脑卒中患者就医延迟关键风险因素分析与策略研究

目的 探讨导致脑卒中患者就医延迟的关键风险因素,构建就医延迟风险评价体系,为提出有针对性的风险管理策略提供参考。方法 采用文献研究、专家访谈和2轮专家函询识别脑卒中患者就医延迟风险因素, 形成包含44项风险因素的脑卒中患者就医延迟风险因素调查表,使用调查表分别对447例脑卒中患者和202名医生进行问卷调查,运用主观评价法和逼近理想排序法（TOPSIS法）2种方法对患者及医生数据中各阶段的风险因素进行重要性排序分析,结合二八定律提取就医延迟的关键风险因素。结果 44项风险因素中共提取出16项关键风险因素：患者延迟阶段7项,转运延迟阶段4项,院内延迟阶段5项。结论 脑卒中患者就医延迟受诸多因素影响,应针对16项关键风险因素构建多维全程的患者就医风险管理机制, 提高患者自身风险应对能力,提高120急救系统使用率,围绕就医环节完善相关流程和制度。     

中青年首发脑卒中患者急性应激障碍动态列线图模型的构建

目的 探讨首发中青年脑卒中患者急性应激障碍的影响因素并构建动态列线图模型，以帮助医护人员早期识别急性应激障碍。 方法 选取锦州医科大学附属第一医院298例首发脑卒中的中青年患者为研究对象，其中建模组208例和验证组90例。以生物-心理-社会医学模式为理论指导，收集15个备选因素。使用LASSO回归和多因素logistic回归分析筛选出急性应激障碍的危险因素。基于R-shiny构建动态列线图预测模型，采用Bootstrap法分别在建模组和验证组进行验证。 结果 298例首发中青年脑卒中患者中141例发生ASD，发生率（47.32%）。筛选出心理韧性、ADL、神经受损程度、吞咽障碍、偏瘫5个影响因素构建预测模型。建模组验证AUC为0.884，验证组验证AUC为0.879，2次验证Calibration曲线均与理想曲线接近。 结论 所构建的动态在线列线图模型预测效能良好，可为首发中青年脑卒中患者急性应激障碍筛查提供借鉴。     

影响脑卒中患者人院延迟的相关因素调查研究

目的探讨目前影响脑卒中患者人院延迟的相关因素。方法对2008年4—9月确诊脑卒中住院患者179例进行问卷调查。根据发病至住院的时间将患者分为≤6h组（85例）和〉6h组（94例）,分析影响入院延迟的相关因素。结果179例患者发病至住院的平均时间（26．2±0．1）h,中位时间为7．5h。两组患者既往有心脏病和糖尿病病史、发病地点距医院较近、首发症状有抽搐或意识障碍、首诊地点为急诊室、选择急救120、就诊途中时间等因素比较差异有统计学意义（P〈0．05）。logistic回归分析显示,发病地区远、门急诊处置时间长是影响入院延迟的主要因素。结论目前脑卒中患者入院延迟现象严重,缺血性脑卒中溶栓率低。主要原因在于患者对脑卒中相关知识不了解,不能充分利用院前急救系统。     

延迟阑尾切除时间对急性阑尾炎病情的影响

目的 观察手术延迟时间和延迟就诊时间对急性阑尾炎病情的影响.方法 410例在我院行急性阑尾炎手术患者分别按手术延迟时间、延迟就诊时间进行分组,选择相关临床因素.结果 手术延迟时间<12h组和12～24h组相比,各指标间差异无统计学意义(P>0.05);随延迟就诊时间延长,术后-出院时间、穿孔发生率、脓肿形成率、并发症发生率明显增高(P<0.05).结论 延迟就诊时间影响急性阑尾炎的病情发展,而适当延迟住院后阑尾切除时间不影响急性阑尾炎的病情及预后.     

