肿瘤瘤栓性肺栓塞的临床特点

肺栓塞是指在循环血液中出现的不溶于血的异常物质,随着血流运行至肺动脉及其分支,导致血管腔阻塞所引起的病理现象.以脱落的血栓栓子引起的栓塞最常见,癌细胞团、脂肪滴、气体和羊水等亦可引起栓塞,但较为少见.近年来,随着恶性肿瘤发病率逐年增加,肿瘤瘤栓性肺栓塞逐渐引起临床医师的重视.尽管与肺血栓栓塞相比,瘤栓性肺栓塞在临床较为少见,但由于其缺乏特异性临床表现,并且患者生前确诊率低,常常在死亡后进行尸检时发现肺动脉血管内的瘤细胞栓子才能确诊,因此常常导致右心衰竭甚至死亡等不良临床后果.此外,近年来临床观察发现,肿瘤瘤栓性肺栓塞可以作为恶性实体肿瘤的首发临床表现.因此,对肿瘤瘤栓性肺栓塞做出早期、明确的诊断,对恶性肿瘤患者具有重要临床意义.     

Pulmonary Sclerosing Pneumocytoma of the Lung: CT Characteristics in a Large Series of a Tertiary Referral Center

The purpose of this study is to describe the detailed clinical, chest computed tomography (CT), and ¹⁸F-fluorodeoxyglucose positron emission tomography (FDG PET) characteristics of the tumor boundary for the diagnosis and investigate the outcome of pulmonary sclerosing pneumocytoma (PSP) using confirmed large data of a tertiary referral center.Confirmed 76 patients were included. We evaluated the findings of CT including 4 CT signs, FDG PET, and histopathology.Most patients had a single lesion (92.1%), smooth boundary (65.8%), and oval shape (65.8%) and the mean diameter was 22.7 mm. The CT signs included marginal pseudocapsule (50%), overlying vessel (26.3%), air gap (2.6%), and halo sign (17.1%). A predominantly solid was the most common histopathologic type. The mean maximum standardized uptake value on FDG PET of 17 patients was 1.8 (range, near 0 or normal tissue metabolism ∼2.9).PSP should be considered in middle-aged women whose CT features show incidental nodule(s), commonly with surrounding ground-glass opacity and characteristic CT signs of the tumor boundary, and hypometabolic uptake on FDG PET. Outcome of patients is excellent.     

肺栓塞21例临床分析

本文总结了21例无其它心肺疾患肺栓塞患者的临床特点。发现：（1）患者发病平均年龄41±12岁。（2）病程在一个月以内者6例（29％），一个月以上者15例（71％）。（3）呼吸困难是最常出现的症状（81％），呼吸困难和／或胸痛发生率为95％。（4）动脉血氧分压低于60mmHg占47％。（5）T波倒置是最常出现的心电图异常。（6）超声心动图异常发生率为93％。（7）胸部X线检查示肺不张和／或肺实质异常发生率为40％。（8）43％的患者有下肢静脉血栓证据。所有这些发现，虽然并非确诊肺栓塞的必不可少的要素，但应视为通过合理的分析，可以提高诊断肺栓塞敏感性和特异性的基础。     

Short- and Long-term Mortality Risk After Acute Pulmonary Embolism

Purpose of Review

Acute pulmonary embolism is a major cause of morbidity and mortality in the USA and throughout the world. This review will summarize recent developments in short- and long-term mortality risk assessment after an acute pulmonary embolism.

Recent Findings

Recent guidelines have emphasized risk stratification of acute PE patients on the basis of blood pressure, right ventricular size, and biomarker status. Ongoing work is testing various acute treatment strategies for improvement of symptom burden, length of stay, quality of life, and possibly mortality risk reduction. Long-term outcomes among subjects with acute PE are less well studied. Long-term mortality largely correlates with baseline co-morbidity burden, although there may be an association between acute PE severity and long-term outcomes.

