截止至2002年5月,現有早產治療的臨床證據如下: (1) 高危早產:在一些國家實施的RCT發現,在降低早產危險方面,加強產前保健與普通產前保健沒有明顯差異.包括5個RCT的1個系統評價發現,對有宮頸改變的婦女行宮頸環扎術有不同的結果,沒有明確的結論.1個大樣本的RCT發現,孕9～29周宮頸功能可能不全的婦女進行預防性宮頸環扎手術與不環扎相比,能明顯降低早產(＜33孕周),但也會明顯增加產褥感染的危險.另外4篇較小樣本的RCT發現,孕10～30周、具各種早產高危因素的婦女,進行預防性宮頸環扎手術與不環扎相比,并不能降低早產(＜34孕周).1篇系統評價的2個RCT報告,對有宮頸改變的婦女進行環扎術有不同的結果,其中1個RCT發現其并不能明顯降低早產(＜34孕周),而另外1個較小樣本的RCT卻發現宮頸環扎手術加臥床休息與單純臥床休息比較,能明顯降低34周前的早產.沒有1個RCT證實行環扎術加臥床休息與單純臥床休息相比,能降低圍生兒死亡率. (2) 胎膜早破:1個系統評價發現,對胎膜早破的婦女,抗生素較安慰劑能明顯延長孕周、降低新生兒發病率的危險,如新生兒感染、出生后氧療、腦部超聲異常等.阿莫西林加克拉維酸治療與新生兒壞死性小腸結腸炎的發生率明顯增加有關.一個基于1個RCT的系統評價發現,沒有充足的證據證實羊膜腔灌注與不灌注比較能改善胎膜早破后的新生兒結局. (3) 先兆早產的治療:①β-腎上腺素興奮劑:1個系統評價發現,β-腎上腺素興奮劑與安慰劑或不治療相比,并不能明顯降低圍生兒死亡率、呼吸窘迫綜合征及低體重兒(＜2 500 g)發生率,且與與安慰劑或不治療相比,β-腎上腺素興奮劑增加孕母副反應,如胸痛、心悸、呼吸困難、震顫、惡心、嘔吐、頭痛、高血糖、低鉀血癥.②鈣離子通道拮抗劑: 沒有關于鈣離子通道拮抗劑與安慰劑比較的系統評價或RCT.1個系統評價發現,鈣離子通道抑制劑與其它保胎藥(主要是β-腎上腺受體興奮劑)比較,能顯著降低48 h內的早產分娩,減少因孕母副反應退出治療和新生兒發病率.③硫酸鎂:1個系統評價發現,硫酸鎂與安慰劑比較,并不能明顯降低孕36周前的早產率、圍生兒死亡率、呼吸窘迫綜合征的發生率.另一個系統評價發現,硫酸鎂和其他宮縮抑制劑(β-腎上腺素興奮劑、鈣離子通道拮抗劑、前列腺素合成抑制劑、硝化甘油、酒精和葡萄糖注射劑)比較,并不能明顯降低48 h內早產率(盡管結果沒有差異).④垂體受體拮抗劑(阿托西班):1個系統評價納入 2個RCT,對阿托西班和安慰劑治療早產進行比較有不同的結果.較大樣本的RCT發現,阿托西班較安慰劑能延長孕周,但阿托西班增加了孕28周以下的胎兒死亡率.另一個RCT發現,阿托西班增加了48 h內的早產.⑤前列腺素抑制劑(消炎痛):1個系統評價發現,消炎痛與安慰劑比較,能明顯降低孕37周前的48 h和7天的早產率的證據有限.然而,同時發現消炎痛與安慰劑或不治療相比,并不能明顯降低圍生兒死亡率、新生兒呼吸窘迫綜合征、肺支氣管發育不良、壞死性小腸結腸炎、新生兒敗血癥或低體重兒.但這個系統評價樣本太小,尚不能發現有臨床意義的差異. (4) 擇期或非擇期剖宮產對早產婦女治療效果:1個系統評價結果發現,擇期剖宮產較非擇期剖宮產會增加孕母的發病率,卻不能降低新生兒的發病率和死亡率.但尚不能證明此效果是否對新生兒有臨床意義. (5) 改善早產妊娠結局的干預措施:①對早產者采用皮質類固醇:1個系統評價認為,對可能發生早產的婦女使用皮質激素較安慰劑或不處理能明顯降低早產兒出生后呼吸窘迫綜合征、新生兒死亡率和顱內出血的發生.②促甲狀腺激素釋放激素在早產中的運用:1個系統評價發現,在早產的高危婦女中,促甲狀腺激素釋放激素和類固醇激素聯合應用與單用皮質類固醇激素比較,對新生兒結局的影響無明顯差異,但會明顯增加孕母和胎兒的不良反應.③抗生素:1個系統評價發現,抗生素與安慰劑比較,不能延長孕周、降低新生兒死亡率,但可降低孕母感染率.
