弥漫性结缔组织病并发弥漫性肺泡出血32例临床分析

目的 通过分析总结弥漫性结缔组织病(CTD)合并弥漫性肺泡出血(DHA)的临床资料,提高对其的认识.方法 回顾分析北京协和医院2004年4月-2007年6月确诊的32例弥漫性CTD并发DAH的临床特点和诊疗方法.结果 弥漫性CTD合并DAH的患者中,显微镜下多血管炎(MPA)发病率为58.8%(10/17),系统性红斑狼疮(SLE)为1.5%(19/1267),韦格纳肉芽肿(WG)为3.6%(2/56),类风湿关节炎(RA)为0.2%(1/570);诊断DAH时的年龄:SLE(27.3±13.1)岁,MPA(50.1±20.7)岁;诊断DAH时的病程:SLE(16.7±18.3)个月,MPA(10.6士18.7)个月;SLE合并DAH时SLE疾病活动指数(SLEDAI)评分为(17.1 4±6.7)分,抗双链DNA抗体呈高滴度,补体c3为(41.8±25.2)ms/dl.WG、MPA、RA患者ESR、C反应蛋白均明显升高,MPA/WG患者髓过氧化物酶抗体(MPO)/丝氨酸蛋白酶抗体(PR3)呈高滴度阳性;DAH主要表现是咯血、胸闷、呼吸困难、Hb下降;X线胸片、高分辨率CT可出现异常.多肺段支气管肺泡灌洗诊断DAH阳性率为100%.20例患者(20/32,62.5%)发生肺部感染,其中真菌感染10例(10/20,50%),混合性感染10例(10/20,50%).死亡19例(19/32,59.4%),其中SLE 12例(12/19,63.2%),MPA 5例(5/10),WG 2例(2/2);直接死于呼吸衰竭12例(12/19,63.2%).结论 弥漫性CTD患者出现咯血、呼吸困难,不明原因的Hb下降,胸部x线和高分辨率CT出现弥漫性浸润影,应警惕DAH,支气管肺泡灌洗有助于确诊.DAH与弥漫性CTD原发病的活动性密切相关,容易导致呼吸衰竭和肺部感染.弥漫性CTD合并DAH病死率较高,应早期诊断,早期治疗.     

综合分析肺部感染诱发老年多器官功能不全综合征的临床特点

目的综合分析肺部感染诱发老年多器官功能不全综合征(multiple organ dysfunction syndrome in the elderly,MODSE)的临床特点。方法回顾性综合分析我院老年科64例因肺部感染诱发MODSE患者的临床特点、影像和实验室资料、APACHEⅡ评分变化等情况。结果 64例因肺部感染诱发MODSE患者均存在≥3种基础疾病,以脑血管疾病最多,占70.3%(45/64)。全部肺部感染病原体以耐药铜绿假单胞菌54.7%(35/64)、金黄色葡萄球菌28.1%(18/64)为多见。好转41例(64.1%),死亡23例(35.9%),其中2个器官功能衰竭者死亡3例(13.1%,2/23),3个器官功能衰竭者死亡18例(72.3%,18/23),≥4个以上器官功能衰竭者2例全部死亡。存活患者APACHEⅡ评分明显低于死亡患者。结论肺部感染是诱发MODSE主要诱因之一,基础疾病、受累器官越多,APACHEⅡ评分高,抗菌药物初始治疗不合理者,病死率越高。早期、合理使用抗菌药物治疗,对肺部感染诱发的MODSE具有重要临床价值。     

53例显微镜下多血管炎临床特点及预后

目的回顾性分析显微镜下多血管炎(microscopic polyangiitis,MPA)患者临床资料及对预后进行比较,提高对本病的认识。方法对2008年12月至2014年5月在北京协和医院住院治疗并门诊随诊的MPA患者进行回顾性分析。结果共纳入53例患者,其中男25例,女28例,平均发病年龄(61.7±13.6)岁,平均病程(13.5±20.6)个月。临床表现以肺脏和肾脏受累为主,100%患者存在肾脏受累,其中有32例行肾活检(60.3%),以新月体肾炎Ⅲ型多见(46.8%),无或少有免疫复合物沉积。肺脏以肺泡出血(20.8%)及肺间质病变为主。抗中性粒胞浆抗体(antineutrophil cytoplasmic antibody,ANCA)均为阳性,髓过氧化物酶-ANCA阳性者占92.4%,蛋白酶3-ANCA阳性3.7%,抗核抗体阳性41.5%,抗肾小球基底膜抗体阳性1例,抗心磷脂抗体阳性1例。其中死亡16例,占30.2%。主要的死亡原因包括为肺部感染,肺泡出血,中枢神经系统受累,以及心血管疾病。多在诊断后1~3个月内死亡(81.3%)。结论 MPA患者的受累脏器以肺肾为主,96.2%的患者P-ANCA阳性,30.2%的患者死亡,高龄、低蛋白血症、高疾病活动性为预后不良因素。     