基于IScore评分的早期神经功能恶化预测模型的构建与评价

目的探讨急性缺血性脑卒中患者早期神经功能恶化的危险因素,构建基于IScore评分的预测模型,并评价其预测效果。方法选取452例急性缺血性脑卒中患者的临床病例资料,根据是否发生早期神经功能恶化分为恶化组(n=73)和非恶化组(n=379),比较两组的危险因素,通过二分类Logistic回归模型建立预测模型,采用ROC曲线下面积评价模型的预测效果。结果早期神经功能恶化发生率为16.15%。最终进入预测模型的指标包括IScore评分、白细胞计数、大脑中动脉M1段中重度狭窄、颈动脉中重度狭窄共4个预测因子,模型ROC曲线下面积为0.790,特异度为0.834,灵敏度为0.635,准确度为0.798,约登指数为0.469。结论基于IScore评分的预测模型对急性缺血性脑卒中患者早期神经功能恶化具有较好的预测效能与可重复性。     

中青年脑卒中住院患者戒烟行为影响因素的质性研究

目的了解中青年脑卒中患者在不同戒烟行为阶段的影响因素,为戒烟干预提供参考。方法以行为转变理论为基础,采用质性研究中行为事件访谈法对12例中青年脑卒中住院患者进行访谈,使用Colaizzi内容分析法分析资料。结果提炼出两个主题群,分别是戒烟行为的促进因素和阻碍因素。结论不同戒烟行为阶段中青年脑卒中患者戒烟行为的影响因素不同,需根据患者的戒烟意愿和行为特点,采取相应的戒烟干预措施,以提高戒烟成功率。     

急性脑卒中患者就医延迟影响因素研究进展

对急性脑卒中患者就医延迟(包括院前及院内延迟)的影响因素进行阐述,院前延迟影响因素包括人口学特征,症状识别及严重性感知,转运方式和环境因素。院内延迟影响因素有医院管理因素和基础设施,医务人员、患者及家属因素。提出针对性的建议,以缩短院前及院内延迟时间,同时为患者接受超早期的静脉溶栓治疗奠定基础。     

脑卒中院前延迟综合健康教育方案的构建脑卒中院前延迟综合健康教育方案的构建

在健康信念模式、社会认知理论和缺血性脑卒中院前应对模式等理论指引的基础上,结合适宜的健康教育方法和内容,以脑卒中高危者和其家属为健康教育对象,构建了可行性较强的脑卒中院前延迟综合性健康教育方案,以达到提高社区高危人群和其家属对脑卒中疾病认知,减少院前延迟的发生,推动社区健康教育活动发展的目的。     

脑卒中院前延迟综合健康教育方案的构建

在健康信念模式、社会认知理论和缺血性脑卒中院前应对模式等理论指引的基础上,结合适宜的健康教育方法和内容,以脑卒中高危者和其家属为健康教育对象,构建了可行性较强的脑卒中院前延迟综合性健康教育方案,以达到提高社区高危人群和其家属对脑卒中疾病认知,减少院前延迟的发生,推动社区健康教育活动发展的目的。     

前列腺增生患者延迟就诊原因调查

目的探讨前列腺增生患者延迟就诊的原因。方法采用访谈法对120例前列腺增生患者用20～30min进行逐步深入主题的访谈。结果早期就诊者仅占28.3%,患者的认知水平、健康状况及对疾病的畏惧程度是前列腺增生患者延迟就诊的主要因素。结论应大力宣传泌尿专科医学知识,提高中老年男性对前列腺增生的认知水平,降低其畏惧程度,使其出现不适及时就诊。     

Vasopressor hormone response following mesenteric traction during major abdominal surgery

