胸腺切除术后预防重症肌无力危象的护理

我院自1991年1月～2003年1月共手术治疗胸腺瘤合并重症肌无力(MG)病人11例,无1例手术及住院死亡,全部痊愈出院。现将护理体会报告如下。 1 临床资料 1.1 一般资料本组11例,男性7例,女性4例。平均年龄     

抢救重症肌无力危象2例成功的护理体会

我科于1998年收治2例重症肌无力危象患者,经及时抢救、治疗及精心护理,病情好转出院。现将护理体会总结如下。1 加强呼吸道护理患者首先出现呼吸频率的改变,濒死感,烦躁,随后出现不同程度的呼吸困难,以致呼吸停止,应尽早气管切开及人工呼吸机应用,保证有效的通气,否则大多死于呼吸衰竭。因此设专人护理,制订周密的护理计划,严密观察生命体征,血氧饱和度,肌力,痰量,胆碱能危象的发生,详细记录重症护理单。抢救时,护士保持镇定,为减少干扰抢救应疏散惊慌的家属及围观人群,及时有效地配合医     

重症肌无力危象合并肺部感染患者机械通气的护理

重症肌无力(MG)是由乙酰胆碱受体抗体介导、细胞免疫依赖性、补体参与的自身免疫性疾病[1].临床上主要表现以受累骨骼肌极易疲劳,经服用抗胆碱脂酶药物后部分恢复为特征.     

重症肌无力危象抢救的体会

1　临床资料例 1,张× ,女 ,4 9岁 ,于 1年前因先后两眼睑下垂 ,早上轻、午后重 ,经检查和新斯的明试验 (+ )而诊断为眼肌型重症肌无力 (ＭＧ) ,经用药治疗 ,症状有好转。继而出现吞咽困难 ,呛咳和上肢无力 ,经纵膈ＭＲ检查示胸腺瘤 ,确诊为全身型ＭＧ伴胸腺瘤。而投用强的松和吡啶斯的明治疗 ,症状时重时轻 ,近 5ｄ因受凉后咳嗽 ,咳痰 ,初步治疗后 ,疗效不好 ,肌无力和重伴呼吸困难 1ｄ而送来我院就诊以肺部感染 ,肌无力危象收住入院。平常身体尚好 ,家族中无类似病史。入院后查体 :Ｔ 38 2℃ ,Ｐ 12 0次 /ｍｉｎ ,Ｒ 2 4次 /ｍｉｎ ,神志…     

机械通气在重症肌无力危象中的应用观察

目的探讨机械通气及其护理对重症肌无力危象患者的效果。方法通过对比分析机械通气前后重症肌无力危象患者临床表现及血气分析结果,回顾总结患者的抢救经过、诊治和护理要点。结果10例患者中9例顺利度过肌无力危象过程,逐渐康复。结论及早进行机械通气是肌无力危象抢救的关键,同时配合精心细致有效的呼吸、饮食、心理、基础护理,有助于增强疗效,提高抢救的成功率。     

无创呼吸机治疗重症肌无力危象35例护理体会

目的：探讨无创呼吸机治疗重症肌无力危象35例护理方法及效果。方法：以回顾性方法,选取我院在2014年12月到2015年12月间收治的重症肌无力危象患者35例,对其进行无创呼吸机治疗,观察护理效果。结果：经治疗及护理,35例患者中显效17例（49.6%）,有效18例（50.4%）,无1例无效,总有效率为100%。所有患者在治疗后,血气指标、生命体征均显著改善,与治疗前相比差异显著,具有统计学意义（t=16.495,p<0.05）。结论：对于重症肌无力危象患者,通过应用无创呼吸机治疗及护理之后,可以有效的改善患者症状,提高治疗效果。     

优质护理在预防胸腺瘤患者术后并发肌无力危象中的应用效果

目的观察优质护理在预防胸腺瘤患者术后并发肌无力危象中的应用效果。方法我院2017年6月-2020年6月收治的60例胸腺瘤手术患者为本次研究对象,按照是否开展优质护理将患者随机分为对照组30例进行常规护理与实验组30例进行优质护理,比较两组患者护理效果。结果实验组患者术后肌无力危象等并发症发生率均低于对照组,差异有统计学意义(P<0.05)。实验组患者平均手术时间、术后引流管平均放置时间以及平均住院时间均优于对照组,差异有统计学意义(P<0.05)。实验组患者围术期依从性高于对照组,数据差异有统计学意义(P<0.05)。结论胸腺瘤手术患者护理干预可直接影响患者预后效果,其中优质护理干预显著优于常规护理。     

