ARDS. The future

Improving the course and outcome of patients with ARDS presents a considerable challenge. An important component of meeting this challenge is a more comprehensive understanding of the heterogeneous pathophysiology of ARDS and the biologic response of the individual patient. This understanding may be developed through the power of genomics and its related technology. In particular, it will be crucial to characterize the immunophenotypes of individual patients with ARDS. By understanding the immune status of a given patient at a given point in the disease process, physicians can consider manipulating proinflammatory systems more rationally, such as the complement and chemokine cascades, or the anti-inflammatory arm of the immune system. Finally, a more refined molecular and genetic understanding of endogenous cytoprotective molecules and mechanisms, such as the heat shock response and HO-1, may provide further tools in the future armamentarium against ARDS.     

A world look at the venereal diseases: recrudescence of the venereal diseases

Factors affecting the increased incidence of the venereal diseases syphilis and gonorrhea throughout the world since World War 2 are considered. Both diseases declined after the war to a minimum in about 1957, but they have since increased, particularly gonorrhea to even higher incidence in many countries. Late and congenital syphilis, however, have declined almost universally. Factors invoked to explain the recrudescence include decreased virulence of both organisms, perhaps aided by better nutrition and hygiene. An important trend is antibiotic resistance. Sulfonamide resistance was noted during World War 2. A relative penicillin resistence, threatening the convinient use of cheap single-dose treatment, is particularly frequent in the Far East. Other antibiotics and penicillin-probeneoid combinations are still available and have contributed to improved cure rates in some countries, e.g., Canada, United Kingdom, Denmark, Greenland and Norway. Environmental fa ctors suggested are more susceptible persons, greater population mobility, promiscuity, use of pills and IUDs instead of condoms, and changed sexual practices resulting in rectal and oral infections. Hopes for control in the future include formation of adequate case finding organizations in more places, health education, modification of behavior, discovery of a serologic test for gonnorrhea, and although unlikely, immunization. The author concluded that the problems of venereal disease will probably increase: even if syphilis and gonorrhea were controlled, the other sexually transmitted entities (spirochetes, bacteria, virus, protozoa, fungi, parasites and possible cervical carcinoma) will pose problems.     

Update in ARDS management: recent randomized controlled trials that changed our practice

In the last 7 years, 14 randomized controlled trials in patients with acute respiratory distress syndrome (ARDS) have shown that: Mechanical ventilation with a tidal volume of 6 mL/kg of predicted body weight is better than mechanical ventilation with a tidal volume of 12 mL/kg of predicted body weight. Prone positioning improves oxygenation but poses safety concerns. A high level of positive end-expiratory pressure does not improve survival. High-frequency oscillatory ventilation is in theory the ideal "lung-protective" method, but its benefits have not been proven. No drug therapy has been shown to improve survival in patients with ARDS. Exogenous surfactant may improve oxygenation but has no significant effect on the death rate or length of use of mechanical ventilation. Low-dose inhaled nitric oxide has no substantial impact on the duration of ventilatory support or on the death rate. Partial liquid ventilation may be beneficial in young patients with acute lung injury or ARDS, although further study is needed to confirm this.     

Nod‐like receptors in innate immunity and inflammatory diseases

Over the past few years the field of innate immunity has undergone a revolution with the discovery of pattern recognition molecules (PRM) and their role in microbe detection. Among these molecules, the Nod‐like receptors (NLRs) have emerged as key microbial sensors that participate in the global immune responses to pathogens and contribute to the resolution of infections. This growing group of proteins is divided into subfamilies with basis in their different signaling domains. Prominent among them are Nod1, Nod2, Nalp3, Ipaf, and Naip that have been shown to play important roles against intracellular bacteria. Furthermore, mutations in the genes that encode these proteins have been associated with complex inflammatory disorders including Crohn's disease, asthma, familial cold urticaria, Muckle‐Wells syndrome, and Blau syndrome. In this review we will present the current knowledge on the role of these proteins in immunity and inflammatory diseases.     

肺结核合并结核性肛瘘1例

肺结核合并结核性肛瘘１例邓仲贵四川省第四人民医院内科（６１００００）患者，男，２０岁，农民，因低热、盗汗、咳嗽伴肛周脓肿破溃溢大便半年。于１９９５年６月６日收入我院外科治疗。病员于半年前因低热盗汗咳嗽到当地医院就诊，未进行胸透及查痰，诊断为“上感”，...     

腹部外科疾病并发ALI/ARDS患者特点及影响预后的多因素分析

目的 回顾分析腹部外科疾患患者的临床资料,以观察腹部外科疾病患者急性肺损伤/急性呼吸窘迫综合征(ALI/ ARDS) 的发病情况及预后影响因素.方法 2004-01 ～2008-12收治的符合ALI/ ARDS诊断标准的126例腹部外科疾病并发ALI/ ARDS患者病例纳入本研究.收集符合纳入和排除标准患者的年龄、既往病史、器官衰竭数目、血pH值、氧合指数和白蛋白等临床资料,并应用Logistic回归分析以上各因素对ALI/ ARDS患者总死亡率的影响.结果 腹部外科疾病并发ALI/ ARDS原发病因依次是胰腺炎,其他类(包括肿瘤、创伤、腹部疾病并发心搏、呼吸骤停行心肺复苏后等)、胆道感染性疾病、上消化道穿孔或出血及肠梗阻等.其中126例并发ALI/ ARDS患者,死亡67例(病死率53.17%).且病死率随着受累器官数目的 增加而增高,其中3个及以下器官衰竭者病死率为40.28%,3个以上为70.37%.研究表明,年龄、器官衰竭数目、氧合指数及白蛋白是影响患者预后的相关因素.结论 高龄、多脏器功能不全、损伤脏器多、低氧血症、低蛋白血症的腹部外科疾病患者更容易发生 ALI/ ARDS,应加强此类高危患者的围术期管理,从而降低外此类患者ALI/ ARDS的发病率,减少发病患者的死亡率.