Background : We investigated the vasopressor hormone response following mesenteric traction (MT) with hypotension due to prostacyclin (PGI₂) release in patients undergoing abdominal surgery with a combined general and epidural anesthesia. Methods : In a prospective, randomized, placebo-controlled study we administered 400 mg ibuprofen (i.v.) in 42 patients scheduled for abdominal surgery. General anesthesia was combined with epidural anesthesia (T4-L1). Before as well as 5, 15, 30, 45, and 90 min after MT we recorded plasma osmolality, hemodynamics and measured 6-keto-PGFlα (stabile metabolite of PGI₂), TXB₂ (stabile metabolite of thromboxane A₂) active renin, and arginine vasopressin (AVP) plasma concentrations by radioimmunoassay. Catecholamine levels were assessed by high-pressure liquid chromatography (HPLC) with electrochemical detection. Results : Following MT, arterial hypotension occurred along with a substantial PGI₂ release. This was completely abolished by ibuprofen administration. Although plasma levels of 6-keto-PGF_1α (1133 (708) vs. 60 (3) ng/L, median (median absolute deviation), P=0.0001, placebo vs. ibuprofen) remained significantly elevated, blood pressure was restored within 30 min after MT in the placebo group. At the same point in time plasma concentrations of TXB² (164 (87) vs. 58 (1) ng/L, P=0.0001), epinephrine (46 (33) vs. 14 (6) ng/L, P=0.001), AVP (41 ± (18) vs. 12 (7) ng/L, P=0.0004), and active renin (27 (12) vs. 12 (4) ng/L, P = 0.001) were significantly higher in placebo-treated patients. Conclusion : Under combined general and epidural anesthesia arterial hypotension following MT due to endogenous PGI₂ release is associated with enhanced release of AVP, active renin, epinephrine and thromboxane A₂, presumably contributing to hemodynamic stability within 30 min after MT.     

A comparison of the inhibitory effects of four volatile anaesthetics on the metabolism of chlorzoxazone, a substrate for CYP2E1, in rabbits

Background: Halothane inhibits in vitro and in vivo activity of cytochrome P-450 (CYP) 2E1. There are several fluorinated volatile anaesthetics besides halothane, and most of them are defluorinated by CYP2E1. It is unclear whether other fluorinated anaesthetics inhibit the in vivo activity of CYP2E1.
Methods: We compared the inhibitory effects of therapeutic concentrations of four inhalational anaesthetics, halothane, enflurane, isoflurane, and sevoflurane, on chlorzoxazone metabolism in rabbits receiving artificial ventilation.
Results: All four inhalational anaesthetics decreased arterial blood pressure and increased plasma chlorzoxazone concentration. However, no significant differences in the plasma chlorzoxazone concentration were found between the four anaesthetics. The estimated chlorzoxazone clearance increased after beginning inhalation with all four agents, but no significant difference in clearance was noted between agents.
Conclusions: At therapeutic concentrations, the in vivo inhibitory effect on chlorzoxazone metabolism was similar for all four inhalational anaesthetics examined, even though their chemical characteristics and extent of hepatic metabolism differ considerably.     

A Teaspoon Pump for Pumping Blood with High Hydraulic Efficiency and Low Hemolysis Potential

Abstract: Virtually all blood pumps contain some kind of rubbing, sliding, closely moving machinery surfaces that are exposed to the blood being pumped. These valves, internal bearings, magnetic bearing position sensors, and shaft seals cause most of the problems with blood pumps. The original teaspoon pump design prevented the rubbing, sliding machinery surfaces from contacting the blood. However, the hydraulic efficiency was low because the blood was able to "slip around" the rotating impeller so that the blood itself never rotated fast enough to develop adequate pressure. An improved teaspoon blood pump has been designed and tested and has shown acceptable hydraulic performance and low hemolysis potential. The new pump uses a nonrotating "swinging" hose as the pump impeller. The fluid enters the pump through the center of the swinging hose; therefore, there can be no fluid slip between the revolving blood and the revolving impeller. The new pump uses an impeller that is comparable to a flexible garden hose. If the free end of the hose were swung around in a circle like half of a jump rope, the fluid inside the hose would rotate and develop pressure even though the hose impeller itself did not "rotate"; therefore, no rotating shaft seal or internal bearings are required.     

Microspheres Based Detoxification System: A New Method in Convective Blood Purification

Abstract: A variety of protein-bound or hydrophobic substances, accumulating as a result of pathologic conditions such as exogenous or endogenous intoxications, are removed poorly by conventional detoxification methods because of low accessibility (hemodialysis), insufficient adsorption capabilities (hemosorption), low efficiency (peritoneal dialysis), or economic limitations (high-volume plasmapheresis). Combining advantages of existing methods with microspheric technology, a module-based system was designed. Major operating parameters of the latter can be modified to allow for adjustment to individual clinical situations. An extracorporeal blood circuit including a plasmafilter is combined with a secondary high-velocity plasma circuit driven by a centrifugal pump. Different microspheric adsorbers can be combined in one circuit or applied in sequence. Thus, a prolonged treatment can be tailored using specially designed selective adsorber materials. Comparing this system with existing methods (high-flux hemodialysis, molecular adsorbent recycling system), results from our in vitro studies and animal experiments demonstrate the superior efficiency of substance removal.     

