俯卧位通气对急性呼吸窘迫综合征患者影响的Meta分析

目的评价俯卧位通气对急性呼吸窘迫综合征(acute respiratory distress syndrom,ARDS)患者的影响。方法计算机检索the Cochrane library、PubMed、Embase、Medline、Ovid、CBM、CNKI、维普数据库中截至2013年12月1日所有公开发表的关于ARDS患者俯卧位通气影响的随机对照试验(randomized controlled trial,RCT),并通过纳入文献的参考文献进行引证检索,纳入文献的质量由两名经过专业医学循证培训的医学生完成,对符合质量标准的文献进行Meta分析。结果共纳入12篇RCT,其中7个RCT的研究结果显示,俯卧位通气对患者氧合指数的提高有显著影响[OR=69.65,95%CI(37.13~102.7),P0.0001];另外8个研究结果表明,俯卧位通气对降低病死率有显著效果[OR=0.63,95%CI(0.51,0.78),P0.001]。结论俯卧位通气可以有效地改善ARDS患者的氧合指数,降低病死率。     

俯卧位通气对高海拔地区肺复张治疗无效急性呼吸窘迫综合征患者氧合的影响

目的 探讨俯卧位通气对高海拔地区肺复张术(RM)治疗无效急性呼吸窘迫综合征(ARDS)患者的治疗作用.方法 从海拔2260m的地区医院筛选RM治疗无效的41例ARDS患者[平均氧合指数( PaO2/FiO2)较RM前升高＜20％视为RM无效],依不同病因分为肺内源性ARDS组(ARDSp组)和肺外源性ARDS组(ARDSexp组),每组再按信封法随机分为俯卧位组和仰卧位组,即ARDSp俯卧位组(11例)、ARDSp仰卧位组(9例)、ARDSexp俯卧位组(10例)、ARDSexp仰卧位组(11例).在通气前及通气1、2、3、4h监测动脉血氧分压( PaO2)、PaO2/FiO2、静态顺应性(Cst)、气道阻力(Raw)的变化.结果 通气lh时,ARDSexp俯卧位组PaO2/FiO2( mm Hg,l mm Hg=0.133 kPa)即较通气前显著升高(157.4±40.6比129.3±48.7,P＜0.05),并随通气时间延长呈持续增高趋势,4h达峰值(219.1 ±41.1);且ARDSexp俯卧位组通气3h内PaO2/FiO2较其他3组显著增高,另3组间则差异无统计学意义.ARDSp俯卧位组、ARDSexp俯卧位组通气4h时PaO2/FiO2均较相应仰卧位组显著增高(208.8±39.7比127.4±47.1,219.1±41.1比124.9±50.8,均P＜0.05).4组通气前后Cst无显著改变,各组间差异也无统计学意义.ARDSp俯卧位组通气4h时Raw(cmH2O·L-1·s-1)较通气前显著降低(6.8±1.7比10.7±1.8,P＜0.05),且明显低于其他3组;其他3组各时间点Raw组内及组间比较差异均无统计学意义.结论 俯卧位通气作为ARDS机械通气重要策略之一,可以改善RM无效高原ARDS患者的氧合,为抢救患者赢得宝贵的时间.     

俯卧位通气治疗急性呼吸窘迫综合征疗效观察

目的：探讨俯卧位通气在治疗急性呼吸窘迫综合征（ARDS）的治疗效果。方法：42例ARDS患者分为2组,其中一组采用仰卧位肺保护通气策略,另一组采用俯卧位肺保护通气策略。比较2组患者PaCO2、PaO2／FiO2及pH值的改善情况。结果：俯卧位组与仰卧位组比较氧合指数、动脉血气分析明显改善（P〈0．05）。上机时间、住院时间和死亡率大大降低。结论：俯卧位肺保护通气策略治疗ARDS具有良好的肺保护效果和疗效,在抢救ARDS中有重要的应用价值。     

