心内直视术中患者血浆PGE2水平变化及其负性免疫调节作用

为了探讨心内直视术体外循环（ＣＰＢ）对患者血浆前列腺素Ｅ２（ＰＧＥ２）含量影响及ＰＧＥ２与ＣＰＢ后免疫功能关系，选择了３０例心内直视术患者，分别监测术前、ＣＰＢ６０分钟、１２０分、术毕、术后第１、７、１４天外周静脉血血浆ＰＧＥ２水平和外周血淋巴细胞白介素－２受体（ＩＬ－２Ｒ）表达及诱生白介素－２能力变化。结果显示ＣＰＢ中ＰＧＥ２急剧升高，是基础值的１０倍，术毕及术后第７天仍高于基础值（Ｐ〈０．０５     

体外循环手术前后病人血清sIL-2R水平和T淋巴细胞亚群、NK细胞的变化及临床意义

目的：通过检测心脏体外循环（ＣＰＢ）手术前后病人血清中可溶性白介素２－受体（ｓＩＬ－２Ｒ）、Ｔ细胞亚群、自然杀伤细胞（ＮＫ），观察分析心脏ＣＰＢ手术病人细胞免疫的影响及其临床意义。方法：选择２４例风心病择期换瓣病人，术前、ＣＰＢ１０分钟、ＣＰＢ２小时、术后第１天、３天、５天检测血清ｓＩＬ－２Ｒ水平、Ｔ细胞亚群及ＮＫ细胞活性。术后第１天血清ｓＩＬ－２Ｒ水平升高，ＣＯ４（辅助细胞）活性明显降低，ＣＤ４／ＣＤ８（辅助细胞／抑制细胞）比值下降，ＮＫ活性降低；并且ｓＩＬ－２Ｒ与ＣＤ４、ＮＫ活性呈负相关。结论：低温心脏ＣＰＢ手术对病人免疫机能有不良影响，临床应采取相应措施，改善术后病人的免疫机能。     

白细胞介素－6在老年女性原发性骨质疏松症发病中的作用

为探讨白细胞介素－６（ＩＬ－６）在老年女性原发性骨质疏松症（ｏｓｔｅｏｐｏｒｏｓｉｓＯＰ）发病中的作用，本文采用ＩＬ－６依赖性细胞株ＭＨ６０．ＢＳＦ增殖反应ＭＴＴ法检测了３０例老年女性骨质疏松性骨折患者和２４例正常者以及１４例健康绝经前女性外周血单核细胞培养上清（ＰＢＭＣ）ＩＬ－６水平以及血清雌激素（Ｅ２）、骨钙素（ＢＧＰ）等水平的变化。结果：绝经后妇女ＩＬ－６水平高于绝经前，而ＯＰ组又高于ＮＯＰ组。以ＯＰ组ＩＬ－６为因变量的多元回归分析发现：ＩＬ－６与年龄无明显相关关系，与前臂骨密度（ＢＭＤ）和Ｅ２呈负相关，与ＢＧＰ和尿钙与尿肌酐比值（Ｃａ／Ｃｒ）呈正相关。结果提示老年女性骨丢失属于高转换型，雌激素水平减少使分泌ＩＬ－６细胞活化，ＩＬ－６分泌增多，从而刺激骨吸收，骨吸收超过骨形成就会导致ＯＰ的发生     

表皮生长因子对应用TPN大鼠肠道免疫功能的作用

应用大鼠全肠外营养（ＴＰＮ）模型，观察ＴＰＮ过程中表皮生长因子（ＥＧＦ）对小肠谷氨酰胺（Ｇｌｎ）摄取及肠道免疫功能的调节作用。结果显示：常规ＴＰＮ可导致血浆及组织Ｇｌｎ明显下降，肠粘膜淋巴细胞ＩＬ－２活性明显下降，细菌易位增高；而在ＴＰＮ过程中，加用ＥＧＦ可防止肠道Ｇｌｎ水平下降；提高肠道对Ｇｌｎ的摄取率；并可有效防止粘膜淋巴细胞ＩＬ－２活性的下降；减少细菌易位。提示ＥＧＦ具有防止ＴＰＮ后肠粘膜屏障损伤和细菌易位作用。     

