急性脑出血患者下肢深静脉血栓形成的危险因素分析

目的 分析急性脑出血患者住院期间下肢深静脉血栓形成（deep venous thrombosis，DVT）发生率、发生时间及危险因素。方法 选取首都医科大学附属北京天坛医院急性卒中入院后并发症队列研究中的脑出血患者，根据患者住院期间是否发生下肢DVT分为DVT组和无DVT组，比较两组患者的临床特征，采用多因素logistic回归分析脑出血患者发生DVT的危险因素。 结果 研究最终纳入314例脑出血患者，其中18例（5.7%）住院期间发生了DVT，发生脑出血至DVT确诊的中位时间为7.5（4.0～9.0）d。多因素logistic回归分析结果显示：女性（OR 3.43，95%CI 1.04～11.37，P=0.0436）、既往冠心病病史（OR 6.89，95%CI 1.90～25.04，P=0.0034）、入院NIHSS评分高（OR 1.18，95%CI 1.06～1.23，P=0.0004）、住院时间长（OR 1.07，95%CI 1.01～1.13，P=0.0273）是脑出血患者发生DVT的独立危险因素。结论 急性脑出血患者发生下肢DVT时间在卒中后1周左右，女性、既往冠心病病史、入院时病情重、住院时间长的患者更容易发生下肢DVT。     

蛛网膜下腔出血相关性肺炎发生的危险因素分析及对住院结局的影响

目的 分析蛛网膜下腔出血（subarachnoid hemorrhage，SAH）相关性肺炎发生的危险因素及其对住院 结局的影响。 方法 回顾性纳入2015年5月-2018年11月首都医科大学附属北京天坛医院收治的SAH患者，根据住 院期间是否发生肺炎分为肺炎组、非肺炎组，比较两组患者临床资料的差异。采用多因素Logistic回归 模型，分析发生肺炎的危险因素，以及发生肺炎对SAH患者院内死亡、住院天数、住院总费用的影响。 结果 共纳入457例SAH患者，平均年龄54.3±11.2岁，男性219例（47.9%），发生肺炎76例（16.6%）。 男性（OR 2.31,95%CI 1.17～4.58，P =0.016）、吞咽障碍（OR 6.06,95%CI 1.09～33.70，P =0.039）及 Barthel指数0～20分（OR 15.58,95%CI 4.17～58.23，P＜0.001）是SAH患者发生肺炎的独立危险因素； 发生肺炎与院内死亡风险、住院天数和住院总费用增加无关。 结论 男性、吞咽障碍、Barthel指数0～20分是SAH患者发生肺炎的独立危险因素。发生肺炎与院内 死亡风险、住院天数和住院总费用增加无关。     

缺血性卒中相关性肺炎危险因素分析

目的 分析缺血性卒中相关性肺炎危险因素。 方法 连续入组2014年5月-2016年5月收治的急性缺血性卒中患者为研究对象,根据是否在卒中发 病7 d内新发生肺炎将患者分为无卒中相关性肺炎组与卒中相关性肺炎组,比较两组患者的血管危险 因素、入院NIHSS等指标的差异,并采用多因素logistic回归分析卒中相关性肺炎的独立影响因素。 结果 研究共入组1129例急性缺血性卒中患者,无卒中相关性肺炎组1043例,卒中相关性肺炎组86 例。多因素分析显示,年龄增高（OR 1.084,95%CI 1.047～1.122,P <0.0001）、入院NIHSS评分增加（OR 1.192,95%CI 1.133～1.254,P <0.0001）、白细胞计数升高（OR 1.269,95%CI 1.134～1.420,P <0.0001） 及住院天数延长（OR 1.146,95%CI 1.087～1.208,P <0.0001）是卒中相关性肺炎的独立危险因素。 结论 缺血性卒中后卒中相关性肺炎的发生与高龄、神经功能缺损程度重、白细胞增高、住院时间 长有关。     

急性缺血性卒中患者发生院内消化道出血的危险因素分析

目的 分析急性缺血性卒中患者（acute ischemic stroke，AIS）住院期间消化道出血（gastrointestinal bleeding，GIB）的发生率、发生时间及危险因素。 方法 本研究纳入首都医科大学附属北京天坛医院急性卒中院内并发症队列（inhospital medical complication after acute stroke，iMCAS）研究中AIS患者。收集患者临床信息，根据住院期间是否发生 GIB分为GIB组和无GIB组，采用多因素Logistic回归模型，分析AIS患者发生GIB相关危险因素。 结果 共纳入1129例AIS患者，平均年龄58.7±12.5岁，女性230例（20.4%）。47例住院期间发生GIB， 发生率为4.2%，卒中发作至GIB确诊时间为5（3～13）d。合并肝硬化（OR 10.06，95%CI 2.44～41.38）、 高入院NIHSS评分（OR 1.13，95%CI 1.08～1.19）、高白细胞计数（OR 1.25，95%CI 1.13～1.38）、住院时 间长（OR 1.05，95%CI 1.01～1.10）是AIS患者发生消化道出血的独立危险因素。 结论 本单中心研究数据提示合并肝硬化、高入院NI HSS评分、高白细胞计数、住院时间长是AI S患 者住院期间发生GIB的独立危险因素。     

