A prospective study of agitation in a medical-surgical ICU: incidence, risk factors, and outcomes

STUDY OBJECTIVES: Although agitation is thought to be common in the ICU, it has been poorly studied. We evaluated the incidence, risks factors, and outcomes of agitation in ICU. DESIGN: Prospective observational study. INTERVENTIONS: None. METHOD: All consecutive ICU admissions over an 8-month period were analyzed. MEASUREMENTS AND RESULTS: Two hundred eleven patients were admitted a total of 216 times during the period of the study. Twenty-nine patients were excluded from the study because their pathology findings did not allow an evaluation of their level of consciousness; 182 patients were actually enrolled. Agitation developed in 95 of 182 patients (52%). Agitation began 4.4 +/- 5.6 days (+/- SD) after admission to the ICU and lasted 3.9 +/- 4.1 days. Patients with agitation had a higher Simplified Acute Physiology Score II on ICU admission than those who did not have agitation (40 +/- 16 vs 33 +/- 13, p < 0.01). By stepwise logistic regression, the independent risks factors for development of agitation included psychoactive drug use at the time of ICU admission (odds ratio, 5.63; 95% confidence interval [CI], 1.32 to 23.70), history of alcohol abuse (odds ratio, 3.32; 95% CI, 1.12 to 10.00), dysnatremia (odds ratio, 4.95; 95% CI, 1.95 to 12.54), fever (odds ratio, 4.52; 95% CI, 1.80 to 11.49), use of sedatives in the ICU (odds ratio, 4.03; 95% CI, 1.62 to 10.40), and sepsis (odds ratio, 2.61; 95% CI, 1.03 to 6.58). Agitation was associated with a prolonged ICU stay (16 +/- 19 days vs 6 +/- 6 days, p = 0.0001), nosocomial infections (34% vs 7%, p < 0.0001), unplanned extubations (17% vs 2%, p = 0.003), and unplanned central venous catheter removal (16% vs 1%, p = 0.001), but not with mortality (12% in the agitation group vs 8% in patients without agitation). CONCLUSIONS: Agitation is a common event in a mixed medical-surgical ICU. It is associated with adverse outcomes including prolonged stay, nosocomial infections, and unplanned extubations. A better knowledge of incidence and risk factors should facilitate identification of patients at risk and decrease the incidence of agitation.     

结核性胸膜炎内科胸腔镜下表型及其诊断价值

目的观察结核性胸膜炎患者胸腔镜下表现特征,探讨结核性胸膜炎镜下不同表型对诊断的价值。方法回顾分析2011年4月-2013年7月60例确诊结核性胸膜炎患者内科胸腔镜下表现特征。结果 60例结核性胸膜炎患者胸腔镜下主要表现为4种类型:胸膜弥漫性充血水肿、糜烂;粟粒性结节型(多发或散在的小结节型,个别融合成大结节,直径1~2 cm);胸膜肥厚、胸膜腔呈多房改变;纤维苔素沉积及粘连。结论结核性胸膜炎患者内科胸腔镜下表现形态多样,以结节、弥漫性充血水肿为主,内科胸腔镜检查安全,创伤小,诊断率高,对结核性胸腔积液具有重要应用价值。     

监测中心动脉压对预防颈动脉斑块形成的研究进展

颈动脉斑块能够有效预测心脑血管疾病的发生,故寻找其相关危险因素、防止斑块形成对心脑血管疾病的预防有非同寻常的作用。本文将详细说明颈动脉斑块形成发展过程中各种影响因素及中心动脉压的病理生理特点,两者之间的联系及监测中心动脉压对预防劲动脉斑块形成的意义。     