BCG和IL—2膀胱灌注预防膀胱癌复发的疗效观察

为了解ＢＣＧ与白介素２（ＩＬ２）联合应用膀胱灌注预防膀胱癌术后复发的疗效，将６８例膀胱癌随机分为两组：一组用ＢＣＧ１５０ｍｇ＋ＩＬ２１００００Ｕ，另一组单用ＢＣＧ１５０ｍｇ行膀胱内灌注。随访３～７５个月，平均３９．６个月，无肿瘤复发者ＢＣＧ＋ＩＬ２组３２例（９４％），单用ＢＣＧ组２８例（８２％），两组比较有显著性差异（Ｐ＜０．０１）。结果表明：ＢＣＧ与ＩＬ２联合应用能更有效地防止膀胱癌术后复发。     

IL-6、IL-1和PDGF对大鼠肾小球系膜细胞生长的影响

目的：探讨白细胞介素－６（ＩＬ－６）、白细胞介素－１（ＩＬ－１）和血小板源生长因子（ＰＤＧＦ）对大鼠肾小球系膜细胞（ＭｓＣ）增殖的影响。方法：采用改良的ＭＴＴ法和ＢｒｄＵ掺入法检测ＳＤ大鼠体外ＭｓＣ悬液中加入ＩＬ－６、ＩＬ－１及ＰＤＧＦ后１２ｈ及２４ｈ的增殖情况。分７组进行观察。结果：ＩＬ－６组、ＩＬ－１组和ＰＤＧＦ组１２ｈ及２４ｈ的光密度（ＯＤ值）与标记指数（ＬＩ）均为２％ＦＣＳ组也均高,但所有实验组均不能达２０％ＦＣＳ组的细胞增殖水平。联合应用双因子刺激１２ｈ及２４ｈ均未见明显的协同促增殖作用。结论：ＩＬ－６、ＩＬ－１及ＰＤＧＦ均能在一定程度上刺激大鼠肾小球ＭｓＣ增生。联合应用双因子刺激无明显的协同效应。     

重组合异种骨移植对IL—2生成影响的研究

采用重组合异种骨移植建立ＢＡＬＢ／Ｃ小鼠股后肌袋模型，以研究对Ｔ淋巴细胞分泌Ｉ－２的功能变化及对细胞免疫的影响。结果显示：（１）ＲＢＸ移植后２天ＩＬ－２升高是由于手术他伤刺激所致的应激反应。（２）术后７￣１４天ＲＢＸ，ｂＢＭＰ对ＩＬ－２ 显著的抑制作用，２８￣４２天回升。（３）对Ｔ淋巴细胞功能的抑制作用主要是ＢＭＰ所致，经处理的牛板质骨泣不具免疫源性。提示：ＲＢＸ移植无明显免疫排异反应。ＢＭＰ能抑     

