维持性血液透析合并便秘患者护理干预方案的构建

目的 以计划行为理论与知信行整合模式为理论框架,构建维持性血液透析（maintenance hemodialysis,MHD）合并便秘患者护理干预方案,为临床患者提供系统化、标准化、规范化的护理干预措施。方法 以计划行为理论与知信行整合模式为理论框架,通过文献回顾及专家讨论,初步拟定MHD合并便秘患者干预方案初稿;采用德尔菲专家函询方法,根据专家意见对护理干预方案条目进行修改,形成最终方案。结果 16位专家经过2轮函询后意见趋于一致,第1、2轮函询问卷有效回收率分别为80%、100%,专家权威系数为0.89,第1、2轮函询各项指标重要性的肯德尔协调系数W分别为0.299、0.355,具有统计学意义（均P<0.05）。最终构建的干预方案包括提高疾病知识、转变行为态度、引导主观规范、强化行为控制及转变行为意向5个一级指标、10个二级指标、40个三级指标。结论 本研究构建的护理干预方案具有可靠性、科学性及实用性,可供临床医护人员应用于MHD合并便秘患者的护理。     

基于叙事理论的晚期癌症患者家庭照护者预期性悲伤干预方案的构建

目的基于叙事理论构建晚期癌症患者家庭照护者预期性悲伤干预方案, 为预期性悲伤护理干预提供参考依据。方法于2022年10月至2023年5月, 通过文献检索、半结构式访谈和头脑风暴法构建晚期癌症患者家庭照护者预期性悲伤干预方案初稿, 采用德尔菲法对15名专家进行2轮函询, 根据专家意见对各级指标进行修改, 形成干预方案终稿。结果 15名专家均为女性, 年龄(49.67 ± 5.83)岁。2轮专家的权威系数均为0.87, 第1轮专家函询后的一、二、三级指标的Kendall协调系数分别为0.195、0.113、0.093, 第2轮专家函询后的一、二、三级指标的Kendall协调系数分别为0.200、0.119、0.101, 差异均有统计学意义(χ2值为8.76 ～ 107.21, 均P<0.05)。最终形成了包含4个一级指标、19个二级指标和72个三级指标的基于叙事理论的晚期癌症患者家庭照护者预期性悲伤的护理干预方案。结论晚期癌症患者家庭照护者预期性悲伤干预方案具有一定的科学性、实用性、可行性, 可用于家庭照护者的心理护理。     

安宁疗护患者远程居家照护方案的构建及初步应用

目的 构建安宁疗护患者远程居家照护方案并进行初步应用,为开展安宁疗护远程居家照护实践提供参考。方法 以支持性照护模型为理论指导,在文献研究的基础上结合质性访谈初步拟订安宁疗护患者远程居家照护方案。2023年3月进行2轮函询,征询专家意见并修订方案,形成终稿。2023年4月,采用便利抽样法选取湖南省长沙市某三级甲等肿瘤专科医院安宁疗护病房即将出院的10例患者初步应用该方案,采用不良事件发生例数、远程照护满意度评价方案应用效果。结果 共16名专家完成2轮函询,其权威系数为0.928。2轮函询的有效问卷回收率分别为94.12%、100%,专家意见提出率分别为100%、25.00%,条目评分的变异系数分别为0.05～0.18、0～0.16,肯德尔和谐系数分别为0.093、0.210(P<0.001)。最终构建的方案包括症状管理、生活照护、心理及精神照护、社会信息支持4个维度,疼痛管理、呼吸困难管理、胃肠道症状管理、咳嗽/咳痰管理等17个模块,涵盖37项具体实施内容。方案应用期间脱落1例患者,最终纳入9例。患者均未发生不良事件,其远程照护满意度问卷得分为（60.22±7.41）分,处于高满...     

