1 病例资料 1.1 病例1 患者女,44岁,武汉人,因"咳嗽、发热3d"于2020年1月29日入院.查体:呼吸24次/min,心率95 次/min,口唇无发绀,呼吸略急促,双肺呼吸音减低,未闻及干湿啰音.入院查:白细胞4.87 ×109/L,淋巴细胞0.76 ×109/L (见图1),降钙素原0.065ng/ml,血沉16mm/h,肝肾功能、凝血功能、心肌酶正常,胸部CT提示病毒性肺炎(影像动态变化见图2),咽拭子及痰液新型冠状病毒RNA阳性,血气分析血氧分压60mmHg(1mmHg=0.133kPa)(见图3),氧饱和度93％,氧合指数146mmHg,按照新型冠状病毒肺炎诊疗方案(试行第五版、第六版)标准,诊断为"新型冠状病毒肺炎重型",予以干扰素雾化抗病毒,口服甘草酸二铵肠溶胶囊150mg tid抗炎,同时氧疗、改善肺通气,密切监测血常规、炎性指标、血气分析、胸部影像学、病毒核酸等.经治疗患者症状逐日改善,未继续恶化加重,治疗1d后体温正常、咳嗽、气促减轻,血氧分压在吸氧状态下达 100mmHg,氧合指数207mmHg,1 周后停止吸氧,10d后胸部影像学明显吸收好转,14d时病毒核酸转阴.

目的:探讨洛匹那韦/利托那韦(克力芝)治疗新型冠状病毒肺炎(COVID-19)的临床疗效及安全性.方法:回顾性分析2020年1月23日～3月11日南充市中心医院治愈出院的22例COVID-19患者的临床资料,抗病毒治疗方案均含洛匹那韦/利托那韦.收集患者的基本特征、临床症状、实验室指标、肺部影像学及不良反应发生情况、住院时间等资料.结果:全部患者均口服洛匹那韦/利托那韦抗病毒治疗,均治疗出院,住院时间11～42(21.09±8.513)d,临床症状缓解时间约5～7 d,核酸转阴时间4～38(13.32±8.916)d,肺部影像学吸收时间0～29(12.27±5.742)d.出现不良反应10例,发生率为45.5％,主要表现为恶心、腹泻、转氨酶升高、血脂升高等.结论:洛匹那韦/利托那韦联合其他抗病毒药物治疗尚未观察到显著临床疗效,早期使用可能潜在缩短病程、避免疾病进展的作用,但药物不良反应发生率较高,尤其是胃肠道反应、肝毒性及血脂代谢异常.临床应用时尤其应关注其安全性,是否具有临床使用价值、如何选择用药时机尚需大样本数据研究.

目的 探讨CD4细胞计数,IL-6/IL-10比值联合对艾滋病合并肺孢子菌肺炎的诊断价值.方法 纳入2018年1月至2019年5月南充市中心医院收治的100例艾滋病合并肺孢子菌肺炎患者为艾滋肺炎组、100例艾滋病患者为艾滋组、100例健康体检者为对照组;通过流式细胞仪检测血清中CD4+T细胞的数量;酶联免疫吸附试验检测血清中IL-6,IL-10的表达水平.用受试者工作特征曲线(receiver operating characteristic curve,ROC)的AUC分析CD4细胞计数,IL-6/IL-10检测在艾滋病合并肺孢子菌肺炎中的诊断意义.结果 艾滋病合并肺孢子菌肺炎患者血清中CD4细胞数量均<艾滋病患者与健康体检者(t=28.31,P<0.0001;t=36.90,P<0.0001),但是,IL-6/IL-10比值均高于艾滋病患者与健康体检者(t=7.184,P<0.0001;t=19.03,P<0.0001).CD4细胞计数,IL-6/IL-10比值联合对艾滋病合并肺孢子菌肺炎的诊断的的灵敏度为92.00％,特异度为88.00％,准确度为89.33％.结论 CD4细胞计数,IL-6/IL-10比值的检测可作为诊断艾滋病合并肺孢子菌肺炎的潜在标志.

