不同Wagner分级糖尿病足患者肾损害的临床研究

目的 探讨不同严重程度的糖尿病足（Wagner 1～5级）患者的肾损害情况，了解糖尿病足与肾病之间的临床关系，提高临床实践中对糖尿病足的诊治。方法 对解放军第306医院内分泌科2009年6月至2014年6月收治的622例2型糖尿病合并糖尿病足的患者及215例2型糖尿病非足病的患者作回顾性分析，将足病与非足病各分为一组，收集相关临床资料并检测相关生化指标分析糖尿病足的影响因素。将非足病、Wagner 1级、2级、3级各分为一组，Wagner 4级和5级分为一组，以尿白蛋白肌酐比值（UACR）、估算的肾小球滤过率（eGFR）为指标分析不同程度足病的肾损害情况。应用SPSS19.0统计软件进行统计学分析。结果 糖尿病足病组与非足病组相比UACR明显升高，（78.00 vs 10.60mg/g，P＜0.05），eGFR明显下降[（100.91±44.98） vs （114.27±35.88）ml/（min·1.73m2），P＜0.05]；多元逐步回归分析结果显示性别、糖尿病视网膜病变、血清白蛋白、尿酸、餐后2h血糖、UACR与2型糖尿病足发生、发展相关（β＝0.707、0.850、-0.183、-0.006、0.104、0.003，均P＜0.05）；Wagner 3级组与Wagner 2级组相比微量白蛋白尿（UACR 30～300mg/g）发生率明显升高 [49.7%（87/175） vs 39.2%（67/171），χ2＝3.885]，Wagner 4～5级组与Wagner 3级组相比肾功能不全[eGFR＜60ml/（min·1.73m2）]的发生率明显升高 [23.5%（43/183） vs 11.0%（24/220），χ2＝11.421]，差异均有统计学意义（均P＜0.05）；大量白蛋白尿（UACR≥300mg/g）、肾功能不全在Wagner 3级组的发生率低于2级组，但在Wagner 4～5级组重新升高。结论 糖尿病足Wagner分级越高，肾损害越严重，微量白蛋白尿较肾小球滤过率能更早提示糖尿病肾损害，Wagner 3级是肾病进展及临床治疗的转折点，当患者处于Wagner 3级时应加强足部护理及肾脏保护的力度。     

踝臂指数与缺血性脑卒中患者颅内动脉狭窄的相关性

目的 探讨缺血性脑卒中患者踝臂指数（ABI）与颅内动脉狭窄程度、数量、部位以及不同类型缺血性脑卒中的关系.方法 选择82例行全脑血管造影（DSA）的缺血性脑卒中患者,所有患者在造影前均进行ABI测量和常规生化检查.按血管狭窄程度及病变血管数量对患者进行分组,并进行中国缺血性脑卒中亚型（CISS）分型,比较颅内动脉狭窄程度、病变数量、部位以及不同类型脑卒中与ABI的关系.运用SPSS 13.5统计学软件进行统计学分析.结果 （1）颅内动脉狭窄组的ABI值（1.00±0.23）较无狭窄组（1.07±0.33）显著降低（t=1.990,P〈0.05）.3支及以1：病变组与无狭窄组、1支病变组和2支病变组ABI值有显著差异（t=1.684,t=2.441,P〈0.05）,但无狭窄组（ABI为1.07±0.33）、1支病变组（ABI为1.04±0.11）、2支病变组（ABI为1.02±0.35）之间比较没有显著性差异（t=1.684,t=1.688,t=1.711,P〉0.05）.（2）前后循环均狭窄组（0.89±0.08）的患者与无狭窄组（1.07±0.33）、颈内动脉狭窄组（1.02±0.17）、椎基底动脉狭窄组（1.04±0.15）比较ABI水平有显著性降低（t=1.725,t=2.0,t=2.12,P〈0.05）.（3）AB1≤0.9时预测重度颅内动脉狭窄的敏感度、特异度、准确度分别为85.4%、92.5%和69.7%.（4）大动脉粥样硬化（LAA）组ABI异常率显著高于穿支动脉疾病（PAD）组（P〈0.01）,LAA组ABI值（0.89±0.17）显著降低（t=2.639,P〈0.01）.结论 缺血性脑卒中患者ABI与颅内动脉狭窄严重程度、病变支数、病变部位相关,重度颅内动脉狭窄、3支以上病变以及前后循环系统均狭窄的缺血性脑卒中患者ABI值明显降低.ABI对重度颅内动脉狭窄有较高的预测价值.ABI与LAA有关,与PAD无关.     

