糖尿病足溃疡感染的诊治

糖尿病足溃疡感染的诊断依据是临床炎性表现,其感染严重程度分1～4级,常为多重需氧菌感染,厌氧菌可单独或联合作用.创面所处的环境、感染的类型和严重程度不同,其细菌学特点亦不同.糖尿病足溃疡感染需多学科综合治疗,包括外科治疗(清创、血管重建等)、使用抗生素或其他辅助治疗(如粒细胞集落刺激因子).有效治疗多能控制感染、降低截肢率.所以,糖尿病足溃疡感染需要明确诊断、有效治疗,从而改善预后.     

��������������

糖尿病足部病变是糖尿病常见并发症之一,临床主要表现为足部溃疡、感染和坏疽,给患者带来很大的痛苦和沉重的经济负担,其后果常会导致截肢甚至危及生命.1999年,世界卫生组织(WHO)对糖尿病足定义为:糖尿病患者合并神经病变及各种不同程度末梢血管病变而导致下肢感染、溃疡形成和(或)深部组织的破坏.     

前列腺素E1治疗老年糖尿病足的疗效

糖尿病足( diabetic foot,DF)是由糖尿病综合因素引起的足部疼痛、皮肤深溃疡、肢端坏疽等病变的总称,是与下肢远端神经异常和不同程度的周围血管病变相关的足部感染、溃疡和深层组织破坏,是糖尿病慢性并发症之一,也是导致糖尿病患者致残死亡的主要原因之一[1].主要临床表现为足部溃疡和坏疽,严重者需要截肢,截肢率高达40％.中国国内糖尿病患者并发足坏疽的约占0.9％ ～ 1.7％,60岁以上的老年病人并发DF坏疽的占2.8％ ～14.5％.近年来,我院采用前列腺素E1(PGE1)治疗老年糖尿病足患者,取得良好疗效.     

糖尿病足创面的局部治疗

糖尿病足是糖尿病的严重并发症之一.良好的创面治疗可以促进创面愈合,减少截肢风险.糖尿病足溃疡创面的局部治疗主要包括局部减压、清创和敷料及高级伤口愈合产品的应用.近年,新观念、新技术及新材料小断涌现,并且取得了显著的临床疗效.如速成全接触石膏支具在减压中的应用.蛆虫疗法应用于糖尿病足清创日趋成熟,新型敷料及高级愈合产品通过多种生理机制促进糖尿病溃疡的愈合.本文主要对糖尿病足创面的局部治疗及相关研究作一综述.     

糖尿病周围神经病变的诊断方法

糖尿病周围神经病变( DPN)难以治愈,不仅影响患者生活质量,还易造成其足部疼痛、溃疡、截肢等不良后果.现有的DPN诊断方法或对早期病变灵敏度低,如临床评分方法、单丝检测;或为侵入性检查,如皮肤活检、神经活检,亟需灵敏、简单、有效且安全的方法.一些新的诊断技术如泌汗功能检测、足底压力测定、角膜共聚焦显微镜等也已在临床上开始应用.     

糖尿病足溃疡的临床特点及危险因素分析

WHO将糖尿病足(DF)定义为〔1〕:糖尿病患者由于合并神经病变及各种不同程度末梢血管病变而导致下肢感染、溃疡形成和(或)深部组织的破坏。溃疡是DF发展的常见后果,致残率较高,在老年人中的发病率可达2.7%～14.5%,如果不及时治疗可引起截肢甚至死亡〔2〕。本文回顾性分析DF溃疡患者的临床特点及危险因素。     

