脓毒症相关性脑病的研究进展

<正>脓毒症相关性脑病(sepsis associated encephalopathy,SAE),是脓毒症常见的一种并发症,是全身炎症反应引起的弥漫性的脑功能障碍状态,是重症监护病房(Intensive care unit,ICU)病死率增加的重要原因之一。临床主要表现为精神状态、意识的急性改变,又称脓毒症性脑病(septic encephalopathy,SE),最早于1827年由Bright提出,表明早期脓毒症患者的急性认知改变会增加患者的死亡率。2003年Young等将这种脑功能障碍称为脓     

脓毒症相关性脑病研究进展

脓毒症脑病又称脓毒症相关性脑病(sepsis-associated encephalopathy,SAE)是由全身炎症反应引起的弥散性脑功能障碍,其发病率在8％～70％,合并SAE时脓毒症的死亡率明显增加.Young等[1]随访ICU内69例脓毒症患者,49例合并不同程度的脓毒症脑病,其中轻微型脑病( mild encephalopathy) 17例,病死率为35％;严重型脑病(severe eneephalopathy) 32例,病死率为53％.可见SAE的严重程度与患者的死亡率呈正相关.而幸存者常有长期记忆功能缺失等严重并发症表现.因此,更好地了解SAE的发病机制,并努力研究相应的治疗方案,对提高SAE患者的神经功能及减少死亡率有极其重要的作用.由于SAE的诊断无明显特异性,且ICU患者常处于镇静、机械通气等状态,观察患者的行为意识改变较困难,因此SAE的漏诊率高,现就SAE有关的研究进展做一综述.     

脓毒症相关性脑病的诊断与治疗研究进展

脓毒症患者通常伴有急性、可逆的精神状态改变,它首先影响意识、认知和行为〔1〕。人们曾用脓毒性脑病(sepsisenc ephalopathy)、脓毒症相关性脑病(sepsis-associated encephalopathy,SAE)、脓     

甲状腺功能与皮层下动脉硬化性脑病认知功能相关性分析

目的研究患者甲状腺功能与皮层下动脉硬化性脑病（subcortical artriosclerotic encephalopathy,SAE）认知能力之间的相关性。 方法采用蒙特利尔认知评测量表（MoCA）对甲状腺功能正常及甲状腺功能低下的SAE患者的认知能力进行评价,并且分析不同甲状腺功能患者中影响SAE认知能力危险因素的差异。结果两组患者性别、年龄以及高血压、脑梗死、糖尿病、吸烟等患病危险因素比较差异均无统计学意义（P均〉0.05）。甲状腺功能低下组游离三碘甲腺原胺酸（FT3）、游离甲状腺素（FT4）、促甲状腺激素（TSH）水平及MoCA、日常生活活动能力评分（ADL）评分分别为（2.92±0.35）pmol/L、（15.61±2.76）pmol/L、（13.05±1.64） mU/L、（12.73±5.75）分、（45.64±25.77）分,甲状腺功能正常组FT3、FT4、TSH水平及MoCA、ADL评分分别为（4.27±0.55）pmol/L、（16.74±2.35）pmol/L、（2.73±0.38） mU/L、（18.15±5.35）分、（62.17±26.72）分,甲状腺功能低下组显著低于甲状腺功能正常组,差异均有统计学意义（t值分别为3.591、3.012、12.753、8.967、15.442,P均〈0.05）,SAE患者FT3水平与MoCA评分及ADL评分均呈显著正相关（r值分别为0.518、0.617,P值分别为0.026、0.018）,而FT4水平与MoCA及ADL评分无显著相关性（r值分别为0.015、0.007,P值分别为0.852、0.074）,MoCA评分及ADL评分与TSH水平呈负相关（r值分别为-0.651、－0.582,P值分别为0.016、0.005）。结论甲状腺功能与SAE患者的认知能力具有显著相关性,患者甲状腺功能可能成为皮层下脑动脉硬化患者临床检验指标,为皮层下脑动脉硬化患者合理用药提供依据。     

帕金森病主观性认知功能减退临床特点及研究进展

主观性认知功能减退可能是轻度认知功能障碍的临床前阶段。帕金森病随病程进展可出现认知功能损害。伴有主观性认知功能减退的帕金森病患者多表现为认知量表整体评分正常,但某些分项领域异常,且可能同时合并局部脑皮层密度、厚度改变及多巴胺能水平改变。正确认识主观性认知功能减退在帕金森病认知损害发展中的作用,对早期干预和避免认知功能损害发展至不可逆阶段有重要意义。本文就帕金森病患者主观性认知功能减退的临床特点及研究进展作一综述。     

