急性肺血栓栓塞兔血管活性物质的变化及其意义

肺血栓栓塞症是来自静脉系统或右心的血栓阻塞肺动脉或其分支所致的疾病，以肺循环和呼吸功能障碍为其主要病理生理和临床特征。以往认为，肺血栓栓塞症引起的肺循环障碍是肺栓塞发病的主要机制。近年来的研究认识到急性肺栓塞的血流动力学影响除与栓子的机械性阻塞有关外，栓塞后炎性介质的释放等因素对栓塞后的血流动力学及呼吸功能障碍亦有着重要作用。本研究旨在观察急性肺血栓栓塞兔血前列环素I2（PGI2）、前列腺素E2（PGE2）、NO、血小板活化因子（PAF）等炎性介质的改变及意义。     

肺栓塞的诊治

肺栓塞（pulmonary embolism，PE）是以各种栓子阻塞肺动脉系统为其发病原因的一组疾病或临床综合征的总称，包括肺血栓栓塞症（VIE）、脂肪栓塞综合征、羊水栓塞、空气栓塞等。VIE为来自静脉系统或右心的血栓阻塞肺动脉或其分支所致疾病，以肺循环和呼吸功能障碍为其主要临床和病理生理特征。PIE为PE的最常见类型，占PE中的绝大多数，通常所称PE即指VIE。肺动脉发生栓塞后，若其支配区的肺组织因血流受阻或中断而发生坏死，称为肺梗死（PI）。引起VIE的血栓主要来源于深静脉血栓形成（DVT）。PTE常为DVT的并发症。FIE与DVT共属于静脉血栓栓塞症（VTE），为VTE的二种类别。     

肺血栓栓塞症患者高敏C反应蛋白水平与肺动脉压相关性的研究

目的探讨急、慢性肺血栓栓塞症患者血清高敏C反应蛋白（high-sensitive C-reactive protein,hs-CRP）的差异及其与肺动脉压之间的相关性。方法选择肺血栓栓塞症患者102例,其中急性44例,慢性58例。所有患者均经多普勒超声心动图检查,将两组患者各自分为肺动脉压正常组与高压组,采用颗粒增强免疫透射比浊法检测hs-CRP水平。结果急性组hs-CRP（24.0±13.4 mg/L）明显高于慢性组（5.2±4.6 mg/L）（P〈0.01）。急性患者中肺动脉压正常组与高压组hs-CRP无明显差异（P=0.338）。慢性患者肺动脉压正常组hs-CRP（3.3±3.0）明显低于高压组（9.5±4.7 mg/L）（P〈0.05）。慢性肺血栓栓塞症肺动脉高压组患者hs-CRP水平和肺动脉压呈正相关（P〈0.05）。结论急性肺血栓栓塞症患者血清hs-CRP水平明显升高,慢性肺血栓栓塞症肺动脉高压组患者血清hs-CRP水平和肺动脉压显著相关。血清hs-CRP水平可用于PTE的危险分层及判断预后。     

急性肺血栓栓塞症的误诊分析

急性肺血栓栓塞症的误诊分析浙江省绍兴市人民医院谢培怡急性肺血栓栓塞症（ＡｃｕｔｅＰｕｌｍｏｎａｒｖＴｈｒｏｍｂｏｅｍｂｏｌｉｓｍ，ＡＰＴＥ）是肺血流循环的急性障碍，由于发病急骤，表现多样又缺乏特异性，容易造成误诊或漏诊。现报告笔者遇到的２例并复习近年...     

老年慢性阻塞性肺疾病合并肺血栓栓塞症诊治进展

肺血栓栓塞症（PTE）是老年慢性阻塞性肺疾病（COPD）患者的重要并发症,发病率、病死率和复发率均较高。COPD和PTE临床表现均缺乏特异性并相互重叠,易导致延迟诊断或漏诊。因此,提高诊断意识在临床上非常重要。对老年COPD合并PTE患者选择溶栓或抗凝时应充分考虑老年人的病理生理特点以及其他合并症的影响,慎重权衡病情轻重与出血风险。     

肺血栓栓塞症的临床诊断进展

肺血栓栓塞症（pulmonary thromboembolism，VIE）为来自静脉系统或右心的血栓阻塞肺动脉或其分支所致疾病，以肺循环和呼吸功能障碍为其主要临床和病理生理特征。VIE为肺栓塞（pulmonary embolism，PE）的最常见类型，占PE中的绝大多数，通常所称PE即VIE。肺动脉发生栓塞后，若其支配区的肺组织因血流受阻或中断而发生坏死，称为肺梗死（pulmonary infarction，PI）。     

