Related factors of early mortality in young adults with cerebral hemorrhage
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Hong Xia Zhou
Abstract
Background
The main causes of intracerebral hemorrhage differ between young adults and older adults. Data regarding potential targets for early intervention in young adult patients with intracerebral hemorrhage are lacking.
Methods
We retrospectively analysed data for 196 young adult patients with intracerebral hemorrhage who were admitted to Tianjin Huanhu Hospital and died within 30 days of admission between June 2005 and June 2015. The Kaplan–Meier method was used to calculate survival rate, and the log-rank test was used to determine survival rate significance. A Cox proportional hazards regression model was used for univariate and multivariate analyses.
Results
Univariate analysis revealed a statistically significant association of age, disturbance of consciousness, National Institutes of Health Stroke Scale and Glasgow Coma Scale scores, seizure occurrence, infratentorial hemorrhage, intraventricular extension, hernia, glucose level, white blood cell count, albumin level, creatinine level, uric acid level, and surgical treatment with early mortality (P<0.05). However, multivariate regression analysis revealed that only infratentorial hemorrhage (P=0.003) and intraventricular extension (P=0.003) were significant risk factors for early mortality.
Conclusions
Our results suggest that young adult patients who exhibit infratentorial hemorrhage and intraventricular extension in the early stages of intracerebral hemorrhage onset exhibit an increased risk of early mortality.
1 Introduction
Intracerebral hemorrhage (ICH) refers to primary nontraumatic hemorrhage of the cerebral parenchyma. The incidence rate of ICH is second only to that of cerebral ischemic stroke. Koivunen et al. reported that approximately 25 of every 100,000 individuals experience ICH each year, and the incidence rate is even higher among the Asian population [1]. The main causes of ICH differ between young adults and older adults. In the elderly, the main causes of ICH include hypertension, type 2 diabetes mellitus, hypertensive arteriopathy, cerebral amyloid angiopathy, and medication. In young adults, structural factors, systemic diseases, and other or unknown causes are substantially more prevalent [1]. However, data regarding potential targets for early intervention in young adult patients with ICH are still lacking. Therefore, we conducted the present study to analyse risk factors associated with early mortality in young adult patients with ICH, with the goal of elucidating targets for decreasing mortality and disability rates and improving clinical outcomes.
2 Materials and methods
2.1 Patients
We analysed data from a total of 196 young adult patients (mean age, 38.51 ± 6.36 years; range, 16–45 years) with ICH admitted to Tianjin Huanhu Hospital who died within 30 days of admission between June 2005 and June 2015. All patients had been confirmed to meet the diagnostic criteria for spontaneous ICH formulated at the Fourth National Cerebrovascular Disease Conference (excluding 26 cases of subarachnoid hemorrhage) [2].
All diagnoses had been confirmed via computed tomography or magnetic resonance imaging. In addition, 15 patients underwent digital subtraction angiography, magnetic resonance angiography, or computed tomography angiography. Patients who experienced pure subarachnoid hemorrhage or traumatic cerebral hemorrhage and those who died over 30 days after admission were excluded from further analysis. This study was approved by the ethics committee of Tianjin Huanhu Hospital, and the requirement for informed consent was waived due to the retrospective nature of the study design.
We compiled and analysed the following data for the included patients: sex, medical history, blood pressure at admission, glucose level, disturbance of consciousness, National Institutes of Health Stroke Scale (NIHSS) score at admission, Glasgow Coma Scale (GCS) score at admission, seizure occurrence, imaging characteristics (site of bleeding, hematoma volume, rupture of hematoma into the ventricle, and the presence of intraventricular extension), hernia (lateral shift of cerebral midline structures by≥ 5 mm), fasting laboratory values (white blood cell [WBC] count, serum albumin, serum creatinine, and uric acid), and the use of surgical treatment. All laboratory values were obtained from venous blood in the early morning of the second day of admission. However, because some patients died within a very short period, certain laboratory values could not be obtained. Hemorrhage volume was calculated using the ABC/2 method [3].
2.2 Statistical analysis
All statistical analyses were performed using SPSS version 17.0 statistical software (SPSS Inc., Chicago, IL, USA). The threshold for statistical significance was set at a P-value of <0.05. The Kaplan–Meier method was used to calculate the survival rate, while the log-rank test was used to assess the significance of the survival rate. A Cox proportional hazards regression model was used for univariate and multivariate analyses. The survival period was defined as the period between the date of diagnosis and the date of death and was calculated in days.
