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Chemotherapy efficacy in metastatic neuroendocrine colorectal cancer 转移性神经内分泌结直肠癌的化疗疗效
Pub Date : 2023-06-21 DOI: 10.33878/2073-7556-2023-22-2-103-111
A. Seidinovich, S. Gordeev, A. Markovich, I. Komarov, D. V. Alexancev, Z. Mamedli
AIM: to evaluate the effectiveness of first-line chemotherapy in patients with colorectal neuroendocrine cancer (NEC).PATIENTS AND METHODS: a retrospective study included patients with metastatic colorectal NEC (2000-2020). The main analyzed parameter was the response rate to treatment according to the RECIST criteria, depending on the regimen used in the first line. The overall survival was additional parameter.RESULTS: the study included 27 patients (13 with initial stage IV disease and 14 with progression after primary radical treatment). Ten patients in the 1st line underwent chemotherapy according to the EP scheme, 4 — XELOX, 2 — FOLFIRI, 2 — Irinotecan and Cisplatin, 1 — Samarium, 1 — Nivolumab, 1 — 5-FU-LV. Most often, the treatment effect (partial response or stabilization) was observed against the background of chemotherapy according to the EP scheme — in 60% of patients. The median OS was 7 months.CONCLUSION: the use of chemotherapy according to the EP regimen is the preferred options for the treatment of metastatic colorectal NEC. The median OS in this group of patients remains extremely low, and new clinical trials are needed.
目的:评价结直肠神经内分泌癌(NEC)患者一线化疗的疗效。患者和方法:一项回顾性研究包括转移性结直肠NEC患者(2000-2020)。主要分析参数是根据RECIST标准的治疗反应率,取决于一线使用的方案。总生存期是附加参数。结果:该研究纳入了27例患者(13例为初始IV期疾病,14例为原发性根治后进展)。10例一线患者根据EP方案接受化疗,4 - XELOX, 2 - FOLFIRI, 2 -伊立替康和顺铂,1 - Samarium, 1 - Nivolumab, 1 - 5-FU-LV。大多数情况下,60%的患者在EP方案化疗的背景下观察到治疗效果(部分缓解或稳定)。中位生存期为7个月。结论:根据EP方案进行化疗是治疗转移性结直肠NEC的首选方案。这组患者的中位总生存期仍然极低,需要进行新的临床试验。
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引用次数: 0
The role of diet in bowel cleansing for colonoscopy (results of prospective observation study). Prospective observations study 饮食在结肠镜检查肠道清洁中的作用(前瞻性观察研究的结果)。前瞻性观察研究
Pub Date : 2023-06-21 DOI: 10.33878/2073-7556-2023-22-2-57-63
A. V. Galyaev, E. Surovegin, A. Likutov, O. Sushkov, Yu. E. Vaganov, A. S. Voskanyan, E. Merkulova
AIM: to evaluate the impact of dietary compliance in bowel cleansing for colonoscopy on the quality of the procedure.PATIENTS AND METHODS: one thousand patients who scheduled for diagnostic colonoscopy were included in the prospective observation study. The quality of bowel preparation was assessed using the Boston scale. Neoplasms were detected and endoscopically evaluated. The optical verification of tumors was used to calculate the indicators of identified adenomas and polyps (ADR and PDR).RESULTS: the quality of bowel cleansing by the Boston Scale was 6 (6; 8) points. One hundred eight (19.8%) patients did not follow the recommended diet. Poor preparation, which did not allow a total colonoscopy was found in 91 (9,1%) cases. The ADR was 37.4%, PDR — 43.4%. Logistic regression analysis showed that the noncompliance for diet recommendation was the only one significantly negative factor associated whit inadequate bowel cleansing.CONCLUSION: the leading factor worsening the quality of bowel cleansing was non-compliance with the prescribed diet before the colonoscopy.
