呼吸机辅助治疗呼吸衰竭中的系统化决策分析

呼吸衰竭是临床众多专业常常面对的危重综合症,呼吸机辅助通气是救治呼吸衰竭十分有效的措施.孤立看待呼吸机子系统和患者子系统常不能实现良好的治疗效果,而将呼吸机和患者看做一个巨大的系统,充分构建协调一致呼吸机与患者这个大系统稳定有效性,监测其工作协调性是保证救治有效性重要途径.充分站在整体高度,考虑到救治措施的协调一致和互相配合.从整体的角度维护其稳定,注意系统下各个不同环节的异常,从整体角度调整不足都将使得措施更加有效而简便,也会大大增加救治呼吸衰竭成功率和加快对于呼吸机掌握应用速度.对于呼吸机和疾病的充分理解与掌握则是重要的前提.系统化决策分析法将会帮助我们全面、准确、快速掌握并良好使用呼吸机救治呼吸衰竭患者.     

56例创伤性休克患者的救治体会

目的 探讨创伤性休克的救治措施,最大限度提高创伤性休克患者的存活率.方法 回顾性分析2005年1月~2011年12月我院收治的56例创伤性休克患者的抢救过程.结果 抢救成功53例,成功率为94.6%;死亡3例,死亡率为5.4%.结论 创伤性休克病情迅猛,院前进行适当救护措施结合院内早期快速合理的抗休克治疗是创伤性休克的救治关键.     

四川短尾鼩尿液气味在社会等级识别中的作用

本文在中立竞技场中通过两两互作确定四川短尾鼩(Anourosorex squamipes)同性个体间的社会等级,并在此基础上利用其尿液,研究不同社会等级个体的自我/非自我识别能力及模式、尿液气味的行为响应机制,以及社会等级识别能力。结果表明：(1)四川短尾鼩优势个体表现攻击行为较多,从属个体防御行为较多,优势个体的标记行为显著高于从属个体。攻击行为表现为同等级雄性高于同等级雌性,且雌性间的攻击强度低于雄性。(2)从属个体和优势个体分别对自身尿液气味和非自身尿液气味存在明显偏好差异。不同性别、等级个体自我识别模式差异不明显,不同社会等级个体对于自身识别模式和非自身尿液的行为反应模式均不同。不同社会等级个体具有自我识别能力且能力不同。(3)四川短尾鼩能够识别不同社会等级个体的尿液气味,雌性对雄性尿液更感兴趣,雄性对优势雄性尿液选择回避。雄性对其他个体的访问时间与嗅舔频次均显著高于雌性,雌雄个体在识别不同社会等级的尿液气味时存在性二型。     

我国特有植物缙云卫矛同功酶变异的数量分析

研究了分布于重庆市的我国特有植物———缙云卫矛 7个居群 91个个体功能叶片的过氧化物酶、细胞色素氧化酶、超氧化物歧化酶、酯酶和淀粉酶同工酶谱带的变异式样 ,用Jaccard结合系数的UPGMA法进行聚类分析和主成分分析 ,结果表明 :1 0 .81 %的同工酶谱带是恒定的 ,89.1 9%的同工酶谱带在个体间表现出或多或少的变异 ;居群有 2 9.73 %的同工酶谱带是恒定的 ,70 .2 7%的同工酶谱带在居群间存在着一定程度的分化。来自同一居群的个体在谱带上表现出极大的相似性 ,而来源于不同居群的个体却表现出明显的趋异性 ,这可能是环境因子作用的结果或者是由于不同地域间基因流阻断所致。     

猕猴不同性别年龄组个体时间分配和姿态行为的差异分析

2005 年11 月至2006 年10 月,对生活在广西桂林七星公园内的一群半野生猕猴进行观察,采用瞬时扫描取样法收集不同性别-年龄组个体的活动时间分配、活动高度和姿态行为的数据。研究结果表明:七星公园猕猴属半地栖性灵长类动物,花费较多的时间休息(41.5% );坐是猕猴最主要的休息姿态
(85. 5% )和觅食姿态(85. 4% ),四足行走是最主要的移动模式(64.5% )。成年个体的活动时间分配表现出明显的性别差异,主要表现为成年雌猴花费更多的时间相互理毛。不同年龄组个体的活动时间分配也表现出显著差异。休息时间随年龄的增长而增加,而玩耍时间则表现出相反的趋势。猕猴的活动高度和移动模式也表现出明显的年龄差异。成年个体花费更多的时间在地面活动。在移动过程中,成年个体采用四足行走的频率明显高于其它年龄组个体;亚成年个体跳跃最多;少年个体采用攀爬和架桥的频率明显高于成年个体。这些差异可能与个体在不同发育阶段的体型和活动水平差异以及林冠的不连续性有关。本研究结果将有助于了解猕猴不同性别年龄组个体对其栖息的社会和自然环境的行为适应机制。     

