3个国外糖尿病危险评分量表在我国体检人群中的应用研究

目的检验芬兰、丹麦、泰国3个糖尿病危险评分量表在我国体检人群中的应用效力。方法对500名体检空腹血糖≥5．60mmol／L者采用3个量表分别对其进行评分,同时行口服葡萄糖耐量试验,计算各量表的灵敏度、特异度、正确诊断指数及ROC曲线下面积（AUC）,以评价不同量表的效力。结果3个糖尿病危险评分量表的灵敏度、特异度均低于原人群;丹麦量表的筛检效力较理想,泰国量表的预测能力较高,芬兰量表的筛检与预测能力均一般。结论3个国外糖尿病危险评分量表应用于我国体检人群时,其筛查效力低于原人群,主要可能与不同人群的人口学特征差异有关,在推广应用时需对其进行效力检验。     

Braden-Q量表评估我国儿童压疮危险因素适用性研究

目的 探讨Braden-Q儿童压疮危险评估量表(下称Braden-Q量表)对国内ICU患儿压疮评估的预测效力.方法 采用儿童日常活动能力分类量表(POPC)、Braden-Q量表对133例ICU患儿进行评估.结果 POPC评分1～5(1.12±0.63)分;Braden-Q量表7个条目评分为2.10±0.89～3.84±0.43,压疮发生率为5.26%;Braden-Q量表临界值为13～16分时,灵敏度为0.15～0.23,特异度为0.96～0.98,阳性预测值为0.07～0.53,阴性预测值为0.86～0.99.结论 ICU患儿病情危重度不高,BrademQ量表临界值取15分时其灵敏度和特异度较好,Braden-Q量表对国内患儿压疮的预测效果不佳,其适用性尚需进一步扩大样本深入研究.     

不同骨质疏松风险评估工具的筛检效果评价

目的通过对7种骨质疏松风险评估工具的对比,评价其社区与临床应用价值,为预防和筛查骨质疏松提供科学依据。方法共纳入299名40周岁以上的中老年人,其中女性均已绝经,应用双能X线骨密度仪测量其骨密度值并诊断是否患有骨质疏松症,计算各个工具得分,比较变量、灵敏度、特异度和曲线下面积(area under the curve,AUC)。结果绝经后妇女的各个工具得分均有统计学意义(P0.05),亚洲人骨质疏松自评工具(osteoporosis self-assessment tool for asian, OSTA)的灵敏度为96.3%,特异度为6.3%,AUC为0.710;骨质疏松风险评估工具(osteoporosis risk assessment instrument, ORAI)的灵敏度为90.1%,特异度为12.7%, AUC为0.661;骨质疏松风险简单评估(simple calculated osteoporosis risk estimation, SCORE)的灵敏度为25.9%,特异度为81.9%, AUC为0.686;骨质疏松危险指数(osteoporosis index of risk, OSIRIS)的灵敏度为90%,特异度为30.8%, AUC为0.734;骨质疏松预筛选风险评估(osteoporosis prescreening risk assessment, OPERA)的灵敏度为38.2%,特异度为84%, AUC为0.658;美国骨质疏松基金会快速诊断法(National Osteoporosis Foundation, NOF)的灵敏度为90.4%,特异度为26.6%, AUC为0.652。仅NOF筛检的中老年男性骨质疏松具有统计学意义(P0.05),NOF的灵敏度为93.5%,特异度为25.8%, AUC为0.697;而男性骨质疏松症风险评估(male osteoporosis risk estimation score, MORES)筛检的灵敏度为74.1%,特异度为29.0%,AUC为0.575,不具有统计学意义(P=0.190)。结论 OSTA的灵敏度最高,且仅有2个变量,使用最为简便,适合筛检大样本人群;OSIRIS灵敏度和特异度均较好,用于临床筛检更为准确;ORAI和NOF灵敏度较高,适合筛检阳性人群;SCORE和OPERA特异度较好,适合筛检阴性人群;NOF可用于筛检中老年男性骨质疏松。     

