2型糖尿病大血管并发症防治

糖尿病大血管并发症是2型糖尿病患者重要的致残和死亡原因,对糖尿病大血管病变的防治具有重要意义。由于大血管并发症发病机制复杂,对大血管病变的防治必须注重危险因素的全面干预。本文针对2型糖尿病大血管并发症的主要危险因素血糖、血脂、血压及抗血小板治疗的新进展做一综述。     

2型糖尿病患者血清胎球蛋白A水平与大血管并发症的关系

目的 探讨胎球蛋白A(AHSG)在2型糖尿病大血管并发症中的可能作用,为预防和治疗糖尿病(DM)大血管并发症提供理论依据.方法 分别收集30例2型糖尿病大血管病变患者(DMM组)、38例2型糖尿病无大血管病变患者(DMN组)和30例健康对照组(C组)为研究对象;采用酶联免疫吸附试验测定各组血清AHSG水平.结果 DMM组、DMN组的血清AHSG浓度均较健康对照组明显升高,其中DMM组升高更明显(P<0.01);随着血清AHSG浓度升高,糖尿病伴发大血管病变发生率逐渐增加,二者呈正相关(P<0.01);血清AHSG浓度是独立的大血管病变预测因素(P<0.01),病程、高血压与大血管病变呈正相关(P<0.01).结论 血清AHSG可能参与了糖尿病大血管并发症的形成和发展.     

血浆D-二聚体水平与2型糖尿病及其大血管病变关系的研究

目的通过对成人2型糖尿病、合并大血管病变以及出现大血管病变却无糖尿病的患者的血浆D-二聚体水平进行检测,比较分析。探讨D-二聚体与2型糖尿病及其大血管并发症的关系。方法选择在我院门诊及住院患者分为2型糖尿病无并发症组、2型糖尿病伴有大血管并发症组、非糖尿病大血管病变组。健康对照组选择门诊体检患者。所有受试者均进行体重指数、腰臀围比、空腹血糖、糖化血红蛋白、血脂以及血浆D-二聚体的检测,进行统计学分析。结果与健康对照组比较,2型糖尿病组、非糖尿病大血管病变组、2型糖尿病并发大血管病变组均明显增高,差异有显著性(P<0.05;P<0.05;P<0.01);与2型糖尿病组相比较,2型糖尿病并发大血管病变组D-二聚体明显升高(P<0.05);与非糖尿病大血管病变组相比较,2型糖尿病并发大血管病变组D-二聚体明显增高(P<0.01)。结论我们的研究显示2型糖尿病患者在未发生并发症时体内就已存在凝血、纤溶系统的失衡。而合并大血管病变的2型糖尿病患者D-二聚体明显升高,提示D-二聚体与大血管并发症之间的关系,提示体内处于血栓前状态,高凝纤溶过程参与了大血管病变的发生及发展。     

2型糖尿病大血管病变患者血清肝细胞生长因子水平

目的:探讨2型糖尿病大血管病变患者血清肝细胞生长因子水平及与其相关因素分析。方法:选取2004-01/06中国医科大学附属第一临床医院152例实验对象,包括2型糖尿病合并大血管病变组44例,2型糖尿病无大血管病变组32例、无糖尿病大血管病变组36例以及40例健康体检者(正常对照组),行常规体质量、腰围、臀围、血压测量,测定空腹血糖、糖化血红蛋白、总胆固醇、三酰甘油、低密度脂蛋白胆固醇、高密度脂蛋白胆固醇和尿酸,并采用酶联免疫吸附实验方法测定其血清肝细胞生长因子水平。结果用x珔±s表示,组间比较采用方差分析,血清肝细胞生长因子与各指标的相关性采用直线回归、多元逐步回归。结果:①2型糖尿病伴有或不伴有大血管病变患者及无糖尿病的大血管病变患者血清肝细胞生长因子水平比正常对照组明显增高,(1.745±0.475),(1.329±0.464),(1.413±0.565),(1.034±0.276)μg/L,P<0.05～0.01;无糖尿病大血管病变患者和2型糖尿病无大血管病变患者血清肝细胞生长因子水平基本相似;2型糖尿病伴有大血管病变患者血清肝细胞生长因子水平较2型糖尿病无大血管病变患者及无糖尿病大血管病变者明显增高(P<0.05)。②血清肝细胞生长因子和收缩压、空腹血糖、糖化血红蛋白及低密度脂蛋白胆固醇在P<0.05的水平上有显著的正相     

