INTRODUCTION

Patients with cerebrovascular diseases requiring ventilator support treatment have poor prognosis with high mortality and severe disability even though they were treated aggressively in the ICU[18]. Cerebrovascular diseases such as intracerebral hemorrhage, subarachnoid hemorrhage, and cerebral arteriovenous malformations often cause severe intracerebral hemorrhage, which blocks normal circulation of cerebrospinal fluid and results in brain herniation and even death. These patients, therefore, often need to be mechanically ventilated before and/or after surgery. Comorbidity rate of surgery in the patients with cerebrovascular diseases were 14% and some of them require mechanical ventilation[19]. In this regard, Mayer

[12]reported that 5% of ischemic stroke patients, 26% of intracerebral hemorrhage patients, and 47% of subarachnoid hemorrhage patients required mechanical ventilation, with two third of mortality rate and majority of neuro-dysfunction. In the current study, we found that in-hospital mortality of the patients with cerebrovascular diseases was 36.9% and 45.0% during the 3-month follow-up period, and that 46.8% of them had 4-5 mRS score at discharge from the hospital and 29.7% of them had 4-5 mRS score 3 mo after discharge.

Previous studies indicated that mortality of the patients with cerebrovascular disease was 18%-19% and majority of the survivors remained severely disabled[10,11]. Several factors, including age (> 65 years), unconsciousness at admission [glasgow coma scale (GCS) score], intubation, and disappearance of brainstem reflexes, have been identified as independent predictors for the long-term survival and functional outcome in the patients with cerebrovascular diseases who required mechanical ventilation [1,2,12,13]. However, the prognosis of cerebrovascular diseases treated with mechanical ventilation during perioperative has not been clearly reported.

The aim of the current study was to evaluate mortality and severe disability of patients with cerebrovascular diseases who required mechanical ventilation during acute phase of treatment at an intensive care unit (ICU) (in-hospital), and to explore the predictors of death and functional disability of these patients.

式中：L為回路電感(包含變壓器漏感和勵磁電感)；R為回路電阻(包含合閘電阻、變壓器繞組電阻和勵磁支路等效電阻)。

MATERIALS AND METHODS

Patients

This cross-sectional study focuses on patients with cerebrovascular disease who underwent ventilatorassisted respiration during perioperative period. 113 patients from the neurovascular surgery ICU of the First hospital of Jilin University were collected from June 2016 to June 2019. The inclusion criteria included: (1) Patients had neurovascular surgery perioperative ventilator assisted breathing; (2) patients were on mechanical ventilation at least for 48 h; and (3) age ≥ 18 years old. The exclusion criteria are the patient’s family members gave up treatment or the patient died of disease. Two patients under the age of 18 were excluded. Finally total of 111 patients were included. The patient diagnoses cerebral hemorrhage, cerebral arteriovenous malformation, subarachnoid hemorrhage, cerebral vascular stenosis or occlusion, cerebral infarction,

through head computerized tomography (CT), CT angiography and cerebrovascular angiography. This study was adhered to the strengthening the reporting of observational studies in epidemiology statement for reporting[14].

在進行移動路線的選擇時（表2），國內(nèi)多集中于直線、小弧線、極地端點完成，國外則比較均衡，國內(nèi)運動員在極地端點完成的大多是身體難度。從運動員在場地使用的區(qū)域范圍來看，國外運動員熱衷于利用大弧線以及曲線進行展示，將成套動作的藝術(shù)性作為重中之重，而最具藝術(shù)代表性的帶操國外平均運用4.25次，國內(nèi)平均每套僅有1.25次，僅僅是為了完成難度動作而選擇單一的直線形路線，移動方向以向前、向后、左右簡單的移動為主，對于變化多樣的移動較少，這不僅影響了單個組合的多變形式，而且致使個人成套動作的獨特魅力無法盡情展現(xiàn)。

Ethics statement

The study protocol was approved by the Ethics Committee of the First Hospital of Jilin University. Informed consent was waived due to the retrospective nature of this study.

Information collection and follow-up

Basic demographic information and following clinical information were collected and analyzed: Age, gender, smoking, hypertension, diabetes, diagnosis of cerebrovascular diseases[15], tracheotomy, subarachnoid hemorrhage (SAH) gradings[16]. Preoperative GCS score, surgical operation methods, reason for mechanical ventilation, time from admission to start using ventilator, ventilation initiation, operation hours, mechanical ventilation time, and reason for ventilation.

