2008年NCCN关于遗传性非息肉病性结肠癌的筛查指南要点解读

遗传性非息肉病性结肠癌(hereditary nonpolyposis colon cancer,HNPCC),也称Lynch综合征,占结直肠癌发病总数的2%～3%[1].其发病机制主要是由于DNA错配修复基因(主要是MLH1,MSH2,MSH6,PMS2)突变导致,携带一个HNPCC突变基因的个体终生结直肠癌的危险度为80%[2].HNPCC的主要临床特点为肿瘤发病年龄早,通常在50岁前发生结肠癌,好发于近端结肠(盲肠、升结肠和横结肠),有同时或异时原发性结肠癌,且常见肠外恶性肿瘤,肠外恶性肿瘤常见的部位是子宫内膜,其次是胃、小肠、肝胆系统、上泌尿道和卵巢等.HNPCC的主要危险是以常染色体显性遗传方式传给子代,尤其是一级或二级亲属好发结肠癌.HNPCC临床预后较好,早期发现、早期治疗将极大改善患者的预后.对HNPCC患者及其亲属必须进行密切的监测,NCCN指南[3]对HNPCC的筛查包括分子诊断、遗传检测、随访监测及手术治疗等.

明代临床各科名著《证治准绳》

我国历代都有大量的医学丛作刊行于世,而具有学术内涵、指导各科诊疗工作的主要是中医临床医学的编著.每一朝代都有其学科代表性的名著,以明代而言,王肯堂的<证治准绳>,堪称具有代表性,值得各科临床医师借鉴、参阅.今予综论如下.

Opportunities to Fast-Track Chinese Herbal Therapies into Clinical Practice Through Research Networks

Chinese herbal therapies provide new opportunities to treat cancer and reduce adverse events at multiple chemical,molecular, and physiological levels. Chinese medicine incorporates the notion of 'biosemiosis.' This emphasizes biology considered from the perspectives of signs conveyed and interpreted in a variety of ways,through systems at the macroscopic and microscopic levels, including the communication of singns and meaning between molecules.

On Oct. 20-22, 2001, a commemorating meeting for the 20th anniversary on the founding of Chinese Association of Integration of Traditional and Western Medicine (CAIM) and the start publication of Chinese Journal of Integrated Traditional and Western Medicine (CJIM) was held in Xi'’an, 436 participants from various provinces and districts, as well as Taiwan province attended the meeting. Rapid development and outstanding achievements were summarized by Prof. Wei BEI-hai, Vice-President of CAIM. Since 1981, CAIM has held 12 international and 380 national academic conferences, 62,000 member-times participated the meetings, the CAIM member increased from 13,000 to 52,000 in 20 years. There are 57 integrated hospitals, over 30 integrated institutes, 10 integrated journals, 35 specialty committees nationwide. Some well-known scholars delivered special lectures, such as Prof. XU Xiao-jie of Peking University (“Chemistry and Chinese Medicine”), Prof. HOU Can from Sun Yat-sen University of Medical Sciences (“Unified Medicine of Post-Gene Era”), Prof. Yang Sze Piao of Taiwan Association of Integrated Medicine (“Education of New Generation Chinese Medical Practitioner of Taiwan”) and other 5 scholars'’ lectures. Deputy Director of Editorial Board CHEN Dong-yan reported that CJIM ( Chinese edition) has published 21 volumes, particularly the citation frequency listed 1st among 2 804 scientific journals in China 1999, indicating the quality of this journal is high. Prof. WANG Wen-jian of Shanghai has been elected as Vice President of CAIM, and Prof. ZHAO Jian-xiong elected as member of director board of CAIM. Prof. SHE Jin, on behalf of State Administration of TCM (SATCM), delivered a speech entitled “4 Famous Veteran TCM Practitioners in Beijing and Integrated Medicine” to congratulate the convening of the meeting. Academician of Chinese Academy of Sciences, President of CAIM Prof. CHEN Ke-ji chaired the meeting, he said, “Past 20 years was the developing and rapidly expanding 20 years under the governmental policy of ‘integrating Chinese and western medicine’ despite many difficulties have been conquered”, he strengthened in his opening speech, “This meeting would inspire the huge passion of engaging in integrating both medicines as well as creating in clinical practice, strive to rally together Chinese and western practitioners, to promote academic exchange of integrated medicine at home and abroad, so as to realize the modernization of Chinese medicine, enrich the world medicine and contribute to the health of mankind”.

