晚期肿瘤患者及家属对预先指示态度的一致性研究

目的 调查并分析肿瘤患者及其家属对预先指示及生命支持治疗（life-sustaining treatments,LSTs）态度的一致性。方法 便利抽取武汉市2所三级甲等医院肿瘤科配对患者及家属242对, 采用预先指示态度调查表调查患者及家属对预先指示及LSTs的态度。结果 向患者解释预先指示后,51.65%的肿瘤患者愿意制订预先指示,如果患者制订了预先指示,大部分家属（89.26%）表示愿意遵循患者的意愿。肿瘤患者及其家属对预先指示态度均为愿意占48.35%、均为不愿意占1.65%,Kappa值为0.05（P＞0.05）,一致性一般。肿瘤患者及家属对6项LSTs（心肺复苏、机械通气、鼻饲、输血、手术、血液透析）的态度均为愿意占16.94%~38.84%;均为不愿意占1.65%~4.96%,均没考虑过为9.92%~17.77%,Kappa值为0.09~0.18（P＜0.05）,一致性较弱。结论 肿瘤患者及家属对预先指示的态度无差异,均表现为积极的接受态度;家属对LSTs的选择不能完全代表患者的意愿。     

医护人员对预先指示的态度及其影响因素分析

目的：调查临床医护人员对预先指示的态度并分析其影响因素,为有针对性地在临床医护人员中推广预先指示观念提供依据。方法：采用分层抽样与方便抽样相结合的方法,对郑州市不同等级医疗机构的298名一线医护人员进行问卷调查,采用logistic回归分析筛选医护人员预先指示态度的影响因素。结果：86.6%的医护人员支持使用预先指示,子女情况、患者家属因素（曾遇到患者家属因治疗措施争执）、患者自主权、促进安乐死的应用、有被滥用的可能（患者可能被迫签署及医生会忽视病情）、医护人员主观因素（工作中情感负担过重、讨论预先指示显得冷漠麻木及应尽可能延长患者生命）等为预先指示态度的影响因素。结论：医护人员对预先指示的态度受多种因素影响,应采取针对性措施对医护人员、患者及家属进行教育,为预先指示的应用做好准备。     

4级手术病人预先指示知识现状及其影响因素分析

[目的]调查4级手术病人预先指示知识水平并分析其影响因素,为推广预先指示在我国医学临床上的应用提供参考。[方法]采用横断面调查方法,应用预先指示知识量表以及自设的一般资料调查表对安徽省某2所三级医院120例4级手术病人进行问卷调查。[结果]4级手术病人的预先指示知识得分为(2.79±1.63)分,单因素分析显示不同年龄、文化程度、居住地4级手术病人预先指示知识水平不同(P0.05),多元线性回归分析显示居住地为影响4级手术病人预先指示水平的独立影响因素(P0.01)。[结论]4级手术病人预先指示知识水平较低,特别是农村病人。应采取针对性措施对病人进行宣教,为预先指示的推广与应用做好准备。     

预先指示的国内外发展现状

归纳预先指示相关概念,总结国内外发展现状及评估工具,分析预先指示在我国推广的影响因素,为预先指示在我国医疗实践中的推广提供一定有益参考.     

125例非霍奇金淋巴瘤患者的临床和预后分析

本研究旨在分析非霍奇金淋巴瘤（NHL）的临床资料，探讨影响预后的因素。对125例NHL病例进行了回溯性分析。结果发现，125例病例中B—NHL85例（68％），T—NHL35例（28％），不能分类的5例（4％）。B—NHL易于侵犯骨髓，而T—NHL多伴有B症状，乳酸脱氢酶（LDH）升高，临床分期晚，国际预后指数（IPI）评分高，且T—NHL的3年存活率明显低于B—NHL。生存分析显示，年龄、B症状、LDH水平、临床分期为预后相关因素，免疫分型对预后无显著性影响。骨髓侵犯的发生率为31．2％（39／125），在B—NHL多见。骨髓侵犯方式与年龄、B症状、LDH水平、T／B免疫分型无关，但弥漫型骨髓侵犯多伴有肝脾肿大，且总体生存率明显低于局灶型。结论：年龄、B症状、LDH水平和临床分期是影响NHL预后的主要因素，免疫分型尚不足以成为判断预后的独立因素，骨髓侵犯方式对预后有一定的提示意义。     

