心脏瓣膜术后患者谵妄与围术期心功能的相关性研究

目的：分析心脏瓣膜术后患者谵妄发生的影响因素以及术后谵妄与心功能的相关性。方法：选取2021年10月至2022年12月于安贞医院行心脏瓣膜手术的患者300例,收集患者术前及术后经胸心脏超声检查结果、术后血管活性药物使用情况及临床相关资料。结果：284名患者最终纳入分析,其中88例患者发生了术后谵妄（31.0%）,经多因素Logistic回归分析结果显示,年龄（OR=1.085,P=0.048）、术前简易精神状态检查量表评分（OR=0.615,P=0.004）、术前EF值（OR=0.865,P=0.02）、麻醉时间（OR=1.687,P=0.045）、术后机械通气时间（OR=2.17,P=0.01）、住院天数（OR=1.378,P=0.043）、ICU天数(OR=1.699,P=0.018）和手术后前3d平均血管活性药物指数（OR=2.206,P=0.006)是心脏瓣膜手术患者术后谵妄发生的相关因素。结论：心脏瓣膜手术术后谵妄发生的影响因素较复杂,患者年龄、术前认知功能、麻醉时间、机械通气时间、术后ICU时间、住院时间和围术期心功能是术后谵妄的相关因素。重视和规避这些因素对改善患者术后转...     

神经损伤标志物与老年患者心脏瓣膜置换术后谵妄的相关性

探讨血浆中神经损伤标志物与老年患者心脏瓣膜置换术后谵妄发生的相关性。方法 将2018年12月至2019年12月在西部战区总医院住院并择期行心脏瓣膜置换手术的老年患者共109例纳入本研究。术后在监护室采用重症监护意识紊乱评估法评估谵妄。对比手术前后患者血浆中神经损伤标志物神经元特异性烯醇酶(NSE)和S100β的表达变化。患者基线资料,采用单因素和多因素logistic回归分析,明确NSE和S100β与谵妄发生的关系及其他谵妄的危险因素。结果 老年患者心脏瓣膜置换术后谵妄发生率为30.3％(33/109)。术后血浆中NSE和S100β水平均较术前明显升高(均P＜0.01)。多因素logistic回归分析表明:糖尿病(OR=1.76,95%CI 1.02~2.61;P=0.04)、机械通气时间(OR=3.11,95%CI 1.29~7.52;P＜0.01)、NSE浓度(OR=5.94,95%CI 1.53~12.04;P＜0.01)及S100β浓度(OR=5.11,95%CI 1.38~10.14;P＜0.01)是谵妄发生的危险因素。结论 神经损伤标志物NSE和S100β浓度与老年患者心脏瓣膜置换术后谵妄密切相关,血浆NSE和S100β浓度的升高可能是谵妄发生的有效预测因子。     

急性肾损伤患者发生谵妄的危险因素

目的 总结急性肾损伤（Acute renal injury, AKI）患者发生谵妄的危险因素。方法 136例急性肾损伤患者,采用意识模糊评估表（CAM-ICU）观察AKI患者谵妄的发生情况,采用多因素Logistic回归法分析急性肾损伤患者发生谵妄的危险因素。结果 136例患者中65例发生谵妄。与未发生谵妄者比较,发生谵妄的AKI患者年龄大、高血压比例高、急性生理学与慢性健康评分Ⅱ高、营养筛查评分高、血清降钙素原水平高、白细胞高、血清肌酐水平高、血尿素氮水平高,机械通气时间长、肾脏替代治疗时间长、ICU住院时间长（P均<0.05）。高血压、血清肌酐水平、机械通气时间、入住ICU时间是AKI患者发生谵妄的危险因素（OR=10.793,1.052,1.134,1.108;P均<0.05）。结论 存在高血压病史、血清肌酐浓度高、机械通气时间和入住ICU时间长是急性肾损伤患者发生谵妄的危险因素。     

心脏瓣膜置换术后呼吸机相关性肺炎的危险因素分析

目的 探讨心脏瓣膜置换术后呼吸机相关性肺炎（VAP）的危险因素.方法 对我院收治的98例心脏瓣膜置换术后机械通气超过48 h患者的临床资料进行分析.结果 分析显示围术期输血量、体外循环时间、主动脉阻断时间、机械通气时间、术前左室射血分数（LVEF）、术后氧合指数（PaO2/FiO2）、ICU住院天数、双瓣置换术、重度肺动脉高压、气管切开、再次插管、应用抑酸剂、术后死亡率13个因素与VAP有关（P＜0.05）.Logistic多因素回归分析显示体外循环时间≥120 min、机械通气时间≥4 d、再次插管、应用抑酸剂4个因素是VAP发生的危险因素.结论 围手术期尽量避免危险因素,以减少VAP的发生.     