少数民族老年人认知功能障碍与居住地改变相关性的研究进展

我国少数民族与汉族人群的认知功能障碍患病率存在差异。老年人居住地改变可能造成其认知功能的改变,其原因有社会人文环境改变、地理环境改变、心理应激等方面。本文对相关研究进展进行综述,以便预防和减缓少数民族人群认知功能障碍的发生发展。     

皮质下动脉硬化性脑病的CT诊断及鉴别诊断

本文对44例皮质下动脉硬化性脑病（SAE）的CT表现，结合病理学基础进行对照分析。说明有神经，精神症状的老年高血压、动脉硬化患者；双侧侧脑室周围及半卵圆中心脑白质斑片状或弥漫性低密度改变，多伴发脑萎缩及腔隙性梗塞，是诊断SAE的主要依据。提出无症状的脑白质稀疏症是SAE的早期征象。阐述了与SAE相似的疾病的鉴别要点。     

糖尿病肾病对认知功能损害研究现状

<正>糖尿病是一种严重威胁认知功能的潜在性疾患。糖尿病肾病(diabetic kidney disease,DKD)为糖尿病微血管并发症之一,肾脏血管及脑血管有相似的血流动力学特征,肾脏的病理性改变对于认知功能具有一定影响。本文从DKD及认知功能损害流行病学现状、DKD合并认知功能损害可能机制、当前神经心理学及影像学依据等3个方面对DKD对认知功能的影响做一简单阐述。1 DKD及认知功能损害流行病学现状     

蛛网膜下腔出血患者脑血流动力学改变与认知功能障碍的相关性分析

目的探讨蛛网膜下腔出血（SAH）患者脑血流动力学改变与认知功能障碍的关系。 方法前瞻性连续纳入符合标准的SAH患者115例,收集患者年龄、性别、入院时格拉斯哥昏迷量表(GCS)评分、Hunt-Hess分级、Fisher分级、医院感染、手术或介入治疗等基线资料,于发病后7d、14d时采用经颅多普勒（TCD）检测患者血流动力学改变,于发病2周及3个月时采用蒙特利尔认知评估量表（MoCA）对患者认知功能进行评价,再分析血流动力学改变与认知功能障碍间的相关性。 结果共入选115例患者,其中脑血管痉挛52例,认知功能障碍37例,通过校正各种危险因素,经Logistic回归分析脑血管痉挛与认知功能障碍间的关系,结果显示脑血流动力学改变与认知功能障碍具有正相关性。 结论SAH患者脑血流动力学改变与认知功能障碍具有正相关性,是认知功能障碍发生的独立危险因素。     

老年人认知功能的研究进展及对策

阐述了老年人认知功能状况及其影响因素,总结了关于认知功能的常用测量工具及认知功能改变对老年人的影响.根据认知功能具有可塑性,提出了延缓老年人认知功能下降的对策.     

Impaired cerebrovascular reactivity in sepsis-associated encephalopathy studied by acetazolamide test

Introduction  

The pathophysiology of sepsis-associated encephalopathy (SAE) is not entirely clear. One of the possible underlying mechanisms is the alteration of the cerebral microvascular function induced by the systemic inflammation. The aim of the present work was to test whether cerebral vasomotor-reactivity is impaired in patients with SAE.     

皮层下动脉硬化性脑病CT诊断及临床分析

目的探讨皮层下动脉硬化性脑病(SAE)的病理变化、临床特点及CT主要征象,旨在提高SAE的诊断水平。方法收集我院94例SAE,男58例,女36例,年龄62～92岁,平均77岁。临床表现与症状多数病人有高血压、糖尿病、眼底动脉硬化及老年性痴呆。特点为进行性智力减退,不同程度偏瘫,语言不清或失语、头晕、眼花、恶心、手足麻木等。结果本病常见于60岁以上,CT特点为双侧脑室周围脑白质及半卵圆中心脑白质对称性低密度影,病变模糊不清,可伴发脑萎缩或腔隙性脑梗塞,有的可伴发脑出血和蛛网膜下腔出血。结论熟悉掌握本病的病理、临床及CT特点,对提高本病的诊断和鉴别诊断有重要价值。     

