影响重症感染患者ICU治疗时间的危险因素分析

目的探讨影响重症感染患者ICU治疗时间的危险因素。方法选择重症感染患者75例,按住院时间分为≤48 h组（19例）和〉48 h组（56例）,采用多因素非条件Logistic回归分析探讨急性生理学和慢性健康状况系统Ⅱ（APACHEⅡ）评分、序贯性器官衰竭评分（SOFA）、乳酸水平、DIC和MODS的发病率对重症感染患者ICU治疗时间的影响。结果两组间慢性疾病史、平均动脉压、APACHEⅡ评分、SOFA评分、乳酸水平及DIC和MODS的发病率存在显著差异（P均〈0.01）。Logistic回归分析显示,APACHEⅡ评分、SOFA评分、乳酸水平及D IC和MODS的发病率是影响患者ICU治疗时间长短的独立危险因素（OR分别为2.065、4.902、1.927、1.098、7.514,P〈0.05或〈0.01）。结论 APACHEⅡ评分、SOFA评分、乳酸水平及D IC和MODS的发病率是影响重症感染患者ICU治疗时间的危险因素。     

重症医学科老年患者急性肾损伤危险因素和预后分析

目的了解重症医学科(ICU)老年患者住院期间急性肾损伤(AKI)的发生情况、相关危险因素及预后。方法收集2012-01-01—2016-03-01安徽中医药大学第一附属医院内科ICU收治的581例老年患者的临床资料和实验室检查数据;根据改善全球肾脏病预后组织(KDIGO)标准将患者分成AKI组和非AKI组,比较两组患者的临床指标、住院时间和患者病死率;应用Logistic多元回归法分析ICU中老年患者发生AKI的危险因素。结果共119例发生AKI,发生率为20.5%,AKI患者病死率为61.3%(73例);AKI组脓毒症发生、基础慢性肾脏病(CKD)、系统急性生理学及慢性健康状况评分系统(APACHE)-Ⅱ评分、基础脑钠肽、代谢性酸中毒、液体超负荷明显高于非AKI组(P0.05)。经Logistic多元回归分析,CKD、脓毒症、APACHE-Ⅱ评分、基础脑钠肽、代谢性酸中毒、液体超负荷是发生AKI的独立相关危险因素。AKI组患者ICU内住院时间和住院病死率显著高于非AKI组(P均0.05),随着AKI程度的增加,患者ICU内住院时间显著延长(P0.05),病死率显著增加(P0.01)。结论老年患者AKI的发生率及病死率均较高,CKD、脓毒症、APACHE-Ⅱ评分、基础脑钠肽、代谢性酸中毒、液体超负荷是发生AKI的独立相关危险因素;老年患者发生AKI后预后更差。了解和预防老年患者AKI的发生及危险因素可以为改善该类患者的预后提供依据。     

ICU老年患者肺部真菌感染的危险因素及抢先治疗临床分析

目的 探讨ICU老年患者肺部真菌感染的危险因素以及抢先治疗对其预后的影响.方法 2008年1月～2011年6月,本院ICU中达到临床诊断PFI标准的老年患者120例,分为A、B两组:A组59例,B组61例,A组给予伏立康唑,B组确诊后开始抗真菌治疗.记录B组病原菌检出时间,对两组患者进行APACHEⅡ评分、计算MODS发生率及病死率.结果 危险因素包括应用广谱抗生素、侵入性操作、机械通气时间≥7 d、ICU住院时间≥14 d、免疫功能低下、激素应用时间≥3 d、伴发糖尿病等;A组的MODS发生率、APACHEⅡ分值均明显低于B组(P＜0.05)、住院时间少于B组(P＜0.01).结论 抢先治疗ICU老年患者PFI可有效的改善预后,减少住院时间.     

