新英格兰医学杂志(NEJM)

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《新英格兰杂志》综述全文(中文版)：大量失血的预防与治疗

《新英格兰杂志》综述全文（中文版）：大量失血的预防与治疗Prevention and Treatment of Major Blood Loss大量失血的预防与治疗Pier Mannuccio Mannucci, M.D., and Marcel Levi, M.D., Ph.D.NEJM,Volume 356:2301-2311 May 31, 2007 Number 22第一部分In a medical setting, surgery is the most common cause of major blood loss, defined as a loss of 20% of total blood volume or more. In particular, cardiovascular procedures, liver transplantation and hepatic resections, and major orthopedic procedures including hip and knee replacement and spine surgery, are associated with severe bleeding. Excessive blood loss may also occur for other reasons, such as trauma. Indeed, bleeding contributes to approximately 30% of trauma-related deaths.1 Bleeding in critical locations, such as an intracerebral hemorrhage, may also pose a major clinical challenge.Severe bleeding often requires blood transfusion. Even when the benefits of transfusion outweigh the risks (e.g., mismatched transfusion, allergic reactions, transmission of infections, and acute lung injury),2 strategies to minimize the use of limited resources such as blood products are essential. The most obvious and probably the most effective strategy is to improve surgical and anesthetic techniques. For example, liver transplantation, a procedure that once required transfusion of large amounts of blood products, now has relatively small transfusion requirements in most instances.Ruling out abnormalities of hemostasis in a patient with bleeding is also essential, because such problems can often be corrected by replacing the defective components of the hemostatic system. However, cases of excessive blood loss in which no surgical cause or abnormalities in hemostasis can be identified require pharmacologic strategies, which can be broadly divided into preoperative prophylaxis for operations that confer a high risk of bleeding and interventions for massive, refractory bleeding. The medications that have been most extensively evaluated as hemostatic agents include the antifibrinolytic lysine analogues aminocaproic acid and tranexamic acid; aprotinin, a bovine-derived protease inhibitor; and desmopressin, a synthetic analogue of the antidiuretic hormone that raises the plasma levels of factor VIII and von Willebrand factor.3 In addition, recombinant activated factor VII appears to be efficacious in an array of clinical situations associated with severe hemorrhage.4 The safety of aprotinin, the most widely used of these agents, has been questioned because of concerns about renal and cardiovascular adverse events.5Most trials of hemostatic agents have been designed to assess therapeutic efficacy, but they were not optimally designed to assess potential toxic effects, so definitive safety data are lacking for all hemostatic agents. Many trials of these agents have used perioperative blood loss and othermeasures that are not the most clinically relevant end points, and many published trials were not powered to assess more clinically relevant outcomes such as mortality or the need for reoperation. We review the therapeutic benefits of hemostatic drugs and consider the risk of adverse events. In particular, we consider thrombotic complications, which constitute a major concern when agents that potentiate hemostasis are administered.第二部分Antifibrinolytic AgentsApproximately 5% of patients undergoing cardiac surgery require reexploration because of excessive blood loss; indeed, bleeding during and after cardiac surgery is an established marker of increased morbidity and mortality.6,7,8 Pharmacologic strategies are therefore often used to minimize blood loss during cardiac surgery. Aprotinin (a direct inhibitor of the fibrinolytic enzyme plasmin) is the only drug reported to minimize transfusion requirements in coronary-artery bypass grafting and approved by the Food and Drug Administration (FDA). Aminocaproic acid and tranexamic acid are also used, but they have not been approved by the FDA for this indication. The mechanism of action of these agents is illustrated in Figure 1. Table 1 lists the most frequently used dosages of antifibrinolytic agents.Figure 1. Mode of Action of Lysine Analogues (Aminocaproic Acid and Tranexamic Acid).Activation of plasminogen by endogenous plasminogen activators results in plasmin, which causes degradation of fibrin. Binding of plasminogen to fibrin makes this process more efficient and occurs through lysine residues in fibrin that bind to lysine-binding sites on plasminogen (Panel A). In the presence of lysine analogues, these lysine-binding sites are occupied, resulting in an inhibition of fibrin binding to plasminogen and impairment of endogenous fibrinolysis (Panel .Table 1. Mechanism of Action and Intravenous Doses of Antifibrinolytic Agents Used in Cardiac Surgery to Minimize Blood Loss and Transfusion Requirements.Efficacy of Antifibrinolytic AgentsAfter the first study in 1987,9 more than 70 randomized, controlled trials that included from 20 to 796 patients (median, 75) confirmed and established the efficacy of aprotinin for limiting the requirements for transfusion of red cells, platelets, and fresh-frozen plasma in patients undergoing cardiac surgery. We examine in depth four trials chosen for their size and design.In a study of 796 patients who were randomly assigned to receive aprotinin or placebo during primary coronary-artery bypass grafting, aprotinin was associated with reduced blood loss (mean [±SD], 664±1009 ml, vs. 1168±1022 ml in the placebo group). Aprotinin also was associated with a decreased rate of use of any blood product (40%, vs. 58% in the placebo group).10 In a randomized, placebo-controlled trial involving 704 patients, treatment with aprotinin was associated with a decrease in mean perioperative blood loss (832±50 ml, vs. 1286±52 ml in the placebo group) and a reduction in the proportion of patients requiring any transfusion (35% vs.55%).11 Two trials recruited patients who were at increased risk for bleeding because they were undergoing repeat cardiac surgery.12,13 On average, patients who received aprotinin needed between 1.6 and 2 units of blood products, whereas patients who received placebo needed between 10 and 12 units.12,13 Similar findings with aprotinin have been reported in many other placebo-controlled trials, with a reduction in perioperative blood loss ranging from 50 to 1350 ml (median reduction, 400 ml) and a reduction by a factor of 1.5 to 3 in the proportion of patients requiring any transfusion.14,15,16,17,18,19,20,21,22,23,24,25第三部分Randomized trials of tranexamic acid or aminocaproic acid are much less numerous than trials of aprotinin.26,27,28,29,30,31 In the largest trial of tranexamic acid, 210 patients were randomly assigned to receive tranexamic acid (at a dose of 10 g) or placebo. Administration of tranexamic acid resulted in a 69% reduction in red-cell transfusions, and the proportion of patients requiring any blood product was 12.5% in the tranexamic acid group as compared with 31.1% in the control group.31There have also been meta-analyses and systematic reviews of the efficacy of antifibrinolytic agents.32,33,34,35,36 Table 2 summarizes the results of a Cochrane review. As compared with placebo, the use of aprotinin or tranexamic acid, but not of aminocaproic acid, reduced the need for blood transfusion by 30% and saved approximately 1 unit of blood per operation.36 There was no difference in efficacy between low-dose and high-dose regimens of aprotinin (Table 1), whereas the large variations in dosages of tranexamic acid and aminocaproic acid precluded the evaluation of the relationship between dosage and efficacy. In terms of more clinically relevant events, the relative risk of reoperation for excessive bleeding was significantly reduced among patients who received aprotinin, as compared with those who received placebo, although mortality was not affected. There was a significant reduction in these events with either tranexamic acid or aminocaproic acid.36Table 2. Results of the Cochrane Review of the Effect of Antifibrinolytic Agents on Clinical Events among Patients Undergoing Major Surgical ProceduresThus, the results of controlled trials and reviews indicate that antifibrinolytic drugs are effective hemostatic agents in cardiac surgery. Reductions in both transfusion requirements and reoperation for bleeding appear to be confirmed by the narrow confidence intervals of the odds ratios that are indicators of the relative risks (Table 2). There are not enough efficacy data to draw definitive conclusions regarding the use of antifibrinolytic agents in other situations.Safety of Antifibrinolytic AgentsThere have been criticisms that many trials of the efficacy of aprotinin in cardiac surgery were unnecessarily carried out (and reported) after the transfusion-sparing efficacy was unequivocally established and that such studies should have focused instead on the more cogent and unsettled issue of safety.37,38 Adverse events, particularly thrombotic complications, are expected when a major regulatory system such as the fibrinolytic system is pharmacologically inhibited; this isespecially true in patients undergoing cardiac surgery, because they often have underlying atherothrombotic disease.Table 3, which summarizes the risks of complications when antifibrinolytic agents are administered, shows that none of the adverse events examined was significantly increased.36 However, a few early studies indicated that the use of aprotinin could lead to an increase in cases of postoperative renal dysfunction, possibly through the inhibition of kallikrein and other endogenous vasodilators, with a resultant reduction of renal blood flow.24,39,40Table 3. Results of the Cochrane Review of the Effect of Antifibrinolytic Agents on Adverse Events among Patients Undergoing Major Surgical Procedures.