"阳化气,阴成形"是对阴阳生理功能的高度概括,阳推动有形阴精弥散为无形之气以实现脏腑功能,阴凝聚无形之气为有形阴精而滋润周身内外,二者在相互制约中维持动态平衡,其中阳化气在该过程中占据主导地位.系统性硬化症(systemic sclerosis,SSc)属于中医"皮痹"范畴,全程分为水肿期、硬化期和萎缩期,病程中常易累及心、肺、肾、胃肠道等脏腑.阳化气不足是SSc发病的根本原因,以肺脾肾三脏阳气亏虚为主,脏腑功能减退,有形阴邪凝聚过多,阴成形太过是SSc发展的必经环节.治疗以温阳化气、化痰祛瘀为原则,温补与温通共施,促进气化,振奋脏腑机能,助阴翳消散;祛瘀化痰治其标证,助阳气通达.扶阳、抑阴二法贯穿疾病始终,相辅相成.又因疾病分期中存在脏腑、虚实等主次之别而各有侧重,同时兼顾养阴以荣润肌肤、阴中求阳.病理上阳化气不足促使阴成形过度,阴成形太过又阻碍阳化气过程,二者形成恶性循环,导致SSc的发生发展.治疗上扶阳为主导,打破恶性循环,兼能抑阴,抑阴又能扶阳,二法形成正向循环,使得阳气复、阴凝散,改善患者症状、延缓病情进展.

Objective: To preliminarily analyze the application experience of veno-arterio-venous extracorporeal membrane oxygenation (VAV-ECMO).The VAV-ECMO is a rescue strategy for patients with extremely critical respiratory failure combined with refractory shock. Methods: From February 2016 to February 2022, the characteristics and outcomes of patients who were started on either veno-venous or veno-arterial ECMO due to respiratory or hemodynamic failure, and then converted to VAV-ECMO in respiratory intensive care unit (ICU) of Beijing Chaoyang Hospital were analyzed. Results: A total of 15 patients underwent VAV-ECMO, aged 53 (40, 65) years, and 11 of whom were male. Within the group, VV-ECMO was initially used in 12 patients due to respiratory failure, but then VAV-ECMO was used due to cardiogenic shock (7/12) and septic shock (4/12), while VAV-ECMO was established in two patients due to lung transplantation. One patient was diagnosed with pneumonia complicated by septic shock, which was initially determined to be VA-ECMO, but then switched to VAV-ECMO because it was difficult to maintain oxygenation. The time from the establishment of VV or VA-ECMO to the switch to VAV-ECMO was 3 (1, 5) days and the VAV-ECMO support time was 5 (2, 8) days. ECMO-related complications were bleeding, mostly in the digestive tract (n=4) and airway hemorrhage (n=4), without intracranial hemorrhage, and poor arterial perfusion of the lower limbs (n=2). Among these 15 patients, the overall ICU mortality was 53.3%. The mortality of patients who received VAV-ECMO due to septic shock and cardiogenic shock was 100% (4/4) and 42.8% (3/7), respectively. Two patients who received VAV-ECMO due to lung transplantation all survived. Conclusion: VAV-ECMO may be a safe and effective treatment for carefully selected patients with critical respiratory failure associated with cardiogenic shock or end-stage lung disease lung transplantation transition, however, patients with septic shock may benefit the least.

张春艳主任医师认为类风湿关节炎活动期多见湿热痹阻证,湿热邪气是其发生的根源,经络闭阻、气血阻滞是病机本质,二者共同组成该病的核心病机.临证常运用吴鞠通《温病条辨》中宣痹汤为底方,清热祛湿为主,宣气化湿、通达经络为辅,共奏清湿热、开郁结、通经络之功,且不拘泥于原方,随证化裁,制方出新.

