人脐带间充质干细胞对小鼠肝缺血-再灌注损伤后肝内CD4~+T细胞的影响

目的探讨人脐带间充质干细胞(HUC-MSCs)对小鼠肝缺血-再灌注损伤(HIRI)后肝内CD4+T细胞的影响。方法将225只小鼠随机分为sham组、control组和MSC组,每组75只。其中MSC组和control组均为HIRI模型小鼠,MSC组通过下腔静脉注射HUC-MSCs,control组通过下腔静脉注射生理盐水,sham组仅进行开腹、关腹等操作,不行血管夹闭。分别于术后6、12、24 h,每组随机取15只小鼠,用于眼球取血法采血及取肝组织样本,每组剩下的30只小鼠用于肝内单核细胞的提取。比较各组小鼠不同时间点肝内单核细胞数量,CD4+T细胞比例、数量和阳性率;比较各组小鼠不同时间点血清和肝组织中白细胞介素(IL)-17含量,及肝组织内共刺激分子B7-1和B7-2信使核糖核酸(m RNA)表达水平。结果术后12、24 h,control组的肝内单核细胞数量明显高于sham组,而MSC组的肝内单核细胞数量明显低于control组(P0.01~0.05)。术后6、12、24 h,control组的CD4+T细胞比例、数量及阳性率均明显高于sham组(均为P0.01),MSC组的CD4+T细胞比例明显低于control组(P0.01~0.05);术后12、24 h,MSC组的CD4+T细胞数量和阳性率均明显低于control组(P0.01~0.05)。术后6、12、24 h,control组血清和肝组织中的IL-17含量均高于sham组(均为P0.01),而MSC组血清和肝组织中的IL-17含量均低于control组(均为P0.01)。术后6 h,control组B7-2的m RNA表达水平高于sham组(P0.05);术后12、24 h,control组B7-1和B7-2的m RNA表达水平均高于sham组(均为P0.01),而MSC组B7-1和B7-2的m RNA表达水平均低于control组(均为P0.01)。结论 HUC-MSCs抑制HIRI后肝内CD4+T细胞的数量和IL-17的分泌,同时减少肝内单核细胞数量及B7-1和B7-2 m RNA表达,减轻HIRI。     

外科ICU院内感染的病原菌及其耐药性分析

目的了解外科ICU内引起院内感染的主要病原菌及其耐药性,为临床合理用药提供依据。方法回顾性分析中山大学附属第三医院2010年1月至2014年5月确定为ICU院内感染137例患者的感染病原菌及其耐药性。结果137例患者中分离出感染病原菌223株。病原菌中革兰阴性杆菌最多,为120株,占53．8％,前三位分别为鲍曼不动杆菌、铜绿假单胞菌、肺炎克雷伯菌;革兰阳性球菌41株,占18．4％,前三位分别为金黄色葡萄球菌、屎肠球菌、溶血葡萄球菌;真菌62株,占27．8％,前三位分别为白色念珠菌、光滑念珠菌、季也蒙假丝酵母菌。耐药性结果显示革兰阴性杆菌耐药性鲍曼不动杆菌呈现多重耐药或泛耐药趋势,铜绿假单胞菌对碳青霉烯类药物的耐药性普遍升高,而敏感性降低,肺炎克雷伯菌表现了相对于鲍曼不动杆菌及铜绿假单胞菌较好的敏感性及较低的耐药性。阳性菌菌株及真菌菌株对药物的敏感性下降,耐药性上升,但目前尚未发现对万古霉素及利奈唑胺耐药的阳性菌株及对两性霉素B耐药的真菌菌株。结论该ICU的院内感染中以革兰阴性杆菌为主,鲍曼不动杆菌、铜绿假单胞菌、肺炎克雷伯菌为主要构成菌,耐甲氧西林金黄色葡萄球菌（MRSA）和真菌的感染比例也较高,且耐药性严重。     

