脓毒症的流行病学研究进展

脓毒症（sepsis）是创伤、烧伤、休克、感染等临床急危重病患者的常见严重并发症之一，一份来自北美的流行病学调查发现脓毒症的发病率大约是0．3％，所有患者中老年人的死亡率大约是30％～40％，而感染性休克患者的死亡率可高达50％以上。美国每年有75万脓毒症患者，约9％的脓毒症患者发展成重症脓毒症（severe sepsis），3％发展为脓毒性休克（septic shock），超过21万（28％）死亡，是ICU中主要的死亡原因。近年来，尽管早期积极地抗感染、液体复苏及相关脏器的功能支持，但总体病死率仍居高不下。因此对脓毒症流行病学调查研究有助于阐明其发病规律及影响因素，对指导临床治疗具有重要的意义。     

脓毒症研究现状与思考

脓毒症是严重创伤、烧伤、休克、大手术后常见的并发症,也是严重创伤、烧伤患者主要的死亡原因之一.由创伤导致的脓毒症和MODS在ICU内的病死率高达60%[1,2].有报道称,尽管抗生素治疗有新进展,但脓毒症的病死率却呈不断上升趋势,从1980年的4.2/10万上升到1992年的7.7/10万,12年间增加了83%[2].     

脓毒症研究概况

脓毒症是严重创伤、烧伤、休克、大手术后常见的并发症 ,是创伤、烧伤患者重要的死亡原因之一[1,2 ] 。美国每年有 75万脓毒症患者 ,其中约 2 2～2 5万人死亡 ,并呈逐年上升趋势。由于创伤导致的脓毒症和多脏器功能衰竭在重症监护病房 (ＩＣＵ)内的病死率为 60 %。有报告称 ,尽管抗生素治疗有新的进展 ,但脓毒症的病死率从 1980年的4 .2人 10万人上升到 1992年的 7.7人 10万人 ,12年间增加了 83% [3] 。一、几个名词概念长期以来 ,文献上将感染、菌血症、脓毒症、脓毒综合征、脓毒性休克等混用。Ｆａｂｉａｎ等[4 ] 曾作如下的表述 :感染…     

细胞凋亡在脓毒症免疫紊乱中作用及其调控途径的思考

严重创伤、烧伤、休克及外科大手术应激后常常并发脓毒症,进一步发展可导致脓毒性休克甚至MODS,是临床危重症最主要的死亡原因之一.严重脓毒症和MODS病情进展迅速、临床处理棘手、患者预后不良,已成为现代创伤外科及危重病医学面临的突出难题.近年来的资料提示,创伤后脓毒症的发生与机体免疫功能紊乱密切相关,突出表现为细胞免疫功能受抑,其中大量免疫细胞特别是淋巴细胞凋亡进而诱发免疫功能失调被认为是脓毒症发生的重要机制.因此,深入了解细胞凋亡在脓毒症发病中的确切作用与地位,探讨其关键作用环节并寻求新的防治途径无疑具有极其重要的临床意义.     

关注树突状细胞在严重创伤感染中的作用及意义

严重创、烧伤及外科大手术应激后易并发脓毒症(sepsis),进一步发展可导致脓毒性休克及MODS,是严重创、烧伤和危重患者最主要的死亡原因之一.迄今为止,有关感染并发症包括脓毒症及MODS的确切发病机制尚未充分阐明,尤其是对机体免疫功能紊乱的发病过程和意义认识不足,临床缺乏有效的预防与治疗措施[1].树突状细胞(dendritic cell,DC)是近年来备受人们关注的专职抗原呈递细胞(antigen presenting cell,APG),能摄取、加工及呈递抗原,启动T细胞介导的免疫反应,是调节和维持机体免疫应答的核心因素之一,在创伤感染并发症的病理过程和干预途径中具有重要意义.     

脓毒症认识的变迁与治疗进展

脓毒症(Sepsis)是创伤、烧伤、休克、感染等临床急危重患者的严重并发症之一,也是诱发脓毒性休克、多器官功能障碍综合征(Multipleorgandysfunctionsyndrome,MODS)的重要原因[1]。由于脓毒症来势凶猛,病情进展迅速,病死率高,给临床救治工作带来极大困难[2]。如何早期识别、及时诊断、有效防治脓毒症的形成与发展,是提高急危重症救治成功率的关键所在[1]。本文拟就脓毒症的研究历史,定义和诊断标准新认识、临床治疗进展等若干问题进行简要阐述。1脓毒症研究的历史“Sepsis”的提法可归功于希波克拉底,他用这个词来描述组织降解。“Sepsis…     

抑制补体激活对脓毒症影响的研究进展

脓毒症是一种由感染导致的以全身炎症反应为特征的综合征,是严重创伤、烧伤、休克、外科大手术、感染等临床急危重患者的严重且常见并发症之一,也是诱发脓毒性休克、多器官功能障碍综合征(MODS)及多器官功能衰竭(MOF)的重要原因.脓毒症的发生发展涉及到补体、凝血、纤溶等多个系统及它们之间的相互作用,现在越来越多的研究表明,脓毒症与天然免疫特别是补体系统失控的激活有关,而且大量实验及临床研究也证实,脓毒症时应用补体抑制剂可以取得较理想的效果[1].     

