机械通气并发生VAP患者PCT、IL-17和sTREM-1水平及其临床意义分析

【摘要】目的 探究机械通气并发生呼吸机相关肺炎（ventilator associated pneumonia,VAP）患者降钙素原（procalcitonin,PCT）、白细胞介素-17（Interleukin-17,IL-17）和可溶性髓系细胞触发受体1（sTREM-1,Soluble triggering receptor expressed on myeloid cells）的水平及其临床意义分析。方法 选择2015年5月至2017年3月间于我院重症监护室住院治疗的110例疑似发生VAP的机械通气患者测定血清和支气管肺泡灌洗液（bronchoalveolar lavage fluid,BALF）中的PCT、IL-17和sTREM-1的水平。应用受试者工作曲线（receiver operating characteristic curve,ROC）评价三项指标单独和联合诊断VAP的诊断效能（包括诊断准确率、灵敏度、特异度、阳性预测值和阴性预测值等）。结果 两组患者血清PCT、IL-17和sTREM-1水平间不存在统计学差异（P>0.05）;VAP组患者BALF中PCT、IL-17和sTREM-1的水平显著高于非VAP组,差异间具有统计学意义（P<0.05）。ROC曲线显示,应用BALF中PCT、IL-17、sTREM-1水平单独和联合预测VAP的AUC分别为0.887、0.759、0.788和0.959,其最佳截点分别为sTREM-1≥201.33 pg/ml、PCT≥2.06 ng/ml和IL-17≥6.38μg/ml。与PCT和IL-17相比,sTREM-1的敏感度较高而特异度较低（P<0.05）,三项指标的诊断准确率间无明显统计学差异（P>0.05）。以sTREM-1≥201.33 pg/ml和PCT≥2.06 ng/ml或IL-17≥6.38μg/ml为联合诊断指标,联合诊断的准确率、特异度和阳性预测值得到明显提高（P<0.05）。结论 机械通气并发生VAP患者BALF中的PCT、IL-17和sTREM-1水平明显升高,应用三项指标联合诊断VAP的效能较高。     

肺结核患者血清降钙素原与sTREM-1水平及其临床价值

目的探讨PCT和s TREM-1在肺结核患者血清中水平及临床意义。方法随机选取87例结核患者,另纳入健康志愿者60例。采用免疫荧光法检测血清PCT,酶联免疫吸附试验(ELISA)检测血清s TREM-1。结果肺结核组血清PCT、CRP和s TREM-1的水平均高于健康人组(PPCT0.01,PCRP=0.037,Ps TREM-10.01),重症肺结核患者血清PCT、CRP和s TREM-1的水平均高于轻症肺结核组(PPCT0.01,PCRP=0.041,Ps TREM-1=0.039);PCT对重症肺结核的诊断曲线下面积为0.738(P0.01),当PCT的诊断阈值为0.22ng/ml时,其诊断的敏感性为69%,特异性为74%,s TREM-1的诊断曲线下面积为0.715(P0.01),当s TREM-1的诊断阈值为15.82 ng/m L时,其诊断的敏感性为66%,特异性为79%;两者联合诊断的ROC曲线下面积为0.840(P0.01)。结论血清PCT和s TREM-1在肺结核患者中均有所升高,联合PCT和s TREM对肺结核的诊断具有一定的指示作用。     

