老年腹股沟疝手术选择和自我临床报告结果

目的探讨老年腹股沟疝患者的术式选择,比较开放和腹腔镜疝修补≧60岁,小于60岁的患者临床报告结果。方法日期从2015年1月到2016年5月接受腹股沟疝手术患者被纳入本研究,共有137例接受调查,其中72例小于60岁(60组),65例大于等于60岁(≧60组)。在60组,29例患者行腹腔镜疝修补术(TEP)和43例开放式疝修补术。在≧60组,29例患者行腹腔镜疝修补术(TEP)和36例开放式疝修补术。术后6月随访,患者临床报告结果(PROM)包括总体感觉、疼痛、恶心、呕吐、头晕、疲倦和满意度。结果 137例得到术后6个月随访。严重疼痛患者8例,其中6例为60岁组,≧60岁组仅2例出现严重疼痛(P0.05)。≧60 TEP组中只有1例患者中度疼痛,60 TEP组中有3例中度疼痛(P0.05)。绝大多数患者对手术满意程度在所有组患者中满意或非常满意,只有2例病人主诉手术疤痕和术后疼痛。结论 60岁以上腹股沟疝患者的手术,采用TEP术式安全、痛苦少;但比较60岁患者,无论腹腔镜还是开放的腹股沟疝修补术,均未体现更多优势。     

高龄患者行膀胱癌根治术后的疗效分析及预后危险因素探讨

目的:探讨高龄患者(≥75岁)行根治性全膀胱切除手术的疗效及影响高龄患者全膀胱手术预后的危险因素。方法:收集2009年1月~2013年11月在我院行根治性全膀胱切除手术中年龄≥75岁且随访资料完整的患者46例,观察手术时间、术中出血量、术后临床数据、术后并发症,通过COX生存分析探讨影响高龄患者全膀胱术后预后的危险因素。结果:46例患者平均手术时间(372±110)min,中位出血量450ml。术后早期并发症发生率达43.5%(20/46),后期并发症发生率为21.7%(12/46),术后手术相关死亡率为4.3%(2/46)。COX生存分析发现肿瘤是否器官局限,淋巴结是否转移与患者术后预后有关。结论:对于能够耐受根治性全膀胱切除术的高龄患者,全膀胱切除治疗仍应为推荐方案。     

基于患者参与框架的住院老年患者跌倒预防干预策略的实施

目的 探讨基于患者参与框架的住院老年患者跌倒预防干预策略的实施效果.方法 根据住院时间将2019年1～6月收治的58例老年患者作为对照组,2019年7?12月收治的58例作为观察组.对照组按常规实施预防跌倒措施,观察组基于患者参与框架制订并实施住院老年患者跌倒预防干预策略,包括"告知、参与、赋权、合作及电子化信息支持"...     

以结局为导向构建老年前列腺增生手术护理方案

目的 探索以结局为导向建立老年前列腺增生手术护理方案,弥补常规护理的缺陷,改善患者的护理结局.方法 以奥马哈问题分类表、护理措施分类和护理结局分类为框架,建立以可测量的目标为导向的老年前列腺增生手术患者护理方案,并结合护理程序对37例老年前列腺增生手术患者进行从入院到术前、从手术至出院前和出院后3个月3个阶段的连续性跟进,分析并评价3个阶段的主要护理问题及护理结局的变化.结果 从入院至出院后3个月内,发生率超过30％的护理问题有泌尿功能、排便功能、睡眠障碍和休息型态等.患者出院后3个月内干预前后认知、行为、状况均明显改善(P＜0.05);认知评分高于行为和状况评分,均＞4分.结论 以结局为导向的老年前列腺增生手术患者护理方案可以改善前列腺增生老年患者的护理结局.     

Hospital volume and surgical outcomes for elderly patients with colorectal cancer in the United States

