入院血糖水平对糖尿病和非糖尿病ST段抬高急性心肌梗死患者预后的影响

目的 探讨人院时血糖水平与糖尿病和非糖尿病患者ST段抬高急性心肌梗死(STEMI)患者近期病死率的相关性.方法 观察性分析国际性随机对照临床试验中7446例出现症状12 h内STEMI的中国患者,以入院血糖不同水平将已知糖尿病和非糖尿病的患者分组:入院血糖水平<6.1 mmol/L组(2018例),6.1～7.7 mmol/L组(2170例),7.8～11.0 mmol/L组(1929例),11.1～13.0 mmol/L组(465例)和>13.0 mmol/L组(864例),后3组定义为入院高血糖组.分析各组患者30 d的病死率.结果 在人院高血糖患者中有相当比例无既往的糖尿病史;各血糖水平组内,非糖尿病的患者使用胰岛素的比例均明显低于糖尿病患者.随血糖水平升高,非糖尿病患者病死率呈逐渐增加趋势(血糖<6.1 mmol/L组6.8%,6.1～7.7 mmol/L组8.3%,>13.0 mmol/L组18.6%,P<0.001),而糖尿病患者的病死率呈先降低后升高的变化(血糖<6.1 mmol/L组16.7%,6.1～7.7 mmol/L组8.2%,>13.0 mmol/L组22.0%,P<0.001);除显著高血糖(血糖>13.0mmol/L)外,非糖尿病的高血糖患者病死率高于相同血糖水平的糖尿病患者(均P<0.05).多变量logistic回归分析显示,在非糖尿病患者中,随血糖升高死亡危险逐步增加(血糖7.8～11.0 mmol/L组:OR=1.85,95%CI:1.45～2.34,P<0.001;血糖>13.0 mmoL/L组:OR=2.69,95%CI:1.97～3.66,P<0.001);而糖尿病患者中,除显著高血糖组外(血糖>13.0 mmol/L组:OR=3.08,95%CI:1.16～8.17,P=0.024),其他组近期死亡危险均无明显增加(均P>0.05).结论 与糖尿病患者相比,无既往糖尿病史的STEMI患者入院血糖水平升高也很常见,但接受治疗的比例较低,并且是与近期预后不良更密切相关的危险因素.     

实施临床路径干预对急性冠状动脉综合征临床疗效观察

目的通过优化和畅通急性冠脉综合征（ACS）患者的诊疗流程,缩小临床试验与循证医学的差距,持续改进诊疗质量,合理利用有限的医疗资源,使患者最大获益。方法以宝鸡市中医医院心内科住院ACS患者为研究对象,收集干预前2006年10月至2008年3月194例ACS患者作为执行路径前病例,执行路径干预后连续收集2008年4月至2009年9月ACS病例175例。根据美国心脏病学学会/美国心脏协会（ACC/AHA）及中国急性冠状动脉综合征诊治指南制定我院ACS临床路径,将临床路径附在病例中,对诊治关键环节进行干预,每6个月对执行情况评估1次,分析数据,提出改进措施。结果临床路径干预后急性心肌梗死（AMI）患者住院时间较干预前明显缩短,其中急性ST抬高心肌梗死（STEMI）患者平均住院天数降低了3.5d,急性非ST抬高心肌梗死（NSTEMI）患者平均住院时间降低6.14d,差异具有统计学意义（P〈0.05）。干预后高危患者接受冠脉造影率为66.1%,较干预前的32.9%明显增高,差异具有统计学意义（P〈0.05）。干预后STEMI患者入院到球囊扩张时间（D-B时间）较干预前下降了43.4%（P〈0.01）。12h内到达医院的STEMI患者中早期再灌注治疗率干预前后分别为63.6%和87.3%（P〈0.05）。ACS药物规范治疗方面,干预后明显提高。干预后ACS患者住院死亡率下降4.1%（P〈0.05）。结论本研究通过临床路径的干预显著降低了AMI患者住院天数、缩短了D-B时间,提高了STEMI患者接受急诊PCI的比例,ACS住院患者死亡率明显下降。同时,使临床医生的医疗行为更接近指南的要求,使医疗资源的利用更加合理。对AMI干预的结果优于不稳定性心绞痛（UA）。     

Prognostic impact of pre-operative albumin on short-term mortality and complications in patients with hip fracture

