糖皮质激素治疗对急性呼吸窘迫综合征患者预后的影响

目的：探讨早期应用糖皮质激素（GC）治疗对急性呼吸窘迫综合征（ARDS）患者预后的影响。方法回顾性分析成都军区总医院2008年1月至2011年12月收治的所有ARDS病例的临床资料,选择符合2012年柏林ARDS诊断标准的成人患者,根据是否采用过GC治疗将患者分为GC组与非GC组。GC组患者均在ARDS发生48 h内开始静脉使用低剂量GC（＜5 mg·kg-1·d-1,均换算为氢化可的松的剂量）治疗,激素种类为甲泼尼松龙、地塞米松,疗程为7～21 d;而非GC组为ARDS发生后未使用GC治疗。比较两组患者机械通气时间、重症加强治疗病房（ICU）住院时间、总住院时间、医疗费用和28 d生存率的差异。结果共纳入ARDS患者117例,其中GC组56例（占47.86%）,非GC组61例（占52.14%）。与非GC组比较,GC组机械通气时间明显缩短〔d：0（0,2.50）比2.00（0,2.50）,Z＝2.015,P＝0.044〕,28 d生存率明显升高〔71.43%（40/56）比50.82%（31/61）,χ2＝5.198,P＝0.023〕,ICU住院时间〔d：7.50（2.00,11.00）比4.00（1.00,9.00）,Z＝1.879, P＝0.060〕和总住院时间〔d：16.00（10.00,27.75）比15.00（7.00,28.00）,Z＝0.592,P＝0.552〕差异无统计学意义,但非GC组患者的医疗费用显著低于GC组〔万元：3.15（1.51,5.78）比4.39（1.66,10.88）,Z＝2.204,P＝0.028〕。结论早期使用GC治疗ADRS患者可改善预后,特别是28 d生存率。     

α7nAChR参与生理浓度糖皮质激素的抗炎作用*

 目的： 探讨α7烟碱型乙酰胆碱受体（α7nAChR）在生理浓度糖皮质激素（GCs）抗炎过程中的作用。方法: MTT法检测不同浓度氢化可的松对小胶质细胞BV-2活性的影响;在建立LPS刺激的BV-2细胞炎症模型基础上,实验分组如下：(1) 空白对照组;(2) LPS组;(3) GCs＋LPS组;(4) α7nAChR阻断剂甲基牛扁亭碱（MLA）＋GCs＋LPS组,ELISA法测定细胞上清中TNF-α和IL-1β的含量。结果: 2 000 和1 000 nmol/L 氢化可的松可分别使细胞存活率降低至(76.9±5.5)%和(90.8±7.3)%,表现出超生理剂量GCs的细胞损伤作用。LPS明显刺激BV-2细胞释放TNF-α和IL-1β,并呈现时间和剂量依赖性。生理浓度（500和250 nmol/L）的氢化可的松均可减少LPS诱导BV-2细胞释放TNF-α和IL-1β,10 nmol/L MLA预处理BV-2细胞能拮抗GCs抑制炎症因子释放的作用。结论: α7nAChR参与了生理浓度GCs的抗炎作用。     

B型胰岛素抵抗的临床特点分析

目的　了解我国B型胰岛素抵抗（B-IR）患者的临床特点,提高诊治水平。方法　以“B型胰岛素抵抗”为关键词,检索中国知网和万方数据知识服务平台;以“type B insulin resistance”为关键词,检索PubMed数据库,检索2000年1月-2019年1月公开发表的文献,其中PubMed数据库中所检索文献筛选出报道中国患者的文献。根据筛选标准,共纳入13篇文献,15例患者。对其临床表现、实验室检查、治疗及随访情况进行归纳总结。结果　15例患者中男3例,平均年龄（46.3±17.0）岁;女12例,平均年龄（45.3±11.4）岁;年龄24~63岁,平均年龄（45.6±11.6）岁。15例患者均合并自身免疫性疾病,其中12例（12/15）合并1种疾病,3例（3/15）合并两种及以上疾病;9例（9/15）合并系统性红斑狼疮。15例患者中14例以高血糖起病者糖化血红蛋白为（11.9±2.7）%,1例以低血糖起病者糖化血红蛋白为7.6%。11例（11/15）患者空腹血清胰岛素>300 μU/ml,5例（5/15）有高睾酮血症。15例患者中7例（7/15）进行胰岛素受体抗体（AIRA）检测,结果均为阳性;6例（6/15）行13C呼气试验,其中4例阳性,2例阴性。糖皮质激素联合免疫抑制剂作为治疗该病的主要方案,其中4例（4/15）采用起始大剂量糖皮质激素冲击治疗（甲泼尼龙≥250 mg/d,共3 d）,其余11例（11/15）起始剂量为甲泼尼龙20~40 mg/d或醋酸泼尼松40~60 mg/d。12例（12/15）患者应用小剂量糖皮质激素（甲泼尼龙4~8 mg/d,醋酸泼尼松片2.5~10.0 mg/d）维持治疗。关于起始应用免疫抑制剂的方案,8例（8/15）患者起始选用环磷酰胺治疗,0.4~0.6 g/周起始应用,一般应用1~3周。血糖得以控制的时限为2周~1年。1例患者无随访记录,其余患者均进行随访,时间为2个月~7年。结论　B-IR临床罕见,有比较典型的血糖紊乱、高胰岛素血症和合并自身免疫性疾病,治疗方案主要包括糖皮质激素联合免疫抑制剂,需密切随访,改善预后。     