BACKGROUND: Recent emphasis has been placed on the quality of surgical care in the United States. As such, patients, providers, and payers are increasingly aware of the outcomes of surgical care as a marker of quality. The objective of this study was to determine the impact of hospital volume on mortality for patients of different age groups to determine whether elderly patients would derive more benefit from selective referral policies. METHODS: Data from the Nationwide Inpatient Sample for all patients undergoing surgery for colorectal cancer during 1997 were obtained (N = 20,862). Differences in mortality associated with increasing age and hospital volume quartiles were determined. Risk-adjusted analyses of mortality were performed using multiple logistic regression. RESULTS: The overall mortality rate was 3.1% for the 842 hospitals included. Patient age breakdown was the following: age <50, 7%; age 50 to 64, 19%; age 65 to 80, 51%; and age >80, 22%. Increasing age was associated with higher mortality rates: age <50, 0.8%; age 51 to 65, 1.3%; age 66 to 80, 2.9%; and >80, 6.9%. Overall, the highest volume hospitals (HVH) (>150/year) had lower mortality than the lowest volume hospitals (LVH) (<55/year) (2.5% vs. 3.7%; P = 0.006). However, the effect of volume on mortality was primarily due to differences in older patients. For patients greater than 65 years old, the mortality rate was 3.1% at HVH and 4.5% at LVH (P = 0.03). For patients greater than 80 years old, the mortality rate was 4.6% at HVH and 7.3% at LVH (P = 0.04). The results were unchanged after adjustment for patient demographics, comorbid disease, site of cancer, and type of resection. CONCLUSIONS: The majority of deaths after surgery for colorectal cancer occur in older patients. Hospitals that perform higher volumes of colorectal resection have lower mortality rates, especially for older patients. In the absence of other information about the quality of surgical care, provider volumes are a useful marker of postoperative outcomes for older patients in need of surgery for colorectal cancer.     

Trauma case management: improving patient outcomes

BACKGROUND: The purpose of the study was to measure the effect of trauma case management (TCM) on patient outcomes, using practice-specific outcome variables such as in-hospital complication rates, length of stay, resource use and allied health service intervention rates. METHODS: TCM was provided 7 days a week to all trauma patient admissions. Data from 754 patients were collected over 14 months. These data were compared with 777 matched patients from the previous 14 months. RESULTS: TCM greatly improved time to allied health intervention (p<0.0001). Results demonstrated a decrease in the occurrence of deep vein thrombosis (p<0.038) and a trend towards decreased patient morbidity, unplanned admissions to the intensive care unit and operating suite. A reduced hospital stay LOS, particularly in the paediatric and 45-64 years age group was noted. Six thousand six hundred twenty-one fewer pathology tests were performed and the total number of bed days was 483 days less than predicted from the control group. CONCLUSION: The introduction of TCM improved the efficiency and effectiveness of trauma patient care in our institution. This initiative demonstrates that TCM results in improvements to quality of care, trauma patient morbidity, financial performance and resource use.     

The impact of obesity on outcomes in patients receiving extracorporeal life support

Extracorporeal life support (ECLS) has been increasingly utilized to manage cardiac and pulmonary dysfunction. The impact of obesity on outcomes of ECLS is poorly defined. The purpose of the study was to compare in-hospital mortality, resource use, complications, and readmissions in obese versus non-obese patients receiving ECLS. We performed a retrospective cohort study of all adult ECLS patients with and without an obesity diagnosis using the 2010–2016 Nationwide Readmissions Database (NRD). Mortality, length of stay (LOS), hospital charges, complications, and readmissions were evaluated using multivariable logistic and linear regression. Of 23 876, patients who received ECLS, 1924 (8.1%) were obese. Obese patients received ECLS more frequently for respiratory failure (29.5% vs. 23.7%, P = .001). After adjustment for patient and hospital factors, obesity was not associated with increased odds of mortality (AOR = 1.06, P = .44) and was associated with decreased LOS (13.7 vs. 21.2 days, P < .001), hospital charges ($171 866 vs. $211 445, P < .001), and 30-day readmission (AOR = 0.71, P = .03). Obesity was also associated with reduced odds of hemorrhage (AOR = 0.43, P < .001), neurologic complications (AOR = 0.55, P = .004), and acute kidney injury (AOR=0.83, P = .04). After stratification by ECLS indication, obesity remained predictive of shorter LOS (AOR range: 0.53-0.78, all P < .05 ) and did not impact mortality (all P > .05). Respiratory support remains the most common indication for ECLS among obese patients. Among all patients, as well as by individual ECLS indication, obesity was not associated with increased odds of mortality. These findings suggest that obesity should not be considered a high-risk contraindication to ECLS.     

Transporting the adult critically ill patient

More than 10,000 intensive care patients are transferred each year in the UK, of whom the vast majority are accompanied by staff from the referring hospital. The high frequency of transfers of critically ill patients is primarily due to the escalating complexity of healthcare, the concentration of skills into specialized regional centres, and the relative lack of availability of intensive care unit (ICU) beds. The care practised during the constraints of patient transfer (whether within or between hospitals) should mirror the detailed attention to detail provided in the hospital ICU, and it is the responsibility of the transport team to ensure the efficacy of the process and safety of the patient. This is achieved through careful preparation and planning. Preparation starts with adequate and appropriate training of transfer personnel as well as selection of equipment which is fit for purpose. Success is based on anticipation and prevention of potential complications and hazards to the patient and transfer team. This article gives an overview of the hazards, organization and planning of patient transfers, and highlights the importance of interdisciplinary teamwork, good communications and appropriate decision making. It also discusses special situations encountered in the transfer or retrieval of patients with complex needs.     

