Disturbances of potassium balance are often encountered when managing kidney transplant recipients(KTR).Both hyperkalemia and hypokalemia may present either as medical emergencies or chronic outpatient abnormalities.D...Disturbances of potassium balance are often encountered when managing kidney transplant recipients(KTR).Both hyperkalemia and hypokalemia may present either as medical emergencies or chronic outpatient abnormalities.Despite the high incidence of hyperkalemia and its potential life-threatening implications,consensus on its management in KTR is lacking.Hypokalemia in KTR is also well-described,although it is given less attention by clinicians compared to hyper-kalemia.This article discusses the etiology,pathophysiology and management of both types of potassium disorders in KTR.Once any emergent situation has been corrected,treatment approaches include correcting insulin deficiency if present,adjusting non-immunosuppressive and immunosuppressive medications,elimi-nating or supplementing potassium as needed,and dietary counselling.Although commonly of multifactorial etiology,ascertaining the specific cause in a particular patient will help guide successful management.Monitoring KTR through regular laboratory testing is essential to detect serious disturbances in potassium balance since patients are often asymptomatic.展开更多
Platelets are small anucleate cells generated from megakaryocytes in the bone marrow. Although platelet genera- tion, maturation, and clearance are still not fully understood, significant progress has been made in the...Platelets are small anucleate cells generated from megakaryocytes in the bone marrow. Although platelet genera- tion, maturation, and clearance are still not fully understood, significant progress has been made in the last 1-2 dec- ades. In blood circulation, platelets can quickly adhere and aggregate at sites of vascular injury, forming the platelet plug （i.e. the first wave of hemostasis）. Activated platelets can also provide negatively charged phosphatidylserine- rich membrane surface that enhances cell-based thrombin generation, which facilitates blood coagulation （i.e. the second wave of hemostasis）. Platelets therefore play central roles in hemostasis. However, the same process of hemostasis may also cause thrombosis and vessel occlusion, which are the most common mechanisms leading to heart attack and stroke following ruptured atherosclerotic lesions. In this review, we will introduce the classical mechanisms and newly discovered pathways of platelets in hemostasis and thrombosis, including fibrinogen-inde- pendent platelet aggregation and thrombosis, and the plasma fibronectin-mediated ＂protein wave＂ of hemostasis that precedes the classical first wave of hemostasis. Furthermore, we briefly discuss the roles of platelets in inflam- marion and atherosclerosis and the potential strategies to control atherothrombosis.展开更多
AIMTo quantify the risk of gastric cancer in first-degree relatives of patients with the cancer.METHODSA comprehensive literature search was performed. Case-control trials comparing the frequency of a positive family ...AIMTo quantify the risk of gastric cancer in first-degree relatives of patients with the cancer.METHODSA comprehensive literature search was performed. Case-control trials comparing the frequency of a positive family history of gastric cancer in patients with gastric cancer, vs non-gastric cancer controls were retrieved. Studies with missed or non-extractable data, studies in children, abstracts, and duplicate publications were excluded. A meta-analysis of pooled odd ratios was performed using Review Manager 5.0.25. We performed subgroup analysis on Asian studies and a sensitivity analysis based on the quality of the studies, type of the outcome, sample size, and whether studies considered only first-degree relatives.RESULTSThirty-two relevant studies out of 612 potential abstracts (n = 80690 individuals) were included. 19.0% of the patients and 10.9% of the controls had at least one relative with gastric cancer (P < 0.00001). The pooled relative risk for the development of gastric cancer in association with a positive family history was 2.35 (95%CI: 1.96-2.81). The Cochran Q test for heterogeneity was positive (P < 0.00001, I² = 92%). After excluding the three outlier studies with the highest relative risks, heterogeneity remained significant (P < 0.00001, I² = 90%). The result was not different among Asian studies as compared to others and remained robust in several sensitivity analyses. In the 26 studies which exclusively analysed the history of gastric cancer in first-degree relatives, the relative risk was 2.71 (95%CI: 2.08-3.53; P < 0.00001).CONCLUSIONIndividuals with a first-degree relative affected with gastric cancer have a risk of about 2.5-fold for the development of gastric cancer. This could be due to genetic or environmental factors. Screening and preventive strategies should be developed for this high-risk population.展开更多
Background: We undertook a prospective electrocardiogram(ECG) substudy in the ESSENCE trial and hypothesized that patient subgroups with ST-segment deviation would experience greater benefit from enoxaparin, as compar...Background: We undertook a prospective electrocardiogram(ECG) substudy in the ESSENCE trial and hypothesized that patient subgroups with ST-segment deviation would experience greater benefit from enoxaparin, as compared with unfractionated heparin(UFH). Methods: Of the 3171 patients in the trial, 3087 had a qualifying ECG available for analysis by the core laboratory. Patients were divided into 4 mutually exclusive groups based upon the qualifying ECG:(1) ST-segment elevation,(2) ST-segment depression,(3) T-wave inversions, or(4) others. Results: The 30-day and 1-year primary outcomes(death, myocardial infarction, or recurrent angina) were significantly lower among patients with ST elevation or ST depression who received enoxaparin, as compared with UFH(20.8%vs 28.0%, P=.0019 and 32%vs 40.4%, P=.0011, respectively). The greatest absolute benefit of enoxaparin over UFH was seen in patients with ST depression(primary end point at 30 days, 24.6%vs 32.4%, P=.018; at 1 year, 35.5%vs 44.5%, P=.012). Conclusion: Specific recognition of patients with ST-segment depression appears to identify those not only at high risk for adverse outcome, but also patients most likely to derive the greatest benefit from enoxaparin, as compared with UFH therapy.展开更多
