序贯机械通气治疗急性呼吸窘迫综合征的临床效果观察与护理

目的:探讨序贯机械通气(MV)治疗急性呼吸窘迫综合征(ARDS)的临床效果与护理方法。方法:将我院ICU 2010年10月至2013年10月收治的61例ARDS患者随机分为序贯组(n=31)和对照组(n=30),序贯组使用有创-无创序贯MV,对照组常规有创MV。结果:序贯组拔管后改用无创MV24 h及48 h后与对照组比较无显著性差异(P0.05),有创通气时间、总通气时间、ICU驻留时间及呼吸机相关性肺炎(VAP)的发生率有显著性差异(P0.05)。结论:序贯MV治疗ARDS能有效减少有创通气时间、总通气时间、ICU驻留时间及VAP的发生率。     

支气管镜联合无创通气治疗慢性阻塞性肺疾病急性发作合并呼吸衰竭的临床疗效观察

目的探讨支气管镜联合无创通气在慢性阻塞性肺疾病急性发作合并呼吸衰竭的患者中的应用效果。方法选取2015年2月至2016年2月接受治疗的慢性阻塞性肺病急性发作合并呼吸衰竭的患者80例,按照随机数字表的方法,随机地分为观察组(n=40)和对照组(n=40),对观察组的患者采取在常规治疗基础上给予支气管镜联合无创呼吸机进行正压通气的治疗方法,对照组在常规治疗的基础上给予无创呼吸机正压通气治疗,比较两组患者的无创通气时间、住院时间,比较两组患者的有创机械通气发生率、病死率,比较两组患者治疗前后的氧分压(Pa O_2)、二氧化碳分压(Pa CO_2)和p H。结果观察组患者的无创通气时间和住院时间显著短于对照组患者(P0.05),观察组患者的有创机械通气发生率和病死率显著低于对照组(P0.05),治疗前两组患者的Pa O_2、Pa CO_2、p H差异无统计学意义(P0.05)。治疗后,观察组患者的Pa O_2、Pa CO_2、p H显著优于对照组(P0.05)。结论支气管镜联合无创正压通气治疗能够有效改善慢阻肺急性发作合并呼吸衰竭患者血气指示,降低病死率,促进患者康复,值得推广应用。     

无创通气治疗急性心源性肺水肿44例临床观察

目的观察无创正压通气治疗急性心源性肺水肿的临床疗效。方法 44例急性心源性肺水肿依据是否应用无创通气（noninvasive ventilation,NIV）分为NIV组30例和常规治疗组14例,监测2组治疗前、后各项生理指标、动脉血气分析、血乳酸和血B型利钠肽的变化。结果与治疗前比较,NIV组治疗后心率、血压、呼吸频率、脉搏血氧饱和度、氧分压、乳酸和B型利钠肽水平有明显改善;常规治疗组仅血压、呼吸频率、脉搏血氧饱和度、氧分压和B型利钠肽水平有改善（P〈0.05）;治疗后NIV组心率、呼吸频率、脉搏血氧饱和度、pH值、氧分压和B型利钠肽水平均较常规治疗组改善明显（P〈0.05）;NIV组气管插管率低于常规治疗组（P〈0.05）。结论 NIV是治疗急性心源性肺水肿快速有效的方法,疗效可靠。     

无创通气在重度支气管哮喘急性发作的作用

目的:探讨无创通气在重度支气管哮喘急性发作的作用。方法:选取2016年1月至2017年12月我院收治的重度支气管哮喘急性发作患者49例,以随机数字法分为对照组(20例)与观察组(29例),对照组采取常规治疗,观察组在对照组基础中联合口鼻面罩的双水平气道正压(BiPAP)通气治疗。记录两组患者治疗前后pH值、PaO_2与PaCO_2的变化与治疗后(FEV1%pred、FEV_1/FVC%和PEF的变化情况以及并发症(腹胀、CO_2潴留、重新插管上机)。结果:两组治疗前动脉血气等资料无统计学差异(P0.05),治疗两组动脉血气指标显著转归,且观察组pH值、PaCO_2、PaCO_2等指标改善情况显著优于对照组(P0.05);治疗后,观察组FEV_1%pred、FEV_1/FVC%、PEF(L/S)肺功能指标显著优于对照组(P0.05);观察组患儿并发症明显低于对照组,差异显著(P0.05)。结论:临床中治疗重度支气管哮喘急性发作应用无创通气,动脉血气与肺功能显著转好且不良反应率降低。     

两种无创正压通气模式治疗急性心源性肺水肿的临床观察

目的:探讨无创机械通气双水平正压通气(BiPAP)模式与持续正气道压通气(CPAP)模式治疗急性心源性肺水肿(ACPE)的临床疗效.方法:65例ACPE患者在应用常规吸氧及药物治疗基础上随机分为BiPAP组(n=33)和CPAP组(n=32),分别联用无创呼吸机进行BiPAP和CPAP模式治疗,比较两组临床症状和体征、动脉血气分析及N末端利钠肽前体(NT-proBNP)等.结果:两组患者治疗后临床症状、体征明显改善,呼吸频率、心率、平均动脉压及NT-proBNP均较治疗前显著降低(P＜0.01),PaO2、Sa02较治疗前显著增高(P＜0.01),BiPAP组(n=33)的总有效率100.0％与CPAP组(n=32)的96.88％无显著性差异(P＞0.05).结论:无创机械通气BiPAP和CPAP治疗ACPE均疗效显著.     

