拉米夫定和阿德福韦酯抗病毒疗效与HBV基因型的关系

目的探讨慢性乙型肝炎患者应用拉米夫定、阿德福韦酯的疗效与HBV基因型的关系。方法选取125例慢性乙型肝炎患者,分别给予拉米夫定(拉米夫定组,n=60)和阿德福韦酯(阿德福韦酯组,n=65)抗病毒治疗。观察2组治疗3、6、12个月后的病毒学应答率、血清学应答率及生化学应答率,并于治疗12个月后检测耐药率及耐药基因突变位点。结果拉米夫定组在治疗6、12个月后,B基因型HBV感染患者病毒学应答率、血清学应答率明显高于C基因型HBV感染患者(P0.05),但生化学应答率差异无统计学意义(P0.05)。阿德福韦酯组在治疗期间B基因型HBV感染患者与C基因型HBV感染患者的病毒学应答率、血清学应答率、生化学应答率差异均无统计学意义(P0.05)。治疗12个月后,拉米夫定组耐药率明显高于阿德福韦酯组(P0.05),拉米夫定组和阿德福韦酯组耐药基因突变位点分别以rt108M、rt236T为主。结论拉米夫定对B基因型HBV的抑制作用优于C基因型HBV;阿德福韦酯的抗病毒疗效与HBV基因型无关;在慢性乙肝型炎治疗过程中要重视HBV耐药性发生,加强疗效评估。     

替比夫定联合阿德福韦酯治疗阿德福韦酯应答不佳的乙型肝炎病毒e抗原阳性慢性乙型肝炎患者

目的评估替比夫定与阿德福韦酯联合治疗优化阿德福韦酯单药治疗应答不佳的阳性慢性乙型肝炎患者的疗效。方法选择2008年6月-2009年8月间共26例阿德福韦酯治疗至少12个月且病毒学应答不佳的乙型肝炎病毒e抗原(HBeAg),阳性的慢性乙型肝炎患者,在10 mg阿德福韦酯治疗的基础上,加用600 mg替比夫定。肝功能和乙型肝炎病毒(HBV)DNA每3个月评估1次,乙型肝炎两对半和腹部B型超声每半年评估1次。结果在第1年的治疗期间,所有患者血清HBV DNA水平均呈进行性下降,其中24例(92.3%)血清HBV DNA水平在联合治疗12个月时低于检测值下限,有25例(96.2%)患者丙氨酸转氨酶水平复常。治疗6个月时,分别有7例(26.9%)和2例(7.7%)患者发生HBeAg消失和血清学转换;治疗12个月时,分别有11例(42.3%)和8例(30.8%)患者发生HBeAg消失和血清学转换。整个治疗期间,26例患者均未出现病毒学突破。结论阿德福韦酯单药治疗应答不佳时,加用替比夫定可有效控制病毒,使患者获得较好的病毒学、生化学和免疫学应答。     

替比夫定治疗HBeAg阳性的慢性乙型肝炎104周疗效分析

目的观察替比夫定治疗HBeAg阳性的慢性乙型肝炎(CHB)的疗效,比较初治与序贯阿德福韦酯的疗效差异。方法将HBeAg阳性的CHB患者90例分2组,替比夫定初治组和替比夫定序贯阿德福韦酯初始疗效不佳的序贯组各45例,疗程104周。观察治疗前后肝功能、乙型肝炎病毒(HBV)标志物、HBV DNA及耐药变化。结果替比夫定疗效好,肝功能复常率、HBV DNA阴转率、HBeAg阴转率和血清转换率分别为91.1%、80.0%、57.8%和30.0%。初治组的HBV DNA转阴率高于序贯组(P0.05),但有早期应答的患者两组疗效比较差异无统计学意义(P0.05)。两组有早期应答患者各项疗效指标均显著好于无早期应答患者,而且发生病毒学突破也明显减少,两者比较差异有非常显著的统计学意义(P0.000 1~0.05)。结论替比夫定治疗CHB疗效肯定,初治疗效好于序贯阿德福韦酯疗效不佳患者,但后者有早期应答反应时其治疗104周的各项疗效指标与初治组差异无统计学意义(P0.05),因此,替比夫定序贯治疗时应严密观察早期抗病毒应答反应,及时进行优化治疗。     

