静脉血栓栓塞症高危因素和临床表现的荟萃分析

目的:收集相关的文献资料,对静脉血栓栓塞症(VTE)患者的临床表现、危险因素进行荟萃分析。方法:查询中国生物医学文献库,查阅1999年至2009年中国期刊全文数据库(CNKI)、维普全文电子期刊中有关VTE的文献,对确诊为深静脉血栓形成(DVT)和肺血栓栓塞症(PTE)患者的一般情况、临床表现、高危因素等进行统计分析。结果:共纳入文献142篇,其中DVT相关80篇,PTE相关62篇;共计纳入患者9 049例,其中DVT患者6 296例,PTE患者2 753例。DVT患者的症状主要为患肢肿胀(68.23%)、疼痛(61.68%)、浅静脉曲张(16.95%)、下肢活动障碍(12.96%);PTE患者的主要临床表现为呼吸困难(61.00%)、胸痛(47.55%)、咳嗽(27.43%)、心率>100次/分(25.33%)等。DVT的危险因素包括年龄>40岁(92.72%)、手术(27.51%)、吸烟(18.56%)、心脏疾病(12.76%)、高血压(11.29%)、肿瘤(10.42%)等;PTE的危险因素则包括年龄>40岁(93.25%)、DVT史(33.97%)、心脏疾病(16.95%)、卧床(10.22%)、高血压(9.84%)。结论:通过了解VTE致病的危险因素,细致掌握具有一定特点的临床表现,可提高VTE的诊断水平,减少误诊、漏诊,并可及早开展干预治疗,降低病死率。     

超声心动图联合外周血管超声对肺血栓栓塞症的诊断价值

目的 联合应用超声心动图(TTE)和外周血管超声评价右心功能不全(RVD)和下肢深静脉血栓(DVT)对肺血栓栓塞症(PTE)的诊断价值.方法 研究对象为全国41家医院的520例确诊为急性PTE的住院患者.结果 56.0%的患者伴RVD,49.1%存在DVT.363例资料完整患者57.0%有RVD,49.6%伴DVT;伴RVD和(或)DVT者中,33.3%RVD、DVT均阳性.而其中207例(次)大面积PTE,99.5%有RVD,58.5%伴DVT.RVD在近端肺动脉PTE中阳性率(78.9%)明显高于叶肺动脉PTE(51.4%)和段肺动脉PTE(21.7%),DVT阳性率分别为61.7%、46.8%、37.0%,RVD+DVT阳性率分别为51.1%、24.3%和8.7%.结论 RVD/DVT阳性率与PTE严重程度及解剖部位有关,联合TTE和外周血管超声可提高超声技术在急性PTE尤其在(次)大面积PTE、近端肺动脉PTE中的诊断价值.     

恶性肿瘤围术期发生静脉血栓栓塞症患者的临床特征

目的总结恶性肿瘤围术期发生静脉血栓栓塞症(venous thromboembolism, VTE)患者的临床特征。方法回顾性分析114例围术期发生VTE的恶性肿瘤患者的临床资料,其中发生肺血栓栓塞症(pulmonary thromboembolism, PTE)18例为PTE组,发生深静脉血栓形成(deep venous thrombosis, DVT)79例为DVT组,发生PTE+DVT 17例为PTE+DVT组。结果 PTE组、PTE+DVT组呼吸系统肿瘤患者分别占50.0%、41.2%,DVT组消化系统肿瘤患者占41.8%。PTE组、PTE+DVT组、DVT组肿瘤TNM分期Ⅲ～Ⅳ期比率分别为88.9%、88.2%、73.4%,中低分化肿瘤比率分别为83.3%、88.2%、86.1%,3组比较差异无统计学意义(P0.05)。PTE+DVT组活化部分凝血酶原时间[(43.67±9.76)s]较PTE组[(38.43±8.56)s]、DVT组[(36.25±6.63)s]延长(P0.05),PTE组与DVT组比较差异无统计学意义(P0.05);PTE+DVT组国际标准化比值(1.73±0.93)较DVT组(1.13±0.37)高,凝血酶原时间[(21.41±10.59)s]较DVT组[(14.61±4.52)s]延长(P0.05),PTE组国际标准化比值、凝血酶原时间与PTE+DVT、DVT组比较差异无统计学意义(P0.05);PTE组血浆纤维蛋白原[(5.02±2.45)g/L]较PTE+DVT组[(3.77±1.65)g/L]、DVT组[(3.93±1.54)g/L]升高(P0.05),PTE+DVT组纤维蛋白原与DVT组差异无统计学意义(P0.05)。结论恶性肿瘤患者围术期发生DVT和/或PTE多见于TNM分期高、分化程度低的消化系统和呼吸系统肿瘤患者,凝血功能检测可能有助于VTE类型的鉴别。     

