国内外安宁疗护准入标准的研究进展

安宁疗护可提高患者在生命终末阶段的生活质量，减轻患者和家属的身心痛苦。科学合理的安宁疗护准入标准可帮助医护人员识别出需要安宁疗护服务的患者，使其及时获得安宁疗护服务，因此明确安宁疗护的准入标准是推进安宁疗护发展的基础。本文就国内外安宁疗护准入标准的制定方法、具体内容及优缺点进行综述，以期为我国安宁疗护准入标准的构建提供参考。     

连续性肾脏替代治疗联合中药灌肠对急性肾损伤患者尿KIM-1、NGAL水平的影响

目的:探讨连续性肾脏替代治疗(CRRT)联合中药灌肠对重症急性肾损伤患者尿肾损伤分子-1(KIM-1)、中性粒细胞明胶酶相关脂质运载蛋白(NGAL)水平和预后的影响。方法:回顾性分析89例重症急性肾损伤患者临床资料,依据不同治疗方式分为对照组43例和研究组46例,对照组采用CRRT治疗,研究组采用CRRT联合中药灌肠治疗。比较两组尿量恢复时间、重症医学科(ICU)住院时间、治疗前后肾功能、尿KIM-1、NGAL水平,序贯器官衰竭估计评分(SOFA)、急性生理与慢性健康评分表(APACHEⅡ)评分和预后情况。结果:研究组尿量恢复时间、ICU住院时间均少于对照组(P<0.05)。治疗前,两组肾功能、尿KIM-1、NGAL水平,SOFA、APACHEⅡ评分比较,差异无统计学意义(P>0.05); 治疗后,两组肾功能指标、尿KIM-1、NGAL水平,SOFA、APACHEⅡ评分均较治疗前下降,研究组低于对照组,差异有统计学意义(P<0.05)。研究组死亡率较对照组低(P<0.05)。结论:CRRT联合中药灌肠能够促进重症急性肾损伤患者肾功能的恢复,降低尿KIM-1、NGAL水平,改善预后。     

Analysis of early mortality and related risk factors in maintenance hemodialysis patients

Objective To analyze the early mortality and related risk factors of new hemodialysis patients in Zhejiang province, and provide basis for reducing the death risk of hemodialysis patients. Methods The early mortality and related factors of new hemodialysis patients from January 1, 2010 to June 30, 2018 were retrospectively analyzed using the database of Zhejiang province hemodialysis registration. The early mortality was defined as death within 90 days of dialysis. Cox regression model was used to analyze the related risk factors of the early mortality in hemodialysis patients. Results The mortality was the highest in the first month after dialysis (46.40/100 person year), and gradually stabilized after three months. The early mortality was 25.33/100 person year. The mortality within 120 days and 360 days were 21.40/100 person year and 11.37/100 person year, respectively. The elderly (≥65 years old, HR=1.981, 95%CI 1.319-2.977, P＜0.001), primary tumor (HR=3.308, 95%CI 1.137-5.624, P=0.028), combined with tumors (not including the primary tumor, HR=2.327, 95%CI 1.200-4.513, P=0.012), temporary catheter (the initial dialysis pathway, HR=3.632, 95%CI 1.806-7.307, P＜0.001), lower albumin (＜30 g/L, HR=2.181, 95%CI 1.459-3.260, P＜0.001), lower hemoglobin (every 0.01 g/L increase, HR=0.861, 95%CI 0.793-0.935, P=0.001), lower high density lipoprotein (＜0.7 mmol/L, HR=1.796, 95%CI 1.068-3.019, P=0.027) and higher C reactive protein (≥40 mg/L, HR=1.889, 95%CI 1.185-3.012, P=0.008) were the risk factors of early death for hemodialysis patients. Conclusions The early mortality of hemodialysis patients is high after dialysis, and gradually stable after 3 months. The elderly, primary tumor, combined with tumors, the initial dialysis pathway, lower albumin, lower hemoglobin, lower high density lipoprotein and higher C reactive protein are the risk factors of early death for hemodialysis patients.     

