颅内压监测对重度颅脑外伤行开颅血肿清除术患者GCS评分、并发症及预后的影响

目的探讨颅内压监测对重度颅脑外伤开颅血肿清除术后患者GCS评分、并发症及预后的影响。方法选取重度颅脑外伤患者84例,将以上患者分成常规组和监测组。常规组患者行标准外伤大骨瓣开颅减压术,监测组患者则在行标准外伤大骨瓣开颅减压术的基础上联合术后颅内压监测。比较2组患者手术前后格拉斯哥昏迷评分(GCS)、颅内压变化、术后并发症发生情况以及预后。结果监测组患者术后3、7 d的颅内压下降值显著大于常规组(P0.05);2组患者术后28 d GCS评分均显著升高,且监测组患者GCS评分升高较常规组更显著(P0.05);与常规组相比,术后3个月的格拉斯哥预后评分(GOS)提示监测组的预后较好(P0.05);术后6个月,常规组与监测组的电解质紊乱发生率分别为59.5%、33.3%(P0.05)。结论对重度颅脑外伤患者行标准外伤大骨瓣开颅减压术联合术后颅内压监测的疗效较好。     

脑氧分压与颅内压联合监测在指导重型颅脑损伤治疗中的应用价值

目的：探讨脑氧分压联合颅内压监测在重型颅脑损伤患者治疗中的指导作用。方法收集84例重型颅脑损伤的患者随机分为A、B、C 3个组,每组28例,分别给予单独脑氧分压监测、单独颅内压监测和脑氧分压联合颅内压监测,分别统计3个组患者入院时和治疗72 h后的脑氧分压值、治疗1周内的甘露醇应用总量、格拉斯哥预后（GOS ）评分各等级的病例数进行对比。结果 A组和C组治疗后脑氧分压值的上升水平明显高于B组,差异有统计学意义（P＜0．05）;B组和C组治疗1周内应用甘露醇的总量明显少于 A组,差异有统计学意义（P＜0．05）;C组患者治疗后3个月恢复良好的11例,明显多于 A 组的4例和B组的3例,差异有统计学意义（ P＜0．05）;C组无死亡患者,明显少于A组的4例和B组的5例,差异有统计学意义（P＜0．05）。结论行脑氧分压联合颅内压监测既可及时有效地指导纠正脑缺血缺氧情况,又可正确地指导脱水剂的应用,在重型颅脑损伤患者的治疗中具有良好的效果和重要的价值。     

持续有创颅内压监测对重型颅脑损伤病人救治的临床价值分析

目的 探讨持续有创颅内压监测对重型颅脑损伤患者术后临床治疗的价值及意义。方法 回顾性分析60例重型颅脑损伤手术患者临床资料,根据检查方式分为颅内监测组和对照组各30例。比较两组患者脱水剂使用剂量、术后GCS评分及预后。结果 对照组甘露醇使用时间为17.1±7.3d、剂量为900±75g,颅内监测组分别为10.4±5.7d、500±80g,组间比较,差异显著(t=3.962、19.979,P0.01)。两组患者颅内压均逐渐下降,GCS评分均逐渐升高。术后第1d开始,颅内监测组患者颅内压均明显低于对照组,术后第7d开始,颅内监测组GCS明显高于对照组(P0.05)。颅内监测组预后不良率更低。结论 持续有创颅内压监测对重型颅脑损伤术后患者救治具有重要价值,可及时评估病情变化并给予有效处置,可避免盲目使用脱水剂,改善预后,值得临床推广应用。     