目的:评价饮食依从性对结肠镜清洁手术质量的影响。患者和方法:1000名预定进行诊断性结肠镜检查的患者被纳入前瞻性观察研究。采用波士顿量表评估肠道准备质量。检测肿瘤并进行内镜评估。采用肿瘤光学验证法计算鉴定腺瘤和息肉的指标(ADR和PDR)。结果:肠道清洁质量波士顿评分为6 (6;8)点。108例(19.8%)患者没有遵循推荐饮食。91例(9.1%)患者术前准备不充分,无法进行全结肠镜检查。ADR为37.4%,PDR为43.4%。Logistic回归分析显示,不遵守饮食建议是唯一与肠道清洁不足相关的显著负性因素。结论:肠镜检查前不遵医嘱饮食是导致清肠质量恶化的主要因素。
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引用次数: 0
Consensus on controversial issues of the surgery for Crohn’s disease by Delphi method 德尔菲法治疗克罗恩病争议性问题的共识
Pub Date : 2023-06-21 DOI: 10.33878/2073-7556-2023-22-2-172-183
Y. Shelygin, S. Achkasov, I. Reshetov, I. V. Mayev, O. Drapkina, E. Belousova, A. Vardanyan, B. Nanaeva, D. Abdulganieva, L. Adamyan, L. Namazova-Baranova, A. Razumovsky, A. Revishvili, I. Khatkov, A. Shabunin, M. Livzan, A. Sazhin, V. M. Timerbulatov, O. Khlynova, S. Yatsyk, R. Abdulkhakov, O. P. Alekseeva, S. Alekseenko, I. Bakulin, O. Barysheva, D. A. Blagovestnov, K. Bolikhov, V. Veselov, Y. Vinogradov, O. Golovenko, I. Gubonina, A. Gulyaev, A. Dolgushina, E. Dyakonova, T. Zhigalova, O. Karpukhin, O. Knyazev, N. V. Kostenko, I. D. Loranskaya, A. Moskalev, A. Odintsova, V. V. Omelyanovsky, M. Osipenko, V. Pavlenko, E. Poluektova, D. Popov, G. Rodoman, A. Segal, S. Sitkin, M. I. Skalinskaya, A. Surkov, L. V. Tarasova, Y. B. Uspenskaya, S. Frolov, E. Chashkova, S. Shapovalyants, O. Shifrin, O. Shcherbakova, O. Shchukina, T. Shkurko, I. Nazarov, A. Mingazov
AIM: to establish the consensus on controversial issues of the surgery for Сrohn’s disease by Delphi method.METHODS: a cross-sectional study was conducted by the Delphi method. 62 experts voted intramural and anonymous (31.03.23). 5 statements from the current edition of clinical guidelines were selected for correction by working group and further voting [2]. Based on the practical experience of the working group and literature data, 3 new statements were created also. Statements that do not reach the required level of agreement (80% or more) will be subjected to Round 2 of the Delphi method.RESULTS: all experts took part in the anonymous voting. The panel of experts is represented by 8 different areas of practical medicine and the median of the professional experience of the respondents was 30 (12–49) years. Of the 8 statements submitted for voting, consensus (80% or more) was reached on 6 out of 8. 2 statements have been revised by working group for the distance 2nd round of the Delphi study. Consensus (more than 80%) was reached on both.CONCLUSION: a cross-sectional study by the Delphi method provided the opinions of a panel of experts on controversial issues in the surgical treatment of Crohn’s disease. Statements that reach consensus will be included by the working group in a new edition of clinical guidelines of Crohn’s disease.
