Captopril test: time over?

OBJECTIVE: The role of non-invasive tests for the detection of renovascular hypertension is still a matter of controversy. The 'captopril test' is widely used; its clinical usefulness, however, remains questionable. The aim of the current study was therefore to report our own experience and to review the published data on the diagnostic significance of the test. PATIENTS AND METHODS: Data from 485 hypertensive patients who underwent a captopril test in consecutive order at our institution were analysed retrospectively. After a 30-min resting period in the supine position 50 mg of captopril was given orally. Blood was collected before and 90 min after dosage for the determination of plasma renin concentration (normal range 3.5-8.0 ng/ml/h). An increase by 100% or more of the baseline value was considered a positive response. Blood pressure was recorded at baseline and at 90 min. RESULTS: A positive response was present in 62 patients; further diagnostic work-up revealed significant renal artery stenosis in 11 of these patients. In the 423 patients with a negative response renal artery stenosis was found in three cases. With some limitations of retrospective analyses in mind, sensitivity and specificity of the test were calculated as 79% and 89%, respectively. No severe complication occurred during the test. CONCLUSION: Our data on the diagnostic indices and the safety of the captopril test are in good agreement with most published series. Altogether, available data suggest that the captopril test has a limited diagnostic accuracy as a screening test for the detection of renovascular hypertension. New radiologic non-invasive techniques with greater diagnostic value are therefore likely to challenge the clinical role of the test in the future.     

aVR 导联 ST 段改变对不同冠脉血管病变的诊断及鉴别诊断意义

冠状动脉左主干及其主要分支病变均可引起心电图 aVR 导联 ST 段的抬高或压低,但不同血管病变所致心肌缺血或梗死的危险分层及临床预后却相差甚远,因此对不同冠脉血管病变的诊断及鉴别诊断非常重要。这其中 aVR 导联 ST 段的改变具有重要的临床意义,其诊断及鉴别诊断价值高于其他任何单一或多个导联。本文就 aVR 导联 ST 段的抬高或压低对不同冠脉血管病变的诊断及鉴别诊断意义、诊断标准及国外近年来的研究进展进行综述。     

The Women's Ischemia Syndrome Evaluation (WISE) study: protocol design, methodology and feasibility report.

OBJECTIVES: The Women's Ischemia Syndrome Evaluation (WISE) is a National Heart, Lung and Blood Institute-sponsored, four-center study designed to: 1) optimize symptom evaluation and diagnostic testing for ischemic heart disease; 2) explore mechanisms for symptoms and myocardial ischemia in the absence of epicardial coronary artery stenoses, and 3) evaluate the influence of reproductive hormones on symptoms and diagnostic test response. BACKGROUND: Accurate diagnosis of ischemic heart disease in women is a major challenge to physicians, and the role reproductive hormones play in this diagnostic uncertainty is unexplored. Moreover, the significance and pathophysiology of ischemia in the absence of significant epicardial coronary stenoses is unknown. METHODS: The WISE common core data include demographic and clinical data, symptom and psychosocial variables, coronary angiographic and ventriculographic data, brachial artery reactivity testing, resting/ambulatory electrocardiographic monitoring and a variety of blood determinations. Site-specific complementary methods include physiologic and functional cardiovascular assessments of myocardial perfusion and metabolism, ventriculography, endothelial vascular function and coronary angiography. Women are followed for at least 1 year to assess clinical events and symptom status. RESULTS: In Phase I (1996-1997), a pilot phase, 256 women were studied. These data indicate that the WISE protocol is safe and feasible for identifying symptomatic women with and without significant epicardial coronary artery stenoses. CONCLUSIONS: The WISE study will define contemporary diagnostic testing to evaluate women with suspected ischemic heart disease. Phase II (1997-1999) is ongoing and will study an additional 680 women, for a total WISE enrollment of 936 women. Phase III (2000) will include patient follow-up, data analysis and a National Institutes of Health WISE workshop.     

重建心向量图与常规心向量图,心电图诊断价值的比较

我们在同一病例组上对两个计算机诊断系统的诊断价值进行了比较。两个系统中，一个完成对心电图的解释，另一个完成对心向量图和重建心向量图的解释。病例组总数为２６２５例，其中正常人１０６５例，左心室肥大２１６例，右心室肥大３４例，双心室肥大２３例，前壁心梗３４０例，下壁心梗７００例，复合心梗２４７例。结果显示，重建心向量图具有与常规心向量图类似的诊断精度，将这个由心电图推算而来的诊断与心电图并用，可以提高心电图对正常、左心室肥大以及复合心梗的诊断正确率。提示重建心向量图在多种疾病的诊断中具有一定价值，存在于常规心向量图中的诊断信息也存在于同步记录的心电图中，对后者的利用可以提高心电图的诊断价值。     

