重症脑卒中并发应激性溃疡出血采用早期胃肠道营养联合雷尼替丁预防

目的观察重症脑卒中患者并发临床应激性溃疡使用早期胃肠道营养联合雷尼替丁预防的临床效果。方法选取2017年8月至2018年8月经青海大学附属医院确诊为脑卒中的患者120例,随机分为对照组和观察组各60例;两组患者联合治疗前均采用临床常规治疗,观察组在常规基础治疗上使用雷尼替丁治疗联合早期胃肠道干预,对照组在常规治疗上加以早期胃肠道干预;观察并比较两组治疗后临床并发症等情况。检测两组第1～2次胃镜检查的生长抑制素(SS)、胃泌素(GAS)、前列腺素(PGE)-2及1 w后胃酸强度等指标。结果观察组治疗1 w后胃酸pH及夜间胃内pH等指标均显著优于对照组(P0.05);观察组与对照组胃镜第1次检查PGE-2、GAS及SS明显低于第2次检查(P0.05),但观察组PGE-2及GAS第1次检查明显优于对照组。观察组应激性溃疡出血率明显优于对照组;对照组病死率明显高于观察组(P0.05);观察组出血时间明显高于对照组(P0.05),但对照组住院天数明显短于观察组(P0.05)。观察组头痛、失眠及肝肾功能异常等指标明显低于对照组(P0.05)。结论早期胃肠营养联合雷尼替丁治疗重症脑卒中并发应激溃疡性出血具有显著疗效,降低了临床并发症发生率。     

早期肠内营养预防脑出血术后应激性溃疡的临床研究

目的探讨早期肠内营养对脑出血术后应激性溃疡的预防作用。方法将108例脑出血术后昏迷患者随机分为早期肠内营养组(EEN组)和延迟肠内营养组(DEN组),各54例。EEN组患者在脑出血术后24 h内给予肠内营养,DEN组患者72 h内给予静脉营养,72 h后无消化道出血方给予肠内营养,观察并比较两组患者应激性溃疡的发生率。结果 EEN组应激性溃疡的发生率低于DEN组(P0.05)。结论对脑出血术后昏迷患者给予早期肠内营养可减少应激性溃疡的发生,改善疾病预后。     

大面积烧伤并发应激性溃疡出血患者行早期胃肠营养的预防作用

目的探讨早期胃肠营养预防大面积烧伤并发应激性溃疡出血的临床疗效。方法将102例大面积烧伤患者随机分为两组,每组51例。对照组给予抑酸药物埃索美拉唑治疗,观察组在使用埃索美拉唑治疗的基础上给予早期胃肠营养支持,对比两组治疗前后胃液p H值的变化情况、应激性溃疡出血发生率等。结果治疗后第4天、第7天观察组胃液p H值高于对照组(P0.05);观察组应激性溃疡出血发生率为11.8%,远低于对照组的27.5%,差异显著(P0.05)。结论对大面积烧伤患者行早期胃肠营养支持可对其胃肠道黏膜起到一定保护作用,能有效预防应激性溃疡出血的发生,对改善患者预后,提高其生活质量具有重要意义。     

法莫替丁预防急性心肌梗死后应激性溃疡出血

目的 观察法莫替丁对急性心肌梗死后应激性溃疡出血的预防作用。方法 65例急性心肌梗死患者随机分为两组，基础治疗相同。治疗组34例，加用法莫替丁20mg入壶，一日两次，持续5－7天。对照组31例，未用法莫替丁。结果 治疗组34例中未发生应激性溃疡出血，对照组31例中5例发生应激性溃疡出血，统计学处理有显著差异（X^2=3.91,P＜0．05）。结论 法莫替丁能预防急性心肌梗死后应激性溃疡出血。     

