糖尿病手及其现代治疗

在20世纪70、80年代,关于糖尿病手部表现国外学者有很多讨论,但在国内学术界则鲜见涉猎。本次综述是为了重温糖尿病手并探讨手的病理可能对于糖尿病患者有非常重要的临床意义。在严格意义上来说,糖尿病手主要有三个临床表现,关节活动收限、掌腱膜挛缩症和扳机手。有证据表明,糖尿病患者出现这些症状的几率更高,其发病率可能与糖尿病的病程,血糖控制不佳,以及微血管的并发症有关。在更普遍的意义上,虽然有其他因素影响手部的病变,但是糖尿病会使其发生几率更高。从临床角度来看,对神经性病变导致的手溃疡和糖尿病手感染提高警觉是非常有必要的。最近,手的力量减少也被确认为糖尿病的并发症。因此,手部表现在糖尿病中有可能揭示实质性的病理过程,临床检查不应忽视。

糖尿病手的研究现状

糖尿病手是糖尿病慢性并发症之一,在文献中很少被报道,因此极易被忽视和低估。早期在临床治疗中常被患者和医护人员忽视,导致患者病情不能得到及时、有效地控制和治疗,从而对其生活和工作造成不良影响。本文就糖尿病手的定义、临床表现、发病机制、治疗及与其他糖尿病并发症的内在联系等方面的研究进行综述,供临床研究糖尿病手进行参考。

手指伸不直，警惕“糖尿病手”

最近几年，张先生发现手指有些僵硬，总伸不直。前段时间，他剪指甲时不小心剪到右手中指指肚，开始并没有重视，在家消毒包扎了一下。直到10天后，手指红肿加重，伤口也流脓了才到医院就诊。检查后发现患了骨关节炎，白细胞过高，合并细菌感染，被诊断为“糖尿病手”。

Pre-operative factors that can predict neoplastic polypoid lesions of the gallbladder

AIM:To investigate the preoperative factors that can predict neoplastic polypoid lesions of the gallbladder(PLGs) as well as malignant PLGs.METHODS:A retrospective analysis was conducted on the 210 consecutively enrolled patients who underwent cholecystectomy due to a PLG larger than 10 mm,as was determined by preoperative trans-abdominal ultrasonography or endoscopic ultrasonography.We ana-lyzed the medical,laboratory,radiologic data and the pathologic results.RESULTS:In 210 cases,146 had non-neoplastic polyps(69.5%) and 64 cases were neoplastic polyps(30.5%).An older age(≥ 65 years),the presence of diabetes mellitus(DM) and the size of polyp(≥ 15 mm) were revealed to be independent predictive variables for neoplastic polyps with odd ratios(OR) of 2.27(P = 0.044),2.64(P = 0.021) and 4.94(P < 0.01),respectively.Among the neoplastic PLGs,an older age(≥ 65 years),the presence of DM and polyp size(≥ 15 mm) were associated with malignancy with ORs of 4.97(P = 0.005),6.13(P = 0.001) and 20.55(P < 0.001),respectively.CONCLUSION:Among patients with PLGs larger than 10 mm in size,higher risk groups such as elderly patients more than 65 years old,those with DM or a large polyp size(≥ 15 mm) should be managed by cholecystectomy.

Key details of the duodenal-jejunal bypass in type 2 diabetes mellitus rats

AIM: To investigate which surgical techniques and perioperative regimens yielded the best survival rates for diabetic rats undergoing gastric bypass. METHODS: We performed Roux-en-Y gastric bypass with reserved gastric volume, a procedure in which gastrointestinal continuity was reestablished while excluding the entire duodenum and proximal jejunal loop. We observed the procedural success rate, long-term survival, and histopathological sequelae associated with a number of technical modifications. These included: use of anatomical markers to precisely identify Treitz's ligament; careful dissection along surgical planes; careful attention to the choice of regional transection sites; reconstruction using full-thickness anastomoses; use of a minimally invasive procedure with prohemostatic pretreatment and hemorrhage control; prevention of hypo-thermic damage; reduction in the length of the procedure; and accelerated surgical recovery using fast-track surgical modalities such as perioperative permissive underfeeding and goal-directed volume therapy. RESULTS: The series of modif ications we adopted reduced operation time from 110.02 ± 12.34 min to 78.39 ± 7.26 min (P < 0.01), and the procedural success rate increased from 43.3% (13/30) to 90% (18/20) (P < 0.01), with a long-term survival of 83.3% (15/18) (P < 0.01). CONCLUSION: Using a number of fast-track and damage control surgical techniques, we have successfully established a stable model of gastric bypass in diabetic rats.

THERAPEUTIC EFFECT OF NON-SURGICAL TREATMENT OF CHRONIC PERIODONTITIS IN DIABETIC CHINESE

Objective To observe the therapeutic effect of non-surgical treatment on diabetic Chinese withchronic periodontitis. Methods Moderate to advanced chronic periodontitis ( CP) was studied in 36 diabetes mellitus (DM) patients classified as 20 with high and fluctuating blood glucose level (DM-H) and 16 with relatively low and stable blood glucose level (DM-L). 28 non-DM CP patients acted as controls (Non-DM). Plaque index (PlI) , gingival index (GI) , bleeding on probing (BOP) , probing depth (PD) and clinical attachment loss (AL) of all patients were recorded at 6 sites on each tooth at the baseline and 1, 3 and 6 months after oral hygiene instruction (OHI), scaling and root planing. Results It was found that the short-term effect of non-surgical periodon-tal procedure had resulted in significant resolution of gingival inflammation and pronounced reduction in pocket depth and gain of attachment loss in both DM and Non-DM CP patients. Conclusion The pilot study suggested that non-surgical periodontal treatment allowed for favorable treatment responses in a group of Chinese diabetic subjects with chronic periodontitis and that their various profiles of blood glucose did not influence the short-term healing response to OHI, scaling and root planning.

