Poster 2: When are deconditioned patients ready for acute rehabilitation?

Objectives: To assess ability of a medical acuity screening protocol to classify accurately deconditioned patients at risk for medical disruptions of acute rehabilitation. Design: Prospective comparison of 2 equivalent samples of consecutive admissions, 2 months apart, each divided into medically stable and unstable groups before admission. Setting: Acute rehabilitation unit, community hospital. Participants: 30 consecutive adult admissions to acute rehabilitation for deconditioning between September 25, 2000, and November 29, 2000; and 31 between February 1, 2001, and April 30, 2001. Interventions: Deconditioned rehabilitation candidates were screened for medical instability (protocol available), grouped as medically stable or unstable, reviewed with a physiatrist, and tracked prospectively. First sample findings were discussed with admitting physiatrists in multidisciplinary teams before the second sample. Main Outcome Measures: Planned completion of acute rehabilitation versus unplanned discharge due to acute medical setback, and length of rehabilitation stay. Results: Admission medical stability was associated with subsequent acute medical setbacks (Fisher exact test, P=.004). Medically unstable admissions had 6:1 odds of a medical disruption. Predictive success was associated with days from acute hospital to rehabilitation admission (Fisher exact test p=0.01). All predictive errors occurred with patients admitted to rehabilitation in less than 18 days from hospital admission. Medical disruptions of acute rehabilitation declined from the first (38.7%) to the second sample (16.7%). Conclusions: Data-driven team consensus about preadmission medical acuity screening preceded a decline in medical disruptions of acute rehabilitation among deconditioned patients.     

Article 13: Acupuncture in stroke rehabilitation: what does recent evidence really say?

Objective: To reexamine recent stroke-acupuncture studies using “relative improvement” on outcome measures, as opposed to simple endpoint raw score, as the primary clinical outcome. Data Sources: Using the recent Sze meta-analysis published in Stroke (2002) as an organizing schema, clinical trials involving stroke patients by Gosman-Hedstrom (1998), Johansson (1993, 2001), Sallstrom (1996), Sze (2002), and Wong (1999) were reexamined. Study selection: Studies were evaluated using the criterion of “relative improvement” as the primary outcome measure. The studies focused on the use of acupuncture compared with various control conditions across studies, including sham acupuncture, shallow acupuncture, transcutaneous electroneural stimulation, and subliminal electric stimulation. Data Extraction: Relative improvement on standardized measures used in the studies reviewed, focusing on disability (eg, FIM™ instrument) and impairment (eg, Fugl-Meyer Assessment). Data Synthesis: Evidence that acupuncture is effective in stroke rehabilitation is stronger when using relative improvement as a criterion than when using endpoint raw scores only—the procedure used by most recent researchers. Conclusions: Acupuncture may be helpful as an adjunct rehabilitation treatment. A number of methodologic issues need to be addressed in future research, including the most appropriate definition of a stroke clinical outcome, and the timeframe within which acupuncture effects are observed.     

Poster 21: Does severe left ventricular dysfunction impact the result of cardiac rehabilitation?

Objective: To evaluate the effect of severe left ventricular dysfunction on the improvement of functional capacity (FC) in cardiac patients undergoing phase 2 of a cardiac rehabilitation program (CRP). Design: Retrospective cohort study. Setting: Hospital-based CRP. Participants: 199 male cardiac patients. Group 1 (n=169) had a left ventricular ejection fraction (LVEF) >30% (age, 66.2±9.8y); group 2 (n=30) had a LVEF ≤30% (age, 69.0±8.1y). Intervention: 10 weeks, thrice weekly, of phase 2 CRP, consisting of 60 minutes of supervised exercise to reach the target heart rate determined by the Karvonen method. Main Outcome Measures: We measured FC before and after completion of the CRP and the improvement expressed in percents of FC before the CRP. The FC results were compared using the Student t test. Results: FC in both patient groups improved after the CRP. In group 1 patients, FC increased from 5.6±2.3 metabolic equivalents (METS) before the CRP to 7.5±2.6 METS after the CRP (P<.01). In group 2 patients, FC increased from 4.7±2.1 METS before the CRP to 6.2±2.2 METS after the CRP (P<.01). Before the CRP, group 2 patients had significantly lower FC compared with group 1 patients (P<.05). Similarly, after the CRP, the FC of group 2 patients remained lower than FC of group 1 patients (P<.05). However, the percentage of improvement for group 1 patients (40.6%±34.3%) did not differ significantly from the percentage of improvement for group 2 patients (39.9%±34.5%). Conclusions: The CRP improved FC of all cardiac patients, including those with severe left ventricular dysfunction. Patients with severe left ventricular dysfunction have lower FC before and after the CRP. However, the FC of these patients improved to the same degree as the patients with better left ventricular function. These findings are important in designing strategies for the CRP in patients with severely impaired LVEF.     

