酒精性肝病合并弧菌性脓毒症的临床及病理学特点

目的：探讨酒精性肝病合并弧菌性脓毒症患者的临床病理特点。方法：自2002年8月至2004年8月问符合酒精性肝病合并弧菌性脓毒症早期临床诊断主要依据的患者6例，在应用抗菌药物、补液扩容、升压及1～2h内切开患肢以减压、引流、清创等外科治疗，在总结其临床特点同时，观察患者下肢的临床病理特点及超微结构改变。结果：患者首先出现下肢足背或小腿肿胀、剧烈疼痛、局部红斑、数小时内血疱增多、融合成大血疱、皮肤大片淤血斑，下肢病变迅速扩大并向大腿或躯体蔓延，患者同时出现休克、MODS表现。2例下肢皮肤苍白、肌肉色红。肌酸磷酸激酶(CPK)正常或轻度升高，经清创、植皮后保存了患肢。另4例见皮肤脂肪坏死，筋膜肌肉坏死范围广．小血管血栓形成，患者的CPK明显升高，其中2例下肢病变严重，行截去患肢治疗，2例切开患肢以减压、引流、清创等病情好转，因经济原因放弃进一步治疗。6例中4例患者治愈出院。作者通过光镜及电镜对弧菌感染患者下肢病变组织系统观察，包括皮肤、肌肉、脂肪、坐骨神经、股动脉、股静脉，结合大体表现发现创伤弧菌脓毒症患者下肢病变组织病理改变主要表现为炎症性改变。结论：及早正确认识下肢临床及病理改变特点对早期临床诊断及治疗十分重要，可有效提高患者生存率。     

Sex Hormone Changes in Chronic Liver Disease: A Matched Study of Alcoholic versus Non-alcoholic Liver Disease

Men with liver disease are hypogonadal and feminished. Europeanworkers consider the liver disease itself to be the major factorbut American workers blame alcohal consumption. We studied sexualdysfunction and sex hormones in three matched groups of men;controls (n=22), those with alcoholic liver disease (n=21),and those with non-alcoholic liver disease (n=21). Men withalcoholic liver disease had maore sexual dysfunction. Testosteroneand androsastenedione concentrations were lower and oestradiaoland dehydroepiandrosterone sulphate levels were raised in theliver disease groups. The changes were greatest in the alcoholicliver disease group. In this, the first controlled study, liverdisease per se appeares to cause sexual dysfunction and sexhormone changes but these changes are amplified by ethanol.     

Sex Differences in Long Chain Fatty Acid Utilization and Fatty Acid Binding Protein Concentration in Rat Liver

Female sex and estrogen administration are associated with increased hepatic production of triglyceride-rich lipoproteins; the basis for this has not been fully elucidated. Inasmuch as hepatic lipoprotein production is also influenced by FFA availability and triglyceride biosynthesis, we investigated sex differences in FFA utilization in rat hepatocyte suspensions and in the components of the triglyceride biosynthetic pathway.Isolated adult rat hepatocyte suspensions were incubated with albumin-bound [(14)C]oleate for up to 15 min. At physiological and low oleate concentrations, cells from females incorporated significantly more (14)C into glycerolipids, especially triglycerides, and into oxidation products than did male cells, per milligram cell protein. At 0.44 mM oleate, incorporation into triglycerides in female cells was approximately twice that in male cells. Comparable sex differences were observed in cells from fasted animals and when [(14)C]-glycerol incorporation was measured. At higher oleate concentrations, i.e., fatty acid:albumin mole ratios in excess of 2:1, these sex differences were no longer demonstrable, suggesting that maximal rates of fatty acid esterification and oxidation were similar in female and male cells.In female and male hepatic microsomes, specific activities of long chain acyl coenzyme A synthetase, phosphatidate phosphohydrolase, and diglyceride acyltransferase were similar, but glycerol-3-phosphate acyltransferase activity was slightly greater in females at certain substrate concentrations. Microsomal incorporation of [(14)C]oleate into total glycerolipids was not significantly greater in females. In further contrast to intact cells, microsomal incorporation of [(14)C]oleate into triglycerides, although significantly greater in female microsomes, accounted for only a small fraction of the fatty acid esterified.The binding affinity and stoichiometry of partially purified female hepatic fatty acid binding protein (FABP) were similar to those of male FABP. In contrast, the concentration of FABP, per milligram cytosolic protein, was 44% greater in female liver than in male, as indicated by measurement of [(14)C]oleate binding and of 280 nm OD in the FABP fraction of 105,000 g supernate after gel filtration chromatography.These experiments demonstrate profound sex differences in hepatocyte utilization of long chain fatty acids at concentrations within and below the physiological range, and suggest that these are attributable at least in part to corresponding differences in cytosolic FABP concentration. At higher FFA concentrations, sex differences in hepatocyte FFA utilization are virtually eliminated, suggesting that under these conditions, differences in FABP concentration are not rate determining. Sex differences in hepatic lipoprotein production may largely reflect these important differences in the initial stages of hepatocyte FFA utilization.     