Low serum albumin may have prognostic value for morbidity and mortality in patients with hip fracture. The primary aim of the study was to evaluate the independent association between low serum albumin (<35 g/l) at hospital admission and short-term (in-hospital) mortality and post-operative complications of patients with hip fracture. We reviewed a prospective population-based cohort of 583 hip fracture patients who had pre-operative albumin values measured at hospital admission in one of the 3 tertiary hospitals in Northern Alberta, Canada. Patients with a primary diagnosis of hip fracture and 65 years or older were included. The primary outcomes were in-hospital mortality and any pre-specified post-operative complication. Mean serum albumin level was 33.8 ± 4.5 g/l (±S.D.), and overall 55% (n = 318) of patients had a low albumin. The in-hospital mortality was 8% (n = 46) and rate of any non-fatal post-operative complication rate was 31/100. Mortality was 11% (n = 35) among those with low albumin levels and 4% (n = 11) for those with normal values (unadjusted odds ratio (OR) 2.86, 95% CI = 1.42-5.74). After multivariate adjustment, the association between low serum albumin and mortality remained large and statistically significant (adjusted OR = 2.44, 95% confidence interval (CI) = 1.17-5.12). Low albumin levels were also significantly associated with post-operative medical complications (adjusted OR = 1.96, 95% CI = 1.36-2.83). We conclude that routine measurement of serum albumin provides valuable prognostic information for treating this frail population.     

Análisis de las transiciones en el modelo integrado de tratamiento sustitutivo renal en un sistema regional de salud

Introduction and objectivesThe choice of renal replacement therapy (RRT) is an important decision that determines the quality of life and survival. Most patients change from one RRT modality to another to adapt RRT to clinical and psychosocial needs. This has been called «integrated model of RRT» that implies new questions about the best sequence of techniques.Material and methodsThe study describes the impact of transitions between RRT modalities on survival using the Madrid Registry of Renal Patients (2008–2018). This study used the proportional hazards models and competitive risk models to perform an intention-to-treat (ITT), according to their 1^st RRT modality and as-treated (AT) analysis, that consider also their 1^st transition.ResultsA total of 8971 patients started RRT during this period in Madrid (6.6 Million population): 7207 (80.3%) on hemodialysis (HD), 1401 (15.6%) on peritoneal dialysis (PD) and 363 (4.2%) received a pre-emptive kidney transplantation (KTX). Incident HD-patients were older (HD group 65.3 years (SD 15.3) vs PD group 58.1 years (SD 14.8) vs KTX group 52 years (SD 17.2); p < 0.001) and had more comorbidities. They presented higher mortality (HD group 40.9% vs PD group 22.8% vs 8.3% KTX group, p < 0.001) and less access to a transplant (HD group 30.4% vs DP group 51.6%; p < 0.001). Transitions between dialysis techniques define different groups of patients with different clinical outcomes. Those who change from HD to PD do it earlier (HD → PD: 0.7 years (SD 1.1) vs PD → HD: 1.5 years (SD 1.4) p < 0.001), are younger (HD → PD: 53.5 years (SD 16.7) vs PD → HD: 61.6 years (SD 14.6); p < 0.001), presented less mortality (HD → PD: 24.5% vs PD → HD: 32.0%; p < 0.001) and higher access to a transplant (HD → PD: 49.4% vs PD → HD: 31.7%; p < 0.001). Survival analysis by competitive risks is essential for integrated RRT models, especially in groups such as PD patients, where 51.6% of the patients were considered as lost follow-up (received a KTX after during the first 2.5 years on PD). In this analysis, survival of patients who change from one technique to another, is more similar to the destination modality than the origin one.ConclusionOur data suggest that transitions between RRT-techniques describes different patients, who associate different risks, and could be analyzed in an integrated manner to define improvement actions. This approach should be incorporated into the analysis and reports of renal registries.     

我国冠状动脉旁路移植术住院死亡预测模型研究及欧洲心血管手术危险评分系统效能检验

目的:分析并初步建立我国冠状动脉旁路移植术(coronary artery bypass grafting,CABG)风险预测模型,并与欧洲心血管手术危险因素评分系统即EuroSCORE及EuroSCORE对数回归模型对比。方法:回顾性分析2006年1月1日至2007年6月30日,北京安贞医院心脏外科行CABG手术或CABG合并手术的1637例患者资料。收集影响手术死亡的42个术前危险因素,经过单因素与多因素Logistic回归分析确立独立危险因素,并据此初步建立CABG手术死亡危险评估模型,再对模型进行分辨度、校准度检验,并与EuroSCORE及EuroSCORE对数回归模型进行对比研究。结果:全组患者年龄(61.9±9.7)岁,实际病死率4.03%(66/1637),CABG合并手术3.85%(63/1637),多因素Logistic回归分析结果:慢性肺部疾病、外周血管疾病、急性心肌梗死、既往介入治疗(PTCA、溶栓或支架)、心源性休克、主动脉瓣反流及二尖瓣反流为CABG手术死亡的独立危险因素。据此建立CABG手术死亡危险评估模型。并与EuroSCORE及EuroSCORE对数回归模型进行对比研究。受试者工作特征(Receiver-OperatingCharacteristic,ROC)曲线下面积:新建立风险模型(0.83)EuroSCORE对数回归模型(0.82)EuroSCORE模型(0.81),Hosmer-Lemeshowχ2检验新模型P=0.225,P0.05,即预计病死率与实际观测病死率差异无统计学意义;而其他2种模型P0.05。结论:慢性肺部疾病、外周血管疾病、急性心肌梗死、既往介入治疗(PTCA、溶栓或支架)、心源性休克、主动脉瓣反流及二尖瓣反流等7个因素为CABG手术死亡的独立危险因素。据此建立的CABG手术死亡危险评估模型具有良好的分辨度和校准度。     

