12例SARS患者死亡危险因素分析

目的 :探讨严重急性呼吸综合征 (SARS)患者的死亡危险因素。方法 :采用回顾性调查方式 ,对 12例SARS死亡患者和 3 2例治愈病例 (对照组 )进行分析比较。结果 :12例 SARS死亡患者平均年龄为 67岁 ,治愈对照组平均年龄仅为 42岁 ,而且死亡组中有 5例患者存在 1～ 5种基础疾病。 SARS存活患者 CD+4 (4 16.6±2 3 5 .0 )个 /μl、CD+8(2 96.1± 181.5 )个 /μl;死亡患者的 CD+4 (14 3 .8± 78.1)个 /μl,CD+8(10 3 .6± 63 .2 )个 /μl;较正常参考值均有下降 ,但死亡组的 CD+4 、CD+8下降更为显著。死亡组 12例合并细菌感染 5例 ,其中真菌感染3例 ,败血症 2例 ,出现电解质紊乱和肾脏损害率为 41.67% ,明显高于治愈对照组 3 .12 %。应用有创呼吸机患者的病死率高达 80 .0 % ,且 5例患者继发肺部细菌性感染 ;而应用无创呼吸机者无一例死亡。结论 :年龄及基础疾病是 SARS患者死亡的最主要危险因素 ;患者机体免疫功能低下、继发感染、并发症的出现以及有创呼吸机的应用等也与死亡有关     

Close relative intermingled skin allograft and autograft use in the treatment of major burns in adults and children

Major burns still continue to pose problems of inadequate auto skin closure. Patients suffering severe burns lack adequate skin graft donor site. We present the results of 17 major adult and pediatric burns that we applied close relative intermingled skin allograft and autograft in the course of treatment. The extent of burn injury ranged from 40%-70% total body surface are (TBSA). Seven patients survived and 10 patients died. Mean percent TBSA of the dead and surviving patients were 55.5 +/- 11.16 (range, 40-70) and 55.0 +/- 4.08 (range, 50-60) respectively. Mean age of the dead and surviving patients were 16.1 +/- 13.77 (range, 2-42) and 11.1 +/- 6.74 (range, 2-21), respectively. We present a safe and satisfactory means of effective alternative treatment to resurface major burns in case of limited auto skin graft donor site without exposure to bacteria, human immunodeficiency virus, and hepatitis virus when keratinocyte culture facilities and skin banks are not available.     

Cost–benefit assessment of inferior vena cava filter placement in advanced cancer patients

We retrospectively collected data recorded between 1994 and 2000, with the aim of evaluating the cost and benefits of IVCFP (inferior vena cava filter placement) in advanced cancer patients treated in our institution alone from the radio-diagnosis department's point of view. A total of 30 procedures were performed. The benefits were represented by the efficacy and the safety of the filter. The costing procedure consisted in multiplying the value of the unit index by the number of relative complexity indices. Eighty percent (24/30) of the patients were dead at the time of the study. Twenty percent (6/30) of the patients died before even being discharged from hospital. Three of them died from renal failure, owing to complete renal vein thrombosis (n=2) or hydronephrosis (n=1), and 1 from pulmonary embolism because it was exceptionally severe; the other 2 patients were cachectic, i.e., in poor general condition. The individual cost of the procedures represented only 2% of the mean entire cost of hospitalization. Seventy-six percent, 56% and 40% of the patients, were still alive at 1 month; 3 months and 6 months, respectively, with an improved quality of survival in at least 53% of the patients. The low complication rate and the low cost relative to the mean cost of hospitalization (2%) are factors in favor of using IVCFP if it is medically indicated.     

