体外循环下心脏手术肺保护策略

背景 肺损伤是心脏手术体外循环(cardiopulmonary bypass,CPB)的主要并发症之一,肺保护一直是临床、实验研究热点.目的 为CPB下心脏手术肺保护提供参考.内容 就近年来心脏手术CPB期间通气策略和麻醉药物、CPB设备和技术、肺动脉灌注技术、药物干预对肺保护作用的进展进行综述.趋向 CPB下心脏手术...     

小儿体外循环心脏手术中呼吸管理策略

背景 术后急性肺损伤是小儿体外循环(cardiopulmonary bypass,CPB)心脏手术后主要并发症之一,是小儿心脏手术后死亡的主要原因之一. 目的 CPB后肺损伤可导致患儿术后恢复时间延长,增加术后并发症,CPB期间及CPB后期可采用一定肺保护性通气策略从而改善术后呼吸功能. 内容 目前关于CPB心脏手术中肺损伤机制及肺保护性通气策略的研究很广泛,但针对小儿先天性心脏病的研究相对缺乏,且具有局限性. 趋向 为减轻肺损伤、改善小儿先天性心脏病手术预后,小儿CPB心脏手术中呼吸管理策略有广阔的研究前景.     

体外循环术后肺损伤及肺保护的研究进展

背景 日趋完善的体外循环心肺转流(cardiopulmonary bypass,CPB)技术改善了心脏外科的治疗结果,但CPB术后肺损伤仍然是一个威胁生命的重要并发症.目的 对CPB术后肺损伤及肺保护的研究进展进行探讨和总结.内容 炎症反应,缺血/再灌注损伤,肺血管内皮细胞功能受损等均被认为参与肺损伤机制.针对肺损伤,可以从生物技术和药物治疗等多方面来进行肺保护.趋向有助于减低术后死亡率,扩大手术适应证,为患者提供更合理有效的治疗方法.     

体外循环对肺表面活性蛋白A的影响

目的观察体外循环(CPB)对肺泡表面活性蛋白A(SP-A)组成的影响。方法以6周龄左右的猪为实验动物,常规建立CPB,于CPB前、CPB60min、120min及CPB结束3h以纤维支气管镜吸取支气管肺泡灌洗液(BALF),通过蛋白免疫印迹反应法测定SP-A。结果SP-A总量在CPB过程中明显下降,CPB60min和120min时与CPB前比较差别有统计学意义(P=0.045,0.017),但在CPB结束3h时基本恢复至CPB前水平;36.70ku组分在CPB过程中无明显变化,但在CPB结束3h明显增加(P=0.034);25.79ku组分在CPB过程中明显降低,在CPB后也未明显恢复(P=0.044,0.022)。结论在CPB过程中,SP-A总量减少,其不同组分的变化则不相同。     

体外循环前后血清的差异蛋白质组学研究

目的 研究体外循环(CPB)相关病理状态的分子机制,筛选出心脏手术患者CPB前后血清中的差异表达蛋白质. 方法 采用双向凝胶电泳技术(two-dimensional gel electrophoresis, 2-DE),分别分离16例心脏手术患者CPB开始前30 min、CPB结束后1 h和24 h的血清蛋白质,PDQuest识别差异蛋白质点,再用基质辅助激光解吸/电离飞行时间质谱进行分析,数据库查询后对差异蛋白质点进行鉴定,然后应用酶联免疫吸附试验(Enzyme-linked immunosorbent assay, ELISA)检测差异表达蛋白质--血清淀粉样蛋白A(serum amyloid A protein, SAA)在健康人、心脏手术患者CPB前后血清中的表达情况. 结果 采用2-DE联合质谱技术最终成功鉴定了7种差异蛋白质,即SAA、触珠蛋白(Haptoglobin, HPT)、富亮氨酸α-2糖蛋白(Leucine-rich alpha-2-glycoprotein, A2GL)、血红蛋白β亚基(Hemoglobin subunit beta, HBB)、丝氨酸/苏氨酸-蛋白磷酸酶2A调节亚基-β亚基-γ(Serine/threonine-protein phosphatase 2A regulatory subunit B″ subunit gamma, P2R3C)、转甲状腺素蛋白(Transthyretin, TTHY)、T-合成蛋白11-类蛋白2(T-complex protein 11-like protein 2, T11L2).ELISA分析结果显示:心脏手术患者与健康人CPB前30 min血清中SAA的表达水平差异无统计学意义(t=-1.955, P=0.056),心脏手术患者血清中SAA表达水平由CPB开始前30 min的54.47±48.32 μg/ml上升到CPB结束后24 h时的1 017.78±189.92 μg/ml. 结论 SAA、HPT、A2GL、HBB、P2R3C、TTHY、T11L2可能是CPB相关病理状态的分子标记物;机体在CPB后会发生强烈的急性期反应.     