单纯脑白质疏松症和皮质下动脉硬化性脑病患者认知功能的对比

背景:单纯脑白质疏松症和皮质下动脉硬化性脑病的认知功能是脑血管病神经心理研究的一部分,但目前关于两者的对比研究还是空白。目的:探讨单纯脑白质疏松症、皮质下动脉硬化性脑病及单纯脑白质疏松症合并脑梗死认知功能的不同特点。设计:随机对照观察。单位:山东大学齐鲁医院神经内科。对象:选择1997-03/2000-05在山东大学齐鲁医院神经内科就诊的脑血管病患者91例,均自愿参加观察。按疾病类型分为3组,其中单纯脑白质疏松症组27例,皮质下动脉硬化性脑病组33例,单纯脑白质疏松症 脑梗死组31例。另外选择健康对照组30例。以上各组观察对象均自愿参加观察。方法:对各组观察对象进行认知功能及记忆能力评定,并进行对比分析。认知功能测定采用简易精神状态量表,按不同文化程度(文盲、小学、中学、大学)评分分别低于17,20,22,23分为痴呆。记忆能力测查采用中国医学科学院心理研究所等编制的临床记忆量表甲式,测查内容包括联想学习、指向记忆、无意义图形再认、图像自由回忆和人像特点联系回忆,将上述5项测查成绩换算成量表分并算出记忆商。主要观察指标:各组观察对象认知功能障碍情况及简易精神状态量表、临床记忆量表评分。结果:纳入脑血管病患者91例及健康对照者30例,全部进入结果分析,无脱落。①各组观察对象认知功能障碍情况比较:单纯脑白质疏松症组轻度认知功能障碍21例(77.8%);皮质下动脉硬化性脑病组中度认知功能障碍8例(24.2%),痴呆25例(75.8%);单纯脑白质疏松症 脑梗死组中度认知功能障碍6例(19.4%),痴呆24例(77.4%)。②各组观察对象简易精神状态量表及临床记忆量表评分比较:单纯脑白质疏松症组、皮质下动脉硬化性脑病组、单纯脑白质疏松症 脑梗死组两量表评分均显著低于健康对照组(t=2.14～3.81,P<0.05～0.01)。皮质下动脉硬化性脑病组和单纯脑白质疏松症 脑梗死组评分显著低于单纯脑白质疏松症组(t=2.13～3.37,P<0.05～0.01)。结论:①单纯脑白质疏松症认知损害以轻度认知功能障碍为主。②皮质下动脉硬化性脑病和单纯脑白质疏松症 脑梗死的认知障碍以中度认知功能障碍和痴呆为主,其程度明显重于轻度认知功能障碍。认知功能可以作为评估单纯脑白质疏松症和皮质下动脉硬化性脑病的参考指标。     

Correlation of the Endocardial Fragmented Electrogram with Body Surface Signal-Averaged Electrocardiographic Mapping

We compared signal-averaged electrocardiography (SAE), SAE mapping, and left ventricular catheter mapping in 60 patients with ischemic heart disease. Using the data obtained in patients with no fragmented electrograms (EE) in the left ventricle, the late potential was defined by SAE as a filtered QRS duration > 131 msec or a root mean square voltage < 16 μV for the last 40 msec of the QRS complex. SAE mapping was performed by recording the signal-averaged electrocardiogram at 48 sites on the body surface. With SAE mapping, the filtered QRS duration and the area in the last 20 msec of the QRS complex were significantly different between the patients with and without EEs. The late potential was defined by SAE mapping as a filtered QRS duration > 136 msec or an area < 28 μV.msec for the last 20 msec of the QRS complex. The sensitivity and specificity of detecting FEs were 46% and 88%, respectively, by the SAE filtered QRS criterion, while they were 66% and 88% by the root mean square criterion. In contrast, SAE mapping gave values of 66% and 92% by the filtered QRS criterion, as well as values of 100% and 92% by the area criterion. Thus, SAE mapping provided better detection of the EE and was more closely correlated with the results of catheter mapping, suggesting its potential for clinical application.     

