Acute lung injury and ARDS in acute pancreatitis: Mechanisms and potential intervention

Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) in acute pancreatitis still represents a substantial problem,with a mortality rate in the range of 30%-40%.The present review evaluates underlying pathophysiological mechanisms in both ALI and ARDS and potential clinical implications.Several mediators and pathophysiological pathways are involved during the different phases of ALI and ARDS.The initial exudative phase is characterized by diffuse alveolar damage,microvascular injury and influx of inflammatory cells.This phase is followed by a fibro-proliferative phase with lung repair,type Ⅱ pneumocyte hypoplasia and proliferation of fibroblasts.Proteases derived from polymorphonuclear neutrophils,various pro-inflammatory mediators,and phospholipases are all involved,among others.Contributing factors that promote pancreatitis-associated ALI may be found in the gut and mesenteric lymphatics.There is a lack of complete understanding of the underlying mechanisms,and by improving our knowledge,novel tools for prevention and intervention may be developed,thus contributing to improved outcome.

Tissue factor in predicted severe acute pancreatitis

AIM: To study tissue factor (TF) in acute pancreatitis and evaluate the role of TF as a predictive marker of severity. METHODS: Forty-nine consecutive patients admitted to Lund University Hospital, fulfilling the criteria of predicted severe acute pancreatitis (AP), were recruited prospectively between 2002 and 2004. Blood samples for TF analyses were drawn at inclusion in the study and 12 h, 1 d and 3 d later. RESULTS: Twenty-seven patients developed mild AP, and 22 patients severe AP. At inclusion in the study, the groups were comparable with respect to gender, aetiology, Acute Physiology and Chronic Health Evaluation Ⅱ score, and duration of pain. At inclusion in the study and at 12 h, TF was higher in the severe AP group (P = 0.035 and P = 0.049, respectively). After 1 and 3 d, no differences in TF levels were noted. Interleukin (IL)-6 was significantly higher in the severe AP group at all of the studied time points. C-reactive protein (CRP) was significantly higher in the AP group at 1 and 3 d. In receiver operating characteristic-curves, the area under the curve (AUC) for TF was 0.679 (P = 0.035) at inclusion in the study, and a cut off level for TF of 40 pg/mL showed a sensitivity of 71% and a specificity of 67%, whereas corresponding AUC for IL-6 was 0.775, P = 0.001, and for CRP was 0.653. IL-6 showed better AUC-values than TF at all time points studied. CONCLUSION: TF-levels are raised early in severe AP. TF as an early predictive marker of severe AP is superior to CRP, but inferior to IL-6.

Pancreatic function,quality of life and costs at long-term follow-up after acute pancreatitis

AIM:To evaluate long-term endocrine and exocrine pancreatic function,quality of life and health care costs after mild acute pancreatitis and severe acute pancreatitis(SAP).METHODS:Patients prospectively included in 2001-2005 were followed-up after 42(36-53)mo.Pancreatic function was evaluated with laboratory tests,the oral glucose tolerance test(OGTT),fecal elastase-1 and a questionnaire.Short Form(SF)-36,was completed.RESULTS:Fourteen patients with a history of SAP and 26 with mild acute pancreatitis were included.Plasma glucose after OGTT was higher after SAP(9.2 mmol/L vs 7.0 mmol/L,P=0.044).Diabetes mellitus or impaired glucose tolerance in fasting plasma glucose and/or 120 min plasma glucose were more common in SAP patients(11/14 vs 11/25,P=0.037).Sick leave,time until the patients could take up recreational activities and time until they had recovered were all longer after SAP(P <0.001).No significant differences in SF-36 were seen between the groups,or when comparing with age and gender matched reference groups.Total hospital costs,including primary care,follow-up and treatment of complications,were higher after SAP(median€16572 vs €5000,P<0.001).CONCLUSION:Endocrine pancreatic function was affected,especially after severe disease.SAP requires greater resource use with long recovery,but most patients regained a good quality of life.