长期照护机构智能照护安全质量评价指标体系的构建

目的:构建老年长期照护机构智能化照护安全质量评价指标体系。方法:以结构-过程-结果理论为框架,在文献查阅和访谈的基础上,采用德尔菲专家函询法,构建老年长期照护机构智能化照护安全质量评价指标体系,并运用层次分析法确定各指标权重。结果:共进行了2轮专家函询,专家积极系数分别为88%、100%,权威系数均为0.90,两轮肯德尔和谐系数分别为0.248,0.302(P<0.001)。最终构建的老年长期照护机构智能照护安全质量评价指标体系包含环境设施管理、照护设备管理、专业护理照护、生活照护服务、信息结果监测5个一级指标和42个二级指标。结论:构建的老年长期照护机构智能照护安全质量评价体系具有科学性和可靠性,可运用于老年长期照护机构智能照护安全质量监测和护理员培训体系。     

护理院失能老年人长期照护需求评估指标的研究

目的确定护理院失能老年人长期照护需求评估指标。方法基于文献研究、半结构式访谈以及专家座谈初步拟订评估指标,采用德尔菲法,经过2轮对23名专家的函询确定护理院失能老年人长期照护需求评估指标。结果 2轮专家函询问卷的有效回收率分别为74.19%和95.65%,专家的权威系数分别为0.850和0.905,第2轮函询中,一、二级指标专家意见协调系数分别为0.600和0.269(P0.001)。最终确立护理院失能老年人长期照护需求评估指标包含5个一级指标,40个二级指标。结论护理院失能老年人长期照护需求评估指标可靠、科学,可为进一步制订护理院失能老年人长期照护内容、提高长期照护质量提供参考依据。     

住院患者参与健康照护评价指标体系的构建

目的构建住院患者参与健康照护评价指标体系,为医院制订患者参与健康照护方案提供参考。方法通过文献回顾、质性访谈和小组讨论初步拟定住院患者参与健康照护评价指标体系,并在此基础上编制专家函询问卷,于2019年1—2月,选择来自山东省10所三级甲等医院和2所高等护理院校的专家20名,采用德尔菲法对其进行2轮专家函询,结合专家意见及指标筛选标准对指标体系进行修改。结果 2轮函询专家的积极系数为95.24%、100.00%,权威系数为0.89、0.93,协调系数为0.391～0.441(P0.001)。最终形成住院患者参与健康照护评价指标体系,共包括3个一级指标、18个二级指标及58个三级指标。结论采用德尔菲法构建的住院患者参与健康照护评价指标体系具有较高的科学性,能为医院制订患者参与健康照护方案、推行患者参与健康照护工作提供参考依据。     

老年住院患者睡眠管理方案的构建研究

目的 构建老年住院患者睡眠管理方案，为评估和改善老年住院患者的睡眠质量提供参考。方法 在文献研究和召开专家小组会议的基础上，于2022年2月—4月采用德尔菲法对10名专家进行2轮函询，征询专家意见，并对条目进行反复修改，最终确定老年住院患者睡眠管理方案。结果 10名专家均经过2轮函询，问卷总回收率均为100%,专家熟悉程度依次为0.796、0.760,权威系数分别为0.893、0.845,一级、二级和三级指标的肯德尔和谐系数分别为0.286、0.359和0.320,均具有统计学意义(P<0.05);最终确定并构建了包含4项一级指标、13项二级指标、49项三级指标的老年住院患者睡眠管理方案。结论 本研究形成的老年住院患者睡眠管理方案科学可靠，可为临床工作者提高老年住院患者的睡眠质量提供借鉴。     