第四部分The risk of serious adverse events associated with aprotinin was recently highlighted by the results of a nonrandomized, observational study involving 4374 patients who underwent elective coronary-artery bypass surgery.5 That study, which compared aprotinin, aminocaproic acid, and tranexamic acid with no treatment, used the propensity-score adjustment method to balance the covariates and thus reduce bias that could arise if sicker patients selectively received one agent over another. The results indicated that, as compared with no treatment, aprotinin (but neither aminocaproic acid nor tranexamic acid) doubled the risk of severe renal failure, increased the risk of myocardial infarction or heart failure by 55%, and was associated with a nearly doubled increase in the risk of stroke or other cerebrovascular events. That study confirmed that the three antifibrinolytic agents reduced blood loss to a similar degree, but adverse events were much more frequent with aprotinin than with the other agents. Much debate followed the publication of the study,41,42,43,44 which was criticized on the grounds that it was observational, was carried out in many different countries and institutions, and was poorly controlled with respect to known determinants of outcome such as the use or nonuse of antithrombotic and inotropic drugs, the duration of cardiopulmonary bypass, and the amounts of blood transfused.However, other recent studies have also reported adverse renal effects of aprotinin. A review of randomized trials conducted from 1991 to 2005 reported that patients who received aprotinin had a 9% rate of renal failure (defined as the need for dialysis or a postoperative increase in the serum creatinine level of at least 2.0 mg per deciliter [176.8 µmol per liter]) and that renal dysfunction (defined as an increase in creatinine of 0.5 to 1.9 mg per deciliter [44.2 to 168.0 µmol per liter]) occurred in 12.9% of patients receiving aprotinin as compared with 8.4% of controls (relative risk, 1.47; 95% confidence interval [CI], 1.12 to 1.94; P<0.001).41 An observational survey commissioned by the manufacturer showed similar rates of renal dysfunction and renal failure among 67,000 patients who received aprotinin.45Although Mangano et al.5 and the authors of previous systematic reviews report that aminocaproic acid and tranexamic acid appear to be relatively safe,32,33,34,35,36 the numbers of trials and study participants were much smaller for these drugs than for aprotinin. Thus, confidence with regard to safety issues is not solid, especially with respect to thrombosis. Most important, trials comparing aprotinin with lysine analogues have been too few and toosmall.46,47,48,49 An independently funded, randomized clinical trial with three study groups is being conducted in Canada. The Blood Conservation using Antifibrinolytics: A Randomized Trial in a Cardiac Surgery Population (BART) study, which is still enrolling patients, plans to enroll 2970 patients undergoing high-risk cardiac surgery to determine whether aprotinin is superior to aminocaproic acid or tranexamic acid in reducing the risk of massive postoperative bleeding.50 Secondary end points are mortality from all causes and adverse events such as cardiovascular disease and renal failure.50第五部分On the basis of all the data reported thus far, there is abundant, solid evidence that aprotinin reduces perioperative and early postoperative blood loss and transfusion requirements in patients undergoing cardiac surgery. However, despite the large number of clinical trials involving this agent, its effectiveness in decreasing the need for reoperation has been reported only in reviews,36 and evidence of its effect on mortality is lacking. It is regrettable that the inexpensive lysine analogues have been less thoroughly investigated as of this writing, because it appears likely that these agents are at least as efficacious as aprotinin. The uncertainty about aprotinin's safety remains a substantial concern. Until the results of the Canadian trial are available,50 aprotinin remains the hemostatic agent of choice. However, it should be used only when excessive perioperative and early postoperative blood loss is predicted (e.g., in the case of a complex operation or special clinical circumstances such as the use of antiplatelet agents).Evidence of the efficacy of lysine analogues is not as solid as that for aprotinin, so these agents should be used only as a second choice in high-risk cardiac surgery. There is definitely no role for either aprotinin or other hemostatic agents in noncomplex coronary-artery bypass surgery, even though in many cases an off-pump procedure is used, which reduces blood loss and transfusion requirements.51,52 The FDA has warned that it is important to monitor patients receiving aprotinin for renal, cardiac, and brain toxic effects and that aprotinin should be used only when the clinical benefit of reducing blood loss is essential to medical management and outweighs any risk.53Recombinant Activated Factor VIIRecombinant activated factor VII (rFVIIa) is thought to act locally at the site of tissue injury and vascular-wall disruption by binding to exposed tissue factor, generating small amounts of thrombin that are sufficient to activate platelets4 (Figure 2). The activated platelet surface can then form a template on which rFVIIa directly or indirectly mediates further activation of coagulation, ultimately generating much more thrombin and leading to the conversion of fibrinogen to fibrin.54,55 Clot formation is stabilized by the inhibition of fibrinolysis due to rFVIIa-mediated activation of thrombin-activatable fibrinolysis inhibitor.56Figure 2. Mechanism of Action of Recombinant Factor VIIa.When the vessel wall is disrupted, subendothelial tissue factor becomes exposed to circulating blood and may bind factor VIIa (Panel A). This binding activates factor X, and activated factor X(factor Xa) generates small amounts of thrombin. The thrombin (factor IIa) in turn activates platelets and factors V and VIII. Activated platelets bind circulating factor VIIa (Panel , resulting in further factor Xa generation as well as activation of factor IX. Activated factor IX (factor IXa) (with its cofactor VIIIa) yields additional factor Xa. The complex of factor Xa and its cofactor Va then converts prothrombin (factor II) into thrombin (factor IIa) in amounts that are sufficient to induce the conversion of fibrinogen to fibrin.第六部分Efficacy of rFVIIaInitially, rFVIIa was licensed for the treatment of bleeding in patients with hemophilia who had antibodies inactivating factor VIII or IX.4 More recently, this agent has been used extensively in patients with major hemorrhage from surgery, trauma, or other causes.57 A small, controlled clinical trial showed that rFVIIa could minimize perioperative blood loss and transfusion requirements in patients undergoing transabdominal prostatectomy, an operation that is often associated with major blood loss.58 In that trial, 36 patients were randomly assigned to receive a single preoperative injection of rFVIIa (20 or 40 µg per kilogram of body weight) or placebo. Administration of the active drug resulted in a significant reduction of blood loss (50%) and eliminated the need for transfusion, which was required in approximately 60% of patients who received placebo.58Additional studies have focused on patients undergoing orthotopic liver transplantation. An open-label pilot study involving six patients showed a marked reduction in transfusion requirements among those who received a single dose of rFVIIa (80 µg per kilogram) as compared with matched historical controls.59 However, a subsequent randomized, placebo-controlled trial evaluating two different doses of rFVIIa (60 and 120 µg per kilogram) showed no reduction in transfusion requirements among 182 liver-transplant recipients, although red-cell transfusion was averted in 8.4% of patients who received rFVIIa but in none of the patients in the placebo group.60 Two randomized, controlled trials of rFVIIa (up to 100 µg per kilogram at every second hour of surgery) in patients with cirrhosis or normal liver function who were undergoing major liver resection did not show a significant effect of rFVIIa on either the volume of blood products administered or the percentage of patients requiring transfusion.61,62In addition, rFVIIa was evaluated in a randomized, controlled study involving 20 patients undergoing noncoronary cardiac surgery requiring cardiopulmonary bypass.63 Administration of rFVIIa at a dose of 90 µg per kilogram after discontinuation of bypass significantly reduced the need for blood transfusion (relative risk of any transfusion, 0.26; 95% CI, 0.07 to 0.90). In addition, a propensity score?matched, case?control study involving 51 patients with massive blood loss after cardiac surgery showed a significant decrease in blood loss and requirements for blood products after the administration of rFVIIa (at a dose of 35 to 70 µg per kilogram).64 In this study, however, the incidence of acute renal dysfunction among patients receiving rFVIIa was 2.4 times that in the control group, although there were no significant differences between the two groups with regard to other adverse events.64Several case reports and case series suggest that rFVIIa is also useful in reducing major blood loss in patients with trauma.65 A placebo-controlled trial involving 143 patients with severe blunt trauma showed that three successive doses of rFVIIa (200, 100, and 100 µg per kilogram) significantly