Stanford A型主动脉夹层围术期拔管时机的选择

目的 研究Stanford A型主动脉夹层（Stanford type A aortic dissection,AAD)术后患者,清醒肌力恢复即拔除气管插管与常规术后第一日清晨拔管后,对呼吸与循环系统的影响。方法 2018年9月1日至2019年4月1日,将北京安贞医院心脏外科因Stanford A型主动脉夹层入院手术,术后符合纳排标准的40例患者随机分为实验组和对照组2组,每组20例[年龄(岁) 47.7±13.4 vs. 51.3±12.7,p>0.05;男性65.0% vs. 70.0%,p>0.05],实验组为清醒肌力恢复即拔管,对照组为按常规处理术后第一日清晨拔除气管插管,观察分析二组患者的一般情况、机械通气时间、拔管后呼吸循环系统情况、呼吸系统并发症、监护室（intensive care unit,ICU）时间及住院时间等指标的变化。结果 比较2组,发现实验组机械通气（Mechanical ventilation,MV）时间[小时（hour,h）]较对照组明显缩短[6.9±4.3 vs. 15.2±6.9（p<0.05）],ICU时间（h）也有所减少[13.4±5.1 vs. 21.5±7.0（p<0.05）],拔管后2组氧合指数（PaO2/FiO2）无明显差异,但实验组动脉二氧化碳分压（PaCO2）于拔管后6h有所升高[48.6±23.7 vs. 40.1±20.4（p<0.05）],后期逐渐下降;循环指标如心率（heart rate,HR）、平均动脉压（mean arterial pressure,MAP）、左室射血分数（left ventricular ejection fraction ,LVEF）等无明显差异;拔管后呼吸系统并发症发生率无明显差异。结论 对于Stanford A型主动脉夹层围术期患者,术后根据病情于清醒和肌力恢复后及时拔除气管插管,较传统于术后第一日清晨拔管,可明显缩短呼吸机辅助机械通气时间及ICU时间,但患者于拔管后早期PaCO2可短暂升高,循环系统指标及呼吸系统并发症2组无明显差异。     

依达拉奉对急性ST段抬高型心肌梗死再灌注损伤的影响

目的：研究依达拉奉对急性心肌梗死再灌注损伤的影响。 方法：96名拟行溶栓治疗的急性ST段抬高型心肌梗死患者在溶栓之前随机分为依达拉奉组和对照组，入院后立即给予30 mg依达拉奉静推（n=48）或生理盐水20ml静推(n=48)。监测TNI,CK-MB，MCP-1,并于入院后及2周时查心脏超声心动图，测左心功能。结果：与对照组比绞，依达拉奉组CK-MB峰值明显下降(193±49U/Lvs 221±58U/L,p= 0.01)， TNI峰值明显下降（16.3±4.7ng/ml,vs 18.6±5.2ng/ml P=0.03），三天时测依达拉奉组MCP-1较对照组明显减少（784±105 pg/ml vs 857±122 pg/ml, p= 0.002）,入院24小时心功能明显改善（54.6±4.9vs 51.8±5.6， P=0.01）。依达拉奉组再灌注心律失常发生11例，较对照组18例，无明显差异.(p=0.1)。 结论：依达拉奉可减少急性心肌梗死溶栓再灌注损伤，改善患者心功能及降低 MCP-1。     

