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Coronary artery disease (CAD) is one of the leading causes of death in the United States. Eighty percent of people having heart attacks have normal cholesterol levels. A quarter of the population have a condition called low-density lipoprotein (LDL) pattern B that has been associated with a threefold risk of myocardial infarction. Although early intervention can often prevent an otherwise fatal event, these patients often go unrecognized until after a myocardial infarction has occurred because they may not have the usual risk factors associated with cardiovascular disease. In patients with LDL pattern B, the standard lipid panel may be normal and inadequate for diagnosis and treatment of the condition. This article discusses how to identify a potentially high risk patient, available laboratory tests, management options, and the role of nurses in identifying high risk patients. The second author tells his personal story of surviving multiple cardiac arrests at a young age before being diagnosed with this condition.

SUMMARYA total of 100 hospital dental cases were reviewed. No significant long‐term complications were seen that resulted from the anesthesia or operative procedures. Most of the minor postoperative changes that we saw were related to the operative procedures. In this study, few minor changes could be related to the anesthesia techniques or duration of the surgery. This is probably related to optimizing preoperative health and proper intra‐ and postoperative care. However, the results could also be related to the age of our patients, because younger age groups are less likely to have postoperative complications. Despite the potentially high‐risk patient population, dental treatment in the hospital environment is a safe procedure.

This article contains information related to a recent study "Selective screening for detection of mucopolysaccharidoses (MPS) in Malaysia; A Two-year Study" Affandi et al., 2019. Any patient registered under government healthcare facilities in Malaysia and fit at least two inclusion criteria were included in this selective screening. Urine and blood from these high risk patients were obtained and analysed for glycosaminoglycans (GAGs) level before characterization using high resolution electrophoresis (HRE). Thereafter, enzyme assay for different types of MPS based on result of HRE were determined using specific substrate. Demographic data as well as laboratory findings were tabulated and analysed. The data of this study demonstrate between clinical presentation and laboratory findings among high risk patients of MPS and can be employed to improve diagnosis of MPS.

Abstract
Background: Therapies to prevent alcohol-associated liver disease (ALD) in high-risk patients are needed. Aims: In this retrospective association study, we examined whether patients with alcohol use disorder (AUD) who reported greater exercise were less likely to develop liver disease. Methods: In this retrospective cohort study, we used the Mass General Brigham Biobank to investigate the impact of both moderate-high and light-intensity exercise on the development of ALD in patients with AUD, using clinician-provided diagnostic International Classification of Diseases 10 codes. Exercise was evaluated using a questionnaire completed after an AUD diagnosis, and before evidence of liver disease. Cox regressions were used to generate hazard ratios (HRs) for the development of ALD. Results: 1987 patients met inclusion criteria. These patients were followed for an average of 10.7 years. In multivariable analyses, we found that patients that reported at least 2.5 h of moderate-high intensity exercise/week (confidence interval recommendation for exercise) were less likely to develop ALD compared to patients that did not exercise (HR: 0.26, 95%CI: 0.085–0.64, P = 0.007). Indeed, each hour of moderate-high intensity exercise was associated with progressively decreasing odds of developing ALD (HR: 0.76, 95%CI: 0.58–0.91, P = 0.02). Conversely, patients who did not engage in any moderate-high intensity exercise were more likely to develop ALD (HR: 2.76, 95%CI: 1.44–5.40, P = 0.003). Conclusions: In our cohort, patients with AUD who reported moderate-high intensity exercise showed a lower association with incidence of ALD development than patients who did not exercise.

Background: The purpose of this study was to produce a risk stratification within a population of high-risk patients with multiple chronic conditions who are currently treated under a case management program and to explore the existence of different risk subgroups. Different care strategies were then suggested for healthcare reform according to the characteristics of each subgroup. Methods: All high-risk multimorbid patients from a case management program in the Navarra region of Spain were included in the study (n = 885). A 1-year mortality risk score was estimated for each patient by logistic regression. The population was then divided into subgroups according to the patients' estimated risk scores. We used cluster analysis to produce the stratification with Ward's linkage hierarchical algorithm. The characteristics of the resulting subgroups were analyzed, and post hoc pairwise tests were performed. Results: Three distinct risk strata were found, containing 45, 38 and 17% of patients. Age increased from cluster to cluster, and functional status, clinical severity, nursing needs and nutritional values deteriorated. Patients in cluster 1 had lower renal deterioration values, and patients in cluster 3 had higher rates of pressure skin ulcers, higher rates of cerebrovascular disease and dementia, and lower prevalence rates of chronic obstructive pulmonary disease. Conclusions: This study demonstrates the existence of distinct subgroups within a population of high-risk patients with multiple chronic conditions. Current case management integrated care programs use a uniform treatment strategy for patients who have diverse needs. Alternative treatment strategies should be considered to fit the needs of each patient subgroup. ; Pablo E. Bretos-Azcona thanks the Government of Navarra for their financial support under the funding scheme 'Plan de Formación y de I+D 2018'.