Poster 17: Is length of stay associated with spinal cord injury functional outcome at discharge from acute rehabilitation?

Objective: To determine whether rehabilitation length of stay (LOS) is associated with discharge motor function for persons with spinal cord injury (SCI). Design: Longitudinal. Setting: Spinal Cord Injury Model Systems center. Participants: 920 persons with traumatic, complete SCI enrolled in the Spinal Cord Injury National Database, with levels of injury (LOI) at C5, C6, C7, and T1-5; and inpatient rehabilitation discharge dates between 1989 and 1992 (“early”) and 1999 and 2002 (“late”). Interventions: Not applicable. Main Outcome Measures: FIM™ instrument at rehabilitation discharge. Results: For all LOI groups, the late group had a LOS shorter than the early group, with the largest difference in the C7 group: 107 days (early) versus 59 days (late). FIM motor scores at rehabilitation discharge also differed significantly for the C5, C7, and T1-5 LOI groups. For each of these LOIs, the late group was discharged with lower FIM motor scores; the largest difference was again noted for the C7 group, which had FIM motor scores of 51.9 (early) versus 40.7 (late). Conclusions: Decreased inpatient rehabilitation LOS was associated with decreased function at rehabilitation discharge. Persons with C7-level SCI were the most affected group; this group had the largest decrease in LOS and motor FIM score.     

How safe are HEMS-programmes in Germany? : A retrospective analysis

INTRODUCTION: Recent accidents with helicopter emergency medical service (HEMS) aircraft raise the question how safe HEMS in Germany is and how accidents could be prevented. MATERIALS AND METHODS: We surveyed all German HEMS-programmes and reviewed the data of the German Aviation Authority regarding accidents with HEMS. RESULTS: An average German HEMS-programme encounters one accident leading to at least severe damage or loss of the helicopter in 26 operating years, one accident resulting in casualties in 65 operating years and one fatal accident in 111 operating years. The major causes of accidents were obstacle strikes during landing at the scene. Flying in bad weather conditions and lack of discipline were other factors contributing to HEMS-accidents. CONCLUSION: HEMS-safety could be improved by special training programmes for pilots and HEMS-crewmembers to address the factors listed above. Safety training for doctors is recommended but we did not find support for the notion of changing the doctor's legal position of a passenger to a HEMS-crewmember.     

Do trauma teams make a difference? : A single centre registry study

OBJECTIVE: To evaluate the association between trauma team activation according to well-established protocols and patient survival. METHODS: Single centre, registry study of data collected prospectively from trauma patients (who were treated in a trauma resuscitation room, who died or who were admitted to ICU) of a tertiary referral trauma centre Emergency Department (ED) in Hong Kong. A 10-point protocol was used to activate rapid trauma team response to the ED. The main outcome measures were mortality, need for ICU care, or operation within 6h of injury. RESULTS: Between 1 January 2001 and 31 December 2005, 2539 consecutive trauma patients were included in our trauma registry, of which 674 patients (mean age 43 years, S.D. 22; 71% male; 94% blunt trauma) met trauma call criteria. Four hundred and eighty two (72%) correctly triggered a trauma call, and 192 (28%) were not called ('undercall'). Patients were less likely to have a trauma call despite meeting criteria if they were aged over 64 years, had sustained a fall, had a respiratory rate <10 or >29 per minute, a systolic blood pressure between 60 and 89 mm Hg, or a GCS of 9-13. In a sub-group of moderately poor probability of survival (probability of survival, P(s), 0.5-0.75), the odds ratio for mortality in the undercall group compared with the trauma call group was 7.6 (95% CI, 1.1-33.0). CONCLUSIONS: In our institution, undercalls account for 28% of patients who meet trauma call criteria and in patients with moderately poor probability of survival undercall is associated with decreased survival. Although trauma team activation does not guarantee better survival, better compliance with trauma team activation protocols optimises processes of care and may translate into improved survival.     

Post resuscitation care : What are the therapeutic alternatives and what do we know?

