17例异位ACTH综合征的前瞻性研究

目的 探讨未明确病因异位ACTH综合征的最佳诊治方法.方法 分析我院近年来随访的17例异位ACTH综合征患者的临床特征、影像学检查、治疗方案等资料.结果 所有患者临床上大多具有库欣综合征的典型表现;均有低血钾性碱中毒,血皮质醇明显升高且节律消失,尿皮质醇和血浆ACTH升高,大剂量地塞米松抑制试验绝大部分不被抑制;影像学检查主要依靠CT和(或)MRI,明确定位的患者手术切除肿瘤预后良好;未明确定位的9例患者中,3例行双侧肾上腺次全切除术后糖皮质激素替代治疗,2例行右侧肾上腺全切除术后肾上腺皮质激素抑制剂治疗,4例单纯肾上腺皮质激素抑制剂治疗,患者高皮质醇状态均得到一定控制.结论 根治性切除异位肿瘤预后较好.对于未能早期发现的患者,双侧肾上腺次全切除、单侧肾上腺切除或药物治疗是控制临床高皮质醇水平的有效手段.     

异位促肾上腺皮质激素综合征的诊断治疗进展

异位促肾上腺皮质激素综合征(EAS)由不同的内分泌或非内分泌肿瘤分泌促肾上腺皮质激素(ACTH)导致肾上腺皮质增生并分泌过量的皮质醇引起的一种临床综合征。联合不同的试验和影像学检查对准确诊断异位ACTH十分关键。如能早期发现异位肿瘤来源并行根治性切除,一般预后较好。对于未能发现异位肿瘤来源或者没有手术适应证的患者,通过药物控制高皮质醇血症,可以明显降低患者的并发症,提高患者的生活质量,延长患者的生命。因此单纯药物治疗在某种程度上可以代替双侧肾上腺切除手术。     

促肾上腺皮质激素非依赖性肾上腺皮质大结节增生症12例临床分析

回顾分析12例促肾上腺皮质激素（ACTH）非依赖性肾上腺皮质大结节增生症（AIMAH）患者的临床资料．12例均具有库欣综合征的临床和生化特点,大、小剂量地塞米松抑制试验均不被抑制,血浆ACTH水平降低。CT检查均示双侧肾上腺结节样增生,均经病理检查证实为双侧肾上腺大结节样增生,4例行双侧肾上腺全切术后血压正常,随访8年,未升高;8例行单侧肾上腺切除．术后血压明显下降,但3年后血压复升,2例再行对侧肾上腺全切除后治愈,术后均无纳尔逊（Nelson）综合征.     

库欣综合征3种不同类型病例诊治思考

目的 总结不同类型库欣综合征的临床特点,以供临床医生借鉴.方法 分析3例库欣综合征患者(其中库欣病1例,异位ACTH综合征1例,肾上腺腺瘤1例)的临床特征、实验室及影像学检查特点.结果 3例患者均存在血皮质醇节律消失和尿游离皮质醇升高.库欣病和异位ACTH综合征患者血ACTH水平升高, 影像学检查分别发现垂体微腺瘤和左下肺占位病变(术后病理为类癌);肾上腺腺瘤患者血ACTH水平降低;大剂量地塞米松抑制试验在库欣病患者可抑制,在异位ACTH综合征和肾上腺腺瘤患者不被抑制.结论 不同类型库欣综合征有其不同临床特点,对此种疾病有充分的了解,可以帮助及早诊断和治疗.     

