室壁运动异常患者发生Takotsubo综合征的危险因素分析

目的 初步探讨左心功能异常的危重患者触发Takotsubo综合征（TTC）的危险因素和机制。方法 选取2015年3月—2019年3月三亚中心医院重症监护室（ICU）收治的左心功能异常危重患者384例作为研究对象。根据是否符合TTC诊断标准分为TTC组38例和非TTC组346例。收集患者的年龄、性别、体重指数，以及炎症指标、心肌酶谱等实验室参数。观察ICU内发生TTC的危险因素。比较两组患者的住院时间、28 d院内病死率及再住院率。采用多因素Logistic回归模型进行危险因素分析。结果 单因素分析显示TTC组的女性比例升高（P <0.05），此外TTC组除pH值降低外，APACHE Ⅱ、心率、cTnT、NT-proBNP均较非TTC组升高（P <0.05），并且脓毒症、创伤性脑损伤、使用正性肌力药物的构成比高于非TTC组（P <0.05）。多因素Logistic回归分析结果显示脓毒症［R=1.955（95% CI：1.126，4.255）］，创伤性脑损伤［R=1.263（95% CI：1.016，3.549）］是左心功能异常的危重患者触发TTC的独立危险因素（P <0.05）。结论 脓毒症、创伤性脑损伤是危重患者发生TTC的危险因素，对于这类高风险患者需进行早期监测和预防。     

血清维生素A及碱性成纤维细胞生长因子水平预测早产儿视网膜病变的临床价值

目的：探讨血清维生素A(Vit A)及碱性成纤维细胞生长因子(bFGF)水平预测早产儿视网膜病变(ROP)的临床价值。方法：采用前瞻性队列研究。选取2020-01/2022-12在上海交通大学医学院附属上海儿童医学中心海南医院分娩且胎龄小于37 wk或出生体质量小于2 500 g的早产儿或低出生体质量儿411例作为研究对象，分别于出生后7 d和35 d进行外周血Vit A和bFGF水平检测。结果：最终完成临床研究的早产儿或低出生体质量儿共392例，其中1-2期ROP组 51例，3-5期ROP组 23例，未发生ROP组318例。生后7 d，1-2期ROP组血清Vit A(0.44±0.17 μmol/L)和bFGF(0.53±0.16 ng/L)水平分别低于未发生ROP组(0.50±0.12 μmol/L和0.63±0.15 ng/L)(均P&#x003C;0.05)； 3-5期ROP组血清Vit A(0.34±0.18 μmol/L)和bFGF(0.44±0.18 ng/L)水平分别低于未发生ROP组(均P&#x003C;0.05)； 3-5期ROP组血清Vit A和bFGF水平分别低于1-2期ROP组(均P&#x003C;0.05)。生后35d，3-5期ROP组血清Vit A(0.33±0.19 μmol/L)和bFGF(0.39±0.19 ng/L)水平分别低于1-2期ROP组(0.43±0.16 μmol/L和0.48±0.17 ng/L)(均P&#x003C;0.05)； 根据血清Vit A绘制的ROC曲线，AUC值为0.853，Youden指数最大值为0.68，最佳灵敏度为73%，最佳特异度为95%； 根据血清bFGF绘制的ROC曲线，AUC值为0.828，Youden指数最大值为0.58，最佳灵敏度为90%，最佳特异度为68%； 根据血清Vit A联合bFGF绘制的ROC曲线，AUC值为0.917，Youden指数最大值为0.70，最佳灵敏度为70%，最佳特异度为100%。结论：血清Vit A及bFGF水平均是预测ROP较敏感的有效指标，如果早产儿或低出生体质量儿血清Vit A或bFGF水平越低，可能提示ROP患病率越高及其病理分期越重。血清Vit A联合bFGF诊断ROP的临床价值较其单独诊断价值高，且减少误诊率。     

单侧胸腔镜下肺减容术治疗老年性大疱型肺气肿

探讨单侧胸腔镜下行肺减容术（LVRS）治疗老年性慢性阻塞性肺疾病（COPD）的方法及疗效。方法经严格掌控手术适应证，30 例重度大疱型肺气肿的患者被纳入手术，术中应用腔镜用切割缝合器（Endo GIA）切除无功能肺组织，切除部分占肺容积的20%～30%。对比术前、术后3、6 和12 个月的肺功能、血气及6 min步行试验等监测指标。结果30 例患者无死亡病例，术后随访肺功能、血气指标改善，呼吸困难症状减轻，活动耐力不同程度增加。术后3、6 和12 个月比较第1 秒用力呼气量（FEV1）、最大肺活量（FVC）、肺残 气量（RV），差异有统计学意义，术后3 个月血氧分压（PO2）、6 min 步行实验（6MWT）与术后12 月比较差异有统计学意义。结论胸腔镜下行肺减容术对于大疱型肺气肿是一种有效的治疗方法，可改善患者术后活动能力，提高患者生活质量，近期手术效果明显，随着时间延长手术效果有减退趋势。     

