目的 探讨重组人脑利钠肽(rhBNP)对急性非ST段抬高型心肌梗死(NSTEMI)患者经急诊经皮冠状动脉介入治疗(PCI)后造影剂肾病(CIN)的预防作用.方法 将收治的100 例NSTEMI患者随机分为rhBNP组与对照组,每组 50 例.入院后均行急诊PCI,且两组均在术后予以生理氯化钠溶液 1 mL/(kg·h)持续水化维持12～24 h.rhBNP组在此基础上给予注射用重组人脑利钠肽,负荷剂量 1.5 μg/kg,随后以 0.0075 μg/(kg·min)维持静脉微泵72 h.比较两组的干预效果.结果 术后 7 d,rhBNP组的左室射血分数(LVEF)高于对照组,心功能Killip分级优于对照组(P<0.05).术后72 h、术后7 d,rhBNP组的血清肌酐(SCr)、血清胱抑素C(Cys-C)、高敏C反应蛋白(hs-CRP)水平均明显低于对照组,估算肾小球滤过率(eGFR)高于对照组(P<0.05).rhBNP组的CIN发生率低于对照组(P<0.05).结论 NSTEMI患者急诊PCI术后早期应用rhBNP能有效保护肾功能,减少CIN发生.

[目的]分析新型冠状病毒肺炎(COVID-19)不同时期防控措施对非ST段抬高型心肌梗死(NSTEMI)住院患者并发肺部感染的诊断和预后影响.[方法]回顾性分析苏州大学附属第三医院在COVID-19不同防控措施下收治的126例NSTEMI患者,分为非新冠疫情流行组(2019年1月25日至2019年2月25日,非流行组,n=47),新冠疫情一级响应组(2020年1月25日至2020年2月25日,一级响应组,n=42)和新冠疫情常态化防控组(2021年1月25日至2021年2月25日,常态防控组,n=37).比较三组研究对象的临床特征、肺部感染以及院内病死率,分析疫情防控措施下NSTEMI住院患者并发肺部感染的影响因素.[结果]三组患者就诊时间、卧床时间、心率和心力衰竭比较,差异有统计学意义(P<0.05).非流行组、一级响应组和常态防控组肺部感染发生率比较差异有统计学意义(P<0.01).多因素二元Logistic回归分析显示,就诊时间、心力衰竭和卧床时间是NSTEMI患者发生肺部感染的影响因素(均P<0.05).[结论]COVID-19防控一级响应期间的救治措施提高了NSTEMI患者中肺部感染的诊断率,但未增加NSTEMI并发肺部感染患者院内不良预后.

目的 研究分析新型冠状病毒肺炎(COVID-19)不同时期防控措施对急性ST段抬高型心肌梗死(STEMI)住院患者的救治和院内病死率影响.方法 回顾性分析苏州大学附属第三医院心内科2019年1月25日至2019年2月25日(COVID-19非流行期间组)、2020年1月25日至2020年2月25日(COVID-19一级响应组)、2021年1月25日至2021年2月25日(COVID-19常态化防控组)三个时期的STEMI住院患者,比较分析不同疫情防控措施下研究对象的就诊时间、治疗策略、首次医疗接触时间(FMC)、球囊扩张时间(D-to-B)以及院内全因病死率等指标.结果 共纳入107例STEMI患者,其中非流行期间组37例,一级响应组28例,常态化防控组42例;三组急诊溶栓和FMC以及D-to-B时间差异有统计学意义(P＜0.05);COVID-19一级响应组的FMC时间[14.0(7.0,21.3) min]显著长于非流行期间组[8.0(5.0,10.0) min]和常态化防控组[5.0(4.0,6.5) min](P＜0.05),D-to-B时间较非流行期间组显著延长[87.5(68.8,116.3)h vs 67.5(55.0,91.3)h,P＜0.05];一级响应组院内病死率显著高于常态化防控组(28.6％ vs 4.8％,P＜0.05);一级响应组非PCI患者病死率高于PCI患者(17.4％ vs 80.0％,P＜0.05).结论 COVID-19一级响应期间STEMI患者急诊再灌注的救治时间延长,在遵循COVID-19防控原则基础上,通过优化STEMI的救治流程可以降低院内全因死亡率.

