肝胆胰外科围手术期营养支持的规范应用

围手术期营养支持理念近年来逐渐被外科医师重视,临床营养治疗也趋于系统化和规范化。研究表明,合理规范的营养支持可以降低患者营养不良发生风险,从而降低围手术期并发症发生率,提高生活质量,改善临床结局。肝胆胰外科患者具有疾病复杂、手术风险高、难度大、发病率及死亡率高等特点,因此,其围手术期的营养评估和营养支持显得尤为重要。本文将肝胆胰外科围手术期营养支持的规范应用作一综述,以期为营养理念在该领域的推广以及临床实践的规范化提供参考。     

Effects of an Eating Ability Promotion Program for Community-Dwelling Older Adults

ObjectiveTaiwan is projected to become a super-aged society in 2026. Taiwan's government introduced an innovative preventive care policy to improve aging-related conditions in 2017. In this study, we examine the effectiveness of an eating ability promotion program (EAPP) on the physical and mental performance of community-dwelling older adults.DesignSingle-masked, cluster randomized trial.SettingTwo community care stations in Taichung, Taiwan.ParticipantsVolunteers were recruited from these 2 community care stations. The 70 participants were aged ≥60 years, able to walk independently and take care of themselves, and understood Mandarin or Taiwanese.InterventionThe volunteers were randomly assigned to an intervention; 40 participated in EAPP training courses (experimental group) and 30 participated in originally scheduled activities only (control group). EAPP training courses were conducted in the care stations 4 hours per week for 12 weeks (for a total of 48 hours).MeasuresThe physical performance outcomes were oral health, nutritional status, and fragility, assessed using the Oral Health Assessment Tool, the Mini Nutritional Assessment, and the Study of Osteoporotic Fractures fragility index, respectively. Cognitive function was evaluated with the Mini-Cog test. Measurements were performed at baseline, at the end of the 12-week intervention, and 1 month later.ResultsFollowing the EAPP intervention, controlling for baseline differences, the oral health (F = 33.29, P < .001), nutritional status (F = 7.30, P = .009), and scale of fragility (F = 19.05, P < .001) of the participants in the experimental group were significantly better than those reported in the control group.Conclusions and ImplicationsResults of this preliminary study suggest that the EAPP intervention may be an effective approach for improving oral health, nutritional status, and fragility in community-dwelling older adults. This training course, which provides clear and concise information regarding eating ability strategies, should undergo further evaluation and, if demonstrated to be effective and cost-effective in broader trials, may be useful in promoting healthy living.     

大数据时代的药品安全主动监测:对照选择的挑战与机遇

电子医疗数据已成为大数据时代开展药品安全主动监测的重要资源。基于此确认药品与不良事件是否存在关联，要回归传统的流行病学研究设计，选取恰当的对照进行对比。本文主要阐述不同对照选取的原理、适用情形，介绍、评价并比较各种对照选取的思路与参数，引入对照选择批量化实现的进展性成果，以期为我国利用电子医疗数据开展上市后药品安全性监测提供方法学参考。     

Views of healthcare professionals about the role of active monitoring in the management of ductal carcinoma in situ (DCIS): Qualitative interview study

BackgroundDuctal carcinoma in situ (DCIS) is an in-situ (pre-cancerous) breast malignancy whereby malignant cells are contained within the basement membrane of the breast ducts. Increasing awareness that some low-risk forms of DCIS might remain indolent for many years has led to concern about overtreatment, with at least 3 clinical trials underway internationally assessing the safety of active monitoring for low-risk DCIS. This study aimed to understand healthcare professionals’ (HCPs) views on the management options for patients with DCIS.MethodsQualitative study using semi-structured interviews with HCPs involved in the diagnosis and management of DCIS in Australia and New Zealand. Interviews were audio-recorded, transcribed and analysed thematically using Framework Analysis method.ResultsTwenty-six HCPs including 10 breast surgeons, 3 breast physicians, 6 radiation oncologists, and 7 breast care nurses participated. There was a strong overall consensus that DCIS requires active treatment. HCPs generally felt uncomfortable recommending active monitoring as a management option for low-risk DCIS as they viewed this as outside current standard care. Overall, HCPs felt that active monitoring was an unproven strategy in need of an evidence base; however, many acknowledged that active monitoring for low-risk DCIS could be appropriate for patients with significant co-morbidities or limited life expectancy. They believed that most patients would opt for surgery wherever possible.ConclusionsThis study highlights the important need for robust randomised controlled trial data about active monitoring for women with low-risk DCIS, to provide HCPs with confidence in their management recommendations and decision-making.     