休克过程中内源性阿片样物质对交感-肾上腺髓质系统的影响

内源性阿片样物质(endogenous opiate substance,EOS)在中枢及外周广泛分布,对机体功能产生多方面影响。就其心血管效应而言,休克等应激状态 EOS水平明显升高,可在心血管中枢、交感神经节、交感神经末梢膨体、肾上腺髓质及心血管效应器官等多个环节程度不同地影响交感-肾上腺髓质系统的活性,参与抑制心血管功能。纳洛酮等阿片受体阻断剂可能通过上述环节程度不等地拮抗 EOS 的作用,部分改善休克个体的心血管功能而表现出一定的抗休克效应。     

经皮神经电刺激的镇痛机制及其临床应用

经皮神经电刺激(transcutaneous electrical nerve stimulation,TENS)是一种非侵入式的通过电流脉冲来激活外周神经纤维的镇痛疗法,具有非药理性、安全无创伤、费用低等多方面优点,已用于临床中多种疼痛的缓解。然而,TENS的临床镇痛效果存在较大的差异,这可能是由于不同刺激参数下的TENS涉及不同的镇痛机制。为推进TENS相关的基础研究与临床应用,本文首先综述了不同类型TENS镇痛的神经生理和生化机制,进而从刺激位置、脉冲参数(电流强度、频率与脉宽)以及使用时长和使用频度等多个方面讨论了影响TENS镇痛效果的因素,并总结了TENS在临床镇痛的相关应用,包括术后痛、慢性腰背痛、分娩痛等情况下的应用。最后,为实现更好的临床镇痛效果,本文提出在TENS相关的临床应用中,应充分考虑到不同刺激参数对TENS镇痛效果的影响以及患者个体间差异所导致的TENS镇痛效果的差别,优化TENS参数设置,建立基于患者疼痛评分与TENS刺激输入之间的动态关系模型,自适应地根据患者实时疼痛评分调整TENS刺激模式。     

两个雌核发育白鲢群体同工酶分析及遗传标记的确定

取源于武汉两个不同渔场两尾白鲢的卵子,经紫外照射遗传物质失活的鲤鱼精子刺激雌核发育和热休克诱导第二极体保留的基因组操作技术,获得了两个不同的人工雌核发育白鲢群体。采用聚丙烯酰胺垂直板电泳技术,分析了这两个不同人工雌核发育白鲢群体(分别称为Hy-G1和Hy-G2)内不同个体的肝脏、肌肉组织以及红细胞中乳酸脱氢酶(LDH)、苹果酸脱氢酶(MDH)、酯酶(EST)、超氧化物歧化酶(SOD)等几种同工酶的表达谱式,并与普通繁殖的同龄白鲢进行了比较。结果表明,各个雌核发育白鲢群体内不同个体间的酶谱表现出很大程度的一致性,具较高的纯合度,而两个不同雌核发育群体Hy-G1和Hy-G2之间表现有明显差异。特别是肝脏和肌肉组织迁移率较快的酯酶谱带等以其稳定的差异,建议作为区分这两个人工雌核发育白鲢群体的生化遗传标记。       

青藏高原东缘风毛菊亚属16种植物果皮微形态研究

采用扫描电子显微镜对青藏高原东缘风毛菊亚属中的16种植物果实表皮微形态特征进行观察,结果表明：（1）果皮纹饰类型为：条纹型,有隔条纹型和网纹型。（2）根据种内个体间、组内种间以及组间的比较, 认为在风毛菊亚属中, 果实表皮显微特征在种内个体间比较稳定, 变异很小; 同组内种间表现出较大的相似性而不同组间存在着一定差异。说明在组和组下等级的分类学处理以及在系统位置和亲缘关系的探讨上, 果实显微特征具有重要的分类学价值。     

