The outcome of critically ill Indigenous patients

OBJECTIVE: To investigate the short-term outcome of critically ill Indigenous patients. DESIGN AND PARTICIPANTS: Retrospective cohort study using de-identified audit data from a tertiary intensive care unit (ICU) in Western Australia for the 11-year period 1 January 1993 to 31 December 2003. MAIN OUTCOME MEASURES: Hospital mortality (crude, and adjusted for severity of illness). RESULTS: Of 16 757 ICU patients, 1076 (6.4%) were identified as Indigenous. The Indigenous patients were younger and more commonly had chronic liver and renal diseases. Indigenous people represented 3.2% of the population of Western Australia in 2001, but represented 3.1% and 9.5% of all elective and emergency ICU admissions, respectively. Diagnoses of sepsis, pneumonia, trauma, and cardiopulmonary arrest were common among critically ill Indigenous patients. Following emergency admission, the crude hospital mortality for Indigenous patients was higher (22.7% v 19.2%; crude odds ratio, 1.24; 95% CI, 1.04-1.47) than for non-Indigenous patients. The crude hospital mortality of critically ill Indigenous patients was lower than that predicted by the APACHE II prognostic model and was similar to that of non-Indigenous patients after adjusting for severity of illness and chronic health status. CONCLUSIONS: The pattern of critical illness affecting Indigenous Australians in Western Australia was different from that affecting non-Indigenous patients. The crude hospital mortality was high, but similar to that of non-Indigenous Australians after adjusting for severity of illness and chronic health status.     

老年性急性心肌梗塞临床分析（附97例报告）

目的：研究老年性急性心肌梗塞（AMI）的临床经过及预后。方法。将我院1990－1999年中的133例AMI病人分为老年组（97例）和非老年组（36例）,分析两组的临床症状,主要并发症,住院病死率及死亡原因,结果：老年组中不典型或无明显我痛者多,泵衰竭或心律失常的发展率及住院病死率高,死亡原因依次为泵衰竭,休克及恶性心律失常,结论：老年性AMI症状不典型,并发症多,死亡率高,泵衰竭是老年AMI的主要死亡原因。     

中国危重症住院患者急性肾损伤的流行病学分析

目的明确中国危重症住院患者中急性肾损伤（AKI）的流行病学现状,包括AKI的发生率、临床特征、院内预后及相关危 险因素。方法收集全国9家地区性中心医院2013年间所有成人危重症住院患者的住院病历资料及血肌酐检验资料,AKI诊断 及分期采用改善全球肾脏病预后组织（KDIGO）2012年提出的AKI诊断标准。回顾性分析所有纳入患者的人口学特征、临床合 并症、AKI分期、院内预后、危险因素等指标。结果符合入选标准的危重症患者共14305人,其中4298人（30.04%）发生AKI, AKI 1、2、3期患者分别为2240（52.1%）、845（19.7%）及1213（28.2%）。AKI患者死亡716 人,院内死亡率为16.7%,死亡风险优 势比为7.59（95% CI 6.54~8.79, P<0.001）。随着AKI分期升高,患者住院天数延长、日均住院花费增多、死亡率升高（P值均小于 0.001）。多因素Logistic回归分析发现慢性肾脏病（CKD）（OR=5.45, 95% CI: 4.71~6.32, P<0.001）,肾外器官衰竭（OR=12.57, 95% CI: 11.24~14.07, P<0.001）,休克（OR=2.44, 95% CI: 2.01~2.96, P<0.001）,心脏手术（OR=5.96, 95% CI: 5.16~6.87, P< 0.001）等是危重症患者发生AKI的独立危险因素。在血肌酐变化符合KDIGO诊断标准的AKI人群中,仅有5.4%的患者出院有 “AKI”诊断。结论危重症患者中AKI发生率高,预后差。AKI分期与院内预后相关,CKD、肾外器官衰竭、休克、心脏手术是危 重症住院患者AKI主要的危险因素。住院期间多数AKI被漏诊,我们应提高对住院患者尤其是危重症患者AKI的重视。     

