優(yōu)質(zhì)護(hù)理對(duì)消化性潰瘍患者腸黏膜分泌型免疫球蛋白IgA的影響

葉江華

(首都醫(yī)科大學(xué)附屬北京同仁醫(yī)院, 北京, 100730)

優(yōu)質(zhì)護(hù)理對(duì)消化性潰瘍患者腸黏膜分泌型免疫球蛋白IgA的影響

葉江華

(首都醫(yī)科大學(xué)附屬北京同仁醫(yī)院, 北京, 100730)

摘要:目的探討優(yōu)質(zhì)護(hù)理干預(yù)對(duì)消化性潰瘍患者腸黏膜分泌型免疫球蛋白SIgA的影響。方法選取消化性潰瘍患者60例，隨機(jī)分為2組各30例，對(duì)照組給予常規(guī)PPI三聯(lián)療法，觀察組在對(duì)照組的基礎(chǔ)上給予優(yōu)質(zhì)護(hù)理；比較2組患者的臨床療效和漢密頓不良情緒評(píng)分，并分別于治療前后取患者結(jié)腸內(nèi)膜組織，以ELISA試劑盒檢測SIgA含量，以RT-PCR和免疫印跡法檢測5-HT的mRNA與蛋白表達(dá)水平。結(jié)果觀察組臨床有效率顯著優(yōu)于對(duì)照組(P<0.05)。治療前2組患者各項(xiàng)考察指標(biāo)無顯著差異(P>0.05), 觀察組HAMD/HAMA評(píng)分及5-HT表達(dá)水平均顯著低于對(duì)照組(P<0.05), SIgA含量顯著高于對(duì)照組(P<0.05), 線性回歸分析結(jié)果顯示SIgA含量與5-HT的表達(dá)水平呈直線負(fù)相關(guān)(P<0.05)。結(jié)論優(yōu)質(zhì)護(hù)理干預(yù)可提高消化性潰瘍患者腸黏膜分泌型免疫球蛋白SIgA, 且該作用可能與情致因素調(diào)控的5-HT通路有關(guān)。

關(guān)鍵詞:心理護(hù)理; 消化性潰瘍; 腸黏膜; 分泌型IgA; 5-HT

消化性潰瘍(UC)是消化系統(tǒng)常見病，其發(fā)病率逐年遞增。近年研究[1-3]表明，UC為一類非典型免疫相關(guān)性疾病，其發(fā)病過程涉及多種免疫細(xì)胞、炎性因子及免疫球蛋白的代謝失衡。作為黏膜防御系統(tǒng)的重要組成部分，腸黏膜微環(huán)境變更勢必為影響UC發(fā)病進(jìn)程的關(guān)鍵因素之一。免疫球蛋白多存在于體液，主司體液免疫，分泌型免疫球蛋白IgA(SIgA)主要存在于黏膜組織，是機(jī)體黏膜防御系統(tǒng)的主要成分之一。5-HT最初發(fā)現(xiàn)于腸嗜鉻細(xì)胞，屬單胺類神經(jīng)遞質(zhì)，在情緒障礙性疾病中發(fā)揮了重要作用；后經(jīng)證實(shí)90%以上合成于腸黏膜，可影響胃腸道蠕動(dòng)、分泌及分子信號(hào)感知等多種功能[4-5]。近年, UC患者的5-HT異常和負(fù)面情緒反應(yīng)受到越來越多的關(guān)注，優(yōu)質(zhì)護(hù)理策略在其臨床治療中亦取得了一定成效。本研究重在探討優(yōu)質(zhì)護(hù)理對(duì)UC患者SIgA有無實(shí)質(zhì)性影響，現(xiàn)報(bào)告如下。

1資料和方法

選取本院2012年3月—2013年3月收治的消化性潰瘍患者60例為研究對(duì)象，所有患者均符合WHO UC胃鏡及臨床癥狀診斷標(biāo)準(zhǔn)。以隨機(jī)數(shù)字法將患者分為2組，對(duì)照組實(shí)施常規(guī)護(hù)理，觀察組實(shí)施優(yōu)質(zhì)護(hù)理。觀察組男12例，女18例，年齡24～76歲，平均(53.6±13.4)歲；胃潰瘍9例，十二指腸潰瘍21例。對(duì)照組男10例，女20例；年齡23～78歲，平均(54.1±13.4)歲，胃潰瘍11例，十二指腸潰瘍19例。2組患者的年齡、性別及病變位置無統(tǒng)計(jì)學(xué)差異(P>0.05)。

治療方法：常規(guī)PPI三聯(lián)療法：奧美拉唑腸溶膠囊(H20060390，北京韓美), 20 mg/次, 2次/d; 克拉霉素片(H20033044，上海雅培), 0.25 g/次, 2次/d; 阿莫西林(H19993034，山東魯抗), 0.25 g/次, 2次/d。

