基于RoSCo评分系统的早期下床活动时机在肾部分切除术患者中的应用

目的 探讨基于RoSCo评分系统的早期下床活动时机在肾部分切除术患者中的应用效果。方法 将108例肾部分切除术患者按照住院时间分为对照组53例和试验组55例。对照组采用常规加速康复外科理念下的早期下床活动,根据患者术后意识、生命体征、疼痛、引流液量等评估结果决定下床活动时机,试验组在对照组的基础上术前基于RoSCo评分系统的手术并发症风险等级综合确定术后早期下床活动时机。结果 试验组术后首次下床活动时间、首次排气时间、术后住院时间显著短于对照组(均P<0.05),两组术后并发症及30 d内再入院率差异无统计学意义(均P>0.05)。结论 基于RoSCo评分系统确定早期下床活动时机有利于促进肾部分切除术后患者快速康复,且不增加手术并发症的发生率及非计划性再入院率。     

手术后腰椎间隙感染10例诊疗体会

目的：探讨手术后腰椎间隙感染的临床特点及早期诊疗措施。方法：对手 腰椎间隙感染１０例的临床资料及特点进行分析总结。结果：１０例均有术后腰腿痛加剧,５例早期血沉增快,５例经ＭＲＩ检查早期诊断,７例切口一期愈合,２例行病灶切开引流二期愈合,１例术后第９天死亡。结论：腰腿痛症状加剧血沉增快是早期诊断的重要的依据,ＭＲＩ检查是早期诊断有效的方法,治疗上应抓住抗生素、制动及严重病例早期病灶清除三个环节。     

Tomita及改良Tokuhashi结合脊柱肿瘤不稳评分在脊柱转移瘤患者治疗决策中的可信度和可重复性研究

目的 :分析Tomita评分结合脊柱肿瘤不稳评分(spinal instability neoplastic score,SINS)和改良Tokuhashi评分结合SINS评分用于脊柱转移瘤患者治疗决策的可信度和可重复性,评价两套评分系统临床运用价值。方法:3名具有一定临床经验的脊柱外科医生对41例脊柱转移瘤患者进行回顾性分析。这3名脊柱外科医生用Tomita评分、改良Tokuhashi评分、SINS评分对每位患者进行评分,并运用改良Tokuhashi结合SINS评分及Tomita结合SINS评分决定患者的治疗方案。间隔20天后对上述病例进行重复分析,分析观察者间一致性和观察者内一致性。结果:Tomita结合SINS评分用于治疗决策时,平均观察者间一致性Kappa值为0.78(0.75~0.81),平均观察者内一致性Cronbach′sα系数为0.79(0.77~0.82)。改良Tokuhashi结合SINS评分用于治疗决策时,平均观察者间一致性Kappa值为0.68(0.65~0.72),平均观察者内一致性Cronbach′sα系数为0.73(0.72~0.75)。有17.9%的患者在两组系统评估后而得出不同治疗方案。结论:Tomita结合SINS评分和改良Tokuhashi结合SINS评分均具有较好的可信度和可重复性。     

Renal injury in the elderly: diagnosis, biomarkers and prevention

Acute kidney injury (AKI) in the elderly patient is a common iatrogenic complication of major surgery that impacts morbidity, mortality and resource use. Several renal functional and structural changes have been described, including a substantially decreased nephron mass. Loss of renal function defines AKI and is classified by the RIFLE (R: renal risk, I: injury, F: failure, L: Loss and E: End-stage renal disease) criteria; however, it frequently occurs many hours to several days after the injury to the kidney. Therefore, novel biomarkers indicating tubulo-interstitial damage are needed for early AKI diagnosis. The limitations of serum creatinine are much more pronounced in the elderly, including its dependence on muscle mass and the presence of multiple drug use and co-morbidities. Although it is conceivable that earlier AKI diagnosis and application of classical preventive measurements, including postponement of surgery or preference of medical treatment, optimisation of haemodynamics, euvolaemia, aggressive avoidance of nephrotoxic antibiotics or analgesics may translate into better patient outcomes, much more data are needed in this specific cohort.     