3 Results
3.1 Sex and age
The study population included 168 (85.71%) men and 28 (14.29%) women, resulting in a man-to-woman ratio of 6:1. The patients were divided into three age groups: 16–25 years (n = 16,8.16%), 26–35 years (n = 28, 14.29%), and 36–45 years (n = 152, 77.55%).
3.2 Disturbance of consciousness and seizure occurrence
Among the 196 included patients, 156 (79.59%) experienced disturbance of consciousness. The NIHSS score was 0–6 for eight patients (4.08%), 7–14 for 15 patients (7.65%), and >14 for 173 patients (88.27%). The GCS score was 3–8 for 155 patients (79.08%) and 9–15 for 41 patients (20.92%). Twenty-three patients (11.73%) experienced seizures after admission.
3.3 Blood pressure and glucose levels at admission
The included patients were classified into three groups according to their systolic (SBP) and diastolic blood pressure (DBP) values: SBP < 140 mmHg, 28 patients (14.29%); 140 mmHg ≤ BP < 180 mmHg, 58 patients (29.59%); SBP ≥ 180 mmHg, 110 patients (56.12%); DBP < 90 mmHg, 52 patients (26.53%); 90 mmHg ≤ DBP < 110 mmHg,71 patients (36.22%); and DBP ≥ 110 mmHg, 73 patients (37.24%). A total of 122 patients (62.24%) exhibited an increase in their fasting glucose levels following admission, while 55 patients (28.06%) exhibited normal glucose levels.
3.4 Imaging characteristics
We further classified patients according to the site of hemorrhage as follows: lobar, 24 patients (12.24%); basal ganglia, 89 patients (45.41%); thalamus, 12 patients (6.12%); and infratentorial, 47 patients (23.98%). Among these, we also noted one case of cerebellar hemorrhage (0.51%), one case involving both the cerebellum and brainstem (0.51%), 45 cases of brainstem hemorrhage (22.96%), 10 cases of ventricular hemorrhage (5.10%), and 14 cases of multiple hemorrhages (7.14%). We further classified the patients on the basis of hematoma volume as follows: 0–29 mL, 69 patients (38.12%); 30–59 mL, 54 patients (29.83%), and ≥60 mL, 58 patients (29.59%). Rupture into the ventricle was noted in 104 patients (53.06%), intraventricular extension in 120 (61.22%), and hernia in 132 (67.35%).
3.5 Laboratory values
A total of 163 patients (83.16%) exhibited an increased WBC count. Decreased levels of albumin, creatinine, and blood uric acid were noted in 32 (16.33%), 95 (48.47%), and 102 patients (52.04%), respectively.
3.6 Use of surgical treatment
Of the total 196 patients, 134 (68.37%) underwent surgery after admission and 62 (31.63%) received conservative treatment. Surgical treatment included hematoma evacuation, cerebrospinal fluid (CSF) drainage, or both.
Univariate analysis revealed statistically significant associations (P < 0.05) of age (P = 0.000), disturbance of consciousness (P = 0.048; Fig. 1), NIHSS (P = 0.049) and GCS (P = 0.005) scores, seizure occurrence (P = 0.001), infratentorial hemorrhage (P = 0.048), intraventricular extension (P = 0.02), hernia (P = 0.026), glucose level (P = 0.014; Fig. 2), WBC count (P = 0.023), albumin level (P = 0.014), creatinine level (P = 0.028), uric acid level (P = 0.047), and the use of surgical treatment (P = 0.024) with early mortality in young adult patients with ICH. Patient sex; history of hypertension, heart disease, and/or oral anticoagulant and antithrombotic drug use; blood pressure at admission; hematoma volume; and rupture into the ventricle were not associated with patient survival (Table 1).
The impact of consciousness disturbance on the survival rate of young adult patients with intracranial hemorrhage. Patients with consciousness disturbance following cerebral hemorrhage showed shorter survival times and a higher risk of death.
The impact of glucose level on the survival rate of young adult patients with intracranial hemorrhage. Patients with cerebral hemorrhage who showed elevated blood glucose levels tended to have shorter survival times and a higher risk of death.