下肢动脉血管病变对糖尿病足部溃疡疗效及预后的影响

对267例Ⅰ～Ⅴ期糖尿病足部溃疡患者用彩色多谱勒超声检测双下肢动脉血管情况.在全身综合治疗的基础上,溃疡局部彻底清创后用黄芪液加适量短效胰岛素外敷局部,观察溃疡处肉芽组织生长时间(GT),溃疡愈合时间(HT),治愈率,截肢率.结果①显著狭窄者19例,中度28例,轻度34例,血管病变发生率为30.34%.②其GT和HT均显著长于患肢无动脉血管病变者(均P＜0.05);③且有血管病变的患者截肢率高达35%,亦显著高于无血管病变的足部溃疡患者(P＜0.01),且严重血管病变时不仅溃疡病变严重,而且截肢率高达82%;④GT和HT与下肢血管狭窄的程度呈显著的正相关关系(r1=0.4679,P＜0.05,r2=0.5377,P＜0.05).结论下肢血管病变不仅是糖尿病足部溃疡的主要原因之一,而且也是影响疗效及预后非常重要因素,提示改善下肢血流状态将有助于足部溃疡的愈合.     

避免截肢,小伤不容忽视

在我国糖尿病发病率高,由于糖尿病早期症状不典型,很多患者病情发现时常因并发症而就诊,尤其是小伤不重视。造成感染,足部溃疡甚至截肢。重视小伤,防截肢糖尿病足是指糖尿病患者由于合并神经病变,及各种不同程度末梢血管病变,而导致下肢感染、溃疡形成和(或)深部组织的破坏。糖尿病引起的下肢血管病变,是糖尿病足发病的主要原因,长期     

糖尿病足截趾患者的转归——5年的随访研究

目的 观察糖尿病截趾患者的转归情况,并对影响因素进行分析.方法 根据截趾后愈合情况,将245例糖尿病截趾患者分为愈合组(n=202)和未愈合组(n=43),分析影响愈合的因素.并对愈合组进行随访,记录患者足部新发溃疡、再截肢、死亡情况及日常生活能力状况,对影响因素进行相关分析.结果 截趾后愈合率为82.4％.愈合组随访率为91.6％.1、3和5年的累积新发溃疡率为27.3％、57.2％和76.4％;1、3和5年的累积再截肢率为17.5％、22.3％和47.1％;1、3和5年的累积死亡率为3.8％、15.1％和32.7％,死亡患者平均生存期为3.8(95％ CI3.4～4.1)年.多因素分析:HbA1c( ＞9％)是截趾术后愈合、新发溃疡和再截肢的危险因素;年龄(＞70岁)是再截肢、死亡和日常生活能力受损的危险因素.结论 截趾术后愈合效果好,但愈合后长期随访结果并不乐观.高龄患者预后差,良好的血糖控制可改善预后.     

伤口负压引流在高能量四肢开放骨折中的应用

目的评价在高能量四肢开放性损伤中伤口负压引流的作用。方法对51例高能量所致四肢开放性损伤（GustiloⅢ）患者行常规清创、适当固定,软组织损伤一期使用负压引流装置维斯第敷料覆盖,二期闭合伤口。对其感染率、是否需要截肢、骨折不愈合需要进一步处理、伤口闭合方法、手术至最终闭合伤口的时间进行分析。结果本组病例中18例出现感染,其中13例需要进一步手术治疗。GustiloⅢA型感染率为12.5%,ⅢB型感染率为63%,ⅢC型为42%。13例需要二期手术促进骨折愈合。2例患者行二期截肢。5例患者通过清创及维斯第治疗可直接闭合伤口,46例患者须行游离皮片移植或皮瓣手术闭合伤口。结论使用伤口负压引流作为四肢开放骨折伤口的临时覆盖物,与传统方法治疗效果相近,但可能有助于减少二期软组织重建手术以闭合伤口。     