急性ST段抬高型心肌梗死合并急性肾损伤的危险因素及其对预后的影响

目的：探讨急性ST段抬高型心肌梗死(STEMI)患者并发急性肾损伤(AKI)的危险因素及其对预后影响。方法选择我院2009年7月至2014年6月急性STEMI住院患者302例,根据是否发生AKI将患者分成AKI组和非AKI组。分析AKI发生的相关危险因素,观察住院期间主要不良心血管事件(充血性心力衰竭、恶性心律失常、心源性休克)发生率及死亡率。随访观察出院后1年全因死亡率。结果 STEMI患者并发AKI 75例,发病率为24.83%。多因素Logistic回归分析结果显示,左心室射血分数(LVEF)降低(OR=0.013,95%CI：0.000~0.327)、KillipⅣ级(OR=20.050,95%CI：6.520~61.654)、利尿剂(OR=3.102,95%CI：1.250~7.697)是AKI发生的独立危险因素;与非AKI组患者比较,AKI组患者住院期间主要不良心血管事件发生率及住院死亡率(5.28%vs 13.33%)显著升高,两组间比较差异均有统计学意义(P<0.05)。两组患者随访1年的生存曲线结果显示,AKI组患者全因死亡率明显高于非AKI组,两组间比较差异有统计学意义(P=0.003)。结论 LVEF降低、KillipⅣ级及利尿剂应用是STEMI患者并发AKI的独立危险因素;STEMI患者并发AKI增加住院不良心血管事件发生率及死亡率,降低患者1年生存率。     

Lower than expected morbidity and mortality for an Australian Aboriginal population: 10-year follow-up in a decentralised community

OBJECTIVE: To examine mortality from all causes and from cardiovascular disease (CVD), and CVD hospitalisation rate for a decentralised Aboriginal community in the Northern Territory. DESIGN AND PARTICIPANTS: For a community-based cohort of 296 people aged 15 years or older screened in 1995, we reviewed hospital and primary health care records and death certificates for the period up to December 2004 (2800 person-years of follow-up). MAIN OUTCOME MEASURES: Mortality from all causes and CVD, and hospitalisation with CVD coded as a primary cause of admission; comparison with prior trends (1988 to 1995) in CVD risk factor prevalence for the community, and with NT-specific Indigenous mortality and hospitalisation rates. RESULTS: Mortality in the cohort was 964/100,000 person-years, significantly lower than that of the NT Indigenous population (standardised mortality ratio [SMR], 0.62; 95% CI, 0.42-0.89). CVD mortality was 358/100,000 person-years for people aged 25 years or older (SMR, 0.52; 95% CI, 0.23-1.02). Hospitalisation with CVD as a primary cause was 13/1000 person-years for the cohort, compared with 33/1000 person-years for the NT Indigenous population. CONCLUSION: Contributors to lower than expected morbidity and mortality are likely to include the nature of primary health care services, which provide regular outreach to outstation communities, as well as the decentralised mode of outstation living (with its attendant benefits for physical activity, diet and limited access to alcohol), and social factors, including connectedness to culture, family and land, and opportunities for self-determination.     

血糖浓度增高对急性心肌梗塞预后的影响

目的:回顾性地了解无论是否伴有糖尿病,血糖浓度增高对急性心肌梗塞住院病死率及心梗后心衰、心源性休克的影响。方法:1990年1月～2000年10月我院心肌梗塞住院病人100例,将入院时血糖浓度<6.6mmol/L作为A组。入院时血糖浓度增高在6.6～11.1mmol/L为B组。入院时血糖浓度>11.1mmol/L为C组,分别计算各组发生心衰、心源性休克的百分率及住院病死率。结果:A组心衰发生率10.71％,心源性休克发生率3.57％,住院病死率3.57％;B组心衰发生率41.18％,心源性休克发生率29.41％,住院病死率26.47％;C组心衰发生率52.63％,心源性休克发生率31.58％,住院病死率26.32％。B组、C组心衰发生率、心源性休克发生率及住院病死率比A组明显增加,差异有显著性。而B组与C组心衰发生率、心源性休克发生率及住院病死率无显著性差异。结论:血糖浓度增高,心衰、心源性休克发生率及住院病死率明显增高。     

