危重病患者SIRS早期细胞因子水平动态变化的研究

目的：探讨炎性细胞因子[肿瘤坏死因子－α（TNF-α）,白细胞介素－1β（IL-1β）和白细胞介素－6（IL－6）在危重病患者SIRS早期的动态变化及对MODS早期诊断的意义。方法：应用酶联免疫法测定30例危重病患者SIRS早期TNF－α、IL－1β及IL－6的动态变化,比较SIRS组及正常对照组的TNF－α、IL－1β及IL－6的变化,结果：30例患者血 TNF－α、IL－1β及IL－6水平均明显升高,较正常对照组差异显著（P均＜0．01）。结论：炎性细胞因子参与子MODS的发生发展;SIRS期血中TNF－α、IL－1β及IL－6水平对MODS的早期诊断有十分重要的意义。     

急性脑出血伴全身炎症反应综合征患者CD62p与细胞因子的表达及其对预后的影响

目的 探讨急性脑出血伴全身炎症反应综合征(SIRS)及多器官功能障碍综合征(MODS)患者血液中细胞因子的表达及其对预后的影响.方法 采用流式细胞方法 对单纯急性脑出血、合并SIRS或MODS患者的血小板活化标记物CD62p及细胞因子的表达进行检测,并与正常对照组进行比较.结果 单纯急性脑出血及合并SIRS或MODS患者的CD62p、肿瘤坏死因子-α及白细胞介素-6浓度均明显高于正常对照组(P<0.01),MODS组高于SIRS组,且MODS死亡组高于存活组(P<0.01).结论 血小板活化及细胞因子过度表达参与急性脑出血、SIRS及MODS的病理生理过程,且与病情及预后有关.     

血清C-反应蛋白和白细胞介素-6在危重病患者中的临床价值

目的　探讨细胞因子在全身炎性反应综合征 (SIRS)向多脏器功能衰竭综合征 (MODS)转化中的诊断价值和临床意义。方法　用ELISA法测定SIRS组、正常对照组、动态观察组血清CRP、IL 6含量。结果　血清CRP、IL - 6的含量于危重患者发病后 2 4小时内即明显高于正常对照组 (P <0 .0 1)。动态观察组中含量呈先升后下降趋势 ,高峰值多出现在第 6天 ,但各时间段测值仍显著高于正常对照组 (P <0 .0 5 )。结论　危重患者SIRS发生后 2 4小时内血清CRP与IL 6等炎性因子参与了SIRS向MODS过度的发生发展过程。SIRS患者早期血中CRP、IL 6的测定可用于早期诊断MODS。     

病毒性心肌炎、扩张型心肌病患者TNF、sIL-2R、IL-6、IL-8、T细胞亚群的改变

目的 :研究免疫反应在病毒性心肌炎 (VMC)、扩张型心肌病 (DCM )发病中所起的作用。方法 :对 30例VMC患者、40例DCM患者分别采用放免法测定血清肿瘤坏死因子 (TNF)水平 ;ELISA法测定血清可溶性白细胞介素 2受体 (sIL -2R)、白细胞介素 6 (IL -6 )、白细胞介素 8(IL -8)水平 ;ABC染色法测定外周血T淋巴细胞亚群 ,并与 30例正常人 (NC)对照。结果 :VMC组、DCM组血清TNF、sIL -2R、IL -6、IL -8水平均显著高于NC组 (P <0 0 1～ 0 0 0 1) ,T细胞亚群中CD4、CD8显著低于NC组 (P <0 0 5～ 0 0 0 1) ,CD4/CD8显著高于NC组 (P <0 0 0 1)。结论 :一系列细胞因子介导的免疫、炎症反应 ,免疫调节网络功能的失衡在VMC、DCM的发生、发展中起重要作用     

