李东垣论治泄泻理论探讨

李东垣的升脾阳法对于泄泻的治疗具有重要价值。泄泻的基本病机是脾虚湿盛，脾虚为病机之核心，或兼肺虚，或兼湿盛，或兼寒积，脾虚则清阳不升，正所谓"清气在下，则生飧泄"。治疗以补脾健脾为本，根据不同的病机或补益脾肺，或燥湿健脾，或攻逐寒积，或健脾升阳。     

益气养精法对老年肺癌患者肿瘤标志物、生存期影响研究

目的探究益气养精法对老年肺癌患者肿瘤标志物、生存期影响。方法研究纳入60例老年肺癌患者,均由本院2016年1月-2017年1月收治,采取随机数字表法将患者分为两组,对照组患者(30例)常规化疗治疗,观察组患者(30例)在化疗基础上联合益气养精法治疗,比较两组患者治疗效果、治疗前后癌胚抗原(carcino-embryonic antigen,CEA)及血清癌抗原125(serum oncoantigen 125,CA 125)肿瘤标志物水平、不良反应情况及患者2年生存率。结果观察组患治疗有效率高于对照组,P<0.05;治疗前,两组患者CEA及CA 125水平相当,P>0.05,治疗后均改善,观察组优于对照组,P<0.05;观察组患者不良反应与对照组相当,均较低,P>0.05;观察组患者2年生存率高于对照组,P<0.05。结论益气养精法治疗老年肺癌患者效果患者,患者症状改善,不良反应少,安全可靠,且患者2年生存率较高。     

Flap raising on pulsatile perfused cadaveric tissue: A novel method for surgical teaching and exercise

Exercising flap raising procedures on cadavers is considered a prerequisite to prepare for clinical practise. To improve teaching and create conditions as realistic as possible, a perfusion device was developed providing pulsatile flow through the vessels of different donor sites. A plastic bag filled with red stained tab water was placed into a pump, which was driven by an electric motor. The bag was set under rhythmic compression with variable frequency and pressure. The pedicles of the radial forearm, anterolateral thigh, rectus abdominis, fibular and iliac crest flap were cannulated at the origin from their source arteries. Flap raising was performed under pulsatile perfusion in 15 fresh bodies and subsequently in 6 Thiel-embalmed cadavers during a flap raising course. We regularly observed staining of the skin and skin bleeding in fresh bodies and less reliable in embalmed cadavers. All flap pedicles showed pulsatile movements, and the radial pulse became palpable. Most perforators of the anterolateral thigh and osteocutaneous fibular flap could be identified by their pulse. Bleeding from bony tissue and venous return was seldom observed. We conclude that pulsatile perfusion of cadaveric tissue creates more realistic conditions for flap raising and improves teaching for beginners and advanced surgeons.     

基金平衡视角下城乡居民基本医疗保险缴费调整方案研究

目的:通过分析使城乡居民医保基金维持收支平衡的缴费率和缴费调整方案,为城乡居民医保制度可持续发展和建立科学的筹资机制提供理论和数据支撑。方法:基于社会保险精算理论构建缴费率调整模型,对预测期内维持基金收支平衡的费率进行测算和分析。结果:(1)调整缴费率是实现城乡居民医保基金在预测期内平稳运行的关键。但相较一次性费率调整方案,渐进式调整方案对基金的年度压力更小,也更易于实施;(2)在上一步基础上引入控制措施或者提高补偿水平,均将影响预测期内基金的运行情况。并且,随着"全面二孩"生育意愿的提高,这种影响也更明显。结论:维持基金平稳运行,需建立科学的筹资机制,但同时应结合控制不合理医疗费用上涨和适度提高医疗补偿水平等措施。     

被动抬腿试验预测严重感染和感染性休克患者的容量反应性

目的 观察被动抬腿试验(PLR)预测严重感染和感染性休克患者容量反应性的价值.方法 采用前瞻性观察性研究方法,选择2009年2月至2010年1月北京大学深圳医院重症监护病房(ICU)的30例严重感染和感染性休克患者.在患者平卧位、PLR期间和扩容后进行血流动力学监测,用超声心排血量监测仪无创监测每搏量(SV)、心排血量(CO)、外周血管阻力(SVR)等血流动力学指标,持续监测有创动脉血压、中心静脉压(CVP).将扩容后SV增加值(△SV)≥15%定义为有容量反应性,用受试者工作特征曲线(ROC曲线)评价PLR预测容量反应性的价值.结果 扩容后有15例患者有容量反应.PLR期间无反应组和有反应组患者CVP(cm H2O,1 cm H2O=0.098 kPa)均较平卧位时增加(13.6±6.6比12.1±6.0,11.9±5.5比10.8±5.2,均P＜0.01);有反应组PLR期间△SV明显高于无反应组[(16.6±5.5)%比(3.8±8.2)%,P=0.000];PLR期间△SV与扩容后△SV呈显著正相关(r=0.681,P=0.000);PLR预测容量反应性的ROC曲线下面积(AUC)为0.944±0.039(P=0.000),PLR期间△SV＞11%预测容量反应性的敏感性和特异性分别为86.7%和93.3%,阳性预测率和阴性预测率分别为92.9%和87.5%.结论 PLR能精确预测严重感染和感染性休克患者的容量反应性,可指导临床治疗.

