老年患者颈动脉内膜切除术的危险因素、术中颈动脉血流动力学变化及近期并发症——英国三级医疗中心的回顾性分析

本项研究探讨了〉75岁高龄患者动脉内膜切除术（CEA）的安全性，同时分析了术中超声血流动力学的改变。连续纳入了496例有症状或无症状颈动脉狭窄患者，颈动脉狭窄率〉70％，并接受CEA治疗。按年龄分为≤75岁组408例（平均64岁）和〉75岁组88例（平均78岁）。

球囊导管扩张咽鼓管的初步研究

咽鼓管功能障碍是常见疾病，经内镜鼻球囊导管扩张咽鼓管是一种新的手术技术，本研究的目的是回顾性分析这种新技术的演化并报道其适应症、初步结果和并发症。 2009年1月～2011年1月期间，一家三级医疗中心的70例（100耳）主诉慢性耳胀满感、压迫感、疼痛及气压创伤性中耳炎的成人（18～73岁）患者，自幼均无咽鼓管功能不良的病史，行单侧或双侧咽鼓管球囊导管扩张术。手术在手术室全麻或在诊室用利多卡因凝胶行咽鼓管局麻下进行，将F-70的引导导管尖部经鼻置于咽鼓管咽口，将宽5mm、长16mm的鼻用球囊导管放置于咽鼓管的近端以扩张咽鼓管软骨部，扩张压力为6～8个大气压，扩张时间10～30秒。

重症监护病房产科患者生理改变、年龄及健康(APACHE Ⅲ)评分的应用

Objective: Amean Acute Physiology,Age, and Chronic Health Evaluation (APACHE III) score of > 50 is associated with increased intensive care unit mortality rate in nonpregnant cardiac and trauma patients. The objective was to determine the usefulness of the APACHE III score in maternal admissions to an intensive care unit in a tertiary care center in an urban multicul turalcity. Study design: This was a retrospective review of all maternal admissions ( > 20 weeks of gestation or after delivery)- to an intensive care unit between January 2002 and May 2004. Demographics, obstetric and medical history, and 20 physiologic variables that comprise the APACHE III were recorded.The minimum APACHE III score (lowest risk of death) is 0;maximum is 299. The association between APACHE III scoreand maternal death was assessed with Mann Whitney U test.Significance was assumed at a probability value of < .05. Results:Fifty-eight subjects met the study criteria. Thirty percent of these women were admitted antepartum (27 ± 1.0 weeks of gestation); 31% of the women were admitted on the day of delivery; and 29% of the women were admitted after delivery.Mean maternal age was 27 ± 6.7 years. Acute conditions that resulted in transfer to the intensive care unit included preeclampsia(24% ), cardiorespiratory disease (21% ), hemorrhage(16% ), infection (12% ), trauma (7% ), and thromboembolism(3% ). Fifty-five percent of the women had no previous underlying obstetric complications, and 98% of the women had no underlying chronic health condition. Fifty-eight percent of the women received care in a medical intensive care unit; 28% of the women received care in a surgical intensive care unit; 10% of the women received care in a cardiac intensive care unit, and 3% of the women received care in a neurologic intensive care unit. The mean intensive care unit stay was 3.7 ± 4.6 days, and the mean hospital stay was 9.0 ± 7 days. Three patients died; the rest of the patients went home in good condition. The median APACHE III score was 34 (range, 14- 102) and was not correlated with maternal death. Conclusion: The APACHE III is not associated with risk of intensive care unit- related maternal death.

强直性脊柱炎患者接受infliximab治疗时发生眶蜂窝织炎1例

PURPOSE:To describe a case of orbital cellulitis arising in a patient treated with an anti-TNFα agent.DESIGN:Single interventional case report.METHODS:A 42-year-old man developed severe unilateral orbital cellulitis while receiving infliximab(Remicade,Centocor)treatment for Ankylosing spondylitis(AS)as part of the open-label phase of a trial conducted at our tertiary referral center.Cultures grew Staphylococcus aureus.RESULTS:Infliximab treatment was stopped and the patient made a full recovery after receiving appropriate antibiotic therapy.Infliximab therapy was resumed after three weeks.CONCLUSIONS:Clinical vigilance is warranted when treating patients with anti-TNFα agents as these are associated with a diverse and growing number of ophthalmic complications.Resolved infection does not preclude the use of such agents.

