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WAO News & Notes - May 2008
Volume 5, Issue 5

Medical Journal Reviews


Medical Journal Reviews
                 
医学杂志回顾

 

Reviewed by Prof. Richard F. Lockey, MD, WAO Web Editor-in-Chief

 

1. House dust mite control (HDM) measures for asthma (review)
This is a review of 54 trials (3002 patients) which assessed whether or not mattress encasings, chemical treatment, and a combination of chemical and physical methods impact the exposure to HDM allergens in homes of people with mite sensitive asthma. With various dust prevention methods, there were no statistical differences in PEF, number of patients who improve, asthma symptom scores, or medication usage. The authors conclude that chemical and physical methods aimed at reducing exposure to HDM allergens do not work and that it is doubtful whether further studies similar to the ones reviewed would be worthwhile. Editor's comment: This Cochrane meta-analysis indicates that chemical and physical methods to reduce HDM allergen levels are not effective to treat mite sensitive asthma. Gøtzsche PC, Johansen HK, Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No: CD001187. DOI: 10.1002/14651858.CD001187.pub3.

 

 哮喘的户尘螨(HDM)控制措施(综述)

54项试验(共计3002名患者)进行回顾,评价是否防螨床罩,化学处理,以及合用两者可以影响尘螨过敏的哮喘患者在家中对HDM过敏原的暴露情况。各种防尘措施对于患者的PEF,哮喘症状积分,药物使用情况没有显著影响,获得改善的患者的数量也没有显著差异。作者的结论是化学及物理防螨措施不会影响对HDM变应原的暴露,是否值得进一步行相关研究还有待商榷。编者点评:该Cochrane荟萃分析显示以降低HDM变应原水平为目的的各种物化措施对于治疗螨过敏的哮喘是无效的Gøtzsche PC, Johansen HK, Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No: CD001187. DOI: 10.1002/14651858.CD001187.pub3.

  

2. Respiratory complications of obesity
This is a European Respiratory Society (ERS) designated CME review of the respiratory problems associated with obesity, which is associated with sleep apnea, obesity hypoventilation syndrome and asthma. Obesity is known to alter pulmonary function, respiratory mechanics, respiratory muscle strength and endurance, gas exchange, control of breathing, and exercise capacity. The authors also indicate that there is a relative risk of asthma in obese subjects of 1.4 - 2.2, a ratio which is stronger in women than men. There seems to be a dose-effect relationship as the prevalence of asthma increases in proportion to BMI, and while obesity may not cause asthma, it seems to be a complicating factor for this disease. Editor's comment: Obesity is associated with various medical problems, including asthma. Veale D, et al., Breathe 2008; 4:210.

 

 肥胖的呼吸系统并发症

 

这是欧洲呼吸协会指定的对肥胖相关的呼吸系统疾病的CME综述。相关疾病包括呼吸暂停,低通气综合征,以及哮喘。肥胖会改变肺功能,呼吸动力,呼吸肌力量及耐力,气体交换,呼吸控制,以及运动耐量。作者还指出肥胖人群哮喘的相对危险是1.4-2.2,女性比男性的危险指数更高。肥胖与哮喘之间似乎存在量效关系,因为哮喘的患病率随BMI成比例升高,即使肥胖不会引起哮喘,但也是该病的一个并发症。编者点评:肥胖与各种疾病相关,包括哮喘。Veale D, et al., Breathe 2008; 4:210.

 

 3. Antibiotics for adults with clinically diagnosed acute rhinosinusitis: a meta-analysis of individual patient data
This is a meta-analysis of randomized trials based on individual patients' data assessing whether common signs and symptoms can be used to identify those patients who need and will benefit from antibiotics (Ab). Data from 2,547 adults in nine trials were checked and analyzed to assess the overall effect of antibiotic treatment and the prognostic value of common signs and symptoms by the number needed to treat (NNT) with Ab to cure one additional patient. 15 patients with rhinosinusitis-like complaints needed to be given Ab before an additional patient was cured (95% CI NNT[benefit] 7 to NNT[harm] 190). Patients with posterior pharyngeal discharge took longer to cure vs. those without the sign with an NNT of eight patients with this sign before one additional patient was cured (95% CI NNT[benefit] 4 to NNT[harm] 47). The authors conclude that signs and symptoms cannot identify patients with rhinosinusitis for whom Ab treatment is justified, even if their symptoms are present for longer than 7-10 days. Editor's comment: Acute rhinosinusitis almost always gets better, even without Ab treatment. Young J, et al., The Lancet 2008; 371:908.

