Application Value of NLR,PLR,LMR,HEART score,and POCT in Early Warning and Accurate Graded Diagnosis of High-Risk Chest Pain in Emergency Medicine

Objective: To evaluate the application value of neutrophils/lymphocytes (NLR), platelets/lymphocytes (PLR), lymphocytes/monocytes (LMR), HEART (history, electrocardiogram, age, risk factors, and troponin) score, and point-of- care testing (POCT) in the early warning and precise diagnosis of high-risk chest pain in emergency medicine. Methods: A total of 157 patients with acute chest pain who were admitted to the emergency department and chest pain treatment unit of our hospital between August 2022 and September 2023 were selected. Rapid testing of bedside myocardial markers (ultrasensitive troponin (hs-cTnI), myoglobin (MYO), creatine kinase isoenzyme (CK-MB), D-dimer (D-Dimer), and N-terminal B-type natriuretic peptide precursor (NT-proBNP)) was performed on the patients using a POCT device (ThermoKing BioMQ60proB). A HEART score was used to classify the patients into low (n = 53), intermediate (n = 59), and high-risk (n = 45) groups, and the NLR, PLR, and LMR were calculated. The NLR, PLR, and LMR values were compared among the three groups of patients, and the optimal cutoff values as well as sensitivity and specificity were determined based on receiver operating characteristic (ROC) analysis. Results: The HEART scores of patients in the low-risk, intermediate-risk, and high-risk groups were (2.72 ± 0.24), (4.75 ± 0.56), and (5.32 ± 0.73) respectively, and the differences were statistically significant (P < 0.05). Compared with the low-risk group, the intermediate-risk group and high-risk group had a significantly higher NLR and PLR, and a significantly lower LMR;the high-risk group had higher NLR and PLR and lower values of LMR as compared to the other two groups, and the difference was statistically significant (P < 0.05). The ROC curves suggested that the area under the curve, sensitivity, and specificity of the combined diagnosis of NLR, PLR, LMR, HEART score, and POCT were greater than those of LR, PLR, and LMR with HEART score and POCT alone. Conclusion: The combined application of NLR, PLR, LMR, HEART score, and POCT has significant application value in the early warning and precise diagnosis of emergency high-risk chest pain. It provides a more simple, easy-to-access, and efficient assessment index for the clinical prediction and treatment of emergency high- risk chest pain.

Impact of Optimizing Emergency Nursing Processes on Resuscitation Success in Patients with Acute Chest Pain

Objective:To analyze the effect of optimizing the emergency nursing process in the resuscitation of patients with acute chest pain and the impact on the resuscitation success rate.Methods:66 patients with acute chest pain received by the emergency department of our hospital from January 2022 to December 2023 were selected as the study subjects and divided into two groups according to the differences in the emergency nursing process,i.e.,33 patients receiving routine emergency care were included in the control group,and 33 patients receiving the optimization of emergency nursing process intervention were included in the observation group.Patients’resuscitation effect and satisfaction with nursing care in the two groups were compared.Results:The observation group’s consultation assessment time,reception time,admission to the start of resuscitation time,and resuscitation time were shorter than that of the control group,the resuscitation success rate was higher than that of the control group,and the incidence of adverse events was lower than that of the control group,with statistically significant differences(P<0.05);and the observation group’s satisfaction with nursing care was higher than that of the control group,with statistically significant differences(P<0.05).Conclusion:Optimization of emergency nursing process intervention in the resuscitation of acute chest pain patients can greatly shorten the rescue time and improve the success rate of resuscitation,with higher patient satisfaction.

