杜斌---Stress Cardiomyopathy in Sepsis

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沙库巴曲缬沙坦对慢性心衰伴高血压患者的疗效及心功能的影响

药物与临床DOI：10.16662/ki.1674-0742.2024.01.090沙库巴曲缬沙坦对慢性心衰伴高血压患者的疗效及心功能的影响袁玉香1，袁永红21.邹城市人民医院心内科，山东济宁273500；2.兖矿新里程总医院心内科，山东济宁273500［摘要］目的分析沙库巴曲缬沙坦治疗慢性心衰伴高血压患者的疗效及对心功能的影响。

方法随机选取2021年1月—2022年12月邹城市人民医院治疗的150例慢性心衰伴高血压患者为研究对象，采用双盲法分为两组，每组75例。

对照组采取常规疗法，观察组采取常规疗法联合沙库巴曲缬沙坦治疗，比较两组患者临床治疗效果、不良反应发生率、肾功能指标和心功能指标。

结果治疗后，观察组患者不良反应发生率9.33%低于对照组的21.33%，差异有统计学意义（χ2=4.160，P<0.05）。

治疗后，观察组血肌酐、尿素氮、脑利钠肽水平均低于对照组，差异有统计学意义（P均<0.05）。

治疗后，观察组左心室射血分数高于对照组，左心室舒张末期内径、左心室收缩末期内径均低于对照组，差异有统计学意义（P均<0.05）。

结论慢性心衰伴高血压患者使用沙库巴曲缬沙坦治疗，能够明显改善患者心功能、肾功能水平，且不良反应发生率较低。

［关键词］沙库巴曲缬沙坦；慢性心衰；高血压；临床疗效；心功能［中图分类号］R544.1 ［文献标识码］A ［文章编号］1674-0742（2024）01(a)-0090-05Effect of Sacubactril Valsartan on Chronic Heart Failure with Hyperten⁃sion and Its Effects on Cardiac FunctionYUAN Yuxiang1, YUAN Yonghong21.Department of Cardiology, Zoucheng People's Hospital, Jining, Shandong Province, 273500 China;2.Department of Cardiology, Yankuang New Journey General Hospital, Jining, Shandong Province, 273500 China[Abstract] Objective To treat patients with chronic heart failure and hypertension with the drug sacubactril valsartan, and to analyze the efficacy and effect of this drug on cardiac function. Methods A total of 150 patients with chronic heart failure and hypertension treated by Zoucheng People's Hospital from January 2021 to December 2022 were ran⁃domly selected and divided into two groups by double-blind method, with 75 patients in each group. The control group was treated with conventional therapy, and the observation group was treated with conventional therapy com⁃bined with the drug sacubactril valsartan. The clinical therapeutic effect, incidence of adverse reactions, renal function indexes and cardiac function indexes were compared between the two groups. Results After treatment, the incidence of adverse reactions in observation group was 9.33% lower than that in control group 21.33%, the difference was statisti⁃cally significant (χ2=4.160, P<0.05). After treatment, the levels of serum creatinine, urea nitrogen and brain natri⁃uretic peptide in the observation group were lower than those in the control group, the differences were statistically sig⁃nificant (all P<0.05). After treatment, left ventricular ejection fraction in observation group was higher than control group, and left ventricular end-diastolic diameter and left ventricular end-systolic diameter were lower than control group, the differences were statistically significant (all P<0.05). Conclusion In the treatment of chronic heart failure patients with hypertension, the use of the drug sacubactril valsartan can significantly improve the level of cardiac func⁃tion and renal function related indicators of patients, and the incidence of adverse reactions was low.[Key words] Sacubactril valsartan; Chronic heart failure; High blood pressure; Clinical effect; Cardiac function[作者简介] 袁玉香（1974-），女，硕士，副主任医师，研究方向为心血管内科。

211113621_脊髓损伤患者脊髓神经刺激器植入术后康复治疗1例报告

·专家论坛·脊髓损伤患者脊髓神经刺激器植入术后康复治疗1例报告陈楠陈婵顾雨薇凌骏麒白玉龙(复旦大学附属华山医院康复医学科上海 200040)摘要目的：观察硬膜外脊髓神经电刺激结合康复训练对1例脊髓损伤患者肢体功能恢复的效果。

