血浆可溶性晚期糖基化终末产物受体和APACHEⅡ评分对脓毒症预后的评价北大核心CSCD

目的探讨血浆可溶性晚期糖基化终末产物受体（sRAGE）和急性生理与慢性健康状况评分Ⅱ（APACHEⅡ）在预测脓毒症患者预后中的意义。方法选择2013－02-2014－08我院ICU收治的脓毒症患者79例。检测患者入院后第1、3天血浆sRAGE水平,同时记录当天APACHEⅡ评分,根据28d生存与否分为存活组和死亡组,分析两组血浆sRAGE水平、APACHEⅡ评分于第1、3天的变化及相关性,并分析两项指标对脓毒症患者预后的判断价值。结果第1、3天存活组血浆sRAGE水平及APACHEⅡ评分均显著低于死亡组（P＜0．05）;当日血浆sRAGE水平与APACHEⅡ评分之间均存在正相关（r＝0．74,P＜0．05;r＝0．61,P＜0．05）;第1天血浆sRAGE水平及APACHEⅡ评分对脓毒症预后判断的ROC曲线下面积分别为0．93、0．86（P＜0．05）,第3天两指标的曲线下面积分别为0．75、0．69（P＜0．05）。结论脓毒症患者血浆sRAGE水平与APACHEⅡ评分显著相关,血浆sRAGE水平可作为脓毒症患者转归的早期预测指标。     

凝血功能紊乱与脓毒症严重程度及预后的相关性研究

【目的】探讨脓毒症患者凝血功能紊乱与病情严重程度及预后的相关性。【方法】分析北京市大兴医院ICU自2011年7月至2013年7月收治的148例脓毒症患者的临床资料,记录脓毒症当日的APACHEⅡ评分及凝血指标,采用Spearman等级相关评价二者的相关性。【结果】148例脓毒症患者的住院病死率为48％（71／148）。98（66．2％）例患者发生凝血功能紊乱,其中87（58．8％）例患者存在血小板（PLT）减低,70（47．3％）例患者存在血浆凝血原时间（PT）延长,84（56．8％）例患者存在活化部分凝血酶原时间（APTT）延长,93（62．8％）例患者存在D‐二聚体（D‐D ）增高。且上述凝血指标的异常发生率在存活组与死亡组之间存在统计学差异（ P ＜0．05）。随着APACHEⅡ评分水平的增高,其凝血功能紊乱发生率增加,两者具有相关性（ r ＝0．555,P＜0．001）。【结论】凝血功能紊乱可预测患者危重病的严重程度,并反映预后状况,对于脓毒症诊治具有积极地指导意义。     

脓毒症患者血浆Presepsin水平检测的临床意义

目的：探讨脓毒症患者Presepsin变化的临床意义。方法：选取江苏大学附属医院重症监护病房2011年10月至2013年3月脓毒症患者52例,SIRS患者40例。另选30例健康正常人为对照组。检测各组入院时血浆Presepsin、及降钙素原（PCT）水平,并进行APACHEⅡ评分。对比分析各组患者血浆Presepsin水平、降钙素原水平与APACHEⅡ评分。 ROC曲线分析各指标对脓毒症的诊断性能。结果：死亡组血浆Presepsin、PCT水平及APACHEⅡ评分均显著高于存活组和对照组（P＜0．01）;脓毒症组患者血浆Presepsin、PCT水平高于SIRS组及对照组（P＜0．05）。 APACHEⅡ评分在SIRS组和脓毒症组间比较差异无统计学意义。相关分析显示：血浆Presepsin水平与PCT水平呈正相关性（r ＝0．82）,与APACHEⅡ评分呈正相关性（r＝0．69）。 Presepsin的AUC为0．908（95％CI：0．848～0．967）;分界值为629 pg／mL时灵敏度为68．6％,特异度为90％。 PCT的AUC为0．862（95％CI：0．787～0．937）;分界值为1．98 ng／mL时灵敏度为92％,特异度为65％。结论：脓毒症患者血浆中Presepsin升高,Presepsin水平升高提示患者病情危重。     

