Studies on monitoring hemodynamics and oxygen dynamics of adult respiratory distress syndrome secondary to high altitude pulmonary edema

To study monitoring hemodynamics and oxygen dynamics of adult respiratory distress syndrome (ARDS) secondary to high altitude pulmonary edema (HAPE),we performed clinic and laboratory studies in 8 patients who preliminarily developed high altitude cerebral edema (HACE) and then ARDS occurred at an altitude of 4 500 m. After an initial emergency treatment on high mountains,all the patients were rapidly transported to a hospital at a lower altitude of 2 808 m. The right cardiac catheterizations were carried out within 5 h after hospitalized. The monitoring hemodynamics and oxygen dynamics were studied via a thermodilution Swan-Gaze catheter. The results showed that before treatments at the beginning of monitoring,there presented a significant pulmonary artery hypertension with a decreased cardiac function,and a lower oxygen metabolism in all the 8 patients. However,after some effective treatments,including mechanical ventilation and using dexamethasone,furosemide,etc,four days later the result of a repeated monitoring showed that their pulmonary artery pressure had been decreased with an improved cardiac function with all the oxygen metabolic indexes increased significantly. Our studies suggested that performing monitoring hemodynamics in patients with ARDS secondary to HAPE will define the clinical therapeutic measures which will benefit the outcome.

Study on acid-base disorders in patients with adult respiratory distress syndrome

Arterial blood gases and electrolytes were determined in 159 cases of adult respirato-ry distress syndrome(ARDS).It was found that disordered acid-base balance was a commonfinding in various kinds of ARDS.In mild ARDS,respiratory alkalosis and the combination ofrespiratory alkalosis plus metabolic alkalosis or metabolic acidosis were usually encounted,whilein moderate and severe cases of ARDS,triple acid-base disorders,respiratory acidosis,and thecombination of respiratory acidosis plus metabolic acidosis were commonly seen.Severe alkalosiswas one of the factors to result in death.

Effect of bronchofiberscope airway lavage on respiratory function and inflammatory stress level in adults with severe pneumonia

Objective:To study the effect of bronchofiberscope airway lavage on respiratory function and inflammatory stress level in adults with severe pneumonia.Methods:80 adults with severe pneumonia treated in our hospital between July 2011 and March 2015 were collected, and after the treatment process and auxiliary examination results were retrospectively analyzed, they were divided into control group (n=45) who accepted conventional treatment and observation group (n=35) who accepted bronchofiberscope airway lavage. Before and after treatment, the spirometer was used to test the respiratory function of two groups of patients;ELISA method was used to detect serum inflammatory factor levels;RIA method was used to detect serum stress index levels.Results:Before treatment, differences in serum levels of inflammatory cytokines and stress indexes were not statistically significant between two groups of patients (P>0.05);after treatment, respiratory function parameters forced expiratory volume in 1 s (FEV1), alveolar ventilation (VA), maximal mid-expiratory flow (FEF25-75), instantaneous late-expiratory flow (FEF50%) and instantaneous late-expiratory flow (FEF75%) levels of observation group were higher than those of control group (P<0.05), serum high mobility group box B1 (HMGB1), interleukin-2 (IL-2), interferonγ (IFN-γ), cortisol (Cor), adrenaline (ADR) and noradrenaline (NADR) levels were significantly lower than those of control group while interleukin-13 (IL-13) level was significantly higher than that of control group (P<0.05). Conclusions: Bronchofiberscope airway lavage can optimize the respiratory function and reduce systemic inflammatory and stress response in adults with severe pneumonia.

成人急性呼吸道传染病患者俯卧位通气管理的最佳证据总结

目的检索、评价、提取并汇总成人急性呼吸道传染病患者俯卧位通气管理的最佳证据,为俯卧位通气规范化治疗提供循证依据。方法根据“6S”证据模型,系统检索各指南网站及中英文数据库相关文献,由研究人员对纳入文献进行质量评价、证据提取与汇总。结果共纳入11篇文献,包括3篇临床决策、5篇指南、1篇证据总结、2篇专家共识。最终形成包括人员准备、院感防控、护理评估、实施要点、风险管理、健康教育和特殊人群照护等7个方面共48条的最佳证据。结论在证据应用过程中医护人员应基于具体临床情境,制订个体化俯卧位通气治疗方案,以改善患者临床结局。