人蛋白C系统及内皮细胞在脓毒症中的作用

尽管目前危重病医学有了长足的进步 ,广谱抗生素在临床上广泛应用 ,但由严重细菌感染引起的脓毒症迄今仍然是世界范围内非心脏病重症监护患者的首位死亡原因。在美国外科重症监护病房 (SICU)中脓毒症的病死率高达 15 %,重度脓毒症可达到 30 %～5 0 %,而在脓毒性休克的病例中可超过 6 0 %[1～ 5] 。随着对脓毒症发病机制研究的进一步深入 ,人蛋白C系统及内皮细胞在脓毒症中所发挥的作用受到广泛关注 ,以下对人蛋白C系统、内皮细胞及其在脓毒症中的作用做一简要综述。1　脓毒症及其发病机制研究的进展脓毒症是指由感染引起或高度怀疑存在感…     

严重烧伤延迟复苏脓毒症防治的临床研究

目的　对烧伤延迟复苏患者脓毒症的发生情况进行临床分析 ,旨在进一步降低烧伤后脓毒症的发生率。方法　将 72例延迟复苏的严重烧伤患者分二个阶段 ,即 1990年 4月— 1994年 12月 (第一阶段 ,n =2 6)及 1995年 1月— 2 0 0 1年 12月 (第二阶段 ,n =46) ,进行比较分析。结果　第二阶段烧伤治愈率升高 ,创面愈合时间及住院时间缩短 ,主要内脏器官并发症发生率及脓毒症发病率明显下降 ,血清肿瘤坏死因子(TNF)水平下降 (P <0 .0 1～ 0 .0 5 )。结论　早期、快速、有效的液体复苏 ,早期削 (切 )痂 ,早期肠内喂养 ,加强营养支持治疗和进行免疫调理 ,合理应用抗生素 ,输注经紫外线照射的异体全血 ,重视防治内源性感染和减少有创性诊疗操作等均可降低烧伤延迟复苏患者脓毒症的发生率。     

连续性血浆滤过吸附辅助治疗烧伤脓毒症的临床效果分析

目的：分析烧伤脓毒症患者经连续性血浆滤过吸附辅助治疗的临床效果。方法分析收治的90例烧伤脓毒症患者的临床资料,按照入院顺序将所有患者分为两组,即：研究组（45例）与对照组（45）例。对照组45例烧伤脓毒症患者给予常规治疗,观察组45例烧伤脓毒症患者给予连续性血浆滤过吸附辅助治疗。对比观察组与对照组的临床效果与28 d死亡率及病死率。结果治疗之后,观察组与对照组TNF－a、IL－6、IL－1水平以及临床相关性指标值显著优于治疗之前;且观察组显著优于对照组,差异有统计学意义（ P＜0．05）。观察组患者的28 d死亡率、住院病死率均低于对照组患者,差异有统计学意义（ P＜0．05）。结论烧伤脓毒症患者经连续性血浆滤过吸附辅助治疗的临床效果十分显著,值得在临床中推广应用。     

Glutamine supplementation in vitro and in vivo,in exercise and in immunodepression

In situations of stress, such as clinical trauma, starvation or prolonged, strenuous exercise, the concentration of glutamine in the blood is decreased, often substantially. In endurance athletes this decrease occurs concomitantly with relatively transient immunodepression. Glutamine is used as a fuel by some cells of the immune system. Provision of glutamine or a glutamine precursor, such as branched chain amino acids, has been seen to have a beneficial effect on gut function, on morbidity and mortality, and on some aspects of immune cell function in clinical studies. It has also been seen to decrease the self-reported incidence of illness in endurance athletes. So far, there is no firm evidence as to precisely which aspect of the immune system is affected by glutamine feeding during the transient immunodepression that occurs after prolonged, strenuous exercise. However, there is increasing evidence that neutrophils may be implicated. Other aspects of glutamine and glutamine supplementation are also addressed.     

