Prognostic factors in patients with endocrine tumours of the duodenopancreatic area

Background—Thedevelopment of endocrine tumours of the duodenopancreatic area (ETDP)is thought to be slow, but their natural history is not well known. Theaim of this study was to determine the factors that influence survivalof patients with ETDP.
Patients/Methods—Eightytwo patients with ETDP (44 non-functioning tumours, 23 gastrinomas,seven calcitonin-secreting tumours, four glucagonomas, threeinsulinomas, one somatostatinoma) followed from October 1991 to June1997 were included in the study. The following factors wereinvestigated: primary tumour size, hormonal clinical syndrome, livermetastases, lymph node metastases, extranodular/extrahepatic metastases, progression of liver metastases, local invasion, complete resection of the primary tumour, and degree of tumoral differentiation. The prognostic significance of these factors was investigated by uni-and multi-variate analysis.
Results—Twenty eightpatients (34%) died within a median of 17 months (range 1-110) fromdiagnosis. Liver metastases (p =0.001), lymph node metastases (p = 0.001), progression of liver metastases (p<0.00001), lack of completeresection of the primary tumour (p = 0.001), extranodular/extrahepaticmetastases (p =0.001), local invasion (p = 0.001), primary tumour size3 cm (p = 0.001), non-functioning tumours (p = 0.02), and poortumoral differentiation (p = 0.006) were associated with anunfavourable outcome by univariate analysis. Multivariate analysisidentified only liver metastases (risk ratio (RR) = 8.3; p<0.0001),poor tumoral cell differentiation (RR = 8.1; p = 0.0001), and lack ofcomplete resection of the primary tumour (RR = 4.8; p = 0.0007) asindependent risk factors. Five year survival rates were 40and 100% inpatients with and without liver metastases, 85 and 42% in patientswith and without complete resection of primary tumour, and 17 and 71%in patients with poor and good tumour cell differentiation respectively.
Conclusion—Livermetastases are a major prognostic factor in patients with ETDP.Progression of liver metastases is also an important factor which mustbe taken into account when deciding on the therapeutic approach. Theonly other independent prognostic factors are tumoral celldifferentiation and complete resection of the primary tumour.

Keywords:prognostic factors; survival; endocrine tumours; gastrinoma; cell differentiation; liver metastases

     

Thoracic aortic dissection in an 18-year-old woman with no risk factors

Spontaneous aortic dissection is a rare, life-threatening cause of chest pain, and has a higher prevalence when traditional risks such as age, hypertension, dyslipidemia, or connective tissue disorders are present. However, even in the absence of risk factors, non-traumatic rupture of an aortic dissection may occur. Most are found in patients over 40 years of age. Younger victims of this disease often also suffer from other conditions such as cystic medial necrosis, connective tissue disorders such as Marfan's syndrome, or vasculitis. We present the case of an 18-year-old, previously healthy woman who was country line dancing when she began to complain of severe, cramping chest and back pain. She was hemodynamically stable on initial presentation but experienced two seizures while in the emergency department and was intubated. Subsequently, her blood pressure dropped and she developed cardiac arrest, and despite vigorous resuscitation that included blood products and emergency department thoracotomy, she was refractory to all attempts. At autopsy she was found to have a spontaneous, non-traumatic rupture of an aortic dissection. This patient had no discernable risk factors for aortic dissection or discoverable cause on necropsy. We present this case to raise awareness among physicians and review other reported cases in the literature of aortic dissection in patients under age 40 years.     

三级甲等医院护师及以上职称护理人员科研现状的调查

目的:了解三级甲等医院护师及以上职称护理人员的科研状况及影响因素。方法:对182名三级甲等医院护师及以上职称护理人员进行自设问卷调查,内容包括科研现状、对科研的态度、科研的困难、激励因素及对科研相关知识的需求。结果:23.1%的护理人员在专业期刊上发表过护理论文,51.6%参与过科研活动;其中时间、相关知识、激励制度、信息资源等被认为是护理人员从事临床科研的主要影响因素。结论:临床护理人员的科研水平有待提高,管理者可通过创造必要的客观条件,如时间安排、科研培训、激励制度、信息资源等促进临床科研的发展。     

Secular trends in cardiovascular risk factors with a 36-year perspective: observations from 38- and 50-year-olds in the Population Study of Women in Gothenburg

Objectives

To study secular trends in cardiovascular risk factors in four different cohorts of women examined in 1968–1969, 1980–1981, 1992–1993 and 2004–2005.