Oligo-monocytic CMML and other pre-CMML states: Clinical impact,prognostication and management

Chronic myelomonocytic leukemia (CMML) is defined by myelodysplasia, pathologic accumulation of monocytes and a substantial risk to transform to secondary acute myeloid leukemia (sAML). In recent years, minimal diagnostic criteria for classical CMML and CMML-variants were proposed. Moreover, potential pre-stages of CMML and interface conditions have been postulated. Oligomonocytic CMML is a condition where the absolute peripheral blood monocyte count does not reach a diagnostic level but all other criteria for CMML are fulfilled. Among potential pre-stages of CMML, clonal and non-clonal conditions have been described, including idiopathic monocytosis (IMUS) and clonal monocytosis of unknown significance (CMUS). Patients with myelodysplastic syndromes (MDS), clonal cytopenia of unknown significance (CCUS), clonal hematopoiesis of indeterminate potential (CHIP) and idiopathic cytopenia of undetermined significance (ICUS) may also progress to CMML. The current article provides an overview of pre-CMML conditions and oligomonocytic CMML, with special reference to diagnostic criteria, differential diagnoses, clinical outcomes and management.     

Jejunal Biopsy: Criteria and Significance

The classification and diagnostic significance of 1,500 specimens of jejunal mucosa obtained from nine hundred patients are considered. The only biopsies with a positive diagnostic appearance were those obtained in adult coeliac disease, intestinal lipodystrophy and hypogamniaglobulinaemia. Acanthocy- tosis and lymphangiectasis were not encountered in this series. Mucosal abnormalities such as leaves, ridges or convolutions had no diagnostic significance, nor did mild and moderate changes under light histology (Grades I and II), On the evidence available at present a flat mucosa with mosaic pattern anti the associated severe histological changes (Grade III) should be considered diagnostic af adult coeliac disease.     

Diagnosing coronary artery disease in diabetic patients

Although several diagnostic modalities are available to the clinician interested in diagnosing coronary artery disease, very few have been validated in diabetic populations. This review discusses the non-invasive diagnosis of coronary disease in diabetic patients. Evidence regarding the prevalence and prognostic significance of silent ischemia is reviewed and the potential impact of silent ischemia on the diagnostic characteristics of the exercise treadmill test discussed. Other diagnostic tools are considered, and recommendations are made with respect to screening asymptomatic diabetic patients for coronary artery disease.     

Biochemical characterization of amyloid derived from the variable region of the kappa light chain subgroup III

We report the clinical data and results of biochemical studies of amyloid in a postpartum patient. The amyloidosis was not associated with myeloma, and immunopathologic examination of the amyloid deposits gave inconclusive results. Biochemical analysis of the deposits proved that the amyloid protein JUN was derived from the variable region of the kappa light chain subgroup III and is homologous to a rarely expressed protein POM, which was previously shown to have rheumatoid factor activity. The significance of this association and the diagnostic problems associated with certain cases of amyloid derived from immunoglobulin light chain (type AL) are discussed.     

Fever of unknown origin caused by adult juvenile rheumatoid arthritis: the diagnostic significance of double quotidian fevers and elevated serum ferritin levels

Fever of unknown origin (FUO) in adults is a commonly encountered clinical problem. Treatable causes of FUO in the adult should be the primary focus of the diagnostic workup. Neoplasms have replaced infectious diseases as being the most common cause of FUO in adults, and collagen vascular diseases are now relatively rare. The most important collagen vascular diseases presenting as an FUO include Takayasu's arteritis, Kikuchi's disease, polymyalgia rheumatica, and adult juvenile rheumatoid arthritis (JRA) (adult Still's disease). There are no specific diagnostic tests for these disorders, which commonly present as prolonged fevers that are not easily diagnosed (i.e., FUO). Adult JRA is a rare but important cause of FUO in adults. Typically, patients with adult Still's disease present with liver/spleen involvement, posi-articular arthritis, ocular involvement, and evanescent salmon-colored truncal rash. An important diagnostic finding in adult JRA is the presence of a double quotidian fever, which occurs in few other disorders. Only visceral leishmaniasis and adult JRA are causes of FUO in adults associated with double quotidian fevers. Highly elevated serum ferritin levels are the most important nonspecific diagnostic finding associated with adult JRA. We present a case of FUO caused by adult JRA presenting with diffuse polyarticular migrating arthritis, evanescent rash, and splenomegaly. The diagnosis of adult JRA was suggested by these findings in association with a double quotidian fever and a highly elevated serum ferritin level. Clinicians should appreciate the diagnostic significance of fever patterns and the diagnostic significance of elevated serum ferritin levels in patients with FUO.     