高同型半胱氨酸血症与肺血栓栓塞症和(或)深静脉血栓形成的关系

目的　探讨高同型半胱氨酸血症 (HHcy)及同型半胱氨酸 (Hcy)代谢中的相关因素与肺血栓栓塞症 (PTE)和(或 )深静脉血栓形成 (DVT)的关系 ,以便有效防治静脉血栓栓塞症 (VTE)的发生与复发。方法　用病例对照研究的方法对 5 8例既往确诊为VTE的患者及与其性别、年龄相匹配的 5 8例对照 ,调查流行病学危险因素 ,高效液相色谱分析法测定血浆中Hcy、蛋氨酸和半胱氨酸的浓度。结果　①血浆Hcy浓度在两组之间有显著性差异 (P <0 0 5 )。其OR值及其 95 %可信区间为1 5 (1 2 16～ 2 2 13)。但血浆蛋氨酸和半胱氨酸浓度在两组之间无显著性差异 (P >0 0 5 )。②血浆Hcy在病例组内DVT组、单纯PTE组和DVT合并PTE组之间无显著差异 (P >0 0 5 )。结论　HHcy是中国人群PTE和 (或 )DVT独立的危险因素。     

肺血栓栓塞症的预防

肺血栓栓塞症（PTE）和深静脉血栓形成（DVT）统称为静脉血栓栓塞症（VTE），其中90％以上的PTE患者血栓栓子来源于下肢深静脉，PTE是DVT的严重并发症，在美国每年10万人因PTE死亡，有10万人因PTE促发死亡，在我国对PTE的流行病学资料较少，但大多数医院诊断的病例数明显较前增多，且呈继续上升趋势，其原因除临床医生诊断意识提高，漏误诊率降低外，也有危险人群数量增加，危险因素暴露增多，对高危人群识别、预防治疗不足有关。     

516例维、汉两民族住院肺血栓栓塞症患者危险因素分析

目的回顾性分析新疆医科大学第一附属医院近7年住院的516例肺血栓栓塞症(pulmonary thromboembolism,PTE)患者的危险因素、临床资料,探讨维、汉两民族PTE患者危险因素构成特点的差异性。方法回顾性分析2004至2010年7年间在新疆医科大学第一附属医院住院的PTE患者的临床资料。统计学处理采用t检验、χ2检验。结果①共纳入资料完整的PTE患者516例,其平均年龄57.5±14.8岁。其中汉族360例(69.8%),平均年龄63.5±15.5岁;维吾尔族156例(30.2%),平均年龄52.8±14.3岁。汉族PTE患者高峰年龄在70岁以上,维吾尔族PTE患者高峰年龄为60～69岁。②维、汉两民族PTE患者临床表现比较差异无统计学意义。③维、汉两民族PTE患者较常见的基础病因和获得性危险因素为年龄≥40岁(87.0%),其次为肥胖(70.5%)、既往栓塞史(60.9%,包括DVT、PTE、脑梗塞、心肌梗死)及高脂血症(38.0%)。维吾尔族PTE人群的主要获得性危险因素中肥胖多见(79.5%),而汉族人群是吸烟(37.8%)。结论年龄≥40岁、肥胖、既往栓塞史及高脂血症可能是PTE患者较常见的获得性危险因素及基础疾病,维吾尔族PTE人群肥胖较多见。本结论尚需进一步开展更多大样本的病例-对照研究验证。     

预防髋膝关节置换术后深静脉血栓形成的研究进展

正深静脉血栓形成(DVT)作为静脉血栓栓塞症(VTE)之一,是一种严重的具有潜在危险的疾病~[1],除可引起患者疼痛、肿胀、血栓后综合征等外,血栓脱落引起的肺血栓栓塞(PTE)还极易导致患者死亡。DVT是全髋关节置换术(THR)或全膝关节置换术(TKR)术后常见的并发症,在未采取预防措施时,经静脉造影检查证实的THR术后DVT发生率为42%~57%,PTE发生率为     

卵巢癌患者血浆D-二聚体水平与静脉血栓栓塞的关系研究

<正>静脉血栓栓塞症(VTE)是一种严重威胁人类生命健康的疾病,包括深静脉血栓形成(DVT)和肺动脉血栓栓塞症(PTE)。据报道:90%以上的PTE血栓来源于DVT,但50%-80%的DVT并无临床症状,然而一旦栓子脱落形成PTE将会导致生命危险,可引起猝死[1]。VTE是常见的妇科癌症手术并发症[2]。本文探讨了D-二聚体在卵巢癌患者静脉     

