血栓弹力图在 2型糖尿病并发症中的应用

2型糖尿病(T2DM)是一种代谢性慢性疾病,占糖尿病病人的 90%以上。高血糖、胰岛素缺乏及胰岛素抵抗等为其主要特点。持续性高血糖易引起血液高凝趋向,带来慢性并发症包括心脏病、脑卒中、糖尿病视网膜病变、糖尿病周围神经病变等。血栓弹力图( TEG)是反映血液凝固动态变化的指标,利用 TEG对凝血过程进行检测对糖尿病并发症的预测、治疗、预后有着重要意义。该文就 TEG在 2型糖尿病并发症中的应用进行综述。     

探讨血栓弹力图在冠状动脉介入术患者抗血小板治疗中的应用价值

目的讨论运用血栓弹力图在冠状动脉介入术患者抗血小板治疗中是否具有广泛的应用价值。方法选取2015年1月至2015年6月间,在医院接受抗血小板经皮冠状动脉介入治疗的患者412例;将他们分为M、N两组,M组为试验组206例,患者在接受治疗的过程中使用血栓弹力图对血凝状况进行监测;N组为对照组206例,进行正常冠状动脉介入抗血小板治疗。对比M、N两组在接受手术之后的2个月内心血管不良缺血状况与出血状况的出现频率,以及M组在血栓弹力图指导下调整药物用量前后血小板压抑效率。结果通过M、N组患者术后的数据可得,M组心血管不良缺血状况出现概率为7.77%、出血状况出现概率为2.42%,N组分别为21.84%和5.34%,对上述差异进行χ2检验所得P值<0.05,说明使用血栓弹力图能够有效减少心血管不良缺血与出血事件的出现。M组在调整抗血小板药物使用量之前阿司匹林抑制作用率与氯吡格雷抑制作用率分别为(87.26±23.15)%和(60.24±30.37)%,在调整药物使用量之后分别为(95.72±12.74)%和(71.33±22.58)%,对上述差异进行t检验所得P值<0.05,说明使用血栓弹力图可以增加压抑血小板活性的作用。结论使用血栓弹力图在冠状动脉介入抗血小板治疗中能够有效降低心血管不良缺血事件与出血事件的发生频率,提高对血小板的抑制效率,因此在临床医疗中具有较高的应用价值。     

血栓弹力图在脑血管支架术抗血小板聚集方案治疗中的应用分析

目的 探讨血栓弹力图在脑血管支架术抗血小板聚集方案治疗中的应用效果。方法 选取脑梗死老年患者100例,随机分为对照组和研究组,各50例。两组均进行脑血管支架术,在抗血小板聚集方案中对照组采用光密度比浊法,研究组采用血栓弹力图法,对比分析两组患者脑血管支架术后血小板抑制率、出血的情况。结果 两组患者第3天、第5天的血小板抑制率均显著高于第1天,研究组第3天、第5天AA的血小板抑制率以及ADP的血小板抑制率均显著高于对照组(P<0.05);研究组患者出血情况Ⅲ级显著低于对照组(P<0.05),但Ⅰ级、Ⅱ级与对照组无显著差异(P>0.05),且研究组无脑血管痉挛发生。结论 血栓弹力图检测在脑血管支架术抗血小板聚集方案中,明显降低脑血管事件的发生率,降低出血的风险,值得临床推广应用。     

血栓弹力图在深静脉血栓形成诊疗中的研究进展

深静脉血栓形成（DVT）是一种常见具有潜在致死性疾病。目前国内对深静脉血栓诊疗存在一定局限性,普通凝血测试对部分高危患者不能进行有效的筛选,可能无法提供准确的治疗指导决策。血栓弹力图（TEG）技术可在体外模拟血栓形成的整个过程,能客观准确地显示反应时间、血块形成时间、血块形成速率、最大振幅、凝血指数等相关信息,全面准确地反映人体的凝血功能,从而为临床预防、诊断、治疗深静脉血栓提供指导。本文对血栓弹力图在深静脉血栓疾病临床诊疗这一领域的研究进展进行综述。     