Univariate analysis of factors influencing survival in 196 young adult patients with ICH
| Indicator | Number of Cases | MST (Days) | Survival Rate (%) | P-Value | |
|---|---|---|---|---|---|
| 10 Days | 20 Days | ||||
| Sex (M/F) | 168/28 | 5/4 | 25.6/10.7 | 7.7/3.6 | 0.085 |
| Age (16–25/26–35/36–45) | 16/28/152 | 3/4/5 | 12.5/35.7/26.3 | 0/28.6/4.6 | 0.000 |
| Use of Anticoagulant and Antithrombotic Drugs (N/Y) | 183/13 | 5/4 | 27.3/30.8 | 6.6/- | 0.788 |
| Consciousness Disturbance (N/Y) | 40/156 | 5/4 | 40/24.4 | 15/3.8 | 0.048 |
| NIHSS Score (0–6/7–14/>14) | 8/15/173 | 6/5/4 | 37.5/40/26 | 25/13.3/5.2 | 0.049 |
| GCS Score (3–8/9–15) | 155/41 | 4/5 | 23.9/41.5 | 2.6/14.6 | 0.005 |
| Systolic Blood Pressure at Admission (<140/140–180/≥180 mmHg) | 28/58/110 | 4/4/5 | 35.7/25.9/26.4 | 10.7/5.2/6.4 | 0.581 |
| Diastolic Blood Pressure at Admission (<90/90–110/≥110 mmHg) | 52/71/73 | 4/5/5 | 32.7/23.9/27.4 | 5.8/5.6/8.2 | 0.335 |
| Glucose Level at Admission (Normal/Elevated) | 55/122 | 5/4 | 30.9/25.4 | 14.5/4.1 | 0.014 |
| Hematoma Volume (0–29/30–59/≥60 mL) | 69/54/58 | 4/5/5 | 18.8/29.6/24.1 | 4.3/9.3/3.4 | 0.634 |
| Rupture into Ventricle (N/Y) | 92/104 | 4/5 | 16.3/29.8 | 3.3/6.7 | 0.062 |
| Intraventricular Extension (N/Y) | 76/120 | 5/4 | 31.6/25 | 11.8/3.3 | 0.02 |
| Hematoma Site | 0.048 | ||||
| Lobar | 24 | 4 | 25 | 12.5 | |
| Basal Ganglia | 89 | 5 | 28.1 | 7.9 | |
| Thalamus | 12 | 9 | 50 | 8.3 | |
| Infratentorial | 47 | 3 | 19.1 | 0 | |
| Intraventricular | 10 | 4 | 10 | 0 | |
| Multiple Hemorrhage | 14 | 5 | 35.7 | 7.1 | |
| Hernia (N/Y) | 64/132 | 3/5 | 25/28.8 | 6.3/4.5 | 0.026 |
| Surgical Treatment (N/Y) | 62/134 | 3/5 | 14.5/27.6 | 1.6/6.7 | 0.024 |
| Seizure Onset (N/Y) | 173/23 | 10/4 | 56.5/23.7 | 8.7/5.8 | 0.001 |
| White Blood Cells (Elevated/Normal/Low) | 163/14/2 | 4/5/10 | 26.4/28.6/- | 5.5/21.4/- | 0.023 |
| Albumin (Elevated/Normal/Low) | 5/140/32 | 4/5/3 | -/27.1/25 | -/7.9/6.3 | 0.014 |
| Creatinine (Elevated/Normal/Low) | 95/79/3 | 4/5/- | 25.3/30.4/- | 5.3/10.1/- | 0.028 |
| Uric Acid (Elevated/Normal) | 102/72 | 4/5 | 27.5/26.4 | 5.9/9.7 | 0.047 |
ICH: intracranial hemorrhage, NIHSS: National Institutes of Health Stroke Scale, GCS: Glasgow Coma Scale, MST: median survival time.
3.7 Multivariate Cox regression analysis
Factors that exhibited statistical significance in univariate analysis were imported into the Cox proportional hazards regression model for multivariate analysis. The results of this analysis revealed that infratentorial hemorrhage (P = 0.003; odds ratio, 3.811) and intraventricular extension (P = 0.003; odds ratio, 0.511) were independent risk factors for early mortality in young adult patients with ICH (Table 2).
