慢性血栓栓塞性肺动脉高压的抗凝治疗进展

慢性血栓栓塞性肺动脉高压(CTEPH)在2018年第6届世界肺动脉高压大会中归为第四大类肺动脉高压[1].CTEPH由慢性、纤维性、未能完全溶解的肺血管床血栓栓塞,以及肺动脉重塑导致肺血管阻力增高,肺动脉压力进行性增高.国际公认,CTEPH患者首选肺动脉内膜剥脱术(PEA),外科手术是唯一有望达到治愈疗效的方法.随着手...     

慢性血栓栓塞性疾病一例

肺栓塞是以各种栓子阻塞肺动脉或其分支引发的一组疾病或临床综合征的总称,最常见的是肺血栓栓塞症（PTE）。其中部分患者因血栓不溶、机化、肺血管重塑致血管狭窄或闭塞,导致肺血管阻力（PVR）增加,肺动脉压力进行性增高,最终可引起右心室肥厚和右心衰竭,称为慢性血栓栓塞性肺动脉高压（CTEPH）。国外经右心漂浮导管确诊的症状性...     

心肺运动试验参数预测慢性血栓栓塞性肺动脉高压患者心输出量的性别差异性

目的:探究心肺运动试验(CPET)参数评估慢性血栓栓塞性肺动脉高压(CTEPH)患者心输出量的性别差异性特征。方法:回顾性纳入了来自2010年5月至2016年2月上海市肺科医院肺循环科初次住院治疗的73例成年CTEPH患者(男32例,女41例),以是否发生临床恶化事件为标准进行亚组分析。所有患者均进行了CPET及右心导管检查。多元线性回归分析心输出量降低的独立预测因素。结果:女性CTEPH患者较男性患者年轻( P<0.05),其他一般资料与血流动力学参数在两性患者中的差异无统计学意义。男性患者较女性有较高的无氧域点氧脉搏、峰值分钟通气量和无氧域点呼气末氧分压、峰值氧脉搏和无氧域点分钟通气量以及二氧化碳通气当量最低点( P值均<0.05),而女性患者的摄氧效率平台较高( P<0.05)。在亚组分析中,男性患者的CPET参数在有恶化事件组和无恶化事件组中差异无统计学意义,而峰值摄氧量在女性患者有恶化事件组中显著降低( P<0.05)。此外,与男性有恶化事件组比较,女性有恶化事件组的峰值摄氧量、无氧域点分钟通气量和峰值分钟通气量相对较低( P值均<0.05)。二氧化碳通气当量最低点和峰值呼气末氧分压分别是预测男性和女性CTEPH患者心输出量的独立预测因子。 结论:CPET参数评估男性和女性CTEPH患者心输出量的独立预测因子不同,提示将CPET的性别差异纳入CTEPH患者的临床评估中可使更多患者受益。     

慢性血栓栓塞性肺高压的治疗现状

慢性血栓栓塞性肺高压（chronic thromboembolic puhnonary hypertension, CTEPH）是指由于机化血栓阻塞近端或远端肺动脉后,造成以肺动脉压力增高为特点的一类疾病。过去曾认为CTEPH是非常罕见的疾病,目前国际上虽仍缺乏确切可靠的流行病学资料,但实际上其发病率被远远低估。CTEPH已成为引起严重肺高压的重要病因之一。     

慢性血栓栓塞性肺动脉高压基础与转化研究进展

慢性血栓栓塞性肺动脉高压(CTEPH)属于肺动脉高压的第四大类, 以肺动脉血栓机化、肺血管重塑致血管狭窄或闭塞, 肺动脉压力进行性升高, 最终出现右心功能衰竭导致患者死亡。CTEPH发病机制有待进一步阐明。然而, 对于CTEPH的诊断以及治疗方案尚需要探索, 其预后及其机制尚未明确。本文对CTEPH病理机制及基础转化研究新进展进行梳理。     

2020年《欧洲呼吸学会慢性血栓栓塞性肺动脉高压的专家共识》解读

慢性血栓栓塞性肺动脉高压(chronic thromboembolic pulmonary hypertension,CTEPH)是以肺动脉血栓机化、肺血管重构致肺血管狭窄或闭塞,引起肺动脉压力进行性升高,最终导致右心衰竭为特征的一类疾病.CTEPH 属于肺动脉高压(pulmonary hypertension,PH)...     