儿童脑出血患者住院期间脑积水危险因素研究

目的 探讨儿童脑出血患者发生脑积水的相关危险因素,为早期识别儿童脑出血患者发生脑积水 的风险提供循证依据。 方法 本研究为多中心回顾性分析,纳入北京市4家医院2018年度诊治的脑出血或非创伤颅内出血 的儿童患者资料。从病案资料中收集患儿年龄、性别、医疗保险类型、影像检查结果、住院期间并发 症（脑积水、癫痫和肺部感染）、住院时长和住院总费用等信息。通过多因素logistic回归分析,探讨儿 童脑出血患者住院期间发生脑积水的危险因素。 结果 研究共纳入140例脑出血儿童患者,其中17例（12.14%）发生脑积水。与未发生脑积水患者相 比,脑积水患者脑室内出血比例更高（64.71% vs 20.33%,P＜0.01）,住院发生肺部感染的比例也更 高（41.18% vs 4.88%,P＜0.01）。多因素logistic回归模型分析显示,低龄（OR 1.15,95%CI 1.01～1.31, P =0.03）、脑室出血（OR 9.77,95%CI 2.99～31.87,P <0.01）是儿童脑出血患者住院期间发生脑积水 的独立危险因素。     

急性缺血性卒中患者发生院内消化道出血的危险因素分析

目的 分析急性缺血性卒中患者（acute ischemic stroke，AIS）住院期间消化道出血（gastrointestinal
bleeding，GIB）的发生率、发生时间及危险因素。
方法 本研究纳入首都医科大学附属北京天坛医院急性卒中院内并发症队列（inhospital medical
complication after acute stroke，iMCAS）研究中AIS患者。收集患者临床信息，根据住院期间是否发生
GIB分为GIB组和无GIB组，采用多因素Logistic回归模型，分析AIS患者发生GIB相关危险因素。
结果 共纳入1129例AIS患者，平均年龄58.7±12.5岁，女性230例（20.4%）。47例住院期间发生GIB，
发生率为4.2%，卒中发作至GIB确诊时间为5（3～13）d。合并肝硬化（OR 10.06，95%CI 2.44～41.38）、
高入院NIHSS评分（OR 1.13，95%CI 1.08～1.19）、高白细胞计数（OR 1.25，95%CI 1.13～1.38）、住院时
间长（OR 1.05，95%CI 1.01～1.10）是AIS患者发生消化道出血的独立危险因素。
结论 本单中心研究数据提示合并肝硬化、高入院NI HSS评分、高白细胞计数、住院时间长是AI S患
者住院期间发生GIB的独立危险因素。     

前列腺癌合并急性脑梗死的临床特点及病因分析

目的 分析前列腺癌合并急性脑梗死的临床特点,探讨其相关危险因素。 方法 本研究为病例对照研究,前列腺癌合并急性脑梗死组收集2010年1月-2019年10月于首都医 科大学附属北京世纪坛医院连续就诊的前列腺癌合并急性脑梗死患者,前列腺癌无脑梗死组按年 龄匹配（1∶1）同时期泌尿外科住院被确诊为前列腺癌且未曾发生过脑梗死的患者。分析前列腺癌 合并急性脑梗死的临床特点,比较两组患者传统血管危险因素、实验室检查及肿瘤相关治疗间的差 异,采用多因素logistic回归分析前列腺癌合并急性脑梗死的影响因素。 结果 两组各纳入43例患者。前列腺癌合并急性脑梗死组年龄71～93岁,平均82.2±4.8岁;腔隙 性脑梗死（病灶＜10 mm）占74.4%（32/43）,前、后循环同时受累多发性脑梗死占23.3%（10/43)。多 因素logistic回归分析显示,高脂血症（OR 7.494,95%CI 1.371～40.971）、D-二聚体升高（OR 1.012, 95%CI 1.003～1.021）、放射性粒子植入治疗（OR 0.144,95%CI 0.037～0.557）是前列腺癌合并急性 脑梗死的独立影响因素。 结论 前列腺癌合并急性脑梗死患者年龄较大,以小病灶、多发性梗死灶常见。高脂血症和D-二聚 体升高是前列腺癌合并急性脑梗死独立危险因素,放射性粒子植入治疗是前列腺癌合并急性脑梗 死的独立保护因素。     