Idiopathic Membranous Nephropathy

The clinical and histopathological features of 37 patients withidiopathic membranous nephropathy are presented. Males werefour times as commonly affected as females and the age at presentationranged from nine to 70 years. The period of observation variedfrom three months to 23 years. Twenty-eight patients (76 percent)presented with the nephrotic syndrome and nine patients (24per cent) presented with non-nephrotic proteinuria. At the endof the study, of the patients presenting with the nephroticsyndrome, seven (25 per cent) were in remission, seven (25 percent) remained nephrotic, nine (32 per cent) showed only proteinuriaand five (18 per cent) were dead or on dialysis. Altogethereight patients (28 per cent) developed renal failure. The ninepatients who presented with non-nephrotic proteinuria appearedto do better, and none developed renal failure. The occurrence of spontaneous remission makes assessment ofbenefit from immunosuppressivet herapy difficult. However, analysisof our data and a review of the literature suggest that in thiscondition oral prednisone, cyclophosphamide and azathioprinehave no significant therapeutic properties. Histological assessment confirmed the occurrence of mild (Grade1) changes in patients biopsied soon after presentation, andtubular atrophy increased with the duration of illness. Immunofluorescenceconfirmed deposition of mainly IgG and complement. Repeat biopsiesin 14 patients showed no histological improvement and remissionwas not accompanied by resolution of histological abnormalities.     

心血管病患者死亡时间规律分析及护理对策

目的分析心血管病患者死亡时间的规律,探讨护理对应措施。方法回顾性调查我院心血管科2003年1月-2005年12月住院死亡病历94份,并对患者死亡时间的规律进行总结分析。结果94例死亡患者中,死亡高峰月份在11-次年3月,占61.7%;死亡时间多集中在4:00～12:00,占68.06%。结论心血管病患者死亡时间存在昼夜节律变化,应针对高危时间段,加强对患者病情的监护。     

HCV lookback in the United States: effectiveness of an extended lookback program

BACKGROUND: In 1998, the FDA recommended look-back for HCV. The recommendation was initially limited, however, to donors who reacted on a multiantigen HCV screening test and to components collected since January 1, 1988. A lookback program was extended to include donors who reacted on the first-generation (single-antigen) HCV screening test and who were positive on a supplemental assay (RIBA-1 or -2) and all components for which transfusion records could be found (back to 1978). STUDY DESIGN AND METHODS: The yield of the incremental lookback programs was compared to that originally recommended by the FDA by comparing the number of newly identified HCV-positive recipients in each program. The results of lookbacks were reviewed on 385 blood components for which 314 transfusion recipients were identified. RESULTS: Of the 135 recipients in the FDA program, 70 percent were dead, 28 percent were living and notified, and 2 percent could not be located. In the incremental programs, there were 179 recipients, of whom 80.4 percent were dead, 16.2 percent were living and notified, and 3.4 percent could not be located. Most adult recipients were dead (81%), but the majority of pediatric recipients were alive (57%); 76 percent of tested recipients were HCV seropositive, with no significant difference between programs. One-half of test-positive recipients in each program were newly identified through the lookback program. Seven of the 20 newly identified HCV-positive recipients were found through the incremental programs. The yield, defined as newly detected HCV cases per total number of recipients, was 9.6 percent for the FDA and 3.9 percent for the incremental programs. This difference was significant (p = 0.04). CONCLUSION: The yield of both programs was limited by the high percentage of recipients who had died. Pediatric recipients were more likely to be living at the time of notification. The incremental program was less efficacious than the FDA program in identifying newly HCV-positive recipients, but one-third of the newly detected HCV cases were identified through the incremental program.     

Attitudes and practice of funeral directors toward newborn death

We performed a study to measure funeral director attitudes and practice toward selected newborn death issues. A questionnaire was designed, piloted and then mailed to 269 funeral directors in northeastern Ohio. One hundred and thirteen (42 percent) responded and they constitute the sample. The sample indicated that 85 percent of the time fathers alone plan the newborn funeral, 13 percent of the time mothers and fathers together, and 12 percent of the time grandparents plan alone or assist others. Eighty-one percent of funeral directors would offer parents the option to see their dead baby, 64 percent to touch, 27 percent to hold, and 11 percent the option to dress the baby. Thus, the more intimate the contact, the less likely an option will be offered. In contrast, 81 percent would seldom or almost never encourage viewing the visibly deformed dead infant. Funeral directors had misconceptions and mixed feelings about the newborn autopsy. Sixty-five percent thought the newborn autopsy is performed primarily for research, 48 percent felt it provides helpful information for parents, and 36 percent indicated that it makes their job more difficult. Lack of cooperation between funeral directors and pathologists and lack of funeral director skill in preparing the autopsied newborn seems to account for most of the difficulties. Improved physician-to-funeral director cooperation and expanded pre-and-post graduate funeral director education and training may enhance the ability of funeral directors to help families achieve a healthy outcome when a newborn dies.     

