高菁主任医师中西医结合治疗甲状腺功能亢进症的经验

甲亢是一种内分泌疾病,是临床上的常见病,近年来发病率逐年上升,现代医学对于治疗甲亢功能有明显优势,但不良反应较大且对于患者的症状并无明显改善,且易复发,而对此中医具有明显的优势,故研究中西医结合治疗甲亢对临床有重要意义。高菁主任医师主张用中西医结合的方法治疗甲亢,西医治疗为抗甲状腺素药物,中医治疗方面,根据患者的体质因素定证型,标实证定证候,总结出“四型、四候”的辨证方法,方药则以证型定主方,以证候定加减,使临床辨证变得简单灵活且易于掌握。经过临床验证发现,中西医结合治疗的疗效明显高于单纯西药的治疗。     

B-型钠尿肽系列测定判定急性冠脉综合征患者预后的价值

目的探索对急性冠脉综合征（ACS）患者，B-型钠尿肽（BNP）系列测定联合TnT、CRP与不良心脏事件发生率的关系。方法对83例ACS患者分别在入院时、48h、72h测定其BNP、TnT、CRP值，以死亡、心肌梗死、症状性心衰为随访终点，平均随访12个月，对BNP等生化指标与心脏事件发生率的相关性进行统计学分析。结果随访中发现，BNP〉250ng／L的患者与BNP≤250ng／L的患者相比，心脏事件的发生率显著升高，为9％和27％（OR3．7，95％CI：2．3-5．7，P〈0．01）。在TnT阴性的患者，高BNP组与低BNP组相比，其危险比为5．9（95％CI2．6-13.3，P〈0．01）。在临床稳定、没有难治性心肌缺血的患者，BNP值快速下降，基线、48h、72h时的BNP值分别为248．6±10、188．9±8（-24％）、126．8±11（-49％），与基线相比，48h、72h差异均有统计学意义（P〈0．01）。BNP在基线时水平较低，而在72h显著升高的患者，预后较差，OR值为24．0（95％CI：8．4-32．5，P〈0．01）。而在基线时BNP值较高，72h时明显下降者，MACE发生率显著降低，与持续升高者相比，为16％vs38％（OR18．5，95％CI：7．6-21-3，P〈0．01）。结论对ACS患者，BNP是一个强有力的预后判断指标，并且BNP的系列测定与单一基线水平测定相比，其预后判断价值显著增加。     

The medical management of acute coronary syndromes and potential roles for new antithrombotic agents

Antithrombic therapy is recommended to prevent ischemic complications in patients with high-risk non-ST-segment elevation acute coronary syndromes, including patients with unstable angina/non-ST-segment elevation myocardial infarction and patients with ST-segment elevation myocardial infarction undergoing fibrinolysis with fibrin-specific agents. Ischemic benefit from these agents must be balanced against an increased risk of bleeding, which may itself carry adverse long-term consequences. Recent trials suggest that the low-molecular-weight heparin enoxaparin may be superior to unfractionated heparin for preventing ischemic complications, although it also may be associated with an increase in bleeding risk. In two other contemporary trials, the Factor Xa inhibitor fondaparinux improved mortality and morbidity in patients with unstable angina/non-ST-segment elevation myocardial infarction and in patients with ST-segment elevation myocardial infarction undergoing fibrinolytic reperfusion, without increasing bleeding risk. These data underscore the promise of new antithrombotic agents to improve outcomes in acute coronary syndrome (ACS) patients being medically managed.     

氨磷汀联合重组人红细胞生成素治疗高龄骨髓增生异常综合征近期疗效观察

本研究的目的是观察氨磷汀(amifostine，AMF)联合红细胞生成素(EPO)治疗高龄骨髓增生异常综合征(MDS)患者的近期疗效。治疗的2例高龄MDS患者中1例为MDS-RA患者(9l岁)，另1例为MDS—RCMD患者(86岁)。治疗方案为rh—EPO6000u皮下注射，1周3次；AMF0．4g静脉滴注，每周连续5天，休息2天，连用4周。结果表明：4周后2例患者均显示出很好的近期疗效，其中MDS—RA患者输血时间间隔均较治疗前有的延长。1例MDS-RA患者的网织红细胞在治疗开始后第1周即恢复正常，并一直保持在正常水平；另1例MDS-RCMD患者治疗后血像三系细胞量均明显上升，异常增高的网织红细胞数量呈下降趋势。结论：AMF联合rh-EPO在治疗高龄MDS患者可能有良好的应用前景，但其临床远期疗效还有待于进一步研究。     

Troponin level and efficacy of abciximab in patients with acute coronary syndromes undergoing early intervention after clopidogrel pretreatment

