凶险型恶性疟7例的临床特点分析

目的探讨凶险型恶性疟的特征及防治措施。方法对本院收治的7例凶险型恶性疟病例临床资料进行回顾性分析。结果 7例凶险型恶性疟患者均为境外输入,有明确的疫区生活史。该类患者临床症状不典型,病情发展迅速,容易出现严重并发症,急性肾功能不全、DIC和继发细菌感染是该类患者最常见的并发症。青蒿素及其衍生物对凶险型疟疾患者疗效确切。结论加强对凶险型恶性疟疾的认识,及时有效的抗疟治疗和并发症的积极治疗是抢救这类患者的关键。     

1例多器官功能衰竭体外膜肺联合连续性血液净化治疗的护理

对1例肺、肾功能衰竭患者行组合式体外膜肺联合连续性血液净化治疗,结果患者病情得到控制并最终康复出院.提出多器官功能衰竭患者病情发展迅速,预后极差,在临床上除行体外膜肺联合连续性血液净化治疗的护理外,还应注意预防感染、出血等严重并发症,以积极改善预后,提高患者生活质量.     

前列地尔联合持续性血液净化对急性肾功能衰竭的疗效影响

目的 探讨前列地尔联合连续性血液净化对急性肾功能衰竭患者肾功能的影响.方法 急性肾功能衰竭患者60例,按随机数字表法分为前列地尔组(30例)和对照组(30例),两组均予以连续性血液净化治疗7d,前列地尔组在此基础上联合前列地尔治疗.记录治疗3、7d后患者的血肌酐、血尿素氮,血尿酸、肌酐清除率、尿量、APACHEⅡ评分....     

恶性疟合并溶血尿毒综合征的诊疗探讨

目的探讨恶性疟引起的溶血尿毒综合征（HUS）的诊断及治疗要点。 方法对本院2008至2014年13例恶性疟引起的溶血尿毒综合征患者的临床特点、辅助检查及治疗情况进行回顾性分析。 结果入组患者中男性12例,女性1例,年龄22～60岁,均符合恶性疟疾合并溶血尿毒综合征的诊断。其中10例合并脑型疟,1例合并消化道出血,2例出现呼吸循环衰竭。经抗疟原虫治疗、激素治疗、补液对症治疗以及呼吸机、血液透析滤过等,入组的13例患者中1例死亡,1例自动出院,11例治愈出院,其中5例因急性肾功能衰竭行血液透析滤过治疗肾功能恢复,随访11例治愈患者均未出现慢性肾功能损害,2例病例出现再燃。 结论疟疾的早期诊断及治疗,对控制溶血及阻止脏器损害具有重要作用;大剂量长疗程使用蒿甲醚可增强抗疟原虫效果,早期应用激素可有效阻止溶血,减轻肾脏损害,对严重溶血、急性肾功能衰竭病例应及时采取血液透析滤过治疗,以降低病死率。     

注射用青蒿琥酯治疗疟疾的疗效观察

目的观察注射用青蒿琥酯治疗疟疾的疗效和安全性。方法选择本院2013年6月至2014年4月收治的66例疟疾患者,采用数字表随机法分为两组,观察组33例患者给予注射用青蒿琥酯治疗,对照组33例患者单纯口服青蒿琥酯阿莫地喹片治疗。观察两组患者退热时间、疟原虫转阴时间及不良反应,所有患者1个月后再次复查,分别对疗程结束时、复查的疗效进行评价。结果观察组治疗24 h后血中平均疟原虫数下降幅度显著大于对照组,平均退热时间、疟原虫平均转阴时间均显著短于对照组,观察组治疗7 d疗效与对照组比较差异无统计学意义(χ2=0.9243、P=0.3382)。28 d后复查疗效,观察组痊愈率为96.97%,显著高于对照组(χ2=4.0217、P=0.0351)。观察组不良反应发生率分别为3.03%和21.21%;观察组和对照组不良反应发生率显著低于对照组,两组比较差异具有统计学意义(χ2=5.6241、P=0.0184)。结论注射用青蒿琥酯具有起效快、复燃率低,而且安全性高,是国内外疟疾流行区的首选治疗药物。     