29例急性心肌梗死院内死亡原因分析

目的探讨导致急性心肌梗死院内死亡的相关危险因素。方法总结437例急性心肌梗死患者资料,分为院内死亡组（29例）及存活组（408例）,对比临床资料,分析年龄、入院时心功能Killip分级、入院时心率、及非心脏合并症等情况,并分析29例院内死亡病例的死亡直接原因。结果死亡组年龄〉70岁,入院时心功能Killip分级在〉Ⅱ级,入院时心率〉100次/分,前壁心肌梗死,新发的阵发性心房颤动/心房扑动较对照组有显著性差异（P〈0.05）。多因素Logistic回归分析表明,年龄〉70岁（P=0.0104,OR=4.68,95%CI1.286～15.792）、入院时心功能Killip〉Ⅱ级（P=0.0072,OR=6.93,95%CI1.647～19.314）、前壁心肌梗死（P=0.0247,OR=3.81,95%CI 1.165～11.389）、新发的阵发性心房颤动/心房扑动（P=0.0169,OR=5.26,95%CI1.401～16.129）是急性心肌梗死院内死亡的独立危险因素。在29例死亡病例中,心源性休克导致死亡的病例是16例（55%）,心脏破裂导致死亡的病例是11例（38%）。结论年龄〉70岁、入院时心功能Killip〉Ⅱ级、前壁心肌梗死、新发的阵发性心房颤动/心房扑动是急性心肌梗死院内死亡的独立危险因素。     

急性主动脉夹层患者入院时血糖水平与其院内死亡的相关性研究

背景急性主动脉夹层（AAD）多见危重症,而高血糖是影响危重症患者死亡率的不良因素。目的探讨AAD患者入院时血糖水平与院内死亡率之间的关系。方法回顾性分析2015年1月至2020年8月在河北医科大学第四医院接受手术治疗的非糖尿病AAD患者的病例资料,根据入院时血糖水平分为：高血糖组（>7.8 mmol/L）和正常血糖组（≤7.8 mmol/L）。收集AAD患者基本信息及入院时实验室检查结果,以住院期间全因死亡或术后30 d无终点事件发生为观察终点。采用Cox回归模型分析AAD患者入院时血糖水平与院内死亡的关系,采用Kaplan-Meier方法进行生存曲线分析,绘制受试者工作特征（ROC）曲线评价入院时血糖水平对AAD患者院内死亡的预测价值;采用Cox回归模型分析AAD患者院内死亡的影响因素。结果491例AAD患者中高血糖组165例（33.6%）,正常血糖组326例（66.4%）。高血糖组患者院内死亡率较正常血糖组高（19.4% vs 10.4%,χ2=4.172,P=0.006）。在未调整模型中,高血糖组患者院内死亡风险为1.943〔95%CI（1.199,3.150）,P=0.007〕;调整年龄、性别后,高血糖组患者院内死亡风险为1.900〔95%CI（1.171,3.082）,P=0.009〕;调整年龄、性别、高血压、冠心病、吸烟、Stanford分型、收缩压及舒张压后,高血糖组患者院内死亡风险为1.840〔95%CI（1.124,3.010）,P=0.015〕。入院时血糖预测AAD患者院内死亡的ROC曲线下面积为0.612（0.546,0.696）,入院血糖截断值为9.4 mmol/L时,灵敏度为37.9%,特异度为84.9%。经多因素Cox回归模型分析,结果显示,Stanford A型〔HR=4.277,95%CI（1.942,9.420）,P<0.001〕和血糖〔HR=1.864,95%CI（1.617,2.113）,P=0.007〕为AAD患者院内死亡的影响因素。结论入院时血糖水平是AAD患者院内死亡的影响因素,且高血糖水平可能会增加AAD患者院内死亡风险。     