异位促肾上腺皮质激素综合征的外科治疗

目的：探讨异位促肾上腺皮质激素（adrenocorticotrophic hormone,ACTH）综合征的诊断与外科治疗。方法：对1996 年1月至2016年12月北京协和医院收治的异位ACTH综合征57例的临床资料进行总结,其中男32例、女25例,年龄11~68岁,平均32岁。血ACTH显著升高,平均77.6 pmol/L（16.5~365.6 pmol/L,正常值为＜10.1 pmol/L）,垂体MRI未见占位,CT检查双侧肾上腺均有不同程度弥漫性或结节样增生。按照不同治疗方案选择分为3组：A组25例,未发现异位肿瘤的异位ACTH 综合征,行双侧或单侧肾上腺切除的手术治疗;B组16例,发现异位肿瘤行肿瘤根治性切除术;C组16例,非手术治疗。分析不同治疗方法疗效及预后。结果：57例患者中有40例随访6个月至10 年,A组因病情凶险程度不同、术中情况各异,采取的治疗方式也有差别,部分为分期双侧肾上腺切除或仅行单侧肾上腺切除术,其中4例死于严重库欣综合征(Cushing’s syndrome)导致的糖尿病、肺部感染,18例存活至今,3例失访,存活率为81%（18/22）。B组16例行异位肿瘤根治性切除者,5例术后0.5~6.0年死于肿瘤复发, 3例存活至今,8例失访,存活率为37.5%（3/8）。C组4例放射疗法加化学药物治疗者1年内均死于肿瘤转移、糖尿病或肺部感染, 6例单纯化学药物治疗者均于1年内死于肺部感染,另6例失访,无1例存活。结论：异位ACTH 综合征的治疗难度大,靶腺切除是有效的治疗方法,尤其适用于库欣综合征临床症状严重而原发肿瘤无法定位者。     

双侧肾上腺高功能皮质腺瘤致ACTH非依赖性库欣综合征3例临床诊疗探索

目的 探讨双侧肾上腺高功能皮质腺瘤致促肾上腺皮质激素（ACTH）非依赖性库欣综合征的临床特点、诊治思路,提高对该疾病的认知。 方法 收集2016～2021年四川大学华西医院内分泌代谢科收治的3例双侧肾上腺功能性皮质腺瘤致ACTH非依赖性库欣综合征患者行回顾性分析,分析患者的一般情况、症状及体征、辅助检查、诊治过程等临床资料,并结合文献进行复习和讨论。 结果 3例患者均表现为典型且严重的库欣综合征,并伴有显著的心脏和代谢并发症,影像学提示双侧肾上腺单发腺瘤;2例患者行双侧肾上腺静脉采血,均提示双侧肾上腺皮质醇高分泌且无优势侧;1例患者行双侧肾上腺肿物切除术,另外2例患者因为心功能不全严重,行分期双侧肾上腺肿物切除术,术后病理结果3例均提示双侧肾上腺皮质腺瘤,术后皮质醇浓度均明显降低,均给长期予糖激素替代治疗。 结论 双侧肾上腺高功能皮质腺瘤致ACTH非依赖性库欣综合征非常罕见,明确诊断并判断双侧功能定位非常重要,治疗上应根据患者的病情及并发症情况个体化的选择最适合患者的手术方式,术后应严密随访,及时给予并调整糖皮质激素替代治疗,并终身随访。     

异位促肾上腺皮质激素综合征5例报告

目的探讨异位促肾上腺皮质激素(ACTH)综合征的临床特点、诊断及治疗,提高临床医生对该病的认识。方法对我院2007-2013年确诊的5例异位ACTH综合征患者的临床资料及诊治过程进行回顾性分析。结果 5例患者均不具有库欣综合征的典型临床表现,但均出现低血钾、水肿,3例伴有糖代谢紊乱,3例伴有高血压,1例伴有皮肤色素沉着。病程15 d-2月。实验室化验显示严重低血钾碱中毒,血皮质醇水平明显升高且昼夜节律消失,血ACTH明显增高,大剂量地塞米松抑制试验不被抑制。影像学检查主要依靠CT和/或MRI,5例患者均找到异位肿瘤,1例卵巢肿瘤,3例肺癌,1例食管癌术后肝转移。结论对病程短、顽固性低血钾、水肿明显而库欣综合征临床表现不明显的患者,应及时检测血浆ACTH和皮质醇水平,明确是否为异位ACTH综合征,改善患者预后。     

异位促肾上腺皮质激素综合征临床诊断策略探讨

目的 探讨异位促肾上腺皮质激素(ACTH)综合征的临床诊断策略.方法 分析2例异位ACTH综合征患者临床特点并做文献复习.结果 2例患者均存在血ACTH和尿游离皮质醇水平明显升高,大小剂量地塞米松抑制试验不能抑制等临床特点.1例患者胸部CT检查发现左下肺结节,经手术证实为类癌.另1例患者胸部CT检查发现右上肺、中肺多个小结节样影,不能明确性质;奥曲肽显像结果阴性;18F-脱氧葡萄糖正电子发射断层显像/CT(PET/CT)检查于右肺上叶前段见一放射性浓聚结节影,提示神经内分泌肿瘤.结论 异位ACTH综合征患者临床表现各异,当常规影像学检查结合奥曲肽显像不能明确肿瘤性质和部位时,PET/CT检查可提高肿瘤的检出率,有利于患者的进一步治疗.     

