Quantitative ultrasound (QUS) at the calcaneus and hand phalanges in Polish healthy postmenopausal women

In a cross-sectional study, 109 postmenopausal, healthy women, mean age 58.8 years, were studied. The aim of the study was to compare quantitative ultrasound (QUS) performed at two measurement sites of the same persons (correlations between parameters studied, age, and years since menopause (YSM)-related changes, influence of body size). Bone status was established using measurements at the calcaneus by Achilles (Lunar, USA), which measures speed of sound (SOS [m/s], CV% = 0.22%), broadband ultrasound attenuation (BUA [dB/MHz], CV% = 1.8%), stiffness index (SI [%], CV% = 1.3%), and by DBM Sonic 1200 (Igea, Italy), which measures amplitude-dependent speed of sound (Ad-SoS [m/s], CV% = 0.64%) at the hand phalanges. Mean and SD values were: SOS = 1498 +/- 24.8 m/s, BUA = 104.6 +/- 9.4 dB/MHz, SI = 69.2 +/- 12.3%, Ad-SoS = 1879 +/- 90.1 m/s. Age- and YSM-related changes were as follows: age-SOS r = -0.37, p < 0.0001, age-BUA r = -0.33, p < 0.001, age-SI r = -0.36, p < 0.001, age-Ad-SoS r = -0.62, p < 0.00001, YSM-SOS r = -0.27, p < 0.01, YSM-BUA r = -0.32, p < 0.001, YSM-Ad-SoS r = -0.44, p < 0.00001, YSM-SI r = -0.29, p < 0.01. In stepwise, multiple regression analyses of ultrasound parameters on age, YSM, height, and weight, the following equations were obtained: SOS [m/s] = 1564.9 - 1.1 x age [y], r = -0.37, p < 0.0001; BUA [dB/MHz] = 88.7 + 0.28 x weight [kg] - 0.36 x YSM [y], r = -0.51, p < 0.00001; SI [%]) = 79.2 - 0.5 x age [y] + 0.28 x weight [kg], r = -0.47, p < 0.00001; Ad-SoS [m/s] = 2287 to 6.9 x age [y], r = -0.62, p < 0.00001. In conclusion, QUS at the calcaneus and hand phalanges express similar trends in skeletal changes due to aging and the postmenopausal period, although measurements at the phalanges seem to be more sensitive for detecting bone changes, due to faster decrease rate of the Ad-SoS value than calcaneal measurements.     

Physician Medical Direction andClinical Performance at an Established Emergency Medical Services System

Objective. Few developed emergency medical services (EMS) systems operate without dedicated medical direction. We describe the experience of Hamad Medical Corporation (HMC) EMS, which in 2007 first engaged an EMS medical director to develop andimplement medical direction andquality assurance programs. We report subsequent changes to system performance over time. Methods. Over one year, changes to the service's clinical infrastructure were made: Policies were revised, paramedic scopes of practice were adjusted, evidence-based clinical protocols were developed, andskills maintenance andeducation programs were implemented. Credentialing, physician chart auditing, clinical remediation, andonline medical command/hospital notification systems were introduced. Results. Following these interventions, we report associated improvements to key indicators: Chart reviews revealed significant improvements in clinical quality. A comparison of pre- andpost-intervention audited charts reveals a decrease in cases requiring remediation (11% to 5%, odds ratio [OR] 0.43 [95% confidence interval (CI) 0.20–0.85], p = 0.01). The proportion of charts rated as clinically acceptable rose from 48% to 84% (OR 6 [95% CI 3.9–9.1], p < 0.001). The proportion of misplaced endotracheal tubes fell (3.8% baseline to 0.6%, OR 0.16 [95% CI 0.004–1.06], (exact) p = 0.05), corresponding to improved adherence to an airway placement policy mandating use of airway confirmation devices andsecuring devices (0.7% compliance to 98%, OR 714 [95% CI 64–29,334], (exact) p < 0.001). Intravenous catheter insertion in unstable cases increased from 67% of cases to 92% (OR 1.31 [95% CI 1.09–1.71], p = 0.004). EMS administration of aspirin to patients with suspected ischemic chest pain improved from 2% to 77% (OR 178 [95% CI 35–1,604], p < 0.001). Conclusions. We suggest that implementation of a physician medical direction is associated with improved clinical indicators andoverall quality of care at an established EMS system     

Dietary and herbal supplements use among patients hospitalized in internal medicine departments