Exploring the Feasibility of Machine Learning to Predict Risk Stratification Within 3 Months in Chest Pain Patients with Suspected NSTE-ACS

Objective We aimed to assess the feasibility and superiority of machine learning(ML)methods to predict the risk of Major Adverse Cardiovascular Events(MACEs)in chest pain patients with NSTE-ACS.Methods Enrolled chest pain patients were from two centers,Beijing Anzhen Emergency Chest Pain Center Beijing Bo’ai Hospital,China Rehabilitation Research Center.Five classifiers were used to develop ML models.Accuracy,Precision,Recall,F-Measure and AUC were used to assess the model performance and prediction effect compared with HEART risk scoring system.Ultimately,ML model constructed by Naïve Bayes was employed to predict the occurrence of MACEs.Results According to learning metrics,ML models constructed by different classifiers were superior over HEART(History,ECG,Age,Risk factors,&Troponin)scoring system when predicting acute myocardial infarction(AMI)and all-cause death.However,according to ROC curves and AUC,ML model constructed by different classifiers performed better than HEART scoring system only in prediction for AMI.Among the five ML algorithms,Linear support vector machine(SVC),Naïve Bayes and Logistic regression classifiers stood out with all Accuracy,Precision,Recall and F-Measure from 0.8 to 1.0 for predicting any event,AMI,revascularization and all-cause death(vs.HEART≤0.78),with AUC from 0.88 to 0.98 for predicting any event,AMI and revascularization(vs.HEART≤0.85).ML model developed by Naïve Bayes predicted that suspected acute coronary syndrome(ACS),abnormal electrocardiogram(ECG),elevated hs-cTn I,sex and smoking were risk factors of MACEs.Conclusion Compared with HEART risk scoring system,the superiority of ML method was demonstrated when employing Linear SVC classifier,Naïve Bayes and Logistic.ML method could be a promising method to predict MACEs in chest pain patients with NSTE-ACS.

New scoring system for acute chest pain risk stratification: Is it worth SVEAT-ing it?

The emergency room is a very potent environment in the hospital.With the growing demands of the population,improved accessibility to health resources,and the onslaught of the triple pandemic,it is extremely crucial to triage patients at presentation.In the spectrum of complaints,chest pain is the commonest.Despite it being a daily ailment,chest pain brings concern to every physician at first.Chest pain could span from acute coronary syndrome,pulmonary embolism,and aortic dissection(all potentially fatal)to reflux,zoster,or musculoskeletal causes that do not need rapid interventions.We often employ scoring systems such as GRACE/PURSUIT/TIMI to assist in clinical decision-making.Over the years,the HEART score became a popular and effective tool for predicting the risk of 30-d major adverse cardiovascular events.Recently,a new scoring system called SVEAT was developed and compared to the HEART score.We have attempted to summarize how these scoring systems differ and their generalizability.With an increasing number of scoring systems being introduced,one must also prevent anchorage bias;i.e.,tools such as these are only diagnosis-specific and not organ-specific,and other emergent differential diagnoses must also be kept in mind before discharging the patient home without additional workup.

Chest pain caused by multiple exostoses of the ribs: A case report and a review of literature

The aim of this paper is to report an exceptional case of multiple internal exostoses of the ribs in a young patient affected by multiple hereditary exostoses(MHE) coming to our observation for chest pain as the only symptom of an intra-thoracic localization. A 16 years old patient with familiar history of MHE came to our observation complaining a left-sided chest pain. This pain had increased in the last months with no correlation to a traumatic event. The computed tomography(CT) scan revealed the presence of three exostoses located on the left third, fourth and sixth ribs, all protruding into the thoracic cavity, directly in contact with visceral pleura. Moreover, the apex of the one located on the sixth rib revealed to be only 12 mm away from pericardium. Patient underwent video-assisted thoracoscopy with an additional 4-cm mini toracotomy approach. At the last 1-year followup, patient was very satisfied and no signs of recurrence or major complication had occured. In conclusion, chest pain could be the only symptom of an intra-thoracic exostoses localization, possibly leading to serious complications. Thoracic localization in MHE must be suspected when patients complain chest pain. A chest CT scan is indicated to confirm exostoses and to clarify relationship with surrounding structures. Video-assisted thoracoscopic surgery can be considered a valuable option for exostoses removal, alone or in addiction to a mini-thoracotomy approach, in order to reduce thoracotomy morbidity.