基于决策树的肿瘤患者难免性压疮风险预测模型研究

目的评价决策树预测肿瘤患者难免性压疮风险的准确性与合理性,为压疮预防提供依据。方法收集Braden评分高风险肿瘤患者611例的临床病例资料,采用CHAID算法构建肿瘤患者难免性压疮风险预测的决策树模型,并通过ROC曲线下面积、灵敏度和特异度指标比较其与Braden评分的预测效果。结果 46例发生难免性压疮,发生率为7.53%。决策树模型包含3层共11个节点,提取6条分类规则,筛选出4类高危人群,即Braden评分≤11分,翻身计划无法落实;Braden评分11分,皮肤有现存或潜在损伤;Braden评分≤11分,翻身计划可以落实,但存在增加压疮发生风险的特殊情况;Braden评分11分,皮肤没有现存或潜在损伤,但翻身计划无法落实。决策树模型ROC曲线下面积为0.840;决策树模型的灵敏度为0.848、特异度为0.774。结论决策树模型ROC曲线下面积、灵敏度及特异度均较好,可以用于肿瘤患者难免性压疮高危人群的筛选和管理。     

止血相关参数对2型糖尿病和糖尿病肾病预测的临床意义

目的本研究旨在评估止血相关参数对2型糖尿病(type 2 diabetes mellitus,T2DM)和糖尿病肾病(diabetic nephropathy,DN)的预测价值。方法研究纳入96例T2DM患者分为两组,无并发症T2DM组(52例)和DN组(44例),同时纳入同期进行体检的50例性别、年龄匹配的健康人群作为对照组,测量各组基线实验室指标和止血相关参数,分析T2DM和DN的危险因素及其预测指标。结果无并发症的T2DM患者与对照组相比,活化部分促凝血酶原激酶时间(activated partial thromboplastin time,APTT)、血小板(platelets,PLT)和D-二聚体(D-Dimer,D-D)水平显著不同(P<0.01)。与没有并发症的T2DM患者相比,DN患者的纤维蛋白原(fibrinogen,FIB)、PLT和D-D增加(P<0.05)。APTT和PLT均为T2DM的独立危险因素(OR值分别为1.743、1.238,P<0.01),FIB和PLT是DN的独立危险因素(OR值分别为1.642、1.317,P<0.01)。APTT和PLT预测T2DM的ROC曲线下面积(area under curve,AUC)分别为0.601和0.642,且灵敏度较低。FIB取临界值3.15 g/L时预测DN的AUC为0.876,灵敏度(84%)和特异度(77%)较高,PLT取临界值245×109/L预测的DN的AUC为0.571,灵敏度为61%,特异度为89%。当联合FIB和PLT时,其预测DN能力增加(AUC:0.887,95%CI:0.841~0.937,灵敏度:91%,特异度:74%)。结论止血相关参数对T2DM的预测价值较低,而FIB是DN的独立危险因素,对DN有较高的预测价值。     

2型糖尿病人群中应用FRAX评价骨折风险的研究

目的 探讨骨折风险预测简易工具（fracture risk assessment tool,FRAX)评分在2型糖尿病患者中骨折风险评估的应用。方法 选取278例糖尿病人群（糖尿病组）以及正常对照人群（对照组）504例,并收集相关临床指标。研究2型糖尿病患者中FRAX与糖尿病相关临床危险因素及其并发症之间的关系。结果 糖尿病组股骨颈、Ll、3、4的骨密度高于对照组,而糖尿病组中10年主要骨质疏松性骨折发生概率和10年髋部骨折发生概率低于对照组。多重线性回归中提示糖尿病患者中 FRAX评分与糖化血红蛋白、低血糖发生有相关性。结论 糖尿病应作为FRAX评分工具中的独立危险因素,以便建立更加精确预测糖尿病人群骨折发生风险的评分模型公式。     

