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1.
Elizabeth D. Krebs Robert B. Hawkins J. Hunter Mehaffey Clifford E. Fonner Alan M. Speir Mohammed A. Quader Jeffrey B. Rich Leora T. Yarboro Nicholas R. Teman Gorav Ailawadi 《The Journal of thoracic and cardiovascular surgery》2019,157(4):1533-1542.e2
Objectives
Expedient extubation after cardiac surgery has been associated with improved outcomes, leading to postoperative extubation frequently during overnight hours. However, recent evidence in a mixed medical-surgical intensive care unit population demonstrated worse outcomes with overnight extubation. This study investigated the impact of overnight extubation in a statewide, multicenter Society of Thoracic Surgeons database.Methods
Records from 39,812 patients undergoing coronary artery bypass grafting or valve operations (2008-2016) and extubated within 24 hours were stratified according to extubation time between 06:00 and 18:00 (day) or between 18:00 and 6:00 (overnight). Outcomes including reintubation, mortality, and composite morbidity-mortality were evaluated using hierarchical regression models adjusted for Society of Thoracic Surgeons predictive risk scores. To further analyze extubation during the night, a subanalysis stratified patients into 3 groups: 06:00 to 18:00, 18:00 to 24:00, and 24:00 to 06:00.Results
A total of 20,758 patients were extubated overnight (52.1%) and were slightly older (median age 66 vs 65 years, P < .001) with a longer duration of ventilation (4 vs 7 hours, P < .001). Day and overnight extubation were associated with equivalent operative mortality (1.7% vs 1.7%, P = .880), reintubation (3.7% vs 3.4%, P = .141), and composite morbidity-mortality (8.2% vs 8.0%, P = .314). After risk adjustment, overnight extubation was not associated with any difference in reintubation, mortality, or composite morbidity-mortality. On subanalysis, those extubated between 24:00 and 06:00 exhibited increased composite morbidity-mortality (odds ratio, 1.18; P = .001) but no difference in reintubation or mortality.Conclusions
Extubation overnight was not associated with increased mortality or reintubation. These results suggest that in the appropriate clinical setting, it is safe to routinely extubate cardiac surgery patients overnight. 相似文献2.
A mixed‐method study of effects of a therapeutic play intervention for children on parental anxiety and parents' perceptions of the intervention
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Transcutaneous oxygen (TcPO(2)) measurements provide a noninvasive, objective determination of the oxygen level at the skin surface. This offers a means of estimating the underlying circulation and tissue oxygenation. The purpose of the pilot study was to measure the TcPO(2) value of the lower extremity of healthy men and women and of patients with peripheral arterial disease (PAD) in 4 different body and leg positions 24 hours after peripheral vascular surgery reconstruction. The specific aim was to determine if lower-extremity TcPO(2) measurements were affected by changes in extremity position in these subject populations. A convenience sample of 4 healthy health care professionals and 4 patients who had peripheral vascular reconstruction surgery 24 hours before the measurements were studied. Subjects were studied in 4 different leg and body positions: supine with legs extended, sitting with legs dependent, a 5 degrees head-up reverse Trendelenburg, and supine with legs elevated 10 in. The Radiometer TCM30 TcPO(2) monitor was used to carry out these measures. Findings revealed a statistically significant difference in TcPO(2) measurements between the 2 groups, with the healthy subjects having a significantly higher TcPO(2) measurement in all extremity positions compared with the revascularized subjects with PAD (P =.02-.05). Significant changes were noted in both the foot temperature (P =.03) and TcPO(2) measurements with extremity positions within the healthy subject group (P =.001). The foot and leg TcPO(2) measurements affect from leg and body position did not reach significance (P =.09) in the subjects with PAD. No change in foot temperature with extremity positioning (P =.42) was noted in the subjects with PAD. This pilot study provides a base in which additional research will be performed with TcPO(2) measurements in both the healthy and revascularized person. 相似文献
5.
Scott A Fields Elizabeth Morrison Ernie Yoder Kevin Krane Thomas Agresta Rich Esham Frederick McCurdy Jonathan Rosen James Shumway 《Academic medicine》2002,77(6):543-546
PURPOSE: Chart notes are used to support billing codes under the evaluation and management guidelines of the Health Care Financing Administration (HCFA), in addition to serving as a record of the visit. To better understand the effect of the HCFA documentation guidelines, the authors collected data on how the guidelines affect participation by university- and community-based faculty in clinical education programs. METHOD: In 2000, the authors sent six copies of their questionnaire to the associate deans of the 125 U.S. medical schools and requested they distribute them to all core clerkship directors. The questionnaire consisted of multiple-choice and short-answer questions regarding documentation of medical visits, participation of community-based faculty, understanding of HCFA documentation guidelines, and effects on education programs. RESULTS: The response rate was about 50%. Most of the 379 clerkship directors who responded (77%) stated they were aware the HCFA documentation guidelines include specifications regarding the role medical students can play and documentation of medical visits, and 64% indicated they were concerned the guidelines would affect their educational programs. Concerns included the loss of student independence and active participation in the patient care environment (37), time constraints and the changing balance between education and service (16), loss of faculty and decreased morale (11), and decreased quality of care for patients (7). CONCLUSION: Leaders of medical education must work to modify these guidelines to protect the quality of patients' care, while maximizing students' educational opportunity and participation. 相似文献
6.