方法：采用常规康复训练方法治疗脊髓损伤后植入脊髓神经刺激器的截瘫患者，每周6次共3周。

治疗前、后和1个月随访时通过美国脊髓损伤协会脊髓损伤分级、Lovett肌力分级、改良Barthel指数量表、Berg平衡功能量表和改良Ashworth量表评估患者的肢体功能和日常生活活动能力。

结果：治疗3周后，患者的运动、感觉、平衡功能和日常生活活动能力均获得明显改善，且这些改善在1个月随访时仍得以保留。

结论：康复训练能改善脊髓损伤后植入脊髓神经刺激器的截瘫患者的肢体功能，是此类患者不可或缺的治疗手段，但要获得良好的效果，患者须长期坚持康复训练。

关键词脊髓损伤硬膜外脊髓神经电刺激康复训练中图分类号：R493; R651.2 文献标志码：B 文章编号：1006-1533(2023)07-0008-03引用本文陈楠, 陈婵, 顾雨薇, 等. 脊髓损伤患者脊髓神经刺激器植入术后康复治疗1例报告[J]. 上海医药, 2023, 44(7): 8-10; 36.Postoperative rehabilitation of spinal cord nerve stimulator implantationin a patient with spinal cord injury: a case reportCHEN Nan, CHEN Chan, GU Yuwei, LING Junqi, BAI Yulong(Department of Rehabilitation Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China) ABSTRACT Objective: To observe the effect of epidural spinal cord stimulation combined with rehabilitation training on the recovery of limb function in a patient with spinal cord injury. Methods: The paraplegic patients with spinal cord nerve stimulator implanted after spinal cord injury was treated with routine rehabilitation training, 6 times a week for 3 weeks. The limb function and the abilities of daily living were assessed by the American Spinal Cord Injury Association spinal cord injury scale, Lovett muscle strength scale, modified Barthel index scale, Berg balance function scale, and modified Ashworth scale at pre-treatment, post-treatment, and 1-month follow-up. Results: After 3 weeks of treatment, the patient showed significant improvements in motor, sensory, balance, and daily living, and these improvements were maintained at 1-month follow-up.Conclusion: Rehabilitation training can improve the limb function of paraplegic patients with spinal cord nerve stimulator implantation after spinal cord injury, and is an indispensable treatment for such patients. However, patients must adhere to long-term rehabilitation training to obtain good results.KEY WORDS spinal cord injury; epidural spinal cord stimulation; rehabilitation training脊髓损伤是指由于各种原因引起的脊髓结构和功能的破坏，多继发于外伤[1]，可导致损伤平面以下运动、感觉和自主神经功能障碍。

探讨巴氯芬治疗脑卒中后肌张力障碍的临床疗效

·内科研究·SYSTEMS MEDICINE 系统医学系统医学2017年12月第2卷第23期DOI:10.19368/ki.2096-1782.2017.23.043探讨巴氯芬治疗脑卒中后肌张力障碍的临床疗效董卫华常州市武进中医医院康复科,江苏常州213100[摘要]目的探讨巴氯芬治疗脑卒中后肌张力障碍的临床疗效。

方法选取该院(2015年10月—2017年8月)收治的112例脑卒中后肌张力障碍患者为该研究对象,根据治疗方法差异分为观察组与对照组,每组56例,观察组患者给予康复训练联合巴氯芬治疗,对照组患者单纯进行康复训练,连续治疗4周,对比两组患者治疗2、4周后肌张力改变程度和运动障碍程度。