目的 观察中医蜡药疗联合柳氮磺吡啶对强直性脊柱炎的临床疗效.方法 选取2016年6月至2019年2月北京中医药大学东方医院风湿科130例寒湿痹阻、肝肾不足型强直性脊柱炎患者126例,按照随机数字表法分为治疗组与对照组,各63例.对照组给予柳氮磺吡啶肠溶片治疗,治疗组在对照组基础上加予中医蜡药疗,疗程8周,分别观察治疗前和第2、4、8周患者中医症状体征评分、脊柱疼痛视觉模拟评分(visual analogue scale,VAS),监测患者血常规、尿常规、便常规、肝肾功能和心电图评估安全性.结果 治疗组总有效率71.42％,高于对照组的50.79％(P<0.05).治疗后,治疗组腰骶脊背疼痛、夜间痛和脊柱疼痛VAS评分在第2、4和8周评分均较治疗前下降(P<0.05),晨僵和腰膝酸软评分在第4和8周评分较治疗前下降(P<0.05),足跟痛评分在第8周较治疗前下降(P<0.05),对照组中腰骶脊背疼痛及晨僵评分在第4和8周较治疗前下降,夜间痛及腰膝酸软评分在第8周较治疗前下降(P<0.05),且治疗组中腰骶脊背疼痛和脊柱VAS评分在第2、4、8周均较对照组显著降低(P<0.05),晨僵评分在第8周较对照组显著降低(P<0.05),夜间痛评分在第4和8周较对照组显著降低(P<0.05).两组均未发生过敏反应及血常规、尿常规、便常规、肝肾功能、心电图异常.结论 中医蜡药疗联合柳氮磺吡啶治疗寒湿痹阻,肝肾不足型强直性脊柱炎患者疗效确切.

清代著名医家叶天士对于杂病的造诣颇深,对于痹证有较为丰富的论治,《临证指南医案》是叶天士学术思想的集中体现,其中痹证医案较多,也独具特色,较好地反映叶天士的辨证论治思想体系和用药特点.叶氏对于仲景治疗痹证的思想加以继承发扬,在治疗上具有疏风宣肺、补益中焦和温肾壮督等理论特色,用药上根据不同病情讲究芪术同用,善用寒凉以及温药壮督,其疗效显著.本文基于仲景学说,探究叶氏在痹证治疗过程中的继承与创新.

青霉素类药物抗菌活性强、抗菌谱广、毒性低,是具有重要临床价值且广泛应用的抗菌药物.变态反应为青霉素类最常见的不良反应,Ⅰ、Ⅱ和Ⅲ型变态反应总发生率为3％～10％,最严重的是Ⅰ型速发型过敏反应,即过敏性休克,发生率占用药人数的0. 4?～1. 5?,病死率为0. 1?[1].《中华人民共和国药典临床用药须知(2015年版)》规定:使用青霉素类药物前需做青霉素皮肤敏感试验,阳性反应者禁用[2].

目的 评价耳穴压丸联合神阙穴贴敷在危重症急性胃肠损伤(AGI)患者护理中的应用效果.方法 选取2018年10月—2019年10月北京中医药大学东方医院急诊监护病房住院的60例危重症急性胃肠损伤患者为研究对象,按组间基本特征具有可比性的原则分为对照组和观察组,每组30例.对照组实施常规护理,观察组在对照组基础上给予耳穴压丸联合神阙穴贴敷.治疗疗程为7 d.在入组前及贴敷后第7天记录AGI分级、腹胀评分、胃残留、西药通便药的使用情况及血红蛋白(HGB)、白蛋白(ALB)、肝肾功能(AST,ALT,BUN,CERA).结果 与对照组相比,耳穴压丸联合神阙穴贴敷可以降低AGI分级、减轻腹胀、改善胃残留、减少西药通便药的使用、提高ALB(P<0.05);但对HGB、肝肾功能及病死率比较,差异无统计学意义(P>0.05).结论 耳穴压丸联合神阙穴贴敷可以改善危重患者急性胃肠损伤,促进胃肠功能营养恢复,同时具有操作简单、方便、无创伤、安全易于接受等优点.

