糖皮质激素联合大剂量免疫球蛋白成功治疗重型新型冠状病毒肺炎1例临床经验分析

目的 报道1例重型新型冠状病毒肺炎（COVID-19）应用糖皮质激素联合免疫球蛋白救治成功的病例,分享重型COVID-19的临床治疗经验。方法和结果 患者为武汉市医务工作者,起病前曾多次接触COVID-19患者,2020年1月16日起无明显诱因出现咳嗽伴少许白黏痰,1月22日出现发热（最高38.5℃）并入院治疗,查CT示双肺散在少量渗出,予口服奥司他韦、静脉输注莫西沙星及头孢哌酮舒巴坦钠、加强营养等治疗。1月26日出现胸闷气急,咽拭子检测示严重急性呼吸综合征冠状病毒2（SARS-CoV-2）核酸阳性,CT示双肺渗出较前增加。1月28日气急加重,输注甲泼尼龙（40 mg,每天1次）和人免疫球蛋白（10 g,每天1次）治疗。1月30日体温升高至40.7℃,气急进一步加重,脉搏血氧饱和度（SpO₂）降至83%（吸氧量10 L/min）,淋巴细胞计数降至0.5×10⁹/L,调整甲泼尼龙剂量（40 mg,每12 h 1次）及人免疫球蛋白剂量（20 g,每天1次）,增加胸腺法新（1.6 mg,皮下注射,每天1次）等治疗,体温恢复正常,胸闷气急逐渐好转。1月31日SpO₂ 88%（吸氧量10 L/min）,复查胸部CT提示双肺大片渗出影。2月2日SpO₂ 95%（吸氧量5 L/min）,开始逐渐减少甲泼尼龙用量。2月3日复查胸部CT提示肺部炎症较前好转,2月4日及9日复查咽拭子示SARS-CoV-2核酸阴性。结论 早期及轻型COVID-19患者应尽量避免使用糖皮质激素,当患者出现呼吸衰竭失代偿时可适当使用糖皮质激素降低免疫指标,但剂量不宜过高,必要时可予大剂量免疫球蛋白帮助平衡免疫功能。     

Increased median nerve latency at the carpal tunnel of patients with "trigger finger": Comparison of 62 patients and 13 controls

An association between symptomatic compression neuropathy of the median nerve at the carpal tunnel and "trigger finger" has been reported in endocrine and metabolic disorders. We assessed the incidence of increased median nerve latency in subjects with "trigger finger". 62 consecutive patients with "trigger finger" and no signs or symptoms of median nerve compression underwent nerve conduction studies of the median nerve. 13 healthy adults served as controls. 39/62 patients had increased distal motor latency in the median nerve. Only 1 of 13 subjects in the control group had a borderline value of distal motor latency.     

Corticosteroids in Duchenne muscular dystrophy: Major variations in practice

Introduction: In 2004, a Cochrane Review and AAN practice parameter concluded that prednisone 0.75 mg/kg/day is of short‐term efficacy in Duchenne muscular dystrophy (DMD). Subsequent efforts to standardize care for DMD indicated wide variation in corticosteroid use. Methods: We surveyed physicians who follow patients with DMD, including: (1) clinics in the TREAT‐NMD (Translational Research in Europe—Assessment and Treatment of Neuromuscular Diseases) network (predominantly Europe) and (2) U.S. MDA clinic directors. We also documented the co‐administered corticosteroids in a trial of a putative treatment (ataluren) for DMD. Results: Of 105 Treat‐NMD clinicians, corticosteroids were not used in 10 clinics, and 29 different regimens were used—the most frequent 0.75 mg/kg/day prednisone (61 centers); 10 days on/10 days off (36 centers); 0.9 mg/kg/day deflazacort (32 centers); and 5 mg/kg/day on weekends (10 centers). Similar diversity was identified in MDA clinics and in the ataluren trial. Conclusions: Variability in corticosteroid use suggests uncertainty about risks/benefits of corticosteroid regimens for DMD. Muscle Nerve, 2013     

Magnetic resonance imaging in duchenne muscular dystrophy: Longitudinal assessment of natural history over 18 months

Introduction: In Duchenne muscular dystrophy (DMD), fat replacement of muscle may be a useful endpoint in trials of therapy, although progression in different muscle groups is uneven. In this study we assessed the progression of fat replacement with T₁‐weighted imaging over 2 9‐month periods. Methods: Eight ambulant, corticosteroid‐treated boys with DMD were imaged at 3 Tesla at 3 time‐points (baseline and 9 and 18 months) with T₁‐weighted imaging to measure fat replacement. Results: The greatest increase in fat content was measured in the biceps femoris long head, vastus lateralis, and rectus femoris, whereas the biceps femoris short head and gluteus maximus progressed more slowly. None of the lower leg muscles studied changed significantly. Conclusions: MRI can measure specific changes in fat replacement of muscle over time, demonstrating the variability in rates of natural progression between muscle groups and identifying those muscles suitable for use as biomarkers in clinical trials. Muscle Nerve 48 : 586–588, 2013     

Differential anti-inflammatory effects of large and small particle size inhaled corticosteroids in asthma

