连续硬膜外复合全麻下老年人胸腔手术时脑电功率谱的变化

目的 探讨老年人连续硬膜外复合全麻下胞腔手术时数量化脑电图与麻醉深度的关系。方法 ３０例老年人胸腔手术,均为连续硬膜外复合静吸全麻,根据吸入异氟醚浓度不同分为肺泡气最低有效浓度（ＭＡＣ）０．６（Ⅰ组）和ＭＡＣ１．０（Ⅱ组）两组,观察术前、诱导前、插管后、切皮进胸探查、进胞后３０,６０ｍｉｎ以及术毕时循环和脑电图边缘频率（ＳＥＦ）、中位频率（ＭＦ）、比率（δＲ）和双频谱指数（ＢＩＳ）的变化。结果 Ⅰ     

硬膜外阻滞复合全身麻醉用于慢性阻塞性肺病病人的临床效果

目的比较硬膜外阻滞复合全身麻醉或单纯全身麻醉对上腹部和胸腔内手术病人术后肺功能和肺部并发症的影响。方法24名伴有中度术后肺部并发症危险的慢阻肺病人,接受上腹部或胸腔内手术,随机分成单纯全身麻醉(GA组)和硬膜外阻滞复合全身麻醉(Epi-Ga组)两组。术后采用VRS法评定镇痛效果。根据临床症状和体征、X线胸片、血气分析和床旁肺功能测定评估是否发生肺部并发症。术前1d和术后3d内评估和记录上述指标。结果术毕,GA组病人平均(34±16)min苏醒,(67±22)min拔除气管导管;Epi-Ga组苏醒时间和拔管时间分别为(12±4)和(32±12)min。术后第1天和第2天,Epi-Ga组病人术后镇痛效果明显优于GA组(P<0.01)。术后第1天,Epi-Ga组病人的FVC、FEV1/FVC%和FEF25%-75%下降不如GA组显著(P<0.05)。GA组有4例需要纤维支气管镜协助吸痰,而Epi-Ga组则无一例需要。两组病人术后肺炎、肺不张、支气管痉挛和呼吸衰竭的发生率无显著差异。结论局麻药加阿片类药物硬膜外自控镇痛使病人术后更加舒适,且能够改善病人术后肺功能。尽管两组病人术后肺部并发症无明显差异,但硬膜外阻滞复合全身麻醉以及术后硬膜外自控镇痛确实能够方便慢阻肺病人的术后管理。     

Factors Influencing the Growth in Knowledge of Trainees in General Practice

Objectives: The relation between the content of postgraduate training for general practice and the outcome in terms of the growth in knowledge of trainees was investigated. The training variables included were: (1) the number of patients seen per day, (2) the trainer, (3) the practice and (4) the theoretical curriculum.Methods: Subjects were 58 trainee-trainer pairs. Growth in knowledge was assessed by two written tests administered with eight months interval. Training variables were evaluated by means of questionnaires and logbook-registration. The correlation was explored between each of the training variables and the knowledge tests scores. To correct for interactional effects, a step-wise multiple regression analysis was performed with the second test as dependent variable and the first test as well as the training variables as independent variables.Results: Significant growth in knowledge was demonstrated. Non of all training variables investigated explained the variance in scores on the second test equally good or better than the scores on the entry test.Conclusions: The impact of the separate training-components on the growth in knowledge, remains unclear. We may speculate, that the sort of knowledge assessed with the written literature based true/false test is different from the sort of knowledge transferred during every day training: evidence based knowledge versus experience based knowledge. Equally valid is the conclusion that these findings fit into the theory that in adult learning the outcome is more learner than teacher dependent.This revised version was published online in September 2005 with corrections to the Cover Date.     

Anaesthesia and the Sturge-Weber syndrome

We report a series of 13 patients with Sturge-Weber syndrome anaesthetised on 17 occasions. Anaesthesia management varied depending on the clinical manifestations which ranged from localized, superficial skin lesions to extensive systemic involvement. These patients tolerate anaesthesia well but anaesthetic management includes evaluation for associated anomalies. Difficulty with intubation may occur due to angiomas of the mouth and upper airway. Anaesthesia should be planned to avoid trauma to the haemangiomata and increases in intraocular and intracranial pressure. Nous rapportons une série d’observations concernant des porteurs du syndrome de Sturge-Weber anesthésiés à 17 occasions. L’anesthésie a varié selon les manifestations cliniques qui allaient de la lésion superficielle localisée à l’atteinte systémique grave. Ces patients tolèrent bien l’anesthésie mais celle-ci nécessite une recherche des anomalies associées pour fin d’évaluation. La présence d’angiomes de la bouche et des voies respiratoires supérieures peut rendre l’intubation difficile. La planification de l’anesthésie doit inclure la prévention du traumatisme aux hémangiomes et de l’augmentation de la tension intraoculaire et cérébrale.     

The emergency medicine training needs of rural general practitioners

This study aimed to identify the emergency medicine training needs of rural general practitioners (GPs) in the catchment area of the Hunter Rural Division of General Practice. The GPs were surveyed using a questionnaire in which they were asked about their confidence levels in a number of specific emergency medicine skills, and about the areas of emergency medicine that they saw as priorities for upskilling. More than a third of GPs who were responsible for on-call work at the hospital indicated that they had low levels of confidence in a number of their emergency medicine skills, in particular skills relating to paediatric emergencies, cardiovascular emergencies, and respiratory emergencies. These emergency medicine domains were also seen as high priorities for upskilling by the majority of the respondents. The study shows that rural doctors need the opportunity to access emergency medicine training that provides upskilling not only in the management of clinical problems, but also in practical procedures.     