结果治疗2周后,两组患者上肢Ashworth 评分(28.57%、57.14%、14.29%、0.00%vs 14.29%、32.14%、50.00%、3.57%、对比差异有统计学意义(χ2=6.0555、12.6453、29.2317、3.6349,P <0.05);两组患者下肢Ashworth(评分42.86%、39.29%、14.29%、3.57%vs 21.43%、42.86%、28.57%、7.14%)对比差异有统计学意义(χ2=10.5273、0.2633、6.0555、1.2573,P <0.05);治疗4周后,两组患者上肢Ashworth 评分(35.71%、50.00%、14.29%vs 17.86%、35.71%、46.43%)对比差异有统计学意义(χ2=8.1237、4.1692、24.4287,P <0.05);两组患者下肢Ashworth 评分(46.43%、42.86%、10.41%、0.00%vs 25.00%、46.43%、25.00%、3.57%)对比差异有统计学意义(χ2=10.0012、0.2579、7.3048、3.6349,P <0.05);治疗2周后,两组患者Brunstrum 评分(21.43%、28.57%、25.00%、7.14%、3.57%vs 32.14%、35.71%、14.29%、3.57%、0.00%)对比差异有统计学意义(χ2=2.9245、1.1687、3.6332、1.2573、3.6349,P <0.05);治疗4周后,两组患者Brunstrum 评分(7.14%、10.41%、25.00%、35.71%、14.29%、7.14%vs 10.41%、25.00%、28.57%、25.00%、7.14%、3.57%)对比差异有统计学意义(χ2=0.6679、7.3048、0.3249、2.7129、2.6718、1.2573,P <0.05)。

丝裂原活化蛋白激酶在动脉粥样硬化中的作用研究进展

丝裂原活化蛋白激酶在动脉粥样硬化中的作用研究进展陈伟强;徐新;张社兵;陶军【期刊名称】《中国心血管病研究》【年(卷),期】2017(015)007【总页数】5页(P582-586)【关键词】丝裂原活化蛋白激酶;动脉粥样硬化;炎症反应;黏附分子;抑制剂【作者】陈伟强;徐新;张社兵;陶军【作者单位】512026 广东省韶关市,汕头大学医学院附属粤北人民医院心血管内科;512026 广东省韶关市,汕头大学医学院附属粤北人民医院心血管内科;512026 广东省韶关市,汕头大学医学院附属粤北人民医院心血管内科;中山大学第一附属医院心内科【正文语种】中文【中图分类】R541.4动脉粥样硬化（AS）是一类主要累及大中动脉血管壁的慢性炎症疾病，主要由血脂紊乱引起，炎症反应参与AS发生、发展的全过程[1]。

在AS发生发展过程中，炎症细胞、血管内皮细胞、平滑肌细胞和细胞因子、趋化蛋白、黏附分子等相互作用，相互影响动脉粥样化过程。

促炎细胞因子可改变动脉粥样硬化早期血管内皮功能，诱导血管内皮细胞表达趋化因子和黏附分子，促进白细胞、淋巴细胞和单核细胞迁移、募集、黏附到发炎的血管壁中。

白细胞在动脉血管内膜中被局部产生的细胞因子永久激活，其可以通过刺激清道夫受体的表达和增强细胞介导的氧化来加速巨噬细胞向泡沫细胞的转化，加剧动脉粥样硬化病变进展[2-5]。

致炎细胞因子发挥生物学功能是通过与细胞膜表面受体相互作用，经过跨膜信号转导活化细胞内的相关信号通路，最终促进靶基因的表达。

目前认为，丝裂原活化蛋白激酶（mitogen activated protein kinase，MAPKs）、Janus激酶-信号转导子及转录激活子（Janus kinase signal transduction and activator of transcription，JAKSTAT）和核因子kB（nuclear factor kB，NF-kB）是细胞内3条重要信号通路，在炎症信号转导调控中起重要作用。

基于脂质与动脉粥样硬化通路探讨侯氏黑散治疗脑缺血再灌注损伤的机制研究

杨毅,李若冰,黄丽娜,王博,蒋希成*黑龙江中医药大学,黑龙江哈尔滨150040〔收稿日期〕2023-09-06〔基金项目〕国家自然科学基金面上项目(82174261,81673865);黑龙江省自然科学基金联合引导项目(LH2021H084);黑龙江中医药大学新药临床前研究基金项目(2019XY01)。

〔通信作者〕*蒋希成,男,博士,博士研究生导师,E-mail:************************。

〔摘要〕目的利用网络药理学和动物实验验证分析《金匮要略》侯氏黑散治疗脑缺血再灌注损伤(cerebral ischemia reperfu⁃sion injury ,CIRI )的成分、靶点及信号通路,并通过脂质与动脉粥样硬化通路研究其作用机制。

方法在TCMIP 、GeneCards 和OMIM 疾病数据库获取侯氏黑散与CIRI 的交集靶点,使用STRING 网站构建交集靶点的蛋白质-蛋白质相互作用(protein-protein interac⁃tion ,PPI )网络,使用Cytoscape 软件筛选核心靶点和成分并构建“成分-靶点”网络。

