To the editor:Peer workers-people with personal experiences of using mental health services,trained to provide support to others currently using similar services--are increasingly integrated into the workforce of ment...To the editor:Peer workers-people with personal experiences of using mental health services,trained to provide support to others currently using similar services--are increasingly integrated into the workforce of mental health systems internationally.展开更多
Background:Muscular strength is a powerful marker of current health status and robust predictor of age-related disease and disability.Handgrip strength(HGS)using isometric dynamometry is a convenient,feasible,and wide...Background:Muscular strength is a powerful marker of current health status and robust predictor of age-related disease and disability.Handgrip strength(HGS)using isometric dynamometry is a convenient,feasible,and widely used method of assessing muscular strength among people of all ages.While adult HGS norms have been published for many countries,no study has yet synthesized available data to produce international norms.The objective of this study was to generate international sex-and age-specific norms for absolute and body size-normalized HGS across the adult lifespan.Methods:Systematic searches were conducted in 6 databases/web search engines(MEDLINE,SPORTDiscus,Embase,Web of Science,CINAHL,and Google Scholar)up to December 1,2023.We included full-text peer-reviewed observational studies that reported normative HGS data for adults aged ≥20 years by sex and age.Pseudo data were generated using Monte Carlo simulation following harmonization for methodo-logical variation.Population-weighted Generalized Additive Models for Location,Scale,and Shape were used to develop sex-and age-specific norms for absolute HGS(kg)and HGS normalized by height(Ht,m)squared(i.e.,HGS/Ht^(2)in kg/m^(2)).Norms were tabulated as percentile values(5th to 95th)and visualized as smoothed percentile curves.Results:We included data from 100 unique observational studies representing 2,405,863 adults(51.9%female)aged 20 to 100+years from 69 countries and regions tested from the year 2000 onward.On average,absolute and normalized HGS values negligibly improved throughout early adulthood,peaked from age 3039 years(at 49.7 kg(males)and 29.7 kg(females)for absolute HGS or 16.3 kg/m^(2)(males)and 11.3 kg/m^(2)(females)for HGS/Ht^(2)),and declined afterwards.The age-related decline in HGS accelerated from middle to late adulthood and was slightly larger for males than for females during middle adulthood.Conclusion:This study provides the world’s largest and most geographically comprehensive international norms for adult HGS by sex and age.These norms have utility for global peer-comparisons,health screening,and surveillance.展开更多
Atrial fibrillation(AF)is the most common arrhythmia diagnosed in clinical practice.The consequences of AF have been clearly estab-lished in multiple large observational cohort studies and include increased stroke and...Atrial fibrillation(AF)is the most common arrhythmia diagnosed in clinical practice.The consequences of AF have been clearly estab-lished in multiple large observational cohort studies and include increased stroke and systemic embolism rates if no oral anticoagulation is prescribed,with increased morbidity and mortality.With the worldwide aging of the population characterized by a large influx of"baby boomers"with or without risk factors for developing AF,an epidemic is forecasted within the next 10 to 20 years.Although not all studies support this evidence,it is clear that AF is on the rise and a significant amount of health resources are invested in detecting and managing AF This review focuses on the worldwide burden of AF and reviews global health strategies focused on improving detection,prevention and risk stratification of AF,recently recommended by the World Heart Federation.展开更多
Background:Both hypertension and grip strength(GS)are predictors of mortality and cardiovascular disease(CVD),but whether these risk factors interact to affect CVD and all-cause mortality is unknown.This study sought ...Background:Both hypertension and grip strength(GS)are predictors of mortality and cardiovascular disease(CVD),but whether these risk factors interact to affect CVD and all-cause mortality is unknown.This study sought to investigate the associations of GS with the risk of major CVD incidence,CVD mortality,and all-cause mortality in patients with hypertension.Methods:GS was measured using a Jamar dynamometer(Sammons Preston,Bolingbrook,IL,USA)in participants aged 3570 years from 12 provinces included in the Prospective Urban Rural Epidemiology China Study.Cox frailty proportional hazards models were used to examine the associations of GS and hypertension and the outcomes of all-cause mortality and CVD incidence/mortality.Results:Among 39,862 participants included in this study,15,964 reported having hypertension,and 9095 had high GS at baseline.After a median follow-up of 8.9 years(interquartile range,6.79.9 years),1822 participants developed major CVD,and 1250 deaths occurred(388 as a result of CVD).Compared with normotensive participants with high GS,hypertensive patients with high GS had a higher risk of major CVD incidence(hazard ratio(HR)=2.39;95%confidence interval(95%CI):1.863.06;p<0.001)or CVD mortality(HR=3.11;95%CI:1.596.06;p<0.001)but did not have a significantly increased risk of all-cause mortality(HR=1.24;95%CI:0.921.68;p=0.159).These risks were further increased if hypertensive participants whose GS level was low(major CVD incidence,HR=3.31,95%CI:2.604.22,p<0.001;CVD mortality,HR=4.99,95%CI:2.649.43,p<0.001;and all-cause mortality,HR=1.93,95%CI:1.472.53,p<0.001).Conclusion:The present study demonstrates that low GS is associated with the highest risk of major CVD incidence,CVD mortality,and all-cause mortality among hypertensive patients.High levels of GS appear to mitigate long-term mortality risk among hypertensive patients.展开更多
AIM:To investigate whether routinely measured clinical variables could aid in differentiating intestinal tuberculosis(ITB)from Crohn’s disease(CD).METHODS:ITB and CD patients were prospectively included at four South...AIM:To investigate whether routinely measured clinical variables could aid in differentiating intestinal tuberculosis(ITB)from Crohn’s disease(CD).METHODS:ITB and CD patients were prospectively included at four South Indian medical centres from October 2009 to July 2012.Routine investigations included case history,physical examination,blood biochemistry,ileocolonoscopy and histopathological examination of biopsies.Patients were followed-up after 2 and 6 mo of treatment.The diagnosis of ITB or CD was re-evaluated after 2 mo of antituberculous chemotherapy or immune suppressive therapy respectively,based on improvement in signs,symptoms and laboratory variables.This study was considered to be an exploratory analysis.Clinical,endoscopic and histopathological features recorded at the time of inclusion were subject to univariate analyses.Disease variables with sufficient number of recordings and P<0.05 were entered into logistic regression models,adjusted for known confounders.Finally,we calculated the odds ratios with respective confidence intervals for variables associated with either ITB or CD.RESULTS:This study included 38 ITB and 37 CD patients.Overall,ITB patients had the lowest body mass index(19.6 vs 22.7,P=0.01)and more commonly reported weight loss(73%vs 38%,P<0.01),watery diarrhoea(64%vs 33%,P=0.01)and rural domicile(58%vs 35%,P<0.05).Endoscopy typically showed mucosal nodularity(17/31 vs 2/37,P<0.01)and histopathology more frequently showed granulomas(10/30vs 2/35,P<0.01).The CD patients more frequently reported malaise(87%vs 64%,P=0.03),nausea(84%vs 56%,P=0.01),pain in the right lower abdominal quadrant on examination(90%vs 54%,P<0.01)and urban domicile(65%vs 42%,P<0.05).In CD,endoscopy typically showed involvement of multiple intestinal segments(27/37 vs 9/31,P<0.01).Using logistic regression analysis we found weight loss and nodularity of the mucosa were independently associated with ITB,with adjusted odds ratios of 8.6(95%CI:2.1-35.6)and 18.9(95%CI:3.5-102.8)respectively.Right lower abdominal quadrant pain on examination and involvement of≥3 intestinal segments were independently associated with CD with adjusted odds ratios of 10.1(95%CI:2.0-51.3)and 5.9(95%CI:1.7-20.6),respectively.CONCLUSION:Weight loss and mucosal nodularity were associated with ITB.Abdominal pain and excessive intestinal involvement were associated with CD.ITB and CD were equally common.展开更多