Attitudes and practice of funeral directors toward newborn death

Abstract

We performed a study to measure funeral director attitudes and practice toward selected newborn death issues. A questionnaire was designed, piloted and then mailed to 269 funeral directors in northeastern Ohio. One hundred and thirteen (42 percent) responded and they constitute the sample. The sample indicated that 85 percent of the time fathers alone plan the newborn funeral, 13 percent of the time mothers and fathers together, and 12 percent of the time grandparents plan alone or assist others. Eighty-one percent of funeral directors would offer parents the option to see their dead baby, 64 percent to touch, 27 percent to hold, and 11 percent the option to dress the baby. Thus, the more intimate the contact, the less likely an option will be offered. In contrast, 81 percent would seldom or almost never encourage viewing the visibly deformed dead infant. Funeral directors had misconceptions and mixed feelings about the newborn autopsy. Sixty-five percent thought the newborn autopsy is performed primarily for research, 48 percent felt it provides helpful information for parents, and 36 percent indicated that it makes their job more difficult. Lack of cooperation between funeral directors and pathologists and lack of funeral director skill in preparing the autopsied newborn seems to account for most of the difficulties. Improved physician-to-funeral director cooperation and expanded pre-and-post graduate funeral director education and training may enhance the ability of funeral directors to help families achieve a healthy outcome when a newborn dies.     

Attitudes toward death in rural areas of Japan

Attitudes toward death in rural areas of Japan were investigated by means of a questionnaire. One hundred and sixty out of the 319 families residing on a small island were randomly chosen and 94 percent of them (average age 48 years, male 57 percent; living with parents 41 percent) responded. The respondents did not clearly distinguish the dead from the living in their life-styles. They seemed to recognize a continuity between living and death. They reported having confronted death as members of a family or small local community rather than individually. Community or family is seen as playing a more important role in determining respondents' attitudes toward death than their personal feelings.     

发热、胸部X线改变与SARS鉴别诊断的研究

目的 探讨严重急性呼吸综合征(SARS)与其他肺部疾病的相同点和不同点，包括临床表现，胸部X显影像、实验室检查、诊断及鉴别诊断等特点。方法 对我院发热门诊接诊的440例发热患者的临床表现，X线胸片及实际室资料进行回顾性分析。结果 除1例患者与SARS患者有接触史，其他患者无SARS接触史，全部患者以发热为首发症状(100％)，伴有干咳(77．0％)，气促(34．0％)；无腹泻；高热患者均有胸部X线改变，多数累及单肺，肺部体征与脑部X线表现多数一致；治疗以综合治疗为主，99．8％的患者经使用抗菌药物、抗病毒药物、糖皮质激素有明显疗效。结论 SARS传染性极强，有一定的病死率，以发热为首发症状，对有胸部X线改变的患者需要认真分析、细致研究、仔细鉴别，才能不误诊，不漏诊。     

Idiopathic scoliosis. Gas exchange and the age dependence of arterial blood gases.

The aims were to examine the gas exchange and arterial blood gas abnormalities among patients with scoliosis, and the correlation of these abnormalities with age and severity of deformity. Means among 51 patients were as follows: age 25.4 +/- 17.5 yr, angle of scoliosis 80.2 +/- 29.9 (SD), vital capacity 1.94 +/- 0.91 (SD) (i.e. 60.6 +/- 19.2% of predicted), PaO2 85.8 +/- 12.0 (SD), PaCO2 42.4 +/- 8.0, physiological dead space to tidal volume ratio 0.438 +/- 0.074 (SD), and alveolar-arterial oxygen difference breathing air 14.9 +/- 8.9 (SD). Statistically significant correlations were as follows: the PaCO2 and physiological dead space to tidal volume ratio increased with age, and the PaO2 and alveolar ventilation decreased with age. The PaO2, alveolar ventilation, and tidal volume were inversely related to the angle of scoliosis and directly related to the vital capacity, precent predicted vital capacity, and the compliance of the respiratory system. The physiological dead space to tidal volume ratio and the alveolar-arterial oxygen difference were inversely related to the vital capacity, percent predicted vital capacity, and the compliance of the respiratory system. PaCO2 was directly related to the elastance of the respiratory system. We conclude that ventilation-blood flow maldistribution as a result of deformity of the rib cage was the primary abnormality in gas exchange, and that with age there was progressive deterioration in gas exchange. The age-dependent increase in PaCO2 and decrease in alveolar ventilation were due to the increasing physiological dead space to tidal volume ratio and failure of a compensatory increase in ventilation.     

