A case of confirmed nonbacterial thrombotic endocarditis with correlative transesophageal echocardiographic findings

The diagnosis of nonbacterial thrombotic endocarditis is rarely made during life. We describe a patient with non-Hodgkin's lymphoma with evidence of systemic embolism in which transesophageal echocardiography was useful in establishing the diagnosis. The clinical and echocardiographic features of nonbacterial thrombotic endocarditis should be remembered when a valvular mass is seen on echocardiography.     

Spondyloarthritis and nonbacterial thrombotic endocarditis as paraneoplastic manifestations in treatment-naive Burkitt lymphoma

Non-radiographic axial spondyloarthropathy (nr-axSpA) is a clinical diagnosis of symptoms matching inflammatory back pain criteria without radiological lesions at the sacroiliac joint. The frequency of an early nr-axSpA-like presentation in lymphoma patients has not been clarified. Here we report a woman in her 20s with a fever and musculoskeletal discomfort. Detailed investigations revealed that she was suffering from Burkitt lymphoma in which nr-axSpA-like symptoms were a musculoskeletal manifestation of the disease, irrelevant to the anti-neoplastic treatment.     

Libman-Sacks endocarditis and cerebral embolization in antiphospholipid syndrome

In antiphospholipid syndrome (APS), there is a high prevalenceof valvular heart disease which leads to increased risk of thrombo-embolicevents, in particular, cerebrovascular events. We present apatient with cerebral infarction, previous deep-vein thrombosis,and miscarriages with positive lupus anticoagulant and anticardiolipinantibodies. Echocardiographic examination revealed mitral valveleaflet thickening and verrucous vegetations consistent withLibman–Sacks endocarditis, which is commonly associatedwith APS. In patients with combined Libman–Sacks endocarditisand antiphospholipid antibodies, anticoagulation therapy withwarfarin is indicated due to high risk of valvular thrombusformation and subsequent embolization.     

Antiphospholipid syndrome and palindromic rheumatism: a new possible association

Objective The aim of this study was to report six patients with palindromic rheumatism (PR) in whom signs, symptoms, and/or serologic evidence of antiphospholipid syndrome (APS) developed.Methods The medical histories of the patients were reviewed with special emphasis on age, gender, duration of PR, and lapse of time until antiphospholipid antibodies were detected or APS was diagnosed. Three representative cases are described.Results Two patients were women and four were men. Their mean age was 49.3 years (range 36–80), and the mean duration of PR was 5.5 years (range 3–8). In all patients, raised titers of antiphospholipid antibodies were found on two or more occasions. Two patients developed clinical pictures compatible with APS, two showed symptoms which may be attributable for APS, and raised titers of antiphospholipid antibodies were found in only two.Conclusion It seems that the appearance of these two uncommon conditions together is more than coincidental and may point to a previously unreported clinical association.     

抗磷脂抗体综合征合并肺栓塞5例报道及文献复习

目的 提高对抗磷脂抗体综合征(APS)合并肺栓塞(PE)诊治的认识.方法 结合近2年在同济大学附属上海市肺科医院住院诊治的5例APS合并PE患者的临床资料进行文献复习,对APS合并PE的发病机制、诊断及治疗探讨分析.结果 5例患者均通过胸部CT肺动脉造影确诊为PE,且其血浆抗心磷脂扰体均阳性.其中女性1例,男性4例,同...     

Tai Ji Quan and global cognitive function in older adults with cognitive impairment: A pilot study

This study evaluated whether Tai Ji Quan: Moving for Better Balance (TJQMBB) could improve global cognitive function in older adults with cognitive impairment. Using a nonrandomized control group pretest–posttest design, participants aged ≥65 years who scored between 20 and 25 on the Mini-Mental State Examination (MMSE) were allocated into either a 14-week TJQMBB program (n = 22) or a control group (n = 24). The primary outcome was MMSE as a measure of global cognitive function with secondary outcomes of 50-ft speed walk, Timed Up&Go, and Activities-Specific Balance Confidence (ABC) scale. At 14 weeks, Tai Ji Quan participants showed significant improvement on MMSE (mean = 2.26, p < 0.001) compared to controls (mean = 0.63, p = 0.08). Similarly, Tai Ji Quan participants performed significantly better compared to the controls in both physical performance and balance efficacy measures (p < 0.05). Improvement in cognition as measured by MMSE was related to improved physical performance and balance efficacy. These results provide preliminary evidence of the utility of the TJQMBB program to promote cognitive function in older adults in addition to physical benefits.     

