影响老年心脏瓣膜置换术病人死亡的危险因素及护理对策

[目的]研究影响老年心脏瓣膜置换术病人死亡的危险因素及护理对策。[方法]回顾性分析进行心脏瓣膜置换术老年病人130例,统计病人所有手术相关资料,包括年龄、术前左心室射血分数(LVEF)、主动脉阻断时间、手术方式等,采用单因素及多因素Logistic回归分析术后死亡高危影响因素。[结果]年龄、LVEF、同期行冠状动脉旁路移植术(CABG)、体外循环时间与老年心脏瓣膜置换术后死亡有关,差异有统计学意义(P0.05);年龄≥70岁,LVEF≤50%,体外循环时间≥120min,同期CAGB是老年心脏瓣膜置换术后死亡独立危险因素,差异有统计学意义(P0.05)。[结论]年龄≥70岁,LVEF≤50%,体外循环时间≥120min,同期CABG影响老年心脏瓣膜置换术后死亡率。     

Atricure双极射频消融治疗器质性心脏病心房颤动29例分析

目的 评价心内直视下Atricure双极射频消融(RFA)治疗器质性心脏病(OHD)合并心房颤动(AF)的手术疗效.方法 2007年8月至2008年11月间采用Atricure双极射频消融机为29例OHD(27例风湿性心脏病、2例先天性心脏病)合并AF患者施行RFA术,总结其临床疗效.结果 全组手术均顺利完成,体外循环时间(108.3±24.6)min,主动脉阻断时间(69.9±22.7)min,RFA时间(18.4±2.03)min;术后均立即恢复窦性心律;10例(34.48%)分别于术后1～5天发生阵发性房颤,经静脉推注盐酸胺碘硐后转为窦性心律,予以口服盐酸胺碘硐维持;无高度房室传导阻滞发生;2例(6.89%)分别于术后2天和4天死于低心排,其余痊愈出院,平均住院(9.2±3.5)天;术后随访27例,平均随访(6.8±1.4)个月,96.29%(26/27)维持窦性心律,3.71%(1/27)为AF心律,无死亡及脑卒中发生.结论 OHD合并AF术中同期行Atricure双极RFA治疗,术后长期窦性心律维持率高.RFA作为心脏手术的辅助手术具有安全、省时、治疗AF效果好等优点,值得临床推广应用.     

重症心脏瓣膜疾病的外科治疗

目的 探讨重症心脏瓣膜疾病瓣膜置换术的治疗.方法 35例患者均在气管内插管静脉复合全身麻醉、中低温体外循环下经胸骨正中切口行心瓣膜置换术.体外循环时间53～177 min,平均(93.4±34.2)min,主动脉阻断时间为37～119 min,平均(72.5±22.3)min.结果 35例患者中22例心脏自动复跳,11例行电击除颤复跳,均治愈出院,治愈率为94.29%.死亡2例(1例为低心排综合征,1例为器官功能衰竭),病死率为5.71%.33例患者出院后均获随访,随访时间10～48个月,结果心功能较术前均有不同程度提高,其中恢复至Ⅱ级11例,Ⅲ级16例,IV级5例;晚期死亡1例(颅内出血).结论 重症心脏瓣膜病变特别是联合瓣膜病变者,术前心功能均较差,应重视围术期处理,主动脉瓣环过小,可采用扩大瓣环方法,在置换二尖瓣时,保留二尖瓣下结构.合并中、重度或三尖瓣关闭不全患者应行Devega环缩术.     

心脏瓣膜置换术治疗大左心室心脏瓣膜病的临床疗效及其影响因素

目的探讨心脏瓣膜置换术治疗大左心室心脏瓣膜病的临床疗效及其影响因素。方法回顾性分析80例行心脏瓣膜置换术治疗的大左心室心脏瓣膜病患者临床资料。单因素分析、多因素Logistic回归分析心脏瓣膜置换术疗效及并发症的危险因素。结果术后死亡4例,存活76例,发生并发症58例。术后2周,患者LVEDD、LAD、LVEF均显著降低(P0.05)。单因素分析结果显示,年龄(50岁)、NYHAⅢ级或Ⅳ级、术前非窦性心律、风湿性心脏病瓣膜病、体外循环时间108 min、LVEDD80 mm、LAD60 mm、LVEF50%是发生室性心律失常的危险因素。Logistic多因素回归分析显示,NYHAⅢ级或Ⅳ级、术前非窦性心律是术后室性心律失常发生的危险因素。结论心脏瓣膜置换术能有效治疗大左心室心脏瓣膜病。NYHAⅢ级或Ⅳ级、术前非窦性心律是术后室性心律失常发生的危险因素。     