High-resolution computed tomography in patients with atypical 'cardiac' chest pain: a study investigating patients at 10-year cardiovascular risks defined by the Framingham and PROCAM scores

Background and objective Atypical 'cardiac' chest pain (ACCP) is not usually caused by myocardial ischaemia. Current noninvasive investigations for these symptoms are not yet as accurate as invasive coronary angiography. The latest 64-row multi-detector computed tomography (MDCT) technology is non-invasive, has high specificity and negative predictive values for the detection of significant coronary disease. Our aim was to investigate if this modality can provide more information in the assessment of outpatients with ACCP in addition to established cardiovascular risk scores. Methods Seventy consecutive patients presenting to the outpatient clinic with ACCP underwent 64-row MDCT scan of the coronary arteries. They were categorized into low, medium or high risk groups based upon the Framingham and PROCAM scores. We defined a clinically abnormal MDCT scan as coronary stenosis =50% or calcium score ＞400 Agatston. Results Fifty-three (75.7%) patients did not have clinically abnormal scans. Framingham score classified 43 patients as low-risk while PROCAM classified 59 patients as low-risk. MDCT scans were abnormal for 18.6% and 22.0% of the respective low-risk group of patients. For patients with medium-to-high risk, 33.3% and 36.4% of Framingham and PROCAM patient groups respectively had abnormal MDCT scans. Conclusion MDCT adds valuable information in the assessment of patients with ACCP by identifying a significant proportion of patients categorized as low-risk to have underlying significant coronary stenosis and coronary calcification by established cardiovascular risk scores.

Exertional esophageal pH-metry and manometry in recurrent chest pain

AIM: To investigate the diagnostic efficacy of 24-h and exertional esophageal pH-metry and manometry in patients with recurrent chest pain. METHODS: The study included 111 patients (54% male) with recurrent angina-like chest pain, non-respon- sive to therapy with proton pump inhibitors. Sixty-five (59%) had non-obstructive lesions in coronary artery angiography, and in 46 (41%) significant coronary artery narrowing was found. In all patients, 24-h esophageal pH-metry and manometry, and treadmill stress tests with simultaneous esophageal pH-metry and manometry monitoring were performed. During a 24-h examination the percentage of spontaneous chest pain (sCP) episodes associated with acid reflux or dysmotility (symptom index, SI) was calculated. Patients with SI > 50% for acid gastroesophageal reflux (GER) were classified as having GER-related sCP. The remaining symptomatic individuals were determined as having non-GER-related sCP. During the stress test, the occurrence of chest pain, episodes of esophageal acidification (pH < 4 for 10 s) and esophageal spasm with more than 55% of simultaneous contractions (exercise-provoked esophageal spasm or EPES) were noted. RESULTS: Sixty-eight (61%) individuals reported sCP during 24-h esophageal function monitoring. Eleven of these (16%) were classified as having GER-related sCP and 53/68 (84%) as having non-GER-related sCP. The exercise-provoked chest pain during a stress test occurred in 13/111 (12%) subjects. In order to compare the clinical usefulness of 24-h esophageal function monitoring and its examination limited only to the treadmill stress test, the standard parameters of diagnostic test evaluation were determined. The occurrence of GER- related or non-GER-related sCP was assumed as a "gold standard". Afterwards, accuracy, sensitivity and specificity were calculated. These parameters expressed a prediction of GER-related or non-GER-related sCP occurrence by the presence of chest pain, esophageal acidification and EPES. Accuracy, sensitivity and specificity of chest pain during the stress test predicting any sCP occurrence were 28%, 35% and 80%, respectively, predicting GER- related sCP were 42%, 0% and 83%, respectively, and predicting non-GER-related sCP were 57%, 36% and 83%, respectively. Similar values were obtained for exercise-related acidification with pH < 4 longer than 10 s in the prediction of GER-related sCP (44%, 36% and 92%, respectively) and EPES in relation to non-GER-related sCP (48%, 23% and 84%, respectively). CONCLUSION: The presence of chest pain, esophageal acidification and EPES had greater than 80% specificity to exclude the GER-related and non-GER-related causes of recurrent chest pain.