急诊创伤患者低体温风险评分量表的研制

目的 研制急诊创伤患者低体温风险评分量袁,验证其临床预测效果.方法 选取489例急诊创伤患者作为建模组,根据是否出现低体温分为为低体温组和常温组,采用二元Logistic回归法分析影响创伤低体温的独立风险因素,构建创伤低体温风险评分量表,确定预测界值.再选取228例急诊创伤患者作为验证组,使用构建的量表预测评分,根据实际低体温的发生情况验证预测效果.结果 建模组构建的创伤低体温风险评分量表包括4个条目:受伤环境温度≤8℃(1分),修正创伤评分＜4分(2分),衣物潮湿(2分),入室时发生休克(2分).验证组中低体温组患者和体温正常组患者风险评分量袁评分差异具有统计学差异(P＜0.01).预测界值3分时,量表预测敏感度为0.709、特异度为0.920、阳性预测值为82.24％、阴性预测值为85.63％、总体正确率为86.08％,ROC曲线下面积为0.829[95％CI(0.769,0.888)].结论 构建的急诊创伤患者低体温风险评分量表具有良好的区分度和预测效果,可用于创伤患者低体温预测.     

成人术中低体温风险评估量表的研制及检验

目的 研制成人术中低体温风险评估量表并进行信效度检验，为手术室护理人员提供科学、有效的评估工具。方法 通过文献回顾建立指标条目池，根据2轮专家函询结果形成量表初稿，采用便利抽样法抽取150例择期手术患者进行术中低体温风险评估，采用ROC曲线确定量表危险阈值，四分位法进行量表风险等级划分，采用Cronbach′s α系数进行信度检验。结果 成人术中低体温风险评估量表包含2个维度、10个风险因素；量表危险阈值为15分，ROC曲线下面积为0.820，灵敏度为100%，特异度为47.52%；15～16分为低风险，17～20分为中风险，＞20分为高风险；量表Cronbach′s α系数为0.780。结论 成人术中低体温风险评估量表具有良好的预测效能，可用于成人术中低体温风险评估。     

两个造影后急性肾损伤预警评分在冠脉介入诊疗术人群中的外部验证和比较

目的通过外部验证比较"Mehran评分"和"国内评分"这两个造影后急性肾损伤(PC-AKI)预警评分预测的准确性,筛选出更适宜于国人的PC-AKI预警评分。方法连续性收集内蒙古自治区人民医院594例接受冠状动脉造影检查或经皮冠状动脉介入术治疗(PCI)的患者,通过Hosmer-Lemeshow拟合优度检验评价两个评分的校正能力,应用接收者工作特征曲线(ROC)下面积评价两个评分对PC-AKI的判别能力;比较分析两个评分危险分层后其相应的发病率以及与院内不良事件的相关性。结果 PC-AKI发病率为5.2%(31/594)。经Hosmer-Lemeshow拟合优度检验,两个评分都有良好的校正能力,国内评分显示χ~2=5.98,P=0.43,Mehran评分显示χ~2=2.42,P=0.88;但国内评分预测能力优于Mehran评分,国内评分ROC曲线下面积为0.71(95%CI0.61～0.80),而Mehran评分ROC曲线下面积为仅为0.56(95%CI0.48～0.63)。并且按国内评分评估为低危、中危、高危和极高危患者的PC-AKI发病率分别为2.1%、6.2%、18.4%和33.3%(P0.01);而Mehran评分的低危、中危、高危和极高危患者的PC-AKI发病率分别为10.1%、13.2%、24.0%和25.0%(P=0.125)。此外我国评分还与术后院内不良事件发生相关(OR=1.20,95%CI 1.09～1.32,P0.01),而Mehran评分并未观察到(OR=1.06 95%CI0.99～1.14,P=0.061)。结论两个PC-AKI预警评分都有较好的拟合优度,但国内评分能更好的预测PC-AKI的发生,更适宜应用于我国行冠脉介入诊疗术的人群。     

