1例终末期结肠癌伴恶性腹水患者的安宁疗护

目的 总结1例终末期癌症患者安宁疗护的临床经验。方法 运用安宁疗护的理念、知识和技能,对1例结肠癌伴恶性腹水的终末期患者进行护理,帮助患者解决疼痛、腹胀、便秘等躯体问题;根据病情,在合适时机恰当转换治疗重点;评估灵性需求和困扰,采取尊严疗法和意义疗法,提供灵性照护;尊重患者的自主决策权,谈论预先医疗照护计划,指导家属有效参与护理。结果 帮助患者接纳死亡,满足其心愿,返回故乡,安静离世。结论 将安宁疗护的理念应用到临床实践中,为终末期患者提供了身、心、社、灵全方位的照护,最终达到了患者善终、善别和家属的善生,为安宁疗护的开展提供借鉴。     

安宁疗护咨询在危重症患者中的应用进展

ICU与安宁疗护的结合,有助于提高ICU患者的生命质量,减少过度医疗。ICU安宁疗护咨询是以ICU临终患者和家属为中心,由安宁疗护咨询者提供有关症状控制、医疗决策制订和安宁疗护转诊信息的共享照护实践,是整合安宁疗护和ICU护理的有效途径。该文对ICU安宁疗护咨询的概念和内容、实施效果及障碍进行综述,为国内ICU开展安宁疗护咨询提供参考。     

ICU终末期病人死亡质量现状及影响因素的研究进展

对重症监护室(ICU)终末期病人死亡质量的概念、评价方法、测评工具及ICU终末期病人死亡质量的影响因素进行综述,建议医护人员关注ICU终末期病人的死亡质量,积极探索提升ICU终末期病人死亡质量的护理干预策略,旨在为ICU规范开展安宁疗护、提高终末期病人的死亡质量奠定基础。     

ICU生命末期患者死亡质量评价和提升的研究进展

本文对死亡质量的概念、评价指标、ICU生命末期患者死亡质量测评工具及应用现状、提高ICU生命末期患者死亡质量的干预策略进行综述,建议医护人员关注ICU生命末期患者的死亡质量,积极探索适合本土的患者死亡质量测评工具,为在ICU规范开展安宁疗护,提高终末期患者的死亡质量奠定基础。     

安宁疗护门诊的构建与应用效果

目的 建立安宁疗护门诊,满足更多终末期患者的需求。 方法 设置安宁疗护诊室,由护士出诊,对患者进行筛查、签订安宁疗护知情同意和意愿确认书、全面评估、建立档案、发起多学科会诊、制订照护方案、合理转介、定期随访、提供安宁疗护信息咨询。统计门诊工作量和成效。 结果 2020年10月安宁疗护门诊开诊,至2021年5月30日,门诊量为136例次,针对患者痛苦症状,出诊护士能独立解决108项,发起多学科会诊28次;开展“互联网+”居家照护59例次、收治入院52例、转介基层医院25例;随访388例次。患者的安宁疗护需求满足程度较高;患者综合服务满意度为99.5%,家属综合服务满意度为99.3%。 结论 安宁疗护门诊能够满足终末期患者的需求,体现公立医院的公益性,整合地区资源进行区域安宁疗护联动,促进安宁疗护分级诊疗的开展,加强安宁疗护专科护士培养,推动安宁疗护事业的进一步发展。     

肿瘤专科医院安宁共同照护模式的探索与实践

本院探索适合肿瘤专科医院的安宁疗护服务模式,形成了以安宁共同照护为主的模式,即安宁共同照护团队与原治疗团队共同提供服务,构建弹性安宁共同照护病床,协同医联体单位共建安宁疗护病床、共同照护模式。安宁共同照护服务内容包括多学科团队协同症状管理,舒适照护,灵性照护,哀伤辅导,心理、社会支持等。安宁共同照护模式的实施为终末期肿瘤患者和家属提供多元医疗决策,全病程、全方位照顾终末期患者及家属的感受,为践行安宁疗护、探索适合我国国情的安宁共同照护模式积累了经验。     

从叙事医学视角下浅谈舒缓疗护中死亡教育体会

目的探讨从叙事医学视角下讨论舒缓疗护(临终关怀)工作中死亡教育体会,旨在为患者提供更好的灵性照护提供理论依据。方法选择入住本院舒缓疗护病房的终末期肿瘤患者及家属为研究对象,采用叙事能力进行医患沟通,包括倾听患者及家属叙事、面对面沟通访谈、护士工作日记、患者日记等,安宁护士仔细阅读原始材料构成叙事分析。结果患者越知晓自己病情的越容易实施死亡教育;完全不知晓自己病情的,死亡教育较难实施且造成患者与家属在终末期留有遗憾。结论患者知晓病情和家属坦然面对死亡是舒缓疗护工作中死亡教育实施的关键。     

家庭照顾者安宁疗护满意度评估工具的研究进展

<正>随着失能、失智老年群体及慢性病群体扩大，当前社会面临着巨大的安宁疗护需求。安宁疗护指由医疗健康照顾人员和志愿者为终末期患者及其家属提供的全方位照护，包括生理、心理、精神和社会支持，从而帮助终末期患者舒适、平静和有尊严地离世，并维护家属身心健康^[1]。     

安宁疗护对终末期肿瘤患者自我感受负担、生命态度及生活质量的影响

[目的]探讨安宁疗护对终末期肿瘤患者自我感受负担、生命态度及生活质量的影响。[方法]选择2017年7月至2019年3月本院收治的89例终末期癌症患者,根据疗护方案的不同将其分为观察组(常规护理干预联合安宁疗护,n=45)和对照组(常规护理干预,n=44)。干预1个月后,比较两组患者自我感受负担、生命态度、生活质量评分。[结果]千预后,两组患者照护负担、经济负担、家庭负担、心理及情感负担、治疗负担评分均低于干预前,且观察组低于对照组,差异有统计学意义(P<0.05);两组死亡恐惧、死亡逃避、逸离接受评分低于干预前,自然接受、超近接受评分高于干预前,且观察组优于对照组,差异有统计学意义(P<0.05);两组患者生理功能、情感职能、精神健康评分均高于干预前,且观察组高于对照组,差异有统计学意义(P<0.05)。[结论]安宁疗护有助于缓解终末期患者自我感受负担,减轻面对死亡临近的恐惧与逃避心理,改善患者生活质量。     

国外儿童安宁疗护现状及启示

随着医学技术发展和健康意识提高,全生命周期照护模式成为未来健康照护的主要方向。安宁疗护是生命末期健康照护的主要方法,又称临终关怀,指为生存期≤6个月的癌症患者及家属提供生命末期关怀性照护,其概念在应用范围上已发展为能满足所有疾病类型临终患者及家属“身-心-社-灵”全方位需求的照护模式。不同地区对安宁称呼不同,现专家共识下统称“安宁疗护”[1]。以往研究多关注老年慢病患者及肿瘤患者,儿童安宁疗护研究较少,本文综述了国外儿童安宁疗护的概念、模式、需求及影响因素,从基础建设、多模式结合、关注参与人员及专科儿童安宁疗护建设等方面探讨对我国的启示,以期为开展相关研究提供参考。     

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.