静脉-动脉改良超滤在Standford A型主动脉夹层手术的应用

【摘要】 目的 探讨静脉-动脉改良超滤（venoarterial modified ultrafiltration,VA-MUF）应用于Standford A型主动脉夹层（Stanford type A aortic dissection,TAAD）手术的临床效果。 方法 回顾性分析2018年1月至2021年3月南方医科大学南方医院心血管外科接受手术治疗的TAAD患者81例,其中在体外循环（CPB）中应用改良超滤（MUF组）32例,采用常规超滤（CUF组）49例。记录并比较两组的在麻醉诱导后（T1）、体外循环结束（T2）、返ICU即刻（T3）、术后6h(T4)、术后12h(T5)、术后24h（T6）等不同时点的红细胞比积（HCT）、血清乳酸值（Lac）等血气指标,对比两组的体外循环时间、主动脉阻断时间、转流中的尿量、出入量、红细胞用量及术后早期各项恢复指标。 结果 与CUF组相比,MUF组在CPB中超滤量更多[（8268.8±2132）ml vs.（7185.7±2105.4）ml,P=0.027],转中负平衡更明显[（-3509.3±1872）ml vs.（-2598.4±1708.8）ml,P=0.027],术后24h引流量更少[（547.4±124.3）ml vs.（715.1±96）ml,P＜0.01],监护室停留时间更短[（5.7±1）d vs.（6.4±1.1）d,P=0.003],在时点T3、T4、T5的HCT更高（均P＜0.01）。其余各临床指标两组间无显著性差异。结论 在Standford A型主动脉夹层手术中应用VA-MUF技术相对安全、可行,不增加体外循环时间、在一定程度上有利于减少术后出血并促进患者早期恢复。     

早期康复对心脏重症患者的作用及安全性分析研究

【摘要】 目的 探讨早期康复对心脏重症患者的短期临床作用和安全性。方法 选择2019年6月至2020年5月间在阜外华中心血管病医院心脏重症监护室(Cardiac Intensive Care Unit, CICU)接受机械通气治疗的患者63例，按患者出生月份单双数随机分为两组：对照组（32例）：进行常规的心脏重症监护与诊治；观察组（31例）：除常规监护与诊治外，进行基于无创心排量评估的早期康复治疗。分别统计两组的机械通气时间、每搏输出量（stroke volume, SV）、心输出量（cardiac output, CO）、心指数（cardiac index, CI）、肺炎发生率和不良事件发生率。结果 通过对比，观察组的机械通气时间明显缩短[(21.48±2.13) vs. (29.09±3.65),p<0.05]；肺炎发生率明显下降[3.2% vs. 15.6%,p<0.05]；出CICU时每搏输出量（SV）[(56.38±3.36) vs. (53.85±3.89),p<0.05]、心输出量（CO）[(4.82±1.14) vs. (3.90±1.23),p<0.05]和心指数（CI）[(3.62±1.36) vs. (3.01±1.24),p<0.05]均明显提高，差异具有统计学意义；两组间不良事件发生率[1.0% vs. 0,p>0.05]差异无统计学意义。结论 早期康复对心脏重症患者安全有效，促进心脏功能恢复，值得在临床推广。     

依达拉奉复合氯胺酮预处理对肺癌单肺通气患者围术期炎性细胞因子平衡的影响

目的观察依达拉奉复合氯胺酮预处理对肺癌单肺通气患者围术期炎性细胞因子平衡的影响。方法将择期拟行肺叶切除术肺癌患者48例随机分为对照组、依达拉奉组、氯胺酮组、联合组各12例。四组均先行麻醉诱导,依达拉奉组于诱导后予依达拉奉0.5 mg/kg,氯胺酮组于诱导前予氯胺酮0.5 mg/kg,联合组于诱导前予氯胺酮,诱导后予依达拉奉,剂量同前两组,对照组诱导前后予等量生理盐水。单肺通气时双腔管非通气侧开放,与大气相通,呼吸参数不变。于切皮前即刻、膨肺后60 min、术后60 min取四组血样测定TNF-α、IL-6和IL-10水平。结果依达拉奉组、氯胺酮组、联合组TNF-α、IL-6水平均明显低于对照组,IL-10水平明显高于对照组;依达拉奉组IL-10水平明显高于氯胺酮组;联合组TNF-α、IL-6水平均明显低于依达拉奉组及氯胺酮组,IL-10水平明显高于依达拉奉组;P均<0.05。联合组TNF-α/IL-10、IL-6/IL-10值均明显低于其他三组。结论依达拉奉复合氯胺酮预处理能更有效地抑制促炎性细胞因子生成、维持围术期促炎性细胞因子和抗炎性细胞因子相对平衡,有利于患者预后恢复。     

