新生儿应激性溃疡的药物治疗

应激性溃疡是新生儿上消化道出血最常见的原因,正确预防和合理治疗应激性溃疡是抢救危重新生儿的一个不可忽视的环节,作者综述近年来新生儿应激性溃疡药物治疗的研究进展,为临床提供参考.     

消化性溃疡病的药物治疗

消化系统中胃溃疡病，是多发病，普遍病分为：(1)H2受体拮抗剂；(2)质子泵抑制剂；(3)胶体铋剂；(4)其他类；(5)抗幽门螺旋杆菌药的抗菌药。治疗消化系统溃疡病的方案为：(1)一般消化性溃疡的治疗；(2)难治性、顽固性消化性溃疡的治疗；(3)联合用药。     

H2受体阻滞剂对应激性溃疡早期干预机制分析

急性应激可引起应激性溃疡已是共识。自2000年以来，我院应用H2受体阻滞剂，对应激性溃疡进行预防性干预治疗，现报告如下。     

4种消化性溃疡药物治疗方案成本-效果分析

本文利用成本-效果分析法选择安全、有效、经济、合理的消化性溃疡药物治疗方案.选择258例消化性溃疡患者以4种不同药物治疗方案随机分组治疗,对治疗效果与成本进行统计比较.现将结果报道如下.     

应用抑酸剂与骨质疏松性骨折关系的Meta分析

背景：3年以上长期使用抑酸剂者是否会增加骨折的风险度,一直以来都是争议的焦点。目的：系统评价使用抑酸剂（包括质子泵抑制剂和H2受体拮抗剂）对骨质疏松性骨折的影响。方法：计算机检索MEDLINE、Cochrane、Embase、CNKI数字图书馆等数据库,并手工检索查找有关研究使用抑酸剂和骨折风险度之间关联性的临床试验研究。由2名评价员独立筛查试验、提取资料和评估方法学质量,采用Cochrane协作网提供的RevMan 5.0软件进行Meta分析。结果与结论：纳入11篇文献进行荟萃分析,3篇为队列研究,5篇为病例-对照研究,3篇为组内病例对照研究。使用质子泵抑制剂对骨折风险度的影响有统计学意义[OR=1.29,95%CI（1.18,1.41）,P〈0.001],而使用H2受体拮抗剂对骨折风险度的影响无统计学意义[OR=1.10,95%CI（0.99,1.23）,P=0.34]。长期使用质子泵抑制剂将使骨折风险度显著增高,该效应对于患骨质疏松症的老年人群尤为明显。     

雷贝拉唑与法莫替丁治疗十二指肠溃疡疗效比较

消化性溃疡的治疗,已从中和胃酸、H2受体拮抗剂发展到质子泵抑制剂（PPI）第二代。经多年临床实践证实,雷贝拉唑作为新一代质子泵抑制剂,由于有独特的药理作用和很好的疗效,已广泛应用于临床。2006年3月-2009年10月我院对需贝拉唑与法莫替丁治疗十二指肠溃疡疗效进行了比较,报告如下。     

H_2受体拮抗剂与质子泵抑制剂预防重症监护病房患者应激性溃疡出血和肺炎发生率的荟萃分析

目的 评价质子泵抑制剂(PPI)及H_2受体拮抗剂(H_2RA)对预防重症患者应激性溃疡出血的有效性及安全性.方法 检索MEDLINE(1966年至2009年3月)、Ebsco、CNKI全文数据库,纳入PPI及H_2RA预防应激性溃疡出血的随机对照试验,由2名研究者独立对纳入试验进行质量评价和资料提取,通过病例选择、病例特征、随机方法、盲法、出血和肺炎的定义6个方面进行评分,讨论并采用RevMan 4.2.2软件进行Meta分析.结果 最终纳入4项临床试验,包括771例患者,Meta分析显示PPI组消化道大出血的发生率较H_2RA组低(2.2%比6.8%),差异有统计学意义[比值比(OR)0.45,95%可信区间(CI)0.21～0.96,P=0.04];PPI组与H_2RA组间医源性肺炎的发生率(10.0%比9.9%,OR 1.03,95%CI 0.63～1.70,P=0.89)及重症监护病房(ICU)病死率(14.5%比14.3%,OR 1.17,95%CI 0.76～1.80,P=0.47)差异无统计学意义.结论 通过现有资料的Meta分析提示PPI较H_2RA对应激性溃疡出血有更好的预防作用,两组间医源性肺炎的发生率及ICU病死率无显著差异.但鉴于目前关于PPI和H_2RA对预防应激性溃疡出血的随机对照研究较少,本次Meta分析总的样本量偏少,并且发表偏倚难以避免,上述分析结果应谨慎对待,有关结论尚需大样本、多中心的随机对照研究证实.     

