• 【心房纤颤近期发生脑栓塞后,可否将导管定向溶栓术用于急性下肢动脉栓塞?】 复制标题 收藏 收藏
    DOI:10.1016/j.crad.2008.04.014 复制DOI
    作者列表:Si TG,Guo Z,Hao XS
    BACKGROUND & AIMS: PURPOSE:To assess the feasibility and efficacy of catheter-directed thrombolysis with recombinant tissue plasminogen activator (rt-PA) for acute limb embolism in patients with recent cerebral embolism due to atrial fibrillation. MATERIALS AND METHODS:Eight patients (six men, two women; mean age 63.5 years) with acute embolic occlusion of two left common iliac arteries, four femoral arteries (three left; one right), and two right popliteal arteries were treated. All patients had a history of recent cerebral embolism (mean 6 days, range 5-15 days) and all had a history of atrial fibrillation (duration 5-10 years). Catheter-directed thrombolysis started a few hours (mean 6.2h; range 3-10h) after the onset of arterial embolism. Two 5mg boluses of rt-PA were injected into the proximal clot through a 5 F end-hole catheter and, subsequently, two additional boluses of 5mg rt-PA were injected into the emboli. In patients with residual emboli, infusion with rt-PA (1mg/h) was continued. Percutaneous transluminal angioplasty was performed in three patients, and a stent was deployed in one patient. RESULTS:Technical success was achieved in all patients. Clinical success rate was 87.5% (7/8). The one clinical failure was secondary to chronic occlusion of outflow runoff vessels. The mean duration of continuous rt-PA infusion was 3.6h, the mean total dose of rt-PA administered was 23.6 mg (range 20-28 mg). There was no significant change in stroke scale scores during thrombolysis and no intracerebral haemorrhage was found at computed tomography (CT) after thrombolysis. Minor complications included haematomata at puncture sites (6/8), bleeding around the vascular sheath (2/8), and haematuria (1/8). During the follow-up period of 3-6 months, one patient suffered from recurrent cerebral embolism and died. CONCLUSIONS:Catheter-directed thrombolysis with rt-PA is an option for acute lower extremity arterial embolism in patients with recent cerebral embolism and a history of atrial fibrillation. Further studies should be undertaken to determine the risk of intracerebral haemorrhage caused by catheter-directed thrombolysis in individual stroke patients.
    背景与目标: 目的:评估重组组织型纤溶酶原激活物(rt-PA)指导的导管溶栓治疗在房颤引起的近期脑栓塞患者中急性肢体栓塞的可行性和有效性。
    材料与方法:对八例急性栓塞闭塞的患者(六名男性,两名女性;平均年龄63.5岁)进行了治疗,该患者有两条左common总动脉,四股股动脉(左三;一右)和两根pop小动脉。所有患者均具有近期脑栓塞病史(平均6天,范围5-15天),均具有房颤病史(持续时间5-10年)。导管栓塞发生后数小时(平均6.2h;范围3-10h)开始进行导管溶栓治疗。通过5 F端孔导管将两个5mg rt-PA大剂量注入近端血块,随后再将两个5mg rt-PA大剂量注入栓子。在残留栓子的患者中,继续输注rt-PA(1mg / h)。在三名患者中进行了经皮腔内血管成形术,在一名患者中部署了支架。
    结果:所有患者均获得技术成功。临床成功率为87.5%(7/8)。一种临床失败是继发于流出径流血管的慢性阻塞。 rt-PA连续输注的平均持续时间为3.6h,rt-PA的平均给药总剂量为23.6 mg(范围为20-28 mg)。溶栓后卒中量表评分无明显变化,溶栓后计算机断层扫描(CT)未发现脑出血。较小的并发症包括穿刺部位的血肿(6/8),血管鞘周围的出血(2/8)和血尿(1/8)。在3至6个月的随访期间,一名患者反复发作脑栓塞并死亡。
    结论:对于近期脑栓塞并有心房颤动病史的患者,rt-PA导管定向溶栓术是急性下肢动脉栓塞的一种选择。应进行进一步的研究以确定在个体卒中患者中因导管定向溶栓引起的脑内出血的风险。
  • 【大鼠实验性肺栓塞后炎症在右心室损伤和修复中的作用。】 复制标题 收藏 收藏
    DOI:10.1111/j.1365-2613.2008.00610.x 复制DOI
    作者列表:Watts JA,Gellar MA,Obraztsova M,Kline JA,Zagorski J
    BACKGROUND & AIMS: :Right ventricular (RV) dysfunction is associated with poor clinical outcome following pulmonary embolism (PE). Previous studies in our laboratory show that influx of neutrophils contributes to acute RV damage seen in an 18 h rat model of PE. The present study describes the further progression of inflammation over 6 weeks and compares the neutrophil and monocyte responses. The RV outflow tract became white in colour by day 1 with influx of neutrophils (tissue myeloperoxidase activity increased 17-fold) and mononuclear cells with characteristics of M1 phenotype (high in Ccl20, Cxcl10, CcR2, MHCII, DNA microarray analysis). Matrix metalloproteinase activities were increased and tissue was thinned to produce a translucent appearance in weeks 1 through 6 in 40% of hearts. RV contractile function was significantly reduced at 6 weeks of PE. In this later phase, there was accumulation of myofibroblasts, the presence of mononuclear cells with M2 characteristics (high in scavenger mannose receptors, macrophage galactose lectin 1, PDGFR1, PDGFRbeta), enrichment of the subendocardial region of the RV outflow tract with neovesels (alpha-smooth muscle immunohistochemistry) and deposition of collagen fibres (picrosirius red staining) beginning scar formation. Thus, while neutrophil response is associated with the early, acute inflammatory events, macrophage cells continue to be present during the proliferative phase and initial deposition of collagen in this model, changing from the M1 to the M2 phenotype. This suggests that the macrophage cell response is biphasic.
