Clinical and biological aspects of juvenile thrombophilia

Summary The clinical status of 418 consecutive thrombotic patients was assessed and they were investigated for deficiencies of the proteins involved in the modulation of blood coagulation and fibrinolysis. The whole cohort was divided into two groups according to the age at which the first thrombotic event occurred: group 1 younger than 45 years and group 2 older than 45 years. Deficiencies were significantly more frequent in the juvenile thrombotic population; in this subset of patients the prevalences of single deficiencies were: protein S (6.9%), protein C (4.9%), antithrombin III (3%), plasminogen (0.5%) and dysfibrinogenemia (0.3%). It was possible to diagnose 41 additional deficiencies in the relatives of the probands. The clinical picture and the presence, absence and type of predisposing factors were not statistically different in deficient and non-deficient patients. However, deficient patients experienced their first episode significantly earlier than non-deficient patients and had a significantly higher number of recurrences and pulmonary embolism episodes. From the analysis of the thrombosis-free survival curves, there is no doubt that age represents a strong cofactor in thrombotic risk-related deficiency.     

血栓性疾病患者抗凝蛋白检测的临床意义

目的 探讨血栓性疾病患者蛋白C(PC)、蛋白S(PS)和抗凝血酶(AT)活性水平检测在排除常见获得性血栓危险因素中的临床意义.方法 检测85例血栓性疾病患者与50名正常健康对照者血浆PC、PS、AT活性水平,并作比较分析.结果 85例血栓性疾病患者中位年龄42(17～69)岁.其中≤45岁者60例(70.6%).动脉血栓组和静脉血栓组患者PC、PS、AT活性均明显低于正常对照组(P<0.01);复发组PC、PS、AT平均活性低于初发组(P<0.01);年龄≤45岁患者组PC、PS、AT平均活性低于45岁以上组(P<0.01).共有26例(30.6%)患者存在抗凝蛋白活性降低;PS活性降低的发生率最高(10.6%),其次为PC活性降低(8.2%),AT活性降低和联合活性降低(各占5.9%).结论 无明确常见获得性血栓危险因素的血栓患者发病年龄较轻,且普遍存在抗凝蛋白水平低下;抗凝蛋白活性降低不仅与血栓性疾病的发生有关,而且与血栓复发密切相关.     

Recurrent venous thrombosis and hypercoagulable states

Patients with recurrent venous thrombosis, or those with thrombosis at a young age (less than 45 years) and a family history of thrombotic disorders, may have an inherited hypercoagulable disorder. The most common disorders are deficiencies of protein S, protein C and antithrombin III, inhibitors of the coagulation cascade. These deficiencies may be found in approximately 10 percent of patients who are under age 45 and have venous thrombosis. Acquired disorders associated with recurrent venous thrombosis include carcinoma and antiphospholipid antibody syndrome. Appropriate anticoagulation can reduce the risk of recurrent thrombosis in patients with inherited and acquired abnormalities.     

Headache in acute cerebrovascular disease: a prospective clinical study in 240 patients

To evaluate the clinical features of headache in stroke, a prospective study was carried out in 240 consecutive patients with acute stroke who had intact expressive function. Headache occurred in 38%: 32% of 195 patients with ischemic stroke and 64.5% of 45 patients with hemorrhagic stroke ( p < 0.0001). Headache patients were younger (mean age 62 ± 15 vs 67 ± 11.5 years) than non-headache patients ( p < 0.01). A history of previous vascular or tension-type headache was found in 40.5% of the headache group, but in only 23.5% of the non-headache group ( p < 0.01). In ischemic stroke, headache was observed in 41% of thrombotic infarcts, in 39% of cardioembolic infarcts, in 23% of lacunar infarcts and in 26% of TIA. Headache was significantly more common in thrombotic than lacunar infarcts ( p < 0.05). In hemorrhagic stroke, headache was observed in all subarachnoid hemorrhages and in 58% of intraparenchymal hemorrhages. In ischemic stroke, the mean duration of the headache was 25 ± 28 h and in hemorrhagic stroke 64.5 ± 36.5 h ( p < 0.00001). In ischemic stroke the headache was focal in 74% and mild or moderate in intensity in 74%. In hemorrhagic stroke, it was diffuse in 52% and the pain intensity was incapacitating in 70%. Headache was more common in vertebrobasilar stroke (59%), in comparison with carotid stroke (26%) or stroke of unclear vascular topography (33%) (p < 0.00001). Fifty-six and a half percent of patients with cortical stroke had headaches, as opposed to only 26.5% of patients with subcortical stroke ( p < 0.005). Ten percent of the patients presented with sentinel headache.     