Objective To present 3-15 years follow-up of patients older than 70 years who underwent cementless total hip arthroplasty. Methods One hundred and two consecutive primary total hip arthroplasties utilizing a circumfer...Objective To present 3-15 years follow-up of patients older than 70 years who underwent cementless total hip arthroplasty. Methods One hundred and two consecutive primary total hip arthroplasties utilizing a circumferential proximal porous coated femoral component and smooth surfaced threaded acetabular were performed in 92 patients. The patients were followed up clinically and radiographically every two years from their third year after surgery. Ten patients (10 hips) died and 14 patients (15 hips) were lost to follow up in three years after surgery. Sixty-seven patients (77 hips) were included in this study. Results The pre-operative Harris hip scores and pain scores were 45 and 15 points. They increased to 89 and 42 points by the third year. These scores decreased to 81 and 42 points in the ninth year and 77 and 37 points in the fifteenth year, respectively. More than 75% of the hips demonstrated good or excellent clinical results in the fifth year and 60% of the hips were rated good to excellent in the seventh to eleventh year. In the fifteenth year, only 50% of the hips had good or excellent results. All femoral components showed stable fixation by bone in-growth. Eight acetabular components were revised, with 5 due to mechanical loosening and 3 for recurrent instability. Thigh pain was documented in 4 hips. ConclusionThe smooth-surfaced threaded acetabular component has a high rate of failure. Circumferential proximal porous coated femoral components provided excellent radiographic results and acceptable clinical outcome with definite bone ingrowth. Patients older than 70 may be suitable candidates for cementless total hip arthroplasty.展开更多
Virtual reality simulation is becoming the standard when beginning endoscopic training. It offers various benefits including learning in a low-stakes environment, improvement of patient safety and optimization of valu...Virtual reality simulation is becoming the standard when beginning endoscopic training. It offers various benefits including learning in a low-stakes environment, improvement of patient safety and optimization of valuable endoscopy time. This is a review of the evidence surrounding virtual reality simulation and its efficacy in teaching endoscopic techniques. There have been 21 randomized controlled trials(RCTs) that have investigated virtual reality simulation as a teaching tool in endoscopy. 10 RCTs studied virtual reality in colonoscopy, 3 in flexible sigmoidoscopy, 5 in esophagogastroduodenoscopy, and 3 in endoscopic retrograde cholangiopancreatography. RCTs reported many outcomes including distance advanced in colonoscopy, comprehensive assessment of technical and non-technical skills, and patient comfort. Generally, these RCTs reveal that trainees with virtual reality simulation based learning improve in all of these areas in the beginning of the learning process. Virtual reality simulation was not effective as a replacement of conventional teaching methods. Additionally, feedback was shown to be an essential part of the learning process. Overall, virtual reality endoscopic simulation is emerging as a necessary augment to conventional learning given the ever increasing importance of patient safety and increasingly valuable endoscopy time; although work is still needed to study the nuances surrounding its integration into curriculum.展开更多
A common challenge in managing kidney transplant recipients(KTR)is posttransplant diabetes mellitus(PTDM)or diabetes mellitus(DM)newly diagnosed after transplantation,in addition to known pre-existing DM.PTDM is an im...A common challenge in managing kidney transplant recipients(KTR)is posttransplant diabetes mellitus(PTDM)or diabetes mellitus(DM)newly diagnosed after transplantation,in addition to known pre-existing DM.PTDM is an important risk factor for post-transplant cardiovascular(CV)disease,which adversely affects patient survival and quality of life.CV disease in KTR may manifest as ischemic heart disease,heart failure,and/or left ventricular hypertrophy.Available therapies for PTDM include most agents currently used to treat type 2 diabetes.More recently,the use of sodium glucose co-transporter 2 inhibitors(SGLT2i),glucagon-like peptide-1 receptor agonists(GLP-1 RA),and dipeptidyl peptidase 4 inhibitors(DPP4i)has cautiously extended to KTR with PTDM,even though KTR are typically excluded from large general population clinical trials.Initial evidence from observational studies seems to indicate that SGLT2i,GLP-1 RA,and DPP4i may be safe and effective for glycemic control in KTR,but their benefit in reducing CV events in this otherwise high-risk population remains unproven.These newer drugs must still be used with care due to the increased propensity of KTR for intravascular volume depletion and acute kidney injury due to diarrhea and their single-kidney status,pre-existing burden of peripheral vascular disease,urinary tract infections due to immunosuppression and a surgically altered urinary tract,erythrocytosis from calcineurin inhibitors,and reduced kidney function from acute or chronic rejection.展开更多