Multivariate analysis of factors influencing survival in 196 young adult patients with ICH
| B | SE | Wald | df | P | Exp (B) | 95.0% CI applied in Exp (B) | ||
|---|---|---|---|---|---|---|---|---|
| Lower Section | Upper Section | |||||||
| Intraventricular Extension | -0.671 | .229 | 8.611 | 1 | .003 | 0.511 | 0.326 | 0.800 |
| Site of Hematoma | 1.338 | .449 | 8.879 | 5 | .003 | 3.811 | 1.581 | 9.186 |
ICH: intracranial hemorrhage, CI: confidence interval, B: Partial regression coefficient, SE: standard error of survival rate, df: degree of freedom, Exp (B): Odds ratio value, 95.0% CI applied in Exp (B): 95% confidence interval
4 Discussion
In the present study, we retrospectively analysed data from 196 young adult patients with ICH who had died within 30 days of hospital admission. Our results revealed a significantly higher number of male patients. The low incidence of cerebral hemorrhage in young women was related to the female gonadal hormones [4]. In addition, the frequency of unhealthy habits, such as smoking and alcohol consumption, is higher among men than among women [5]. However, no statistically significant difference was observed in the distribution of mortality rates among men and women in the present study. This finding is consistent with the findings of previous studies [6,7].
The results of the present study indicate that the incidence of ICH tends to increase with age. This finding may be explained by the increased incidence of hypertension in older adults. In addition, a previous study reported that hypertension, smoking, and alcohol consumption were risk factors for stroke in young Chinese individuals [8]. We also report that the mortality risk in the 16–25-year age group was high. The main reason for such a high rate in this age group was the presence of congenital structural lesions such as vascular malformations. Low rates of diagnosis and poorly controlled hypertension were also noted in this group. However, Rutten-Jacobs et al. [6] found that the 30-day ICH mortality rate did not significantly differ by age. Therefore, multicentre studies involving larger sample sizes are required in order to confirm the findings of the present study.
Although hypertension has been found to be a primary risk factor for ICH [9,10], and it is considered a risk factor for a poor prognosis in patients with ICH [11], univariate analysis in the present study revealed no correlation between a history of hypertension and early mortality in young adults with ICH. Furthermore, we observed no significant correlation between blood pressure at admission and early mortality, which may be attributable to the fact that the conditions of some patients had become critical immediately after ICH onset, resulting in a severe decrease in blood pressure that could have masked other factors.
Numerous studies have reported a strong correlation between post-ICH elevation of glucose levels and poor prognosis. Tapia-Pérez et al. [12] proposed that a glucose level of >140 mg/dL within 24 hours of ICH onset might increase the risk of 30-day mortality. A study by Yi et al [13] also revealed that the near-term mortality risk in patients with early high-glucose levels was 4.95 times higher than that in patients with normal glucose levels. The results of the present study are consistent with those previously reported, suggesting that glucose levels in patients with ICH should be controlled in a timely fashion.
The patient’s level of consciousness can reflect the level of brain damage, and mortality was found to be four times higher in patients with disturbance of consciousness following ICH than in those who remained conscious [14]. A study by Rutten-Jacobs et al.[6] revealed that higher average NIHSS scores (17 vs. 10, P = 0.01) and lower average GCS scores (3 vs. 14, P = 0.004) were risk factors for early mortality in patients with ICH. Earlier occurrence of consciousness disturbance and more severe conditions may therefore indicate greater damage to the involved cerebral structures and a higher mortality rate.
Different causes of ICH in young adults lead to hemorrhage at different sites. The current study and previous studies suggested that deep cerebral hemorrhage is associated with a higher mortality rate compared with lobar haemorrhage [15]. In addition, the results of the present study indicate that infratentorial hemorrhage is an independent risk factor for early mortality in young adult patients with ICH, consistent with the results of previous studies [7,16]. As opposed to the results of previous studies [7,17], our univariate analysis revealed no correlation between hematoma volume and early mortality. This disparity can be explained by a hematoma volume of 0–29 mL in 47 of the 69 cases with infratentorial hemorrhage. ICH occurring either above or below the infratentorial region results in different outcomes with relatively low survival rates. Our results indicate that the site of hemorrhage exerts a greater impact on the prognosis of patients with ICH compared with hematoma volume.
Intraventricular extension is a common complication observed in patients with ICH. A recent study revealed that the 30-day mortality rate for patients with intraventricular extension was 4.7 times higher than that for patients without this complication [7]. The results of the present study also revealed that intraventricular extension was an independent risk factor for early mortality in young adult patients with ICH. Existing reports present varying conclusions regarding the impact of rupture into the ventricle at the site of hemorrhage on prognosis. A study by Jai-hi et al. [14] showed that a greater extent of hemorrhage rupture into the ventricle would lead to a poorer prognosis, probably because rupture influences the circulation of CSF, which increases intracranial pressure and promotes the development of hernia. However, our results indicate that hemorrhage rupture into the ventricle was not a risk factor for early mortality, likely because of the decrease in hematoma pressure shortly after rupture into the ventricle. Furthermore, timely surgery following admission allowed drainage of the hematoma and CSF, which relieved intracranial hypertension.
