Cost-effectiveness of hepatic venous pressure gradient measurements for prophylaxis of variceal re-bleeding

BACKGROUND: Measurement of the hepatic venous pressure gradient may identify a sub-optimal response to drug prophylaxis in patients with a history of variceal bleeding. However, the cost-effectiveness of routine hepatic venous pressure gradient measurements to guide secondary prophylaxis has not been examined. METHODS: A Markov model was constructed using specialized software (DATA 3.5, Williamstown, MA, USA). Three strategies involved secondary prophylaxis without haemodynamic monitoring using beta-blockers alone, beta-blockers plus isosorbide mononitrate or endoscopic variceal ligation alone. Four strategies involved secondary prophylaxis with beta-blockers plus isosorbide mononitrate or beta-blockers alone, accompanied by one or two hepatic venous pressure gradient measurements to identify haemodynamic non-responders, who underwent endoscopic variceal ligation as an alternative. The total expected costs, variceal bleeding episodes and total deaths were calculated for each strategy over 3 years. RESULTS: The two most effective strategies were combination therapy alone and combination therapy with two hepatic venous pressure gradient measurements. The incremental cost-effectiveness ratio of the latter strategy was 136,700 dollars per year of life saved compared with combination therapy alone. The ratio improved as the time horizon was extended or the rates of variceal re-bleeding were increased. CONCLUSIONS: The cost-effectiveness of haemodynamic monitoring to guide secondary prophylaxis of recurrent variceal bleeding is highly dependent on local hepatic venous pressure gradient measurement costs, life expectancy and re-bleeding rates.     

急性心肌梗死患者住院死亡的危险因素分析

目的探讨急性心肌梗死（AMI）患者住院死亡的独立危险因素。方法收集本院2008年10月~2013年10月收治的463例AMI患者的临床资料,其中存活（存活组）384例,死亡（死亡组）79例,采用单因素及多因素Logistic回归分析筛选AMI患者住院死亡的独立危险因素。结果两组患者的性别、年龄、吸烟史、既往病史、心率、收缩压、肌钙蛋白T（cTnT）峰值、肌酸激酶同工酶（CK-MB）峰值、空腹血糖、肌酐（Cr）、高密度脂蛋白胆固醇（HDL-C）、超敏C反应蛋白（hs-CRP）、N-端脑利钠肽前体（NT-proBNP）、梗死部位、Killip分级、左心室射血分数（LVEF）、室性心律失常及再灌注等方面比较,差异有统计学意义（P〈0.05）。Logistic回归分析显示年龄、糖尿病、陈旧性心肌梗死（OMI）、心率、收缩压、cTnT峰值、Cr峰值、室性心动过速及心室颤动、Killip分级、LVEF及再灌注治疗与AMI患者住院死亡相关。结论高龄、糖尿病及OMI病史、心率增快、cTnT及Cr升高、出现室性心动过速及心室颤动、Killip分级高是AMI患者住院死亡的独立危险因素,收缩压、LVEF及再灌注治疗为保护性因素。     

外周血半乳糖凝集素-3及脑钠肽与急性心肌梗死患者预后的关系

目的探讨急性心肌梗死患者外周血循环中Galectin-3及BNP浓度变化与其危险度及预后的关系。方法选取确诊为急性心肌梗死患者80例,入院后24 h内检测外周血Galectin-3浓度,所有患者均定期随访6个月,观察外周血Galectin-3及BNP浓度与急性心肌梗死预后的关系。结果与健康对照组(40例)相比较,AMI组外周血Galectin-3及BNP浓度明显升高(P<0.01),且Galectin-3表达水平高的患者心血管事件发生率高(P<0.05)。结论 AMI组外周血半乳糖凝集素-3及BNP的表达水平可反映AMI的严重程度,可作为心血管事件预测指标。     

Prognostic value of long QT interval in acute and severe organophosphate poisoning

Introduction

Suicidal poisoning with organophosphorus (OP) pesticides is common, particularly from rural areas. This high-lights the importance of determining an OP poisoning prognosis to decide how aggressive treatment should be. There are reports suggesting a relationship between prolonged corrected QT (QTC) interval and the severity of poisoning. We aimed to evaluate the prognostic utility of this clinical tool in OP poisoning (OPP) patients.

Methods

Patients with the primary diagnosis of OPP who were admitted to the intensive care unit (ICU) of Loghman-Hakim Hospital Poison Centre (LHHPC) were the subjects of this prospective study. Cholinesterase (CE) activity and the QTC interval was determined for each patient using the Bazett formula and considering <440 msec as normal. Comparative outcomes of the study were duration of both hospitalization and mechanical ventilation, serum CE activity on admission and its daily level, total amount of atropine administered, analysis of the QT and QTC intervals in the primary ECG on admission and at the end of hospitalization, and rate of mortality.