    背景与目标: :右心室(RV)功能障碍与肺栓塞(PE)后的临床预后不良有关。在我们实验室的先前研究表明,嗜中性粒细胞的大量涌入可导致在18小时的PE大鼠模型中出现急性RV损伤。本研究描述了6周内炎症的进一步发展,并比较了中性粒细胞和单核细胞的反应。到第1天,RV流出道变成白色,伴有嗜中性粒细胞的流入(组织髓过氧化物酶活性增加了17倍)和具有M1表型特征的单核细胞(Ccl20,Cxcl10,CcR2,MHCII,DNA芯片分析高)。在40%的心脏中,第1周到第6周,基质金属蛋白酶的活性增加,组织变薄,形成半透明的外观。 PE发生6周后,RV收缩功能显着降低。在此后期阶段,存在成肌纤维细胞的积累,具有M2特征的单核细胞的存在(高清除率甘露糖受体,巨噬细胞半乳糖凝集素1,PDGFR1,PDGFRbeta),右室流出道的心内膜下区域被新血管(α)富集。 -平滑肌免疫组织化学)和胶原纤维沉积(picrosirius红染色)开始形成疤痕。因此,尽管嗜中性粒细胞反应与早期急性炎症事件有关,但在该模型中胶原的增生期和初始沉积期间,巨噬细胞继续存在,从M1变为M2表型。这表明巨噬细胞反应是双相的。
  • 【矛盾性栓塞导致的急性精神病综合症。】 复制标题 收藏 收藏
    DOI:10.1016/j.ejvs.2006.07.014 复制DOI
    作者列表:Gouëffic Y,Piffeteau T,Patra P
    BACKGROUND & AIMS: :Paradoxical embolism, describing the passage of venous or right-sided cardiac thrombus into the arterial or systemic circulation through patent foramen ovale, is an uncommon cause of acute arterial occlusion. Here, we report acute Leriche syndrome in a young woman attributable to paradoxical embolism. Ischaemia, patent foramen ovale, and venous thrombosis were the triad of evidence for paradoxical embolism.
    背景与目标: :偏瘫性栓塞描述了静脉或右侧心脏血栓通过卵圆形未闭孔进入动脉或全身循环,是导致急性动脉闭塞的罕见原因。在这里,我们报道了一名年轻女性因矛盾性栓塞而发生的急性莱里希综合症。缺血,卵圆孔未闭和静脉血栓形成是三元悖论性栓塞的证据。
  • 【周围动脉栓塞:患病率,预后以及超声心动图在管理中的作用。】 复制标题 收藏 收藏
    DOI:10.1177/1538574406291820 复制DOI
    作者列表:Gossage JA,Ali T,Chambers J,Burnand KG
    BACKGROUND & AIMS: :The aims of this study were to review the prevalence and outcome of all surgically treated upper and lower limb emboli presenting to one vascular unit in the last 3 years and to compare transthoracic with transesophageal echocardiography for defining the source of the embolus. All patients who underwent surgical embolectomy for acute limb ischemia from January 2001 to June 2004 were reviewed. Transthoracic and transesophageal echocardiography were carried out on a subset of consecutive unselected patients. Forty-two patients, with a mean age of 80 years, underwent surgical embolectomy from January 2001 to June 2004 (M/F 1:1.8): 27 for lower limb ischemia and 15 for upper limb ischemia. Two thirds of these patients were found to be in atrial fibrillation at presentation (n = 28), of whom less than a third were receiving anticoagulants or antiplatelet agents (n = 8). The mean hospital stay was 15 days with 36 patients (86%) being fully anticoagulated before discharge from hospital. The 30-day mortality rate was 11% (n = 3/27) with 5 patients requiring fasciotomies (12%) and 3 patients requiring an amputation of the lower limb (11%). Postoperatively, 34 patients (81%) had transthoracic echocardiography (TTE), which demonstrated a source or potential source for thrombus in 19 (56%). Fifteen patients (36%) had transesophageal echocardiography (TEE), which changed the subsequent management in 3 patients. All patients in whom TEE altered clinical management would have required this investigation if standard clinical guidelines were followed. TEE did not identify any additional patients with cardiac embolic sources that were not detected by TTE. Arterial limb emboli are still prevalent, but limb salvage and mortality rates appear to be improving. Despite clear guidelines on anticoagulation for patients in atrial fibrillation, many are not receiving appropriate treatment. Transthoracic echocardiography is a good screening tool for detecting a potential cardiac source for peripheral embolism, with transesophageal echocardiography being reserved for specific indications.
