调脂治疗的回顾与展望(五)第五节美国国家胆固醇教育计划——成人治疗组(ATP)Ⅲ指(上)

在美国,心血管疾病占发病率和死亡率的第一位.为此,美国国家心,肺和血液研究院(NHLDI)于1985年颁布了国家胆固醇教育计划(The National Cholesterol Education Program,NCEP)其目的是教育广大医学专业人员和分众,使公众从控制血指,进而减少冠心病发病率和死亡率的措施中得益.     

Florida's response to the Physician's National Cholesterol Education Program.

To assess the impact of the National Cholesterol Education Program (NCEP) guidelines, the 7,347 primary care members of the Florida Medical Association received a confidential mailed questionnaire. A follow-up survey polling 5% of the nonresponders validated the initial observations. Of the 1,909 analyzed returns, 96% of the physicians' responses indicated that they believed cholesterol is an important factor in preventing atherosclerosis. However, responses to other questions were far less uniform. For example, 92% of general internists (n = 495) reported being aware of the NCEP guidelines versus 98% of cardiologists (n = 212) (p less than .01) and only 78.7% of OB/GYN specialists (n = 218) (p less than .0001). While 88.2% of general internists responded that the guidelines were relevant in treating their patients, 80.2% of OB/GYN physicians answered likewise (p less than .03). Moreover, only 54% of OB/GYN specialists reported routinely measuring serum cholesterol in their patients compared to 96.7% of general internists (p less than .0001). Most Florida primary care physicians are aware of the NCEP guidelines; however, the impact varies widely among practitioners.     

An evidence-based assessment of the NCEP Adult Treatment Panel II guidelines. National Cholesterol Education Program

CONTEXT: The Second Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel II) was issued without the benefit of multiple recently published large clinical trials. OBJECTIVE: To analyze the panel's guidelines for treatment of high cholesterol levels in the context of currently available clinical trial results. DATA SOURCES: MEDLINE was searched for all English-language clinical trial data from 1993 through February 1999 relating to the effects of cholesterol treatment on cardiovascular clinical outcomes. STUDY SELECTION: Studies that were selected for detailed review assessed the effects of cholesterol lowering on either coronary events, coronary mortality, stroke, and/or total mortality, preferably by randomized, double-blind, placebo-controlled design. Selection was by consensus of a general internist, a lipid clinic director, and a researcher in atherosclerotic plaque biology. A core of 37 of the 317 initially screened studies were selected and used as the primary means by which to assess the guidelines. DATA EXTRACTION: By consensus of the group, only prespecified end points of trials were included, unless post hoc analysis addressed issues not studied elsewhere. DATA SYNTHESIS: Recent clinical trial data mostly support the Adult Treatment Panel II guidelines for cholesterol management. While existing trials have validated the target low-density lipoprotein cholesterol (LDL-C) goals in the report, studies are lacking that address mortality benefit from reduction below these levels. Few lipid-lowering trials have treated patients with low high-density lipoprotein cholesterol and/or elevated triglyceride levels with LDL-C levels at or below treatment goals. CONCLUSIONS: Lipid-lowering therapy generally should be more aggressively applied to patients with diabetes and/or at the time of coronary heart disease (CHD) diagnosis. The evidence for statin use in secondary CHD prevention in postmenopausal women outweighs current evidence for use of estrogen replacement in this setting. Further studies are needed to address the effects of lipid modification in primary prevention of CHD in populations other than middle-aged men and to study markers of lipid metabolism other than LDL-C.     

Primary prevention of hypertension: clinical and public health advisory from The National High Blood Pressure Education Program

Paul K. Whelton, MD, MSc; Jiang He, MD, PhD; Lawrence J. Appel, MD, MPH; Jeffrey A. Cutler, MD, MPH; Stephen Havas, MD, MPH, MS; Theodore A. Kotchen, MD; Edward J. Roccella, PhD, MPH; Ron Stout, MD, MPH; Carlos Vallbona, MD; Mary C. Winston, EdD, RD; Joanne Karimbakas, MS, RD; for the National High Blood Pressure Education Program Coordinating Committee

JAMA. 2002;288:1882-1888.

The National High Blood Pressure Education Program Coordinating Committee published its first statement on the primary prevention of hypertension in 1993. This article updates the 1993 report, using new and further evidence from the scientific literature. Current recommendations for primary prevention of hypertension involve a population-based approach and an intensive targeted strategy focused on individuals at high risk for hypertension. These 2 strategies are complementary and emphasize 6 approaches with proven efficacy for prevention of hypertension: engage in moderate physical activity; maintain normal body weight; limit alcohol consumption; reduce sodium intake; maintain adequate intake of potassium; and consume a diet rich in fruits, vegetables, and low-fat dairy products and reduced in saturated and total fat. Applying these approaches to the general population as a component of public health and clinical practice can help prevent blood pressure from increasing and can help decrease elevated blood pressure levels for those with high normal blood pressure or hypertension.