Is the recovery profile of mivacurium independent of the rate of decay of its plasma concentration in patients with normal plasma cholinesterase activity?

Background: The duration of action of muscle relaxants is poorly correlated to the rate of decay of their plasma concentration. The plasma concentration of mivacurium may rapidly decrease below its active concentration because of the extensive hydrolysis of mivacurium. By inflating a tourniquet on one upper limb for 3 min after the administration of atracurium, mivacurium or vecuronium, we studied the influence of the initial decline of their plasma concentration on their effect. Methods: In 50 patients anaesthetised with thiopental, isoflurane and fentanyl, the effect of bolus doses of 0.15 or 0.25 mg . kg^?1 mivacurium (MIV 15, MIV 25), 0.3 or 0.5 mg . kg^?1 atracurium (ATR 30, ATR 50) and 0.06 or 0.1 mg . kg^?1 vecuronium (VEC 06, VEC 10) were measured on both arms (evoked response of the adductor pollicis to train-of-four stimulation every 12 s), a tourniquet being applied on one arm just before and during 3 min after the muscle relaxant bolus. Results: Tourniquet inflation of 3 min almost abolished the neuromuscular effect of mivacurium. In the vecuronium groups and in the ATR 50 group, tourniquet inflation did not modify the maximum degree of depression of the twitch response. Also, the duration of action of vecuronium was unaffected by the tourniquet. In the ATR 30 group, times to return of the twitch response to 25% (duration 25%) and 75% (duration 75%) of control response were significantly shorter in the cuffed arm, 23 min vs 27 min, and 41 min vs 45 min, respectively. In the ATR 50 group, only duration 25% was significantly shorter in the cuffed arm (41 min vs 45 min). Conclusion: The results suggest that the rate of decline of the plasma concentration of mivacurium is so rapid, that a very low and almost clinically ineffective concentration is present as soon as 3 min after its administration. The results also indicate that the recovery from a mivacurium-induced neuromuscular blockade is not influenced by the rate of decay of its plasma concentration in patients with genotypically normal plasma cholinesterase.     

Membranes in Artificial Organs

Abstract: Membrane processes play a pivotal and enabling role in modern replacement therapy for acute and chronic organ failure and in the management of immunologic diseases. In fact, virtually all contemporary extracorporeal blood purification methods employ membrane devices, and the next generation of artificial organs and tissue engineering therapies are almost certain to be similarly grounded in membrane technology. In this short essay, we comment on the similarities and differences among synthetic membranes and their natural counterparts and also provide a critical overview of the demographics and technology of hemodialysis, hemofiltration, apheresis, oxygenation, and emerging membrane technologies and applications.     

Tissue perfusion in relation to cardiac output during continuous positive-pressure ventilation and administration of propranolol or verapamil

Background : Our objective was to determine whether administration of propranolol or verapamil modifies the hemodynamic adaptation to continuous positive-pressure ventilation (CPPV), in particular the regional distribution of cardiac output (CO).
Methods : General hemodynamics and regional blood flows assessed by microsphere technique (15 (μm) were recorded in 16 anesthetized pigs during spontaneous breathing (SB) and CPPV with 8 cm H₂O end-expiratory pressure (CPPV8) before and after intravenous administration of propranolol (0.3 mg · kg⁻¹ followed by 0.15 mg · kg⁻¹ · h⁻¹, n=8) or verapamil (0.1 mg · kg⁻¹ followed by 0.3 mg · kg⁻¹ · h⁻¹, n=8).
Results : CPPV8 depressed CO by 25% without shifts in its relative distribution with the exception of a noteworthy increase in adrenal perfusion. Propranolol increased arterial blood pressure, and due to a fall in heart rate, CO dropped by 25%. The kidneys and, to a lesser extent, the splanchic region and central nervous system received increased fractions of the remaining CO at the expense of skeletal muscle flow. Similar patterns were seen during SB and CPPV8 such that the combination of propranolol and CPPV8 depressed CO by 50%. The circulatory effects of verapamil were less evident but myocardial perfusion tended to increase.
Conclusions : The combination of propranolol or verapamil with CPPV does not result in any specific hemodynamic interaction in anesthetized pigs, except that the combined effect of propranolol and CPPV may severely reduce CO.     

