Objective To assess the influence of age on the error of estimate （EE） of maximal oxygen uptake （VO2max） using sex and population specific-equations in cycle ergometer exercise testing, since estimated VO2 max is ...Objective To assess the influence of age on the error of estimate （EE） of maximal oxygen uptake （VO2max） using sex and population specific-equations in cycle ergometer exercise testing, since estimated VO2 max is associated with a substantial EE, often exceeding 20%, possibly due to intrinsic variability of mechanical efficiency. Methods 1850 adults （68% men）, aged 18 to 91 years, underwent maximal cycle ergometer cardiopulmonary exercise testing. Cardiorespiratory fitness （CRF） was assessed relative to sex and age [younger （18 to 35 years）, middle-aged （36 to 60 years） and older （〉 60 years）]. VO2max [mL.（kg.min）-1] was directly measured by assessment of gas exchange and estimated using sex and population specific-equations. Measured and estimated values of VO2max and related EE were compared among the three age- and sex-specific groups. Results Directly measured VO2max of men and women were 29.5 ± 10.5 mL.（kg.min）-1 and 24.2 ± 9.0 mL.（kg·min） -1 （P 〈 0.01）. EE [mL·（kg·min）-1] and percent errors （%E） for men and women had similar values, 0.5 ± 3.2 and 0.4 ± 2.9 mL·（kg·min）-1, and -0.8 ± 13.1% and -1.7 ± 15.4% （P 〉 0.05）, respectively. EE and %E for each age-group were, respectively, for men： younger = 1.9 ± 4.1 mL·（kg·min）-1 and 3.8 ± 10.5%, middle-aged = 0.6 ± 3.1 mL.（kg·min）-1 and 0.4 ± 10.3%, older = -0.2 ± 2.7 mL·（kg·min） -1 and -4.2 ± 16.6% （P 〈 0.01）; and for women： younger = 1.2 ± 3.1 mL.（kg.min）-1 and 2.7 ±10.0%, middle-aged = 0.7 ± 2.8 mL·（kg·min）-1 and 0.5 ± 11.1%, older = -0.8 ± 2.3 mL-（kg·min）-1 and -9.5 ± 22.4% （P 〈 0.01）. Conclusion VO2max were underestimated in younger age-groups and were overestimated in older age groups. Age significantly influences the magnitude of the EE of VO2max in both men and women and should be considered when CRF is estimated using population specific equations, rather than directly measured.展开更多
Background Patient autonomy is a leading principle in bioethics and a basis for shared decision making. This study explores conditions for an autonomous choice experienced by older adults who recently underwent trans-...Background Patient autonomy is a leading principle in bioethics and a basis for shared decision making. This study explores conditions for an autonomous choice experienced by older adults who recently underwent trans-catheter aortic valve replacement （TAVR）. Methods Qualitative study entailing semi-structured interviews of a purposive sample often older （range 73-89, median 83.5 years） adults after TAVR （median 23 days）. The study setting was a cardiac department at a university hospital performing TAVR since 2010. Analysis was by systematic text condensation. Results Even when choice seemed hard or absent, TAVR-patients deliberately took the chance offered them by processing risk assessment, ambivalence and fate. They regarded declining the treatment to be worse than accepting the risk related to the procedure. The experience of being thoroughly advised by their physician formed the basis of an autonomous trust. The trust they felt for the physicians＇ recommendations mitigated ambivalence about the procedure and risks. TAVR patients expressed feelings consistent with self-empowerment and claimed that it had to be their decision. Even so, choosing the intervention as an obligation to their family or passively accepting it was also reported. Conclusions Older TAVR patients＇ experience of an autonomous decision may encompass frank tradeoff; deliberate physician dependency as well as a resilient self-view. Physicians should be especially aware of how older adults＇ subtle cognitive declines and inclinations to preserve their identities which can influence their medical decision making when obtaining in- formed consent. Cardiologists and other providers may also use these insights to develop new strategies that better respond to such inherent complexities.展开更多
1 The rationale for a geriatric cardiology skillset Throughout most of the world, people are living substantially longer. As a result, there is a rapidly expanding population of older adults who did not previously sur...1 The rationale for a geriatric cardiology skillset Throughout most of the world, people are living substantially longer. As a result, there is a rapidly expanding population of older adults who did not previously survive into old age. These adults are exposed to advanced aging processes that did not previously occur. Physiological changes of age predispose to cardiovascular diseases. Ironically, coronary heart disease, heart failure, valvular heart disease, peripheral artery disease, arrhythmias and other cardiovascular problems all soar with survival into senior years.展开更多
