遭遇“情感约定”，我的婚姻患了“衰竭症”

结婚前，丈夫与妻子微了个“约定”，但婚后没多久，妻子觉得自己对丈夫付出的爱很多，而且是不断地付出，但丈夫对自己的爱好像停止了，两人的情感关系开始不平衡。可是，因为婚前的“约定”，妻子又不便询问丈夫太多的事情。而丈夫在不知不觉中对妻子使用了“情感暴力”，导致婚姻与性的关系都“衰竭”了……

Symptom clusters and quality of life among patients with advanced heart failure

Objectives To identify symptom clusters among patients with advanced heart failure （HF） and the independent relationships with their quality of life （QoL）. Methods This is the secondary data analysis of a cross-sectional study which interviewed 119 patients with advanced HF in the geriatric unit of a regional hospital in Hong Kong. The symptom profile and QoL were assessed by using the Edmonton Symptom Assessment Scale （ESAS） and the McGill QoL Questionnaire. Exploratory factor analysis was used to identify the symptom clusters. Hier- archical regression analysis was used to examine the independent relationships with their QoL, after adjusting the effects of age, gender, and comorbidities. Results The patients were at an advanced age （82.9± 6.5 years）. Three distinct symptom clusters were identified： they were the distress cluster （including shortness of breath, anxiety, and depression）, the decondition cluster （fatigue, drowsiness, nausea, and reduced appetite）, and the discomfort cluster （pain, and sense of generalized discomfort）. These three symptom clusters accounted for 63.25% of variance of the patients＇ symptom experience. The small to moderate correlations between these symptom clusters indicated that they were rather independent of one another. After adjusting the age, gender and comorbidities, the distress （β = -0.635, P 〈 0.001）, the decondition （β = -0.148, P = 0.01）, and the discomfort （β = -0.258, P 〈 0.001） symptom clusters independently predicted their QoL. Conclusions This study identified the distinctive symptom clusters among patients with advanced HF. The results shed light on the need to develop palliative care interventions for optimizing the symptom control for this life-limiting disease.

Management of chronic heart failure in the older population

Chronic heart failure （CHF） is the leading cause of hospitalization for those over the age of 65 and represents a significant clinical and economic burden. About half of hospital re-admissions are related to co-morbidities, polypharmacy and disabilities associated with CHF. Moreover, CHF also has an enormous cost in terms of poor prognosis with an average one year mortality of 33%–35%. While more than half of patients with CHF are over 75 years, most clinical trials have included younger patients with a mean age of 61 years. Inadequate data makes treatment decisions challenging for the providers. Older CHF patients are more often female, have less cardiovascular diseases and associated risk factors, but higher rates of non-cardiovascular conditions and diastolic dysfunction. The prevalence of CHF with reduced ejection fraction, ischemic heart disease, and its risk factors declines with age, whereas the prevalence of non-cardiac co-morbidities, such as chronic renal failure, dementia, anemia and malignancy increases with age. Diabetes and hypertension are among the strongest risk factors as predictors of CHF particularly among women with coronary heart disease. This review paper will focus on the specific consideration for CHF assessment in the older population. Management strategies will be reviewed, including non-pharmacologic, pharmacologic, quality care indicators, quality improvement in care transition and lastly, end-of-life issues. Palliative care should be an integral part of an interdiscipli-nary team approach for a comprehensive care plan over the whole disease trajectory. In addition, frailty contributes valuable prognostic in-sight incremental to existing risk models and assists clinicians in defining optimal care pathways for their patients.

L-arginine administration ameliorates serum and pulmonary cytokine response after gut ischemia-reperfusion in immature rats