高密度脂蛋白水平对脓毒症相关急性呼吸窘迫综合征患者预后的影响

目的 评价高密度脂蛋白(HDL)水平对脓毒症相关急性呼吸窘迫综合征(ARDS)预后的影响。方法 采用回顾性研究,选取2016年6月至2023年6月航天中心医院重症医学科收治的102例脓毒症相关ARDS患者为观察对象,按患者入院28 d预后将其分为存活组(n=46)、死亡组(n=56)。分析所有患者的性别、年龄、原发感染部位、既往史、急性生理学和慢性健康状况评价Ⅱ(APACHEⅡ)评分、呼吸频率、体温、胆固醇、甘油三酯、白蛋白、HDL、低密度脂蛋白(LDL)、降钙素原、C反应蛋白(CRP)、白细胞、是否使用呼吸机、住院时是否合并感染性休克以及抗细菌和抗真菌治疗等资料,经单因素、多因素分析脓毒症相关ARDS患者预后的危险因素。采用受试者工作特征(ROC)曲线分析HDL水平对脓毒症相关ARDS死亡患者发生的预测效能。结果 (1)102例脓毒症相关ARDS患者病死率为54.90%。(2)死亡组患者的年龄、APACHEⅡ评分、使用呼吸机比例、合并感染性休克比例分别为(72.59±14.86)岁、26.50分、80.36%、73.21%,均显著高于存活组[(64.43±15.86)岁、20.00分、69.57%、36.96%],外周血HDL水平为(0.60±0.25) mmol/L,低于ARDS存活组[(0.90±0.33) mmol/L],差异均有统计学意义(P<0.05)。多因素Logistic回归分析显示,高APACHEⅡ评分(OR=0.88,95%CI:0.81~0.95,P=0.002)、合并感染性休克(OR=0.25,95%CI:0.08~0.76,P=0.014)、低水平的HDL(OR=4.46,95%CI:2.34~8.48,P=0.001)是脓毒症相关ARDS患者死亡的独立危险因素。(3)HDL预测脓毒症相关ARDS患者死亡的ROC的曲线下面积(AUC)为0.755,以HDL 0.735 mmol/L作为预测ARDS死亡的临界点,其敏感度为71.74%,特异度为73.21%。结论 低水平的HDL是脓毒症相关ARDS死亡的独立危险因素,HDL水平对脓毒症相关ARDS患者的预后有一定的预测价值。

布洛芬缓释胶囊在成年女性呼吸道感染伴发热中的退热效果

目的探讨成年女性呼吸道感染伴发热采用药物布洛芬缓释胶囊治疗的效果。方法以2020年1月—2023年10月西苑医院济宁医院接诊成年女性呼吸道感染伴发热患者80例作为本次进行治疗分析的对象,以随机数字表法分组,对照组(40例)采用药物对乙酰氨基酚片治疗,观察组(40例)采用药物布洛芬缓释胶囊治疗;比较两组退热效果,监测两组患者用药前后不同时间点体温情况、用药前后炎症指标以及患者用药后的不良反应发生率。结果观察组呼吸道感染伴发热患者通过布洛芬治疗后退热效果优于对照组(P<0.05);观察组患者用药后1 h、2 h、3 h及6 h体温均低于对照组(均P<0.05);观察组患者用药后炎症指标(白细胞计数、C反应蛋白、白细胞介素6)检测结果均低于对照组,不良反应总发生率低于对照组(均P<0.05)。结论成年女性患呼吸道感染伴发热疾病,服用布洛芬缓释胶囊治疗,具有较好退热效果,同时不良反应少。