使用R 语言进行GO 和KEGG 富集分析,使用AutoDock Vina 验证成分与靶点的对接能。

动物实验中将60只SPF 级SD 大鼠随机分为假手术组、模型组、西药组和侯氏黑散低、中、高剂量组。

用线栓法制备大脑中动脉闭塞/再灌注(middle cerebral artery occlusion/reperfusion ,MCAO/R )大鼠模型,造模7d 后通过改良神经功能评分(modifiedneurological severity score ,mNSS )评估神经功能,TTC 染色检测脑梗死体积,HE 染色观察脑组织病理变化,全自动生化分析仪检测血清低密度脂蛋白胆固醇(low density lipoprotein cholesterol ,LDL-C )、高密度脂蛋白胆固醇(how density lipoprotein cholesterol ,HDL-C )、总胆固醇(total cholesterol ,TC )和甘油三酯(triglycerides ,TG )含量,ELISA 检测血清白介素-1β(interleukin 1β,IL-1β)、白介素-6(interleukin-6,IL-6)和肿瘤坏死因子-α(tumor necrosis factor-α,TNF-α)水平,免疫组织化学和RT-qPCR 检测脑组织中HSP90AA1、NF-κB1、SRC 的蛋白及mRNA 表达水平。

脓毒症血小板减少需升板治疗

➢ 治疗血小板减少
• 当血小板计数≤10×109/L（排除假性血小板减少）、并存在出血高风险时,推荐预防性输注血小板(Ⅰ类推荐,C级证据)。
• 对活动性出血、外科手术或介入性操作时，血小板需达到≥50×109/L
• 当PLT<75×109/L，应考虑注射重组人血小板生成素（rhTPO），直至血小板数量连续2d增加量超过50× 109/L,停止注射(Ⅱa类推荐,B级证据)。
– 有输注后免疫反应风险。
Schiffer CA, et al. J Clin Oncol. 2001;19:1519-38 中华人民共和国卫生部..中国临床医生. 2001,29(3):29-30 王芳..内科急危重症杂志.2008.14(2): 109-112
血小板贮存时间越长，患者预后越差
一项回顾性分析纳入2006-2009年间一级创伤中心需要输血的381例创伤患者，分析死亡及并发症（脓毒症、急性呼吸窘迫综合征、肾功能衰竭和肝衰竭)发生率
曹曰针,等.中国输血杂志.2014;27(6):578-580
多次输注是血小板输注无效的主要诱因
*
输注无效次数的占比
*：同输注 1 次相比较，P<0.01
曹曰针,等.中国输血杂志.2014;27(6):578-580
内容概要
脓毒症是ICU患者血小板减少的最常见病因血小板减少增加感染风险，不利于感染的控制血小板减少与疾病的不良预后密切相关血小板输注“有利有弊” 重组人血小板生成素能有效治疗脓毒症患者血小板减少
血小板减少症导致克雷伯氏杆菌诱导的肺炎鼠生存降低和细菌生长增加
生存率
分布细菌计数
h
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De Stoppelaar SF,et al.Blood 2014 Dec 11;124(25)

儿童功能性消化不良患者使用四磨汤联合双歧杆菌三联活菌的治疗效果

DOI：10.16662/ki.1674-0742.2024.01.086儿童功能性消化不良患者使用四磨汤联合双歧杆菌三联活菌的治疗效果吴丽珊，魏世梁，连清荣福建医科大学附属厦门弘爱医院儿科，福建厦门361006［摘要］目的观察功能性消化不良患儿在使用四磨汤联合双歧杆菌三联活菌后的治疗效果。

方法随机选取2021年1月—2022年12月福建医科大学附属厦门弘爱医院儿科80例功能性消化不良患儿为研究对象。

按照随机数表法分为对照组（n=40）和观察组（n=40）。

对照组给予四磨汤治疗，观察组以四磨汤联合双歧杆菌三联活菌进行治疗。

以多项症状积分为疗效分析切入点，比较胃肠功能指标，评价治疗的有效性及安全性。

结果治疗后，观察组症状积分比对照组更低，差异有统计学意义（P<0.05）；治疗后，观察组胃肠功能指标均显著优于对照组，差异有统计学意义（P<0.05）；观察组经治疗后的总有效率（95.00%）高于对照组的77.50%，观察组的不良反应发生率（5.00%）明显低于对照组，差异有统计学意义（χ2=5.165、4.114，P均<0.05）。