老年结肠镜检查患者肠道准备关键点指导方案的构建研究

目的探讨构建老年结肠镜检查患者的肠道准备关键点指导方案。方法以理论分析、文献回顾、质性访谈为基础,选择全国7个省市临床护理、护理教育、医疗专家3个领域的14名专家采用德尔菲法(Delphi)对该方案进行2轮专家咨询,最终确立老年结肠镜检查患者肠道准备关键点指导方案表。结果两轮专家函询表有效回收率均为100.00%;两轮专家的权威程度系数均为0.89;第一轮与第二轮各条目的变异系数分别为0.07~0.27与0.05~0.13;Kendall's协调系数分别为0.377和0.404(χ2值分别为105.473和124.307,均P0.001);第一轮函询各条目的重要性均数为3.50~4.95,标准差为0.35~0.95,第二轮函询各条目的重要性均数为4.71~4.93,标准差为0.27~0.61。老年结肠镜检查患者肠道准备关键点指导方案包括3个肠道准备关键点,4个关键指导时机,7项关键指导内容,4项肠道准备判断标准及4项对应的补救措施。结论本研究构建了老年结肠镜检查患者肠道准备关键点指导方案,经统计分析咨询结果可靠,专家的积极程度、权威程度、协调程度及集中程度均较高,能为临床开展规范化的肠道准备指导工作提供参考。     

我国老年高级临床专科护士培养目标体系的构建

目的:构建我国老年高级临床专科护士培养目标体系。方法:基于《加拿大高级护理实践框架》,采用文献分析、半结构式访谈、德尔菲专家函询和层次分析法确定我国老年高级临床专科护士培养目标体系及各指标权重。结果:最终形成包括3个一级指标、7个二级指标、51个三级指标的我国老年高级临床专科护士培养目标体系。2轮函询问卷有效回收率分别为100.00%和90.91%,专家权威系数分别为0.89和0.87,肯德尔和谐系数分别为0.374和0.406（均P<0.01）。2轮函询后,指标变异系数为0.00～0.11。结论:本研究构建的指标体系可作为我国老年高级临床专科护士培养项目的内容框架,为我国老年高级临床专科护士的培养提供参考。     

血液透析患者认知功能管理指标的构建

目的 构建血液透析患者认知功能管理指标,用于指导临床对认知功能障碍患者实施早期干预,实现科学化、规范化的管理。方法 通过专家焦点小组讨论、采用德尔菲咨询法对13名相关领域专家进行2轮专家函询,采用层次分析法确定各指标权重。结果 2轮专家函询的问卷有效回收率分别为92.31%和100%,专家权威系数均为0.850,肯德尔和谐系数分别为0.203、0.224,差异有统计学意义(P<0.001)。最终构建的血液透析患者认知功能管理指标包括血液透析前认知功能评估预测、血液透析中认知功能干预、血液透析间期认知功能远程预控监控三大模块,即3个一级指标、11个二级指标、22个三级指标。结论 构建的血液透析患者认知功能管理指标具有科学性和实用性,可以为开展患者认知功能护理研究及实践提供借鉴。     

Determination of creatine kinase isoenzyme MB activity in serum using immunological inhibition of creatine kinase M subunit activity. Activity kinetics and diagnostic significance in myocardial infarction.

This is a new method for the determination of creatine kinase isoenzyme MB activity in serum. The method uses direct activity measurement of creatine kinase B subunit activity after blocking of CK-M subunit activity by inhibiting antibodies. The test takes no longer than 15 min. The method yields an intra-serial C.V. of 2.0-12.9%, and a C.V. from day to day of 5.5%. The detection limit is 3.4 U/l creatine kinase MB. In the 95 cases with proven myocardial infarction several types of creatine kinase MB activity kinetics could be determined. The percentage of creatine kinase MB of peak CK-total is 6-25%, with a mean of 11.1%. The amount of creatine kinase MB with respect to total CK activity after reinfarction is higher than the amount after initial infarction.     