胰岛素瘤的解剖分布特点分析

目的胰岛素瘤是最常见的胰腺神经内分泌肿瘤，因其临床表现多样，导致诊断困难。影像学诊断尤其是超声内镜(EUS)在胰岛素瘤的诊断中起着重要作用，拥有较高的敏感性和特异性。本研究拟通过明确胰岛素瘤的解剖分布特点，以期有助于提高影像学的诊断准确率和降低漏诊率，尤其是在教育和培训实践中对于EUS的学习者更具有指导价值。 方法回顾性分析解放军总医院第一医学中心病案资料数据库1993年1月至2019年11月经外科手术、病理确诊为胰岛素瘤的患者的临床资料，检索方法采取搜索术后病理诊断为"胰岛素瘤"的病例，通过查阅病例的方法，提取出胰岛素瘤的大小和解剖分布等数据，进一步分析其特点。 结果共检索到确诊为胰岛素瘤的患者116例，其中，男45例、女71例，年龄13～76岁，平均年龄(44.4±14.85)岁。胰岛素瘤单发110例(94.8%)、多发6例(5.2%)。位置分布：头颈部46例(39.7%)，单发45例、多发1例；体尾部68例(58.6%)，单发65例、多发3例；全胰腺多发2例(1.7%)。病变大小特点：最大径0.4～3.4 cm，平均大小(1.53±0.58)cm。≤1 cm 29例、>1 cm而≤1.5 cm41例、>1.5 cm而≤2.0 cm28例，≤3 cm 15例，>3 cm 3例。年龄与肿瘤的大小相关，≤44岁患者肿瘤平均大小为(1.36±0.51)cm、>44岁患者肿瘤平均大小为(1.70±0.60)cm，P<0.05。头颈部的肿瘤大于体尾部的肿瘤，头颈部肿瘤平均大小(1.66±0.63)cm，体尾部(1.42±0.52)cm，P<0.05。 结论胰岛素瘤在胰腺体尾部较头颈部更好发；绝大多数单发，但可以全胰腺多发；多数小于1.5 cm，肿瘤的大小与患者年龄和肿瘤的解剖分布相关。     

Pathogenesis of carcinoma of the papilla of Vater

Most adenomas and carcinomas of the small intestine and extrahepatic bile ducts arise in the region of the papilla of Vater. In familial adenomatous polyposis (FAP) it is the main location for carcinomas after proctocolectomy. In many cases symptoms due to stenosis lead to diagnosis at an early tumor stage. In about 80%, curative intended resection is possible. Operability is the most relevant prognostic factor. Most ampullary carcinomas resp. carcinomas of the papilla of Vater develop from adenomatous or flat dysplastic precursor lesions. They can be sited in the ampulloduodenal part of the papilla of Vater, which is lined by intestinal mucosa. They also can develop in deeper parts of the ampulla, which are lined by pancreaticobiliary duct mucosa. Intestinal-type adenocarcinoma and pancreaticobiliary-type adenocarcinoma represent the main histological types of ampullary carcinoma. Furthermore, there exist unusual types and undifferentiated carcinomas. Many carcinomas of intestinal type express the immunohistochemical marker profile of intestinal mucosa (keratin 7?, keratin 20+, MUC2+). Carcinomas of pancreaticobiliary type usually show the immunohistochemical profile of pancreaticobiliary duct mucosa (keratin 7+, keratin 20?, MUC2?). Even poorly differentiated carcinomas, as well as unusual histological types, may conserve the marker profile of the mucosa they developed from. These findings underline the concept of histogenetically different carcinomas of the papilla of Vater which develop either from intestinal- or from pancreaticobiliary-type mucosa of the papilla of Vater. Molecular alterations in ampullary carcinomas are similar to those of colorectal as well as pancreatic carcinomas, although they appear at different frequencies. In future studies, molecular alterations in ampullary carcinomas should be correlated closely with the different histologic tumor types. Consequently, the histologic classification should reflect the histogenesis of ampullary tumors from the two different types of papillary mucosa.     