Ethnic and Sex Differences in Fatty Liver on Cardiac Computed Tomography: The Multi-Ethnic Study of Atherosclerosis

ObjectiveTo describe ethnic and sex differences in the prevalence and determinants of fatty liver in a multiethnic cohort.Patients and MethodsWe studied participants of the Multi-Ethnic Study of Atherosclerosis who underwent baseline noncontrast cardiac computed tomography between July 17, 2000, and August 29, 2002, and had adequate hepatic and splenic imaging for fatty liver determination (n=4088). Fatty liver was defined as a liver/spleen attenuation ratio of less than 1. We compared the prevalence and severity of fatty liver, in 4 ethnicities (white, Asian, African American, and Hispanic), and the factors associated with fatty liver in each ethnicity, stratifying by obesity and metabolic syndrome. Multivariable ordinal logistic regression was used to determine the effect of cardiometabolic risk factors on the prevalence of fatty liver in different ethnicities.ResultsThe prevalence of fatty liver varied significantly by ethnicity (African American, 11%; white, 15%; Asian, 20%; and Hispanic, 27%; P<.001). Although African Americans had the highest prevalence of obesity, a smaller percentage of obese African Americans received a diagnosis of fatty liver than did other ethnicities (African American, 17%; white, 31%; Asian, 37%; and Hispanic 39%; P<.001). Hispanics had the highest prevalence of fatty liver, including the obese and metabolic syndrome population. An increase in insulin resistance predicted a 2-fold increased prevalence of fatty liver in all ethnicities after multivariable adjustment.ConclusionAfrican Americans have a lower prevalence and Hispanics have a higher prevalence of fatty liver than do other ethnicities. There are distinct ethnic variations in the prevalence of fatty liver even in patients with the metabolic syndrome or obesity, suggesting that genetic factors may play a substantial role in the phenotypic expression of fatty liver.     

Sex Differences in Diabetes and Risk of Incident Coronary Artery Disease in Healthy Young and Middle-Aged Adults

OBJECTIVE

Controversy exists about the coronary artery disease (CAD) risk conveyed by diabetes in young and middle-aged women. We investigated sex differences in CAD by diabetes status among healthy individuals with different underlying risks of heart disease.

RESEARCH DESIGN AND METHODS

We examined subjects aged <60 years without CAD at enrollment in the high-risk GeneSTAR Study (n = 1,448; follow-up ∼12 years), Multi-Ethnic Study of Atherosclerosis (MESA; n = 3,072; follow-up ∼7 years), and National Health and Nutrition Examination Survey III (NHANES III) Mortality Follow-up Study (n = 6,997; follow-up ∼15 years). Diabetes was defined by report, hypoglycemic use, and/or fasting glucose ≥126 mg/dL. The outcome was any CAD event during follow-up (fatal CAD in NHANES).