糖尿病大血管病变的综合防治

糖尿病大血管病变主要指中等或较大的动脉发生粥样硬化导致血管腔狭窄或闭塞而导致心、脑、肾及周围血管缺血性病变，严重者可引起功能衰竭，而在糖尿病患者中动脉硬化发生率高，发病年龄相对轻，发展过程快，病情重，病死率高，是2型糖尿病患者致残、致死的主要原因。英国UKPDS研究对2型糖尿病患者强化控制血糖，观察微血管病变下降25％，而大血管病变下降只有16％。另有研究表明在诊断2型糖尿病前(5～6年)无症状期大血管病变已经开始，这需要临床医师更加关注糖尿病大血管病变，提前预防，综合治疗，达到2003年《中国糖尿病防治指南》2型糖尿病控制目标。需要注意以下几方面的问题。     

2型糖尿病患者下肢动脉病变与颈动脉病变关系研究

大血管病变是2型糖尿病患者重要的并发症,下肢动脉病变和颈动脉病变是主要的大血管病变之一,前者与糖尿病足的发生和预后密切相关,后者与脑卒中的发生和预后密切相关,本研究旨在研究二者之间的相互关系,以及影响二者发生发展的危险因素,旨在为2型糖尿病患者大血管病变预防和治疗提供理论依据。     

2型糖尿病合并大血管病变患者肝细胞生长因子水平观察

目的观察2型糖尿病合并大血管病变患者肝细胞生长因子（HGF）水平的变化，探讨HGF与2型糖尿病大血管病变发生的关系。方法用酶联免疫吸附法测定2型糖尿病患者、无糖尿病的大血管病变患者以及正常对照组的血清HGF水平。结果与正常对照组相比，2型糖尿病伴或不伴大血管病变患者及无糖尿病的大血管病变患者血清HGF水平明显增高（P〈0.05或P〈0．01）；无糖尿病大血管病变患者和2型糖尿病无大血管病变患者血清HGF水平差异无显著性；2型糖尿病伴大血管病变患者血清HGF水平较2型糖尿病无大血管病变患者及无糠尿病大血管病变者明显增高（P〈0．05）。结论2型糖尿病患者血清HGF水平显著增高，2型糖尿病合并大血管病变者增高更明显；HGF可作为反映糖尿病患者大血管病变严重程度的指标之一。     

血浆纤溶酶原激活物抑制物-1与不同糖化血红蛋白水平2型糖尿病患者大血管病变的关系

目的：探讨不同糖化血红蛋白（HBA1c）水平的2型糖尿病患者血浆纤溶酶原激活物抑制物-1（PAI-1）与糖尿病大血管病变的关系。方法：246例2型糖尿病患者，按不同HBA1c水平及有无大血管并发症分为4组，采用酶联免疫吸附法测定其PAI-1的水平。选49例健康体检者为正常对照组。结果：有大血管病变组的PAI-1水平比无大血管病变组及对照组均升高（P〈0.01）；多元逐步回归分析显示糖尿病有大血管病变组的PAI-1与年龄、游离脂肪酸（FFA）、体重指数（BMI）和腰臂比（WHR）相关；在有大血管病变组或无大血管病变组中，不同HBA1c水平组间PAI-1水平无显著差异（P≥0.05）；相同HBA1c水平病例组间，糖尿病大血管病变患病率无显著差异（P≥0.05）。结论：PAI-1水平升高与糖尿病大血管病变有关。单纯血糖控制达标，不能有效降低PAI-1水平，对糖尿病患者进行多个代谢因素同时控制可能更有利于预防大血管病变的出现。     

2型糖尿病患者股动脉声像图特点

2型糖尿病常合并周围血管不同程度的粥样硬化性病变，大血管病变是2型糖尿病患者最常见的并发症之一，尽早明确糖尿病大血管病变的存在，并对其进行早期治疗可以降低糖尿病患者致残率和致死率。本研究应用彩色多普勒超声分析糖尿病与非糖尿病人群的股动脉形态及血流动力学的变化差异，旨在探讨2型糖尿病与股动脉粥样硬化的关系。     

2型糖尿病与大血管病变

糖尿病是由多种病因引起的以高血糖为主要特征的代谢紊乱性疾病。而心、脑及外周动脉等大血管发生病变是糖尿病患者致残和早亡的主要原因。欧洲糖尿病诊断标准协作研究(DECODE)指出餐后高血糖与大血管并发症关系密切,且与心血管事件及其伴随的死亡率之间有独立相关性[1]。因而,探讨糖尿病大血管病变的发病机制,寻找大血管病变的早期诊断方法和大血管病变进程的预防和治疗对策,已经成为近年来糖尿病研究的重要课题之一。本文就2型糖尿病的发病机制和内皮功能障碍的关系及内皮功能的超声评价综述如下。1 2型糖尿病大血管病变发病机制与内皮…     

Determination of creatine kinase isoenzyme MB activity in serum using immunological inhibition of creatine kinase M subunit activity. Activity kinetics and diagnostic significance in myocardial infarction.

