一种可延长术后生存期的大鼠左肺原位移植模型制备方法*★

目的：目前袖套技术已广泛应用于肺移植的制备，但其远期效果不能肯定。实验拟改进大鼠左肺原位移植模型，重点解决动物移植术后存活时间的延长。 方法：①实验时间：实验于2007-03/07在上海市肺科医院动物实验室完成，动物实验方法符合医学伦理学要求。②实验材料及方法：取SD大鼠40只，沿用套管技术吻合肺动静脉，8/0带针锦纶丝线连续缝合支气管，建立20例同种异体大鼠左肺原位移植模型。③实验评估：术后监测动物胸部X射线及存活情况。麻醉处死动物后取出供体肺，制成4 μm厚切片并行苏木精–伊红染色，观察肺组织结构及细胞浸润情况。 结果：①共完成20例大鼠左肺原位移植手术，成功18例，失败2例，术后动物存活时间均超过3个月。②大鼠移植肺病理切片显示肺组织结构基本正常。 结论：该模型动物术后存活时间长，肺呼吸功能正常，适用于需长期存活的大鼠左肺原位移植实验研究。     

慢性阻塞性肺疾病继发肺曲霉菌感染20例护理体会

慢性阻塞性肺疾病急性加重期（AECOPD）多是由病毒、细菌、非典型病原体引起。侵袭性肺曲菌病（invasive pulmonary aspergiillosis,IPA）是一种病死率高达50％～100％的深部真菌感染疾病。近年来,COPD合并肺曲霉菌感染的报道逐年增加,严重影响患者的预后与康复。     

同种异体单肺移植7例报告

总结7例同种异体单肺移植资料的移植方案、肺保存及移植后管理监测情况。7例同种异体单肺移植患者中特发性肺纤维化3例，慢性阻塞性肺病2例，双侧矽肺、肺气肿1例，双肺结核右毁损肺1例。7例供体均为脑死亡者，供肺均采用Euro-Colins液或低钾右旋糖酐液灌注并良好保存。受体与供体血型匹配，5例患者行右侧单肺移植，2例行左侧单肺移植。肺支气管、肺动脉为端端吻合，肺静脉为心房-心房吻合。移植前后均常规应用抗生素和免疫抑制剂。肺移植后进行全面指标监测，包括心肺功能、抗生素使用及免疫抑制药物的调整。7例患者均未出现支气管、肺动静脉吻合口并发症。5例移植后2个月内死亡，1例存活近1年，另1例存活近2年。死亡者中4例死于肺感染导致多脏器功能衰竭，1例死于多曲霉菌感染致严重肺出血。6例移植后出现排斥反应，其中1例出现3次。肺移植手术适应证的选择、供肺的选择和保存、肺移植操作以及移植前后的管理已逐渐成熟，移植前心肺功能差者、移植后使用免疫抑制药物同时合并严重感染者病死率仍很高。     

慢性阻塞性肺疾病骨骼肌功能障碍

慢性阻塞性肺疾病(COPD)患者普遍存在骨骼肌功能障碍,表现为骨骼肌耐力和肌力的下降,对运动的易疲劳性。它既可以由骨骼肌萎缩引起,也可以是肌肉氧化能力下降引起的功能性改变。其具体机制目前仍有争论,但越来越多的证据表明COPD患者普遍存在的系统性炎症可能扮演着重要的作用,它通过增加肌肉蛋白降解、减少肌肉蛋白合成修复、促进肌细胞凋亡、抑制肌细胞再生影响骨骼肌容积变化;还可通过抑制过氧化物酶体增殖物激活受体,激活氧化应激等途径改变骨骼肌氧化能力。本文介绍COPD骨骼肌功能障碍的表现和系统性炎症在其中的作用。     

慢性阻塞性肺疾病与缺血性卒中

缺血性卒中和慢性阻塞性肺疾病（chronic obstructive pulmonary disease,COPD）分别位居中 国人口死亡原因的第一位和第三位,近年来两者之间的相关性越来越受到关注。本文总结了近年来 关于缺血性卒中和COPD之间关系的研究进展,就COPD与缺血性卒中的相关性进行探讨,希望能够借 此寻找更加有效的方式共同管理这两种疾病。     

