指南的恰当实施:保证脑血管病规范化诊治的重要途径

美国国家卒中协会(National Stroke Association,NSA)对短暂性脑缺血发作(transient ischemic attack,TIA)医疗诊治体系的推荐意见[1-2]是继NSA于2006年底发布TIA处理指南[3-4]后的又一重要文件,也是为数不多的有关缺血性脑血管病诊治体系的建议.类似的建议包括2007年美国心脏协会(American Heart Association,AHA)和美国卒中协会(American Stroke Association,ASA)联合发布的在卒中诊疗系统中实施急诊医疗的策略[5-6]以及2009年AHA发布的在卒中治疗系统中实施远程医疗的建议[7].     

AHA/ASA关于卒中和短暂性脑缺血发作患者卒中预防推荐的更新

在卒中和短暂性脑缺血发作(transient ischemic attack,TIA)患者卒中预防推荐[1]发表以后,美国心脏协会和美国卒中协会(American Heart Association/American Stroke Association,AHA/ASA)著述委员会对最近的一些试验结果进行了回顾.本文的目的是对这些新资料做简要回顾、更新某些推荐意见并说明进行这些修改的理由.在2个领域已发表了一些新的重要临床试验结果:(1)在非心源性栓塞所致缺血性卒中或TIA患者卒中二级预防中具体抗血小板药的应用;(2)他汀类药物在预防卒中复发中的应用.     

急性缺血性卒中患者早期处理指南:美国心脏协会/美国卒中协会对医疗专业人员的指南

背景和目的 作者提供了关于成年急性缺血性卒中患者评估和治疗方面的现有证据和处理推荐的一份概述.目标读者为涉及急性缺血性卒中患者发病48 h内诊治的院前诊疗人员、医生、综合医疗保健人员和医院管理者.该指南将取代先前的2007年版指南及其2009年更新版.方法 著述委员会成员由美国卒中协会卒中委员会的科学声明监督委员会指定,代表各个领域的医疗专家.在形成共识的整个过程中,严格遵循美国心脏协会的利益冲突原则.委员会成员被分配给与其专业领域相关的内容,对卒中文献进行回顾,重点为前一版指南发表之后的文献,然后按照美国心脏协会卒中委员会的证据强度分级方案起草推荐意见.结果 本指南的目的是减少卒中相关的残疾和死亡.本指南支持卒中医疗体系的全局性概念以及从患者识别、急救医疗服务激活、转送和分诊到急诊室和卒中单元内最初数小时诊治的卒中诊治细节.本指南讨论了早期卒中评估和一般治疗、缺血性卒中治疗、特殊干预措施,如再灌注策略以及脑复苏的一般生理学干预原则.结论 由于许多推荐意见基于有限的证据,还迫切需要对急性缺血性卒中的治疗做进一步的研究.     

美国国家卒中协会短暂性脑缺血发作处理指南

目的：短暂性脑缺血发作（TIA）是常见和重要的卒中先兆。其处理方法多样，大多数发表的指南在近年来均未被更新。我们试图制定一个全面的、无偏倚的、循证的TIA处理指南。方法：根据一种客观标准（可以预测在该研究领域中执业医师对专家提名的文献测量学方法）挑选出15名专家组成员。通过系统回顾检索到过去发表的指南，由专家对其中的推荐意见的质量进行独立评价。选择出质量最高的推荐意见，然后让专家组采用改良Delphi法通过多次问卷调查的方式进行修订，从而对新的修改达成共识。给专家们提供近期临床研究的系统评价，要求专家根据新的证据判断措辞修改的合理性并且根据证据等级和质量对最终的推荐意见进行评定。不允许专家在预期有可能存在任何利益冲突的专题方面提出推荐意见。结果：通过系统回顾检索到257个指南，其中有13篇文献包括的137条推荐意见符合所有纳入标准。需要6次重复的问卷调查对53条最终推荐意见的措辞达成共识。最终的推荐意见涉及TIA的初步处理、评价、内科治疗、外科治疗和危险因素控制。结论：对TIA患者医疗诊治的最终推荐意见强调了紧急评价和治疗的重要性。这种用于制定本指南的新方法是可行的，考虑到了快速更新并能减少偏倚。     

