山东省综合医院心内科护士识别病人风险能力现状及影响因素分析

目的:调查山东省综合医院心内科护士识别病人风险能力水平,分析护士识别病人风险能力的影响因素,为护理管理者准确地认识心内科护士识别病人风险能力现状,从而采取有效措施以促进病人安全提供依据。方法:采用一般资料调查表和护士识别病人护理风险能力评估问卷对山东省8个地级市30所综合医院的心内科护士进行调查。结果:心内科护士识别病人风险能力总分(79.82±12.42)分,风险知识掌握能力得分为(30.74±4.81)分,风险感知能力得分为(18.96±3.14)分,风险分析能力得分为(30.12±5.17)分;是否参加过识别病人风险的培训、是否参加过专科护士培训、从事护理工作年限、工作医院等级及从事心内科工作的科室是影响心内科护士识别病人风险能力的影响因素(P<0.05)。结论:心内科护士识别病人风险能力呈中等水平,对风险的感知和分析能力有待加强,护理管理者应重视心内科护士识别风险能力的培训与教育,建立风险管理体系,提高心内科护士识别风险的能力,以保障护理安全。

预立医疗照护计划在高风险手术病人中的应用进展

介绍高风险手术病人和预立医疗照护计划的概念内涵,综述预立医疗照护计划在高风险手术病人中应用的必要性、启动时机、参与人员、讨论内容、干预措施、辅助工具、影响因素,以期为我国在外科环境中开展预立医疗照护计划提供参考。

住院精神病人自杀风险评估量表的初步编制

目的：编制住院精神病人自杀风险评估量表，为评估住院精神病患者高自杀风险，制定针对性、预防性干预措施提供依据。方法随机抽取云南省8家精神病医院的住院精神病患者作为研究对象，根据量表编制程序及要求，查阅精神病患者自杀影响因素相关文献及有关自杀风险管理手册，初步编制形成量表，先后3次（预测、初测、再测）对876例住院精神病患者进行量表评估及修订；以简明精神病量表、汉密顿抑郁量表、护士用自杀评估风险量表为校标工具，最终编制形成住院精神病人自杀风险评估量表。结果编制形成具有25个条目的住院精神病人自杀风险评估量表，该量表在不同样本群体中总分与各条目的相关系数 r 值为0．13—0．64，内部一致性系数为0．79，分半信度为0．76，与简明精神病量表、汉密顿抑郁量表、护士用自杀评估风险量表校标相关系数分别为0．21、0．25、0．74，量表具有较好的信效度。结论住院精神病人自杀风险评估量表能甄别出具有高自杀风险的住院精神病患者，能够为制定针对性、预防性干预措施提供理论依据。

136例心房颤动病人抗凝治疗效果及安全性分析

目的分析心房颤动病人抗凝治疗用药情况及治疗效果。方法房颤病人卒中风险评估评分系统(CHADS2)评分≥2分的心房颤动病人均应口服华法林抗凝治疗;若评分为1分,可口服华法林或阿司匹林;评分为0分一般无须抗凝治疗。观察心房颤动病人采取不同抗凝治疗方案血栓及出血的发生情况。结果 87例病人CHADS2评分≥2分,29例口服华法林,其中出血4例,血栓2例;52例口服阿司匹林,其中出血2例,血栓5例;6例未服药,其中血栓3例。29例病人CHADS2评分为1分,9例口服华法林,其中出血2例,血栓1例;10例口服阿司匹林,其中出血1例,血栓1例;10例未服药,其中2例血栓。20例病人CHADS2评分为0分,其中2例口服阿司匹林,未发生出血或栓塞;18例未服药中发生1例脑梗死。结论抗凝是治疗心房颤动的重要方法,根据病人的病情选择适合的药物,给予个体化治疗尤为关键。

代谢综合征与脑卒中

代谢综合征（MS）患者是具有多重心脑血管病危险因素的高风险病人。MS与脑卒中密切相关，是独立于传统心脑血管危险因子之外的脑卒中危险因子。MS患者脑卒中风险和死亡率分别是无MS的3倍和5～6倍。胰岛素抵抗可能是联系MS与脑卒中的共同桥梁。控制体质量、调整情绪是预防MS的重要措施，综合治疗是防治MS脑卒中的基本原则，包括降糖、调脂、降压、减肥、抗血小板等。