俯卧位通气治疗ARDS患者有效性与安全性的Meta分析

目的 :评价俯卧位通气治疗急性呼吸窘迫综合征患者的有效性及安全性。方法 :计算机检索Pub Med、Embase、Web of Sience、the Cochrane Library、中国知网、中国生物医学文献、维普、万方数据库中发表的关于俯卧位通气对ARDS患者影响的相关研究,纳入文献的质量由两名经过专业循证医学培训的学生完成,采用Rev Man 5.3软件对纳入文献进行Meta分析。结果 :共纳入9篇随机对照试验文献,纳入患者数2 359人。Meta分析结果显示,病死率效应值[OR=0.60,95%CI(0.40,0.90),P=0.01],合并效应有统计学意义;而在意外脱管发生率、呼吸机相关性肺炎发生率、气胸发生率、ICU住院时间方面并无统计学意义。结论 :俯卧位通气可降低ARDS患者病死率,且不增加意外脱管率,但在预防呼吸机相关性肺炎(VAP)、气胸发生率及ICU住院时间方面并无统计学意义。     

血必净注射液治疗急性呼吸窘迫综合征随机对照试验的系统评价

目的 评价血必净注射液治疗急性呼吸窘迫综合征(ARDS)的疗效和安全性.方法 检索2000年至2010年中国期刊网全文数据库(CNKI)、万方数据库、中文科技期刊数据库、中国生物医学文献数据库(CBM)、PubMed、Cochrane 临床试验数据库中有关血必净注射液治疗ARDS的临床随机对照试验文献,提取文献中的相关资料,采用Cochrane RevMan 5.0软件进行荟萃分析(Meta分析).结果 符合纳入标准的文献共13篇,疗效指标以病死率、痊愈率、机械通气时间、入住重症监护病房(ICU)时间、氧合指数(PaO2/FiO2)、动脉血氧分压(PaO2)等进行分析.Meta分析显示:血必净组病死率明显低于对照组[优势比(OR)为0.41,95%可信区间(95%CI)为0.27～0.62,P＜0.000 1];痊愈率明显高于对照组(OR为2.58,95%CI为1.49～4.48,P=0.000 7);机械通气时间较对照组明显缩短[权重均数差值(WMD)为2.03,95%CI为3.38～0.68,P=0.003];入住ICU时间较对照组明显缩短(WMD为3.60,95%CI为4.49～2.71,P<0.000 01);治疗后PaO2/FiO2、PaO2均较对照组明显升高(PaO2/FiO2:WMD为56.15,95%CI为42.97～69.33;PaO2:WMD为8.87,95%CI为5.70～12.04,均P＜0.000 01).试验未报告有严重不良反应发生.结论 血必净注射液治疗ARDS有一定优势;但纳入的文献方法学质量较低,有待更多高质量的试验进一步验证.     

俯卧位机械通气治疗肺内/外源性急性呼吸窘迫综合征的比较研究

目的探讨俯卧位机械通气对肺内／外源性急性呼吸窘迫综合征（ARDS）的治疗作用。方法2001年1月-2004年2月华北煤碳医学院附属开滦医院重症监护治疗病房（ICU）收治42例ARDS患者，按ARDS病原不同分为肺内源性ARDS组（ARDSp）和肺外源性ARDS组（ARDSexp）。两组均早期予以俯卧位机械通气治疗。记录仰卧位及俯卧位2h和4h的动脉血气分析、呼吸频率（RR）、吸入氧浓度（FiO2）、氧合指数（PaO2／FiO2）、胸肺顺应性（C）、潮气量（VT）、气道阻力（Raw）的变化。5例患者进行了两种体位的胸部CT比较。结果俯卧位机械通气后，两组患者FiO2减少。RR减慢。PaO2／FiO2、动脉血氧饱和度（SaO2）、Raw均显著增加。ARDSexp组VT明显高于同时间点ARDSp组；而动脉血pH和动脉血二氧化碳分压（PaCO2）则无明显变化；ARDSp组与ARDSexp组同时间点比较，PaO2／FiO2显著增加；ARDSp组应用俯卧位机械通气改善氧合的有效率为65％，ARDSexp组为68％，二者比较差异无显著性；胸部CT显示俯卧位后原背侧渗出性改变有所改善。原腹侧正常肺组织出现渗出性改变。结论无论是ARDSp组还是ARDSexp组。俯卧位机械通气均能显著改善PaO2／FiO2，是ARDS患者早期支持治疗的重要而有效的手段。     