维生素D对老年重症监护室患者预后的影响

目的调查老年重症监护室(ICU)患者维生素D缺乏的情况,并探讨其对预后的影响。方法收集2012年6月至2013年12月入住新华医院老年ICU的患者213例,检测血清25羟维生素D[25(OH)D]水平,比较25(OH)D充足组、25(OH)D不足组和25(OH)D缺乏组组间主要生化指标、多器官功能障碍综合征(MODS)、急性生理学与慢性健康状况评分系统Ⅱ(APACHEⅡ)评分以及30 d住院死亡率的差异;同时运用多因素logistic回归分析影响老年ICU患者预后的独立危险因素。结果老年ICU患者维生素D缺乏82例(38.50%),维生素D不足90例(42.25%),维生素D充足41例(19.25%)。与维生素D充足组比较,维生素D缺乏组APACHEⅡ评分、血浆乳酸、C反应蛋白(CRP)水平均较高(P<0.05),MODS发生率和死亡率亦较高(P<0.05)。多因素分析提示维生素D缺乏是影响老年ICU患者预后的独立危险因素。血清25(OH)D水平与存活组ICU留住时间呈负相关(r=-0.18,P<0.05)。结论老年ICU患者维生素D缺乏普遍存在;维生素D缺乏与患者疾病的严重程度相关,可能是影响疾病预后的独立危险因素。     

MODS修订评分对老年多器官功能障碍综合征患者的预后评估

目的比较多器官功能障碍综合征(MODS)评分修订系统与现用评分系统对老年多器官功能不全综合征(MODSE)患者的预后评估价值。 方法回顾性分析解放军总医院2009年1月至2012年6月收治的387例符合MODSE标准患者入重症监护室后第一个24 h的急性生理及慢性健康状态评分(APACHE Ⅱ、APACHE Ⅲ)、简化急性生理评分(SAPS Ⅱ)、MODS评分、MODS联合年龄评分、MODS联合年龄评分加倍修订、MODS联合年龄评分指数修订系统,评估并检验各自预后评估效能。 结果与女性组相比,男性组平均住ICU时间和死亡平均年龄显著降低,28天病死率和总体病死率高于女性组;随着年龄增大,器官衰竭数目、28天病死率和总体病死率逐渐增加,平均住ICU时间逐渐缩短;与生存组相比,死亡组年龄及各种评分均高,差异具有统计学意义;APACHE Ⅱ、APACHE Ⅲ、SAPS Ⅱ、MODS、MODS联合年龄评分、MODS联合年龄评分加倍修订、MODS联合年龄评分指数化修订系统受试者工作曲线下面积：0.810、0.791、0.712、0.801、0.834、0.787、0.793。其中MODS联合年龄评分敏感性最高,APACHE Ⅱ特异性最好,MODS联合年龄评分系统Youden指数和曲线下面积最大。 结论MODS评分修订系统与现用评分系统均可较好的早期评估老年多器官功能不全综合征患者的预后;其中MODS联合年龄评分系统具有更优秀的预后评估效能。     

动态血糖监测对应激性高血糖患者处置的意义

目的：观察实时动态血糖监测（RT-CGMS）对应激性高血糖患者处理的意义.方法：APACHEⅡ评分＞15分的重症监护室患者148例,随机分为动态血糖监测组（CGMS组,n=69）和指尖血糖监测组（GM组,n=79）,比较2组患者的低血糖发生率、血糖变异度、ICU入住时间、多器官功能障碍综合征（MODS）发生率、28 d病死率.结果：CGMS组的血糖变异度、低血糖发生率、MODS发生率、病死率明显低于GM组（均P＜0.05）,ICU入住时间明显短于GM组（P＜0.05）.结论：动态血糖监测能优化血糖控制,改善预后,降低病死率.     

早期动脉血乳酸监测在老年多发伤中的应用价值

目的：评估初始血乳酸监测在老年多发伤患者中的应用价值。方法采用回顾性研究方法,收集2012年11月至2013年7月武进人民医院重症监护病房收治的老年多发伤患者78例,入ICU后立即采集动脉血进行血气分析,根据患者动脉乳酸水平分为3组（＜2mmol/L组,2～4mmol/l组,＞4mmol/L组）,并记录患者基本资料,比较入ICU 24h APACHEⅡ评分、ICU住院时间、感染发生率、器官衰竭数目、24h补液量以及住院病死率;最后按患者预后分为死亡组和存活组,通过单因素及多因素回归分析影响预后的危险因素。结果（1）入科时3组基本资料差异无统计学意义（P＞0.05）;（2）住院期间3组资料在入科24h APACHEⅡ评分、24h补液量、器官功能衰竭数目、ICU住院时间以及住院病死率方面差异有统计学意义（P＜0.05）,在初始收缩压、感染发生率方面差异无统计学意义（P＞0.05）;（3）多因素回归分析显示,初始乳酸水平及器官功能衰竭数目是影响老年多发伤患者预后的独立影响因素。结论初始血乳酸是老年创伤患者临床治疗中重要的监测指标,其对患者预后有一定的评估价值。     

