肺牵张反射对急性呼吸窘迫综合征的肺保护作用

目的 观察肺牵张反射对急性呼吸窘迫综合征(ARDS)兔肺损伤的影响.方法 盐酸吸入法复制兔ARDS模型,应用神经电活动辅助通气(NAVA)进行机械通气,潮气量(VT)维持6 mL/kg,膈肌电活动(EAdi)法选择呼气末正压(PEEP),随机(随机数字法)分为2组:(1)假手术(Sham)组(5只);(2)迷走神经离断(VAG)组(5只).观察在基础状态、ARDS成模、机械通气1,2,3 h时的气体交换及呼吸力学指标.测定肺通透性、病理以及炎症反应指标.结果 机械通气2,3 h,VAG组氧合指数(PaO2/FiO2)显著低于Sham组(P＜0.05).在机械通气1,2,3 h时,VAG组二氧化碳分压(PaCO2)与Sham组差异无统计学意义(P＞0.05),VAG组VT、气道峰压(Ppeak)及平均气道压(Pm)均显著高于Sham组(P＜0.05).机械通气3 h,与Sham组相比,VAG组死腔分数(VD/VT)、肺弹性阻力(Ers)明显升高,肺静态顺应性(Cst)明显降低(P＜0.05).与Sham组相比,VAG组肺组织湿/干质量(W/D)、肺损伤评分、肿瘤坏死因子-α(TNF-α)、白介素-8(IL-8)、髓过氧化物酶(MPO)及丙二醛(MDA)含最均显著升高(P＜0.05).结论 离断迷走神经加重ARDS肺损伤,维持完整肺牵张反射对ARDS具有肺保护作用.

Abstract：

Objective To evaluate the effect of the pulmonary stretch reflex on the lung injury in acute respiratory distress syndrome (ARDS). Method ARDS models of rabbits were induced by intratracheal infusion hydrochloric acid and ventilated with neurally adjusted ventilatory assist (NAVA) with a tidal volume ( VT) of 6 mL/kg and the electrical activity of diaphragm ( Eadi)-determined PEEP level. The rabbits were randomly ( random number) divided into two groups: ( 1 ) sham operation (Sham) group ( n = 5 ),(2) bilateral vagotom (VAG) group( n = 5 ). Gas exchange and pulmonary mechanics were determined at baseline, after lung injury and ventilation 1, 2, 3 h respectively. Indices about pulmonary permeability,pathological changes and inflammatory response were also measured. Results Compared with Sham group,the PaO2/FiO2in VAG group decreased significantly at ventilation 2 h, 3 h (P ＜0.05). There was no significant difference on PaCO2 between Sham and VAG group (P ＞ 0.05 ), and VAG group had the higher VT,peak pressure ( Ppeak), mean pressure (Pm) compared with Sham group at the time point of ventilation 1 h, 2 h, 3 h (P＜0.05). Compared with Sham group, the dead space fraction (VD/VT) and the respiratory system elastance (Ers) in VAG group increased (P ＜ 0.05 ) and the static pulmonary compliance (Cst)decreased markedly (P ＜ 0.05 ) after 3 h ventilation. The wet/dry weight (W/D), lung injury score, tumor necrosis factor-α ( TNF-α), interleukin-8 ( IL-8 ), myeloperoxidase ( M PO ) and malondialdehyde ( M DA )in VAG group elevated significantly when compared with Sham group ( P ＜ 0.05 ). Conclusions The lung injury in ARDS was aggravated after bilateral vagotomy, which demonstrated that the pulmonary stretch reflex may have the lung protective effect.     

评价膈肌功能指导慢性阻塞性肺疾病患者撤机的可行性研究

Objective To evaluate the predictive performance of neuro-mechanical coupling (NMC) and neuro-ventilatory coupling (NVC) in the weaning outcome in patients with chronic obstructive pulmonary disease (COPD). Methods Sixteen patients were enrolled when the criteria for their first spontaneous breathing trial (SBT) was met. A 30-minute SBT was attempted, with the measurement of electrical activity of the diaphragm (Edi) , NMC, NVC, NVC ×NMC, index of rapid shallow breathing (f/Vt) , airway occlusion pressure (P0.1) and f/Vt ×P0.1 at 0, 5 and 30 min. The receiver operating characteristic (ROC) curve was calculated to evaluate the predictive performance of each index. Results Successful weaning(S group) was observed in 6 patients while weaning failure(F group) in 10 patients. (1)The predictive capacity of Edi: at 30 min of SBT, Edi showed higher values in the F group (P ＜ 0. 05), the area under the ROC curves(AUC) was 0. 817(P ＜0. 05). (2) The predictive capacity of NVC and NMC:at 5, 30 min of SBT, NVC and NMC showed higher values in the S group (P ＜0. 05); at 30 min of SBT NVC presented the largest AUC than any other time of SBT (0. 822, P ＜ 0. 05), while the AUC of NMC was 0. 800 (P ＞ 0. 05). (3) The predictive capacity of NVC × NMC: at 30 min of SBT, the AUC of NVC × NMC was larger than NVC (0. 864, P ＜ 0. 05) , showing greater sensitivity (100. 0%) and specificity (83. 3%) .(4) The predictive capacity of f/Vt and P0.1: f/Vt and f/Vt × P0.1 presented poor predictive performance in the failed patients. Conclusions Edi, NVC and NVC × NMC were good predictor for the weaning outcome in patients with COPD.     