Congenital partial absence of the pericardium in a young man with atypical chest pain

Pericardial defects are infrequent congenital anomalies due to agenesis caused by premature atrophy of the common cardinal vein or Cuvier duct during the 5th or 6th week of embryonic life. These congenital defects are rare, typically observed as an incidental finding and usually remain asymptomatic. Nevertheless, the more widespread use of modern imaging techniques has contributed to an increase of its incidence in recent years. There is currently no consensus regarding therapeutic options, all of which are based on small retrospective studies that evaluate the risk of developing a life-threatening complication such as herniation and incarceration of the myocardium. We report on a 22-year-old male who presented with sudden onset of sharp chest pain and dyspnea. Computed tomography and cardiac magnetic resonance scan revealed a pericardial defect adjacent to the lateral free wall of the left atrium with associated herniation of the left atrial appendage. The patient was managed conservatively and had an uneventful clinical progress.

Exercise-provoked esophageal motility disorder in patients with recurrent chest pain

AIM:To investigate the relationship between exerciseprovoked esophageal motility disorders and the prognosis for patients with chest pain.METHODS:The study involved 63 subjects with recurrent angina-like chest pain non-responsive to empirical therapy with proton pump inhibitor(PPI).In all,a coronary artery angiography,panendoscopy,24-h esophageal pH-metry and manometry,as well as a treadmill stress test with simultaneous esophageal pH-metry and manometry monitoring,were performed.Thirtyfive subjects had no significant coronary artery lesions,and 28 had more than 50% coronary artery narrowing.In patients with hypertensive esophageal motility disorders,a calcium antagonist was recommended.The average follow-up period was 977 ± 249 d.RESULTS:The prevalence of esophageal disorders,such as gastroesophageal reflux or diffuse esophageal spasm,was similar in patients both with and without significant coronary artery narrowing.Exercise prompted esophageal motility disorders,such as a decrease in the percentage of peristaltic and effective contractions and their amplitude,as well as an increase in the percentage of simultaneous and non-effective contractions.In 14(22%) patients the percentage of simultaneous contractions during the treadmill stress test exceeded the value of 55%.Using Kaplan-Meier analysis and the proportional hazard Cox regression model,it was shown that the administration of a calcium channel antagonist in patients with such an esophageal motility disorder significantly decreased the risk of hospitalization as a result of a suspicion of acute coronary syndrome after the 2.7-year follow-up period.CONCLUSION:In patients with chest pain non-responsive to PPIs,a diagnosis of exercise-provoked esophageal spasm may have the effect of lowering the risk of the next hospitalization.

Health-related quality of life in gastroesophageal reflux patients with noncardiac chest pain: Emphasis on the role of psychological distress

AIM To investigate the effects of depression and anxiety on health-related quality of life(QoL)in gastroesophageal reflux disease(GERD)patients and those suffering from cardiac(CCP)and noncardiac(NCCP)chest pain in Wuhan,China.METHODS In this cross-sectional study,a total of 358 consecutive patients with GERD were enrolled in Wuhan,China,of which 176 subjects had complaints of chest pain.Those with chest pain underwent coronary angiography and were divided into a CCP group(52 cases)and NCCP group(124 cases).Validated GERD questionnaires were completed,and the 36-item Short-Form Health Survey and Hospital Anxiety/Depression Scale were used for evaluation of Qo L and psychological symptoms,respectively.RESULTS There were similar ratios and levels of depression and anxiety in GERD with NCCP and CCP.However,the QoL was obviously lower in GERD with CCP than NCCP(48.34±17.68 vs 60.21±20.27,P<0.01).In the GERD-NCCP group,rather than the GERD-CCP group,the physical and mental QoL were much poorer in subjects with depression and/or anxiety than those without anxiety or depression.Anxiety and depression had strong negative correlations with both physical and mental health in GERD-NCCP(all P<0.01),but only a weak relationship with mental components of QoL in GERD-CCP.CONCLUSION High levels of anxiety and depression may be more related to the poorer QoL in GERD patients with NCCP than those with CCP.This highlights the importance of evaluation and management of psychological impact for improving QoL in GERD-NCCP patients.

Experimental human pain models in gastro-esophageal reflux disease and unexplained chest pain

Methods related to experimental human pain research aim at activating different nociceptors, evoke pain from different organs and activate specific pathways and mechanisms. The different possibilities for using mechanical, electrical, thermal and chemical methods in visceral pain research are discussed with emphasis of combinations (e.g., the multimodal approach). The methods have been used widely in assessment of pain mechanisms in the esophagus and have contributed to our understanding of the symptoms reported in these patients. Hence abnormal activation and plastic changes of central pain pathways seem to play a major role in the symptoms in some patients with gastro-esophageal reflux disease and in patients with functional chest pain of esophageal origin. These findings may lead to an alternative approach for treatment in patients that does not respond to conventional medical or surgical therapy.

