重症监护病房镇静治疗的应用

,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PublicHealthNutr.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：LiLWerlerMM）美国波士顿大学公共卫生学院流行病学系LiL与WerlerMM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1.91servings/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:Thepresentstudyevaluatedtheassociationbetweenfruitandvegetableintakeandtheincidenceofupperrespiratorytractinfection(URTI)duringpregnancy.DESIGN:Inacohortof1034NorthAmericanwomen,eachsubjectwasaskedretrospectivelyabouttheirfruitandvegetableintakeduringthesixmonthsbeforethepregnancyandtheiroccurrencesofURTIduringthefirsthalfofpregnancy.Multivariable-adjustedhazardratios(HR)werecalculatedwithCoxproportionalhazardsmodels.,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:TheadjustedHRofURTIforwomeninthehighestquartile(median8.54servings/d)v.thelowestquartile(median1.91servings/d)oftotalfruitandvegetableintakewas0.74(95%CI0.53,1.05)forthe5-monthfollow-upperiodand0.61(95%CI0.39,0.97)forthe3-monthfollow-upperiod,respectively.Adose-relatedreductionofURTIriskaccordingtoquartileofintakewasfoundinthe3month(Pfortrend=0.03)butnotthe5-monthfollow-up.Noassociationwasfoundbetweeneitherfruitorvegetableintakealoneinrelationtothe5-monthorthe3-monthriskofURTI.CONCLUSIONS:WomenwhoconsumemorefruitsandvegetableshaveamoderatereductioninriskofURTIduringpregnancy,andthisbenefitappearstobederivedfrombothfruitsandvegetablesinsteadofeitheralone.,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:Guidelinesrecommendbloodculturesamplingfromhospitalizedpatientswithsuspectedcommunity-acquiredpneumonia(CAP).However,theyieldoftruepositiveresultsislow.Weinvestigatedthebenefitofprocalcitonin(PCT)onadmissiontopredictbloodculturepositivityinCAP.METHODS:Thisisaprospectivecohortstudywithaderivationandvalidationsetincludingatotalof925CAPpatientswithbloodculturesamplinguponhospitaladmission.RESULTS:Atotalof73patients(7.9%)hadtruebacteremia(43/463inthederivationcohort,30/462inthevalidationcohort).Theareaunderthereceiver-operating-characteristicscurveofPCTinthederivationandvalidationcohortweresimilar(0.83(95%CI0.78-0.89),0.79(95%CI0.72-0.88).Overall,PCTwasasignificantlybetterpredictorforbloodculturepositivityascomparedtowhitebloodcellcount,C-reactiveproteinandotherclinicalparameters.,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,Inmultivariateregressionanalysis,onlyantibioticpretreatment(adjustedOR0.25,p0.05)andPCTserumlevels(adjustedOR3.72,p0.001)wereindependentpredictors.Overall,aPCTcut-offof0.1mug/Lwouldallowreducingthetotalnumberofbloodculturesby12.6%andstillidentifying99%ofthepositivebloodcultures.Similarly,0.25mug/Land0.5mug/Lcutoffswouldallowreducingbloodculturesby37%and52%andstillidentifying96%and88%ofpositivebloodcultures.CONCLUSION:InitialPCTlevelaccuratelypredictedbloodculturepositivityinCAPpatients.PCTmeasurementhasthepotentialtoreducethenumberofdrawnbloodculturesintheEmergencyDepartmentandtoimplementamoretargetedallocationoflimitedhealthcareresources.,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：MllerF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MllerF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52%，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：AustralianIndigenouschildrenaretheonlypopulationworldwidetoreceivethe7-valentpneumococcalconjugatevaccine(7vPCV)at2,4,and6monthsofageandthe23-valentpneumococcalpolysaccharidevaccine(23vPPV)at18monthsofage.Weevaluatedthisprogramseffectivenessinreducingtheriskofhospitalizationforacutelowerrespiratorytractinfection(ALRI)inNorthernTerritory(NT)Indigenouschildrenaged5-23months.Methods.WeconductedaretrospectivecohortstudyinvolvingallNTIndigenouschildrenbornfrom1April2000through31October2004.Person-timeat-riskafter0,1,2,and3dosesof7vPCVandafter0and1doseof23vPPVandthenumberofALRIfollowingeachdosewereusedtocalculatedose-specificratesofALRIforchildren5-23monthsofage.,RateswerecomparedusingCoxproportionalhazardsmodels,withthenumberofdosesofeachvaccineservingastime-dependentcovariates.Results.Therewere5482childrenand8315child-yearsatrisk,with2174episodesofALRIrequiringhospitalization(overallincidence,261episodesper1000child-yearsatrisk).ElevatedriskofALRIrequiringhospitalizationwasobservedaftereachdoseofthe7vPCVvaccine,comparedwiththatforchildrenwhoreceivednodoses,andanevengreaterelevationinriskwasobservedaftereachdoseofthe23vPPV(adjustedhazardratioHRvsnodose,1.39;95%confidenceintervalCI,1.12-1.71;Formula:seetext).Riskwashighestamongchildrenvaccinatedwiththe23vPPVwhohadreceived/=day2).AmultivariableanalysisusingCoxproportionalhazardmodelwascreatedwiththeprimaryoutcomeof30-daymortality(dependentmeasure),andtheAmericanThoracicSociety(ATS)severityadjustmentcriteriaandtimetoICUadmissionastheindependentmeasures.RESULTS:Eighty-eightpercent(n=142)wereEICUAcomparedto12%(n=19)LICUApatients.Groupsweresimilarwithrespecttoage,gender,comorbidities,clinicalparameters,andCAP-relatedprocessofcaremeasures,andneedformechanicalventilation.LICUApatientshadlowerratesofATSseveritycriteriaatpresentation(26.3%vs.53.5%;p=0.03).LICUApatients(47.4%)hadahigher30-daymortalitycomparedtoEICUA(23.2%)patients(p=0.02),andremainedafteradjustinginthemultivariableanalysis(Hazardratio2.6,95%ConfidenceInterval1.2-5.5;p=0.02).CONCLUSION:SevereCAPpatientswithalateICUadmissionhaveincreased30-daymortalityafteradjustmentforseverityofillness.FurtherresearchshouldevaluatetheriskfactorsassociatedandtheirimpactonclinicaloutcomesinpatientsadmittedlatetotheICU.,AntibioticUseintheManagementofPulmonaryNodules.,BACKGROUND:Pulmonarynodulesarecommonincidentalfindingsonthoracicimaging.Thisstudysoughttodeterminewhetherantibioticuseisassociatedwithanyimprovementinnoduleappearanceandtoidentifyclinicalfindingsandnodulecharacteristicspotentiallyinfluencingthedecisiontoprescribeantibiotics.METHODS:ElectronicmedicalrecordswerereviewedofoutpatientsreferredtoametropolitancancercenterforpulmonarynodulesseenonchestCTscansthatdidnotundergobiopsy.Theprimaryendpointwastheappearanceofeachnoduleonthefirstfollow-upscan.Asubsetanalysiswasperformedforpatientsmanifestingsymptomsorradiographicfindingssuggestinginfection.Ananalysiswasperformedtodeterminewhatclinicalandradiographicfindingswereassociatedwiththedecisiontoprescribeantibiotics.RESULTS:BetweenJanuary2003andDecember2004,143evaluationswereperformedfor293nodules.Antibioticswereprescribedamong34(24%)evaluations.Atrendtowardsimprovementwasseenwithantibioticuse,whichwasnotsignificant.Thepercentageofnodulesthatimprovedwas33%amongthosereceivingantibioticsand27%amongthosewhodidnot(Oddsratio1.33,95%CI0.55-3.27).Among63patientswithpulmonarysymptoms,41%ofnodulesimprovedamongthosereceivingantibioticsand28%amongthosewhodidnot(Oddsratio1.78,95%CI0.42-7.78).Thedecisiontoprescribeantibioticswasassociatedonlywithlargernodulesizeandbronchiectasis.CONCLUSION:Thesedatadonotsupportantibioticuseforpulmonarynodules.However,thetrendtowardsimprovednoduleappearancesuggeststhatlargerprospectivetrialsarewarrantedtoclarifytheroleofantibioticsinmanaginglungnodules.,ClinicalOutbreakofLinezolid-ResistantstaphylococcusaureusinanIntensivenCareUnit,CONTEXT:LinezolidresistanceisextremelyuncommoninStaphylococcusaureus.OBJECTIVE:Toreportanoutbreakwithlinezolidandmethicillin-resistantSaureus(LRSA)inanintensivecaredepartmentandtheeffectivecontrolmeasurestaken.Design,Setting,andPATIENTS:Outbreakstudyofconsecutivecriticallyillpatientscolonizedand/orinfectedwithLRSAatanintensivecaredepartmentofa1000-bedtertiarycareuniversityteachinghospitalinMadrid,Spain.Patientswereplacedunderstrictcontactisolation.Dailyupdatesofoutbreakdataandrecommendationsfortheuseoflinezolidwereissued.Extensiveenvironmentalsamplingandscreeningofthehandsofhealthcareworkerswereperformed.MAINOUTCOMEMEASURES:Linezoliduseandclinicalandepidemiologicalcharacteristicsandoutcomesusingminimalinhibitoryconcentrations,pulsed-fieldgelelectrophoresis,andpolymerasechainreactionofLRSAisolates.RESULTS:BetweenApril13andJune26,2008,12pati