高频振荡机械通气在血液肿瘤及多种疾病并发儿童急性低氧性呼吸衰竭中的应用

目的 评估儿童急性低氧性呼吸衰竭（acute hypoxemic respiratory failure,AHRF）给予高频振荡机械通气（high-frequency oscillatory ventilation,HFOV）治疗的意义.方法 回顾2011年1月至2013年9月收入我院PICU诊断为AHRF的病例,首先给予常规机械通气（CMV）,当PIP＞ 30cmH2O（1 cmH2O =0.098 kPa）或PEEP＞ 10 cmH2O、FiO2100％时具有以下情况之一：（1）SpO2 ＜90％或PaO2 ＜60 mmHg（1 mmHg =0.133 kPa）;（2）有严重呼吸性酸中毒（PaCO2＞ 80mmHg）;（3）严重气漏（纵隔气肿或气胸）,改为HFOV通气治疗.收集患儿性别、年龄、住PICU时间、CMV通气时间、HFOV通气时间等一般资料.分别于CMV通气末（H0）及HFOV后2 h（H2）、6 h（H6）、12 h（H12）、24 h（H24）、48 h（H48）记录并比较各时间点呼吸机参数（平均气道压、振幅、频率、FiO2）、氧合指数（PaO2/FiO2、OI）、动脉血气、心率、血压变化.分别比较存活组与死亡组、血液肿瘤组及非血液肿瘤组在H0、H2、H6、H12、H24、H48时间点的指标变化.结果 HFOV通气后,H2时间点PaO2较H0升高[76.9（61.9～128.0） mm-Hg vs 50.1 （49.5 ～ 68.0） mmHg],差异有统计学意义（P=0.006）.H2、H48时间点PaO2/FiO2分别较Ho、H24升高,差异有统计学意义[94.9（66.8 ～ 138.9） mmHg vs 68.0（49.5 ～ 86.8）mmHg,P=0.039;135.0（77.6 ～240.0）mmHg vs 90.7（54.6 ～ 161.7） mmHg,P=0.023）].所有患儿收缩压、舒张压、心率在各时间点没有明显变化（P＞0.05）.存活组（n=9）与死亡组（n=14）相比,PaO2/FiO2、OI在H6、H12、H24、H48差异有统计学意义（P＜0.05）.非血液肿瘤组（n=10）与血液肿瘤组（n=13）相比,OI在H2、H6差异有统计学意义[19.2（13.9～26.6） vs 33.8（19.7 ～48.3）,P=0.049;16.0（8.4～27.1） vs28.9（20.9 ～38.9）,P=0.027）],两组的平均气道压在H2、H6、H12差异有统计学意义（P＜0.05）.两组病死率差异无统计学意义（40.0％ vs 76.9％,P=0.086）.结论     

Effect of Tiotropium on Cough Reflex Sensitivity in Acute Viral Cough

Study Objectives Cough is the most common complaint for which patients in the United States seek medical attention. Few, if any, effective therapies exist for the most common form of acute cough, that due to viral upper respiratory tract infection (URI). The aim of this study was to evaluate the effect of the anticholinergic agent tiotropium bromide on cough reflex sensitivity in subjects with acute viral URI. Patients Otherwise healthy adult nonsmokers with acute viral URI were randomized to receive inhaled tiotropium, 18 μg once daily, or matched placebo, for 7 days. A control group of healthy volunteers underwent an identical protocol. Measurements and Results Cough reflex sensitivity to inhaled capsaicin was measured at baseline (Day 0), and 1 h after the first (Day 1) and seventh (Day 7) dose of tiotropium or placebo. Concentrations of capsaicin inducing two or more (C ₂) and five or more coughs (C ₅) were determined. In subjects with URI, tiotropium (n = 11) demonstrated inhibition of cough reflex sensitivity relative to baseline (increased log C ₂ [p = 0.004] and log C ₅ [p = 0.0004]) after the first dose. No change occurred in the placebo group (n = 10). After 7 days, mean log C ₂ was significantly increased in the tiotropium group relative to placebo (p = 0.03). Although FEF_25–75 was also increased in the tiotropium group (p = 0.016), there was no significant correlation between changes in cough reflex sensitivity and FEF_25–75. Tiotropium had no effect in healthy volunteers (n = 24). Conclusions Tiotropium inhibits cough reflex sensitivity to capsaicin in subjects with acute viral URI. The antitussive effect of tiotropium may occur through a mechanism other than bronchodilation.     