静脉使用多黏菌素的肾毒性

2003年1月至2007年12月期间，对华盛顿一所三级医疗中心接受静脉多黏菌素治疗疗程大于72h的患者（年龄大于18岁）进行回顾性研究。根据RIFLE标准（risk，injury，failure，loss，end—stagekidneydisease）评价肾功能不全，即（1）风险（Risk）：肌酐水平增加1．5倍或肾小球滤过率减低25％以上；（2）损伤（Injury）：肌酐水平增加2倍或‘肾小球滤过率减低50％以上；

产前检查对先天性膈疝结局的影响:在Auvergne地区12年的经验总结

Objective: To evaluate the detection rate of prenatal diagnosis and its impact on outcome in congenital diaphragmatic hernia(CDH). Study design: We retrospectively studied 51 cases of CDH registered in the Auvergne area from January 1992 to December 2003 (Birth Defect Registry of Auvergne,Institut Europé en des Gé nomutations). Our main outcome measurements were the detection rate of prenatal diagnosis, the incidence and types of associated anomalies and outcome (termination of pregnancy, in utero fetal demise, neonatal death, survivalat the time of registration). Results: Twenty-nine cases of isolated CDH were identified of which 13 were detected prenatally (45% ) at a mean gestational age of 26.1 weeks and 22 cases of CDH with associated anomalies with prenatal diagnosis of CDH or any associated anomaly in 16 (73% ; p = 0.03) at a mean gestational age of 23.9 weeks. In the prenatally detectedgroup (29 cases), there was 1 (3% ) in utero fetal death (IUFD),17 (59% ) terminations of pregnancy (TOP) and 11 (38% ) live births with early neonatal death in 7 (24% ) cases despite delivery in a tertiary care centre in 10/11 cases (four survivors = 14% ). Most of the undetected cases were isolated CDH (16/22 = 73% ) of which 1 (5% ) was a stillborn and 21 (95% ) live births with 17 survivors (77% ) although 15/21 (71% ) were not born at the tertiary care centre (p = 0.001). The overall survival rate was 41% with a large variability depending on associated anomalies and prenatal diagnosis (p < 0.0001) (prenatally detected cases:3/13 (23% ) isolated CDH and 1/16 (6% ) CDH with associated anomalies; undetected cases: 13/16 (81% ) isolated CDH and 4/6 (67% ) CDH with associated anomalies). Conclusion: Prenatal diagnosis of CDH leads to the delivery of affected babies in tertiary care centres but it remains a challenge in particular for isolated CDH cases and it is associated with a lower survival rate. Associated anomalies contribute to prenatal detection, are related to a higher TOP rate but do not facilitate the detection of diaphragmatic defect per se.

预测埋藏式除颤器植入后的早期死亡率:选择患者的最佳临床风险评分

Background: Patients with advanced heart disease are at risk from sudden death; however, benefit from implantable cardioverter defibrillators(ICDs) may be limited as a result of early mortality from other causes. The objective of this study was to develop a model to predict mortality within the first year after ICD implantation. Methods and Results: A retrospective analysis was performed of 469 consecutive patients who underwent ICD implantation at a single tertiary- care center from 1999 to 2002. Vital status was determined from the Social Security Death Index. Patients were randomized into prediction and validation cohorts. A risk score was derived from the prediction cohort by multivariate logistic regression and applied to the validation cohort. One point was assigned for each variable in the risk score(age>80 years, history of atrial fibrillation, creatinine> 1.8 mg/dL,New York Heart Association class III or IV). One- year mortality significantly increased with increasing risk score in both the prediction and validation cohorts. Validation cohort mortality was 3.4% for 0 points, 4.3% for 1 point, 17% for 2 points, and 33% for ≥ 3 points(P for trend< .0001). A risk score ≥ 2 predicted a 1- year mortality rate of 21% , whereas a risk score< 2 predicted a mortality rate of 4% at 1 year(P< .0001). Conclusion: A risk score using simple clinical criteria may identify patients at high risk of early mortality after ICD implantation. This may be helpful in consideration of ICD risk/benefit for individual patients. Further studies conducted in a prospective manner using these clinical criteria are warranted.