目的 探讨乳腺导管内癌(DCIS)以及导管内癌伴微浸润(DCIS-MI)的临床、病理及超声特点.方法 选取2016年1月至2018年11月江苏省人民医院经手术病理证实为导管内癌的病灶103个及导管内癌伴微浸润的病灶73个,两者超声表现均为肿块型,回顾性分析比较两者的临床、病理及超声特点.结果 两组患者的首发临床症状、肿块大小比较,差异具有统计学意义(P<0.05),前哨淋巴结转移两者差异无统计学意义(P>0.05);两者在病理组织分级、病理分子分型、ER、HER-2以及Ki-67上差异具有统计学意义(P<0.05);两者在超声图像上的形态、边缘、内部回声、钙化以及血流分级上差异具有统计学意义(P<0.05).DCIS-MI与DCIS相比,肿块大小以≥2.5 cm为主,超声图像上更多表现为形态不规则,边缘不光整,内部回声不均匀,內伴钙化,病灶内血流丰富,具有部分浸润性癌的特征;病理分子分型以Luminal B型及HER-2过表达型为主,组织分级以高级别为主.结论 DCIS与DCIS-MI之间有不同的临床表现,病理特征以及超声声像图特点,在临床诊断上可以提供更多信息与依据.

目的:探讨单纯性乳腺导管内原位癌(ductal carcinoma in situ,DCIS)的超声声像图特征及病理学特征.方法:回顾并分析2016年10月—2019年4月南京医科大学第一附属医院经手术后病理学检查证实为单纯性DCIS的144例患者的超声表现及病理学特征.根据超声声像图特征将其分为肿块型(Ⅰ)、腺体紊乱型(Ⅱ)、单纯导管扩张型(Ⅲ)、导管扩张伴低回声型(Ⅳ)、单纯钙化型(Ⅴ)、超声无表现型(Ⅵ).结果:Ⅰ型95例(66.0％),Ⅱ型21例(14.6％),Ⅲ型7例(4.9％),Ⅳ型7例(4.9％),Ⅴ型12例(8.3％),Ⅵ型2例(1.4％),超声诊断准确率分别为83.2％(79/95)、76.2％(16/21)、0.0％(0/7)、42.9％(3/7)、83.3％(10/12)、0.0％(0/2).超声图像上表现出钙化的患者占75例(52.1％),超声诊断准确率为86.7％(65/75),高于无钙化组且差异有统计学意义(χ2=11.362,P=0.001);血流分级为Ⅱ级、Ⅲ级的患者占99例(68.8％),超声诊断准确率为86.9％(86/99),高于血流分级为0级、Ⅰ级的DCIS且差异有统计学意义(χ2=23.801,P=0.000).病理学特征上,低、中级别占71例(49.3％),高级别占73例(50.7％);分子分型中Luminal A型占50例(34.7％),Luminal B型占63例(43.8％),人表皮生长因子受体2(human epidermal growth factor receptor 2,HER2)阳性占29例(20.1％),三阴性型占2例(1.4％).钙化组与无钙化组病灶的病理组织学分级、分子分型差异均有统计学意义.结论:肿块型是DCIS最常见的超声表现,超声对DCIS的诊断准确率与其超声声像图特征有关,有无钙化以及血流的丰富程度是DCIS的诊断要点,DCIS的病理学特征与有无钙化密切相关.超声对临床诊断DCIS有重要指导作用.

目前,乳腺癌的诊疗模式日趋个体化,需要多学科团队的共同合作,如乳腺外科、肿瘤内科、病理科、影像科、放疗科、整形外科.而超声医学作为医学影像诊断中的一门学科,在乳腺癌的诊疗过程中起着重要的作用.在临床活动中熟悉准确的诊疗过程,有利于超声医生培养准确的乳腺癌的诊断思维,从而有利于患者个体化精准治疗方案的制定.

