目的 探讨多模态运动护理干预措施对维持性血液透析患者疲乏-负性情绪-睡眠障碍症状群的影响.方法 选择收治的89例维持性血液透析患者,随机分为对照组45例和研究组44例.对照组采用常规护理,研究组在对照组基础上采用多模态运动护理干预.采用Piper疲乏修订量表(RPFS)、汉密尔顿焦虑及抑郁量表(HAMA、HAMD)、匹兹堡睡眠质量指数量表(PSQI)、透析患者症状负担调查表(DFSSBI)评估患者干预前后疲乏程度,焦虑及抑郁情绪、睡眠质量及症状负担.结果 研究组患者RPFS、DFSSBI各维度评分及总分低于对照组(P<0.05);研究组患者HAMA及HAMD量表评分低于对照组(P<0.05);研究组患者PSQI量表睡眠质量、睡眠时间、睡眠效率、睡眠障碍、日间功能障碍及总分低于对照组(P<0.05).结论 对于维持性血液透析患者,多模态运动护理干预措施能够改善疲乏状态;焦虑及抑郁情绪;提高睡眠质量;降低症状负担.

Background Mesenchymal stem cell (MSC)-derived exosomes have seen great advances in human disease control in a minimally invasive manner. This research aimed to explore the function of MSC-derived exosomes in diabetic nephropathy (DN) progression and the molecules involved. Methods A rat model with DN and rat glomerular mesangial cell (GMC) models treated with high glucose (HG) were established, which were treated with exosomes from adipose-derived-MSCs (adMSCs). The levels of blood glucose, serum creatinine, and urinary protein, the urine albumin-to-creatinine ratio (UACR), kidney weight/body weight, and mesangial hyperplasia and kidney fibrosis in rats were determined. The expression of interleukin-6 (IL-6), collagen I (Col. I), fibronectin (FN), Bax and Bcl-2 in HG-treated GMCs was assessed. The microRNA (miRNA) carried by adMSC-exosomes was identified, and the implicated down-stream molecules were analyzed. Results adMSC-derived exosomes decreased levels of blood glucose, serum creatinine, 24-h urinary protein, UACR and kidney weight/body weight, and they suppressed mesangial hyperplasia and kidney fibrosis in DN rats. The exosomes also suppressed levels of IL6, Col. I and FN in HG-treated GMCs and promoted cell apoptosis. miR-125a was at least partially responsible for the above protective events mediated by adMSC-exosomes. miR-125a directly bound to histone deacetylase 1 (HDAC1), while HDAC1 further regulated endothelin-1 (ET-1) activation. Up-regulation of HDAC1 blocked the functions of adMSC-exosomal miR-125a. Conclusion This study suggested that adMSC-derived exosomes inhibit DN progression and alleviate the symptoms by carrying miR-125a, during which HDAC1 and ET-1 were inhibited. This study may provide novel effects into DN treatment.

目的:研究经皮腔内血管成形术(PTA)术后抗凝与不抗凝治疗对自体动静脉内瘘(AVF)的通畅性及出血相关并发症的影响.方法:选取2018年1月—2019年6月在自贡市第一人民医院诊断人工动静脉内瘘狭窄的120例PTA术后患者,分为抗凝组和对照组,每组各60例.测量术前及术后肱动脉流量、狭窄处流速、透析血流量,记录两组患者术后6个月内的出血事件.结果:两组患者术后1天、术后1个月的肱动脉流量、透析血流量与术前相比明显升高(P<0.05).两组患者术后1天狭窄处流速与术前相比,明显下降(P<0.05).对照组术后1个月与术后1天相比,肱动脉流量及透析血流量下降显著(P<0.05).抗凝组和对照组术后6个月内瘘通畅率分别为65％、41.7％,血栓形成率分别为2％、14％,差异有统计学意义(P<0.05).术后6个月内,两组患者发生出血相关事件差异无统计学意义.结论:PTA术后长期抗凝出血风险小,能减少血栓事件发生,有利于提高内瘘的长期通畅率.

目的:观察康复运动(居家有氧运动+透析中抗阻运动)对改善血液透析患者衰弱的效果.方法:通过整群抽样法选取2018年7月—2019年2月期间在自贡市第一人民医院透析中心230例透析患者中,Frail评分为1～5分的患者共100例,分为两组.对照组依据个人习惯进行活动,实验组指导患者进行康复运动.比较实验组干预前后衰弱评分、两组患者干预后衰弱评分及自理能力(ADL)、营养风险、血清白蛋白、血红蛋白、C反应蛋白(CRP)、BMI等指标,研究康复运动对衰弱程度的改善情况.结果:实验组干预后衰弱评分低于干预前,低于对照组.干预后衰弱5项指标中疲劳感、耐力、步行能力、体重下降优于干预前和对照组.实验组衰弱相关指标中自理能力、营养风险、血清白蛋白、CRP结果优于对照组,差异有统计学意义(P<0.05).结论:早期实施运动干预能改善血液透析患者的衰弱状态,提高衰弱患者的自理能力和血清白蛋白水平,降低营养风险、改善微炎症状态,但对衰弱患者的血红蛋白及体质指数的改变优势不明显.