抗磷脂抗体综合征合并急性心肌梗死10例分析

目的通过对抗磷脂抗体综合征(APS)引起的急性心肌梗死病例的分析提高对本病的认识。方法回顾性分析本院274例APS患者的临床资料。结果 274例APS患者中,合并急性心肌梗死者10例,发生率为3.6%,10例患者年龄为(45±13)岁,男女比为1:4,其中原发性APS和继发性APS各5例,8例患者在诊断急性心肌梗死后才明确APS的诊断。经激素、免疫抑制剂和抗栓治疗后2例(20%)死亡。结论 APS患者合并急性心肌梗死少见,预后差,治疗措施主要为抗血小板聚集和抗凝。对发生急性心肌梗死的年轻女性需考虑APS。     

盐酸多奈哌齐治疗老年人认知功能障碍疗效及安全性观察

目的观察盐酸多奈哌齐（Donepezil）治疗老年人认知功能障碍的有效性及安全性。方法对517例老年认知功能障碍患者行盐酸多奈哌齐治疗,观察6m。应用简易精神状态检查（MMSE）评定临床疗效,并记录治疗过程中的副反应。结果盐酸多奈哌齐在治疗3m起MMSE评分显著升高,第6月有继续上升趋势（P〈0．05）,治疗总有效率为65％。盐酸多奈哌齐对中、重度认知功能障碍者作用显著,入选时MMSE评分与MMSE改善程度呈负相关。盐酸多奈哌齐治疗不良反应轻微,仅有2例患者存在轻度的恶心或胃纳减退,无严重不良反应。结论盐酸多奈哌齐能有效治疗老年认知功能障碍,病情较重的患者MMSE改善更明显;药物治疗不良反应少而轻微。     

慢性阻塞性肺疾病患者认知障碍的发病机制

COPD是气道的慢性炎症性疾病，其病程进行性发展，预计在2020年将成为引起死亡的第三位疾病。近年来，随着人们对COPD的认识，COPD所引起的肺外并发症越来越受到重视。认知障碍是COPD患者的并发症之一，可影响患者的健康水平及日常生活能力，文章结合相关文献，对COPD患者的认知受损作如下综述。     

Severe hypoglycaemia and cognitive impairment in older patients with diabetes: the Fremantle Diabetes Study

Aims/hypothesis  The aim was to investigate the relationship between severe hypoglycaemia and cognitive impairment in older patients with diabetes. Methods  A sample of 302 diabetic patients aged ≥70 years was assessed for dementia or cognitive impairment without dementia in 2001–2002 and a subsample of non-demented patients (n = 205) was followed to assess cognitive decline. A history of severe hypoglycaemia was determined from self-reports, physician assessments and records of health service use for hypoglycaemia (HSH). Prospective HSH was determined up to 2006. Data analysis, including multiple logistic and Cox regression models, was used to determine whether: (1) there were cross-sectional associations between hypoglycaemia and cognitive status, (2) historical hypoglycaemia predicted cognitive decline, and (3) baseline cognitive status predicted subsequent HSH. Results  There were significant cross-sectional associations between both cognitive impairment and dementia and hypoglycaemia. Independent risk factors for future HSH included dementia (hazard ratio 3.00, 95% CI 1.06–8.48) and inability to self-manage medications (hazard ratio 4.17, 95% CI 1.43–12.13). However, there were no significant associations between historical hypoglycaemia, incident HSH and cognitive decline. Conclusions/interpretation  Dementia is an important risk factor for hypoglycaemia requiring health service utilisation. We found no evidence that hypoglycaemia contributes to cognitive impairment in older patients with diabetes.     

抗磷脂综合征100例临床特征分析

目的探讨抗磷脂综合征（APS）的临床特征和血清学特点。方法回顾性分析总结100例APS患者的临床表现和免疫学改变。结果原发性APS（PAPS）37例，继发性APS（SAPS）63例，其中继发于系统性红斑狼疮（SLE）46例、狼疮样综合征14例。80％患者出现血管性血栓形成，其中静脉血栓43例、动脉闭塞18例、静脉血栓和动脉闭塞15例。52％为单一部位，32％有2个部位，15％多个部位血栓。56％单次，25％2次，19％多次血栓形成。血栓事件以下肢深静脉血栓（36％）、肺栓塞（30％）和脑卒中（26％）常见。51％（34／67）女性出现病态妊娠，胎死宫内占37％，习惯性自发性流产13％。血小板减少71例。抗心磷脂抗体（ACL）和狼疮抗凝物（LA）的阳性率分别为84％和58％。SLE继发APS组关节炎、白细胞减少、抗核抗体（ANA）阳性和低补体血症较PAPS多见。男性患者下肢深静脉血栓和LA阳性较多见；而女性白细胞减少、ANA阳性和ACL阳性较多见。结论APS以血栓形成及病态妊娠为特点．高滴度ACL和（或）LA阳性是其免疫学特征。其临床表现受基础疾病（SLE）和性别的影响而有不同。     

Effect of renal impairment on cognitive function during a 3‐year follow up in elderly patients with type 2 diabetes: Association with microinflammation

Aims/Introduction

We investigated the effect of renal impairment on cognitive function during a 3‐year follow up in elderly type 2 diabetic patients, and an association with microinflammation.

