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目的　研究含精氨酸、谷氨酰胺及ω -3脂肪酸等含特殊营养物质的肠内免疫营养对腹部手术后机体免疫、炎症反应及预后的影响。方法　 2 0 0 1年 1月至 2 0 0 2年 1月采用多中心、前瞻、随机、对照的临床研究。将 12 4例腹部中等以上手术病人随机分为肠内免疫营养组 (研究组 )和常规肠内营养组 (对照组 ) ,分别于术后第 2～ 8天给予等氮、等热量 [12 5 4kJ/ (kg·d) ]的营养支持。于术前 1d、术后 1d和术后 9d分别取外周血检测IgG、IgM、IgA、CD4、CD8、CD4/CD8、IL -1α、IL -2、IL -6、IL -10、TNF -α ,并在用药期间观察感染并发症的发生情况。结果　 12 0例完成研究。用药后研究组IgG、IgA、CD4、CD4/CD8显著高于对照组 ,TNF -α、IL -6显著低于对照组 ;研究前后研究组IgA、CD4、CD4/CD8差值显著高于对照组 ,TNF -α差值显著低于对照组。两组在感染并发症方面差异无显著性。结论　含精氨酸、谷氨酰胺及ω -3脂肪酸的肠内免疫营养制剂可减轻手术创伤应激后机体炎症反应 ,改善机体免疫功能     

脓毒症与免疫营养治疗

脓毒症病人常因能量需求增加及某些特殊营养素缺乏,从而导致器官功能障碍。营养支持对脓毒症病人非常重要。某些特殊营养素包括谷氨酰胺、精氨酸、ω-3脂肪酸、核苷酸、维生素及微量元素除了能够发挥营养支持的作用之外,还能够发挥免疫调节作用以改善机体防御能力并促进恢复。谷氨酰胺能够抑制促炎因子反应并维持肠道黏膜屏障及细胞防御功能。精氨酸通过一氧化氮依赖性及非依赖性途径发挥代谢性、免疫调节性及血流动力学作用。ω-3脂肪酸能够减轻炎性反应。维生素和微量元素能够发挥抗氧化作用。但是,脓毒症病人免疫营养治疗仍存在理论与实践上的差异,目前并不能常规应用于脓毒症病人的治疗。临床医生应根据脓毒症病人的具体情况及相关影响因素仔细选择营养制剂的成分,合理应用免疫营养治疗。     

早期肠内免疫营养对烫伤大鼠免疫功能的影响

目的了解早期肠内免疫营养对烫伤大鼠全身及肠道免疫功能的影响。方法将健康SD大鼠分为标准营养组（EN组）和免疫营养组（EIN组），每组32只。将两组大鼠制成烧伤总面积30％TBSA的Ⅲ度烫伤模型，于伤后1、4、7、10d检测其外周血T淋巴细胞亚群、肠黏膜增殖细胞核抗原（PCNA）表达水平、浆细胞数量及肠黏液分泌型免疫球蛋白A（S-IgA）含量的变化。另取8只健康大鼠检测上述指标作为正常参考值。结果（1）与正常值比较，伤后EN组CD3^＋、CD4^＋、CD4^＋／CD8^＋降低但CD8^＋升高，与各项指标大部分时相点比较，差异有统计学意义（P〈0．05或P〈0．01）。伤后10d与EN组（CD4^＋／CD8^＋为1．26±0．10）比较，EIN组CD3^＋、CD4^＋、CD4^＋／CD8^＋（CD4^＋／CD8^＋为1．86±0．25）升高而CD8^＋下降（P〈0．01）。（2）伤后4、7、10d，EIN组肠黏膜PCNA表达水平、浆细胞数量及肠黏液S-IgA含量较EN组明显升高（P〈0．05或P〈0．01）。结论烫伤后早期给予肠内免疫营养，可以提高全身及肠道免疫功能，效果优于标准肠内营养。     