護(hù)理方法：對(duì)照組實(shí)施常規(guī)護(hù)理方法，觀察組實(shí)施優(yōu)質(zhì)護(hù)理: ① 由護(hù)理人員主動(dòng)向介紹UC的健康知識(shí)，做知識(shí)輔導(dǎo)時(shí)注重個(gè)體化交流，對(duì)文化水平較低患者使用通俗易懂的語言；對(duì)文化水平高的患者可以用專業(yè)術(shù)語，以拉近醫(yī)患距離；在普及知識(shí)的同時(shí)，重點(diǎn)暗示疾病康復(fù)的可能性，以緩解患者內(nèi)心的不良情緒; ② 耐心傾聽、密切關(guān)注并及時(shí)疏導(dǎo)患者負(fù)面心理，對(duì)于焦慮、抑郁及失眠等較為嚴(yán)重患者適量使用藥物；設(shè)立自律訓(xùn)練培訓(xùn)課程，指導(dǎo)患者以心理意念療法克服情緒障礙; ③ 注重家庭互動(dòng)，指導(dǎo)患者家屬對(duì)患者情緒進(jìn)行專業(yè)的評(píng)估和疏導(dǎo)，以便及時(shí)了解患者的心理動(dòng)態(tài)；配合家屬對(duì)患者進(jìn)行心理上的鼓勵(lì)和安慰，以親情為紐帶，加強(qiáng)患者配合治療的積極性。

臨床療效：痊愈，胃鏡下潰瘍面完全愈合，血腫、膿性分泌物等炎性征象消失；顯效，胃鏡下潰瘍面基本愈合，但仍存在輕微炎性征象；有效，胃鏡下潰瘍病面愈合50%以上，炎性征象有所改善；無效，胃鏡下潰瘍病面愈合不足50%或炎性征象無改善均為無效。

不良情緒：分別評(píng)定患者的漢密頓抑郁程度HAMD評(píng)分和焦慮程度HAMA評(píng)分。

微觀指標(biāo)：刮取患者炎性反應(yīng)較為明顯的降結(jié)腸或直腸組織，分裝于三管。管A以生理鹽水制備勻漿液，ELISA試劑盒檢測SIgA含量。管B以Trizol裂解液提取蛋白質(zhì), BCA試劑盒測濃度；以10 μg為單孔上樣量進(jìn)行垂直凝膠電泳(80 V, 30 min; 120 V, 60 min); 蛋白條帶分離后轉(zhuǎn)印至羥甲纖維素膜(80 V, 60 min), 抗體孵育并顯影(抗體濃度: Anti-Serotonin 1∶2 000; Anti-GAPDH 1∶4 000; Goat anti-rabbit 1∶1 000)。管C以總RNA提取試劑盒提取RNA, 常規(guī)RT-PCR; 溫度條件: 94 ℃ 2 min; (94 ℃ 15 s, 59 ℃ 10 s, 75℃ 30 s); 75 ℃ 5 min 10 min。

2結(jié)果

2.1臨床療效

觀察組痊愈17例、顯效6例、有效6例；對(duì)照組痊愈9例、顯效5例、有效4例；觀察組臨床有效率顯著優(yōu)于對(duì)照組(P<0.05)。

2.2不良情緒評(píng)分

治療前，兩組患者的不良情緒評(píng)分無顯著差異(P>0.05); 治療后，觀察組HAMD和HAMA評(píng)分均顯著小于對(duì)照組(P<0.05), 見圖1。

2.35-HT表達(dá)水平

治療前，2組患者5-HT表達(dá)水平無顯著差異(P>0.05); 治療后，觀察組5-HT蛋白和mRNA表達(dá)水平均顯著低于對(duì)照組(P<0.05)。

2.4SIgA含量

治療前，2組患者SIgA含量無顯著差異(P>0.05); 治療后, SIgA含量顯著高于對(duì)照組(P<0.05); 線性回歸分析結(jié)果顯示SIgA含量與5-HT的mRNA表達(dá)水平呈直線負(fù)相關(guān)R2(蛋白)=0.7678,P<0.01; R2(mRNA)=0.7678,P<0.05)

3討論

近年，情緒應(yīng)激在UC的機(jī)制研究愈加受到重視，Tominaga K等研究結(jié)果[6]顯示UC患者普遍存在一定程度的負(fù)面心理，以抑郁和焦慮情緒最為常見。Rosenstock S等[7]認(rèn)為負(fù)面情緒評(píng)分與UC患者的發(fā)病程度密切相關(guān)，通過優(yōu)質(zhì)護(hù)理適當(dāng)疏導(dǎo)患者不良情緒可提高其臨床治療效果。

