重症监护病房镇静治疗的应用2.ppt

,1.共同进食蔬菜和水果可使孕妇上呼吸道 感染风险降低,【据Public Health Nutr.2010年2月报道】题：进食蔬菜和水果与孕妇上呼吸道感染风险间的关系（作者：Li L Werler MM）美国波士顿大学公共卫生学院流行病学系Li L与Werler MM开展此次研究，旨在评估在妊娠期间进食蔬菜和水果与上呼吸道感染（URTI)）发生率之间的关系。研究纳入北美妇女1034例，让其回顾其在妊娠前6个月进食蔬菜和水果与在妊娠前半期时结果显示，摄入总的水果和蔬菜量的最高四分位（中位量8.54servings/d）vs.最低四分位（中位量1.91 servings/d）的妇女，在随访5个月时发生URTI的校正HR 为0.74，随访3个月时为0.61。在随访3个月时摄入的水果和蔬菜与URTI风险降低呈剂量相关，但随访5个月时无此相关性。未发现单独进食蔬菜或水果与5个月或3个月时URTI风险的关系。URTI的发生率。用Cox比例危害模型计算多变量校正危害（HR）。,1.共同进食蔬菜和水果可使孕妇上呼吸道 感染风险降低,研究表明，妇女进食蔬菜和水果较多可中度降低妊娠期间URTI的风险，这种获益似乎来源于蔬菜与水果共同进食而非单一进食。,1.共同进食蔬菜和水果可使孕妇上呼吸道 感染风险降低,OBJECTIVE:The present study evaluated the association between fruit and vegetable intake and the incidence of upper respiratory tract infection(URTI)during pregnancy.DESIGN:In a cohort of 1034 North American women,each subject was asked retrospectively about their fruit and vegetable intake during the six months before the pregnancy and their occurrences of URTI during the first half of pregnancy.Multivariable-adjusted hazard ratios(HR)were calculated with Cox proportional hazards models.,1.共同进食蔬菜和水果可使孕妇上呼吸道 感染风险降低,RESULTS:The adjusted HR of URTI for women in the highest quartile(median 8.54 servings/d)v.the lowest quartile(median 1.91 servings/d)of total fruit and vegetable intake was 0.74(95%CI 0.53,1.05)for the 5-month follow-up period and 0.61(95%CI 0.39,0.97)for the 3-month follow-up period,respectively.A dose-related reduction of URTI risk according to quartile of intake was found in the 3month(P for trend=0.03)but not the 5-month follow-up.No association was found between either fruit or vegetable intake alone in relation to the 5-month or the 3-month risk of URTI.CONCLUSIONS:Women who consume more fruits and vegetables have a moderate reduction in risk of URTI during pregnancy,and this benefit appears to be derived from both fruits and vegetables instead of either alone.,2.降钙素原水平可预测社区获得性肺炎患者 的菌血症水平,BACKGROUND:Guidelines recommend blood culture sampling from hospitalized patients with suspected community-acquired pneumonia(CAP).However,the yield of true positive results is low.We investigated the benefit of procalcitonin(PCT)on admission to predict blood culture positivity in CAP.METHODS:This is a prospective cohort study with a derivation and validation set including a total of 925 CAP patients with blood culture sampling upon hospital admission.RESULTS:A total of 73 patients(7.9%)had true bacteremia(43/463 in the derivation cohort,30/462 in the validation cohort).The area under the receiver-operating-characteristics curve of PCT in the derivation and validation cohort were similar(0.83(95%CI 0.78-0.89),0.79(95%CI 0.72-0.88).Overall,PCT was a significantly better predictor for blood culture positivity as compared to white blood cell count,C-reactive protein and other clinical parameters.,2.