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1.
Purpose of Review
The merit of imaging “vulnerable atherosclerotic plaques” remains highly controversial. This review aims at providing current evidence for both its benefit and limitations.Recent Findings
Results from optical coherence tomography and intravascular ultrasound imaging in patients with coronary heart disease suggest that certain individual coronary atherosclerotic plaque characteristics, e.g., large lipid core in a fibroatheroma, are associated with greater risk of adverse patient outcome. However, a closer look at these studies reveals that these associations are confounded by the relationship of “vulnerable plaque” characteristics with baseline lumen obstruction, which is a known predictor of recurrent angina and the main component of the reported adverse patient outcome. Recent insights into the pathophysiology of acute coronary syndromes suggest it to be an exceedingly complex process involving numerous local and systemic factors, which hinders outcome prediction.Summary
The quest for the vulnerable plaque rests on the erroneous assumption that detecting coronary atherosclerotic lesions, which are prone to rupture or erode, will identify individuals at high risk of suffering acute coronary events. However, there is strong and consistent evidence suggesting that plaques most commonly rupture without associated clinical symptoms. Instead, ruptured plaques typically heal clinically silently and lead to plaque progression. The atherosclerotic disease burden, its metabolic activity, and risk factors for an inadequate response by the coagulation system to plaque disruption, on the other hand, are important predictors of acute coronary event risk and deserve our attention more than individual plaques.2.
Yanping Zha Yong Chen Fayun Xu Tian Li Chuanyan Zhao Lianqun Cui 《Biomedicine & Pharmacotherapy》2010
Objective
A recent study indicates that ADAMTS4 (a disintegrin and metalloprotease with thrombospondin motifs 4) was expressed in macrophage rich areas of human atherosclerotic carotid plaques and coronary unstable plaques suggesting a pathogenic role in the development of acute coronary syndromes (ACS). The aim of the study was to compare ADAMTS4 across the entire spectrum of coronary artery disease (CAD) and to investigate the temporal profiles of ADAMTS4.Methods
Plasma levels of ADAMTS4 were measured in patients with stable effort angina pectoris (SAP), ACS and in controls. Venous blood was sampled upon admission before angiography and drug administration. In patients with ACS who underwent medical treatment, serial blood samples were also collected on days 1, 2, 3, 5 and 7 after admission. ADAMTS4 was measured using an enzyme immunoassay.Results
Plasma ADAMTS4 level in cases was significantly greater than in controls (P < 0.001). Higher levels of ADAMTS4 were found with progression of CAD from SAP to unstable angina pectoris (UAP) to non-ST-segment elevation acute myocardial infarction (NSTEMI) and to ST-segment elevation acute myocardial infarction (STEMI) (P < 0.001). Elevated ADAMTS4 level was associated with ACS with an area under receiver operating characteristic (ROC) curve of 0.753 (95% CI 0.654–0.851; P < 0.001). The pattern of ADAMTS4 release observed was clearly different in various forms of ACS. ADAMTS4 showed a weak correlation with high-sensitivity C-reactive protein (hs-CRP); however, no significant correlation was found between ADAMTS4 and troponin T (TnT) in ACS patients.Conclusions
Serial changes in plasma ADAMTS4 were documented in patients with ACS and may serve as a marker of plaque destabilization. 相似文献3.
Background
The use of cannabis is not usually regarded as a risk factor for acute coronary syndrome. However, several cases of myocardial infarction (MI) associated with cannabis use have been reported in the scientific literature. The etiology of this phenomenon is not known.Objectives
To present a case of cannabis-associated MI in which atherosclerotic coronary disease was excluded as a potential etiology by intravascular ultrasound examination, and briefly review the other possible mechanisms by which this effect may be mediated.Case Report
We present the case of a previously healthy 21-year-old man who regularly smoked cannabis and presented to the Emergency Department with ST-elevation myocardial infarction after participating in a sport. He was also a cigarette smoker, but had no other conventional cardiovascular risk factors. At coronary angiography, a large amount of thrombus was found in the left anterior descending coronary artery. He recovered with medical treatment, and subsequent intravascular ultrasound examination showed no evidence of atherosclerosis at the site of the thrombus.Conclusion
Cannabis-associated MI is increasingly recognized. The etiology is unclear, but we believe this is the first report of the phenomenon where atherosclerotic plaque rupture has been excluded as the cause with a high degree of confidence. 相似文献4.