阿司匹林对重症脑血管病早期发生急性呼吸窘迫综合征的影响

目的 探讨服用阿司匹林对重症脑血管病早期急性呼吸窘迫综合征（acute respiratory distress syndrome,ARDS）发生率的影响。 方法 该研究为前瞻性队列研究,连续纳入收住首都医科大学附属北京天坛医院脑血管病中心神经 重症监护室（neurologic intensive care unit,NICU）的急性重症脑血管病[发病48 h内格拉斯哥昏迷评分 （Glasgow coma scale,GCS）≤8分]的309例患者,登记患者的性别、年龄、既往病史、卒中前服药史、基 线GCS评分、原发病、是否进行全身麻醉及开颅手术、是否早期发生ARDS以及机械通气时间、NICU住 院时间、死亡率等。按照患者发病前是否规律服用阿司匹林分为阿司匹林组和非阿司匹林组,对比两 组患者早期ARDS发生率。同时对发生ARDS的患者与非ARDS患者两组的临床因素进行比较。 结果 阿司匹林组（106例）较非阿司匹林组（203例）的ARDS发生率（20.8% vs 30.5%,P =0.045）显 著减低,阿司匹林组患者的平均年龄较大（[ 62.41±10.69）岁vs（57.40±14.80）岁,P=0.002]、合并高 血压（50.9% vs 38.4%,P =0.035）、冠状动脉粥样硬化性心脏病（31.1% vs 20.2%,P =0.032）、同时 服用他汀类药物的比例（26.4% vs 8.4%,P =0.002）也较高,原发病构成比例中缺血性卒中的比例 更高。ARDS组（86例）与非ARDS（223例）组比较,患者入院时GCS评分（[ 3.87±1.61）vs（6.48±1.51）, P =0.043]较低、机械通气时间[6（5～8）d vs 0（0～3）d,P =0.001]和NI CU住院时间[8（6～10）d vs 3 （2～4）d,P =0.001]较长,但死亡率无显著差异。 结论 发病前规律服用阿司匹林能够减少重症脑血管病患者早期ARDS的发生率,但不能降低机械 通气时间、NICU住院时间及死亡率。     

急性神经重症患者7天内进展为脑死亡的预测评分

目的构建急性神经重症患者在7 d内进展为脑死亡的预测评分，为此类患者的临床决策（姑息治疗或器官捐献）提供指导。 方法前瞻性纳入中山大学附属第一医院神经外科和重症医学科自2017年5月至2019年4月收治的急性神经重症患者，动态记录评估患者脑损伤的相关参数，依据入院时间将患者分为2组，训练集（2017年5月至2018年4月）和验证集（2018年5月至2019年4月）。在训练集中，以严重脑损伤（GCS<8分）发生后7 d，作为分组因素；通过单因素和多因素分析组间差异，筛选与急性神经重症患者在7 d内进展为脑死亡的相关因素，并进行Cox回归统计分析，构建曲线下面积（AUC）；构建神经学预测评分，并在验证集中验证评分效能。 结果纳入研究的患者231例，其中139例进入训练集，92例进入验证集。在训练集中，经单因素和多因素分析显示：气管插管行机械通气（OR=4.87，95%CI：1.36~17.35）、对光反射消失（OR=4.86，95%CI:1.75~33.92）、咳嗽反射消失（OR=4.43，95%CI：1.97~20.21）和中线结构移位≥5 mm（OR=3.82，95%CI：1.05~12.32）是患者7 d内进展为脑死亡独立危险因素。在验证集中，结果一致。基于相关因素构建的预测评分，其对于7 d内进展为脑死亡预测的AUC值为0.84。进一步对评分进行分层，其中4~6分对7 d内进展为脑死亡的阳性预测率为85.7%，而0~3分对7 d内不进展为脑死亡的阴性预测率为74.3%。 结论基于脑损伤评估参数构建的神经学评分，可预测急性神经重症患者进展为脑死亡的时间，结果有待外部数据验证。     