Abstract
Atrial fibrillation (AF) conversion to sinus rhythm by electrical cardioversion (ECV) is followed by the challenge of preventing arrhythmia recurrence, especially in high-risk patients. The properties of class IC, class III and also class II antiarrhythmic medications have been established, but not all effects have been studied. The aim of the study was to compare efficacy of class IC and class III antiarrhythmic medications, and additionally medication with a class II mechanism of action, or taken concomitantly with a beta-blocker, for post-cardioversion sinus rhythm maintenance in patients with high-risk AF. A total of 112 patients who underwent successful ECV in Latvian Centre of Cardiology were included. Data was acquired by a face-to-face interview and 1-, 3-, 6-month follow-up interviews. Comparing class IC (used by 34.8%) and class III (used by 65.2%) drugs, there was no statistically significant difference between six-month sinus rhythm maintenance rates (53.8% vs. 63.0%, p = 0.346) and arrhythmia-free survival (p = 0.313). Comparing amiodarone (used by 57.1%) and ethacizine, concurrently with a beta-blocker (used by 25.9%), no statistically significant difference was found between six-month sinus rhythm maintenance (64.1% vs. 58.6%, p = 0.616) and arrhythmia-free survival (p = 0.706). The results showed that specific antiarrhythmic drug choice was not associated with superior effectiveness, highlighting that, if not contraindicated, ethacizine, concomitantly with a beta-blocker, could be used as a similarly effective alternative for amiodarone, which has adverse health effects.

PURPOSE: Over 95% of patients who screen positive on the Patient Health Questionnaire-9 (PHQ-9) suicide risk item do not attempt or die by suicide, which could lead to unnecessary treatment and/or misallocation of limited resources. The present study seeks to determine if suicide risk screening can be meaningfully improved to identify the highest-risk patients. METHODS: Patients eligible to receive medical treatment from the US Department of Defense medical system were recruited from 6 military primary care clinics located at 5 military installations around the United States. Patients completed self-report measures including the PHQ-9 and 16 items from the Suicide Cognitions Scale (SCS) during routine primary care clinic visits. Postbaseline suicidal behaviors (suicide attempts, interrupted attempts, and aborted attempts) were assessed by evaluators who were blind to screening results using the Self-Injurious Thoughts and Behaviors Interview. RESULTS: Among 2,744 patients, 13 (0.5%) engaged in suicidal behavior in the 30 days after screening and 28 (1.0%) displayed suicidal behavior in the 90 days after screening. Multiple SCS items differentiated patients with suicidal behavior less than 30 days after screening positive for suicide risk. Augmenting the PHQ-9 suicide risk item with SCS items improved the identification of patients who were most likely to have suicidal behavior within a month of screening positive without sacrificing sensitivity. CONCLUSION: Among primary care patients who screen positive for suicide risk on the PHQ-9, SCS items improved screening efficiency by identifying those patients who are most likely to engage in suicidal behavior within the next 30 days.

