《2023年欧洲肝病学会临床实践指南：妊娠期肝脏疾病管理》摘译

妊娠期肝脏疾病包括妊娠期肝病, 以及在妊娠期间偶然发生的急性和慢性肝脏疾病, 无论是否与妊娠相关, 妊娠期间的肝脏疾病都与孕产妇及胎儿的高发病风险和高死亡风险相关。因此, 欧洲肝病学会邀请相关专家制定临床实践指南, 旨在根据现有的最佳证据, 为肝病学家、胃肠病学家、妇产科医师、全科医师、培训专家, 以及为该患者群体提供护理的医疗保健人员提供妊娠期肝脏疾病管理建议。     

妊娠期肝病的临床特征及研究进展

严重的妊娠期肝病临床罕见。妊娠期肝病最常见的发病原因为肝功能紊乱,总发病率约为3%。妊娠期肝病主要分为妊娠期特有肝病和非妊娠期特有肝病,即妊娠前已经存在的基础性肝病或妊娠期间偶发肝病。对妊娠期已存在的肝脏疾病及合并的肝脏疾病进行鉴别诊断,有助于改善母婴结局。在临床诊断、选择治疗、干预方式时,应优先考虑对母婴的潜在影响。介绍了妊娠期主要肝脏疾病的概况、发病机制、治疗和妊娠结局的最新研究进展,阐述了患基础性肝病的妊娠风险及应对措施,以指导临床诊疗和患者管理。     

妊娠期肝病临床研究进展

根据肝损伤与妊娠的关系可将妊娠期肝病分为妊娠期特异性肝病和肝病合并妊娠。妊娠期特异性肝病指的是只发生在妊娠期的肝脏疾病,而肝病合并妊娠指的是既往肝脏疾病基础上合并妊娠。由于妊娠期涉及母亲和胎儿健康的特殊性,妊娠期肝病的诊治对产科和肝病科医生都具有一定挑战性。在妊娠过程中迅速识别诊断及处理相关疾病,对母亲和胎儿预后十分重要。总结评述了妊娠期肝病的流行病学、发病机制、临床表现、诊断治疗、预后等方面研究进展,以期为更多临床医生提供给参考。     

2016年美国胃肠病学院临床指南:肝脏疾病与妊娠

育龄肝病患者能否怀孕?妊娠前、妊娠中、生产时及生产后应当如何处理?这是长期困扰临床肝病和消化病医师及广大肝病患者的常见而重要的问题,其关注的焦点是母体与胎儿的安全性.针对这些问题,美国胃肠病学院(American College of Gastroenterology,ACG)于2016年2月发布了《肝脏疾病与妊娠》这一临床指南[1],旨在对罹患肝病的妊娠妇女所面临的诊断和处理问题进行较全面的述评,并采用“推荐意见分级的评估、制订和评价(the grading of recommendation assessment,development,and evaluation,GRADE)”系统(表1)对各类循证医学证据进行评估,进而提出36条诊治和预防建议(表2),并指出应用这些建议时应注意灵活性和个体化.现介绍如下.     

妊娠特有肝病诊治进展

妊娠期肝脏存在正常的生理变化。尽管如此,妊娠期仍有3%的孕妇出现肝功能异常。妊娠特有肝病是妊娠期肝功能异常的常见原因,在死亡的妊娠期妇女中,约0%～25%孕妇死于妊娠特有性肝病。提高对妊娠特有肝病的认知度和诊治水平尤为重要。本文回顾了近几年有关妊娠特有肝病的研究文献,总结了部分妊娠特有肝病的诊断和治疗进展,供临床医师参考。     

《美国肝病研究学会-感染疾病研究学会关于成人感染HCV筛查、管理和治疗指南(2015)》简介

美国肝病研究学会(American Association for the Study of Liver Diseases,AASLD)和美国感染疾病研究学会(Infectious Diseases Society of America,IDSA)联合制定的《美国肝病研究学会-感染疾病研究学会关于成人感染HCV筛查、管理和治疗指南(2015)》已于2015年6月在线发表于《Hepatology》,对丙型肝炎最新筛查、管理、治疗办法进行了具体介绍。本文对该指南推荐意见进行高度概括并予以介绍。     