This is a new method for the determination of creatine kinase isoenzyme MB activity in serum. The method uses direct activity measurement of creatine kinase B subunit activity after blocking of CK-M subunit activity by inhibiting antibodies. The test takes no longer than 15 min. The method yields an intra-serial C.V. of 2.0-12.9%, and a C.V. from day to day of 5.5%. The detection limit is 3.4 U/l creatine kinase MB. In the 95 cases with proven myocardial infarction several types of creatine kinase MB activity kinetics could be determined. The percentage of creatine kinase MB of peak CK-total is 6-25%, with a mean of 11.1%. The amount of creatine kinase MB with respect to total CK activity after reinfarction is higher than the amount after initial infarction.     

Dissociable correlates of two classes of retrieval processing in prefrontal cortex

Although substantial evidence suggests that the prefrontal cortex (PFC) implements processes that are critical for accurate episodic memory judgments, the specific roles of different PFC subregions remain unclear. Here, we used event-related functional magnetic resonance imaging to distinguish between prefrontal activity related to operations that (1) influence processing of retrieval cues based on current task demands, or (2) are involved in monitoring the outputs of retrieval. Fourteen participants studied auditory words spoken by a male or female speaker and completed memory tests in which the stimuli were unstudied foil words and studied words spoken by either the same speaker at study, or the alternate speaker. On "general" test trials, participants were to determine whether each word was studied, regardless of the voice of the speaker, whereas on "specific" test trials, participants were to additionally distinguish between studied words that were spoken in the same voice or a different voice at study. Thus, on specific test trials, participants were explicitly required to attend to voice information in order to evaluate each test item. Anterior (right BA 10), dorsolateral prefrontal (right BA 46), and inferior frontal (bilateral BA 47/12) regions were more active during specific than during general trials. Activation in anterior and dorsolateral PFC was enhanced during specific test trials even in response to unstudied items, suggesting that activation in these regions was related to the differential processing of retrieval cues in the two tasks. In contrast, differences between specific and general test trials in inferior frontal regions (bilateral BA 47/12) were seen only for studied items, suggesting a role for these regions in post-retrieval monitoring processes. Results from this study are consistent with the idea that different PFC subregions implement distinct, but complementary processes that collectively support accurate episodic memory judgments.     

俯卧位通气对高海拔地区肺复张治疗无效急性呼吸窘迫综合征患者氧合的影响

目的 探讨俯卧位通气对高海拔地区肺复张术(RM)治疗无效急性呼吸窘迫综合征(ARDS)患者的治疗作用.方法 从海拔2260m的地区医院筛选RM治疗无效的41例ARDS患者[平均氧合指数( PaO2/FiO2)较RM前升高＜20％视为RM无效],依不同病因分为肺内源性ARDS组(ARDSp组)和肺外源性ARDS组(ARDSexp组),每组再按信封法随机分为俯卧位组和仰卧位组,即ARDSp俯卧位组(11例)、ARDSp仰卧位组(9例)、ARDSexp俯卧位组(10例)、ARDSexp仰卧位组(11例).在通气前及通气1、2、3、4h监测动脉血氧分压( PaO2)、PaO2/FiO2、静态顺应性(Cst)、气道阻力(Raw)的变化.结果 通气lh时,ARDSexp俯卧位组PaO2/FiO2( mm Hg,l mm Hg=0.133 kPa)即较通气前显著升高(157.4±40.6比129.3±48.7,P＜0.05),并随通气时间延长呈持续增高趋势,4h达峰值(219.1 ±41.1);且ARDSexp俯卧位组通气3h内PaO2/FiO2较其他3组显著增高,另3组间则差异无统计学意义.ARDSp俯卧位组、ARDSexp俯卧位组通气4h时PaO2/FiO2均较相应仰卧位组显著增高(208.8±39.7比127.4±47.1,219.1±41.1比124.9±50.8,均P＜0.05).4组通气前后Cst无显著改变,各组间差异也无统计学意义.ARDSp俯卧位组通气4h时Raw(cmH2O·L-1·s-1)较通气前显著降低(6.8±1.7比10.7±1.8,P＜0.05),且明显低于其他3组;其他3组各时间点Raw组内及组间比较差异均无统计学意义.结论 俯卧位通气作为ARDS机械通气重要策略之一,可以改善RM无效高原ARDS患者的氧合,为抢救患者赢得宝贵的时间.     

