早期经皮扩张气管切开对长期机械通气患者预后的影响

目的探讨早期气管切开对长期机械通气患者预后的影响。方法回顾分析衡水市哈励逊临床医学院重症医学科2009年6月至2012年11月经皮扩张气管切开的患者178例,按气管切开时间分为早期气管切开组（机械通气≤10d）及晚期气管切开组（机械通气〉10d）,比较两组患者呼吸机相关性肺炎（VAP）的发生率、机械通气时间、住ICU时间和28d病死率。结果早期气管切开组VAP的发生率低于晚期气管切开组,机械通气时间及住ICU时间均明显缩短,28d病死率差异无统计学意义。结论对于需要长时间机械通气患者,早期气管切开可以降低VAP的发生率,缩短患者机械通气时间及住ICU时间,但对患者28d病死率无影响。     

BiPAP在有创-无创序贯治疗中的临床观察

目的探讨双水平正压通气(BiPAP)无创呼吸机在呼吸衰竭气管切开患者序贯治疗中的可行性。方法选择15例呼吸衰竭气管切开机械通气患者,肺部感染基本控制,均有自主呼吸,生命体征稳定,呼吸机通气模式为压力支持、但撤机困难,应用双水平正压通气无创呼吸机,连接气管切开导管,行序惯呼吸支持治疗,观察呼吸机参数及患者呼吸频率、心率、血气分析,并于同期住院的15例呼吸衰竭患者经口鼻面罩行无创通气相比较。结果两组患者通气24、72 h吸气压、呼气压、潮气量、每分通气量、呼吸次数、心率、pH、PaO2、PaCO2无明显差异,但有创通气组漏气量明显减于无创通气组。结论 BiPAP无创呼吸机应用于稳病情定,但撤机困难的气管切开呼吸衰竭患者序贯治疗是可行、安全、有效的。     

有创无创呼吸机在呼吸衰竭气管切开患者的临床观察

目的探讨双水平正压通气在呼吸衰竭气管切开患者序贯治疗中应用的价值。方法选择10例呼吸衰竭气管切开机械通气患者,肺部感染基本控制,均有自主呼吸,病情稳定,呼吸机通气模式为压力支持、但撤机困难。应用双水平正压通气无创呼吸机,连接气管切开导管,呼吸支持治疗,观察患者呼吸次数、心率、血压、血气分析指标的变化及预后。结果双水平正压通气无创呼吸机可应用于呼吸衰竭气管切开患者的呼吸支持治疗,患者呼吸次数、心率、血压稳定,PH、PaO2、PaCO2基本维持正常。观察、随访24周,10例患者中7例停用BiPAP,拔除气管导管,封闭气管切开开口。1例BiPAP通气24周,病情稳定。2例因再次感染死亡。结论双水平正压通气可应用于病情稳定,但撤机困难的气管切开呼吸衰竭患者序贯治疗。     

有创-无创序贯机械通气治疗老年慢性阻塞性肺疾病合并呼吸衰竭临床研究

目的:探讨有创-无创序贯机械通气对老年慢性阻塞性肺疾病(COPD)合并呼吸衰竭患者的疗效.方法:对46例老年COPD合并呼吸衰竭患者早期进行气管插管机械通气治疗,随机分为有创-无创序贯机械通气组(治疗组)和有创机械通气组(对照组),在肺部感染控制窗出现后,治疗组拔出气管插管,改用经鼻面罩无创通气模式,逐渐减低压力参数,直至成功脱机.对照组继续有创通气治疗,逐渐减低SIMV频率及PSV水平直至脱机成功.观察2组患者有创通气时间、总机械通气时间、呼吸机相关性肺炎(VAP)发生例数和住ICU时间.结果:治疗组的有创通气时间、总机械通气时间较对照组明显缩短(P<0.05),VAP发生率明显减少(P<0.05),住ICU时间明显缩短(P<0.05).结论:对于老年重症COPD合并呼吸衰竭患者在肺部感染控制窗出现后,应用有创-无创序贯机械通气可缩短机械通气时间,减少VAP发生率,缩短ICU住院时间.     

床旁超声联合镇静躁动评分指导老年ICU机械通气患者拔管时机

目的研究床旁超声联合镇静躁动评分(RASS)对老年重症监护室(ICU)机械通气患者拔管时机的指导作用。方法选取120例老年ICU机械通气患者按照随机分为常规组和研究组各60例。常规组采用常规方法评估拔管时机,研究组在常规方法的基础上结合床旁超声联合RASS指导拔管。对比不良事件发生率,撤机成功率,撤机成功患者机械通气时间,机械通气治疗前、24 h后及撤机2 h后中心静脉压(CVP)、平均动脉压(MAP)、心率(HR)、呼吸频率(RR)变化。结果研究组气管插管移位、输液外渗、谵妄、依赖综合征发生率均明显低于常规组(P0.05);研究组撤机成功率明显高于常规组(P0.05);研究组撤机成功患者机械通气时间明显短于常规组(P0.05);两组撤机成功患者撤机2 h后CVP、MAP、HR和RR均有所升高(P0.05),且撤机2 h后研究组撤机成功患者CVP、MAP、HR和RR均明显低于常规组(P0.05)。结论床旁超声联合RASS指导老年ICU机械通气患者拔管时机有助于减少不良事件,提高一次撤机成功率,缩短机械通气时间,避免CVP、MAP、HR和RR大幅变化。     