ObjectivesTo assess consumption of dietary and herbal supplements (DHS) among patients in internal medicine departments and determine whether such use is documented in their medical files.Methods267 patients from three internal medicine departments of an academic medical center in Haifa, Israel were assessed prospectively with questionnaires about their DHS use in the month preceding hospitalization. DHS were categorized into vitamins & minerals, herbal supplements and others. Further data was then collected from patients' medical records on socio-demographic and medical characteristics, as well as documentation of DHS use.Results123 patients (50.6 %) used DHS on a daily basis. Most of them (53.7 %) were using more than one DHS. DHS use was more prevalent in older (OR = 1.02 [1.001–1.036], p = 0.034) and educated (OR = 0.482 [0.252-0.923], p = 0.028) patients. Vitamins & minerals were used mainly to enhance vitality and address laboratory abnormalities, whereas herbal supplements were used mainly for gastrointestinal problems (p < 0.001). DHS use was reported to the physicians by 42 % of the patients, mostly at the patients’ initiative [92 (82.1 %), p < 0.001)]. Vitamins and minerals were the most reported category of DHS (94 (57.3 %), p < 0.001). The use of DHS was reported to physicians for 112 DHS (41.8 %) but only 32 DHS (11.9 %) were documented in their medical files. The documentation of vitamins and minerals was significantly higher compared to herbal supplements documentation (29 (17.7 %) & 3 (2.9 %) respectively, P < 0.001).ConclusionsDHS are commonly used by patients hospitalized in the internal medicine departments. Many patients do not report such use to the physicians, and more strikingly, physicians do not document DHS use in patient medical files. This communication gap may have serious medico-legal ramifications due to DHS side effects and DHS interactions with other DHS and with conventional drugs.     

老年患者结肠镜检查前肠道准备质量的影响因素及护理对策

目的:探索影响我国老年患者肠道准备状态的相关因素,为制定有针对性的肠道准备优化护理干预措施提供有价值的参考依据。方法:选取上海市第十人民医院2018年1月至2019年4月间行结肠镜检查的≥60岁老年患者作为研究对象。记录患者年龄、性别、体质量指数(body mass index,BMI)、腹部手术及结肠镜检查史、心肺等合并症、肠道准备前饮食情况、药物服用时间和剂量、期间运动时间、排便次数、最后一次排便特征及不良反应发生情况进行统计学分析。结果:肠道准备不足率为31.46%。与肠道准备不足密切相关的因素有年龄(P=0.018),腹部手术史[优势比(odds ratio,OR)=2.834,95%置信区间(confidence interval,CI:1.412~5.423),合并脑卒中(OR=2.853,95%CI:1.534~5.183),合并慢性便秘(OR=3.464,95%CI:1.673~6.982),用药剂量不足(OR=4.934,95%CI:1.934~11.234),非少渣流质饮食(OR=2.984,95%CI:1.498~5.983),运动时间<30 min(OR=2.475,95%CI:1.253~4.886)],服药后大便次数(P<0.001)。结论:老年患者的既往患病史及用药剂量、饮食种类、运动时间与肠道准备情况关系密切,护理人员应针对老年患者个体状况,进行针对性的护理干预提高肠道准备质量。     

冠状动脉杂交技术对比冠状动脉旁路移植术在冠状动脉再血管化中的meta分析

目的 评价冠状动脉再血管化杂交技术（HCR）与冠状动脉旁路移植术（CABG）在冠心病治疗中的有效性和安全性。方法 检索MEDLINE,EMBASE数据库,中国知网,Corchrane图书馆及二次资源。检索词：杂交技术、冠状动脉旁路移植术、经皮冠状动脉支架置入术、一站式冠状动脉杂交术、分站式冠状动脉杂交术。采用比值比（odd ratio, OR）和95%可信区间（95% confidence interval, CI）作为评价HCR和CABG的主要心脑血管事件发生率（死亡率、卒中发生率、心肌梗死发生率、目标血管再血管化率、主要的心脑血管事件发生率、新发的心房颤动发生率以及红细胞输注率）有无差异的指标;用均数差（median difference,MD）和 95%CI作为评价机械通气时间、ICU时间、总住院时间有无差异的指标。统计学分析应用RevMan 5.2进行异质性检验及Meta分析。结果 在检索到的文献中共有17篇文献满足条件,总计8 608例患者。行HCR的患者和非体外循环CABG的患者比较,在死亡率［OR=0.77, 95%CI（0.42, 1.41）, I2（0%）,P=0.39］、心肌梗死发生率［OR=0.78, 95%CI（0.40,1.52）, I2（0%）,P=0.47］、卒中发生率［OR=0.67, 95%CI（0.34,1.33）, I2（0%）,P＝0.26］、主要的心脑血管事件发生率［OR=0.74, 95%CI（0.53,1.03）, I2（0%）,P=0.07］、目标血管再血管化率［OR=2.41, 95%CI（0.91,6.38）, I2（0%）,P=0.08］以及新发的心房颤动发生率［OR=0.92, 95%CI（0.70,1.22）, I2（29%）,P=0.56］方面差异无统计学意义;在红细胞输注率［OR=-0.16, 95%CI（-0.22,-0.09）, I2（34%）,P＜0.01］方面有所降低;在机械通气时间［OR=-6.25,95%CI（-9.01,-5.32）, I2（22%）,P＜0.01］、ICU时间［OR=-18.58, 95%CI（-23.65,-13.52）, I2（45%）,P＜0.01］、总住院时间［OR=-0.3, 95%CI（-0.46,-0.15）, I2（6%）,P＜0.01］方面,时间均有所缩短。结论 HCR安全可行,且较CABG具有一定优势。     

