首发脑卒中患者5年生存率及死亡影响因素分析

目的探讨首发脑卒中患者生存情况,分析其死亡的相关影响因素。方法收集2013年浙江省慢性病监测信息管理系统中脑卒中的新发病例,通过5年随访获得患者生存状况。应用Kaplan-Meier法进行生存率分析,采用Cox比例风险模型进行预后影响因素的分析。结果共收集2 748例脑卒中患者,其中男性1 415例,女性1 333例,平均发病年龄(71.41±12.06)岁;脑卒中患者的1年生存率为84.01%,3年生存率为75.52%,5年生存率为66.42%;Cox比例风险分析显示影响患者死亡的主要因素有发病年龄(RR=1.082,P <0.05),文化程度(RR=0.669,P <0.05),脑卒中亚型(RR=1.767,P <0.05),高血压(RR=1.860,P <0.05)。结论萧山区首发脑卒中患者的生存率处于较高水平,有效进行脑卒中危险因素的干预,积极进行二级预防可显著减少脑卒中的死亡。     

急性心肌梗死发病时间与心脏标记物敏感性之间的相关性分析

目的探讨急性心肌梗死(AMI)患者的发病时间与三种常用的心脏标记物敏感性之间的关系。方法将症状提示有急性冠状动脉综合征(ACS)可能的就诊患者按症状持续的时间分为两组(<6h组和6~24h组),分别测定就诊即刻(0h)和就诊2h患者的血清磷酸肌酸激酶(CK)、磷酸肌酸激酶同工酶(CK-MB)和肌钙蛋白T(cTNT)。比较两组患者三种标记物的敏感性。结果在就诊即刻(0h),症状持续时间6h以上的患者三种标记物明显高于症状持续时间短(<6h)的患者。在就诊2h,敏感性没有显著差异。结论症状发作6h以上的患者,在到达急诊室0h测定的血清心脏标记物的敏感性显著高于症状发作时间少于6h的患者;尤其是cTNT,敏感性增加3倍。     

首次脑梗死住院患者对疾病预防知识认知情况的调查研究

目的调查不同文化程度的首次脑梗死住院患者对疾病预防知识的知晓水平,为开展健康教育和制定干预治疗计划提供依据。方法采用自行设计的脑卒中一级预防知识问卷对186例不同文化程度的首次脑梗死患者于住院期间进行脑卒中预防知识调查。结果首次住院患者中不知晓脑卒中、脑血管疾病或中风的占16.8%;脑卒中一级预防知识的平均知晓率为35.2%;问卷中3个维度脑卒中首发临床症状、主要危险因素和主要危害的平均知晓率分别为33.2%、26.8%和30.4%;不同文化程度患者对脑卒中一级预防知识知晓率差异具有统计学意义(P<0.05)。结论首次脑梗死患者对脑卒中疾病预防知识的认知水平普遍缺乏,特别是低、中学历患者存在不良生活方式及行为,需要对不同学历人群进行针对性的脑卒中预防知识教育。     

多中心老年急性缺血性脑卒中静脉溶栓占比及院前延迟原因分析

目的 调查多中心老年急性缺血性脑卒中(AIS)静脉溶栓及院前延迟的情况，并分析影响老年AIS院前延迟的就医行为，为老年AIS的科普和管理决策提供依据。方法 回顾性分析2018年1月1日至2022年8月31日来自3家卒中中心住院的老年AIS患者1867例，记录患者年龄、性别、发病至就诊时间、医疗费用类型、来院方式、独居、转诊、发病地点、危险因素、发病前改良的Rankin量表、发病时美国国立卫生研究院卒中量表(NIHSS)、脑卒中意识、新型冠状病毒肺炎影响等。根据患者发病至就诊时间是否在4.5 h内分为及时组447例和延迟组1420例。统计老年AIS静脉溶栓率，采用多因素logistic分析评估院前延迟的影响因素。结果 本研究431例(23.1%)使用了静脉溶栓治疗；而在未使用静脉溶栓的原因中，院前延迟1272例(88.6%),占比最大。2组使用急救服务系统、独居、转诊、心房颤动、NIHSS评分、缺乏脑卒中意识比例比较有统计学差异(P<0.05,P<0.01)。多因素logistic回归分析显示，发病时NIHSS评分高(OR=0.876,95%CI:-0.192～-0.073)...     

