基于决策树的肿瘤患者难免性压疮风险预测模型研究

目的评价决策树预测肿瘤患者难免性压疮风险的准确性与合理性,为压疮预防提供依据。方法收集Braden评分高风险肿瘤患者611例的临床病例资料,采用CHAID算法构建肿瘤患者难免性压疮风险预测的决策树模型,并通过ROC曲线下面积、灵敏度和特异度指标比较其与Braden评分的预测效果。结果 46例发生难免性压疮,发生率为7.53%。决策树模型包含3层共11个节点,提取6条分类规则,筛选出4类高危人群,即Braden评分≤11分,翻身计划无法落实;Braden评分11分,皮肤有现存或潜在损伤;Braden评分≤11分,翻身计划可以落实,但存在增加压疮发生风险的特殊情况;Braden评分11分,皮肤没有现存或潜在损伤,但翻身计划无法落实。决策树模型ROC曲线下面积为0.840;决策树模型的灵敏度为0.848、特异度为0.774。结论决策树模型ROC曲线下面积、灵敏度及特异度均较好,可以用于肿瘤患者难免性压疮高危人群的筛选和管理。     

神经外科术后恶心呕吐预测模型的构建与评价

目的 探讨神经外科患者发生术后恶心呕吐的高危因素,构建预测模型,并评价其效果.方法 收集326例神经外科全麻择期手术成人患者的临床病例资料,根据术后24 h是否发生恶心呕吐分为发生组和未发生组,比较两组高危因素,通过Logistic回归分析结果建立预测模型,采用ROC曲线下面积评价该模型的预测效果.结果 神经外科患者术...     

EuroSCORE和SinoSCORE在预测成人心脏病术后死亡率中的应用回顾和展望

随着现心血管外科中高危病人的比例明显增加。心血管外科医师需要量化的评估体系对患者围手术期危险性进行术前评估。目前国际影响较大的风险预测模型是欧洲心血管手术危险因素评分系统（European system for cardiac operative risk evaluation,EuroSCORE）。中国心血管外科注册登记研究的数据表明,EuroSCORE不能很好地预测我国心血管外科患者的手术风险。因此,中国心血管外科注册登记研究协作组应用最新的心血管外科病例数据建立我国首个冠状动脉旁路移植手术风险评估系统（Sinosystem for coronary operative risk evaluation,SinoSCORE）,目前正广泛应用于临床。我们结合文献对EuroSCORE和 SinoSCORE两个指标在预测成人心脏病术后死亡率中的应用进行回顾和展望。     

心血管疾病患者静脉留置针穿刺点渗血风险评估研究

目的探讨心血管疾病患者静脉留置针相关渗血的影响因素,并建立风险预测模型,为渗血预测及预防提供依据。方法采用前瞻性队列研究设计,纳入采用静脉留置针输液治疗的心血管疾病患者301例,根据是否发生留置针相关渗血事件分为对照组和渗血组。采用Logistic回归分析筛选渗血的影响因素,并建立回归方程模型。在143例心血管疾病患者中验证模型预测价值。结果心血管疾病患者留置针相关渗血发生率为51.5%。年龄≥65岁、血管条件Ⅱ～Ⅲ级、置管侧肢体频繁测血压、凝血异常为渗血的危险因素,软管外留为保护因素(P0.05,P0.01)。以Logistic回归分析结果构建回归方程,该方程预测渗血事件的ROC曲线下面积为0.815(95%CI 0.741～0.888,P0.01),预测一致率为73.4%。结论心血管疾病患者使用静脉留置针存在高危渗血风险,以年龄、血管条件、凝血功能、置管侧肢体频繁测血压及软管外留构建的回归方程对预测留置针渗血事件有较高的准确性。     

