Long-term outcome of delirium during intensive care unit stay in survivors of critical illness: a prospective cohort study

Introduction

Delirium is associated with impaired outcome, but it is unclear whether this relationship is limited to in-hospital outcomes and whether this relationship is independent of the severity of underlying conditions. The aim of this study was to investigate the association between delirium in the intensive care unit (ICU) and long-term mortality, self-reported health-related quality of life (HRQoL), and self-reported problems with cognitive functioning in survivors of critical illness, taking severity of illness at baseline and throughout ICU stay into account.

Methods

A prospective cohort study was conducted. We included patients who survived an ICU stay of at least a day; exclusions were neurocritical care patients and patients who sustained deep sedation during the entire ICU stay. Delirium was assessed twice daily with the Confusion Assessment Method for the ICU (CAM-ICU) and additionally, patients who received haloperidol were considered delirious. Twelve months after ICU admission, data on mortality were obtained and HRQoL and cognitive functioning were measured with the European Quality of Life – Six dimensions self-classifier (EQ-6D). Regression analyses were used to assess the associations between delirium and the outcome measures adjusted for gender, type of admission, the Acute Physiology And Chronic Health Evaluation IV (APACHE IV) score, and the cumulative Sequential Organ Failure Assessment (SOFA) score throughout ICU stay.

Results

Of 1101 survivors of critical illness, 412 persons (37%) had been delirious during ICU stay, and 198 (18%) died within twelve months. When correcting for confounders, no significant association between delirium and long-term mortality was found (hazard ratio: 1.26; 95% confidence interval (CI) 0.93 to 1.71). In multivariable analysis, delirium was not associated with HRQoL either (regression coefficient: -0.04; 95% CI -0.10 to 0.01). Yet, delirium remained associated with mild and severe problems with cognitive functioning in multivariable analysis (odds ratios: 2.41; 95% CI 1.57 to 3.69 and 3.10; 95% CI 1.10 to 8.74, respectively).

Conclusions

In this group of survivors of critical illness, delirium during ICU stay was not associated with long-term mortality or HRQoL after adjusting for confounding, including severity of illness throughout ICU stay. In contrast, delirium appears to be an independent risk factor for long-term self-reported problems with cognitive functioning.     

多孔髓芯减压联合干细胞移植治疗股骨头坏死的早期随访结果

目的:探讨多孔髓芯减压联合自体骨髓干细胞移植治疗股骨头坏死的疗效及临床分析。方法:选择2003-02/2006-12在南京医科大学附属南京第一医院骨关节中心采用多孔髓芯减压联合干细胞移植治疗的股骨头坏死患者22例,共28髋,年龄17～48岁,根据世界骨循环研究学会(ARCO)的国际骨坏死分期标准:Ⅰ期13髋,Ⅱ期11髋,Ⅲ期4髋。长期使用激素史9例,长期酗酒史6例,外伤史5例,原因不明者2例。纳入标准:有髋关节疼痛,功能受限;经髋关节X射线片及MRI检查确诊;ARCO分期Ⅰ～Ⅲ期;患者知情同意并签署知情同意书。排除标准:其他髋关节疾病。自患者髂前上棘处行骨髓穿刺分离与培养骨髓间充质干细胞。取患肢大粗隆下大腿外侧纵向直切口约3.0cm,钝性分离至股骨,在C形臂机引导下自股骨头中心钻入3枚直径4.0mm斯氏针,选位置较好的斯氏针,将直径约8.0mm特制套管在斯氏针的引导下钻至股骨头关节软骨面下1.0～2.0mm,不穿破关节面。将一长注射器针头置入股骨头坏死中心,立即行X射线正侧位摄片,确保针头位于股骨头内,从针头向股骨头内加压注入自体骨髓间充质干细胞悬液1.5～2.0mL。术后12个月随访,每3个月1次,随访时门诊复查,拍正、侧位和蛙式位X射线片,行MRI检查,观察病情变化。使用髋关节Harris评分进行疗效评价,>90分为优,75～90分为良,60～74分为可,<60分评定为差。若Harris评分提高,X射线骨形态变化改善及MRI股骨头坏死区体积变小可认为联合治疗有效。结果:①22例患者均完成随访,进入结果分析。②随访3个月时X射线及MRI检查:2例(2髋)激素引起的Ⅲ期患者股骨头发生进一步变形及塌陷,其余患者在随访期间未出现严重并发症,不良反应及病情恶化。股骨头坏死体积由术前31.07%减小到17.46%。激素组治疗前后股骨头坏死体积差值小于外伤、酗酒组,就本随访资料而言激素组疗效不如外伤及酗酒组。③随访12个月Harris评分:由术前54.3上升到84.6,有较明显提高,其中优7髋(25.0%),良15髋(53.6%),可4髋(14.3%),差2髋(0.07%)。结论:多孔髓芯减压联合干细胞移植是治疗股骨头坏死的一种新手段,尤其适合于年青、ARCO-Ⅰ或Ⅱ期、非激素导致的股骨头坏死治疗。     