Circulating microparticles (cMPs) are small phospholipid-rich microvesicles shed by activated cells that play a pivotal role in cell signalling related to the pathogenesis of atherothrombosis. We aimed to investigate the prognostic value of cMPs released from different vascular cells for cardiovascular event (CVE) presentation in asymptomatic patients at high cardiovascular risk factors under nutritional and pharmacologic treatment. This is a nested case-control study of 50 patients from the five-year follow-up prospective PREDIMED trial enrolled in the nuts arm of the Mediterranean diet (MedDiet-nuts). We randomly selected 25 patients who had suffered a CVE during follow-up and pair-matched them for sex, age, and classical CV risk factors to 25 patients who remained asymptomatic (no-CVE). Total Annexin V-(AV)+ cMPs and cMPs from cells of the vascular compartment were quantified by flow cytometry at baseline and after one year follow-up. MedDiet-nuts and pharmacological treatment neither modified levels nor source of MP shedding in CVE patients. However, no-CVE patients showed 40-86 % decreased total AV+, PAC-1+/AV+, CD61+/AV+, CD142+/CD61+/AV+, CD62P+/AV+, CD146+/AV+, CD63+/AV+ and CD11a+/AV+ cMPs at one year follow-up (p≤0.046, all). CD142+/CD61+/AV+, CD146+/AV+ and CD45+/AV+ cMPs were decreased in no-CVE patients compared to CVE patients. A ROC-curve clustered model for CD142+/CD61+/AV+, CD45+/AV+ and CD146+/AV+ cMPs predicted a future CVE [p<0.0001, AUC=0.805 (0.672 to 0.938)]. In patients at high CV risk profile treated with a controlled MedDiet supplemented with nuts and receiving up-to-date CV drug treatment, reduced cMPs derived from activated platelets, leukocytes and endothelial cells are predictive of protection against CVE within the next four years. ; GC-B is a Sara Borrell Postdoctoral Fellow (CD13/00023) from Instituto de Salud Carlos III. This work has been possible thanks to funding received from the Spanish Ministry of Economy and Competitiveness (Plan Estatal de I+D+I 2013-2016, SAF2013-42962-R, to LB), from the Cardiovascular Research Network of Instituto de Salud Carlos III (RIC, RD12/0042/0027 to LB; SAF2012-40208 to GV) and from CIBER CB06/03 Fisiopatología de la Obesidad y la Nutrición of Instituto de Salud Carlos III, (CIBERobn, RD06/0045 to RE). All grants were co-financed by European Union Funds, Fondo Europeo de Desarrollo Regional (FEDER) "Una manera de hacer Europa."

BACKGROUND: Efforts to improve the outcome of liver surgery by combining curative resection with chemotherapy have failed to demonstrate definite overall survival benefit. This may partly be due to the fact that these studies often involve strict inclusion criteria. Consequently, patients with a high risk profile as characterized by Fong's Clinical Risk Score (CRS) are often underrepresented in these studies. Conceptually, this group of patients might benefit the most from chemotherapy. The present study evaluates the impact of neo-adjuvant chemotherapy in high-risk patients with primary resectable colorectal liver metastases, without extrahepatic disease. Our hypothesis is that adding neo-adjuvant chemotherapy to surgery will provide an improvement in overall survival (OS) in patients with a high-risk profile. METHODS/DESIGN: CHARISMA is a multicenter, randomized, phase III clinical trial. Patients will be randomized to either surgery alone (standard treatment, arm A) or to 6 cycles of neo-adjuvant oxaliplatin-based chemotherapy, followed by surgery (arm B). Patients must be >/= 18 years of age with liver metastases of histologically confirmed primary colorectal carcinoma. Patients with extrahepatic metastases are excluded. Liver metastases must be deemed primarily resectable. Only patients with a CRS of 3-5 are eligible. The primary study endpoint is OS. Secondary endpoints are progression free survival (PFS), quality of life, morbidity of resection, treatment response on neo-adjuvant chemotherapy, and whether CEA levels can predict treatment response. DISCUSSION: CHARISMA is a multicenter, randomized, phase III clinical trial that will provide an answer to the question if adding neo-adjuvant chemotherapy to surgery will improve OS in a well-defined high-risk patient group with colorectal liver metastases. TRIAL REGISTRATION: The CHARISMA is registered at European Union Clinical Trials Register (EudraCT), number: 2013-004952-39 , and in the "Netherlands national Trial Register (NTR), number: 4893.

