重症急性胰腺炎合并腹腔高压患者早期肠内营养耐受性的管理

目的 探寻重症急性胰腺炎合并腹腔高压患者行早期肠内营养期间的耐受性管理方案。 方法 选择入住我院外科ICU诊断为重症急性胰腺炎并伴有腹腔内高压的患者105 例,根据住院时间分为实验组和对照组。 两组均在入住外科ICU24～48 h内开始早期肠内营养。 实验组采用自行设计的肠内营养耐受性评估和管理方案定时评估,对照组采用常规方案观察和处理。 结果 实验组1 周后白蛋白、前白蛋白均高于对照组（P＜0.01）,实验组达到目标喂养量的时间早于对照组（3.45 d与4.37 d）,住ICU天数、机械通气时间分别与对照组比较,差异均有统计学意义（P＜0.01）。 结论 重症急性胰腺炎伴有腹腔内高压患者行早期肠内营养时,采取耐受性评估管理方案,定时主动评估与干预,可提高患者的耐受性,改善其营养指标和预后。     

早期肠内营养耐受性管理对重症急性胰腺炎合并腹腔高压患者的影响

目的探讨早期肠内营养耐受性管理对重症急性胰腺炎合并腹腔高压患者的影响。方法选取我院2017年6月至2018年6月收治的68例重症急性胰腺炎合并腹腔高压患者为研究对象,根据住院顺序将其等分为研究组和对照组,对照组采用常规肠内营养支持,研究组在对照组基础上联合营养耐受性管理。比较两组患者不耐受症状、营养指标及达到目标喂养量时间。结果研究组白蛋白、前白蛋白、转铁蛋白、血红蛋白营养指标水平高于对照组,差异有统计学意义(P0.05);研究组腹泻、误吸、呕吐、腹胀、胃潴留不耐受症状发生次数少于对照组,发生率比较差异有统计学意义(P0.05);研究组患者达到预期目标喂养量时间短于对照组,差异有统计学意义(P0.05)。结论重症急性胰腺炎合并腹腔高压患者实施早期肠内营养联合耐受性管理,可有效预防和控制胃肠功能不耐受等症状发生,改善喂养指标及预后。     

肠内营养耐受性定时评估管理对重症急性胰腺炎患者的影响

目的探讨肠内营养耐受性定时评估管理对重症急性胰腺炎患者的影响。方法选择2016年6—12月在我院ICU接受治疗的重症急性胰腺炎患者40例作为对照组,选择2017年1—6月在我院ICU治疗的重症急性胰腺炎患者42例作为观察组,所有患者均于入院后48 h内开始进行早期肠内营养,对照组进行常规肠内营养观察及处理,观察组采用自行制定的肠内营养耐受性定时评估管理方案对患者进行观察及处理。比较两组患者肠内营养期间不耐受症状及并发症发生情况,肠内营养治疗1,2周后营养指标以及免疫功能相关指标变化,患者目标营养量达标时间、机械通气时间、ICU停留时间。结果观察组肠内营养不耐受率明显低于对照组,目标营养量达标时间短于对照组,差异均有统计学意义(P 0. 05);肠内营养治疗1,2周后观察组血清蛋白水平、T淋巴细胞亚群(除肠内营养治疗1,2周后CD8~+外)及免疫球蛋白水平(除肠内营养治疗2周后Ig G,Ig M外)均明显高于对照组,差异有统计学意义(P 0. 05);观察组机械通气时间及ICU停留时间均短于对照组,差异有统计学意义(P 0. 05);两组治疗过程中均无死亡病例,观察组多器官功能衰竭、胰腺坏死等并发症发生率低于对照组,但差异无统计学意义(P0. 05)。结论肠内营养耐受性定时评估管理能使医护人员准确评价耐受性,采取规范化处置方案,有利于降低不耐受率,进一步改善患者的营养状况及免疫功能,对改善临床预后具有重要价值。     

肠内营养耐受性定时评估管理的营养支持对急性重症胰腺炎临床疗效分析

目的探讨基于肠内营养耐受性定时评估管理的营养支持对急性重症胰腺炎的临床疗效。方法选取2016年7月至2019年7月我院收治的87例急性重症胰腺炎患者为研究对象,随机将其分为研究组43例和对照组44例,对照组实施常规肠内营养支持,研究组在对照组的基础上采用肠内营养耐受性定时评估管理的营养支持,对比两组机械通气时间、ICU停留时间、目标营养量达标时间、营养指标及免疫功能指标改善情况。结果研究组机械通气时间、ICU停留时间、目标营养量达标时间短于对照组(P 0.05),研究组总蛋白、白蛋白、前白蛋白、转铁蛋白及降钙素水平优于对照组(P 0.05)。结论急性重症胰腺炎在应用肠内营养耐受性定时评估的营养支持,可准确评估肠内耐受性,予以规范、量化的营养支持方案,缩短各项操作时间,降低不耐受发生率,促进营养状态和免疫功能恢复,具有临床推广价值。     

