学习慈济医院护理理念做好优质护理服务

在全国医院都开展优质护理服务的大背景下,台湾慈济医院在质量管理、人文关怀、不良事件应对办法和健康教育等方面都起到了榜样作用,这使医务工作者对于优质护理服务的内涵有了更加深刻的认识。     

A Cox Regression Analysis of Covariates for Asthma Hospital Readmissions

Background.?Asthma hospital admissions and readmissions are unacceptably high, thus, a method to identify those at greatest risk could be helpful. Methods.?An observational retrospective study using a Cox regression to determine the relationship between the time interval between admissions and possible covariates of a readmission. The covariates were age, sex, ethnicity, smoking habit, history of allergy or eczema/hay fever, age of onset, Townsend index (TI), Jarman score (JS), and drugs on discharge. Those with p<0.2, together with interacting covariates, from the preliminary analysis were eligible for the multivariate Cox regression analysis. Results.?Of the 523 patients admitted between 1994 and 1998 because of their asthma, complete data were available for 440. Of these, 112 were readmitted. Eligible covariates for the multivariate Cox regression analysis were sex, allergy status, history of eczema/hay fever, the JS and TI together with interactions between JS and TI, JS and allergy, and allergy with eczema/hay fever. There were 278 subjects (71 with a readmission) with complete data for these eligible covariates. The multivariate analysis revealed that female sex (odds ratio [OR] = 2.65, 95% confidence interval [CI] 1.42, 4.92), high JS (OR = 2.03, 95% CI 1.13–3.65), and history of allergy (OR = 1.88, 95% CI 1.06–3.32) formed the final model as significant predictors of readmission. Conclusion.?Females with a history of allergy that were registered at a practice with a high workload (JS) had a higher risk of readmission. The analysis method used highlights how those at risk of readmission can be identified so that they can be targeted post discharge.     

老年人肺癌并发院内获得性肺炎的临床研究

目的为探讨老年人肺癌院内获得性肺炎的临床特点、病原菌及耐药情况,为临床提供依据。方法分析72例老年人肺癌并发院内获得性肺炎的临床资料。结果老年人肺癌平均住院日期延长,化疗时不合理使用抗菌药物,发生院内获得性肺炎的机会最大。主要病原菌为G~-杆菌占80.70％,其中以铜绿假单胞菌、肺炎克雷伯氏菌为主,其次为表皮葡萄球菌占10.53％。病原菌对氨苄青霉素、哌拉西林、头孢菌素耐药性增加,对亚胺培南、万古霉素、阿米卡星敏感。病死率达30.56％。结论老年人肺癌免疫功能低下,住院日期延长,不合理使用抗生素是造成院内感染的主要因素。病原菌的耐药率呈增加趋势,病死率较高。     

Total correction of tetralogy of Fallot at age 40 years and older: long-term follow-up

Whether total surgical correction of tetralogy of Fallot in adults aged 40 years old or older has acceptable operative risk and gratifying long-term results is unknown. The Mayo Clinic experience (June 1960 to May 1982) with 30 patients 40 to 60 years old (mean 47) who had total surgical correction of tetralogy of Fallot was reviewed. Preoperatively, 4 patients (13%) were in functional class I, 9 (30%) in class II and 17 (57%) in classes III and IV. Eight patients (27%) had had preoperative complications: five had a cerebrovascular accident and three had infective endocarditis. Only 11 patients (37%) had had palliative surgery 16 to 34 years (mean 22) before total surgical correction. Total surgical correction was successful in all patients. Right ventricular to left ventricular (RV/LV) pressure ratio of 0.65 or less was achieved in 28 (93%) of the 30 patients. One patient died of ventricular fibrillation (RV/LV ratio = 0.8) 2 days postoperatively, one had complete heart block and one had a cerebrovascular accident 7 days after operation. At follow-up of 5 to 266 months (mean 110), there were seven late deaths: two sudden at 5 and 21 years, respectively, after operation, one from myocardial infarction at 11 years, one from cerebrovascular accident at 11 years, one from congestive heart failure (RV/LV ratio = 1.0) at 8 years and two from noncardiac causes. Of the 22 patients who survived, 16 are in class I, 5 are in class II and 1 is in class III.(ABSTRACT TRUNCATED AT 250 WORDS)     

Is endoscopic sphincterotomy for disabling biliary-type pain after cholecystectomy effective?

