Dyspnoea in the elderly: a clinical approach to diagnosis

This review briefly overviews the pathophysiology of dyspnoea and then focuses on discussion of the most frequent causes of chronic and acute dyspnoea in the elderly. The most common causes of dyspnoea in the elderly include heart failure, chronic obstructive pulmonary disease and asthma. Other causes include parenchymal lung disease, pulmonary vascular diseases, upper airway obstruction and pneumonia. Dyspnoea should not be attributed to aging alone. Careful clinical evaluation and spirometry is indicated, and additional testing may be appropriate. In this article, emphasis is placed on the clinical manifestations of dyspnoea in the elderly and an approach to their differential diagnosis is provided. Discussion of available therapy is beyond the scope of this article.     

Current approach to masked hypertension: From diagnosis to clinical management

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A multidisciplinary approach to patient controlled analgesia.

Patient controlled analgesia (PCA) is an innovative method for delivering intravenous analgesia, which requires therapeutic and technical expertise from various health care professionals. This article describes a multi-disciplinary process of implementing a PCA program including approaches to solving problems encountered. A pharmacy and therapeutics subcommittee was established with various aspects of the program assigned to the medical, nursing and pharmacy staffs, intravenous (IV) therapy team, and clinical equipment support. A detailed comparison of PCA pumps was prepared to aid in selection. A pharmacy-based protocol describes the role of each health care professional. Usage guidelines are presented and evaluated. Physician order sheets and narcotic disposition forms were designed specifically for PCA. Problems encountered include dedicated IV access, PCA use in specialized hospital units, and use in pediatric patients. A multi-disciplinary approach was successful in implementing and maintaining a quality PCA program. Similar approaches should be used for other sophisticated drug-delivery systems.     

Noncoeliac enteropathy: the differential diagnosis of villous atrophy in contemporary clinical practice

Background Duodenal villous atrophy (DVA) is a key diagnostic finding in coeliac disease (CD). However, the differential diagnosis for this finding is broad. Aim To identify conditions causing noncoeliac enteropathy (NCE) with villous atrophy and methods to differentiate between CD and NCE in clinical practice. Methods Through record review we identified patients with DVA due to conditions other than CD. Patient demographics, clinical features and relevant investigations were compared with CD patients. Rates of CD misdiagnosis, and response to treatments were recorded. Results Thirty cases of NCE were identified with ten different aetiologies. Unspecified immune‐mediated enteropathy was the most common aetiology; affecting 10 patients. Gastrointestinal symptoms were more common in NCE than those in CD patients (P < 0.01). Twenty of the 24 NCE patients tested were HLA‐DQ2/DQ8 negative. Twenty‐six NCE patients were negative for IgA tissue transglutaminase (tTG) (P = 0.0001). Intraepithelial lymphocytosis was absent in 10 (33.3%) patients. Twenty‐one NCE patients initially misdiagnosed with CD and one with gluten intolerance were prescribed a gluten free diet (GFD). Fifteen of 22 had repeat biopsy and none showed histological improvement. Conclusions Although coeliac disease is the most common cause of DVA, noncoeliac enteropathy is not rare and may easily be mistaken for coeliac disease. Noncoeliac enteropathy is suggested by a normal initial tTG (87%), lack of intraepithelial lymphocytosis on biopsy, and lack of histological response to a gluten free diet. Subjective response to gluten free diet has poor predictive value for coeliac disease. Noncoeliac enteropathy can often be confirmed by negative HLA‐DQ2/DQ8 testing and targeted investigations can ascertain a definitive aetiology in most cases.     

A portfolio-based approach to optimize proof-of-concept clinical trials

Improving proof-of-concept (PoC) studies is a primary lever for improving drug development. Since drug development is often done by institutions that work on multiple drugs simultaneously, the present work focused on optimum choices for rates of false positive (α) and false negative (β) results across a portfolio of PoC studies. Simple examples and a newly derived equation provided conceptual understanding of basic principles regarding optimum choices of α and β in PoC trials. In examples that incorporated realistic development costs and constraints, the levels of α and β that maximized the number of approved drugs and portfolio value varied by scenario. Optimum choices were sensitive to the probability the drug was effective and to the proportion of total investment cost prior to establishing PoC. Results of the present investigation agree with previous research in that it is important to assess optimum levels of α and β. However, the present work also highlighted the need to consider cost structure using realistic input parameters relevant to the question of interest.     

A standard approach to compiling clinical pharmacokinetic data

A standard format for a Clinical Pharmacokinetic Summary is proposed. It consists of a heading, table, notes, and references for each drug reviewed. The table presents a unified and logical set of clinically useful population pharmacokinetic parameters. They concern four major areas: absorption, distribution, elimination, and the relationship of concentration to effect. Within each major group, parameters dealing with extents and rates of processes are given. Each such parameter is really two: a population mean value (for example, average volume of distribution) and the standard deviation of individual values about this mean. The first value allows individual predictions of dosage or drug level to be made; the second allows computation of the likely proximity of subsequently observed quantities to those predictions. The table presents single consensus values for each population parameter, rather than a list of values. A procedure for computing these consensus values, and for revising them in the light of new data, or reinterpreted old data, is given. Examples of Summaries are given. The method appears applicable to a variety of drugs. We suggest our approach as a standard one for preparing Clinical Pharmacokinetic Summaries, and urge our colleagues to consider it for that purpose.Supported in part by National Institutes of Health, Grants GM 26691 and GM 26676.     

