肠黏膜血流改变在创伤性脑损伤大鼠肠黏膜屏障应激性变化中的作用

目的探讨肠黏膜血流改变在创伤性脑损伤大鼠肠黏膜屏障应激性变化机制中的作用。方法雄性Wistar大鼠64只，随机分为创伤性脑损伤组和假手术组，2组大鼠分别按术后6、12、24和48小时时相点分为4个亚组（n=8），测定肠黏膜血流量，光镜和透射电镜下观察肠黏膜组织形态学变化。结果创伤性脑损伤组各时相点的肠黏膜血流量均低于假手术组（P〈0．05）；光镜下创伤性脑损伤组肠黏膜上皮细胞受损，电镜下可见肠黏膜细胞间紧密连接较假手术组增宽。结论创伤性脑损伤后早期肠黏膜屏障即已受损，而肠黏膜血流量的下降是导致这一病理生理变化的重要因素之一。     

早期肠内营养和肠外营养支持重型颅脑损伤的效果观察

目的探讨早期营养支持对重型颅脑损伤患者营养状况的效果影响。方法回顾性分析我院2004年1月～2008年10月间收治的重型颅脑损伤患者38例,随机分为肠内营养加肠外营养支持组(观察组)19例和全肠外营养支持组(对照组)19例。观察组早期肠内营养(enteral nutrition,EN)和肠外营养(parenteral nutrition,PN)结合,10天后转为全肠道营养,对照组10天内行全肠外营养支持,观察血糖、血浆白蛋白、淋巴细胞计数,并发症发生率及预后。结果观察组能获得充足的能量和蛋白质合成物,1周时的血糖控制程度、血浆白蛋白及外周血淋巴细胞总数优于对照组(P<0.05),观察组并发症少于对照组。观察组10天后病死率为(15.79%)明显低于对照组(31.58%)。结论重型颅脑损伤行早期肠内营养和肠外营养结合符合病人的病理、生理要求,能使该类病人营养状况和生存率提高。     

早期肠内营养和肠外营养支持重型颅脑损伤的效果观察

目的探讨早期营养支持对重型颅脑损伤患者营养状况的效果影响。方法回顾性分析我院2004年1月-2008年10月间收治的重型颅脑损伤患者38例,随机分为肠内营养加肠外营养支持组（观察组）19例和全肠外营养支持组（对照组）19例。观察组早期肠内营养（enteral nutrition,EN）和肠外营养（parenterl nutrition,PN）结合,10天后转为全肠道营养,对照组10天内行全肠外营养支持,观察血糖、血浆白蛋白、淋巴细胞计数,并发症发生率及预后。结果观察组能获得充足的能量和蛋白质合成物,1周时的血糖控制程度、血浆白蛋白及外周血淋巴细胞总数优于对照组（P〈0．05）,观察组并发症少于对照组。观察组10天后病死率为（15．79％）明显低于对照组（31．58％）。结论重型颅脑损伤行早期肠内营养和肠外营养结合符合病人的病理、生理要求,能使该类病人营养状况和生存率提高。     

Effects of Enteral Immunonutrition on the Maintenance of Gut Barrier Function and Immune Function in Pigs With Severe Acute Pancreatitis

Background: This study evaluated the effects of enteral immunonutrition (EIN) supplemented with glutamine, arginine, and probiotics on gut barrier function and immune function in pigs with severe acute pancreatitis (SAP). Methods: The model was induced by retrograde injection of 5% sodium taurocholate and trypsin via the pancreatic duct. After induction of SAP, 18 pigs were randomly divided into 3 groups, in which either parenteral nutrition (PN), control enteral nutrition (CEN), or EIN was applied for 8 days. Serum and pancreatic fluid amylase concentration was determined. Intestinal permeability (lactulose to mannitol ratio) was measured by high‐performance liquid chromatography, and plasma endotoxin was quantified by the chromogenic limulus amebocyte lysate technique. Samples of venous blood and organs were cultured using standard techniques. Pancreatitis severity and villi of ileum were scored according to histopathologic grading. Plasma T‐lymphocyte subsets were measured by flow cytometry, and immunoglobulins (Igs) were determined via enzyme‐linked immunosorbent assay. Results: There were no significant differences in serum and pancreatic fluid amylases concentrations or in pancreatitis severity between any 2 of the 3 groups. Compared with PN and CEN, EIN significantly decreased intestinal permeability, plasma endotoxin concentration, and the incidence and magnitudes of bacterial translocation, but increased ileal mucosal thickness, villous height, crypt depth, and percentage of normal intestinal villi. Significant differences were found in CD3⁺, CD4⁺ lymphocyte subsets, the ratio of CD4⁺: CD8⁺ lymphocyte subsets, and serum IgA and IgG, but not IgM, between any 2 of the 3 groups. Conclusions: EIN maintained gut barrier function and immune function in pigs with SAP.     