BACKGROUND:Ultrasound has the first line investigation role in the diagnosis of acute appendicitis in children.The purpose of this study was to perform a quality assessment review on the visualization rate of appendix...BACKGROUND:Ultrasound has the first line investigation role in the diagnosis of acute appendicitis in children.The purpose of this study was to perform a quality assessment review on the visualization rate of appendix on ultrasound in children in the community hospital setting.METHODS:A retrospective chart review of the abdominal ultrasound findings for the visualization of the appendix was performed on paediatric patients ranging from 5 to 18 years.Data were collected from the two community hospitals of Toronto by using hospital electronic medical record for the ultrasound findings in patients presented with abdominal pain.RESULTS:Data from two community hospitals indicated visualization rate of the appendix as 11.0%and 23.2%for site 1 and site 2 respectively.In cases where the ultrasound was repeated the visualization rate remains the same.A two-proportion z-test was performed to find whether the visualization of appendix increases the likelihood of diagnosing appendicitis.The results revealed that the visualization of an appendix(P=0.52),significantly improved the diagnosis of appendicitis(z=34,P<0.001).CONCLUSION:Visualization of an appendix on ultrasound increases the likelihood of correctly diagnosing appendicitis.In our study,we found low visualization rate of appendix on ultrasound that could be the result of many factors that contribute towards the low visualization rate of an appendix on ultrasound.Hence,the challenges in identifying appendix should be minimized to improve the visualization and diagnosis of appendicitis on ultrasound.展开更多
The objective of this guideline is to outline the role of magnetic resonance imaging(MRI) in clinical decision making and outcome prediction in patients with traumatic spinal cord injury(SCI).Methods A systematic revi...The objective of this guideline is to outline the role of magnetic resonance imaging(MRI) in clinical decision making and outcome prediction in patients with traumatic spinal cord injury(SCI).Methods A systematic review of the literature was conducted to address key questions related to the use of MRI in patients with traumatic SCI.This review focused on longitudinal studies that controlled for baseline neurologic status.A multidisciplinary Guideline Development Group(GDG) used this information,their clinical expertise,and patient input to develop recommendations on the use of MRI for SCI patients.Based on GRADE(Grading of Recommendation,Assessment,Development and Evaluation),a strong recommendation is worded as " we recommend," whereas a weaker recommendation is indicated by "we suggest." Results Based on the limited available evidence and the clinical expertise of the GDG,our recommendations were:(1) "We suggest that MRI be performed in adult patients with acute SCI prior to surgical intervention,when feasible,to facilitate improved clinical decision-making"(quality of evidence,very low) and(2) "We suggest that MRI should be performed in adult patients in the acute period following SCI,before or after surgical intervention,to improve prediction of neurologic outcome "(quality of evidence,low).Conclusions These guidelines should be implemented into clinical practice to improve outcomes and prognostication for patients with SCI.展开更多
脓毒症是一种由感染引起的异质性疾病,感染触发了一系列复杂的局部或者全身的免疫炎症反应,引起多器官功能衰竭,发病率和病死率显著升高。由于至今仍然没有诊断脓毒症的金标准,所以脓毒症的临床诊断仍是一个难题。因此,脓毒症的临床诊...脓毒症是一种由感染引起的异质性疾病,感染触发了一系列复杂的局部或者全身的免疫炎症反应,引起多器官功能衰竭,发病率和病死率显著升高。由于至今仍然没有诊断脓毒症的金标准,所以脓毒症的临床诊断仍是一个难题。因此,脓毒症的临床诊断需要不断改变来满足临床和研究的要求。然而,尽管有许多新型的生物标记和筛选工具去预测脓毒症发生的风险,但是这些措施的诊断价值和有效性不足以让人满意,并且没有充分的证据去建议临床使用这些新技术。因此,脓毒症的临床诊断标准需要定期更新去适应不断产生的新证据。这篇综述旨在呈现当前脓毒症的诊断和早期识别方面的最新研究证据。临床运用不同的诊断方法的推荐意见依赖于推荐、评价、发展和评估分级体系(Grades of Recommendation Assessment,Development and Evaluation,GRADE),因为大部分的研究是观察性研究,并没有对这些方法进行可靠评估,采用的是两步推理方法。未来需要更多研究来确认或者反驳某一特殊的指标检测,同时应该直接采用相关病人的结果数据。展开更多
Context: Renal dysfunction is a complication of coronary artery bypass graft(CABG) surgery performed with cardiopulmonary bypass(CPB) that is associated with increased morbidity and mortality. N-acetylcysteine, an ant...Context: Renal dysfunction is a complication of coronary artery bypass graft(CABG) surgery performed with cardiopulmonary bypass(CPB) that is associated with increased morbidity and mortality. N-acetylcysteine, an antioxidant and vasodilator, counteracts renal ischemia and hypoxia. Objective: To determine whether perioperative intravenous(IV) N-acetylcysteine preserves renal function in high-risk patients undergoing CABG surgery with CPB compared with placebo. Design, Setting, and Patients: Randomized, quadruple blind, placebo-controlled trial(October 2003-September 2004) in operating rooms and general intensive care units(ICUs) of 2 Ontario tertiary care centers. The 295 patients required elective or urgent CABG and had at least 1 of the following: preexisting renal dysfunction, at least 70 years old, diabetes mellitus, impaired left ventricular function, or undergoing concomitant valve or redo surgery. Interventions: Patients received 4(2 intraoperative and 2 postoperative)doses of IV N-acetylcysteine(600 mg)(n=148) or placebo(n=147) over 24 hours. Main Outcome Measures: The primary outcome was the proportion of patients developing postoperative renal dysfunction, defined by an increase in serum creatinine level greater than 0.5 mg/dL(44 μmol/L) or a 25%increase from baseline within the first 5 postoperative days. Secondary outcomes included postoperative