先说肺栓塞，本周的MEDSCAP看刊登了转自《Seminars in Respiratory and Critical Care Medicine》一篇《Massive Pulmonary Embolism: What Level of Aggression?》，作者是来自德国哥庭根大学的Stavros V. Konstantinides。《Seminars in Respiratory and Critical Care Medicine》来自Thime公司，应该也属于sciencedirect，不过可能独立运营，经营的一些杂志也很不错，看来我的rss又可以加新了。这次的medscape引用的这篇文献其实是该杂志2008年第一卷《Deep Venous Thrombosis and Pulmonary Thromboembolism: Evolving Concepts and Controversies 》专刊（也就是深静脉血栓）的，2008年第二卷是关于真菌感染专刊的。本文的要目是：
ABSTRACT
RESOLVED AND UNRESOLVED ISSUES IN THE MANAGMENT OF ACUTE PULMONARY EMBOLISM
THROMBOLYSIS: BENEFITS, RISKS, AND UNCERTAINTIES
AGGRESSIVE THROMBOLYTIC TREATMENT FOR UNSTABLE PATIENTS WITH MASSIVE PULMONARY EMBOLISM
NORMOTENSIVE PATIENTS WITH NONMASSIVE PULMONARY EMBOLISM: THE RATIONALE FOR RISK STRATIFICATION
RISK STRATIFICATION OF NORMOTENSIVE PATIENTS WITH PULMONARY EMBOLISM: IMAGING OF THE RIGHT VENTRICLE
ADDITIONAL TOOLS FOR RISK ASSESMENT: CARDIAC BIOMARKERS
IS SUBMASSIVE PULMONARY EMBOLISM AN INDICATION FOR THROMBOLYTIC TREATMENT?
CONCLUSION
REFERENCES
从章节的题目看起来，还不错，讨论了目前肺栓塞溶栓治疗的现状，值得一看。
这一期专刊的详细目录专刊因为是专刊性质，因此每篇文章就像综述一样。下面是本期的目录，看了一下，没有特大腕，只有大腕，但是内容非常好，仅从题目看就很吸引人，很值得推荐：
PREFACE
Tapson, Victor F.:
Deep Venous Thrombosis and Pulmonary Thromboembolism: Evolving Concepts and Controversies
Moores, Lisa K.; Holley, Aaron B.:
Computed Tomography Pulmonary Angiography and Venography: Diagnostic and Prognostic Properties
Hargett, C. William; Tapson, Victor F.:
Clinical Probability and D-dimer Testing: How Should We Use Them in Clinical Practice?
Whitlatch, Nicole L.; ortel, Thomas L.:
Thrombophilias: When Should We Test and How Does It Help?
Garcia, David A.; Spyropoulos, Alex C.:
Update in the Treatment of Venous Thromboembolism
Konstantinides, Stavros V.:
Massive Pulmonary Embolism: What Level of Aggression?
Vedantham, Suresh:
Interventional Approaches to Acute Venous Thromboembolism
Linkins, Lori-Ann; Warkentin, Theodore E.:
The Approach to Heparin-Induced Thrombocytopenia
Yavin, Yshai; Cohen, Alexander T.:
Venous Thromboembolism Prophylaxis for the Medical Patient: Where Do We Stand?
Petralia, Gloria A.; Kakkar, Ajay K.:
Venous Thromboembolism Prophylaxis for the General Surgical Patient: Where Do We Stand?
Hoppensteadt, Debra A.; Jeske, Walter; Walenga, Jeanine; Fareed, Jawed; Hemostasis and Thrombosis Research Laboratories Loyola University Chicago:
The Future of Anticoagulation
......

本周的《JAMA》一篇的《Improvement in Process of Care and Outcome After a Multicenter Severe Sepsis Educational Program in Spain》(AMA. 2008;299(19):2294-2303.)的西班牙“edusepsis项目”值得一看:
Context  Concern exists that current guidelines for care of patients with severe sepsis and septic shock are followed variably, possibly due to a lack of adequate education.