每日唤醒在机械通气患者镇静中的应用

目的评价每日唤醒在机械通气患者镇静过程中的效果。方法将ICU内行机械通气并需镇静的患者160例随机分为观察组和对照组各80例,两组均予咪唑安定静脉负荷量0．03～0．1mg／kg静注,注药时间30～60s,其后以微量泵0．03～0．2mg／（kg·h）静注,维持理想的镇静状态。在此基础上,观察组次日起实施每日唤醒（上午9时）。两组均维持理想的镇静状态,直至脱机。观察两组停用镇静药物后完全清醒时间、撤机时间、拔管时间及ICU住院时间、气管切开率、总镇静时间。结果观察组停用镇静药后患者完全清醒时间、撤机时间、拔管时间、ICU住院时间、总镇静时间明显短于对照组（P〈0．05）,气管切开率显著低于对照组（P〈0．05）。结论每日唤醒用于ICU机械通气镇静患者可减少镇静药用量、缩短机械通气时间,降低气管切开率,且简便易行。     

重症脑血管病患者气管切开的时机及临床价值

目的 探讨重症脑血管病患者气管切开的时机及临床价值.方法 选择重症脑血管病患者64例,均在入院48 h内行气管插管.以气管插管5d为界,分为早期气管切开组(气管插管≤5 d)34例、晚期气管切开组(气管插管＞5d)30例,比较两组生存情况、医院获得性肺炎(HAP)发生情况、机械通气时间、ICU住院时间.结果 两组病死率、HAP发生率比较无统计学意义(P＞0.05);两组机械通气时间、ICU住院时间比较有统计学意义(P均＜0.05).结论 早期气管切开可显著缩短重症脑血管病患者的机械通气时间和ICU住院时间,但不能降低其病死率和HAP发生率.     

机械通气患者进行呼吸力学监测的临床意义

目的 探讨呼吸力学监测指导机械通气参数调节的临床意义.方法 纳入2014年1月至2015年12月入住RICU行有创机械通气的呼吸衰竭患者,随机选择进行有创机械通气患者60例,设为呼吸力学监测组,给予该组患者进行呼吸力学监测(监测参数包括气道阻力、顺应性、平台压、跨肺压等),根据监测指标指导其机械通气参数的调节;随机选择进行有创机械通气患者53例,设为对照组,该组患者按照经验进行机械通气参数设置和调节;统计两组机械通气患者的机械通气时间、住RICU时间和气压伤的发生率.结果 与按经验进行机械通气设置的患者相比,进行呼吸力学监测指导机械通气的患者机械通气时间(6.40±0.82)d vs (5.20±0.63)d(P＜0.05)及住RICU时间(10.49土1.32)d vs (8.83±0.88)d(P＜0.05)缩短,气压伤的发生率下降(11.32％ vs 3.33％,P＜0.01).结论 常规对有创机械通气患者进行呼吸力学监测可以缩短机械通气时间和住RICU时间,提高机械通气的安全性.     

早期气管切开术在重型颅脑损伤患者中的应用效果分析

目的分析早期气管切开术在重型颅脑损伤患者中的应用效果。方法选取2014年10月—2016年10月张家港市第一人民医院收治的重型颅脑损伤患者227例,随机分为对照组114例和治疗组113例。对照组患者于伤后24 h后行气管切开术,治疗组患者于伤后24 h内行气管切开术。比较两组患者肺部感染发生率、控制率及控制时间,病死率,住院时间,机械通气时间。结果治疗组患者肺部感染发生率低于对照组,肺部感染控制率高于对照组,肺部感染控制时间短于对照组(P<0.05)。治疗组患者病死率低于对照组,住院时间、机械通气时间短于对照组(P<0.05)。结论早期气管切开术在重型颅脑损伤患者中的应用效果良好,可有效降低患者肺部感染发生率,提高肺部感染控制率,缩短肺部感染控制时间、住院时间及机械通气时间。     

COPD气管切开患者的拔管时机研究

目的研究COPD气管切开患者的拔管时机。方法13例行机械通气治疗的COPD气管切开患者随机分为两组,试验组6例,当自主呼吸试验时间大于24h拔管,对照组7例,当自主呼吸试验时间大于2h拔管,比较拔管后48h内的再插管率。结果试验组和对照组的再插管率分别为16．7％和85．7％,差异有统计学意义（P〈0．05）。结论COPD气管切开患者,当自主呼吸试验时间大于24小时的时候拔管具有较低的再插管率。     

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.     

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.     

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.     

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.