不同年龄段人群布鲁氏菌病急性期临床特征分析

目的 探讨不同年龄组布鲁氏菌病（布病）患者急性期临床特点。 方法 回顾性分析246例布病急性期住院患者的临床资料,按年龄分为婴幼儿组、学龄前组、青少年组、青年组、中老年组共5组。 结果 不同年龄组布病患者的急性期临床特点存在差异,在临床症状体征中乏力（P＝0.015）、多汗（P＝0.048）、腰痛（P＜0.001）、肝脾肿大（P＝0.013）等方面存在差异;在实验室检查中白细胞（P＝0.001）、中性粒细胞百分比（P＜0.001）、淋巴细胞计数（P＜0.001）、谷丙转氨酶（P＝0.024）、谷草转氨酶（P＜0.001）、白蛋白（P＜0.001）、C反应蛋白（P＜0.001）、红细胞沉降率（P＜0.001）等指标差异有统计学意义。 其中,儿童患者发生乏力和多汗较成年患者少,更易发生肝功能损害出现肝脾肿大,而累及脊椎。 临床表现为腰痛者以中老年患者最多,中老年患者组C反应蛋白和动态红细胞沉降率升高的发生率高于低年龄组。 结论 不同年龄组布病患者有不同的临床差异性,临床诊治中需要注意其特点。      

不同年龄组新型冠状病毒肺炎患者临床特征分析

  目的  通过对不同年龄组新型冠状病毒肺炎（COVID-19）病例发病早期的临床特征进行分析,为及时发现和治疗管理COVID-19患者并防止病情进展,进一步采取有效防控措施提供参考。  方法  将2020年1月19日至3月9日全国COVID-19流行病学调查网络报告系统中湖北省以外省份报告的COVID-19确诊病例纳入作为研究对象。 对不同年龄组病例发病时的临床表现、临床严重程度、实验室和影像学表现、基础性疾病等情况进行对比分析。  结果  本研究共纳入12 647例COVID-19确诊病例,年龄中位数为45岁［四分位数间距（IQR）:33～56岁］,0～5岁组196例（1.5%）、6～17岁组508例（4.0%）、18～44岁组5 491例（43.4%）、45～59岁组4 004例（31.7%）以及≥60岁组2 448例（19.4%）,其中102例死亡,病死率为0.8%,≤17岁年龄组无死亡病例。 ≥60岁组病例出现重症和危重症的比例均为各年龄组最高,分别为18.7%和10.6%,病死率为3.6%;0～17岁组病例以轻型（62.2%）和普通型（37.1%）为主。 0～5岁组重症比例（1.0%）高于6～17岁组（0.6%）,两个年龄组中均无危重症病例报告。 ≤17岁病例出现白细胞计数减少和淋巴细胞计数减少的比例均显著低于≥18岁病例（χ2=225.037,P<0.001和χ2=479.737,P<0.001）;≤17岁病例CT出现肺炎影像学特征的比例为44.7%,显著低于≥18岁人群（76.1%）。 0～5岁病例出现流涕和呕吐的比例最高,分别占13.3%和2.6%;白细胞计数增加、淋巴细胞计数增加、淋巴细胞百分比增加比例在各年龄组中均为最高,分别为24.3%,51.0%和66.9%。 18～44岁组出现关节肌肉酸痛、头痛、腹泻和咽痛的比例最高,分别为12.4%、12.3%、5.1%和11.9%;45～59岁组出现干咳和胸闷的比例最高,分别为34.3%和8.1%;≥60岁组出现腹痛、结膜充血、胸痛和鼻塞的比例最高,分别有2.2%、1.5%、7.7%和10.2%。 有慢性基础性疾病的病例主要为≥60岁病例,占41.0%,有慢性基础性疾病的病例重症率（19.6%）显著高于无基础性疾病病例（11.1%）（χ2=451.301,P<0.001）。  结论  ≥60岁COVID-19病例重症率和病死率在各年龄组最高,有慢性基础疾病的病例临床重症率更高。不同年龄组病例早期临床特征差异明显,≤17岁病例白细胞计数减少、淋巴细胞计数减少和CT肺炎影像学特征的比例低于≥18岁病例。 0～5岁病例流涕、呕吐、白细胞计数、淋巴细胞计数和淋巴细胞百分比增加比例在各年龄组最高;18～44岁组病例关节肌肉酸痛、头痛、腹泻和咽痛比例最高;45～59岁组干咳和胸闷比例最高;≥60岁组腹痛、结膜充血、胸痛和鼻塞的比例最高。 这些早期临床特征为早发现和治疗管理COVID-19患者及防制病情进展,以便及时采取相关防控措施提供参考。     