新鲜下肢骨折术前深静脉血栓形成危险程度评分量表初探

目的 初步尝试建立新鲜下肢骨折术前深静脉血栓形成危险程度评分量表,用于院内下肢骨折患者术前深静脉血栓形成危险程度的客观判断.方法 回顾性分析2011年1月至2012年12月北京积水潭医院创伤骨科治疗的新鲜下肢骨折患者资料,依据排除标准剔除病例后共纳入分析1 705例.这些患者被随机分为两组,研究组(879组)通过logistic回归分析筛选出危险因素,以多因素logistic回归OR值赋分的方法产生新鲜下肢骨折术前深静脉血栓形成危险程度评分量表,检验组(826例)对评分表进行验证.结果 纳入患者中男性1 106例,女性599例;平均年龄(50±18)岁,logistic回归分析显示可以预测深静脉血栓形成的因素包括年龄、待术时间、受伤原因、受伤部位、心脑血管疾病史以及D-二聚体(D-Dimer)检测值.根据回归OR值得出的分值分别是:年龄≤35岁为1分,＞35 ～ ＜65岁为4分,≥65岁为6分;待术时间＜8d为1分,≥8d为2分;受伤原因低能量为1分,高能量为3分;受伤部位中,足踝损伤为1分,小腿骨折为3分,膝关节周围骨折为5分,股骨中上段为7分,骨盆髋臼为4分,多发骨折为6分;无心脑血管疾病史为1分,有心脑血管疾病史为2分;D-Dimer＜ 600 μg/L为1分,≥600μg/L为3分.受试者工作特征曲线下面积为0.79,临界点15.5分,总体数据临界点灵敏度为77.00％,特异度为68.17％.结论 新鲜下肢骨折术前血栓危险程度评分量表对深静脉血栓形成具有一定的预测效能,但是存在局限性.     

Evaluation of the Finnish Diabetes Risk Score to predict type 2 diabetes mellitus in a Colombian population: A longitudinal observational study

AIM: To assess the performance of the Finnish Diabetes Risk Score(FINDRISC) questionnaire for detecting and predicting type 2 diabetes mellitus(DM2) in a Colombian population.METHODS: This is a longitudinal observational study conducted in Floridablanca, Colombia. Adult subjects(age ≥ 35 years) without known diabetes, were included. A modified version of FINDRISC was completed, and the glycemia values from all the subjects were collected from the hospital's database. Firstly, a cross-sectional analysis was performed and then, the subsample of prediabetic participants was followed for diabetes incidence. RESULTS: A total of 772 subjects were suitable for the study. The overall prevalence of undiagnosed DM2 was 2.59%, and the incidence of DM2 among the prediabetic participants was 7.5 per 100 person-years after a total of 265257 person-years follow-up. The FINDRISC at baseline was significantly associated with undiagnosed and incident DM2. The area under receiver operating characteristics curve of the FINDRISC score for detecting undiagnosed DM2 in both men and women was 0.7477 and 0.7175, respectively; and for predicting the incidence of DM2 among prediabetics was 71.99% in men and 67.74% in women. CONCLUSION: The FINDRISC questionnaire is a useful screening tool to identify cross-sectionally unknown DM2 and to predict the incidence of DM2 among prediabetics in the Colombian population.     

Impact of metabolic surgery on 10-year cardiovascular disease risk in Chinese individuals with type 2 diabetes