分析体外循环时间对心脏瓣膜置换术后肾功能的影响

目的:评价体外循环(cardiopulmonary bypass,CPB)时间对心脏瓣膜置换术后肾功能的影响.方法:选取28例行心脏瓣膜置换术后出现肾功能损伤的患者作为肾功能异常组,随机选取37例同期行心脏瓣膜置换术肾功能正常的患者作为对照组,收集它们的资料,对两组病例的CPB时间进行对比分析.结果:肾功能正常组的CPB平均时间(143.41 ± 48.20)min,肾功能异常组的CPB平均时间(197.82 ± 43.39)min,两组比较差异有统计学意义(P ＝ 0.000 27),CPB时间＜ 150 min肾功能异常的患者5/27例(18.5%),CPB时间＞ 150 min肾功能异常的患者23/38例(60.5%),两者比较差异有统计学意义(P ＜ 0.005).结论:CPB时间可明显影响心脏瓣膜置换术后的肾功能.     

全胸腔镜下成人房间隔缺损修补手术20例临床分析

目的回顾性分析全胸腔镜下行20例成人房间隔缺损修补手术的临床效果,总结全胸腔镜下心脏手术经验。方法该院自2014年3月-2016年8月,采用右侧股动脉、股静脉插管建立周围体外循环,主动脉根部顺行灌注冷血停跳液保护心肌,在右侧胸壁打3孔完成成人房间隔缺损修补心脏手术20例,分析手术时间、主动脉阻断时间、体外循环时间、呼吸机辅助时间、胸腔引流情况、住院天数和并发症等临床资料。结果全组患者手术时间为3.5~5.0 h,平均(3.8±0.5)h;升主动脉阻断时间为28~46 min,平均(29.8±8.2)min;体外循环时间为86~108 min,平均(80.6±11.5)min;呼吸机辅助时间5~8 h,平均(6.0±0.8)h;胸腔引流量100~260 ml,平均(150.0±35.0)ml;术后住院时间6~9 d,平均(6.5±1.2)d。全组患者无手术死亡,术后无残余分流发生,有1例患者腹股沟伤口脂肪液化,予以加强伤口换药处理;1例患者胸腔积气,予以穿刺后好转;1例患者因右侧胸腔粘连改为胸腔镜辅助,患者恢复顺利,全组无严重并发症发生。术后3~5天超声心动图示手术效果满意,患者顺利出院。随访1~28个月,无残余分流,无下肢静脉血栓形成,心功能均为Ⅰ级。结论全胸腔镜下成人房间隔缺损修补心脏手术安全可行,手术创伤小,切口美观,术后引流少,患者恢复快。     

冠状动脉旁路术同期进行心脏瓣膜替换术对冠心病心脏瓣膜病变的疗效分析

目的探讨冠状动脉旁路术同期进行心脏瓣膜替换术对冠心病心脏瓣膜病变的临床治疗效果。方法选择2013年6月28日至2014年6月28日于该院就诊的64例冠心病心脏瓣膜病变患者,对所有患者均选择冠状动脉旁路术,并同期采用心脏瓣膜替换术进行治疗,分析心功能恢复情况、并发症发生率、随访情况。结果相比治疗前,治疗后患者左心室射血分数明显提高,左心室舒张末期内径、左心室收缩末期内径明显降低(P0.05);术后并发症发生率为7.81%;患者呼吸机使用时间、重症监护室监护时间、住院时间分别为(34.61±2.84)h、(4.72±1.63)d、(13.31±2.32)d;术后随访得知,61例(95.31%)患者心功能明显改善。结论对冠心病心脏瓣膜病变患者采用冠状动脉旁路术同期心脏瓣膜替换术治疗的效果显著,并发症发生率较低,可明显改善患者的心功能,值得临床推广应用。     

