Blood cell count

血细胞计数
  • 文章类型: Journal Article
    本研究旨在评估六种全血细胞计数(CBC)衍生的炎症标志物之间的关联[中性粒细胞与淋巴细胞比率(NLR),单核细胞与淋巴细胞比率(MLR),血小板与淋巴细胞比率(PLR),全身免疫炎症指数(SII),全身炎症反应指数(SIRI),和泛免疫性炎症值(PIV)]以及虚弱和死亡的风险。
    数据来自1999-2018年的国家健康和营养检查调查(NHANES)。死亡率是使用国家死亡指数确定的,直到2019年12月31日。进行了多逻辑回归分析以评估六个CBC衍生的炎症标志物与虚弱之间的关联。Cox回归模型评估了6种CBC来源的炎症标志物与虚弱人群死亡率之间的关联。使用限制性三次样条(RCS)可视化六个CBC衍生的炎症标志物与死亡风险的关联。使用随机生存森林(RSF)方法进一步评估CBC衍生的炎症标志物对死亡率的预测价值。
    这项研究分析了总共16,705名中年和老年参与者的数据。其中,6,503名参与者身体虚弱,死亡率为41.47%。多元logistic回归分析显示,NLR,MLR,PLR,SII,SIRI,和PIV与虚弱风险呈正相关。Cox回归模型显示,与最低四分位数的参与者相比,最高四分位数的参与者的死亡风险显着增加:NLR(HR=1.73,95%CI:1.54,1.94),MLR(HR=1.71,95%CI:1.51,1.93),PLR(HR=1.28,95CI:1.15,1.43),SII(HR=1.50,95CI:1.34,1.68),SIRI(HR=1.88,CI95%:1.67,2.12),PIV(HR=1.55,95CI:1.38,1.73)。随机生存森林(RSF)分析表明,MLR对中年和老年成年体弱参与者的死亡风险具有最高的预测价值。
    结果表明,在美国中老年人群中,CBC衍生的炎症标志物与更高的虚弱和死亡风险相关。
    UNASSIGNED: This study aimed to evaluate the association between six complete blood count (CBC)-derived inflammatory markers [neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), platelet-to-lymphocyte ratio (PLR), systemic immune-inflammatory index (SII), systemic inflammatory response index (SIRI), and pan-immune inflammation value (PIV)] and the risk of frailty and mortality.
    UNASSIGNED: Data were obtained from the National Health and Nutrition Examination Survey (NHANES) 1999-2018. Mortality was identified using the National Death Index until December 31, 2019. Multiple logistic regression analysis was conducted to evaluate the association between six CBC-derived inflammatory markers and frailty. The Cox regression model assessed the association between six CBC-derived inflammatory markers and mortality in frail populations. Restricted cubic spline (RCS) was used to visualize the association of the six CBC-derived inflammatory markers with mortality risk. The predictive value of CBC-derived inflammatory markers for mortality was further assessed using a random survival forest (RSF) approach.
    UNASSIGNED: This study analyzed data from a total of 16,705 middle-aged and older participants. Among them, 6,503 participants were frail, with a mortality rate of 41.47%. Multiple logistic regression analysis showed that NLR, MLR, PLR, SII, SIRI, and PIV were positively associated with frailty risk. The Cox regression model revealed that participants in the highest quartile had a significantly increased risk of death compared to those in the lowest quartile: NLR (HR = 1.73, 95% CI:1.54, 1.94), MLR (HR = 1.71, 95% CI:1.51, 1.93), PLR (HR = 1.28, 95%CI: 1.15, 1.43), SII (HR = 1.50, 95%CI:1.34, 1.68), SIRI (HR = 1.88, CI 95%:1.67, 2.12), PIV (HR = 1.55, 95%CI:1.38, 1.73). Random survival forest (RSF) analyses demonstrated that MLR had the highest predictive value for mortality risk middle-aged and older adult frail participants.
    UNASSIGNED: The results suggest that CBC-derived inflammatory markers are associated with a higher risk of frailty as well as mortality in the middle and old-aged population of the United States.