Gender Differences in Anxiety and Concerns about the Cardioverter Defibrillator

Background: Little is known about gender differences in the response to implantable cardioverter defibrillator (ICD) therapy. We compared female and male ICD patients on anxiety, depression, health-related quality of life (HRQL), ICD concerns, and ICD acceptance.
Methods: A cohort of consecutive, surviving patients (n = 535; mean age = 61.5 ± 14.4, 81.9% male) implanted with an ICD between 1989 and 2006 completed the Hospital Anxiety and Depression Scale, the Short-Form Health Survey (SF-36), the ICD concerns questionnaire, and the Florida Patient Acceptance Survey.
Results: High levels of anxiety (52% vs 34%, P < 0.001) and ICD concerns (34% vs 16%, P = 0.001) were more prevalent in women than men, whereas no significant differences were found on depression and device acceptance (Ps > 0.05). Women were more anxious (odds ratio [OR]: 2.60 [95% confidence interval (CI): 1.46–4.64], P < 0.01) and had more ICD concerns (OR: 1.81 [95% CI: 1.09–3.00], P < 0.05) than men, adjusting for demographic and clinical characteristics. Those ICD patients experiencing shocks were also more anxious (OR: 2.02 [95% CI: 1.20–3.42], P < 0.01) and had higher levels of ICD concerns (OR: 2.70 [95% CI: 1.76–4.16], P < 0.01). In multivariable analysis of variance, significant gender differences were found for only three of the eight subscales of the SF-36 (the physical social functioning and the mental health subscale), with women reporting poorer HRQL on all three subscales.
Conclusions: Women were more prone to experience anxiety and ICD concerns compared to men regardless of whether they had experienced shocks. In clinical practice, female ICD patients should be closely monitored, and if warranted offered psychosocial intervention, as increased anxiety has been shown to precipitate arrhythmic events in defibrillator patients.     

肺癌合并肺栓塞危险因素的Meta分析

目的系统评价肺癌合并肺栓塞的相关危险因素。方法计算机检索PubMed、Embase、中国知网、万方等数据库,收集有关肺癌合并肺栓塞危险因素的文献,检索时限均为建库至2021年1月。由2名研究人员独立进行文献筛选、资料提取以及文献质量评价,并采用RevMan5.4软件和Stata16.0软件对纳入的数据进行Meta分析。结果共纳入25项研究,共3480例。Meta分析研究结果显示,肺癌患者发生肺栓塞的危险因素包括腺癌(OR=2.06,95%CI:1.75~2.44,P<0.01)、肿瘤分期(Ⅲ~Ⅳ期)(OR=2.67,95%CI:2.19~3.26,P<0.01)、化疗(OR=2.69,95%CI:2.08~3.47,P<0.01)、深静脉置管(OR=2.66,95%CI:1.68~4.19,P<0.01)、白蛋白<30 g/L(OR=6.65,95%CI:2.91~15.18,P<0.01)、D二聚体>500 mg/L(OR=5.87,95%CI:2.12~16.27,P<0.01)、白细胞>11×10^(9)/L(OR=8.26,95%CI:4.50~15.13,P<0.01)及慢性阻塞性肺疾病(OR=1.51,95%CI:1.16~1.95,P<0.01)。结论本研究显示腺癌、肿瘤分期(Ⅲ~Ⅳ期)、化疗、深静脉置管、白蛋白<30 g/L、D二聚体>500 mg/L、白细胞>11×10^(9)/L及慢性阻塞性肺疾病是肺癌患者发生肺栓塞的危险因素。受纳入研究数量及质量的限制,需更多高质量文章进一步加以验证。     

经鼻高流量湿化氧疗在成人重症免疫抑制患者应用疗效的meta分析

目的 系统评价经鼻高流量湿化氧疗（HFNC）在成人重症免疫抑制患者的应用疗效。方法 计算机检索PubMed、Embase、Cochrane Library、Ovid、EBSCO、万方、维普、CNKI、CBM,查找HFNC治疗成人重症免疫抑制患者的随机对照试验。检索时限为建库至2019年5月。同时为了避免遗漏,对纳入文献的参考文献进行手工检索。并采用Revman 5.3软件进行meta分析。结果 共纳入8项研究,涉及1 302例患者。Meta分析结果显示,HFNC与传统氧疗相比,能降低患者的插管率［OR=0.77,95%CI（0.60,0.97）,Z=2.19,P=0.03］,但与无创通气相比,在降低插管率上差异无统计学意义［OR=0.43,95%CI（0.17,1.08),Z=1.80,P=0.07］。两个亚组合并结果显示,HFNC较对照氧疗相比,能显著降低重症免疫抑制患者的插管率［合并: OR=0.74,95%CI（0.58,0.93）,Z=2.58,P=0.01］,但对降低病死率、感染率及缩短ICU住院时间差异无统计学意义［病死率：OR=0.84,95%CI（0.66,1.08）,Z=1.34,P=0.18;感染率：OR=0.80,95%CI（0.56,1.15）,Z=1.19,P=0.24;ICU住院时间：OR=-0.19,95%CI（-2.51,2.12）,Z=0.16,P=0.87］。而在进行敏感性分析时发现,HFNC与对照氧疗相比,能显著降低患者的ICU住院时间。结论 HFNC与对照氧疗相比,能显著降低患者的插管率,但不能降低患者的病死率及感染率。     

