以复方电解质为溶剂的羟乙基淀粉溶液研究进展

背景 羟乙基淀粉(hydroxyethylstarch,HES)是一种临床上广泛应用于容量替代和改善微循环的血浆代用品.以0.9%的NaCl溶液作为溶剂的HES,我们称之为非生理性的胶体,但过多的输入易导致高氯性酸中毒.近来,已研制出以复方电解质为溶剂的HES溶液,或可大大提高HES的安全性.目的 此文回顾了HES的基本理化性质及HES的研发历程,并讨论了新型的以复方电解质为溶剂的羟乙基淀粉溶液在维持酸碱平衡、凝血和肾功能等方面的优势.内容 越来越多的证据显示HES溶液与传统的HES相比,能够更好的维持酸碱平衡,对凝血功能的影响更小,在增加微循环灌注等方面也有独特的优势.此外,"生理性容量替代治疗"的初步研究结果也令人鼓舞.趋向 以复方电解质为溶剂的胶体在临床将会得到更为广泛的应用,"生理性容量替代治疗"的策略也为临床提供了良好的思路.     

Hypothermia for cardiac arrest

Therapeutic hypothermia for cardiac arrest survivors has emerged as a highly effective means of improving neurologic outcome. There are a number of purported mechanisms by which it is felt to be effective, but the exact mechanism is unknown. This article reviews the biochemical mechanisms of injury occurring in cardiac arrest, as well as the avenues that hypothermia takes to combat this injury. It also reviews the animal model data in support of this, as well as the newer animal studies that may help to improve the field. Several human studies of hypothermia in cardiac arrest have been performed, and this article reviews these for their methods and shortcomings. Our currently recommended guidelines for performing therapeutic hypothermia are presented. With therapeutic hypothermia comes potential risks to the patient, primarily affecting cardiac, metabolic, and hematologic systems, and these risks and their management are discussed. Multiple methods of cooling exist, including selective cranial as well as systemic cooling by internal or external approaches. Finally, the article discusses the current research in the field of hypothermia for cardiac arrest and implications for future practice.     

The Objective of Psychological Evaluation in the Process of Qualifying Candidates for Bariatric Surgery

Psychosocial and behavioral variables play an important role in both the development and treatment of obesity. Therefore, in the process of qualifying the patient for bariatric surgery, it is necessary to professionally evaluate his/her psychological state. Such evaluation is very helpful in the identification of factors potentially disturbing the effectiveness of the treatment. Clinical interviews with a group of 80 patients were conducted by a psychologist in the pre- and post-surgical period. The qualitative analysis of the interviews led to the identification of the major elements which should become the object of psychological evaluation in the process of qualifying patients for bariatric surgery. Conducting a clinical interview comprising these elements allows one to evaluate their potential influence on the process of surgical treatment of obesity and to provide optimal psychological support for the patient before and after the surgery.     

Incidence and Impact of Risk Factors in Critically Ill Trauma Patients

There is a paucity of data describing the incidence of pre-existing diseases or risk factors and their effects in trauma patients. We conducted a prospective study to determine the incidence of such factors in critically ill trauma patients and to evaluate their impact on outcome. The study, performed over a 2-year period, examined the hospital course of all trauma patients admitted to the ICU. Multiple risk factors were evaluated and analyzed via multivariate regression analysis. Outcome was evaluated by infection rate, hospital length of stay, ventilator days, and mortality matched for age and Injury Severity Score (ISS). A total of 1172 patients (73% blunt injury) were enrolled over the study period. Of these, 873 (74.5%) were male. The mean age was 42.5 years with an ISS of 19.8. Tobacco use (24%) was the most common risk factor identified, followed by hypertension (HTN, 17%), coronary artery disease (9%), chronic obstructive pulmonary disease (COPD)/reactive airway disease (4%), non-insulin-dependent diabetes (NIDDM) (4%), insulin-dependent diabetes (IDDM) (3.2%), cancer (3%), liver disease (2%), and HIV/AIDS (1.4%). Of these risk factors, IDDM was found to be an independent risk factor for infection (0.004) and ventilator days (0.047), increasing age was found to be an independent risk factor for hospital length of stay (0.023) and mortality (<0.001), and HTN was found to be an independent risk factor for increased ventilator days (0.04). In addition, COPD/reactive airway disease was found to be an independent predictor of ventilator days, infection, and ICU days (P < 0.05). Thus, increased age, IDDM, COPD, and HTN are most predictive of outcome in critically ill trauma patients. With our aging population it is becoming increasingly important to identify pre-existing risk factors on admission in order to minimize their effects on outcome. Presented at the 2005 Annual Scientific Meeting of the South Eastern Surgical Congress, February 11–15, 2005,New Orleans, Louisiana.     