2010女性急性单纯性膀胱炎和肾盂肾炎临床治疗指南(摘译)

美国感染病学会、欧洲临床微生物与感染病学会共同组织专家对1999年美国感染病学会单纯性尿路感染的指南进行了更新。2010指南更新的重点是治疗女性急性单纯性膀胱炎和肾盂肾炎,仅适用于无已知尿道畸形或合并症的绝经前及未妊娠的女性患者。作者就指南的主要内容进行摘译。

Brain natriuretic peptide is a potent vasodilator in aged human microcircula- tion and shows a blunted response in heart failure patients

BackgroundBrain natriuretic 肽(BNP ) 在在发行量的底层是通常在场的，但是它在心失败题目(CHF ) 与拥挤的度同时被提高。BNP 有 natriuretic 效果并且是有势力血管扩张药。BNP 能是在 CHF 的一种治疗学的选择，这被建议。然而，我们要求了在 CHF 的传播 BNP 的高水平可以 downregulate microvascular natriuretic 受体的反应。这被比较 15 个 CHF 病人测试(BNP &#x0003e；3000 ng/L ) 与 10 匹配的、健康 controls.MethodsCutaneous microvascular 血，在前臂的流动被激光 Doppler Flowmetry 测量。本地加热(+44 &#x000b0； C， 10 min ) 被用来唤起一个最大的本地扩张器 BNP 或醋胆素(ACh ) 的 response.ResultsNon 侵略的 iontophoretic 管理，一个已知的内皮细胞层依赖者扩张器，在本地流动得到了增加。氮的氧化物 synthase 禁止者， l-N-Arginine- 甲基酉旨(L 名字) ，堵住了 BNP 反应(在控制) 。有趣地，对在 CHF 病人的 BNP 的回答被归结为在健康控制看见的大约三分之一那些(的增加流动：251% 在 CHF 对 908% 在控制；P &#x0003c；0.001 ) 。相反，对 ACh 并且到本地加热的血管扩张药回答仅仅有点在 CHF 病人被稀释。因此，发信号的扩张器能力和氮的氧化物没被影响到象调停 BNP 的膨胀的一样的程度，第一次显示后者 response.ConclusionsThe 调查结果表演的特定的 downregulation 对 BNP 的 microvascular 回答显著地在 CHF 病人被减少。这与 BNP 受体功能的假设一致是在 CHF 的 downregulated。

Deteriorated function of cutaneous microcirculation in chronic congestive heart failure

背景长期的充血的心失败是在外部 microcirculation 导致机能障碍的一个复杂条件。我们以前证明了那脉管的反应与增加年龄被减少。在这研究，我们与严重的长期的心失败检查了一组很老的病人测试脉管的功能被心失败和老化的联合进一步损害的假设。方法皮肤的前臂血流动被激光 Doppler flowmetry 测量并且在三之中比较了组：组织 1 (n = 20，吝啬的 +/- SE：85.5 +/- 4 年) ，有纽约心协会班 IV (NYHA IV ) 并且与 NT-proBNP 的心失败病人铺平 5000 ng/L；组织 2 (n = 15，吝啬的 +/- SE：76.5 +/- 2 年) ，有 NYHA II 和 NT-proBNP 2000 ng/L 的心失败病人，和组 3 (n = 10，吝啬的 +/- SE：67.6 +/- 3.0 年) ，没有心失败的临床的符号的健康控制。对醋胆素(ACh ) 的 iontophoretic 管理的血管扩张药反应，经由 endothelial 机制，和钠 nitroprusside (SNP ) 行动，经由光滑的肌肉房间机制行动，被学习。结果当时，有心失败的所有病人显著地减少了刺激(ACh， SNP 或热) 的模式的脉管的反应独立人士与健康控制相比。然而，回答没在二组心失败病人之间不同。结论皮肤的脉管的反应在心失败病人被减少并且不与条件的严厉或病人的年龄相关。

Transplanting embryonic stem cells onto damaged human corneal endothelium

AIM To investigate whether human embryonic stem cells(hESCs) could be made to attach, grow and differentiate on a human Descemet's membrane(DM).METHODS Spontaneously differentiated hESCs were transferred onto a human corneal button with the endothelial layer removed using ocular sticks. The cells were cultured on a DM for up to 15 d. The genetically engineered hESC line expressed green fluorescent protein, which facilitated identification during the culture experiments, tissue preparation, and analysis. To detect any differentiation into human corneal endothelial-like cells, we analysed the transplanted cells by immunohistochemistry using specific antibodies.RESULTS We found transplanted cells form a single layer of cells with a hexagonal shape in the periphery of the DM. The majority of the cells were negative for octamer-binding transcription factor 4 but positive for paired box 6 protein, sodium potassium adenosine triphosphatase(NaKATPase), and Zona Occludens protein 1. In four of the 18 trials, the transplanted cells were found to express CK3, which indicates that the stem cells differentiated into corneal epithelial cells in these cases. CONCLUSION It is possible to get cells originating from hESCs to become established on a human DM, where they grow and differentiate into corneal endothelial-like cells in vitro.

