Assessment of cardiovascular risk in diabetes:Risk scores and provocative testing

Cardiovascular disease(CVD) is the leading cause of morbidity and mortality among patients with diabetes mellitus,who have a risk of cardiovascular mortality two to four times that of people without diabetes.An individualised approach to cardiovascular risk estimation and management is needed.Over the past decades,many risk scores have been developed to predict CVD.However,few have been externally validated in a diabetic population and limited studies have examined the impact of applying a prediction model in clinical practice.Currently,guidelines are focused on testing for CVD in symptomatic patients.Atypical symptoms or silent ischemia are more common in the diabetic population,and with additional markers of vascular disease such as erectile dysfunction and autonomic neuropathy,these guidelines can be difficult to interpret.We propose an algorithm incorporating cardiovascular risk scores in combination with typical and atypical signs and symptoms to alert clinicians to consider further investigation with provocative testing.The modalities for investigation of CVD are discussed.

基于区块链的清洁能源数据溯源机制

全球正处于低碳发展的大趋势中,清洁能源是低碳发展的核心,也是解决气候问题的关键。目前清洁能源数据溯源方式,如中心化数据库、电子标签和能源证书等,存在中心化、数据来源和数据处理不透明等问题,无法保证数据与溯源结果的可信度和安全性。相比之下,区块链具有去中心化、透明性、不可篡改等特点,可以有效解决以上问题。因此,文章提出了一种基于区块链的清洁能源数据溯源机制。首先,文章提出了改进数据溯源描述模型ProVOC,实现清洁能源数据的全生命周期可信溯源,并通过结合区块链和图数据库实现数据的轻量化存储,提高了溯源效率;然后,文章提出了基于零知识证明的数据隐私保护机制,在用户数据隐私保护方面引入可撤销机制,在溯源数据隐私保护方面结合同态加密,实现更加安全的数据共享;最后,文章对所提出的数据溯源机制进行了功能验证和性能分析,实验结果表明,相比于现有的数据溯源框架,该机制在安全性等方面具有一定的优势。

Do changes in intracoronary pressure aid coronary spasm diagnosis using the spasm provocation test?

BACKGROUND Although the spasm provocation test(SPT)can diagnose coronary spasms,it would be helpful if it could also predict their occurrence.AIM To investigate whether coronary spasms can be predicted using changes in intracoronary artery pressure measured using a pressure wire during the SPT.METHODS Seventy patients underwent SPTs with pressure-wire measurement of intracoronary artery pressure.During each SPT,the pressure wire was advanced into the distal portion of the right coronary artery(RCA)and left anterior descending coronary artery,and the ratio of intracoronary pressure to aortic pressure(Pd/Pa)was monitored.Coronary spasm was defined as an arterial narrowing of>90%in response to the administration of acetylcholine(ACh),with chest symptoms and/or ischemic electrocardiographic changes.ACh was administered to the RCA at low,moderate,or high doses of 20,50,or 80μg,respectively,and to the left coronary artery(LCA)at low,moderate,or high doses of 50,100,or 200μg,respectively.Coronary arteries with coronary spasms at low doses of ACh were defined as group L,and those with coronary spasms at moderate or high doses were defined as group MH.Those who did not occur coronary spasms at any ACh dose were designated as group N.RESULTS Among the 132 coronary arteries assessed using a pressure wire,there were 49 in group N,25 in group L,and 58 in group MH.Baseline Pd/Pa was the lowest in group L(P=0.001).The decrease in the Pd/Pa between baseline to low doses of ACh was lower in group MH than in group N(P<0.001).A receiver-operating characteristics analysis showed that the cutoff baseline Pd/Pa value for predicting group L was 0.95,with a sensitivity of 0.600(15/25)and a specificity of 0.713(76/107)and that the cutoff value of Pd/Pa from baseline to low doses of ACh for predicting group MH was−0.04,with a sensitivity of 0.741(43/58)and a specificity of 0.694(34/49).CONCLUSION These findings suggest that indices of intracoronary pressure during SPT may be useful means for predicting the occurrence of coronary spasms.

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.