机械通气抢救重症肌无力危象12例临床分析

目的复习重症肌无力危象的抢救方法提高抢救成功率.方法对6年来12例重症肌无力危象患者应用机械通气抢救,同时静点糖皮质激素.结果12例患者存活11例,死亡1例.结论呼吸衰竭是重症肌无力危象死亡原因,早期气管插管或气管切开行机械通气治疗是抢救成功的关键,改善危象的预后,明显降低死亡率.     

儿童重症肌无力危象的易发因素与护理

对16例次重症肌无力(MG)危象进行观察分析,重点讨论MG危象的易发因素及护理。认为合并感染是MG危象发生的主要原因,心理因素是常见诱因,药物因素及饮食因素均可引起肌无力危象的发生。因此,在护理上应做到注意预防感染,有效实施心理护理,严格给药时间、剂量,加强饮食管理,可以减少或避免MG危象的发生。     

经颈横切口行胸腺切除术在治疗重症肌无力中的应用

目的 探讨经颈横切口行胸腺切除术治疗重症肌无力的可行性和疗效.方法 选取2006年7月至2008年12月收治的12例重症肌无力合并胸腺增生或胸腺瘤形成的患者,经颈横切口行胸腺切除术.结果 12例患者均顺利切除胸腺及前纵隔脂肪组织,无一例患者因出血或无法完整切除胸腺而中转开胸手术.平均手术时间(85±27)min,平均出血量(42±8)ml,术后平均住院时间(3.5±0.1)d.无切口感染、膈神经损伤、纵隔及肺部感染等并发症发生.本组术后疗效优5例,良7例.结论 经颈横切口行胸腺切除术治疗重症肌无力有创伤小、术后疼痛轻、并发症少、住院时间短等显著优势,是一种安全有效的手术方式.     

三种小切口行胸腺切除治疗重症肌无力的对照分析

目的 比较三种小切口行胸腺切除治疗重症肌无力的手术效果,合理选择手术方式.方法 回顾性分析行胸腺切除术治疗109例重症肌无力患者的临床资料,根据手术切口方式的不同分为胸骨部分劈开组、横断胸骨组和胸腔镜组,比较三组的手术时间、术中出血量、术后胸腔引流量及时间、术后住院时间、术后肺部感染及切口感染、术后肌无力危象、术后慢性疼痛上肢运动障碍和疗效.结果 胸腔镜组术中出血量[(77.5±18.0)ml]、术后胸腔引流量[(100.8±11.8)ml]、术后胸腔引流时间[(2.3±0.5)d]、术后切口感染率(0)优于横断胸骨组[分别为(97.4±14.3)ml、(175.8±18.3)ml、(3.1±0.7)d、6.2%(2/32)]及胸骨部分劈开组[分别为(130.1±24.0)ml、(379.0±45.6)ml、(4.2±0.6)d、13.8%(9/65)](P＜0.05),同时横断胸骨组又优于胸骨部分劈开组(P＜0.05);胸腔镜组术后肺部感染、术后肌无力危象、术后慢性疼痛上肢运动障碍的发生率及术后住院时间均优于横断胸骨组及胸骨部分劈开组(P＜0.05).结论 三种小切口手术方式安全可行,疗效显著,胸腔镜切口手术有着显著的优越性,值得在各大中型医院广泛推广;而对于技术设备不发达的基层医院,横断胸骨切口为更好的选择.