目的:通过德尔菲法对Сrohn病手术中存在争议的问题建立共识。方法:采用德尔菲法进行横断面研究。62名专家进行校内匿名投票(31.03.23)。工作组从现行版临床指南中选择5条表述进行修正并进一步投票[2]。根据工作组的实际经验和文献资料,还编制了3项新的说明。未达到要求的一致性水平(80%或以上)的陈述将进行德尔菲法的第2轮。结果:所有专家均参加了匿名投票。专家小组由8个不同的实用医学领域代表,受访者的专业经验中位数为30(12-49)年。在提交投票的8项声明中,8项中有6项达成了共识(80%或以上)。工作组对2项声明进行了修改,以进行第二轮德尔菲研究。双方达成了共识(超过80%)。结论:采用德尔菲法的横断面研究提供了专家组对克罗恩病手术治疗中有争议的问题的意见。达成共识的声明将被工作组纳入新版克罗恩病临床指南。
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引用次数: 1
Clinical features and quality of life of patients with idiopathic megacolon 特发性巨结肠患者的临床特征及生活质量
Pub Date : 2023-06-21 DOI: 10.33878/2073-7556-2023-22-2-40-48
D. Aleshin, S. Achkasov, O. Sushkov, D. Shakhmatov, E. Surovegin, O. Fomenko
PATIENTS AND METHODS: the retrospective study of clinical features and diagnostic tests results included 81 patients with idiopathic megacolon/megarectum (2004–2022). The diagnosis of megacolon/megarectum was confirmed with a barium enema, Hirschsprung’s disease was excluded based on anorectal manometry and (if needed) rectal Swenson biopsy. The QoL was assessed by IBSQOL questionnaire; clinical symptoms were assessed with a point scale.RESULTS: the quality of life in patients with idiopathic megacolon has most affected energy (emotional and physical) and physical role (work/main activity). In univariate analysis the significant correlation was revealed between QoL and age, sex, rate of defecation without assistance, rate of integral parameters “abdominal discomfort” and “defecation difficulties”, duration of anamnesis, Wexner constipation scale rate and gut transit time (p < 0,05). In the same time, the presence or absence of constipation or anal incontinence (leakage), colon and rectum sizes (based on barium enema), parameters of defecografy and rectal compliance test have not correlated with a QoL. No significant difference of QoL in patients added to conservative treatment and operated after. Due to multivariate analysis (multiple linear regression) the age and rate of “abdominal discomfort” and “defecation difficulties” were only independent factors affected quality of life.CONCLUSION: in terms of quality of life, idiopathic megacolon has the greatest impact on general tone and ability to perform basic professional activities. Independent factors that statistically significantly affect the assessment of quality of life are the age of patients and the severity of symptoms of abdominal discomfort and defecation disorders.
患者与方法:回顾性研究2004-2022年81例特发性巨结肠/巨直肠患者的临床特征和诊断试验结果。通过钡剂灌肠确认了巨结肠/大直肠的诊断,根据肛门直肠测压和(如果需要)直肠Swenson活检排除了巨结肠/大直肠。采用IBSQOL问卷评估生活质量;临床症状用积分量表进行评估。结果:特发性巨结肠患者的生活质量受能量(情绪和身体)和身体角色(工作/主要活动)影响最大。单因素分析显示,生活质量与年龄、性别、无辅助排便率、“腹部不适”和“排便困难”积分参数率、记忆持续时间、Wexner便秘量表率和肠道转运时间之间存在显著相关(p < 0.05)。同时,是否存在便秘或肛门失禁(渗漏)、结肠和直肠大小(基于钡灌肠)、排便术参数和直肠顺应性试验与生活质量无关。加保守治疗与术后患者生活质量无显著差异。通过多变量分析(多元线性回归),年龄、“腹部不适”和“排便困难”的发生率是影响生活质量的独立因素。结论:在生活质量方面,特发性巨结肠对患者的一般情绪和基本专业活动能力影响最大。统计上显著影响生活质量评估的独立因素是患者的年龄和腹部不适和排便障碍症状的严重程度。
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引用次数: 0
Treatment of complications after surgery for Hirschsprung’s disease using posterior sagittal transanal approach (clinical observation) 后矢状面经肛门入路治疗先天性巨结肠术后并发症(临床观察)
Pub Date : 2023-06-04 DOI: 10.33878/2073-7556-2023-22-2-118-124
N. Stepanova, V. Novozhilov, D. A. Zvonkov, I. Latynceva
The experience of complications treatment after surgery for Hirschsprung’s disease using posterior sagittal transanal approach is presented. It allows to obtain a sufficient overview of the main anatomical structures of the small pelvis in a “frozen pelvis” situation, helping to avoid their damage at the scar tissue changes.
本文介绍后矢状面经肛门入路治疗先天性巨结肠术后并发症的经验。它允许在“冻结骨盆”情况下获得小骨盆主要解剖结构的充分概述,有助于避免其在瘢痕组织变化时的损伤。
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引用次数: 0
Eugeniy I. Semionkin. 75 years
Pub Date : 2023-06-04 DOI: 10.33878/2073-7556-2023-22-2-184
A. Editorial
.