个案管理师主导的多学科协作重症患者肠内营养管理方案的实践

目的 构建个案管理师主导的多学科协作肠内营养管理方案并探讨其对重症患者肠内营养耐受性、营养学指标、炎症指标的干预效果。方法 选择2021年1月至6月本院收治的51例重症患者作为对照组,2021年7月至12月收治的51例重症患者作为观察组。对照组患者实施常规肠内营养护理,观察组患者在对照组的基础上实施个案管理师主导的多学科协作肠内营养管理方案,干预时间7d。比较干预前后两组患者的营养耐受性、营养指标和炎性指标。结果 对照组1例患者因病情变化退出,观察组1例患者因转院资料不全而退出干预后观察组患者肠内营养耐受性、白蛋白、血红蛋白、白细胞、C反应蛋白优于对照组,两组比较,差异具有统计学意义（均P<0.05）。结论 个案管理师主导的多学科协作肠内营养管理方案有利于提高重症患者肠内营养耐受性,改善行肠内营养的营养学指标与炎症指标。     

重症急性胰腺炎合并乳糜瘘患者肠内营养期间的安全管理

目的 探讨重症急性胰腺炎合并乳糜瘘患者在实施肠内营养期间安全管理的方法.方法 分析5例普通外科ICU内重症急性胰腺炎合 并乳糜瘘患者实施肠内营养过程的安全管理方法,包括:在合适的时间进行合适的肠内营养,采取合理有效的护理措施、严密监测腹腔引流液量及其甘油三酯浓度和乳糜试验的变化.结果 5例患者应用肠内营养支持治疗后,腹...     

输液泵在急性重症胰腺炎患者肠内营养治疗中的应用

目的：观察输液泵持续滴注在急性重症胰腺炎肠内营养支持治疗中的效果.方法：将60例急性重症胰腺炎肠内营养患者随机分为试验组和对照组各30例.试验组使用输液泵持续匀速输注,对照组使用50 ml注射器分次推注肠内营养液.比较两组患者住院时间、住院费用及肠内营养相关不良反应发生情况.结果：试验组住院时间短于对照组,住院费用低于对照组,其肠内营养相关不良反应发生低于对照组,两组比较差异有统计学意义（P＜0.05）.结论：输液泵持续滴注肠内营养用于急性重症胰腺炎肠内营养支持治疗,可有效改善患者营养状况,减轻护理工作,减少肠内营养相关不良反应的发生,减少患者住院时间及治疗费用,值得在重症胰腺炎患者中推广运用.     

鼻空肠管在合并腹腔高压重症患者肠内营养中的应用

目的 鼻空肠管应用于肠内营养，用于合并腹腔高压重症病人。方法 连续收录于 2021 年 1 月至 2022 年 12 月间，随机 分为对照组(留置鼻胃管)/观察组(留置鼻空肠管)共 36 例合并腹腔高压重症患者，各 18 例。对比两组相关情况。结果 10d 后观 察组 MAMC、TSF、BMI 指标水平较对照组更优，观察组营养代谢指标均优于对照组，观察组 SGA 营养状况显著优于对照组， P<0.05。结论 在合并腹腔高压重症病人的肠内营养中应用鼻空肠管，对于促进病人营养状况改善，适应病人生理要求的机体营 养供给需求，更容易得到满足，是一种值得应用和推广的方法。     

重症急性胰腺炎早期应用肠内营养的临床疗效观察

目的:探讨早期肠内营养的运用在重症急性胰腺炎患者中的临床效果。方法:将2015年8月~2016年8月我院收治的66例重症急性胰腺炎患者随机分为观察组和对照组,各33例。观察组给予早期肠内营养,对照组给予全胃肠外营养,比较两组疗效。结果:治疗前,两组营养指标比较无差异(P0.05);治疗后,观察组营养指标优于对照组,治愈率高于对照组,住院费用及住院时间、腹痛缓解时间均低于对照组(P0.05)。结论:给予重症急性胰腺炎患者早期肠内营养,可缩短住院时间,较快改善患者临床症状,促进康复。     