无创正压通气对轻、中度支气管哮喘急性发作患者的影响

目的:探讨在没有史气管舒张药治疗下,无创正压通气(NPPV)治疗在轻、中度急性支气管哮喘发作中的价值.方法:42位轻、中度急性哮喘发作患者随机分成:NPPV组(n=21)和对照组(n=21),在研究前两组均给予静注甲基强的松龙(40mg/人).治疗前及治疗后20、40、60min评估呼吸频率(RR)、心率(HR)、血氧饱和度(SaO2)、第1秒用力呼气容积占预计值百分比(FEV1%).结果:NPPV组在治疗后RR、HR、SaO2、FEV1%与对照组比较,差异均有显著性(P＜0.05).结论:NPPV治疗能改善轻、中度急性哮喘发作的症状.     

肺泡灌洗术在有创机械通气治疗重症肺炎患者中的临床疗效

目的:探讨肺泡灌洗术(BAL)在有创机械通气治疗重症肺炎患者中的作用.方法:将95例进行有创机械通气治疗的重症肺炎患者随机分成对照组(n=53)和治疗组(n=42),对照组采用常规药物治疗,治疗组在常规药物治疗基础上于机械通气期间每天进行肺泡灌洗,比较两组预后、机械通气时间和ICU逗留时间.结果:治疗组死亡率明显低于对照组(P<0.05),两组中生存患者的机械通气时间、ICU逗留时间均有统计学差异(P<0.05).结论:肺泡灌洗术可改善机械通气治疗重症肺炎患者的预后.     

Copeptin联合pro-BNP在BIPAP治疗急性心力衰竭中的意义

目的:探讨和肽素(copeptin)联合脑钠肽前体(pro-BNP)在双水平无创正压通气(BIPAP)治疗急性心力衰竭中的意义。方法:120例急性心力衰竭患者按照Kiliip分级方法分为3组:Killip 2级(n=40)、Killip 3级(n=40)、Killip 4级(n=40),每级40例随机分为常规治疗组(n=20)及无创通气组(n=20),分别在各级中比较常规治疗组及无创通气组的copeptin、pro-BNP水平,同时在治疗第3天、第7天比较所有常规治疗组及无创通气组的再Killip分级情况。结果:Killip 4级与Killip 3级的copeptin、pro-BNP水平明显高于Killip 2级患者,差异有统计学意义(P0.05);Killip 4级的copeptin、pro-BNP水平明显高于Killip 3级,差异有统计学意义(P0.05);copeptin水平和pro-BNP呈正相关(r=0.803,P0.01),在治疗第3天、第7天,无创通气组的疗效优于常规治疗组。结论:copeptin与pro-BNP可以很好地评价经BIPAP治疗后患者心力衰竭的程度,可以作为早期诊断及预后疗效的判定指标。     

丙氨酰谷氨酰胺在创伤性急性肺损伤机械通气治疗中的临床研究

目的:探讨丙氨酰谷氨酰胺(Ala-Gln)在创伤性急性肺损伤(ALI)机械通气治疗中的临床疗效.方法:将创伤性ALI机械通气患者60例随机分为观察组(n=30)和对照组(n=30),观察组在常规治疗基础上加Ala-Gln 0.5 g/(kg·d),连用7 d,比较两组的 PaO2、氧合指数、APACHEⅡ评分、机械通气时间、住 ICU 时间、ARDS发生率及病死率.结果:观察组治疗后PaO2、氧合指数、APACHEⅡ评分、机械通气时间、住ICU 时间、ARDS发生率组均明显优于对照组(P均<0.05),但病死率无显著性差异(P>0.05).结论:Ala-Gln在创伤性ALI机械通气治疗中可能有肺保护作用,适合创伤性ALI的治疗.     

双水平气道正压通气治疗重度哮喘的临床评价

目的 对双水平气道正压通气在重度哮喘治疗中的作用进行分析和评价.方法 通过70例重度哮喘患者的回顾性分析研究,根据患者所接受的治疗方式分为无创通气组和对照组.对照组31例,接受吸氧以及抗生素、化痰药物、支气管扩张剂等常规治疗方法;无创通气组39例,除给予对照组患者相同常规治疗外,给予BiPAP无创通气治疗.观察患者的心率、呼吸频率和血气分析的改变情况.结果 治疗前两组患者各项指标差异无统计学意义(P>0.05),治疗12h后,无创通气组患者的PaO2、HR、PR明显好转(P<0.05),并且随着治疗时间的增加而得到进一步改善;对照组患者在治疗12h后,各项指标改善尚不明显(P>0.05),直到治疗72h才出现明显好转(P<0.05).治疗12h后,无创通气组与对照组比较,前者PaO2、HR、PR的变化明显(P<0.05);治疗72h无创通气组与对照组比较各指标改善更明显(P<0.05).结论 联合运用BiPAP无创通气较常规治疗能快速改善患者的缺氧状态、缩短哮喘缓解时间,在重度哮喘的治疗中有积极作用.     

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.     

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.     

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.