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引用次数: 0
Acute malignant colorectal obstruction (K56.6; C18, C19, C20), adults 急性恶性结直肠梗阻(K56.6;C18, C19, C20),成人
Pub Date : 2023-06-03 DOI: 10.33878/2073-7556-2023-22-2-10-31
S. Achkasov, Z. A. Bagatelia, S. Bagnenko, A. Belyaev, Y. Gevorkyan, V. L. Denisenko, I. I. Zatevakhin, A. Kaprin, A. Karachun, O. Kit, Z. Z. Mammedli, A. Moskalev, I. Nazarov, A. Revishvili, A. Sazhin, I. Stilidi, O. Sushkov, V. M. Timerbulatov, V. Totikov, V. S. Trifonov, A. Tyagunov, I. Khatkov, A. Shabunin, Y. Shelygin, P. Yartsev
.
{"title":"Acute malignant colorectal obstruction (K56.6; C18, C19, C20), adults","authors":"S. Achkasov, Z. A. Bagatelia, S. Bagnenko, A. Belyaev, Y. Gevorkyan, V. L. Denisenko, I. I. Zatevakhin, A. Kaprin, A. Karachun, O. Kit, Z. Z. Mammedli, A. Moskalev, I. Nazarov, A. Revishvili, A. Sazhin, I. Stilidi, O. Sushkov, V. M. Timerbulatov, V. Totikov, V. S. Trifonov, A. Tyagunov, I. Khatkov, A. Shabunin, Y. Shelygin, P. Yartsev","doi":"10.33878/2073-7556-2023-22-2-10-31","DOIUrl":"https://doi.org/10.33878/2073-7556-2023-22-2-10-31","url":null,"abstract":"<jats:p>.</jats:p>","PeriodicalId":17840,"journal":{"name":"Koloproktologia","volume":"17 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-06-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"83241449","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Does the type of anastomosis affect the risk of recurrence in Crohn disease? 吻合方式是否影响克罗恩病复发的风险?
Pub Date : 2023-03-21 DOI: 10.33878/2073-7556-2023-22-1-83-90
A. Vardanyan, I. S. Anosov, V. A. Michalchenko, B. Nanaeva
AIM: to evaluate the effect of intestinal anastomosis type on risk of Crohn’s disease (CD) recurrence.PATIENTS AND METHODS: the retrospective cohort study included 130 patients with CD who underwent surgery for a complicated CD in 2012–2017. Ileocecal resection with anastomosis was performed in 112/130 (86.2%) patients. Resection of the terminal ileum with resection of the right side of the colon with the formation of an ileo-transverse anastomosis. In 18/130 (13.2%) cases. Stapled “side-to-side” anastomosis was formed in 57/130 (43.8%) patients, while hand sewn “end-to-end” — in 73/130 (56.2%) patients. Post-op complications occurred in 21/130 (16.2%) cases. After surgery, most patients were treated by azathioprine as an anti-recurrence therapy — 112/130 (86.2%) patients, while in 31/112 (23.8%) cases, additional biological therapy was done. In 14/130 (10.7%) patients, anti-recurrence therapy was carried out in mono mode with a biological drug.RESULTS: mean follow-up was 28.5 (1.9–95.4) months. Recurrence occurred in 54/130 (41.5%) patients on average 18 ± 5 (12–41) months after surgery. Thus, the operative time exceeding 200 minutes was significantly associated with an increase in the recurrence rate (p = 0.03). It was found that the type of anastomosis does not affect the recurrence risk. Moreover, among the significant factors was the operative time. It increases the chance of recurrence by 2.9 times in the univariate model (p < 0.05), and in the multivariate model — by 6.3 times, when exceeding 155 minutes.CONCLUSION: the type of anastomosis does not affect the recurrence risk. The operation time exceeding 155 minutes increases the chance of recurrence by 6 times (p < 0.01).