健康老年人群血浆可溶性血栓调节蛋白和肾小球滤过率的关系

目的：探讨老年人群血浆可溶性血栓调节蛋白（sTM）与估算的肾小球滤过率（eGFR）的相关性。方法采用整群随机抽样的方法对北京市9个社区283名≥65岁健康老年人进行研究,酶联免疫吸附法测定血浆可溶性血栓调节蛋白水平,应用CKD-EPI公式评估eGFR,同时行人体学测量及血清生化指标测定,并做相关和回归分析。结果北京社区健康老年人群eGFR水平与sTM、年龄、尿素氮、肌酐、C反应蛋白（CRP）及收缩压呈负相关,与白蛋白、高密度脂蛋白胆固醇（HDL-C）、低密度脂蛋白胆固醇（LDL-C）水平呈正相关;在校正了年龄、血压、血糖（GLU）、CRP、血脂、尿酸（UA）等指标后,健康老年人血浆sTM仍然和eGFR呈负相关（B＝-3.340,P＝0.000）。在进一步的研究中,将入组的北京社区健康老年人分为老年（65～80岁）和高龄老年（＞80岁）两组;两组之间eGFR和sTM水平差异均无统计学意义（P＞0.05）,老年组和高龄老年组eGFR均与sTM水平呈负相关（r＝-0.229,P＝0.000;r＝-0.3613,P＝0.02）,校正了年龄、血压、GLU、CRP、血脂、UA等指标后差异仍有统计学意义（B＝-3.26,P＝0.000;B＝-4.45,P＝0.013）。结论 sTM可作为判断老年人群肾功能下降的指标。     

经皮颈内静脉长期导管在老年维持性血液透析患者中的临床应用

目的：探讨经皮颈内静脉长期导管在老年维持性血液透析患者中的应用及其常见并发症的防治。方法对2009年12月至2012年12月在中南大学湘雅医院行经皮颈内静脉长期置管的15例维持性血液透析老年患者的临床资料进行回顾性分析,观察置管术后情况、导管的使用情况、常见并发症的防治、透析充分性评价等。结果（1）实施颈内静脉长期置管18例次,其中3例为重新置管,置管成功率100%。（2）导管相关并发症：2例患者术后1周内出现置管处局部渗血;1例出现导管出口感染,2例发生导管相关性血流感染;3例患者出现导管血栓形成;2例诊断导管纤维鞘形成;1例因人为损坏出现导管破裂。经过相应处理后均使问题得到解决。（3）导管使用期限：本组患者长期导管使用时间为4～41个月,除1例死亡（原因为脑出血）,3例为重新置管,余患者仍继续使用。（4）透析充分性评价：15例患者平均尿素下降率为72%,平均尿素清除指数达1.54。结论对于血管条件差无法建立动静脉内瘘的老年血透患者,使用颈内静脉长期导管行血液透析可以达到充分透析;提高置管及导管护理技术、加强健康宣教,能延长导管使用年限,减少导管并发症。     

Human liver stem/progenitor cells decrease serum bilirubin in hyperbilirubinemic Gunn rat

AIM:To test the ability of adult-derived human liver stem/progenitor cells(ADHLSC)from large scale cultures to conjugate bilirubin in vitro and in bilirubin conjugation deficient rat.METHODS:ADHLSC from large scale cultures were tested for their phenotype and for their capacity to conjugate bilirubin in vitro after hepatogenic differentiation.In vivo,Gunn rats[uridine diphosphate-glucuronosyltransferase 1A1(UGT1A1)deficient animal]were injected with ADHLSC and cryopreserved hepatocytes(positive control).Two,4,13 and 27 wk posttransplantation,transplanted Gunn rat bilirubin serum levels were determined by high performance liquid chromatography.Human cell engraftment of trans-planted cells was assessed 27 wk post-transplantation using immunohistochemistry and RTqPCR.RESULTS:Large scale culture conditions do not modified ADHLSC phenotype,ADHLSC were able to specifically conjugate bilirubin.ADHLSC were intraportally injected into Gunn rats and blood UCB was measured at different times post-transplantation,infused-Gunn rats exhibited a metabolic effect 3 mo post-transplantation and maintained over a 6 mo period.ADHLSC engraftment into Gunn rat’s liver was demonstrated by RTqPCR and immunohistochemistry against albumin and UGT1A1.CONCLUSION:ADHLSC from large scale cultures are efficient in conjugating bilirubin in vitro and in restoring a deficient metabolic function(reducing bilirubin level)in hyperbilirubinemic rats.     