急性脑卒中并发应激性溃疡危险因素分析

目的 分析急性脑卒中患者发生应激性溃疡的危险因素,指导临床更好地预防及治疗急性脑卒中并发应激性溃疡。方法采用回顾性分析的方法,建立《急性脑卒中后应激性溃疡的高危因素调查量表》,收集2200例急性脑卒中患者的住院病史,根据量表内容进行多因素分析。结果本研究最后有效病例2034例,并发应激性溃疡126例,发生率为6．21％。男性脑卒中并发应激性溃疡发生率明显高于女性,〉60岁患者脑卒中并发应激性溃疡发生率高于≤60岁患者,脑出血并发应激性溃疡发生率明显高于脑梗死和蛛网膜下腔出血,GCS评分5—3分患者脑卒中并发应激性溃疡发生率高于10-6分和15～11分患者,预防性使用阿司匹林〉90d患者脑卒中并发应激性溃疡发生率高于≤90d患者,差异均有统计学意义（P〈0．05）。主要影响脑卒中并发应激性溃疡的因素为：男性、年龄〉60岁、病变性质为脑出血、病变位于脑干或小脑、预防应用小剂量阿司匹林≤90d。结论急性脑卒中出现消化道出血临床症状的高危因素包括：年龄〉60岁、男性、0CS评分〈5分、病变位于脑干及小脑、高血压脑出血、病前曾使用小剂量阿司匹林预防用药。     

脑卒中应激性溃疡的治疗及预防

应激性溃疡（stress ulcer,SU）是指机体在各类严重创伤、危重疾病或严重心理应激状态下所引起的食管、胃或十二指肠等部位急性糜烂、溃疡．可并发消化道出血、穿孔,使原有病变恶化,现多以更为合理的应激性黏膜病变（stress-related mucosal disease,SRMD）命名。脑卒中急性期。应激性溃疡是一种严重并发症,是脑卒中早期死亡的主要原因之一,这在脑出血比脑梗死更常见。近期研究发现,高血压性脑出血急性期并发应激性溃疡出血高达14％～76％,致使其病死率高达78．6％。     

早期肠内营养对预防COPD机械通气患者应激性溃疡的效果观察

目的探讨早期肠内营养对预防COPD机械通气患者应激性溃疡出血的临床效果。方法 72例COPD机械通气患者随机分成实验组（早期肠内营养组）和对照组（肠外营养组）,每组36例。实验组机械通气24 h内即行肠内营养支持;对照组早期给予全胃肠外营养,7 d后再逐渐过度至肠内营养。比较两组患者的消化道出血及胃液pH值变化情况。结果实验组上消化道出血发生率明显少于对照组（P〈0.05）,两组患者胃液pH值在营养支持第1天时无显著性差异,第3天、5及7天实验组胃液pH值均显著高于对照组（P〈0.05）。结论早期肠内营养可中和患者的胃酸,升高胃液pH值,能有效预防COPD机械通气患者应激性溃疡的发生。     

早期干预脑卒中后情感障碍对患者预后的影响

脑卒中患者情感障碍的发生率较高 ,据报道抑郁状态发生率为 2 0 %～ 6 0 %,焦虑为 19%～ 40 %。我们对 2 42例急性脑卒中早期出现情感障碍患者采取干预措施并观察其预后。现报告如下。资料与方法 :本组男 134例 ,女 10 8例 ;平均年龄 (6 1.0±7.10 )岁。原发病为脑出血 114例 ,脑梗死 12 8例 ,符合第四届全国脑血管病会议制定的诊断标准和《中国精神障碍分类与诊断标准》(第三版 ) ,且经头颅 CT或 MRI检查证实诊断 ,排除痴呆、感觉性失语、耳聋、意识障碍等所致的情感障碍 ,病前无抑郁、焦虑症史。情感障碍类型为抑郁 115例 ,焦虑 12 7例…     

奥美拉唑预防老年人应激性溃疡出血临床疗效

老年人胃粘膜镜下常见粘膜小血管扭曲、玻璃样变狭窄，可使粘膜营养不良，屏障功能低下，在严重感染、创伤或脑出血等因素诱发下，较一般人群易产生应激性溃疡出血，死亡率较高。因此，临床上治疗老年原发病的同时，还应积极有效地预防应激性溃疡出血的产生。总结2000年12月至2003年3月54例严重创伤、感染或脑出血老年患者应用奥美拉唑预防应激性溃疡出血的临床资料。     

