探讨蔓越莓对预防泌尿道感染-之成效.ppt

按一下以編輯母片標題樣式,按一下以編輯母片,第二層,第三層,第四層,第五層,*,精品,PPT,课件 浏览免费 下载后可以编辑修改。,打造最权威的专业课件,医学精品课件,本文档免费浏览阅读，下载后可以编辑修改。,探討蔓越莓對預防泌尿道感染 之成效,動機,目的,EBN問題與步驟,文獻評讀,結論,討論,大綱,全院感染率,1-6,月份以泌尿道感染率為最高,:1.68,0/00,外科病房的泌尿道感染率有偏高的趨勢,95,年,1-6,月,9A,病房,4.1 0/00,醫生常常告訴病人多喝蔓越莓汁醫院製作的衛教單張也衛教病人多喝蔓越莓汁但究竟應,喝多少？有何效果？,院內護理之家住民有長期食用蔓越莓汁之情形，,why,？,動機,Step 1:,整理出一個可以回答的問題,Step 2:,尋找文獻證據,Step 3:,嚴格評讀文獻,Step 4:,應用於病人身上,Step 5:,對過程進行稽核,實證五步驟,蔓越莓對預防泌尿道感染的成效?,Step 1:,整理出一個可以回答的問題,名詞解釋,蔓越苺：,又稱小紅莓，,(cranberry,，,學名,Vaccinium,macrocarpon,),蔓生植物漿果，正圓球體約,1,公分大小，呈紅、暗紅色，表面平滑富光澤。,原產地及大面積耕種的地區是北美及加拿大，主要的產季在九月及十月左右。,MoweryDB：The scientific vlidation of herbal Medicine New Canaan Conn:Keats Pub,1986:316,有症狀的泌尿道感染,症狀：發燒,、,急尿,、,小便困難,、,恥骨上 壓痛,具有尿路感染的症狀任一項且尿液培養-菌落數每毫升大於或等於十萬個,（colony count,10,5,ml),尿液培養之微生物七天內,連續兩次相同,方式,取得之尿液標本，連續兩次相同，菌落數每,毫升大於或等於十萬個,無症狀的菌尿症,Step 3:,嚴格評讀文獻,研究證據的價值取決於其品質及效度,評讀文獻的黃金標準中,以,雙盲隨機對照臨床試驗,得出的結果為最佳證據等級,The Evidence Pyramid臨床研究證據等級,Grade A,Effectiveness established to a degree that merits application,Grade B,Effectiveness established to a degree that suggests application,Grade C,Effectiveness established to a degree that warrants consideration of applying the finding,Grade D,Effectiveness established to a limited degree,Grade E,Effectiveness not established,文獻推薦等級,Develop by JBI,文獻評讀,文獻評讀,预防肾结石复发的方法：,肾结石有若干种类，一旦医师确认你的结石种类，改变生活习惯可以预防和减少结石的生长和发病。下列食物有助于减少复发的机会。多喝水,不论你的结石属于哪一类，最重要的预防之道是提高水分的摄取量。水能稀释尿液，并防止高浓度的盐类及矿物质聚积成结石。合适的饮水量是达到一天排,2,升的尿液，就算足够。如果你一整天都在烈日下工作，你需要喝,2,加仑的水。防治肾结石，每天到底得喝多少水？,一说到肾结石的防治，很多医生都会建议患者多饮水，多运动；那么防治肾结石，每天到底得喝多少水才够呢？这是很多人都在关心的问题。在此，中医五绝网的结石病专家为您解答这个问题，防治肾结石，每天到底需要喝多少水。,在生命活动过程中，人体时时会产生这样那样的废物，这些废物必须不断地从体内排出，人体废物的主要排泄器官由肾脏、输尿管、膀胱、尿道组成。肾脏除了担任“排污”任务外，还负责有益物质的吸收工作。肾脏每时每刻都有大量的血液流过，由肾小球负责“过滤”，污物和杂质由它滤出来，“合格”的血液则重新流回体内去。正常人每天流经肾脏过滤的液体有,1800,毫升左右，可排出的尿液大约为,1000,2000,毫升。肾脏因为要接触体内各种各样的物质，因而有可能患病，尤以肾炎和肾结石为多。,日常生活中，喝水太少也是生长结石的因素之一，人体内的水分会随时随地从不同途径丧失，必须随时补充来保持平衡。在气候炎热的季节或大量运动、出汗后更应多饮水，避免尿液过分浓缩，防止尿中晶体沉积。,所以，正常的饮水量一般控制在每天,2000,毫升左右为宜；但这个是按常规来说的，实际的饮水量，是按每个人的消耗所需而定的；简单的说，就是“能喝多少就喝多少”，不能用标准来衡量，也不要刻意去控制。补充纤维素,加食米糠，可以防止结石发生。,吃富含,维生素,A,的食物,维生素,A,是维持尿道内膜健康所必要的物质，它也有助于阻碍结石复发。健康的成年人，一天需摄取,5,，,O00,单位（,Iu,）的维生素,A,。一杯,胡萝卜,便能提供,10,，,055 Iu,的维生素,A,。其他富含维生素,A,的食物尚有绿花椰菜、杏果、香瓜、,南瓜,、牛肝。（维生素,A,在高剂量时有毒。故欲补充维生素,A,之前，应先经由医师同意。）,补充营养素,全身性因素,新陈代谢紊乱,饮食与营养,长期卧床,生活环境,精神、性别、遗传因素,tp:/,精品,PPT,课件 浏览免费 下载后可以编辑修改。,打造最权威的专业课件,医学精品课件,本文档免费浏览阅读，下载后可以编辑修改。,每100g蔓越莓汁成分,Water(%).92.9,Solid r(%).7.1,Calories.27,Total carbohydrate(g)6.8,Sugar(g).3.7,Dietary fiber(g).0.1,Protein(g)0.1,Fat(g).0.1,Mineral,Sodium(mg).3.8,potassium(mg)85.2,calcium(mg).6.8,iron(mg).0.33,Vitamin C(mg)2,PH2.5,其他的成分還包括,：,類黃酮(flavonoids),、,前花青素(proanthocyanidins)、兒茶素(catechin),Lowe,F.C.