HIV-1感染孕妇未达到最佳病毒抑制时分娩的临床特点

This study was undertaken to determine clinical characteristics and factors associated with suboptimal viral suppression at delivery in human immunodeficiency virus (HIV)- infected women. Study design: All HIV- infected women who delivered at a single urban tertiary care center from January 1999 to June 2004 were studied. Women were divided into 2 groups based on HIV viral load (VL) proximate to delivery: VL <1000 copies per milliliter and VL ≥ 1000 copies per milliliter. Demographic and clinical factors were analyzed and compared between the 2 groups. Results: A total of 146 women had adequate data available for analysis: 102 (69.9% ) had VL < 1000 copies per milliliter and 44 (30.1% ) had VL ≥ 1000 copies per milliliter at delivery. Women with a viral load ≥ 1000 copies per milliliter at delivery were more likely to have a baseline viral load VL ≥ 10,000 copies per milliliter (66.7% vs 32% , P < .001) and less likely to report medication adherence, (50% vs 87.8% , P < .001). Conclusion: Our findings support the concept that in addition to antiviral medical therapy, intervention to improve adherence and maintaining a low baseline VL are key components to VL suppression in pregnancy.

孕妇的种族是否影响重度先兆子痫的表现

There is considerable variation in the expression of severe preeclampsia. Our purpose was to determine if this is associated with maternal race or ethnicity. Study design: Individual chart review was performed for women diagnosed with severe preeclampsia at a tertiary care center from 1993 to 2003. Demographic, clinical, and lab findings from diagnosis (Dx) to 6 weeks’ postpartum (PP) were documented. Data were compared between Caucasian, African American, and Hispanic women. Data were presented for the total cohort if no significant difference was found. Results: We evaluated 473 pregnancies: 201 (Caucasian), 216 (African American), and 56 (Hispanic). Groups had similar baseline characteristics: chronic hypertension (HTN), diabetes, and initial antenatal blood pressure (mean BP 118/68). Caucasian women were older (27 vs 24 yrs), more likely nulliparous (63 vs 49% ), and had more multiple gestations (9 vs 1.5% ), P < .002 for each. African Americans had less epigastric pain (7.4 vs 10% ) and nausea (2.3 vs 5% ), P < .05 for each. Platelets < 100,000/μ L and asparate aminotransferase >60 mg/dL were more common in Caucasian women at Dx (9 vs 12% , 11 vs 21% ) and at delivery (14 vs 24% , 19 vs 34% ), P < .05 for each. No difference in severe proteinuria was seen. African Americans had more severe HTN at both Dx (44.9 vs 30% ) and peak BP (85 vs 67% ), and required more antihypertensive Rx intrapartum (12 vs 6% ), PP (38 vs 12% ), and at discharge (35 vs 21% ), P < .03 for each. Hispanics presented later (36 vs 34.6 weeks) and had less severe HTN (27 vs 40% ), P < .04 for each. BP on DC was not different between groups. Caucasian women had more hemolysis, elevated liver enzymes and low platelets syndrome (29 vs 19% , P = .01). Eclampsia, intrauterine fetal demise, intrauterine growth restriction, abruption, PP preeclampsia, and recurrent preeclampsia were similar between groups. Conclusion: African American women with severe preeclampsia demonstrate more severe hypertension and required more antihypertensive Rx, while Caucasian women have more frequent hemolysis, elevated liver enzymes and low platelets syndrome.

肾功能不全可预测首次适当除颤器电击时间

Background: Indications for implantable cardioverter defibrillator(ICD) implantation are expanding, but many primary and secondary ICD trials have excluded patients with advanced renal insufficiency. We investigated the effect of renal function on the incidence and time to first appropriate ICD shock. Method: We analyzed data from all new ICD implantations at a tertiary care center from July 2001 to December 2002. Results: During a mean follow-up time of 445±285 days, 29(13%) of 230 patients(age 63±14 years, 79%men, 77%white, 75%coronary artery disease, left ventricular ejection fraction 0.28±0.14) received 41 appropriate shocks. Patients were divided into tertiles according to their serum creatinine level. The 1-year incidence of appropriate ICD shock was 3.8%, 10.8%, and 22.7%in the first, second, and third tertiles, respectively(P=.003). Using the same cut off values of serum creatinine, the 1-year incidence of appropriate ICD therapy(shock and antitachycardia pacing)was 8.8%, 20.8%, and 26.3%(P=.02). After correcting for age, sex, race, left ventricular ejection fraction, indication for ICD implantation, and use of β-blockers in a Cox regression model, serum creatinine was still an independent predictor of the time to first appropriate ICD shock(hazard ratio 6.0 for the third compared with the first tertile, P=.001). Conclusion: Renal insufficiency is a strong predictor of appropriate ICD shocks. Defibrillator therapy should therefore not be withheld based on the presence of this comorbidity. The mechanisms underlying the relationship between renal function and ventricular arrhythmias deserve further investigation.