慢性血栓栓塞性肺动脉高压的误诊分析

慢性血栓栓塞性肺动脉高压(CTEPH)是指肺动脉及其主要分支由于血栓栓塞导致的血流受阻,长期不能缓解或进行性加重,导致肺动脉高压。CTEPH的误诊率很高,笔者对近3年所收治的7例CHEPH患者进行误诊分析,以提高对CTEPH的认识。1对象与方法近3年我院心内科确诊的CTEPH患者共7例,男2例,女5例。年龄40~66(52±9.52)岁。均经螺旋CT肺血管造影(CTPA)和肺通气灌注扫描证实的至少有1个肺段以上的肺栓塞。患者均经过超声多普勒检测肺动脉收缩压>30mmHg(1mmHg=0·133kPa)以上,均排除其他非血栓栓塞性肺动脉高压。2结果症状体征:主要症状有…     

慢性血栓栓塞性肺动脉高压的诊疗进展

慢性血栓栓塞性肺动脉高压(chronic thromboembolic pulmonary hypertension,CTEPH),属于肺动脉高压分型的第四大类,是目前唯一可能治愈的肺动脉高压,不干预则远期预后不佳,故明确诊断和积极治疗非常重要。对于CTEPH的诊断,肺通气灌注显像较CT肺动脉造影有更高的敏感性。CTEPH的预后与其治疗决策密切相关:所有患者都需要终身抗凝,利奥西呱是目前唯一获批用于CTEPH治疗的靶向药物。能否手术治疗取决于CTEPH的血栓机化部位:对于血栓栓塞在肺动脉近端,可行肺动脉内皮剥脱,其治愈率高,术后恢复以及长期预后往往较为理想;如果病变部位在中段,可以尝试进行肺动脉球囊扩张,球囊扩张往往需要分次逐步进行,扩张后患者活动耐量有显著提升,此外球囊扩张也用于如外科内皮剥脱后残余肺动脉高压或肺动脉高压复发;如果病变部位在肺血管末端,则只能选择药物保守治疗。多种治疗手段联合治疗或为未来CTEPH治疗的发展方向。     

慢性血栓栓塞性肺动脉高压治疗策略选择

慢性血栓栓塞性肺动脉高压(CTEPH)是一种严重威胁生命的疾病,临床一次或多次血栓栓塞事件发生或反复发生使肺血管床阻塞,血流阻力增加,肺动脉压力进行性增高,最终导致右心力衰竭。肺动脉血栓内膜切除术(pulmonary thromboendarterectomy)是CTEPH的治疗手段之一,为CTEPH的患者提供了治愈的可能。CTEPH远端肺动脉病变可考虑内科药物治疗。但是何时选择外科手术干预,如何正确选择内科药物治疗,仍需要进一步的研究进行评价。     

2018版中国《肺血栓栓塞症诊治与预防指南》解读之五:慢性血栓栓塞性肺动脉高压的诊治

慢性血栓栓塞性肺动脉高压(CTEPH)是急性肺血栓栓塞症(PTE)的远期并发症,属于第四大类肺动脉高压。肺动脉血栓内膜剥脱术(PEA)是CTEPH的首选治疗方法,不能行PEA或PEA术后残余肺动脉高压的患者可选择介入治疗和(或)药物治疗。与2001年《肺血栓栓塞症的诊断与治疗指南(草案)》相比,2018版《肺血栓栓塞症诊治与预防指南》增加了CTEPH的诊断和治疗。文章旨在详细解读新版指南中CTEPH的诊断策略和最新治疗方法,更好地指导临床实践。     