Roldan CJ 《The Journal of emergency medicine》2012,43(1):196-203
Background
In recent years, different aortic pathologies have been grouped together and described in terms of a spectrum of disease referred to as Acute Aortic Syndrome (AAS). Overlapping of these conditions has traditionally introduced discrepancy to the understanding of the pathophysiology and definitive care. Penetrating atherosclerotic ulcer (PAU), an ulceration of an atherosclerotic plaque, has been increasingly recognized as the individual cause of the acute aortic pathology.Objective
The natural evolution and complications of PAU are described, as well as the current diagnostic strategies, definitive management options, and initial care in the emergency department.Discussion
The natural history of PAU is variable but is generally considered to be an AAS with a high incidence of complications. The clinical differentiation of symptomatic PAU from other causes of AAS is very challenging. Computed tomography imaging has provided additional accuracy with the use of the retrospective electrocardiographic gating technique. Despite traditional surgical therapies for aortic pathology, later studies have demonstrated the success of non-operative management, such as endoluminal grafting.Conclusion
The relative rarity of this disease, the difficulties in its detection, and the lack of precise guidelines about its management may result in diagnostic delays. Asymptomatic patients with well-controlled blood pressure are safely managed as outpatients in close consultation with vascular surgery. 相似文献5.
6.
Background
Spontaneous coronary artery dissection (SCAD) causes acute coronary syndromes or sudden death in young patients who are often lacking classic coronary disease risk factors. Systemic inflammatory and connective tissue diseases have been suggested as risk factors for SCAD.Objective
To review the risk factors, diagnosis, and management of this uncommon but life-threatening disease.Case Report
We report a case of a 27-year-old woman with a history of an ill-defined inflammatory arthropathy who presented with an acute ST-elevation myocardial infarction. SCAD was diagnosed by coronary angiography. Percutaneous coronary intervention was attempted but was unsuccessful. The patient recovered uneventfully with medical management and was ultimately diagnosed with systemic lupus erythematosus.Conclusions
SCAD is a rare but important cause of acute coronary syndromes and sudden death. It commonly occurs in young women. Although pregnancy is the most well-established risk factor, systemic inflammatory and connective tissue diseases have also been suggested as risk factors. 相似文献7.
Shawn Farrokhi Carrie A. Voycheck Brian A. Klatt Jonathan A. Gustafson Scott Tashman G. Kelley Fitzgerald 《Clinical biomechanics (Bristol, Avon)》2014
Background
To evaluate knee joint contact mechanics and kinematics during the loading response phase of downhill gait in knee osteoarthritis patients with self-reported instability.Methods
Forty-three subjects, 11 with medial compartment knee osteoarthritis and self-reported instability (unstable), 7 with medial compartment knee osteoarthritis but no reports of instability (stable), and 25 without knee osteoarthritis or instability (control) underwent Dynamic Stereo X-ray analysis during a downhill gait task on a treadmill.Findings
The medial compartment contact point excursions were longer in the unstable group compared to the stable (P = 0.046) and the control groups (P = 0.016). The peak medial compartment contact point velocity was also greater for the unstable group compared to the stable (P = 0.047) and control groups (P = 0.022). Additionally, the unstable group demonstrated a coupled movement pattern of knee extension and external rotation after heel contact which was different than the coupled motion of knee flexion and internal rotation demonstrated by stable and control groups.Interpretation
Our findings suggest that knee joint contact mechanics and kinematics are altered during the loading response phase of downhill gait in knee osteoarthritis patients with self-reported instability. The observed longer medial compartment contact point excursions and higher velocities represent objective signs of mechanical instability that may place the arthritic knee joint at increased risk for disease progression. Further research is indicated to explore the clinical relevance of altered contact mechanics and kinematics during other common daily activities and to assess the efficacy of rehabilitation programs to improve altered joint biomechanics in knee osteoarthritis patients with self-reported instability. 相似文献8.