Context: Experimental and epidemiological data suggest that vitamin E supplementation may prevent cancer and cardiovascular events. Clinical trials have generally failed to confirm benefits, possibly due to their rela...Context: Experimental and epidemiological data suggest that vitamin E supplementation may prevent cancer and cardiovascular events. Clinical trials have generally failed to confirm benefits, possibly due to their relatively short duration. Objective: To evaluate whether long-term supplementation with vitamin E decreases the risk of cancer, cancer death, and major cardiovascular events. Design, Setting, and Patients: A randomized, double-blind, placebo-controlled international trial(the initial Heart Outcomes Prevention Evaluation[HOPE] trial conducted between December 21, 1993, and April 15,1999) of patients at least 55 years old with vascular disease or diabetes mellitus was extended(HOPE-The Ongoing Outcomes[HOPE-TOO]) between April 16,1999, and May 26, 2003. Of the initial 267 HOPE centers that had enrolled 9541 patients, 174 centers participated in the HOPE-TOO trial. Of 7030 patients enrolled at these centers, 916 were deceased at the beginning of the extension, 1382 refused participation, 3994 continued to take the study intervention, and 738 agreed to passive follow-up. Median duration of follow-up was 7.0 years. Intervention: Daily dose of natural source vitamin E(400 IU) or matching placebo. Main Outcome Measures: Primary outcomes included cancer incidence, cancer deaths, and major cardiovascular events(myocardial infarction, stroke, and cardiovascular death). Secondary outcomes included heart failure, unstable angina, and revascularizations. Results: Among all HOPE patients, there were no significant differences in the primary analysis: for cancer incidence, there were 552 patients(11.6%) in the vitamin E group vs 586(12.3%) in the placebo group(relative risk[RR], 0.94; 95%confidence interval[CI], 0.84-1.06; P=.30); for cancer deaths, 156(3.3%) vs 178(3.7%), respectively(RR, 0.88; 95%CI, 0.71-1.09; P=.24); and for major cardiovascular events, 1022(21.5%) vs 985(20.6%), respectively(RR, 1.04; 95%CI, 0.96-1.14; P=.34). Patients in the vitamin E group had a higher risk of heart failure(RR, 1.13; 95%CI, 1.01-1.26; P=.03) and hospitalization for heart failure(RR, 1.21; 95%CI, 1.00-1,47; P=.045). Similarly, among patients enrolled at the centers participating in the HOPE-TOO trial, there were no differences in cancer incidence, cancer deaths, and major cardiovascular events, but higher rates of heart failure and hospitalizations for heart failure. Conclusion: In patients with vascular disease or diabetes mellitus, longterm vitamin E supplementation does not prevent cancer or major cardiovascular events and may increase the risk for heart failure.展开更多
BACKGROUND: In observational studies, lower homocysteine levels are associated with lower rates of coronary heart disease and stroke. Folic acid and vitamins B6 and B12 lower homocysteine levels. We assessed whether s...BACKGROUND: In observational studies, lower homocysteine levels are associated with lower rates of coronary heart disease and stroke. Folic acid and vitamins B6 and B12 lower homocysteine levels. We assessed whether supplementation reduced the risk of major cardiovascular events in patients with vascular disease. METHODS: We randomly assigned 5522 patients 55 years of age or older who had vascular disease or diabetes to daily treatment either with the combination of 2.5 mg of folic acid, 50 mg of vitamin B6, and 1 mg of vitamin B12 or with placebo for an average of five years. The primary outcome was a composite of death from cardiovascular causes, myocardial infarction, and stroke. RESULTS: Mean plasma homocysteine levels decreased by 2.4 μmol per liter(0.3 mg per liter) in the active-treatment group and increased by 0.8 μmol per liter(0.1 mg per liter) in the placebo group. Primary outcome events occurred in 519 patients(18.8 percent) assigned to active therapy and 547(19.8 percent) assigned to placebo(relative risk, 0.95; 95 percent confidence interval, 0.84 to 1.07; P=0.41). As compared with placebo, active treatment did not significantly decrease the risk of death from cardiovascular causes(relative risk, 0.96; 95 percent confidence interval, 0.81 to 1.13), myocardial infarction(relative risk, 0.98; 95 percent confidence interval, 0.85 to 1.14), or any of the secondary outcomes. Fewer patients assigned to active treatment than to placebo had a stroke(relative risk, 0.75; 95 percent confidence interval, 0.59 to 0.97). More patients in the active-treatment group were hospitalized for unstable angina(relative risk, 1.24; 95 percent confidence interval, 1.04 to 1.49). CONCLUSIONS: Supplements combining folic acid and vitamins B6 and B12 did not reduce the risk of major cardiovascular events in patients with vascular disease.展开更多
BACKGROUND: The combined use of anticoagulants, antiplatelet agents, and invasive coronary procedures reduces ischemic coronary events but also increases bleeding in patients with acute coronary syndromes. We therefor...BACKGROUND: The combined use of anticoagulants, antiplatelet agents, and invasive coronary procedures reduces ischemic coronary events but also increases bleeding in patients with acute coronary syndromes. We therefore assessed whether fondaparinux would preserve the anti-ischemic benefits of enoxaparin while reducing bleeding. METHODS: We randomly assigned 20,078 patients with acute coronary syndromes to receive either fondaparinux(2.5 mg daily) or enoxaparin(1 mg per kilogram of body weight twice daily) for a mean of six days and evaluated death, myocardial infarction, or refractory ischemia at nine days(the primary outcome); major bleeding; and their combination. Patients were followed for up to six months. RESULTS: The number of patients with primary outcome events was similar in the two groups(579 with fondaparinux[5.8 percent] vs. 573 with enoxaparin[5.7 percent]; hazard ratio in the fondaparinux group, 1.01; 95 percent confidence interval, 0.90 to 1.13), satisfying the noninferiority criteria. The number of events meeting this combined outcome showed a nonsignificant trend toward a lower value in the fondaparinux group at 30 days(805 vs. 864, P=0.13) and at the end of the study(1222 vs. 1308, P=0.06). The rate of major bleeding at nine days was markedly lower with fondaparinux than with enoxaparin(217 events[2.2 percent] vs. 412 events[4.1 percent]; hazard ratio, 0.52; P< 0.001). The composite of the primary outcome and major bleeding at nine days favored fondaparinux(737 events[7.3 percent] vs. 905 events[9.0 percent]; hazard ratio, 0.81; P< 0.001). Fondaparinux was associated with a significantly reduced number of deaths at 30 days(295 vs. 352, P=0.02) and at 180 days(574 vs. 638, P=0.05). CONCLUSIONS: Fondaparinux is similar to enoxaparin in reducing the risk of ischemic events at nine days, but it substantially reduces major bleeding and improves long term mortality and morbidity.展开更多