Decreased expression of Klotho in cardiac atria biopsy samples from patients at higher risk of atherosclerotic cardiovascular disease

Background Klotho proteins （α- and β） are membrane-based circulating proteins that regulate cell metabolism, as well as the lifespan modulating activity of Fibroblast Growth Factors （FGFs）. Recent data has shown that higher plasma circulating Klotho levels reduce cardio- vascular risk, suggesting Klotho has a protective role in cardiovascular diseases. However, although so far it has been identified in various organs, it is unknown whether cardiomyocytes express Klotho and FGFs, and whether high cardiovascular risk could affect cardiac expres- sion ofKlotho, FGFs and other molecules. Methods We selected 20 patients with an estimated 10-year high atherosclerotic cardiovascular disease and 10 age-matched control subjects with an estimated 10-year low risk undergone cardiac surgery for reasons other than coronary artery by-pass. In myocardial biopsies, we evaluated by immuno-histochemistry whether Klotho and FGFs were expressed in cardiomyo- cytes, and whether higher cardiovascular risk influenced the expression of other molecules involved in endoplasmic reticulum stress, oxida- tive stress, inflammation and fibrosis. Results Only cardiomyocytes of patients with a higher cardiovascular risk showed lower expression of Klotho, but higher expressions of FGFs. Furthermore, higher cardiovascular risk was associated with increased expression of oxidative and endoplasmic reticular stress, inflammation and fibrosis. Conclusions This study showed for the first time that Klotho proteins are ex- pressed in human cardiomyocytes and that cardiac expression of Klotho is down-regulated in higher cardiovascular risk patients, while expression of stress-related molecules were significantly increased.

Genetic characteristics and pathogenicity of human hepatitis E virus in Nanjing,China

AIM： To investigate the genetic characteristics and pathogenicity of hepatitis E virus （HEV） and assess the potential risk factors for sporadic hepatitis E.

Clinical features and treatment options for mitral regurgitation in elderly inpatients

Objective To summarize clinical characteristics and treatment strategy of Chinese elderly mitral regurgitation （MR） inpatients under the current guidelines, and to identify factors related to treatment options in them. Methods A single center retrospective study was conducted in which patients hospitalized in Fuwai hospital from May ist of 2014 to April 30 of 2015 with moderate to severe MR assessed by transthoraeic echocardiography were enrolled consecutively （n = 1741）. Patients 〉 60 years old were grouped as elderly group （n = 680） and patients 〈 60 years were grouped as control group （n = 1061）. The elderly group was categorized into two subgroups based on surgical status. Results The mean age of the elderly group was 66.98 i 5.94 years. The most common reason of MR in elderly group was degenerative MR （41.18%）. Atherosclerotic risk factors such as hypertension, diabetes or hyperlipidaemia were more commonly observed in elderly group than the control group （45.44% vs. 25.17%, P 〈 0.001; 19.56% vs. 8.48%, P 〈 0.001; 35.29% vs. 19.51%, P 〈 0.001）. Elderly group had higher Enroscore Ⅱ score （5.54 ± 2.42 vs. 3.15 ± 1.66）, greater left ventricular end diastolic diameter （LVEDD） （57.72±12.3 vs. 57.33 ± 10.19 ram） and a lower surgery rate （54.71% vs. 63.91%）; P 〈 0.05. Age, left ventricular ejection fraction （LVEF）, regurgitation grade, Eu- roScore-Ⅱ high risk stratification and having diabetes were identified as factors associated with therapy decisions in elderly MR patients. Conclusions Valve surgery was denied in 45.29% of elderly MR inpatients. Older age, impaired LVEF, lower regurgitation grade, Euro- Score-Ⅱ high risk stratification, and having diabetes were factors most significantly associated with surgery denial among elderly Chinese inpatients with MR.