生长抑素联合H2受体拮抗剂治疗应激性溃疡出血的疗效观察

目的：探讨生长抑素类似物(善宁)与H2受体拮抗剂联合应用治疗应激性溃疡出血的临床疗效。方法：联合应用生长抑素八肽(善宁)及H2受体拮抗剂治疗应激性溃疡出血37例．给予善宁100mg静脉点滴每8h一次,同时给予法莫替丁40mg静脉点滴,每日一次。结果24h、48h、72h．止血率分别为21．6％、29．7％、37．8％,3d总止血率89．2％,无效率10．8％。结论：联合应用生长抑索及H2受体拮抗剂对各种严重应激导致的溃疡大出血有较显著疗效,明显优于单纯应用H2受体拮抗剂。     

H2受体拮抗剂预防应激性溃疡出血的系统评价

目的评价H2受体拮抗剂(H2RA)对预防重危病人应激性溃疡出血(SUB)的有效性及安全性。方法按既定的检索策略,全面检索Cochrane临床对照试验数据库(2006年第4期)、MEDLINE光盘数据库(1980～2006年10月)、EMbase光盘数据库(1984～2006年10月)、中国生物医学文献数据库(1978～2006年10月)、维普中刊数据库(1989～2006年10月)和中文循证医学随机对照试验数据库。手工检索5种相关中文期刊、相关会议论文集及所有检索到试验的参考文献。纳入H2RA预防SUB的随机对照试验。由两位研究者独立地对纳入试验进行质量评价和资料提取,并交叉核对。如有分歧,通过讨论解决。结局指标包括SUB的发生率、医源性肺炎(nosocomial pneumonia,NP)发生率、病死率、药物不良反应的发生率、胃液pH值等指标评价药物预防SUB的效果和安全性。采用RevMan4.2.7软件进行Meta分析。结果共检索到18个可能符合纳入标准的临床试验,其中16个试验共包括2014例病人符合纳入标准,2个试验被排除。纳入试验的方法学质量高低不齐。提取数据后,进行Meta分析或描述性分析。①H2RA能降低SUB的发生率[RR0.39,95%CI(0.28,0.56);P<0.00001,NNT=6],H2RA(P=0.11),不能降低临床大出血的发生率[RR0.51,95%CI(0.17,1.53);P=0.11]。②H2RA与安慰剂相比较,NP发生率差别无统计学意义[RR1.02,95%CI(0.55,1.89);P=0.95]。③H2RA能降低病死率[RR0.68,95%CI(0.52,0.90);P=0.007,NNT=18]。④H2RA的安全性好。⑤药物预防SUB对胃内pH值的影响,由于所纳入的试验在pH值的测量方法、测量时间上的差异,无法提取资料进行合并分析。所有试验均未将住院时间作为观察指标。结论现有的有限证据表明,预防性使用H2RA均能降低SUB发生率、病死率但不能降低临床大出血的发生率。因所发表的临床研究方法学质量普遍不高,存在多种方法学局限性。故应谨慎看待以上结论。今后有必要进一步开展大样本、高质量的临床随机对照试验,为H2RA预防SUB提供更为可靠证据。     

两种治疗方案根除幽门螺杆菌的疗效观察

目的 比较质子泵抑制剂（PPI）与H2受体拮抗剂（H2RA）在根除幽门螺杆菌（Hp）治疗中的疗效。方法 回顾性分析我院2002年3月至2005年5月72例十二指肠球部溃疡患者的临床资料。结果 以PPI为主的三联疗法组Hp根除率为82．35％，以H2RA为主的三联疗法组Hp根除率为60．53％。差异有显著性意义（P〈0．05）。结论 PPI根除Hp的疗效优于H2RA。     

Overuse of stress ulcer prophylaxis in the critical care setting and beyond

Background

Patients admitted to the intensive care unit (ICU) are susceptible to stress ulcers. We hypothesize that despite recommendations, stress ulcer prophylaxis (SUP) is still overused in the ICU and often continued after resolution of risk factors for bleeding.

