基于虚拟实践社区的临床医学继续教育新模式探讨

隐性医疗知识是决定医疗机构诊疗水平和竞争力的核心因素之一。构建基于虚拟实践社区的临床医学继续教育模式,打破时空和地域限制,为高等级大型综合医院与基层医疗机构之间的隐性医疗知识共享、管理和传承提供平台,从而促进基层医疗机构诊疗水平的提高,提升基层医疗资源利用率,造福各地百姓。     

乳糖酶添加剂对早产儿乳糖不耐受有效性及安全性：一项前瞻性、多中心、随机对照研究

目的 探讨乳糖酶添加剂对早产儿乳糖不耐受改善的有效性以及安全性。方法 2018年1月至2019年12月对上海交通大学医学院附属新华医院、上海市第一妇婴保健院、浙江大学医学院附属儿童医院和苏州大学附属儿童医院收治的有乳糖不耐受症状并符合入组标准的早产儿进行研究,将研究对象随机分为乳糖酶治疗组及对照组,各80例。乳糖酶治疗组患儿每顿母乳或早产儿配方奶中加入4滴（180mg）乳糖酶,同时予双歧杆菌三联活菌散口服及腹部按摩作为辅助治疗。对照组患儿则在每顿奶中加入同等剂量的安慰剂,并予与治疗组相同的益生菌和腹部按摩进行辅助治疗。在干预后第1周末和第2周末比较两组患儿临床症状、体重、粪便pH值、粪便还原糖等指标。结果 乳糖酶治疗组和对照组分别有78例、77例完成研究。干预后第1周末,乳糖酶治疗组还原糖阳性率较对照组低（P<0.05）;干预后第2周末,乳糖酶治疗组患儿腹胀发生率较对照组低（P<0.05）,还原糖阳性率低于对照组（P<0.05）,同时乳糖酶治疗组患儿喂养增加量高于对照组（P<0.05）。研究过程中两组均未发现患儿对乳糖酶添加剂或益生菌产生不良反应。结论 外源性乳...     

2型糖尿病伴骨质疏松患者健康素养状况及影响因素分析

目的了解2型糖尿病伴骨质疏松患者健康素养状况及影响因素,为制定提高2型糖尿病伴骨质疏松患者健康素养干预措施提供参考。方法采用自制的健康素养量表对268名2型糖尿病伴骨质疏松患者进行问卷调查,分析调查对象的健康素养状况及其影响因素。结果 268名2型糖尿病伴骨质疏松患者健康素养得分为144.68±62.81分,占满分的62.91%(满分230分),其中书面素养得分为124.82±58.74分,占该领域满分的75.65%(满分165分);运算能力得分为26.84±10.42分,占该领域满分的41.30%(满分65分)。其中有109例(40.71%)的患者得分150分,属于健康素养缺乏;有86例(32.10%)的患者得分为150~180分,属于临界健康素养;另有73例(27.20%)的患者得分180分,属于健康素养充足。多元线性回归分析结果显示,年龄、文化程度、病程、有无职业、月收入、住院次数、居住地是2型糖尿病伴骨质疏松患者健康素养的影响因素。结论 2型糖尿病伴骨质疏松患者存在较低健康素养现象,对其影响因素制定针对性的干预措施是提高患者健康素养的重要途径。     

术前经皮置管引流治疗腰椎结核合并腰大肌脓肿的可行性研究

目的:通过比较两种不同方法治疗腰椎结核伴腰大肌脓肿,探讨术前经皮置管引流的临床疗效。方法:将2015年1月至2017年1月收治的符合纳入标准的腰椎结核伴腰大肌脓肿36患者纳入研究,按照不同的治疗方法将患者分为A、B两组,均给予标准抗结核治疗。A组入院后立即行腰大肌脓肿术前经皮置管引流,B组腰大肌脓肿无特殊处理,两组患者经3周抗结核治疗后复查红细胞沉降率(ESR)和C-反应蛋白(CRP),B组2例患者因复查ESR和CRP无降低需暂缓手术而排除,最终两组共34例患者纳入研究。A组18例,其中男10例,女8例;年龄24～73(42.5±10.2)岁;B组16例,其中男9例,女7例;年龄23～75(42.3±9.8)岁。两组患者均行后路椎弓根螺钉内固定,前路椎体病灶清除、植骨融合术。对比分析前路手术出血量、手术时间、前路切口长度,术后肛门排气时间、VAS评分、Cobb角、ESR、CRP变化及窦道形成情况。结果:34例患者均获随访,时间6～21个月,平均13个月。至末次随访,均未见混合感染、结核复发及椎弓根螺钉松动、退钉发生。A组平均手术时间、前路手术出血量和前路切口长度少于B组(P0.05)。A组肛门排气时间低于B组(P0.05)。ESR、CRP改善程度在抗结核3周、术后1周A组优于B组(P0.05),术后1、6个月两组差异无统计学意义(P0.05)。A组窦道形成1例,B组窦道形成5例,两组患者窦道形成率差异有统计学意义(P0.05)。术后1个月两组患者的VAS疼痛评分及Cobb角均有所改善(P0.05),组间比较差异无统计学意义(P0.05)。术后脊髓神经损伤均有改善,组间比较差异无统计学意义。结论:术前经皮置管引流是治疗腰椎结核伴腰大肌脓肿安全可行的方法,能增加术前抗结核效果,减少手术创伤,降低术后并发症的发生,可在临床中推荐应用。     

