食管癌术后并发心房纤颤的相关因素分析及临床护理

目的探讨食管癌术后发生心房纤颤的高危因素及其对围术期护理的影响.方法总结食管癌术后发生房颤的病人63例,并与同期手术的126例未发生房颤的食管癌术后病人做对照,分析可能导致房颤的高危因素,比较2组病人的术后住院时间及围术期死亡率.结果房颤组中年龄在65岁以上、男性、术前合并心脏病、慢性阻塞性肺疾病(P＜0.01)病人的比例高于对照组(P＞0.05);房颤组中高血压和糖尿病人与对照组差异无统计学意义(P＞0.05).术后房颤组中并发氧饱和度低和胸胃扩张的病人高于对照组(P＜0.05),术后发热2组差异无统计学意义;房颤组与对照组的围术期死亡率(x2=0.51,P＞0.05)及术后住院时间(t=4.82,P＞0.05)差异无统计学意义.结论高龄、男性以及术前合并心脏病、慢性阻塞性肺疾病的病人在行食管癌术后容易发生心房纤颤,术后低氧饱和度、胸胃扩张是诱发房颤的危险因素;及时发现、及时治疗,房颤不会增加围术期死亡率和术后住院时间.     

食管癌术后并发心房纤颤的原因分析及护理对策

目的:探讨食管癌病人术后并发心房纤颤的原因及预防对策。方法:回顾性总结食管癌术后并发心房纤颤病人50例,并以同期手术的100例未发心房纤颤的食管癌病人做对照。分析食管癌术后并发心房纤颤的高危因素及预防对策。结果:食管癌术后并发心房纤颤是多因素引起的,多发生于术后3天以内,房颤组围术期死亡率为4·01%(2/50),对照组围术期死亡率为3·02%(3/100),两组间没有显著差异(P>0·05)。结论:要以“防重于治”的态度积极对待术后并发心房纤颤的发生,护理观察要全面细致,及时发现,找出原因,立即处理、治疗可取得较好的效果。     

手术过程中应用胺碘酮治疗心房纤颤疗效观察

心房纤颤（房颤）是临床最常见的心律失常，多见于老年人和心脏病患者，它不仅可以引起血流动力学恶化，导致心力衰竭，也是缺血性脑卒中的重要原因。围手术期发生房颤，可使手术的安全性降低，增加手术的风险及术后的并发症。近年来笔者应用胺碘酮治疗围手术期心房纤颤取得了显著效果，现报告如下。     

老年非瓣膜性持续性心房纤颤左心房大小及炎性标志物表达的研究

目的：了解不同类型老年非瓣膜性心房纤颤（Atrial Fibrillation,AF）患者左心房的大小的差异,以及左房的大小是否与炎性标志物的表达有关.方法：15例心电图和既往病史证实持续性心房纤颤老年患者分别通过使用超声心动图检查了解左心房的大小,并同时测定血浆CRP的浓度,并与阵发房颤和对照组比较.结果：持续房颤组左房内径明显大于阵发房颤组和对照组（P＜0.05）.利用放免法测定C反应蛋白浓度,持续房颤高于阵发房颤组及对照组,后两者的两项指标无显著差异（P＞0.05）.结论：左房长大是房颤持续状态的原因,其机制可能与炎症有关.     

食管癌术后并发心房纤颤的原因分析及护理措施

目的:探讨食管癌术后并发心房纤颤的原因及预防措施。方法:回顾性总结分析食管癌术后并发心房纤颤25例病人的原因及护理措施。结果:心房纤颤大都发生在3d内,经过及时治疗及护理,本组病人均转为窦性心律。结论:护理观察要全面细致,及时发现并找出房颤原因汇报医师立即处理,及时正确治疗可获得较好的效果。     

