中青年糖尿病患者胰岛素治疗存在的问题及护理干预

糖尿病易导致严重的急慢性并发症,已成为影响人们生活质量的一种常见疾病。胰岛素作为降糖激素,在控制糖尿病的发生、发展中有不可取代的作用。本文对中青年糖尿病患者在接受胰岛素治疗方面存在的问题及护理干预进行归纳。     

Lumbar fusion outcomes stratified by specific diagnostic indication

BACKGROUND: One of the primary difficulties in evaluating the effectiveness of lumbar fusion is that, with the exception of spondylolisthesis, specific diagnostic indications for surgery are poorly defined. Diagnostic specificity beyond the symptom of low back pain or the presence of lumbar degeneration needs to be delineated such that outcomes data can be effectively translated into clinical decision making or evidence-based guidelines. PURPOSE: The purpose of this study was to report on prospectively collected clinical outcome measures, stratified by diagnosis, among a series of patients with lumbar degenerative disease whose treatment included lumbar spine fusion. STUDY DESIGN: Demographics, diagnostic categorization, and clinical outcome measures were prospectively collected by six spine surgeons at a single tertiary spine center, as part of the surgeons' standard clinical practice. PATIENT SAMPLE: Four hundred and twenty-eight patients were enrolled in the study and complete 1- and 2-year Health-Related Quality of Life (HRQOL) data were available in 327 patients whose treatment included decompression and posterolateral lumbar fusion. OUTCOME MEASURES: The Oswestry Disability Index (ODI), Short Form-36 (SF-36), numeric rating scales for back pain and leg pain. METHODS: Preoperative diagnosis was classified, in the primary surgical cases, as disc pathology, spondylolisthesis, instability, stenosis, or scoliosis. In revision cases, the diagnosis was classified as nonunion, adjacent level degeneration, or postdiscectomy revision. Patient-reported outcomes at 1 and 2 years post-op were assessed based on diagnostic stratification. Statistical evaluation of clinical outcome was performed for both mean net change in outcome scores and the percentage of patients reaching a minimum clinically important difference (MCID) threshold for each outcome measure. RESULTS: Preoperative diagnosis was spondylolisthesis (n=80), scoliosis (n=17), disc pathology (n=33), instability (n=21), stenosis (n=46), postdiscectomy revision (n=67), adjacent level degeneration (n=40), or nonunion (n=23). Evaluation of 2-year post-op HRQOL measures by diagnostic subgroup revealed the most substantial improvement in ODI score for patients with spondylolisthesis (22.7 points) and scoliosis (21.2 points). Patients with the diagnosis of disc pathology (16.2 points), postdiscectomy revision (14.0 points), instability (12.7 points), stenosis (10.6 points), and adjacent level degeneration (9.5 points) demonstrated a progressively smaller magnitude of ODI improvement. The least ODI improvement at 2 years after surgery was seen in patients with nonunion of a prior fusion (5.5 points). The percentage of patients reaching MCID for ODI at 2 years post-op ranged from 71.0% in the spondylolisthesis subgroup to 34.8% in the nonunion subgroup. The greatest SF-36 physical component score improvement at 2-year follow-up was seen in patients with disc pathology (7.9 points) and spondylolisthesis (7.7 points), followed by scoliosis (6.6 points) and stenosis (6.5 points), instability (5.6 points), postdiscectomy revision (5.3 points) nonunion (3.1 points) and adjacent level degeneration (2.5 points). No significant changes from Year 1 to Year 2 were noted in any of the subgroups. For SF-36 physical component score, percentage of patients reaching MCID ranged from 63.6% in the disc pathology subgroup to 25% in the nonunion subgroup. CONCLUSIONS: This study supports the concept that added diagnostic specificity is a critical component in building an improved evidence base for lumbar fusion surgery. The magnitude of HRQOL improvement was not equal among diagnostic subgroups. The percentage of patients reaching an MCID level of improvement was also significantly influenced by diagnostic stratification. Without diagnostic specificity for entities beyond spondylolisthesis, the absence of well-defined study populations will continue to limit our ability to move toward evidence-based decision making.     