Clinicopathological features of antineutrophil cytoplasmic antibodies associated vasculitis with glomerular IgA deposits

Objective To investigate the clinical manifestations, renal pathology and prognosis of antineutrophil cytoplasmic antibody-associated small-vessel vasculitis (AAV) accompanied with renal glomerular IgA deposition. Methods A retrospective analysis was performed at the First Affiliated Hospital of Zhejiang University College of Medicine. Patients diagnosed with AAV associated renal injury by renal biopsy from February 2004 to February 2017 were enrolled. Patients with antiglomerular basement membrane antibody-mediated nephritis, systemic lupus erythematosus nephritis, Henoch Schonlein purpura nephritis, hepatitis B virus associated nephritis and other known etiology were excluded. According to immunofluorescence examination, the patients were divided into IgA deposition group and pauci-immune complex deposition group. The differences in clinical manifestation, pathological features and prognosis were compared between groups. Results A total of 150 AAV cases were included, among which 25 cases were with IgA deposition and 125 cases with pauci-immune complex deposition. The level of serum albumin in IgA deposition group was higher than that in pauci-immune complex deposition group [(35.0±6.2) g/L vs (32.6±5.3) g/L, P=0.049], but the titer of MPO-ANCA was lower [24.8(10.4, 71.8) U/ml vs 63.0(21.9, 100.0) U/ml, P=0.044] in IgA deposition group. There was no significant difference between two groups in other laboratory indexes and renal pathological findings. The median follow-up time was 15.2 months in IgA deposition group and 8.9 months in pauci immune complex deposition group. During the follow-up there were 8 patients (32.0%) in IgA deposition group and 29 patients (23.2%) in pauci immune complex deposition group on maintaining dialysis; 2 patients (8.0%) in IgA deposition group and 7 patients (5.6%) in pauci immune complex deposition group died. There was no significant difference between two groups in patients' outcomes. Conclusions AAV patients with glomerular IgA deposition and AAV patients with typical glomerular immunoglobulin complex deposition are similar as regards clinical appearance and prognosis.     

Pregnancy in patients on maintenance hemodialysis: seven cases report and 169 reported cases review

Objective To analyze and summarize the cases of pregnancy on maintenance hemodialysis (MHD), and review the literature. Methods Seven cases of pregnancy and childbirth in patients on MHD in the First Affiliated Hospital of Zhejiang University from Jan 2009 to Dec 2017 were analyzed, and the literature about pregnancy in patients on MHD reported in Pubmed and Web of Science database was retrieved. Both maternal and fetal outcome were studied. Results There are seven pregnant MHD patients in this center, among whom six patients went through a smooth pregnancy and one patient had intra-uterine fetal death at 14 weeks of pregnancy. The six patients had preterm labor. Among six fetuses, four grew in good health and developed well, one had physical development retardation and one had heart malformation at born. In the literature, 169 cases reported pregnant patients and 182 fetuses were evaluated, of which 145 live infants were delivered, 79.67% overall fetal survival rate, with gestational age of (32.94±3.34) weeks. In 164 delivered fetuses, 147 were preterm labor (89.63%). The weight of live births was (1824±609) g. There were no maternal deaths. Fetal survival rate was zero in＜20 weeks of gestational age, 20-24 weeks was 14.29%, 25-27 weeks was 45.45%, ≥28 weeks was 94.44%. The fetal survival rate was higher in pregnant woman receiving hemodialysis≥28 hours weekly compared to women receiving ＜16 hours weekly (92.31% vs 52.94%, P=0.02). Conclusions There are still a very high maternal and fetal complication rate in hemodialysis patients, especially in fetus. Gestational age≥28 weeks has a high fetal survival rate. Intensive dialysis during pregnancy may benefit higher fetal survival rate.     

