The Mayo Three-Community Hypertension Control Program. III. Outcome in a community-based hypertension clinic.

As part of a broader community program to evaluate approaches to hypertension control, a Community Hypertension Clinic, staffed by two nurse practitioners, was set up in a rural community. Hypertensive persons were identified either by an initial central blood pressure screening or by a subsequent home screening. Slightly more than half of the hypertensive patients at initial screening, or 256 persons, elected to go to the Community Hypertension Clinic for second-stage screening, whereas the remainder elected to see their physicians or to do neither. After secondary screening at the Clinic, 120 patients eventually came under care and were managed by the nurse practitioners. After 2 years of follow-up, 57% of the Clinic patients had office-recorded diastolic blood pressures of less than 90 mm Hg. The Community Hypertension Clinic dropout rate was only 5% after 30 months of operation, for participants whose duration of follow-up ranged from 12 to 27 months (median 16 months), when a repeat home blood pressure screening examination was performed. Comparison of outcomes was thus possible between persons who attended the Community Hypertension Clinic and those who were referred to their physicians' offices. Persons with more severe hypertension most often elected to go to the Clinic, whereas patients with milder degrees of hypertension tended to go to their private physicians for follow-up or failed to make the recommended second-stage screening contact altogether. Greater declines in blood pressure were observed in the Clinic group.     

The Mayo Three-Community Hypertension Control Program. I. Design and initial screening results.

The Mayo Three-Community Hypertension Control Program implemented graduated programs for the control of high blood pressure in three rural southeastern Minnesota communities, beginning in 1974. Prevalence of hypertension (when defined as diastolic blood pressure, at initial screening, of 95 mm Hg or more) was similar to that found for comparable groups by age and sex in the United States generally, but an atypically high frequency of known but untreated hypertension was found. Programs of public and professional information, systematic household screening, continuing professional education (two communities), and a new community hypertension clinic (one community) were initiated, and plans were made to evaluate the programs simultaneously by means of total rescreening of persons found to be hypertensive initially. The present report describes in detail the design of the program and the results of initial screening in relation to findings in other populations at the time. Subsequent reports assess the impact of each program on its target community and of a community hypertension clinic within the one setting where this component of a model program was established.     

围生期肺动脉高压的妊娠结局

目的:探讨围生期肺动脉高压患者的妊娠结局.方法:收集1996年1月至2009年12月我院产科收治的32例妊娠并肺动脉高压患者的临床资料,根据肺动脉压力情况分为轻度组19例(30～49 mm Hg),中度组7例(50～79 mm Hg)和重度组6例(≥80 mm Hg),分析三组病人心脏病种类、心功能级别、以及母儿结局.结果:(1)轻度组心功能Ⅰ、Ⅱ、Ⅲ级的病例数分别为13、4、2例,中度组心功能Ⅰ、Ⅱ、Ⅲ、Ⅳ级的病例数分别为1、3、1、2例,重度组心功能Ⅱ、Ⅲ、Ⅳ级的病例数均为2例.(2)32例患者中风湿性心脏病15例,先天性心脏病7例,其他10例.(3)32例中有1例孕产妇院内死亡,围产儿丢失率9%.(4)剖宫产分娩率为79%(25/32).结论:孕产妇并肺动脉高压心功能衰竭的发生率随肺动脉压力升高而增加,妊娠并风湿性心脏病患者中、重度肺动脉高压的发生率高于先天性心脏病患者;剖宫产是终止妊娠较安全的首选分娩方式.     

Pancreas transplantation at Mayo: II. Operative and perioperative management

Better perioperative and operative management techniques have contributed to an improvement in the success rate of pancreas transplantation. Because of a shortage of donor organs, the criteria for acceptability of the allograft have been liberalized, and the development of techniques such as combined liver and pancreas procurement has increased allograft availability. Major advances have been made in organ preservation. Currently, pancreas allografts can routinely be stored for 18 to 24 hours. The technique of pancreaticoduodenal transplantation with a duodenocystostomy for the exocrine drainage is widely used. Experience with anesthetic and intensive-care unit management of these patients is accumulating. With the evolution of pancreas transplantation and with the help of the excellent transplant centers in our area, we developed a pancreas transplantation protocol and performed transplantation based on this protocol in 16 recipients at the Mayo Clinic from October 1987 through December 1988.     