慢性阻塞性肺疾病合并肺血栓栓塞症2例并文献复习

目的 提高临床医生对慢性阻塞性肺疾病（COPD）合并肺血栓栓塞症（PTE）的认识。方法 分析2例COPD合并PTE的临床特点，并复习相关文献。结果 2例COPD合并PTE患者临床表现以呼吸困难为突出表现，咳嗽、咳痰较轻，肺部缺乏啰音。动脉血气分析均有低氧血症，二氧化碳分压正常，其中1例二氧化碳分压较前下降。2例均经CT肺动脉造影确诊PTE。结论 缺乏感染征象、呼吸困难突出、二氧化碳分压较前降低是诊断COPD合并PTE的重要线索，CT肺动脉造影是确诊的重要技术之一。     

肺血栓栓塞症的诊疗现状及展望

肺血栓栓塞症具有高发病率、高误诊率和高病死率。其栓子主要来源于下肢深静脉血栓，其和下肢深静脉血栓是一个疾病的两个阶段。该病各种临床表现多与缺氧及肺动脉高压导致的血流动力学不稳定密切相关。常用的无创诊断手段包括心电图、胸部X线、D二聚体定量、血气分析、心脏超声、CTPA、MRA及核素肺通气灌注扫描等。有创检查主要是肺血管造影。CTPA在肺动脉主干、叶、段水平的肺栓塞诊断敏感性为96％，特异性为92％，已经逐步被认为是取代肺血管造影的无创检查之首选。肺血栓栓塞症的主要治疗包括病因干预、抗栓治疗及并发症对症支持等治疗。对急性大面积血栓患者，溶栓治疗疗效优于单纯抗凝。抗凝治疗是肺血栓栓塞症的基础治疗，常用药物有普通肝素、低分子肝素和华法林。普通肝素治疗强调早达标和稳定达标，在治疗急性大面积血栓中疗效优于低分子肝素，后者在治疗急性非大面积血栓中疗效等于甚至优于普通肝素。华法林半衰期长，起效慢，用于预防慢性血栓形成，使用疗程至少3个月。影响肺血栓栓塞症的预后因素为急性右心衰和慢性肺动脉高压。急性肺血栓栓塞症患者未能及时诊治、病程慢性迁延、溶栓治疗无效、多发的反复的亚型肺小血栓导致压力升高等因素均容易导致慢性血栓栓塞性肺动脉高压的发展。降低肺动脉高压的药物可能有助于改善预后。     

慢性肺血栓栓塞症与慢性血栓栓塞性肺动脉高压

慢性肺血栓栓塞症（简称慢性肺栓塞）与慢性血栓栓塞性肺动脉高压（CTEPH）被认为是急性肺栓塞的远期并 发症。近年来，随着对慢性血栓认识的深入以及介入、手术等治疗技术的发展，慢性肺栓塞和CTEPH患者的诊治进 展迅速，患者预后显著改善。但另一方面，慢性肺栓塞和CTEPH的诊治相对复杂，而国内医师对其认识相对不足，临 床不规范诊治的情况并不少见。文章重点阐述慢性肺栓塞和CTEPH的基本概念及诊治思路。     

慢性阻塞性肺疾病血栓前状态与静脉血栓形成

慢性阻塞性肺疾病(COPD)是一种常见的呼吸系统疾病.COPD患者尤其是急性发作期发生静脉血栓栓塞症(VTE)越来越受到重视.有关COPD急性加重合并VTE的发病机制、诊断方法以及血栓前状态的研究是如今的热点.COPD患者存在血栓前状态已成为公认的事实,然而目前尚没有统一的肺血栓栓塞症相关的诊断指标,很难给临床的治疗提供依据.通过检索与此相关的文献,针对COPD急性加重合并VTE的发病机制,诊断以及抗凝治疗进行综述,为今后的研究和诊疗工作提供信息.     

MUTATION FREQUENCY IN NURSES AND PHARMACISTS WORKING WITH CYTOTOXIC DRUGS

Individuals occupationally exposed to cytotoxic drugs may be at risk owing to the effects of these agents on DNA. As an index of DNA damage, in vivo mutations were measured in lymphocytes from 24 oncology nurses or pharmacists and 24 matched controls. Mutation frequency was significantly increased in exposed individuals and appeared to be related to duration of exposure. However, the overall magnitude of the increase was small and its biological significance remains to be determined.     