成人房间隔封堵:心脏重构是早期事件

Background: Study aimed to describe the extent and the temporal profile of cardiac remodeling after atrial septal defect closure in the adult. Methods: Prospective and longitudinal echocardiographic assessment of right and left heart size before and after(1 day-1 week/1/4/12 months) surgical or catheter-based atrial septal closure in 39 adults(age 54± 15 years). Results: Right ventricular and atrial sizes were markedly reduced, left ventricular size increased and left atrial size remained unchanged after closure. Older age and a history of atrial fibrillation reduced the potential to normalize right and left atrial size after closure. The greater part of the changes occurred very early, in the 1st day/1st week. From then on the speed of change gradually diminished and after 4 months no important changes were observed. The mode of closure did not influence the degree or the pace of the remodeling. Conclusion: Cardiac remodeling after atrial septal closure in the adult is a common and early event that seems by and large completed within the first half year after closure. The ventricles seem to have a higher capacity of remodeling than the atria in this setting. The mode of closure does not seem to significantly impact remodeling.

Increased mortality in elderly heart failure patients receiving infusion of furosemide compared to elderly heart failure patients receiving bolus injection

Heart failure(HF)is a condition of cardiac dysfunction and fluid overload.Neurohormonal activation via the reninangiotensin-aldosterone system and the sympathetic nervous system are the pathophysiological cornerstones.[1]Furthermore,HF is a disorder widely associated with grave adverse outcomes and poor prognosis.[2]A loop diuretic is the fundamental drug used to prevent multiorgan failure and improve symptoms in these patients.[3]

Detection of Bronchial Function of NHBD Lung Following One-h Warm Ischemia by Organ Bath Model

This study investigated the feasibility and effects of organ bath to be used for detection of bronchial function of non-heart-beating donor (NHBD) lung after 1-h warm ischemia. Sixteen Swed-ish pigs were divided into two groups randomly: heart-beating donor (HBD) group and NHBD with 1-h warm ischemia (NHBD-1 h) group. The bronchial rings whose lengths and inner diameters were both 1.5 mm were obtained from isolated left lungs of all the pigs. Acetylcholine, arachidonic acid natrium and papaverine were used to test and compare the contractile and relaxant function of bron-chial smooth muscles and epithelium-dependent relaxation (EpiDR) response between HBD and NHBD-1 h groups. The results showed that there was no significant difference in the values of bron-chial precontraction between HBD and NHBD-1 h groups (5.18±0.07 vs 5.10±0.11 mN, P>0.05). No significant difference in the values of EpiDR responses between HBD and NHBD-1 h groups (1.26±0.05 vs 1.23±0.07 mN, P>0.05) was observed either. During the process of EpiDR induction, the rings had no spontaneous relaxation in two groups. In addition, papaverine solution completely relaxed the bronchial smooth muscles of all bronchial rings. It was concluded that after warm ische-mia for 1 h, the contractile and relaxant abilities of bronchial smooth muscles, and the epithe-lium-dependent adjustment both kept intact. Organ bath model could be a liable and scientific way to evaluate the bronchial function of NHBD lung.

Reduced peripheral vascular reactivity in refractory angina pectoris:Effect of enhanced external counterpulsation