Patients with ICH accompanied by hernia are often critical. Some studies have suggested that early mortality in patients with ICH is correlated with hernia development [15]. However, our analysis indicated the opposite result, probably because of the relatively low incidence of infratentorial hemorrhage in patients without hernia; that is, only eight of the 132 patients with hernia experienced infratentorial hemorrhage. However, among the 64 patients without hernia, 39 experienced infratentorial hemorrhage. Subgroup analysis revealed that this difference was statistically significant (χ2 = 71.204, P < 0.001). Seizure is a relatively common complication of ICH, although the mechanism of seizure onset remains unclear. One previous study indicates that seizure onset may be associated with the mass effect of the intracranial hematoma, focal ischemia, and decomposition products in the blood[18].
Seizure onset in the early stages of ICH may lead to the elevation of intracranial pressure, while overexcitement and increased metabolic demand lead to neuronal death and, consequently, increase the mortality rate. However, the conclusions of various studies on the correlation between early seizure onset and ICH mortality remain inconsistent [18]. In the present study, we found that early seizure onset was a relevant risk factor for early mortality in young adult patients with ICH. Therefore, timely clinical diagnosis and effective control and prevention of seizure onset may have significant implications for improving the prognosis and decreasing the mortality rate.
Peripheral WBC count is an indication of the immune system response and a reflection of the activation of inflammatory cascades following ICH[19]. Some studies show that activation of the peripheral immune system may aggravate post-ICH damage [20]. Blood uric acid level is closely correlated with the prognosis of patients with ICH, and a study by Zeng et al. [21] concluded that a high concentration of uric acid was a risk factor for early poor prognosis in patients with ICH. However, the relationship between uric acid level and stroke remains debatable [22], and further statistical analysis is required using larger sample sizes from multiple centres. Nevertheless, the blood uric acid level is a known independent risk factor for hypertension [23] that results in kidney damage. Previous studies [23] have shown that acute kidney injury is associated with increased hospital mortality in patients with stroke. The present study involving young adult patients with ICH found that, although acute kidney injury is related to early death, it is not an independent risk factor for early death. Further research and discussion are necessary to confirm these results. Our analysis revealed that hypoproteinaemia is associated with early mortality in young adult patients with ICH, probably because significantly low levels of serum albumin lead to poor health and decrease the level of immunity in patients. Low serum albumin levels also lead to decreases in the plasma colloid osmotic pressure, which results in accumulation of fluid in the spaces between tissues. This accumulation decreases the effective circulating blood volume, in turn leading to inadequate perfusion of vital tissues, particularly the brain tissues surrounding the hematoma, aggravation of the condition, and a poor prognosis.
It has been well-established that patients who require surgery are more critical and are more likely to exhibit massive bleeding or early hernia and other neurological deficits, which increase the risk of death [24]. Therefore, surgical treatment is very important for patients with cerebral hemorrhage. Univariate statistical analysis in the present study showed that nonsurgical treatment was associated with a high risk of death in young adults with ICH. Han et al.[25] showed that the prognosis of patients who underwent surgery for ICH was better than that of patients who received conservative treatment. The findings of the present study are consistent with this finding. Therefore, timely surgical treatment involving hematoma evacuation and lowering of brain oedema and intracranial pressure can improve the prognosis of some patients. Additionally, younger patients exhibit better tolerance for surgery, and aggressive surgical treatment should therefore be performed for young patients with ICH.
The present study has several limitations. First, all included patients were obtained from a single centre. Second, our results may have been influenced, to some extent, by missing clinical data, because some patients died shortly after ICH onset. Third, we did not conduct a subgroup analysis for hemorrhage at different sites with regard to the hematoma volume.
5 Conclusion
The results of the present study, in conjunction with those of previous studies, highlight the severity of the consequences of ICH in young adult patients, which lead to high rates of disability and mortality. Affect the prognosis of young patients with ICH a lot of related factors, our results suggest that young adult patients who exhibit infratentorial hemorrhage and intraventricular extension in the early stages of ICH onset exhibit an increased risk of early mortality. Patients with ICH should seek prompt treatment to identify and control risk factors that may lead to a poor prognosis and lower the likelihood of mortality and disability.
