新生儿缺氧缺血性脑病合并心肌损伤血浆N端脑利钠肽前体的变化及与预后的相关性

目的 探讨N端脑利钠肽前体(NT-proBNP)在缺氧缺血性脑病(HIE)合并心肌损伤患儿中的变化,为临床早期诊断、治疗及预后判断提供依据.方法 选择我院收住的40例HIE患儿为研究对象(心肌损伤16例,非心肌损伤24例),以20例正常新生儿为对照组,应用ELISA方法测定血浆NT-proBNP水平;超声心动图测定患儿的心脏收缩功能.结果 (1)心肌损伤患儿NT-proBNP水平[(350±56)pmol/L]显著高于非心肌损伤组[(135±37)pmol/L]和正常对照组[(117±23)pmol/L],差异有统计学意义(P＜0.05);(2)轻、中、重度HIE组NT-proBNP水平分别为(132±34)pmol/L、(247±43)pmol/L和(343±53)pmol/L,中、重度HIE组显著高于对照组;轻、中、重度HIE组间比较差异有统计学意义(P＜0.05);(3)心肌损伤组急性期血浆NT-proBNP水平[(350±56)pmol/L]明显高于恢复期[(250±78)pmoyl/L],差异有统计学意义(P＜0.05);(4)HIE患儿NT-proBNP水平和肺动脉收缩压、左室收缩功能密切相关.结论 HIE合并心肌损伤急性期血浆NT-proBNP水平升高,有助于早期诊断心肌损伤,判断HIE病情.

Abstract：

Objective To investigate the changes of N-terminal pro-brain natriuretic peptide (NT-proBNP) in neonates with hypoxic-ischemic encephalopathy (HIE) complicated by myocardial ischemic injury. Methods Forty neonates with HIE ( 16 cases with concurrent myocardial injury and 24 cases without) were enrolled. Twenty healthy neonates were used as control. Plasma NT-proBNP levels were measured using enzyme immunoassay. Cardiac function was measured by echocardiography. Results ( 1 ) The mean plasma NT-proBNP levels in patients with myocardial injury[(350 ± 56) pmol/L]were significantly higher than those in patients without myocardial injury[(135 ± 37 ) pmol/L]and in the control group [(117 ±23) pmol/L](P ＜0. 05). (2) The NT-proBNP levels in mild,moderate and severe HIE neonates were ( 132 ±34) pmol/L, (247 ±43) pmol/L and (343 ±53) pmol/L. Compared with the control group,the NT-proBNP levels in the neonates with moderate and severe HIE significantly increased. There were significant differences in the NT-proBNP levels among the mild, moderate and severe HIE neonates ( P ＜ 0. 05 ).(3) In patients with myocardial injury,the NT-proBNP levels significantly decreased in the convalescent phase [(250±78) pmol/L]compared with those in the acute phase[(350±56) pmol/L](P ＜0.05). (4) The NT-proBNP levels were significantly related with left ventricular ejection fraction. Conclusion Plasma NT-proBNP levels increase in neonates with HIE complicated with myocardial ischemic injury in the acute phase.Detection of NT-proBNP levels maybe useful in the diagnosis of myocardial ischemic injury and severe HIE.     

呼吸衰竭新生儿肾上腺皮质功能状态分析

Objective To observe the adrenal function in neonates with respiratory failure(neonatal respiratory distress syndrome,pneumonia and severe wet lung),the incidence of adrenal insufficiency,and the relationships between adrenal function and lung diseases.Methods Fifty-five cases of neonates(the preterm group of 33 cases,the term group of 22 cases)were enrolled the study.Serum cortisol values and plasma adrenocorticotropic hormone(ACTH)concentration were detected in the morning.Peak serum cortisol values were detected after 30 minutes low-dose(1 μg/1.73 m2)ACTH stimulation test.Adrenal insufficiency was defined as the peak serum cortisol values ＜ 200 μg/L.Results The mean basal serum cortisol values of the preterm group was significantly higher than that of the term group[(139.2±85.4)μg/L vs(92.1±75.0)μg/L,P=0.0407],and the mean poststimulation increase cortisol level[(122.3±56.4)μg/L vs(198.2±77.9)μg/L,P=0.000 1]and the mean ACTH level[(5.22±2.40)ng/L vs(8.66±5.41)ng/L,P =0.008 4]of the preterm group were significantly lower than that of the term group.The total incidence of adrenal insufficiency in neonates with respiratory failure was 20.0%(11/55),and the incidence of adrenal insufficiency was 21.2%(7/33)in the preterm group and 18.2%(4/22)in the term group.Neonates who had the ventilatory requirements had significantly higher incidence of adrenal insufficiency than neonates who did not have the requirements(29.4% vs 4.8%,P = 0.037).None neonate with adrenal insufficiency died.Conclusion The adrenal and the pituitary function of preterm infants are poor than term infants.The incidence of adrenal insufficiency in neonates with respiratory failure is high,especially in the neonates who have the ventilatory requirements.We do not found relationship between the mortality and adrenal insufficiency.The low-dose ACTH test could be a valuable tool in assessing the function of HPA-axis in neonates with respiratory failure.     

