重症手足口病患儿死亡风险评估模型的建立

目的 探讨重症手足口病患儿实验室指标与预后的相关性,建立判断发生死亡的风险评分模型。方法 回顾性收集2012 年 1 月至 2014 年 6月湖南省儿童医院PICU收治的重症手足口病病例,其中2012年1月至2013年12月的病例数据用于建立死亡风险模型,2014年1~6月的病例数据用于模型的验证。以入住PICU首次血清N-末端脑钠素原（NT-proBNP）、乳酸、WBC计数、血糖、心肌酶谱（CK、CK-Mb、LDH、 Mb）、PCT、CRP 检查结果作为分析指标,通过受试者特征工作（ROC）曲线,筛选出曲线下面积（AUC）>0.7的实验室指标,确定各项指标的最佳界值。以 Logistic 回归分析各项实验室指标对预后的影响,以进入Logistic回归模型各项实验室指标的β值作为原始赋分,同时对β值取整后作为简化赋分,建立风险模型并验证,考察不同总评分的敏感度和特异度。结果 362例数据纳入死亡风险模型的建立,男230例（63.5%）,女132例,年龄(24.0±14.8)个月,死亡25例（6.9%）;验证数据共171例,男111例（64.9%）,女60例,年龄 （24.3±13.5）个月,死亡11例（6.4%）。①血 NT-proBNP、乳酸、WBC、血糖、心肌酶谱和PCT的 ROC AUC均＞0.70。②Logistic 回归分析显示血清 NT-proBNP、乳酸、WBC和血糖是死亡的危险因素,OR（95%CI）分别为30.67 (3.64~258.68)、5.22 (1.22~22.33)、10.04 (2.12~ 47.53)和10.56 (1.88~59.27)。③WBC＞16.5×109·L-1、血糖＞7.8 mmol·L-1、NT-proBNP＞10 ng·mL-1、乳酸＞3.2 mmol·L-1、NT-proBNP 1.3~10 ng·mL-1分别赋2.31、1.65、3.42、2.36和1.98分,简化赋分分别为2、2、3、2和2分。④使用原始赋分和简化赋分,以验证数据预测死亡的ROC 曲线 AUC均为 0.99;简化赋分以4分为界值时其预测死亡的敏感度和特异度分别为 100%和 95.6%。结论 4项实验室检查指标的简化赋分对预测重症手足口病患儿的预后有较好价值,总评分≥4分的患儿应引起高度重视。     

Patient-Reported Outcome Measures Modestly Enhance Prediction of Readmission in Patients with Cirrhosis

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Effects of lipids and lipoproteins on thrombosis and rheology

Atherosclerotic plaque rupture and erosions precipitate thrombus formation and may lead to an acute ischemic syndrome. Lipids and lipoproteins modulate the expression and/or function of thrombotic, fibrinolytic and rheologic factors, and thereby influence hemostasis and potential tissue damage resulting from vascular injury. Triglyceride-enriched lipoproteins are accompanied by elevations in factor VII clotting activity, plasminogen activator inhibitor (PAI-1) and viscosity of blood and plasma. Low density lipoprotein (LDL) promotes platelet activation and tissue factor expression and LDL levels correlate with levels of vitamin K dependent coagulation factors and fibrinogen. Conversely, LDL inhibits tissue factor pathway inhibitor (TFPI) which limits activation of the extrinsic coagulation pathway. High density lipoprotein (HDL) has anti-atherothrombotic properties that result from inhibition of platelet and erythrocyte aggregation, reduced blood viscosity and suppression of tissue factor activity and PAI-1 activity and antigen levels. The effects of lipids and lipoproteins on hemostasis and rheology may have important implications for the clinical sequelae following plaque disruption and erosion.     

The closing survival gap after liver transplantation for hepatocellular carcinoma in the United States

BackgroundSocio-economic inequalities among different racial/ethnic groups have increased in many high-income countries. It is unclear, however, whether increasing socio-economic inequalities are associated with increasing differences in survival in liver transplant (LT) recipients.MethodsAdults undergoing first time LT for hepatocellular carcinoma (HCC) between 2002 and 2017 recorded in the Scientific Registry of Transplant Recipients (SRTR) were included and grouped into three cohorts. Patient survival and graft survival stratified by race/ethnicity were compared among the cohorts using unadjusted and adjusted analyses.ResultsWhite/Caucasians comprised the largest group (n=9,006, 64.9%), followed by Hispanic/Latinos (n=2,018, 14.5%), Black/African Americans (n=1,379, 9.9%), Asians (n=1,265, 9.1%) and other ethnic/racial groups (n=188, 1.3%). Compared to Cohort I (2002-2007), the 5-year survival of Cohort III (2012-2017) increased by 18% for Black/African Americans, by 13% for Whites/Caucasians, by 10% for Hispanic/Latinos, by 9% for patients of other racial/ethnic groups and by 8% for Asians (All P values<0.05). Despite Black/African Americans experienced the highest survival improvement, their overall outcomes remained significantly lower than other ethnic∕racial groups (adjusted HR for death=1.20; 95%CI 1.05-1.36; P=0.005; adjusted HR for graft loss=1.21; 95%CI 1.08-1.37; P=0.002).ConclusionThe survival gap between Black/African Americans and other ethnic/racial groups undergoing LT for HCC has significantly decreased over time. However, Black/African Americans continue to have the lowest survival among all racial/ethnic groups.     