目的:探讨肠吻合方式对克罗恩病(CD)复发风险的影响。患者和方法:该回顾性队列研究包括130例2012-2017年因复杂CD接受手术的CD患者。130例患者中有112例(86.2%)行回盲切除吻合。切除回肠末端,同时切除结肠右侧,形成回肠横断吻合。130例中有18例(13.2%)。57/130(43.8%)患者采用订书式“侧对侧”吻合,73/130(56.2%)患者采用手缝“端对端”吻合。术后并发症发生率为21/130(16.2%)。术后大多数患者采用硫唑嘌呤作为抗复发治疗,112/130例(86.2%),31/112例(23.8%)患者采用生物治疗。130例患者中有14例(10.7%)采用生物药物单药抗复发治疗。结果:平均随访时间28.5(1.9 ~ 95.4)个月。54/130(41.5%)例患者术后平均18±5(12-41)个月复发。因此,手术时间超过200分钟与复发率增加显著相关(p = 0.03)。吻合方式与复发风险无明显关系。此外,手术时间也是影响手术效果的重要因素之一。在单因素模型中,它使复发率增加2.9倍(p < 0.05),在多因素模型中,当超过155分钟时,复发率增加6.3倍。结论:吻合方式对复发风险无影响。手术时间超过155分钟,复发率增加6倍(p < 0.01)。
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引用次数: 0
Results of multicenter observational study «predictors of colectomy in patients with extremely severe ulcerative colitis 多中心观察性研究的结果——极严重溃疡性结肠炎患者结肠切除术的预测因素
Pub Date : 2023-03-21 DOI: 10.33878/2073-7556-2023-22-1-45-53
A. Mingazov, A. Vardanyan, O. Sushkov, D. G. Shahmatov, B. Nanaeva, T. Baranova, S. Katorkin, N. V. Kostenko, S. Achkasov
AIM: to improve the results of treatment of patients with «extremely severe» ulcerative colitis (UC).PATIENTS AND METHODS: A multicenter observational prospective «case-control» study was conducted. The study included 71 patients with «extremely» severe UC from June 2019 to October 2021. All patients underwent conservative therapy in accordance with current clinical guidelines. Evaluation of the effectiveness of treatment was carried out on the 3rd and 7th days of therapy, a "response" or "no response" to steroid therapy was stated.RESULTS: A total of 48 (68%) patients underwent surgical treatment during the follow-up period during hospitalization. 23 (32%) patients "responded" to conservative therapy and were discharged without colectomy. A reliable independent predictor of colectomy at the time of hospitalization was the level of albumin less than 29 g/l (OR – 8,6 95% CI: 2,5 – 39,9, p=0,002). On day 3, the reliable predictors were the level of C-reactive protein over 15.5 mg/l (OR – 9 95% CI: 2.4 – 46.1, p=0.003) and the value of the Mayo index above 7 points (OR – 13.3 95% CI: 3.3 – 75.7, p=0.0009).CONCLUSION: The study has demonstrated that the only reliable and independent predictor of colectomy at admission to the clinic is the level of albumin less than 29 g/l. Reliable factors that make it possible to evaluate and predict the effectiveness of therapy are the level of C-reactive protein more than 15.5 mg/l and the value of the Mayo index above 7 points on the 3rd day of therapy, as well as the level of C-reactive protein above 29 mg/l on the 7th day.
目的:提高“极严重”溃疡性结肠炎(UC)患者的治疗效果。患者和方法:进行了一项多中心观察性前瞻性“病例对照”研究。该研究包括2019年6月至2021年10月期间71名“极”严重UC患者。所有患者均按照现行临床指南进行保守治疗。在治疗的第3天和第7天对治疗效果进行评估,对类固醇治疗有“反应”或“无反应”。结果:48例(68%)患者在住院期间随访期间接受了手术治疗。23例(32%)患者对保守治疗“有反应”,出院时未行结肠切除术。住院时结肠切除术的可靠独立预测因子是白蛋白水平低于29 g/l (OR - 8,6 95% CI: 2,5 - 39,9, p=0,002)。在第3天,可靠的预测因子是c反应蛋白水平超过15.5 mg/l (OR - 9 95% CI: 2.4 - 46.1, p=0.003)和Mayo指数高于7点(OR - 13.3 95% CI: 3.3 - 75.7, p=0.0009)。结论:该研究表明,入院时结肠切除术的唯一可靠和独立的预测指标是白蛋白水平低于29 g/l。治疗第3天c -反应蛋白水平大于15.5 mg/l,梅奥指数大于7分,第7天c -反应蛋白水平大于29 mg/l,是评价和预测治疗效果的可靠因素。