尿激酶原联合尼可地尔术前冠脉灌注对STEMI患者PCI术后心功能、炎性反应及MACE影响

[摘要]目的：探讨尿激酶原联合尼可地尔对ST段抬高型心肌梗死（STEMI）患者急诊直接经皮冠状动脉介入（PCI）术后心功能、炎性反应及心血管事件发生的影响。方法：入选2018年11月～2019年11月在我院心内科收治的126例行PCI的STEMI患者为研究对象,按照随机数表法分为观察组和对照组各63例,对照组给予尿激酶原（10mg）;观察组在对照组基础给予尼可地尔（12mg）治疗。比较两组患者术后心功能超声指标、炎症反应及不良心血管事件发生情况。 结果：两组术后6个月心功能、炎性反应较本组术后1、3个月均有所改善（P <0.05）;观察组术后1、3个月LEVDD、LVESVI较对照组均有所下降（P< 0.05),术后6个月LEVDD（43.29±3.18vs.47.43±3.58 ）mm、LVESVI（32.86 ±6.43vs.38.17±6.93）ml/m2显著低于对照组,（P<0.05);观察组术后1、3个月LEVF、PER较对照组有所提高（P<0.05),术后6个LEVF(59.48±4.19vs.56.89±4.49 )%、PER(1.91±0.19vs.1.82±0.24)EDV/s显著高于对照组,（P<0.05);两组术后炎性反应CRP（12h、7d）、IL-6（12h）时点出现升高,术后其他时点均有所下降（P<0.05）;观察组术后6个月MPO（171.62±21.11vs.198.25±20.11）mg/L、CRP（3.08±0.86vs.4.23±0.51）mg/L、IL-6（2.51±0.44vs.3.08±0.95）mg/L、BNP（139.94±17.36vs.168.95±19.64）pg/ml显著低于对照组（P<0.05）;观察组靶血管血运重建、心绞痛、心力衰竭、再发心肌梗死比例均低于对照组,但差异无统计学意义(P＞0.05),不良心血管事件（MACE）总发生率为（11.11%vs.28.57%）显著低于对照组（P<0.05）。结论：尿激酶原联合尼可地尔应用于行PCI术的STEMI患者,可进一步有效改善其心功能,抑制炎症反应,减少不良心血管事件的发生。     

体外循环术中致炎性和抗炎性细胞因子失衡的动态观察

目的研究体外循环术对致炎性细胞因子和抗炎性细胞因子异常释放的影响,并探讨其在术后炎症反应中的作用.方法ELISA测定7例风湿性心脏病瓣膜置换术不同时点血浆肿瘤坏死因子α(TNFα)、白细胞介素(IL)-6、IL-10和IL-1β浓度,同时用流式细胞术检测淋巴细胞内相应细胞因子的表达.结果4种细胞因子在体外循环术中和(或)术后均明显增高(P＜0.05),它们之间存在明显相关.手术开始后以TNFa、IL-6和IL-1β为主[峰值时间和浓度分别为体外循环术开始后30minTNFa(24.5±4.9)pg/ml,体外循环术停止后4hIL-6(361.8±75.1)pg/ml和IL-1β(18.4±2.8)pg/ml],而术后24h以IL-10为主[(957.4±206.6)pg/ml].淋巴细胞内3种细胞因子表达无明显变化(P＞0.05).结论体外循环术中致炎性细胞因子与抗炎性细胞因子平衡失调启动炎症反应并通过抑制细胞和体液免疫反应促进炎症反应.     