妊娠合并心脏病伴肺动脉高压患者的产科结局分析

【目的】分析妊娠合并心脏病伴肺动脉高压患者的产科结局,为临床诊治提供依据。【方法】回顾性分析10年来本院产科收治的妊娠合并心脏病伴肺动脉高压31例患者的临床资料,探讨母婴的产科结局。【结果131例孕妇中,死胎引产2例（6．5％）,妊娠中期医源性终止妊娠3例（9．7％）,余26例妊娠期满行剖宫产术（83．9％）。31例产妇死亡1例（3．2％）;16例（51．6％）产后转ICU,持续监护后康复;余14例产后较为稳定（45．2％）。31例孕妇死胎引产2例,余29例围产儿死亡6例,存活23例。孕妇肺动脉高压严重程度高者,产儿的死亡率越高（χ^2=12．314,P一0．002）。存活的23例胎产儿中,孕妇肺动脉高压程度轻者,产儿体重较高（t=2．516,P=0．019）;并且孕妇肺动脉高压程度轻者,早产率较低（χ^2=5．855,P=0．016）。【结论】妊娠合并肺动脉高压对母婴均有较高的风险,并且随肺动脉高压程度增加,风险增大;妊娠合并轻度肺动脉高压经积极处理,仍有望获得满意的产科结局。     

Cost-effectiveness of the North Karelia Hypertension Program. 1972-1977

The North Karelia Hypertension Program was initiated in 1972 as part of the North Karelia Project. This article examines the costs and effects of the first 5 years of the project. There were 288 fewer than expected fatal strokes and myocardial infarctions during the period; 134 of these are attributable to the hypertension program. The costs of the hypertension program totalled $5.16 million. Drugs consumed 86% of this cost. Using the zero discount rate as an outside boundary, the program is expected to increase old age pension costs by $2.5 million for the 5 years but will decrease earnings losses by $7 million for the same period. With earnings excluded, the cost per quality-adjusted life-year gained is $3,612 at zero discount and $5,830 at 10% discount. Hypertension care is more cost-effective than many of the treatments applied after the appearance of coronary heart disease symptoms but would be much more cost-effective if hypertension could be treated as effectively without medications or if the costs of medications could be reduced.     

The Calgary Conjoint Nursing Program. Part II: Successful political action.

When three calgary institutions decided to develop a collaborative nursing program to prepare for the transition to baccalaureate nursing education by the year 2000, the planners found that they had to overcome a broad range of political and institutional hurdles. Faculty from Mount Royal College, Foothills Hospital School of Nursing and the University of Calgary spent six years developing the curriculum and planning for the implementation of the Calgary Conjoint Nursing Program (CCNP). (See The Calgary Conjoint Nursing Program, Part I: Spirit of Collaboration, in the March 1999 issue of this journal.)     

社区新婚夫妻间乙型肝炎病毒传播的干预方法

目的探讨社区新婚夫妻间乙型肝炎病毒传播的干预方法.方法选择社区192对新婚夫妻查体中发现的一方为乙型肝炎病毒携带者,实施有关乙型肝炎病毒夫妻间传播的干预方法：114例乙肝标志物检查（HBV-M）全阴的配偶注射基因工程乙肝疫苗（HBVV）,其中18例注射乙肝疫苗前15d先注射乙肝高效价免疫球蛋白（HBIG）2次,200μg/次;其余78例未采用任何预防措施.2年后检测所有被观察者的血清乙肝标志物检查结果.结果114例正规接种基因工程乙肝疫苗的乙型肝炎病毒感染者的配偶的感染率为2.1%,比未接种者的感染率（11.5%）有明显降低,18例同时注射HBIG者之中没有检测到HBV新发感染者的存在.3组乙型肝炎病毒感染率经行乘列χ^2检验有显著性差异,P＜0.05.结论及时接种基因工程乙肝疫苗和乙肝高效价免疫球蛋白能有效预防乙型肝炎病毒在夫妻间的传播.     