小鼠气管异位移植后模拟肺移植慢性排斥反应模型的建立*☆

目的：闭塞性细支气管炎是引起肺移植后移植物功能异常的主要并发症，原位肺移植动物模型技术难度高且费时，限制了其在闭塞性细支气管炎研究中的应用。通过小鼠的气管异位移植来建立模拟肺移植慢性排斥反应模型，以期为国内的闭塞性细支气管炎研究提供一种新的模型选择。 方法：①实验材料及分组：实验于2007-07/08在上海市肺科医院动物实验室完成，动物实验方法符合动物伦理学要求。实验组采用10只C57BL/6小鼠为供体，10只BALB/c小鼠为受体；对照组10只供体、10只受体均采用BALB/c小鼠。②实验方法：取供体小鼠的气管、左右主支气管连续气道作为供体，两端结扎后异位移植到受体小鼠背部皮下。③实验评估：移植28 d后获取移植气管标本，石蜡包埋，行苏木精-伊红染色观察移植气管病理变化；比较两组小鼠的移植气管闭塞性细支气管炎发生率。 结果：20例模型动物全部存活，无感染。①模型动物手术时间（12±2）min。②苏木精-伊红染色病理切片示实验组小鼠移植气管管腔闭塞，慢性炎细胞浸润广泛，气管上皮完全脱落，纤维组织增生明显，呈现闭塞性细支气管炎表现；对照组小鼠移植气管的组织形态未见明显异常。③实验组小鼠移植气管闭塞性细支气管炎发生率高于对照组（P=0.000）。 结论：小鼠气管异位移植后模拟肺移植慢性排斥反应模型作为研究闭塞性细支气管炎的动物模型具有诸多优点。     

ICU内慢性阻塞性肺疾病患者失眠原因与干预措施

目的探讨ICU内慢性阻塞性肺疾病（COPD）患者失眠原因与干预措施。方法通过对108例ICU内COPD病人失眠原因、失眠程度问卷调查，进行统计分析。结果加强睡眠护理后，ICU内COPD病人的失眠程度减轻失眠的主要原因不再是环境和心理因素，而是疾病引起舒适的改变。结论ICU内COPD病人失眠严重，有针对性地做好睡眠护理对提高患者的生存率和生命质量非常重要。     

时间护理干预对慢性阻塞性肺疾病的效果观察

目的探讨时间护理干预对慢性阻塞性肺疾病（COPD）的治疗效果。方法收集我科2008—12—2010～12COPD患者80例,随机分为实验组和对照组各40例,进行用药时间调整和心理护理的时间调整,2组均随访检测1a。结果对80例COPD患者进行实验组、对照组的治疗护理效果对比,实验组收效率明显高于对照组。结论COPD应用时间护理干预,可有效提高治疗COPD的疗效,缓解患者的心理压力,改善患者的生活质量,值得在临床护理工作中推广应用。     

时间护理干预对慢性阻塞性肺疾病的效果观察

目的探讨时间护理干预对慢性阻塞性肺疾病(COPD)的治疗效果。方法收集我科2008-12-2010-12COPD患者80例,随机分为实验组和对照组各40例,进行用药时间调整和心理护理的时间调整,2组均随访检测1a。结果对80例COPD患者进行实验组、对照组的治疗护理效果对比,实验组收效率明显高于对照组。结论 COPD应用时间护理干预,可有效提高治疗COPD的疗效,缓解患者的心理压力,改善患者的生活质量,值得在临床护理工作中推广应用。     

无创正压通气联合纳洛酮治疗慢性阻塞性肺疾病合并肺性脑病

目的探讨无创正压通气联合纳洛酮治疗慢性阻塞性肺疾病(COPD)的临床治疗效果。方法选取2010-06—2013-01我院收治的60例慢性阻塞性肺疾病合并肺性脑病患者,根据用药的不同随机分成治疗组和对照组进行治疗,每组均30例。治疗组常规用药及BIPAP联合纳洛酮治疗,对照组常规治疗及BIPAP治疗,观察2组患者的意识恢复情况、动脉血气变化、气管插管率、治疗有效率、住院时间等指标。结果 2组治疗后意识恢复情况、动脉血气分析指标、气管插管率以及临床治疗有效率、住院时间等各项情况对比差异有统计学意义(P<0.05)。结论 BIPAP联合纳洛酮治疗COPD合并肺性脑病可较快改善患者的临床症状,提高与患者的人机同步率。     