6-羟基多巴胺帕金森病模型大鼠氧化应激反应

目的:观察6-羟基多巴胺帕金森病大鼠模型的氧化应激反应及其可能的机制。方法:实验于2005-06/12在上海中医药大学科研实验中心完成。实验分组:Wistar雄性大鼠18只,随机分为正常对照组、假手术组、模型组,每组6只。实验干预:采用6-羟基多巴胺(溶于0.2g/L抗坏血酸的生理盐水中)注射于脑右侧黑质,10d后以腹腔注射阿朴吗啡0.5mg/kg诱发大鼠向一侧旋转,记录开始旋转至30min内的旋转圈数,以平均每分钟旋转圈数超过7次者为合格的帕金森病模型。假手术组6只大鼠只注射含0.2g/L抗坏血酸的等量生理盐水,其余条件与造模组手术相同。正常对照组6只大鼠只进行大鼠固定,不进行任何处理。在旋转诱发实验完成后,动物每天自由饮水与进食,共45d。实验评估:应用化学比色法测定大鼠中脑黑质纹状体部位活性氧、丙二醛、谷胱甘肽含量,谷胱甘肽过氧化物酶、超氧化物歧化酶的活性。结果:18只大鼠均进入结果分析。①活性氧含量:模型组明显高于正常对照组和假手术组[(451.13±73.42),(135.62±53.46),(161.15±61.16)U/mg,P<0.01]。②谷胱甘肽含量:模型组明显低于正常对照组和假手术组[(4.26±0.75),(7.03±1.39),(7.03±1.42)mg/g,P<0.05]。③谷胱甘肽过氧化物酶活性:模型组明显低于正常对照组和假手术组[(3.05±0.38),(3.96±0.39),(3.77±0.38)NU/g,P<0.01]。④超氧化物歧化酶活性:模型组明显低于正常对照组和假手术组[(137.74±4.65),(190.77±8.47),(199.73±8.23)NU/mg,P<0.01]。⑤丙二醛含量:模型组明显高于正常对照组和假手术组[(10.90±2.17),(4.18±2.88),(4.52±2.45)μmol/g,P<0.01]。结论:帕金森病模型大鼠的氧化反应被激活,处于氧化应激状态,氧化应激反应增强可能是帕金森病的发病机制之一。     

人白细胞介素24mRNA在瘢痕疙瘩中的表达及意义

目的:从基因水平测量瘢痕疙瘩组织中白细胞介素24的表达水平,探讨白细胞介素24在瘢痕疙瘩发生、发展过程中的作用和意义。方法:实验于2005-10/2006-09在广东医学院整形外科研究所完成。①选取2004-06/2005-10广东医学院附属医院整形外科收治的患者,瘢痕疙瘩标本12例,正常瘢痕标本10例,行巨乳缩小、除皱术、植皮等患者正常皮肤标本12例,患者均知情同意且自愿捐献标本,实验经医学伦理委员会批准。标本取材部位为颜面、前胸、四肢等,切取后液氮保存。②低温条件下切取秤量组织,采用Trizol法提取总RNA。电泳鉴定总RNA完整性,并统一调整总RNA含量为10g/L,-70℃储存。RT-PCR二步法合成cDNA。③以正常皮肤、正常瘢痕为对照,以GAPDH作为扩增内参照基因,将正常皮肤、正常瘢痕和瘢痕疙瘩各类标本总RNA反转录的cDNA模板浓度调整相对一致进行扩增反应。以白细胞介素24mRNA与GAPDHmRNA的光密度积分值之比作为各类组织标本中白细胞介素24的相对含量,比较白细胞介素24mRNA在正常皮肤、正常瘢痕及瘢痕疙瘩组织中的表达情况。结果:①各类组织标本中总RNA抽提结果:正常皮肤、正常瘢痕和瘢痕疙瘩组织中抽提总RNA经甲醛变性凝胶电泳后显示较清晰的18s和28s条带,经紫外分光光度计测定A260/A280≈2.0。②各类组织标本中白细胞介素24mRNA的表达:白细胞介素24和GAPDH基因表达产物通过RT-PCR方法得到的特异性DNA片段长度分别为173bp和577bp。瘢痕疙瘩的白细胞介素24mRNA与GAPDHmRNA的吸光度比值明显低于正常皮肤、正常瘢痕(0.577±0.113,1.070±0.185,1.139±0.195;t=7.436×10-8～4.745×10-8,P均<0.01),正常皮肤与正常瘢痕白细胞介素24mRNA的相对表达量基本一致(t=0.405,P>0.05)。结论:瘢痕疙瘩的形成可能与白细胞介素24在组织中的表达降低有关。提示采用基因疗法提高早期瘢痕疙瘩中白细胞介素24的含量与活性,可能为瘢痕疙瘩的康复治疗提供有效途径。     