Sjgren-Larsson综合征成年同胞的表型可变性

Background: Sjgren-Larsson syndrome (SLS) is an early childhood-onset disorder with ichthyosis, mental retardation, spastic paraparesis, macular dystrophy, and leukoencephalopathy caused by the deficiency of fatty aldehyde dehydrogenase due to mutations in the ALDH3A2 gene (the gene that encodes microsomal fatty aldehyde dehydrogenase). Cerebral proton magnetic resonance spectroscopy in those with SLS demonstrates an abnormal white matter peak at 1.3 ppm, consistent wit h long-chain fatty alcohol accumulation. Objective: To define the clinical cour se and proton magnetic resonance spectroscopic findings of SLS in adults. Design and Setting: Case series in a tertiary care center. Patients: Six siblings of a consanguineous Arab family with early childhood-onset SLS who carry the 682C→T mutation in the ALDH3A2 gene were reinvestigated in adulthood. Results: The 6 affected siblings ranged in age from 16 to 36 years. All exhibited the typical c linical and imaging manifestations of SLS, but their severity markedly varied. N eurological involvement was apparently nonprogressive, and its severity showed n o correlation with age. Cerebral proton magnetic resonance spectroscopy showed a lipid peak at 1.3 ppm, with decreasing intensity in the older siblings. Conclus ion: These observations document significant clinical variability and the nonpro gressive neurological course of SLS in adult siblings with the same ALDH3A2 geno type, and demonstrate possible correlation of proton magnetic resonance spectros copic changes with age, suggesting unknown pathogenic mechanisms to compensate f or the responsible biochemical defect in this disease.

术中使用依诺肝素可以减轻儿童白内障术后的炎症反应

PURPOSE: To evaluate the effect of intraocular infusion of enoxaparin,a low-molecular-weight heparin,on postoperative inflammatory response in pediatric cataract surgery. DESIGN: Prospective,comparative,consecutive interventional case series. METHODS: Seventeen consecutive eyes (11 patients) underwent pediatric cataract surgery in two tertiary medical centers. During the procedure,balanced salt solution with enoxaparin (40 mg in 500 ml) was infused into the anterior chamber. Eleven consecutive eyes (eight patients) received balanced salt solution without enoxaparin in the infusion bottle. The inflammatory response in the anterior chamber was compared between the two groups by semiquantification with slit-lamp biomicroscopy. Postoperative inflammatory complications,including fibrin formation,intraocular lens precipitates,anterior and posterior synechiae,cyclitic and pupillary membrane formation,and anterior subluxation of the intraocular lens,were also compared. The follow-up period after surgery was between 3 and 36 months (average 12.3 months). RESULTS: The number of cells and the degree of flare were minimal in the group with enoxaparin in the infusion bottle (P < .001). The total number of postoperative inflammation related complications was also lower in the enoxaparin-treated group (P=.007). All corneas remained clear,and the endothelial cell count,which was performed in two patients,did not show substantial decrease in their density or changes in shape and size. No other enoxaparin-related complications were observed. CONCLUSIONS: Infusion of enoxaparin during pediatric cataract surgery may minimize the postoperative inflammatory response and decrease the number of postoperative inflammatory related complications. Enoxaparin should also be evaluated for cataract surgery in other conditions where postoperative inflammation may be exacerbated.

为地区综合医院中的先天性心脏病成人患者建立联合门诊是一种可选的治疗模式

Congenital heart disease(CHD) affects approximately 250,000 adults in the UK. Most of these patients would benefit from specialized follow-up. However, there is at present a significant shortfall of specialized tertiary care expertise and facilities for this growing cardiovascular field in the UK and around the world. We aimed to report our experience with a joint adult CHD clinic run in a district general hospital with regular input from the local cardiology team and a visiting adult CHD specialist. In total, 148 patients aged 33.6+/-14.1 years were seen once or more in 12 clinics over the study period(September 1999 to January 2003). Diagnostic case mix consisted of 2.9%complex, 67.9%moderate and 29.2%minor cases of CHD. Twenty percent of patients visited the counterpart tertiary center for additional investigations(mostly MRI) and 8%for intervention(with no operative mortality). There was one death during the study period giving an overall mortality of 0.2%/year. Patients were referred to the clinic from tertiary centres, the local cardiology and paediatric clinics and with time from obstetric and community sources. Nonattendance rates were relatively low, comparing favourably with tertiary care. This model of joint care for the adult CHD patient at a general district hospital with regular onsite specialized input appears to be effective and highlights the need for additional resource allocation to provide optimal care for these patients. Our data may be useful in future planning for CHD services.