 

抗生素对临床诊断急性鼻鼻窦炎的成人患者的疗效:荟萃分析

 

这是一个基于患者的个体资料对随机试验所做的荟萃分析,评估是否常见症状及体征可用于识别哪些患者需要且能得益于抗生素(Ab)治疗。核实分析了9个临床试验的2547名成人患者的资料,用每再治愈一名患者而需要用抗生素治疗的患者人数(NNT)“来评价抗生素治疗的总体疗效以及常见症状体征的对预后的意义。要再治愈一名患者,需要15名有鼻鼻窦炎样主诉的患者接受Ab治疗(95% CI NNT[获益] 7 to NNT[伤害] 190) 有后咽滴涕的患者比起没有这个症状的患者而言,其所需的治疗时间更长,该患者群中,要每多治愈一名患者所需的治疗人数为8(95% CI NNT[获益] 4 to NNT[伤害] 47)。作者的结论是,即使患者的症状持续超过7-10天,也不能把症状和体征作为识别鼻鼻窦炎是否需要Ab治疗的指征。编者点评:即使不用Ab治疗,急性鼻鼻窦炎几乎总会好转起来。Young J, et al., The Lancet 2008; 371:908.

 

4. Recent resurgence of mumps (M) in the United States
A total of 6,584 cases of M in 2006 were reported with 76% occurring between March and May. There were 85 hospitalizations, but no deaths. 85% of patients lived in eight contiguous Midwestern states. The incidence of M was 2.2 per 100,000, with the highest incidence among persons 18-24 years of age (an incidence 3.7 times that of other age groups combined). In a subgroup analysis, 83% reported current college attendance. Vaccination status revealed that 63% overall and 84% between the ages of 18 and 24 had received two doses of M vaccine. The authors conclude that despite a high coverage rate with two doses of mumps-containing vaccine, M occurred, indicating two-dose vaccine failure, particularly among Midwestern college-age adults. The paper calls for a more effective M vaccine or vaccine policy to avert future outbreaks. Editor's comment: National vaccine policies and enforcement are very important since vaccination remains the most effective method to prevent infectious diseases. Dayan GH, et al., N Engl J Med 2008; 358:1580.

 

近年美国麻疹(M)的再流行

 

2006年全美共报道了6584例麻疹,76%发生在三月份和五月份之间。85名患者住院治疗,但没有死亡。85%的患者居住在中西部地区的相邻州县。麻疹的发病率为2.2/100,00018-24岁的人群发病率最高(是其它年龄组的总体发病率的3.7倍)。亚组分析显示83%的患者正上大学。总体上有63%的患者以及84%年龄在18-24岁间的患者接受过两次麻疹疫苗注射。作者的结论认为虽然很多人都接受过两次麻疹预防接种,但仍然发生了麻疹,提示两次接种没有成功,尤其对于中西部大学年龄段的成人。文章呼吁研制更加有效的麻疹疫苗,或出台更有效的预防接种政策以避免将来麻疹的大暴发。编者点评:国家的预防免疫政策及法规非常重要,因为免疫接种是预防感染性疾病的最有效的措施。 Dayan GH, et al., N Engl J Med 2008; 358:1580

 

