Laser Lead Extraction: Is There a Learning Curve?

Laser extraction of device leads offers an attractive alternative to countertraction and electrosurgical dissection sheath, potentially increasing efficacy and reducing complications. Wider adoption of this technology depends on relative ease of use. We report the experience of a new center to define the "learning curve." We performed 76 laser lead extractions in 75 patients (age 63 +/- 17 years, 59 male) from July 2001 to January 2004. Two experienced device implanters who were novice extractors underwent a 2-day site visit to a high volume extraction center for training. Lead extractions were performed in the operating room with immediate surgical backup. The indication for extraction was infection in 39 (systemic in 15), erosion or pain in 11, and lead related or debulking in 25. Complete removal was achieved in 139 of 145 leads (14 ICD, 131 pacemaker). Partial removal (<4 cm retained) was achieved in five leads (4%), and one lead could not be extracted. Complete success was 95% in the first third of patients, 94% in the second third, and 100% in the latter third. Fluoroscopy time fell from 19 +/- 22 minute in the first third of patients to 11 +/- 8 minute in the second third to 8 +/- 4 minute in the latter third (ANOVA P = 0.02). No major complications occurred. Local bleeding required minor left subclavian vein repair in two individuals. Symptomatic venous thrombosis occurred in 3 of the first 11 cases 1-21 days after extraction, but did not occur in the next 64 consecutive patients who received a 1-month anticoagulation regimen (27% vs 0%, P < 0.001). One patient developed venous thrombosis 3 weeks following cessation of warfarin therapy. Practice guidelines reasonably recommend appropriate training prior to independent performance of lead extraction. The current study suggests that experienced device implanters with appropriate operative backup taking a limited, but intensive training program can be safe and effective at lead extraction in a short time, in part a reflection of the improved technology.     

心肌损伤标志物对急性心肌梗死诊断价值的ROC分析

[目的]用受试者操作特性曲线（Receiver Operating Characteristic curves，ROC）分析方法评价心肌损伤标志物肌红蛋白（myoglobin，Myo）、肌酸激酶同功酶质量（creatine kinase isoenzyme mass，CK—MB mass）和心肌肌钙蛋白I（cardiac troponin I，cT—nI）对急性心肌梗死（acute myocardial infarction，AMI）的诊断价值。[方法]对91例急性胸痛患者，在入院6h内不同时间定量检测Myo、CK—MBmass和cTnI浓度，用SPSS软件对结果进行ROC分析。[结果]54例患者最终被诊断为AMI；AMI组的Myo，CK—MB mass，cTnI在入院即刻，入院后2h、4h的测定值均显著高于非AMI组；ROC分析显示，Myo在AMI发病早期具有高度灵敏性，而入院后6h cTnI的ROC曲线下面积（AUC）为0．954，表明cTnI对AMI的诊断具有高度的临床准确性。[结论]对急性胸痛患者，联合检测Myo，CK—MBmass和cTnI，有助于AMI的早期诊断。     

血脂8项指标在缺血性脑血管疾病中的应用评价

目的了解胆固醇、三酰甘油（TG）、高密度脂蛋白胆固醇（HDL-C）及低密度脂蛋白胆固醇（LDL—C）、载脂蛋白A1、载脂蛋白B、非高密度脂蛋白胆固醇（non—HDL-C）、血浆促动脉硬化指数（AIP）在缺血性脑血管疾病中的应用价值。方法使用全自动生化分析仪对116例缺血性脑血管疾病患者和30例健康者进行血脂检测，并按照有关公式计算non-HDL-C、LDL-C、AIP，对结果进行统计学分析。结果在短暂性脑缺血发作时，AIP与健康对照组比较，差异有统计学意义，AIP的曲线下面积（AUC）为0．682。在脑动脉硬化时，non—HDL-C、AIP、HDL-C与对照组比较，差异有统计学意义，non-HDL-C、AIP、HDL-C的AUC分别为0．860、0．807和0．716。脑梗死时，non—HDL—C、AIP、HDL—C、LDL-C与对照组比较，差异有统计学意义，non-HDL-C、AIP、HDL-C、LDL-C的AUC分别为0．765、0．812、0．764和0．695。结论在短暂性脑缺血发作时，AIP、TG应用价值较高；脑动脉硬化时，AIP、non-HDL-C、LDL-C具有较高应用价值；脑梗死时，AIP、non—HDL-C、HDL-C具有较高应用价值。     