The immunoneuroendocrine role of melatonin

Abstract: A tight, physiological link between the pineal gland and the immune system is emerging from a series of experimental studies. This link might reflect the evolutionary connection between self-recognition and reproduction. Pinealectomy or other experimental methods which inhibit melatonin synthesis and secretion induce a state of immunodepression which is counteracted by melatonin. In general, melatonin seems to have an immunoenhancing effect that is particularly apparent in immunodepressive states. The negative effect of acute stress or immunosuppressive pharmacological treatments on various immune parameters are counteracted by melatonin. It seems important to note that one of the main targets of melatonin is the thymus, i.e., the central organ of the immune system. The clinical use of melatonin as an immunotherapeutic agent seems promising in primary and secondary immunodeficiencies as well as in cancer immunotherapy. The immunoenhancing action of melatonin seems to be mediated by T-helper cell-derived opioid peptides as well as by lymphokines and, perhaps, by pituitary hormones. Melatonin-induced-immuno-opioids (MHO) and lymphokines imply the presence of specific binding sites or melatonin receptors on cells of the immune system. On the other hand, lymphokines such as -γ-interferon and interleukin-2 as well as thymic hormones can modulate the synthesis of melatonin in the pineal gland. The pineal gland might thus be viewed as the crux of a sophisticated immunoneuroendocrine network which functions as an unconscious, diffuse sensory organ.     

Changes in connexin43, the gap junction protein of astrocytes, during development of the rat pineal gland

Abstract: The abundance of gap junctions between rat pineal astrocytes formed by connexin43 (Cx43) was studied during development. Levels and distribution of Cx43 were measured by immunoblotting and indirect immunofluorescence, respectively. The amount of Cx43 in cells located within the gland was low until about the 7th postnatal day and increased to adult values between the 14th and 21st days postpartum. Although astrocytes, recognized by their vimentin immunoreactivity, were scarce before birth, they were abundant by the 7th postnatal day suggesting that the low levels of Cx43 found at this age corresponded to a low expression of this protein. Localization of the immunoreactivity to Cx43 and vimentin showed a close correlation, indicating that mature or immature pineal astrocytes form gap junctions made of Cx43. Since Cx43 levels attained their adult values at about the time the innervation and the functional state of the gland reached maturity (2–3 weeks after birth), it is proposed that astrocyte gap junctions are involved in the function of the adult rat pineal gland.     

Response of rat pineal melatonin to calcium, magnesium, and lithium is circadian stage dependent

Abstract: Herein we documented the response of pineal melatonin production to electrolytes known to be effective on pineal function in view of a possible circadian stage dependence. We studied the release of melatonin by perifused rat pineal glands at 2 different circadian stages corresponding to the middle of the light and dark periods, i.e., respectively, 7 and 19 HALO (Hours After Light Onset, L:D = 12:12). The initial efflux rates were, as expected, much higher in the perifusates of glands removed from rats sacrificed during the dark phase than of those removed during the light phase. After 3 hr of perifusion, melatonin release reached similar levels which were found constant up to the 8th hr of perifusion, whatever the circadian stage. Perifusion of the glands with physiological concentrations for the rat of calcium (5.2 mmol/1) and magnesium (1.34 mmol/1) resulted in a stimulatory effect on the pineal glands removed from rats sacrificed in the middle of the dark period (19 HALO), whereas no effects were observed on the pineal glands removed from rats sacrificed during the light (7 HALO). Lithium (0.28 and 0.55 mmol/1) was ineffective on melatonin release in pineal glands removed 7 and 19 HALO. Our results show differences in the initial efflux rates of melatonin and in the response of perifused pineal glands to calcium and magnesium according to the circadian stage.     

Conservative management of perforated duodenal diverticulum： A case report and review of the literature

Duodenal diverticula are a relatively common condition. They are asymptomatic, unless they become complicated, with perforation being the rarest but most severe complication. Surgical treatment is the most frequently performed approach. We report the case of a patient with a perforated duodenal diverticulum, which was diagnosed early and treated conservatively with antibiotics and percutaneous drainage of secondary retroperitoneal abscesses. We suggest this method could be an acceptable option for the management of similar cases, provided that the patient is in good general condition and without septic signs.     

