腔隙性脑梗塞患者脑内微出血的发生、分布及其意义

目的 探讨脑内微出血在腔隙性梗塞病人中的发生率及在脑内各区域的分布情况,以及与其他微小血管病变包括脑白质改变和腔隙性梗塞之间的关系。方法 连续入选腔隙性脑梗塞病人82例。记录一般临床资料、实验室检查及神经精神功能评分包括入院时的美国国立卫生研究院卒中评分(NIHSS)和发病三个月时的Barthel生活指数(BI)和简易精神状态量表(MMSE)。所有病人均进行头颅MR检查观察脑内微出血的数目及部位,脑白质改变的程度和腔隙性脑梗塞的数目及部位。数据处理均采用SPSS软件进行。结果 22例患者(27％)存在脑内微出血,数目由1～42个,分布于脑内不同部位包括皮层-皮层下、丘脑基底节区、小脑和脑干。微出血的数目与腔隙性梗塞的数目以及脑白质改变的程度显著相关(r=0.297,0.552;P=0.007,<0.001)。3个月时微出血组病人的MMSE和BI有低于无微出血组病人的趋势(22.56 vs 24.53,16.71 vs 19.11),但无统计学差异(P=0.162,0.052)。结论 脑内微出血在腔隙性脑梗塞中发生率较高,且与脑白质改变的严重程度以及腔隙性梗塞的数目相关。提示脑内微出血是另外一种微小血管病损的标志,可能代表着更为严重的小血管壁的损害,更为直接地提示出血倾向,在腔隙性脑梗塞的治疗及预防过程中应予以相应的重视。     

Neurologic complications due to catheterization

In our university cardiac center, the incidence of a cohort of children with acute neurologic complications resulting from cardiac catheterization performed for acyanotic or cyanotic congenital heart disease is 0.38% (14 children of a total of 3,648 catheterization procedures). Neurologic complications consisted of convulsion (n = 10), stroke (n = 6), intracranial hemorrhage (n = 2), extrapyramidal features (n = 1), paraplegia (n = 1), visual impairment (n = 1), hearing impairment (n = 1), and brachial plexus injury (n = 1). The main risk factors included prolonged duration of catheterization procedure and interventional manipulation in addition to cardiac catheterization. The possible mechanisms causing brain injury included cerebral embolism from local clots and hypoxia resulting from complications during the procedure. Other complications included intracranial hemorrhage secondary to anticoagulation and peripheral plexopathy because of prolonged fixed posture during anesthesia. The prognosis for the majority of patients with stroke is good. Neurologic sequelae, such as global developmental delay or epilepsy, occurred in those with hypoxic-ischemic encephalopathy.     

Esomeprazole with aspirin versus clopidogrel for prevention of recurrent gastrointestinal ulcer complications.

BACKGROUND AND AIMS: The role of clopidogrel in patients at risk for gastrointestinal complications is uncertain, although it has been recommended for patients who have gastrointestinal intolerance to aspirin. We tested the hypothesis that clopidogrel is as effective as esomeprazole and aspirin in preventing recurrences of ulcer complications. METHODS: This was a prospective, double-blind, randomized, controlled study of 170 patients who developed ulcer bleeding after the use of low-dose aspirin between November 2002 and January 2005. After healing of ulcers and eradication of Helicobacter pylori, if present, patients were assigned randomly to treatment with esomeprazole 20 mg/day and aspirin 100 mg/day (n = 86) or clopidogrel 75 mg/day (n = 84) for 52 weeks. The primary end point was recurrent ulcer complications. RESULTS: During a median follow-up period of 52 weeks, no patient in the esomeprazole group, as compared with 9 patients in the clopidogrel group, developed recurrent ulcer complications. The cumulative incidences of recurrent ulcer complications were 0% in patients receiving esomeprazole and aspirin and 13.6% in patients receiving clopidogrel (absolute difference, 13.6%; 95% confidence interval for the difference, 6.3-20.9; log-rank test, P = .0019). CONCLUSIONS: The combination of esomeprazole and aspirin is superior to clopidogrel in preventing ulcer complications in patients who have a past history of aspirin-related peptic ulcer bleeding.     