清热化瘀汤对严重脓毒症患者凝血功能及预后的影响

目的观察清热化瘀汤对严重脓毒症患者凝血功能及预后的影响,为其临床运用提供依据。方法选择72例2010年至2012年于清远市中医院ICU住院的严重脓毒症患者,随机分为治疗组（38例）和对照组（34例）,两组均按照指南要求给予常规治疗,治疗组于常规治疗基础上加用清热化瘀汤治疗。治疗前及治疗7d后两组均检测PLT、PT、APTT、FIB、D—D等凝血相关指标,并记录APACHE-Ⅱ评分,随访统计住院天数及28d病死率。结果（1）与治疗前比较,治疗后治疗组PLT、PT、APTF、FIB、D—D等凝血指标均有改善（P均〈0．01）,对照组仅PLT、FIB、D-D有改善（P均〈0．01）;且治疗后,治疗组PLT、FIB高于对照组（P均〈0．05）,PT、APTT、D-D低于对照组（P均〈0．05）。（2）治疗后两组APACCHE-Ⅱ评分均下降（P均〈0．01）,且治疗组低于对照组（P〈0．05）。（3）两组住院天数相近。（4）两组28d病死率差异无统计学意义（P〉0．05）。结论清热化瘀汤可通过改善严重脓毒症患者的凝血功能而改善预后。     

降钙素原、血小板监测对脓毒症患者的预后判断价值

目的：探讨降钙素原（PCT）、血小板（PLT）监测对脓毒症患者预后判断的临床价值。方法：90例脓毒血症患者分别在人ICU第1、3、5、7天进行PCT和PLT检测,根据预后情况分为生存组（n=60例）和死亡组（n=30）,比较两组间PCT、PIJT与APACHEⅡ评分的关系。结果：与生存组比较,死亡组PCT明显增高,且持续保持较高水平（P〈O．05）;PLT明显下降,且呈进行性下降趋势（P〈0．05）。PCT、PIJT水平和APACHEⅡ评分明显相关（P〈0．05）。结论：PCT、PLT对判断脓毒症患者预后有一定的临床价值。     

降钙素原在脓毒症致急性肾损伤患者病情及预后评估中的作用

目的：研究降钙素原（PCT ）在脓毒症致急性肾损伤患者病情及预后评估中的作用。方法选择脓毒症致急性肾损伤患者（AKI组）、脓毒症无急性肾损伤患者（SEP组）和体检健康者（CON组）为研究对象,比较血清肌酐（Scr）、血尿素氮（BUN）、PCT、慢性健康状况评价（APACHEⅡ）评分和序贯器官衰竭估计（SOFA ）评分组间差异,分析PCT和Scr、BUN、APACHEⅡ评分和SOFA评分的相关性,比较不同 PCT 水平患者的病死率。结果AKI组和SEP组Scr、BUN和PCT水平均显著高于CON组（P＜0．05）;AKI组Scr、BUN、PCT、APACHEⅡ评分和SOFA评分显著高于SEP组（P＜0．05）。AKI组PCT水平与Scr、BUN、APACHEⅡ评分和SOFA评分均呈正相关（P＜0．05）,SEP组PCT水平与Scr和BUN无相关性（P＞0．05）,与APACHEⅡ评分和SOFA评分均呈正相关（P＜0．05）。脓毒症致急性肾损伤患者血清PCT越高,病死率越高（P＜0．05）。结论PCT 可作为脓毒症致急性肾损伤患者病情及预后评估的血清标志物。     

早期乳酸清除率和中心静脉血氧饱和度监测对重症肺炎患者预后的研究

目的：探讨重症肺炎患者早期动脉血乳酸清除率、中心静脉血氧饱和度（ScvO2）的监测价值。方法回顾性研究2012年1月—2013月12月56例重症肺炎患者,入科即刻和6 h时测定动脉血乳酸浓度和早期ScvO2,计算6 h乳酸清除率,并进行急性生理与慢性健康（APACHEⅡ）评分,根据APACHEⅡ评分将患者分为3组：10-＜20分组（A组）,20-＜30分组（B组）,≥30分组（C组）,比较不同组别早期乳酸清除率和ScvO2的差别,并分析其与预后的关系。结果①B组初始动脉血乳酸较A组高,C组初始动脉血乳酸较B组高,但组间差异均无统计学意义（均 P＞0．05）;②B组早期6 h乳酸清除率、ScvO2均较A组低,差异有统计学意义（ P＜0．05）,C组早期6 h乳酸清除率、ScvO2均低于B组,差异有统计学意义（ P＜0．05）。③B组病死率高于A组,C组病死率高于B组,差异均有统计学意义（均 P＜0．05）;④死亡组APACHE Ⅱ评分高于存活组,早期动脉血乳酸清除率和ScvO2水平低于存活组,差异均有统计学意义（均 P＜0．05）;⑤APACHEⅡ评分与早期乳酸清除率呈显著负相关（r＝0．661,P＜0．01）,与早期ScvO2水平呈显著负相关（r＝0．579,P＜0．01）。结论早期动脉血乳酸清除率及ScvO2水平是反映重症肺炎患者病情严重程度和预测患者转归的参考指标。     

