ST段抬高心肌梗死（STEMI）的治疗：美国及欧洲更新指南的比较（2）

7抗凝剂——再灌注疗法的辅助疗法更新的指南根据许多新的临床试验的结果,对4种新的抗凝剂提出了新的临床应用建议,见表2,有3项重要的临床试验：EXTRACT—TIMI25,OASIS-6以及CREATE证实,进行纤溶疗法的患者应用新的抗凝剂可以降低死亡率或MI的发生率。     

The failed thoracocentesis

How often do we consider a differential diagnosis of diaphragmatic hernia in cases of failed thoracocentesis? How many of us remember that omental fat in the chest can behave in a fluid manner, layering along the chest wall, resulting in the misinterpretation of a decubitus view. A case is presented of a diaphragmatic hernia that was missed on conventional chest radiographs resulting in CT having to be performed. A high degree of suspicion is mandatory to reach the final diagnosis. Radiographs could be used more effectively and CT avoided.     

Use of routine computed tomography brain scanning of psychiatry patients*

The aim of this study was to evaluate the usefulness of CT of the brain in patients presenting with a psychiatric condition without focal neurological signs. The reports of 397 consecutive CT brain scans of patients presenting to two acute tertiary hospital psychiatric services over a 2‐year period were assessed retrospectively. Of the 397 patients, 241 had psychosis, 87 had depression, 44 had bipolar affective disorder, seven had alcohol dependence, five had dementia, and the remaining 13 had a variety of diagnoses including personality disorder and transient ischaemic attack. Findings on 377 (95%) of the CT scans showed no abnormality. Specific abnormalities were described in 20 (5%) of the CT scans. Three scans showed non‐specific minor abnormalities, which, when followed up by MRI, showed no relevant abnormality. All the abnormalities shown on CT were considered to be clinically unrelated to the patient's psychiatric condition. In conclusion, the pretest probability of finding a space‐occupying lesion or other pertinent abnormality in patients presenting with psychiatric illnesses in this retrospective study appears not to be greater than that of the general population. The outcome of this study could be implemented to develop a clinical pathway for limiting assessment by CT for possible organic pathology in acute psychiatric illness.     

The natural history of anterior cruciate ligament reconstruction using patellar tendon autograft

The purpose of this study was to review the results of ACL reconstruction using a patellar tendon graft placed ‘over the top’ plus a Macintosh lateral tenodesis, examining changes in knee laxity and functional status with increasing time. There were 74 patients operated on over an 11 year period, and divided into four groups for analysis according to postoperative time. There was a significant and progressive increase in side-to-side laxity difference with time, although functional status did not change significantly, indicating a lack of correlation between objective clinical tests and subjective findings. The highest Lysholm, Tegner and IKDC scores were at 4–5 years after operation, when 60% of patients were at their pre-injury level of sports activity. However, there was always a very significant difference between actual and desired Tegner activity levels for the group as a whole. While there was a significant correlation between degenerative changes and the time between injury and reconstruction, there was no correlation with postoperative time: this provides evidence that ACL reconstruction can protect the knee from later degeneration.     

Association of ABO blood group with fracture pattern and mortality in hip fracture patients

Introduction

The mechanism of falling has been proposed as the exclusive explanation for hip fracture pattern. Evidence exists that other genetic factors also influence proximal femoral fracture configuration. The ABO blood group serotype has been associated with other pathologies but any role in hip fracture has yet to be definitively characterised.

Methods

Our National Hip Fracture Database was interrogated over a four-year period. All patients had their blood group retrieved, and this was compared with hip fracture pattern and mortality rates. Confounding factors were accounted for using logistic regression and the Cox proportional hazards model.

Results

A total of 2,987 consecutive patients presented to our institution. Those with blood group A were significantly more likely to sustain intracapsular fractures than ‘non-A’ individuals (p=0.009). The blood group distribution of patients with intracapsular fractures was identical to that of the national population of England. However, blood group A was less common in patients with intertrochanteric fractures than in the general population (p=0.0002). Even after correction for age and sex, blood group A was associated with a decrease in the odds of suffering an intertrochanteric fracture to 80% (p=0.002). Blood group A had inferior survivorship correcting for age, sex and hip fracture pattern (hazard ratio: 1.14, p=0.035). This may be due to associated increased prevalence of co-morbid disease in this cohort.

Conclusions

Blood group is an independent predictor of hip fracture pattern, with group A patients more likely to sustain an intracapsular fracture and non-A individuals more likely to sustain an intertrochanteric fracture. The determinants of fracture pattern are likely to be related to complex interactions at a molecular level based on genetic susceptibility. The mechanism of fall may not be the only aetiological determinant of proximal femoral fracture configuration.     

Induction of proliferation of purified human myeloid progenitor cells: a rapid assay for granulocyte colony-stimulating factors

The proliferation and differentiation of granulocyte and monocyte progenitor cells (CFU-C) in vitro is dependent on the presence of a group of closely related glycoproteins termed colony-stimulating factors (CSF). In order to investigate the interaction of these factors with CFU-C, we purified CFU-C from the peripheral blood of chronic myeloid leukemia patients with an immune rosette technique using specific monoclonal antibodies (mean 74-fold enrichment, 45% cloning efficiency). Colony formation by purified CFU-C demonstrated an absolute dependence on an exogenous source of CSF. Liquid culture of small aliquots of enriched CFU-C with CSF-containing medium resulted in a rapid, time- and concentration-dependent induction of DNA synthesis as measured by 3H-thymidine incorporation. This specific CSF induction of DNA synthesis by enriched CFU-C was used to develop a microassay system for CSF activity. CSF activity could be reproducibly quantitated in 24-48 hr. The proliferating cells in this assay system were shown to be myeloid progenitor cells by examining the morphology of their progeny and by determining the surface antigen phenotype of the responding cells (Ia+, T3-, B1-, Mo1-). This microassay provides a quantitative assessment of CSF activity that may be useful in the purification of human CSF and in the generation of monoclonal antibodies to CFU-C surface structures.