672例静脉血栓栓塞症相关危险因素分析

目的 分析静脉血栓栓塞症（VrrE）住院患者的患病情况、临床特征和危险因素。方法 回顾性分析北京协和医院1994年至2004年住院VTE病例的患病趋势、人口学特点、获得性及遗传性危险因素。结果 共收集VTE患者672例，男：女=1．2：1，中位年龄53（14—92）岁。初发患者580例（86．3％），发病高峰年龄男性患者为40～50岁，女性为50-60岁。主要获得性危险因素有抗磷脂抗体阳性（32．0％）、外伤和（或）手术（31．1％）、肿瘤（17．1％）。其中具有多种获得性危险因素者占35．7％。94例患者在抗凝治疗前取外周血检测了蛋白C（PC）、蛋白S（PS）和抗凝血酶（AT）活性。抗凝蛋白总缺陷率为44．7％，以PC缺乏以及PC与AT联合缺乏为主，分别占13．8％和10．6％。同时具有遗传和获得性危险因素者占31．6％。结论 研究结果显示综合医院的住院VTE病例数呈逐年上升趋势，男性VTE患者的初发年龄较女性提早约10年。主要获得性危险因素为抗磷脂抗体阳性、外伤或手术和肿瘤，而遗传性危险因素则以PC缺乏和PC与AT联合缺乏为主。多种危险因素并存是促发VTE的重要原因。     

蛋白质Z检测在心脑血管疾病中的临床意义

目的研究蛋白质Z(Protein Z,PZ)在心脑血管疾病中的变化,并探讨其临床意义及与血液凝固因子X(FX)的关系.方法PZ及FXAg用ELISA法检测,血浆FXC采用一期法测定.对170例急性缺血性脑卒中(AIS)、40例急性心肌梗死(AMI)、60名健康者的PZ、FXC、FXAg进行测定及相关性比较,同时对初发与再发、不同年龄、不同性别患者PZ、FXC、FXAg水平进行比较.结果AIS组和AMI组的PZ水平分别为(940.02±229.82)μg/L与(1071.44±180.52)μg/L,与对照组[(2257.97±479.76)μg/L]相比明显下降(P值均＜0.001).AIS组的FXC、FXAg水平分别为(136.73±34.93)%、(135.54±54.39)%,AMI组分别为(139.53±29.18)%、(129.75±21.91)%,与对照组[分别为(94.33±20.00)%和(77.22±13.19)%]相比显著升高(P值均＜0.001).AIS、AMI组及对照组中的PZ水平与FXC、FXAg水平之间均存在明显负相关(P值均＜0.001),同时再发AIS、AMI组PZ、FXC、FXAg分别与初发组比较,有显著性差异(P值均＜0.05),显示PZ水平的下降程度反映了疾病的病理过程.PZ水平随年龄增加而下降(P＜0.05),而FXC、FXAg水平与年龄因素无关(P＞0.05),PZ、FXC、FXAg水平与性别之间未发现相关性(P＞0.05).结论PZ水平在AIS、AMI患者中明显减低,PZ与FXC、FXAg存在明显负相关,FX水平升高的机制可能部分与PZ水平下降有关.PZ水平与疾病初发与再发有关,并随年龄增加而呈下降的趋势.提示PZ缺乏可能是心脑动脉血栓性疾病存在的一个危险因素.     