含谷氨酰胺二肽全肠外营养对急性放射性小肠炎的营养作用

作者将３４只Ｓｐｒａｇｕｅ－Ｄａｗｌｅｙ大鼠随机分四组，Ａ组不含丙氨酰－谷氨酰胺二肽（Ａｌａ－Ｇｌｎ），而给予相应量的甘、丝、丙及脯氨酸的常规全肠外营养（ＴＰＮ－Ｃｏｎｖ）；Ｂ组含Ａｌａ－Ｇｌｎ的全肠外营养（ＴＰＮ－Ｇｌｎ）；两组间的热、氮及液体量相同。Ｃ组为消化道营养组。Ｄ组为正常组。实验组给予８戈瑞（ＧＹ）剂量全腹照射，然后分别给予ＴＰＮ及肠道营养７天。观察在急性放射性小肠炎时，Ａｌａ－Ｇｌｎ作为Ｇｌｎ源对小肠的代谢、结构及功能的影响，及经消化道营养的作用。实验结果表明，Ｂ组动脉血Ｇｌｎ浓度显著高于其它各组（Ｐ＜０．０５），说明Ａｌａ－Ｇｌｎ二肽输入后迅速分解为游离谷氨酰胺，利于组织使用。其小肠蛋白质和ＤＮＡ含量优于Ａ组。形态学结果显示组Ｂ小肠壁全层厚度、粘膜厚度及绒毛高度显著高于Ａ和Ｃ组（Ｐ＜０．０００１），且小肠腺窝细胞平均分裂数高于Ａ和Ｃ组（Ｐ＜０．０５），肠道内细菌移位率亦低于Ａ和Ｃ组（Ｐ＜０．０５）。粘液血便及体重降低以Ａ、Ｃ组为重。Ｃ组的摄食量不足，氮和热量摄取低于Ａ、Ｂ组，其体重下降超过Ｂ组。Ｃ组８只实验大鼠死亡２只，其中１只为末段回肠穿孔。Ａ、Ｂ组中无１例发生死亡及并发症。     

丙氨酰－谷氨酰胺对机体创伤后肠道屏障功能的保护作用

作者采用ＳＰＦ大鼠以ＴＰＮ、ＴＰＮ液中添加丙氨酰－谷氨酰胺（Ａｌａ－Ｇｌｎ）和经肠饮食（ＥＮ）三种营养方式支持一周后，造成创伤性休克，观察了大鼠在接受不同营养方式支持一周后，肠道屏障功能对严重创伤应激状态的影响，以及Ａｌａ－Ｇｌｎ是否具有维持肠道屏障功能的作用。结果显示，标准ＴＰＮ组与ＥＮ组相比，血浆二胺氧化酶（ＤＡＯ）水平明显低下；肠固有层（ＬＰ）淋巴细胞和浆细胞、肠上皮内淋巴细胞（ＩＥＬ）及肠腔细菌分泌型ＩｇＡ（Ｓ－ＩｇＡ）包被率明显下降；盲肠粘膜菌群Ｅ．ｃｏｌｉ优势增殖，双歧杆菌／大肠杆菌（Ｂ／Ｅ）比值倒置，肠上皮细菌粘附增多；肠道细菌移位率升高；死亡率（４／ｌ２）高。而Ａｌａ－Ｇｌｎ组因添加肠道必需氨基酸Ｇｌｎ前体Ａｌａ－Ｇｌｎ，各参数接近ＥＮ组，肠屏障储备增加，死亡率下降。提示：标准ＴＰＮ由于缺乏肠粘膜必需氨基酸（Ｇｌｎ）和肠道刺激，严重损伤肠屏障功能，创伤性休克可加重损害，促发脓毒症和多器官功能不全（ＭＯＤＳ）。对标准ＴＰＮ进行改良，添加肠粘膜保护剂Ａｌａ－Ｇｌｎ对肠屏障有较好维持作用。这对临床创伤和围手术期患者进行营养支持有一定指导意义。     

腹膜炎时血清中可溶性白介素-2受体水平变化与ATP-MgCl_2的免疫调节作用

为探讨三磷酸腺苷－氯化镁（ＡＴＰ－ＭｇＣｌ＿２）对腹膜炎动物免疫机能的影响，通过来用ＡＴＰ－ＭｇＣｌ＿２经腹腔注射治疗大鼠腹膜炎，并同时监测血清中可溶性白介素－２受体（ｓｌＬ－２Ｒ）水平变化。结果显示：随着时间的延长与感染程度的加重，治疗组和对照组血清ｓＩＬ－２Ｒ水平均呈逐渐升高趋势；且前者血清ｓＩＬ－２Ｒ水平在各时相中均明显低于后者（Ｐ＜０．０５，Ｐ＜０．０１）。结果表明：ｓＩＬ－２Ｒ的增高程度可间接反映腹膜炎大鼠体内免疫机能的受抑制程度，结果亦证实ＡＴＰ－ＭｇＣｌ＿２能恢复机体在疾病时受抑制的免疫应答，具有明显的免疫增强作用。     