The symptom burden of chronic critical illness

OBJECTIVE: To assess self-reported symptom burden of chronic critical illness. DESIGN: Prospective cohort study. SETTING: Respiratory care unit for treatment of chronically critically ill patients at an academic, tertiary-care, urban medical center. PATIENTS: Fifty patients who underwent elective tracheotomy and transfer from an adult intensive care unit to the respiratory care unit for weaning from mechanical ventilation. INTERVENTIONS: Assessment of physical and psychological symptoms through patients' self-reports using a modification of the Condensed Form of the Memorial Symptom Assessment Scale. MEASUREMENTS AND MAIN RESULTS: We measured self-reported symptom burden, ventilator outcomes, and vital status and functional status at discharge and 3 and 6 months after discharge. Half of the patients were successfully liberated from mechanical ventilation, but most hospital survivors were discharged to skilled nursing facilities and more than half of the cohort was dead at 3 months after discharge. Seventy-two percent (36 of 50) of patients were able to self-report symptoms during the period of respiratory care unit treatment. Among patients responding to symptom assessment, approximately 90% were symptomatic. Forty-four percent of patients reported pain at the highest levels. More than 60% reported psychological symptoms at these levels, and approximately 90% of patients reported severe distress due to difficulty communicating. CONCLUSIONS: Physical and psychological symptom distress is common and severe among patients receiving treatment for chronic critical illness. The majority of these patients die soon after hospital discharge. Given the level of distress in our study patients and the high mortality rate that we and others have observed, greater attention should be given to relief of pain and other distressing symptoms and to assessment of burdens and benefits of treatment for the chronically critically ill.     

神经内窥镜治疗高血压性脑出血

目的：探讨高血压性脑出血微创手术治疗的新方法。方法：采用单纯颅骨钻孔，应用硬质神经内窥镜治疗高血压性脑出血共２１例。其中包括脑实质内出血１８例和脑室出血３例。结果：手术时间５５～１１５ｍｉｎ，平均７５ｍｉｎ。１８例脑实质内出血血肿清除５０％者４例，５０％～７０％者１０例，７０％～９０％者４例；３例脑室内出血清除均在９０％以上。未发现术后血肿。术后显著好转者１４例，无变化者３例，死亡４例。结论：应用神经内窥镜清除脑内血肿，具有直视下操作、手术时间短、手术创伤小、血肿清除效率市和术后疗效好等优点。术后应用尿激酶灌注有助于巩固术后疗效。     

临终医疗的卫生技术评估系列研究Ⅰ.围脑死亡期医疗服务的现状及费用分析

目的　了解我国围脑死亡期医疗服务现状 ,分析其治疗效果和费用特点。　方法　采用回顾性系列病例研究方法 ,对 1 999年 6月～ 2 0 0 0年 1 2月、2 0 0 1年 1 1月～ 2 0 0 2年 6月间四川大学华西医院外科ICU 940例患者的治疗情况和部分直接医疗成本进行调查分析 ,数据统计与分析使用SPSS 1 0 .0软件。　结果　以病人出现深昏迷、瞳孔对光反射消失和无自主呼吸中的任二种 ,且持续时间超过 1h为围脑死亡期的纳入标准 ,共纳入病例 1 1 5例 ,死亡率高达 99.1 0 % ,人均医疗费 2 5 1 5 .9元 /天。影响费用的主要因素是院内感染 (P =0 .0 0 7)和围脑死亡期持续时间 (P <0 .0 5 )。且随着围脑死亡期持续时间延长 ,患者死亡率迅速增加 ,80 %的病人在符合纳入标准后 72h内死亡。　结论　国内围脑死亡期医疗服务仍主要采用全力抢救模式 ,资源浪费严重。应积极促进脑死亡立法 ,呼吁理性的临终医疗。     