Cognitive impairment in chronic obstructive pulmonary disease

Some analogy exists between cognitive impairment in hypoxemic patients with chronic obstructive pulmonary disease (COPD) and Alzheimer's disease (AD). We purposed to verify whether the analogy extends to the cerebral perfusion pattern. Ten normal subjects, 15 COPD patients with and 18 without hypoxemia, and 15 patients with mild AD matched for age and educational level underwent brain perfusion single photon emission computed tomography (SPECT) and neuropsychological assessment. Normal subjects and non hypoxemic COPD patients had comparable perfusion patterns. The average perfusion decreased from non hypoxemic to hypoxemic COPD and, then, to AD patients. Hypoperfusion of associative areas was the hallmark of AD, whereas the average perfusion of anterior cortical and subcortical regions did not distinguish AD and hypoxemic COPD patients. Both COPD groups scored higher than AD patients (p 相似文献   

Sleep and chronic obstructive pulmonary disease

Patients with COPD who are hypoxaemic during wakefulness become more hypoxaemic during sleep. The most severe episodes of nocturnal desaturation generally occur during REM sleep. There is a strong relationship between nocturnal O2 saturation and the level of daytime PaO2: the more pronounced daytime hypoxaemia, the more severe nocturnal hypoxaemia. The worsening of hypoxaemia is due to a variable combination of alveolar hypoventilation and ventilation-perfusion mismatching, alveolar hypoventilation being the predominant mechanism, at least during REM sleep. The consequences of sleep-related hypoxaemia include peaks of pulmonary hypertension due to hypoxic pulmonary vasoconstriction, generally observed in patients with marked daytime hypoxaemia. Cardiac arrhythmias have been described but their clinical relevance has not been established. The prevalence of obstructive sleep apnoea syndrome (OSAS) is not greater in chronic obstructive pulmonary disease (COPD) patients than in the general population, but this association (Overlap Syndrome) is not rare since COPD and OSAS are both frequent diseases. Overlap patients are at a higher risk of developing respiratory insufficiency than are pure OSAS patients. Polysomnography is only indicated in COPD patients who are suspected of having OSAS. The treatment of nocturnal hypoxaemia is conventional O2 therapy (> or = 16/24 h) in COPD patients with marked daytime hypoxaemia (PaO2 < 55-60 mmHg) and conventional O2 therapy plus nocturnal non-invasive ventilation in some patients with marked hypercapnia. At present data are not sufficient for justifying the use of isolated nocturnal oxygen therapy in COPD patients with nocturnal desaturation but with mild daytime hypoxaemia (PaO2 > 60 mmHg).     

Hypnotic use for insomnia management in chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is one of the leading causes of mortality and morbidity worldwide. Because of the chronic nature of the disease, optimal care for patients includes successful treatment of comorbidities that accompany COPD, including insomnia. Insomnia symptoms and associated disruption of sleep are prevalent in COPD patients but treatment with traditional benzodiazepines may compromise respiratory function. This review summarizes the efficacy and safety consideration of current drugs available for the treatment of insomnia in COPD patients including benzodiazepines, non-benzodiazepine receptor agonists such as eszopiclone, zolpidem, and zaleplon, sedating antidepressants such as trazodone, and the melatonin receptor agonist ramelteon.     