There has been a significant decline in cardiovascular morbidity and mortality amidst pervasive advances in care, including percutane- ous revascularization, mechanical circulatory support, and transcatheter valvular ...There has been a significant decline in cardiovascular morbidity and mortality amidst pervasive advances in care, including percutane- ous revascularization, mechanical circulatory support, and transcatheter valvular therapies. While advancing therapies may add significant longevity, they also bring about new end-of-life decision-making challenges for patients and their families who also must weigh the advan- tages of reduced mortality to the possibility of longer lives consisting of high morbidity, frailty, pain, and poor quality of living. Advance care entails options of withholding or withdrawing therapies, and has become a familiar part of cardiovascular care for older patients in Western countries. However, as advanced cardiovascular practices extend to developing countries, the interrelated concept of advance care is rarely straight forward as it is affected by local cultural traditions and mores, and can lead to very different inferences and use. This paper discusses the concepts of advance care planning, surrogate decision-making, orders for resuscitation and futility in patients with cardiac dis- ease with comparisons of West to East, focusing particularly on the United States versus India.展开更多
Dear editor,Hepatopulmonary syndrome(HPS)is not uncommon in the setting of liver disease,especially in liver cirrhosis patients.The prevalence of HPS in liver cirrhosis patients varies from 4%to 47%.[1-3]About the def...Dear editor,Hepatopulmonary syndrome(HPS)is not uncommon in the setting of liver disease,especially in liver cirrhosis patients.The prevalence of HPS in liver cirrhosis patients varies from 4%to 47%.[1-3]About the definition of HPS,it is a pulmonary vascular disorder with evidence of intrapulmonary arterial venous shunt.[4]Pulmonary dyspnea and polycythemia are common presentations of HPS.Dyspnea,cyanosis and clubbed fingers were present in most of all cases.Spider nevi is another common clinical feature of patients with HPS.展开更多
Emerged evidence has indicated that immunosuppression is involved in the occurrence and development of sepsis.To provide clinical practice recommendations on the immune function in sepsis,an expert consensus focusing ...Emerged evidence has indicated that immunosuppression is involved in the occurrence and development of sepsis.To provide clinical practice recommendations on the immune function in sepsis,an expert consensus focusing on the monitoring and treatment of sepsis-induced immunosuppression was developed.Literature related to the immune monitoring and treatment of sepsis were retrieved from PubMed,Web of Science,and Chinese National Knowledge Infrastructure to design items and expert opinions were collected through an online questionnaire.Then,the Delphi method was used to form consensus opinions,and RAND appropriateness method was developed to provide consistency evaluation and recommendation levels for consensus opinions.This consensus achieved satisfactory results through two rounds of questionnaire survey,with 2 statements rated as perfect consistency,13 as very good consistency,and 9 as good consistency.After summarizing the results,a total of 14 strong recommended opinions,8 weak recommended opinions and 2 non-recommended opinions were produced.Finally,a face-to-face discussion of the consensus opinions was performed through an online meeting,and all judges unanimously agreed on the content of this consensus.In summary,this expert consensus provides a preliminary guidance for the monitoring and treatment of immunosuppression in patients with sepsis.展开更多
1 Introduction Ischemic heart disease is caused by atherosclerotic and/or thrombotic obstruction of coronary arteries. Clinical spec- trum of ischemic heart disease expands from asymptomatic atherosclerosis of corona...1 Introduction Ischemic heart disease is caused by atherosclerotic and/or thrombotic obstruction of coronary arteries. Clinical spec- trum of ischemic heart disease expands from asymptomatic atherosclerosis of coronary arteries to acute coronary syn- dromes （ACS） including unstable angina, acute myocardial infarction （non-ST elevation myocardial infarction and ST elevation myocardial infarction）. Stable ischemic heart dis- ease （SIHD） refers to patients with known or suspected SIHD who have no recent or acute changes in their symp- tomatic status, suggesting no active thrombotic process is underway.展开更多