TNF-α、sTREM-1、IL-6、PCT在慢性阻塞性肺疾病伴肺炎诊断中的应用

目的研究肿瘤坏死因子-α(TNF-α)、可溶性髓样细胞触发受体-1(s TREM-1)、白细胞介素-6(IL-6)、降钙素原(PCT)在慢性阻塞性肺疾病(简称慢阻肺)伴肺炎患者临床诊断中的意义。方法选择36例慢阻肺伴肺炎和30例慢阻肺不伴肺炎患者,通过ELISA法检测血清TNF-α、s TREM-1、IL-6、PCT表达水平,绘制ROC曲线分析确定四种细胞炎性因子诊断慢阻肺伴肺炎的临界值,并评价其特异性、敏感性及诊断效能。结果慢阻肺疾病进展中TNF-α、s TREM-1、IL-6、PCT存在升高,并且肺炎患者高于未伴肺炎患者,差异具有显著统计学意义(P0.01)。慢阻肺伴肺炎患者中,加重期和缓解期的TNF-α、s TREM-1、IL-6、PCT表达水平均高于对照组,差异具有统计学意义(P0.01),且加重期TNF-α、s TREM-1、PCT水平均高于缓解期,差异具有统计学意义(P0.01)。伴肺炎患者中,加重期和缓解期TNF-α、s TREM-1、IL-6、PCT表达水平均高于未伴肺炎患者中其相应的组别,差异具有统计学意义(P0.01)。TNF-α、s TREM-1诊断COPD伴肺炎的临界值依次为124.54 ng/L、118.76 ng/m L,敏感性依次为89.5%、91.4%,特异性依次为92.6%、89.3%;通过比较ROC曲线下面积大小,提示TNF-α的诊断效能和s TREM-1接近。结论血清中TNF-α、s TREM-1水平测定有助于慢阻肺伴肺炎的临床诊断。     

髓系细胞触发受体-1、降钙素原分别联合临床肺部感染评分对呼吸机相关性肺炎的诊断价值

目的探讨TREM-1、PCT分别联合CPIS在VAP中的诊断价值。方法选取2020年1月5月我院ICU收治的气管插管或气管切开接受有创机械通气治疗的住院患者156例,根据病情分为VAP组(66例)和非VAP组(90例),比较两组患者在机械通气后第1 d、3 d、7 d的血清TREM-1、PCT及CPIS间的差异。绘制ROC曲线评估血清TREM-1、PCT分别联合CPIS诊断VAP的应用价值。结果对两组患者TREM-1、PCT、CPIS进行重复测量方差分析显示:①TREM-1的时间效应、处理效应和交互效应均有统计学意义(F_时间=135.684,P<0.001;F_处理=577.117,P<0.001;F_交互=62.408,P<0.001);②PCT的时间效应、处理效应和交互效应均有统计学意义(F_时间=35.129,P<0.001;F_处理=158.284,P<0.001;F_交互=31.220,P<0.001);③CPIS的时间效应、处理效应和交互效应均有统计学意义(F_时间=14.445,P<0.001;F_处理=148.629,P<0.001;F_交互=4.968,P=0.008)。血清TREM-1、PCT和CPIS诊断VAP的AUC分别为0.977、0.907和0.922。而TREM-1+CPIS评分和PCT+CPIS评分联合诊断VAP的AUC分别为0.976和0.944,均明显高于3项指标的单独应用。结论TREM-1尤其是TREM-1+CPIS评分对机械通气患者早期诊断VAP具有优势,TREM-1+CPIS评分对评估VAP具有更高的诊断效能。     

血清降钙素原与sTREM-1水平对多重耐药肺结核患者临床预后的相关性研究

目的探讨血清降钙素原与s TREM-1水平对多重耐药肺结核患有者早期临床疗效的相关性研究。方法连续性收录自2012年4月至2014年4月于我院就诊并被确诊为耐多药肺结核的患者160例。另纳入同期来院体检的志愿者60例。采用免疫荧光法检测血清PCT,酶联免疫吸附试验(ELISA)检测血清s TREM-1。并分析两种血清指标与耐多药肺结核的临床疗效与预后的相关性。结果在治疗前,肺结核患者血清PCT和s TREM-1水平明显高于对照组(0.19±0.08 ng/ml vs 0.03±0.01 ng/ml,181.32±34.2 ng/m L vs23.5±11.6 ng/m L)(P0.05)。而有效组患者治疗前PCT和s TREM-1水平与无效组患者比较未见明显差异(P0.05),经治疗后可见有效组患者在治疗后2个月和6个月两个时间点中血清PCT和s TREM-1水平明显低于无效组患者(P0.05)。治疗后2个月时的血清PCT和s TREM-1水平具有较高的预后评价意义(AUC分别为0.82和0.86)。多因素COX分析可见白蛋白,PCT以及s TREM-1水平三者是独立的危险因素(P0.05)。结论血清PCT和s TREM-1的水平与耐多药肺结核患者病情程度以及临床预后密切相关。     