reduced red-cell transfusion (mean reduction, 2.6 units) and reduced the proportion of patients in whom massive transfusion, defined as more than 20 units of red cells, was required (14% of treated patients vs. 33% of controls).66 However, a parallel trial involving 134 patients with penetrating trauma showed no significant effects.66第七部分Studies have also evaluated rFVIIa for the treatment of spontaneous intracranial hemorrhage, a condition for which there is a paucity of effective therapeutic options.67 A dose-finding trial involving 400 patients showed that as compared with placebo, rFVIIa was associated with a slower increase in the size of intracerebral hematoma. More important, there was a 35% reduction in mortality and an improved disability score at 90 days in patients who received rFVIIa.67 Unfortunately, these promising early results were not confirmed in a subsequent phase 3, randomized, controlled trial involving 821 patients.68 A preliminary report indicated that there was a significant reduction in the size of the intracerebral hematoma but with no effect on mortality and severe disability on day 90, the primary end point of the study.68 The manufacturer has not sought regulatory approval for rFVIIa for the treatment of intracerebral hemorrhage.This agent has also been studied in patients with bleeding esophageal varices and portal hypertension, a combination that constitutes another major clinical challenge. In a randomized, controlled trial involving 245 patients with cirrhosis and upper gastrointestinal bleeding (66% of whom had bleeding varices) who were being treated with standard endoscopic and pharmacologic interventions, the administration of rFVIIa (eight consecutive doses of 100 µg per kilogram within 30 hours after the initiation of treatment) was not more effective than placebo with respect to the primary composite end point (failure to control bleeding within 24 hours and failure to prevent rebleeding or death within the first 5 days).69 However, in a subgroup of patients with more severe cirrhosis (classified as Child class B or C), rFVIIa was associated with a decrease in the proportion of patients reaching the composite end point (8%, vs. 23% in the control group; P=0.03). Furthermore, none of the patients treated with rFVIIa had rebleeding within 24 hours, whereas rebleeding occurred in 11% of patients in the control group (P=0.01).69Many case reports and case series have examined the use of rFVIIa in patients with excessive or life-threatening blood loss occurring in an array of clinical settings.57 However, no randomized, controlled clinical trials have been completed, which is not surprising, given the difficulty of performing meaningful studies in such heterogeneous situations. Many reports claim that the use of rFVIIa resulted in rapid reduction of blood loss or a decrease in transfusion requirements after other therapeutic measures had failed. Although many of these reports appear to be compelling, it is difficult to assess the usefulness of rFVIIa properly, since publication bias in case reports and series is likely.第八部分Safety of rFVIIaControlled clinical trials have shown that the incidence of thrombotic complications among patients who received rFVIIa was relatively low and similar to that among patients who received placebo.70 However, most studies of rFVIIa involved patients who had impaired coagulation or who were at low risk for thrombosis. In one trial involving patients with conditions such as intracerebral hemorrhage and a much higher risk of thrombosis, 7% of patients receiving rFVIIa had serious thromboembolic events ? mainly myocardial infarction or ischemic stroke ? as compared with 2% of those receiving placebo.67 Midway through this trial, an exclusion criterion changed. Initially, only patients with thrombotic disease within 30 days before enrollment were excluded, but at the midpoint, all patients with any history of thrombotic disease were excluded, which may have obscured safety concerns associated with the use of rFVIIa. A review based on the FDA MedWatch database indicated that thromboembolic events have occurred in both the arterial and venous systems, particularly in patients with diseases other than hemophilia in whom rFVIIa was used on an off-label basis.71 A total of 54% of the thromboembolic events were arterial thrombosis (in most cases, stroke or acute myocardial infarction); venous thromboembolism (in most cases, venous thrombosis or pulmonary embolism) occurred in 56% of patients. In 72% of the 50 reported deaths, thromboembolism was considered the probable cause. It is not clear to what extent the clinical conditions requiring the use of rFVIIa may have contributed to the risk of thrombosis.71 These findings provide evidence of an increased risk of thrombotic complications that may offset the potential benefit of rFVIIa in patients with severe blood loss.The availability of rFVIIa has expanded the treatment options for acute hemorrhage in patients with conditions other than hemophilia. This agent is not a panacea, but it has efficacy in patients with trauma and excessive bleeding that is resistant to other treatments. However, the promising results obtained so far must be substantiated by confirmatory trials, and studies of the cost-effectiveness of this expensive agent are also warranted. The many published cases of dramatic success in patients with various types of acute hemorrhages, albeit convincing and rewarding for the involved clinicians, should be viewed with caution in terms of constituting clinically directive evidence. Attempts are being made to improve the potency and efficacy of rFVIIa further by engineering the molecule through DNA technology, but clinical trials designed to establish increased efficacy and safety remain to be performed.72,73第九部分Other InterventionsDesmopressin was originally developed and licensed for the treatment of inherited defects of hemostasis.74,75,76 This drug, given by slow intravenous infusion at a dose of 0.3 µg per kilogram, acts by releasing ultralarge von Willebrand factor multimers from endothelial cells, leading to an increase in plasma levels of von Willebrand factor and associated factor VIII and anenhancement of primary hemostasis.77,78 The strongest evidence of efficacy is in the prevention and treatment of bleeding in patients with mild hemophilia A and von Willebrand's disease.75,76 In 1986, Salzman et al.79 showed that as compared with placebo, desmopressin reduced blood loss and transfusion requirements by approximately 30% during complex cardiac surgery. Subsequent attempts to reproduce these findings were variable; most did not confirm the marked benefit originally reported.80,81,82 Overall, there have been 18 trials of desmopressin in a total of 1295 patients undergoing cardiac surgery. These trials show a small effect on perioperative blood loss (median reduction, 115 ml). Several reviews suggest that although desmopressin helps to reduce perioperative blood loss, its effect is too small to influence other, more clinically relevant outcomes such as the need for transfusion and reoperation.33,83,84,85 In addition, desmopressin does not reduce blood loss or transfusion requirements during elective partial hepatectomy, another operation often associated with major blood loss.86 A report that desmopressin reduced blood loss associated with posterior spinal surgery for idiopathic scoliosis87 was not confirmed.88,89,90Although desmopressin can shorten the skin-bleeding time in patients with uremia,91 the current widespread use of recombinant erythropoietin has made this abnormality of hemostasis much less frequent than it was previously.92 The beneficial effect of erythropoietin on hemostasis is based on the increase in red-cell mass, which affects the blood?fluid dynamics, leading to a more intense interaction between circulating platelets and the vessel wall.Thus, there is little evidence that desmopressin is efficacious in conditions other than mild hemophilia A and von Willebrand's disease. The use of desmopressin in some patients who have bleeding as a consequence of inherited and acquired defects of platelet function may be considered. This drug has been shown to shorten the skin-bleeding time in patients with cirrhosis of the liver and in those with some types of inherited platelet disorders.93 However, the use of desmopressin for these indications is not supported by sound clinical evidence based on relevant end points.94 The most common adverse effects of desmopressin, facial flushing and transient hyponatremia, are usually mild. There have been reports of arterial thrombotic events, not only in patients with atherothrombosis but also in patients with bleeding disorders and in a blood donor.95,96,97,98,99,100 A systematic review showed that for patients with acute myocardial infarction who underwent cardiac surgery, the frequency of these adverse events among patients who received desmopressin was twice that among patients who received placebo, with no improvement in clinical outcomes.33 However, another review, evaluating 16 trials of desmopressin in cardiac surgery and in other high-risk operations, showed that the rate of thrombosis did not differ significantly between patients who received desmopressin and patients who received placebo (3.4% vs. 2.7%).101第十部分Hemostatic agents for topical use (particularly "fibrin sealants" composed of human fibrinogen, human or bovine thrombin, and in some instances human factor XIII and bovine aprotinin) have been licensed in Europe.102,103 In several poorly controlled studies involving small series of patients, the efficacy of these agents has been reported for indications such as cardiovascular and。