俯卧位通气对静脉-静脉体外膜肺氧合支持的急性呼吸窘迫综合征患者病死率影响的Meta分析

目的系统评价俯卧位通气对静脉-静脉体外膜肺氧合（VV-ECMO）支持的急性呼吸窘迫综合征（ARDS）患者病死率的影响。 方法计算机检索Medline、荷兰医学文摘Embase、Cochrane临床试验数据库、万方数据库及中国知网数据库从2002年1月至2022年1月关于VV-ECMO支持ARDS期间使用俯卧位通气的随机对照研究或观察性研究。试验组为俯卧位通气患者,对照组为仰卧位通气患者。由2名研究人员独立进行筛选文献、提取文献资料及评估方法学质量后,采用RevMan 5.3软件进行Meta分析。 结果最终纳入14项研究,共计1 880例患者,其中试验组869例,对照组1 011例。Meta分析显示,与对照组比较,试验组VV-ECMO支持的ARDS患者的28 d病死率[相对危险度（RR）=0.59,95%置信区间（CI）（0.43,0.80）,Z = 3.41,P = 0.000 7]及住院病死率[RR = 0.73,95%CI（0.66,0.81）,Z = 5.86,P < 0.000 01]均显著降低;但两组患者间其他病死率（30 d、60 d、90 d、ICU、6个月病死率）的比较,差异无统计学意义[RR = 0.80,95%CI（0.61,1.05）,Z = 1.60,P = 0.11]。 结论俯卧位通气能够降低VV-ECMO支持的ARDS患者28 d病死率以及住院病死率。     

俯卧位通气对急性肺损伤和急性呼吸窘迫综合征临床疗效影响的Meta分析

目的 系统评价俯卧位通气(PPV)对我国急性肺损伤(ALI)和急性呼吸窘迫综合征(ARDS)患者的短期临床疗效.方法 利用Cochrane系统评价法,全面检索2000年至2009年国内公开发表的所有ALI与ARDS患者PPV的临床研究资料.对纳入研究独立进行质量评价、资料提取、交叉核对后行Meta分析.结果 纳入研究8项共184例患者,PPV时患者动脉血氧分压(PaO2)、氧合指数(PaO2/FiO2)、呼吸系统总顺应性(C)均显著升高;动脉血二氧化碳分压(PaCO2)、中心静脉压(CVP)、呼吸道峰压(PIP)和呼吸系统总阻力(Raw)无显著的变化;心率(HR)与平均动脉压(MAP)显著升高. 结论 ALI与ARDS患者行PPV可增加呼吸系统总顺应性,改善患者低氧血症,相关临床研究结果基本一致.但因Meta分析的自身局限性,我们仍急需开展设计严谨的高质量大样本临床研究,明确PPV临床疗效、作用机制、科学的操作流程及PPV对患者血流动力学的影响等临床实际问题,改善国内ALI与ARDS患者的临床护理水平.     

俯卧位通气联合肺保护性通气策略对急性呼吸窘迫综合征病人病死率影响的累积Meta分析

目的:应用累积Meta分析的方法评价俯卧位通气(prone positioning ventilation, PPV)联合肺保护性通气策略对急性呼吸窘迫综合征(ARDS)病人病死率的影响。方法:计算机检索PubMed、Web ofScience、the Cochrane Library、中国知网、维普数据库、万方数据库所有公开发表的关于PPV联合肺保护性通气策略应用于ARDS病人的随机对照试验,检索时限为建库至2022年7月31日。通过纳入文献的参考文献进行引证检索。采用StataSE 12.0软件对不同时间段纳入文献中病人的病死率进行累积Meta分析,采用试验序贯分析法估算累积Meta分析样本量评价研究结果的真实性,采用Beggs法对纳入研究进行发表偏倚检验。结果:共纳入4篇英文文献,涉及病人984例,其中试验组502例,对照组482例。累积Meta分析结果显示,PPV联合肺保护性通气策略能降低ARDS病人病死率,差异有统计学意义[OR=0.60,95%CI(0.46,0.78),P<0.001]。试验序贯分析结果显示,累积Meta分析样本量虽未达到估算样本量,但已获得较肯定结...     

气道压力释放通气对急性呼吸窘迫综合征患者住院病死率影响的累积Meta分析

目的 应用累积Meta分析的方法评价气道压力释放通气（APRV）对急性呼吸窘迫综合征（ARDS患者住院病死率的影响。方法 计算机检索PubMed、Web of Science、Cochrane Library、WanFang Data、CNKI和VIP数据库,搜集与研究目的相关的随机对照试验（RCT）,检索时限均为建库至2022年6月30日。由2名研究者独立筛选文献、提取资料并评价纳入研究的偏倚风险后,采用StataSE 12.0软件进行累积Meta分析。结果 共纳入9个RCT,包括533例患者。Meta分析结果显示,与传统机械通气相比,APRV能够降低ARDS患者的住院病死率[RR=0.70,95%CI(0.54,0.91),P<0.01]。结论 当前证据表明,APRV可降低ARDS患者住院病死率。受纳入研究数量和质量的限制,上述结论尚待更多高质量研究予以验证。     