缬沙坦治疗原发性高血压并阵发性心房纤颤的临床观察

目的：探讨缬沙坦对原发性高血压合并阵发性心房纤颤患者的治疗效果。方法：将35例合并阵发性心房纤颤的原发性高血压患者随机分成治疗组20例和对照组15例。两组均予常规降压治疗,治疗组加用缬沙坦80 mg/d,1周后依据血压变化将其剂量调整为80-160 mg/d。比较2组治疗前及治疗1年后左室重量、左房内径、P波离散度、夜间平均收缩压、A波最大速度和房颤平均持续时间的差异。结果：治疗1年后,治疗组左室重量、左室内径、A波最大速度和P波离散度均有明显改善（P均〈0.01）,而对照组无明显改善（P均〉0.05）;夜间平均收缩压在对照组和治疗组均明显下降（P均〈0.01）;治疗组房颤的平均持续时间缩短（P〈0.05）。结论：缬沙坦治疗原发性高血压合并阵发性心房纤颤能显著改善预测房颤发生的各项指标。     

血管紧张素转换酶抑制剂预防阵发性心房纤颤复发的临床探讨

目的：探讨血管紧张素转换酶抑制剂（ACEI）类药物预防阵发性心房纤颤复发的作用。方法：将46例阵发性心房纤颤患者分为两组,治疗组给予胺碘酮＋卡托普利治疗,对照组只给予胺碘酮治疗,随访1年,观察两组心房纤颤的复发率。结果：治疗组房颤的复发率明显减少,总有效率为96%,对照组总有效率为70%,两组比较,差异有显著性（P〈0.05）。结论：ACEI类药物能减少阵发性心房纤颤的复发率,对房颤有预防复发的作用。     

预见性护理干预在预防阻塞性呼吸暂停综合征并发心房纤颤的应用研究

目的探讨预见性护理干预在预防阻塞性呼吸暂停综合征并发心房纤颤的应用效果。方法选取2015年1月~2016年9月本院收治的100例阻塞性呼吸暂停综合征合并心房颤动患者作为研究对象,根据随机数表法分成对照组和观察组,每组各50例。对照组接受常规护理,观察组在常规护理基础上实施预见性护理干预。比较两组患者的情绪、生命体征、心房纤颤复发率以及并发症情况。结果护理后两组患者焦虑、抑郁评分均低于护理前,且观察组低于对照组,差异有统计学意义(P0.05);护理后两组患者Sp O2、LVEF水平均高于护理前,且观察组高于对照组,差异有统计学意义(P0.05);护理后两组患者BNP、HR水平均低于护理前,且观察组低于对照组,差异有统计学意义(P0.05);护理后观察组心房纤颤转复率高于对照组,心房纤颤复发率低于对照组,差异有统计学意义(P0.05);观察组并发症总发生率低于对照组,差异有统计学意义(P0.05)。结论预见性护理干预能有效减少或预防阻塞性呼吸暂停综合征并发心房纤颤发生,改善患者心理健康水平,降低并发症发生风险。     

快速康复理念应用于胸腹腔镜联合食管癌根治术围术期对术后恢复的影响

[目的]探讨胸腹腔镜联合食管癌根治术围术期应用快速康复理念对术后恢复的影响。[方法]选取行胸腹腔镜联合食管癌根治术的病人78例为研究对象,以随机数字表法分为观察组和对照组各39例,对照组围术期接受常规干预,观察组围术期应用快速康复理念,对两组病人术后恢复情况进行观察。[结果]观察组术后排气时间、镇痛药使用次数、住院时间及胸腔引流管拔除时间与对照组比较差异有统计学意义(P0.05);观察组术后并发症发生率低于对照组(P0.05);对照组病人术后生存质量评分均较观察组低,差异有统计学意义(P0.05)。[结论]胸腹腔镜联合食管癌根治术围术期应用快速康复理念能促进病人术后恢复,控制并发症发生,并能提高病人生存质量。     

质量反馈理论对食管癌病人围术期负性情绪及康复效果的影响

[目的]探讨质量反馈理论对食管癌病人围术期负性情绪、术后并发症及生存质量的影响。[方法]将84例行手术治疗的食管癌病人根据随机数字表法随机分为观察组及对照组各42例,对照组术后给予常规护理,观察组在常规性护理基础上应用质量反馈理论指导围术期护理。干预前后应用焦虑自评表（SAS）、抑郁自评表（SDS）及肿瘤生存质量量表（QOL）对两组病人负性情绪及生存质量进行评价。[结果]观察组干预后 SAS、SDS评分低于对照组（P〈0.05）,QOL 生存质量总评分及各维度评分高于对照组（P〈0.05）;观察组术后并发症发生率为16.67%,对照术后并发症发生率为40.48%,两组并发症发生率比较,差异有统计学意义（P〈0.05）。[结论]质量反馈理论可有效改善食管癌围术期病人负性情绪、降低病人术后并发症发生率、提高病人术后生存质量。     

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.     