Methods

We retrospectively studied all ICU admissions for 4 months. Risk factors for stress ulcer bleeding were collected. Patients were categorized into 4 groups: (1) ≥1 major risk factor; (2) ≥1 minor risk factors; (3) no risk factors; (4) preadmission use of acid-suppressive medication. The rate of SUP was calculated by group during ICU stay, on transfer from the ICU, and at hospital discharge.

Results

Two hundred ten patients were studied. Of all the ICU admissions, 87.1% received SUP. Among patients with no risk factors, 68.1% were placed on prophylaxis on ICU admission; 60.4% continued on treatment upon transfer from the ICU; 31.0% were discharged home on an agent without a new indication.

Conclusions

Although judicious use of SUP in high-risk patients can decrease the incidence of gastrointestinal bleeding, inappropriate use may increase drug reactions, unnecessary hospital costs, and personal monetary burden. Our findings argue for improvement measures to reduce initial inpatient overuse of SUP and to prompt discontinuation before hospital discharge.     

The role of proton pump inhibitors in the treatment of heartburn during pregnancy

PURPOSE: To review the problem of heartburn in gravid women, discuss the present treatment options, and examine the use of proton pump inhibitors (PPIs) as one of the treatment options for moderate to severe heartburn. DATA SOURCES: Extensive review of worldwide scientific literature on the use and safety of PPIs during pregnancy and heartburn during pregnancy. CONCLUSIONS: Preliminary information indicates that use of PPIs during pregnancy is safe for both the fetus and the woman and that obstetrical practitioners are using them more frequently. Randomized controlled trials are needed to examine the efficacy of PPIs to treat heartburn during pregnancy, especially as they are compared to histamine(2) receptor antagonists. IMPLICATIONS FOR PRACTICE: Heartburn during pregnancy is at risk for being undertreated, given that delivery is the cure. As PPIs are more widely used by women, questions will arise regarding their use in the first trimester as well as throughout pregnancy. This article brings nurse practitioners up to date on the safety of PPIs through the literature review and suggests various treatment options that can be discussed with the patient.     

埃索美拉唑预防机械通气患者应激性溃疡的疗效观察

目的：对比埃索美拉唑和奥美拉唑预防机械通气患者应激性溃疡的效果。方法：按照随机数字表随机将214例患者分为埃索美拉唑组（108例）、奥美拉唑组（106例）。观察治疗后一周内2组应激性溃疡的发生率。结果：埃索美拉唑组和奥美拉唑组的SU发生率分别为4.63%、12.26%,2组差异有统计学意义（P〈0.05）。结论：埃索美拉唑较奥美拉唑能更有效预防机械通气患者应激性溃疡的发生。     

The effect of an integrated stress management program on the psychologic and physiologic stress reactions of peptic ulcer in Korea

The purpose of this study was to identify the effects of an integrated stress management program on symptoms of stress and ulcer healing in a sample of Koreans at a major medical center in Seoul, Korea. The study employed an experimental design with two treatment groups. One treatment group (n=23) participated in an integrated stress management program that consisted of seven 1h sessions over a 4-week period. A second treatment group (n=24) was only given a tape on progressive muscle relaxation. Data were collected over a 4-month period on 47 subjects. Participants were randomly assigned to the two treatment groups. Symptoms of stress were measured by the symptoms of stress scale (Kogan, Self-regulation on Stress Reaction by Biofeedback, Korean Psychiatric Academic Society, Korea) translated into Korean. Stage of ulcer healing was evaluated by a physician using an endoscope. Physiologic stress reactions were measured by biofeedback equipment. The integrated stress management program treatment group reported significantly lower stress symptom scores than the progressive muscle relaxation-only group (t=3.66, P<0.001). The integrated stress management group also demonstrated a greater improvement in ulcer healing than the progressive muscle relaxation group (t=1.95, P<0.05).The integrated stress management program was more effective in decreasing self-reported stress symptoms and resulted in a more significant ulcer healing than the progressive muscle relaxation treatment.     