液体通气:体外循环肺损伤的保护措施

预防或者减轻心肺转流(cardiopulmonary bypass,CPB)心脏手术引起的肺损伤是心血管麻醉一个极为重要的研究领域.人工的循环、缺血/再灌注损伤以及肺塌陷后复张是造成肺部炎症反应的关键因素.急性肺损伤后应用全氟化碳进行液体通气已经被证实可以改善肺的氧合.在体外循环前、期间以及体外循环后进行液体通气(liquid ventilation,LV),可以有效地减少中性粒细胞的浸润,减少肺内活性氧族产物,从而产生肺保护作用.     

体外循环下肺损伤及肺保护策略研究进展

<正>体外循环(cardioplumonary byass,CPB)使得大多数心脏手术得以开展,而肺损伤作为心脏手术后的一个常见并发症严重影响患者的临床转归。目前认为肺损伤主要与术后全身炎症反应、肺缺血-再灌注损伤及炎症因子基因多态性等因素有关。CPB期间血液与CPB循环回路表面的接触、输血输液、肝素-鱼精蛋白的使用、术中肺动脉阻断等均可引起显著的全身炎症反应,导致肺内粒细胞集聚最终引起弥漫     

儿童胸腔镜心脏手术中奥美拉唑对胃肠道的保护作用

目的探讨奥美拉唑在婴幼儿胸腔镜体外循环(CPB)心脏手术中对胃肠道的保护作用。方法将127例先天性心脏病患者(年龄3～12岁)随机分为3组,实验组A和实验组B:行胸腔镜微创手术治疗,对照组:行常规手术治疗;实验组A在CPB预充液中给予奥美拉唑10mg,实验组B和对照组均注入等量生理盐水。3组均于术前、CPB30min、CPB结束、术后4h、24h进行胃液常规检查,并采集血液标本,用ELISA法测定血清促胃液素。结果与CPB前比较:实验组A胃液pH值较CPB结束后有明显升高(P<0.01),实验组B于术毕有明显降低(P<0.05),对照组于术后4h较术前有明显降低(P<0.05);3组胃液红细胞计数及血清促胃液素与CPB前比较均有明显上升(P<0.01)。与对照组比较:实验组A胃液pH于CPB结束后各时间点较对照组有明显上升,而胃液红细胞计数则有明显下降,血清促胃液素于CPB30min时即较其它两组有明显降低。实验组B胃液pH于术毕有明显降低,但术后24h恢复至术前水平,同时间点胃液红细胞计数与促胃液素则有明显降低。结论儿童胸腔镜心脏手术中CPB时间较常规手术时间长,需要在此期间进行胃肠道保护,术后各项指标恢复较常规手术时间短。     

小儿心脏手术前补充甲状腺激素的作用

目的 观察小儿心脏手术前补充小剂量甲状腺激素对围术期甲状腺激素水平的影响及其对心肌的保护作用.方法 40例3～12岁先心病患儿随机均分为研究组(A组)和空白对照组(B组).A组于术前4 d至术前1 d每天按0.4 mg/kg口服甲状腺素片;B组不进行任何处理.分别于入院后、CPB前、CPB体温最低点、术后第1天、第2天、第4天取血测定三碘甲状腺原氨酸(T3)、游离三碘甲状腺原氨酸(FT3)、甲状腺素(T4)、游离甲状腺素(FT4)和促甲状腺激素(TSH)浓度.在手术结束前每组随机选6例患儿留取心房标本测定心肌球蛋白重链(MHC)亚型α、β mRNA的表达情况,在术后24 h取血测定血清肌酸激酶同工酶(CK-MB)及心肌肌钙蛋白(cTnI)阳性率.结果 A组患儿的T4浓度CPB体温最低点时降低(P＜0.05),而B组患儿的T4浓度CPB体温最低点、术后第1天和第2天时均有下降(P＜0.01).A组患儿T3和T4浓度在术后第1天、第2天高于B组(P＜0.05);FT3在CPB体温最低点、术后第1天和第2天时高于B组(P＜0.05);FT4在CPB前、术后第1天、第4天高于B组(P＜0.05).A组患儿正性肌力药的使用率低于B组(P＜0.05),CK-MB含量及cTnI阳性率也低于B组(P＜0.05).A组MHCα mRNA的表达量增强而MHCβmRNA的表达量减弱(P＜0.05).结论 心脏手术前补充小剂量甲状腺激素可明显纠正术后正常甲状腺病态综合征,减少正性肌力药物的使用并提供良好的心肌保护作用.     