Correlation of patient-reported outcome measures to performance-based function in critical care survivors: PREDICTABLE

BackgroundEstablishing sequela following critical illness is a public health priority; however, recruitment and retention of this cohort make assessing functional outcomes difficult. Completing patient-reported outcome measures (PROMs) via telephone may improve participant and researcher involvement; however, there is little evidence regarding the correlation of PROMs to performance-based outcome measures in critical care survivors.ObjectivesThe objective of this study was to assess the relationship between self-reported and performance-based measures of function in survivors of critical illness.MethodsThis was a nested cohort study of patients enrolled within a previously published study determining predictors of disability-free survival. Spearman's correlation (r_s) was calculated between four performance-based outcomes (the Functional Independence Measure [FIM], 6-min walk distance [6MWD], Functional Reach Test [FRT], and grip strength) that were collected during a home visit 6 months following their intensive care unit admission, with two commonly used PROMs (World Health Organization Disability Assessment Scale 2.0 12 Level [WHODAS 2.0] and EuroQol-5 Dimension-5 Level [EQ-5D-5L]) obtained via phone interview (via the PREDICT study) at the same time point.ResultsThere were 38 PROMs obtained from 40 recruited patients (mean age = 59.8 ± 16 yrs, M:F = 24:16). All 40 completed the FIM and grip strength, 37 the 6MWD, and 39 the FRT. A strong correlation was found between the primary outcome of the WHODAS 2.0 with all performance-based outcomes apart from grip strength where a moderate correlation was identified. Although strong correlations were also established between the EQ-5D-5L utility score and the FIM, 6MWD, and FRT, it only correlated weakly with grip strength. The EQ-5D overall global health rating only had very weak to moderate correlations with the performance-based outcomes.ConclusionThe WHODAS 2.0 correlated stronger across multiple performance-based outcome measures of functional recovery and is recommended for use in survivors of critical illness.     

Appraising the quality of guidelines for peripheral arterial catheters care: A systematic review of reviews

IntroductionCatheter-related bloodstream infections are among the most critical adverse events in critical patients with peripheral arterial catheters (ACs). Adherence to evidence-based guidelines can prevent and reduce arterial bloodstream infections.ObjectiveThe objectives of this study were to assess clinical practice guidelines for AC care and analyse methodological factors related to their development for effective dissemination and implementation in clinical practice.Review method usedThis was a systematic review of guidelines.Data sourcesWe searched PubMed, CINAHL, EMBASE, CNKI, and WANFANG databases from inception until September 2021 and evaluated websites of organisations that complied or produced guidelines.Review methodsA comprehensive list of guidelines for ACs care was included. We excluded incomplete guidelines, guidelines translated in other languages, duplicate publications, and summaries of multiple guidelines. Two reviewers independently extracted and collected the data, and three authors conducted quality assessments independently using the Appraisal of Guidelines for Research and Evaluation, Second Edition (AGREE II) tool. The intraclass correlation coefficient (two-way random) with a 95% confidence interval was used to evaluate the concordance between reviewers.ResultsOf the 738 total publications screened, seven were selected for evaluation. The concordance between observers was substantial (intraclass correlation coefficient >0.9, P < 0.001). Most guidelines (4/6) were developed in the United States and the United Kingdom. The median scores for the six domains were 89.0%, 65.5%, 58.0%, 86.0%, 65.0%, and 86.0%. The domains of stakeholder involvement, rigour of development, and applicability had the lowest scores. Guidelines by the United Kingdom's National Institute for Health and Care Excellence showed the highest quality.ConclusionsThe guidelines we included scored poorly on crucial domains (rigour of development, applicability, and stakeholder involvement). Most of the current recommendations on ACs were included in the guidelines for vascular catheter–related bloodstream infections. Therefore, targeted guidelines created specifically for ACs are warranted to reduce the incidence of catheter-related complications and ensure patient safety.     

咳喘顺丸联合多索茶碱治疗慢性支气管炎的临床研究

目的 观察咳喘顺丸联合多索茶碱片治疗慢性支气管炎的临床效果。方法 选择2016年9月—2018年3月三亚市人民医院治疗的慢性支气管炎患者125例，采用随机数法将患者随机分为对照组（62例）和观察组（63例）。对照组采用多索茶碱片进行治疗，0.2 g/次，2次/d。观察组在对照组治疗的基础上服用咳喘顺丸进行治疗，5 g/次，3次/d。两组患者均接受1个月治疗。观察两组临床疗效，对比患者临床症状消失时间、炎症介质水平以及不良反应情况。结果 治疗后，观察组患者治疗总有效率显著高于对照组（P<0.05）。治疗后，观察组咳痰、喘息、咳嗽3项症状消失时间明显比对照组短（P<0.05）。治疗后，两组肿瘤坏死因子-α（TNF-α）、白细胞介素-6（IL-6）、C反应蛋白（CRP）和白细胞介素-4（IL-4）水平均明显降低（P<0.05），且治疗后，观察组TNF-α、IL-6、CRP和IL-4水平明显低于对照组（P<0.05）。两组不良反应发生率无显著差异。结论 咳喘顺丸联合多索茶碱片治疗慢性支气管炎可明显改善患者临床症状，缓解炎症反应，该方法具有较好的临床疗效，安全可靠，临床应用价值较高，值得应用推广。     