58例严重感染患者死亡风险因素分析

选2006年10月～2008年5月入住北京世纪坛医院重症监护室（ICU）的严重感染患者58例,根据预后分为存活组、死亡组。分别记录年龄、性别、人ICU时急性生理学与慢性健康状况评分系统Ⅱ（APACHEⅡ评分）、多器官功能障碍评分（MODS评分）、感染部位、血培养结果、动脉血乳酸数值。结果发现,死亡组患者年龄、A—PACHEⅡ评分、MODS评分、血培养阳性率、动脉血乳酸值均高于存活组（P〈0．05）。Logistic回归分析显示,患者的MODS评分和动脉血乳酸值是影响患者死亡率的独立风险因素。认为严重感染患者初始MODS评分和血乳酸值对判断预后有重要价值。     

重症医学科超高水平血清降钙素原患者的预后分析

目的 :探讨重症监护室(intensive care unit,ICU)超高水平血清降钙素原(procalcitonin,PCT)患者的预后影响因素。方法:采用回顾性研究方法,收集2016年12月至2017年11月南京医科大学第一附属医院收治的ICU住院期间PCT100μg/L的63例患者的临床资料。按照入住ICU后28 d预后分为存活组和死亡组,比较2组患者的临床资料,分析影响该类患者预后的危险因素。结果:63例患者PCT升高的主要原因为腹腔感染(21例,33.3%)、肺部感染(18例,28.6%)、非感染性炎症反应(14例,22.2%)等。单因素分析发现,死亡组患者多器官功能障碍综合征(multiple organ dysfunction syndrome,MODS)的发生率、血乳酸、急性生理与慢性健康评价(acute physiology and chronic health evaluation,APACHE)Ⅱ评分等指标均明显高于存活组,差异具有统计学意义(均P0.05);多因素分析发现,APACHEⅡ评分是影响超高水平血清PCT患者预后的危险因素。结论:ICU超高水平血清PCT患者常见的原因是感染,其次为非感染性炎症反应等。此类患者的预后与血乳酸水平、发生MODS和APACHEⅡ评分等密切相关,而APACHEⅡ评分是影响该类患者预后的独立危险因素。     

脓毒症相关脑病在ICU中发生的危险因素分析

目的探讨ICU中脓毒症相关脑病（SAE）发生的危险因素。方法回顾性分析从2009年1～12月我院重症医学科收治的284例脓毒症患者的临床资料,比较SAE与非SAE患者的年龄、性别构成、病死率、住ICU时间、生命体征、血常规、电解质、肝肾功能、血气、APACHEⅡ评分。结果 SAE发病率为37.68%,SAE与非SAE患者病死率、PaO2、血清总胆红素（TB il）、AST、ALT、pH值、APACHEⅡ评分的差异有统计学意义。结论 PaO2、ALT、A-PACHEⅡ评分是SAE发生的危险因素。     

Three layer functional model and energy exchange concept of aging process

Relying on a certain degree of abstraction, we can propose that no particular distinction exists between animate or living matter and inanimate matter. While focusing attention on some specifics, the dividing line between the two can be drawn. The most apparent distinction is in the level of structural and functional organization with the dissimilar streams of ‘energy flow’ between the observed entity and the surrounding environment. In essence, living matter is created from inanimate matter which is organized to contain internal intense energy processes and maintain lower intensity energy exchange processes with the environment. Taking internal and external energy processes into account, we contend in this paper that living matter can be referred to as matter of dissipative structure, with this structure assumed to be a common quality of all living creatures and living matter in general. Interruption of internal energy conversion processes and terminating the controlled energy exchange with the environment leads to degeneration of dissipative structure and reduction of the same to inanimate matter, (gas, liquid and/or solid inanimate substances), and ultimately what can be called ‘death.’ This concept of what we call dissipative nature can be extended from living organisms to social groups of animals, to mankind. An analogy based on the organization of matter provides a basis for a functional model of living entities. The models relies on the parallels among the three central structures of any cell (nucleus, cytoplasm and outer membrane) and the human body (central organs, body fluids along with the connective tissues, and external skin integument). This three-part structural organization may be observed almost universally in nature. It can be observed from the atomic structure to the planetary and intergalactic organizations. This similarity is corroborated by the membrane theory applied to living organisms. According to the energy nature of living matter and the proposed functional model, the decreased integrity of a human body's external envelope membrane is a first cause of the structural degradation and aging of the entire organism. The aging process than progresses externally to internally, as in single cell organisms, suggesting that much of the efforts towards the restoration and maintenance of the mechanisms responsible for structural development should be focused accordingly, on the membrane, i.e., the skin. Numerous reports indicate that all parts of the human body, like: bones, blood with blood vessels, muscles, skin, and so on, have some ability for restoration. Therefore, actual revival of not only aging tissue of the human body's membrane, but the entire human body enclosed within, with all internal organs, might be expected. We assess several aging theories within the context of our model and provide suggestions on how to activate the body's own anti-aging mechanisms and increase longevity. This paper presents some analogies and some distinctions that exist between the living dissipative structure matter and inanimate matter, discusses the aging process and proposes certain aging reversal solutions.     