脑卒中延迟就诊因素分析

目的初步探讨脑卒中就诊延迟的相关因素及其相应的处理对策。方法用问卷调查的方法收集239例急性脑卒中患者资料,采用χ2和Logistic回归模型分析就诊延迟的相关因素。结果发病6小时内就诊者占55.23%。就诊延迟主要与到达方式、卒中类型有关。62.62%的患者因不重视而就诊延迟。结论应提高公众特别是高危人群对卒中症状及危害性的认识,增强脑卒中诊疗的急救意识,建立并完善急诊急救医疗服务体系。     

青岛地区急性脑血管病患者就诊时间延迟及其影响因素分析

目的 调查青岛地区不同级别医院急性脑血管病患者就诊延迟程度并分析其影响因素.方法 选取2008年6月-2009年2月就诊于青岛市、县、乡多家医院的急性脑血管病患者共700例,采用问卷调查的形式,对卒中患者就诊时间及其可能的影响因素进行调查和分析.结果 青岛地区急性脑血管病患者在发病4.5 h内的平均就诊率为30%,乡镇医院最低(26%),市级医院次之(28%),县级医院最高(36%).对于市级医院,男性患者多就诊延迟,高中以上文化程度、城镇医保、120转运以及美国国立卫生研究院卒中量表(National Institutes of Health Stroke Scale,NIHSS)＜3分的患者多能及时就诊;对于县级医院,初中以上文化程度、120转运和NIHSS＜3分的患者多能及时就诊;对于乡镇医院,NIHSS＞7分和意识不清的患者多能及时就诊.结论 青岛地区市、县、乡三级医院的急性脑血管病患者均有明显的就诊延迟,其中120转运和教育水平较高能减少患者就诊延误.因此,完善各级医院的卒中急救网络系统,提高全民教育水平,加强卒中知识宣教对卒中患者的及时就诊至关重要.     

急性心肌梗死治疗前延误时间的研究

目的 探讨影响急性心肌梗死(AMI)患者治疗前延误时间(BDT)的相关因素.方法 回顾性分析2002年5月至2008年4月华北煤炭医学院附属医院收治的AMI患者255例;将就诊时间与发病时间的时间差作为BDT.根据BDT,将患者分为≤2h和＞2h,分析年龄、性别、文化程度、吸烟、饮酒、既往糖尿病史或心绞痛史、以及来院交通方式等因素对BDT的影响.结果 与≤2h组比较,＞2 h组患者年龄偏大,女性较多,既往多有糖尿病史,吸烟者较少,夜间发病者多(P＜0.05).结论 年龄、性别、糖尿病史、吸烟、夜间发病、发病地点以及来院就诊方式影响BDT.其中年龄、糖尿病史、夜间发病以及急救车来院就诊是影响BDT的独立相关因素.     

新型冠状病毒肺炎疫情期间脑卒中患者的就医行为分析

目的 探讨新型冠状病毒肺炎疫情对急性脑卒中患者就医行为的影响,为后疫情时期优化脑卒中管理提供依据。方法 收集2020年1月23日至2020年3月2日疫情期间就诊于浙江医院的脑卒中患者作为观察组,以2019年2月3日至2019年3月15日(农历与2020年相对应)期间就诊的急性脑卒中患者为对照组,将脑卒中类型分为缺血性脑卒中和出血性脑卒中。比较疫情前后缺血性脑卒中患者和出血性脑卒中患者一般资料以及就医行为(本地患者、转诊、120入院、发病至就诊时间、延迟就诊)的区别。结果 疫情前后缺血性脑卒中与出血性脑卒中患者在性别、年龄、教育程度、吸烟、饮酒及合并疾病方面比较差异无统计学意义(P 0.05)。与对照组相比,观察组数量下降了37.1%,本地患者比例高于对照组(χ2=11.999,P 0.01),转诊患者比例低于对照组(χ2=7.387,P 0.05),发病至就诊时间两组差异无统计学意义(t=1.967,P=0.05),延迟患者比例较对照组减少(χ2=3.599,P 0.05),120入院比例两组差异无统计学意义(P 0.05)。缺血性脑卒中患者疫情后较疫情前数量下降25.6%,本地患者比例高于疫情前(χ2=6.198,P 0.05),转诊患者比例低于疫情前(χ2=10.442,P 0.01),发病至就诊时间低于疫情前(t=2.392,P 0.05),120入院比例两者比较差异无统计学意义(P 0.05),延迟患者比例较疫情前减少(χ2=15.351,P 0.05)。出血性脑卒中患者疫情后较疫情前下降54.4%,本地患者比例高于疫情前(χ2=4.408,P 0.05),转诊患者比例、120入院比例、发病至就诊时间、延迟患者比例比较差异均无统计学意义(P 0.05)。结论 疫情期间我院收治的脑卒中患者数量较去年同期减少,本地患者就诊比例增高。缺血性脑卒中患者转诊比例减少,发病至就诊时间缩短。     