Pathogenesis of acute encephalitis and acute encephalopathy

Many aspects of the pathogenesis of acute encephalitis and acute encephalopathy have been clarified in this decade, although many unknown mechanisms remain to be elucidated. According to progress of MRI and neuroimmunological analysis and the observation of clinical findings, many new syndromes were found, which enhanced our understanding of acute encephalitis and acute encephalopathy. The pathogenesis of encephalitis is divided into infection and immune mediated mechanisms. The antibodies to neuronal surface antigens(NSA) such as NMDA receptors, leucin-rich glioma inactivated 1 (LGI1) and aquaporin 4 were demonstrated in specific encephalitis, limbic encephalitis and neuromyelitis optica. Anti-NSA antibody encephalitis should be treated by immunotherapy such as corticosteroid and plasmapheresis. Acute encephalitis with refractory repetitive partial seizures (AERRPS) is a devastating postinfectious disease in children and adults, although the pathogenesis of AERRPS is poorly understood. Influenza associated encephalopathy(IAE) is characterized by it's high incidence in Japanese children between 1 year and 5 years of age, its onset in the first or the second day of illness and its high mortality (15-30%) and morbidity (25-40%). We proposed the classification of IAE with poor prognosis from the neuroradiological findings. Four types of encephalopathy seem to be differentiated from each other, acute necrotizing encephalopathy (ANE) type, hemorrhagic shock and encephalopathy syndrome (HSES) type, acute brain swelling (ABS) type, febrile convulsive status epilepticus (FCSE) type. The notable radiological features are thalamic lesions in ANE, diffuse cerebral cortical cytotoxic edema in HSES, reversible cerebral swelling in ABS which sometimes reaches lethal brain herniation, and in FCSE type, dendritic high signal in subcortical white matter by DWI ("bright tree appearance") appears simultaneously with the later onset of repetitive focal seizure. These four types are not specific to IAE but are noticed in another encephalopathies caused by HHV6, rotavirus, etc.     

Concomitant acute sinusitis and acute lung rejection

Two lung transplant recipients had concomitant acute sinusitis and acute lung rejection. Antibiotics and decongestants alleviated the sinusitis, but the symptoms of cough and dyspnea as well as spirometric defects necessitated treatment of acute lung rejection. In patients with clinical evidence of acute sinusitis after lung transplantation, concomitant acute lung rejection should be suspected if dyspnea or pulmonary dysfunction is also present. This appears to be the first report of concomitant acute sinusitis and acute lung rejection.     

从急性肾衰竭到急性肾损伤

早在古希腊时代,医学研究者就已经对肾脏疾病有所认识.作为临床肾病学的奠基人,希波克拉底曾经这样描述:"尿液表面出现泡沫可以表明肾脏疾病的发生和迁延."这可能是关于肾脏疾病最早的临床记录.在20世纪的两次世界大战中,大量伤员死于休克后的肾衰竭,而当时将这种疾病描述为"战争性肾炎".直到1951年,急性肾衰竭(ARF)这一名称才首次出现在Smith所编写的教科书中,他从生理学、病理学和临床方面对其进行了全面描述并提出了治疗原则[1].直至2002年,一个由肾脏科与危重症医师组成的团体--"急性透析质量指导组"(ADQI)建议使用急性肾损伤(AKI)代替ARF,这样就把轻度的急性肾功能减低也包含其中,更加有利于早期诊断和干预[2].无论称谓如何变迁,ARF的主要临床特点仍然是肾小球滤过率(GFR)下降,以及由此导致的代谢产物潴留、水和电解质及酸碱平衡紊乱等一系列病理生理改变,并伴随着血液中某些反映肾功能的标志物如血肌酐(SCr)、尿素氮(BUN)等明显升高.     

A focus on acute cholecystitis and acute cholangitis

Biliary infections are very common intra-abdominal infections. Laparoscopic cholecystectomy for acute cholecystitis and endoscopic retrograde management of acute cholangitis play important roles in the treatment of biliary infections. Also antimicrobial therapy is nevertheless important in the overall management of biliary infections. A multidisciplinary team of physicians, including surgeons trained in laparoscopic techniques, interventional gastroenterologists, and interventional radiologists may improve outcomes of patients with biliary infections. This review focuses the clinical presentation, diagnosis, and state of the art management of acute cholecystitis and acute cholangitis.     