皮质醇增多症的病理类型和治疗方案的选择——111例临床分析

本文结合111例皮质醇增多症的临床分析,根据其不同病理类型,对治疗方案的选择进行了讨论。增生型无明确垂体瘸者主张肾上腺次全切除加垂体放疗;有明显垂体瘤者,不论有无压迫症状均主张先行垂体手术,3～6月后皮质醇增多症症状未缓解者,再行肾上腺次全切除术。肾上腺腺瘤手术疗效满意。腺癌应手术根治,晚期不能手术者可用二氯苯二氯乙烷治疗。异位ACTH综合征根治原发病灶后皮质醇增多症可期缓解。     

一例不同组织来源的双侧肾上腺肿瘤并文献分析

目的提高对不同组织来源的双侧肾上腺肿瘤的认识,探讨其诊治方法。方法回顾性分析中国医学科学院北京协和医院泌尿外科收治的1例双侧肾上腺分别患嗜铬细胞瘤和库欣腺瘤患者的症状、体征、辅助检查及诊治经过等资料。结果患者因脸变圆红于外院诊断为非促肾上腺皮质激素（adrenocorticotropic hormone,ACTH）依赖性皮质醇增多症,右肾上腺肿瘤,行腹腔镜右肾上腺肿瘤切除,术中血压升高,病理诊断为嗜铬细胞瘤。术后皮质醇增多症状未缓解,复查血ACTH〈5pg／ml,24h尿游离皮质醇（urinary-free cortisol,UFC）571．32μg;24h尿儿茶酚胺：去甲肾上腺素22．80μg,肾上腺素2．55μg,多巴胺92．92μg;CT示左肾上腺肿瘤。诊断为库欣综合征,左。肾上腺肿瘤,右肾上腺嗜铬细胞瘤术后。转入中国医学科学院北京协和医院行腹腔镜左肾上腺肿瘤切除术,术后病理：肾上腺皮质腺瘤。术后1周复查UFC56．2μg。结论不同组织来源的双侧肾上腺肿瘤可以发生,但罕见,治疗应选择双侧肿瘤切除,并保留部分肾上腺组织。     

APPLICATION OF LORNOXICAM TO PATIENT-CONTROLLED ANALGESIA IN PATIENTS UNDERGOING ABDOMINAL SURGERIES

FOR anesthesiologis s ,treatingpostoperativepainhas alwaysbeen a problem.Althoughopioidshave been provedtobe effective,theirsideeffectscouldnotbeignored.With thedevelopmentofscienceand pharmacology,many drugs with aspectsof satisfactoryanalgesicefficacyand couldbe welltoleratedby patientshave been developed.And lornoxicamisone of them, which isa non-steroidalanti-inflammatorydrug (NSAID ), with analgesic, anti-infl-ammatory,andantipyreticproperties.Itseliminationhalf-time(3 to 5 hours) isle…     

Dr.Zhang Ren''''s Experience in the Acupuncture Treatment of Different Diseases with the Same Therapeutic Principle

Dr.Zhang Ren,the chief physician,is the chairman of Shanghai Acupuncture and Moxibustion Association.Having been engaged in medicine for about 40 years,he is experienced in treating various intractable diseases.In his long years of clinical practice,he advocates taking the TCM differentiation as the basis to seek for the acupuncture method for treatment of modern intractable diseases.The author of this essay had the fortune to follow Dr.Zhang in study.The following is a summary of Dr.Zhang's experience in the acupuncture treatment for different intractable diseases with the same therapeutic principle.     

Luo Lingjie''''s Experience in Treating Chronic Nephropathy

In treating chronic nephropathy,Luo Lingjie,a chief physician,pays attention to regulating the balance between yin and yang,treating infection if present,and removing pathogenic factors.He prescribes gentle drugs and uses carefully strongly warming-tonifying ones,emphasizes the importance of persuading the patient to persist in treatment with medication and nurse one's health for recuperation,and is good at combined use of TCM and western medicine therapy and brings the merits of various therapies into full play,with obvious theraoeutic effects.     