自体血小板凝胶在糖尿病足溃疡治疗中的应用研究

目的 观察自体富血小板凝胶治疗糖尿病足溃疡（DFU）的疗效. 方法 72例DFU患者按照数字随机法分为两组.治疗组采用自体富血小板凝胶外敷;对照组采用常规疗法.比较两组DFU治愈率、好转率及愈合时间. 结果 两组间年龄、糖尿病病程、FPG、FIns、HbA1c、稳态模型评估胰岛素抵抗指数（HOMA-IR）、BMI、TG、TC、LDL-C、HDL-C、溃疡面积及溃疡体积比较差异均无统计学意义（P＞0.05）.两组Wagner Ⅰ级DFU治疗的疗效比较差异均无统计学意义（P＞0.05）.在WagnerⅡ、Ⅲ级DFU病例中,治疗组治愈率（66.7％、70.0％）、总有效率（94.4％、90.0％）均高于对照组（治愈率：26.3％、57.9％;总有效率：10.0％、30.0％）（P＜0.05）;治疗组Wagner Ⅰ～Ⅲ级DFU愈合时间均短于对照组[WagnerⅠ级：（14.75±1.82） vs （22.00±1.63）d;WagnerⅡ级：（27.12±2.15） vs （34.93±1.44）d;WagnerⅢ级：（41.89±3.22） vs （53.83±1.17）d] （P＜0.05）. 结论 自体富血小板凝胶可能具有促进DFU愈合的作用.     

自体富血小板凝胶治疗糖尿病足溃疡的疗效研究

目的探讨自体富血小板凝胶治疗糖尿病足溃疡的疗效。方法选取2013年12月—2015年8月于该院进行治疗的糖尿病足48例,将其中24例设为对照组,采取常规治疗,将另外24例设为观察组,在常规治疗的基础上采用自体富血小板凝胶治疗。治疗后对比对照组和观察组的疗效。结果观察组患者治疗总有效率为93.1%,对照组为72.4%,观察组明显较高,差异有统计学意义(P0.05)。观察组糖尿病足Wagner等级1-2级、3级、4级患者的溃疡愈合时间与对照组同等级患者相比,溃疡愈合时间明显较短,差异有统计学意义(P0.05)。观察组糖尿病足Wagner等级1~2级、3级、4级溃疡患者的治疗费用与对照组同等级患者对比,明显较少,差异有统计学意义(P0.05)。结论临床上治疗糖尿病足溃疡时采用自体富血小板凝胶疗法能明显提高患者的治疗总有效率,疗效显著,值得应用。     

双套管冲洗负压吸引技术在Ⅲ级糖尿病足患者伤口的应用

目的了解双套管冲洗负压吸引技术在Ⅲ级糖尿病足患者中应用的可行性。方法2011年1月至2012年2月,选取在我科住院确诊的Ⅲ级糖尿病足患者（均为单足）共36例,其中男15例、女21例,按随机数字表法分为试验组17例,年龄（63±8）岁;对照组19例,年龄（65±6）岁。对照组实施脓肿切开引流术后常规换药,试验组实施脓肿切开引流术后置人双套管持续冲洗吸引,至引流液澄清拔除双套管,采用常规换药,观察两组患者创面愈合情况。统计学分析采用卡方检验和t检验。结果试验组17例患者中,14例完全愈合,3例明显好转,治愈率达82．4％。对照组19例有8例治愈,8例好转,治愈率42．1％,差异有统计学意义（x^2=6．12,P〈0．05）。对照组3例经1个月换药等综合治疗后未见明显好转,其中包括2例在治疗期间病情恶化经截肢术处理。试验组患者创面愈合时间（20±3）d,对照组为（29±4）d,差异有统计学意义（t=6．5,P〈0．001）。结论双套管冲洗负压吸引技术可促进Ⅲ级糖尿病足患者伤口的愈合,减轻患者疼痛,并减少截肢的发生。     