胶体磷酸铬^32P关节腔内注射改善佐剂型关节炎大鼠的相关指标

目的:观察胶体磷酸铬32P关节腔内注射治疗大鼠佐剂型关节炎的效果。方法:实验于2006-07/09在南京市第一医院动物实验室完成。选择6～8周龄清洁级SD雌性大鼠30只,按随机数字表法分为3组,正常对照组、模型组、胶体磷酸铬32P治疗组,每组10只。大鼠左足跖皮内注射完全弗氏佐剂0.1mL免疫法制备佐剂型关节炎模型。胶体磷酸铬32P治疗组于造模后10d左踝关节腔内注射37GBq/L胶体磷酸铬32P0.02mL,即0.74MBq,正常对照组和模型组分别给予等量生理盐水左踝关节腔内注射。①每2周观察1次大鼠左踝关节左右径宽度。②关节炎指数评定采用关节炎评分法(0～4分),分数越高,症状越重。③于用药后2,4,6周采用99Tcm-MDP显像感兴趣区分析法计算大鼠左踝关节区和右胫腓骨的放射性计数比。④于用药后4,6周测定血清肿瘤坏死因子和白细胞介素1β水平。⑤于用药后4,6周观察大鼠滑膜组织和软骨组织病理学改变。结果:纳入大鼠30只,均进入结果分析。①用药后2周模型组大鼠左踝关节左右径宽度大于正常对照组[分别为(7.82±0.36),(5.89±0.35)mm],差异有显著性意义(t=12.16,P<0.001),胶体磷酸铬32P治疗组大鼠左踝关节左右径宽度大于模型组,差异无显著性意义(P>0.05)。用药后6周胶体磷酸铬32P治疗组大鼠左踝关节左右径宽度小于模型组[分别为(6.87±0.27),(7.25±0.26)mm],差异有显著性意义(t=2.87,P<0.05)。②用药后2周和4周胶体磷酸铬32P治疗组大鼠关节炎指数高于模型组,用药后6周胶体磷酸铬32P治疗组大鼠关节炎指数低于模型组,两组间差异均无显著性意义(P>0.05)。③用药后2周模型组大鼠感兴趣区放射性计数比高于正常对照组(分别为2.05±0.20,1.46±0.15),差异有显著性意义(t=7.46,P<0.001)。用药后6周胶体磷酸铬32P治疗组大鼠感兴趣区放射性计数比低于模型组(分别为1.52±0.18,1.78±0.24),差异有显著性意义(t=2.45,P<0.05)。④用药后4,6周模型组大鼠血清肿瘤坏死因子和白细胞介素1β水平高于正常对照组,差异有显著性意义[用药后4周分别为(2.039±0.344),(1.115±0.192)μg/L;(0.305±0.034),(0.192±0.041)μg/L,t=7.42,6.71,P<0.001。用药后6周分别为(1.694±0.305),(1.126±0.256)μg/L;(0.259±0.027),(0.191±0.019)μg/L,t=4.03,5.83,P<0.01,0.001]。用药后4,6周胶体磷酸铬32P治疗组在血清肿瘤坏死因子和白细胞介素1β水平与模型组比较,差异无显著性意义(P>0.05)。⑤用药后4周胶体磷酸铬32P治疗组和模型组滑膜组织增生和炎症细胞浸润均较明显;用药后6周胶体磷酸铬32P治疗组与正常对照组比较仍有滑膜组织增生和炎症细胞浸润,与模型组比较滑膜组织增生程度明显减轻,而炎症细胞浸润程度稍轻。用药后6周胶体磷酸铬32P治疗组大鼠左踝关节的软骨组织未见有异常改变。结论:胶体磷酸铬32P关节腔注射可减轻完全弗氏佐剂免疫大鼠受注射关节的滑膜增生程度,改善关节肿胀症状,疗效肯定。     

