关于重型颅脑损伤患者留置胃管时机的探讨

目的 为临床重型颅脑损伤患者留置胃管提供一个最佳时机,以期把重型颅脑损伤后并发应激性溃疡的发生率降到最低.方法 将60例重型颅脑损伤的患者按照伤后留置胃管的时间分成2组,实验组30例为重型颅脑外伤6 h内入院立即留置胃管,对照组30例为重型颅脑外伤后24 h留置胃管,2组患者的基础治疗和护理均相同,对2组患者的胃液pH值、胃液隐血试验阳性率,应激性溃疡的发生率和病死率等方面作统计学处理和对比分析.结果 2组患者的胃液pH值、胃液隐血试验阳性率,应激性溃疡发生率、病死率分别经统计学处理,有显著性差异(P＜0.05).结论 对重型颅脑损伤的患者受伤6 h内入院立即留置胃管,能最大限度地预见此类患者应激性溃疡的发生.     

关于重型颅脑损伤患者留置胃管时机的探讨

目的 为临床重型颅脑损伤患者留置胃管提供一个最佳时机,以期把重型颅脑损伤后并发应激性溃疡的发生率降到最低.方法 将60例重型颅脑损伤的患者按照伤后留置胃管的时间分成2组,实验组30例为重型颅脑外伤6 h内入院立即留置胃管,对照组30例为重型颅脑外伤后24 h留置胃管,2组患者的基础治疗和护理均相同,对2组患者的胃液pH值、胃液隐血试验阳性率,应激性溃疡的发生率和病死率等方面作统计学处理和对比分析.结果 2组患者的胃液pH值、胃液隐血试验阳性率,应激性溃疡发生率、病死率分别经统计学处理,有显著性差异(P＜0.05).结论 对重型颅脑损伤的患者受伤6 h内入院立即留置胃管,能最大限度地预见此类患者应激性溃疡的发生.     

SOFA评分对多器官功能障碍综合征患者的预后评价作用

目的 :探讨序贯器官衰竭估计 (SOFA)评分与多器官功能障碍综合征 (MODS)患者预后的关系。方法 :应用欧洲重症监护医学协会 (ESICM)感染相关问题工作组制订的 SOFA评分体系 ,进行回顾性统计分析 ,比较存活组与死亡组患者入院时 SOFA评分、最大 SOFA评分、Δ SOFA评分的差异 ,评价 SOFA评分在预后估计中的作用。结果 :累计最大 SOFA评分、累计ΔSOFA评分存活组与死亡组相比显著差异 (P均 <0 .0 1) ,入院时累计 SOFA评分无显著差异 (P >0 .0 5 )。各单个器官系统相比 ,存活组与死亡组最大 SOFA评分和ΔSOFA评分中除肝、肾外 ,余均有显著差异 (P均 <0 .0 5 ) ;而入院时各单个器官 SOFA评分仍无显著差异。存活组在入院最初 7日每日平均评分逐渐下降 ,而死亡组每日平均评分逐渐升高 ,7日内 2组有显著差异的变化出现在入院后 4 8小时 (P<0 .0 5 )。随器官衰竭个数的增加 ,病死率急剧增加 ,累计最大 SOFA评分呈直线上升 ,组间有非常显著差异 (P<0 .0 1)。结论 :最大 SOFA评分和 ΔSOFA评分对 MODS有良好的预后评价作用     

早期留置胃管对预防重型颅脑损伤患者应激性溃疡的影响

目的:探讨重型颅脑损伤患者早期留置胃管护理干预对预防应激性溃疡的影响。方法:将60例重型颅脑损伤患者随机分为实验组和对照组各30例,实验组入院后即留置胃管,监测胃液pH值、胃液隐血试验、及早行鼻饲流质、有胃潴留者行胃肠减压。对照组入院后24 h常规留置胃管。结果:实验组应激性溃疡出血的发生率明显低于对照组(P<0.05)。结论:重型颅脑损伤患者早期留置胃管,并对其给予护理干预可最大限度地预防应激性溃疡的发生。     

损伤前进餐对重型颅脑损伤患者并发应激性溃疡的影响

目的 探讨损伤前进餐与否对重型颅脑损伤患者并发应激性溃疡的影响,以便针对不同病情的患者及早进行护理干预.方法 将60例重型颅脑损伤患者按照损伤前进餐与空腹分为两组,对照组30例为损伤前空腹,观察组30例为损伤前进餐,两组患者采取常规治疗和护理,观测两组患者的胃液隐血试验、胃液pH值和应激性溃疡发生率,进行统计学处理和对比分析.结果 两组患者的胃液隐血试验、胃液pH值和应激性溃疡发生率差异有统计学意义(P<0.01).结论 损伤前进餐的重型颅脑损伤患者更易并发应激性溃疡.     