颅脑外伤患者肠内营养并发症分析及预防

目的探讨颅脑外伤患者肠内营养（EN）并发症的发生原因和防治措施。方法回顾性分析我院2005年1月至2008年12月103例接受EN的颅脑外伤患者的临床资料。结果103例接受EN的颅脑外伤患者中发生EN并发症者38例（66％）,无因EN并发症发生死亡。结论EN并发症在颅脑外伤患者营养支持疗法中常会发生,以胃肠道、代谢性并发症多见,其发生与疾病的严重程度、营养液的输注速度和用量、患者的代谢状况等因素密切相关。     

小剂量激素对大鼠脑创伤后认知影响的研究

目的探讨小剂量糖皮质激素对大鼠颅脑创伤后认知功能的影响及其可能机制。方法对成年雄性Wistar大鼠实施液压打击术,制备颅脑创伤模型,mNSS评分评价大鼠伤后神经功能;免疫组织化学染色观察患侧海马区血管内皮生长因子(VEGF)表达水平;Morris水迷宫实验评价大鼠创伤后认知功能恢复程度。结果与TBI对照组相比,创伤后14d、21dTBI后给药组大鼠mNSS评分降低;与TBI对照组比较,创伤后4d、7dTBI后给药组大鼠海马区VEGF表达增加;与TBI对照组相比,Morris水迷宫实验训练第3天时TBI后给药组大鼠逃避潜伏期开始缩短,伴随训练时间延长,组间差异明显增加并具有统计学意义(P0.05)。结论小剂量糖皮质激素可促进颅脑创伤后认知功能的恢复。其潜在机制可能是与其促进伤后VEGF表达升高有关。     

肠内营养增加谷氨酰胺对重型脑外伤病人的人类白细胞抗原DR表达的影响

[目的]探讨在重度脑外伤病人住院后的前15 d中,在肠内营养中增加谷氨酰胺,观察其对单核细胞的HLA DR的表达。[方法]2002年1月至2004年6月,在山东省千佛山医院,将55 例严重脑外伤病人随机分2 组,实验组28例增加谷氨酰胺的肠内营养,对照组27例给予同等热量、同等氮量的肠内营养液,选出年龄相当的健康志愿者43 人为健康对照组。在外伤后第1、5、9、14 d测定单核细胞的HLA DR的表达,测定血浆谷氨酰胺含量。[结果]在第3 天至5天,血浆中谷氨酰胺含量,实验组与对照组低于健康对照组,实验组高于对照组;HLA DR的表达,外伤第1 天实验组与对照组明显低于健康对照组,第5天、第9天和第14天实验组高于对照组。[结论]增加谷氨酰胺的肠内营养饮食能增加严重脑外伤病人单核细胞的HLA DR的表达,从而提高病人的细胞免疫功能。     

Partial Enteral Nutrition Preserves Elements of Gut Barrier Function,Including Innate Immunity,Intestinal Alkaline Phosphatase (IAP) Level,and Intestinal Microbiota in Mice