目的:探讨多模态超声在评估乳腺癌新辅助化疗疗效中的价值,建立评估乳腺癌新辅助化疗的多因素Logistic回归模型.方法:回顾性分析54例乳腺癌新辅助化疗患者的常规超声、弹性超声及超声造影的图像特征.用单因素和多因素Logistic分析影响新辅助化疗疗效的因素.绘制各因素受试者工作曲线(receiver operating characterisric,ROC),计算ROC曲线下面积及准确度等评价指标.结果:新辅助化疗后肿瘤最长径缩小率、阻力指数(resistance index,RI)、收缩期峰值流速(peak systole velocity,PSV)、应变率比值(strain ratio,SR)、弹性评分、峰值强度(peak intensity,PI)和曲线下面积(area under curve,AUC)是影响新辅助化疗疗效的因素(P＜0.05),多因素Logistic回归模型显示肿瘤最长径缩小率,PI和SR是乳腺癌新辅助化疗的危险因素.多因素回归模型ROC曲线下面积是0.95,准确度、灵敏度和特异度分别为90.74％、93.94％、85.71％,较单因素模型有较高的准确性.结论:多模态超声的多因素回归模型能较好地评估新辅助化疗疗效,提高诊断符合率.

患儿女,3岁.主因“发现左乳肿物3个月余”入院.查体:左侧乳腺乳头旁可触及约20 mm×20mm的质韧肿物,边界清,活动度差,无压痛,乳头无凹陷及溢液,皮肤无红肿及橘皮样变,无乳房表面皮肤改变.双侧腋窝及锁骨上下未触及肿大淋巴结. 超声彩色检查示(图1～2):左侧乳腺乳头旁见一大小约25 mm×26 mm×18 mm囊实性混合回声,形态规则,呈椭圆形,平行于皮肤,边缘不光整,后方回声无改变,未见明显粗大及微小钙化,实性部分见丰富血流,探及动脉频谱,RI 0.83.超声诊断:左侧乳腺占位性病变(BI-RADS 4B类).行左乳保乳、前哨淋巴结活检术.术后病理示:(左侧乳腺)幼年性乳腺分泌性癌,前哨淋巴结阴性.免疫组化:ER(一),PR(一),Ki67(20％+),S-100(+).基因检测:ETV6-NTRK3基因发生融合.

目的:探讨不同弹性参数在不同切面诊断乳腺肿块的价值.方法:对236例乳腺肿块行超声检查,测量横切面及纵切面的应变弹性成像(elasticity imaging,EI)的应变率比值、面积比、长度比,以及剪切波速度(shear wave velocity,SWV)的最大值、最小值及平均值.采用受试者工作特征(receiver operating characteristic,ROC)曲线的曲线下面积(area under curve,AUC)比较各参数对乳腺肿块的的诊断效能.结果:SWV最大值、平均值、最小值,以及面积比、长度比和应变率比值在横切面的AUC分别为0.882、0.871、0.833、0.744、0.722和0.623;在纵切面的AUC分别为0.866、0.863、0.786、0.774、0.719和0.593;在联合切面的AUC分别为0.884、0.875、0.823、0.776、0.735和0.620.两切面之间仅SWV最小值的AUC差异有统计学意义(P=0.031),其余参数差异无统计学意义(P＞0.05).SWV最大值和平均值的AUC显著高于EI的应变率比值、面积比及长度比(P＜0.05).多因素分析显示,SWV最大值联合面积比的AUC为0.901,灵敏度和特异度分别为86.60％、79.86％.结论:SWV最大值和平均值诊断乳腺肿块良恶性的效能更好,SWV联合EI可提高诊断效能.

临床资料 患者1,女,31岁. 头皮部赘生物十余年. 患者十余年前头皮出现一赘生物,逐渐增大,无特殊感觉,2015年1月来我院就诊. 查体:左侧头皮见一杏仁大赘生物,呈球形,质中,表面无破溃(图1a) . 组织病理示:表皮轻度角化不全伴渗出、结痂,真皮内瘤细胞呈团块状浸润,部分团块与表皮相连,瘤细胞呈立方形或圆形、核圆,深嗜碱性,胞质淡染,部分团块中可见管腔样结构,团块周围未见栅栏状排列(图1b、1c). 诊断:小汗腺汗孔瘤. 治疗:手术全切.

