平板运动试验与心脏变时功能不全对冠状动脉病变的诊断价值

目的探讨平板运动试验（treadmill exercise testing,TET）心脏变时功能不全（chronotropic incompetence,CI）对冠心病（CHD）患者的的诊断价值及与冠状动脉病变的临床意义。方法165例临床拟诊CHD患者,先后行TET和冠状动脉造影（CAG）检查,对传统指标、CI及两项联合指标诊断CHD的敏感性、特异性、准确率进行比较;并根据CAG结果分CHD组和非CHD组,分析比较两组间心脏变时功能（chronotropic response,CR）：运动中心率变化的各项指标和心脏变时指数（chronotropic responseindex,CRI）。结果（1）单纯以CI指标诊断冠状动脉病变的敏感性、特异性与传统指标相比,无统计学意义（P〉0．05）,准确率高于传统指标（P〈0．05）;两项联合指标诊断CHD的敏感性、特异性及准确率均显著高于传统指标（P〈0．01）。（2）CHD组运动CR明显低于非CHD组（P〈0．01）。CHD组3支冠脉病变者CR明显低于1、2支冠脉病变者（P〈0．01）。CRI与冠脉病变分支数目（r=-0．699,P〈0．01）呈负性相关。（3）右冠支、回旋支病变的CR均低于前降支病变（P〈0．05）。结论CI指标是诊断CHD的重要价值的指标,可以提高TET对CHD的诊断率。CHD患者CI可以预测心肌缺血程度,预测自主神经功能受损情况,提示窦房结发生供血不足的可能性,为临床早期诊治提供更快捷的准确信息。     

Obesity as a predictor of poor antibody response to hepatitis B plasma vaccine

Factors associated with lack of antibody response to the hepatitis B virus plasma vaccine were retrospectively evaluated by means of a logistic regression in 194 previously seronegative staff members of a community hospital. All subjects had received three doses of vaccine by intramuscular buttock injection using a 1-in, 23-gauge needle. Overall, only 55.7% of subjects developed detectable antibody to hepatitis B surface antigen in serum after immunization. The weight-height index served as a surrogate measure of obesity. Predictors of poor immunogenic response to hepatitis B vaccine included higher weight-height index, older age, and vaccine batch. Sex, race, timing of vaccine doses, and timing of postimmunization determination of antibody to hepatitis B surface antigen were not predictors of vaccine efficacy.     

Global risk scores and exercise testing for predicting all-cause mortality in a preventive medicine program

Context  The usefulness of exercise stress test results and global cardiovascular risk systems for predicting all-cause mortality in asymptomatic individuals seen in clinical settings is unclear. Objectives  To determine the validity for prediction of all-cause mortality of the Framingham Risk Score and of a recently described European global scoring system Systematic Coronary Risk Evaluation (SCORE) for cardiovascular mortality among asymptomatic individuals evaluated in a clinical setting and to determine the potential prognostic value of exercise stress testing once these baseline risks are known. Design, Setting, and Participants  Prospective cohort study of 3554 asymptomatic adults between the ages of 50 and 75 years who underwent exercise stress testing as part of an executive health program between October 1990 and December 2002; participants were followed up for a mean of 8 years. Main Outcome Measures  Global risk based on the Framingham Risk Score and the European SCORE. Prospectively recorded exercise stress test result abnormalities included impaired physical fitness, abnormal heart rate recovery, ventricular ectopy, and ST-segment abnormalities. The primary end point was all-cause mortality. Results  There were 114 deaths. The c-index, which corresponds to receiver operating characteristic curve values, and the Akaike Information Criteria found that the European SCORE was superior to the Framingham Risk Score in estimating global mortality risk. In a multivariable model, independent predictors of death were a higher SCORE (for 1% predicted increase in absolute risk, relative risk [RR], 1.07; 95% confidence interval [CI], 1.04-1.09; P<.001), impaired functional capacity (RR, 2.95; 95% CI, 1.98-4.39; P<.001), and an abnormal heart rate recovery (RR, 1.59; 95%, 1.04-2.41; P = .03). ST-segment depression did not predict mortality. Among patients in the highest tertile from the SCORE, an abnormal exercise stress test result, defined as either impaired functional capacity or an abnormal heart rate recovery, identified a mortality risk of more than 1% per year. Conclusion  Exercise stress testing when combined with the European global risk SCORE may be useful for stratifying risk in asymptomatic individuals in a comprehensive executive health screening program.      

Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit

Context  In the intensive care unit (ICU), delirium is a common yet underdiagnosed form of organ dysfunction, and its contribution to patient outcomes is unclear. Objective  To determine if delirium is an independent predictor of clinical outcomes, including 6-month mortality and length of stay among ICU patients receiving mechanical ventilation. Design, Setting, and Participants  Prospective cohort study enrolling 275 consecutive mechanically ventilated patients admitted to adult medical and coronary ICUs of a US university-based medical center between February 2000 and May 2001. Patients were followed up for development of delirium over 2158 ICU days using the Confusion Assessment Method for the ICU and the Richmond Agitation-Sedation Scale. Main Outcome Measures  Primary outcomes included 6-month mortality, overall hospital length of stay, and length of stay in the post-ICU period. Secondary outcomes were ventilator-free days and cognitive impairment at hospital discharge. Results  Of 275 patients, 51 (18.5%) had persistent coma and died in the hospital. Among the remaining 224 patients, 183 (81.7%) developed delirium at some point during the ICU stay. Baseline demographics including age, comorbidity scores, dementia scores, activities of daily living, severity of illness, and admission diagnoses were similar between those with and without delirium (P>.05 for all). Patients who developed delirium had higher 6-month mortality rates (34% vs 15%, P = .03) and spent 10 days longer in the hospital than those who never developed delirium (P<.001). After adjusting for covariates (including age, severity of illness, comorbid conditions, coma, and use of sedatives or analgesic medications), delirium was independently associated with higher 6-month mortality (adjusted hazard ratio [HR], 3.2; 95% confidence interval [CI], 1.4-7.7; P = .008), and longer hospital stay (adjusted HR, 2.0; 95% CI, 1.4-3.0; P<.001). Delirium in the ICU was also independently associated with a longer post-ICU stay (adjusted HR, 1.6; 95% CI, 1.2-2.3; P = .009), fewer median days alive and without mechanical ventilation (19 [interquartile range, 4-23] vs 24 [19-26]; adjusted P = .03), and a higher incidence of cognitive impairment at hospital discharge (adjusted HR, 9.1; 95% CI, 2.3-35.3; P = .002). Conclusion  Delirium was an independent predictor of higher 6-month mortality and longer hospital stay even after adjusting for relevant covariates including coma, sedatives, and analgesics in patients receiving mechanical ventilation.      

Role of exercise stress testing and safety monitoring for older persons starting an exercise program

While the benefits of physical activity and exercise among older persons are becoming increasingly clear, the role of exercise stress testing and safety monitoring for older persons who want to start an exercise program is unclear. Current guidelines regarding exercise stress testing likely are not applicable to the majority of persons aged 75 years or older who are interested in restoring or enhancing their physical function through a program of physical activity and exercise. In addition to being expensive and of unproven benefit, the current policy of routine exercise stress testing potentially could deter many older persons from participating in an exercise program. Research is needed to investigate current physician practices, evaluate the risk of adverse cardiac events, determine the role of pharmacological stress testing, and measure and compare absolute and relative exercise intensities. To assist clinicians, we offer a set of recommendations regarding precautions that can be taken to minimize the risk of adverse cardiac events among previously sedentary older persons who do not have symptomatic cardiovascular disease and are interested in starting an exercise program. JAMA. 2000;284:342-349     

Presence of notched QRS on paced electrocardiographs as a predictor of poor response to cardiac resynchronization therapy