Essential thrombocythemia beyond the first decade: life expectancy, long-term complication rates, and prognostic factors

OBJECTIVE: To describe the long-term natural history of essential thrombocythemia (ET) in terms of life expectancy, risk of disease transformation Into a more aggressive myeloid disorder, and prognostic factors for both survival and disease complications. PATIENTS AND METHODS: The study population consisted of a consecutive cohort of patients seen at the Mayo Clinic In Rochester, Minn, in whom a diagnosis of ET was established before 1992, thus allowing a minimum of 10 years of potential follow-up. The conventional criteria-based diagnosis was confirmed by bone marrow biopsy in all Instances. RESULTS: A total of 322 patients were studied (median age, 54 years; median follow-up, 13.6 years). With a median survival time of 18.9 years, survival in the first decade of disease was similar to that of the control population (risk ratio, 0.72; 95% confidence interval, 0.50-0.99) but became significantly worse thereafter (risk ratio, 2.21; 95% confidence Interval, 1.74-2.76). Multivariable analysis identified age at diagnosis of 60 years or older, leukocytosis, tobacco use, and diabetes mellitus as Independent predictors of poor survival. A 2-variable model based on an age cutoff of 60 years and leukocyte count of 15 x 10(9)/L resulted in 3 risk groups with significant difference in survival. In addition, age at diagnosis of 60 years or older, leukocytosis, and history of thrombosis were independent predictors of major thrombotic events. The risk of leukemic or any myeloid disease transformation was low in the first 10 years (1.4% and 9.1%, respectively) but increased substantially in the second (8.1% and 28.3%, respectively) and third (24.0% and 58.5%, respectively) decades of the disease. CONCLUSION: Life expectancy in patients with ET is significantly worse than that of the control population. Leukocytosis is identified as a novel independent risk factor for both inferior survival and thrombotic events.     

Polymorphism of GPIIIA platelet glycoprotein gene PIA1/A2 compared to plasma hemostasis in myocardial infarction patients]

