普通肝素和低分子肝素对骨代谢的影响

普通肝素和低分子肝素常用来预防和治疗老年骨质疏松骨折伴发的下肢深静脉血栓形成。临床研究上证明了在骨代谢的影响方面,低分子肝素要优于普通肝素。普通肝素可能通过多种途径促进破骨细胞的形成,抑制成骨细胞的成骨作用,从而对骨代谢有不良影响。而低分子肝素也能够抑制成骨细胞的作用,但对破骨细胞的作用明显低于普通肝素,总体上造成骨量流失的作用要低于普通肝素,在骨代谢上显示了更好的安全性。肝素类药物对骨代谢的作用可能涉及到了破骨细胞抑制凝集素、护骨素及硬化素等多种途径。     

肝素及肝素代用品的评价与展望

肝素的抗凝作用强,监测简便易行、抗凝活性易被中和,在心肺转流时常用,但仍存在明显不足。近年来,对肝素代用品进行了广泛研究,它们虽各具特色,但综合特性均低于肝素。如能在应用肝素的同时辅以肝素代用品,则有望达到更好的效果。     

关于Heparan sulfate和Heparin sulfate的译名问题

近10多年来,在许多肾脏病学和肾脏病杂志中,大多数作者都把heparan sulfate翻译成硫酸肝素,这是一大错误。heparinsulfate传统地译为硫酸肝素,且一直沿用至今,这是被公认的。heparan sulfate不能译为硫酸肝素可以肯定。在15年前,笔者将其译为硫酸肝素样物(见本人主编肾脏病学第2版328页,1990)。此后,笔者在自己所写的文稿中都将其译为硫酸乙醯肝素。但生物化学专家们知其不是硫酸肝素,因它化学结构类似硫酸肝素,将其译为硫     

微量肝素防治术后早期高粘滞血症的临床研究

目的　探讨将微量肝素应用于术后早期病人预防高粘滞血症。方法　 3 0例病人术后随机分为 15mg肝素组和 10 0mg肝素组 ,每组 15例 ,均在术后 1h应用肝素。 15mg肝素组 :肝素 5mg +5 %葡萄糖液 5 0 0ml静脉滴注 ,3次 /日。 10 0mg肝素组 :肝素 5 0mg皮下注射 ,2次 /日。两组病人在用药前及用药后 3～ 4h内分别采静脉血测定血液粘度 ,并观察用药后手术切口渗血情况。结果　 15mg肝素组全血粘度、全血还原粘度和血浆粘度明显降低 ,较用药前有非常显著变化 ,无一例患者手术切口渗血。 10 0mg肝素组各项指标较用药前无明显改变 ,9例患者出现切口渗血。结论　术后早期应用微量肝素静脉滴注降低病人血液粘度的效果显著 ,该剂量不会引起手术切口渗血 ,是防治术后早期静脉血栓形成安全、有效、简便的方法之一。     

肝素过敏患者血液净化治疗抗凝方法探讨

肝素是血液透析常规抗凝药物,由肝素引起的过敏性反应少有报道。本院收治1例患者,既往有肝素过敏史,表现为过敏性休克。我们在无肝素生理盐水冲洗法的基础上加用口服抗凝药进行尝试,抗凝效果满意,现报道如下。     

低分子量肝素在血液透析抗凝中的应用

低分子量肝素是肝素中的一种新剂型，与目前临床上应用的标准肝素比较，具有高效、低副作用的优点。本文对低分子量肝素在血液透析抗凝中应用的现状进行了综述。     

血型对肝素及鱼精蛋白作用的影响

目的探讨血型对肝素及其拮抗剂鱼精蛋白作用的影响。方法选择A、B、AB、O型血患者各20例,分别测定静注肝素前、肝素后5、15、30 min的激活全血凝血时间(ACT),然后计算静注肝素后各时点ACT与静注肝素前ACT的差值,并计算中和肝素达到生理ACT所需鱼精蛋白量,比较不同血型患者间ACT和鱼精蛋白中和肝素效果的差异。结果 O型血患者肝素抗凝效果最好,其次AB、A、B型血患者。与此相反,O型血患者中和肝素所需鱼精蛋白剂量最多,其次AB、A、B型患者。结论不同ABO血型患者对肝素及其拮抗剂效果存在明显差异。     