拉米夫定联合阿德福韦酯治疗阿德福韦酯停药后出现的病毒学反弹

目的比较拉米夫定+阿德福韦酯联合治疗与阿德福韦酯单药治疗对阿德福韦酯停药后出现病毒学反弹而无基因型耐药变异患者的疗效及安全性。方法回顾研究2007年1月-2012年1月在传染科门诊就诊的67例阿德福韦酯治疗获得病毒学应答但停药后出现病毒学反弹的e抗原阳性慢性乙型肝炎患者,分别给予拉米夫定+阿德福韦酯联合治疗(联合组,n=35)和阿德福韦酯单药治疗(单药组,n=32)。结果治疗1年后,联合组(32例,85.7%)较单药组(21例,65.6%)有更多的患者重新获得了丙氨酸转氨酶复常(P=0.009),联合组34例(97.1%)乙型肝炎病毒DNA阴转,单药组22例(68.8%)阴转,两组差异有统计学意义(P=0.002);在血清学转换方面,联合组和单药组分别有4例(11.4%)和1例(3.1%)患者获得了e抗原的血清学转换。在治疗中所有患者均未发生任何严重不良反应。结论阿德福韦酯停药后出现病毒学反弹,选择拉米夫定与阿德福韦酯联合治疗可使患者重新获得较好的生化学和病毒学应答。     

恩替卡韦初治HBeAg阳性的慢性乙型肝炎肝纤维化疗效评价

目的评价恩替卡韦和阿德福韦酯抗慢性乙型肝炎肝纤维化的效果。方法选择2007年10月至2009年10月HBeAg阳性的慢性乙型肝炎患者158例予恩替卡韦抗病毒治疗,另选择同期的HBeAg阳性慢性乙型肝炎患者167例予阿德福韦酯抗病毒治疗,观察2组患者治疗前、治疗后12、24个月乙型肝炎病毒(HBV)-DNA阴转率、HBeAg阴转率及血清肝纤维化指标的变化情况。随机对其中42例恩替卡韦治疗者、36例阿德福韦酯治疗者治疗前和治疗后24个月行肝组织穿刺术作组织炎症活动度和纤维化程度的评分比较。结果恩替卡韦组患者治疗12、24个月HBV-DNA阴转率分别为68.4%、80.4%,明显高于阿德福韦酯组患者的31.1%、41.9%(P均<0.05);2组HBeAg阴转率比较差异无统计学意义(P>0.05)。2组患者治疗后血清肝纤维化指标(PCⅢ、LN、HA、ⅣC)水平均低于治疗前(P均<0.01),且恩替卡韦组治疗后各指标均低于阿德福韦酯组(P均<0.05)。恩替卡韦组治疗后24个月组织学炎症活动度、肝纤维化程度评分均低于阿德福韦酯组,差异均有统计学意义(P<0.05)。结论肝纤维化程度的改善与抗病毒疗效密切相关,恩替卡韦治疗HBeAg阳性的慢性乙型肝炎较阿德福韦酯更能抑制HBV复制,可改善肝纤维化程度。     

乙肝表面抗原滴度动态变化对慢乙肝患者拉米夫定耐药后加用阿德福韦酯挽救治疗效果的预测价值研究

目的探讨拉米夫定耐药后e抗原(HBeAg)阳性慢乙肝(CHB)患者血清表面抗原(HBsAg)滴度的动态变化对拉米夫定联用阿德福韦酯挽救治疗疗效的预测价值。方法收集51例拉米夫定耐药的HBeAg阳性CHB患者联用阿德福韦酯挽救治疗前后的血清,检测并分析不同应答组各时间点丙氨酸氨基转移酶(ALT)、HBsAg滴度、乙肝病毒(HBV)DNA载量差异。结果从基线到治疗12周开始,发生病毒学应答VR(+)组患者HBsAg滴度较无应答VR(-)组患者下降更快(P=0.041)。治疗12周时HBsAg滴度预测病毒学应答的ROC曲线下面积最大(AUC=0.821,P=0.006)。ROC曲线提示HBsAg为3.50 lg IU/ml时对应的Youden指数(0.612)最大。结论拉米夫定耐药后加用阿德福韦酯挽救治疗12周时HBsAg≤3.50 lg IU/ml可作为预测治疗72周发生病毒学应答的指标。     