The University Hospital Nurse Extender Model. Part II, Program implementation

This second article in a four-part series provides a detailed discussion of each phase of the implementation process, along with a demographic summary of the University Hospital Patient Care Technicians' Program 2 years after program implementation. Part I provided the overview and conceptual framework for the model. Parts III and IV will present the results of a year-long evaluation of the model and the lessons learned during the implementation process.     

Dyslipidemia in type II diabetes. Implications for therapeutic intervention.

Cardiovascular disease, and in particular ischemic heart disease, is the principal cause of morbidity, functional disability, and mortality in patients with non-insulin-dependent (type II) diabetes. The main risk factors for the macrovascular complications of diabetes are dyslipidemia, hypertension, and cigarette smoking. Although degree of hyperglycemia is a risk factor for microvascular complications, it is not a prominent risk factor for macrovascular complications. Nevertheless, there are theoretical reasons for believing that glycemic control could lower cardiovascular risk. For example, glycemic control may both improve clearance and suppress hepatic overproduction of very-low-density lipoprotein. Moreover, there is direct empirical evidence that improved glycemic control can favorably alter lipid profiles in type II diabetic patients. Despite this, the only clinical trial that has assessed cardiovascular mortality as an end point in diabetic subjects (i.e., the University Group Diabetes Program) failed to demonstrate a benefit of glycemic control. In this study, the insulin-variable group, which achieved sustained glycemic control relative to the placebo group, had essentially the same cardiovascular mortality as the latter group. All of the conventional lipid-lowering agents have been shown to produce favorable changes in lipid profiles in diabetic subjects. However, the optimum regimen remains to be defined. Metabolic differences between diabetic and nondiabetic subjects mean that the optimum lipid-lowering regimens for the two categories of patients may differ. For example, nicotinic acid, which is a powerful lipid-altering drug, may worsen glucose intolerance. The characteristic lipid abnormalities in type II diabetic subjects are hypertriglyceridemia and low high-density lipoprotein cholesterol, not hypercholesterolemia. Although the role of hypertriglyceridemia as a cardiovascular risk factor in the general population has been questioned, there is evidence that this lipid abnormality may play a stronger role in diabetic subjects. For all of the above reasons, there is an urgent need for large-scale clinical trials assessing cardiovascular end points and testing various strategies of improving lipid profiles in diabetic subjects, particularly given the fact that all of the current generation of lipid-lowering trials have systematically excluded diabetic patients.     

A Stochastic Control Program to Predict Outcome and to Support Therapeutic Decisions: A Preliminery Report

Background and Objectives. Early noninvasive hemodynamic monitoring with an outcome predictor and a therapeutic decision support system may be useful to identify and correct hemodynamic deficiencies in emergency patients. The first aim was to apply a stochastic (probability) search and display model to predict outcome as early as possible. The second aim was to explore the usefulness of a therapeutic decision support system to evaluate the relative effectiveness of various therapies. Methods. A stochastic control and display program based on noninvasive hemodynamic monitoring was applied in 100 consecutive critically ill patients admitted to the emergency department of an inner city public hospital. The program continuously displayed the noninvasive hemodynamic data and the patient's predicted survival probability (SP) that was based on the patient's diagnosis, covariates, and hemodynamic data. The accuracy of the SP at the initial resuscitation on admission to the emergency department (ED) was evaluated by the actual outcome at hospital discharge. The therapeutic decision support program evaluated the relative effectiveness of various therapies on based on their hemodynamic and SP responses and outcome of patients with similar clinical-hemodynamic states. Results. The cardiac index, mean arterial pressure, arterial saturation, transcutaneous oxygen and carbon dioxide tensions were appreciably higher in survivors than in nonsurvivors in the initial resuscitation. Heart rate was higher in the nonsurvivors. The calculated Survival Probability (SP) of survivors averaged 81 ± 1.4% in the first 24-hour observation period. It was 58 ± 2.2% for nonsurvivors during this period. Misclassifications were 10/100 or 10%. The content of the information does not necessarily reflect the position or policy of the Government, and no official endorsement should be inferred.     

