H型高血压患者卒中的现况调查

目的调查H型高血压患者合并脑卒中的情况。方法纳入2012年1月至2014年2月于我院住院的原发性高血压患者814例,H型高血压患者628例,非H型高血压患者186例。依据其病史,辅助检查调查其合并卒中的情况。结果原发性高血压人群同型半胱氨酸平均水平为(15.41±8.4)μmol/L。H型高血压患者占高血压患者的比例约77.1%(628/814)。H型与非H型高血压患者年龄[(71.42±11.93)岁vs.(66.97±11.15)岁],男性比例(38.0%vs.16.0%),肌酐水平[(105.88±47.08)μmol/L vs.(88.60±35.92)μmol/L],均高于非H型高血压患者(P均<0.001)。据影像学检查显示,原发性高血压患者合并出血性脑卒中比例约为1.07%,缺血性脑卒中为12.66%,腔隙性脑梗死为54.08%,缺血灶为7.73%。H型与非H型高血压患者间仅缺血灶(4.8%vs.16.8%,P<0.001)有统计学差异。结论原发性高血压患者合并卒中的比例高,H型高血压患者合并缺血灶比例比非H型高血压患者低。     

高流量氧疗对心衰并心律失常患者心功能的影响研究

目的:探讨高流量氧疗对心衰合并心律失常患者心功能影响。方法:选取2019年1月至2020年10月我院诊治心衰合并心律失常患者50例进行研究,用随机表法将患者分为高流量氧疗组(25例)和低流量吸氧组(25例),比较两组患者治疗期间心律失常发生率、治疗前后心功能指标及预后。结果:高流量氧疗组患者室上性心律失常、传导阻滞发生率显著低于低流量吸氧组(4.00%vs 24.00%,4.00%vs 28.00%,P0.05)。治疗前,两组LVEF、CK、BNP水平无明显差异(P0.05);治疗后,相对治疗前,两组LVEF水平升高,CK、BNP水平降低,但高流量氧疗组改善程度更高(P0.05)。高流量氧疗组患者预后良好率显著高于低流量吸氧组(92.00%vs. 68.00%,P0.05)。结论:高流量氧疗在心衰合并心律失常患者中应用,可协助改善心律失常,改善心功能。     

不同类型心力衰竭合并心房颤动的临床特点及心脏结构变化

目的探讨不同类型心力衰竭患者并发房颤的临床特点及心脏结构改变。方法采用回顾性分析法,收集并分析慢性心力衰竭患者401例的临床资料。按照有无房颤分组,比较两组患者在发病年龄、性别、基础病因等方面的情况,对比两组心脏结构改变。结果高血压和冠心病是心力衰竭的主要病因,高血压引起房颤的发病率远高于其他病因。舒张性心衰明显比收缩性心衰更容易发生房颤(χ~2=3. 948,P 0. 05),而急性心衰与慢性心衰发生房颤的比例无差别;心衰的合并症的个数与房颤无关,合并糖尿病、肾功能不全不会增加房颤的发生率,而心衰合并高血压更容易并发房颤。心衰房颤组左心房内径比非房颤组明显增大(P 0. 01),而左室内径及室壁厚度无明显差别。结论心衰合并高血压者及舒张性心衰患者更容易并发心房颤动,房颤发生与患者的心房增大相关。     

腔隙性脑梗死患者术后神经功能恶化危险因素分析

目的分析腔隙性脑梗死患者术后发生神经功能恶化的危险因素。方法回顾性分析2015-01/2020-01期间在我院进行手术治疗的990例合并腔隙性脑梗死患者临床资料,按照术后1年内是否发生神经功能恶化,分为非恶化组(n=963)和恶化组(n=27)。比较2组患者一般资料,采用多因素Logistic回归分析腔隙性脑梗死患者术后出现神经功能恶化的独立危险因素,计算受试者工作特征曲线下面积(AUC)、敏感度和特异度。结果恶化组患者术前多发性腔隙性脑梗死、合并高血压、动脉斑块及卒中病史的比例明显高于非恶化组(88.9%vs 64.7%, 66.7%vs 46.9%, 48.2%vs 26.5%, 33.3%vs 7.0%)(P0.05)。多因素Logistic回归分析显示,术前腔隙性脑梗死数目及卒中病史是诱发术后神经功能恶化的独立危险因素(P0.05)。术前腔隙性脑梗死数目预测术后神经功能恶化敏感度为88.9%,特异度为35.1%, AUC为0.620(95%CI 0.528～0.712,P0.05);卒中病史预测术后神经功能恶化敏感度为33.3%,特异度为93.3%, AUC为0.633(95%CI 0.511～0.756,P0.05)。结论术前合并腔隙性脑梗死患者术后可发生神经功能恶化,术前腔隙性脑梗死数目及卒中病史是其独立危险因素,临床医生应予以重视。     

