单中心医疗机构20年肺栓塞发病的回顾性分析

Objective To evaluate the correlation of pulmonary embolism (PE) and original diseases by retrospectively analysis of the patients for 20 years in single medical center. Methods Five hundred and five patients with PE were admitted and treated in General Hospital of Chinese PLA from January 1989 to January 2009, and their clinical data were retrospectively reviewed to analyze the risk factors of PE and the correlations of PE with the original diseases. Results Of the 505 patients with PE in the past 20 years, the incidence of PE was increased year by year, especially it increased spectacularly after the year of 2004 [61.2% (309) vs. 38.8% (196)]. It was found to be most prevalent in patients of 41 - 60 years old. Its incidence in males was 1.52 folds higher than that of the females [60. 4% (305) vs. 39.6% (200)].Dyspnea, chest pain and hemoptysis were the initial symptoms in the PE patients. Among the 505 patients,40.0% of them complained dyspnea with chest pain and hemoptysis. Among them, dyspnea occurred in 100.0% of patients, hemoptysis in 52.1%, and chest pain in 40.0%. In 31.1% of the patients if was complicated with deep venous thrombosis (DVT), 19. 8% of them suffering from varicosity, 9. 5% of them had the history of surgery less than 30 days before, 22. 0% of them suffering from neoplasm, 3. 6% of them were accompanied with cerebrovascular disease within 4 days, 17.4% of them were accompanied with infection, 10. 1 % of them were accompanied with primary pulmonary hypertension, and 16. 8% of them were accompanied with heart diseases. Multivariate analysis showed that the history of surgery, DVT and neoplasm had significant correlation with the occurrence of PE [odds ratio (95% confidence interval), OR (95%CI) was 4.540 (2.186-9.443), 0.325 (0.155 -0.682), 2.610 (1.020-6.708), P＜0.05 or P＜ 0. 013, while oral contraception, primary pulmonary hypertension and cerebrovascular disease showed a less significant correlation with the occurrence of PE [OR (95%CI) was 0. 297 (0. 078 - 1. 126), 3. 210 (0. 855 -12. 110), 2. 939 (0. 862 - 10. 020), all P＞0. 05]. The age and infection did not show significant correlation with the occurrence of PE [OR (95%CI) was 1. 041 (0. 674 - 1. 607) and 0. 820 (0. 410 - 1. 665), both P＞0.05]. Conclusion The PE is difficult in diagnosis, but with increasing cognizance, the diagnostic rate of PE has been increased. Patients with history of surgical operation, DVT or neoplasm, who complain dyspnea without known cause, chest pain or hemoptysis, should be subjected to further examinations, as to confirm the diagnosis of PE, then the survival rate of the patients with PE may be elevated.     

Clinical characteristics and prognosis of community-acquired pneumonia in autoimmune disease-induced immunocompromised host: A retrospective observational study

BACKGROUND:Community-acquired pneumonia(CAP)in autoimmune diseases(AID)-induced immunocompromised host(ICH)had a high incidence and poor prognosis.However,only a few studies had determined the clinical characteristics of these patients.Our study was to explore the characteristics and predictors of mortality in CAP patients accompanied with AID-induced ICH.METHODS:From 2013 to 2018,a total of 94 CAP patients accompanied with AID-induced ICH,admitted to Emergency Department of Zhongshan Hospital,Fudan University,were enrolled in this study.Clinical data and the risk regression estimates of repeated predictors were evaluated by generalized estimating equations(GEEs)analysis.An open-cohort approach was used to classify patient's outcomes into the survival or non-survival group.RESULTS:The hospital mortality of patients with CAP occurring in AID-induced ICH was 60.64%.No significant differences were found with respect to clinical symptoms and lung images between survival and non-survival groups,while renal insufficiency and dysfunction of coagulation had higher proportions in non-survival patients(P<0.05).Both noninvasive ventilation(NIV)and invasive mechanical ventilation(IMV)were performed more frequently in non-survival group(P<0.05).By the multivariate GEEs analysis,the repeated measured longitudinal indices of neutrophilto-lymphocyte ratio(NLR)(odds ratio[OR]=1.055,95%confidence interval[95%CI]1.025–1.086),lactate dehydrogenase(LDH)(OR=1.004,95%CI 1.002–1.006)and serum creatinine(s Cr)(OR=1.018,95%CI 1.008–1.028),were associated with a higher risk of mortality.CONCLUSION:The CAP patients in AID-induced ICH had a high mortality.A significant relationship was demonstrated between the factors of NLR,LDH,s Cr and mortality risk in these patients.     

Treatment strategy for gallstone pancreatitis and the timing of cholecystectomy

AIM:To reviewed the literature and evaluated the scope and timing of the application of endoscopic retrograde cholangiopancreatography(ERCP)/endoscopic sphincterotomy(ES)and cholecystectomy.METHODS:A pooled odds ratio(OR)and a pooled mean difference with the 95%CI were used to assess the enumeration data of included studies.A pooled weighted mean difference(WMD)and a pooled mean difference with the 95%CI were used to assess the measurement data of included studies.Statistical heterogeneity was tested with theχ2 test.According to forest plots,heterogeneity was not significant,so the fixed effect model was adopted.The significance of the pooled OR was determined by the Z test and statistical significance was considered at P0.05.RESULTS:Data were collected from two studies(353patients,142 in the early cholecystectomy group and211 in the delayed cholecystectomy group)regarding the length of hospital stay[The WMD was-2.87(95%CI:-3.36--2.39,P0.01).Data were collected from four studies(618 patients,211 in the early cholecystectomygroup and 408 in the delayed cholecystectomy group)regarding perioperative complications(OR=0.94,95%CI:0.41-2.12,P0.05).Data were collected from four studies(618 patients,211 in the early cholecystectomy group and 408 in the delayed cholecystectomy group)on the number of patients who underwent ERCP±ES postoperatively(OR=0.80,95%CI:0.45-1.41,P0.05).CONCLUSION:Cholecystectomy offers better protection than ES against further bouts of pancreatitis in patients with gallstone pancreatitis,although ES is an acceptable alternative.     