Program for managing chronic pain. II. Short-term results.

A program for treating inpatients who had chronic pain resulted in significant improvement in 79% of them by the time of their dismissal. At the time of short-term follow-up (6 months), however, this improvement rate had diminished to 50%. It was observed that this type of chronically disabled person can return home and increase work-related activity without returning to previous patterns of drug use and repeated hospitalizations.     

The Adrenal Receptor for Angiotensin II is Altered in Essential Hypertension

To determine the mechanism underlying altered adrenal responsiveness in patients with essential hypertension, the renin-angiotensin-aldosterone axis was assessed in normotensive and hypertensive subjects using three pharmacological probes: SQ 20881, a converting enzyme inhibitor; saralasin, a competitive angiotensin antagonist with prominent agonist properties; and angiotensin itself. All subjects were studied while supine and in balance on a 10 meq Na/100 meq K intake. The decrement in plasma aldosterone with SQ 20881 in 26 hypertensive subjects (15+/-3 ng/dl) was normal (13+/-4 ng/dl), suggesting that the altered adrenal responsiveness in hypertensives is not because of a change in a postreceptor event or in the relative contribution of angiotensin to the control of aldosterone secretion.Saralasin at a dose (0.1 mug/kg per min) that reduced aldosterone levels in all normals produced a normal aldosterone decrement (14+/-3 ng/dl) in 19 patients with renovascular hypertension (12+/-4 ng/dl). The same dose, however, had no net effect on plasma aldosterone levels in 70 patients with normal or high renin essential hypertension (-1+/-1 ng/dl) despite identical metabolic balance and control renin and angiotensin levels. The altered response could be explained by an agonist effect, aldosterone rising in 45 of the essential hypertensives. There were no significant differences between normal and abnormal responders in pre- and postcortisol, -potassium, -renin and -angiotensin concentrations.Angiotensin was infused (0.1-3 ng/kg per min) in 15 patients with normal renin essential hypertension, previously studied with saralasin. A probit transformation defined the dose required to induce a 50% increase in aldosterone (ED50). In the patients in whom aldosterone rose with saralasin, the dose required to induce a 50% increase was significantly greater (P < 0.001) than in those in whom aldosterone fell normally (1.02+/-0.06 [SD] vs. 0.38+/-0.07 ng/kg per min). Vascular responses were similar in the various groups. We conclude that altered adrenal responsiveness to angiotensin in some essential hypertensive patients is secondary to a change in the interaction of angiotensin with its adrenal receptor.     

系统化全程护理干预对食管癌患者术后生活质量的影响

目的 探讨系统化全程护理干预对食管癌患者术后生活质量的影响.方法 选择我院胸外科行食管癌手术患者106例,按随机化原则分为对照组52例和干预组54例.对照组采取常规的治疗和护理;干预组在常规的治疗和护理基础上,加强心理指导、完善健康宣教、加强营养指导、出院后随访等全程化护理干预的方法 .观察对比两组患者焦虑抑郁水平、生活质量评分有无差异性.结果 经统计学处理,结果 发现两组患者焦虑抑郁水平、生活质量评分均有显著性差异(P<0.01,P<0.05).结论 临床结果 表明,对食道癌患者手术后进行加强心理指导、完善健康宣教、加强营养指导、出院后随访等系统化全程护理干预的方法 ,从心理、社会、疾病等多个方面,进行多元化、预见性护理,可以减轻食道癌患者手术后的负性心理状态,从心理和生理两方面促进患者的康复,提高患者的生活质量,对患者的生命意义具有积极的促进作用.可取得较好的经济效益和社会效益,值得临床推广应用.