Objective  To determine whether a national educational program based on the Surviving Sepsis Campaign guidelines affected processes of care and hospital mortality for severe sepsis.
Design, Setting, and Patients  Before and after design in 59 medical-surgical intensive care units (ICUs) located throughout Spain. All ICU patients were screened daily and enrolled if they fulfilled severe sepsis or septic shock criteria. A total of 854 patients were enrolled in the preintervention period (November-December 2005), 1465 patients during the postintervention period (March-June 2006), and 247 patients during the long-term follow-up period 1 year later (November-December 2006) in a subset of 23 ICUs.
Intervention  The educational program consisted of training physicians and nursing staff from the emergency department, wards, and ICU in the definition, recognition, and treatment of severe sepsis and septic shock as outlined in the guidelines. Treatment was organized in 2 bundles: a resuscitation bundle (6 tasks to begin immediately and be accomplished within 6 hours) and a management bundle (4 tasks to be completed within 24 hours).
Main Outcome Measures  Hospital mortality, differences in adherence to the bundles' process-of-care variables, ICU mortality, 28-day mortality, hospital length of stay, and ICU length of stay.
Results  Patients included before and after the intervention were similar in terms of age, sex, and Acute Physiology and Chronic Health Evaluation II score. At baseline, only 3 process-of-care measurements (blood cultures before antibiotics, early administration of broad-spectrum antibiotics, and mechanical ventilation with adequate inspiratory plateau pressure) we had compliance rates higher than 50%. Patients in the postintervention cohort had a lower risk of hospital mortality (44.0% vs 39.7%; P = .04). The compliance with process-of-care variables also improved after the intervention in the sepsis resuscitation bundle (5.3% [95% confidence interval [CI], 4%-7%] vs 10.0% [95% CI, 8%-12%]; P < .001) and in the sepsis management bundle (10.9% [95% CI, 9%-13%] vs 15.7% [95% CI, 14%-18%]; P = .001). Hospital length of stay and ICU length of stay did not change after the intervention. During long-term follow-up, compliance with the sepsis resuscitation bundle returned to baseline but compliance with the sepsis management bundle and mortality remained stable with respect to the postintervention period.
Conclusions  A national educational effort to promote bundles of care for severe sepsis and septic shock was associated with improved guideline compliance and lower hospital mortality. However, compliance rates were still low, and the improvement in the resuscitation bundle lapsed by 1 year.
看来所谓的sepsis集束化治疗截至目前最大型的研究已经出炉了，而且获得了阳性结论，如果我们再看医生护士极低的顺应性就应该预见到如果提高顺应性，可能病死率会更为显著的减少—— 但是我对这种简单的“说教运动”就能改善病死率的做法表示怀疑——在文后的述评中对此也有评论。
为此，刊发了波士顿大学Jeremy M. Kahn,等人的述评——《Improving Sepsis Care  The Road Ahead》（JAMA. 2008;299(19):2322-2323.），主要内容如下：
In recent years there have been unprecedented advances in the understanding of the epidemiology, pathophysiology, and treatment of sepsis syndrome.1-3 This work has culminated in several clinical trials demonstrating the efficacy of targeted interventions to improve sepsis-related outcomes.4-6 These interventions include not only novel therapeutic agents such as drotrecogin alfa but also treatments directed at improving the way more traditional therapy is delivered, such as early resuscitation and low-tidal volume ventilation for acute lung injury.4-6
Unfortunately the gaps between evidence and practice have long been huge.7 Indeed, most available data suggest that clinical trial and observational study results have not yet changed clinical practice in sepsis care. Few emergency departments have implemented protocols for early resuscitation of patients with severe sepsis, delayed and inappropriate antibiotic administration remains common, and many patients with acute lung injury receive mechanical ventilation with potentially injurious tidal volumes.8-10
Numerous obstacles get in the way of implementing clinical evidence. Clinicians may be unaware of published evidence, disagree with practice guidelines, or be unable to effect change due to environmental and structural barriers.11 These challenges are particularly salient in sepsis care, which requires dedicated efforts between multiple disciplines and coordination of care throughout the hospital, all in a setting in which time to treatment is central. Comprehensive strategies are needed to standardize practice, improve care processes, and optimize outcomes for this high-risk patient group.
