肿瘤坏死因子-α与糖尿病肾病

肿瘤坏死因子（TNF）-α是重要的炎症因子,近来越来越多的证据显示其在糖尿病肾病（DKD）的发生发展中起重要作用。实验与临床研究均已经证实,TNF-α在DKD中通过多种机制产生。肾脏损伤,而且其活性调节的潜在益处已作为目前临床治疗的一个策略。     

Normal parathyroid hormone levels in a diabetic patient with parathyroid adenoma

Objective The incidence of diabetes mellitus in patients with primary hyperparathyroidism and, conversely, primary hyperparathyroidism in diabetic patients are approximately threefold higher than the respective expected prevalence in the general populace. The diagnosis is straightforward when the patient presents hypercalcemia and inappropriately elevated serum parathyroid hormone (PTH) levels. We report a case of parathyroid adenoma in a diabetic patient with persistent hypercalcemia and normal PTH levels. Patient A 50-year-old female patient who was referred to our outpatient clinic presented with persistent hypercalcemia (serum Ca levels between 10.5 and 11 mg/dl) with a normal serum intact PTH level of 46.1 pg/ml. Her blood pressure was 120/80 mmHg, and she was being treated with antihypertensive therapy. Her HbA1c was 7.2%, and her triglycerides were in the normal range. A bone densitometry exam revealed osteopenia of radius −1.39, femoral neck −1.39, and the total hip −1.04. A neck ultrasound revealed a mass of 13 mm next to the inferior and posterior of the right thyroid lobe. A dual phase Tc-99m-sestamibi scan revealed an area of increased uptake in the same region, which is indicative of a parathyroid adenoma. The parathyroid adenoma was removed, which resulted in the achievement of normocalcemia. Conclusion Diabetic patients should be evaluated for hyperparathyroidism as associated hypertension can complicate the course of the disease. These patients should be evaluated for primary hyperparathyroidism when they exhibit persistent hypercalcemia and when clinical suspicion is aroused even if the serum PTH levels are within the normal range.     

Early results of a rotational flap to treat chronic anal fissures

Background Treatment of anal fissures has changed dramatically in the past decade. Only a few fail to respond to medical therapy. Sphincterotomy and anal dilatation have fallen out of favour due to the risk of incontinence. Island flaps have been proposed to address this, but 60–70% of flap donor sites break down with complications. We proposed that using a rotational flap would overcome this problem.Methods Twenty-one patients (14 women,7 men) with chronic anal fissures were treated with rotation flap from perianal skin. The median age was 43 (range 21–76) years. All patients had failed chemical sphincterotomy and showed no signs of improvement following at least a 3-month course of topical GTN 0.2% ointment.Results The median hospital stay was 2 days. Seventeen patients had complete resolution of symptoms. Only one patient continued to have severe pain. Two developed a recurrent fissure. One patient had a combined fistula–fissure complex at diagnosis and suffered from a breakdown of the flap and donor site. Another patient had had haemorrhoidectomy and an advancement flap in the past. He developed problems with the donor site, which was successfully managed conservatively. One patient had persistent mild pain after surgery, but the cause could not be found. None of the patients suffered continence defects after surgery.Conclusion Use of a rotational flap is a simple, safe and successful treatment for anal fissures. Donor site problems are minimised using this approach. It should be a treatment of choice when surgery is required for chronic anal fissures, particularly in patients in whom there is a risk of incontinence.These are the results of the initial ten cases presented as a poster at the annual meeting of The Association of Coloproctology of Great Britain and Ireland, July 2003. The abstract was published in Colorectal Disease, 5 [Suppl 1]:73, July 2003. Poster presentation at the British Society of Gastroenterology meeting, Glasgow, March 2004. The abstract was published in Gut, A66 [Suppl 3:53, April 2004. Oral presentation at the Association of Surgeons of Great Britain and Ireland meeting, 28–30th April 2004. The abstract was published in Br J Surg 91(1), May 2004.     

糖尿病性骨质疏松的影响因素

糖尿病系全身性代谢紊乱性疾病,不仅包括碳水化合物、蛋白质和脂肪的代谢异常,而且也涉及骨矿物质代谢异常.糖尿病性骨质疏松易致骨折,伤残率高,严重威胁人类的健康.研究发现,糖尿病患者骨代谢异常由多种原因导致,包括胰岛素水平异常、高血糖、晚期糖基化终末产物增多及微血管并发症等.     