Metabolic syndrome after liver transplantation: Preventable illness or common consequence?

The metabolic syndrome is common after liver transplant being present in approximately half of recipients. It has been associated with adverse outcomes such as progression of hepatitis C and major vascular events. As the United States population ages and the rate of obesity increases, prevention of the metabolic syndrome in the post-transplant population deserves special consideration. Currently, the metabolic syndrome after transplant appears at least two times more common than observed rates in the general population. Specific guidelines for patients after transplant does not exist, therefore prevention rests upon knowledge of risk factors and the presence of modifiable elements. The current article will focus on risk factors for the development of the metabolic syndrome after transplant, will highlight potentially modifiable factors and propose potential areas for intervention. As in the non-transplant population, behavioral choices might have a major role. Opportunities exist in this regard for health prevention studies incorporating lifestyle changes. Other factors such as the need for immunosuppression, and the changing characteristics of wait listed patients are not modifiable, but are important to know in order to identify persons at higher risk. Although immunosuppression after transplant is unavoidable, the contribution of different agents to the development of components of the metabolic syndrome is also discussed. Ultimately, an increased risk of the metabolic syndrome after transplant is likely unavoidable, however, there are many opportunities to reduce the prevalence.

Biomarkers and potential pathogenesis of colorectal cancer-related ischemic stroke

AIM To investigate the specific biomarkers and potential pathogenesis of colorectal cancer-related ischemic stroke(CRCIS).METHODS A retrospective study was conducted on CRCIS patients(colorectal cancer patients with ischemic stroke without conventional stroke risk factors) registered at seven centers between January 2007 and December 2017. Clinical data and laboratory and imaging findings were compared with age-and sex-matched patients with colorectal cancer(CRC) without ischemic stroke that were admitted to the same hospital during the same period. Univariate and multivariate analyses were performed to analyze the independent risk factors for CRCIS. A receiver operator characteristic curve was configured to calculate the optimal cut-off value of the products of the independent risk factors for CRCIS. RESULTS A total of 114 CRCIS patients and 114 CRC patients were included. Multiple lesions in multiple vascular territories were common in CRCIS patients(71, 62.28%). The levels of plasma D-dimer, carcinoembryonic antigen(CEA), cancer antigen 125, and neutrophil count were significantly higher in CRCIS patients than in CRC patients. Multiple logistic regression analysis revealed that plasma D-dimer levels [odds ratio(OR) = 1.002, 95% confidence interval(CI): 1.001-1.003, P < 0.001], CEA levels(OR = 1.011, 95%CI: 1.006-1.015, P < 0.001), and neutrophil count levels(OR = 1.626, 95%CI: 1.268-2.087, P < 0.001) were independent risk factors for CRCIS. In addition, receiver operator characteristic curve revealed that the area under curve for the products of plasma D-dimer, CEA, and neutrophil count was 0.889 ± 0.022(95%CI: 0.847-0.932, P < 0.001), and the optimal cut-off value for the product was 252.06, which was called the CRCIS Index, with a sensitivity of 86.0% and specificity of 79.8%.CONCLUSION Hypercoagulability induced by elevated CEA and neutrophils may be an important cause of CRCIS. The CRCIS index, which serves as a biomarker of CRCIS, needs further study.

Obesity paradox among elderly patients with coronary artery disease undergoing non-cardiac surgery