    背景与目标: :这项研究的目的是回顾过去3年中所有接受手术治疗的上肢和下肢栓塞在一个血管内的发生率和结局,并比较经胸和经食道超声心动图检查来确定栓子的来源。回顾性分析了2001年1月至2004年6月所有因急性肢体缺血而行外科手术栓塞切除术的患者。经胸和经食道超声心动图检查是对连续的未选择患者的子集进行的。 2001年1月至2004年6月,平均年龄为80岁的42例患者接受了手术栓塞切除术(M / F 1:1.8):下肢缺血27例,上肢缺血15例。这些患者中有三分之二被发现存在房颤(n = 28),其中不到三分之一接受抗凝剂或抗血小板药物(n = 8)。平均住院时间为15天,其中36例患者(86%)在出院前已充分抗凝。 30天死亡率为11%(n = 3/27),其中5例需要行筋膜切开术(12%),3例需要下肢截肢(11%)。术后34例(81%)患者经胸超声心动图(TTE),其中19例(56%)证明有血栓来源或潜在来源。 15例患者(36%)进行了食管超声心动图检查(TEE),这改变了3例患者的后续治疗方法。如果遵循标准的临床指南,所有TEE改变了临床管理的患者都需要进行此项调查。 TEE并未发现TTE未发现的其他心脏栓塞患者。动脉肢体栓塞仍很普遍,但肢体抢救和死亡率似乎正在提高。尽管对房颤患者的抗凝治疗有明确的指导原则,但许多人并未得到适当的治疗。经胸超声心动图检查是一种很好的筛查工具,可用于检测周围性栓塞的潜在心脏源,保留经食道超声心动图检查以用于特定适应症。
  • 【使用Amplatz血栓切除术器械对主要和大规模肺栓塞进行机械血栓切除术。】 复制标题 收藏 收藏
    DOI:10.1097/00004424-200106000-00003 复制DOI
    作者列表:Müller-Hülsbeck S,Brossmann J,Jahnke T,Grimm J,Reuter M,Bewig B,Heller M
    BACKGROUND & AIMS: RATIONALE AND OBJECTIVES:To evaluate the feasibility of mechanical thrombectomy with the Amplatz thrombectomy device (ATD) in restoring patency of acutely thrombosed pulmonary arteries resulting from pulmonary embolism for the improvement of patient outcome. METHODS:Mechanical thrombectomy with the ATD (8F) was performed in nine consecutive patients with angiographically documented thrombus in the left or right pulmonary artery resulting from deep vein thrombosis (n = 4) or unknown cause (n = 5). RESULTS:The Miller index decreased from 18 to 11. In all patients, the majority of the thrombus in the pulmonary artery was cleared after a mean activation time of the ATD of 367 seconds. Thrombectomy was performed with the ATD alone (n = 4) or with additional long-term fibrinolysis therapy (n = 5) with infusion of recombinant tissue-type plasminogen activator. Pulmonary arterial pressure decreased from a mean of 57 mm Hg before mechanical thrombectomy to 55 mm Hg directly after the procedure and to 39 mm Hg after termination of the recombinant tissue-type plasminogen activator infusion. CONCLUSIONS:Mechanical thrombectomy with the ATD in patients with minor and major pulmonary embolism is technically feasible and safe. It is a potential alternative to drug-mediated thrombolysis and surgery. However, the incremental benefit of the ATD over conventional treatments could be shown only in a randomized controlled study.
    背景与目标: 理由和目的:评估使用Amplatz血栓切除术装置(ATD)进行机械血栓切除术,以恢复由肺栓塞引起的急性血栓形成的肺动脉通畅以改善患者预后的可行性。
    方法:对9例因深静脉血栓形成(n = 4)或原因不明(n = 5)而在血管造影上记录的左或右肺动脉血栓的患者,进行了ATD(8F)机械血栓切除术。
    结果:米勒指数从18降低至11。在所有患者中,平均ATD激活时间为367秒后,大部分肺动脉血栓被清除。单独使用ATD(n = 4)或进行其他长期纤溶治疗(n = 5),并注入重组组织型纤溶酶原激活剂,即可行血栓切除术。肺动脉压从机械血栓切除术前的平均57 mm Hg降低到手术后的55 mm Hg,而在重组组织型纤溶酶原激活剂输注终止后降低到39 mm Hg。
    结论:对于轻度和重度肺动脉栓塞患者,采用ATD机械血栓切除术在技术上是可行和安全的。它是药物介导的溶栓和手术的潜在替代方法。但是,只有在随机对照研究中才能显示出ATD优于传统疗法的益处。
  • 【评价各种预防中央静脉导管放置过程中的空气栓塞的方法。】 复制标题 收藏 收藏
    DOI:10.1016/s1051-0443(07)61451-1 复制DOI
    作者列表:Wysoki MG,Covey A,Pollak J,Rosenblatt M,Aruny J,Denbow N
    BACKGROUND & AIMS: :This study is designed to evaluate the various physiologic maneuvers (Valsalva, humming, breath-hold) for the potential prevention of air embolism during central venous catheter placement. Central venous pressure measurements were prospectively obtained in 40 patients undergoing central venous catheter placement. The average central venous pressure at baseline was 3.275 mm Hg (range = -4 to 16, SD = 5.99). The average central venous pressure during breath hold was 6.1 mm Hg (range = -6 to 24, SD = 7.99). The average central venous pressure during humming was 5.1 mm Hg (range = -4 to 20, SD = 6.4) The average central venous pressure during the Valsalva maneuver was 18.43 (range = -3 to 48, SD = 14.73). Forty percent of patients (16 of 40) had negative central venous pressures at rest, 25% (10 of 40) had negative pressures during breath hold, 20% (8 of 40) had negative pressures during humming, and 2.5% (1 of 40) had negative pressures during Valsalva maneuver. The average increases in central venous pressure during breath hold, humming, and Valsalva were 2.85, 1.82, and 15.2 mm Hg, respectively. The difference between pressures during Valsalva and other maneuvers was statistically significant (P <.05). The conclusion is that the Valsalva maneuver is superior to breath-hold and humming for increasing central venous pressure during central venous catheter placement and, therefore, it is more likely to prevent air embolism in cooperative patients.