Hysterosalpingography was performed in 31 patients by means of a low-dose scanning-beam digital radiographic system. The technique permits adequate evaluation of gynecologic abnormalities while allowing significant reduction in radiation: 2.4-mR (6.1 X 10(-7) C/kg) exposure to the skin and 0.7-mrad (7 X 10(-6) Gy) mean dose to the ovaries per image obtained. Sixteen patients demonstrated readily recognizable and documented abnormalities, corroborated by laparoscopy, laparotomy, or other supportive evidence. 相似文献
7.
Death of sensory ganglion neurons after acute withdrawal of nerve growth factor in dissociated cell cultures 总被引:1,自引:0,他引:1
The time course of dependence on nerve growth factor (NGF) for survival in sensory neurons in vitro was examined with microscopic and biochemical methods. Primary dorsal root ganglion (DRG) cultures from embryonic-day-15 (E-15) and day-19 (E-19) rats were maintained with standard dissociated cell culture techniques in the absence of most non-neuronal cells. After various times in culture, neurons were acutely deprived of neurotrophic support by changing to NGF-free medium and adding NGF antiserum to eliminate any residual NGF. Neuronal cultures were examined with phase microscopy; and, their metabolic activity was measured with a protein assay at various time points after NGF deprivation. E-15 neurons grown in culture for 5 days were exquisitely sensitive to acute NGF deprivation. By 12 h after NGF deprivation, neuronal morphology was severely disrupted and the majority of neurons appeared dead. E-15 neurons grown in culture for 8 or 11 days showed progressively less dependence on NGF for survival. These older neurons did not die until 24 and 48 h, respectively, following NGF withdrawal. Neurons grown in culture for 20 days did not show any morphologic changes by phase microscopy up to 4 days after NGF deprivation. Protein incorporation progressively decreased between 12 and 48 h after NGF withdrawal in E-15 neurons grown in culture for 5, 8, or 11 days.(ABSTRACT TRUNCATED AT 250 WORDS) 相似文献
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Anu Kilpi Alison M. Rich Yrjö T. Konttinen Peter C. Reade 《European journal of oral sciences》1996,104(3):278-284
Oral mucosal lichen planus (OMLP) is a well recognized mucosal disease with unknown etiology. Considerable controversy exists as to whether OMLP is intrinsically premalignant, or if the disorder facilitates the development of oral mucosal squamous cell carcinoma (OMSCC) by external factors. The aim of the present study was to investigate the expression of c-erbB-2 protein in the keratinocytes of initial biopsies of oral mucosal disorders diagnosed as OMLP with no evidence of epithelial dysplasia. and to compare the results with the expression of c-erbB-2 protein in subsequent biopsies obtained from the same patients. These results were compared with the findings from control groups (patients with dysplasia with no evidence of OMLP, patients with OMSCC with no evidence of OMLP and normal oral mucosa). The expression of the c-erbB-2 protein was evaluated by immunohistochemical staining of the gene product with the avidin-biotin-complex method using paraffin-embedded tissue sections. Five of the initial biopsies from patients with OMLP expressed the c-erhB-2 protein and one did not. None of the OMLP cases that subsequently showed evidence of dysplasia expressed the c-erhB-2 protein, and of the three OMSCC specimens from the patients with OMLP. two were negative and one expressed c-erbB-2 protein. The specimens from the control groups all expressed the c-erhB-2 protein. The results indicated the probability of the absence of c-erbB-2 staining being an indication of a potential for neoplastic transformation in OMLP with dysplastic changes. 相似文献
10.
The sequence and configuration of amino acids in the cytostatic cyclic tetrapeptide WF-3161 are established as cyclo(L-Leu-L-Pip-L-Aoe-D-Phe) where Pip = pipecolic acid and Aoe = 2-amino-8-oxo-9,10-epoxydecanoic acid. In chloroform, WF-3161 adopts a conformation with a possible gamma-turn between Leu NH and Aoe C = O and a cis amide bond between Leu and Pip. The torsion angles for this conformation are L-Aoe, phi, -95 degrees, psi, +85 degrees, omega, -155 degrees; D-Phe, phi, +120 degrees, psi, -80 degrees, omega, -175 degrees; L-Leu, phi, -145 degrees, psi, +35 degrees, omega, -10 degrees; L-Pip, phi, +20 degrees, psi, -135 degrees, omega, -170 degrees. The cis,trans,trans,trans amide bond sequence is related to the dimethyl sulfoxide conformation of chlamydocin, another cytostatic cyclic tetrapeptide. 相似文献