A single injection of adrenergic agonists enhances pineal melatonin production in Turkish hamsters

Abstract: The purpose of this study was to determine whether the pineal gland of Turkish hamsters (Mesocricetus brandti) responds to adrenergic agonists with an increase in melatonin production, and, if it does, whether the sensitivity of the pineal gland to agonists would differ throughout the dark phase. Adult Turkish hamsters weighing 110–210 g received a subcutaneous injection of isoproterenol (ISO, 1 mg/kg B.W.) or norepinephrine (NE, 1 mg/kg B.W.) at different times of night. Animals exposed to LD 16:8 responded to ISO or NE with increased pineal melatonin content only when injected at dawn, when endogenous melatonin is at basal or near-basal levels. When the 8 hr scotophase was entirely replaced with light, the responsiveness to ISO injections at dawn disappeared. In animals exposed to light from 30 min prior to injection to the time of sacrifice, ISO injections increased pineal melatonin content (P < 0.005, three-way ANOVA), which varied, depending on the specific time of injection (effect of time of night, P < 0.05, three-way ANOVA). These results demonstrate that (1) adrenergic agonists enhance the production of pineal melatonin in Turkish hamsters, (2) this stimulatory effect takes place late, but not early in the 8 hr scotophase, and (3) the adrenergic induction of pineal melatonin production in Turkish hamsters requires priming by darkness during the appropriate circadian phase.     

Immune effector mechanisms in malaria: An update focusing on human immunity

The past decade has witnessed dramatic decreases in malaria‐associated mortality and morbidity around the world. This progress has largely been due to intensified malaria control measures, implementation of rapid diagnostics and establishing a network to anticipate and mitigate antimalarial drug resistance. However, the ultimate tool for malaria prevention is the development and implementation of an effective vaccine. To date, malaria vaccine efforts have focused on determining which of the thousands of antigens expressed by Plasmodium falciparum are instrumental targets of protective immunity. The antigenic variation and antigenic polymorphisms arising in parasite genes under immune selection present a daunting challenge for target antigen selection and prioritization, and is a given caveat when interpreting immune recall responses or results from monovalent vaccine trials. Other immune evasion strategies executed by the parasite highlight the myriad of ways in which it can become a recurrent infection. This review provides an update on immune effector mechanisms in malaria and focuses on our improved ability to interrogate the complexity of human immune system, accelerated by recent methodological advances. Appreciating how the human immune landscape influences the effectiveness and longevity of antimalarial immunity will help explain which conditions are necessary for immune effector mechanisms to prevail.     

Secondary aortoduodenal fistula

Aorto-duodenal fistulae （ADF） are the most frequent aorto-enteric fistulae （80%）, presenting with upper gastrointestinal bleeding. We report the first case of a man with a secondary aorto-duodenal fistula presenting with a history of persistent occlusive syndrome. A 59-year old man who underwent an aortic-bi-femoral bypass 5 years ago, presented with dyspepsia and biliary vomiting. Computed tomography scan showed in the third duodenal segment the presence of inflammatory tissue with air bubbles between the duodenum and prosthesis, adherent to the duodenum. The patient was submitted to surgery, during which the prosthesis was detached from the duodenum, the intestine failed to close and a gastro-jejunal anastomosis was performed. The post-operative course was simple, secondary ADF was a complication （0.3%-2%） of aortic surgery. Mechanical erosion of the prosthetic material into the bowel was due to the lack of interposed retroperitoneal tissue or the excessive pulsation of redundantly placed grafts or septic procedures. The third or fourth duodenal segment was most frequently involved. Diagnosis of ADF was difficult. Surgical treatment is always recommended by explorative laparotomy. ADF must be suspected whenever a patient with aortic prosthesis has digestive bleeding or unexplained obstructive syndrome. Rarely the clinical picture of ADF is subtle presenting as an obstructive syndrome and in these cases the principal goal is to effectively relieve the mechanical bowel obstruction.     

Married to M. tuberculosis: risk of infection and disease in spouses of smear-positive tuberculosis patients

Objectives To quantify the risk of infection and disease in spouses of tuberculosis patients and the extent to which intervention could reduce the risk in this highly exposed group. Methods We compared HIV prevalence, TB prevalence and incidence and tuberculin skin test (TST) results in spouses of TB patients and community controls. HIV‐positive spouses were offered isoniazid preventive therapy (IPT), and TST was repeated at 6, 12 and 24 months. Results We recruited 148 spouses of smear‐positive patients ascertained prospectively and 3% had active TB. We identified 203 spouses of previously diagnosed smear‐positive patients, 11 had already had TB, and the rate of TB was 2.4 per 100 person years(py) over 2 years (95% CI 1.15–5.09). 116 were found alive and recruited. HIV prevalence was 37% and 39% in the prospective and retrospective spouse groups and 17% in controls. TST was ≥10 mm in 80% of HIV negative and in 57% of HIV‐positive spouses ascertained retrospectively; 74% HIV negative and 62% HIV‐positive spouses ascertained prospectively, and 48% HIV negative and 26% HIV‐positive community controls. Of 54 HIV‐positive spouses, 18 completed 6‐month IPT. At 2 year follow‐up, 87% of surviving spouses had TST ≥10 mm and the rate of TB was 1.1 per 100 py (95% CI 0.34–3.29). Conclusions Spouses are a high‐risk group who should be screened for HIV and active TB. TST prevalence was already high by the time the spouses were approached but further infections were seen to occur. Uptake and adherence to IPT was disappointing, lessening the impact of short‐duration therapy.     