Comparative effectiveness and survival of infliximab,adalimumab, and etanercept for rheumatoid arthritis patients in the Hellenic Registry of Biologics: Low rates of remission and 5-year drug survival

Objective

To compare effectiveness, drug survival, and safety between infliximab, adalimumab, and etanercept, in a nationwide cohort of rheumatoid arthritis (RA) patients.

Methods

This study is a prospective cohort study of 1208 active RA patients. Effectiveness, drug survival, and serious adverse events during entire follow-up (median 2.9 years) were monitored.

Results

EULAR and CDAI responses were comparable between the three agents (EULAR good/moderate responses at 12 months ranged 76–79%). At 12 months, 15–23% achieved remission. For adalimumab and etanercept, adjusted hazard rate (HR) for EULAR/ACR remission (reference: infliximab) was 2.7 and 2.1 (95% confidence interval was 1.7–4.1 and 1.3–3.4, respectively); males (HR 1.6; 1.1–2.4), use of glucocorticoids (HR 2.0; 1.3–3.0), and swollen joint count >7 (HR 0.36; 0.24–0.55) were independent predictors. Five-year drug survival was 31%, 43%, and 49% for infliximab, adalimumab, and etanercept, respectively (p = 0.010). Infliximab was associated with significantly more withdrawals due to adverse events. Disease activity, CRP, and use of glucocorticoids predicted efficacy-related drug survival; age, use of methotrexate, and prior DMARDs failures predicted safety-related survival. Risk for serious infections was lower with adalimumab (odds ratio [OR] 0.62; 0.38–1.00) or etanercept (OR 0.39; 0.21–0.72) than infliximab, independent of the effects of age (OR 1.65; 1.37–2.00 per 10 years), tender joint count >10 (OR 1.86; 1.21–2.86), and glucocorticoids >35 mg/week (OR 1.83; 1.12–2.99).

Conclusions

Response rates were comparable among anti-TNF agents. Overall, 5-year drug survival was below 50%, with infliximab demonstrating increased safety-related discontinuations. Remission rates are low in clinical practice. Strategies to increase effectiveness and long-term survival of anti-TNF agents in RA are needed.     

IgG4相关性疾病20例临床特征分析

目的 总结IgG4相关性疾病临床特征及预后,提高认识,做到早期诊断及合理治疗.方法 对在我院住院明确诊断的20例IgG4相关性疾病患者资料进行回顾性分析.结果 20例患者中男性14例,女性6例,平均年龄58岁,胰腺和胆管为最常见受累器官,17例患者(85％)有≥2个器官受累.所有患者血清IgG4均明显升高(＞1350 mg/L).12例患者行组织病理学检查,主要表现为组织弥漫性纤维化,伴有大量淋巴细胞、浆细胞浸润,免疫组织化学可见CD38阳性浆细胞浸润,IgG4阳性浆细胞浸润,IgG4阳性浆细胞占IgG阳性浆细胞比例均＞40％.20例患者中,除1例患者死于急性化脓性胆管炎及1例未治疗,其余患者病情均明显缓解.结论 IgG4相关性疾病临床症状无特异性,血清IgG4可作为疑似病例的首选检查方法,及时应用糖皮质激素可迅速缓解病情.     

Meta-analysis of combined therapy for adult hepatitis B virus-associated glomerulonephritis

