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Journal: Zhonghua nei ke za zhi

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Objective: To compare the differences in cognitive function and behavioral and psychological symptoms between patients with Alzheimer’s disease (AD) and behavioral variant frontotemporal dementia (bvFTD). Methods: Thirty-six AD patients and 20 bvFTD patients at mild-to-moderate stage, who were biomarker-confirmed by positron emission tomography (PET), were assessed with a neuropsychological battery and neuropsychiatry inventory (NPI). Cognitive domains, including memory, language, information processing speed and executive function, and behavioral and psychological symptoms were assessed and compared. Results: AD patients had lower scores in immediate recall, delayed recall and recognition than bvFTD patients (all P<0.05); while bvFTD patients had poorer performance in language and executive function than AD patients (all P<0.05). The NPI total score was significantly higher in patients with bvFTD compared with patients with AD (17.5±5.7 vs 9.3±3.5, P<0.05). In respect to the 12 items of NPI, the incidence of agitation and irritability was higher in AD group than in bvFTD group (72.2% vs 35.0%, 55.6% vs 20.0%, all P<0.05); while the incidence of apathy, disinhibition, euphoria, aberrant motor behavior and appetite/eating was higher in bvFTD group than in AD group (65.0% vs 33.3%, 80.0% vs 5.5%, 70.0% vs 5.6%, 40.0% vs 11.1%, 50.0% vs 5.6%, all P<0.05). Conclusion: Comprehensive neuropsychological assessment and evaluation of behavioral and psychological symptoms of patients with dementia are helpful in distinguishing AD from bvFTD.

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Objective: To compare the performance of the revision of Atlanta classification (RAC) and determinant-based classification (DBC) in acute pancreatitis. Methods: Consecutive patients with acute pancreatitis admitted to a single center from January 2001 to January 2015 were retrospectively analyzed. Patients were classified into mild, moderately severe and severe categories based on RAC and were simultaneously classified into mild, moderate, severe and critical grades according to DBC. Disease severity and clinical outcomes were compared between subgroups. The receiver operating curve (ROC) was used to compare the utility of RAC and DBC by calculating the area under curve (AUC). Results: Among 1 120 patients enrolled, organ failure occurred in 343 patients (30.6%) and infected necrosis in 74 patients(6.6%). A total of 63 patients (5.6%) died. Statistically significant difference of disease severity and outcomes was observed between all the subgroups in RAC and DBC (P<0.001). The category of critical acute pancreatitis (with both persistent organ failure and infected necrosis) had the most severe clinical course and the highest mortality (19/31, 61.3%). DBC had a larger AUC (0.73, 95%CI 0.69-0.78) than RAC (0.68, 95%CI 0.65-0.73) in classifying ICU admissions (P=0.031), but both were similar in predicting mortality(P=0.372) and prolonged ICU stay (P=0.266). Conclusions: DBC and RAC perform comparably well in categorizing patients with acute pancreatitis regarding disease severity and clinical outcome. DBC is slightly better than RAC in predicting prolonged hospital stay. Persistent organ failure and infected necrosis are risk factors for poor prognosis and presence of both is associated with the most dismal outcome.