目的:探讨MRI扩散加权成像(diffusion weighted imaging,DWI)对肝细胞癌(hepatocellular carcinoma,HCC)病理分级的预测价值分析.方法:2014年2月至2018年4月选择在南充市中心医院肿瘤科住院诊治的HCC患者74例,病理分级为Ⅰ级34例,Ⅱ级30例,Ⅲ级10例.所有患者都给予常规MRI与DWI检查,记录诊断特征与预测病理分级状况.结果:Ⅰ级患者中14例DWI为高信号,8例为低信号,12例为等信号;Ⅱ级患者中16例DWI为高信号,7例为低信号,7例为等信号;Ⅲ级患者中DWI为高信号.Ⅲ级患者的病灶ADC值显著低于Ⅰ级与Ⅱ级患者,Ⅱ级患者低于Ⅰ级患者,对比差异都有统计学意义(P<0.05).在74例患者中,MRI DWI都诊断为HCC,判断为Ⅰ级32例,Ⅱ级32例,Ⅲ级10例,诊断正确率为94.6％.以ADC值=1.42×10-3mm2/s与1.13×10-3mm2/s作为鉴别诊断HCC病理Ⅰ级/Ⅱ级和Ⅱ级/Ⅲ级的分级标准,诊断AUC值分别为0.786和0.739.结论:MRI DWI对HCC病理分级具有中等的预测诊断价值,可为HCC的病例分级补充提供有价值的鉴别诊断信息.

目的:探讨与研究(HBV)病毒cccDNA和血清巨噬细胞移动抑制因子(MIF)的表达相关性.方法:选择2015年2月到2018年7月,在我院接受治疗的78例乙型肝炎患者作为观察组,同期选择78例非肝炎感染患者作为对照组,对两组患者血清MIF、ALT、AST、TBil的表达进行检测,并进行HBV cccDNA表达分析.结果:观察组的血清ALT、TBiL、AST含量都显著高于对照组,对比差异显著(P＜0.05).观察组的血清MIF含量为(9.08±2.19) μg/L,显著高于对照组的(1.98±0.92) μg/L(t=8.272,P=0.000).观察组的HBV cccDNA阳性率为50.0％,对照组为2.6％,观察组的HBV cccDNA阳性率显著高于对照组(P＜0.05).直线相关分析显示观察组的血清HBV cccDNA阳性率与血清ALT、TBiL、AST、MIF含量都呈现显著正相关性(P＜0.05).结论:乙肝患者体内血清MIF水平显著升高,也伴随有HBV cccDNA的阳性表达,两者存在显著的相关性.

目的 探讨miRNA-23靶向gremlin1调节肝癌细胞的生物学功能.方法 将人肝癌细胞株HSMMC-7721分为高表达组、抑制组和对照组,高表达组转染miRNA-23mimics,抑制组转染miRNA-23inhibitor,对照组不进行转染.MTT实验检测细胞增殖,流式细胞仪实验检测细胞周期,Transwell小室实验检测细胞侵袭,Western blot检测gremlin1表达.结果 高表达组的miRNA-23相对表达量显著高于抑制组和对照组(P<0.05),抑制组和对照组比较差异无统计学意义(P>0.05).与抑制组和对照组相比,高表达组的细胞增殖率显著降低,S期与G2/M期比例显著增加,GO/G1期比例显著减少,细胞侵袭数显著减少,差异均有统计学意义(P<0.05).与抑制组和对照组相比,高表达组的gremlin1蛋白相对表达量显著下降(P<0.05).结论 miRNA-23高表达能抑制gremlin1的表达,调节肝癌细胞周期,抑制肝癌细胞增殖与侵袭,可为防治肝癌提供新的思路和治疗靶点.