老年患者心脏手术后呼吸机相关性肺炎的临床分析

目的 探讨＞70岁老年患者心脏手术后呼吸机相关性肺炎（VAP）的发病风险及相关病原学特点,以指导临床合理使用抗菌药物。方法 回顾性地分析2013年1月至2014年6月南京医科大学附属南京医院心脏外科重症监护病房（ICU）收治的机械通气时间＞48h且年龄＞70岁的老年患者33例,根据是否发生VAP分为VAP组及非VAP组,对两组患者的临床资料进行分析,筛选术后VAP的危险因素、致病菌及相应敏感药物。结果 33例患者中共16例患者发生VAP。单因素分析显示,两组之间急性生理与慢性健康评分Ⅱ（APACHE Ⅱ）、主动脉阻断时间、体外循环时间、机械通气时间及ICU住院时间差异有统计学意义（P＜0.01）。多因素回归分析显示,主动脉阻断时间及机械通气时间与VAP发生明显相关。分离病原菌19株,多以革兰阴性杆菌为主（84.2%）,其中肺炎克雷伯菌及铜绿假单胞菌是主要致病菌,革兰阳性球菌及真菌发生率较低,万古霉素对革兰阳性球菌抗菌活性为100%。结论 老年患者心脏术后VAP的发生与多种因素有关,需提高手术技术缩短主动脉阻断时间,尽早拔管,合理使用抗菌药物,以改善老年患者心脏术后VAP预后。     

体外循环下心脏瓣膜病换瓣术后ICU延迟脱离呼吸机病例对照研究

目的探讨心脏瓣膜病换瓣术后住ICU延迟脱离呼吸机的危险因素,为制订心脏瓣膜病换瓣术后住ICU延迟脱离呼吸机的防治措施提供依据。方法采用回顾性病例对照研究和非条件logistic多元回归分析方法,收集宜昌市第一人民医院重症医学科2008年1月至2012年1月心脏瓣膜病换瓣术后的71例患者资料,33例住ICU延迟脱离呼吸机患者与脱呼吸机时间无延迟的38例患者进行对照研究。结果心脏瓣膜病换瓣术后住ICU脱呼吸机时间延迟发生率为46．47％。心脏瓣膜病换瓣术后住ICU延迟脱离呼吸机的危险因素有术后低心排、术后。肾功能衰竭、年龄≥50岁、ST—T改变、住ICU〉5d等。心脏瓣膜病换瓣术后住ICU延迟脱离呼吸机的独立危险因素有：术后低心排（OR=5．329,95％CI1．682-16．881）、术后肾功能衰竭（OR=3．163,95％CI1．007-9．931）。结论心脏瓣膜病换瓣术后住ICU延迟脱离呼吸机的独立危险因素是术后低心排和肾功能衰竭。明确心脏瓣膜病换瓣术后住ICU延迟脱离呼吸机的危险因素,以缩短心脏瓣膜病换瓣术后呼吸机机械通气时间。     

ICU老年患者发生谵妄危险因素的Meta分析

目的 系统评价ICU老年患者发生谵妄的危险因素。方法 使用计算机检索中国知网、万方数据知识服务平台、维普网、中国生物医学文献数据库、PubMed、Embase、Web of Science、Cochrane Library公开发表的ICU老年患者发生谵妄危险因素的病例对照研究和队列研究，对照组为未发生谵妄的老年患者，病例组为发生谵妄的老年患者。检索时限为建库至2022-09-20。提取纳入文献的资料，采用纽卡斯尔-渥太华量表（NOS）进行质量评价，采用RevMan 5.4软件进行Meta分析。结果 本研究纳入33篇文献，共7 636例患者，其中病例组3 016例、对照组4 620例。Meta分析结果显示，年龄增长、营养状况差、脑卒中史、痴呆史、认知功能下降、急性生理与慢性健康评价系统Ⅱ（APACHEⅡ）评分升高、低血压、低氧血症、疼痛、机械通气、应用镇静药物、身体约束、睡眠剥夺是ICU老年患者发生谵妄的危险因素（P<0.05）。单篇文献研究结果显示，合并症多、美国麻醉医师协会（ASA）分级升高、ICU住院时间延长是ICU老年患者发生谵妄的危险因素（P<0.05）。结论 现有...     

