贲门失弛缓症患者食管压力及运动功能变化的研究

目的研究贲门失弛缓症（achalasia cardia）患者食管下段括约肌（LES）压力及食道体部运动功能的变化。方法采用荷兰MMS多功能消化道测压仪，分别对48例贲门失弛缓症患者与30位正常人测量并记录LES长度、LES静息压力，10次湿咽动作中食道体部收缩及LES松弛功能变化，对LES、食管上括约肌（UES）松弛率和推进性蠕动进行评价。结果贲门失弛缓症患者与对照组相比，LES静息压力明显升高（P＜0．05），LES松弛率明显降低（P＜0．05）；贲门失弛缓症均为无传导性同步蠕动波；病例组与对照组食管体部蠕动波、LES长度、UES的各项指标比较差异均无统计学意义。结论LES压力升高、LES松弛率降低和食管体部运动功能失调是贲门失弛缓症患者的重要特征，对贲门失弛缓症的诊断有指导意义。     

食管测压在不典型贲门失弛缓症诊断中的应用

早期或不典型贲门失弛缓症临床诊断较难,X线钡餐检查敏感性较低.该病可能与食管动力障碍有关,食管测压对其诊断可能有较高的价值.目的:通过分析不典型贲门失弛缓症患者的食管测压参数,探讨其特征性表现,为早期诊断提供依据.方法:对21例不典型贲门失弛缓症、15例典型贲门失弛缓症和10名健康对照者进行食管压力测定.结果:不典型贲门失弛缓症组与典型贲门失弛缓症组的LES静息压类似,但均显著高于健康对照组(P＜0.01).健康对照组、不典型贲门失弛缓症组和典型贲门失弛缓症组的LES残余压呈递增趋势,且两两比较有显著差异(P＜0.01);不典型贲门失弛缓症组仅6例(28.6%)患者LES静息压增加,但有14例(67.7%)LES残余压增加.不典型贲门失弛缓症组50.2%的患者吞咽后LES可完全松弛,松弛率与典型贲门失弛缓症组比较无显著差异,但显著低于健康对照组(P＜0.01).食管体部收缩振幅在三组间无显著差异,多数失弛缓症患者湿咽后表现为无传导性同步收缩,与健康对照组比较有显著差异(P＜0.01).结论:不典型和典型贲门失弛缓症患者的LES静息压和LES松弛率均显著高于健康对照组,但用于诊断贲门失弛缓症敏感性较低.LES残余压对不典型贲门失弛缓症的诊断有较高的敏感性.吞咽后食管体部无传导性同步收缩是所有贲门失弛缓症患者的特征.     

食管压力测定在贲门失弛缓症诊治中的应用及评价

目的 研究贲门失弛缓症患者全覆膜防反流食管支架治疗前后食管压力变化.方法 对30例贲门失弛缓症患者经全覆膜防反流食管支架治疗前后食管压力测定数据进行分析.结果 贲门失弛缓症患者食管下括约肌静息压(LESP)较扩张前显著下降(P<0.05),食管下括约肌松弛率(LESRR)明显提高(P<0.05);支架治疗后食管体部同步收缩峰值增高,食管体部静息压降低(P<0.05),扩张后食管体部同步收缩波与扩张前比较无显著变化.结论 食管压力测定可用于评价全覆膜防反流食管支架治疗贲门失弛缓症的疗效.     

贲门失弛缓症的治疗

贲门失弛缓症是一种病因尚未明确、累及食管平滑肌和下食管括约肌（LES）的动力障碍性疾病。以吞咽时食管体部蠕动消失、LES松弛障碍为特征。本病的治疗方式包括药物、注射肉毒杆菌毒素、气囊扩张术和肌切开术,旨在降低LES压力,促进食管排空,多数患者可获得较理想的结局。本文就贲门失弛缓症的治疗现状作一综述。     

