目的 观察存在免疫抑制的重症社区获得性肺炎(SCAP)患者血清巨噬细胞效应分子血清肿瘤坏死因子-α(TNF-α)及白细胞介素-6(IL-6)的水平变化.方法 185例SCAP患者,其中免疫正常者131例(免疫正常组)、存在免疫抑制者54例(免疫抑制组).分别于进入ICU第1、3、7天时抽取两组外周静脉血检测血清TNF-α及IL-6.第1天时抽取两组外周静脉血采用三色流式细胞术测算外周血总T细胞(CD3+T)、CD3+CD4+T细胞(CD4+T)、CD3+CD8+T细胞(CD8+T).两组均于ICU第1天时采用急性生理与慢性健康Ⅱ(APACHEⅡ)评分,分别于ICU第1、3、7天时采用序贯器官衰竭(SOFA)评分评估病情严重程度.Spearman秩相关分析法分析血清TNF-α、IL-6水平与存在免疫抑制的SCAP患者APACHEⅡ评分、SOFA评分相关性.ICU第7天时判定两组预后.结果 与免疫正常组比较,免疫抑制组ICU第1天血清TNF-α水平低、ICU第7天血清TNF-α水平高,ICU第3、7天血清IL-6水平高(P均<0.05);与ICU第1天比较,免疫正常组及免疫抑制组第3、7天血清TNF-α、IL-6水平高(P均<0.05);与ICU第3天比较,免疫抑制组ICU第7天血清TNF-α、IL-6水平高(P均<0.05).与免疫正常组比较,第1天免疫抑制组CD4+T、CD8+T、CD3+T计数较低,APACHEⅡ评分高(P均<0.05);与ICU第1、3天比较,ICU第7天免疫抑制组患者SOFA评分高(F=19.722,P<0.05);与免疫正常组比较,ICU第3、7天免疫抑制组患者SOFA评分高(t分别为4.162、7.317;P<0.05).血清TNF-α及IL-6水平与存在免疫抑制的SCAP患者APACHEⅡ评分、SOFA评分均呈正相关(P均<0.05).免疫抑制组患者好转率低于免疫正常组(χ2=5.904;P<0.05).结论 与免疫正常的SCAP患者相比,免疫抑制SCAP患者血清TNF-α、IL-6水平均升高,病情严重,预后差.检测存在免疫抑制的SCAP患者血清TNF-α、IL-6有助于评估患者病情严重程度,预测预后.

目的 探讨静脉-静脉体外膜肺氧合(V-V ECMO)治疗重度急性呼吸窘迫综合征(ARDS)的影响因素.方法 采用回顾性观察研究方法 ,收集并分析2018年1月至2020年7月郑州大学第一附属医院收治的60例接受V-V ECMO治疗的重度ARDS患者临床资料,根据出院情况分为好转组和恶化组.采用SPSS 26.0统计分析两组治疗前后的临床资料,经Logistic回归分析确定V-V ECMO治疗重度ARDS患者预后的影响因素.结果 共60例重度ARDS患者接受V-V ECMO治疗,其中好转组32例,恶化组28例.单因素分析表明,吸烟史、应用ECMO前机械通气时间、血白细胞计数、需行持续肾脏替代治疗(CRRT)、发生多器官功能障碍综合征(MODS)及凝血功能障碍可能是预后的影响因素(P均<0.05);二元Logistic回归分析发现,血白细胞计数、应用ECMO后48 h机械通气PEEP、发生MODS及凝血功能障碍是预后的独立危险因素.结论 血白细胞计数、应用ECMO后48 h机械通气PEEP、发生MODS及凝血功能障碍是影响V-V ECMO治疗重度ARDS患者预后的独立危险因素.

目的 探讨慢性阻塞性肺疾病急性加重期(AECOPD)机械通气患者外周血中性粒细胞与淋巴细胞比值(NLR)与预后的相关性.方法 回顾性分析2015年1月至2019年1月郑州大学第一附属医院呼吸重症监护室收治的97例AECOPD机械通气患者的临床资料.根据28 d预后将患者分为好转组(66例)和恶化组(31例).比较两组中性粒细胞计数(NC)、淋巴细胞计数(LC)、NLR、C反应蛋白(CRP)及急性生理与慢性健康评分Ⅱ(APACHEⅡ).对NLR与CRP、APACHEⅡ评分进行相关性分析.统计基线期NLR四分位区间,并比较各个区间的死亡率.结果 恶化组NLR、CRP和APACHEⅡ评分均高于好转组,差异有统计学意义(均P<0.05).两组NC、LC比较,差异无统计学意义(均P>0.05).AECOPD机械通气患者NLR与CRP、APACHEⅡ评分呈正相关(r=0.279、0.315,P=0.006、0.002).不同NLR四分位区间患者的死亡率比较,差异有统计学意义(P<0.05).结论 监测AECOPD机械通气患者的NLR水平,有助于评估病情严重程度及预后.