体外循环后鱼精蛋白逆转肝素抗凝会影响激活的全血凝固时间和血小板聚集

体外循环(CPB)后逆转肝素抗凝,最好根据血中肝素水平来决定鱼精蛋白用量,但测定血中肝素在临床上难以广泛开展,因而通常只能参照肝素使用的总量和激活的全血凝固时间(ACT)来确定鱼精蛋白用量,而并未考虑到肝素的消耗。但CPB后出血的原因很多,而ACT又受许多因素的影响。人们往往错误地把鱼精蛋白逆转肝素后的ACT延长归咎于剩余肝素(或称肝素反跳)的作用而追加鱼精蛋白,以致凝血结构遭到破坏并降低血小板功能。作者通过与重组血小板因子4(rPF4)和抗肝素灵对比,测定了鱼精蛋白对CPB后ACT的作用,以及鱼精蛋白对体外血小板聚集的影响。     

血液透析中肝素/血小板因子4复合物抗体的研究状况

随着肝素在血液透析中的广泛应用,肝素/血小板因子4复合物抗体(AHPF4抗体)的产生及其引起的并发症已日益受到重视.长期使用肝素抗凝的维持性血透患者,具有产生AHPF4抗体的风险,AHPF4抗体可以导致肝素诱导的血小板减少症以及血栓形成.AHPF4抗体介导的HIT治疗原则主要为停用肝素.选择其他抗凝药物.     

肝素抗血栓作用机理及临床应用(文献综述)

肝素已有70年的历史,但用于抗血栓治疗还只是最近30年的事情。因此,人们对其抗血栓作用机理和临床应用并不甚熟悉。最近10年,肝素的基础和临床研究都取得了重大进展。本文旨在对肝素的基础研究,特别是在抗血栓作用机理方面取得的进展,以及肝素在预防术后深静脉血栓和治疗急性静脉血栓中的应用作一介绍。一、肝素的基础研究:肝素是1916年由美国医学生 J·Mclean 发现     

维生素D受体在糖尿病肾病足细胞损伤及蛋白尿缓解中的作用

目的探讨维生素D受体(VDR)在糖尿病肾病(DKD)足细胞中的表达水平及在足细胞损伤及蛋白尿缓解中的作用。方法(1)本研究纳入了65例诊断患有2型糖尿病(伴或不伴蛋白尿)的患者,并纳入了25例年龄和性别相匹配的健康体检者为对照组。根据白蛋白/肌酐(ACR)的尿排泄比例对2型糖尿病患者进行分组,分别为无蛋白尿(ACR<30 mg/g,n=24)、微量白蛋白尿(ACR 30~300 mg/g,n=18)和临床蛋白尿(ACR>300 mg/g,n=23)。另选择25例经肾活检确诊的DKD患者作为DKD组。正常肾脏组织标本均取自泌尿外科同一时期肾脏肿瘤切除患者10例。将各组检测指标进行对比,同时采用实时定量PCR、ELISA法和免疫组化法检测VDR在各组患者的血液、尿液样本和肾脏组织中的表达情况,以及使用Pearson相关分析分析VDR与尿蛋白的相关性。(2)在2型糖尿病肾病小鼠模型中对上述结果进行验证,将遗传背景均为C57BLKs/J的雄性db/db小鼠及同窝出生的db/m小鼠,随机分为正常对照组(A组)、DKD对照组(B组)、DKD二甲基亚砜处理组(C组)、DKD帕立骨化醇(VDR激动剂)处理组(D组),C、D组连续腹腔注射处理8周,对照组不做任何处理。小鼠10周龄时开始连续干预8周,在小鼠22周龄(开始干预后12周)检测各组小鼠体重、血、尿生化指标对比;Western印迹法检测β⁃catenin、VDR的变化;免疫荧光观察足细胞标志蛋白podocin及足细胞损伤蛋白α⁃SMA的表达变化。结果(1)与正常健康对照组相比,无蛋白尿组、微量白蛋白尿组和临床蛋白尿组的糖尿病患者血浆中VDR的mRNA和蛋白水平均较低(均P<0.05);与无蛋白尿组的糖尿病患者相比,微量白蛋白尿组和临床蛋白尿组的糖尿病患者血浆中VDR的mRNA和蛋白水平均较低(均P<0.05)。(2)与正常健康对照组相比,无蛋白尿糖尿病组和DKD组患者血浆中VDR的mRNA和蛋白水平均较低(均P<0.05);与无蛋白尿糖尿病组患者相比,DKD组患者血浆中VDR的mRNA和蛋白水平亦较低(均P<0.05)。(3)免疫组化结果显示,DKD组肾组织中VDR的表达明显少于正常对照组。(4)DKD患者血浆中VDR mRNA相对水平与ACR呈负相关(r=-0.342,P<0.05)。(5)各组尿液上清液中VDR的水平与血浆中的水平呈相反趋势。(6)Western印迹结果显示,B组、C组肾小球足细胞β⁃catenin蛋白表达高于D组(均P<0.05),VDR蛋白的表达低于D组(均P<0.05);免疫荧光结果显示,B组、C组肾小球足细胞podocin的表达低于D组(均P<0.05),α⁃SMA的表达高于D组(均P<0.05)。结论VDR高表达缓解DKD足细胞损伤及蛋白尿。     