Objective:Bariatric surgery has been shown to be an effective method of treatment for obstructive sleep apnea(OSA)with long-term benefits,however,the mechanisms of action and the optimum operative procedure remains un...Objective:Bariatric surgery has been shown to be an effective method of treatment for obstructive sleep apnea(OSA)with long-term benefits,however,the mechanisms of action and the optimum operative procedure remains unclear.The aim of this systemic review was to compare the efficacy of laparoscopic sleeve gastrectomy(LSG)and Roux-en-Y gastric bypass(RYGB)in resolving OSA.Methods:A comprehensive search of MEDLINE,Pubmed,Embase,and OVID was performed.Studies that reported OSA resolution in obese patients with BMI>30 kg/m2 were included in the study.RCTs,comparative prospective and matched cohort studies comparing RYGB with LSG were considered for this study.Results:Five studies(309 participants)were included:4 cohort studies and 1 RCT;all with low risk of bias.At 12 months follow-up,there was a trend towards improved resolution of OSA with LSG(OR 0.47,95%CI[0.20 to 1.06];p=0.07)when compared to RYGB.In contrast,there was a trend to poorer weight loss in the LSG group(SMD 3.83,95%CI[-1.82 to 9.48];p=0.18).Similarly,at 36 months follow-up,there was a trend towards better resolution of OSA with LSG(OR 0.52,95%CI[0.16 to 1.71];p=0.28)and a significantly poorer weight loss in LSG when compared to RYGB(SMD 8.25,95%CI[2.91 to 13.58];p=0.002).Conclusion:Despite poorer weight loss following LSG,there is a trend towards increased resolution of sleep apnea post-LSG.These findings suggest the possibility of weight loss independent factors causing OSA resolution,which should be further investigated.Registration:PROSPERO:CRD42018090367.展开更多
AIM:To molecularly characterize hepatitis B virus(HBV)isolates from Kerala and to relate them to the clinical manifestation of infection.METHODS:Sera and clinical data were collected from91 patients diagnosed with chr...AIM:To molecularly characterize hepatitis B virus(HBV)isolates from Kerala and to relate them to the clinical manifestation of infection.METHODS:Sera and clinical data were collected from91 patients diagnosed with chronic HBV infection and HBV-related hepatocellular carcinoma(HCC).HBV from44 HCC,22 cirrhotic and 25 chronic hepatitis patients were genotyped by sequencing of the complete S region or by restriction fragment length polymorphism assays.The basic core promoter/precore region was sequenced.The complete surface DNA sequences were assembled and aligned manually,and then compared with the sequences of HBV of genotypes(A-J)from GenBank.The evolutionary history was inferred using the Neighbor-Joining method and the evolutionary distances computed using the Kimura 2-parameter method.Bootstrapping was performed using 1000 replicates.The TaqMan BS-1 probe was used to quantify HBV DNA at a lower detection limit of approximately20 IU/mL.Continuous variables were compared using an independent Student’s t test.Theχ2test or Fisher’s exact test was used to compare categorical variables.The differences were considered statistically significant at P<0.05.RESULTS:Irrespective of disease status,the predominant genotype was A(72%);95%belonging to subgenotype A1,followed by genotypes D(27%)and C(1%).HCC patients infected with subgenotype A1were significantly younger than those infected with D.Mutation A1762T/G1764A was significantly associated with HCC in both genotypes A and D.Mutation G1862T was more frequent in subgenotype A1(P<0.0001),and in combination with A1762T/G1764A,it was significantly associated with HBV from HCC patients.Mutation C1766T/T1768A was significantly associated with genotype A(P=0.05)and HCC(P=0.03).The preS2start codon M1T/I mutation was unique to genotype A strains(15.6%)from all disease groups and occurred at a higher frequency in isolates from HCC patients(P=0.076).A higher frequency of preS deletion mutants(33.3%)was observed in genotype A from HCC compared with non-HCC patients,but did not reach statistical significance.The preS2:F22L mutation was found in genotypes A and D.CONCLUSION:Kerala is the first Indian state in which subgenotype A1 has been found to predominate in liver disease patients who developed HCC at a relatively young age.展开更多
Objective: To assess current heart failure (HF) care processes and organizational context in long-term care (LTC) homes as a prelude to adapting the Canadian Cardiovascular Society (CCS) HF guidelines for use in these...Objective: To assess current heart failure (HF) care processes and organizational context in long-term care (LTC) homes as a prelude to adapting the Canadian Cardiovascular Society (CCS) HF guidelines for use in these settings. Methods: This research reports on the results of thirteen focus groups (N = 83 participants;average of 60 minutes duration) conducted in three Ontario LTC homes to better understand how HF was managed and how organizational context impacted care. Participants included physicians, nurse practitioners, registered nurses, registered practical nurses, and personal support workers. Results: Focus group findings revealed that the complexity of the LTC environment presents challenges for managing HF. Most residents have multiple advanced chronic conditions that must be managed simultaneously. Culturally, LTC is first and foremost a resident’s home where residents may choose not to comply with care recommendations. Staff routines, scopes of practice, professional hierarchies, available resources and government regulations limit flexibility in providing care. Staff lacked knowledge, skills and resources for managing HF. Nevertheless, all staff viewed LTC as the preferred place for managing HF, avoiding residents’ hospitalizations wherever possible. These data suggest that strategies for improving LTC staff communication and education, strengthening existing relationships between staff, family, residents and community resources, and acquiring additional resources in LTC homes have the potential to improve HF management in this setting. Conclusion: LTC is a complex and dynamic environment that presents many challenges for providing care for residents. This research provides the foundation for subsequent work to develop and test implementation strategies to manage HF in LTC, which are consistent with the CCS HF guidelines and are feasible within LTC staff’s work routines, capacities and resources.展开更多
Context: Although reperfusion therapy, aspirin, β-blockers, and angiotensin-converting enzyme inhibitors reduce mortality when used early in patients with acute myocardial infarction(MI), mortality and morbidity rema...Context: Although reperfusion therapy, aspirin, β-blockers, and angiotensin-converting enzyme inhibitors reduce mortality when used early in patients with acute myocardial infarction(MI), mortality and morbidity remain high. No antithrombotic or newer antiplatelet drug has been shown to reduce mortality in acute MI. Objective: To evaluate the effects of reviparin, a low-molecular-weight heparin, when initiated early and given for 7 days in addition to usual therapy on the primary composite outcome of death,myocardial reinfarction, or strokes at 7 and 30 days. Design, Setting, and Patients: A randomized, doubleblind, placebo-controlled trial(Clinical Trial of Reviparin and Metabolic Modulation in Acute Myocardial Infarction Treatment Evaluation [CREATE]) of 15570 patients with ST-segment elevation or new left bundle-branch block, presenting within 12 hours of symptom onset at 341 hospitals in India and China from July 2001 through July 2004. Intervention: Reviparin or placebo subcutaneously twice daily for 7 days. Main Outcome Measure: Primary composite outcome of death, myocardial reinfarction, or stroke at 7 and 30 days. Results: The primary composite outcome was significantly reduced from 854(11.0%) of 7790 patients in the placebo group to 745(9.6%) of 7780 in the reviparin group(hazard ratio [HR], 0.87; 95%CI, 0.79-0.96; P=.005). These benefits persisted at 30 days(1056 [13.6%] vs 921 [11.8%] patients; HR, 0.87; 95%CI, 0.79-0.95; P=.001) with significant reductions in 30-day mortality(877 [11.3%] vs 766 [9.8%]; HR, 0.87; 95%CI, 0.79-0.96; P=.005) and reinfarction(199 [2.6%] vs 154 [2.0%]; HR, 0.77; 95%CI, 0.62-0.95; P=.01), and no significant differences in strokes(64 [0.8%] vs 80 [1.0%]; P=.19). Reviparin treatment was significantly better when it was initiated very early after symptom onset at 7 days(< 2 hours: HR, 0.70; 95%CI, 0.52-0.96; P=.03; 30/1000 events prevented; 2 to< 4 hours: HR, 0.81; 95%CI, 0.67-0.98; P=.03; 21/1000 events prevented; 4 to< 8 hours: HR, 0.85; 95%CI, 0.73-0.99; P=.05; 16/1000 events prevented; and ≥8 hours:HR,1.06; 95%CI, 0.86-1.30; P=.58; P=.04 for trend). There was an increase in lifethreatening bleeding at 7 days with reviparin and placebo(17 [0.2%] vs 7 [0.1%], respectively; P=.07), but the absolute excess was small(1 more per 1000) vs reductions in the primary outcome(18 fewer per 1000) or mortality(15 fewer per 1000). Conclusions: In patients with acute ST-segment elevation or new left bundle-branch block MI, reviparin reduces mortality and reinfarction, without a substantive increase in overall stroke rates. There is a small absolute excess of life-threatening bleeding but the benefits outweigh the risks.展开更多