Digital imaging among medical facilities

The Department of Veterans Affairs (VA) in the USA operates a network of 172 medical centres which all utilize a hospital information system (HIS) which has been developed and is currently maintained by the VA. During the past several years, an image management and communication module has been developed, installed and clinically utilized at the Washington DC and Maryland VA Medical Centres. This image management and communication system, referred to as the decentralized hospital computer program (DHCP) imaging system, is fully integrated with a commercial picture archiving and communication system (PACS). The system is utilized to capture, archive, and display all images generated within the hospital including radiology, nuclear medicine, pathology, endoscopy, bronchoscopy, and dermatology, intraoperative photographs, ECG data, and a limited number of paper documents. The ultimate goal of the project is to have all patient text and image data available at any clinical workstation to any authorized user anywhere within the network of medical centres. Clinical requirements for an imaging workstation include ease of use, rapid and reliable access to the complete set of patient information, and images which are of acceptable quality to meet the requirements of the user and the subspecialty. Patient confidentiality and data security must be safeguarded at all times. Integration of the images with the remainder of the patient's database was found to be critical to the success of the project. The experience at the Washington and Maryland facilities suggests that an imaging system that is successfully integrated with a hospital information system can provide substantial clinical and economic benefits both within and among medical centres. Clinical acceptance and utilization of the system has been excellent, particularly in diagnostic radiology where DHCP Imaging has been interfaced to a commercial PAC system. Based upon this initial experience, the VA has begun to deploy the system throughout its large network of medical centres.     

Myocardial elastography at both high temporal and spatial resolution for the detection of infarcts

Myocardial elastography is a novel method for noninvasively assessing regional myocardial function, with the advantages of high spatial and temporal resolution and high signal-to-noise ratio (SNR). In this paper, in-vivo experiments were performed in anesthetized normal and infarcted mice (one day after left anterior descending coronary artery [LAD] ligation) using a high-resolution (30 MHz) ultrasound system (Vevo 770, VisualSonics Inc., Toronto, ON, Canada). Radiofrequency (RF) signals of the left ventricle (LV) in longitudinal (long-axis) view and the associated electrocardiogram (ECG) were simultaneously acquired. Using a retrospective ECG gating technique, 2-D full field-of-view RF frames were acquired at an extremely high frame rate (8 kHz) that resulted in high-quality incremental displacement and strain estimation of the myocardium. The incremental results were further accumulated to obtain the cumulative displacements and strains. Two-dimensional and M-mode displacement images and strain images (elastograms), as well as displacement and strain profiles as a function of time, were compared between normal and infarcted mice. Incremental results clearly depicted cardiac events including LV contraction, LV relaxation and isovolumetric phases in both normal and infarcted mice, and also evidently indicated reduced motion and deformation in the infarcted myocardium. The elastograms indicated that the infarcted regions underwent thinning during systole rather than thickening, as in the normal case. The cumulative elastograms were found to have higher elastographic SNR (SNR(e)) than the incremental elastograms (e.g., 10.6 vs. 4.7 in a normal myocardium, and 6.0 vs. 2.4 in an infarcted myocardium). Finally, preliminary statistical results from nine normal (m = 9) and seven infarcted (n = 7) mice indicated the capability of the cumulative strain in differentiating infracted from normal myocardia. In conclusion, myocardial elastography could provide regional strain information at simultaneously high temporal (>/=0.125 ms) and spatial ( approximately 55 microm) resolution as well as high precision ( approximately 0.05 microm displacement). This technique was thus capable of accurately characterizing normal myocardial function throughout an entire cardiac cycle, at the same high resolution, and detecting and localizing myocardial infarction in vivo.     

Clinical Pharmacokinetics of Morphine

Morphine, the most widely used mu-opioid analgesic for acute and chronic pain, is the standard against which new analgesics are measured. A thorough understanding of the pharmacokinetics of morphine is required in order to safely and effectively use this analgesic in a wide variety of patients with different levels of organ function. A MEDLINE search was conducted to identify literature published between 1966 and January 2002 relevant to the pharmacokinetics of morphine. These publications were reviewed and the literature summarized regarding unique and clinically important elements of morphine disposition relative to its parenteral administration (including intravenous, intramuscular, subcutaneous, epidural and intrathecal administration), absorption profile (immediate release, controlled release, and sublingual/buccal, and rectal administration), distribution, and its metabolism/ excretion. Special populations, including infants, elderly, and those with renal/liver failure, have a unique morphine pharmacokinetic profile that must be taken into account in order to maximize analgesic efficacy and reduce the risk of adverse events.