胃粘膜内pH与APACHEⅡ评分对危重患者评估的比较

目的及时准确地评估患者的危重程度.方法对23例患者(其中存活组13例,死亡组10例)在入科时和入科后24h的胃粘膜内pH(pHi)测定结果与APACHEⅡ评分结果以及pHa、PaO2/FiO2分别作一比较.结果存活组与死亡组的pHi在入ICU时即有显著差异(P<0.01),入科24h时差异更具显著性(P<0.001);而两组的APACHEⅡ评分在入ICU时差异无显著性(P>0.05),入科24h时差异显著(P<0.01).结论 pHi检测比APACHEⅡ评分更早期、更灵敏、更准确地反映了患者的危重程度.     

空气胃张力计在失血性休克中的应用

目的：评价空气胃张力计在失血性休克病人中的临床应用价值。方法：42例失血性休克病人人外科 ICU 后给予积极复苏治 疗，用空气胃张力计来测定24h 的胃粘膜 pH 值(pHi)，同时记录血流动力学指标，比较存活组和死亡组资料。结果：空气胃张力计可 连续自动测量胃黏膜二氧化碳分压(PgCO_2) ，平衡时间短，不需要特定的血气分析仪；存活组和死亡组病人人 ICU 后24h内 pHi 值有 极显著性差异(7． 38±0． 09vs7． 25±0． 07，P＜0． 01) ；pHi≤7． 32的病人的死亡率明显高于 pHi＞7． 32的病人(48%vs 10%，P＜0． 01) 。结论：空气胃张力计使用方便，其测得的 pHi 可作为早期评估休克复苏效果的良好指标。     

胃粘膜内pH与KAPACHE Ⅱ评分对危重患者评估的比较

目的：及时准确地评估患者的危重程度。方法：对23例患者（其中存活组13例，死亡组10例）在入科时和入科后24h的胃粘膜内pH(pHi)测定结果与APACHE Ⅱ评分结果以及pHa,PaO2/FiO2分别作一比较。结果：存活组与死亡组的pHi在入ICU时即有显著差异（P＜0．01），入科24h时差异更具显著性（P＜0．001）；而两组的APACHE Ⅱ评分在入ICU时差异无显著性（P＞0．05），入科24h时差异显著（P＜0．01）。结论：pHi检测比APACHE Ⅱ评分更早期、更灵敏、更准确地反映了患者的危重程度。     

重型颅脑损伤患者胃液监测的临床观察

目的:探讨早期留置胃管持续监测胃液pH值和隐血试验对预防和治疗应激性上消化道出血的效果。方法:将30例重型颅脑损伤患者随机分为实验组和对照组各15例,两组均于入院24h内预防性应用西米替叮,实验组入院12h内留置胃管,监测胃液pH值并行隐血试验检查,对pH值<3者,给予凝血酶胃管注入。对照组病情相对好转后,胃管回抽有咖啡色液或排柏油样便时予凝血酶治疗。结果:两组上消化道出血发生率及出血程度比较均有显著性差异(P<0.05),实验组低于对照组。结论:早期留置胃管监测胃液pH值和隐血试验能早期发现和治疗应激性上消化道出血,避免上消化道大出血的发生。     

高渗盐水对前列腺电切患者胃黏膜灌注和电切综合征的影响

目的观察输注高渗氯化钠溶液对前列腺电切患者胃黏膜灌注的影响和前列腺电切综合征（TURS）的发生率。方法 TURP的患者60例随机分两组,Ⅰ组为实验组输注高渗氯化钠溶液,Ⅱ组为对照组输注氯化钠溶液。监测患者血流动力学、电解质、胃内二氧化碳分压（PgCO2）和胃黏膜pH（pHi）变化,记录两组患者的TURS发生率。结果 T60时点Ⅱ组平均动脉压、血Na^＋、胃黏膜pHi显著低于Ⅰ组（P〈0.05）,而PgCO2显著高于Ⅰ组（P〈0.05）;Ⅱ组出现4例电切综合征（TURS）,而Ⅰ组无一例。结论输注高渗氯化钠溶液能改善胃黏膜灌注,预防TURS的发生。     

Guns and Knives in New Mexico: Patterns of Penetrating Trauma, 1978–1993

Objective: To identify patterns of nonfatal and fatal penetrating trauma among children and adults in New Mexico using ED and medical examiner data.
Methods: The authors retrospectively sampled in 5-year intervals all victims of penetrating trauma who presented to either the state Level-1 trauma center or the state medical examiner from a 16-year period (1978–1993). Rates of nonfatal and fatal firearm and stabbing injury were compared for children and adults.
Results: Rates of nonfatal injury were similar (firearm, 34.3 per 100,000 person-years; stabbing, 35.1). However, rates of fatal injury were significantly different (firearm, 21.9; stabbing, 2.7; relative risk: 8.2; 95% confidence interval: 5.4, 12.5). From 1978 to 1993, nonfatal injury rates increased for children (p = 0.0043) and adults (p < 0.0001), while fatal penetrating injury remained constant. The increase in nonfatal injury in children resulted from increased firearm injury rates. In adults, both stabbing and firearm nonfatal injury rates increased.
Conclusions: Nonfatal injury data suggest that nonfatal violence has increased; fatal injury data suggest that violent death rates have remained constant. Injury patterns vary by age, mechanism of trauma, and data source. These results suggest that ED and medical examiner data differ and that both are needed to guide injury prevention programs.     

