肠屏障功能损伤机制及其临床检测方法研究现状

肠道作为机体的消化器官,除了具有消化吸收和蠕动功能外,还具有内分泌、免疫调节和黏膜屏障功能。生理状态下的肠屏障功能可消化和吸收营养物质、有效防止机体内环境受到有害物质的侵害,保障机体内环境稳定,由机械屏障、免疫屏障、化学屏障和生物屏障共同组成。肠屏障功能损伤机制复杂,临床上多种因素可直接或间接破坏肠屏障功能,这些因素包括严重感染、创伤、烧伤、肠梗阻、急性胰腺炎、重度营养不良、重度失血、失液、长期应用广谱抗生素或免疫抑制剂、电离辐射、放疗、化疗等。这些因素可从一个或多个方面造成肠屏障功能损伤,导致肠内病原微生物及其代谢物经门静脉和淋巴系统纵向易位入血,引发菌血症和毒血症,严重时可导致全身炎症反应综合征和多系统器官功能衰竭。目前检测多采用血液中D-乳酸的水平、二胺氧化酶、内毒素等来评估肠屏障功能。临床工作中应予重视肠屏障功能障碍的治疗。本文对肠道屏障及其损伤发生的机制,诊断和治疗方法进行综述。     

谷氨酰胺对结肠癌患者术后肠黏膜屏障功能的影响

目的 探讨静脉补充谷氨酰胺对结肠癌患者术后肠黏膜屏障功能的影响。方法 选取 2016 年 5 月至 2017 年 8 月在山西医科大学第一医院进行结肠癌手术治疗的 98 例患者,根据患者住院号尾数奇数与偶数差别,将其分成观察组 （Ala-Gln）46 例（添加丙氨酰谷氨酰胺注射液）和对照组 52 例（空白对照）,通过观察两组患者血清中二胺氧化酶、 D- 乳酸（D-lactate）、内毒素（endotoxin）变化,探究两组患者术后肠黏膜屏障功能的变化情况。结果 手术前及术后第 1 天两组患者的血清中 D- 乳酸、二胺氧化酶和内毒素水平无统计学意义（P ＞ 0.05）,术后第 3 天、第 5 天、第 7 天观察 组的血清中 D- 乳酸、二胺氧化酶和内毒素水平均显著低于对照组（P ＜ 0.05）,术后第 3、5、7 天的 D- 乳酸、二胺氧化 酶和内毒素水平与术后第 1 天的差值均具有统计学意义,且观察组的差值显著高于对照组的差值（P ＜ 0.05）。结论 手术 能够引起结肠癌患者肠黏膜屏障功能进一步的损伤,术后静脉补充谷氨酰胺能显著改善肠黏膜屏障功能,对结肠癌患者术 后肠黏膜屏障功能恢复是有益的。     

放疗对肠屏障功能的影响及研究进展

放疗是腹盆部恶性肿瘤常用的治疗方法,放疗除了能杀伤肿瘤细胞外,也会严重损伤照射区域内对射线敏感的正常组织。放疗对肠黏膜的损伤可导致肠屏障功能障碍,引起肠道细菌或内毒素易位,成为全身炎症反应和多器官功能障碍的始动因素,对疾病的发生、发展和转归有重要影响。本文就放疗对肠屏障功能的影响及其诊治进展作一综述。     

硬膜外阻滞联合全身麻醉对老年胃癌根治术患者血气分析指标、肠屏障功能及认知功能的影响

目的 探讨硬膜外阻滞联合全身麻醉对老年胃癌根治术患者血气分析指标、肠屏障功能及认知功能的影响.方法 根据麻醉方式将80例胃癌患者分为对照组(n=38)和观察组(n=42),对照组患者给予全身麻醉,观察组患者给予硬膜外麻醉联合全身麻醉.比较两组患者的术后疼痛程度[视觉模拟评分法(VAS)]、血气分析指标[动脉血二氧化碳分压(PaCO2)及pH值]、肠屏障功能指标[乳酸(D-LA)、二胺氧化酶(DAO)]、认知功能障碍(POCD)发生情况、简易智能精神状态检查量表(MMSE)评分、术中情况和并发症发生情况.结果 观察组患者的VAS评分和吗啡用量均低于对照组(P﹤0.05).气腹后,观察组患者PaCO2、pH值与气腹前比较,差异均无统计学意义(P﹥0.05);但对照组患者PaCO2明显高于本组气腹前和观察组(P﹤0.01),pH值明显低于本组气腹前和观察组(P﹤0.01).术后24、72 h,两组患者D-LA、DAO水平均低于本组术前(P﹤0.05),且观察组患者D-LA、DAO水平均低于对照组(P﹤0.05).术后24、72 h,观察组患者POCD总发生率为23.81%,低于对照组患者的50.00%(P﹤0.05),MMSE评分均明显高于对照组(P﹤0.01).观察组患者并发症总发生率为4.76%,低于对照组患者的23.68%(P﹤0.05).结论 硬膜外阻滞联合全身麻醉能明显降低胃癌根治术患者的疼痛程度,改善患者术后血气分析指标与肠屏障功能,降低术后POCD及并发症发生率.     