亚低温下呼气末正压通气对成人急性呼吸窘迫综合征氧代谢情况及预后结局的影响研究

目的:观察亚低温下呼气末正压通气(PEEP)对改善成人急性呼吸窘迫综合征(ARDS)氧代谢情况及预后结局的影响。方法:选取2021年5月—2022年5月在南阳市第一人民医院接受持续正压通气治疗的126例ARDS患者作为研究对象。采用抽签法将患者分为两组,每组各63例。对照组予以常规体温下PEEP治疗。观察组予以亚低温下PEEP治疗。比较两组患者治疗前后的肺部炎症指标、氧代谢指标变化情况以及两组患者的治疗情况、预后结局。结果:治疗后,观察组患者的肺部局部白细胞介素-6(IL-6)、血清降钙素原(PCT)、C-反应蛋白(CRP)水平均低于对照组,差异有统计学意义(t=4.973、6.714、4.442,P<0.05);观察组患者的氧分指数(P/F)、混合静脉血氧饱和度(SvO2)高于对照组、血清乳酸水平(LAC)水平低于对照组,差异有统计学意义(t=2.901、2.974、10.809、P<0.05);观察组的肺顺应性高于对照组,ICU住院时长、机械通气时长均低于对照组,差异有统计学意义(t=9.476、6.907、3.530,P<0.05);观察组患者并发症发生率(7.94%)低于对照组(19.05%)、病死率(4.76%)低于对照组(15.87%),差异有统计学意义(χ^(2)=5.287、6.671,P<0.05)。结论:采用亚低温技术配合PEEP可促进ARDS患者的肺部炎症反应及氧代谢情况恢复,可增加患者临床获益并改善预后结局。

Alveolar Hemorrhage and Acute Respiratory Distress Syndrome Associated with Pulmonary Cement Following Percutaneous Vertebroplasty with Polymethylmethacrylate

We report a rare complication of diffuse alveolar hemorrhage and respiratory failure following percutaneous vertebroplasty in a patient who has evidence of cement leakage. Cement injection was done two days prior to presentation and covered 2 vertebral levels for osteoporosis induced fractures.

Respiratory failure in diabetic ketoacidosis

Respiratory failure complicating the course of diabetic ketoacidosis(DKA)is a source of increased morbidity and mortality.Detection of respiratory failure in DKA requires focused clinical monitoring,careful interpretation of arterial blood gases,and investigation for conditions that can affect adversely the respiration.Conditions that compromise respiratory function caused by DKA can be detected at presentation but are usually more prevalent during treatment.These conditions include deficits of potassium,magnesium and phosphate and hydrostatic or non-hydrostatic pulmonary edema.Conditions not caused by DKA that can worsen respiratory function under the added stress of DKA include infections of the respiratory system,pre-existing respiratory or neuromuscular disease and miscellaneous other conditions.Prompt recognition and management of the conditions that can lead to respiratory failure in DKA may prevent respiratory failure and improve mortality from DKA.

Acute cor pulmonale in patients with acute respiratory distress syndrome:A comprehensive review

Acute respiratory distress syndrome(ARDS)-related acute cor pulmonale(ACP)is found in 8%-50%of all patients with ARDS,and is associated with adverse hemodynamic and survival outcomes.ARDS-related ACP is an echocardiographic diagnosis marked by combined right ventricular dilatation and septal dyskinesia,which connote simultaneous diastolic(volume)and systolic(pressure)overload respectively.Risk factors include pneumonia,hypercapnia,hypoxemia,high airway pressures and concomitant pulmonary disease.Current evidence suggests that ARDS-related ACP is amenable to multimodal treatments including ventilator adjustment(aiming for arterial partial pressure of carbon dioxide<60 mmHg,plateau pressure<27 cmH2O,driving pressure<17 cmH2O),prone positioning,fluid balance optimization and pharmacotherapy.Further research is required to elucidate the optimal frequency and duration of routine bedside echocardiography screening for ARDS-related ACP,to more clearly delineate the diagnostic role of transthoracic echocardiography relative to transesophageal echocardiography,and to validate current and novel therapies.

Cupping Therapy for 103 Cases of High Fever due to Infection of the Upper Respiratory Tract

The cupping therapy has remarkable antipyretic effect in the treatment of fever. In recent years, the author has treated 103 cases of high fever caused by infection of the upper respiratory tract and obtained quite satisfactory therapeutic results. A report follows.

