针刺治疗慢性疼痛的功能磁共振研究述评＊

目的基于针刺治疗慢性疼痛的功能磁共振(Functional magnetic resonance imaging,fMRI)文献进行述评,为针刺治疗慢性疼痛的机制研究提供思路和借鉴。方法对近10年针刺治疗慢性疼痛的fMRI研究进行回顾,依据病种选择、样本量计算、试验设计、研究结果四方面内容进行述评,分析并总结当前研究现状。结果偏头痛、膝骨关节炎和下腰痛是目前研究中涉及频次最高的3个病种。受试者的疾病亚型、年龄段、利手习惯及fMRI禁忌症在研究中基本都保证了一致性和规范性。但多数研究仍存在样本量计算方式不明确的问题。对照组设置主要包括标准对照、无效对照和安慰对照。针刺效应因素在各研究间存在较大差异。研究中结局指标包括疾病特异性量表、疼痛评分及心理、精神状态的评估。fMRI设计以静息态和单一任务态设计为主,多任务fMRI研究相对较少。研究证实针刺可调节疼痛处理网络的功能连接,有效建立心理物理疼痛稳态。结论运用fMRI探讨针刺治疗慢性疼痛作用机制的研究成果丰硕,未来可通过扩大病种的选择,完善质量控制,关注针刺效应影响因素,丰富数据处理手段,借鉴多学科任务设计方式等方式,促进针刺疗慢性疼痛机制研究的进一步发展。     

The association of nighttime sleep duration and quality with chronic kidney disease in middle-aged and older Chinese: a cohort study

ObjectiveThis cohort study aimed to assess the associations between sleep duration and quality with the risk of incident chronic kidney disease (CKD) in middle-aged and older Chinese.MethodsWe used the 2011 and 2015 surveys of the China Health and Retirement Longitudinal Study (CHARLS). Nighttime sleep duration was categorized into five groups: ≤4, (4–6], (6–8], (8–10], and >10 h/night. Sleep quality was assessed by restless days in the past week (<1, 1–2, 3–4, and 5–7 days/week). Multivariate logistic regression was used to assess the association between sleep duration and quality with incident CKD.ResultsA total of 11,339 participants free of CKD at baseline were included in this study. After four years follow-up, the incidence of CKD was 7.8%. There was a “U-shaped” association between sleep duration and risk of CKD. Compared to 6–8 h of nighttime sleep duration, those who slept ≤4 h/night (RR: 1.639, 95% CI: 1.287–2.087) or >10 h/night (RR: 2.342, 95% CI: 1.007–5.451) had increased risk of developing CKD after adjustment for confounders. Participants with 5–7 restless days per week had significantly increased risk of CKD (adjusted RR: 1.686, 95% CI: 1.352–2.102), compared to those who rarely or never had a restless sleep.ConclusionsExtreme nighttime sleep duration and poor sleep quality were associated with increased risk of CKD in middle-aged and older Chinese. Obtaining an optimal nighttime sleep duration and better sleep quality might reduce the risk of CKD.     

Emerging therapeutic options in inflammatory bowel disease

Inflammatory bowel disease (IBD) is a chronic disease that requires chronic treatment throughout the evolution of the disease, with a complex physiopathology that entails great challenges for the development of new and specific treatments for ulcerative colitis and Crohn´s disease. The anti-tumor necrosis factor alpha therapy has impacted the clinical course of IBD in those patients who do not respond to conventional treatment, so there is a need to develop new therapies and markers of treatment response. Various pathways involved in the development of the disease are known and the new therapies have focused on blocking the inflammatory process at the gastrointestinal level by oral, intravenous, subcutaneous, and topical route. All these new therapies can lead to more personalized treatments with higher success rates and fewer relapses. These treatments have not only focused on clinical remission, but also on achieving macroscopic changes at the endoscopic level and microscopic changes by achieving mucosal healing. These treatments are mainly based on modifying signaling pathways, by blocking receptors or ligands, reducing cell migration and maintaining the integrity of the epithelial barrier. Therefore, this review presents the efficacy and safety of the new treatments that are currently under study and the advances that have been made in this area in recent years.     