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  • 文章类型: Journal Article
    背景:登革热(DF)是一种蚊媒疾病,具有重大的经济和社会影响。了解住院多米尼加共和国(DR)儿科患者的实验室趋势可能有助于在资源匮乏的环境中开发筛查程序。我们试图描述2018年至2020年DF和DF严重程度的DR儿童随时间的实验室发现。方法:前瞻性地从招募的DF患儿中获得临床信息。在发烧的第1-10天评估全血细胞计数(CBC)实验室测量。参与者分为DF阴性和DF阳性,并按严重程度分组。我们评估了DF严重程度与人口统计学的关联,临床特征,和外周血研究。使用线性混合模型,我们评估了血液学值/轨迹是否因DF状态/严重程度而异。结果:在1101个有DF临床诊断的患者中,共597个进行了血清学评估,574(471DF阳性)符合纳入标准。在DF中,在发热早期,血小板计数和血红蛋白较高(p<=0.0017).八十个有严重的DF。严重的DF风险与血小板减少症有关,病内贫血,和白细胞增多,不同的发烧日(p<=0.001)。结论:在儿科住院DR队列中,我们在严重DF的晚期发现了明显的贫血,与通常看到的血液浓缩不同。这些发现,伴随着临床症状随时间的变化,可能有助于指导资源有限环境的风险分层筛查。
    Background: Dengue fever (DF) is a mosquito-borne illness with substantial economic and societal impact. Understanding laboratory trends of hospitalized Dominican Republic (DR) pediatric patients could help develop screening procedures in low-resourced settings. We sought to describe laboratory findings over time in DR children with DF and DF severity from 2018 to 2020. Methods: Clinical information was obtained prospectively from recruited children with DF. Complete blood count (CBC) laboratory measures were assessed across Days 1-10 of fever. Participants were classified as DF-negative and DF-positive and grouped by severity. We assessed associations of DF severity with demographics, clinical characteristics, and peripheral blood studies. Using linear mixed-models, we assessed if hematologic values/trajectories differed by DF status/severity. Results: A total of 597 of 1101 with a DF clinical diagnosis were serologically evaluated, and 574 (471 DF-positive) met inclusion criteria. In DF, platelet count and hemoglobin were higher on earlier days of fever (p < = 0.0017). Eighty had severe DF. Severe DF risk was associated with thrombocytopenia, intraillness anemia, and leukocytosis, differing by fever day (p < = 0.001). Conclusions: In a pediatric hospitalized DR cohort, we found marked anemia in late stages of severe DF, unlike the typically seen hemoconcentration. These findings, paired with clinical symptom changes over time, may help guide risk-stratified screenings for resource-limited settings.
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  • 文章类型: Journal Article
    传统的手工血涂片诊断方法耗时长,容易出错,通常在很大程度上依赖于临床实验室分析师的经验来保证准确性。随着神经网络和深度学习等关键技术的突破不断推动医疗领域的数字化转型,图像识别技术正越来越多地被利用来增强现有的医疗流程。近年来,计算机技术的进步通过使用图像识别技术提高了血液涂片中血细胞识别的效率。本文全面总结了利用图像识别算法诊断血涂片疾病的方法和步骤,重点是疟疾和白血病。此外,它为开发全面的血细胞病理检测系统提供了前瞻性的研究方向。
    Traditional manual blood smear diagnosis methods are time-consuming and prone to errors, often relying heavily on the experience of clinical laboratory analysts for accuracy. As breakthroughs in key technologies such as neural networks and deep learning continue to drive digital transformation in the medical field, image recognition technology is increasingly being leveraged to enhance existing medical processes. In recent years, advancements in computer technology have led to improved efficiency in the identification of blood cells in blood smears through the use of image recognition technology. This paper provides a comprehensive summary of the methods and steps involved in utilizing image recognition algorithms for diagnosing diseases in blood smears, with a focus on malaria and leukemia. Furthermore, it offers a forward-looking research direction for the development of a comprehensive blood cell pathological detection system.
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  • 文章类型: Journal Article
    骨髓增生异常综合征(MDS)具有多态性和非特异性诊断特征血液学分析仪的研究参数可能有助于区分MDS相关的血细胞减少症。诸如NeuX(与细胞质复杂性相关)和NeuY(与核酸含量相关)的参数显示出检测MDS的发育异常并帮助识别来自其他病因的血细胞减少的MDS的希望。
    Myelodysplastic syndromes (MDS) present with polymorphic and non-specific diagnostic features Research parametersfrom hematology analyzers may be useful to discriminate MDS-related cytopenia.Parameters such as Neu X (related to the cytoplasmic complexity) and Neu Y (related to nucleic acid content) show promise to detect dysplasia of MDS and aid to recognize MDS from cytopenias of other etiologies.
