医院获得性肺炎药物防治策略

回顾近年来有关医院获得性肺炎的诊疗指南、病原体流行病学分析和抗感染药物对其预防和治疗方面的进展。最常见的病原菌为金黄色葡萄球菌和铜绿假单胞菌;氯己啶等消毒剂口腔用药可预防呼吸机相关肺炎发生,但此类消毒剂以及抗生素均不能降低其死亡率;在各类抗感染药物中,美罗培南、亚胺培南等碳青霉烯类对医院获得性肺炎的治疗作用优越。     

Successful self-infusion of activated prothrombin complex concentrate for prophylaxis in a child with a factor VIII inhibitor

Regular self-infusion of an activated prothrombin complex concentrate (APCC) has been successfully introduced to a 14-year-old boy with hemophilia A. The child was diagnosed as a neonate, and at age 7 years, developed a high titer (127 BU/mL) factor VIII inhibitor coincident with a protracted ankle joint bleeding. From age 7-10 years, he received on-demand therapy using a prothrombin complex concentrate (PCC), PROPLEX-ST. From age 10-14 years, he received prophylaxis with PROPLEX-ST, initiated after an intracranial hemorrhage and coincident anamnestic inhibitor response. Throughout 7-year period of PCC treatment, he experienced recurrent bleeding episodes. Self-prophylaxis with APCC, FEIBA VH [Anti-inhibitor Coagulant Complex] (50 U/kg/dose three times per week) using infusion pump was initiated at 14 years of age and has continued for 2 years. There were no bleeding, thrombotic events or other adverse events after initiation of this prophylaxis, and inhibitor levels decreased to 1 BU/mL. His quality of life was improved, particularly with respect to school. Our long observation proposes a well-disciplined home-based FEIBA prophylaxis in inhibitor-positive hemophiliacs.     

Bilateral occipital infarcts associated with carotid atherosclerosis and a persistent hypoglossal artery

The persistent hypoglossal artery (PHA) is the second most common persistent embryological carotid-basilar connection and usually represents an incidental finding in cerebral arteriograms. The hypoglossal artery connects the primordial carotid artery with the longitudinal neural arteries, which later form the basilar artery. The PHA leaves the internal carotid artery as an extracranial branch, enters the skull through the anterior condyloid foramen, the hypoglossal canal and joins the caudal portion of the basilar artery. We report magnetic resonance and digital subtraction angiography findings in the first case of bilateral occipital infarctions associated with PHA and carotid atherosclerosis. The probable mechanism underlying bilateral occipital infarcts was embolism from the carotid territory to the posterior cerebral arteries. PHA may present a challenge in diagnosis and management of patients with carotid atherosclerosis and vertebrobasilar ischemia.     

Meta分析抗生素对经直肠前列腺活检术后感染性并发症的预防效果

目的:分析预防性抗生素能否减少术前为清洁尿、行经直肠前列腺活检术(TPB)患者的术后感染性并发症.方法:制定原始文献的纳入标准、排除标准及检索策略, 在MEDLINE(1979.01-2007.12)、EMBASE(1988.01-2007.12)、Cochrane Collaboration Reviews (1993.01-2007.12)、中国生物医学期刊文献数据库(CMCC,1979-2007.12)、CNKI数字图书馆(1979.01-2007.12)进行相关的随机对照试验(RCT)的检索,采用Rev Man 4.2软件进行Meta分析.结果:共检索到相关随机对照试验68篇,排除56篇,符合纳入标准12篇进入Meta分析.结果显示,术前清洁尿的患者,预防性抗生素能显著降低TPB术后1周内菌尿和术后中度发热的发生率, 但不能减少菌血症的发生率,其RR值及其95%CI分别为0.32(0.23～0.46),0.37(0.17～0.77) 和0.96(0.61～1.50);各疗程抗生素均能明显减少TPB术后菌尿的发生率,差别无统计学意义;喹诺酮、喹诺酮联合硝基咪唑以及TMP+SMZ均能明显降低TPB术后发生菌尿的危险.结论:术前为清洁尿的患者,预防性应用抗生素能减少TPB术后菌尿和发热的发生率,但不能降低菌血症的发生率;喹诺酮、喹诺酮联合硝基咪唑均能明显降低TPB术后发生菌尿的危险,各疗程抗生素均能明显减少TPB术后菌尿的发生率.     

The performative function of expectations in translating treatment to prevention: The case of HIV pre-exposure prophylaxis,or PrEP

This paper is about expectations of oral PrEP, ‘a pill a day’ HIV pre-exposure prophylaxis that could be the first systemic form of HIV prevention for sexual or needle stick exposures. If found safe and effective—a difficult criteria to establish and, as such, is central to this paper—PrEP has the potential to significantly alter HIV prevention, well ahead of a vaccine or topical microbicide. Hence, despite uncertainty about PrEP's viability, the potential significance of its impact on the HIV field requires early planning. In order to address this potentiality, we use a methodological approach drawn from the sociology of expectations to examine interviews with United States-based scientific stakeholders in the trialing of PrEP. We identify how PrEP is anticipated as both stable object and process involving multiple contingencies. These divergent conceptions enable us to illuminate a range of social, cultural, ethical, pharmaceutical and medical possibilities understood to potentially arise with PrEP. Further, they lead us to propose that the multiple contingencies that enact PrEP as an emergent entity offer scope for rethinking PrEP and, more broadly, the challenges of HIV prevention.     

