护理硕士研究生质量与安全能力临床评估量表的汉化及信效度检验

口咽通气导管为一种非气管导管性通气管道,其操作简便,易于掌握,不需要特殊器械能在数秒钟内迅速获得有效通气,并保持呼吸道通畅,在抢救危重、昏迷患者过程中发挥着重要的作用[1].但传统口咽通气导管使用中因不易固定,容易全部滑入患者口腔,有并发食管、气管异物,引起患者误吸、窒息甚至危及患者生命的危险[2].为此,我科对传统口咽通气导管进行改良,介绍如下.     

TGF-β1对鼠肾小球白蛋白通透性的影响

[目的]探讨转化生长因子-β1(TGF-β1)对大鼠离体肾小球白蛋白通透性的影响及可能的作用机制.[方法]正常雄性SD大鼠,用标准筛技术游离肾小球,应用电视显微术通过肾小球体积变化计算肾小球白蛋白的通透性(Palb).大鼠离体肾小球分别与不同浓度(1 ng/ml、2.5 ng/ml、5 ng/ml、10 ng/ml)TGF-β1孵育30 min;与10 ng/ml TGF-β1孵育不同时间(15 min、30 min、45 min、60 min);与5 ng/ml、10 ng/ml TGF-β1及超氧化物歧化酶(SOD)孵育60 min;在没有TGF-β1下与SOD一起孵育60 min,观察不同情况下Palb.[结果]大鼠离体肾小球与1或2.5 ng/ml TGF-β1孵育30 min对Palb无明显影响,与5或10 ng/ml TGF-β1孵育导致Palb显著增加(P＜0.01),且10 ng/ml TGF-β1对Palb影响更为显著;与10 ng/mlTGF-β1一起孵育15、30、45、60 min,Palb均较对照组明显增加(P＜0.01),且随时间延长Palb逐渐增加,孵育60 min时Palb最大;与5 ng/ml、10 ng/mlTGF-β1及SOD一起孵育60 min,Palb无明显增加;与SOD一起孵育Palb亦无明显增加.[结论]TGF-β1呈剂量时间依赖性增加鼠肾小球Palb,TGF-β1可能通过活性氧簇(ROS)介导P出增加,导致蛋白尿;而SOD可减少白蛋白排泄而有肾保护作用.     

高容量血液滤过治疗置换液配方初探

目的探讨高容量血液滤过治疗时置换液的合理配制问题。方法应用高容量血液滤过治疗复旦大学附属中山医院2002年1月～2003年12月,37例MODS患者,前瞻性观察治疗前后患者血流动力学、肝肾功能、血电解质及酸碱平衡的变化。置换液配方生理盐水2500ml、注射用水1000ml、50%葡萄糖水10ml、5%NaHCO3250ml、10%KCl12ml、10%葡萄糖酸钙40ml、25%MgSO43ml。以前稀释方式输入,采用低分子肝素抗凝。结果37例患者共治疗171例次,血液滤过治疗过程中患者心率、平均动脉压、中心静脉压等血流动力学参数稳定,血钾、钠、氯、钙、磷、镁、ALT、AST、白蛋白、球蛋白、血糖等生化指标治疗前后稳定。血pH、PCO2、HCO3-等酸碱指标治疗前后稳定,PO2、BE治疗后较治疗前显著改善。治疗后TB、CB、Cr等指标则均较治疗前显著改善。结论本院自制置换液配制简单、离子浓度准确,可安全应用于高容量血液滤过治疗。     

Evaluation of renal biopsies in type 2 diabetic patients with kidney disease: a clinicopathological study of 216 cases

Objectives

The outcome and the therapy of patients with diabetes mellitus (DM), diabetic nephropathy (DN), and non-diabetic renal disease (NDRD) are quite different, so the differential diagnosis is of considerable importance. To evaluate the usefulness of renal biopsy in type 2 diabetic patients, we examined the relationship between the clinical parameters and the histopathological findings in different age groups.

Methods

Renal biopsy specimens and clinical and laboratory data from 216 patients with type 2 DM were evaluated. According to their age, three groups were defined: 17–35 years (group I), 36–59 years (group II), and more than 60 years (group III).