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  • 文章类型: Journal Article
    全血细胞计数(CBC)方法从手动计算到复杂的高通量血液学分析仪的演变是本文的重点。近年来,血液学测试极大地受益于各种技术与自动神经网络的组合。除了实验室仪器越来越复杂之外,CBC检测有其优点和缺点。本文重点介绍了血液学检测从过去到现在和未来的令人兴奋的进步。
    The evolution of complete blood count (CBC) methodology from manual calculations to sophisticated high throughput hematology analyzers is the focus of this article. In recent years, hematology testing has greatly benefitted from the combination of various technologies with automated neural networks. In addition to an increasing complexity of the laboratory instrumentation, there is a demand on point of care CBC testing with its benefits and drawbacks. This article highlights exciting advancements of hematology testing from the past to the present and into the future.
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  • 文章类型: Journal Article
    背景:尘肺主要是肺部和心血管疾病,其中肺心病(PHD)因其对尘肺患者的生存有重大影响而备受关注。白细胞计数(WCC),红细胞分布宽度(RDW)和血小板参数被认为会影响炎症反应,并可能是各种心血管疾病的预测因子。然而,很少有研究集中在PHD上。
    目的:检查基线全血细胞计数参数(WCC,RDW,血小板参数)和尘肺患者发生PHD的风险。
    方法:回顾性队列研究。
    方法:这是一个单中心,使用职业病医院数据的回顾性队列研究,成都,四川。
    方法:将2012年1月至2021年11月的946例尘肺患者纳入研究。女性患者和有PHD的患者,冠心病,高血压性心脏病,心肌病,心力衰竭,肿瘤疾病,多器官功能障碍,基线和随访时间少于6个月的AIDS也被排除。
    方法:我们根据患者出院诊断确定PHD。我们构建了Cox比例风险回归模型来评估尘肺中PHD的HR,以及95%CIs。
    结果:在多重Cox比例风险回归分析中,高于基线中位数的血小板计数(PLT)和血小板计数(PCT)与尘肺患者的PHD风险增加相关,校正HR为1.52(95%CI1.09~2.12)和1.42(95%CI1.02~1.99),分别。
    结论:较高的基线PLT和PCT与尘肺患者的PHD风险较高相关。
    BACKGROUND: Pneumoconiosis mostly combines pulmonary and cardiovascular diseases, among which pulmonary heart disease (PHD) is of major concern due to its significant impact on the survival of pneumoconiosis patients. White cell count (WCC), red cell distribution width (RDW) and platelet parameters are thought to affect inflammatory responses and may be predictors of various cardiovascular diseases. However, very few studies have focused on PHD.
    OBJECTIVE: To examine the relationship between baseline complete blood count parameters (WCC, RDW, platelet parameters) and the risk of incident PHD in pneumoconiosis patients.
    METHODS: A retrospective cohort study.
    METHODS: This was a single-centre, retrospective cohort study that used data from an Occupational Disease Hospital, Chengdu, Sichuan.
    METHODS: A total of 946 pneumoconiosis patients from January 2012 to November 2021 were included in the study. Female patients and patients who had PHD, coronary heart disease, hypertensive heart disease, cardiomyopathy, heart failure, oncological disease, multiple organ dysfunction, AIDS at baseline and follow-up time of less than 6 months were also excluded.
    METHODS: We identified PHD according to the patient\'s discharge diagnosis. We constructed Cox proportional hazard regression models to assess the HR of incident PHD in pneumoconiosis, as well as 95% CIs.
    RESULTS: In the multiple Cox proportional hazard regression analysis, platelet count (PLT) and plateletcrit (PCT) above the median at baseline were associated with an increased risk of PHD in pneumoconiosis with adjusted HR of 1.52 (95% CI 1.09 to 2.12) and 1.42 (95% CI 1.02 to 1.99), respectively.
    CONCLUSIONS: Higher baseline PLT and PCT are associated with a higher risk of PHD in pneumoconiosis.
