特征选择技术在江西地区缺血性脑卒中合并肺部感染风险预测模型中的应用

目的 采用不同特征选择技术构建基于机器学习的预测模型，探讨江西地区缺血性脑卒中患者发生肺部感染的风险因素，为江西地区缺血性脑卒中合并肺部感染的控制和预防提供参考。方法 分别采用互信息、Lasso回归、决策树对特征进行筛选，比较XGboost、SVM、随机森林、MLP、logistic回归在缺血性脑卒中合并肺部感染模型中的效果。结果 Lasso回归优于其他两种特征选择方法，筛选的侵入性操作、NIHSS评分、中性粒细胞计数等15个特征纳入最终模型，与其他分类算法相比，MLP分类性能最好，AUC与约登指数分别是0.8740（95%CI:0.8694～0.8804）和0.6267。结论 Lasso回归可以限制多重共线性带来的影响，并输出高风险因素，结合MLP分类算法，能够较好的预测缺血性脑卒中患者是否会发生肺部感染，为其精准防控提供借鉴，具有一定的临床实践意义。     

Risk Factors for Surgical Shunting in a Large Cohort With Ischemic Priapism

BackgroundIschemic priapism is treated with a stepwise algorithm, but some patients may benefit from immediate shunt placement.AimTo identify risk factors for surgical shunt placement in a large series of patients with ischemic priapism.MethodsWe identified all patients presenting to our institution with ischemic priapism from January 2010 to December 2018. Multivariable was performed to assess risk factors for surgical shunting. Receiver operating characteristic curve analysis (Youden Index) was used to assess which cutoff time for the duration of priapism was most predictive requiring shunting.OutcomesWe assess risk factors for surgical shunting and what duration of priapism was most predictive of requiring a shunt.ResultsWe identified a total of 169 ischemic priapism encounters from 143 unique patients, of which 26 (15%) encounters resulted in a surgical shunt. Patients treated with a shunt had longer priapism durations than those without (median 36 vs 10 hours, P < .001). Independent predictors of a surgical shunt on multivariate logistic regression were the duration of priapism in hours (odds ratio: 1.05, 95% confidence interval: 1.02–1.10; P < .001) and history of prior priapism (odds ratio: 3.15, 95% confidence interval: 1.03–9.60; P = .045). Receiver operating characteristic curve analysis using priapism duration to predict the need for shunt generated an area under curve of 0.83. A duration of 24 hours correlated to a sensitivity of 0.77 and specificity of 0.90.Clinical ImplicationsThese results can be used to counsel future patients and assist in the decision-making process for providers.Strengths & LimitationsThis is one of the largest series of priapism in the literature. Most (74%) of the priapism were due to intracavernosal injections so the results may not be generalizable to populations with different priapism etiologies.ConclusionIn this study of 169 priapism encounters, we found that the priapism duration and history of prior priapism were independent predictors of surgical shunt placement. These results can aid urologists in the counseling and decision-making process of these challenging cases.Zhao H, Dallas K, Masterson J, et al. Risk Factors for Surgical Shunting in a Large Cohort With Ischemic Priapism. J Sex Med 2020;17:2472–2477.     

睡眠时相相关阻塞性睡眠呼吸暂停对急性脑梗死患者睡眠结构及预后的影响

目的 探讨REM期与非快动眼睡眠（non-rapid eye movement，NREM）期相关OSA对急性脑梗死（acute ischemic stroke，AIS）患者睡眠结构及预后的影响。 方法 回顾性收集2011年2月-2018年8月于苏州大学附属第二医院就诊且完成PSG的AIS患者，收集 的数据包括一般资料，情绪、认知、睡眠量表评估，MRI 、PSG检查，出院时功能恢复情况（应用NI HSS 量表和mRS量表评估）及3个月预后（应用mRS量表评估）。根据总睡眠期、REM期和NREM期睡眠AHI， 将患者分为单纯脑梗死组、脑梗死合并REM期相关OSA组和脑梗死合并NREM期相关OSA组，对3组一 般资料、临床量表评分、睡眠数据及预后情况进行单因素和多因素分析，观察睡眠不同时相OSA对患 者睡眠结构及预后的影响。 结果 最终纳入110例患者，其中单纯脑梗死组30例（27.3%），脑梗死合并REM期相关OSA组15例 （13.6%），脑梗死合并NREM期相关OSA组65例（59.1%）。脑梗死合并NREM期相关OSA组BMI高于单纯 脑梗死组。脑梗死组病灶部位多位于大脑半球，脑梗死合并REM期相关OSA组病灶依次位于脑干、大 脑半球、间脑。与单纯脑梗死组相比，脑梗死合并NREM期相关OSA组NREM1期睡眠时间及比例高， 慢波睡眠时间及比例低。与脑梗死合并REM期相关OSA组相比较，脑梗死合并NREM期相关OSA组微 觉醒指数、呼吸相关微觉醒指数、自发相关微觉醒指数高，上述差异均具有统计学意义。各组间3个 月后mRS评分差异无统计学意义。Logistic回归分析提示入院时高NIHSS评分、低受教育水平、高BMI是脑 梗死患者预后不良的独立危险因素。 结论 NREM期相关OSA会改变脑梗死患者的睡眠结构，使其浅睡眠1期延长，深睡眠（NREM 3期 和4期）缩短，睡眠片段化，此种改变可能会导致脑梗死患者预后更差。     