连续性肾替代治疗对全身炎症反应综合征预后的影响

目的 :对全身炎症反应综合征 (SIRS)的病人使用连续肾替代治疗 (CRRT)研究它对各种炎症介质 (如肿瘤坏死因子TNF 浕 ,白介素IL 1β,IL 6 ,IL 8)的清除作用 ,通过调控炎症反应阻断SIRS向多器官功能不全综合征 (MODS)的发展 ,降低MODS的发生 ,提高SIRS的抢救成功率。方法 :应用连续性静脉 静脉血液滤过 (CVVH)抢救 15例急性重症肾衰伴SIRS患者 (Ⅰ组 )及 2 3例肾功能衰竭前的SIRS患者 (Ⅱ组 )。结果 :两组患者TNF α、IL Iβ、IL 6均明显升高 ,经治疗后均降低 ,但II组降低更明显 ,两组对照比较有显著差异 (P <0 .0 1) ;I组 15例全部发生MODS ,10例死亡 ;II组 2 3例其中 6例发生MODS ,4例死亡 ,两组MODS发生率及死亡率均有显著差异 (P <0 .0 1)。结论 :CRRT能有效地清除各种炎症介质 ,在肾功能衰竭前的SIRS患者应用CRRT能有效地阻断SIRS向MODS的发展 ,抢救成功率明显提高。     

高容量连续性静脉-静脉血液滤过对多器官功能障碍综合征患者外周血细胞因子的影响

目的　应用高容量连续性静脉 静脉血液滤过 (Hv -CVVH)技术 ,探讨其对多器官功能障碍综合征 (MODS)患者外周血细胞因子的影响。方法　 2 0例非创伤性MODS患者经中心静脉插管留置单针双腔导管 ,使用BaxterBM2 5机器行Hv CVVH方式治疗。于治疗前和治疗后 2、 4、 6、 8h时分别抽取静脉血 ,采用ELISA法测定血浆肿瘤坏死因子α (TNF -α)、白细胞介素 1(IL - 1)、白细胞介素 6 (IL - 6 )、白细胞介素 8(IL - 8)的含量 ,并在每日早晨抽取静脉血检测Bun、Scr、K+ 的浓度 ,同时抽取动脉血作血气分析。结果　所有患者的Hv CVVH后血清Bun、Scr、K+ 均逐渐明显下降 (P <0 0 5或P <0 0 1) ,血浆TNF -α、IL - 1、IL - 8水平均逐渐降低 (P <0 0 5 ) ,血浆IL 6水平在CBP前后均无统计学差异 (P >0 0 5 )。结论　Hv CVVH能清除MODS患者血浆中多种细胞因子 ,并改善血液生化指标 ,因此可以用于MODS的治疗     

急性脑梗死辨证分型与细胞因子的关系

目的 :探讨急性脑梗死 (ACI)中医辨证分型与细胞因子介导的免疫损伤的关系。方法 :采用电化学发光免疫技术对 6 0例 ACI患者治疗前后的肿瘤坏死因子 α(TNFα)、白介素 2受体 (IL 2 R)、白介素 6(IL 6 )水平进行检测并作对照分析。结果 :ACI患者治疗前后 TNFα、IL 2 R、IL 6均显著高于健康对照组(P均 <0 .0 1) ,治疗后 TNFα、IL 2 R、IL 6均明显降低 ,与治疗前比较均有显著性差异 (P均 <0 .0 5 ) ;中脏腑患者 TNFα、IL 2 R和 IL 6水平均明显高于中经络组 (P均 <0 .0 5 ) ;风痰瘀阻、痰热痹阻、肝阳上亢型患者 TNFα、IL 2 R、IL 6活性水平均显著高于阴虚风动和气虚血瘀型 ,差异有显著性 (P均 <0 .0 1)。结论 :中风病的致病因素、病情轻重和辨证分型与 TNFα、IL 2 R、IL 6介导的炎性反应、神经内分泌和免疫网络功能的失调密切相关。     