5. Head and neck cancer (HNC): changing epidemiology, diagnosis, and treatment
HNC accounts for less than 5% of all cancers and for less than 3% of all cancer deaths in the United States. Those at greatest risk have a long-standing history of smoking and alcohol use. The incidence of oropharyngeal cancer in younger populations has increased associated with exposure to the human papillomavirus. This subset has a better overall prognosis and response to treatment. Squamous cell histology accounts for 90% of HNC, and the review calls for a multidisciplinary approach for diagnosis and treatment. The reviewer highlights treatment with surgery, chemotherapy, radiation therapy, and, in particular, the role of inhibitors of epidermal growth factor receptor. Worldwide, 644,000 new cases of head and neck cancers are diagnosed each year, with 2/3 of these in developing countries. Editor's comment: A thorough direct and indirect examination (via rhinoscopy) of the nasal, oral and laryngeal pharynx is of extreme importance, especially when cancer is suspected. Marur S, Forastiere AA, Mayo Clin Proc 2008; 83:489.

 

头颈部癌(HNC): 流行状况,诊断及治疗进展

 

 在美国,头颈部肿瘤的比例不到全部肿瘤的5%,其所致的死亡也仅占所有肿瘤所致死亡的3%以下。长期吸烟酗酒的人最容易罹患此病。年轻人群口咽癌发病率的增高与人乳头瘤病毒的暴露增加相关。但这个群体的总体预后及治疗反应也更好。90%HNC是鳞状细胞癌,文章呼吁在诊断和治疗方面要多科协作。作者强调了手术治疗,化学治疗,放疗,尤其是表皮生长因子受体拮抗剂的作用。全球每年新诊断644,000例头颈部肿瘤,其中2/3在发展中国家。编者点评:全面的直接或间接(用鼻内镜)检查鼻腔、口腔以及咽喉非常重要,尤其是在怀疑肿瘤时。Marur S, Forastiere AA, Mayo Clin Proc 2008; 83:489.

 

6. Impaired lung homeostasis in neonatal mice exposed to cigarette smoke (CS)
It is hypothesized that the perinatal lung in humans is particularly susceptible to the damaging effects of CS and that exposure may alter immune response genes and adversely affect lung growth. These authors expose neonatal mice to 14 days of CS. Immune response gene expression and impairment of alveolar growth were studied in exposed vs. controlled mice. Exposure to CS during the neonatal period inhibits expression of genes involved in innate immunity and impairs postnatal lung growth. The authors conclude that these findings may partly explain the increased incidence of respiratory symptoms in infants and children exposed to CS. Editor's comment: Exposure to tobacco smoke is a known risk factor for asthma; these findings in mice may be applicable to humans. McGrath-Morrow S, et al., Am J Resp Cell Mol Biology 2008; 38:393.

 

新生儿期大鼠暴露于烟草(CS)后肺内环境的失平衡 

 

有人推测烟草对人类围产期肺的发育有害,暴露于烟草可能改变免疫应答基因,不利于肺的生长。作者把新生小鼠暴露于烟草中14天。研究暴露组与对照组的免疫应答基因表达情况以及肺泡生长障碍。新生儿期暴露于烟草抑制了与先天免疫相关的基因的表达,阻碍了产后肺的生长。作者认为这些发现可以部份解释暴露于烟草的婴儿及儿童呼吸道疾病增高的原因。编者点评:已知烟草暴露是哮喘的危险因素;这些在大鼠模型的发现可能用于人类。McGrath-Morrow S, et al., Am J Resp Cell Mol Biology 2008; 38:393.

 

7. In the clinic - Chronic obstructive pulmonary disease
There has been a 100% worldwide increase in age-adjusted mortality between 1970 and 2002 secondary to COPD, the fourth leading cause of mortality. In 2000, the number of deaths in women was equal to that in men. 80% to 90% of COPD is secondary to tobacco smoke, whereas 10% to 20% is secondary to occupational or other exposures to chemical vapors, irritants, and fumes. COPD should be suspected with symptoms of chronic cough, sputum production, dyspnea, and decreased exercise tolerance. The spirometric criterion for the diagnosis of COPD is a postbronchodilator FEV1/FVC ratio less than 0.70. The FEV1 percentage predicted can be used to classify COPD as mild (>80%), moderate (50% - 80%), severe (30% - 50%), or very severe (<30%). Various treatments are also reviewed. Editor's comment: This is an extremely good review of COPD, its diagnosis and treatment. Littner MR, et al., Annals of Int Med 2008; 148: ITC3-1.