降钙素原水平可预测社区获得性肺炎患者 的菌血症水平,In multivariate regression analysis,only antibiotic pretreatment(adjusted OR 0.25,p0.05)and PCT serum levels(adjusted OR 3.72,p0.001)were independent predictors.Overall,a PCT cut-off of 0.1mug/L would allow reducing the total number of blood cultures by 12.6%and still identifying 99%of the positive blood cultures.Similarly,0.25mug/L and 0.5mug/L cut offs would allow reducing blood cultures by 37%and 52%and still identifying 96%and 88%of positive blood cultures.CONCLUSION:Initial PCT level accurately predicted blood culture positivity in CAP patients.PCT measurement has the potential to reduce the number of drawn blood cultures in the Emergency Department and to implement a more targeted allocation of limited health care resources.,2.降钙素原水平可预测社区获得性肺炎患者 的菌血症水平,据【Chest2010年3月报道】题：降钙素原水平可预测社区获得性肺炎患者的菌血症水平：一项前瞻性队列研究（作者：Mller F等）指南建议，怀疑患有社区获得性肺炎（CAP）的住院患者应采集血样进行血培养。然而，血培养结果的真阳性率较低。因此，瑞士Basel大学医院Mller F等开展此前瞻性队列研究，旨在探讨接诊时血降钙素原水平用于预测CAP患者血培养阳性的价值。该研究共入组了925例怀疑患有CAP的住院患者，入院时均立即进行血培养检测血降钙素原水平。结果显示，共73例（7.9%）患者有菌血症。与白细胞计数、C反应蛋白以及其他临床指标相比，降钙素原水平是一个更好的血培养阳性预测因子。多因素回归分析显示，只有入院接受治疗前应用抗菌药物（校正OR 为0.25）和血清降钙素原水平（校正OR为3.72）为独立预测因子。,2.降钙素原水平可预测社区获得性肺炎患者 的菌血症水平,降钙素原水平切点为0.1g/L时可减少血培养总数达12.6%，而且采用此切点仍可发现99%的阳性血培养。当降钙素原水平切点为0.25g/L和0.5g/L时可分别减少血培养总数37%和5 2%，而且仍可分别发现96%和88%的阳性血培养。研究表明，初始降钙素原水平可准确预测社区获得性肺炎患者是否血培养阳性。检测降钙素原可减少急诊采血进行血培养的次数，有利于合理分配有效的医疗资源。,3.儿童接种肺炎链球菌疫苗后急性下呼吸道 感染住院风险增加,Background：Australian Indigenous children are the only population worldwide to receive the 7-valent pneumococcal conjugate vaccine(7vPCV)at 2,4,and 6 months of age and the 23-valent pneumococcal polysaccharide vaccine(23vPPV)at 18 months of age.We evaluated this programs effectiveness in reducing the risk of hospitalization for acute lower respiratory tract infection(ALRI)in Northern Territory(NT)Indigenous children aged 5-23 months.Methods.We conducted a retrospective cohort study involving all NT Indigenous children born from 1 April 2000 through 31 October 2004.Person-time at-risk after 0,1,2,and 3 doses of 7vPCV and after 0 and 1 dose of 23vPPV and the number of ALRI following each dose were used to calculate dose-specific rates of ALRI for children 5-23 months of age.,Rates were compared using Cox proportional hazards models,with the number of doses of each vaccine serving as time-dependent covariates.Results.There were 5482 children and 8315 child-years at risk,with 2174 episodes of ALRI requiring hospitalization(overall incidence,261 episodes per 1000 child-years at risk).Elevated risk of ALRI requiring hospitalization was observed after each dose of the 7vPCV vaccine,compared with that for children who received no doses,and an even greater elevation in risk was observed after each dose of the 23vPPV(adjusted hazard ratio HR vs no dose,1.39;95%confidence interval CI,1.12-1.71;Formula:see text).Risk was highest among children vaccinated with the 23vPPV who had received 3 doses of the 7vPCV(adjusted HR,1.81;95%CI,1.32-2.48).Conclusions.Our results suggest an increased risk of ALRI requiring hospitalization after pneumococcal vaccination,particularly after receipt of the 23vPPV booster.The use of the 23vPPV booster should be reevaluated.,【据Clin Infect Dis.2010年4月报道】题：澳大利亚523个月的土著婴儿在接种肺炎链球菌疫苗后因急性下呼吸道感染住院的风险增加：一项队列研究（作者：OGrady KA等）澳大利亚土著儿童是世界范围内唯一在2、4、6个月接受7价肺炎链球菌结合疫苗（7vPCV），且在18个月接受23价肺炎球菌多糖疫苗（23vPPV）的人群。