Anterior Interosseous Nerve Palsy After Shoulder Arthroscopy Treated With Surgical Decompression: A Case Series and Systematic Review of the Literature

Background: Anterior interosseous nerve (AIN) palsy is a very uncommon cause of upper extremity pain and weakness that comprises less than 1% of all upper extremity nerve palsies. Rarely reported but also mentioned in the literature is AIN palsy after shoulder arthroscopy. Methods: A systematic review of the literature to date using PubMed was conducted to identify patients who suffered AIN palsy after shoulder arthroscopy procedures. Articles included met the following criteria: (1) published in English; (2) primary presentation of the data; (3) patients had undergone shoulder arthroscopy before developing symptoms of AIN palsy; and (4) diagnosis was confirmed with clinical symptoms of AIN palsy. Measured outcomes included patient demographics, specific shoulder procedure, anesthesia procedure, intra-operative patient positioning, intra-operative compressive dressing, intra-operative traction, surgical versus conservative treatment, abnormal findings during decompression procedure, proposed mechanism of injury, and follow-up. Results: The search yielded 6 articles, of which 4 (13 cases) met inclusion criteria. An additional 2 cases were included in this report totaling 15 cases. The average patient age was 49 years (range: 31-64) with 73% males. At average follow-up of 24 months, 67% of patients experienced complete resolution of symptoms—more than half of which underwent surgical decompression. Patients who failed to progress experienced weakness of the flexor digitorum profundus and flexor pollicis longus muscles. Conclusions: Proposed injury mechanisms for AIN palsy after shoulder arthroscopy range from mechanical trauma, compressive hematoma, and direct anesthetic neurotoxicity. Management should be directed by clinical symptoms, imaging, and patient factors with majority of patients expected to have excellent clinical outcomes.     

不同尿钙水平的Gitelman综合征患者临床特点比较

目的观察不同尿钙水平Gitelman综合征(GS)患者的临床特点,探讨尿钙在GS疾病临床分型中的价值。方法收集2016—2018年来自中国国家罕见病注册系统(NRSC)、在北京协和医院行SLC12A3基因检测诊断为GS患者的临床资料,分析其尿钙特点,比较不同尿钙水平患者的临床和实验室检查指标。氢氯噻嗪试验按照标准操作流程进行,测定患者基线和用药后3 h内氯离子排泄分数改变量的最大值(ΔFECl)。结果共有83例GS患者被纳入研究,其中低尿钙患者53例(63.86%)。低尿钙组尿钙/肌酐比明显低于非低尿钙组[(0.085±0.058)mmol/mmol比(0.471±0.284)mmol/mmol,t=7.349,P<0.001]。两组患者在年龄、性别、估算肾小球滤过率、血压、血尿电解质水平、代谢性碱中毒方面差异均无统计学意义。低尿钙组患者乏力(χ2=4.595,P=0.032)及多尿(χ2=5.778,P=0.016)发生比例低于非低尿钙组,两组患者在其他临床症状方面差异无统计学意义。低尿钙和非低尿钙组各有16例患者行氢氯噻嗪试验,中位ΔFECl结果分别为0.539%(0.430%,1.283%)和0.829%(0.119%,1.298%),均提示对氢氯噻嗪无反应,组间差异无统计学意义(U=130.000,P=0.956)。结论GS患者中低尿钙比例为63.86%,尿钙水平与疾病临床表型、NCC功能损伤严重程度之间均无明确相关性。     

Role of Conventional and Diffusion-Weighted Magnetic Resonance Imaging of Spinal Treatment Protocol for Hydatid Disease

Objective:

To demonstrate the role of magnetic resonance imaging (MRI) in determining the treatment protocol for hydatid disease of the spine.

Design:

Case report; literature review.

Findings:

Diffusion-weighted MRI can help differentiate complicated infected hydatidosis from abscesses, epidermoid cysts from arachnoid cysts, and benign from malignant vertebral compression fractures. It is also helpful in differentiating between abscesses and necrotic tumors.

Conclusion:

Diffusion-weighted MRI can help differentiate between infections requiring immediate surgery and those that can be treated medically with antihelmintic treatment.     