Positive end-expiratory pressure prevents atelectasis during general anaesthesia even in the presence of a high inspired oxygen concentration

BACKGROUND: General anaesthesia impairs the gas exchange in the lungs, and moderate desaturation (SaO2 86-90%) occurred in 50% of anaesthetised patients in a blinded pulse oximetry study. A high FiO2 might reduce the risk of hypoxaemia, but can also promote atelectasis. We hypothesised that a moderate positive end-expiratory pressure (PEEP) level of 10 cmH2O can prevent atelectasis during ventilation with an FiO2 = 1.0. METHODS: Atelectasis was evaluated by computed tomography (CT) in 13 ASA I-II patients undergoing elective surgery. CT scans were obtained before and 15 min after induction of anaesthesia. Then, recruitment of collapsed lung tissue was performed as a "vital capacity manoeuvre" (VCM, inspiration with Paw = 40 cmH2O for 15 s), and a CT scan was obtained at the end of the VCM. Thereafter, PEEP = 0 cmH2O was applied in group 1, and PEEP = 10 cmH2O in group 2. Additional CT scans were obtained after the VCM. Oxygenation was measured before and after the VCM. RESULTS: Atelectasis (> 1 cm2) was present in 12 of the 13 patients after induction of anaesthesia. At 5 and 10 min after the VCM, atelectasis was significantly smaller in group 2 than group 1 (P < 0.005). A significant inverse correlation was found between PaO2 and atelectasis. CONCLUSIONS: PEEP = 10 cmH2O reduced atelectasis formation after a VCM, when FiO2 = 1.0 was used. Thus, a VCM followed by PEEP = 10 cmH2O should be considered when patients are ventilated with a high FiO2 and gas exchange is impaired.     

试析大型综合医院在社区医疗服务中的作用

根据国家城市卫生服务体系改革的原则及对基层医院和大医院的功能定位,分析大型综合医院在社区医疗服务中的作用。指出大型综合医院应加强与城市基层医院的联系,建立全科医生培训基地,为社区医疗服务输送适用人才,建立切实可行的转诊制度,成为社区医疗服务的坚强后盾,提高社区医疗服务的质量和水平,促进社区医疗服务的发展。     

A study of the provision of health checks and health-promotion clinics in 18 general practices

Summary

• ? The objective of this study was to describe the variation in provision of health checks and health-promotion clinics operating under the regulations of the 1990 Contract for general practice in the UK.
• ? Eighteen group practices in three Family Health Service Authority (FHSA) areas of England (two in the South West Thames region and one in the Yorkshire region) were selected for the study. The nurses, largely responsible for the implementation of the health checks at these practices, were interviewed using semi-structured interview schedules. They were asked about age-groups targeted, means of recruiting patients for clinics, duration of clinic appointments, and procedures carried out in clinics.
• ? All practices offered health checks, and 55% had started doing so before introduction of the 1990 Contract. Recruitment for health checks took place in a number of ways: self-referral (83% of practices); opportunistically in those with coronary heart disease risk factors (78%); opportunistically during attendance for cervical smears (62%); screening in at least one patient group (78%). Blood pressure, height, weight, urinalysis and life-style advice were included by all practices. Stress management and quit smoking strategies were offered only by a minority of practices. Duration of first health-check appointment ranged between 15 and 30 minutes.
• ? The basic content of health checks, and life-style advice given appeared consistent between the widely varying practices. However, the resources available for intervention and follow up showed more variation.

     

全身麻醉对小儿听性脑干反应测试结果的影响

目的　研究应用听性脑干反应 (auditorybrainstemreaction ,ABR)作为监测小儿全身麻醉深度与觉醒的客观指标。方法　选择听力正常的外科择期手术患儿 4 5例 ,按照美国麻醉学家学会表针分为Ⅰ～Ⅱ级 ,分别施行异丙酚静脉麻醉、芬太尼静脉麻醉及异氟醚吸入全身麻醉 ,随机每组 15例 ,应用丹麦Madsen诱发电位反应仪监测并记录麻醉各阶段ABR的Ⅰ、Ⅲ、Ⅴ波潜伏期及Ⅰ Ⅲ、Ⅲ Ⅴ、Ⅰ Ⅴ波间期 ,研究观察潜伏期和波间期随时间推移及麻醉剂量变化之间的关系 ,探讨ABR在异丙酚、芬太尼及异氟醚等不同麻醉中的表现特征和规律。结果　①异丙酚静脉麻醉和异氟醚吸入麻醉与剂量呈良好的正相关 ;②Ⅰ波的潜伏期特性对于控制麻醉深度极为重要 ;③Ⅴ波监测麻醉具有最佳的稳定性及相关性 ;④停用麻醉药一段时间或患儿基本清醒时 ,ABR各波潜伏期和波间期有的仍高于正常值 ,这是滞后 (延迟 )反应 ;⑤ABR对芬太尼术中的觉醒监测不太敏感。结论　ABR各波的潜伏期及波间期变化 ,可判断小儿全身麻醉深度 ,在一定程度上可作为判断觉醒的参考 ,但应考虑有延迟反应的可能     

广佛手主要病害及综合防治

目的　制定广佛手病害的综合防治措施 ,以降低病害 ,促进广佛手生产的发展。方法　文献查找和实地调查。结果　综述了广佛手主要病害衰退病、黄龙病、炭疽病及溃疡病的发病状况和防治措施 ,分析了其发病原因和传播方式 ,制定了广佛手病害的综合防治措施。结论　认为广佛手病害的防治应采取预防为主、综合防治的原则 ,将农业防治、生物防治和药剂防治相结合。