RESULTS

In the absence of diabetes, CAD rates were lower among women in GeneSTAR, MESA, and NHANES (4.27, 1.66, and 0.40/1,000 person-years, respectively) versus men (11.22, 5.64, and 0.88/1,000 person-years); log-rank P < 0.001 (GeneSTAR/MESA) and P = 0.07 (NHANES). In the presence of diabetes, CAD event rates were similar among women (17.65, 7.34, and 2.37/1,000 person-years) versus men (12.86, 9.71, and 1.83/1,000 person-years); all log-rank P values > 0.05. Adjusting for demographics, diabetes was associated with a significant four- to fivefold higher CAD rate among women in each cohort, without differences in men. In meta-analyses of three cohorts, additionally adjusted for BMI, smoking, hypertension, HDL, and non-HDL cholesterol, antihypertensive and cholesterol-lowering medication use, the hazard ratio of CAD in men versus women among nondiabetes was 2.43 (1.76–3.35) and diabetes was 0.89 (0.43–1.83); P = 0.013 interaction by diabetes status.

CONCLUSIONS

Though young and middle-aged women are less likely to develop CAD in the absence of diabetes, the presence of diabetes equalizes the risk by sex. Our findings support aggressive CAD prevention strategies in women with diabetes and at similar levels to those that exist in men.     

Sex Differences in Prior Pain Experience

Sex differences in clinical and experimental pain experiences are well documented. However, there has been little work investigating men's and women's experiences with common painful events. This study examined sex differences in the nature and intensity of common pain experiences. Participants (102 women and 85 men) completed the Prior Pain Experience Questionnaire, which is a 79-item assessment of an individual's pain experience, recalled pain ratings, and imagined pain ratings. Analyses of variance were conducted to assess for sex differences in overall pain experience and pain ratings. Men and women did not have significant differences in the overall number of reported pain experiences or in the overall mean pain rating of those experiences. However, they differed in specific pain events experienced (eg, men experienced concussions more than women) and pain ratings (eg, women rated minor surgery as significantly more painful than men). Individuals who imagined pain events tended to rate them as equally or more painful than individuals who experienced those pain events.PerspectiveResults of this study demonstrate that men and women have varying types of pain experiences without evidence that the overall pain experience differs between sexes. It was also found that imagined pain ratings are often worse than experienced pain ratings, lending support for the tendency of individuals to catastrophize.     

Sex Differences in Common Sports Injuries

Common sports injuries include bone stress injuries (BSIs), anterior cruciate ligament (ACL) injuries, and concussions. Less commonly recognized are the specific sex differences in epidemiology, risk factors, and outcomes of these conditions by sex. An understanding of these factors can improve their clinical management, from prescribing appropriate prehabilitation to guiding postinjury rehabilitation and return to play. This narrative review summarizes the sex differences in the diagnosis and management of BSIs, ACL injuries, and concussions. Although BSIs are more common in female athletes, risk factors for both sexes include prior injury and relative energy deficiency in sport (RED-S). Risk factors in female athletes include smaller calf girth, femoral adduction, and higher rates of loading. Female athletes are also at greater risk for developing ACL injuries in high school and college, but their injury rate is similar in professional sports. Increased lateral tibial slope, smaller ACL size, and suboptimal landing mechanics are additional risk factors more often present in female athletes. Male athletes are more likely to have ACL surgery and have a higher rate of return to sport. Concussions occur more commonly in female athletes; however, female athletes are also more likely to report concussions. Male athletes more commonly sustain concussion through contact with another player. Female athletes more commonly sustain injury from contact with playing equipment. Managing post-concussion symptoms is important, and female athletes may have prolonged symptoms. An understanding of the sex-specific differences in these common sports injuries can help optimize their prehabilitation and rehabilitation.

Sex Differences in Children and Young Adults With Bicuspid Aortic Valve Disease in First Two Decades of Life