背景：南亚人中年轻时急性心肌梗死（AMI）的发生率高于其他国家个体，但原因不明。目的：评价并比较南亚本地人和来自其他国家的个体中危险因素与AMI的关系，尤其关注较年轻AMI。设计、地点和参与者：此标准化病例对照研究于1999年2月...背景：南亚人中年轻时急性心肌梗死（AMI）的发生率高于其他国家个体，但原因不明。目的：评价并比较南亚本地人和来自其他国家的个体中危险因素与AMI的关系，尤其关注较年轻AMI。设计、地点和参与者：此标准化病例对照研究于1999年2月至2003年3月间纳入研究对象，包括来自5个南亚国家15所医学中心的1732例首发AMI患者和2204例年龄、性别匹配的对照者，以及来自其他国家的10728例患者和12431例对照者。主要观察指标：AMI与危险因素的关系。结果：南亚首发AMI患者的平均年龄低于其他国家（53．0±11．4岁 vs 58．8±12．2岁；P〈0．001）。展开更多
Background Some dietary patterns are risk factors for acute myocardial infarction （AMI）. Chinese traditional food and habits vary from other cultures. The present study determined whether different dietary patterns ...Background Some dietary patterns are risk factors for acute myocardial infarction （AMI）. Chinese traditional food and habits vary from other cultures. The present study determined whether different dietary patterns were associated with AMI in Chinese people. Methods We conducted a case-control study. There were 1312 cases of first AMI and 2235 control subjects who did not have previous angina, diabetes mellitus, hypertension or stroke. Controls were matched to cases on age and gender. Diet was measured with a validated, 19 item food frequency questionnaire. We identified three major dietary patterns using factor analysis： vitamin and microelement pattern （high intake of vegetables, fruits and tofu）, carbohydrate pattern （high in grain）, and fat and protein pattern （high in meat, fish, eggs and fried foods）. Results After adjusting for all risk factors, the vitamin and microelement pattern was inversely associated with AMI risk （global P value, 0.0001）. Compared with the first quartile, the adjusted ORs of AMI were 0.81 （95% CI： 0.66-1.00） for the second quartile, 0.67 （95% CI： 0.54-0.82） for the third, and 0.70 （95% CI： 0.56-0.88） for the fourth. Several dietary frequencies （serves per week） including vegetables, fruits and tofu were closely associated with decrease of AMI risk. Carbohydrate pattern showed weak relationship with AMI. We observed a U-shaped association between frequencies of fat and protein pattern and AMI risk. Excessive fat intake increased the AMI risk. The adjusted OR of AMI associated with the higher level of green vegetables was 0.37 （95% CI： 0.24-0.57） in women and 0.65 （95% CI： 0.51-0.82） in men （P value for heterogeneity, 0.0140）. Conclusions Unhealthy dietary intake can increase the AMI risk. Improving intake of vegetables, fruits and tofu have the potential to partially prevent the rising epidemic of cardiovascular disease in China.展开更多
Background Many researches report that low socioeconomic status （SES） is associated with a higher risk of coronary heart disease （CHD）. This study aimed to determine whether levels of education, family income, and...Background Many researches report that low socioeconomic status （SES） is associated with a higher risk of coronary heart disease （CHD）. This study aimed to determine whether levels of education, family income, and other SES were associated with acute myocardial infarction （AMI） in the Chinese population, and to compare the difference in this association between northern and southern regions in China. Methods We conducted a case-control study. Cases were first AMI （n=2909）. Controls （n=2947） were randomly selected and frequency matched to cases on age and sex. SES was measured using education, family income, possessions in the household, and occupation. Results Low levels of education （8 years） were more common in cases compared to controls （53.4% and 44.1%; P=0,0001）. After adjusting all risk factors, the level of education was associated with AMI risk in the Chinese population （P=-0.0005）. The odds ratio （OR） associated with education of 8 years or less, compared with more than 12 years （trade school/college/university） was 1.33 （95% CI 1.12-1.59）, and for education of 9-12 years 1.04 （95% CI 0.88-1.33）. The proportion of higher income population was more in controls than cases （39.4% and 35.3%）. Number of possessions and non-professional occupation were only weakly or not at all independently related to AMI. The adjusted OR associated with the lower education was 2.38 （95% CI 1.67-3.39） in women, and 1.18 （95% CI 0.99-1.42） in men （P=0.0001, for heterogeneity）. The interaction between levels of education and different regions was significant （P=0.0206, for interaction）. Conclusion Several socioeconomic factors including levels of education and income were closely associated with increase of AMI risk in China, most markedly in northeast and southern area. The effect of education was stronger towards AMI in women than men.展开更多
To the Editor:Ovarian cancer(OC)is the third cause of death among women globally.[1]Approximately 90%of OC cases are derived from epithelial cells,and these tumors have distinct epidemiological,molecular,and clinical ...To the Editor:Ovarian cancer(OC)is the third cause of death among women globally.[1]Approximately 90%of OC cases are derived from epithelial cells,and these tumors have distinct epidemiological,molecular,and clinical characteristics.[2]High-grade serous ovarian cancer(HGSOC)is the most common subtype of epithelial ovarian cancer(EOC)and has been widely investigated.[3]Ovarian carcinosarcoma(OCS),also known as malignant mixed mesodermal tumor,is a rare and aggressive tumor that typically develops in the female genital tract.[4]Histologically,OCS is considered a high-grade lesion that harbors both carcinomatous and sarcomatous components.[5]Although OCS accounts for only 1–4%of EOC cases,it presents the worst prognosis among all EOC subtypes,[6,7]with a median survival time(MST)of less than 18 months.[5]Due to its rarity,ovarian OCS is challenging to study through prospective trials,resulting in a limited understanding of the disease.Despite this,no targeted treatment strategies are specifically developed for OCS.展开更多
This document is about heart failure(HF),including acute and chronic heart failure,heart failure with reduced ejection fraction and heart failure with preserved ejection fraction as well as cardiomyopathies.Context-sp...This document is about heart failure(HF),including acute and chronic heart failure,heart failure with reduced ejection fraction and heart failure with preserved ejection fraction as well as cardiomyopathies.Context-specific recommendations tailored to individual patient needs are highlighted providing a thorough evaluation of the risks,benefits,and overall value of each therapy,aiming to establish a standard of care that improves patient outcomes and reduces the burden of hospitalization in this susceptible population.These guidelines provide evidence-based recommendations that represent a group consensus considering many other published guidelines that have reviewed many of the issues discussed here,but they also make new recommendations where new evidence has recently emerged.Most importantly these guidelines also provide recommendations on a number of issues where resource limitations may put constraints on the care provided to HF patients.Such"economic adjustment"recommendations aim to provide guidance for situations when"Resources are somewhat limited"or when"Resources are severely limited".Hence,this document presents not only a comprehensive but also concise update to HF management guidelines thereby aiming to provide a unified strategy for the pharmacological,non-pharmacological,invasive and interventional management of this significant global health challenge that is applicable to the needs of healthcare around the globe.展开更多
基金funded by National Institute for Health Research(NIHR)(RP-PG-1212-20019)。
文摘To the editor:Peer workers-people with personal experiences of using mental health services,trained to provide support to others currently using similar services--are increasingly integrated into the workforce of mental health systems internationally.