interventions and complications, the requirement for renal replacement therapy(RRT), adverse events, hospital mortality, and ICU and hospital length of stay. Results: There was no difference in the proportion of patients with postoperative renal dysfunction(29.7%vs 29.0%, P=.89; relative risk[RR], 1.03[95%confidence interval {CI}, 0.72-1.46]) in the N-acetylcysteine and placebo groups, respectively. We noted nonsignificant differences in postoperative interventions and complications, the need for RRT(0.7%vs 2.1%; P=.37), total(6.1%vs 9.6%; P=.26) and serious adverse events, hospital mortality(3.4%vs 2.7%; P >.99), and ICU and hospital length of stay between the N-acetylcysteine and placebo groups. A post hoc subgroup analysis of patients(baseline creatinine level >1.4 mg/dL[120 μmol/L]) showed a nonsignificant trend toward fewer patients experiencing postoperative renal dysfunction in the N-acetylcysteine group compared with the placebo group(25.0%vs 37.1%; P=.29). Conclusions: N-acety-lcysteine did not prevent postoperative renal dysfunction, interventions, complications, or mortality in high-risk patients undergoing CABG surgery with CPB. Further research is required to identify CABG patients at risk for postoperative renal events, valid markers of renal dysfunction, and to establish renal thresholds associated with important clinical outcomes.展开更多
An association between minor endometriosis and subfertility is shown by prevalence studies but a clear causal relationship has not yet been demonstrated. This review presents the evidence for pituitary-ovarian dysfunc...An association between minor endometriosis and subfertility is shown by prevalence studies but a clear causal relationship has not yet been demonstrated. This review presents the evidence for pituitary-ovarian dysfunction as a cause for subfertility in women with minor endometriosis. Using tubal infertility cases as controls, group comparison has shown effects on the following: follicular growth (impaired) , preovulatory circulating oestradiol levels (reduced) and early luteal phase oestradiol and progesterone (reduced) , and LH surge patterns (disordered), preovulatory follicular fluid LH concentration (reduced) , and granulosa cell steroidogenic capacity (impaired) . However, these findings are not consistent in the literature. Compared with controls, reduced oocyte fertilisation and implantation rates are reported in natural and go-nadotrophin stimulated cycles. An inherent disorder of follicular function is possible as a cause, with LH surge impairment probably a secondary phenomenon. Natural sub-fertility is substantially disordered as a result of oocyte fertilisation impairment. However, as excess numbers of oocytes are available in bitrofertility in vitro fertility (IVF) is still successful.展开更多
To theeditor:The incidence of depression and obesity is on the rise,posing significant public health concerns.While the literature largely supports a positive correlation between depression and body mass index(BMI),I2...To theeditor:The incidence of depression and obesity is on the rise,posing significant public health concerns.While the literature largely supports a positive correlation between depression and body mass index(BMI),I2 earlier studies have suggested an inverse relationship or indicated a lack of association between depression and obesity.展开更多
South Asians(SA)are at higher cardiovascular risk than other ethnic groups,and SA kidney transplant recipients(SA KTR)are no exception.SA KTR experience increased major adverse cardiovascular events both early and lat...South Asians(SA)are at higher cardiovascular risk than other ethnic groups,and SA kidney transplant recipients(SA KTR)are no exception.SA KTR experience increased major adverse cardiovascular events both early and late posttransplantation.Cardiovascular risk management should therefore begin well before transplantation.SA candidates may require aggressive screening for pretransplant cardiovascular disease(CVD)due to their ethnicity and comorbidities.Recording SA ethnicity during the pre-transplant evaluation may enable programs to better assess cardiovascular risk,thus allowing for earlier targeted periand post-transplant intervention to improve cardiovascular outcomes.Diabetes remains the most prominent post-transplant cardiovascular risk factor in SA KTR.Diabetes also clusters with other metabolic syndrome components including lower high-density lipoprotein cholesterol,higher triglycerides,hypertension,and central obesity in this population.Dyslipidemia,metabolic syndrome,and obesity are all significant CVD risk factors in SA KTR,and contribute to increased insulin resistance.Novel biomarkers such as adiponectin,apolipoprotein B,and lipoprotein(a)may be especially important to study in SA KTR.Focused interventions to improve health behaviors involving diet and exercise may especially benefit SA KTR.However,there are few interventional clinical trials specific to the SA population,and none are specific to SA KTR.In all cases,understanding the nuances of managing SA KTR as a distinct post-transplant group,while still screening for and managing each CVD risk factor individually in all patients may help improve the long-term success of all kidney transplant programs catering to multi-ethnic populations.展开更多
