替格瑞洛用于急性冠脉综合征行药物洗脱支架植入患者抗血小板治疗有效性及安全性分析

目的探讨替格瑞洛对急性冠脉综合征行药物洗脱支架植入患者抗血小板治疗的有效性及安全性。方法选取4 401例接受药物洗脱支架植入的急性冠脉综合征患者,在规律应用阿司匹林的基础上(300 mg负荷剂量,100 mg 1次/d),联用替格瑞洛(180 mg负荷剂量,90 mg 2次/d)或氯吡格雷(300~600 mg负荷剂量,75 mg 1次/d),并根据联合用药分为替格瑞洛组和氯吡格雷组。研究终点为术后1年内的有效性终点事件(心血管死亡、心肌梗死、缺血性脑卒中、支架内血栓及复合终点事件)和安全性终点事件(根据美国出血学术研究会制定的标准定义划分的全部出血、大出血和小出血事件)。结果替格瑞洛组的有效性的复合终点事件(HR=0.64,95%可信区间0.42~0.99,P<0.05)和心血管死亡事件(HR=0.07,95%可信区间0.02~0.30,P<0.01)明显低于氯吡格雷组,且安全性终点中大出血事件,差异无统计学意义(HR=0.97,95%可信区间0.50~1.87,P>0.05),但替格瑞洛组小出血和总出血事件明显高于氯吡格雷组。结论对于急性冠脉综合征行药物洗脱支架植入的患者,替格瑞洛与氯吡格雷相比能够明显减少血栓事件再发风险且不增加致命性大出血事件。     

急性心肌梗死和冠脉支架术后再狭窄患者氯吡格雷抵抗相关因素分析

目的探讨急性心肌梗死和冠脉支架内再狭窄患者双联抗血小板治疗后氯吡格雷抵抗的发生率及相关影响因素。方法对102例急性心肌梗死和冠脉支架内再狭窄的患者给予氯吡格雷治疗后,经Verify Now检测系统测定血小板功能。以Verify Now测试结果 P2Y12反应单位≥208定义为氯吡格雷抵抗。比较氯吡格雷抵抗患者和无氯吡格雷抵抗患者的一般临床资料、基因多态性、实验室指标和影像学特征差异,分析氯吡格雷抵抗的相关因素。结果氯吡格雷抵抗发生率为47.06%,两组在女性、年龄、全球急性冠状动脉事件注册危险(GRACE)评分、尿素氮、血红蛋白、红细胞计数、肌酸激酶同工酶(CKMB)、CYP2C19*2基因型的差异有统计学意义(P<0.05)。相关性分析显示,氯吡格雷抵抗与年龄、性别、尿素氮、肾小球滤过率、红细胞计数、血红蛋白、GRACE评分、GRUSADE评分、CYP2C19*2纯合子基因型存在相关性(P<0.05),相关系数在0.2~0.5间。Logistic回归结果发现GRACE评分、CYP2C19*2基因型、尿素氮可能是氯吡格雷抵抗的独立预测因素(P<0.05)。结论 GRACE评分、CYP2C19*2纯合子基因型、尿素氮可能是氯吡格雷抵抗的独立预测因素。     

CPGR对糖尿病合并冠心病患者PCI术后不良事件发生的影响

目的 探讨氯吡格雷抵抗(CPGR)对冠心病合并糖尿病患者经皮冠脉介入手术(PCI)治疗后不良事件的影响.方法 回顾性分析我院2010年3月～2014年1月收治的180例冠心病合并糖尿病患者的临床资料,根据术前是否出现CPGR分为氯吡格雷抵抗组(观察组,84例)和非氯吡格雷抵抗组(对照组,96例).比较两组术前的血糖、血脂以及炎症指标;并于PCI术后随访1年,比较两组心血管不良事件的发生情况.结果 观察组的血糖和hs-CRP水平均明显高于对照组,而HDL-C水平则低于对照组(P＜0.05).观察组发生非致死性心梗、支架内血栓发生率及再住院率等均明显高于对照组(P＜0.05).结论 冠心病合并糖尿病患者存在CPGR时,可能增加PCI术后心梗、支架内血栓率等发生率.对于此类患者,应积极降血糖、血脂,对降低CPGR具有积极的意义.     