联合检测血清sTREM-1、IL-17、hs-CRP在肺炎中的诊断价值

目的研究可溶性髓系细胞触发受体(s TREM)-1、白细胞介素(IL)-17、超敏C反应蛋白(hs-CRP)在社区获得性肺炎中的诊断价值。方法 120例社区获得性肺炎患者为肺炎组、30例急性支气管炎患者为支气管炎组、30例健康志愿者为健康对照组,急性支气管炎患者、健康志愿者就诊时抽血检测血清s TREM-1、IL-17、hs-CRP的水平,肺炎组入院后第1、4、7天检测血清s TREM-1、IL-17、hs-CRP的水平。结果肺炎组与支气管炎组第1天血清s TREM-1、IL-17、hs-CRP水平均显著高于健康对照组(P0.05),肺炎组s TREM-1、IL-17、hs-CRP水平均显著高于支气管炎组(P0.05);肺炎组第4天、第7天血清s TREM-1、IL-17、hs-CRP与第1天相比较均有明显下降(P0.05);第7天血清s TREM-1、IL-17、hs-CRP分别与第4天比较有明显降低(P0.05);肺炎组入院第1天、第7天s TREM-1、hs-CRP下降幅度比IL-17显著大(P0.05);肺炎组s TREM-1、IL-17浓度与社区获得性肺炎评分(CURB)-65呈正相关(r=0.690,r=0.622,均P0.05)。而hs-CRP的水平与CURB-65评分无相关性(r=0.122,P0.05)。结论s TREM-1可望成为评价肺炎炎症程度的新生物学指标,联合检测血清s TREM-1、IL-17、hs-CRP的水平,对临床上预测肺炎患者病情严重程度有一定的参考价值。     

多沙普仑联合无创正压通气治疗慢性阻塞性肺疾病急性加重期并发呼吸衰竭的临床意义

目的:探讨多沙普仑联合无创正压通气对慢性阻塞性肺疾病急性加重期(AECOPD)并发呼吸衰竭患者外周血中Th1/Th2、TREM-1的影响。方法:选择AECOPD伴呼吸衰竭患者80例,按照随机数字表法分为对照组和观察组,每组40例。对照组采用无创正压通气治疗,观察组予多沙普仑联合无创正压通气治疗。比较2组患者治疗前及治疗24 h后血气指标,检测治疗前和治疗结束后呼吸频率、潮气量和分钟通气量、血IL-2、IL-4、Th1/Th2及TREM-1水平,观察2组患者治疗期间不良反应发生情况。结果:治疗前2组患者的血气指标、呼吸频率、潮气量和分钟通气量、血IL-2、IL-4、Th1/Th2及TREM-1水平比较,差异无统计学意义(均P 0. 05),治疗后以上指标均得到不同程度的改善(均P 0. 05),其中观察组的Pa O2显著高于对照组,Pa CO2显著低于对照组,呼吸频率和分钟通气量显著高于对照组(均P 0. 05)。观察组的有创通气率及死亡率显著低于对照组(P 0. 05)。治疗后观察组的IL-2、Th1/Th2水平显著高于对照组,IL-4、TREM-1水平显著低于对照组(P 0. 05)。2组不良反应发生情况比较,差异无统计学意义(P 0. 05)。结论:多沙普仑联合无创正压通气治疗可改善AECOPD患者的血气指标,提高通气量,并具有一定安全性。     