有金黄色葡萄球菌菌血症的婴幼儿感染性心内膜炎的发生率

Purpose. The prevalence of infective endocarditis (IE) among children with Staphylococcus aureus bacteremia (SAB) is unknown. The objective of this study was to determine prospectively the prevalence of IE among pediatric patients with SAB in a large tertiary care center. Methods. Between July 1998 and June 2001, all children who developed SAB whose parent/guardian signed informed consent underwent echocardiography. Clinical and follow-up results were collected prospectively. Endocarditis was classified according to the modified Duke criteria. Results. Fifty-one children developed SAB during the study interval. Definite (6 patients [11.8%] ) or possible (4 patients [7.8%]) IE was present in 10 of 51 (20%) children with SAB. Most children (73%) developed bacteremia as a consequence of an infected intravascular device. Children with underlying congenital heart disease had a significantly higher prevalence of definite or possible IE, compared with those with structurally normal hearts (53%vs 3%). All patients with definite IE had multiple positive blood cultures. Mortality was high among patients with and without IE (40%vs 12%). Conclusions. In this study, the preva- lence of definite IE among children with SAB was ～12%and was frequently associated with congenital heart disease and multiple positive blood cultures. The mortality for children with SAB and defi-nite or possible S aureus IE is high.

Second-order problem solving:Nurses'perspectives on learning from.near misses

Objectives:Near misses happen more frequently than actual errors,and highlight system vulnerabilities without causing any harm,thus provide a safe space for organizational learning.Second-order problem solving behavior offers a new perspective to better understand how nurses promote learning from near misses to improve organizational outcomes.This study aimed to explore frontline nurses’perspectives on using second-order problem solving behavior in learning from near misses to improve patient safety.Methods:A qualitative exploratory study design was employed.This study was conducted in three tertiary hospitals in east China from June to November 2015.Purposive sampling was used to recruit 19 frontline nurses.Semi-structured interviews and a qualitative directed content analysis was undertaken using Crossan’s 4I Framework of Organizational Learning as a coding framework.Results:Second-order problem solving behavior,based on the 4I Framework of Organizational Learning,was referred to as being a leader in exposing near misses,pushing forward the cause analysis within limited capacity,balancing the active and passive role during improvement project,and promoting the continuous improvement with passion while feeling low-powered.Conclusions:4I Framework of Organizational Learning can be an underlying guide to enrich frontline nurses’role in promoting organizations to learn from near misses.In this study,nurses displayed their pivotal role in organizational learning from near misses by using second-order problem solving.However,additional knowledge,skills,and support are needed to maximize the application of second-order problem solving behavior when near misses are recognized.

危重患儿72h转诊死亡风险模型的建立与验证

重症患儿转诊至三级医疗中心的重症监护病房是院问转诊服务区域化的一个重要组成部分，近年来，随着我国医疗体制的不断发展完善，以及儿童重症监护病房的快速发展，导致了重症患儿向三级医疗机构的集中化，重症患儿转诊至三级医疗中心可以获得更高水平的救治，而转诊的最终目的是为了改善愈后降低病死率。

心电图预激表现与心血管病和死亡风险的关系:哥本哈根心电图研究结果

大部分心室预激患者临床发病过程中的心电图资料来源于三级医疗中心。为了调查患有心电图预激的初级保健人群的长期预后，来自丹麦哥本哈根Rigshospitalet心脏中心分子心脏病学实验室的研究人员在2001—2011年收集了328638例初级保健患者的电子心电图数据，确定了310例心电图显示预激（年龄8～85岁）的个体。并从丹麦全国注册管理机构获取关于患者药物、合并症和临床结局的资料。随访中位数为7．4（四分位间距4．6～10．3）年。

补充医学

Jack是最令我感到震惊的患者.1年多前我负责住院患者,他来找我看病是因还没有自己的医生.最初,除了出现双侧扩散性肺炎外,-般情况还可以,然而静脉用抗生素后未能奏效,并出现了过度充气、水泡音和渗出;抽出空气后将其转至三级医疗中心,经支气管镜检查示弥漫性间质性肺炎和肺部纤维化,但没有做气管插管,予以类固醇药物、吸氧等治疗3周后因预后不良而出院.