Due to the high risk of morbidity and mortality associated with surgical resection in this tract,endoscopic resection(ER)has taken the place of surgical resection as the first line treatment for non-ampullary duodenal...Due to the high risk of morbidity and mortality associated with surgical resection in this tract,endoscopic resection(ER)has taken the place of surgical resection as the first line treatment for non-ampullary duodenal adenomas.However,due to the anatomical characteristics of this area,which enhance the risk of post-ER problems,ER in the duodenum is particularly difficult.Due to a lack of data,no ER technique for superficial non-ampullary duodenal epithelial tumours(SNADETs)has yet been backed by strong,high-quality evidence;yet,traditional hot snare-based techniques are still regarded as the standard treatment.Despite having a favourable efficiency profile,adverse events during duodenal hot snare polypectomy(HSP)and hot endoscopic mucosal resection,such as delayed bleeding and perforation,have been reported to be frequent.These events are primarily caused by electrocautery-induced damage.Thus,ER techniques with a better safety profile are needed to overcome these shortcomings.Cold snare polypectomy,which has already been shown as a safer,equally effective pro-cedure compared to HSP for treatment of small colorectal polyps,is being increasingly evaluated as a potential therapeutic option for non-ampullary duodenal adenomas.The aim of this review is to report and discuss the early outcomes of the first experiences with cold snaring for SNADETs.展开更多
文摘Disturbances of potassium balance are often encountered when managing kidney transplant recipients(KTR).Both hyperkalemia and hypokalemia may present either as medical emergencies or chronic outpatient abnormalities.Despite the high incidence of hyperkalemia and its potential life-threatening implications,consensus on its management in KTR is lacking.Hypokalemia in KTR is also well-described,although it is given less attention by clinicians compared to hyper-kalemia.This article discusses the etiology,pathophysiology and management of both types of potassium disorders in KTR.Once any emergent situation has been corrected,treatment approaches include correcting insulin deficiency if present,adjusting non-immunosuppressive and immunosuppressive medications,elimi-nating or supplementing potassium as needed,and dietary counselling.Although commonly of multifactorial etiology,ascertaining the specific cause in a particular patient will help guide successful management.Monitoring KTR through regular laboratory testing is essential to detect serious disturbances in potassium balance since patients are often asymptomatic.
基金supported in part by Canadian Institutes of Health Research(MOP 119540),National Natural Science Foundation of China-Canadian Institutes of Health Research(China-Canada Joint Health Research Initiative Program),Heart and Stroke Foundation of Canada(Ontario)supported by equipment Funds from St.Michael's Hospital,Canadian Blood Services,and Canada Foundation for Innovation
文摘Platelets are small anucleate cells generated from megakaryocytes in the bone marrow. Although platelet genera- tion, maturation, and clearance are still not fully understood, significant progress has been made in the last 1-2 dec- ades. In blood circulation, platelets can quickly adhere and aggregate at sites of vascular injury, forming the platelet plug （i.e. the first wave of hemostasis）. Activated platelets can also provide negatively charged phosphatidylserine- rich membrane surface that enhances cell-based thrombin generation, which facilitates blood coagulation （i.e. the second wave of hemostasis）. Platelets therefore play central roles in hemostasis. However, the same process of hemostasis may also cause thrombosis and vessel occlusion, which are the most common mechanisms leading to heart attack and stroke following ruptured atherosclerotic lesions. In this review, we will introduce the classical mechanisms and newly discovered pathways of platelets in hemostasis and thrombosis, including fibrinogen-inde- pendent platelet aggregation and thrombosis, and the plasma fibronectin-mediated ＂protein wave＂ of hemostasis that precedes the classical first wave of hemostasis. Furthermore, we briefly discuss the roles of platelets in inflam- marion and atherosclerosis and the potential strategies to control atherothrombosis.
文摘AIMTo quantify the risk of gastric cancer in first-degree relatives of patients with the cancer.METHODSA comprehensive literature search was performed. Case-control trials comparing the frequency of a positive family history of gastric cancer in patients with gastric cancer, vs non-gastric cancer controls were retrieved. Studies with missed or non-extractable data, studies in children, abstracts, and duplicate publications were excluded. A meta-analysis of pooled odd ratios was performed using Review Manager 5.0.25. We performed subgroup analysis on Asian studies and a sensitivity analysis based on the quality of the studies, type of the outcome, sample size, and whether studies considered only first-degree relatives.RESULTSThirty-two relevant studies out of 612 potential abstracts (n = 80690 individuals) were included. 19.0% of the patients and 10.9% of the controls had at least one relative with gastric cancer (P < 0.00001). The pooled relative risk for the development of gastric cancer in association with a positive family history was 2.35 (95%CI: 1.96-2.81). The Cochran Q test for heterogeneity was positive (P < 0.00001, I² = 92%). After excluding the three outlier studies with the highest relative risks, heterogeneity remained significant (P < 0.00001, I² = 90%). The result was not different among Asian studies as compared to others and remained robust in several sensitivity analyses. In the 26 studies which exclusively analysed the history of gastric cancer in first-degree relatives, the relative risk was 2.71 (95%CI: 2.08-3.53; P < 0.00001).CONCLUSIONIndividuals with a first-degree relative affected with gastric cancer have a risk of about 2.5-fold for the development of gastric cancer. This could be due to genetic or environmental factors. Screening and preventive strategies should be developed for this high-risk population.