加速康复外科理念下胰十二指肠切除术后早期进食与乳糜瘘相关性研究

目的 探讨胰十二指肠切除术后早期进食的安全性及其与乳糜瘘的发生和严重程度是否具有相关性。 方法 回顾性分析宿迁医院2014年6月至2018年6月123例胰十二指肠切除术患者临床资料,排除28例导管肠内营养治疗患者,共有95例患者纳入研究,依据患者是否术后早期进食分为早期进食组（46例）和对照组（49例）,比较两组患者术后恢复情况和乳糜瘘的发生率及严重程度。 结果 早期进食组术后住院时间短于对照组的[（13.6±7.8）d vs（17.8±12.4）d,P=0.047]。早期进食组乳糜瘘10例,其中A级7例、B级3例;对照组乳糜瘘10例,其中A级6例、B级4例;两组乳糜瘘发生率无统计学差异[21.7%（10/46）vs     

Managing sedation withdrawal in children who undergo prolonged PICU admission after discharge to the ward

Children who undergo a prolonged stay within the intensive care unit require adequate sedation and analgesia. During the recovery phase there will need to be a period of sedation withdrawal to prevent occurrence of an abstinence syndrome. We present a strategy developed within our hospital for managing this process which uses the resource of the Pain Service, along with guidelines to help prevent the development of withdrawal, and a plan for managing any signs of abstinence which occur.     

各评分系统对胰腺炎疾病严重程度预测价值的临床研究

目的：探讨各评分系统对急性胰腺炎（acute pancreatitis,AP）疾病严重程度预测价值的差异。方法回顾性分析156例 AP 患者的临床资料,记录患者入院时的 c-反应蛋白（CRP）等实验室检测值,结合中国胰腺炎诊治指南（2007）将患者分为轻症胰腺炎（mild acute pancreatitis, MAP）组、重症胰腺炎（severe acute pancreatitis,SAP）组。按照各评分系统的相应评分标准对患者进行急性生理学和慢性健康状况评分（APACHEⅡ）、Ranson、BISAP、CTSI 评分。按照APACHEⅡ≥8分、Ranson≥3分、BISAP≥2分、CTSI≥3分、CRP≥21．4 mg／L 的标准分别将患者区分为 MAP 组、SAP 组,ROC 曲线比较各评分系统对 AP 疾病严重程度预测价值的差异。结果156例 AP 患者,确诊为 SAP21例,另135例诊断为 MAP。APACHEⅡ≥8分、Ranson≥3分、BISAP≥2分、CTSI≥3分、CRP≥21．4 mg／L 预测 SAP 的 AUC 分别为0．78（95％CI：0．70～0．84）,0．69（95％CI：0．62～0．76）,0．74（95％CI：0．66～0．80）,0．69（95％ CI：0．61～0．76）,0．68（95％CI：0．57～0．78）,各评分系统间差异无统计学意义。结论各评分系统对 SAP 的预测价值差异无统计学意义,在临床工作中,SAP 的早期预测应参考多种评价体系,临床获取及应用更为简便的单一实验室指标的参考意义,值得进一步深入研究。     

Which children could benefit from additional diagnostic tools in case of suspected appendicitis?

Background

New diagnostic tools such as ultrasound scan, computed tomography (CT) scan, and diagnostic laparoscopy, have become available for children with suspected appendicitis but should be reserved for equivocal cases. The aim of this study was to develop a scoring system to identify this subgroup of children.

Methods

Patients from 2 different periods (period 1, 99 consecutive children [group 1] and period 2, 62 consecutive children [group 2] with suspected appendicitis) were prospectively evaluated. Variables predicting appendicitis were obtained from group 1. By means of a regression analysis, a scoring system was created and applied to the patients of group 2. Missed appendicitis and negative appendectomy rates obtained by clinical practice were compared with the results that would have been accomplished based on the scoring system. Thereafter, the scoring system was externally validated in a group of children presented at another hospital (group 3, n = 114).