智能染色内镜诊断结肠病变腺管开口的临床价值及Ang-2表达、MVD值与腺管开口相关性研究

目的探讨FICE放大内镜对结肠瘤性、非瘤性病变的诊断价值以及血管生成素-2（Ang-2）表达、肿瘤微血管密度（MVD）与腺管开口的相互关系。方法选择富士能智能染色内镜（FICE）放大观查判定腺管开口为Ⅰ～Ⅴ型的结肠病变标本（Ⅰ～Ⅴ型各20例）,Ⅰ、Ⅱ型纳入A组,Ⅲ、Ⅳ型纳入B组,Ⅴ型纳入C组。对照病理诊断结果,判断FICE放大内镜对结肠病变的诊断价值。并采用免疫组化SP法分别测定不同腺管开口结肠病变中Ang-2表达情况及MVD值,分析3者间的相互关系。结果FICE放大内镜对非瘤性病变诊断的敏感性和特异性分别为88．0％和92．5％,符合率为90．2％;对瘤性病变诊断的敏感性和特异性分别为94．8％和91．7％,符合率为93．2％;对结肠病变诊断的总符合率为92．0％。结肠病变中Ang-2的阳性表达率和MVD值在A组（Ⅰ、Ⅱ型合并组）、B组（Ⅲ、Ⅳ型合并组）、C组（腺管开口V型）3组逐渐升高。且Ang-2阳性表达组MVD值明显增高。结论FICE放大内镜对结肠病变腺管开口分型的判断可基本准确区别瘤性、非瘤性病变,结肠病变中Ang-2的阳性表达、肿瘤血管的生成与其腺管开口关系密切。     

上海市黄浦区老年人群肿瘤监测结果分析

目的 了解黄浦区老年人群肿瘤发病、死亡和生存情况,为政府制定老年人群相关政策提供依据.方法 利用上海市肿瘤监测系统导出的数据,分析2010年上海市黄浦区60岁及以上户籍老年人群肿瘤发病、死亡和生存情况.结果 老年人群肿瘤发病率为1 007.9/10万,发病顺位前5位：肺、结直肠、胃、肝和胰腺;死亡率为979.5/10万,死亡顺位前5位：肺、结直肠、胃、肝和胰腺;老年人群肿瘤的1年生存率为36.0％,5年生存率为22.0％,中位生存期为345.9 d.结论 老年人群肿瘤发病率、死亡率高,生存率低,中位生存期短.     

Impact of severe left ventricular dysfunction on mid-term mortality in elderly patients undergoing transcatheter aortic valve implantation

Background Whether patients with reduced left ventricular function present worse outcome after transcatheter aortic valve implantation (TAVI) is controversial. The aim of this study was to assess the impact of baseline severe impairment of left ventricular ejection fraction (LVEF) on mortality after TAVI. Methods Six-hundred-forty-nine patients with aortic stenosis underwent TAVI with the CoreValve system (92.8%) or the Edwards SAPIEN valve system (7.2%). Baseline LVEF was measured by the echocardiographic Simpson method. The impact of LVEF ≤ 30% on mortality was assessed by Cox regression. Results Patients with LVEF ≤ 30% (n = 63), as compared to those with LVEF > 30% (n = 586), had a higher prevalence of NHYA class > 2 (P < 0.001) and presented with a higher Euroscore (P < 0.001). Procedural success was similar in both groups (98.4% vs. 97.2%, P = 1). After a median follow-up of 436 days (25th–75th percentile, 357–737 days), all-cause mortality [23.8% vs. 23.7%, P = 0.87, hazard ratios (HR): 0.96, 95% confidence intervals (CI): 0.56–1.63] and cardiac mortality (19.1% vs. 17.6%, P = 0.89, HR: 1.04, 95% CI: 0.57–1.90) were similar in patients with LVEF ≤ 30% as compared to those with LVEF > 30%. Thirty-day all-cause mortality was not significantly different between the two groups (11.1% vs. 6.3%, P = 0.14, HR: 1.81, 95% CI: 0.81–4.06). Patients with LVEF ≤ 30% had a trend toward higher risk of 30-day cardiac mortality (11.1% vs.5.3%; P = 0.06, HR: 2.16, 95% CI: 0.95–4.90), which disappeared after multivariable adjustment (P = 0.22). Conclusions Baseline severe impairment of LVEF is not a predictor of increased short-term and mid-term mortality after TAVI. Selected patients with severe impairment of left ventricular function should not be denied TAVI.