Objective: To evaluate the therapeutic effect of Yangxin Fumai Oral Liquid (YFOL,养心复脉口服液), a Chinese herbal medicine for nourishing Heart and restoring pulse, in treating patients with extrasystole. Methods: The effect of YFOL was observed in treating 30 patients with different kinds of extrasystole and compared with that in 30 patients treated by propafenone. The effect of YFOL on experimental arrhythmia was studied in animals as well. Results: Clinical observation showed that the effect of treatment against extrasystole in the two groups was similar, but the YFOL group showed better results in symptom improvement (P<0.01) with no marked side-effect. Experimental study showed that YFOL could reduce the chloroform induced ventricular fibrillation occurrence in mice, delay the initiating time of ventricular extrasystole, tachycardia and fibrillation induced by aconitine, BaCl2 and coronary artery ligation in rats, or shorten the lasting time of arrhythmia, reduce the attacking frequency of ventricular extrasystole. There was significant difference in comparing with the control group (P<0.05, P<0.01). Conclusion:YFOL is a good and convenient Chinese herbal preparation for different kinds of extrasystole with few toxic and side-effect in clinical practice.

　　A great deal of research work about acupuncture in terms of modern medicine has been done in China. The initial investigation about the mechanism of the clinical effect of acupuncture in the fifties, the extensive clinical practice with acupuncture in the mid-sixties, and the large scale of experimental studies on animal models about acupuncture in the seventies, especially the nineties, which have all provided many new progresses. And the following is an overview of the achievements of these research work.

临床实习带教坚持中医特色之我见

从中医药申遗到沸沸扬扬的存废之争,过去的一年,中医药可谓喜忧参半.回顾几千年中医药发展的历史,几多辉煌,几多磨难.

Acupuncture treatment integrated with cupping for enhancing the therapeutic effect is a technique in Yang's school of acupuncture carried forward from generation to generation. The author's grandfather created Yang's shallow puncturing and cupping therapy to enhance the effect of promoting blood flow and removing blood stasis in the light of his clinical experience. In this therapy, the gentle puncturing and heavy tapping are carried out with the seven-star needle until light bleeding occurs, followed by drawing out of pituita or stagnant blood and coagula by cupping, in an attempt to promote tissue regeneration by removing blood stasis for promoting the flow of qi and blood in the meridians. The therapy has been developed by Dr. Yang Yifang (the author's father) in clinical practice over the past six decades. Satisfactory therapeutic results have been obtained in clinical practice, which are introduced with examples below.

Fengchi (GB 20) is a point of the Gallbladder Meridian of Foot-Shaoyang. It is commonly used in clinical practice. According to the literature of traditional Chinese medicine, Fengchi (GB 20) can be used to treat many diseases, especially for the disorders caused by pathogenic wind. The indications include common cold, headache, cervical spondylosis, trigeminal neuralgia, hypertension, apoplexy, neurasthenia, epilepsy, optic atrophy, tinnitus, myopia, and painful heel etc. The viewpoints of different schools varies on the needling angle and depth at Fengchi (GB 20). Perpendicularly puncturing 0.3-0.7cun deep is recorded in most of the ancient books. Puncturing to a depth of 1.2 cun is mentioned in Fundamentals of Acupuncture and Moxibustion (针灸资生经) and Compendium of Acupuncture and Moxibustion (针灸大成). Jiang Yijun, a modern famous acupuncturist, holds that the depth of needle insertion at Fengchi (GB 20) should be varied in different individuals and different diseases. In general, deep puncture should be adopted for the disease in deep location, shallow puncture for the disease in shallow area, and tapping with plum-blossom needle for the disease on the skin. These will be introduced below.

Integration of acupuncture and drug is a therapeutic method in which acupuncture treatment and pharmacotherapy are synchronously performed in the same patient to prevent and treat the disease. Its importance can be traced back to Sun Simiao (581-682 A.D.), a prominent physician of China's Tang Dynasty. He pointed out that: A physician who masters only acupuncture treatment in clinical practice but not moxibustion, or masters only moxibustion treatment but not acupuncture is not a skillful doctor; and a physician who is only aware of the application of acupuncture and moxibustion but ignorant of pharmacotherapy, or is only aware of pharmacotherapy but ignorant of the application of acupuncture and moxibustion also should not be a skillful one. Not only should a skillful doctor have the knack of applying acupuncture and moxibustion, but he should have the knack at pharmacotherapy in treating diseases. Each of acupuncture and moxibustion, and drug has its strong points. Therefore, both of them should be used simultaneously, thus bringing the strong points of both individuals into full play and offsetting their weaknesses so as to obtain a satisfactory therapeutic effect. With the development of modern medicine and introduction of advanced technology, there have been brilliant developments in the method and applied range of integration of acupuncture and drug, particularly in the studies on combined anesthesia induced by using acupuncture and drug, and administering drug by acupoint. All these have provided us a ground to further probe into the mechanism underlying the integration of acupuncture and drug.

Neuritis of lateral cutaneous nerve of thigh, also called meralgia paresthetica, is a commonly encountered disease in clinical practice. The author has treated 28 cases of meralgia paresthetica since 1996 by acupuncture plus point-injection with satisfactory results. A report follows.Clinical Data Among the 28 cases, 13 were male and 15 female. Their age ranged from 24 to 72 years, most of the patients being 35 to 50 years; the duration of illness varied from one month to ten years and 6 cases were affected on left side, 8 cases on right side and 14 cases on both sides.

