Delirium: An Independent Predictor of Functional Decline After Cardiac Surgery

OBJECTIVES: To determine whether patients who developed delirium after cardiac surgery were at risk of functional decline. DESIGN: Prospective cohort study. SETTING: Two academic hospitals and a Veterans Affairs Medical Center. PARTICIPANTS: One hundred ninety patients aged 60 and older undergoing elective or urgent cardiac surgery. MEASUREMENTS: Delirium was assessed daily and was diagnosed according to the Confusion Assessment Method. Before surgery and 1 and 12 months postoperatively, patients were assessed for function using the instrumental activities of daily living (IADL) scale. Functional decline was defined as a decrease in ability to perform one IADL at follow‐up. RESULTS: Delirium occurred in 43.1% (n=82) of the patients (mean age 73.7±6.7). Functional decline occurred in 36.3% (n=65/179) at 1 month and in 14.6% (n=26/178) at 12 months. Delirium was associated with greater risk of functional decline at 1 month (relative risk (RR)=1.9, 95% confidence interval (CI)=1.3–2.8) and tended toward greater risk at 12 months (RR=1.9, 95% CI=0.9–3.8). After adjustment for age, cognition, comorbidity, and baseline function, delirium remained significantly associated with functional decline at 1 month (adjusted RR=1.8, 95% CI=1.2–2.6) but not at 12 months (adjusted RR=1.5, 95% CI=0.6–3.3). CONCLUSION: Delirium was independently associated with functional decline at 1 month and had a trend toward association at 12 months. These findings provide justification for intervention trials to evaluate whether delirium prevention or treatment strategies might improve postoperative functional recovery.     

Moderate Alcohol Intake and Risk of Functional Decline: The Health, Aging, and Body Composition Study

OBJECTIVES: To investigate the prospective relationship between alcohol consumption and incident mobility limitation. DESIGN: Cohort study. SETTING: The Health Aging and Body Composition study, conducted in Memphis, Tennessee, and Pittsburgh, Pennsylvania. PARTICIPANTS: Three thousand sixty‐one adults aged 70 to 79 without mobility disability at baseline. MEASUREMENTS: Incidence of mobility limitation, defined as self‐report at two consecutive semiannual interviews of any difficulty walking one‐quarter of a mile or climbing stairs, and incidence of mobility disability, defined as severe difficulty or inability to perform these tasks at two consecutive reports. Alcohol intake, lifestyle‐related variables, diseases, and health status indicators were assessed at baseline. RESULTS: During a follow‐up time of 6.5 years, participants consuming moderate levels of alcohol had the lowest incidence of mobility limitation (total: 6.4 per 100 person‐years (person‐years); men: 6.4 per 100 person‐years; women: 7.3 per 100 person‐years) and mobility disability (total: 2.7 per 100 person‐years; men: 2.5 per 100 person‐years; women: 2.9 per 100 person‐years). Adjusting for demographic characteristics, moderate alcohol intake was associated with lower risk of mobility limitation (hazard ratio (HR)=0.70, 95% confidence interval (CI)=0.55–0.89) and mobility disability (HR=0.66, 95% CI=0.45–0.95) than never or occasional consumption. Additional adjustment for lifestyle‐related variables substantially reduced the strength of the associations (HR=0.85, 95% CI=0.66–1.08 and HR=0.81, 95% CI=0.56–1.18, respectively). Adjustment for diseases and health status indicators did not affect the strength of the associations, suggesting that lifestyle is most important in confounding this relationship. CONCLUSION: Lifestyle‐related characteristics mainly accounted for the association between moderate alcohol intake and lower risk of functional decline over time. These findings do not support a direct causal effect of alcohol intake on physical function.     

术中超声心动图在心脏外科的应用价值

术中超声心动图包括经食道和心外膜超声心动图 ,在心脏外科体外循环前能完善诊断 ,有效降低围术期的并发症。本文概述该项技术在心脏外科手术中的应用价值。     

胸腔镜心脏外科手术现状及展望

胸腔镜应用于心脏外科已有十多年,相对于传统心脏外科手术具有减少外科创伤、减缓疼痛、失血少、恢复快、美容效果好等优点。国外胸腔镜心脏外科多以机器人辅助完成多种心脏手术,国内一般单用胸腔镜辅助完成房间隔缺损修补术、室间隔缺损修补术、二尖瓣置换术,以及心房颤动射频消融术,现将胸腔镜辅助心脏外科手术的现状及进展进行综述。     