Results

The study showed that, beside the duration of diabetes, other clinical parameters were not significantly different between the three groups. Chronic nephritic syndrome was the most common clinical manifestation in group I (44.1 %) and in group II (34.0 %). Among patients in group III, we found a high prevalence of chronic renal failure (34.3 %) and nephrotic syndrome (28.6 %). Consistent with the clinical manifestations, IgA nephropathy was the most common pathologic finding in group I (29.4 %) and in group II (34.7 %), whereas the most frequent abnormalities in group III were membranous nephropathy (25.7 %) and tubulointerstitial lesions (14.3 %). Overall, among these patients, 14 cases were diagnosed with DN (6.5 %), 179 with NDRD (82.9 %), while 23 had concurrent DN and NDRD (10.7 %).

Conclusions

Our results indicated that the clinical manifestations and pathologic findings in type 2 diabetic patients in different age groups have different features. This study emphasized the usefulness of renal biopsy for determining the pattern of renal damage and thus for the overall management of type 2 diabetic patients.     

山药苦瓜复方制剂降低2型糖尿病大鼠血糖和血脂的实

背景药食两用中药山药、苦瓜和甘蔗纤维等降糖和降脂作用明显,但作用机制仍不十分清楚.目的观察山药苦瓜复方制剂对2型糖尿病大鼠血糖、血脂、血胰岛素水平及抗感染能力的影响.设计随机对照动物实验.单位广东医学院科技开发中心、药理教研室、实验动物中心、中心实验室.材料选用SPF级雌性SD大鼠80只,鼠龄4个月.二甲双胍(吉林省东北亚药业股份有限公司,批号040126).总胆固醇、高密度脂蛋白胆固醇、三酰甘油试剂盒购于北京中生生物技术股份有限公司;Surestep Life scan血糖仪及试纸(美国强生公司);胰岛素放射免疫试剂盒(上海海军医学研究所);UV-3010紫外分光光度计(日本岛津);山药苦瓜复方制剂由广东医学院科技开发中心提供,批号040321,混悬液,由山药、苦瓜和甘蔗渣膳食纤维等成分经水提而成,其中生药含量1 kg/L.方法实验中的动物饲养和标本采集于2004-06/2005-12在广东医学院实验动物中心和科技开发中心实验室完成,指标的检测在广东医学院药理研究室和中心实验室完成.①随机选取20只为正常对照组,每天灌胃生理盐水5 mL/kg.其余60只大鼠灌胃脂肪乳剂5 mL/kg,1次/d,连续4周后,大鼠禁食12 h,腹腔注射2g/L链脲佐菌素30 mg/kg.正常对照组腹腔注射等体积柠檬酸缓冲液.3 d后测随机血糖,2周后重复测血糖,以血糖水平高于13.5 mmol/L或尿糖＞++以上且持续2周为造模成功(n=48).②将48只大鼠按随机摸球法分为3组模型组,二甲双胍组和山药苦瓜复方制剂组,每组16只.模型组灌胃脂肪乳剂5 mL/kg;二甲双胍组和山药苦瓜复方制剂组灌胃脂肪乳剂5 mL/kg后分别灌胃二甲双胍1 mg/kg和含生药1 kg/L的山药苦瓜复方制剂5 mL/kg.正常对照组灌胃生理盐水5 mL/kg.各组均1次/d,连续6周.③在实验结束前1天测随机血糖.禁食12 h用放射免疫法测定血浆胰岛素水平,用分光光度法测定血浆总蛋白、白蛋白水平,按相应试剂盒说明测定三酰甘油、总胆固醇、高密度脂蛋白胆固醇水平.④计量资料差异比较采用方差分析,先用Levene'stest对数据进行方差齐性检验,如方差齐用Bonferroni检验,如方差不齐则用Tamhane's T2检验.主要观察指标山药苦瓜复方制剂对2型糖尿病大鼠血糖、胰岛素、血脂和血浆蛋白水平的影响.结果造模失败脱失12只,模型组和二甲双胍组在实验过程有4,2只动物死亡,最终62只进入结果分析.①空腹血糖和血浆胰岛素测定结果正常对照组大鼠空腹血糖水平明显低于其他3组(t=2.673～4.224,＜0.05～0.01),血胰岛素水平明显高于其他3组(t=3.780～5.824,P＜0.05～0.01).模型组大鼠空腹胰岛素水平明显低于山药苦瓜复方制剂组(t=2.825,P＜0.05),空腹血糖水平明显高于二甲双胍组和山药苦瓜复方制剂组(t=3.906,3.056,P＜0.05).二甲双胍组大鼠胰岛素水平明显低于山药苦瓜复方制剂组(t=3.014,P＜0.05),但空腹血糖水平与山药苦瓜复方制剂组相近(P＞0.05).②血脂水平测定结果正常对照组大鼠血浆总胆固醇和三酰甘油水平明显低于其他3组,高密度脂蛋白胆固醇水平明显高于其他3组(t=2.521～4.892,P＜0.05～0.01).模型组大鼠血浆总胆固醇水平明显高于二甲双胍组和山药苦瓜复方制剂组(t=2.466,2.512,P＜0.05),三酰甘油水平明显高于山药苦瓜复方制剂组(t=2.612,P＜0.05),高密度脂蛋白胆固醇水平明显低于山药苦瓜复方制剂组(t=3.688,P＜0.05).二甲双胍组大鼠血浆三酰甘油水平明显高于山药苦瓜复方制剂组(t=2.620,P＜0.05).③血浆蛋白水平测定结果各组大鼠血浆总蛋白水平相近(P＞0.05);正常对照组大鼠血浆白蛋白水平明显高于模型组和二甲双胍组(t=3.773,3.104,P＜0.05),与山药苦瓜复方制剂组相近(P＞0.05),白蛋白与球蛋白比值明显高于其他3组(t=2.830～3.056,P＜0.05).模型组大鼠血浆白蛋白水平和白蛋白与球蛋白比值明显低于山药苦瓜复方制剂组(t=2.604,3.808,P＜0.05).结论山药苦瓜复方制剂可降低2型糖尿病模型大鼠血糖、血脂水平,升高胰岛素水平,提高抗感染能力.     