Prostate cancer is the most frequent malignant disease in men in United States, Western Europe and in Lithuania. Due to ageing population incidence of prostate cancer will rise even more in the future. Since the year 2003 prostate cancer became the most common form of cancer diagnosed in men in Lithuania (more than 1500 new prostate cancer cases a year). There were 2005 of new prostate cancer cases diagnosed in the year 2005. According to Lithuanian Cancer Registry data during the years 1995-2005 the prevalence of prostate cancer was increasing 14.5 percent annually. Prostate cancer was detected in 24.3 percent of all cancer cases in men in the year 2005 in Lithuania and in 48.3 percent of them disease was detected in the stages I and II. In the year 2005 the prevalence of prostate cancer in Lithuanian men was 125.9 per 100000 population and mortality was 31 per 100000 population. Prostate cancer is a second common form of death after lung cancer in cancer-associated mortality group in Lithuania. Prostate cancer mortality ranged between 19 and 55 per 100000 in Europe and it was 23.2 per 100000 populations in the year 2006 in European Union. Many authors stress that it is important to diagnose prostate cancer in the early stages in order to reduce prostate cancer mortality rate. The aim of the study was to optimize investigation and follow-up of the high prostate cancer risk patients, and to define the relation between prostate cancer risk factors and prostate cancer detection. The objectives of study: 1. To estimate the rate of prostate cancer detection by the first and repeat laterally directed sextant transrectal ultrasound guided prostate biopsies, and to evaluate efficacy of repeat laterally directed sextant prostate biopsies. 2. To evaluate the influence of age, smoking, alcohol use, obesity, elevated cholesterol and prostate cancer history in relatives for prostate cancer detection in high risk patients. 3. To analyze the relevance of PSA, digital rectal examination and transrectal ultrasound examination for prostate cancer detection in high risk patients. 4. To evaluate the importance of prostate volume and transition zone prostate volume for prostate cancer detection in high risk patients. To estimate the relevance of transition zone index (TZI) and to detect TZI cutoff value for prostate cancer detection. 5. To predict the development of prostate cancer using free and total PSA, free/total PSA ratio, PSA density, transition zone PSA density. 6. To optimize indications and frequency for repeat biopsies in high prostate cancer risk patients. Prospective study was performed in Urology department of Kaunas University of Medicine during the years of 2003-2007. 195 men with high risk (elevated prostate specific antigen test (PSA >4 ng/ml) and/or pathological digital rectal examination) for prostate cancer were included into the study. The patients were followed up to 4 years. Conclusions: 1. We detected prostate cancer in 30.3% of patients after the first, 13.1% after the second, 10.3% after the third and 7.7% after the fourth laterally directed sextant transrectal ultrasound guided prostate biopsy. Of all prostate cancer cases detected in our study 78.7 percent were found after the first biopsy. After the second biopsy we found additional 14.6% of cancer cases and together with the first biopsy detected 93.3% of all prostate cancers. 2. The patients with prostate cancer had more malignant diseases in the past than benign prostate hyperplasia group. Patient's age, smoking, alcohol use, familial cancer anamnesis, obesity and elevated cholesterol concentration did not differ between cancer and benign groups. 3. PSA test and digital rectal examination are important in suspecting prostate cancer. Transrectal ultrasound test allows to evaluate prostate volume, transition zone prostate volume and to calculate secondary values (PSA density, transition zone PSA density, transition zone index) which enable to determine indications for repeat prostate biopsies. 4. Prostate volume and transition zone prostate volume were significantly smaller in prostate cancer group as compared to benign group. Patients with benign prostate hyperplasia had statistically significant increment of prostate volume and transition zone prostate volume with every subsequent biopsy. Transition zone index was also lower in prostate cancer group as compared to benign. We estimated a cutoff value of transition zone index for prostate cancer detection: transition zone index 0.17 ng/ml/cm3 increased prostate cancer detection risk by 5 fold, free/total PSA ratio 0.17 ng/ml/cm3 and transition zone index 0.17 ng/ml/cm3.