Dissociable correlates of two classes of retrieval processing in prefrontal cortex

Although substantial evidence suggests that the prefrontal cortex (PFC) implements processes that are critical for accurate episodic memory judgments, the specific roles of different PFC subregions remain unclear. Here, we used event-related functional magnetic resonance imaging to distinguish between prefrontal activity related to operations that (1) influence processing of retrieval cues based on current task demands, or (2) are involved in monitoring the outputs of retrieval. Fourteen participants studied auditory words spoken by a male or female speaker and completed memory tests in which the stimuli were unstudied foil words and studied words spoken by either the same speaker at study, or the alternate speaker. On "general" test trials, participants were to determine whether each word was studied, regardless of the voice of the speaker, whereas on "specific" test trials, participants were to additionally distinguish between studied words that were spoken in the same voice or a different voice at study. Thus, on specific test trials, participants were explicitly required to attend to voice information in order to evaluate each test item. Anterior (right BA 10), dorsolateral prefrontal (right BA 46), and inferior frontal (bilateral BA 47/12) regions were more active during specific than during general trials. Activation in anterior and dorsolateral PFC was enhanced during specific test trials even in response to unstudied items, suggesting that activation in these regions was related to the differential processing of retrieval cues in the two tasks. In contrast, differences between specific and general test trials in inferior frontal regions (bilateral BA 47/12) were seen only for studied items, suggesting a role for these regions in post-retrieval monitoring processes. Results from this study are consistent with the idea that different PFC subregions implement distinct, but complementary processes that collectively support accurate episodic memory judgments.     

俯卧位通气对高海拔地区肺复张治疗无效急性呼吸窘迫综合征患者氧合的影响

目的 探讨俯卧位通气对高海拔地区肺复张术(RM)治疗无效急性呼吸窘迫综合征(ARDS)患者的治疗作用.方法 从海拔2260m的地区医院筛选RM治疗无效的41例ARDS患者[平均氧合指数( PaO2/FiO2)较RM前升高＜20％视为RM无效],依不同病因分为肺内源性ARDS组(ARDSp组)和肺外源性ARDS组(ARDSexp组),每组再按信封法随机分为俯卧位组和仰卧位组,即ARDSp俯卧位组(11例)、ARDSp仰卧位组(9例)、ARDSexp俯卧位组(10例)、ARDSexp仰卧位组(11例).在通气前及通气1、2、3、4h监测动脉血氧分压( PaO2)、PaO2/FiO2、静态顺应性(Cst)、气道阻力(Raw)的变化.结果 通气lh时,ARDSexp俯卧位组PaO2/FiO2( mm Hg,l mm Hg=0.133 kPa)即较通气前显著升高(157.4±40.6比129.3±48.7,P＜0.05),并随通气时间延长呈持续增高趋势,4h达峰值(219.1 ±41.1);且ARDSexp俯卧位组通气3h内PaO2/FiO2较其他3组显著增高,另3组间则差异无统计学意义.ARDSp俯卧位组、ARDSexp俯卧位组通气4h时PaO2/FiO2均较相应仰卧位组显著增高(208.8±39.7比127.4±47.1,219.1±41.1比124.9±50.8,均P＜0.05).4组通气前后Cst无显著改变,各组间差异也无统计学意义.ARDSp俯卧位组通气4h时Raw(cmH2O·L-1·s-1)较通气前显著降低(6.8±1.7比10.7±1.8,P＜0.05),且明显低于其他3组;其他3组各时间点Raw组内及组间比较差异均无统计学意义.结论 俯卧位通气作为ARDS机械通气重要策略之一,可以改善RM无效高原ARDS患者的氧合,为抢救患者赢得宝贵的时间.     