 

门诊慢性阻塞性肺疾病

1970-2002年间全球继发于COPD的年龄调整后死亡率增加了100%COPD成为第4位死亡原因。2000年女性和男性因COPD所致的死亡人数相等。80-90%COPD继发于吸烟,而10-20%继发于对化学蒸汽、刺激物以及烟雾的职业暴露或其它形式的暴露。出现慢性咳嗽,咳痰,呼吸困难以及运动耐量降低等症状时应该怀疑COPD。诊断COPD的肺功能指标为经支气管扩张后FEV1/FVC低于0.7。可以用FEV1占预计值的百分比将COPD分为轻度(>80%),中度(50% - 80%),重度(30% - 50%), 以及极重度 (<30%)。文章还复习了COPD的各种治疗措施。编者点评:本文是对COPD的诊断及治疗的很好的综述。Littner MR, et al., Annals of Int Med 2008; 148: ITC3-1.

 

8. Atopic Dermatitis
Atopic dermatitis or eczema is a skin disorder that is becoming more common. This is a nice review that discusses the Th1 - Th2 paradigm and its role in allergy and the skin as the site of initiation for sensitization. Dendritic cells, Staphylococcus aureus, and the mechanism of pruritus are reviewed. The author proposes a unifying hypotheses for both IgE and non-IgE associated forms of atopic dermatitis. He concludes that genetic and immunologic mechanisms drive cutaneous inflammation in atopic dermatitis and highlights the critical role of the epidermal-barrier function and the immune system. Both contribute to IgE-mediated sensitization and should be considered as major targets for therapy. Editor's comment: A very nice review which summarizes the mechanism involved in atopic dermatitis. Bieber T, N Engl J Med 2008; 358:1483.

 

特应性皮炎或湿疹是一个越来越常见的皮肤病。本文讨论了Th1-Th2细胞类型及其在皮肤这个致敏部位的作用。作者回顾了树突状细胞,金黄色葡萄球菌,以及瘙痒的机制,为IgE相关及非IgE相关的特应性皮炎提出了统一的假设。他的结论是遗传及免疫学机制决定了特应性皮炎的皮肤炎症,强调了上皮屏障功能及免疫系统的重要作用。认为两者都对IgE介导的致敏起作用,应该作为治疗的主要目标。编者点评:本文是一篇很好的综述,总结了特应性皮炎的发生机制。Bieber T, N Engl J Med 2008; 358:1483.

 

9. Effect of increasing doses of mannitol on mucus clearance in patients with bronchiectasis
A 400-mg dose of inhaled mannitol improves mucus clearance; however, the effect of other doses remains unknown. In 14 patients aged 63.3 ± 5.7 yrs, mucus clearance at baseline and with mannitol, 160, 320 and 480 mg, were determined using technetium-99m-sulphur colloid and imaging with a gamma camera over 45 min, followed by a further 30 min involving 100 voluntary coughs. Clearance over 45 min with 480 mg mannitol was greater vs. 320 and 160 mg. Total clearance over 75 min, after mannitol administration and voluntary coughs was 36.1 ± 5.5, 40.9 ± 5.6 and 46.0 ± 5.2% with 160, 320 and 480 mg mannitol, respectively, all significantly different from baseline and control. In conclusion, mucus clearance increases with increasing doses of mannitol and is enhanced by cough in patients with bronchiectasis. Editor's comment: This paper supports the present and previous studies to indicate that doses > 400 mg of mannitol achieve optimal mucus clearance in patients with bronchiectasis. Daviskas E, et al., Eur Resp J 2008; 31:765.