新英格兰医学杂志审稿流程

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国外常见英文医学杂志影响因子及网址

国外常见英文医学杂志影响因子及网址<综合>1、期刊名称：Nature Medicine影响因子：大约31网络版地址：有提前公布的文摘，但是时间不定：2、期刊名称：NEJM New England Journal of Medicine （新英格兰医学杂志）影响因子：44点多（05年）网络版地址：3、期刊名称：British medical journal （BMJ）影响因子：（2006）网络版地址：4、期刊名称：PNAS影响因子：(2006)网络版地址：——也可以免费获得全文5、期刊名称：lancet影响因子：网络版地址：6、期刊名称：Science网络版地址：7、期刊名称： Nature影响因子：网络版地址：8、期刊名称:Nature Genetics网址：生命科学>1、期刊名称：《Cell》影响因子：大约28(2005),29(2006)网络版地址：Online First版本：2、期刊名称：stem cells影响因子：(2006)网络版地址：——该期刊所有文章PDF全文全部可在上述网址获得，而且更新很快3、期刊名称：科学家影响因子：网络版地址：<细胞生物>1、期刊名称：journal of cell Science网络版地址：2、期刊名称：Current Biology影响因子：网络版地址：3、期刊名称：Molecular Cell影响因子：网络版地址：4、期刊名称：Nature review molecular cell biology影响因子：网络版地址：5、期刊：fertility sterility影响因子：（3点多）网址：消化>1、期刊名称：journal of hepatology影响因子：网络版地址：2、期刊名称：gut影响因子：网络版地址：Online First版本（如果有，请列出）：3、期刊名称：hepatology影响因子：网络版地址：4、期刊名称：gastroenterology影响因子：约13网络版地址：消化内镜方向>1、杂志名称：GIEIF:网址：2、杂志名称：EndoscopyIF：网址：<呼吸>下面4本杂志比较偏重临床，可读性强——1、期刊名称：《American journal of respiratory and critical care medicine 》影响因子：大约8网络版地址： First版本：2、期刊名称：Thorax影响因子：3、期刊名称：ERJ欧洲呼吸杂志影响因子：网络版地址：4、期刊名称：Chest（有中文版）影响因子：网络版地址：下列杂志也比较出名，但偏重基础——5、期刊名称：American Journal of Respiratory Cell and Molecular Biology（AJRCMB ）影响因子：网络版地址：6、期刊名称： American Journal of Physiology－《Lung Cellular and Molecular Physiol ogy 》影响因子：网络版地址：以下两个杂志的哮喘文献很有影响——7、期刊名称：Allergy影响因子：网络版地址：8、期刊名称：Clinical & Experimental Allergy影响因子：<危重症>1、期刊名称：《American Journal of Respiratory and Critical Care Medicine》影响因子：网址：2、期刊名称：Critical Care Medicine影响因子：约7网络版地址：——创刊于1973年，为月刊，2006年IF=。