麝香注射液对急性脑梗死患者CD62P与TNF-α的影响

目的 :观察麝香注射液治疗急性脑梗死 ( ACI)的作用机制。方法 :6 3例 ACI患者随机分为两组 ,治疗组 32例用麝香注射液加盐酸川芎嗪注射液治疗 ,对照组 31例用盐酸川芎嗪注射液治疗。采用流式细胞仪、电化学发光法测定两组 ACI患者治疗前后血小板 CD6 2 P的阳性表达率与肿瘤坏死因子 α( TNFα)、白介素 6( IL 6 )水平 ,并与 30例健康人组作对照及相关分析。结果 :ACI患者治疗前后 CD6 2 P、TNFα和 IL 6均显著高于健康人组 ( P<0 .0 5或 P<0 .0 1) ,ACI患者 CD6 2 P表达与 TNFα、IL 6水平升高呈正相关 ;麝香注射液组治疗后 CD6 2 P、TNFα和 IL 6水平的降低较对照组显著 ( P<0 .0 5或 P<0 .0 1) ,临床治愈、显效率亦明显高于对照组 ( P均 <0 .0 5 )。结论 :麝香注射液治疗 ACI的作用机制与其抑制血小板活化增强、减轻细胞因子介导的中枢神经系统免疫应答及炎症损伤等有关。     

连续性血液净化对全身炎性反应综合征合并急性肾衰患者血浆炎性介质水平的影响

目的　应用连续静静脉血液滤过 (CVVH)技术 ,探讨其对全身炎性反应综合征 (SIRS)合并急性肾衰 (ARF)患者体内促炎与抗炎细胞因子水平的影响。方法　 16例SIRS合并ARF患者经右侧股静脉插管留置单针双腔导管 ,使用DiapactCRRT机行高容量连续静脉—静脉血液滤过 (HV -CVVH)模式治疗。治疗上除连续性血液净化 (CBP)外 ,主要包括原发病的处理和重要脏器或系统功能的支持或维护。于CVVH治疗前和治疗后 2、4、6h以及停止CVVH后 6h ,分别抽取静脉血检测血液电解质、肾功能和有关细胞因子 ,动脉血做血气分析 ,其中采用ELISA法测定有关细胞因子。结果　 16例患者CVVH后血清BUN、Scr、K+ 均逐渐地呈明显下降趋势 (P均 <0 0 5或 0 0 1) ,血浆TNF -α、IL - 1β、IL - 2、IL - 2R以及IL - 8水平均逐渐降低 ,血浆IL - 6、IL - 4、IL - 10水平在CBP治疗前后均无统计学差异 (P均 >0 0 5 )。结论　CBP能清除SIRS合并ARF患者血浆多种致炎细胞因子 ,并可改善血液生化指标。     

原发性高血压红细胞CD35分子表达及其免疫调整

目的 :探讨原发性高血压致动脉硬化者红细胞Ⅰ型补体受体 (CR1 、CD3 5)分子表达和血清前炎症细胞因子水平 ,以及胸腺素的非特异免疫调整作用。方法 :用间接免疫荧光法 ,流式细胞仪检测患者红细胞CD3 5,用酶联免疫吸附法检测其血清IL -6、IL -8、TNF -α水平 ,用聚乙二醇 (PEG)法检测循环免疫复合物 (CIC) ,并使用胸腺素调整患者上述免疫指标异常。结果 :患者红细胞CD3 5分子表达明显低下 (P <0 .0 0 1) ,CIC在血管内大量堆积 ,而血清IL -6、IL -8、TNF -α水平明显增高 (P <0 .0 0 19) ,通过实验治疗 ,上述指标均明显改善。结论 :红细胞CD3 5分子表达和前炎症细胞因子异常作为重要免疫病理机制 ,参与了高血压病动脉硬化的发生发展 ,而胸腺素对促进红细胞CD3 5表达 ,清除过量CIC ,下调前炎症细胞因子水平均具重要的临床意义     

Migraine and genetic and acquired vasculopathies

It is remarkable that migraine is a prominent part of the phenotype of several genetic vasculopathies, including cerebral autosomal dominant arteriopathy with subcortical infarcts and leucoencephalopathy (CADASIL), retinal vasculopathy with cerebral leukodystrophy (RVCL) and hereditary infantile hemiparessis, retinal arteriolar tortuosity and leukoencephalopahty (HIHRATL). The mechanisms by which these genetic vasculopathies give rise to migraine are still unclear. Common genetic susceptibility, increased susceptibility to cortical spreading depression (CSD) and vascular endothelial dysfunction are among the possible explanations. The relation between migraine and acquired vasculopathies such as ischaemic stroke and coronary heart disease has long been established, further supporting a role of the (cerebral) blood vessels in migraine. This review focuses on genetic and acquired vasculopathies associated with migraine. We speculate how genetic and acquired vascular mechanisms might be involved in migraine.     

