冠状动脉造影正常的胸痛患者病因分析

目的:探讨冠状动脉造影正常的胸痛患者的病因及其临床特征.方法:对49例临床拟诊冠心病而冠状动脉造影正常的胸痛患者的临床特征进行回顾性分析,为胸痛的临床诊断提供思路.结果:最后诊断:急性心梗死1例(2.04%);冠心病心绞痛10例(20.45%);高血压病12例(24.49%);心律失常8例(16.33%);糖尿病6例(12.24%);X综合症7例(14.29%);急性胆囊炎2例(4.08%);急性胰腺炎2例(4.08%);反流性食管炎1例(2.04%);颈椎病2例(4.08%).结论:冠状动脉造影正常的胸痛患者并不能完全排除冠心痛,要考虑心外病变、非冠心病性器质性心脏病和X综合症等众多的影响因素.     

Anemia in Patients With Diabetes and Prediabetes With Normal Kidney Function: Prevalence and Clinical Outcomes

ObjectiveAnemia is a known complication of diabetes mellitus (DM); however, its prevalence and prognostic relevance in patients with DM and pre-DM with normal kidney function have not been well defined. This study assessed the prevalence of anemia in patients with DM and pre-DM and evaluated its association with clinical outcomes during a 4-year follow-up period.MethodsThis retrospective analysis included patients with DM and pre-DM referred to the Meir Medical Center Endocrine Institute in 2015. Patients with an estimated glomerular filtration rate (eGFR) of <60 mL/min or any other recognized cause of anemia were excluded. The risk of developing microvascular or macrovascular complications or of death during the 4-year follow-up period was determined.ResultsA total of 622 patients (408 with DM and 214 with pre-DM) were included. The mean age of the patients was 64 ± 10.6 years, and 70% were women. The baseline hemoglobin A1C level was 7.1% ± 1.7% (54 mmol/mol), and the eGFR was 86.1 ± 15.3 mL/min. At the time of inclusion, 77 patients (19%) with DM and 23 (11%) with pre-DM had anemia (hemoglobin level 11.9 ± 0.8 and 11.8 ± 0.8 g/dL, respectively), compared with normal hemoglobin levels of 13.8 ± 0.9 and 13.7± 0.9 g/dL, respectively, in the others. A multivariable analysis demonstrated an inverse correlation between baseline hemoglobin (as a continuous variable) and mortality (P = .035), microvascular complications (P = .003), and eGFR decline (P < .001) but not between baseline hemoglobin and macrovascular complications (P = .567).ConclusionThis study found a significant prevalence of anemia unrelated to renal failure, both in patients with DM and pre-DM. Anemia in these patients is associated with the development of microvascular complications, eGFR decline, and mortality. These results underscore the need for intensive lifestyle and pharmacologic interventions in these patients.     

Clinical Outcomes and Cost Effectiveness of Accelerated Diagnostic Protocol in a Chest Pain Center Compared with Routine Care of Patients with Chest Pain

Aims

The aim of this study was to compare in patients presenting with acute chest pain the clinical outcomes and cost-effectiveness of an accelerated diagnostic protocol utilizing contemporary technology in a chest pain unit versus routine care in an internal medicine department.

Methods and Results

Hospital and 90-day course were prospectively studied in 585 consecutive low-moderate risk acute chest pain patients, of whom 304 were investigated in a designated chest pain center using a pre-specified accelerated diagnostic protocol, while 281 underwent routine care in an internal medicine ward. Hospitalization was longer in the routine care compared with the accelerated diagnostic protocol group (p<0.001). During hospitalization, 298 accelerated diagnostic protocol patients (98%) vs. 57 (20%) routine care patients underwent non-invasive testing, (p<0.001). Throughout the 90-day follow-up, diagnostic imaging testing was performed in 125 (44%) and 26 (9%) patients in the routine care and accelerated diagnostic protocol patients, respectively (p<0.001). Ultimately, most patients in both groups had non-invasive imaging testing. Accelerated diagnostic protocol patients compared with those receiving routine care was associated with a lower incidence of readmissions for chest pain [8 (3%) vs. 24 (9%), p<0.01], and acute coronary syndromes [1 (0.3%) vs. 9 (3.2%), p<0.01], during the follow-up period. The accelerated diagnostic protocol remained a predictor of lower acute coronary syndromes and readmissions after propensity score analysis [OR = 0.28 (CI 95% 0.14–0.59)]. Cost per patient was similar in both groups [($2510 vs. $2703 for the accelerated diagnostic protocol and routine care group, respectively, (p = 0.9)].

