دانلود گزارش کارورزی و کار آموزی

چکیده : 

BACKGROUND: Asymptomatic left ventricular systolic dysfunction is an important risk factor for heart

failure and death. Given the availability of patients, trained personnel, and equipment, the hospital is an

ideal setting to identify and initiate treatment for left ventricular systolic dysfunction. The purpose of this

study was to determine the prevalence of asymptomatic left ventricular systolic dysfunction in patients 45

years of age or older with at least one clinical heart failure risk factor admitted to a general medical service.

METHODS: Bedside, hand-carried echocardiography provided quantitative assessment of left ventricular systolic

function in 217 medical inpatients 45 years of age or older who had at least one heart failure risk factor. Patients

with known or suspected heart failure or with an assessment of left ventricular function in the past 5 years were

excluded. We measured the prevalence of asymptomatic left ventricular systolic dysfunction, defined by left

ventricular ejection fraction of 50% or lower, and its association with heart failure risk factors.

RESULTS: Of 207 patients with interpretable images, 11 (5.3%) had a left ventricular ejection fraction of

50% or lower. Patients with left ventricular systolic dysfunction had more heart failure risk factors than

those without left ventricular systolic dysfunction (3.090.8 vs 2.51.0, P.04). The total number of

heart failure risk factors trended towards an association with a greater prevalence of asymptomatic left

ventricular systolic dysfunction, but this did not reach significance (odds ratio 1.74; 95% confidence

interval, 0.97-3.12, P.06).

CONCLUSIONS: Asymptomatic left ventricular systolic dysfunction is present in about 1 of every 20 general

medical inpatients with at least one risk factor for heart failure. Because treatment of asymptomatic left

ventricular systolic dysfunction may reduce morbidity, further studies examining the costs and benefits of using

hand-carried ultrasound to identify this important condition in general medical inpatients are warranted

چکیده : 

BACKGROUND: Computed tomography (CT) pulmonary angiography use has increased dramatically, raising

concerns for patient safety. Adherence to recommendations and guidelines may protect patients. We measured

adherence to the recommendations of Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED

II) investigators for evaluation of suspected pulmonary embolism and the rate of potential false-positive

pulmonary embolism diagnoses when recommendations of PIOPED II investigators were not followed.

METHODS: We used a structured record review to identify 3500 consecutive CT pulmonary angiograms

performed to investigate suspected pulmonary embolism in 2 urban emergency departments, calculating

the revised Geneva score (RGS) to classify patients as “pulmonary embolism unlikely” (RGS10) or

“pulmonary embolism likely” (RGS10). CT pulmonary angiograms were concordant with PIOPED II

investigator recommendations if pulmonary embolism was likely or pulmonary embolism was unlikely and

a highly sensitive D-dimer test result was positive. We independently reviewed 482 CT pulmonary

angiograms to measure the rate of potential false-positive pulmonary embolism diagnoses.

RESULTS: A total of 1592 of 3500 CT pulmonary angiograms (45.5%) followed the recommendations of

PIOPED II investigators. The remaining 1908 CT pulmonary angiograms were performed on patients with

an RGS10 without a D-dimer test (n1588) or after a negative D-dimer test result (n320). The

overall rate of pulmonary embolism was 9.7%. Potential false-positive diagnoses of pulmonary embolism

occurred in 2 of 3 patients with an RGS10 and a negative D-dimer test result.

CONCLUSIONS: Nonadherence to recommendations for CT pulmonary angiography is common and

exposes patients to increased risks, including potential false-positive diagnoses of pulmonary embolism.

چکیده : 

OBJECTIVE: In the United States, young and middle-aged black men have significantly higher total

mortality than any other racial or ethnic group. We describe the characteristics of US counties with low

non–Hispanic Black or African American male mortality (ages 25-64 years, 1999-2007).

METHODS: Information was accessed through public data, the US Census, the US Compressed Mortality

File, and the Native American Graves Repatriation Act military database.

RESULTS: Of 1307 counties with black mortality rates classified as reliable by the National Center for

Health Statistics (at least 20 deaths), 66 recorded lower mortality among black men than corresponding US

whites. Most notable, 97% of the 66 counties were home to or adjacent a military installation versus 37%

of comparable US counties (P.001). Blacks in these counties had less poverty, higher percentages of

elderly civilian veterans, and higher per capita income. Within these counties, national black:white

disparities in mortality were eliminated for ischemic heart disease, accidents, diseases of the liver, chronic

lower respiratory diseases, and mental disorder from psychoactive substance use. Application of age-,

race-, ethnicity-, gender-, and urbanization-specific mortality rates from counties with relatively low

mortality would reduce the black:white mortality rate ratio for black men aged 25 to 64 years from 1.67

to 1.20 nationally and to 1.00 in areas outside large central metropolitan areas.

CONCLUSIONS: These descriptive data demonstrate a small number of communities with low mortality

rates among young and middle-aged black/African American men. Their characteristics may provide

clinical and public health insights to reduce these higher mortality rates in the US population. Analytic

epidemiologic studies are necessary to test these hypotheses.