Materials and Methods

Four cognitive function tests – Mini‐Mental State Examination (MMSE), word recall, Digit Symbol Substitution (DSS) and Stroop Color Word – were carried out in 67 patients. Renal impairment was defined as the presence of albuminuria and a decline in estimated glomerular filtration (eGFR) <60 mL/min/1.73 m². Inflammatory markers, such as highly sensitive C‐reactive protein (hs‐CRP), tumor necrotizing factor‐α (TNF‐α), interleukin (IL)‐1β and IL‐6, were measured at baseline.

Results

At baseline, cognitive decline was found in patients with renal impairment. The DSS test was independently associated with eGFR decline, whereas MMSE tended to be associated with albuminuria after adjusting for confounding factors. Regarding changes in cognitive function and renal impairment, changes in urinary albumin to creatinine ratios were strongly and independently associated with changes in word recall scores. In patients with persistent eGFR decline, there was a tendency toward a greater decrease in MMSE and DSS scores, whereas in those with newly detected albuminuria, there was a tendency toward a greater decrease in word recall scores. Increased baseline levels of hs‐CRP, TNF‐α and IL‐6 were associated with renal impairment and cognitive function, especially DSS tests, respectively. However, the increased levels were not independent predictors for cognitive decline.

Conclusions

The present study showed a reciprocal relationship between cognitive decline and renal impairment, especially progression of albuminuria. Thus, monitoring treatment using renal biomarkers will be important for preserving both renal and cognitive function.     

无症状性颈动脉狭窄患者认知功能障碍的特点

目的探讨蒙特利尔认知评估量表（MoCA）在无症状性颈动脉狭窄（ACS）患者中筛查认知功能障碍者的作用及ACS认知功能障碍的神经心理学特点。方法前瞻性连续纳入72例符合研究标准的患者,按CT血管造影（CTA）显示颈动脉狭窄程度（〉150％或〈50％）分为ACS组和对照组各36例,采用MoCA和简易精神状态量表（MMSE）对患者进行认知评估。比较两组MoCA总分、各子项目评分和MMSE评分。结果①两组基线学特征和血管性危险因素差异无统计学意义（均P〉0．05）。ACS组采用MoCA法检测认知功能障碍的阳性率（80．6％）高于MMSE法（13．9％）,差异有统计学意义（P〈0．叭）,对照组采用MoCA法检测认知功能障碍的阳性率（38．9％）高于MMSE法（5．6％）,差异有统计学意义（P〈0．01）。②ACS组MoCA总分中位数低于对照组[21．5（10－29）和25（14～28）,P=0．001]。ACS组与对照组各子项目评分显示,执行能力[0（0～1）和1（0～1）,P：0．004]、视空间功能[3（0－4）和3．5（0～4）,P=0．004]、注意力[5（2～6）和6（4～6）,P=0．001]、延迟回忆[2（0～5）和3（0～5）,P=0．038],差异均有统计学意义。结论MoCA比MMSE可更灵敏地检测出无痴呆ACS患者的认知功能障碍。以MoCA为测评工具,无痴呆ACS患者认知功能障碍的神经心理学特点以执行能力、视空间功能、注意力及延迟回忆受损为主。     

Neurocognitive impairment in Chinese patients with obstructive sleep apnoea hypopnoea syndrome