显微镜下多血管炎中枢神经系统受累临床特征分析

目的探究显微镜下多血管炎(MPA)中枢神经系统(CNS)受累的临床特点与预后。方法回顾性分析2010年1月1日至2019年11月1日就诊于天津医科大学总医院的138例MPA患者临床资料。根据有无CNS受累分为2组, 采用Kaplan-Meier分析中枢神经系统受累对MPA生存率的影响, Logistic回归模型分析进行危险因素分析, 以P<0.05为差异有统计学意义。结果①138例MPA患者中枢神经系统受累29例(21.0%), 男性13例(44.8%), 女性16例(55.2%)。20例(69.0%)发生在诊断时, 9例(31.0%)发生在诊断后。②临床表现为运动功能障碍14例(48.3%), 感觉功能障碍10例(34.5%), 失语9例(31%), 头痛8例(27.6%), 意识障碍7例(24.1%), 吞咽困难、饮水呛咳4例(13.8%), 颅神经受累3例(10.3%)。头颅影像表现有脑梗死、脑出血、脑梗死合并脑出血、硬脑膜增厚并线样强化。5例行脑脊液检查, 1例脑脊液压力升高, 1例脑脊液白蛋白升高, 5例脑脊液LDH升高。③中枢神经系统受累患者中18例采用激素联合环磷酰...     

老年人疝术后心肺并发症死亡七例分析

我科自 1997年 2月至 1999年 12月共收治 6 5岁以上老年疝患者 2 0 2例 ,因术后心肺并发症死亡 7例 ,报道如下。　　一、临床资料　　 2 0 2例中 ,男 176例 ,女 2 6例 ,年龄 6 5～ 92岁 ,平均 71 6岁。均经手术治疗 ,择期手术 184例 ,急诊手术 18例。术前并存心血管和 (或 )肺部疾病者 4 4例 ,占 2 1 8%。 8例于术后 2周内死亡 ,病死率 4 0 %。除 1例为肝硬化腹水 ,术后上消化道出血死亡 ;其余 7例均死于心肺并发症 ,其平均年龄 74 9岁 ,见表 1。并发症诊断依据心电图、胸部Ｘ线检查等。术后 4例死于肺部感染、呼吸衰竭 ;2例死于术后急性…     

165例急性白血病死亡原因回顾

目的:分析探讨165例急性白血病(非M3)的死因。方法:回顾165例急性白血病(非M3)死亡病例,总结急性白血病主要死亡原因及死亡时的疾病状态。结果:116例急性非淋巴细胞性白血病(非M3)的主要死因为感染(45.7%)和出血(28.4%),其次为中枢神经系统(8.6%)和肺部弥漫性损害(6.9%),44.0%病例死于疾病的复发阶段,28.4%在发病早期,25.0%在未缓解期内,仅2.6%死于完全缓解阶段。49例急性淋巴细胞性白血病的主要死因为感染(34.7%)、出血(30.6%)和浸润(26.5%),最常见的感染形式为败血症,出血和浸润最易累及的部位分别为颅内和中枢神经系统,多数病例死于疾病的早期(45.0%)和复发阶段(51.0%)。结论:感染、出血和浸润是急性白血病(非M3)的三大主要死因。     

