严重脓毒症——评价指标带给我们的启示

目前,严重脓毒症的诊断指标已对脓毒症导致的临床情况作出较好的诠释,进一步寻找相关的指标将更有助于临床判断.我们评价了血流动力学和组织灌注参数,免疫紊乱、凝血障碍的相关参数以及前降钙素等指标在临床上的价值.目前所采用的一些指标确实有助于严重脓毒症的诊断,但是,我们需要更特异的指标来指导临床工作.     

脓毒症及其治疗策略的反思

脓毒症是各种严重创伤、烧伤、缺氧、再灌注损伤及外科大手术常见的并发症.目前脓毒症休克的临床病死率仍高达50%以上.对脓毒症发病机制的进一步深入认识和现行治疗措施的反思有助于改善其临床防治.     

生物标志物在脓毒症诊断与治疗中的价值

脓毒症是重症医学最常见的临床综合征。生物标志物常用于脓毒症的诊断、治疗、评估预后。降钙素原、C-反应蛋白是最常用的急性期蛋白指标,降钙素原指导的抗感染治疗方案应用价值极大。细胞因子如IL-6等可反映炎症反应的严重程度,但特异性不大。免疫指标单核细胞人白细胞抗原(mHLA-DR)侧重于筛选免疫调理治疗目标人群,有效指导治疗。检测特异性真菌生物标志物(1,3-β-D-葡聚糖、半乳甘露聚糖)可更早诊断真菌感染,有效进行抢先治疗。生物标志物在脓毒症有着不凡的价值,因此被国际各类脓毒症指南所推荐,临床应用前景极大。     

脓毒症的前世今生

自1991年脓毒症首次被提出以来,脓毒症的定义和诊断标准不断更新和完善,今年已经是"第三版"(Sepsis 3.0),每次更新都融入许多新的理论或观点,但同时也充满了争议,在这种争议和讨论中脓毒症的定义和诊断标准趋于更加完善。它代表了我们对感染引起的患者全身炎症反应以及后续器官功能障碍等病理生理机制或状态认识水平的不断提高,是与当前医疗现状密不可分的。本文就脓毒症的整个发展历程和相关争论进行详述,期望大家从理论上更好地理解脓毒症的内涵。     

外科脓毒症：从科学认识到合理防治

脓毒症(sepsis)是一种严重威胁患者生命的外科危重症,也是诱发脓毒性休克(septic shock)、多器官功能障碍综合征(MODS)的重要原因。基于对脓毒症的病理生理的认识正不断深入,脓毒症的防治水平业已取得重要的进展。深入认识脓毒症,研究新的防治策略,实施正确的治疗,将有助于提高脓毒症的临床治疗水平。     

脓毒症的病原学诊断

脓毒症是感染引起宿主反应失调而导致致死性器官功能障碍的临床综合征,是严重烧伤、孕产妇、ICU和新生儿监护病房最主要的致死性疾病之一。早期发现并采取合理的方法进行治疗,可以大大提高患者的存活率。通过实验室检测查找致病菌并通过药物敏感性试验为临床明确诊断以及提供合理用药方案是治疗脓毒症的关键,而标本的合理采集和运送则是保证病原菌检测正确的前提。     

外科脓毒症:从科学认识到合理防治

脓毒症(sepsis)是一种严重威胁患者生命的外科危重症,也是诱发脓毒性休克(septicshock)、多器官功能障碍综合征(MODS)的重要原因.基于对脓毒症的病理生理的认识正不断深入,脓毒症的防治水平业已取得重要的进展.深入认识脓毒症,研究新的防治策略,实施正确的治疗,将有助于提高脓毒症的临床治疗水平.     

严重过敏反应诊断和治疗中存在的若干问题探讨

近年来严重过敏反应发病率有增高的趋势,国外学者对此研究较为深入并相继发布指南及指导意见.我国目前在严重过敏反应诊断及治疗中尚存在一些问题.呼吁相关学术机构发布相应指南以指导临床.     

脓毒症肺循环功能障碍的发病机制

脓毒症可以引起多器官功能障碍,脓毒症是重症加强治疗病房内患者死亡的主要病因。脓毒症时循环系统常常最先受累,引起组织器官血流灌注不足。目前对脓毒症时体循环、微循环及心脏改变的相关研究较多,但对肺循环的改变研究相对较少,肺循环改变可影响气体交换引起急性呼吸窘迫综合征、增加右心后负荷甚至引起右心功能衰竭,对脓毒症患者的预后产生严重影响,本文针对脓毒症肺循环功能障碍的发病机制进行综述。     