构建可控释血管内皮生长因子多壁碳纳米管的复合支架

背景：单纯植入猪小肠黏膜下层修复腹壁缺损存在早期血管化不足,导致修复失败。目的：构建可控释血管内皮生长因子的多壁碳纳米管-猪小肠黏膜下层复合支架,评价其体外控释血管内皮生长因子性能、力学性能及细胞毒性。方法：通过浸染将装载血管内皮生长因子的多壁碳纳米管复合到猪小肠黏膜下层上,构建可控释血管内皮生长因子的复合支架,并根据多壁碳纳米管与猪小肠黏膜下层的不同质量比（0,1%,3%,5%,10%）构建5种多壁碳纳米管-猪小肠黏膜下层。结果与结论：①复合支架的血管内皮生长因子控释性能：随时间的延长,各组的累积浓度增高,且随着多壁碳纳米管质量的增加,释放浓度也逐渐增加。②复合支架的力学性能：1%,3%,5%,10%多壁碳纳米管-猪小肠黏膜下层最大载荷及弹性模量均高于猪小肠黏膜下层（P〈0.05）,且随着多壁碳纳米管质量的增加,最大载荷逐渐增加。③复合支架的成纤维细胞毒性：多壁碳纳米管在复合支架中质量分数≤5%时对细胞的生长无影响。表明构建的多壁碳纳米管复合支架具备良好的血管内皮生长因子控释性能、力学性能及促进内皮细胞增殖的能力。     

疝病手术的微创化“私人定制”

疝俗称“小肠气”,是人类最常见的疾病之一.疝主要发生在腹壁,包括腹股沟疝、脐疝、切口疝、腰疝等,其中以发生在下腹和大腿交界位置的腹股沟疝最为常见.除了婴幼儿的腹股沟疝、脐疝可以暂时临床观察外,绝大部分疝都需要进行手术治疗. 现在网络便捷,大家可以查到很多文章,了解到目前疝的手术方式是多种多样的,因此不少患者和家属也在纠结该选什么手术合适.从临床实践角度,每个患者的具体情况是有差异的,那么是否存在一个可以共同遵循的手术选择原则和方案,去确定每个患者的最佳手术方式?     

人脱细胞真皮在腹壁缺损修复中的应用

目的:探讨人脱细胞真皮(human acellular dermal marx,HADM)在腹壁缺损修复中的应用.方法:回顾我院外科自2007年5月至2008年9月14例使用HADM修复腹壁缺损病人的临床资料,分析手术效果及并发症的发生率.结果:14例均顺利重建腹壁,无感染及肠梗阻、肠瘘等并发症发生;随访1～16月,无疝复发和其他类型腹壁疝出现.结论:HADM在腹壁缺损的修复上具有一定优势,尤其是在处理感染或污染创面时,是一种值得在临床上推广应用的理想补片材料.     

红细胞分布宽度对急性缺血性卒中静脉溶栓早期神经功能改善不良的预测作用

目的：探讨红细胞分布宽度（RDW）对急性缺血性卒中静脉溶栓早期神经功能改善不良的预测价值。方法：回顾性连续纳入发病4.5 h内行重组组织型纤溶酶原激活剂（rt-PA）静脉溶栓的急性缺血性卒中患者102例，均于溶栓前检测RDW。采用NIHSS评分，将溶栓后24 h神经功能与溶栓前对比，根据变化百分率分为两组：早期神经功能改善良好组，变化≥30%，共53例；改善不良组，变化<30%，共49例。采用单因素及多因素Logistic回归分析，探究RDW是否是溶栓后早期神经功能改善独立影响因素，应用受试者工作特征曲线（ROC）评价RDW对溶栓后早期神经功能改善不良的预测价值。结果：早期神经功能改善不良组与改善良好组相比，房颤（24.5%vs. 9.4%,P=0.042）、糖尿病（57.1%vs. 30.2%,P=0.006）、出血转化（10.2%vs. 0%,P=0.023）的比例在改善不良组均明显高于改善良好组，RDW水平也显著高于改善良好组[（14.09±0.77）vs.(13.31±0.63),P=0.000]。Logistic回归分析显示既往糖尿病史（OR=2.606,95%CI:1...     

肝癌肝移植转化治疗策略进展

肝移植能够在彻底去除肿瘤的同时完整移除病肝,对于合并肝硬化的肝癌患者是最佳选择。近年来,随着肝癌综合治疗研究的进展,转化治疗理念被引入肝癌外科治疗领域以及肝移植领域,成功的转化治疗有望将超出标准肝癌患者转变为符合标准而接受肝移植手术,从而极大改善其预后。就肝癌肝移植转化治疗的进展进行简要介绍。