Fibrinogen-thrombin collagen patch reinforcement of highrisk colonic anastomoses in rats

AIM To evaluate the effectiveness of human fibrinogenthrombin collagen patch(TachoSil~?) in the reinforcement of high-risk colon anastomoses.METHODS A quasi-experimental study was conducted in Wistar rats(n = 56) that all underwent high-risk anastomoses(anastomosis with only two sutures) after colectomies. The rats were divided into two randomized groups: Control group(24 rats) and treatment group(24 rats). In the treatment group, high-risk anastomosis was reinforced with TachoSil~? (a piece of Tacho Sil? was applied over this high-risk anastomosis, covering the gap). Leak incidence, overall survival, intra-abdominal adhesions, and histologic healing of anastomoses were analyzed. Survivors were divided into two subgroups and euthanized at 15 and 30 d after intervention in order to analyze the adhesions and histologic changes. RESULTS Overall survival was 71.4% and 57.14% in the TachoSil~? group and control group, respectively(P = 0.29); four rats died from other causes and six rats in the treatment group and 10 in the control group experienced colonic leakage(P 0.05). The intra-abdominal adhesion score was similar in both groups, with no differences between subgroups. We found non-significant differences in the healing process according to the histologic score used in both groups(P = 0.066).CONCLUSION In our study, the use of TachoSil~? was associated with a non-statistically significant reduction in the rate of leakage in high-risk anastomoses. TachoSil~? has been shown to be a safe product because it does not affect the histologic healing process or increase intra-abdominal adhesions.     

Fluorescence in the Sclera,Nails, and Teeth Secondary to Favipiravir Use for COVID-19 Infections

Favipiravir, an antiviral agent originally used for influenza infections, has become popular due to its beneficial signals in coronavirus disease. It is currently used in some countries within COVID-19 treatment protocols. This is an initial report of favipiravir-related fluorescence observed in three healthcare providers working in the same ward in our hospital. All three individuals had been diagnosed with COVID-19 two months earlier and were treated with favipiravir. None of the three individuals received hydroxychloroquine or tetracyclines. Wood’s light examination led to an incidental discovery of favipiravir-induced fluorescence involving the sclera, nails, and teeth. In all patients, white linear, square, and band-like specks of fluorescence were noticed on the sclera of both eyes, some teeth, and the proximal part of all fingernails and toenails. Exposure of the eyes to the Wood’s light was for a brief duration of 3 to 5 seconds during examination and photodocumentation. Favipiravir might cause bright white fluorescence of nails, sclera, and teeth, detectable by Wood’s light even two months after its cessation.     

Safety and tolerability of single intravenous doses of sugammadex administered simultaneously with rocuronium or vecuronium in healthy volunteers

BACKGROUND: Sugammadex rapidly reverses rocuronium- and vecuronium-induced neuromuscular block. To investigate the effect of combination of sugammadex and rocuronium or vecuronium on QT interval, it would be preferable to avoid the interference of anaesthesia. Therefore, this pilot study was performed to investigate the safety, tolerability, and plasma pharmacokinetics of single i.v. doses of sugammadex administered simultaneously with rocuronium or vecuronium to anaesthetized and non-anaesthetized healthy volunteers. METHODS: In this phase I study, 12 subjects were anaesthetized with propofol/remifentanil and received sugammadex 16, 20, or 32 mg kg(-1) combined with rocuronium 1.2 mg kg(-1) or vecuronium 0.1 mg kg(-1); four subjects were not anaesthetized and received sugammadex 32 mg kg(-1) with rocuronium 1.2 mg kg(-1) or vecuronium 0.1 mg kg(-1) (n=2 per treatment). Neuromuscular function was assessed by TOF-Watch SX monitoring in anaesthetized subjects and by clinical tests in non-anaesthetized volunteers. Sugammadex, rocuronium, and vecuronium plasma concentrations were measured at several time points. RESULTS: No serious adverse events (AEs) were reported. Fourteen subjects reported 23 AEs after study drug administration. Episodes of mild headache, tiredness, cold feeling (application site), dry mouth, oral discomfort, nausea, increased aspartate aminotransferase and gamma-glutamyltransferase levels, and moderate injection site irritation were considered as possibly related to the study drug. The ECG and vital signs showed no clinically relevant changes. Rocuronium/vecuronium plasma concentrations declined faster than those of sugammadex. CONCLUSIONS: Single-dose administration of sugammadex 16, 20, or 32 mg kg(-1) in combination with rocuronium 1.2 mg kg(-1) or vecuronium 0.1 mg kg(-1) was well tolerated with no clinical evidence of residual neuromuscular block, confirming that these combinations can safely be administered simultaneously to non-anaesthetized subjects. Rocuronium and vecuronium plasma concentrations decreased faster than those of sugammadex, reducing the theoretical risk of neuromuscular block developing over time.     