 

支气管扩张患者用大剂量甘露醇吸入对粘液清除的影响

 

吸入400mg甘露醇能改善粘液清除,但其它剂量的效果还不为人知。以14名年龄在63.3 ± 5.7岁的患者作为受试者,测定其基础粘液清除率以及吸入160mg320mg480mg甘露醇后的粘液清除率。用锝99标记的放射性胶体作为介质,在吸入甘露醇后45分钟内显象,然后用30分钟主动咳嗽100次并进行显象。吸入480mg甘露醇后45分钟的粘液清除率比吸入320mg160mg甘露醇都要高。吸入160, 320 以及480mg甘露醇并配合主动咳嗽,75分钟内总的粘液清除率分别是36.1 ± 5.5, 40.9 ± 5.6 以及46.0 ± 5.2%,都比基础清除率及对照的清除率低。结论是,粘液清除随着甘露醇剂量的增加而升高,咳嗽能更进一步增加粘液清除。编者点评:这篇文章印证了目前及既往的研究,显示400mg以上的甘露醇对于支气管扩张患者能达到最佳的粘液清除效果。Daviskas E, et al., Eur Resp J 2008; 31:765.

 

 10. Control of Treg and Th17 cell differentiation by the aryl hydrocarbon receptor (AHR)
Reviewed by Gary Hellermann, Ph.D.

The mechanism by which environmental pollutants, such as dioxin (D), affect the immune system is not understood. The AHR binds a variety of aromatic and polycyclic chemicals, such as D, and then acts as a transcription factor to promote expression of specific genes. Using a mouse model, the authors show that D treatment activates AHR which binds to the FoxP3 promoter to convert CD4+FoxP3- T cells to CD4+FoxP3+ Treg cells. These Treg cells suppress experimental autoimmune encephalitis (EAE) in mice. Binding of a different ligand to AHR interferes with Treg cell differentiation but enhances Th17 cell production and EAE. This supports other observations on the reciprocal relationship between Th17 and Treg cell differentiation. In another paper in this issue of Nature (Veldhoen M et al, Letters, Mar. 23, 2008; epub ahead of print), AHR expression in CD4+ T cells occurs predominantly in the Th17 subset. Binding of a ligand to the AHR induces Th17 cells to produce the pro-inflammatory cytokine IL-22 and to worsen the pathology of EAE. Editor's Comment: These new findings linking environmental factors with autoimmune disease suggest that closer scrutiny of specific pollutant levels may be necessary. Qintana FJ et al., Nature, 2008, Mar. 23, 2008; epub ahead of print.

 

()烃受体对TregTh17细胞分化的控制作用

Gary Hellermann, Ph.D 复习

 

环境污染物,如二恶英影响免疫系统的机制尚未明了。芳()烃受体与多种芳香族及多环化学物如二恶英结合,然后作为转录因子增强某些基因的表达。作者通过老鼠实验模型,显示二恶英可以激活结合到FoxP3启动子上的芳()烃受体,将CD4+FoxP3- T细胞转化为CD4+FoxP3+ Treg 细胞。Treg细胞抑制大鼠发生试验性自身免疫性脑炎(EAE)。其它配体与芳香烃受体的结合干扰了Treg细胞的分化,但增强了Th17细胞的生成和EAE的发生。关于Th17细胞与Treg细胞分化的相互关系,该研究与其它研究取得了一致的结果。在本期Nature上有另外一篇文章,指出芳()烃受体主要在Th17亚群的CD4+T细胞上表达。AHR与配体的结合诱导Th17细胞产生促炎因子IL-22,加重EAE的病理。编者点评:有关环境因素与自身免疫性疾病关联的新发现提示有必要进一步监控某些污染物的水平。Qintana FJ et al., Nature, 2008, Mar. 23, 2008; epub ahead of print.

 

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世界过敏组织(WAO)网站支持WAO使命。 WAO是全球性资源中心,过敏、哮喘和临床免疫学领域的提倡者,通过全世界过敏和临床免疫学会联盟推进过敏性疾病的最佳临床治疗、教育、研究和培训。

 

WAO网站面向包括专家、其他医疗保健专家在内的所有医师和患者,提供关于过敏、哮喘和免疫学的最新信息。也在这一领域提供一个全球性联系网络

 

WAO网站上可找到如下信息:

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Translator: Liping Wen MD Peking Medical College Hospital   译者:北京协和医院变态反应科 文利平