Background High body mass index （BMI） is a risk factor for chronic cardiac disease. However, mounting evidence supports that high BMI is associated with less risk of cardiac morbidity and mortality compared with normal BMI, also known as the obesity paradox. There- fore, we sought to determine the existence of the obesity paradox in regard to perioperative 30-day cardiac events among elderly Chinese patients with known coronary artery disease undergoing non-cardiac surgery. Methods A post-hoc analysis of a prospective, multi-institutional cohort study was performed. Patients aged 〉 60 years with a history of coronary artery disease and undergoing non-cardiac surgery were grouped according to BMI： underweight （〈 18.5 kg/m2）, normal weight （18.5-24.9 kg/m2）, overweight （25-29.9 kg/m2） and obese （≥ 30 kg/m2）. Demographic information, perioperative clinical variables and incidence of 30-day postoperative cardiac adverse event were retrieved from a research database. Results We identified 1202 eligible patients （BMI： 24.3 ± 3.8 kg/m2）. Across BMI groups, a U-shaped distribution pattern of incidence of 30-day postoperative major cardiac events was observed, with the lowest risk in the overweight group. When using the normal-weight group as a reference, no difference was found in either the obesity or overweight groups in terms of a major cardiac adverse event （MACE）. However, risk of a 30-day postoperative MACE was significantly higher in the underweight group （odds ratio [OR] 2.916, 95% confidence interval [CI]： 1.072-7.931, P = 0.036）. Conclusion Although not statistically significant, the U-shaped relation between BMI and cardiac complications indicates the obesity paradox possibly exists.

Different risk factors influence peptic ulcer disease development in a Brazilian population

AIM: To investigate age, sex, histopathology and Helicobacter pylori (H. pylori) status, as risk factors for gastroduodenal disease outcome in Brazilian dyspeptic patients.tients submitted to upper gastroscopy at Hospital das Clinicas of Marilia, antral biopsy specimens were obtained and subjected to histopathology and H. pylori diagnosis. All patients presenting chronic gastritis (CG) and peptic ulcer (PU) disease localized in the stomach, gastric ulcer (GU) and/or duodenal ulcer (DU) were included in the study. Gastric biopsies (n = 668) positive for H. pylori by rapid urease test were investigated for vacuolating cytotoxin A (vacA ) medium (m) region mosaicism by polymerase chain reaction. Logistic regression analysis was performed to verify the association of age, sex, histopathologic alterations, H. pylori diagnosis and vacA m region mosaicism with the incidence of DU, GU and CG in patients. RESULTS: Of 1466 patients submitted to endoscopy, 1060 (72.3%) presented CG [male/female = 506/554; mean age (year) ± SD = 51.2 ± 17.81], 88 (6.0%) presented DU [male/female = 54/34; mean age (year) ± SD = 51.4 ± 17.14], and 75 (5.1%) presented GU [male/female = 54/21; mean age (year) ± SD = 51.3 ± 17.12] and were included in the comparative analysis. Sex and age showed no detectable effect on CG incidence (overall c 2 = 2.1, P = 0.3423). Sex [Odds ratios (OR) = 1.8631, P = 0.0058] but not age (OR = 0.9929, P = 0.2699) was associated with DU and both parameters had a highly significant effect on GU (overall c 2 = 30.5, P < 0.0001). The histopathological results showed a significant contribution of ageing for both atrophy (OR = 1.0297, P < 0.0001) and intestinal metaplasia (OR = 1.0520, P < 0.0001). Presence of H. pylori was significantly associated with decreasing age (OR = 0.9827, P < 0.0001) and with the incidence of DU (OR = 3.6077, P < 0.0001). The prevalence of m1 in DU was statistically significant (OR = 2.3563, P = 0.0018) but not in CG (OR = 2.678, P = 0.0863) and GU (OR = 1.520, P = 0.2863). CONCLUSION: In our population, male gender was a risk factor for PU; ageing for GU, atrophy and metapla-sia; and H. pylori of vacA m1 genotype for DU.

Association of glutathione peroxidase-1 （GPx-1） rs1050450 Pro198Leu and Pro197Leu polymorphisms with cardiovascular risk：a meta-analysis of ob-servational studies

