#31
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Óâàæàåìûé ìîäåðàòîð ôîðóìà "Îçîíîòåðàïèÿ"!
Íåæåëàòåëüíûå ýôôåêòû àíòèáàêòåðèàëüíûõ ïðåïàðàòîâ õîðîøî èçâåñòíû è îïèñàíû. Âàøè äåòñêèå ïðåäñòàâëåíèÿ î ëå÷åíèè áîëüíûõ (â ò.÷., ïî-âèäèìîìó, è íîâîðîæäåííûõ ñ ñåïñèñîì) , ê ñîæàëåíèþ, òîæå õîðîøî èçâåñòíû. Óáåäèòåëüíî ïðîøó Âàñ ïðîäîëæèòü ñìåøèòü ëþäåé â ðàìêàõ Âàøåãî ôîðóìà. |
#32
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Ðåàãèðîâàòü íà ðåïëèêó ïðåäûäóùåãî àâòîðà íåò æåëàíèÿ.
Äëÿ îñòàëüíûõ ó÷àñòíèêîâ. Îò àíòèáèîòèêîâ, òåì áîëåå ïðè ñåïñèñå, åñòåñòâåííî íèêòî íå îòêàçûâàåòñÿ. Íî êîãäà ïðè ëå÷åíèè îíè åäèíñòâåííûå è íåïîâòîðèìûå - õîðîøåãî ìàëî. Ïîýòîìó è ïðèâåë ñîîáùåíèå, ëèøíèé ðàç ïîä÷åðêèâàþùåå, ÷òî âîïðîñû ïî èììóíîêîððåêöèè, èììóíîðåàáèëèòàöèè çëîáîäíåâíû óæå â÷åðà, à íå â íåîïðåäåëåííîì áóäóùåì. |
#33
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Âèäèòå ëè , Âëàäèìèð ßêîâëåâè÷ , îáû÷íî äîêòîðà íå áåãàþò ïî êâàðòèðàì è íå âñûïàþò â ðîò äåòÿì àíòèáèîòèêè. Èõ íàçíà÷àþò ( â òîì ÷èñëå è äî 7 ëåò ) äåòÿì , êîòîðûå áîëåëè ÷åì-òî òàêèì , ÷òî ïîòðåáîâàëî ëå÷åíåèÿ . ( Áóðíûé ñïè÷ î íàçíà÷åíèÿõ áåç ïîêàçàíèé óìåñòåí , íî â äðóãîé áåñåäå). Âðÿä ëè ìîæíî óäèâëÿòüñÿ òîìó , ÷òî ýòè æå äåòè â äàëüíåéøåì èìåëè è áîëüøèé ðèñê áðîíõèàëüíîé àñòìû .
Íàïðèìåð , èõ ðîäèòåëè áûëè êóðÿùèìè è ïëîõî çàáîòèëèñü î äåòÿõ , ÷òî è ïðèâåëî ê òîìó , ÷òî ðåñïèðàòîðíûé òðàêò ýòèõ äåòåé áûë ïîðàæåí ñóùåñòâåííî óæå â ðàííåì âîçðàñòå , è , åñòåñòâåííî , áûëî áîëüøå øàíñîâ íà ôîðìèðîâàíèå õðîíè÷åñêèõ áîëåçåíé . Âïðî÷åì , Âû â ÂÀøåì îòäåëåíèè èíòåíñèâíîé òåðàïèè íîâîðîæäåííûõ è âñåãî ïðî÷åãî , ñ ÂÀøèì êîëîññàëüíûì îïûòîì ïåäèàòðà , óðîëîãà , ãèíåêîëîãà è ýíäîêðèíîëîãà ìîæåòå , ñ ðàçðåøåíèÿ ýòè÷åñêîãî êîìèòåòà , ðàçäåëèòü íîâîðîæäåííûõ íà äâå ãðóïïû ( íå çàáóäüòå ðàçðåøåíèå îò ðîäèòåëåé ) è ëå÷èòü îäíó ãðóïïó ïðèçíàííûìè ìåòîäàìè , à äðóãóþ - ðàçðàáîòàííûìè ëè÷íî ÂÀìè . Ðåçóëüòàòû , ïîäîçðåâàþ , áóäóò åùå áîëåå âïå÷àòëÿþùèìè - ó ëå÷åííûõ òðàäèöèîííûìè ìåòîäàìè ñôîðìèðóþòñÿ èíôàðêòû ê 60 ãîäàì , èíñóëüòû ê 70 , à ðàêè ùèòîâèäíîé æåëåçû ê 1120 ãîäàì ãîðàçäî â áîëüøåì ïðîöåíòå ñëó÷àåâ , ÷åì â êîíòðîëüíîé ( ðàíäîìèçèðîâàíî â êîíòðîëüíóþ ãðóïïó 100 ÷åëîâåê , âûæèë 1 , ê ãîäó èìåë âñåãî - íàâñåãî îòñòàâàíèå ôèçè÷åñêîãî è ïñèõè÷åñêîãî ðàçâèòèÿ , íàáëþäåíèå ïëàíèðóåòñÿ ïðîäîëæèòü ). Ïðîøó ïðîùåíèÿ ó äåòñêèõ ðåàíèìàòîëîãîâ , ëþäåé , ïåðåä òÿæåëåéøèì òðóäîì êîòîðûõ ïðåêëîíÿþñü , çà âóëüãàðíóþ ðåïëèêó.