大剂量乌司他丁在高危肝移植患者术后早期的器官保护作用

目的比较不同剂量蛋白酶抑制剂乌司他丁对高危肝移植手术患者术后的器官保护作用。方法回顾性队列分析2003年1月至2014年7月在中山大学附属第三医院器官移植中心146例术中失血量3 000 ml以上的肝移植患者的临床资料。所有患者均签署知情同意书,治疗符合医学伦理学规定。根据术后静脉使用乌司他丁剂量将上述高危患者分为大剂量组(HD组:400 kU,q6 h)和常规剂量组(RD组:400 kU,q12 h)。HD组63例,术中失血量(5.0±2.9)L,术后当天APACHEⅡ评分20.9±7.5、SOFA评分15.0±3.2;RD组83例,术中失血量(6.2±4.5)L,术后当天APACHEⅡ评分20.0±7.4、SOFA评分14.6±3.4。观察静脉应用乌司他丁5 d治疗后第3、7天APACHEⅡ评分和SOFA评分改变。同时了解两组患者感染发生率、机械通气时间、ICU停留时间、肾替代治疗比例以及90 d生存曲线。连续性资料如符合正态分布采用t检验,非正态分布采用非参数检验;分类资料率的比较采用?2检验。结果两组患者年龄、性别、术前MELD评分、CTP评分、术中失血量、输血量、手术时间、无肝期时间、术后当天APACHEⅡ和SOFA评分无统计学差异。静脉应用5 d乌司他丁后,未观察到有不良反应发生。虽然两组术后90 d生存曲线无统计学差异(?2=0.566,P=0.452),但HD组第3天和第7天的APACHEⅡ评分、第7天的SOFA评分改善更为明显(5.6±4.5vs.3.6±3.4,t=-2.910,P=0.004;8.5±4.7 vs.4.5±3.9,t=-5.468,P<0.001;4.7±3.2 vs.3.2±2.8,t=-2.944,P=0.004);RD/HD感染发生率(39.6%vs.23.8%,OR 2.11,95%CI 1.02⁴.37,?2=4.129,P=0.042)、肾替代治疗比例(22.9%vs.9.5%,OR 2.82,95%CI 1.054.37,?2=4.129,P=0.042)、肾替代治疗比例(22.9%vs.9.5%,OR 2.82,95%CI 1.05⁷.55,?2=4.51,P=0.034)、机械通气时间(Z=-5.112,P<0.01)、ICU停留时间(Z=-2.604,P<0.01)较RD组均有统计学差异。结论大剂量乌司他丁能显著改善高危肝移植术后患者多器官功能。     

肝移植术后原发性肝癌复发与乙型肝炎病毒再感染的关系

目的 探讨肝移植术后原发性肝癌复发与HBV再感染的关系.方法 对2004年1月-2008年12月在中山大学附属第三医院因乙型肝炎相关性终末期肝病行肝移植手术并长期随访的340例患者回顾性分析.患者被列入肝移植等待名单后给予核苷(酸)类似物抗病毒治疗,术中和术后均给予核苷(酸)类似物联合低剂量乙型肝炎免疫球蛋白进行预防.术后定期随访并监测患者HBV再感染的发生率及生存率,用多因素COX回归分析筛选出影响术后HBV再感染的危险因素.计量资料用t检验、计数资料用x2检验进行统计学处理.用Kaplan-Meier方法进行生存率分析,对HBV再感染危险因素用COX多因素回归分析,对HBV再感染与原发性肝癌复发的时间进行Spearman线性相关分析.结果 340例患者术后发生HBV再感染33例,术后1、3、5年再感染率分别为7%、10%、13%.HBV再感染的时间为1～21个月,中位数为5个月.原发病为原发性肝癌(风险比为2.98;95%可信区间为1.08～8.25,P＜0.05)、术前HBV DNA载量＞5log10拷贝/ml(风险比为3.99;95%可信区间为1.85～8.62,P＜0.01)是发生HBV再感染的危险因素.原发性肝癌复发者HBV再感染发生率高于未复发者,分别为27.9%和8.7%(风险比为4.58; 95%可信区间为1.88～11.12;P＜0.01).12例患者肝移植术后发生HBV再感染和原发性肝癌复发,两者的复发时间具有相关性(r=0.583,P＜0.05).结论肝移植术后原发性肝癌复发是HBV再感染的危险因素.