老年重症患者骨质流失相关危险因素分析

目的探讨老年重症患者骨质流失的相关危险因素。 方法纳入2020年7月至2021年7月浙江大学医学院附属金华医院收治的老年重症患者,测量其入住ICU前后的骨密度数据,T值下降>10%为存在骨质流失。先采用t检验、秩和检验、χ²检验比较骨质流失组与对照组临床资料的差异,再通过多因素logistic回归分析骨质流失的相关危险因素。 结果共纳入老年重症患者71例,骨质流失组41例,对照组30例。与对照组比较,骨质流失组入院时氧合指数较低、序贯器官衰竭评估评分较高、接受连续性肾脏替代治疗患者的比例较高、机械通气时间及制动时间均较长（t=-3.516,χ²=8.019,Z=-3.990、-3.161、-2.056,P<0.05或0.01）。两组患者入ICU时实验室检查指标中仅白细胞计数、C反应蛋白、白介素-6的差异有统计学意义（t=2.682,Z=-3.108、3.307,P<0.01）。多因素分析结果显示,引起患者骨质流失的相关危险因素包括入ICU时SOFA评分高、白介素-6水平高,住ICU期间行CRRT以及机械通气时间长（OR=1.223、1.080、6.635、1.004,P<0.05）。 结论老年重症患者住ICU期间发生骨质流失的风险较高,引起骨质流失相关的危险因素包括入ICU时SOFA评分高、白介素-6水平高,住ICU期间进行CRRT以及机械通气时间长。     

重症非心脏手术患者术后谵妄的危险因素及其对患者远期生存质量的影响研究

目的探讨重症非心脏手术患者术后谵妄的危险因素及其对患者远期生存质量的影响。方法选择2011-04-01—2012-12-31在成都市崇州市人民医院行非心脏手术并在术后转入外科重症监护室(SICU)的患者205例,采用"护理谵妄筛选评分表"评估其术后谵妄情况,分析重症非心脏手术患者术后谵妄的危险因素及其对患者远期生存质量的影响。结果最终共纳入184例患者,其中86例患者出现术后谵妄(术后谵妄组),98例患者未出现术后谵妄(非术后谵妄组),术后谵妄发生率为46.7%(86/184)。两组患者性别,体质指数,高血压、冠心病、糖尿病及肾功能不全发生率,急诊入院者所占比例比较,差异无统计学意义(P0.05);两组患者年龄、受教育年限、脑血管疾病及慢性阻塞性肺疾病发生率、美国麻醉医师学会(ASA)分级、转入SICU时急性生理学和慢性健康状况评价系统Ⅱ(APACHEⅡ)评分、入住SICU期间机械通气时间、入住SICU期间阿片类药物使用率、入住SICU期间咪达唑仑使用率、SICU停留时间比较,差异有统计学意义(P0.05)。多因素logistic回归分析结果显示,年龄〔OR=1.927,95%CI(1.019,3.642)〕、脑血管疾病〔OR=3.396,95%CI(1.019,11.532)〕、转入SICU时APACHEⅡ评分〔OR=1.526,95%CI(1.061,2.196)〕是重症非心脏手术患者术后谵妄的独立危险因素(P0.05)。最终完成随访98例,其中术后谵妄组30例,非术后谵妄组68例。术后谵妄组患者SF-36量表生理功能评分及简明心智状态测量表(MMSE)评分低于非术后谵妄组(P0.05);两组患者SF-36量表生理职能、躯体疼痛、总体健康、活力、社会功能、情感职能、精神健康评分及焦虑自评量表(SAS)评分、抑郁自评量表(SDS)评分比较,差异均无统计学意义(P0.05)。两组患者术后脑卒中、心肌梗死、肾功能不全、消化道出血发生率及再入院率比较,差异无统计学意义(P0.05)。两组患者Kaplan-Meier生存曲线比较,差异有统计学意义(P0.05);Cox回归分析结果显示,伴有术后谵妄的重症非心脏手术患者死亡风险是非术后谵妄患者的1.976倍〔HR=1.976,95%CI(1.138,3.431),P=0.016〕。结论重症非心脏手术患者术后谵妄发生率较高,年龄、脑血管疾病、转入SICU时APACHEⅡ评分是重症非心脏手术患者术后谵妄的独立危险因素,伴有术后谵妄的重症非心脏手术患者死亡风险是非术后谵妄患者的1.976倍,术后谵妄会对重症非心脏手术患者远期生存质量造成一定不良影响。     