Prostate cancer is the most frequent malignant disease in men in United States, Western Europe and in Lithuania. Due to ageing population incidence of prostate cancer will rise even more in the future. Since the year 2003 prostate cancer became the most common form of cancer diagnosed in men in Lithuania (more than 1500 new prostate cancer cases a year). There were 2005 of new prostate cancer cases diagnosed in the year 2005. According to Lithuanian Cancer Registry data during the years 1995-2005 the prevalence of prostate cancer was increasing 14.5 percent annually. Prostate cancer was detected in 24.3 percent of all cancer cases in men in the year 2005 in Lithuania and in 48.3 percent of them disease was detected in the stages I and II. In the year 2005 the prevalence of prostate cancer in Lithuanian men was 125.9 per 100000 population and mortality was 31 per 100000 population. Prostate cancer is a second common form of death after lung cancer in cancer-associated mortality group in Lithuania. Prostate cancer mortality ranged between 19 and 55 per 100000 in Europe and it was 23.2 per 100000 populations in the year 2006 in European Union. Many authors stress that it is important to diagnose prostate cancer in the early stages in order to reduce prostate cancer mortality rate. The aim of the study was to optimize investigation and follow-up of the high prostate cancer risk patients, and to define the relation between prostate cancer risk factors and prostate cancer detection. The objectives of study: 1. To estimate the rate of prostate cancer detection by the first and repeat laterally directed sextant transrectal ultrasound guided prostate biopsies, and to evaluate efficacy of repeat laterally directed sextant prostate biopsies. 2. To evaluate the influence of age, smoking, alcohol use, obesity, elevated cholesterol and prostate cancer history in relatives for prostate cancer detection in high risk patients. 3. To analyze the relevance of PSA, digital rectal examination and transrectal ultrasound examination for prostate cancer detection in high risk patients. 4. To evaluate the importance of prostate volume and transition zone prostate volume for prostate cancer detection in high risk patients. To estimate the relevance of transition zone index (TZI) and to detect TZI cutoff value for prostate cancer detection. 5. To predict the development of prostate cancer using free and total PSA, free/total PSA ratio, PSA density, transition zone PSA density. 6. To optimize indications and frequency for repeat biopsies in high prostate cancer risk patients. Prospective study was performed in Urology department of Kaunas University of Medicine during the years of 2003-2007. 195 men with high risk (elevated prostate specific antigen test (PSA >4 ng/ml) and/or pathological digital rectal examination) for prostate cancer were included into the study. The patients were followed up to 4 years. Conclusions: 1. We detected prostate cancer in 30.3% of patients after the first, 13.1% after the second, 10.3% after the third and 7.7% after the fourth laterally directed sextant transrectal ultrasound guided prostate biopsy. Of all prostate cancer cases detected in our study 78.7 percent were found after the first biopsy. After the second biopsy we found additional 14.6% of cancer cases and together with the first biopsy detected 93.3% of all prostate cancers. 2. The patients with prostate cancer had more malignant diseases in the past than benign prostate hyperplasia group. Patient's age, smoking, alcohol use, familial cancer anamnesis, obesity and elevated cholesterol concentration did not differ between cancer and benign groups. 3. PSA test and digital rectal examination are important in suspecting prostate cancer. Transrectal ultrasound test allows to evaluate prostate volume, transition zone prostate volume and to calculate secondary values (PSA density, transition zone PSA density, transition zone index) which enable to determine indications for repeat prostate biopsies. 4. Prostate volume and transition zone prostate volume were significantly smaller in prostate cancer group as compared to benign group. Patients with benign prostate hyperplasia had statistically significant increment of prostate volume and transition zone prostate volume with every subsequent biopsy. Transition zone index was also lower in prostate cancer group as compared to benign. We estimated a cutoff value of transition zone index for prostate cancer detection: transition zone index 0.17 ng/ml/cm3 increased prostate cancer detection risk by 5 fold, free/total PSA ratio 0.17 ng/ml/cm3 and transition zone index 0.17 ng/ml/cm3.

Tao Wang,* Hao Luo,* Hong-tao Yan,* Guo-hu Zhang, Wei-hui Liu, Li-jun Tang General Surgery Center, Chengdu Military General Hospital, Chengdu, Sichuan, People's Republic of China *These authors contributed equally to this work Objective: Cholecystolithiasis is a common disease in the elderly patient. The routine therapy is open or laparoscopic cholecystectomy. In the previous study, we designed a minimally invasive cholecystolithotomy based on percutaneous cholecystostomy combined with a choledochoscope (PCCLC) under local anesthesia. Methods: To investigate the effect of PCCLC on the gallbladder contractility function, PCCLC and laparoscope combined with a choledochoscope were compared in this study. Results: The preoperational age and American Society of Anesthesiologists (ASA) scores, as well as postoperational lithotrity rate and common biliary duct stone rate in the PCCLC group, were significantly higher than the choledochoscope group. However, the pre- and postoperational gallbladder ejection fraction was not significantly different. Univariable and multivariable logistic regression analyses indicated that the preoperational thickness of gallbladder wall (odds ratio [OR]: 0.540; 95% confidence interval [CI]: 0.317–0.920; P=0.023) and lithotrity (OR: 0.150; 95% CI: 0.023–0.965; P=0.046) were risk factors for postoperational gallbladder ejection fraction. The area under receiver operating characteristics curve was 0.714 (P=0.016; 95% CI: 0.553–0.854). Conclusion: PCCLC strategy should be carried out cautiously. First, restricted by the diameter of the drainage tube, the PCCLC should be used only for small gallstones in high-risk surgical patients. Second, the usage of lithotrity should be strictly limited to avoid undermining the gallbladder contractility and increasing the risk of secondary common bile duct stones. Keywords: cholecystolithotomy, lithotrity, thickness of gallbladder wall, GBEF, gallbladder motility