Fibrinogen and fibrin structure and functions

Fibrinogen molecules are comprised of two sets of disulfide-bridged Aalpha-, Bbeta-, and gamma-chains. Each molecule contains two outer D domains connected to a central E domain by a coiled-coil segment. Fibrin is formed after thrombin cleavage of fibrinopeptide A (FPA) from fibrinogen Aalpha-chains, thus initiating fibrin polymerization. Double-stranded fibrils form through end-to-middle domain (D:E) associations, and concomitant lateral fibril associations and branching create a clot network. Fibrin assembly facilitates intermolecular antiparallel C-terminal alignment of gamma-chain pairs, which are then covalently 'cross-linked' by factor XIII ('plasma protransglutaminase') or XIIIa to form 'gamma-dimers'. In addition to its primary role of providing scaffolding for the intravascular thrombus and also accounting for important clot viscoelastic properties, fibrin(ogen) participates in other biologic functions involving unique binding sites, some of which become exposed as a consequence of fibrin formation. This review provides details about fibrinogen and fibrin structure, and correlates this information with biological functions that include: (i) suppression of plasma factor XIII-mediated cross-linking activity in blood by binding the factor XIII A2B2 complex. (ii) Non-substrate thrombin binding to fibrin, termed antithrombin I (AT-I), which down-regulates thrombin generation in clotting blood. (iii) Tissue-type plasminogen activator (tPA)-stimulated plasminogen activation by fibrin that results from formation of a ternary tPA-plasminogen-fibrin complex. Binding of inhibitors such as alpha2-antiplasmin, plasminogen activator inhibitor-2, lipoprotein(a), or histidine-rich glycoprotein, impairs plasminogen activation. (iv) Enhanced interactions with the extracellular matrix by binding of fibronectin to fibrin(ogen). (v) Molecular and cellular interactions of fibrin beta15-42. This sequence binds to heparin and mediates platelet and endothelial cell spreading, fibroblast proliferation, and capillary tube formation. Interactions between beta15-42 and vascular endothelial (VE)-cadherin, an endothelial cell receptor, also promote capillary tube formation and angiogenesis. These activities are enhanced by binding of growth factors like fibroblast growth factor-2 (FGF-2) and vascular endothelial growth factor (VEGF), and cytokines like interleukin (IL)-1. (vi) Fibrinogen binding to the platelet alpha(IIb)beta3 receptor, which is important for incorporating platelets into a developing thrombus. (vii) Leukocyte binding to fibrin(ogen) via integrin alpha(M)beta2 (Mac-1), which is a high affinity receptor on stimulated monocytes and neutrophils.     

Telemedicine and teleradiology technologies and applications

Summary. Telemedicine and teleradiology hold the key for improving future health care delivery. In this paper we first review current communication and computer technologies used in telemedicine and teleradiology. Five examples in teleradiology applications are given including hospital-integrated picture archiving and communication systems, tele-neuro-imaging, telemammography, university consortium teleradiology service, and teleradiology for second opinion. Parameters important to teleradiology applications like costs, image quality, system reliability, and turn around time are considered. Data security is discussed, including patient confidentiality and image authenticity-which will be a major issue in future teleradiology applications.     