ObjectiveTo elucidate sex differences in valve morphology, disease phenotype, progression, and outcomes among children and young adults with bicuspid aortic valve (BAV).Patients and MethodsThis is a retrospective cohort study examining all children and young adults (aged ≤22 years) with isolated BAV diagnosed, by excluding patients with concomitant congenital heart defects or genetic syndromes, from January 1, 1990, through December 1, 2016, at Mayo Clinic in Rochester, Minnesota.ResultsOf 1010 patients with BAV, 558 had isolated BAV. Distributions of morphology were right-left in 65.8% (n=367), right-noncoronary in 34% (n=190), and left-noncoronary cusp fusion in 0.2% (n=1) of patients; with no sex differences. Male to female ratio was 3:1. At the first echocardiographic evaluation in the study, there were no sex differences in terms of frequency of aortic valve stenosis or regurgitation. However, males had significantly higher grades of aortic valve regurgitation at 17 years of age onward (P<.0001). Males had significantly larger mid-ascending aorta (P=.01) and sinus of Valsalva dimensions (z score; P=.0001) as compared with females, with a novel finding of peak aortic dimensions around 8 years of age. Males also had more than 2-fold higher risk for sinus of Valsalva dilation (z score >2) as compared with females (odds ratio, 2.3; 95% CI, 1.2 to 4.2; P=.01). There were no significant sex differences in the primary cardiac outcomes of interventions on aortic valve and/or aorta, aortic dissection, or death.ConclusionIn children and young adults with BAV, males have a higher grade of aortic regurgitation in late adolescence, significantly larger aortic dimensions, different patterns of aortic growth, and more frequent sinus of Valsalva dilation as compared with females. Overall, the rate of primary cardiac events is lower in young patients, with no significant sex differences.     

Machine Learning Techniques Differentiate Alcohol-Associated Hepatitis From Acute Cholangitis in Patients With Systemic Inflammation and Elevated Liver Enzymes

ObjectiveTo develop machine learning algorithms (MLAs) that can differentiate patients with acute cholangitis (AC) and alcohol-associated hepatitis (AH) using simple laboratory variables.MethodsA study was conducted of 459 adult patients admitted to Mayo Clinic, Rochester, with AH (n=265) or AC (n=194) from January 1, 2010, to December 31, 2019. Ten laboratory variables (white blood cell count, hemoglobin, mean corpuscular volume, platelet count, aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, total bilirubin, direct bilirubin, albumin) were collected as input variables. Eight supervised MLAs (decision tree, naive Bayes, logistic regression, k-nearest neighbor, support vector machine, artificial neural networks, random forest, gradient boosting) were trained and tested for classification of AC vs AH. External validation was performed with patients with AC (n=213) and AH (n=92) from the MIMIC-III database. A feature selection strategy was used to choose the best 5-variable combination. There were 143 physicians who took an online quiz to distinguish AC from AH using the same 10 laboratory variables alone.ResultsThe MLAs demonstrated excellent performances with accuracies up to 0.932 and area under the curve (AUC) up to 0.986. In external validation, the MLAs showed comparable accuracy up to 0.909 and AUC up to 0.970. Feature selection in terms of information-theoretic measures was effective, and the choice of the best 5-variable subset produced high performance with an AUC up to 0.994. Physicians did worse, with mean accuracy of 0.790.ConclusionUsing a few routine laboratory variables, MLAs can differentiate patients with AC and AH and may serve valuable adjunctive roles in cases of diagnostic uncertainty.     

Cardiovascular Disease in Alcohol Abusers

Moderate alcohol use (two or fewer drinks daily) may offer some degree of protection from coronary artery disease and stroke. Any potential benefit must be weighed against an individual's risk profile for alcohol abuse or dependence and the associated health and social consequences. Health costs of alcohol abuse are well into the billions. Heavy alcohol consumption is associated with cardiomyopathy, arrhythmias, hypertension, stroke, and sudden death. Alcohol is the major cause of nonischemic cardiomyopathy in the Western world. In any health care setting, education about the potential risks and benefits of alcohol use must be provided with health promotion and maintenance strategies tailored to the individual.     