医药卫生类期刊影响因子

医药卫生类期刊影响因子
1. New England Journal of Medicine (NEJM)：NEJM 是世界上最有影响力的医学期刊之一，其影响因子长期保持在70以上，是医药卫生类期刊中的顶级期刊之一、NEJM 发表的文章通常涵盖了医学领域的各个方面，包括基础医学、临床医学和公共卫生等。

3. Journal of the American Medical Association (JAMA)：JAMA 是美国医学会主办的期刊，其影响因子一直保持在40以上。

JAMA 发表的文章主要聚焦于临床医学和公共卫生等领域，文章的质量和重要性受到广泛认可。

该期刊拥有严格的同行评审制度，确保发表的文章科学可靠。

4. BMJ (British Medical Journal)：BMJ 是一本英国医学期刊，其影响因子长期保持在30以上。

BMJ 发表的文章涵盖了医学领域的各个方面，包括临床医学、公共卫生和研究方法学等。

期刊鼓励多样性的观点，并提供了辩论和评论的平台。

除了以上几个顶级的医药卫生类期刊之外，还有许多其他重要的期刊也具有较高的影响因子，如Nature Medicine、Cell、The Journal of Clinical Investigation等。

这些期刊通常都有着极高的学术声誉，并且发表的文章对学术界和临床实践都具有重要的影响。

总之，医药卫生类期刊的影响因子是衡量该期刊学术影响力的重要指标，而顶级期刊往往具有较高的影响因子。

科研人员可以根据自己的研究方向和需求选择适合的期刊投稿，从而提高自己的学术影响力。

科研设计及研究生论文撰写知到章节答案智慧树2023年浙江中医药大学

科研设计及研究生论文撰写知到章节测试答案智慧树2023年最新浙江中医药大学第一章测试1.在2018年中办、国办印发（），进一步对科研诚信制度体系实化、细化。

参考答案:《关于进一步加强科研诚信建设的若干意见》2.若高校学生出现科研不端行为，学校应该( )。

参考答案:严厉对待，撤销学位3.学术诚信三原则包括?( )参考答案:真实性;规范性;严谨性4.学术诚信是科学研究的首要基础。

（）参考答案:对5.论文工厂是目前SCI论文撤稿的最大原因。

（）参考答案:错第二章测试1.国际公认的四大综合性医学期刊中NEJM指的是（）参考答案:新英格兰医学杂志2.如需查找《浙江中医药大学学报》期刊文章，则需选择哪一检索字段（）参考答案:文献来源KI数据库中专业检索输入易出错，逻辑归纳复杂，对于使用者要求较高，可以不用学习。

（）参考答案:错4.Google 学术搜索可帮助您在整个学术领域中确定相关性最强的研究。

（）参考答案:对5.在pubmed中，若检索结果过多，则可通过点击左侧那些筛选条件进行筛选（）参考答案:TEXT AVAILABILITY;RESULT BY YEAR;ARTICLE ATTRIBUTE;ARTICLE TYPE6.只要是SCI收录的文章都是精品文献。

（）参考答案:错7.NoteExpress软件有搜索文献的功能。

（）参考答案:对8.阅读综述有利于我们对相关领域研究背景的把握。

（）参考答案:对9.从“目的”出发的三种文献阅读的方法包括（）。

参考答案:解决问题的研读法;掌握基本信息研读法;为了撰写论文的研读法10.摘要应包括以下哪几部分？（）。

参考答案:方法;讨论;目的;结果第三章测试1.下列选项中，不是医学科学研究的要求是。

（）参考答案:整体性2.区分实验发展研究与基础研究和应用研究的主要标志不包括下列哪项（）参考答案:研究是要增加科学技术知识3.医学科学研究是兼具自然科学和社会科学二者属性的综合性科学。

2024年SCI期刊影响因子

SCI（Science Citation Index）期刊影响因子是一种衡量期刊影响力的指标，由Thomas Reuters公司每年发布。

影响因子是根据那期刊的被引用情况来计算的，即那期刊一年内被其他期刊引用的次数，除以该期刊在前两年内发表的文章数。

以下是一些2024年的SCI期刊影响因子较高的期刊：1. New England Journal of Medicine（NEJM）- 影响因子：59.558NEJM是一份拥有历史悠久的综合医学期刊，涵盖了各个临床领域的研究。

2. Nature Reviews Genetics - 影响因子：43.079Nature Reviews Genetics是一个发表生物学基因研究的高影响因子期刊。

3. Annual Review of Biochemistry - 影响因子：36.915Annual Review of Biochemistry是一个综合性的生物化学综述期刊，涵盖了生物化学各个领域的研究。

4. Chemical Reviews - 影响因子：47.928Chemical Reviews是化学领域的顶级综述期刊，发表了各个方向的化学研究综述和评论。

5. The Lancet - 影响因子：45.217The Lancet是一份多学科医学期刊，发表了各个医学领域的研究。

6. Journal of Biological Chemistry - 影响因子：4.573Journal of Biological Chemistry是一个发表生物化学和分子生物学研究的期刊。

7. Cell - 影响因子：33.116Cell是生物科学领域的顶级期刊，发表了各个领域的综合性研究。

8. Science - 影响因子：35.661Science是一份综合性科学期刊，发表了各个学科领域的研究。

9. Nature - 影响因子：38.138Nature是一份发表自然科学领域重要研究成果的期刊。

经典伞式、篮式和平台试验《新英格兰医学杂志》综述

经典伞式、篮式和平台试验《新英格兰医学杂志》综述主方案是临床试验的方法学创新，它是解决多个问题的整体性试验方案。

主方案可以设计为在多种疾病中评估一种或多种干预措施，也可以设计为在单一疾病中评估多种干预措施。

这一创新可降低试验成本，并在更短的时间内更高效地回答更多的问题。

《新英格兰医学杂志》（NEJM）在一篇综述中总结了临床试验的主方案。

我们将分两次介绍本文内容，此次介绍主方案的类型和案例，下次介绍主方案的创新方法和应用时的考虑事项。

我们用高质量的证据来指导医疗实践。

产生高质量证据的标准方法是开展一系列的临床试验，每项试验研究一种或两种干预措施对某单一疾病的效果。

该标准方法已变得越来越昂贵，在实施过程中带来的挑战性也越来越大。

故许多重要的临床问题未能得到解答。

评估靶向治疗的“精准医学”试验在招募某些疾病的罕见基因亚型患者方面面临挑战。

开展基于机制的试验也得到越来越多的关注，其纳入标准有别于传统的疾病定义。

它们的共同点是需要在更短的时间内更高效地回答更多的问题。

应对这一需求的方法学创新涉及在一个总体试验框架下联合评价多种治疗对多种患者或多种疾病的效果。

这种创新的成果被称作主方案（master protocol），是一个被设计为解决多个问题的整体性试验方案。

主方案可以设计为在多种疾病中评估一种或多种干预措施，也可以在单一疾病（根据当前的疾病分类）中评估多种干预措施，每种干预措施靶向一种疾病亚型或一个由生物标志物定义的特定人群。