脓毒症患者血牛磺酸变化的研究进展

脓毒症是临床上常见的感染性疾病,因其发病率高、病死率高和医疗费用高而引起广泛关注,并进行深入研究。在脓毒症进展过程中,往往伴随新陈代谢的改变,其中氨基酸代谢紊乱常见。牛磺酸是一种非必需含硫氨基酸,具有独特的生理作用,机体牛磺酸主要来源于食物,牛磺酸缺乏可能导致机体病变。脓毒症患者的血牛磺酸水平明显下降并具有特异性,此外,牛磺酸水平下降与急性生理与慢性健康评分、序贯器官衰竭评分及血乳酸等具有关系。牛磺酸可能是危重患者营养治疗的重要添加剂,适量补充牛磺酸有助于延缓病程进展,有利于脓毒症患者的临床预后。     

Childhood multiple sclerosis: a review

Multiple sclerosis (MS) is an autoimmune demyelinating disorder of the central nervous system (CNS) that is increasingly recognized as a disease that affects children. Similar to adult-onset MS, children present with visual and sensory complaints, as well as weakness, spasticity, and ataxia. A lumbar puncture can be helpful in diagnosing MS when CSF immunoglobulins and oligoclonal bands are present. White matter demyelinating lesions on MRI are required for the diagnosis; however, children typically have fewer lesions than adults. Many criteria have been proposed to diagnose MS that have been applied to children, mostly above 10 years of age. The recent revisions to the McDonald criteria allow for earlier diagnosis, such as after a clinically isolated event. However, children are more likely than adults to have monosymptomatic illnesses. None of the approved disease-modifying therapies used in adult-onset MS have been approved for pediatrics; however, a few studies have verified their safety and tolerability in children. Although children and adults with MS have similar neurological symptoms, laboratory (cerebrospinal fluid) data, and neuroimaging findings, the clinical course, pathogenesis, and treatment of childhood onset MS require further investigation.     

Quantitative criteria for insomnia

Formal diagnostic systems (DSM-IV, ICSD, and ICD-10) do not provide adequate quantitative criteria to diagnose insomnia. This may not present a serious problem in clinical settings where extensive interviews determine the need for clinical management. However, lack of standard criteria introduce disruptive variability into the insomnia research domain. The present study reviewed two decades of psychology clinical trials for insomnia to determine common practice with regard to frequency, severity, and duration criteria for insomnia. Modal patterns established frequency (> or =3 nights a week) and duration (> or =6 months) standard criteria. We then applied four versions of severity criteria to a random sample and used sensitivity-specificity analyses to identify the most valid criterion. We found that severity of sleep onset latency or wake time after sleep onset of: (a) > or =31 min; (b) occurring > or =3 nights a week; (c) for > or =6 months are the most defensible quantitative criteria for insomnia.     

Problems Caused for Mental Health Professionals Worldwide by Increasing Multicultural Populations and Proposed Solutions

Psychiatric disorders on a global scale, combined with rapid national population diversification, demand that mental health professionals worldwide become more informed about the realities of diagnosing and treating a multicultural patient population. Recommendations are offered to enable such professionals to most efficaciously diagnose and treat patients from diverse sociocultural backgrounds.     

Specific Cognitive Deficits in ADHD: A Diagnostic Concern in Differential Diagnosis

We present a critical account of existing tools used to diagnose children with Attention Deficit Hyperactivity Disorder and to make a case for the assessment of cognitive impairments as a part of diagnostic system. Surveys have shown that clinicians rely almost entirely upon subjective reports or their own clinical judgment when arriving at diagnostic decisions relating to this prevalent disorder. While information from parents and teachers should always be carefully considered, they are often influenced by a host of emotional and perceptual factors. It increases the possibility for misdiagnosis of a condition like ADHD. Recent experimental literature on ADHD has identified unique underlying cognitive dysfunction, specific to ADHD. Therefore, we propose that there is a need to incorporate information on cognitive mechanisms underlying ADHD and inculcate such information in the diagnostic system, which will provide a more sensitive as well as specific tool in differential diagnosis of ADHD.     

Synesthesia in children with difficulties in written language learning

We tested whether the acquisition of grapheme-color synesthesia during childhood is related to difficulties in written language learning by measuring whether it is more frequent in 79 children receiving speech and language therapy for such difficulties than in the general population of children (1.3%). By using criteria as similar as possible to those used in the reference study (Simner et al., 2009), we did not identify any synesthete (Bayesian 95% credible interval [0, 4.5]% for a flat prior). The odds of the null model (no difference between 0/79 and 1.3%) over alternative models is 28 (Bayes Factor). A higher prevalence of grapheme-color synesthetes among children with learning difficulties is therefore very unlikely, questioning the hypothesis of a link between synesthesia and difficulties in language acquisition. We also describe the difficulty of diagnosing synesthesia in children and discuss the need for new approaches to do so.     