Ventilator weaning and extubation practices in critically ill children: An Australian and New Zealand survey of practice

ObjectivesWe aimed to (i) describe current weaning and extubation practices in children (protocols to identify weaning candidates, spontaneous breathing trials, and other aspects of care such as sedation weaning) and (ii) understand responsibilities for ventilation weaning decisions across Australia and New Zealand (ANZ).MethodsA cross-sectional survey of ANZ intensive care units who routinely intubate and ventilate children (<18 years) was conducted. We worked with the Australian and New Zealand Intensive Care Society Paediatric Study Group to identify units and potential respondents (senior nurse representative per unit) and to administer questionnaires. Survey questions (n = 35) examined current protocols, practices, unit staffing, and decision-making responsibilities for ventilation weaning and extubation. Open-ended questions examined respondents' experiences of weaning and extubation.ResultsA senior nursing respondent from 18/22 intensive care units (82%) completed the survey. Across units, most used sedation assessment tools (88%), and less often, sedation weaning tools (55%). Spontaneous awakening protocols were not used; one unit (5%) reported the use of a spontaneous breathing protocol. Two respondents reported that ventilation weaning protocols (11%) were in use, with 44% of units reporting the use of extubation protocols. Weaning and extubation practices were largely perceived as medically driven, with qualitative data demonstrating a desire from most respondents for greater shared decision-making.ConclusionIn ANZ, ventilation weaning and extubation practices are largely medically driven with variation in the use of protocols to support mechanical ventilation weaning and extubation in children. Our findings highlight the importance of future research to determine the impact of greater collaboration of the multidisciplinary team on weaning practices.     

Internal and external validation of machine learning–assisted prediction models for mechanical ventilation–associated severe acute kidney injury

BackgroundCurrently, very few preventive or therapeutic strategies are used for mechanical ventilation (MV)-associated severe acute kidney injury (AKI).ObjectivesWe developed clinical prediction models to detect the onset of severe AKI in the first week of intensive care unit (ICU) stay during the initiation of MV.MethodsA large ICU database Medical Information Mart for Intensive Care IV (MIMIC-IV) was analysed retrospectively. Data were collected from the clinical information recorded at the time of ICU admission and during the initial 12 h of MV. Using univariate and multivariate analyses, the predictors were selected successively. For model development, two machine learning algorithms were compared. The primary goal was to predict the development of AKI stage 2 or 3 (AKI-23) and AKI stage 3 (AKI-3) in the first week of patients’ ICU stay after initial 12 h of MV. The developed models were externally validated using another multicentre ICU database (eICU Collaborative Research Database, eICU) and evaluated in various patient subpopulations.ResultsModels were developed using data from the development cohort (MIMIC-IV: 2008–2016; n = 3986); the random forest algorithm outperformed the logistic regression algorithm. In the internal (MIMIC-IV: 2017–2019; n = 1210) and external (eICU; n = 1494) validation cohorts, the incidences of AKI-23 were 154 (12.7%) and 119 (8.0%), respectively, with areas under the receiver operator characteristic curve of 0.78 (95% confidence interval [CI]: 0.74–0.82) and 0.80 (95% CI: 0.76–0.84); the incidences of AKI-3 were 81 (6.7%) and 67 (4.5%), with areas under the receiver operator characteristic curve of 0.81 (95% CI: 0.76–0.87) and 0.80 (95% CI: 0.73–0.86), respectively.ConclusionsModels driven by machine learning and based on routine clinical data may facilitate the early prediction of MV-associated severe AKI. The validated models can be found at: https://apoet.shinyapps.io/mv_aki_2021_v2/.     

针刺联合自制穴位贴对带状疱疹后遗神经痛血脉瘀阻证患者疗效与安全性的影响

目的 探究通督扶阳针法联合自制穴位贴治疗带状疱疹后遗神经痛血脉瘀阻证的疗效与安全性.方法 纳入本院于2019年4月至2021年3月收治的带状疱疹后遗神经痛血脉瘀阻证的患者116例,随机分为观察组58例、对照组58例.观察组应用通督扶阳针法联合自制穴位贴治疗,对照组应用利多卡因凝胶贴膏治疗,两组治疗周期均为4周.应用简易...