盐酸右美托咪定对老年患者非体外循环冠脉搭桥术后早期认知功能的影响

【目的】探讨盐酸右美托咪定对老年患者行非体外循环冠脉搭桥术后早期认知功能的影响。【方法】收集111例符合纳入标准的老年行非体外循环冠脉搭桥手术患者随机分为两组,其中观察组56例,麻醉诱导后静脉注射盐酸右美托咪定;对照组55例,麻醉诱导后注射等量0．9％氯化钠注射液。评价比较两组术前与术后简易智力状态检查表（MMSE）评分、术后认知功能障碍（POCD）发生率及不良反应发生率。【结果】两组患者手术情况顺利,术前两组患者 MMSE 评分相比较差异无显著性（ P ＞0．05）。两组术后6 h和术后1 d 的 MMSE 评分明显低于术前,且差异有显著性（ P ＜0．05）,但观察组术后6 h 和术后1 d 的MMSE 评分明显高于对照组,且差异有显著性（ P ＜0．05）;观察组术后6 h 和1 d 的 POCD 发生率明显低于对照组,且差异有显著性（ P ＜0．05）。但两组术后3 d 的 MMSE 评分和 POCD 发生率相比较差异均无显著性（ P ＞0．05）。观察组术中低血压发生率和心动过缓发生率明显高于对照组（ P ＜0．05）。【结论】盐酸右美托咪定可预防老年行非体外循环冠脉搭桥手术患者 POCD 的发生,值得临床推广应用。     

髋关节置换术老年患者血清IL-6水平与术后早期认知功能障碍的关系

目的研究髋关节置换术老年患者血清白介素-6（IL一6）水平与术后早期认知功能障碍的关系。方法33例择期髋关节置换术老年患者分全麻组（G组，静吸复合全麻）和腰硬组（E组，腰硬联合麻醉）。患者均未麻醉前用药，术中收缩压的变化维持在基础值±25％之内，SpO2≥95％。术后采用0.001％芬太尼（2ml／h）静脉48h镇痛。评估患者麻醉前，术后3、6h，1d和3d的MMSE评分。分别在麻醉前、术后3、6h采集右颈内静脉血检测血清IL-6水平。结果老年患者术后3、6h，1d的MMSE评分较麻醉前明显降低（P〈0．01），术后3d基本恢复正常。G组术后3h点POCD发生率明显高于E组（67％ vs 22％，P〈0．05），术后6h、1d点POCD发生率与E组相似（27％ VS 17％、20％ vs 11％，P〉0．05）。两组术后3、6h点IL-6水平均较麻醉前明显升高（P〈0．01），G组明显高于E组（P〈0．01），且14例POCD患者IL-67水平明昂高于无POCD者（P〈0．01）。结论髋关节置换术老年患者行伞麻后早期POCD的发牛率较高可能与IL-6的升高有关。     

右美托咪定对食管癌全麻术中单肺通气患者手术后认知功能障碍的影响

【目的】探讨食管癌全身麻醉术中单肺通气（OLV）患者应用右美托咪定（Dex）对手术后认知功能障碍（POCD）的影响。【方法】本院诊治的食管癌根治术患者74例,将患者随机分为观察组（ n ＝40）和对照组（ n ＝34）,观察组麻醉诱导后静脉注射Dex ,对照组麻醉诱导后注射等量生理盐水。比较两组手术情况,简易智力状态检查表（MMSE）评分、POCD发生情况等。【结果】两组OLV时间、出血量等相比较差异均无显著性（ P ＞00．5）;观察组术后与术前MMSE评分比较差异无显著性（ P ＞00．5）,对照组术后1 d、3 d MMSE评分较术前明显降低（P ＜00．5）;观察组术后1d、3d患者MMSE评分分别为（264．0±21．6）分和（267．2±20．1）分,明显高于对照组,且差异有显著性（ P ＜00．5）;观察组术后1 d、3 d患者POCD发生率分别为125．0％,25．0％,均明显低于对照组的323．5％和205．9％,且差异有显著性（ P ＜0．05）。【结论】Dex 能有效降低食管癌全身麻醉术中 OLV 患者POCD的发生,值的在临床推广。     