Beyond randomized controlled trials: a "real life" experience of respiratory syncytial virus infection prevention in infancy with and without palivizumab

A population-based study of the impact of palivizumab on confirmed Respiratory Syncytial Virus (RSV) hospitalizations over a 7-year period within and between two similar health regions . Clinicians in Calgary implemented palivizumab prophylaxis for high-risk infants during the last four RSV seasons; clinicians in Edmonton did not. The two cities are part of a unified health care system and similar sociodemographics. Infants <36 weeks (wk) of gestational age (GA) were identified. RSV prophylaxis data and RSV-hospitalizations for high-risk infants eligible for prophylaxis were reviewed, as well as that of moderate-risk infants (33-35 weeks GA) for whom RSV prophylaxis was not given a high priority in the recommendations published by the Canadian Paediatric Society (CPS). Prevalence of RSV hospitalization before and after palivizumab was determined (1995-1998 and 1999-2002, respectively). There were 411 high-risk infants eligible for palivizumab prior to its provision (Pre) and 496 during the prophylaxis program (Post) in Calgary. There were 401 Pre and 425 Post in Edmonton, where no such prophylaxis program was implemented. In Calgary where palivizumab was offered (Post), RSV hospitalization was significantly reduced: 7.3% Pre versus 3.0% Post (OR, 2.53, 95% CI, 1.34, 4.76). No reduction was observed in Edmonton where palivizumab was not offered: 5.0% Pre versus 7.1% Post (OR, 1.45, 95% CI, 0.81, 2.59; P = 0.212). RSV hospitalizations did not change for moderate-risk infants not receiving palivizumab in Calgary (OR, 1.26, 95% CI, 0.75, 2.12; P = 0.389). An RSV prevention program with palivizumab for high-risk infants reduced RSV hospitalizations, providing "real life" evidence of the benefits of this prophylaxis strategy. Further research is required to determine if specific sub-sets of moderate-risk infants would also benefit from an RSV prophylaxis program with palivizumab.     

Low-molecular-weight heparin, bemiparin, in the outpatient treatment and secondary prophylaxis of venous thromboembolism in standard clinical practice: the ESFERA Study

The objective of this study is to assess the clinical and economic outcomes associated with outpatient treatment and secondary prophylaxis of acute venous thromboembolism (VTE) with a low-molecular-weight heparin, bemiparin. This study was designed as an open-label, multicentre, prospective, cohort study in standard clinical practice. Sixty-three investigators from 54 Spanish centres participated in the study. Five hundred eighty-three patients (434 outpatients and 149 inpatients) with acute VTE were followed up for 98 days (median). Outcome measures were costs and adverse events during initial VTE treatment with bemiparin (outpatient vs. inpatient cohorts) and long-term treatment [bemiparin (BEM) vs. vitamin K antagonists (VKA) cohorts]. Mean total costs per patient were lower in the outpatient cohort as compared with those in the inpatient cohort (1206 vs. 5191 euros; difference = -3985 euros; p < 0.001), with similar rates of adverse events (5.1 outpatient vs. 7.4% inpatient; p = 0.196) over 98 days. Mean total costs per patient were similar in the BEM/BEM and BEM/VKA cohorts (3616 vs. 3831 euros; difference = -215 euros; p = 0.412), but patients on long-term bemiparin treatment had lower rates of major bleeding (0.4 vs. 1.7%; p = 0.047), minor bleeding (1.8 vs. 6%; p = 0.032) and total adverse events (2.9 vs. 9.5%; p = 0.007) than patients in the BEM/VKA cohort. Outpatient management of VTE with bemiparin in selected patients resulted in significant cost-savings compared to inpatient treatment, while maintaining effectiveness and safety. Bemiparin may be a safer and cost-neutral alternative to VKA for long-term treatment of VTE.     

Open, multicenter study to evaluate the tolerability and efficacy of Echinaforce Forte tablets in athletes

This open, multicenter study investigated the tolerability and efficacy of a new tablet formulation ofEchinacea purpurea extract (Echinaforce Forte; A. Vogel, Bioforce AG, Roggwil, Switzerland) in 80 subjects actively involved in sports. Most investigators (97.5%) rated the treatment as having “very good” or “good” tolerability. About 75% of patients and investigators rated its efficacy during a common cold as “very good” or “good,” and 71 % of subjects were free of cold episodes. This study is the first to suggest that Echinaforce is effective in the prophylaxis, as well as the treatment, of the common cold in persons who actively participate in sports.