Abstract：

Objective To evaluate the role of passive leg raising(PLR)test in predicting volume responsiveness in severe sepsis and septic shock patients. Methods Thirty severe sepsis and septic shock patients in intensive care unit(ICU)of Peking University Shenzhen Hospital were prospectively observed from February 2009 to January 2010. The hemodynamics including stroke volume(SV), cardiac output (CO)and systemic vascular resistance(SVR)were measured non-invasively by ultrasonic cardiac output monitor(USCOM)device in the supine position, during PLR and after volume expansion(VE), and invasive arterial blood pressure and central venous pressure(CVP)were monitored consecutively. Responders were defined by the appearance of an increase in SV(△SV)≥15% after VE. The role of PLR for predicting volume responsiveness was evaluated by receiver operating characteristic(ROC)curves. Results The CVP (cm H2O, 1 cm H2O=0. 098 kPa)during PLR was increased compared with that at supine position in both responder group(n= 15)and non-responder group(n= 15, 13. 6± 6. 6 vs. 12. 1 ± 6. 0, 11.9± 5.5 vs.10. 8±5.2, both P＜0. 01). △SV was higher in responder group than in non-responder group during PLR [(16. 6±5.5)% vs.(3. 8±8. 2)%, P=0. 000]. △SV during PLR was highly correlated to △SV after VE (r=0. 681, P=0. 000). The area under the ROC curve(AUC)for PLR predicting volume responsiveness was 0. 944±0. 039(P=0. 000). The △SV＞11% during PLR was found to predict volume responsiveness with a sensitivity of 86. 7%, specificity of 93. 3 %, positive predictive value of 92. 9 % and negative predictive value of 87.5%. Conclusion PLR can be used generally to predict volume responsiveness accurately in severe sepsis and septic shock patients, and it can be used to direct clinical practice.     

被动抬腿试验联合无创心排血量监测系统预测容量反应性的临床研究

目的 评价被动抬腿试验联合无创心排血量监测系统(USCOM)预测自主呼吸患者的容量反应性.方法 采用前瞻性、观察性队列研究设计方法,选择33例有自主呼吸且需补液的患者,先后进行被动抬腿试验和容量负荷试验,在每个试验前后分别采用经胸超声心动图(TTE)和USCOM测量每搏量(SV).根据对容量负荷试验的反应(以容量负荷试验后SVTTE增加≥15%者为有反应)将患者分为有反应组和无反应组.观察试验后SV的变化(△SV)及其相关性.结果 33例患者共行容量负荷试验36例次,有反应组24例次,无反应组12例次.两组一般资料及初始床头抬高45°时的血流动力学指标无明显差异.被动抬腿试验后,有反应组SVTTE和SVUSCOM的增加量均明显大于无反应组[△SVTTE:(21.7±13.2)%比(4.8±9.4)%,△SVUSCOM:(23.5±13.0)%比(4.6±8.9)%,均P＜0.01];△SVTTE与△SVUSCOM呈显著正相关(r=0.792,P＜0.01).容量负荷试验后,有反应组SVTTE和SVUSCOM的增加量均明显大于无反应组[△SVTTE:(27.3±14.1)%比(7.2±8.4)%,△SVUSCOM:(25.4±13.8)%比(6.7±8.6)%,均P＜0.01];△SVTTE与△SVUSCOM呈显著正相关(r=0.855,P＜0.01).用△SVTTE≥15%预测容量反应性,其敏感性为100.0%[95%可信区间(95%CI)85.0～100.0],特异性为83.3%(95%CI 68.4～98.2);而用△SVUSCOM≥15%预测容量反应性,其敏感性为83.3%(95%CI 66.1～100.0),特异性为94.4%(95%CI 83.9～100.0).被动抬腿试验后△SVTTE与△SVUSCOM的受试者工作特征曲线下面积比较差异无统计学意义(0.95±0.04比0.93±0.05,P＞0.05).结论 用USCOM测量被动抬腿试验后的△SV可反映自主呼吸患者液体治疗时的容量反应性,用以指导患者的液体治疗.