Risk factors for postoperative sepsis in patients with gastrointestinal perforation

BACKGROUND Sepsis is fatal in patients with gastrointestinal perforation(GIP).However,few studies have focused on this issue.AIM To investigate the risk factors for postoperative sepsis in patients with GIP.METHODS This was a retrospective study performed at the Department of General Surgery in our treatment center.From January 2016 to December 2018,the medical records of patients with GIP who underwent emergency surgery were reviewed.Patients younger than 17 years or who did not undergo surgical treatment were excluded.The patients were divided into the postoperative sepsis group and the non-postoperative sepsis group.Clinical data for both groups were collected and compared,and the risk factors for postoperative sepsis were investigated.The institutional ethical committee of our hospital approved the study.RESULTS Two hundred twenty-six patients were admitted to our department with GIP.Fourteen patients were excluded:Four were under 17 years old,and 10 did not undergo emergency surgery due to high surgical risk and/or disagreement with the patients and their family members.Two hundred twelve patients were finally enrolled in the study;161 were men,and 51 were women.The average age was 62.98±15.65 years.Postoperative sepsis occurred in 48 cases.The prevalence of postoperative sepsis was 22.6%[95%confidence interval(CI):17.0%-28.3%].Twenty-eight patients(13.21%)died after emergency surgery.Multiple logistic regression analysis confirmed that the time interval from abdominal pain to emergency surgery[odds ratio(OR)=1.021,95%CI:1.005-1.038,P=0.006],colonic perforation(OR=2.761,CI:1.821–14.776,P=0.007),perforation diameter(OR=1.062,95%CI:1.007-1.121,P=0.027),and incidence of malignant tumorrelated perforation(OR=5.384,95%CI:1.762-32.844,P=0.021)were associated with postoperative sepsis.CONCLUSION The time interval from abdominal pain to surgery,colonic perforation,diameter of perforation,and the incidence of malignant tumor-related perforation were risk factors for postoperative sepsis in patients with GIP.     

Relationship between intubation rate and continuous positive airway pressure therapy in the prehospital setting

BACKGROUND: To determine whether the prehospital use of continuous positive airway pressure(CPAP) therapy is associated with a reduced rate of endotracheal intubation in patients with an acute respiratory disorder brought to the emergency department(ED).METHODS: We reviewed medical records of patients with acute respiratory distress who had been treated with CPAP in the Mobile Intensive Care Unit(MICU) from January 2010 to December 2011. These records were compared with those of patients who received standardized care without CPAP in the MICU from January 2004 to December 2004. Categorical variables were summarized as frequencies and compared between groups using Fisher's exact test or the Chi-square test. Continuous variables were summarized as medians(interquartile range), and comparison between the groups was made using Wilcoxon's rank-sum test. The relationship between CPAP and intubation rate was determined using multivariable logistic regression analysis of propensity scores. The results were presented as odds ratio(OR), 95% confidence interval(CI), and P value for test effect. The adequacy of the model was calibrated using Hosmer and Lemeshow's goodness-of-fit test. P0.05 was considered statistically significant.RESULTS: The records of 785 patients were reviewed. Of the 215 patients treated with CPAP in the MICU, 13% were intubated after admission. In contrast, of the 570 patients who did not receive CPAP, 28% were intubated after ED admission. Unadjusted logistic regression analysis showed that patients who had been treated with CPAP were less likely to be intubated than those without CPAP treatment(OR=0.37, 95% CI, 0.24–0.57, P0.0001). With propensity scores adjusted, multivariate logistic regression analysis showed that CPAP treatment was associated with a 62% reduction of intubation(OR=0.384, 95%CI, 0.25–0.60, P≤0.0001).CONCLUSIONS: In patients with acute respiratory disorder, there was a relationship between CPAP therapy and the decreased intubation rate. CPAP therapy was feasible in prehospital management of patients with respiratory distress.     

Mortality characteristics during the two waves of COVID-19 in India:A retrospective observational study

Objective:To evaluate patient demographic characteristics and risk factors for mortality during the first and the second wave among COVID-19 patients in a tertiary care hospital of India.Methods:Data were taken from the hospital’s electronic system for COVID-19 patients from August 2020 to December 2020,and the second from January 2021 to May 2021.The mortality rate,demographic and clinical characteristics,laboratory profile,and reasons for the death of the two waves were retrieved and compared,and the risk factors of the two waves were determined.Results:In the first wave,1177 COVID-19 cases visited the hospital and 96(8.2%)died.In comparison,the death rate in the second wave was significantly higher(244/2038,12.0%)(P<0.001).No significant difference in age[60(50-69)vs.60.5(53-70),P=0.11]or gender(P=0.34)was observed between the two waves.Compared to the first wave.there were significantly more cases with fever,cough,weakness,loss of taste and smell,and sore throat during the second wave(P<0.05),but significantly fewer cases with kidney disease(6.6%vs.13.5%,P=0.038)and diabetes mellitus(35.7%vs.50.0%,P=0.015).Besides,during the second wave,more patients had abnormal X-ray findings,higher levels of lymphocytes and serum ferritin(P<0.05).In addition,there were significant differences in the rate of death cases with acidosis,septic shock,acute kidney injury,diabetes mellitus,cardiovascular events,hypothyroidism(P<0.05).Multivariate regression showed that during the first wave,age(OR:1.10;95%CI:1.02-1.21),diabetes mellitus(OR:3.16;95%CI:2.08-3.53),and abnormal X-ray(2.67;95%CI:2.32-2.87)were significant independent risk factors of mortality;while in the second wave,age(OR:1.13;95%CI:1.12-1.28),diabetes mellitus(OR:8.98;95%CI:1.79-45.67),abnormal X-ray(OR:12.83;95%CI:2.32-54.76),high D-dimer(OR:10.89;95%CI:1.56-134.53),and high IL-6(OR:7.89;95%CI:1.18-47.82)were significant independent risk factors of mortality.Conclusion:Overall mortality and incidence of severe diseases are higher in the second wave than the first wave.Demographic characteristics,co-morbidities,and laboratory inflammatory parameters,especially D-dimer and IL-6,are significant risk facors of mortality during the COVID-19 pandemic.     