妊娠期甲状腺疾病诊治中的困惑与思考

妊娠对甲状腺功能影响很大,反之母体甲状腺功能异常对妊娠过程和胎儿也会带来不良后果.约有15％的妊娠妇女患有不同程度的甲状腺功能异常,包括临床甲状腺功能减退(甲减)、亚临床甲减(SCH)、临床甲状腺功能亢进(甲亢)、亚临床甲亢、低甲状腺素血症(低T4血症)和甲状腺功能正常单纯甲状腺过氧化物酶抗体( TPOAb)阳性.根据本课题组调查妊娠前半期临床甲减、亚临床甲减、低T4血症和单纯TPOAb阳性的患病率分别为0.37％、5.27％、2.15％和8.6％[1].由此可见,妊娠期甲状腺疾病是妊娠妇女的常见病、多发病.最近几年,甲状腺功能与孕产期相互影响的认识进展迅速,2007年由美国内分泌学会牵头,国际上4个甲状腺学会和美国临床内分泌医师学会的专家耗时2年,汇总271篇文献,共同完成了《妊娠期和产后甲状腺疾病临床处理指南》[2].时隔4年,在2011年10月,美国甲状腺学会( ATA)首次颁布了该学会的《妊娠期和产后甲状腺疾病诊断和处理指南》(ATA指南)[3].ATA指南采用问答形式提出了84个问题,结合相关领域的317篇文献展开讨论,然后根据临床证据强度分级(USPSTF)给出76个临床推荐.以下结合ATA指南,就在妊娠期甲状腺疾病诊治中尚存争议的问题重点论述.     

成人肝移植术后长期管理:美国肝脏疾病和移植学研究协会2012实践指南

正本指南为肝移植成年受者的管理提供数据支持,已由肝脏疾病研究协会和美国移植学会批准。美国肝脏疾病研究协会实践指南采用的分类被建议所采纳,该建议的力度被分为强或弱(1级或2级)。支持建议的证据被定为3个水平:高、中、低(A、B、C)。肝移植(liver transplantation,LT)是失代偿期肝硬化、急性肝衰竭、小肝癌,或急性肝功能衰竭患者的有效     

中美欧三大指南对酒精性肝病诊断的共识与差异

2010年Hepatology发表了美国肝病学会酒精性肝病(alcoholic liver disease,ALD)诊疗指南(简称美国指南)[1],并在中华肝脏病杂志给予介绍;同年中国肝病学会脂肪肝和酒精性肝病学组也发表了中国的ALD诊疗指南(简称中国指南)[2];2012年欧洲肝病学会在J Hepatol上发表了欧洲ALD诊疗指南(简称欧洲指南)[3],欧州指南在本期由曾民德教授给与详细介绍和述评.     

第58届美国肝病学会年会纪要

第58届美国肝病学会年会于2007年11月1-6日在美国波士顿召开。本次年会报道了近一年来肝脏疾病基础研究与临床治疗新进展。2日下午和3日全天为继续教育的内容；主题是“肝脏疾病：肝脏疾病治疗的病理生理基础”。大会交流分为七个部分，分别是遗传性肝病、病毒性肝炎、脂肪性肝炎、肝脏血管性疾病、门静脉高压、肝移植以及肝胆肿瘤。本次大会对肝脏疾病取得的进展进行了广泛的交流，限于篇幅，仅对肝脏疾病临床治疗新进展进行简要介绍。     

The history of the (Young) AEMI(E) and the EFIM

The European Federation of Internal Medicine (EFIM) was formed in 1996 through a merger between the Association Européenne de Médicine Interne (d' Ensemble) (AEMI(E)) and the Forum of Presidents of National Societies of Internal Medicine (IM). It arose as a result of ideas from Carcassi (Rome/Cagliari) and Merino (Alicante) to transform the largely French-speaking and rather elitist AEMI into a more easily accessible and English-speaking federation of national societies. The founding meeting of the General Assembly of the EFIM took place in May 1996 in Paris. Since then, the EFIM has initiated many activities, some of them originating from the time of the AEMI(E).     