Summary

Acute PE risk stratification and treatment, as well as long-term follow-up of patients with acute PE, are rapidly developing areas and many promising innovations are underway.

     

Primary Pulmonary Synovial Sarcoma in a Tertiary Referral Center: Clinical Characteristics,CT, and 18F-FDG PET Findings,With Pathologic Correlations

The purpose of this study was to describe the patient characteristics, computed tomography (CT) and ¹⁸F-fluorodeoxyglucose positron emission tomography (FDG PET) findings, and clinical outcomes of primary pulmonary synovial sarcoma (PPSS), together with their pathologic correlations. The medical records of 14 patients with pathologically proven PPSS in a tertiary hospital from January 1997 to December 2014 were retrospectively reviewed. The CT findings were evaluated. The maximum standardized uptake value (maxSUV) of the tumors was obtained, and clinical outcomes with respect to tumor recurrence and mortality were assessed by Kaplan–Meier analysis. The median tumor size was 10.2 cm and the most common anatomic location was the lung followed by the pleura/chest wall and mediastinum. Most of the tumors appeared as single lesions and had circumscribed margins. All the cases showed heterogeneous enhancement with necrotic or cystic portions, and intratumoral vessels were frequently seen. Half of the tumors had intratumoral calcifications, and tumor rupture, pleural/chest wall extension, and pleural effusion occurred frequently. However, lymph node enlargement was rare. The median maxSUV of the tumors was 4.35. Patient outcomes with respect to tumor recurrence (n = 8, 57.1%) and death (n = 3, 21.4%) were poor despite their young age, and the mean follow-up period was 28.5 months.In conclusion, PPSS usually occurs in young adults, generally in the lung, presents as a large, circumscribed mass, and tumor rupture or extension of the pleura/chest wall may occur. The tumors often contain calcifications and vessels; they may exhibit triple attenuation on enhanced CT images, and clinical outcomes are poor.     

Management of Pulmonary Embolism: 2010 State-of-the-Art Update

The morbidity and mortality of venous thromboembolism remain underrecognized and underappreciated. Suspected pulmonary embolism should be risk stratified using a validated clinical risk prediction tool; intermediate to high clinical suspicion requires objective diagnostic testing to confirm or refute the diagnosis. Therapy with unfractionated heparin, low molecular weight heparin, or fondaparinux should be initiated while diagnostic testing is pursued. Conversion to vitamin K antagonists requires a minimum of 5 days’ overlap between the parenteral agent and the vitamin K antagonist. Anticoagulation should be continued for a minimum of 3 to 6 months. Longer or even indefinite therapy may be required with a persistent hypercoagulable state. In patients with cancer, low molecular weight heparin monotherapy for the initial 3 to 6 months is preferred. In stable patients with normal biomarkers and a normal echocardiogram, accelerated discharge and outpatient therapy may be considered. In patients with hemodynamic instability, systemic thrombolytic therapy, catheter-directed therapy, or surgical embolectomy may be considered. Cancer screening and/or thrombophilia testing should be pursued only if the findings will directly affect patient therapy or long-term care.     

Nocardiosis: Updated Clinical Review and Experience at a Tertiary Center

Nocardiosis is a rare opportunistic disease that affects mainly patients with deficient cell-mediated immunity, such as those with acquired immunodeficiency syndrome (AIDS) or transplant recipients. Pulmonary disease is the most common presentation in immunosuppressed patients and approximately one-third have a disseminated disease. Primary cutaneous nocardiosis is more frequently observed in immunocompetent patients with direct inoculation of the organism through professional exposure. The diagnosis can be challenging, as signs and symptoms are not specific and a high index of clinical of suspicion is necessary. Although gram stain, modified acid-fast stain, and cultures remain as the standard diagnostic tools, novel molecular techniques have changed the taxonomy of these organisms and, in some instances, have facilitated their identification. The disease has a marked tendency to recur and a high morbidity and mortality rate in immunosuppressed patients. Treatment is usually prolonged and an associated antibiotic treatment is preferred for severe disease. Although sulfonamides in combination with other antibiotics are still the treatment of choice, other associations such as imipenem plus amikacin are preferred in some centers. Linezolid is a useful alternative therapeutic agent due to its oral availability and activity against most of the isolates studied. Twenty-eight cases of nocardiosis were diagnosed at our center between January 1989 and April 2009. We report the epidemiologic characteristics of Nocardia spp. observed in our institution and discuss the risk factors, clinical features, diagnosis, and management of the disease.     

