Withdrawal of fluticasone propionate from combined salmeterol/fluticasone treatment in patients with COPD causes immediate and sustained disease deterioration: a randomised controlled trial

BACKGROUND: Guidelines recommend inhaled corticosteroids (ICS) as maintenance treatment for patients with chronic obstructive pulmonary disease (COPD) with a post-bronchodilator forced expiratory volume in 1 second (FEV1) <50% predicted and frequent exacerbations, although they have only a small preventive effect on the accelerated decline in lung function. Combined treatment with ICS and long acting beta2 agonists (LABA) may provide benefit to the stability of COPD, but it is unknown if withdrawal of ICS will result in disease deterioration. METHODS: The effects of 1 year withdrawal of the ICS fluticasone propionate (FP) after a 3 month run-in treatment period with FP combined with the LABA salmeterol (S) (500 microg FP + 50 microg S twice daily; SFC) were investigated in patients with COPD in a randomised, double blind study. 497 patients were enrolled from 39 centres throughout the Netherlands; 373 were randomised and 293 completed the study. RESULTS: The drop out rate after randomisation was similar in the two groups. Withdrawal of FP resulted in a sustained decrease in FEV1: mean (SE) change from baseline -4.4 (0.9)% (S) v -0.1 (0.9)% (SFC); adjusted difference 4.1 (95% CI 1.6 to 6.6) percentage points (p<0.001). Corresponding figures for the FEV1/FVC ratio were -3.7 (0.8)% (S) v 0.0 (0.8)% (SFC) (p = 0.002). The annual moderate to severe exacerbation rate was 1.6 and 1.3 in the S and SFC groups, respectively (adjusted rate ratio 1.2; 95% CI 0.9 to 1.5; p = 0.15). The mean annual incidence rate of mild exacerbations was 1.3 (S) v 0.6 (SFC), p = 0.020. An immediate and sustained increase in dyspnoea score (scale 0-4; mean difference between groups 0.17 (0.04), p<0.001) and in the percentage of disturbed nights (6 (2) percentage points, p<0.001) occurred after withdrawal of fluticasone. CONCLUSIONS: Withdrawal of FP in COPD patients using SFC resulted in acute and persistent deterioration in lung function and dyspnoea and in an increase in mild exacerbations and percentage of disturbed nights. This study clearly indicates a key role for ICS in the management of COPD as their discontinuation leads to disease deterioration, even under treatment with a LABA.     

Quality Improvement Guidelines for Placement of Esophageal Stents

Esophageal cancer is now the sixth leading cause of death from cancer worldwide [1, 2]. During the past three decades, important changes have occurred in the epidemiologic patterns associated with this disease [1]. Due to the distensible characteristics of the esophagus, patients may not recognize any symptoms until 50% of the luminal diameter is compromised, explaining why cancer of the esophagus is generally associated with late presentation and poor prognosis [3]. Esophageal cancer has a poor outcome, with an overall 5 year survival rate of less than 10%, and fewer than 50% of patients are suitable for resection at presentation. As a result palliation is the best option in this group of patients [3, 4]. The aims of palliation are maintenance of oral intake, minimizing hospital stay, relief of pain, elimination of reflux and regurgitation, and prevention of aspiration [3, 5, 6]. For palliative care, current treatment options include thermal ablation [7–9], photodynamic therapy [10–12], radiotherapy [13], chemotherapy [14, 15], chemical injection therapy [16–18], argon beam or bipolar electrocoagulation therapy [19], enteral feeding (nasogastric tube/percutaneous endoscopic gastrostomy) [20–22], and intubation (self-expanding metal stents (SEMS) or semi-rigid prosthetic tubes) [5, 6, 23–26] with different success and complications rates.     

糖皮质激素对出血性休克大鼠生存率的影响及对脏器的保护作用

目的研究糖皮质激素甲强龙和氢考对出血性休克大鼠生存率的影响,并探讨其机制。方法80只Wistar大鼠随机分成假休克组、休克组、甲强龙治疗组和氢考治疗组。经动脉放血建立大鼠出血性休克模型,随后采用自体血和生理盐水静脉回输进行复苏。结果复苏后72h,休克组大鼠的生存率明显低于甲强龙治疗组和氢考治疗组(P<0.01和P<0.05)。复苏后18h器官病理取材,光镜下显示休克组大鼠的心、肺、肾、肝组织出现不同程度水肿、细胞变性、间质炎性细胞浸润等,甲强龙治疗组和氢考治疗组大鼠上述脏器的病理改变明显减轻。复苏后2h,肝脏Kupffer细胞经脂多糖刺激后,休克组细胞内Ca2 浓度和肿瘤坏死因子α含量明显增高,而甲强龙治疗组和氢考治疗组轻度增高,差异显著(P<0.01)。结论甲强龙和氢考可以通过抑制Kupffer细胞内Ca2 升高和激活、阻止肿瘤坏死因子α的过度产生来降低机体全身炎性反应程度,最终减轻出血性休克大鼠脏器的损伤并降低死亡率。     

创伤性休克复苏后脏器缺血/再灌注损伤的实验研究

目的 观察创伤性休克复苏后大白鼠脏器缺血/再灌注损伤的病理学改变和特征.方法 Wistar大鼠用铁块从固定高度垂直落下砸击左侧大腿并同时放血来建立大白鼠创伤性休克模型,随后用自体血和生理盐水进行复苏,复苏前大鼠分成两组:对照组和休克组.结果 24小时后休克组中各脏器组织的病理变化明显:间质细胞增多,组织内大量炎性细胞浸润,毛细血管扩张、充血,微血管内可见微血栓形成,细胞肿胀、变性和坏死;病理损伤评分均显著重于对照组(P＜0.05).结论 创伤性休克复苏后组织脏器存在明显的病理变化,动物实验证实,创伤性休克复苏后脏器缺血/再灌注损伤向多器官功能障碍综合征(MODS)转变存在病理学特征和基础.     

结核病人耐药204例临床分析

本文就我院几年来结核菌涂片204例耐药情况进行分析讨论。1 临床资料204例结核菌阳性肺结核病人,年龄18～68岁,大多数为20～60岁。初治51例,复治153例。在本院的治疗中,除有并发症外,大多数是院外治疗失败而进入本院的。     

IgA肾病中医病理机制的探讨

lgA肾病是指一组以肾小球系膜区显著的IgA沉积为特征的肾小球疾病,为原发性肾小球肾炎中最常见者。据黎磊石140O例肾穿刺的报道,我国IgA肾病的发生率约32％［1］。对该病目前尚无特殊治疗,有人研究,其中378％的病人有发展为慢性肾功能衰竭的可能［2］。所以,探索本病的中医中药治疗途经大有必要。综合现代医学关于IgA肾病发病机理的认识和传统中医理论来认识IgA肾病中医的发病机制,将为我们的临床实践提供有益的指导。至气虚为本,相关肝、脾、肾虽然IgA肾病的发病机理尚未完全明了,但粘膜免疫功能的异常或缺陷是已经肯定的。I…     

肾炎湿热论

<正>江苏省中西医结合专家,百年金陵名医余承惠主任医师,从事中西医结合肾病研究四十余年,他提出肾炎湿热论,认为湿热蕴肾是肾炎的基本病理,贯穿于肾炎整个病程中,虚实夹杂是证型的基本表现,清利湿热抗炎是治疗肾炎的主要环节。笔者有幸师承学习,现将余主任的经验整理如下,供同道