(2001),Role of Cranberry Juice on Molecular-Scale,Surface Characteristics and Adhesion Behavior of Escherichia coli,BIOTECHNOLOGY AND BIOENGINEERING,VOL.93,NO.2,FEBRUARY 5,2006,Yatao Liu,Matthew A.Black,Lizabeth Caron,Terri A.Camesano,文獻查證,蔓越莓對預防泌尿道感染作用機轉,RESULT,&DISCUSSION,Exposure to cranberry juice resulted in a decrease in the equilibrium,length,of the p-fimbriae on the surface of E.coli,Cranberry juice,blocks adhesive action,of P-fimbriae(proanthocyanidin),Cranberry juice causes loss of expression of P-fimbriae,年份,:1995,篇名：,Efficacy of cranberry in prevention of urinary tract infection in a susceptible pediatric population.,作者,：,Foda MM,Middlebrook PF,Gatfield CT,Potvin G,Wells G,Schillinger JF,.,Can J Urol;2:98-102,收案族群：,40/21,位診所小朋友，有神經性膀胱,並需間歇性導尿（平均,9.35,歲),文獻評讀,-1,文獻查證,相關研究(一),年份：,1999,篇名：,Effect of cranberry juice on bacteriuria in children with neurogenic bladder receiving intermittent catheterization.J Pediatr 1999;135:698-702.,作者,：,Schlager TA,Anderson S,Trudell J,Hendley JO.,收案族群：,15/15小朋友，有神經性膀胱並需間,歇性導尿（2-18歲),文獻查證,相關研究(二),實驗設計,：隨機/,Double blind,/交叉設計,措施：,每天,300cc cranberry（,成分,30,）,，,控制組：,Placebo controlled,（安慰劑）看起來和嚐起來相似的果汁，持續3個月,cranberry juice,，持續3個月安慰劑,結果：,有症狀的上泌尿道感染,-Cranberry：3 times UTI In 2 children,-Placebo：3times UTI In 3 children,無症狀的上泌尿道感染,-Cranberry：120/160 months（75）,-Placebo,：,114/151months,（,75,）,AHCPR文獻等級：,I a,年份：,2002,篇名：,randomized trial to evaluate effectiveness and cost effectiveness of naturopathic cranberry products as prophylaxis against urinary tract infection in women.Can J Urol 2002;9:1558-62,.,作者,：,Walker EB,Barney DP,Mickelsen JN,Walton RJ,Mickelsen RA Jr.,收案族群：,19/10有性交活動的女性（28-44歲),收案條件：,未懷孕有性交活動的女性（18-45歲）,有過UTI病史,文獻查證,相關研究(三),年份,：,2005,題目,：,Dose ingestion of cranberry juice reduce symptomatic urinary tract infection In older people in hospital?,作者,：,MarionE.T.Mcmurdo,LINDA Y.BISSETT,ROSEMARY J.G.PRICE,GABBY PHILLIPS,LAIN K,CROMBIE,文獻評讀-5,文獻查證,相關研究(四),對象:,376,在醫院的老年人,方法:,隨機、雙盲,措施：,隨機給予,300ml/day cranberry juice or,matching placebo beverage,結論：,no significant differences were found between treatment group,AHCPR文獻等級：,I a,（一）,Objective,To determine whether,recurrences of urinary tract infection can be prevented,with cranberrylingonberry juice or with,Lactobacillus,GG drink.,Design,Open,randomized controlled 12 month follow up trial.,Setting,Health centers for university students and staff of university hospital.,Participants,150 women with urinary tract infection caused by,Escherichia coli,randomly allocated into three groups.,Intervention,50 ml of cranberrylingonberry juice,concentrate daily for six months or,100 ml of lactobacillus GG drink,five days a week for one year,and the third group served as,an open control group.,（二）This is a 20%reduction in absolute risk in the cranberry group compared with the control group,P.Di Martino A R.Agniel A K.David A C.TemplerJ.L.Gaillard A