少量漏气技术在老年患者长期机械通气气囊管理中的应用

目的寻求一种在老年长期机械通气中较为理想的气囊管理方法。方法采用少量漏起技术（minimal leak technique,MLT）和指感估压法给气管导管气囊进行充气,观察两组气囊漏气、气囊破裂、气管黏膜损伤及呼吸机相关肺炎的发生情况。结果MLT组气囊漏气、气囊破裂、气管黏膜损伤的发生率明显低于指感估压组（P〈0．05）;而呼吸机相关肺炎的发生率无明显差异（P〉0．05）。结论MLT可减少长期机械通气时气管导管气囊过度充气所致的并发症。     

Assessment of a New Method to Distinguish Esophageal from Tracheal Intubation by Measuring the Endotracheal Cuff Pressure in a Porcine Model

Objectives: With the knowledge of differences in anatomic structures between the trachea and the esophagus, the authors conducted an animal study to evaluate the usefulness of endotracheal cuff pressure in distinguishing endotracheal and esophageal intubations. Methods: Six swine were anesthetized and endotracheally intubated with 7.5-mm cuffed endotracheal tubes. The intubations were confirmed by fiber-optic bronchoscopy. Each pilot balloon was connected to a 10-mL syringe and a manometer via a three-way stopcock. The cuff pressures were measured for each 1-mL incremental filling of air (1–10 mL). After removal of the endotracheal tubes, each swine was then intubated with the same endotracheal tubes into its esophagus. The cuff pressures of the esophageal intubation were measured with the same procedure. The cuff pressures and the pressure–volume relationships in both intubations were compared. Results: The cuff pressure increased significantly in the esophageal intubation in comparison with the endotracheal intubation in all the comparisons from 1 mL to 10 mL (p = 0.028 for all Wilcoxon signed-rank tests). The slope of the pressure–volume curve of the cuff pressure was also significantly higher in the esophageal intubation during the inflation of the cuff on average (0.047 vs. 0.032 cm H₂O/mL; p = 0.001), particularly in the first 5 mL of air inflation. Conclusions: The cuff pressure in the esophageal intubation was significantly higher than that in the endotracheal intubation under the same inflated volume from 1 to 10 mL. This may provide the basis for an adjunctive, simple, rapid, and reliable method to verify endotracheal intubation.     

Clinical Evaluation of Tracheal Pressure Estimation from the Endotracheal Tube Cuff Pressure

Objective. Air flow through an endotracheal tube causes a pressure drop across the tube. This pressure drop creates a difference between air pressure measured in the trachea and the pressure measured in the breathing circuit, which can lead to errors when calculating pulmonary mechanics and when setting ventilators. We have developed a method of estimating tracheal pressure from the pressure in the endotracheal tube cuff and tested this system in clinical trials. Methods. Pressure measurement ports were placed between the Y piece of the ventilator circuit and the ETT connector, in the trachea at the carinal end of the ETT, and in the ETT cuff inflation line. Tracheal pressures and cuff pressures were found at end-inspiration and end-expiration (no flow states) and used to define a linear relationship between cuff pressure and tracheal pressure. Using the estimated tracheal pressure (P_trach) and the measured pressure at the Y piece of the breathing circuit (P_Y), the pressure drop across the ETT was found as a function of flow through the tube. Tracheal pressure was then calculated from the flow-dependent pressure drop and P_Y. Tests of this system were performed in six patients in the operating room and six patients in the intensive care unit. Results. The flow-based tracheal pressure estimates were within 0.7 ± 0.4 cm H₂O of actual tracheal pressure (mean ± SD). At peak inspiratory pressure the difference averaged 0.5 ± 0.3 cm H₂O. The difference between our estimate of tracheal pressure and actual tracheal pressure was always less than 1 cm H₂O. Conclusion. The flow-based tracheal pressure estimates were accurate during intermittent spontaneous breathing, but not during spontaneous breathing or with a poorly inflated cuff. The estimates were more immune to noise than the cuff-based estimates of tracheal pressure. The estimates of tracheal pressure measured from the ETT cuff should be accurate enough for clinical use in the operating room.     

