老年脑血管意外患者全身炎症反应综合征评分与医院感染及预后相关性研究

目的:分析老年脑血管意外患者全身炎症反应综合征评分(SIRS)与医院感染相关性情况,提出处理对策。方法:选择2015年1月~2016年12月来我院就诊的128例脑血管意外患者为研究对象,在患者入院后72 h进行SIRS评分,分析其医院感染情况和预后情况。结果:128例患者中有24例发生院内感染,发生部位前3位分别为下呼吸道、上呼吸道和泌尿道。SIRS评分越高,院内感染发生率越大,死亡率越高,呈现上升趋势。结论:住院时间在24 h以上,SIRS分数在2分以上者应警惕医院感染发生,每天实施SIRS评分,第一时间发现异常情况,并给予针对性处理措施,可促进疾病转归,提升预后结局。     

就诊时心力衰竭对感染性休克患者生存状况的影响

【目的】探讨就诊时心力衰竭对感染性休克患者生存状况影响。【方法】选取2016年6月至2018年6月本院收治的82例感染性休克患者,根据就诊时是否合并心力衰竭将其分为观察组(合并心力衰竭)和对照组(不合并心力衰竭),每组各41例。比较两组患者的机械通气时间和住院时间、急性生理学与慢性健康状况评分系统Ⅱ(APACHEⅡ)评分以及全身炎症反应综合征(SIRS)、多器官功能障碍综合征(MODS)的发生率和死亡率。【结果】观察组患者机械通气时间和住院时间均高于对照组.APACHEⅡ评分小于对照组患者,差异具有统计学意义(P<0.05)。观察组患者发生SIRS22例(53.66%)、MODS23例(56.10%),死亡人数为13例(31.70%),对照组患者发生SIRS13例(31.71%),MODS15例(36.59%),死亡人数为6例(14.63%),两组患者的SIRS的发生率、MODS的发生率和死亡率比较均具有统计学意义(P<0.05)。【结论】就诊时心力衰竭会影响感染性休克患者的预后,增加机械通气时间和住院时间,增加MODS的发生率和死亡率,威胁患者的生存状况,临床上对此类患者应高度重视。     

胰腺坏死程度对急性胰腺炎预后的影响

目的 探讨胰腺坏死程度对急性胰腺炎(AP)临床严重程度及预后的影响,提高对急性胰腺坏死的认识.方法 回顾分析2009年12月至2011年10月,我院经临床证实AP 162例患者的CT表现及临床相关资料,统计胰腺坏死程度、CT严重程度指数(CTSI)评分、患者病死率及全身炎症反应综合征(SIRS)发生率,并比较各指标间相关性.结果 162例患者中,138例无胰腺坏死,占85.1%,发生SIRS 19例(13.8%),均未发生继发胰腺感染,病死2例(1.5%).24例发生胰腺坏死,16例胰腺坏死面积≤30%,继发胰腺感染2例,发生SIRS 11例(68.7%),病死2例(12.5%);4例胰腺坏死面积30%~50%,继发胰腺感染2例,发生SIRS 3例(75.0%),病死2例(50.0%);4例胰腺坏死面积>50%,继发胰腺感染3例,发生SIRS 3例(75.0%),病死3例(75.0%).全组病死9例,病死率5.6%.不同胰腺坏死程度的胰腺感染发生及病死率有差异(P<0.05),SIRS发生率无差异.结论 AP坏死范围能够反映AP的严重程度,胰腺坏死与继发胰腺感染的发生及病死率有关,坏死面积越大,越容易发生胰腺感染,病死率越高.胰腺坏死面积可作为一种临床上初步判断重症AP的快速而简易的方法.     

APACHEⅡ评分对全身炎症反应综合征患者预后的评估作用

目的探讨APACHEⅡ评分对全身炎症反应综合征(SIRS)的预后评估作用。方法回顾性分析总结2007年12月至2009年3月南京军区总医院呼吸科及腹部外科ICU中的92例SIRS的临床资料,并予以APACHEⅡ评分,根据病情转归分为存活组及死亡组,比较两组APACHEⅡ差异有无统计学意义。根据APACHEⅡ评分分为三组:A组(APACHEⅡ评分<15)、B组(15≤A-PACHEⅡ评分<25)和C组(APACHEⅡ评分≥25),分析三组之间的死亡率差异有无统计学意义。将92例SIRS患者依据感染发生与否再分为两组:SIRS感染组和SIRS非感染组,比较两组APACHEⅡ差异有无统计学意义。结果全身性感染组中死亡组的APACHEⅡ评分与存活组的评分差异有统计学意义(P<0.01);不同评分组的死亡率差异有统计学意义(P<0.01);SIRS感染组和SIRS非感染组的APACHEⅡ评分差异无统计学意义(P>0.05)。结论 APACHEⅡ评分对全身性感染预后有预示作用。     

