Differences in mortality from coronary artery bypass graft surgery at five teaching hospitals

OBJECTIVE. To measure hospital- and surgeon-specific mortality rates for patients with coronary artery bypass graft (CABG) surgery and to examine possible reasons for any differences. DESIGN. Cohort study using hospital discharge abstracts and itemized bills. SETTING. Five major teaching hospitals in Philadelphia, Pa. PATIENTS. Consecutive sample of all 4613 patients over a 30-month period. MAIN OUTCOME MEASURE. In hospital mortality rates. RESULTS. We observed differences in hospital mortality rates for patients who underwent coronary artery catheterization and CABG surgery during the same admission (diagnosis related group 106) but not for patients who underwent only CABG surgery during the admission (diagnosis related group 107). There were threefold differences in surgeon-specific mortality rates. The hospital mortality rates for coronary artery catheterization and CABG surgery during the same admission changed during the study and coincided with moves of surgeons among study hospitals. Our measures of illness severity did identify patients who were more likely to die, but differences in severity of illness did not explain differences in hospital- or surgeon-specific mortality rates. Patient mortality rates were not associated with the volume of procedures performed by individual surgeons. We found inconclusive evidence for an association with surgeons' clinical skills, and to a lesser extent, with the hospital's volume of procedures and the hospital's organization and staffing. A greater intensity of hospital services was not necessary for a lower mortality rate. CONCLUSIONS. We conclude that studies of CABG mortality should examine mortality rates by diagnosis related group, collect data from more than 1 year, examine associations with surgeons' clinical skills, include information on hospital organization and staffing, and cautiously explore more efficient ways of providing care.     

同期手术治疗心脏病和非心脏疾病

目的: 探讨同期手术治疗心脏病和非心脏疾病的可能性和可行性。方法: 自1999年7月至2018年8月,北京大学第一医院心脏外科联合胸外科、普通外科、泌尿外科、妇产科对111例同时患有心脏病和非心脏疾病的患者同期行心脏手术和其他外科手术,其中男性83例(74.8%)、女性28例(25.2%),年龄41~84岁,平均(64.64±8.97)岁。心脏疾病的构成包括冠心病、心脏瓣膜病、心脏肿瘤、慢性缩窄性心包炎和先天性心脏病;非心脏疾病的构成包括肺部良恶性疾病、胸腺瘤和胸腺囊肿、乳腺癌、胸壁巨大血管瘤、消化道良恶性疾病、泌尿系恶性肿瘤和妇科疾病。观察手术的短期和长期效果。结果: 2例患者术后死亡,住院死亡率为1.8%,其中1例为急诊冠状动脉搭桥术+膀胱癌根治术后第153天因多器官功能衰竭死亡,另1例为心包剥脱术+肺癌手术后第10天因多器官功能衰竭死亡,其余109例患者康复出院。住院期间手术并发症共13例,发病率为11.7%,包括术后出血2例(1.8%),肺部感染及低氧血症3例 (2.7%),上消化道出血1 例(0.9%),切口感染3例(2.7%),膈下脓肿1例(0.9%),术后急性肾功能衰竭及血液滤过3例(2.7%)。109例出院患者中,108例完成随访,所有患者都存活6个月以上,21例患者在随访1~5年期间因肿瘤复发或转移死亡,无心脏源性死亡。随访期间心功能不全1例,行经皮冠状动脉介入治疗1例,术后抗凝过度导致脑出血1例,切口疝1例。结论: 同期手术治疗心脏病和非心脏良性或恶性疾病安全可行,短期和长期生存率均满意。     

Incidence and risk factors of delirium in critically ill patients after non-cardiac surgery

Background Delirium is a common and deleterious complication in critically ill patients after surgery. The purpose of this study was to determine the incidence and risk factors of delirium in critically ill patients after non-cardiac surgery, and to investigate the relationship between the serum cortisol level and the occurrence of postoperative delirium. Methods In a prospective cohort study, 164 consecutive patients who were admitted to the surgical intensive care unit after non-cardiac surgery were enrolled. Baseline characteristics and perioperative variables were collected. Blood samples were obtained on the first postoperative day and serum cortisol concentrations were measured. Delirium was assessed using the Nursing Delirium Screening Scale until the seventh postoperative day or the disappearance of delirious symptoms. Results Postoperative delirium occurred in 44.5% of patients （73 of 164）. The median time to first onset of delirium is 0 （range 0 to 5 days） and the median duration of delirium is 3 （1 to 13） days. Independent risk factors of postoperative delirium included increasing age （odds ratio （OR） 2.646, 95% confidence interval （C/） 1.431 to 4.890, P=-0.002）, a history of previous stroke （OR 4.499, 95%C/1.228 to 16.481, P=-0.023）, high Acute Physiology and Chronic Health Evaluation II score on surgical intensive care unite admission （OR 1.391, 95%C/1.201 to 1.612, P 〈0.001）, and high serum cortisol level on the 1st postoperative day （OR 3.381, 95%CI 1.690 to 6.765, P=-0.001）. The development of delirium was linked to higher incidence of postoperative complications （28.8% vs. 7.7%, P 〈0.001）, and longer duration of hospitalization （18 （7 to 74） days vs. 13 （3 to 48） days, P 〈0.001）. Conclusions Delirium was a frequent complication in critically ill patients after non-cardiac surgery. High serum cortisol level was associated with increased incidence of postoperative delirium.     

