原发性醛固酮增多症中不同筛查和确诊试验的应用及评价

目的比较血浆醛固酮与肾素活性比值(ARR)、卡托普利试验(CCT)及盐水负荷试验(SIT)在原发性醛固酮增多症(PA)中的诊断效率。方法回顾性连续纳入2008年8月至2016年6月在中山大学孙逸仙纪念医院内分泌科住院的原发性高血压(EH)患者183例及PA患者105例的临床资料,利用受试者工作特征(ROC)曲线分析不同试验的诊断效率。结果共288例行筛查试验,基础ARR切点为27.2(ng/dL)/[μg/(L·h)]时,敏感性为86.7%,特异性为90.7%。261例行CCT,试验后血浆醛固酮浓度(PAC)、PAC抑制率(%)及ARR的ROC曲线下面积分别为0.876(95%CI0.828~0.924,P0.001)、0.691(95%CI 0.621~0.760,P0.001)和0.932(95%CI0.898~0.966,P0.001),三者比较,CCT后ARR的诊断效率最高(P0.001)。108例行SIT,试验后PAC及ARR的ROC曲线下面积分别为0.795(95%CI 0.675~0.915,P0.001)和0.915(95%CI 0.838~0.991,P0.001),SIT后ARR的诊断效率更高(P0.05)。102例同时行CCT和SIT,一致性检验Kappa值为0.715(P0.001);比较CCT后ARR、SIT后ARR及联合两指标的ROC曲线下面积,三者间差异无统计学意义。结论基础ARR筛查效率较高;CCT后ARR及SIT后ARR具有较高的诊断效率,两者一致性较好,但联合两者未能提高诊断效率。     

采用化学发光法测定的立位醛固酮与肾素比值筛查四川省高血压人群中原发性醛固酮增多症的切点

目的 应用化学发光法检测立位血浆醛固酮浓度(PAC)和直接肾素浓度(DRC),计算醛固酮与肾素比值(ARR),探索立位ARR用于筛查四川省高血压人群原发性醛固酮增多症(PA)的切点。方法 纳入2020年10月至2022年5月在四川大学华西医院内分泌代谢科进行PA筛查的高血压患者423例,采用化学发光法测定立位2 h的PAC、DRC,应用受试者工作特征(ROC)曲线确定立位ARR筛查PA的切点,进一步分析不同性别和年龄患者中ARR切点的变化。结果 在纳入的高血压患者中,确诊为PA 199例,原发性高血压(EH)224例。PA患者的立位ARR高于EH患者[12.1(5.5～30.0)比0.5(0.2～1.1)(ng/dL)/(mU/L),Z=-17.434,P<0.001]。ROC曲线显示,当立位ARR切点为2.4 (ng/dL)/(mU/L)时,约登指数最大,其敏感度为95.5%,特异度为94.2%。男、女患者筛查PA的立位ARR切点值分别为2.0、2.4 (ng/dL)/(mU/L),敏感度分别为96.5%、95.6%,特异度分别为95.3%、91.5%。年龄≤40、>40...     

醛固酮与直接肾素浓度比值联合醛固酮在老年高血压人群原发性醛固酮增多症筛查中的应用

目的探索老年高血压人群中筛查原发性醛固酮增多症(PA)的醛固酮与直接肾素浓度比值(ARR)的最佳切点,评价ARR联合醛固酮水平在提高筛查特异度中的作用,以减少确诊试验带来的风险。方法入选2016年3月至2019年3月,中国医学科学院阜外医院高血压病区收治的年龄60～80岁、经卡托普利抑制试验或静脉盐水负荷试验确诊为PA的患者65例,同时收集年龄、性别匹配的确诊为原发性高血压(EH)的患者118例。采用化学发光法测定直接肾素浓度、醛固酮浓度。根据ARR绘制受试者工作特征(ROC)曲线,取得最佳筛查切点。比较单用ARR与ARR联合醛固酮的ROC曲线下面积(AUC)。结果 ARR的AUC为0.859(95%CI 0.807～0.911)。ARR切点定在4.4 (ng/dL)/(mU/L)时,约登指数最高,此时诊断PA的敏感度为80.0%,特异度为78.8%。ARR≥4.4 (ng/dL)/(mU/L)联合醛固酮≥15 ng/dL时敏感度为72.3%,特异度为96.6%。联合ARR与醛固酮用于初筛PA时,AUC为0.911(95%CI 0.867～0.954),较单用ARR显著改善(P=0.038)。结论 ARR≥4.4 (ng/dL)/(mU/L)可考虑作为老年PA的初筛切点,联合醛固酮可改善筛查特异性。     