暂时性金属支架扩张术治疗贲门失弛缓症对食管动力中远期的影响

目的:探讨暂时性金属支架治疗贲门失弛缓症对食管动力中远期的影响.方法:19例贲门失弛缓症患者在X线下置入国产可扩张带膜金属支架,术后3-7d由胃镜取出.治疗前、后2wk及2a测定LES静息压、松弛率、食管内24h pH监测,12例健康人测定下食管括约肌(LES)静息压、松弛率.结果:扩张后2wk和2a LES静息压显著低于扩张前LES静息压(12.32±5.87 mmHg,14.21±7.34 mmHg vs 47.43±9.84 mmHg,P<0.05),松弛率显著高于扩张前松弛率压(76.66%,73.46% vs 13.33%,P<0.05),但他们均与正常人无显著差异.扩张后2a GER阳性率显著高.于扩张后2wk及扩张前(66.12% vs 27.72%,2.95%;P<0.01).结论:中远期暂时性金属支架扩张术仍能显著降低贲门失弛缓症患者的LES压力.但GER也显著增加.     

内镜下三种方法治疗贲门失弛缓症后下食管括约肌及体部动力学比较

目的 比较分析内镜下单纯扩张术、扩张加肉毒杆菌毒素注射术及支架扩张术治疗贲门失弛缓症后下食管括约肌(LES)及食管体部动力学变化情况.方法 将99例临床确诊的贲门失弛缓症患者分为扩张组、扩张注射组和支架组,分别进行内镜下单纯扩张术、扩张加肉毒杆菌毒素注射术及支架扩张术治疗,并于治疗前、治疗后1周、治疗后6个月及治疗后12个月分别检测LES静息压、松弛率及食管体部顺行性收缩比例、非协调性收缩比例、LES上10 cm处的收缩幅度,比较分析治疗前后各项指标的变化值.结果 治疗前,各组LES静息压、食管体部非协调性收缩比例、收缩幅度均较正常值显著升高,LES松弛率及食管体部顺行性收缩比例则均显著降低,3组间差异无统计学意义.治疗后1周,3组间各项检测指标与术前比较的变化值差异均无统计学意义.治疗后6个月,扩张注射组和支架组LES静息压、LES松弛率、食管体部收缩幅度的改善情况均优于扩张组,P值分别为0.041、0.006、0.037和0.029、0.004、0.033,但扩张注射组和支架组间比较差异无统计学意义(P值均＞0.05).治疗后12个月,支架组LES静息压、LES松弛率、食管体部顺行性收缩比例、食管体部收缩幅度的改善情况均优于扩张组,P值分别为0.035、0.028、0.008、0.007,扩张注射组与扩张组比较则差异均无统计学意义(P值均＞0.05).结论 内镜下单纯扩张术、扩张加肉毒杆菌毒素注射术及支架扩张术是治疗贲门失弛缓症的有效方法 ,近期疗效显著,远期复发率随时间延长均呈上升趋势,但支架扩张术的远期疗效相对优于其他两种方法 .     

胃镜下气囊扩张治疗贲门失弛缓症的疗效及随访观察

目的 评价胃镜下用Rigiflex气囊扩张器治疗原发性贲门失弛缓症的近期及远期疗效.方法 经临床症状、食管钡餐、食管测压和胃镜检查确诊的125例贲门失弛缓症患者在胃镜下用直径为3.5 cm的Rigiflex气囊扩张器进行扩张,术后根据临床症状积分、食管体正常蠕动率（EPR）、下食管括约肌静息压（LESBP）、下食管括约肌松弛率（LESRR）、下食管括约肌松弛度（LESRD）、食管钡餐和胃镜进行术后1月、6月、1年、3年和5年的随访.结果 治疗后1月内所有患者临床症状积分、LESBP、食管钡餐和胃镜均显著改善（P＜0.01）,EPR、LESRR和LESRD均无显著改善（P＞0.05）,5年随访中有7例复发,有效率达92.14%.治疗中1例出现食管穿孔.结论 在胃镜下用直径3.5 cm的Rigiflex气囊扩张器治疗原发性贲门失弛缓症是非常有效的方法,疗效较持久.随访中间歇性出现的临床症状可能与失调的食管蠕动和LES的松弛有密切关系.     