    背景与目标: :这项研究旨在评估各种生理动作(Valsalva,嗡嗡声,屏气),以潜在地防止在中心静脉导管放置过程中发生空气栓塞。前瞻性测量了40名接受中心静脉导管置入的患者的中心静脉压。基线时的平均中心静脉压为3.275毫米汞柱(范围= -4至16,SD = 5.99)。屏气期间的平均中心静脉压为6.1 mm Hg(范围= -6至24,SD = 7.99)。嗡嗡声期间的平均中心静脉压为5.1 mm Hg(范围= -4至20,SD = 6.4)。Valsalva动作期间的平均中心静脉压为18.43(范围= -3至48,SD = 14.73)。 40%的患者(40名患者中有16名)在休息时中心静脉负压,25%(40名患者中的10名)屏气时负压,20%(40名患者中的8名)哼唱时负压,2.5%(1名患者)。 40)在瓦尔萨尔瓦(Valsalva)演习中有负压。屏气,嗡嗡声和Valsalva期间中心静脉压的平均升高分别为2.85、1.82和15.2 mm Hg。瓦尔萨尔瓦(Valsalva)和其他动作之间的压力差异具有统计学意义(P <.05)。结论是,在中央静脉导管置入过程中,Valsalva的操作在增加中央静脉压力方面优于屏气和嗡嗡作响,因此,它更有可能在合作患者中预防空气栓塞。
  • 【下腔静脉滤器的放置可降低正在进行减肥手术的超级病态肥胖患者的肺栓塞风险。】 复制标题 收藏 收藏
    DOI:10.1016/j.soard.2007.03.243 复制DOI
    作者列表:Trigilio-Black CM,Ringley CD,McBride CL,Sorensen VJ,Thompson JS,Longo GM,Pipinos II,Johanning JM
    BACKGROUND & AIMS: BACKGROUND:Pulmonary embolism (PE) is a leading cause of mortality after bariatric surgery. We evaluated inferior vena cava (IVC) filter use for PE risk reduction in high-risk super morbidly obese bariatric surgery patients. METHODS:IVC filters were inserted according to the patient's risk factors, including immobility, previous deep venous thrombosis (DVT)/PE, venous stasis, and pulmonary compromise. All filters were placed concomitant to bariatric surgery and were placed through a right internal jugular vein access site. We analyzed the prospectively collected data from this cohort and evaluated the incidence of PE and complications. RESULTS:Since April 2003, 41 patients (12 men and 29 women) with a mean age of 47.3 +/- 10.0 years and body mass index of 64.2 +/- 12 kg/m2 (range 47-105) underwent IVC filter placement. These and all other patients underwent standard DVT/PE risk reduction measures. All IVC filter patients had one or more significant risk factors for thromboembolic events. No instances of PE were documented, although 1 patient experienced DVT, and no immediate or late complications related to filter placement occurred. One patient, with a body mass index of 105 kg/m2, died secondary to rhabdomyolysis after an extended procedure. The average filter placement time was 34.3 +/- 9 minutes. CONCLUSION:IVC filter placement for PE risk reduction is safe and feasible in the super morbidly obese. Our data have shown that the filters can be placed expeditiously and with minimal morbidity concomitant with bariatric surgery. In this limited series, IVC filter placement was associated with no PE. Additional studies are needed to confirm the efficacy of IVC filter placement for PE risk reduction and related mortality in the super morbidly obese.
    背景与目标: 背景:肺栓塞(PE)是减肥手术后死亡的主要原因。我们评估了下腔静脉滤器(IVC)在高风险,超级病态肥胖减肥手术患者中降低PE风险的使用。
    方法:根据患者的危险因素插入IVC过滤器,包括不动,先前的深静脉血栓形成(DVT)/ PE,静脉淤滞和肺部损害。所有过滤器均与减肥手术同时放置,并通过右颈内静脉进入部位放置。我们分析了该队列的前瞻性收集数据,并评估了PE和并发症的发生率。
    结果:自2003年4月以来,对41例平均年龄为47.3 /-10.0岁,体重指数为64.2 /-12 kg / m2(范围47-105)的患者(12例男性和29例女性)进行了IVC过滤器置入。这些患者和所有其他患者均接受了标准的DVT / PE降低风险措施。所有IVC滤过器患者均具有一个或多个血栓栓塞事件的重要危险因素。尽管有1例患者经历了DVT,但没有记录到PE病例,也没有发生与滤器放置有关的即刻或晚期并发症。一名体重指数为105 kg / m2的患者在延长手术后死于横纹肌溶解症。过滤器的平均放置时间为34.3 /-9分钟。
    结论:在超级病态肥胖者中,IVC过滤器放置可降低PE风险是安全可行的。我们的数据表明,过滤器可以快速放置,并且与肥胖手术相伴的发病率极低。在这个有限的系列中,IVC过滤器的放置与没有PE相关联。需要更多的研究来确认IVC滤器放置对于降低超级病态肥胖患者PE风险和相关死亡率的功效。
  • 【下腔静脉滤器作为肾病综合征患者复发性肺栓塞的预防装置。】 复制标题 收藏 收藏
    DOI:10.1159/000102158 复制DOI
    作者列表:Tsai YC,Hsieh YK,Lee CT
    BACKGROUND & AIMS: OBJECTIVE:This study describes a patient with nephrotic syndrome who experienced recurrent pulmonary emboli as renal disease relapsed frequently. CLINICAL PRESENTATION:A 30-year-old male, who was diagnosed as having nephrotic syndrome at 12, presented with general edema, ascites and hypoalbuminemia. Although the patient responded well to steroid therapy, a common cold frequently caused flare-up of nephrotic syndrome. Histopathological examination of renal tissue revealed minimal disease change. At 17, the patient had a first pulmonary embolism attack with concurrent upper respiratory tract infection. Full-blown manifestations of nephrotic syndrome with low antithrombin III levels were identified at that time. Anticoagulant therapy was administered to treat the pulmonary embolism. Since the first attack, several episodes of pulmonary emboli occurred, which, combined with kidney disease, triggered refractory nephrotic syndrome. The nephrotic syndrome did not remit, and a secondary renal biopsy identified glomerular pathological changes similar to previous biopsy results. To prevent recurrent pulmonary emboli, a Greenfield inferior vena cava filter was implanted in April 2002. No further pulmonary embolism events occurred after interventional filter deployment. CONCLUSION:The results of this study suggest that inferior vena cava filter implantation can be effective for preventing recurrent pulmonary embolism complicating refractory nephrotic syndrome.