AIM: Small intestinal ischemia-reperfusion (IR) has been demonstrated to result in both local mucosal injury and systemic injuries. The exact role of nitric oxide (NO) in intestinal IR is unclear. We propose that NO and some other cytokines change in the reperfusion period and these changes are associated with lung injury. The aim of this study was to determine the effect of supplementing NO substrate, L-arginine (L-arg), on serum and pulmonary cytokine production during small intestinal IR in immature rats. METHODS: Immature rats underwent 60 min. of superior mesenteric artery occlusion followed by 90 min of reperfusion. L-arg (250 mg/kg) was given intravenously to the experimental group (IR+L-arg) which received L-arg after 45 min of intestinal ischemia. Serum and lung endothelin-1 (ET-1), NO, malondialdehyde (MDA), and tumor necrosis factor a (TNFα) were measured. Sham operation (SHAM) and intestinal IR (IR) groups were performed as control. The lavage fluid of the lung was collected by bronchoalveolar lavage (BAL) and white blood cells and polymorphonuclear cells (PMNs) were immediately counted to identify lung damage. RESULTS: When L-arg was given during small intestinal IR, serum NO concentration increased significantly in IR+L-arg group (162.17±42.93 μmol/L) when compared with IR group (87.57±23.17 μmol/L, t=3.190, P= 0.008 <0.01). Serum MDA reduced significantly in IR+L-arg group (8.93±1.50 nmol/L) when compared with SHAM (23.78±7.81 nmol/L, t= 3.243, P= 0.007<0.01) and IR (25.54±9.32 nmol/L, t= 3.421, P= 0.006<0.01). ET-1 level in lung tissues was significantly lower in IR+L-arg group (13.81±7.84 pg/mL) than that in SHAM (35.52±10.82 pg/mL, t= 2,571, P= 0,03<0.05) and IR (50.83±22.05 pg/mL, t= 3.025, P= 0.009<0.01) groups. MDA contents in lung tissues were significantly lower in IR+L-arg group (10.73±1.99 nmol/L) than in SHAM (16.62±2.28 nmol/L, t= 3.280, P = 0.007<0.01) and IR (21.90±4.82 nmol/L, t= 3.322, P= 0.007<0.01) groups. Serum and lung TNFα concentrations were not significantly different in three groups. NO contents in lung homogenates and white blood cell counts in BAL had no significant difference in three groups; but the percentage of PMNs in BAL was 13.50±8.92, 33.20±16.59, and 22.50±6.09 in SHAM, IR, and IR+L-arg groups, respectively. CONCLUSION: Small intestinal IR induced increases of pulmonary neutrophil infiltration in immature rats. Neutrophil infiltration in lung tissues was reduced by L-arg administration but remained higher than in SHAM group. L-arg administration during intestinal IR enhances serum NO production, reduces serum MDA and lung ET-1 and MDA levels, resulting in the improvement of systemic endothelial function. L-arg supplementation before reperfusion may act as a useful clinical adjunct in the management of intestinal IR, thus preventing the development of adult respiratory distress syndrome, even multiple organ dysfunction syndrome (MODS).

How albumin administration for cirrhosis impacts on hospital albumin consumption and expenditure

AIM:To assess the impact of guidelines for albumin prescription in an academic hospital,which is a referral center for liver diseases.METHODS:Although randomized trials and guidelines support albumin administration for some complications of cirrhosis,the high cost of albumin greatly limits its use in clinical practice.In 2003,a multidisciplinary panel at Sant'Orsola-Malpighi University Hospital(Bologna,Italy)used a literature-based consensus method to list all the acute and chronic conditions for which albumin is indicated as first-or second-line treatment.Indications in hepatology included prevention of post-paracentesis circulatory dysfunction and renal failure induced by spontaneous bacterial peritonitis,and treatment of hepatorenal syndrome and refractory ascites.Although still debated,albumin administration in refractory ascites is accepted by the Italian health care system.We analyzedalbumin prescription and related costs before and after implementation of the new guidelines.RESULTS:While albumin consumption and costs doubled from 1998 to 2002,they dropped 20%after 2003,and remained stable for the following 6 years.Complications of cirrhosis,namely refractory ascites and paracentesis,represented the predominant indications,followed by major surgery,shock,enteric diseases,and plasmapheresis.Albumin consumption increased significantly after guideline implementation in the liver units,whereas it declined elsewhere in the hospital.Lastly,extra-protocol albumin prescription was estimated as<10%.CONCLUSION:Albumin administration in cirrhosis according to international guidelines does not increase total hospital albumin consumption if its use in settings without evidence of efficacy is avoided.

Depression is associated with increased C-reactive protein levels in patients with heart failure and hyperuricemia

Psychological depression is considered a major determinant of health status in patients with heart failure （HF）. The incidence of depression in HF is four to five times higher than that in the general population.

Clinical outcomes in patients with ICU-related pancreatitis

AIM:To identify risk factors predictive of intensive care unit(ICU) mortality in patients with ventilator-related pancreatitis.The clinical outcomes of patients with ventilator-related pancreatitis were compared with those of patients with pancreatitis-related respiratory failure as well as controls.METHODS:One hundred and forty-eight patients with respiratory failure requiring mechanical ventilation and concomitant acute pancreatitis were identified from a prospectively collected dataset of 9108 consecutive patients admitted with respiratory failure over a period of five years.Sixty patients met the criteria for ventilator-related pancreatitis,and 88(control patients),for pancreatitis-related respiratory failure.RESULTS:Mortality rate in ventilator-related pancreatitis was comparable to that in ICU patients without pancreatitis by case-control methodology(P=0.544).Multivariate logistic regression analysis identified low PaO2/FiO2(OR:1.032,95% CI:1.006-1.059,P=0.016) as an independent risk factor for mortality in patients with ventilator-related pancreatitis.The mortality rate in patients with ventilator-related pancreatitis was lower than that in patients with acute pancreatitis-related respiratory failure(P<0.001).CONCLUSION:We found that low PaO2/FiO2 was an independent clinical parameter predictive of ICU mortality in patients with ventilator-related pancreatitis.