Suicide mortality in South Africa

BACKGROUND: South Africa offers a valuable study environment to assess the impact of political and social changes on health. Increasing urbanisation has led to a focus on city development and its effect on its residents. The study assesses whether sex- and race-specific suicide rates differ across six of South Africa's major cities. Regional differences may reflect varying contextual and individual underlying mechanisms. Those need to be understood for appropriately targeted prevention efforts. METHODS: Suicide mortality data (n=4,946) for the six cities between 2001 and 2003 were used to assess whether there are differences in rates for age-standardised race and sex groups across cities and whether these differences are constant across cities. The overall age-standardised rates for the six cities was 25.3/100,000 for men and 5.6/100,000 for women. RESULTS: Suicide rates are most often highest among whites and men, but both the magnitude and distribution of suicide vary considerably for different race and sex groups within and across cities. There is a strong association between the method of suicide used and the city. CONCLUSIONS: Despite some common trends in the suicide profile across South African cities, city does matter for the magnitude and distribution of suicide mortality across race and sex groups and for the method of suicide used. The need for locally based suicide research investigating possible reasons for these differences is highlighted.     

Suicide mortality and agricultural rationalization in post-war Europe

BACKGROUND: The relationship between agricultural rationalization and suicide mortality has been little researched. On the basis of the hypothesis that agricultural rationalization leads to more suicide, this study investigated whether a general relationship could be found between structural change in agriculture and suicide mortality in post-war Europe. METHOD: Due to the expected small size of the effect, the data were deliberately collected so as to maximize the variation in the independent variable. Annual national-level data on suicide mortality, the percentage of the work force in agricultural employment, and the unemployment level were collected from those countries and 10-year periods where the structural changes (reductions in employment) in agriculture between 1950 and 1995 had been most and least pronounced. In order to avoid confounders, the annual changes in the variables' values were correlated with each other, adding a control for the level of unemployment, and allowing for lagged effects. RESULTS: The annual changes in the levels of agricultural employment and those of suicide mortality did not covary at all. Controlling for unemployment levels did not change this, nor could any lagged effects be found. CONCLUSIONS: At the most general level, no causal relation between agricultural rationalization and suicide mortality was detected. This lack of a universal relation does not, however, preclude the possibility of the relationship existing given certain socio-historical circumstances.     

Social disadvantage and schizophrenia

Objective To study, in a geographically defined area, associations between the neighbourhood social environment and individual socioeconomic status on the one hand, and treated incidence of schizophrenia and level of subsequent service use on the other. Method A combined data set of (i) patients with a case register diagnosis of schizophrenia and (ii) population controls was subjected to multilevel analyses, including neighbourhood exposures (neighbourhood socioeconomic disadvantage and social capital) and individual level confounders. Separate analyses were conducted for inpatient and outpatient psychiatric service consumption as indexed by the case register. Results Neighbourhood socioeconomic disadvantage and neighbourhood social capital did not impact on the treated incidence of schizophrenia, but quantity of inpatient service consumption was higher in neighbourhoods with higher level of social control (i.e. where it is more likely that neighbours intervene in neighbourhood-threatening situations). In addition, most indicators of lower individual socioeconomic status were associated with higher treated incidence, while treated incidence was lower when individual educational status was low. Conclusion Residents of high social control neighbourhoods may seek greater levels of resolution of psychiatric disorder in patient-residents, and by consequence may induce greater levels of inpatient service consumption in patients diagnosed with schizophrenia. Individual-level indicators of social disadvantage are associated with higher risk of treated psychotic disorder, with the exception of lower educational status, which may confer a lower probability of treatment given the presence of psychotic disorder.     

Spinal injuries in contact sports

Contact and collision sports such as American football expose the athlete to a wide array of potential injuries. Knee injuries garner much of the attention, but spinal injuries are potentially catastrophic and all levels of medical coverage of football must be knowledgeable and prepared to attend to an athlete with a neck injury. Of the other possible spinal conditions, some resolve on their own, others might require conservative therapy, and still others might require surgical intervention. The spectrum of potential injury is wide, yet the medical team must practice and prepare to treat the possible catastrophic neck injury.     

Adapting Smoking Relapse–Prevention Materials for Pregnant and Postpartum Women: Formative Research

Objective: To decrease smoking relapse among pregnant and postpartum women by adapting existing, validated relapse–prevention materials to meet the unique needs of pregnant and postpartum women. Methods: A series of semi-structured interviews and learner verification activities were conducted with pregnant abstinent, postpartum abstinent, and postpartum relapsed women. Results were used to create new relapse–prevention materials, specific to the needs of pregnant and postpartum women, which are currently being used in a randomized clinical trial. Results: Findings are consistent with the recurrent themes in the literature regarding smoking cessation among pregnant and postpartum women and revealed exceptional needs for coping and stress reduction strategies related to remaining abstinent postpartum. Conflict levels were also high in areas of identity, social support, and reasons for quitting. Conclusion: By interviewing women about their cessation related needs, the current study was able to produce smoking relapse–prevention materials specific to this population. Having pregnant and postpartum women review the modified program materials before starting the clinical trial enhanced the quality, dependability, and validity of the materials. We await the results of the clinical trial to determine if this intervention is indeed more efficacious than previous attempts to intervene with this population.