文摘Background: We undertook a prospective electrocardiogram(ECG) substudy in the ESSENCE trial and hypothesized that patient subgroups with ST-segment deviation would experience greater benefit from enoxaparin, as compared with unfractionated heparin(UFH). Methods: Of the 3171 patients in the trial, 3087 had a qualifying ECG available for analysis by the core laboratory. Patients were divided into 4 mutually exclusive groups based upon the qualifying ECG:(1) ST-segment elevation,(2) ST-segment depression,(3) T-wave inversions, or(4) others. Results: The 30-day and 1-year primary outcomes(death, myocardial infarction, or recurrent angina) were significantly lower among patients with ST elevation or ST depression who received enoxaparin, as compared with UFH(20.8%vs 28.0%, P=.0019 and 32%vs 40.4%, P=.0011, respectively). The greatest absolute benefit of enoxaparin over UFH was seen in patients with ST depression(primary end point at 30 days, 24.6%vs 32.4%, P=.018; at 1 year, 35.5%vs 44.5%, P=.012). Conclusion: Specific recognition of patients with ST-segment depression appears to identify those not only at high risk for adverse outcome, but also patients most likely to derive the greatest benefit from enoxaparin, as compared with UFH therapy.
文摘Objective To present 3-15 years follow-up of patients older than 70 years who underwent cementless total hip arthroplasty. Methods One hundred and two consecutive primary total hip arthroplasties utilizing a circumferential proximal porous coated femoral component and smooth surfaced threaded acetabular were performed in 92 patients. The patients were followed up clinically and radiographically every two years from their third year after surgery. Ten patients (10 hips) died and 14 patients (15 hips) were lost to follow up in three years after surgery. Sixty-seven patients (77 hips) were included in this study. Results The pre-operative Harris hip scores and pain scores were 45 and 15 points. They increased to 89 and 42 points by the third year. These scores decreased to 81 and 42 points in the ninth year and 77 and 37 points in the fifteenth year, respectively. More than 75% of the hips demonstrated good or excellent clinical results in the fifth year and 60% of the hips were rated good to excellent in the seventh to eleventh year. In the fifteenth year, only 50% of the hips had good or excellent results. All femoral components showed stable fixation by bone in-growth. Eight acetabular components were revised, with 5 due to mechanical loosening and 3 for recurrent instability. Thigh pain was documented in 4 hips. ConclusionThe smooth-surfaced threaded acetabular component has a high rate of failure. Circumferential proximal porous coated femoral components provided excellent radiographic results and acceptable clinical outcome with definite bone ingrowth. Patients older than 70 may be suitable candidates for cementless total hip arthroplasty.
文摘Virtual reality simulation is becoming the standard when beginning endoscopic training. It offers various benefits including learning in a low-stakes environment, improvement of patient safety and optimization of valuable endoscopy time. This is a review of the evidence surrounding virtual reality simulation and its efficacy in teaching endoscopic techniques. There have been 21 randomized controlled trials(RCTs) that have investigated virtual reality simulation as a teaching tool in endoscopy. 10 RCTs studied virtual reality in colonoscopy, 3 in flexible sigmoidoscopy, 5 in esophagogastroduodenoscopy, and 3 in endoscopic retrograde cholangiopancreatography. RCTs reported many outcomes including distance advanced in colonoscopy, comprehensive assessment of technical and non-technical skills, and patient comfort. Generally, these RCTs reveal that trainees with virtual reality simulation based learning improve in all of these areas in the beginning of the learning process. Virtual reality simulation was not effective as a replacement of conventional teaching methods. Additionally, feedback was shown to be an essential part of the learning process. Overall, virtual reality endoscopic simulation is emerging as a necessary augment to conventional learning given the ever increasing importance of patient safety and increasingly valuable endoscopy time; although work is still needed to study the nuances surrounding its integration into curriculum.
文摘A common challenge in managing kidney transplant recipients(KTR)is posttransplant diabetes mellitus(PTDM)or diabetes mellitus(DM)newly diagnosed after transplantation,in addition to known pre-existing DM.PTDM is an important risk factor for post-transplant cardiovascular(CV)disease,which adversely affects patient survival and quality of life.CV disease in KTR may manifest as ischemic heart disease,heart failure,and/or left ventricular hypertrophy.Available therapies for PTDM include most agents currently used to treat type 2 diabetes.More recently,the use of sodium glucose co-transporter 2 inhibitors(SGLT2i),glucagon-like peptide-1 receptor agonists(GLP-1 RA),and dipeptidyl peptidase 4 inhibitors(DPP4i)has cautiously extended to KTR with PTDM,even though KTR are typically excluded from large general population clinical trials.Initial evidence from observational studies seems to indicate that SGLT2i,GLP-1 RA,and DPP4i may be safe and effective for glycemic control in KTR,but their benefit in reducing CV events in this otherwise high-risk population remains unproven.These newer drugs must still be used with care due to the increased propensity of KTR for intravascular volume depletion and acute kidney injury due to diarrhea and their single-kidney status,pre-existing burden of peripheral vascular disease,urinary tract infections due to immunosuppression and a surgically altered urinary tract,erythrocytosis from calcineurin inhibitors,and reduced kidney function from acute or chronic rejection.