肿瘤患者围术期免疫功能的影响因素

手术、低温、输血、疼痛、焦虑、麻醉药物和麻醉方式的选择等都可以影响患者的免疫功能。特别对于肿瘤患者而言,围术期免疫功能的抑制,可以使残存的肿瘤细胞转移和复发,影响远期预后,降低生活质量。因此,临床医生必须从多个方面来评估并改善围术期肿瘤患者免疫功能抑制的状态。     

肿瘤患者肠道菌群特征及益生菌改善其营养不良的应用前景

肿瘤营养不良会增加患者术后并发症、降低生活质量、增加死亡率,根据肿瘤产生部位不同其发生率在40%～80%,改善肿瘤患者营养不良至关重要。肿瘤营养不良与肿瘤自身高代谢、肿瘤相关厌食症以及肿瘤治疗产生的不良反应密切相关。目前肿瘤专用肠内营养制剂并没有完全消除患者的营养不良风险。人体肠道菌群可通过多种机制维持人体健康,健康的肠道微生物多样性高、结构复杂稳定、具有抵抗外部环境压力的能力,在有限的外部干扰时仍能保持菌群结构稳定;而非健康人体则表现为菌群多样性降低,丧失对外部环境压力的抵抗力,发生肠道微生态紊乱等不良状况,如肿瘤患者在疾病进程中往往会伴随肠道菌群总数下降、多样性降低、有益菌比例减少等现象发生,严重影响了机体免疫能力和患者的食欲。益生菌作为一种重要的微生态制剂对人的健康产生有益影响,可预测其调节肿瘤患者肠道菌群结构及组成,细胞因子、胃肠肽等介质分泌改善食物摄入和小肠营养吸收对肿瘤患者发生的营养不良将会产生积极影响。本文就营养不良肿瘤患者的肠道菌群特征及益生菌的潜在作用进行系统论述,并提出应用前景。     

针刺保护胃肠道肿瘤术后TPN过程肠粘膜屏障损害的临床研究

目的　研究耳 体穴针刺防治胃肠道肿瘤术后TPN引起的肠粘膜屏障功能损害及促进肝细胞代谢的意义。方法　胃肠道肿瘤术后行TPN支持的病人 (n =40 ) ,实验组 (n =2 0 )配合耳 体穴针刺 ,两组同时观察胃肠道功能恢复时间、肝功能各项指标、术前及术后第 7天作乳果糖排泄率 /甘露醇排泄率 (L/M)实验。结果　术前后组内与组间比较 ,AST、ALT、TBIL、AKP均无增高 ,血浆白蛋白术后第三天较术前有明显下降 (P <0 .0 1) ,术后第 7天均有明显回升 ,研究组比对照组升高明显 (P <0 .0 5 )。术后第 7天 ,对照组与术前及与实验组比较 ,6h尿L/M明显增大 (P <0 .0 1) ;而实验组手术前后无显著性差异 (P >0 .0 5 )。结论　胃肠道肿瘤术后行TPN支持的病人 ,配合针刺可保护肠粘膜屏障、促进肝细胞代谢功能。     

