感染性心内膜炎临床分型对围术期护理的指导

目的:探讨感染性心内膜炎临床分型对围手术期护理的指导,提出有针对性的护理,提高患者生存率。方法:对115例外科手术治疗的感染性心内膜炎患者进行回顾性分析。根据手术前感染情况,分为感染活动型、感染静止型和感染隐匿型。比较三组患者间围手术期临床特征和预后情况,找出有针对性护理,正确使用抗菌素,维持有效血药浓度;正确评价心脏功能,有效使用维持心功能药物;加强基础护理,减少院内感染的发生,提高患者存活率。结果:感染活动型患者血白蛋白、血白细胞和血沉等血液指标异常率、血液细菌培养阳性率、接受急诊手术治疗的比例,以及术后并发症发生率均显著高于感染静止型和感染隐匿型患者。通过对感染活动型患者围术期护理加强,能提高患者的存活率,因此三组患者手术死亡率无显著性差异。结论:不同临床分型的感染性心内膜炎患者经早期诊断、正确选择手术时机和手术方法以及良好的围手术期护理,均能获得较满意的手术疗效。     

感染性心内膜炎多瓣膜置换1例围术期观察

感染性心内膜炎可造成心脏瓣膜严重损害,导致心脏、肺脏功能及其他重要脏器功能障碍.瓣膜置换围术期并发症多、病死率高,术后观察十分重要.本文回顾性分析1例感染性心内膜炎多瓣膜置换手术患者围术期的临床资料,报道如下.     

重症感染性心内膜炎33例围手术期的监护

目的：总结重症感染性心内膜炎患者围术期监护经验。方法：对33例复杂性心内膜炎行赘生物彻底清除心脏瓣膜置换术的患者加强围术期监护,做好患者心理及高热的护理,预防赘生物脱落;防治心律失常及低心排综合征,严防感染复发;认真做好健康指导是关键。结果：本组早期无死亡,无感染复发,瓣膜置换者无瓣周漏。结论：重症感染性心内膜炎加强围手术期监护,预防术后并发症,可提高手术成功率及患者的生活质量。     

血培养阴性的感染性心内膜炎97例外科治疗经验

目的 探讨血培养阴性的感染性心内膜炎的外科治疗方法.方法 对2000年10月至2010年10月经手术治疗的97例血培养阴性感染性心内膜炎患者的临床资料进行回顾性分析,以明确血培养阴性的感染性心内膜炎的治疗特点及手术时机与手术疗效.结果 本组患者均手术治疗,6例死亡,91例术后心功能明显改善,痊愈出院.随访81例,复发2例,79例心功能(NYHA)恢复至Ⅰ或Ⅱ级.结论 血培养阴性的感染性心内膜炎患者做到早期诊断,掌握适当的手术时机和手术原则,合理用药同时加强围手术期管理可取得较好的治疗效果.     

亚急性感染性心内膜炎36例临床分析

目的 探讨亚急性感染性心内膜炎的基础病因、临床特征、治疗方法及预后,以提高对该病的诊治水平.方法 对36例亚急性感染性心内膜炎患者的基础心脏疾病、临床特点、致病菌、超声心动图、治疗方法、预后等进行回顾性分析.结果 本资料亚急性感染性心内膜炎的基础病因构成发生改变,风湿性心脏病所占比例下降,先天性心脏病及无基础心脏病所占比例升高;临床特征仍以发热、心力衰竭、中性粒细胞增加、红细胞沉降率增加、贫血常见;血培养阳性率58.33%,致病菌以草绿色链球菌多见.63.89%患者经胸超声心动图发现心脏有赘生物形成;本资料亚急性感染性心内膜炎的近期病死率是19.44%.结论 亚急性感染性心内膜炎的基础病因构成、临床特征、致病菌和以往比较发生改变,虽经积极治疗,病死率仍很高,对有手术适应证的患者应尽早手术治疗.     

感染性心内膜炎患儿围手术期的护理

目的探讨感染性心内膜炎患儿围手术期的护理措施。方法回顾性分析28例感染性心内膜炎患儿的术前资料、手术方式和预后，总结护理体会和经验。结果27例患儿痊愈出院，1例因术后霉菌性感染不能控制、多器官功能衰竭死亡。结论个性化的心理护理、准确采集微生物标本、积极控制感染、严密观察生命体征是感染性心内膜炎手术患儿围术期护理的重点。     