Lack of enteral nutrition (EN) during parenteral nutrition (PN) leads to higher incidence of infection because of gut barrier dysfunction. However, the effects of partial EN on intestina linnate immunity, intestinal alkaline phosphatase (IAP) and microbiota remain unclear. The mice were randomized into six groups to receive either standard chow or isocaloric and isonitrogenous nutritional support with variable partial EN to PN ratios. Five days later, the mice were sacrificed and tissue samples were collected. Bacterial translocation, the levels of lysozyme, mucin 2 (MUC2), and IAP were analyzed. The composition of intestinal microbiota was analyzed by 16S rRNA pyrosequencing. Compared with chow, total parenteral nutrition (TPN) resulted in a dysfunctional mucosal barrier, as evidenced by increased bacterial translocation (p < 0.05), loss of lysozyme, MUC2, and IAP, and changes in the gut microbiota (p < 0.001). Administration of 20% EN supplemented with PN significantly increased the concentrations of lysozyme, MUC2, IAP, and the mRNA levels of lysozyme and MUC2 (p < 0.001). The percentages of Bacteroidetes and Tenericutes were significantly lower in the 20% EN group than in the TPN group (p < 0.001). These changes were accompanied by maintained barrier function in bacterial culture (p < 0.05). Supplementation of PN with 20% EN preserves gut barrier function, by way of maintaining innate immunity, IAP and intestinal microbiota.     

Disparate Response to Metoclopramide Therapy for Gastric Feeding Intolerance in Trauma Patients With and Without Traumatic Brain Injury

Patients with traumatic brain injury (TBI) have delayed gastric emptying and often require prokinetic drug therapy to improve enteral feeding tolerance. The authors hypothesized that metoclopramide was less efficacious for improving gastric feeding tolerance for trauma patients with TBI compared to trauma patients without TBI. A retrospective analysis was conducted of patients admitted to the trauma or neurosurgical intensive care unit who received gastric feeding from January 2006 to April 2008. Gastric feeding intolerance was defined by a gastric residual volume >200 mL or emesis with abdominal distension or discomfort. Patients with gastric feeding intolerance were given metoclopramide 10 mg intravenously every 6 hours, followed by a dose escalation to 20 mg, and then combination therapy with metoclopramide and erythromycin 250 mg intravenously every 6 hours if intolerance persisted. In total, 882 trauma patients (49% with TBI) were evaluated. TBI patients had a higher incidence of gastric feeding intolerance than those without TBI (18.6% vs 10.4%, P ≤ .001). Efficacy rates for metoclopramide 10 mg, metoclopramide 20 mg, and metoclopramide‐erythromycin were 55%, 62%, and 79%, respectively (P ≤ .03). Metoclopramide failure occurred in 54% of patients with TBI compared to 35% of patients without TBI, respectively (P ≤ .02), due to a greater prevalence of tachyphylaxis. Single‐drug therapy with metoclopramide was less effective for TBI trauma patients compared to trauma patients without TBI. Combination therapy with erythromycin as first‐line therapy for TBI trauma patients with gastric feeding intolerance is indicated if there are no contraindications or significant drug interactions.     

Barriers to Nutrition Intervention for Patients With a Traumatic Brain Injury: Views and Attitudes of Medical and Nursing Practitioners in the Acute Care Setting

Background: Nutrition delivered to patients with a traumatic brain injury (TBI) is typically below prescribed amounts. While the dietitian plays an important role in the assessment and provision of nutrition needs, they are part of a multidisciplinary team. The views and attitudes of medical and nursing practitioners are likely to be crucial to implementation of nutrition to patients with TBI, but there is limited information describing these. Methods: A qualitative exploratory approach was used to explore the views and attitudes of medical and nursing practitioners on nutrition for patients with TBI. Participants at 2 major neurotrauma hospitals in Australia completed individual semi‐structured interviews with a set of questions and a case study. Interviews were transcribed and coded for themes. Results: Thirty‐four health practitioners participated: 18 nurses and 16 physicians. Three major themes emerged: (1) nutrition practices over the hospital admission reflect the recovery course, (2) there are competing priorities when caring for patients with TBI, and (3) the implementation of nutrition therapy is influenced by practitioner roles and expectations. Conclusion: Use of qualitative inquiry in the study of attitudes toward nutrition provision to patients with TBI provided detailed insights into the challenges of operationalizing nutrition therapy. These insights can be used to clarify communication between health practitioners working with patients with TBI across the continuum of care.     