通腑活血汤联合谷氨酰胺对胃癌根治术后患者氧化应激和肠黏膜屏障功能的影响

目的探讨通腑活血汤联合谷氨酰胺对胃癌根治术后患者氧化应激和肠黏膜屏障功能的影响。方法选取2016年11月至2018年10月间陕西省西安市中医医院收治的134例胃癌根治术患者,按照入院先后顺序对患者进行编号,采用奇偶法分组分为观察组和对照组,每组67例。观察组患者采用通腑活血汤和谷氨酰胺治疗,对照组患者采用谷氨酰胺治疗。持续治疗7d后,比较两组患者的胃肠功能恢复情况、氧化应激情况及肠黏膜屏障功能。结果观察组患者胃肠功能恢复情况各项指标均优于对照组患者,差异均有统计学意义(均P <0. 05)。两组患者术后的血清超氧化物歧化酶(SOD)和丙二醛(MDA)比较,差异无统计学意义(P> 0. 05),治疗7d后,两组患者的SOD均高于术前,观察组更高,两组患者的MDA均低于术前,观察组更低,差异均有统计学意义(均P <0. 05,表2)。两组患者术后的二胺氧化酶和D-乳酸水平比较,差异无统计学意义(P> 0. 05),治疗7d后,两组患者的二胺氧化酶和D-乳酸水平均低于术前,观察组更低,差异均有统计学意义(均P <0. 05)。结论通腑活血汤联合谷氨酰胺对胃癌根治术后患者氧化应激的抑制以及肠黏膜屏障功能的保护具有显著的积极作用,可促进患者术后胃肠功能的恢复,改善患者预后。     

加速康复医护一体化模式对直肠癌手术患者肠黏膜屏障功能、健康状态的影响研究

目的 探讨加速康复医护一体化模式对直肠癌手术患者肠黏膜屏障功能、健康状态的影响.方法 将116例直肠癌患者随机分为观察组和对照组各58例.对照组患者接受传统的手术治疗及护理,观察组围手术期增加加速康复医护一体化的外科治疗干预.观察记录并比较术前与术后3天肠黏膜屏障功能指标的变化以及两组患者术后恢复以及出院后短期健康状况的差异.结果 术后,两组患者二胺氧化酶(DAO)、D乳酸(D-LAC)、脂多糖(LPS)水平均升高(P﹤0.05),且观察组各指标均明显低于对照组(P﹤0.01).观察组患者手术时间、首次肛门排气时间、首次下床活动时间、首次进食时间、住院时间均短于对照组,术中出血量少于对照组,并发症总发生率、手术相关再入院率均低于对照组,差异均有统计学意义(P﹤0.05).观察组患者总体健康状况,功能指标中的情绪功能、社会功能、躯体功能、角色功能,症状指标中的食欲丧失、疲倦、恶心呕吐、疼痛、失眠、便秘、腹泻、心促评分均明显高于对照组,差异均有统计学意义(P﹤0.01).结论 加速康复医护一体化模式能够减轻直肠癌手术患者肠黏膜屏障功能的损伤以及加快术后胃肠功能的恢复,且能够有效改善患者术后健康状态.     

放疗对肿瘤患者肠道菌群影响的研究进展

摘 要：放疗是胃肠道肿瘤的常见治疗方法之一,常可导致患者出现胃肠道症状等不良反应,涉及放疗对肠道腔壁、肠道菌群等的影响。全文系统综述放疗对肿瘤患者的肠道腔壁和肠道菌群的影响,分析相应治疗措施的效果。     

CD44基因在肠息肉和结直肠癌中的表达及其临床意义

摘 要：［目的］ 检测CD44基因在肠息肉和结直肠癌中的表达,探讨其对结直肠肿瘤癌变的临床意义。［方法］ 采用Real-time PCR方法检测CD44在82例结直肠增生型炎性息肉、腺瘤性息肉和癌变息肉组织中的表达。［结果］ 增生型炎性息肉组织中CD44 mRNA相对表达量为0.0006±0.0001,腺瘤性息肉组织中为0.0019±0.0006,癌变息肉组织中为0.0073±0.0016,三组相比,P均<0.05。有淋巴结转移者与无淋巴结转移者肿瘤组织中CD44 mRNA表达量相比,P<0.05;TNM分期Ⅲ+Ⅳ者与Ⅰ+Ⅱ者肿瘤组织中CD44 mRNA表达量相比,P<0.05。相关性分析结果显示,CD44的表达强度与肠息肉癌变进展呈正相关(r=0.562,P<0.0001)。［结论］ CD44基因在结肠癌组织中表达异常升高,提示CD44可能与结肠癌的发生、发展有密切关系。     