Recent evidence suggests that grouping care practices together into "bundles" may be an effective method to improve outcomes for complex diseases such as catheter-related bloodstream infections, ventilator-associated pneumonia, and even sepsis.12-14 But it has proved extremely challenging to take complex care improvement programs and disseminate them broadly across a region, state, country, or across national boundaries.
In this issue of JAMA, Ferrer and colleagues15 report the findings of an ambitious, nationwide effort to improve the quality of care for patients with severe sepsis and septic shock. ..... Improvement in survival was greatest in hospitals with the poorest baseline performance. These performance gains provide an important process-outcome link in support of the sepsis guidelines because some of the elements of this campaign have not yet been strongly linked to outcome in patients with severe sepsis.
The intervention was associated with important process and outcome improvements even though it was relatively simple. Didactic teaching and passive guideline dissemination are not the most effective methods of behavior change.17 The investigators did not include some of the more effective methods for implementing evidence-based practice, including academic detailing, computerized reminders, and repeated audit and feedback.18-19 Additionally, the intervention was homogeneous across sites, with no attempt to customize the program based on local cultures or specific organizational barriers.20 The fact that performance improved even after this type of intervention is probably due to poor compliance and high mortality at baseline.
The study has limitations. Most notably, the absence of a cluster randomized design or even concurrent controls leaves open the possibility that temporal trends or changes in case-mix led to the observed association. Nonetheless, the sheer scope and scale of this initiative should not be discounted. The campaign in Spain represents the culmination of a multi-year effort involving coordination between the investigators, the Spanish Society of Intensive Care Medicine and Coronary Care Units, and the participating sites. Simply the fact that a national professional society undertook a project to improve its country's health and was able to achieve improvements in both process and outcome makes this work unlike any previous quality-improvement initiative in hospital medicine. Perhaps the greatest lesson of this study is that through multicenter collaboration it is possible to meaningfully effect change in the quality of hospital care, not just locally but across an entire nation.
This work also highlights several of the challenges in hospital-based quality improvement. First, only a minority of Spanish hospitals were willing to participate in the program, and several dropped out. Hospitals were not asked to justify their nonparticipation, but many likely either could not identify a local champion or were unwilling to devote scarce resources for a collaborative quality-improvement effort. Innovative methods of quality improvement that do not require local champions and are more easily exportable to multiple sites, perhaps involving use of information technology, may be more effective.
Second, baseline performance was relatively poor despite the presence of 24-hour intensivist staffing at all sites. Intensivist physician staffing is consistently linked to improvements in the process and outcome of critical care.21-22 Yet it is clear that intensivists alone are not a cure for poor quality. Aggressive quality-improvement efforts are needed even in optimally staffed ICUs.
Third, the increases in guideline adherence were modest, with some process measures increasing by only a few percentage points. Even after the intervention, performance on many measures was far below what would be considered ideal. Nor were all improvements sustained in a subset of hospitals that measured process and outcome for a year after the intervention; many measures returned to baseline rates. The benefits of this type of intervention might well increase over time if organizations develop effective ways to ensure that the bundles are implemented, but might also wane if the focus shifts to other areas. Future research should address how to better maintain process improvements, including the role of incentives and ongoing performance measurement.
Ferrer and colleagues supply powerful evidence that broad-based quality improvement in sepsis care is feasible on a national scale. The data also suggest that delivering a bundle of care effectively for patients with sepsis may be as or even more important than developing new therapies. Indeed, the absolute risk reduction in hospital mortality observed in this study would translate to an impressive number of lives saved if this type of intervention were successfully implemented on an international scale. The science of quality improvement must include not only development of effective measures, but also evaluation of what techniques for spreading and maintaining them are most effective.