深低温停循环围手术期的高血糖监测及控制

目的 观察深低温停循环(DHCA)围手术期患者血糖的变化趋势,评价血糖升高的各种影响因素以及应用胰岛素控制高血糖的临床效果.方法 选择2000年1月至2010年1月长海医院胸心外科176例应用DHCA技术实施主动脉手术患者.在体外循环(CPB)前、DHCA前、DHCA后、术后进入重症监护病房(ICU)后检测血糖、动脉血气和乳酸.采用间断皮下注射或持续静脉微泵注射胰岛素的方式控制术后血糖在6～8 mmol/L,同时统计术后24 h内的胰岛素累积用量.结果 DHCA前血糖(mmol/L)较CPB前明显升高(9.62±1.79比5.04±1.40,P<0.05),DHCA后血糖(14.91±2.36)进一步升高(P<0.01),进入ICU后血糖(15.32±2.47)仍持续升高(P<0.01),且血糖升高水平与血乳酸升高水平呈明显正相关;134例患者(占76.1%)术后因间断皮下注射胰岛素控制血糖效果不佳而改用持续静脉微泵注射胰岛素,其中30例患者(占17.0%)有明显的胰岛素抵抗现象;高龄(≥50岁),合并原发性高血压、主动脉瓣中-重度病变、糖尿病或严重冠心病病史,急诊手术,CPB时间≥3 h及DHCA时间≥45 min等影响因素会明显加重DHCA围手术期高血糖,且术后24 h内胰岛素累积用量明显增加.入ICU后血糖(mmol/L)在年龄≥50岁和<50岁(18.66±2.52比12.90±2.27)、有无原发性高血压(18.98±2.55比12.31±2.34)、有无主动脉瓣中-重度病变(19.59±2.95比12.13±2.23)、有无糖尿病(20.62±1.76比11.75±1.11)、有无冠心病(19.77±2.98比12.01±2.02)、有无急诊手术(19.78±1.97比12.23±1.38)、CPB时间≥3 h和<3 h(19.86±1.89比11.70±1.15)、DHCA时间≥45 min和<45 min(19.92±1.88比11.64±1.12)等因素间差异均有统计学意义(均P<0.05);术后24 h内胰岛素累积用量(U)在年龄≥50岁和<50岁(169.5±56.6比110.2±38.5)、有无原发性高血压(171.6±64.0比104.8±34.3)、有无主动脉瓣中-重度病变(171.4±36.8比109.4±27.6)、有无糖尿病(202.5±46.7比100.4±31.5)、有无冠心病(178.5±38.6比104.6±26.4)、有无急诊手术(178.3±35.7比102.7±26.8)、CPB时间≥3 h和<3 h(168.6±37.2比107.3±27.5)、DHCA时间≥45 min和<45 min(172.5±36.1比105.4±28.7)等因素间差异均有统计学意义(均P<0.05).结论 DHCA 可引起围手术期明显的血糖和乳酸升高,甚至导致胰岛素抵抗,术后常需持续静脉应用大剂量胰岛素;DHCA 围手术期高血糖与诸多影响因素有关,在临床控制血糖的过程中应综合考虑.