口服谷氨酰胺颗粒对烧创伤患者的疗效及安全性分析

目的观察口服谷氨酰胺(Gln)颗粒对烧(创)伤及大手术患者的疗效及可能发生的不良反应.方法采用随机双盲、安慰剂对照法,将受试患者分为Gln组和对照组,每组60例,两组患者采用等氮、等热量的营养支持.Gln组口服或管饲Gln 0.5 g·kg-1·d-1,对照组使用同等剂量的安慰剂甘氨酸,疗程均为7 d.比较用药前后两组患者肠黏膜屏障功能、蛋白代谢、免疫功能、肝和肾功能的变化及不良反应等. 结果伤后两组患者血浆Gln浓度明显低于正常值,而血浆二胺氧化酶(DAO)活性、内毒素含量、肠黏膜通透性[尿乳果糖/甘露醇(L/M)]及尿氮排量均明显增高;但Gln组用药7 d后血浆Gln浓度与用药前比较增加38.04%(P＜0.01).Gln组血浆前白蛋白、转铁蛋白及白细胞介素2(IL-2)含量均显著高于对照组(P＜0.01),升幅分别为21.19%、51.11%、57.54%.血浆DAO活性、L/M比值、内毒素含量及尿氮排量明显低于对照组,降幅分别为47.26%、52.18%、22.22%、27.78%(P＜0.05或0.01).两组患者的血浆总蛋白、白蛋白、血尿常规及肝、肾功能在用约前后变化不明显(P＞0.05).用药后有少数患者出现轻微不良反应如恶心、腹泻和便秘等,2～3 d后自行缓解,两组间比较,差异无显著性意义(P＞0.05).结论口服Gln能显著提高患者血浆Gln浓度,明显减轻伤后肠黏膜受损程度,并能促进机体蛋白合成,降低蛋白分解,提高机体免疫功能,且临床应用无明显不良反应.     

Immunoprotective effects of cyclooxygenase inhibition in patients with major surgical trauma

Dysfunctional monocytes (M phi), exerting their inhibitory functions via prostaglandin E2 (PGE2), have been implicated in the depression of immune responses following major surgical, accidental, and burn trauma. A randomized prospective study of the PG-synthetase inhibitor indomethacin (Indo) was performed in 43 patients undergoing major surgical procedures, to evaluate its efficacy in correcting postoperative abnormalities of the cell-mediated immune system (CMI) and preventing infectious morbidity and mortality. Patients, following gastrectomy (GX) or reconstruction of the abdominal aorta (AG), in the treated group (PIndo), received 100 mg IV of Indo 6 hours postoperatively and 3 x 50 mg IV Indo over 24 hours on postoperative days (D) 1,2,3,4. The rate of infectious complications was recorded. Parameters of CMI evaluated preoperatively (D0) and on D1,D3,D5,D7 were: Delayed type hypersensitivity (DTH) response to recall antigens, mitogen-induced lymphocyte proliferation (LP), interleukin 2 (IL-2) synthesis, and phenotyping of mononuclear blood leukocytes (PBMC's) with the monoclonal antibodies for CD3+, CD4+, IL-2 receptor (IL-2R)+ and LeuM3+ receptor sites. In contrast to the group of untreated patients (Pc), PIndo did not show a depression of their preoperative DTH responses, and they also showed a lower rate of early opportunistic infections. The in vitro test of CMI revealed that there was a higher LP capacity in PBMC's of PIndo (p less than 0.05); the postoperative profile of IL-2 synthesis was not statistically different between the groups. Indomethacin administration resulted in a considerable alleviation of postoperative monocytosis (p less than 0.05) and in a protective effect on lymphocyte receptor expression of CD3+, CD4+, and IL-2R+ cells. From these data it is concluded that in vivo cyclooxygenase inhibition may be useful to prevent impairment of CMI, a crucial predisposing factor of the high susceptibility to postoperative infection.     