文摘BACKGROUND:Ultrasound has the first line investigation role in the diagnosis of acute appendicitis in children.The purpose of this study was to perform a quality assessment review on the visualization rate of appendix on ultrasound in children in the community hospital setting.METHODS:A retrospective chart review of the abdominal ultrasound findings for the visualization of the appendix was performed on paediatric patients ranging from 5 to 18 years.Data were collected from the two community hospitals of Toronto by using hospital electronic medical record for the ultrasound findings in patients presented with abdominal pain.RESULTS:Data from two community hospitals indicated visualization rate of the appendix as 11.0%and 23.2%for site 1 and site 2 respectively.In cases where the ultrasound was repeated the visualization rate remains the same.A two-proportion z-test was performed to find whether the visualization of appendix increases the likelihood of diagnosing appendicitis.The results revealed that the visualization of an appendix(P=0.52),significantly improved the diagnosis of appendicitis(z=34,P<0.001).CONCLUSION:Visualization of an appendix on ultrasound increases the likelihood of correctly diagnosing appendicitis.In our study,we found low visualization rate of appendix on ultrasound that could be the result of many factors that contribute towards the low visualization rate of an appendix on ultrasound.Hence,the challenges in identifying appendix should be minimized to improve the visualization and diagnosis of appendicitis on ultrasound.
文摘The objective of this guideline is to outline the role of magnetic resonance imaging(MRI) in clinical decision making and outcome prediction in patients with traumatic spinal cord injury(SCI).Methods A systematic review of the literature was conducted to address key questions related to the use of MRI in patients with traumatic SCI.This review focused on longitudinal studies that controlled for baseline neurologic status.A multidisciplinary Guideline Development Group(GDG) used this information,their clinical expertise,and patient input to develop recommendations on the use of MRI for SCI patients.Based on GRADE(Grading of Recommendation,Assessment,Development and Evaluation),a strong recommendation is worded as " we recommend," whereas a weaker recommendation is indicated by "we suggest." Results Based on the limited available evidence and the clinical expertise of the GDG,our recommendations were:(1) "We suggest that MRI be performed in adult patients with acute SCI prior to surgical intervention,when feasible,to facilitate improved clinical decision-making"(quality of evidence,very low) and(2) "We suggest that MRI should be performed in adult patients in the acute period following SCI,before or after surgical intervention,to improve prediction of neurologic outcome "(quality of evidence,low).Conclusions These guidelines should be implemented into clinical practice to improve outcomes and prognostication for patients with SCI.
文摘脓毒症是一种由感染引起的异质性疾病,感染触发了一系列复杂的局部或者全身的免疫炎症反应,引起多器官功能衰竭,发病率和病死率显著升高。由于至今仍然没有诊断脓毒症的金标准,所以脓毒症的临床诊断仍是一个难题。因此,脓毒症的临床诊断需要不断改变来满足临床和研究的要求。然而,尽管有许多新型的生物标记和筛选工具去预测脓毒症发生的风险,但是这些措施的诊断价值和有效性不足以让人满意,并且没有充分的证据去建议临床使用这些新技术。因此,脓毒症的临床诊断标准需要定期更新去适应不断产生的新证据。这篇综述旨在呈现当前脓毒症的诊断和早期识别方面的最新研究证据。临床运用不同的诊断方法的推荐意见依赖于推荐、评价、发展和评估分级体系(Grades of Recommendation Assessment,Development and Evaluation,GRADE),因为大部分的研究是观察性研究,并没有对这些方法进行可靠评估,采用的是两步推理方法。未来需要更多研究来确认或者反驳某一特殊的指标检测,同时应该直接采用相关病人的结果数据。
文摘Context: Renal dysfunction is a complication of coronary artery bypass graft(CABG) surgery performed with cardiopulmonary bypass(CPB) that is associated with increased morbidity and mortality. N-acetylcysteine, an antioxidant and vasodilator, counteracts renal ischemia and hypoxia. Objective: To determine whether perioperative intravenous(IV) N-acetylcysteine preserves renal function in high-risk patients undergoing CABG surgery with CPB compared with placebo. Design, Setting, and Patients: Randomized, quadruple blind, placebo-controlled trial(October 2003-September 2004) in operating rooms and general intensive care units(ICUs) of 2 Ontario tertiary care centers. The 295 patients required elective or urgent CABG and had at least 1 of the following: preexisting renal dysfunction, at least 70 years old, diabetes mellitus, impaired left ventricular function, or undergoing concomitant valve or redo surgery. Interventions: Patients received 4(2 intraoperative and 2 postoperative)doses of IV N-acetylcysteine(600 mg)(n=148) or placebo(n=147) over 24 hours. Main Outcome Measures: The primary outcome was the proportion of patients developing postoperative renal dysfunction, defined by an increase in serum creatinine level greater than 0.5 mg/dL(44 μmol/L) or a 25%increase from baseline within the first 5 postoperative days. Secondary outcomes included postoperative interventions and complications, the requirement for renal replacement therapy(RRT), adverse events, hospital mortality, and ICU and hospital length of stay. Results: There was no difference in the proportion of patients with postoperative renal dysfunction(29.7%vs 29.0%, P=.89; relative risk[RR], 1.03[95%confidence interval {CI}, 0.72-1.46]) in the N-acetylcysteine and placebo groups, respectively. We noted nonsignificant differences in postoperative interventions and complications, the need for RRT(0.7%vs 2.1%; P=.37), total(6.1%vs 9.6%; P=.26) and serious adverse events, hospital mortality(3.4%vs 2.7%; P >.99), and ICU and hospital length of stay between the N-acetylcysteine and placebo groups. A post hoc subgroup analysis of patients(baseline creatinine level >1.4 mg/dL[120 μmol/L]) showed a nonsignificant trend toward fewer patients experiencing postoperative renal dysfunction in the N-acetylcysteine group compared with the placebo group(25.0%vs 37.1%; P=.29). Conclusions: N-acety-lcysteine did not prevent postoperative renal dysfunction, interventions, complications, or mortality in high-risk patients undergoing CABG surgery with CPB. Further research is required to identify CABG patients at risk for postoperative renal events, valid markers of renal dysfunction, and to establish renal thresholds associated with important clinical outcomes.