前列腺素E1治疗糖尿病足疗效观察

目的：观察前列腺素E1治疗糖尿病足的疗效。方法：48例糖尿病足患者随机分成治疗组26例和对照组22例，治疗组给予前列腺素E1治疗。结果：治疗组治愈率、总有效率均明显高于对照组（P〈0．05），平均好转天数、平均治愈天数均明显短于对照组（P〈0．05）。结论：前列腺素E1是治疗糖尿病足安全有效的药物。     

前列腺素E1治疗糖尿病足疗效观察

目的观察前列腺素E1治疗糖尿病足的疗效.方法48例糖尿病足患者随机分成治疗组26例和对照组22例,治疗组给予前列腺素E1治疗.结果治疗组治愈率、总有效率均明显高于对照组(P＜0.05),平均好转天数、平均治愈天数均明显短于对照组(P＜0.05).结论前列腺素E1是治疗糖尿病足安全有效的药物.     

皮质醇分泌状态与糖尿病足溃疡程度及预后的相关性分析

目的 分析糖尿病足溃疡（DFU）严重性、感染程度与皮质醇分泌状态的关系,探讨糖尿病足病不同状态下垂体-肾上腺轴功能的差异及其对预后的影响.方法 选取2010年3月至2012年3月于上海交通大学医学院附属瑞金医院内分泌科住院的DFU患者188例以及同期住院DFU高危患者173例为研究对象,分别按照Wagner溃疡深度分级（Wagner 0～5级）和感染程度分级（无、轻度、中度及重度感染）,分组观察血浆促肾上腺皮质激素、08：00、16：00和24：00血浆皮质醇以及24 h尿游离皮质醇排出量与糖尿病足病严重性、感染程度的关系;随访3个月,观察不同皮质醇水平对愈合率的影响.采用ANOVA分析进行组间比较,各变量的变化趋势采用线性回归分析.结果 随着Wagner级别增加,08：00、16：00、24：00血浆皮质醇及24 h尿游离皮质醇水平不断上升（F=8.47、19.15、14.58、6.23,均趋势P＜0.05）;随着感染程度的加重,上述皮质醇指标也逐渐升高（F=4.98、11.26、5.95、3.79,均趋势P＜0.05）;Wagner各级及不同感染程度各组间血促肾上腺皮质激素水平差异无统计学意义（F=1.79、1.39,均趋势P＞0.05）;DFU患者体内皮质醇水平升高与溃疡愈合率降低密切相关,08：00血浆皮质醇及24 h尿游离皮质醇基线水平正常组、升高组和显著升高组3个月溃疡愈合率逐渐降低（x2 =3.09、9.56,均P＜0.05）.结论 DFU患者随着溃疡深度增加、感染加重,体内皮质醇水平逐渐升高,同时溃疡愈合率降低,提示皮质醇水平可作为判断DFU患者病情严重性的一个指标.     

股动脉置管持续微量动脉泵给药治疗糖尿病足病的疗效观察

目的 观察微量动脉泵持续股动脉输注前列地尔治疗糖尿病足病（DF）的疗效.方法 DF患者56例随机分为微量泵治疗组和对照组,治疗组给予微量泵持续股动脉输注前列地尔,对照组予静脉输注前列地尔,均持续3～7 d.观察两组冷感或红肿减轻例数及侧支循环建立例数.结果 治疗组病变肢体皮温升高多于对照组,比较差异有统计学意义[（2.52±0.70） vs （0.07±0.26）℃,t=17.61,P=0.002].治疗组患肢溃疡愈合情况好于对照组（P=0.001）.结论 微量动脉泵持续股动脉输注前列地尔治疗Foutain 3级及3级以上DF,可使患肢血管建立侧支循环,改善足部血供.     