基于网络药理学和临床试验探讨前列消汤对ⅢA型前列腺炎IL-17与Foxp3表达影响研究＊

目的 基于网络药理学进行前列消汤治疗慢性前列腺炎的预测，同时采用临床试验进行验证，证明前列消汤对ⅢA型前列腺炎患者的临床疗效及对前列腺液（Expressed Prostatic Secretion， EPS）中白细胞介素17（interleukin 17， IL-17）及双头叉转录因子p3（Forkhead box p3， Foxp3）表达的影响。方法 采用网络信息学分析方法，筛选出前列消汤在ⅢA型前列腺炎治疗中发挥疗效的主要作用靶点，采用临床随机非盲法，将符合纳入标准的80例ⅢA型前列腺炎湿热下注证患者随机分为观察组和对照组各40例，观察组口服自拟前列消汤，对照组口服银花泌炎灵片。观察治疗前后两组的症状及证候评分情况、前列腺按摩液以及其IL17、Foxp3表达的差异。取40例正常男性前列腺液为正常对照。结果 网络药理学分析结果提示IL17信号通路为前列消汤治疗慢性前列腺炎的重要通路之一，临床试验结果提示经治疗后观察组有效率达89.19%，较对照组的73.68%为优（P < 0.05）。两组患者服药后的临床表现、前列腺按摩液WBC、症状及证候评分均存在明显改善。观察组和对照组IL-17水平较治疗前下降，Foxp3表达较治疗前升高（P < 0.05）。观察组对降低IL-17表达和提升Foxp3表达上较对照组差异更大（P < 0.05）。观察组治疗后与正常组IL-17和Foxp3水平比较差异较小（P > 0.05）。结论 网络药理学能一定程度上预测中药作用于疾病的相应靶点，前列消汤对ⅢA型前列腺炎湿热下注证患者的临床症状有明显改善作用，并能降低IL-17表达，对Foxp3表达有提升作用，在总有效率和对细胞因子的影响上较银花泌炎灵片组明显。     

Subtypes of insomnia and the risk of chronic spinal pain: the HUNT study

ObjectiveTo examine the association between subtypes of insomnia and the risk of chronic spinal pain.MethodsThe study comprised 16,401 participants without chronic spinal pain at baseline who were followed for ∼11 years. People were categorized into ‘no insomnia symptoms’, ‘subthreshold insomnia’, and ‘insomnia’. Insomnia was defined according to the diagnostic classification system requiring both daytime and nighttime symptoms, and further categorized into subtypes based on nighttime symptoms (ie, sleep onset latency [SOL-insomnia], wake after sleep onset [WASO-insomnia], early morning awakening [EMA-insomnia], or combinations of these). Subthreshold insomnia comprised those with only daytime impairment or one or more nighttime symptoms. Chronic spinal pain was defined as pain in either ‘neck’, ‘low back’, or ‘upper back’, or a combination of these.ResultsIn multivariable regression analysis using people without insomnia as reference, people with subthreshold insomnia or insomnia had relative risks (RRs) of chronic spinal pain of 1.29 (95% confidence interval [CI] 1.21–1.38) and 1.50 (95% CI 1.34–1.68), respectively. The RRs for people with one nighttime symptom were 1.30 (95% CI 0.83–2.05) for WASO-insomnia, 1.32 (95% CI 1.06–1.65) for EMA-insomnia, and 1.70 (95% CI 1.32–2.18) for SOL-insomnia, respectively. Combinations of nighttime insomnia symptoms gave RRs from 1.45 (95% CI 1.08–1.94) for WASO + EMA-insomnia to 1.72 (95% CI 1.36–2.19) for all nighttime symptoms (SOL + WASO + EMA-insomnia).ConclusionsThese findings suggest that the risk of chronic spinal pain is highest among persons with insomnia subtypes characterized by sleep onset latency or among those having insomnia symptoms in all parts of the sleep period.     

Racial and geographic disparities with gastrostomy tube placement in dementia and parkinsonian disorders

IntroductionMany patients with advanced dementia and Parkinson's disease and related disorders (PDRD) are receiving gastrostomy tube (GT) placement annually, despite its lack of proven benefit for preventing aspiration, enhancing nutrition, or prolonging survival. Given clinical practice variability in the care of people with neurodegenerative disorders, we sought to examine racial and geographic disparities in GT placement for these populations in the United States.MethodData were extracted from a publicly-available national database using diagnostic and procedural codes from 2006 to 2010. GT placement rates and odds ratios were calculated for two groups: PDRD and non-parkinsonian dementia (NPD).ResultsIn the PDRD group, odds of GT placement were higher among patients coded as Black (OR 1.69, CI 0.80–3.56, p = 0.17) and Asian (OR 2.17, CI 0.70–6.78, p = 0.18) than Whites; although these tendencies did not reach statistical significance. In the NPD group, GT placement among Black patients was significantly more likely (OR 2.88, CI 1.90–4.36, p < 0.001) than their white counterparts, while Asian patients were significantly less likely (OR 0.12, CI 0.02–0.91, p = 0.04). Compared to the Northeast region, there were significantly lower odds of GT placement in the Midwest region (OR 0.37, CI 0.24–0.58, p < 0.001) in the NPD group only. No difference in odds was observed between the sexes in both groups.ConclusionThis study showed geographic and racial disparities in GT placement among PDRD and NPD patients. Further studies should aim to clarify best practices for GT placement in PDRD and causes of practice differences within and between PDRD and NPD groups.