认知、社会及行为因素对急性缺血性脑卒中患者院前延迟的影响

目的 了解认知、社会及行为等因素对急性缺血性脑卒中患者发病后院前延迟的影响.方法 采用自制调查问卷,于2012年7月至2012年10月连续对217例重庆医科大学附属第二医院神经内科住院的急性缺血性脑卒中患者进行调查,记录患者的一般信息、起病情况、发病后的反应及就诊过程等.主要对认知、社会及行为等因素对院前延迟(＞4.5 h)的影响进行分析.结果 217例患者平均年龄(67.1±11.8)岁,从症状发生至寻求医学帮助的中位数时间为10(3～30.5)h,从症状发生至到达医院的中位数时间为12(3.5 ～48)h.多因素回归分析显示,发病后患者即刻反应为寻求医学帮助,首诊医生为120急救医生,他人意识到发生中风以及他人建议求医与院前延迟缩短有关.结论 认知、社会及行为等因素与急性缺血性脑卒中患者院前延迟有关.     

2270例卒中患者延误诊治时间的因素分析

目的 分析延误卒中患者诊治时间的院前、院后因素以及对溶栓治疗的影响。方法 采用问卷调查方法，收集2002年6月30日至2003年4月30日在全国35家医院就诊、资料完整的卒中患者2270例，输入数据库。对卒中发生时间、发病后就诊时间、就诊后查检时间、检查方式、医疗方式及到达医院的方式等影响因素进行单因素分析。结果2270例患者中1039例在3h内到达医院，占45．8％；就诊到头部CT或MRI检查时间在30min内的患者为1084例，占47，8％；CT、MRI检查到读出结果所用时间在30min内有1221例，占53，8％；就诊后60min内得到治疗的患者为1250例，为55．1％；家庭运送为1652例，占72．8％，其中有811例，占49、1％，是在发病后6h以内到达医院；救护车运送为618例，占27．2％，使用急救车的患者在6h内到达医院494例，占79，9％；急诊作MRI检查的患者为1178例，占51．9％；无条件作MRI检查者为1092，占48．1％。发病后就诊时间≤6h患者，下列影响因素差异具有显著意义：即到达医院的方式(P＜0．01)、生活方式(P＜0．05)、医疗状况(P＜0．001)、知晓是否为高危个体(P＜0．001)、发病地点(P＜0，01)、居住地点(P＜0．001)、发病地点到医院的距离(P＜0．001)。结论 就诊前延误因素主要为途中延误，求助于120／999急救运送，可缩短医院前延误的时间。     

洛杉矶院前脑卒中量表及其改良版对院前诊断脑卒中的价值

目的评价洛杉矶院前脑卒中量表(LAPSS)及其改良量表对院前诊断脑卒中的价值。方法选择急诊患者412例,由院前急救医师分别填写LAPSS和LAPSS改良量表,并与最后出院诊断作比较,判断2个量表的准确性。结果 LAPSS诊断的脑卒中敏感性84.8%,特异性86.5%;LAPSS改良量表敏感性92.0%,特异性74.2%。结论 LAPSS的应用,使院前诊断脑卒中更准确,更及时,应该在院前急救系统中推广。     

Prehospital management of exacerbations of asthma: relation to patient and disease characteristics