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Ã.À. Ìåëüíè÷åíêî |
#34
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Ãàëèíà Àôàíàñüåâíà!
Çà ìåíÿ ìîæíî äîìûñëèòü âñå ÷òî óãîäíî, ñ ÷åì ïîñòîÿííî ñòàëêèâàþñü íà ôîðóìå. Íî ìîé ïîñò áûë ëèøü ðåàêöèÿ íà ðåêîìåíäàöèè, ÷òî îïðåäåëèòåñü ñ ðàöèîíàëüíîé àíòèáàêòåðèàëüíîé òåðàïèåé (÷òî ñàìî ïî ñåáå ñîâåðøåííî ðàçóìíî), à îá èììóíèòåòå ìîæíî áóäåò ïîðàññóæäàòü, êîãäà î íåì íàïèøóò â ñòàíäàðòàõ. |
#35
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Óâàæàåìûé Âëàäëåí!
Ïîíÿòíî, ÷òî ðóòèííîå íàçíà÷åíèå ÊÑÔ íå ïîêàçàíî äëÿ ïðîôèëàêòèêè/ëå÷åíèÿ ñåïñèñà ó íîâîðîæäåííûõ, íî õîòåëîñü áû óñëûøàòü Âàøå ìíåíèå îá èõ èñïîëüçîâàíèè ïðè ñåïòè÷åñêîì ïðîöåññå íà ôîíå ïðîäîëæàþùåéñÿ íåéòðîïåíèè? Êàêîâû ðåêîìåíäàöèè ïî ýòîìó ïîâîäó â Èçðàèëå? Ìîæåò ëè òàêàÿ òåðàïèÿ áûòü "òåðàïèåé îò÷àÿíèÿ" èëè òîëüêî îãðàíè÷èòüñÿ â ïðåäåëàõ çàïëàíèðîâàííîãî òðàéëà? |
#36
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[Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ]
Òàêèì îáðàçîì, ñòàíîâèòñÿ î÷åâèäíî, ÷òî çîëîòûì ñòàíäàðòîì òåðàïèè ñåïñèñà ÿâëÿåòñÿ îäíîâðåìåííîå èñïîëüçîâàíèå íàðÿäó ñ àíòèáàêòåðèàëüíîé òåðàïèåé ... [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] …îòäåëåíèÿ ïàòîëîãèè íîâîðîæäåííûõ Äåòñêîé Ãîðîäñêîé êëèíè÷åñêîé áîëüíèöû N 13 èìåíè Í.Ô. Ôèëàòîâà ñ ïîìîùüþ äâîéíîãî ñëåïîãî ðàíäîìèçèðîâàííîãî ìåòîäà ñ ôîðìèðîâàíèåì äâóõ îñíîâíûõ….. |
#37
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Óâàæàåìûé Dr. Vad !
