心脏除颤器的滥用

海量资料下载 免费学习英语 www.englishvip.com/xinlw.htm （申请网址） Doctors are implanting high-tech heart devices in thousands of people who probably do not need them, a new study finds. The procedures cost more than $35,000, involve surgery and anesthesia, and may unnecessarily harm some patients. 一项新的研究发现，医生们可能正在给成百上千的人植入并非真正需要的高科技心脏除颤器。该装置售价超过3万5千美元（约合23万元人民币），佩戴者需要接受麻醉和外科手术，甚至某些患者可能还要承受不必要的身体伤害。The devices, called defibrillators, fire an electrical shock to jolt the heart back into a normal rhythm if it starts to beat in a disordered way that can cause sudden death. In people who truly need them, for conditions that can fatally disrupt heart rhythm, defibrillators can be life-saving. 若心脏发生不规则跳动，有可能致人突然死亡。心脏除颤器能产生较强的脉冲电流通过心脏，使之恢复窦性心律。对于那些真正需要的人，比如患有致命的心律失常者，心脏除颤器能挽救他们的生命。Each year, about 100,000 are implanted in the United States. Former Vice President Dick Cheney received one in 2001. 在美国，包括2001年接受植入的前副总统迪克·切尼在内，每年约有十万人植入体内心脏除颤器。The new findings fit into a larger pattern of misuse of defibrillators: paradoxically, previous research has also found that many people who need defibrillators do not get them. The reasons are not known, but may include the cost and also a reluctance by both doctors and patients to accept a surgically implanted device, especially if the patient is feeling fine and has no symptoms of the underlying problem. 这项新发现展现出一个心脏除颤器被大规模滥用的现状，颇为自相矛盾的是，此前的研究还发现许多需要者却未能获得。原因无从知悉，也许是因为价格，也许包括医生和病患在内都抗拒这种外科植入式装置，特别是当患者情况好转，已无潜在征兆之时。Professional societies set guidelines that specify when the defibrillators should be used, based on studies showing which patients they help. To find out if doctors have been complying, researchers examined the records of 111,707 people who received the implants at 1,227 hospitals in the United States from January 2006 to June 2009. The records were part of a national registry, and the National Heart, Lung and Blood Institute paid for the study. 职业协会操作指南规定了只有在基于研究显示对患者有帮助时才可以使用除颤器。为了确认医生是否有遵守规定，研究人员检查了从2006年1月到2009年6月间，在美国1227所医院接受除颤器植入的111707人的记录。这些记录是国家档案的一部分，美国国家心肺血液协会赞助了这项研究。The researchers were surprised to find that more than 25,000 people — 22.5 percent of all those who got defibrillators — did not match the guidelines. Most of the patients were 64 to 68. For unknown reasons, blacks and Hispanics were more likely than whites to get defibrillators they probably did not need. At many centers, more than 40 percent of the devices went to patients outside the guidelines. 研究人员惊奇地发现，对超过25,000人的处置 － 即所有接受植入者中的22.5% － 并不符合该指导方针。大多数患者年龄在64岁至68岁之间。不知什么原因，黑人和西班牙裔比白人更容易获得可能并非必须的除颤器。在许多医疗中心，不按指导方针给患者植入的例子超过了40%。“I didn’t expect the rate to be that high,” said Dr. Sana M. Al-Khatib, an associate professor of medicine at Duke University and the lead author of the study, which is being published Wednesday in The Journal of the American Medical Association. Dr. Khatib said experts did not expect rigid adherence to the guidelines, and knew that doctors would sometimes make judgment calls for individual patients. “比率之高超出我的预料，”杜克大学医学副教授萨娜米·哈提卜博士示，她也是将于周三发表在美国医学协会期刊上的该项研究第一作者。哈提卜博士说，专家们预料到会有不完全严格遵守指导方针的行为，也明白有时医生会对个别患者做出主观判断。“I’m sure some of these cases were reasonable,” she said. “The physicians did what they thought was best. But even taking that into account, 22.5 percent is way too high.” “我可以肯定其中一些案例是有情可原的，”她说。“医生们选择了他们认为最好的方法。但是，即使考虑到这一点，22.5%的比率还是太高了。”Why are doctors not following the expert advice? Apart from the reasonable judgment calls, Dr. Khatib said she thought many doctors did not know the guidelines or understand the evidence behind them, and thought they were helping patients by putting in the devices to save them just in case their heart rhythms went awry. 为什么医生不遵循专家的建议呢？除了可以理解的主观判断，哈提卜博士说她认为很多医生并不知道或理解指导方针的背后依据，反而认为为患者植入除颤器是在帮助他们，以防万一出现心律失常时能拯救他们的生命。“Take patients who just had a heart attack,” Dr. Khatib said. “Two randomized controlled studies show that defibrillators do not benefit patients who just had a heart attack. “选择刚好心脏病发作的患者，”哈提卜博士说。“两组随机的受控对照研究表明，除颤器不能为刚好心脏病发作的患者带来好处。”