老年慢性阻塞性肺疾病急性加重期通气治疗患者谵妄发生情况及其影响因素

目的 分析老年慢性阻塞性肺疾病急性加重期(AECOPD)通气治疗患者谵妄发生情况及其影响因素。方法 选择182例老年AECOPD患者,统计患者住院治疗期间谵妄发生情况并分组(发生组与未发生组),调查患者基线资料,分析老年AECOPD通气治疗患者谵妄发生的相关因素。结果 住院期间,182例患者中66例(36.26%)发生谵妄;发生组机械通气时间较未发生组长,血清脑源性神经营养因子(BDNF)、白蛋白(ALB)水平较未发生组低,使用咪达唑仑镇静占比较未发生组高,差异有统计学意义(P<0.05);经Logistic回归分析结果显示,机械通气时间较短是老年AECOPD通气治疗患者谵妄发生的保护因素(OR<1,P<0.05),血清BDNF、ALB低表达是老年AECOPD通气治疗患者谵妄发生的危险因素(OR>1,P<0.05)。结论 老年AECOPD通气治疗患者谵妄发生率较高,机械通气时间较长、血清BDNF、ALB低表达均为患者发生谵妄的影响因素。     

The immunoneuroendocrine role of melatonin

Abstract: A tight, physiological link between the pineal gland and the immune system is emerging from a series of experimental studies. This link might reflect the evolutionary connection between self-recognition and reproduction. Pinealectomy or other experimental methods which inhibit melatonin synthesis and secretion induce a state of immunodepression which is counteracted by melatonin. In general, melatonin seems to have an immunoenhancing effect that is particularly apparent in immunodepressive states. The negative effect of acute stress or immunosuppressive pharmacological treatments on various immune parameters are counteracted by melatonin. It seems important to note that one of the main targets of melatonin is the thymus, i.e., the central organ of the immune system. The clinical use of melatonin as an immunotherapeutic agent seems promising in primary and secondary immunodeficiencies as well as in cancer immunotherapy. The immunoenhancing action of melatonin seems to be mediated by T-helper cell-derived opioid peptides as well as by lymphokines and, perhaps, by pituitary hormones. Melatonin-induced-immuno-opioids (MHO) and lymphokines imply the presence of specific binding sites or melatonin receptors on cells of the immune system. On the other hand, lymphokines such as -γ-interferon and interleukin-2 as well as thymic hormones can modulate the synthesis of melatonin in the pineal gland. The pineal gland might thus be viewed as the crux of a sophisticated immunoneuroendocrine network which functions as an unconscious, diffuse sensory organ.     

Response of rat pineal melatonin to calcium, magnesium, and lithium is circadian stage dependent

Abstract: Herein we documented the response of pineal melatonin production to electrolytes known to be effective on pineal function in view of a possible circadian stage dependence. We studied the release of melatonin by perifused rat pineal glands at 2 different circadian stages corresponding to the middle of the light and dark periods, i.e., respectively, 7 and 19 HALO (Hours After Light Onset, L:D = 12:12). The initial efflux rates were, as expected, much higher in the perifusates of glands removed from rats sacrificed during the dark phase than of those removed during the light phase. After 3 hr of perifusion, melatonin release reached similar levels which were found constant up to the 8th hr of perifusion, whatever the circadian stage. Perifusion of the glands with physiological concentrations for the rat of calcium (5.2 mmol/1) and magnesium (1.34 mmol/1) resulted in a stimulatory effect on the pineal glands removed from rats sacrificed in the middle of the dark period (19 HALO), whereas no effects were observed on the pineal glands removed from rats sacrificed during the light (7 HALO). Lithium (0.28 and 0.55 mmol/1) was ineffective on melatonin release in pineal glands removed 7 and 19 HALO. Our results show differences in the initial efflux rates of melatonin and in the response of perifused pineal glands to calcium and magnesium according to the circadian stage.     

Changes in connexin43, the gap junction protein of astrocytes, during development of the rat pineal gland

Abstract: The abundance of gap junctions between rat pineal astrocytes formed by connexin43 (Cx43) was studied during development. Levels and distribution of Cx43 were measured by immunoblotting and indirect immunofluorescence, respectively. The amount of Cx43 in cells located within the gland was low until about the 7th postnatal day and increased to adult values between the 14th and 21st days postpartum. Although astrocytes, recognized by their vimentin immunoreactivity, were scarce before birth, they were abundant by the 7th postnatal day suggesting that the low levels of Cx43 found at this age corresponded to a low expression of this protein. Localization of the immunoreactivity to Cx43 and vimentin showed a close correlation, indicating that mature or immature pineal astrocytes form gap junctions made of Cx43. Since Cx43 levels attained their adult values at about the time the innervation and the functional state of the gland reached maturity (2–3 weeks after birth), it is proposed that astrocyte gap junctions are involved in the function of the adult rat pineal gland.     