自拟扶肝康方对阿德福韦酯治疗慢性乙型肝炎疗效的影响

目的:观察自拟扶肝康方联合阿德福韦酯治疗慢性乙型肝炎(CHB)的临床疗效.方法:将86例CHB患者随机分为治疗组(44例)与对照组(42例),治疗组给予自拟扶肝康方联合阿德福韦酯治疗,对照组单用阿德福韦酯治疗.根据不同证型辨证论治,每日服中药1剂,疗程48周.结果:治疗组的肝功能在治疗后4、12周内复常率明显高于对照组(P《0.01);在12周治疗组的HBV-DNA阴转率均较对照组明显增高(P＜0.01).且治疗组中阿德福韦酯临床耐药率明显降低.结论:自拟扶肝康方联合阿德福韦酯治疗,可提高CHB患者抗病毒治疗的持续应答率,提高临床疗效.     

阿德福韦酯治疗慢性乙肝及代偿期肝硬化合并肾损害的临床分析

研究阿德福韦酯治疗慢性乙肝及代偿期肝硬化合并肾损害的临床效果。纳入我院2014年5月~2015年2月慢性乙肝及代偿期肝硬化患者100例并根据随机数字表法分为均等两组。常规组采用常规利尿、保肝和抗病毒等治疗,阿德福韦酯组在常规组基础上加用阿德福韦酯治疗。比较两组患者慢性乙肝及代偿期肝硬化治疗总有效率;ALT复常率、HBV DNA转阴率、HBe Ag血清学转换率、肾损害发生率;给药前和给药后患者肝纤维化指标的差异。阿德福韦酯组慢性乙肝及代偿期肝硬化治疗总有效率显著比常规组高,P<0.05;阿德福韦酯组相较于常规组ALT复常率、HBV DNA转阴率、HBe Ag血清学转换率更高,肾损害发生率更高,P<0.05;给药前两组肝纤维化指标相似,P>0.05;给药后阿德福韦酯组相较于常规组肝纤维化指标改善更显著,P<0.05。阿德福韦酯治疗慢性乙肝及代偿期肝硬化效果确切,可有效改善肝功能,提高血清学转换率,但阿德福韦酯用药可造成一定肾损害,但均为可逆性,需加强注意。     

阿德福韦酯联合胸腺肽治疗慢性乙型肝炎

目的 评价阿德福韦酯联合胸腺肽治疗慢性乙性肝炎的疗效,探讨两者治疗的协同作用.方法 将207例HBV DNA及HbeAg阳性的患者随机分成两组,A组采用阿德福韦酯联合胸腺肽治疗.B组采用阿德福韦酯单独治疗.A组在阿德福韦酯组治疗基础上加用胸腺肽1.6 mg皮下注射,2次/周,连用48周;B组给予阿德福韦酯10 mg/d,连用48周.结果 与结论阿德福韦酯联合胸腺肽治疗慢性乙性肝炎疗效明显优于阿德福韦酯单独治疗,具有显著的抗炎和抗病毒作用,在整体治疗慢性乙肝方面具有一定的优势,是慢性乙肝患者安全经济有效的治疗方法.     

