血小板平均体积对急性心肌梗死患者住院期间死亡事件的预测价值

目的评价初诊时的血小板平均体积（MPV）对急性心肌梗死（AMI）患者发生住院期间死亡事件的预测价值。方法回顾性地分析了415例AMI患者的住院病历,从中提取出患者初诊时临床特征的数据（包括胸痛发生时间及是否患有高血压、糖尿病和高血脂等）和实验室特征数据：心肌肌钙蛋白I（cTnI）水平、肌酐浓度和血小板计数、MPV。分析MPV与患者的临床和实验室特征之间的关系。采用受试者工作特征曲线（ROC）法评价MPV对患者发生住院期间死亡事件的总体预测价值。采用多元Logistic回归分析MPV与AMI患者发生住院期间死亡事件的关系。结果随着MPV的增加,AMI患者发生住院期间死亡事件的比例增高。MPV预测AMI患者发生住院期问死亡价值的曲线下面积（AUC）（95％可信区间）为0．77（0．72-0．82）。当将界值设定为12．55n时,MPV预测AMI患者发生住院期间死亡时间的敏感度（95％可信区间）为0．59（0．49-0．69）,特异度（95％可信区间）为0．85（0．81-0．89）。在校正了cTnI、胸痛发生时间、肌酐和年龄以后,MPV〉12．55fl仍然与所有AMI患者、STEMI和NSTEMI患者发生住院期间死亡事件相关,优势比（95％CI）分别为10．87（5．08-23．25）、26．19（7．36-93．17）和5．35（1．80．15．92）。结论AMI患者就诊时的MPV值可以作为预测其发生住院期间死亡事件的指标,MPV〉12．55n是AMI患者发生住院期间发生死亡事件的独立危险因子。     

Structure and duration of consultations in Estonian family practice

Duration of the consultation is dependent on patient-related factors as well as on factors related to the health care system. Video-recording allows direct evaluation of the consultation and is acceptable to patients. Length of time of consultation is dependent on the patient's age and on the number and nature of the problems, but is not influenced by gender. Objective - &#114 To study the influence of age, gender and the nature of the patient's problems on length of time of consultation in the practices of newly trained family doctors in a recently reconstructed health care system. Design &#114 - &#114 Video-recordings of consultations with consecutive patients in family practice were studied for duration of consultation in relation to age, gender and nature of the problem(s). Setting &#114 - &#114 Primary health care. Subjects &#114 - &#114 405 consecutive consultations were video-taped in the practices of 27 family doctors. Main outcome measures &#114 - &#114 Length of time of consultation and its segments was analysed using the Statistical Package for the Social Sciences. The problems were classified according to the ICPC. Results &#114 - &#114 The average consultation lasted 9.0 min ( &#45 4.9). Physical examination was 2.0 min ( &#45 1.9) and was performed in 79% of all consultations. Respiratory and circulatory problems were the most common. More than one reason for the encounter was given in one-fourth of cases. Consultation time was longer for older age groups and for patients with psychological problems. Conclusion &#114 - &#114 Video-recording allows consultations to be evaluated directly and is acceptable to patients. The high participation rate of patients in our study can be explained by the individual approach and by the family doctor system. The period of consultation was dependent on patient age and on the number and nature of the problems, but was not influenced by gender.     

Duration of hospital participation in Get With the Guidelines-Resuscitation and survival of in-hospital cardiac arrest

Background

Get With the Guidelines (GWTG-R) is a data registry and quality improvement program for in-hospital cardiac arrest (IHCA). It is unknown if duration of hospital participation in GWTG-R is associated with IHCA outcomes.

Methods

We analyzed adults with IHCA from 362 hospitals participating in GWTG-R between 2000 and 2009. Using logistic regression with generalized estimating equations to account for clustering on hospital, we determined the association between duration of hospital participation in GWTG-R and patient outcomes after IHCA, adjusted for patient and arrest characteristics and secular trend. Using these methods, we also evaluated the association between duration of participation and factors previously correlated with survival after IHCA, including ECG monitored status, after-hours arrest, and time to defibrillation.

Results

Of 104,732 patients with IHCA, 17,646 patients (16.9%) survived to discharge. Duration of hospital participation in GWTG-R was associated with IHCA event survival (per year of participation, odds ratio [OR] 1.02; 95% CI 1.00–1.04; p = 0.046) but not survival to discharge (OR 1.02; 95% CI 0.99–1.04; p = 0.18). Among factors previously correlated with IHCA survival, duration of participation was associated with time to defibrillation ≤2 min (per year of participation, OR 1.06; 95% CI 1.03–1.10; p < 0.001), but not ECG monitored status (OR 1.00; 95% CI 0.93–1.06; p = 0.90) or survival of after-hours arrest (OR 1.01; 95% CI 0.99–1.03; p = 0.41). Among ventricular tachycardia or ventricular fibrillation (VT/VF) arrests, time to defibrillation attenuated the association between duration of hospital participation and outcomes.

Conclusion

Duration of hospital participation in GWTG-R was significantly associated with survival of the IHCA event, but not with survival to discharge. In VT/VF arrests, this association may have been mediated by improvements in time to defibrillation.     