COMPARISON BETWEEN CORONARY ARTERY BYPASS SURGERY AND DRUG-ELUTING STENTS IMPLANTATION TO DIABETIC PATIENTS WITH MULTIVESSEL CORONARY ARTERY DISEASE

Objective To evaluate the safety and efficacy of drug-elating stents （DES） implantation in diabetic patients with multivessel coronary artery disease （MVD） compared with coronary artery bypass graft （CABG） on the clinical outcomes. Methods From May 2003 to April 2005, 150 consecutive type 2 diabetic patients with MVD underwent revascularization, 84 by percutaneous coronary intervention （PC1） with DES and 66 by CABG. The study end point was the incidence of major adverse cardiovascular events （MACEs） during hospital interval after procedure and follow-up. Results Most preoperative characteristics were similar in two groups, but left main disease （30% vs 4%, P = 0. 001 ） and three-vessel disease （ 70% vs 54%, P = 0. 045 ） were more prevalent in CABG group. Complete revascularization was achieved in more patients in CABG group than that in PC1 group （82% vs 67%, P =0. 037）. Cumulative incidence of MACEs in hospital was similar between two groups （2.4% PC1 vs 9. 1% CABG , P =0. 069） despite the higher early morbidity （6. 1% vs 0%, P =0. 022） associated with CABG. Patients were followed up clinically for a mean of 18 - 8 months （ range 13- 36 months）. The incidence of MACEs remained higher after PC1 with multiple DES （21.4% vs 9. 1%, P =0. 041 ） mainly driven by a more require for repeat revascularization （ 13. 1% vs 3. 0%, P = 0. 030 ）. Conclusion PC1 with DES implantation, combined with tight glycemic control, aggressive cardiovascular risk factor modification and antiplatelet treatment, may be a safe and feasible alternative to CABG for selected diabetic patients with multivessel disease.

Outcome of surgical treatment of type Ⅳ capitellum frac- tures in adults

Objective： Fractures of the capitellum and trochlea constitute less than 1% of all elbow fractures and a shear fracture involving the capitellum and extending medially into most of the trochlea is rarely reported. Type Ⅳ capitellum fracture is still controversial in regard to its ra- diographic appearance, surgical approach and osteosynthesis. We report 10 cases of type Ⅳ capitellum fracture with a view to elucidating its clinical features and treatment outcome. Methods： We treated 10 patients of type Ⅳ capitellum fracture with a mean age of 32 years. A uniform surgical approach and postoperative rehabilitation were followed. Results： Nine patients presented to us after a mean of 4 days of injury and one patient was nonunion after 6 months of injury who had been treated conservatively by a bone setter. Double arc sign was absent in 6 cases. Intraopera- tively 6 capitellotrochlear fragments were devoid of soft tissue attachments. By Mayo Elbow Performance Score evaluation, 7 patients got excellent, 2 good and 1 fair results. One patient with associated elbow dislocation developed heterotopic ossification. There was no case of avascular necrosis, osteoarthrosis or fixation failures. Conclusions： Type Ⅳ capitellum fractures are rare and belong to complex articular injuries. A good functional out- come can only be achieved with open reduction and stable internal fixation followed by early mobilization. Preopera- tive radiographic assessment and computed tomography help surgeons in choosing the right surgical approach and implants. Good surgical technique and stable internal fixa- tion are the keys to early mobilization and good functional outcome.

Observation of the efficacy and safety of the Song-Relaxing and Zhen-Vibrating abdomen manipulation for patients with prediabetes

Objective:To observe the safety of the Song-Relaxing and Zhen-Vibrating abdomen manipulation in treating patients with prediabetes and its effects on blood glucose and lipid metabolism.Methods:One hundred and two patients with prediabetes were divided into a manipulation group and a control group according to the random number table method,with 51 cases in each group.All patients received the general behavioral intervention for prediabetes,with additional Song-Relaxing and Zhen-Vibrating abdomen manipulation in the manipulation group and oral metformin hydrochloride tablets in the control group.Both groups received the intervention for six months.Results:Fourteen patients dropped out during the treatment,and a total of 88 patients completed the trial,including 45 cases in the manipulation group and 43 cases in the control group.After the treatment,the prediabetes control rate was 93.3%in the manipulation group and 74.4%in the control group,and the difference between the two groups was statistically significant(P<0.05);no patient in the manipulation group progressed to diabetes,while the rate of conversion to diabetes in the control group was 6.9%,with a significant difference between the two groups(P<0.05).After the treatment,the body mass index(BMI),glycosylated hemoglobin A1c(HbA1c),fasting plasma glucose(FPG),2-hour postload plasma glucose(2hPG)level during an oral glucose tolerance test(OGTT),fasting insulin(FINS),homeostasis model assessment-2 of insulin resistance(HOMA2-IR),total cholesterol(TC),and triglycerides(TG)decreased in both groups versus baseline,with significant differences within the groups;the levels of all indicators were lower in the manipulation group than in the control group(P<0.05),and the differences between the two groups were more prominent at the sixth month(P<0.01).At the sixth month,the high-density lipoprotein cholesterol(HDL-C)in the manipulation group was increased,while there was no significant change in the control group.In the control group,three patients reported mild gastrointestinal reactions at the initial dosing,which improved after medication adjustment.No other adverse events were observed in either group.Conclusion:Both metformin hydrochloride tablets and the Song-Relaxing and Zhen-Vibrating abdomen manipulation can improve blood glucose and lipid metabolism and reduce insulin resistance and clinical discomfort in patients with prediabetes,but the Song-Relaxing and Zhen-Vibrating abdomen manipulation has higher efficacy and safety.