老年住院患者82例跌倒原因分析与干预对策

目的探讨老年住院患者跌倒的原因及对策。方法对82例老年住院患者住院期间发生跌倒的原因进行回顾性分析。结果老年患者跌倒的原因和年龄、自理能力、活动状态、时间、地点、病房环境等有关。结论为预防老年患者跌倒事件的发生,应在管理中贯穿预防为主,细节管理的方案,针对跌倒原因采取综合干预措施。     

Human immunodeficiency virus type-1 group M quasispecies evolution: diversity and divergence in patients co-infected with active tuberculosis

The evolution of intra-host human immunodeficiency virus type 1 (HIV-1) quasispecies prior and after treating active tuberculosis (TB) with chemotherapy in HIV-1/TB patients was assessed. Two time points HIV-1 quasispecies were evaluated by comparing HIV-1-infected patients with active tuberculosis (HIV-1/TB) and HIV-1-infected patients without tuberculosis (HIV-1/non-TB). Plasma samples were obtained from the Frankfurt HIV cohort, and HIV-1 RNA was isolated. C2V5 env was amplified by PCR and molecular cloning was performed. Eight to twenty-five clones were sequenced from each patient. Various phylogenetic analyses were performed. We found a significant increase in diversity and divergence in HIV-1/TB compared to the HIV-1/non-TB. For HIV-1/TB, the average rate of evolution of C2V5 env was higher than previous reports (2.4 × 10⁻⁴ substitution/site/day). Two groups of HIV-1/TB were observed based on the rate of HIV-1 evolution and coreceptor usage: A fast evolving R5-tropic dominating group and a relatively slowly evolving X4 group. The results demonstrated that active TB has an impact on HIV-1 viral diversity and divergence over time. The influence of active TB on longitudinal evolution of HIV-1 may be predominant for R5 viruses.     

老年人心房纤颤27例临床分析

本文对27例老年人心房纤颤的病因、临床特点和治疗方法进行了分析。老年人房颤的主要病因是冠心病,多为阵发性,发作时心室率大多<100次/分,转复后往往有窦性心动过缓,且为间歇性。肺心病、风心病和心肌病引起的房颤多为慢性,发作时心室率多>100次/分,易合并心力衰竭。房颤发作时心室率过快或合并心力衰竭,宜用洋地黄类药物治疗。而心室率不快、症状不多者,无血流动力学改变者不必转复治疗。老年人房颤乙胺碘呋酮转复有效。     

Targeting insulin inhibition as a metabolic therapy in advanced cancer: A pilot safety and feasibility dietary trial in 10 patients

ObjectiveMost aggressive cancers demonstrate a positive positron emission tomographic (PET) result using ¹⁸F-2-fluoro-2-deoxyglucose (FDG), reflecting a glycolytic phenotype. Inhibiting insulin secretion provides a method, consistent with published mechanisms, for limiting cancer growth.MethodsEligible patients with advanced incurable cancers had a positive PET result, an Eastern Cooperative Oncology Group performance status of 0 to 2, normal organ function without diabetes or recent weight loss, and a body mass index of at least 20 kg/m². Insulin inhibition, effected by a supervised carbohydrate dietary restriction (5% of total kilocalories), was monitored for macronutrient intake, body weight, serum electrolytes, β-hydroxybutyrate, insulin, and insulin-like growth factors-1 and -2. An FDG-PET scan was obtained at study entry and exit.ResultsTen subjects completed 26 to 28 d of the study diet without associated unsafe adverse effects. Mean caloric intake decreased 35 ± 6% versus baseline, and weight decreased by a median of 4% (range 0.0–6.1%). In nine patients with prior rapid disease progression, five with stable disease or partial remission on PET scan after the diet exhibited a three-fold higher dietary ketosis than those with continued progressive disease (n = 4, P = 0.018). Caloric intake (P = 0.65) and weight loss (P = 0.45) did not differ in those with stable disease or partial remission versus progressive disease. Ketosis was associated inversely with serum insulin levels (P = 0.03).ConclusionPreliminary data demonstrate that an insulin-inhibiting diet is safe and feasible in selected patients with advanced cancer. The extent of ketosis, but not calorie deficit or weight loss, correlated with stable disease or partial remission. Further study is needed to assess insulin inhibition as complementary to standard cytotoxic and endocrine therapies.     

孕早期血红蛋白水平与妊娠期糖尿病的关联性

目的：探讨孕早期血红蛋白（Hb）与妊娠期糖尿病（GDM）发病风险间的关系。方法：应用病例对照研究设计,对109例GDM孕妇（GDM组）和151例健康孕妇（对照组）的临床资料进行分析。结果：单因素分析显示GDM组孕妇年龄、孕前体质量指数（BMI）、孕早期Hb浓度、孕早期收缩压、孕早期舒张压、文化水平、孕次、产次均明显高于对照组（P〈0．05）。将孕早期Hb浓度按四分位间距分为四组,比较各四分位和GDM组发病的关系,发现Hb浓度升高,GDM发生风险增加;spearman相关分析示孕早期Hb浓度与GDM的发生呈正相关（r=0．201,P=0．001）。在校正了可能的混杂因素后,多元loglstic回归分析结果显示,孕早期高Hb水平（Hb〉130g／L）可显著增加GDM的发生风险（OR=3．54,95％CI：1．60～7．83,P=-0．002）。结论：孕早期高Hb浓度将增加GDM的发病风险,应加强对孕早期妇女血Hb水平的监测,为有效预测及预防GDM的发生提供依据。