超声在肺血栓栓塞-深静脉血栓形成不同治疗方案疗效分析中的作用

目的采用不同治疗方案对肺血栓栓塞症(PTE)-深静脉血栓形成(DVT)后短期疗效进行分析,探讨超声在其疗效分析中的作用。方法选择性肺动脉造影或放射性肺灌注通气扫描确诊的急性肺血栓栓塞患者384例,根据肺血栓栓塞症的诊断与治疗指南分型标准及右心功能,分为大面积和次大面积PTE171例(Ⅰ组)及非大面积PTE213例(Ⅱ组),I组患者给以溶栓方案,II组患者给以抗凝方案,分别于治疗前及治疗14天后进行常规下肢深静脉探查。结果DVT阳性患者212例,占所有PTE患者总数的55.2%,其中Ⅰ组DVT阳性患者115例,Ⅱ组DVT阳性患者97例。两组患者给予抗凝和溶栓不同方案治疗14天后,下肢深静脉血栓完全溶解并不明显,组间差异无统计学意义(P&gt;0.05)。DVT患者下肢血栓分布左侧多于右侧,腘静脉及胫后静脉出现血栓的几率最高,其次为股浅静脉及腓静脉。结论下肢深静脉超声探查能够及时发现下肢深静脉血栓,治疗结束后定期复查超声可以及时提示静脉血栓栓塞再发,降低患者罹患致死性PTE的危险。     

超声在急性肺血栓栓塞症危险分层的应用意义

目的探讨经胸心脏超声联合下肢深静脉超声在急性肺血栓栓塞症(PTE)危险分层评价的临床意义。方法选择本院2010年1月至2014年11月收治的118例符合入组标准的急性肺血栓栓塞症患者作为研究对象,将PTE分为大面积、次大面积PTE组(A组)55例和非大面积PTE组(B组)63例。所有患者均进行经胸心脏超声和下肢深静脉超声检查,收集心脏超声相关指标和下肢深静脉血栓形成(DVT)发生情况。结果 A组舒张期右室横径/左室横径比值(RVTD/LVTD)、舒张期右室前后径/左室前后径比值(RVD/LVD)、右室舒张末期内径(RVID)及三尖瓣反流压差(TRPG)均明显高于B组,差异具有统计学意义,均P0.05;A组和B组DVT发生率及下肢静脉栓塞条数差异无统计学意义,均P0.05。双下肢深静脉血栓栓塞以腓静脉最为多见,约占24.85%,其次为胫后静脉、胭静脉,分别占21.21%、18.18%。超声各指标对A组与B组进行分层预测,RVTD/LVTD、RVD/LVD、RVID、RVAWM、TRPG、累及静脉条数的ROC曲线下面积分别为0.872、0.874、0.711、0.725、1.000、0.594,大于0.7是RVTD/LVTD、RVD/LVD、RVID、RVAWM、TRPG,具有良好预测价值,累及静脉条数的预测性较差。结论经胸心脏超声TRPG是评价PTE危险分层的敏感指标,下肢深静脉血栓是PTE的常见危险因素,经胸心脏超声联合下肢深静脉超声利于筛选出PTE高危患者,具有重要的临床意义。     

Guns and Knives in New Mexico: Patterns of Penetrating Trauma, 1978–1993

Objective: To identify patterns of nonfatal and fatal penetrating trauma among children and adults in New Mexico using ED and medical examiner data.
Methods: The authors retrospectively sampled in 5-year intervals all victims of penetrating trauma who presented to either the state Level-1 trauma center or the state medical examiner from a 16-year period (1978–1993). Rates of nonfatal and fatal firearm and stabbing injury were compared for children and adults.
Results: Rates of nonfatal injury were similar (firearm, 34.3 per 100,000 person-years; stabbing, 35.1). However, rates of fatal injury were significantly different (firearm, 21.9; stabbing, 2.7; relative risk: 8.2; 95% confidence interval: 5.4, 12.5). From 1978 to 1993, nonfatal injury rates increased for children (p = 0.0043) and adults (p < 0.0001), while fatal penetrating injury remained constant. The increase in nonfatal injury in children resulted from increased firearm injury rates. In adults, both stabbing and firearm nonfatal injury rates increased.
Conclusions: Nonfatal injury data suggest that nonfatal violence has increased; fatal injury data suggest that violent death rates have remained constant. Injury patterns vary by age, mechanism of trauma, and data source. These results suggest that ED and medical examiner data differ and that both are needed to guide injury prevention programs.     