二尖瓣及主动脉瓣置换术后发生心房颤动的危险因素

目的探讨窦性心律瓣膜病患者同期行二尖瓣及主动脉瓣置换术后发生心房颤动(atrial fibrillation,AF)的危险因素。方法窦性心律瓣膜病患者100例,同期行二尖瓣及主动脉瓣双瓣置换术,术后2周发生AF 54例为AF组,未发生AF 46例为非AF组,比较2组一般资料及手术相关指标,多因素logistic回归分析术后2周发生AF的危险因素。结果 AF组年龄[(55.24±10.50)岁]较非AF组[(47.15±13.0)岁]大,体外循环时间[180.00(136.00,231.00)min]较非AF组[150.00(140.00,188.25)min]长,术后血清脑钠肽水平[3 975.00(1 655.00,6 345.00))ng/L]高于非AF组[800.00(600.00,1 025.00)ng/L](P0.05);合并高血压比率(17.39%)、冠状动脉狭窄比率(34.78%)、术前NYHA心功能Ⅲ~Ⅳ级比率(17.39%)、术前肺动脉收缩压≥40mm Hg比率(23.91%)、同期行其他手术比率(47.83%)、术后机械通气时间3d比率(13.04%)、术后发生肺炎比率(34.78%)均高于非AF组(37.04%、66.67%、57.41%、46.30%、79.63%、51.85%、62.96%)(P0.05);多因素logistic回归分析结果显示,术前NYHA心功能分级Ⅲ~Ⅳ级(OR=5.55,95%CI:1.424~21.629,P=0.014)、同期行其他手术(OR=4.67,95%CI:1.293~16.885,P=0.019)、术后发生肺炎(OR=19.40,95%CI:4.840~77.753,P0.001)、术后血清脑钠肽水平1 580ng/L(OR=5.01,95%CI:1.518~16.514,P=0.008)为同期行二尖瓣及主动脉瓣置换术窦性心律瓣膜病患者术后2周发生AF的危险因素。结论术前心功能差(NYHA心功能Ⅲ~Ⅳ级)、同期行其他手术、术后发生肺炎及血清脑钠肽水平较高(1 580ng/L)是同期行二尖瓣及主动脉瓣双瓣置换术窦性心律瓣膜病患者术后发生AF的危险因素。     

冠状动脉搭桥术71例临床分析

[目的]总结冠状动脉搭桥手术(CABG)治疗冠心病的体会.[方法]回顾性分析本院71例CABG的临床资料.[结果]患者平均年龄(61.3±8.1)岁,平均远端吻合口(3.2±0.6)个,其中体外循环心停跳下手术18例,非体外循环心跳动下手术53例.同期二尖瓣手术2例.无手术死亡病例,术后随访3~36个月,所有患者无心脏...     

冠状动脉旁路移植同期行瓣膜置换术患者术后早期并发症的观察和护理

目的总结15例冠状动脉旁路移植术同期行瓣膜置换术患者术后早期并发症的观察和护理经验。方法自2005年6月至2007年10月共施行冠状动脉旁路移植术同期行瓣膜置换术15例,均在全麻低温体外循环下行手术,体外循环时间为92-156min,术后予以针对性观察和预见性护理。结果本组患者中有8例发生术后并发症,经过治疗护理后情况好转并转出ICU,无死亡病例。平均监护时间（5±1．8）d,平均住院时间（15±3．3）d。结论本组患者术后早期无一例死亡,表明对该类患者进行针对性的观察和预见性的护理能有效减少病死率,提高治愈率。     

Guns and Knives in New Mexico: Patterns of Penetrating Trauma, 1978–1993

Objective: To identify patterns of nonfatal and fatal penetrating trauma among children and adults in New Mexico using ED and medical examiner data.
Methods: The authors retrospectively sampled in 5-year intervals all victims of penetrating trauma who presented to either the state Level-1 trauma center or the state medical examiner from a 16-year period (1978–1993). Rates of nonfatal and fatal firearm and stabbing injury were compared for children and adults.
Results: Rates of nonfatal injury were similar (firearm, 34.3 per 100,000 person-years; stabbing, 35.1). However, rates of fatal injury were significantly different (firearm, 21.9; stabbing, 2.7; relative risk: 8.2; 95% confidence interval: 5.4, 12.5). From 1978 to 1993, nonfatal injury rates increased for children (p = 0.0043) and adults (p < 0.0001), while fatal penetrating injury remained constant. The increase in nonfatal injury in children resulted from increased firearm injury rates. In adults, both stabbing and firearm nonfatal injury rates increased.
Conclusions: Nonfatal injury data suggest that nonfatal violence has increased; fatal injury data suggest that violent death rates have remained constant. Injury patterns vary by age, mechanism of trauma, and data source. These results suggest that ED and medical examiner data differ and that both are needed to guide injury prevention programs.     