高龄老年肺部感染预后的影响因素

目的分析高龄老年肺部感染影响预后的危险因素。方法回顾性分析华东医院2004年7月至2012年2月收治的高龄(≥80岁)老年肺部感染患者的临床资料,比较死亡患者与存活患者的临床资料,并行单因素及多因素回归分析。结果 157例老年肺部感染患者,年龄80¹00〔平均(85±5.14)〕岁。死亡率20.4%(32/157)。死亡年龄组(87±4.7)岁高于存活组〔(85±4.9)岁,P<0.05)〕。死亡组中体温≥38.5℃者高于存活组(50%和17.6%),并且以意识障碍首诊者高于存活组〔28.1%和4%,P<0.05)〕。死亡组中合并胸腔积液者达50%,而存活组仅36.8%,特别是合并中至大量胸腔积液者显著高于存活组(15.3%和1.6%,P<0.05)。死亡组中意识障碍例数和肾功能减退者均高于存活组,白细胞及中性粒细胞、血肌酐和尿素氮水平、CRP升高、血总蛋白和白蛋白降低的病例数、纤维蛋白原、纤维蛋白降解产物(FDP)和D-二聚体异常,均明显高于存活组(P<0.05)。结论高龄老年肺部感染者预后不佳,入院时出现意识障碍、高热、胸腔积液、低蛋白血症、纤维蛋白原、FDP和D-二聚体异常、肾功能减退、C-反应蛋白升高均提示预后不佳,是独立危险因素。     

呼吸道瘘患者封堵器治疗前后胸部影像学及病原学情况比较

目的了解呼吸道瘘患者封堵器置入前后肺部感染变化情况。方法本研究为回顾性、观察性研究。选取2016年1月至2022年1月于广东省人民医院诊断为呼吸道瘘并行封堵器治疗的住院患者14例, 收集患者人口学资料、原发疾病、合并疾病、呼吸道瘘口部位、封堵器类型、置入前后胸部影像学情况、病原体检测结果、感染指标变化的情况, 比较呼吸道瘘患者封堵器置入前后对影像学及感染病原体的影响。结果 14例患者中气管食管瘘3例(21.4%), 支气管胸膜瘘11例(78.6%)(右侧9例, 左侧2例)。共置入封堵器14枚, 其中室间隔封堵器3例(21.4%), 动脉导管封堵器1例(7.1%), 房间隔封堵器10例(71.4%)。置入前肺部感染13例(92.86%), 气胸9例(64.29%), 胸腔积液10例(71.43%);置入后肺部感染好转率46.15%(6/13), 气胸好转率100%(9/9), 胸腔积液好转率100%(10/10)。置入前痰培养检出细菌3株、真菌1株, 支气管肺泡灌洗液检出细菌3株、真菌1株, 胸腔积液检出细菌2株、真菌2株;置入后痰培养检出细菌3株, 胸腔积液检出细菌7株, 置入封堵器前...     

脑出血并发肺部感染的临床特点及防治对策

目的研究脑出血并发肺部感染的临床特点及防治措施。方法回顾性分析2010年3月—2012年3月我院收治的脑出血并发肺部感染患者118例的临床资料,包括:脑出血部位、出血量、感染时间及感染原因。结果患者出血部位:脑叶出血66例(56.1%),脑桥出血20例(16.9%),壳核-内囊出血19例(16.1%),原发性脑室出血13例(11.1%);出血量≥32 ml者98例(85.2%);感染时间:≤2周发生肺部感染者占80.5%(95/118),2周发生肺部感染者占19.5%(23/118);≤2周感染被控制者占82.2%(97/118),2周感染被控制者占12.7%(15/118);有意识障碍者105例(88.9%),脑水肿97例(82.2%)。结论脑出血并发肺部感染由多种原因所致,及时预防,并做好相关治疗工作,可减少肺部感染发生率。     

肺部感染与老年多器官功能衰竭的研究

目的探讨肺部感染在老年多器官功能衰竭中的作用。方法回顾分析2000-01-01~2001-12-31,入住解放军总医院老年心血管病研究所和空军总医院心内科,年龄≥65岁的5组连续住院患者的临床资料:急性单纯肺部感染、以急性肺水肿为首发表现的肺部感染、慢性支气管炎(慢支)合并肺部感染、慢性心力衰竭(心衰)合并肺部感染、慢支和慢性心衰合并肺部感染。结果68例患者年龄(72·5±7·6)岁,急性单纯肺部感染3例(4%),以急性肺水肿为首发表现者12例(18%),慢支合并肺部感染16例(24%),慢性心衰合并肺部感染15例(22%),慢支和慢性心衰合并肺部感染22例(32%)。因肺部感染发展为多器官功能衰竭25例(37%),主要发生于已有慢支和(或)慢性心衰者(23例,34%)。伴发性肺部感染病死率高于非伴发性肺部感染(7·4%对0%,P<0·05)。结论慢支和(或)慢性心衰老年人伴发肺部感染易导致多器官功能衰竭。老年人肺部感染可以急性左心衰为首发表现。控制感染、缓解气道痉挛和纠正缺氧是预防老年人肺部感染多器官功能衰竭的重要措施。     