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  • 文章类型: Journal Article
    背景和目的:脊柱布氏菌炎和ModicI型改变(MC1)之间的区别包括困难。血液炎症指标(HII),如中性粒细胞与淋巴细胞比率(NLR)和全身炎症聚集指数(AISI)被认为是炎症和感染的指标,具有诊断价值。预后,以及在各种疾病中的预测作用。本研究旨在评估布鲁氏菌脊柱盘炎和MC1在HII方面的差异。材料与方法:本研究纳入了35例布氏杆菌脊柱盘炎患者和37例MC1患者。布鲁氏菌脊柱盘炎和MC1通过微生物学诊断,血清学,和放射诊断工具。HII(NLR,MLR,PLR,NLPR,SII,SIRI,AISI)来自基线全血细胞计数。结果:两组患者年龄(p=0.579)和性别(p=0.092)相似,白细胞(p=0.127),中性粒细胞(p=0.366),淋巴细胞(p=0.090),和单核细胞(p=0.756)评分。布鲁氏杆菌组疼痛持续时间显著降低(p<0.001),较高的CRP和ESR水平(p<0.001),血小板计数(p=0.047)低于MC1组。两组在HII:NLR方面具有相似性(p=0.553),MLR(p=0.294),PLR(p=0.772),NLPR(p=0.115),SII(p=0.798),SIRI(p=0.447),和AISI(p=0.248)。结论:HII增加可用于区分感染性和非感染性疾病,但这在布鲁氏菌病中可能无效。然而,疼痛持续时间,CRP和ESR水平,和血小板计数可能有助于区分布鲁杆菌和MC1。
    Background and Objectives: Differentiation between brucella spondylodiscitis and Modic type I changes (MC1) includes difficulties. Hematological inflammatory indices (HII) such as neutrophil to lymphocyte ratio (NLR) and aggregate index of systemic inflammation (AISI) are suggested as indicators of inflammation and infection and have diagnostic, prognostic, and predictive roles in various diseases. This study aimed to evaluate differences between brucella spondylodiscitis and MC1 in terms of HII. Materials and Methods: Thirty-five patients with brucella spondylodiscitis and thirty-seven with MC1 were enrolled in the study. Brucella spondylodiscitis and MC1 were diagnosed by microbiological, serological, and radiological diagnostic tools. HII (NLR, MLR, PLR, NLPR, SII, SIRI, AISI) were derived from baseline complete blood count. Results: The two groups were similar for age (p = 0.579) and gender (p = 0.092), leukocyte (p = 0.127), neutrophil (p = 0.366), lymphocyte (p = 0.090), and monocyte (p = 0.756) scores. The Brucella spondylodiscitis group had significantly lower pain duration (p < 0.001), higher CRP and ESR levels (p < 0.001), and lower platelet count (p = 0.047) than the MC1 group. The two groups had similarity in terms of HII: NLR (p = 0.553), MLR (p = 0.294), PLR (p = 0.772), NLPR (p = 0.115), SII (p = 0.798), SIRI (p = 0.447), and AISI (p = 0.248). Conclusions: Increased HII can be used to differentiate infectious and non-infectious conditions, but this may be invalid in brucellosis. However, pain duration, CRP and ESR levels, and platelet count may be useful to distinguish brucella spondylodiscitis from MC1.
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  • 文章类型: Journal Article
    背景:精神分裂症谱系障碍(SSD)与免疫炎症激活有关。最近,基于全血细胞计数(CBC)的炎症指标,如中性粒细胞与淋巴细胞比率(NLR),单核细胞与淋巴细胞比率(MLR),血小板与淋巴细胞比率(PLR)已成为精神疾病中可重复且具有成本效益的炎症标志物.在这项研究中,我们旨在调查NLR的关系,MLR,和有SSD患者症状严重的PLR,测试与相关临床变量的相互作用。
    方法:我们纳入了2020年5月至2024年3月连续住院的18-65岁SSD患者。记录社会人口统计学和临床数据。从常规收集的血液样品估计基于CBC的比率。进行结构方程模型(SEM)以测试涉及症状严重程度构造和基于CBC的比率的关系,考虑物质使用障碍,抗精神病药物治疗,和肥胖。
    结果:160名参与者符合纳入标准。SEM分析揭示了MLR与正相关的显着关系(coeff。:0.19,p=0.048)和负(系数。:0.27,p=0.004)症状,还显示了药物使用障碍和抗精神病药物治疗与症状严重程度以及抗精神病药物治疗与肥胖的显着联系。
    结论:尽管横截面设计和样本代表性有限,这项研究表明,MLR-而不是NLR或PLR-与阳性和阴性症状的严重程度之间存在显着关系,同时测试与其他临床变量的相互作用。考虑到该领域数据的不足和不一致,需要进一步的研究来验证我们的研究结果,并阐明驱动MLR和SSD症状之间观察到的关系的潜在机制.
