家属参与式全方位护理干预在动脉瘤性蛛网膜下腔出血患者中的应用价值

目的 探究家属参与式全方位护理干预在动脉瘤性蛛网膜下腔出血患者中的应用价值.方法 由本院2012年2月至2015年收治的动脉瘤性蛛网膜下腔出血患者中选取90例进行本次实验研究,采取随机双盲法将患者分为观察组(45例)和对照组(45例),对照组患者实施临床常规护理,观察组患者实施家属参与式全方位护理干预,对比两组患者再出血率、并发症情况、护理满意度、住院时间,并采取汉密尔顿焦虑量表(HAMA)及汉密尔顿抑郁量表(HAMD)评估患者的心理状况.结果 观察组患者再出血率为0.00％,总并发症率为4.44％,总满意率为95.56％,对照组分别为11.11％、17.78％、77.78％,观察组再出血率及总并发症率显著低于对照组,总满意率高于对照组,住院时间明显短于对照组[(41.24±3.45)d vs.(49.56±4.34)d],两组比较差异有统计学意义(P＜ 0.05);护理干预前两组患者均存在一定焦虑、抑郁情绪,HAMA、HAMD评分相近;护理干预后各组评分均改善,观察组改善程度优于对照组,差异有统计学意义(P＜0.05).结论 家属参与式全方位护理干预在动脉瘤性蛛网膜下腔出血患者中效果极好,患者再出血率及并发症率显著降低,心理状况改善,患者恢复快,满意度高,具有极高临床应用及推广价值.     

聚集解决护理模式预防肝硬化食管胃底静脉曲张患者再次出血的效果观察

目的：观察聚集解决护理模式对肝硬化食管胃底静脉曲张患者再次出血的预防作用。方法将120例肝硬化食管胃底静脉曲张患者按照奇偶数字法随机均分为对照组与观察组各60例,分别采用常规护理与聚集解决护理模式。比较两组预防再出血效果、护理干预前后焦虑自评量表(SAS)及抑郁自评量表(SDS)评分、游离肝静脉压(FHVP)、肝静脉楔压(WHVP)及肝静脉压力梯度(HVPG)的变化、静脉主干血流动力学及脾静脉血流动力学变化情况。结果观察组预防再出血效果显著优于对照组(P<0.05);观察组护理干预后SAS及SDS评分显著低于干预前及对照组护理干预后(P<0.05);观察组护理干预后WHVP及HVPG水平较护理干预前显著降低(P<0.05);两组护理干预后血流动力学指标均较护理干预前显著降低(P<0.05);两组护理干预前后脾静脉内径(Dpv)差异均无统计学意义(P>0.05),但两组护理干预前后脾静脉流速(Vpv)及流量(Qpv)差异均具有统计学意义(P<0.05)。结论聚集解决护理模式能够更好地预防肝硬化食管胃底静脉曲张患者再出血,应在临床上加以推广应用。     

Platelet-albumin-bilirubin score-a predictor of outcome of acute variceal bleeding in patients with cirrhosis

BACKGROUND The albumin-bilirubin(ALBI) score was validated as a prognostic indicator in patients with liver disease and hepatocellular carcinoma. Incorporating platelet count in the platelet-albumin-bilirubin(PALBI) score improved validity in predicting outcome of patients undergoing resection and ablation.AIM To evaluate the PALBI score in predicting outcome of acute variceal bleeding in patients with cirrhosis.METHODS The data of 1517 patients with cirrhosis presenting with variceal bleeding were analyzed. Child Turcotte Pugh(CTP) class, Model of End-stage Liver Disease(MELD), ALBI and PALBI scores were calculated on admission, and were correlated to the outcome of variceal bleeding. Areas under the receivingoperator characteristic curve(AUROC) were calculated for survival and rebleeding.RESULTS Mean age was 52.6 years; 1176 were male(77.5%), 69 CTP-A(4.5%), 434 CTP-B(29.2%), 1014 CTP-C(66.8%); 306 PALBI-1(20.2%), 285 PALBI-2(18.8%), and 926 PALBI-3(61.1%). Three hundred and thirty-two patients died during hospitalization(21.9%). Bleeding-related mortality occurred in 11% of CTP-B,28% of CTP-C, in 21.8% of PALBI-2 and 34.4% of PALBI-3 patients. The AUROC for predicting survival of acute variceal bleeding was 0.668, 0.689, 0.803 and 0.871 for CTP, MELD, ALBI and PALBI scores, respectively. For predicting rebleeding the AUROC was 0.681, 0.74, 0.766 and 0.794 for CTP, MELD, ALBI and PALBI scores, respectively.CONCLUSION PALBI score on admission is a good prognostic indicator for patients with acute variceal bleeding and predicts early mortality and rebleeding.     