    背景与目标: 目的:本研究描述了一名肾病综合症患者,由于肾脏疾病频繁复发而经历了肺栓塞复发。
    临床表现:一名30岁的男性,在12岁时被诊断出患有肾病综合症,表现为全身水肿,腹水和低白蛋白血症。尽管患者对类固醇疗法反应良好,但普通感冒常常引起肾病综合征的发作。肾脏组织的组织病理学检查显示最小的疾病变化。患者在17岁时首次发生肺栓塞发作,并发上呼吸道感染。当时已确定抗凝血酶III水平低的肾病综合征的全面表现。进行抗凝治疗以治疗肺栓塞。自第一次发作以来,发生了数次肺栓塞,并伴有肾脏疾病,引发了难治性肾病综合征。肾病综合征没有缓解,第二次肾脏活检发现肾小球病理改变与先前的活检结果相似。为防止复发性肺栓塞,2002年4月植入了Greenfield下腔静脉滤器。介入滤器部署后,没有发生进一步的肺栓塞事件。
    结论:本研究结果提示下腔静脉滤器植入术可有效预防复发性肺栓塞并发难治性肾病综合征。
  • 【在怀疑有羊水栓塞的情况下,通过旋转血栓弹力测定法诊断为高纤维蛋白溶解。】 复制标题 收藏 收藏
    DOI:10.1016/j.ijoa.2012.09.008 复制DOI
    作者列表:Collins NF,Bloor M,McDonnell NJ
    BACKGROUND & AIMS: :Rotational thromboelastometry is a viscoelastomeric, point-of-care method for testing haemostasis in whole blood which can be visualised rapidly, in real time, in the operating theatre. Advantages over traditional coagulation tests relate to the rapid feedback of results and the ability to visualise hyperfibrinolysis. We present a case of suspected amniotic fluid embolism that presented with sudden respiratory arrest associated with haemodynamic compromise during a non-elective caesarean delivery. Soon after the collapse, coagulopathy developed. Rotational thromboelastometry showed hyperfibrinolysis and hypofibrinogenaemia, which allowed targeted coagulation factor replacement therapy and the use of tranexamic acid. Hyperfibrinolysis may be a contributor to the coagulopathy associated with amniotic fluid embolism but has been infrequently reported, perhaps due to limited diagnosis with traditional coagulation tests. Treatment of the coagulopathy associated with a suspected amniotic fluid embolism with antifibrinolytic agents may deserve greater consideration.
    背景与目标: :比例血栓弹力测定法是一种粘弹性体的即时检验方法,用于测试全血中的止血效果,可以在手术室中快速实时地进行可视化。相对于传统凝血测试的优势在于结果的快速反馈和可视化超纤维蛋白溶解的能力。我们提出了一例疑似羊水栓塞的病例,该病例在非选择性剖宫产过程中出现突然的呼吸暂停,并伴有血流动力学的损害。崩溃后不久,凝血病就发展了。旋转血栓弹力测定显示高纤蛋白溶解和低纤维蛋白原性贫血,可进行靶向凝血因子替代治疗和使用氨甲环酸。高纤蛋白溶解可能是与羊水栓塞相关的凝血病的病因,但鲜有报道,这可能是由于传统凝血试验的诊断有限所致。与抗纤溶剂一起治疗怀疑与羊水栓塞有关的凝血病可能值得更多考虑。
  • 【D-二聚体和C反应蛋白是诊断脑栓塞患者Trousseau综合征的潜在生物标志物。】 复制标题 收藏 收藏
    DOI:10.1016/j.jstrokecerebrovasdis.2019.104534 复制DOI
    作者列表:Tsushima M,Metoki N,Hagii J,Saito S,Shiroto H,Yasujima M,Kato T,Kudo N,Toyama Y,Yokono Y,Nozaka M,Kawamura Y,Nakata M,Tomita H
    BACKGROUND & AIMS: BACKGROUND:Differentiating stroke due to Trousseau's syndrome from other types of cerebral embolism is challenging, especially in patients with occult cancer. The current study aimed to determine predicting factors and biomarkers of stroke due to Trousseau's syndrome. METHODS:This retrospective study comprised 496 consecutive patients with acute cerebral embolism, including 19, 85, 310, and, 82 patients with stroke due to Trousseau's syndrome, artery-to-artery embolism, cardioembolic stroke, and embolic stroke with undetermined source, respectively. All patients were evaluated within 72 hours of onset. The clinical characteristics, laboratory findings, and patterns on diffusion-weighted magnetic resonance imaging (DWI) were compared among the groups. RESULTS:Plasma D-dimer and C-reactive protein (CRP) levels were significantly higher in the Trousseau's syndrome than in the other causes of cerebral embolism. Multivariate analyses demonstrated that female sex, multiple lesions on DWI, high D-dimer and CRP levels, and low platelet and low brain natriuretic peptide levels were independent predictors that could distinguish Trousseau's syndrome from the other causes of cerebral embolism. The cutoff values of D-dimer and CRP to identify stroke due to Trousseau's syndrome was 2.68 µg/mL fibrinogen equivalent units and .29 mg/dL, respectively. CONCLUSIONS:The elevated D-dimer and CRP levels on admission in addition to specific clinical features may be useful for diagnosis of Trousseau's syndrome in patients with cerebral embolism.