    BACKGROUND: Schizophrenia spectrum disorders (SSDs) are associated with immune-inflammatory activation. Recently, complete blood count (CBC)-based inflammation indexes such as the neutrophil-to-lymphocyte ratio (NLR), the monocyte-to-lymphocyte ratio (MLR), and the platelet-to-lymphocyte ratio (PLR) have emerged as reproducible and cost-effective inflammation markers in mental disorders. In this study, we aimed at investigating the relationship of NLR, MLR, and PLR with symptom severity in people with SSDs, testing interactions with relevant clinical variables.
    METHODS: We included inpatients with SSDs aged 18-65 consecutively hospitalized from May 2020 to March 2024. Socio-demographic and clinical data were recorded. CBC-based ratios were estimated from routinely collected blood samples. Structural equation modelling (SEM) was performed to test relationships involving symptom severity constructs and CBC-based ratios, accounting for substance use disorder, antipsychotic treatment, and obesity.
    RESULTS: Two hundred sixty-six participants met inclusion criteria. The SEM analysis uncovered a significant relationship of MLR with positive (coeff.: 0.19, p=0.048) and negative (coeff.: 0.27, p=0.004) symptoms, also showing a significant link of substance use disorder and antipsychotic treatment with symptom severity as well as of antipsychotic treatment with obesity.
    CONCLUSIONS: Notwithstanding the cross-sectional design and the somewhat limited sample representativeness, this study showed a significant relationship between the MLR - but not the NLR or the PLR - and the severity of both positive and negative symptoms, testing at the same time the interactions with other clinical variables. Considering the insufficiency and inconsistency of data in this field, further research is needed to validate our findings and elucidate the underlying mechanisms driving the observed relationships between the MLR and SSD symptoms.
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  • 文章类型: Journal Article
    慢性自发性荨麻疹(CSU)是一种免疫性疾病,由患者和社会的高患病率和突出负担来描述,这归因于症状的任意性质以及评估活动和严重程度的工具不一致。转谷氨酰胺酶-2(TG2)是在包括肥大细胞的许多细胞和组织类型中普遍表达的翻译后酶。它具有多种生物学功能,它在过敏性疾病中的作用已经通过几种假定的机制得到了强调和描述。本病例对照研究旨在确定血清TG2水平与CSU严重程度之间的关系。据我们所知,这是埃及首次确定血清TG2与CSU严重程度之间关系的研究。我们招募了60例确诊为CSU的成年患者。根据荨麻疹活动评分(UAS),患者分为3组[20例轻度疾病;UAS=0,20例中度疾病;UAS=1-3,20例重度疾病;UAS=4-6].另外20名健康个体(年龄和性别匹配)作为对照组。所有患者都有详细的病史,临床检查,有差别的全血细胞计数,血清总IgE,CRP,ESR,TSH,安娜,肝肾功能检查.通过定量ELISA对所有入选患者和对照进行TG2的血清水平。患者组血清TG2明显高于对照组(P值<0.001)。重症患者的血清TG2水平明显高于中度或轻度疾病患者。这通过血清TG2和UAS之间的显着正相关(r0.814和P值0.000)来说明。此外,血清TG2准确地将CSU患者分为轻度,中度和重度亚组:关于轻度和中度病例之间的区别(敏感性70%,特异性80%,PPV77.8,NPV72.7)以及中度和重度病例之间的区别(敏感性95%,特异性90%,PPV90.5,净现值94.7)。血清TG2可能作为CSU患者严重程度的标志物具有关键作用。
    Chronic spontaneous urticaria (CSU) is an immunological disease that is depicted by high prevalence and eminent burden for patients and society that is attributable to the arbitrary nature of symptoms and inconsistent tools for assessment of activity and severity. Transglutaminase-2 (TG2) is a posttranslational enzyme that is pervasively expressed in many cells and tissue types including mast cells. It has various biological functions, and its role in allergic disorders has been highlighted and delineated through several postulated mechanisms. This case-control study aimed at determining the relationship between serum levels TG2 and severity of CSU. To the best of our knowledge, this is the first study in Egypt to determine the relationship between serum TG2 and severity of CSU. We enrolled 60 adult