领域驱动模型的WEB软件系统设计研究

首先分析了J2EE3层架构的特性及局限,说明了领域驱动设计模型中的充血模型的优势。通过运用最新JDKI．7及Tomcat的相应改造,设计出能实现以充血模型结构为基础的新型WEB系统开发框架,并通过一简单实例说明架构如何支持系统开发。     

Is hepcidin‐25 a predictor of atherosclerosis in hemodialysis patients?

Atherosclerotic cardiovascular disease is an important cause of mortality and morbidity in hemodialysis patients. Iron accumulation in arterial wall macrophages is increased in atherosclerotic lesions. Hepcidin is a key hepatic hormone regulating iron balance. It inhibits iron release from macrophages and iron absorption from enterocytes by binding and inactivating the cellular iron exporter ferroportin. The aim of this study is to investigate the relation of hepcidin‐25, iron parameters, and atherosclerosis measured by carotid intima media thickness (CIMT) in hemodialysis patients. Eighty‐two hemodialysis patients were enrolled in this cross‐sectional study. Predialysis blood samples were centrifuged at 1500 g and 4°C for 10 minutes and stored at ?80°C for the measurement of hepcidin‐25. DRG hepcidin enzyme‐linked immunosorbent assay kit was used for the measurement of hepcidin‐25. Ultrasonographical B‐mode imaging of bilateral carotid arteries was performed with a high‐resolution real‐time ultrasonography (Mindray DC7). Mean age of the study population was 57.90 ± 16.08 years and 43.9% were men. Total study population was grouped into two according to median value of hepcidin‐25. There was no difference between groups with respect to age, dialysis vintage, and C‐reactive protein. CIMT was found to be statistically significantly higher in low hepcidin‐25 group. In correlation analysis, CIMT was found to be correlated with age (P < 0.01, R = 0.33) and hepcidin‐25 (P < 0.01, R = 0.46). In linear regression analysis, age (β = 0.31) and hepcidin‐25 (β = 0.44) were found to be the determinants of CIMT in hemodialysis patients. Our results implicate that hepcidin may take part in pathophysiology of atherosclerosis and cardiovascular disease in hemodialysis patients.     

自身免疫性溶血性贫血患者成分输血的疗效观察

目的探讨自身免疫性溶血性贫血(AHIA)患者成分输血的临床疗效。方法对15例输注洗涤红细胞的AHIA患者(A组)和15例输注红细胞悬液的AHIA患者(B组)的临床资料进行回顾性对比分析。结果 A、B两组患者输血24h后,血红蛋白(Hb)、红细胞(RBC)数量和血细胞比容(Hct)均升高;同组内输血前后比较,差异均有统计学意义;两组间输血前后差异均无统计学意义。A组中5例患者输注洗涤红细胞联合血浆置换治疗AHIA,临床症状明显改善。结论输注洗涤红细胞与红细胞悬液治疗AHIA,其临床效果差异无统计学意义;输注洗涤红细胞联合血浆置换治疗AHIA效果显著。     

腺嘌呤致大鼠慢性肾功能衰竭贫血动物模型的建立

给大鼠口服含 0 .75 %腺嘌呤饲料 7周 ,造成大鼠慢性肾功能衰竭 ,并引起较严重的贫血 ,为进行重组人红细胞生成素 (rHuEPO)对慢性肾衰所致贫血的药效研究提供了稳定的实验动物模型。     

Dialysis patients treated with Epoetin α show improved exercise tolerance and physical function: A new analysis of the Canadian Erythropoietin Study Group trial

The risks/benefits of anemia treatment in dialysis patients have been redefined in the US Epoetin α label. This analysis was carried out to determine if increasing hemoglobin (Hb) levels improve exercise tolerance and physical function in anemic dialysis patients. This is a new analysis of the Canadian Erythropoietin Study Group trial, a double‐blind, randomized, placebo‐controlled trial in dialysis patients. Subjects were 18 to 75 years old, on hemodialysis for >3 months, and had a baseline Hb <9.0 g/dL. Patients with a history of diabetes mellitus, ischemic heart disease, or severe/uncontrolled hypertension were excluded. Patients were randomized to receive Epoetin α to a target Hb of 9.5 to 11.0 g/dL (n=40) or a target of 11.5 to 13.0 g/dL (n=38), or receive placebo (n=40). Results from patients in the Epoetin‐α–treated arms were combined for this analysis. Hb level, exercise tolerance (Treadmill Stress Test and 6‐Minute Walk Test) and patient‐reported physical function measures (Physical Summary domain from the Kidney Disease Questionnaire, and 4 domains from the Sickness Impact Profile) were reported at baseline and months 2, 4, and 6. Differences in measures were statistically significant for exercise tolerance (Treadmill Stress, P=0.0001) and patient‐reported physical function (Kidney Disease Questionnaire Physical, P=0.0001; Sickness Impact Profile Physical, P=0.0015) across all time points for Epoetin‐α–treated patients compared with placebo. Improvements were seen at 2 months and were maintained through months 4 and 6. Dialysis patients receiving Epoetin α showed improved exercise tolerance and physical function. These findings should be considered as physicians weigh the risks and benefits of treatment.     