胸外按压器械AutoPulse在急诊科心搏骤停的应用及对血气和N末端B型钠尿肽的影响

Objective To investigate the value of AutoPulse in the patients with cardiac arrest (CA)in emergency department.Methods Patients with CA seen in the Emergency Department of Chaoyang Hospital, Affiliated to Capital Medical University from September 2008 to August 2009 were divided into standard manual external chest compression group (n= 42) and mechanical chest compression group with AutoPulse (n = 43), based on the method of the external chest compression.Tracheal intubation was performed and mechanical ventilation instituted in all the patients.Other rescue measures, such as intravenous infusion of fluids, electrocardiogram, electric shock for defibrillation were performed following the cardiopulmonary guideline of 2005.The patients with restoration of spontaneous circulation in 20 minutes were excluded.Among patients with resuscitation over 20 minutes, there were 29 cases in AutoPulse group and 28 cases in standard manual external chest compression group.The blood gas and N-terminal B-type natriuretic peptide (NT-proBNP) from the blood samples obtained from the femoral artery 20 minutes after resuscitation were determined, and the survival rate at 2 hours and 24 hours in both groups was recorded.Results Twenty minutes after cardiopulmonary resuscitation, the Ph value and the arterial partial pressure of oxygen (PaO2) of the AutoPulse group (n= 29) were significantly higher than those of the standard manual external chest compression group[n = 28, Ph value: 7.142 ± 0.134 vs.7.010 ± 0.136, PaO2(mmHg, 1mmHg=0.133kPa): 71.92±9.59 vs.65.61±7.66, both P＜0.01], the arterial partial pressure of carbon dioxide (PaCO2) and NT-proBNP were significantly lower than those of the standard manual external chest compression group[PaCO2(mm Hg): 39.43±14.09 vs.51.07±16.31, NT-proBNP (ng/L): 548.18 ± 256.93 vs.699.40 ± 303.35, P＜0.01 and P＜0.05].The 2-hour survival rate in AutoPulse group was higher than that in the standard manual external chest compression group, the disparity of the two groups was statistically significant[74.4% (32/43) vs.52.4% (22/42), P＜0.05].Though the 24-hour survival rate of AutoPulse group was higher than that of the standard manual external chest compression group, the difference was not statistically significant[9.3% (4/43) vs.4.8% (2/42), P＞0.05].Conclusion The device of AutoPulse can improve the tissue perfusion in patients with CA.Though this device may give rise some benefit in resuscitation for a short time, there is no decisive improvement in term of outcome of the patient.     

结合珠蛋白基因多态性与急性冠脉综合征的相关性研究

Objective To assess the association of Haptoglobin(Hp) polymorphism with acute coronary syndrome(ACS) in Chinese. Method A total of 112 patients with ACS including 57 patients with acute myocardial infarction and 55 patients with unstable angina pectoris confirmed with angiography and 121healthy controls were recruited in this study. Polymerase chain reaction (PCR) method was utilized to genotype Hpl and Hp2 alleles and genotype frequencies in cases and controls were compared. All polymorphisms were test of Hardy-Weinberg equilibrium in both groups separately. The differences of genotypes and alleles between two groups were analyzed with x2 test. The association between Hp polymorphism and the risk of ACS was estimated by odds ratio (OR) and their 95% confidence intervals (95% CI), and the comprehensive evaluation of the factors associated with ACS were determined by using multivariate logistic regression analysis. P ＜0.05 was considered to be statistically significant. Results The frequency of Hp2-2 genotype was significantly higher in ACSs than in controls (0. 571 vs. 0. 355, P = 0. 001; OR = 2. 419, 95% CI:1. 427 ～4. 100), multivariate Logistic regression analysis indicates that Hp2-2 genotype is an independent risk factor to ACS (P = 0.002; OR = 2.557,95% CI: 1. 392 - 4.637). Similarly, the Hp2 allele frequency in ACS groups was significantly higher than that in the control subjects (0. 759 vs. 0. 616, P =0.001; OR = 1. 965,95% CI 1. 316 ～2. 934). Conclusion The Hp2-2 genotype is associated with ACS in Chinese. Hp2-2 genotype may be an independent risk factor to ACS, and Hp2 allele may be a genetic susceptibility factor to ACS in Chinese.     