Outcome

The primary outcome of this study was death or functional outcome in patients with cerebrovascular disease 3 mo after discharge. The secondary outcome was death or functional outcome at discharge. Patient’s outcome was scaled with modified rankin scale (mRS) score[17], mRS ≤ 3 was defined as good recovery; mRS = 4 or 5 as severe disability; mRS = 6 as dead. Functional outcome assessment was carried out by a physician through telephone call.

It has also been reported that status epilepticus was an independent risk factor for fatality of the patients with spontaneous cerebral hemorrhage[29], especially, in the patients with refractory and nonconvulsive epilepsy. These patients often require intubation and mechanical ventilation because these patients might stop breathing and heart-beating. In our study, 9 patients had status epilepticus with unexpected unconsciousness, stop breathing, but normal brain CT examination. Of them, 3 patients had status epilepticus before the surgery and the rest 6 patients had it after the surgery. One of the six patients had it 334 h after the surgery. The treatment of status epilepticus is to ensure the airway, maintain circulation, and give benzodiazepines, such as diazepam, lorazepam, midazolam,

[30].

Statistical analysis

Discrete variables were expressed by frequency (%),

test and fisher exact test were used to compare outcomes of the patients with various features. The Kolmogorov-Smirnov test was used to test the normality of the continuous variables. Continuous variables that fit the normal distribution were expressed by either mean ± SD otherwise as median and interquartile range (IQR). Wilcoxon rank sum test or Kruskal-Wallis rank sum test was used to compare outcomes of the patients with various features. We used ordinal Logistic Regression to analyze the association of mortality and functional outcome in patients with cerebrovascular disease and related factors. R software (R version 4.1.2) was used to perform all analysis and

value < 0.05 was considered as significant.

RESULTS

Basic demographic information of the patients

After 3 mo of follow-up, 29 (26.1%) of the 111 patients had good recovery, there were 32 (28.8%) patients with poor prognosis and 50 deaths (45.0%). The results of univariate analysis showed that there was also no significant difference in age, gender, smoking, hypertension, diabetes, diagnosis of neurovascular diseases, tracheotomy, SAH gradings, surgical operation methods, ventilation initiation, operation hours, and mechanical ventilation time (

> 0.05). There were significant differences in preoperative GCS score (

= 0.002), time from admission to start using ventilator (

= 0.038) and reason for ventilation (

< 0.001) among different prognostic groups (Table 2).

Median mechanical ventilation hour was 113 h with 69-187 h of IQR. Over half of the patients (50.45%) had tracheotomy for the mechanical ventilation. Majority (94, 84.68%) patients were given mechanical ventilation before the surgery and rest 17 (15.32%) were on ventilation after the surgery. There were variety kinds of reasons for the patients to have mechanical ventilation. Of them, 55 (49.55%) cases were due to pulmonary disease; 9 (8.11%) were status epilepticus; 6 (5.41%) were due to impaired function of respiratory center function; 14 (9.73%) were shock; 27 (24.32%) were because of brainstem compression with cerebral hemorrhage and brain herniation (Table 1).

PFS投加量為1000 mg/L，設(shè)定磁場強度12 mT、磁化時間5 min，分析磁化頻率對出水余鐵及亞鐵含量和pH值影響，結(jié)果如圖7所示。由圖7可知，隨磁化頻率的增大，出水的余鐵和亞鐵含量先增大后減小；當磁化頻率為130 Hz時，混凝處理造紙廢水的效果最為明顯，故選擇磁化頻率為130 Hz較適宜。

Comparison of mRS score in hospital and 3-month follow up

Figure 1 showed the comparison of mRS score with cerebrovascular disease at discharge and 3 mo after discharge. Of 71 survivors, 46.47% were seriously disabled and 12.67% died after three months of follow-up. Compared with the period of hospitalization, 11 patients with poor prognosis turned to good, and 9 deaths were added. In general, compared with hospitalization, the proportion of patients with good prognosis (MRS ≤ 3) after 3 mo of discharge has increased. However, the number of deaths continues to increase, and the total mortality rate reaches 45.0% after three months.