创伤高血糖与感染和MODS早期诊断和干预

本文详细介绍了创伤后血糖应激适度理论,以及高血糖与感染和多器官功能不全综合征的关系;提出涉及胰岛B细胞功能不全的MODS实验诊断新方案和极化液个体化干预新措施,可早期发现创伤MODS、降低感染率及MODS发生率和病死率。     

腹膜后纤维化与肾积水发生关系的临床研究

目的：探讨腹膜后纤维化（RPF）导致肾积水的原因及诊治经验。方法：回顾分析2004年1月—2010年12月24例腹膜后纤维化致肾积水患者的诊治资料。结果：（1）RPF患者常见首发症状为腰背痛或腹痛（69.2%）;（2）红细胞沉降率（ESR）增快和血清IgG4升高最常见。超声检查仅提示上尿路积水。RPF的静脉肾盂造影（IVP）和CT尿路成像（CTU）表现具有特征性。IVP肾盂输尿管显影不良时,CTU能较清晰的显示上尿路影像。CT扫描发现腹膜后软组织肿块9例（37.5%）,优于超声检查;（3）输尿管松解和腹腔化手术治疗22例;行肾切除术1例;行输尿管置双J管术1例。最终确诊为继发性RPF8例,其中4例为术前诊断,3例为术中腹膜后软组织肿块冷冻活检证实,1例为术后病理证实;（4）特发性RPF手术后肾积水均获长期缓解,而继发性RPF的预后取决于原发疾病及其治疗方案。结论：影像学检查是诊断RPF的重要手段,CTU优于超声检查和IVP。输尿管松解和腹腔化手术可以使特发性RPF输尿管梗阻得到长期的缓解,术中对肿块进行冷冻活检有助于鉴别特发性和继发性RPF,及时调整治疗方案。     

探讨儿童慢性顽固性咳嗽与支原体感染的关系及临床治疗观察

目的探讨儿童慢性顽固性咳嗽与肺炎支原体（MP）感染的关系及临床疗效观察。方法采用回顾性研究方法对于现将2005年3月至2008年3月在我院的55例确诊慢性顽固性咳嗽患儿,主要表现为肺炎支原体感染为临床特点进行分析,并进一步临床治疗研究。结果①临床特点：在55例确诊慢性咳嗽的患儿中,以慢性顽固性咳嗽为主要症状。58％（32／55）的病例无肺部体征;②外周血：85％（47／55）的病例外周血变化不大,WBC（4—10）×10 9／L之间,嗜酸性粒细胞增多;③特别检查：47．27％（26／55）肺炎支原体IgM（MP—IgM）抗体阳性,83．64％（46／55）PeR技术检测肺炎支原体特异性DNA;④X光报告为多种形式。结论肺炎支原体（MP）感染是引起儿童慢性顽固性咳嗽的病因之一,对儿童慢性咳嗽,特别是顽固性咳嗽的诊治中应更加重视。     

Acetaminophen and acetylcysteine dose and duration: Past,present and future

Abstract

Acetylcysteine has been utilized successfully in the treatment of acetaminophen overdose since the 1970s. Although prospective trials as to efficacy and safety of acetylcysteine were conducted, there were no randomized controlled trials. This commentary addresses the reasons for this, and the background to choice of dose of acetylcysteine utilized in the oral and IV dosing regimens. Nomograms to predict possible hepatotoxicity based upon time of ingestion of acetaminophen were developed from a relatively arbitrary definition of toxicity as an aspartate aminotransferase/alanine aminotransferase (ALT/AST) greater than 1000 IU/L. While these have proved generally useful, patients still continue to develop hepatic damage after acetaminophen overdose, particularly if they present late after ingestion. The optimum management of these patients remains unclear, and one area of uncertainty is the dose and duration of acetylcysteine in various circumstances. This article discusses the issues that need to be elucidated to better target changes in acetylcysteine dose. The potential for measurements of other markers to improve treatment selection is the subject of further research.     

Physician and Nurse Practitioner Teamwork and Job Satisfaction: Gender and Profession

Designing interprofessional primary care teams composed of physicians and nurse practitioners (NPs) is a national priority. We assessed how profession and gender affect teamwork and job satisfaction among primary care physicians and NPs by using survey data from 186 physicians and 398 NPs practicing in New York State. Our regression models show profession (NP vs physician) moderates the associations of gender with teamwork and job satisfaction. Among NPs, men had higher job satisfaction than women. Among physicians, women had higher job satisfaction than men. Our results can benefit interprofessional primary care teams to optimize their professional and gender mix.