Alterations of coagulation and fibrinolysis in patients with blunt splenic injury after splenic artery embolization

BackgroundThrombotic complications following splenectomy have been documented. However, there has been sparse literature regarding thrombotic complications following splenic artery embolization (SAE).The objective of this study was to determine changes in coagulation and fibrinolysis and assess the thrombotic risk after SAE in patients with blunt splenic injury (BSI).MethodsThis study included 38 BSI patients who were hemodynamically stable on admission. SAE was performed if the splenic injury was classed as grade III or greater and had no requirement of immediate surgery. Platelet (PLT), fibrinogen (FIB), D‐dimers (D‐D), fibrinogen/fibrin degradation products (FDP), antithrombin III (AT III), prothrombin time (PT), activated partial thromboplastin time (APTT), thrombin time (TT), hemoglobin (Hb), and hematocrit (Hct) were measured before SAE procedures and then 1d, 3d, and 7d after SAE.ResultsThe technical success rate of SAE and the splenic salvage rate were 100%. There was no mortality. Compared with pre‐SAE values, the levels of PLT, FIB, D‐D, and FDP increased significantly at 3 days and 7 days after SAE (p < 0.05). However, AT III, PT, APTT, TT, Hb, and Hct showed no statistically significant difference at 1d, 3d, and 7d after SAE (p > 0.05).ConclusionAlterations in PLT and hemostatic parameters might contribute to the increased risk of thrombotic complications in BSI patients undergoing SAE. Thromboembolism following SAE should be considered and thrombotic prophylaxis should be recommended.     

Effect of L-arginine on platelet aggregation, endothelial function adn exercise tolerance in patients with stable angina pectoris

AIM: Examination of the action of donor NO (L-arginine) on platelet aggregation, endothelial function and exercise tolerance in patients with stable angina of effort (SAE). MATERIAL AND METHODS: 42 patients with SAE (functional class I-II) and 10 healthy volunteers (control group) were assigned to two groups. 22 patients of group 1 were randomized to cross-over. They received cardiket (60 mg/day for 10 days or cardiket (60 mg/day) in combination with L-arginine (15 g/day for 10 days). 20 SAE patients of group 2 and control group received L-arginine (15 g/day for 10 days). In each group blood lipids were examined, and bicycle exercise test (BET) was performed. In addition, platelet aggregation and endothelial function were studied in group 2 and control group before and after the course of L-arginine. RESULTS: Compared to control group, endothelial function significantly improved in group 2 (from 5.0 +/- 2.9 to 7.8 +/- 4.1% vs 7.1 +/- 1.9 to 6.6 +/- 4.8%) (M +/- SD). BET duration increased in all the patients. After ADP addition in concentrations 1.5, 2.0, and 5.0 micromol/l platelet aggregation declined in 17 patients except 3 in whom the aggregation remained unchanged. CONCLUSION: Positive effect of L-arginine on endothelial function, exercise tolerance and platelet aggregation was observed in patients with stable angina of effort (functional class I-II). Therefore, arginine can be recommended as an adjuvant in the treatment of patients with ischemic heart disease.     

Noninvasive identification of patients at risk for ventricular tachycardia with the signal-averaged electrocardiogram

The signal-averaged electrocardiogram (SAE) is a noninvasive means of detecting cardiac late potentials. Late potentials in patients with coronary artery disease indicate a high risk for the development of ventricular tachycardia. Although the usefulness of the SAE for directing therapy has not yet been clearly established, the test appears to be useful in the stratification of arrhythmia risk in select groups of high-risk patients. As critical care nurses frequently care for these patients, they need to be familiar with tools such as the SAE that may be used in high-risk patient assessment. This article describes the physiologic basis underlying the use of the SAE, the SAE technique, implications for nursing practice, and clinical applications of the SAE.     

Higher incidence of major complications after splenic embolization for blunt splenic injuries in elderly patients

Background

Nonoperative management (NOM) of blunt splenic injuries has been widely accepted, and the application of splenic artery embolization (SAE) has become an effective adjunct to NOM. However, complications do occur after SAE. In this study, we assess the factors leading to the major complications associated with SAE.

Materials and Methods

Focusing on the major complications after SAE, we retrospectively studied patients who received SAE and were admitted to 2 major referral trauma centers under the same established algorithm for management of blunt splenic injuries. The demographics, angiographic findings, and factors for major complications after SAE were examined. Major complications were considered to be direct adverse effects arising from SAE that were potentially fatal or were capable of causing disability.

Results

There were a total of 261 patients with blunt splenic injuries in this study. Of the 261 patients, 53 underwent SAE, 11 (21%) of whom were noted to have 12 major complications: 8 cases of postprocedural bleeding, 2 cases of total infarction, 1 case of splenic abscess, and 1 case of splenic atrophy. Patients older than 65 years were more susceptible to major complications after SAE.

Conclusion

Splenic artery embolization is considered an effective adjunct to NOM in patients with blunt splenic injuries. However, risks of major complications do exist, and being elderly is, in part, associated with a higher major complication incidence.