基金supported by European Union's Horizon 2020 research and innovation programme under the Marie Sklodowska Curie grant agreement(No.101028929)BJFis supported by National Heart Foundation of Australia Postdoc-toral Fellowship(No.106588)+1 种基金BG is supported by Australian Government Research Training Program ScholarshipDPLis supported by Clive Kearon Award,McMaster University.Additional funding information can be found in Supplemen-tary Funding.
文摘Background:Muscular strength is a powerful marker of current health status and robust predictor of age-related disease and disability.Handgrip strength(HGS)using isometric dynamometry is a convenient,feasible,and widely used method of assessing muscular strength among people of all ages.While adult HGS norms have been published for many countries,no study has yet synthesized available data to produce international norms.The objective of this study was to generate international sex-and age-specific norms for absolute and body size-normalized HGS across the adult lifespan.Methods:Systematic searches were conducted in 6 databases/web search engines(MEDLINE,SPORTDiscus,Embase,Web of Science,CINAHL,and Google Scholar)up to December 1,2023.We included full-text peer-reviewed observational studies that reported normative HGS data for adults aged ≥20 years by sex and age.Pseudo data were generated using Monte Carlo simulation following harmonization for methodo-logical variation.Population-weighted Generalized Additive Models for Location,Scale,and Shape were used to develop sex-and age-specific norms for absolute HGS(kg)and HGS normalized by height(Ht,m)squared(i.e.,HGS/Ht^(2)in kg/m^(2)).Norms were tabulated as percentile values(5th to 95th)and visualized as smoothed percentile curves.Results:We included data from 100 unique observational studies representing 2,405,863 adults(51.9%female)aged 20 to 100+years from 69 countries and regions tested from the year 2000 onward.On average,absolute and normalized HGS values negligibly improved throughout early adulthood,peaked from age 3039 years(at 49.7 kg(males)and 29.7 kg(females)for absolute HGS or 16.3 kg/m^(2)(males)and 11.3 kg/m^(2)(females)for HGS/Ht^(2)),and declined afterwards.The age-related decline in HGS accelerated from middle to late adulthood and was slightly larger for males than for females during middle adulthood.Conclusion:This study provides the world’s largest and most geographically comprehensive international norms for adult HGS by sex and age.These norms have utility for global peer-comparisons,health screening,and surveillance.
文摘Atrial fibrillation(AF)is the most common arrhythmia diagnosed in clinical practice.The consequences of AF have been clearly estab-lished in multiple large observational cohort studies and include increased stroke and systemic embolism rates if no oral anticoagulation is prescribed,with increased morbidity and mortality.With the worldwide aging of the population characterized by a large influx of"baby boomers"with or without risk factors for developing AF,an epidemic is forecasted within the next 10 to 20 years.Although not all studies support this evidence,it is clear that AF is on the rise and a significant amount of health resources are invested in detecting and managing AF This review focuses on the worldwide burden of AF and reviews global health strategies focused on improving detection,prevention and risk stratification of AF,recently recommended by the World Heart Federation.
文摘Background:Both hypertension and grip strength(GS)are predictors of mortality and cardiovascular disease(CVD),but whether these risk factors interact to affect CVD and all-cause mortality is unknown.This study sought to investigate the associations of GS with the risk of major CVD incidence,CVD mortality,and all-cause mortality in patients with hypertension.Methods:GS was measured using a Jamar dynamometer(Sammons Preston,Bolingbrook,IL,USA)in participants aged 3570 years from 12 provinces included in the Prospective Urban Rural Epidemiology China Study.Cox frailty proportional hazards models were used to examine the associations of GS and hypertension and the outcomes of all-cause mortality and CVD incidence/mortality.Results:Among 39,862 participants included in this study,15,964 reported having hypertension,and 9095 had high GS at baseline.After a median follow-up of 8.9 years(interquartile range,6.79.9 years),1822 participants developed major CVD,and 1250 deaths occurred(388 as a result of CVD).Compared with normotensive participants with high GS,hypertensive patients with high GS had a higher risk of major CVD incidence(hazard ratio(HR)=2.39;95%confidence interval(95%CI):1.863.06;p<0.001)or CVD mortality(HR=3.11;95%CI:1.596.06;p<0.001)but did not have a significantly increased risk of all-cause mortality(HR=1.24;95%CI:0.921.68;p=0.159).These risks were further increased if hypertensive participants whose GS level was low(major CVD incidence,HR=3.31,95%CI:2.604.22,p<0.001;CVD mortality,HR=4.99,95%CI:2.649.43,p<0.001;and all-cause mortality,HR=1.93,95%CI:1.472.53,p<0.001).Conclusion:The present study demonstrates that low GS is associated with the highest risk of major CVD incidence,CVD mortality,and all-cause mortality among hypertensive patients.High levels of GS appear to mitigate long-term mortality risk among hypertensive patients.
基金Supported by The South-Eastern Norwegian Regional Health Authority,No.2011132,Lovisenberg Diaconal Hospital’s Research FundThe Unger-Vetlesen Medical Fund
文摘AIM:To investigate whether routinely measured clinical variables could aid in differentiating intestinal tuberculosis(ITB)from Crohn’s disease(CD).METHODS:ITB and CD patients were prospectively included at four South Indian medical centres from October 2009 to July 2012.Routine investigations included case history,physical examination,blood biochemistry,ileocolonoscopy and histopathological examination of biopsies.Patients were followed-up after 2 and 6 mo of treatment.The diagnosis of ITB or CD was re-evaluated after 2 mo of antituberculous chemotherapy or immune suppressive therapy respectively,based on improvement in signs,symptoms and laboratory variables.This study was considered to be an exploratory analysis.Clinical,endoscopic and histopathological features recorded at the time of inclusion were subject to univariate analyses.Disease variables with sufficient number of recordings and P<0.05 were entered into logistic regression models,adjusted for known confounders.Finally,we calculated the odds ratios with respective confidence intervals for variables associated with either ITB or CD.RESULTS:This study included 38 ITB and 37 CD patients.Overall,ITB patients had the lowest body mass index(19.6 vs 22.7,P=0.01)and more commonly reported weight loss(73%vs 38%,P<0.01),watery diarrhoea(64%vs 33%,P=0.01)and rural domicile(58%vs 35%,P<0.05).Endoscopy typically showed mucosal nodularity(17/31 vs 2/37,P<0.01)and histopathology more frequently showed granulomas(10/30vs 2/35,P<0.01).The CD patients more frequently reported malaise(87%vs 64%,P=0.03),nausea(84%vs 56%,P=0.01),pain in the right lower abdominal quadrant on examination(90%vs 54%,P<0.01)and urban domicile(65%vs 42%,P<0.05).In CD,endoscopy typically showed involvement of multiple intestinal segments(27/37 vs 9/31,P<0.01).Using logistic regression analysis we found weight loss and nodularity of the mucosa were independently associated with ITB,with adjusted odds ratios of 8.6(95%CI:2.1-35.6)and 18.9(95%CI:3.5-102.8)respectively.Right lower abdominal quadrant pain on examination and involvement of≥3 intestinal segments were independently associated with CD with adjusted odds ratios of 10.1(95%CI:2.0-51.3)and 5.9(95%CI:1.7-20.6),respectively.CONCLUSION:Weight loss and mucosal nodularity were associated with ITB.Abdominal pain and excessive intestinal involvement were associated with CD.ITB and CD were equally common.