Outcomes of critically ill cancer patients with Acinetobacter baumannii infection

AIM: To describe the intensive care unit(ICU) outcomes of critically ill cancer patients with Acinetobacter baumannii(AB) infection.METHODS: This was an observational study that included 23 consecutive cancer patients who acquired AB infections during their stay at ICU of the National Cancer Institute of Mexico(INCan), located in Mexico City. Data collection took place between January 2011, and December 2012. Patients who had AB infections before ICU admission, and infections that occurred during the first 2 d of ICU stay were excluded. Data were obtained by reviewing the electronic health record of each patient. This investigation was approved by the Scientific and Ethics Committees at INCan. Because of its observational nature, informed consent of the patients was not required.RESULTS: Throughout the study period, a total of 494 critically ill patients with cancer were admitted to the ICU of the INCan, 23(4.6%) of whom developed AB infections. Sixteen(60.9%) of these patients had hematologic malignancies. Most frequent reasons for ICU admission were severe sepsis or septic shock(56.2%) and postoperative care(21.7%). The respiratory tract was the most frequent site of AB infection(91.3%). The most common organ dysfunction observed in our group of patients were the respiratory(100%), cardiovascular(100%), hepatic(73.9%) and renal dysfunction(65.2%). The ICU mortality of patients with 3 or less organ system dysfunctions was 11.7%(2/17) compared with 66.6%(4/6) for the group of patients with 4 or more organ system dysfunctions(P = 0.021). Multivariate analysis identified blood lactate levels(BLL) as the only variable independently associated with inICU death(OR = 2.59, 95%CI: 1.04-6.43, P = 0.040). ICU and hospital mortality rates were 26.1% and 43.5%, respectively.CONCLUSION: The mortality rate in critically ill patients with both HM, and AB infections who are admitted to the ICU is high. The variable most associated with increased mortality was a BLL ≥ 2.6 mmol/L in the first day of stay in the ICU.     

Health literacy,behavioral and psychosocial characteristics in coronary artery patients:A hospital-based study in Turkey

Objective:To investigate health literacy,behavioral and psychosocial characteristics in coronary artery patients.Methods:Between March 2019 and 2020 years,275 coronary artery patients aged≥50 years were included in the study.Turkish Health Literacy Scale-32 and Beck Depression Inventory were used to collect the data.Results:General health literacy index score was 31.7 and the prevalence of limited health literacy was 59.3%.Adequate health literacy was 2.8 fold higher in the 50-64 age group,3.1 fold higher among men,3.4 fold higher among married and 5.3 fold higher among those who believed in the necessity of individual protective practices(P<0.05).Significant differences were also found in different working status,living places,perceived economic situation,perceived general health status,comorbidities,family history of coronary artery disease,angiography history,material skills on reading and understanding,level of depressive syptom,commitment to individual protective practices health check-ups,utilizing health services,cigarette and alcohol use,and exercise and nutrition between limited and adequate health literacy(P<0.05).Logistic regression analysis showed that adequate health literacy was significantly higher among younger patients(OR:2.81;95%CI:1.46-5.62),male gender(OR:3.10;95%CI:1.46-6.58),married(OR:3.42;95%CI:1.39-8.44)and those with belief in individual protective practices(OR:5.3;95%CI:1.93-14.96).Conclusions:Health literacy is poor among coronary artery patients and behavioral and psychosocial variables differ with health literacy levels.To keep cardiovascular health among these patients,health literacy-based interventions should be adopted in coronary artery clinics,especially for risky population.     

Is atrial fibrillation associated with pulmonary embolism?

Summary. Background: A pulmonary embolism (PE) is thought to be associated with atrial fibrillation (AF). Nevertheless, this association is based on weak data. Objectives: To assess whether the presence of AF influences the clinical probability of PE in a cohort of patients with suspected PE and to confirm the association between PE and AF. Patients/methods: We retrospectively analyzed the data from two trials that included 2449 consecutive patients admitted for a clinically suspected PE. An electrocardiography (ECG) was systematically performed and a PE was diagnosed by computer tomography (CT). The prevalence of AF among patients with or without a PE was compared in a multivariate logistic regression model. Results: The prevalence of PE was 22.8% (519/2272) in patients without AF and 18.8% (25/133) in patients with AF (P = 0.28). After adjustment for confounding factors, AF did not significantly modify the probability of PE (odds ratio [OR] 0.68, 95% confidence interval [CI] 0.42–1.11). However, when PE suspicion was based on new‐onset dyspnea, AF significantly decreased the probability of PE (OR 0.47, 95% CI 0.26–0.84). If isolated chest pain without dyspnea was the presenting complaint, AF tended to increase the probability of PE (OR 2.42, 95% CI 0.97–6.07). Conclusions: Overall, the presence of AF does not increase the probability of PE when this diagnosis is suspected. Nevertheless, when PE suspicion is based on new‐onset dyspnea, AF significantly decreases the probability of PE, as AF may mimic its clinical presentation. However, in patients with chest pain alone, AF tends to increase PE probability.     

Cardiac biomarkers for risk stratification in non-massive pulmonary embolism: a multicenter prospective study