Furthermore, this study should be a wake-up call to policy makers, a challenge to the leaders of professional societies, and a road map for the path ahead. No longer is it acceptable to simply publish practice guidelines and hope that quality improvement happens at the local level. Development of these guidelines should be followed by rigorous testing, and, when results are positive, by dedicated regional, national, and even international implementation efforts. Such broad-based efforts are needed to achieve population-level benefits from interventions known to be effective.
REFERENCES
1. Abraham E, Singer M. Mechanisms of sepsis-induced organ dysfunction. Crit Care Med. 2007;35(10):2408-2416.
2. Wheeler AP. Recent developments in the diagnosis and management of severe sepsis. Chest.2007;132(6):1967-1976.
3. Angus DC, Linde-Zwirble WT, Lidicker J; et al. Epidemiology of severe sepsis in the United States. Crit Care Med. 2001;29(7):1303-1310.
4. Bernard GR, Vincent JL, Laterre PF; et al. Efficacy and safety of recombinant human activated protein C for severe sepsis. N Engl J Med. 2001;344(10):699-709.
5. Rivers E, Nguyen B, Havstad S; et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345(19):1368-1377.
6. Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med. 2000;342(18):1301-1308.
7. Lomas J, Sisk JE, Stocking B. From evidence to practice in the United States, the United Kingdom, and Canada. Milbank Q. 1993;71(3):405-410
8. Carlbom DJ, Rubenfeld GD. Barriers to implementing protocol-based sepsis resuscitation in the emergency department. Crit Care Med. 2007;35(11):2525-2532.
9. Esteban A, Ferguson ND, Meade MO; et al. Evolution of mechanical ventilation in response to clinical research. Am J Respir Crit Care Med. 2008;177(2):170-177.
10. De Miguel-Yanes JM, Andueza-Lillo JA, Gonzalez-Ramallo VJ; et al. Failure to implement evidence-based clinical guidelines for sepsis at the ED. Am J Emerg Med. 2006;24(5):553-559.
11. Cabana MD, Rand CS, Powe NR; et al. Why don't physicians follow clinical practice guidelines? a framework for improvement. JAMA. 1999;282(15):1458-1465
12. Resar R, Pronovost P, Haraden C; et al. Using a bundle approach to improve ventilator care processes and reduce ventilator-associated pneumonia. Jt Comm J Qual Patient Saf. 2005;31(5):243-248.
13. Nguyen HB, Corbett SW, Steele R; et al. Implementation of a bundle of quality indicators for the early management of severe sepsis and septic shock is associated with decreased mortality. Crit Care Med. 2007;35(4):1105-1112.
14. Pronovost P, Needham D, Berenholtz S; et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355(26):2725-2732.
15. Ferrer R, Artigas A, Levy MM; et al, for the Edusepsis Study Group. Improvement in process of care and outcome after a multicenter severe sepsis educational program in Spain. JAMA. 2008;299(19):2294-2303.
16. Dellinger RP, Levy MM, Carlet JM; et al. Surviving Sepsis Campaign. Crit Care Med. 2008;36(1):296-327.
17. Grimshaw JM, Shirran L, Thomas R; et al. Changing provider behavior. Med Care. 2001;39(8)(suppl 2):II2-II45.
18. Soumerai SB, McLaughlin TJ, Avorn J. Improving drug prescribing in primary care. Milbank Q. 1989;67(2):268-317
19. Bates DW, Kuperman GJ, Wang S; et al. Ten commandments for effective clinical decision support. J Am Med Inform Assoc. 2003;10(6):523-530.