AIM: To investigate gene PIA1/A2 polymorphism and some parameters of plasma hemostasis in postmyocardial infarction (PMI) patients with chronic cardiac failure (CCF). MATERIALS AND METHODS: A total of 58 PMI patients with CCF, pulmonary artery thromboembolism (PATE), phlebothrombosis (PT) were examined. The age of the patients ranged from 24 to 84 years. Polymorphism of platelet glycoprotein GPIIIa gene was assessed according to the standard PCR-RFLP. RESULTS: Occurrence of genotypes PIA1/A2, PIA1/A2 was 70.8 and 29.2%, respectively; of allele PIA1 and PIA2 84.5 and 15.5%, respectively. In PMI patients genotype PIA1/A1 occurred in 71.7% of cases, genotype PIA1/A2--in 28.3%. Incidence of alleles was: 84.0% (PIA1), 16.0% (PIA2). PATE patients had genotype PIA1/A1, PT patients had distribution of the genotypes 50.0% and 50.0%, respectively. In patients who had suffered MI at the age under 45 years prevalence of the genotypes was 63.2% PIA1A1, 36.8% PIA1A2, of alleles 83.6% PIA1, 16.4% PIA2. In patients with a history of MI at the age over 50 the incidence of the genotypes and alleles was, respectively, 75.0% PIA1A1, 25.0% PIA1A2, 87.7% PIA1, 12.3% PIA2. Patients with genotype PIA1/A2 had a significantly higher fibrinogen than PIA1A1. Concentration of soluble fibrin monomeric complex was higher in patients with genotype PIA1/A2 reflecting activation of intravascular clotting. AT-III decrease by 5.4% indicated lower anticoagulant activity in patients with genotype PIA1A2. CONCLUSION: In patients with MI at the age under 45 years gene PIA1A2 and allel PIA2 occurred more frequently than in patients who had MI at older age. Allele PIA2 was associated with the risk of MI onset at young age. It is suggested that patients with genotype PIA1/A2 are at higher risk of thrombotic conditions, of coronary artery thrombosis in particular, than patients with genotype PIA1/A1.     

Constitutional thrombophilias: indications of the biological profile and therapeutic consequences

In laboratory screening in patients with clinical thrombophilia (early thromboembolism episode < 50 years, spontaneous thrombosis, recurrent thrombosis, unusual site of thrombosis, thrombotic family history or coumarin-induced skin necrosis complication), an isolated or combined inherited thrombophilia can be observed: antithrombin (0.5 to 4.9 per cent), protein C (1.4 to 8.6 per cent) and protein S (1.4 to 7.5 per cent) deficiencies or factor V Leiden (20 to 30 per cent). Special attention is mandatory in prescribing biological exploration because of the many physiological or pharmacological interferences which can modify the results. Identification of a genetic defect may induce specific management and individuals should receive counselling regarding the implications of this diagnosis. Further prospective studies should help to determine the thrombotic risk in symptomatic and non-symptomatic patients with inherited thrombophilia and the risk/benefit ratio of laboratory screening for hereditary thrombophilia and therapeutic intervention.     

新型冠状病毒肺炎患者不同临床转归影响因素分析

目的:回顾性分析新型冠状病毒肺炎(COVID-19)治愈患者和死亡患者的临床特征,分析差异,为临床诊疗提供参考。方法:选取2020年1月10日至2月15日华中科技大学同济医学院附属同济医院收治的113例COVID-19患者为研究对象,根据病情转归分为治愈组69例,死亡组44例。收集2组患者的临床特征、实验室检查、影像学结果等,分析组间差异以及与预后的关系。结果:113例COVID-19患者平均年龄为(58.6±15.9)岁,男性68人,女性45人。死亡组患者较治愈组患者年龄更大,男性比例更高,合并症比例更高,差异有统计学意义(P<0.05)。影像学方面,死亡组更多表现为双肺的弥漫病变(P<0.05)。在实验室检查中,死亡组患者较治愈组患者白细胞计数和中性粒细胞计数增加,淋巴细胞计数降低(P<0.05)。在炎症相关指标中,死亡组患者C-反应蛋白(CRP)、铁蛋白、D-D二聚体、乳酸脱氢酶(LDH)、白细胞介素2受体(interleukin 2 receptor,IL-2R)、IL-6、IL-8、IL-10、肿瘤坏死因子-α(TNF-α)明显高于治愈组患者(P<0.01)。对有差异的指标进行受试者工作特征(ROC)曲线分析,发现D-D二聚体的曲线下面积高于其他指标,灵敏度为90.3%,特异度为90.2%,是较好的预测指标。结论:高龄、男性、有合并症的COVID-19患者死亡风险更大;CRP、D-D二聚体、IL-2R等细胞因子水平的升高均提示预后不良;D-D二聚体对于患者预后有着较高的预测价值,综合考虑各项指标,更有助于判断患者转归,指导治疗。     

Elevated levels of FVIII:C within families are associated with an increased risk for venous and arterial thrombosis.