Results

The study included 42 patients with a diagnosis of OPP. The mean age of the patients was 32, ranged from 12 to 81 years old. The mortality rate was 37.5%. There was no significant difference between two groups (prolonged and normal QTC intervals) according to gender and age (p=.491 andp=.133, respectively). The CE level for long and normal QTC interval groups was 3.90±0.33 kU/L vs. 4.41±0.23 kU/L, respectively. The mortality rate in the long QTC group was significantly higher than that of the normal QTC group (p=.044). Moreover, the average period of hospitalization in patients with prolonged QTC interval was higher than the other group (p=.02). The average atropine required to control the muscarinic signs and symptoms such as salivation, bronchorrehea, and miosis in patients with prolonged QTC interval was 38.60 mg; in patients with normal QTC interval it was 20.02 mg (p=.013).

Conclusion

QTC interval prolongation may have prognostic value in OPP.     

Advances in the treatment of severe alcoholic hepatitis

Severe alcoholic hepatitis (SAH) is a costly and worldwide public health issue with high morbidity and mortality. Specific effective treatments for SAH have yet to be established. The aim of the present article is to review the current knowledge of the pathogenesis, assessment and treatment options in patients with SAH. To date, alcohol abstinence and enteral nutrition are the recommended first-line treatments. Although corticosteroids remain the preferred therapy for certain patients with a modified Maddrey discriminant function level greater than 54, they only improve short-term survival rates. New research focuses on liver inflammation, liver regeneration, the gut–liver axis, human induced pluripotent stem cells and extracorporeal albumin dialysis. Liver transplantation is considered the last medical option for patients with SAH who are nonresponsive to other medical treatments.     

重症酒精性肝炎临床治疗进展

重症酒精性肝炎是一种由酒精导致的、潜在威胁生命的急性肝损伤,死亡率高,临床治疗面临巨大挑战。本文从营养支持治疗以及糖皮质激素、抗细胞因子应用等几个方面综述重症酒精性肝炎的临床治疗进展。     

NGAL和C反应蛋白预测急性胰腺炎患者急性肾损伤的价值

目的评估中性粒细胞明胶酶相关脂质运载蛋白(NGAL)和C反应蛋白(CRP)对急性胰腺炎(AP)患者发生急性肾损伤(AKI)的预测价值,为AKI早期诊断提供有价值的参考。方法选取深圳市第六人民医院2013年1月~2015年12月住院的新发AP患者125例,分为轻型AP组(MAP组)、重型AP组(SAP组),依据是否发生AKI又分为AKI亚组和非AKI亚组,采用ELISA法测定尿NGAL水平及绘制受试者工作曲线反应比较CRP预测AKI的价值。结果所有MAP患者均无AKI发生,47例SAP患者中有30例发生AKI(占63.8%);入院后2h内测MAP组及SAP组患者尿NGAL水平相近,差异无统计学意义(P>0.05)。此后尿NGAL逐渐升高,峰值出现在入院后12h,且SAP组AKI亚组NGAL明显高于非AKI亚组和MAP组,差异有统计学意义(P<0.05);NGAL预测AKI发生的ROC曲线下面积(AUC)>CRP,差异有统计学意义(P<0.05)。结论 NGAL对SAP患者并发AKI具有早期诊断价值,早期诊断价值高于CRP。     

有创呼吸机在急性重度心力衰竭患者中的应用

目的：探讨急性重度心力衰竭患者应用有创呼吸机治疗的临床意义以及应用价值。方法选择36例临床诊断为重度急性心力衰竭患者,并且经常规药物治疗效果不佳,急行经口鼻插管呼吸机辅助通气,观察患者临床疗效,治疗前、治疗24h后、撤机后血气分析及B型脑钠肽前体测定（ BNP）。结果所有患者中治疗后24h,有效22例,无效14例,有效率61.11%。其中患者要求主动出院10例,死亡4例。死亡病例中,死于心源性休克3例,死于肺部感染1例;所有患者经有创呼吸机治疗后缺氧状况均有不同程度改善;所有患者治疗24h后、撤机后血浆脑钠肽水平均低于治疗前,差异有统计学意义（P﹤0.05）;其中有效患者（22例）血浆脑钠肽水平降低较无效患者（14例）更为明显,差异有统计学意义（ P﹤0.05）。结论对于重度急性心力衰竭患者,在常规治疗效果不佳或患者已出现昏迷、濒临死亡,及时行气管插管有创呼吸支持,可迅速改善低氧血症和CO2潴留,血浆脑钠肽（ BNP）明显降低,改善心功能,提高生存率。     