Abstract：

Objective To investigate whether passive leg raising(PLR)combined with ultrasonic cardiac output monitoring system(USCOM)could be used to predict the hemodynamic response to volume expansion(VE)in patients with spontaneous respiration. Methods The study was performed with prospective, cohort study method. Thirty-three patients with spontaneous breathing activity who were admitted to the intensive care unit(ICU)from October 2009 to April 2010 were included. Measurements of stroke volume(SV)were obtained with transthoracic echocardiography(TTE)and USCOM. Patients were considered to be responders to VE if SVTTE increased≥ 15%. Based on the responsiveness of VE, all the patients were divided into responders and non-responders. The change in SV(△SV)after the experiment and its correlation were observed. Results A total of 36 fluid load tests in 33 patients were evaluated resulting in 24 responders and 12 non-responders. There was no significant difference between two groups in the clinical data and hemodynamics parameters at incipient stage when head side of bed was raised for 45°. After PLR,the △SVTTE and △SVUSCOM in responder group were significantly higher than those in non-responder group [△SVTTE:(21.7±13.2)% vs.(4.8±9.4)%, △SVUSCOM:(23.5±13.0)% vs.(4.6±8.9)%, both P＜0. 01], with positive correlation between △SVTTE and △SVUSCOM(r = 0. 792, P＜0. 01). After VE, the △SVTTE and △SVUSCOM in responder group were significantly higher than those in non-responder group [△SVTTE:(27.3±14.1)% vs.(7.2±8.4)%, △SVUSCOM:(25.4±13.8)% vs.(6.7±8.6)%, both P＜0. 01], with positive correlation between △SVTTE and △SVUSCOM(r= 0. 855, P＜0. 01). The △SVTTE≥ 15%during PLR was predictive of response to VE with a sensitivity of 100. 0%[95% confidence interval (95%CI)85.0 - 100. 0]and a specificity of 83. 3%(95%CI 68.4 - 98. 2). The △SVUSCOM≥15% during PLR was predictive of response to VE with a sensitivity of 83.3%(95%CI 66. 1 - 100. 0)and a specificity of 94.4%(95%CI 83. 9 - 100. 0). There was no difference between the area under the receiver operating characteristic(ROC)curve for PLR-induced △SVTTE and △SVUSCOM(0. 95±0. 04 vs. 0. 93±0. 05, P＞0. 05).Conclusion PLR combined with USCOM can predict the hemodynamic response to VE in spontaneously breathing patients, and the procedure can be used to guide fluid therapy in spontaneously breathing patients.     

被动抬腿试验预测容量反应性研究进展

被动抬腿试验是预测容量反应性的一种新方法,通过监测被动抬腿试验诱导的心搏量或其替代指标的变化大小来预测机体的容量反应性,是功能性血流动力学监测指标,是可逆的自体容量负荷试验。该试验能够精确预测容量反应性,并具有操作简单、安全性高、不受自主呼吸和心律失常干扰、不受监测设备限制的优点,但其预测价值与血流动力学参数、监测时机、体位和腹压等因素有关。     

Haemodynamic effects of frusemide and its influence on repetitive rapid volume loading in acute myocardial infarction

The haemodynamic effects of intravenous frusemide (1 mg/kg)were studied in 22 male patients with left ventricular failurefollowing acute myocardial infarction. Radiographic pulmonaryoedema was present in all patients and their average left heartfilling pressure was 20 mmHg. Bolus injection of the drug wasfollowed by immediate increases in systemic arterial pressure(P < 0.05) and heart rate (<0.05); these declined to pre-injectionvalues after 60 min. Following frusemide there were progressivereductions in left heart filling pressure (P < 0.01), thermodilutioncardiac output (P < 0.01) and stroke volume (P < 0.05)and a progressive increase in the derived systemic vascularresistance (P < 0.05). There was an average diuresis of 860ml during the 90 min following the frusemide injection. Theinfluence of frusemide on left ventricular performance was studiedby comparing the circulatory effects of passive leg raisingin the control period with those at 30, 60 and 90 min afterthe drug. In the control period this manoeuvre increased leftheart filling pressure, but not heart rate, cardiac output,stroke volume or systemic vascular resistance. Ninety minutesafter frusemide, but not before, passive leg raising resultedin a significant increase in cardiac output (P < 0.01) andstroke volume at a similar increment in filling pressure anda significant reduction in the systemic vascular resistance(P <0.05). These circulatory actions of intravenous frusemideare compatible with initial arteriolar constriction and venodilatationfollowed by depletion of blood volume with subsequent changein left ventricular pumping performance.     

直腿抬高试验在腰椎间盘突出症诊断中的临床意义

目的探讨直腿抬高试验在腰椎间盘突出症诊断中的临床意义。方法回顾性分析我院收治的100例腰椎间盘突出患者的临床资料。结果直腿抬高试验及加强试验阳性患者髋,膝、踝关节的运动角度治疗后较治疗前比较,存在统计学差异（P〈0．05）。L4-5椎间盘突出患者直腿抬高试验阳性的度数比Ls～S1低,L4-5,Ls-S1患者直腿抬高试验阳性的角度存在统计学差异（P〈0．05）。结论直腿抬高试验诊断腰椎间盘突出症可以为疾病的诊断提供重要的指导依据,值得广泛推广。