基于质谱法的坐位盐水抑制试验诊断原发性醛固酮增多症的适宜切点研究

目的探索基于质谱法诊断原发性醛固酮增多症(PA)的坐位盐水抑制试验(SSST)适宜切点。方法横断面研究。收集2018年1月至2022年3月就诊于重庆医科大学附属第一医院疑为PA而进行SSST的患者, 包括PA患者300例、原发性高血压(EH)患者119例。采用液相色谱-串联质谱法(LC-MS/MS)测定SSST后血浆醛固酮浓度(PAC), 以原发性醛固酮增多症确诊试验(PACT)评分作为诊断PA的参考标准, 构建受试者工作特征曲线(ROC)并探索诊断PA的适宜切点。结果 PA患者年龄(50.8±10.5)岁, 男性159例(53.00%);EH患者年龄(49.4±11.2)岁, 男性32例(26.89%)。SSST后PAC诊断PA的ROC曲线下面积为0.819(95%CI 0.775～0.862)。当选择PAC 40 pg/ml(110.8 pmol/L)作为诊断PA的适宜切点时, 敏感度为83.67%(95%CI 78.88%～87.56%), 特异度为60.50%(95%CI 51.10%～69.21%), 95.09%(155/163)的单侧PA患者能够被识别。结论质谱法测定SS...     

应用血浆肾素浓度进行原发性醛固酮增多症筛查的评价及不同体位筛查效率的比较

目的 比较应用血浆醛固酮/血浆肾素活性(PAC/PRA,ARR)及PAC/血浆肾素浓度(PAC/PRC,AARR)进行原发性醛固酮增多症(PA)筛查的特异性和敏感性差异,评价测定血浆肾素浓度在PA筛查中的价值,并比较不同体位下AARR的筛查效率.方法 (1)对28例通过确诊试验或手术病理证实的PA患者和51例原发性高血压患者测定卧位、立位1 h和立位2 h的AARR,比较不同体位和时间下测定的AARR在PA筛查中的效率.(2)对31例PA患者、242例原发性高血压患者及145名健康志愿者测定立位1h PAC、PRA和PRC,计算ARR和AARR,通过构建ARR和AARR对诊断PA的受试者工作特征曲线(ROC),比较两者在PA筛查中的敏感性和特异性,探讨AARR在筛查PA中的价值,并确定最佳的切点.结果 (1)卧位、立位1 h和立位2 h AARR的ROC曲线下面积分别是0.950(95%CI 0.906～0.994,P<0.01)、0.979(95%CI 0.956～1.000,P<0.01)和0.917(95%CI0.856～0.979,P<0.01).立位1 h AARR具有最高的筛查效率.(2)立位1 h Log-PRA和Log-PRC相关系数为0.705,Log-ARR和Log-AARR的相关系数为0.788.ARR和AARR的ROC曲线下面积分别为0.998(95%CI0.981～1.000,P<0.01)和0.957(95%CI0.929～0.985,P<0.01).AARR的最佳切点为42.36 ng·dl-1/ng·dl-1,其敏感性和特异性分别达到87.10%和93.75%.结论 应用AARR和ARR在高血压患者中进行PA的诊断效果相当,以立位1 h测定的AARR具有最佳的筛查效率,最佳切点为42.36 ng·dl-1/ng·dl-1.     