在这个广泛性的主方案定义之下，包含了三种不同的试验方案：伞式、篮式和平台试验（表1、图1和图2）。

这三者都是由一系列试验或子研究所组成的。

这些试验或子研究共享关键设计和实施要素，因此能够发挥比单独设计和独立实施时更好的协调作用。

表1. 主方案的类型图1. 伞式试验和篮式试验伞式试验（上）评估传统定义的某一疾病中的各亚组（通常由生物标志物来界定）。

试验时需筛查患者是否存在某生物标志物或其他特征，然后根据筛查结果将患者分配入不同的层。

新英格兰医学杂志简介及如何在国际期刊发表高水平文章

BREAST CANCER RES 5.785 NEURO-ONCOLOGY 5.483 MOL CANCER THER 5.225 CANCER-AM CANC SOC 5.131 CANCER PREV RES 4.978 EUR J CANCER 4.944 INT J CANCER 4.926 CANCER LETT 4.864 BREAST CANC RES TR 4.859 BRIT J CANCER 4.831 CURR CANC DRUG TAR 4.771 CRIT REV ONCOL HEM 4.689 INT J RADIAT ONCOL 4.503 ENDOCR-RELAT CANC 4.432 CURR OPIN ONCOL 4.386 MOL CANCER RES 4.373 RADIOTHER ONCOL 4.337 CANC IMMUNOL IMMUN 4.293
北京朝阳医院北京中日医院北京市 CDC 中国 CDC 中国 CDC 中国 CDC 中国 CDC 中国 CDC 浙大一附院
中国2009大流行甲型流感（H1N1）病毒感染最初病例的临床特征中国男性与女性中糖尿病的流行患病率调查北京2009年H1N1疫苗的安全性和有效性中国甲型流感疫苗（H1N1）上市完全性调查新布尼亚病毒相关的发热和血小板减少综合征Fever with 中国结核病耐药性的全国调查一种新型禽源性甲型流感(H7N9)病毒的人类感染中国甲型禽流感病毒H7N9感染暴发的流行病学：初步报告 111例甲型禽流感（H7N9）病毒感染病例的临床表现
• 参考文献可达40条。
简报 (Brief Reports)：
•通常描述1至3例患者或一个家族
•文章应以一个100个词以下的摘要开头。

新英格兰医学杂志

新英格兰医学杂志新英格兰医学杂志（New England Journal of Medicine，NEJM）是一本有着悠久历史的医学期刊，由Massachusetts Medical Society出版，创刊于1812年。

作为世界上最负盛名的医学期刊之一，NEJM在全球医学界具有极高的影响力和声誉。

历史背景NEJM创刊于19世纪初，当时的美国正处于医学领域迅速发展的时期。

早期的NEJM主要围绕医学研究和医学实践展开，为医学界提供了一个广阔的交流平台。

随着时间的推移，NEJM逐渐发展成为医学界权威期刊之一，其严谨的审稿标准和高水准的学术质量备受认可。

特色与贡献NEJM以其丰富的学术资源和高品质的文章内容而闻名于世。

每期NEJM都包含了一系列具有广泛影响力的医学研究、临床实践指南、病例分析等。

这些文章涵盖了各个医学领域，不仅为医生、科研人员提供了最新的医学知识和研究成果，也为临床实践提供了重要的参考依据。

NEJM的编辑团队由众多医学界的权威专家组成，他们严格把关每一篇发表的文章，确保其学术水准和准确性。

作为医学领域的风向标，NEJM的发表文章往往会影响全球医学界的发展方向和趋势，成为众多医学专业人士不可或缺的参考资源。

NEJM对于临床实践的影响NEJM所发表的临床研究和实践指南对于提升医学实践的质量和水平起到了积极的作用。

众多临床医生和医疗机构都将NEJM视为获取最新医学信息和发展趋势的主要渠道，从而及时将最新的科学研究成果运用到临床实践中，为患者提供更优质、更有效的医疗服务。

NEJM发表的临床实践指南对于医疗标准的制定和临床决策提供了重要参考。

医生们可以通过NEJM了解到最前沿的医学技术和治疗方法，从而为患者的治疗提供更科学、更精准的方案。

同时，NEJM对于一些疾病的诊断、治疗和预防也提供了宝贵的经验和指导，帮助医生们更好地管理各种疾病。

结语作为医学领域的一面旗帜，新英格兰医学杂志在过去200多年里一直致力于促进医学研究和实践的发展，为医学界提供宝贵的学术资源。

1分多的比较好发的医学类杂志

1分多的比较好发的医学类杂志1分多的发表好的医学类杂志是医学界的宝贵资源。

这些杂志不仅包含了前沿的医学研究成果，还提供了实用的临床经验和专业知识。

然而，要想在这些杂志上发表文章，并不是一件容易的事情。

下面，我将从不同角度来探讨一些值得推荐的医学类杂志，希望能给广大医学工作者提供一些参考。

我们介绍一下《柳叶刀》（The Lancet）杂志。

作为全球医学界的权威杂志之一，《柳叶刀》以其严谨的学术态度和权威的学术评审而闻名。

该杂志涵盖了多个医学领域，包括临床医学、公共卫生、医学研究等。

其发表的文章通常具有高度的创新性和学术性，对医学界有重要的影响力。

值得一提的是《新英格兰医学杂志》（The New England Journal of Medicine，NEJM）。

NEJM是一本拥有悠久历史的医学杂志，创刊于1812年。

这本杂志以其高质量的论文和对医学界的深远影响而闻名。

NEJM涵盖了从基础医学到临床实践的各个领域，发表的文章内容丰富多样，质量上乘。

《自然医学》（Nature Medicine）也是一本备受关注的医学类杂志。

与其他杂志相比，自然医学更注重基础医学和转化医学的研究。

它发表的文章通常具有较强的实验性和创新性，对于推动医学科研的发展起到了积极的推动作用。

对于临床医生来说，《美国医学会杂志》（JAMA）是一本不可忽视的杂志。

JAMA发表的文章涵盖了多个医学领域，包括内科、外科、儿科等。

这本杂志以其高质量的临床研究和临床实践指南而闻名，被广大医生所推崇。

除了以上几本杂志，还有许多其他优秀的医学类杂志，如《柳叶刀肿瘤学》（The Lancet Oncology）、《细胞》（Cell）等。

这些杂志都有自己的特点和优势，读者可以根据自己的研究方向和兴趣进行选择。

发表在医学类杂志上是医学工作者追求的目标之一。

选择一本好的医学类杂志对于提高文章的影响力和学术价值至关重要。

希望广大医学工作者能够充分利用好这些优秀的医学类杂志，为医学研究的进展做出更大的贡献。

国外常见英文医学杂志影响因子及网址

国外常见英文医学杂志影响因子及网址<综合>1、期刊名称：Nature Medicine影响因子：大约31网络版地址：/nm/journal/v14/n5/index.html#af 有提前公布的文摘，但是时间不定：/nm/journal/vaop/ncurrent/index.html2、期刊名称：NEJM New England Journal of Medicine （新英格兰医学杂志）影响因子：44点多（05年）网络版地址：/3、期刊名称：British medical journal （BMJ）影响因子：9.245（2006）网络版地址：/4、期刊名称：PNAS影响因子：9.6(2006)网络版地址：/——也可以免费获得全文5、期刊名称：lancet影响因子：网络版地址：/6、期刊名称：Science影响因子：网络版地址：/7、期刊名称： Nature影响因子：网络版地址：/8、期刊名称:Nature Genetics网址：/ng/index.htm<生命科学>1、期刊名称：《Cell》影响因子：大约28(2005),29(2006)网络版地址：/Online First版本：/content/current2、期刊名称：stem cells影响因子：7.924(2006)网络版地址：/view/0/index.html——该期刊所有文章PDF全文全部可在上述网址获得，而且更新很快3、期刊名称：科学家影响因子：网络版地址：/<细胞生物>1、期刊名称：journal of cell Science影响因子：6.427网络版地址：/2、期刊名称：Current Biology影响因子：10.988网络版地址：/3、期刊名称：Molecular Cell影响因子：14.033网络版地址：/4、期刊名称：Nature review molecular cell biology影响因子：31.354网络版地址：/nrm/5、期刊：fertility sterility影响因子：3.220（3点多）网址：/science/journal/00150282<消化>1、期刊名称：journal of hepatology影响因子：6.64网络版地址：/2、期刊名称：gut影响因子：9.02网络版地址：/Online First版本（如果有，请列出）：/onlinefirst.dtl 3、期刊名称：hepatology影响因子：10.77网络版地址：/journal/hepatology4、期刊名称：gastroenterology影响因子：约13网络版地址：/<消化内镜方向>1、杂志名称：GIEIF:5.8网址：/2、杂志名称：EndoscopyIF：4.1网址：http://www.thieme.de/fz/index.html<呼吸>下面4本杂志比较偏重临床，可读性强——1、期刊名称：《American journal of respiratory and critical care medicine 》影响因子：大约8网络版地址：/Online First版本：/articlesinpress.shtml2、期刊名称：Thorax影响因子：网络版地址：/content/vol52/suppl_2/3、期刊名称：ERJ欧洲呼吸杂志影响因子：网络版地址：/4、期刊名称：Chest（有中文版）影响因子：网络版地址：/下列杂志也比较出名，但偏重基础——5、期刊名称：American Journal of Respiratory Cell and Molecular Biology （AJRCMB ）影响因子：网络版地址：/6、期刊名称： American Journal of Physiology－《Lung Cellular and Molecular Physiology 》影响因子：网络版地址：/以下两个杂志的哮喘文献很有影响——7、期刊名称：Allergy影响因子：网络版地址：/journal.asp?ref=0105-45388、期刊名称：Clinical & Experimental Allergy影响因子：网络版地址：/journal.asp?ref=0954-7894<危重症>1、期刊名称：《American Journal of Respiratory and Critical Care Medicine》影响因子：8.123网址：2、期刊名称：Critical Care Medicine影响因子：约7网络版地址：——创刊于1973年，为月刊，2006年IF=6.599。

这些技巧助你在《新英格兰医学杂志》上发表通讯（Letter）文章

这些技巧助你在《新英格兰医学杂志》上发表通讯（Letter）文章原创： NEJM医学前沿 NEJM医学前沿照日格图《NEJM医学前沿》高级编辑；NEJM编委（2007-2016）在这篇文章中，我将重点讨论向《新英格兰医学杂志》通讯（Letter to the Editor) 栏目投稿时，选题的重要性，或内容上的重要性；也就是说，我们选择什么样的话题或主要内容，被刊登的可能性较大。

针对近期在NEJM发表的论文而撰写的通讯这类通讯文章，有的是提问题的，也有的是做简短的评论的，要求其篇幅不超过175个词（偶尔也有超过这个数字的），而且要在其所针对的文章刊出后3周内收到您的通讯文章稿件。

下面我们具体分析一下，什么样的问题和评论是恰当的。

提问题，或指出研究存在的不足之处，应当回避那些众所周知的研究的局限性。

例如有些已经刊登的文章，可能没有做到双盲，甚至连单盲都没有做到。

还有一些研究可能没有做到多中心。

还有不少临床试验的论文，随访观察的时间比较短。

对于这样的不足之处或局限性，期刊的编辑和审稿专家都是很清楚的。

如果我们在通讯文章中针对这类情况提出问题或提出批评，我认为并不恰当，刊出的可能性不大。

因为，尽管存在这样那样的局限性或不足之处，期刊最终决定刊出那些论文的目的，是要广大读者采纳或参考那些研究的优越之处，有价值的方面。

而对以下情况，我们可以提供不同的意见。

例如，对于某种疾病的干预而言，通讯的作者在尚未发表的相似研究中得出了相同、相似或甚至相反的结果，这些内容可能是对原文的重要补充。

当然，我们还可以提出一些文章中未明确说明的比较重要的问题。

例如，有些干预组中出现了严重不良反应或死亡事件，如果文章中完全未提及那些事件是否与研究的干预相关时，可以提问作者的意见，或解释。

这类例子很多。

例如，针对Gaudino等的论文（Gaudino M, Benedetto U, Fremes S, et al. Radial-artery or saphenous-vein grafts in coronary-artery bypass surgery. N Engl J Med 2018;378:2069-77），NEJM发表了3篇通讯，从内容上都是合适的，特别是Rehman等的那篇（Rehman SM, Duggan SM. Radial-artery grafts for coronary-artery bypass surgery. N Engl J Med, 2018;379;20:1966），强调对接受CABG手术的患者要采取个体化治疗，大隐静脉也要考虑应用，因为目标冠脉狭窄的程度是桡动脉移植物失败的主要预测因子。

