围手术期抗生素的合理应用

近年来,由于抗生素的滥用导致外科术后感染率明显上升,同时,在医院环境诱导了对抗生素耐药菌株的产生或引起细菌或霉菌的二从感染.为了有效地降低术后感染率,减少抗生素药物的副反应,自2001年1月份开始,我们采用围手术期抗生素的合理运用,与以往同期相比,骨科术后感染率明显下降,副反应减少.……     

围手术期肠外营养支持在胃癌根治术的应用

1986～1988年的胃癌扩大根治术221例及根治性全胃切除术19例非肠外营养(N-TPN)支持为对照组,与1991～1993年的198例及61例施行TPN治疗为实验组进行对比。N-TPN组术后并发症总发生率为7.2％,TPN组则为2.0％;全胃切除术并发症发生率分别为31.6％和4.9％(P<0.01)。吻合口瘘发生率N-TPN组分别为2.7％和10.5％,而TPN组则均为0.0％(P<0.01)。膈下脓肿发生率N-TPN组为31.6％和15.8％,而TPN组则为1.5％和3.3％(P<0.05)。但本研究是回顾性的,所以要有待进行前瞻性的、对照的、随机的大范围研究。     

Diagnosis and management of severe atherosclerosis of the ascending aorta and aortic arch during cardiac surgery: focus on aortic replacement

Objective: Severe atherosclerosis of the ascending aorta and arch frequently causes difficulties during heart operations, hindering surgical manoeuvres and potentially leading to systemic embolism. The aim of our study was to assess the safety and effectiveness of replacing the atherosclerotic ascending aorta in this setting. Methods: Aortic atherosclerosis was characterized by epiaortic ultrasonographic scanning in 90.1% of 1927 consecutive adult patients undergoing cardiac operations, and by computed tomographic chest scanning in selected cases. Thirty-six of the 152 patients requiring major derangements from our standard practice due to aortic atherosclerosis underwent replacement of the ascending aorta and constitute the study group. Replacement of the aorta was extended to the arch in 13 cases (36.1%). It was associated with single or multiple valve surgery in 34 patients (94.4%) and with coronary revascularization in 30 (83.3%). Two patients (5.6%) underwent coronary bypass grafting without valve surgery. A cryoablation procedure was associated in three patients with permanent atrial fibrillation. Deep hypothermic circulatory arrest was employed in 34 patients (94.4%), while proximal aortic disease allowed conventional distal crossclamping in 2 cases. The risk of operative mortality was estimated by the logistic EuroSCORE both with and withholding the variable ‘surgery of the thoracic aorta’. All survivors were followed-up for 1–41 months (16 ± 12). Results: Two patients died in the hospital (5.6%) and two during follow-up, for a cumulative survival of 91.3% and 85.6% at 1 and 3 years, respectively (hospital deaths included). The hospital death rate compared favourably with the expected estimates of 25.5% (p < 0.05) and 10.3% (p = 0.67) obtained by the EuroSCORE full model and without ‘aortic surgery’, respectively. In-hospital adverse neurologic events occurred in six patients (16.7%), including stroke in one patient (2.8%) and neurocognitive disturbances in five (13.9%), although they were all transient and cleared before discharge. Excess bleeding required re-exploration in four patients (11.1%), and one more patient underwent emergency grafting for acute postoperative coronary occlusion. Ten patients (38.5%) were intubated for longer than 24 h. Conclusion: Despite significant perioperative morbidity, replacement of the severely atherosclerotic aorta is worth consideration to avert expectedly higher death and stroke rates.     

63例CT导引下经皮肺穿刺活检术的围手术期护理

目的：探讨CT导引下经皮肺穿刺活检术围手术期的护理程序及注意事项。方法：对我院2007年11月至2009年7月63例行CT导引下经皮肺穿刺活检术的患者实施术前、术中、术后护理及健康指导等围手术期护理程序。结果：实施围手术期护理程序后,患者焦虑程度明显减轻,并发症明显减少,术后恢复良好,患者均安全度过围手术期。结论：认真落实护理程序各阶段的护理措施,是减少CT导引下经皮肺穿刺活检术围手术期意外和各种护理并发症的关键。应用围手术期护理程序可提高手术的护理质量,减少术后并发症,为患者迅速康复奠定良好的基础。     

Does exposure to infectious diseases in infancy affect old-age mortality? Evidence from a pre-industrial population

Many studies have shown that health conditions experienced in childhood play an important role on an individual's adult mortality. Recent research suggests that past reductions in early life exposure to infectious diseases have been a major contributor to the historical decline in old-age mortality. Drawing on French-Canadian data from cohorts born in the 17th and 18th centuries, we test whether a progressive deterioration in early life conditions (as revealed by an increasing infant mortality rate) translates into a decrease in survival prospects in late life. We use traditional demographic measures such as the age-specific probability of death, and a series of proportional hazard models to control for familial and environmental conditions. Results point toward little evidence of any early life effects. The trend of increasing infant mortality does not correlate with a general increase of mortality in older ages within the same cohorts. Period changes affecting survival at older ages (war, epidemics) as well as demographic and biological characteristics shared within families have a much larger role in old-age mortality than early life characteristics shared within the same cohorts.     