Incidence of bariatric surgery and postoperative outcomes: a population-based analysis in Western Australia

OBJECTIVE: To investigate the incidence of bariatric surgery and postoperative outcomes in a population-based cohort of patients in Western Australia over a 17-year period. DESIGN AND SETTING: A population-based incidence study of all bariatric procedures (n = 1403) performed in WA hospitals over the period 1988-2004, based on hospital morbidity and death data from the WA Data Linkage System. MAIN OUTCOME MEASURES: Changes in incidence of bariatric procedures over time; mortality and complications within 30 days after surgery; survival rates after surgery relative to age-, sex-, and period-matched survival rates in the general population; factors predictive of re-admission to hospital. RESULTS: The incidence of bariatric surgery increased from 1.2 procedures per 100 000 person-years in 1988 to 24.2 procedures per 100 000 person-years in 2004. Although some of this was ascribed to a rising prevalence of obesity generally, there was a 13-fold increase in the bariatric procedure rate within the obese population itself. At 5 years, the relative survival rate in bariatric patients was the same as the survival rate in the general population. Within the 30-day postoperative period, mortality was low (0.07%) and 9.6% of patients experienced complications. Those who had bypass-type procedures were more likely to be re-admitted within 30 days than those who had gastric reduction procedures (adjusted hazard ratio, 5.80 [95% CI, 3.42-9.84]). CONCLUSION: The use of bariatric surgery increased 20-fold over the study period. Relative survival after surgery was in line with population norms. The observed low mortality rates and moderate level of complications are similar to findings in other studies in which the proportion of reduction procedures has been high.     

Sixty-two severe and critical patients with 2009 influenza A (H1N1) in Shanghai, China

Background Pandemic influenza A (H1N1) emerged rapidly in China in May 2009. Preliminary comparisons with seasonal influenza suggest that pandemic 2009 influenza A (H1N1) disproportionately affects younger ages and causes generally mild disease. To characterize disease progress, comorbidities, and treatment outcomes among consecutive severe and critically ill patients in a hospital served as a reference center for the care of patients with H1N1 in Shanghai,China.Methods A retrospective study on 62 severe and critically ill patients with 2009 influenza A (H1N1) was conducted in Shanghai Public Health Clinical Center. Demographic data, symptoms, comorbidities, disease progression, treatments,and clinical outcomes were collected for analysis.Results Sixty-two severe or critically ill patients were admitted to the hospital with confirmed 2009 influenza A (H1N1) infection. The median age of the study cohort was 40 years old with a range from 18 years to 75 years, and 67.7% were males. All patients presented with fever and respiratory symptoms. At presentation, 34 patients (54.8%) had comorbidities such as smoking (29.0%), hypertension (29.0%) and hepatitis B virus infection (9.7%). The median time from symptom onset to hospital admission was 6 days (interquartile-range 3-14 days) and 23 critically ill patients were admitted to Intensive Care Unit after admission. All the patients received neuraminidase inhibitors (oseltaminir), while 60 patients (96.7%) were treated with antibiotics, and 39 (62.9%) with corticosteroids. Twenty-three critical cases received noninvasive mechanical ventilation on the first day of admission, and 3 of them ultimately required invasive ventilation.Four death reports (6.5%) were filed within the first 14 days from the onset of critical illness with the primary causes of severe acute respiratory distress syndrome, hypoxemia, or complications, secondary infection and sepsis,pyopneumothorax and stroke.Conclusions Severe illness from 2009 influenza A (H1N1) infection in Shanghai occurred among young individuals. Critical cases were associated with severe hypoxemia, multisystem organ failure, and a requirement for mechanical ventilation. Most patients had a good prognosis.     