血流动力学稳定伴右心室功能不全的急性肺血栓栓塞症的临床研究

目的:分析血流动力学稳定伴右心室功能不全(right ventricular dysfunction,RVD)的急性肺血栓栓塞症(简称急性肺栓塞,acute pulmonary embolism,APE)的临床特点、诊断、治疗和预后,以提高对血流动力学稳定伴右心室功能不全的急性肺栓塞的认识.方法:对我院近8年来141例急性肺栓塞患者进行回顾分析,根据超声心动图是否存在右心室功能不全将血流动力学稳定的131例患者分为两组,分别为血流动力学稳定伴RVD(伴RVD组)50例和血流动力学稳定不伴RVD(不伴RVD组)81例,对两组患者的高危因素、临床特点、诊断及治疗等进行分析及比较.结果:血流动力学稳定伴BVD的急性肺栓塞占所有的急性肺栓寒的比率为35.5%.伴RVD组的高危因素主要包括慢性静脉机能不全、陈旧深静脉血栓形成、骨折及手术等.临床表现伴RVD组以呼吸困难最常见(68.0%),与不伴RVD组比较仅晕厥、P2亢进、呼吸频率＞20次/分、心率＞100次/分、低碳酸血症、心电图异常更常见,差异均有统计学意义(P＜0.05).急性肺栓塞患者同时存在晕厥、P2亢进和心电图异常时,对右心室功能不全的阳性预测率可达100%.静脉溶栓治疗伴RVD组(42.0%)明显多于不伴RVD组(9.9%),差异有统计学意义(P＜0.01).结论:血流动力学稳定伴RVD的急性肺栓塞是肺栓塞的重要亚组,对临床上存在晕厥、P2亢进、心电图异常的肺栓塞患者,应尽早行超声心动图检查明确有无RVD,以指导进一步治疗.     

Demonstrating a Conceptual Framework to Provide Efficient Wound Management Service for a Wound Care Center in a Tertiary Hospital

Although the benefits of wound care services and multidisciplinary team care have been well elaborated on in the literature, there is a gap in the actual practice of wound care and the establishment of an efficient referral system. The conceptual framework for establishing efficient wound management services requires elucidation.A wound care center was established in a tertiary hospital in 2010, staffed by an integrated multidisciplinary team including plastic surgeons, a full-time coordinator, a physical therapist, occupational therapists, and other physician specialists. Referral patients were efficiently managed following a conceptual framework for wound care. This efficient wound management service consists of 3 steps: patient entry and onsite immediate wound debridement, wound re-evaluation, and individual wound bed preparation plan. Wound conditions were documented annually over 4 consecutive years.From January 2011 to December 2014, 1103 patients were recruited from outpatient clinics or inpatient consultations for the 3-step wound management service. Of these, 62% of patients achieved healing or improvement in wounds, 13% of patients experienced no change, and 25% of patients failed to follow-up. The outcome of wound treatment varied by wound type. Sixty-nine percent of diabetic foot ulcer patients were significantly healed or improved. In contrast, pressure ulcers were the most poorly healed wound type, with only 55% of patients achieving significantly healed or improved wounds.The 3-step wound management service in the wound care center efficiently provided onsite screening, timely debridement, and multidisciplinary team care. Patients could schedule appointments instead of waiting indefinitely for care. Further wound condition follow-up, education, and prevention were also continually provided.