1 BackgroundIn the United States, life expectancy is rising, particularly among the older population （〉 65 years）, with projected estimates approaching 20% by year 2050. Despite improved survival estimates, cardiov...1 BackgroundIn the United States, life expectancy is rising, particularly among the older population （〉 65 years）, with projected estimates approaching 20% by year 2050. Despite improved survival estimates, cardiovascular diseases remain the leading cause of morbidity and mortality resulting in substantial increase in health care cost. For younger adults, the evidence for secondary cardiovascular prevention is well established and corroborated by robust data. However, the application of risk reduction strategies in older populations remains an area of active debate. Many assume that vulnerability to chronic cardiovascular diseases is an inexorable part of aging such that the risks attributable to prevention outweigh potential benefits.展开更多
BACKGROUND: As the field of Emergency Medicine grows worldwide, the importance of an Emergency Department Crash Cart(EDCC) has long been recognized. Yet, there is paucity of relevant peer-reviewed literature specifica...BACKGROUND: As the field of Emergency Medicine grows worldwide, the importance of an Emergency Department Crash Cart(EDCC) has long been recognized. Yet, there is paucity of relevant peer-reviewed literature specifically discussing EDCCs or proposing detailed features for an EDCC suitable for both adult and pediatric patients. METHODS: The authors performed a systematic review of EDCC-specific literature indexed in Pubmed and Embase on December 20, 2016. In addition, the authors reviewed the 2015 American Heart Association(AHA) guidelines for cardiopulmonary resuscitation and emergency cardiovascular care, the 2015 European Resuscitation Council(ERC) guidelines for resuscitation, and the 2013 American College of Surgeons(ACS) Advanced Trauma Life Support(ATLS) 9 th edition.RESULTS: There were a total of 277 results, with 192 unique results and 85 duplicates. After careful review by two independent reviewers, all but four references were excluded. None of the four included articles described comprehensive contents of equipment and medications for both the adult and pediatric populations. This article describes in detail the final four articles specific to EDCC, and proposes a set of suggested contents for the EDCC. CONCLUSION: Our systematic review shows the striking paucity of such a high impact indispensable item in the ED. We hope that our EDCC content suggestions help enhance the level of response of EDs in the resuscitation of adult and pediatric populations, and encourage the implementation of and adherence to the latest evidence-based resuscitation guidelines.展开更多
1 Introduction Although older adults are generally among the highest users of cardiovascular medications, they are typically underrepresented or excluded from most efficacy and safety trials. Drug developers are usual...1 Introduction Although older adults are generally among the highest users of cardiovascular medications, they are typically underrepresented or excluded from most efficacy and safety trials. Drug developers are usually reluctant to include many senior adults in randomized controlled clinical trials in part due to their high prevalence of multiple comorbidities, frailty, and polypharmacy; and to age-related pharmacokinetic and pharmacodynamic complexities. Consequently, there is often insufficient high quality evidence-based data to inform pharmacologic management of common cardiovascular conditions on older adults. In the absence of data, clinicians often rely on conceptual principles regarding metabolism and drug-drug interactions to minimize adverse drug events, but this is often not well-substantiated or standardized. A related challenge is poor cardiovascular medication adherence among older adults, and its detrimental impact on their health outcomes. In this brief review we highlight some aspects of these topics.展开更多
Background: Identification of elevated intracranial pressure is important following traumatic brain injury. We assessed the feasibility of educating military trainees on accurately obtaining optic nerve sheath diamete...Background: Identification of elevated intracranial pressure is important following traumatic brain injury. We assessed the feasibility of educating military trainees on accurately obtaining optic nerve sheath diameter measurements using a brief didactic and hands-on training session. Optic nerve sheath diameter is a noninvasive surrogate marker for elevated intracranial pressure, and may be of value in remote military operations, where rapid triage decisions must be made without access to advanced medical equipment.Methods: Military trainees with minimal ultrasound