Mild Traumatic Brain Injury: Implications for Social Work Research and Practice With Civilian and Military Populations

Over one million mild traumatic brain injuries (mTBI) are treated in U.S. hospitals each year. In addition, mTBI has affected thousands of soldiers returning from the Iraq and Afghanistan wars. Many individuals experience post-concussive symptoms immediately after mTBI; some experience severe and prolonged symptoms. Symptom etiology is not well understood, and effective psychosocial interventions have not been well developed. Because of the high incidence of mTBI, many social workers in health care settings will come in contact with mTBI patients and need specialized knowledge to provide appropriate services. Social work researchers can contribute to improved services by elucidating symptom course, and developing and testing effective interventions aimed at preventing or alleviating symptoms. This article provides an overview of civilian- and military-related mTBI outcomes and psychosocial interventions. Recommendations for current social work practice and research are made with the goal of improving the care of persons with mTBI.     

静脉应用谷氨酰胺双肽对肠外瘘大鼠肠黏膜结构的影响

目的探讨谷氨酰胺(Gln)的静脉注射制剂L-丙氨酰-L-谷氨酰胺对肠外瘘大鼠的黏膜完整性和黏膜细胞增殖的影响。方法肠外瘘大鼠模型制作成功后分为全胃肠外营养(TPN)组和TPN Gln组,7天后采集大鼠静脉血,利用分光光度法检测血浆Gln含量、改良的酶学分光光度法检测血浆D-乳酸含量、偶氮显色鲎试剂法测定血浆内毒素含量,切取部分小肠作石蜡切片观察黏膜形态,小肠黏膜标本制作细胞悬液利用流式细胞仪检测细胞增殖指数和S期细胞比率。结果TPN组小肠绒毛数量减少,变短变粗,黏膜层及固有层厚度变薄,小肠腺变短变细,成萎缩样变。TPN Gln组与TPN组相比,小肠绒毛形态完整,上皮细胞排列整齐,未见细胞坏死现象,腺体未见萎缩。TPN Gln组大鼠血浆Gln浓度、小肠黏膜的S期细胞比率和增殖指数均较TPN组显著增高(P<0.05);血浆D-乳酸、内毒素浓度较TPN组显著降低(P<0.05)。结论Gln的静脉注射制剂L-丙氨酰-L-谷氨酰胺可以促进肠外瘘大鼠肠黏膜细胞的增殖,恢复肠黏膜屏障,减少内毒素的吸收。     

创伤性脑损伤后应激性肝损害及与肠源性内毒素血症的关系

目的探讨创伤性脑损伤（TBI）后发生应激性肝脏损害（HSI）的机制及与肠黏膜屏障损伤和肠源性内毒素血症（GET）的关系。方法用改良Allen法建立TBI模型。40只健康雄性Wister大鼠随机分为5组：正常对照组、TBI后6、12、24、48小时时相组。测定肝血清酶、肝组织超氧化物歧化酶（SOD）、丙二醛（MDA）、血清肿瘤坏死因子-α（TNF-α）和血浆内毒素（脂多糖，LPS）水平，观察肝组织和肠黏膜超微结构的改变。结果TBI早期，各组血清丙氨酸氨基转移酶、天门冬氨酸氨基转移酶、TNF-α及LPS水平均升高，肝组织SOD减少、MDA增加，与对照组比较差异具有显著性（P〈0．05，P〈0．01）；TBI各组LPS与肝血清酶、TNF-α及MDA呈显著正相关（P〈0．05），与SOD呈显著负相关（P〈0．05）；TBI各组光镜和电镜下肝组织和肠黏膜上皮细胞均不同程度受损。结论TBI早期即出现肝脏和肠黏膜上皮的应激性损伤，HSI与GET和氧化应激等关系密切。     