Conclusion

An accelerated diagnostic protocol is clinically superior and as cost effective as routine in acute chest pain patients, and may save time and resources.     

The Molecular Genetic Expression as a Novel Biomarker in the Evaluation and Monitoring of Patients With Osteosarcoma-Subtype Bone Cancer Disease

One of the leading causes of death among patients with malignancies is represented by bone cancer. According to current studies, the leading cause of death among these patients is represented by late diagnosis, poor response to therapy, and the lack of accuracy in terms of clinical evaluation. In this regard, there have been developed a series of methods of diagnosis and evaluation, the most investigated being represented by miRNA expression. In this updated work, we want to present a series of changes in the expression of miRNAs in bone cancer. Moreover, we want to present the implications of miRNAs in targeted therapy in such patients. Studies available in scientific databases such as PubMed and Scopus were examined. The studies were searched using the keywords “miRNAs expression”, “bone cancer”, “genetic therapy” and “genetic biomarkers.” For the evaluation and monitoring of bone cancer, the expression of miRNAs can be successfully used due to increased specificity. Using miRNAs as gene therapy can be also considered a therapeutic method of the future, mainly due to selective and targeted response of the body.     

通过简单临床观察构建胸痛患者冠心病预测模型过程中的风险因素分析

目的:在具有胸痛症状的患者中构建冠心病预测模型。方法:选取疑诊冠心病的胸痛患者7981例,分为典型心绞痛组3636例、非典型心绞痛组3420例和非心绞痛性胸痛组925例,行冠状动脉造影最终确诊。对相关临床因素进行logistic多元回归分析并对危险因素进行组合得出危险积分。研究三组人群最终经冠脉造影确诊冠心病的正确诊断率。结果:(1)30-49岁至≧70岁典型心绞痛组、非典型心绞痛组、非心绞痛性胸痛组3组男性冠心病比例分别增加26.9%、36.3%及38.4%,3组女性分别33.5%、41.0%及43.3%,典型心绞痛、非典型心绞痛及非心绞痛性胸痛患者比例逐渐增加。(2)青年至老年典型心绞痛组、非典型心绞痛组及非心绞痛性胸痛组3组低危组冠心病发病率分别增加41.6%、增加57.3%及增加39.9%,高危组分别由增加15.8%、增加6.7%及增加33.3%。典型心绞痛组、非典型心绞痛组及非心绞痛性胸痛组3组危险积分由1分至6分冠心病发病率分别增加45.3%、52.6%及54.4%。(3)冠心病预测价值排序:在典型心绞痛分组中,男、女及不考虑性别情况预测值由78.5%至53.0%、64.4%至24.3%及72.5%至39.5%;在非典型心绞痛分组中,男、女及不考虑性别情况预测值由71.8%至37.0%、53.6%至27.8%及64.2%至32.9%;在非心绞痛性胸痛分组中,男、女及不考虑性别情况预测值由64.1%至50.0%、51.4%至35.0%及58.8%至43.2%。结论:随着年龄增加,胸痛症状越来越不典型。同一性别及胸痛特征分组中,同一危险分层及胸痛特征分组中,年龄增加冠心病可能性增加。同一性别及年龄段分组中,中年低危及高危,青年高危情况,胸痛症状越不典型冠心病可能性越小。同一危险积分分组中,胸痛症状越不典型则冠心病可能性越小。同一年龄段及胸痛特征分组中,男性冠心病概率大于女性,高危比低危人群冠心病可能性增加。同一胸痛特征分组中,危险积分得分越?     