ObjectiveTo systematically review the clinical efficacy and safety of glucocorticoids, acetaminophen and antimicrobial drugs in the treatment of intrapartum fever in labor analgesia. MethodsThe PubMed, Embase, Cochrane Library, Web of Science, CBM, VIP, and CNKI databases were electronically searched to collect randomized controlled trials (RCTs) of glucocorticoids, acetaminophen, and antimicrobial drugs for intrapartum fever in labor analgesia from inception to June 30, 2023. Two reviewers independently screened the literature, extracted data, and evaluated the risk of bias of the included literature. Meta-analysis was then performed by using RevMan 5.4 software. ResultsA total of 10 RCTs involving 1 337 women were included. Meta-analysis showed that the use of glucocorticoids reduced the incidence of intrapartum fever in women with labor analgesia compared with the control group (OR=0.52, 95%CI 0.33 to 0.82, P<0.01). But there was no statistically significant difference between acetaminophen or antimicrobial drugs and the control group. ConclusionCurrent evidence shows that the use of glucocorticoids can reduce the incidence of intrapartum fever in labor analgesia, but the use of acetaminophen and antimicrobial drugs cannot reduce the incidence of intrapartum fever. Due to the limited quality and quantity of the included studies, more high quality studies are needed to verify the above conclusion.
ObjectiveTo evaluate the effect of low-to-moderate doses of corticosteroids on human infections with avian influenza A (H7N9) virus, and explore when to initiate the treatment of corticosteroids and the duration of corticosteroids administration.MethodsThe study collected clinical data of 8 cases with avian influenza A (H7N9) virus infection admitted from January 25, 2017 to May 12, 2017. The final analysis included 5 severe patients who had received adjuvant corticosteroid treatment. The variation curves of WBC, CRP, PCT, CK, HBDH, LDH, temperature, ratio of SpO2/FiO2 were depicted and analyzed. The progress of clinical improvements, deterioration and prognosis were observed and discussed.ResultsThere were 1 female and 4 males in the 5 included patients with a median age of 58.0 years, among them 3 survived. The median time of illness onset to hospitalization and diagnosis confirmed were 4 days and 8 days respectively; the median duration of hospitalization to admission to infective ICU were 3 days. The first course of adjuvant corticosteroid treatment was initiated 11 days (median) after admission with a duration of 4 days (median), during which, the serum levels of HBDH and LDH decreased remarkably except the patient 3, and the oxygenation (SpO2/FiO2) improved except the patient 3. The second course of systemic administration of corticosteroid was given at a median of 26.5 days after admission with a duration of 9 days (median), during which, the patients survived with improved oxygenation (SpO2/FiO2), and weaned from mechanical ventilation.ConclusionsFor patients suffered severe human infection with avian influenza A (H7N9) virus, low-to-moderate doses of corticosteroids may decrease the level of inflammation, regulate the aberrant immune response, improve the oxygenation, make an early unassisted breathing. And corticosteroids treatment can be initiated at the time of disease deterioration, after/at the peak inflammatory response, and within 10-14 days of ARDS. Also, the adjuvant corticosteroids may be administered when oxygenation is dificult to be improved by other ways, or dificult to be liberated from mechanical ventilation, suffering severe septic shock, and refractory fever. And the duration of corticosteroids may be prolonged to 10-14 days, or until the higher level of HBDH and LDH decreased again.
糖皮質激素在甲型H1N1流感中的應用探討
Objective To systematically evaluate the effect and safety of systemic corticosteroids for acute exacerbation of chronic obstructive pulmonary disease (COPD). Methods Databases including PubMed, EMbase, The Cochrane Library (Issue 6, 2015), Wanfang Data, CBM, CNKI were searched to collect randomized controlled trails (RCTs) about systemic corticosteroids for acute exacerbation of COPD from inception to July 2015. The meta-analysis was conducted using RevMan 5.3 software. Results A total of 11 RCTs involving 1298 patients were included. The results of meta-analysis showed that a statistically significant increase in the treatment success rate when using systemic corticosteroids (RR=1.11, 95%CI 1.01-1.21,P=0.02), and a non-significant difference of effect in the subgroup of emergency department and ICU patients (RR=0.98, 95%CI 0.90-1.08,P=0.74;RR=1.19, 95%CI 0.84-1.69,P=0.34). Conclusions Current studies suggest that systemic corticosteroids is beneficial in terms of treatment success rate, but subgroup analysis shows that this benefit is controversial in emergency department and ICU. however, due to the limited quantity of the included studies, the above conclusions still need more high quality research to be verified.