Functional Gastrointestinal Disorders and Associated Health Impairment in Individuals with Celiac Disease

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Five-year mortality in patients with diabetic foot ulcer during 2009–2010 was lower than expected

AimMortality rates are decreasing in patients with diabetes. However, as this observation also concerns patients with diabetic foot ulcer (DFU), additional data are needed. For this reason, our study evaluated the 5-year mortality rate in patients with DFU during 2009–2010 and identified risk factors associated with mortality.MethodsConsecutive patients who attended a clinic for new DFU during 2009–2010 were followed until healing and at 1 year. Data on mortality were collected at year 5. Multivariate Cox proportional-hazards model was used to identify mortality risk factors.ResultsA total of 347 patients were included: mean age was 65 ± 12 years, diabetes duration was 16 [10; 27] years; 13% were on dialysis; and 7% had an organ transplant. At 5 years, 49 patients (14%) were considered lost to follow-up. Total mortality rate at 5 years was 35%, and 16% in patients with neuropathy. On multivariate analyses, mortality was positively associated with: age [hazard ratio (HR): 1.05 (1.03–1.07), P < 0.0001]; duration of diabetes [HR: 1.02 (1.001–1.03], P = 0.03]; PEDIS perfusion grade 2 vs. 1 [HR: 2.35 (1.28–4.29), P = 0.006)]; PEDIS perfusion grade 3 vs. 1 [HR: 3.14 (1.58–6.24), P = 0.001); and ulcer duration at year 1 [HR 2.09 (1.35–3.22), P = 0.0009].ConclusionMortality rates were not as high as expected despite the large number of comorbidities, suggesting that progress has been made in the health management of these patients. In particular, patients with neuropathic foot ulcer had a survival rate of 84% at 5 years.     

雷帕霉素洗脱支架对糖尿病患者经皮冠状动脉介入治疗的远期影响

目的分析雷帕霉素洗脱支架(SES)对糖尿病患经皮冠状动脉介入治疗后的远期影响。方法采用回顾性研究方法,在1004．例接受冠状动脉内支架术治疗的冠心病患中,84例糖尿病和250例非糖尿病患置入SES;168例糖尿病和502例非糖尿病患置入普通支架。记录并比较一般临床资料、冠状动脉造影及冠状动脉内支架术情况、远期心脏事件发生率和1年无心脏事件生存率。结果随访期间(平均16．2个月),SES组中糖尿病亚组和非糖尿病亚组的远期心脏事件发生率为4．8％比3．6％,P=0．744;1年无心脏事件生存率为95．0％比96．7％,P=0．602,两亚组差异均无统计学意义。但BMS组中,糖尿病亚组的远期心脏事件发生率显高于非糖尿病组(31.0%比21．7％,P=0．015);两亚组的1年无心脏事件生存率分别为74．2％比86．8％(P=0．001)。结论SES能显改善糖尿病患冠状动脉支架术的远期疗效,降低靶病变再狭窄和远期心脏事件的发生率,提高1年无心脏事件生存率。     

氟伐他汀对冠心病患者白介素-6、白介素-10和基质金属蛋白酶-1水平的影响

目的探讨氟伐他汀对冠心病患者白细胞介互素-6（IL-6）、白细胞介素-10（IL-10）和基质金属蛋白酶-1（MMP-1）水平的影响。方法冠心病患者51例：急性心肌梗死（AMI）13例、不稳定型心绞痛（UAP）18例、稳定型心绞痛（SAP）20例；健康对照者20名。所有试验对象当天采集空腹静脉血5ml。冠心病患者随机分为2组：氟伐他汀40mg治疗组（26例）和80mg治疗组（25例），30d时再次采血5ml，测定IL-6、IL-10和MMP-1浓度。结果治疗前AMI、UAP组IL-6和MMP-1显著升高（P〈0．01）；两组治疗后IL-6和MMP-1均有明显下降（P〈0．01），但80mg组下降更甚（P〈0．01）。血清IL-6水平与血清MMP-1水平呈显著正相关（r=0．847，P〈0．01）。IL-10在治疗前、后均无明显变化。结论IL-6、MMP-1在ACS患者中血清水平明显升高，可能与炎症反应、斑块不稳定相关，从而促进了冠心病患者发展为临床上的ACS；IL-10在冠心病患者血清水平中无明显变化；IL-6、MMP-1和IL-10与冠脉病变支数无关；氟伐他汀可能通过抑制IL-6、MMP-1的水平而发挥抗炎作用，其效用与药物浓度相关。     

85岁及以上老年冠心病患者经皮冠状动脉支架治疗的临床观察

目的 探讨85～94岁冠心病患者经皮冠状动脉支架治疗的疗效和预后.方法 回顾性分析90例85岁以上冠心病患者经皮冠状动脉支架治疗的临床和造影特点、住院期间和长期疗效.结果 90例中,21例应用金属裸支架(BMS),69例应用药物洗脱支架(DES).三支病变41例,2支病变21例,单支病变28例.手术成功率为94.4%,术前与术后TIMI-3级血流比例分别为72.2%和94.4%.手术相关并发症为15.6%,主要为冠脉夹层(11.1%).住院期间主要心血管不良事件(MACE)为7.8%,其中DES组住院期间MACE为5.8%,BMS组为14.3%.DES组出现2例严重出血.86例患者随访1年时,总的MACE为4.6%,其中DES组为6.0%,BMS组没有任何MACE.DES组出现]例脑卒中和1例严重出血.47例患者随访2年时,总的MACE为14.9%,其中DES组MACE为19.4%,BMS组无任何MACE.DES组1例发生严重出血,BMS组1例发生脑卒中.多因素COX回归分析表明,肌酐水平和高血压是影响长期预后的重要因素.结论 85岁以上冠心病患者经皮冠状动脉支架治疗手术成功牢较高,住院期间和长期的MACE事件发生率较低,并存高血压和严重.肾功能不全的患者MACE的发生率相对较高.