阿德福韦酯单用与拉米夫定/阿德福韦酯序贯治疗对慢性乙型肝炎的疗效对比观察

目的:观察阿德福韦酯单用与拉米夫定/阿德福韦酯序贯治疗慢性乙型肝炎的疗效。方法:75例慢性乙型肝炎患者分为单用阿德福韦酯组41例,每日服用阿德福韦酯10 mg,疗程48周。拉米夫定/阿德福韦酯序贯治疗组34例,每日服用拉米夫定100 mg,24周后换用阿德福韦酯10 mg,总疗程48周。结果:联合治疗组在12周时有更高的ALT复常率及HBVDNA转阴率(P<0.05)。结论:序贯治疗组具有更高的早期应答率,有助于尽快控制病情。     

Determination of creatine kinase isoenzyme MB activity in serum using immunological inhibition of creatine kinase M subunit activity. Activity kinetics and diagnostic significance in myocardial infarction.

This is a new method for the determination of creatine kinase isoenzyme MB activity in serum. The method uses direct activity measurement of creatine kinase B subunit activity after blocking of CK-M subunit activity by inhibiting antibodies. The test takes no longer than 15 min. The method yields an intra-serial C.V. of 2.0-12.9%, and a C.V. from day to day of 5.5%. The detection limit is 3.4 U/l creatine kinase MB. In the 95 cases with proven myocardial infarction several types of creatine kinase MB activity kinetics could be determined. The percentage of creatine kinase MB of peak CK-total is 6-25%, with a mean of 11.1%. The amount of creatine kinase MB with respect to total CK activity after reinfarction is higher than the amount after initial infarction.     

俯卧位通气对高海拔地区肺复张治疗无效急性呼吸窘迫综合征患者氧合的影响

目的 探讨俯卧位通气对高海拔地区肺复张术(RM)治疗无效急性呼吸窘迫综合征(ARDS)患者的治疗作用.方法 从海拔2260m的地区医院筛选RM治疗无效的41例ARDS患者[平均氧合指数( PaO2/FiO2)较RM前升高＜20％视为RM无效],依不同病因分为肺内源性ARDS组(ARDSp组)和肺外源性ARDS组(ARDSexp组),每组再按信封法随机分为俯卧位组和仰卧位组,即ARDSp俯卧位组(11例)、ARDSp仰卧位组(9例)、ARDSexp俯卧位组(10例)、ARDSexp仰卧位组(11例).在通气前及通气1、2、3、4h监测动脉血氧分压( PaO2)、PaO2/FiO2、静态顺应性(Cst)、气道阻力(Raw)的变化.结果 通气lh时,ARDSexp俯卧位组PaO2/FiO2( mm Hg,l mm Hg=0.133 kPa)即较通气前显著升高(157.4±40.6比129.3±48.7,P＜0.05),并随通气时间延长呈持续增高趋势,4h达峰值(219.1 ±41.1);且ARDSexp俯卧位组通气3h内PaO2/FiO2较其他3组显著增高,另3组间则差异无统计学意义.ARDSp俯卧位组、ARDSexp俯卧位组通气4h时PaO2/FiO2均较相应仰卧位组显著增高(208.8±39.7比127.4±47.1,219.1±41.1比124.9±50.8,均P＜0.05).4组通气前后Cst无显著改变,各组间差异也无统计学意义.ARDSp俯卧位组通气4h时Raw(cmH2O·L-1·s-1)较通气前显著降低(6.8±1.7比10.7±1.8,P＜0.05),且明显低于其他3组;其他3组各时间点Raw组内及组间比较差异均无统计学意义.结论 俯卧位通气作为ARDS机械通气重要策略之一,可以改善RM无效高原ARDS患者的氧合,为抢救患者赢得宝贵的时间.     