Digital imaging among medical facilities

The Department of Veterans Affairs (VA) in the USA operates a network of 172 medical centres which all utilize a hospital information system (HIS) which has been developed and is currently maintained by the VA. During the past several years, an image management and communication module has been developed, installed and clinically utilized at the Washington DC and Maryland VA Medical Centres. This image management and communication system, referred to as the decentralized hospital computer program (DHCP) imaging system, is fully integrated with a commercial picture archiving and communication system (PACS). The system is utilized to capture, archive, and display all images generated within the hospital including radiology, nuclear medicine, pathology, endoscopy, bronchoscopy, and dermatology, intraoperative photographs, ECG data, and a limited number of paper documents. The ultimate goal of the project is to have all patient text and image data available at any clinical workstation to any authorized user anywhere within the network of medical centres. Clinical requirements for an imaging workstation include ease of use, rapid and reliable access to the complete set of patient information, and images which are of acceptable quality to meet the requirements of the user and the subspecialty. Patient confidentiality and data security must be safeguarded at all times. Integration of the images with the remainder of the patient's database was found to be critical to the success of the project. The experience at the Washington and Maryland facilities suggests that an imaging system that is successfully integrated with a hospital information system can provide substantial clinical and economic benefits both within and among medical centres. Clinical acceptance and utilization of the system has been excellent, particularly in diagnostic radiology where DHCP Imaging has been interfaced to a commercial PAC system. Based upon this initial experience, the VA has begun to deploy the system throughout its large network of medical centres.     

Myocardial elastography at both high temporal and spatial resolution for the detection of infarcts

Myocardial elastography is a novel method for noninvasively assessing regional myocardial function, with the advantages of high spatial and temporal resolution and high signal-to-noise ratio (SNR). In this paper, in-vivo experiments were performed in anesthetized normal and infarcted mice (one day after left anterior descending coronary artery [LAD] ligation) using a high-resolution (30 MHz) ultrasound system (Vevo 770, VisualSonics Inc., Toronto, ON, Canada). Radiofrequency (RF) signals of the left ventricle (LV) in longitudinal (long-axis) view and the associated electrocardiogram (ECG) were simultaneously acquired. Using a retrospective ECG gating technique, 2-D full field-of-view RF frames were acquired at an extremely high frame rate (8 kHz) that resulted in high-quality incremental displacement and strain estimation of the myocardium. The incremental results were further accumulated to obtain the cumulative displacements and strains. Two-dimensional and M-mode displacement images and strain images (elastograms), as well as displacement and strain profiles as a function of time, were compared between normal and infarcted mice. Incremental results clearly depicted cardiac events including LV contraction, LV relaxation and isovolumetric phases in both normal and infarcted mice, and also evidently indicated reduced motion and deformation in the infarcted myocardium. The elastograms indicated that the infarcted regions underwent thinning during systole rather than thickening, as in the normal case. The cumulative elastograms were found to have higher elastographic SNR (SNR(e)) than the incremental elastograms (e.g., 10.6 vs. 4.7 in a normal myocardium, and 6.0 vs. 2.4 in an infarcted myocardium). Finally, preliminary statistical results from nine normal (m = 9) and seven infarcted (n = 7) mice indicated the capability of the cumulative strain in differentiating infracted from normal myocardia. In conclusion, myocardial elastography could provide regional strain information at simultaneously high temporal (>/=0.125 ms) and spatial ( approximately 55 microm) resolution as well as high precision ( approximately 0.05 microm displacement). This technique was thus capable of accurately characterizing normal myocardial function throughout an entire cardiac cycle, at the same high resolution, and detecting and localizing myocardial infarction in vivo.     

Clinical Pharmacokinetics of Morphine

Morphine, the most widely used mu-opioid analgesic for acute and chronic pain, is the standard against which new analgesics are measured. A thorough understanding of the pharmacokinetics of morphine is required in order to safely and effectively use this analgesic in a wide variety of patients with different levels of organ function. A MEDLINE search was conducted to identify literature published between 1966 and January 2002 relevant to the pharmacokinetics of morphine. These publications were reviewed and the literature summarized regarding unique and clinically important elements of morphine disposition relative to its parenteral administration (including intravenous, intramuscular, subcutaneous, epidural and intrathecal administration), absorption profile (immediate release, controlled release, and sublingual/buccal, and rectal administration), distribution, and its metabolism/ excretion. Special populations, including infants, elderly, and those with renal/liver failure, have a unique morphine pharmacokinetic profile that must be taken into account in order to maximize analgesic efficacy and reduce the risk of adverse events.