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Objective: To increase the consciousness of incident deep venous thrombosis (DVT) in hospitalized patients. Methods: This is a retrospective study of hospitalized patients with DVT in Beijing Shijitan Hospital from 2007 to 2016. Clinical features of DVT patients who were admitted with no DVT were summarized. The demographic and epidemiological characteristics, involved site of veins, department of patients and risk factors were discussed. Results: A total of 5 063 patients were complicated with DVT from 305 922 inpatients who were without DVT at the admission during past 10 years. Among them, 54.36% (2 752/5 063) were men. The age of the patients was (74.1±15.9) years old (range 1-103 years) with 37.78% of them in 80 to 89 age group. The incidence of DVT in the hospital was 1.65%. It increased yearly during the past decade (from 0.50% to 2.74%), and increased with age in patients from 1 to 99 years old (7.32% in 90-99 age group). Totally, 5 204 veins were involved in the patients. Most thrombosis involved inferior vena cava system (96.54%,5 024/5 204), especially deep veins of lower extremity (83.78%,4 360/5 204), some involved portal veins (8.61%,448/5 204) and a little was found in superior venae cava (3.46%, 180/5 204). More DVT patients were in department of internal medicine than those in department of surgery (2.95% vs 0.97%, P<0.01). ICU had the highest rate of DVT among the hospital departments (9.75%). No DVT occurred in department of newborn. Risk factors of DVT were inflammatory diseases (71.54%), age over 75 years old (67.25%), and heart diseases (58.98%). Conclusion: Sensitivity of detection on DVT should be emphasized in hospitalized patients with DVT risk, especially at the department with high incident of DVT.

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Objective: To explore the characteristics of electrocardiogram(ECG) and target potential features of premature ventricular contraction (PVC) in patients with complete left/right bundle branch block (CL/RBBB) and compare with those without CL/RBBB. Methods: A retrospective analysis was done in 8 outflow tract PVC patients with CL/RBBB, who successfully underwent radiofrequency ablation from August 2009 to June 2017. According to the bundle branch block chamber, patients were divided into the complete right bundle branch block (CRBBB) group (n=4) and the complete left bundle branch block (CLBBB) group (n=4). The control group were those who successfully underwent ablation at the same position as the above two groups but without CL/RBBB. The characteristics of ECG and target potential features were compared among groups. Results: One case in the CRBBB group was successfully ablated in the great cardiac vein with precordial R/S>1 transition at V(1) and one case in the CLBBB group was successfully ablated in the right coronary cusp with precordial R/S>1 transition at V(2), while other 6 cases were all with precordial R/S>1 transition at lead V(4). Precordial R/S>1 transition was not later than sinus rhythm (SR) in the CLBBB group. No statistical difference was found in the QRS complex duration between SR and PVC in the CL/RBBB patients [(134.38±23.80)ms vs (156.75±25.93)ms, P>0.05], while statistical difference was shown in the control group [(92.63±5.76)ms vs (140.25±15.97)ms, P<0.05]. Conclusion: Bundle branch block can lead to misjudgment of PVC origin with CL/RBBB during sinus rhythm, thus the origin chamber of the PVC should be determined according to the mapping and ablation result.

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Objective: To analyze the clinicopathological characteristics of renal lesions in type 2 diabetic patients and to differentiate diabetic nephropathy (DN) from non-diabetic renal diseases(NDRD). Methods: Type 2 diabetic patients who received renal biopsy in Ruijin Hospital from January 2011 to December 2015 were recruited in this study. Clinical history, laboratory results and pathological data were retrospectively collected. According to the pathological findings, the patients were divided into 3 groups: DN, NDRD, DN+NDRD. Logistic model was applied to explore the independent clinical predictive factors in differentiating DN from NDRD. Results: A total of 207 type 2 diabetic patients received renal biopsy, accounting for 6.82% of all biopsy population. Fifty-one patients were diagnosed with DN, 142 with NDRD and 14 with both DN and NDRD. In NDRD, membranous nephropathy(MN)(34.5%) was the most common finding, followed by IgA nephropathy(19.7%).By contrast, NDRD patients manifested a shorter diabetic course, a higher baseline hemoglobin level, a lower baseline serum creatinine, a higher prevalence of hematuria, a lower prevalence of hypertension and diabetic retinopathy, a better control of blood glucose, better compliance of monitoring blood glucose and less family history of diabetes. In multivariate logistic model, diabetic family history(OR=4.68, P=0.04) and long history of diabetes(OR=1.01, P=0.02) were risk factors of DN. Conclusion: There is a high prevalence of NDRD in diabetic patients with renal lesions. Family history of diabetes and duration of diabetes are independent predictors of DN.