OBJECTIVE: Admission to hospital due to an exacerbation of asthma may represent a failure of prehospital management to prevent an attack or bring about its remission. We aim to describe the steps taken prior to hospital attendance in patients with asthma and to identify patient or disease characteristics that were associated with failure to take appropriate actions. METHODOLOGY: Patients aged over 15 years who were discharged from hospital or the Emergency Department with a primary diagnosis of asthma completed a questionnaire about the impact of asthma and its management prior to the onset of the recent exacerbation. The impact of asthma on quality of life was measured using our Asthma Quality of Life Questionnaire (AQLQ). RESULTS: Seventy-eight subjects completed the questionnaire including 49 who had been inpatients and 29 who had been discharged from the Emergency Department. They included many subjects with severe asthma: 41% had nocturnal symptoms three or more times per week and 41% had been admitted to hospital with asthma in the 12 months prior to this episode. Their AQLQ scores were high (severe) (mean 4.5+/-2.2). Most subjects described their presenting exacerbation as slow in onset and moderate or severe in intensity. During this exacerbation and prior to hospital attendance, only 27% of subjects had measured their peak expiratory flow rate, 19% had commenced or increased the dose of inhaled steroids, and 22% had commenced oral steroids. These actions were not related to the self-perceived speed of onset of the attack. Patients with lower levels of asthma-related concerns for health and more severe mood disturbance associated with asthma were less likely to take these appropriate self-management steps. CONCLUSIONS: This study shows that the failure of prehospital management to prevent the necessity of hospital attendance in most cases stems from a failure to implement currently recommended actions or treatments for exacerbations. Addressing this problem should result in a reduction in rates of hospitalization for asthma.     

Causes of prehospital delay in stroke patients in an urban aging society

PurposePrehospital delay is the major cause of treatment delay in cerebrovascular disease (CVD). An increasing number of elderly people reside alone or with their spouse with limited support from younger generations. The aim of this study was to identify the factors that may affect prehospital delay in our aging society, and examine the role of lifestyle on prehospital delay.MethodsWe retrospectively analyzed data for 469 consecutive patients who were hospitalized within 2 weeks of the onset of CVD between May 2007 and March 2009. Prehospital delay was defined as the time from the onset to arrival at our hospital.ResultsThere was no significant difference in prehospital delay between 91 patients who lived alone and 378 patients who lived with other people. We also analyzed whether lifestyle factors were causes of prehospital delay in the 378 patients who lived with other people. Living with a spouse was associated with a significant prehospital delay compared with patients living in a nursing home or those living with two or more generations. There were significant differences in prehospital delay between those living alone or with other people, and between those living with a spouse or with other people. Living with a spouse and living alone were associated with the prehospital delay. Knowledge of recombinant tissue plasminogen activator and the use of emergency medical systems were associated with a shorter prehospital delay, whereas visiting local doctors and the patient's recognition of symptoms increased the prehospital delay. The onset of CVD after office hours, National Institute of Health Stroke Scale score ≤ 4 at the initial visit, and prior stroke did not affect the prehospital delay.ConclusionHealth care promotion should target patients living alone as well as patients living with a spouse, especially in aging societies.     

Emergency department utilization among HIV‐infected patients in a multisite multistate study*

Objective

The aim of this study was to examine Emergency Department (ED) utilization and clinical and sociodemographic correlates of ED use among HIV‐infected patients.

Methods

During 2003, 951 patients participated in face‐to‐face interviews at 14 HIV clinics in the HIV Research Network. Respondents reported the number of ED visits in the preceding 6 months. Using logistic regression, we identified factors associated with visiting the ED in the last 6 months and admission to the hospital from the ED.

Results

Thirty‐two per cent of respondents reported at least one ED visit in the last 6 months. In multivariate analysis, any ED use was associated with Medicaid insurance, high levels of pain (the third or fourth quartile), more than seven primary care visits in the last 6 months, current or former illicit drug use, social alcohol use and female gender. Of those who used ED services, 39% reported at least one admission to the hospital. Patients with pain in the highest quartile reported increased admission rates from the ED as did those who made six or seven primary care visits, or more than seven primary care visits vs. three or fewer.

Conclusions

The likelihood of visiting the ED has not diminished since the advent of highly active antiretroviral therapy (HAART). More ED visits are to treat illnesses not related to HIV or injuries than to treat direct sequelae of HIV infection. With the growing prevalence of people living with HIV infection, the numbers of HIV‐infected patients visiting the ED may increase, and ED providers need to understand potential complications produced by HIV disease.     

