缺血性脑血管病的循证治疗

目的 借助循证医学的方法为初诊缺血性脑血管病患者确定治疗目标及治疗方案.方法 在充分评估患者情况后,提出临床问题,从Cochrane 图书馆(2010年第3期) 、Medline( PubMed 网站2001年1月-2010年2月) 和EMBASE(2001年1月～2010年2月).检索主题词为:lipid management; hypertension management;hyertension therapy;Antiplatelet therapy;Clopidogrel;aspirin;cerebral infarction;brain infarction;cerebral ischemia; RCT;human; mate-analysis; systematic review.结果 共检索出多个问题相关的随机对照试验84篇,系统评价或Meta-分析25篇.通过对检索结果进行分析,为患者制定了合理的治疗方案.经半年随访证实,该方案适合患者.结论 采用循证治疗的方法,为缺血性脑卒中患者确定合理的治疗目标和治疗方案,可有效提高治疗效果.     

还原型谷胱甘肽联合川芎嗪治疗酒精性肝病疗效观察

观察还原型谷胱甘肽联合川芎嗪治疗酒精性肝病的疗效。方法将62例酒精性肝病患者随机分为2组,对照组31例患者给予还原型谷胱甘肽1.2g静脉点滴,每天一次,30d为1疗程;治疗组31例患者在此基础上加用川芎嗪120mg静脉点滴,每天1次,30d为1疗程。观察两组患者肝功能、血清肝纤维化指标。结果治疗30d后,两组患者肝功能指标改善,血清肝纤维化指标明显下降(均P<0.05),治疗组疗效优于对照组(P<0.05)。结论还原型谷胱甘肽联合川芎嗪治疗酒精性肝病,疗效显著,且无不良反应发生。     

利拉鲁肽联合达格列净治疗肥胖2型糖尿病合并蛋白尿患者1例

报道1例在济南市莱芜人民医院内分泌科住院的肥胖2型糖尿病合并蛋白尿、非酒精性脂肪性肝病患者通过利拉鲁肽联合达格列净治疗的经过。患者为40岁男性, 因发现血糖升高5年, 尿蛋白1周入院。患者身高170 cm, 体重107 kg, 体重指数37.02 kg/m2, 入院时随机血糖17.4 mmol/L, 尿蛋白(2+), 伴肝功能轻度受损, 入院后完善各项辅助检查, 2型糖尿病诊断明确, 同时合并糖尿病肾脏病、非酒精性脂肪性肝病、肥胖症。住院期间给予利拉鲁肽注射液(0.6～1.2 mg、1次/d)、达格列净片(10 mg、1次/d)、盐酸二甲双胍缓释片(1 g、2次/d)联合胰岛素强化方案降糖, 血糖控制平稳后停用胰岛素, 院外调整为利拉鲁肽注射液(1.2 mg、1次/d)联合达格列净片(10 mg、1次/d)、盐酸二甲双胍缓释片(1 g、2次/d)治疗, 患者血糖控制好转。6周后门诊复查血糖控制良好, 体重下降、蛋白尿减少、肝功能改善, 患者治疗效果满意。     

美他多辛治疗酒精性肝病临床研究

目的探讨美他多辛治疗酒精性肝病临床价值,以期能为酒精性肝病的治疗提供参考。方法选取100例酒精性肝病患者为研究对象,嘱戒酒基础上给予美他多辛500 mg/次,口服,3次/d,连续服药治疗8周。观察患者治疗前后丙氨酸氨基转移酶(ALT)、天冬氨酸氨基转移酶(AST)、γ-谷氨酰转肽酶(GGT)、甘油三酯(TG)、总胆固醇(TC)、白球蛋白比率(A/G)变化及治疗期间药物不良反应发生情况。结果两组患者治疗前ALT、AST、GGT、TG、TC、A/G比较,差异无统计学意义(P0.05);治疗后ALT、AST、GGT、TG、TC均较治疗前明显下降,A/G较治疗前升高;治疗前后组内比较,差异具有统计学意义(P0.05),观察组较对照组改善更为明显(P0.05);疗效评定:以生化指标进行疗效评定,观察组总有效率为82.00%,对照组总有效率为40.00%,对脂肪肝患者超声影像学检查结果进行评定,观察组总有效率为45.71%,对照组总有效率为19.44%,两组生化指标总有效率、超声影像学总有效率比较,差异具有统计学意义(P0.05)。结论美他多辛治疗酒精性肝病能明显改善肝功能及降低血脂,无严重不良反应,可用于治疗酒精性肝病。     