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Objective: To investigate doctors' and nurses' perceptions and implementation of delirium management in intensive care unit. Methods: A total of 197 doctors and nurses in 2 general ICUs and 3 special ICUs at Peking Union Medical College Hospital finished a self-designed questionnaire of delirium management. Results: There were 47 males and 150 females, 43 doctors and 154 nurses who participated in the survey.One hundred and twenty five participators were from general ICU and the others from special ICU. The ICU staff had a significant difference on the perceptions and implementation of delirium management(P< 0.001) including. Doctors and nurses scored lowest in "family engagement and empowerment" and "sleep management" with (4.620±2.393) and (5.430±2.153) respectively. There was a significant difference between nurses and doctors in the management of analgesia and sedation (P< 0.05).Doctors and nurses from different ICUs had significant discrepancy in the implementation of "delirium assessment" (P< 0.05). Conclusions: The ICU staff should improve the perceptions and the implementation of delirium management,especially in special ICUs. Delirium management should be included as a routine care in ICU to improve patients' outcome.

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Objective: To evaluate the efficacy and safety of golimumab in patients with active ankylosing spondylitis (AS). Methods: This was a randomized, double-blind, placebo-controlled trial. The subjects were randomized to receive either golimumab 50mg subcutaneously or placebo every 4 weeks. Patients in both groups received golimumab 50mg from week 24 to week 48. The primary endpoint was the proportion of at least 20% improvement in the Assessment of Spondyloarthritis International Society (ASAS20) at week 14. The secondary endpoints included at least 40% improvement in the Assessment of Spondyloarthritis International Society (ASAS40), ASAS partial-remission, Bath AS functional index, Bath AS disease activity index, Bath AS metrology index, enthesitis index and Jenkins sleep evaluation questionnaire. Results: A total of 25 subjects were included in this study, 13 with golimumab and 12 with placebo. At Week 14, 6(46.2%) subjects achieved ASAS20 in golimumab group and 2(16.7%) in placebo group. Significant improvements of other efficacy endpoints were also found in golimumab group. Golimumab was safe and well to lerated. Most of the adverse events were slightly impaired liver function, where as elevated aspartate aminotransferase and/or alanine aminotransferase returned to normal without drug with drawal. Conclusion: Golimumab improves AS activity, clinical symptoms and sleep disturbance in patients with active AS with good safety and tolerability.

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To investigate the accuracy and feasibility of Brix value on monitoring gastric residual volume (GRV) in patients with enteral nutrition. Fifty patients with enteral nutrition via nasogastric tube were enrolled. The GRV was measured by both ultrasonography and Brix value. The results were compared according to the methods. The Pearson correlation coefficients showed that GRV measured by these two ways was positively correlated (r=0.986, P<0.05). Moreover paired sample t-test showed that the discrepancy was not statistically significant (P>0.05) between different measurements. The consistency was analyzed by Bland-Altman graph, showing that the two measurements were consistent. Brix value is recommended to measure GRV due to its convenience and easy operation.