目的 探讨血清肝素结合蛋白(HBP)对免疫功能受损合并重症肺炎患者病情严重程度及预后的评估价值.方法 选取2017年12月至2018年11月郑州大学第一附属医院呼吸重症监护病房(RICU)收治的89例重症肺炎患者,根据免疫功能是否受损分为免疫功能受损组(50例)和免疫功能正常组(39例),根据临床结局将免疫受损患者分为死亡组(30例)和存活组(20例).入院后进行慢性健康状况评分系统Ⅱ(APACHEⅡ)评分、淋巴细胞亚群、HBP、降钙素原(PCT)检测.比较各组患者病情严重程度、结局,分析血清HBP表达水平与预后的相关性.建立受试者工作特征(ROC)曲线并计算曲线下面积,分析HBP对免疫功能受损合并重症肺炎患者预后的预测价值.结果 免疫功能受损组PCT、APACHEⅡ评分、HBP、死亡率均高于免疫正常组,CD3、CD4+、CD8+及CD4+/CD8+均低于免疫功能正常组,差异有统计学意义(均P<0.05).死亡组PCT、HBP、APACHEⅡ评分均高于存活组,差异有统计学意义(均P<0.05).免疫功能受损患者血清HBP水平与血清PCT水平、APACHEⅡ评分呈正相关(均P<0.05).由ROC曲线分析可知,最大曲线下面积是HBP(0.725),其次是APACHEⅡ评分(0.721),最小是PCT(0.710).HBP最佳截断值为139.39 ng/mL,灵敏度为0.600,特异度为0.898;APACHEⅡ评分最佳截断值为20.50分,灵敏度为0.633,特异度为0.780;PCT最佳截断值为2.11μg/L,灵敏度为0.633,特异度为0.746.结论 血清HBP水平可以反映免疫功能受损合并重症肺炎患者的病情严重程度,是免疫功能受损合并重症肺炎死亡的早期特异性预测指标.早期测定HBP对免疫功能受损合并重症肺炎患者的诊疗有指导意义.

Interleukin (IL)-17A is a characteristic pro-inflammatory cytokine ,secreted by helper T cell (Th cell) 17 , induces diverse cytokines to participate in the process of immunoregulation and inflammatory response ,so it plays an important role in the occurrence and development of multiple systemic diseases and tumors , such as respiratory , immune and hematological system .The potential values of IL-17A and its signal pathway in acute respiratory distress syndrome (ARDS) are the hotspot of current research ,which is beneficial in the diagnosis , condition and prognosis assessment .This review focuses on the IL-17A and its signal pathways in ARDS .

目的 探讨白细胞介素(IL)-6和IL-10在重症肺炎中的表达情况及两者的平衡与预后的关系.方法 选取81例重症肺炎患者(根据入院后28 d是否存活分为死亡组38例,存活组43例)、60例普通肺炎患者,入院24 h内行APECHEⅡ评分,采用流式细胞仪微球捕获芯片技术检测IL-6和IL-10,并计算IL-6/IL-10比值.比较各组间血清中IL-6、IL-10水平和IL-6/IL-10比值差异,及其与预后的相关性.采用四分位法将IL-6/IL-10比值划分为4个区间Q 1、Q 2、Q 3和Q 4,比较4个区间的死亡率.结果 重症肺炎组血清IL-6、IL-10和APECHEⅡ评分高于普通肺炎组,差异有统计学意义(P<0.05).重症肺炎死亡组血清IL-6、IL-10、IL6/IL-10比值及APECHEⅡ评分高于存活组,差异有统计学意义(均P<0.05).相关性分析显示,血清IL-6、IL-10和IL-6/IL-10比值与APECHEⅡ评分呈正相关(均P<0.05).结论 重症肺炎患者机体存在过度炎症反应,IL-6/IL-10比值升高,增加患者死亡风险.