Temporal changes in the oxidation state in in vitro blood

The rates at which the paramagnetic compounds deoxyhemoglobin (Hb) and methemoglobin (MHb) form in vivo within an area of hemorrhage are unknown. The present experiment establishes the baseline concentrations and rates of change in paramagnetic hemoglobin concentrations, as well as the pH in normal heparinized and clotted human blood maintained in vitro at 37 degrees C under anaerobic conditions over 30 hours. There was a moderate increase in Hb concentration in normal heparinized blood (average increase was 15.5%, rate = 0.50%/hour) and a slight increase in MHb concentration in the heparinized blood and clots (average increase was 1.4%, rate = 0.044%/hour). A second experiment was done to verify the activity of the RBC systems responsible for maintaining the hemoglobin molecule in the reduced state. Conversion of MHb to Hb in these samples proceeded at a rate of 5.6%/hour. In a third experiment, blood from 11 normal subjects maintained at 4 degrees C 25 degrees C was analyzed for MHb concentration over the course of 28 days. The level of MHb formation remained in the range of normal for at least 11 days in all subjects. The authors conclude that at basal conditions created in vitro, the blood levels of both Hb and MHb remain at relatively low levels. Therefore, if the accumulation of Hb and/or MHb occurs in acute in vivo hematomas it must be driven by intrinsic tissue factors.     

Carcinoma in situ in cryptorchid testes in post-pubertal patients]

The pathohistologic analysis of testis sections of 37 postpuberty patients with different types of cryptorchism is performed. The tissue samples were taken during orchiopehy, fixed in Bouin's solution and treated by the standard histologic techniques. The morphologic criteria are presented for identification of the presence of the so called carcinoma in situ cells found in two cases. Besides, in 13 patients rare, mainly single, atypical germinative cells were found in a smaller number of the seminiferous tubules. It has been concluded that the presence of carcinoma in situ cells in undescended testes of some patients and considering the simple way of sampling, lack of complications and high reliability of the diagnostic procedure, it is absolutely justified to take routine biopsy of testes during orchiopexy in each postpuberty and perhaps prepuberty patient.     

颈动脉斑块患者血液流变学指标变化探讨

颈动脉斑块形成是动脉硬化的明显特征，可作为观察全身动脉硬化病变的窗口。近年来，颈动脉斑块发病率越来越高，有关这方面的文献报道也较多。颈动脉位置表浅、运动较少，又是动脉粥样硬化的好发部位，故此处的粥样斑块比较容易检测。本研究随机抽取了2005年12月～2007年10月我院住院患者249例，分析其颈动脉病变的超声检查结果与血液流变学指标，探讨颈动脉硬化、斑块形成与血液黏度的相关性。     

Advances in uroradiologic imaging in children

Diagnostic imaging of pediatric urologic disorders is continuously changing as technologic advances are made. Although the backbone of pediatric urologic imaging has been ultrasound, voiding cystourethrography, and radionuclide scintigraphy, newer and advanced modalities are becoming increasingly important. This article discusses the techniques and clinical applications of three such imaging modalities as they pertain to pediatric urologic disorders: (1) MR urography; (2) advanced ultrasound (harmonic imaging, three-dimensional, and voiding urosonography); and (3) CT angiography.     

Oxalosis in primary hyperoxaluria in infancy

Primary hyperoxaluria (PH1) is a rare inborn autosomal recessive metabolic disorder due to the deficiency of hepatic alanine-glyoxylate-aminotransferase. This deficiency results in excessive synthesis and urinary excretion of oxalate, inducing renal stone formation and deposition of calcium oxalate in the kidney, bone, myocardium, and vessels (systemic oxalosis, SO) in the most severely affected individuals. We report renal and skeletal changes in a 3-month-old girl with PH1 and SO. Intense cortico-medullary hyperechogenicity and increased homogeneous radiopacity of normal-sized kidneys suggested the diagnosis of SO. Skeletal survey showed osteopenia and characteristic symmetrical metaphyseal transverse bands in long bones, progressively becoming more dense and migrating towards the diaphysis. Multiple pathological and slowly healing fractures of the limbs occurred at the dense band level. A radiopaque rim was then observed in flat bones, epiphyseal nuclei, and vertebral bodies. Inflammatory granulomatous reaction, induced by the presence of oxalate crystals in the marrow spaces, coexisted with progressively evident radiological signs of secondary hyperparathyroidism, with partially overlapping features. The patient was treated by peritoneal dialysis and hemodialysis until combined liver–kidney transplantation. There are no previous reports of infants treated with hemodialysis for more than 2 years.