TSAT is a better predictor than ferritin of hemoglobin response to Epoetin alfa in US dialysis patients

Clinical guidelines recommend concurrent treatment of anemia in end‐stage renal disease with erythropoiesis‐stimulating agents (ESAs) and iron. However, there are mixed data about optimal iron supplementation. To help address this gap, the relationship between iron markers and hemoglobin (Hb) response to ESA (Epoetin alfa) dose was examined. Electronic medical records of 1902 US chronic hemodialysis patients were analyzed over a 12‐month period between June 2009 and June 2010. The analysis included patients who had at least one Hb value during each 4‐week interval for four consecutive intervals (k ? 2, k ? 1, k, and k + 1; k is the index interval), received at least one ESA dose during intervals k ? 1 or k, had at least one transferrin saturation (TSAT) value at interval k, and at least one ferritin value during intervals k ? 2, k ? 1, or k. Effect modification by TSAT and ferritin on Hb response was evaluated using the generalized estimating equations approach. Patients had a mean (standard deviation) age of 62 (15) years; 41% were Caucasian, 34% African American, 65% had hypertension, and 39% diabetes. Transferrin saturation, but not ferritin, had a statistically significant (P < 0.05) modifying effect on Hb response. Maximum Hb response was achieved when TSAT was 34%, with minimal incremental effect beyond these levels. Of the two standard clinical iron markers, TSAT should be used as the primary marker of the modifying effect of iron on Hb response to ESA. Long‐term safety of iron use to improve Hb response to ESA warrants further study.     

Interactions between iron deficiency and lead poisoning: epidemiology and pathogenesis

Iron deficiency and lead poisoning are common among infants and children in many parts of the world, and often these two problems are associated. Both conditions are known to cause anemia and appear to produce a more severe form of anemia when in combination. Although the nature of their relationship is not completely elucidated, characterization of a common iron-lead transporter and epidemiological studies among children strongly suggest that iron deficiency may increase susceptibility to lead poisoning. Recent human studies suggest that high iron intake and sufficient iron stores may reduce the risk of lead poisoning. Future clinical trials are necessary to assess the effect of iron supplementation in the public health prevention of lead poisoning and the kinetics of lead in the body.     

Association of increased travel distance to dialysis units with the risk of anemia in rural chronic hemodialysis elderly

Geographic remoteness has been found to influence health‐related outcomes negatively. As reported in the literature, rural dialysis patients have a higher risk of mortality with increasing travel distance to dialysis units. However, few studies have focused on the impact of travel distances on the development of dialysis complications. We utilized a prospectively collected chronic hemodialysis patient cohort from a rural regional hospital for analysis. Data on demographics, comorbidities, and serum laboratory results were obtained. Correlation analyses between travel distance to dialysis units and dialysis complications were conducted, and significantly correlated parameters were entered into multivariate logistic regression models to determine their exact associations. A total of 46 rural chronic hemodialysis patients were enrolled, with an average age higher than others in the literature. Significant correlation was found between travel distance and serum hemoglobin levels (R² = −0.34, P value = 0.029). Multivariate logistic regression found that every 1 km increase in travel distance was associated with an increased risk of anemia (hemoglobin <9 g/dL) (odds ratio 1.46; P value = 0.01). Sensitivity analyses further showed that the associated risk was partially attenuated by serum albumin (odds ratio 1.83; P value = 0.07) and ferritin (odds ratio 1.39; P value = 0.08) levels. This is the first study to demonstrate the association between increased travel distance to dialysis units and the risk of anemia in chronic dialysis patients, especially elderly. Malnutrition, inflammation, and atherosclerosis syndrome could be partially responsible for the observed association. Further research is required to confirm our findings.     

The greatly misunderstood erythropoietin resistance index and the case for a new responsiveness measure

Introduction The optimal use of erythropoiesis stimulating agents (ESAs) to treat anemia in end stage renal disease remains controversial due to reported associations with adverse events. In analyzing these associations, studies often utilize ESA resistance indices (ERIs), to characterize a patient's response to ESA. In this study, we examine whether ERI is an adequate measure of ESA resistance. Methods We used retrospective data from a nonconcurrent cohort study of incident hemodialysis patients in the United States (n = 9386). ERI is defined as average weekly erythropoietin (EPO) dose per kg body weight (wt) per average hemoglobin (Hgb), over a 3‐month period (ERI = (EPO/wt)/Hgb). Linear regression was used to demonstrate the relationship between ERI and weight‐adjusted EPO. The coefficient of variation was used to compare the variability of Hgb with that of weight‐adjusted EPO to explain this relationship. This analysis was done for each quarter during the first year of dialysis. Findings ERI is strongly linearly related with weight‐adjusted EPO dose in each of the four quarters by the equation ERI = 0.0899*(EPO/wt) (range of R² = 0.97–0.98) and weakly linearly related to 1/Hgb (range of R² = 0.06–0.16). These correlations hold independent of age, sex, hgb level, ERI level, and epo‐naïve stratifications. Discussion ERI is strongly linearly related to weight‐adjusted (and nonweight‐adjusted) EPO dose by a “universal,” not patient‐specific formula, and thus is a surrogate of EPO dose. Therefore, associations between ERI and clinical outcomes are associations between a confounded EPO dose and those outcomes.