问题 多项选择题 案例分析题

患者男,56岁,因“全身皮肤黄染3年,口干、眼干伴腮腺及泪腺肿大2年”入院。3年前,患者巩膜及全身皮肤黄染,腹部CT示“胰头癌”,行胰腺十二指肠切除术。病理示:慢性纤维化胰腺炎、胆管炎。出院后,患者碱性磷酸酶(ALP)、γ-谷氨酰转移酶(GGT)水平持续升高,伴双眼突出、泪腺及腮腺肿大。给予熊去氧胆酸及泼尼松治疗3个月后,症状缓解,但ALP、GGT水平仍轻度升高。2年前,患者出现口干、眼干、哭时无泪,伴反复发作的双侧腮腺无痛性肿大、夜尿增多。抗核抗体(ANA)阳性,类风湿因子(RF)、CRP及ESR均升高。抗SSA及抗SSB抗体阴性。外院唇腺活检示:淋巴细胞灶性浸润,考虑为“干燥综合征”。近半年来,患者于着凉后反复发热,体温波动范围为37.5~39℃,使用退热药及抗生素后体温降至正常。发热时,患者有全身多关节疼痛,伴尿急、尿频、尿痛,尿中泡沫增多,口腔溃疡多发。患者精神、食欲可,睡眠欠佳。7年前被确诊为2型糖尿病;5年前,因颌下淋巴结肿大行双侧颌下淋巴结及右侧颌下腺切除术。

提示:若患者GGT81U/L(↑),ALP260U/L(↑),肌酐171μmol/L(↑),二氧化碳结合力15.2mmol/L(↓),24小时尿蛋白定量1.58g/d(↑)。尿渗透压下降,尿酸化功能减退,肾小管蛋白三项[即β2微球蛋白、视黄醇结合蛋白、N-乙酰-β-D-氨基葡糖苷酶(NAG)]升高。血气分析示,pH7.383,碳酸氢根21.6mmol/L(↓)。双肾B超:轻度弥漫性病变,左肾实性结节。以下叙述正确的是()。

A.肾酸化功能减退

B.肾小管间质病变的诊断基本明确

C.需考虑IgG4相关性肾病

D.需考虑胰腺癌累及肾脏

E.必须行左肾实性结节肾脏活检术明确诊断

F.结合临床不必行肾脏活检术

答案

参考答案:A, B, C, F

解析:

1.对考虑IgG4相关自身免疫性疾病,所有检查均属必需。

2.IgG4相关性涎腺炎与干燥综合征的鉴别。

3.要点是IgG4相关性胆管炎与PBC、PSC的鉴别。

4.要点是IgG4相关性肾病与其他类型肾病的鉴别。

5.要点是IgG4阳性的自身免疫性胰腺炎与胰腺肿瘤的鉴别。

填空题
填空题

Of all the employed workers in the United States, 12.5 million are part of a temporary workforce. The United States Bureau of Labor Statistics counts 9.2 percent of workers as those who have______(1) they term "alternative employment arrangements." The government predicts that temporary staffing agencies______(2) experience growth of 49 percent by 2010. If numbers increase at the rate ______ (3), these companies will add 1.9 million new jobs by 2010. That’’s more than any______(4) industry.Temporary workers were the first ones to be affected by the recent economic recession, but they are______(5) to be the first to regain positions as the economy picks up and companies work to rebuild. Employers use temporary workers as a resource because_______(6) offer flexibility and come at a low cost. Many temporaries are categorized as "independent contractors" instead of employees,______(7) allows the employer to avoid______(8) certain taxes. Because they are not required to offer benefits to temporary workers, companies can save a great deal of money by hiring temps. Usually, temporary workers can qualify_______(9) benefits if they work for a staffing company for a certain length of time. Most temps, however, do not continue with one company long______(10) to qualify for them because they regard the position as a step on the ladder to a______(11) position later.According to Richard Wahlquist, president of the American Staffing Association, 75_______(12) of temporary workers hope for transition out of the temporary staffing category______(13) a period of time. Wahlquist finds that temporary workers spend about 11 weeks on various assignments before their______(14) out of the temporary workforce. Many use temporary positions to gain experience and skills______(15) they move on to better jobs. Wahlquist says that the temp workforce as a whole turns______(16) 400 percent each year.Tom Dilworth, research director at the Employment Policies Institute, explains______(17) some workers like having temporary jobs______(18) it affords them a great deal of elasticity with time and everything. Some temps only have a limited______(19) of time to work and temp agencies can help coordinate jobs to fit their schedules. Other sometimes-employees use temporary jobs to get an______(20) to a company from the inside, to get a foot in the door of a certain business or career._______(21) others take temporary positions in hopes their employers will change them over to permanent positions eventually.Nearly all the industries in the United States use temporary workers.______(22) to Tim Costello, coordinator of the North American Alliance for Fair Employment, the growth of temporary labor threatens______(23) job security of permanent workers who fear replacement, as well as the temps who are more accustomed to turnover. He predicts that there will continue to______(24) a gradual shift from permanent employees to contingent staffing, and that such a_____(25) in workplace demographics will "lead to lower wages, poorer working conditions, and more instability."