Objective We investigated how does troponin level (TnT) affect the benefit achieved by abciximab in patients with acute coronary syndromes (ACS) undergoing percutaneous coronary intervention (PCI) after pretreatment with a high loading dose of clopidogrel. Methods The Intracoronary Stenting and Antithrombotic Regimen: Rapid Early Action for Coronary Treatment (ISAR-REACT 2) trial included 2,022 patients with non-ST elevation ACS undergoing PCI who were randomized to abciximab or placebo after pretreatment with 600 mg of clopidogrel. The patients were divided into groups with elevated TnT level (n = 1,049) and no elevated TnT level (n = 973). The primary end point of the trial was the composite of death, myocardial infarction and urgent reintervention at 30 days. Results In patients with elevated TnT level the incidence of the primary end point was 13.1% in the abciximab group Vs. 18.3% in the placebo group [relative risk (RR): 0.70; 95% confidence interval (CI), 0.52–0.95, P = 0.02]. The combined incidence of death or myocardial infarction was 12.9% in the abciximab group vs. 17.9% in the placebo group (RR: 0.71; 95% CI, 0.52–0.96, P = 0.03). In contrast, the incidence of the primary end point in patients with no elevated TnT level was identical in both treatment groups (4.6%). The risk of bleeding was not related to TnT level. Conclusions Baseline troponin level affects the benefit of abciximab in patients with ACS undergoing PCI after pretreatment with a high loading dose of clopidogrel. Abciximab reduces the risk of ischemic events only in patients with ACS and elevated troponin level.     

肺癌的副肿瘤性神经综合征20例分析

目的 探讨肺癌的副肿瘤性神经综合征（PNS）的临床特点以防止肺癌诊断的延误。方法 对我院1991-01-2002-01住院的20例经病理和细胞学确诊肺癌并PNS患的临床资料进行回顾性分析。结果 肺癌并PNS发生率为2.2%(20/919)，其中LambertEaton肌无力综合征8例，感觉运动性神经病5例，脑脊髓炎3例，感觉性神经病1例，癌的关系不熟悉或重视不够是延误诊断的主要原因。对有PNS应进一步检查以减少肺癌的误（漏）诊率。     

Down-regulation of TET2 in CD3+ and CD34+ cells of myelodysplastic syndromes and enhances CD34+ cells proliferation

Aims and background: To investigate the expressions of TET2 mRNA in bone marrow CD3⁺ and CD34⁺ cells of the patients with myelodysplastic syndromes (MDS) and to study the effect of silencing TET2 by small interfering RNA (siRNA) on the biological characteristics of CD34⁺ cells. Methods: CD3⁺ and CD34⁺ cells were sorted by magnetic activated cell-sorting system from bone marrow of MDS patients and controls. The mRNA expressions of TET2 in bone marrow CD3⁺ and CD34⁺ cells of 28 MDS patients and 20 controls were detected by qPCR. The silencing effect of RNA interference (RNAi) on TET2 expression in CD34⁺ bone marrow cells of normal control was identified by qPCR and Western blot analysis. The cell cycle kinetics and cell apoptosis were then detected by flow cytometry. Results: The expression of TET2 mRNA in CD3⁺ and CD34⁺ cells was down-regulated in MDS compared with that in controls [(0.16±0.11) vs. (1.05±0.32) (P<0.001); (0.58±0.26) vs. (1.25±0.94) (P<0.005)]. The siRNA targeting TET2 suppressed the expression of TET2 in normal CD34⁺ cells. Meanwhile, the proliferation activity was significantly enhanced [G0/G1: (87.82±8.25)% vs. (92.65±7.06)% and (93.60±5.54)%, P<0.05; S: (11.50±8.31)% vs. (6.92±7.04)% and (5.95±5.53)%, P<0.05] and the apoptosis rate was declined [(21.28±9.73)% vs. (26.17±9.88)% and (26.20±9.78)%] in the cells which transfected with TET2 siRNA as compared to those in the cells transfected with scrambled siRNA and control cells. Conclusions: The TET2 expression of in CD3⁺ and CD34⁺ cells of MDS patients was decreased. Suppression of TET2 expression renders the CD34⁺ cells harboring more aggressive phenotype. This preliminary finding suggests that CD34⁺ cells lowering expression of TET2 may play an oncogenic role on myeloid tumor and CD3⁺ T cells of MDS patients may be derived from the malignant clone.     

骨髓增生异常综合征发病分子机制研究进展

骨髓增生异常综合征(MDS)发病相关基因已经成为国内外的研究热点.MDS中最常见的基因突变有表观遗传调节子突变(TET2、ASXL1、DNMT3A)、RNA剪接子突变(SF3B1、SRSF2、U2AF1、ZRSR2)、信号转导调节因子突变(NRAS、JAK2)和转录因子突变(RUNX1、TP53)等.已证实基因突变在MDS发病分子机制中起着决定性的作用,并且与某些临床表型、疗效及预后密切相关,深入研究MDS分子发病相关基因,对于明确MDS的发病机制,寻找治疗靶点具有重要意义.