血流动力学参数与脓毒症休克患者容量反应性的预测及相关性分析

目的 探讨容量负荷试验前后脓毒症休克患者血流动力学参数的变化及对患者发生容量反应的预测价值。方法 选取脓毒症休克患者 98 例进行临床研究,根据补液治疗前后患者的每搏输出量变化值(ΔSV)分为容量负荷阳性组(ΔSV≥15% )53 例、容量负荷阴性组(ΔSV<15% )45 例,对比两组患者容量负荷试验前后脉搏指数连续心 输出量( pulse-indicated continuous cardiac output,PICCO)、超声心动图相关指标,并采用受试者工作曲线( receiveroperating curve,ROC)分析具有统计学意义的指标对于脓毒症休克患者发生容量负荷试验反应性的价值,采用Logistics 回归模型分析各项参数与容量负荷试验反应的关系。 结果 在容量负荷试验前,两组患者心排量( cardiacoutput,CO)、心脏指数( cardiac index,CI)、每搏输出量变异量( stroke volume variation,SVV)、中心静脉压( centralvenous pressure,CVP)、心率(heart rate, HR)测定值比较,差异均无统计学意义(P>0. 05);试验后,容量负荷阳性组CO、CI、CVP 测定值均高于容量负荷阴性组(P<0. 05),HR、SVV 均低于容量负荷阴性组(P<0. 05)。 容量负荷试验前,两组患者左室流出道(left ventricular outflow tract, LVOT)内径时间积分(VTI)峰值流速呼吸变异度、VEpeak 测定值比较,差异均无统计学意义(P>0. 05);试验后,容量负荷阳性组 LVOT VTI 测定值高于容量负荷阴性组(P<0. 05),LVOT 峰值流速呼吸变异度低于容量负荷阴性组(P<0. 05);ROC 曲线结果显示,HR、CO、CI、CVP、SVV、LVOT 峰值流速呼吸变异度、LVOT VTI 各项指标预测容量负荷反应阳性的曲线下面积(area under the curve, AUC)分别为 0. 515、0. 560、0. 556、0. 499、0. 898、0. 912、0. 922;Logistic 回归模型结果显示,APACHEⅡ评分越高、SOFA 评分越高、CO 越低、CI 越低、CVP 越低、SVV 越高、LVOT VTI 越低、LVOT 峰值流速呼吸变异度越大,是脓毒症休克患者容量负荷试验阴性的独立危险因素(P<0. 05)。 结论 密切监测脓毒症休克患者的相关血流动力学参数,对于预测患者容量负荷反应性具有临床价值,可以指导患者临床液体复苏。     

Acute Kidney Injury in Patients with Sepsis and Septic Shock: Risk Factors and Clinical Outcomes

Purpose

The aim of this study was to investigate clinical characteristics and risk factors of acute kidney injury (AKI) in patients with sepsis and septic shock. Additionally, we explored whether the severity of AKI affects on the clinical outcomes.

Materials and Methods

Data were collected retrospectively in a single center. Among 5680 patients who visited emergency department from January to December 2010, 992 patients with sepsis and septic shock were enrolled. Patients were divided into two groups, patients who developed AKI or not, to compare the baseline characteristics, and laboratory and physiologic data. Patients with AKI were subdivided according to its stages for survival analysis.

Results

AKI was developed in 57.7% of patients. Multivariable logistic regression analysis revealed that development of septic AKI was associated with older age, pre-existing chronic kidney disease, use of angiotensin converting enzyme inhibitor or angiotensin receptor blocker, presence of shock, positive blood culture results, and low white blood cell and platelet counts. Hospital mortality was higher in AKI group. Crude Kaplan-Meier survival curves demonstrated reduced 30-day survival rate was significantly associated with the severity of acute kidney injury.

Conclusion

The development of septic AKI was associated with poor clinical outcomes. Furthermore, the severity of AKI was associated with increased mortality.     