全身与局部麻醉对老年急性出血性脑卒中患者术后认知功能的影响比较

【目的】比较全身与局部麻醉对老年急性出血性脑卒中患者术后认知功能的影响。【方法】72例急性出血性脑卒中患者,随机分为两组,A 组给予全身麻醉,B 组予以局部麻醉,记录麻醉前（T0）、手术前（T1）、手术0．5 h（T2）、手术操作（T3）、术毕（T4）时患者心率（HR）、动脉压（MAP）变化,比较两组镇痛效果,术后认知功能障碍（POCD）发生率,记录术后不良反应发生率。【结果】① T0点,两组 MAP 、HR 相比较差异无显著性（P ＞0．05）;T1、T2、T3、T4点两组 MAP 降低,HR 略有上升,但组间比较差异均无显著性（P ＞0．05）;②术后即刻、术后1 d 、术后3 d A 组视觉模拟评分（VAS）均低于 B 组（P ＜0．05）;③术前两组简易智能精神状态量表（MMSE）评分无差异（P ＞0．05）,术后3 h 、术后1 d A 组 MMSE 评分均低于 B 组（P ＜0．05）,术后3 d A 组 MMSE 评分上升,与 B 组比较差异无显著性（P ＞0．05）;④两组睁眼、拔管及完全苏醒时间相比较差异无显著性（P ＞0．05）;⑤ A 组术后 POCD 发生率略高于 B 组,但差异无显著性（ P ＞0．05）,两组不良反应发生率比较差异无显著性（P ＞0．05）。【结论】全身麻醉、局部麻醉对老年急性出血性脑卒中患者血流动力学影响相似,患者术后 POCD 发生率无差异,但全身麻醉镇痛完全,可提高患者对手术的耐受性。     

老年全身麻醉患者ADP和MMP-9的含量与术后认知功能障碍的相关性分析

【目的】探讨老年全身麻醉患者血液中基质金属蛋白酶‐9（MM P‐9）、脂联素（ADP）含量的变化与患者术后认知功能障碍（POCD）的相关性。【方法】本院接受手术治疗的老年患者64例根据其术后是否发生POCD 分为发生组和未发生组,比较两组患者手术前后血液中 ADP 和 MMP‐9含量的变化以及认知功能情况以及其相关性。【结果】64例患者中,发生 POCD 者12例,发生率为18．75％（12／64）;发生组和未发生组患者术前 ADP 和 MMP‐9水平相比较差异无显著性（ P ＞0．05）;手术后两组患者的 ADP 均较术前降低,MMP‐9均较术前增高（ P ＜0．05）,且发生组的上述指标变化更明显（ P ＜0．05）。两组患者术前简易精神状态评定量表（MMSE）中的定向力、瞬时记忆、注意力和计算力等认知功能评分相比较差异无显著性（ P ＞0．05）;术后发生组患者的上述指标均较术前降低,而未发生组的上述指标较术前无明显改变;患者 ADP 与 MMSE 得分呈显著正相关,而 MMP‐9与 MMSE 得分呈显著负相关（均 P ＜0．05）。【结论】ADP 和 MMP‐9在老年全身麻醉术后出现 POCD 的患者中水平较高,可作为临床重要的监测指标。     

氯诺昔康超前镇痛对胃癌患者术后血浆皮质醇浓度的影响

目的：观察非甾体消炎镇痛药氯诺昔康超前镇痛对胃癌患者术后血浆皮质醇浓度的影响。方法：Ⅰ组15例术前给予氯诺昔康8mg,手术后经PCA泵以氯诺昔康和吗啡镇痛;Ⅱ组15例仅在术后经PCA泵给予吗啡镇痛。分别于术前、术毕、术后24h、术后72h抽取外周血,测定血浆皮质醇（Cor）浓度。结果：两组患者术后VAS评分差异无统计学意义。与术前值比较,Ⅱ组患者术毕、术后24h时血浆皮质醇水平升高,Ⅰ组血浆皮质醇水平仅在术毕时高于术前（P〈0．05）。与Ⅱ组相比,Ⅰ组术毕、术后24h血浆皮质醇水平明显降低（P〈0．05）。结论：氯诺昔康超前镇痛能减轻皮质醇的增高程度,减轻胃癌患者术后的过度应激状态。     

颈丛复合全麻在颈动脉内膜剥脱术中的应用

【目的】观察颈丛阻滞复合全麻在颈动脉内膜剥脱术（carotid endarterectomy ,CEA ）中的应用。【方法】将2012年1月至2013年8月在本院行CEA术的40例患者按照麻醉方式分为两组：对照组（G组）20例采用单纯全麻,观察组（GL组）20例采用颈丛复合全麻。观察并分析两组患者围术期的血流动力学变化、苏醒时间以及镇痛药物用量等。采用简易精神状态检查量表（MMSE）观察患者术前1 d、术后1 d、3 d、6 d变化,初步评估患者神经功能。【方法】G L组患者在各时点血流动力学的波动均明显小于G组（ P ＜0．05）,术中血管活性药物的使用亦明显低于G组（ P ＜0．05）;G组苏醒时间、镇痛药用量显著多于GL 组（ P ＜0．05）。与术前基础值比较,两组患者术后1 d的MMSE值均明显降低（ P ＜0．05）,且G组MMSE值较GL组低,差异有统计学意义（ P ＜0．05）。术后3 d和术后6 d两组的MMSE值与术前基础值相比较均无统计学意义（ P ＞0．05）。【结论】颈丛阻滞复合全麻在颈动脉内膜剥脱术中患者血流动力学稳定,苏醒时间短,镇痛药用量少,术后对神经功能影响小,临床效果满意,能明显提高麻醉安全和质量。     