目的 探讨体外膜肺氧合(ECMO)联合应用期间连续性肾脏替代治疗(CRRT)非计划性下机的影响因素,构建预测模型并评价其效能.方法 选择呼吸重症监护病房行ECMO联合CRRT治疗的45例患者,统计ECMO联合应用期间CRRT发生非计划性下机的例次,对比计划下机组和非计划性下机组指标,采用logistic回归方程构建预测模型,运用ROC曲线下面积检验模型预测效果.结果45例患者共行ECMO联合CRRT治疗343例次,其中无明确诱因的CRRT非计划性下机为212例次(61.8％),logistic回归分析显示,CRRT血流速度(OR=0.924)、ECMO血流速度(OR=1.706)及ECMO模式(OR=4.764)是ECMO联合应用期间CRRT非计划性下机的预测因子,预测模型ROC曲线下面积为0.812,灵敏度0.825,特异度0.696,最大约登指数0.521,预测模型拟合优势比X2=10.113,P=0.257.结论 本预测模型效果良好,临床医务人员在ECMO联合CRRT治疗期间,可结合预测模型做好运行监测并进行针对性处理.

新安医学作为具有地域特色的医学流派,对脾胃极为重视,认为脾胃为气血生化之源,主运化,为营卫生化之本,是维系四肢关节运动功能正常的基础,脾胃功能失常则可引起肌肉骨节的相关病变.新安医家从脾胃阳明论治痹证,其治则治法独具特色,包含:培元护本,正盛托邪;健脾利湿,化瘀通痹;善用参芪,调和营卫.上述经验对当今风湿性疾病的治疗仍有较大的指导意义.附验案1则以佐证.

目的 分析原发性干燥综合征合并肾损害的临床特点.方法 回顾性分析2015年9月1日至2020年9月1日北京中医药大学东方医院收治的153例原发性干燥综合征患者的临床资料.根据慢性肾脏病诊断标准及慢性肾衰竭的诊断标准将153例患者分为肾损害组(81例)和无肾损害组(72例),比较两组临床特征的差异.结果 肾损害组低钾血症、高尿酸血症、白内障的发生率高于无肾损害组(P<0.05),尿频、乏力、气短、腹泻的发生率高于无肾损害组(P<0.05);实验室指标中肾损害组血清钠、白蛋白、肌酐清除率和估算肾小球滤过率低于无肾损害组,尿素、β2微球蛋白水平高于无肾损害组,差异有显著性(P<0.05);两组免疫指标比较差异无显著性(P>0.05).结论 原发性干燥综合征患者肾损害发生率较高,临床应予以重视.

目的 探讨《中华医典》中古代医家治疗膝骨关节炎的遣方用药规律.方法 在《中华医典》中检索古代膝骨关节炎的内治方,采用中医传承辅助平台软件对方剂进行关联规则、复杂系统熵聚类等分析,挖掘药物使用规律.结果 共纳入197首方剂,包含236味中药,对其进行分析,发现这些中药性偏温平,味以辛、甘、苦为主,多归肝、脾、肾经.其中活血类药物占比最高,频数在前三位的是当归、牛膝和川芎,活血药多配伍祛风湿药、补益药、温里药使用;通过关联规则分析,挖掘出新处方9个.结论 《中华医典》中记载古代医家治疗膝骨关节炎最常使用的药物是当归、牛膝和川芎,最注重活血化瘀法,并配以祛风湿、补益、温里等治法.