Protective effect of heme oxygenase-1 on Wistar rats with heart failure through the inhibition of inflammation and amelioration of intestinal micro- circulation

Background Myocardial infarction （MI） has likely contributed to the increased prevalence of heart failure （HF）. As a result of re- duced cardiac function, splanchnic blood flow decreases, causing ischemia in villi and damage to the intestinal barrier. The induction of heme oxygenase-1 （HO-1） could prevent, or lessen the effects of stress and inflammation. Thus, the effect and mechanism thereof of HO-1 on the intestines of rats with HF was investigated. Methods Male Wistar rats with heart failure through ligation of the left coronary artery were identified with an left ventricular ejection fraction of 〈 45% through echocardiography and then divided into various experimental groups based on the type of peritoneal injection they received [MI： saline; MI ＋ Cobalt protoporphyrin （CoPP）： CoPP solution; and MI ＋ Tin mesoporphyrin IX dichloride （SnMP）： SnMP solution]. The control group was comprised of rats without coronary ligation. Echocardiogra- phy was performed before ligation for a baseline and eight weeks after ligation in order to evaluate the cardiac function of the rats. The bac- terial translocation （BT） incidence, mesenteric microcirculation, amount of endotoxins in the vein serum, ileum levels of HO- 1, carbon oxide （CO）, nitric oxide （NO）, intedeuldn （IL）-10, turnour necrosis factor-et （TNF-ct）, and the ileum morphology were determined eight weeks after the operation. Results The rats receiving MI ＋ CoPP injections exhibited a recovery in cardiac function, an amelioration of mesenteric microcirculation and change in morphology, a lower BT incidence, a reduction in serum and ileac NO and TNF-ct levels, and an elevation in ileac HO-1, CO, and interleukin-10 （[L-10） levels compared to the MI group （P 〈 0.05）. The rats that received the MI ＋ SnMP injections exhibited results inverse to the MI （P 〈 0.05） group. Conclusions HO-1 exerted a protective effect on the intestines of rats with HF by inhibiting the inflammation and amelioration of microcirculation through the CO pathway. This protective effect could be independent from the recovery of cardiac function.

Comparative study of pressure-control ventilation and volume-control ventilation in treating traumatic acute respiratory distress syndrome

Objective: To observe the clinical therapeutic effect and side effect of pressure-control ventilation (PCV) on traumatic acute respiratory distress syndrome (ARDS) compared with volume-control ventilation (VCV). Methods: Forty patients with traumatic ARDS were hospitalized in our department from June 1996 to December 2002. Twenty were treated with PCV (PCV group) and 20 with VCV (VCV group). The changes of the peak inflating pressure and the mean pressure of the airway were observed at the very beginning of the mechanical ventilation and the following 12 and 24 hours, respectively. The transcutaneous saturation of oxygen pressure, the pressure of oxygen in artery, the mean blood pressure, the central venous pressure, the heart rate and the incidence of the pressure injury were also monitored before ventilation and 12 hours after ventilation. Results: The pressure of oxygen in artery, the transcutaneous saturation of oxygen pressure, the heart rate and the respiratory rate in the PCV group were obviously improved after ventilation treatment. The peak inflating pressure, the mean pressure of the airway and the central venous pressure in the PCV group were lower than in the VCV group. The incidence of pressure injury was 0 in the PCV group while 10% in the VCV group. Conclusions: The clinical effect of PCV on traumatic ARDS is better and the incidence rate of pressure injury is lower than that of VCV. PCV has minimal effects on the hemodynamics.

RESPIRATORY FAILURE AS THE FIRST PRESENTATION OF PATIENTS WITH MYASTHENIA GRAVIS:ONE CASE REPORT

Although respiratory failure commonly occurs during the course of myasthenia gravis (MG),it is rarely described as the first presentation in patients with previously unrecognized MG.Here we reported one case of MG in a 76-year-old man with the isolated respiratory failure as the first symptom.As illustrated by this case,it is important to consider neuromuscular disorders in cases of unexplained respiratory failure.