何首乌致药物性肝损伤的病理学特点

目的了解何首乌致药物性肝损伤(Polygonum multiflorum-associated drug induce liver injury,PM-DILI)的临床病理学特点。方法收集2019年3月1日至2021年3月1日深圳市第三人民医院收治的8例PM-DILI患者临床资料。肝穿组织进行苏木素-伊红染色、网状纤维染色、Masson三色染色、铁、铜特殊染色和免疫组织化学染色,显微镜下观察分析。结果8例PM-DILI患者男女比为1∶1,平均年龄43岁,其中6例为急性PM-DILI,2例慢性为PM-DILI。入院血清学检查异常主要包括转氨酶升高和淤胆均为7例。主要组织病理学改变为点灶状坏死8例、界面炎5例、融合坏死4例,融合坏死以肝腺泡3带为主,不伴或伴少数炎细胞浸润;胆汁淤积5例,为肝腺泡3带的肝细胞、毛细胆管内淤胆,不伴或伴少数炎细胞浸润;中央静脉炎3例;病程长者可发生肝纤维化,甚至肝硬化2例。结论肝腺泡3带为主的急性淤胆和肝细胞坏死是PM-DILI主要组织学表现,严重者可发生静脉炎等血管损伤。     

癫痫发作后状态及其临床意义

癫痫发作后状态(PIS)是指癫痫发作停止到恢复至发病前水平的异常状态,包括认知、运动、感觉、自主神经和精神行为等异常,症状多样,严重程度不一,持续数秒至数天不等,对患者的健康和生活质量产生很大影响。然而,目前国内外相关的研究较少,临床医生对此缺乏正确认识,容易误诊误治。本文将从PIS的定义、病理生理机制、临床表现、诊断和鉴别诊断、临床意义以及干预策略等进行综述,以提高临床医生的认识,并为今后临床研究提供参考。     

基于雨课堂的临床流行病学教学改革与实践

目的探讨雨课堂在临床流行病学教学中的作用和效果。方法采用随机对照法在本科阶段无流行病学学习经历的临床专业硕士研究生中,使用雨课堂线上课前预习及课后随堂练习的功能,用于评价雨课堂线上功能的辅助教学效果。结果应用雨课堂线上功能干预组与对照组在基线、阶段小测和末考卷面成绩均无统计学差异;但对于主动学习,雨课堂参与度较高的学生成绩提高明显。结论雨课堂有利于理论性较强课程的学习,但是仍不能忽略课堂教学师生互动过程。     

糖尿病黄斑水肿患者病变程度与脉络膜厚度的关系

目的　利用频域光学相干断层扫描深度增强（enhanced depth imaging spectral domain optical coherence tomography，EDI SD-OCT）观察糖尿病黄斑水肿（diabetic macular edema，DME）患者脉络膜厚度（choroidal thickness，CT）的变化及结构特点，探讨DME病变程度与CT的关系。方法　纳入2型糖尿病患者共123例204眼，其中69眼诊断为DME（DME组），135眼无黄斑水肿为对照组。DME眼依据OCT形态学特点进一步分为视网膜弥漫性增厚（diffuse retinal thickness，DRT）型（34眼）、黄斑囊样水肿（cystoid macular edema，CME）型（19眼）和浆液性视网膜脱离（serous retinal detachment，SRD）型（16眼），利用EDI-OCT分别测量黄斑中心凹下CT和以黄斑为中心上、下、鼻、颞500 μm、1000 μm、1500 μm、2000 μm处CT。结果　DME组黄斑中心凹下CT为（326.72±90.15）μm，对照组为（320.17±106.46）μm，两组之间无统计学差异，但黄斑中心凹下CT与视网膜厚度间具有明显正相关关系（r=0.270，P=0.025）。DME亚型CT分别为:DRT型（303.94±81.47）μm、CME型（304.42±73.98）μm和SRD型（401.63±88.80）μm，SRD型CT明显高于其他亚型（P<0.05），此外，SRD型的周边CT同样呈现均匀一致的增厚；鼻侧CT从500 μm至2000 μm呈距离敏感性降低（P<0.05），但SRD型鼻侧CT降低幅度明显变缓（P=0.195）。结论　SRD型黄斑水肿患者CT在中心凹下及周边部均显著增厚，CT与DME病变程度之间有一定相关性。     

