急性心肌梗死患者延迟就医的影响因素分析

目的 探讨急性心肌梗死(acute myocardial infarction,AMI)患者延迟就医的影响因素.方法 采用问卷调查332例急性心肌梗死患者院前延迟时间,并采用多因素Logistic回归分析影响患者延迟就医的因素.结果 患者延迟(patient delay, PD)中位数时间为90 min;院前延迟(pre-hospital delay,PHD)中位数时间为170 min.以PD≤60 min为界限点,多因素Logistic回归分析显示:症状难以忍受、重视症状、周围有人3种因素是预测患者及早就医的因素,可以缩短PD时间;梗死前心绞痛、服止痛药、不愿打扰别人、等症状消失、逐渐发病、年龄≥65岁、无医疗保险7种因素可以延长PD时间.结论 急性心肌梗死患者延迟就医受多种因素影响.建议完善相关机制与服务体系,解除患者就医的后顾之优;加强健康教育,提高人群特别是高危人群对AMI疾病的认知,改善患者的就医观,在紧急状况下呼叫救护车.对提高AMI患者的抢救成功率,降低死亡率,改善预后具有深远意义.     

影响急性ST段抬高心肌梗死患者应用急救医疗服务的因素

目的探讨急性ST段抬高心肌梗死（STEMI）患者到达医院时交通工具的选择类型及影响患者选择急救医疗服务（EMS）的因素。方法2003－09～2004—07连续住院并确诊的329例SFEMI患者,根据是否应用EMS到医院分为两组：EMS组和自我转运组,对比分析两组资料。结果仅有26．75％的患者应用EMS到达指定医院。单因素分析表明。与选择EMS相关的因素是冠心病住院史、症状进展、恶心、呕吐、头晕、晕厥、知道心肌梗死应及早治疗、严重疼痛、重视反应、等待症状消失、恐惧感、认为是心脏起源的疾病。而症状能忍受、等待症状消失、不想打扰别人与自我转运有关。多元Logistic回归分析表明,症状进展、恶心、晕厥、认为是心脏起源的疾病是预测患者应用EMS的独立变量,而症状能忍受是不应用EMS的预测因素。结论只有1／4的STEMI患者应用EMS到达医院,只有当患者感觉病重时才想到EMS。应当宣传EMS不仅仅是运输工具,同时也是及早诊断和治疗的手段。     

急性ST段抬高型心肌梗死患者院前延迟影响因素分析

目的分析急性ST段抬高型心肌梗死(STEMI)患者院前延迟影响因素,为降低急性心肌梗死患者院前延迟时间提供理论依据。方法连续收集我院2014年1月-2015年12月行急诊PCI治疗的ST段抬高型急性心肌梗死患者267例为研究对象,以调查问卷及查阅病历资料形式收集患者的一般资料、冠心病相关危险因素、心肌梗死相关症状等具体因素,从而分析出可能影响患者及时就诊的相关因素。结果根据院前延迟时间分为痛门时间≤2h组(108例)、2h痛门时间6h组(117例)、痛门时间≥6h三组(42例),院前延迟时间与年龄、糖尿病病史、家庭人均收入、既往心绞痛病史、突然起病、重症症状/典型症状及把症状归因于心脏病等相关(P0.05)。结论应加强心血管疾病的普及、宣传力度,能够让患者深刻认识到心脏疾病的起病特点、临床表现、高危害性和早期及时诊治的重要性,尤其对高龄、患有糖尿病、低收入家庭及既往存在心绞痛病史者。     

中青年急性心肌梗死患者院前延迟行为意向现状及影响因素分析

目的 分析中青年急性心肌梗死患者院前延迟行为意向现状及影响因素。方法 选取2021年3月—2022年4月医院收治的330例中青年急性心肌梗死患者作为调查对象,进行院前延迟行为意向评分,并分析院前延迟行为意向的影响因素。结果 单因素分析结果显示,中青年急性心肌梗死患者院前延迟行为意向与其年龄、学历、家庭人均月收入、其他疾病史数目、医保状况、体检情况、居住情况、心肌梗死急救培训相关。以中青年急性心肌梗死患者院前延迟行为意向为因变量,进行多因素Logistic回归分析,结果显示年龄、学历、家庭人均月收入、其他疾病史数目、医保状况、体检情况、居住情况、是否进行心肌梗死急救培训为影响中青年急性心肌梗死患者院前延迟行为意向的影响因素（P<0.05）。结论影响中青年急性心肌梗死患者院前延迟行为意向的主要因素较多,针对影响因素,对患者进行提前干预,对中青年急性心肌梗死患者院前延迟行为意向改善具有重要意义。     