Design

Comparison of four representative cohorts of 38- and 50-year-old women over a period of 36 years.

Setting

Gothenburg, Sweden with ∼450 000 inhabitants.

Subjects

Four representative samples of 38- and 50-year-old women were invited to free health examinations (participation rate 59–90%, n =1901).

Main outcome measures

Body mass index (BMI), systolic and diastolic blood pressure (SBP, DBP), leisure time exercise, use of antihypertensive medication, smoking, levels of haemoglobin, b-glucose, s-cholesterol, s-triglycerides and HDL-cholesterol.

Results

There was no significant difference in mean BMI from 1968–1969 versus 2004–2005. Mean leisure time exercise was significantly higher in later born cohorts; in 1968, around 15% were physically active compared with 40% in 2004. SBP and DBP, mean s-cholesterol and s-triglyceride levels were significantly lower in both 38- and 50-year-old cohorts in 2004–2005 versus 1968–1969. HDL-cholesterol (not measured until 1992–1993), showed a significantly higher mean level in 2004–2005. Reduction of risk factors was apparent in women with a high as well as low level of physical activity. Smoking declined most in women with high levels of physical activity.

Conclusions

Several cardiovascular risk factors related to lifestyle have improved in middle-aged women from the 1960s until today. Most of the positive trends are observed in women with both low and high physical activity.     

Incidence and risk factors of pneumonia acquired in intensive care units

Objective To estimate the incidence of pneumonia acquired in the intensive care unit (ICU), and to define risk factors for developing such an event.Design European prospective survey, in which all patients admitted to the participating ICU from January, 17 to 23, 1990, were followed until ICU discharge.Setting 107 general ICUs from 18 countries.Patients Of 1078 admitted to the ICUs, 996 patients without pneumonia at admission were studied.Measurements Pneumonia was diagnosed by the staff physician on the basis of clinical, radiological and microbiological criteria, secondly validated by an expert committee who reviewed all the forms and even recontacted ICU physicians. Crude incidence and time to occurrence of pneumonia were estimated, then both used as endpoints for prognosis analysis.Results 89 pneumoniae were observed: crude incidence was estimated at 8.9%, 7-day and 14-day pneumonia rates at 15.8% and 23.4%, respectively. The risk of developing pneumonia increased when either coma, trauma, respiratory support, Apache II >16 and/or impaired airway reflexes were present at ICU admission. To predict time to occurrence of pneumonia, only two variables remained significant: the presence of impaired airway reflexes at admission and the use of mechanical ventilation during ICU course.Conclusion The role of the injury to the respiratory system — with the subsequent need for respiratory support-appears central in determining the risk to acquire pneumonia in ICU. In the future, the predictive value of severity scores during ICU course should be otherwise assessed.     

Sense of coherence: quality of life before and after coronary artery bypass surgery--a longitudinal study

The attention to patient outcome has nowadays extended from morbidity and mortality to an aspect of patients' benefits in terms of quality of life. One factor crucial for quality of life is coping capacity, in this study represented by the sense of coherence concept. Physical status and emotional state (often measured by comprehensive instruments not always suitable for clinical use) are also additionally used to reflect quality of life. The purpose was therefore to study sense of coherence and emotional state as indirect measures of quality of life in relation to coronary artery bypass grafting surgery. One hundred and eleven patients were studied by a developed questionnaire on five occasions in relation to the surgery: the week before the angiography, the day before surgery and then at 3, 6, and 12 months post-operatively. The main findings were: (1) The sense of coherence was changed (more than +/-10%) from before to 1 year after surgery in 41% of the patients, which is contrary to the theory of sense of coherence as a stable personality characteristic in adults. (2) Experience of depressed mood, stress, and anxiety decreased significantly from before to after surgery. (3) Beneficial outcome with regard to sense of coherence was significantly related to less experience of loneliness, depressed mood, stress and anxiety, and to less experience of chest pain 1 year after surgery. In conclusion, sense of coherence and emotional state variables, are suggested to be valuable as measurements of quality of life in relation to coronary artery bypass grafting surgery.     