Objective To investigate effects of anti-tuberculosis (anti-TB) therapy on CD4 + lymphocyte and its prognosis in patients with acquired immunodeficiency syndrome (AIDS) complicated with pulmonary tuberculosis (PTB). Methods A total of 84 patients with AIDS complicated with PTB were treated with the same regimen of anti-TB. CD4+ lym-phocytes were counted before and in 1,3 and 6 months after anti-TB therapy. Correlations between clinical symptoms,nega-tive conversion condition of sputum bacterium and condition of lesion absorption by chest X-ray examination with CD4+ lym-phocyte count before anti-TB treatment was analyzed after the anti-TB therapy were analyzed. Conditions of adverse reactions during anti-TB therapy and prognosis were statistically analyzed. Results Numbers of CD4+ lymphocytes less than 100/μl, 100-200/μl and equal or larger than 200/μl before and in 1,3 and 6 months after anti-TB treatment were 48,19 and 17 ca-ses,46,17 and 21 cases,40,12 and 32 cases and 31,10 and 43 cases respectively. There were significant differences in improvement rate of clinical symptoms and absorption rate by chest X-ray examination after anti-TB therapy in patients with CD4+ lymphocyte count less than 100/μl,100-200 μl and equal or large than 200/μl (P<0.05). Improvement rate of clinical symptoms and absorption rate by chest X-ray examination after anti-TB therapy in patients with CD4 + lymphocyte count less than 100/μl were significantly lower than those in patients with CD4+ lymphocyte count equal or large than 200/μl (P<0.05). During anti-TB therapy,incidence rate of adverse reactions was 22.62%,and there were 16 patients with gas-trointestinal reactions,2 patients with mildly increased transaminase and 1 with mildly renal dysfunction. In this study,fatality rate was 17.86% after anti-TB therapy. Conclusion Anti-TB in treatment of patients with acquired immunodeficiency syn-drome complicated with pulmonary tuberculosis may improve prognosis,prolong survival time and improve quality of life of pa-tients.

目的 探究硫普罗宁片联合恩替卡韦分散片治疗慢性乙型肝炎的临床疗效.方法 选取2014年3月-2016年11月于南充市中心医院收治的HBeAg阳性慢性乙型肝炎患者94例,按随机数字表法分为对照组和治疗组,每组各47例.对照组患者口服恩替卡韦分散片,0.5 mg/次,1次/d,治疗组在对照组治疗的基础上口服硫普罗宁片,0.1 g/次,3次/d.两组均连续治疗6个月.观察两组的临床疗效,比较两组肝功能指标、炎症因子水平和血清病毒学指标.结果 治疗后,对照组总有效率78.72%,明显低于治疗组的93.62%,两组比较差异具有统计学意义(P<0.05).治疗3、6个月后,两组血清丙氨酸氨基转移酶(ALT)、天冬氨酸氨基转移酶(AST)、总胆红素(TBIL)水平均明显下降,血清白蛋白水平明显升高,同组治疗前后比较差异具有统计学意义(P<0.05);且治疗后治疗组与对照组同期比较差异有统计学意义(P<0.05).治疗3、6个月后,两组血清白介素(IL)-2、肿瘤坏死因子(TNF)-α 水平均明显下降,血清白介素(IL)-10水平明显升高,同组治疗前后比较差异具有统计学意义(P<0.05);且治疗后治疗组与对照组同期比较差异具有统计学意义(P<0.05).对照组HBV-DNA阴转率为55.32%,HBeAg阴转率为40.43%,HBeAg转换率为34.04%;治疗组HBV-DNA阴转率59.57%,HBeAg阴转率为38.30%,HBeAg转换率为31.91%,两组血清病毒学指标比较差异无统计学意义.结论 硫普罗宁片联合恩替卡韦分散片治疗慢性乙型肝炎具有较好的临床疗效,能有效改善肝功能,缓解炎症因子紊乱,具有一定的临床推广应用价值.