基于团抱行为的太行山猕猴社会联属

社会联属是指一些社会性动物社群内由于不同年龄、性别组的个体的社会角色与等级地位存在明显差异,在个体间形成的复杂的支配-从属关系,而这种支配-从属关系在不同的物种有着各自独特的模式(Clutton-Brock,1974)。了解社群内个体通过亲缘、非亲缘联盟、婚配、竞争而建立的支配-从属关系,是进一步开展社群内个体等级与资源竞争、互惠利益、母系投入策略等诸多研究的前提,     

组学时代下机器学习方法在临床决策支持中的应用

随着组学技术的不断发展,对于不同层次和类型的生物数据的获取方法日益成熟。在疾病诊治过程中会产生大量数据,通过机器学习等人工智能方法解析复杂、多维、多尺度的疾病大数据,构建临床决策支持工具,辅助医生寻找快速且有效的疾病诊疗方案是非常必要的。在此过程中,机器学习等人工智能方法的选择显得尤为重要。基于此,本文首先从类型和算法角度对临床决策支持领域中常用的机器学习等方法进行简要综述,分别介绍了支持向量机、逻辑回归、聚类算法、Bagging、随机森林和深度学习,对机器学习等方法在临床决策支持中的应用做了相应总结和分类,并对它们的优势和不足分别进行讨论和阐述,为临床决策支持中机器学习等人工智能方法的选择提供有效参考。     

Optimum probabilistic processing in colour perception. I. Colour discrimination.

A comprehensive account of wavelength discrimination and colour saturation discrimination is given in terms of optimum probabilistic signal detection. The theory is a logical deduction from statistical estimation theory of the visual estimate of the spectral parameters of the stimulus. In place of geometrical concepts associated with colour-space geometry, stimulus discriminability is determined by optimum decision rules given by likelihood ratio tests on statistics that are postulated for the trichromatic responses. The classical line element theory and its formulations are deduced to be discriminability measures between signals. The different mathematical forms of classical theory are shown to correspond to different statistical constraints.     

The number needed to treat: a clinically useful measure of treatment effect.

The relative benefit of an active treatment over a control is usually expressed as the relative risk, the relative risk reduction, or the odds ratio. These measures are used extensively in both clinical and epidemiological investigations. For clinical decision making, however, it is more meaningful to use the measure "number needed to treat." This measure is calculated on the inverse of the absolute risk reduction. It has the advantage that it conveys both statistical and clinical significance to the doctor. Furthermore, it can be used to extrapolate published findings to a patient at an arbitrary specified baseline risk when the relative risk reduction associated with treatment is constant for all levels of risk.     

不同麻醉方式处理休克病人的46 例临床研究

目的：观察并分析对休克病人实施不同的麻醉处理方式的临床效果。方法：选取2012 年2 月至2013 年2 月我院收治的临 床休克患者46 例，选择性的实施不同的麻醉方式进行处理。比较患者麻醉前后各项监测指标的变化情况。结果：实施麻醉术后， 有43 例患者表现为正常；2 例因大出血抢救无效而死亡；1 例因多器官功能发生衰竭而死亡；术中未发生因麻醉不当而导致的患 者死亡。术后生命体征正常的患者明显高于死亡的患者，差异有统计学意义(P＜0.05)。患者手术之后各项指标显著优于手术前，差 异有统计学意义(P＜0.05)。结论：对临床休克病人采取合适的麻醉方式，可以有效的辅助手术顺利进行，提高手术的成功率和患 者的存活率，值得临床推广。     

不同麻醉方式处理休克病人的46例临床研究

目的：观察并分析对休克病人实施不同的麻醉处理方式的临床效果。方法：选取2012年2月至2013年2月我院收治的临床休克患者46例,选择性的实施不同的麻醉方式进行处理。比较患者麻醉前后各项监测指标的变化情况。结果：实施麻醉术后,有43例患者表现为正常;2例因大出血抢救无效而死亡;1例因多器官功能发生衰竭而死亡;术中未发生因麻醉不当而导致的患者死亡。术后生命体征正常的患者明显高于死亡的患者,差异有统计学意义（P〈0．05）。患者手术之后各项指标显著优于手术前,差异有统计学意义（P〈0．05）。结论：对临床休克病人采取合适的麻醉方式,可以有效的辅助手术顺利进行,提高手术的成功率和患者的存活率,值得临床推广。     

Validity of the "bother score" in the evaluation and treatment of symptomatic benign prostatic hyperplasia

Benign prostatic hyperplasia (BPH) is a condition that is common among older men. It causes a variety of clinically significant lower urinary tract signs and symptoms. BPH is rarely life-threatening; the decision to seek treatment is frequently based on the degree to which patients find the symptoms bothersome and disruptive of daily activities. Recently developed reliable and valid outcome measures to evaluate treatments for BPH are clinical tools that urologists can use to determine the extent of bother and make treatment decisions. A single question used to determine the "bother score" provides a widely used and statistically valid measure of the need for treatment of BPH. Validation data support the argument that the bother score is a statistically reliable measure of treatment outcome in patients with BPH who view their symptoms as bothersome.     