Elevated levels of coagulation factor VIII:C (FVIII:C) are associated with an increased risk for venous and arterial thromboembolism. Whether relatives of patients with elevated levels of FVIII:C are also at increased risk for thrombotic disease is unknown. The objective was to determine the annual incidences of both venous and arterial thrombotic events in first-degree relatives of patients with elevated levels of FVIII:C and venous thromboembolism (VTE) or premature atherosclerosis. A retrospective study with 584 first-degree relatives of 177 patients with elevated levels of FVIII:C was performed. The level of FVIII:C was determined and relatives with elevated and normal levels of FVIII:C were compared. Of the participants, 40% had elevated levels of FVIII:C. The annual incidence of a first episode of VTE was 0.34% and 0.13% in relatives with elevated levels of FVIII:C and those with normal levels, respectively [OR 3.7 (95% CI 1.9-7.5)]. The absolute annual incidence in the youngest age group with elevated levels of FVIII:C was 0.16% (0.05-0.37) and gradually increased to 0.99% (0.40-2.04) in those older than 60 years of age, although the odds ratios were not statistically significant. The annual incidences of a first arterial thrombotic event were 0.29% and 0.14% in relatives with and without elevated levels of FVIII:C, respectively [OR 3.1 (1.4-6.6)]. In particular the risks for a first myocardial infarction [OR 4.3 (1.0-18.1); P =0.046] and a first peripheral arterial thrombosis [OR 8.6 (1.6-47.6)] were increased. Within families of patients with elevated levels of FVIII:C and VTE or premature atherosclerosis, 40% of their first-degree relatives has elevated levels of FVIII:C as well, and they are at increased risk for both VTE and arterial thrombosis as compared with their relatives with normal levels.     

Better adherence to the guidelines during cardiopulmonary resuscitation through the provision of audio-prompts

OBJECTIVE: Quality assurance to optimize clinical resuscitation performance is important. The aims of the present study were to identify the deficiencies in the clinical practice of resuscitation by motion analysis of video-recorded cardiopulmonary resuscitation (CPR), and to evaluate the effectiveness of quality improvement strategies based on audio-prompt methods. MATERIALS AND METHODS: A two-stage prospective trial was conducted. The first stage (observation group) was designed to identify any major clinical nonconformity to current resuscitation guidelines by videotaped CPR sessions. The second stage (intervention group) was designed to evaluate the effectiveness of audio prompts in ameliorating the problems identified at the first stage. The demographic data of patients and CPR variables between the two groups were analysed. RESULTS: A total of 30 resuscitation attempts were recorded during study period: 17 patients were in the observation group and 13 patients in the intervention group. Inadequate number of chest compressions per minute, lack of re-oxygenation during prolonged intubation attempts and unnecessary hands-off periods were identified as the three most important deficiencies in CPR practice. Compared to the observation group, the intervention group showed a significant improvement in the hands-off period per minute during CPR (12.7 +/- 5.3 s versus 16.9+/-7.9 s, P < 0.05), the total hands-off time during CPR (164 +/- 94 s versus 273 +/- 153 s, P < 0.05), the proportion of intubation attempts taking under 20 s (56.3% versus 10%, P < 0.05). CONCLUSIONS: Audio-prompts can improve the adherence to current CPR guidelines in the clinical setting significantly. The quality improvement measures described in this study are helpful in translating CPR knowledge into clinical practice.     