Unmasking lower gastrointestinal bleeding under administration of norepinephrine

BACKGROUND Bleeding in the gastrointestinal tract is common and transarterial embolization enables the clinician to control gastrointestinal bleeding.Contrast extravasation is a prerequisite for successful embolization.Provocative angiography is helpful in the detection of elusive bleeding.AIM We performed a retrospective analysis of angiographic treatment in patients with lower gastrointestinal hemorrhage and initially negative angiographies,as well as the role of norepinephrine(NE)in unmasking bleeding.METHODS We analyzed 41 patients with lower gastrointestinal bleeding after angiography who had undergone treatment over a period of 10 years.All patients had a positive shock index and needed intensive care.RESULTS In three of four patients,angiography disclosed the site of bleeding when NE was used during the procedure for hemodynamic stabilization.CONCLUSION We suggest that angiography performed after the administration of NE in unstable patients with gastrointestinal bleeding and an initially negative angiography has the potential to unmask bleeding sites for successful embolization.However,this statement must be confirmed in prospective studies.

西蒙·C.埃斯托克:《生态恐惧症假说》,纽约:劳特利奇出版社,2018年版,197页（英文）

Provocative,playful,and enlightening,Simon Estok's The Ecophobia Hypothesis awakens us to ourselves with both compassion and wisdom about a psychological condition he calls ecophobia,which is also profoundly social,economic,and political.Estok defines ecophobia in his Introduction as"a uniquely human psychological condition that prompts antipathy toward nature"(1).Ecophobia,Estok also writes,can embody"fear,contempt,indifference,or lack of mindfulness"(1).It is,in a nutshell,an irrational fear of nature and a groundless hatred of the natural world human beings seem to have adapted and are suffering from whether they consciously recognize it or not.

The Wingate anaerobic test cannot be used for the evaluation of growth hormone secretion in children with short stature

Purpose: To assess the growth hormone(GH) response to the Wingate anaerobic test(WAn T) among children with short stature and suspected GH deficiency. We hypothesized that the GH response to the WAn T would be similar to the GH response to a commonly used pharmacologic provocation test.Methods: Ten children(6 males and 4 females, age range 9.0–14.9 years) participated in the study. Each participant performed 2 tests: a standard all-out WAn T, cycling for 30 s against constant resistance, and a standardized pharmacologic test(clonidine or glucagon). Blood samples for GH were collected before and 10, 30, 45, and 60 min after the beginning of exercise. In addition, we collected pre-and post-exercise blood lactate levels.Results: There was a significant increase in GH levels after the WAn T, yet in 9 of 10 participants, this increase was below the threshold for GH sufficiency. Peak GH after the WAn T was significantly lower compared to the pharmacologic GH provocation tests(with 9 of 10 demonstrating GH-sufficient response).Conclusion: The traditional WAn T cannot be used as a GH provocation test. Further research is needed to develop anaerobic exercise protocols sufficient to promote GH secretion.

Correlation between self-reported recovery and central sensitization in whiplash patients

Central sensitization has been associated with chronic pain in whiplash patients.Methods:Consecutive whiplash patients were assessed at 3 months post-whiplash injury with the brachial plexus provocation test(BPPT)as a sign of central sensitization.Self-reported recovery was assessed by the response to the question ‘Do you feel you have recovered fully from your accident injuries?'Results:Sixty-nine subjects(32 males,37 females,age 37.5±13.0 years(mean±SD),range 18-71)were included.Of these,34 reported a lack of recovery,and 35 reported recovery at 3 months post-injury.The mean BPPT elbow extension(from 180°)was 41.5±23.0°,and the mean VAS score for the BPPT was 2.2 ± 1.2(out of 10).Those who reported recovery had a mean BPPT elbow extension angle of 25.1±15.8 while those who did not report recovery had a mean BPPT angle of 58.4 ± 15.9(P＜0.05).The visual analogue scale(VAS)score for recovered subjects was 1.8 ± 1.1 and 2.7 ± 1.1(P＜0.05)for non-recovered.There was a moderate correlation between self-reported recovery and BPPT elbow extension angle(-0.44)and a lower correlation between self-reported recovery and VAS score(-0.30).Conclusion:Self-reported recovery correlates well with a lower likelihood of signs of central sensitization.Copyright(c)2012,Shanghai University of Sport.Production and hosting by Elsevier B.V.All rights reserved.