Summary.  Background: Troponins (cTnI and cTnT), N-terminal pro-Brain Natriuretic Peptide (NT-proBNP), myoglobin, heart-type fatty acid-binding protein (H-FABP) and fibrin D-Dimer are emergent candidates for risk stratification in pulmonary embolism (PE). Objective: To compare the respective prognostic values of biomarker with non-massive PE to predict an adverse outcome at 3 months. Patients/Methods: One hundred and forty-six consecutive patients with non-massive PE were included in this multicenter prospective study. The combined outcome consisted of intensive care monitoring on admission, death or hospitalization attributable to either a PE-related complication [defined by PE/deep vein thrombosis (DVT) relapse or major bleeding under anticoagulation] or to dyspnoea with or without chest pain during follow-up. Results: The outcome was met in 12% of patients. In univariate analysis, a NT-proBNP level above 300 pg/ml was the strongest predictor of unfavorable outcome with an odds ratio (OR) of 15.8 [95% confidence interval (CI): 2.05–122). ORs for the other variables were: 8.0 for D-dimer >2000 ng/ml (95% CI: 1.1–64), 4.7 for H-FABP >6ng/ml (95% CI:1.5–14.8), 3.5 for cTnI >0.09 ng/ml (95% CI:1.2–9.7), 3.4 for myoglobin >70 ng/ml (95% CI:0.9–12.2). Receiver operating curve (ROC) analysis indicated that NT-proBNP was the best predictor [area under the curve (AUC) 0.84; 95%CI: 0.76–0.92; P  < 0.0001] with a negative predictive value of 100% (95% CI: 91–100) at 300 pg/ml. At that cut-off, the true negative rate for NT-proBNP was 40%. In multivariate analysis, NT-proBNP was the only significant independent predictors. Conclusions: NT-proBNP appears to be a good risk stratification marker in identifying low-risk patients with non-massive PE who could be treated in an outpatient setting.     

危重症甲型H1N1流感临床初期危险因素的早期快速识别探讨

目的 探讨提高临床急诊医师对甲型H1N1流感危重症病例的快速识别能力.方法 回顾性分析65例甲型H1N1流感重症病例初期的临床特征,采用成组比较的病例对照研究方法,通过单因素分析筛选及多因素Logistic回归分析确定危重症病例发生的高危因素;拟定预测危重病例发生的预测重症甲型H1N1流感评分系统(PCIS)并进行拟合优度检验.结果 65例甲型H1N1流感重症病例中危重症(22例)和重症(43例)两组年龄、合并1个以上基础疾病、存在慢性心血管疾病、合并肿瘤性疾病、咯痰、肌肉或关节酸痛、呼吸困难、入院时脉搏血氧饱和度(SpO2)8个因素比较差异均有统计学意义.多因素Logistic回归分析显示,合并1个以上基础疾病[相对比值比(OR)=7.611,95%可信区间(95%CI)1.635～35.429]、肌肉或关节酸痛(OR=7.523,95%CI 1.462～38.716)、呼吸困难(OR=11.090,95%CI 1.373～89.565)、入院时SpO2＜0.95(OR=8.088,95%CI 1.019～84.969)是发生危重症的独立危险因素(均P＜0.05);受试者工作特征曲线(ROC)下面积(AUC)为0.922(95%CI 0.860～0.985,P=0.000).PCIS分级(低危0～1分、中危2分、高危3分、极高危≥4分)与实际危重病例吻合度良好,判定系数(R2)为0.940 6,P=0.030 1.结论 急诊临床医师可以根据基础疾病的多少、有无肌肉或关节酸痛、呼吸困难、入院时SpO2水平的综合评分(PCIS)早期快速识别易发生危重症甲型H1N1流感患者.

Abstract：

Objective To investigate clinical risky factors and improve the ability to discover critically ill patients suffering from influenza A H1N1 in emergency department. Methods A retrospective study of 65 cases with severe influenza A H1N1 was conducted. Univariate analysis and multivariate Logistic regression analysis were used to identify independent predictors of critically ill cases. Goodness of Fit test was performed on an established clinical predicting scoring (prediction of critically ill with influenza score,PCIS) system. Results Univariate analysis showed that significant difference between critically ill and severe group consisted of eight factors including age distribution, more than one comorbidity, chronic cardiovascular disease, oncologic diseases, sputum, myalgia/arthralgia, dyspnea and oxygen saturation at admission. A multivariate Logistic regression showed an association between development of critical illness and more than one comorbidity [odds ratio (OR) = 7. 611, 95% confidence interval (95%CI) 1. 635 -35. 429], myalgia/arthralgia (OR=7. 523, 95%CI 1.462 - 38. 716), dyspnea (OR= 11. 090, 95%CI 1. 373 -89. 565), and oxygen saturation＜0. 95 at admission (OR=8. 088, 95%CI 1. 019 - 84. 969, all P＜0. 05).The prognostic criteria had a good discriminative ability [area under receiver operating characteristic curve (AUC) was 0. 922, 95 %CI 0. 860 - 0. 985, P = 0. 000]. The PCIS scoring system was established according to the level of four high risk factors. Low risk (PCIS 0 - 1), intermediate risk (PCIS 2), high risk (PCIS 3), and very high risk (PCIS≥4) were categorized for predicting the occurrence of critical illness, and the Goodness of Fit test was good (R2= 0. 940 6, P = 0. 030 1). Conclusion Emergency physician can predict the development of critical condition in patients with influenza A H1N1 by using clinical characteristics including comorbidity, myalgia/arthralgia, dyspnea, and oxygen saturation at admission, and it is helpful in making clinical decision.     

Clinical criteria to prevent unnecessary diagnostic testing in emergency department patients with suspected pulmonary embolism.

Overuse of the d-dimer to screen for possible pulmonary embolism (PE) can have negative consequences. This study derives and tests clinical criteria to justify not ordering a d-dimer. The test threshold was estimated at 1.8% using the method of Pauker and Kassirer. The PE rule-out criteria were derived from logistic regression analysis with stepwise backward elimination of 21 variables collected on 3148 emergency department patients evaluated for PE at 10 US hospitals. Eight variables were included in a block rule: Age < 50 years, pulse < 100 bpm, SaO(2) > 94%, no unilateral leg swelling, no hemoptysis, no recent trauma or surgery, no prior PE or DVT, no hormone use. The rule was then prospectively tested in a low-risk group (1427 patients from two hospitals initially tested for PE with a d-dimer) and a very low-risk group (convenience sample of 382 patients with chief complaint of dyspnea, PE not suspected). The prevalence of PE was 8% (95% confidence interval: 7-9%) in the low-risk group and 2% (1-4%) in the very low-risk group on longitudinal follow-up. Application of the rule in the low-risk and very low-risk populations yielded sensitivities of 96% and 100% and specificities of 27% and 15%, respectively. The prevalence of PE in those who met the rule criteria was 1.4% (0.5-3.0%) and 0% (0-6.2%), respectively. The derived eight-factor block rule reduced the pretest probability below the test threshold for d-dimer in two validation populations, but the rule's utility was limited by low specificity.     