目的 探讨降钙素原(procalcitonin,PCT)、C-反应蛋白(C-reactive protein,CRP)、白细胞计数(leukocyte count,WBC)和血清抗结核抗体IgG阳性(IgG抗PPD-IgG)在肺结核诊断中的检测意义.方法 选取2016年5月至2017年5月本院收治的120例肺结核患者,其中活动性肺结核患者60例,非活动性肺结核患者60例;选取同期健康体检者60例和肺部感染(非肺结核)患者60例为对照.收集受试者血清并检测血清中PCT、CRP和WBC表达水平和IgG抗PPD-IgG阳性率.结果 与对照组相比,活动性肺结核组与非活动性肺结核组患者血清内PCT和CRP血清水平、白细胞计数,IgG抗PPD-IgG阳性率显著升高,差异具有统计学意义(P＜0.05).与肺部感染组相比,活动性肺结核组与非活动性肺结核组患者血清内PCT和CRP血清水平、白细胞计数显著降低,差异具有统计学意义(P＜0.05).与活动性肺结核组相比,非活动性肺结核组患者血清内PCT和CRP血清水平、白细胞计数,IgG抗PPD-IgG阳性率明显下降,差异具有统计学意义(P＜0.05).活动性肺结核组患者PCT和CRP血清水平、WBC和IgG抗PPD-IgG阳性率的单独检出率明显低于四指标的联合检测率,差异具有统计学意义(P＜0.05).非活动性肺结核组患者PCT和CRP血清水平、WBC和IgG抗PPD-IgG阳性率的单独检出率明显低于四指标的联合检测率,差异具有统计学意义(P＜0.05).结论 PCT、CRP、WBC和IgG抗PPD-IgG阳性率在肺结核患者的血清中呈高表达状态;其联合检测在肺结核的临床诊断中具有重要的作用.

Objective To investigate the preventive effects of lamivudine combined with chemotherapy drugs on hepatitis B virus reactivation in patients with HBV infection and tumor. Methods From July 2014 to February 2017,a total of one hundred and twenty patients with HBV infection and tumor in Nanchong Central Hospital were selected and were divided into the observation group and control group with 60 cases in each group. The control group received conventional chemotherapy and liver protection treatment,the observation group was given lamivudine prophylaxis treatment(100 mg/d,1 time/d) based on the treatment in the control group, two groups were treated for 8 weeks. Results The rates of hepatitis B virus reactivation in the observation group and the control group were 5. 0％(3/60) and 33. 3％(20/60),respectively,and the difference between the two groups was statistically significant (χ2=15. 692,P<0. 05) . There was no significant difference in serum glutamic acid transferase and aspartic transferase in the patients before and after treatment ( P>0. 05 ) , and the control group showed an upward trend ( P<0. 05) . After treatment,the serum ALT and AST in the observation group ((31. 98±6. 33)U/L,(26. 38±4. 98)U/L) were lower than those in the control group((43. 89±6. 73)U/L, (51. 78±5. 99)U/L)(t=8. 294,11. 842,P<0. 05). After treatment,the HBV DNA in the observation group and the control group((0. 16±0. 04) ×103copies/ml,(5. 02±1. 72) ×103copies/ml) were lower than those before treatment ((14. 55±2. 14)×103copies/ml,(14. 09±1. 98 copies/ml )(t=25. 498,8. 142,P<0. 05),and the HBV DNA in the observation group after treatment was also lower than that of the control group. The difference between the two groups was statistically significant ( t=24. 292,P<0. 05) . Conclusion Lamivudine combined with chemotherapy drugs used in patients with HBV infection and tumor can prevent hepatitis B virus reactivation,it does not affect the patient′s liver function,it can inhibit the replication of hepatitis B virus,so it has good application values.

目的 探讨拉米夫定辅助治疗乙型肝炎病毒(HBV)携带者合并肺结核病的价值.方法 HBV携带者合并肺结核病患者94例,随机分为试验组和对照组,每组47例,两组患者均给予2HRZE/4HR方案进行抗结核治疗,试验组在上述治疗的基础上口服拉米夫定,两组疗程均为6个月.比较两组患者疗效,HBV-DNA阴转率及阴转时间、肺结核指标、肝脏损伤情况.结果 试验组治疗总有效率为95.75％,高于对照组的82.98％ (P ＜0.05);试验组的HBV-DNA阴转率为100.00％,高于对照组的89.36％,且试验组HBV-DNA阴转时间为(2.22±1.23)个月,短于对照组的(2.89±1.11)个月(P＜0.05);试验组的痰菌阴转率、病灶显吸率分别为97.9％、89.36％,均高于对照组的74.5％、61.7％ (P ＜0.05);试验组的肝损伤率为8.51％,低于对照组的36.17％ (P ＜0.05).结论 拉米夫定辅助治疗HBV携带合并肺结核病能降低肝功能损伤,抑制体内HBV复制,提高痰菌阴转率及病灶显吸率,从而改善总体病情.