Abstract：

Objective To investigate the relationship between hepatocellular carcinoma (HCC)recurrence and hepatitis B virus (HBV) recurrence. Method The clinical data of 340 patients underwent liver transplantation due to HBV related end-stage liver disease and received long-term follow up in our hospital from Jan 2004 to Dec 2008 were retrospectively analyzed. All patients received nucleoside analogues therapy formally before entering into the waiting list and nucleoside analogues combined low-dose HBIG therapy during and after transplantation. Patients were regularly followed up at the outpatient, monitoring the HBV recurrence and survival. Multivariate Cox regression analysis was used to evaluate the risk factors for hepatitis recurrence. Result 33 patients suffered from HBV recurrence post transplantation.The 1-, 3- and 5- year recurrence rates were 7.0%, 10% and 13% respectively. The median HBV recurrence time was 5 months (1-21 months). COX regression analysis revealed that risk factors for HBV recurrence were HCC (HR = 2.98; 95% CI 1.08-8.25; P＜0.05) and pre-transplantation HBV-DNA load over 5 log10 copies/ml (HR = 3.99; 95% CI 1.85-8.62; P＜0.01). Further stratified analysis showed that patients who suffered from carcinoma recurrence had a higher incidence of HBV recurrence than those who did not, which were 27.9% and 8.7% (HR =- 4.58;95% CI 1.88-11.12; P＜0.01) respectively. 12 patients suffered from both HCC and HBV recurrence. Spearman correlation analysis demonstrated a strong correlation between HBV and HCC recurrence times (r= 0.583, P＜0.05). Conclusion Post transplantation HCC recurrence is a risk factor for HBV recurrence.     

肝移植术后应用利奈唑胺对血小板的影响

目的分析肝移植术后应用利奈唑胺的不良反应及对患者预后的影响,评价其发生血小板减少的风险及治疗的有效性和安全性。方法选取2007年9月至2009年6月在本院肝移植中心行肝移植的患者85例,采取随机、对照的方法分为利奈唑胺组和万古霉素组,以治疗前、治疗后第3天、第5天、第7天、治疗结束以及治疗结束后第7天等6个时间点,分别从临床特征、血小板计数、发生血小板减少患者的累计发生率、临床疗效和细菌学检查结果等方面进行对比分析。结果随着用药时间的延长,两组患者平均血小板数量无减少的趋势,利奈唑胺组用药前及治疗结束后血小板计数分别为（71.25±11.01）×109/L和（86.74±11.60）×109/L;万古霉素组用药前及治疗结束后分别为（62.0±19.11）×109/L和（85.2±12.73）×109/L,两组差异无统计学意义;用药前后发生血小板减少的患者累计发生率两组的差异无统计学意义（利奈唑胺组2.3%,万古霉素组2.5%）,其中利奈唑胺组45%的患者血小板计数无明显变化或增加,万古霉素组47%的患者血小板计数无明显变化或增加。通过临床疗效及细菌学疗效对比,利奈唑胺组和万古霉素组的有效性差异也无统计学意义。其中临床疗效的有效率分别为90.9%和92.5%,细菌学疗效的有效率分别为91.8%和92.8%。结论与万古霉素相比,在肝移植术后发生革兰阳性球菌的患者中使用利奈唑胺并不会引起血小板的减少,其安全性及有效性与万古霉素相似。     