6％羟乙基淀粉130／0．4对脓毒症大鼠凝血功能的影响

[目的]观察6％羟乙基淀粉130/0．4对脓毒症大鼠凝血四项和血小板的影响。[方法]利用盲肠结扎穿孔术（CLP）制备脓毒症动物模型。80只SD大鼠随机分为4组：正常组（ n ＝8）、假手术组（Sham组,行假手术后3 h用生理盐水作为输注液体,n ＝24）、模型组（SEP组,造脓毒症模型后3 h用生理盐水作为复苏液体,n＝24）和羟乙基淀粉组（HES组,造脓毒症模型后3 h用6％羟乙基淀粉130/0．4作为复苏液体,n＝24）。后三组按采样时间再分为手术后6 h、12 h、24 h三个亚组,每组8只。各组于相应3个时间点经心脏采血,测定大鼠的凝血酶原时间（PT）、凝血酶时间（TT）、活化部分凝血活酶时间（APTT）、纤维蛋白原（FIB）和血小板计数（PLT ）的变化。[结果]与正常组相比,Sham组凝血四项指标和PLT手术前后相比较无明显变化（ P ＞0．05）。与Sham组相比,SEP组、HES组在各时间点PT、TT、APTT 明显延长（ P均＜0．05）,FIB、PLT 明显减少（ P均＜0．05）,但12 h、24 h HES组PT、TT、APTT 升高程度及FIB、PLT 降低程度较SEP组小,且差异有显著性（ P均＜0．05）。[结论]早期应用羟乙基淀粉130/0．4可有效改善脓毒症的凝血功能障碍,一定程度上可缓解脓毒症的进一步发展。     

降钙素原对脓毒症致急性肾损伤患者预后评估的临床价值

【目的】探讨降钙素原（PCT）的检测在脓毒症急性肾损伤（AKI）患者预后评估的临床价值。【方法】选择本院收治的脓毒症致AKI患者63例作为A组,同期收治的69例脓毒症无AKI作为B组,比较两组患者肾功能指标、PCT以及APACHEⅡ评分,并分析AKI患者PCT水平与APACHEⅡ评分及与患者死亡之间的关系。【结果】A组患者肌酐（SCr）、血尿素氮（BUN）,PCT以及APACHEⅡ评分均显著高于B组,且差异具有显著性（P〈0．05）;A组PCT水平与SCr、BUN以及APACHEⅡ评分均呈显著正相关关系（P〈0．05）;B组PCT水平与SCr、BUN以及APACHEⅡ评分无明显相关性（P〉0．05）;不同APACHEⅡ评分患者血清PCT水平差异具有显著性（P〈0．05）,随着APACHEⅡ评分的增高,患者PCT水平显著升高;应用ROC曲线分析PCT对AKI患者死亡预测作用,ROC曲线下面积为0．829,95％可信区间为（0．719～0．939）（P〈0．05）。【结论】PCT对于脓毒症致AKI患者具有着较高的诊断和预测价值,能够较好预测患者的病情和预后。     

连续性血液净化对重症脓毒症患者内皮损伤的保护作用

目的研究连续性血液净化（CBP）治疗重症脓毒症患者,对血管内皮损伤的保护作用,及血管内皮损伤与病情演变之间的关系。方法17例重症脓毒症患者接受连续性血液净化（CBP）治疗共25次,观察患者接受CBP治疗前、治疗结束后次日血管性假性血友病因子（vWF）、凝血象、血常规及生化指标等变化;根据患者接受CBP治疗前和治疗后采集血标本时间不同,分为治疗前组和治疗后组;根据患者的预后分为存活组和死亡组。结果CBP治疗后组vWF较治疗前组显著降低（P〈0．05）,治疗后组APACHEⅡ和MODS评分也较治疗前组明显降低（P〈0．05）;CBP治疗前组,vWF与血白细胞计数（WBC）及血小板计数（PLT）呈正相关（P〈0．01）,与氧合指数呈负相关（P〈0．05）;CBP治疗后组,vWF与WBC和D-二聚体均呈正相关（P〈0．01,0．05）。CBP治疗后存活组患者,vWF仅仅与血WBC呈正相关（P〈0．01）;而CBP治疗后死亡组患者,vWF与总脱水量及红细胞比积呈正相关（P〈0．01）,而与PT-INR和APTT呈负相关（P〈0．01,P〈0．05）。结论CBP治疗对重症脓毒症患者血管内皮损伤起到保护作用;在CBP治疗过程中,脱水过多,又可能加重血管内皮损伤。     

Determination of creatine kinase isoenzyme MB activity in serum using immunological inhibition of creatine kinase M subunit activity. Activity kinetics and diagnostic significance in myocardial infarction.