亚低温对创伤性脑损伤患者脑脊液髓鞘基本蛋白的影响

目的 探讨亚低温对创伤性脑损伤患者脑脊液髓鞘基本蛋白(MBP)水平的影响.方法 36例重型颅脑损伤患者,随机分为亚低温治疗组及常温治疗组,在不同时间点评价颅内压变化、GOS预后,通过酶联免疫吸附实验(ELISA)分析治疗各时间点脑脊液MBP的变化,综合分析亚低温对重型颅脑损伤患者的影响.结果 两组比较,治疗1d脑脊液MBP浓度差异无统计学意义[分别为(24.95±2.07)、(26.72±2.43)μg/L,t=2.36,P＞0.05].在治疗7、14 d亚低温治疗组比常温治疗组脑脊液MBP浓度明显降低,差异均有统计学意义[(12.41±0.74)、(19.54±1.38)μg/L,t=19.86,P＜0.05;(7.85±0.32)、(13.51±1.46)μg/L,t=16.89,P＜0.05].而颅内压监测显示,两组治疗1d颅内压变化差异无统计学意义,在治疗7、14 d颅内压变化差异均有统计学意义[(19.0±2.1)、(26.0±2.6)mm Hg,t=8.94,P＜0.05;(13.0±1.8)、(19.0±1.6)mm Hg,=10.43,P＜0.05].两组预后比较差异有统计学意义(Z=-2.82,P＜0.05);亚低温治疗组预后良好率明显高于常温治疗组(P＜0.05),但在病死率方面差异无统计学意义(P＞0.05).结论 亚低温治疗可能通过减少MBP降解来稳定中枢神经系统髓鞘,达到脑保护作用,从而改善重型颅脑损伤患者的预后.     

颅脑损伤合并低钠血症患者血钠水平与颅脑损伤类型、程度及预后的相关性研究

目的探讨颅脑损伤合并低钠血症患者血钠水平与颅脑损伤类型、程度及预后的相关性。方法选取2014年1月—2016年12月我院收治的300例颅脑损伤合并低钠血症患者,根据血钠降低程度分为A组(轻度低钠组,血钠浓度130～135 mmol/L)187例,B组(中度低钠组,血钠浓度120～130 mmol/L)74例和C组(重度低钠组,血钠浓度120 mmol/L)39例。比较3组损伤类型;通过格拉斯哥昏迷评分(glasgow coma score, GCS)评价3组入院时颅脑损伤程度;比较3组治疗后1个月和6个月时格拉斯哥预后量表(glasgow outcome scale, GOS)评分和Barthel指数(barthel index, BI),评估患者预后情况。结果 3组患者在损伤类型上比较差异无统计学意义(P0.05)。由A组到C组,随着血钠值的降低,患者GCS评分呈逐步降低趋势(P0.05)。治疗后1个月、6个月时,3组患者GOS评分随着血钠值的降低而降低,整体及各组间比较差异均有统计学意义(P0.05或P0.01);且与治疗后1个月时比较,治疗6个月时A、B组GOS评分均升高,差异均有统计学意义(P0.05)。治疗后3组BI均显著升高,且同一时间点C组B组A组,差异均有统计学意义(P0.05)。结论颅脑损伤合并低钠血症患者血钠水平与颅脑损伤类型无关,与颅脑损伤程度存在密切联系,血钠值越低其颅脑损伤程度越重,且治疗后临床预后也更差。     

术区ICP监测与脑室外引流联合ICP监测在重型颅脑损伤患者中的应用研究

目的探讨术区ICP监测与脑室外引流联合ICP监测在重型颅脑损伤患者中的应用价值。方法选取2014年5月～2017年5月本院收治的27例重型颅脑损伤患者(A组),应用脑室型颅内压监测套装行脑室外引流联合ICP监测;随机选取同期27例重型颅脑损伤患者(B组),行术区ICP监测。比较治疗效果。结果治疗1d、3d、7d时,A组ICP低于B组(P0.05);A组预后良好率高于B组(P0.05),外伤性脑积水发生率低于B组(P0.05)。结论重型颅脑损伤治疗中联用ICP监测与脑室外引流可控制ICP水平,改善预后,且能降低外伤性脑积水发生风险,值得临床推广。     

高渗盐水可降低重型颅脑创伤患者颅内压

目的:评价高渗盐水和甘露醇降低重型颅脑创伤患者颅内压(ICP)的效果。方法:我院治疗的重型颅脑损伤患者132例,随机分为高渗盐水组65例和甘露醇组67例,在常规治疗基础上,分别给予3%高渗盐水5.4 mL/kg和20%甘露醇5.0 mL/kg静脉滴注。评价2组治疗期间的药物起效时间、最大ICP下降幅度、累积颅内压负荷(CICPB)、平均ICP负荷时间、压力累及时间(PTD)、ICU停留时间和格拉斯哥预后评分(GOS)。结果:2组起效时间、最大ICP下降幅度组间比较差异无统计学意义(P0.05);高渗盐水组PTD、CICPB和ICP负荷时间均小于甘露醇组(P0.05);2组ICU停留时间、GOS评分和临床预后差异无统计学意义(P0.05)。以GOS评分为因变量的多元线性回归分析结果显示,PTD、CICPB、ICP负荷时间与GOS呈负相关(P0.05),起效时间、最大ICP下降幅度与GOS不相关(P0.05)。结论:高渗盐水稳定重型颅脑损伤患者ICP的效果优于甘露醇,但不能改善临床预后。     