肠内结合肠外营养治疗重症急性胰腺炎临床观察

目的探讨肠内结合肠外营养治疗重症急性胰腺炎的临床应用。方法选取2008年1月至2012年1月收治的重症急性胰腺炎64例分为全胃肠外营养组30例,肠内、肠外联合营养组34例,观察两组临床效果。结果 64例重症急性胰腺炎经积极救治,5例采取手术治疗,6例死亡,全部为全胃肠外营养组患者;全胃肠外营养组二重感染16例(53.3%),联合营养组12例(35.3%)。结论重症急性胰腺炎进行营养支持中采取肠外、肠内联合序贯性的策略,是最佳的营养方案。     

Fibrinogen and fibrin structure and functions

Fibrinogen molecules are comprised of two sets of disulfide-bridged Aalpha-, Bbeta-, and gamma-chains. Each molecule contains two outer D domains connected to a central E domain by a coiled-coil segment. Fibrin is formed after thrombin cleavage of fibrinopeptide A (FPA) from fibrinogen Aalpha-chains, thus initiating fibrin polymerization. Double-stranded fibrils form through end-to-middle domain (D:E) associations, and concomitant lateral fibril associations and branching create a clot network. Fibrin assembly facilitates intermolecular antiparallel C-terminal alignment of gamma-chain pairs, which are then covalently 'cross-linked' by factor XIII ('plasma protransglutaminase') or XIIIa to form 'gamma-dimers'. In addition to its primary role of providing scaffolding for the intravascular thrombus and also accounting for important clot viscoelastic properties, fibrin(ogen) participates in other biologic functions involving unique binding sites, some of which become exposed as a consequence of fibrin formation. This review provides details about fibrinogen and fibrin structure, and correlates this information with biological functions that include: (i) suppression of plasma factor XIII-mediated cross-linking activity in blood by binding the factor XIII A2B2 complex. (ii) Non-substrate thrombin binding to fibrin, termed antithrombin I (AT-I), which down-regulates thrombin generation in clotting blood. (iii) Tissue-type plasminogen activator (tPA)-stimulated plasminogen activation by fibrin that results from formation of a ternary tPA-plasminogen-fibrin complex. Binding of inhibitors such as alpha2-antiplasmin, plasminogen activator inhibitor-2, lipoprotein(a), or histidine-rich glycoprotein, impairs plasminogen activation. (iv) Enhanced interactions with the extracellular matrix by binding of fibronectin to fibrin(ogen). (v) Molecular and cellular interactions of fibrin beta15-42. This sequence binds to heparin and mediates platelet and endothelial cell spreading, fibroblast proliferation, and capillary tube formation. Interactions between beta15-42 and vascular endothelial (VE)-cadherin, an endothelial cell receptor, also promote capillary tube formation and angiogenesis. These activities are enhanced by binding of growth factors like fibroblast growth factor-2 (FGF-2) and vascular endothelial growth factor (VEGF), and cytokines like interleukin (IL)-1. (vi) Fibrinogen binding to the platelet alpha(IIb)beta3 receptor, which is important for incorporating platelets into a developing thrombus. (vii) Leukocyte binding to fibrin(ogen) via integrin alpha(M)beta2 (Mac-1), which is a high affinity receptor on stimulated monocytes and neutrophils.     

Migraine and genetic and acquired vasculopathies

It is remarkable that migraine is a prominent part of the phenotype of several genetic vasculopathies, including cerebral autosomal dominant arteriopathy with subcortical infarcts and leucoencephalopathy (CADASIL), retinal vasculopathy with cerebral leukodystrophy (RVCL) and hereditary infantile hemiparessis, retinal arteriolar tortuosity and leukoencephalopahty (HIHRATL). The mechanisms by which these genetic vasculopathies give rise to migraine are still unclear. Common genetic susceptibility, increased susceptibility to cortical spreading depression (CSD) and vascular endothelial dysfunction are among the possible explanations. The relation between migraine and acquired vasculopathies such as ischaemic stroke and coronary heart disease has long been established, further supporting a role of the (cerebral) blood vessels in migraine. This review focuses on genetic and acquired vasculopathies associated with migraine. We speculate how genetic and acquired vascular mechanisms might be involved in migraine.     