PCT、CRP动力学评估脓毒血症预后及诊断意义的研究

目的 观察血清降钙素原(PCT)、C反应蛋白(CRP)及其动力学变化,评估其在严重脓毒症/感染性休克患者的诊断及预后价值.方法 本研究采用回顾性分析方法,2014年9月1日至2016年4月30日选择184例ICU中被诊断为严重脓毒症/感染性休克疾病患者,检测入院时血清PCT、CRP水平和治疗后第2,第3和第5天的PCT、CRP水平.结果 通过△PCT、△CRP评估PCT、CRP的动力学在存活者与死亡组中有显著性统计学意(△PCT2/0,P=0.0001;△PCT3/0,P=0.0001;△PCT5/0,P=0.0001;△CRP2/0,P=0.0069;△CRP3/0,P=0.0001;△CRP5/0,P=0.0001),在严重脓毒症和感染性休克组中也存在显著差异(PCT5,P=0.007;△PCT5/0,P=0.007).受试者工作特征曲线(ROC)模型显示,△PCT3/0(AUC=0.721)、△PCT5/0(AUC=0.77)、△CRP5/0(AUC=0.766)水平判断严重脓毒症/感染性休克患者预后有较好的临床意义.△PCT5/0 (0.619)对严重脓毒症或感染性休克有一定的辅助诊断效果,其在ROC曲线上灵敏度、特异性均较高的临界点为0.624,所以,以第5天的血清△PCT5/0水平＞0.624可作为预测感染性休克的临界点.结论 血清中PCT、CRP对严重脓毒症/感染性休克早期有较好的临床诊断及预后价值,其动力学研究可以提高对严重脓毒症/感染性休克诊断及预后评估的敏感性及准确性.     

Hypoalbuminemia,Low Base Excess Values,and Tachypnea Predict 28-Day Mortality in Severe Sepsis and Septic Shock Patients in the Emergency Department

PurposeThe objective of this study was to develop a new nomogram that can predict 28-day mortality in severe sepsis and/or septic shock patients using a combination of several biomarkers that are inexpensive and readily available in most emergency departments, with and without scoring systems.ResultsThe prediction model that included albumin, base excess, and respiratory rate demonstrated the largest area under the receiver operating characteristic curve (AUC) value of 0.8173 [95% confidence interval (CI), 0.7605–0.8741]. The logistic analysis revealed that a conventional scoring system was not associated with 28-day mortality. In the validation set, the discrimination of a newly developed nomogram was also good, with an AUC value of 0.7537 (95% CI, 0.6563–0.8512).ConclusionOur new nomogram is valuable in predicting the 28-day mortality of patients with severe sepsis and/or septic shock in the emergency department. Moreover, our readily available nomogram is superior to conventional scoring systems in predicting mortality.     

Assessment of Neutrophil Function in Patients with Septic Shock: Comparison of Methods

Patients with septic shock are shown to have decreased neutrophil phagocytic function by multiple assays, and their assessment by whole-blood assays (fluorescence-activated cell sorter analysis) correlates with assays requiring isolated neutrophils (microscopic and spectrophotometric assays). For patients with similar underlying conditions but without septic shock, this correlation does not occur.     

感染性休克患者CRP/ALB比值对预测急性呼吸窘迫综合征的临床价值

目的 探讨感染性休克患者血清C反应蛋白(C reactive protein,CRP)、白蛋白(albumin,ALB)比值(CRP/ALB)对预测急性呼吸窘迫综合征(acute respiratory distress syndrome,ARDS)的临床价值.方法 回顾性分析2013年1月至2015年5月我院ICU感染性休克患者65例.患者于入ICU后采外周静脉血,检测CRP、ALB,前7d每天进行急性生理功能和慢性健康状况评分系统Ⅱ(acute physiology and chronic health evaluation-Ⅱ,APACHE-Ⅱ),根据7d内是否合并ARDS分成感染性休克组和ARDS组.比较两组CRP、ALB和CRP/ALB,APACHE Ⅱ评分,Spearman相关分析入选时CRP/ALB、APACHE-Ⅱ评分的关系,受试者工作特征(ROC)曲线下面积法检验CRP/ALB的预测效力.结果 感染性休克组与ARDS组患者CRP、ALB含量差异无统计学意义(P＞0.05),而CRP/ALB比值差异具有统计学意义(=5.93,P＜0.05).CRP/ALB和APACHE-Ⅱ预测脓毒症的ROC曲线下面积分别为0.904(95％,CI:0.821 ～0.998),0.748(95％,CI:0.625 ～0.903).CRP/ALB与APACHEⅡ评分呈正相关(r=0.74,P＜0.05).结论 CRP/ALB可预测感染性休克即将发生的ARDS,可能是一个有价值的临床指标,值得进一步研究.     