Factors influencing neck pain intensity in whiplash-associated disorders in Sweden

OBJECTIVES: To investigate if sociodemographic and economic factors, preinjury health status, and collision factors are associated with initial neck pain intensity in whiplash-associated disorders (WAD) in Sweden. The factors of interest were demographic and socioeconomic factors, prior health, and collision factors. METHODS: A cohort study of car occupants, insured by either of 2 Swedish traffic insurers, age 18 to 74 years, who filed an injury claim and reported WAD after a motor vehicle collision (n=1187) were approached with mailed questionnaires. These contained questions about prior health, details about the collision, and symptoms after the collision. Neck pain intensity was measured on a visual analog scale and categorized into mild pain (0 to 30 mm), moderate pain (31 to 54 mm), and severe pain (55 to 100 mm). RESULTS: Low educational level [odds ratio (OR) 2.8; 95% confidence interval (CI) 1.8-4.5], being sole adult in the family (OR 1.6; 95%CI 1.1-2.2), prior neck pain (OR 2.9; 95%CI 1.4-6.2), prior headache (OR 2.2; 95%CI 0.7-6.9), prior poor general health (OR 2.6; 95%CI 1.4-4.8), and exposure to rollover collision (OR 1.9; 95%CI 1.0-3.8) were all associated with severe initial neck pain intensity. Most of these factors were also associated with moderate pain intensity. DISCUSSION: This study confirms results from a previous study that sociodemographic and economic status, preinjury health status, and collision-related factors are associated with participants' rating of initial neck pain intensity in WAD. The findings are of importance for interpreting and understanding the underlying factors of pain rating.     

ICU患者发生获得性衰弱的危险因素分析

目的分析ICU患者发生获得性衰弱的危险因素。 方法选择2015年6月至2018年9月南充市中心医院ICU收治的280例患者作为研究对象,其中63例患者发生ICU获得性衰弱,217例患者未发生ICU获得性衰弱。根据临床工作经验,将与ICU获得性衰弱有直接或间接尚待求证的因素如性别、年龄、体质量指数（BMI）、入ICU时简化急性生理学评分（SAPS）Ⅱ、急性病生理学和长期健康评价（APACHE）Ⅱ评分、意识障碍、高血压、高血糖、来源科室、弥散性血管内凝血（DIC）、脓毒症、脓毒性休克、多器官功能障碍综合征（MODS）、长期卧床制动、低蛋白血症、机械通气时间、应用糖皮质激素、应用神经肌肉阻滞剂、应用去甲肾上腺素、实施早期康复干预等因素纳入Logistic回归分析,筛选出ICU获得性衰弱的影响因素。 结果单因素Logistic回归分析结果显示,女性[比值比（OR）= 1.514,95%置信区间（CI）（1.074,1.328）,P = 0.042]、年龄≥ 60岁[OR = 1.613,95% CI（1.142,2.002）,P = 0.042]、SAPSⅡ评分≥ 25分[OR = 1.982,95% CI（1.003,2.925）,P = 0.013]、APACHEⅡ评分≥ 8分[OR = 1.770,95%CI（1.192,2.742）,P = 0.014]、高血糖[OR = 1.853,95%CI（1.035,2.214）,P = 0.015]、脓毒症[OR = 2.309,95%CI（1.013,3.063）,P = 0.021]、脓毒性休克[OR = 2.106,95%CI（1.995,4.947）,P = 0.025]、MODS [OR = 3.721,95%CI（1.001,4.980）,P = 0.007]、长期卧床制动[OR = 4.641,95%CI（1.932,5.253）,P < 0.001]、机械通气时间≥ 72 h [OR = 3.367,95%CI（1.635,4.254）,P = 0.005]、应用糖皮质激素[OR = 1.709,95%CI（1.424,2.757）,P = 0.021]、应用神经肌肉阻滞剂[OR = 2.042,95%CI（1.331,4.953）,P = 0.011]以及实施早期康复干预[OR = 0.586,95%CI（0.953,1.472）,P = 0.037]与ICU获得性衰弱相关。将其纳入多因素Logistic回归分析后发现,年龄≥ 60岁[OR =1.576,95%CI（1.095,1.753）,P = 0.038]、SAPSⅡ评分≥ 25分[OR = 1.988,95%CI（1.115,1.803）,P = 0.013]、APACHEⅡ评分≥ 8分[OR = 1.768,95%CI（1.189,2.364）,P = 0.014]、高血糖[OR = 1.680,95%CI（1.033,1.689）,P = 0.015]、脓毒症[OR = 1.842,95%CI（1.011,1.976）,P = 0.010]、长期卧床制动[OR = 4.745,95%CI（1.931,3.470）,P < 0.001]、机械通气时间≥ 72 h[OR = 3.353,95%CI（1.722,4.314）,P = 0.003]、应用神经肌肉阻滞剂[OR = 1.931,95%CI（1.247,2.573）,P = 0.005]是ICU患者发生获得性衰弱的独立危险因素,而实施早期康复干预[OR = 0.598,95%CI（0.978,1.674）,P = 0.037]是其保护因素。 结论ICU获得性衰弱的危险因素复杂,应加强高危患者的早期干预,积极控制好血糖,减少制动时间和机械通气时间,预防ICU获得性衰弱的发生。     