免疫营养制剂临床应用争议与共识

随着临床营养学的不断发展,免疫营养因可以提升病人营养状态和改善免疫功能而受到越来越多的临床关注。含谷氨酰胺、精氨酸、ω-3多不饱和脂肪酸、膳食纤维等中一种或多种的免疫营养制剂可通过刺激免疫细胞,增强免疫应答功能,维持正常、适度的免疫反应,调理机体代谢,减轻有害或过度炎性反应,保护肠屏障功能完整性,减少细菌易位等作用,从而改善病人预后。免疫营养制剂的临床应用逐渐广泛,在部分病人中的临床应用价值也已得到认可,但仍存在较多争议和问题,如各种免疫营养素组合和剂量的个体化选择、免疫营养治疗的最佳时机、生态免疫营养中微生态制剂的选择等。     

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ω - 3脂肪酸属多不饱和脂肪酸 (ｐｏｌｙｕｎｓａｔｕｒａｔｅｄｆａｔｔｙａｃｉｄ ,ＰＵＦＡ) ,包括α亚麻酸 (Ｃ18:3)、二十碳五烯酸 (ｅｉｃｏｓ ａｐｅｎｔａｅｎｏｉｃａｃｉｄ ,ＥＰＡ ,Ｃ2 0 :5 )和二十二碳六烯酸 (ｄｏｃｏｓａ ｈｅｘａｅｎｏｉｃａｃｉｄ ,ＤＨＡ ,Ｃ2 2 :6 ) [1] 。海洋鱼油中含有丰富的ＥＰＡ和ＤＨＡ ,是肠内营养ω - 3脂肪酸的主要来源[1] 。ω - 3脂肪酸与ω - 6脂肪酸具有同样的代谢路径和催化酶。α亚麻酸可竞争性抑制δ - 6去饱和酶 ,减少花生四烯酸 (ａｒａｃｈｉｄｏｎｉｃａｃｉｄ ,ＡＡ ,ω6 )的合…     

术后病人添加精氨酸、RNA、ω-3脂肪酸的肠道营养:免疫、代谢及临床结局

术后在肠道营养中添加精氨酸、RNA和ω-3脂肪酸有益于免疫和代谢功能的改善     

免疫营养在急性胰腺炎中的应用

急性胰腺炎时常导致肠黏膜屏障功能受损、肠内细菌易位,免疫功能下降.以谷氨酰胺、精氨酸、-3多不饱和脂肪酸、膳食纤维为代表的免疫营养剂可以防止肠黏膜屏障功能受损及肠内细菌易位,加强机体的免疫功能,促进急性胰腺炎的恢复.本文综述国内外文献,阐述免疫营养在急性胰腺炎中的作用.     

免疫营养素在外科感染防治中的价值及评价

外科感染是外科手术最常见的术后并发症,给病人的康复和生存带来重大挑战。免疫系统在预防感染和清除病原体中起关键作用。免疫营养素,如ω-3多聚不饱和脂肪酸(ω-3 PUFA)、谷氨酰胺、精氨酸和核糖核酸等作为维持免疫功能和提高抵抗力的重要因素,在外科感染的预防和治疗中具有重要作用。随着医学营养的不断发展,免疫营养素的临床应用日益普及,其临床效果也得到认可,但尚存在较多争议。在使用免疫营养素时,应考虑不同病人的营养状况和疾病状态,以及免疫营养素的个体化选择和剂量使用。     

肠内营养添加谷氨酰胺对烧伤患者的免疫调理作用

目的 了解烧伤后早期肠内营养添加谷氨酰胺(Gln)对患者免疫调理状态的影响.方法 将24例烧伤患者随机分为2组,每组12例.标准营养(EN)组:给患者喂食标准肠内营养制剂能全力;免疫营养(EIN)组:喂食能全力+Gln.分别于伤后1、4、7、10 d清晨空腹抽血,检测血清总蛋白(TP)、白蛋白(ALB)、前白蛋白(PAB)、转铁蛋白(TF)和免疫球蛋白IgG、IgA、IgM的浓度以及T淋巴细胞亚群CD3+、CD4+、CD8+和CD4+/CD8+的比值.结果 伤后各时相点2组患者TP、ALB、TF、CD3+、IgM组间比较,差异均无统计学意义(P＞0.05).伤后4、7、10 d,EIN组患者PAB浓度分别为(90±14)、(92±16)、(106±21)mg/L,显著高于EN组(60±15)、(64±13)、(72±17)mg/L(P＜0.05).伤后7、10 d,EIN组CD4+细胞百分比为(55±5)%、(56±5)%,明显高于EN组的(45±5)%、(49±5)%(P＜0.05);CD4+/CD8+比值为1.92±0.31和2.36±0.36,明显高于EN组的1.53±0.27和1.72±0.42(P＜0.05);IgA分别为(2.8±0.6)、(3.1±0.6)g/L,IgG为(12.1±1.3)、(14.2±1.3)g/L,显著高于EN组的IgA[(2.2±0.5)、(2.5±0.5)g/L,P＜0.05]和IgG[(9.8±1.2)、(10.4±1.3)g/L,P＜0.05].结论 添加Gln的肠内营养制剂可以促进免疫球蛋白IgA、IgG的合成并增加PAB浓度,改善患者营养状况,纠正免疫功能紊乱.     