小剂量尿激酶与前列腺素E1联合治疗糖尿病足观察

将47例糖尿病足患者随机分为治疗组和对照组，两组均给予糖尿病的基本治疗，治疗组24例在常规治疗的基本上加用小剂量尿激酶和前列腺素E1。结果治疗组治愈率、总有效率均明显高于对照组（P〈0．05）。结论小剂量尿激酶与前列腺素E1联合治疗糖尿病足具有明显疗效。     

The immunoneuroendocrine role of melatonin

Abstract: A tight, physiological link between the pineal gland and the immune system is emerging from a series of experimental studies. This link might reflect the evolutionary connection between self-recognition and reproduction. Pinealectomy or other experimental methods which inhibit melatonin synthesis and secretion induce a state of immunodepression which is counteracted by melatonin. In general, melatonin seems to have an immunoenhancing effect that is particularly apparent in immunodepressive states. The negative effect of acute stress or immunosuppressive pharmacological treatments on various immune parameters are counteracted by melatonin. It seems important to note that one of the main targets of melatonin is the thymus, i.e., the central organ of the immune system. The clinical use of melatonin as an immunotherapeutic agent seems promising in primary and secondary immunodeficiencies as well as in cancer immunotherapy. The immunoenhancing action of melatonin seems to be mediated by T-helper cell-derived opioid peptides as well as by lymphokines and, perhaps, by pituitary hormones. Melatonin-induced-immuno-opioids (MHO) and lymphokines imply the presence of specific binding sites or melatonin receptors on cells of the immune system. On the other hand, lymphokines such as -γ-interferon and interleukin-2 as well as thymic hormones can modulate the synthesis of melatonin in the pineal gland. The pineal gland might thus be viewed as the crux of a sophisticated immunoneuroendocrine network which functions as an unconscious, diffuse sensory organ.     

Changes in connexin43, the gap junction protein of astrocytes, during development of the rat pineal gland

Abstract: The abundance of gap junctions between rat pineal astrocytes formed by connexin43 (Cx43) was studied during development. Levels and distribution of Cx43 were measured by immunoblotting and indirect immunofluorescence, respectively. The amount of Cx43 in cells located within the gland was low until about the 7th postnatal day and increased to adult values between the 14th and 21st days postpartum. Although astrocytes, recognized by their vimentin immunoreactivity, were scarce before birth, they were abundant by the 7th postnatal day suggesting that the low levels of Cx43 found at this age corresponded to a low expression of this protein. Localization of the immunoreactivity to Cx43 and vimentin showed a close correlation, indicating that mature or immature pineal astrocytes form gap junctions made of Cx43. Since Cx43 levels attained their adult values at about the time the innervation and the functional state of the gland reached maturity (2–3 weeks after birth), it is proposed that astrocyte gap junctions are involved in the function of the adult rat pineal gland.     

Response of rat pineal melatonin to calcium, magnesium, and lithium is circadian stage dependent

Abstract: Herein we documented the response of pineal melatonin production to electrolytes known to be effective on pineal function in view of a possible circadian stage dependence. We studied the release of melatonin by perifused rat pineal glands at 2 different circadian stages corresponding to the middle of the light and dark periods, i.e., respectively, 7 and 19 HALO (Hours After Light Onset, L:D = 12:12). The initial efflux rates were, as expected, much higher in the perifusates of glands removed from rats sacrificed during the dark phase than of those removed during the light phase. After 3 hr of perifusion, melatonin release reached similar levels which were found constant up to the 8th hr of perifusion, whatever the circadian stage. Perifusion of the glands with physiological concentrations for the rat of calcium (5.2 mmol/1) and magnesium (1.34 mmol/1) resulted in a stimulatory effect on the pineal glands removed from rats sacrificed in the middle of the dark period (19 HALO), whereas no effects were observed on the pineal glands removed from rats sacrificed during the light (7 HALO). Lithium (0.28 and 0.55 mmol/1) was ineffective on melatonin release in pineal glands removed 7 and 19 HALO. Our results show differences in the initial efflux rates of melatonin and in the response of perifused pineal glands to calcium and magnesium according to the circadian stage.     

Conservative management of perforated duodenal diverticulum： A case report and review of the literature

Duodenal diverticula are a relatively common condition. They are asymptomatic, unless they become complicated, with perforation being the rarest but most severe complication. Surgical treatment is the most frequently performed approach. We report the case of a patient with a perforated duodenal diverticulum, which was diagnosed early and treated conservatively with antibiotics and percutaneous drainage of secondary retroperitoneal abscesses. We suggest this method could be an acceptable option for the management of similar cases, provided that the patient is in good general condition and without septic signs.     