重症神经疾病ICU内机械撤机方案探讨

目的探讨ICU重症神经疾病患者的机械通气撤机方案。方法收集机械通气时间≥24h的ICU重症神经疾病患者66例,随机分为观察组与对照组各33例,观察组行程序化撤机方案,对照组行经验性撤机方案。结果观察组机械通气时间、住ICU时间以及总住院时间均较对照组显著缩短(P0.05);观察组撤机成功率69.7%,显著高于对照组的42.4%;观察组VAP发生率、气管切开率、再插管率以及住院期间病死率均显著低于对照组(P0.05)。结论在ICU重症神经疾病患者中应用程序化撤机方案,可有效提高撤机成功率,降低并发症发生率,缩短机械通气时间以及住院时间,值得推广应用。     

Prolonged travel and venous thromboembolism findings from the RIETE registry

There is a lack of information on clinical risk factors for venous thromboembolism (VTE) development following prolonged traveling. Clinical characteristics and additional risk factors for VTE in travelers were analyzed in RIETE, an ongoing registry of patients with symptomatic, confirmed acute VTE. Of 26,172 patients enrolled in RIETE as of May 2009, 2% developed VTE in association with recent traveling. Travelers were ten years younger, had significantly more previous VTE events (20% vs. 16%; OR: 1.4; 95%CI: 1.1-1.7) and their body mass index (BMI) was 28.4 ± 5.1 vs. 27.7 ± 5.2 in other patients from the registry (P = 0.004). 115 (20%) of recent travelers had previous VTE compared to 16% among others patients (OR: 1.4; 95%CI: 1.1-1.7). Recent travelers used hormones significantly more frequently (8.7% vs. 3.7%; OR: 2.5; 95% CI: 1.8-3.3) and more often had a positive thrombophilia test (16% vs. 8.7%; OR: 2; 95%CI: 1.6-2.6). Travelers used LMWH prophylaxis significantly less frequently than other patients in the registry (2.4% vs. 13%; OR 0.2; 95%CI: 0.1-0.3). There were differences in VTE risk in professional drivers compared to passengers. The current study demonstrates four risk factors for VTE development after long traveling: high BMI, previous VTE, hormone use and thrombophilia. Studies of prophylactic antithrombotic therapy in high risk travelers are warranted.     

Venous thromboembolism in medical patients treated in the setting of primary care: A nationwide case-control study in Italy

Objectives

The risk of venous thrombotic events (VTE) among medical outpatients is still not clear and it remains to be clarified whether medical diseases involve the same risk if managed at home or in hospital. The aim of this study was to evaluate in the setting of outpatient family medicine the relationship between VTE and medical conditions known to be at risk during a hospital stay.

Design and setting

The study involved a nationwide retrospective observation according to a nested case-control method; 400 general practitioners throughout Italy constituted the network for data collection. Between 2001 and 2004, all cases recorded as having VTE were entered; ten control patients without VTE, matched by sex, physician, and age, were selected from the database for each case.

Results

The eligible population comprised 372,000 patients and 1,624 incident VTE were recorded. Univariate analysis indicated hospitalization (OR 5.02; 95% CI 4.01-6.29), cancer (OR 3.06; 95% CI 2.47-3.79), acute infectious disease (OR 2.93; 95% CI 1.94-4.43), neurological disease (OR 2.60; 95% CI 1.56-4.33), congestive heart failure (CHF) (OR 2.48; 95% CI 1.68-3.69), paralysis (OR 1.87; 95% CI 1.51-2.32), COPD (OR 1.58; 95% CI 1.29-1.95), stroke (OR 1.62; 95% CI 1.24-2.12), superficial venous thrombosis (OR 1.51; 95% CI 1.11-2.04, and rheumatic diseases (OR 1.49; 95% CI 1.28-1.74) as significantly associated with an increased risk for VTE. After adjustment, only transient or definitive paralysis, cancer, acute infectious disease, congestive heart failure, neurological diseases, and previous hospitalization remained associated.

Conclusions

This large study indicates that VTE outpatients seen by general practitioners in Italy have a high prevalence of the same medical diseases associated with VTE among patients treated in hospital.     

Multicenter evaluation of the use of venous thromboembolism prophylaxis in acutely ill medical patients in Canada