凝血试验真空管"死腔"所致 APTT、PF4偏差探讨

目的　探讨“有死腔”凝血试验管收集的血样进行血小板功能和肝素治疗患者APTT结果的偏差及机制。方法　将 2 0例肝素治疗心肌梗死患者血液分别收集在无或能形成死腔的采血管中 ,分别进行APTT和PF4检测。结果　“有死腔”的采血管使7例患者APTT结果缩短 ,PF4活性增强。结论　采血管死腔增加了血小板与管壁或死腔气体的接触而激活血小板 ,释放PF4并中和肝素 ,造成APTT负偏差。建议进行血小板功能试验或APTT用于肝素治疗监测时使用“无死腔”真空采血管     

The course and prognosis of manic-depressive psychosis: a quantitative analysis of episodes and intervals

A quantitative analysis of episodes and symptom-free intervals in the course of manic-depressive psychosis was attempted. 1,066 patients who visited Tohoku University Hospital between 1955 and 1965 were investigated by a mail questionnaire and subsequent review of records in their care hospitals. There was no difference between the reply group and non-reply group in terms of demographic status. About 6.2% of patients were chronically ill. Eighteen percent of patients were dead at the time of study. The number of episodes was about three in depression and about seven in bipolar type during twelve years of observation. The length of symptom-free interval between episodes was about five years in depression and two years in bipolar type. There was no difference in the number of episodes or in the length of interval between 1955-1959 group and 1960-1965 group. The change of length was not confirmed between early and late intervals.     

Is it ethical to practice intubations on the deceased?

One-third to one-half of emergency departments in the United States and Australia perform endotracheal intubations (ETI's) on the newly dead. Sixty-three percent of emergency medicine and 58% of neonatal critical care training programs allowed procedures to be performed on patients after death; only 10% of these programs required family consent for this practice. This article reviews the arguments for and against this ethical issue. A case study is included to highlight the issue's complexity, and to assist readers in identifying their beliefs (and those of their institutions) about the tissue. An overview of ethically related terms, definitions, and theories and a decision-making model are included to establish a knowledgeable baseline for dealing with any ethical issue.     

Anatomic dead space cannot be predicted by body weight

BACKGROUND: Anatomic dead space (also called airway or tracheal dead space) is the part of the tidal volume that does not participate in gas exchange. Some contemporary ventilation protocols, such as the Acute Respiratory Distress Syndrome Network protocol, call for smaller tidal volumes than were traditionally delivered. With smaller tidal volumes, the percentage of each delivered breath that is wasted in the anatomic dead space is greater than it is with larger tidal volumes. Many respiratory and medical textbooks state that anatomic dead space can be estimated from the patient's weight by assuming there is approximately 1 mL of dead space for every pound of body weight. With a volumetric capnography monitor that measures on-airway flow and CO2, the anatomic dead space can be automatically and directly measured with the Fowler method, in which dead space equals the exhaled volume up to the point when CO2 rises above a threshold. METHODS: We analyzed data from 58 patients (43 male, 15 female) to assess the accuracy of 5 anatomic dead space estimation methods. Anatomic dead space was measured during the first 10 min of monitoring and compared to the estimates. RESULTS: The coefficient of determination (r2) between the anatomic dead space estimate based on body weight and the measured anatomic dead space was r2 = 0.0002. The mean +/- SD error between the body weight estimate and the measured dead space was 60 +/- 54 mL. CONCLUSIONS: It appears that the anatomic dead space estimate methods were sufficient when used (as originally intended) together with other assumptions to identify a starting point in a ventilation algorithm, but the poor agreement between an individual patient's measured and estimated anatomic dead space contradicts the assumption that dead space can be predicted from actual or ideal weight alone.     