“清宣理肺、舒风解痉”法对60例支气管哮喘急性发作期热哮患者肺功能、ACT评分及气道炎症因子影响

目的初步评价"清宣理肺、疏风解痉"中药复方治疗支气管哮喘急性发作期热哮患者的肺功能、ACT评分及气道炎症关键指标及免疫失衡相关炎症因子的影响,探讨中药治疗支气管哮喘急性发作中气道慢性炎症的演变,阐释中药作用机制,为中医药防治支气管哮喘提供研究思路和有效方剂。方法遵循随机、平行对照临床试验设计原则,将60例支气管哮喘发作期热哮患者随机分为两组,其中,中药组30例,西药组30例。中药组予"清宣理肺、疏风解痉"中药复方,1剂/d,分2次温服,西药组根据病情严重程度属于轻度持续者(哮喘控制水平第2级):普米克气雾剂,2喷/d,早晚各1次。病情严重程度属于中度持续者(哮喘控制水平第3级):舒利迭2吸/d,早晚各1次,疗程4周。观察比较治疗前后两组患者肺功能、ACT评分及气道关键炎性指标IL-8、IL-10、Ig E、ECP、IL-17、IL-33的变化。结果肺功能:中药组FVC、FEV1、PEF治疗前后比较,差异有统计学意义(P<0.05),治疗后明显改善;FEV1/FVC治疗前后比较差异无统计学意义(P>0.05),治疗后无明显改变;西药组PEF比值治疗前后比较差异有统计学意义(P<0.05),治疗后明显改善;FVC比值、FEV1比值、FEV1/FVC治疗前后比较,差异无统计学意义(P>0.05),治疗后无明显改善。两组比较治疗后肺功能各项比值FVC比值、FEV1比值、PEF比值、FEV1/FVC无统计学差异(P>0.05)。ACT评分:西药组及中药组治疗前后,差异均有统计学意义(P<0.05),治疗后均明显改善;组间比较,差异有统计学意义(P<0.05),治疗后中药组ACT评分明显好于西药组。炎症因子:西药组IL-8、IL-10、Ig-E、ECP治疗前后治疗前后比较差异均有统计学意义(P<0.05),治疗后改善明显;IL-17、IL-33差异无统计学意义,治疗后无明显变化(P>0.05)。中药组IL-8、IL-10、Ig-E、ECP、IL-33治疗前后治疗前后比较差异均有统计学意义(P<0.05),治疗后改善明显;IL-17差异无统计学意义(P>0.05),治疗后无明显变化,组间比较无差异(P>0.05)。结论"清宣理肺、疏风解痉"中药复方治疗支气管哮喘疗效确切,可改善肺功能,改善ACT评分,降低气道炎症水平,减少Ig E结合效应细胞产生脱颗粒,减少致敏因素;降低ECP水平,减少气道损伤;提高IL-10水平,抑制中性粒细胞和嗜酸性粒细胞产生促炎因子和趋化因子来改善了气道炎症反应,抑制Ig E产生,从而减轻过敏反应,抑制炎症的发生发展。     

益气活血通络方下调TGF-β/ERK信号通路对蛛网膜下腔出血大鼠的神经保护作用

目的探讨益气活血通络方对蛛网膜下腔出血大鼠TGF-β/ERK信号通路的影响及神经保护作用。方法 SD大鼠随机分为假手术组,模型组,益气活血通络方5、10、15 g/kg组和尼莫地平组,除假手术组外,其余各组建立蛛网膜下腔出血模型大鼠,分组处理后,各组大鼠进行神经功能缺损评分;以伊文思蓝染料外渗实验检测大鼠血脑屏障通透性;以TUNEL染色检测大鼠脑皮质神经细胞凋亡情况;以酶联免疫吸附法(ELISA)检测大鼠血清肿瘤坏死因子-α(TNF-α)、白细胞介素-6(IL-6)水平;以蛋白免疫印迹法检测大鼠脑皮质组织TGF-β/ERK通路相关蛋白TGF-β1、p-ERK/ERK表达情况。结果与假手术组相比,模型组大鼠神经功能缺损评分、伊文思蓝渗出量、TUNEL阳性细胞比例、血清IL-6、TNF-α水平、TGF-β1表达、p-ERK/ERK明显升高(P0.05)。与模型组相比,益气活血通络方5、10、15 g/kg组和尼莫地平组大鼠神经功能缺损评分、伊文思蓝渗出量、TUNEL阳性细胞比例、血清IL-6、TNF-α水平、TGF-β1表达和p-ERK/ERK水平明显降低(P0.05),且益气活血通络方各组呈剂量相关性,益气活血通络方15 g/kg组与尼莫地平组相比,各指标比较差异无统计学意义。结论益气活血通络方可下调TGF-β/ERK信号,保护蛛网膜下腔出血大鼠神经功能。     