Conflicts of interest: The authors have no conflicts of interest to declare.
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List of acronyms
- CSF
cerebrospinal fluid
- DBP
diastolic blood pressure
- GCS
Glasgow Coma Scale
- ICH
intracerebral hemorrhage
- NIHSS
National Institutes of Health Stroke Scale
- SBP
systolic blood pressure
- WBC
white blood cell
© 2018 Hong Xia Zhou et al., published by De Gruyter
This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 License.
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- Distinct expression and prognostic value of MS4A in gastric cancer
- MAPK pathway involved in epidermal terminal differentiation of normal human epidermal keratinocytes
- Association of central obesity with sex hormonebinding globulin: a cross-sectional study of 1166 Chinese men
- Successful endovascular therapy in an elderly patient with severe hemorrhage caused by traumatic injury
- Inflammatory biomarkers and risk of atherosclerotic cardiovascular disease
- Related factors of early mortality in young adults with cerebral hemorrhage
- Growth suppression of glioma cells using HDAC6 inhibitor, tubacin
- Post-stroke upper limb spasticity incidence for different cerebral infarction site
- The esophageal manometry with gas-perfused catheters
- MMP-2 and TIMP-2 in patients with heart failure and chronic kidney disease
- Genetic testing: ethical aspects
- Intervention for physician burnout: A systematic review
- The melanin-concentrating hormone system in human, rodent and avian brain
- Clinical effects of piribedil in adjuvant treatment of Parkinson’s Disease: A meta-analysis
- Identification of a novel BRAF Thr599dup mutation in lung adenocarcinoma
- Adrenal incidentaloma – diagnostic and treating problem – own experience
- Common illnesses in tropical Asia and significance of medical volunteering
- Genetic risk in insurance field
- Genetic testing and professional responsibility: the italian experience
- The mechanism of mitral regurgitant jets identified by 3-dimensional transesophageal echocardiography
- Control of blood pressure and cardiovascular outcomes in type 2 diabetes
- Pseudomesotheliomatous primary squamous cell lung carcinoma: The first case reported in Turkey and a review of the literature
- Diagnostic efficacy of serum 1,3-β-D-glucan for invasive fungal infection: An update meta-analysis based on 37 case or cohort studies
- GPER was associated with hypertension in post-menopausal women
- Metabolic activity of sulfate-reducing bacteria from rodents with colitis
- Association of miRNA122 & ADAM17 with lipids among hypertensives in Nigeria
- The efficacy and safety of enoxaparin: a meta-analysis
- Cuffed versus uncuffed endotracheal tubes in pediatrics: a meta-analysis
- Thresholding for medical image segmentation for cancer using fuzzy entropy with level set algorithm
- Sleep deprivation in Intensive Care Unit – systematic review
- Benefits of computed tomography in reducing mortality in emergency medicine
- Ipragliflozin ameliorates liver damage in non-alcoholic fatty liver disease
- Limits of professional competency in nurses working in Nicu
- MDA-19 suppresses progression of melanoma via inhibiting the PI3K/Akt pathway
- The effect of smoking on posttraumatic pseudoarthrosis healing after internal stabilization, treated with platelet rich plasma (PRP)
- Partial deletion of the long arm of chromosome 7: a case report
- Meta-analysis of PET/CT detect lymph nodes metastases of cervical cancer
- High Expression of NLRC5 is associated with prognosis of gastric cancer
- Is monitoring mean platelet volume necessary in breast cancer patients?
- Resectable single hepatic epithelioid hemangioendothelioma in the left lobe of the liver: a case report
- Epidemiological study of carbapenem-resistant Klebsiella pneumoniae
- The CCR5-Delta32 genetic polymorphism and HIV-1 infection susceptibility: a meta-analysis
- Phenotypic and molecular characterisation of Staphylococcus aureus with reduced vancomycin susceptibility derivated in vitro
- Preliminary results of Highly Injectable Bi-Phasic Bone Substitute (CERAMENT) in the treatment of benign bone tumors and tumor-like lesions
- Analysis of patient satisfaction with emergency medical services
- Guillain-Barré syndrome and Low back pain: two cases and literature review
- HELLP syndrome complicated by pulmonary edema: a case report
- Pharmacokinetics of vancomycin in patients with different renal function levels
- Recurrent chronic subdural hematoma: Report of 13 cases
- Is awareness enough to bring patients to colorectal screening?