20. Curtis JR, Cook DJ, Wall RJ; et al. Intensive care unit quality improvement. Crit Care Med. 2006;34(1):211-218.
21. Pronovost PJ, Angus DC, Dorman T, Robinson KA, Dremsizov TT, Young TL. Physician staffing patterns and clinical outcomes in critically ill patients: a systematic review. JAMA. 2002;288(17):2151-2162. FREE FULL TEXT
22. Kahn JM, Brake H, Steinberg KP. Intensivist physician staffing and the process of care in academic medical centres. Qual Saf Health Care. 2007;16(5):329-333.

本周另外一篇重要的文献是血液替代品造成心梗以及死亡风险的荟萃分析——《Cell-Free Hemoglobin-Based Blood Substitutes and Risk of Myocardial Infarction and Death》（JAMA. 2008;299(19):2304-2312.）
Context  Hemoglobin-based blood substitutes (HBBSs) are infusible oxygen-carrying liquids that have long shelf lives, have no need for refrigeration or cross-matching, and are ideal for treating hemorrhagic shock in remote settings. Some trials of HBBSs during the last decade have reported increased risks without clinical benefit.
Objective  To assess the safety of HBBSs in surgical, stroke, and trauma patients.
Data Sources  PubMed, EMBASE, and Cochrane Library searches for articles using hemoglobin and blood substitutes from 1980 through March 25, 2008; reviews of Food and Drug Administration (FDA) advisory committee meeting materials; and Internet searches for company press releases.
Study Selection  Randomized controlled trials including patients aged 19 years and older receiving HBBSs therapeutically. The database searches yielded 70 trials of which 13 met these criteria; in addition, data from 2 other trials were reported in 2 press releases, and additional data were included in 1 relevant FDA review.
Data Extraction  Data on death and myocardial infarction (MI) as outcome variables.
Results  Sixteen trials involving 5 different products and 3711 patients in varied patient populations were identified. A test for heterogeneity of the results of these trials was not significant for either mortality or MI (for both, I2 = 0%, P ≥ .60), and data were combined using a fixed-effects model. Overall, there was a statistically significant increase in the risk of death (164 deaths in the HBBS-treated groups and 123 deaths in the control groups; relative risk [RR], 1.30; 95% confidence interval [CI], 1.05-1.61) and risk of MI (59 MIs in the HBBS-treated groups and 16 MIs in the control groups; RR, 2.71; 95% CI, 1.67-4.40) with these HBBSs. Subgroup analysis of these trials indicated the increased risk was not restricted to a particular HBBS or clinical indication.
Conclusion  Based on the available data, use of HBBSs is associated with a significantly increased risk of death and MI.

本周的《NEJM》最重要的文章就是the VA/NIH Acute Renal Failure Trial Network发表的《Intensity of Renal Support in Critically Ill Patients with Acute Kidney Injury》。也就是危重症肾脏替代治疗的比较研究 ——本文对所谓的强化肾脏替代治疗与非强化肾脏替代治疗进行了比较。所谓的强化与非强化肾脏替代治疗按照作者的定义是：In the group receiving the intensive-therapy strategy, intermittent hemodialysis and sustained low-efficiency dialysis were provided six times per week (every day except Sunday), and continuous venovenous hemodiafiltration was prescribed to provide a flow rate of the total effluent (the sum of the dialysate and ultrafiltrate) of 35 ml per kilogram of body weight per hour, based on the weight before the onset of acute illness. In the less-intensive strategy, intermittent hemodialysis and sustained low-efficiency dialysis were provided three times per week (on alternate days except Sunday), and continuous venovenous hemodiafiltration was prescribed to provide a total effluent flow rate of 20 ml per kilogram per hour. 主要的区别就是大流量血滤（强化组 35 ml per kilogram of body weight per hour）与小流量血滤（ 20 ml per kilogram per hour）以及透析次数的区别。结果发现强化治疗与非强化治疗在病死率，肾功能改善或者脏器衰竭评分等各方面都没有差异！！
Background The optimal intensity of renal-replacement therapy in critically ill patients with acute kidney injury is controversial.