Anemia as an Independent Predictor of Adverse Cardiac Outcomes in Patients with Atrial Fibrillation

Background: Anemia and echocardiographic systolic and diastolic parameters are useful predictors of cardiovascular outcomes in patients with atrial fibrillation (AF). However, no studies have evaluated the use of anemia for predicting cardiovascular outcome in AF patients when the important echocardiographic parameters are known. Therefore, this study was designed to evaluate whether low hemoglobin is a useful parameter for predicting poor cardiac outcome after adjustment for important echocardiographic parameters in AF patients.Methods: Index beat method was used to measure echocardiographic parameters in 166 patients with persistent AF. Cardiac events were defined as death and hospitalization for heart failure. The association of hemoglobin with adverse cardiac events was assessed by Cox proportional hazards model.Results: The 49 cardiac events identified in this population included 21 deaths and 28 hospitalizations for heart failure during an average follow-up of 20 months (25th-75th percentile: 14-32 months). Multivariable analysis showed that increased left ventricular mass index (LVMI) and decreased body mass index, estimated glomerular filtration rate, and hemoglobin (hazard ratio 0.827; P = 0.015) were independently associated with increased cardiac events. Additionally, tests of a Cox model that included important clinic variables, LVMI, left ventricular ejection fraction, and the ratio of transmitral E-wave velocity to early diastolic mitral annulus velocity showed that including hemoglobin significantly increased value in predicting adverse cardiac events (P = 0.010).Conclusions: Hemoglobin is a useful parameter for predicting adverse cardiac events, and including hemoglobin may improve the prognostic prediction of conventional clinical and echocardiographic parameters in patients with AF.     

Clinical outcome and predictors of mortality in children with sepsis,severe sepsis,and septic shock from Rohtak,Haryana: A prospective observational study

Background:

Information regarding early predictive factors for mortality and morbidity in sepsis is limited from developing countries.

Methods:

A prospective observational study was conducted to determine the clinical outcome and predictors of mortality in children with sepsis, severe sepsis, and septic shock. Children aged 1 month to 14 years admitted to a tertiary care pediatric intensive care unit (PICU) with a diagnosis of sepsis, severe sepsis, or septic shock were enrolled in the study. Hemodynamic and laboratory parameters which discriminate survivors from nonsurvivors were evaluated.

Results:

A total of 50 patients (30 [60%] males) were enrolled in the study, of whom 21 (42%) were discharged (survivors) and rest 29 (58%) expired (nonsurvivor). Median (interquartile range) age of enrolled patients were 18 (6, 60) months. Mortality was not significantly predicted individually by any factor including age (odds ratio [OR] [95% confidence interval [CI]]: 0.96 [0.91-1.01], P = 0.17), duration of PICU stay (OR [95% CI]: 1.18 [0.99-1.25], P = 0.054), time lag to PICU transfer (OR [95% CI]: 1.02 [0.93-1.12], P = 0.63), Pediatric Risk of Mortality (PRISM) score at admission (OR [95% CI]: 0.71 [0.47-1.04], P = 0.07) and number of organ dysfunction (OR [95% CI]: 0.03 [0.01-1.53], P = 0.08).

Conclusion:

Mortality among children with sepsis, severe sepsis, and septic shock were not predicted by any individual factors including the time lag to PICU transfer, duration of PICU stay, presence of multiorgan dysfunction, and PRISM score at admission.     

NGF and HB-EGF: Potential Biomarkers that Reflect the Effects of Fesoterodine in Patients with Overactive Bladder Syndrome

Purpose

To determine whether levels of nerve growth factor (NGF) and heparin-binding epidermal growth factor-like growth factor (HB-EGF) can be used to objectively assess overactive bladder syndrome (OAB) treatment outcome and to evaluate the effects of fixed-dose fesoterodine on OAB symptoms.

Materials and Methods

This study included 124 participants (62 patients with OAB and 62 controls) in Severance Hospital between 2010 and 2012. In patients with OAB, 4 mg fesoterodine was administered once daily. Repeated evaluations of putative biomarker levels, urine creatinine (Cr) levels, and questionnaire responses, including the Overactive Bladder Symptom Score (OABSS) and the Overactive Bladder Questionnaire (OAB q), were performed from baseline to 16 weeks.