通过简单临床观察构建胸痛患者冠心病预测模型过程中的风险因素分析

目的:在具有胸痛症状的患者中构建冠心病预测模型.方法:选取疑诊冠心痛的胸痛患者7981例,分为典型心绞痛组3636例、非典型心绞痛组3420例和非心绞痛性胸痛组925例,行冠状动脉造影最终确诊.对相关临床因素进行logistic多元回归分析并对危险因素进行组合得出危险积分.研究三组人群最终经冠脉造影确诊冠心病的正确诊断率结果:(1 )30-49岁至≥70岁典型心绞痛组、非典型心绞痛组、非心绞痛性胸痛组3组男性冠心病比例分别增加26.9％、36.3％及38.4％,3组女性分别33.5％、41.0％及43.3％,典型心绞痛、非典型心绞痛及非心绞痛性胸痛患者比例逐渐增加.(2)青年至老年典型心绞痛组、非典型心绞痛组及非心绞痛性胸痛组3组低危组冠心病发病率分别增加41.6％、增加57.3％及增加39.9％,高危组分别由增加15.8％、增加6.7％及增加33.3％.典型心绞痛组、非典型心绞痛组及非心绞痛性胸痛组3组危险积分由1分至6分冠心病发病率分别增加45.3％、52.6％及54.4％.(3)冠心痛预测价值排序:在典型心绞痛分组中,男、女及不考虑性别情况预测值由78.5％至53.0％、64.4％至24.3％及72.5％至39.5％;在非典型心绞痛分组中,男、女及不考虑性别情况预测值由71.8％至37.0％、53.6％至27.8％及64.2％至32.9％;在非心绞痛性胸痛分组中,男、女及不考虑性别情况预测值由64.1％至50.0％、51.4％至35.0％及58.8％至43.2％.结论:随着年龄增加,胸痛症状越来越不典型.同一性别及胸痛特征分组中,同一危险分层及胸痛特征分组中,年龄增加冠心病可能性增加.同一性别及年龄段分组中,中年低危及高危,青年高危情况,胸痛症状越不典型冠心病可能性越小.同一危险积分分组中,胸痛症状越不典型则冠心病可能性越小.同一年龄段及胸痛特征分组中,男性冠心病概率大于女性,高危比低危人群冠心病可能性增加.同一胸痛特征分组中,危险积分得分越高冠心病可能性越大,年龄越小危险因素作用越突出.同一胸痛特征及异常心电图分组中,男性冠心病概率大于女性.24h动态心电图预测价值逐渐增大.同一性别及异常心电图分组中,胸痛症状越不典型,心电图预测价值越小.性别、年龄、胸痛症状、危险因素是冠心病的预测指标.简单观察的临床指标和冠心病发病率之间规律性明显,该模型对冠心病的预测具有有效性和可行性.     

Evaluation of the Shape Symmetry of Bilateral Normal Corneas in a Chinese Population

Purpose

To investigate the bilateral symmetry of the global corneal topography in normal corneas with a wide range of curvature, astigmatism and thickness values

Design

Cross-Sectional Study

Methods

Topography images were recorded for the anterior and posterior surfaces of 342 participants using a Pentacam. Elevation data were fitted to a general quadratic model that considered both translational and rotational displacements. Comparisons between fellow corneas of estimates of corneal shape parameters (elevation, radius in two main directions, R_x and R_y, and corresponding shape factors, Q_x and Q_y) and corneal position parameters (translational displacements: x₀, y₀ and z₀, and rotational displacements: α, β and γ) were statistically analyzed.