Methods We randomly assigned critically ill patients with acute kidney injury and failure of at least one nonrenal organ or sepsis to receive intensive or less intensive renal-replacement therapy. The primary end point was death from any cause by day 60. In both study groups, hemodynamically stable patients underwent intermittent hemodialysis, and hemodynamically unstable patients underwent continuous venovenous hemodiafiltration or sustained low-efficiency dialysis. Patients receiving the intensive treatment strategy underwent intermittent hemodialysis and sustained low-efficiency dialysis six times per week and continuous venovenous hemodiafiltration at 35 ml per kilogram of body weight per hour; for patients receiving the less-intensive treatment strategy, the corresponding treatments were provided thrice weekly and at 20 ml per kilogram per hour.
Results Baseline characteristics of the 1124 patients in the two groups were similar. The rate of death from any cause by day 60 was 53.6% with intensive therapy and 51.5% with less-intensive therapy (odds ratio, 1.09; 95% confidence interval, 0.86 to 1.40; P=0.47). There was no significant difference between the two groups in the duration of renal-replacement therapy or the rate of recovery of kidney function or nonrenal organ failure. Hypotension during intermittent dialysis occurred in more patients randomly assigned to receive intensive therapy, although the frequency of hemodialysis sessions complicated by hypotension was similar in the two groups.
Conclusions Intensive renal support in critically ill patients with acute kidney injury did not decrease mortality, improve recovery of kidney function, or reduce the rate of nonrenal organ failure as compared with less-intensive therapy involving a defined dose of intermittent hemodialysis three times per week and continuous renal-replacement therapy at 20 ml per kilogram per hour.
建议大家看一看本文的述评《Dialysis in Acute Kidney Injury — More Is Not Better》(Joseph V. Bonventre, M.D., Ph.D.)

New Fever in Critically Ill Patients ^{New! 重症患者发热指南}

"Guidelines for evaluation of new fever in critically ill adult patients: 2008 update from the American College of Critical Care Medicine and the Infectious Diseases Society of America"

Crit Care Med 2008 Vol. 36, No. 4 这是IDSA( Infectious Disease Society of America )继《Clinical Infectious Diseases》1998年发表成人重症患者发热指南后的最新更新，是和美国危重病协会（SCCM）联合发表，因此转移到《Critical care medicine》发表。我这里给的链接是从IDSA看到的。

本周的《Lancet》刊登了中国中山医科大学主持的多中心的早期强化胰岛素对于初诊2型糖尿病的疗效观察研究，这项前瞻性的病例对照研究作为本周《Lancet》的封面报道，看来意义非凡。
Background
Early intensive insulin therapy in patients with newly diagnosed type 2 diabetes might improve β-cell function and result in extended glycaemic remissions. We did a multicentre, randomised trial to compare the effects of transient intensive insulin therapy (continuous subcutaneous insulin infusion [CSII] or multiple daily insulin injections [MDI]) with oral hypoglycaemic agents on β-cell function and diabetes remission rate.
Methods
382 patients, aged 25–70 years, were enrolled from nine centres in China between September, 2004, and October, 2006. The patients, with fasting plasma glucose of 7·0–16·7 mmol/L, were randomly assigned to therapy with insulin (CSII or MDI) or oral hypoglycaemic agents for initial rapid correction of hyperglycaemia. Treatment was stopped after normoglycaemia was maintained for 2 weeks. Patients were then followed-up on diet and exercise alone. Intravenous glucose tolerance tests were done and blood glucose, insulin, and proinsulin were measured before and after therapy withdrawal and at 1-year follow-up. Primary endpoint was time of glycaemic remission and remission rate at 1 year after short-term intensive therapy. Analysis was per protocol. This study was registered with ClinicalTrials.gov, number NCT00147836.