Background
Undifferentiated altered mental status and hemodynamic instability are common presenting complaints in the Emergency Department (ED). Emergency practitioners do not have the luxury of time to perform sequential examination, history, testing, diagnosis, and treatment. Rather, we do all of these things at once to save lives and decrease morbidity. An important diagnosis to consider and upon which we can easily intervene is that of thiamine deficiency.Objectives
We present a case of an altered and unstable woman who presented to our busy ED and had rapid improvement after the administration of vitamin B1. We discuss the presentation, pathophysiology, consequences of missed diagnosis, and management of this disease process.Case Report
A middle-aged woman presented to our ED with unstable vital signs and an alteration in her mental status. She was unable to provide a history. Empiric treatment with thiamine resulted in the resolution of her hemodynamic instability and improvement in her mental status.Conclusion
Our patient benefited from the swift administration of thiamine and illustrates the importance of thiamine administration in the altered or hemodynamically unstable emergency patient with an elevated lactate. 相似文献9.
Rich Teitell Matthew VaseyElaine Josephson MD Muhammad WaseemYocheved Rose MD 《The Journal of emergency medicine》2013
Background
Acute upper gastrointestinal (GI) bleed is a well-known presentation to the emergency department (ED) frequently accompanied by hematemesis. We describe the case of a patient with abdominal content herniation into the chest wall with a recent history of coronary artery bypass graft presenting with acute onset of hematemesis.Objectives
To present an exceedingly rare herniation of abdominal contents into the chest wall that was accompanied by hematemesis and to present the rare visual findings inherent in this pathology.Case Report
A 65-year-old man presented to the ED vomiting large amounts of blood upon presentation, compromising hemodynamic stability and prompting emergent resuscitation. The patient’s presentation was complicated by a large 30 × 40-cm anterior chest wall mass extending 2 cm inferior to the sternal notch expanding with each episode of hematemesis. Computed tomography after stabilization revealed a large ventral hernia extending into the chest wall, containing small and large bowel. We suspected this large, unusual hernia to be the underlying cause of the patient’s GI bleeding.Conclusion
The emergency physician must be able to assess hemodynamic stability of an upper GI bleed and resuscitate the unstable patient if warranted. Diagnosis is to be subsequently determined after stabilization. 相似文献10.
Gregory J. Fermann MD Christopher J. Lindsell PhD Brian J. O'Neil MD W. Brian Gibler MD 《The American journal of emergency medicine》2009,27(7):816-822
Objective
We compared the performance characteristics of the 12-lead electrocardiography (ECG) with body surface mapping (BSM) in patients presenting for evaluation of symptoms suggestive of acute coronary syndromes.Methods
The diagnostic test characteristics (sensitivity, specificity, likelihood ratios, and predictive values) for 12-lead ECG and BSM were computed using 3 different criterion standards.Results
Of the 150 patients enrolled, 19 were positive for acute coronary syndromes using the criterion standard of cardiac troponin T >0.1 ng/mL, percutaneous coronary intervention, more than 70% stenosis, abnormal noninvasive testing, and coronary artery bypass graft. Changes not known to be old on ECG and BSM had sensitivities of 10.5 (95% confidence interval [CI95], 1.8-34.5) and 15.8 (CI95, 4.2-40.5), and specificities of 90.1 (CI95, 83.3-94.4) and 86.3 (CI95, 78.9-91.4), respectively.Conclusion
In this emergency department population, both the BSM and the 12-lead ECG exhibited similar test characteristics. 相似文献11.
Benno M. Nigg Karelia E. Tecante G. Peter Federolf Scott C. Landry 《Clinical biomechanics (Bristol, Avon)》2010,25(10):1047-1052
Background
In recent years several unstable shoe designs that cause increased instability at the ankle joint have been developed with the aims of training static and dynamic posture and postural control. However, earlier research found significant gender differences in the generation of ankle torque and in the reaction times after a perturbation. Therefore it is possible that men and women are affected differently by the instability that unstable shoes create. The purpose of this study was to investigate if gender differences exist a) during bilateral quiet stance or b) in lower extremity gait kinematics and kinetics when using unstable shoes.Methods
Seventeen females and seventeen males were included in this study. Masai Barefoot Technology® shoes were used as test shoes. Center of pressure excursion was recorded during 30 s bilateral quiet stance trials using a force plate. Joint angles, resultant joint moments and joint moment impulses during walking were determined using standard gait analysis methods.Findings
In bipedal stance, female subjects had significantly greater anterior–posterior center of pressure excursion than male subjects. In the stance phase of the gait cycle gender differences were found in the ankle joint moments which had not been reported in earlier studies using barefoot or normal shoe conditions.Interpretation
The results suggest that women and men use different strategies to control the ankle joint when standing or walking in unstable shoes. Gender effects should therefore be taken into consideration if functional or therapeutic effects of unstable shoes are assessed. 相似文献12.