Evaluation of Model for End Stage Liver Disease (MELD)-based systems as prognostic index for hepatocellular carcinoma

Background:  The Cancer of Liver Italian Program (CLIP) and Japan Integrated Scoring System (JIS) used the Child-Turcotte-Pugh (CTP) score to evaluate the liver function.
Aim:  We aimed to evaluate the performance of Model for End Stage Liver Disease (MELD) based CLIP and JIS to predict the prognosis of hepatocellular carcinoma (HCC).
Methods:  Consecutive patients with HCC who presented to our Hepatoma Clinic from January 2003 to April 2005 were studied. MELD-based CLIP and JIS were generated by replacing the original CTP score with MELD score at three categories (<10, 10–14 and >14).
Results:  Among 471 HCC patients (85.1% males; aged 58.8 ± 12.2 years), 73% had chronic hepatitis B, 37.4% had >1 nodule, 84.1% had tumor size >2 cm, 55.0% had Child's B cirrhosis, 12.7% underwent tumor resection and 20.6% received locoregional therapy. The cumulative survival at 3 and 6 months were 67% and 55%, respectively. For 3-month survival, the area under the receiver operating characteristic curves (AUC) of MELD-CLIP (0.69) and MELD-JIS (0.69) were superior to the original systems (0.64, P  = 0.004 and 0.64, P  = 0.0018, respectively). For 6-month survival, AUC of MELD-CLIP (0.64) and MELD-JIS (0.62) were also superior to the original systems (0.54, P  = 0.003 and 0.59, P  = 0.002, respectively). The MELD-based systems performed best among patients who received locoregional therapy to HCC. Advanced cirrhosis (hypoalbuminemia, hyperbilirubinemia, ascites, coagulopathy and elevated creatinine), and cancer (portal vein thrombosis, elevated alpha-fetoprotein, large and multiple tumors) were associated with higher mortality.
Conclusions:  MELD-based systems performed better than Child-Pugh based systems as prognostic indexes for HCC.     

CT结肠成像在结肠癌防治中的应用

近年来,结肠癌的发病率呈明显上升趋势,传统的检查方法包括大便潜血试验、结肠双对比造影和结肠内镜等在结肠癌的防治中具有十分重要的作用,但仍不能完全满足临床要求.CT结肠成像(CT Colonography,CTC)随着其技术的进步,临床应用明显增加,逐渐从一种研究方法变成切实可行的应用技术.显然,CTC因其丰富的后处理技术,全方位的观察手段,可能对结肠癌的防治起到积极的促进作用,CTC不但可观察肠腔内结构,还可清晰显示肠壁、肠腔外情况以及邻近脏器,提供大量的影像学信息,因此有可能成为结肠癌高危人群筛查的有效方法.     

高脂饮食小鼠脂肪和肝矿物元素代谢与游泳运动干预

目的:观察游泳运动干预对高脂饮食小鼠脂肪和肝矿物元素代谢的影响。方法:实验于2005-04/08在广东医学院生理学教研室完成。①实验分组:普通级新生昆明种小白鼠28只,雌15只,雄13只,出生28d即随机摸球法分为普饲组10只、高脂组10只、高脂运动组8只。②实验方法:高脂组和高脂运动组从出生28d至133d给予高脂饲料喂养,共15周。高脂运动组从出生28d开始进行游泳运动,每周游泳5d,前2周8min/d,第3,4周12min/d,以后15min/d,共15周。③实验评估:实验结束时,检测各组小鼠体质量、身长、脂肪质量、血清中胆固醇、三酰甘油含量,原子吸收光谱法测量其肝脏中矿物元素含量。结果:纳入小鼠28只,均进入结果分析。高脂组总胆固醇、皮下脂肪、肠系膜脂肪、腹腔脂肪和三酰甘油含量均高于普饲组(P<0.01),体质量高于普饲组(P<0.05),肝脏脂质沉积程度比普饲组明显,肝中钙、锰、锌、铜含量比普饲组低(P<0.01,P<0.05)。与高脂组比较,高脂运动组三酰甘油含量、皮下脂肪、肠系膜脂肪、腹腔脂肪质量显著减少(P<0.01),体质量、总胆固醇含量降低(P<0.05),肝脏脂质沉积程度明显减轻。肝中钙、锰含量升高(P<0.01),铜、铁含量升高(P<0.05),镁含量下降(P<0.01)。结论:①高脂饮食致脂肪代谢紊乱同时伴有肝矿物元素代谢紊乱。②适量的游泳运动对两者有良好的干预作用。③在同一机体中肥胖和脂代谢紊乱的发生可能与多种矿物元素代谢紊乱密切相关。     