Pituitary necrosis in diabetes mellitus

Summary Adenohypophysial necrosis occurred approximately 4.5 times more frequently in patients with diabetes mellitus than in non-diabetics. A higher incidence of necrosis was especially apparent in males belonging to the older age group with mild, maturity-onset diabetes mellitus. Histologically, the anterior lobes of diabetics did not markedly differ from those of non-diabetics. The pituitary lesions in both groups corresponded to ischemic infarction resulting from suppression of blood flow to the anterior lobe. The cause of the circulatory arrest has yet to be elucidated. It was remarkable that more than 50 % of the diabetic patients received insulin for the first time a few days before death. This finding is consistent with the results of certain animal experiments and suggests that insulin hypoglycaemia, or some other related mechanism, predisposes the individual to adenohypophysial infarction.

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Zusammenfassung Hypophysenvorderlappen-Nekrose wurde bei Patienten mit Diabetes mellitus etwa 4,5mal häufiger beobachtet als bei Nichtdiabetikern. Eine vermehrte Häufigkeit der Nekrose fiel besonders bei männlichen Patienten der höheren Altersgruppen mit leichtem Altersdiabetes auf. Histologisch unterschieden sich die Vorderlappen der Diabetiker nicht wesentlich von denen der Nichtdiabetiker. Die Läsion der Hypophyse bei beiden Gruppen bestand in ischämischem Infarkt infolge Drosselung der Blutzufuhr zum Vorderlappen. Die Ursache dieser Zirkulationsstörung bleibt noch zu klären. Es fällt auf, daß über 50 % der Diabetiker wenige Tage vor ihrem Tode zum ersten Mal Insulin erhalten hatten. Diese Beobachtung deckt sich mit den Ergebnissen gewisser Tierexperimente und legt die Hypothese nahe, daß der durch Insulin verursachte Abfall des Blutzuckers oder ein anderer damit zusammenhängender Mechanismus als prädisponierender Faktor den Infarkt der Adenohypophyse begünstigt.

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Resumen Confrontando individuos afectos de diabetes mellitus con otros no diabéticos, se ha podido observar que la frecuencia de la necrosis adenohipofisaria es 4,5 veces mayor en los diabéticos que en los sanos. Sobre todo en los individuos de sexo masculino pertenecientes al grupo de edad más anciano con diabetes de la edad madura, de leve entidad, se ha observado una frecuencia de la necrosis todavía más alta. Desde el punto de vista histológico, entre el lóbulo anterior de los diabéticos y el de los no diabéticos, no se advertían notables diferencias. En ambos grupos las lesiones hipofisarias consistían en un infarto isquémico debido a la supresión de la irroración del lóbulo anterior. La causa de la interrupción circulatoria todavía no ha sido aclarada. Es muy singular el hecho de que más del 50 % de los diabéticos fueron tratados con insulina por vez primera unos días antes de la defunción. Ese elemento coincide con los resultados de algunos experimentos llevados a cabo en animales y da lugar a que se pueda suponer que la hipoglicemia insulínica o algún mecanismo distinto en relación con ella, predisponga al individuo al infarto de la adenohipófisis.

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Résumé La nécrose adénohypophysaire a été fréquemment vérifiée environ 4 à 5 fois plus grande chez des patients atteints de diabète mellite que les individus non-diabétiques. On a vérifié une incidence plus forte de la nécrose notamment chez les individus de sexe masculin appartenant au groupe d'âge le plus élevé, atteint d'une légère forme de diabète de l'âge mûr. Au point de vue histologique, entre le lobe antérieur des diabétiques et celui des non-diabétiques n'existait aucune différence importante. Dans les deux groupes, les lésions hypophysaires consistaient en un infarctus ischémique dû à la suppression de l'irroration du lobe antérieur. La cause de l'arrêt circulatoire n'a été pas encore éclaircie. Il est important d'observer que plus de 50 % des diabétiques avaient été traités avec insuline pour la première fois quelques jours avant leur décès. Ce rapport confirme les réusultatts de certaines expériences faites sur l'animal et laisse croire que l'hypoglycémie insulinique ou quelques autres mécanismes en relation avec elle prépare l'individu à l'infarctus de l'adénohypophyse.