Objective To evaluate the efficacies of urethroscopic holmium YAG laser lithotripsy(ureteroscopy) and open ureterolithotomy for ureteral calculi more than 15 mm in diameter. Methods 110 patients with ureteral calculi over 15 mm in diameter treated at our hospital from June, 2009 to June, 2017 were selected. 62 patients were treated with urethroscopic holmium YAG laser lithotripsy (URL group) and 48 patients with open ureterolithotomy (OU group). The operative effect, operation time, bleeding volume, hospital stay, complication, and postoperative recovery were investigated in both groups. Results One patient in the URL group was transferred for open surgery. One week and 1-2 months after the operation, the calculi clearance rates were 82.00% and 93.50% in the URL group and were 100.00% and 100.00% in the OU group. The mean operation time and mean postoperative hospital stay were (42±27) mins and (3.1±1.8) days in the URL group and were (73±35) mins and (6.8±2.2) days in the OU group(P<0.05), respectively. Conclusions For most ureteral calculi patients, urethroscopic holmium YAG laser lithotripsy is an effective and safe treatment. For several special cases, open ureterolithotomy may be the reasonable therapeutic option. Key words: Ureteral calculi; YAG laser lithotripsy; Open ureterolithotomy

Objective To analyze the correlation of the lung ultrasound score (LUS) with X-ray classification and clinical indicators in neonatal respiratory distress syndrome (NRDS) , and to explore the diagnostic value of pulmonary ultrasound for NRDS. Methods From May 2016 to June 2017, 80 newborns who underwent lung ultrasound examination in the First Affiliated Hospital of Nanjing Medical University were collected in this study, including 44 cases of NRDS. The difference between the score of anterior chest wall and posterior chest wall was analyzed by independent sample t test. LUS and X-ray grading were analyzed by Spearman correlation. The correlation between LUS and oxygenation index (PaO2/FiO2) and positive end expiratory pressure (PEEP) was analyzed by Pearson correlation analysis. Results The total LUS in 44 cases was (18.89±10.43), and LUS of the posterior wall of the chest was (8.59±3.14), which was significantly higher than that of the anterior chest wall (4.70±3.90). The difference was statistically significant (P<0.05). There was a positive correlation between LUS and X-ray grading (r=0.924, P<0.05). The total LUS was negatively correlated with oxygenation index (r=-0.524, P<0.01), while positively correlated with PEEP (r=0.662, P<0.01). Conclusion Pulmonary ultrasound is of value in the diagnosis of NRDS. LUS is positively correlated with the X-ray classification, which is an important supplement for the diagnosis of NRDS. Key words: Ultrasonography; Respiratory distress syndrome, Neonate; Lung

目的:探讨乳腺结节的良恶性超声造影表现及超声造影联合常规超声检查在乳腺病变(BI-RADS 3-5类)诊断中的应用价值;方法:采用常规超声及超声造影对527个乳腺病灶(BI-RADS 3-5类)进行检查,分析乳腺病灶的增强模式、时间-强度曲线类型及参数等指标,再次判定肿块的BI-RADS分类,以BI-RADS 4A类判定可疑恶性,并与术后病理及粗针穿刺结果进行比较.结果:①527例乳腺肿块中良性肿块254例,恶性肿块273例;②肿块内部血管走行紊乱、边缘见放射状增强、造影后范围增大、是否高增强、边界是否清晰等在良恶性间差异有统计学意义(P＜0.05)、向心性及非向心性增强、是否充盈缺损在良恶性间差异无统计学意义(P＞0.05);③多因素分析结果显示放射状增强内部弱于周边,穿入及扭曲血管、造影后范围增大及周边放谢增强OR较高(46.84、14.89、11.06);④时间强度曲线类型:本组病例对203个结节进行了时间-强度曲线分析,时间-强度曲线类型分布在良恶性组间差异无统计学意义,时间-强度曲线参数(峰值强度、达峰时间、曲线下面积)恶性与正常组织差值及良性与正常组织差值间差异有统计学意义,良恶性间差异无统计学意义;⑤常规超声ROC曲线下面积US检查为0.767,两者联合应用ROC曲线下面积为0.877,两者间的差异有统计学意义(P＜ 0.001).结论:超声造影联合常规超声检查对乳腺肿块的BI-RADS分类较单纯常规超声更为准确,对结节进行更准确的BI-RADS分类,减少了部分不必要的活检,可更好地指导临床.