Effects of serum uric acid level on all-cause death and cardiovascular death in patients of maintaining peritoneal dialysis

Objective To investigate the effects of serum uric acid (SUA) on all-cause death and cardiovascular death in patients of maintaining peritoneal dialysis (PD). Methods One thousand and sixty-three PD patients in the First Affiliated Hospital of Zhejiang University Medical College were included. The SUA levels at 6 months after PD start were measured. Patients with SUA≥420 μmol/L were grouped in hyperuricemia group (492 cases) and patients with SUA＜420 μmol/L were grouped in normal uric acid group (571 cases). The effects on all-cause mortality and cardiovascular mortality were retrospectively analyzed. Results The median age of the patients was 51(41, 62) years; 557 cases were male (52.40%); the median follow-up time was 33(20, 54) months (6-96 months); 167 cases (15.71%) died during the follow-up period, including 64 cases (6.02%) with cardiovascular causes. The mortality in hyperuricemia group was 19.11%(94/492) and the cardiovascular mortality was 7.93%(39/492), both rates were higher than those in normal uric acid group, and the differences were statistically significant (P=0.005, P=0.015, respectively). Hyperuricemia (SUA≥420 μmol/L) at 6 months after PD start (HR=1.572, 95%CI 1.155-2.141, P=0.004), high uric acid level (continuous variable) at 6 months after PD start (HR=1.002, 95%CI 1.001-1.004, P=0.008), and age≥65 years (HR=3.571, 95%CI 2.556-4.990, P＜0.001), serum albumin≤30 g/L (HR=1.907, 95%CI 1.278-2.845, P=0.002), high Charlson comorbidity index (HR=1.209, 95%CI 1.032-1.417, P=0.019) at the beginning of PD start were independent risk factors for all-causes death in PD patients. Hyperuricemia (SUA≥420 μmol/L) at 6 months after PD start (HR=1.734, 95%CI 1.033-2.912, P=0.037) and age≥65 years (HR=1.761, 95%CI 1.024-3.209, P=0.041), with diabetes (HR=2.775, 95%CI 1.358-5.671, P=0.005) at the beginning of PD start were independent risk factors for cardiovascular death in PD patients. Conclusions SUA at 6 months after PD is an independent risk factor for all-cause death and cardiovascular death in PD patients.     

雾化吸入盐酸肾上腺素注射液的过敏性和刺激性研究

目的 通过豚鼠雾化吸入给予盐酸肾上腺素注射液,评价临床超说明书给予盐酸肾上腺素注射液的安全性。方法 通过建立雾化给药药物浓度检测方法,确定吸入给药实际给药量。以临床使用盐酸肾上腺素给药频次与剂量结合过敏性试验评价方法,采用豚鼠全身主动过敏试验方案,评价盐酸肾上腺素注射液雾化吸入后对豚鼠产生的全身过敏反应及呼吸系统毒性反应。32只豚鼠按体质量随机分成4组：阴性对照组(等体积的生理盐水)、阳性对照组(致敏剂量：20 mg·kg^-1卵白蛋白)、低剂量组(致敏剂量：15.5 μg·kg^-1盐酸肾上腺素)和高剂量组(致敏剂量：31 μg·kg^-1盐酸肾上腺素)。各组激发剂量是致敏剂量的2倍,激发时观察过敏反应症状,激发后采集血液与肺泡灌洗液,全血用于检测血液学,分离血清和肺泡灌洗液用于检测IgE。动物解剖后取支气管与肺脏组织做组织学检测与免疫组化。结果 使用雾化装置给予豚鼠盐酸肾上腺素在给药3.95 min时可达到临床等效剂量。各组豚鼠在致敏给药期间体质量正常增长,无明显异常反应。激发时,阳性对照组豚鼠出现强阳性过敏反应,阴性对照组、低剂量组和高剂量组豚鼠均无明显过敏反应。与阴性对照组比较,阳性对照组豚鼠血液中嗜酸性粒细胞显著升高(P<0.05),血清和肺泡灌洗液中IgE含量明显增加(P<0.05或P<0.01);组织病理学结果显示阳性对照组豚鼠激发后肺组织内出现炎性细胞浸润,肺泡内出现大量红细胞和渗出液;免疫组化结果提示阳性组豚鼠肺组织内炎性症状与B淋巴细胞增多相关。而低剂量组和高剂量组豚鼠血液学指标、血清IgE含量、免疫组化和组织学检查结果均与阴性对照组无明显差异。结论 盐酸肾上腺素注射液经雾化给予豚鼠不发生过敏反应,且未产生呼吸系统毒性。盐酸肾上腺素注射液雾化吸入是安全可行的。