A large proportion of deaths in the Western World are caused by ischaemic heart disease. Among these patients a majority die outside hospital due to sudden cardiac death. The prognosis among these patients is in general, poor. However, a significant proportion are admitted to a hospital ward alive. The proportion of patients who survive the hospital phase of an out of hospital cardiac arrest varies considerably. Several treatment strategies are applicable during the post resuscitation care phase, but the level of evidence is weak for most of them. Four treatments are recommended for selected patients based on relatively good clinical evidence: therapeutic hypothermia, beta-blockers, coronary artery bypass grafting, and an implantable cardioverter defibrillator. The patient's cerebral function might influence implementation of the latter two alternatives. There is some evidence for revascularisation treatment in patients with suspected myocardial infarction. On pathophysiological grounds, an early coronary angiogram is a reasonable alternative. Further randomised clinical trials of other post resuscitation therapies are essential.     

神经外科患者医院感染的目标性监测

目的了解神经外科住院病人医院感染情况和危险因素,制定预防控制措施。方法采取目标性监测方法,对某医院神经外科住院患者进行医院感染率和危险因素的调查。结果共调查住院患者958例,发生医院感染96例,106例次,医院感染发生率为10.02%、例次感染率11.06%。病人接受气管切开、吸痰、使用呼吸机、留置导尿管等侵入性操作构成医院感染主要危险因素;病人昏迷、住院时间较长、长期大量使用抗菌药物与感染的发生有一定相关性。结论该医院神经外科是医院感染的高发科室,危险因素较多,应采取综合的干预措施才能有效地降低医院感染的发生。     

音乐疗法在言语康复中的应用进展

音乐和言语可能有着共同的神经通路。近年来音乐疗法在言语康复中的作用逐渐引起康复医学界的重视。本文将就音乐疗法促进言语功能恢复的疗效和作用机制以及治疗方案的制定进行综述。     

糖尿病患者尿路感染病原菌分布及耐药性研究

目的研究糖尿病患者尿路感染病原菌分布及其耐药性,指导临床合理使用抗菌药物。方法采用临床病原学标本检测和药敏试验方法,对某医院2011-2012年住院糖尿病合并尿路感染患者尿标本进行了监测与分析。结果糖尿病合并尿路感染患者尿标本检出的病原菌中,革兰阴性杆菌占75.42%,革兰阳性球菌占15.25%。革兰阴性杆菌中大肠埃希菌、克雷伯菌、铜绿假单胞菌、鲍曼不动杆菌分居前4位,革兰阳性菌中主要是肠球菌,还检出部分真菌。药敏试验结果显示,革兰阴性杆菌对亚胺培南与哌拉西林/他唑巴坦等抗菌药物较敏感,肠球菌对替考拉宁、利奈唑胺和万古霉素全部敏感,但对氨苄西林、红霉素、克林霉素、利福平、青霉素等耐药率较高。结论糖尿病患者尿路感染以革兰阴性杆菌为主,只对少数抗菌药物敏感,应加强监测和药敏试验,合理使用抗菌药物。     

医院检验科离心机的消毒及气溶胶防控

检验科工作量很大,每天都要承担患者血液、体液、分泌物、排泄物等多种临床标本的检验工作,这些标本中血液的标本量最大,并且血液标本都需要离心,分离血清才能检验,其他许多标本也需离心,离心机的利用率非常大,所以,检验科离心机的消毒及气溶胶防控非常重要。     

脊髓损伤恒河猴后肢步态数据处理方法的设计

目的基于Matlab建立一套适用于非人灵长类动物的步态数据处理方法。方法通过VICON系统在3只恒河猴脊髓损伤术后6周进行后肢步态分析测试,获取运动学数据。通过Excel Link将Matlab与Microsoft Excel相结合,实现对运动学原始数据的筛选和提取,并在Matlab环境下进行计算。结果通过计算得到步长、步高以及膝关节和踝关节角度等运动学参数。在0.2km/h、0.5 km/h、0.8 km/h速度下,步长(F=2.869,P=0.088)和步高(F=1.148,P=0.344)均值无显著性差异(P>0.05),表明数据模型可重复。通过计算得到的角度-时间曲线图反映了关节功能和运动变化规律。系统初步实现了足部步态轨迹的描绘,还实现了步态运动的二维/三维轨迹图的生成。结论该系统使得实验原始数据的处理不依赖于VICON系统,计算得到的参数和轨迹描绘可基本满足非人灵长类动物后肢行为学评价的需求。     

Immediate life support (ILS) training : Impact in a primary care setting?