早期肠内营养预防应激性溃疡的临床研究

目的研究早期肠内营养对应激性溃疡的预防作用。方法将2005年2月至2006年2月温州医学院附属第一医院收治的38例危重患者随机分为3组。第1组:抑酸药物加早期肠内营养组(发病24 h内给予肠内营养)13例;第2组:抑酸药物加延迟肠内营养组(发病72 h后给予肠内营养)13例;第3组:单纯应用抑酸药物预防组(鼻饲或静脉应用奥美拉唑)12例。于发病后5 d、2周分别行胃镜检查,观察溃疡的发生情况,同时测定胃黏膜中前列腺素E-2(PGE-2)和丙二醛(MDA)的含量。结果第1组患者的溃疡发生率及溃疡指数较其它2组患者低(P<0.01),而溃疡抑制率较其它2组高(P<0.01),2周后溃疡愈合率亦较其它2组高(P<0.05);第2组患者溃疡发生率、溃疡指数低于对照组,但差异无显著性,而溃疡愈合率高于对照组(P<0.05),第1组患者胃黏膜中的PGE-2浓度较其它2组明显增高,而MDA较其它2组明显降低,差异有显著性。第2组患者胃黏膜中的PGE-2浓度亦较第3组高,而MDA较后者低,差异有显著性。结论应用抑酸药物同时给予早期肠内营养治疗可能对应激性溃疡的发生有一定的预防作用。肠内营养可能通过调节胃黏膜中PGE-2和MDA等物质的含量起作用。     

Impact of Stress Hyperglycemia on No-Reflow Phenomenon in Patients with ST Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention

Background:Stress hyperglycemia is a common finding during acute myocardial infarction and associated with poor prognosis. To reduce the occurrence of no-reflow, prognostic factors must be identified before primary percutaneous coronary intervention (PPCI). Our objective was to investigate the impact of stress hyperglycemia in non-diabetic and diabetic patients on no-reflow phenomenon after PPCI.Methods:The study comprised 480 patients with ST elevation myocardial infarction (STEMI) who were managed by PPCI. Patients were classified into two groups according to thrombolysis in myocardial infarction (TIMI) flow grade: Group I (Patients with normal flow, TIMI 3 flow) and Group II (Patients with no-reflow, TIMI 0-2 flow). Patients were analyzed for clinical outcomes including mortality and major adverse cardiac events.Results:Incidence of stress hyperglycemia was 14.8% in non-diabetic patients and 22.2% in diabetic patients; the incidence of no-reflow phenomenon was 13.5% and no-reflow was significantly higher in patients with stress hyperglycemia. Multivariate regression analysis identified the independent predictors of no-reflow phenomenon: stress hyperglycemia OR 3.247 (CI95% 1.656–6.368, P = 0.001), Killip class >1 OR 1.893 (CI95% 1.004–3.570, P = 0.049) and cardiogenic shock OR 3.778 (CI95% 1.458–9.790, P = 0.006).Conclusion:Stress hyperglycemia was associated with higher incidence of no-reflow phenomenon. The independent predictors of no-reflow were stress hyperglycemia, Killip class >1 and cardiogenic shock.     

Effectiveness and Feasibility of Transradial Approach for Primary Percutaneous Coronary Intervention in Patients With Acute Myocardial Infarction

Objectives To evaluate the effectiveness and feasibility of transradial approach for primary, emergency percutaneous coronary intervention （PCI） in patients with acute myocardial infarction （AMI）. Methods One hundred and ninety five patients with AMI undergone primary PCI were randomized into two groups using different catheter insertion pathways ： 105 cases by transfemoral approach and 90 cases by transradial approach. We compared data of different operating approaches in terms of success rate of access, cannulation time, the time from local anesthesia to the first balloon inflation, the total procedure time, success rate of PCI, access site complications, total duration of hospitalization, and the clinical outcomes at six-month follow-up. Results The success rate of artery puncture, cannulation time, and the time from local anesthesia to the first balloon inflation in the transradial and transfemoral groups were 98.9 % vs 100 % （P 〉0. 05）, 3.15 ± 1.56 minutes vs 2. 86 ± 0.97 minutes （P 〉0. 05）, and 18.56 ± 4. 37 minutes vs 17.75± 3.21 minutes （P 〉 0. 05 ）, respectively. Although the total procedure time was significantly shorter in the transfemoral group （27.89 ± 3.95 minutes） than in the transradial group （29.75 ±4. 38 minutes） （P 〈0. 05）, the overall PCI success rate was similar between the two groups （96.2 % vs 96. 7 % ）. Use of the transradial approach was associated with fewer access site complications （ 2. 2 % vs 11.4 %, P 〈 0. 05 ） and a shorter length of hospital stay （ 10. 6 days vs 13.8 days, P 〈 0. 05 ）. At six-month follow-up, the cumulative cardiac event-free survival rate was 86. 1% and 86. 4% （P 〉 0. 05 ）, respectively, in the transradial and transfemoral groups. Conclusions Transradial approach achieved similar effectiveness as transfemoral approach in emergency PCI. However, the use of the transradial approach decreased access complications and hospital stay. Primary PCI via transradial approach is safe, effective, and feasible in patients with AMI.     