不同质子泵抑制剂对PCI术后氯吡格雷抗血小板临床效果的影响

目的 探讨不同机制的质子泵抑制剂对冠脉介入治疗(PCI)术后氯吡格雷抗血小板临床效果的影响.方法 选择2008年10月-2009年9月在解放军总医院实施PCI术后氯吡格雷联合阿司匹林抗血小板治疗(氯吡格雷75mg/d+阿司匹林100mg/d)的患者406例.将患者随机分为奥美拉唑组(40mg/d,146例)、泮托拉唑组(40mg/d,140例)和对照组(未服用质子泵抑制剂,120例),连续用药30d.观察比较各组主要不良心血管事件(心源性死亡、非致死性急性心肌梗死、紧急靶血管血运重建、亚急性支架内血栓、脑卒中)发生率和出血并发症发生情况.结果 三组的临床基本资料、冠脉造影及PCI结果无统计学差异.奥美拉唑组的心源性死亡、非致死性急性心肌梗死、紧急靶血管血运重建、亚急性支架内血栓、脑卒中的发生率分别为0.70%、2.11%、3.52%、1.41%、0.70%;泮托拉唑组分别为0.72%、2.90%、2.90%、0.72%、0.72%,对照组分别为0.83%、1.66%、3.33%、1.66%、0.83%,三组主要不良心血管事件发生率相近,差异无统计学意义(P>0.05).与对照组(10.83%)比较,奥美拉唑组和泮托拉唑组出血发生率(分别为6.33%、6.52%)均明显减少,差异有统计学意义(P<0.01),但两组之间的出血发生率差异无统计学意义(P>0.05).结论 奥美拉唑和泮托拉唑作用相近,不降低冠脉支架植入术后氯吡格雷联合抗血小板治疗对心血管事件的预防效果,同时可明显降低患者出血事件发生率.     

冠状动脉支架术后优化抗血小板治疗的单中心随机对照预试验

目的 探讨根据实验室检测结果调整、优化冠状动脉支架术后抗血小板治疗方案的可行性和有效性.方法 收集2006年6月-2007年2月在沈阳军区总医院行冠状动脉支架术患者305例,计算机随机分为优化组(n＝154)及标准组(n＝151).氯吡格雷抵抗(CR)定义为氯吡格雷治疗24h后血小板聚集率(PAR)降低＜10%.标准组所有病例均采用标准阿司匹林、氯吡格雷两联抗血小板治疗;优化组非CR患者接受标准两联抗血小板治疗,CR患者在标准两联治疗基础上加服西洛他唑6个月.研究主要终点为随访1年时的死亡、心肌梗死(MI)和缺血性卒中复合终点,次要终点为随访1年时的死亡、MI、缺血性卒中、血运重建及外周动脉闭塞的复合终点.结果 优化组及标准组CR患者分别为41例和33例.优化组CR患者PAR在两联抗血小板治疗基础上加用西洛他唑治疗后(64.5%±12.1%)显著低于单纯应用两联抗血小板治疗(77.5%±12.1%,P＜0.001).随访1年后,优化组主要终点事件风险(5.8%)较标准组(9.3%)下降37%,但差异无统计学显著意义(P＝0.257).优化组心性死亡、心肌梗死、缺血性卒中、血运重建及下肢动脉闭塞的复合终点事件发生率为9.7%,标准组为14.6%,两组比较无显著差异(P＝0.197),但优化组有降低趋势.两组支架内血栓形成及出血事件发生率均无显著差异.优化组CR患者的主要心脑血管缺血事件发生率为19.5%,与标准组CR患者(36.4%)相比有降低趋势,但差异无统计学意义(P＝0.105).结论 根据PAR检测结果调整抗血小板治疗方案可能有利于改善CR患者的长期预后,但其有效性和安全性还需大样本临床研究证实.     