国产重组人脑钠素与硝普钠用于心脏手术围术期处理的对比研究

目的 对重组人脑钠素（rhBNP）用于心脏手术围术期处理的可行性、安全性和有效性进行初步观察，并与硝普钠的作用进行比较。方法 选择择期心脏手术病人22例，随机分为rhBNP组（B组）和硝普钠（SNP）组（s组），每组11例。比较rhBNP与SNP对病人血流动力学和肝肾功能的影响。结果 与给药前和S组比较，B组用药后15、30、60、120和180min各点心输出量增加显著（P〈0．05，P〈0．01）；B组与给药前比较，给药后即刻、15、30和60min时点外周血管阻力下降显著（P〈0．05）；给药后即刻、15和30点与S组比较，下降显著（P〈0．05）。B组肺毛细血管楔压（PCWP）与用药前比较，用药后即刻、15、30、60、120和180min下降显著（P〈0．05，P〈0．01）；与S组比较，给药后30、60、120和180min差异有统计学意义（P〈0．05，P〈0．01）。S组PCWP与用药前比较，用药后60min、120min和180min下降显著（P〈0．05）。B组与输注rhBNP前以及S组比较，平均动脉压、心率和中心静脉压差异均无统计学意义。输注rhBNP后病人24h尿量明显增加。用药过程中以及30d后进行电话随访，未见药物不良反应。结论 rhBNP用于心脏手术围术期处理是可行的，具有改善心功能和稳定循环的作用。     

老年股骨颈骨折围手术期的治疗分析

目的探讨老年人股骨颈骨折的治疗及围手术期的处理。方法回顾性分析2003年1月～2006年12月手术治疗的201例老年股骨颈骨折患者资料，其中男51例，女150例，年龄60～98岁，平均78．2岁。按Garden分型，Ⅱ型20例，Ⅲ型86例，Ⅳ型95例。采用多枚中空螺钉固定、Morre型人工股骨头置换术或双极人工股骨头置换手术进行治疗。结果本组患者平均住院10～14d，5～7d即能早期下床活动，住院期间及术后1年内无一例死亡。85％患者获得8个月～4年（平均2年）的随访，功能恢复按Harris评分，优良率为85％。结论老年人各脏器机能衰退，多同时合并各种内科疾病，手术治疗存在风险，但老年人股骨颈骨折的手术治疗仍能取得满意疗效。     

An Appraisal of Different Cardiac Risk Reduction Strategies in Vascular Surgery Patients

OBJECTIVES: to summarize existing evidence regarding the benefits and the risks of all available interventional and medical means aimed at cardiac risk reduction in patients undergoing vascular surgery. DESIGN: review of the literature. MATERIALS AND METHODS: a critical review of all studies examining the impact of various prophylactic cardiac maneuvers on perioperative outcome following vascular surgery was performed. Overall mortality, cardiac mortality and myocardial infarction rate were used as the outcome measures. RESULTS: coronary artery bypass grafting is associated with a 60% decrease in perioperative mortality in patients undergoing vascular surgery, but in most of the cases this decrease does not outweigh the combined risk of the cardiac and the subsequent noncardiac vascular procedure. Data supporting the cardioprotective effect of percutaneous transluminal angioplasty in the perioperative setting are insufficient. beta-blockade has been shown to decrease perioperative mortality and cardiac morbidity in both high-risk (strong evidence) and low-risk (weak evidence) patients. CONCLUSIONS: coronary revascularization is rarely indicated to simply get the patient through vascular surgery and should be reserved for patients who would need it irrespective of the scheduled vascular procedure. Among all available pharmacological agents, including beta-blockers, alpha-agonists, calcium channel blockers and nitrates, only beta-blockers have been proven to reduce the cardiac risk of vascular surgery.     

Risk factors for myocardial infarction during coronary artery bypass graft surgery

Patients with a particular thrombotic profile may be at greaterrisk of myocardial infarction during coronary artery bypassgraft surgery. The thrombotic profile of 50 patients admitted to hospital withstable angina pectoris was determined prior to haemodynamicinvestigation. ECG results and determination of cardiac enzymesshowed that 12 patients had suffered a perioperative myocardialinfarction. These patients had a higher mean atheroscleroticscore (42.1 ± 10.5 vs 32.9 ± 13, P<0.02), alonger aortic cross clamp time (59 ± 15.2 vs 45.7 ±16.3 min, P < 0.05), lower serum levels of protein C (101.2±26vs 124.7+ 31.4%, P<0.05) and tissue plasminogen activator(322 ± 580 vs 2307±2830 IU ml^–1, P<0.01). There were no differences between the two groups in Jenkin'scoronary score, the number and type of grafts, ejection fraction,left ventricular end-diastolic pressure, lipid profile or levelsof markers of platelet release. In addition to a more severe distal coronary atheroma and alonger aortic cross-clamp time, patients with impaired endothelialfibrinolytic activity appeared to be at greater risk of myocardialinfarction during coronary artery bypass graft surgery.     

Food-anticipatory activity and liver per1-luc activity in diabetic transgenic rats

The mammalian Per1 gene is an important component of the core cellular clock mechanism responsible for circadian rhythms. The rodent liver and other tissues rhythmically express Per1 in vitro but typically damp out within a few cycles. In the liver, the peak of this rhythm occurs in the late subjective night in an ad lib-fed rat, but will show a large phase advance in response to restricted availability of food during the day. The relationship between this shift in the liver clock and food-anticipatory activity (FAA), the circadian behavior entrained by daily feeding, is currently unknown. Insulin is released during feeding in mammals and could serve as an entraining signal to the liver. To test the role of insulin in the shift in liver Per1 expression and the generation of FAA, per-luciferase transgenic rats were made diabetic with a single injection of streptozotocine. Following 1 week of restricted feeding and locomotor activity monitoring, liver was collected for per-luc recording. In two separate experiments, FAA emerged and liver Per1 phase-shifted in response to daytime 8-h food restriction. The results rule out insulin as a necessary component of this system.