文摘Context: Experimental and epidemiological data suggest that vitamin E supplementation may prevent cancer and cardiovascular events. Clinical trials have generally failed to confirm benefits, possibly due to their relatively short duration. Objective: To evaluate whether long-term supplementation with vitamin E decreases the risk of cancer, cancer death, and major cardiovascular events. Design, Setting, and Patients: A randomized, double-blind, placebo-controlled international trial(the initial Heart Outcomes Prevention Evaluation[HOPE] trial conducted between December 21, 1993, and April 15,1999) of patients at least 55 years old with vascular disease or diabetes mellitus was extended(HOPE-The Ongoing Outcomes[HOPE-TOO]) between April 16,1999, and May 26, 2003. Of the initial 267 HOPE centers that had enrolled 9541 patients, 174 centers participated in the HOPE-TOO trial. Of 7030 patients enrolled at these centers, 916 were deceased at the beginning of the extension, 1382 refused participation, 3994 continued to take the study intervention, and 738 agreed to passive follow-up. Median duration of follow-up was 7.0 years. Intervention: Daily dose of natural source vitamin E(400 IU) or matching placebo. Main Outcome Measures: Primary outcomes included cancer incidence, cancer deaths, and major cardiovascular events(myocardial infarction, stroke, and cardiovascular death). Secondary outcomes included heart failure, unstable angina, and revascularizations. Results: Among all HOPE patients, there were no significant differences in the primary analysis: for cancer incidence, there were 552 patients(11.6%) in the vitamin E group vs 586(12.3%) in the placebo group(relative risk[RR], 0.94; 95%confidence interval[CI], 0.84-1.06; P=.30); for cancer deaths, 156(3.3%) vs 178(3.7%), respectively(RR, 0.88; 95%CI, 0.71-1.09; P=.24); and for major cardiovascular events, 1022(21.5%) vs 985(20.6%), respectively(RR, 1.04; 95%CI, 0.96-1.14; P=.34). Patients in the vitamin E group had a higher risk of heart failure(RR, 1.13; 95%CI, 1.01-1.26; P=.03) and hospitalization for heart failure(RR, 1.21; 95%CI, 1.00-1,47; P=.045). Similarly, among patients enrolled at the centers participating in the HOPE-TOO trial, there were no differences in cancer incidence, cancer deaths, and major cardiovascular events, but higher rates of heart failure and hospitalizations for heart failure. Conclusion: In patients with vascular disease or diabetes mellitus, longterm vitamin E supplementation does not prevent cancer or major cardiovascular events and may increase the risk for heart failure.
文摘BACKGROUND: In observational studies, lower homocysteine levels are associated with lower rates of coronary heart disease and stroke. Folic acid and vitamins B6 and B12 lower homocysteine levels. We assessed whether supplementation reduced the risk of major cardiovascular events in patients with vascular disease. METHODS: We randomly assigned 5522 patients 55 years of age or older who had vascular disease or diabetes to daily treatment either with the combination of 2.5 mg of folic acid, 50 mg of vitamin B6, and 1 mg of vitamin B12 or with placebo for an average of five years. The primary outcome was a composite of death from cardiovascular causes, myocardial infarction, and stroke. RESULTS: Mean plasma homocysteine levels decreased by 2.4 μmol per liter(0.3 mg per liter) in the active-treatment group and increased by 0.8 μmol per liter(0.1 mg per liter) in the placebo group. Primary outcome events occurred in 519 patients(18.8 percent) assigned to active therapy and 547(19.8 percent) assigned to placebo(relative risk, 0.95; 95 percent confidence interval, 0.84 to 1.07; P=0.41). As compared with placebo, active treatment did not significantly decrease the risk of death from cardiovascular causes(relative risk, 0.96; 95 percent confidence interval, 0.81 to 1.13), myocardial infarction(relative risk, 0.98; 95 percent confidence interval, 0.85 to 1.14), or any of the secondary outcomes. Fewer patients assigned to active treatment than to placebo had a stroke(relative risk, 0.75; 95 percent confidence interval, 0.59 to 0.97). More patients in the active-treatment group were hospitalized for unstable angina(relative risk, 1.24; 95 percent confidence interval, 1.04 to 1.49). CONCLUSIONS: Supplements combining folic acid and vitamins B6 and B12 did not reduce the risk of major cardiovascular events in patients with vascular disease.
文摘BACKGROUND: The combined use of anticoagulants, antiplatelet agents, and invasive coronary procedures reduces ischemic coronary events but also increases bleeding in patients with acute coronary syndromes. We therefore assessed whether fondaparinux would preserve the anti-ischemic benefits of enoxaparin while reducing bleeding. METHODS: We randomly assigned 20,078 patients with acute coronary syndromes to receive either fondaparinux(2.5 mg daily) or enoxaparin(1 mg per kilogram of body weight twice daily) for a mean of six days and evaluated death, myocardial infarction, or refractory ischemia at nine days(the primary outcome); major bleeding; and their combination. Patients were followed for up to six months. RESULTS: The number of patients with primary outcome events was similar in the two groups(579 with fondaparinux[5.8 percent] vs. 573 with enoxaparin[5.7 percent]; hazard ratio in the fondaparinux group, 1.01; 95 percent confidence interval, 0.90 to 1.13), satisfying the noninferiority criteria. The number of events meeting this combined outcome showed a nonsignificant trend toward a lower value in the fondaparinux group at 30 days(805 vs. 864, P=0.13) and at the end of the study(1222 vs. 1308, P=0.06). The rate of major bleeding at nine days was markedly lower with fondaparinux than with enoxaparin(217 events[2.2 percent] vs. 412 events[4.1 percent]; hazard ratio, 0.52; P< 0.001). The composite of the primary outcome and major bleeding at nine days favored fondaparinux(737 events[7.3 percent] vs. 905 events[9.0 percent]; hazard ratio, 0.81; P< 0.001). Fondaparinux was associated with a significantly reduced number of deaths at 30 days(295 vs. 352, P=0.02) and at 180 days(574 vs. 638, P=0.05). CONCLUSIONS: Fondaparinux is similar to enoxaparin in reducing the risk of ischemic events at nine days, but it substantially reduces major bleeding and improves long term mortality and morbidity.
基金The study was pre-registered with the Prospective Register of Systematic Reviews,PROSPERO identification code:CRD42018090367.