肿瘤患者肠功能不全及其治疗

肠功能不全又称肠功能障碍,不但包括肠道消化吸收障碍,也包括肠道黏膜屏障功能障碍。它是晚期肿瘤患者常出现的一种病理过程。正确地认识肠功能不全、合理治疗,在肿瘤患者的营养支持治疗中极其关键。本文就肠功能不全的概念、肿瘤患者肠功能不全的特点及治疗作一综述。     

肿瘤患者中HIV感染状况的初步调查分析

目的:探讨肿瘤患者中人类免疫缺陷病毒(HIV)感染情况及肿瘤分布特点,以协助临床诊断和治疗,防止HIV院内传播.方法:对我院2005年2月至2010年5月期间,57 916例肿瘤患者中检出HIV抗体阳性患者的临床资料进行回顾性统计分析.结果:患者中检出HIV抗体阳性41例,占总检测例数的0.071%;2005年至2010年6年中,分别为3例、1例、6例、9例、12例、10例;其中肺癌7例、颈部肿瘤6例、肝癌5例,分别占阳性总数的17.1%、14.6%、12.2%.结论:肿瘤患者中HIV阳性病例数有逐年增加的趋势,对肿瘤患者手术前、输血前和各种创伤性检查前有必要进行HIV常规检查.     

天津市男性恶性肿瘤患者的发病特征与吸烟情况分析

摘 要：［目的］ 分析天津男性肿瘤患者发病与吸烟的关系,用循证数据诠释吸烟的危害。［方法］ 应用覆盖全市户籍人口的天津肿瘤登记系统收集患者的吸烟信息,并结合患者的诊断等信息综合分析男性肿瘤患者中发病与吸烟的关系。［结果］ 2010~2013年天津男性前5位的恶性肿瘤分别是肺癌、肝癌、结直肠癌、胃癌和膀胱癌,患者中吸烟的构成比明显高于非吸烟者,吸烟者的发病率均显著高于非吸烟者,其中肺癌吸烟者的发病风险是非吸烟者3.26倍（OR=3.26;95%CI：3.14~3.38）。前5位恶性肿瘤的发病病例中,吸烟者的发病年龄早于非吸烟者1.35年（P<0.01）。城市吸烟男性的恶性肿瘤发病率高于农村吸烟男性,而发病年龄则是农村早于城市,二者差异均有统计学意义（P<0.01）。［结论］ 吸烟与多脏器、多系统的恶性肿瘤高发有关,控制吸烟应成为疾病预防控制的重要任务。     

Determinants of Guideline-Based Treatment in Patients With cT1 Bladder Cancer

IntroductionClinical T1 (cT1) bladder cancer is associated with high rates of recurrence, upstaging, and progression. Guidelines recommend that these patients be treated with adjuvant intravesical Bacillus Calmette-Guérin immunotherapy (BCG) or upfront radical cystectomy (RC). We analyzed the National Cancer Database (NCDB) to identify demographic and clinical determinants of guideline-based treatment (GBT) and RC.Patients and MethodsWe identified 47,694 patients in the NCDB with cT1 bladder cancer diagnosed in 2004-2013. Those who did not receive any treatment or underwent primary chemotherapy were excluded. Mixed effects logistic regression adjusted for facility-level variation was used to identify factors associated with receipt of GBT.ResultsThe median age of the cohort was 72 years (interquartile range, 63-79). Of the patients, 22.4% were female, 5.1% were African American, and 2.7% had variant histology. Nearly one-third of patients received GBT: 11,453 (24%) were initially treated with BCG and 3320 (7%) were initially treated with RC. Recent year of diagnosis (odds ratio [OR], 1.67; 95% confidence interval [CI], 1.52-1.85; P < .001), treatment at an academic center (OR, 2.42; 95% CI, 2.27-2.59; P < .001), and private insurance status (OR, 1.41; 95% CI, 1.19-1.66; P < .001) were associated with increased odds of GBT. Of patients who received GBT, variant histology (OR, 5.89; 95% CI, 4.65-7.47; P < .001), and recent year of diagnosis (OR, 1.89; 95% CI, 1.50-2.39; P < .001) were associated with greater odds of RC.ConclusionThere is low treatment-guideline compliance for patients with cT1 disease. However, there appears to be a temporal trend toward increased use of GBT. Efforts should be made to understand why many cT1 bladder cancer patients do not receive GBT.     