可溶性髓系细胞触发受体-1、降钙素原及超敏C反应蛋白在脓毒血症诊断中的价值

目的:探讨可溶性髓系细胞触发受体-1(s TREM-1)、降钙素原(PCT)及超敏C反应蛋白(hs-CRP)在脓毒血症诊断中的价值。方法:选取84例脓毒血症患者作为脓毒血症组。其中根据生存情况又分为死亡组27例,生存组57例;另选同期36例非脓毒血症患者作为对照组,运用ELISA法检测所有患者血浆s TREM-1和PCT水平,运用免疫比浊法检测所有患者血浆hs-CRP水平,运用序贯器官衰竭估计评分(SOFA)对患者进行评分,并比较组间差异。结果:脓毒血症组患者的血浆s TREM-1、PCT、hs-CRP以及SOFA评分均显著高于对照组(P0.01);脓毒血症患者各亚组间的血浆sTREM-1、PCT水平差异显著(P0.01),而组间hs-CRP水平无显著差异(P0.05);sTREM-1、PCT、SOFA评分和hs-CRP诊断脓毒血症的曲线下面积(AUC)由高到低分别为0.92、0.85、0.67、0.55,hs-CRP诊断脓毒血症价值不高;死亡组患者的血浆sTREM-1、PCT水平随时间推移,变化不大(P0.05),生存组患者第4、7天的血浆s TREM-1、PCT水平显著低于死亡组(P0.05),生存组和死亡组hs-CRP水平在各时间点无差异(P0.05);脓毒血症组的sTREM-1、PCT与SOFA评分之间呈正相关性关系(r分别为0.46、0.32,均P=0.01),而hs-CRP与SOFA无显著相关性(P0.05)。结论:血浆s TREM-1、PCT水平在脓毒血症患者的早期诊断方面具有更高的临床意义。     

IL-33和IL-17在类风湿性关节炎合并间质性肺病中的表达及临床意义

目的检测类风湿性关节炎合并间质性肺病患者IL-33和IL-17浓度水平的变化,探讨其相关的临床意义。方法收集我院风湿免疫科2016年4月至2018年2月诊治的类风湿性关节炎患者65例,其中含32例合并间质性肺病患者,另取我院体检中心正常体检者60例作为非类风湿性关节炎对照。ELISA法检测IL-33和IL-17浓度水平。结果对照组IL-33和IL-17浓度水平为8. 63±1. 72 ng/m L和11. 32±2. 06ng/m L,显著低于RA组的16. 28±3. 41ng/m L和23. 15±5. 24 ng/m L(P 0. 01)。单纯类风湿性关节炎患者和伴发间质性肺病患者在性别组成、年龄分布、疼痛关节数、肿胀关节数、DAS28评分、ESR、RF临床指标间差异无统计学意义(P 0. 05)。但伴发间质性肺病类风湿性关节炎患者IL-33和IL-17浓度水平为20. 35±4. 12 ng/m L和29. 07±6. 38ng/m L,显著高于单纯类风湿性关节炎患者的12. 33±2. 65ng/m L和17. 41±4. 15ng/m L(P 0. 01)。伴发间质性肺病类风湿性关节炎患者吡非尼酮治疗4周后IL-33和IL-17浓度水平为15. 48±3. 23ng/m L和21. 34±5. 12ng/m L,显著低于治疗前的20. 35±4. 12 ng/m L和29. 07±6. 38ng/m L(P0. 05)。伴发间质性肺病类风湿性关节炎患者治疗前磨玻璃影4例(12. 5%)、网格状影7例(21. 9%)、蜂窝状影6例(18. 8%),治疗后磨玻璃影12例(37. 5%)、网格状影4例(12. 5%)、蜂窝状影3例(9. 4%),治疗前后有显著性差异(P 0. 05)。结论类风湿性关节炎间质性肺病患者IL-33和IL-17水平升高,有可能成为病变早期诊断和疗效评价的血液学指标。     