Objective To clarify the association between rs1050450 polymorphism in Glutathione peroxidase-1 （GPx-1） and the risk of cardi-ovascular diseases （CVD） by performing a meta-analysis of published studies. There is growing evidence from different study types for an association of the GPx-1 polymorphism and cardiovascular outcomes, but observational studies have so far shown inconsistent results. Me-thods Relevant publications were searched through PubMed, Embase database databases and the Cochrane Library. We used odds ratios （ORs） with 95%confidence intervals （CIs） to assess the strength of association under the best genetic model. Both Q statistic and the I2 were used to check heterogeneity. Meta-regression analysis was performed to explore heterogeneity source. Sensitivity analysis, cumulative me-ta-analysis analysis and publication bias were used to test the reliability of the results. Results Data were available from two cohort studies and 8 case-control studies involving 1,430 cases and 3,767 controls. The pooled ORs for overall CVD risk was 1.36 with 95%CI：1.08-1.70 under a co-dominant model, and that for East Asian subgroup was 1.84 （95%CI：1.39-2.43）. Substantial heterogeneity for ORs were de-tected among all the included studies, mainly caused by ethnic differences between East Asian and non-East Asian populations. Although Egger＇s regression test suggested no statistical significant publication bias, Begg＇s funnel plot exhibited obvious asymmetry. The statistical significance disappeared after adjusting for potential publication bias in the overall studies. However, no substantial publication bias was found in the East Asian subgroup. Conclusions GPx-1 gene Pro198Leu and Pro197Leu polymorphisms considerably increased the risk of CVD in the East Asian population. Large-scale investigations are needed to confirm the results in different ethnicities.

Incidence and survival of stomach cancer in a high-risk population of Chile

AIM:To study the incidence and survival rate of stomach cancer(SC)and its associated factors in a high risk population in Chile. METHODS:The population-based cancer registry of Valdivia,included in the International Agency for Research on Cancer system,covers 356 396 residents of Valdivia Province,Southern Chile.We studied all SC cases entered in this Registry during 1998-2002 (529 cases).Population data came from the Chilean census(2002).Standardized incidence rates per 100 000 inhabitants(SIR)using the world population, cumulative risk of developing cancer before age 75, and rate ratios by sex,age,ethnicity and social factors were estimated.Relative survival(EdererⅡmethod) and age-standardized estimates(Brenner method) were calculated.Specific survival rates(Kaplan-Meier) were measured at 3 and 5 years and survival curves were analyzed with the Logrank and Breslow tests. Survival was studied in relation to demographics, clinical presentation,laboratory results and medical management of the cases.Those variables significantly associated with survival were later included in a Cox multivariate model. RESULTS:Between 1998 and 2002,529 primary gastric cancers occurred in Valdivia(crude incidence rate 29.2 per 100000 inhabitants).Most cases were male(69.0%), residents of urban areas(57.5%)and Hispanic(83.2%), with a low education level(84.5%<8 school years). SC SIR was higher in men than women(40.8 and 14.8 respectively,P<0.001),risk factors were low education RR 4.4(95%CI:2.9-6.8)and 1.6,(95%CI:1.1-2.1) for women and men respectively and Mapuche ethnicity only significant for women(RR 2.2,95%CI:1.2-3.7).Of all cases,76.4%were histologically confirmed,11.5% had a death certificate only(DCO),56.1%were TNM stageⅣ;445 cases(84.1%)were eligible for survival analysis,all completed five years follow-up;42 remained alive,392 died of SC and 11 died from other causes. Specific 5-year survival,excluding cases with DCO,was 10.6%(95%CI:7.7-13.5);5-year relative survival rate was 12.3%(95%CI:9.1-16.1),men 10.9%(95%CI: 7.4-15.2)and women 16.1%(95%CI:9.5-24.5).Fiveyear specific survival was higher for patients aged<55 years(17.3%),with intestinal type of cancer(14.6%), without metastasis(22.2%),tumor size<4 cm(60.0%), without lymphatic invasion(77.1%),only involvement of the mucous membrane(100%).Statistically significant independent prognostic factors were:TNM staging, diffuse type,metastasis,supraclavicular adenopathy, palpable tumor,and hepatitis or ascites. CONCLUSION:Social determinants are the main risk factors for SC,but not for survival.An advanced clinical stage at consultation is the main cause of poor SC survival.