    背景与目标: 背景:特鲁索综合症引起的中风与其他类型的脑栓塞的区别是具有挑战性的,特别是在隐匿性癌症患者中。当前的研究旨在确定特鲁索综合症所致中风的预测因素和生物标志物。
    方法:这项回顾性研究包括496例连续的急性脑栓塞患者,包括19例,85例,310例和82例因Trousseau综合征而患中风,动脉-动脉栓塞,心栓性中风和栓塞性中风的来源不明。 。所有患者在发病72小时内进行了评估。比较各组的临床特征,实验室检查结果和弥散加权磁共振成像(DWI)的模式。
    结果:Trousseau综合征的血浆D-二聚体和C反应蛋白(CRP)水平显着高于其他原因的脑栓塞。多变量分析表明,女性,DWI的多个病变,D-二聚体和CRP含量高,血小板和脑钠肽含量低是独立的预测因素,可以将Trousseau综合征与其他脑栓塞原因区分开。 D-二聚体和CRP识别Trousseau综合征所致中风的临界值分别为2.68 µg / mL纤维蛋白原当量单位和0.29 mg / dL。
    结论:入院时D-二聚体和CRP水平升高,除了具有特定的临床特征外,可能有助于诊断脑栓塞患者的特鲁索综合症。
  • 【冠状动脉搭桥手术中的单主动脉钳夹术可减少脑栓塞并改善神经认知结果。】 复制标题 收藏 收藏
    DOI:10.1177/1358863X13502699 复制DOI
    作者列表:Gasparovic H,Borojevic M,Malojcic B,Gasparovic K,Biocina B
    BACKGROUND & AIMS: :Aortic manipulation releases embolic material, thereby enhancing the probability of adverse neurologic outcomes following coronary artery bypass grafting (CABG). We prospectively evaluated 59 patients undergoing CABG. Patients in the single (SC, n = 37) and multiple clamp (MC, n = 22) groups were comparable in relation to age and operative risk (p > 0.05). Neurocognitive evaluation consisted of the Auditory Verbal Learning Test (AVLT), Color Trails Test A, the Grooved Pegboard test and the Mini-Mental State Examination. Data acquisition was performed preoperatively, early postoperatively and at the 4-month follow-up. Intraoperative transcranial Doppler (TCD) monitoring was used to quantify the embolic load in relation to different aortic clamping strategies. Preoperative neurocognitive results were similar between the groups (p > 0.05). The incidence of postoperative delirium was greater in the MC group but this failed to reach statistical significance (23% vs 8%, p = 0.14). SC patients had fewer embolization signals (270 ± 181 vs 465 ± 160, p < 0.0001). Early postoperative neurocognitive results were depressed in comparison to preoperative values in both groups (p < 0.05 for multiple comparisons). The magnitude of this cognitive depression was greater in the MC group (p < 0.05 for multiple comparisons). Preoperative levels of neurocognition were restored at follow-up in the SC group in all tests except the AVLT. A trend towards improvements in neurocognitive performances at follow-up was also observed in the MC group. Residual attention, motor skill and memory deficits were, however, documented with multiple tests. In conclusion, the embolic burden was significantly lower in the SC group. This TCD imaging outcome translated into fewer early cognition deficits and superior late restoration of function.
    背景与目标: :主动脉操作释放栓塞物质,从而增加冠状动脉搭桥术(CABG)后发生不良神经系统预后的可能性。我们前瞻性评估了59名接受CABG的患者。单组(SC,n = 37)和多钳位(MC,n = 22)组的患者在年龄和手术风险方面具有可比性(p> 0.05)。神经认知评估包括听觉言语学习测验(AVLT),色迹测验A,沟槽式钉板测验和迷你精神状态测验。术前,术后早期以及术后4个月进行数据采集。术中经颅多普勒(TCD)监测用于量化与不同主动脉钳夹策略相关的栓塞负荷。两组之间的术前神经认知结果相似(p> 0.05)。 MC组术后ir妄的发生率较高,但未达到统计学显着性(23%vs 8%,p = 0.14)。 SC患者的栓塞信号较少(270±181 vs 465±160,p <0.0001)。与两组的术前值相比,术后早期的神经认知结果均较低(多重比较,p <0.05)。在MC组中,这种认知抑郁的程度更大(多次比较,p <0.05)。在SC组中,除AVLT以外的所有测试中,术前神经认知水平均得到恢复。 MC组也观察到随访时神经认知能力有改善的趋势。残留的注意力,运动技能和记忆力不足则通过多次测试得到记录。总之,SC组的栓塞负担明显降低。该TCD成像结果可减少较少的早期认知缺陷和晚期功能恢复。
  • 【低危性肺栓塞慢性阻塞性肺疾病患者的红细胞增多症与院内死亡率之间的关系。】 复制标题 收藏 收藏
    DOI:10.21037/jtd.2016.11.31 复制DOI
    作者列表:Guo L,Chughtai AR,Jiang H,Gao L,Yang Y,Yang Y,Liu Y,Xie Z,Li W
    BACKGROUND & AIMS: BACKGROUNDS:Pulmonary embolism (PE) is frequent in subjects with chronic obstructive pulmonary disease (COPD) and associated with high mortality. This multi-center retrospective study was performed to investigate if secondary polycythemia is associated with in-hospital mortality in COPD patients with low-risk PE. METHODS:We identified COPD patients with proven PE between October, 2005 and October, 2015. Patients in risk classes III-V on the basis of the PESI score were excluded. We extracted demographic, clinical and laboratory information at the time of admission from medical records. All subjects were followed until hospital discharge to identify all-cause mortality. RESULTS:We enrolled 629 consecutive patients with COPD and PE at low risk: 132 of them (21.0%) with and 497 (79.0%) without secondary polycythemia. Compared with those without polycythemia, the polycythemia group had significantly lower forced expiratory volume in one second (FEV1) level (0.9±0.3 vs. 1.4±0.5, P=0.000), lower PaO2 and SpO2 as well as higher PaCO2 (P=0.03, P=0.03 and P=0.000, respectively). COPD patients with polycythemia had a higher proportion of arrhythmia in electrocardiogram (ECG) (49.5% vs. 35.7%, P=0.02), a longer hospital duration time (15.3±10.1 vs. 9.7±9.1, P=0.001), a higher mechanical ventilation rate (noninvasive and invasive, 51.7% vs. 30.3%, P=0.04 and 31.0% vs. 7.9%, P=0.04, respectively), and a higher in-hospital mortality (12.1% vs. 6.6%, P=0.04). Multivariate logistic regression analysis revealed that polycythemia was associated with mortality in COPD patients with low-risk PE (adjusted OR 1.11; 95% CI, 1.04-1.66). CONCLUSIONS:Polycythemia is an independent risk factor for all-cause in-hospital mortality in COPD patients with PE at low risk.