PAI-1在造血干细胞移植早期血栓病变中的临床意义

目的 观察造血干细胞移植早期患者纤溶酶原激活剂抑制物-1(PAI-1)指标的动态改变,探讨其在移植相关性血栓病变中的临床意义.方法 采用ELISA法监测95例接受造血干细胞移植的患者在预处理过程中以及干细胞移植后4周内血浆中PAI-1等凝血指标的动态改变.根据移植后并发症的发生情况将患者分为平稳组、急性移植物抗宿主病(aGVHD)组、血栓组以及感染组进行统计学分析.结果 造血干细胞移植过程中患者的各项凝血相关指标呈现动态改变.其中PAI-1水平在预处理后升高,移植当周下降,随后又逐步上升.根据移植后首先出现的并发症情况将患者分为四组:平稳组41例、aGVHD组29例、血柃组6例[肝静脉闭塞病(VOD)5例,血栓性微血管病(TMA)1例]和感染组19例.自体移植中发生血栓1例(3.3%),异基因移植组发生血栓5例(7.7%).移植后发生血栓患者PAI-1水平较发生血栓者无增高,后者又高于自体移植无血栓患者.有并发症的移植患者PAI-1水平明显高于无并发症患者.出现血栓病变的6例患者PAI-1极度升高,为(62.8±7.5)μg/L,明显高于GVHD组[(45.1±9.1)μg/L]和感染组[(50.0±11.2)μg/L]患者的移植后平均水平.结论 血浆PAI-1水平的增高可能是移植相关性血栓病变的特异性指标,提示VOD、TMA等血栓并发症的发生.PAI-1水平的明显升高有益于移植相关性血栓并发症的早期诊断.     

结肠镜筛查在中老年人群健康体检中的应用

目的探究结肠镜筛查在中老年人群健康体检中的应用。方法收集并整理2010年1月-2018年1月来该院行健康检查的11 547名中老年人的结肠镜检查数据,分析结肠镜检查在中老年人群大肠癌筛查中的效果。结果 11 547名中老年人初筛阳性率为16.77%(1 937/11 547),男性患者第1次和第2次参与率均低于女性,但男性患者第1次、第2次和初筛整体阳性率均高于女性,差异有统计学意义(P 0.05)。45～55岁、56～60岁、61～65岁和66～70岁的人群初筛参与率无明显差异,但年龄为71～75岁阶段的患者初筛参与率明显低于其他年龄组患者,且随着年龄的增长,患者第1次、第2次和初筛整体阳性率均升高,差异具有统计学意义(P 0.05)。患者以炎症、普通腺瘤、非腺瘤性息肉为主要病变,男性患者大肠癌、进展期腺瘤、普通腺瘤、非腺瘤性息肉的病变率高于女性患者,黑变病和炎症病变率低于女性患者,差异有统计学意义(P 0.05)。45～55岁和61～65岁患者以炎症病变为主,56～60岁以黑变病为主,66～70岁和71～75岁患者以普通腺瘤为主。结论结肠镜筛查能够有效发现中老年人群的肠道病变,大肠癌发病率随年龄增长而增高。因此,应提高中老年人群的结肠镜检查顺应性。     

不同年龄段获得性免疫缺陷综合征患者心电图分析

目的 了解不同年龄段获得性免疫缺陷综合征(AIDS)患者的心电图变化规律.方法 回顾性分析400例不同年龄段AIDS患者的心电图.结果 ①AIDS患者心电图异常率比较:46～50岁组高于11～15岁组(P=0.008)、21～25岁组(P=0.041)、31～35岁组(P=0.022)、41～45岁组(P=0.001)、51～55岁组(P=0.047),差异均有统计学意义(P均＜0.05).②缓慢心律失常发生率:46～50岁组高于31～35岁组(U=2.44)、36～40岁组(U=2.18)和41～45岁组(U=2.57),差异均有统计学意义(P均＜0.05).③左房室肥大发生率:11～15岁组小于46～50岁组(U=2.53)、56～60岁组(U=1.97)、60岁以上组(U=2.94),＞60岁组大于36～40岁组(U=2.22)、41～45岁组(U=2.48)和51～55岁组(U=2.04),差异均有统计学意义(P均＜0.05).结论 不同年龄段AIDS患者均可出现心电图异常,但与年龄呈正相关.     