澳大利亚查尔斯达尔文大学OGrady KA等设计了一项回顾性队列研究，评估了此疫苗接种项目在降低北方地区（NorthernT e r r i t o r y，N T）52 3个月土著儿童急性下呼吸道感染（ALRI）住院风险的疗效。研究纳入于2000年4月1日至2004年10月31日间出生的所有NT土著儿童。应用在第0、1、2、3剂接种7vPCV后和第0、1剂接种23vPPV后的危险人次以及每剂接种后出现ALRI的数量计算523个月儿童ALRI的剂量特异性发生率。结果显示，共纳入5482 名儿童，患病风险为8315儿童-年，共2174次ALRI事件需要住院（总的发生率，261/1000儿童-年风险）。与未接种疫苗的儿童相比，接种每一剂7vPCV疫苗后的儿童，ALRI需要住院的风险增加，在接种每一剂的2 3 v P P V后，风险增加的似乎更高（与未接种者相比，接种者的校正HR 为1.39）。接种23vPPV疫苗同时接种7vPCV疫苗小于3剂的儿童风险最高（校正HR，1.81）。研究表明，儿童在接种肺炎疫苗后A L R I 需住院的风险增加，尤其是在接受23vPPV加强免疫之后。故应重新评估23vPPV加强免疫的疗效。,4.住院期间血小板增多或减少可预测CAP患者的死亡率,【据Chest2010年2月报道】题：住院期间血小板增多或减少可预测社区获得性肺炎患者死亡率（作者：Mirsaeidi M等）血小板属于炎症细胞，在抗微生物宿主防御中起重要作用。据推测血小板计数异常也许是社区获得性肺炎（CAP）患者病情严重的一个标志。美国路易斯维尔大学Mirsaeidi M等开展了一项回顾性队列研究，评估了CAP住院患者异常的血小板计数是否与其30天死亡率相关，并对血小板计数和白细胞计数作为30天死亡率的预测因子进行比较。此研究纳入500例连续的CAP患者，调查血小板计数和白细胞计数与患者30天死亡率的关系。预测变量为血小板计数和白细胞计数。异常血小板计数为100 000/L（血小板减少）和400 000/L（血小板增多）。结局变量为30天死亡率。应用包括33个变量的倾向评分控制潜在混杂因素。结果显示，血小板计数与30天死亡率强烈相关（P=0.0009），未发现白细胞计数与30天死亡率的关系。高血小板计数可致患者死亡率显著增加。研究表明，血小板增多或减少与住院的CAP患者的死亡率相关。当对CAP患者进行初始CBC检测评估时，异常的血小板计数比异常的白细胞计数更能预测患者结局,BACKGROUND:Platelets are inflammatory cells with an important role in antimicrobial host defenses.We speculate that an abnormal platelet count may be a marker of severity in patients with community-acquired pneumonia(CAP).The objectives of this study were to evaluate in hospitalized patients with CAP,if abnormal platelet count was associated with 30-day mortality,and to compare platelet count and leukocyte count as predictors of 30-day mortality.METHODS:We performed a retrospective cohort study of 500 consecutive patients hospitalized with CAP at the Veterans Hospital of Louisville,KY between June 2001 and March 2006 to investigate the association of platelet count and leukocyte count with 30-day mortality.Predictor variables were platelet count and leukocyte count.Abnormal platelet count was less than 100,000/L(thrombocytopenia)and greater than 400,000/L(thrombocytosis).The outcome variable was 30-day mortality.To control for potential confounding,a propensity score that incorporated 33 variables was used.RESULTS:Platelet count was strongly associated(P=0.0009)with 30-day mortality while no association was observed for leukocyte count(P=0.5114).High platelet counts resulted in a significantly increased risk of mortality.CONCLUSIONS:Thrombocytopenia and thrombocytosis are associated with mortality in patients hospitalized with CAP.When evaluating an initial CBC test in patients with CAP,an abnormal platelet count is a better predictor of outcome than an abnormal leukocyte count.,【据Chest2010年2月报道】题：住院期间血小板增多或减少可预测社区获得性肺炎患者死亡率（作者：Mirsaeidi M等）血小板属于炎症细胞，在抗微生物宿主防御中起重要作用。据推测血小板计数异常也许是社区获得性肺炎（CAP）患者病情严重的一个标志。美国路易斯维尔大学Mirsaeidi M等开展了一项回顾性队列研究，评估了CAP住院患者异常的血小板计数是否与其30天死亡率相关，并对血小板计数和白细胞计数作为30天死亡率的预测因子进行比较。此研究纳入500例连续的CAP患者，调查血小板计数和白细胞计数与患者30天死亡率的关系。预测变量为血小板计数和白细胞计数。异常血小板计数为100 000/L（血小板减少）和400 000/L（血小板增多）。