重症急性胰腺炎并发急性呼吸窘迫综合征危险因素的分析

为了探讨重症急性胰腺炎（SAP）并发急性呼吸窘迫综合征（ARDs）的危险因素,回顾性分析了我院76例SAP患者入ICU时的年龄、血糖、APACHEⅡ评分等17项指标,根据是否合并ARDS对各项指标进行单因素及多因素Logistic回归分析。单因素分析显示两组在年龄、呼吸频率、血糖、感染、APACHEⅡ评分、Ranson评分、CT评分、ICU住院日方面差异有显著性（P〈0．05）,多因素Logistic回归分析显示年龄、血糖、感染、APACHEⅡ、Ranson、CT评分与SAP并发ARDS有关。故得出结论,年龄、血糖、感染、APACHEⅡ、Ranson与CT评分是SAP并发ARDS的独立危险因素。     

Justice distributive et critères de distributions financières : entre performance,allégeance et besoin des salariés

We examine the respective importance given to the five criteria of financial distributions: performance (individual and team work), individual needs, degree of allegiance/rebellion to hierarchical orders and the reason for this allegiance/rebellion (legalism vs opportunism). In total, 1315 participants were confronted with a specific case in which they had to advise a manager on the distribution of bonus among his employees. These employees were characterized by their respective individual performance, the performance of their team, one of the employees being also defined as being (or not) in financial need and to use to obey (or not) hierarchical orders. It is observed that the best performing employees are more rewarded, but each of the other criteria also have influence, both separately and with interactions.     

Emergent features, attention, and perceptual glue in visual form perception

We examined the grouping of line segments into unitary shapes and attempted to identify procedures to diagnose when such grouping is taking place. Previous research has indicated that attentional measures may diagnose grouping: With grouped parts, selective attention to individual parts is difficult and divided attention across parts is easy, whereas with ungrouped parts selective attention is easy and divided attention is difficult. This result suggests that grouping operates via a perceptual glue binding parts into wholes that are difficult or impossible to divide. Other studies have suggested in addition that grouped parts produce emergent features, possibly including symmetry and closure, that make possible configural superiority effects, where whole shapes are more discriminable than are their distinguishing contours shown in isolation. The 13 experiments reported here indicate that perceptual glue is not needed to explain known findings about grouping, a claim that agrees with conclusions by other investigators using other criteria. Rather, emergent features alone may suffice to explain grouping, provided that reliable and accurate diagnostic criteria can be identified. It is shown that the diagnostics now available are not fully adequate for this purpose. Surprisingly, it appears that some prime candidates for emergent features--namely, closure and line terminators--may not be of central importance to form perception.     

Suicide survivors' mental health and grief reactions: a systematic review of controlled studies

There has been a debate over several decades whether suicide survivors experience more severe mental health consequences and grief reactions than those who have been bereaved through other causes of death. This is the first systematic review of suicide survivors' reactions compared with survivors after other modes of death. Studies were identified by searching the PsychINFO and MEDLINE databases. Forty-one studies met the eligibility criteria. A qualitative data analysis was performed. There were no significant differences between survivors of suicide and other bereaved groups regarding general mental health, depression, PTSD symptoms, anxiety, and suicidal behavior. The results regarding the overall level of grief are less clear, depending on whether general grief instruments or suicide-specific instruments are used. Considering specific grief variables, suicide survivors report higher levels of rejection, shame, stigma, need for concealing the cause of death, and blaming than all other survivor groups.     

Hyperactivity and pediatrician diagnoses,parental ratings,specific cognitive abilities,and laboratory measures

Children diagnosed as hyperactive and treated for hyperactivity by private pediatricians were compared to a large unselected sample of children on parental ratings of behavioral problems (Conners Symptoms Rating Questionnaire), laboratory measures (a week-long assessment of locomotion as measured by pedometers, sustained attention, selective attention, fidgeting, and aggressiveness), and 10 tests of specific cognitive abilities (verbal reasoning, spatial reasoning, memory, and perceptual speed). Test-retest reliability was obtained for all measures. The results indicated that pediatrician diagnoses of hyperactivity are related to parental ratings but not to laboratory assessments. Diagnoses by private pediatricians may include more heterogeneous and nonspecific behavioral problems than diagnoses made in most research contexts. Pediatrician diagnoses were related to deficits in specific cognitive abilities, most notably perceptual speed and verbal ability. Hyperactivity as diagnosed by private pediatricians may reflect deficits in skills necessary to pace oneself appropriately in school-related tasks. In general, these results suggest that the criteria and methods used to diagnose hyperactivity deserve greater attention.We are grateful to the Spencer Foundation for their support of this research. Preparation of this report was supported in part by a Research Scientist Development Award (AA-00041) from the ADAMHA NIAAA.