Background and objective: Sleep‐disordered breathing is known to be associated with impairment in cognitive function. The aim of this study was to characterize neurocognitive impairment in a cohort of Chinese patients with varying severities of obstructive sleep apnoea hypopnoea syndrome (OSAHS), and to develop a sensitive instrument for routine screening of cognitive impairment. Methods: Eligible patients (n = 394) were categorized into a primary snoring group, and mild, moderate and severe OSAHS groups, based on assessment of AHI. The Montreal Cognitive Assessment (MoCA) and the Mini‐Mental State Examination (MMSE) questionnaires were administered to assess cognitive function, and the correlations between questionnaire scores and clinical and polysomnographic parameters were further evaluated by stepwise multivariate regression. Results: MoCA scores decreased progressively across the spectrum from primary snoring to severe OSAHS. Importantly, mild neurocognitive impairment as defined by a MoCA score <26 was more common in the moderate (38.6%) and severe (41.4%) OSAHS groups than in the mild OSAHS (25.0%) and primary snoring (15.2%) groups. In contrast, MMSE scores were largely normal and comparable among all four groups. Evaluation of MoCA subdomains further revealed selective reduction in memory/delayed recall, visuospatial and executive function, and attention span in the severe OSAHS group compared with the other groups. Stepwise multivariate regression analysis demonstrated that MoCA scores correlated significantly with lowest oxygen saturation (L‐SaO₂) and years of education. Conclusions: Neurocognitive impairment is common in patients with OSAHS. The MoCA is a brief and sensitive tool for the assessment of cognitive impairment in OSAHS patients, whose performance on the MMSE is in the normal range.     

Clinical and laboratory patterns of the haemolytic uraemic syndrome and thrombotic thrombocytopenic purpura in southern Iran

OBJECTIVE: The haemolytic uraemic syndrome (HUS) and thrombotic thrombocytopenic purpura (TTP) are rare disorders characterised by intravascular platelet aggregation and widespread thrombus formation in the microcirculation resulting in tissue ischaemia. A retrospective analysis was carried out in 136 patients with HUS or TTP hospitalized from April 1991 through March 2004 in three tertiary referral hospitals of Shiraz (the largest city in southern Iran) to evaluate the epidemiological aspects, clinical characteristics and laboratory findings of the two diseases. METHODS: One hundred and one cases of HUS (49 females and 52 males) and 35 cases of TTP (21 females and 14 males) were identified. The mean age was 3.5 years for HUS, 30.8 years for TTP. RESULTS: The mean annual incidence rate of HUS decreased approximately 30-fold throughout the observed period, while the incidence rate of TTP increased approximately 6-fold. A seasonal pattern was noted for both TTP and HUS, with the highest incidence during the summer months. Twenty patients with HUS and 16 patients with TTP died, resulting in case fatality rates of 19.8% and 45.7%, respectively. No prognostic factor was identified for TTP, whereas signs of neurological impairment and high leucocyte counts had an adverse effect on the prognosis of HUS patients. CONCLUSIONS: This study shows that, in contrast to other countries, the incidence rate of HUS shows a decreasing trend in southern Iran, probably related to the prevention of gastrointestinal diarrhoeal infections (especially Escherichia coli 0157:H7) and to their improved management. The incidence of TTP is increasing in Iran as in other countries.     

代谢综合征、基质金属蛋白酶-9活性与老年人轻度认知功能障碍的相关性研究

目的 探讨老年患者代谢综合征(MS)与轻度认知功能障碍(MCI)的相关性及基质金属蛋白酶9(MMP-9)活性的作用.方法 采用简明智力状态量表(MMSE)对135例MS患者及75例健康老年人(对照组)进行认知功能评定;通过测定MMP-9和金属蛋白酶组织抑制因子1(TIMP-1)的血清浓度,计算MMP-9∶TIMP-1比值作为MMP-9的活性指标.结果 MS组MCI的发生率显著高于对照组(22.2% vs 9.33%,P＜0.05);MS组的MMSE评分显著低于对照组[(26.12±1.15) vs (29.37±0.58),P＜0.05];MS组的MMP-9活性则显著高于对照组[(0.81±0.35)vs(0.59±0.27),P＜0.05],在MS组内MMP-9活性与MMSE呈显著性负相关(r=-0.519,P＜0.05);文化程度高是MCI的保护性因素(OR=0.615,P=0.023),而MS、糖尿病和MMP-9活性是MCI发生的独立危险因素(OR1=6.981,P1=0.011;OR2=6.250,P2=0.017;OR3=3.262,P3=0.031).结论 MS是MCI的独立危险因素,MS患者的MMP-9活性水平与其认知功能损伤的程度呈正相关.     