Presence of immunoreactive growth hormone and prolactin in the ovine pineal gland

Abstract: The use of antisera raised against bovine growth hormone (GH) and ovine prolactin (PRL) enabled the detection of related immunoreactive (ir) sequences of proteins in ovine pineal tissue. The isolation of PRL-like ir-material was accomplished using a 0.25 M ammonium sulphate (pH 5.5) extraction followed by ethanol precipitation, whereas the resulting 2.0 M ammonium sulphate (pH 7.0) precipitate contained a GH-like immunoreactivity. Gel chromatography of the GH-like immunoreactivity (Sephadex G-100) indicated the presence of several GH-like fragments ranging in the M_r range of 7,000 to 55,000. Analyses of the PRL-like ir-material found in pineal tissue on HPLC using a TSK 545-DEAE column led to the resolution into a single peak of immunoreactivity. A single peak of activity was also observed following chromatofocusing and hydrophobic interaction chromatography of the ir-peak from the TSK 545-DEAE column. The PRL-like ir-material inhibited the binding of [¹²⁵I]ovine PRL-S14 to anti-ovine PRL antibodies without showing an affinity for binding to anti-rat PRL or anti-bovine GH antibodies. Scatchard analysis of the binding of pineal PRL-like ir-material and pituitary ovine PRL-S14 to liver membranes from day-20 pregnant rats revealed similar affinity constants (K_a of 4.7 ± 0.2 × 10⁹ M^-1). In addition, the replication of Nb 2 Node rat lymphoma cells was stimulated by pineal PRL-like ir-material, an effect known to be specific for lactogenic hormones. The pineal PRL-like immunoreactivity appeared on sodium dodecyl sulfate polyacrylamide gels as a single major band of M_r 24,000. The functional status of PRL-and GH-like ir-material in the ovine pineal remains to be determined, but evidence is presented that the overall protein synthesis rate of the rat pineal responded to circulating concentrations of PRL.     

Microbiology of human immunodeficiency virus anorectal disease

PURPOSE: Individuals who are seropositive for the human immunodeficiency virus are at high risk for opportunistic infection and anorectal disorders. Little prospective information is available regarding anorectal pathogens in these patients. METHODS: One hundred sixty-three HIV-seropositive patients presented to the colorectal clinic between 1989 and 1992. Forty-seven (29 percent) patients were thought to have an infectious process and were prospectively studied using a standardized multiculture protocol. RESULTS: Mean age was 33 (range, 19–59) years. All were male; high-risk behavior accounted for 87 percent of HIV transmissions. Presenting complaints included anorectal pain (79 percent), pus per anum (28 percent), and blood per anum (26 percent). Examination revealed perianal tenderness (60 percent), condyloma (38 percent), perianal ulcers (38 percent), and anal fissures (34 percent). Sixty-six sets of cultures were performed; 28 patients had one set, 15 had two sets, and 4 had three sets. Thirty-two of these 47 patients (68 percent) had positive cultures including herpes (50 percent), cytomegalovirus (25 percent),Neisseria gonorrhoeae (16 percent), chlamydia (16 percent), acidfast bacilli (2 percent), and others (9 percent). Six of 32 patients with positive cultures had more than one organism cultured. Sixteen (50 percent) patients with positive cultures were treated medically, 8 (25 percent) were treated surgically and 8 (25 percent) were treated with both modalities. Sixty-one procedures were performed on 17 patients for condylomata. Eighteen patients had 20 procedures for abscesses, 50 percent of whom had positive cultures for other than common bowel flora; all improved. Fourteen patients underwent 33 procedures for perianal fistulas.Mycobacterium fortuitum was cultured from one patient who required 13 procedures for abscesses and fistulas. Forty-five (96 percent) patients were followed for an average of 12.5 months ±2.9 SEM (range, 1–94 months). Symptoms were improved or resolved in 22 of 32 (69 percent) patients with positive cultures and in 11 of 13 (84 percent) with negative cultures. CONCLUSIONS: Specific pathogens may often be identified in human immunodeficiency virus-seropositive patients with anorectal disorders if aggressively sought. Although patients without specific pathogens identified may be expected to improve with planned empiric treatment, positive identification allows more directed therapy.