patients with confirmed diagnosis of CSU. According to urticaria activity score (UAS), patients were categorized into three groups [20 with mild disease; UAS = 0, 20 with moderate disease; UAS = 1-3, 20 with severe disease; UAS = 4-6]. Another 20 healthy individuals (age and gender matched) served as a control group. All patients were subjected to detailed medical history, clinical examination, complete blood count with differential, serum total IgE, CRP, ESR, TSH, ANA, liver and renal function tests. Serum level of TG2 was done by quantitative ELISA for all enrolled patients and controls. Serum TG2 is significantly higher in patients group compared to control group (P value < 0.001). Serum TG2 levels were significantly higher in patients with severe disease compared to patients with moderate or mild disease. This is illustrated by the significant positive correlation between serum TG2 and UAS (r 0.814 and P value 0.000). Moreover, serum TG2 accurately classified CSU patients into mild, moderate and severe subgroups: as regards differentiation between mild and moderate cases (sensitivity 70%, specificity 80%, PPV 77.8, NPV 72.7) and as for the differentiation between moderate and severe cases (sensitivity 95%, specificity 90%, PPV 90.5, NPV 94.7). Serum TG2 may have a pivotal role as a marker of severity in patients with CSU.
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  • 文章类型: Journal Article
    目的:本研究旨在评估成人心脏手术患者的delta中性粒细胞指数(DNI)对30天死亡率的预测准确性。方法:本研究纳入2016年3月至2022年5月在韩国一家三级医院接受全身麻醉心脏手术的患者。术前测量DNI,在术后到达外科重症监护病房(ICU)时,术后12、24、48和72h。采用接收器工作特性(ROC)分析来确定DNI的预测准确性。ROC曲线下面积(AUROC)≥0.700被定义为令人满意的预测准确性。在ROC曲线中揭示了DNI值最大化预测准确性的最佳截止点,其中[敏感性+特异性]最大。结果:本研究最终纳入843例患者。研究人群的平均年龄为66.9±12.2岁,其中38.4%为女性患者。总体30天死亡率为5.2%。涉及胸主动脉的手术,既往心脏手术史,或急诊手术与较高的死亡率相关.DNI在24h时显示出令人满意的预测准确性,48h,术后72小时,AUROC分别为0.729、0.711和0.755。DNI在每个时间点的最佳截止点分别为3.2、3.8和2.3。结论:术后DNI是心脏手术后30天死亡率的良好预测指标,并且没有额外的财务成本或时间。
    Purpose: This study aimed to assess the predictive accuracy of 30-day mortality with delta neutrophil index (DNI) in adult cardiac surgical patients. Methods: This study enrolled patients who underwent cardiac surgery under general anesthesia between March 2016 and May 2022 at a tertiary hospital in the Republic of Korea. DNI was measured preoperatively, on postoperative arrival to the surgical intensive care unit (ICU), and 12, 24, 48, and 72 h postoperatively. Receiver operating characteristic (ROC) analysis was employed to identify the prediction accuracy of DNI. An area under ROC curve (AUROC) ≥0.700 was defined as satisfactory predictive accuracy. An optimal cutoff point for the DNI value to maximize predictive accuracy was revealed in the ROC curve, where [sensitivity + specificity] was maximum. Results: This study included a total of 843 patients in the final analyses. The mean age of the study population was 66.9±12.2 years and 38.4% of them were female patients. The overall 30-day mortality rate was 5.2%. Surgery involving the thoracic aorta, history of prior cardiac surgery, or emergency surgery were associated with a higher mortality rate. The DNI showed satisfactory predictive accuracy at 24 h, 48 h, and 72 h postoperatively, with AUROC of 0.729, 0.711, and 0.755, respectively. The optimal cutoff points of DNI at each time point were 3.2, 3.8, and 2.3, respectively. Conclusions: Postoperative DNI is a good predictor of 30-day mortality after cardiac surgery and has the benefit of no additional financial costs or time.
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