Screening for Posttraumatic Stress Disorder in VA Primary Care Patients with Depression Symptoms

Background Unrecognized posttraumatic stress disorder (PTSD) is common and may be an important factor in treatment-resistant depression. Brief screens for PTSD have not been evaluated for patients with depression. Objective The objective was to evaluate a 4-item screen for PTSD in patients with depression. Design Baseline data from a depression study were used to evaluate sensitivity, specificity, and likelihood ratios (LRs) using the PTSD checklist (PCL-17) as the reference standard. Subjects Subjects are 398 depressed patients seen in Veterans Affairs (VA) primary care clinics. Measures The Patient Health Questionnaire (PHQ) for depression, PCL-17, and 4-item screen for PTSD were used. Results Patients had a mean PHQ score of 14.8 (SD 3.7). Using a conservative PCL-17 cut point “(>50)”, the prevalence of PTSD was 37%. PCL-17 scores were strongly associated with PHQ scores (r = 0.59, P < 0.001). Among the 342 (86%) patients endorsing trauma, a score of 0 on the remaining 3 symptom items had a LR = 0.21, score of 1 a LR = .62, score of 2 a LR = 1.36, and score of 3 a LR = 4.38. Conclusions Most depressed VA primary care patients report a history of trauma, and one third may have comorbid PTSD. Our 4-item screen has useful LRs for scores of 0 and 3. Modifying item rating options may improve screening characteristics.     

急性卒中期患者脑血管血液动力学检测分析

目的　探讨卒中急性期患者脑血管血液动力学 (CVHD)指标的特征及其临床意义。方法　选择经头颅CT或MRI确诊的 5 5例急性期脑卒中患者 ,在发病 1周内进行CVHD检测 ,分析各检测指标的特征。结果　全部患者的CVHD的积分值均在 75分以下 ,中位数 32 .5分。与正常男性 70岁年龄组CVHD测定值比较 ,平均血流速度、血流量、最大血流速度、最小血流速度和舒张压与临界压的差值均有明显降低 (P <0 .0 1) ,而脉搏波速、外周阻力、特异性阻抗、以及临界压水平均有显著升高(P <0 .0 1)。结论　卒中发病一周内脑血管血液动力学积分值降低 ,各项检测指标均有明显的改变。CVHD检测能较敏感地反映脑血管供血不足或预警卒中发生     

Nutritional Status in Patients with Acute Stroke

ABSTRACT By measuring three anthropometric variables (relative weight, triceps skinfold thickness and arm muscle circumference) and three circulating proteins (albumin, transferrin and prealbumin), nutritional status was assessed in 100 consecutive patients with acute stroke. On admission to hospital, two or more indicators showed subnormal values for 16%; this was associated with the female sex, high age and a history of atrial fibrillation. At discharge, 22% had two or more subnormal indicators. Poor nutritional status during the hospital stay appeared to be related to infections, the male sex, the intake of cardiovascular drugs and high age. Fewer of the patients with two or more subnormal nutritional indicators were able to return home than of the patients with none or one subnormal nutritional indicator. We conclude that undernutrition is not uncommon at the onset of stroke and that certain risk groups for the development of undernutrition during hospital stay can be identified.     