Background Cardiac resynchronization therapy （CRT） on patients with advanced and refractory heart failure has made remarkable progress.Clinically,notched QRS （nQRS） is commonly seen on electrocardiographs （ECGs） with bundle branch block morphology and on paced ECGs after implantation of a CRT device,which may reflect the heterogeneity of ventricular myocardial depolarization and electrical activity.The aim of this study was to determine whether patients with more nQRS myocardial segments on paced ECGs had a worse response to CRT than patients with fewer nQRS myocardial segments.Methods We prospectively enrolled 56 patients of CRT with chronic heart failure from People＇s Hospital affiliated to Peking University from January 2007 to October 2013.Based on nQRS segments on ECGs before CRT,we allocated them to two groups：fewer nQRS （〈2） myocardial segments （lateral,inferior,anterior segments） group （F-nQRS,G1,n=23） and more nQRS （≥2） myocardial segments group （M-nQRS,G2,n=33）.Then according to nQRS segments on ECGs after CRT,we divided them into two groups similarly：fewer nQRS （〈2） myocardial segments group （G3,n=24） and more nQRS （≥2） myocardial segments group （G4,n=32）.This study was approved by the ethics committee of People＇s Hospital.Results At 6 months in the baseline-ECG group,there was a greater absolute increase in left ventricular ejection fraction （LVEF） in G2 than in G1 （（11.5±8.9）% vs.（5.5±10.4）%,P=0.023）,with the incidence of nonresponse lower in G2than in G1 （9.1% vs.39.1%,P=0.018）.In the paced-ECG group,the absolute increase in LVEF was less in G4 than in G3 （（6.4±8.8）% vs.（12.5±10.4）%,P=0.024） and the incidence of nonresponse was higher in G4 than in G3 （31.3% vs.8.3%,P=0.039）.Multivariate analysis showed that fewer nQRS （〈2） myocardial segments on paced ECGs （odds ratio 13.920） was a predictor of positive response to CRT.Conclusion nQRS ≥2 myocardial segments （lateral,inferior,anterio     

窦性心动过缓人群心脏变时性功能的评价

目的:评价窦性心动过缓人群的心脏变时性功能;比较运动试验与动态心电图对心脏变时性功能检测的价值.方法:选择窦性心动过缓患者(窦缓组)67例和窦性心律、心率正常者(对照组)47例,进行运动平板试验和动态心电图检测,观察运动试验中的最大心率和动态心电图的最大心率.心脏变时性功能不全的诊断标准:运动试验以运动后最大心率未达85%年龄预测心率,动态心电图以最大心率不超过100次/min.结果:①采用运动试验诊断标准:窦缓组心脏变时性功能不全16例(23.88%),对照组4例(8.51%),两组间有显著性差异(P<0.05);②窦缓组中运动试验对心脏变时性功能不全的诊断率为23.88%,显著高于动态心电图的7.46%(P<0.05).结论:窦性心动过缓人群心脏变时性功能不全的发生率明显高于正常心率者,运动试验对心脏变时性功能不全的诊断价值优于动态心电图.     

中年健康男性中运动试验的变时性反应与颈动脉粥样硬化相关

目的:变时性功能不全即运动时心率(H R)反应减弱,是心血管疾病死亡的独立预测因素,但是尚不清楚变时性功能不全是否与颈动脉粥样硬化相关。在8567例健康男性(平均47.6±8.8岁)中对变时性功能不全与颈动脉粥样硬化的关系进行了研究。方法和结果:变时性功能不全的定义为不能达到年龄预计最大H R(APM H R)的85%、<80%H R储备(H RR)以及变时性反应指数(CRI)。颈动脉粥样硬化定义为B超检查发现狭窄>25%和(或)内膜中层厚度(IM T)>1.2m m。多变量校正的Logistic回归模型中,不能达到85%APM H R的研究对象患颈动脉粥样硬化的比值比(OR)为…     

Proteinuria: value as predictor of cardiovascular mortality in insulin dependent diabetes mellitus