结局变量为30天死亡率。应用包括33个变量的倾向评分控制潜在混杂因素。结果显示，血小板计数与30天死亡率强烈相关（P=0.0009），未发现白细胞计数与30天死亡率的关系。高血小板计数可致患者死亡率显著增加。研究表明，血小板增多或减少与住院的CAP患者的死亡率相关。当对CAP患者进行初始CBC检测评估时，异常的血小板计数比异常的白细胞计数更能预测患者结局,5.重度社区获得性肺炎患者入住ICU较晚与死亡率较高相关,【据Chest2010年3月报道】题：晚期入住ICU与社区获得性肺炎患者的高死亡率相关（作者：Restrepo MI等）有关入住ICU的时间对重度社区获得性肺炎（CAP）结局的影响的可靠数据有限，美国南德克萨斯退伍军人医疗保健系统Restrepo MI等此次研究旨在调查入住ICU的时间与重度CAP 患者30天死亡率的关系。此项在两个三级教学医院开展的，为期超过3年的回顾性队列研究，纳入161例入住 ICU的CAP患者（国际疾病分类，第9次修订、编码）。将入住ICU的时间划分为两个级别，即早入住ICU（EICUA，直接入住或在24小时内入住），入住ICU较晚（LICUA，2天入住）。应用Cox比例危害模型进行多变量分析，主要测量结果为30天死亡率、美国胸科协会（ATS）疾病严重程度判定和入住ICU的时间。结果显示，88%（n=142）为EICUA患者，12%（n=19）为LICUA患者。两组患者在年龄、性别、共病、临床参数、CAP相关的护理方法以及需要机械通气方面相似。入院时LICUA患者ATS严重程度标准的符合率较低（26.3%vs.53.5%；P=0.03）。与EICUA患者相比，LICUA患者的死亡率较高（47.4%vs.23.2%，P=0.02），经多变量分析校正后这种关系依然存在（HR，2.6；P=0.02）。研究表明，在校正疾病严重程度后，重度CAP患者入住ICU时间较晚可增加患者30天死亡率。进一步的研究应该探讨影响较晚入住ICU的危险因素及其对这些患者临床结局的影响。共同进食蔬菜和水果可使孕妇上呼吸道感染风险降低【据Public Health Nutr.2010年2月报道】题：进食蔬菜和水果与孕妇上呼吸道感染风险间的关系（作者：Li L Werler MM）美国波士顿大学公共卫生学院流行病学系Li L与Werler MM开展此次研究，旨在评估在妊娠期间进食蔬菜和水果与上呼吸道感染（URTI)）发生率之间的关系。研究纳入北美妇女1034例，让其回顾其在妊娠前6个月进食蔬菜和水果与在妊娠前半期时URTI的发生率。用Cox比例危害模型计算多变量校正危害比（HR）。结果显示，摄入总的水果和蔬菜量的最高四分位（中位量8.54 servings/d）vs.最低四分位（中位量1.91 servings/d）的妇女，在随访5个月时发生URTI的校正HR 为0.74，随访3个月时为0.61。在随访3个月时摄入的水果和蔬菜与URTI风险降低呈剂量相关，但随访5个月时无此相关性。未发现单独进食蔬菜或水果与5个月或3个月时URTI风险的关系。研究表明，妇女进食蔬菜和水果较多可中度降低妊娠期间URTI的风险，这种获益似乎来源于蔬菜与水果共同进食而非单一进食。Examination Questions不定项选择题1.进食蔬菜和水果与孕妇上呼吸道感染风险的关系，下列说法正确的是（）A 进食蔬菜和水果与孕妇上呼吸道感染风险无关 B 单进食蔬菜可以降低孕妇上呼吸道感染风险C 单进食水果可以降低孕妇上呼吸道感染风险 D 共同进食蔬菜和水果可以降低孕妇上呼吸道感染风险,BACKGROUND:Limited data are available on the impact of time to ICU admission and outcomes for patients with severe community acquired pneumonia(CAP).Our objective was to examine the association of time to ICU admission and 30-day mortality in severe CAP patients.METHODS:A retrospective cohort study of 161 ICU CAP subjects(by ICD-9 codes)was conducted over a three year period at two tertiary teaching hospitals.Timing of the ICU admission was dichotomized into early ICU admission(EICUA-direct admission or within 24 hours)and late ICU admission(LICUA-/=day 2).A multivariable analysis using Cox proportional hazard model was created with the primary outcome of 30-day mortality(dependent measure),and the American Thoracic Society(ATS)severity adjustment criteria and time to ICU admission as the independent measures.RESULTS:Eighty-eight percent(n=142)were EICUA compared to 12%(n=19)LICUA patients.Groups were similar with respect to age,gender,comorbidities,clinical parameters,and CAP-related process of care measures,and need for mechanical ventilation.LICUA patients had lower rates of ATS severity criteria at presentation(26.3%vs.53.5%;p=0.03).LICUA patients(47.4%)had a higher 30-day mortality compared to EICUA(23.2%)patients(p=0.02),and remained after adjusting in the multivariable analysis(Hazard ratio 2.6,95%Confidence Interval 1.2-5.5;p=0.02).CONCLUSION:Severe CAP patients with a late ICU admission have increased 30-day mortality after adjustment for severity