回顾性分析医院病例统计数据。机构:所有开展小儿心脏直视手术的英国医院。试验对象:收集1991年4月至2002年3 月间,接受心脏直视手术、年龄小于16岁的患者。对3 个时间段的死亡率进行研究:阶段3(1991年4月至1995年3月),阶段5(1996年4月至1999年3月)。

摘要：此研究的目的是设计一个全景腔内显示技术．以影像变形极少的带状显示，明确其作为CT结肠成像（CTC）节省时间的主要三维显示方法的可行性。对照带状显示与其他4种三维显示方法显示10个10mm、10个20mm电子生成息肉影像的变形。52例病人行CTC检查．并于同天行结肠镜检查。对照2名独立读片医生利用带状显示与常规腔内显示的诊断操作与影像诊断时间。

摘要：目的 与“不用针灸”对比,确定“使用针 灸”的治疗方法对慢性头痛患者的头痛、健康状 况及无病时间的影响。 设计 随机对照试验。 试验场所 英格兰和威尔士的开业医生诊所。 受试对象 401位慢性头痛患者,主要是偏 头痛患者。 干预 患者被随机分配进入针灸治疗组(在 3个月内接受12次针灸治疗)和对照组(接受常 规治疗)。 主要结果测定指标 治疗前、治疗后3个月 及12个月对头痛积分,SF-36健康状况及用药量 进行评估。每3个月对治疗方法作1次评估。头 痛积分即判定疗效的主要终点指标。 结果 针灸组治疗后12个月的头痛积分(针 灸组161例患者,平均头痛积分为16．2,标准差 13．7,比治疗前减少34％)比对照组低(对照组140 例患者,平均头痛积分为22．3,标准差17．0,比 治疗前减少16％)。两种方法调整后的差异为4．6 (95％可信区间为2．2-7．0;P=0．0002)。对于包 含缺失数据的灵敏度分析,该结果也是肯定的。 针灸组的患者每年少头痛22(8-38)天。尽管达到 统计学差异的项目仅有生理功能、精力和健康改 变等,SF-36的资料也有利于针灸组。与对照组相 比,针灸组的患者减少了15％的服药量(P=0．02), 减少了25％的就诊量(P=0．10),同时减少15％的 病休时间(P=0．2)。 结论 针灸在初级保健中用于治疗慢性头痛, 特别是偏头痛,可以产生与临床相关的持久益 处。应当考虑扩大英国国家医疗保险体系中针灸 治疗的范围。

摘要：Objectives: We assessed the impact of intravenous fluconazole prophylaxis (FP) in extremely low birthweight (ELBW[<1000 g]) infants on the incidence of and ou tcome from invasive candidiasis (IC) in all infants admitted to a neonatal inten sive care unit (NICU). Study design: Beginning April 1, 2002, FP was given to EL BW infants aged < 5 days admitted to the NICU of Woman’s Hospital of Texas. Inf ants in NICU in whom IC developed during the first 2 years of FP (FP period) wer e compared with those with IC during 2000-2001. Results: During 2000-2001 and the FP period, the incidence of IC in ELBW infants decreased from 7%(15 of 206) to 2%(5 of 240) (P = .01), and the IC-related mortality rate decreased from 1 2%(4 of 33) to 0 (0 of 40) (P = .04); the incidence of IC increased from 0.1%( 4 of 2806) to 0.2%(8 of 3372) in infants of birth weight ≥1000 g (P = .06), an d no IC-related deaths occurred. During the FP period, IC developed in older in fants (24 vs 12 days; P = .12) who had similar risk factors for IC. Conclusion: Invasive candidiasis occurred in our NICU in spite of FP and shifted to bigger,m ore mature infants who had a better outcome.