經(jīng)過劉清多年的悉心經(jīng)營，船廠所造之舟不僅數(shù)量眾多，而且規(guī)模宏大，經(jīng)得起江海聯(lián)運的萬里風(fēng)浪。應(yīng)該說，明代亦失哈下黑龍江及其利用松花江、黑龍江到庫頁島、北海道的水運、海運，是黑龍江省和俄羅斯聯(lián)邦江海聯(lián)運的源頭，為今天的江海聯(lián)運提供了有益的歷史借鑒。不僅所走水路和海路大體相同，而且運輸方式也大體相同，只是今天不再是從吉林船廠出發(fā)，也不再像明代那樣全部是國內(nèi)航線了。同時，還有必要指出這個船廠到清代仍被沿用，清圣祖康熙年間(1662－1722)在此造船，往雅克薩前線運兵運糧，反擊沙俄侵略。而且，清代吉林舊稱“船廠”也是始自明代。

Patients characteristics of the study population stratified by the functional outcome

Average age of the 111 patients, who received surgical operation and peri-operative mechanical ventilation at a neurovascular surgical department during the 3-month study period, was 56.46 ± 12.53 years old, the median preoperative GCS was 9 (8, 15), and operation hour was 3.30 h (IQR: 2.14-4.70). Of them, 53.15% were male and 30.63% were smokers. Majority of them had comorbidities with 72.07% of hypertension and 16.22% diabetes (Table 1). Of the 111 patients, 96 (86.48%) were diagnosed as hemorrhagic cerebrovascular disease, 4 (3.6%) were brain tumor, and 10 (9.01%) were malformed or narrowed intracerebral blood vessels. The following operation methods were applied in this study: Aneurysm clipping in 29 (26.13%) cases; aneurysm embolization in 23 (20.27%) patients; craniotomy for hematoma removal in 30 (27.03%) patients; external ventricular drainage in 12 (10.81%) patients; cranial drilling and hemorrhage drainage in 8 (7.21%) patients, and other surgeries in the rest of 9 (8.11%) cases. Of the 111 patient, 16 (55.2%) were non-SAH, 5 (17.2%) were SAH grading I, 3 (10.3%) were SAH grading II and 5 (17.2%) were SAH grading III (Table 1).

Analysis of risk factors for mortality and prognosis of patients after mechanical ventilation

Multiple logistic regression analysis showed that preoperative GCS score and time from admission to start using ventilator were not related to the death and prognosis of patients with cerebrovascular diseases (

> 0.05), and the reason of ventilation was related to the death and poor prognosis of patients with cerebrovascular diseases. Compared with brainstem compression, The risk of death or severe disability of pulmonary diseases was 0.096 times (

< 0.001, 95%CI: 0.028-0.328); The risk of death or severe disability of status epilepticus was 0.026 times (

< 0.001, 95%CI: 0.004-0.163), The risk of death or severe disability of impaired respiratory center function was 0.095 times (

= 0.022, 95%CI: 0.013-0.709), The risk of death or severe disability of shock was 0.095 times (

= 0.003, 95%CI: 0.020-0.444) (Table 3).

We also identified that shock could be a prediction of the outcome for the patients with mechanical ventilation. In the early stage of shock, due to the excitement of the patient's respiratory center and the increase of ventilation, it can cause hypocapnia and respiratory alkalosis. Generally, it can be used as an early indicator of shock before the decrease of blood pressure and the increase of lactate. However, in the late stage of shock, acute respiratory failure often occurs, which is characterized by progressive hypoxemia and dyspnea, which is called shock lung. Those with hypoxemia in the early and late stage of shock need ventilator assisted respiration[31]. In this regard, total 11 patients were ventilated after being diagnosed as shocked. Of them, 4 patients who were diagnosed in early stage of shock and given treatment such as raising blood pressure and improving circulation. The patients recovered well. While 5 patients who were diagnosed at a late stage of shock, died, suggesting identification of shock at its early stage is crucial for the patient’s outcome. Myint

[32] reported that shock index at presentation to the emergency department predicts patient-related clinical outcomes in ischemic and hemorrhagic stroke.

DISCUSSION

In the current study, we found that mechanical ventilation was required for the patients who underwent surgical operation with various kinds of cerebrovascular diseases. Outcome of mechanical ventilation in these patients, however, revealed that mortality and occurrence of severe disability were high. Prognosis of the patients treated with mechanical ventilation in this study was associated with the comorbidities that required mechanical ventilation. Compared with brainstem compression, the survival and functional outcome of pulmonary disease, status epilepticus, status epilepticus, impaired respiratory center function, and shock are relatively well.