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.     

Guns and Knives in New Mexico: Patterns of Penetrating Trauma, 1978–1993

Objective: To identify patterns of nonfatal and fatal penetrating trauma among children and adults in New Mexico using ED and medical examiner data.
Methods: The authors retrospectively sampled in 5-year intervals all victims of penetrating trauma who presented to either the state Level-1 trauma center or the state medical examiner from a 16-year period (1978–1993). Rates of nonfatal and fatal firearm and stabbing injury were compared for children and adults.
Results: Rates of nonfatal injury were similar (firearm, 34.3 per 100,000 person-years; stabbing, 35.1). However, rates of fatal injury were significantly different (firearm, 21.9; stabbing, 2.7; relative risk: 8.2; 95% confidence interval: 5.4, 12.5). From 1978 to 1993, nonfatal injury rates increased for children (p = 0.0043) and adults (p < 0.0001), while fatal penetrating injury remained constant. The increase in nonfatal injury in children resulted from increased firearm injury rates. In adults, both stabbing and firearm nonfatal injury rates increased.
Conclusions: Nonfatal injury data suggest that nonfatal violence has increased; fatal injury data suggest that violent death rates have remained constant. Injury patterns vary by age, mechanism of trauma, and data source. These results suggest that ED and medical examiner data differ and that both are needed to guide injury prevention programs.     

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.     

手转胎头术失败的原因与分娩结局临床分析

目的 探讨手转胎头术失败的原因与分娩结局.方法 选择2008年1月至2010年12月于我院住院分娩的持续性枕横位、枕后位产妇198例,根据行手转胎头术后结果分为成功组126例、失败组72例.比较两组分娩结局,对比分析失败原因.结果 失败组胎儿体质量≥3500 g的发生率[76.4％(55/72)]明显高于成功组[31.7％(40/126)],差异有统计学意义(x2=30.177,P=0.001)、失败组宫缩乏力发生率[58.3％(42/72)]高于成功组[38.1％ (48/126)],差异有统计学意义(x2=7.569,P=0.006)、失败组骨盆临界或轻度狭窄发生率[38.9％ (28/72)]高于成功组[23.8％(30/126)],差异有统计学意义(x2 =5.030,P=0.002)、失败组手转胎头时机不当(宫口开大＜6 cm、胎头位于坐骨棘上及宫口开大8～10 cm、胎头位于坐骨棘下≥2 cm)发生率[61.1％(44/72)]高于成功组[38.9％(49/126)],差异有统计学意义(x2=9.084,P=0.003).失败组母儿并发症(产后出血、产褥病率、胎儿窘迫、新生儿窒息)发生率高于成功组(x2 =9.586,P=0.002、x2=9.334,P=0.002、x2=5.910,P=0.015、x2=5.240,P=0.022)、失败组剖宫产发生率[72.2％(52/72)]明显高于成功组[34.1 ％(43/126),x2=26.641,P=0.001)].结论 手转胎头术能使难产变顺产,降低剖宫产率,减少母儿并发症,但须积极预防、处理导致手转胎头术失败的原因,对矫正失败后继续矫正及试产应慎重.     

Evidence-Based Pain Management and Palliative Care in Issue Four for 2009 of The Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly. Issue 4 for 2009 contains 4027 complete reviews, 1906 protocols for reviews in production, and 11447 one-page summaries of systematic reviews published in the general medical literature. In addition, there are citations of 600,000 randomized controlled trials, and 12,200 cited papers in the Cochrane methodology register. The health technology assessment database contains over 7500 citations. This edition of the Library contains 90 new reviews, of which 19 have potential relevance for practitioners in pain and palliative medicine.