非体外循环下冠状动脉搭桥术的麻醉处理

非体外循环下冠状动脉搭桥术( off- pump coronary artery bypass ,OPCAB)与常规体外循环下冠状动脉搭桥术( conventional coronary artery bypass grafting,cCABG)相比,从理论上避免了体外循环损伤和心肌缺血再灌注损伤,手术创伤小、术后并发症发生率低、住院时间短,已成为当代微创心脏外科手术的热点术式之一.我院自 2001年至今共施行 OPCAB手术 10例,现将麻醉作一总结.     

非体外循环下冠脉搭桥术与体外循环下冠脉搭桥术对冠心病患者肾功能及心功能的影响

目的比较非体外循环及体外循环下冠脉搭桥术对冠心病患者肾功能及心功能的影响。方法选取2017年6月至2019年5月98例冠心病患者,随机分为对照组与观察组,每组49例。对照组采取体外循环下冠脉搭桥术治疗,观察组采取非体外循环下冠脉搭桥术治疗。比较两组患者术前、术后24 h肾功能及心功能指标。结果术后24 h,观察组尿素氮、血肌酐水平明显低于对照组,肾小球滤过率高于对照组(P0.05)。观察组心脏指数、左心室收缩压明显高于对照组,肌酸激酶同工酶低于对照组(P0.05)。结论对冠心病患者采取非体外循环下冠脉搭桥术治疗对肾功能、心功能影响更小,有利于术后恢复,具有显著优势。     

肺癌患者围术期心肌酶谱变化的临床分析

目的探讨肺癌患者围术期心肌酶谱变化的情况。方法回顾性分析本院手术治疗肺癌患者35例的临床资料。结果单纯手术组中,术后天门冬氨酸转氨酶(AST)、肌酸激酶(CK)、α-羟丁酸脱氢酶(α-HBDH)、肌钙蛋白I(cTnI)、肌红蛋白(Mb)指标水平明显比术前升高。新辅助化疗组中,术后AST、乳酸脱氢酶(LDH-L)、CK、肌酸激酶同工酶(CK-MB)、α-HBDH、cTnI、Mb等指标水平较术前明显升高。手术前后,新辅助化疗心肌酶谱指标α-HBDH、cTnI、LDH-L与CK明显高于单纯手术组患者。结论开胸手术和术前新辅助化疗均可以导致肺癌患者围术期心肌酶谱异常。     

非体外循环下心脏搭桥术对患者心肌指标的影响分析

目的 探讨非体外循环下心脏搭桥术对患者心肌指标的影响。方法 回顾性分析我院2017年10月～2020年9月收治的63例冠心病行心脏搭桥术患者的临床资料,根据心脏搭桥术循环方式不同,将行体外循环的31例患者设为对照组,将行非体外循环的32例患者设为观察组。观察两组临床指标,比较两组手术前后心肌指标:血清肌钙蛋白I(c TnI)、肌酸激酶同工酶(CK-MB),比较肾功能水平:[血肌酐(SCr)、血清尿素氮(BUN)。结果 观察组手术时间、气管插管、住院及ICU观察时间均较对照组短,差异均有统计学意义(P0.05);术后6h,两组c Tn I、CK-MB、SCr、BUN水平均有不同程度升高,但观察组低于对照组,差异均有统计学意义(P0.05)。结论 非体外循环下心脏搭桥术能够降低体外循环对各脏器带来的损伤,改善心肌指标及肾功能,缩短术后恢复时间。     

体外与非体外循环冠状动脉搭桥术临床对比及护理研究

目的观察比较体外循环冠状动脉搭桥术（CPABG）和非体外循环冠状动脉搭桥术（OPCAB）的疗效，探讨其护理措施。方法选取65例冠脉搭桥术患者，随机分为两组，33例行OPCAB，32例行CPABG，对两组患者分别行相应的护理，包括术后严密监测生命体征，严密心电监护，加强呼吸系统的监护，维持血压稳定，患肢动脉血栓预防，华法林的合理使用等，观察比较两组患者手术情况，术后恢复及心功能改善情况。结果OPCAB组患者手术时间及出血量均明显低于CPABG组，两组比较差异具有统计学意义（P〈0．05）。两组患者手术前后心功能分级，组间比较差异无统计学意义（P〉0．05）；术后与术前相比，心功能均显著改善，差异均有统计学意义（P〈0．05）。OPCAB组患者ICU留住时间，辅助呼吸时间，并发症发生情况，拔纵隔、心包引流管时间，住院时间及住院费用均明显低于CPABG组，差异均有统计学意义（P〈0．05）。结论OPCAB较CPABG治疗冠心病患者术后恢复快，疗效更为显著；护士掌握手术相关知识及护理要点，为患者提供优质高效专业的护理，是保证手术成功的关键。     