A survey on patients admitted in severe coma: implications for brain death identification and organ donation

Objective To identify factors to improve the identification of brain dead patients in intensive care units (ICUs).Design and setting Prospective study conducted in 79 ICUs in 54 hospitals.Patients All hospitalized patients with a Glasgow Coma Scale (GCS) score less than 8.Measurements and results During the study period hospital staff completed a form for each patient with a GCS less than 8. Hospital information units provided us with statistics from the discharge forms. The characteristics of the hospitals were also recorded. We included a total of 792 patients with a GCS less than 8; 120 of these patients were diagnosed as being clinically brain dead (15.1%). These patients accounted for 11.8% of the comatose patients in ICUs, 11.7% of the deaths occurring in ICUs, and 3.3% of the deaths that occurred in the hospital during the study period. Two multivariate linear regressions were performed to predict the number of clinically brain dead patients in the ICUs. The regression analyses included causes of death or causes of coma, and hospital characteristics. The presence of a coordination team and the number of transplant coordinators were positively associated with the number of brain dead patients in both models. The number of patients carried to the ICU by a mobile emergency unit was also positively associated in the model with causes of coma.Conclusions Increasing the number of hospital coordinators and collaboration with mobile emergency units should lead to the identification of more brain dead patients among comatose patients in ICUs.An editorial regarding this article can be found in the same issue     

The effects of passive humidifier dead space on respiratory variables in paralyzed and spontaneously breathing patients

BACKGROUND: Passive humidifiers have gained acceptance in the intensive care unit because of their low cost, simple operation, and elimination of condensate from the breathing circuit. However, the additional dead space of these devices may adversely affect respiratory function in certain patients. This study evaluates the effects of passive humidifier dead space on respiratory function. METHODS: Two groups of patients were studied. The first group consisted of patients recovering from acute lung injury and breathing spontaneously on pressure support ventilation. The second group consisted of patients who were receiving controlled mechanical ventilation and were chemically paralyzed following operative procedures. All patients used 3 humidification devices in random order for one hour each. The devices were a heated humidifier (HH), a hygroscopic heat and moisture exchanger (HHME) with a dead space of 28 mL, and a heat and moisture exchanger (HME) with a dead space of 90 mL. During each measurement period the following were recorded: tidal volume, minute volume, respiratory frequency, oxygen consumption, carbon dioxide production, ratio of dead space volume to tidal volume (VD/VT), and blood gases. In the second group, intrinsic positive end-expiratory pressure was also measured. RESULTS: Addition of either of the passive humidifiers was associated with increased VD/VT. In spontaneously breathing patients, VD/VT increased from 59 +/- 13 (HH) to 62 +/- 13 (HHME) to 68 +/- 11% (HME) (p < 0.05). In these patients, constant alveolar ventilation was maintained as a result of increased respiratory frequency, from 22.1 +/- 6.6 breaths/min (HH) to 24.5 +/- 6.9 breaths/min (HHME) to 27.7 +/- 7.4 breaths/min (HME) (p < 0.05), and increased minute volume, from 9.1 +/- 3.5 L/min (HH) to 9.9 +/- 3.6 L/min (HHME) to 11.7 +/- 4.2 L/min (HME) (p < 0.05). There were no changes in blood gases or carbon dioxide production. In the paralyzed patient group, VD/VT increased from 54 +/- 12% (HH) to 56 +/- 10% (HHME) to 59 +/- 11% (HME) (p < 0.05) and arterial partial pressure of carbon dioxide (PaCO2) increased from 43.2 +/- 8.5 mm Hg (HH) to 43.9 +/- 8.7 mm Hg (HHME) to 46.8 +/- 11 mm Hg (HME) (p < 0.05). There were no changes in respiratory frequency, tidal volume, minute volume, carbon dioxide production, or intrinsic positive end-expiratory pressure. DISCUSSION: These findings suggest that use of passive humidifiers with increased dead space is associated with increased VD/VT. In spontaneously breathing patients this is associated with an increase in respiratory rate and minute volume to maintain constant alveolar ventilation. In paralyzed patients this is associated with a small but statistically significant increase in PaCO2. CONCLUSION: Clinicians should be aware that each type of passive humidifier has inherent dead space characteristics. Passive humidifiers with high dead space may negatively impact the respiratory function of spontaneously breathing patients or carbon dioxide retention in paralyzed patients. When choosing a passive humidifier, the device with the smallest dead space, but which meets the desired moisture output requirements, should be selected.