基因型指导下急性冠脉综合征患者择期经皮冠状动脉介入术后应用替格瑞洛与氯吡格雷有效性分析

目的探讨在基因检测条件下急性冠脉综合征(ACS)患者择期经皮冠状动脉介入(PCI)术后应用替格瑞洛和氯吡格雷的有效性。方法选取2015年1—6月在西京医院心血管内科诊断为ACS并行择期PCI术的患者作为研究对象,随访1年,最终纳入有1年随访资料并行基因检测患者933例。依据患者服用双联抗血小板药物(DAPT)不同,分为替格瑞洛组(n=239)和氯吡格雷组(n=694)。根据等位基因功能缺失的基因型差异分为快代谢型、中间代谢型和慢代谢型。比较3种代谢型下两种药物的临床效益,即主要心脑血管不良事件(MACCE),包括心血管死亡、缺血驱动的血运重建、缺血性卒中。结果在快代谢型组,与服用替格瑞洛患者比较,氯吡格雷是发生MACCE的保护性因素(HR=0.481,95%可信区间0.268~0.863,P=0.014);在慢代谢型组,与服用替格瑞洛患者比较,氯吡格雷是发生MACCE的危险性因素(HR=3.481,95%可信区间1.122~10.799,P=0.031)。氯吡格雷与其代谢型间存在明显交互作用(P<0.05)。结论对于慢代谢基因型患者,替格瑞洛的临床效益明显优于氯吡格雷。     

药物洗脱支架治疗老年女性多支冠脉病变的临床研究

目的探讨药物洗脱支架(DES)治疗老年女性多支冠状动脉病变的疗效及安全性。方法2002年10月～2005年6月经冠脉造影证实为多支冠状动脉病变老年(≥65岁)女性患者387例,均行经皮冠状动脉介入治疗(PCI),其中DES组139例,普通金属支架(BMS)组248例。比较两组支架术后近期及远期的临床疗效。结果DES组糖尿病患者的比例明显高于BMS组(42.4%vs29.8%,P<0.05)。两组高血压病和心功能不全的比例、冠状动脉病变的严重程度、PCI成功率及并发症发生率均无统计学差异。对371例患者随访6～36个月(20.8±12.6个月),DES组和BMS组造影随访率分别为53.7%和56.1%,无明显差异(P>0.05),但DES组复查造影再狭窄率和主要不良心脏事件(MACE)发生率均明显低于BMS组(分别为4.2%vs15.8%和7.5%vs17.3%,P<0.05)。结论老年女性多支病变患者应用多枚DES的成功率高,严重并发症少,术后再狭窄率低,长期临床疗效良好。     

糖尿病患者冠状动脉介入治疗术后三联抗血小板治疗的长期疗效

目的 评价急性冠脉综合征(ACS)合并糖尿病(DM)患者冠状动脉介入治疗(PCD)术后应用新型三联抗血小板治疗(西洛他唑、阿司匹林和氯吡格雷)的长期疗效和安全性.方法 收集2005年4月-2006年2月沈阳军区总医院ACS患者,PCI术后进行两联和三联抗血小板治疗的疗效对比.本研究中入选的合并DM患者共263例,其中122例随机接受标准的阿司匹林和氯吡格雷两联抗血小板治疗(两联组),141例接受阿司匹林、氯吡格雷和西洛他唑三联抗血小板治疗(三联组).主要终点包括随访1年时的心源性死亡、非致死性心肌梗死(MD、卒中或靶血管血运重建(TVR).结果 两组临床和冠脉造影基线特征无显著差异.随访1年两组无支架内血栓和非致死性MI事件发生;三联组心性死亡、卒中、TVR发生率分别为1.4%、0.7%、7.8%,两联组分别为4.1%、3.3%、12.3%,两组比较均无显著差异(P＝0.255,P＝0.186,P＝0.223);但三联组术后1年主要不良心脑事件发生率[9.9%(14/141)]低于两联组[18.9%(23/122),P＝0.038],其中接受降糖药物治疗者获益更明显.两组出血性事件、过早停用抗血小板药物的发生率无显著差异.结论 DM患者PCI术后接受氯吡格雷、阿司匹林和西洛他唑三联抗血小板治疗可有效地减少长期不良心脑血管事件发生率,尤其对DM程度严重的ACS者效果更加明显.     