Objective To examine if the skin microvascular bed is altered and can be modified by enhanced external counterpulsation(EECP)in patients with chronic refractory angina.Methods Twenty patients diagnosed with refractory angina were divided into EECP(n=10)or no EECP(n=10)groups.The data were compared to matched healthy subjects(n=20).The cutaneous forearm microvascular blood flow was measured by Laser-Doppler flowmetry.The vascular responsiveness to iontophoretic administration of acetylcholine(ACh),sodium nitroprusside(SNP)and local skin warming were studied.Measurements of Canadian Cardiovascular Society(CCS)-class,blood pressure and plasma samples were registered.Results EECP patients showed reduced CCS-class compared to no EECP(P<0.05).Both EECP and no EECP(P<0.05)groups had decreased systolic blood pressure(SBP)as compared to SBP at baseline(P<0.05).There was no difference in resting blood flow between the two refractory groups at baseline as well as after EECP and seven weeks of follow-up.Responses to heating,the responses to ACh and SNP in the cutaneous microcirculation were lower in both groups of refractory angina patients as compared to healthy subjects(P<0.05).EECP patients corresponded positively to the treatment shown by reduced plasma level of soluble interleukin-2 receptor and CCS-class.Conclusions Refractory angina patients have reduced responsiveness in their cutaneous microcirculation to ACh,SNP and heat compared to healthy subjects.Although EECP reduced the CCS-class,this effect was not associated with improvements in responsiveness of the cutaneous microcirculation.

Changes in cerebral perfusion detected by dynamic susceptibility contrast magnetic resonance imaging: normal volunteers examined during normal breathing and hyperventilation

Global cerebral perfusion parameters were measured using dynamic susceptibility contrast magnetic resonance imaging (DSC-MRI) in eight healthy volunteers examined during normal breathing and spontaneous hyperventilation. DSC-MRI-based cerebral blood flow (CBF) de-creased during hyperventilation in all volun-teers (average decrease 29%), and the corre-sponding global CBF estimates were 73±19ml/ (min100g) during normal breathing and 52± 7.9ml/(min100g) during hyperventilation (mean ±SD, n=8). Furthermore, the hypocapnic condi-tions induced by hyperventilation resulted in a prolongation of the global mean transit time (MTT) by on average 14%. The observed CBF estimates appeared to be systematically over-estimated, in accordance with previously pub-lished DSC-MRI results, but reduced to more reasonable levels when a previously retrieved calibration factor was applied.

Management of HIV in Children Using a Bovine Colostrum-Based Food Product— An Observational Field Study

Aim: Malnutrition increases the severity and mortality of HIV infection. Therefore, this field study was started and aimed to provide a major cohort of HIV-infected children with the colostrum-based food product ColoPlus (ColoPlus AB, Malm&ouml;, Sweden) and to investigate the effects of ColoPlus on the nutritional status and immunological capacity of children including tolerability and safety of the product. Methods: In this major field program comprising 850 malnourished HIV positive children, 50 grams of ColoPlus was administrated for 4 weeks as the first meal in selected health facilities in Northern Uganda. Forty-eight of these children (8 months - 14 years of age) were recruited into a descriptive prospective study and were followed for 12 weeks. At the start (week 0) and at weeks 4, 8 and 12, CD4+ cell counts, serum albumin and hemoglobin were analyzed. The remaining 802 patients were observed to register safety and tolerability of ColoPlus. Results: There was a general improvement of wellbeing of the children with increased body weight and decreased fatigue. In the descriptive study of the 48 children, there was a significant rise of the CD4+ values at week 4 (+15.4% ± 2.8%, p = 0.0001) compared to week 0, and at week 8 (+39.1% ± 3.9%, p < 0.0001), but a return towards the 0-values at week 12 (+2.1%, ±2.8%, NS). Hemoglobin and serum albumin showed an almost similar trend. ColoPlus was well tolerated by all the 850 children and no side effects or adverse events were seen. Conclusion: These results show that addition of a colostrum-based food product to the daily diet is beneficial in HIV-positive malnourished children. An improvement in nutritional status as well as in immune capacity was seen. These effects were prolonged and remained at least 4 weeks after cessation of ColoPlus administration.

2例日光性视网膜病变患者的多焦视网膜电图和光学相干断层扫描表现

Purpose: Clinical investigation of central retinal dysfunction in two cases of solar retinopathy. Methods: Two patients were examined for best corrected visua l acuity (VA), fundus inspection, visual fields, multifocal electroretinography (mfERG) with a stimulus pattern of 241 hexagons and, at follow-up, also with op tical coherence tomography (OCT). Results: At the initial examination, mfERG rev ealed central retinal dysfunction, which had improved by the time of follow-up. In Case 1, a foveal oedema regressed over time, although VA remained slightly r educed. In Case 2, OCT showed spots of increased reflectivity corresponding to t he patient’s symptoms. Conclusion: Central retinal dysfunction due to solar ret inopathy may improve over time. However, structural and functional changes may p ersist. This report illustrates that mfERG and OCT are useful tools for objectiv e documentation of the pathology in solar retinopathy.