持续动态颅内压监测在重型颅脑外伤术后临床意义

目的动态观察颅内压（ICP）的变化，探讨颅内压监测在重型颅脑外伤术后的作用和临床意义。方法对180例重型颅脑外伤术后患者进行持续动态颅内压监测，随机分为ICP监测组和常规神经外科治疗组，根据监测结果，调整治疗方案并观察其疗效。结果①ICP监测组在脱水剂应用时间、剂量及并发症方面均低于常规治疗组，两组差异有统计学意义（P〈0．01）；②ICP监测组疗效优于常规神经外科治疗组，两者差异有统计学意义（P〈0．05）。结论对颅脑外伤术后患者应及早动态观察颅内压有助于指导和及时调整治疗措施，降低并发症，提高疗效及估计预后。     

有创颅内压监测在颅脑损伤开颅术后患者中的应用

目的探讨颅内压(ICP)监测在中重型颅脑损伤行开颅去骨瓣减压术后患者中的应用效果。方法回顾性收集惠州市中大惠亚医院2013年7月~2017年7月68例中重型颅脑损伤行去骨瓣减压术患者,根据术中有无留置有创颅内压监测传感器分为观察组(24例)和对照组(44例)。分析ICP与格拉斯哥昏迷评分(GCS)和格拉斯哥预后评分(GOS)之间的关系,了解ICP对此类患者预后的影响;对比两组患者28d后GCS和GOS预后评分,以及两组患者脱水剂应用天数、剂量,常见并发症的发生率(如轻、中、重度高钠血症、急性肾功能损伤)等,分析持续颅内压监测对患者预后及并发症的影响。结果 ICP与GCS评分呈负相关(P0.05),与GOS预后评分也呈负相关(P0.05)。观察组甘露醇应用天数(9±3)d及总剂量(630.25±45.03)g均明显低于对照组(14±3)d、(1732.50±98.50)g,两组差异均有统计学意义(P0.05);观察组患者出现重度高钠血症的1例(4.17%),中度高钠血症2例(8.3%),轻度高钠血症4例(16.7%),急性肾功能损害1例(4.17%),而对照组严重高钠血症的6例(9.09%),中度高钠血症6例(13.6%),轻度高钠血症9例(20.45%),急性肾功能损害3例(6.81%),差异均有统计学意义(P0.05)。观察组患者死亡率和植物生存状态的比例明显少于对照组(P0.05),但在轻度到重度残疾方面,两组差异无统计学意义(P0.05)。结论颅高压严重影响中重型颅脑损伤患者的预后,持续颅内压监测对中重型颅脑损伤患者的预后会产生积极的影响,并明显减少相关的并发症,值得临床应用。     

不同颅骨修补时间在高能量交通事故引起的颅脑外伤及高血压病引起的脑出血治疗中的效果分析

目的分析不同颅骨修补时间在高能量交通事故引起的颅脑外伤及高血压病引起的脑出血治疗中的效果。方法选取于2018年7月～2019年9月在我院进行骨瓣减压治疗的84例脑出血患者为研究对象,按照颅骨修补时机法分成A组和B组各42例,颅骨修补时间3个月为A组,颅骨修补时间3个月为B组。比较两组手术前后格拉斯哥预后分级评分(GOS)及简易智力评分(MMSE);比较两组手术前后平均通过时间(MTT)、手术侧脑血流量(CBF)、脑血容量(CBV)等CT灌注扫描指标。结果术前两组GOS及MMSE评分无明显差异(P0.05);术后,A组GOS评分、MMES评分均高于B组,差异有统计学意义(P0.05);术前两组MTT、CBF、CBV无明显差异(P0.05);术后,A组MTT低于B组,CBF、CBV高于B组(P0.05)。结论颅脑外伤或高血压脑出血3个月内,进行早期颅骨修补治疗高能量交通事故引起的颅脑外伤及高血压病引起的脑出血疗效显著,有利于降低患者脑神经功能损伤,改善大脑血流灌注。     

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.     