Chemokines and Antimicrobial Peptides Have a cag-Dependent Early Response to Helicobacter pylori Infection in Primary Human Gastric Epithelial Cells

Helicobacter pylori infection systematically causes chronic gastric inflammation that can persist asymptomatically or evolve toward more severe gastroduodenal pathologies, such as ulcer, mucosa-associated lymphoid tissue (MALT) lymphoma, and gastric cancer. The cag pathogenicity island (cag PAI) of H. pylori allows translocation of the virulence protein CagA and fragments of peptidoglycan into host cells, thereby inducing production of chemokines, cytokines, and antimicrobial peptides. In order to characterize the inflammatory response to H. pylori, a new experimental protocol for isolating and culturing primary human gastric epithelial cells was established using pieces of stomach from patients who had undergone sleeve gastrectomy. Isolated cells expressed markers indicating that they were mucin-secreting epithelial cells. Challenge of primary epithelial cells with H. pylori B128 underscored early dose-dependent induction of expression of mRNAs of the inflammatory mediators CXCL1 to -3, CXCL5, CXCL8, CCL20, BD2, and tumor necrosis factor alpha (TNF-α). In AGS cells, significant expression of only CXCL5 and CXCL8 was observed following infection, suggesting that these cells were less reactive than primary epithelial cells. Infection of both cellular models with H. pylori B128ΔcagM, a cag PAI mutant, resulted in weak inflammatory-mediator mRNA induction. At 24 h after infection of primary epithelial cells with H. pylori, inflammatory-mediator production was largely due to cag PAI substrate-independent virulence factors. Thus, H. pylori cag PAI substrate appears to be involved in eliciting an epithelial response during the early phases of infection. Afterwards, other virulence factors of the bacterium take over in development of the inflammatory response. Using a relevant cellular model, this study provides new information on the modulation of inflammation during H. pylori infection.     

介入途径对冠状动脉介入术后焦虑和抑郁状态的影响

目的:研究经桡动脉或经股动脉冠状动脉介入治疗术后,患者焦虑抑郁状态的发生情况。方法:对99例因冠心病准备行经皮冠状动脉介入治疗(PCI)的患者根据采用路径分为两组:经桡动脉冠状动脉介入治疗(TRI,n=50)和经股动脉行冠状动脉介入治疗(TFI,n=49)。同时采用汉密尔顿焦虑量表(HAMA)和汉密尔顿抑郁量表(HAMD),对两组患者术前及术后1d分别进行焦虑抑郁状态评分。HAMA8分定义为焦虑状态,HAMD8分定义为抑郁状态。结果:术前两组患者的HAMA和HAMD评分差异均无统计学意义[分别为(7.15±1.78)vs.(7.75±1.82),P=0.216]和[(6.80±1.75)vs.(6.78±2.15),P=0.763]。术后TRI组的HAMA平均评分:[(9.74±3.36)vs.(12.82±5.68),P=0.038]和HAMD的平均评分:[(9.94±3.37)vs.(13.02±3.75),P=0.022)]均显著低于TFI组。TRI组患者焦虑和抑郁状态的发生率显著低于TFI组[焦虑状态:18.0%vs.38.8%,P=0.022);抑郁状态:16.0%vs.34.7%,P=0.032]。多因素Logistic分析显示TFI和TRI相比是术后抑郁和焦虑状态的独立预测因素。结论:焦虑和抑郁状态均是PCI术后常见的情绪障碍,而TRI在对患者这两种情绪障碍的影响上均明显优于TFI。     

Situation of antithrombotic therapy in elderly patients with atrial fibrillation and acute coronary syndrome

Background Atrial fibrillation is the most common cardiac arrhythmia in clinical practice. The study examines the situation of antithrombotic therapy in elderly patients(more than 60 years old) with non-valvular atrial fibrillation(NVAF) and acute coronary syndrome(ACS) / percutaneous coronary intervention(PCI).Methods This study enrolled 381 elderly patients [mean age(69.95 ± 8.41) years; 289 males, 92 females]with NVAF and ACS / PCI between January 2006 and September 2013. According to clinical data, these patients were categorized into 4 groups: triple therapy(TT) group, dual antiplatelet therapy(DAT) group,vitamin K antagonist(VKA) plus single antiplatelet therapy(SAT) group and VKA group. According to score of CHA2DS2-VASc and HAS-BLED, all the patients were divided into 4 combinations. Statistical methods were used to analyze the situation of antithrombotic therapy and potential associations between the different combinations. Results 38 patients(9.97%) received TT and 300 patients(78.74%) received DAT. TT was received in 20 patients with CHA2DS2-VASc ≥2 and HAS-BLED ≥3, and 16 patients with CHA2DS2-VASc≥2 and HAS-BLED 3. Conclusions Elderly patients who suffered NVAF and ACS / PCI were with high risk of stroke and low risk of bleeding. Majority of these patients received DAT instead of TT.