This is a new method for the determination of creatine kinase isoenzyme MB activity in serum. The method uses direct activity measurement of creatine kinase B subunit activity after blocking of CK-M subunit activity by inhibiting antibodies. The test takes no longer than 15 min. The method yields an intra-serial C.V. of 2.0-12.9%, and a C.V. from day to day of 5.5%. The detection limit is 3.4 U/l creatine kinase MB. In the 95 cases with proven myocardial infarction several types of creatine kinase MB activity kinetics could be determined. The percentage of creatine kinase MB of peak CK-total is 6-25%, with a mean of 11.1%. The amount of creatine kinase MB with respect to total CK activity after reinfarction is higher than the amount after initial infarction.     

Dissociable correlates of two classes of retrieval processing in prefrontal cortex

Although substantial evidence suggests that the prefrontal cortex (PFC) implements processes that are critical for accurate episodic memory judgments, the specific roles of different PFC subregions remain unclear. Here, we used event-related functional magnetic resonance imaging to distinguish between prefrontal activity related to operations that (1) influence processing of retrieval cues based on current task demands, or (2) are involved in monitoring the outputs of retrieval. Fourteen participants studied auditory words spoken by a male or female speaker and completed memory tests in which the stimuli were unstudied foil words and studied words spoken by either the same speaker at study, or the alternate speaker. On "general" test trials, participants were to determine whether each word was studied, regardless of the voice of the speaker, whereas on "specific" test trials, participants were to additionally distinguish between studied words that were spoken in the same voice or a different voice at study. Thus, on specific test trials, participants were explicitly required to attend to voice information in order to evaluate each test item. Anterior (right BA 10), dorsolateral prefrontal (right BA 46), and inferior frontal (bilateral BA 47/12) regions were more active during specific than during general trials. Activation in anterior and dorsolateral PFC was enhanced during specific test trials even in response to unstudied items, suggesting that activation in these regions was related to the differential processing of retrieval cues in the two tasks. In contrast, differences between specific and general test trials in inferior frontal regions (bilateral BA 47/12) were seen only for studied items, suggesting a role for these regions in post-retrieval monitoring processes. Results from this study are consistent with the idea that different PFC subregions implement distinct, but complementary processes that collectively support accurate episodic memory judgments.     

俯卧位通气对高海拔地区肺复张治疗无效急性呼吸窘迫综合征患者氧合的影响

目的 探讨俯卧位通气对高海拔地区肺复张术(RM)治疗无效急性呼吸窘迫综合征(ARDS)患者的治疗作用.方法 从海拔2260m的地区医院筛选RM治疗无效的41例ARDS患者[平均氧合指数( PaO2/FiO2)较RM前升高＜20％视为RM无效],依不同病因分为肺内源性ARDS组(ARDSp组)和肺外源性ARDS组(ARDSexp组),每组再按信封法随机分为俯卧位组和仰卧位组,即ARDSp俯卧位组(11例)、ARDSp仰卧位组(9例)、ARDSexp俯卧位组(10例)、ARDSexp仰卧位组(11例).在通气前及通气1、2、3、4h监测动脉血氧分压( PaO2)、PaO2/FiO2、静态顺应性(Cst)、气道阻力(Raw)的变化.结果 通气lh时,ARDSexp俯卧位组PaO2/FiO2( mm Hg,l mm Hg=0.133 kPa)即较通气前显著升高(157.4±40.6比129.3±48.7,P＜0.05),并随通气时间延长呈持续增高趋势,4h达峰值(219.1 ±41.1);且ARDSexp俯卧位组通气3h内PaO2/FiO2较其他3组显著增高,另3组间则差异无统计学意义.ARDSp俯卧位组、ARDSexp俯卧位组通气4h时PaO2/FiO2均较相应仰卧位组显著增高(208.8±39.7比127.4±47.1,219.1±41.1比124.9±50.8,均P＜0.05).4组通气前后Cst无显著改变,各组间差异也无统计学意义.ARDSp俯卧位组通气4h时Raw(cmH2O·L-1·s-1)较通气前显著降低(6.8±1.7比10.7±1.8,P＜0.05),且明显低于其他3组;其他3组各时间点Raw组内及组间比较差异均无统计学意义.结论 俯卧位通气作为ARDS机械通气重要策略之一,可以改善RM无效高原ARDS患者的氧合,为抢救患者赢得宝贵的时间.     