Ko SF Ng SH Fang FM Wan YL Hsieh MJ Liu PP Kung CT Liu BM 《The American journal of emergency medicine》2007,25(9):1051-1056
Objective
To report the clinical and computed tomographic findings of 5 cases of left brachiocephalic vein perforation (LBCVP).Methods
The clinical and imaging features of 5 patients with LBCVP (1 woman, 4 men; mean age, 57.6 years) encountered over the last 2 decades were reviewed.Results
Etiologies included left jugular central catheter penetration in 2 patients, blunt trauma in 2, and idiopathic in 1. All patients manifested acute chest pain with a widened mediastinum on chest radiographs. Characteristic computed tomographic features included a cord-like hematoma along the course of the left brachiocephalic vein associated with a left upper anterior mediastinal hematoma (AMH). Three clinically stable patients with AMH smaller than 5 cm convalesced after conservative treatment and 2 clinically unstable patients with AMH bigger than 7 cm recovered well after surgery.Conclusions
Computed tomography is helpful in diagnosing LBCVP. Under close surveillance, patients with stable LBCVP with AMH smaller than 5 cm may be managed conservatively. However, emergency surgery is warranted if there are any signs of instability. 相似文献13.
Background
Reduction in plasma low-density lipoprotein cholesterol (LDL-C) is a fundamental treatment for the prevention of acute coronary syndromes (ACS). Although statin therapy confers significant protection against ACS in both primary and secondary prevention, a considerable residual risk remains after intensive therapy. In addition, a significant proportion of high-risk patients do not achieve the optimal LDL-C goal recommended in the current guidelines (<1.8 mmol/L). Hence, novel LDL-C-lowering agents that act via mechanisms distinct from HMG-CoA reductase inhibition are under investigation.Objective
We reviewed the recent literature on the development of novel LDL-C–lowering agents that could potentially be used as an alternative or adjunct to statin therapy in high-risk coronary patients.Methods
PubMed and Scopus databases were searched to retrieve studies on the efficacy and/or tolerability of novel LDL-C-lowering agents in animals and humans.Results
Agents that inhibit proprotein convertase subtilisin/kexin type 9 (PCSK9), apolipoprotein (apo) B, and microsomal triglyceride transfer protein (MTTP) are the most promising therapies. Inhibition of PCSK9, apoB, and MTTP has been achieved mostly via fully humanized monoclonal antibodies (mAbs), antisense oligonucleotides, and synthetic compounds, respectively. PCSK9 inhibitors increase the hepatic uptake of LDL-C, while apoB and MTTP inhibitors decrease the synthesis and secretion of apoB-containing lipoproteins. These 3 mechanisms lead to marked reductions in plasma LDL-C in patients with hypercholesterolemia at risk for ACS, particularly those with familial hypercholesterolemia. Moreover, these agents can exert additional benefits by decreasing plasma levels of apoB, triglycerides, and lipoprotein(a). Mipomersen and lomitapide have been approved by the United States Food and Drug Administration (US FDA) for use in patients with homozygous familial hypercholesterolemia. PCSK9 inhibitors are currently under final evaluation in clinical outcomes studies and are anticipated to find wide application either as monotherapy or as an adjunct to statins. A main safety concern is the risk for hepatic steatosis with apoB and MTTP inhibitors, which needs to be explored in prospective, long-term trials.Conclusions
PCSK9, apoB, and MTTP inhibitors can exert potent reductions in plasma LDL-C and apoB concentrations, either as monotherapy or in combination with statins. These effects are particularly relevant to high-risk individuals with marked hypercholesterolemia, such as those with familial hypercholesterolemia. Although the use of mipomersen and lomitapide is limited to severe familial hypercholesterolemia as a replacement for LDL-apheresis, PCSK9 inhibitors are likely to be more widely prescribed in patients at high risk for CVD, especially those who are resistant to or intolerant of high-intensity statin therapy. PCSK9 mAbs are efficacious and have an excellent safety profile, but their long-term impact on cardiovascular events is currently under investigation. Whether PCSK9 mAbs decrease the rates of recurrent cardiovascular events within 3 months following ACS is questionable; however, these agents, unlike statins, may not have pleiotropic benefits on the unstable plaque. 相似文献14.