创伤高血糖与感染和MODS早期诊断和干预

本文详细介绍了创伤后血糖应激适度理论,以及高血糖与感染和多器官功能不全综合征的关系;提出涉及胰岛B细胞功能不全的MODS实验诊断新方案和极化液个体化干预新措施,可早期发现创伤MODS、降低感染率及MODS发生率和病死率。     

腹膜后纤维化与肾积水发生关系的临床研究

目的：探讨腹膜后纤维化（RPF）导致肾积水的原因及诊治经验。方法：回顾分析2004年1月—2010年12月24例腹膜后纤维化致肾积水患者的诊治资料。结果：（1）RPF患者常见首发症状为腰背痛或腹痛（69.2%）;（2）红细胞沉降率（ESR）增快和血清IgG4升高最常见。超声检查仅提示上尿路积水。RPF的静脉肾盂造影（IVP）和CT尿路成像（CTU）表现具有特征性。IVP肾盂输尿管显影不良时,CTU能较清晰的显示上尿路影像。CT扫描发现腹膜后软组织肿块9例（37.5%）,优于超声检查;（3）输尿管松解和腹腔化手术治疗22例;行肾切除术1例;行输尿管置双J管术1例。最终确诊为继发性RPF8例,其中4例为术前诊断,3例为术中腹膜后软组织肿块冷冻活检证实,1例为术后病理证实;（4）特发性RPF手术后肾积水均获长期缓解,而继发性RPF的预后取决于原发疾病及其治疗方案。结论：影像学检查是诊断RPF的重要手段,CTU优于超声检查和IVP。输尿管松解和腹腔化手术可以使特发性RPF输尿管梗阻得到长期的缓解,术中对肿块进行冷冻活检有助于鉴别特发性和继发性RPF,及时调整治疗方案。     

Telemedicine and teleradiology technologies and applications

Summary. Telemedicine and teleradiology hold the key for improving future health care delivery. In this paper we first review current communication and computer technologies used in telemedicine and teleradiology. Five examples in teleradiology applications are given including hospital-integrated picture archiving and communication systems, tele-neuro-imaging, telemammography, university consortium teleradiology service, and teleradiology for second opinion. Parameters important to teleradiology applications like costs, image quality, system reliability, and turn around time are considered. Data security is discussed, including patient confidentiality and image authenticity-which will be a major issue in future teleradiology applications.     

Physician and Nurse Practitioner Teamwork and Job Satisfaction: Gender and Profession

Designing interprofessional primary care teams composed of physicians and nurse practitioners (NPs) is a national priority. We assessed how profession and gender affect teamwork and job satisfaction among primary care physicians and NPs by using survey data from 186 physicians and 398 NPs practicing in New York State. Our regression models show profession (NP vs physician) moderates the associations of gender with teamwork and job satisfaction. Among NPs, men had higher job satisfaction than women. Among physicians, women had higher job satisfaction than men. Our results can benefit interprofessional primary care teams to optimize their professional and gender mix.     

探讨儿童慢性顽固性咳嗽与支原体感染的关系及临床治疗观察

目的探讨儿童慢性顽固性咳嗽与肺炎支原体（MP）感染的关系及临床疗效观察。方法采用回顾性研究方法对于现将2005年3月至2008年3月在我院的55例确诊慢性顽固性咳嗽患儿,主要表现为肺炎支原体感染为临床特点进行分析,并进一步临床治疗研究。结果①临床特点：在55例确诊慢性咳嗽的患儿中,以慢性顽固性咳嗽为主要症状。58％（32／55）的病例无肺部体征;②外周血：85％（47／55）的病例外周血变化不大,WBC（4—10）×10 9／L之间,嗜酸性粒细胞增多;③特别检查：47．27％（26／55）肺炎支原体IgM（MP—IgM）抗体阳性,83．64％（46／55）PeR技术检测肺炎支原体特异性DNA;④X光报告为多种形式。结论肺炎支原体（MP）感染是引起儿童慢性顽固性咳嗽的病因之一,对儿童慢性咳嗽,特别是顽固性咳嗽的诊治中应更加重视。     

Acetaminophen and acetylcysteine dose and duration: Past,present and future

Abstract

Acetylcysteine has been utilized successfully in the treatment of acetaminophen overdose since the 1970s. Although prospective trials as to efficacy and safety of acetylcysteine were conducted, there were no randomized controlled trials. This commentary addresses the reasons for this, and the background to choice of dose of acetylcysteine utilized in the oral and IV dosing regimens. Nomograms to predict possible hepatotoxicity based upon time of ingestion of acetaminophen were developed from a relatively arbitrary definition of toxicity as an aspartate aminotransferase/alanine aminotransferase (ALT/AST) greater than 1000 IU/L. While these have proved generally useful, patients still continue to develop hepatic damage after acetaminophen overdose, particularly if they present late after ingestion. The optimum management of these patients remains unclear, and one area of uncertainty is the dose and duration of acetylcysteine in various circumstances. This article discusses the issues that need to be elucidated to better target changes in acetylcysteine dose. The potential for measurements of other markers to improve treatment selection is the subject of further research.