Results

The general quadratic model provided average RMS of fit errors with the topography data of 1.7±0.6 µm and 5.7±1.3 µm in anterior and posterior corneal surfaces. The comparisons showed highly significant bilateral correlations with the differences between fellow corneas in R_x, R_y, Q_x and Q_y of anterior and posterior surfaces remaining insignificantly different from zero. Bilateral differences in elevation measurements at randomly-selected points in both corneal central and peripheral areas indicated strong mirror symmetry between fellow corneas. The mean geometric center (x₀, y₀, z₀) of both right and left corneas was located on the temporal side and inferior-temporal side of the apex in anterior and posterior topography map, respectively. Rotational displacement angle α along X axis had similar distributions in bilateral corneas, while rotation angle β along Y axis showed both eyes tilting towards the nasal side. Further, rotation angle γ along Z axis, which is related to corneal astigmatism, showed clear mirror symmetry.

Conclusions

Analysis of corneal topography demonstrated strong and statistically-significant mirror symmetry between bilateral corneas. This characteristic could help in detection of pathological abnormalities, disease diagnosis, measurement validation and surgery planning.     

Risk Stratification in Young Patients With Channelopathies

Identifying the young patient at risk of malignant arrhythmias and sudden cardiac death remains a challenge. It is increasingly recognised that sudden death, syncope and aborted cardiac arrest at a young age in patients with a structurally normal heart may be the result of various ion channel disorders - the channelopathies. The approach to risk stratification involves a combination of the clinical presentation, taken in conjunction with the family history, genetic testing, invasive electrophysiological studies or other provocative tests where appropriate and feasible. A logical approach to risk stratification in some of the commoner channelopathies seen in paediatric practice is presented.     

Overexpression of miRNA 4451 is Associated With a Poor Survival of Patients With Hypopharyngeal Cancer After Surgery With Postoperative Radiotherapy

Hypopharyngeal cancer (HC) is the most common subset of head and neck cancers. These tumors often have an aggressive clinical outcome characterized by local invasion and regional nodal metastasis. Upregulated miRNAs might be useful as biomarkers for prognosis and molecular targets for these tumors. We determined tumor expression of candidate miRNAs using microarray in 8 HC patients and validated in 372 HC patients. We also used paired tumorous and mucosal tissue to verify the miRNA expression. Log-rank test and Cox model were used to evaluate the survival; and Harrell's C-index was used to compare concordance of Cox models. Our results indicated 7 miRNAs aberrantly expressed in HC. Three of these candidate miRNAs (miRNA-4415, miRNA-200a, and miRNA-30b) were selected for further qRT-PCR validation and all of them were frequently found upregulated in HC tumors; with miR-4451 being the most differentially expressed. Moreover, high expression of miR-4451 was positively correlated with advanced tumor stage and increased mortality risk (HR: 1.6, 95% CI: 1.2–2.3; adjusted HR: 1.5, adjusted 95% CI: 1.1–2.1). Finally, significantly higher expression of miR-4451 in tumors compared to in fresh adjacent normal tissues indicates an oncogenic role of miR-4451 in this tumor. Upregulated miR-4451 in HC samples were frequently found and is significantly associated with advanced stage and poor survival of HC, which may indicate an association of this miRNA with the carcinogenesis process in this tumor site; and they could serve as a prognostic biomarker as well as help develop potential new targets for therapy.     

Normal Values for Segmental Bioimpedance Spectroscopy in Pediatric Patients

Introduction

Localized limb edema is a clinically relevant sign in diseases such as post-thrombotic syndrome and lymphedema. Quantitative evaluation of localized edema in children is mainly done by measuring the absolute difference in limb circumference, which includes fat and fat-free mass. Bioimpedance spectroscopy (BIS) provides information on the fluid volume of a body segment. Our objective was to determine normal ranges for segmental (arm and leg) BIS measurements in healthy children. Additionally, we determined the normal ranges for the difference in arm and ankle circumference and explored the influence of handedness and the correlation between techniques.

