PICC置管前评估的临床实践指南构建及AGREE评价

目的构建以证据为基础的经外周穿刺中心静脉导管(PICC)置管前评估的临床实践指南并进行AGREE评价。方法通过现况调查,制作PICC置管前评估的系统评价,对PICC置管前评估相关临床实践指南进行文献内容分析,构建指南草案并通过德尔菲法对指南相关附件进行修订,使用AGREE评估系统进行评价。结果指南形成包含置管护士、环境与设备、患者评估、导管选择、穿刺技术与穿刺部位、知情同意6个方面共31项推荐意见。AGREE评价的标准化总分分别为98%、93%、95%、92%、89%、100%,6名PICC护理专家均给予"强烈推荐"评价。结论该指南是基于我国临床现状、循证证据、患者意愿和偏好、专业人员判断的循证性临床实践指南,可作为PICC置管前评估的依据。     

Decreased lymphocyte and increased monocyte count in peripheral blood is associated with cardiovascular disease and one - year mortality in maintenance hemodialysis patients

ObjectiveTo investigate the association between peripheral white blood cell count including its subtypes and cardiovascular disease (CVD) incidence and one-year all-cause mortality in maintenance hemodialysis (MHD) patients. MethodsA total of 371 MHD patients at Zhongshan Hospital, Fudan University between March 2009 and February, 2011 were enrolled. Demographic, hematological, nutritional and inflammatory markers were obtained. All patients were followed for one year to investigate the risks for CVD event and mortality. Spearman correlation and linear regression were used to assess the relationship between white blood cell count and other laboratory parameters. Difference in categorical factors between two groups were determined with Chi-square test, Difference in continuous values between two groups were assessed with t test. Kaplan - Meier analysis and Cox proportional hazards model were applied to assess one-year mortality predictors. ResultsPatients with CVD event had lower lymphocyte count level (1.17±0.38 vs 1.34±0.51, P＜0.05) and higher monocyte count level (0.44 ± 0.15 vs 0.37 ± 0.15, P＜0.01) than those without CVD event. Cox proportional hazard regression showed that an increased lymphocyte count was associated with reduced mortality risk, 95%CI: 0.136-0.719, P＜0.01) and that an increased monocyte count was associated with increased mortality risk, 95% CI: 2.657 - 74.396, P＜0.01) after adjustment for hsCRP. ConclusionDecreased lymphocyte level and increased monocyte level are significantly related to CVD event and are independent predictors of increased one - year all - cause mortality risk in MHD patients.     

系统性红斑狼疮并发肺部感染的口腔相关因素及护理研究进展

系统性红斑狼疮患者由于免疫功能下降、口腔环境发生变化等原因,容易并发肺部感染。做好口腔护理,选择适当的口腔护理用药,密切观察病情变化可防范肺部感染发生。     

Eculizumab and recurrent C3 glomerulonephritis

Background

Hyperactivity of the alternative complement pathway is the principle defect in C3 glomerulopathies (C3G). Eculizumab, a monoclonal antibody that binds C5 to prevent formation of the membrane attack complex, has been shown to be beneficial in some patients with this disease.

Methods

In this open-label, proof-of-concept efficacy-and-safety study, a patient with the initial diagnosis of dense deposit disease (DDD) and allograft recurrence of C3 glomerulonephritis (C3GN) was treated with eculizumab every other week for 1 year. The patient had pathological evidence of C3GN and proteinuria >1 g/day at enrollment. He underwent graft biopsy before enrollment and repeat biopsy at 6 and 12 months.

Results

Although no mutations were identified in complement genes, functional studies were positive for C3 nephritic factors and elevated levels of soluble membrane attack complex (sMAC). On therapy, sMAC levels normalized and although proteinuria initially decreased, it increased reaching pre-treatment levels at 12 months. Although serum creatinine remained stable, repeat allograft biopsies showed progression of disease.

Conclusions

Clinical and histopathologic data suggest a partial response to eculizumab in this patient. While eculizumab blocked activation of the terminal complement cascade, persistent dysregulation of the alternative pathway remained, indicating eculizumab alone cannot control disease in this patient. Additional research is required to identify effective anticomplement therapy for this group of C3G patients.     