experience were given a 5-min didactic presentation on optic nerve sheath diameter ultrasound. Trainees practiced optic nerve sheath diameter measurements guided by emergency physician ultrasound experts. Trainees then measured the optic nerve sheath diameter on normal volunteers. Following this, a trained physician measured the optic nerve sheath diameter on the same volunteer as a criterion standard. An average of three measurements was taken.Results: Twenty-three military trainees were enrolled. A mixed design ANOVA was used to compare measurements by trainees to those of physicians, with a mean difference of –0.6 mm(P=0.76). A Bland-Altman analysis showed that the degree of bias in optic nerve sheath diameter measures provided by trainees was very small: d=–0.004 for the right eye and d=–0.007 for the left eye.Conclusions: This study demonstrates that optic nerve sheath diameter measurement can be accurately performed by novice ultrasonographers after a brief training session. If validated, point-of-care optic nerve sheath diameter measurement could impact the triage of injured patients in remote areas.展开更多
文摘Objective To assess the influence of age on the error of estimate （EE） of maximal oxygen uptake （VO2max） using sex and population specific-equations in cycle ergometer exercise testing, since estimated VO2 max is associated with a substantial EE, often exceeding 20%, possibly due to intrinsic variability of mechanical efficiency. Methods 1850 adults （68% men）, aged 18 to 91 years, underwent maximal cycle ergometer cardiopulmonary exercise testing. Cardiorespiratory fitness （CRF） was assessed relative to sex and age [younger （18 to 35 years）, middle-aged （36 to 60 years） and older （〉 60 years）]. VO2max [mL.（kg.min）-1] was directly measured by assessment of gas exchange and estimated using sex and population specific-equations. Measured and estimated values of VO2max and related EE were compared among the three age- and sex-specific groups. Results Directly measured VO2max of men and women were 29.5 ± 10.5 mL.（kg.min）-1 and 24.2 ± 9.0 mL.（kg·min） -1 （P 〈 0.01）. EE [mL·（kg·min）-1] and percent errors （%E） for men and women had similar values, 0.5 ± 3.2 and 0.4 ± 2.9 mL·（kg·min）-1, and -0.8 ± 13.1% and -1.7 ± 15.4% （P 〉 0.05）, respectively. EE and %E for each age-group were, respectively, for men： younger = 1.9 ± 4.1 mL·（kg·min）-1 and 3.8 ± 10.5%, middle-aged = 0.6 ± 3.1 mL.（kg·min）-1 and 0.4 ± 10.3%, older = -0.2 ± 2.7 mL·（kg·min） -1 and -4.2 ± 16.6% （P 〈 0.01）; and for women： younger = 1.2 ± 3.1 mL.（kg.min）-1 and 2.7 ±10.0%, middle-aged = 0.7 ± 2.8 mL·（kg·min）-1 and 0.5 ± 11.1%, older = -0.8 ± 2.3 mL-（kg·min）-1 and -9.5 ± 22.4% （P 〈 0.01）. Conclusion VO2max were underestimated in younger age-groups and were overestimated in older age groups. Age significantly influences the magnitude of the EE of VO2max in both men and women and should be considered when CRF is estimated using population specific equations, rather than directly measured.
文摘Background Patient autonomy is a leading principle in bioethics and a basis for shared decision making. This study explores conditions for an autonomous choice experienced by older adults who recently underwent trans-catheter aortic valve replacement （TAVR）. Methods Qualitative study entailing semi-structured interviews of a purposive sample often older （range 73-89, median 83.5 years） adults after TAVR （median 23 days）. The study setting was a cardiac department at a university hospital performing TAVR since 2010. Analysis was by systematic text condensation. Results Even when choice seemed hard or absent, TAVR-patients deliberately took the chance offered them by processing risk assessment, ambivalence and fate. They regarded declining the treatment to be worse than accepting the risk related to the procedure. The experience of being thoroughly advised by their physician formed the basis of an autonomous trust. The trust they felt for the physicians＇ recommendations mitigated ambivalence about the procedure and risks. TAVR patients expressed feelings consistent with self-empowerment and claimed that it had to be their decision. Even so, choosing the intervention as an obligation to their family or passively accepting it was also reported. Conclusions Older TAVR patients＇ experience of an autonomous decision may encompass frank tradeoff; deliberate physician dependency as well as a resilient self-view. Physicians should be especially aware of how older adults＇ subtle cognitive declines and inclinations to preserve their identities which can influence their medical decision making when obtaining in- formed consent. Cardiologists and other providers may also use these insights to develop new strategies that better respond to such inherent complexities.
