原发性甲状旁腺功能亢进症致高钙血症静脉注射双膦酸盐治疗后低钙血症相关因素分析

目的 探讨原发性甲状旁腺功能亢进症(PHPT)致高钙血症患者经静脉注射双膦酸盐治疗后出现低钙血症的相关危险因素。方法 纳入2011年～2022年解放军总医院收治的PHPT致高钙血症患者54例。根据血清钙检测结果，将所有患者分为正常血钙组(45例，血钙≥2.25 mmol/L)和低血钙组(9例，血钙<2.25 mmol/L);根据使用双膦酸盐药物的不同，再将所有患者分为唑来膦酸组(37例)、帕米膦酸二钠组(10例)和伊班膦酸组(7例)。收集所有患者的一般资料、临床表现、实验室及影像学检查结果、诊治情况并分组进行比较。采用二元logistic回归分析评估PHPT患者经静脉注射双磷酸盐治疗后出现低钙血症的危险因素；采用受试者工作特征(ROC)曲线评估相关指标对PHPT患者发生低钙血症的预测价值。结果 正常血钙组患者BMI、腰椎及股骨颈骨矿密度(BMD)均高于低血钙组，腰椎BMD T及Z值、股骨颈BMD T及Z值均低于低血钙组(P<0.05);三种静脉注射双膦酸盐药物组降钙疗效及达最低血钙天数比较差异均无统计学意义(P>0.05)。二元Logistic回归分析结果显示，PHP...     

高龄老年女性骨质疏松患者骨代谢特点及使用双膦酸盐的疗效

目的研究高龄(≥80岁)老年女性骨质疏松患者骨代谢特点及使用双膦酸盐的疗效。方法回顾2005年8月至2013年8月在上海交通大学附属第一人民医院骨质疏松门诊就诊的初诊患者,所有患者均接受双膦酸盐药物治疗≥12个月,用药前后测骨密度(bone mineral density,BMD)和骨转换指标(bone turnover marker,BTM)等,≥80岁的高龄老年女性骨质疏松患者232例(高龄老年组)和47~65岁的绝经后女性骨质疏松患者454例(对照组)。记录所有纳入患者的年龄、身高,体质量、体质量指数(body mass index,BMI),用药时间,治疗前后骨密度、血钙、血磷、血清25-羟维生素D(25-hydroxy-vitamin D,25OHD)、骨钙素(bone gamma-carboxyglutamic-acid-containing proteins,BGP)和Ⅰ型胶原羧基端肽(Ⅰtype collagen pyridine cross-linked final peptide,β-CTx)等临床资料。结果两组治疗前BMI、血钙、血磷和L1-4BMD差异无统计学意义;高龄老年女性骨质疏松患者的骨转换水平、股骨颈BMD、全髋BMD和25OHD明显低于对照组(P0.05)。双膦酸盐治疗12个月后,两组BMD和25OHD水平均增加,骨转换指标均下降。高龄老年组L1-4BMD升高3.29%,股骨颈BMD升高1.24%,全髋关节BMD升高1.00%;对照组L1-4BMD升高3.51%,股骨颈BMD升高1.18%,全髋关节BMD升高1.58%。两组BMD升高程度比较差异无统计学意义(P0.05);老年组BGP下降23.63%,β-CTx下降40.62%,对照组BGP下降36.65%,β-CTx下降60.26%,两者下降程度比较差异有统计学意义(P0.05);老年组25OHD升高17.85%,对照组升高8.97%;双膦酸盐治疗12个月后,两组血钙和血磷比较差异无统计学意义(P0.05)。结论高龄老年骨质疏松患者骨转换水平处于低骨转换状态,对于不同骨转换水平的骨质疏松患者,双膦酸盐增加BMD的作用相似,双膦酸盐可以应用于80岁以上的老年骨质疏松患者。     

早期应用双膦酸盐在老年非小细胞肺癌治疗中的作用

目的探讨早期静脉应用双膦酸盐在老年非小细胞肺癌(NSCLC)治疗中的作用。方法对照研究中国石油中心医院住院治疗的老年NSCLC患者68例,将骨密度(BMD)T-Score≤-2.5作为双膦酸盐应用指征,在确诊骨转移之前即开始应用双膦酸盐定义为早期应用。按是否早期应用双膦酸盐,将68例患者按照临床分期分为两组,早期应用双膦酸盐患者34例为治疗组;未早期应用者34例为对照组。比较两组骨转移发生率及确诊时间。结果治疗组骨转移发生率47.06%(16/34),对照组82.35%(28/34),二者差异显著(χ~2=9.27,P0.01);治疗组中位骨转移发生时间较对照组延迟87(218 vs 131)d,二者差异显著(P=0.006)。结论早期应用双膦酸盐治疗经老年NSCLC患者,可以减少骨转移发生率,并推迟骨转移发生时间。     