Background
Second-generation antipsychotic medications, or “atypical antipsychotics,” are now first-line therapy in the treatment of schizophrenia and other psychotic disorders, and are additionally being used in a wide array of other psychiatric and non-psychiatric conditions in both adults and children. Overdose is frequently reported to poison control centers.Objectives
We review the toxicology and general management of poisonings involving the atypical antipsychotic medications.Discussion
The most serious toxicity involves the cardiovascular system and the central nervous system. All typical and atypical antipsychotics cause sedation, which is pronounced in overdose. The most common cardiovascular effects that occur after atypical antipsychotic overdose are tachycardia, mild hypotension, and prolongation of the QTc interval. Other clinical syndromes in overdose include neuroleptic malignant syndrome (NMS) and antimuscarinic delirium. Seizures may be observed. No antidotes exist for these poisonings, but they most often do well with supportive care.Conclusion
Antipsychotic overdose produces a gamut of manifestations that affect multiple organ systems. Treatment is primarily supportive. Specific therapies for NMS, hypotension, and seizures are discussed. 相似文献15.
Milind S. Phadke Pritesh PunjabiSohan Sharma MD Sandeep KideJaywant Nawale MD DM Ajay Chaurasia MD DM 《The Journal of emergency medicine》2013
Background
Electrocardiographic abnormalities mimicking myocardial ischemia have been reported in intra-abdominal conditions, including acute pancreatitis. However, the occurrence of ST-elevation myocardial infarction (STEMI) is rare.Objectives
To present a case report of a young man with acute pancreatitis subsequently complicated by acute STEMI. The diagnosis and management of STEMI in acute pancreatitis can present unique diagnostic and therapeutic challenges, which are reviewed.Case Report
A 31-year-old man with no conventional coronary risk factors presented with acute abdominal pain, elevated pancreatic enzymes, and computed tomography scan findings of acute pancreatitis. The patient developed chest discomfort and presented to us on Day 2 with electrocardiographic evidence of an evolved extensive anterior wall myocardial infarction. Cardiac troponin I levels were elevated, and the electrocardiogram showed regional wall motion abnormalities in the left anterior descending territory (LAD). Coronary angiography done after stabilization showed a thrombus in the LAD, with no atherosclerotic lesions whatsoever. Hemostatic abnormalities are known in acute pancreatitis, and the development of a transient hypercoagulable state may be responsible for thrombotic complications. The overlap of some of the symptoms of the two conditions may cause diagnostic difficulty. Management issues include the choice of revascularization therapy, the safety of antiplatelet and anticoagulant therapy, intravenous fluid administration, and the use of cardiac medications that potentially can cause hypotension.Conclusion
The diagnosis and management of STEMI in the setting of acute pancreatitis can be challenging. In the absence of guidelines, a multidisciplinary approach individualized to the patient’s clinical situation may be most appropriate. 相似文献16.
Background
Dual antiplatelet therapy is a guideline mandated for patients with acute coronary syndromes (ACS). Despite its use, thrombotic events continue to occur both early and late. Platelet function testing has been used to define the in vitro effects of new antiplatelet agents, and it has been suggested that it be used to choose therapy. The role of platelet function testing, particularly with newer antiplatelet agents, remains unclear.Objective
We review the rationale for platelet function testing and its application in monitoring patients on antiplatelet therapy. We also review recent clinical trials of newer antiplatelet agents. On the basis of this review, we reach conclusions on the current role of antiplatelet function testing in monitoring modern antiplatelet therapy and the role of the new antiplatelet agents in the treatment of ACS.Methods
We reviewed recent publications on platelet function testing and clinical trials of newer antiplatelet therapies compared with clopidogrel.Results
Platelet function testing is complex, but there is now a bedside test, VerifyNow. High platelet reactivity has been associated with worse cardiovascular outcomes in patients undergoing percutaneous coronary intervention. Recent clinical trials have not found any advantage in outcomes in patients who have their therapy adjusted by monitoring their platelet function. Newer agents, prasugrel, ticagrelor, and cangrelor, produce more rapid, complete, less variable effects on platelet function than clopidogrel. Prasugrel was found to improve outcomes compared with clopidogrel in patients with ACS undergoing percutaneous intervention. Ticagrelor is beneficial in all patients with ACS and reduces cardiovascular mortality compared with clopidogrel. Cangrelor improves outcomes in patients undergoing stenting. Recent studies to assess the role of platelet function monitoring of the effects of clopidogrel and modifying treatments have not been successful.Conclusion
Recent clinical trials have indicated that newer antiplatelet agents have advantages over clopidogrel in the treatment of ACS. Platelet function testing gives us a guide to the timing, efficacy, and variability of therapy and can correlate with poor patient outcomes; however, the use of antiplatelet function testing to tailor therapy does not seem appropriate. 相似文献17.