Mortality prediction in chronic obstructive pulmonary disease and obstructive sleep apnea

BackgroundWe aimed to assess mortality in chronic obstructive pulmonary disease (COPD), obstructive sleep apnea (OSA), and overlap syndrome, and evaluate which polysomnographic indices—apnea-hypopnea index (AHI) or hypoxemic load measurements—better predict mortality within 10 years.MethodsAdults with symptoms suggestive of sleep apnea and airway disease who underwent both polysomnography and spirometry plus bronchodilator response tests between 2000 and 2018 were included and divided into four groups according to presence of COPD and moderate-to-severe OSA (AHI ≥15/h). We estimated mortality using a Cox model adjusted for demographic/anthropometric covariates and comorbidities; this was called clinical model. To evaluate prognostic performance, we compared the concordance index (C-index) between clinical model and extended models, which incorporated one of polysomnographic indices—AHI, sleep time spent with SpO₂ < 90% (TS90), and mean and lowest SpO₂.ResultsAmong 355 participants, patients with COPD alone (57/355, 16.1%) and COPD–OSA overlap syndrome (37/355, 10.4%) had increased all-cause mortality than those who had neither disease (152/355, 42.8%) (adjusted HR, 2.98 and 3.19, respectively). The C-indices of extended models with TS90 (%) and mean SpO₂ were significantly higher than that of clinical model (0.765 vs. 0.737 and 0.756 vs. 0.737, respectively; all P < 0.05); however, the C-index of extended model with AHI was not (0.739 vs. 0.737; P = 0.15).ConclusionsIn this cohort with symptoms of sleep apnea and airway disease, patients with overlap syndrome had increased mortality, but not higher than in those with COPD alone. The measurement of hypoxemic load, not AHI, better predicted mortality.     

同种异体肌腱移植重建跖腱膜32例

文章对承德医学院附属医院足底跖腱膜缺损的32例患者进行回顾性病例分析,所有患者应用同种异体肌腱重建跖腱膜,以期最大限度地恢复足的外观,保留足的功能。手术分2期进行：一期完成足底创面的覆盖和修复,根据患者足底损伤的情况,20例患者应用小腿内侧皮瓣修复足底创面,其余12例患者的撕脱皮瓣进行了原位缝合,在创面完全愈合后1个月,进行2期手术。2期手术根据跖腱膜的损伤情况,26例跖腱膜完全缺失的患者应用3条同种异体肌腱进行修复,其余6例跖腱膜部分缺损的患者应用2条同种异体肌腱进行了重建,修复的同时均应用钢丝进行了辅助固定。术后6周,患者扶拐下地行功能锻炼,术后6个月抽出钢丝。32例患者未出现排斥反应,创面均1期愈合。26例术后6个月复查,患者已部分负重行走,X射线平片示足弓形状维持良好;1年后复查,患者已完全负重行走,X射线平片示足弓形状维持良好;2年后复查,患足功能良好,外形满意,X射线平片示足弓形状维持良好。可见,应用同种异体肌腱重建跖腱膜,不损坏正常的组织结构,不涉及到肌腱粘连的问题,可以维持足的基本形态结构,保留足的功能,是一种可行术式。     

Actigraphy scoring for sleep outcome measures in chronic obstructive pulmonary disease

BackgroundActigraphy is commonly used to measure sleep outcomes so that sleep can be measured conveniently at home over multiple nights. Actigraphy has been validated in people with sleep disturbances; however, the validity of scoring settings in people with chronic medical illnesses such as chronic obstructive pulmonary disease remains unclear. The purpose of this secondary analysis was to compare actigraphy-customized scoring settings with polysomnography (PSG) for the measurement of sleep outcomes in people with chronic obstructive pulmonary disease who have insomnia.MethodsParticipants underwent overnight sleep assessment simultaneously by PSG and actigraphy at the University of Illinois of Chicago Sleep Science Center. Fifty participants (35 men and 15 women) with mild-to-severe chronic obstructive pulmonary disease and co-existing insomnia were included in the analysis. Sleep onset latency, total sleep time (TST), wake after sleep onset (WASO), and sleep efficiency (SE) were calculated independently from data derived from PSG and actigraphy. Actigraphy sleep outcome scores obtained at the default setting and several customized actigraphy settings were compared to the scored PSG results.ResultsAlthough no single setting was optimal for all sleep outcomes, the combination of 10 consecutive immobile minutes for sleep onset or end and an activity threshold of 10 worked well. Actigraphy overestimated TST and SE and underestimated WASO, but there was no difference in variance between PSG and actigraphy in TST and SE when the 10 × 10 combination was used. As the average TST and SE increased, the agreement between PSG and actigraphy appeared to increase, and as the average WASO decreased, the agreement between PSG and actigraphy appeared to increase.ConclusionResults support the conclusion that the default actigraphy settings may not be optimal for people with chronic obstructive pulmonary disease and co-existing insomnia.     