谷氨酰胺强化的肠内营养对烧伤后肠源性高代谢的影响

目的:探讨谷氨酰胺强化的肠内营养对烧伤后肠源性高代谢的影响及机制。方法:将88只Wistar大鼠随机分为烧伤后常规肠内营养支持组(B)和谷氨酰胺(Gln)强化的肠内营养组,并与烧伤前指标作对照(PBD0)。烧伤大鼠均经占体表面积30%的全层皮肤烧伤,B组和Gln组采用等氮、等热卡的营养支持,Gln组予1.0g/(kg·d)的Gln,B组予等量的甘氨酸。观察烧伤前和烧伤后(PBD)1、3、5、7、10d大鼠静息能量代谢率(REE)的变化,同时检测了血浆Gln浓度、二胺氧化酶(DAO)活性、内毒素(LPS)、肿瘤坏死因子(TNF)和白细胞介素-1(IL-1)含量,并进行比较分析。结果:烧伤后两组大鼠血浆Gln浓度明显低于烧伤前,而REE、DAO、TNF、LPS及IL-1水平则明显高于烧伤前。两组相比,烧伤后Gln组大鼠的血浆Gln浓度明显高于B组,增幅约达40%,而REE、DAO、LPS、TNF及IL-1水平则明显低于B组。相关分析显示,REE与血浆Gln浓度呈显著负相关(r=-0.89,P<0.01)。结论:Gln强化的肠内营养可有效地提高烧伤大鼠的血浆Gln浓度,减轻肠道受损程度,抑制炎症介质的释放,从而降低肠源性高代谢。     

Missing Effect of Glutamine Supplementation on the Surgical Outcome after Pancreaticoduodenectomy for Periampullary Tumors: A Prospective, Randomized, Double-blind, Controlled Clinical Trial

Background The effect of glutamine (Gln) supplementation in patients undergoing a major operation has not been conclusively established. This study was designed to elucidate the effect of Gln supplementation on the surgical outcome after a pancreaticoduodenectomy (PD) for periampullary tumors. Methods A prospective, randomized, double-blind, and controlled clinical trial was undertaken for patients who underwent a classical PD or a pylorus-preserving PD for periampullary tumors. The Gln and control groups received isonitrogenous amino acid, with a 0.2 g/kg per day Gln regimen administered to the Gln group. The surgical outcome was compared in light of length of postoperative hospital stay, nutritional and chemical profiles, and complication rate between the Gln and control groups. Results Sixty of the consecutive 143 patients who were admitted to undergo operation for periampullary tumors were enrolled in our study; 32 were in the Gln group and 28 in the control group. The two groups were comparable prior to and during the operation. The median length of the postoperative hospital stay and the postoperative nutritional and chemical profiles were not different between two groups. The overall and PD-related complication rates of the Gln group (37.5% and 25.0%) and the control group (28.6% and 14.3%) were not statistically different. Conclusions No significant beneficial effect of Gln supplementation with a low-dose parenteral regimen was demonstrated on the surgical outcome after a PD for periampullary tumors. Therefore, we should be prudent in using Gln as a routine pharmacologic supplement to the standard nutrition in patients who undergo major operations.     