Influence of an Audiovisual Resource on the Preoperative Anxiety of Adult Endodontic Patients: A Randomized Controlled Clinical Trial

IntroductionThe expectation of undergoing endodontic treatment can cause anxiety in patients. Anxiety is described as a transient emotional state closely related to pain, fear, and imbalance of the organism. The clinician commonly must use some type of tool to alleviate the patient’s preoperative anxiety before treatment can be applied. The aim of this study was to evaluate the influence of an audiovisual resource on the preoperative anxiety of adult patients undergoing endodontic treatment.MethodsOne hundred sixty endodontic patients were randomly divided into experimental and control groups (n = 80) and then assessed at 2 preoperative time points separated by a 10-minute interval. After the first assessment, the patients in the experimental group watched a video of their own choice obtained from the Internet to provide them with a relaxing experience. In both groups and at both time points, the assessments consisted of collecting the patients’ vital signs (diastolic blood pressure, systolic blood pressure, and heart rate) and data regarding their subjective perception of anxiety using a visual analog scale.ResultsThere were no significant differences between the groups regarding the vital sign variation observed between the 2 assessment time points. However, the variation in the scores obtained on the visual analog scale was significantly greater in the experimental group (P < .05), indicating a greater reduction in the level of preoperative anxiety in this group.ConclusionsThe preoperative use of an audiovisual resource was associated with a decrease in the perception of anxiety by patients undergoing endodontic treatment.     

早期皮肤接触对剖宫产产妇心理状态及母乳喂养的影响:前瞻性随机对照试验

目的探讨母婴早期皮肤接触(skin-to-skin contact,SSC)对剖宫产产妇心理状态及母乳喂养的影响。方法前瞻性选取2017年8月1日至12月31日在深圳市南山区妇幼保健院行择期足月剖宫产的产妇221例,随机分为早接触组和对照组。对照组产后常规护理;早接触组实施母婴早期SSC,即新生儿娩出后1 h内赤裸全身俯卧于母亲裸露的乳房之间,持续1~2 h。观察指标包括:(1)泌乳启动时间以及首次母乳喂养测量工具评分;(2)产后72 h和42 d的纯母乳喂养率、母乳喂养自我效能量表评分和爱丁堡产后抑郁量表评分。采用两独立样本t检验、χ2检验和二分类logistic回归进行统计学分析。结果最终210例产妇纳入分析,早接触组和对照组各105例。42 d随访时早接触组失访20例,对照组失访17例。与对照组比较,早接触组首次母乳喂养成功率[77.1%(81/105)与59.1%(62/105),χ2=7.913]、首次母乳喂养测量工具评分[(9.5±1.7)与(8.6±1.4)分,t=4.115]、泌乳启动时间≤24 h的比例[41.0%(43/105)与12.4%(13/105),χ2=23.205]、产后72 h和42 d的纯母乳喂养率[36.2%(38/105)与22.9%(24/105);76.5%(65/85)与60.2%(63/88);χ2值分别为4.486和5.261]以及产后72 h和42 d母乳喂养自我效能量表评分[(117.5±12.0)与(111.8±22.3)分;(124.3±11.6)与(113.1±19.0)分;t值分别为2.100和4.710]均提高,差异均有统计学意义(P值均<0.05)。但早接触组产后72 h和42 d的爱丁堡产后抑郁量表评分与对照组差异无统计学意义[(5.4±3.5)与(5.9±4.0)分,t=0.937,P=0.350;(7.0±3.7)与(8.1±4.0)分,t=0.905,P=0.058]。二分类logistic回归分析显示,早期SSC是产后42 d纯母乳喂养成功的保护因素(OR=2.359,95%CI:1.173~4.743,P=0.016)。结论早期SSC可以提高剖宫产产妇母乳喂养自信心,促进泌乳启动,提高首次母乳喂养的成功率和产褥期纯母乳喂养率,是一种值得推广的临床实践。     