Transporting the adult critically ill patient

More than 10,000 intensive care patients are transferred each year in the UK, of whom the vast majority are accompanied by staff from the referring hospital. The high frequency of transfer of critically ill patients is primarily due to the escalating complexity of healthcare, the concentration of skills into specialized regional centres, and the relative lack of availability of intensive care unit (ICU) beds. The care practised during the constraints of patient transfer (whether within or between hospitals) should attempt to mirror the detailed attention provided in the hospital ICU, and it is the responsibility of the transport team to ensure the efficacy of the process and safety of the patient. This is achieved through careful preparation and planning and preparation starts with adequate and appropriate training of transfer personnel as well as selection of equipment which is fit for purpose. Success is based on anticipation and prevention of potential complications and hazards to the patient and transfer team. This article gives an overview of the hazards, organization, and planning of patient transfers, and highlights the importance of interdisciplinary teamwork, good communications, and appropriate decision-making. It also discusses special situations encountered in the transfer or retrieval of patients with complex needs, such as those requiring intra-aortic balloon counterpulsation or extracorporeal membrane oxygenation.     

动力髋螺钉与人工关节置换治疗高龄股骨转子间骨折疗效比较

目的 探讨动力髋螺钉(DHS)内固定与人工关节置换术治疗高龄股骨转子间骨折的方法及治疗效果.方法 66例高龄不稳定股骨转子间骨折患者随机分为2组,DHS内固定治疗35例,人工股骨头置换治疗31例.比较2组术后并发症及髋关节功能.结果 60例获随访,时间8个月～6年,随访期内死亡5例.并发症:关节组发生3例,DHS组发生12例,差异有显著性(P＜0.05) .患髋功能评定采用Harris评分法: 关节组72～95(84.5±5.4) 分,DHS组68～91(82.1±6.8)分,差异无显著性(P＞0.05).结论 对于年龄≥80岁、骨质疏松及不稳定股骨转子间骨折患者,采用人工股骨头置换治疗是可行的,远期效果仍需继续观察.     

Clinical features and management of brain arteriovenous malformations in elderly patients

Summary. Background. Brain arteriovenous malformations (AVMs) of the elderly have not received sufficient attention, given the increase in age of individuals in recent years. We therefore designed a retrospective study to clarify features of brain AVMs in this age group in comparison with their counterparts in the general population.Methods. A retrospective study was performed, based on data for AVMs treated in Nara Medical University Hospital and affiliated hospitals over the past 13 years. The series included all cases of brain AVMs, except for pure dural AVMs, diagnosed from June 1989 to June 2003. A total of 175 patients were diagnosed as having an AVM during this period, including 32 patients more than 60 years old. Clinical features and effective treatment of brain AVMs in those over and under 60 were explored and outcome at 3 to 6 months after surgery was evaluated according to a modified neurological scale.Findings. The most common mode of presentation was intracranial hemorrhage in both groups, and this was remarkable in the elderly. Epilepsy at presentation was less frequent in the elderly (P<0.05). In the elderly group infratentorial lesions were encountered more frequently (P<0.05). Good or excellent outcomes of surgery were accomplished in 82.6% of the non-elderly group, and in 69.6% of the elderly group. When restricted to the grades I or II of Spetzler and Martin (S & M) grading, postoperative neurological scores of both groups were significantly better than preoperative values (P<0.01). In the grade III cases, the non-elderly demonstrated significant improvement after surgery (P<0.01), but the elderly did not.Interpretation. Elderly patients with a brain AVM had clinical features of less frequent epileptic presentation and more frequent infratentorial lesions. It was suggested that surgery was acceptable in elderly patients with pallial AVMs of grade I and II. Surgery for grade III AVMs of the elderly remains to be clarified.     

Measuring patient outcomes: a primer

When designing a study, it is important to select appropriate instruments to measure health outcomes. An investigator must have a comprehensive understanding of the disease and its effects on patient health to inform instrument selection. We provide a brief introduction of different ways that health is defined and the properties of a good measurement tool (reliability, validity, sensitivity to change). We describe patient-reported outcomes (PROs) and methods to improve their interpretability, and we include strategies to reduce bias in health measurement and considerations that may improve the feasibility of measuring outcomes in a research study.