Ëè÷íî ìíå íå èçâåñòíû ðàáîòû, îäíîçíà÷íî ïîäòâåðæäàþùèå ýôôåêòèâíîñòü granulocyte colony-stimulating factor ïðè ëå÷åíèè ñåïñèñà ñ íåéòðîïåíèåé ó íîâîðîæäåííûõ (âêëþ÷àÿ íåäîíîøåííûõ).  íàøåé êëèíèêå çà ïîñëåäíèå íåñêîëüêî ëåò îí èñïîëüçîâàëñÿ äëÿ ýòîé öåëè ëèøü îäíàæäû â ñëó÷àå ñåïñèñà ñî ñòîéêîé íåéòðîïåíèåé ó ãëóáîêî íåäîíîøåííîãî ðåáåíêà.Òîãäà íåéòðîïåíèÿ èñ÷åçëà â òå÷åíèå íåñêîëüêèõ äíåé. Êàê âû ïðåêðàñíî ïîíèìàåòå, ýòîãî íàáëþäåíèÿ íå äîñòàòî÷íî äëÿ îöåíêè åãî ýôôåêòèâíîñòè. Ñëåäóåò òàêæå îòìåòèòü, ÷òî íåêîòîðûå èçâåñòíûå íåæåëàòåëüíûå ýôôåêòû granulocyte colony-stimulating factor, íàïðèìåð, òðîìáîöèòîïåíèÿ, ñóùåñòâåííî îãðàíè÷èâàþò åãî ïðèìåíåíèå ïðè òÿæåëûõ ôîðìàõ ñåïñèñà ó íîâîðîæäåííûõ\íåäîíîøåííûõ äåòåé. Ïðè ýòîì ðàöèîíàëüíàÿ àíòèáèîòèêîòåðàïèÿ ÿâëÿåòñÿ âûñîêîýôôåêòèâíûì ìåòîäîì ëå÷åíèÿ ñåïñèñà è â ïîäàâëÿþùåì áîëüøèíñòâå ñëó÷àåâ ïðèâîäèò ê èçëå÷åíèþ äàæå ó äåòåé, ðîæäåííûõ íà 24-25 íåäåëÿõ áåðåìåííîñòè. Äóìàþ, ÷òî ïðè ïðàâèëüíî ïîñòàâëåííîé äèàãíîñòèêå è ñâîåâðåìåííî íàçíà÷åííîì àíòèáàêòðåðèàëüíîì ëå÷åíèè â ïðèíöèïå íîâîðîæäåííûå íå äîëæíû óìèðàòü îò áàêòåðèàëüíûõ îñëîæíåíèé.  çàêëþ÷åíèå ïîçâîëþ ñåáå ïðèâåñòè ðÿä ññûëîê, êîòîðûå, âîçìîæíî, âàñ çàèíòåðåñóþò ( åñëè âû õîòèòå ïîëó÷èòü full text íàïèøèòå ìíå îá ýòîì). 1. A randomized, double-masked, placebo-controlled trial of recombinant granulocyte colony-stimulating factor administration to preterm infants with the clinical diagnosis of early-onset sepsis. Miura E - Pediatrics - 01-JAN-2001; 107(1): 30-5 From NIH/NLM MEDLINE Department of Pediatrics, Division of Neonatology, Hospital de Clínicas de Porto Alegre, Faculty of Medicine, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil. Abstract: OBJECTIVE: We performed a randomized, double-masked, parallel-groups, placebo-controlled trial of recombinant granulocyte colony-stimulating factor (rG-CSF) administration to 44 preterm neonates who had blood cultures obtained and antibiotics begun because of the clinical diagnosis of early-onset sepsis. Two primary outcome variables were tested 1) mortality and 2) development of nosocomial infections over the 2-week period after dosing. DESIGN AND METHODS: The treatment group (n = 22) received 10 microgram/kg/day of intravenous rG-CSF once daily for 3 days and the placebo group (n = 22) received the same volume of a visually indistinguishable vehicle. Mortality and culture-proven nosocomial infections were recorded. Immediately before the first, second, and third doses, and again 10 days after the first dose, serum concentrations were determined for tumor necrosis factor-alpha, interleukin 6, granulocyte-macrophage colony stimulating factor, and G-CSF, and blood leukocyte counts, absolute neutrophil counts, immature/total neutrophil ratios, platelet counts, and hemoglobin concentrations were measured. RESULTS: The treatment and placebo groups were of similar gestational age (29 +/- 3 vs 