OBJECTIVE: To evaluate immediate life support (ILS) training in a primary care setting. METHODS: A 12 month pre/post-quasi-experimental and qualitative evaluation of ILS training across the counties of Devon and Cornwall (UK). Data were collected via feedback forms, pre/post course knowledge and skills tests and by focus group interviews with key stakeholders. RESULTS: One hundred and seventy-three professionals from 10 courses took part in the evaluation with a response rate of 93%. Feedback on the course was overwhelmingly positive. A significant improvement in both skills (p < or = 0.001) and knowledge (p < or = 0.001) was shown. However, a proportion of participants had a decline in knowledge by the end of the course. Those attending ILS had a significantly higher knowledge score at the start of the course (p = 0.002) than a group attending a BLS course, indicating that the preparatory course manual had been beneficial. Knowledge did not decline significantly by 6 months but skills did (p = 0.02), but remained higher than pre-course levels (p < or = 0.001). Knowledge (p = 0.008) and skill (p < or = 0.002) retention following the ILS course was significantly higher than in the BLS course sub-group, indicating the added value of ILS. The focus groups raised a number of themes relating to release of staff; funding issues; and the observed and reported effects of assessment inequity mainly relating to 'failure to fail' and 'dove and hawk' approaches. CONCLUSION: The course leads to a significant increase in skills and knowledge with good knowledge retention. Skill decline is significant which raises questions about the practice of practitioners who are not updated regularly. Issues of funding, staff resources and the assessment ethics and strategy need to be addressed.     

Is There an Asian Idiom of Distress?: Somatic Symptoms in Female Japanese and Korean Students

The term 'idiom of distress' is used to describe culturally specific experiences of suffering. Most of these studies have been conducted with small groups, making comparison of symptom profiles difficult. Female undergraduate and graduate students in Japan (n = 50) and Korea (n = 61) completed the Beck Depression Inventory (BDI) and 7-day daily reports of their experiences of 46 somatic symptoms. Between-culture comparisons revealed that BDI scores did not differ; however, the Korean women had significantly higher somatic distress means than the Japanese women. Despite the higher Korean distress mean, regression analysis showed that somatic distress explained 30% of the variance of BDI score for the Japanese but only 22% of the variance for the Koreans. Within-culture comparisons showed that both high-BDI Japanese and Koreans had 19 somatic distress symptoms with significantly higher means than their low-BDI counterparts; 11 somatic symptoms were shared by the two groups. Multidimensional scaling matrices were used to compare symptom proximities and revealed cultural differences. The problems with using broad racial categories in clinical research, the clinical significance of these findings, and the implications for psychiatric nursing assessment and practice are discussed.     

深圳市龙华新区社区护士心肺复苏知识技能分析及对策

目的了解深圳市龙华新区社区护士心肺复苏(cardiopulmonary resuscitation,CPR)知识、技能掌握情况,为社区护士心肺复苏技能培训提供科学依据。方法采用闭卷理论考试对深圳市龙华新区248名社区护士进行理论考核,采用现场考核法进行CPR技能考核。结果248名社区护士CPR理论知识(83.83±9.32)分,合格率89.9%;操作技能(76.38±8.58)分,合格率72.2%;不同年龄、职称、学历、社区工作年限的社区护士CPR理论知识、操作技能得分差异有统计学意义(P<0.05);不同用工性质的社区护士的理论知识得分差异有统计学意义(P<0.05)。结论龙华新区社区护士CPR理论知识掌握情况优于操作技能,建议加大培训力度,有针对性地对社区护士进行CPR技能培训。     

层流洁净手术室手术过程中空气细菌总数变化趋势的研究

目的研究层流洁净手术室手术过程中空气中细菌总数动态变化趋势,为有效控制手术室空气质量提供参考。方法采用平板沉降法采样和细菌培养,对某层流洁净手术室在手术过程中空气菌数变化趋势进行研究。结果层流洁净手术室在手术过程中,手术区和周边区空气细菌总数分别呈"N"形和类似"M"形曲线变化,手术结束时空气中细菌总数分别达到41 cfu/m3和138 cfu/m3,术中30 min手术区空气细菌总数降至最低值为6 cfu/m3,未检出溶血性链球菌及金黄色葡萄球菌。结论某医院千级层流洁净手术室手术期间,除术中30 min时手术区空气平均细菌总数达到卫生标准(≤10 cfu/m3)外,其他时间点空气中平均细菌总数均未达到卫生标准,建议制定手术室手术期间空气细菌总数的动态卫生标准。     