文摘Objective:Bariatric surgery has been shown to be an effective method of treatment for obstructive sleep apnea(OSA)with long-term benefits,however,the mechanisms of action and the optimum operative procedure remains unclear.The aim of this systemic review was to compare the efficacy of laparoscopic sleeve gastrectomy(LSG)and Roux-en-Y gastric bypass(RYGB)in resolving OSA.Methods:A comprehensive search of MEDLINE,Pubmed,Embase,and OVID was performed.Studies that reported OSA resolution in obese patients with BMI>30 kg/m2 were included in the study.RCTs,comparative prospective and matched cohort studies comparing RYGB with LSG were considered for this study.Results:Five studies(309 participants)were included:4 cohort studies and 1 RCT;all with low risk of bias.At 12 months follow-up,there was a trend towards improved resolution of OSA with LSG(OR 0.47,95%CI[0.20 to 1.06];p=0.07)when compared to RYGB.In contrast,there was a trend to poorer weight loss in the LSG group(SMD 3.83,95%CI[-1.82 to 9.48];p=0.18).Similarly,at 36 months follow-up,there was a trend towards better resolution of OSA with LSG(OR 0.52,95%CI[0.16 to 1.71];p=0.28)and a significantly poorer weight loss in LSG when compared to RYGB(SMD 8.25,95%CI[2.91 to 13.58];p=0.002).Conclusion:Despite poorer weight loss following LSG,there is a trend towards increased resolution of sleep apnea post-LSG.These findings suggest the possibility of weight loss independent factors causing OSA resolution,which should be further investigated.Registration:PROSPERO:CRD42018090367.
基金Supported by The National Research Foundation of South Africa,NRF,GUN 65530(to Kramvis A)and the Cancer Associationof South Africapostdoctoral funding from the NRF,GUN 75055 and the University of the Witwatersrand(to Gopalakrishnan D)bursaries from the University of the Witwatersrand,the Poliomyelitis Research Foundation and the Ernst and Ethel Eriksen Trust(to Keyter M)
文摘AIM:To molecularly characterize hepatitis B virus(HBV)isolates from Kerala and to relate them to the clinical manifestation of infection.METHODS:Sera and clinical data were collected from91 patients diagnosed with chronic HBV infection and HBV-related hepatocellular carcinoma(HCC).HBV from44 HCC,22 cirrhotic and 25 chronic hepatitis patients were genotyped by sequencing of the complete S region or by restriction fragment length polymorphism assays.The basic core promoter/precore region was sequenced.The complete surface DNA sequences were assembled and aligned manually,and then compared with the sequences of HBV of genotypes(A-J)from GenBank.The evolutionary history was inferred using the Neighbor-Joining method and the evolutionary distances computed using the Kimura 2-parameter method.Bootstrapping was performed using 1000 replicates.The TaqMan BS-1 probe was used to quantify HBV DNA at a lower detection limit of approximately20 IU/mL.Continuous variables were compared using an independent Student’s t test.Theχ2test or Fisher’s exact test was used to compare categorical variables.The differences were considered statistically significant at P<0.05.RESULTS:Irrespective of disease status,the predominant genotype was A(72%);95%belonging to subgenotype A1,followed by genotypes D(27%)and C(1%).HCC patients infected with subgenotype A1were significantly younger than those infected with D.Mutation A1762T/G1764A was significantly associated with HCC in both genotypes A and D.Mutation G1862T was more frequent in subgenotype A1(P<0.0001),and in combination with A1762T/G1764A,it was significantly associated with HBV from HCC patients.Mutation C1766T/T1768A was significantly associated with genotype A(P=0.05)and HCC(P=0.03).The preS2start codon M1T/I mutation was unique to genotype A strains(15.6%)from all disease groups and occurred at a higher frequency in isolates from HCC patients(P=0.076).A higher frequency of preS deletion mutants(33.3%)was observed in genotype A from HCC compared with non-HCC patients,but did not reach statistical significance.The preS2:F22L mutation was found in genotypes A and D.CONCLUSION:Kerala is the first Indian state in which subgenotype A1 has been found to predominate in liver disease patients who developed HCC at a relatively young age.
文摘Objective: To assess current heart failure (HF) care processes and organizational context in long-term care (LTC) homes as a prelude to adapting the Canadian Cardiovascular Society (CCS) HF guidelines for use in these settings. Methods: This research reports on the results of thirteen focus groups (N = 83 participants;average of 60 minutes duration) conducted in three Ontario LTC homes to better understand how HF was managed and how organizational context impacted care. Participants included physicians, nurse practitioners, registered nurses, registered practical nurses, and personal support workers. Results: Focus group findings revealed that the complexity of the LTC environment presents challenges for managing HF. Most residents have multiple advanced chronic conditions that must be managed simultaneously. Culturally, LTC is first and foremost a resident’s home where residents may choose not to comply with care recommendations. Staff routines, scopes of practice, professional hierarchies, available resources and government regulations limit flexibility in providing care. Staff lacked knowledge, skills and resources for managing HF. Nevertheless, all staff viewed LTC as the preferred place for managing HF, avoiding residents’ hospitalizations wherever possible. These data suggest that strategies for improving LTC staff communication and education, strengthening existing relationships between staff, family, residents and community resources, and acquiring additional resources in LTC homes have the potential to improve HF management in this setting. Conclusion: LTC is a complex and dynamic environment that presents many challenges for providing care for residents. This research provides the foundation for subsequent work to develop and test implementation strategies to manage HF in LTC, which are consistent with the CCS HF guidelines and are feasible within LTC staff’s work routines, capacities and resources.
文摘Context: Although reperfusion therapy, aspirin, β-blockers, and angiotensin-converting enzyme inhibitors reduce mortality when used early in patients with acute myocardial infarction(MI), mortality and morbidity remain high. No antithrombotic or newer antiplatelet drug has been shown to reduce mortality in acute MI. Objective: To evaluate the effects of reviparin, a low-molecular-weight heparin, when initiated early and given for 7 days in addition to usual therapy on the primary composite outcome of death,myocardial reinfarction, or strokes at 7 and 30 days. Design, Setting, and Patients: A randomized, doubleblind, placebo-controlled trial(Clinical Trial of Reviparin and Metabolic Modulation in Acute Myocardial Infarction Treatment Evaluation [CREATE]) of 15570 patients with ST-segment elevation or new left bundle-branch block, presenting within 12 hours of symptom onset at 341 hospitals in India and China from July 2001 through July 2004. Intervention: Reviparin or placebo subcutaneously twice daily for 7 days. Main Outcome Measure: Primary composite outcome of death, myocardial reinfarction, or stroke at 7 and 30 days. Results: The primary composite outcome was significantly reduced from 854(11.0%) of 7790 patients in the placebo group to 745(9.6%) of 7780 in the reviparin group(hazard ratio [HR], 0.87; 95%CI, 0.79-0.96; P=.005). These benefits persisted at 30 days(1056 [13.6%] vs 921 [11.8%] patients; HR, 0.87; 95%CI, 0.79-0.95; P=.001) with significant reductions in 30-day mortality(877 [11.3%] vs 766 [9.8%]; HR, 0.87; 95%CI, 0.79-0.96; P=.005) and reinfarction(199 [2.6%] vs 154 [2.0%]; HR, 0.77; 95%CI, 0.62-0.95; P=.01), and no significant differences in strokes(64 [0.8%] vs 80 [1.0%]; P=.19). Reviparin treatment was significantly better when it was initiated very early after symptom onset at 7 days(< 2 hours: HR, 0.70; 95%CI, 0.52-0.96; P=.03; 30/1000 events prevented; 2 to< 4 hours: HR, 0.81; 95%CI, 0.67-0.98; P=.03; 21/1000 events prevented; 4 to< 8 hours: HR, 0.85; 95%CI, 0.73-0.99; P=.05; 16/1000 events prevented; and ≥8 hours:HR,1.06; 95%CI, 0.86-1.30; P=.58; P=.04 for trend). There was an increase in lifethreatening bleeding at 7 days with reviparin and placebo(17 [0.2%] vs 7 [0.1%], respectively; P=.07), but the absolute excess was small(1 more per 1000) vs reductions in the primary outcome(18 fewer per 1000) or mortality(15 fewer per 1000). Conclusions: In patients with acute ST-segment elevation or new left bundle-branch block MI, reviparin reduces mortality and reinfarction, without a substantive increase in overall stroke rates. There is a small absolute excess of life-threatening bleeding but the benefits outweigh the risks.