The evaluation of walking footwear on postural stability in healthy older adults: an exploratory study

Background

It has been proposed that walking footwear enhances postural stability in healthy older adults. The aim of the study is to evaluate differences between two different types of athletic footwear in relation to postural stability in healthy older adults.

Methods

A convenience sample of 21 healthy older adults with mean (SD) of 74 (5) years was recruited. Postural stability was measured using a force plate for anterior–posterior (AP) and mediolateral (ML) centre of pressure excursion for 30 s with eyes closed and open using two different types of athletic footwear. Each participant performed three repetitions of bipedal standing. Two-way analysis of variance tested the interaction effect of the footwear and eye conditions on anterior–posterior (AP) and mediolateral (ML) postural sway.

Findings

There was no significant footwear–eye condition interaction for anterior-posterior(AP) postural sway but there were significant main effects for both the footwear and eye conditions (P < 0.05). The significant main effects for the footwear conditions occurred between barefeet and the two shoe conditions, but not between the two shoe conditions. For mediolateral (ML) postural sway there was no significant interaction effect and no main effects for the footwear and eye conditions (P > 0.05).

Interpretation

The results suggest that older adults demonstrate an initial destabilisation effect which could possibly be of benefit to functional ability but the long-term effects of ability of athletic footwear to enhance postural stability requires further investigation.     

Factors Predisposing to the Development of Atrial Fibrillation

Atrial fibrillation (AF) is in most patients (approximately 70%) associated with organic heart disease including valvular heart disease, coronary artery disease, hypertension, hypertrophic cardiomyopathy, dilated cardiomyopathy, and congenital heart disease, mostly atrial septal defect in adults. In many chronic conditions, determining whether AF is the result or is unrelated to the underlying heart disease, remains unclear. The list of possible etiologies also include cardiac amyloidosis, hemochromatosis and endomyocardial fibrosis. Other heart diseases, such as mitral valve prolapse (without mitral regurgitation), calcifications of the mitral annulus, atrial myxoma, pheochomocytoma, and idiopathic dilated right atrium may present with AF. Atrial fibrillation may occur in the absence of detectable organic heart disease, the so-called “lone AF”, in about 30% of cases. The term “idiopathic AF” implies the absence of any detectable etiology including hyperthyroidism, chronic obstructive lung disease, overt sinus node dysfunction, and overt or concealed preexcitation (Wolff-Parkinson-White syndrome), only to mention a few of other uncommon causes of AF. The autonomous nervous system may contribute to the occurrence of AF in some patients. AF occurs commonly. In patients with valvular heart disease, AF is common, particularly when the mitral valve is involved. The occurrence of AF is unrelated to the severity of mitral stenosis or mitral regurgitation but is more common in patients with enlarged left atrium and congestive heart failure. In patients with coronary artery disease, AF occurs predominantly in older patients, males, and patients with left ventricular dysfunction. Important predictive factors of AF include hypertension, left ventricular hypertrophy and diabetes. The risk of the development of AF, in an individual patient, is often difficult to assess. Increasing age, presence of valvular heart disease, and congestive heart failure increase the risk of atrial fibrillation.     

冠状动脉粥样硬化患者高危因素相关分析与护理指导

目的 研究冠状动脉粥样硬化患者危险因素,有利于预防和改善预后。方法 回顾2011年1月-2012年3月我科行冠脉造影的连续住院的患者245例。通过冠脉造影确定为冠状动脉粥样硬化患者狭窄程度>50%者188例为冠心病组,57例为冠状动脉粥样硬化患者狭窄程度<50%者为对照组。记录纳入样本的临床资料,分析心血管病危险因素,包括左心射血分数、血脂系统等。进行单因素分析和多因素非条件逐步Logistic回归。结果 冠心病组患者在高血压、高血糖、高血脂、抽烟明显高于对照组(P<0.01)。进一步对血压、血糖、血脂、抽烟危险因素作非条件逐步Logistic回归,其OR值依次为:抽烟OR=2.78,高血脂OR=3.10,高血压OR=1.65,高血糖OR=1.02。结论 冠状动脉粥样硬化患者狭窄程度>50%者在高血压、高血糖、高血脂、抽烟等危险因素均与冠状动脉病变严重程度密切相关,因此有必要在疾病的进行性发展过程中重视护理干预,如戒烟酒、提倡规律生活、改善遵医行为等,以减少危险因素对冠状动脉的进一步的损害。