单肺通气前静脉注射依达拉奉对肺功能的作用

目的 探讨单肺通气前静脉注射依达拉奉对肺功能的保护作用.方法 择期行单肺通气开胸手术患者46例,随机分为依达拉奉组（E组,n=23）和对照组（C组,n=23）.所有患者行双腔支气管插管并机械通气,E组在行单肺通气前5 min静脉滴注依达拉奉0.5 mg/kg,C组以同等量生理盐水相同速度静脉注射.分别于设定的时间点采血进行血气分析,计算呼吸指数（RI）并记录患者术后留置气管导管时间、ICU病房留观时间及术后住院时间.结果 与T0时比较,两组T1时和T2时Pmean和RI升高,PaO2降低 （P〈0.05）;与C组比较,E组T1、T2时RI、Pmean降低和PaO2升高（P〈0.05）.且E组术后留置气管导管时间明显缩短.结论 单肺通气前静脉输注依达拉奉可减轻患者肺功能的损害,具有肺保护作用.     

先天性心脏病患儿围术期三尖瓣环收缩期位移的初探研究

目的 研究左向右分流型先天性心脏病（先心病）患儿围术期三尖瓣环收缩期位移（tricuspid annular plane systolic excursion,TAPSE）的变化趋势、影响因素以及与预后的关系。方法 选择2020年9月至2021年5月我院收治的左向右分流型先心病患儿共39例,其中男（17例）/女（22例）;房间隔缺损（16例）/室间隔缺损（23例）;年龄为12-84月,中位数20(7,36)月,体质量11.32±4.96kg;体外循环时间63±17min;主动脉阻断时间16-62min,中位数34(24,45)min;术前心衰标志物N末端-脑钠肽前体（N-terminal proBNP,NT-proBNP）22-3148pg/ml,中位数204(107,380)pg/ml。分别记录患儿术前(T1)、术后第1天(T2)以及术后第5天(T3)的超声心动图指标和NT-proBNP的值以及预后指标,最后通过SPSS25.0进行统计学分析。结果 术后第1天TAPSE较术前显著下降（p<0.05）,术后第5天与术后第1天TAPSE无统计学差异（p>0.05）;术前NT-proBNP和年龄是左向右分流型先心病患儿围术期TAPSE变化的影响因素：术前NT-proBNP越高、年龄越小,术后TAPSE降低程度越大;术前TAPSE与监护室时间、气管插管时间、住院时间、住院费用等预后指标均呈负性相关（p<0.05）;术后第一天TAPSE与部分预后指标（除外气管插管时间）呈负性相关(p<0.05);术后第五天TAPSE与住院时间成负性相关(p<0.05)。结论 左向右分流型先心病围术期右心室收缩功能减低,具有临床意义,应该进行深入研究。     

依达拉奉对单肺通气患者血浆SP-D、TNF-α和IL-8的影响

目的 观察依达拉奉对术中单肺通气患者血浆中肺表面活性物质相关蛋白D（SP-D）、TNF-α及IL-8水平的影响,探讨依达拉奉的肺保护作用.方法 选择ASA Ⅰ～Ⅱ级需行单肺通气肺叶切除的肺癌患者30例,随机分成依达拉奉组（Y组）和对照组（C组）各15例.患者均行双腔支气管插管并行机械通气;麻醉诱导后,Y组给予依达拉奉0.5 mg/kg加入生理盐水100 mL中,30 min内静滴;C组给予等量生理盐水静滴.两组分别在麻醉诱导后切皮前（T0）、单肺通气60min（T1）、术后2 h（T2）抽取静脉血4 mL,测定SP-D、TNF-α、IL-8及丙二醛（MDA）、超氧化物歧化酶（SOD）水平.结果 两组T1、T2的SP-D、TNF-α、IL-8水平明显高于To（P均＜0.05）,Y组T2的SP-D、TNF-α、IL-8水平明显低于C组（P均＜0.05）;T1、T2时Y组SOD明显高于C组（P均＜0.05）,MDA明显低于C组（P均＜0.05）.结论 依达拉奉能够有效减轻开胸手术单肺通气患者的炎症反应,具有肺保护作用.     

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.