老年人群发生急性肺栓塞的相关危险因素

目的：探讨老年人群发生急性肺栓塞(APE)的相关危险因素。方法回顾我院收治的105例 APE 患者临床资料,按年龄分为老年组55例和非老年组50例,比较两组临床表现,分析老年人 APE 危险因素。结果非老年组和老年组的呼吸困难、咳嗽、胸闷的发生率分别为82.0%(41/50)vs 85.5%(47/55)、70.0%(35/50)vs 78.5%(43/55)、62.0%(31/50)vs 52.7%(29/55)(均 P >0.05)。老年组的危险因素有慢性阻塞性肺疾病病史、心脑血管病史、糖尿病病史;非老年组的危险因素有深静脉血栓史、外伤及手术史。结论老年组 APE 患者的临床表现多不典型,与非老年组相似,老年组发生 APE 的危险因素与非老年组不同,临床上应密切注意。     

肺癌患者发生肺栓塞的相关危险因素及对预后的影响

目的探讨肺癌患者发生肺栓塞(PTE)的危险因素,并分析其对患者预后的影响。方法 46例肺癌合并PTE患者为观察组,46例无PTE的单纯肺癌患者为对照组。对比2组患者性别、年龄、体质量指数(BMI)、病理类型、TNM分期、手术史、中心静脉置管、血红蛋白(Hb)、D-二聚体、吸烟史、饮酒史、放化疗史、COPD史、糖尿病病史、心脑血管疾病史,并进行Logistic回归分析,探讨肺癌发生PTE的危险因素,并对比2组患者3、6、12个月生存率与中位生存时间。结果 2组患者在性别、年龄、手术史、吸烟史、饮酒史、放疗史、糖尿病病史、心脑血管病史方面比较无显著差异(P0.05),而在BMI、病理类型、TNM分期、Hb、D-Dimer、化疗史、中心静脉置管、COPD病史方面具有显著差异(P0.05或P0.01)。Logistic回归分析发现,病理类型为腺癌、TNM分期高、D-Dimer浓度高、有化疗史均为肺癌患者发生PTE的独立危险因素(P0.05或P0.01)。观察组3、6、12个月生存率均显著低于对照组(P0.05或P0.01),观察组中位生存时间显著短于对照组(P0.01)。结论PTE将严重缩短肺癌患者生存期,降低生存率。对病理类型为腺癌、TNM分期较高、D-Dimer浓度较高、有化疗史的肺癌患者,应早期给予抗凝治疗,以降低PTE风险,延长患者生存期,提高患者生活质量。     

Clinical prediction rules for mortality in patients with pulmonary embolism and cancer to guide outpatient management: a meta‐analysis

Essentials

• Clinical prediction rules (CPRs) can stratify patients with pulmonary embolism (PE) and cancer.
• A meta‐analysis was done to assess prognostic accuracy in CPRs for mortality in these patients.
• Eight studies evaluating ten CPRs were included in this study.
• CPRs should continue to be used with other patient factors for mortality risk stratification.

Summary

Background

Cancer treatment is commonly complicated by pulmonary embolism (PE), which remains a leading cause of morbidity and mortality in these patients. Some guidelines recommend the use of clinical prediction rules (CPRs) to help clinicians identify patients at low risk of mortality and therefore guide care.

Objective

To determine and compare the accuracy of available CPRs for identifying cancer patients with PE at low risk of mortality.

Methods

A literature search of Medline and Scopus (January 2000 to August 2017) was performed. Studies deriving/validating ≥ 1 CPR for early post‐PE all‐cause mortality were included. A bivariate, random‐effects model was used to pool sensitivity and specificity estimates for each CPR. Traditional random‐effects meta‐analysis was performed to estimate the weighted proportion of patients deemed at low risk of early mortality, mortality in low risk patients and odds ratios for death compared with higher‐risk patients.