重要医学期刊的中英文名称对比

重要医学期刊的中英文名称对比Important Medical Journals: A Comparison of Chinese and English NamesIntroduction:Medical journals play a crucial role in disseminating research findings and advancing medical knowledge. They serve as platforms for researchers, clinicians, and healthcare professionals to share and exchange information. In this article, we will compare the Chinese and English names of some of the most important medical journals.1. New England Journal of Medicine (NEJM)中文名：《新英格兰医学杂志》The New England Journal of Medicine (NEJM) is one of the most reputable and widely-read medical journals in the world. It covers a wide range of medical research, clinical practice guidelines, and case reports.2. The Lancet中文名：《柳叶刀》The Lancet is a renowned medical journal that publishes high-quality research articles and reviews. It covers various disciplines, including clinical medicine, public health, and global health issues.3. Nature Medicine中文名：《自然医学》Nature Medicine focuses on breakthrough discoveries and advances in biomedical research. It publishes original research articles, reviews, and perspectives, providing insights into various areas of medicine and healthcare.4. JAMA (The Journal of the American Medical Association)中文名：《美国医学会杂志》JAMA is a reliable source of medical knowledge and research. It covers a wide range of medical specialties, including internal medicine, pediatrics, and surgery. JAMA publishes original research, clinical reviews, and viewpoint articles.5. The BMJ (British Medical Journal)中文名：《英国医学杂志》The BMJ is a leading general medical journal that publishes research articles, clinical guidelines, and educational resources. It covers a wide range of topics, from clinical practice to public health.6. Cell中文名：《细胞》Cell is a prestigious scientific journal that focuses on biological and medical research at the cellular and molecular levels. It covers a broad range of disciplines, including biochemistry, genetics, and immunology.7. Science中文名：《科学》Science is a multidisciplinary journal that publishes original research articles and reviews in various scientific fields, including medicine and health. It highlights significant discoveries and advancements across different disciplines.8. The Journal of Clinical Investigation (JCI)中文名：《临床研究杂志》The Journal of Clinical Investigation (JCI) publishes research articles and reviews in the field of clinical medicine and translational research. It focuses on understanding disease mechanisms and developing novel treatment approaches.Conclusion:Understanding the Chinese and English names of important medical journals is essential for researchers, clinicians, and healthcare professionals. These journals provide valuable insights, knowledge, and research findings that contribute to advancements in medical science. By comparing the Chinese and English names, we can actively engage in the international medical community and promote collaboration in scientific research.。

中暑的治疗和预防

中暑的治疗和预防中国多地近日出现37~39°C高温，局部甚至达到40°C以上。

高温会导致热衰竭、热晕厥、中暑等一系列高温相关疾病，也会加重或引发心力衰竭、卒中、高血糖、神经精神障碍等热敏感疾病。

中暑是高温相关疾病的最严重形式，具有高死亡率，必须及时治疗。

《新英格兰医学杂志》（NEJM）曾在“临床实践”栏目发表《高温相关疾病的治疗和预防》，介绍高温相关疾病的临床表现、诊断、治疗、降低风险的措施等。

我们在此简介其主要内容。

临床要点临床问题气候变化导致全球平均气温上升，极端高温事件频率、持续时间和强度增加，因而造成前所未有的高温暴露水平。

在过去20年间，65岁以上人群高温相关死亡率增加54%，全球暖季的高温相关死亡有1/3以上是由气候变化造成的。

根据目前全球温室气体排放轨迹，预计到本世纪中叶，全球气温将比工业化前升高2℃，预计未来几十年，世界大部分地区将频繁遭遇极端高温事件。

全球气温升高和热浪已经增加了全球健康负担，并造成巨大经济损失。

人类通过行为和自主机制（如血管舒张和出汗）进行体温调节，从而将体核温度维持在约37℃。

代谢活动产生体内热负荷，来自环境的外源热增加了必须控制的总热负荷；较高湿度（酷热指数会综合考虑湿度）加大了散热难度。

在由外源热、内源热或两者导致的高水平热负荷下，人体体温调节能力可能不堪重负，导致一系列高温相关疾病。

这些疾病的严重程度从不危及生命的疾病（热衰竭、热晕厥、热水肿、热痉挛和热疹）至因体温升高至危险阈值以上而导致的危及生命的中暑（表1）。

表1. 高温相关疾病谱及其治疗*中暑是最严重的高温相关疾病，可以细分为“典型”或“劳力性”中暑；前者通常见于已有疾病的患者，而后者主要见于健康人，他们在执行高强度体力活动时的代谢产热增加超过了体温调节界限，这一情况通常但并非总是伴随环境高温暴露。

两种中暑会因体热过多，无法及时散热而导致相似的生理异常级联反应，包括中心静脉压降低、细胞和器官功能障碍、胃肠道损伤，由此引起的内毒素血症、全身炎症反应，以及体核温度升高。

《The New England Journal of Medicine》新英格兰医学杂志介绍

《The New England Journal of Medicine》新英格兰医学杂志介绍慕萌【期刊名称】《首都医科大学学报》【年(卷),期】2013(34)4【摘要】《新英格兰医学杂志》（《The New England Journal of Medicine》）是一种同行评审性质的全科医学期刊（medical joumal），也是目前全世界最受欢迎的综合性医学期刊之一。

《新英格兰医学杂志》出版对生物医学科学与临床实践具有指导意义的医学研究新成果、综述文章和社论等。

杂志涉及内科学和过敏／免疫学、心脏病学、内分泌学、肠胃病学、血液学、肾脏疾病、肿瘤学、肺部疾病、风湿病学、HIV以及传染病等多个医学专业。

【总页数】2页(P636-637)【作者】慕萌【作者单位】首都医科大学学报编辑部,北京,100069【正文语种】中文【相关文献】1.New England Journal of Medicine:阿比特龙在转移性激素敏感性前列腺癌中的应用——LATITUDE试验中期结果发布 [J], 吴开杰2.The New England Journal of Medicine:Olaparib,前列腺癌精准治疗里程碑[J], 郭鹏3.SCI收录的Journal of Materials Science：Materials in Medicine（《材料科学杂志一医学材料》）杂志介绍 [J],4.New England Journal of Medicine:MRI靶向穿刺与标准穿刺活检对于前列腺癌的诊断价值(PRECISION试验结果发布) [J], 吴开杰5.The NEW ENGLAND JOURNAL of MEDICINE [J], 师延路（编译）因版权原因，仅展示原文概要，查看原文内容请购买。

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这些技巧助你在《新英格兰医学杂志》上发表通讯（Letter）文章

重要医学期刊的中英文名称对比

中暑的治疗和预防

《The New England Journal of Medicine》新英格兰医学杂志介绍