评价卧立位醛固酮与肾素比值诊断原发性醛固酮增多症的价值

目的 探讨高血压患者卧立位检测血浆醛固酮浓度(plasma aldosterone concentration,PAC）与血浆肾素浓度(plasma renin concentration, PRC)比值（ratio of aldosterone/rennin,ARR）对原发性醛固酮增多症（primary aldosteronism,PA）的诊断价值与临床应用。 方法 回顾性分析2018~2019年240例高血压卧立位试验阳性或可疑阳性患者,通过卡托普利试验阳性联合盐水负荷试验阳性确诊114例PA患者及126例原发性高血压（essential hypertension,EH）患者。采用化学发光法检测卧立位PAC及PRC,基于受试者工作特征曲线分析诊断PA卧立位PAC、ARR截断点,评价不同指标诊断PA的敏感性及特异性。 结果 PA组与EH组间年龄、性别等基线资料差异无统计学意义,以卡托普利试验联合盐水负荷试验同时阳性为诊断标准,卧位ARR诊断PA最佳截断点6.73,敏感度=79.8%,特异度=90.5%,ROC曲线下面积为0.916(95% CI:0.873,0.948）;卧位PAC诊断PA的截断点18.15,敏感度83.3%,特异度64.3%,ROC曲线下面积为0.777 (95% CI:0.719,0.828）;立位ARR诊断PA的截断点4.08,敏感度58.8%,特异度87.3%,ROC曲线下面积为0.798 (95% CI:0.742,0.847）;立位PAC诊断PA截断点24.39,敏感度69.3%,特异度74.6%,ROC曲线下面积为0.744 (95% CI:0.687,0.801）。 结论 卧立位ARR较卧立位PAC诊断PA的特异度强而敏感度差,综合两种体位下的激素检查结果可提高诊断PA的准确性。     

坐位盐水试验对原发性醛固酮增多症的诊断价值及切点探究

目的 评估坐位盐水试验(SSST)对原发性醛固酮增多症(PA)的诊断价值及适宜切点.方法 分析2018年9月至2019年9月就诊于重庆医科大学附属第一医院内分泌科的242例PA高危的高血压患者的临床资料,所有患者均接受SSST和氟氢可的松试验(FST).以FST作为PA的诊断标准,利用受试者工作特征(ROC)曲线评价S...     

卡托普利抑制试验给药后不同时间测定的醛固酮水平对原发性醛固酮增多症患者诊断的价值

目的：探讨卡托普利抑制试验（CCT）中给药后不同时间测定的血浆醛固酮水平（PAC）对原发性醛固酮增多症（PA）患者诊断的价值。方法：纳入2019年1月至2020年6月于中国医学科学院阜外医院高血压中心住院筛查的继发性高血压患者45例,其中男性18例（40%）,女性27例（60%）,平均年龄（50.60±10.33）岁。立位试验醛固酮/肾素值（ARR）≥2.4(ng/dl)/（μIU/ml）,需进一步行CCT的患者共45例,根据2 h CCT法将患者分为PA组和非PA组。于给药前及给药后1 h、1.5 h及2 h抽血化验PAC、直接肾素浓度（DRC）、皮质醇（COR）水平。结果：PA组患者20例,非PA组患者25例。两组患者的PAC、ARR变化均在给药后随采血间隔时间延长呈下降趋势,DRC在给药后随采血间隔时间延长呈上升趋势（P均<0.001）,这种差异主要由0～1 h的差异所产生（P均<0.05）,而1～1.5 h、1.5～2 h之间的PAC、 DRC、ARR变化差异均无统计学意义（P均>0.05）。PAC 1 h及PAC 1.5 h截断点均为9.95 ng/dl,灵...     

苏北地区ALD,ARR,ALD联合ARR诊断原发性醛固酮增多症的价值

目的:评估血浆醛固酮(ALD)、醛固酮/肾素活性比值(ARR)、ALD联合ARR在高血压患者中对原发性醛固酮增多症(PA)的诊断价值.方法:收集于我院和医联体医院就诊的346例ARR＞15的高血压患者.根据卡托普利试验(CCT)/静脉盐水负荷试验(SIT)结果,患者被分为原发性高血压(EH)组(237例)和PA组(10...     

贝叶斯判别分析在原发性醛固酮增多症诊断中的价值研究

目的探讨贝叶斯判别分析在诊断原发性醛固酮增多症中的价值。方法收集2008年7月至2013年12月近5年重庆医科大学附属第一医院疑诊原发性醛固酮增多症(原醛)病例321例,分为原发性醛固酮增多症组和原发性高血压组。利用贝叶斯判别函数获取原醛分类函数系数及原醛后验概率,根据受试者工作特征曲线(ROC),获取最佳切点。进一步对此法及立位血浆醛固酮/肾素浓度比值(ARR)在原醛筛查中的价值进行对比。结果原醛后验概率为0.34时,其诊断原醛的灵敏度和特异度最高,分别为0.84、0.84,立位ARR切点取43.45时灵敏度和特异度达最高,分别为0.88、0.76,原醛后验概率的ROC曲线下面积为0.911(0.870-0.951),大于立位ARR曲线下面积0.893(0.845-0.941)。结论贝叶斯判别分析诊断原醛的价值优于立位ARR。     

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     

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。     

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。