Critical illness polyneuropathy: risk factors and clinical consequences. A cohort study in septic patients

OBJECTIVE: To determine risk factors and clinical consequences of critical illness polyneuropathy (CIP) evaluated by the impact on duration of mechanical ventilation, length of stay and mortality. DESIGN: Inception cohort study. SETTING: Intensive care unit of a tertiary hospital. PATIENTS: Septic patients with multiple organ dysfunction syndrome requiring mechanical ventilation and without previous history of polyneuropathy. INTERVENTIONS: Patients underwent two scheduled electrophysiologic studies (EPS): on the 10th and 21st days after the onset of mechanical ventilation. RESULTS: Eighty-two patients were enrolled, although nine of them were not analyzed. Forty-six of the 73 patients presented CIP on the first EPS and 4 other subjects were diagnosed with CIP on the second evaluation. The APACHE II scores of patients with and without CIP were similar on admission and on the day of the first EPS. However, days of mechanical ventilation [32.3 (21.1) versus 18.5 (5.8); p=0.002], length of ICU and hospital stay in patients discharged alive from the ICU as well as in-hospital mortality were greater in patients with CIP (42/50, 84% versus 13/23, 56.5%; p=0.01). After multivariate analysis, independent risk factors were hyperosmolality [odds ratio (OR) 4.8; 95% confidence intervals (95% CI) 1.05-24.38; p=0.046], parenteral nutrition (OR 5.11; 95% CI 1.14-22.88; p=0.02), use of neuromuscular blocking agents (OR 16.32; 95% CI 1.34-199; p=0.0008) and neurologic failure (GCS below 10) (OR 24.02; 95% CI 3.68-156.7; p<0.001), while patients with renal replacement therapy had a lower risk for CIP development (OR 0.02; 95% CI 0.05-0.15; p<0.001). By multivariate analysis, CIP (OR 7.11; 95% CI 1.54-32.75; p<0.007), age over 60 years (OR 9.07; 95% CI 2.02-40.68; p<0.002) and the worst renal SOFA (OR 2.18; 95% CI 1.27-3.74; p<0.002) were independent predictors of in-hospital mortality. CONCLUSIONS: CIP is associated with increased duration of mechanical ventilation and in-hospital mortality. Hyperosmolality, parenteral nutrition, non-depolarizing neuromuscular blockers and neurologic failure can favor CIP development.     

Risk factors for microbial contamination of peripheral blood stem cell products

BACKGROUND: Despite the well‐known contamination rates and presence of microbial agents in stem cell products, the risk factors affecting microbial contamination have not been well described. STUDY DESIGN AND METHODS: In a 12‐year period, we retrospectively reviewed culture results of peripheral blood stem cell products with the intent of identifying risk factors for microbial contamination. RESULTS: Microbial contamination was detected in 28 (5.7%) products of the postprocessing period and in 18 (3.66%) products of the postthawing period. Large‐volume leukapheresis (LVL; odds ratio [OR], 5.85; 95% confidence interval [CI], 1.52‐22.49; p = 0.01) and high numbers of stem cell culture sampling (OR, 1.4; 95% CI, 1.03‐1.91; p = 0.03) were found to be risk factors for postprocessing bacterial contamination. The presence of postprocessing bacterial contamination was a risk factor for postthawing (OR, 28.89; 95% CI, 6.67‐125.15; p < 0.001) and posttransplant (OR, 3.25; 95% CI, 1.24‐8.50; p = 0.01) microbial growth. In transplants that were performed using contaminated products, the same pathogen was detected in 20% of patients and different pathogens were found in 35% of patients. CONCLUSION: Cultures should be carefully monitored in LVL products and in samples with high numbers of cultures performed. Growth of different bacterial pathogens must be considered in transplants that are performed with contaminated products.     

Ability of the Medical Priority Dispatch System Protocol to Predict the Acuity of “Unknown Problem” Dispatch Response Levels