血压计袖带充气管朝上测量血压的可行性研究

目的探讨血压计袖带充气口朝上测量血压的可行性。方法选取实习护生105名,分别用电子血压计和汞柱血压计测量血压,比较袖带充气管朝上测量血压和用常规法测量血压值有无差别。结果用两种血压计两种测量方法所测得的血压值相比较,差异均无统计学意义（P〉0．05）。结论袖带充气管朝上测量血压的方法能较准确地测量人体血压。     

ICU护士估测气管导管气囊压准确性的研究

目的 测试各职称护士估测法测量气管导管气囊内压力的准确率。方法 呼吸科ICU工作1年以上的各职称护士30名,分别使用估测法测量气囊内压力30次,并将测量值与测压表的实测压力相比较。结果 准确率：护士55％～62％。护师58％～68％,主管护师63％～70％;准确率低主要表现在估测压偏低。结论 临床工作中应利用气囊压力表科学地为机械通气患者气囊充气和放气,减少误差,增加机械通气的安全性。     

气管内套管消毒方法的探讨

文章对气管切开病人使用的内套管进行细菌培养,内套管存在大量细菌。消毒方法选用了４种：高压蒸汽灭菌法,煮沸消毒法,１‰新洁尔灭浸泡消毒法,１％“８４”消毒液浸泡消毒法。消毒前后细菌阳性例数比较,结果有明显差异。     

A Randomized Trial Assessing the Value of Ultrasound-Guided Puncture of the Femoral Artery for Interventional Investigations

Using a prospectively collected database of patients undergoing diagnostic or therapeutic angiography via transfemoral access, we sought to determine those patients who may benefit from ultrasound-guided puncture of the femoral artery. One-hundred-twelve patients with normal anticoagulation parameters were randomized in two groups. Fifty-six patients received ultrasound-guided puncture of the femoral artery, 56 patients underwent traditional palpation-guided vessel cannulation. Parameters assessed included procedure-time, number of attempts for successful puncture, intensity of the arterial pulse, previous ipsilateral punctures, history and risk factors of arteriosclerosis and leg circumference at the site of puncture. The data was analyzed by using outcome measures according to evidence-based medicine criteria. Only in patients with weak arterial pulse and thoses with a leg circumference of 60 cm or greater ultrasound guidance significantly decreased the number of attempts needed as well as the time for successful arterial puncture. In both patient subgroups, the number needed to treat (NNT) was 2, the absolute benefit increase (ABI) was 50 and 57%, respectively. In contrast, time for vessel cannulation was increased in patients with strong arterial pulse using ultrasound guidance. No significant differences were found with respect to diminished complications neither comparing both patient groups nor comparing risk subgroups. In conclusion ultrasound guidance for femoral artery access is recommended only in patients with a weak or absent arterial pulse and obese patients.     

Endotracheal Tube Suctioning in the Newborn: A Review of the Literature

Maintaining the patency of the endotracheal tube (ETT) is crucial to effective ventilation and oxygenation of the patient receiving assisted ventilation. Performed frequently in the NICU, ETT suctioning has not received extensive study in this population. However, the deleterious effects of this procedure in the newborn are well documented. Methods to reduce these effects include suctioning only as needed instead of using a routine schedule, shallow (or measured) suctioning to avoid trauma to the carina, and closed systems for suctioning in which ventilator pressure is mostly maintained throughout the procedure. Overall, there is limited scientific evidence to guide practice related to ETT suctioning in the newborn, and unit protocols and clinician practices vary. This article will review the current literature regarding ETT suctioning in the newborn and summarize recommendations for best practice.     

Comparing Occupation-Based and Repetitive Task Practice Interventions for Optimal Stroke Recovery: A Pilot Randomized Trial

Aims: This pilot randomized comparative study investigated changes in motor performance and indices of neuroplasticity associated with occupation-based intervention and repetitive task practice in the recovery of occupational performance following stroke. Method: Sixteen participants received either occupation-based intervention or repetitive task practice for eight 55-minute sessions. Motor performance was measured by the Fugl Meyer Assessment (FMA), Stroke Impact Scale (SIS), the Canadian Occupational Performance Measure (COPM) and the Goal Attainment Scale (GAS). Indices of neuroplastic change were assessed by transcranial magnetic stimulation (TMS). Results: Both occupation-based intervention and repetitive task practice groups demonstrated significant changes on the FMA and the occupation-based group demonstrated significant changes on the GAS goals. Neurophysiological measures showed enlargement in TMS volume maps in the affected hemisphere for both groups. Conclusion: Occupation-based and repetitive task practice interventions can yield similar improvements in chronic stroke.     