BACKGROUND: Venous thromboembolism (VTE) prophylaxis in acutely ill medical patients has been shown to be safe and effective. Underutilization of this patient safety practice may result in avoidable mortality and morbidity. OBJECTIVES: We aimed to determine the proportion of hospitalized, acutely ill medical patients across Canada who were eligible to receive thromboprophylaxis and to evaluate the frequency, determinants and appropriateness of its use. PATIENTS/METHODS: CURVE is a national, multicenter chart audit of 29 Canadian hospitals. Data were collected on consecutive patients admitted to hospital for an acute medical illness during a defined 3-week study period. Information on demographic and clinical characteristics, risk factors for VTE and bleeding and use of VTE prophylaxis were recorded. The indications for and appropriateness of VTE prophylaxis were assessed using pre-specified criteria based on international consensus guidelines. Multivariable analyses were performed to identify determinants of prophylaxis use. RESULTS: Of the 4124 medical admissions screened over the study period, 1894 patients (46%) were eligible for study inclusion. The most common specified admitting diagnoses were severe infection (28%), COPD exacerbation or respiratory failure (12%), malignancy (9%) and congestive heart failure (8%). Thromboprophylaxis was indicated in 1702 (90%) study patients. Overall, some form of prophylaxis was administered to 23% of all patients. However, only 16% received appropriate thromboprophylaxis. Factors independently associated with greater use of prophylaxis included internist (vs. other specialty) as attending physician (OR 1.33, 95% confidence interval (CI) [1.03, 1.71]), university-associated (vs. community) hospital (OR 1.46, 95% CI [1.03, 2.07]), immobilization (per day) (OR 1.60, 95% CI [1.45, 1.77]), presence of >or=1 VTE risk factors (OR=1.78, 95% CI [1.35, 2.34]) and duration of hospitalization (per day of stay) (OR 1.05, 95% CI [1.03, 1.07]), however, use of prophylaxis was unacceptably low in all groups. Patients with cancer had a significantly reduced likelihood of receiving prophylaxis (OR=0.40, 95% CI [0.24, 0.68]). Presence of risk factors for bleeding did not influence the use or choice of prophylaxis. CONCLUSION: Most patients hospitalized for medical illness had indications for thromboprophylaxis, yet only 16% received appropriate prophylaxis. Efforts should be made to elucidate the reasons that underlie the very low rate of thromboprophylaxis in medical patients and to develop and test strategies to improve implementation of this patient safety practice.     

Maternal smoking, obesity, and risk of venous thromboembolism during pregnancy and the puerperium: a population-based nested case-control study

BACKGROUND: Smoking and obesity are associated with adverse pregnancy outcomes. The aim of the present study was to examine the association between smoking, obesity (BMI>30), and risk for venous thromboembolism (VTE) during pregnancy and the puerperium. MATERIALS AND METHODS: In a population-based case-control study nested within a Danish cohort of 71,729 women, we identified 129 cases with VTE in pregnancy or the puerperium, and 258 pregnant non-VTE controls. We obtained data from medical records regarding current smoking status, BMI, and other covariates, and computed the odds ratios (OR) for VTE as a measure of relative risk. RESULTS: Smoking and obesity were associated with increased risk of VTE during pregnancy and the puerperium (adjusted OR 2.7 (95% CI: 1.5, 4.9) and 5.3 (95% CI: 2.1, 13.5), respectively). Obesity appeared to be associated with a higher risk of pulmonary embolism (adjusted OR: 14.9 (95% CI: 3.0, 74.8) than of deep venous thrombosis (adjusted OR: 4.4, 95% CI: 1.6, 11.9). CONCLUSION: Smoking and obesity are risk factors for VTE in pregnancy and the puerperium.     

Long-term anticoagulation treatment for acute venous thromboembolism in patients with and without cancer. The SWIss Venous ThromboEmbolism Registry (SWIVTER) II

In patients with acute cancer-associated thrombosis, current consensus guidelines recommend anticoagulation therapy for an indefinite duration or until the cancer is resolved. Among 1,247 patients with acute venous thromboembolism (VTE) enrolled in the prospective Swiss Venous Thromboembolism Registry (SWIVTER) II from 18 hospitals, 315 (25%) had cancer of whom 179 (57%) had metastatic disease, 159 (50%) ongoing or recent chemotherapy, 83 (26%) prior cancer surgery, and 63 (20%) recurrent VTE. Long-term anticoagulation treatment for >12 months was more often planned in patients with versus without cancer (47% vs. 19%; p<0.001), with recurrent cancer-associated versus first cancer-associated VTE (70% vs. 41%; p<0.001), and with metastatic versus non-metastatic cancer (59% vs. 31%; p<0.001). In patients with cancer, recurrent VTE (OR 3.46; 95%CI 1.83-6.53), metastatic disease (OR 3.04; 95%CI 1.86-4.97), and the absence of an acute infection (OR 3.55; 95%CI 1.65-7.65) were independently associated with the intention to maintain anticoagulation for >12 months. In conclusion, long-term anticoagulation treatment for more than 12 months was planned in less than half of the cancer patients with acute VTE. The low rates of long-term anticoagulation in cancer patients with a first episode of VTE and in patients with non-metastatic cancer require particular attention.