Profiling schoolchildren in pain and associated demographic and behavioural factors: a latent class approach

Musculoskeletal pain in adolescence is common and individuals frequently report pain in different sites. However, statistical analysis is often limited to considering one or a few pain sites. In this study latent class analysis was used to classify individuals into latent classes in terms of their patterns of endorsing ten musculoskeletal sites. Previously established covariates of musculoskeletal pain in adolescents were then assessed across emergent latent classes. The study was a cross sectional survey of adolescents attending post-primary schools in England. A total of 679 took part in the study with an age range from 11 to 14 years. Pain was operationalised as the occurrence of pain for one day or more in the past month. Schoolchildren self-reported on the incidence of pain aided by a nordic manikin. A three-class model emerged as the best fit. Classes were labelled 'Pain free' (63.4%), 'Neck and back' pain (28.2%) and 'Widespread' pain (8.4%). The 'Widespread' pain class was significantly related with Age (OR=1.79; 95%CI 1.24-2.57), Sex (OR=0.35, 95%CI 0.16-0.79), bag weight to body weight (OR=1.12, 95%CI 1.03-1.22), bag carrying method (OR=2.08, 95%CI 1.08-3.97), Schoolwork difficult (OR=2.78, 95%CI 1.27-6.07), and headaches (OR=2.13, 95%CI 1.65-2.76). While Strengths and Difficulties Questionnaire scores (OR=1.05, 95%CI 1.01-1.11), and Headaches (OR=1.78, 95%CI 1.39-2.26) were significant for the 'Back and neck' class. It is suggested that research should seek to identify typical pain profiles for adolescents, rather than concentrating on specific pain sites since some risk factors may be obscured or inflated by inappropriately amalgamating or segregating pain sites.     

血浆N末端B型钠尿肽前体对重症患者预后的预测价值研究

目的 探讨入重症监护病房(ICU)时血浆N末端B型钠尿肽前体(NT-pro-BNP)水平是否是预测重症患者预后的独立因子.方法 采用前瞻性、单中心、观察性研究方法.选择6个月内入本院ICU＞18岁的120例患者,最终有88例患者符合试验要求.血浆NT-pro-BNP样本在进入ICU时收集;计算进入ICU后24 h内急性生理学与慢性健康状况评分系统Ⅱ(APACHE Ⅱ)的最差值;入ICU后28 d患者生存状态为预测终点.结果 入ICU 28 d死亡35例,病死率为39.8%.88例患者血浆NT-pro-BNP水平(ng/L)为1221.7(78.7～5 500.0),生存组明显低于死亡组[781.8(78.7～5 066.6)比2 774.5(166.8～5 500.0),P＜0.01].男性NT-pro-BNP水平(ng/L)高于女性[1 585.5(103.7～5 100.0)比794.5(78.7～5 500.0),P＜0.05];性别与NT-pro-BNP水平有相关性(r=-0.224,P＜0.05).进入ICU时重度感染患者NT-pro-BNP水平(ng/L)较其他患者更高[3 416.1(103.7～5 100.0)比883.4(78.7～5 500.0),P＜0.01];入ICU时是否存在重度感染与NT-pro-BNP水平有相关性(r=0.285,P＜0.01).NT-pro-BNP和APACHE Ⅱ评分的受试者工作特征曲线(ROC曲线)下面积分别为0.734[95%可信区间(95%CI)0.628～0.840]和0.747(95%CI0.637～0.858).Logistic回归分析显示:入ICU时NT-pro-BNP水平＞1 418 ng/L和APACHE Ⅱ评分均可作为28 d生存状态预测的独立因子[相对比值比(OR)5.235,95%CI 1.819～15.071;OR 1.105,95%CI1.819～15.071].以入ICU时NT-pro-BNP最佳临界值1 418 ng/L为分界点进行生存分析,高于此值者生存率比低于此值者低(x2=16.9,P＜0.01).结论 入ICU时血浆NT-pro-BNP＞1 418 ng/L和APACHE Ⅱ评分可作为重症患者短期生存状态的预测因子;NT-pro-BNP值可能用来诊断或者鉴别重度感染患者.