Lung mechanics in canine oleic acid-induced respiratory distress syndrome model

In mechanically ventilated anesthetized dogs (pentobarbital sodium,30mg/kg) with acute lung injury induced by intravenous infusion of oleic acid(OA),changes in airflow,lung volume,and tracheal (Pao),transpulmonary (Ptp)and esophageal (Pes) pressures were measured.Changes in lung mechanics werestudied before and after OA infusion at intervals,during an observation periodlasting 4h,using curve-fitting method,interrupter technique and pressure-volume(PV) loops measurement.The main findings are listed as follows:(1)Complianceand functional residual capacity (FRC) showed a marked decrease,while Pao andPtp showed a marked increase within 2h after OA.(2) Airflow resistance atexpiratory phase estimated by the curve-fitting method showed a marked increaseafter OA.(3)PV loops of the lungs or total respiratory system showed similarchanges 4h after OA,characterized by the presence of an inflexion point at theinflation limb,increased hysteresis and rightward and downward shift of the loop.It is suggested that use of the curve-fitting method in combination with the PVloop for the total respiratory system would be more appropriate for monitoringlung mechanics during mechanical ventilatory support of ARDS patients.

Effects of pulmonary stretch reflex on lung injury in rabbits with acute respiratory distress syndrome

BACKGROUND： Pulmonary stretch reflex plays an important role in regulation of respiratorymovement. This study aimed to evaluate the effect of pulmonary stretch reflex on lung injury inrabbits with acute respiratory distress syndrome （ARDS）.METHODS： ARDS rabbits were given intratracheal infusion of hydrochloric acid and ventilatedwith neurally adjusted ventilatory assistance （NAVA） with a tidal volume （VT） of 6 mL/kg and theelectrical activity of diaphragm （EAdi）-determined positive end expiratory pressure. After isolation ofthe bilateral vagus nerve trunk, the rabbits were randomized into two groups： sham operation （SHAM）group （n=5） and bilateral vagotomy （VAG） group （n=5）. Gas exchange and respiratory mechanicswere detected at baseline, after lung injury and 1, 2, and 3 hours after ventilation respectively.Pulmonary permeability index, pathological changes and infl ammatory response were also measured.RESULTS： Compared with the SHAM group, PaO2/FiO2 in the VAG group decreased signifi cantly2 and 3 hours after ventilation （P〈0.05）. There was no significant difference in PaCO2 betweenthe SHAM and VAG groups （P〉0.05）, and the VAG group had a high VT, peak pressure （Ppeak）,and mean pressure （Pm） compared with the SHAM group 1, 2, 3 hours after ventilation （P〈0.05）.Compared to the SHAM group, dead space fraction （VD/VT） and respiratory system elastance （Ers）in the VAG group increased （P〈0.05） and static pulmonary compliance （Cst） decreased markedly（P〈0.05） after ventilation for 3 hours. Lung wet/dry weight ratio （W/D） （8.4±1.2 vs. 6.6±1.0）, lung injuryscore （6.3±1.8 vs. 3.8±1.3）, tumor necrosis factor-# （TNF-#） （779±372 pg/mL vs. 355±130 pg/mL）and interleukin-8 （IL-8） （169±21 pg/mL vs. 118±17 pg/mL） increased significantly in the VAG groupcompared with the SHAM group （P〈0.05）.CONCLUSION： Lung injury is aggravated after bilateral vagotomy, demonstrating thatpulmonary stretch refl ex may have protective effect on the lung.

成人呼吸道感染病原诊断核酸检测技术临床应用专家共识(2023)

呼吸道感染性疾病在临床中极为常见,病原体的快速检测和精准诊断是其有效治疗的前提。传统微生物学及免疫学技术对呼吸道病原体检测的灵敏度偏低,核酸检测技术的发展和临床应用大幅提高了呼吸道病原体的诊断能力。如何基于患者基础疾病、呼吸道感染类型及病原谱合理选择核酸检测技术并正确理解其临床应用价值,成为重要的临床问题。为此,中华检验医学培训工程专家委员会联合中华医学会呼吸病学分会组织我国多学科专家共同撰写了《成人呼吸道感染病原诊断核酸检测技术临床应用专家共识(2023)》。该共识参考国内外指南及文献,分析了实时荧光聚合酶链反应(polymerase chain reaction, PCR)技术、等温扩增技术、数字PCR技术、核酸即时检测技术和病原体高通量测序技术的临床应用场景、技术特点和性能验证要求,以及该类技术在成人急性上呼吸道感染、气管支气管炎、社区获得性肺炎、医院获得性肺炎/呼吸机相关性肺炎、慢性阻塞性肺疾病急性加重、肺结核和免疫功能受损人群呼吸道感染中的应用,以供临床参考借鉴。