文摘1 The rationale for a geriatric cardiology skillset Throughout most of the world, people are living substantially longer. As a result, there is a rapidly expanding population of older adults who did not previously survive into old age. These adults are exposed to advanced aging processes that did not previously occur. Physiological changes of age predispose to cardiovascular diseases. Ironically, coronary heart disease, heart failure, valvular heart disease, peripheral artery disease, arrhythmias and other cardiovascular problems all soar with survival into senior years.
文摘There has been a significant decline in cardiovascular morbidity and mortality amidst pervasive advances in care, including percutane- ous revascularization, mechanical circulatory support, and transcatheter valvular therapies. While advancing therapies may add significant longevity, they also bring about new end-of-life decision-making challenges for patients and their families who also must weigh the advan- tages of reduced mortality to the possibility of longer lives consisting of high morbidity, frailty, pain, and poor quality of living. Advance care entails options of withholding or withdrawing therapies, and has become a familiar part of cardiovascular care for older patients in Western countries. However, as advanced cardiovascular practices extend to developing countries, the interrelated concept of advance care is rarely straight forward as it is affected by local cultural traditions and mores, and can lead to very different inferences and use. This paper discusses the concepts of advance care planning, surrogate decision-making, orders for resuscitation and futility in patients with cardiac dis- ease with comparisons of West to East, focusing particularly on the United States versus India.
文摘Dear editor,Hepatopulmonary syndrome(HPS)is not uncommon in the setting of liver disease,especially in liver cirrhosis patients.The prevalence of HPS in liver cirrhosis patients varies from 4%to 47%.[1-3]About the definition of HPS,it is a pulmonary vascular disorder with evidence of intrapulmonary arterial venous shunt.[4]Pulmonary dyspnea and polycythemia are common presentations of HPS.Dyspnea,cyanosis and clubbed fingers were present in most of all cases.Spider nevi is another common clinical feature of patients with HPS.
基金supported by grants from the National Natural Science Foundation of China(81730057,82130062)the Key Project of Military Medical Innovation Program of Chinese PLA(18CXZ026)+1 种基金the Guangdong Clinical Research Center for Critical Care Medicine(2020B1111170005)the Sun Yat?sen University Clinical Research Program 5010(2019002)。
文摘Emerged evidence has indicated that immunosuppression is involved in the occurrence and development of sepsis.To provide clinical practice recommendations on the immune function in sepsis,an expert consensus focusing on the monitoring and treatment of sepsis-induced immunosuppression was developed.Literature related to the immune monitoring and treatment of sepsis were retrieved from PubMed,Web of Science,and Chinese National Knowledge Infrastructure to design items and expert opinions were collected through an online questionnaire.Then,the Delphi method was used to form consensus opinions,and RAND appropriateness method was developed to provide consistency evaluation and recommendation levels for consensus opinions.This consensus achieved satisfactory results through two rounds of questionnaire survey,with 2 statements rated as perfect consistency,13 as very good consistency,and 9 as good consistency.After summarizing the results,a total of 14 strong recommended opinions,8 weak recommended opinions and 2 non-recommended opinions were produced.Finally,a face-to-face discussion of the consensus opinions was performed through an online meeting,and all judges unanimously agreed on the content of this consensus.In summary,this expert consensus provides a preliminary guidance for the monitoring and treatment of immunosuppression in patients with sepsis.
文摘1 Introduction Ischemic heart disease is caused by atherosclerotic and/or thrombotic obstruction of coronary arteries. Clinical spec- trum of ischemic heart disease expands from asymptomatic atherosclerosis of coronary arteries to acute coronary syn- dromes （ACS） including unstable angina, acute myocardial infarction （non-ST elevation myocardial infarction and ST elevation myocardial infarction）. Stable ischemic heart dis- ease （SIHD） refers to patients with known or suspected SIHD who have no recent or acute changes in their symp- tomatic status, suggesting no active thrombotic process is underway.