Diastolic micropotentials in high-resolution surface ECG in QT syndrome

Patients suffering from long QT syndrome are threatened by torsade de pointes tachycardias and sudden arrhythmic cardiac death. An inhomogenic sympathetic innervation of the heart with dominance of the left cervicothoracic sympathetic nerves has been considered to be a major cause of life threatening cardiac arrhythmias. This study presents the electrocardiographic and electrophysiologic results of 7 patients with long QT syndrome. In agreement with data published earlier our results of Holter monitoring, exercise testing and programmed electrical right ventricular stimulation were of no diagnostic or prognostic significance in predicting syncopal attacks or sudden arrhythmic cardiac death. Thus, the high resolution ECG methods played an important role in this study. During noninvasive recordings of signal averaged ECGs and high resolution surface ECGs with beat to beat registration, diastolic microvolt potentials could be detected in 6/7 patients within the ST segment and in 5/7 patients after the T wave. Our results evidently show that the signal averaged ECG and the high resolution surface ECG could be of diagnostic significance in patients with long QT syndrome.     

P-选择素与静脉血栓栓塞症

血小板激活是静脉血栓形成的重要组成步骤,P-选择素是血小板的活性受体,也能被上皮细胞所识别.作为血小板/内皮细胞活化标志和细胞黏附受体.其可通过介导血小板、内皮细胞黏附及与白细胞的相互作用,启动参与包括炎症和血栓形成等多种病理生理起始过程,是血栓形成的重要介质和靶分子.检验P.选择素可以通过流式细胞仪检测血小板表面的P一选择素或通过酶联免疫吸附试验检测血液中可溶性P-选择素,方法简便,这些数据可作为血小板激活的判断.从而为血栓形成提供依据.抑制P一选择素及其配体的结合,可使病理状态下血栓局部白细胞聚集减少,细胞因子及组织因子表达降低,纤维蛋白生成减少,从而有助于抑制血栓的形成.     

Biochemical characterization of amyloid derived from the variable region of the k light chain subgroup III

We report the clinical data and results of biochemical studies of amyloid in a postpartum patient. The amyloidosis was not associated with myeloma, and immunopathologic examination of the amyloid deposits gave inconclusive results. Biochemical analysis of the deposits proved that the amyloid protein JUN was derived from the variable region of the k light chain subgroup III and is homologous to a rarely expressed protein POM, which was previously shown to have rheumatoid factor activity. The significance of this association and the diagnostic problems associated with certain cases of amyloid derived from immunoglobulin light chain (type AL) are discussed.     

复杂先天性心脏病双源螺旋CT诊断的标准化

目的:探讨图像后处理标准切面重建序列能否提高双源螺旋CT对小儿复杂先天性心脏病的诊断准确性。方法: 经心腔开放性手术确诊的小儿复杂先天性心脏病患者38（男18,女20）例,月龄（15±6）月,体质量（10±5） kg。以手术结果为标准,对比传统经验法和标准切面重建序列法对复杂先天性心脏病心内结构性畸形的诊断准确率。结果: 标准切面重建序列法对于复杂先天性心脏病心内结构性畸形的诊断的灵敏度优于传统经验法（95% vs. 86%,P<0.05）,而诊断的特异度和准确度无显著差异。结论: 标准切面重建序列的图像后处理技术可以提高双源螺旋CT对小儿复杂先天性心脏病心内结构性畸形诊断的灵敏度。     

Diastolic heart failure: progress, treatment challenges, and prevention

Diastolic heart failure (DHF) is an important entity, the significance of which is increasingly recognized. This report examines the available evidence regarding the role, significance, and mechanisms of DHF. Epidemiologic studies have documented the rising burden of DHF, and experimental data are revealing the unique mechanisms distinguishing it from systolic heart failure. Despite controversies on the definition of DHF, or heart failure with preserved ejection fraction, standardized clinical criteria with supplementary imaging and structural data have identified DHF as a distinct pathophysiological entity. The mechanisms underlying DHF include abnormal matrix dynamics, altered myocyte cytoskeleton, and impaired active relaxation. The commonly held belief that survival of patients with DHF is better than that of patients with systolic heart failure has been challenged by updated data. The heterogeneous etiologies or risk factors for the condition include aging, diabetes, hypertension, and ischemia, making a common diagnostic or treatment pathway difficult. Novel therapeutic targets that address the pathophysiology of this disease are under consideration, although there are no proven therapies for DHF to date. Exacerbating factors include volume and sodium indiscretion, arrhythmias, ischemia, and comorbidities. Strategies to ameliorate or to obviate these precipitating factors are most effective in preventing DHF and its exacerbations. Meanwhile, prevention of DHF through appropriate and aggressive risk factor identification and management must remain the cornerstone of clinical intervention.     