烧伤临床营养新理念:从营养支持到营养治疗

For many years,the major concerns in the treatment of a major burn injury have always been shock resuscitation,infection control,and wound treatment,while nutrition has been considered as a subordinate concern.The concept of nutrition in the treatment of a major burn has been recognized as “nutrition support”,only with the purpose of restraining negative nitrogen balance through administration of energy and protein,in order to prevent malnutrition in patients with severe burn.In recent 10 years,however,increasing evidences have showed that optimal nutritional management could improve the outcome of severe burn patients.Now it is recognized that nutrition is not only to provide exogenous nutrients to improve nutritional status of the patients,but also to regulate celI metabolism,enhance cell activity,maintain and uphold the structure and function of the gastrointestinal mucosa,thus to improve patient's outcome.Therefore,the term of “nutrition support”seems to be far from comprehensiveness to reflect the purpose and the aim of this important treatment strategy.Medical literatures especially those in nutritional guidelines have begun to use the term of “nutrition therapy” instead of “ nutrition support”,which typifies the changes in nutritional concept,aim,means,and clinical evaluation.The aim of nutrition has changed from simply “providing nutritional substrate and improving nutritional status of patients” to “ regulating cell metabolism,maintaining organ structure and function,and ultimately improving outcome of patient”.Meanwhile,nutritional means has been more consummate,including special nutrients,hormones,and growth factors,in addition to use of conventional nutrients,in order to enhance therapeutic effect of nutrition in treatment of massive burn injury.Burn nutrition is no longer confined to maintenance of positive nitrogen balance,it should also consider the regulation of cell activity,metabolic status,immune and organ function.The purpose of the article is to analyze and discuss the important issues concerning nutrition therapy in treatment of burn injury,including risk screening,optimal energy supply and ratio of different nutritional ingredients,the choice of special nutrient,as well as the determination of optimal time for giving various nutritional supplements.     

Artificial nutrition in severe acute pancreatitis: an evolving concept

We reviewed our series of consecutive cases of severe pancreatitis observed from 2002 to 2004, in order to verify how our actual therapeutic strategy improved prognosis. Seventeen patients with diagnosis of severe pancreatitis (SP) were admitted. On presumption of SP we inserted a naso-jejunal self-propelling feeding tube (SPT) in all but one patients, and an early enteral nutrition ( EEN ) was started. Severity of pancreatitis has been scored by APACHE II (> 8), IMRIE (> or = 3), and Balthazar Computed Tomography findings (> 30% necrosis). We always used a polymeric diet added with glutamine and fibres at initial rate of 20-30 ml/h until achievement of a full regimen of EEN, based on Harris-Benedict formula but no more than 30 kcal/kg/day. Only one patient has been submitted to surgical removal of infected necrosis. A patient died (5.8%) by dis-metabolic and septic state. From our experience we can state EEN is safe and useful to determine a favourable outcome on this dismal pathology, preserving the patient from infection, without significative alterations of nutritional index.     