Risk factors and gene polymorphisms of inflammatory bowel disease in population of Zhejiang,China

AIM:To identify the risk factors and three single nucleotide polymorphisms(SNPs) of NOD2/CARD15 gene in inflammatory bowel disease(IBD) of the population in Zhejiang,China.METHODS:A case-control study was conducted using recall questionnaire to collect data on demographic,socioeconomic,lifestyle characteristics and dietary behaviors from 136 determined IBD patients and 136 paired healthy controls.COX regression method was used to screen the statistically significant risk factors for IBD.The polymorphisms of NOD2/CARD15 gene Arg702Trp,Gly908Arg and Leu1007fsinsC were genotyped and further compared between 60 patients with IBD and 60 healthy controls by polymerase chain reaction and restriction fragment length polymorphism.RESULTS:IBD occurred primarily in young and middle-aged people.The mean age for IBD patients was 42.6 years.The ratio of males to females was 1.23:1.COX regression indicated a higher statistical significance in milk,fried food and stress compared with the other postulated risk factors for IBD.None of the patients with IBD and healthy controls had heterozygous or homozygous SNPs variants.CONCLUSION:Milk,fried food and stress are associated with increased risk of IBD.The common variants in NOD2/CARD15 gene are not associated with IBD in China's Zhejiang population.

Effects of angiotensinogen gene polymorphisms on the risk of coronary heart disease in the Chinese population： a meta-analysis

Objective Coronary heart disease （CHD） is a multifactorial disease. This meta-analysis was performed to evaluate the relationship between angiotensinogen gene polymorphisms and CHD in the Chinese population. Methods We searched literature in pubmed （1990- 2010.8） and CNKI （1990-2010.8） for all the relevant studies on 2 angiotensinogen polymorphisms （M235T and T174M） and risk of CHD. The meta-analysis software Stata 10.0 was used for ascertaining heterogeneity among individual studies and for combining all the studies. Furthermore,Egger＇s test and sensitivity analysis were performed to insure authenticity of the outcome.Results Ten associations studies on 2 angiotensinogen polymorphisms （M235T and T174M） were included in this meta-analysis. In a combined analysis, the summary per-allele odds ratio for CHD of the M235T polymorphism was 1.374 （95% confidence interval, 1.019 to 1.852） and T174M polymorphism was 4.089 （95% confidence interval, 1.697 to 9.851）. Conclusions The M235T polymorphism had weak but statistically significant association with CHD while the T174M polymorphism was more strongly associated with a CHD risk in Chinese population, but further confirmation studies are needed

接诊中的艺术别忘记

法制的逐步完善即保护了病人的利益,也维护了医生的权益,使医疗纠纷的处理有法可循,依法处理。在日常的医疗活动中,如果医生在兼顾治疗的同时能注意接诊的艺术,不但会减少医疗纠纷的发生,更能改善医患关系。本文作者对接诊中可能遇到的问题和处理方法予以介绍,我们也欢迎广大读者能参与到这一话题中。

Chronic kidney disease as a predictor of clinical risk in the elderly

Facing the needs of an increasingly ageing population is rapidly becoming a major public health issue in western countries, Chronic kidney disease （CKD）, whose current prevalence is estimated around 10%-15% in the general population, with considerably higher figures in at-risk groups, is widely known to increase with age. In the elderly, renal impairment is often concomitant or secondary to several other systemic disorders such as hypertension, atherosclerosis,

低剂量替格瑞洛在高出血风险ACS病人PCI术后抗血小板治疗中的有效性及安全性分析

评价替格瑞洛对高出血危险的 ACS患者进行 PCI后应用于抗血小板药物的疗效和安全性。方法 选择在2022年至2023年间在本院行 PCI手术的高出血危险 ACS病人356例,分2组,对照组选用正常剂量替格瑞洛,研究组选用低剂量替格瑞洛。结果 与对照组比,研究组心血管事件及不良反应发生率均较低(P<0.05);研究组的各项凝血指标检测水平存在明显差异性(P<0.05);研究组的TEG结果以及血小板参数具有明显差异(P<0.05)。结论 低剂量替格瑞洛在高出血风险ACS病人PCI术后抗血小板的治疗效果更好,可以明显减少患者心血管事件的整体发生情况,改善凝血指标,降低不良反应发生率,安全性更好,值得推广。