新生儿感染诊断指标的研究进展

随着免疫学、基因诊断学研究以及流式细胞技术的发展,新生儿感染性疾病的诊断有了许多新的进展.血清淀粉样蛋白A、干扰素-诱导蛋白-10、髓样细胞表达触发受体-1等对新生儿细菌感染的诊断有较高价值;细菌基因诊断等方面的研究可用于快速诊断新生儿脓毒症,增加基因芯片杂交方法还可明确菌种.由于每个诊断感染的指标均具有各自的临床及实验室特性,综合了解每一个感染指标的生物学特性、敏感度、特异度,连续并且联合监测几种指标可以提高诊断的敏感度和阴性预测值,是今后诊断感染性疾病的方向.     

新生儿缺氧缺血性脑病合并心肌损伤血浆N端脑利钠肽前体的变化及与预后的相关性

Objective To investigate the changes of N-terminal pro-brain natriuretic peptide (NT-proBNP) in neonates with hypoxic-ischemic encephalopathy (HIE) complicated by myocardial ischemic injury. Methods Forty neonates with HIE ( 16 cases with concurrent myocardial injury and 24 cases without) were enrolled. Twenty healthy neonates were used as control. Plasma NT-proBNP levels were measured using enzyme immunoassay. Cardiac function was measured by echocardiography. Results ( 1 ) The mean plasma NT-proBNP levels in patients with myocardial injury[(350 ± 56) pmol/L]were significantly higher than those in patients without myocardial injury[(135 ± 37 ) pmol/L]and in the control group [(117 ±23) pmol/L](P ＜0. 05). (2) The NT-proBNP levels in mild,moderate and severe HIE neonates were ( 132 ±34) pmol/L, (247 ±43) pmol/L and (343 ±53) pmol/L. Compared with the control group,the NT-proBNP levels in the neonates with moderate and severe HIE significantly increased. There were significant differences in the NT-proBNP levels among the mild, moderate and severe HIE neonates ( P ＜ 0. 05 ).(3) In patients with myocardial injury,the NT-proBNP levels significantly decreased in the convalescent phase [(250±78) pmol/L]compared with those in the acute phase[(350±56) pmol/L](P ＜0.05). (4) The NT-proBNP levels were significantly related with left ventricular ejection fraction. Conclusion Plasma NT-proBNP levels increase in neonates with HIE complicated with myocardial ischemic injury in the acute phase.Detection of NT-proBNP levels maybe useful in the diagnosis of myocardial ischemic injury and severe HIE.     

新生儿慢性肺疾病与肾上腺皮质功能

新生儿皮质醇分泌缺乏正常生理节奏,且肾上腺皮质功能与胎龄相关。肾上腺皮质功能低下与新生儿慢性肺疾病（CLD）及其预后有一定关系,并可能对新生儿死亡率有影响。其机制尚不明确,可能是由于促炎症反应和抗炎症反应机制的不平衡引起,促炎症细胞因子大量增加使HPA轴调节受到抑制。目前肾上腺皮质功能不全没有统一的诊断标准。糖皮质激素作为抗炎剂,其应用有较好疗效,但是应小剂量、短疗程,并且应注意糖皮质激素的不良反应。     