血乳酸、乳酸清除率对重症患者预后的影响

目的:观察重症患者血乳酸、乳酸清除率和急性生理学与慢性健康状况评分Ⅱ(APACHEⅡ)评分对疗效和预后评估的意义.方法:68例重症患者行乳酸和乳酸清除率监测,24 h内行APACHEⅡ评分.分为存活组和病死组,高乳酸清除率组和低乳酸清除率组.结果:存活组患者6h乳酸清除率明显高于病死组(P<0.01),APACHEⅡ评分明显低于病死组(P<0.01).高乳酸清除率组患者APACHEⅡ评分和病死率均明显低于低乳酸清除率组(P<0.01).结论:重症患者乳酸清除率可作为危重病严重程度的监测指标,值得临床关注.     

Sixty-two severe and critical patients with 2009 influenza A (H1N1) in Shanghai, China

Background  Pandemic influenza A (H1N1) emerged rapidly in China in May 2009. Preliminary comparisons with seasonal influenza suggest that pandemic 2009 influenza A (H1N1) disproportionately affects younger ages and causes generally mild disease. To characterize disease progress, comorbidities, and treatment outcomes among consecutive severe and critically ill patients in a hospital served as a reference center for the care of patients with H1N1 in Shanghai, China.

Methods  A retrospective study on 62 severe and critically ill patients with 2009 influenza A (H1N1) was conducted in Shanghai Public Health Clinical Center. Demographic data, symptoms, comorbidities, disease progression, treatments, and clinical outcomes were collected for analysis.

Results  Sixty-two severe or critically ill patients were admitted to the hospital with confirmed 2009 influenza A (H1N1) infection. The median age of the study cohort was 40 years old with a range from 18 years to 75 years, and 67.7% were males. All patients presented with fever and respiratory symptoms. At presentation, 34 patients (54.8%) had comorbidities such as smoking (29.0%), hypertension (29.0%) and hepatitis B virus infection (9.7%). The median time from symptom onset to hospital admission was 6 days (interquartile-range 3–14 days) and 23 critically ill patients were admitted to Intensive Care Unit after admission. All the patients received neuraminidase inhibitors (oseltaminir), while 60 patients (96.7%) were treated with antibiotics, and 39 (62.9%) with corticosteroids. Twenty-three critical cases received noninvasive mechanical ventilation on the first day of admission, and 3 of them ultimately required invasive ventilation. Four death reports (6.5%) were filed within the first 14 days from the onset of critical illness with the primary causes of severe acute respiratory distress syndrome, hypoxemia, or complications, secondary infection and sepsis, pyopneumothorax and stroke.

Conclusions  Severe illness from 2009 influenza A (H1N1) infection in Shanghai occurred among young individuals. Critical cases were associated with severe hypoxemia, multisystem organ failure, and a requirement for mechanical ventilation. Most patients had a good prognosis.

     

中南地区结缔组织病住院患者10年死亡趋势：2005—2014

目的：分析结缔组织病(connective tissue diseases,CTDs)住院患者在10年期间死亡原因等的变化趋势。 方法：采用回顾性分析的方法,收集中南大学湘雅医院风湿免疫科在2005年1月1日至2014年12月31日期间,确诊的 CTDs住院患者中所有死亡病例的所有临床资料。结果：10年期间CTDs住院患者的总体住院病死率为15.68‰。在 CTDs患者的3大类死亡原因中,疾病本身占44.71%,感染占42.94%,合并症占12.35%。其中,疾病本身的死因构成比 和住院病死率呈逐年下降趋势,感染和合并症的死因构成比呈逐年上升趋势。2013—2014年,感染成为最主要的死 亡原因,其死因构成比为51.06%。合并肺间质病变的CTDs患者与没有合并肺间质病变的CTDs患者相比,前者的生存 时间明显缩短,其死亡风险是后者的1.722倍。在各种CTDs中,特发性炎性肌病患者的总住院病死率最高(45.98‰), 系统性硬化症和系统性红斑狼疮患者的因疾病本身死亡比例最高,特发性炎性肌病患者的因感染死亡比例最高,类 风湿关节炎的患者因合并症死亡比例最高。结论：在CTDs住院患者中,因疾病本身导致死亡的死因构成比和住院病 死率均呈逐年下降趋势;因感染和合并症导致死亡的死因构成比呈逐年上升趋势,且感染成为第一位死因。CTDs合 并肺间质病变患者生存时间缩短,死亡风险增加。     

