原发性脑出血后静脉血栓栓塞的预防

静脉血栓栓塞包括深静脉血栓形成和肺栓塞，是神经科较为常见且可以预防的并发症。对静脉血栓栓塞的预防是脑出血患者治疗中的重要组成部分，其措施包括机械预防和药物预防。机械性预防措施包括间歇气动加压装置和梯度压力弹力袜。研究提示，抗凝药预防亦发挥着重要的作用。全面系统地了解脑出血后静脉血栓栓塞的预防，将有助于指导临床和改善患者的转归。     

卒中或短暂性脑缺血发作患者的卒中预防指南 美国心脏协会／美国卒中协会为医疗卫生专业人员制定的指南

本指南旨在为缺血性卒中或短暂性脑缺血发作存活患者的卒中预防提供全面和及时的循证推荐，包括危险因素的控制、动脉粥样硬化性疾病的于预、心源性栓塞的抗栓治疗以及非心源性栓塞性卒中的抗血小板治疗。另外，还对其他许多特殊情况下的复发性卒中预防提供了推荐意见，包括动脉夹层分离、卯圆孔未闭、高同型半胱氨酸血症、高凝状态、镰状细胞病、脑静脉窦血栓形成、女性卒中（尤其是与妊娠和绝经后雌激素替代治疗相关性卒中）、脑出血后抗凝药的使用等，以及实施本指南及其在高危人群中应用的特定方法。     

缺血性卒中或短暂性脑缺血发作患者的卒中预防指南美国心脏协会/美国卒中协会卒中委员会向医疗卫生专业人员的声明心血管放射学与介入委员会共同倡导

这份新声明旨在为缺血性卒中或短暂性脑缺血发作存活者的缺血性卒中预防提供全面和及时的循证推荐.循证推荐包括对危险因素的控制、动脉粥样硬化性疾病的干预措施、心源性栓塞的抗栓治疗以及非心源性栓塞性卒中抗血小板药的应用.另外,还为其他多种特殊情况下复发性卒中的预防提供了推荐,包括动脉夹层分离、卵圆孔未闭、高同型半胱氨酸血症、高凝状态、镰状细胞病、脑静脉窦血栓形成、女性卒中(特别是与妊娠和绝经后激素替代治疗相关卒中)、脑出血后抗凝药的应用,以及该指南在高危人群中执行和应用的特殊措施.     

新型口服抗凝药时代华法林的应用

新型口服抗凝药正逐渐作为非瓣膜性心房颤动患者卒中预防的一线抗凝治疗选择。然而新型口服抗凝药价格昂贵,不适用于孕妇、儿童、瓣膜病及严重肾功能不全患者,大多数患者仍需使用华法林抗凝治疗。华法林被推荐用于系统性血栓、卒中、静脉血栓栓塞的防治。新型口服抗凝药时代如何优化华法林抗凝治疗尤为重要。     

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新型抗凝药物的研发是近年来心血管疾病治疗中最活跃的部分,但是华法林作为最古老的口服抗凝药物仍然是需要长期抗凝治疗患者的最常用药物,例如静脉血栓栓塞性疾病、心房颤动血栓栓塞的预防、瓣膜病和瓣膜置换术后,也包括某些特殊情况下动脉血栓栓塞性疾病的抗凝治疗。凝血因子     

肺癌合并静脉血栓栓塞症的风险评估

静脉血栓栓塞症(venous thromboembolism,VTE)是癌症常见的并发症和最常见的死亡原因之一,主要包括深静脉血栓栓塞症和肺血栓栓塞症.近年来,随着血栓栓塞性疾病研究的深入,肺癌相关性VTE已引起关注.其中,肺癌患者的预防性抗凝治疗具有很大争议性.初级预防能使肺癌相关性VTE发生风险减少,但相关研究同时提示患者出血风险提高.目前尚不推荐对肺癌患者进行常规抗凝,但对血栓风险高、出血风险低的肺癌患者进行选择性抗凝可使其获益.因此,肺癌相关性VTE的风险评估和分级可提高预防性抗凝的临床获益,减少相关出血事件.     

利伐沙班临床研究与应用进展

利伐沙班（Rivaroxaban）是一种新型的口服的直接Xa因子抑制剂。与传统抗凝药相比,利伐沙班的优势非常明显,它是一种疗效确切、不需要不断监测、安全性良好、使用方便的新型抗凝药物^[1]。目前利伐沙班用以防治各种急、慢性血栓栓塞性疾病,主要包括骨科术后静脉血栓形成的预防、静脉血栓栓塞（Venous thromboembolism,VTE）的治疗,心房颤动患者脑卒中的预防、急性冠状动脉综合征二级预防、内科住院患者VTE的预防。笔者参阅相关文献,就利伐沙班的临床研究与应用进展作一综述。     

卒中后深静脉血栓形成的治疗和预防

由于高龄、肢体偏瘫、脱水、血管壁损伤等自身特异性,卒中易引起静脉血栓栓塞(venous thromboembolism,VTE).VTE主要包括深静脉血栓形成(deep vein thrombosis,DVT)和肺栓塞(pulmonary embolism,PE).DVT是指血液在静脉内的非正常凝结,阻碍静脉回流,血栓脱落可形成血栓性栓塞,引起PE、心肌梗死和卒中,不仅会延长住院时间,而且可使病死率增高.文章对卒中后DVT的发病率、危险因素、治疗和预防进行了综述.     