非心脏手术患儿围术期死亡的危险因素分析和预警系统建立

目的探讨非心脏手术患儿围术期死亡的危险因素,建立预测死亡的风险评分系统。方法选择2008年1月至2013年12月0~14岁非心脏手术围术期死亡患儿(57例)及非死亡患儿（114例）的临床资料,对其年龄、BMI、ASA分级、是否早产、手术方式、手术类别、体温、血氧饱和度（SpO2）、是否饱胃、手术时间、手术次数、WBC、是否贫血、是否低白蛋白、是否凝血功能异常及是否血电解质异常共17项可能的风险因素进行多因素和单因素分析,确定死亡危险因素,建立预测评分系统。结果多因素回归确定非心脏手术患儿围术期死亡的危险因素为：年龄＞1岁,BMI＜15kg/cm2、ASA≥3级、SpO2＜96%、饱胃、凝血功能异常（均P＜0.05）。非心脏手术患儿围术期死亡发生的风险评分系统如下：年龄＜1岁（14分）,BMI＜15kg/cm2（17分）,ASA≥3级（30分）,SpO2＜96%（22分）,饱胃（16分）,凝血异常（27分）（P＜0.05或0.01）。根据方程绘制ROC曲线,所对应的非心脏手术患儿发生死亡的风险得分为30.5分,灵敏度为98.2%,特异度为89.5%。如患儿得分＞30.5分,则围术期死亡的发生率大大增加。结论非心脏手术患儿围术期死亡的预警评分系统简单易行,结果可靠,可为围术期死亡的早期发现和干预提供帮助。     

基层医院开展突击性大规模白内障复明手术并发症的防治

目的 :探讨边远地区基层医院开展大规模突击性白内障复明手术并发症的防治方法。方法 :回顾性地分析 3 85例 3 94眼白内障手术及其并发症发生的原因。结果 :3 94眼白内障手术中 ,人工晶体植入率为 86 % ,术后发生角膜水肿 8眼 ,前房出血 2眼 ,继发性青光眼 1眼 ,人工晶体偏中心 3眼。所有患者术后出院时视力 (含针孔矫正视力 )较术前明显提高 (P <0 .0 1 ) ,脱盲率达 98% ,脱残率达 86 % ,手术成功率为 1 0 0 %。结论 :术前仔细检查 ,术中细致操作和术后认真观察、及时处理是减少和避免术后发生严重并发症的关键。     

影响学生外科临床实习效果的因素探讨及解决策略分析

分析目前外科临床的实习质量存在的问题及其原因,提出应从增强教学意识,提升教学水平,加强实习管理和改善实习条件等多个方面,促进临床外科实习教学质量的提升。     

Myocardial injury in non-cardiac surgery: complexities and challenges

The term MINS (myocardial injury after non-cardiac surgery) was coined to broadly describe perioperative troponin elevation that is deemed to be due to a cardiac cause. However, this term is commonly used in literature to represent cases that do not fulfil the criteria for the diagnosis of myocardial infarction. Asymptomatic troponin elevation that does not fulfil the criteria for acute coronary syndrome in the perioperative setting has been shown to be associated with increased mortality. The discovery of MINS presents new opportunities to improve outcomes for surgical patients. Unfortunately, awareness of MINS among practitioners remains low and implementation of perioperative troponin monitoring is poor. Given its significance, the detection, management and prevention of MINS should not be overlooked.     