31 +/- 3 weeks) and birth weight (1376 +/- 491 vs 1404 +/- 508 g), and had similar Apgar scores and 24-hour Score for Neonatal Acute Physiology scores. The mortality rate was not different between treatment and placebo groups. However, the occurrence of a subsequent nosocomial infection was lower in the rG-CSF recipients (relative risk:.19; 95% confidence interval:.05-.78). rG-CSF treatment did not alter the serum concentrations of the cytokines measured (except for G-CSF). Serum G-CSF levels and blood neutrophil counts were higher in the treatment than in the placebo group 24 hours and 48 hours after dosing. CONCLUSIONS: Administration of 3 daily doses of rG-CSF (10 microgram/kg/day) to premature neonates with the clinical diagnosis of early-onset sepsis did not improve mortality but was associated with acquiring fewer nosocomial infections over the subsequent 2 weeks. 2.Administration of recombinant granulocyte colony-stimulating factor to neonates with septicemia: A meta-analysis. Bernstein HM - J Pediatr - 01-JUN-2001; 138(6): 917-20 From NIH/NLM MEDLINE Author Affiliation: Division of Neonatology, Department of Pediatrics, University of Florida College of Medicine, Gainesville, FL 32610, USA. Abstract: A meta-analysis was used to determine whether administering recombinant granulocyte colony-stimulating factor (rG-CSF) to neonates with bacterial septicemia reduces mortality. Five studies were identified, involving 73 rG-CSF recipients and 82 control subjects. Mortality was lower among the rG-CSF recipients (odds ratio, 0.17; CI, 0.03-0.70; P <.05). However, when the non-randomized studies were excluded, the P value was.13. For the subgroups "<2000 g" or "neutropenia," the P value was <.02. Thus the routine use of rG-CSF cannot be recommended for all neonates with sepsis. |
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#38
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Óâàæàåìûé Âëàäëåí!
Áîëüøîå ñïàñèáî, çíàêîì ñ íåêîòîðûìè ïîëíîòåêñòîâûìè ðàáîòàìè, êîòîðûå êàê è â ïðèâåäåííûõ Âàìè óêàçûâàþò íà íåîáõîäèìîñòü ïðîâåäåíèÿ ñïåö. îðãàíèçîâàííûõ òðàéëîâ äëÿ ðåøåíèÿ âîïðîñà î öåëåñîîáðàçíîñòè ïðèìåíåíèÿ ÊÑÔ ïðè ñåïñèñå è íåéòðîïåíèè ó íîâîðîæäåííûõ.  íàøèõ óñëîâèÿõ âñå æå áîëüøåå âíèìàíèå óäåëÿåì ñîêðàùåíèþ ïåðèîäà ôåáðèëüíîé íåéòðîïåíèè/àãðàíóëîöèòîçà, òê äàæå îïàñíóþ òðîìáîöèòîïåíèþ ìîæíî ïîääåðæàòü òðàíñôóçèåé òðîìáîêîíöåíòðàòà, à âîò "ïîäëèòü" ãðàíóëîöèòû íåò âîçìîæíîñòè, òàê æå íå ïîëó÷àåòñÿ ñîçäàòü àñåïòè÷åñêèõ óñëîâèé ñîäåðæàíèÿ ïàöèåíòà... Ïîíÿòíî, ÷òî â Âàìè ïðèâåäåííîì ñëó÷àå óäàëîñü ïîäíÿòü íåéòðîôèëû, à êàê ýòî ïîâëèÿëî íà âûçäîðîâëåíèå/êóðàöèþ ñåïñèñà ïî Âàøåìó ìíåíèþ? Êàê è êòî ïðèíèìàë ðåøåíèå î íà÷àëå òåðàïèè ÊÑÔ â ýòîì ñëó÷àå? |
#39
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Ðåøåíèå, êàê âñåãäà â ïîäîáíûõ ñëó÷àÿõ, ïðèíÿëè ëå÷àùèå íåîíàòîëîãè (êîëëåãèàëüíî). Ïî ïîâîäó ýôôåêòèâíîñòè - ñì. ïðåäûäóùèé ïîñò.