Results

Eight studies evaluating 10 CPRs were included. The highest sensitivities were observed with Hestia (98.1%, 95% confidence interval [CI] = 75.6–99.9%) and the EPIPHANY index (97.4%, 95% CI = 93.2–99.0%); sensitivities of remaining rules ranged from 59.9 to 96.6%. Of the six CPRs with sensitivities ≥ 95%, none had specificities > 33%. Random‐effects meta‐analysis suggested that 6.6–51.6% of cancer patients with PE were at low risk of mortality, 0–14.3% of low‐risk patients died and low‐risk patients had a 43–94% lower odds of death compared with those at higher risk.

Conclusions

Because of the limited total body of evidence regarding CPRs, their results, in conjunction with other pertinent patient‐specific clinical factors, should continue to be used in identifying appropriate management for PE in patients with cancer.

     

The effects of cause of death classification on prognostic assessment of patients with pulmonary embolism

Summary. Background: Although previous studies have provided evidence that the majority of deaths following an acute pulmonary embolism (PE) directly relate to the PE, more recent registries and cohort studies suggest otherwise. Methods: We assessed the cause of death during the first 30 days after the diagnosis of acute symptomatic PE in a consecutive series of patients. We also assessed the prognostic characteristics of the simplified Pulmonary Embolism Severity Index (sPESI) and cardiac troponin I (cTnI) obtained at the time of PE diagnosis. Results: During the first 30 days after diagnosis, 127 of the 1291 patients died (9.8%; 95% confidence interval [CI], 8.2–11.5). Sixty patients (4.6%; 95% CI, 3.5–5.8) died from definite or possible PE, and 67 (5.2%; 95% CI, 4.0–6.4) died from other causes (cancer 25, infection 18, hemorrhage 7, heart failure 7, chronic obstructive pulmonary disease 5, renal failure 1, seizures 1, unknown 3). The sPESI predicted all‐cause (odds ratio [OR], 5.97; 95% CI, 1.74–20.54; P < 0.01) and PE‐associated mortality (OR, 8.79; 95% CI, 1.12–68.79; P = 0.04). cTnI only predicted PE‐associated mortality (adjusted OR, 2.39; 95% CI, 1.25–4.57; P < 0.01). For all‐cause mortality, the sPESI low‐risk strata had a negative predictive value of 98.8% (95% CI, 97.4–100) in comparison with 91.3% (95% CI, 88.9–93.6) for the cTnI. Conclusions: Within the first 30 days after the diagnosis of acute symptomatic PE, death due to PE and death due to other causes occur in a similar proportion of patients. As cTnI only predicted PE‐associated mortality, low‐risk sPESI had a higher negative predictive value for all‐cause mortality compared with cTnI.     

Validation of a clinical algorithm to identify low‐risk patients with pulmonary embolism

Summary. Background: We previously derived a clinical prognostic algorithm to identify patients with pulmonary embolism (PE) who are at low risk of short‐term mortality and who could be safely discharged early or treated entirely in an outpatient setting. Objectives: To externally validate the clinical prognostic algorithm in an independent patient sample. Methods: We validated the algorithm in 983 consecutive patients prospectively diagnosed with PE at an emergency department of a university hospital. Patients with none of the algorithm’s 10 prognostic variables (age ≥ 70 years, cancer, heart failure, chronic lung disease, chronic renal disease, cerebrovascular disease, pulse ≥ 110 min^–1, systolic blood pressure < 100 mmHg, oxygen saturation < 90%, and altered mental status) at baseline were defined as being at low risk. We compared 30‐day overall mortality among low‐risk patients, on the basis of the algorithm, between the validation sample and the original derivation sample. We also assessed the rate of PE‐related and bleeding‐related mortality among low‐risk patients. Results: Overall, the algorithm classified 16.3% of patients with PE as being at low risk. Mortality at 30 days was 1.9% among low‐risk patients, and did not differ between the validation sample and the original derivation sample. Among low‐risk patients, only 0.6% died from definite or possible PE, and 0% died from bleeding. Conclusions: This study validates an easy‐to‐use, clinical prognostic algorithm for PE that accurately identifies patients with PE who are at low risk of short‐term mortality. Patients who are at low risk according to our algorithm are potential candidates for less costly outpatient treatment.     