Chest pain without a clue-ultrasound to rescue occult multiple myeloma: A case report

BACKGROUND Chest pain is one of the most common symptoms with which a patient presents to a doctor.Differentials include,but are not limited to,cardiac pulmonary,gastrointestinal,psychosomatic and musculoskeletal causes.In our case,ultrasound of the chest wall paved the way for the diagnosis of multiple myeloma,which occultly presented with chronic chest pain.CASE SUMMARY Here we report a case of 50-year-old man with chronic chest pain without anemia or renal failure who was diagnosed with multiple myeloma,despite negative bence jones protein and M band electrophoresis.An ultrasound of the chest wall showed cortical irregularities along with a hypoechoic mass in the sternum and left 5th rib,which helped us in clinching the diagnosis.CONCLUSION Ultrasound of bone can often aid in reaching a diagnosis indirectly if not directly.

Takotsubo cardiomyopathy misdiagnosed as acute myocardial infarction under the Chest Pain Center model:A case report

BACKGROUND With the spread and establishment of the Chest Pain Center in China,adhering to the idea that“time is myocardial cell and time is life”,many hospitals have set up a standardized process that ensures that patients with acute myocardial infarction(AMI)who meet emergency percutaneous coronary intervention(PCI)guidelines are sent directly to the DSA room by the prehospital emergency doctor,saving the time spent on queuing,registration,payment,re-examination by the emergency doctor,and obtaining consent for surgery after arriving at the hospital.Takotsubo cardiomyopathy is an acute disease that is triggered by intense emotional or physical stress and must be promptly differentiated from AMI for its appropriate management.CASE SUMMARY A 52-year-old female patient was taken directly to the catheterization room to perform PCI due to 4 h of continuous thoracalgia and elevation of the ST segment in the V3–V5 lead,without being transferred to the emergency department according to the Chest Pain Center model.Loading doses of aspirin,clopidogrel and statins were administered and informed consent for PCI was signed in the ambulance.On first look,the patient looked nervous in the DSA room.Coronary angiography showed no obvious stenosis.Left ventricular angiography showed that the contraction of the left ventricular apex was weakened,and the systolic period was ballooning out,showing a typical“octopus trap”change.The patient was diagnosed with Takotsubo cardiomyopathy.Five days later,the patient had no symptoms of thoracalgia,and the serological indicators returned to normal.She was discharged with a prescription of medication.CONCLUSION Under the Chest Pain Center model for the treatment of patients with chest pain showing ST segment elevation,despite the urgency of time,Takotsubo cardiomy-opathy must be promptly differentiated from AMI for its appropriate management.

A modified HEART risk score in chest pain patients with suspected non-ST-segment elevation acute coronary syndrome

ObjectiveTo 验证一颗修改的心[历史，心动电流描记器( ECG )，年龄，风险因素和 Troponin ]在有怀疑的 non-ST-segment 举起的胸疼痛病人的风险分数在紧急情况部门(编辑)的急性冠的症候群(NSTE交流)回顾的队学习使用了的 .MethodsThis 病人们与怀疑的NSTE交流承认了到紧急情况部门的有希望地获得的数据库和胸疼痛被注册。在 ED 在到达上记录的数据被使用。除我在心风险使用了的常规心脏的 Troponin 以外，我获得的高敏感的心脏的 Troponin 的浆液样品被测试。修改的心风险分数是计算的。结束 point ；是出现 of ；主要 adverse ；定义为的心脏的事件(向)一尖锐心肌的梗塞( AMI )合成，经皮的干预(一种总线标准)，冠的动脉绕过接枝( CABG )，或所有原因死亡，在在 1,300 全部的起始的 presentation.ResultsA 以后的三个月以内，病人们被注册。606 个病人(46.6%) 的一个总数在三个月以内有向：205 个病人(15.8%) 与 AMI 被诊断， 465 个病人(35.8%) 经历了一种总线标准，并且 119 个病人(9.2%) 经历了 CABG。有 10 (0.8%) 死亡。当分数增加了，增加事件率的一个进步、重要模式被观察(P <；0.001 由 χ；为趋势的 2) 。在操作典型曲线的接收装置下面的区域是 0.84。所有病人被分类进三个组：低风险(20 0-2 ) ，中间的风险(20 3-4 ) ，和高风险(20 5-10 ) 。事件率是 1.1% ， 18.5% ，和 67.0% ，分别地(P <；0.001 ).ConclusionsThe 修改了心风险 20 与怀疑的 NSTE 交流在胸疼痛病人被验证并且可以在编辑 A 补充向风险评价和病人 triage 分数的未来的学习被保证。