The immunoneuroendocrine role of melatonin

Abstract: A tight, physiological link between the pineal gland and the immune system is emerging from a series of experimental studies. This link might reflect the evolutionary connection between self-recognition and reproduction. Pinealectomy or other experimental methods which inhibit melatonin synthesis and secretion induce a state of immunodepression which is counteracted by melatonin. In general, melatonin seems to have an immunoenhancing effect that is particularly apparent in immunodepressive states. The negative effect of acute stress or immunosuppressive pharmacological treatments on various immune parameters are counteracted by melatonin. It seems important to note that one of the main targets of melatonin is the thymus, i.e., the central organ of the immune system. The clinical use of melatonin as an immunotherapeutic agent seems promising in primary and secondary immunodeficiencies as well as in cancer immunotherapy. The immunoenhancing action of melatonin seems to be mediated by T-helper cell-derived opioid peptides as well as by lymphokines and, perhaps, by pituitary hormones. Melatonin-induced-immuno-opioids (MHO) and lymphokines imply the presence of specific binding sites or melatonin receptors on cells of the immune system. On the other hand, lymphokines such as -γ-interferon and interleukin-2 as well as thymic hormones can modulate the synthesis of melatonin in the pineal gland. The pineal gland might thus be viewed as the crux of a sophisticated immunoneuroendocrine network which functions as an unconscious, diffuse sensory organ.     

Changes in connexin43, the gap junction protein of astrocytes, during development of the rat pineal gland

Abstract: The abundance of gap junctions between rat pineal astrocytes formed by connexin43 (Cx43) was studied during development. Levels and distribution of Cx43 were measured by immunoblotting and indirect immunofluorescence, respectively. The amount of Cx43 in cells located within the gland was low until about the 7th postnatal day and increased to adult values between the 14th and 21st days postpartum. Although astrocytes, recognized by their vimentin immunoreactivity, were scarce before birth, they were abundant by the 7th postnatal day suggesting that the low levels of Cx43 found at this age corresponded to a low expression of this protein. Localization of the immunoreactivity to Cx43 and vimentin showed a close correlation, indicating that mature or immature pineal astrocytes form gap junctions made of Cx43. Since Cx43 levels attained their adult values at about the time the innervation and the functional state of the gland reached maturity (2–3 weeks after birth), it is proposed that astrocyte gap junctions are involved in the function of the adult rat pineal gland.     

Conservative management of perforated duodenal diverticulum： A case report and review of the literature

Duodenal diverticula are a relatively common condition. They are asymptomatic, unless they become complicated, with perforation being the rarest but most severe complication. Surgical treatment is the most frequently performed approach. We report the case of a patient with a perforated duodenal diverticulum, which was diagnosed early and treated conservatively with antibiotics and percutaneous drainage of secondary retroperitoneal abscesses. We suggest this method could be an acceptable option for the management of similar cases, provided that the patient is in good general condition and without septic signs.     

Response of rat pineal melatonin to calcium, magnesium, and lithium is circadian stage dependent

Abstract: Herein we documented the response of pineal melatonin production to electrolytes known to be effective on pineal function in view of a possible circadian stage dependence. We studied the release of melatonin by perifused rat pineal glands at 2 different circadian stages corresponding to the middle of the light and dark periods, i.e., respectively, 7 and 19 HALO (Hours After Light Onset, L:D = 12:12). The initial efflux rates were, as expected, much higher in the perifusates of glands removed from rats sacrificed during the dark phase than of those removed during the light phase. After 3 hr of perifusion, melatonin release reached similar levels which were found constant up to the 8th hr of perifusion, whatever the circadian stage. Perifusion of the glands with physiological concentrations for the rat of calcium (5.2 mmol/1) and magnesium (1.34 mmol/1) resulted in a stimulatory effect on the pineal glands removed from rats sacrificed in the middle of the dark period (19 HALO), whereas no effects were observed on the pineal glands removed from rats sacrificed during the light (7 HALO). Lithium (0.28 and 0.55 mmol/1) was ineffective on melatonin release in pineal glands removed 7 and 19 HALO. Our results show differences in the initial efflux rates of melatonin and in the response of perifused pineal glands to calcium and magnesium according to the circadian stage.     