Abstract：

Objective To investigate the best operative approach in the treatment of myasthenia gravis (MG) by comparing surgical effects of median sternotomy, trans-sternal surgery and video-assisted thoracoscope surgery (VATS). Methods One hundred and nine patients who received thymectomy for MG were divided into median sternotomy group,trans-sternal group and VATS group according to the way of operative incision. The clinical features, such as operative time, operative blood loss, postoperative drainage volume and drainage time, postoperative hospitalization time, postoperative pulmonary infection, incisional infection, MG crisis, postoperative chronic pain and upper limb's movement disorder were retrospectively analyzed to evaluate the effect of the surgery. Results The operative blood loss, postoperative drainage volume and drainage time,and incisional infection in VATS group [(77.5 ± 18.0) ml, ( 100.8 ± 11.8) ml,( 2.3 ± 0.5 ) d, 0 ] were superior to those in trans-sternal group[ (97.4 ± 14.3 ) ml, ( 175.8 ± 18.3 ) ml, ( 3.1 ±0.7 ) d, 6.2% ( 2/32 ) ] and median stemotomy group [ ( 130.1 ± 24.0) ml, ( 379.0 ± 45.6 ) ml, (4.2 ± 0.6) d,13.8% (9/65)] (P ＜0.05),and median sternotomy group was the worst. The incidence of postoperative pulmonary infection, MG crisis, upper limb's movement disorder and postoperative hospitalization time in VATS group were superior to those in trans-sternal group and median sternotomy group (P ＜0.05).Conclusions Three mini-incision surgical approaches are safe, feasible and effective. VATS is more advantageous and is worth popularizing in large and medium-sized hospitals. Trans-sternal surgery is the better choice for primary hospitals without advanced technology and equipments.     

流式细胞术检测重症肌无力患者调节性T细胞变化

目的：探讨并发胸腺疾病的重症肌无力患者的外周血和胸腺中调节性T细胞变化。方法：采用流式细胞仪多参数（三标CD4、CD25和Foxp3）逐层分析法分析并发胸腺疾病的重症肌无力患者的外周血和胸腺中调节性T细胞比例。结果：正常人、MG并胸腺增生者和MG并胸腺瘤者外周血中CD4＋阳性细胞中调节性T细胞比例差别无统计学意义（F=0.095,P=0.910）,胸腺中CD4＋阳性细胞中调节性T细胞比例差别有统计学意义（F=16.162,P〈0.001）。结论：调节性T细胞数量减少或功能异常在MG中起重要作用。用流式细胞仪多参数逐层分析法是淋巴细胞亚型分析的重要方法。     

中药干预对实验性重症肌无力小鼠T细胞及IL-6、Bcl-2的影响

目的探讨温肾活血、益气升清的益筋方对实验性自身免疫性重症肌无力小鼠的治疗机制。方法采用重症肌无力患者的血清被动免疫小鼠,建立实验性自身免疫性重症肌无力模型。分组后分别给予益筋方、强的松灌胃21d,处死动物、采血。利用流式细胞技术,以T细胞及其亚群、IL-6为指标,观察益筋方、强的松对实验性重症肌无力小鼠细胞免疫和细胞因子的影响;检测胸腺Bcl-2的表达。结果益筋方、强的松均能升高CD3^＋,降低CD4^＋／CD8^＋比值;二者对IL-6无显著影响,均减低胸腺Bcl-2的表达。结论益筋方能通过影响T细胞及其亚群、Bcl-2,达到治疗重症肌无力的作用。     

Outcome after thymectomy for myasthenia gravis: a retrospective review.

This is a retrospective study of 54 patients, who in the period November 1977 to November 1986 underwent thymectomy as treatment for myasthenia gravis. Patients in whom difficulty attempting complete excision of the gland was anticipated were selected for a transthoracic procedure. All others underwent an initial transcervical approach, proceeding to an upper sternal splitting incision if further access was required to remove adequately a large gland. The sample was split almost equally between the two surgical procedures. Patients in the transthoracic group were significantly older and experienced significantly greater peri-operative morbidity or mortality. There was no significant difference in outcome between the two groups, 52% achieving a good result (defined as remission or clinically significant improvement of symptoms) that was sustained over the five year follow-up period. In our opinion, complete removal of the thymus should be the goal of surgical treatment for myasthenia gravis.     