国家婴儿喂养推荐方案变更前后乳糜泻患病率的变化

Objective. A national change in infant feeding recommendations was proposed in 1996 in Sweden: a slow introduction to gluten during weaning was stressed, the recommendation being introduction at 4 instead of 6 months of age. The aim of the present study was to compare the prevalence of celiac disease in healthy young children born before and after the new feeding recommendations in 1996. Material and methods. Sera from 679 children at a median age of 2.9 years (range 2.5-4.2 years) born between January 1996 and November 1997 were investigated with IgA-antigliadin antibodies (AGA) and IgA-endomysial autoantibodies (EMA) and compared with 690 age-matched children born between July 1992 and June 1993. Children with a positive test for EMA and AGA or EMA only were re-tested, and if positive at follow-up, investigated with intestinal biopsy. Results. At baseline, 2.2%(15/679) children were positive for EMA and another 0.6%(4/679) for both EMA and AGA. One child refused to be re-tested and eight children were still EMA positive at follow-up. Intestinal biopsy was performed in seven children (one declined biopsy), of whom three showed total villous atrophy. Two children with EMA titers 1∶640, respectively, refused further participation in the study, but were strongly suspected to have celiac disease. In total, 0.7%(5/679) (95%confidence interval (CI) = 0.1-1.4%)were considered to have celiac disease compared with 1.3%(9/690) (95%CI = 0.4-2.2%) in the control group (p = 0.4217). In addition, 0.3%of the children were diagnosed with symptomatic celiac disease compared with 0.7%in controls (p = 0.0134). Conclusions. The prevalence of symptomatic celiac disease declined after the infant dietary recommendations were introduced in 1996, but we could not find any difference in undiagnosed celiac disease between the screened children born before and those born after 1996.

ColoPlus:基于牛初乳的一种可以缓解HIV相关性腹泻的新产品

Objective.HIV-associated diarrhoea occurs in nearly all patients with acquired immunodeficiency syndrome(AIDS) in the developing countries.Diarrhoea is caused by the HIV-related immune dysfunction and is pivotal in the decrease of the helper T-cell(CD4+) population.Enteric pathogens in HIV-associated diarrhoea are,for example,Cryptosporidium,Amoeba and Campylobacter species.Bovine colostrum is the first milk the suckling calf receives from the cow.It is rich in immunoglobulins,growth factors,antibacterial peptides and nutrients.It supplies the calf with a passive immunity before its own active immunity is established.ColoPlus is a product based on bovine colostrum and is designed for slow passage through the gastrointestinal tract,as well as having a high nutritional value.The aim of the study was to investigate whether ColoPlus given orally can influence the severe diarrhoea associated with HIV infection.Material and methods.The study was carried out at Braithwaite Memorial Specialist Hospital,Port Harcourt,Nigeria.Thirty patients with HIV-associated diarrhoea were included in the study.The patients were treated with ColoPlus for 4 weeks in an open-labelled non-randomized study,after an observational period of one week.After a post-treatment period of another two weeks,treatment with anti-HIV drugs was started,if deemed appropriate.The effects on the frequency of stool evacuations per day,on body-weight,fatigue,haemoglobin levels and CD4+ counts before(week 1) and after treatment with ColoPlus(week 7) were measured.Results.There was a dramatic decrease in stool evacuations per day from 7.0± 2.7 to 1.3± 0.5(± SD) ,a substantial decrease in self-estimated fatigue of 81%,an increase in body-weight of 7.3 kg per patient and an increase in CD4+ count by 125%.Conclusion.ColoPlus may be an important alternative or additional treatment in HIV-associated diarrhoea.