文摘背景：南亚人中年轻时急性心肌梗死（AMI）的发生率高于其他国家个体，但原因不明。目的：评价并比较南亚本地人和来自其他国家的个体中危险因素与AMI的关系，尤其关注较年轻AMI。设计、地点和参与者：此标准化病例对照研究于1999年2月至2003年3月间纳入研究对象，包括来自5个南亚国家15所医学中心的1732例首发AMI患者和2204例年龄、性别匹配的对照者，以及来自其他国家的10728例患者和12431例对照者。主要观察指标：AMI与危险因素的关系。结果：南亚首发AMI患者的平均年龄低于其他国家（53．0±11．4岁 vs 58．8±12．2岁；P〈0．001）。
文摘Background Some dietary patterns are risk factors for acute myocardial infarction （AMI）. Chinese traditional food and habits vary from other cultures. The present study determined whether different dietary patterns were associated with AMI in Chinese people. Methods We conducted a case-control study. There were 1312 cases of first AMI and 2235 control subjects who did not have previous angina, diabetes mellitus, hypertension or stroke. Controls were matched to cases on age and gender. Diet was measured with a validated, 19 item food frequency questionnaire. We identified three major dietary patterns using factor analysis： vitamin and microelement pattern （high intake of vegetables, fruits and tofu）, carbohydrate pattern （high in grain）, and fat and protein pattern （high in meat, fish, eggs and fried foods）. Results After adjusting for all risk factors, the vitamin and microelement pattern was inversely associated with AMI risk （global P value, 0.0001）. Compared with the first quartile, the adjusted ORs of AMI were 0.81 （95% CI： 0.66-1.00） for the second quartile, 0.67 （95% CI： 0.54-0.82） for the third, and 0.70 （95% CI： 0.56-0.88） for the fourth. Several dietary frequencies （serves per week） including vegetables, fruits and tofu were closely associated with decrease of AMI risk. Carbohydrate pattern showed weak relationship with AMI. We observed a U-shaped association between frequencies of fat and protein pattern and AMI risk. Excessive fat intake increased the AMI risk. The adjusted OR of AMI associated with the higher level of green vegetables was 0.37 （95% CI： 0.24-0.57） in women and 0.65 （95% CI： 0.51-0.82） in men （P value for heterogeneity, 0.0140）. Conclusions Unhealthy dietary intake can increase the AMI risk. Improving intake of vegetables, fruits and tofu have the potential to partially prevent the rising epidemic of cardiovascular disease in China.
文摘Background Many researches report that low socioeconomic status （SES） is associated with a higher risk of coronary heart disease （CHD）. This study aimed to determine whether levels of education, family income, and other SES were associated with acute myocardial infarction （AMI） in the Chinese population, and to compare the difference in this association between northern and southern regions in China. Methods We conducted a case-control study. Cases were first AMI （n=2909）. Controls （n=2947） were randomly selected and frequency matched to cases on age and sex. SES was measured using education, family income, possessions in the household, and occupation. Results Low levels of education （8 years） were more common in cases compared to controls （53.4% and 44.1%; P=0,0001）. After adjusting all risk factors, the level of education was associated with AMI risk in the Chinese population （P=-0.0005）. The odds ratio （OR） associated with education of 8 years or less, compared with more than 12 years （trade school/college/university） was 1.33 （95% CI 1.12-1.59）, and for education of 9-12 years 1.04 （95% CI 0.88-1.33）. The proportion of higher income population was more in controls than cases （39.4% and 35.3%）. Number of possessions and non-professional occupation were only weakly or not at all independently related to AMI. The adjusted OR associated with the lower education was 2.38 （95% CI 1.67-3.39） in women, and 1.18 （95% CI 0.99-1.42） in men （P=0.0001, for heterogeneity）. The interaction between levels of education and different regions was significant （P=0.0206, for interaction）. Conclusion Several socioeconomic factors including levels of education and income were closely associated with increase of AMI risk in China, most markedly in northeast and southern area. The effect of education was stronger towards AMI in women than men.
基金supported by grants from the National Natural Science Foundation of China(No.81702569)the Natural Science Foundation of Jiangsu Province(No.BK20221183)+3 种基金the Science Fund for Distinguished Young Scholars of Jiangsu Province(No.BK20211533)the Jiangsu Maternal and Child Health Research Association(No.FYX202344)the Postgraduate Research&Practice Innovation Program of Jiangsu Province(No.KYCX23_1969)the Nanjing Medical Science and Technique Development Foundation(No.YKK23156).
文摘To the Editor:Ovarian cancer(OC)is the third cause of death among women globally.[1]Approximately 90%of OC cases are derived from epithelial cells,and these tumors have distinct epidemiological,molecular,and clinical characteristics.[2]High-grade serous ovarian cancer(HGSOC)is the most common subtype of epithelial ovarian cancer(EOC)and has been widely investigated.[3]Ovarian carcinosarcoma(OCS),also known as malignant mixed mesodermal tumor,is a rare and aggressive tumor that typically develops in the female genital tract.[4]Histologically,OCS is considered a high-grade lesion that harbors both carcinomatous and sarcomatous components.[5]Although OCS accounts for only 1–4%of EOC cases,it presents the worst prognosis among all EOC subtypes,[6,7]with a median survival time(MST)of less than 18 months.[5]Due to its rarity,ovarian OCS is challenging to study through prospective trials,resulting in a limited understanding of the disease.Despite this,no targeted treatment strategies are specifically developed for OCS.
文摘This document is about heart failure(HF),including acute and chronic heart failure,heart failure with reduced ejection fraction and heart failure with preserved ejection fraction as well as cardiomyopathies.Context-specific recommendations tailored to individual patient needs are highlighted providing a thorough evaluation of the risks,benefits,and overall value of each therapy,aiming to establish a standard of care that improves patient outcomes and reduces the burden of hospitalization in this susceptible population.These guidelines provide evidence-based recommendations that represent a group consensus considering many other published guidelines that have reviewed many of the issues discussed here,but they also make new recommendations where new evidence has recently emerged.Most importantly these guidelines also provide recommendations on a number of issues where resource limitations may put constraints on the care provided to HF patients.Such"economic adjustment"recommendations aim to provide guidance for situations when"Resources are somewhat limited"or when"Resources are severely limited".Hence,this document presents not only a comprehensive but also concise update to HF management guidelines thereby aiming to provide a unified strategy for the pharmacological,non-pharmacological,invasive and interventional management of this significant global health challenge that is applicable to the needs of healthcare around the globe.