Findings
More patients achieved target glycaemic control in the insulin groups (97·1% [133 of 137] in CSII and 95·2% [118 of 124] in MDI) in less time (4·0 days [SD 2·5] in CSII and 5·6 days [SD 3·8] in MDI) than those treated with oral hypoglycaemic agents (83·5% [101 of 121] and 9·3 days [SD 5·3]). Remission rates after 1 year were significantly higher in the insulin groups (51·1% in CSII and 44·9% in MDI) than in the oral hypoglycaemic agents group (26·7%; p=0.0012). β-cell function represented by HOMA B and acute insulin response improved significantly after intensive interventions. The increase in acute insulin response was sustained in the insulin groups but significantly declined in the oral hypoglycaemic agents group at 1 year in all patients in the remission group.
Interpretation
Early intensive insulin therapy in patients with newly diagnosed type 2 diabetes has favourable outcomes on recovery and maintenance of β-cell function and protracted glycaemic remission compared with treatment with oral hypoglycaemic agents.
Funding
973 Programme from the Chinese Government, the Natural Science Foundation of Guangdong Province Government, Novo Nordisk (China), and Roche Diagnostics (Shanghai).
Affiliations
a. Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
b. First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
c. Affiliated Hospital of Guiyang Medical College, Guizhou, China
d. Gulou Hospital of Nanjing University, Nanjing, China
e. Xiangya Second Affiliated Hospital of Central South University, Changsha, China
f. West China Hospital of Sichuan University, Chengdu, China
g. First Affiliated Hospital of Guangxi Medical University, Nanning, China
h. Second Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
i. First Affiliated Hospital of Fujian Medical University, Fuzhou, China
Correspondence to: Professor Jianping Weng, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China, 510630

本月，也就是6月号的《Anesthesia & Analgesia 》主要的课题之一就是在“儿科麻醉”栏目中对麻醉是否影响儿童脑/神经系统发育进行了综合报道，既有正面意见又有反面意见。这个栏目中另外一篇综述值得推荐—— Neuroprotective Strategies for the Neonatal Brain (Review Article，Anesth Analg 2008 106: 1670-1680. 【IMPLICATIONS: Injury to the perinatal brain is a leading cause of death and disability in children. Understanding the pathophysiology of perinatal brain damage will help to identify potential targets for neuroprotective strategies.】 也就是新生儿的神经保护策略。在《Anesthesia & Analgesia 》的“危重病与创伤”栏目下，有三篇文献，分别是：
1. Peripheral Blood Hematocrit in Critically Ill Surgical Patients: An Imprecise Surrogate of True Red Blood Cell Volume
Anesth Analg 2008 106: 1808-1812.  
IMPLICATIONS: The peripheral blood hematocrit assayed in the clinical laboratory may not provide an accurate estimate of red blood cell volume in critically ill surgical patients. Measurement of plasma volume and red blood cell volume may provide a more accurate guide for blood transfusion requirements.
2. Free Cortisol in Sepsis and Septic Shock
Anesth Analg 2008 106: 1813-1819. 
IMPLICATIONS: Calculated free cortisol concentrations correlate well with total cortisol concentration, and free cortisol calculation does not predict unfavorable outcome better than total cortisol levels. Clinically, calculation of free cortisol does not help to identify patients who would benefit from corticoid treatment in severe sepsis and septic shock.
3. Vascular Endothelial Growth Factor in Severe Sepsis and Septic Shock
Anesth Analg 2008 106: 1820-1826. 
IMPLICATIONS: Serum vascular endothelial growth factor (VEGF) concentrations are increased in patients with severe sepsis. Although nonsurvivors have significantly lower levels than patients with better outcome, VEGF concentrations do not predict hospital mortality.
3篇文献发的共同点就是其所报道的指标——外周血红细胞压积、游离皮质醇以及血清内皮生长因子都不能用于有效评估病情或者用于预后评估；后两篇文献都是芬兰“Finnsepsis Study Group”的研究报告。