套囊充气法对经鼻盲探气管插管有效性的meta分析

目的：探讨应用套囊充气法辅助经鼻盲探气管插管（BNTI）的有效性。方法：在中文期刊全文库（CHNK）、PUBMED2个电子文献数据库中,检索出有关套囊充气法对经鼻盲探气管插管术成功率影响的前瞻性对照研究的文献进行Meta分析。结果：10篇研究文献被选中。其中,对提供一次插管成功数据的8篇文献应用固定效应模型计算出套囊充气组BNTI一次成功率大于非套囊充气组,2组间合并统计P值〈0.05;对提供最终插管结果数据的9篇文献应用随机效应模型计算出囊充气组BNTI总成功率大于非套囊充气组,2组间合并统计P值〈0.01。结论：应用套囊充气法可提高经BNTI成功率,推荐可常规作为该技术的辅助方法。     

Pulsed Electromagnetic Field and Exercises in Patients With Shoulder Impingement Syndrome: A Randomized,Double-Blind,Placebo-Controlled Clinical Trial

Objective

To evaluate the effects of pulsed electromagnetic field (PEMF) and exercises in reducing pain and improving function and muscle strength in patients with shoulder impingement syndrome (SIS).

Design

Double-blind, randomized controlled trial with a 3-month posttreatment follow-up.

Setting

Outpatient rehabilitation of a public hospital.

Participants

Patients (N=56) between 40 and 60 years of age, with a diagnosis of SIS, were randomly assigned to receive active PEMF (n=26; mean age, 50.1y) or placebo PEMF (n=30; mean age, 50.8y).

Interventions

After 3 weeks of active or placebo PEMF, both groups performed the same program of exercises that focused on shoulder strengthening.

Main Outcome Measures

A visual analog scale, the University of California/Los Angeles shoulder rating scale, the Constant-Murley shoulder score, and handheld dynamometry for muscle strength were used as outcome measures at baseline (pretreatment), at 3 weeks (after active or placebo PEMF), at 9 weeks (postexercise), and at 3 months posttreatment.

Results

Patients in the active PEMF group had a higher level of function and less pain at all follow-up time frames compared with baseline (P<.05). However, the placebo PEMF group had increased function and reduced pain only at the 9-week and 3-month follow-ups (P<.05)—that is, after performing the associated exercises. For the shoulder dynamometry, the active PEMF group had increased strength for lateral rotation at 9 weeks (P<.05), and increased strength for medial rotation at 9 weeks and 3 months (both P<.05) when compared with baseline. There was no significant difference for shoulder strength in the placebo PEMF group (P>.05), as well as no significant differences (P>.05) for all outcome measures.

Conclusions

The combination of PEMF and shoulder exercises is effective in improving function and muscle strength and decreasing pain in patients with SIS. However, these results should be carefully interpreted because of the lack of differences between groups.     

Defining Optimal Care for Functional Gut Disorders - Multi-Disciplinary Versus Standard Care: A Randomized Controlled Trial Protocol

BackgroundFunctional gastrointestinal disorders (FGIDs) are the commonest reason for gastroenterological consultation, with patients usually seen by a specialist working in isolation. There is a wealth of evidence testifying to the benefit provided by dieticians, behavioral therapists, hypnotherapists and psychotherapists in treating these conditions, yet they rarely form a part of the therapeutic team, and these treatment modalities are rarely offered as part of the therapeutic management. There has been little examination of different models of care for FGIDs. We hypothesize that multi-disciplinary integrated care is superior to standard specialist-based care in the treatment of functional gut disorders.MethodsThe “MANTRA” (Multidisciplinary Treatment for Functional Gut Disorders) study compares comprehensive multi-disciplinary outpatient care with standard hospital outpatient care. Consecutive new referrals to the gastroenterology and colorectal outpatient clinics of a single secondary and tertiary care hospital of patients with an FGID, defined by the Rome IV criteria, will be included. Patients will be prospectively randomized 2:1 to multi-disciplinary (gastroenterologist, gut-hypnotherapist, psychiatrist, behavioral therapist (‘biofeedback’) and dietician) or standard care (gastroenterologist or colorectal surgeon). Patients are assessed up to 12 months after completing treatment. The primary outcome is an improvement on a global assessment scale at the end of treatment. Symptoms, quality of life, psychological well-being, and healthcare costs are secondary outcome measures.DiscussionThere have been few studies examining how best to deliver care for functional gut disorders. The MANTRA study will define the clinical and cost benefits of two different models of care for these highly prevalent disorders.TRIAL REGISTRATION Number: Clinicaltrials.gov NCT03078634Registered on Clinicaltrials.gov, completed recruitment, registered on March 13th 2017.Ethics and Dissemination:Ethical approval has been received by the St Vincent's Hospital Melbourne human research ethics committee (HREC-A 138/16). The results will be disseminated in peer-reviewed journals and presented at international conferences.Protocol version 1.2     