非霍奇金淋巴瘤患者护理方法探讨

近年来,淋巴瘤的发病率越来越高,尤其是非霍奇金淋巴瘤（non-Hodgkin＇s lymphoma,NHL）侵袭性强,化疗是最常用的方法之一,但是化疗药物在抑制或杀伤肿瘤细胞的同时,也给患者机体带来了较大的不良反应,患者难以承受而中断治疗,而化疗过程中的护理可明显减轻患者的病痛及心理负担,增加化疗依从性,提高其生存质量。     

霍奇金淋巴瘤的研究进展

霍奇金淋巴瘤病理学方面的进展包括分类和R -S细胞的来源 ,其病因还不清楚 ,主要是与EBV感染有关 ,也有EBV阴性且其他一系列病毒也阴性的报道。尽管HL的发生率低于NHL ,但误诊率在国内、外报道均很高 ,故就其病因、发病机理及诊断等问题作以论述     

我国预先指示的文献计量学分析

目的分析我国预先指示研究现状及其潜在的问题,为今后预先指示进一步在我国的发展提供参考。方法在中国知网、万方、中国生物医学数据库、PubMed和CINAHL数据库上系统搜索从建库至2018年12月31日所有关于我国预先指示的文献,将符合标准的文献纳入进行计量分析。结果共纳入113篇文献,最早的文献发表于1993年,自2011年后文献数量逐渐增多,多数研究集中于经济发达的沿海地区、中、东部,较缺乏国家级等基金支持。研究类型以描述性研究为主,占78.9%;研究主题以预先指示的认知状况调查为主,占45.49%;研究对象以老年人和癌症患者居多,占66.2%。结论我国研究预先指示的文献数量不多且总体质量偏低。应加大对预先指示的重点研究,结合多学科理论和临床实践,推进预先指示的发展。     

非霍奇金淋巴瘤研究的新进展

WHO(2008)淋巴造血组织肿瘤分类自出版以来已被广泛接受,成为病理与临床之间沟通的语言。本文着重根据近期相关文献,对存在争议的问题和新进展作以介绍。     

非霍奇金淋巴瘤的超声研究

目的研究非霍奇金淋巴瘤的超声特点,为临床医师诊治提供有效依据。 方法收集资料完整的非霍奇金淋巴瘤患者115例。对淋巴结的大小、硬度、淋巴门结构和纵横比等指标与病理学诊断对照进行分析研究。 结果详细描述非霍奇金淋巴瘤侵犯淋巴结、骨髓（或血）和结外组织的超声特点。发现该瘤还是侵犯淋巴结为主,以颈部最多;当淋巴结〉20mm时,淋巴结门结构不清,硬度硬和纵横比〉0.6可以提示为淋巴瘤。并且对误诊病例进行仔细回顾和分析。 结论超声是辅助检查中最有效方便的,通过连续观察淋巴结变化特点等指标能反映患者的治疗疗效。     

An exploration of decision-making factors regarding advance directives in a long-term care facility

PURPOSE: To explore the experiences of residents who had signed an advance directive on admission to a long-term care facility and apply the Advance Directive Decision-Making Model to this process. DATA SOURCES: Interactive interviews with 13 elders. Questions related to how each felt about their life and death, how each perceived the advance directive discussion, and what factors influenced their decisions were discussed. CONCLUSIONS: The thematic analysis suggested that the decision regarding advance directives was multifaceted and complex. It required preparation, understanding, and time. Decision-making ability was sometimes compromised by the other stressors associated with the move to a long-term care facility. IMPLICATIONS FOR PRACTICE: Nurse practitioners will have an easier time discussing medical conditions and choices regarding end-of-life care with residents and their families if advance directives are discussed thoroughly on admission to a long-term care facility and are updated routinely.     

晚期肿瘤患者及家属对生命支持治疗“预先委托”接受度的调查分析

目的 调查并比较晚期肿瘤患者及家属对生命支持治疗“预先委托”的态度,为探讨其在中国内地实施的可行性提供一定的依据.方法 采用描述性研究设计,调查了上海市某三级甲等肿瘤医院晚期肿瘤患者75例和晚期肿瘤患者家属112名,研究工具包括一般资料调查表及“预先委托”态度问卷.结果 患者与家属的态度差异具有统计学意义,但都呈现较为积极的接纳态度;文化程度及宗教信仰对患者的态度存在显著性影响;患者与家属对患者终末治疗选择表现出矛盾的心理,医护人员应给予正确引导.结论 晚期肿瘤患者和家属对“预先委托”的接受度较高,具体实施还需医护人员的支持和正确引导.     