慢性阻塞性肺疾病稳定期患者吸入装置使用不依从风险预测模型的建立与验证

目的 建立和验证慢性阻塞性肺疾病（COPD）稳定期患者吸入装置使用不依从风险预测列线图模型，为筛选高危人群、减少吸入装置使用不依从提供参考。方法 采用方便取样法，收集215例COPD稳定期患者人口学、疾病和治疗相关资料，并评估其吸入装置使用依从性。应用Lasso回归模型筛选预测因子,构建风险预测模型，采用R软件生成风险预测列线图。分别采用C-index、校正曲线和决策曲线分析模型的预测能力、预测值与实际观测值之间的一致性以及临床应用价值，通过ROC曲线下面积对模型进行内部验证。结果 215例患者中，117例（54.4%）吸入装置使用不依从。性别、文化程度、病程、急性加重次数、住院史和mMRC分级6个因子构成风险预测模型。模型C-index为0.842，校正曲线表现出良好的一致性。决策曲线表明阈值概率超过21%时模型的净获益更高。内部验证得到ROC曲线下面积为0.824。结论 COPD稳定期患者吸入装置使用不依从发生率较高；性别、文化程度、病程、急性加重次数、住院史和mMRC分级构成的列线图模型可较好地预测COPD稳定期患者吸入装置使用的不依从风险，为临床筛查高危患者提供评估工具。     

ICU患者肠内营养相关性腹泻列线图预测模型构建

目的 建立ICU患者肠内营养相关性腹泻风险预测模型，为预防性护理干预提供依据。方法 回顾分析335例ICU行肠内营养治疗的患者资料，采用单因素和多因素logistic分析肠内营养相关性腹泻的独立危险因素，构建风险预测模型，用列线图展示预测模型。采用Bootstrap法进行内部验证，受试者工作特征(ROC)曲线评价模型区分度，采用校准曲线评价模型准确度，采用临床决策曲线(DCA)评价模型的有效性。结果 163例(48.66%)ICU患者发生肠内营养相关性腹泻。肠内营养相关性腹泻风险预测模型纳入APACHE-Ⅱ评分、口服钾制剂时间、使用胃肠动力药、禁食时间和白蛋白水平5个预测因子。预测模型的ROC曲线下面积为0.940,灵敏度为81.82%,特异度为91.18%,准确度为86.57%,最大Youden指数0.73所对应的预测临界值为122分。校准曲线为斜率接近于1的直线，准确度良好。临床决策曲线显示模型的净获益值较高。结论 该模型可以有效预测ICU患者肠内营养相关性腹泻的发生，且评价指标在开始行肠内营养时即可获得，可为ICU医护人员及时采取预防性护理干预提供借鉴。     

Munro与Braden压疮评估表用于手术患者压疮评估预测效度比较

目的比较Munro与Braden评估表预测手术患者压疮的效果。方法 2名护士分别应用2种评估表,同时、独立、连续地于术前、手术结束、术后返回病房2h内对111例外科手术患者进行压疮风险评估,另1名护士在手术结束、返回病房交接、术后24h、48h、72h评估压疮发生情况并记录,计算ROC曲线下面积、灵敏度和特异度。结果手术结束11例发生压疮(9.9%),术后24h内共有4例压疮患者,其中2例新发(1.8%);Munro评估表术前、中、后的ROC曲线下面积分别为0.850、0.889、0.864,高于Braden评估表(0.727、0.724、0.600);术前、中、后Braden评估表最佳临界值分别为19分、13分、14分,灵敏度分别为0.545、0.909、0.250,特异度0.700、0.350、0.916;术前、中、后Munro评估表最佳临界值为9分、22分、29分,灵敏度分别为0.818、0.909、0.750,特异度为0.610、0.730、0.822。结论 Munro评估表评估压疮更具有针对性,对手术压疮诊断价值高于Braden评估表,但在使用过程中需要与其他医务人员配合,且个别评估指标不是常规监测项目,增加了护理工作量,需进一步研究和加以完善。     