高钙危象的诊治

高钙血症是临床较常见的内分泌代谢紊乱之一,按血钙升高水平可将高钙血症分为轻、中和重度,轻度高血钙为血总钙值＜3.0 mmol/L,中度为血总钙值3.0～ 3.5 mmol/L,重度为血总钙值＞3.5 mmol/L,同时可导致一系列严重的临床征象,即称高钙危象,其可危及生命,是内科急症之一.高钙血症最常见的原因为原发性甲状旁腺功能亢进症(PHPT)和恶性肿瘤,占总致病因素的90％以上.高钙危象发生时需要及时有效地降低血钙水平,使血钙维持在相对安全的范围,对于PHPT患者有效的治疗可以争取时间明确定位诊断以尽早手术达到根治[1].     

二膦酸盐对2型糖尿病绝经后妇女骨密度及骨生化指标的影响

目的观察二膦酸盐对2型糖尿病绝经后女性患者骨密度以及生化指标的影响。方法2型糖尿病绝经后女性骨密度减低患者55例,随机分为两组,二膦酸盐组和糖尿病对照组,分别给予二膦酸盐10mg/d、维生素B110mg/d;基础用药:钙尔奇D600mg/d,治疗1年。检测治疗前后空腹血糖(FBS)、空腹胰岛素(Ins)、糖基化血红蛋白(HbA1c)。治疗前后采用双能X线骨密度测量仪(DEXA)测量腰椎、髋部骨密度;检测血清骨钙素、尿吡啶酚/尿肌酐(尿PYD/Cr);观察新骨折发生和不良反应。结果二膦酸盐治疗组腰椎骨密度增加1.45%,髋部骨密度增加1.93%;而对照组腰椎、髋部的骨密度分别下降0.7%、2.3%;二膦酸盐治疗组血清骨钙素、尿PYD/Cr分别下降17%、24%。二膦酸盐的不良反应主要为上腹部不适。结论二膦酸盐能提高2型糖尿病绝经后女性患者骨密度;结合补充适量钙剂,是预防和治疗2型糖尿病病人绝经后骨质疏松症的重要手段。     

双膦酸盐治疗原发性骨质疏松症疗程的研究进展

双膦酸盐是目前临床上抗骨质疏松症的一线药物,已被证实在降低椎体和非椎体骨折方面疗效显著。但近年来研究发现,长期应用双膦酸盐不仅不能产生额外的收益,而且可能诱发如下颌骨坏死(ONJ)和不典型股骨骨折(AFF)等严重不良反应的出现,并由此提出"药物假期"的问题。本文将对近年来国内外关于"药物假期"的文献研究进行综述,为原发性骨质疏松患者提供更加合理的用药参考。     

双膦酸盐类药物处方点评工作实践

目的了解该院门诊和住院双膦酸盐类药物的使用情况,探讨双膦酸盐类药物处方专项点评的工作模式和方法。方法回顾性抽取该院2013-04~2014-03双膦酸盐类药物全部门诊处方和住院医嘱,对双膦酸盐类药物各品种的处方使用率进行统计分析;并逐张处方进行用药合理性点评,对不适宜处方进行问题分类统计分析。结果该院门诊2013-04~2014-03双膦酸盐类药物处方共计3 080张,其中唑来膦酸1 594张(51.75%)和阿仑膦酸1 341张(43.54%)为门诊应用最多的双膦酸盐类药物。相关科室住院病历中使用双膦酸盐类药物共计2 958人次,住院使用率为19.95%,其中以唑来膦酸1 585张(63.72%)和帕米膦酸二钠856张(25.56%)为临床应用最为广泛。专项处方点评辨识出不适宜处方689张,占全部用药处方和医嘱的11.67%。处方问题涉及适应证不适宜186张(27.00%)、用法用量不适宜310张(44.99%)、溶媒选择不适宜24张(3.48%)、配伍不适宜135张(19.59%)、其他不适宜34张(4.93%)。结论该院双膦酸盐类药物处方和医嘱用药仍存在不适宜问题。开展专项处方点评工作有助于发现用药典型问题,为合理用药干预和持续改进提供参考。     