Arginase I expression and activity in human mononuclear cells after injury

OBJECTIVE: To determine the effect of trauma on arginase, an arginine-metabolizing enzyme, in cells of the immune system in humans. SUMMARY BACKGROUND DATA: Arginase, classically considered an enzyme exclusive to the liver, is now known to exist in cells of the immune system. Arginase expression is induced in these cells by cytokines interleukin (IL) 4, IL-10, and transforming growth factor beta, corresponding to a T-helper 2 cytokine profile. In contrast, nitric oxide synthase expression is induced by IL-1, tumor necrosis factor, and gamma interferon, a T-helper 1 cytokine profile. Trauma is associated with a decrease in the production of nitric oxide metabolites and a state of immunosuppression characterized by an increase in the production of IL-4, IL-10, and transforming growth factor beta. This study tests the hypothesis that trauma increases arginase activity and expression in cells of the immune system. METHODS: Seventeen severely traumatized patients were prospectively followed up in the intensive care unit for 7 days. Twenty volunteers served as controls. Peripheral mononuclear cells were isolated and assayed for arginase activity and expression, and plasma was collected for evaluation of levels of arginine, citrulline, ornithine, nitrogen oxides, and IL-10. RESULTS: Markedly increased mononuclear cell arginase activity was observed early after trauma and persisted throughout the intensive care unit stay. Increased arginase activity corresponded with increased arginase I expression. Increased arginase activity coincided with decreased plasma arginine concentration. Plasma arginine and citrulline levels were decreased throughout the study period. Ornithine levels decreased early after injury but recovered by postinjury day 3. Increased arginase activity correlated with the severity of trauma, early alterations in lactate level, and increased levels of circulating IL-10. Increased arginase activity was associated with an increase in length of stay. Plasma nitric oxide metabolites were decreased during this same period. CONCLUSIONS: Markedly altered arginase expression and activity in cells of the human immune system after trauma have not been reported previously. Increased mononuclear cell arginase may partially explain the benefit of arginine supplementation for trauma patients. Arginase, rather than nitric oxide synthase, appears to be the dominant route for arginine metabolism in immune cells after trauma.     

Glutamine granule-supplemented enteral nutrition maintains immunological function in severely burned patients

Glutamine is an important energy source for immune cells. It is a necessary nutrient for cell proliferation, and serves as specific fuel for lymphocytes, macrophages, and enterocytes when it is present in appropriate concentrations. The purpose of this clinical study was to observe the effects of enteral nutrition supplemented with glutamine granules on immunologic function in severely burned patients. Forty-eight severely burned patients (total burn surface area 30-75%, full thickness burn area 20-58%) who met the requirements of the protocol joined this double-blind randomized controlled clinical trail. Patients were randomly divided into two groups: burn control group (B group, 23 patients) and glutamine treated group (Gln group, 25 patients). There was isonitrogenous and isocaloric intake in both groups, Gln and B group patents were given glutamine granules or placebo (glycine) at 0.5 g/kgd for 14 days with oral feeding or tube feeding, respectively. The plasma level of glutamine and several indices of immunologic function including lymphocyte transformation ratio, neutrophil phagocytosis index (NPI), CD4/CD8 ratio, the content of immunoglobulin, complement C3, C4 and IL-2 levels were determined. Moreover, wound healing rate of burn area was observed and then hospital stay was recorded. The results showed significantly reduced plasma glutamine and damaged immunological function after severe burn Indices of cellular immunity function were remarkably decreased from normal controls. After taking glutamine granules for 14 days, plasma glutamine concentration was significantly higher in Gln group than that in B group (607.86+/-147.25 micromol/L versus 447.63+/-132.38 micromol/L, P<0.01). On the other hand, cellular immunity functions were improved in Gln group, such as lymphocyte transformation ratio, NPI, CD4/CD8 ratio and IL-2 compared those in the B group (P<0.05-0.01). However, for humoral immunity function such as the concentration of IgG, IgM, C3, C4, no marked changes were seen compared with the B group (P>0.05). In addition, wound healing was better and hospital stay days were reduced in Gln group (46.59+/-12.98 days versus 55.68+/-17.36 days, P<0.05). These indicated that immunological function damage is present after severe burn; supplemented glutamine granules with oral feeding or tube feeding abate the degree of immunosuppression, improve immunological function especially cellular immunity function, ameliorate wound healing and reduce hospital stay.     