ICU患者外周动脉导管非计划性拔管风险预测模型的构建及验证

目的 构建并验证ICU患者外周动脉导管非计划性拔管的风险预测模型。方法 选择300例(建模组)ICU留置外周动脉导管患者作为研究对象,回顾性收集患者相关资料,采用单因素分析、logistic回归分析筛选非计划性拔管的危险因素,构建风险预测模型。选择117例ICU留置外周动脉导管患者对风险预测模型进行验证。结果 建模组23.00%患者发生非计划性拔管。年龄≥65岁,并存高血压、静脉血栓栓塞症,置入部位为桡动脉及置入导管为静脉留置针是ICU患者外周动脉导管非计划性拔管的高危因素（均P<0.05）。预测模型的ROC曲线下面积为0.888。模型验证结果显示,ROC曲线下面积为0.903,灵敏度为86.2%,特异度为85.2%,约登指数为0.714。结论 构建的ICU患者外周动脉导管非计划性拔管的风险预测模型预测效果良好,可为医护人员及时采取预防性护理措施提供依据。     

全麻苏醒期患儿躁动风险预测模型的建立与验证

目的 建立与验证全麻苏醒期患儿躁动风险列线图预测模型,为识别躁动高风险患儿提供评估工具。方法 收集全麻手术的1～6岁患儿651例,随机分为建模组(n=459)和验证组(n=192),利用多因素logistic回归分析确定建模组全麻苏醒期患儿躁动的危险因素,构建列线图预测模型,分别使用建模组和验证组数据集对模型进行验证。结果 苏醒期发生躁动160例(建模组113例,验证组47例),躁动发生率24.58%。多因素logistic回归显示,年龄、手术科室、身体约束、麻醉方式、镇痛治疗、留置尿管是全麻苏醒期患儿躁动的影响因素(均P<0.05)。基于6个危险因素构建列线图预测模型,模型验证的校正曲线显示模型准确度良好,建模组ROC曲线下面积为0.767,验证组为0.827。结论 全麻苏醒期患儿躁动风险列线图预测模型具有良好的准确度和区分度,可为临床筛查术后躁动高危患儿提供评估工具。     

基于Meta分析构建ICU获得性衰弱风险预测模型

目的 构建并验证ICU获得性衰弱风险预测模型，为早期筛查ICU获得性衰弱危险人群提供有效工具。方法 Meta分析ICU获得性衰弱的危险因素，以各危险因素的综合危险度的自然对数为模型的β系数，以某时段ICU获得性衰弱发病率与未发病率比值的自然对数为模型的α系数，建立预测模型。收集137例ICU患者资料，分析模型的预测性能。结果 ICU获得性衰弱预测模型为logit(P)=-0.781+0.039年龄+0.077APACHE+0.940休克+0.122机械通气时长+0.971脓毒血症+0.756神经肌肉阻滞剂+1.311血管活性药物+1.308皮质类固醇+0.747性别+0.626高血糖+1.973肾脏替代治疗；模型ROC曲线下面积为0.752,95%CI(0.672,0.833),概率P函数的临界值为0.998,敏感度为0.930,特异度为0.489。结论 基于Meta分析建立的ICU获得性衰弱风险预测模型可作为早期预测ICU获得性衰弱危险人群的工具。     

A comparison of four risk models for the prediction of cardiovascular complications in patients with a history of atrial fibrillation undergoing non-cardiac surgery

It is unclear how best to predict peri-operative cardiovascular risk in patients with atrial fibrillation undergoing non-cardiac surgery. This study examined the accuracy of the revised cardiac risk index and three atrial fibrillation thrombo-embolic risk models for predicting 30-day cardiovascular events after non-cardiac surgery in patients with a pre-operative history of atrial fibrillation. We conducted a prospective cohort study in 28 centres from 2007 to 2013 of 40,004 patients ≥ 45 years of age undergoing inpatient non-cardiac surgery who were followed until 30 days after surgery for cardiovascular events (defined as myocardial injury, heart failure, stroke, resuscitated cardiac arrest or cardiovascular death). The 2088 patients with a pre-operative history of atrial fibrillation were at higher risk of peri-operative cardiovascular events compared with the 34,830 patients without a history of atrial fibrillation (29% vs. 13%, respectively, adjusted odds ratio 1.30 (95%CI 1.17–1.45). Compared with the revised cardiac risk index (c-index 0.60), all atrial fibrillation thrombo-embolic risk scores were significantly better at predicting peri-operative cardiovascular events: CHADS₂ (c-index 0.62); CHA₂DS₂-VASc (c-index 0.63); and R₂CHADS₂ (c-index 0.65), respectively. Although the three thrombo-embolic risk prediction models were significantly better than the revised cardiac risk index for prediction of peri-operative cardiovascular events, none of the four models exhibited strong discrimination metrics. There remains a need to develop a better peri-operative risk prediction model.     