The namesake channel point selection is a method adopted in acupuncture treatment, in which the points on the six pairs of channels on the upper and lower extremities with same names are selected and needled. Clinically, this method is mainly used for some acute soft tissue injuries, for instance, needling point Yangchi (TE 4) with reducing method for sprain of external malleolus, needling Qiuxu (GB 40) with reducing method for sprain of dorsal carpus, and needling Tiaokou (ST 38) for lateral shoulder pain. The therapeutic effect given by this point selection method is often superior to that given by the conventional needling method. In clinical practice, the author has found some typical cases, which respond well to this method, and reports them below.

In present clinical practice, point Tianzong (SI 11) is often used to treat pain and numbness in the scapular region and the upper limbs. The authors have tried various needling manipulations at this point and obtained extraordinarily good therapeutic result, as is reported in the following.

让基础医学与临床医学之桥更加畅通

病理学是基础医学与临床医学的桥梁,这既反映了病理学科在医学中的重要地位,也对病理学提出了须以基础医学知识和技术方法服务于临床实践的任务.今天,我们常能听到和见到一些临床科室希望建设和发展自己的病理(组)室的诉求和行动,也常能听到一些临床科室对病理科工作的种种微词,以及临床医师有自己建桥或借船过河的想法甚至行动.这些都提示病理学之桥还不够畅通,还未能充分适应和满足快速发展的临床医学的需要,未能充分实现病理学与临床医学,尤其是与日趋专科化和精细分工的临床医学专科的无缝对接.

危重病人达到肠内营养支持营养目标的短期疗效

目的对1998年以来临床28例危重病人,实施达到营养目标的肠内营养支持,并做了短期疗效观察.方法1.依病情需要分TEN管饲匀浆膳、要素膳组(一组)9例,外科6例,内科3例,支持时间平均25.8天.EN+PN组(二组)9例,外科7例,内科2例,支持时间平均22.1天.口服营养补充剂组(三组)10例,外科7例,内科3例,支持时间平均16.1天.每日摄人热能以BEE×活动系数×应激系数公式计算,蛋白质平均1.2g/kg,脂肪平均占25%,碳水化物平均占55%.维生素、矿物质、微量元素以RDA计算. 2.营养目标:①恢复或保持血浆白蛋白正常水平.②降低异常或保持血糖正常水平.③纠正电解质平衡紊乱.结果短期内血浆白蛋白达标率分别为:89%、78%、80%,血糖达标率为:89%、86%、80%,离子达标率为:K78%、100%、80%,Na89%、88%、90%,Cl100%、88%、100%,Ca89%、100%、100%,P100%、100%、100%o 结论虽然三组各自的应用范围不同,但只要有明确的营养目标,各组血浆白蛋白、血糖、血清离子在短期内都会取得显著改善,有效地提高疾病临床治愈率.应注意的是在临床实际应用时,为防止正常血糖、离子等的异常变化,营养医师应及时了解病情动态,随时调整个体化的营养素配方.

AACE糖尿病临床综合管理指南

糖尿病临床综合管理指南(中)

Q7.治疗高血糖时有哪些特殊的考虑?07.1.T1DM的高血糖治疗·R28.胰岛素类似物推荐用于大多数T1DM患者.相关的治疗方案包括:(a)每日多次胰岛素注射(MDI),指每日1针或2针基础胰岛素(控制三餐之间和夜间血糖波动)以及餐前胰岛素注射(控制餐后血糖);(b)持续皮下胰岛素输注(CSII),是一种比较符合人体生理性的胰岛素治疗方式,在尽可能改善血糖水平的同时,降低低血糖风险;(c)其他患者(特别是有低血糖问题的患者),选择使用胰岛素类似物.

论医学基础研究对临床工作的重要性

医学基础研究是指以认识与医学相关的自然现象,探索自然规律,获取新知识、新原理、新方法为主要目标的实验性和理论性工作.如何加强基础研究与临床工作的结合,促进基础研究成果向临床转化,是实现临床事业跨越式发展的关键所在.

正确看待与应用循证医学提高临床实践水平

循证医学的研究结果在临床实践中的应用,是临床医学由"经验医学"迈向"医学科学"的一个重要里程碑.目前我国临床医学界在应用循证医学、提高临床工作水平方面存在着两种不良倾向.

观察性研究在临床实践中的重要意义

在越来越强调循证医学的今天,医生也越来越重视来源于临床研究的各种证据.随着试验设计和研究方法的改善,观察性研究越来越受到医生和学者们的关注,来源于观察性研究的证据也日益广泛地应用在医生的日常临床实践中.