Routine immunophenotyping of acute leukaemias

Summary Recent progress in immunophenotyping includes the availability of monoclonal antibodies (MAbs), knowledge of specificity and reactivity patterns of these reagents, and the technical improvements and standardization of immunofluorescence and immunocytology staining procedures, including flow cytometry. These advances have contributed significantly to the establishment of immunophenotyping as an essential diagnostic tool in the differential diagnosis of types of acute leukaemia. Immunophenotyping allows for the objective and reproducible distinction of acute lymphoblastic leukaemia (ALL) from acute myeloblastic leukaemia (AML) and of T-lineage from B-lineage ALL. Immunologically defined ALL and AML subtypes have been found to convey prognostic significance. Using cell lineage-specific and differentiation stage-specific MAbs, cases of T- and B-lineage ALL and of AML can be further classified into a number of different subtypes. Routine immunophenotyping concentrates on the diagnostic enquiry into a few major, clinically relevant subtypes; only a limited number of crucial reagents are employed that are commercially available. The simplification and standardization of discriminatory immunomarker panels make immunophenotyping a reliable diagnostic instrument for the provision of critical data to make a differential diagnosis. An effort to identify the nature and origin of the blast cells precisely, immunological typing definitely plays an important part in the multiple-marker analysis of acute leukaemia (morphology, cytochemistry, karyotying, genotyping) for applied diagnostic and fundamental research purposes.     

Modern development of imaging procedures in oncology

From the oncologic point of view, imaging diagnostic techniques have been and will be of steadily increasing significance. This paper gives a survey of the present state of the art and of various aspects of current international trends in X-ray diagnostics, computed tomography, ultrasound and magnetic resonance. High tech developments raise the expenditures, so that the cost-benefit-relations have to be considered in future diagnostic strategies. Some aspects for further research tasks are mentioned. The aim of all improvements in imaging procedures is to increase the influence of diagnostic procedures on treatment planning and to improve the treatment results and, ultimately, the prognosis of cancer patients.     

Fever of unknown origin: clinical overview of classic and current concepts

Fever of unknown origin (FUO) refers to disorders that present with prolonged and perplexing fevers that are difficult to diagnose. This article presents a clinical overview of classic and current causes of FUOs, which may be due to infectious, rheumatic/inflammatory, neoplastic, or miscellaneous disorders. Comprehensive but nonfocused diagnostic testing is ineffective and should be avoided. The FUO workup should be directed by the key history, physical, and laboratory findings in clinical presentation. The clinical syndromic approach in the differential diagnosis of FUOs is emphasized, and the diagnostic importance and significance of fever patterns are discussed.     

The epidemiologic and clinical importance of norovirus infection

Noroviruses are a major cause of sporadic cases and epidemic outbreaks of gastroenteritis. The development of molecular diagnostic assays has led to an increased recognition of the significance of these viruses as causes of gastroenteritis in all age groups. This article reviews the epidemiology, clinical manifestations and pathogenesis of norovirus infection, and it describes the diagnostic and therapeutic approaches to this disease.     

Issues of origin,morphology and clinical significance of tumor microvessels in gastric cancer

Gastric cancer (GC) remains a serious oncological problem, ranking third in the structure of mortality from malignant neoplasms. Improving treatment outcomes for this pathology largely depends on understanding the pathogenesis and biological characteristics of GC, including the identification and characterization of diagnostic, prognostic, predictive, and therapeutic biomarkers. It is known that the main cause of death from malignant neoplasms and GC, in particular, is tumor metastasis. Given that angiogenesis is a critical process for tumor growth and metastasis, it is now considered an important marker of disease prognosis and sensitivity to anticancer therapy. In the presented review, modern concepts of the mechanisms of tumor vessel formation and the peculiarities of their morphology are considered; data on numerous factors influencing the formation of tumor microvessels and their role in GC progression are summarized; and various approaches to the classification of tumor vessels, as well as the methods for assessing angiogenesis activity in a tumor, are highlighted. Here, results from studies on the prognostic and predictive significance of tumor microvessels in GC are also discussed, and a new classification of tumor microvessels in GC, based on their morphology and clinical significance, is proposed for consideration.     

非创伤性诊断肝纤维化临床研究进展

正确评估肝纤维化程度有利于临床治疗和随访慢性肝病。笔者就非创伤性诊断肝纤维化的不同方法、适应证和步骤的最新进展进行讨论。瞬间弹性超声检查与多项血清标志物组合的诊断模型,符合非创伤性肝纤维化诊断技术的多项要求,能有效诊断严重肝纤维化（S≥3期）,但区分轻、中度肝纤维化（S≤2期）欠佳。目前,非创伤性诊断肝纤维化方法仍不成熟,还不能完全取代肝脏活体组织检查。