Systematic Reviews Published in the January 2011 Issue of The Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly as a DVD and monthly online. The January 2011 issue (first quarterly DVD for 2011) contains 4515 complete reviews, 1985 protocols for reviews in production, and 13,521 one-page summaries of systematic reviews published in the general medical literature. In addition, there are citations of 641,000 randomized controlled trials, and 14,018 cited papers in the Cochrane methodology register. The health technology assessment database contains over 9300 citations. One hundred and seven new reviews have been published in the last 3 months, of which five have potential relevance for practitioners in pain and palliative medicine.     

Interprofessional approaches to creating safe,high quality health care

Three supplementary perspectives are presented arguing that interprofessional collaboration is both necessary and desirable. Nonetheless, there are often too many serious intra-professional barriers and obstacles to interprofessional collaboration to make it successful. Some of these barriers, it is argued and illustrated, are found in the multiple ways in which professional identity is tacitly acquired and embodied in the practitioners' habitual, everyday practice. The paper then explores ways in which reflection, especially Second order reflection, can help to elucidate and overcome these obstacles, as well as increasing professional adaptability and competence.     

Determination of creatine kinase isoenzyme MB activity in serum using immunological inhibition of creatine kinase M subunit activity. Activity kinetics and diagnostic significance in myocardial infarction.

This is a new method for the determination of creatine kinase isoenzyme MB activity in serum. The method uses direct activity measurement of creatine kinase B subunit activity after blocking of CK-M subunit activity by inhibiting antibodies. The test takes no longer than 15 min. The method yields an intra-serial C.V. of 2.0-12.9%, and a C.V. from day to day of 5.5%. The detection limit is 3.4 U/l creatine kinase MB. In the 95 cases with proven myocardial infarction several types of creatine kinase MB activity kinetics could be determined. The percentage of creatine kinase MB of peak CK-total is 6-25%, with a mean of 11.1%. The amount of creatine kinase MB with respect to total CK activity after reinfarction is higher than the amount after initial infarction.     

Prise en charge des entorses externes de cheville : étude clinique préliminaire sur l’efficacité du dispositif Myolux™

Ankle sprains are the most common injury of the musculoskeletal system and are associated with significant societal and economic impacts. It has been proven that classical therapeutic strategies may not be effective in preventing recurrent injuries: the recurrence rates reported in the literature can reach 73%. In order to provide an effective rehabilitation solution, a destabilizing orthosis was developed. This device is equipped with a mechanical articulator reproducing the subtalar mechanics and placed under the heel. In this paper, we present the main results of a preliminary clinical study conducted between 2004 and 2007. All subjects included in this study were treated with the abovementioned orthosis during 10 rehabilitation sessions of 30 minutes each. Data show a relatively low recurrence rate of 12% for the overall population. Moreover, it's of primary importance to note that this satisfactory ratio is largely reduced (3% of recurrence rate) for the 29 patients who performed one training session per month after the 10th initial rehabilitation sessions. Hence, the destabilizing orthosis appears to be an effective solution to prevent recurrent ankle sprains. However, joint protection requires long-term and regular training sessions. This result has motivated the development of a similar device allowing patients to perform training sessions at home. Finally, data obtained in this study are promising awaiting the final results of the comparative, multicentric and independent clinical trials currently managed by the Hospices Civils de Lyon.     