The relation between diabetic microangiopathy and macroangiopathy was studied by analysing the relative mortality from cardiovascular disease in patients with insulin dependent diabetes mellitus with and without persistent proteinuria. The study group comprised 2890 diabetics diagnosed between 1933 and 1972 before the age of 31, and the study was conducted by using the linear logistic discrete failure time model. In patients with proteinuria the relative mortality from cardiovascular disease was 37 times that in the general population; in patients without proteinuria it was 4.2 times that in the general population. In both groups women had a relative mortality twice to 2.6 times that of men. In neither group was relative mortality correlated with duration of diabetes, suggesting that the association between diabetes and cardiovascular disease may be conferred by factors other than hyperglycaemia and hyperinsulinaemia. The high relative mortality from cardiovascular disease in diabetics with proteinuria indicates a strong association between diabetic microangiopathy and macroangiopathy, suggesting a common (pathogenetic?) mechanism for these two late diabetic complications.     

Preoperative pulmonary function as a predictor of respiratory complications and mortality in patients undergoing lung cancer resection

OBJECTIVE: We evaluated preoperative pulmonary function as a predictor of respiratory complications and mortality in patients undergoing lung cancer resection to confirm the guideline of the British Thoracic Society: lung cancer surgery in patients with predictive postoperative FEV(1.0) (%FEV(1.0)ppo) > 40% and predictive postoperative diffusion capacity for carbon monoxide (%DL(co)ppo) > 40% can be carried out with average risk. METHODS: We retrospectively studied 356 consecutive patients who underwent pulmonary resection at our Department from January 1992 to December 2001. Preoperative pulmonary function tests included vital capacity (VC), %VC, forced expiratory volume in one second (FEV(1.0)), FEV(1.0)%, diffusion capacity for carbon monoxide (DL(co)), predictive postoperative FEV(1.0) (FEV(1.0)ppo), postoperative respiratory function expressed as a percentage of the predicted normal value (%FEV(1.0) ppo, %DL(co)ppo). Postoperative complications were divided into 2 groups: respiratory complications (pneumonia, atelectasis, etc) and other complications (bronchopleural fistula, prolonged air leak, arrhythmia, etc). RESULTS: Postoperative deaths occurred in 14 (3.9%) patients. Postoperative respiratory complications developed in 27 (7.6%) patients. Pneumonectomy (p < 0.001), preoperative chemotherapy (p < 0.01) and advanced stage (p < 0.05) were identified as risk factors of postoperative deaths. Patients undergoing lobectomy with FEV(1.0) > or = 1,500 ml did not die of respiratory complications. Patients undergoing pneumonectomy with FEV(1.0)ppo > or = 800ml/m2 did not die of respiratory complications. Patients undergoing pneumonectomy with %FEV(1.0)ppo < 40% and %DL(co)ppo < 40% did not survive. Five of the 7 patients who died of respiratory complications were treated with preoperative chemotherapy. The values of their %DL(co)ppo were all less than 40%. By multivariate analysis, %FEV(1.0)ppo was significant independent factor associated postoperative death. CONCLUSIONS: We conclude that the guideline is useful for the selection for surgery of lung cancer patients. If preoperative chemotherapy is performed, the measurement of %DL(co) is recommended before surgery.     

外周血单个核细胞内乙型肝炎病毒DNA评估拉米夫定治疗慢性乙型肝炎预后的研究

目的探讨拉米夫定治疗慢性乙型肝炎结束时,外周血单个核细胞(PBMC)中HBV DNA检测对持续性应答的预测作用。方法对100例慢性乙型肝炎患者进行拉米夫定治疗96周,选择完全应答的80例病人,检测PBMC中HBV DNA,并对患者进行长期的血清HBV DNA监测。结果治疗结束时,有68例患者的PBMC HBV DNA为阳性,12例为阴性。在PBMC中HBV DNA阳性患者,停止治疗的6个月内所有患者的HBV DNA复发。而PBMC HBV DNA阴性者,随访至停药1年,12例中仅2例HBV DNA阳转,其余10例,随访至3.5年,血清中HBV DNA仍阴性。结论拉米夫定治疗结束时PBCMC中HBV DNA检测能预测慢性乙型肝炎的治疗效果。     