Lack of correlation of degree of villous atrophy with severity of clinical presentation of coeliac disease

BACKGROUND AND AIM: Both the clinical presentation and the degree of mucosal damage in coeliac disease vary greatly. In view of conflicting information as to whether the mode of presentation correlates with the degree of villous atrophy, we reviewed a large cohort of patients with coeliac disease. PATIENTS AND METHODS: We correlated mode of presentation (classical, diarrhoea predominant or atypical/silent) with histology of duodenal biopsies and examined their trends over time. RESULTS: The cohort consisted of 499 adults, mean age 44.1 years, 68% females. The majority had silent coeliac disease (56%) and total villous atrophy (65%). There was no correlation of mode of presentation with the degree of villous atrophy (p=0.25). Sixty-eight percent of females and 58% of males had a severe villous atrophy (p=0.052). There was a significant trend over time for a greater proportion of patients presenting as atypical/silent coeliac disease and having partial villous atrophy, though the majority still had total villous atrophy. CONCLUSIONS: Among our patients the degree of villous atrophy in duodenal biopsies did not correlate with the mode of presentation, indicating that factors other than the degree of villous atrophy must account for diarrhoea in coeliac disease.     

Demonstration of the mechanism of action of biguanides

Summary Palmitic acid oxidation in rat diaphragm homogenate is depressed by biguanide concentrations that are still incapable of inhibiting oxidative phosphorylation. Glucose oxidation is not directly effected by the same biguanide concentrations: however, the inhibitory effect of palmitic acid on glucose oxidation is partly removed by biguanides. Inhibition of fatty acid oxidation, which accounts for most of the metabolic effects caused by these drugs, can be regarded as the fundamental mechanism of action of biguanides. There is some evidence suggesting that these drugs might interact with carnitine, thus preventing long-chain fatty acids from being transported across the mitochondrial membrane to the site of oxidation. Traduzione a cura degli AA.     

血吸虫童虫生长发育及其机制的研究进展

血吸虫童虫是宿主免疫系统攻击的重要靶标,包括皮肤型、肺型和肝门型童虫。宿主分子对童虫生长发育具有重要作用。童虫生长发育机制包括免疫调节、信号转导、性别发育及凋亡等。肌动蛋白、组织蛋白酶、烯醇化酶和葡萄糖基转移酶等分子为血吸虫童虫生长发育的重要分子。本文对血吸虫童虫生长发育及其机制的研究进展做一综述。     

124例耐多药结核分枝杆菌基因突变特征分析

目的对临床分离的耐多药结核分枝杆菌相关基因的突变特征进行分析。方法对124例耐多药结核分枝杆菌以及50株敏感株的耐药相关基因(包括异烟肼inh A、kat G、oxyR-ahp C间隔区以及利福平rpo B)进行序列测定,分析其基因突变情况。结果异烟肼耐药inh A基因突变率为14.5%;kat G基因突变率为70.2%(87/124),主要位于315位;oxyR-ahp C间隔区突变率为15.3%;inh A、kat G两种基因同时突变率75.0%,三种基因同时突变率为89.5%。利福平rpo B基因突变的检出率高达95.2%,突变主要发生在531、526、516位点。结论我省耐多药菌异烟肼耐药相关基因最常见突变为kat G 315、inh A C-T(-15)、axyR-ahp C间隔区(-10)C-T,利福平为rpo B531、526、516。结合MDR-TB耐药相关基因的特征分析,可以建立一种快速、准确、特异的适合于我省的检测结核菌耐多药性的新方法。     

Assessment of quality of life of parents of children with juvenile chronic arthritis

The aim of the study was to assess the quality of life (QOL) and the psychological status of parents of children with juvenile chronic arthritis (JCA). The QOL, anxiety and depression of the parents of 28 children with JCA were evaluated and compared to those of the parents of 28 healthy children. Mothers of JCA children and mothers of healthy children reported similar QOL. The reported anxiety and depression levels were similar for mothers and fathers in both groups. The parents of children with pauciarticular-type JCA reported lower QOL and higher levels of anxiety and depression than the parents of children with other types, namely polyarticular and systemic JCA. These findings may be explained by the fact that the pauciarticular patients had shorter disease duration and were less frequently seen in the outpatient clinic. The QOL of mothers of children with JCA was found to be slightly impaired in the group of children with pauciarticular JCA. Future larger studies are needed to confirm these results, as the number of subjects in the three groups was rather low. Received: 26 September 2001 / Accepted: 8 February 2002     