阿德福韦酯对抗HBc阳性霍奇金淋巴瘤患者肝功能的影响

目的探讨抗HBc阳性霍奇金淋巴瘤患者化疗期间服用阿德福韦酯预防肝功能损害的效果。方法选取2009年3月—2012年5月本院收治的抗HBc阳性霍奇金淋巴瘤患者52例,随机分为观察组和对照组,每组26例。对照组患者仅给予化疗治疗,观察组患者在化疗治疗基础上加用阿德福韦酯治疗。比较2组患者的肝功能变化。结果治疗后4周,观察组患者血清AST、ALT、ALP水平低于对照组,差异具有统计学意义(P<0.05);观察组患者人血白蛋白水平高于对照组(P<0.05),血清胆红素以及胆汁酸水平低于对照组,差异均有统计学意义(P<0.05)。结论抗HBc阳性霍奇金淋巴瘤患者化疗期间服用阿德福韦酯可以有效保护肝脏功能,减轻乙肝病毒的损害,值得临床推广应用。     

The use of advance directives among patients with implantable cardioverter defibrillators

Background: We aimed to determine the prevalence of advance directives (ADs) among patients with implantable cardioverter defibrillators (ICDs) and of ADs that addressed ICD management at the end of life. Methods: The medical records of all patients who underwent ICD implantation during 2007 at a single institution were reviewed retrospectively to determine the number of patients with an AD and the number of ADs mentioning the ICD specifically (i.e. ICD management at end of life). Results: During 2007, 420 patients (males, 71%) underwent ICD implantation at our institution (mean age [range] at implantation, 63 [1–90] years). Primary prevention was the most common indication for device therapy (254 patients [61%]). Overall, 127 patients (30%) had an AD, with 83 ADs (65%) completed more than 12 months before ICD implantation and 10 (8%) completed after it. Several life‐sustaining treatments were mentioned in the ADs: tube feeding, 46 (37%); cardiopulmonary resuscitation, 25 (20%); mechanical ventilation, 22 (17%); and hemodialysis, nine (7%). Pain control was mentioned in 58 ADs (46%) and comfort measures in 38 (30%). However, only two ADs (2%) mentioned the ICD or its deactivation at end of life. Conclusions: About one‐third of patients with ICDs had an AD, but only a couple ADs mentioned the ICD. These results suggest that clinicians should not only encourage patients with ICDs to complete an AD, but also encourage them to address ICD management specifically. Not addressing ICD management in an AD may result in ethical dilemmas during end‐of‐life care. (PACE 2012; xx; 1–7)     

Use of advance care directives for individuals with dementia living in residential accommodation: A descriptive survey

BackgroundEnd-of-life decision-making for individuals living with a dementia needs to be addressed because as dementia progresses, individuals need support to make decisions about their health care, living arrangements and end-of-life care changes. Advance care directives (ACDs) provide an opportunity for individuals living with a dementia to communicate their wishes about these important issues.AimThe aim of this study was to understand how Australian registered nurses (RNs) use ACDs for individuals with a dementia living in residential accommodation.MethodsTwo hundred and thirty eight RNs working in Australian residential accommodation were recruited via social media, professional organisations and organisations providing residential accomodation. Respondents completed an online survey delivered via Survey Monkey.Findings59.7% of respondents reported commencing discussions around ACDs within the first month of individuals living with a dementia relocating to residential accommodation. However, 42.4% never or rarely completed ACDs. Only 59.3% stated that ACDs for individuals living with a dementia were always or often regularly reviewed. 53.8% identified that ACDs were always adhered to when an individuals’ circumstances changed. 62.6% felt that understanding among families about ACDs was sometimes, or often, a barrier to using ACDs.ConclusionThe implementation of ACDs in Australian residential accommodation for those living with a dementia remains sub-optimal. This study has demonstrated that ACD documentation and policies describing how they should be used exist, but gaps remain around the practical implementation of ACDs. Strategies to promote communication and collaboration between residential facilities, general practitioners and carers / families could also assist in providing cohesive, high quality care.     