Do female sex steroids adversely or beneficially affect the depressed immune responses in males after trauma-hemorrhage?

HYPOTHESIS: Administration of female sex steroids in males after trauma-hemorrhage has salutary effects on the depressed immune responses. DESIGN: Randomized laboratory experiment. INTERVENTIONS: Male C3H/HeN mice were subjected to midline laparotomy and hemorrhagic shock (35+/-5 mm Hg for 90 minutes, then resuscitation) or sham operation and received subcutaneous 17beta-estradiol (40 microg/kg body weight) or corn oil vehicle at the beginning of resuscitation. MAIN OUTCOME MEASURES: At 24 hours after hemorrhage, the animals were killed and plasma 17beta-estradiol and IL-6, splenocyte interleukin (IL) 2, IL-3, and IL-10 production as well as splenic and peritoneal macrophage IL-1beta, IL-10, and IL-6 release were measured. RESULTS: Splenocyte IL-2 and IL-3 release were significantly depressed after hemorrhage in vehicle-treated mice (P<.05, analysis of variance). Treatment with 17beta-estradiol after hemorrhage led to the restoration of splenocyte IL-2 and IL-3 release. The depressed proinflammatory cytokine (IL-1 and IL-6) release seen in splenic and peritoneal macrophages was restored in the 17beta-estradiol-treated hemorrhage group. In contrast, the sustained release of the anti-inflammatory cytokine IL-10 by splenocytes and splenic and peritoneal macrophages in vehicle-treated mice after hemorrhage was decreased in 17beta-estradiol-treated mice. The increase in circulating IL-6 levels after hemorrhage was significantly attenuated in 17beta-estradiol-treated mice. Although administration of 17beta-estradiol increased plasma 17beta-estradiol levels by approximately 100% in sham as well as hemorrhage groups, improved immune responses were seen only in posthemorrhage 17beta-estradiol-treated mice. There was no adverse effect of 17beta-estradiol treatment in the sham or posthemorrhage groups. CONCLUSION: Since administration of a single dose of 17beta-estradiol in males after trauma-hemorrhage restores the immune functions and decreases circulating levels of IL-6, hormones with estrogenic properties should be considered as safe and novel therapeutic agents for restoring the immune responsiveness in male trauma victims.     

Immune responses and prediction of major infection in patients undergoing transhiatal or transthoracic esophagectomy for cancer

OBJECTIVE: To investigate alterations in immune responses after transhiatal versus transthoracic esophageal resection and to evaluate the role of preoperative immune functions in predicting postoperative infectious complications. SUMMARY BACKGROUND DATA: Impaired immune defense is associated with a decreased resistance to infection. Patients undergoing esophageal resection via a transhiatal or transthoracic approach are prone to develop infectious complications. There are no randomized data on immune responses after two major surgical interventions. METHODS: The study group consisted of 20 patients who were randomly allocated to a limited transhiatal or extended transthoracic esophagectomy for cancer. Blood samples were taken before the operation and at regular intervals thereafter from day 1 to day 10. Monocyte and T-helper type 1 (Th1) and type 2 (Th2) lymphocyte functions were assessed in stimulated whole blood cultures. RESULTS: Both surgical groups had severely depressed in vitro production of interleukin (IL)-12, IL-10, interferon-gamma, IL-2, IL-4, and IL-13 on postoperative day 1. Depression of Th2-type cytokine production was more profound after transthoracic than after transhiatal esophagectomy (IL-4, P=.005; IL-13,P=.007). Postoperative reduction in Th1-type cytokine production was similar between the two groups (interferon-gamma, P=.40; IL-2, P=.06). Irrespective of the surgical approach, patients who developed major infectious complications after surgery presented with a diminished T-cell cytokine production before the operation compared to those who had a relatively uneventful recovery (IL-4, P=.045; interferon-gamma, P=.064). In regression analysis, the occurrence of postoperative major infection was best predicted by increased duration of anesthesia ( P<.0001) and low preoperative interferon-gamma production ( P=.006). CONCLUSIONS: Both transhiatal and transthoracic esophagectomy induced severely depressed monocyte and T-lymphocyte cytokine production. The extent of the surgical procedure had a differential immunosuppressive impact on Th2-type but not on Th1-type cell activity, indicating that the two Th pathways were downregulated through distinct mechanisms. Preoperative interferon-gamma determination would be useful to anticipate the occurrence of postoperative major infectious complications.     