P.Denys A H.BottoPublished online:6 January 2006 Springer-Verlag 2006,Reduction of Escherichia coli adherence to uroepithelial bladder cellsafter consumption of cranberry juice,文獻查證,相關研究(六),（一）,Abstract,To,determine the efficacy of the consumption of cranberry juice versus placebo,with regard to,the presence of in vitro bacterial,anti-adherence activity,in the urine of healthy volunteers,Participants,Twenty healthy volunteers,10 men and 10 women,were included,Design,The study was a double-blind,randomized,placebo-controlled,and cross-over study.,with a washout period of at least 6 days between every change in regimen,AHCPR文獻等級：1a,（二）,INTRODUCTION,ZafririD,ofek I,Pocino M,Sharon N(1989)inhibitory activity of cranberry juice on adherence of type 1and type p fimbriated E coli to eukaryotic cells,E Coli adherence:,type 1 and type p fimbriae,cranberry juice constituents,proanthocyanidins(cranberry juice)-type p,fructose(many fruit juice)-type 1,(三),成份比較,Cranberry juice Placebo,Calories(Kcal),41.6,42.7,Total carbohydrates(g),10.4,10.7,Ascorbic acid(mg),63,63,Total organic acids(g),1.8,1.6,Total phenolics(mg),179,161,Total anthocyanidins(mg),9.3,42,Proanthocyanidins(mg),40,ND,(四)Result,Anti-adherence activity of the cranberry juice,:comparisonof the regimens,means for the 20 volunteers and 6 types of E coli strains,Regimens,Decrease in bacterial adherence(%),250 ml placebo+500 ml mineral water,-,750 ml placebo,12,250 ml cranberry+500 ml mineral water,45,750 ml cranberry,65,(四)Result,No significant differences in the pH or specific gravity between the urine samples collected after cranberry or placebo consumption.,We observed,a dose dependent,significant decrease in bacterial adherence associated with cranberry consumption.,Reduction of bacteriuria and pyuria after ingestion of Cranberry juice,Avorn,jerry Md;JAMA,271(1o).March9,1994.751-754,文獻查證,相關研究(七),(一),Objectives,To determine the effect of,regular intake,of cranberry juice beverage on bacteriuria and pyuria,in elderly women,Intervention,Subjects were randomly to consume,300 mL,per day of a commercially available,standard cranberry beverage,or a,specially prepared synthetic placebo cranberry drink-,6MONTHSurine samples were collected at approximately 1-month intervals and tests quantitatively for,bacteriuria and the presence of white blood cells.,Design,Randomized,double-blind,placebo-controlled trial.,Participants,109:LONG-TERM COMMUNITY DWELLING.,44:LONG TERM CARE FACILITY,AHCPR文獻等級：1a,METHOD,Ocean spray cranberry,Bacterial culture,Antibiotic sensitivity,外觀顏色(使用糖精),瓶蓋每月收集一 次,教導中間尿,Results,Escherichal coli was the most commonly identified organism(43%of isolates),with Klebsiella the second most common single organism(7%);mixed flora accounted for 22%of bacteriuric-pyuric