重型药物性肝炎患者的护理策略

目的：分析32例重型药物性肝炎患者的临床特征,强化特色护理和整体护理实践,以提高重型肝炎患者的治疗效果及降低病死率,提高患者的生存质量。方法：针对重型肝炎及其并发症的特点,通过内科的综合治疗,结合中医体征鉴别,给予个性化的饮食指导、用药护理和心理护理。结果：32例重型药物性肝炎患者中好转22例（68.8%）,死亡8例（25.0%）,放弃治疗自动出院2例（6.2%）,平均住院时间为28.75d。结论：重型药物性肝炎患者的个性化饮食指导,体现了中医学同病异治、同病异食的理念,特色护理充实了整体护理内涵,对提高重型药物性肝炎患者的存活率和康复具有临床指导意义。     

改良早期预警评分对重症胰腺炎患者预后的预测价值研究

目的探讨改良早期预警评分(MEWS)应用于重症胰腺炎(SAP)患者预后预测的价值和可行性。方法 63例患者按临床结果分为存活组42例和死亡组21例。以确诊为SAP时作为观察起点,同时采集相关数据,对每位患者分别进行MEWS及APACHE-O评分;以1个月后作为观察终点,比较2种评分系统对预后的预测价值。结果 存活组MEWS和APACHE-O评分均低于死亡组,差异均有统计学意义(P<0.05和P<0.01)。2种评分系统均以死亡为预测指标,MEWS评分界值为7分,灵敏度(Sen)为76.19%,特异度(Spe)为85.71%,ROC曲线下面积Az=0.8741,U=8.3958,P=0.0000,均有较强的预测价值。APACHE-O评分界值为21分,Sen为85.71%,Spe为88.10%;ROC曲线下面积Az=0.9138,U=11.2608,P=0.0000。结论 MEWS和APACHE-O评分对SAP患者预后具有同等预测价值,但MEWS评分系统结构简单,获取数据方便,既省时又节省费用,可用于对SAP患者预后的预测。     

Clinical pharmacokinetics of chlordiazepoxide in patients with alcoholic hepatitis

Summary The clearance of chlordiazepoxide from the systemic circulation was studied in 20 subjects which included 15 patients with alcoholic hepatitis and 5 normal volunteers. The half-life for the appearance of the drug in the systemic circulation was found to increase exponentially with age (r=0.73, P<0.0005) and was independent of the presence of alcoholic hepatitis. The metabolic clearance of chlordiazepoxide was significantly lower in the patients than in the normal subjects (7.6 compared to 13.8 ml/kg-h, P<0.005). Linear regression analysis revealed a significant correlation between clearance and albumin (r=0.77, P<0.00005). However, the predictive value of this relationship was shown to be minimal. Multiple regression analysis produced only a slight improvement in the correlation when both albumin and lactate dehydrogenase were used as variables (r=0.83, P<0.00005). In six of the patients, a second clearance study was conducted three weeks following their initial one. All repeat subjects showed improvement both clinically and as reflected by their laboratory tests for liver injury, but there was not a significant change in their clearance of chlordiazepoxide. Multiple regression analysis of the clearance data on the initial and repeat subjects showed a significant correlation between clearance and the variables age, albumin, and lactate dehydrogenase (r=0.91, P<0.0025). This relationship suggests that over a short period of time (where age can be considered constant) changes in albumin and lactate dehydrogenase could be potentially useful in predicting clearance changes in a single individual.     

胸主动脉瘤及主动脉夹层患者住院死亡危险因素分析

目的 探讨胸主动脉瘤及主动脉夹层(TAA/AD)患者住院死亡危险因素.方法 回顾性分析105例TAA/AD患者术前主动脉瘤壁破裂及限期手术患者的临床资料.结果 105例中,9例死亡,均为主动脉瘤壁破裂患者.其中的8例累及升主动脉.死亡原因与处于疾病急性期、术前心功能较差、合并主动脉夹层、较高术前肌酐水平以及累及主动脉弓三分支密切相关(P<0.01或P<0.05).结论 TAA/AD破裂与累及升主动脉和急性期有关,而术前较差心功能、合并主动脉夹层、较高肌酐水平及累及主动脉弓三分支是手术死亡的危险因素.     

The importance of in-hospital statin therapy for patients with acute coronary syndromes

Starting lipid-lowering therapy in the hospital, especially with statins, has become an important component in the management of patients with acute coronary syndromes (ACS). It improves outcomes and increases patient motivation and long-term adherence. In addition, discontinuation of statin therapy in patients with ACS after hospital admission is associated with an increased risk of adverse outcomes. Recent non-ST elevation ACS guidelines recommend beginning statin therapy, along with dietary intervention, in patients whose low-density lipoprotein cholesterol levels exceed 130 mg/dl within 24-96 hours after hospital admission. Various strategies have been developed to aid in the implementation of in-hospital lipid-lowering therapy. Pharmacists can play a valuable role in optimizing drug therapy for dyslipidemia and ensuring long-term adherence.