罗伊适应模式对腹股沟疝无张力疝修补术后恢复情况的影响

目的探讨罗伊适应模式对患者腹股沟疝无张力疝修补术后恢复情况的影响。 方法将2016年1月至2019年5月在秦皇岛市第二医院择期进行无张力修补术治疗的120例腹股沟疝患者，按照随机数字法分为对照组和观察组，每组各60例。对照组采用常规护理治疗，观察组在对照组的基础上采用罗伊适应模式。比较2组患者的术后临床指标、心理状态、围手术期并发症发生情况及满意度。 结果术后观察组患者的首次排气时间、恢复正常饮食时间、离床活动时间和术后住院时间均低于对照组（P<0.05）；术后观察组患者的抑郁自评量表（SDS）和焦虑自评量表（SAS）评分显著低于对照组（P<0.05）；术后2组患者均无切口感染发生，2组患者尿潴留、急性疼痛、认知功能障碍、发热、血肿等发生率相比无统计学差异（P>0.05）；术后观察组患者护理满意度为96.67%，显著高于对照组的83.33%（P<0.05）。 结论在常规护理的基础上，罗伊适应模式用于患者腹股沟疝无张力修补围手术期，能有效改善术后患者的焦虑/抑郁情绪，不增加围手术期并发症，促进术后患者的恢复及提高治疗满意度。     

Factors Associated With Reoperation After Silicone Proximal Interphalangeal Joint Arthroplasty

Background: Silicone proximal interphalangeal (PIP) joint arthroplasty has a high revision rate. It has been suggested that persistent ulnar deviation and joint instability influence the durability of PIP silicone arthroplasties. The goal of this study was to evaluate what factors are associated with reoperation after silicone PIP arthroplasty. Methods: We retrospectively evaluated all adult patients who underwent PIP silicone arthroplasty between 2002 and 2016 at one institutional system for inflammatory-, posttraumatic-, and primary degenerative arthritis. After manual chart review, we included 91 patients who underwent 114 arthroplasties. Fingers operated included 14 index, 41 middle, 38 ring, and 21 small fingers. Results: The overall reoperation rate was 14% (n = 16). Non-Caucasian race (P = .040), smoking (P = .022) and PIP silicone arthroplasty for post-traumatic osteoarthritis (P = .021) were associated with reoperation. The 1-, 5- and 10-year implant survival rates were 87%, 85%, and 85%, respectively. Conclusion: Caution should be exercised when considering PIP silicone arthroplasty of the index finger or in patients with post-traumatic osteoarthritis. It may be worthwhile addressing smoking behavior before pursuing silicone PIP arthroplasty.     

血浆凝血因子VIII水平与IgA肾病患者临床病理改变及预后的关系

目的探讨血浆凝血因子VIII(factor VIII,FVIII)水平与IgA肾病(IgAN)患者临床参数及预后的关系。方法收集2016年1月至2016年12月中南大学湘雅二医院确诊的IgAN患者的临床资料。按照时间依赖的受试者工作特征曲线(ROC)得出的血浆FVIII预测IgAN预后的临界值,将患者分为高FVIII组(FVIII>140.50%)和低FVIII组(FVIII≤140.50%),比较两组患者肾活检时基线临床参数的差异。以估算肾小球滤过率(eGFR)下降≥30%或进入终末期肾脏病(ESRD)为终点事件,采用Kaplan-Meier生存曲线及Cox回归方程法分析血浆FVIII水平对IgAN患者预后的影响。结果共93例IgAN患者纳入本研究,中位随访时间为35.15(33.77,36.76)个月,12例(12.90%)患者发生终点事件。高FVIII组患者年龄、血肌酐、尿素氮、血三酰甘油、血总胆固醇、血浆纤维蛋白原、D-二聚体、24 h尿蛋白量、蛋白C、蛋白S和eGFR下降速率高于低FVIII组(均P<0.05);eGFR、血白蛋白、中位随访时间低于低FVIII组(均P<0.05)。Kaplan-Meier生存分析结果显示,与低FVIII组比较,高FVIII组患者肾脏累积生存率降低(χ2=5.635,P=0.018)。在校正收缩压、eGFR、尿蛋白、肾小管萎缩/间质纤维化程度等因素后,多因素Cox回归分析结果显示,高血浆FVIII水平是IgAN患者肾脏预后不良的独立危险因素(HR=4.147,95%CI 1.055~16.308,P=0.042)。结论血浆FVIII水平与IgAN患者临床指标及预后相关,高血浆FVIII水平是IgAN患者肾脏预后不良的独立危险因素。