“You have to be cognizant of the evidence out there and learn from what has been published. Not only do we have one clinical trial, we have two. And these patients are more likely to have complications. You’re truly not helping these patients.” “你必须认识到指导方针是有依据的，并从中学习。我们不是只做了一组临床试验，我们有两组以供对比。而这些患者非常有可能出现并发症，你不是真的在帮助他们。”Even so, 37 percent of the devices implanted outside the guidelines went to people who had had heart attacks in the previous 40 days. 即便如此，还是有37%的心脏除颤器未按指导方针植入了在之前40天内曾心脏病发作的人。Some of those patients will eventually need defibrillators anyway, but 30 to 40 percent will not, said Dr. Alan Kadish, a cardiologist who is president of Touro College (based in New York), and who wrote an editorial accompanying the article in the journal. 不管怎么说，其中有些患者最终确实需要除颤器，但也有30%到40%并不需要，杜鲁大学（位于纽约）校长，心脏病专家艾伦·卡迪什博士说，他为在期刊上发表的研究文章写了一篇评论。The study found that electrophysiologists — cardiologists with extra training in heart-rhythm disorders — were less likely than other doctors to implant defibrillators inappropriately. Both Dr. Kadish and Dr. Khatib are electrophysiologists. 研究发现，电生理学家 － 在心律失常方面受过额外训练的心脏病专家 － 不太可能像其他医生一样不当植入心脏除颤器。卡迪什博士和哈提卜博士都是这种电生理学专家。Dr. Kadish said he thought it possible but unlikely that some doctors were implanting devices unnecessarily to make money. Physician fees for the implantation are only $1,000 to $2,000, he said, adding that the device itself costs $20,000 to $30,000, and hospital fees for the procedure are generally about $10,000. 卡迪什博士说，通过植入不必要的除颤器赚钱，不是没有可能但未必如此。植入手术医生的收费只有1000美元到2000美元，他说，此外是设备本身的成本20000美元到30000美元，以及整个过程的住院费，一般约为10000美元。He said that if a defibrillator was recommended, it was reasonable for patients to ask their doctors if they met the guidelines, and also to ask if the doctor was an electrophysiologist. 他说，如果医生建议植入除颤器，患者有理由询问是否依据了前述的指导方针，也有理由询问医生是否是电生理学专家。Implanting the device is not minor surgery, Dr. Khatib said. 植入除颤器并非小型外科手术，哈提卜博士说。“It is an invasive procedure,” she said. “You’re putting wires in the patient’s heart. You’re putting a needle in the subclavian vein next to the lung, threading two wires down to the heart, and implanting the device. “这是一种外科器械手术，”她说。“你要把导线放入患者的心脏，在紧挨着肺部的锁骨下静脉里埋入电极，引出两根线往下连到心脏，然后植入除颤器。”“And in some patients we test the defibrillator by causing the heart to go into a life-threatening rhythm, to make sure the defibrillator can recognize it and shock them out of it. It’s not a minor procedure by any means.” “而且对有些患者我们还要诱发其产生危及生命的心律失常来测试，以保证除颤器能正确识别并完成对心脏的去颤。不管怎么说这绝不是小手术。”Patients who did not match the medical guidelines for receiving an implant but were given one anyway were more likely to die in the hospital or suffer complications than people who got the device and met the guidelines. 与遵守指导方针植入装置的患者相比，不符合医学规定的被植入者更有可能死在医院或出现并发症。The death rate for the first group was 0.57 percent; for those who met the guidelines, it was just 0.18 percent. The causes of death were not available, and part of the explanation for the disparity may be that patients given the defibrillators inappropriately were sicker to begin with. 第一组临床对象的死亡率为0.57%；而符合指导方针的只有0.18%。死亡原因不可预见，存在差距的部分原因可能是不恰当给予除颤器的患者一开始就更为虚弱。But Dr. Kadish said, “We can’t exclude the possibility that indeed some people are being harmed.” 但卡迪什博士说，“也不排除实际上有些人正在受到伤害这种可能性。”Even so, he said, the problem of people who need defibrillators not getting them is far worse. He estimated that as many as 100,000 patients a year were missing out on the device, which could save their lives. 尽管如此，他说，更为严重的问题是需要除颤器的人却得不到。他估计每年有同样多达10万的患者错失对他们来说可以救命的设备。“We’re not doing as good a job as we should in putting them in the right people,” Dr. Kadish said. “我们没有做到把需要的设备提供给需要的人，”卡迪什博士说。Both Dr. Khatib and Dr. Kadish said the solution was better education for doctors. Neither wanted hospital panels, insurance companies or the government to be given the power to decide who should receive a defibrillator. 哈提卜博士和卡迪什博士均表示解决办法是更好地对医生开展专业教育。而不是依赖医院委员会、保险公司，或是把权力给予政府来决定谁能得到安装除颤器的机会。 “成千上万人疯狂下载。。。。。。 更多价值连城的绝密英语学习资料， 洛基内部秘密英语，技巧，策略 请在 网上 申请报名” 洛基国际英语 竭诚为您服务