urine samples.,Placebo group,Cranberry group,Result,The difference was not present in the first month,INFECTED URINE SAMPLES%,Result,We did not find evidence that urinary acidification was responsible for the observed effect,since the median pH of urine samples in the,cranberry group(6.0),was,actually higher than that in the experimental group(5.5).,.,8,Result,Demonstration of the capacity of cranberry beverage to reduce the occurrence of bacteriuria with pyuria in elderly women dose,lend credence to the belief,that it contains a substance with biologic activity in relation to the urinary tract.,Conclusions,These findings suggest that use of a cranberry beverage reduces the frequency of bacteriuria with pyuria in older women.,Prevalent beliefs,about the effects of cranberry juice on the urinary tract may have microbiologic,justification.,Jama.1994;271;751-754,COMMENT,These finding,if replicated in other settings,would,suggest evidence for the bacteriostatic property of cranberry beverage in the bladder.,Further studies are needed on the biochemical properties of,this substance,As an adjunct to antibiotic，in the treatment of this common disorder.,Step 4:,應用於病人身上,現況：院內護理之家住民長期在食用蔓越莓汁,食品處方：由營養室設計安排，費用算在伙食費內。,使用方法：每天下午由營養室配送蔓越莓原液,100g,（無糖），護理人員稀釋成200cc，餵食時間為,11pm,（原因：避免與白天藥物有交叉反應）,對象：泌尿道感染的住民一定使用，除糖尿病、腸胃出血、高血鉀、洗腎病人不給，其他住民也一律給。但意識清楚，由口禁食住民多半不喝，,則不強迫。,為何不用錠劑：,因為曾有住民食用後有高血鉀情形。,泌尿道感染率：,未做研究分析。,經研究證實蔓越莓可以預防泌尿道感染,文獻上並無明確建議,蔓越莓食用,劑量,泌尿道感染常在病人無症狀的幾個月後才發生，有些的研究期間較短，較無法看出成果,研究中退出的病人數較高,(20-55),可能因病人較無法接受需長期飲用蔓越莓汁，,在小孩身上這是主要原因,結論,蔓越莓汁成本高：長期飲用耗費的成本需考量,(,平均每年約需,625-1400,元美金,),，蔓越莓的濃 縮物或錠劑也許可以克服。,但當病人每年有經歷,2,次的有症狀泌尿道感染，和抗生素的成本比較起來則有大大的節省。,結論,錠劑好?果汁好?,蔓越莓汁到底要喝多少?,日後可以努力的方向,1.要長時間追蹤,2.衛教單宜增加使用劑量的說明,3.需註明服用,蔓越莓的禁忌,討論,報告完畢,敬請指教,精品,PPT,课件 浏览免费 下载后可以编,p:/,结石由无机盐或有机物组成。结石中正常有一核心，由脱落的上皮,结石,细胞、,细菌,团块、寄生虫卵或虫体、粪块或异物组成，无机盐或有机物再层层沉积核心之上。由于受累,器官,的不同，结石形成的机理所含的成分、形状、质地、对,机体,的影响等均不相同。常见的结石有,胆结石,、,膀胱结石,、,输尿管结石,、胰导管结石、,唾液腺导管结石,、阑尾,粪石,、,胃石,、,包皮,石和牙石等。,尿石症,是肾、输尿管、,膀胱,及尿道等部位结石的统称，是,泌尿系统,的常见疾病之一。,泌尿系结石,多数原发于,肾脏,和膀胱，输尿管结石往往继发于,肾结石,，,尿道结石,往往是膀胱内结石随尿流冲出时梗阻所致。肾、输尿管结石与膀胱、尿道结石比约为,5.5,61,。尿石症的发生率男性高于女性，肾与输尿管结石多见于,20,40,岁的青壮年，约占,70%,左右；膀胱和尿道结石多发生在,10,岁以下的儿童和,50,岁以上的老年患者。尿石症引起,尿路梗阻,和感染后，对,肾功能,损害较大，尤以下尿路长期梗阻及,孤立肾,梗阻时，对全身影响更为严重，处理上也较复杂，严重者可危及生命。,结石病是一种顽固性疾病，症状复杂，,并发症,多，易于残留一般口服消石胶囊每日,4-6,粒可以预防结石生成。,ht,经临床观察发现，含钙结石是泌尿系结石中最常见的结石类型。约占全部泌尿,结石,系结石的,70%-80%,。目前，仅有少数含钙结石病例能明确其,病理,病因，而大多数含钙结石的病因尚不十分清楚。按结石化学成分可分为含钙结石、感染结石、尿酸结石、,胱氨酸,结石四类。含钙结石可分为：单纯的,草酸,钙、草酸钙和,磷酸钙,、以及除草酸钙还有少量的尿酸；感染结石主要成分是磷酸镁铵和羟磷灰石；尿酸结石成分可分为：尿酸、尿酸胺或除上述成分外还含有少量的草酸钙；胱氨酸结石可分为：纯胱氨酸或含有少量草酸钙成分。,编辑本段,结石病因：,正常尿内晶体饱和度和晶体聚合抑制因子的活性两者处于平衡状态，一旦由于某种因素破坏了这种平衡，不管是前者饱和度过高，或是后者活性降低，均可引起尿内晶体聚合，导致尿石形成。下列因素对尿石的成因有明显的诱发作用。,全身性因素,新陈代谢紊乱,饮食与营养,长期卧床,生活环境,精神、性别、遗传因素,tp:/,精品,PPT,课件 浏览免费 下载后可以编辑修改。,打造最权威的专业课件,医学精品课件,本文档免费浏览阅读，下载后可以编辑修改。,