Numerical Simulation of the Effect of Rate of Change of Glucose on Measurement Error of Continuous Glucose Monitors

Background

A 5-day in-patient study designed to assess the accuracy of the FreeStyle Navigator® Continuous Glucose Monitoring System revealed that the level of accuracy of the continuous sensor measurements was dependent on the rate of glucose change. When the absolute rate of change was less than 1 mg•dl⁻¹•min⁻¹ (75% of the time), the median absolute relative difference (ARD) was 8.5%, with 85% of all points falling within the A zone of the Clarke error grid. When the absolute rate of change was greater than 2 mg•dl⁻¹•min⁻¹ (8% of the time), the median ARD was 17.5%, with 59% of all points falling within the Clarke A zone.

Method

Numerical simulations were performed to investigate effects of the rate of change of glucose on sensor measurement error. This approach enabled physiologically relevant distributions of glucose values to be reordered to explore the effect of different glucose rate-of-change distributions on apparent sensor accuracy.

Results

The physiological lag between blood and interstitial fluid glucose levels is sufficient to account for the observed difference in sensor accuracy between periods of stable glucose and periods of rapidly changing glucose.

Conclusions

The role of physiological lag on the apparent decrease in sensor accuracy at high glucose rates of change has implications for clinical study design, regulatory review of continuous glucose sensors, and development of performance standards for this new technology. This work demonstrates the difficulty in comparing accuracy measures between different clinical studies and highlights the need for studies to include both relevant glucose distributions and relevant glucose rate-of-change distributions.     

氯硝柳胺悬浮剂的毒性评价

目的评价氯硝柳胺悬浮剂的毒性，为现场大规模应用灭螺提供依据。方法按照中华人民共和国国家标准GB 15670-1995《农药登记毒理学试验方法》和鱼类毒性试验方法进行。结果经口、经皮肤的LDso雌、雄性大鼠均>5 000 mg/kg，经呼吸道的LCso雌、雄性大鼠均>5 000mg/m3，该药经口、经皮肤、经呼吸道毒性均属微毒类药物；兔眼用药后，观察期内无不良反应，对眼无刺激性；皮肤用药后对皮肤无刺激性。与氯硝柳胺原药、氯硝柳胺乙醇胺盐原药和氯硝柳胺乙醇胺盐可湿性粉剂相比，氯硝柳胺悬浮剂对鱼急性毒性最低。结论氯硝柳胺悬浮剂属微毒类药物，对鱼的毒性低于其乙醇胺盐可湿性粉剂，适合于现场应用。     

Study of constancy of hydrogen-consuming flora of human colon

The constancy of the hydrogen consuming flora of the human colon was studied in 15 healthy subjects via two measurements obtained 18 to 36 months apart. Hydrogen disappearance rate and the major products of H₂-consuming bacteria, methane and sulfide, were measured during incubation of fecal homogenates with excess hydrogen and sulfate. In 11/15, the hydrogen consumption rate and the predominant hydrogen-consuming pathway (methanogenesis, sulfate reduction, or neither) remained constant. However, major shifts in these pathways were observed in four subjects, with two losing and two gaining the ability to produce methane. Methanogenesis was associated with the highest hydrogen consumption rate. This study demonstrates that clinically unrecognizable, major alterations of the colonic flora occur in healthy subjects. Understanding of the factors responsible for these alterations might allow for therapeutic manipulation of the colonic flora.Supported in part by the Department of Veterans Affairs and NIDDKD RO1 DK 13309-25.