急性ST段抬高型心肌梗死患者到院后接PCI治疗时间影响因素及改进措施

目的：探讨影响急性ST段抬高型心肌梗死（STEMI）患者从入院后到接受经皮冠状动脉介入（PCI）治疗时间的因素，并提出相关改进措施。方法：选取2021年1月至2022年12月我院86例心梗患者，依据入门-首次球囊扩张（D2B）时间将患者分为延迟组（n=32）和未延迟组（n=54），比较两组患者临床资料并采用Logistic多因素分析其影响因素。结果：86例患者中，STEMI患者D2B时间延迟率为37.21%。因素分析结果显示，患者的受教育程度、居住地、消化系统疾病、来院方式、心脏疾病史、对疾病的认识程度、首诊明确心梗、PCI史和院前延迟时间是STEMI患者D2B时间延迟的主要因素，其中，院前延迟时间、自行前往医院、有消化系统疾病和对疾病不认识是独立危险因素（P＜0.05，OR＞1），居住地为城镇、首诊明确心梗、有PCI史、有心脏疾病史和受教育程度高是独立保护因素（P＜0.05，OR＜1）。结论：急性STEMI患者到入院后到接受PCI治疗时间受多重因素影响，临床可实施个性化针对性措施改进。     

糖尿病和非糖尿病首次急性心肌梗死者院前延迟行为研究

目的探讨糖尿病和非糖尿病首次急性心肌梗死者院前延迟行为现状及影响因素。方法采用院前延迟行为意向测评量表对96例首次急性心肌梗死者进行调查,将其分为糖尿病组(n=41)与非糖尿病组(n=55)。比较两组院前延迟时间、院前延迟行为意向及影响因素。结果糖尿病组院前延迟时间为(1.73±0.58)h、院前延迟行为评分为(50.16±14.07)分,非糖尿病组分别为(2.87±0.61)h、(58.93±13.24)分,糖尿病组短于非糖尿病组,组间比较差异有统计学意义(P0.05);糖尿病组患者症状觉察、习惯性行为、症状程度判断评分明显高于非糖尿病组,组间比较差异有统计学意义(P0.05);糖尿病急性心梗患者MACE发生率为27.27%,非糖尿病患者发生率为55.77%,差异有统计学意义(P0.05);体检情况与院前延误时间2 h以上有关(r=-0.155,P0.05)。结论糖尿病合并急性心肌梗死患者院前延误时间明显短于非糖尿病患者,症状觉察更敏锐、症状程度判断较准确可能是其主要原因。     

ST段抬高心肌梗死患者延迟诊治的性别差异

对于STEMI来说,时间就是生命,其最有效的治疗措施为尽快再灌注治疗,血管开通越早获益越大.然而许多研究表明心梗患者存在不同程度的就诊延迟,院前延迟时间约为1.5-6 h~([1-5]),女性患者无论是院前延迟时间还是院内得到有效治疗的时间均长于男性,部分研究甚至发现女性是心肌梗死患者延迟诊治的独立危险因素~([1-4]),但并未得到一致的结论.     

急诊胸痛患者院前延迟行为意向现状及影响因素分析

目的探讨急诊胸痛患者院前延迟行为意向现状及其影响因素。方法选取2017年4月至2018年9月在我院救治的急诊胸痛患者273例为研究对象,采用我院自制的急诊胸痛患者院前延迟行为意向测评表评估急诊胸痛患者院前延迟行为意向现状及影响因素。结果273例急诊胸痛患者院前延迟行为意向得分(59.85±14.35)分。单因素分析显示,年龄、学历、医疗费用承担情况、家庭人均月收入、居住情况、家庭住地、体检情况、患病史/家族史、自己或家人是否接受过急救培训、转运方式、进院前是否寻求帮助是影响急诊胸痛患者院前延迟行为意向的相关因素(P<0.05)。多元逐步回归分析显示,年龄、家庭人均月收入、体检情况、患病史/家族史、自己或家人是否接受过急救培训是影响急诊胸痛患者院前延迟行为意向的独立危险因素(P<0.05)。结论急诊胸痛患者院前延迟行为意向呈现中等水平,医护人员需要重视急诊胸痛患者对症状的习惯反应,加强教育和急救系统的运用,督促相关患者定期体检。     

心血管危重病

马里兰急诊医学必知 (Maryland Emergency Medicine Pearls) 2013年美国心脏病基金会学院(ACCF)和美国心脏病协会(AHA)ST段升高心肌梗死(STEMI)治疗指南 1区域性体制和早期经皮冠状动脉介入治疗 院前急救人员在现场第一时间内对怀疑STEMI的患者做12导联心电图;在症状出现后12 h内对所有STEMI患者进行再灌注治疗;在有经验操作者时尽快进行早期经皮冠状动脉介入治疗(PCI);EMS要在从到现场到PCI设备90 min内将患者直接送到有PCI能力的医院;如果一个STEMI患者就诊于或送到一个不能做PCI的医院,要迅速地在从第一时间接触到PCI设备120 min内将患者转运到能做PCI医院;在没有禁忌证情况下,对于在不能做PCI医院或由于不可避免的延误不能在120 min内将STEMI患者转到有PCI能力的医院,要进行溶栓治疗;如果溶栓治疗作为首选再灌注手段,要在患者到达医院30 min内开始;在12 ～24 h内,如STEMI患者有临床和/或EKG持续缺血表现,也可以进行再灌注治疗.     