Screening of cognitive impairment in chronic obstructive pulmonary disease

Cognitive dysfunction is common and clinically important in severe chronic obstructive pulmonary disease (COPD). We investigated the diagnostic accuracy of the Mini Mental State Examination (MMSE) and Instrumental Activities of Daily Living (IADL) scale in screening severe cognitive dysfunction in 149 patients with COPD, mean age 69.3+/-8.5 years, forced expiratory volume in 1 s=36.6+/-17.8% of the predicted. Patients underwent the MMSE and an in-depth neuropsychological assessment based upon the Mental Deterioration Battery (MDB). The 5-item IADL scale was assessed. The sample was randomly divided into a training (n=73) and a testing (n=76) population. The diagnostic accuracy of MMSE, IADL scale or both versus cognitive dysfunction corresponding to abnormal performance in 3 or more MDB tests was assessed in the training population and the model obtained was tested in the testing population. The combination of MMSE<24 and dependence in at least 1 IADL had better diagnostic accuracy than either MMSE or IADL, with sensitivity=52.4, specificity=82.7, positive predictive value=55.0% and negative predictive value=81.1% in the testing population. MMSE and the 5-item IADL scale can be used to exclude, but not to detect cognitive dysfunction in COPD patients. A confirmatory cognitive test should be administered to patients with an MMSE score of <24 and who are dependent in at least 1 IADL.     

Behavioral and characterological self-blame in chronic obstructive pulmonary disease

ObjectiveTo assess behavioral and characterological self-blame, identify demographic and relational correlates of self-blame, and determine the association of self-blame with psychological and clinical outcomes of chronic obstructive pulmonary disease (COPD).MethodsData were collected via self-report questionnaires completed by 398 individuals with COPD who had at least a 10 pack-year history of smoking. Behavioral and characterological self-blame were measured, and multiple regression was used to identify correlates of both types of self-blame. Multiple regression was also used to determine the association of self-blame with outcomes of COPD.ResultsMore than one-third of participants endorsed the maximum possible score on the measure of behavioral self-blame. The perception that family members blamed the individual for having COPD (p = .001), tobacco exposure (p = .005), and general family functioning (p = .002) were associated with behavioral self-blame. Current smoking status (p = .001) and perception of blame from family (p < .001) were associated with characterological self-blame. While behavioral self-blame was associated with fewer symptoms of depression (p = .02), characterological self-blame was associated with more symptoms of depression (p = .02).ConclusionsIndividuals with COPD tend to blame themselves for smoking and other behaviors that may have led to their COPD. Smoking-related variables and the perception that family members blamed the individual for having COPD were associated with self-blame. Findings support the importance of distinguishing between behavioral and characterological self-blame in COPD, as behavioral self-blame had a negative association with depression and characterological self-blame had a positive association with depression.     

Tissue wasting in patients with chronic obstructive pulmonary disease

Malnutrition is common among individuals suffering from hypoxemic chronic obstructive pulmonary disease (COPD), advanced HIV disease, and in patients with chronic, severe congestive heart failure. Although increased morbidity and mortality has been associated with weight loss in these conditions, the pathophysiology of malnutrition remains somewhat unclear for each. In COPD, the primary postulated mechanism is hypermetabolism resulting in elevated total caloric expenditure arising from increased airway resistance, increased O2 cost of ventilation, increased dietary induced thermogenesis, inefficient substrate use and perhaps, increased levels of proinflammatory cytokines. In AIDS, postulated mechanisms include hypermetabolism arising from increased activation of proinflammatory cytokines, along with futile cycling of fatty acids and de novo lipogenesis early in the course of HIV infection; intestinal malabsorption and anorexia also play a role in many inflicted individuals. In cardiac cachexia, dietary and metabolic factors, and levels and activity of cytokines, thyroid hormone, catecholamines and cortisol have been suggested as being responsible for causing weight loss in a most cases.