胸部手术后肺栓塞的护理进展

从肺栓塞的病因、发病机制、危险因素、预防及护理方面综述了胸部手术后肺栓塞的护理进展。     

肺动脉栓塞指数的研究进展

急性肺栓塞(acute pulmonary embolism,APE)是以各种栓子阻塞肺动脉及其分支为其发病原因的一组疾病或综合征,也是临床病死率较高的疾病之一。肺栓塞的诊断方法有螺旋CT、放射性核素肺通气/血流灌注(V/Q)显像、磁共振成像和磁共振肺动脉造影、肺动脉造影。螺旋CT中的多排螺旋CT肺动脉造影诊断肺栓塞的敏感性及特异性较高,因此广泛应用于临床。肺动脉栓塞指数(pulmonary artery obstruction index,PAOI)是通过螺旋CT的多排螺旋CT肺动脉造影进行计算的一种临床指标。本文就PAOI与APE危险分层,PaO2,PaCO2,P(A-a)O2,SaO2,RVd/LVd,MPAd,SVCd,肺动脉高压,D-二聚体等的相关性研究现状作一综述。     

慢性阻塞性肺疾病急性加重期伴肺动脉栓塞的危险因素分析

目的探讨慢性阻塞性肺疾病急性加重期(AECOPD)伴肺动脉栓塞(PE)的危险因素。方法选取因AECOPD住院且行螺旋CT肺动脉造影(CTPA)检查的患者466例,据CTPA是否出现PE或充盈缺损,将患者分为PE组45例和对照组421例,比较2组临床资料,分析AECOPD合并PE的危险因素。结果 2组年龄≥70岁、卧床≥3 d、下肢水肿、肺炎、静脉血栓、动脉栓塞、D-二聚体≥2 000 ng/m L和N末端脑钠肽前体(NT-pro BNP)≥1 200 ng/m L差异显著(P0.05或P0.01)。多因素Logistic回归分析示,卧床时间≥3 d、下肢水肿、D-二聚体≥2 000 ng/m L为AECOPD伴发PE的危险因素。结论因AECOPD住院的患者,有卧床3 d以上、下肢水肿或D-二聚体≥2 000 ng/m L,应高度重视,尽快行CTPA,以确定是否伴发PE。     

Emergency department diagnosis of pulmonary embolism is associated with significantly reduced mortality: A linked data population study

Objectives: We characterized patients admitted via ED with a principal hospital discharge diagnosis of pulmonary embolism (PE) and compared mortality of those diagnosed in the ED with those diagnosed after admission. Methods: Patients with a hospital discharge diagnosis ICD 10 I26 presenting to the ED in Perth, Western Australia between 1 July 2000 and 30 December 2006 had records from the Emergency Department Information System linked to the Western Australian Hospital Morbidity Data System and the death registry. Results: Of 2250 patients (mean age 60.4), 1227 (54.5%) were female. Of 1931 patients with an ED diagnosis recorded, 1207 (62.5%) were diagnosed with PE in ED. Of these, 383 (17.0%) had presented to an ED within 28 days previously, 142 (37.1%) with either chest pain or breathing problems, with 207 (54.0%) admitted but not receiving a principal hospital discharge diagnosis of PE. There were 127 (5.6%) in‐hospital deaths. Controlling for age and comorbidity with logistic regression, patients diagnosed with PE in ED were less likely to die in hospital, within 7 and 30 days of ED arrival, than those diagnosed after admission (adjusted OR 0.31, 95% CI 0.20–0.47; adjusted OR 0.32, 95% CI 0.19–0.53; adjusted OR 0.30, 95% CI 0.20–0.44; respectively). Conclusion: Making the diagnosis of PE in ED was associated with a substantial survival advantage that persisted after hospital discharge.     