Presence of immunoreactive growth hormone and prolactin in the ovine pineal gland

Abstract: The use of antisera raised against bovine growth hormone (GH) and ovine prolactin (PRL) enabled the detection of related immunoreactive (ir) sequences of proteins in ovine pineal tissue. The isolation of PRL-like ir-material was accomplished using a 0.25 M ammonium sulphate (pH 5.5) extraction followed by ethanol precipitation, whereas the resulting 2.0 M ammonium sulphate (pH 7.0) precipitate contained a GH-like immunoreactivity. Gel chromatography of the GH-like immunoreactivity (Sephadex G-100) indicated the presence of several GH-like fragments ranging in the M_r range of 7,000 to 55,000. Analyses of the PRL-like ir-material found in pineal tissue on HPLC using a TSK 545-DEAE column led to the resolution into a single peak of immunoreactivity. A single peak of activity was also observed following chromatofocusing and hydrophobic interaction chromatography of the ir-peak from the TSK 545-DEAE column. The PRL-like ir-material inhibited the binding of [¹²⁵I]ovine PRL-S14 to anti-ovine PRL antibodies without showing an affinity for binding to anti-rat PRL or anti-bovine GH antibodies. Scatchard analysis of the binding of pineal PRL-like ir-material and pituitary ovine PRL-S14 to liver membranes from day-20 pregnant rats revealed similar affinity constants (K_a of 4.7 ± 0.2 × 10⁹ M^-1). In addition, the replication of Nb 2 Node rat lymphoma cells was stimulated by pineal PRL-like ir-material, an effect known to be specific for lactogenic hormones. The pineal PRL-like immunoreactivity appeared on sodium dodecyl sulfate polyacrylamide gels as a single major band of M_r 24,000. The functional status of PRL-and GH-like ir-material in the ovine pineal remains to be determined, but evidence is presented that the overall protein synthesis rate of the rat pineal responded to circulating concentrations of PRL.     

Microbiology of human immunodeficiency virus anorectal disease

PURPOSE: Individuals who are seropositive for the human immunodeficiency virus are at high risk for opportunistic infection and anorectal disorders. Little prospective information is available regarding anorectal pathogens in these patients. METHODS: One hundred sixty-three HIV-seropositive patients presented to the colorectal clinic between 1989 and 1992. Forty-seven (29 percent) patients were thought to have an infectious process and were prospectively studied using a standardized multiculture protocol. RESULTS: Mean age was 33 (range, 19–59) years. All were male; high-risk behavior accounted for 87 percent of HIV transmissions. Presenting complaints included anorectal pain (79 percent), pus per anum (28 percent), and blood per anum (26 percent). Examination revealed perianal tenderness (60 percent), condyloma (38 percent), perianal ulcers (38 percent), and anal fissures (34 percent). Sixty-six sets of cultures were performed; 28 patients had one set, 15 had two sets, and 4 had three sets. Thirty-two of these 47 patients (68 percent) had positive cultures including herpes (50 percent), cytomegalovirus (25 percent),Neisseria gonorrhoeae (16 percent), chlamydia (16 percent), acidfast bacilli (2 percent), and others (9 percent). Six of 32 patients with positive cultures had more than one organism cultured. Sixteen (50 percent) patients with positive cultures were treated medically, 8 (25 percent) were treated surgically and 8 (25 percent) were treated with both modalities. Sixty-one procedures were performed on 17 patients for condylomata. Eighteen patients had 20 procedures for abscesses, 50 percent of whom had positive cultures for other than common bowel flora; all improved. Fourteen patients underwent 33 procedures for perianal fistulas.Mycobacterium fortuitum was cultured from one patient who required 13 procedures for abscesses and fistulas. Forty-five (96 percent) patients were followed for an average of 12.5 months ±2.9 SEM (range, 1–94 months). Symptoms were improved or resolved in 22 of 32 (69 percent) patients with positive cultures and in 11 of 13 (84 percent) with negative cultures. CONCLUSIONS: Specific pathogens may often be identified in human immunodeficiency virus-seropositive patients with anorectal disorders if aggressively sought. Although patients without specific pathogens identified may be expected to improve with planned empiric treatment, positive identification allows more directed therapy.