血小板减少合并缺血性卒中的诊治进展

在临床中，如果免疫性血小板减少（immune thrombocytopenia，ITP）、肝素诱发的血小板减少 （heparin-induced thrombocytopenia，HIT）、血栓性血小板减少性紫癜（thrombotic thrombocytopenic purpura， TTP）等血小板减少疾病患者合并缺血性卒中，其治疗存在矛盾。本文对血小板减少的病因机制及血小 板减少合并急性缺血性卒中时静脉溶栓、机械取栓及抗血小板治疗等方面的研究进展进行了综述。     

First trimester prediction of ischemic placental disease

Ischemic placental disease is characterized by one or more of the clinical manifestations of preeclampsia, fetal growth restriction, and/or placental abruption, resulting in indicated preterm delivery. Since over half of the indicated preterm deliveries are due to ischemic placental disease, accurate early prediction of the disease is of paramount importance in developing prevention strategies. This review article focuses on studies that have used the first trimester aneuploidy screening timing window to predict those patients who later develop ischemic placental disease. Emphasis was given to studies originating from the Fetal Medicine Foundation because of their uniformity in definitions and expertise of the personnel who performed the ultrasound screening exams.     

Ischemic bowel as a late sequela of abdominal compartment syndrome secondary to severe burn injury

Abdominal compartment syndrome (ACS) is a known complication of the large-volume resuscitation that burn patients receive. Bowel ischemia has been theorized to occur in ACS but has yet to be described in the literature. The authors report an occurrence of late bowel obstruction related to ACS-associated bowel ischemia in a burn patient.A four-year-old previously well girl sustained 70% total body surface area burns with inhalation injury. The areas injured were the anterior neck, circumferential torso from neck to waist, left arm, left thigh and two-thirds of her right thigh. Fluid resuscitation was initially administered using the modified Parkland formula. Her transfer to the regional burn unit from a local hospital was complicated by early septic shock from a line infection, which increased her resuscitation fluid requirements. Infection ultimately led to multiple instances of ACS. Intervention with percutaneous drainage led to immediate improvement; however, the episodes of ACS resulted in a late small bowel obstruction secondary to stricture, requiring a laparotomy and bowel resection.     

1990－2017年中国人群缺血性心脏病疾病负担及其危险因素变化趋势研究

目的 探讨1990－2017年中国人群缺血性心脏病（IHD）疾病负担及其危险因素的变化趋势。方法 基于2017年全球疾病负担（GBD）中国研究开放数据，利用伤残损失寿命年（YLD）、早死损失寿命年（YLL）、伤残调整寿命年（DALY）等指标对1990－2017年中国不同性别和年龄人群IHD疾病负担变化趋势进行描述，并结合人群归因分值（PAF）分析IHD危险因素的变化情况。结果 2017年，IHD的YLD率、YLL率、DALY率分别为74.2/10万、2 057.2/10万、2 131.0/10万。YLD率为女性高于男性，YLL率和DALY率则为男性高于女性。与IHD有关的24种可改变危险因素中，导致DALYs、PAF、DALY率排名前5位的危险因素均为高血压（1 642.9万人年、54.6%、1 163.1/10万）、高LDL-C（1 394.1万人年、46.3%、987.0/10万）、钠摄入过多（1 090.0万人年、36.2%、771.1/10万）、吸烟（864.7万人年、28.7%、612.2/10万）、坚果摄入不足（745.2万人年、24.8%、527.6/10万）。IHD DALY率由1990年1 116.4/10万增至2017年2 131.0/10万，增长率为90.9%。与1990年相比，2017年15~49岁和≥70岁人群IHD的YLD率增加，且≥70岁人群YLD率的2007－2017年年均增长率（0.4%）高于1990－2007年年均增长率（0.2%）。但YLL率和DALY率的2007－2017年年均增长率（0.6%、0.6%）低于1990－2007年年均增长率（1.3%、1.2%）。与1990年相比，2017年归因于加工肉摄入过多（929.7%）、高糖饮料摄入过多（822.7%）、高BMI（327.3%）的DALYs增幅较大；PAF值增幅最大的为高糖饮料摄入过多（400.0%）。2007－2017年，有8种IHD危险因素的DALY率顺位上升，7种危险因素的DALY率顺位下降。结论 IHD所致伤残负担增大，尽管其所致的过早死亡得到了有效控制，但仍为疾病负担的主要来源，≥70岁人群中表现尤为明显。IHD对男性患者的影响主要为早死所致疾病负担，对女性主要为失能所致负担。加强对高血压的预防和控制、减少吸烟和改善不合理膳食习惯等行为危险因素是防控IHD的优先措施。