文拉法辛与阿米替林治疗抑郁症不良反应的Meta分析

目的 评价文拉法辛与阿米替林治疗抑郁症出现不良反应的差异性.方法 以文拉法辛、阿米替林、抑郁症为关键词,检索cnki数字图书馆、万方数据库收集符合入组条件的相关文献,对纳入研究文献不良反应的统计结果进行Meta分析.结果 共纳入17篇研究文献,17篇文献中共发生不良反应1810例次,剔除不良反应发生率在1.0%以下者,共收集1730例次,其中文拉法辛治疗565例次(32.66%),阿米替林治疗1165例次(67.34%);经Meta分析显示,文拉法辛出现口干、头痛头晕、视力模糊、便秘、震颤、乏力、性功能障碍等不良反应的发生率均显著低于阿米替林(P＜0.05或0.01),而嗜睡、心动过速、失眠、恶心呕吐、食欲减退、体重增加、肝功能异常、心电图异常、心悸等不良反应发生率与阿米替林差异均无显著性(P＞0.05).结论 文拉法辛治疗抑郁症总体不良反应发生率显著低于阿米替林,安全性更高,依从性更好.     

索拉非尼治疗肝细胞肝癌不良反应的护理

目的探讨索拉非尼治疗中晚期肝细胞肝癌的不良反应及护理措施。方法回顾性分析26例中晚期肝细胞肝癌患者服用索拉非尼期间出现的不良反应。结果 26例患者发生的不良反应有手足综合征(57.7%)、腹泻(53.8%)、高血压(50.0%)、皮疹(46.2%)、疲乏(46.2%)等,一般为1～2级,仅1例患者出现3级手足综合征,予减半量治疗,所有患者经护理干预后不良反应均有所好转。结论索拉非尼作为分子靶向治疗新药,服药期间应严密观察患者的不良反应,及时采取有效的护理干预,从而提高治疗疗效和患者的生活质量。     

Proton pump inhibitors versus histamine-2 receptor blockers for stress ulcer prophylaxis in patients with sepsis: a retrospective cohort study

ObjectiveWe aimed to compare the efficacy and risks of proton pump inhibitor (PPI) versus histamine-2 receptor blocker (H2B) use for stress ulcer prophylaxis (SUP) in critically ill patients with sepsis and risk factors for gastrointestinal bleeding (GIB).MethodsIn this retrospective cohort study, we used the Medical Information Mart for Intensive Care III Clinical Database to identify critically ill adult patients with sepsis who had at least one risk factor for GIB and received either an H2B or PPI for ≥48 hours. Propensity score matching (PSM) was conducted to balance baseline characteristics. The primary outcome was in-hospital mortality.ResultsAfter 1:1 PSM, 1056 patients were included in the H2B and PPI groups. The PPI group had higher in-hospital mortality (23.8% vs. 17.5%), GIB (8.9% vs. 1.6%), and pneumonia (49.6% vs. 41.6%) rates than the H2B group. After adjusting for risk factors of GIB and pneumonia, PPI use was associated with a 1.28-times increased risk of in-hospital mortality, 5.89-times increased risk of GIB, and 1.32-times increased risk of pneumonia.ConclusionsAmong critically ill adult patients with sepsis at risk for GIB, SUP with PPIs was associated with higher in-hospital mortality and higher risk of GIB and pneumonia than H2Bs.     

Appropriate choice of proton pump inhibitor therapy in the prevention and management of NSAID-related gastrointestinal damage

Non-steroidal anti-inflammatory drugs (NSAIDs) are associated with gastrointestinal adverse effects, ranging from dyspepsia and peptic ulcer disease to more serious complications such as haemorrhage or perforation. NSAID-induced gastrointestinal toxicity is a significant medical problem worldwide. Misoprostol is effective in reducing NSAID-induced mucosal damage, but patient compliance is limited by poor tolerance. Histamine receptor antagonists are relatively effective against duodenal ulcers but offer no significant protection against gastric ulcers. Proton pump inhibitors (PPIs), such as pantoprazole, omeprazole and lansoprazole, have been shown to be effective in preventing the development of gastric and duodenal ulcers in high-risk patients taking NSAIDs. PPI therapy is also beneficial in healing NSAID-induced ulcers and preventing their recurrence in patients requiring ongoing NSAID therapy. PPIs have an excellent safety profile, and pantoprazole--with its low potential for drug-drug interactions--is particularly suitable for administration to elderly patients who often require concomitant treatment with other medications.