慢性完全闭塞病变对接受急诊介入治疗的急性心肌梗死患者远期预后的影响

目的:分析慢性完全闭塞(CTO)病变对接受急诊介入治疗的急性心肌梗死(AMI)患者远期预后的影响。方法:分析自2013年1月至2014年9月间纳入中国急性心肌梗死(CAMI)注册登记研究的接受急诊介入治疗的14176例AMI患者,根据冠状动脉造影的结果,将患者分为AMI合并CTO病变组(n=1235)和AMI不合并CTO病变组(n=12941)。随访2年,比较两组的临床预后,主要研究终点为死亡率,次要研究终点为包括心原性死亡、脑卒中、心力衰竭再入院、再次血运重建等的主要不良心血管事件。结果:合并CTO病变的AMI患者占8.7%(1235/14176)。随访2年,AMI合并CTO病变组的患者全因死亡率(9.9%vs.5.4%)和心原性死亡率(5.0%vs.2.6%)明显高于AMI不合并CTO病变组患者(P均<0.01)。单因素分析显示,CTO病变增加AMI患者死亡(HR=1.44,95%CI:1.02~2.03,P=0.04)和再次血运重建(HR=2.14,95%CI:1.55~2.96,P<0.01)风险。多因素回归分析显示,高龄(HR=1.07,95%CI:1.05~1.09)和就诊时存在心力衰竭(HR=2.05,95%CI:1.36~3.09)与患者2年死亡的不良预后明显相关(P均<0.01),而CTO病变不是2年死亡的独立危险因素(HR=1.33,95%CI:0.93~1.90,P=0.11)。结论:合并CTO病变的AMI患者的远期死亡率和心原性死亡率明显高于不合并CTO病变的患者。高龄和就诊时存在心力衰竭是远期死亡的独立危险因素,而CTO病变并不是远期死亡的独立危险因素。     

老年前期中风危险因素跟踪监测与干预性治疗的研究

目的探讨老年前期中风危险因素跟踪监测与干预性治疗的临床疗效和意义.方法对450例老年前期有中风危险因素的病人,根据其意愿与条件分为中西结合组、西药组、自然组.3组均建档,西药组给予常规西药干预治疗,中西结合组在常规西药治疗基础上,加用中药通脉胶囊,自然组不系统干预.观察3组病人血压、血液流变学、血脂及血压控制率、中风发病率的变化情况.结果中西结合组与西药组、自然组在血压控制、血液流变学、血脂变化、中风发病率等方面比较均有统计学意义(P＜0.05).结论老年前期中风危险因素跟踪监测与干预性治疗有较好的临床疗效和预防意义,而中西医结合干预性治疗效果更加显著.     

社区脑卒中患者社会支持调查分析

目的了解社区脑卒中患者的社会支持状况及其影响因素。方法采用肖水源的社会支持评定量表（SSRS）对长沙市社区的125名脑卒中患者社会支持状况进行调查,并随机抽取了128名健康居民作为对照进行比较。结果社区脑卒中患者的主观支持得分（21.16±5.45）分;客观支持得分（7.94±2.35）分;支持利用度得分（6.72±2.44）分;总体得分（35.8±7.31）分,与对照组相比〔主观支持（23.23±6.78）分;客观支持（9.36±2.63）分;支持利用度（7.92±3.02）分;总体得分（40.51±8.12）分〕差异有统计学意义（P〈0.01）。其中年龄、婚姻状况、收入和病程是影响社会支持得分的显著性因素。结论社区脑卒中患者的社会支持状况不容乐观,社区医护人员应为患者营造良好的社会支持性环境。     

Prevalence of Early Left Ventricular Thrombus after Primary Coronary Intervention for Acute Myocardial Infarction

The prevalence of left ventricular (LV) thrombus after acute myocardial infarction (AMI) has been reported high at 20–60%. Current reperfusion therapies such as thrombolysis have shown a trend toward reducing the incidence of LV thrombosis. However, the prevalence of LV thrombus after primary percutaneous coronary intervention (PCI) for AMI has not been systematically studied. At Massachusetts General Hospital 71 consecutive patients who underwent primary PCI for acute ST elevation MI were reviewed for the prevalence of LV thrombus evaluated by echocardiography. Echocardiography was performed within 5 days of infarction. PCI was successful in all patients. The time delay from symptom onset to intervention was 191 minutes. Thrombolysis in Myocardiol Infarction (TIMI) grade 3 flow was achieved in more than 80% of cases. Only 3 patients (4%) had echocardiographic evidence of LV thrombus. All 3 patients had anterior infarctions. The incidence among patients with anterior MI was 10% (3 of 30 patients). The prevalence of LV thrombus in patients treated with primary PCI for AMI is low (4%).