血栓弹力图在消化道出血患者输血治疗中的应用

目的 探讨血栓弹力图对消化道出血患者成分输血的指导价值。方法 分析106例消化道出血患者,根据是否在血常规与凝血功能四项(TT、PT、APTT、FIB)基础上联合应用血栓弹力图指导用血,随机分为对照组和观察组,对比两组输血前、后凝血四项及观察组输血前、后血栓弹力图各指标变化,输血后的预后情况及血制品使用情况。结果 凝血指标方面,两组输血后凝血四项比输血前有所改善,观察组输血后血栓弹力图指标比输血前有明显改善;患者预后转归方面,观察组好转率高于对照组,住院天数短于对照组;血制品使用方面,观察组红细胞、血浆用量低于对照组,冷沉淀和血小板用量高于对照组。以上指标组间差异均有统计学意义(P<0.05)。结论 联合应用血栓弹力图精准指导消化道出血患者的输血治疗,能及时有效纠正凝血功能障碍,减少不必要的出血,减少红细胞用量,有助于消化道出血的治疗,从而改善患者的预后。     

血栓弹力图在肝硬化患者围术期的应用

目的 评价肝炎肝硬化手术患者术中血栓弹力图（TEG）监测的临床意义。方法 45例乙型肝炎肝硬化患者与30例肝功能正常者进行TEG监测,肝硬化患者随机分为两组：22例用凝血酶原复合物600PE、纤维蛋白原1．0g、血小板10单位静脉输注（治疗组）;未经治疗的23例（对照组）。比较麻醉前、手术后TEG主要参数及红细胞比容、手术时间和术中出血量。结果 与肝功能正常者比较,肝硬化患者麻醉前TEG参数有异常变化：R和K时间明显延长（P〈0．05）;α角、MA、G和C1均显著降低（P〈0．01）;CI〉＋3者0例,α角、MA无一例异常增大;Ly30均在正常范围。与麻醉前比,治疗组术后R明显缩短（P〈0．05）,α角和MA值显著增大（P〈0．01）。对照组术后R明显延长（P〈0．05）;α角和MA值均明显降低（P〈0．05）;治疗组术中出血量显著少于对照组（P〈0．01）。结论 肝硬化患者麻醉前TEG监测反映血液低凝状态;经针对性治疗,术后TEG提示低凝状态被逆转。肝硬化患者围手术期TEG监测可为治疗提供重要依据。     

血栓弹力图在先天性心脏病患儿介入术后抗血小板治疗中的应用价值

目的 探讨血栓弹力图（TEG）在先天性心脏病（CHD） 患儿介入术后抗血小板治疗中的应用价值。方法 选择2014年12月至2015年1月在上海交通大学医学院附属儿童医学中心接受介入治疗的29例CHD患儿,根据患儿介入术后每天口服阿司匹林剂量的不同,分为A组（3 mg/kg,20例）和B组（5 mg/kg,9例）,通过TEG检测方法,比较两组血小板功能,并监测临床出血及缺血事件的发生情况。结果 29例患儿服用阿司匹林后,花生四烯酸（AA）途径诱导的血小板抑制率高于治疗前,差异有统计学意义（t=-29.923,P=0.000）。阿司匹林治疗后,两组患儿AA途径诱导的血小板抑制率差异无统计学意义 （t=-1.126,P=0.270）。B组2例患儿术后发生异常出血,A组无出血患儿,两组差异有统计学意义（χ²=5.021,P=0.025）。随访期间无血栓事件发生。结论 TEG可以监测CHD患儿介入术后服用阿司匹林后血小板功能的变化,5 mg/（kg·d）剂量阿司匹林抗血小板治疗出血的可能性增大。TEG可作为抗血小板治疗评价指标。     