缺血性卒中/短暂性脑缺血发作二级预防中抗血小板药物规范化应用专家共识

大量临床研究证明了抗血小板治疗在缺血性卒中/短暂性脑缺血发作(TIA)二级预防的疗效,各国的循证指南亦强力推荐抗血小板治疗为缺血性卒中/TIA二级预防的主要措施,并将依据新的证据而不断更新.但足临床实践与指南仍然存在很大差距.     

2011年ASA／ACCF／AHA／AANN／AANS／ACR／ASNR／CNS／SAIP／SCAI/SIR/SNIS／SVM/SVS颅外颈动脉和椎动脉疾病患者处理指南（续前）

7血运重建术 7．1关于颈动脉血运重建术患者选择的推荐意见 I级推荐 1对于在6个月内有过非致残性缺血性卒中或TIA症状（包括半球事件或一过性黑噱）且手术风险中等或较低的患者,     

卒中前的TIA时间间隔--预防时间窗很短

TIA患者的卒中风险增加,因此需治疗预防。而临床指南对应如何对患者进行紧急评价意见不一。为了明确延误TIA诊断和治疗的可能后果,Rothwell等对卒中前TIA的时间间隔进行了研究,其结果发表在最近的Neurology上。作者收集了近期卒中和卒中前有过TIA的病例资料,主要来源于2项基于人群的研究[牛津血管性研究(OXVASC)和牛津郡社区卒中项目(OSCP)]和2项随机试验[英国TIA阿司匹林研究(UK TIA)和欧洲颈动脉外科研究(ECST)]。在2416例缺血性卒中患者中,549例(23%)在卒中发病前有过TIA(OXVASC为18%,OSCP为15%,UK TIA为23%,ECS…     

卒中前的TIA时间间隔——预防时间窗很短

TIA患者的卒中风险增加，因此需治疗预防。而临床指南对应如何对患者进行紧急评价意见不一。为了明确延误TIA诊断和治疗的可能后果，Rothwell等对卒中前TIA的时间间隔进行了研究，其结果发表在最近的Neurotogy上。     

自发性脑出血治疗指南美国心脏协会/美国卒中协会对医疗卫生专业人员发布的指南

目的 本指南旨在为急性自发性脑出血的诊断和治疗提供最新的综合性推荐意见.方法 通过Medline进行规范的文献检索,利用证据表合并资料.撰写委员会成员通过远程电信会议讨论根据资料得出的推荐意见.采用美国心脏协会卒中委员会的证据分级方案对推荐意见进行分级.由6位同行评议专家以及卒中委员会科学声明监督委员会和卒中委员会领导委员会成员对指南 的草案进行发表前审阅.预期本指南在3年内完全更新.结果 本文为脑出血患者的医疗诊治提供了循证指南.重点包括诊断、止血、血压管理、院内管理和护理、预防内科合并症、外科治疗、转归预测、康复、预防复发以及将来需要考虑的问题.结论 脑出血是一种严重的疾病,早期积极救治可影响其转归.本指南为脑出血患者的目标导向治疗提供了一个框架.     

缺血性卒中或短暂性脑缺血发作患者抗血小板药治疗期间血小板高反应性

抗血小板药是指南推荐的缺血性卒中/短暂性脑缺血发作(transient ischemic attack, TIA)长期治疗及二级预防的基石, 用于降低复发性卒中及其他心血管事件风险。然而, 某些缺血性卒中/TIA患者在抗血小板治疗期间仍会出现缺血性事件, 称为治疗期间血小板高反应性(high on-treatment platelet reactivity, HTPR), 通常发生在服用阿司匹林或氯吡格雷的患者中。文章阐述了缺血性卒中/TIA患者中HTPR的发生率、危险因素和常用评价方法, 阐述HTPR在缺血性卒中/TIA患者中的临床意义, 并探讨HTPR患者的抗血小板治疗方案。     