Abstract：

Objective To investigate whether plasma N-terminal pro-B-type natriuretic peptide (NT-pro-BNP)as measured at admission to intensive care unit(ICU)is an independent predictor of mortality in critically ill patients. Methods A prospective observational study of patients in ICU was conducted. One hundred and twenty patients aged＞18 years were included during a 6-month period. Among them 88 patients were enrolled for the study. Plasma NT-pro-BNP samples were obtained at admission to ICU. The acute physiology and chronic health evaluation Ⅱ(APACHE Ⅱ)score was calculated within 24hours after admission based on the worst values up to that point. The final evaluation was 28-day mortality.Results Thirty-five patients died within 28 days of ICU admission, the mortality was 39. 8%. In 88 patients, the mean plasma NT-pro-BNP levels(ng/L)were 1 221.7(78.7- 5 500.0), and that in survivor group was significantly lower than non-survivor group[781.8(78. 7 - 5 066. 6)vs. 2 774. 5(166.8 - 5 500.0), P＜0.01]. The mean NT-pro-BNP level(ng/L)in male patients was higher than that in females[1 585. 5(103.7 - 5 100. 0)vs. 794. 5(78. 7 - 5 500. 0), P＜0. 05]. There was correlation between gender and NT-pro-BNP levels(r=-0. 224, P＜0. 05). Patients admitted to the ICU because of a severe infection had higher levels of NT-pro-BNP(ng/L)compared with the rest of the cohorts[3 416.1(103. 7 -5 100.0)vs. 883. 4(78. 7 - 5 500. 0), P＜0.01]. There was correlation between severe infection at admission to ICU and NT-pro-BNP levels(r=0. 285, P＜0. 01). Areas under the receiver operating characteristic curves(ROC curves)of NT-pro-BNP and APACHE I score were 0. 734[95% confidence interval(95%CI)0. 628 - 0. 840]and 0. 747(95%CI 0. 637 - 0. 858), respectively. Logistic regression analysis showed that the NT-pro-BNP level ＞ 1 418 ng/L and the APACHE I score were independently associated with 28-day mortality[odds ratio(OR)5.235, 95%CI 1.819- 15.071; OR 1.105, 95%CI 1.819- 15.071]. WithI 418 ng/L of NT-pro-BNP as the cutoff value, survival rate was significantly lower in the patients with higher NT-pro-BNP level as compared with those with lower values at admission(x2= 16.9, P＜0. 01).Conclusion The ICU NT-pro-BNP level higher than 1 418 ng/L and APACHE Ⅱ score at admission are independent prognosis markers of early mortality. NT-pro-BNP might serve as a potent early diagnostic and prognostic marker in critically ill patients.     

Meta-analysis of venous thromboembolism prophylaxis in medically Ill patients

BACKGROUND: Venous thromboembolism (VTE) prophylaxis in medically ill patients has received a level 1A recommendation in previously published clinical guidelines. Pharmacologic prophylaxis for VTE includes unfractionated heparin (UFH), low-molecular-weight heparin (LMWH), and fondaparinux. Few direct comparisons between anticoagulants exist in medically ill patients. OBJECTIVE: This meta-analysis was conducted to assess UFH and LMWH (including the selective factor Xa inhibitor fondaparinux) in the reduction of in-hospital VTE in unselected medically ill patients. METHODS: We searched MEDLINE, EMBASE, and the Cochrane Controlled Trials Registry databases from January 1981 through September 2007 (English language) for randomized controlled trials using the following terms: dalteparin, enoxaparin, fondaparinux, nadroparin, and heparin. References of included articles and key review papers for additional studies were also searched. Data from studies were included in the analysis if the studies included medically ill patients with risk factors for VTE who had been followed up for 7 to 21 days. RESULTS: A total of 12,391 patients (of whom 8357 were in placebo-controlled trials) from 9 studies were included. Mean age for the entire cohort was 72.8 years; mean (SD) body mass index, 25.6 kg/m2; and mean (SD) actual body weight, 68.2 kg. Deep vein thrombosis (DVT) was significantly reduced with the addition of an LMWH compared with placebo (odds ratio [OR], 0.60; 95% CI, 0.47-0.75; P < or = 0.001), but rates of DVT were similar when comparing LMWH with UFH (OR, 0.92; 95% CI, 0.56-1.52). No significant differences in pulmonary embolism (PE) or death were found among the UFH, LMWH, and placebo groups. LMWH was associated with a significant increased risk for minor bleeding compared with placebo (OR, 1.64; 95% CI, 1.18-2.29; P = 0.003). However, no significant difference was found between LMWH and UFH (OR, 0.68; 95% CI, 0.27-1.70). Major bleeding events were similar among all groups: LMWH/fondaparinux versus placebo, OR, 1.65 (95% CI, 0.8-3.4); LMWH/fondaparinux versus UFH, OR, 0.69 (95% CI, 0.29-1.68); LMWH/fondaparinux versus UFH or placebo, OR, 1.16 (95% CI, 0.66-2.04). CONCLUSIONS: This analysis suggests that VTE prophylaxis with an LMWH (including fondaparinux) or UFH is effective in reducing the rate of DVT, but this benefit did not extend to enhanced protection against PE. Additionally, LMWH and UFH had similar bleeding outcomes.     

The Positive Rate of Pulmonary Embolism by CT Pulmonary Angiography Is High in an Emergency Department,Even in Low-Risk or Young Patients

ObjectiveThe clinical presentation of pulmonary embolism (PE) can be various and misleading. We analyzed patients with suspicion of PE and subsequently performed computed tomography pulmonary angiography (CTPA) in an emergency department of Internal Medicine, focusing on patient groups in which PE might be underestimated in the emergency setting, such as young patients and patients with low clinical probability.Material and MethodsIn 2016 and 2017, all patients receiving a CTPA for investigation of PE were retrospectively evaluated for clinical parameters (age, symptoms, and vital parameters) and D-dimers. The Wells score was calculated.ResultsCTPA was performed in 323 patients (158 female and 165 male; mean age 62 years). The leading symptoms for admission were dyspnea or chest pain; 62% showed intermediate or high risk for PE, calculated by applying the Wells score. In 123 (38%) of all patients, a PE was proved and pathologic age-adjusted D-dimers were found in 97.6%. Thirty of 121 (25%) patients with low risk according to Wells score had a PE. Deep vein thrombosis was verified in 67/123 (55%) patients; 43% (15/35) of all suspicions for PE in patients <40 years were positive with 4/15 (26%), showing a central PE. Younger patients (<40 years) with PE presented more often with tachycardia or tachypnea and chest pain or dyspnea than elderly patients with PE.ConclusionCTPA frequently proves a PE in patients with suspicion of PE in an emergency department of Internal Medicine. If PE is suspected and CTPA performed accordingly, the presence of PE is quite common even in low-risk patient groups (Wells score) or in young patients <40 years with chest pain or dyspnea.