چکیده : 

BACKGROUND: There have been substantial improvements in the use of evidence-based, guideline-recommended

therapies for patients with acute myocardial infarction. Nevertheless, some gaps, disparities, and variations in use

remain. To understand how such gaps in recommended care may be narrowed further, it may be useful to determine

those factors associated with lessened adherence to guideline-based care.

METHODS: The Get with the Guidelines-Coronary Artery Disease registry measured adherence with 6 performance

measures (aspirin within 24 hours, discharge on aspirin and beta-blockers, patients with low ejection fraction

discharged on angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, smoking cessation counseling,

use of lipid-lowering medications) in 148,654 patients with acute myocardial infarction between 2002 and 2009.

Logistic multivariable regression models using generalized estimating equations were utilized to identify patient and

hospital characteristics associated with adherence to each of 6 measures, and to a summary score of performance for

all measures, in eligible patients.

RESULTS: We identified 10 variables that were associated significantly with either greater adherence

(hypertension, hyperlipidemia, hospital with full interventional capabilities, calendar year) or worse

adherence (age, female sex, congestive heart failure, chronic renal insufficiency, atrial fibrillation, chronic

dialysis) in at least 4 of the 6 treatment adherence models, as well as the summary score adherence model.

Age, sex, and calendar year were significant in all models.

CONCLUSIONS: Use of evidence-based acute myocardial infarction treatments remains less than ideal for

certain high-risk populations. The close correlations among factors associated with underperformance

highlights the potential for specifically targeting and tailoring quality improvement interventions

چکیده : 

OBJECTIVES: Mastocytosis is a heterogeneous group of clonal mast cell disorders in which bone manifestations

are frequently seen, but poorly understood. In this study, we analyzed correlation of clinical

findings in mastocytosis patients with bone mineral density and bone turnover markers.

METHODS: Serum levels of bone turnover markers were measured in mastocytosis patients and healthy

volunteers. Bone disease was evaluated using radiographic imaging, and measurement of bone mineral density.

RESULTS: Of 45 adult mastocytosis patients, bone abnormalities were detected in 34 (75%). Bone lesions

were documented on radiographic imaging in 16 patients (36%), and bone mineral density in 24 patients

(53%), of which 9 patients (20%) had osteoporosis and 15 (33%) had osteopenia. Serum levels of bone

turnover markers that evaluate bone resorption (C-telopeptide, deoxypyridinoline), bone formation (bonespecific

alkaline phosphatase), and bone remodeling (osteoprotegerin) were significantly higher in the

patient population than in the control population (n28). Levels of C-telopeptide and osteoprotegerin

were higher in patients with advanced systemic mastocytosis than in patients with cutaneous or indolent

systemic mastocytosis. Moreover, C-telopeptide and osteoprotegerin levels were significantly correlated

with those of serum tryptase, a diagnostic marker of mastocytosis.

CONCLUSION: The observed bone turnover markers variations indicate a complex process of bone turnover

in mastocytosis-related bone manifestations. The highly significant correlation between serum tryptase and

serum bone turnover markers levels, and the positive correlation of levels of bone turnover markers with

advanced disease, support the existence of a link between bone remodeling and mast cell burden.

چکیده : 

Background: Kawasaki disease (KD) is a pediatric systemic vasculitis, for which both genetic

and environmental factors are suspected. HLA gene clusters within the major histocompatibility

complex (MHC) region at chromosome 6p21.3 have been recently linked to KD.

However, little was known about the roles of non-MHC genes during KD development. This

study examines the association of psoriasis susceptibility 1 (PSORS1) genetic variants at the

MHC region with KD development.

Methods: A total of 93 KD patients and 680 healthy children were enrolled. Three unique

single nucleotide polymorphisms (SNPs) that cover PSORS1C1, PSORS1C2, and CDSN genes

were genotyped by Taqman genotyping assay. The frequency of genetic variants was

assessed by c2 analysis.

Results: Polymorphism rs1064190 located at the promoter region of PSORS1C1 is found to be

associated with KD development ( p ¼ 0.026) with higher T/T genotype frequency

( p ¼ 0.006) the T-A-T haplotype is more frequent in KD patients than normal controls

( p ¼ 0.033). In addition, T allele at rs1064190 shows a protective allele for coronary artery

aneurysm (CAA) formation in KD patients ( p ¼ 0.015). The plasma activity of GOT/GPT, the

indicators for KD heart damage, are significantly lower in patients with T/T genotype than

in those with non-T/T genotype.

چکیده : 

Personalized medicine is based on the established principle that each individual is born

with unique biological characteristics. Genomics, the science of studying the genes in a

genome and their interactions with each other, forms the foundation of personalized

medicine. Several genomic methods are currently used to identify susceptibility loci for

diseases or phenotypic traits, namely, linkage analysis, candidate gene association studies,

and genome-wide association studies. The success of personalized medicine depends on

having accurate diagnostic tests capable of identifying patients who can benefit from

targeted therapy. Larger cohort studies plus the application of genome-wide association

studies offer great potential for identifying the genetic factors that influence the pharmacology

of specific drugs. By combining these approaches, physicians can predict health

risks, determine and quantify the dynamics of disease development, and tailor therapeutic

protocols to the needs of the individual. In this review, we focus on the effect of genetic