Digital imaging among medical facilities

The Department of Veterans Affairs (VA) in the USA operates a network of 172 medical centres which all utilize a hospital information system (HIS) which has been developed and is currently maintained by the VA. During the past several years, an image management and communication module has been developed, installed and clinically utilized at the Washington DC and Maryland VA Medical Centres. This image management and communication system, referred to as the decentralized hospital computer program (DHCP) imaging system, is fully integrated with a commercial picture archiving and communication system (PACS). The system is utilized to capture, archive, and display all images generated within the hospital including radiology, nuclear medicine, pathology, endoscopy, bronchoscopy, and dermatology, intraoperative photographs, ECG data, and a limited number of paper documents. The ultimate goal of the project is to have all patient text and image data available at any clinical workstation to any authorized user anywhere within the network of medical centres. Clinical requirements for an imaging workstation include ease of use, rapid and reliable access to the complete set of patient information, and images which are of acceptable quality to meet the requirements of the user and the subspecialty. Patient confidentiality and data security must be safeguarded at all times. Integration of the images with the remainder of the patient's database was found to be critical to the success of the project. The experience at the Washington and Maryland facilities suggests that an imaging system that is successfully integrated with a hospital information system can provide substantial clinical and economic benefits both within and among medical centres. Clinical acceptance and utilization of the system has been excellent, particularly in diagnostic radiology where DHCP Imaging has been interfaced to a commercial PAC system. Based upon this initial experience, the VA has begun to deploy the system throughout its large network of medical centres.     

Myocardial elastography at both high temporal and spatial resolution for the detection of infarcts

Myocardial elastography is a novel method for noninvasively assessing regional myocardial function, with the advantages of high spatial and temporal resolution and high signal-to-noise ratio (SNR). In this paper, in-vivo experiments were performed in anesthetized normal and infarcted mice (one day after left anterior descending coronary artery [LAD] ligation) using a high-resolution (30 MHz) ultrasound system (Vevo 770, VisualSonics Inc., Toronto, ON, Canada). Radiofrequency (RF) signals of the left ventricle (LV) in longitudinal (long-axis) view and the associated electrocardiogram (ECG) were simultaneously acquired. Using a retrospective ECG gating technique, 2-D full field-of-view RF frames were acquired at an extremely high frame rate (8 kHz) that resulted in high-quality incremental displacement and strain estimation of the myocardium. The incremental results were further accumulated to obtain the cumulative displacements and strains. Two-dimensional and M-mode displacement images and strain images (elastograms), as well as displacement and strain profiles as a function of time, were compared between normal and infarcted mice. Incremental results clearly depicted cardiac events including LV contraction, LV relaxation and isovolumetric phases in both normal and infarcted mice, and also evidently indicated reduced motion and deformation in the infarcted myocardium. The elastograms indicated that the infarcted regions underwent thinning during systole rather than thickening, as in the normal case. The cumulative elastograms were found to have higher elastographic SNR (SNR(e)) than the incremental elastograms (e.g., 10.6 vs. 4.7 in a normal myocardium, and 6.0 vs. 2.4 in an infarcted myocardium). Finally, preliminary statistical results from nine normal (m = 9) and seven infarcted (n = 7) mice indicated the capability of the cumulative strain in differentiating infracted from normal myocardia. In conclusion, myocardial elastography could provide regional strain information at simultaneously high temporal (>/=0.125 ms) and spatial ( approximately 55 microm) resolution as well as high precision ( approximately 0.05 microm displacement). This technique was thus capable of accurately characterizing normal myocardial function throughout an entire cardiac cycle, at the same high resolution, and detecting and localizing myocardial infarction in vivo.     

Clinical Pharmacokinetics of Morphine

Morphine, the most widely used mu-opioid analgesic for acute and chronic pain, is the standard against which new analgesics are measured. A thorough understanding of the pharmacokinetics of morphine is required in order to safely and effectively use this analgesic in a wide variety of patients with different levels of organ function. A MEDLINE search was conducted to identify literature published between 1966 and January 2002 relevant to the pharmacokinetics of morphine. These publications were reviewed and the literature summarized regarding unique and clinically important elements of morphine disposition relative to its parenteral administration (including intravenous, intramuscular, subcutaneous, epidural and intrathecal administration), absorption profile (immediate release, controlled release, and sublingual/buccal, and rectal administration), distribution, and its metabolism/ excretion. Special populations, including infants, elderly, and those with renal/liver failure, have a unique morphine pharmacokinetic profile that must be taken into account in order to maximize analgesic efficacy and reduce the risk of adverse events.