Prognostic performance of interleukin-10 in patients with chest pain and mild to moderate coronary artery lesions an 8-year follow-up study

BackgroundInterleukin (IL )-10, IL-6 和他们的比率(IL-6/IL-10 ) 在得冠的动脉疾病的风险起一个重要作用，并且可以与它的结果相关。很少临床的试用在与胸 pain.MethodsA 介绍的病人在长期的心血管的事件上调查了这些因素的预示的影响未来的学习在胸疼痛地招收并且识别的 566 个病人上被执行对中等冠的动脉损害温和。IL-10， IL-6 和 IL-6/IL-10 是完成的 511 个病人全部的 measured.ResultsA 后续。中部的后续时间是 74 个月。Kaplan-Meier 分析与 IL-10 的在中部下面的层次在病人在后续时期期间表明了主要不利心脏的事件的发生的清楚的增加(P = 0.006 ) 并且 IL-6/IL-10 的在中部上面的层次(P = 0.012 ) 。比例的危险分析显示了的穆尔蒂瓦里伊特·考克斯是在为内在的 confounders.ConclusionsElevated IL-10 层次的调整以后的强壮的独立预言者的 IL-10 层次胸疼痛地在病人与更有利的长期的预后被联系并且对中等冠的动脉损害温和。IL-10 能被用于对长期的预后的早风险评价。

Diagnosis of chest pain with foregut symptoms in Chinese patients

AIM:To evaluate the diagnosis of chest pain with foregut symptoms in Chinese patients. METHODS:Esophageal manometric studies, 24-h introesophageal pH monitoring and 24-h electrocardiograms(Holter electrocardiography)were performed in 61 patients with chest pain. RESULTS:Thirty-nine patients were diagnosed with non-specific esophageal motility disorders(29 patients with abnormal gastroesophageal reflux and eight patients with myocardial ischemia).Five patients had diffuse spasm of the esophagus plus abnormal gastroesophageal reflux(two patients had concomitant myocardial ischemia),and one patient was diagnosed with nutcracker esophagus. CONCLUSION:The esophageal manometric studies, 24-h intra-esophageal pH monitoring and Holter electrocardiography are significant for the differential diagnosis of chest pain,particularly in patients with foregut symptoms.In cases of esophageal motility disorders,pathological gastroesophageal reflux may be a major cause of chest pain with non-specific esophageal motility disorders.Spasm of the esophageal smooth muscle might affect the heart-coronary smooth muscle,leading to myocardial ischemia.

Correlation between lipid profile and troponin Ⅰ test results in patients with chest pain in Nepal

Objective:To study the usefulness of traditional lipid profile levels in screening subjects who had developed chest pain due lo cardiac event as indicated by a positive troponin I test.Methods:In this retrospective study data of ihe 430 patients presented lo the emergency department with symptoms of cardiac ischemia who underwent both troponin and lipid profiles tests were compared with the lipid profiles of 165 normal healthy subjects(controls).The troponin was detected qualitatively when a specimen contains troponin I(cTnI)above the 99th percentile(TnI>0.5 ng/mL).The total cholesterol,high density lipoproteins cholesterol,very low density lipoproteins and Iriacvl glycerol levels were also analyzed and Ion densilv lipoprotein level was calculated using Friedewald's formula.Results:Patients with chest pain and positive troponin test(with confirmed cardiac event)were found lo have significantly elevated levels of total cholesterol,triacyl glycerol levels,low density lipoprotein level and significantly reduced high densilv lipoproteins cholesterol levels when compared lo the patients who experienced only chesl pain(negative troponin)and healthy controls.Conclusions:Traditional lipid profile levels is still can be used in screening popiilalions lo identify the subjecis with high risk of developing cardiacevent in case if the laboratory set up has not troponin test facilities.