6.來稿中的注釋與參考文獻統(tǒng)一排在文末。按在正文中使用的先后順序用數(shù)字加方括號標出（正文），同一參考文獻如果多次引用，用同一序號標出。

快遞服務(wù)業(yè)必須認清自身的優(yōu)勢和劣勢、把握機遇并不斷提高自身的管理水平才能創(chuàng)造出高質(zhì)量的品牌快遞公司。本文對北京市快遞發(fā)展過程中遇到的問題展開分析，希望能對首都的物流服務(wù)提升有所幫助。

Cerebrovascular diseases remain major cause of disability in the world. Studies showed that approximately 60% of the stroke patients die during the acute phase of therapy and the majority of the survivors suffered from severe disability[1-3], especially, the patients require intensive care therapy and mechanical ventilation. Patients with intracerebral hemorrhage, arteriovenous malformations, subarachnoid hemorrhage require mechanical ventilation because of pneumonia, pulmonary edema, brainstem ischemia or compression, and status epilepticus[4-6]. Mechanical ventilation often has been shown to be cost-ineffective at extending life with good recovery in the patients with stroke or other cerebrovascular diseases[7,8]. However, the dilemma is that although mechanical ventilation could sustain life in patients with acute respiratory failure[9], the survival rate and functional outcome for the patients of cerebrovascular diseases who treated with mechanical ventilation had a poor prognosis. Therefore, identification of risk factors affecting long-term survival and functional outcome in these patients could be useful to improve management after mechanical ventilation, to help family making decision on continuation or withdrawal of care, and to guide orientation after discharge.

Steiner

[2]reported that GCS (< 10) at admission was one of the seven independent factors that influenced 2-month fatality for the stroke patients who received mechanical ventilation. Although our univariate analysis showed that preoperative GSC had statistically significant differences in different prognostic outcomes, considering the confounding factors among multiple variables, further multiple regression analysis did not find a correlation between GSC and poor prognosis. Similarly, Fugate[19] also believe that preoperative GCS score could not predict the patient’s outcome because the intervention of surgical operation could affect the outcome, which could be good recovery, severe disability or even death. It has been reported that mechanical ventilation treatment in the comatose patients resulting from inoperative acute intracerebral hemorrhage, especially patients had brainstem compression due to brain herniation, could only prolong unresponsive life[20]. Brainstem compression causes changes in respiratory rhythm and even respiratory arrest, it is the second reason (24.3%) in this study for the patients required mechanical ventilation and majority of them (85.2%) died. Brainstem compression occurred in the patients with acute hydrocephalus following aneurysm subarachnoid hemorrhage. Although external ventricular drainage might release the pressure, difficulty in weaning from the mechanical ventilator was a problem. The retrospective cohort study of Chang

[21] concluded that brainstem compression is the predictor of mortality within 6-months in patients with spontaneous cerebellar hemorrhage, which is consistent with our findings.

歷史文化街區(qū)要以真實性為前提，并結(jié)合現(xiàn)代化的手段來進行開發(fā)。然而當前的歷史文化街區(qū)往往是打著懷念歷史的旗號，充斥了大量的惡性消費，甚至毫無歷史沉淀，或是缺乏了古典歷史這一保證，現(xiàn)代化氣息過于濃厚，文化底蘊不足。在一些歷史文化旅游街區(qū)，游客僅僅能夠欣賞到一些老房子，其余均演變成一種現(xiàn)代銷售模式，歷史名人像，傳統(tǒng)的藝術(shù)和歷史傳承信息全無，與歷史緊密相關(guān)的產(chǎn)品也多為現(xiàn)代化產(chǎn)品。以旅游紀念品來吸引游客，但紀念品本身卻存在嚴重的雷同性，現(xiàn)代景點旅游中，購物功能已經(jīng)強勢凌駕于其他一切功能之上，旅游的文化情趣已經(jīng)在歷史發(fā)展中悄然走失。

Prognosis of the patients with perioperative mechanical ventilation largely depends on the comorbidities[22]. Pneumonia or other pulmonary complications are often the cause of mechanical ventilation in the cerebrovascular patients following surgeries. It has been reported that mortality of the stroke patients with pneumonia was three times higher than that of the patients without pneumonia[23-25]. The main cause of stroke associated pneumonia is aspiration caused by swallowing dysfunction[26], pneumonia was closely associated with GCS score at admission, that is, patients with lower GCS score were often unconsciousness, vomiting and aspiration may occur when the disease occurs. In severe cases, mechanical ventilation and tracheotomy may be required[27,28]. In the current study, 49.5% of the patients were mechanically ventilated due to pulmonary disease. Of them, mortality was 32.7% and severe disability was 43.6%.