人鼻病毒(HRV)是小核糖核酸病毒科中的一种RNA病毒,因其特别适应在鼻腔中生长,故被称为"鼻病毒".HRV不仅能引起普通感冒,还能导致急、慢性支气管炎等其他呼吸系统感染疾病.近年来也逐渐在下呼吸道感染患者中检测到,其引起的重症肺炎进展迅速,容易被临床医生误诊、漏诊.本文报道1例郑州大学第一附属医院呼吸ICU科收住的成人人鼻病毒感染引起的急性呼吸窘迫综合征病例.

Objective To investigate the changes of Th17 cell function by testing the transcription regulative factor RORγt and the main effect factor cytokine interleukin-17(IL-17)of Th17 cells,and the effect of human immunoglobulin on Th17 cell function in immunosuppressed mice with Pseudomonas aeruginose(PA)pneumonia.Methods Ninety BALB/c mice were divided into five groups randomly:control group,PA group,immunosuppressed group,immunosuppressed+PA group and human immunoglobulin group(named group A,B,C,D and E,n=18 each).All mice were sacrificed at 4,8 and 24 h after the establishment of the experimental models.Gross examination was performed and the lungs were excised for routine histological analysis.The expression level of RORγt mRNA was detected by reverse-transcriptase polymerase chain reaction(RT-PCR)and the concentration of IL-17 was measured in the peripheral blood by enzyme-linked immune sorbent assay(ELISA).Results Histological findings demonstrated that the lung tissues had no inflammatory changes in group A and C.But inflammatory changes,such as congestion of red blood cells in capillaries,edema,infiltration of many inflammatory cells and enlarged alveolar septum,occurred in group B,D,and E.Such changes were most significant at 8 h.The lung jury score was the highest in group D than in any other groups(P<0.01).The levels of RORγt mRNA in the lung were higher in group B,D and E than in group A and C(P<0.01),and they reached the peak at 4 h.The concentration of IL-17 in the peripheral blood was higher in group B,D and E than in group A and C(P<0.01),and it reached the peak at 8 h.All the observed indexes including the lung injury score,the level of RORγt mRNA and the concentration of IL-17 were much higher in group D than in group B(P<0.01),and they were even lower in group E than in group B(P<0.01).Conclusion The over-stimulation of Th17 cells derived from immunosupressed mice with PA pneumonia leads to excessive inflammatory responses and the organ and tissue injuries.Human immunoglobulin can inhibit the inflammatory reactions caused by Th17 cells,and therefore relieve the deterioration of the disease.

目的 探讨血清白细胞介素(IL)-10评估不同年龄免疫功能受损并重症肺炎患者病情严重程度及预后的价值.方法 180例免疫功能受损并重症肺炎患者,根据年龄分为非老年组(年龄<60岁,112例)、老年组(年龄≥60岁,68例);入院后行APACHEⅡ评分、淋巴细胞亚群及血清IL-10水平检测;比较两组患者病情严重程度及结局差异,血清IL-10表达水平差异及与病情严重程度的关系.结果 相比于非老年组,老年组病情重,APACHEⅡ评分较高〔非老年组(24.22±7.51)分,老年组(36.53±13.52)分〕,死亡率高(非老年组51.79%,老年组73.53%;P<0.05);老年患者血清IL-10水平〔(6.72±1.97)mg/dl〕低于非老年组〔(9.66±2.58)mg/dl,P<0.05〕;相关性分析显示,血清IL-10水平与APACHEⅡ评分呈负相关.结论 检测免疫受损合并重症肺炎患者血清IL-10水平,有助于评估及预测病情严重程度及预后.