关节镜辅助小切口治疗肩袖损伤25例分析

【目的】探讨关节镜辅助下小切口治疗肩袖损伤的手术技巧和临床疗效。【方法]自2008年1月至2010年2月收治25例肩袖损伤患者,采用关节镜下辅助小切口修复肩袖损伤,手术均采用smith＆nephew带线铆钉进行肩袖重建。分别在术前及最终随访时采用美国肩肘医师协会评分（ASES）、Constan〉Murley评分以及简易肩关节评分（SST）问卷进行功能恢复评估。【结果】本组25例均获得随访,随访时间6～15个月,平均10．5个月。25例患者手术前及最终随访时ASES平均分（75．2VS89．1）,差异有显著性（P〈0．01）,且VAS疼痛评分（6．1VS2．2）（P〈0．001）,肩关节平均上举幅度（77．6°VS136．6°）（P〈0．001）,平均外旋幅度（25．5°VS40．2°）（P〈0．01）,平均Constant—Murley评分（72．1VS88．6）（P〈0．01）。手术前后比较差异均有显著性（P〈0．01）。【结论】关节镜辅助小切口治疗肩袖损伤具有操作安全、较常规切开手术创伤小、有利于早期功能锻炼的优点,是治疗肩袖损伤的有效方法。     

Antibiotic Prophylaxis for Pacemaker Implantation: A Prospective Randomized Trial

Prophylactic antibiotics are frequently prescribed for patients undergoing permanent pacemaker implantation even though data confirming their effectiveness are limited. Five hundred patients requiring elective permanent pacemaker implantation or generator replacement were prospectively randomized either to receive or not receive prophylactic antibiotic treatment at the time of implantation. The implantation site was treated with 10% povidone-iodine solution and 0.5% alcoholic chlorhexidine preoperatively. The wound were inspected for evidence of infection at 3 days and 1, 3, 6 and 12 months postimplantation. Three patients (two receiving prophylactic antibiotics and one no antibiotics) developed pacemaker pocket infection; Staphylococcus aureus was the pathogenic organism in each case (P = 0.56). Eighteen patients developed clinical evidence of superficial wound inflammation requiring antibiotic treatment but not pacemaker removal. Six had received prophylactic antibiotics and 12 had not (P = 0.27). We conclude that pacemaker pocket infection is unusual with careful preoperative skin preparation and close postoperative follow-up. Under these circumstances prophylactic antibiotic treatment is of no practical value.     

LET versus EMLA for Pretreating Lacerations: A Randomized Trial

OBJECTIVE: To compare the anesthetic efficacy of EMLA cream (eutectic mixture of local anesthetics) with that of LET solution (lidocaine, epinephrine, tetracaine) for pretreating lacerations prior to lidocaine injection. METHODS: This was a randomized, double-blind clinical trial in a convenience sample of 60 patients aged 1 to 59 years with traumatic lacerations. Eligible wounds were uncomplicated, clean lacerations < or = 6 hours old. Finger and toe lacerations were excluded. At the time of initial presentation to triage, patients were randomized to LET or EMLA. A nurse applied the topical anesthetic into the laceration with a 5-mL syringe. A physician assessed the laceration edges for the presence of blanching and adequacy of anesthesia to a 27-gauge needlestick. Supplemental lidocaine was then infiltrated through the wound edges and the pain of infiltration was recorded by the patient (or guardian) on a 100-mm visual analog scale marked "most pain" at the high end. A sample of 44 patients had 90% power to detect a 20-mm difference in injection pain (two-tailed alpha = 0.05). RESULTS: Sixty patients were randomized to LET (29) or EMLA (31). Median age was 8.5 years; 23% were female. Most lacerations were facial and closed with sutures. There was no difference in baseline characteristics between groups. More wounds treated with LET were anesthetic to a needlestick than wounds treated with EMLA (73% vs 40%, p = 0.01); however, there was no between-group difference in the median pain of lidocaine infiltration (LET-12 mm vs EMLA-13 mm, p = 0.89). CONCLUSIONS: Pretreatment of simple lacerations with LET or EMLA at the time of patient presentation results in similar amounts of pain of subsequent local infiltration of lidocaine     

High-Intensity Respiratory Muscle Training Improves Strength and Dyspnea Poststroke: A Double-Blind Randomized Trial

Objective

To examine whether high-intensity home-based respiratory muscle training, that is, with higher loads, delivered more frequently and for longer duration, than previously applied, would increase the strength and endurance of the respiratory muscles, reduce dyspnea and respiratory complications, and improve walking capacity post-stroke.

Use of a Gaming Platform for Balance Training After a Stroke: A Randomized Trial

Objective

To evaluate a personal computer (PC) gaming platform as a means of improving postural balance in stroke patients.