Abstract：

Objective To observe the trend of change in perioperative blood glucose level in patients undergoing deep hypothermic circulatory arrest(DHCA),in order to evaluate the influencing factors of inciting hyperglycemia and the clinical effects of insulin control.Methods In the Department of Cardiothoracic Surgery of Changhai Hospital,176 patients underwent aortic operation under DHCA from January 2000 to January 2010.Blood glucose,arterial blood gas and lactate levels were determined at four time points,including pre-cardiopulmonary bypass(CPB),pre-DHCA,post-DHCA,and at admission to intensive care unit(ICU).Hyperglycemia after surgery was controlled at the level of 6-8 mmol/L by intermittent subcutaneous injection or intravenous micropump injection of insulin.At the same time,the cumulative amount of insulin within 24 hours after surgery was recorded.Results The blood glucose (mmol/L)level at pre-DHCA time point was significantly higher than that of pre-CPB(9.62±1.79 vs.5.04±1.401,P<0.05),and the blood glucose level was further elevated at the time point of post-DHCA (14.91±2.36,P<0.01)and in-ICU(15.32±2.47)compared with that of pre-CPB(P<0.01).The level of blood glucose elevation was positively correlated with blood lactate level.One hundred and thirty-four patients(76.1%)insulin was given with intravenous micropump due to poor effect of intermittent subcutaneous injection of insulin in controlling blood glucose.Among whom 30 patients(17.0%)developed the phenomenon of insulin resistance.Perioperative hyperglycemia during DHCA was associated with old age (≥50 years old),primary hypertension,serious aortic valve disease,diabetes or coronary heart disease,emergency operation,CPB time≥3 hours and DHCA time≥45 minutes.The cumulative amount of insulin within 24 hours after surgery was increased significantly.The results of blood glucose(mmol/L)in-ICU were as follows:age≥50 years old or<50 years old(18.66±2.52 vs.12.90±2.27);hypertension with and without(18.98±2.55 vs.12.31±2.34);serious aortic valve disease with and without(19.59±2.95vs.12.13±2.23); diabetes with and without(20.62±1.76 vs.11.75±1.11); coronary heart disease with and without(19.77±2.98 vs.12.01±2.02); emergency operation with and without(19.78±1.97 vs.12.23±1.38);CPB time≥3 hours or<3 hours(19.86±1.89 vs.11.70±1.15);DHCA time≥45 minutes or<45 minutes(19.92±1.88 vs.11.64±1.12),and all of them should statistical difference(all P<0.05).The cumulative amount of insulin(U)within 24 hours after surgery was as follows:age≥50 years old or<50 years old(169.5±56.6 vs.110.2±38.5);hypertension with and without(171.6±64.0 vs.104.8±34.3);aortic valve disease with and without(171.4±36.8 vs.109.4±27.6);diabetes with and without(202.5±46.7 vs.100.4±31.5);coronary heart disease with and without(178.5±38.6 vs.104.6±26.4);emergency operation with and without(178.3±35.7 vs.102.7±26.8);CPB time≥3 hours or<3 hours(168.6±37.2 vs.107.3±27.5);DHCA time≥45 minutes or<45 minutes(172.5±36.1 vs.105.4±28.7),and all of them showed significant statistical difference(all P<0.05).and all of them showed significant statistical difference(all P<0.05).Conclusion DHCA may cause significant increase in perioperative blood glucose and lactate,and even may lead to insulin resistance.Patients often require continuous intravenous administration of large doses of insulin.Perioperative hyperglycemia during DHCA is related to many factors,which should be considered in control of blood glucose.     

反相高效液相色谱法测定雌三醇栓中雌三醇含量

本文报道用反相高效液相色谱法测定雌三醇栓中雌三醇的含量。采用ＹＷＧ－Ｃ１８不锈钢分析柱（１０μｍ，２５０×４．６ｍｍ），以甲醇∶水（６０∶４０）为流动相，样品用甲醇溶解后取０．５ｍｌ置５０℃水浴中通空气流挥干，残渣溶于１００μｌ流动相，进样２０μｌ。在２８１ｎｍ处检测药物峰高，按外标法定量。本法具有操作简便、灵敏准确等特点，适合于任何含量的雌三醇制剂中雌三醇含量测定。