Interprofessional approaches to creating safe,high quality health care

Three supplementary perspectives are presented arguing that interprofessional collaboration is both necessary and desirable. Nonetheless, there are often too many serious intra-professional barriers and obstacles to interprofessional collaboration to make it successful. Some of these barriers, it is argued and illustrated, are found in the multiple ways in which professional identity is tacitly acquired and embodied in the practitioners' habitual, everyday practice. The paper then explores ways in which reflection, especially Second order reflection, can help to elucidate and overcome these obstacles, as well as increasing professional adaptability and competence.     

Systematic Reviews Published in the January 2011 Issue of The Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly as a DVD and monthly online. The January 2011 issue (first quarterly DVD for 2011) contains 4515 complete reviews, 1985 protocols for reviews in production, and 13,521 one-page summaries of systematic reviews published in the general medical literature. In addition, there are citations of 641,000 randomized controlled trials, and 14,018 cited papers in the Cochrane methodology register. The health technology assessment database contains over 9300 citations. One hundred and seven new reviews have been published in the last 3 months, of which five have potential relevance for practitioners in pain and palliative medicine.     

Determination of creatine kinase isoenzyme MB activity in serum using immunological inhibition of creatine kinase M subunit activity. Activity kinetics and diagnostic significance in myocardial infarction.

This is a new method for the determination of creatine kinase isoenzyme MB activity in serum. The method uses direct activity measurement of creatine kinase B subunit activity after blocking of CK-M subunit activity by inhibiting antibodies. The test takes no longer than 15 min. The method yields an intra-serial C.V. of 2.0-12.9%, and a C.V. from day to day of 5.5%. The detection limit is 3.4 U/l creatine kinase MB. In the 95 cases with proven myocardial infarction several types of creatine kinase MB activity kinetics could be determined. The percentage of creatine kinase MB of peak CK-total is 6-25%, with a mean of 11.1%. The amount of creatine kinase MB with respect to total CK activity after reinfarction is higher than the amount after initial infarction.     

俯卧位通气对高海拔地区肺复张治疗无效急性呼吸窘迫综合征患者氧合的影响

目的 探讨俯卧位通气对高海拔地区肺复张术(RM)治疗无效急性呼吸窘迫综合征(ARDS)患者的治疗作用.方法 从海拔2260m的地区医院筛选RM治疗无效的41例ARDS患者[平均氧合指数( PaO2/FiO2)较RM前升高＜20％视为RM无效],依不同病因分为肺内源性ARDS组(ARDSp组)和肺外源性ARDS组(ARDSexp组),每组再按信封法随机分为俯卧位组和仰卧位组,即ARDSp俯卧位组(11例)、ARDSp仰卧位组(9例)、ARDSexp俯卧位组(10例)、ARDSexp仰卧位组(11例).在通气前及通气1、2、3、4h监测动脉血氧分压( PaO2)、PaO2/FiO2、静态顺应性(Cst)、气道阻力(Raw)的变化.结果 通气lh时,ARDSexp俯卧位组PaO2/FiO2( mm Hg,l mm Hg=0.133 kPa)即较通气前显著升高(157.4±40.6比129.3±48.7,P＜0.05),并随通气时间延长呈持续增高趋势,4h达峰值(219.1 ±41.1);且ARDSexp俯卧位组通气3h内PaO2/FiO2较其他3组显著增高,另3组间则差异无统计学意义.ARDSp俯卧位组、ARDSexp俯卧位组通气4h时PaO2/FiO2均较相应仰卧位组显著增高(208.8±39.7比127.4±47.1,219.1±41.1比124.9±50.8,均P＜0.05).4组通气前后Cst无显著改变,各组间差异也无统计学意义.ARDSp俯卧位组通气4h时Raw(cmH2O·L-1·s-1)较通气前显著降低(6.8±1.7比10.7±1.8,P＜0.05),且明显低于其他3组;其他3组各时间点Raw组内及组间比较差异均无统计学意义.结论 俯卧位通气作为ARDS机械通气重要策略之一,可以改善RM无效高原ARDS患者的氧合,为抢救患者赢得宝贵的时间.     