Results

The variables, leukocyte count ≥ 10.10⁹/L (2 points); rebound tenderness (2 points); and temperature ≥ 38°C (1 point) correlated significantly with appendicitis. The scoring system was used to categorize patients into 3 groups: appendicitis unlikely, doubtful appendicitis, and suspected appendicitis. The specificity and sensitivity of the scoring system were, respectively, 85% and 89%. Applying the scoring system would lead to comparable negative appendectomy rates of 8% versus 6% using clinical judgement and a comparable number of performed laparoscopies (26% v 31%). However, it could lead to a lower missed appendicitis rate (1% v 6%) and a lower perforation rate (0% v 11%). External validation showed comparable performed laparoscopies (32%) and missed appendicitis (2%) rates but a higher negative appendectomy rate (19%), probably owing to a lower percentage of appendicitis in hospital (2, 47%) compared with hospital (1, 71%).

Conclusions

Children can be observed if leukocyte count is less than 10.10⁹/L and rebound tenderness is absent; a diagnostic laparoscopy should be performed if one of these is present, and if both are present one could perform an appendectomy.     

智能化护理风险防控系统的建立与应用

目的 指导护士识别并预警护理风险,提供风险防控计划及措施的决策支持.方法 建立智能化护理风险防控系统,经过文献检索、循证证据筛选、德尔菲专家咨询,筛选护理风险指标、确定护理风险的评估工具、制订评估指引及一系列针对不同风险及不同风险级别的防控措施,与电子病历整合,优化界面与功能.培训后在全院普通病区应用.护理部每季度审核各病区使用情况、统计不良事件发生率,并自行设计问卷进行满意度调查.结果 全院普通病区应用率达100％,应用后压力性损伤发生率显著下降(P＜0.05);护士对该系统的整体满意率为90.56％,对系统能够提高工作效率、保障患者安全、提供科学的决策支持的赞同率分别为85.66％、84.30％和89.66％.结论 智能化护理风险防控系统能够增强护士对护理风险的预见性及风险管理意识,提高工作效率,降低护理不良事件发生率,保障患者安全.     

Referral proformas improve compliance to national colorectal 2‐week wait targets: does this affect cancer detection rates?

Aim To facilitate implementation of National Institute for Health and Clinical Excellence (NICE) guidelines for urgent colorectal cancer referral, local cancer networks have promoted the use of standardized proformas in primary care. This clinical audit assessed use of the proforma within the Thames Valley Cancer Network (TVCN) to see whether increased proforma use was associated with higher compliance to NICE guidelines and higher cancer detection rates. Method All 2‐week wait referrals for lower bowel cancer to the six Acute NHS Trusts in the TVCN received during the month of June 2010 were identified, anonymized and analysed in relation to colorectal cancer detection rates. Results Of the 586 referrals audited, proforma usage varied significantly across the six Acute NHS Trusts from 18% to 96%. Referral letters from primary care had NICE compliance ranging from 30 to 50%. In those which received a referral protocol, 50–90% were NICE compliant. Proforma use was associated with higher cancer detection rates (P = 0.03). Conclusion These results have wide‐ranging implications since they suggest that the adoption of a simple proforma in primary care can improve the effectiveness of referral for suspected cancer.     

前列腺特异性抗原前体用于前列腺癌早期诊断

PSA前体(proPSA)是血清游离PSA的特殊形式,由天然proPSA及其各种剪接的亚型组成,其中[-2]proPSA和[-4]proPSA和前列腺癌(PCa)的相关性高于[-7]proPSA和[-5]proPSA。临床研究表明,[-2]proPSA可以显著提高PCa的检测能力,特别是血清PSA低于4μg/L时。本文对proPSA的形成机制、特点及其对PCa早期诊断的影响进行了综述。     

Application of high-dose rate Co remote after loading system for local recurrent neuroblastoma

The local control of neuroblastoma is a very important treatment consideration. We describe a patient who received high-dose rate 60Co remote after loading system treatment for local control of recurrent neuroblastoma and discuss the efficacy of high-dose rate 60Co remote after loading system treatment.