不同全身麻醉剂对老年冠心病患者实施非心脏手术后不良事件的影响

目的 探讨3种不同全身麻醉剂对老年冠心病患者实施非心脏手术后不良事件发生率及死亡率的影响,为优化麻醉策略奠定基础.方法 择期行非心脏手术的老年冠心病患者65例,ASAⅢ级或Ⅳ级,年龄60～80岁,随机分为七氟醚组(S组,n=20)、丙泊酚组(P组,n=25)和咪达唑仑组(M组,n=20),分别以七氟醚-芬太尼-维库溴铵、丙泊酚-芬太尼-维库溴铵和咪达唑仑-芬太尼-维库溴铵实施麻醉诱导及维持.术中常规监测患者生命体征,术后3 d內观察随访恶心、呕吐、高血压、低血压、心律失常、心绞痛、急性心肌梗死、急性心衰的发生情况.结果 S组患者术后2 h内恶心、呕吐的发生率明显高于P组与M组,差异有统计学意义(P<0.05),3组间术后3 d内心律失常、心绞痛的发生率差异有统计学意义(P<0.05),M组患者出院后30 d内心绞痛的发生率明显高于S组(P<0.05),3组间其他不良事件的发生率及死亡率的差异无统计学意义.结论 老年冠心病患者行非心脏手术时,咪达唑仑容易诱发术后心脏相关不良事件的发生,七氟醚具有一定的心肌保护作用,心脏相关不良事件的发生率较低,但术后早期恶心呕吐发生率较高.     

东莨菪碱对非心脏手术后老年患者早期认知功能障碍发生率的影响

目的:观察术前应用东莨菪碱对老年患者全麻下非心脏手术后早期认知功能障碍发生率的影响.方法:选择全麻下行择期非心脏手术且年龄≥60岁的老年患者121(男78,女43)例,随机分为东莨菪碱组和对照组.东莨菪碱组在麻醉诱导前10 min静脉注射东莨菪碱(5μg/kg);对照组则给予等容积生理盐水,麻醉诱导后持续微量泵注射瑞芬太尼及吸入异氟醚、间断注射维库溴铵维持麻醉.分别在术前及术后第7日进行神经心理学评估,采用简易智力量表、数字广度测试、数字符号测试、循迹连线测试和小故事记忆测试等5项测试.结果:因各种原因,仅有64例患者完成全部测试,其中东莨菪碱组35例,对照组29例.两组患者身高、体质量、性别、受教育年限等一般资料及手术时间和麻醉药物总量差异无统计学意义(P＞0.05).东莨菪碱组术后认知功能障碍(POCD)发生率为25.7%,对照组为24.1%,两组间差异无统计学意义(P＞0.05).结论:术前静脉注射5μg/kg东莨菪碱对老年患者非心脏手术POCD发生率无显著影响.     

基层医院开展突出性大规模白内障复明手术并发症的防治

目的：探讨边远地区基层医院开展大规模突击性白内障复明手术并发症的防治方法，方法：回顾性地分析385例394眼白内障手术及其并发症发生的原因。结果：394眼白内障手术中，人工晶体植入率为86％，术后发生角膜水肿8眼，前房出血2眼，继发性青光眼1眼，人工晶体偏中心3眼，所有患者术后出院时视力（含针孔矫正视力）较术前明显提高（P＜0．01），脱盲率达98％，脱残率达86％，手术成功率为100％，结论：术前仔细检查，术中细致操作和术后认真观察，及时处理是减少和避免术后发生严重并发症的关键。     

PCI术后患者再行非心脏手术的抗凝方案研究

目的 探讨经皮冠状动脉介入治疗(PCI)术后患者再行非心脏手术围术期早期抗凝治疗方案.方法 选择2014年1月至2016年6月于该院诊断及治疗的PCI术后行非心脏手术患者71例,于择期手术前予以低分子肝素治疗,术后分为抗凝组与非抗凝组,观察术后心脏不良事件的发生情况.结果 两组患者的性别、年龄、合并高血压、糖尿病、支架长度等一般指标及并发症情况比较,差异无统计学意义(P＞0.05).术后7d内,抗凝组出现3例不稳定型心绞痛患者,非抗凝组出现10例,两组比较差异有统计学意义(P＜0.05).抗凝组和非抗凝组患者术后24 h磷酸肌酸激酶(CK)水平均较术前升高(P＜0.05),CK同工酶(CK-MB)、肌钙蛋白Ⅰ(cTnI)水平虽较术前有升高趋势,但差异无统计学意义(P＞0.05).两组患者术前及术后24 h CK、CK-MB、cTnⅠ水平比较,差异无统计学意义(P＞0.05).结论 PCI术后1年内的患者再行非心脏手术,围术期予以抗凝治疗可明显降低心脏不良事件的发生.     