停跳与不停跳冠状动脉搭桥术临床结果及短期随访比较分析:附233例报告

目的探讨停跳冠脉搭桥术(CCAB)和不停跳冠脉搭桥术(OPCAB)的优缺点,并对术后3年的随访结果进行比较分析。方法总结分析了近8年来我中心的单纯冠脉搭桥手术病例临床资料,包括心脏停跳下单纯冠脉搭桥术88例和心脏不停跳冠脉搭桥术145例,主要比较分析术前常见的危险因素,术中平均远端吻合口数、手术时间,术后机械通气时间、IUC时间、术后住院天数、血管活性药物应用、术后IABP的使用、术后常见并发症及死亡率等,并对术后3年随访情况进行了分析,内容包括症状、心电图、心功能及死亡率等。结果术前危险因素中,除年龄和糖尿病外其余两组之间无明显差别,OPCAB与CCAB相比较,平均远端血管吻合口数明显减少(3.1±0.9 vs 3.5±0.9,P0.001)而手术时间、术后机械通气时间、术后ICU时间和术后住院天数则显著缩短;术后主要并发症(如低心排、IABP使用、肾功能不全)明显减少;术后多巴胺和肾上腺素用量显著减少,而硝酸甘油和硝普钠用量二者无明显差别;术后输血量显著减少,而引流量无明显差别;住院死亡率无明显差别(1.4%vs 3.4%,P=0.287)。术后3年随访显示OPCAB组EF值显著比CCAB组高(66.1%±7.6%vs 62.0%±10.2%,P=0.043),出现心衰症状的概率OPCAB组也明显高于CCAB组(10.9%vs 28.6%,P=0.012)。结论(1)OPCAB术在术后恢复和术后主要并发症发生减少方面均明显优于CCAB术。虽然OPCAB手术操作较为困难,但其近期优越性是显而易见的;(2)从术后3年的短期随访来看,OPCAB组的心衰症状明显少于CCAB组,反映心功能的指标EF值也显著高于CCAB组。     

70岁以上患者两种施术方式下冠脉搭桥术早期结果分析

【目的】比较常规体外循环(CPB)和非体外循环(OPCAB)下老年患者冠脉搭桥术(CABG)术后的早期结果。【方法】119例70岁以上拟行CABG患者分为两组,比较两组术后早期死亡率、合并症等的发生情况,分析其差异。【结果】OPCAB组术后早期死亡率显著低于CABG-CPB组(1.3%vs 9.5%);OPCAB组与CABG组比较术后平均气管插管时间[(11.95±11.66)h vs(38.92±56.8)h],平均ICU时间[(48.32±42.3)h vs(87.1±83.3)h],平均输血量[(635±768)ml vs(924±1015)ml],出血二次开胸(2.6%vs 4.8%),神经系统并发症明显少于CABG组;OPCAB组术后新发房颤明显高于CABG-CPB组(10.4%vs 7.1%)。【结论】OPCAB在老年患者中能够取得良好的临床效果,特别是在一些传统以为高风险的患者中有应用价值。     

非体外循环下心脏搭桥对心脏搭桥患者CK、cTnI水平的影响

目的探讨非体外循环下心脏搭桥对心脏搭桥患者肌酸激酶(CK)和肌钙蛋白I(cTnI)水平的影响。方法选择2016年2月～2019年3月我院收治的60例接受心脏搭桥术患者作为研究对象,随机分为2组各30例。对照组行体外循环心脏搭桥术,观察组则接受非体外循环下心脏搭桥术。比较两组患者术前、术后4h CK、cTnI水平变化情况以及围术期指标。结果术后4h,两组CK及cTnI水平均上升,但观察组低于对照组,此外,观察组手术时间、辅助呼吸时间以及住院天数均短于对照组,24h引流量少于对照组,差异有统计学意义(P<0.05)。结论与体外循环下心脏搭桥术相比,非体外循环下心脏搭桥术对患者心肌损伤程度更低,可有效保护心功能,缩短治疗时间,预后良好,具有较高的应用价值。     