老年女性骨质疏松性骨折手术后静脉应用唑来膦酸治疗的临床反应

目的了解老年女性骨质疏松性骨折患者手术后应用双膦酸盐的临床反应,分析常见不良反应的相关特点。方法收集苏州大学附属第二医院骨科151例老年女性骨质疏松性骨折术后初次静脉应用双膦酸盐治疗病例,记录患者年龄、体质量、体质量指数(body mass index,BMI)、腰椎和股骨骨密度(bone mineral density,BMD)、肌酐清除率、Ⅰ型胶原C端肽交联(β-C-terminal peptide of typeⅠcollagen,β-CTX)、Ⅰ型原胶原N端前肽(procollagen typeⅠN-terminal prepeptide,P1NP)、术后用药时间、常见不良反应等数据;按患者不同年龄、体质量指数、骨密度分别分组,分析术后用药时间与不良反应发生的相关性;比较术后2周内与术后≥2周用药时间与常见不良反应(发热、肌肉酸痛、腹泻、排尿困难、结膜充血、恶心、头晕和头痛)发生的相关性。结果在年龄分组中,80～89岁年龄段组术后用药时间(18.4±21.7) d与不良反应发生率(25%)的相关系数为-0.314,差异有统计学意义(P0.05),其他各年龄组都提示术后用药时间与不良反应发生无相关性(P0.05);在BMI、骨密度分组中,术后用药时间与不良反应发生无相关性(P0.05);"术后2周内应用组"与"术后≥2周应用组"之间,发热、肌肉酸痛、腹泻、排尿困难、结膜充血、恶心、头晕和头痛等不良反应发生率均差异无统计学意义(P0.05)。结论 80岁以上骨质疏松性骨折术后静脉应用双膦酸盐的时间间隔应适当延长;在骨科手术后静脉应用双膦酸盐时,早期应用(2周)或晚期应用(≥2周)与常见不良反应发生无相关性。     

以高钙危象起病的原发性甲状旁腺功能亢进症误诊一例

为探讨高钙危象病因的诊断和治疗,对1例以高钙危象为首发症状的原发性甲状旁腺功能亢进症患者的临床资料进行回顾性分析.该例患者高钙危象反复发作,病因诊断历经波折,术后证实为甲状旁腺腺瘤.原发性甲状旁腺功能亢进症的主要临床特点为高血钙、低血磷、碱性磷酸酶升高、骨骼病变、尿路结石、消化性溃疡等,约90％以上是由甲状旁腺腺瘤引起,在确诊后切除肿瘤为治疗首选.     

血钙正常的原发性甲状旁腺功能亢进症

血钙正常的原发性甲状旁腺功能亢进症是近年来逐渐被认识的疾病,其诊断要点是血总钙、血离子钙水平持续正常,血甲状旁腺素(parathyroid hormone,PTH)水平升高,同时需除外继发性甲状旁腺功能亢进的因素。其诊断多在进行骨质疏松症或其他疾病检查时发现,部分患者临床无症状,部分有骨质疏松、骨折、肾结石等靶器官损害或代谢异常。关于其发病机制、临床表现、自然进程、转归目前尚无统一意见,双膦酸盐、拟钙剂药物治疗及手术切除治疗或有益处。     

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.     

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。     

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。     

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     

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.     

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。     

Angiographic diagnosis of the degree of serosal invasion of carcinoma of the colon

Angiography using Prostaglandin El^® was performed on 38 patients with carcinoma of the colon in order to diagnose the degree of serosal cancer invasion. The findings at angiography were classified into four groups:1) AG-S3, abnormal change (irregularity and/or encasement) up to marginal vessels; 2) AG-S2, abnormality up to vasa recta; 3) AG-S1, abnormality of penetrating branches of vasa recta within the wall of the colon; and 4) AG-S0, no distinct findings of abovementioned vessels. These angiographic findings were compared with both macroscopic and microscopic serosal cancer invasion. Angiographic diagnosis is in accord with the macroscopic findings in 84.2 percent of cases. Angiographic diagnosis is in accord with the microscopic findings in 32.4 percent of cases. Macroscopic findings confirm the angiographic diagnosis precisely but the conflict with microscopic findings should not be overlooked. This may be the result of inflammatory change, adhesion, and fibrosis around carcinoma of the colon.