结论以四磨汤联合双歧杆菌三联活菌片治疗儿童功能性消化不良的有效性、安全性非常高，在改善症状、恢复肠道功能等方面的优势更显著。

［关键词］儿童功能性消化不良；四磨汤；双歧杆菌三联活菌；治疗效果［中图分类号］R722 ［文献标识码］A ［文章编号］1674-0742（2024）01(a)-0086-04Therapeutic Effect of Simo Decoction Combined with Bifidobacterium Triple Live Bacteria in Children with Functional DyspepsiaWU Lishan, WEI Shiliang, LIAN QingrongDepartment of Pediatrics, Xiamen Hongai Hospital Affiliated to Fujian Medical University, Xiamen, Fujian Province, 361006 China[Abstract] Objective To observe the effect of Simo decoction combined with bifidobacterium triple live bacteria in children with functional dyspepsia. Methods80 children with functional dyspepsia were randomly selected from the department of Pediatrics, Xiamen Hongai Hospital Affiliated to the Fujian Medical University from January 2021 to December 2022. They were divided into control group (n=40) and observation group (n=40) according to random num⁃ber table method. The control group was treated with Simo decoction, and the observation group was treated with Simo decoction combined with bifidobacterium triple live bacteria. The efficacy and safety of the treatment were evaluated by comparing the gastrointestinal function indexes with the scores of multiple symptoms. Results After treatment, the scores of symptoms in the observation group were significantly lower than those in the control group, the difference was statistically significant (P<0.05) ,and the gastrointestinal function indexes in the observation group were signifi⁃cantly better than those in the control group, the difference was statistically significant (P<0.05). The total effective rate of the observation group was 96.00% , which was significantly higher than that of the control group (77.50%), and the adverse reaction rate of the observation group (5.00%) was significantly lower than that of the control group, the differences were statistically significant (χ2=5.165,4.114, both P<0.05). Conclusion The effectiveness and safety of Simo decoction combined with bifidobacterium triple live bacteria in the treatment of children with functional dyspep⁃sia are very high, and the advantages of improving symptoms and restoring intestinal function are more significant. [作者简介] 吴丽珊（1986-），女，硕士，主治医师，研究方向为儿童消化系统疾病。

mechanicalventilationofcopd杜斌 ppt课件

PEEP与呼气流速
半径
PEEP
Savian C, Chan P, Paratz J. The Effect of Positive End-Expiratory Pressure Level on Peak Expiratory Flow During Manual Hyperinflation. Anesth Analg 2019; 100: 1112-6
e = 2.718 k = 1/ =1/(R x C)
时间常数()
时间常数
Tau
呼出气容积残余容积成人(正常值)
2 x 0.10 = 0.20”
0
0%
100% 术后气管插管成人患者
5 x 0.06 = 0.30”
1
63%
37%
COPD成人患者
15 x 0.06 = 0.90”
3
COPD稳定期: PEEP
总结对于处于稳定期的严重COPD患者, 应用
高水平的CPAP能够
降低PEEPi及肌肉活动指标肺容积显著增加
O’Donoghue FJ, Catcheside PG, Jordan AS, Bersten AD, McEvoy RD. Effect of CPAP on intrinsic PEEP, inspiratory effort, and lung volume in severe stable COPD. Thorax 2019;57:533-539
95%
5%
ARDS成人患者
8 x 0.03 = 0.24”
ARDS患儿
5
99.9%
0.1%
5 x 0.01 = 0.05”
动态过度充盈: DHI

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Myocardial Dysfunction in Sepsis: Mechanisms