青蒿琥酯对糖尿病肾病大鼠肾功能和单核细胞趋化蛋白-1及肿瘤坏死因子-α的影响*

摘要目的 观察青蒿琥酯对糖尿病肾病大鼠肾功能及单核细胞趋化蛋白1（MCP1）、肿瘤坏死因子α（TNFα）表达的影响。方法雄性斯泼累格·多雷（SD）大鼠36只,随机分为6组,每组6只：正常对照组,模型对照组,青蒿琥酯小剂量组（10 mg·kg－1·d 1）、中剂量组（20 mg·kg－1·d 1）、大剂量组（30 mg·kg－1·d－1）,依那普利组（10 mg·kg－1·d－1）。采用高糖高脂饮食联合一次性腹腔注射小剂量链脲佐菌素法建立2型糖尿病肾病模型。分别干预8周后,检测各组大鼠血糖、24 h尿蛋白定量、血肌酐、尿素氮等评估肾功能情况;光镜下观察肾组织病理形态学变化;检测大鼠血清MCP 1、TNF α水平。结果与模型对照组比较,各治疗组24 h尿蛋白、血肌酐、血尿素氮、血糖均一定程度下降（均P＜0.01）,尤以青蒿琥酯中、大剂量组下降更显著（均P＜0.01）。模型对照组MCP 1及TNF α的含量分别为（181.71±23.06）,（3.98±0.24） pg·mL－1;青蒿琥酯小剂量组分别为（157.47±38.53）,（3.14±0.38） pg·mL－1,中剂量组分别为（138.65±18.03）,（2.58±0.11） pg·mL－1,大剂量组分别为（105.09±12.64）,（2.25±0.16） pg·mL－1,均显著降低（均P＜0.05）。结论青蒿琥酯对2型糖尿病肾病具有一定的治疗作用,其机制可能部分是通过减少炎性因子MCP 1、TNF α的分泌,抑制肾脏炎性反应,调节肾功能,缓解肾脏的病理损伤,从而延缓肾脏病变的发展。     

血液净化联合中药外敷治疗33例危重型毒蛇咬伤的疗效分析

目的：探讨血液净化联合中药外敷治疗危重型毒蛇咬伤的临床疗效。方法：回顾性分析2010年1月～2011年8月我院收治的危重型毒蛇咬伤患者治疗效果,比较血液净化联合中药外敷治疗前后患者一般状况、局部症状、实验室指标变化及预后。结果：总共33例患者符合条件纳入观察,其中截肢1例,死亡1例,其余痊愈,治愈率93.9%。联合治疗后,患者一般状况改善,局部肿胀疼痛缓解,实验室指标改善。结论：血液净化联合中药外敷是治疗危重型毒蛇咬伤的重要手段,能降低患者致残率和死亡率,提高治愈率。     

75例多发性骨髓瘤合并肾损害的临床特点及预后的分析

目的：分析75例多发性骨髓瘤（MM）并骨髓瘤肾病（MMN）临床特征及与预后的相关危险因素。方法：对75例MM病例进行随访。记录病人的临床和实验室检查结果，及合并感染或急性肾衰竭（ARF）情况。结果：初诊时肾脏累及：蛋白尿型26．7％，肾病综合征16.0％，肾衰竭型57．3％。肾综型及肾衰竭型血钙水平较蛋白尿型明显增高。肾综型易并发ARF。存活少于12个月者多为老年人、初诊合并感染及高钙血症或／和肾衰竭、发生ARF经治疗肾功能不能恢复者。化疗加血液净化可延长患者的生存时间。结论：MM合并MMN是非常常见。〉70岁、高钙血症、初诊有肾功能减退及感染、治疗后肾功能不能恢复是预后差的主要危险因素：积极化疗加血液净化治疗能改善肾功能，延长患者的生存时间。     

序贯性血液净化治疗重症毒鼠强中毒

目的观察血液净化治疗重症毒鼠强中毒患者的临床疗效和对预后的影响。方法11例重症毒鼠强中毒的患者人院后．除给予镇静、抗惊厥、冼胃、利尿、导泻、营养神经、支持等常规治疗外,并给予序贯性血液净化治疗。观察患者的临床症状、血压、脉搏、血清酶学变化。结果11例患者进行血液净化治疗,死亡1例,1例临床症状好转后自动出院．其余9例患者痊愈。结论及时有效的血液净化治疗可明显改善毒鼠强中毒患者的预后。     

青蒿琥酯对大鼠胶原诱导性关节炎骨质疏松的保护作用

目的 探讨青蒿琥酯是否能抑制CIA大鼠骨质破坏及预防骨质疏松及其可能的机制。方法 随机将大鼠分为对照组、CIA 模型对照组、MTX组、青蒿琥酯组、甲基泼尼松龙组及rhTNFR:Fc组并灌胃给药。行大鼠四肢关节钼靶拍片,并予影像学评分。收取大鼠血液和尿液测定血钙、血磷、尿钙、尿磷的含量,同时测定血、尿液中脱氧吡啶啉（DPD）含量、血清碱性磷酸酶、骨保护钙素含量,并采用骨密度仪对大鼠全身骨骼进行扫描。结果 青蒿琥酯组与MP、MTX和CIA比较有统计学意义（P<0.01), 21w时与10w周比较无统计学意义。rhTNFR:Fc组在与健康组比较均无统计学意义,与其他药物干预组比较均有统计学意义（P<0.05); CIA模型对照组、甲氨蝶呤组、甲基泼尼松龙组各项检测指标与造模后21w与10w比较有统计学意义（P<0.01)。骨密度检测提示甲基泼尼松龙及甲氨蝶呤组在第10w及21w均不能抑制骨质疏松的发生,而青蒿琥酯组和rhTNFR:Fc组于第10w及21w均可预防骨质疏松的发生。影像学亦显示青蒿琥酯组和rhTNFR:Fc组可预防CIA大鼠发生骨质疏松。结论 青蒿琥酯有预防CIA大鼠骨质疏松及抑制骨质破坏的作用,其可能的机制是抑制TNF-α的分泌、作用于OPG/RANK/RANKL信号系统从而阻断破骨细胞的生成和活化。     