Technical and biologic sources of variability in the mapping of aortic, mitral and tricuspid color flow jets

The quantification of valvular regurgitation by 2-dimensional Doppler imaging depends on identifying and minimizing variability. Aortic, mitral and tricuspid regurgitant jet areas were measured in 50 patients with sinus rhythm or atrial fibrillation to analyze the variables of reading error, valve site, jet size, rhythm and frame rate. One technician recorded jet velocities at 1 frame/cycle at a triggered interval after the electrocardiographic R wave and at frame rates of 7.5 and 15 frames/s. Jet areas from 5 consecutive beats were measured by planimetry by 1 observer. Coefficients of variation between and among groups were compared by analysis of variance; mean values were 14 to 22%. Jets grouped less than 2.5, 2.5 to 5 and greater than 5 cm2 showed the variance of small jets exceeding that of medium and large jets. Aortic regurgitant jets were largest and had smaller variance than mitral tricuspid jets. Variability due to atrial fibrillation and the slower frame rate was marginal. Intraobserver error was 4.3% and interobserver 15.4%. Thus, reproducing jet areas carries a minimum variability of 15% or higher, depending on jet size. Valve site could not be excluded as a separate variable. Comparative quantification is best limited to 1 observer.     

Nonalcoholic fatty liver disease in Asia: A story of growth

Ten years ago, few if any researchers in Asia showed interest in nonalcoholic fatty liver disease (NAFLD). Today, NAFLD is increasingly recognized as a major chronic liver disease not only in Western countries but also in Asia. Its importance is exemplified by its high prevalence, disease progression, and association with major medical disorders. In Asia, 15–30% of the general adult population suffers from NAFLD. In patients with diabetes and metabolic syndrome, the reported prevalence is typically over 50%. Patients with the active form of NAFLD, namely steatohepatitis (NASH), may have fibrosis progression and eventually develop cirrhosis. Patients with NASH‐related cirrhosis have similar mortality to those with other causes of cirrhosis, and they have a high risk of developing hepatocellular carcinoma up to 2–3% per year. In addition, NAFLD patients have a high prevalence of cardiovascular disease and colorectal neoplasm. One major challenge for practicing clinicians is how to identify patients with significant liver disease among many who are found to have NAFLD. While liver biopsy is traditionally considered the gold standard for disease staging, it is invasive and unpleasant, and is an impractical tool for a disease that affects a quarter of the general population. To this end, new developments in transient elastography and biomarkers such as cytokeratin‐18 fragments can help exclude significant liver fibrosis and NASH, respectively. This article summarizes a young researcher's journey through this exciting area of research and what he has learned from amazing people all around the world.     

Gastro-oesophageal reflux disease and eosinophilic oesophagitis: What is the relationship?

Eosinophilic oesophagitis(EoE) and gastro-oesophageal reflux disease(GORD) are the most common causes of chronic oesophagitis and dysphagia associated with oesophageal mucosal eosinophilia. Distinguishing between the two is imperative but challenging due to overlapping clinical and histological features. A diagnosis of EoE requires clinical, histological and endoscopic correlation whereas a diagnosis of GORD is mainly clinical without the need for other investigations. Both entities may exhibit oesophageal eosinophilia at a similar level making a histological distinction between them difficult. Although the term proton-pump inhibitor responsive oesophageal eosinophilia has recently been retracted from the guidelines, a relationship between Eo E and GORD still exists. This relationship is complex as they may coexist, either interacting bidirectionally or are unrelated. This review aims to outline the differences and potential relationship between the two conditions, with specific focus on histology, immunology, pathogenesis and treatment.