Presence of immunoreactive growth hormone and prolactin in the ovine pineal gland

Abstract: The use of antisera raised against bovine growth hormone (GH) and ovine prolactin (PRL) enabled the detection of related immunoreactive (ir) sequences of proteins in ovine pineal tissue. The isolation of PRL-like ir-material was accomplished using a 0.25 M ammonium sulphate (pH 5.5) extraction followed by ethanol precipitation, whereas the resulting 2.0 M ammonium sulphate (pH 7.0) precipitate contained a GH-like immunoreactivity. Gel chromatography of the GH-like immunoreactivity (Sephadex G-100) indicated the presence of several GH-like fragments ranging in the M_r range of 7,000 to 55,000. Analyses of the PRL-like ir-material found in pineal tissue on HPLC using a TSK 545-DEAE column led to the resolution into a single peak of immunoreactivity. A single peak of activity was also observed following chromatofocusing and hydrophobic interaction chromatography of the ir-peak from the TSK 545-DEAE column. The PRL-like ir-material inhibited the binding of [¹²⁵I]ovine PRL-S14 to anti-ovine PRL antibodies without showing an affinity for binding to anti-rat PRL or anti-bovine GH antibodies. Scatchard analysis of the binding of pineal PRL-like ir-material and pituitary ovine PRL-S14 to liver membranes from day-20 pregnant rats revealed similar affinity constants (K_a of 4.7 ± 0.2 × 10⁹ M^-1). In addition, the replication of Nb 2 Node rat lymphoma cells was stimulated by pineal PRL-like ir-material, an effect known to be specific for lactogenic hormones. The pineal PRL-like immunoreactivity appeared on sodium dodecyl sulfate polyacrylamide gels as a single major band of M_r 24,000. The functional status of PRL-and GH-like ir-material in the ovine pineal remains to be determined, but evidence is presented that the overall protein synthesis rate of the rat pineal responded to circulating concentrations of PRL.     

Microbiology of human immunodeficiency virus anorectal disease

PURPOSE: Individuals who are seropositive for the human immunodeficiency virus are at high risk for opportunistic infection and anorectal disorders. Little prospective information is available regarding anorectal pathogens in these patients. METHODS: One hundred sixty-three HIV-seropositive patients presented to the colorectal clinic between 1989 and 1992. Forty-seven (29 percent) patients were thought to have an infectious process and were prospectively studied using a standardized multiculture protocol. RESULTS: Mean age was 33 (range, 19–59) years. All were male; high-risk behavior accounted for 87 percent of HIV transmissions. Presenting complaints included anorectal pain (79 percent), pus per anum (28 percent), and blood per anum (26 percent). Examination revealed perianal tenderness (60 percent), condyloma (38 percent), perianal ulcers (38 percent), and anal fissures (34 percent). Sixty-six sets of cultures were performed; 28 patients had one set, 15 had two sets, and 4 had three sets. Thirty-two of these 47 patients (68 percent) had positive cultures including herpes (50 percent), cytomegalovirus (25 percent),Neisseria gonorrhoeae (16 percent), chlamydia (16 percent), acidfast bacilli (2 percent), and others (9 percent). Six of 32 patients with positive cultures had more than one organism cultured. Sixteen (50 percent) patients with positive cultures were treated medically, 8 (25 percent) were treated surgically and 8 (25 percent) were treated with both modalities. Sixty-one procedures were performed on 17 patients for condylomata. Eighteen patients had 20 procedures for abscesses, 50 percent of whom had positive cultures for other than common bowel flora; all improved. Fourteen patients underwent 33 procedures for perianal fistulas.Mycobacterium fortuitum was cultured from one patient who required 13 procedures for abscesses and fistulas. Forty-five (96 percent) patients were followed for an average of 12.5 months ±2.9 SEM (range, 1–94 months). Symptoms were improved or resolved in 22 of 32 (69 percent) patients with positive cultures and in 11 of 13 (84 percent) with negative cultures. CONCLUSIONS: Specific pathogens may often be identified in human immunodeficiency virus-seropositive patients with anorectal disorders if aggressively sought. Although patients without specific pathogens identified may be expected to improve with planned empiric treatment, positive identification allows more directed therapy.