     

我国免费艾滋病抗病毒治疗策略与“治疗即预防”进展情况

本文通过对比我国多年免费艾滋病抗病毒治疗的相关研究,阐述了自2003年始,我国免费艾滋病抗病毒治疗策略的调整和取得成效：随着治疗标准、用药方案和治疗点管理模式等的调整以及艾滋病患者社会人口学特征变化,艾滋病抗病毒治疗的效果不断提高,患者的死亡率显著降低,预期寿命不断提高,HIV耐药率也得到有效的控制;“治疗即预防”是减少HIV新发感染的最有效措施之一,在公共卫生层面早期开展抗病毒治疗可以有效降低HIV的传播。同时指出,随着免费艾滋病抗病毒治疗标准的降低,接受免费抗病毒治疗的患者服药依从性降低,脱失比例升高,病毒抑制率较理论值偏低等,这些是制约我国“治疗即预防”效果的关键因素。     

The National Resident Matching Program and antitrust law

In May 2002, a group of physicians filed a class action lawsuit alleging that the National Resident Matching Program (NRMP) violates antitrust laws. The plaintiffs contend that NRMP practices have stabilized lower-than-competitive wages and imposed exhausting working conditions on residents. They also maintain that NRMP procedures virtually force applicants for house officer positions to forfeit their right to negotiate for better wages and conditions. The plaintiffs also allege that the defendants have collectively fostered anticompetitive accreditation standards through the Accreditation Council for Graduate Medical Education. Jung v Association of American Medical Colleges could present antitrust law with some difficult challenges. Although the matching program on its face appears to limit competition in a manner that previous cases have found illegal, it operates in the context of important professional activities (medical education and quality improvement) that may generate some judicial deference. At this early stage, no confident prediction can be made about the outcome of the case if it goes to trial; however, the plaintiffs appear to have a plausible case under existing antitrust doctrine, and lengthy litigation is possible. Given the important questions that the litigation will not address, such as the potential costs of a finding of illegality to the government and other payers, and the impact of such a finding on the health care system as a whole, a legislative solution seems highly desirable.      

中药品质研究现状与展望

中药品质是保证中药安全、有效、质量可控的基础。本文综述了中药品质内涵、研究模式和内容、评价标准。笔者认为只有把握中医药内在规律,遵循国际标准制定的规则和规范,才能制定出既有中医药特色又符合国际规范的中药品质评价标准和质量保证体系,加快中药国际化进程。     

Progress in lipid reporting practices and reliability of blood cholesterol measurement in clinical laboratories in Nebraska. Efforts to align results with the Centers for Disease Control, and feasibility of meeting National Cholesterol Education Program Guidelines

The National Cholesterol Education Program has recommended that all laboratories be consistent, precise, and accurate in the reporting and measurement of blood cholesterol levels. In a follow-up to a 1984 survey study, we assessed the changes in reporting procedures for measurements of blood lipid levels in 16 clinical laboratories in Nebraska. Using human serum reference materials of known cholesterol concentrations provided by the Centers for Disease Control, we also assessed the precision and accuracy of measurement of blood cholesterol levels in clinical laboratories in Nebraska. Fourteen of the 16 laboratories restudied in 1987 had altered the reference range for total serum cholesterol since 1984, 86% of whom lowered the upper limit of the reference range. Eleven of 16 laboratories expressed reference ranges for total serum cholesterol in terms of patient age in 1987, while only 7 of 20 did in 1984. Gender-based reference ranges increased from 0 to 5 from 1984 to 1987. Similar trends were seen in the reporting of high-density lipoprotein cholesterol and triglyceride concentrations. Reporting procedures varied greatly; only 1 laboratory used National Cholesterol Education Program risk levels for measuring total serum cholesterol levels. Fifteen laboratories met the National Cholesterol Education Program recommendation for precision (coefficient of variation, less than or equal to 5%) and 78% of laboratories obtained results that satisfied the current recommendation for accuracy (within 5% of "true value," as determined by the Centers for Disease Control).     

高胆固醇与骨关节炎的研究进展

研究指出,骨关节炎不仅受衰老影响,还受多种因素共同影响。其中一个危险因素可能是体内高胆固醇水平。尽管研究已经明确高胆固醇会促进心血管疾病的发生,但其在肌肉骨骼疾病,尤其是骨关节炎中的作用尚不清楚。本文将讨论高胆固醇如何影响骨关节炎,并介绍通过哪些分子机制对其产生影响。这将是一个新的研究方向,并对骨关节炎的防治及药物治疗提供新的策略。     

胆固醇与淀粉样蛋白代谢关系的研究进展

阿尔茨海默病(AD)的潜在病因和发病机制目前有多种假说,其中淀粉样前体蛋白(APP)代谢异常、以β-淀粉样蛋白(Aβ)为核心的老年斑异常沉积得到学术界普遍认同.神经元膜胆固醇水平的改变和(或)胆固醇在亚细胞结构中的分布被认为与Aβ的形成、异常聚集、神经毒性以及降解有着潜在关联.基于流行病学以及基础医学研究提示高胆固醇与AD相关联,人们进行了大量关于降低胆固醇的药物特别是他汀类药物治疗AD疗效的临床研究.     

卵磷脂胆固醇酰基转移酶的研究进展

卵磷脂胆固醇酰基转移酶(LCAT)是人体血浆脂蛋白代谢过程中起关键作用的一种酶,对维持胆固醇稳态、调节胆固醇在血液循环中的转运及胆固醇在外周组织中的清除有十分重要的作用。它能催化血浆中高密度脂蛋白(HDL)游离胆固醇的酯化,参与胆固醇逆向转运,在HDL的成熟代谢及动脉粥样硬化发生、发展过程中起重要作用,因此,对LCAT的深入探讨和研究,有利于心血管疾病的防治。     

胆囊胆固醇结石的成因研究进展

近几十年来胆囊结石的发病率呈逐渐上升的趋势。胆石成因尚未完全阐明。近年来,对胆汁成分的改变、细菌感染、致石基因、促成核因子和抗成核因子的失衡病理因素作了较多研究。从全世界范围来看,胆囊结石主要为胆固醇结石。该综述将从以上方面对胆固醇结石的发生机制进行阐述。