小鼠皮肤超氧化物歧化酶活性与枸杞多糖的干预

目的:观察枸杞多糖对皮肤胶原代谢和自由基产生的影响,探讨其抗皮肤衰老的作用。方法:实验于2005-06/2006-05在广东医学院整形外科研究所完成。①实验材料:清洁级昆明小鼠60只,月龄2个月,体质量16～24g,雌雄各半。②实验分组:将小鼠随机分为正常对照组、衰老模型组和抗衰老模型组,每组20只。③实验干预:模型组每日用D-半乳糖溶液皮下注射制造衰老模型,用量和时间为80mg/(kg·d)7d,120mg/(kg·d)14d,140mg/(kg·d)14d,180mg/(kg·d)7d。正常对照组每日注射同体积的生理盐水。抗衰老模型组在注射D-半乳糖期间以枸杞多糖灌胃,剂量为20mg/(kg·d),正常对照组和衰老组则以同体积的生理盐水代之灌胃。④实验评估:42d后切取小鼠颈背部皮肤,测定超氧化物歧化酶活力、羟脯氨酸和丙二醛含量。结果:56只小鼠进入结果分析(4只死亡)。①小鼠皮肤超氧化物歧化酶活力:与正常对照组相比,衰老组和抗衰老组小鼠皮肤超氧化物歧化酶活力降低,差异有显著性意义(P<0.01);抗衰老组与衰老模型组比较,超氧化物歧化酶活力增加,差异有显著性意义(P<0.01)。②与正常对照组相比,衰老组和抗衰老组小鼠皮肤羟脯氨酸和丙二醛含量增加,差异有显著性意义(P<0.01);抗衰老组与衰老组比较,羟脯氨酸和丙二醛含量均降低,差异有显著性意义(P<0.01)。结论:枸杞多糖改善皮肤老化的作用与提高小鼠皮肤超氧化物歧化酶活力,降低羟脯氨酸、丙二醛含量,影响胶原代谢有关。     

白藜芦醇对一次性力竭游泳大鼠肝脏组织保护作用的量效关系

目的:观察白藜芦醇对一次性力竭游泳大鼠肝脏组织的作用及发挥作用的最佳口服剂量。方法:实验于2006-05/07在成都体育学院运动医学系动物实验室完成。①实验分组:选取雄性SD大鼠70只,随机分为7组,每组10只,分别为安静对照组,运动对照组,运动 15mg/kg白藜芦醇组,运动 50mg/kg白藜芦醇组,运动 100mg/kg白藜芦醇组,运动 200mg/kg白藜芦醇组,运动 300mg/kg白藜芦醇组。②实验干预:不同剂量白藜芦醇组每天灌胃15,50,100,200,300mg/kg白藜芦醇,安静对照组和运动对照组分别灌胃相同体积的溶媒(二甲亚砜 生理盐水),连续5周。末次给予实验用样品1h后,各运动组每只鼠尾跟部负荷3%体质量铅皮,置于水深50cm、水温(31±1)℃游泳槽中游泳。游泳力竭后即刻,股动脉取血并迅速取出肝组织。③指标检测:赖氏比色法测定血清中谷丙转氨酶活性;邻苯三酚自氧化法测定肝组织超氧化物歧化酶活性;硫代巴比妥酸法测定肝组织丙二醛含量。结果:纳入动物70只,均进入结果分析。①血清谷丙转氨酶活性和肝组织中丙二醛含量:运动对照组显著高于安静对照组,不同剂量白藜芦醇组低于运动对照组(P<0.05或P<0.01)。运动 100,200,300mg/kg白藜芦醇组低于运动 15,50mg/kg白藜芦醇组[谷丙转氨酶活性:(972.36±121.86),(944.36±105.35),(888.34±88.68),(1773.52±89.35),(1377.78±27.01)nkat/L,P<0.01;丙二醛含量:(7.90±2.56),(7.69±3.69),(7.13±2.62),(19.90±2.21),(12.16±1.78)μmol/g,P<0.05]。100,200,300mg/kg白藜芦醇组间差异无显著性。②肝脏组织中超氧化物歧化酶活性:运动对照组显著低于安静对照组,不同剂量白藜芦醇组高于运动对照组(P<0.05或P<0.01)。运动 100,200,300mg/kg白藜芦醇组高于15,50mg/kg白藜芦醇组[(2325.80±163.37),(2379.14±121.86),(2447.16±89.18),(1096.05±120.19),(1514.64±28.17)μkat/g,P<0.01]。结论:①白藜芦醇对力竭性运动大鼠肝脏组织具有保护作用。②100,200,300mg/kg白藜芦醇对肝脏组织发挥保护作用效果优于15,50mg/kg,建议使用100mg/kg白藜芦醇就能达到理想效果。     