Malaria and acute kidney injury

Malaria is a major public health problem in tropical countries. About 500 million people suffer from malaria, leading to death in 1 to 3 million cases. Acute kidney injury (AKI) is one of the most dreaded complications of severe malaria. As per World Health Organization criteria, acute renal failure (serum creatinine level, > or =3 mg/dL or > or =265 micromol/L) occurs as a complication of Plasmodium falciparum malaria in less than 1% of cases, but the mortality rate in these cases may be up to 45%. It is more common in adults than children. Renal involvement varies from mild proteinuria to severe azotemia associated with metabolic acidosis. It may be oliguric or nonoliguric. AKI may be present as a component of multi-organ dysfunction or as a lone complication. The prognosis in the latter is generally better. Several pathogenic mechanisms interplay for the clinical manifestation. The predominant lesions are acute tubular necrosis and mild proliferative glomerulonephropathy. These patients do not progress to chronic kidney disease. The management of malaria-induced AKI includes appropriate antimalarials (parenteral artesunate or quinine), fluid electrolyte management, and renal replacement therapy at the earliest. The use of diuretics should be avoided.     

Severe malaria in expatriates in an intensive care unit in Abidjan (Ivory Coast)

OBJECTIVE: To analyse clinical and prognosis aspects of severe malaria in expatriates hospitalized between 1990 and 1999 in the intensive care unit in Abidjan. STUDY DESIGN: Retrospective survey. METHODS: According to the World Health Organization's criteria, the retrospective study of severe cases of malaria who received treatment and care at the intensive care unit. Epidemiological, clinical manifestations and evolution were analysed on each patients. RESULTS: 66 upon 927 expatriates hospitalised in the period of the study, had severe malaria with falciparum Plasmodium (7.12%). The average age was 42 years. Eleven patients took prophylactic treatment (17%). The clinical aspects were neurological (83%) followed by renal failure (48%), haemoglobinuria (48%) and hyperparasitemia (59%). During the hospitalisation we recorded 12 deaths (18%). The criteria that were associated with mortality in pejorative order were: coma (RR = 8.04), respiratory distress (RR = 5.06), metabolic acidosis (RR = 5.06), shock (RR = 3.67) and convulsions (RR = 2.86). CONCLUSION: Severe malaria was frequent and associated with high mortality in expatriates who are living in Africa. This study reinsists the necessity of prophylactic treatment to be reinforced in informing the travellers. This study showed frequency and mortality rate of survey of malaria and the criteria associated with high mortality rate.     

Severe falciparum malaria in five soldiers from East Timor: a case series and literature review

Despite chemoprophylaxis, malaria remains a serious threat for large numbers of non-immune soldiers deployed in endemic areas. Five adult cases of severe falciparum malaria are reported. Three cases were complicated by multiorgan failure and one of these patients died from cerebral malaria. These cases serve to highlight issues, in an Australian intensive care unit, associated with the management of severe malaria, an uncommon disease in our country. The need for rapid diagnosis and commencement of appropriate treatment is paramount in preventing further morbidity and mortality. Understanding and management of malaria continues to evolve rapidly. The pathophysiology of acute lung injury, shock and brain injury associated with malaria are examined in light of recent research. This article discusses the current controversies of exchange blood transfusion and the use of the new artemisinin derivatives.     

Therapeutic efficacy of sulfadoxine-pyrimethamine for Plasmodium falciparum malaria.