Interprofessional approaches to creating safe,high quality health care

Three supplementary perspectives are presented arguing that interprofessional collaboration is both necessary and desirable. Nonetheless, there are often too many serious intra-professional barriers and obstacles to interprofessional collaboration to make it successful. Some of these barriers, it is argued and illustrated, are found in the multiple ways in which professional identity is tacitly acquired and embodied in the practitioners' habitual, everyday practice. The paper then explores ways in which reflection, especially Second order reflection, can help to elucidate and overcome these obstacles, as well as increasing professional adaptability and competence.     

Systematic Reviews Published in the January 2011 Issue of The Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly as a DVD and monthly online. The January 2011 issue (first quarterly DVD for 2011) contains 4515 complete reviews, 1985 protocols for reviews in production, and 13,521 one-page summaries of systematic reviews published in the general medical literature. In addition, there are citations of 641,000 randomized controlled trials, and 14,018 cited papers in the Cochrane methodology register. The health technology assessment database contains over 9300 citations. One hundred and seven new reviews have been published in the last 3 months, of which five have potential relevance for practitioners in pain and palliative medicine.     

Determination of creatine kinase isoenzyme MB activity in serum using immunological inhibition of creatine kinase M subunit activity. Activity kinetics and diagnostic significance in myocardial infarction.

This is a new method for the determination of creatine kinase isoenzyme MB activity in serum. The method uses direct activity measurement of creatine kinase B subunit activity after blocking of CK-M subunit activity by inhibiting antibodies. The test takes no longer than 15 min. The method yields an intra-serial C.V. of 2.0-12.9%, and a C.V. from day to day of 5.5%. The detection limit is 3.4 U/l creatine kinase MB. In the 95 cases with proven myocardial infarction several types of creatine kinase MB activity kinetics could be determined. The percentage of creatine kinase MB of peak CK-total is 6-25%, with a mean of 11.1%. The amount of creatine kinase MB with respect to total CK activity after reinfarction is higher than the amount after initial infarction.     

俯卧位通气对高海拔地区肺复张治疗无效急性呼吸窘迫综合征患者氧合的影响

目的 探讨俯卧位通气对高海拔地区肺复张术(RM)治疗无效急性呼吸窘迫综合征(ARDS)患者的治疗作用.方法 从海拔2260m的地区医院筛选RM治疗无效的41例ARDS患者[平均氧合指数( PaO2/FiO2)较RM前升高＜20％视为RM无效],依不同病因分为肺内源性ARDS组(ARDSp组)和肺外源性ARDS组(ARDSexp组),每组再按信封法随机分为俯卧位组和仰卧位组,即ARDSp俯卧位组(11例)、ARDSp仰卧位组(9例)、ARDSexp俯卧位组(10例)、ARDSexp仰卧位组(11例).在通气前及通气1、2、3、4h监测动脉血氧分压( PaO2)、PaO2/FiO2、静态顺应性(Cst)、气道阻力(Raw)的变化.结果 通气lh时,ARDSexp俯卧位组PaO2/FiO2( mm Hg,l mm Hg=0.133 kPa)即较通气前显著升高(157.4±40.6比129.3±48.7,P＜0.05),并随通气时间延长呈持续增高趋势,4h达峰值(219.1 ±41.1);且ARDSexp俯卧位组通气3h内PaO2/FiO2较其他3组显著增高,另3组间则差异无统计学意义.ARDSp俯卧位组、ARDSexp俯卧位组通气4h时PaO2/FiO2均较相应仰卧位组显著增高(208.8±39.7比127.4±47.1,219.1±41.1比124.9±50.8,均P＜0.05).4组通气前后Cst无显著改变,各组间差异也无统计学意义.ARDSp俯卧位组通气4h时Raw(cmH2O·L-1·s-1)较通气前显著降低(6.8±1.7比10.7±1.8,P＜0.05),且明显低于其他3组;其他3组各时间点Raw组内及组间比较差异均无统计学意义.结论 俯卧位通气作为ARDS机械通气重要策略之一,可以改善RM无效高原ARDS患者的氧合,为抢救患者赢得宝贵的时间.     