早期肠内营养支持对胃肠肿瘤术后患者肠黏膜通透性的影响

目的研究术后早期肠内营养支持对胃肠肿瘤患者肠黏膜通透性的影响。方法20例经病理证实为胃肠肿瘤的患者随机分为PN组和EN组。PN组术后行TPN支持,能量为105kJ·kg-1·d-1,氮入量0.2g·kg-1·d-1。EN组术后第1天起经鼻饲管(放置于Treitz韧带下或空肠输出袢下30cm)输注能全力,量由500ml/d递增至1500ml/d,速度由21ml/h递增至63ml/h。分别于术前1d及术后第8天分别给患者口服甘露醇5g和乳果糖10g,收集患者随后6h的全部尿液,测量6h尿中甘露醇排除率与乳果糖排除率之比值(lactulose/mannitolratio,L/M比值)。结果20例胃肠肿瘤患者术前L/M值为0.047±0.025,与正常人群的L/M值相比差异有极显著性(P<0.01)。术前PN组的L/M比值为0.050±0.030,EN组的L/M比值为0.044±0.023,两组间差异无显著性(P>0.05)。术后第8天分别经一段时期的EN和PN支持后,PN组的L/M比值为0.105±0.034,PN组的L/M比值为0.084±0.40,两组分别与术前相比差异有极显著性(P<0.01),两组间相比差异无显著性(P>0.05)。结论术后早期短程应用能全力肠内营养支持对于胃肠肿瘤患者的肠黏膜通透性的影响与肠外营养支持相比差异无显著性。     

精细化护理在重症颅脑损伤患者肠内营养中的应用

目的 研究重症颅脑损伤患者肠内营养中运用精细化护理的临床干预效果。方法 共选取医院在2019年1月—2020年10月收治的50例重症颅脑损伤患者作为主要研究对象,所有患者均行肠内营养支持。用随机数字表法将其分为两组,每组25例。对照组行常规护理,观察组行精细化护理,比较两种护理模式对营养学指标、并发症发生率、GCS评分、生活质量以及患者满意度产生影响的异同。结果 经护理后,两组患者血清白蛋白、血红蛋白和总蛋白均显著高于护理前,且观察组护理后的血清白蛋白、血红蛋白和总蛋白均明显高于对照组,差异有统计学意义（P <0.05）;观察组和对照组相比患者的并发症发生率相对较低,两组相比差异有统计学意义（P <0.05）;护理后两组的GCS评分均明显高于护理前,且观察组护理后的GCS评分显著高于对照组,差异有统计学意义（P <0.05）;观察组护理后患者的生活质量与对照组相比更高,并且患者对于护理工作的整体满意度也较对照组高,并且两项指标的比较差异有统计学意义（P <0.05）。结论 重症颅脑损伤患者肠内营养中运用精细化护理有利于改善机体营养状态,降低并发症的发生风险,降低...     

免疫增强型肠内营养对重症急性胰腺炎大鼠炎症反应和免疫功能的影响

目的 探讨免疫增强型肠内营养对重症急性胰腺炎大鼠炎症反应和免疫功能的影响。方法 采用牛磺胆酸钠逆行注射法建立重症急性胰腺炎模型，将60只建模成功的胰腺炎大鼠分为全肠外营养组（TPN组）、普通肠内营养组（EN组）和免疫增强型肠内营养组（SEN组），每组20只。肠外营养和肠内营养分别采用经右颈内静脉插管输液和经胃造口空肠上段给液的方式。各组自建模成功后均应用乙酸奥曲肽皮下注射做基础治疗。于第24小时，第4、7、14天分别收集血液标本，测定血浆细胞因子TNF-α、IL-10及外周血中的CD3＋、CD4＋、CD8＋淋巴细胞亚群。并于建模前取10只大鼠测定血清淀粉酶，作为正常对照，建模后24小时，第3、5、7、9、11、14天检测各组血清淀粉酶。结果 （1）建模24小时，3组动物血浆TNF-α水平均相对较高，而IL-10处于相对较低水平；第4天时，3组TNF-α均明显下降，而IL-10浓度升高并达到最高水平，此时3组间的TNF-α和IL-10水平差异均无显著性（P〉0．05）；第7天和第14天时，3组的TNF-α和IL-10均呈不同程度下降趋势，其中SEN组TNF-α和IL-10水平明显低于TPN组和EN组（P〈0．05），而后两组间差异无显著性（P〉0．05）。（2）建模24小时，3组的CD3＋、CD4＋和CD4＋／CD8＋均升高；第7天和第14天时SEN组的CD3＋、CD4＋和CD4＋／CD8＋均明显高于TPN组和EN组（P〈0．05），但CD8＋变化不大。（3）建模24小时，3组血淀粉酶明显升高，此后均逐渐下降；第7天时，SEN组的血淀粉酶达正常范围，而TPN组和EN组的血淀粉酶在第9天才接近正常水平。SEN组14天死亡率明显低于TPN组和EN组（P〈0．05）。结论 免疫增强型肠内营养能有效调节重症急性胰腺炎大鼠细胞因子水平，增强免疫功能，缩短病程，降低死亡率。     