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To establish the experts consensus on the right heart function management in critically ill patients. The panel of consensus was composed of 30 experts in critical care medicine who are all members of Critical Hemodynamic Therapy Collaboration Group (CHTC Group). Each statement was assessed based on the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) principle. Then the Delphi method was adopted by 52 experts to reassess all the statements. (1) Right heart function is prone to be affected in critically illness, which will result in a auto-exaggerated vicious cycle. (2) Right heart function management is a key step of the hemodynamic therapy in critically ill patients. (3) Fluid resuscitation means the process of fluid therapy through rapid adjustment of intravascular volume aiming to improve tissue perfusion. Reversed fluid resuscitation means reducing volume. (4) The right ventricle afterload should be taken into consideration when using stroke volume variation (SVV) or pulse pressure variation (PPV) to assess fluid responsiveness.(5)Volume overload alone could lead to septal displacement and damage the diastolic function of the left ventricle. (6) The Starling curve of the right ventricle is not the same as the one applied to the left ventricle,the judgement of the different states for the right ventricle is the key of volume management. (7) The alteration of right heart function has its own characteristics, volume assessment and adjustment is an important part of the treatment of right ventricular dysfunction (8) Right ventricular enlargement is the prerequisite for increased cardiac output during reversed fluid resuscitation; Nonetheless, right heart enlargement does not mandate reversed fluid resuscitation.(9)Increased pulmonary vascular resistance induced by a variety of factors could affect right heart function by obstructing the blood flow. (10) When pulmonary hypertension was detected in clinical scenario, the differentiation of critical care-related pulmonary hypertension should be a priority. (11) Attention should be paid to the change of right heart function before and after implementation of mechanical ventilation and adjustment of ventilator parameter. (12) The pulmonary arterial pressure should be monitored timingly when dealing with critical care-related pulmonary hypertension accompanied with circulatory failure.(13) The elevation of pulmonary aterial pressure should be taken into account in critical patients with acute right heart dysfunction. (14) Prone position ventilation is an important measure to reduce pulmonary vascular resistance when treating acute respiratory distress syndrome patients accompanied with acute cor pulmonale. (15) Attention should be paid to right ventricle-pulmonary artery coupling during the management of right heart function. (16) Right ventricular diastolic function is more prone to be affected in critically ill patients, the application of critical ultrasound is more conducive to quantitative assessment of right ventricular diastolic function. (17) As one of the parameters to assess the filling pressure of right heart, central venous pressure can be used to assess right heart diastolic function. (18). The early and prominent manifestation of non-focal cardiac tamponade is right ventricular diastolic involvement, the elevated right atrial pressure should be noticed. (19) The effect of increased intrathoracic pressure on right heart diastolic function should be valued. (20) Ttricuspid annular plane systolic excursion (TAPSE) is an important parameter that reflects right ventricular systolic function, and it is recommended as a general indicator of critically ill patient. (21) Circulation management with right heart protection as the core strategy is the key point of the treatment of acute respiratory distress syndrome. (22) Right heart function involvement after cardiac surgery is very common and should be highly valued. (23) Right ventricular dysfunction should not be considered as a routine excuse for maintaining higher central venous pressure. (24) When left ventricular dilation, attention should be paid to the effect of left ventricle on right ventricular diastolic function. (25) The impact of left ventricular function should be excluded when the contractility of the right ventricle is decreased. (26) When the right heart load increases acutely, the shunt between the left and right heart should be monitored. (27) Attention should be paid to the increase of central venous pressure caused by right ventricular dysfunction and its influence on microcirculation blood flow. (28) When the vasoactive drugs was used to reduce the pressure of pulmonary circulation, different effects on pulmonary and systemic circulation should be evaluated. (29) Right atrial pressure is an important factor affecting venous return. Attention should be paid to the influence of the pressure composition of the right atrium on the venous return. (30) Attention should be paid to the role of the right ventricle in the acute pulmonary edema. (31) Monitoring the difference between the mean systemic filling pressure and the right atrial pressure is helpful to determine whether the infusion increases the venous return. (32) Venous return resistance is often considered to be a insignificant factor that affects venous return, but attention should be paid to the effect of the specific pathophysiological status, such as intrathoracic hypertension, intra-abdominal hypertension and so on. Consensus can promote right heart function management in critically ill patients, optimize hemodynamic therapy, and even affect prognosis.

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An 61-year-old woman presenting deep vein thrombosis and persistent positive anticardiolipin antibodies was diagnosed as antiphospholipid syndrome and treated with low molecular weight heparin. Before and after anticoagulant therapy, continuous positive fecal occult-blood was found asymptomatically. Colonoscopy confirmed rectal cancer. Antiphospholipid autoantibodies are non-specially positive in some malignances, especially in elder onset patients. Thus, routine screening of malignancies is strongly suggested.