血清白介素17、降钙素原及超敏C反应蛋白水平对冠状动脉重度狭窄患者冠状动脉侧支循环形成不良的诊断价值研究

目的分析血清白介素17(IL-17)、降钙素原(PCT)及超敏C反应蛋白(hs-CRP)水平对冠状动脉重度狭窄患者冠状动脉侧支循环形成不良的诊断价值。方法选取2017年1—6月衡水市第四人民医院心血管内二科收治的冠状动脉重度狭窄患者120例,根据冠状动脉侧支循环形成情况分为良好组67例(Rentrop分级Ⅱ～Ⅲ级)和不良组53例(Rentrop分级0～Ⅰ级)。比较两组患者临床资料及血清IL-17、PCT、hs-CRP水平,绘制ROC曲线并设计平行诊断试验以评价血清IL-17、PCT、hs-CRP水平对冠状动脉重度狭窄患者冠状动脉侧支循环形成不良的诊断价值。结果两组患者性别、年龄、体质量、高血压发生率、糖尿病发生率、吸烟率、心率、收缩压、三酰甘油及总胆固醇比较,差异无统计学意义(P0.05)。良好组患者血清IL-17、PCT、hs-CRP水平低于不良组(P0.05)。ROC曲线结果显示,血清IL-17水平诊断冠状动脉重度狭窄患者冠状动脉侧支循环形成不良的曲线下面积(AUC)为0.770[95%CI(0.681,0.859)],最佳截断值为9.11 ng/L,灵敏度为81.5%,特异度为78.7%;血清PCT水平诊断冠状动脉重度狭窄患者冠状动脉侧支循环形成不良的AUC为0.775[95%CI(0.687,0.863)],最佳截断值为0.036μg/L,灵敏度为73.7%,特异度为75.6%;血清hs-CRP水平诊断冠状动脉重度狭窄患者冠状动脉侧支循环形成不良的AUC为0.750[95%CI(0.654,0.846)],最佳截断值为2.96 mg/L,灵敏度为84.2%,特异度为73.0%。以血清IL-17、PCT、hs-CRP任一指标水平≥最佳截断值为阳性设计平行诊断试验,结果显示,三者平行试验诊断冠状动脉重度狭窄患者冠状动脉侧支循环形成不良的灵敏度为99.2%,特异度为43.4%。结论血清IL-17、PCT、hs-CRP水平对冠状动脉重度狭窄患者冠状动脉侧支循环形成不良的诊断价值中等,但三者平行试验可明显降低漏诊率。     

肿瘤病人弓形虫感染分析

在肿瘤的发生和发展进程中 ,多伴有免疫功能低下或缺陷 ,从而极易遭受各种感染。弓形虫是机会感染因子 ,当患者免疫功能受损时 ,易于感染 ,还会使隐性感染激活 ,引起低热不退、淋巴结肿和脑神经系统的反应 ,此现象尚未引起临床医师的重视。近年来 ,我们对 4 0 9例肿瘤病人进行了弓形虫感染及弓形虫病的分析观察 ,报告如下 :1　材料与方法1 1　材料　 30 4例病人血清取自江西省肿瘤医院住院或门诊病人 ,随机抽样后低温保存待检 ,10 5例取自其他医院送检样品 ,有急性症状者随到随检 ,以便及时做病原学检测。1 2　弓形虫病诊断方法1 2 1　免疫…     

A patient with rectal ulcer with severe stenosis presenting with perforated peritonitis

We report a patient with rectal ulcer with severe stenosis, who underwent urgent surgical treatment for perforated peritonitis. The 54-year-old man suddenly developed cramping abdominal pain and fever while hospitalized, with signs of peritoneal irritation. An emergency laparotomy was performed, and severe stenosis of the rectum and a perforated lesion on the oral side approximately 10 cm distant from the stenosis were found, with massive abdominal purulent fluid. He was treated by rectosigmoid colon resection with transverse colon loop colostomy. Histopathologically, the stenosis was caused by ulceration extending to all muscular layers of the rectum, with inflammatory changes. Benign rectal stenosis is so rare that differential diagnosis from malignancy may be difficult when there are inflammatory changes in the surrounding tissues. However, it is necessary to keep in mind the likelihood of this disease in differentiation from rectal cancer. Received: December 21, 1998 / Accepted: May 28, 1999     