负荷剂量的氯吡格雷在急性心肌梗死直接支架术中的应用

目的　分析负荷剂量的氯吡格雷对急性心肌梗死、直接支架术的治疗效果。方法　采用回顾性分析临床资料的方法 ,将 74例直接支架植入的病例分为氯吡格雷组 (38例 )及噻氯匹定组 (36例 ) ,观察发病 4周内出血、粒细胞及血小板减少等并发症的发生情况 ,随访发病后 6个月内临床事件的发生情况。结果　临床事件总发生数分别为氯吡格雷组 8(2 1.1% )及噻氯匹定组 16例 (4 4 .4 % ) ,P =0 .0 31。轻度出血数分别为 6例 (15 .8% )及 14例 (38.9% ) ,白细胞计数分别为 (5 .8± 1.7)及 (4 .2± 3.6 )(× 10 9 L) ,血小板计数分别为 (130 .3± 4 2 .1)× 10 9及 (89.2± 5 3.3)× 10 9 L(P <0 .0 5 )。结论　负荷剂量的氯吡格雷对直接支架术的急性心肌梗死有良好的治疗效果 ,不良反应发生少于噻氯匹定     

药物涂层支架与冠脉搭桥术治疗冠状动脉多支病变疗效对比与评估

目的:评价与比较多支冠脉病变行冠状动脉旁路移植术(CABG)与药物洗脱支架(SES)植入的近期与中期治疗效果。方法:入选2007年7月至2010年6月在我院行血管重建术的407例冠心病多支冠脉病变患者,其中251例行DES置入术(DES组),156例行冠脉旁路移植术(CABG组)。比较两组住院期和随访期不良心血管事件(死亡、非致死性心肌梗死、再次血管重建术和脑血管意外)的发生情况。结果:两组的临床和冠脉病变特征相似,CABG组三支病变、前降支近段病变、左主干病变和慢性完全闭塞病变,及陈旧性心梗(OMI)患者数与SES组差异有统计学意义(p﹤0.05)。住院期两组总体不良心血管事件发生率无明显差异,随访367例患者(92.1%),平均临床随访12～36(17±9)个月,2组总体不良心血管事件发生率仍无明显差异(9.2%∶11.4%,P0.05),但DES组再次血管重建的发生率较CABG组有增高趋势(8.9%∶2.6%,P0.05)。结论对于多支冠状动脉病变患者,DES置入术安全可行,总体不良心血管事件发生率与CABG无明显差异。     

Knee injury and Osteoarthritis Outcome Score (KOOS) - validation of a Swedish version

The Knee injury and Osteoarthritis Outcome Score (KOOS) is a self-administered instrument measuring outcome after knee injury at impairment, disability, and handicap level in five subscales. Reliability, validity, and responsiveness of a Swedish version was assessed in 142 patients who underwent arthroscopy because of injury to the menisci, anterior cruciate ligament, or cartilage of the knee. The clinimetric properties were found to be good and comparable to the American version of the KOOS. Comparison to the Short Form-36 and the Lysholm knee scoring scale revealed expected correlations and construct validity. Item by item, symptoms and functional limitations were compared between diagnostic groups. High responsiveness was found three months after arthroscopic partial meniscectomy for all subscales but Activities of Daily Living.     