生化检测在糖尿病视网膜病变患者中的应用价值

目的：探究生化检测在糖尿病视网膜病变患者中的应用价值。方法选取2012年5月至2014年7月该院收治的2型糖尿病患者206例,根据眼底检查结果分为无糖尿病视网膜病变（DR）组（n＝80）、非增殖期DR组（n＝97）和增殖期DR组（n＝29）三组,对比患者的一般资料、生化检测指标等。结果与无DR组相比,非增殖期DR组与增殖期DR组患者高血压病程较长、糖尿病病程较长、血脂蛋白a较高,增殖期DR组患者血肌酐（Cr）、尿素氮（BUN）较高（P＜0．05）;与非增殖期DR组相比,增殖期DR组患者糖尿病病程较长、血脂蛋白a、Cr、BUN较高（P＜0．05）。多因素分析发现,脂蛋白a（OR＝1．014,95％CI＝1．004～1．024）、糖尿病病程（OR＝1．306,95％CI＝1．179～1．446）是糖尿病患者发生DR的危险因素。结论生化检测指标脂蛋白a和糖尿病病程是糖尿病患者发生DR的危险因素,对其检测有利于早期诊治糖尿病视网膜病变。     

Pharmacologic vitreolysis in diabetic retinopathy

Diabetic retinopathy remains a major cause of worldwide preventable blindness. The vitreo-retinal interface plays a critical role in the pathogenesis of diabetic retinopathy. The term pharmacologic vitreolysis refers to the use of enzymes to liquefy the vitreous gel, and to induce posterior vitreous detachment (PVD). Intravitreal ovine hyaluronidase injection was effective in clearing vitreous hemorrhage. Several human case series demonstrated that intravitreal injection of autologous plasmin enzyme was a safe and effective adjunct to vitreous surgery for the treatment of diabetic macular edema and proliferative diabetic retinopathy. Recently, it was shown that intravitreal injection of plasmin enzyme without the performance of vitrectomy induced complete PVD and reduced macular thickening due to refractory diabetic macular edema.     

Anti-angiogenesis drugs in diabetic retinopathy

The vascular endothelial growth factor (VEGF) plays a key role in the development of proliferative diabetic retinopathy (PDR) and diabetic macular edema (DME), resulting in a significant visual loss among patients with diabetes mellitus. Systemic VEGF-A and the interplay between membrane-bound VEGF receptors and VEGF-R1 (soluble form) are key to angiogenesis and vasculogenesis. Furthermore, patients with diabetes have a higher risk of hypertension and proteinuria, two surrogate markers of systemic VEGF inhibition. Pegaptanib, ranibizumab, bevacizumab and roboxistaurin are the currently available anti-VEGF agents. Agents with activity occurring later down the angiogenic pathway and those drugs with potential to synergize with anti-VEGF-A technologies are being developed. In recent years, inhibition of ocular VEGF has emerged as a promising treatment modality for diabetes and is currently undergoing evaluation in clinical trials. A potential role for these anti-VEGF agents in the prevention of PDR and DME are also emerging.     