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Riassunto La necrosi adenoipofisaria è stata osservata con frequenza circa 4,5 volte maggiore in pazienti affetti da diabete mellito che in soggetti non diabetici. Una più elevata incidenza di necrosi è stata riscontrata specialmente in individui di sesso maschile appartenenti al gruppo di età più anziano, con diabete dell'età matura di lieve entità. Dal punto di vista istologico, tra il lobo anteriore dei diabetici e quello dei non-diabetici non vi erano notevoli differenze. In entrambi i gruppi, le lesioni ipofisarie consistevano in un infarto ischemico dovuto alla soppressione dell'irrorazione del lobo anteriore. La causa dell'arresto circolatorio non è stata ancora chiarita. Notevole il fatto che più del 50 % dei diabetici fossero stati trattati con insulina per la prima volta qualche giorno prima del decesso. Questo reperto concorda con i risultati di alcuni esperimenti condotti nell'animale e fa ritenere che l'ipoglicemia insulinica o qualche altro meccanismo in rapporto con essa predisponga l'individuo all'infarto dell'adenoipofisi.

     

Cardiorespiratory arrest in a patient with advanced diabetic autonomic neuropathy

A 53-year-old diabetic woman who had been diabetic for 14 years had recurrent episodes of cardiorespiratory arrest, which were easily resuscitated by a few chest massages. In 2 of 4 episodes a radial pulse was detected, so respiratory arrest was thought to be a primary event. Pentazocine was injected several hours prior to each of the 3 episodes. This was considered to be a precipitating factor. From the first episode of cardiorespiratory arrest, she received oxygen inhalation. When oxygen inhalation was withdrawn for 5-10 min, she became cyanotic. This was considered to be a sign of lack of hypoxic drive mediated by peripheral chemoreceptors. Ventilatory responses to hypercapnia was markedly decreased, indicating impaired central chemosensitivity. The possibility that impaired chemosensitivity could be a cause of respiratory arrest was suggested.     

Superior mesenteric artery syndrome in a diabetic patient with acute weight loss

Superior mesenteric artery (SMA) syndrome is an uncommon disease resulting compression of the third portion of the duodenum from the superior mesenteric artery. This disease shares many common manifestations with diabetic gastroparesis, including postprandial fullness, nausea, vomiting, and bloating. Therefore, it is often overlooked in diabetic patients. Here, we report a 41-year-old man with poorly controlled diabetic mellitus who developed SMA syndrome due to rapid weight loss. The diagnosis was confirmed by computed tomography and an upper gastrointestinal series. His condition improved after parenteral nutrient, strict sugar control, and gradual weight gain.     

Acute esophageal necrosis after cellulitis in an obese patient with diabetes mellitus

A 59‐year‐old obese Japanese man with poorly controlled type 2 diabetes mellitus presented with severe heartburn for 3 days after inguinal cellulitis and exacerbated glycemic control, without any signs of upper gastrointestinal bleeding. The patient had a high plasma glucose level (34.0 mmol/L) and was dehydrated. Emergent esophagogastroduodenoscopy showed black discoloration predominantly affecting the lower esophagus; thus, acute esophageal necrosis (AEN) was diagnosed. This black discoloration was not present on esophagogastroduodenoscopy 20 days prior to presentation, and disappeared 6 days after conservative treatment. To conclude, acute esophageal necrosis should be considered if a patient in marked hyperglycemic status presents with unendurable heartburn, even when upper gastrointestinal bleeding is not observed or recent esophagogastroduodenoscopy was unremarkable.     

糖尿病患者血浆肿瘤坏死因子的变化

用生物活性法测定了４４例糖尿病患者血浆ＴＮＦ－α水平，并与２０倒正常健康人进行了比较。结果发现：４４例糖尿病患者ＴＮＦ－α水平显著升高。糖尿病患者中，血糖控制越差者，病程越长者，ＴＮＦ－α水平越高。伴有血管并发症的糖尿病患者ＴＮＦ－α水平明显高于不伴有血管并发症者。作者对ＴＮＦ－α与糖尿病血管并发症的关系进行了讨论。     

链脲佐菌素所致糖尿病大鼠骨髓中存在胰岛样细胞

本研究证实糖尿病大鼠骨髓中存在表达胰岛素、C肽、胰高血糖素、生长抑素和胰淀粉样多肽的细胞簇，并检测到胰岛发育和功能相关基因的表达，这些胰岛样细胞可能是骨髓中的成体干细胞转分化而来。     

Ketoalkalosis as a result of triple derangement of acid-base equilibrium in a diabetic patient

Summary A diabetic patient presented with weight loss, ketosis, and hyperventilation, thus mimicking the clinical picture of diabetic ketoacidosis. Laboratory investigations revealed alkalemia and a pattern consistent with a triple derangement of acid-base equilibrium: respiratory alkalosis, metabolic acidosis and metabolic alkalosis. High cortisol level suggested a genesis of ketosis different from diabetes mellitus. The patient died suddenly from acute gastrointestinal bleeding. Autopsy showed a carcinoma of the head of the pancreas with secondary portal hypertension and rupture of varices. Pulmonary micrometastases were demonstrated. It is suggested that stress hormones were the main cause of the ‘ketoalkalotic’ pattern observed.     