Objective To evaluate the early diagnostic value of circulating microRNA-1 (miR-1) on acute myocardial infarction (AMI). Methods A prospective cohort study was conducted. The patients with chest pain admitted to the Second People's Hospital of Wuxi from November 2012 to June 2015 were enrolled. According to AMI diagnostic criteria, the patients were divided into AMI group and non-AMI group, and healthy individuals during the same period were served as heath controls. The venous samples of the onset patients were collected within 3 hours after admission. The plasma miR-1 was determined by real-time quantitative reverse transcription-polymerase chain reaction (RT-PCR), and the levels of plasma cardiac troponin I (cTnI) and MB isoenzyme of creatine kinase (CK-MB) were measured by electrochemiluminescence. The correlation between plasma miR-1 and cTnI as well as CK-MB was performed by Spearman analysis. The early diagnostic performance of plasma miR-1, cTnI, and CK-MB for AMI was estimated by receiver operating characteristic (ROC) curve analysis. Results There were 127 patients in AMI group, and 107 in non-AMI group, including 82 patients with angina pectoris, 2 with pulmonary embolism, 3 with aortic dissection, 2 with acute pericarditis, 3 with myocarditis, 13 with acute heart failure, and 2 with peptic ulcer. Ninety volunteers were served as healthy controls. There was no difference in clinical characteristics including gender and hyperlipidemia between AMI group and non-AMI group. The expressions of plasma miR-1, cTnI and CK-MB were significantly increased in AMI patients as compared with those of the healthy controls [miR-1 (2-ΔΔCt): 4.32±2.60 vs. 1.44±0.75 and 0.98±0.18, cTnI (μg/L): 3.23 (0.63, 10.70) vs. 0.02 (0.00, 0.17) and 0.00 (0.00, 0.00), CK-MB (U/L): 32.40 (14.20, 95.40) vs. 14.40 (11.20, 17.10) and 8.90 (8.28, 9.50), all P < 0.01]. The expression of plasma miR-1 had a significantly positive correlation with cTnI and CK-MB in AMI patients (r1 = 0.395, r2 = 0.490, both P < 0.000). It was demonstrated by ROC curve analysis that the area under ROC curve (AUC) for the diagnostic value of miR-1 on AMI was 0.905 [95% confidence interval (95%CI) = 0.860-0.950, P = 0.000], the sensitivity was 86.6%, and the specificity was 95.4%; the AUC for cTnI was 0.908 (95%CI = 0.870-0.946, P = 0.000), the sensitivity was 81.9%, and the specificity was 95.9%; the AUC for CK-MB was 0.795 (95%CI = 0.736-0.854, P = 0.000), the sensitivity was 63.0%, and the specificity was 92.9%. Conclusions Plasma miR-1 has the capacity in early diagnosis of AMI, superior to CK-MB, and equal to cTnI. It can provide additional diagnostic information beyond cTnI. The diagnostic accuracy for early AMI can be improved with the combination of plasma miR-1 and cTnI.

The data of 5 pregnants with impetigo herpetiformis ( IH) were analyzed retrospectively. All the patients presented with widespread erythema, some of which were covered with pustules sized from needle point to mung bean. All patients had general malaise, fever and chill. Three cases had a history of psoriasis. Laboratory evaluation revealed hypocalcemia, and increased leukocytosis and neutrophilia. One patient who asked to end the pregnancy was treated with methotrexate ( MTX) and retinoid. The other four were treated with antibiotics combined with glucocorticosteroid or intravenous immunoglobulin or recombinant human tumor necrosis factor-α receptor II:IgG Fc fusion protein. All patients got improved and newborns were health.

目的 比较后腹腔镜和输尿管镜治疗输尿管上段＞2 cm嵌顿性结石的临床效果.方法 回顾分析4年来采用后腹腔镜输尿管切开取石术(RPUL)和输尿管镜钬激光碎石术(URL)治疗输尿管上段嵌顿性结石165例,男76例,女89例,年龄40～63岁,左侧81例,右侧84例,结石长径2.0～3.5cm.其中RPUL 92例,左侧38例,右侧54例.URL 73例,左侧43例,右侧30例.比较两组结石长径、肾盂分离、手术时间、术后住院时间、手术成功率、结石清除率及手术并发症等指标.结果 后腹腔镜组92例,87例成功,5例术中结石滑入肾盂,均中转开放,伴并发症9例,均为术后输尿管吻合口漏尿.输尿管镜组73例,69例成功施行,4例失败而中转开放.伴并发症5例,其中输尿管小穿孔2例,术后石街2例,感染性休克1例.输尿管镜组、后腹腔镜组手术时间分别为(61±17)min、(84±24)min,术后住院时间分别为(5±1)d、(7±1)d,手术成功率分别为94.5％(69/73)、94.6％(87/92),结石清除率分别为89.9％(62/69)、100％(87/87),并发症发生率分别为7.3％(5/69)、10.3％(9/87).术后住院时间两组间差异有统计学意义(P＜0.05),结石清除率两组间差异有统计学意义(P＜0.05),并发症发生率两组间差异无统计学意义(P＞0.05).结论 后腹腔镜输尿管切开取石术因其结石完整取出,无严重并发症,是治疗输尿管上段较大嵌顿性结石的可靠术式.