疑似乳腺癌患者诊断期不同时间点信息需求调查分析

目的了解疑似乳腺癌患者诊断期信息需求现状,为进行针对性的健康教育提供依据。方法采用整群抽样的方法抽取105例疑似乳腺癌患者,采用一般资料调查问卷和疑似乳腺癌患者信息需求问卷调查患者在3个时间点的信息需求,分别为在普通外科门诊经初步物理或影像学检查发现乳房肿块并被告知需要进行乳房活检时(T1);在手术等候室等待乳房活检时(T2);在门诊得知乳房活检结果后(T3)。结果105例疑似乳腺癌患者经问卷评价后3个时间点信息需求总分均分为110.08分,对信息的需求较大,其中在手术等候室等待乳房活检时需求最高;不同时间点信息需求排序基本一致,T1、T2从高到低依次为诊断信息需求、治疗信息需求、随访咨询需求、疾病信息需求、社会心理信息需求、家人和朋友的参与需求。结论疑似乳腺癌患者在诊断期不同时间点对信息需求高,且需求较为一致。护理人员对疑似乳腺癌患者进行护理时,应当根据患者自身的不同情况,在诊断时期提供有针对性的信息支持,缓解患者焦虑情绪。     

Are emergency medical technician-basics able to use a selective immobilization of the cervical spine protocol? : A preliminary report

Objective

To be a first step in determining whether emergency medicine technician (EMT)-Basics are capable of using a protocol that allows for selective immobilization of the cervical spine. Such protocols are coming into use at an advanced life support level and could be beneficial when used by basic life support providers.

Method

A convenience sample of participants (n = 95) from 11 emergency medical services agencies and one college class participated in the study. All participants evaluated six patients in written scenarios and decided which should be placed into spinal precautions according to a selective spinal immobilization protocol. Systems without an existing selective spinal immobilization protocol received a one-hour continuing education lecture regarding the topic. College students received a similar lecture written so laypersons could understand the protocol.

Results

All participants showed proficiency when applying a selective immobilization protocol to patients in paper-based scenarios. Furthermore, EMT-Basics performed at the same level as paramedics when following the protocol. Statistical analysis revealed no significant differences between EMT-Basics and paramedics. A follow-up group of college students (added to have a non-EMS comparison group) also performed as well as paramedics when making decisions to use spinal precautions. Differences between college students and paramedics were also statistically insignificant.

Conclusions

The results suggest that EMT-Basics are as accurate as paramedics when making decisions regarding selective immobilization of the cervical spine during paper-based scenarios. That laypersons are also proficient when using the protocol could indicate that it is extremely simple to follow. This study is a first step toward the necessary additional studies evaluating the efficacy of EMT-Basics using selective immobilization as a regular practice.     

Biologische Therapieformen zur Behandlung chronisch entzündlicher Darmerkrankungen Eine aktuelle Standortbestimmung

Zusammenfassung Hintergrund: Zur Therapie chronisch entzündlicher Darmerkrankungen sind in den letzten Jahren verschiedene gentechnologisch hergestellte Antikörper, Zytokine und Antisense-Oligonukleotide entwickelt und geprüft worden, die als "biologische Therapeutika" bezeichnet werden. Wirksamkeit biologischer Therapeutika: Wirksam und zugelassen zur Behandlung des therapierefraktären Morbus Crohn, auch bei Fisteln, ist allein Infliximab, ein chimärer TNF-!-Antikörper. Aufgrund seines Nebenwirkungspotentials, z. B. Sepsis, erscheint Infliximab jedoch nicht unbedenklich und bedarf einer strengsten Indikationsstellung und sorgfältigen Überwachung. Des Weiteren sind andere anti-TNF-!-wirksame Substanzen (CDP 571, Etanercept, Thalidomid), Interleukin-10, Interleukin-11, ICAM-1-Antisense-Oligonukleotide sowie Ŏ-Integrin-Antikörper bei Morbus Crohn geprüft worden. Es war meist eine gewisse, allerdings geringe Wirksamkeit erkennbar, so dass ihnen im gesamten Therapiekonzept bislang kein Stellenwert zukommt. Eine Zulassung für diese Medikamente besteht nicht. Entwicklungen werden mit Spannung erwartet. Abstract Background: For the treatment of inflammatory bowel diseases in recent years several antibodies, cytokines and antisense oligonucleotides have been developed using recombinant technology and were tested as so-called "biological therapeutics". Effectiveness of Biological Therapeutics: Infliximab, a chimeric TNF-! antibody, is the only biological remedy approved for the treatment of refractory and fistulizing Crohn's disease. Because of inherent risks for severe side effects, such as sepsis, the indication should be restricted to truly refractory patients and treated patients must be followed very carfully. In clinical trials other anti-TNF-!-effective substances (CDP 571, etanercept, thalidomide), interleukin-10, interleukin-11, ICAM-1-antisense-oligonucleotides and antibodies against Ŏ-integrin were evaluated for the treatment of Crohn's disease. In summary, for a slight effect was noted but their place in the therapeutical repertoire is not yet defined. None of these substances is approved for patients with inflammatory bowel disease. Future developments are eagerly awaited.