Application of a computerised method to measure static pressure volume curve in acute respiratory distress syndrome

Objective: To assess the safety and the bedside feasibility of a new computerised method to record the static pressure-volume curves (Pst/V) of the respiratory system.¶Design: The Pst/V curves were recorded in 13 medical patients with the acute respiratory distress syndrome (ARDS). During the Pst/V curve tracing the following parameters were recorded: time required for the recording and the automatic analysis of the Pst/V curve and modifications in electrocardiograms, blood pressure, and arterial oxygen satmation (SaO₂).¶Setting: The study was performed in the intensive care unit of the University of Naples “Federico II”.¶Results: No statistically significant modifications in heart rate (HR, b min^–1), blood pressure (BP, mmHg), and SaO₂ were observed between conditions at baseline (HR 97.2 ± 17.7; BP 65.4 ± 9.3; SaO₂ 93.6 ± 2.0), during the recording (HR 99.8 ± 19.5; BP 66.2 ± 11.6; SaO₂ 93.7 ± 2.4), and 2 min after the procedure (HR 98.2 ± 17.8; BP 65.2 ± 11.7; SaO₂ 93.7 ± 1.9). The Pst/V curves were recorded in 8.38 ± 1.19 min and fully analysed in 2.69 ± 0.85 min. Mean value of static compliance was 41.1 ± 12.7 ml cmH₂O^–1. A lower inflection point was found in ten patients (mean value 9.2 ± 1.9 cmH₂O).¶Conclusions: In ARDS patients, the present new computerised method gave valuable data to ordinary intensivists and was shown to be safe, easy, and fast.     

Predicting Delirium Risk Using an Automated Mayo Delirium Prediction Tool: Development and Validation of a Risk-Stratification Model

ObjectiveTo develop a delirium risk-prediction tool that is applicable across different clinical patient populations and can predict the risk of delirium at admission to hospital.MethodsThis retrospective study included 120,764 patients admitted to Mayo Clinic between January 1, 2012, and December 31, 2017, with age 50 and greater. The study group was randomized into a derivation cohort (n=80,000) and a validation cohort (n=40,764). Different risk factors were extracted and analyzed using least absolute shrinkage and selection operator (LASSO) penalized logistic regression.ResultsThe area under the receiver operating characteristic curve (AUROC) for Mayo Delirium Prediction (MDP) tool using derivation cohort was 0.85 (95% confidence interval [CI], .846 to .855). Using the regression coefficients obtained from the derivation cohort, predicted probability of delirium was calculated for each patient in the validation cohort. For the validation cohort, AUROC was 0.84 (95% CI, .834 to .847). Patients were classified into 1 of the 3 risk groups, based on their predicted probability of delirium: low (≤5%), moderate (6% to 29%), and high (≥30%). In the derivation cohort, observed incidence of delirium was 1.7%, 12.8%, and 44.8% (low, moderate, and high risk, respectively), which is similar to the incidence rates in the validation cohort of 1.9%, 12.7%, and 46.3%.ConclusionThe Mayo Delirium Prediction tool was developed from a large heterogeneous patient population with good validation results and appears to be a reliable automated tool for delirium risk prediction with hospitalization. Further prospective validation studies are required.     

不同剂量卡铂动脉灌注化疗宫颈癌组织铂浓度的研究

目的 探讨不同剂量卡铂动脉灌注化疗子宫颈癌组织内铂浓度的分布规律,研究癌组织对卡铂有无吸收饱和度.方法 选择经病理学证实的中晚期宫颈癌病人12例,分成A、B两组,分别按300 mg/m2、200 mg/m2 的剂量经双侧子宫动脉灌注卡铂.于灌注卡铂后0、10 、20和30 min,取新鲜活体癌组织0.3～0.5 g,以原子吸收光谱法测量铂离子浓度.结果 ①A、B两组动脉灌注后宫颈癌组织内铂离子浓度的高峰值均出现在化疗结束后即刻,且随时间的延长而快速下降,呈下降曲线;②动脉灌注卡铂后0、10、20和30 min,A组宫颈癌组织内铂离子浓度分别是B组的3.18倍、2.10倍、2.11倍和2.10倍,差异均具显著意义(P＜0.05 );③两组AUC0～30 min,A组是B组的2.32倍,差异有显著意义(P＜0.05 ).结论 子宫颈癌行动脉灌注化疗时,在卡铂≤300 mg/m2的剂量范围之内,癌组织内的铂离子浓度随着卡铂剂量的增加而成倍数地增加,宫颈癌组织对卡铂无吸收饱和度.     