Objective. To determine if Medical Priority Dispatch System's (MPDS's) Protocol 32–Unknown Problem interrogation-based differential dispatch coding distinguishes the acuity of patients as found at the scene by responders, when little (if any) clinical information is known. Methods. “Unknown problem” situations (i.e., all cases not fitting into any other chief complaint group) constitute 5–8% of all calls to dispatch centers. From the total patient encounters (n = 599,107) in the aggregate data of one year (September 2005 to August 2006), we examined 3,947 (0.7%) encounters initially coded as “unknown problem” by the London Ambulance Service Communications Center for the scene presence of cardiac arrest (CA) andparamedic-determined high-acuity (blue-in [BI]/“lights andsiren”) findings. Odds ratios (ORs) with 95% confidence intervals (95% CIs) andp-values were used to assess the degree of associations between determinant codes andcase outcomes (i.e., CA/BI). Results. Statistically significant association between clinical dispatch determinant codes andcase outcomes was observed in the “life status questionable” (LSQ; DELTA-1 [D-1]) andthe “standing, sitting, moving, or talking” (BRAVO-1 [B-1]) code pair for the CA outcome (OR [95% CI]: 0.11 [0, 0.63], p = 0.005) andfor the BI outcome (OR [95% CI]: 0.47 [0.28, 0.77], p = 0.003). The LSQ andall three code pairs (i.e., B-1; “community alarm notifications” [B-2]; and“unknown status” [B-3]) also demonstrated significant associations both with the CA outcome (OR [95% CI]: 0.43 [0.23, 0.81], p = 0.010) andwith the BI outcome (OR [95% CI]: 0.74 [0.56, 0.97], p = 0.033). All the determinant code levels yielded significant association between BI andCA cases. Conclusion. This dispatch protocol for unknown problems successfully differentiates dispatch coding of low-acuity andnon-CA patients only when specific situational information such as the patient's standing, sitting, moving, or talking can be determined during the interrogation process. Also, emergency medical dispatcher (EMD) reliance on caller-volunteered information to identify predefined critical situations does not appear to add to the protocol's ability to differentiate high-acuity andCA patients. LSQ proved to be a better predictor of both CA andBI outcomes, when compared with the BRAVO-level determinant codes within the “unknown problem” chief complaint. The B-3 (completely unknown) determinant code is a better predictor of severe outcomes than nearly all of the clinically similar BRAVO determinant codes in the entire MPDS protocol. Hence, the B-3 coding should be considered—in terms of its predictability for severe outcome—as falling somewhere between a typical DELTA anda typical BRAVO determinant code.     

重症监护病房脓毒症患者危险因素的logistic回归分析

目的 探讨脓毒症患者入重症监护病房(ICU)时各项指标与预后的相关关系.方法 回顾性分析2004年1月-2008年12月450例脓毒症患者临床资料,选择24个可能对脓毒症预后产生影响的临床、化验及评分指标,通过非条件logistic回归模型进行单因素及多因素回归分析.结果 单因素回归分析显示:住院天数[优势比(OR)=0.951,P<0.001]、格拉斯哥昏迷评分(GCS,OR=0.858,P<0.001)、平均动脉压(MAP,OR=0.991,P=0.041)、血小板计数(PLT,OR=0.997,P<0.001)、总蛋白(TP,OR=0.975,P=0.003)、白蛋白(Alb,OR=0.955,P<0.001)、动脉血pH值(OR=0.077,P=0.001)、动脉血氧分压(PaO2,OR=0.996,P=0.014)为脓毒症预后的非危险因素,急性生理学与慢性健康状况评分系统Ⅰ(APACHE Ⅰ)评分(OR=1.115,P<0.001)、体温(OR=1.215,P=0.041)、凝血酶原时间(PT,OR=1.057,P=0.007)、天冬氨酸转氨酶(AST,OR=1.001,P=0.011)、血肌酐(SCr,OR=1.002,P=0.002)、血钾(OR=1.391,P=0.003)、血糖(OR=1.051,P=0.002)、C-反应蛋白(CRP,OR=1.245,P=0.001)为脓毒症预后的危险因素.多因素回归分析显示:APACHE Ⅰ评分(OR=1.094,P<0.001)、住院天数(OR=0.946,P<0.001)、PLT(OR=0.976,p=0.004)、Alb(OR=0.957,P=0.017)4个指标为脓毒症预后的独立危险因素.结论 APACHE Ⅰ评分、住院天数、PLT、Alb是临床上判断危重病患者预后的有效指标.     

Association among individual deprivation, glycemic control, and diabetes complications: the EPICES score

OBJECTIVE: Previous studies have related poor glycemic control and/or some diabetes complications to low socioeconomic status. Some aspects of socioeconomic status have not been assessed in these studies. In the present study, we used an individual index of deprivation, the Evaluation de la Précarité et des Inégalités de santé dans les Centres d'Examens de Santé (Evaluation of Precarity and Inequalities in Health Examination Centers [EPICES]) score, to determine the relationship among glycemic control, diabetes complications, and individual conditions of deprivation. RESEARCH DESIGN AND METHODS: We conducted a cross-sectional prevalence study in 135 consecutive diabetic patients (age 59.41 +/- 13.2 years [mean +/- SD]) admitted in the hospitalization unit of a French endocrine department. Individual deprivation was assessed by the EPICES score, calculated from 11 socioeconomic questions. Glycemic control, lipid levels, blood pressure, retinopathy, neuropathy, and nephropathy were assessed. RESULTS: HbA(1c) level was significantly correlated with the EPICES score (r = 0.366, P < 0.001). The more deprived patients were more likely than the less deprived patients to have poor glycemic control (beta = 1.984 [SE 0.477], P < 0.001), neuropathy (odds ratio 2.39 [95% CI 1.05-5.43], P = 0.037), retinopathy (3.66 [1.39-9.64], P = 0.009), and being less often admitted for 1-day hospitalization (0.32 [0.14-0.74], P = 0.008). No significant relationship was observed with either nephropathy or cardiovascular risk factors. CONCLUSIONS: Deprivation status is associated with poor metabolic control and more frequent microvascular complications, i.e., retinopathy and neuropathy. The medical and economic burden of deprived patients is high.     