Digital imaging among medical facilities

The Department of Veterans Affairs (VA) in the USA operates a network of 172 medical centres which all utilize a hospital information system (HIS) which has been developed and is currently maintained by the VA. During the past several years, an image management and communication module has been developed, installed and clinically utilized at the Washington DC and Maryland VA Medical Centres. This image management and communication system, referred to as the decentralized hospital computer program (DHCP) imaging system, is fully integrated with a commercial picture archiving and communication system (PACS). The system is utilized to capture, archive, and display all images generated within the hospital including radiology, nuclear medicine, pathology, endoscopy, bronchoscopy, and dermatology, intraoperative photographs, ECG data, and a limited number of paper documents. The ultimate goal of the project is to have all patient text and image data available at any clinical workstation to any authorized user anywhere within the network of medical centres. Clinical requirements for an imaging workstation include ease of use, rapid and reliable access to the complete set of patient information, and images which are of acceptable quality to meet the requirements of the user and the subspecialty. Patient confidentiality and data security must be safeguarded at all times. Integration of the images with the remainder of the patient's database was found to be critical to the success of the project. The experience at the Washington and Maryland facilities suggests that an imaging system that is successfully integrated with a hospital information system can provide substantial clinical and economic benefits both within and among medical centres. Clinical acceptance and utilization of the system has been excellent, particularly in diagnostic radiology where DHCP Imaging has been interfaced to a commercial PAC system. Based upon this initial experience, the VA has begun to deploy the system throughout its large network of medical centres.     

Myocardial elastography at both high temporal and spatial resolution for the detection of infarcts

Myocardial elastography is a novel method for noninvasively assessing regional myocardial function, with the advantages of high spatial and temporal resolution and high signal-to-noise ratio (SNR). In this paper, in-vivo experiments were performed in anesthetized normal and infarcted mice (one day after left anterior descending coronary artery [LAD] ligation) using a high-resolution (30 MHz) ultrasound system (Vevo 770, VisualSonics Inc., Toronto, ON, Canada). Radiofrequency (RF) signals of the left ventricle (LV) in longitudinal (long-axis) view and the associated electrocardiogram (ECG) were simultaneously acquired. Using a retrospective ECG gating technique, 2-D full field-of-view RF frames were acquired at an extremely high frame rate (8 kHz) that resulted in high-quality incremental displacement and strain estimation of the myocardium. The incremental results were further accumulated to obtain the cumulative displacements and strains. Two-dimensional and M-mode displacement images and strain images (elastograms), as well as displacement and strain profiles as a function of time, were compared between normal and infarcted mice. Incremental results clearly depicted cardiac events including LV contraction, LV relaxation and isovolumetric phases in both normal and infarcted mice, and also evidently indicated reduced motion and deformation in the infarcted myocardium. The elastograms indicated that the infarcted regions underwent thinning during systole rather than thickening, as in the normal case. The cumulative elastograms were found to have higher elastographic SNR (SNR(e)) than the incremental elastograms (e.g., 10.6 vs. 4.7 in a normal myocardium, and 6.0 vs. 2.4 in an infarcted myocardium). Finally, preliminary statistical results from nine normal (m = 9) and seven infarcted (n = 7) mice indicated the capability of the cumulative strain in differentiating infracted from normal myocardia. In conclusion, myocardial elastography could provide regional strain information at simultaneously high temporal (>/=0.125 ms) and spatial ( approximately 55 microm) resolution as well as high precision ( approximately 0.05 microm displacement). This technique was thus capable of accurately characterizing normal myocardial function throughout an entire cardiac cycle, at the same high resolution, and detecting and localizing myocardial infarction in vivo.     

Clinical Pharmacokinetics of Morphine

Morphine, the most widely used mu-opioid analgesic for acute and chronic pain, is the standard against which new analgesics are measured. A thorough understanding of the pharmacokinetics of morphine is required in order to safely and effectively use this analgesic in a wide variety of patients with different levels of organ function. A MEDLINE search was conducted to identify literature published between 1966 and January 2002 relevant to the pharmacokinetics of morphine. These publications were reviewed and the literature summarized regarding unique and clinically important elements of morphine disposition relative to its parenteral administration (including intravenous, intramuscular, subcutaneous, epidural and intrathecal administration), absorption profile (immediate release, controlled release, and sublingual/buccal, and rectal administration), distribution, and its metabolism/ excretion. Special populations, including infants, elderly, and those with renal/liver failure, have a unique morphine pharmacokinetic profile that must be taken into account in order to maximize analgesic efficacy and reduce the risk of adverse events.     