IMP3和CD30蛋白在霍奇金淋巴瘤H/RS细胞中的表达及意义

目的 探讨IMP3蛋白在霍奇金淋巴瘤(HL) H/RS细胞中的表达及意义.方法 采用免疫组化半定量及计数方法观测34例HL组织标本中IMP3和CD30蛋白的表达,比较两种蛋白在H/RS细胞中的阳性率和表达强度之间的差异.结果 34例HL中结节性淋巴细胞为主型(NLPHL) 13例,经典型(CHL)21例.13例NLPHL中,IMP3阳性率100％,CD30均呈(-);IMP3阳性的H/RS细胞所占比例86.07％±14.21％,明显高于CD30(P＜0.01).在21例CHL中,IMP3和CD30阳性率100％,病变中～重度中IMP3阳性率90.4％(19/21)明显高于CD30的阳性率42.8％ (9/21)(P＜0.01).H/RS阳性细胞数占总H/RS细胞数的比例,IMP3 (92.07％±5.34％)明显高于CD30 (84.86％±10.65％)(P＜ 0.05).结论 IMP3在NLPHL和CHL的瘤细胞胞质内普遍高强度表达,极易识别,结合CD30蛋白免疫标记,可以提高HL的诊断率.IMP3很有可能成为HL辅助诊断的新型免疫标记物.     

癌症病人对生前预嘱态度的质性研究

[目的]了解癌症病人对生前预嘱的态度,为生前预嘱推广策略的制定及开展提供依据。[方法]通过文献回顾、专家咨询,制成访谈提纲。采用目的抽样法,选择2018年5月—2018年11月在武汉市某三级甲等医院肿瘤科住院的14例癌症病人,进行面对面、半结构式深入访谈。[结果]共得出5个主题:对生前预嘱知识的了解程度、生前预嘱知识的获取途径、对生前预嘱的态度、临终决策的制定者、临终阶段的治疗侧重点。[结论]需进一步加强对病人和家属生前预嘱、死亡方面的相关教育,加强医务人员相关培训,并逐渐改变临终治疗的决策模式,以促进生前预嘱的开展。     

Randomized study of stability and change in patients' advance directives

Little is known about ethnic differences in understanding or using advance directives (ADs). Although health practitioners may presume AD intentions are durable over time, there is no supporting evidence. This randomized study intended to (a) examine differences between hospitalized Hispanic and non-Hispanic patients' AD preferences, (b) assess AD stability, and (c) discover if the Life Support Preferences Questionnaire (LSPQ) influences AD preferences. Hispanics and non-Hispanics showed no difference in AD preferences. However, non-Hispanics were more likely to change AD preferences. The LSPQ itself prompted change in AD preferences, delivering an educational effect with no specific educational intent. Change seen in patients' ADs, even over a brief interval, suggests revisiting AD preferences with patients and their families after hospitalization.     

Patients' understanding of advance directives and cardiopulmonary resuscitation

OBJECTIVE: To describe understanding of end-of-life issues and compare characteristics of patients with and without advance directives. SETTING: A 325-bed community teaching hospital. MEASUREMENTS: Questionnaires were administered to all patients admitted to the medical-surgical wards. RESULTS: Of 755 patients admitted during the study period, 264 patients participated in the study, and 82 (31%) had living wills. Patients with living wills were more likely to be white, Protestant, and highly educated. Most (76%) created them with a lawyer or family member, whereas only 7% involved physicians. Although these patients were able to identify some components of cardiopulmonary resuscitation (CPR), few (19%) understood the prognosis after CPR. After explaining CPR, 37% of those with living wills did not want it, which was not stated in their directive or hospital record. If life-sustaining therapies were already started, 39% of these patients stated that they would not want CPR or mechanical ventilation if the likelihood of recovery was < or =10%. Patients without living wills either had not heard (18%) or did not know enough (51%) about them. After education, 5% did not want CPR, and 32% would terminate life-sustaining therapies if the likelihood of recovery was < or =10%. Seventy percent of these patients expressed interest in creating a living will. CONCLUSIONS: Patients with living wills understand poorly "life-sustaining therapies" and the implications of their advance directives. Most fail to involve physicians in creating directives. A significant number of those without living wills have end-of-life wishes that could be addressed by and appear open to the idea of creating advance directives.