    背景与目标: 背景:肺栓塞(PE)在患有慢性阻塞性肺疾病(COPD)的受试者中很常见,并伴有较高的死亡率。这项多中心回顾性研究旨在调查低危PE的COPD患者继发性红细胞增多症是否与院内死亡率相关。
    方法:我们在2005年10月至2015年10月之间确定了COPD确诊为PEPD的患者。根据PESI评分将风险级别为III-V的患者排除在外。我们在入院时从病历中提取了人口统计学,临床和实验室信息。随访所有受试者直至出院以确定全因死亡率。
    结果:我们纳入了629例低危的COPD和PE患者,其中132例(21.0%)有继发性红细胞增多症,497例(79.0%)无继发性红细胞增多症。与没有红细胞增多症的人相比,红细胞增多症组的一秒钟强迫呼气量(FEV1)水平显着降低(0.9±0.3对1.4±0.5,P = 0.000),PaO2和SpO2降低,PaCO2升高(P = 0.03 ,分别为P = 0.03和P = 0.000)。 COPD合并红细胞增多症的患者在心电图(ECG)中的心律失常比例更高(49.5%vs. 35.7%,P = 0.02),住院时间更长(15.3±10.1 vs. 9.7±9.1,P = 0.001),更高机械通气率(无创和有创,分别为51.7%和30.3%,P = 0.04和31.0%vs. 7.9%,P = 0.04),以及更高的院内死亡率(12.1%vs. 6.6%,P = 0.04)。多元logistic回归分析显示,低危PE的COPD患者的红细胞增多症与死亡率相关(校正OR 1.11; 95%CI 1.04-1.66)。
    结论:红细胞增多症是低危PE患者COPD全院住院死亡率的独立危险因素。
  • 【医师对患者微笑的理解在急性肺栓塞的预测概率评估中的作用。】 复制标题 收藏 收藏
    DOI:10.1136/emermed-2016-205874 复制DOI
    作者列表:Kline JA,Neumann D,Hall CL,Capito J
    BACKGROUND & AIMS: BACKGROUND:Many clinicians use a global visual interpretation of patient appearance to decide if a patient looks sick or not. For patients with suspected acute pulmonary embolism (PE), we tested the relationship between visual appearance of a happy patient facial affect and probability of PE+ on CT pulmonary angiography (CTPA). METHODS:Eligible patients were selected by usual care to undergo CTPA, the criterion standard for PE+ or PE-. Prior to CTPA result, trained study personnel obtained physician pretest probability using the gestalt method (visual analogue scale, 0%-100%), the Wells score (0-12) and physicians' impression of whether the patient smiled during the initial examination (smile+). Patients' faces were also video recorded and analysed with an automated neural network-based algorithm (Noldus FaceReader) for happy affect. RESULTS:Of the 208 patients enrolled, 27 were PE+ and smile+ was more frequent in patients with PE+ than PE-, a finding confirmed by the Noldus. The diagnostic sensitivity and specificity of smile was low, and physicians overestimated presence of an alternative diagnosis more likely to PE with smile+ than smile- patients in patients with true PE. As a result, the area under the receiver operating characteristic curve (AUROC) was lower for the Wells score in smile+ patients. However, the physicians' mean gestalt estimate of PE did not differ with smile status, nor did smile status affect the AUROC for gestalt. CONCLUSIONS:In patients with suspected PE, physician recollection of patients' smile+ was more common in PE+ patients, and was associated with a less accurate Wells score, primarily because physicians overestimated probability of alternative diagnosis. However, the overall diagnostic accuracy of physicians' gestalt did not differ with perceived smile status. These data suggest that the patients' smile had less effect on the numeric gestalt pretest probability assessment than on the binary decision about an alternative diagnosis.
    背景与目标: 背景:许多临床医生使用患者外观的整体视觉解释来确定患者是否生病。对于疑似急性肺栓塞(PE)的患者,我们测试了患者面部表情愉悦的视觉外观与CT肺血管造影(CTPA)上PE的可能性之间的关系。
    方法:通过常规护理选择符合条件的患者接受CTPA,即PE或PE-的标准标准。在获得CTPA结果之前,训练有素的研究人员使用格式塔方法(视觉模拟量表,0%-100%),Wells评分(0-12)和医生对患者在初次检查时是否微笑的印象来获得医师的预测概率(微笑 )。还对患者的面部进行了视频记录,并使用基于自动神经网络的算法(Noldus FaceReader)进行了分析,以取得快乐的效果。
    结果:在208名患者中,有27名是PE,PE患者的笑容比PE-高,Noldus证实了这一发现。微笑的诊断敏感性和特异性较低,并且医生高估了真正的PE患者比微笑患者更容易出现微笑的PE的替代诊断。结果,微笑患者的Wells评分接收器工作特征曲线(AUROC)下的面积较低。然而,医生对PE的平均格式塔估计值与微笑状态没有差异,微笑状态也不会影响AUROC的格式塔。
    结论:在怀疑患有PE的患者中,医师对患者微笑的回忆在PE患者中更为常见,并且与Wells评分的准确性较低有关,这主要是因为医师高估了替代诊断的可能性。但是,医生的格式塔的总体诊断准确性与所感知的微笑状态没有差异。这些数据表明,患者的微笑对数字格式塔预测试概率评估的影响小于对替代诊断的二元决策的影响。
  • 【田间生长的月桂属植物的木材薄壁组织中淀粉到糖的转化:栓塞修复信号通路的组成部分吗?】 复制标题 收藏 收藏
    DOI:10.1071/FP09103 复制DOI
    作者列表:Salleo S,Trifilò P,Esposito S,Nardini A,Lo Gullo MA
    BACKGROUND & AIMS: :The ability of stems of Laurus nobilis (L.) to refill embolised xylem conduits was studied in plants both at optimal water supply (W) and under conditions of soil drought inducing xylem pressures (Px) of -1.54 (S1) and -2.35 MPa (S2). Starch depolymerisation in wood parenchyma was measured as percentage of cells 'with high starch content' (HSC-cells) counted under a microscope. HSC-cells decreased during embolism and increased again in refilled stems. A direct relationship was found between percentage of HSC-cells and Px, with HSC-cells between 65 and 75% of the total at Px ≥ -0.6 MPa, at which recovery from PLC was recorded. At low transpiration, starch re-appeared in wood parenchyma cells but only in plants that showed diurnal stomatal opening (W- and S1-plants). In S2-plants showing diurnal stomatal closure and nocturnal opening with Px between -1.2 to -2.4 MPa, HSC-cells were only 25% and plants did not recover from PLC. This finding suggests that (i) the Px threshold for embolism repair was ≥ -0.6 MPa, and (ii) impeded phloem loading limits starch content in wood parenchyma and embolism repair. We conclude that starch depolymerisation acts as a signal to phloem unloading sugars to embolised conduits thus generating the necessary osmotic gradients driving refilling.