抗凝药物在慢性肾脏病中的使用

几种新型抗凝药物已经替代了传统的抗凝药物用来预防和治疗静脉血栓栓塞症(VTE)和急性冠状动脉综合征(ACS).大多数抗凝药物主要通过肾脏清除;因此在严重肾功能不全的患者中有蓄积的可能,从而增加出血的风险.抗凝治疗增加患者出血的风险是一件令人忧虑的问题.     

卒中和短暂性脑缺血发作患者的卒中预防指南美国心脏协会/美国卒中协会为医疗卫生专业人员制定的指南

本更新版指南旨在为缺血性卒中或短暂性脑缺血发作存活者的卒中预防提供全面和及时的循证推荐.本指南适用于所有为上述患者提供二级预防的临床医生.这些循证推荐包括危险因素的控制、血管闭塞的干预、心源性栓塞的抗栓治疗以及非心源性栓塞性卒中的抗血小板治疗.还对各种特殊情况下复发性卒中的预防提供了推荐意见,包括主动脉弓粥样硬化、动脉夹层分离、卵圆孔未闭、高同型半胱氨酸血症、高凝状态、抗心磷脂抗体综合征、镰状细胞病、脑静脉窦血栓形成以及妊娠.此外,还有专门的章节对颅内出血后抗栓和抗凝治疗的应用以及指南的实施进行了讨论.     

Effectiveness of venous thromboembolism prophylaxis in patients with liver disease

BACKGROUND Patients with liver disease are concomitantly at increased risk of venous thromboembolism(VTE) and bleeding events due to changes in the balance of pro-and anti-hemostatic substances. As such, recommendations for the use of pharmacological VTE prophylaxis are lacking. Recent studies have found no difference in rates of VTE in those receiving and not receiving pharmacological VTE prophylaxis, though most studies have been small. Thus, our study sought to establish if pharmacological VTE prophylaxis is effective and safe in patients with liver disease.AIM To determine if there is net clinical benefit to providing pharmacological VTE prophylaxis to cirrhotic patients.METHODS In this retrospective study, 1806 patients were propensity matched to assess if pharmacological VTE prophylaxis is effective and safe in patients with cirrhosis.Patients were divided and evaluated based on receipt of pharmacological VTE prophylaxis.RESULTS The composite primary outcome of VTE or major bleeding was more common in the no prophylaxis group than the prophylaxis group(8.7% vs 5.1%, P = 0.002),though this outcome was driven by higher rates of major bleeding(6.9% vs 2.9%,P 0.001) rather than VTE(1.9% vs 2.2%, P = 0.62). There was no difference inlength of stay or in-hospital mortality between groups. Pharmacological VTE prophylaxis was independently associated with lower rates of major bleeding(OR = 0.42, 95%CI: 0.25-0.68, P = 0.0005), but was not protective against VTE on multivariable analysis.CONCLUSION Pharmacological VTE prophylaxis was not associated with a significant reduction in the rate of VTE in patients with liver disease, though no increase in major bleeding events was observed.     

临床评分和D-二聚体检查在下肢深静脉血栓中的应用

Objective To evaluate the value of Wells score or/and D-dimer test on diagnosing or excluding deep venous thrombosis (DVT). Methods Patients with suspected DVT were retrospectively analyzed. All patients underwent clinical assessment, D-dimer assay and bilateral lower extremity eompression sonography within 48 hours of admission. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for diagnosing DVT by Wells score, D-direct test, and combined Wells score and D-dimer were compared. Results A total of 274 patients were analyzed. If low probability was defined as negative and moderate and high probabilities were defined as positive, the sensitivity, specificity, PPV and NPV of the Wells score were 78.4%, 66.1%, 52.3% and 86.6%, respectively. At a cut-off of 500 μg/L, the sensitivity, specificity, PPV and NPV of D-dimer test were 73.9% ,66.1%, 50.8% and 84. 2%, respectively. If low probability and D-dimer < 500 μgL were defined as negative, moderate and high probabilities and D-dimer≥500 μg/L were defined as positive, the sensitivity, specificity, PPV and NPV of the combined Wells score and D-dimer test were 88.3%, 76.8%, 67.1% and 92.5% , respectively. Conclusion For clinical suspected DVT patients, DVT diagnosis could be reliably obtained by combined Wells score and D-dimer test.     