俯卧位通气对高海拔地区肺复张治疗无效急性呼吸窘迫综合征患者氧合的影响

目的 探讨俯卧位通气对高海拔地区肺复张术(RM)治疗无效急性呼吸窘迫综合征(ARDS)患者的治疗作用.方法 从海拔2260m的地区医院筛选RM治疗无效的41例ARDS患者[平均氧合指数( PaO2/FiO2)较RM前升高＜20％视为RM无效],依不同病因分为肺内源性ARDS组(ARDSp组)和肺外源性ARDS组(ARDSexp组),每组再按信封法随机分为俯卧位组和仰卧位组,即ARDSp俯卧位组(11例)、ARDSp仰卧位组(9例)、ARDSexp俯卧位组(10例)、ARDSexp仰卧位组(11例).在通气前及通气1、2、3、4h监测动脉血氧分压( PaO2)、PaO2/FiO2、静态顺应性(Cst)、气道阻力(Raw)的变化.结果 通气lh时,ARDSexp俯卧位组PaO2/FiO2( mm Hg,l mm Hg=0.133 kPa)即较通气前显著升高(157.4±40.6比129.3±48.7,P＜0.05),并随通气时间延长呈持续增高趋势,4h达峰值(219.1 ±41.1);且ARDSexp俯卧位组通气3h内PaO2/FiO2较其他3组显著增高,另3组间则差异无统计学意义.ARDSp俯卧位组、ARDSexp俯卧位组通气4h时PaO2/FiO2均较相应仰卧位组显著增高(208.8±39.7比127.4±47.1,219.1±41.1比124.9±50.8,均P＜0.05).4组通气前后Cst无显著改变,各组间差异也无统计学意义.ARDSp俯卧位组通气4h时Raw(cmH2O·L-1·s-1)较通气前显著降低(6.8±1.7比10.7±1.8,P＜0.05),且明显低于其他3组;其他3组各时间点Raw组内及组间比较差异均无统计学意义.结论 俯卧位通气作为ARDS机械通气重要策略之一,可以改善RM无效高原ARDS患者的氧合,为抢救患者赢得宝贵的时间.     

Digital imaging among medical facilities

The Department of Veterans Affairs (VA) in the USA operates a network of 172 medical centres which all utilize a hospital information system (HIS) which has been developed and is currently maintained by the VA. During the past several years, an image management and communication module has been developed, installed and clinically utilized at the Washington DC and Maryland VA Medical Centres. This image management and communication system, referred to as the decentralized hospital computer program (DHCP) imaging system, is fully integrated with a commercial picture archiving and communication system (PACS). The system is utilized to capture, archive, and display all images generated within the hospital including radiology, nuclear medicine, pathology, endoscopy, bronchoscopy, and dermatology, intraoperative photographs, ECG data, and a limited number of paper documents. The ultimate goal of the project is to have all patient text and image data available at any clinical workstation to any authorized user anywhere within the network of medical centres. Clinical requirements for an imaging workstation include ease of use, rapid and reliable access to the complete set of patient information, and images which are of acceptable quality to meet the requirements of the user and the subspecialty. Patient confidentiality and data security must be safeguarded at all times. Integration of the images with the remainder of the patient's database was found to be critical to the success of the project. The experience at the Washington and Maryland facilities suggests that an imaging system that is successfully integrated with a hospital information system can provide substantial clinical and economic benefits both within and among medical centres. Clinical acceptance and utilization of the system has been excellent, particularly in diagnostic radiology where DHCP Imaging has been interfaced to a commercial PAC system. Based upon this initial experience, the VA has begun to deploy the system throughout its large network of medical centres.     

Myocardial elastography at both high temporal and spatial resolution for the detection of infarcts

Myocardial elastography is a novel method for noninvasively assessing regional myocardial function, with the advantages of high spatial and temporal resolution and high signal-to-noise ratio (SNR). In this paper, in-vivo experiments were performed in anesthetized normal and infarcted mice (one day after left anterior descending coronary artery [LAD] ligation) using a high-resolution (30 MHz) ultrasound system (Vevo 770, VisualSonics Inc., Toronto, ON, Canada). Radiofrequency (RF) signals of the left ventricle (LV) in longitudinal (long-axis) view and the associated electrocardiogram (ECG) were simultaneously acquired. Using a retrospective ECG gating technique, 2-D full field-of-view RF frames were acquired at an extremely high frame rate (8 kHz) that resulted in high-quality incremental displacement and strain estimation of the myocardium. The incremental results were further accumulated to obtain the cumulative displacements and strains. Two-dimensional and M-mode displacement images and strain images (elastograms), as well as displacement and strain profiles as a function of time, were compared between normal and infarcted mice. Incremental results clearly depicted cardiac events including LV contraction, LV relaxation and isovolumetric phases in both normal and infarcted mice, and also evidently indicated reduced motion and deformation in the infarcted myocardium. The elastograms indicated that the infarcted regions underwent thinning during systole rather than thickening, as in the normal case. The cumulative elastograms were found to have higher elastographic SNR (SNR(e)) than the incremental elastograms (e.g., 10.6 vs. 4.7 in a normal myocardium, and 6.0 vs. 2.4 in an infarcted myocardium). Finally, preliminary statistical results from nine normal (m = 9) and seven infarcted (n = 7) mice indicated the capability of the cumulative strain in differentiating infracted from normal myocardia. In conclusion, myocardial elastography could provide regional strain information at simultaneously high temporal (>/=0.125 ms) and spatial ( approximately 55 microm) resolution as well as high precision ( approximately 0.05 microm displacement). This technique was thus capable of accurately characterizing normal myocardial function throughout an entire cardiac cycle, at the same high resolution, and detecting and localizing myocardial infarction in vivo.