Unusual responses of nocturnal pineal melatonin synthesis and secretion to swimming: Attempts to define mechanisms

Abstract: The effect of swimming at night on rat pineal melatonin synthesis was compared with that of light exposure at night. Rats were forced to swim at 0030 hr (lights out at 2000 hr) and sacrificed by decapitation 15 and 30 min later, immediately after swimming. Other groups of animals were exposed to white light (650μW/cm²) for 15 and 30 min at same time. Swimming caused a rapid and highly significant drop in the melatonin content in the pineal gland; however, the activity of N-acetyltransferase (NAT), the supposed rate limiting enzyme in the melatonin production, was not changed. Despite the drop in pineal melatonin levels, serum concentrations of the indole remained elevated in the rats that swam. In contrast, melatonin levels in the pineal and serum of light exposed rats fell precipitously, accompanied by a significant suppression of NAT activity. Since we anticipated that the strenuous exercise associated with swimming may induce release of artrial natriuretic peptide (ANP) from the heart, which in turn could cause the release of pineal melatonin, in a second study we injected physiological saline intravenously to stretch the cardiac muscle and release ANP. Three milliliters of normal saline was injected during the day into the jugular vein of anesthetized rats that were pretreated with isoproterenol to stimulate pineal melatonin production. Animals were killed 15 min after the saline injection, and pineal NAT activity and pineal melatonin levels were measured. The saline injections caused no alteration in the elevated levels of either NAT or melatonin. These data suggest that the disparity in pineal NAT activity (which was high) and pineal melatonin (which was low), in animals swum at night, may not be caused by ANP which is released during strenuous exercise such as swimming.     

Melatonin and photoperiodic time measurement: Seasonal breeding in the sheep

Abstract: Well-established circadian physiology supports the view that photoperiodic time measurement utilizes the coincidence between the presence of light and a photosensitive phase of a 'biological clock' to alter reproductive status—the so-called external coincidence model of seasonal breeding. In this review, we examine the mechanism whereby photoperiod interacts with presumed suprachiasmatic nuclei activity to allow endogenous melatonin to normally synchronize reproductive activity to the optimal time of year. The Romney Marsh sheep is particularly explored as an experimental model. It is suggested that the on/off activity of seasonal reproduction may be a robust mechanism able to be predictably manipulated by the judicious use of the light/dark cycle and exogenous melatonin, but firmly based on circadian principles.     

The immunoneuroendocrine role of melatonin

Abstract: A tight, physiological link between the pineal gland and the immune system is emerging from a series of experimental studies. This link might reflect the evolutionary connection between self-recognition and reproduction. Pinealectomy or other experimental methods which inhibit melatonin synthesis and secretion induce a state of immunodepression which is counteracted by melatonin. In general, melatonin seems to have an immunoenhancing effect that is particularly apparent in immunodepressive states. The negative effect of acute stress or immunosuppressive pharmacological treatments on various immune parameters are counteracted by melatonin. It seems important to note that one of the main targets of melatonin is the thymus, i.e., the central organ of the immune system. The clinical use of melatonin as an immunotherapeutic agent seems promising in primary and secondary immunodeficiencies as well as in cancer immunotherapy. The immunoenhancing action of melatonin seems to be mediated by T-helper cell-derived opioid peptides as well as by lymphokines and, perhaps, by pituitary hormones. Melatonin-induced-immuno-opioids (MHO) and lymphokines imply the presence of specific binding sites or melatonin receptors on cells of the immune system. On the other hand, lymphokines such as -γ-interferon and interleukin-2 as well as thymic hormones can modulate the synthesis of melatonin in the pineal gland. The pineal gland might thus be viewed as the crux of a sophisticated immunoneuroendocrine network which functions as an unconscious, diffuse sensory organ.     