血乳酸水平监测对老年危重患者预后的意义

目的探讨老年危重患者血乳酸水平与预后的相关关系,为临床治疗提供指导。方法回顾性分析卫生部北京医院2008年2月～2012年2月重症监护病房收治的老年危重症患者临床资料,根据患者预后分为存活组和死亡组,检测患者入住ICU时、入院后6 h静脉血乳酸水平,计算6 h乳酸清除率,并行急性生理学及慢性健康状况评分（APACHEⅡ）,分析乳酸清除率与老年危重症患者预后的关系。结果入院治疗期间患者死亡率为30.0%（30/100）;存活组血乳酸平均值为（4.12±3.20）mmol/L,阳性率为52.86%,死亡组血乳酸平均值为（8.86±5.60）mmol/L,阳性率为96.67%;两组比较差异有统计学意义（P〈0.05）。血乳酸平均值≥10.0 mmol/L时患者死亡率最高为95.45%,血乳酸平均值≤2.40 mmol/L时患者死亡率最低为3.84%。存活组6 h乳酸清除率[（38.73±2.22）%]明显高于死亡组[（16.21±2.30）%];存活组APACHEⅡ评分为（17.19±6.30）分,明显低于死亡组的（25.84±5.26）分,差异均有统计学意义（P〈0.05）。高乳酸血症患者APACHEⅡ评分和院内死亡率明显低于乳酸酸中毒患者,差异有统计学意义（P〈0.05）;高乳酸血症患者乳酸清除率明显高于乳酸酸中毒者,且差异有统计学意义（P〈0.01）。低清除率组死亡人数明显高于高清除率组,且差异有统计学意义（P〈0.05）。血乳酸水平与A-PACHEⅡ评分呈正相关（r=0.572,P〈0.05）;血乳酸水平与院内死亡率呈正相关（r=0.506,P〈0.05）。结论血乳酸是评价老年危重患者预后的良好指标,血乳酸值≥5.5 mmol/L应警惕患者有较差的预后,老年危重患者血乳酸水平与APACHEⅡ评分呈正相关,可作为评价危重病情的重要指标。     

The early effect of Medicare's prospective payment system on the use of medical intensive care services in three community hospitals

To assess the impact of Medicare's prospective payment system (PPS) on patient care and outcome from the medical intensive care unit (MICU), we reviewed the medical records of 400 MICU patients from three community hospitals: 200 patients were admitted before the PPS and 200 were admitted after the PPS. We sampled Medicare patients, aged 65 years and over, and non-Medicare comparison patients, aged 50 to 64 years, collecting data on case mix, treatment intensity and discharge disposition, hospital and six-month mortality, length of stay, and number of intensive care unit beds. After the PPS, the number of intensive care unit beds decreased 31%, without changes in MICU patients' illness severity or treatment intensity. Hospital length of stay decreased 15% in the Medicare group and 43% in the comparison group. For both Medicare and comparison patients combined, MICU length of stay decreased 14% and patients after the PPS were less likely to be discharged to go home. There were no significant changes in in-hospital or six-month mortality. Thus, clinically meaningful decreases in length of stay among seriously ill patients did not result in a change in in-hospital or six-month mortality.     