1 病例资料 患者,女,72岁,因"双手近端第2、3指间关节肿胀疼痛2月"于2020年3月30日就诊于本院风湿科,查体:双手近端第2、3指间关节肿胀压痛,晨僵>1 h,辅助检查:类风湿因子 301 IU·mL-1,抗环瓜氨酸抗体>200 RU·mL-1,C-反应蛋白(CRP)12.5 mg·L-1,血沉47 mm·h-1,抗核抗体谱(-),血常规及肝肾功能正常,诊断为类风湿关节炎.既往无肺部相关基础疾病,给予来氟米特(苏州长征-欣凯制药有限公司,批号:191006)常规剂量治疗(20 mg po qd),并定期复查.6月5日复诊时,患者诉近1月无明显诱因出现阵发性干咳,无呼吸困难,无咳痰,无鼻痒流涕,无关节肿痛,晨僵不明显.复查CRP<5.0 mg·L-1,血沉47 mm·h-1,血常规、肝肾功能均未见异常.同期,患者因阵发性干咳已前往外院呼吸科就诊,并完善胸部CT检查,提示双肺散在少许斑索影,外院呼吸科暂未考虑肺系疾病,并嘱患者密切观察.故在原治疗方案不变的基础上加用苏黄止咳胶囊对症治疗,2周后患者咳嗽症状未缓解,停用苏黄止咳胶囊.7月3日复诊时患者诉仍有阵发性干咳,夜间症状明显,考虑患者咳嗽可能与胃食管反流相关,原治疗方案不变,加用雷贝拉唑钠肠溶胶囊(20 mg qd)试探性治疗.治疗3周后,患者咳嗽症状仍无缓解,停用雷贝拉唑钠肠溶胶囊.患者于8月3日再次复查胸部CT仍提示双肺散在少许斑索影与前相仿.8月21日患者复诊时仍以阵发性干咳为主诉,关节肿痛、晨僵等症状均不明显,血常规、肝肾功能及炎症指标均正常,考虑患者咳嗽可能与来氟米特有关,故停用,治疗方案改为艾拉莫德(25 mg po bid).

Objective:To systematically evaluate the efficacy of high-flow nasal cannula (HFNC) on hypoxemia after cardiac surgery.Methods:SinoMed, CNKI, Wanfang data, VIP databases, PubMed, EBSCO, Elsevier, Cochrane Library for randomized controlled trials (RCTs) or cohort studies evaluating the efficacy of HFNC on hypoxemia in patients after cardiac surgery, with the search time limitation from the inception of the database to April 2, 2021. The references of these included articles were retrieved.Two researchers extracted and evaluated the literature, and used Revman 5.3 software for statistical analysis.Results:The analyses included 14 studies, including 12 RCTs and 2 cohort studies, with a total of 2 139 patients. The Meta-analysis results showed that compared with conventional oxygen therapy and non-invasive positive pressure ventilation, HFNC could reduce intubation rate ( MD=0.33, 95% CI: 0.15 to 0.72, P=0.005) , respiratory rate ( MD=-3.20, 95% CI: -5.26 to -1.13, P=0.002) , heart rate ( MD=-9.44, 95% CI: -18.44 to 0.45, P=0.04) , and increase oxygenation index ( MD= 29.21, 95% CI: 8.63 to 49.79, P=0.005) . There was no significant difference in the length of stay in ICU ( MD=-7.92, 95% CI: -17.23 to 1.40, P=0.10) . Conclusions:HFNC is superior to conventional oxygen therapy and non-invasive positive pressure ventilation in reducing the respiratory rate, heart rate, intubation rate and increasing the oxygenation index of patients with hypoxemia after cardiac surgery.

目的 基于中医传承辅助平台V2.5软件,探讨活血化瘀法治疗膝骨关节炎的组方用药规律.方法检索中国期刊全文数据库(CNKI)、万方数据库(Wanfang)、维普数据库(VIP),收集活血化瘀法治疗膝骨关节炎的相关文献,录入中医传承辅助平台建立数据库,采用关联规则、复杂系统熵聚类等方法进行相关数据挖掘.结果共筛选出155个中药处方,涉及164味中药,对其进行分析,方剂中应用频次在前3位的活血药分别是牛膝、当归、鸡血藤,频次最高的药性为温,药味为甘,药物归经为肝.通过关联规则分析,挖掘出16个核心组合和8个新处方.结论活血化瘀法治疗膝骨关节炎,药物的配伍以牛膝为核心,和血药与活血药相须为用,最常配伍补益肝肾药,次为益气补血药.

目的:评价ICU后门诊的实践效果.方法:设立ICU后门诊,采用医护协作诊疗模式,对ICU出院患者进行综合评估,制定康复方案并指导实施,必要时专科转诊,同时提供动态延续护理服务.结果:ICU后门诊开设2年多来,共随访患者146例,健康评估346例次,运动方案指导及日常生活能力训练334例次,呼吸训练214例次,健康指导379例次,ICU后门诊随访患者的再住院率低于电话随访组(P<0.05),重返工作率高于电话随访组(P<0.05).患者及家属满意度为99.07％,出诊护士认为ICU后门诊有利于提高自我专业问题处理能力.结论:ICU后门诊可有效解决ICU出院患者康复问题,有利于患者身体及社会功能恢复,提升患者满意度及护士专业能力.