Comparison of anterior cervical fusion by titanium mesh cage versus nano-hydroxyapatite/polyamide cage following single-level corpectomy

Purpose

The titanium mesh cage (TMC) is a typical metal cage device which has been widely used in cervical reconstruction for decades. Nano-hydroxyapatite/polyamide-66 (n-HA/PA66) cage is a novel biomimetic non-metal cage device growing in popularity in many medical centres in recent years. There has been no comparison of the efficacy between these two anterior reconstructing cages. The purpose of this study was to compare the radiographic and clinical outcomes of these two different devices.

Methods

Sixty-seven eligible patients with single-level ACCF using TMC or n-HA/PA66 cage for cervical degenerative diseases, with four-year minimum follow-up, were included in this prospective non-randomised comparative study. Their radiographic (cage subsidence, fusion status, segmental sagittal alignment [SSA]) and clinical (VAS and JOA scales) data before surgery and at each follow-up was recorded completely.

Results

The fusion rate of the n-HA/PA66 group was higher than TMC at one year after surgery (94 % vs. 84 %) though their finial fusion rates were similar (97 % vs. 94 %). Finial n-HA/PA66 cage subsidence was 1.5 mm with 6 % of severe subsidence over three millimetres, which was significantly lower than the respective 2.9 mm and 22 % of TMC (P < 0.0001). Lastly, SSA, VAS and JOA in TMC group were worse than in the n-HA/PA66 group (P = 0.235, 0.034 and 0.007, respectively).

Conclusions

The n-HA/PA66 cage is associated with earlier radiographic fusion, less subsidence and better clinical results than TMC within four years after one-level ACCF. With the added benefit of radiolucency, the n-HA/PA66 cage may be superior to TMC in anterior cervical construction.     

Modified posterior soft tissue repair for the prevention of early postoperative dislocation in total hip arthroplasty

Purpose

Dislocation following total hip arthroplasty (THA) with the posterior approach has been quite a common and bothering complication. Previous researches suggest that careful repair of the posterior structures significantly reduces this risk. The purposes of the present study were to describe a modified posterior soft tissue repair procedure in THA using a suture anchor (TwinFix Ti 5.0, Smith & Nephew, Andover, MA) and evaluate the early postoperative dislocation rate.

Methods

From July 2004 to June 2008, 220 consecutive primary total hip arthroplasties were performed using the modified surgical approach. The average age in the group was 46.4 years (range from 21 to 90) at the time of the procedure. The rate of postoperative hip dislocation, as well as any signs of complications related to the technique, has been observed and analyzed in this study.

Results

There was no postoperative dislocation following primary THA in 220 cases, and no signs of complications related to the technique, such as greater trochanteric fractures and sciatic nerve palsy, have been noted in any of the cases at their most recent follow-up.

Conclusions

These initial results demonstrate that the modified repair in THA using the suture anchor can serve as an effective and reliable mean for prevention of early postoperative dislocation     

Comparison of Nitrous Oxide to No Sedation and Deep Sedation for Diagnostic Upper Gastrointestinal Endoscopy

Background

In China, great efforts are dedicated to reducing discomfort and minimizing undesirable complications for patients undergoing upper gastrointestinal (UGI) endoscopy.

Methods

This study was conducted to compare the diagnostic accuracy, safety, complications, and patient and examiner satisfaction for different sedation approaches. We carried out a prospective and randomized study on 450 patients undergoing diagnostic UGI endoscopy. During the procedure, patients received N₂O by inhalation; an intravenous mixture of midazolam, remifentanil, and propofol; or no sedative. The cardiorespiratory functions, procedure duration, recovery time, length of hospital stay, complications, and ratings of patient and examiner satisfaction were recorded.

Results

Compared to those deeply sedated, patients inhaling N₂O had comparable diagnostic accuracy, significantly shorter procedure and recovery times, a lower risk of cardiorespiratory distress, but a higher number of minor complications and post-procedure mental issues. The procedural satisfaction ratings were highest for those receiving deep sedation; fewer patients reported willingness to reconsider N₂O for a future upper GI endoscopy. The lowest satisfaction rating was given by those who received no sedation.

Conclusions

Multiple factors should be considered before selecting N₂O as the sedative for diagnostic UGI endoscopy, including the patient’s economic status, potential risk of cardiorespiratory distress, and sensitivity to potential adverse effects of N₂O administration.