非体外循环冠状动脉旁路移植术后机械通气时间延长的危险因素及预后分析

目的分析影响非体外循环冠状动脉旁路移植术（OPCABG）后机械通气时间延长（PMV）的因素,以及PMV对患者预后的影响。 方法回顾性分析2013年6月至2018年12月在首都医科大学附属北京安贞医院接受OPCABG的1 097例患者。根据术后气管插管的时间,分为对照组（术后气管插管时间≤ 24 h,972例）和PMV组（术后气管插管时间> 24 h,125例）。比较两组患者术前、术中及术后的临床资料,采用多因素Logistic回归分析筛选影响患者PMV的相关因素,探讨PMV对接受OPCABG患者预后的影响。 结果对照组及PMV组患者间纽约心脏病协会（NYHA）分级（ χ² = 34.138,P < 0.001）及左室舒张功能分级（ χ² = 215.175,P < 0.001）比较,差异均有统计学意义。同时,与对照组比较,PMV组患者年龄[（62 ± 9）岁vs.（67 ± 9）岁,t = 6.618,P < 0.001]、手术时间[（4.0 ± 1.2）h vs.（5.9 ± 2.5）h,t = 8.246,P < 0.001]、移植桥血管数目[（2.8 ± 0.6）支vs.（3.2 ± 0.9）支,t = 4.769,P < 0.001]、冠状动脉内膜剥脱术（CE）[4.0%（39 / 972）vs. 20.8%（26 / 125）,χ² = 55.998,P < 0.001]及左心室成形术（SVR）[2.3%（22 / 972）vs. 12.8%（16 / 125）,χ² = 36.771,P < 0.001]发生率均显著升高,而左室射血分数（LVEF）[（58 ± 6）% vs.（47 ± 7）%,t = 18.006,P < 0.001]水平则显著降低。将年龄、NYHA分级、LVEF、左室舒张功能分级、手术时间、移植桥血管数目、CE和SVR纳入多因素Logistic回归分析,结果显示,年龄[比值比（OR）= 1.881,95%置信区间（CI）（1.399,2.529）,P < 0.001]、NYHA分级[OR = 1.476,95%CI（1.220,1.785）,P < 0.001]、左室舒张功能分级[OR = 2.866,95%CI（1.712,4.799）,P < 0.001]、手术时间[OR = 1.599,95%CI（1.068,2.394）,P = 0.003]和SVR [OR = 2.334,95%CI（1.196,4.554）,P < 0.001]是接受OPCABG的患者术后发生PMV的独立危险因素,而LVEF [OR = 0.287,95%CI（0.189,0.436）,P = 0.009]是其保护因素。PMV组患者术后心律失常[29.6% （37 / 125）vs. 14.7%（143 / 972）,χ² = 17.898,P < 0.001]、肺部感染[10.4% （13 / 125）vs. 2.3%（22 / 972）,χ² = 26.281,P < 0.001]、胸腔积液[12.8%（16 / 125）vs. 3.0%（29 / 972）,χ² = 27.131,P < 0.001]、血清肌酐[（114 ± 37）μmol / L vs.（81 ± 27）μmol / L,t = 9.547,P < 0.001]、脑血管事件[10.4%（13 / 125）vs. 3.2%（31 / 972）,χ² = 14.957,P = 0.001]、胃肠道事件[17.6%（22 / 125）vs. 4.0%（39 / 972）,χ² = 38.939,P < 0.001]、住ICU时间[（43 ± 20）h vs.（13 ± 8）h,t = 16.187,P < 0.001]、术后住院时间[（11 ± 9）d vs.（6 ± 3）d,t = 5.937,P < 0.001]和30 d病死率[8.8%（11 / 125）vs. 0.9%（9 / 972）,χ² = 38.365,P < 0.001]均显著高于对照组。 结论年龄、NYHA分级、LVEF、左室舒张功能分级、手术时间及同期行SVR是影响患者OPCABG术后PMV的相关因素。预防PMV的发生可减少术后多种并发症的发生、缩短住院时间、降低患者30 d病死率。     