Dénervation rénale pour HTA réfractaire sans anesthésie générale : intérêt d’un protocole MEOPA Morphine. Expérience préliminaire

Renal denervation using the technique of radiofrequency is used only recently for the treatment of resistant hypertension. Normally, it is done under general anesthesia because the ablation point technique is painful. We suggest an alternative to general anesthesia comprising an association of morphin 0.1 mg/kg IV to MEOPA (gas combining oxygen and azot protoxyd) delivered through an oxygen mask. Our series includes 12 consecutive patients treated between October 2011 and June 2013, the first five patients (group 1) have received only an hydroxizin and morphin sedation. Every five have felt the ablation painful, in two cases bearable pain (EVA < 5), in three cases intense (EVA > 5) pain leading to increasing doses of morphin, (total dose of 0.25 mg/kg in two cases, 0.17 mg in one case). For the seven following patients, a protocol including hydroxyzin, morphin and MEOPA given through a mask has been set up. Only one patient has felt a mild pain (EVA 5) leading to an increasing dose of morphin (total dose 0.17 mg/kg). None of the six other patients has felt any pain during the procedure. The average dose of morphin is 0.17 mg/kg in group 1, 0.11 mg/kg in group 2. This is a preliminary study; if confirmed, it will allow a lot of hospitals without on-site possibilities of general anesthesia, to realize such procedures. Conclusion: regarding pain, the procedure of renal ablation was well tolerated for six among seven patients receiving the association MEOPA and IV morphin. In contrast, in the five patients treated only with IV morphin, we observed a less good tolerance to pain and the need to increase the doses of IV morphin.     

Scale‐up of TB and HIV programme collaborative activities in Zambia – a 10‐year review

Objective To review the activities, progress, achievements and challenges of the Zambia Ministry of Health tuberculosis (TB)/HIV collaborative activities over the past decade. Methods Analysis of Zambia Ministry of Health National TB and HIV programme documents and external independent programme review reports pertaining to 2000–2010. Results The number of people testing for HIV increased from 37 557 persons in 2003 to 1 327 995 persons in 2010 nationally. Those receiving anti‐retroviral therapy (ART) increased from 143 in 2003 to 344 304 in 2010. The national HIV prevalence estimates declined from 14.3% in 2001 to 13.5% in 2009. The proportion of TB patients being tested for HIV increased from 22.6% in 2006 to 84% in 2010 and approximately 70% were HIV positive. The proportion of the HIV‐infected TB patients who: (i) started on ART increased from 38% in 2006 to 50% in 2010; (ii) commenced co‐trimoxazole preventive therapy (CPT) increased from 31% in 2006 to 70% in 2010; and (iii) were successfully treated increased to an average of 80% resulting in decline of deaths from 13% in 2006 to 9% in 2010. Conclusions The scale‐up of TB/HIV collaborative programme activities in Zambia has steadily increased over the past decade resulting in increased testing for TB and HIV, and anti‐retroviral (ARV) rollout with improved treatment outcomes among TB patients co‐infected with HIV. Getting service delivery points to adhere to WHO guidelines for collaborative TB/HIV activities remains problematic, especially those meant to reduce the burden of TB in people living with HIV/AIDS (PLWHA).     

C-MET在非小细胞肺癌对表皮生长因子受体酪氨酸激酶抑制剂耐药中的作用研究进展

以表皮生长因子受体(EGFR)为靶点的酪氨酸酶抑制剂(TKI)是近年来非小细胞肺癌(NSCLC)治疗的重大突破.但是随着临床的广泛应用,耐药成为新的难点.新近研究已发现对EGFRTKI的耐药产生主要涉及原癌基因C-MET的扩增突变.C-MET是原癌基因,是蛋白产物肝细胞生长因子/离散离子(HGF/SF)的受体,具有酪氨酸酶活性,C-MET基因扩增激活ErbB3-PI3K信号途径导致NSCLC对EGFR-TKI产生耐药,大量研究证实NSCLC患者对EGFR-TKI耐药约20％归因于C-MET基因扩增.     

Artificial intelligence in pancreaticobiliary endoscopy

Artificial intelligence (AI) applications in health care have exponentially increased in recent years, and a few of these are related to pancreatobiliary disorders. AI‐based methods were applied to extract information, in prognostication, to guide clinical treatment decisions and in pancreatobiliary endoscopy to characterize lesions. AI applications in endoscopy are expected to reduce inter‐operator variability, improve the accuracy of diagnosis, and assist in therapeutic decision‐making in real time. AI‐based literature must however be interpreted with caution given the limited external validation. A multidisciplinary approach combining clinical and imaging or endoscopy data will better utilize AI‐based technologies to further improve patient care.