Objective To evaluate the safety and efficacy of dexamethasone intravitreal implant 0.7 mg (DEX) for treatment of macular edema associated with retinal vein occlusion (RVO). Methods This study was a six-month, randomized, double-masked, sham-controlled, multicenter, phase 3 clinical trial with a 2-month open-label study extension. Patients with branch or central RVO received DEX (n=129) or sham procedure (n=130) in the study eye at baseline; all patients who met re-treatment criteria received DEX at month 6. Efficacy measures included Early Treatment Diabetic Retinopathy Study (ETDRS), best-corrected visual acuity (BCVA), and central retinal thickness (CRT) on optical coherence tomography. Results Time to ≥15-letter BCVA improvement from baseline during the first 6 months (primary endpoint) was earlier with DEX than sham (P＜0.001). At month 2 (peak effect), the percentage of patients with ≥15-letter BCVA improvement from baseline was DEX: 34.9%, sham: 11.5%; mean BCVA change from baseline was DEX: 10.6±10.4 letters, sham: 1.7±12.3 letters; and mean CRT change from baseline was DEX: ?407±212 μm, sham: ?62±224 μm (all P＜0.001). Outcomes were better with DEX than sham in both branch and central RVO. The most common treatment-emergent adverse event was in-creased intraocular pressure (IOP). Increase sin IOP generally were controlled with topical medication. Mean IOP normalized by month 4, and no patient required incisional glaucoma surgery. Conclusions DEX had a favorable safety profile and provided clinically significant benefit in a Chinese patient population with RVO. Visual and anatomic outcomes were improved with DEX relative to sham for 3 - 4 months after a single implant.
Objective To examine the levels of nitrite /nitrate( NO2 /NO3 ) , IL-4 and IFN-γin exhaled breath condensates( EBCs) in patients with asthma, and to investigate the effect of corticosteroid treatment. Methods Forty patients diagnosed as mild to moderate asthma were recruited. Among them, twenty were newly diagnosed and steroid naive( non-treatment group) . The other 20 patients had been treated with corticosteroid treatment( treatment group) . Twenty healthy volunteers were enrolled as normal control.EBC samples were taken for measurement of NO2 /NO3, IL-4 and IFN-γlevels. Serum IL-4 and IFN-γ concentrations were also measured. Results NO2 /NO3 level in EBC of the non-treatment group was significantly higher than that of the normal controls and the treatment group[ ( 48. 55 ±27. 37) μmol / L vs( 24. 51 ±18. 22) μmol /L, ( 36. 06 ±25. 13) μmol /L, respectively, both P lt; 0. 05] , and no significant difference was found between the treatment group and the normal controls( P gt;0. 05) . The IL-4 and IFN-γ levels in both EBC and serum had no significant difference between the three groups ( all P gt; 0. 05) . Conclusion NO2 /NO3 in EBCs increases in asthmatic patients, and decreases after corticosteroid treatment. Whether IL-4 and IFN-γlevels can be used for reflecting airway inflammation need further study.
Objective To analyze the risk factors for postoperative cognitive confusion in a surgical intensive care unit. Methods A total of 388 consecutive patients in Surgical Intensive Care Unit of General Hospital of PLA were retrospectively studied. We posed clinical questions according to the patients with older age and large dosage corticosteroid. Using “Postoperative cognitive confusion” and“Intensive Care” as key words, we searched for evidence from MEDLINE (1968-2004). Results We found 3.1% (10/388) of the patients developed postoperative cognitive confusion. Of the 10 postoperative cognitive confusion patients, 9 were over 65 years old. 6.6% (9/136) of the patients (≥ 65 years old) developed postoperative cognitive confusion. While 0.4%(1/252) of the patients (＜65 years old) developed postoperative cognitive confusion. Older age (≥ 65 years old) may induce more postoperative cognitive confusion (P＜0.05). While 7.0% (5/71) of the patients treated by large dose corticosteroids (≥1 000 mg) developed postoperative cognitive confusion. And 1.65% (5/317) of the patients received corticosteroid with large dosage (＜1 000 mg) developed postoperative cognitive confusion. Large dosage corticosteroid (≥1 000 mg) may induce more postoperative cognitive confusion (P＜0.05). Conclusion Older age (≥ 65 years old) and high dose corticosteroid (≥1 000 mg) may be the two main risk factors for postoperative cognitive confusion.