老年人群血清胱抑素C、同型半胱氨酸与脑白质疏松症的相关性研究

目的探讨老年人群血清胱抑素C和同型半胱氨酸与脑白质疏松症的关系，以寻找可靠的生物学标志物。 方法收集2016年11月至2017年9月于浙江大学医学院附属第一医院老年病科住院的130例老年患者电子病历，记录所有患者的年龄、性别、高血压、高血压病程等一般资料和甘油三酯、总胆固醇、高密度脂蛋白、低密度脂蛋白、尿酸、胱抑素C及同型半胱氨酸等生化指标。采用半定量法将130例老年患者分为正常组（31例）、轻度异常组（26例）、中度异常组（32例）和重度异常组（41例）。采用Spearman相关分析年龄、高血压病程、尿酸、胱抑素C及同型半胱氨酸与脑白质疏松症严重程度的相关性；将年龄、高血压病程、尿酸、胱抑素C及同型半胱氨酸纳入Logistic多因素回归模型，分析影响脑白质疏松症严重程度的相关因素。 结果正常组、轻度异常组、中度异常组及重度异常组老年患者年龄[（73 ± 6）、（72 ± 7）、（76 ± 6）、（79 ± 7）岁，F = 10.487，P < 0.001]、高血压病程[0（0，2）、4（0，16）、2（0，15）、10（0，15）年，H = 10.711，P = 0.013]、尿酸[（274 ± 74）、（294 ± 67）、（315 ± 64）、（343 ± 120）μmol/L，F = 3.964，P = 0.010]、胱抑素C[（0.96 ± 0.29）、（1.24 ± 0.32）、（1.42 ± 0.40）、（1.84 ± 0.65）mg/L，F = 23.025，P < 0.001]及同型半胱氨酸[（10.1 ± 2.3）、（11.4 ± 2.9）、（12.5 ± 2.7）、（18.0 ± 3.5）μmol/L，F = 39.271，P < 0.001]水平比较，差异均有统计学意义。进一步两两比较发现，重度异常组患者年龄较正常组、轻度异常组及中度异常组均显著增高（P均< 0.05）；轻、重度异常组患者高血压病程均较正常组显著延长（P均< 0.05）；轻度异常组患者胱抑素C水平较正常组显著升高（P < 0.05）；中度异常组患者胱抑素C及同型半胱氨酸水平均较正常组显著升高（P均< 0.05）；重度异常组患者胱抑素C及同型半胱氨酸水平均较正常组、轻度异常组及中度异常组显著升高（P均< 0.05）；且重度异常组患者尿酸水平均较正常组和轻度异常组显著升高（P均< 0.05）。相关分析结果显示，年龄（r = 0.406，P < 0.001）、高血压病程（r = 0.263，P = 0.002）、尿酸（r = 0.293，P = 0.001）、胱抑素C（r = 0.588，P < 0.001）及同型半胱氨酸（r = 0.646，P < 0.001）均与脑白质疏松症具有相关性。Logistic回归分析显示年龄[比值比（OR）= 1.099，95%置信区间（CI）（1.030，1.168），P = 0.003]、胱抑素C [OR = 11.345，95%CI（3.725，34.549），P < 0.001]及同型半胱氨酸[OR = 1.438，95%CI（1.262，1.638），P < 0.001]均为影响脑白质疏松症严重程度的危险因素。 结论血清胱抑素C、同型半胱氨酸是老年患者脑白质疏松症的危险因素，可以初步评价其脑白质疏松症的严重程度。     

Determinants of return behavior: a comparison of current and lapsed donors

BACKGROUND: There is a need to identify factors explaining why some people stop donating blood. STUDY DESIGN AND METHODS: A random mail survey of first-time (FT) and repeat (RPT) current (donating within 6 months before survey) and lapsed (donating >2 years prior) donors was conducted. The self-administered questionnaire included questions on personal, social, and behavioral characteristics. RESULTS: Among 1280 current and 1672 lapsed donors with valid addresses, the participation rate was 66.8 and 39.2 percent, respectively. In FT donors, the odds of lapsing increased with education (odds ratio [OR], 2.18; 95% confidence interval [CI], 1.34-3.55 for college or higher vs. Grade 12 or less education). Lapsed FT donors were more often asked to donate (OR, 1.89; 95% CI, 1.32-2.70) and had less interest in incentives (p < 0.001) than current FT donors. In RPT donors, lapsed status was associated with being younger (p < 0.001) and female (OR, 1.19; 95% CI, 1.00-1.42). Lapsed status was inversely associated with satisfaction with the last donation experience in both FT (p = 0.043) and RPT (p < 0.001) donors. Lapsed and current donors did not differ in perceived need for blood, personal transfusion experience, or mean reported altruistic behavior score. CONCLUSION: A positive donation experience appears to be a major determinant of donor return behavior. Lapsed donors do not appear, on average, to engage in fewer altruistic behaviors than currently active donors. Retention marketing strategies that appeal solely to altruistic values need to be further evaluated for their effectiveness.     