肿瘤患者静脉血栓栓塞症的预测及预防用药

静脉血栓栓塞症(VTE)在肿瘤患者中发生率较高,是肿瘤患者致残、致死的重要原因之一.采取简单易行的方案预测其发生,并采取相应预防用药,有助于减少VTE的发生,减少其致残率及死亡率,延长患者的生存期.对肿瘤患者VTE早预防、早发现、早诊断、早治疗是提高肿瘤患者治疗疗效、防止并发症的关键.     

Venous thromboembolism in cirrhosis: A review of the literature

Although hemorrhage has traditionally been regarded as the most significant hemostatic complication of liver disease, there is increasing recognition that hypercoagulability is a prominent aspect of cirrhosis. Identifying markers of coagulability and monitoring anticoagulation therapy in the setting of cirrhosis is problematic. The bleeding risk of venous thromboembolism (VTE) prophylaxis and treatment in patients with chronic liver disease is unclear and there are currently no recommendations to guide practice in this regard. In the present report, the mechanism of coagulation disturbance in chronic liver disease is reviewed with an examination of the evidence for an increased VTE risk in cirrhosis. Finally, the available evidence is assessed for prophylaxis and therapy of VTE in chronic liver disease, and the role it may play in decreasing clinical decompensation and improving survival.     

P-选择素与静脉血栓栓塞症

血小板激活是静脉血栓形成的重要组成步骤,P-选择素是血小板的活性受体,也能被上皮细胞所识别.作为血小板/内皮细胞活化标志和细胞黏附受体.其可通过介导血小板、内皮细胞黏附及与白细胞的相互作用,启动参与包括炎症和血栓形成等多种病理生理起始过程,是血栓形成的重要介质和靶分子.检验P.选择素可以通过流式细胞仪检测血小板表面的P一选择素或通过酶联免疫吸附试验检测血液中可溶性P-选择素,方法简便,这些数据可作为血小板激活的判断.从而为血栓形成提供依据.抑制P一选择素及其配体的结合,可使病理状态下血栓局部白细胞聚集减少,细胞因子及组织因子表达降低,纤维蛋白生成减少,从而有助于抑制血栓的形成.     

Secular Trends in Occurrence of Acute Venous Thromboembolism: The Worcester VTE Study (1985-2009)

Background

The clinical epidemiology of venous thromboembolism has changed recently because of advances in identification, prophylaxis, and treatment. We sought to describe secular trends in the occurrence of venous thromboembolism among residents of the Worcester, Massachusetts, metropolitan statistical area.

Methods

Population-based methods were used to monitor trends in event rates of first-time or recurrent venous thromboembolism in 5025 Worcester, Massachusetts, metropolitan statistical area residents who were diagnosed with acute pulmonary embolism or lower-extremity deep vein thrombosis during 9 annual periods between 1985 and 2009. Medical records were reviewed by abstractors and validated by clinicians.

Results

Age- and sex-adjusted annual event rates for first-time venous thromboembolism increased from 73 (95% confidence interval [CI], 64-82) per 100,000 in 1985/1986 to 133 (CI, 122-143) in 2009, primarily because of an increase in pulmonary embolism. The rate of recurrent venous thromboembolism decreased from 39 (CI, 32-45) in 1985/1986 to 19 (CI, 15-23) in 2003, and then increased to 35 (CI, 29-40) in 2009. There was an increasing trend in using noninvasive diagnostic testing, with approximately half of tests being invasive in 1985/1986 and almost all noninvasive by 2009.

Conclusions

Despite advances in identification, prophylaxis, and treatment between 1985 and 2009, the annual event rate of venous thromboembolism has increased and remains high. Although these increases partially may be due to increased sensitivity of diagnostic methods, especially for pulmonary embolism, they also may imply that current prevention and treatment strategies are less than optimal.     

Gastric Tonometry in Assessing Splanchnic Tissue Perfusion in Acute Pancreatitis

Background: Hypovolemia is typical early in acute pancreatitis. Despite fluid resuscitation splanchnic hypoperfusion may be present and may have a role in the course of pancreatitis. To test this hypothesis, we assessed gastric mucosal pH (pHi) and PCO₂ during the first 48 h of hospitalization for acute pancreatitis. Methods: Thirty-three patients were studied. A gastric tonometer was inserted on admission, and gastric mucosal pH and PCO₂ were measured on admission and then every 12 h during next 48 h. Results: On the basis of the Atlanta classification there were 22 cases of mild and 8 of severe pancreatitis. Three patients were excluded because of consent withdrawal. The groups were similar with regard to age, sex ratio, and etiology of pancreatitis. Independently of disease severity the gastric pHi decreased, and the gastric mucosal-arterial PCO₂ difference and pH difference both increased over time as compared with base line. No difference was seen in these values between mild and severe pancreatitis. Conclusions: Moderate gastric mucosal hypoperfusion was found early in acute pancreatitis. However, gastric pHi measurement with tonometry has no obvious value as a screening tool to assess the severity of pancreatitis.