A humanised tissue‐engineered bone model allows species‐specific breast cancer‐related bone metastasis in vivo

Bone metastases frequently occur in the advanced stages of breast cancer. At this stage, the disease is deemed incurable. To date, the mechanisms of breast cancer‐related metastasis to bone are poorly understood. This may be attributed to the lack of appropriate animal models to investigate the complex cancer cell–bone interactions. In this study, two established tissue‐engineered bone constructs (TEBCs) were applied to a breast cancer‐related metastasis model. A cylindrical medical‐grade polycaprolactone‐tricalcium phosphate scaffold produced by fused deposition modelling (scaffold 1) was compared with a tubular calcium phosphate‐coated polycaprolactone scaffold fabricated by solution electrospinning (scaffold 2) for their potential to generate ectopic humanised bone in NOD/SCID mice. While scaffold 1 was found not suitable to generate a sufficient amount of ectopic bone tissue due to poor ectopic integration, scaffold 2 showed excellent integration into the host tissue, leading to bone formation. To mimic breast cancer cell colonisation to the bone, MDA‐MB‐231, SUM1315, and MDA‐MB‐231BO breast cancer cells were cultured in polyethylene glycol‐based hydrogels and implanted adjacent to the TEBCs. Histological analysis indicated that the breast cancer cells induced an osteoclastic reaction in the TEBCs, demonstrating analogies to breast cancer‐related bone metastasis seen in patients.     

Detection of fetal red cells in fetomaternal hemorrhage using a fetal hemoglobin monoclonal antibody by flow cytometry

BACKGROUND: The laboratory determination of the level of fetal cells in maternal circulation remains an important support in the obstetrical management of women with suspected uterine trauma and in the proper dose administration of anti-D for prevention of Rh hemolytic disease of the newborn. Limitations in the sensitivity and precision of the widely used manual Kleihauer-Betke test have prompted an increased utilization of flow cytometric methods for fetal cell detection in maternal blood samples. STUDY DESIGN AND METHODS: Murine monoclonal antibodies directed against fetal hemoglobin (HbF) were developed, conjugated to fluorescein isothiocyanate, and used in a multiparametric flow cytometric assay developed for the quantitation of fetal red cells. A rapid intracellular staining method using brief glutaraldehyde fixation and Triton X-100 permeabilization prior to monoclonal antibody incubation was developed, along with optimization of the flow cytometric analysis protocol for the analysis of 50,000 cells. The performance of the assay was assessed for linearity and precision and correlated with the Kleihauer-Betke acid elution method. RESULTS: The anti-HbF flow cytometric method showed good correlation with the Kleihauer-Betke method (r2 = 0.86) and superior precision with a CV < 15 percent for blood samples with > 0.1 percent fetal cells. Analysis of 150 blood samples from nonpregnant adults, including individuals with elevated HbF due to hemoglobinopathies and hereditary persistence of HbF, gave a mean value of 0.02 percent fetal cells, and all results were less than 0.1 percent. CONCLUSIONS: The anti-HbF flow cytometric method for detection of fetal cells offers a simple, reliable, and more precise alternative to the Kleihauer-Betke manual technique for the assessment of fetomaternal hemorrhage. The method has additional potential applications for the study of HbF levels or frequency of adult red cells with low levels of HbF (F cells) in individuals with hemoglobinopathies.