联合检测中性粒细胞与白蛋白比值和乳酸对脓毒性休克患者早期预后的评估价值

目的探讨中性粒细胞与白蛋白比值（NAR）和乳酸对脓毒性休克患者28 d死亡的预测价值。 方法回顾性分析2017年10月至2019年10月南京市第一医院ICU收治的118例脓毒性休克患者的临床资料,记录所有患者的年龄、性别、体质量指数（BMI）、急性病生理学和长期健康评价（APACHE）Ⅱ评分、序贯器官衰竭估计（SOFA）评分、C反应蛋白质（CRP）、降钙素原、NAR、白细胞计数、红细胞分布宽度（RDW）、乳酸、住ICU时间、机械通气时间、行连续肾脏替代疗法（CRRT）、肺部感染、腹腔感染、泌尿系感染、血行感染和28 d死亡情况。将上述因素纳入单因素Logistic回归分析,初步筛选出相关的影响因素,再纳入多因素Logistic回归分析,得到影响脓毒性休克患者28 d死亡的独立危险因素;采用受试者工作特征（ROC）曲线分析NAR、乳酸及两者联合对脓毒性休克患者28 d死亡的预测价值,并用Z检验比较曲线下面积（AUC）。 结果经单因素Logistic回归分析,初步筛选出影响脓毒性休克患者28 d死亡的9个因素,包括男性[比值比（OR）= 0.345,95%置信区间（CI）（0.603,3.357）,P = 0.004]、SOFA评分[OR = 1.183,95%CI（1.036,1.350）,P = 0.013]、NAR [OR = 2.849,95%CI（1.487,5.457）,P = 0.002]、乳酸[OR = 1.275,95%CI（1.108,1.467）,P = 0.001]、机械通气时间[OR = 0.254,95%CI（1.025,1.223）,P < 0.001]、行CRRT [OR = 4.585,95%CI（1.737,12.100）,P = 0.002]、存在肺部感染[OR = 0.282,95%CI（0.898,4.732）,P < 0.001]、存在腹腔感染[OR = 0.460,95%CI（0.392,1.989）,P = 0.002]、存在泌尿系感染[OR = 0.464,95%CI（0.201,2.195）,P < 0.001]。将上述影响因素纳入多因素Logistic回归分析,结果显示,NAR [OR = 4.424,95%CI（1.427,13.717）,P = 0.010]、乳酸[OR = 1.267,95%CI（1.008,1.594）,P = 0.043]、机械通气时间[OR = 1.168,95%CI（1.007,1.356）,P = 0.041]、行CRRT [OR = 5.148,95%CI（1.069,24.794）,P = 0.041]是脓毒性休克患者28 d死亡的独立危险因素。ROC曲线分析结果显示,NAR [AUC = 0.676,95%CI（0.572,0.780）,P = 0.001]、乳酸[AUC = 0.696,95%CI（0.592,0.800）,P < 0.001]及NAR和乳酸联合[AUC = 0.759,95%CI（0.699,0.850）,P < 0.001]均对脓毒性休克患者28 d死亡具有预测价值,且NAR和乳酸联合的AUC显著高于NAR（Z = 2.110,P = 0.035）及乳酸（Z = 1.991,P = 0.047）。 结论NAR和乳酸对脓毒性休克患者28 d死亡有一定的预测价值,且两者联合能够提高预测价值。     

早期预测新型冠状病毒肺炎患者病情严重程度列线图的建立及应用

目的建立早期预测新型冠状病毒肺炎患者病情严重程度的列线图,以指导临床治疗。 方法选择2020年1月17日至2020年2月14日温州市中心医院收治的116例新型冠状病毒肺炎患者,根据临床表现,将116例患者分为轻型组（4例）、普通型组（90例）、重型组（18例）和危重型组（4例）。记录所有患者的住院时间和并发症,比较4组患者的一般资料及临床指标。通过多因素Logistic回归分析得到影响新型冠状病毒肺炎患者预后的危险因素,并用R语言软件建立可视化的回归列线图,最后采用受试者工作特征（ROC）曲线检测该列线图的效能。 结果轻型组、普通型组、重型组和危重型组新型冠状病毒肺炎患者年龄[（39 ± 11）、（43 ± 12）、（53 ± 13）、（60 ± 8）岁,F = 5.815,P = 0.001]、C反应蛋白质[1.7（0.6,7.1）、7.9（2.9,21.6）、28.4（13.9,42.5）、61.7（44.7,79.8）mg/L,H = 8.424,P < 0.001]、红细胞比容[（36 ± 5）%、（41 ± 4）%、（39 ± 4）%、（37 ± 5）%,F = 4.344,P = 0.006]、血小板计数[318.0（251.0,409.0）× 10⁹/L、180.5（140.0,225.5）× 10⁹/L、162.0（130.0,222.8）× 10⁹/L、108.5（82.0,103.0）× 10⁹/L,H = 7.225,P < 0.001]、天冬氨酸氨基转移酶[16.0（15.5,19.5）、23.0（19.0,31.0）、34.5（26.3,55.0）、39.5（29.0,82.3）U/L,H = 6.159,P = 0.001]、白蛋白[（44 ± 6）、（43 ± 16）、（39 ± 3）、（33 ± 4）g/L,F = 9.508,P < 0.001]和乳酸脱氢酶[142.5（107.8,189.3）、198.0（159.5,238.0）、295.0（251.0,323.0）、369.5（295.2,436.3）U/L,H = 14.225,P < 0.001]水平比较,差异均有统计学意义。将年龄、C反应蛋白质、红细胞比容、血小板计数、天冬氨酸氨基转移酶、白蛋白和乳酸脱氢酶纳入多因素Logistic回归分析,结果显示,白蛋白[比值比（OR）= 0.756,95%置信区间（CI）（0.581,0.982）,P = 0.036]和乳酸脱氢酶[OR = 1.019,95%CI（1.007,1.032）,P = 0.002]为影响新型冠状病毒肺炎患者预后的危险因素。通过R语言软件得到可靠直观的列线图。ROC曲线分析结果显示,该列线图对重型及危重型患者[曲线下面积（AUC）= 0.903,95%CI（0.831,0.975）,P < 0.001]、单独预测危重型患者[AUC = 0.974,95%CI（0.932,1.000）,P < 0.001]、单独预测重型患者[AUC = 0.848,95%CI（0.759,0.937）,P < 0.001]均具有优秀的预测能力。 结论该列线图可以早期并有效预测新型冠状病毒肺炎患者严重程度,可能成为指导临床治疗的一项实用工具。