圖12組患者治療前后HAMD和HAMA評(píng)分對(duì)比

從微觀機(jī)制來看，腸黏膜免疫微環(huán)境失調(diào)是促進(jìn)UC發(fā)病和進(jìn)展的關(guān)鍵因素之一。SIgA由具有免疫活性的淋巴細(xì)胞分泌，主要存在于黏膜組織，是機(jī)體黏膜防御系統(tǒng)的主要成分，能夠抑制腸黏膜病原菌的定植和繁殖。微生物感染和炎性反應(yīng)為UC的最主要病理特征之一，以往研究已證實(shí)[8], Th2、NKT以及多種固有免疫細(xì)胞參與了UC的發(fā)病進(jìn)程，然而SIgA的研究尚為罕見。本研究探討的首要問題為優(yōu)質(zhì)護(hù)理是否能夠通過調(diào)控SIgA改善臨床患者的病理狀態(tài)。本研究對(duì)護(hù)理干預(yù)UC患者和單純用藥UC患者對(duì)比研究結(jié)果顯示，優(yōu)質(zhì)護(hù)理患者的腸黏膜SIgA含量與臨床用藥整體有效率顯著高于對(duì)照組，HAMD與HAMA評(píng)分顯著低于對(duì)照組。初步肯定了優(yōu)質(zhì)護(hù)理在改善患者抑郁、焦慮情緒及臨床用藥效果方面的正向作用，并提示該有效性可能與其促進(jìn)腸黏膜SIgA分泌、改善患者腸道免疫微環(huán)境有關(guān)。

5-HT最初發(fā)現(xiàn)于腸嗜鉻細(xì)胞，屬單胺類神經(jīng)遞質(zhì)，在情緒障礙性疾病中發(fā)揮了重要作用[9]; 后經(jīng)證實(shí)90%以上合成于腸黏膜，可影響胃腸道蠕動(dòng)、分泌及分子信號(hào)感知等多種功能。據(jù)報(bào)道[10-12], 5-HT的異常高表達(dá)與腸道黏膜損傷息息相關(guān)，可預(yù)示了較為嚴(yán)重的炎性反應(yīng)及功能障礙；且其含量與患者的不良情緒反應(yīng)亦有密切聯(lián)系。Hung A等[13]也已證實(shí)，5-HT及其受體的相關(guān)調(diào)控不僅可緩解患者的情緒障礙，且對(duì)其免疫機(jī)能也有一定程度的改善。在整體臨床療效和漢密爾頓抑郁、焦慮評(píng)分的基礎(chǔ)上，本研究對(duì)患者的5-HT表達(dá)情況亦做了相關(guān)考察，以初探優(yōu)質(zhì)護(hù)理調(diào)控SIgA的可能機(jī)制。研究結(jié)果顯示優(yōu)質(zhì)護(hù)理患者的腸黏膜5-HT mRNA及蛋白表達(dá)水平均顯著低于對(duì)照組；進(jìn)一步的線性分析結(jié)果顯示UC患者的腸黏膜SIgA含量與5-HT mRNA及蛋白表達(dá)水平呈直線負(fù)相關(guān)。該結(jié)果說明SIgA含量的變更與5-HT表達(dá)水平變更具有一定的相關(guān)性；優(yōu)質(zhì)護(hù)理可能通過對(duì)5-HT通路的調(diào)節(jié)緩解UC患者的不良情緒，同時(shí)改善其免疫機(jī)能，促進(jìn)免疫活性細(xì)胞分泌IgA。

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Influence of high quality nursing on intestinal mucosal secretory IgA of patients with peptic ulcer

YE Jianghua

(BeijingTongrenHospitalAffiliatedtoCapitalMedicalUniversity,Beijing, 100730)

ABSTRACT:ObjectiveTo explore the influence of high quality nursing on intestinal mucosal secretory IgA of patients with peptic ulcer. MethodsA total of 60 patients with peptic ulcer were randomly divided into two groups (n=30). Patients in control group were treated with conventional PPT triple therapy, and those in observation group were given quality nursing on the base of PPT. Clinical effect and negative emotions score were evaluated. At the same time, colon mucosal tissue of patients was extracted to detect SIgA content by ELISA kit and expression of 5-HT protein and mRNA by RT-PCR and Western blot assay were detected. ResultsThe clinical effect of the observation group was significantly higher than that of the control group (P<0.05). And there were no significant difference in the indicators of two groups(P>0.05), HAMD/HAMA score and 5-HT expression level of observation group were significantly lower than that of the control group and the SIgA content was higher than that in the control group(P<0.05). Further more, there was negative correlation between SIgA content and 5-HT expression level(P<0.05). ConclusionHigh quality nursing could improve the level of mucosal SIgA content of patients with peptic ulcer and it may have a correlation with pathway of 5-HT regulated by emotions.

KEYWORDS:mental nursing; peptic ulcer; intestinal mucosa; secretory IgA; 5-HT

收稿日期:2015-01-25

中圖分類號(hào):R 285.5

文獻(xiàn)標(biāo)志碼:A

文章編號(hào):1672-2353(2015)12-047-03

DOI:10.7619/jcmp.201512016