肺癌手术死亡和术后严重并发症及其风险因子的多因素分析

目的 调查肺癌病人的手术死亡和术后并发症，并评价他们的风险因子。方法 回顾性分析了528例手术治疗的肺癌病人的手术死亡和术后严重并发症的情况，并通过单因素分析和多因素分析鉴别出他们的风险因子。结果 手术死亡率为2．8％，全肺切除和冠心病是手术死亡的独立风险因子，全肺切除、冠心病和FEV1≤60％是发生术后严重并发症的独立风险因子。结论 全肺切除是影响手术结果最重要的风险因子，手术死亡的主要原因是严重的心肺并发症，预防并治疗术后严重的心肺并发症可以提高肺癌外科治疗的效果。     

Prescribing patterns of antibiotics at two teaching hospitals in Sanandaj

We report here the results of a prospective analysis of the pattern of antibiotics use over a one month period （May 2009） at two teaching hospitals in Sanandaj, western part of Iran. Data on antibiotic usage were obtained from the pharmacy services. Data was coded, computed and analyzed using SPSS version 11.5. A total of 1336 and 556 patients from Beasat and Tohid hospital respectively received antibiotic. Male patients represented 758 （41. 5 %） and females 1080 （58.5 % ） of the total number of patients evaluated by physicians at the two hospitals during the one month period. Usage of antibiotics varied from hospital to hospital; Beasat hospital had the highest usage. The ward-wise distribution of antibiotic use showed that the prevalence of prescribing was highest in the post partum ward （66.58%）. Similarly, a- mong Tohid hospital wards, men surgical ward and women surgical ward prescribed antibiotics significantly more than all other wards. The route of administration of antibiotics was parentrally for 85.5% and 88.2% at Beasat anf Tohid hospitals respectively. The distribution of use of individual antibiotics showed that cepfzoline was the most frequently prescribed antibiotics used at both the hospitals. Delivery （childbirth） and pneumonia were the most frequent diagnosed pat tern for which an antibiotic was prescribed at Beasat and Tohid hospital respectively. In conclusion our study suggests that there is considerable scope for improving prescribing pattern among the practitioners and minimizing the use of antibiotics. The improvement would be facilitated by providing feedback, prescriber education and hospital formulary.     

老年住院病人的心理问题及护理对策

随着人类社会的不断发展 ,科学的不断进步 ,生活水平的不断提高 ,我国老年人在人口中的比例不断增加 ,据有关资料报道 ,目前我国的“银色群体”已占人口总数的 1 / 4 ,因此关爱老人 ,了解老人 ,重视老年病人的心理健康就成为当今护士必须面对的首要问题。1　心理问题分析1 .1　紧张恐惧心理老年人一般都有慢性或老化性疾病 ,而当某种疾病较重需要住院时 ,他们对病情的估计较为悲观 ,担心自己得了不治之症 ,而产生强烈的紧张恐惧心理。1 .2　焦虑多疑心理老年人住院后对疾病的转归和预后过分担心 ,能否治愈 ,有无并发症及后遗症 ,昂贵的医疗…     

非心脏手术患者围手术期钾离子紊乱的病理生理学及其治疗和预防的研究进展Research progress in pathophysiology,treatment and prevention of perioperative potassium disturbance in non-cardiac surgery patients

非心脏手术围手术期钾离子（K⁺）紊乱最严重的危害是诱发危及生命的心律失常、心脏骤停和呼吸肌麻痹。围手术期患者K⁺摄入异常、排出异常、跨细胞分布异常以及机体内K⁺与其他离子的相互作用异常时,均可导致K⁺稳态失衡。某些基础疾病、遗传疾病和临床用药也会影响患者K⁺稳态。K⁺紊乱在围手术期的高发生率以及其与非心脏手术严重意外不良事件的相关性,引起了研究者的广泛关注,加强高危患者K⁺监测对于K⁺紊乱的早发现、早诊断、早治疗以及治疗后的再评估有积极意义。维持患者围手术期K⁺稳态已成为近年来研究的热点,研究者应需了解一些新的治疗方法、治疗药物和预防理念。现回顾近年来关于K⁺紊乱的相关研究进展,就非心脏手术围手术期K⁺紊乱的病理生理原因及其临床现状、治疗和预防的新进展进行综述,为临床医生系统提高K⁺紊乱的关注度,寻求更合理的方法预防和治疗K⁺紊乱提供新的思路。     

Referral to medical outpatients department at teaching hospitals in Birmingham and Amsterdam

A method of comparing the referral of patients by general practitioners to medical outpatients departments at teaching hospitals in Amsterdam and Birmingham was devised. This was applied to 89 referral letters to medical specialists at the Free University Medical School Policlinic in Amsterdam and to 88 referral letters to clinics at Birmingham University Medical School, UK. The standards of referral were lower in the Netherlands than in Britain, and this may be related to differences in the health care systems, in the culture, or in the organisation of general practice. The delay between the general practitioner's referral and the consultation to the outpatient department was four times greater in Britain than in the Netherlands.