Acupuncture Combined with Spinal Tui Na for Treatment of Primary Dysmenorrhea in 30 Cases

Objective: To observe the therapeutic effects in acupunture treatment of primary dysmenorrhea combined with spinal Tui Na, and study its mechanism. Methods: Thirty cases of the treatment group were treated by acupuncture combined with spinal Tui Na, and thirty cases in the control group were treated by routine acupuncture. Results: The total effective rate was 93.3% in the treatment group, and 73.3% in the control group, with a significant difference between the two groups (P<0.05). Conclusions: Acupuncture combined with spinal Tui Na has good prospects for treatment of primary dysmenorrhea.     

猪肺磷脂注射液联合经鼻持续气道正压通气对呼吸衰竭早产儿的临床疗效及肌酸激酶同工酶活性的影响

目的 探讨猪肺磷脂注射液联合经鼻持续气道正压通气(NCPAP)对呼吸衰竭早产儿的临床疗效及肌酸激酶同工酶活性(CK-MB)的影响.方法 选取呼吸衰竭早产儿80例,分为观察组和对照组各40例.对照组采用NCPAP给氧治疗,观察组给予NCPAP给氧联合猪肺磷脂气管内给药.观察两组患儿治疗前及治疗12h、24 h后PaO2、PaCO2、血氧饱和度(SaO2)、pH的变化情况,检测治疗前及治疗5d后血清CK-MB水平;评估两组患儿的临床治疗效果.结果 两组患儿PaO2、PaCO2、SaO2、pH比较,差异均有统计学意义(P＜0.05),其中观察组治疗后的PaO2、SaO2、pH均高于对照组,PaCO2则低于对照组.两组的PaO2、SaO2、pH均随观察时间延长而升高(P＜0.05),PaCO2均随观察时间的延长而降低(P＜0.05).观察组治疗有效率为87.5％,显著高于对照组的70.0％ (P ＜0.05).治疗5d后两组患儿血清CK-MB水平均较前降低(P＜0.05),且观察组明显低于对照组(P＜0.05).结论 猪肺磷脂注射液气管内给药联合NCPAP可以显著降低呼吸衰竭早产儿CK-MB的含量,提高治疗有效率,起到很好的呼吸循环支持作用.     

Survey and practice of reporting quality of randomized controlled clinical trials on traditional Chinese medicine

Evidence obtained from randomized controlled trials （RCTs） has been generally accepted as the gold standard in the evaluation of clinical effectiveness. Readers need to understand the trial design, implementation, results, analysis and interpretation, so as to fully Jnderstand the results of RCTs. Thus, the investigators of RCTs have to report these items in a complete, accurate and clear manner. Since 1998, we have conducted several evaluations on the reporting quality of RCTs published in Chinese journals on traditional Chinese medicine （TCM） and results have shown that there is an urgent need for higher quality RCTs on TCM.     

TCM Treatment of Ankylosing Spondylitis by Tonifying the Kidney and Strengthening the Governor Vessel

Ankylosing spondylitis is a chronic and progressive disorder with inflammation mainly involving the central axis joints. It mainly affects the cervical spine and the lumbosacral area, with the pathogenesis closely related to the kidney and the Governor Vessel (GV). TCM holds that the syndrome is deficiency in origin and excess in superficiality, which is due to insufficiency of the kidney, deficiency of GV, and blocking of the channels with the invasion of exogenous evil, leading to poor circulation of qi and blood and malnutrition of the bones, muscles and joints. The TCM method of tonifying the kidney and strengthening GV to regulate circulation of qi and blood and check the arthralgia pain should be adopted, with the Kidney-Tonifying and GV Strengthening Decoction (益肾强督汤) prescribed.     

IMPROVING P-gp EXPRESSION IN HUMAN MONONUCLEAR CELLS IN VITRO TRANSFECTED BY MULTIDRUG RESISTANCE-1 mRNA

CHEMOTHERAPY playsa greatrolein the treat- ment of malignanttumors,especiallyingynecolo- gicalones.But inanticancerchemotherapy,leuko-cytopeniaisfrequentlytheprimarydose-limitingsideeffect factor.Moreover,cancersarefrequentlychemoresistantbe-causeof overexpressionof P-glycoprotein(P-gp), which isencodedby multidrugresistancegene (MDR1 ) and detectableinup to50% ofhuman cancersand renderscellsresistancetoanticancerdrugs.The safetyand potentialtherapeuticbenefitof mdr1 gene transferredto h…