OBJECTIVES: To assess the therapeutic efficacy of sulfadoxinepyrimethamine (SP) after 5 years of use as first-line treatment of uncomplicated Plasmodium falciparum malaria, and thus guide the selection of artemisinin-based combination therapy in Mpumalanga, South Africa. DESIGN: An open-label, in vivo therapeutic efficacy study of patients with uncomplicated P. falciparum malaria treated with a single oral dose of SP, with response to treatment monitored clinically and parasitologically on days 1, 2, 3, 7, 14, 21, 28 and 42. SETTING: Mangweni and Naas public health care clinics, Tonga district in rural Mpumalanga. SUBJECTS, OUTCOME MEASURES AND RESULTS: Of 152 patients recruited sequentially, 149 (98%) were successfully followed up for 42 days. One hundred and thirty-four patients (90%) demonstrated adequate clinical and parasitological response. Of the 15 patients (10%) who failed treatment, 2 (1.3%) had an early treatment failure, and polymerase chain reaction confirmed recrudescent infection in all 13 patients (8.7%) who had late parasitological (N = 11) or clinical (N = 2) failure. Gametocyte carriage was prevalent following SP treatment (84/152) and this has increased significantly since implementation in 1998 (relative risk 2.77 (confidence interval 1.65 - 4.66); p = 0.00004). CONCLUSION: Asexual P. falciparum parasites in Mpumalanga remain sensitive to SP, with no significant difference between the baseline cure rate (94.5%) at introduction in 1998, and the present 90% cure rate (p = 0.14). However, since gametocyte carriage has increased significantly we recommend that SP be combined with artesunate in Mpumalanga to reduce gametocyte carriage and thus decrease malaria transmission and potentially delay antimalarial resistance.     

Drotrecogin alfa (activated) in severe falciparum malaria

Drotrecogin alfa (activated) is a drug licensed for the treatment of severe sepsis. We describe the care of a 61-year-old man who developed multi-organ failure secondary to severe falciparum malaria infection with parasitaemia levels of 40%. Included in his care were an exchange blood transfusion and an infusion of Drotrecogin alfa (activated). Within hours of starting the infusion of Drotrecogin alfa (activated), the patient's clinical condition stopped deteriorating. Steady improvement followed with weaning from ventilatory assistance on day 14 post admission. The patient made a full recovery and was discharged home following rehabilitation. The indications for Drotrecogin alfa (activated) and the appropriateness of its use in severe malaria with multi-organ failure are discussed. Drotrecogin alfa (activated) may be a useful treatment in patients with multi-organ failure resulting from severe malaria.     

Acute renal failure due to falciparum malaria

Seventy-two patients with severe falciparum malaria are described. Twenty-four (33.3%) were complicated by acute renal failure. Comparing patients with renal failure and those without, statistically significant differences occurred regarding presence of cerebral malaria (83% vs 46%), jaundice (92% vs 33%), and death (54% vs 17%). A significantly higher number of patients with renal failure were nonimmune visitors to malaria endemic regions. Renal failure was oliguric in 45% of cases. Dialysis was indicated in 38%, 29% died in early renal failure, and 33% recovered spontaneously. It is concluded that falciparum malaria is frequently complicated by cerebral malaria and renal failure. As nonimmune individuals are prone to develop serious complications, malaria prophylaxis and vigorous treatment of cases is mandatory.     

The use of activated protein C in severe Plasmodium falciparum malaria

A 56-year-old man presented to a peripheral hospital in New Zealand with severe Plasmodium falciparum malaria with cerebral involvement and subsequently developed multi-system organ failure. Activated protein C was used in an attempt to stop the cascade of events into multi-organ failure. Severe infection with P. falciparum is life-threatening and appears to activate a hypercoagulable state similar to that of severe sepsis. Activated protein C is currently used in the treatment of severe sepsis and may provide a new adjuvant therapy for severe P. falciparum malaria.     

Continuous peritoneal dialysis in acute renal failure from severe falciparum malaria

Severe falciparum malaria complicated by acute renal failure resulted in very high mortality. Ten patients with acute renal failure from falciparum malaria (infected rbc up to 80%) were continuously dialysed using Tenckhoff peritoneal catheter. Five were oliguric and BUN was maintained between 60 to 80 mg/dl (21.4 to 28.6 mmol/l) by hourly 1 to 1.5 liter dialysate exchange during the acute phase. The peritoneal urea clearance (mean +/- SD) was 12.1 +/- 1.2 ml/min with urea nitrogen removal of 13.4 +/- 2.3 g/day. In nonoliguric cases dialysis was also needed for additional removal of waste products since the remaining renal function could not cope with the hypercatabolic state. Peritoneal glucose absorption (135 to 565 g/day) gave considerable caloric supply without volume load and also contributed to the prevention of hypoglycemia. Varying degree of acute respiratory failure developed in all patients with 5 cases (2 oliguric and 3 nonoliguric) progressing to pulmonary edema. Swan-Ganz catheterization and hemodynamic study suggested the role of increased capillary permeability and volume overload from endogenous water formation in the development of pulmonary complication. Continuous removal of fluid and waste products minimized these problems and may prevent the progression of respiratory failure. One patient died of severe sepsis and the other nine survived. This study showed the beneficial contribution of continuous peritoneal dialysis in the management of acute renal failure from severe falciparum malaria.