    背景与目标: :在最佳供水(W)以及土壤干旱导致木质部压力(Px)为-1.54(S1)和-2.35的条件下,研究了月桂(L.)茎在重新栓塞木质部导管时的能力。 MPa(S2)。木材薄壁组织中的淀粉解聚以显微镜下计数的“具有高淀粉含量”的细胞(HSC细胞)的百分比进行测量。 HSC细胞在栓塞过程中减少,并在重新填充的茎中再次增加。发现HSC细胞的百分比与Px之间存在直接关系,在Px≥≥-0.6MPa时,HSC细胞占总数的65%至75%,并记录了从PLC恢复的情况。在低蒸腾作用下,淀粉重新出现在木实质细胞中,但仅在表现出昼夜气孔开口的植物(W和S1植物)中重新出现。在表现出昼夜气孔关闭和夜间开放且Px在-1.2至-2.4 MPa之间的S2植物中,HSC细胞仅占25%,植物没有从PLC恢复。这一发现表明:(i)栓塞修复的Px阈值≥≥-0.6MPa,(ii)韧皮部负荷受限限制了木材薄壁组织和栓塞修复中的淀粉含量。我们得出的结论是,淀粉解聚反应是韧皮部将糖卸载到栓塞导管中的信号,从而产生了驱动充填的必要渗透梯度。
  • 【老年人肺栓塞的30天病死率。】 复制标题 收藏 收藏
    DOI: 复制DOI
    作者列表:Siddique RM,Siddique MI,Connors AF Jr,Rimm AA
    BACKGROUND & AIMS: BACKGROUND:Short-term race- and sex-specific case- fatality rates for pulmonary embolism (PE) in the elderly have not been studied previously, to our knowledge.

    OBJECTIVES:To examine 30-day race- and sex-specific case-fatality rates of PE in the Medicare population and to determine the risk of fatality when PE was a secondary diagnosis in 6 primary concurrent conditions and 3 surgical procedures.

    METHODS:Case-fatality rates were determined using the Medicare Provider Analysis and Review Record tiles from 1984 through 1991. All Medicare Part A beneficiaries aged 65 years or older were included, yielding more than 400,000 patients with PE. Case-fatality rates 30 days from hospital admission were calculated for both a primary discharge diagnosis of PE and a secondary discharge diagnosis of PE.

    RESULTS:Blacks with PE as a primary discharge diagnosis had an overall age-adjusted case-fatality rate of 16.1% compared with a rate of 12.9% for whites. When PE was a secondary diagnosis, blacks also had higher rates than whites (34.7% vs 30.2%). Men had a fatality rate of 13.7% whereas women had a rate of 12.8% when PE was the primary diagnosis. For a secondary diagnosis of PE, men had a rate of 32.8% compared with a rate of 28.6% for women. The risk of fatality was very high when PE was a secondary discharge diagnosis in 6 primary concurrent conditions (congestive heart failure, cancer, chronic obstructive pulmonary disease, myocardial infarction, hip fracture, and stroke) and 3 common surgical procedures (coronary artery bypass graft, hip replacement, and knee replacement) relative to the case-fatality rate when PE was not present in these conditions.

    CONCLUSIONS:Our results indicate that there are racial and gender differences in 30-day case-fatality rates for PE in elderly patients. The high fatality risk associated with PE as a comorbid factor among common primary concurrent conditions and procedures calls attention to the need for more effective prophylaxis of deep vein thrombosis and rapid diagnosis and treatment of PE when it occurs.

    背景与目标: 背景:据我们所知,以前尚未研究老年人的短期种族和性别特定病例的肺栓塞(PE)死亡率。

    目的:研究在6种主要并发疾病和3种手术方法中对PE进行二次诊断时,在Medicare人群中PE的30天种族和性别特定病死率,并确定死亡风险。

    方法:使用1984年至1991年的Medicare Provider Analysis and Review Record磁贴确定了病死率。其中包括所有65岁或65岁以上的Medicare A部分受益人。超过40万名PE患者。计算住院后30天的PE初次出院诊断和PE初次出院诊断的病死率。

    结果:以PE作为初次出院诊断的黑人年龄调整后的总病死率为16.1%,而白人为12.9%。当PE是继发诊断时,黑人的患病率也高于白人(34.7%对30.2%)。当以PE为主要诊断手段时,男性的死亡率为13.7%,而女性的死亡率为12.8%。对于PE的继发诊断,男性的比率为32.8%,而女性的比率为28.6%。当PE在6种主要的并发情况(充血性心力衰竭,癌症,慢性阻塞性肺疾病,心肌梗塞,髋部骨折和中风)和3种常见外科手术方法(冠状动脉搭桥术)中进行二次出院诊断时,死亡的风险非常高,髋关节置换术和膝关节置换术)相对于在这种情况下不存在PE时的病死率。

    结论:我们的结果表明,老年患者PE的30天病死率。在常见的主要并发疾病和手术过程中,与PE作为合并症的高致死风险一起引起人们的注意,即需要更有效地预防深静脉血栓形成,并在发生PE时迅速进行诊断和治疗。

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