文摘1 BackgroundIn the United States, life expectancy is rising, particularly among the older population （〉 65 years）, with projected estimates approaching 20% by year 2050. Despite improved survival estimates, cardiovascular diseases remain the leading cause of morbidity and mortality resulting in substantial increase in health care cost. For younger adults, the evidence for secondary cardiovascular prevention is well established and corroborated by robust data. However, the application of risk reduction strategies in older populations remains an area of active debate. Many assume that vulnerability to chronic cardiovascular diseases is an inexorable part of aging such that the risks attributable to prevention outweigh potential benefits.
文摘BACKGROUND: As the field of Emergency Medicine grows worldwide, the importance of an Emergency Department Crash Cart(EDCC) has long been recognized. Yet, there is paucity of relevant peer-reviewed literature specifically discussing EDCCs or proposing detailed features for an EDCC suitable for both adult and pediatric patients. METHODS: The authors performed a systematic review of EDCC-specific literature indexed in Pubmed and Embase on December 20, 2016. In addition, the authors reviewed the 2015 American Heart Association(AHA) guidelines for cardiopulmonary resuscitation and emergency cardiovascular care, the 2015 European Resuscitation Council(ERC) guidelines for resuscitation, and the 2013 American College of Surgeons(ACS) Advanced Trauma Life Support(ATLS) 9 th edition.RESULTS: There were a total of 277 results, with 192 unique results and 85 duplicates. After careful review by two independent reviewers, all but four references were excluded. None of the four included articles described comprehensive contents of equipment and medications for both the adult and pediatric populations. This article describes in detail the final four articles specific to EDCC, and proposes a set of suggested contents for the EDCC. CONCLUSION: Our systematic review shows the striking paucity of such a high impact indispensable item in the ED. We hope that our EDCC content suggestions help enhance the level of response of EDs in the resuscitation of adult and pediatric populations, and encourage the implementation of and adherence to the latest evidence-based resuscitation guidelines.
文摘1 Introduction Although older adults are generally among the highest users of cardiovascular medications, they are typically underrepresented or excluded from most efficacy and safety trials. Drug developers are usually reluctant to include many senior adults in randomized controlled clinical trials in part due to their high prevalence of multiple comorbidities, frailty, and polypharmacy; and to age-related pharmacokinetic and pharmacodynamic complexities. Consequently, there is often insufficient high quality evidence-based data to inform pharmacologic management of common cardiovascular conditions on older adults. In the absence of data, clinicians often rely on conceptual principles regarding metabolism and drug-drug interactions to minimize adverse drug events, but this is often not well-substantiated or standardized. A related challenge is poor cardiovascular medication adherence among older adults, and its detrimental impact on their health outcomes. In this brief review we highlight some aspects of these topics.
文摘Background: Identification of elevated intracranial pressure is important following traumatic brain injury. We assessed the feasibility of educating military trainees on accurately obtaining optic nerve sheath diameter measurements using a brief didactic and hands-on training session. Optic nerve sheath diameter is a noninvasive surrogate marker for elevated intracranial pressure, and may be of value in remote military operations, where rapid triage decisions must be made without access to advanced medical equipment.Methods: Military trainees with minimal ultrasound experience were given a 5-min didactic presentation on optic nerve sheath diameter ultrasound. Trainees practiced optic nerve sheath diameter measurements guided by emergency physician ultrasound experts. Trainees then measured the optic nerve sheath diameter on normal volunteers. Following this, a trained physician measured the optic nerve sheath diameter on the same volunteer as a criterion standard. An average of three measurements was taken.Results: Twenty-three military trainees were enrolled. A mixed design ANOVA was used to compare measurements by trainees to those of physicians, with a mean difference of –0.6 mm(P=0.76). A Bland-Altman analysis showed that the degree of bias in optic nerve sheath diameter measures provided by trainees was very small: d=–0.004 for the right eye and d=–0.007 for the left eye.Conclusions: This study demonstrates that optic nerve sheath diameter measurement can be accurately performed by novice ultrasonographers after a brief training session. If validated, point-of-care optic nerve sheath diameter measurement could impact the triage of injured patients in remote areas.