高血压脑出血微创术后再出血的临床多因素分析

目的探讨影响高血压脑出血微创术后再出血的因素及防治策略。方法回顾性分析213例使用微创穿刺血肿清除技术治疗的高血压脑出血病例,对8个可能影响术后再出血的因素进行统计,使用Logistic回归分析选出影响术后再出血的危险因素。结果27例出现术后再出血,血肿形状（β=2．236,P=0．002）、入院时收缩压（β=1．877,P=0．001）、手术时机（β=-1．589,P=0．004）、术中抽吸血肿量（β=1．280,P=0．010）是影响微创术后再出血的主要因素。结论重视血肿形状、入院时收缩压、手术时机、术中抽吸血肿量对微创术后再出血的影响,针对不同患者作个性化的防治策略,有助于减少高血压脑出血微创术后再出血的发生率。     

环形缝扎加胃底折叠术预防晚期血吸虫病病人术后再出血效果

目的 目的 评估食管下段梯状环形缝扎黏膜下血管及胃底折叠术对晚期血吸虫病 （晚血） 门脉高压症并发上消化道 出血的治疗效果。 方法 方法 2006-2011年选择患晚血门脉高压症患者, 随机分为联合手术治疗组 （联合组） 与单纯手术治疗 组 （单纯组）。单纯组患者行门奇静脉断流术, 联合组在此基础上加行食管下段梯状环形缝扎黏膜下血管及胃底折叠术。 术后通过胃镜检查随访, 比较2种术式的治疗效果。结果 结果 共选择晚血患者158例, 联合治疗组75例, 单纯治疗组83例。 术后两组治疗有效率分别为81.3 % （61/75） 和30.1% （25/83）（χ2 =39.44, P < 0.01）, 发生再出血率分别为2.7 %（2/75） 和 12.0% （10/83）（χ2 =24.36, P < 0.01）, 两组差异有统计学意义。结论 结论 食管下段梯状环形缝扎黏膜下血管及胃底折叠术对 预防术后再出血效果明显, 且术式安全, 可作为治疗晚血门脉高压症的常规手术方式。     

门静脉高压脾切除门奇静脉离断术后再出血的食管胃静脉曲张分类研究

目的：探讨门静脉（门脉）高压患者脾切除门奇静脉离断术（脾切断流术）后再发上消化道出血的平均时间、内镜下食管和胃静脉曲张的分类特点及门脉高压性胃病的发病率。方法：190例肝硬化门脉高压出血患者分为脾切断流术后再出血组（40例）和未行手术组（150例）,统计手术患者术后至首次出血的平均时间间隔,每组患者分别行内镜检查,观察并对比其曲张静脉的分型特点及门脉高压性胃病发生率。结果：脾切断流术后再发出血时间平均为24个月,再出血患者内镜皆提示存有食管和（或）胃静脉曲张,2组患者内镜下的曲张静脉分型构成比有明显差异,脾切断流术者以单纯食管静脉曲张及食管胃静脉曲张（GOV）1型为主,未发现孤立性胃静脉曲张（IGV）1型及IGV2型,60．0％患者存在门脉高压性胃病,其发病率及严重程度均高于未行手术组患者。结论：脾切断流术治疗门脉高压近期止血疗效确切,但术后曲张静脉并未有效消退,须强调手术的规范性,并在再出血高发时段定期内镜随访．及时掌握食管胃曲张静脉及门脉高压性胃病的发展情况,早期干预治疗,从而改善患者预后。     

Rebleeding and survival after acute lower gastrointestinal bleeding

BACKGROUND: Previous studies of acute lower gastrointestinal bleeding (LGIB) have focused on evaluation and therapy. Measurement of long-term outcome has been rare. The purpose of this study was to document rebleeding and survival rates in patients with acute LGIB. METHODS: A retrospective review of all patients undergoing technetium-labeled red blood cell scans for LGIB from January of 1997 to December of 2002 was performed. Rebleeding was defined as identification of enteric bleeding requiring a transfusion 2 or more weeks after the initial bleeding episode. RESULTS: A total of 119 patients met inclusion criteria. Rebleeding was documented in 14 of 102 patients surviving for more than 2 weeks. The actuarial rebleeding rate was 15% at 2 years. No factors were identified that portended a higher likelihood of rebleeding. The 30-day mortality was 18% and the median survival was 60 months for the entire cohort. Of the 36 patients in whom cause of death was documented, 4 died of surgical complications and a single patient died as a direct result of hemorrhage. CONCLUSIONS: Rebleeding after an initial episode of LGIB occurs in a small percentage of individuals. Although survival is poor for patients with LGIB, few patients die as a direct consequence of hemorrhage.     