Hypopituitarism following external radiotherapy for pituitary tumours in adults

The development of anterior pituitary hormone deficiencies has been studied in a group of 165 patients who underwent external radiotherapy for tumours of the pituitary or closely related anatomical sites, and who have been observed for up to 10 years. One hundred and forty had undergone pituitary surgery before radiotherapy. All patients received external radiotherapy by a three-field technique, giving 3750-4250 cGy in 15 or 16 fractions over 20-22 days. A combined test of anterior pituitary function using insulin hypoglycaemia or glucagon stimulation in conjunction with thyrotrophin and gonadotrophin releasing hormone tests and basal estimations of prolactin, thyroid hormones and testosterone or oestradiol was performed before radiotherapy. This was repeated six and 12 months later and subsequently annually. Before radiotherapy, 18 per cent of patients had normal growth hormone secretion, 21 per cent had normal gonadotrophin secretion, 57 per cent had normal corticotrophin reserve and 80 per cent had normal thyrotrophin secretion. Life table analysis demonstrated increasing incidences of all anterior pituitary hormone deficiencies with time: by five years all patients were growth hormone deficient, 91 per cent were gonadotrophin deficient, 77 per cent were corticotrophin deficient and 42 per cent were thyrotrophin deficient. At eight years, respective incidences of deficiencies were 100, 96, 84 and 49 per cent. Radiation-induced hyperprolactinaemia was seen in 73 patients; mean serum prolactin concentration rose from 227 +/- 11 mU/l to a peak of 369 +/- 60 mU/l at two years and subsequently declined towards the basal value. The primary diagnosis, patient age, sex, irradiated tissue volume and previous surgery were examined as variables that might influence the rate of development of anterior pituitary hormone deficiencies, but none of these factors had a significant effect. The radiation induced hyperprolactinaemia was however more marked in female patients. Although anterior pituitary hormone deficiencies most commonly developed in the order growth hormone, gonadotrophin, corticotrophin, thyrotrophin (61 per cent of patients), other sequences were evident. Most notably corticotrophin deficiency occurred before gonadotrophin deficiency. There is a high incidence of anterior pituitary hormone deficiencies in patients treated surgically for pituitary tumours and the incidence increases after external radiotherapy. Deficiencies may occur in an unpredictable sequence and endocrine testing is recommended on an annual basis.     

Opportunistic screening for diabetes in routine clinical practice

OBJECTIVE: Since 1997, the American Diabetes Association has recommended that nondiabetic individuals >/=45 years of age be screened for diabetes at least every 3 years. We sought to characterize the frequency, methods, and results of diabetes screening in routine clinical practice. RESEARCH DESIGN AND METHODS: We studied opportunistic screening in nondiabetic members of a health maintenance organization >/=45 years of age who were assigned to a large, integrated, academic health care delivery system. Screening was defined as the first glucose, HbA(1c), or oral glucose tolerance test (OGTT) performed between 1 January 1998 and 31 December 2000. Chart review was performed to determine the prevalence of diabetes risk factors and to describe follow-up. RESULTS: Of 8,286 nondiabetic patients >/=45 years of age, 69% (n = 5,752) were screened. The frequency of screening was greater in patients with one or more primary care visits and increased with age. Women were more likely to be screened than men, and patients with at least one diabetes risk factor were more likely to be screened than those without risk factors. Random plasma glucose was the most common screening test (95%). Four percent (n = 202) of those screened had abnormal results. Only 38% (n = 77) of those with abnormal results received appropriate follow-up, and 17% (n = 35) were diagnosed with diabetes within 6 months of screening. The yield of screening was very low (0.6%, 35 of 5,752). CONCLUSIONS: Despite frequent screening and appropriate targeting of high-risk patients, follow-up of patients with abnormal results is uncommon and the yield of screening is low. Interventions are needed to help physicians recognize and provide appropriate follow-up for patients with potentially abnormal random glucose levels.