急性心肌梗死患者院前诊治延迟因素分析及护理对策

目的:分析急性心肌梗死患者院前诊治延迟的相关因素,为护理工作提供指导。方法:通过查阅出院病历和电话回访相结合的方法,分析159例急性ST段抬高型心肌梗死患者院前诊治延迟的原因,比较患者性别、年龄、文化程度、是否与子女居住、医保类别、心脏基础疾病、梗死类型和部位、发病时危急程度、吸烟等因素与院前诊治延迟的关系。结果:有医保患者、65岁以下患者、与子女居住、发病时症状危急和文化程度高的患者诊治延迟时间较短(P0.05),而不同性别、基础疾病、梗死类型和部位、是否吸烟等患者诊治延迟时间无差异(P0.05)。结论:在临床工作中,应关注老年患者、无医保患者、文化程度低患者的冠心病心肌梗死知识健康教育指导,指导他们如何识别心绞痛症状,及时采取有效的治疗措施,降低致残率和病死率。     

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.     

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.     

手转胎头术失败的原因与分娩结局临床分析

目的 探讨手转胎头术失败的原因与分娩结局.方法 选择2008年1月至2010年12月于我院住院分娩的持续性枕横位、枕后位产妇198例,根据行手转胎头术后结果分为成功组126例、失败组72例.比较两组分娩结局,对比分析失败原因.结果 失败组胎儿体质量≥3500 g的发生率[76.4％(55/72)]明显高于成功组[31.7％(40/126)],差异有统计学意义(x2=30.177,P=0.001)、失败组宫缩乏力发生率[58.3％(42/72)]高于成功组[38.1％ (48/126)],差异有统计学意义(x2=7.569,P=0.006)、失败组骨盆临界或轻度狭窄发生率[38.9％ (28/72)]高于成功组[23.8％(30/126)],差异有统计学意义(x2 =5.030,P=0.002)、失败组手转胎头时机不当(宫口开大＜6 cm、胎头位于坐骨棘上及宫口开大8～10 cm、胎头位于坐骨棘下≥2 cm)发生率[61.1％(44/72)]高于成功组[38.9％(49/126)],差异有统计学意义(x2=9.084,P=0.003).失败组母儿并发症(产后出血、产褥病率、胎儿窘迫、新生儿窒息)发生率高于成功组(x2 =9.586,P=0.002、x2=9.334,P=0.002、x2=5.910,P=0.015、x2=5.240,P=0.022)、失败组剖宫产发生率[72.2％(52/72)]明显高于成功组[34.1 ％(43/126),x2=26.641,P=0.001)].结论 手转胎头术能使难产变顺产,降低剖宫产率,减少母儿并发症,但须积极预防、处理导致手转胎头术失败的原因,对矫正失败后继续矫正及试产应慎重.     

Evidence-Based Pain Management and Palliative Care in Issue Four for 2009 of The Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly. Issue 4 for 2009 contains 4027 complete reviews, 1906 protocols for reviews in production, and 11447 one-page summaries of systematic reviews published in the general medical literature. In addition, there are citations of 600,000 randomized controlled trials, and 12,200 cited papers in the Cochrane methodology register. The health technology assessment database contains over 7500 citations. This edition of the Library contains 90 new reviews, of which 19 have potential relevance for practitioners in pain and palliative medicine.     

Wie zuverlässig sind Angaben zu nichtentzündlichen ausgedehnten Schmerzen?

ZusammenfassungFragestellung Es wurde geprüft, wie sich der Differenziertheitsgrad zweier Schmerzmessmethoden auf Angaben zur Ausgedehntheit klinischer Schmerzen auswirkt. Zugleich wurde der Referenzzeitraum variiert, über den die Patienten berichten sollten.Methode Erfasst wurde der Einfluss zu Lasten der Befragungsdifferenziertheit durch den Vergleich zweier Körperschema-Bildvorlagen. Drei Referenzzeiträume (Schmerz aktuell, letzte Woche, letztes halbes Jahr) wurden vorgegeben.Ergebnisse Patienten mit ausgedehnten Schmerzen gaben bei differenzierter Befragung um so mehr Schmerzen an, je weiter die Schmerzen zurück lagen und je größer der Berichtszeitraum war. Patienten mit gelenknahen Schmerzen gaben bei hoch differenzierter Befragung weniger ausgedehnte Schmerzen in der Vergangenheit an als bei globaler Einschätzung. Patienten mit Rückenschmerzen berichteten bei differenzierter Befragung zum aktuellen Schmerz über weniger ausgedehnte Schmerzen als bei globaler Befragung.Schlussfolgerung Die Angaben zur Schmerzausdehnung variieren vor allem bei Patienten mit ausgedehnten Schmerzen in Abhängigkeit von der Differenziertheit der Befragung. In diesen Fällen ist die Wahrscheinlichkeit erhöht, dass sich die Beschwerdesymptomatik zumindest teilweise erst in der Reaktion auf die situativen Befragungsbedingungen konstituiert und daher nicht auf andere Befragungsbedingungen generalisiert werden kann.