- Serum tumor marker carbohydrate antigen 125 levels and carotid atherosclerosis in patients with coronary artery disease
- Plastic treatment for giant pseudocyst after incisional hernia mesh repair: a case report and comprehensive literature review
- High expression levels of fascin-1 protein in human gliomas and its clinical relevance
- Thromboembolic complications following tissue plasminogen activator therapy in patients of acute ischemic stroke - Case report and possibility for detection of cardiac thrombi
- The effects of gastrointestinal function on the incidence of ventilator-associated pneumonia in critically ill patients
- A report of chronic intestinal pseudo-obstruction related to systemic lupus erythematosus
- Risk model in women with ovarian cancer without mutations
- Direct oral anticoagulants and travel-related venous thromboembolism
- How bispectral index compares to spectral entropy of the EEG and A-line ARX index in the same patient
- Henoch-schonlein purpura nephritis with renal interstitial lesions
- Cardiovascular risk estimated by UKPDS risk engine algorithm in diabetes
- CD5 and CD43 expression are associate with poor prognosis in DLBCL patients
- Combination of novoseven and feiba in hemophiliac patients with inhibitors
Artikel in diesem Heft
- Regular Articles
- Cleidocranial dysplasia-dental disorder treatment and audiology diagnosis
- A hybrid neural network – world cup optimization algorithm for melanoma detection
- Early administration of venovenous extracorporeal life support for status asthmaticus during anaesthetic induction: case report and literature review
- Assessment of maximal isometric hand grip strength in school-aged children
- Evaluation of a neurokinin-1 antagonist in preventing multiple-day cisplatin-induced nausea and vomiting
- Value of continuous video EEG and EEG responses to thermesthesia stimulation in prognosis evaluation of comatose patients after cardiopulmonary resuscitation
- Platelet-rich plasma protects HUVECs against oX-LDL-induced injury
- Pharmacoeconomics of three therapeutic schemes for anti-tuberculosis therapy induced liver injury in China
- Small-cell lung cancer presenting as fatal pulmonary hemorrhage
- Correlation of retinopathy of prematurity with bronchopulmonary dysplasia
- Prognosis of treatment outcomes by cognitive and physical scales
- The efficacy of radiofrequency hyperthermia combined with chemotherapy in the treatment of advanced ovarian cancer
- Arcuate Fasciculus in Autism Spectrum Disorder Toddlers with Language Regression
- Aesthetic dental procedures: legal and medico-legal implications
- Blood transfusion in children: the refusal of Jehovah’s Witness parents’
- Burnout among anesthetists and intensive care physicians
- Relationship of HS CRP and sacroiliac joint inflammation in undifferentiated spondyloarthritis
- Ethical and legal issues in gestational surrogacy
- Effects of arginine vasopressin on migration and respiratory burst activity in human leukocytes
- Associations of diabetic retinopathy with retinal neurodegeneration on the background of diabetes mellitus. Overview of recent medical studies with an assessment of the impact on healthcare systems
- Pituitary dysfunction from an unruptured ophthalmic internal carotid artery aneurysm with improved 2-year follow-up results: A case report
- Effectiveness of treatment with endostatin in combination with emcitabine, carboplatin, and gemcitabine in patients with advanced non-small cell lung cancer: a retrospective study
- Piercing and tattoos in adolescents: legal and medico-legal implications
- The central importance of information in cosmetic surgery and treatments
- Penile calciphylaxis in a patient with end-stage renal disease: a case report and review of the literature
- Serum CA72-4 as a biomarker in the diagnosis of colorectal cancer: A meta-analysis
- Association between uric acid and metabolic syndrome in elderly women
- Distinct expression and prognostic value of MS4A in gastric cancer
- MAPK pathway involved in epidermal terminal differentiation of normal human epidermal keratinocytes
- Association of central obesity with sex hormonebinding globulin: a cross-sectional study of 1166 Chinese men
- Successful endovascular therapy in an elderly patient with severe hemorrhage caused by traumatic injury
- Inflammatory biomarkers and risk of atherosclerotic cardiovascular disease
- Related factors of early mortality in young adults with cerebral hemorrhage
- Growth suppression of glioma cells using HDAC6 inhibitor, tubacin
- Post-stroke upper limb spasticity incidence for different cerebral infarction site