Volatile anaesthetics reduce adhesion of blood platelets under low-flow conditions in the coronary system of isolated guinea pig hearts

Background : Inhibitory effects of volatile anaesthetics on platelet aggregation have been demonstrated in several studies. However, the influence of volatile anaesthetics on intracoronary platelet adhesion has not been elucidated so far.
Methods : Isolated hearts of guinea pigs were perfused with buffer in the absence or presence of volatile anaesthetics (0.5 and 1 MAC) at constant coronary flow rates of 5 ml/min for 25 min, then 1 ml/min for 30 min and again 5 ml/min for 10 min. Before, during and after low-flow perfusion, a bolus of human platelets was applied into the coronary system. To simulate thrombogenic conditions, 0.3 U/ml human thrombin was infused during low-flow perfusion and reperfusion. The number of platelets sequestered to the endothelium was calculated from the difference between coronary in- and output of platelets. The myocardial production of lactate and consumption of pyruvate and coronary perfusion pressure were also determined.
Results : At a flow rate of 5 ml/min only about 3% of the applied platelets did not emerge from the coronary system, in any group. In contrast, 13.1±1.2% (mean±SEM) of infused platelets became adherent in low-flow perfusion in the control group without anaesthetic. The adherence was reduced with each 1 MAC isoflurane (to 6.2±1.2%), sevoflurane (to 4.4±0.9%) or halothane (to 3.2±1.5%) (each P <0.05 vs. control). Volatile anaesthetic, 0.5 MAC, did not inhibit platelet adhesion to a statistically significant extent in any case. Perfusion pressure and metabolic parameters were not statistically different between the control and the hearts exposed to anaesthetics.
Conclusion : Volatile anaesthetics in a concentration of 1 MAC can reduce the adhesion of platelets in the coronary system under reduced flow conditions. This action does not arise from vasodilation or inhibition of ischaemic stress.     

Bariatric Surgery in Some "Central and East-European (former Eastern bloc)"Countries - Current Status and Prediction for the Next Millennium

Background: Obesity is increasing globallly, including in the formerly "Eastern Bloc" countries. Methods: A survey was made of obesity and bariatric surgery. Results: In the 8 East and Central European countries studied, with total population 300 million, roughly 43% of the population was overweight (BMI 25-30), 23% obese (BMI > 30), with about 15 million people morbidly obese (BMI > 40). From 0-10 morbidly obese individuals/100,000/year undergo bariatric surgery. Conclusion: Most countries were found to provide inadequate treatment for obesity.The majority of the morbidly obese are not treated effectively. However, health-care awareness of obesity and bariatric surgeons are slowly increasing.     

Dilemma of Membrane Biocompatibility and Reuse

Abstract: Numerous articles have been published on the multiple use of dialyzers and on the effect of different reprocessing chemicals and techniques on the dialyzer biocompatibility and performance. The results often appear contradictory, especially those comparing standard biocompatibility parameters. Despite this confusion, a discerning review of the published works allows certain limited conclusions to be drawn. Reprocessing of used hemodialyzers changes the biocompatibility profile of a dialyzer as defined by the parameters complement activation. leukopenia, and cytokine release. The effect of reprocessing depends on the chemicals and reprocessing technique applied and also on the type of membrane polymer being subjected to the reprocessing procedure. Reports of pyrogenic reactions indicate that the flux of the membrane also influences how suitable it is for safe reuse. An increased risk of allergic and pyrogenic reactions appears to be associated with dialyzer reuse. Furthermore, there has been a lack of investigations into the immunologic effect of the layer of adsorbed and chemically altered proteins that remains on the inner surface of reprocessed dialyzers. We conclude that the clinical benefit of dialyzer reuse cannot be generally accepted from a biocompatibility point of view.