Objective To explore the clinical value of different usages of lamivudine in the treatment of hepa-titis B virus ( HBV) infection with tuberculosis. Methods One hundred and ninety patients of HBV infection with tu-berculosis in our hospital from August 2011 to November 2015 were selected by using a prospective study method. All the patients were equally divided into two groups according to the order of admission,95 cases in each group. Control group received adefovir dipivoxil combined with lamivudine treatment,and observation group received lamivudine and adefovir dipivoxil sequential therapy, the treatment lasting for 6 months. Results The effective rate of observation group was higher than that of control group (88. 4% vs. 72. 6%,P<0. 05). The levels of ALT,AST,TBIL and DBIL in observation group were lower than those of control group after treatment ( P <0. 05 ) , while the negative rates of HBV-DNA and HBeAg in observation group (91. 6% and 81. 1%) were higher than those of control group (74. 7%and 68. 4%),there being significant differences (P<0. 05). Conclusion Compared with combination therapy,lami-vudine and adefovir dipivoxil sequential therapy can significantly relieve the liver injury,and improve the negative rates of HBV-DNA and HBeAg and the effective rate in the treatment of HBV infection with tuberculosis.

ABSTRAC T Objective: To discuss the necessity and advantages of hierarchical diagnosis and treatment for tuberculosis patients. Methods: From January 2015, our hospital started grading treatment for pulmonary tuberculosis patients. Before and after that (in 2014 and 2015), cases were collected and compared for cure rate, clinical bed turnover rate, patient satisfaction and recurrence rate. Results: After grading diagnosis and treatment, 413 were treated with 187 cured, the cure rate (45.28%) was significantly higher than that of before (34.46%); Hospital beds turnover rate was improved obviously (805.88% vs 438.78, P<0.05); Pa-tients' satisfaction rate increased significantly (98.79% vs 91.38%, P<0.05). Conclusion: Hierarchical diag-nosis and treatment of pulmonary tuberculosis is helpful to improve cure rate, bed turnover rate and pa-tients' satisfaction. Its clinical application in patients at different stage can pay appropriate attention to medication for rationality, sustainability and normativeness, it is suitable for the management of long-term treatment of chronic diseases with obvious advantages and strong necessity.

目的 探讨某地区HIV/AIDS患者CD4+T淋巴细胞检测结果与抗病毒治疗效果,同时进行相关性分析.方法 2013年2月～2016年1月选择在笔者医院诊治的HIV/AIDS患者60例作为观察组,同期选择在笔者医院进行健康体检的健康入60例作为对照组,观察组都给予HAART标准治疗方案,观察组在治疗前后、对照组在入院时都进行CD4+T淋巴细胞与细胞因子表达的检测.结果 观察组外周血的CD4+ CD45RA+、CD4+ CD28+、CD4+ CD45RO+的细胞比例明显低于对照组(P＜0.05),两组CD4+ CD25+的细胞比例对比,差异无统计学意义(P＞0.05).与对照组相比,观察组的血浆IL-10和TGF-β1含量都显著升高(P＜0.05).治疗后观察组的CD4+ CD45RA+、CD4+ CD28+、CD4+ CD45RO+的细胞比例都明显上升(P＜0.05),而血浆IL-10和TGF-B1含量明显降低(P＜0.05).在观察组中,Spearman秩相关分析显示CD4+ CD45RA+、CD4+ CD28+、CD4+ CD45RO+的细胞比例与IL-10、TGF-B1水平均呈负相关(P＜0.05).结论 HIV/AIDS患者只有较低的免疫功能,具有较低的CD4+T淋巴细胞亚群比例和较高的IL-10和TGF-β1水平,HAART治疗能改善免疫功能,为此通过CD4+T淋巴细胞就能判断HIV/AIDS患者的治疗效果和病情.