心力衰竭合并心房颤动患者凝血指标、生化指标与静脉血栓发生情况分析

目的分析心力衰竭(简称心衰)合并心房颤动(简称房颤)患者凝血指标、生化指标水平与静脉血栓发生情况。方法选取86例慢性心衰患者作为研究对象,按是否合并房颤分为对照组(心衰组)和研究组(心衰合并房颤组),比较2组患者心功能分级情况和凝血指标[凝血酶原时间(PT)、活化部分凝血活酶时间(APTT)、D-二聚体]、生化指标[血细胞比容(Hct)、C反应蛋白(CRP)、脑钠肽(BNP)]水平,并比较2组静脉血栓发生率。结果 2组心功能Ⅱ级者比率比较,差异无统计学意义(P0.05);研究组心功能Ⅲ级者比率低于对照组,心功能Ⅳ级者比率高于对照组,差异有统计学意义(P 0.05);研究组患者PT、APTT、D-二聚体水平高于对照组,差异有统计学意义(P 0.05);研究组Hct、CRP、BNP水平高于对照组,差异有统计学意义(P 0.05);研究组静脉血栓发生率为34.88%,高于对照组的16.28%,差异有统计学意义(P 0.05)。结论相较于心衰患者,心衰合并房颤患者的凝血指标、生化指标水平更高,静脉血栓发生率更高,临床治疗时应予以充分重视。     

不同射血分数慢性心衰患者的临床特征分析

[目的]分析不同射血分数慢性心衰患者的临床特征.[方法]选择2015年11月至2016年10月湖南省人民医院收治的381例慢性心衰患者,符合纳入和排除标准348例.根据左室射血分数(LVEF)分组:LVEF<40%分为射血分数降低的心衰(HFrEF)组,LVEF在41%~49%之间为射血分数中间的心衰(HFmrEF)组,LVEF>50%为射血分数保留的心衰(HFpEF)组,对三组间患者进行临床特征分析.[结果]HFrEF组年龄、女性所占比例、合并高血压、房颤明显低于HFpEF组,合并冠心病、陈旧心梗则显著高于HFpEF组(均P<0.05);HFrEF组年龄、女性所占比例高于HFmrEF组(均P<0.05).HFmrEF组和HFpEF组的三酰甘油(TG)、白蛋白(ALB)水平显著高于HFrEF组(P<0.05),其谷丙转氨酶(ALT)、谷草转氨酶(AST)、同型半胱氨酸(Hcy)、氨基末端脑钠肽前体(NT-proBNP)水平明显低于HFrEF组(P<0.05);HFrEF组和HFmrEF组左房内径、左室舒张末期内径明显高于HFpEF组(P<0.05).[结论]HFrEF患者多合并冠心病及陈旧心梗,HFpEF则以高龄、女性、高血压和房颤患者多见,HFmrEF临床特征介于HFrEF和HFpEF之间;HFrEF组血尿酸(UA)、Hcy、NT-proBNP等心衰预后危险因子水平较HFmrEF组和HFpEF组高,提示LVEF降低可能是心衰预后不良的危险因素.     

无创血流动力学监测在急性心衰中的诊断和预后价值

目的:探讨无创血流动力学监测在急性心衰(AHF)中的诊断和预后价值。方法:选取2017年3月至2018年5月期间广州医科大学第二附属医院急诊监护室(EICU)收治的患者215例为研究对象,按诊断标准分为急性心衰组116例和非急性心衰组99例。比较两组间一般资料、实验室检验结果、预后和超声心输出量监测参数;运用单因素Logistic回归分析急性心衰诊断和预后的影响因素。结果:急性心衰组与非急性心衰组年龄比较为[(78.31±11.28)岁vs(72.04±16.13)岁],高血压病史(73.3%vs 50.5%),糖尿病史(30.2%vs 12.1%),冠心病史(35.3%vs 6.1%),以及NYHA心功能分级比较,差异均具有统计学意义(P0.05)。急性心衰组患者气促、肺部啰音发生率和呼吸频率和心率均较非急性心衰组高分别为(78.4%vs 45.5%)、(69.8%vs 40.4%)、(24.22±6.63)vs(22.39±4.56)和(105.33±26.08)vs(97.53±24.01),差异均具有统计学意义(P0.05);急性心衰组pH值较非急性心衰组低(7.34±0.13)vs(7.39±0.11),而急性心衰组血肌酐较非急性心衰组高(227.57±197.49)vs(133.92±30.92),差异均具有统计学意义(P0.05)。单因素Logistic回归分析发现每博输出量变异度(SVV)是AHF患者30天死亡率的独立预测因子,SVV每升高1%,30天死亡率增加0.2%-2.9%(P0.05),其余参数在AHF诊断和预后判断均无明显统计学意义(P0.05)。结论:无创血流动力学监测未能较好地诊断AHF,但能在预后判断上有一定的参考价值。     