RPV‐modified epirubicin and dioscin co‐delivery liposomes suppress non‐small cell lung cancer growth by limiting nutrition supply

Chemotherapy for non‐small cell lung cancer (NSCLC) is far from satisfactory, mainly due to poor targeting of antitumor drugs and self‐adaptations of the tumors. Angiogenesis, vasculogenic mimicry (VM) channels, migration, and invasion are the main ways for tumors to obtain nutrition. Herein, RPV‐modified epirubicin and dioscin co‐delivery liposomes were successfully prepared. These liposomes showed ideal physicochemical properties, enhanced tumor targeting and accumulation in tumor sites, and inhibited VM channel formation, tumor angiogenesis, migration and invasion. The liposomes also downregulated VM‐related and angiogenesis‐related proteins in vitro. Furthermore, when tested in vivo, the targeted co‐delivery liposomes increased selective accumulation of drugs in tumor sites and showed extended stability in blood circulation. In conclusion, RPV‐modified epirubicin and dioscin co‐delivery liposomes showed strong antitumor efficacy in vivo and could thus be considered a promising strategy for NSCLC treatment.     

大体积肺癌IMRT初次及二次计划剂量学变化研究

目的 采用刚性配准和形变配准方法获得大体积非小细胞肺癌(NSCLC) IMRT中靶区和危及器官(OAR)的累加剂量,并与初次计划的剂量进行比较。方法 选择 30例采用IMRT的大体积NSCLC患者,每位患者分别在放疗前和放疗20分次时进行4DCT模拟定位,基于初次4DCT的平均密度投影CT1-avg制定放疗计划为Plan1,基于二次4DCT的平均密度投影CT2-avg修改放疗计划为Plan2,分别采用刚性配准和形变配准方法将两次计划进行剂量累加得到Plan刚性和Plan形变。比较初次定位和二次定位之间大体肿瘤体积(GTV,以吸气末时相图像CT50%上的勾画为准)和OAR (OAR,以平均密度投影图像CTavg上的勾画为准)的体积变化,以及Plan2、Plan刚性、Plan形变的剂量体积指标相比Plan1的差异。结果 二次定位和初次定位相比,GTV、心脏体积分别缩小44.2%、5.5%,患侧肺、健侧肺、全肺体积分别增大5.2%、6.2%、5.8%(P<0.05);对于内GTV (IGTV,10个4DCT时相的GTV融合而来)和计划靶体积(PTV)的D95%、D98%、V100%,Plan2与Plan1相近(P>0.05),Plan刚性、Plan形变较Plan1均略有下降(P<0.05);对于脊髓、心脏、患侧肺、双肺剂量,Plan2、Plan刚性、Plan形变较Plan1均降低(P<0.05),其中心 脏V30Gy和 Dmean分别降低27.3%、16.5%、15.3%和15.2%、6.6%、5.6%,双 肺V20Gy和 Dmean分别降低15.6%、4.5%、3.7%和15.7%、6.2%、5.1%;Plan形变的IGTV和PTV的D95%、D98%,心 脏V40Gy,患侧肺和全肺 的V20Gy、Dmean高于Plan刚性(P<0.05)。形变配准后OAR相似指数明显高于刚性配准(P<0.05)。结论 Plan2中OAR剂量体积指标相比Plan1差别很大,因此它们在预测OAR放射性损伤方面均有较大偏差,而形变配准得到的剂量体积指标可以提高预测精度。