Survival of Patients with Stomach Cancer and its Determinants in Kurdistan

Background: Stomach cancer is the fourth most common cancer and the second leading cause of death from cancer in the world. In Iran, this type of cancer has high rates of incidence and mortality. This study aimed to assess the survival rate of patients with stomach cancer and its determinants in Kurdistan, a province with one of the highest incidence rates of stomach cancer in the country. Materials and Methods: We studied a total of 202 patients with stomach cancer who were admitted to Tohid Hospital in Sanandaj from 2009 to 2013. Using KaplanMeier nonparametric methods the survival rate of patients was calculated in terms of different levels of age at diagnosis, gender, education, residential area, occupation, underweight, and clinical variables including tumor histology, site of tumor, disease stage, and type of treatment. In addition, we compared the survival rates using the logrank test. Finally, Cox proportional hazards regression was applied using Stata 12 and R 3.1.0 software. The significance level was set at 0.05. Results: The mean age at diagnosis was 64.7 12.0 years. The survival rate of patients with stomach cancer was 43.9% and 7% at the first and the fifth year after diagnosis, respectively. The results of logrank test showed significant relationships between survival and age at diagnosis, education, disease stage, type of treatment, and degree of being underweight (P<0.05). Moreover, according to the results of Cox proportional hazards regression model, the variables of education, disease stage, and type of treatment were associated with patient survival (P<0.05). Conclusions: The survival rate of patients with stomach cancer is low and the prognosis is very poor. Given the poor prognosis of the patients, it is critical to find ways for early diagnosis and facilitating timely access to effective treatment methods.     

Quality of Life Determinants in Breast Cancer Patients in Central Rural India

Introduction: Breast cancer is the most frequently diagnosed cancer among women throughout world, with incidence rates increasing in India. Improved survival in breast cancer patients has resulted in their quality of life (QOL) becoming an important issue. Identifying determinants for QOL may provide insights into how to improve their living conditions. This study aimed to assess socio-demographic and clinical factors, as well as the role of self-efficacy, in relation to QOL among women with breast cancer in rural India. Methods: A total of 208 female patients with infiltrating carcinoma of the breast participated in the study. A questionnaire was administered that included sections for socio-demographic characteristics, clinical stage of the cancer and patient delay in seeking health care. A standardized instrument to measure self-efficacy was applied. To assess QOL, the WHOQOL – BREF instrument was used. Results: The overall mean score for QOL was 59.3. For domain 1 (physical health) the mean score across all groups was 55.5, for psychological health 58.2, for social relationships 63.2 and for environmental factors, 60.4. The environmental domain in QOL was negatively associated with lower education. Being divorced/widowed/unmarried had a negative association with the psychological health and social relationship dimensions, whereas higher income was positively associated with QOL parameters such as psychology, social relationships and environmental factors. Self-efficacy was positively associated with all four domains of QOL. Conclusions: The present study demonstrated a moderate QOL in women with breast cancer in rural India. Young age, lack of education and being without a partner were negatively related to QOL, and employment as casual and industrial workers, high monthly family income and higher self-efficacy were positively associated with QOL. A comprehensive public health initiative is required, including social, financial and environmental support, that can provide better QOL for breast cancer survivors.     

Clinical Care of Cancer Patients

Maintaining the physiological and psychological wellbeing of the cancer patient can place significant stress on the health care provider. Potential long-term negative consequences of this stress are discussed within the theoretical context of provider burnout, Thc important role of interpersonal relationships in this setting is underscored.     

Hormone-Metabolic Status in Moderately Smoking Breast Cancer Patients

One hundred and eighteen primary breast cancer (BC) patients, 35 of whom were smokers, in clinical stages I II of the disease were examined. In order to investigate whether smoking changes endocrine function in BC patients, some indices of the hormone-metabolic status of smoking and non-smoking patients of reproductive and menopausal age were compared. It was found that in smokers with BC there was a decline in body weight and body fat content, a lack of lean body mass accumulation along with body mass increase, a tendency to hypotriglyceridemia and hypoinsulinemia, accelerated development of the upper type of body fat distribution with ageing, intensified gonadotropin secretion, shifts in steroidogenesis and SHBG level and elevated catecholamine execretion. It is suggested that a possible relation between hormone-mediated effects inherent to smoking and the mechanisms promoting genotoxic type of hormonal carcinogenesis and the factors of breast cancer prognosis cannot be excluded.