A Tool to Assess Patient and Surrogate Knowledge About the POLST (Physician Orders for Life-Sustaining Treatment) Program

ContextIt is especially important that patients are well informed when making high-stakes, preference-sensitive decisions like those on the Physician Orders for Life-Sustaining Treatment (POLST) form. However, there is currently no way to easily evaluate whether patients understand key concepts when making these important decisions.ObjectivesTo develop a POLST knowledge survey.MethodsExpert (n = 62) ratings of key POLST facts were used to select items for a POLST knowledge survey. The survey was administered to nursing facility residents (n = 97) and surrogate decision-makers (n = 112). A subset (n = 135) were re-administered the survey after a standardized advance care planning discussion to assess the scale's responsiveness to change.ResultsThe 19-item survey demonstrated adequate reliability (α = 0.72.). Residents' scores (x = 11.4, standard deviation 3.3) were significantly lower than surrogate scores (x = 14.7, standard deviation 2.5) (P < 0.001). Scores for both groups increased significantly after administration of a standardized advance care planning discussion (P < 0.001). Although being a surrogate, age, race, education, cognitive functioning, and health literacy were significantly associated with higher POLST Knowledge Survey scores in univariate analyses, only being a surrogate (P < 0.001) and being white (P = 0.028) remained significantly associated with higher scores in multivariate analyses.ConclusionThe 19-item POLST Knowledge Survey demonstrated adequate reliability and responsiveness to change. Findings suggest the survey could be used to identify knowledge deficits and provide targeted education to ensure adequate understanding of key clinical decisions when completing POLST.     

Colorectal serrated pathway cancers and precursors

The serrated pathway (SP) can be viewed as two parallel, but partially overlapping, arrays of colorectal precursor lesions, and their respective endpoint carcinomas, that are distinct from those of the conventional adenoma–carcinoma sequence (APC‐pathway). In this review we focus at the outset on the clinical impact, pathological features, molecular genetics and biological behaviours of the various SP cancers. Then we summarize the clinicopathological features, classification and molecular profiles of the two main precursor lesions that anchor the respective pathways: (i) sessile serrated adenoma/polyp (SSA/P), also called sessile serrated lesion (SSL), and (ii) traditional serrated adenoma (TSA). Activating mutations of the RAS–RAF–MAPK pathway initiate and sustain the lesions of the SP, and CpG island methylation of the promoter regions of tumour suppressor and DNA repair genes play the major role in their neoplastic progression. The SP includes microsatellite stable (MSS) carcinomas that are among the most biologically aggressive colorectal carcinomas (CRC), and also accounts for the great preponderance of sporadic hypermutated, mismatch repair (MMR)‐deficient or microsatellite instable (MSI) CRC. The identification, removal and appropriate classification of at‐risk SP precursors and surveillance of individuals who harbour these lesions present a challenge and opportunity for CRC prevention and mortality reduction.     

25-羟维生素D_3治疗2型糖尿病患者早期肾损害的临床观察

目的观察25-羟维生素D3(Vit D3)对2型糖尿病(T2DM)患者早期肾损害的临床疗效。方法纳入T2DM早期肾损伤患者80例,采用随机数字表法等分为治疗组与对照组,对照组继续原有降糖方案,治疗组在既往用药基础上,肌肉注射Vit D3注射液,疗程均为10个月,治疗结束后进行疗效评价。结果 1与治疗前相比,治疗组糖化血红蛋白(HbA1c)、总胆固醇(TC)、甘油三酯(TG)、低密度脂蛋白胆固醇(LDL-C)水平上调,微量白蛋白(MA)、β2-微球蛋白(β2-M)及肾脏损伤分子-1(KIM-1)水平下调,治疗组低于对照组差异有统计学意义(P<0.05)。2与治疗前相比,治疗组治疗后Vit D3水平上调,治疗组高于对照组差异有统计学意义(P<0.01)。3T2DM患者Vit D3水平与MA(r=-0.432),β2-M(r=-0.615),及KIM-1(r=-0.763)水平均呈负相关(P<0.05)。结论 Vit D3可有效减轻T2DM患者的早期肾损害,对肾脏具有保护作用。