Importance of a second spasm provocation test:Four cases with an initial negative spasm provocation test

The spasm provocation test(SPT) is an important test in the diagnosis of vasospastic angina(VSA). In many cases, this test is performed as the gold standard test, and VSA is considered not present if the SPT is negative. However, some patients continue to experience chest symptoms despite a negative SPT. In this study, we report four cases in which SPT was repeated to evaluate chest symptoms despite the negative results of the first SPT. Two men in their 70 s, one woman in her 60 s, and one woman in her 70 s, all with chest symptoms, underwent a second SPT at 4, 3, 2, and 3 years, respectively, after the first SPT, which was negative. Three patients had positive results in the second SPT(75%). In conclusion, even when SPT is negative, the diagnosis of VSA should be made with clinical symptoms in consideration. In some cases, a second SPT may be required to confirm the diagnosis of VSA.

Clinical significance of prolonged chest pain in vasospastic angina

BACKGROUND Patients with vasospastic angina(VSA)sometimes experience prolonged chest symptoms.The clinical characteristics of these patients have not been clarified.AIM To investigate the clinical characteristics of prolonged VSA patients.METHODS This study included 167 patients with VSA diagnosed by spasm provocation tests(SPTs)using acetylcholine,which recorded the frequencies of positive reactions to a low dose of acetylcholine(L-ACh),total occlusion due to spasm(TOC),focal spasm,and the unavoidable use of nitroglycerin(unavoidable-NTG)during SPTs.The patients underwent a medical interview that investigated the maximum duration and frequency of chest symptoms as well as the frequencies of variant angina and other serious symptoms.The patients were divided into two groups based on the maximal duration:The short-duration group(<15 min;n=114)and the long-duration group(≥15 min;n=53).They were also divided into two groups based on the frequency of chest symptoms:The low-frequency group(<4/mo;n=88)and the high-frequency group(≥4/mo;n=79).RESULTS The long-duration group showed higher frequencies of other serious symptoms(P<0.001)and variant angina(P<0.05)as well as higher frequencies of spasm induction by L-ACh(P<0.05),TOC(P<0.05),focal spasm(P<0.01),and unavoidable-NTG(P<0.01)than the short-duration group.These parameters did not differ significantly between the low-frequency and high-frequency groups.CONCLUSION These findings suggest that patients with VSA who experience prolonged chest symptoms may have more severe characteristics of VSA.

Role of Media in Provoking Cigarette Smoking among Adolescents in Urban Nepal

At current era of globalization, media is the double edged sword that is important both for health education as well as the stimulation of unhealthy behaviour. In Nepal, though there is ban on most forms of advertising, it is not clear about placement of tobacco advertisement in TV, films and other forms of media. Studies about cigarette smoking and its association with media are inadequate in Nepal. The objective of this study was to explore the role of media in cigarette smoking habit of adolescents in Nepal. A cross-sectional study was conducted among 394 adolescent students by using questionnaire method in 3 randomly selected colleges of Kathmandu district, Nepal. Data were analysed by using bivariate and multinomial logistic regression analysis. Statistically significant relationship at 95% CI was found between cigarette smoking status and media related variables like: seeing cigarette advertisement, reading fashion magazine, attending musical program sponsored by cigarette companies, watching movies in cinema hall, liking heavy metal/hard rock music, television watching time and desire to smoke if favourite artist smokes. Multinomial logistic regression showed that those with high receptivity to cigarette advertisement were likely to be current smokers (OR = 71.416, CI: 8.796 - 579.823) and ever smokers (OR = 9.582, CI: 2.201 - 41.714) compared to never smokers. About 79% of respondents agreed that media teaches different ways of smoking to its audiences. Different forms of media including cinema, music, magazines, television, games and music sponsorship are found to be important predictors for smoking status of college students in urban Nepal. Thus smoking prevention activities should consider role of media in smoking provocation among adolescents.

鼻激发试验

皮肤试验和血清学检测特异性IgE是诊断变应性鼻炎的一线方法，但却是间接的诊断方法。直接方法是将鼻黏膜暴露于可疑变应原中，观察鼻黏膜是否出现高反应性，即鼻黏膜激发试验（nasal provocation test，NPT）。由于NPT能够直接确定变应原，明确变应性鼻炎的诊断，故已应用于变应性鼻炎及非变应性鼻炎的鉴别诊断，鼻炎的病理生理学、免疫学以及药物治疗学的研究中。本文将就NPT的操作特征和临床应用做一综述。