Options for screening for colorectal cancer

Unlike other types of cancer, there are several options for screening for colorectal cancer (CRC). The most extensively examined method, faecal occult blood testing (FOBT), has been shown, in three large randomized trials, to reduce mortality from CRC by up to 20% if offered biennally and possibly more if offered every year. Recently published data from the US trial suggest that CRC incidence rates are also reduced by up to 20%, but only after 18 years. In this study, the number of positive slides was associated with the positive predictive value both for CRC and adenomas larger than 1 cm, suggesting that the reduction in CRC incidence was caused by the identification and removal of large adenomas. In this respect, this study supports the concept that removing adenomas prevents CRC. More efficient methods of detecting adenomas include the use of colonoscopy or flexible sigmoidoscopy (FS). Considerable evidence exists from case-control and uncontrolled cohort studies to suggest that endoscopic screening by sigmoidoscopy reduces incidence of distal colorectal cancer. However, in the absence of evidence from a randomized trial, several countries have been reluctant to introduce endoscopic screening. Three trialsare currently in progress (in the UK, Italy and the US) to address this issue. Two of these trials are examining the hypothesis that a single FS screen at around age 55-64 might be a cost-effective and acceptable method for reducing CRC incidence rates. Recruitment and screening are now complete in both studies and the first analysis of results on incidence rates is expected in 2004. Colonoscopy screening at 10-year intervals has recently been endorsed in the US on the basis that the reductions in incidence observed with distal CRC screening can be extrapolated to the proximal colon. However, data are lacking and a pilot study for a trial of the acceptability and efficacy of colonoscopy screening is in progress in the US. It has also been suggested that FOBT testing should be used to detect proximal CRC missed by sigmoidoscopy screening, but the small amount of published data suggest that supplementing FS with FOBT offers very little advantage over FS alone. Other forms of CRC screening are under investigation and represent exciting options for the future. Extraction of DNA from stool is now feasible and a number of research groups have shown high sensitivity for CRC using a panel of DNA markers including mutations in k-ras, APC, p53 and BAT26. Data so far indicate that, with the exception of k-ras, these markers are highly specific and therefore represent a significant improvement over FOBT. Whether these tests will replace or supplement existing methods of screening has yet to be determined. It has been suggested that BAT26, which is a marker of microsatellite instability, a feature of proximal sporadic CRC, might be a useful adjunct to sigmoidoscopy screening. Others have suggested that a test for occult blood should be included with the DNA markers to further increase sensitivity. It is not yet known how sensitive these markers are for adenomas--it is only by detecting adenomas that CRC incidence rates can be reduced. A final exciting new option for screening is virtual colonoscopy (VC), which by screening out people without neoplasia allows colonoscopy to be reserved for patients requiring a therapeutic intervention. The sensitivity of VC for large adenomas and CRC appears to be high, although results vary by centre and there is a steep learning curve. Sensitivity for small adenomas is low, but perhaps it is less essential to find such lesions. Some groups have suggested that virtual colonoscopy might be a useful option for investigating patients who test positive with stool-based screening tests. Whichever CRC screening method is finally chosen (and there is no reason why several methods should not ultimately be available), high quality endoscopy resources will always be required to investigate and treat neoplastic lesions detected.     

Indications for surgery for aortic regurgitation

Aortic valve replacement for isolated aortic regurgitation (AR) is usually not indicated unless the regurgitation is severe. However, not all patients with severe AR require aortic valve replacement. This review focuses on the causes of AR and the pathophysiology of acute versus chronic AR, and the attendant adaptive mechanisms of the left ventricle that ultimately determine their different natural histories. Aortic valve surgery must be performed in a timely manner to prevent cardiac death, ameliorate symptoms, and limit late postoperative excess mortality.