of illness.Further research should evaluate the risk factors associated and their impact on clinical outcomes in patients admitted late to the ICU.,Antibiotic Use in the Management of Pulmonary Nodules.,BACKGROUND:Pulmonary nodules are common incidental findings on thoracic imaging.This study sought to determine whether antibiotic use is associated with any improvement in nodule appearance and to identify clinical findings and nodule characteristics potentially influencing the decision to prescribe antibiotics.METHODS:Electronic medical records were reviewed of outpatients referred to a metropolitan cancer center for pulmonary nodules seen on chest CT scans that did not undergo biopsy.The primary endpoint was the appearance of each nodule on the first follow-up scan.A subset analysis was performed for patients manifesting symptoms or radiographic findings suggesting infection.An analysis was performed to determine what clinical and radiographic findings were associated with the decision to prescribe antibiotics.RESULTS:Between January 2003 and December 2004,143 evaluations were performed for 293 nodules.Antibiotics were prescribed among 34(24%)evaluations.A trend towards improvement was seen with antibiotic use,which was not significant.The percentage of nodules that improved was 33%among those receiving antibiotics and 27%among those who did not(Odds ratio 1.33,95%CI 0.55-3.27).Among 63 patients with pulmonary symptoms,41%of nodules improved among those receiving antibiotics and 28%among those who did not(Odds ratio 1.78,95%CI 0.42-7.78).The decision to prescribe antibiotics was associated only with larger nodule size and bronchiectasis.CONCLUSION:These data do not support antibiotic use for pulmonary nodules.However,the trend towards improved nodule appearance suggests that larger prospective trials are warranted to clarify the role of antibiotics in managing lung nodules.,Clinical Outbreak of Linezolid-Resistant staphylococcus aureus in an Intensiven Care Unit,CONTEXT:Linezolid resistance is extremely uncommon in Staphylococcus aureus.OBJECTIVE:To report an outbreak with linezolid and methicillin-resistant S aureus(LRSA)in an intensive care department and the effective control measures taken.Design,Setting,and PATIENTS:Outbreak study of consecutive critically ill patients colonized and/or infected with LRSA at an intensive care department of a 1000-bed tertiary care university teaching hospital in Madrid,Spain.Patients were placed under strict contact isolation.Daily updates of outbreak data and recommendations for the use of linezolid were issued.Extensive environmental sampling and screening of the hands of health care workers were performed.MAIN OUTCOME MEASURES:Linezolid use and clinical and epidemiological characteristics and outcomes using minimal inhibitory concentrations,pulsed-field gel electrophoresis,and polymerase chain reaction of LRSA isolates.RESULTS:Between April 13 and June 26,2008,12 patients with LRSA were identified.In 6 patien