慢性透析患者脑血管并发症的临床研究

目的 探讨慢性透析患者脑血管并发症的临床特征及影响因素。方法 回顾分析1224例慢性血液透析患者中并发脑血管意外病例的临床资料。结果 1.慢性透析患者脑血管意外的发病率依次为:脑血栓形成、脑出血、脑栓塞;2.高龄透析患者及糖尿病患者脑血管意外发病率明显增加;3.25例并发脑血管意外的透析患者透析病程中有24例有高血压;4.脑出血及脑栓塞发生率低于脑血栓形成,但预后差;5.存活患者多伴有不同程度的后遗症。结论 随着高龄透析患者、糖尿病肾病透析患者和长期透析病例的增加,脑血管意外发病率明显增加;高血压是慢性透析患者发生脑血管意外的重要危险因素;加强慢性透析患者脑血管并发症的研究与认识,减少慢性透析患者脑血管意外并发症的发病率,对提高慢性透析患者的生活质量和长期存活率具有重要意义。     

急性脑血管意外合并医院感染相关因素分析及护理对策

目的探讨急性脑血管意外医院感染的影响因素及护理对策。方法回顾性120例急性脑血管意外患者的临床资料,比较合并医院感染与无发生医院感染组相关因素上的差异。结果 120例急性脑血管意外患者合并医院感染33.33%,医院感染组患者年龄大、脱水剂应用时间长;合并基础疾病、昏迷、侵入性操作、预防应用抗生素比例高(P<0.05),是医院感染危险因素。结论急性脑血管意外合并医院感染率较高,应加强基础护理、减少宿主的自身危险性、严格管理侵入性操作、合理使用抗生素、缩短用脱水剂应用时间。     

胸部创伤患者早期SIRS评分及血清中C反应蛋白含量与创伤后感染的关系

目的:研究胸部创伤患者早期的全身炎性反应综合征(systemic inflammatory response syndrome,SIRS)评分及血清C反应蛋白(C reactive protein,CRP)含量与创伤后感染的关系.方法:选取复旦大学附属上海市第五人民医院胸外科2009年7月-2012年6月收治的以胸部创伤为主的患者406例,入院时均进行SIRS评分,检测伤后24 h血清CRP含量.分析SIRS评分和血清CRP含量与创伤后感染的关系.结果:SIRS评分3～4分患者创伤后感染发生率高于SIRS评分0～1分及2分患者.logistic回归显示,SIRS评分3～4分是胸部创伤患者发生创伤后感染的独立预测因素.感染组伤后24 h血清CRP含量显著高于非感染组.结论:入院后SIRS评分是预测胸部创伤患者发生创伤后感染的有效指标.创伤后24 h血清CRP含量的升高幅度对预测患者后期是否发生感染有一定参考价值.     

入院SIRS评分预测多发伤患者发生院内感染的价值

目的:探讨入院SIRS评分预测多发伤患者发生院内感染的价值。方法:本研究共纳入我院急诊创伤中心2003年1月至2004年1月收治的多发伤患者258例,所有患者入院进行了SIRS评分和ISS评分,SIRS定义为SIRS评分≥2。按照有无感染依据将病人分为感染组与非感染组,比较两组间ISS评分、年龄以及SIRS四个变量的差异,统计分析入院SIRS评分与患者发生感染的相关性。结果:感染患者ISS评分、白细胞计数、平均年龄均比非感染者高、而体温则比非感染者低(所有P<0.01)。统计发现,共有88例(34.11%)诊断为SIRS,当作了年龄和ISS变量调整后,低体温和白细胞增多最能预示感染(P<0.01)。通过多元回归分析后发现,入院SIRS评分≥2能预测多发伤患者发生感染的可能性,而且随着SIRS评分增高,发生感染的危险性增加。结论:入院SIRS评分≥2能独立预测多发伤患者发生院内感染的危险性。每日SIRS评分可能有助于早期发现感染从而早期给予干预。     

脑血管意外患者医院感染分析与护理对策

脑血管意外病程长、死亡率高 ,医院感染为常见的并发症。现将我院 1998年 1月～ 1999年 1月脑血管意外 2 4 9例住院患者按刘氏[1] 医院感染诊断标准诊断医院感染 65例进行总结 ,探索其病因 ,探讨其护理与预防对策。1　一般资料男性 113例 ,女性 13 6例 ,年龄 2 2～ 95岁 ,平均年龄 64 7岁。脑出血 10 2例 ,蛛网膜下腔出血 15例 ,脑梗死 13 2例。出血性脑血管意外与缺血性脑血管意外平均住院日分别为 19 2天和 15 4天。2　结果2 1　医院感染发生率与住院时间 :本组发生医院感染 65例 ,76例次 ,感染率与感染例次率分别为2 6 10 %和 3 0 52 …     

老年住院患者医院感染的原因分析及护理干预

医院感染是医学发展中的重要问题 ,越来越受到医学界的重视。老年患者是医院感染的易感人群 ,为了降低老年患者医院感染的发生率 ,提高其生活质量 ,2 0 0 2年 1月～ 2 0 0 4年 3月 ,我科对 6 0岁以上的老年患者医院感染原因进行回顾性分析 ,并提出相应的护理干预措施 ,现报告如下。资料与方法1.一般资料。收集我科住院时间 >72h、年龄≥ 6 0岁的患者共 6 6 7例。发生医院感染人数 6 5例 ,年龄 6 1～ 97岁 ,平均年龄 76 .4 8岁 ,其中男 5 5例 ,女 10例。就诊原因 :(1)心脑血管疾病 ,如冠心病、高血压病、脑血管意外等。 (2 )呼吸系统疾病 ,如…     

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.