- The esophageal manometry with gas-perfused catheters
- MMP-2 and TIMP-2 in patients with heart failure and chronic kidney disease
- Genetic testing: ethical aspects
- Intervention for physician burnout: A systematic review
- The melanin-concentrating hormone system in human, rodent and avian brain
- Clinical effects of piribedil in adjuvant treatment of Parkinson’s Disease: A meta-analysis
- Identification of a novel BRAF Thr599dup mutation in lung adenocarcinoma
- Adrenal incidentaloma – diagnostic and treating problem – own experience
- Common illnesses in tropical Asia and significance of medical volunteering
- Genetic risk in insurance field
- Genetic testing and professional responsibility: the italian experience
- The mechanism of mitral regurgitant jets identified by 3-dimensional transesophageal echocardiography
- Control of blood pressure and cardiovascular outcomes in type 2 diabetes
- Pseudomesotheliomatous primary squamous cell lung carcinoma: The first case reported in Turkey and a review of the literature
- Diagnostic efficacy of serum 1,3-β-D-glucan for invasive fungal infection: An update meta-analysis based on 37 case or cohort studies
- GPER was associated with hypertension in post-menopausal women
- Metabolic activity of sulfate-reducing bacteria from rodents with colitis
- Association of miRNA122 & ADAM17 with lipids among hypertensives in Nigeria
- The efficacy and safety of enoxaparin: a meta-analysis
- Cuffed versus uncuffed endotracheal tubes in pediatrics: a meta-analysis
- Thresholding for medical image segmentation for cancer using fuzzy entropy with level set algorithm
- Sleep deprivation in Intensive Care Unit – systematic review
- Benefits of computed tomography in reducing mortality in emergency medicine
- Ipragliflozin ameliorates liver damage in non-alcoholic fatty liver disease
- Limits of professional competency in nurses working in Nicu
- MDA-19 suppresses progression of melanoma via inhibiting the PI3K/Akt pathway
- The effect of smoking on posttraumatic pseudoarthrosis healing after internal stabilization, treated with platelet rich plasma (PRP)
- Partial deletion of the long arm of chromosome 7: a case report
- Meta-analysis of PET/CT detect lymph nodes metastases of cervical cancer
- High Expression of NLRC5 is associated with prognosis of gastric cancer
- Is monitoring mean platelet volume necessary in breast cancer patients?
- Resectable single hepatic epithelioid hemangioendothelioma in the left lobe of the liver: a case report
- Epidemiological study of carbapenem-resistant Klebsiella pneumoniae
- The CCR5-Delta32 genetic polymorphism and HIV-1 infection susceptibility: a meta-analysis
- Phenotypic and molecular characterisation of Staphylococcus aureus with reduced vancomycin susceptibility derivated in vitro
- Preliminary results of Highly Injectable Bi-Phasic Bone Substitute (CERAMENT) in the treatment of benign bone tumors and tumor-like lesions
- Analysis of patient satisfaction with emergency medical services
- Guillain-Barré syndrome and Low back pain: two cases and literature review
- HELLP syndrome complicated by pulmonary edema: a case report
- Pharmacokinetics of vancomycin in patients with different renal function levels
- Recurrent chronic subdural hematoma: Report of 13 cases
- Is awareness enough to bring patients to colorectal screening?
- Serum tumor marker carbohydrate antigen 125 levels and carotid atherosclerosis in patients with coronary artery disease
- Plastic treatment for giant pseudocyst after incisional hernia mesh repair: a case report and comprehensive literature review
- High expression levels of fascin-1 protein in human gliomas and its clinical relevance
- Thromboembolic complications following tissue plasminogen activator therapy in patients of acute ischemic stroke - Case report and possibility for detection of cardiac thrombi
- The effects of gastrointestinal function on the incidence of ventilator-associated pneumonia in critically ill patients
- A report of chronic intestinal pseudo-obstruction related to systemic lupus erythematosus
- Risk model in women with ovarian cancer without mutations
- Direct oral anticoagulants and travel-related venous thromboembolism
- How bispectral index compares to spectral entropy of the EEG and A-line ARX index in the same patient
- Henoch-schonlein purpura nephritis with renal interstitial lesions
- Cardiovascular risk estimated by UKPDS risk engine algorithm in diabetes
- CD5 and CD43 expression are associate with poor prognosis in DLBCL patients
- Combination of novoseven and feiba in hemophiliac patients with inhibitors