Potentially Inappropriate Medications and Functional Decline in Elderly Hospitalized Patients

OBJECTIVES: To verify whether the use of potentially inappropriate medications (PIMs) is associated with loss of independence in elderly in-patients by promoting adverse drug reactions (ADRs).
DESIGN: Prospective observational study.
PARTICIPANTS: Five hundred six patients aged 65 and older admitted to 11 acute care medical wards.
MEASUREMENTS: In-hospital loss of one or more activities of daily living (ADLs) and three or more ADLs. PIMs were identified according to diagnosis-independent Beers criteria and ascertained by study physicians based on daily review of medical and nurse records. The relationship between risk factors and outcomes was assessed using logistic regression.
RESULTS: Overall, 104 patients (20.6%) were taking at least one PIM at the time of admission (baseline users), and 49 (9.7%) were newly prescribed at least one PIM during their hospital stay. The loss of one or more ADLs occurred in 9.6% of baseline users, 16.3% of new users, and 8.5% of nonusers ( P =.21) and that of three or more ADLs in 7.7% of baseline users, 12.2% of new users, and 4.8% of nonusers ( P =.10). The lack of association was confirmed after correction for potential confounders, including ADRs. The occurrence of ADRs was strongly associated with both outcomes (odds ratio (OR)=7.80, 95% confidence interval (CI)=3.53–17.3 for the loss of ≥1 ADLs; OR=3.98, 95% CI=1.50–10.5 for the loss of ≥3 ADLs), but PIMs caused only six of 106 ADRs.
CONCLUSIONS: ADRs to any drugs more than the use of PIMs might be associated with functional decline in elderly hospitalized patients, but because the power of this study was too limited to definitively exclude a direct relationship between PIMs and functional decline, this merits further investigation.     

Intraoperative Echocardiography and Minimally Invasive Cardiac Surgery

The term minimally invasive cardiac surgery encompasses a number of different techniques, each with its own rationale, origin, and development, but all focusing on limiting the physiologic trespass of cardiac surgery on the patient. In this article, we discuss the application of intraoperative echocardiography to three types of these procedures: Offpump coronary artery bypass graft (OPCABG) surgery, valvular surgery through limited thoracic incisions, and port-access heart surgery.     

Two-dimensional, Non-Doppler Strain Imaging during Anesthesia and Cardiac Surgery

Transesophageal echochardiography (TEE) has become an essential intraoperative monitor during general anesthesia for cardiac surgical procedures. In clinical practice, ventricular function is visually evaluated using gray scale and Doppler modes, despite the fact that subjective interpretation is influenced by level of experience and training. Echocardiographic strain imaging measures cardiac deformation and provides objective quantification of regional myocardial function. Non-Doppler strain, which is derived by tracking speckles from two-dimensional (2D) images, bypasses the limitations of Doppler-based strain measurements and evaluates the complex myocardial deformation along three dimensions. As a result, longitudinal shortening, circumferential thinning and radial thickening can be quantified using standard midesophageal and transgastric views, being acquired during a comprehensive TEE examination. Once non-Doppler strain becomes available on "real time," it will have the potential to become a valuable tool for detection of ischemia on the regional level and objective quantification of global ventricular function.     

The Vulnerable Elders-13 Survey Predicts 5-Year Functional Decline and Mortality Outcomes in Older Ambulatory Care Patients

OBJECTIVES: To test the predictive properties of the Vulnerable Elders-13 Survey (VES-13) a short tool that predicts functional decline and mortality over a 1- to 2-year follow-up interval over a 5-year interval.
DESIGN: Longitudinal evaluation with mean follow-up of 4.5 years.
SETTING: Two managed-care organizations.
PARTICIPANTS: Six hundred forty-nine community-dwelling older adults (≥75) enrolled in the Assessing Care of Vulnerable Elders observational study who screened positive for symptoms of falls or fear of falling, bothersome urinary incontinence, or memory problems.
MEASUREMENTS: VES-13 score (range 1–10, higher score indicates worse prognosis), functional decline (decline in count of 5 activities of daily living or nursing home entry), and deaths.
RESULTS: Higher VES-13 scores were associated with greater predicted probability of death and decline in older patients over a mean observation period of 4.5 years. For each additional VES-13 point, the odds of the combined outcome of functional decline or death was 1.37 (95% confidence interval (CI)=1.25–1.50), and the area under the receiver operating curve was 0.75 (95% CI=0.71–0.80). In the Cox proportional hazards model predicting time to death, the hazard ratio was 1.23 (95% CI=1.19–1.27) per additional VES-13 point.
CONCLUSION: This study extends the utility of the VES-13 to clinical decisions that require longer-term prognostic estimates of functional status and survival.     