Designing theoretically-informed implementation interventions

Background

A better theoretical base for understanding professional behaviour change is needed to support evidence-based changes in medical practice. Traditionally strategies to encourage changes in clinical practices have been guided empirically, without explicit consideration of underlying theoretical rationales for such strategies. This paper considers a theoretical framework for reasoning from within psychology for identifying individual differences in cognitive processing between doctors that could moderate the decision to incorporate new evidence into their clinical decision-making.

Discussion

Parallel dual processing models of reasoning posit two cognitive modes of information processing that are in constant operation as humans reason. One mode has been described as experiential, fast and heuristic; the other as rational, conscious and rule based. Within such models, the uptake of new research evidence can be represented by the latter mode; it is reflective, explicit and intentional. On the other hand, well practiced clinical judgments can be positioned in the experiential mode, being automatic, reflexive and swift. Research suggests that individual differences between people in both cognitive capacity (e.g., intelligence) and cognitive processing (e.g., thinking styles) influence how both reasoning modes interact. This being so, it is proposed that these same differences between doctors may moderate the uptake of new research evidence. Such dispositional characteristics have largely been ignored in research investigating effective strategies in implementing research evidence. Whilst medical decision-making occurs in a complex social environment with multiple influences and decision makers, it remains true that an individual doctor's judgment still retains a key position in terms of diagnostic and treatment decisions for individual patients. This paper argues therefore, that individual differences between doctors in terms of reasoning are important considerations in any discussion relating to changing clinical practice.

Summary

It is imperative that change strategies in healthcare consider relevant theoretical frameworks from other disciplines such as psychology. Generic dual processing models of reasoning are proposed as potentially useful in identifying factors within doctors that may moderate their individual uptake of evidence into clinical decision-making. Such factors can then inform strategies to change practice.     

The performance of risk prediction models

For medical decision making and patient information, predictions of future status variables play an important role. Risk prediction models can be derived with many different statistical approaches. To compare them, measures of predictive performance are derived from ROC methodology and from probability forecasting theory. These tools can be applied to assess single markers, multivariable regression models and complex model selection algorithms. This article provides a systematic review of the modern way of assessing risk prediction models. Particular attention is put on proper benchmarks and resampling techniques that are important for the interpretation of measured performance. All methods are illustrated with data from a clinical study in head and neck cancer patients.     

脓毒性心肌功能障碍

脓毒症是由感染引起的全身炎症反应综合征,证实有感染灶存在或有高度可疑的感染灶。脓毒症是ICU内重症患者的主要死亡原因,且发病率随着年龄的增长而逐渐增加。近十年来,虽然政府在救治脓毒症患者中投入了巨大的资金和技术支持,但源于脓毒症或脓毒性休克患者的病死率仍高达30%~60%。心血管系统在脓毒症与脓毒性休克的病理生理学中扮演着重要着色。过去的四五十年,开展了很多脓毒性心肌功能障碍方面的研究,也积累了不少循证医学证据。然而,心脏只是心血管系统的一部分。诸如脓毒症患者机体血流动力学的变化系脓毒症对心脏的直接效应,还是脓毒症引起心脏前、后负荷及神经体液因素的变化,继而引起心脏继发改变的研究,至今仍在继续。本文概述了近年来脓毒性心肌功能障碍的研究进展,使读者更全面地了解脓毒性心肌功能障碍的病理生理学改变,合理有效地指导脓毒症和脓毒性休克患者的临床救治。     

A signal detection analysis of morphine effects on the response bias of rats in a two-shock discrimination task

Signal detection theory techniques were used to assess the extent to which morphine affects response bias of rats in a two-choice shock discrimination task. The ratio of low shock (“noise”) to high shock (“signal”) trials was varied to produce different response biases prior to drug administration. Morphine significantly reduced signal sensitivity (d′) under all three conditions without systematically affecting any of the measures of response bias assessed in this study. While consistent with most reports with respect to d′, these results conflict with a few previous reports of morphine disrupting performance more when the discriminative stimulus is the presence of shock than when it is the absence of shock.