Methods

Healthy children aged 1-18 years were recruited. The ratio of extracellular fluid content between contralateral limbs (estimated as the inter-arm and inter-leg extracellular impedance ratio), and the ratio of extracellular to intracellular fluid content for each limb (estimated as the intracellular to extracellular impedance ratio) were determined with a bioimpedance spectrometer. Arm and ankle circumference was determined with a Gulick II tape.

Results

We recruited 223 healthy children (48 infants, 54 preschoolers, 66 school-aged children, and 55 teenagers). Normal values for arm and leg BIS measurements, and for the difference in arm and ankle circumference were estimated for each age category. No influence of handedness was found. We found a statistically significant correlation between extracellular impedance ratio and circumference difference for arms among teenagers.

Conclusion

We determined normal BIS ranges for arms and legs and for the difference in circumference between arms and between ankles in children. There was no statistically significant correlation between extracellular impedance ratio and difference in circumference, except in the case of arms in adolescents. This may indicate that limb circumference measures quantities other than fluid, challenging the adequacy of this technique to determine the presence of localized edema in most age groups.     

Follow-up Study of Patients With Cerebral Palsy

Of 319 patients with cerebral palsy recalled for reevaluation 15 years after the initial visit, 10 percent had died. Of the living, 55 percent had spasticity, 32 percent had athetosis, 4 percent had ataxia and 9 percent had mixed spasticity and athetosis; 38 percent had an intelligence quotient (IQ) less than 50, 24 percent between 50 and 79, and 38 percent had IQ above 80. There was a high correlation between overall functional outcome and intellectual level. Severity of physical disability, as measured by hand use, mobility and speech, also correlated with dependence, in part because increased severity of the disability was associated with decreased intellectual capacity generally.Twenty-five years after the initial visit, parental attitudes and personality intactness were evaluated (using the Minnesota Multiphasic Personality Inventory [MMPI]) and were correlated with satisfaction with status in life in 28 persons predicted to be independent on the 15-year study. Twenty (72 percent) of the 28 were satisfied with their status in life and of these, 16 were evaluated (with the MMPI) with 70 percent scoring in the normal range; 13 (65 percent) had parents with a positive attitude. Positive attitude was defined as parental feelings that the handicapped child was a worthy, valuable person, to be encouraged and assisted but not isolated from the world of nonhandicapped people.Careful serial assessment by professional teams combined with repeated long-term counseling of families can result in optimal outcome for the disability level involved, due to the primary role parents play in the development of a child''s character and behavior.     

尿液分析及胸部X线筛查重度感染或者脓毒性休克感染源的回顾性分析

目的：评估重症监护室的重症感染或者脓毒性休克患者尿常规检查和胸部X线检查的准确性。方法：回顾性分析我院进入重症监护室的确诊为重症感染或者脓毒性休克的患者,收集所有入组患者的个人情况,进入监护室以后的尿液检查结果、胸部X线检查结果,以及体液细菌学培养的结果,分析上述数据与诊断泌尿系感染或者肺部感染之间关系。结果：我们回顾了400例患者,其中70例患者确诊为重症感染或者脓毒性休克,其中13例患者确诊为泌尿系感染（尿常规,白细胞〉10／高倍镜视野）,敏感性和特异性分别为81％（95％CI0．67-0．92）和65％（95％CI0．51—0．75）;36例患者确诊为肺部感染,胸部X线检查诊断肺部感染的的敏感性和特畀性分别为57％（95％C10．45—0．69）和92％（95％C10．82-0．93）。结论：对于脓毒血症或者脓毒性休克的患者,胸部X线检查敏感性较低,这可能与肺部X线检查干扰因素较多,并且肺部感染发生到出现影像学变化有一定的时间间隔：而尿液分析敏感性较高,但是也可能由于尿液中上皮细胞的存在而干扰诊断。     

Evaluation of a Model for Glycemic Prediction in Critically Ill Surgical Patients