血红素加氧酶-1对大鼠体外循环后肺组织抗细胞凋亡的研究

目的观察钴原卟啉(Co PP)诱导肺组织血红素加氧酶-1(HO-1)表达在大鼠体外循环(CPB)后肺组织损伤中的抗细胞凋亡作用,并对其作用机制进行分析。方法将144只雄性Wistar大鼠(体重250~350 g)随机分为3组,每组48只:A组(对照组)、B组(Co PP组)、C组[Co PP+锌原卟啉(Zn PP)组]。建立改良大鼠CPB肺损伤模型。制模成功后采用断颈法分别于CPB前(T0)、CPB结束即刻(T1)、CPB后2 h(T2)、6 h(T3)、12 h(T4)、24 h(T5)将大鼠处死。取肺组织检测相应的指标,免疫组化方法测定血红素加氧酶-1(HO-1)和B细胞淋巴瘤-2(Bcl-2)蛋白的表达以及TUNEL细胞凋亡检测试剂盒检测细胞凋亡。结果 B组大鼠肺组织中HO-1蛋白表达在CPB开始前后均有明显增加,其活性测定结果与蛋白表达结果一致,在各时间点均强于A组和C组(P0.05)。各组大鼠肺组织细胞Bcl-2蛋白表达在CPB前无明显差异(P0.05),在CPB后表达逐渐下调,B组在CPB后各时间点均高于A组和C组(P0.05)。各组大鼠肺组织细胞凋亡指数(AI)在CPB前无显著差异,B组在CPB后各时间点均低于A组和C组(P0.05)。HE染色显示B组肺组织损伤程度较A组和C组明显减轻。结论 Co PP可以诱导肺组织HO-1的高表达,而且经过CPB后,仍保持较高的表达。内源性HO-1高表达在体外循环肺损伤中具有一定的抗细胞凋亡作用。其抗凋亡作用可能通过使抗凋亡蛋白Bcl-2蛋白增高而实现的。     

2015年乳腺癌辅助化疗进展

【摘要】〓乳腺癌是危害我国女性健康的头号杀手,尽管近年来辅助化疗的研究进展突飞猛进,但临床中仍有不少问题未能明确,如辅助化疗的合适人群、化疗的开始时间、蒽环及紫杉类的地位和用法、强化维持治疗的作用、疗效及预后的生物标志物等。本文结合乳腺癌辅助化疗在临床上的常见问题和2015年各大乳腺癌会议阐述乳腺癌辅助化疗的最新进展。     

Alterations in T-Cell Subset Frequency in Peripheral Blood in Obesity

Background: Obesity affects the regulation of immune and inflammatory responses. This study characterizes differences in peripheral blood lymphocyte phenotype in obese humans. Methods: Frequencies of lymphocyte subsets among peripheral blood mononuclear cells were compared between 10 obese (BMI ≥35) and 10 lean subjects, as determined by antibodies directed against cluster differentiation (CD) markers. Results: Obese patients demonstrated an increased frequency of CD3+CD4+ T-cells (mean difference 12%, P=0.004), a decreased frequency of CD3+CD8+ T-cells (mean difference 9.4%, P=0.016) and an increased frequency of CD3+CD8+CD95+ T-cells (mean difference 13.3%, P=0.032). No other differences among T-cell or monocyte subsets were noted. Conclusions: Obesity is associated with alterations in frequencies of peripheral CD4+ and CD8+ T-cells and aberrations in the expression of CD95 among CD8+ T-cells. These data suggest both CD4+ and CD8+ T-cell compartments, as well as the regulation of CD95 expression on CD8+ T-cells, as targets for further study into obesity's effects on the immune system.     

西宁地区烧伤病人动脉血气分析观察

对高海拔地区的27例烧伤病人动脉血气变化进行了分析和观察。结果证明:无论是存活病人还是死亡病人伤后均存在有低氧血症问题。并且在死亡病人和烧伤合并吸入性损伤病人其低氧血症的发生早于单纯烧伤病人。提示:吸入性损伤病人应立即行气管切开术以保障氧气供给,单纯烧伤病人可常规吸氧以维持正常血 PaO_2,ARDS 均发生在合并吸入性损伤的病人,高频喷射通气技术对纠正低氧血症有一定效果。     

Controversies in Fistula in Ano

Managing a complex fistula in ano can be a daunting task for most surgeons; largely due to the two major dreaded complications—recurrence & fecal incontinence. It is important to understand the anatomy of the anal sphincters & the aetiopathological process of the disease to provide better patient care. There are quite a few controversies associated with fistula in ano & its management, which compound the difficulty in treating fistula in ano. This article attempts to clear some of those major controversies.     