老年人胸部外伤的院前干预

目的总结老年胸外伤患者院前急救经验。方法 60岁以上老年胸外伤患者78例,年龄60～89岁,平均(68.9±4.1)岁。致伤原因中跌伤与交通意外伤占80%;伤情分类中肋骨骨折发生率高达77%,约1/3合并有不同程度的头颅外伤;合并症中以心脑血管病为多。所有患者均在现场抢救后车载转送医院。结果呼救反应时间2～35min,平均(9.7±3.7)min;院前时间16min～4.5h,平均(38.5±9.5)min。无现场死亡及转送死亡;院内死亡5例,病死率为6.4%。结论只要掌握老年人胸部外伤的特点,进行快速、有效的院前干预,就能为进一步救治打下良好基础,为降低病死率和伤残率创造有利条件。     

The prehospital emergency cardiac care in patients with acute myocardial infarction

In order to evaluate the current status of prehospital care of acute myocardial infarction (AMI) in this city, the clinical manifestations and the emergency cardiac care in prehospital phase in 210 patients were reviewed in the period from 1987 to 1988. Before admission to CCU, 45.7% of the patients had complications of severe cardiac arrhythmias or hemodynamic disturbances and 14.8% had cardiac arrests. The mortality during the first 4 weeks was 25.2%. Among 53 patients who died, 50.9% occurred before admission and 37.7% within 1 hour. One hundred and ten patients (52.4%) had prehospital care and, 4 of them provided by the City Emergency Center and others by the local clinics near by. The median time from the cardiac attack to the first medical care, hospital arrival and CCU admission was 2, 3.6 and 6.3 hours respectively. The management on the scene was not efficient and effective in many patients. The rate of successful resuscitation in patients who had cardiac arrest out of hospital was only 7.7%. We are impressed that the mortality of patients with AMI is mainly in the early stage after appearance of symptoms. The initiation of emergency cardiac care is very necessary. The current status of prehospital cardiac care needs to be improved immediately, some suggestions are made for this purpose.     

Implementation of prehospital thrombolysis in Sweden: components of delay until delivery of treatment and examination of treatment feasibility

OBJECTIVE: To evaluate the feasibility of prehospital thrombolysis in Sweden in terms of safety and to examine the various components of the delay between onset of symptoms and start of treatment. SETTING: A total of 16 hospitals in Sweden in both urban and less populated areas and the associated ambulance organisations. DESIGN: Prospective evaluation of patients with an ST-elevation infarction treated with reteplase. An ECG was recorded and transmitted to hospital. The ambulances were staffed by a physician in 1% of cases, a nurse in 67% and a staff nurse in 32%. RESULTS: Of the 148 patients who received treatment prior to hospital admission, six (4%) had a cardiac arrest prior to hospital admission and two (1%) died prior to arrival at hospital. One patient was given treatment despite an exclusion criterion (previous stroke) and died on the 1st day in hospital due to a cerebral haemorrhage. The overall 30-day mortality was 7.1% and 1-year mortality 9.8%. Treatment was initiated within 2 h after the onset of symptoms in 53% of patients and within 1 h in 17% of patients. The median interval between the arrival of the ambulance and sending an ECG was 13 min and the median interval between sending an ECG and the start of thrombolysis was 18 min. The delay was similar regardless of ambulance staff. CONCLUSION: Implementation of prehospital thrombolysis on a national basis in Sweden appears to be safe. More than half the patients can be given treatment less than 2 h after the onset of symptoms. There is potential for reducing this time still further.     

Recognising the de Winter ECG pattern – A time critical electrocardiographic diagnosis in the Emergency Department

The de Winter ECG pattern is associated with proximal left anterior descending artery occlusion, being a significant risk factor for anterior wall ST elevation myocardial infarction. We present a case of a patient who attended our Emergency Department with chest pain and a prehospital ECG demonstrating transient infero-lateral lead ST segment elevation, which changed to the de Winter ECG pattern in our Emergency Department. She subsequently underwent primary PCI of the culprit lesion within the left anterior descending artery (LAD). Recognition of de Winter ECG pattern in the Emergency Department results in a time critical diagnosis for acute coronary occlusion and should be followed by emergency coronary revascularization.