血清嗜铬粒蛋白A浓度对急症危重患者死亡的预测价值

目的：探讨ICU重症患者入院后2 h内的血清嗜铬粒蛋白A （Chromogranin A,CGA）水平对患者死亡的预测价值。方法入选连续入住ICU、排除全身反应性疾病的急症危重患者80例（病例组）,同时选取健康对照者20例（对照组）,比较研究对象的CGA、降钙素原（Procalcitonin,PCT）、血肌酐、白细胞计数等水平,探讨CGA水平对患者预后及死亡的影响;连续观察随访30 d,记录分析死亡情况。结果病例组患者入院后2 h内的CGA、血肌酐、PCT、WBC等指标均明显高于健康对照组（P＜0.05）;CGA水平与血肌酐、PCT、WBC均呈正相关（P＜0.05）;CGA=136μg/L为截断值时,CGA对死亡的预测灵敏度、特异度均最高（P＜0.05）;CGA水平升高与较差的预后有关（P＜0.05）。结论急症危重患者入院后2 h内的血清CGA水平与病情的危重症程度、机体炎性反应水平呈正相关,对预测患者的死亡有效,较高的CGA水平与患者较差的预后有关,应开展该类患者CGA的早期监测,为临床决策提供依据。     

重症患者急性期能量平衡对住院期间死亡的影响

目的 分析重症患者急性期(7 d内)不同阶段能量供给与院内病死率的相关性。方法 选取2019年4月至2021年4月收治于清华大学附属北京清华长庚医院重症医学科住重症加强护理病房(intensive care unit, ICU)时间≥7 d的重症患者作为研究对象。收集患者一般人口学资料以及入院7 d内的营养相关资料。采用多因素Logistic回归分析筛选出影响ICU患者院内死亡的独立危险因素。结果 共纳入ICU住院时间≥7 d的重症患者61例,其中死亡18例。多因素Logistic回归分析显示入ICU时营养风险筛查(Nutrition Risk Screening, NRS) 2002评分(P=0.018)、连续性肾脏替代治疗(continuous renal replacement therapy, CRRT)时间(P=0.013)以及ICU住院前3 d累计能量平衡(P=0.044)是院内死亡的独立危险因素,前3 d累计能量平衡每增加500 kcal(1 kcal=4.186 kJ),患者的院内死亡风险增加120%。此外,对于高营养风险患者(NRS 2002≥5),前3 d累计能量平衡(P=0.042)、CRRT时间(P=0.019)是其死亡的独立预测因素。而在低营养风险患者中(NRS 2002＜5),各项指标与院内死亡无相关关系。结论 入ICU最初3 d累计能量平衡、NRS 2002评分以及CRRT时间是影响ICU患者预后的独立危险因素,特别是对高营养风险的重症患者有重要意义。     

缺血性心脏病合并消化道出血患者的住院死亡危险因素分析

  目的   探讨缺血性心脏病（ischemic heart disease, IHD）合并消化道出血（gastrointestinal bleeding, GIB）患者发生住院死亡的危险因素。   方法   纳入2015年1月?2018年1月在四川大学华西医院住院治疗的IHD合并GIB的患者,收集其一般资料、基础疾病史、既往抗凝抗血小板药物史、入院时实验室检查及住院治疗措施等资料。以住院期间死亡作为研究终点事件,通过多因素二元logistic回归等统计方法分析该类患者住院期间死亡的独立危险因素,绘制受试者操作特征（receiver operating characteristic, ROC）曲线并计算曲线下面积（area under curve, AUC）。   结果   本研究共纳入符合标准的患者395例,其中342例患者好转出院,53例患者发生住院死亡事件,死因分析中心源性死亡居首位（54.7%）,其次是感染性死亡（24.5%）。logistic回归分析结果显示ST段抬高型心梗（ST-segment elevated myocardial infarction, STEMI）患者的死亡风险是非急性冠脉综合征患者的2.527倍〔比值比（odds ratio, OR）=2.527,95%置信区间（confidence interval, CI）:1.152～8.277,P=0.043〕,而合并慢性肾脏疾病患者的死亡风险是无肾脏疾病患者的2.89倍（OR=2.89,95%CI:1.187～7.037,P=0.019）。入院时较高的白细胞水平（OR=1.123,95%CI:1.057～1.193,P<0.001）和较低的血红蛋白水平（OR=1.014,95%CI:1.003～1.025,P=0.013）与患者住院死亡相关,而住院期间行内镜诊治（OR=0.305,95%CI:0.103～0.881,P=0.029）可降低患者的死亡风险。联合上述指标的ROC曲线,其预测患者发生住院死亡的AUC为0.79。   结论   IHD类型为STEMI、合并慢性肾脏疾病、入院时白细胞高和血红蛋白水平低,是IHD合并GIB的患者住院死亡结局的独立危险因素,而住院期间行内镜诊治是其保护因素。      