原发性头痛相关认知障碍的病理生理机制及研究进展

随着老龄化社会的发展,认知障碍普遍存在,严重影响患者的工作、学习和社交活动,已成为严重的公共卫生问题。既往研究发现,认知障碍多发于原发性头痛患者,共同的解剖学基础、5-羟色胺系的调节、炎症反应、神经内分泌失调、肠道菌群失调及抑郁症的参与可能是二者共病的病理生理学基础,且不同类型原发性头痛与不同认知域受损有关,由此产生不同的治疗方案。本文综述了原发性头痛相关认知障碍的病理生理机制与研究进展,旨在给予患者更合理的诊治方案。     

老年代谢综合征患者血清炎性因子及脂联素水平与轻度认知功能障碍的关系

目的 探讨老年代谢综合征(metabolic syndrome,MS)患者血清基质金属蛋白酶(MMP)-9、细胞间黏附因子(ICAM-1)、脂联素水平与认知功能的相关性.方法 采用多种神经心理学量表对MS患者74例和健康对照者30例进行认知功能评定,并测量其体质指数(BMI)、腹围、血压及检测空腹血糖(FBG)、血脂等代谢指标;将MS患者再分为MS+轻度认知功能障碍(MCI)组(39例)和MS组(35例);测定所有受试者的MMP-9、ICAM-1和脂联素水平.结果 (1)MS+MCI组的BMI、收缩压、FBG、三酰甘油(TG)水平均高于MS组及对照组(P＜0.05).MS+MCI组、MS组血清MMP-9、ICAM-1的水平明显高于对照组(P＜0.01),而脂联素水平明显低于对照组(x2=26.62,P＜0.01);MS+MCI组血清MMP-9水平明显高于MS组(Z=-4.61,P＜0.05),脂联素水平明显低于MS组(Z=-5.77,P＜0.05);(2)Spearman直线相关分析显示,MS+MCI组、MS组血清MMP-9(r=-0.794,P＜0.001)、ICAM-l(r=-0.501,P＜0.001)与脂联素显著负相关,MMP-9与ICAM-1之间显著正相关(r=0.481,P=0.006);(3)多重线性回归分析显示,蒙特利尔认知评估量表(MoCA)评分与MMP-9(β=-3.438,P=0.001)、脂联素(β=1.337,P=0.006)、收缩压(β=-0.058,P=0.003)、FBG(β=-0.227,P=0.049)具有线性相关关系;(4)多因素Logisic逐步回归分析结果显示,高MMP-9(OR=1.007)、低脂联素(OR=0.359)水平是老年MS患者发生认知功能障碍的危险因素.结论 老年MS患者存在认知功能损害;MCI患者血清炎症因子表达增加,且与代谢异常存在相关性;MMP-9可能促进神经退行性变,而脂联素在这一过程中起到保护作用,表明炎性反应参与老年MS患者MCI的病理过程.

Abstract：

Objective To evaluate the relationships of the serum levels of matrix metalloproteinase-9 (MMP-9), intercellular adhesion molecule-1 (ICAM-1) and adiponectin with the mild cognitive impairment (MCI) in senile metabolic syndrome (MS)patients. Methods The 74 cases with MS and 30 health controls (control group) were enrolled. Mini-mental state examination (MMSE), montreal cognitive assessment (MoCA), digit-symbol test (DST), auditory verbal memory test (AVMT), trail making test(TMT), sunderland clock drawing test (CDT) and verbal fluency test (VFT) were applied to evaluate cognitive function. Based on the cognitive assessment, MS patients were divided into two groups: 39 cases with MCI (MS+MCI group) and 35 cases without cognitive impairment (MS group). The levels of MMP-9, ICAM-1 and adiponectin were measured by ELISA. Biochemical variables were measured by routine methods in all subjects. Results (1)MS+MCI group showed the higher levels of BMI, SBP, FBG and MMP-9 (all P＜0.05) and lower level of adiponectin (P＜0.05) than did the MS group. And MS group had higher levels of MMP-9 and ICAM-1 (P＜0.01) and lower adiponectin level (P＜0.01) than did the control group. (2)Spearman's correlation analysis showed that the serum levels of MMP-9 (r=-0.794, P＜0.001) and ICAM-l (r=-0.501, P＜0.001) were negatively correlated with adiponectin. However, MMP-9 was positively correlated with ICAM-1 (r=0.481, P=0.006). (3)Multiple linear regression analysis indicated that there was linear relationship of MoCA with MMP-9 (β=-3.438, P=0.0019), adiponectin (β=1.337, P=0.006), SBP (β=-0.058, P=0.003) and FBG (β=-0.227, P=0.049). (4)Stepwise logistic analysis showed that both high MMP-9 (OR=1.007) and low adiponectin (OR=0.359) were risk factors for the decline of cognitive function. Conclusions Elderly patients with MS may show deterioration in memory, calculation and visuospatial perception. Elevated inflammatory factors might contribute, in combination with abnormal metabolism, to MCI. MMP-9 might contribute to neuronal degeneration. However, adiponectin could strongly counteract the risk factors for cognitive impairment.