A prospective study of mortality associated with anaesthesia and surgery: risk indicators of mortality in hospital

The aims of this study were to: 1) determine the incidences and causes of mortality associated with anaesthesia and surgery, 2) identify important factors associated with mortality in hospital, and 3) estimate the mortality risk associated with anaesthesia and surgery when a combination of risk factors are present. A total of 7306 anaesthetized patients undergoing abdominal, urological, gynaecological, or orthopaedic surgery were included in the study. Of these, 0.05% (1:1800) died during anaesthesia, 0.1% (1:730) during the recovery period, and the overall mortality rate in hospital was 1.2% (1:81). Most deaths occurred in the elderly (greater than or equal to 70 years of age) and were unavoidable due to progression of the presenting condition, such as advanced cancer, or co-existing diseases such as cardiopulmonary or renal failure. Of the patients who developed myocardial infarction (MI) following anaesthesia, 67% (8/12) died in the postoperative period. Half of the MI patients who died received regional anaesthesia, and in addition suffered from periods of cardiovascular dysfunction intraoperatively. By utilizing logistic regression analysis, a model for prediction of mortality risk was developed. The model included five significant preoperative predictive variables: age; patients with history of chronic heart disease, and renal disease; emergency surgery; and the type of operation. With this model it is possible to distinguish between patients with very different mortality risks.     

A prediction tool for hospital‐acquired pressure ulcers among surgical patients: Surgical pressure ulcer risk score

Surgical patients are prone to developing hospital‐acquired pressure ulcers (HAPU). Therefore, a better prediction tool is needed to predict risk using preoperative data. This study aimed to determine, from previously published HAPU risk factors, which factors are significant among our surgical population and to develop a prediction tool that identifies pressure ulcer risk before the operation. A literature review was first performed to elicit all the published HAPU risk factors before conducting a retrospective case‐control study using medical records. The known HAPU risks were compared between patients with HAPU and without HAPU who underwent operations during the same period (July 2015‐December 2016). A total of 80 HAPU cases and 189 controls were analysed. Multivariate logistic regression analyses identified eight significant risk factors: age ≥ 75 years, female gender, American Society of Anaesthesiologists ≥ 3, body mass index < 23, preoperative Braden score ≤ 14, anaemia, respiratory disease, and hypertension. The model had bootstrap‐corrected c‐statistic 0.78 indicating good discrimination. A cut‐off score of ≥6 is strongly predictive, with a positive predictive value of 73.2% (confidence interval [CI]: 59.7%‐84.2%) and a negative predictive value of 80.7% (CI: 74.3%‐86.1%). SPURS contributes to the preoperative identification of pressure ulcer risk that could help nurses implement preventive measures earlier.     

Recurrent peptic ulcer after surgery in Japan--a nationwide questionnaire survey of 57 institutions]

Patients with recurrent peptic ulcer undergoing surgery were reviewed at 57 institutions by the 18th meeting of the Japanese Research Society of Gastric Surgery. The factors involved in recurrence was analyzed in patients fulfilling the following criteria: the minimum follow-up period was over 5 years, the age was over 15 years, tetragastrin-stimulated acid secretion was measured before surgery, and the recurrence was confirmed by endoscopy or upper gastrointestinal radiography. In 632 patients, the recurrence rate of duodenal ulcer was significantly higher than that of gastric ulcer. However, the duodenal ulcer patients undergoing selective vagotomy and antrectomy did not develop recurrence. A significant difference in the recurrence rate was observed between selective vagotomy and antrectomy and the wide gastrectomy or selective proximal vagotomy. By analysis using the Cox proportional hazard model, the risk factors for recurrence of duodenal ulcer were the ulcer stage, the operative procedure, the location of the ulcer, and the age of the patient. Especially, recurrences in patients receiving selective proximal vagotomy depended on the location of the ulcer and the age, but the risk factors for patients undergoing wide gastrectomy were uncertain.     