手转胎头术失败的原因与分娩结局临床分析

目的 探讨手转胎头术失败的原因与分娩结局.方法 选择2008年1月至2010年12月于我院住院分娩的持续性枕横位、枕后位产妇198例,根据行手转胎头术后结果分为成功组126例、失败组72例.比较两组分娩结局,对比分析失败原因.结果 失败组胎儿体质量≥3500 g的发生率[76.4％(55/72)]明显高于成功组[31.7％(40/126)],差异有统计学意义(x2=30.177,P=0.001)、失败组宫缩乏力发生率[58.3％(42/72)]高于成功组[38.1％ (48/126)],差异有统计学意义(x2=7.569,P=0.006)、失败组骨盆临界或轻度狭窄发生率[38.9％ (28/72)]高于成功组[23.8％(30/126)],差异有统计学意义(x2 =5.030,P=0.002)、失败组手转胎头时机不当(宫口开大＜6 cm、胎头位于坐骨棘上及宫口开大8～10 cm、胎头位于坐骨棘下≥2 cm)发生率[61.1％(44/72)]高于成功组[38.9％(49/126)],差异有统计学意义(x2=9.084,P=0.003).失败组母儿并发症(产后出血、产褥病率、胎儿窘迫、新生儿窒息)发生率高于成功组(x2 =9.586,P=0.002、x2=9.334,P=0.002、x2=5.910,P=0.015、x2=5.240,P=0.022)、失败组剖宫产发生率[72.2％(52/72)]明显高于成功组[34.1 ％(43/126),x2=26.641,P=0.001)].结论 手转胎头术能使难产变顺产,降低剖宫产率,减少母儿并发症,但须积极预防、处理导致手转胎头术失败的原因,对矫正失败后继续矫正及试产应慎重.     

Evidence-Based Pain Management and Palliative Care in Issue Four for 2009 of The Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly. Issue 4 for 2009 contains 4027 complete reviews, 1906 protocols for reviews in production, and 11447 one-page summaries of systematic reviews published in the general medical literature. In addition, there are citations of 600,000 randomized controlled trials, and 12,200 cited papers in the Cochrane methodology register. The health technology assessment database contains over 7500 citations. This edition of the Library contains 90 new reviews, of which 19 have potential relevance for practitioners in pain and palliative medicine.     

Wie zuverlässig sind Angaben zu nichtentzündlichen ausgedehnten Schmerzen?

ZusammenfassungFragestellung Es wurde geprüft, wie sich der Differenziertheitsgrad zweier Schmerzmessmethoden auf Angaben zur Ausgedehntheit klinischer Schmerzen auswirkt. Zugleich wurde der Referenzzeitraum variiert, über den die Patienten berichten sollten.Methode Erfasst wurde der Einfluss zu Lasten der Befragungsdifferenziertheit durch den Vergleich zweier Körperschema-Bildvorlagen. Drei Referenzzeiträume (Schmerz aktuell, letzte Woche, letztes halbes Jahr) wurden vorgegeben.Ergebnisse Patienten mit ausgedehnten Schmerzen gaben bei differenzierter Befragung um so mehr Schmerzen an, je weiter die Schmerzen zurück lagen und je größer der Berichtszeitraum war. Patienten mit gelenknahen Schmerzen gaben bei hoch differenzierter Befragung weniger ausgedehnte Schmerzen in der Vergangenheit an als bei globaler Einschätzung. Patienten mit Rückenschmerzen berichteten bei differenzierter Befragung zum aktuellen Schmerz über weniger ausgedehnte Schmerzen als bei globaler Befragung.Schlussfolgerung Die Angaben zur Schmerzausdehnung variieren vor allem bei Patienten mit ausgedehnten Schmerzen in Abhängigkeit von der Differenziertheit der Befragung. In diesen Fällen ist die Wahrscheinlichkeit erhöht, dass sich die Beschwerdesymptomatik zumindest teilweise erst in der Reaktion auf die situativen Befragungsbedingungen konstituiert und daher nicht auf andere Befragungsbedingungen generalisiert werden kann.