艾灸大鼠天枢、气海穴对结肠成纤维细胞分泌胰岛素样生长因子Ⅰ、转化生长因子β1的调控作用

目的:研究显示,胰岛素样生长因子Ⅰ和转化生长因子β1与溃疡性结肠炎患者肠纤维化的形成关系密切。实验通过艾灸对大鼠结肠成纤维细胞分泌胰岛素样生长因子Ⅰ、转化生长因子β1的影响,探索艾灸防治溃疡性结肠炎肠纤维化机制。方法:实验于2004-05/2005-07在上海中医药大学实验动物室和国家中医药管理局针灸免疫三级实验室完成。①实验材料:SPF级雄性SD大鼠75只,体质量200g左右。②实验分组及处理:采用免疫学方法加局部刺激制备溃疡性结肠炎大鼠模型,随机将大鼠分为正常组、模型组、隔药灸组、温和灸组和西药组。隔药灸组、温和灸组选取天枢、气海穴分别进行隔药灸、温和灸治疗,西药组柳氮磺胺吡啶溶液灌胃治疗,模型组和正常组仅固定不做治疗。治疗结束后麻醉下处死大鼠,剖取结肠组织,分离并培养结肠成纤维细胞。③实验评估:用酶联免疫吸附法检测各组大鼠成纤维细胞上清液中胰岛素样生长因子Ⅰ、转化生长因子β1含量。结果:每组取8只进入结果分析。①造模大鼠结肠黏膜缺损,溃疡形成,胶原纤维增生,Ⅰ、Ⅲ、Ⅳ型胶原纤维排列紊乱,数量增多;肉芽组织、纤维组织增生。②模型组大鼠结肠成纤维细胞大量分泌转化生长因子β1、胰岛素样生长因子Ⅰ;与模型组比较,隔药饼灸、温和灸组大鼠转化生长因子β1分泌量减少(P<0.05,P<0.01),隔药饼灸、温和灸和西药组大鼠胰岛素样生长因子Ⅰ分泌量减少(P均<0.01)。结论:艾灸大鼠天枢、气海穴能抑制大鼠结肠成纤维细胞分泌促细胞外基质细胞因子胰岛素样生长因子Ⅰ、转化生长因子β1,减少细胞外基质的积聚,达到防治肠纤维化的作用。     

丰富环境刺激对缺氧缺血性脑损伤大鼠脑超微结构改变及神经丝蛋白表达的影响

目的:观察丰富环境刺激对缺氧缺血性脑损伤大鼠脑超微结构及神经丝蛋白(NF)的影响。方法:实验于2005-03/2006-06在新桥医院中心实验室完成。取7日龄健康SD大鼠52只随机分为3组:①丰富环境干预组:20只,采用Rice法建立缺氧缺血性脑损伤模型,予早期抚触(15min/次,2次/d)和丰富环境(2h/次,1次/d)刺激共28d。②缺氧缺血非干预组:20只,同前造模,造模后不干预。③正常对照组:12只,不造模,不干预。饲养至1月龄时各组随机选10只进行Morris水迷宫测试学习记忆功能;行为学测定后处死大鼠取脑,免疫组织化学方法观察海马神经丝蛋白的染色情况,借助自动图像分析系统对其进行定量分析;利用透射电镜观察海马神经元超微结构、神经丝蛋白及突触情况。结果:52只进入结果分析。①隐匿平台逃避潜伏期(学习能力):缺氧缺血非干预组较正常对照组明显延长[(39.98±7.86),(26.12±4.03)s,P<0.001],丰富环境干预组较缺氧缺血非干预组缩短[(29.06±5.11)s,P<0.01],与正常对照组无差异。②跨越平台次数(记忆能力):缺氧缺血非干预组明显少于正常对照组[(2.13±1.33),(4.91±2.01)次,P<0.001],丰富环境干预组多于缺氧缺血非干预组[(4.45±1.59)次,P<0.01],与正常对照组无差异。③缺氧缺血非干预组左侧与右侧脑组织NF-H积分吸光度值之比值明显小于正常对照组和丰富环境干预组(0.398±0.110,0.975±0.011,0.821±0.138,P<0.01),后2组比较无差异。④超微结构显示缺氧缺血非干预组海马神经细胞固缩改变,线粒体肿胀,神经丝数量减少,排列稀疏,突触数量减少;丰富环境干预组海马神经元和突触无明显异常。结论:早期抚触及丰富环境刺激可以促进缺血缺氧的脑损伤恢复,脑组织神经网络重建及脑的可塑性增加是其可能的机制之一。     