立体定向软通道颅内血肿清除术与内科保 守治疗高血压性脑出血疗效的Meta分析

目的 系统评价立体定向软通道颅内血肿清除术治疗高血压性脑出血的效果。
方法 计算机检索国内外数据库中关于立体定向软通道颅内血肿清除术与内科保守治疗高血压
性脑出血的随机对照试验（randomized controlled trial,RCT）,同时追索纳入文献的参考文献。检
索时限均从建库至2012年12月。根据卫生系统中证据推荐分级的评估、制订与评价（grading of
recommendations assessment,development and evaluation,GRADE）系统推荐分级方法,对纳入研究的质
量进行严格评价和资料提取,对符合质量标准的RCT进行Meta分析。统计学分析采用RevMan 5.2软件
和GRADE profiler 4.0.3软件。
结果 共纳入11个RCT。Meta分析主要结局结果显示,定向软通道颅内血肿清除术治疗高血压性
脑出血3个月内的临床疗效、病死率、发生感染、发生再出血四个方面,与传统的内科保守治疗方法
相比,其差异有显著性,优势比（odds ratio,OR）和95%可信区间（confidence interval,CI）分别为3.34
（2.13～5.22）、0.42（0.29～0.60）、0.42（0.27～0.64）、0.47（0.28～0.77）。每个结局的GRADE系统
推荐分级均为低等级。
结论 现有研究显示立体定向软通道颅内血肿清除术治疗高血压性脑出血疗效确切,3个月病死率、
发生感染及再出血并发症较传统内科保守治疗更低,临床医师在治疗高血压性脑出血时,可以把立
体定向软通道颅内血肿清除术作为一般推荐。     

Predictors of rebleeding after initial hemostasis with epinephrine injection in high-risk ulcers

AIM: To identify the predictors of rebleeding after initial hemostasis with epinephrine injection (EI) in patients with high-risk ulcers. METHODS: Recent studies have revealed that endoscopic thermocoagulation, or clips alone or combined with EI are superior to EI alone to arrest ulcer bleeding. However, the reality is that EI monotherapy is still common in clinical practice. From October 2006 to April 2008, high-risk ulcer patients in whom hemorrhage was stopped after EI monotherapy were studied using clinical, laboratory and endoscopic variables. The patients were divided into 2 groups: sustained hemostasis and rebleeding. RESULTS: A total of 175 patients (144, sustainedhemostasis; 31, rebleeding) were enrolled. Univariate analysis revealed that older age (≥ 60 years), advanced American Society of Anesthesiology (ASA) status (category Ⅲ , Ⅳ and Ⅴ ), shock, severe anemia (hemoglobin < 80 g/L), EI dose ≥ 12 mL and severe bleeding signs (SBS) including hematemesis or hematochezia were the factors which predicted rebleeding. However, only older age, severe anemia, high EI dose and SBS were independent predictors. Among 31 rebleeding patients, 10 (32.2%) underwent surgical hemostasis, 15 (48.4%) suffered from delayed hemostasis causing major complications and 13 (41.9%) died of these complications. CONCLUSION: Endoscopic EI monotherapy in patients with high-risk ulcers should be avoided. Initial hemostasis with thermocoagulation, clips or additional hemostasis after EI is mandatory for such patients to ensure better hemostatic status and to prevent subsequent rebleeding, surgery, morbidity and mortality.     

蛛网膜下腔出血再出血临床特点和危险因素分析

目的探讨引起蛛网膜下腔出血（SAH）再出血的临床特点和危险因素及预防措施。方法回顾分析普内科及神经内科7年收治的127例SAH患者和28例SAH再出血患者的临床表现和可能的危险因素。结果再出血发生率18.06%,高峰在发病后2周内,再出血多发生在冬季;再出血组平均年龄比SAH组低9.01岁,男性多于女性,为2.1∶1;再出血组病死率高达71.43%,比SAH组21.26%明显增高（P〈0.01）;高血压病、激动、长期的烟酒史和感染等均是再出血间接危险因素。结论 SAH急性期和恢复期,需对再出血可控危险因素及时干预。