结直肠上皮内瘤变和癌的新概念与临床应用

目的介绍WHO（2000年）对结直肠上皮内瘤变和癌的活检诊断标准,旨在避免过度或过低诊断。方法根据WHO（2000年）对结直肠上皮内瘤变和癌的活检诊断标准,对2001年1月至2005年10月间,56例手术标本诊断为癌和上皮内瘤变的病理切片及同一患者术前活检切片进行对照研究。结果56例患者中术前活检诊断原位癌、黏膜内癌、腺瘤癌变16例,根据新标准有14例应更正为高级别上皮内瘤变。结论根据WHO（2000年）对结直肠上皮内瘤变和癌的活检诊断标准,可避免过度诊断;但对活检见不到黏膜肌的病例须紧密结合临床各项检查进行综合诊断,以免造成过低诊断导致贻误治疗。     

早期肠内营养对食管癌患者术后免疫功能和临床结局的影响

目的探讨早期肠内营养（EEN）对食管癌术后患者机体免疫功能和临床结局的影响。方法选取2011年3月至2012年7月在哈尔滨医科大学附属第四医院胸外科行根治性手术治疗的食管癌患者,采用信封法随机分为术后早期肠内营养组（EEN组,30例）和术后按传统治疗方案给予全肠外营养组（TPN组,30例）,两组均行营养支持7d。两组患者分别于术前1d和术后第1、3、7天检测免疫学指标：CD3＋、CD4＋、CD8＋、CD4＋CD8＋比值;营养指标：血清白蛋白（ALB）和前清蛋白（PA）水平。并记录术后首次排气时间、术后住院时间、住院总费用及术后并发症。结果EEN组和TPN组患者术后首次排气时间[（66．5±7．3）h比（75．1±6．8）h,P=0．000],住院时间[（7．8±1．1）d比（9．3±1．3）d,P=0．000]和住院总费用[（3．62±0．38）万元比（3．97±0．40）万元,P=0．001]比较,差异均有统计学意义。两组术后并发症发生率的差异无统计学意义[13．3％（4／30）比20．0％（6／30）,P=-0．488]。术后第3和第7天EEN组患者CD3’、CD4’、CD4＋／CD8＋、ALB和PA均明显高于TPN组（均P〈0．05）：而CD8＋水平显著下降,与TPN组相比,差异亦有统计学意义（尸〈0．05）。结论早期肠内营养用于食管癌术后患者可促进胃肠道功能早期恢复,改善患者的营养状态,降低对免疫功能影响,加速患者的康复。     

The concept of anaesthetic-induced cardioprotection: clinical relevance

Experimental evidence has clearly demonstrated that volatile anaesthetic agents have direct protective properties against reversible and irreversible ischaemic myocardial damage. These properties have been related to a direct preconditioning effect but also to an effect on the extent of reperfusion injury. The implementation of these properties during clinical anaesthesia can provide an additional tool in the treatment and/or prevention of ischaemic cardiac dysfunction in the perioperative period. In clinical practice, these effects should be associated with improved cardiac function, ultimately resulting in a better outcome in patients with coronary artery disease. This potential application of anaesthetic agents has only recently been explored, and its applicability in clinical practice is the subject of ongoing research. This review summarizes the current knowledge on this subject.     

Chemonucleolysis: an evolving concept and clinical review

Chemonucleolysis has had a controversial 20 years of probation, and despite growing clinical evidence supporting the efficacy of chymopapain, the concept is still disputed. To evaluate chemonucleolysis 84 patients, treated with chymopapain over 12 months, were assessed before injection and reviewed 5-15 months after injection. All patients had lumbar disc disease which had failed to respond to conservative therapy. Chemonucleolysis was most effective in those patients with classical signs and symptoms of prolapsed lumbar disc disease of less than 3 months' duration and where sciatica was the predominant complaint. Poor results were obtained in those patients with pain for more than 6 months' duration and with predominantly low back pain. Workers' compensation patients did not respond favourably. Good short term results with chemonucleolysis can be expected by careful patient selection and adequate and accurate placement of enzyme.     

New concept for backache: biopsychosocial pain syndrome

Recently a new concept for explaining backache, “biopsychosocial pain syndrome,” has been suggested. Psychosocial factors play an important role in the development and persistence of backache from an early stage. Diagnosis and treatment of backache should be based on the new concept. A good relationship between doctors and patients influences treatment outcome and patient satisfaction. Treatment should be decided by patients themselves, after being informed of the natural history of the disease and the merit and demerit of the treatment.