患者女，47岁，因“皮疹11个月，四肢无力8个月余，咳嗽、咳痰3个月余，间断发热11 d”于2015年12月5日收入我院。患者于11个月前无明显诱因出现前额、眶周、右侧颈部及前胸处皮疹，至当地医院就诊，诊断为“过敏”，给予抗过敏治疗无效。8个月前出现四肢无力，至当地医院就诊，查谷丙转氨酶为247 U／L，谷草转氨酶为545 U／L，肌酸激酶为9879 U／L，肌酸激酶同工酶为371 U／L，乳酸脱氢酶为1092 U／L，α-羟丁酸脱氢酶为1158 U／L，抗核抗体（ ANA）阳性（1∶320）。肌电图示右肱二头肌、右胫前肌、左右股四头肌均呈肌源性损害，诊断为“皮肌炎”，口服甲泼尼龙75 mg／d（每月减10 mg，服用4个月后每月减5 mg，本次入院时已减至25 mg／d）、氨甲蝶呤10 mg／周（至本次入院时用量未调整）控制病情。3个月余前受凉后出现咳嗽，咳黄色脓痰，至当地医院检查：C反应蛋白为200 mg／L（参考值0～10 mg／L），ESR为86 mm／1 h（参考值为0～20 mm／1 h）；胸部CT示双肺炎症，心包少量积液，双侧胸膜增厚，双侧胸腔少量积液，部分包裹。诊断为“皮肌炎、呼吸道感染”，给予抗感染治疗2周余，症状缓解，复查胸部CT示右肺下叶背段及左肺上叶支气管扩张并感染，双肺下叶炎性病变，双侧胸膜结节。2周前再次咳嗽、咳痰，胸部CT示右肺下叶及左肺炎性改变，左侧胸膜肥厚。11 d前出现间断发热，体温最高39℃，伴双侧腹部疼痛，咳嗽时加重，当地医院查腹部核磁共振（MRI）示左侧腰部及左侧脊柱旁病变（图1），胸部CT示双肺结节，双侧胸膜多发结节较前明显增多，左下肺部分实变，双侧胸膜增厚，少量胸腔积液，少量心包积液。诊断为“皮肌炎、肺部感染”，给予克林霉素磷酸酯、哌拉西林／舒巴坦及氟康唑治疗，但疗效差，后转至我院。

Pseudomonas aeruginosa (PA) pneumonia is a refractory, even lethal complication in immunosuppressive individuals and immune disturbances may promote the pathological process. We aimed to investigate the regulatory T (Treg) cell activity in an immunosuppressive mice model of PA pneumonia by estimating levels of main transcription factor and the main effector of Treg cells, i.e., Forkhead box protein 3 (FOXP3) and interleukine-10 (IL-10). Seventy-two BALB/c mice were divided into four groups randomly: control (A), PA pneumonia (B), immunosuppression (C) and immunosuppression with PA pneumonia (D). Mice were sacrificed at 4, 8 and 24 h after establishing experimental models. The pathological changes of lung tissue were graded, and the FOXP3 mRNA and serum IL-10 levels were detected. Histological analysis of lung tissues showed there were no significantly pathological changes in groups A and C, but significantly pathological changes were found in groups B and D, especially in group D at 8 h (P<0.05). The expression levels of FOXP3 mRNA in groups A and C showed no significant changes at the three time points, which were significantly lower than those in groups B and D (P<0.05). FOXP3 mRNA levels were lowest at 4 h, and there was significant difference between groups B and D (P<0.05). The serum levels of IL-10 in groups A and C were almost normal at the three time points, but decreased significantly in groups B and D (P<0.05). The serum levels of IL-10 decreased to the lowest at 8 h, especially in group D (P<0.05). The results indicate that PA pneumonia in immunosuppressive individuals worsens rapidly, which may be associated with Treg cells function disturbance. And Treg cells may be promising as adjuvant therapeutics for PA pneumonia in immunosuppressive individuals.

Objective To evaluate the diagnostic value of monitoring 1,3-beta-D-glucan (G test) in patients with autoimmune disease complicated with invasive fungal disease (IFD).Methods A retrospective study was performed in hospitalized patients in the First Affiliated Hospital of Zhengzhou Universisty who were diagnosed as autoimmune disease with lung infection during the immunosuppressive therapy between January 2014 and January 2016.A total of 372 patients were enrolled in this study.All subjects were classified according to the 2006 diagnostic criteria and treatment of invasive pulmonaary fungal infection,with serum 1,3-β-D-glucan results not included in the diagnosis.There were 18 cases with proven IFD,35 cases with probable IFD,and 70 ceses with possible IFD.Fifty-three patients with proven IFD or probable IFD were as a case group,and another 249 patients with no evidence for IFD were as a control group.The value of the G test for diagnosis of automimmune disease with IFD was analyzed by ROC curve.Results The serum 1,3-β-D-glucan level was significantly higher in the case group when compared with the control group [median (interquartile range):135.0 (63.1 to 319.0) pg/ml vs.75.9 (41.2 to 88.1) pg/ml,P＜0.05].When the cut-offvalue of serum 1,3-β-D-glucan level was set at 93.8 pg/ml,the sensitivity,specificity,positive predictive value,and negative predictive value for diagnosis of autoimmune disease with IFD were 0.65 (95％ CI 0.56 to 0.73),0.87 (95％ CI 0.83 to 0.92),0.70 (95％ CI 0.64 to 0.81),and 0.83 (95％ CI 0.79 to 0.88),respectively.Conclusion The 1,3-beta-D-glucan test is a valuable method for diagnosis of IFD in patients with autoimmune disease.