Assessment of acute phase proteins in acute ischemic stroke

Acute phase proteins (APPs) have been implicated to play important roles during both acute and chronic inflammatory processes in different diseases including ischemic stroke. Though there are several studies showing the importance of APPs as inflammation markers in acute ischemic stroke (AIS), the time course of these proteins during acute phase of AIS is not well known. Thus, the aim of this study was to show the changes in plasma levels of six APPs (i.e., haptoglobin [Hp], ceruloplasmin [Cp], high-sensitive C-reactive protein [h-CRP], fibrinogen, complement 3 [C3] and complement 4 [C4]) during the first 10 days after acute stroke. The study group consisted of 34 female and 19 male patients (n = 53; mean age 65 +/- 12 years), who had first acute ischemic stroke (AIS). An age-matched control group (n = 53; 32 female and 21 male subjects, mean age 62 +/- 6 years) was also included. To evaluate the plasma levels of six APPs, the blood samples of patients with AIS were withdrawn on admission (day 1), and after 3, 5 and 10 days, whereas only one measurement was performed in the control group. In addition, several cerebrovascular risk factors were determined. The peak levels of APPs were higher in the AIS group than the control group (p < 0.0001). In serial measurements, the levels of h-CRP, Hp, C3 and C4 showed alterations during 10 days after AIS (p < 0.0001, p < 0.05, p < 0.0001, p < 0.0001, respectively). The alterations in levels of fibrinogen and Cp were not statistically significant (p > 0.05). After stroke, h-CRP, C3 and fibrinogen reached their highest values on the third day, Cp and C4 on the fifth day, and Hp on the tenth day. The plasma levels of h-CRP correlated positively with other five APPs studied (p < 0.05). These findings support the importance of inflammation processes after stroke. We suggest that the differences in levels of APPs could be used in predicting the outcome of stroke patients.     

Epidemiology of acute lung injury and acute respiratory distress syndrome

PURPOSE OF REVIEW: Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) are diseases with a significant influence in the public health. A better knowledge of their epidemiology could help to improve the outcome of these diseases. RECENT FINDINGS: Although the clinical criteria of the American-European Consensus Conference definitions for ALI and ARDS are simple, there is a risk of misclassification due to a poor reliability. Except for new emerging infectious diseases, such as severe acute respiratory syndrome, the etiology of ALI/ARDS has remained the same for several years. The only recent innovation is the hypothesis that pulmonary ARDS and extrapulmonary ARDS could be different clinical entities. In recent years, there has been a special interest in the study of genetic predisposition to development ALI/ARDS. Recent studies have estimated the incidence of these diseases to be between 15 and 34 cases per 100,000 inhabitants per year. This wide range could stem from differences in the methodology used to calculate the incidence or could be a true variation due to regional differences. Mortality rate of ALI/ARDS have remained steady for several years. Respiratory failure is the cause of the death in less than 20% of the patients. SUMMARY: The epidemiology of ALI and ARDS has some issues to improve, such as the accuracy of the clinical criteria of ALI/ARDS. Future research must to include study of genetic polymorphisms of the mediators involve in the development of ALI/ARDS. Studies to define better the population at risk are necessary to estimate better their true incidence.     

高血脂症性急性胰腺炎误诊急性阑尾炎患者的护理

目的 探讨高血脂症性急性胰腺炎患者病情观察及护理的要点.方法 回顾分析3例高血脂症性急性胰腺炎误诊为急性阑尾炎病例的临床资料,并对护理方法进行总结.结果 3例误诊病例入院时均有明显的三酰甘油水平升高（14.1～61.0 mmol/L）,血标本呈乳糜状脂浊血清,1例存有明显诱发因素,临床特点除右下腹症状、体征外,上腹部症状、体征持续存在,早期B超提示有腹腔积液,血、尿淀粉酶升高不明显.确诊后经严密观察病情、心理护理、营养支持护理、降血脂护理及健康宣教等护理后均痊愈出院.结论 临床护理工作中应提高对高血脂症性胰腺炎的认识,入院后全面的护理评估、仔细病情观察有助临床医生分析、判断病情,综合的护理干预促进疾病康复,重视健康宣教,有效控制血脂,去除诱发因素是疾病防治重点.