认知护理干预对丙泊酚全麻老年患者术后认知功能障碍的影响

目的探讨认知护理干预对丙泊酚全麻老年患者术后认知功能障碍的影响。方法 60例患者,随机分为观察组及对照组,每组30人,对照组给予常规护理,观察组在常规护理的基础上增加认知护理干预,观察2组手术前后MMSE、HDS、CDT及POCD发生率的情况。结果 2组手术前后MMSE、HDS评分比较,对照组患者术后3d、7d与术前3d比较,MMSE、HDS评分均明显减低,差异有统计学意义(P0.05),观察组患者术后3d与术前3d比较,MMSE、HDS评分均明显减低,差异有统计学意义(P0.05),2组间比较,观察组患者术后3d、7d与对照组术后3d、7d比较,MMSE、HDS评分差异有统计学意义(P0.05);2组患者手术前后CDT比较,对照组患者术后3d、7d与术前3d比较,CDT评分均明显减低,差异有统计学意义(P0.05),观察组患者术后3d、术前3d比较,CDT评分均明显减低,差异有统计学意义(P0.05),观察组术后7d与对照组术后7d比较,CDT评分差异有统计学意义(P0.05);POCD发生率比较,术后3d观察组发生POCD低于对照组,3d后2组POCD发生率比较差异有统计学意义(P0.05);术后7d观察组POCD发生率低于对照组,2组比较差异有统计学意义(P0.05);POCD总发生率比较,观察组低于对照组,差异有统计学意义(P0.05)。结论认知护理能够有效降低POCD发生率及有效改善POCD患者的认知水平。     

小剂量氯胺酮对老年患者椎管内麻醉术后早期认知功能障碍的影响

目的：探讨小剂量氯胺酮对老年患者椎管内麻醉下行全髋关节置换（THR）／全膝关节置换（TKR）术后早期认知功能障碍（POCD）的影响。方法选择在椎管内麻醉下行择期 THR／TKR 手术老年患者60例,随机分为两组,每组各30例,研究组于麻醉后予氯胺酮0．2 mg／kg 负荷量,并以5～10μg·kg －1·min －1持续泵注至手术结束,对照组给予等容量生理盐水。于术前24 h（T1）、切皮时（T2）、手术开始后30 min（T3）、60 min（T4）、90 min（T5）、术后2 h（T6）及术后24 h（T7）点记录平均动脉压（MAP）、心率（HR）和血氧饱和度（SPO2）。记录围术期麻醉相关不良事件,于 T1、T6、T7进行 MMSE 评分并测定神经特异性烯醇化酶、S100B 血清浓度。结果与对照组比较,研究组在 T6处 MMSE 评分较高,POCD 发生率及S －100B血清浓度均显著降低（P ＜0．05）。结论小剂量氯胺酮可安全、有效减少椎管内麻醉下行 TKR／THR老年患者术后2 h POCD 发生率,并改善术后24 h POCD 的发生。     

老年患者全麻术中脑电双频指数变化与术后认知功能障碍的关系

目的：观察老年腹腔镜胆囊切除术（LC）患者全身麻醉早期术后认知功能障碍（POCD）与术中脑电双频指数（BIS）变化的关系。方法选择年龄＞65岁择期在喉罩通气静吸复合全身麻醉下行LC患者75例,ASAⅠ～Ⅲ级,术中根据不同麻醉深度随机分为A组（术中BIS值维持在50～59）、B组（术中BIS值维持在40～49）和C组（术中BIS值维持在30～39）,每组25例。三组患者麻醉诱导用药相同,麻醉维持采用静脉泵注瑞芬太尼0.15μg＆#183;kg-1＆#183;min-1,持续吸入七氟烷,通过调整七氟烷的吸入浓度使BIS值维持在设定范围。记录三组患者术前1 d及术后1 d、2 d和3 d简易智力状态检查（MMSE）评分,并比较术后1 d POCD的发生率。同时记录三组患者手术时间、苏醒时间、拔除喉罩时间、七氟烷用量、麻黄碱用量和术中知晓发生等情况。结果三组患者术前1 d MMSE评分差异无统计学意义,A组术后1 d、2 d MMSE评分明显低于B组、C组和术前1 d评分（P＜0.05）,B组和C组只有术后1 d MMSE评分低于术前（P＜0.05）,术后2 d评分已经恢复至术前水平,而A组直至术后3 d MMSE评分才与术前水平相当。苏醒时间、拔除喉罩时间和七氟烷用量、麻黄碱用量,C组明显长于和多于A组、B组（P＜0.05）。结论老年患者在全身麻醉下行 LC,术后早期可发生不同程度的认知功能障碍,术中 BIS 值维持在40～49,可提供相对稳定的血流动力学,苏醒迅速,术后MMSE评分在较短时间内恢复正常水平,可减少POCD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.     

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.     

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.     

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.     

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.     

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.