肺癌合并肺栓塞危险因素的Meta分析

目的系统评价肺癌合并肺栓塞的相关危险因素。方法计算机检索PubMed、Embase、中国知网、万方等数据库,收集有关肺癌合并肺栓塞危险因素的文献,检索时限均为建库至2021年1月。由2名研究人员独立进行文献筛选、资料提取以及文献质量评价,并采用RevMan5.4软件和Stata16.0软件对纳入的数据进行Meta分析。结果共纳入25项研究,共3480例。Meta分析研究结果显示,肺癌患者发生肺栓塞的危险因素包括腺癌(OR=2.06,95%CI:1.75~2.44,P<0.01)、肿瘤分期(Ⅲ~Ⅳ期)(OR=2.67,95%CI:2.19~3.26,P<0.01)、化疗(OR=2.69,95%CI:2.08~3.47,P<0.01)、深静脉置管(OR=2.66,95%CI:1.68~4.19,P<0.01)、白蛋白<30 g/L(OR=6.65,95%CI:2.91~15.18,P<0.01)、D二聚体>500 mg/L(OR=5.87,95%CI:2.12~16.27,P<0.01)、白细胞>11×10^(9)/L(OR=8.26,95%CI:4.50~15.13,P<0.01)及慢性阻塞性肺疾病(OR=1.51,95%CI:1.16~1.95,P<0.01)。结论本研究显示腺癌、肿瘤分期(Ⅲ~Ⅳ期)、化疗、深静脉置管、白蛋白<30 g/L、D二聚体>500 mg/L、白细胞>11×10^(9)/L及慢性阻塞性肺疾病是肺癌患者发生肺栓塞的危险因素。受纳入研究数量及质量的限制,需更多高质量文章进一步加以验证。     

胸部手术后肺栓塞的护理进展

从肺栓塞的病因、发病机制、危险因素、预防及护理方面综述了胸部手术后肺栓塞的护理进展。     

Incidence and risk factors for pulmonary embolism in the postpartum period

Summary. Background: Pregnancy and the postpartum period are times of hypercoagulability, increasing the risk of pulmonary embolism. Better quantification of risk factors can help target women who are most likely to benefit from postpartum thromboprophylaxis with heparin. Objectives: To determine the incidence rate and timing of postpartum pulmonary embolism, and assess perinatal risk factors predictive of the event. Patients/Methods: Antenatal, delivery and postpartum admission records of a cohort of 510 889 pregnancies were analysed. Pulmonary embolism was identified from ICD‐10 codes at delivery, transfer or upon readmission at any time in the postpartum period. Results: Pulmonary embolism occurred in 375 women and was most common postpartum. The rate of postpartum pulmonary embolism without an antecedent thrombotic event was 0.45 per 1000 births. By the end of 4 weeks postpartum, the weekly rate approached the background rate of pulmonary embolism in the population. Although the Caesarean section rate rose significantly throughout the study period, and pulmonary embolism was more common following abdominal birth, the rate of pulmonary embolism following Caesarean birth fell. Regression modelling demonstrated that stillbirth (adjusted odds ratio [aOR] =5.97), lupus (aOR = 8.83) and transfusion of a coagulation product (aOR = 8.84) were most strongly associated with pulmonary embolism postpartum. Conclusions: Pulmonary embolism most commonly occurs up to 4 weeks postpartum and following abdominal birth. Despite this the absolute event rate is low and a broadly inclusive risk factor approach to the use of pharmacological thromboprophylaxis will require many women to be exposed to heparin to prevent an embolic event.     