Evaluation of D-dimer and factor VIII in cirrhotic patients with asymptomatic portal venous thrombosis

D-dimer and factor VIII levels raise in advanced cirrhosis. We investigated the behavior and the diagnostic usefulness of D-dimer and factor VIII in cirrhotic patients with asymptomatic portal venous thrombosis. Factor VIII coagulant and D-dimer values were measured in 136 consecutive outpatients with stable cirrhosis divided according to Child-Pugh (CP) classification, who underwent color/power ultrasonography to detect portal thrombosis. Portal thrombosis was found in 33 patients (24.2%). In patients without thrombosis, factor VIII was significantly higher in CP class C compared with class A and B. Conversely, class C patients with portal thrombosis had lower factor VIII levels than those without thrombosis. In both groups, D-dimer was significantly increased in class C compared with class A and B. In class C, thrombotic patients showed higher D-dimer values than did patients without thrombosis. In class C, a D-dimer value > or = 0.55 microg/mL provided a sensitivity and a negative predictive value for portal thrombosis of 100%, and a factor VIII coagulant level < or = 80% showed a specificity and a negative predictive value of 76% and 84%, respectively. In class B, a D-dimer value > or = 0.225 microg/mL had a sensitivity of 89% and a negative predictive value of 82%. In conclusion, our study shows that factor VIII values increase in severe cirrhosis but significantly decrease in the presence of concomitant portal thrombosis, likely because of consumption during thrombosis; D-dimer is enhanced by both liver failure and portal thrombosis; in severe cirrhosis, normal D-dimer and factor VIII values may safely exclude the presence of asymptomatic portal thrombosis.     

血清1，5脱水葡糖醇和果糖胺对糖尿病诊断的评价

目的 :评价血清 1,5 -脱水葡糖醇 (1,5 - AG)和果糖胺 (FMN)对糖尿病 (DM)的诊断价值。方法 :对按 WHO标准 (1997)确诊的 83例 DM患者 (DM组 )及 5 7例 non- DM对照 (non- DM组 )血清 1,5 - AG、FMN和空腹血糖 (FBG)进行检测 ,用 ROC曲线评价 1,5 - AG和 FMN对 DM的诊断性能。结果 :DM组 1,5 - AG水平明显低于 non- DM组 (P<0 .0 5 ) ,且与 FBG和 FMN呈负相关 ,而 FMN水平则明显高于 non- DM组 (P<0 .0 5 ) ,并与 FBG高度相关 ;1,5 - AG和FMN的 ROC曲线下面积分别为 0 .977和 0 .90 3;1,5 - AG和 FMN分别以≤ 78.0 0μmol/ L和≥ 2 .30 mmol/ L为参考值时 ,其诊断敏感性分别为 86 .75 %和 6 9.88%、特异性为 91.2 3%和 94 .74 %、阳性似然比为 9.89和 13.2 8、阴性似然比为0 .15和 0 .32。结论 :血清 1,5 - AG和 FMN对 DM均具较高诊断价值 ,前者更为可靠。     

ROC曲线分析及诊断分界点确定程序

目的介绍一种新开发的ROC分析软件.方法①依据非参数法和参数法ROC分析理论建立算法.②对文献中3套数据分别用本软件、SPSS及Analyse-it软件进行ROC分析验证.③应用:肺部良性39,恶性87例的PET FDG图像的SUV最大值及平均值鉴别良恶性效能评估.结果①软件主要功能:提供非参数和参数法两种ROC分析;确定3个典型诊断分界点;计算诊断符合率评价指标.②软件验证:3个软件对3套数据的分析结果完全相同.③应用实例:SUV平均值的诊断效能稍好,但差异无显著性.结论该软件不仅具有较完整的ROC分析功能,而且还具有确定诊断分界点,提供多种诊断符合率指标的功能,是目前性能较完整的软件.