老年颅内大血管闭塞所致急性缺血性脑卒中患者血栓抽吸治疗近期预后

目的 分析老年颅内大血管闭塞(LVO)所致急性缺血性脑卒中(AIS)患者血栓抽吸治疗近期预后。方法 选取284例发病24 h内老年颅内LVO所致AIS患者,按照治疗方式不同分为血栓抽吸组(n=148)与支架取栓组(n=136),记录手术指标、并发症情况、术后24 h与7 d美国国立卫生研究院脑卒中量表(NIHSS)评分、术后90 d改良Rankin量表(mRS)评分及死亡率,依据血栓抽吸治疗患者近期预后分为预后良好组与预后不良组,建立Logistic回归模型分析预后影响因素。结果 血栓抽吸组与支架取栓组发病至再通时间、首次取栓成功再通率无显著差异(P>0.05);血栓抽吸组穿刺至再通时间明显短于支架取栓组(P<0.05),成功再通率、完全再通率明显高于支架取栓组(P<0.05);两组并发症发生率无显著差异(P>0.05);两组术后24 h与7 d NIHSS评分、术后90 d mRS评分及死亡率比较无显著差异(P>0.05);预后良好组与预后不良组发病至再通时间、术前及术后24 h NIHSS评分、脑白质疏松程度、侧支循环分级、糖尿病及成功再通差异有统计学...     

获得性依赖维生素K凝血因子缺乏症62例临床特征及误诊分析

目的 探讨非婴幼儿获得性依赖维生素K凝血因子缺乏症的临床特征及误诊原因.方法 回顾性分析我院诊治的62例获得性依赖维生素K凝血因子缺乏症患者的病因、临床表现、治疗、随访结果及误诊原因.结果 62例患者中51例患者病因不明,11例为杀鼠药中毒.所有患者均同时或先后出现皮肤、黏膜、皮下及关节、肌肉、内脏出血,首发最常见出血症状为血尿;35例(56.5%)失血患者血红蛋白(Hb)＜100g/L,最低仅为32g/L;治疗后患者活化部分凝血活酶时间(APTT)、凝血酶原时间(PT)、国际标准化比值(INR)与治疗前比较差异均有统计学意义[(145.46±43.22)s、(36.62±7.85)s,(107.33±47.38)s、(13.64±4.86)s,(7.63±1.87)、(2.14±0.68),t值分别为19.51、15.49、13.62,P均＜0.01],血小板计数、凝血酶时间(TT)、纤维蛋白原(Fg)均正常,患者自出血症状至明确诊断的中位时间为8(2～192)d,其中16例患者出血1～6个月才确诊,首诊误诊率高达61.3%(38/62),误诊为泌尿系统疾病占60.5%(23/38),其次为血友病占21.1%(8/38).所有患者接受维生素K治疗,总疗程为1～22个月,少数严重出血患者同时使用凝血酶原复合物和(或)血浆输注.中位随访时间为8(1～56)个月,无一例患者复发.结论 非婴幼儿获得性依赖维生素K凝血因子缺乏症多数原因不明.首发出血最常见的症状为血尿,本病易误诊,最常见误诊为泌尿系统疾病,早期的凝血功能检测可减少误诊.维生素K序贯治疗可有效防止复发,患者预后良好.

Abstract：

Objective To explore the clinical features and causes of misdiagnosis of the patients with acquired deficiency of vitamin K-dependent coagulation factors (ADVKDCF). Methods Retrospective analysis was performed with the data from 62 patients with ADVKDCF for etiological factors, clinical manifestations,laboratory examinations, diagnosis and treatments. Results Among the 62 patients, 51 patients were with unknown causes( subgroup A) and 11 were with clear histories of anticoagulant rodenticide poisoning( subgroup B). The presentations of hemorrhage of the patients varied with hematuria as the most common first symptom,followed by skin, mucosa, muscle, internal organs bleeding (28/62). The most common hemorrhage symptom is hematuria. 35 of the 62 patients had hemoglobin(Hb) levels less than 100 g/L due to blood loss( the lowest level was 32 g/L). Thirty-eight patients were misdiagnosed at the first visit and the median time from hemorrhage manifestation to definite diagnosis was 8 days (range,2 to 192 days). ADVKDCF was mostly misdiagnosed as the urinary system diseases (23/38), followed by hemophilia (8/38). Laboratory examinations showed normal platelet count , throm bin time (TT) and normal fibrinogen(Fg) concentration, but prolonged plasma prothrombin time (PT), activated partial prothrombin time (APTT) and international normalized ration (INR). All of patients received high dose vitamin K ( intravenous vitamin K1 with a initial dose of 20 to 240 mg/d and then oral vitamin K4 maintenance) . The bleeding symptoms disappeared 1 day after treatment and the Hb levels increased dramatically. There were significant differences in PT, APTT and INR of the patients before and after treatment( P ＜0. 01 ). Followed by a median follow - up of 8 months , no patient had severe adverse effects or recurrence. Conclusion The hemorrhage presentations of the patients with ADVKDCF are various. The most common hemorrhage symptom is hematuria. The misdiagnosis rate of ADVKDCF is high with urinary systems disorders as the most common misdiagnosis. Sequential treatment with vitamin K is an effective and safe method to prevent recurrence. Early detection of coagulation function is helpful to reduce misdiagnosis possibility.     

血栓性血小板减少性紫癜10例临床分析

目的 探讨血栓性血小板减少性紫癜(TTP)的临床特征及血管性血友病因子裂解酶(ADAMTS13)的诊断价值.方法 回顾性分析10例住院TTP患者的临床特征、诊治情况.结果 6例出现典型5联征,4例患者表现为3联征,10例患者外周血片均可发现1%～10%的破碎红细胞,6例行ADAMTS13检测,2例活性正常,4例活性不同程度降低,有效治疗时活性恢复,再次复发时又下降,确诊中位时间5 d,10例急性期均进行了血浆置换,在糖皮质激素治疗基础上加用长春碱、环磷酰胺、环孢素,中位随访2.1年,9例治愈,1例患者复发,2例难治患者采用了利妥昔单抗治疗,随访至今未复发.结论 仔细目测计数破碎红细胞有助于早期发现TTP,该病仍依赖临床进行综合诊断,但获得性TTP患者ADAMTS13活性与病情明显相关,获得性TTP需强化免疫抑制治疗,利妥昔单抗可能是治疗难治/复发性TTP患者的有效手段.