The Appropriateness Evaluation Protocol is a poor predictor of in-hospital mortality

Background

The Appropriateness Evaluation Protocol (AEP) proposes admission criteria based only on physiological and laboratory parameters and has recently informed an Irish national bed utilisation review. Severity of illness tools can be poorly predictive of outcomes, particularly in older patients.

Aims

To assess the clinical utility of the AEP in moribund older and younger patients.

Methods

The study was conducted in four acute hospitals in South Munster, Ireland, and was of retrospective analytical cohort study design. The Hospital In-Patient Enquiry Scheme was used to ascertain patients who died within 10 days of hospital admission, over a 2-year period. Proximate death was used as a robust measure of validity of admission. Emergency department (ED) records were screened retrospectively to allocate the AEP criteria.

Results

There were 803 eligible in-hospital deaths. Establishment of AEP criteria was available in 72.9 % (585 patients, 50.8 % female). The median length of stay until death was 4 days. Just over 30 % (179/585) of patients did not meet AEP criteria, two-fifths (72/179) of whom had been coded as severely unwell on arrival to the ED. There was no significant difference in AEP identification rates between older and younger age groups.

Conclusions

Our study illustrates that the AEP is a poor predictor of mortality in all age groups, having failed to identify approximately one-third of our cohort. Based on our findings, we feel that this tool should not be used to assess the appropriateness of admission.     

A型行为者对应激反应相似性的逻辑质研究

目的采用逻辑质方法研究医科学生A型行为者应激相似性.方法用A型行为类型量表将75名医科学生测评分型;再测量其应激与安静时的血浆皮质醇(cortisol)和甲状激素(T3)水平值,并分析逻辑四项指标.结果分别在应激和安静时,其cortisol和T3指标之间均无统计差异(t应激≤0.05058,t安静≤1.1095,均P>0.05);cortisol和T3指标每项在A型和非A型行为者间应激反应差别具有显著差性(tcortisol =2.3726,P>0.05,tcortisol ≥2.8426,P<0.05tT3 ≥4.7436,P<0.05,tT3 =0.000,P>0.05),两种指标的逻辑性相同即相似性.结论在逻辑上肯定A型行为者的应激相似性.     

A型行为者对应激反应相似性的逻辑质研究

目的 采用逻辑质方法研究医科学生A型行为者应激相似性。方法 用A型行为类型量表将75名医科学生测评分型；再测量其应激与安静时的血浆皮质醇(cortisol)和甲状激素(T3)水平值，并分析逻辑四项指标。结果 分别在应激和安静时，其cortisol和T3指标之间均无统计差异(t应激≤0．05058，t安静≤1．1095，均P＞0．05)；cortisol和T3指标每项在A型和非A型行为者间应激反应差别具有显著差性(tcortisol=2．3726，P＞0、05，tcortisol≥2．8426，P＜0．05 t T3≥4．7436，P＜0．05，t T3＝0．000，P＞0．05)，两种指标的逻辑性相同即相似性。结论 在逻辑上肯定A型行为者的应激相似性。     

Effect of exercise stress on the bronchospastic response of asthmatics in remission

Twenty asthmatics in remission phase were subjected to exercise stress by running on level ground for 6 minutes and the degree of airway obstruction was measured by a peak flowmeter. The response was compared to 20 normal healthy volunteers. The prevalence of exercise induced asthma (EIA) was observed to be 75% among the asthmatics with male preponderance. A 100% response was seen in asthmatics of more than 25 years age. EIA was more, and so was the degree of response, as the duration of illness increased. The maximal fall in PEFR from its basal value was seen in the 6th minute after stopping the exercise in majority of the cases. No positive response was observed among the healthy controls.