手术治疗感染性心内膜炎70例临床分析

目的:讨论感染性心内膜炎患者临床特征、手术指征和超声心动图特点。方法:对70例手术治疗的感染性心内膜炎患者临床资料进行回顾性分析。结果:术后早期死亡7例(10%),死于脑血管意外3例,死于多脏器功能衰竭3例,死于肾功能衰竭1例。结论:感染性心内膜炎最常见的手术指征是重度反流性心力衰竭。左心室收缩功能下降(左心室射血分数<50%)预示着较高的围术期病死率。     

孤立性主动脉瓣感染性心内膜炎的治疗

目的：根据孤立性主动脉瓣感染性心内膜炎的特点,确定及早换瓣手术在其治疗中的重要地位。方法：将３３例未及时行主动脉瓣换瓣术的孤立性主动脉瓣感染性心内膜炎患者作为对照组,１１例急诊手术者为治疗组,比较其疗效及预后。结果：急诊行主动脉瓣换瓣术者成功率（８１．８％）,随访６个月～５年,均尚存活,且无一例再发感染,存活率明显高于未及时换瓣者（病情好转６例出院后随访２年内均死亡）。结论：孤立性主动脉瓣感染性心内膜炎急诊手术是挽救患者生命的唯一途径。准确地掌握手术适应证,合理应用抗生素,及时纠正心力衰竭是保证手术成功、获得良好预后的关键。     

感染性心内膜炎合并急性脑梗死并多发脑出血1例报告

目的探讨感染性心内膜炎合并急性脑梗死并多发脑出血的临床表现,为临床早期诊断提供有效思路。方法回顾性分析1例急性脑梗死并多发脑出血并发热患者的临床资料、诊治过程及预后。结果入院第7天,患者血培养结果为星座链球菌感染。通过临床综合分析及心脏彩超确诊为感染性心内膜炎,经及时对症处理后住院34d好转出院。结论对感染性心内膜炎的诊断,既要注意典型症状和非典型症状,同时要认识并发脑栓塞等严重并发症的特点。     

感染性心内膜炎三尖瓣置换术的围手术期护理

目的:总结17例感染性心内膜炎三尖瓣置换围手术期护理经验。方法:回顾性分析我院2010年1月~2014年1月因感染性心内膜炎行三尖瓣置换17例患者的围手术期护理措施,术前给予心理干预及改善一般情况,术后给予抗感染、纠正心功能不全及抗凝治疗。结果:本组15例患者顺利出院,术后早期死亡2例,其中1例术后6 h因低心排血量综合征死亡,1例术后第4天因恶性心律失常死亡。结论:感染性心内膜炎三尖瓣置换术患者围手术期及时有针对性的护理可以提高手术成功率,减少并发症。     

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.     

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.     

俯卧位通气对高海拔地区肺复张治疗无效急性呼吸窘迫综合征患者氧合的影响

目的 探讨俯卧位通气对高海拔地区肺复张术(RM)治疗无效急性呼吸窘迫综合征(ARDS)患者的治疗作用.方法 从海拔2260m的地区医院筛选RM治疗无效的41例ARDS患者[平均氧合指数( PaO2/FiO2)较RM前升高＜20％视为RM无效],依不同病因分为肺内源性ARDS组(ARDSp组)和肺外源性ARDS组(ARDSexp组),每组再按信封法随机分为俯卧位组和仰卧位组,即ARDSp俯卧位组(11例)、ARDSp仰卧位组(9例)、ARDSexp俯卧位组(10例)、ARDSexp仰卧位组(11例).在通气前及通气1、2、3、4h监测动脉血氧分压( PaO2)、PaO2/FiO2、静态顺应性(Cst)、气道阻力(Raw)的变化.结果 通气lh时,ARDSexp俯卧位组PaO2/FiO2( mm Hg,l mm Hg=0.133 kPa)即较通气前显著升高(157.4±40.6比129.3±48.7,P＜0.05),并随通气时间延长呈持续增高趋势,4h达峰值(219.1 ±41.1);且ARDSexp俯卧位组通气3h内PaO2/FiO2较其他3组显著增高,另3组间则差异无统计学意义.ARDSp俯卧位组、ARDSexp俯卧位组通气4h时PaO2/FiO2均较相应仰卧位组显著增高(208.8±39.7比127.4±47.1,219.1±41.1比124.9±50.8,均P＜0.05).4组通气前后Cst无显著改变,各组间差异也无统计学意义.ARDSp俯卧位组通气4h时Raw(cmH2O·L-1·s-1)较通气前显著降低(6.8±1.7比10.7±1.8,P＜0.05),且明显低于其他3组;其他3组各时间点Raw组内及组间比较差异均无统计学意义.结论 俯卧位通气作为ARDS机械通气重要策略之一,可以改善RM无效高原ARDS患者的氧合,为抢救患者赢得宝贵的时间.     