影响肝移植术后新发糖尿病逆转的相关因素

目的 探讨影响肝移植术后新发糖尿病(PTDM)逆转的相关因素.方法 回顾分析232例肝移植受者的临床资料,术后共有62例患者发生PTDM,发生率为26.7%.根据PTDM是否发生逆转,将62例患者分为暂时性PTDM组(34例)和持续性PTDM组(28例).对两组患者的性别、年龄、体重指数、糖尿病家族史、乙型肝炎病毒感染情况、术前空腹血糖水平、免疫抑制剂使用及其血药浓度、皮质激素的使用时间等相关因素进行分析.结果 两组间患者的性别、体重指数、糖尿病家族史、术前空腹血糖水平、免疫抑制方案中皮质激素的持续使用时间、术后血他克莫司浓度及使用环孢素A的患者比例等因素的差异均无统计学意义(P＞0.05).与持续性PTDM组相比,暂时性PTDM组患者移植时年龄较轻,分别为(54±8)岁和(42±6)岁(P＜0.05);发生PTDM的术后时间较晚,分别为术后(18±23)d和(35±42)d(P＜0.05);免疫抑制方案中联合运用吗替麦考酚酯(MMF)或西罗莫司(SRL)的患者比例较高,分别为0和8.9%(P＜0.05).经多因素Logistic回归分析显示,只有移植时年龄是PTDM逆转的独立预测因子(比值比为1.312,95%可信区间为1.005～1.743).结论 患者移植时年龄、发生PTDM时的术后时间及免疫抑制方案中使用MMF或SRL的患者比例等因素与肝移植术后PTDM逆转相关,但只有移植时年龄是PTDM逆转的独立预测因子.

Abstract：

Objective To study the related factors associated with the reversal of posttransplant diabetes mellitus (PTDM) following liver transplantation. Methods The clinical data of 62patients with PTDM in 232 patients receiving liver transplantation (26. 7 %) were retrospectively analyzed and the patients were divided into two groups: patients with transient PTDM (34 cases) and those with persistent PTDM (28 cases). Pre-operative and post-operative variables, including sex,age, body mass index, family history of diabetes, hepatitis B virus infection, pretransplantation fasting plasma glucose, the immunosuppressant regime, FK506 concentration and duration of steroid usage, were analyzed retrospectively. Results The variables, including sex, age, body mass index,family history of diabetes, hepatitis B virus infection, pretransplantation fasting plasma glucose,FK506 concentration at month 1, 3 and 6 after operation, rate of cyclosporine usage and duration of steroid usage had no significant difference between the two groups (P＞0. 05). Compared with the persistent PTDM patients, the transient PTDM patients were characterized by younger age at the time of transplantation (54 ± 8 vs. 42 ± 6 years, P＜0. 05), longer time before the development of PTDM (18 ± 23 vs. 35 ± 42 days, P＜0. 05), and higher rate of mycophenolate mofetil or sirolimus usage (0vs. 8. 9 %, P＜0. 05). Based on a multivariate analysis, age at the time of transplantation was determined as the single independent predictive factor associated with reversal of PTDM following liver transplantation (odds ratio: 1. 312, 95 % confidence interval: 1. 005 - 1. 743). Conclusion Age at the time of transplantation, duration before the development of PTDM and rate of mycophenolate mofetil or sirolimus usage are associated with reversal of PTDM following liver transplantation. Among these factors, age at the time of transplantation is only the single independent predictive factor.     

围手术期快速康复护理中运用甘草的SWOT分析

目的:运用SWOT分析法探讨甘草在围手术期快速康复护理中的运用价值。方法:以"围手术期""快速康复护理""甘草临床应用"等为关键词检索文献,分析在围手术期快速康复理念下运用甘草的可行性。结果:共检索文献164篇,经筛选纳入文献68篇,分析文献发现虽然甘草及其分离产物的具体作用环节和活性成分等方面尚不明确,有待进一步研究,但是甘草抗炎、抗变态反应、抗病毒、解痉镇痛、增强免疫等临床药理作用与快速康复外科中减轻手术应激、呼吸系统管理、消化系统管理、预防术后并发症等理念吻合,优势显著。结论:随着临床药理学、药剂学的不断发展,将甘草及其衍生品运用于围手术期快速康复护理中的可行性较大。     

手术室优化护理模式在骨科术中的应用效果及对空气质量、护理满意度的影响

目的 探讨手术室优化护理模式在骨科术中的应用效果及对空气质量、护理满意度的影响。方法 选择2021年1月-2022年12月医院骨科收治的80例患者作为研究对象,在组间基线资料均衡可比的原则下,以随机数字表法分为对照组和观察组,每组40例。对照组采用常规护理,观察组采用手术室优化护理模式。比较两组手术室空气质量、手术情况、护理满意度以及护理质量。结果 观察组术后手术室空气细菌含量低于对照组,患者手术时间短于对照组,术中出血量少于对照组,差异有统计学意义（P<0.05）。观察组患者护理总满意度为97.50%(39/40),高于对照组的80.00%(32/40),差异有统计学意义（P<0.05）。观察组的手术室管理、文书能力、规范操作、感染防护意识、消毒铺巾评分以及总分均高于对照组,差异有统计学意义（P<0.05）。结论 将手术室优化护理模式应用于骨科手术患者,能够保障手术室空气质量,提升患者护理满意度,提高护理质量。     