Sex Differences in T Cells in Hypertension

PurposeHypertension is a major risk factor for cardiovascular disease, stroke, and end-organ damage. There is a sex difference in blood pressure (BP) that begins in adolescence and continues into adulthood, in which men have a higher prevalence of hypertension compared with women until the sixth decade of life. Less than 50% of hypertensive adults in the United States manage to control their BP to recommended levels using current therapeutic options, and women are more likely than are men to have uncontrolled high BP. This, is despite the facts that more women compared with men are aware that they have hypertension and that women are more likely to seek treatment for the disease. Novel therapeutic targets need to be identified in both sexes to increase the percentage of hypertensive individuals with controlled BP. The purpose of this article was to review the available literature on the role of T cells in BP control in both sexes, and the potential therapeutic application/implications of targeting immune cells in hypertension.MethodsA search of PubMed was conducted to determine the impact of sex on T cell–mediated control of BP. The search terms included sex, gender, estrogen, testosterone, inflammation, T cells, T regulatory cells, Th17 cells, hypertension, and blood pressure. Additional data were included from our laboratory examinations of cytokine expression in the kidneys of male and female spontaneously hypertensive rats (SHRs) and differential gene expression in both the renal cortex and mesenteric arterial bed of male and female SHRs.FindingsThere is a growing scientific literature base regarding the role of T cells in the pathogenesis of hypertension and BP control; however, the majority of these studies have been performed exclusively in males, despite the fact that both men and women develop hypertension. There is increasing evidence that although T cells also mediate BP in females, there are distinct differences in both the T-cell profile and the functional impact of sex differences in T cells on cardiovascular health, although more work is needed to better define the relative impact of different T-cell subtypes on BP in both sexes.ImplicationsThe challenge now is to fully understand the molecular mechanisms by which the immune system regulates BP and how the different components of the immune system interact so that specific mechanisms can be targeted therapeutically without compromising natural immune defenses.     

超声影像对中心性肥胖人群非酒精性脂肪肝病变诊断的临床观察

目的:探讨中心性肥胖人群非酒精性脂肪肝病变的声像图特点及临床诊断意义。材料与方法:仪器使用Philips-PH11型超声诊断仪,探头频率3.5-4.5 MHz,患者禁食禁水8h以上,对肝脏进行纵横及多切面扫查,观察其发生部位、大小、形态、内部及后方回声和周围血管的血流情况。结果:500例中心性肥胖受检者超声检查,诊断为非酒精性脂肪肝者共389例,其中,轻度脂肪肝186例,占47.82%;中度脂肪肝132例,占33.93%:重度脂肪肝54例,占13.88%;非均匀性脂肪肝17例,占4.37%。结论:超声扫描对中心性肥胖人群非酒精性脂肪肝病检出率高,对患者的早期诊断、早治疗有极其重要作用。     

非酒精性脂肪性肝病与肝癌

据世界卫生组织统计,我国肝癌发病人数占全球总发病人数的50%,因肝癌病死人数则占55%,实在是国人之大不幸。幸而我国已将乙肝疫苗接种列入儿童计划免疫,该计划免疫实施近20年来,估计至少减少了3000万例乙肝病毒感染者。已有报告表明,接种过疫苗之儿童肝癌发病率显著下降,相信三四十年后,我国肝癌高的发病率必然下降。     

Increased Detection of Alcohol Consumption and At-risk Drinking with Computerized Alcohol Screening

Background

The impact of alcohol use has been widely studied and is considered a public health issue. The National Institute on Alcohol Abuse and Alcoholism (NIAAA) recommends Screening and Brief Intervention and Referral Treatment (SBIRT), but the actual practice in the Emergency Department (ED) is constrained due to limited provider time and financial resources.

Objectives

To assess the effectiveness of alcohol screening using Computerized Alcohol Screening and brief Intervention (CASI) compared to alcohol screening by triage nurse during Medical Screening Examination (MSE) in the ED.

Methods

Retrospective review of CASI/MSE database from January 2008 through December 2009, collected in the tertiary, Level I Trauma ED was performed. Inclusion criteria included age ≥18 years, and completion of both the MSE and CASI. We analyzed the database by comparing age, gender, primary language (English, Spanish), and Alcohol Use Disorders Identification Test scores using McNemar's test.

Results

Data were available for 5835 patients. CASI showed a significant increase in detection of at-risk drinking over MSE across all ages, gender, and primary language (p < 0.05). MSE found 2.5% at-risk drinkers and CASI found 11.5% at-risk drinkers (odds ratio [OR] 8.88, 95% confidence interval [CI] 6.89–11.61). Similar results were found in 18- to 20-year-old patients. MSE identified 1.8% at-risk drinkers and CASI reported 15.94% (OR 19.33, 95% CI 6.30–96.47).

Conclusion

CASI increased detection of at-risk alcohol drinkers compared with MSE across all ages, gender, and primary language. CASI is a promising innovative method for alcohol screening in the ED for the adult population, including under-aged drinkers.