Lower extremities and iliopsoas pyomyositis with concurrent septic arthritis and spinal epidural abscess in a diabetic patient

Pyomyositis is a rarely encountered infection among diabetics, which usually affects lower extremities. Herein, we present a case of lower extremities and iliopsoas pyomyositis with concurrent septic arthritis and spinal epidural abscess in a patient with poorly controlled diabetes mellitus.     

Regression of skin lesions of Kyrle's disease with metronidazole in a diabetic patient

We describe here in a case of a 41-year-old man, with diabetes mellitus, who presented manifestations of Kyrle's disease. Administration of metronidazole, 500 mg twice daily for 1 month, resulted in complete regression of skin lesions with no recurrence during 12 months of follow-up. This successful antibiotic treatment is to support the role of infectious agents (anaerobic bacteria) in the pathogenesis of Kyrle's disease.     

2型糖尿病患者与正常人骨密度的比较

目的　探讨2型糖尿病(T2DM)患者的骨密度(BMD)是否低于正常人。　方法　肾功能正常的T2DM患者615例,与同一地区1116名正常人的BMD比较。　结果　(1)女性 T2DM患者各年龄组腰椎和股骨Ward区的BMD均与正常人近似; 男性 T2DM患者 40 岁和 60 岁以上年龄组腰椎和股骨Ward区的BMD与正常人近似,但是50岁和70岁以上年龄组高于正常人(P<0.05)。(2)多元线形回归分析显示,影响女性T2DM患者 BMD的因素为年龄、体质指数(BMI)和总胆固醇水平,而影响男性T2DM患者的 BMD的因素为 BMI和餐后胰岛素水平。　结论　肾功能正常的T2DM患者的BMD不比正常人低。     

Tumour necrosis factor-beta polymorphism is unlikely to determine susceptibility to Type 1 (insulin-dependent) diabetes mellitus

Summary Tumour necrosis factor gene polymorphism has been proposed as a determinant of Type 1 (insulin-dependent) diabetes mellitus. Tumour necrosis factor-beta gene polymorphisms were analysed in 40 North Indian Asian Type 1 diabetic patients and 63 control subjects. A 5.5 kilobase gene fragment was significantly increased among the patients (82.5% vs 52%, p _c<0.01). A 10.5 kilobase fragment was significantly reduced among the patients (70% vs 90.5%, p _c<0.02). The 5.5 kilobase fragment was associated with DR3, and was not significantly increased among DR3-positive patients compared with DR3-positive control subjects. The 5.5 kilobase/5.5 kilobase genotype was increased among the diabetic subjects (30% vs 9.5%, p _c<0.03). The 10.5 kilobase/10.5 kilobase genotype was reduced among the diabetic subjects (17.5% vs 47.5%, p _c<0.02). The 5.5 kilobase/10.5 kilobase genotype was not significantly associated with disease. These findings contrast with those in a white Caucasian population, suggesting that tumour necrosis factor-beta polymorphisms do not predispose to Type 1 diabetes directly, but are in linkage disequilibrium with disease susceptibility alleles at other MHC loci.     

胰岛素-吡格列酮治疗糖尿病继发磺脲类药失效的研究

目的:比较胰岛素加吡格列酮(INS Pio)和单用胰岛素(INS)对继发磺脲类(SU)失效的2型糖尿病患者的疗效。方法:52例继发性SU失效的2型糖尿病患者随机分二组,分别给INS Pio及单纯INS治疗共3个月。结果:(1)治疗3个月时两组的血糖、糖化血红蛋白(HbA1 c)得到较好控制(P<0．05);(2)INS Pio组治疗后血脂明显改善(_P<0．05);(3)INS组较INS Pio组体重显著增加、血INS水平明显升高(P<0．05)。结论:(1)胰岛素 Pio与胰岛素均可有效地治疗继发磺脲类药失效2型糖尿病患者;(2)与单用胰岛素治疗比较,胰岛素联合Pio 治疗改善高胰岛素血症、血脂异常效果更佳,并可减少胰岛素用量。     

Insulin as an amyloid-fibril protein at sites of repeated insulin injections in a diabetic patient

Summary A patient with Type 1 (insulin-dependent) diabetes mellitus developed localised amyloidosis at the sites of his injections of porcine insulin. A major amyloid fibril protein was extracted and, by means of its amino acid composition and amino acid sequence, it was shown to contain intact insulin molecules. Porcine insulin is the tenth protein and the first foreign protein to be chemically identified in human amyloid fibrils.     