膝关节置换术后肺栓塞发生的相关危险因素研究

目的探讨膝关节置换术后并发肺栓塞的临床表现及相关危险因素干预对患者的影响。方法选取45例膝关节置换术后肺栓塞患者为研究对象,将患者分成联合治疗组和非联合治疗组,比较其在术后功能方面的差异性。结果膝关节置换术后并发肺栓塞的临床症状以呼吸困难、胸闷胸痛为主,体征以哮鸣音和湿性啰音为主;BMI、术后制动、抗凝药物应用、骨水泥、创伤、静脉血栓形成是膝关节置换术后并发肺栓塞的高危险因素(P0.05);经过康复锻炼等干预措施后,联合治疗组在疼痛、功能、僵硬和生存质量上和非联合治疗组比较有显著差异(P0.05)。结论膝关节置换术后并发肺栓塞受多种危险因素影响,干预后可降低发病风险。     

The clinical course of pulmonary embolism patients anticoagulated for 1 year: results of a prospective, observational, cohort study

Summary.  Background : Few studies have examined the clinical course of pulmonary embolism (PE) in patients anticoagulated continuously for 1 year. Objective : We sought to determine the incidence of death, recurrent PE and bleeding during anticoagulation in the first year after acute PE, and to assess associated risk factors. Methods : All consecutive PE patients who were referred to our center in Pisa, Italy between 2001 and 2005 received a conventional initial treatment, followed by vitamin K antagonists [international normalized ratio (INR), 2.0–3.0] for 1 year. They were followed-up at scheduled times at the study center. The development of recurrent PE was objectively documented and recorded. Results : Out of 497 patients, 48 (9.6%) developed recurrent PE, which was fatal in 36. Of these 48 events, 39 occurred within 10 days of diagnosis and only two patients had a non-fatal recurrent PE between 6 and 12 months. Risk factors associated with the risk for overall recurrent PE were persistent severe dyspnoea ( P  =   0.007), a high perfusion defect score index (PDI) ( P  =   0.003) and cardiopulmonary co-morbidities ( P  =   0.005). Unprovoked presentation ( P  =   0.030), persistent severe dyspnoea ( P  =   0.011) and a high PDI ( P  =   0.001) predicted the risk for fatal PE. Overall bleeding incidence was 3.4%, no cases of bleeding occurred between 180 and 360 days post-diagnosis. Conclusions : In spite of conventional anticoagulation, a proportion of patients with PE experience both a fatal and non-fatal recurrent embolism within the first year. The large majority of these occur within the days proceeding diagnosis, with only a small minority occurring in the last 6 months. No bleeding was observed after 6 months. Therefore, prolonging anticoagulation for 1 year represents both a safe and effective treatment.     

Pulmonary Embolism Severity Index and troponin testing for the selection of low‐risk patients with acute symptomatic pulmonary embolism

Summary. Background: The combination of the Pulmonary Embolism Severity Index (PESI) and troponin testing could help physicians identify appropriate patients with acute pulmonary embolism (PE) for early hospital discharge. Methods: This prospective cohort study included a total of 567 patients from a single center registry with objectively confirmed acute symptomatic PE. On the basis of the PESI, each patient was classified into one of five classes (I–V). At the time of hospital admission, patients had troponin I (cTnI) levels measured. The endpoint of the study was all‐cause mortality within 30 days after diagnosis. We calculated the mortality rates in four patient groups: group 1, PESI class I–II plus cTnI < 0.1 ng mL^?1; group 2, PESI classes III–V plus cTnI < 0.1 ng mL^?1; group 3, PESI classes I–II plus cTnI ≥ 0.1 ng mL^?1; and group 4, PESI classes III–V plus cTnI ≥ 0.1 ng mL^?1. Results: The study cohort had a 30‐day mortality of 10% [95% confidence interval (CI), 7.6–12.5%]. Mortality rates in the four groups were 1.3%, 14.2%, 0% and 15.4%, respectively. Compared with non‐elevated cTnl, the low‐risk PESI had a higher negative predictive value (NPV) (98.9% vs. 90.8%) and negative likelihood ratio (NLR) (0.1 vs. 0.9) for predicting mortality. The addition of non‐elevated cTnI to low‐risk PESI did not improve the NPV or the NLR compared with either test alone. Conclusions: Compared with cTnl testing, PESI classification more accurately identified patients with PE who are at low risk of all‐cause death within 30 days of presentation.