联合应用谷氨酰胺和重组人生长激素对严重烧伤患者蛋白代谢的影响

目的　探讨联合应用谷氨酰胺 (Gln)和重组人生长激素 (rhGH)对严重烧伤患者蛋白代谢的影响。　方法　将 6 0例严重烧伤患者随机分为对照组、Gln组及Gln rhGH组 ,每组 2 0例。对照组患者于伤后 1～ 14d口服甘氨酸作为安慰剂 ,并行常规治疗 ;Gln组于伤后 1～ 14d口服Gln 0 5g·kg-1·d-1;Gln rhGH组患者口服Gln(剂量、时间同Gln组 ) ,且伤后 7～ 14d皮下注射rhGH 0.2U·kg-1·d-1。3组患者于伤后 1、7、14d检测其血浆Gln浓度 ,伤后 14、2 1d检测血浆白蛋白水平 ,记录伤后 30d创面愈合率和总住院日。　结果　Gln rhGH组伤后 7d血浆Gln浓度为 ( 4 5 2 .2 8± 2 1.72 )μmol/L,高于对照组 ( 32 5 .12± 2 5 .34) μmol/L(P <0.0 5)。伤后 2 1dGln rhGH组血浆白蛋白水平为( 31.37± 4 .31) g/L,高于对照组 ( 2 6 .16± 3.12 ) g/L及Gln组 ( 2 8.2 6± 3.2 9)g/L( P <0 0 5 )。伤后 30dGln rhGH组创面愈合率高于对照组及Gln组 ,而总住院日少于对照组及Gln组 (P <0.0 5或 0 .0 1)。　结论　联合应用Gln和rhGH能显著提高严重烧伤患者血浆Gln水平 ,促进机体蛋白的合成 ,提高创面愈合率。     

Glutamine-supplemented total parenteral nutrition enhances T-lymphocyte response in surgical patients undergoing colorectal resection.

OBJECTIVE: The authors determined the effect of glutamine-supplementation of TPN on postoperative peripheral blood T-cell response and proinflammatory cytokine production in patients undergoing colorectal resection. SUMMARY BACKGROUND DATA: Several vital tissues, including the immune system, are very dependent on glutamine; however, this amino acid, which may be essential in conditions of stress, only now is becoming formulated suitably for incorporation into TPN. The effects of such supplementation on the immune function of stressed surgical patients is unknown. METHODS: Patients (n = 20) were randomized to receive conventional TPN (0.2 g nitrogen/kg/d) or an isonitrogenous/isocaloric regimen with 0.18 g of glutamine/kg/d from days 1 to 6 postoperatively. T-cell DNA synthesis and interleukin (IL)-2 production and peripheral blood mononuclear cell IL-6 and tumor necrosis factor (TNF) production were measured in vitro preoperatively and on days 1 and 6 postoperatively. RESULTS: T-cell DNA synthesis after 5 days of TPN was increased compared with preoperative values in the glutamine-supplemented group (median preoperative tritiated thymidine uptake: 78.3 x 10(3) cpm, day 6: 95.0 x 10(3) cpm, p < 0.05). There was no such increase in the control TPN group (preoperative: 89.0 x 10(3) cpm, day 6: 69.4 x 10(3) cpm, p > 0.05). Glutamine supplementation did not influence IL-2 production or the production of TNF or IL-6. CONCLUSIONS: Glutamine supplementation may be a method of enhancing T-cell function in the surgical patient receiving TPN.