2003年转博试题

To determine the safety and efficacy of ganciclovir treatment of hepatitis B virus (HBV) infection after liver transplantation, nine patients (seven males, two females; mean age, 38 years) with posttransplant HBV infection were treated with ganciclovir for 3 to 10 months. Ganciclovir was administered intravenously at an initial dose of 5 mg/kg/d and then increased to 10 mg/kg/d. Immunosuppressive drugs therapy was maintained at low levels. There were no major side effects of ganciclovir therapy. Serum HBV DNA levels decreased by a mean of 90% (range, 42% to 100%), and four of nine patients had no measurable HBV DNA at the completion of therapy. Mean serum alanine aminotransferase levels decreased by 83%. Hepatic expression of HBV antigens and HBV DNA was assessed before and after therapy in six patients and found to be reduced in three patients.

Most patients with type 2 DM will eventually need insulin. Insulin therapy was started in patients with type 2 DM with a mean HbA1c level of 10.4 % in the United States, and the UKPDS showed that ß-cell failure is progressive; 50% of normal ß-cell function at diagnosis with a steady decline following diagnosis. Concomitantly, 53% of patients with type 2 DM initially treated with Sus required insulin therapy by 6 years, and almost 80% required insulin by 9 years. Although we may be diagnosing DM earlier and thus altering this time frame, physicians should consider starting insulin therapy in patients whose HbA1c level approaches 8% despite optimal oral therapy.

While aspirin retains its status as the "front-lone" antiplatelet drug, the newer drugs now offer potentially greater and more specific control over platelet function. The blockade of the platelet glycoprotein IIb/IIIa receptor- the final common pathway to platelet aggregation- is effective in the setting of coronary angioplasty and is already being used widely in high-risk or complex angioplasty. It also appears likely that these drugs will be useful in acute coronary syndromes. The orally active ticlopidine has emerged as an effective alternative for patients intolerant of aspirin, and is superior to aspirin for secondary stroke prevention.

Several more drugs are being developed, aimed at controlling different phases of platelet function, such as platelet adhesion.

The gross morphologic features of adenocarcinoma in the large bowel depend on the tumor's site. Carcinomas of the proximal colon, particularly those of cecum and ascending colon, tend to be large and bulky, often outgrowing their blood supply and undergoing necrosis. This polypoid configuration may also be found elsewhere in the colon and rectum. In the more distal colon and rectum, tumors more frequently involve a greater circumference of the bowel, producing an annular constriction or "napkin-ring" appearance. The fibrous stroma of these tumors accouts for constriction and narrowing of the bowel lumen, whereas the circular arrangement of colonic lymphatics is responsible for their annular growth. These tumors may also become ulcerated.

Blood urea is a poor guide to renal function as it varies with protein intake, liver metabolic capacity and renal perfusion. Creatinine is a more reliable guide as it is produced from muscle at a constant rate and almost completely filtered at the glomerulus. As very little creatinine is secreted by tubular cells the creatinine clearance provides a reasonable approximation of the glomerular filtration rate. If muscle mass remains constant, changes in creatinine concentration reflect changes in GFR. However, an increase outwith the normal range is not seen until GFR is reduced by about 50%, and isolated measurements of creatinine give a misleading impression of renal function in those with unusually small amounts (and occasionally in those with very large amounts) of muscle.

Essential monoclonal gammopathy is seen with increasing frequency in the elderly. In a Swedish study of 6,995 individuals over 25 years of age, 64 had a monoclonal protein in the immunoglobulin region on serum electrophoresis. One patient had frank multiple myeloma, and one had chronic lymphocytic leukemia. Eleven years later these two patients had died, and one other developed malignant lymphoma and died. Sixty-one patients had persistent monoclonal gammopathy. Other studies indicate that about 2 percent of patients with monoclonal gammopathy progress to malignant disease each year. The rate of occurrence of monoclonal gammopathy itself is 2 to 4 percent in the eighth decade, 6 to 12 percent in the ninth decade, and over 14 percent in the tenth decade of life.

The Ministry of Health has fired up its anti-smoking campaign by pushing healthcare providers-particularly general practitioners-to take on an aggressive five-step plan to help smokers kick the habit.

Dubbed the "5As approach", the plan was formulated by a workgroup of primary care doctors, health educators, specialists and others, and launched as part of the ministry's brand-new set of clinical practice guidelines on smoking cessation. The "5As" consist of asking, advising, assessing, assisting and arranging.

The first step involves getting family physicians and other healthcare providers such as dentists, nurses, psychologists and pharmacists to implement an office system where every patient is asked about their tobacco use at every visit.

Headache is a common symptom in the normal population, with an estimated point prevalence of 20 percent; whether there is a unique lupus headache is debated. From a practical standpoint, in a patient with lupus and headache, the important thing is to exclude other treatable causes and to not miss an infection, stroke, tumor, or drug-induced cause. An acute headache that is not severe and with no localized neurological signs and symptoms can be treated empirically and the patient observed. A severe headache, with neurological signs or symptoms, or chronic refractory course should prompt an MRI or CT of the brain, spinal fluid studies, and coagulopathy screen. Migrainous phenomenon may occur as a manifestation of active disease or may herald a flare.