BackgroundIn recent years, many reports have highlighted that metabolic surgery may ameliorate the cardiovascular risk in morbidly obese patients with or without type 2 diabetes (T2D). However, few studies have evaluated the long-term cardiovascular disease (CVD) risk after metabolic surgery in T2D patients with a low body mass index (BMI).ObjectivesTo use the Prediction for ASCVD Risk in China (China-PAR) equations and United Kingdom Prospective Diabetes Study (UKPDS) risk engine to assess the 10-year CVD risk in low-BMI T2D patients after metabolic surgery.SettingUniversity hospital, China.MethodsWe retrospectively reviewed our prospectively collected data of T2D patients who underwent metabolic surgery at our hospital between 2010 and 2018. We included patients who met the criteria for calculating a 10-year cardiovascular risk score by the China-PAR equations and UKPDS risk engine. Demographic characteristics, anthropometric variables, and glycolipid metabolic parameters were assessed preoperatively and during a 4-year follow-up period. Patients with a BMI < 30 kg/m² were compared with those with a BMI > 30 kg/m².ResultsWe evaluated 117 patients, of whom 62 (53%) had a BMI < 30 kg/m² and 55 (47%) had a BMI > 30 kg/m². Patients with a BMI < 30 kg/m² were significantly older and had a longer duration of diabetes. The rate of complete T2D remission in the group of patients with BMIs < 30 kg/m² was significantly lower than that in the group with BMIs > 30 kg/m² (35.2% versus 56.1%, respectively; P = .042). The overall 10-year and lifetime atherosclerotic cardiovascular disease risks were reduced from 4.2% to 2.3% and 25.3% to 13.9%, respectively (both P < .05), at 1 year postoperatively using the China-PAR equation. The overall 10-year coronary heart disease (CHD) and fatal CHD risks were reduced by 48.1% and 53.1%, respectively, at 1 year after surgery using the UKPDS risk engine. The advantages of metabolic surgery in reducing CVD risks are similar in both BMI groups, whether using the China-PAR equation or the UKPDS risk engine.ConclusionThe 10-year CVD risk in T2D patients with BMIs < 30 kg/m² and BMIs > 30 kg/m² were significantly reduced after metabolic surgery, although the rate of complete T2D remission T2Din patients with BMIs < 30 kg/m² was lower than that in patients with BMIs > 30 kg/m². The China-PAR equation is a reliable and useful clinical tool for CVD risk evaluation in Chinese patients after metabolic surgery.     

Moderate penetrance genes complicate genetic testing for breast cancer diagnosis: ATM,CHEK2, BARD1 and RAD51D

Breast cancer risk associated with germline likely pathogenic/pathogenic variants (PV) varies by gene, often by penetrance (high >50% or moderate 20–50%), and specific locus.Germline PVs in BRCA1 and BRCA2 play important roles in the development of breast and ovarian cancer in particular, as well as in other cancers such as pancreatic and prostate cancers and melanoma. Recent studies suggest that other cancer susceptibility genes, including ATM, CHEK2, PALB2, RAD51C and RAD51D confer differential risks of breast and other specific cancers.In the era of multigene panel testing, advances in next-generation sequencing technologies have notably reduced costs in the United States (US) and enabled sequencing of BRCA1/2 concomitantly with additional genes. The use of multigene-panel testing is beginning to expand in Europe as well.Further research into the clinical implications of variants in moderate penetrance genes, particularly in unaffected carriers, is needed for appropriate counselling and risk management with data-driven plans for surveillance and/or risk reduction. For individuals at high risk without any pathogenic or likely pathogenic variant in cancer susceptibility genes or some carriers of pathogenic variants in moderate-risk genes such as ATM and CHEK2, polygenic risk scores offer promise to help stratify breast cancer risk and guide appropriate risk management options.Cancer patients whose tumours are driven by the loss of function of both copies of a predisposition gene may benefit from therapies targeting the biological alterations induced by the dysfunctional gene e.g. poly ADP ribose polymerase (PARP) inhibitors and other novel pathway agents in cancers with DNA repair deficiencies. A better understanding of mechanisms by which germline variants drive various malignancies may lead to improvements in both therapeutic and preventive management options.     

Performance of risk prediction models for post-operative mortality in patients undergoing liver resection

BackgroundLiver resection is commonly performed for hepatic tumors, however preoperative risk stratification remains challenging. We evaluated the performance of contemporary prediction models for short-term mortality after liver resection in patients with and without cirrhosis.MethodsThis retrospective cohort study examined National Surgical Quality Improvement Program data. We included patients who underwent liver resections from 2014 to 2019. VOCAL-Penn, MELD, MELD-Na, ALBI, and Mayo risk scores were evaluated in terms of model discrimination and calibration for 30-day post-operative mortality.ResultsA total 15,198 patients underwent liver resection, of whom 249 (1.6%) experienced 30-day post-operative mortality. The VOCAL-Penn score had the highest discrimination (area under the ROC curve [AUC] 0.74) compared to all other models. The VOCAL-Penn score similarly outperformed other models in patients with (AUC 0.70) and without (AUC 0.74) cirrhosis.ConclusionThe VOCAL-Penn score demonstrated superior predictive performance for 30-day post-operative mortality after liver resection as compared to existing clinical standards.     