Results

Urinary levels of NGF/Cr (OAB: 1.13±0.9 pg/mg; control: 0.5±0.29 pg/mg) and HB-EGF/Cr (OAB: 8.73±6.55 pg/mg; control: 4.45±2.93 pg/mg) were significantly higher in subjects with OAB than in controls (p<0.001). After 16 weeks of fixed-dose fesoterodine treatment, urinary NGF/Cr levels (baseline: 1.13±0.08 pg/mg; 16 weeks: 0.60±0.4 pg/mg; p=0.02) and HB-EGF/Cr levels significantly decreased (baseline: 8.73±6.55 pg/mg; 16 weeks: 4.72±2.69 pg/mg; p=0.03, respectively). Both the OABSS and OAB q scores improved (p<0.001). However, there were no a statistically significant correlations between these urinary markers and symptomatic scores.

Conclusion

Urinary levels of NGF and HB-EGF may be potential biomarkers for evaluating outcome of OAB treatment. Fixed-dose fesoterodine improved OAB symptoms. Future studies are needed to further examine the significance of urinary NGF and HB-EGF levels as therapeutic markers for OAB.     

营养风险筛查和BMI在克罗恩病患者营养评估中的应用

目的 运用营养风险筛查（NRS-2002）和体重指数（BMI）评估克罗恩病患者的营养状况。方法 选取2014年9月~2018年5月重庆医科大学附属第一医院胃肠外科收治的43例克罗恩病患者作为研究对象。运用NRS-2002和BMI对全组患者进行营养状况评估,比较克罗恩病合并肠皮瘘患者和非肠皮瘘患者的营养筛查评分、BMI及血红蛋白计数。结果 43例患者营养风险评分≥3分者21例,发生率48.84%;BMI＜18.5 kg/m2者9例,发生率20.93%。合并肠皮瘘患者营养风险评分≥3分者9例,发生率81.81%;BMI＜18.5 kg/m2者6例,发生率54.55%。非肠皮瘘患者营养风险评分≥3分者12例,发生率37.50%;BMI＜18.5 kg/m2者3例,发生率9.38%。合并肠皮瘘患者营养风险和营养不良的发生率分别为81.81%和37.50%,高于非肠皮瘘患者的54.55%和9.38%,差异有统计学意义（P＜0.05）。43例患者中发生贫血23例,其中合并肠皮瘘7例,非肠皮瘘患者16例,非肠皮瘘患者及肠皮瘘患者之间无统计学差异（P＞0.05）。结论 克罗恩病患者营养风险和营养不良发生率高,克罗恩病合并肠皮瘘患者较非肠皮瘘患者具有更高的营养风险和营养不良发生率。因此应加强围手术期克罗恩病患者的营养支持治疗,尤其是合并肠皮瘘患者。     

Basement Membrane Type IV Collagen and Laminin: An Overview of Their Biology and Value as Fibrosis Biomarkers of Liver Disease

Basement membranes provide structural support to epithelium, endothelium, muscles, fat cells, Schwann cells, and axons. Basement membranes are multifunctional: they modulate cellular behavior, regulate organogenesis, promote tissue repair, form a barrier to filtration and tumor metastasis, bind growth factors, and mediate angiogenesis. All basement membranes contain type IV collagen (Col IV), laminin, nidogen, and perlecan. Col IV and laminin self‐assemble into two independent supramolecular networks that are linked to nidogen and perlecan to form a morphological discernable basement membrane/basal lamina. The triple helical region, 7S domain and NCI domain of Col IV, laminin and laminin fragment P1 have been evaluated as noninvasive fibrosis biomarkers of alcoholic liver disease, viral hepatitis, and nonalcoholic fatty liver disease. Elevated serum Col IV and laminin are related to degrees of fibrosis and severity of hepatitis, and may reflect hepatic basement membrane metabolism. But the serum assays have not been linked to disclosing the anatomical sites and lobular distribution of perisinusoidal basement membrane formation in the liver. Hepatic sinusoids normally lack a basement membrane, although Col IV is a normal matrix component of the space of Disse. In liver disease, laminin deposits in the space of Disse and codistributes with Col IV, forming a perisinusoidal basement membrane. Concomitantly, the sinusoidal endothelium loses its fenestrae and is transformed into vascular type endothelium. These changes lead to capillarization of hepatic sinusoids, a significant pathology that impairs hepatic function. Accordingly, codistribution of Col IV and laminin serves as histochemical marker of perisinusoidal basement membrane formation in liver disease. Anat Rec, 300:1371–1390, 2017. © 2017 Wiley Periodicals, Inc.     