Prospects for the control of neglected tropical diseases by mass drug administration

The prospects for the control of neglected tropical diseases, including soil-transmitted helminthiasis, shistosomiasis, lymphatic filariasis, onchocerciasis and trachoma, through mass drug administration, are exemplified by the elimination of the trachoma as a public-health problem in Morocco. In spite of this and other striking successes, mass drug administration programs are faced with major challenges resulting from suboptimal coverage and lack of efficacy. At current suboptimal coverage rates, programs may need prolongation for an extended period, increasing costs and undermining sustainability. Community participation through health education and information appears to be crucial to improve coverage and to achieve sustainability. Implementation of complementary measures, such as vector control, improved hygiene and environmental sanitation, are important to further control transmission and to prevent re-emergence of the infection and, again, may only be achieved effectively through community-based initiatives. To reduce costs and to relieve pressure on the health system, combining neglected tropical disease programs in areas where diseases coexist and integration with existing control programs for malaria, tuberculosis and HIV/AIDS is advocated. The risk of developing drug resistance is of particular concern in view of the lack of alternative drugs, and reduced treatment efficacy due to emerging resistance is evident for the soil-transmitted helminths and onchocerciasis. Given the risk for the development of drug resistance and the need for a high degree of participation, close attention should be paid to the monitoring of the coverage and efficacy of the different program components.     

Bacterial meningitis: an update of new treatment options

The outcome of bacterial meningitis critically depends on the rapid initiation of bactericidal antibiotic therapy and adequate management of septic shock. In community-acquired meningitis, the choice of an optimum initial empirical antibiotic regimen depends on the regional resistance patterns. Pathogens resistant to antibacterials prevail in nosocomial bacterial meningitis. Dexamethasone is recommended as adjunctive therapy for community-acquired meningitis in developed countries. In comatose patients, aggressive measures to lower intracranial pressure <20 mmHg (in particular, external ventriculostomy, osmotherapy and temporary hyperventilation) were effective in a case–control study. Although many experimental approaches were protective in animal models, none of them has been proven effective in patients. Antibiotics, which are bactericidal but do not lyse bacteria, and inhibitors of matrix metalloproteinases or complement factor C5 appear the most promising therapeutic options. At present, vaccination is the most efficient method to reduce disease burden. Palmitoylethanolamide appears promising to enhance the resistance of the brain to infections.     

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.     

Imaging choices in occult hip fracture

Background: Hip fracture is a common injury, with an incidence rate of > 250,000 per year in the United States. Diagnosis is particularly important due to the high dependence on the integrity of the hip in the daily life of most people. Objectives: In this article we review the literature focused on hip fracture detection and discuss advantages and limitations of each major imaging modality. Discussion: Plain radiographs are usually sufficient for diagnosis as they are at least 90% sensitive for hip fracture. However, in the 3–4% of Emergency Department (ED) patients having hip X-ray studies who harbor an occult hip fracture, the Emergency Physician must choose among several methods, each with intrinsic limitations, for further evaluation. These methods include computed tomography, scintigraphy, and magnetic resonance imaging. Conclusion: We present an evidence-based algorithm for the evaluation of a patient suspected to have an occult hip fracture in the ED. Also outlined are future directions for research to distinguish more effective techniques for identifying occult hip fractures.     

Systematic Reviews Published in the April 2012 Issue of the Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly as a DVD but monthly online. The April 2012 issue (second DVD for 2012) contains 5045 complete reviews, 2182 protocols for reviews in production, and 17,084 short summaries of systematic reviews published in the general medical literature. In addition, there are citations of 674,000 randomized controlled trials, and 15,400 cited papers in the Cochrane methodology register. The health technology assessment database contains just over 11,000 citations. One hundred and seventeen new reviews have been published in the last 3 months of which 12 have potential relevance for practitioners in pain and palliative medicine. The impact factor of the Cochrane Library stands at 6.186. Readers are encouraged to access the full report for any articles of interest as only a brief commentary is provided.     

Platelets,thrombosis, coagulation,and atherosclerosis

When I first got the invitation to join a medical delegation going to Moldova, I thought for a moment that our destination was the fictional country in the old Marx Brothers movie Duck Soup. On further checking, it turns out that entertaining place was called Freedonia. I now know that Moldova is indeed a real country, bordered on the west by Romania and on the other three sides by the Ukraine. It is a proud country, rich with traditions, and its people are warm, giving, eager to learn ways to improve their healthcare system, and deeply appreciative of our attempts to help them in the task.