终末期肝病模型评分的临床应用

终末期肝病模型(MELD)是由美国著名肝病中心Mayo Clinic的Malinchoc等[1]在2000年提出的.为了寻找比CTP分级更能准确评估TIPS术后患者生存期的方法,他们选择为治疗肝硬化腹水和预防门静脉高压出血进行TIPS术的患者,用Cox比例风险回归的统计学模型确定了能较好判断患者3个月生存期的4项实验室和临床指标,包括血清肌酐、胆红素、凝血酶原时间的国际标准化比值(INR)和病因,由这四个指标的回归系数组成死亡风险预测公式:R=0.957×loge(肌酐mg/d1) 0.378×loge(胆红素mg/d1) 1.12×loge(INR) 0.643(病因:胆汁淤积性和酒精性肝硬化为0,其他原因为1).此后Kamath又进行了改良,将公式的各系数均乘以10,即R=9.6×loge(肌酐mg/d1) 3.8×loge(胆红素mg/d1) 11.2×loge(INR) 6.4(病因),结果取整数.随后选取4组独立的肝硬化患者资料进行分析验证,发现该公式能较好地预测各组患者的3个月生存期,故将此公式命名为"终末期肝病模型",即MELD[2].通过两年时间的验证,发现MELD某些方面优于传统CTP分级,该模型逐渐推广到肝移植和晚期肝病患者预后的判断,并最终于2002年起由美国器官分配联合网络(UNOS)采纳为成人肝移植的新标准.     

非酒精性脂肪性肝病诊疗指南(2010年修订版)

非酒精性脂肪性肝病(NAFLD)是一种与胰岛素抵抗(insulin resistance,IR)和遗传易感密切相关的代谢应激性肝脏损伤,其病理学改变与酒精性肝病(ALD)相似,但患者无过量饮酒史,疾病谱包括非酒精性单纯性脂肪肝(nonalcoholic simple fatty liver,NAFL)、非酒精性脂肪性肝炎(NASH)及其相关肝硬化和肝细胞癌~([1-2]).NAFLD是21世纪全球重要的公共健康问题之一,亦是我国愈来愈重视的慢性肝病问题~([3]).为进一步规范NAFLD的诊断和治疗,中华医学会肝病学分会脂肪肝和酒精性肝病学组组织有关专家,在参考国内外最新研究成果和相关诊疗共识的基础上~([4-9]),按照循证医学的原则,对2006年制定的<非酒精性脂肪性肝病诊疗指南>"~([10])进行更新.其中推荐的意见所依据的证据等级共分为3个级别5个等次~([11]),文中以括号内罗马数字表示.     

还原型谷胱甘肽治疗酒精性肝病临床疗效观察

观察还原型谷胱甘肽 (阿拓莫兰 )对酒精性肝病的保肝、降酶、退黄等的临床疗效。 73例酒精性肝病患者随机分为还原型谷胱甘肽治疗组 38例 (阿拓莫兰注射液 12 0 0mg/d 丹参、维生素C、肌苷注射液静滴 ) ,对照组 35例 (丹参、维生素C、肌苷注射液静滴 ) ,疗程 30天 ,分别观察两组治疗 1月后ALT、AST、GGT、TBil、TBA等肝功能恢复情况及症状改善情况。治疗组治疗后ALT、AST、TBil、GGT、TBA值较前明显下降 (P <0 0 5 ) ,其下降幅度大于对照组。还原型谷胱甘肽治疗酒精性肝病疗效较好 ,且安全可靠     