目的 探讨双膜血浆置换对需肾替代治疗的抗中性粒细胞胞浆抗体相关性血管炎的疗效及对生存率的影响.方法 纳入2015年1月～2017年3月在自贡市第一人民医院确诊为抗中性粒细胞胞浆抗体(anti-neutrophil cytoplasm antibody,ANCA)相关性血管炎的患者25例,确诊时即需要肾替代治疗,随机分为接受激素联合环磷酰胺免疫抑制治疗+双膜血浆置换(double-filtration plasmapheresis,DFPP)治疗的DFPP组(12例)和只接受激素联合环磷酰胺免疫抑制治疗的对照组(13例),分析入组时患者一般情况,测定2组患者治疗前后的ANCA、IgG水平,记录随访12个月患者的存活情况.结果 DF-PP组治疗后髓过氧化物酶抗体(myeloperoxidase-ANCA,MPO-ANCA)及IgG水平较治疗前明显下降,下降率分别为53.2％(t=12.131,P＜0.001),47.4％(t=10.798,P＜0.001).对照组治疗后MPO-ANCA水平较治疗前下降16.7％(t=10.319,P=0.069),对照组治疗后IgG水平较治疗前下降14.1％(t=10.134,P=0.035).DFPP组治疗后IgG水平与对照组治疗后相比下降33.8％,差异有统计学意义(t-5.334,P=0.012).随访12个月,累计存活率DFPP组为61.5％,对照组为58.3％(x2=0.193,P=-0.046),2组中存活患者均未摆脱透析.结论 双膜血浆置换能有效降低患者IgG及MPO-ANCA抗体水平,提高患者1年存活率,但不能有效提高患者的摆脱透析率.

目的 了解血液透析患者衰弱现状,为透析患者衰弱干预提供依据.方法 采用便利抽样法选取自贡市7所综合医院透析中心201例血液透析患者为调查对象,采用FRAIL量表评估患者衰弱状况,设计一般情况调查表和衰弱影响因素调查表,分别收集患者人口学资料和血液透析相关资料.结果 血液透析患者衰弱得分为2(1,4)分,衰弱占44.8％,衰弱前期占37.8％,无衰弱占17.4％.不同服药情况、血液透析频次、营养不良风险的患者衰弱状况比较,差异有统计学意义;不同衰弱程度患者年龄、ADL评分、C-反应蛋白、白蛋白比较,差异有统计学意义(P＜0.05,P＜0.01).Logistic回归分析显示,营养不良风险、性别、ADL、白蛋白是衰弱状况的影响因素(P＜0.05,P＜0.01).结论 血液透析患者衰弱发生率偏高,女性、白蛋白水平低、自理能力差、营养不良风险是衰弱的易患因素,应及时采取干预策略,以预防衰弱发生、延缓衰弱进程及由此引发的临床不良事件的发生.

呼吸机相关性肺炎是患者接受机械通气48小时后所并发的肺实质的感染,也是居我国第一位的医院感染性疾病。为院内感染首要的死亡原因。国外文献报道VAP的发病率为9%~70%,病死率高达50%~69%[1,2]。且机械通气时间每延长1d,肺炎的发病率增加1%~3%[3],严重影响ICU(重症监护病房)患者的愈后。有研究提示下呼吸道细菌培养有67%与口腔细菌培养菌株相同[4],口腔护理可以减少VAP的发病率[5]。本文就口腔护理护理预防VAP的原因及具体方法进行综述如下。

目的:调查我科透析时间在1年以上,并使用自体动静脉内瘘的病人的内瘘使用情况,了解我科护士对自体动静脉内瘘的维护现状。方法:我科的维持性透析病人102例,筛选出透析时间1年以上并使用自体动静脉内瘘病人60例,回顾分析2010年以前及当前内瘘初始使用时间、内瘘穿刺、动静脉瘤、内瘘狭窄,收集整理数据,判断其使用情况。结果:我科高年资和低年资护士在动静脉内瘘使用方面均存在不足,科室应加强护士对动静脉内瘘维护的理论和操作培训。

血液透析是终末期肾病采取的肾替代治疗方法之一,此类病人由于容量负荷过多及肾素分泌增加,常存在不同程度的高血压甚至高血压急症。本案例报道了一例维持性透析病人在并发高血压急症处理中的教训,供读者参考。

目的 调查ICU医院感染病原菌的种类变迁及耐药情况,为建立有效预防和控制ICU的医院感染提供对策.方法 回顾性调查笔者所在医院ICU 2009年1月～2009年12月住院ICU患者医院感染情况.结果 住院患者249人次,发生医院感染84例,医院感染率33.73%.检出菌株206株,其中真菌67株,占32.52%;G+菌23株,占11.17%;G-菌116株,占56.31%.G-菌中以铜绿假单胞菌及大肠埃希菌为主,分别占G-菌的39.66%和12.07%.结论 ICU医院感染发生率较高,感染病原菌以G-菌和真菌为主;病原菌耐药程度高,应采取积极有效的综合性护理措施控制和降低ICU医院感染率,防止多重耐药菌株的传播与流行.

Objective:To study the cognition status quo of ICU staff's knowledge about hands health. Methods:With a self-designed questionnaire,we solicited feed-back about hands hygiene from ICU staff and analyzed the differences. Results:The correct rate was above 95% of question-answering related with hands hygiene before/after some operations,such as before/after physical contacting with patients,before invasive nursing operation,after contacting with mucous membranes,injured skin and wound dressing,before food preparation and after touching body fluid or excrement. However,the correct rate related to hands hygiene after taking off gloves is 94.6%; after touching objects closed to the patients(including medical instruments) was 86%; before and after answering the cell phones were 78.5%/53.8% respectively. 90.3% staff are aware of washing hands before wearing gloves,and 88.1% of them remember to change gloves before moving their hands from patient's contaminated body part to clean one. The correct rates of staff's knowledge about instant hands disinfectant are 80.6%,84.9%,88.1%,55.9% respectively. Conclusion:ICU staff need to enhance the compliance of washing hands fundamentally by gaining relative knowledge about hands hygiene from more training.