Low-dose amitriptyline combined with proton pump inhibitor for functional chest pain

AIM:To investigate the efficacy of amitriptyline with proton pump inhibitor(PPI)for the treatment of functional chest pain(FCP).METHODS:This was a randomized,open-label trial investigating the addition of low dose amitriptyline(10 mg at bedtime)to a conventional dose of rabeprazole(20 mg/d)(group A,n = 20)vs a double-dose of rabeprazole(20 mg twice daily)(group B,n = 20)for patients with FCP whose symptoms were refractory to PPI.The primary efficacy endpoints were assessed by global symptom score assessment and the total number of individuals with > 50% improvement in their symptom score.RESULTS:The between-group difference in global symptom scores was statistically significant during the last week of treatment(overall mean difference;3.75 ± 0.31 vs 4.35 ± 0.29,the between-group difference;P < 0.001).Furthermore,70.6% of patients in group A had their symptoms improve by > 50%,whereas only 26.3% of patients in group B had a similar treatment response(70.6% vs 26.3%,P = 0.008).Specifically,patients in group A had a significantly greater improvement in the domains of body pain and general health perception than did patients in group B(52.37 ± 17.00 vs 41.32 ± 12.34,P = 0.031 and 47.95 ± 18.58 vs 31.84 ± 16.84,P = 0.01,respectively).CONCLUSION:Adding amitriptyline to a PPI was more effective than a double-dose of PPI in patients with FCP refractory to a conventional dose of PPI.

An unusual emergency department case： ruptured ectopic pregnancy presenting as chest pain

INTRODUCTION Ectopic pregnancy occurs at a rate of 1%–2%of all pregnancies,and tends to occur at a higher rate(up to4%)in patients receiving fertility treatments.[1]Women with ectopic pregnancies are often asymptomatic or may complain of amenorrhea,vaginal spotting,and lower abdominal cramping pain.They may also report common symptoms of early pregnancy such as nausea,vomiting,

Throat Infection,Neck and Chest Pain and Cardiac Response:A Persistent Infection-Related Clinical Syndrome

Dizziness, chest discomfort, chest depression and dyspnea are a group of symptoms that are common complaints in clinical practice. Patients with these symptoms are usually informed that while neurosis consequent to coronary heart disease is excluded nonetheless they remain unhealthy with no rational explanation or treatment. 165 cases of these symptoms and 85 control subjects were reviewed and underwent further medical history inquiry, routine EKG test and cardiac ultrasound examination. Thirty-five patients received coronary artery angiography to exclude coronary heart disease. Serum myocardial autoantibodies against beta1-adrenoceptor, alpha-myosin heavy chain, M2-muscarinic receptor and adenine-nucleotide translocator were tested, and inflammatory cytokines and high sensitivity C-reaction protein were measured and lymphocyte subclass was assayed by flow cytometry. All patients had a complex of four symptoms or tetralogy： （1） persistent throat or upper respiratory tract infection, （2） neck pain, （3） chest pain and （4） chest depression or dyspnea, some of them with anxiety. Anti-myocardial autoantibodies （AMCAs） were present in all patients vs. 8% in controls. TNF-α, IL-1 and IL-6 were significantly higher in patients than in controls （P〈0.01）. CD3^＋ and CD4-CD8^＋ lymphocytes were significantly higher and CD56＋ lymphocytes lower in patients than those in controls （P〈0.01）. The ratio of serum pathogen antibodies positive against Coxsackie virus-B, cytomegalovirus, Mycoplasma pneumoniae and Chlamydia pneumoniae were all markedly higher in patients. These data led to identification of a persistent respiratory infection-related clinical syndrome, including persistent throat infection, neck spinal lesion, rib cartilage inflammation, symptoms of cardiac depression and dyspnea with or without anxiety.