非酒精性脂肪性肝病治疗进展与现状

正目前对非酒精性脂肪性肝病(NAFLD)尚无特效治疗方法,仍在不断探索研究中。基因治疗近年也许会有新的突破。当前的治疗包括改变生活方式、饮食治疗、运动与锻炼、药物治疗和减重手术等几个方面。上述治疗方法经实践证实对NAFLD患者都有不同程度的改善和治疗作用。2015年日本胃肠病学会NAFLD/非酒精性脂肪性肝炎(NASH)循证医学治疗指南[1]提出NAFLD/NASH     

吡格列酮对非酒精性脂肪性肝病患者核因子-κB及白介素-6的影响

目的:观察吡格列酮对非酒精性脂肪性肝病患者核因子-κB(NF-κB)、白细胞介素-6(IL-6)的影响。方法:将80例非酒精性脂肪性肝病患者随机分为吡格列酮治疗组和易善复对照组各40例,两组患者的基线情况相当。治疗组患者在控制饮食、加强运动的基础上加用吡格列酮15mg/次,1次/d治疗,对照组患者在控制饮食、加强运动基础上加用多烯磷脂酰胆碱胶囊456mg/次,3次/d,均治疗24周。观察两组患者肝功能及炎症指标的变化。结果:治疗24周后,治疗组与对照组比较丙氨酸氨基转移酶(ALT)、空腹血糖(FPG)明显降低(P<0.05)。治疗组NF-κB、肿瘤坏死因子-α(TNF-α)、IL-6水平明显低于对照组(P<0.05),但两组间天门冬氨酸氨基转移酶(AST)和谷酰转肽酶(γ-GT)水平无明显差异(P>0.05)。结论:吡格列酮能改善非酒精性脂肪性肝病患者肝功能,降低空腹血糖,改善胰岛素抵抗,降低炎症细胞因子水平,抑制肝脏炎症反应,减轻肝脏炎症程度。     

治疗老年单纯收缩期高血压可减少中风危险

目前尚未证实用抗高血压药物治疗老年单纯收缩期高血压(ISH)是否有效或可减少其中风的危险。作者观察小剂量抗高血压药物对防止老年ISH患者发生中风的效果。对象和方法以收缩压平均160mmHg(21.3kPa.1mmHg=0.133kPa)或更高,而舒张压低于90mmHg为ISH。共4736人,均无抗高血压用药史,收缩压均在160～219mmHg之间,舒张压低于100mmHg。除外心血管疾病、癌症、酒精性肝病、肾病及内科处理困难者。根据初诊时血压平均值分配用药,以基础血压收缩压180mmHg以上降低到160mmHg为治疗目标;如收缩在160～179mmHg之间则以降低20mmHg为度。每天用药一次。先用氯噻酮12.5mg/d,如果血压下降不够明     

Enfermedad hepática por alcohol. Guías de práctica clínica. Documento de consenso auspiciado por la AEEH

Alcohol-related liver disease (ARLD) is the most prevalent cause of advanced liver disease and liver cirrhosis in Europe, including Spain. According to the World Health Organization the fraction of liver cirrhosis attributable to alcohol use in Spain is 73.8% among men and 56.3% among women. ARLD includes various stages such as steatohepatitis, cirrhosis and hepatocellular cancer. In addition, patients with underlying ARLD and heavy alcohol intake may develop alcoholic hepatitis, which is associated with high mortality. To date, the only effective treatment to treat ARLD is prolonged withdrawal. There are no specific treatments, and the only treatment that increases life expectancy in alcoholic hepatitis is prednisolone. For patients with alcoholic hepatitis who do not respond to treatment, some centres offer the possibility of an early transplant. These clinical practice guidelines aim to propose recommendations on ARLD taking into account their relevance as a cause of advanced chronic liver disease and liver cirrhosis in our setting. This paper aims to answer the key questions for the clinical practice of Gastroenterology, Hepatology, as well as Internal Medicine and Primary Health Centres, making the most up-to-date information regarding the management and treatment of ARLD available to health professionals. These guidelines provide evidence-based recommendations for the clinical management of this disease.     