Effect of bariatric surgery versus medical therapy on long-term cardiovascular risk in low BMI Chinese patients with type 2 diabetes: a propensity score-matched analysis

BackgroundReducing the risk of death due to cardiovascular disease (CVD) is an important direction for diabetes prevention and treatment. The Chinese population with type 2 diabetes (T2D) has a high risk of developing CVD at relatively low body mass index (BMI) levels. Currently, no studies have evaluated the effect of bariatric surgery versus medical therapy on long-term CVD risk in patients with T2D and low BMI.ObjectivesTo compare bariatric surgery versus medical therapy for long-term CVD risk in Chinese patients with T2D and low BMI by using the China Prediction for ASCVD Risk equations and the United Kingdom Prospective Diabetes Study risk engine.SettingUniversity hospital, China.MethodsMedical records of patients with T2D with a BMI <35 kg/m² undergoing bariatric surgery or medical therapy from May 2010 to December 2018 were reviewed. A 1:1 propensity score matching was performed by using 7 preoperative characteristics. Variables for calculating CVD risk scores over the 5-year follow-up were assessed.ResultsA total of 684 patients with T2D underwent bariatric surgery (n = 75) or medical therapy (n = 609), and 52 pairs of matched subjects were selected from both groups after propensity score matching. The 10-year and lifetime atherosclerotic CVD risk by using the China Prediction for ASCVD Risk equation at 5 years follow-up period in the bariatric surgery group improved significantly compared with the medical therapy group. In the fifth year of follow-up, the 10-year risk of coronary heart disease, fatal coronary heart disease, stroke, and fatal stroke by using the United Kingdom Prospective Diabetes Study risk engine were much lower in the bariatric surgery group than in the medical therapy group (10.37 ± 5.64% versus 27.25 ± 7.28%, P = .004; 6.3 ± 4.5% versus 22.3 ± 7.35%, P = .002; 4.97 ± 3.73% versus 15.05 ± 3.63%, P = .001; .59 ± .45% versus 1.52 ± .14%, P < .001. respectively). The use of glucose-lowering medications, including insulin, was reduced from baseline in both groups, and patients in the bariatric surgery group required significantly fewer of these medications than those in the medical therapy group.ConclusionBariatric surgery in patients with T2D and low BMI conferred a lower calculated risk of CVD compared with medical therapy over 5 years of follow-up.     

Evaluation of POSSUM for Patients Undergoing Pancreatoduodenectomy

ABSTRACT

Background: The POSSUM score is a predictive scoring system for postoperative morbidity. Although numerous studies have validated its application in major abdominal surgery, few have exclusively considered pancreatic resections, which have unique complications that are costly and problematic. We examined whether POSSUM could accurately reflect the clinical outcomes in pancreatic resection. Methods: A total of 694 consecutive resections of the pancreatic head were performed between 1993 and 2010 at the Department of General, Thoracic, and Vascular Surgery at the University Hospital Dresden. The POSSUM score calculated for each case was compared with the observed morbidity. Relevance and predictive performance of the score were assessed; in particular, because of the poor calibration of the POSSUM predictions on the Dresden data, a new score was created that was externally validated on patient cohorts from two different centers for pancreatic surgery. Results: The goodness-of-fit analysis revealed that the POSSUM score was not well calibrated because the POSSUM-predicted morbidity rate was 58.9% on average whereas the observed morbidity rate was 43.4%. Discrepancies occurred particularly among the predicted high-risk patients, for whom the score actually overestimated the morbidity risk. Therefore, we adapted the score and complemented it with additional prognostic parameters. The new score was validated in a patient cohort from two other German centers and fitted better to the data. Conclusion: The new score, named PS-POSSUM (POSSUM in pancreatic surgery), fits the data better. However, the prediction ability remains rather poor. PS-POSSUM may still be helpful, as it draws attention to additional risk and protective factors in addition to those in the original POSSUM score.