Medical device related pressure ulcers in hospitalized patients

Most pressure ulcers occur over bony prominences such as heels and the sacrum. However, the National Pressure Ulcer Advisory Panel recognises that pressure ulcers can also occur on any tissue under pressure and thereby can develop beneath medical devices. This article reports on results from a secondary analysis of existing data collected by The Nebraska Medical Center on pressure ulcer quality improvement initiatives and outcomes. The purpose of this study was to quantify the extent of the problem and identify risk factors for medical device related (MDR) pressure ulcer development in hospitalised patients. A subset of data collected during eight quarterly pressure ulcer incidence and prevalence studies (N = 2178) was created and analysed. The overall rate of hospital‐acquired pressure ulcers was 5·4% (113 of 2079). The proportion of patients with hospital‐acquired ulcers related to medical devices was 34·5% (39 of 113). Findings indicate that if a patient had a medical device, they were 2·4 times more likely to develop a pressure ulcer of any kind. Numerous risk factors for pressure ulcer development were identified; however, none differentiated between those with MDR and traditional pressure ulcers.     

The Frank Stinchfield Award. Sudden death during primary hip arthroplasty

The records of 23 patients who died intraoperatively during hip arthroplasty at the authors' institution were reviewed. Of the 38,488 hip arthroplasties in 29,431 patients performed between 1969 and 1997, there were 23 deaths during surgery. There were 15 women and eight men with a mean age of 80.9 years. Preoperative diagnoses were acute hip fracture (13 patients), pathologic fracture (four patients), femoral neck nonunion (one patient), osteoarthritis (four patients), and rheumatoid arthritis (one patient). Eleven patients undergoing cemented total hip arthroplasty died and 12 patients undergoing cemented hemiarthroplasty died. All deaths occurred because of irreversible cardiorespiratory disturbances that were initiated during cementing. There were no deaths among 12,551 patients receiving 15,411 uncemented hip arthroplasties during the 28-year period under review. Autopsy was performed in 13 patients. Bone marrow microemboli were seen in the lungs of 11 of 13 patients in whom an autopsy was performed and methylmethacrylate particles were seen in the lungs of three of 13 patients. These data suggest that elderly patients with preexisting cardiovascular conditions undergoing cemented arthroplasty, especially for fracture diagnosis, are at increased risk for intraoperative death compared with patients undergoing elective hip arthroplasty. In the latter years of the current study, modifications of the operative techniques designed to minimize intramedullary hypertension were associated with a reduction greater than three-fold in overall intraoperative mortality rate. These changes in surgical technique should be considered when cement fixation is used in patients thought to be at risk for having cardiopulmonary disturbances develop from venous embolization of marrow contents.     

Risk factors and the potential of nomogram for predicting hospital‐acquired pressure injuries

This 1:5 case‐control study aimed to identify the risk factors of hospital‐acquired pressure injuries (HAPIs) and to develop a mathematical model of nomogram for the risk prediction of HAPIs. Data for 370 patients with HAPIs and 1971 patients without HAPIs were extracted from the adverse events and the electronic medical systems. They were randomly divided into two sets: training (n = 1951) and validation (n = 390). Significant risk factors were identified by univariate and multivariate analyses in the training set, followed by a nomogram constructed. Age, independent movement, sensory perception and response, moisture, perfusion, use of medical devices, compulsive position, hypoalbuminaemia, an existing pressure injury or scarring from a previous pressure injury, and surgery sufferings were considered significant risk factors and were included to construct a nomogram. In both of the training and validation sets, the areas of 0.90 under the receiver operating characteristic curves showed excellent discrimination of the nomogram; calibration plots demonstrated a good consistency between the observed probability and the nomogram's prediction; decision curve analyses exhibited preferable net benefit along with the threshold probability in the nomogram. The excellent performance of the nomogram makes it a convenient and reliable tool for the risk prediction of HAPIs.