Digital imaging among medical facilities

The Department of Veterans Affairs (VA) in the USA operates a network of 172 medical centres which all utilize a hospital information system (HIS) which has been developed and is currently maintained by the VA. During the past several years, an image management and communication module has been developed, installed and clinically utilized at the Washington DC and Maryland VA Medical Centres. This image management and communication system, referred to as the decentralized hospital computer program (DHCP) imaging system, is fully integrated with a commercial picture archiving and communication system (PACS). The system is utilized to capture, archive, and display all images generated within the hospital including radiology, nuclear medicine, pathology, endoscopy, bronchoscopy, and dermatology, intraoperative photographs, ECG data, and a limited number of paper documents. The ultimate goal of the project is to have all patient text and image data available at any clinical workstation to any authorized user anywhere within the network of medical centres. Clinical requirements for an imaging workstation include ease of use, rapid and reliable access to the complete set of patient information, and images which are of acceptable quality to meet the requirements of the user and the subspecialty. Patient confidentiality and data security must be safeguarded at all times. Integration of the images with the remainder of the patient's database was found to be critical to the success of the project. The experience at the Washington and Maryland facilities suggests that an imaging system that is successfully integrated with a hospital information system can provide substantial clinical and economic benefits both within and among medical centres. Clinical acceptance and utilization of the system has been excellent, particularly in diagnostic radiology where DHCP Imaging has been interfaced to a commercial PAC system. Based upon this initial experience, the VA has begun to deploy the system throughout its large network of medical centres.     

Myocardial elastography at both high temporal and spatial resolution for the detection of infarcts

Myocardial elastography is a novel method for noninvasively assessing regional myocardial function, with the advantages of high spatial and temporal resolution and high signal-to-noise ratio (SNR). In this paper, in-vivo experiments were performed in anesthetized normal and infarcted mice (one day after left anterior descending coronary artery [LAD] ligation) using a high-resolution (30 MHz) ultrasound system (Vevo 770, VisualSonics Inc., Toronto, ON, Canada). Radiofrequency (RF) signals of the left ventricle (LV) in longitudinal (long-axis) view and the associated electrocardiogram (ECG) were simultaneously acquired. Using a retrospective ECG gating technique, 2-D full field-of-view RF frames were acquired at an extremely high frame rate (8 kHz) that resulted in high-quality incremental displacement and strain estimation of the myocardium. The incremental results were further accumulated to obtain the cumulative displacements and strains. Two-dimensional and M-mode displacement images and strain images (elastograms), as well as displacement and strain profiles as a function of time, were compared between normal and infarcted mice. Incremental results clearly depicted cardiac events including LV contraction, LV relaxation and isovolumetric phases in both normal and infarcted mice, and also evidently indicated reduced motion and deformation in the infarcted myocardium. The elastograms indicated that the infarcted regions underwent thinning during systole rather than thickening, as in the normal case. The cumulative elastograms were found to have higher elastographic SNR (SNR(e)) than the incremental elastograms (e.g., 10.6 vs. 4.7 in a normal myocardium, and 6.0 vs. 2.4 in an infarcted myocardium). Finally, preliminary statistical results from nine normal (m = 9) and seven infarcted (n = 7) mice indicated the capability of the cumulative strain in differentiating infracted from normal myocardia. In conclusion, myocardial elastography could provide regional strain information at simultaneously high temporal (>/=0.125 ms) and spatial ( approximately 55 microm) resolution as well as high precision ( approximately 0.05 microm displacement). This technique was thus capable of accurately characterizing normal myocardial function throughout an entire cardiac cycle, at the same high resolution, and detecting and localizing myocardial infarction in vivo.     

Clinical Pharmacokinetics of Morphine

Morphine, the most widely used mu-opioid analgesic for acute and chronic pain, is the standard against which new analgesics are measured. A thorough understanding of the pharmacokinetics of morphine is required in order to safely and effectively use this analgesic in a wide variety of patients with different levels of organ function. A MEDLINE search was conducted to identify literature published between 1966 and January 2002 relevant to the pharmacokinetics of morphine. These publications were reviewed and the literature summarized regarding unique and clinically important elements of morphine disposition relative to its parenteral administration (including intravenous, intramuscular, subcutaneous, epidural and intrathecal administration), absorption profile (immediate release, controlled release, and sublingual/buccal, and rectal administration), distribution, and its metabolism/ excretion. Special populations, including infants, elderly, and those with renal/liver failure, have a unique morphine pharmacokinetic profile that must be taken into account in order to maximize analgesic efficacy and reduce the risk of adverse events.