Central bisectionectomy (bisegmentectomy) of the liver (with video)

Surgical techniques and indications for central bisectionectomy (bisegmentectomy) of the liver, i.e., resection of Couinaud's segments 4, 5 and 8, are described. Parenchymal dissection between the left medial and lateral sections is performed by dividing Glisson's branches arising from the right side of the umbilical portion towards the confluence between the middle and left hepatic veins. Parenchymal dissection between the right anterior and posterior sections is performed along the demarcation line created by obliterating the Glisson's pedicle of the right anterior section (Couinaud's segments 5 and 8), and then along the left side of the right hepatic vein. The root of the middle hepatic vein is divided at the bottom of the right and left plane of the parenchymal division. The indications for central bisectionectomy include benign and malignant tumors occupying both the left medial and right anterior sections, i.e., Couinaud's segments 4, 5 and 8, while sparing the left lateral and right posterior sections, i.e., Couinaud's segments 2, 3, 6 and 7. This technique is advocated especially for liver tumors arising in chronic liver diseases such as hepatocellular carcinoma complicating viral hepatitis and metastatic liver tumor with concomitant steatosis of the non-cancerous liver parenchyma, for which right or left trisectionectomy could result in less than optimal remnant liver volume and function.     

Diffusivity of Methane in a Mixture of CCl(4) and c-C(6)F(11)C(2)F(5) of the Critical Composition in the Region above the Temperature of Separation

The diffusivity of CH₄ in a mixture of CCl₄ and c-C₆F₁₁C₂F₅ of the critical composition in the region of temperature close to that of unmixing, decreases as in a homogeneous liquid from 36° to about 32°. It then passes through a minimum of 10⁵D ≈ 4.15 cm²/sec at about 27.5°, then rises to 10⁵D = 4.61 at 25.00°, then steeply to 6.36 cm²/sec in the further drop of only 0.3° to 24.71°.     

Human immunodeficiency virus (HIV) antigenemia (p24) in the acquired immunodeficiency syndrome (AIDS) and the effect of treatment with zidovudine (AZT)

Infection with human immunodeficiency virus (HIV) may cause viral antigenemia, detected primarily as p24 viral core protein. Among 16 patients with the acquired immunodeficiency syndrome (AIDS) or AIDS-related complex studied serially, 12 had or developed antigenemia ranging from 16 to 3006 pg/mL in plasma. The level could be categorized as high (greater than 100 pg/mL) or low (15 to 65 pg/mL). Three patients with anti-p24 antibody had no antigenemia. Zidovudine (AZT), 200 or 250 mg every 4 hours, reduced antigenemia by about 90%; other regimens were less effective. Leukocyte cultures were positive for HIV from patients with antigenemia, and in one third of samples in the absence of antigenemia. High levels of antigenemia correlated with symptoms, CD4 cell count, and prognosis. Drug toxicity requiring a lower dose was followed by increased antigenemia, recurrent symptoms, and decreased CD4 cells, suggesting lymphocyte toxicity. Monitoring antigenemia can be useful in evaluating patients with HIV infection and in evaluating the effect of antiviral chemotherapy.     

Variations of the pre-coronary times (1973-1977) (author's transl)

A comparison has been made between the pre-coronary times of IMA patients in the UCIC of the S. Camillo Hospital in Rome between 1973 and 1977, and the pre-coronary times of patients in another UCIC in the same city, in order to record possible modifications. From 1973 to 1977 there has been a decrease in the pre-coronary times: this is the result of a better hospitalization policy and more frequent admission directly to the UCIC. The mortality rate according to the data in question, has also decreased from 21% in 1973 to 10% in 1977, with a marked reduction for patients with a pre-coronary time superior to 12 hours. This is also connected to the fact that there is a considerable reduction in the number of patients, generally suffering from serious complications, transferred to UCIC from other wards. From an analysis of the data we infer that there has been an improvement in the policy governing the admission of patients to UCIC, a policy which could be improved further by a more adequate training both for doctors and the population in general.