呼气末正压和吸氧浓度调整顺序对急性呼吸窘迫综合征机械通气恢复期病人肺部损伤的影响

目的探究呼气末正压(PEEP)和吸氧浓度(FiO_(2))调整顺序对急性呼吸窘迫综合征(ARDS)机械通气恢复期病人肺部损伤的影响。方法选取2016年7月至2020年8月在河北省人民医院急诊重症监护室(EICU)就诊的80例需机械通气的ARDS病人,采用随机数字表法分为PEEP固定组和FiO_(2)固定组,各40例。两组病人均采用肺保护性通气策略。病情稳定后,PEEP固定组维持呼吸机参数不变(PEEP=12~15 cmH_(2)O),FiO_(2)逐渐调整为80%、60%、40%;FiO_(2)固定组维持FiO_(2)=60%不变,PEEP水平逐渐调整为12、10、8 cm H_(2)O。对比不同时间肺泡灌洗液(BALF)中肿瘤坏死因子(TNF-α)、白细胞介素-6(IL-6)和肺表面活性蛋白A(SP-A)水平。结果随着PEEP水平和FiO_(2)的降低,两组病人TNF-α、IL-6和SP-A水平呈下降趋势;但调整参数1 h后,TNF-α、IL-6和SP-A水平升高。两组病人在调整FiO_(2)=40%、PEEP=8 cm H_(2)O前0 h,TNF-α、IL-6和SP-A水平最低,且FiO_(2)固定组低于PEEP固定组(P<0.05)。结论降低PEEP水平和FiO_(2)有利于减轻ARDS病人炎症反应及降低SP-A水平,先降低PEEP水平后降低FiO_(2),对ARDS机械通气恢复期病人肺部炎性损伤的改善作用较好。

薤胆汤治疗成人肺炎支原体感染相关呼吸道疾病临床观察

【目的】观察薤胆汤(由薤白、龙胆草、川厚朴、延胡索等中药组成)联合左氧氟沙星片治疗成人肺炎支原体感染相关呼吸道疾病的临床疗效。【方法】将86例肺炎支原体感染相关呼吸道疾病肝火郁肺、寒热错杂证患者(年龄>18周岁)随机分为观察组和对照组,每组各43例。对照组患者给予左氧氟沙星片口服治疗,观察组在对照组的基础上配合薤胆汤加减治疗,疗程为14 d,并于治疗结束后3个月随访。观察2组患者治疗前后咳嗽、口苦咽痛、乏力、脘闷纳差等各项中医证候积分的变化情况,比较2组患者各项中医证候的消失时间和肺炎支原体特异性抗体IgM(MP-IgM)转阴率,评价2组患者的临床疗效和安全性。【结果】(1)疗效方面,治疗14 d后,观察组的愈显率为90.7%(39/43),明显高于对照组的74.4%(32/43),组间比较,差异有统计学意义(P<0.05)。(2)治疗后,2组患者的咳嗽、口苦咽痛、乏力、脘闷纳差等各项中医证候积分均较治疗前下降(P<0.05),且观察组对各项中医证候积分的下降作用均明显优于对照组,差异均有统计学意义(P<0.05或P<0.01)。(3)治疗后,观察组的咳嗽、口苦咽痛、乏力、脘闷纳差等各项中医证候的消失时间均较对照组明显缩短,差异均有统计学意义(P<0.01)。(4)治疗结束后随访3个月,观察组的MP-IgM转阴率为88.4%(38/43),明显高于对照组的69.8%(30/43),组间比较,差异有统计学意义(P<0.05)。(5)治疗过程中,2组患者均未出现血常规、肝肾功能等安全性指标的异常变化。【结论】薤胆汤联合左氧氟沙星片治疗成人肺炎支原体感染相关呼吸道疾病疗效确切,能有效改善患者临床症状,缩短症状消失时间,并能改善相关血清学指标。