新疆地区青年缺血性脑卒中危险因素分析

目的:探讨新疆地区青年及老年缺血性脑卒中患者的危险因素.方法:新疆地区5个城市5家医院脑卒中患者816例,年龄18～45岁缺血性脑卒中患者78例为青年组,＞65岁缺血性脑卒中患者317例为老年组.同期年龄18～45岁的外科住院患者236例为对照组.比较各组及青年组中维吾尔族,汉族患者危险因素.结果:青年组主要危险因素比例均高于对照组(P＜0.05);青年组中维吾尔族高血压史及高脂血症史比例均高于汉族(P＜0.05).青年组吸烟和饮酒史比例高于老年组(P＜0.05),高血压病、糖尿病和心脏病史比例低于老年组(P＜0.05).结论:青年与老年缺血性脑卒中患者危险因素不同,应采取不同的预防措施.     

大面积脑梗死患者临床特征分析

目的:分析大面积脑梗死(LHI)的临床特征、结局和危险因素。方法:纳入脑梗死患者805例,根据LHI诊断标准分为LHI组和非LHI组;随访3月,LHI患者根据预后分为幸存组和梗死组;收集患者临床资料,进行不同组别间的比较。结果:本研究共纳入805例脑梗死患者,其中LHI 126例(15.65%),非LHI 679例(83.98%)。LHI组和非LHI组的入院格拉斯哥昏迷量表(GCS)评分、美国国立卫生院脑卒中量表(NIHSS)评分、入院时间延迟,合并心脏瓣膜病、糖尿病、心房颤动及高血压的患者数量差异有统计学意义(P0.05);Logistic回归分析结果显示,入院时间延迟、合并心脏瓣膜病、合并心房颤动、合并高血压为脑梗死患者发生LHI的独立危险因素(P0.05)。根据LHI患者3月随访结果,纳入死亡组48例(38.10%),幸存组78例(61.90%)。2组的年龄、入院GCS评分、NIHSS评分、合并高血压的患者数量差异有统计学意义(P0.05);Logistic回归分析结果显示,NIHSS评分高、合并高血压、GCS评分低、年龄≥60岁是影响LHI患者预后的独立危险因素(P0.05)。结论:脑梗死患者中发生LHI比例较高。入院时间延迟、合并心脏瓣膜病、合并房颤、合并高血压为脑梗死患者发生LHI的独立危险因素(P0.05);NIHSS评分高、合并高血压、GCS评分低、年龄≥60岁是影响LHI患者预后的独立危险因素(P0.05)。     

心房颤动对慢性心力衰竭伴左室射血分数≥0.50患者预后的临床研究

目的 探讨左室射血分数(LVEF)≥0.50的住院慢性心力衰竭(心衰)患者中心房颤动(房颤)的发生和分布类型,及房颤对此类心衰预后的影响.方法 调查患者417例次,按LVEF＜0.50与≥0.50分为两组,根据患者入院前是否有房颤病史分为阵发性房颤、持续性房颤及入院后新发房颤.随后观察并记录严重恶性事件发生情况及因慢性心衰而再人院次数及每两次住院的间隔时间.结果 LVEF＜0.50的慢性心衰更多见于男性,一年内心肌梗死的发病率较LVEF≥0.50者高[15.6%(34/218)比8.0%(16/199),P<0.01],且房颤使得患者脑卒中发生率较不伴房颤者明显增高(24.3%(27/111)比8.4%(9/107),P＜0.05),急性冠脉综合征、心血管死亡事件例数及死亡数也高于不伴房颤者;在LVEF≥0.50的慢性心衰患者中新发房颤数量较LVEF＜0.50者明显增多(51比30,P＜0.05),房颤可见伴发在近2/3的患者中,且再入院次数较不伴房颤者增加[(2.78±1.79)次比(2.00±1.35)次,P＜0.01],前两次入院间隔时间亦较不伴房颤者缩短[(117±107)d比(154±130)d,P＜0.05].结论 房颤更易发生在LVEF≥0.50的慢性心衰患者,导致更短的再入院间隔,强调治疗和管理这类房颤的重要性.     

