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读书笔记 20090124 最近也开始看一些中文的重症书籍了,当然也包括译著类的;除了之前介绍过的《内科会诊病例精粹》外,还读到南京邱海波教授主编的《ICU主治医师手册》.当然铁架也作为编者参加了本书《深静脉血栓栓塞》一章的编写,六合彩特码,但手机因为当时身到国外,全书一直没有看到.这次看完全书,铁架觉得本书非常非常值得向大家推荐.书中有关急性肺损伤和ARDS(含机械通气)的相关章节基本都手机邱教授及其团队完成的,不夸张的说这些内容手机铁架迄今能看到的对ALI/ARDS发病机理,治疗策略最为系统,清晰,明确的阐释;此外像李维勤教授撰写的重症胰腺炎一章也手机非常令人激赏.本书的编写也有一个特点,就手机每一章之前都有一个系统综述性质的导言,为读者整体把握打下基础,个人觉得铁架写的那一章的导言还手机比较好的,掉头发,记得当初也费了不少功夫. 读书不断的好处就手机肯德基永远知道还有那么多专业知识肯德基还没有看到. 1. 比如今天又看到自己漏掉了大名鼎鼎的ARDSNET的2008年11月的研究发现:Excessive tidal volume from breath stacking during lung-protective ventilation for acute lung injury* [Clinical Investigations],这回手机个新名词"breath stacking", 按照FREE DIRECTIONARY的翻译手机:in artificial respiration, incomplete expiration can result in residual air adding to the volume of the next inspiration with eventual over inflation of the lungs(人工通气时,呼气不全导致的残余气体叠加到下一次吸气中,最终造成肺部的过度充气).因此可以翻译成"呼吸堆积、重叠",看起来这手机产生AUTOPEEP的原因之一.那么上面的研究就发现了ARDS的小潮气量通气策略造成breath stacking的发生率显著增加,最终导致实际潮气量大于设定的潮气量.看来小潮气量通气的确切执行除了以前提到的医护人员的依从性之外,这回来自患者自身的生理机制也到"抵抗"小潮气量通气...... 2. 美国心脏协会与美国卒中协会的:动脉瘤性蛛网膜下腔出血的最新治疗指南:New Guidelines on Management of Aneurysmal Subarachnoid Hemorrhage January 22, 2009 m New guidelines on the management of aneurysmal subarachnoid hemorrhage (aSAH) have been released by the American Heart Association/American Stroke Association. Among recommendations based on newly available evidence are that these patients be treated at high-volume centers where endovascular interventions as well as neurosurgical services are available. Guideline authors also caution that despite having generally among the most dramatic presentations in medicine,百家乐, these hemorrhages can present as a milder sentinel headache, and aSAH should be considered in the differential diagnosis of all patients with new headache. Joshua B. Bederson MD, professor and chair of the department of neurosurgery at Mount Sinai Medical Center, in New York, and chair of the writing group for the new guidelines, told Medscape Neurology & Neurosurgery that aSAH is a complex process, from the initial bleed to the devastating delayed effects of rupture. "What has changed over the past 15 or 16 years is a gradual improvement in understanding of many of the separate processes that constitute the disease, as well as the evolution of some new technologies such as endovascular treatment of aneurysms that were really just beginning at the time of the first guidelines," Dr. Bederson said in an interview. The guidelines are published online January 22 in Stroke. Improving Outcomes by Many Paths Mortality associated with aSAH is high, about 45% in the first 30 days after a rupture, Dr. Bederson said. Still, he notes, "The majority of aneurysms do not rupture, and as much as 1% of the population dies of old age with a small, unruptured aneurysm." When they do rupture, the focus of treatment has to be on both prevention of rebleeding and management of the pathological adverse effects that the bleed has in the brain. However, he said, "We still have very few treatments for the hit that the brain takes during the first seconds after the hemorrhage. Most of our progress has been in secondary things like preventing the aneurysm from rebleeding, which can occur in 20% of patients in the first 2 weeks." The last guidelines document was released in 1994, and 1 of the main changes since then has been the development of endovascular approaches to obliteration of aneurysms. Development since that time of the subspecialty of neurocritical care, with its own fellowships and certification, may also have improved outcomes, Dr. Bederson noted. "The current standard of practice calls for microsurgical clipping or endovascular coiling of the aneurysm neck whenever possible," the writing group concludes. "Treatment morbidity is determined by numerous factors, including patient, aneurysm, and institutional factors. Favorable outcomes are more likely in institutions that treat high volumes of patients with SAH, in institutions that offer endovascular services, and in selected patients whose aneurysms are coiled rather than clipped." Other major conclusions in the new guidelines include: SAH is frequently misdiagnosed, in up to 12% of cases. For the initial evaluation of headache, CT scanning for suspected SAH is "strongly recommended," followed by lumbar puncture if the CT is negative. A standard management protocol for the evaluation of patients with headaches and other symptoms that may potentially relate to SAH does not currently exist and should be developed. Early vs later treatment of the aneurysm reduces the risk for rebleeding after SAH, and so early surgery is "reasonable and probably indicated in the majority of cases," the authors write. Medical measures to prevent rebleeding include blood-pressure monitoring and control and bed rest, although these should be part of a broader strategy with more definitive measures. A short course of antifibrinolytics may be considered prior to definitive treatment. To reduce poor outcomes associated with vasospasm, the