Infection with Rhodococcus equi in a patient with sarcoidosis treated with corticosteroids

A 51-year-old female farmer was diagnosed as having sarcoidosis. During 4 years of observation, slow radiological progression was observed. Cough then developed, necessitating treatment with corticosteroids. After 28 months of continuous treatment with prednisolone in low doses (5-7.5 mg daily), she suffered fever episodes, recurrent haemoptyses, general malaise and loss of weight. A chest roentgenogram showed a left upper lobe infiltrate, which progressed and finally cavitated, and rib destruction. Despite efforts, including a thoracotomy, 22 months passed before a diagnosis could be made. Blood and sputum cultures and cultures from the destroyed rib showed growth of Rhodococcus equi, a common soil organism which can cause infections in foals and other animals. Treatment with rifampicin and erythromycin was successful. R. equi has been reported to cause infection in patients with neoplastic disease and/or immunosuppression, but the disease might be more common than is suggested by the sparse case reports in the literature, owing to lack of familiarity with the organism, which will tend to be overlooked as a contaminant.     

Evaluation of atrial vulnerability with transoesophageal stimulation in patients with atrioventricular junctional: Comparison with patients with ventricular pre-excitation and with normal subjects

The aim of our work was to evaluate the inducibility of atrialfibrillation in a group of patients with atrioventricular junctionalreentrant tachycardia and to compare it with that of patientswith a Kent-type ventricular pre-excitation (Wolff-Parkinson-Whitesyndrome) and a control group. One hundred and twenty-five subjects were separated into groups.Group 1 comprised 49 Wolff-Parkinson-White patients, with amean age of 26.4, range 10.66 years; group 2, 51 patients withatrioventricular junctional reentrant tachycardia inducibleby transoesophageal atrial stimulation andlor clinically documented,with a mean age of 43.4, range 16–78 years; group 3, 25control subjects with a mean age of2.64, range 13–76 years. Each subject underwent atrial transoesophageal stimulation withthe following protocol: programmed atrial stimulation with 1and 2 stimuli during atrial pacing of 100. min^–1 and 150.min^–1; atrial stimulation for 10 s at a rate of 200–300–400–500–600.min^–1 with intervals of 10 s between stimulations, fivesuccessive ‘ramp-up’ atrial stimulations for 9 swith the rate increasing from 100 to 800. min^–1 with intervalsof 10 s between stimulations. The end point was the completionof the protocol or induction of sustained atrial fibrillation(>1 min). The chi-square test was used for statistical analysis. Our resultsshowed that in group 1 atrial fibrillation was induced in 27149patients (55.1%); this was sustained in 13149 (26.5%) and non-sustainedin 14149 (28.5%); in group 2, atrial fibrillation was inducedin 22151 patients (43.0%); it was sustained in 7151 (13.7%)and non-sustained in 15151 (29.4%); in group 3, sustained atrialfibrillation was not induced in any subject and in only onesubject was a non-sustained atrial fibrillation (4 s) induced. The chi-square test showed that group 2 vs group 1 were non-significant,while group 2 vs group 3 and group 1 vs group 3 were significant(P<0.003 and P<0.0007, respectively). Therefore group 2 patients showed a greater atrial vulnerabilityin comparison to the control subjects and a similar vulnerabilityto group 1 patients. It is possible that the greater atrialvulnerability in the patients of group 2 was due to the doublenodal pathway.     

Treating patients with lupus with B-cell depletion

A new era in the treatment of systemic lupus erythematosus has dawned with the increasing introduction of monoclonal antibodies and other approaches, that target the key molecules involved in the pathogenesis of the disease. At present the ability to block the CD20 molecule on those B cells that carry this marker has proved the most effective way to treat patients resistant to conventional immunosuppressive drugs. However, these studies have all been open label and the results of double blind controlled studies are eagerly awaited.