对大动脉移位的新生儿实施一氧化氮吸入治疗

Three newborn infants with transposition of the great arteries (TGA) and intact ventricular septum (IVS) developed postnatal persistent pulmonary hypertension of the newborn (PPHN) and were successfully treated with inhaled nitric oxide (iNO). Inter-vention with balloon atrial septostomy (BAS) was performed in two of the infants before the iNO treatment, but they continued to be severely hypoxic with metabolic acidosis. However, the iNO immediately improved oxygenation and the clinical condition. The third neonate had a moderately large atrial communication and echocardiographic signs of PPHN. He received iNO before BAS with dramatic clinical improvement, which therefore postponed BAS. Conclusion: Early diagnosis of PPHN and treatment with iNO may improve final outcome in neonates with TGA and IVS. In the presence of moderately large atrial communication and PPHN, treatment with iNO might be considered before BAS.

心脏直视手术19种术前风险分层模型的比较

Aims: To compare 19 risk score algorithms with regard to their validity to predict 30-day and 1-year mortality after cardiac surgery. Methods and results: Risk factors for patients undergoing heart surgery between 1996 and 2001 at a single centre were prospectively collected. Receiver operating characteristics(ROC) curves were used to describe the performance and accuracy. Survival at 1 year and cause of death were obtained in all cases. The study included 6222 cardiac surgical procedures. Actual mortality was 2.9% at 30 days and 6.1% at 1 year. Discriminatory power for 30-day and 1-year mortality in cardiac surgery was highest for logistic(0.84 and 0.77) and additive(0.84 and 0.77) European System for Cardiac Operative Risk Evaluation(EuroSCORE) algorithms, followed by Cleveland Clinic(0.82 and 0.76) and Magovern(0.82 and 0.76) scoring systems. None of the other 15 risk algorithms had a significantly better discriminatory power than these four. In coronary artery bypass grafting(CABG)-only surgery, EuroSCORE followed by New York State(NYS) and Cleveland Clinic risk score showed the highest discriminatory power for 30-day and 1-year mortality. Conclusion: EuroSCORE, Cleveland Clinic, and Magovern risk algorithms showed superior performance and accuracy in open-heart surgery, and EuroSCORE, NYS, and Cleveland Clinic in CABG-only surgery. Although the models were originally designed to predict early mortality, the 1-year mortality prediction was also reasonably accurate.

马方综合征患者中主动脉根部扩张与年龄的关系

目的：此研究的主要目的是描述马方综合征（MFS）患者发生病理性主动脉根部扩张时的年龄。方法和结果：共对160例在地区心脏中心接受治疗的MFS患者进行了回顾。通过将最大的主动脉窦测量值与文献中的对照资料进行比较来诊断升主动脉扩张。采用Kaplan-Meier生存曲线估计扩张发生时的年龄。所有患者就诊时的平均年龄为15．5岁（极差1．5～40岁）。有95％的患者出现了骨骼畸形。18％的患者累及了眼睛。在160例患者中，有115例发生主动脉根部畸形，其中78例（68％）在19岁之前就发生了主动脉根部扩张。

假性胰腺囊肿的治疗和结果

Objective . Pancreatic pseudocyst is a common complication of both acute and chronic pancreatitis. The aim of the present study was to evaluate the efficacy and complications of different treatment regimens. Material and methods . All patients ≥15 years of age admitted to Lund University Hospital from 1994 to 2003 with pancreatic pseudocysts were analysed retrospectively. Pseudocysts were defined according to the Atlanta classification. Results . Forty-four patients (29M(66%), mean age 55±14 years) were included in the study, and all were subjected to treatment on 88 occasions. Mean size of pseudocysts at diagnosis was 9.6±6.8 cm (1.5-40 cm). Recurrence after treatment was 1.0±1.1 times (range 0-4). No difference was found in recurrence rate or pseudocyst size when comparing conservative versus interventional treatment, but patient weight was higher ( p =0.013) and acute pancreatitis was more frequent ( p =0.046) in conservatively treated patients. Surgical treatment tended to be associated with a lower recurrence rate as compared with percutaneous treatments. The rate of hospital admissions was a median 3 (0-16) and median length of stay (LOS) was 12 days (0-141 days). Six patients (14%) had complications and 3 died (7%). Pseudocysts ≥8 cm did not differ significantly from smaller pseudocysts regarding the choice of conservative treatment, LOS, recurrence and gastrointestinal obstruction, but there was a trend towards more complications in the group with larger pseudocysts (5 versus 1). Conclusions. Patients with pancreatic pseudocysts require frequent hospital admissions and repeated treatments. Larger pseudocysts do not imply more recurrences. The lowest recurrence rate overall was seen after open surgery.