Rates of percutaneous coronary interventions and bypass surgery after acute myocardial infarction in Indigenous patients

OBJECTIVE: To compare rates of percutaneous coronary interventions (PCI) and bypass surgery after acute myocardial infarction (AMI) in Indigenous and non-Indigenous patients. DESIGN: Cohort study of public-sector patients who were followed up for 1 year using administrative hospital data. PARTICIPANTS AND SETTING: We followed up 14 683 public-sector patients admitted to Queensland hospitals for AMI between 1998 and 2002. Of these, 558 (3.8%) identified as Indigenous. OUTCOME MEASURES: Rates of PCI and bypass surgery, adjusted for differences between the Indigenous and non-Indigenous cohorts according to age, sex, socioeconomic status, remote residence, hospital characteristics, and comorbidities. RESULTS: The adjusted rate for PCI during the index admission was significantly lower by 39% (rate ratio [RR], 0.61; 95% CI, 0.38-0.98) among Indigenous versus non-Indigenous patients with AMI; the adjusted rate for subsequent PCI was significantly lower by 28% (RR, 0.72; 95% CI, 0.54-0.96). Adjusted rates for bypass surgery were similar in the two cohorts. For any coronary procedure (ie, PCI or bypass surgery), the adjusted rate was significantly lower by 22% (RR, 0.78; 95% CI, 0.64-0.94) among Indigenous patients with AMI. Diabetes, chronic renal failure, pneumonia, and chronic rheumatic fever were at least twice as common among Indigenous patients with AMI as in the rest of the cohort, and chronic bronchitis and emphysema and heart failure were at least 60% more common. If a patient had at least one comorbidity, then their probability of having a coronary procedure was reduced by 40%. CONCLUSIONS: There are likely to be several reasons for the lower rates of coronary procedures among Indigenous patients, but their high rates of comorbidities and the association of comorbidities with lower procedure rates was an important finding. As investment in primary care can reduce the prevalence and severity of comorbidities, we suggest that adequate primary health care is a prerequisite for effective specialist care.     

Clinical profile and outcomes of atrial fibrillation in elderly patients with acute myocardial infarction

Background Atrial fibrillation （AF） occurs commonly in patients with acute myocardial infarction （MI） and is associated with an increased long-term mortality. This study aimed to investigate the clinical characteristics and outcomes of AF in in-hospital elderly Chinese patients with acute MI.
Methods A total of 967 patients with acute MI, aged 〉65 years, were categorized on the basis of the absence or presence of AF. Patients with documented AF were classified into two subgroups： the ongoing AF group and the new-onset AF group. We retrospectively evaluated the clinical profile, in-hospital outcomes, and effects of revascularization on the incidence of AF in elderly patients with acute MI.
Results AF was documented in 100 （11.53%） patients and the incidence of new-onset AF was 6.51% during hospitalization. History of old MI and cerebrovascular events were more common in patients with AF than in those without AF （P 〈0.001, P 〈0.01, respectively）. The incidence of AF was higher in patients with non-ST elevated MI （P=0.014）, inferior wall MI （P=0.004） and cardiac function of Killip class Ⅲ or Ⅳ （P=-0.008）. Patients with AF had more complication of pneumonia （P=0.003） and longer hospital stay. Left circumflex coronary artery involvement was more common in patients with AF （compared with patients without AF, P 〈0.001）. Percutaneous coronary intervention or coronary artery bypass grafting significantly decreased the incidence of new-onset AF from 7.97% to 3.82% （P=0.017）. AF depended to heart failure, increased the in-hospital mortality.
Conclusions AF is common in elderly patients with acute MI and is associated with poorer clinical outcomes. Revascularization reduces the incidence of AF and thus improves the clinical outcomes in these patients.