Rafal Rozalski Arkadiusz Migdalski Daniel Gackowski Jolanta Guz Agnieszka Siomek Marek Foksinski Anna Szpila Ewelina Zarakowska Marcin Majer Arkadiusz Jawien Ryszard Olinski 《Clinical biochemistry》2013
Objectives
This study explored the relationship between oxidative stress biomarkers and stability of carotid plaque. We decided to analyze the broad range of parameters describing oxidative stress in patients with carotid stenosis.Design and methods
124 consecutive patients undergoing carotid endarterectomy were enrolled in the study group. The control group consisted of 49 patients without symptoms of atherosclerosis. The stability of carotid plaques was assessed using GSM (gray-scale median) scoring system and the study group was divided into three subgroups according to echogenicity of the plaque. The following parameters of oxidative stress/DNA damage were analyzed: i) urinary excretion of the products of oxidative DNA damage repair; ii) the background level of 8-oxo-7,8-dihydro-2′-deoxyguanosine in leukocytes' DNA and in atherosclerotic plaques; and iii) the concentrations of antioxidant vitamins, uric acid and C-reactive protein in plasma.Results
Oxidative stress (described by redox status) was higher in the patient group than in the control group. There is a correlation between oxidative stress of the patients and stability of the plaque, echolucent plaques (GSM < 25) being associated with the highest antioxidant level and lowest excretion of DNA repair markers.Conclusions
The plaque formation/morphology may depend on local environment and is independent of oxidative stress/inflammation observed on the level of the whole body. 相似文献18.
Chiara ZanettaMonica Nizzardo PhD Chiara SimoneErika Monguzzi PhD Nereo BresolinGiacomo P. Comi MD Stefania Corti 《Clinical therapeutics》2014
Background
Spinal muscular atrophy (SMA) is an autosomal recessive motor neuron disease caused by mutations in the survival motor neuron gene (SMN1) and the leading genetic cause of infant mortality. Currently, there is no effective treatment other than supportive care.Objective
This article provides a general overview of the main aspects that need to be taken into account to design a more efficient clinical trial and to summarize the most promising molecular trials that are currently in development or are being planned for the treatment of SMA.Methods
A systematic review of the literature was performed, identifying key clinical trials involving novel molecular therapies in SMA. In addition, abstracts presented at the meetings of the Families of Spinal Muscular Atrophy were searched and the Families of Spinal Muscular Atrophy Web site was carefully analyzed. Finally, a selection of SMA clinical trials registered at clinical- trials.gov has been included in the article.Results
The past decade has seen a marked advancement in the understanding of both SMA genetics and molecular mechanisms. New molecules targeting SMN have shown promise in preclinical studies, and various clinical trials have started to test the drugs that were discovered through basic research.Conclusions
Both preclinical and early clinical trial results involving novel molecular therapies suggest that the clinical care paradigm in SMA will soon change. 相似文献19.
Background
Acute myocardial infarction (AMI) can occur in infants. Early identification of AMI can allow for specific therapies aimed at improving patient outcomes.Objective
This article describes a case of an infant with AMI caused by a previously unreported mechanism and reviews diagnostic and therapeutic strategies for dealing with this rare disease.Case Report
We present a case of a 5-week-old infant with a fatal AMI due to a pedunculated nodule from a dysplastic aortic valve leaflet creating a ball-in-valve mechanism and occluding the left main coronary artery.Conclusion
AMI is an important diagnostic consideration in any infant presenting with signs of unexplained cardiogenic shock. Practitioners who care for children should be aware of diagnostic and therapeutic strategies for AMI in infants. 相似文献20.