医学整合和转化:心血管防治新概念

在过去几年中,医学的整合趋势和转化趋势已非常明显,关注于局部的研究想取得突破已越来越难。1整合1.1血管重建的内外科整合趋势国内胡大一教授几年前提出了心脏中心的模式,并在一些医院进行了初步的探索。而欧美近期发布了两个血管重建指南,为心血管中心的构建提供了理论     

New CDC program focuses on those already infected. Centers for Disease Control and Prevention

The Centers for Disease Control and Prevention (CDC) is instituting a program to provide comprehensive HIV prevention services to those already infected. The goal is to prevent HIV positive people from transmitting the infection to others. Up to five long term demonstration projects will be funded with $3.9 million to start, in order to develop and assess program models that later may be expanded and adapted across the country. The program goals are to increase the proportion of people who know their serostatus, provide primary prevention services, assist people in obtaining medical care and other services, and provide training and quality assurance to people at high risk.     

CDC: better needlestick reporting required. Centers for Disease Control and Prevention

A recent study of percutaneous injuries from phlebotomy devices showed that only about half of all injuries were reported through the hospital surveillance system. In light of the success of post-exposure prophylaxis in reducing occupational HIV transmission, the Centers for Disease Control and Prevention (CDC) has recommended that health care facilities work to improve reporting. The year-long CDC study of health-care professionals revealed that on average 54 percent of needlestick injuries were reported, though reporting rates varied by occupation. Janine Jagger, director of the International Health Care Worker Safety Research and Resource Center, says some workers fail to report injuries because they do not consider a needlestick a high-risk event. Others, she notes, are concerned about the potential problems associated with contracting a bloodborne pathogen. The CDC, which recently issued recommendations for post-exposure prophylaxis, hopes that reports confirming the benefit of treatment will improve the reporting of accidents. Setting up a 24-hour hotline for employees is one way to improve reporting by making it convenient and confidential.     

CDC: avoid preventive therapy for sexual risk. Centers for Disease Control and Prevention

At a recent meeting, AIDS experts questioned why postexposure prophylaxis that protects health care workers against blood exposure to HIV would not protect someone who has been exposed to HIV through sexual contact. There is no scientific evidence that antiretroviral drugs can prevent sexual transmission. The Centers for Disease Control and Prevention (CDC) points out that the dynamics of transmission via blood exposure versus sexual exposure differ in ways not fully known. The CDC acknowledges that the triple combination of drugs recommended for exposed health care workers has the potential to act as a morning-after pill, and have asked for additional funding to study the role of protease inhibitors in this type of prevention and intervention of HIV. Two groups that would directly benefit from the back-up protection are discordant couples and women who have been sexually assaulted and cannot determine the HIV status of their assailant.     

The Role of Transesophageal Echocardiography During Port-Access Minimally Invasive Cardiac Surgery: A New Challenge for the Echocardiographer

The recent development of endovascular catheters that are placed via the femoral artery and vein has enabled patients to be placed on cardiopulmonary bypass without the need for direct visualization of the heart or great vessels via sternotomy. This has allowed cardiac surgery to be performed through smaller, thoracotomy incisions. Placement of these catheters initially was performed under fluoroscopic guidance, which has major imaging limitations. Now, transesophageal echocardiography (TEE) has replaced fluoroscopy as the primary imaging technique to assist in the placement of endovascular catheters during minimally invasive, port-access cardiac surgery. In our institution, 449 port-access procedures have been performed from May 1996 through July 1998. We found that TEE is able to adequately visualize the cardiac structures and assist in the placement of the endovascular catheters in all patients. Fluoroscopy is helpful only as an aid to the use of TEE for placement of the coronary sinus catheter.     

Post-exposure prophylaxis revisited: new CDC guidelines. Centers for Disease Control and Prevention

The Centers for Disease Control and Prevention (CDC) convened a meeting in 1997 to revisit guidelines for post-exposure prophylaxis (PEP) for occupationally acquired HIV infection. Recent data show that the health care worker's infection risk is increased with deeper injury, bloodier needles, and source patients with more advanced disease suggesting higher viral load. A CDC study shows that AZT use of any kind was associated with an 81 percent reduction in the risk of seroconversion compared with controls not given AZT. AZT is the only drug for which proof exists of clinical benefits in the prophylaxis setting. However, attempts to assess AZT's efficacy in a randomized, prospective, placebo-controlled trial have failed, making the assessment of PEP's efficacy unlikely in the future. PEP initiation, according to the CDC, is guided by two principles: relative risks of exposure and the risks of the injury balanced with risks of the drug therapy. Future treatment guidelines are likely to pay more attention to the source patient, disease stage, and/or viral load as determinants of risk. Other nucleotides and protease inhibitors could arguably be included in PEP regimens, particularly for treatment of high-risk cases. Studies show no fetal harm from AZT; there is little information on fetal toxicity of other antiretrovirals. New guidelines are due to be published in the MMWR in early 1998.     

How HIV affects children. Centers for Disease Control and Prevention

The 1997 World AIDS Day drew attention to how the epidemic is affecting children worldwide. Last year, 400,000 children under 15 years of age became contaminated, and if the spread of HIV is not contained, infant mortality rates will climb to 75 percent by the year 2010. AIDS typically runs a faster course in children than in adults, particularly in developing countries. Directing prevention efforts toward children is crucial to contain the further spread of AIDS. Statistics are provided for infection rates worldwide.