我沒有進去與臺灣畫商見面，我在門口站了一會兒，才離開了那家KTV廳的。在走出大廳之后，我就打電話約了一幫圈內(nèi)的朋友一起去酒吧喝酒。我們一邊喝酒，一邊天南地北地聊天，可女人的影子總會時不時的浮現(xiàn)在我眼前。

“我問你話呢？”葉之容停下手里的動作，扭過頭來，繼續(xù)追問，“我問你話呢！涂當今天怎么沒有來？怎么沒有一起來？”

在小學(xué)數(shù)學(xué)教學(xué)的過程中，習(xí)題練習(xí)能夠有效地幫助學(xué)生鞏固知識記憶，同時也能夠幫助教師了解學(xué)生的學(xué)習(xí)難點，從而能夠有針對性地進行講解。而在此過程中，教師也可以結(jié)合微課教學(xué)視頻開展復(fù)習(xí)工作，提升學(xué)生的學(xué)習(xí)效率。

There are some limitations in the current study. First, the study design was observational and followup period was short. Second, relatively small sample size might limit significant effects for some predictive factors that potentially influence outcome. Third, quality of life in those patients, who had severe disability, was not evaluated. Fourth, the retrospective collection of the data may have introduced bias, especially, patients ventilated for less than 48 h were excluded from this study, and thus, this result may not easily be extrapolated to a general elderly population. Finally, the data was from only one department of single center. In the future, we will include more samples, fully consider various confounding factors, and conduct a prospective cohort study to verify the causal relationship between various ventilation causes and the poor prognosis of patients with cerebrovascular diseases undergoing perioperative mechanical ventilation.

CONCLUSION

Taken together, mortality and severe disability rate were high in the cerebrovascular patients who had perioperative mechanical ventilation. The outcome of these patients was not associated with time-length of mechanical ventilation, primary diagnosis of cerebrovascular diseases, surgical operation method, and whether ventilated before or after the surgery. However, comorbidities that require mechanical ventilation significantly affected mortality and functional outcome of the patients in this study. Compared with brainstem compression, the survival and functional outcome of pulmonary disease, status epilepticus, status epilepticus, impaired respiratory center function, and shock are relatively well.

ARTICLE HIGHLIGHTS

Research methods

A retrospective follow-up study of 111 cerebrovascular disease patients who underwent mechanical ventilation during the perioperative period in the First Hospital of Jilin University from June 2016 to June 2019 was performed. Main measurements were mortality and functional outcome in-hospital and after 3-month follow-up. The functional outcome was divided into three groups based the modified rankin scale. Univariate analysis was used to compare the differences between three functional outcomes. Multivariate logistic regression analysis was used to for risk factors of mortality and severe disability.

Research results

To analyze mortality and functional disability and to determine predictors of unfavorable outcome in the patients with cerebrovascular diseases treated with mechanical ventilation.

Research conclusions

To analyze mortality and functional disability and to determine predictors of unfavorable outcome in the patients with cerebrovascular diseases treated with mechanical ventilation.

Research perspectives

The prognosis of cerebrovascular diseases treated with mechanical ventilation during perioperative has not been clearly reported.

FOOTNOTES

Zhang JZ and Xu K contributed to the study conception and design; all authors collected the data and performed the data analysis; and contributed to the interpretation of the data; and complete of figures and tables; and contributed to the drafting of the article; and final approval of the submitted version.

The study protocol was approved by the Ethics Committee of the First Hospital of Jilin University.

The authors declare that they have no conflict of interest to disclose.

The datasets generated and analyzed during the present study are available from the corresponding author on reasonable request.

This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BYNC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is noncommercial. See: https://creativecommons.org/Licenses/by-nc/4.0/

China

Jin-Zhu Zhang 0000-0003-0643-0987; Hao Chen 0000-0001-6989-1014; Xin Wang 0000-0003-0663-5579;Kan Xu 0000-0001-5818-1447.

另有統(tǒng)計數(shù)據(jù)顯示，我國需要蜜蜂授粉的作物面積約2億畝以上，而實際應(yīng)用面積不到10%，蜜蜂授粉市場前景廣闊，發(fā)展空間巨大。因此，有專家呼吁，蜜蜂授粉推廣必須與科學(xué)用藥、綠色防控技術(shù)相配套，要集成隱蔽用藥和提前用藥等技術(shù)，確?；ㄆ诓挥盟幓蚴褂脤γ鄯浒踩牡投巨r(nóng)藥，多種植蜜源植物，創(chuàng)造有利于蜜蜂生存和授粉的環(huán)境。

Guo XR

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Guo XR

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