糖皮质激素对重症肌无力患者外周血T淋巴细胞Fas表达的影响

目的 探讨糖皮质激素治疗重症肌无力(MG)与Fas介导的细胞凋亡的关系.方法 选择17例MG患者,其中6例接受糖皮质激素治疗(糖皮质激素治疗组),11例未接受糖皮质激素治疗(无糖皮质激素治疗组);另选择同期健康自愿献血者13例作为健康对照组,采用流式细胞技术检测三组外周血T淋巴细胞表面CD4、CDs及Fas的表达.结果 糖皮质激素治疗组外周血T淋巴细胞表面CD4-CD8+表达高于健康对照组[(36.75±11.56)%比(26.31±9.00)%],CD4-CD8-表达低于健康对照组[(30.56±9.72)%比(42.96±11.54)%],差异有统计学意义(P=0.027、0.018);糖皮质激素治疗组外周血T淋巴细胞表面CD4-CD8+表达高于无糖皮质激素治疗组[(36.75±11.56)%比(25.24±7.63)%],差异有统计学意义(P=0.019).糖皮质激素治疗组外周血T淋巴细胞表面Fas+、CD8+Fas+表达高于健康对照组[(46.10±7.13)%比(31.22±13.00)%,(62.86±12.29)%比(45.59±11.50)%],差异有统计学意义(P=0.006、0.003).糖皮质激素治疗组CD8+Fas+表达高于无糖皮质激素治疗组[(62.86±12.29)%比(50.84±8.31)%],差异有统计学意义(P=0.034).结论 糖皮质激素治疗对MG患者外周血T淋巴细胞亚群分布具有影响.Fas介导的细胞凋亡可能是糖皮质激素治疗MG的机制之一.

Abstract：

Objective To investigate the relation between Fas-mediated apoptosis and glucocorticoid treatment in myasthenia gravis (MG). Methods In 17 patients with MG, 6 patients received glucocorticoid treatment (glucocorticoid treatment group),and 11 patients were treated without glucocorticoid (nonglucocorticoid treatment group). Meanwhile, 13 healthy cases were selected as healthy control group. CD4,CD8 and Fas expressions in peripheral blood T lymphocyte were detected by flow cytometry in three groups and analyzed. Results The percentage of CD4-CD8+ cells in peripheral blood T lymphocyte in glucocorticoid treatment group was significantly higher than that in healthy control group[(36.75 ± 11.56)% vs. (26.31 ±9.00)%, P = 0.027], while the percentage of CD4-CD8- cells was significantly lower [(30.56 ± 9.72)% vs.(42.96 ± 11.54)%, P =0.018]. The percentage of CD4-CD8+ cells in peripheral blood T lymphocyte in glucocorticoid treatment group was significantly higher than that in non-glucocorticoid treatment group [(36.75 ± 11.56)% vs. (25.24 ±7.63)% ,P =0.019]. The percentages of Fas+ and CD8 +Fas+ cells in peripheral blood T lymphocyte in glucocorticoid treatment group were significantly higher than those in healthy control group[(46.10 ± 7.13)% vs. (31.22 ± 13.00)%, P=0.006; (62.86 ± 12.29)% vs. (45.59 ±11.50)%, P = 0.003]. The percentage of CD8+ Fas+ cells in peripheral blood T lymphocyte in glucocorticoid treatment group was significantly higher than that in non-glucocorticoid treatment group [(62.86 ± 12.29)%vs (50.84 ± 8.31 )%, P = 0.034]. Conclusions Glucocorticoid treatment may have influence on peripheral blood T lymphocyte subsets in patients with MG. Fas-mediated apoptosis may be involved in the mechanism of glucocorticoid treatment in MG.     

A prospective,double-blind,randomized, placebo-controlled study on the efficacy and safety of influenza vaccination in myasthenia gravis

Objective

To investigate the efficacy and safety of an influenza vaccination in patients with myasthenia gravis with acetylcholine receptor antibodies (AChR MG).

A prospective,placebo controlled study on the humoral immune response to and safety of tetanus revaccination in myasthenia gravis