We evaluated a neural network model for prediction of glucose in critically ill trauma and post-operative cardiothoracic surgical patients. A prospective, feasibility trial evaluating a continuous glucose-monitoring device was performed. After institutional review board approval, clinical data from all consenting surgical intensive care unit patients were converted to an electronic format using novel software. This data was utilized to develop and train a neural network model for real-time prediction of serum glucose concentration implementing a prediction horizon of 75 minutes. Glycemic data from 19 patients were used to “train” the neural network model. Subsequent real-time simulated testing was performed in 5 patients to whom the neural network model was naive. Performance of the model was evaluated by calculating the mean absolute difference percent (MAD%), Clarke Error Grid Analysis, and calculation of the percent of hypoglycemic (≤70 mg/dL), normoglycemic (>70 and <150 mg/dL), and hyperglycemic (≥150 mg/dL) values accurately predicted by the model; 9,405 data points were analyzed. The models successfully predicted trends in glucose in the 5 test patients. Clark Error Grid Analysis indicated that 100.0% of predictions were clinically acceptable with 87.3% and 12.7% of predicted values falling within regions A and B of the error grid respectively. Overall model error (MAD%) was 9.0% with respect to actual continuous glucose modeling data. Our model successfully predicted 96.7% and 53.6% of the normo- and hyperglycemic values respectively. No hypoglycemic events occurred in these patients. Use of neural network models for real-time prediction of glucose in the surgical intensive care unit setting offers healthcare providers potentially useful information which could facilitate optimization of glycemic control, patient safety, and improved care. Similar models can be implemented across a wider scale of biomedical variables to offer real-time optimization, training, and adaptation that increase predictive accuracy and performance of therapies.     

Outcomes of Acute Chest Syndrome in Adult Patients with Sickle Cell Disease: Predictors of Mortality

Adults with sickle cell disease(SCD) are a growing population. Recent national estimates of outcomes in acute chest syndrome(ACS) among adults with SCD are lacking. We describe the incidence, outcomes and predictors of mortality in ACS in adults. We hypothesize that any need for mechanical ventilation is an independent predictor of mortality.

Methods

We performed a retrospective analysis of the Nationwide Inpatient Sample(2004–2010),the largest all payer inpatient database in United States, to estimate the incidence and outcomes of ACS needing mechanical ventilation(MV) and exchange transfusion(ET) in patients >21 years. The effects of MV and ET on outcomes including length of stay(LOS) and in-hospital mortality(IHM) were examined using multivariable linear and logistic regression models respectively. The effects of age, sex, race, type of sickle cell crisis, race, co-morbid burden, insurance status, type of admission, and hospital characteristics were adjusted in the regression models.

Results

Of the 24,699 hospitalizations, 4.6% needed MV(2.7% for <96 hours, 1.9% for ≥96 hours), 6% had ET, with a mean length of stay(LOS) of 7.8 days and an in-hospital mortality rate(IHM) of 1.6%. There was a gradual yearly increase in ACS hospitalizations that needed MV(2.6% in 2004 to 5.8% in 2010). Hb-SS disease was the phenotype in 84.3% of all hospitalizations. After adjusting for a multitude of patient and hospital related factors, patients who had MV for <96 hours(OR = 67.53,p<0.01) or those who had MV for ≥96 hours(OR = 8.73,p<0.01) were associated with a significantly higher odds for IHM when compared to their counterparts. Patients who had MV for ≥96 hours and those who had ET had a significantly longer LOS in-hospitals(p<0.001).

Conclusion

In this large cohort of hospitalized adults with SCD patients with ACS, the need for mechanical ventilation predicted higher mortality rates and increased hospital resource utilization. Identification of risk factors may enable optimization of outcomes.     

The Ethics of Isolation for Patients With Tuberculosis in Australia

This case study examines the ethical dimensions of isolation for patients diagnosed with tuberculosis (TB) in Australia. It seeks to explore the issues of resource allocation, liberty, and public safety for wider consideration and discussion.