Obesity, Age, and Cardiac Risk

Obesity is a highly prevalent metabolic disorder affecting all sections of society from young children to adults and the elderly. Obesity is a well-established risk factor for several conventional cardiovascular (CV) risk factors such as hypertension (HTN), type 2 diabetes mellitus, and dyslipidemia. Obesity is also a very potent independent risk factor for CV diseases (CVD), including coronary heart disease (CHD), heart failure (HF), peripheral arterial disease (PAD), atrial fibrillation (AF), and sudden cardiac death (SCD), and is also associated with increased CV and all-cause morbidity. Despite this adverse association between obesity and CV risk factors and several CVDs, numerous studies have identified the phenomenon called the “obesity paradox” or “reverse epidemiology”, meaning better short- and long-term survival in overweight and obese subjects with HTN, HF, CHD, PAD, and AF. This review summarizes the adverse impact of obesity on CV risk factors and CVDs, effects of obesity and aging in the elderly, and the puzzling phenomenon of the “obesity paradox” in the above-mentioned special populations and the elderly.     

33例心内直视手术不用库血的体会

目的：采用综合方法进行血液保护，以期在心内直视手术中不用库血，从而避免感染输血性疾病。方法：综合方法包括①适宜的麻醉深度，避免术中血压过高；②术前经桡动脉或腔静脉放出自体血贮存，放血量为１０～１５ｍｌ／ｋｇ；③术中应用抑肽酶或止血芳酸。抑肽酶总量成人为４００万ｋＩＵ，儿童为２００万ｋＩＵ。止血芳酸用量为４０ｍｇ／ｋｇ；④转流后机器血全部回输，每输１００ｍｌ机器血补给鱼精蛋白５～１０ｍｇ，同时加强利尿，浓缩血液；⑤术中认真止血，术野局部用三磷酸腺苷浸泡。结果：３３例患者，当术后血红蛋白超过９０ｇ／Ｌ，血细胞比容大于０．３０时，围术期可不用库血。术后２４小时引流总量为３２～４１０ｍｌ，平均２０６ｍｌ。出院时血红蛋白均超过１１０ｇ／Ｌ，而血细胞比容大于０．４０。结论：行心脏直视手术患者，术中用综合方法行血液保护，围术期可不输库血     

心脏手术患者围麻醉期液体治疗的研究进展

良好的液体治疗不仅可以维持术中血流动力学稳定和良好的组织器官灌注,还有助于改善患者的预后。但由于心脏手术患者术前的病理生理状态,研究者担忧容量过负荷带来的负面效应会加重心功能的进一步损害,从而对患者预后产生不利影响。现就心脏手术患者围麻醉期液体治疗的争议以及监测方法的进展作一综述。     

机器人辅助内镜下心脏手术应用进展

近十年来,心脏微创外科手术得到了长足发展,其中最引人注目的是机器人系统在心脏手术中的应用。借助机器人系统,心脏外科医生可以更好地通过胸部小切口完成各种心脏手术。而随着配套手术器械的改进,三维视觉系统的建立以及反馈系统的使用,国外已有多位医生在机器人辅助下完全完成了内镜下的心脏手术。     

心脏术后心房颤动的发生机制、危险因素及预防策略

心房颤动是心脏术后最常见的并发症之一。随着近年来心脏外科手术患者的高龄化及危险因素的增高,术后心房颤动的发生率在上升,据报道心房颤动发生率在冠状动脉旁路移植术后可高达30%,冠状动脉旁路移植联合瓣膜术为60%。心房颤动的发生通常会延长住院时间,并有发生栓塞的危险。因此有必要对这一围手术期的并发症给予更多的关注,了解其发生机制、危险因素及预防措施,以减少此并发症的发生。     

