家庭医生的新挑战——躯体化障碍

有研究提示,在初级保健中,有20%~25%的就诊者可能有心理或精神方面的问题,也就是说这些病人的症状不是真正的病理问题,而是情感上或是行为上的问题。美国Oliver Oyama等提出约有50%的病人具有不能用医学解释的症状,其中某些病人为躯体化障碍,首先要排除病人是否存在着躯体疾病,来就诊的病人可为器官疾病与心理问题共存,这时,我们要下两个诊断;有些人因为心理问题长期未得到解决,而转化为躯体症状。如何应对这些病例或案例对全科医生来说是一种挑战。     

Severe exacerbation of hepatitis after short-term corticosteroid therapy in a patients with "latent" chronic hepatitis B

We present a case of severe exacerbation of hepatitis after short-term corticosteroid therapy for chronic inflammatory demyelinating polyneuropathy (CIPD) with "latent" chronic hepatitis B showing no HBV-related antigens and antibodies. After corticosteroid pulse therapy for CIPD, the patient had severe exacerbation of hepatitis twice. Although she did not show any hepatitis B virus (HBV)-related antigens or antibodies, sequences of HBV were detected in serum and liver by a nested polymerase chain reaction. A sequence analysis of HBV at the second exacerbation showed that the G-to-A point mutation at nucleotide 1896 that converted codon 28 from tryptophan (TGG) to a stop codon (TAG) in the precore region resulted in amino acid change, which has been frequently observed in fulminant hepatitis and severe hepatitis in Japan.     

Pre- and postoperative hemodynamic assessments and survival rates in patients with postinfarction ventricular septal perforation

Pre- and postoperative hemodynamics were assessed in 14 consecutive patients who developed ventricular septal perforation (VSP) following acute myocardial infarction (AMI). Results were correlated with the surgical outcome and with postoperative clinical improvements. The patients were divided into 3 groups according to the time intervals between the onset of AMI and the operation; acute (within 2 weeks after AMI), subacute (between 2 and 4 weeks) and chronic (after 4 weeks). In the above groups, 6, 2 and 6 patients were included, respectively. Eleven patients had anteroseptal infarction and 3 patients sustained inferior infarction. The survival rates were 33, 50 and 100% in the acute, subacute and chronic groups, respectively with an overall survival rate of 64%. Hemodynamic comparisons between survivors and non-survivors revealed that the systolic aortic pressure and left ventricular stroke volume index were significantly higher and the right ventricular end-diastolic pressure was significantly lower in survivors than in non-survivors (p less than 0.05). Although no statistical significance was obtained, left ventricular end-diastolic volumes and ejection fractions were higher in survivors. No difference was present between survivors and non-survivors in either Qp/Qs, Pp/Ps, Rp/Rs, systolic pulmonary pressure, left ventricular end-diastolic pressure or cardiac index. Patients with low arterial pressure and high right ventricular end-diastolic pressure under intensive medical regimens, indicating the presence of cardiogenic shock and/or associated right ventricular infarction or severe failure, had a high mortality and should be considered for emergency operation. Postoperative hemodynamics improved significantly in all variables measured (p less than 0.05-0.01). Patients with a VSP should all be considered for surgery unless a definite contraindication exists.     

Leucine-rich alpha-2 glycoprotein is a potential biomarker to monitor disease activity in inflammatory bowel disease receiving adalimumab: PLANET study

Journal of Gastroenterology - This multicenter prospective study (UMIN000019958) aimed to evaluate the usefulness of serum leucin-rich alpha-2 glycoprotein (LRG) levels in monitoring disease...     

Somatostatin-like immunoreactivity in mammalian thyroid glands: contents and partial characterization

Somatostatin (SRIF)-like immunoreactivity (SLI) in the thyroid glands of human and several animal species were compared, and the SLI peptides were characterized chromatographically and immunologically. All specimens were extracted with 2 M acetic acid, and the SLI content determined by RIA. The SLI concentrations in guinea pigs [34.3 +/- (SE) 4.8 ng/mg protein] and rabbits (9.4 +/- 0.8 ng/mg protein) were much greater than those in other mammals: dogs, rats, mice, and humans. On gel filtration of extracts of the guinea pig, rabbit and dog thyroids, the major peak of SLI (1.6 K SLI) coeluted with synthetic SRIF-14 (S-14). Two other forms of SLI ("big" SLI and 3 K SLI) were also detected, although their relative proportions to total SLI were small (2.3 to 8.2%). The 3 K SLI and 1.6 K SLI from guinea pig and rabbit thyroids contained peptides coeluting with synthetic SRIF-28 (S-28) and S-14, respectively, on reverse-phase high performance liquid chromatography. The dilution curves of the two molecular forms of SLI, i.e. 3 K SLI and 1.6 K SLI, were parallel to the displacement curves of S-28 and S-14 in the SRIF RIA. It is concluded 1) that the thyroid contents of SLI varied greatly from species to species, with the highest content being found in guinea pig thyroids; 2) that in guinea pigs, rabbits, and dogs, the predominant form of thyroid SLI is 1.6 K SLI; and 3) that the 3 K SLI and 1.6 K SLI peptides from guinea pig and rabbit thyroids are immunologically and chromatographically indistinguishable from S-28 and S-14, respectively.