Endovascular management of carotid-cavernous fistulas

Objective To investigate endovascular treatment of traumatic direct carotid-cavernous fistulas （CCF） and their complications such as pseudoaneurysms. Methods： Over a five-year period, 22 patients with traumatic direct CCFs were treated endovascularly in our institution. Thirteen patients were treated once with the result of CCF occluded, 8 twice and 1 three times. Treatment modalities included balloon occlusion of the CCF, sacrifice of the ipsilateral internal carotid artery with detachable balloon, coll embolization of the cavernous sinus and secondary pseudoaneurysms, and covered-stem management of the pseudoaneurysms. Results All the direct CCFs were successfully managed endovascularly. Four patients developed a pseudoaneurysm after the occlusion of the CCF with an incidence of pseudoaneurysm formation of 18.2% （4/22）. A total number of 8 patients experienced permanent occlusion of the ICA with a rate of ICA occlusion reaching 36.4% （8/22）. Followed up through telephone consultation from 6 months to 5 years, all did well with no recurrence of CCF symptoms and signs. Conclusion Traumatic direct CCFs can be successfully managed with endovascular means. The pseudoaneurysms secondary to the occlusion of the CCFs can be occluded with stent-assisted coiling and implantation of covered stents.     

The acutely limping child

Acute limping may be the result of multiple pathologies in children. The differential diagnosis varies based on the age of the child. Irrespective of age, the initial imaging work-up includes AP and frog leg radiographs of the pelvis and ultrasound; MRI may sometimes be helpful. In children less than 3 years, infections and trauma are most frequent. MRI is the imaging modality of choice when osteomyelitis is clinically suspected. Between the ages of 3 and 10 years, transient synovitis of the hip and Legg-Calvé-Perthes disease are main considerations but infection, inflammation and focal bony lesions are also considered. In children over 10 years, slipped capital femoral epiphysis also is considered.     

Do Balance Board Training Programs Reduce the Risk of Ankle Sprains in Athletes?

Introduction Ankle sprains are the most common musculo-skeletal injury that occurs in athletes,particularly in sports that require jumping and landing on one foot such as soccer,and basketball(1-4).These injuries often result in significant time loss from participation,long-term disability,and have a major impact on health care costs and resources(5-8).     

High Intensity Interval Training:New Insights

KEY POINTS ·High-intensity interval training(HIT)is characterized by repeated sessions of relatively brief，intermittent exercise.often performed with an“a11 out”effort or at an intensity close to that which elicits peak oxygen uptake(i.e.，≥90%of VO2 peak).     

Developmental validation of the PowerPlex(®) ESI 16 and PowerPlex(®) ESI 17 Systems: STR multiplexes for the new European standard

In response to the ENFSI and EDNAP groups’ call for new STR multiplexes for Europe, Promega^® developed a suite of four new DNA profiling kits. This paper describes the developmental validation study performed on the PowerPlex^® ESI 16 (European Standard Investigator 16) and the PowerPlex^® ESI 17 Systems. The PowerPlex^® ESI 16 System combines the 11 loci compatible with the UK National DNA Database^®, contained within the AmpFlSTR^® SGM Plus^® PCR Amplification Kit, with five additional loci: D2S441, D10S1248, D22S1045, D1S1656 and D12S391. The multiplex was designed to reduce the amplicon size of the loci found in the AmpFlSTR^® SGM Plus^® kit. This design facilitates increased robustness and amplification success for the loci used in the national DNA databases created in many countries, when analyzing degraded DNA samples. The PowerPlex^® ESI 17 System amplifies the same loci as the PowerPlex^® ESI 16 System, but with the addition of a primer pair for the SE33 locus. Tests were designed to address the developmental validation guidelines issued by the Scientific Working Group on DNA Analysis Methods (SWGDAM), and those of the DNA Advisory Board (DAB). Samples processed include DNA mixtures, PCR reactions spiked with inhibitors, a sensitivity series, and 306 United Kingdom donor samples to determine concordance with data generated with the AmpFlSTR^® SGM Plus^® kit. Allele frequencies from 242 white Caucasian samples collected in the United Kingdom are also presented. The PowerPlex^® ESI 16 and ESI 17 Systems are robust and sensitive tools, suitable for the analysis of forensic DNA samples. Full profiles were routinely observed with 62.5 pg of a fully heterozygous single source DNA template. This high level of sensitivity was found to impact on mixture analyses, where 54–86% of unique minor contributor alleles were routinely observed in a 1:19 mixture ratio. Improved sensitivity combined with the robustness afforded by smaller amplicons has substantially improved the quantity of data obtained from degraded samples, and the improved chemistry confers exceptional tolerance to high levels of laboratory prepared inhibitors.