兔心肌缺血与再灌注过程一氧化氮合酶水平变化的意义

目的 探讨心肌缺血再灌注过程心肌组织一氧化氮合酶的作用.方法 采用分别结扎兔冠状动脉左回旋支10,20,30,40 min并再灌60 min制备4组缺血再灌注动物模型,另设假手术组,分别于再灌注60 min时测定血清天门冬氨酸氨基转移酶(AST)、乳酸脱氢酶(LDH)、肌酸激酶(CK)、肌酸激酶同工酶(CK-MB)及心肌组织一氧化氮合酶(NOS)、丙二醛(MDA).结果 ①缺血40 min组AST,LDH,CK及CK-MB水平均明显高于假手术组(P＜0.05);②缺血40 min组NOS,MDA水平较假手术组明显增高(P＜0.05).结论 缺血40 min组心肌酶,NOS,MDA均明显增高,在心肌缺血再灌注损伤中,NOS可能起着心肌细胞毒性作用.     

体外循环搭桥术与左胸小切口非体外循环搭桥术治疗冠心病效果对比

目的比较体外循环搭桥术与左胸小切口非体外循环搭桥术治疗冠心病患者的疗效。方法选取行冠状动脉搭桥术治疗的冠心病患者90例,随机分为两组,每组45例。对照组行体外循环搭桥术,实验组行左胸小切口非体外循环搭桥术。观察并比较两组术后恢复效果及并发症发生情况。结果对照组术后机械通气时间、ICU治疗时间、住院时间及并发症发生率均高于实验组,差异有统计学意义(P0.05)。实验组术后并发症比例为15.56%(7/45),对照组为33.33%(15/45),两组比较差异有统计学意义(χ2=3.850,P0.05)。结论左胸小切口非体外循环搭桥手术治疗冠心病效果优于体外循环搭桥手术,可有效减少术后并发症,帮助患者恢复。     

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.     

Dissociable correlates of two classes of retrieval processing in prefrontal cortex

Although substantial evidence suggests that the prefrontal cortex (PFC) implements processes that are critical for accurate episodic memory judgments, the specific roles of different PFC subregions remain unclear. Here, we used event-related functional magnetic resonance imaging to distinguish between prefrontal activity related to operations that (1) influence processing of retrieval cues based on current task demands, or (2) are involved in monitoring the outputs of retrieval. Fourteen participants studied auditory words spoken by a male or female speaker and completed memory tests in which the stimuli were unstudied foil words and studied words spoken by either the same speaker at study, or the alternate speaker. On "general" test trials, participants were to determine whether each word was studied, regardless of the voice of the speaker, whereas on "specific" test trials, participants were to additionally distinguish between studied words that were spoken in the same voice or a different voice at study. Thus, on specific test trials, participants were explicitly required to attend to voice information in order to evaluate each test item. Anterior (right BA 10), dorsolateral prefrontal (right BA 46), and inferior frontal (bilateral BA 47/12) regions were more active during specific than during general trials. Activation in anterior and dorsolateral PFC was enhanced during specific test trials even in response to unstudied items, suggesting that activation in these regions was related to the differential processing of retrieval cues in the two tasks. In contrast, differences between specific and general test trials in inferior frontal regions (bilateral BA 47/12) were seen only for studied items, suggesting a role for these regions in post-retrieval monitoring processes. Results from this study are consistent with the idea that different PFC subregions implement distinct, but complementary processes that collectively support accurate episodic memory judgments.     

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.     

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.     

Modified micro-superior percutaneously-assisted total hip: early experiences & case reports

Because of the extensile nature and familiarity of the standard posterior-lateral approach to the hip, a family of "micro-posterior" approaches has been developed. This family includes the Percutaneously-Assisted Total Hip (PATH) approach, the Supercapsular (SuperCap) approach and a newer hybrid approach, the Supercapsular Percutaneously-Assisted Total Hip (SuperPATH) approach. Such approaches should ideally provide a continuum for the surgeon: from a "micro" (external rotator sparing) posterior approach, to a "mini" (external rotator sacrificing) posterior approach, to a standard posterior approach. This could keep a surgeon within his comfort zone during the learning curve of the procedure, while leaving options for complicated reconstructions for the more practiced micro-posterior surgeons. This paper details one author's experiences utilizing this combined approach, as well as permutations of this entire micro-posterior family of approaches as applied to more complex hip reconstructions.     

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.     

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.