Response of rat pineal melatonin to calcium, magnesium, and lithium is circadian stage dependent

Abstract: Herein we documented the response of pineal melatonin production to electrolytes known to be effective on pineal function in view of a possible circadian stage dependence. We studied the release of melatonin by perifused rat pineal glands at 2 different circadian stages corresponding to the middle of the light and dark periods, i.e., respectively, 7 and 19 HALO (Hours After Light Onset, L:D = 12:12). The initial efflux rates were, as expected, much higher in the perifusates of glands removed from rats sacrificed during the dark phase than of those removed during the light phase. After 3 hr of perifusion, melatonin release reached similar levels which were found constant up to the 8th hr of perifusion, whatever the circadian stage. Perifusion of the glands with physiological concentrations for the rat of calcium (5.2 mmol/1) and magnesium (1.34 mmol/1) resulted in a stimulatory effect on the pineal glands removed from rats sacrificed in the middle of the dark period (19 HALO), whereas no effects were observed on the pineal glands removed from rats sacrificed during the light (7 HALO). Lithium (0.28 and 0.55 mmol/1) was ineffective on melatonin release in pineal glands removed 7 and 19 HALO. Our results show differences in the initial efflux rates of melatonin and in the response of perifused pineal glands to calcium and magnesium according to the circadian stage.     

Serological survey of HIV and syphilis in pregnant women in Madagascar

Objectives Peripartal transmission of human immunodeficiency virus (HIV) and Treponema pallidum, the causative agent of syphilis, leads to severe consequences for newborns. Preventive measures require awareness of the maternal infection. Although HIV and syphilis testing in Madagascar could be theoretically carried out within the framework of the national pregnancy follow‐up scheme, the required test kits are rarely available at peripheral health centres. In this study, we screened blood samples of pregnant Madagascan women for HIV and syphilis seroprevalence to estimate the demand for systemic screening in pregnancy. Methods Retrospective anonymous serological analysis for HIV and syphilis was performed in plasma samples from 1232 pregnant women that were taken between May and July 2010 in Ambositra, Ifanadiana, Manakara, Mananjary, Moramanga and Tsiroanomandidy (Madagascar) during pregnancy follow‐up. Screening was based on Treponema pallidum haemagglutination tests for syphilis and rapid tests for HIV, with confirmation of positive screening results on line assays. Results Out of 1232 pregnant women, none were seropositive for HIV and 37 (3%) were seropositive for Treponema pallidum. Conclusions Our findings are in line with previous studies that describe considerable syphilis prevalence in the rural Madagascan population. The results suggest a need for screening to prevent peripartal Treponema pallidum transmission, while HIV is still rare. If they are known, Treponema pallidum infections can be easily, safely and inexpensively treated even in pregnancy to reduce the risk of transmission.     

Conservative management of perforated duodenal diverticulum： A case report and review of the literature

Duodenal diverticula are a relatively common condition. They are asymptomatic, unless they become complicated, with perforation being the rarest but most severe complication. Surgical treatment is the most frequently performed approach. We report the case of a patient with a perforated duodenal diverticulum, which was diagnosed early and treated conservatively with antibiotics and percutaneous drainage of secondary retroperitoneal abscesses. We suggest this method could be an acceptable option for the management of similar cases, provided that the patient is in good general condition and without septic signs.     

Changes in connexin43, the gap junction protein of astrocytes, during development of the rat pineal gland

Abstract: The abundance of gap junctions between rat pineal astrocytes formed by connexin43 (Cx43) was studied during development. Levels and distribution of Cx43 were measured by immunoblotting and indirect immunofluorescence, respectively. The amount of Cx43 in cells located within the gland was low until about the 7th postnatal day and increased to adult values between the 14th and 21st days postpartum. Although astrocytes, recognized by their vimentin immunoreactivity, were scarce before birth, they were abundant by the 7th postnatal day suggesting that the low levels of Cx43 found at this age corresponded to a low expression of this protein. Localization of the immunoreactivity to Cx43 and vimentin showed a close correlation, indicating that mature or immature pineal astrocytes form gap junctions made of Cx43. Since Cx43 levels attained their adult values at about the time the innervation and the functional state of the gland reached maturity (2–3 weeks after birth), it is proposed that astrocyte gap junctions are involved in the function of the adult rat pineal gland.