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引用次数: 0
Predictors of steroid dependence and resistance in patients with ulcerative colitis 溃疡性结肠炎患者类固醇依赖和抵抗的预测因素
Pub Date : 2023-03-21 DOI: 10.33878/2073-7556-2023-22-1-99-107
I. Tishaeva, O. Knyazev, T. Baranova, D. Podolskaya, T. Alexandrov, B. Nanaeva
AIM: detection of steroid dependence and steroid resistance predictors in patients with ulcerative colitis (UC).PATIENTS AND METHODS: a retrospective study was conducted. The medical documentation of 1105 patients, who underwent inpatient treatment in Ryzhikh National Medical Research Center of Coloproctology from 2018 to 2021, were analyzed. 69% of patients (n=762) received systemic steroid therapy for UC. In accordance with inclusion and non-inclusion criteria, the medical documentation of 170 patients was selected for statistical analysis. Depending on the steroid status of patients, three groups were identified: group 1 (n=56) with steroid dependence, group 2 (n=56) with steroid resistance and group 3 - control (n=58), who were prescribed systemic GCS without the further development of steroid dependence and resistance.RESULTS: the incidence of steroid dependence was 23.4% (n=259), and steroid resistance was 15.2% (n=168). We identified the following predictors and risk factors of steroid dependence: age of the disease onset <30 y.o. (AOR=0,960, 95%CI= 0,928-0,993, p=0,019), start dose of prednisolone <60 mg (AOR=2,369, 95%ДИ= 1,030-5,441, p=0,042), prescription of systemic GCS ≥2 courses per year (AOR=2,988, 95%ДИ= 1,349-6,619, p=0,007), Mayo Index Score <10 (AOR=0,631, 95%ДИ=0,492-0,809, p<0,001). The risk of steroid resistance statistically significant when Mayo Index Score ≥10 (AOR=2,573, 95%ДИ=1,094-6,050, p=0,030), albumin level <37,1 g/l (AOR=4,571, 95%ДИ=1,567-13,330, p=0,005), CRP ≥47,1 mg/l (AOR=2,641, 95%ДИ=1,102-6,328, p=0,029).CONCLUSION: it is rational to predict an individual response to GCS in patients with UC. With a high risk of developing steroid dependence and steroid resistance, it is advisable to consider early appointment of biological and target therapy, avoiding represcription of GCS.
目的:检测溃疡性结肠炎(UC)患者的类固醇依赖和类固醇耐药预测因素。患者和方法:进行回顾性研究。对2018年至2021年在雷日克国家肛肠医学研究中心住院治疗的1105例患者的医疗记录进行分析。69%的患者(n=762)接受了UC的全身类固醇治疗。按照纳入标准和不纳入标准,选取170例患者的医学文献进行统计分析。根据患者的类固醇状态,分为三组:类固醇依赖组1 (n=56),类固醇耐药组2 (n=56),对照组3 (n=58),在没有进一步发展类固醇依赖和耐药的情况下,给予全身GCS治疗。结果:类固醇依赖发生率为23.4% (n=259),类固醇耐药发生率为15.2% (n=168)。我们确定了以下类固醇依赖的预测因素和危险因素:发病年龄<30岁(AOR=0,960, 95%CI= 0,928-0,993, p=0,019),泼尼松龙起始剂量<60 mg (AOR=2,369, 95%ДИ= 1,030-5,441, p=0,042),全身GCS处方≥2疗程/年(AOR=2,988, 95%ДИ= 1,349-6,619, p=0,007), Mayo指数评分<10 (AOR=0,631, 95%ДИ=0,492-0,809, p<0,001)。Mayo指数≥10 (AOR=2,573, 95%ДИ=1,094-6,050, p=0,030)、白蛋白水平<37,1 g/l (AOR=4,571, 95%ДИ=1,567-13,330, p=0,005)、CRP≥47,1 mg/l (AOR=2,641, 95%ДИ=1,102-6,328, p=0,029)时发生类固醇耐药的风险有统计学意义。结论:预测UC患者对GCS的个体反应是合理的。由于发生类固醇依赖和类固醇耐药的风险较高,建议考虑尽早预约生物和靶向治疗,避免使用GCS。
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引用次数: 0
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Koloproktologia
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