Alcoholic liver disease: Treatment

The excess consumption of alcohol is associated with alcoholic liver diseases(ALD). ALD is a major healthcare problem, personal and social burden, and significant reason for economic loss worldwide. The ALD spectrum includes alcoholic fatty liver, alcoholic hepatitis, cirrhosis, and the development of hepatocellular carcinoma. The diagnosis of ALD is based on a combination of clinical features, including a history of significant alcohol in-take, evidence of liver disease, and laboratory findings. Abstinence is the most important treatment for ALD and the treatment plan varies according to the stage of the disease. Various treatments including abstinence, nutritional therapy, pharmacological therapy, psycho-therapy, and surgery are currently available. For severe alcoholic hepatitis, corticosteroid or pentoxifylline are recommended based on the guidelines. In addition, new therapeutic targets are being under investigation.     

解读非酒精性脂肪性肝病诊治指南

随着肥胖与糖尿病患者的日趋增多,脂肪性肝病(FLD)目前已成为全球性的重要肝病。临床上FLD分为酒精性肝病(ALD)与非酒精性脂肪性肝病(NAFLD);研究表明,NAFLD与肥胖、代谢综合征、2型糖尿病和心血管疾病密切相关。2006年和2010年中华医学会相继制定了中国NAFLD诊疗指南,较全面和广泛地反映了目前NAFLD的临床诊疗现状,与国际上颁布的一些诊治指南相比存在差异。本文就NAFLD诊治指南及相关问题进行解读。     

Cholestasis and alcoholic liver disease

Histologic cholestasis and clinical jaundice may be seen in all stages of alcoholic liver disease. In rare cases, isolated cholestasis without significant steatosis, hepatitis, or cirrhosis is identified in an alcoholic patient. The mechanisms of ethanol-induced cholestasis are not well studied but may involve compression of intrahepatic biliary radicals or interference with basolateral uptake and intracellular transport of bile acids. In the evaluation of the jaundiced alcoholic patient, clinical, biochemical, and radiologic data are usually sufficient to distinguish alcohol-induced liver disease from extrahepatic biliary obstruction. In cases where the diagnosis is not readily apparent, more invasive studies such as liver biopsy or ERCP may be necessary. The risk of these invasive studies is directly related to the degree of underlying hepatic dysfunction.     

Clinical syndromes of alcoholic liver disease

BACKGROUND AND AIMS: Alcoholic liver disease continues to be a major health problem with respect to both morbidity and mortality. To understand the clinical syndromes of alcoholic liver disease, this review highlights the papers on both clinical and basic research of alcoholic liver disease, especially on steatosis, alcoholic hepatitis and fibrosis. METHODS: The various forms of alcoholic liver disease are described, and knowledge about the clinical and pathophysiological features of different stages of alcoholic liver disease are summarized. RESULTS: Clinical studies combined with basic research have established a spectrum of alcoholic liver disease from steatosis to steatohepatitis, fibrosis, and cirrhosis. New insights into the pathogenesis of alcoholic liver disease include the key roles of the excess production of cytokines, reactive oxygen species, and the shortage of protective mediators, including adiponectin. CONCLUSION: These new insights will lead to new specific therapies for the treatment of alcoholic hepatitis and alcoholic liver fibrosis.     

Liver transplantation for severe alcoholic hepatitis– The PRO view

Although liver transplantation has become accepted as a life‐saving treatment of last resort for most life‐threatening liver disorders, the use of liver transplantation to rescue patients with severe alcoholic hepatitis unresponsive to medical therapy remains controversial. I propose the concepts that alcohol use disorder is an illness, that on occasion results in alcoholic liver disease and that treatment of alcoholic liver disease, including treatment of patients with severe alcoholic hepatitis, combines treatment of the alcohol use disorder and of alcoholic liver disease. From this I derive the following principal to govern selection of patients for liver transplantation of patients with alcohol use disorder: that alcohol use disorder should impact suitability for liver transplantation as a co‐morbid disorder, in the same way as other common co‐morbid disorders such as diabetes mellitus or systemic hypertension, are factored in the selection process. We should relate the risk of drinking relapse to the prognosis of the patient after transplantation, rather than in a binary construct of likelihood of maintaining abstinence vs drinking.     