目的 深入了解重症急性呼吸窘迫综合征(acute respiratory distress syndrome,ARDS)出院患者康复体验,为制定有效的康复计划提供依据.方法 采用目的抽样方法,于2019年5月至11月对北京市某三级甲等医院呼吸重症监护室好转出院的12例重症ARDS患者进行半结构式访谈,应用扎根理论三级编码的方法进行资料分析.结果 共提炼4个主题:疾病后遗症带来的康复困扰(治疗并发症导致对康复安全性的顾虑、身体机能减退导致康复类型受限);康复效果的不确定感;社会支持不当(家属过度保护、专业人员康复支持不足);创伤后成长(接受、适应、自我反应).结论 影响重症ARDS出院患者康复的消极和积极因素包括疾病因素、个体因素、家庭因素和创伤后成长.建立康复信心、良好心理调适、调动家属支持和利用互联网+技术,做好出院患者康复管理,是重症ARDS出院患者康复计划制订和实施的有效途径.

目的 开展内科危重症患者规范化深静脉血栓预防的循证护理,制订护理质量审查指标并分析循证护理过程中的障碍因素和促进因素.方法 以澳大利亚循证卫生保健中心"证据临床应用模式"为理论指导,组建团队,系统检索、评价并汇总证据,确立审查指标及审查方法 ,逐条进行质量审查,根据审查指标及审查结果 分析障碍因素及促进因素,制订行动策略.结果 本研究从评估层面、预防实施层面、教育管理层面共汇总最佳证据21条,经过筛选将其中8条最佳证据作为构建审查标准的证据,制订了10条质量审查指标,障碍因素主要为系统层面评估工具缺乏,流程缺失,实践者层面预防意识薄弱.结论 本研究基于最佳证据并结合临床人员的专业判断制订的质量审查指标具有科学性可实施性,需针对障碍和促进因素实施变革,促进证据转化.

ECMO院际转运在国外已经开展得非常成熟且规范,而我国却刚开始尝试,国内相关文献仅有一些个案报道,所以本文从ECMO院际转运的形式、转运流程、转运团队的组成、转运交通工具的选择、转运设备和耗材管理以及转运过程中的不良事件等方面进行综述,以期为国内ECMO院际转运的发展提供借鉴.

Objective To summarize the best evidence for the prevention of deep venous thrombosis (DVT) in critically ill patients, and to provide a reference for medical institutions and medical staff, so as to reduce the incidence of DVT in critically ill patients. MethodsThe PICO problem was raised for the prevention of DVT in critically ill patients during hospitalization. All evidence concerning the prevention of deep venous thrombosis in critically ill patients were retrieved from PubMed, Cochran Library, BMJ Best Practice, UpToDate,Ovid,Web of Science,Joanna Briggs Institute Evidence-based Health Care Center Database, National Guideline Clearinghouse (NGC), National Institute for Health and Care Excellence (NICE), Scottish Intercollegiate Guidelines Network (SIGN), Guidelines International Network (GIN), Registered Nurses' Association of Ontario (RNAO) and China Biology Medicine disc (CBMdisc) by computer, which included guidelines, systematic evaluation, evidence summary and original data intimately related to evidence. The literature quality was evaluated and the recommendation level of evidence was determined according to the JBI evidence recommendation level system (2014 edition). ResultsA total of 15 references were included through electronic database retrieval, including 6 guidelines, 5 evidence summaries and 4 systematic evaluations. According to the judgment of comprehensive professionals, totally 21 evidence selected,including the risk assessment of deep venous thrombosis, drug prevention, mechanical prevention, combined prevention and educational management. ConclusionsThis study summarizes the best evidence for the prevention of DVT in critically ill patients, and helps nurses with ICU decision-making, through the application of best evidence, to promote the prevention of deep venous thrombosis in critical internal medicine patients, improve the outcome of patients and elevate the quality of nursing care.