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.     

Prospects for the control of neglected tropical diseases by mass drug administration

The prospects for the control of neglected tropical diseases, including soil-transmitted helminthiasis, shistosomiasis, lymphatic filariasis, onchocerciasis and trachoma, through mass drug administration, are exemplified by the elimination of the trachoma as a public-health problem in Morocco. In spite of this and other striking successes, mass drug administration programs are faced with major challenges resulting from suboptimal coverage and lack of efficacy. At current suboptimal coverage rates, programs may need prolongation for an extended period, increasing costs and undermining sustainability. Community participation through health education and information appears to be crucial to improve coverage and to achieve sustainability. Implementation of complementary measures, such as vector control, improved hygiene and environmental sanitation, are important to further control transmission and to prevent re-emergence of the infection and, again, may only be achieved effectively through community-based initiatives. To reduce costs and to relieve pressure on the health system, combining neglected tropical disease programs in areas where diseases coexist and integration with existing control programs for malaria, tuberculosis and HIV/AIDS is advocated. The risk of developing drug resistance is of particular concern in view of the lack of alternative drugs, and reduced treatment efficacy due to emerging resistance is evident for the soil-transmitted helminths and onchocerciasis. Given the risk for the development of drug resistance and the need for a high degree of participation, close attention should be paid to the monitoring of the coverage and efficacy of the different program components.     

Bacterial meningitis: an update of new treatment options

The outcome of bacterial meningitis critically depends on the rapid initiation of bactericidal antibiotic therapy and adequate management of septic shock. In community-acquired meningitis, the choice of an optimum initial empirical antibiotic regimen depends on the regional resistance patterns. Pathogens resistant to antibacterials prevail in nosocomial bacterial meningitis. Dexamethasone is recommended as adjunctive therapy for community-acquired meningitis in developed countries. In comatose patients, aggressive measures to lower intracranial pressure <20 mmHg (in particular, external ventriculostomy, osmotherapy and temporary hyperventilation) were effective in a case–control study. Although many experimental approaches were protective in animal models, none of them has been proven effective in patients. Antibiotics, which are bactericidal but do not lyse bacteria, and inhibitors of matrix metalloproteinases or complement factor C5 appear the most promising therapeutic options. At present, vaccination is the most efficient method to reduce disease burden. Palmitoylethanolamide appears promising to enhance the resistance of the brain to infections.     

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.     

Imaging choices in occult hip fracture

Background: Hip fracture is a common injury, with an incidence rate of > 250,000 per year in the United States. Diagnosis is particularly important due to the high dependence on the integrity of the hip in the daily life of most people. Objectives: In this article we review the literature focused on hip fracture detection and discuss advantages and limitations of each major imaging modality. Discussion: Plain radiographs are usually sufficient for diagnosis as they are at least 90% sensitive for hip fracture. However, in the 3–4% of Emergency Department (ED) patients having hip X-ray studies who harbor an occult hip fracture, the Emergency Physician must choose among several methods, each with intrinsic limitations, for further evaluation. These methods include computed tomography, scintigraphy, and magnetic resonance imaging. Conclusion: We present an evidence-based algorithm for the evaluation of a patient suspected to have an occult hip fracture in the ED. Also outlined are future directions for research to distinguish more effective techniques for identifying occult hip fractures.     

Systematic Reviews Published in the April 2012 Issue of the Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly as a DVD but monthly online. The April 2012 issue (second DVD for 2012) contains 5045 complete reviews, 2182 protocols for reviews in production, and 17,084 short summaries of systematic reviews published in the general medical literature. In addition, there are citations of 674,000 randomized controlled trials, and 15,400 cited papers in the Cochrane methodology register. The health technology assessment database contains just over 11,000 citations. One hundred and seventeen new reviews have been published in the last 3 months of which 12 have potential relevance for practitioners in pain and palliative medicine. The impact factor of the Cochrane Library stands at 6.186. Readers are encouraged to access the full report for any articles of interest as only a brief commentary is provided.     

Platelets,thrombosis, coagulation,and atherosclerosis

When I first got the invitation to join a medical delegation going to Moldova, I thought for a moment that our destination was the fictional country in the old Marx Brothers movie Duck Soup. On further checking, it turns out that entertaining place was called Freedonia. I now know that Moldova is indeed a real country, bordered on the west by Romania and on the other three sides by the Ukraine. It is a proud country, rich with traditions, and its people are warm, giving, eager to learn ways to improve their healthcare system, and deeply appreciative of our attempts to help them in the task.