维生素D抗炎机制对糖尿病大鼠骨代谢的影响

目的 探讨活性维生素D3对糖尿病大鼠炎症因子及骨代谢指标的影响.方法 6～8周龄雄性SD大鼠30只,链脲佐菌素诱导建立糖尿病大鼠模型.将糖尿病大鼠分为2组：糖尿病组、维生素D组.选取健康同龄大鼠10只作为正常对照组.维生素D组给予1,25（OH）2D3（0.1μg·kg＾-1·d＾-1）溶于0.05 ml花生油灌胃,正常对照组及糖尿病组给予花生油0.05 ml/d灌胃.12周后处死各组大鼠,测定血清白介素17（IL-17）、钙、磷、骨钙素、24 h尿钙、24 h尿白蛋白（UAlb）水平;免疫组化法检测肾皮质内IL-17的表达;荧光定量RT-PCR检测骨组织骨钙素mRNA表达水平.结果 （1）糖尿病组24 h尿钙、24 hUAlb显著高于正常对照组[分别为（0.31±0.18）比（0.01±0.01） mmol/24 h、（1.15±0.13）比（0.43±0.09） mg/24 h,t值分别为5.125、13.948,均P＜0.05];维生素D组24 hUAlb显著低于糖尿病组[（0.82±0.13）比（1.15±0.13） mg/24 h,t=-5.798,P＜0.05].（2）与正常对照组、维生素D组相比,糖尿病组血清IL-17、肾皮质IL-17表达显著升高[分别为（494±28）比（137±18）、（250±20）pg/ml,（165.0±7.0）比（81.9±5.6）、（119.1±6.6）,t值分别为34.229、-23.263、29.238、-15.475,均P＜0.05].（3）与正常对照组、维生素D组相比,糖尿病组血清骨钙素、骨组织骨钙素mRNA表达显著降低[分别为（485±123）比（752±239）、（621±161）pg/ml,（19.8±2.9）比（24.1±2.9）、（22.9±3.1）,t值分别为-3.147、2.158、-3.220、2.265,均P＜0.05].（4）血清IL-17与血清骨钙素呈负相关（r=-0.544,P＜0.05）.结论 维生素D可抑制糖尿病大鼠IL-17等炎症因子的表达,改善骨代谢.     

2型糖尿病动脉粥样硬化与巨细胞病毒感染及内皮素、肿瘤坏死因子的相关性研究

目的　 (1)从流行病学的角度观察人类巨细胞病毒 (HCMV)与 2型糖尿病 (T2 DM)动脉粥样硬化 (AS)的关系 ;(2 )了解血浆内皮素 (ET)、血清肿瘤坏死因子 (TNF- α)在 T2 DM AS发生、发展中的作用及 HCMV感染与 ET、TNF- α的关系。　方法　采用酶联免疫吸附法测定 T2 DM中有 AS患者 2 1例 ,无明显 AS患者 4 7例及正常对照组 2 0例血清 HCMV抗体 Ig M和 Ig G。用放免法测定血清 TNF- α和血浆 ET的浓度。　结果　 (1) T2 DM患者的 HCMV感染率 [阳性率 Ig G为 93% (6 3/ 6 8)、Ig M为 4 6 %(31/ 6 8) ]高于正常人群 [阳性率 Ig G为 80 % (16 / 2 0 )、Ig M为 10 % (2 / 2 0 ) ],检测抗 HCMV- Ig M(抗 Ig M作为活动性感染或潜伏感染活化指标 )更有意义 (P<0 .0 1)。T2 DM患者 ET的浓度 (6 8.6 8± 17.12 ) ng/L 和 TNF- α的浓度 (1.79± 0 .4 3) μg/ L,也高于正常人 [(49.0 4± 14 .36 ) ng/ L、(1.32± 0 .4 1) μg/ L,P均 <0 .0 0 1]。 (2 ) T2 DM伴有 AS患者中 ,活动性或潜伏感染活化 HCMV感染率 (Ig M阳性率 5 7% )和血浆 ET[(86 .77± 15 .19) ng/ L]、血清 TNF- α[(2 .0 1± 0 .4 5 ) μg/ L]的水平高于不伴有 AS的 T2 DM患者 [Ig M阳性率 4 0 % ,ET为 (6 0 .5 9± 10 .4 9) ng/ L,TNF- α为 (1.6 8