复杂冠状动脉病变一直都是冠心病治疗的重要难题,有些也一度被视为随着经皮冠状动脉介入(PCI)治疗的“禁区”。本文主要讨论三支病变与左主干病变的介入治疗。冠状动脉旁路移植术(CABG)曾是左主干病变和多支血管病变首选治疗措施。但是,PCI技术本身的发展、器械的不断改进,以及 PCI 技术处理复杂冠状动脉疾病能力的不断提高,也进一步扩展了PCI 治疗的适应证范围。在这种背景之下,SYNTAX研究的出现对于目前血运重建策略的选择和未来相关领域的研究均具有一定的指导意义。

Objectives Results from the related published studies on PSCA polymorphisms and cancer risk were somewhat underpowered in general.To assess the role of PSCA exon 1 C ＞ T variant in global cancer by meta-analysis.Methods A computerized literature search was conducted from PubMed and MEDLINE database.Two investigators extracted the data and reached a consensus on all items independently.Results The results showed evidence that PSCA exon 1 C ＞ T pymorphism was associated with increased total cancer risk in the overall comparisons.PSCA exon 1 C ＞T polymorphism has an increased risk in bladder cancer (P ＜0.001,OR =1.09,95％CI:1.05～1.13) and gastric cancer (P =0.006,OR=1.21,95％CI:1.06～1.39).Conclusions Thismeta-analysis showed evidence that PSCA exon 1 C ＞ T polymorphism was associated with bladder cancer and gastric cancer.

<正>微小RNA(microRNA,miRNA)是一类调控基因表达,高度保守的非编码miRNA(21～24nt),参与多种信号通路的调节,在维持内环境稳态中发挥重要作用[1]。从细胞分泌到外周血的miRNA称为循环miRNA,它们在正常人和各种疾病患者体内的表达谱存在明显的差异,并且稳定的存在于外周血中,从而具有诊断相关疾病的内在潜能[2]。作为

Background/aims: Interleukin-13 (IL13) is an immunoregulatory cytokine which plays an important role in carcinogenesis through affecting tumor immunosurveillance. Many studies had reported the influence of IL13 rs1800925 and rs20541 polymorphisms on cancer risk, however, with inconclusive results. The aim of the present study was to conduct a meta-analysis to clarify the relationship. Methods: Twenty studies including a total of 6713 cancer cases and 8693 controls for IL13 rs20541 polymorphism and 4081 cancer cases and 6202 controls for IL13 rs1800925 polymorphism were included in the meta-analysis. Data were extracted from these studies and odds ratios with corresponding 95% confidence intervals were computed to estimate the strength of the association. Results: Overall, the IL13 rs20541 polymorphism were associated with significantly decreased cancer risk in all genetic models (AA vs. GG: OR = 0.82, 95%CI = 0.71-0.95; GA vs. GG: OR = 0.92, 95%CI = 0.85-0.99; GA/AA vs. GG: OR= 0.90, 95%CI = 0.85-0.97; AA vs. GG/GA: OR= 0.85, 95CI% = 0.74-0.98). In the stratified analyses, significant effects were found among European populations, studies with population-based controls and studies of glioma. No influence of the IL13 rs1800925 polymorphism on the overall cancer risk was observed. However, in the stratified analyses, we found the IL13 rs1800925 polymorphism was significantly associated with decreased risk for glioma (CT vs. TT: OR= 0.72, 95%CI = 0.55-0.93; CT/TT vs. TT: OR = 0.76, 95%CI = 0.62-0.89). Conclusion: Our meta-analysis suggests that the IL13 rs20541 polymorphism contributes to susceptibility to cancer, especially for glioma; and the IL13 rs1800925 polymorphism may be associated with glioma risk. (C) 2012 Elsevier B.V. All rights reserved.