Role of endothelin in diabetic retinopathy

Endothelin-1 (ET-1) is a 21 amino acid peptide originally purified from conditioned medium of cultures of porcine aortic endothelial cells. It is now known that there are three endothelin genes in the human genome (ET-1, ET-2, and ET-3 genes). ET-1 and ET-2 are both strong vasoconstrictors, whereas ET-3 is a potentially weaker vasoconstrictor compared to the other two isoforms. Besides being a very potent vasoconstrictor, ET-1 also acts as a mitogen on the vascular smooth muscle and thus it may play a role in the development of vascular diseases. There is evidence that impaired auto-regulation of blood flow is involved in the pathogenesis of diabetic microangiopathy. It is known that the ability of the diabetic's circulation to distribute blood is affected, especially during increased blood flow. In most tissues this causes no serious burden, but three tissues are usually susceptible to disturbance. They are the retina, renal cortex, and peripheral nerves. Retinal vascular auto-regulation is defined as the ability of the blood vessels to keep blood flow constant under varying perfusion pressure in order to match it to tissue oxygen and metabolic requirements. The failure of auto-regulation is an important and often early feature of diabetic retinopathy. Since human retina vessels lack extrinsic innervation, retinal vessel calibre and local blood flow are normally regulated by non-nervous mechanisms intrinsic to the retina. There is now a considerable body of evidence suggesting that retinal pericytes are the main regulators of vascular tone in the retinal capillaries because they contain components of contractile proteins similar to vascular smooth muscle cells and because they also possess ET-1 receptors. Furthermore. ET-1 has been shown to cause vasoconstriction of retinal vessels as well as to have mitogenic effects on retinal pericytes. Hence, alterations in the pericyte-ET interaction may have a role causing early hemodynamic and histopathological abnormalities found in diabetic retinopathy. On the contrary, Chakrabarti et al. demonstrate that retinas from the chronic diabetic BB/W rats (6 months) show an increase in ET-1, ET-3, ET(A) receptor and ET(B) receptor mRNA expressions when compared to those from control rats. Similar results are noted by them using immunohistochemical methods. Finally, an increased ocular, and retina tissue levels of ET-1 in diabetic rats have also been reported by Chakravarthy et al., as well as by Takagi et al. All of these findings suggest that endothelins may also be involved in the pathogenesis of more advanced diabetic retinopathy, such as capillary occlusion and subsequent neovascularization. This review summarizes the reported literature on the role of ET-1 in the development of diabetic retinopathy.     

肾素-血管紧张素系统与糖尿病视网膜病变

眼部组织具有独立的肾素-血管紧张素系统(RAS)。资料显示:RAS在糖尿病视网膜病变(diabetic retinopathyDR)发生发展过程中起着重要的作用。本文就RAS及作用于RAS的药物与糖尿病视网膜病变的关系作一概述。     

Pharmacotherapy for diabetic retinopathy

Background: Diabetic macular edema (DME) and proliferative diabetic retinopathy (PDR) continue to cause significant visual loss among patients with diabetes mellitus. In some patients unresponsive to standard laser techniques, as well as improved control of blood pressure and blood sugar, pharmacologic treatment may be beneficial. Although no agent is now approved by the FDA for this purpose, many agents are now being studied in randomized clinical trials (RCTs). Objective: To review concisely the chief pharmacotherapies for diabetic retinopathy available at present. Methods: Literature review and synopsis. Results: Used alone, intravitreal triamcinolone acetonide (IVTA) seems to have some short-term efficacy against DME, but longer-term outcomes (≤ 3 years) using IVTA monotherapy showed a lesser benefit than focal/grid laser treatment in a prospective RCT done by the Diabetic Retinopathy Clinical Research Network. Intravitreal anti-VEGF agents have demonstrated some short-term efficacy against DME, and continuing RCTs will evaluate combination therapies (anti-VEGF and laser) for both DME and PDR. Other agents are being evaluated in pilot studies and Phase II RCTs. Conclusion: Pharmacotherapies for DME and PDR have potential for vision stabilization or improvement. Continuing RCTs will provide evidence-based data on their role in clinical practice. A potential role for pharmacotherapy in the prevention of DME and PDR is also emerging.     

糖尿病视网膜病变的危险因素

糖尿病视网膜病变(diabeticretinopathy,DR)是糖尿病最常见的微血管并发症之一,也是糖尿病患者致盲的主要原因之一.最新数据显示,2005～2008年超过40岁的美国糖尿病患者有28.5%存在眼底或视网膜病变,国内约为37%～60%.研究发现,糖尿病眼底病变的增加不仅与糖尿病患病率上升和糖尿病相关代谢控制有关,还与重视糖尿病眼病管理、普及常规眼科检查以及不断改进的评估手段密切相关.