Global ischemia Myocardial depression factor Cytokines Prostanoids Endothelin-1 Nitric oxide Adhesion molecules …
Myocardial Dysfunction in Sepsis
Parker MM, Shelhamer JH, Bacharach SL, et al. Profound but reversible myocardial depression in patients with septic shock. Ann Intern Med 1984; 100: 483-490.
▪ decreased ejection fraction ▪ increased end-diastolic volume index
Waisbren BA. Bacteremia due to gram-negative bacilli other than the Salmonella: a clinical and therapeutic study. AMA Arch Intern Med 1951; 88: 467-488 Calvin JE, Driedger AA, Sibbald WJ. An assessment of myocardial function in human sepsis utilizing ECG gated cardiac scintigraphy. Chest 1981; 80: 579-586
Hemodynamics of Septic Shock
Edwards JD. Oxygen transport in cardiogenic and septic shock. Crit Care Med 1991; 19(5): 658-663
Myocardial Dysfunction in Sepsis: History
Tissue Oxygen Debt Associated with Organ Failure
Shoemaker WC, Appel PL, Kram HB. Tissue oxygen debt as a determinant of lethal and nonlethal postoperative organ failure. Crit Care Med 1988; 16: 1117-1120

Waisbren (1951)
cold shock (possible hypovolemic status)
▪ clammy, pale and hypotensive with low volume pulses

Calvin (1981)
After adequate volume-resuscitation
Lab investigation
sputum smear positive for AFB
2010/05/06
General HR MAP Preload CVP PAWP Afterload Contractility SVRI CO CI SV Vasopressor Inotrope Perfusion NE DA Lac
Improved Perfusion Leads to Better Organ Function

40 patients undergoing repair of proximal femoral fracture under general anaesthesia randomly assigned to
How About Myocardial DysfLeabharlann nction in Sepsis?
evidence & possible mechanism
Myocardial Dysfunction in Sepsis
a. b.
Natanson C, et al, Gram-negative bacteremia produces both severe systolic and diastolic cardiac dysfunction in a canine model that simulates human septic shock. J Clin Invest 1986; 78: 259-270 Natanson C, et al, Cardiovascular performance with E. coli challenges in a canine model of human sepsis. Am J Physiol 1988; 254: H558-H569
Myocardial Dysfunction in Sepsis

Left ventricular systolic dysfunction
LVEF < 50% LVEF < 45%
18% (8/45) ~ 46% (16/35) 60% (40/67)

Left ventricular diastolic dysfunction
Improved Perfusion Leads to Better Organ Function
Sinclair S, James S, Singer M. Intraoperative intravascular volume optimisation and length of hospital stay after repair of proximal femoral fracture: randomised controlled trial. BMJ 1997; 315: 909

Empirical antibiotic
imipenem + vancomycin + azithromycin INH + RFP + PZA + EMB + LEVO

Respiratory failure
mechanical ventilation: PEEP 8; FiO2 60%

Sinclair S, James S, Singer M. Intraoperative intravascular volume optimisation and length of hospital stay after repair of proximal femoral fracture: randomised controlled trial. BMJ 1997; 315: 909
6am 138 105/70(83) 10 17 1786 5.0 3.27 36 1.3 0 2.2
2pm 164 114/82(95) 15 26 2022 4.84 3.16 30 4.0 0 4.4

Refractory shock
ABP 70/55 mmHg

PAC
Low afterload？ Low SV
Myocardial Dysfunction in Sepsis: Terminology & Characteristics
Terminology Stress cardiomyopathy Myocardial stunning
Acute ischemia

Characteristics
Merx MW, Weber C. Sepsis and the heart. Circulation 2007; 116: 793-802
Myocardial Depression Factor in Sepsis
Parrillo JE, Burch C, Shelhamer JH, et al. A circulating myocardial depressant substance in humans with septic shock. Septic shock patients with a reduced ejection fraction have a circulating factor that depresses in vitro myocardial cell performance. J Clin Invest 1985; 76: 1539-1553.
Reversible impairment of left ventricular
relaxation
18% (8/45)
Etchecopar-Chevreuil C, Francois B, Clavel M, et al. Cardiac morphological and functional changes during early septic shock: a transesophageal echocardiographic study. Intensive Care Med 2008; 34: 250-256 Vieillard-Baron A, Caille V, Charron C, et al. Actual incidence of global left ventricular hypokinesia in adult septic shock. Crit Care Med 2008; 36: 1701-1706 Bouhemad B, Nicolas-Robin A, Arbelot C, et al. Acute left ventricular dilatation and shock-induced myocardial dysfunction. Crit Care Med 2009; 37(2): 441-447