影响肝移植术后新发糖尿病逆转的相关因素

Objective To study the related factors associated with the reversal of posttransplant diabetes mellitus (PTDM) following liver transplantation. Methods The clinical data of 62patients with PTDM in 232 patients receiving liver transplantation (26. 7 %) were retrospectively analyzed and the patients were divided into two groups: patients with transient PTDM (34 cases) and those with persistent PTDM (28 cases). Pre-operative and post-operative variables, including sex,age, body mass index, family history of diabetes, hepatitis B virus infection, pretransplantation fasting plasma glucose, the immunosuppressant regime, FK506 concentration and duration of steroid usage, were analyzed retrospectively. Results The variables, including sex, age, body mass index,family history of diabetes, hepatitis B virus infection, pretransplantation fasting plasma glucose,FK506 concentration at month 1, 3 and 6 after operation, rate of cyclosporine usage and duration of steroid usage had no significant difference between the two groups (P＞0. 05). Compared with the persistent PTDM patients, the transient PTDM patients were characterized by younger age at the time of transplantation (54 ± 8 vs. 42 ± 6 years, P＜0. 05), longer time before the development of PTDM (18 ± 23 vs. 35 ± 42 days, P＜0. 05), and higher rate of mycophenolate mofetil or sirolimus usage (0vs. 8. 9 %, P＜0. 05). Based on a multivariate analysis, age at the time of transplantation was determined as the single independent predictive factor associated with reversal of PTDM following liver transplantation (odds ratio: 1. 312, 95 % confidence interval: 1. 005 - 1. 743). Conclusion Age at the time of transplantation, duration before the development of PTDM and rate of mycophenolate mofetil or sirolimus usage are associated with reversal of PTDM following liver transplantation. Among these factors, age at the time of transplantation is only the single independent predictive factor.     

影响肝移植术后新发糖尿病逆转的相关因素

Objective To study the related factors associated with the reversal of posttransplant diabetes mellitus (PTDM) following liver transplantation. Methods The clinical data of 62patients with PTDM in 232 patients receiving liver transplantation (26. 7 %) were retrospectively analyzed and the patients were divided into two groups: patients with transient PTDM (34 cases) and those with persistent PTDM (28 cases). Pre-operative and post-operative variables, including sex,age, body mass index, family history of diabetes, hepatitis B virus infection, pretransplantation fasting plasma glucose, the immunosuppressant regime, FK506 concentration and duration of steroid usage, were analyzed retrospectively. Results The variables, including sex, age, body mass index,family history of diabetes, hepatitis B virus infection, pretransplantation fasting plasma glucose,FK506 concentration at month 1, 3 and 6 after operation, rate of cyclosporine usage and duration of steroid usage had no significant difference between the two groups (P＞0. 05). Compared with the persistent PTDM patients, the transient PTDM patients were characterized by younger age at the time of transplantation (54 ± 8 vs. 42 ± 6 years, P＜0. 05), longer time before the development of PTDM (18 ± 23 vs. 35 ± 42 days, P＜0. 05), and higher rate of mycophenolate mofetil or sirolimus usage (0vs. 8. 9 %, P＜0. 05). Based on a multivariate analysis, age at the time of transplantation was determined as the single independent predictive factor associated with reversal of PTDM following liver transplantation (odds ratio: 1. 312, 95 % confidence interval: 1. 005 - 1. 743). Conclusion Age at the time of transplantation, duration before the development of PTDM and rate of mycophenolate mofetil or sirolimus usage are associated with reversal of PTDM following liver transplantation. Among these factors, age at the time of transplantation is only the single independent predictive factor.