Verbal and non-verbal behavior of doctors and patients in primary care consultations - how this relates to patient enablement

Objective

To assess the relationship between observable patient and doctor verbal and non-verbal behaviors and the degree of enablement in consultations according to the Patient Enablement Instrument (PEI) (a patient-reported consultation outcome measure).

Methods

We analyzed 88 recorded routine primary care consultations. Verbal and non-verbal communications were analyzed using the Roter Interaction Analysis System (RIAS) and the Medical Interaction Process System, respectively. Consultations were categorized as patient- or doctor-centered and by whether the patient or doctor was verbally dominant using the RIAS categorizations.

Results

Consultations that were regarded as patient-centered or verbally dominated by the patient on RIAS coding were considered enabling. Socio-emotional interchange (agreements, approvals, laughter, legitimization) was associated with enablement. These features, together with task-related behavior explain up to 33% of the variance of enablement, leaving 67% unexplained. Thus, enablement appears to include aspects beyond those expressed as observable behavior.

Conclusion

For enablement consultations should be patient-centered and doctors should facilitate socio-emotional interchange. Observable behavior included in communication skills training probably contributes to only about a third of the factors that engender enablement in consultations.

Practice implications

To support patient enablement in consultations, clinicians should focus on agreements, approvals and legitimization whilst attending to patient agendas.     

综合医院呼吸科住院患者精神科联络会诊结果分析

目的了解和探讨综合医院呼吸科住院患者精神科联络会诊的特点。方法对2年中申请精神科会诊的130例综合医院呼吸科患者,通过病史收集和精神检查,依照ICD-10进行诊断,并电话随访疗效。结果 2年内会诊患者130例,会诊率3.6%;常见的会诊原因分别是焦虑（24.6%）、抑郁（20%）、气促/咳嗽/胸闷/胸痛（16.2%）、烦躁/兴奋/行为混乱（16.2%）;前4位的会诊诊断分别是适应障碍（25.4%）、焦虑障碍（16.9%）、器质性精神障碍（16.1%）、心境障碍（15.4%）;处理措施以非典型抗精神病药和安全性高的SSRI药物为主。会诊后疗效很好和有效的比例分别为32.3%、59.0%。结论综合医院呼吸科的精神科会诊患者多以轻型精神障碍为主,内科医生及时识别患者的精神障碍和申请会诊有助于患者的临床治疗。     

Predictors and in-hospital prognosis of recurrent acute myocardial infarction

Objective To investigate the contributing factors and in-hospital prognosis of patients with or without recurrent acute myocardial infarction (AMI). Methods A total of 1686 consecutive AMI patients admitted to Peking University People’s Hospital from January 2010 to December 2015 were recruited. Their clinical characteristics were retrospectively compared between patients with or without a recurrent AMI. Then multivariable logistic regression was used to estimate the predictors of recurrent myocardial infarction. Results Recurrent AMI patients were older (69.3 ± 11.5 vs. 64.7 ± 12.8 years, P < 0.001) and had a higher prevalence of diabetes mellitus (DM) (52.2% vs. 35.0%, P < 0.001) compared with incident AMI patients, they also had worse heart function at admission, more severe coronary disease and lower reperfusion therapy. Age (OR = 1.03, 95% CI: 1.02–1.05; P < 0.001), DM (OR = 1.86, 95% CI: 1.37–2.52; P < 0.001) and reperfusion therapy (OR = 0.74; 95% CI: 0.52–0.89; P < 0.001) were independent risk factors for recurrent AMI. Recurrent AMI patients had a higher in-hospital death rate (12.1% vs. 7.8%, P = 0.039) than incident AMI patients. Conclusions Recurrent AMI patients presented with more severe coronary artery conditions. Age, DM and reperfusion therapy were independent risk factors for recurrent AMI, and recurrent AMI was related with a high risk of in-hospital death.     

Characteristics and outcomes of in-hospital cardiac arrest in adults hospitalized with acute coronary syndrome in China

AimsThis retrospective study aims to analyze and explore the clinical characteristics, risk factors, and in-hospital outcomes - including return of spontaneous circulation (ROSC) and survival to discharge - of hospitalized patients admitted with acute coronary syndrome (ACS) suffering cardiac arrest.MethodsACS patients admitted to three tertiary hospitals in Fujian, China, were evaluated retrospectively from January 1, 2012 to December 30, 2016. Data were collected, based on the Utstein Style, for all cases of attempted resuscitation for IHCA. We analyzed patient characteristics, pre-event variables, event variables, and the main outcomes, including ROSC and survival to discharge, and identified the influencing factors on the outcomes.ResultsThe total number of ACS admissions across the three hospitals during this study period was 21,337. Among these admissions, 320 ACS patients experienced IHCA (incidence: 1.50%); 134 (41.9%) patients experienced ROSC; and 68 (21.2%) survived to discharge. The findings indicated that four factors were associated with ROSC, including age <70 years-old, shockable rhythm, duration of resuscitation (≤15 min and 16–30 min), and PCI. Five factors were associated with survival to discharge, including age <70 years-old, shockable rhythm, the duration of resuscitation (≤15 min and 16–30 min), Killip ≤ II, and CCI ≤ 2.ConclusionYounger age, shockable rhythm, and shorter duration of resuscitation were all factors demonstrated to be a predictor of ROSC and survival to hospital discharge.