新冠疫情解封后对成人呼吸道病原体流行特征的影响及分析

目的分析新冠疫情解封后苏州地区成人呼吸道病原体的流行病学特征,探讨新冠疫情解封后对苏州地区呼吸道疾病的影响。方法选取2021年12月20日—2022年10月20日及2022年12月20日—2023年10月20日于苏州大学附属第一医院就诊的4376例成人作为研究对象,检测血清中11项呼吸道病原体IgM抗体。结果2021年12月20日—2022年10月20日苏州地区属于新冠一级防控期间,疫情期间检测1755例,共检测出726例IgM抗体阳性,阳性率41.37%;疫情解封后检测2621例,共检测出1101例IgM抗体阳性,阳性率42.00%。疫情解封后,MP、INFB的阳性率略低于疫情期间的水平,但差异无统计学意义(χ2=5.57、4.91,P=0.06、0.09),INFA、PIVs、埃可病毒、柯萨奇病毒A的阳性率均高于疫情期间水平,差异具有统计学意义(χ2=10.88、9.64、6.53、6.20,P均<0.05)。结论对于新型冠状病毒肺炎的防控措施不仅能够有效地阻断普通呼吸道病原体的传播,还能够减少成人呼吸道疾病的发生。在新冠疫情解封后,个人应该持续采取有效的防疫措施。

感染指标联合血清蛋白指标在成人下呼吸道鲍曼不动杆菌感染与定植鉴别诊断中的应用价值

目的探讨5项常用感染指标联合4项血清蛋白指标检测在成人下呼吸道鲍曼不动杆菌感染和定植鉴别诊断中的应用价值。方法选取2021年1-12月西安大兴医院下呼吸道标本培养出鲍曼不动杆菌的140例患者作为研究对象,根据下呼吸道细菌感染或定植临床诊断标准分为感染组(70例)和定植组(70例)。比较两组鲍曼不动杆菌耐药性差异,比较两组感染指标和血清蛋白指标水平,绘制受试者工作特征曲线(ROC曲线)分析感染指标联合血清蛋白指标鉴别下呼吸道鲍曼不动杆菌感染和定植的价值。结果感染组白细胞计数为(13.53±1.47)×10^(9)/L,中性粒细胞计数为(11.73±1.41)×10^(9)/L,C反应蛋白为(97.07±5.95)mg/L,超敏C反应蛋白为(99.74±6.29)mg/L,降钙素原为(4.20±0.71)ng/mL,球蛋白(GLO)为(26.65±6.61)g/L,均明显高于定植组的(8.64±0.50)×10^(9)/L、(6.64±0.51)×10^(9)/L、(31.37±4.61)mg/L、(31.29±4.56)mg/L、(0.15±0.10)ng/mL、(22.28±4.28)g/L,差异均有统计学意义(P<0.05)。感染组总蛋白为(56.66±8.89)g/L、清蛋白(ALB)为(29.84±5.37)g/L、ALB/GLO(A/G)为1.18±0.28,均明显低于定植组的(60.52±5.79)g/L、(37.79±3.94)g/L、1.76±0.40,差异均有统计学意义(P<0.05)。ROC曲线分析结果显示,9项指标联合检测鉴别下呼吸道鲍曼不动杆菌感染和定植的曲线下面积最大,为0.981(0.964~0.998),其灵敏度为95.70%,特异度为92.90%,阳性预测值为93.10%,阴性预测值为95.60%。结论5项常用感染指标联合4项血清蛋白指标检测在下呼吸道鲍曼不动杆菌感染和定植鉴别诊断中有较好的价值。

5915例成人呼吸道感染患者常见呼吸道病原体IgM检测结果分析

目的了解金华地区成人呼吸道感染的9种常见呼吸道病原体IgM的阳性检出率,分析阳性率在不同性别、年龄、季节的差异,为临床诊疗提供病原学依据。方法对就诊的5915例出现呼吸道感染症状的成人患者的9种常见呼吸道病原体IgM抗体检测结果进行回顾性分析。结果5915例成人呼吸道感染患者9种呼吸道病原体IgM抗体检测总阳性检出率为28.2%;其中肺炎支原体(MP)阳性检出率最高(18.31%),其次为B型流感病毒(BIV)(10.5%)。男性呼吸道病原体IgM检测总阳性检出率高于女性,>60岁年龄组单一阳性与混合阳性高于其他年龄组,差异均有统计学意义(P<0.05)。柯萨奇B组病毒(CoxB)、人副流感病毒(HPIV)的检出率,夏季高于其他季节;MP检出率秋季低于其他季节;BIV的检出率,春、冬季节高于夏、秋季节;差异均有统计学意义(均P<0.05)。结论成人呼吸道感染患者9种呼吸道病原体IgM抗体检测中MP阳性检出率最高,BIV次之,呼吸道病原体的感染分布与性别、年龄、季节等有关。