AIM: To investigate the efficacy and safety of combined antiviral and immunosuppressant therapy in adult hepatitis B virus-associated glomerulonephritis (HBV-GN) patients.METHODS: A computerized literature search was carried out in the PubMed database, Embase, the Cochrane Library, Chinese BioMedical Literature on disc, Chinese Medical Current Contents, Chinese National Knowledge Infrastructure, Wanfang and VIP (Chinese Technological Journal of Database) to collect articles between June 1980 and December 2010 on therapy with immunosuppressants, e.g., glucorticosteroids, mycophenolate mofetil and leflunomide, combined with antivirals, e.g., interferon, lamivudine, entecavir and adefovir dipivoxil, in adult HBV-GN patients. The primary outcomes were remission of proteinuria, clearance of HBV e-antigen, and elevation of serum albumin. The secondary outcomes were blood levels of alanine aminotransferase, serum creatinine, and HBV-DNA titer. Meta-analysis was performed using Review Manager 5.1. Fixed or random effect models were employed to combine the results after a heterogeneity test. The effects of the combined therapy were analyzed for different doses of glucorticosteroid and different types of HBV-GN.RESULTS: Twelve clinical trials with 317 patients were included. A significantly higher incidence of HBV-GN was found in male patients (relative risk = 2.40, 95% CI: 1.98-2.93). Combined therapy reduced the proteinuria significantly with a mean difference of 4.19 (95% CI: 3.86-4.53) and increased the serum albumin concentration significantly with a mean difference of -11.95 (95% CI: -12.97-10.93) without significant alterations of liver function (mean difference: 4.62, 95% CI: -2.55-11.79) and renal function (mean difference: 10.29, 95% CI: 0.14-20.45). No significant activation of HBV-DNA replication occurred (mean difference: 0.12, 95% CI: -0.37-0.62). There was no significant difference between the high dose glucorticosteroid group and the low dose glucorticosteroid group in terms of proteinuria remission (P = 0.76) and between different pathological types of HBV-GN [membranous glomerulonephritis (MN) vs mesangial proliferative glomerulonephritis, P = 0.68; MN vs membranoproliferative glomerulonephritis, P = 0.27].CONCLUSION: Combined antiviral and immunosuppressant therapy can improve the proteinuria in HBV-GN patients without altering HBV replication or damaging liver and renal functions.     

护理干预对哮喘患者吸入糖皮质激素治疗依从性的影响

目的护理干预对哮喘患者糖皮质激素吸入治疗的效果与治疗依从性分析。方法选取2010年1月—2011年12月在我科应用糖皮质激素治疗依从性差的84例中重度哮喘患者,随机分为两组,每组42例,调查分析患者治疗依从性,对比两组服药依从性。结果干预组42例患者,治疗依从率为88.10%,哮喘症状评分为(24.1±0.9)分;对照组42例患者,治疗依从率为19.05%,哮喘症状评分为(13.9±0.7)分。护理干预组的治疗依从性明显较好(P<0.05),疗效显著提高(P<0.05)。结论针对性护理干预能够有效提高患者糖皮质激素治疗依从性,提高疗效。     

特发性急性嗜酸粒细胞性肺炎一例临床特征分析

目的 探讨特发性急性嗜酸粒细胞性肺炎(IAEP)患者的临床特征.方法 分析解放军第81医院收治的1例IAEP患者的临床表现、影像学和病理特点,并综述有关IAEP的文献报道.结果 患者为70岁女性,咳嗽、胸闷、间断发热,急性病程,严重低氧血症.胸部CT示游走性肺浸润影伴少量胸腔积液.诊断性胸腔穿刺示胸水嗜酸粒细胞占28％.支气管肺泡灌洗液嗜酸粒细胞占59％.胸部CT引导下经皮肺穿刺活检示嗜酸粒细胞肺浸润.结论 IAEP是一种少见病,易被误诊为重症肺炎、急性肺损伤或急性呼吸窘迫综合征,对糖皮质激素敏感,治愈后无复发,预后良好.     

骨小梁Micro—CT检测评价阿仑膦酸钠预防大鼠激素性股骨头坏死的效果

目的探讨阿仑膦酸钠预防大鼠激素性股骨头坏死的疗效。方法将200只sD大鼠随机分成两组,其中实验组（A组）140只,对照组（B组）60只。对实验组大鼠给予连续灌喂阿仑膦酸钠溶液干预,对照组大鼠给予连续灌喂生理盐水,两组大鼠同时给予灌喂阿莫西林预防感染,2周后对所有大鼠均连续腹腔内注射大剂量甲级强的松龙4周。注射结束后2、4、8、12周分别处死等量大鼠进行micro—CT检测和HE染色评估造模成功率。结果计算骨小梁空骨陷窝率得出A组大鼠通过组织病理学检测显示造模成功率约30％,而B组造模成功率达50％。A组大鼠在干预开始后2、4、8、12周股骨头标本行Mirco—CT检查显示骨小梁平均间距分别为0．766、0．761、0．753、0．501um,骨小梁平均数目分别为6．146、6．159、6．194、6．723,骨小梁平均厚度为0．097、0．101、0．109、0．138um,组内2、4、8周取材检测结果无明显统计学意义（F值分别为1．670,452．719,1．737,P值均〉0．05）;但是12周时取材检测结果和前次检测结果之间存在显著差异,结果具有统计学意义（F值分别为26．178,58719．299,23．023,P〈0．05）;B组于12周时micro—CT检测结果提示骨小梁平均间距、平均数目、平均厚度分别为0．765um、6．141、0．093um,与干预组12周时Micro-CT结果均具有显著统计学意义（,值分别为13．498,22．557,52．072,P〈0．05）。结论阿仑膦酸钠预防大鼠早期激素性股骨头坏死具有一定作用,但是预防人体股骨头坏死是否具有相同疗效尚需进行多中心临床研究。