B超鉴别诊断甲状腺结节的临床价值探讨

目的研究B超鉴别诊断甲状腺结节的临床价值。方法选取94例我院2016年5月～2018年5月诊治的手术治疗甲状腺结节患者,根据术前检查方式的差异分为两组,各47例,其中对照组采用术前ECT检查,研究组采用B超检查。依照病理学检查结果,比较两种检查方式在甲状腺结节病变诊断中的准确率。结果两种诊断方式在甲状腺腺瘤、结节性甲状腺肿、甲状腺囊肿诊断准确率上差异无统计学意义(P 0.05);但对照组在甲状腺癌85.71%、甲状腺炎100.00%诊断准确率上明显高于研究组50.00%、50.00%,差异有统计学意义(P 0.05)。结论由于ECT检查费用较高,但两种诊断方式在甲状腺腺瘤、结节性甲状腺肿、甲状腺囊肿上无差异,均可进行诊断;在甲状腺腺瘤、结节性甲状腺肿、甲状腺囊肿需要进一步使用ECT检查,确保诊断的准确率。     

A rational approach to the selection of useful drugs for clinical practice

Confusion exists concerning optimal selection of drugs for clinical practice. Many reasons contribute to this confusion which derives from various sources including industry, the FDA and often less than ideal education of physicians in clinical pharmacology during medical school and thereafter. This presentation does not focus on allocating blame for the current unsatisfactory situation, but rather offers a solution to improve drug therapy. Our educational solution consists of a paradigm for rational drug therapy, specifically a checklist of eight criteria for physicians to review before prescribing drugs. Such a review would facilitate better estimation by physicians of risk/benefit ratios involving new, often expensive and, in some cases, questionably effective and safe drugs.     

疑诊为卵巢癌的妇科盆腔良性疾病的临床特点分析及鉴别诊断

目的 探讨常见的疑诊为卵巢癌的妇科良性疾病的种类、临床特点,并对其良恶性的鉴别诊断作相关讨论.方法 对临床征象与卵巢癌类似但经术后病理诊断为良性病变的131例女性妇科盆腔肿物患者的临床资料、影像学及实验室检查等进行回顾性分析,并对其临床特点进行总结.结果 131例患者中,非肿瘤性病变68例,包括非特异性盆腔炎27例、子宫内膜异位症15例、子宫内膜异位症合并非特异性盆腔炎11例、结核8例、异位妊娠7例;肿瘤性病变63例,包括卵泡膜细胞瘤38例、子宫平滑肌瘤25例.慢性盆腔炎(包括慢性输卵管炎、盆腔包裹性积液、输卵管卵巢脓肿及盆腔脓肿)、卵巢子宫内膜异位囊肿、卵巢子宫内膜异位囊肿合并盆腔炎、盆腹腔结核、输卵管卵巢结核、异位妊娠、卵巢卵泡膜细胞瘤及特殊部位的子宫肌瘤(如向阔韧带及后腹膜发育的子宫体部、颈峡部肌瘤)等极易与卵巢癌相混淆.结论 采用多种手段进行综合评价,可以较准确地掌握妇科盆腔良性疾病的临床特点,作出良恶性的鉴别诊断.     

缺血性脑血管病老年患者临床诊治分析

目的：探讨抗血小板聚集药阿昔单抗与溶栓疗法联合应用对缺血性脑血管疾病的临床疗效。方法：收集缺血性脑血管病患者50例,分为治疗组和对照组,治疗组给予阿昔单抗和溶栓疗法联合治疗,对照组给予单纯溶栓治疗。结果：治疗组与对照组的治疗效果有显著差异,阿昔单抗和溶栓疗法联合治疗的疗效明显高于单纯溶栓疗法组。结论：抗血小板聚集药阿昔单抗与溶栓疗法联合应用是治疗缺血性脑血管病的一种较好方案。     

脑脊液脂质运载蛋白2检测对早期鉴别诊断血管性痴呆和阿尔茨海默病的价值

目的 探讨脑脊液脂质运载蛋白2(LCN2)对鉴别诊断血管性痴呆症与阿尔茨海默病的价值。方法 选取2017年1月至2019年10月在陕西省第四人民医院接受治疗的阿尔茨海默病病人46例(阿尔茨海默病组)、血管性痴呆病人32例(血管性痴呆症组)为研究对象,用酶联免疫吸附(ELISA)法检测两组病人脑脊液中LCN2水平、β-淀粉样蛋白(Aβ_1-42)和总tau蛋白(Ttau)水平,并分析两组脑脊液LCN2水平与Aβ1-42蛋白和T-tau蛋白水平、简易精神状态检查量表(MMSE)评分相关性;绘制受试者工作特征(ROC)曲线分析脑脊液LCN2水平对血管性痴呆症和阿尔茨海默病的鉴别诊断价值。结果 与阿尔茨海默病组相比,血管性痴呆症组MMSE评分[(23.19±4.28)分比(16.74±4.03)分]、脑脊液中LCN2水平[(134.65±31.52)ng/L比(98.92±18.27)ng/L]、Aβ_1-42蛋白水平[(362.18±62.15)μg/L比(207.85±36.49)μg/L]较高(P<0.05),T-tau蛋白水平[(246.7...