Del Nido心脏停搏液在成人心脏外科中的应用效果分析

目的：评价Del Nido心脏停搏液在成人心脏外科手术中的安全性及有效性,为成人心脏手术选择合适心肌保护液提供参考。方法：回顾性分析2018年1月至2019年1月我科95例应用Del Nido心脏停搏液的临床资料。结果：本研究中男47例（49.5%）,年龄55.0±17.6岁,病因以心脏瓣膜病（64例,67.4%）为主,术前合并房颤26例（27.4%）。体外循环时间138.6±65.4 min,主动脉阻断时间75.8±32.0 min,灌注次数1.14±0.43次,顺灌94例（98.9%）,自动复跳86例（90.5%）。转流最低肛温33.3±2.7℃,转流结束时乳酸值1.7（1.4-2.3）mmol/L。术后第2天 cTnI浓度3.3（1.8-5.7）ng/ml。呼吸机辅助时间24（18-67）h,ICU停留时间4（3-7）天,术后住院13（9-16）天。术后无脑卒中和新发心肌梗死,新发房颤26例（37.7%）,胸腔积液14例（14.7%）,二次开胸2例（2.1%）,急性肾衰2例（2.1%）,感染3例（3.2%）。出院前最后一次LVEF较术前稍降低（59.6±9.0% vs. 62.4±8.7%,P＜0.01）,围手术期死亡2例,与心脏停搏液无关。结论：Del Nido心脏停搏液灌注次数少,未发现其对心肌的额外损伤,适合多种疾病的心肌保护。近期安全性、有效性良好,提高了手术操作的简便性。     

White Matter Hyperintensities Predict Functional Decline in Voiding,Mobility, and Cognition in Older Adults

OBJECTIVES: To compare magnetic resonance imaging data with functional assessments of mobility, urinary control, and cognition to determine common or distinctive features in the distribution of brain white matter hyperintensities (WMHs) associated with functional decline and impairment. DESIGN: Baseline data from subjects aged 75 to 89 enrolled in a longitudinal study. Assessors and subjects were blinded to group assignment. SETTING: Healthy community‐dwelling volunteers. PARTICIPANTS: Ninety‐nine subjects were enrolled using a balanced 3 × 3 matrix stratified according to age and mobility performance. Exclusion criteria were medication, systemic conditions, and neurological diseases that can compromise mobility. MEASUREMENTS: WMHs were identified using a semi‐automated segmentation method, and regional burdens were assessed using a white matter parcellation atlas. Quantitative measures of mobility, urinary incontinence (UI) severity, and executive function and processing speed were obtained. RESULTS: WMHs occur predictably in predominantly periventricular areas. There were powerful correlations between total (tWMH) and regional (rWMH) WMH, with correlation coefficients of 0.5 to 0.9 for eight of 10 structures analyzed. tWMH predicted functional measures of UI, mobility, executive function, and processing speed nearly as well as the best regional measures. The total volume of WMHs independently explains 5% to 11% of the variability for mobility, UI severity, executive function, and processing speed and is a sensitive (0.7–0.8) predictor of functional decline. The odds of decline in each of the three functional domains was 1.5 to 2.4 times greater with each 1% increase in tWMH. CONCLUSION: This work establishes the importance of brain WMH burden in three major geriatric syndromes. The findings support the inclusion of total WMH burden as a risk factor in the predictive and diagnostic criteria.     

心脏介入术并发急性心包填塞的临床分析

【】 目的 总结心脏介入术中并发急性心包填塞的防治体会。方法 回顾性分析6例心脏介入术中发生急性心包填塞患者的发病特点、发生原因及处理措施。结果 二尖瓣球囊扩张术(PBMV)中1例为房间隔穿刺位置过高致右心房穿孔而发生急性心包填塞,经紧急心外科手术救治成功,1例为送入穿刺鞘致心房穿孔所致,超声引导下心包穿刺置管引流48h后痊愈;冠状动脉介入治疗术(PCI)中1例为反复推送导丝穿破高度狭窄钙化的左前降支所致, 经紧急心外科手术救治成功,1例为急性前壁心肌梗死PCI时发生,经对症治疗及置管引流48小时后痊愈;射频消融术(RFCA)中1例为放置左上肺静脉电极导管时不慎将左心耳穿破所致,行猪尾导管引流、输血、升压等措施后心包填塞症状缓解;心脏永久性起搏器植入术中1例为电极损伤冠状静脉所致,行超声下猪尾导管心包穿刺引流及输血等治疗后,病情稳定。结论：急性心包填塞是心脏介入术的严重并发症,积极预防、及时发现、果断处理是防治的关键措施。