老年急性心肌梗死并心源性休克冠状动脉 介入治疗的临床效果研究

目的 探讨冠状动脉介入治疗老年急性心肌梗死并心源性休克的临床价值。方法 回顾性分析2013年7月~2017年11月在我院接受治疗的155例老年急性心肌梗死并心源性休克患者的临床资料,根据治疗方式分为溶栓组（80例）与介入治疗组（75例）。比较两组患者尿量、心率、左心室射血分数（LVEF）以及血管开通率。结果 治疗后,介入组尿量多于溶栓组,HR值低于溶栓组,差异有统计学意义（P＜0.05）;住院前及出院6个月后,介入组LVEF值均高于溶栓组,差异有统计学意义（P＜0.05）;溶栓组出院6个月后,LVEF值高于出院前,差异有统计学意义（P＜0.05）;介入组出院前后LVEF值对比,差异无统计学意义（P＞0.05）;介入组血管开通率为93.33%,高于溶栓组的77.50%,差异有统计学意义（P＜0.05）。结论 冠状动脉介入为治疗老年急性心肌梗死并心源性休克患者的有效手段,可有效改善血液流变学、尿量,利于心功能恢复。     

Systematic Reviews and Meta-Analyses of Home Telemonitoring Interventions for Patients With Chronic Diseases: A Critical Assessment of Their Methodological Quality

Background

Systematic reviews and meta-analyses of home telemonitoring interventions for patients with chronic diseases have increased over the past decade and become increasingly important to a wide range of clinicians, policy makers, and other health care stakeholders. While a few criticisms about their methodological rigor and synthesis approaches have recently appeared, no formal appraisal of their quality has been conducted yet.

Objective

The primary aim of this critical review was to evaluate the methodology, quality, and reporting characteristics of prior reviews that have investigated the effects of home telemonitoring interventions in the context of chronic diseases.

Methods

Ovid MEDLINE, the Database of Abstract of Reviews of Effects (DARE), and Health Technology Assessment Database (HTA) of the Cochrane Library were electronically searched to find relevant systematic reviews, published between January 1966 and December 2012. Potential reviews were screened and assessed for inclusion independently by three reviewers. Data pertaining to the methods used were extracted from each included review and examined for accuracy by two reviewers. A validated quality assessment instrument, R-AMSTAR, was used as a framework to guide the assessment process.

Results

Twenty-four reviews, nine of which were meta-analyses, were identified from more than 200 citations. The bibliographic search revealed that the number of published reviews has increased substantially over the years in this area and although most reviews focus on studying the effects of home telemonitoring on patients with congestive heart failure, researcher interest has extended to other chronic diseases as well, such as diabetes, hypertension, chronic obstructive pulmonary disease, and asthma. Nevertheless, an important number of these reviews appear to lack optimal scientific rigor due to intrinsic methodological issues. Also, the overall quality of reviews does not appear to have improved over time. While several criteria were met satisfactorily by either all or nearly all reviews, such as the establishment of an a priori design with inclusion and exclusion criteria, use of electronic searches on multiple databases, and reporting of studies characteristics, there were other important areas that needed improvement. Duplicate data extraction, manual searches of highly relevant journals, inclusion of gray and non-English literature, assessment of the methodological quality of included studies and quality of evidence were key methodological procedures that were performed infrequently. Furthermore, certain methodological limitations identified in the synthesis of study results have affected the results and conclusions of some reviews.

Conclusions

Despite the availability of methodological guidelines that can be utilized to guide the proper conduct of systematic reviews and meta-analyses and eliminate potential risks of bias, this knowledge has not yet been fully integrated in the area of home telemonitoring. Further efforts should be made to improve the design, conduct, reporting, and publication of systematic reviews and meta-analyses in this area.