贲门失弛缓症患者经口内镜下肌切开术后食管动力学变化

目的探讨贲门失弛缓症患者经口内镜下肌切开术(POEM)前后食管动力学变化。方法回顾性分析解放军总医院消化内科2010年12月至2014年9月行POEM术的贲门失弛缓患者205例,其中共66例患者术前及术后食管测压检查完善,包括上食管括约肌静息压(UESP)、残余压(UESRP),下食管扩约肌静息压(LESP)、残余压(LESRP)、松弛率(LESRR),以及食管体部蠕动波,从而对POEM术与食管动力学的改善情况做以评估。对上述指标以x±s采集,采用SPSS 16.0统计软件行配对t检验。结果贲门失弛缓患者行POEM术后症状短期缓解率为95%,术后UESRP(16.468±21.672 vs 8.982±7.601,P=0.008)、LESP(34.678±14.908 vs 16.612±8.671,P=0.000)、LESRP(27.459±10.719 vs 11.313±6.792,P=0.000)较术前明显降低,LESRR较术前明显提高(0.211±0.146 vs 0.297±0.224,P=0.008)。但是POEM术对食管体部正常蠕动波无明确改善。结论 POEM术可有效降低贲门失弛缓患者上食管括约肌(UES)和下食管括约肌(LES)的压力,从而缓解临床症状,其远期效果及最终结论仍需进一步研究。     

经口内镜肌切开术对贲门失弛缓症患者食管动力的影响

目的探讨经口内镜肌切开术（POEM）对贲门失弛缓症患者食管动力的影响。方法对3例贲门失弛缓症患者POEM治疗前后的食管测压结果进行对比分析。结果术后3例患者食管下括约肌压力（LESP）和食管上括约肌残余压（UESRP）均低于术前,且差异有统计学意义（P〈0．05）;术后食管下括约肌残余压（LESRP）有2例明显降低至正常值,有1例变化不大,仍高于正常,平均值较术前降低但差异无统计学意义;术前3例患者均有食管蠕动波消失,术后食管蠕动波均无改善;3例患者术前食管下括约肌松弛率（LESRR）均低于正常值,术后仍均低于正常;食管上括约肌压（UESP）平均值术后较术前降低,但差异无统计学意义。结论POEM近期能明显改善贲门失弛缓症患者的食管动力学特征。     

经口内镜下肌切开术治疗贲门失弛缓症前后食管动力的变化

贲门失弛缓症的治疗目的为降低下食管括约肌压力(LESP),减轻梗阻,改善临床症状。经口内镜下肌切开术(POEM)近年来开始用于贲门失弛缓症的治疗。目的:通过分析手术前后食管动力的变化,评估POEM治疗贲门失弛缓症的近期疗效。方法:纳入2011年12月~2012年10月在南京鼓楼医院诊断为贲门失弛缓症并接受POEM治疗的39例患者,对其手术前后食管液态测压和近期随访结果进行回顾性分析。结果:38例患者完成POEM和术后3 d食管测压。术后3 d LESP较术前显著降低(P0.01),LES松弛率与术前相比无明显差异。术前和术后3 d食管体部均表现为蠕动性收缩消失,同步收缩比例增加。术后1个月随访,LESP仍显著低于术前(P0.05),37例患者吞咽困难明显好转,有效率为94.9%。结论:POEM治疗贲门失弛缓症近期内降低LESP和缓解临床症状效果明显,但对恢复食管蠕动功能作用有限。食管测压对贲门失弛缓症术后疗效评估有一定价值。     

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.     

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.     

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.     

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。     

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.     

治疗高血压药物的经济学评价

重视高血压治疗中的经济学评价,对利用我国有限的卫生资源来遏制高血压对人民群众的危害有着重要的现实意义。药物经济学对于药物治疗的成本和治疗的结果给予同样的关注。因为治疗高血压的费用,不仅涉及药物价格,还包括患者的危险水平,降压疗效和对临床终点事件的影响,以及治疗的依从性和安全性。因此药物经济学更强调整体成本和价-效比。低危病人,若非药价低廉,治疗的价-效比不够理想。而在高危的患者,价-效比越小越经济而不是药费越便宜越好。