BACKGROUND: Extra-fine particle formulations of hydrofluoroalkane-134a beclometasone dipropionate (HFA-BDP) exhibit clinical effects comparable with conventional particle formulations of chlorofluorocarbon beclometasone dipropionate (CFC-BDP) at half the dose. There is little data comparing their effects on inflammation. We have evaluated the effects of HFA-BDP and CFC-BDP on pulmonary and systemic markers of asthmatic inflammation. METHODS: A double-blind randomized crossover trial was undertaken comparing the anti-inflammatory effects of HFA-BDP (100 and 400 microg/day) and CFC-BDP (200 and 800 microg/day). Treatment with montelukast was evaluated as add-on to the higher dose of BDP. RESULTS: Compared with baseline after withdrawal of usual asthma therapy, 100 microg of HFA-BDP significantly attenuated serum eosinophilic cationic protein levels (0.61-fold change, 95% CI 0.49-0.77; a 39% reduction, P < 0.001), but 200 microg of CFC-BDP did not (0.87-fold change, 95% CI 0.63-1.23; P = 1). A dose of 800 microg of CFC-BDP and 400 microg of HFA-BDP led to reductions in exhaled nitric oxide (0.57-fold change, 95% CI 0.44-0.73; a 43% reduction, P < 0.001 and 0.65-fold change, 95% CI 0.47-0.91; a 35% reduction, P = 0.008, respectively); and peripheral eosinophils (-74 cells/microl, 95% CI -146 to -2; P = 0.020 and -77 cells/microl, 95% CI -140 to -14; P = 0.012, respectively). Montelukast further reduced exhaled nitric oxide (0.81-fold change, 95% CI 0.66-0.98; P = 0.028) with 400 microg HFA-BDP and eosinophils (-44 cells/microl, 95% CI -80 to -8; P = 0.012) with 800 microg CFC-BDP, but not vice versa. CONCLUSION: Chlorofluorocarbon beclometasone dipropionate and HFA-BDP have differential effects on pulmonary and systemic inflammation, which dictate the additive effects of montelukast.     

Intra-articular corticosteroid injections in haemophilic arthropathy: are they recommended?

Introduction: Intra-articular (IA) corticosteroid (CS) injections are commonly used in the treatment of osteoarthritis. However, they are rarely utilized in haemophilic arthropathy. In fact, the efficacy of this method in haemophilic arthropathy is frequently discussed and debated in clinical practice.

Aim: To investigate the effectiveness of IA CS injections in patients with painful haemophilic arthropathy.

Methods: A review of the literature on the topic was performed.

Results: In osteoarthritis, reports with a high level of evidence state that the efficacy of IA injections of CS is controversial. In haemophilic arthropathy, some low-level evidence reports seem to indicate that short-term pain alleviation can be achieved.

Conclusions: Considering that pain relief after IA injections of CS is controversial and that the cost of the haematologic treatment required to perform the procedure is high in haemophilic arthropathy, we do not recommend the routine use of CS IS injections in haemophilia. Moreover, point of care (POC) ultrasound (US)-guided injections are not advised, because the injection procedure is so simple that the use of POC-US will unnecessarily prolong the duration of the procedure.     

肺部吸入给药制剂及临床应用

目的:分析和综述肺吸入制剂的分类、现状及其临床用药。方法:收集国内外发表出版的相关论文及专著,对肺部吸入给药的特点及临床药物制剂进行了分析总结。结果与结论:肺部吸入给药是防治哮喘、慢性阻塞性肺病等呼吸道疾病的首选给药方式。常见的吸入给药制剂包括定量吸入气雾剂、干粉吸入剂和雾化吸入剂,所用药物主要为β2受体激动剂、抗胆碱药物、吸入性糖皮质激素及复方药物等。     

Dexamethasone inhibits inflammation and cartilage damage in a new model of post‐traumatic osteoarthritis

Corticosteroids are used in musculoskeletal diseases, and offer patient relief. Injections of corticosteroids are recommended for management of osteoarthritis (OA). Current data have shown the role of corticosteroids in ameliorating pain. We hypothesized that repeated intra‐articular injections of high dose dexamethasone would protect the cartilage from damage in a post‐traumatic model of OA. Eighteen female New Zealand White rabbits were used. Twelve underwent surgery to induce OA; six of them received intra‐articular injections of dexamethasone every 3 days for 3 weeks. The other six rabbits served as operated controls. Six additional rabbits served as non‐operated controls. All animals were euthanized 3 weeks post‐surgery. Knees were assessed grossly. Cartilage, synovium, and fat pad were assessed histologically. Synovium and fat pad were analyzed with qPCR and Western blots. Surgical controls had cartilage damage which was supressed with dexamethasone. Dexamethasone significantly decreased synovial expression of interleukin‐1β and collagen I, and a trend to decrease synovial matrix metalloproteinase3 expression. There were also significantly lower levels of interleukin‐1β protein with dexamethasone treatment. Dexamethasone significantly decreased fat pad expression of matrix metalloproteinase13, basic fibroblast growth factor, and interleukin8, and a trend to decrease matrix metalloproteinase3 and transforming growth factorβ expression. Dexamethasone decreased joint inflammation and joint tissue degradation and was chondroprotective in this unique model of PTOA. © 2013 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 32:566–572, 2014.