Digital imaging among medical facilities

The Department of Veterans Affairs (VA) in the USA operates a network of 172 medical centres which all utilize a hospital information system (HIS) which has been developed and is currently maintained by the VA. During the past several years, an image management and communication module has been developed, installed and clinically utilized at the Washington DC and Maryland VA Medical Centres. This image management and communication system, referred to as the decentralized hospital computer program (DHCP) imaging system, is fully integrated with a commercial picture archiving and communication system (PACS). The system is utilized to capture, archive, and display all images generated within the hospital including radiology, nuclear medicine, pathology, endoscopy, bronchoscopy, and dermatology, intraoperative photographs, ECG data, and a limited number of paper documents. The ultimate goal of the project is to have all patient text and image data available at any clinical workstation to any authorized user anywhere within the network of medical centres. Clinical requirements for an imaging workstation include ease of use, rapid and reliable access to the complete set of patient information, and images which are of acceptable quality to meet the requirements of the user and the subspecialty. Patient confidentiality and data security must be safeguarded at all times. Integration of the images with the remainder of the patient's database was found to be critical to the success of the project. The experience at the Washington and Maryland facilities suggests that an imaging system that is successfully integrated with a hospital information system can provide substantial clinical and economic benefits both within and among medical centres. Clinical acceptance and utilization of the system has been excellent, particularly in diagnostic radiology where DHCP Imaging has been interfaced to a commercial PAC system. Based upon this initial experience, the VA has begun to deploy the system throughout its large network of medical centres.     

Myocardial elastography at both high temporal and spatial resolution for the detection of infarcts

Myocardial elastography is a novel method for noninvasively assessing regional myocardial function, with the advantages of high spatial and temporal resolution and high signal-to-noise ratio (SNR). In this paper, in-vivo experiments were performed in anesthetized normal and infarcted mice (one day after left anterior descending coronary artery [LAD] ligation) using a high-resolution (30 MHz) ultrasound system (Vevo 770, VisualSonics Inc., Toronto, ON, Canada). Radiofrequency (RF) signals of the left ventricle (LV) in longitudinal (long-axis) view and the associated electrocardiogram (ECG) were simultaneously acquired. Using a retrospective ECG gating technique, 2-D full field-of-view RF frames were acquired at an extremely high frame rate (8 kHz) that resulted in high-quality incremental displacement and strain estimation of the myocardium. The incremental results were further accumulated to obtain the cumulative displacements and strains. Two-dimensional and M-mode displacement images and strain images (elastograms), as well as displacement and strain profiles as a function of time, were compared between normal and infarcted mice. Incremental results clearly depicted cardiac events including LV contraction, LV relaxation and isovolumetric phases in both normal and infarcted mice, and also evidently indicated reduced motion and deformation in the infarcted myocardium. The elastograms indicated that the infarcted regions underwent thinning during systole rather than thickening, as in the normal case. The cumulative elastograms were found to have higher elastographic SNR (SNR(e)) than the incremental elastograms (e.g., 10.6 vs. 4.7 in a normal myocardium, and 6.0 vs. 2.4 in an infarcted myocardium). Finally, preliminary statistical results from nine normal (m = 9) and seven infarcted (n = 7) mice indicated the capability of the cumulative strain in differentiating infracted from normal myocardia. In conclusion, myocardial elastography could provide regional strain information at simultaneously high temporal (>/=0.125 ms) and spatial ( approximately 55 microm) resolution as well as high precision ( approximately 0.05 microm displacement). This technique was thus capable of accurately characterizing normal myocardial function throughout an entire cardiac cycle, at the same high resolution, and detecting and localizing myocardial infarction in vivo.     

Prise en charge des entorses externes de cheville : étude clinique préliminaire sur l’efficacité du dispositif Myolux™

Ankle sprains are the most common injury of the musculoskeletal system and are associated with significant societal and economic impacts. It has been proven that classical therapeutic strategies may not be effective in preventing recurrent injuries: the recurrence rates reported in the literature can reach 73%. In order to provide an effective rehabilitation solution, a destabilizing orthosis was developed. This device is equipped with a mechanical articulator reproducing the subtalar mechanics and placed under the heel. In this paper, we present the main results of a preliminary clinical study conducted between 2004 and 2007. All subjects included in this study were treated with the abovementioned orthosis during 10 rehabilitation sessions of 30 minutes each. Data show a relatively low recurrence rate of 12% for the overall population. Moreover, it's of primary importance to note that this satisfactory ratio is largely reduced (3% of recurrence rate) for the 29 patients who performed one training session per month after the 10th initial rehabilitation sessions. Hence, the destabilizing orthosis appears to be an effective solution to prevent recurrent ankle sprains. However, joint protection requires long-term and regular training sessions. This result has motivated the development of a similar device allowing patients to perform training sessions at home. Finally, data obtained in this study are promising awaiting the final results of the comparative, multicentric and independent clinical trials currently managed by the Hospices Civils de Lyon.