authors "strongly recommend" use of oral nimodipine. The value of other calcium antagonists remains uncertain, they note. Treatment begins with early management of the ruptured aneurysm, they add; "in most cases maintaining normal circulating blood volume and avoiding hypovolemia is probably indicated." Another "reasonable" approach to symptomatic vasospasm is volume expansion with induction of hypertension and hemodilution, so-called "triple-H therapy (注:即hypervolemia, hypertension和hemodilution)," the authors note. "Alternatively,曾道人, cerebral angioplasty and/or selective intra-arterial vasodilator therapy may also be reasonable, either following, or together with, or in the place of, triple-H therapy, depending on the clinical scenario." The relationship between hypertension and aSAH is "uncertain," they conclude, but management of blood pressure to prevent other clinical problems is recommended. Quitting smoking is "reasonable," they note,皇冠开户, "although the evidence for this association is indirect." Screening for unruptured aneurysms in high-risk populations is of "uncertain value," they conclude. Noninvasive imaging may be used for such screening, "but catheter angiography remains the 'gold standard' when it is clinically imperative to know if an aneurysm exists." Other recommendations in the document focus on the management of hydrocephalus, hyponatremia, and volume contractions, as well as seizures. The management of aSAH is so complex that "people have really been clamoring for recommendations or guidelines," Dr. Bederson said. The final document is large, with over 85 pages and more than 400 references, but basically summarizes the current literature into recommendations on each of the complex processes that run their separate course after aSAH. "Even if there isn't 1 major new earthshaking change, putting it all together for the practitioner may be the most valuable part of this," he said...... 3. 来自美国医学杂志(American journal of medicine)的综述:糖尿病性心脏病变(Diabetic Cardiomyopathy: Insights into Pathogenesis, Diagnostic Challenges, and Therapeutic Options) Abstract: Diabetic cardiomyopathy is the presence of myocardial dysfunction in the absence of coronary artery disease and hypertension. Hyperglycemia seems to be central to the pathogenesis of diabetic cardiomyopathy and to trigger a series of maladaptive stimuli that result in myocardial fibrosis and collagen deposition. These processes are thought to be responsible for altered myocardial relaxation characteristics and manifest as diastolic dysfunction on imaging. Sophisticated imaging technologies also have permitted the detection of subtle systolic dysfunction in the diabetic myocardium. In the early stages, these changes appear reversible with tight metabolic control,安全套的用法, but as the pathologic processes become organized, the changes are irreversible and contribute to an excess risk of heart failure among diabetic patients independently of common comorbidities, such as coronary artery disease and hypertension. Therapeutic agents specifically targeting processes that lead to these pathophysiologic changes are in the early stages of development. Although glycemic control and early administration of neurohormonal antagonists remain the cornerstones of therapeutic approaches, newer treatment targets are currently being explored. 4. 来自华尔街日报卫生版对中国医改方案通过的报道: 5. 关于心肺复苏患者低温治疗的改善神经功能与生活质量,但不能改善预后:The impact of therapeutic hypothermia on neurological function and quality of life after cardiac arrest. AIMS: To assess the impact of therapeutic hypothermia on cognitive function and quality of life in comatose survivors of out of Hospital Cardiac arrest (OHCA). METHODS: We prospectively studied comatose survivors of OHCA consecutively admitted in a 4-year period. Therapeutic hypothermia was implemented in the last 2-year period, intervention period (n=79), and this group was compared to patients admitted the 2 previous years, control period (n=77). We assessed Cerebral Performance Category (CPC), survival, Mini Mental State Examination (MMSE) and self-rated quality of life (SF-36) 6 months after OHCA in the subgroup with VF/VT as initial rhythm. RESULTS: CPC in patients alive at hospital discharge was significantly better in the intervention period with a CPC of 1-2 in 97% vs. 71% in the control period, p=0.003, corresponding to an adjusted odds ratio of a favourable cerebral outcome of 17, p=0.01. No significant differences were found in long-term survival (57% vs. 56% alive at 30 months), MMSE, or SF-36. Therapeutic hypothermia (hazard ratio: 0.15, p=0.007) and bystander CPR (hazard ratio 0.19, p=0.002) were significantly related to survival in the intervention period. CONCLUSION: CPC at discharge from hospital was significantly improved following implementation of therapeutic hypothermia in comatose patients resuscitated from OCHA with VF/VT. However, significant improvement in survival, cognitive status or quality of life could not be detected at long-term follow-up(但手机!长期随访并未发现治疗性低体温能显著改善生存率,认知能力... (责任编辑：admin) |