2型糖尿病的运动疗法及新进展

目的:总结近年来2型糖尿病运动疗法的研究进展。资料来源:应用计算机检索American Diabetes Association(http://www.diabetes.org/home.jsp)2005/2007的相关文章,检索词"Type2diabetes,Exercise therapy",限定文章语言为English。并应用计算机检索中国期刊全文数据库2001-01/2006-12期间的相关文章,检索词"糖尿病的运动疗法",限定文章语言为中文。并手工检索1995-01/2006-12相关专著。资料选择:对资料进行初审,选取与2型糖尿病运动疗法有关的文献。纳入标准:①随机对照研究。②试验包含平行对照组,即饮食控制 药物治疗组。③治疗组为在饮食控制 药物治疗基础上实施运动疗法组。排除综述及重复性研究。资料提炼:共检索到130篇文献,符合纳入标准的30篇,排除5篇重复性研究,2篇meta分析研究。资料综合:①中等强度的有氧耐力运动能够调节糖代谢,降低血糖,增强胰岛素敏感性,延缓糖尿病并发症的发生发展,控制肥胖,降低血脂,提高机体适应性。②运动疗法适用于糖耐量低减、血糖控制良好且无严重并发症的糖尿病患者;运动前应进行必要的检查,以明确能否进行运动疗法。③运动项目因病情不同而异,病情轻者可进行较高强度的运动,病情重者进行较低强度的运动,合适的运动时间为餐后60～90min,运动前后应做好准备活动和整理活动,运动应遵循循序渐进的原则。结论:运动疗法是2型糖尿病的一种行之有效的治疗方法,并能预防、控制2型糖尿病的发生发展,在临床工作中应该得到足够的重视和普及。     

利巴韦林及阿昔洛韦治疗小儿水痘疗效及效价比分析

目的:探讨利巴韦林和阿昔洛韦对小儿水痘的疗效。方法:将108例水痘患儿分为3组。阿昔洛韦组在对照组基础上加用阿昔洛韦注射液15 mg/(kg·d)、分2次静滴。利巴韦林组在对照组基础上加用利巴韦林注射液15 mg/(kg·d),分2次肌注。结果:利巴韦林组与阿昔洛韦组治疗后退热时间及结痂天数无明显差异,均较对照组显著缩短。结论:利巴韦林和阿昔洛韦对小儿水痘均有显著疗效,但利巴韦林效价比更高。     

Undetectable levels of serum FSH immunoactivity and bioactivity in girls with sexual precocity due to ovarian cysts

Low LCK, Wang C, Leung A, Leong LY. Undetectable levels of serum FSH immunoactivity and bioactivity in girls with sexual precocity due to ovarian cysts. Acta Paediatr 1994;83:623–6. Stockholm. ISSN 0803–5253
Clinical presentation and endocrine investigations in five girls with precocious sexual development due to ovarian cysts are presented. These girls had pubertal oestradiol and suppressed gonadotrophin responsiveness to LHRH stimulation. FSH bioactivity as measured by the rat aromatase assay was undetectable in basal and LHRH-stimulated serum samples but our results cannot exclude the possibility of the presence of a species-specific follicle stimulating factor in these patients. IM injection of depot medroxyprogesterone acetate controlled pubertal development in two children.