ObjectiveTo investigate the humoral immune response to and safety of a tetanus revaccination in patients with myasthenia gravis or Lambert-Eaton myasthenic syndrome.MethodsA tetanus revaccination was administered to 66 patients. Before and 4 weeks after revaccination a blood sample and clinical outcome scores were obtained. Anti-tetanus IgG total, IgG1 and IgG4 titres were measured with an ELISA and disease-specific antibody titres (AChR, MuSK or VGCC) with a radio-immunoprecipitation assay. A historic healthy control group was used for comparing tetanus antibody titres with that of our patients. A placebo (saline) vaccination group was used to investigate the variability of clinical outcome scores with a 4 weeks interval.ResultsIn 60 of 65 patients, a significant increase of the anti-tetanus antibody response was measured. Thymectomy did not have an impact on this responsiveness. Patients with immunosuppressive medication had a significantly lower pre and post titre compared to healthy controls, but their response was still significant. The titres of disease-specific antibodies were unchanged 4 weeks after revaccination. The clinical outcome scores showed no exacerbation of symptoms of the disease.ConclusionA tetanus revaccination in patients with myasthenia gravis or Lambert-Eaton myasthenic syndrome is safe and induces a significant immune response, irrespectively of their immunosuppressive medication. We observed neither immunological nor clinical relevant exacerbations associated with the tetanus revaccination.Clinical trial registryThe tetanus trial is listed on clinicaltrialsregister.eu under 2014-004344-35. The placebo AChR MG group was part of another clinical trial, investigating influenza vaccination in myasthenic patients. This trial is listed on clinicaltrialsregister.eu under 2016-003138-26.     

Refractory myasthenia gravis, dysphagia and malnutrition: A case report to suggest disease-specific nutritional issues

ObjectiveWe describe a case of refractory myasthenia gravis with bulbar involvement and the nutritional treatment solutions proposed to treat the associated dysphagia and malnutrition.MethodsA 39-y-old woman with refractory myasthenia gravis was referred to our clinical nutrition unit for deteriorating dysphagia and progressive malnutrition.ResultsThe first-line nutritional approach consisted of dietary counseling and thickened meals. Unfortunately, no adequate oral intake was achieved and an enteral nutrition treatment was proposed. A nasogastric tube was removed after a few days due to local pain and poor quality of life. Despite consistent weight loss and overt malnutrition, the patient refused percutaneous endoscopic gastrostomy placement. Neurologic symptoms did not show any improvement but unexpectedly the patient's weight started to increase to previous values. Anamnestic recall revealed that the patient learned by herself how to position the nasogastric tube that is now temporarily used for formula infusion coinciding with neurologic poussés.ConclusionsCurrent guidelines consider chronic neurologic diseases with associated dysphagia, where refractory myesthania gravis has also been considered, a unique category. Chronic neurogenic dysphagia with high risk of aspiration, long-term inability to obtain adequate oral intakes, and malnutrition are established indications for percutaneous endoscopic gastrostomy placement. However, patients may need different forms of nutritional intervention during the course of their illness and choices and indications should contemplate ethical reasons, clinical benefits, minimal risks, and acceptable quality of life. Minimally invasive intermittent enteral nutrition might be considered a possible clue for nutritional management of exacerbating dysphagia.     

双类似物鼻黏膜耐受对预防实验性自身免疫性重症肌无力的细胞免疫调节机制

目的　选择双类似物 (Lys2 6 2 Ala2 0 7)对实验性自身免疫性重症肌无力 (EAMG)模型进行鼻黏膜免疫耐受 ,探讨其对预防EAMG的细胞免疫调节机制。方法　EAMG模型在致敏前 10d(A组 )及致敏当日 (B组 )鼻腔给药 ,观察预防给药后各组间病情及细胞免疫指标的变化。结果 (1)急性期和慢性期预防耐受A、B组鼠病情明显轻于相应的对照组 ,慢性期A组明显轻于B组 ;(2 )慢性期第5 0天时CD4 CD2 5 T细胞含量 (单位 :cpm× 10 3 )A组 (11 34± 1 6 2 )、B组 (8 6 8± 1 83)均明显高于相应对照组 (C组 :6 78± 1 6 3,D组 :6 4 3± 1 6 9) ,且A组高于B组 ;(3)预防耐受A、B组γ 干扰素 (IFN γ)、白细胞介素 (IL) 4、IL 10阳性细胞含量均明显低于对照组 ;(4)A、B组对乙酰胆碱受体 (AchR)、Lys2 6 2 Ala2 0 7和AChR α 10 0～ 116肽段等特异性抗原的淋巴细胞的增殖反应均明显受到抑制。结论　Lys2 6 2 Ala2 0 7鼻黏膜免疫耐受抑制T细胞免疫功能 ,在防治EAMG中起重要作用。