ObjectiveTo prepare curcumin loaded monomethoxyl poly(ethylene glycol)-poly(lactic-co-glycolicacid) (mPEG-PLGA) nanopaticles (CUR-NPs), investigate the effect of curcumin (CUR) and CUR-NPs on reversing corticosteroid resistance induced by cigarette smoke extract (CSE), and compare biological function between CUR and CUR-NPs in macrophages RAW264.7. MethodsmPEG-PLGA nanoparticles loaded with CUR were prepared via emulsion solvent evaporation.In lipopolysaccharide (LPS) stimulated macrophages RAW264.7, budesonide (BUD) was used to treat macrophages RAW264.7.In LPS and CSE stimulated macrophages RAW264.7, BUD (10-10-10-5 mol/L), CUR(10-10-10-5 mol/L), CUR(10-7 mol/L)+BUD(10-9-10-5 mol/L), CUR(10-9-10-5 mol/L)+BUD(10-7 mol/L), and CUR-NPs(10-9-10-5 mol/L)+BUD(10-7 mol/L) were respectively used to treat macrophages RAW264.7 activated.The level of IL-8 in cell culture supernatant was measured by ELISA.In CSE stimulated macrophages RAW264.7, CUR(10-7 and 10-6 mol/L) and CUR-NPs(10-7 and 10-6 mol/L) were used to treat macrophages RAW264.7.The mRNA level of HDAC2 was measured by real-time PCR, the protein level of HDAC2 was measured by Western blot.Cellular uptake of CUR and CUR-NPs in macrophages RAW264.7 was determined by cellular fluorescence intensity observed and detected by laser confocal microscopy imaging. ResultsThe morphology of CUR-NPs was spherical and the mean particle size was (356.4±146.6)nm.Compared with LPS stimulation, co-stimulation of LPS and CSE led to a significant decrease in the maximum inhibitory rate of BUD on IL-8 (P < 0.05) and a significant increase in the 50% inhibitory concentration (IC50) of BUD on IL-8 (P < 0.05).When using LPS+CSE to stimulate, compared with BUD (10-10-10-5 mol/L) group, the maximum inhibitory rate of BUD in CUR (10-7 mol/L)+BUD (10-9-10-5 mol/L) group on IL-8 was significantly higher (P < 0.05) and the IC50 of BUD decreased significantly (P < 0.05).When using LPS+CSE to stimulate, CUR and CUR-NPs in 10-9, 10-8 and 10-7 mol/L concentration, the inhibitory rate of CUR-NPs+BUD (10-7 mol/L) on IL-8 was significantly higher than that of CUR+BUD (10-7 mol/L) (P < 0.05). CSE stimulation induced a significant decrease in the mRNA and protein expression of HDAC2. Compared with CSE group, the mRNA and protein levels of HDAC2 of CUR(10-7 and 10-6 mol/L) group and CUR-NPs(10-7 and 10-6 mol/L) group were significantly higher (P < 0.05).In 10-7 mol/L concentration, the mRNA and protein levels of HDAC2 in CUR-NPs group were significantly higher than those in CUR group.In 10-7 mol/L concentration, cellular uptake of CUR in CUR-NPs was significantly higher than the native CUR. ConclusionsCUR and CUR-NPs can reverse the corticosteroid resistance induced by CSE.CUR-NPs can improve the cellular uptake of CUR.In the case of low concentration, CUR-NPs have more biological activity than CUR.
Objective To investigate the clinical significance of low dose corticosteroid applied in early period after lung volume reduction surgery（LVRS）. Methods From Apr. 2001 to Mar. 2004, 27 patients with chronic obstructive pulmonary disease were undergone video-assisted unilateral LVRS assisted with mini-incision in our department were retrospectively reviewed. According to whether dispensed with postoperative corticosteroid or not, patients were divided into corticosteroid group and non-corticosteroid group. Corticosteroid group received dexamethasone 10mg iv tid for 3 days and then declined to prednisone 5mg qd for 7 days. Both groups were measured and compared the quantity of thoracic drainage flow, duration of chest tube drainage, the time of air leaks and fever, and so on. At same time, blood gas analysis and blood routine test were performed at 1, 3, 7 and 30 d after operation. Results Corticosteroid and non-corticosteroid groups had no statistically differences in the air leaks time （P 〉 0.05）, but the quantity of thoracic drainage flow of corticosteroid group was lower than that of non-corticosteroid group evidently （700±210ml vs. 950±150ml, P = 0.001）. There was significant difference in average duration of chest tube drainage between both groups （9±3 d vs. 12±2 d, P = 0. 05）. Compared with non-corticosteroidgroup, PaO2 of corticosteroid group was higher at 1, 3d after operation （P〈0.05）. The amount of blood leukocyte of corticosteroid group was lower than that of non-corticosteroid group at 3, 7d after operation, there was no statistically significant in two groups （P 〉 0. 05）. At early period after surgery, both groups had no significant infection and death patient. Conclusion The low dose corticosteroid applied in early period after LVRS for short time（10 days in this research） could shorten the duration of chest tube drainage, decrease the quantity of thoracic drainage flow and the extent of inflammation in pleural cavity. In the mean time, this treatment does not increase the occurrence of significant complications during the early postoperative period, and there is no negative influence to the blood gas analysis.