Digital imaging among medical facilities

The Department of Veterans Affairs (VA) in the USA operates a network of 172 medical centres which all utilize a hospital information system (HIS) which has been developed and is currently maintained by the VA. During the past several years, an image management and communication module has been developed, installed and clinically utilized at the Washington DC and Maryland VA Medical Centres. This image management and communication system, referred to as the decentralized hospital computer program (DHCP) imaging system, is fully integrated with a commercial picture archiving and communication system (PACS). The system is utilized to capture, archive, and display all images generated within the hospital including radiology, nuclear medicine, pathology, endoscopy, bronchoscopy, and dermatology, intraoperative photographs, ECG data, and a limited number of paper documents. The ultimate goal of the project is to have all patient text and image data available at any clinical workstation to any authorized user anywhere within the network of medical centres. Clinical requirements for an imaging workstation include ease of use, rapid and reliable access to the complete set of patient information, and images which are of acceptable quality to meet the requirements of the user and the subspecialty. Patient confidentiality and data security must be safeguarded at all times. Integration of the images with the remainder of the patient's database was found to be critical to the success of the project. The experience at the Washington and Maryland facilities suggests that an imaging system that is successfully integrated with a hospital information system can provide substantial clinical and economic benefits both within and among medical centres. Clinical acceptance and utilization of the system has been excellent, particularly in diagnostic radiology where DHCP Imaging has been interfaced to a commercial PAC system. Based upon this initial experience, the VA has begun to deploy the system throughout its large network of medical centres.     

Myocardial elastography at both high temporal and spatial resolution for the detection of infarcts

Myocardial elastography is a novel method for noninvasively assessing regional myocardial function, with the advantages of high spatial and temporal resolution and high signal-to-noise ratio (SNR). In this paper, in-vivo experiments were performed in anesthetized normal and infarcted mice (one day after left anterior descending coronary artery [LAD] ligation) using a high-resolution (30 MHz) ultrasound system (Vevo 770, VisualSonics Inc., Toronto, ON, Canada). Radiofrequency (RF) signals of the left ventricle (LV) in longitudinal (long-axis) view and the associated electrocardiogram (ECG) were simultaneously acquired. Using a retrospective ECG gating technique, 2-D full field-of-view RF frames were acquired at an extremely high frame rate (8 kHz) that resulted in high-quality incremental displacement and strain estimation of the myocardium. The incremental results were further accumulated to obtain the cumulative displacements and strains. Two-dimensional and M-mode displacement images and strain images (elastograms), as well as displacement and strain profiles as a function of time, were compared between normal and infarcted mice. Incremental results clearly depicted cardiac events including LV contraction, LV relaxation and isovolumetric phases in both normal and infarcted mice, and also evidently indicated reduced motion and deformation in the infarcted myocardium. The elastograms indicated that the infarcted regions underwent thinning during systole rather than thickening, as in the normal case. The cumulative elastograms were found to have higher elastographic SNR (SNR(e)) than the incremental elastograms (e.g., 10.6 vs. 4.7 in a normal myocardium, and 6.0 vs. 2.4 in an infarcted myocardium). Finally, preliminary statistical results from nine normal (m = 9) and seven infarcted (n = 7) mice indicated the capability of the cumulative strain in differentiating infracted from normal myocardia. In conclusion, myocardial elastography could provide regional strain information at simultaneously high temporal (>/=0.125 ms) and spatial ( approximately 55 microm) resolution as well as high precision ( approximately 0.05 microm displacement). This technique was thus capable of accurately characterizing normal myocardial function throughout an entire cardiac cycle, at the same high resolution, and detecting and localizing myocardial infarction in vivo.     

Prise en charge des entorses externes de cheville : étude clinique préliminaire sur l’efficacité du dispositif Myolux™

Ankle sprains are the most common injury of the musculoskeletal system and are associated with significant societal and economic impacts. It has been proven that classical therapeutic strategies may not be effective in preventing recurrent injuries: the recurrence rates reported in the literature can reach 73%. In order to provide an effective rehabilitation solution, a destabilizing orthosis was developed. This device is equipped with a mechanical articulator reproducing the subtalar mechanics and placed under the heel. In this paper, we present the main results of a preliminary clinical study conducted between 2004 and 2007. All subjects included in this study were treated with the abovementioned orthosis during 10 rehabilitation sessions of 30 minutes each. Data show a relatively low recurrence rate of 12% for the overall population. Moreover, it's of primary importance to note that this satisfactory ratio is largely reduced (3% of recurrence rate) for the 29 patients who performed one training session per month after the 10th initial rehabilitation sessions. Hence, the destabilizing orthosis appears to be an effective solution to prevent recurrent ankle sprains. However, joint protection requires long-term and regular training sessions. This result has motivated the development of a similar device allowing patients to perform training sessions at home. Finally, data obtained in this study are promising awaiting the final results of the comparative, multicentric and independent clinical trials currently managed by the Hospices Civils de Lyon.