Between 1979 and 1983, 50 patients were treated by endoscopic sphincterotomy for disabling biliary-type pain after cholecystectomy. Forty-six patients were seen at regular intervals for at least 12 months after the procedure and of these, pain resolved in six (13%), decreased in severity and/or frequency in 22 (48%), and continued unchanged in 18 (39%). Patients with bile duct dilation on a retrograde cholangiogram had a similar outcome to those with a bile duct of normal caliber. Twenty-five patients had a morphine-neostigmine test and endoscopic manometry of the sphincter of Oddi prior to the procedure, and the outcome appeared to be independent of results from these investigations. Subgroups of patients who benefit from sphincterotomy will be determined only by prospective studies in which criteria for inclusion are carefully defined so as to avoid heterogeneity within study groups.     

Regional wall motion improvement after coronary thrombolysis with recombinant tissue plasminogen activator: importance of coronary angioplasty

To evaluate functional recovery in 20 consecutive patients with acute myocardial infarction who received recombinant tissue-type plasminogen activator, serial two-dimensional echocardiograms were performed before and immediately after tissue plasminogen activator administration and at 1 and 10 days postinfarction. Tissue plasminogen activator was administered intravenously (17 patients) or by intracoronary infusion (3 patients) after angiographic confirmation of total occlusion. Reperfusion, documented by angiography, occurred in 13 of the 20 patients. The mean time from onset of chest pain to thrombolysis was 5.1 +/- 1.1 hours. Echocardiograms were evaluated for regional function with a visual semiquantitative scoring system by two independent observers who had no knowledge of patient identity, temporal sequence, therapy or effect of therapy. There was no immediate or 24 hour improvement in wall motion. At day 10 compared with pretreatment, 28 of 33 reperfused infarct zone segments versus 6 of 20 nonreperfused infarct segments demonstrated improved wall motion (p = 0.01). This improvement did not relate to time from onset of chest pain to successful thrombolysis. Of reperfused infarct zone segments in the distribution of coronary artery balloon dilation, 19 of 23 segments exhibited improvement versus 7 of 17 (reperfused, no angioplasty) and 6 of 20 (nonreperfused, no angioplasty) segments (p = 0.001). Infarct zone segments reperfused at the time of ongoing chest pain demonstrated functional recovery compared with segments reperfused in the absence of chest pain (18 of 23 versus 10 of 20, respectively; p = 0.05). Thus, in this uncontrolled series, there was echocardiographically detectable improvement in function of reperfused infarct segments 10 days after coronary thrombolysis with recombinant tissue plasminogen activator.     

Atrial level right to left intracardiac shunt associated with postoperative hypoxemia: demonstration with contrast two-dimensional echocardiography

Transient hypoxemia is not uncommon after major cardiac or thoracic surgery. The differential diagnosis includes atelectasis, pulmonary embolus, pneumonitis, congestive heart failure and several other diverse cardiovascular and pulmonary problems. Less well recognized is transient right to left intracardiac shunting through a patient foramen ovale or previously unsuspected atrial septal defect. Three cases of clinically important hypoxemia associated with right to left shunting after aortocoronary bypass surgery are presented. The right to left shunting was documented with contrast-enhanced echocardiography, which is a simple, inexpensive and accurate means of screening patients for intracardiac right to left shunts and may play a valuable role in the postoperative management of patients.     

Comparison of methicillin-resistant and methicillin-sensitive Staphylococcus aureus bacteremia

Methicillin-resistant Staphylococcus aureus (MRSA) has become endemic in Detroit, accounting for 50% of bacteremias in heroin abusers. To identify the salient epidemiologic and clinical features of MRSA bacteremia, case-control studies were performed comparing 28 cases of MRSA bacteremia to 28 cases of methicillin-sensitive S. aureus (MSSA) bacteremia in intravenous drug abusers. Infective endocarditis was diagnosed in 46.4% (13 of 28). In endocarditis and nonendocarditis bacteremia alike, the duration of fever, length of hospitalization, need for surgery, and mortality rates were similar. A history of recent antimicrobial therapy, especially cephalosporins, was more common in the MRSA group (p = 0.006). Complications including neurologic, renal, vascular, and musculoskeletal manifestations were more common in the MSSA endocarditis patients than MRSA endocarditis patients, although this difference was not significant. Complications related to antibiotic therapy were similar for both groups. The case-control studies indicate that MRSA and MSSA are similar in their virulence as measured by duration of hospitalization, duration of fever, complications, and mortality.