Differential Effects on Intestinal Adaptation Following Exogenous Glucagon‐Like Peptide 2 Therapy With and Without Enteral Nutrition in Neonatal Short Bowel Syndrome

Background: We aim to study the efficacy of exogenously administered glucagon‐like peptide 2 (GLP‐2) on intestinal adaptation in 2 preclinical models of neonatal short bowel syndrome (SBS) according to remnant intestinal anatomy, with and without ileum. Furthermore, we aim to determine if this adaptive effect was potentiated with enteral nutrition (EN). Methods: Neonatal piglets were block‐randomized to 75% mid‐intestinal (JI group, retains ileum) or distal‐intestinal (JC group, has no ileum) resection or no resection (sham control) and GLP‐2 treatment (11 nmol/kg/d) or saline control for 7 days. Piglets received nutrition support, either 100% parenteral nutrition (PN; 0% EN, n = 32 in total) or 80% PN + 40% EN (n = 28 in total). Adaptation was assessed by morphological and histological changes, as well as RT quantitative polymerase chain reaction of nutrient transporters and tight junctional proteins and fat absorption. Data are analyzed by 3‐way analysis of variance (ANOVA) and 2‐way ANOVA per EN level. Results: GLP‐2 treatment lengthened villi, deepened crypts, and improved intestinal weight in the remnant intestine of JC piglets. EN was a more potent adaptive stimulus for JI piglets. Small intestinal lengthening occurred only in the JI group, when given EN. There was no difference in total fat absorption and messenger RNA expression of nutrient transporters and tight junctional proteins. Conclusions: GLP‐2 administration augmented structural adaptation in JC piglets with distal intestinal resection. Given JI anatomy, further stimulation by GLP‐2 treatment over innate adaptation and stimulation by EN was modest and restricted to ileum. The differential effect of GLP‐2 in neonatal SBS, depending on remnant anatomy, has important implications for clinical translation and planning of clinical trials.     

我国癌症患者心理护理现状及展望

本文结合癌症患者的心理护理,介绍心理护理的概念、原则及意义,癌症患者常见心理反应类型,并针对我国当前对癌症患者心理护理中存在的不足,参考国外同领域发展最新成果,提出癌症患者临床护理的未来趋势。癌症患者的临床治疗护理康复中,心理护理将日益受到重视。针对不同类型的心理反应,大量信效度良好的测量工具将提供客观的辅助评估,除一般的支持性心理治疗外,以认知行为治疗等为代表的新技术将应用于心理护理实践,对癌症患者的心理护理也进一步拓展至癌症患者的照顾者,体现对患者社会支持系统的综合强化。     

肠内营养支持重型颅脑外伤患者的临床护理

目的探讨肠内营养支持重型颅脑外伤患者的临床护理。方法根据患者的生理,病理情况和个人经济条件制定营养计划。采用匀浆膳食和新鲜流质饮食联合使用。结果 68例重症颅脑外伤患者中并发症出现率,腹泻31.0%,呕吐19.1%,消化道出血16.1%,误吸13.2%,脱管7.4%,堵管7.4%,采用匀浆膳食和新鲜流质饮食联合使用,患者的体重、握力显著增加。结论肠内营养支持能促进术后患者的蛋白质合成,尽快达到正氮平衡,降低感染性并发症的发生率,并增进患者的神经功能恢复,降低病死率和伤残率。