Information communication technology-enabled instrumental activities of daily living: a paradigm shift in functional assessment

Abstract

Purpose: Information Communication Technology, such as smartphones, apps, the internet, etc., has become all-pervasive in our society. To learn the impact of Information Communication Technology (ICT) on everyday functioning, specifically Instrumental Activities of Daily Living (IADL), an exploratory review was undertaken.

Methods: We identified how many primary IADL domains were substantially influenced by ICT, by examining primary IADL domains, in terms of traditional and ICT-enabled ways of completing these common tasks. The study further explored the implications of the pervasiveness of ICT and the ICT-enabled new normal in everyday functioning that underpins the need to redefine IADLs.

Results: This examination revealed that the impact of ICT on IADLs has been so profound, that it marks a paradigm shift in the way we assess IADL completion. Creation of the concept of “Electronic Instrumental Activities of Daily Living (eIADLs)” would be a first step in marking this paradigm shift, and would foster further advances for understanding the mechanisms underlying the ICT-based life style related outcome measurement in rehabilitation science.

• IMPLICATIONS FOR REHABILITATION

• The presence of Information Communication Technology (ICT) has substantially influenced the way we complete our Instrumental Activities of Daily Living (IADL). Indeed, the impact is so profound, that it marks a paradigm shift in the way we should assess and measure everyday functioning.

• Creation of the concept of eIADLs would be a first step in marking this paradigm shift, and would foster further advances for understanding the mechanisms underlying the ICT-based life style related outcome measurement in the rehabilitation sciences.

     

Increased risk of hip fracture mortality associated with intraoperative hypotension in elderly hip fracture patients is related to under resuscitation

BackgroundAs the US and world population ages, hip fractures are increasingly more common. The mortality associated with these fractures remains high both in the immediate postoperative period and at one year. Perioperative resuscitation in this population is of key interest to prevent organ injury and mortality. Our objectives were to evaluate the effect of fluid resuscitation and hemodynamic status in the form of mean arterial pressure (MAP) on inpatient mortality of hip fracture patients.MethodsAn institutional database was queried to compare elderly hip fracture patients that sustained in-hospital mortality to a matched control cohort. Pre-, intra-, and post-operative intravenous fluid (IVF) administration and MAP were extracted from the electronic medical record. Time from hospital presentation to the OR was also recorded.Results1,114 total hip fractures were identified during the two-year study period, 16 of which suffered inpatient mortalities. The mortality cohort was then matched with a control of 394 hip fracture patients for the same period based on age, sex, and Charlson Comorbidity Index (CCI). Conditional logistical regression analysis found odds ratios (OR) indicating that longer time between presentation and surgery (OR per additional hour: 1.05; 95% CI: 1.01–1.08) and lower intraoperative minimum MAP (OR per 5 mmHg decrease: 0.77; 95% CI: 0.61–0.97) were associated with significantly increased odds of mortality. There was also a marginal relationship between greater intraoperative IVF administration and reduced odds of mortality (OR per 500 cc additional fluid: 0.61; 95% CI: 0.37–1.00).ConclusionExtended time from presentation to surgery and intraoperative hypotension were associated with increased likelihood of inpatient mortality in an elderly hip fracture cohort, with a possible additional effect of under-resuscitation. Further investigation into a safe intraoperative minimum MAP should be pursued.Level of evidenceLevel III.