文摘An association between minor endometriosis and subfertility is shown by prevalence studies but a clear causal relationship has not yet been demonstrated. This review presents the evidence for pituitary-ovarian dysfunction as a cause for subfertility in women with minor endometriosis. Using tubal infertility cases as controls, group comparison has shown effects on the following: follicular growth (impaired) , preovulatory circulating oestradiol levels (reduced) and early luteal phase oestradiol and progesterone (reduced) , and LH surge patterns (disordered), preovulatory follicular fluid LH concentration (reduced) , and granulosa cell steroidogenic capacity (impaired) . However, these findings are not consistent in the literature. Compared with controls, reduced oocyte fertilisation and implantation rates are reported in natural and go-nadotrophin stimulated cycles. An inherent disorder of follicular function is possible as a cause, with LH surge impairment probably a secondary phenomenon. Natural sub-fertility is substantially disordered as a result of oocyte fertilisation impairment. However, as excess numbers of oocytes are available in bitrofertility in vitro fertility (IVF) is still successful.
文摘To theeditor:The incidence of depression and obesity is on the rise,posing significant public health concerns.While the literature largely supports a positive correlation between depression and body mass index(BMI),I2 earlier studies have suggested an inverse relationship or indicated a lack of association between depression and obesity.
文摘South Asians(SA)are at higher cardiovascular risk than other ethnic groups,and SA kidney transplant recipients(SA KTR)are no exception.SA KTR experience increased major adverse cardiovascular events both early and late posttransplantation.Cardiovascular risk management should therefore begin well before transplantation.SA candidates may require aggressive screening for pretransplant cardiovascular disease(CVD)due to their ethnicity and comorbidities.Recording SA ethnicity during the pre-transplant evaluation may enable programs to better assess cardiovascular risk,thus allowing for earlier targeted periand post-transplant intervention to improve cardiovascular outcomes.Diabetes remains the most prominent post-transplant cardiovascular risk factor in SA KTR.Diabetes also clusters with other metabolic syndrome components including lower high-density lipoprotein cholesterol,higher triglycerides,hypertension,and central obesity in this population.Dyslipidemia,metabolic syndrome,and obesity are all significant CVD risk factors in SA KTR,and contribute to increased insulin resistance.Novel biomarkers such as adiponectin,apolipoprotein B,and lipoprotein(a)may be especially important to study in SA KTR.Focused interventions to improve health behaviors involving diet and exercise may especially benefit SA KTR.However,there are few interventional clinical trials specific to the SA population,and none are specific to SA KTR.In all cases,understanding the nuances of managing SA KTR as a distinct post-transplant group,while still screening for and managing each CVD risk factor individually in all patients may help improve the long-term success of all kidney transplant programs catering to multi-ethnic populations.
文摘Due to the high risk of morbidity and mortality associated with surgical resection in this tract,endoscopic resection(ER)has taken the place of surgical resection as the first line treatment for non-ampullary duodenal adenomas.However,due to the anatomical characteristics of this area,which enhance the risk of post-ER problems,ER in the duodenum is particularly difficult.Due to a lack of data,no ER technique for superficial non-ampullary duodenal epithelial tumours(SNADETs)has yet been backed by strong,high-quality evidence;yet,traditional hot snare-based techniques are still regarded as the standard treatment.Despite having a favourable efficiency profile,adverse events during duodenal hot snare polypectomy(HSP)and hot endoscopic mucosal resection,such as delayed bleeding and perforation,have been reported to be frequent.These events are primarily caused by electrocautery-induced damage.Thus,ER techniques with a better safety profile are needed to overcome these shortcomings.Cold snare polypectomy,which has already been shown as a safer,equally effective pro-cedure compared to HSP for treatment of small colorectal polyps,is being increasingly evaluated as a potential therapeutic option for non-ampullary duodenal adenomas.The aim of this review is to report and discuss the early outcomes of the first experiences with cold snaring for SNADETs.