Liver Transplantation for Alcoholic Liver Disease: A Consideration of Reasons For and Against

Orthotopic liver transplantation is a clinical procedure that has been accepted widely as the treatment of choice for individuals with advanced chronic liver disease. As such, its application to the important clinical problem of alcoholic liver disease is inevitable. The arguments for and against liver transplantation for individuals with advanced alcoholic liver disease are presented.     

Diagnostischer Algorithmus bei erhöhten Leberwerten

Elevated liver enzymes are common findings in current clinical practice and the choice of a reasonable diagnostic approach is a challenge for both primary care physicians and gastroenterologists. Identifying an underlying liver disease without causing unnecessary expense and overuse of dispensable tests at an early time point has become crucial in the current healthcare system. Viral hepatitis, alcoholic liver disease and non-alcoholic fatty liver disease are the most common causes of liver diseases in western civilizations. Delayed diagnosis as well as irrational diagnostic tests cause relevant costs for the healthcare system and physical and emotional stress to the patient. Identifying liver diseases at an early stage might help to prevent the development of end stage liver disease by early initiation of a specific treatment. This article presents an algorithm for applying liver tests and diagnostic studies with the objective of a rational and cost-effective patient management. The most common causes of acute and chronic liver disease and the individual rational diagnostic approaches are elucidated.     

慢性肝病伴结核病时化疗方案的选择及肝损害的防治对策

目的探讨慢性肝病伴结核病时化疗方案的选择及肝损害的防治对策。方法170例慢性肝病伴结核病的患者在化疗前常规的作肝功能检河，并根据临床类型及其程度选择不同的化疗方案。对乙肝病毒复制指标阳性伴肝炎活动的患者进行抗病毒治疗。结果肝损害的发生率或恶化率慢性HBV携带者〈酒精性肝病、脂肪性肝病〈慢性肝炎轻度〈慢性肝炎中度〈慢性肝炎重度、肝硬化（P〈0．01）；抗病毒治疗的乙型肝炎肝损害的加重或恶化率低于非抗病毒治疗组（P〈0．05）；综合疗法与单纯化疗者肝损害好转与恶化的发生率和结核病的转归之间有明显的差异（P〈0．01）。结论对于慢性肝病伴结核病的患者，化疗前要做好肝功能状况的评估工作，并依据肝病的临床类型及其程度选择合适的化疗方案，对肝损明显及某些特殊群体要加强抗炎、护肝、免疫、增强等措施，伴HBV复制的活动性乙肝同时进行抗病毒治疗。     

茵芩清肝汤联合硫普罗宁治疗湿热兼血瘀型酒精性肝病的临床研究

目的:观察茵芩清肝汤联合硫普罗宁对酒精性肝病湿热兼血瘀型患者的临床疗效。方法:对武汉市中医医院肝病科门诊110例确诊为酒精性肝病,饮酒史5年以上,近1月内未接受中西药物及其他治疗方法的男性患者,按就诊顺序编号,运用随机数字表法分为治疗组与对照组,各55例。治疗组患者口服茵芩清肝汤和硫普罗宁、对照组患者口服硫普罗宁,观察患者症状、体征、肝功能、血脂、肝纤维化指标、腹部超声波等方面的改善情况,以1个月为1个疗程,共观察两个疗程。结果:通过治疗前后中医证候综合评分的变化来分析各组患者中医证候疗效,结果显示,治疗组总有效率、临床症状改善等方面明显优于对照组(P<0.05),两组患者治疗后肝功能、血脂、血清肝纤维化指标和腹部超声波结果均有明显改善,与本组治疗前比较,差异有显著性意义(P<0.01或P<0.05),且治疗组患者改善更明显。结论:茵芩清肝汤联合硫普罗宁对酒精性肝病湿热兼血瘀型治疗效果好,未见明显不良反应,值得临床推广应用。