β-半乳糖苷酶在体内外成骨细胞中的表达

目的 研究β—半乳糖苷酶(β—gal)在成骨细胞中的表达状况，为阐明MorquioB综合征的发病机制提供依据。方法 裸鼠各器官和骨组织标本行X-gal染色检测。抽取羊和人骨髓行骨髓基质细胞(BMSCs)培养，分为4组：I：Adv-hBMP-2转染组；Ⅱ：Adv—β—gal转染组；Ⅲ：未转染组；Ⅳ：地塞米松诱导组。分别行X-gal染色和RT-PCR检测β—gal的表达。结果 裸鼠骺板两侧、骨膜内面及松质骨的成骨细胞和破骨细胞可见多量β—gal的表达。未转染BMSCs组有少量β—gal的表达，其他3组细胞的β—gal表达增高。结论成骨细胞和破骨细胞可表达多量β—gal，该两种细胞的β—gal缺乏可能是MorquioB综合征骨骼异常的直接原因。     

Smoking-Attributable mortality in Spain in 2016

IntroductionSmoking-attributable mortality (SAM) is a valuable indicator that can be used to characterize the course and health burden of the smoking epidemic. The aim of this paper was to estimate SAM in Spain in 2016 in the population aged 35 and over, using the best available evidence.MethodsA smoking prevalence-dependent analysis based on the estimation of population-attributable fractions was performed. Smoking prevalence (never, former, and current smokers) was calculated from a combination of the Spanish Health Survey (2016) and the European Health Survey (2014); the relative risk of death among current and former smokers was taken from the follow-up of various cohorts; and mortality rates were obtained from National Center for Statistics data. SAM estimates are presented globally, and by sex, age groups, and major disease categories: cancer, cardiometabolic diseases and respiratory diseases.ResultsIn 2016, 56,124 deaths were attributed to tobacco consumption, 84% in men (47,000), and 50% in the population aged over 74 (27,795). Overall, 50% of SAM was due to cancer (28,281), 65% of which was lung cancer. One in 4 attributable deaths (13,849) occurred before the age of 65.ConclusionsOne in 7 deaths in Spain in 2016 were attributable to smoking. This estimation of SAM clearly highlights the great impact of smoking on mortality in Spain, mainly due to lung cancer and chronic obstructive pulmonary disease.     

MicroRNAs in hepatic pathophysiology in diabetes

MicroRNAs(miRNAs or miRs) are small approximately 22 nucleotide RNA species that are believed to regulate diverse metabolic and physiological processes.In the recent past,several reports have surfaced that demonstrate the role of miRNAs in various biological processes and numerous disease states.For a disease as complex as diabetes,the emergence of miRNAs as key regulators leading to the disease phenotype has added a novel dimension to the area of diabetes research.On the other hand,the liver,a metabolic hub,contributes in a major way towards maintaining normal glucose levels in the body as it can both stimulate and inhibit hepatic glucose output.This equilibrium is frequently disturbed in diabetes and hence,the liver assumes special significance considering the correlation between altered hepatic physiology and diabetes.While the understanding of the mechanisms behind this altered hepatic behavior is not yet completely understood,recent reports on the status and role of miRNAs in the diabetic liver have further added to the complexities of the knowledge of hepatic pathophysiology in diabetes.Here,we bring together the various miRNAs that play a role in the altered hepatic behavior during diabetes.     

Fluid-phase transcytosis in the primate epididymis in vitro and in vivo

Ligated tubules from the corpus epididymidis of men and monkeys were incubated in medium containing horseradish peroxidase (HRP) as a marker for fluid-phase endocytosis. HRP was localized by light and electron microscopy after 0, 15, 30 and 60 min of incubation. Movement between the cells was prevented by tight junctions, but bypass of this barrier was apparently achieved by an intracellular vesicular mechanism leading to a time-dependent appearance of HRP in the lumen. Uptake of HRP into basal cells and capture by the lysosomal apparatus of principal cells were also observed. HRP-filled vesicles also appeared in the basal, mid and apical cytoplasm of epithelial cells in the caput 1 h after injection of the tracer into the epididymal circulation of the monkey, suggesting that this pathway also operates in vivo.