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#40
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Íîâîñòè îò Êîêðýéíîâñêîé áàçû äàííûõ:
Cochrane Database Syst Rev. 2003;(4):CD004205. Pentoxifylline for neonatal sepsis. Haque K, Mohan P. Epsom & St Helier NHS Trust, Division of Neonatology, Department of Child Health, Queen Mary's Hospital for Children, Wrythe Lane, Carshalton, Surrey, UK, SM5 1AA. ...MAIN RESULTS: Two RCTs enrolled a total of 140 preterm (< 36 weeks) neonates with suspected late onset (> 7 days) sepsis to evaluate the effect of pentoxifylline on neonatal outcomes. However, the two studies reported outcomes of only the 107 randomised patients with confirmed sepsis. The results showed a reduction in 'all cause mortality during hospital stay' following pentoxifylline treatment [typical RR 0.14 (95% CI 0.03, 0.76), RD -0.16 (95% CI -0.27, - 0.04), NNT 6 (95% CI 4, 25)]. No adverse effects due to pentoxifylline were observed in the two included trials. No other outcomes of interest were reported. REVIEWER'S CONCLUSIONS: Current evidence suggests that the use of pentoxifylline as an adjunct to antibiotics in neonatal sepsis reduces mortality without any adverse effects. But the number of neonates studied is small and considerable methodological weaknesses exist in the included trials. Hence these results should be interpreted with caution. Researchers are encouraged to undertake large well-designed trials to confirm or refute the effectiveness of pentoxifylline to reduce mortality and adverse outcomes in neonates with suspected or confirmed neonatal sepsis. Researchers might also compare pentoxifylline with other adjuncts to antibiotics which modulate inflammation (e.g. intravenous immunoglobulins, haematopoetic colony stimulating factors among others) in reducing mortality and morbidity due to neonatal sepsis. Cochrane Database Syst Rev. 2003;(4):CD003956. Granulocyte transfusions for neonates with confirmed or suspected sepsis and neutropaenia. Mohan P, Brocklehurst P. Pediatrics, Baylor College of Medicine, Houston, Texas, USA, 77030. ...MAIN RESULTS: Four eligible studies were identified. A total of 44 infants with sepsis and neutropaenia on antibiotics were randomised in three trials to granulocyte transfusions OR placebo/no transfusion. In another trial, 35 infants with sepsis and neutropaenia on antibiotics were randomised to granulocyte transfusion or intravenous immunoglobulin.When granulocyte transfusions were compared with placebo or no transfusion, there was no significant difference in all-cause mortality [typical RR 0.89 (95% CI 0.43, 1.86), typical RD -0.05 (95% CI -0.31, 0.21)]. There was no statistical heterogeneity in the results of the included trials.When granulocyte transfusions were compared with intravenous immunoglobulin, there was a reduction in all-cause mortality of borderline statistical significance [RR 0.06 (95% CI 0.00, 1.04), RD -0.34(95% CI -0.60, -0.09), NNT 2.9 (95% CI 1.7, 11.1)].Pulmonary complication, seen in four infants (4%), was the only adverse effect reported. This advefour infants (4%), was the only adverse effect reported. This adverse effect was noticed in the two trials which used buffy coat transfusions. None of the trials reported on neurological outcome at one year of age or later, length of hospital stay in survivors to discharge or immunological outcome at one year of age or later. REVIEWER'S CONCLUSIONS: Currently, there is inconclusive evidence from RCTs to support or refute the routine use of granulocyte transfusions in neonates with sepsis and neutropaenia to reduce mortality and morbidity.Researchers can be encouraged to conduct adequately powered multicentre trials of granulocyte transfusions to clarify their role in neonates with sepsis and neutropaenia. Other adjuncts to antibiotics aimed at improving host defence mechanisms such as colony stimulating factors, IVIG and pentoxifylline should also be tested in RCTs. |
#41
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 ôîðóìå îòðàæåíû ñîâðåìåííûå ïîäõîäû ê èììóíîòåðàïèè ó íîâîðîæäåííûõ.
Õîòåëîñü áû óñëûøàòü îáîñíîâàííûå àðãóìåíòû ïðîòèâ áåñïîëåçíîñòè è âðåäà ïðèìåíåíèÿ â/ìûøå÷íûõ ôîðì èììóíîãëîáóëèíîâ, äàáû óáåäèòü ñâîèõ íåîíàòîëîãîâ îò óñòîÿâøåéñÿ ïðèâû÷êè èõ èñïîëüçîâàíèÿ. Ñïàñèáî. |