先天性心脏病新生儿的远距离转送

大部分患先天性心脏病(先心病)的新生儿需要紧急评估和治疗,目前有关患有先心病的新生儿在远距离转运中可能发生的特殊问题及有关风险方面的研究甚少,该文报道了瑞典在小儿心外科集中化后的4年间,286例先心病新生儿的远距离转运的前瞻性研究的结果。 方法 瑞典是地广人稀的欧洲大国,为了提高医疗质量,将全国的小儿心外科集中为两个中     

肾小管重塑在急性肾损伤中的作用机制

急性肾损伤(AKI)是临床常见的危重症,病死率高。AKI时主要的受损细胞是肾小管上皮细胞。肾小管上皮细胞重塑在AKI发生发展、预后转归中起着至关重要的作用。肾小管重塑过程机制复杂,其确切调控机制尚不清楚,文章就AKI肾小管重塑调控机制进行综述。     

儿童毛细血管渗漏综合征

危重症患儿的抢救治疗中,常发现患儿全身严重水肿,但同时伴有有效循环血量不足.常规补液治疗只能使血压短时间上升,但很快又出现有效循环血量不足,且全身严重水肿进行性加重,这种现象是由于发生了毛细血管渗漏综合征(capillary leak syndrome,CLS).CLS是指由于毛细血管内皮细胞损伤,血管通透性增加,引起的大量血浆小分子蛋白渗漏到组织间隙引起的一组临床综合征.CLS给临床治疗带来极大的困难,同时也是影响抢救成功的因素之一.     

呼吸衰竭早产儿肾上腺皮质功能的研究

目的 研究呼吸衰竭早产儿肾上腺皮质功能的变化,肾上腺皮质功能不全的发生率及其与病情和预后的关系.方法 研究对象为住院早产儿43例(研究组33例,对照组10例),分别检测清晨血清基础皮质醇浓度及小剂量促肾上腺皮质激素(ACTH)刺激试验后血清皮质醇峰值.结果 需机械通气的呼吸衰竭早产儿血清基础皮质醇浓度[(114.6 ±76.1)μg/L]和小剂量ACTH刺激试验后血清皮质醇峰值[(232.5±74.6)μg/L]比非机械通气早产儿[(182.1 ±86.8)、(312.1 ±93.8)μg/L]低;呼吸衰竭早产儿合并肾上腺皮质功能不全的发生率较高(21.21%);肾上腺皮质功能不全早产儿中无死亡及慢性肺疾病(CLD)病例.结论 呼吸衰竭早产儿具有较高肾上腺皮质功能不全的发生率;需机械通气的呼吸衰竭早产儿肾上腺皮质的合成分泌功能较差;未发现肾上腺皮质功能不全与病死率和CLD的发生相关     

肾损伤分子-1在急性缺血缺氧再灌注大鼠肾组织中的表达及意义

目的 观察肾损伤分子-1(kidney injury molecule-1,KIM-1)在急性缺血缺氧再灌注肾损伤(acute ischemia reperfusion kidney injury,AIKI)大鼠肾组织中的表达及分布规律,探讨其在诊断急性肾损伤(acute kidney injury,AKI)中的价值.方法 采用清洁级SD大鼠128只,随机分为对照组和模型组,模型组按国际标准建立大鼠AIKI模型,分别于2h、6h、24h、48h、72h、1周、2周、4周处死(n=8),取肾组织,常规HE染色,参照Sayhan等标准对肾小管间质损伤进行半定量评分;免疫组织化学、Western blot法检测KIM-1蛋白的表达及分布;生化法测定血清肌酐(serum creatinine,Scr)水平.结果 (1)大鼠缺血再灌注后2h即出现明显肾小管间质损伤,随着再灌注时间延长损伤加重,48h达高峰后逐渐减轻,但仍高于对照组(P<0.01);(2)Western blot和免疫组织化学检测发现,缺血再灌注后2h肾组织KIM-1的表达明显升高,KIM-1表达水平与肾小管间质损伤评分呈显著正相关(r=0.887,P=0.003);(3)大鼠缺血再灌注后2h Scr明显升高,48h达到最高值后降至正常,其升高与肾小管间质损伤评分无相关性(r=0.280,P=0.502).结论 AIKI模型中大鼠肾组织KIM-1蛋白表达水平显著增加,其表达水平与肾小管间质损伤评分呈正相关,与Scr相比,KIM-1可能为更准确地反映肾损伤情况的指标.