Conservative management of perforated duodenal diverticulum： A case report and review of the literature

Duodenal diverticula are a relatively common condition. They are asymptomatic, unless they become complicated, with perforation being the rarest but most severe complication. Surgical treatment is the most frequently performed approach. We report the case of a patient with a perforated duodenal diverticulum, which was diagnosed early and treated conservatively with antibiotics and percutaneous drainage of secondary retroperitoneal abscesses. We suggest this method could be an acceptable option for the management of similar cases, provided that the patient is in good general condition and without septic signs.     

Presence of immunoreactive growth hormone and prolactin in the ovine pineal gland

Abstract: The use of antisera raised against bovine growth hormone (GH) and ovine prolactin (PRL) enabled the detection of related immunoreactive (ir) sequences of proteins in ovine pineal tissue. The isolation of PRL-like ir-material was accomplished using a 0.25 M ammonium sulphate (pH 5.5) extraction followed by ethanol precipitation, whereas the resulting 2.0 M ammonium sulphate (pH 7.0) precipitate contained a GH-like immunoreactivity. Gel chromatography of the GH-like immunoreactivity (Sephadex G-100) indicated the presence of several GH-like fragments ranging in the M_r range of 7,000 to 55,000. Analyses of the PRL-like ir-material found in pineal tissue on HPLC using a TSK 545-DEAE column led to the resolution into a single peak of immunoreactivity. A single peak of activity was also observed following chromatofocusing and hydrophobic interaction chromatography of the ir-peak from the TSK 545-DEAE column. The PRL-like ir-material inhibited the binding of [¹²⁵I]ovine PRL-S14 to anti-ovine PRL antibodies without showing an affinity for binding to anti-rat PRL or anti-bovine GH antibodies. Scatchard analysis of the binding of pineal PRL-like ir-material and pituitary ovine PRL-S14 to liver membranes from day-20 pregnant rats revealed similar affinity constants (K_a of 4.7 ± 0.2 × 10⁹ M^-1). In addition, the replication of Nb 2 Node rat lymphoma cells was stimulated by pineal PRL-like ir-material, an effect known to be specific for lactogenic hormones. The pineal PRL-like immunoreactivity appeared on sodium dodecyl sulfate polyacrylamide gels as a single major band of M_r 24,000. The functional status of PRL-and GH-like ir-material in the ovine pineal remains to be determined, but evidence is presented that the overall protein synthesis rate of the rat pineal responded to circulating concentrations of PRL.     

Microbiology of human immunodeficiency virus anorectal disease

PURPOSE: Individuals who are seropositive for the human immunodeficiency virus are at high risk for opportunistic infection and anorectal disorders. Little prospective information is available regarding anorectal pathogens in these patients. METHODS: One hundred sixty-three HIV-seropositive patients presented to the colorectal clinic between 1989 and 1992. Forty-seven (29 percent) patients were thought to have an infectious process and were prospectively studied using a standardized multiculture protocol. RESULTS: Mean age was 33 (range, 19–59) years. All were male; high-risk behavior accounted for 87 percent of HIV transmissions. Presenting complaints included anorectal pain (79 percent), pus per anum (28 percent), and blood per anum (26 percent). Examination revealed perianal tenderness (60 percent), condyloma (38 percent), perianal ulcers (38 percent), and anal fissures (34 percent). Sixty-six sets of cultures were performed; 28 patients had one set, 15 had two sets, and 4 had three sets. Thirty-two of these 47 patients (68 percent) had positive cultures including herpes (50 percent), cytomegalovirus (25 percent),Neisseria gonorrhoeae (16 percent), chlamydia (16 percent), acidfast bacilli (2 percent), and others (9 percent). Six of 32 patients with positive cultures had more than one organism cultured. Sixteen (50 percent) patients with positive cultures were treated medically, 8 (25 percent) were treated surgically and 8 (25 percent) were treated with both modalities. Sixty-one procedures were performed on 17 patients for condylomata. Eighteen patients had 20 procedures for abscesses, 50 percent of whom had positive cultures for other than common bowel flora; all improved. Fourteen patients underwent 33 procedures for perianal fistulas.Mycobacterium fortuitum was cultured from one patient who required 13 procedures for abscesses and fistulas. Forty-five (96 percent) patients were followed for an average of 12.5 months ±2.9 SEM (range, 1–94 months). Symptoms were improved or resolved in 22 of 32 (69 percent) patients with positive cultures and in 11 of 13 (84 percent) with negative cultures. CONCLUSIONS: Specific pathogens may often be identified in human immunodeficiency virus-seropositive patients with anorectal disorders if aggressively sought. Although patients without specific pathogens identified may be expected to improve with planned empiric treatment, positive identification allows more directed therapy.