Low molecular weight heparin in prevention of perioperative thrombosis.

OBJECTIVE--To determine whether prophylactic treatment with low molecular weight heparin reduces the incidence of thrombosis in patients who have had general or orthopaedic surgery. DESIGN--Meta-analysis of results from 52 randomised, controlled clinical studies (29 in general surgery and 23 in orthopaedic surgery) in which low molecular weight heparin was compared with placebo, dextran, or unfractionated heparin. SUBJECTS--Patients who had had general or orthopaedic surgery. INTERVENTION--Once daily injection of a low molecular weight heparin compared with placebo, dextran, or unfractionated heparin. MAIN OUTCOME MEASURES--Incidence of deep venous thrombosis, pulmonary embolism, major haemorrhages, and death. RESULTS--The results confirm that low molecular weight heparins are more efficacious for the prophylactic treatment of deep venous thrombosis than placebo (common odds ratio 0.31, 95% confidence interval 0.22 to 0.43; p < 0.001) and dextran (0.44, 0.30 to 0.65; p < 0.001). The results suggest that low molecular weight heparins are also more efficacious than unfractionated heparin (0.85, 0.74 to 0.97; p = 0.02), with no significant difference in the incidence of major haemorrhages (1.06, 0.93 to 1.20; p = 0.62). CONCLUSIONS--Low molecular weight heparins seem to have a higher benefit to risk ratio than unfractionated heparin in preventing perioperative thrombosis. However, it remains to be shown in a suitably powered clinical trial whether low molecular weight heparin reduces the risk of fatal pulmonary embolism compared with heparin.     

Postoperative Thromboembolism and the Use of Oral Contraceptives

We have previously reported the results of a retrospective study of the relationship between oral contraceptives and deep vein thrombosis and pulmonary embolism occurring in the absence of an evident predisposing cause. The present paper describes a similar investigation of the relationship between oral contraceptives and thromboembolism following certain surgical procedures.Of 30 patients with thromboembolism, 12 (40%) had been using oral contraceptives during the month preceding surgery, while only 9 of 60 matched controls (15%) had been doing so. From these data it is estimated that the risk of postoperative thromboembolism is increased threefold to fourfold by the use of contraceptive steroids.It is recognized that few of the episodes of deep vein thrombosis and pulmonary embolism that occur postoperatively are detectable clinically, and that not all of these are recorded in discharge summaries or diagnostic indexes. Despite these considerations, we have been unable to detect any important bias in the data which could account for the observed association between oral contraceptives and the development of postoperative thromboembolism.     

Collaborative overview of randomised trials of antiplatelet therapy--III: Reduction in venous thrombosis and pulmonary embolism by antiplatelet prophylaxis among surgical and medical patients. Antiplatelet Trialists' Collaboration.

OBJECTIVE--To determine the efficacy of antiplatelet therapy as prophylaxis against deep venous thrombosis or pulmonary embolism in surgical and high risk medical patients. DESIGN--Overviews of all randomised trials of antiplatelet therapy that could have been available by March 1990 and in which deep venous thrombosis was assessed systematically. SETTING--53 trials (total 8400 patients) of an average of two weeks of antiplatelet therapy versus control in general or orthopaedic surgery; nine trials (600 patients) of antiplatelet therapy versus control in other types of immobility; 18 trials (1000 patients) of one antiplatelet regimen versus another. RESULTS--Overall, a few weeks of antiplatelet therapy produced a highly significant (2P < 0.00001) reduction in deep venous thrombosis. 25% of patients allocated antiplatelet therapy versus 34% of appropriately adjusted controls had deep venous thrombosis detected by systematic fibrinogen scanning or venography, representing prevention in about 90 patients per 1000 allocated antiplatelet therapy. There was an even greater proportional reduction in pulmonary embolism: such emboli were detected among 47 (1.0%) antiplatelet allocated patients versus an adjusted control total of 129 (2.7%), representing prevention among about 17 patients per 1000 treated (2P < 0.00001). In analyses confined to surgical trials, the proportional reductions were similar and separately significant for nonfatal pulmonary embolism (0.7% antiplatelet therapy v 1.8% control; 2P < 0.00001) and for deaths attributed to pulmonary embolism (0.2% v 0.9%; 2P = 0.0001). There was a slight but non-significant excess of deaths from other causes (1.0% v 0.7%), which made the difference in total mortality nonsignificant, though still favourable (1.2% v 1.5%). Information on adding antiplatelet therapy to heparin was limited but, at least for pulmonary embolism, suggested more protection from the combination than from heparin alone. The proportional reduction in the odds of suffering a deep venous thrombosis was roughly the same in patients having general surgery, traumatic orthopaedic surgery, and elective orthopaedic surgery (and in medical patients who were at increased risk of thromboembolism). For pulmonary embolism the numbers affected were smaller, but again the reductions were highly significant both in general surgery (16 (0.5%) v 58 (1.7%) pulmonary emboli; 2P < 0.0001) and in orthopaedic surgery (28 (2.7%) v 63 (6.1%) pulmonary emboli; 2P < 0.0002). CONCLUSION--It had previously been supposed that antiplatelet therapy did not influence venous thromboembolism, and many surgeons and physicians do not use it routinely for thromboprophylaxis, even for patients who are at substantial risk of deep venous thrombosis or pulmonary embolism. These results indicate that antiplatelet therapy--either alone or, for greater effect, in addition to other proved forms of thromboprophylaxis (such as subcutaneous heparin)--should be considered.     

Tranexamic acid as an aid to reducing blood transfusion requirements in gastric and duodenal bleeding.

A prospective randomised double blind study examined the effect of the antifibrinolytic drug tranexamic acid compared with placebo in 154 patients bleeding from verified benign lesions in the stomach or duodenum or both. Three out of 72 patients receiving tranexamic acid underwent emergency surgery compared with 15 out of 82 given placebo (p = 0.010). Nineteen patients receiving placebo rebled during their admission as compared with 10 in the active treatment group (p = 0.097). Blood transfusion requirements were significantly reduced by tranexamic acid (p = 0.018). Side effects occurred in six patients, of which an uncomplicated deep venous thrombosis was the most severe. Tranexamic acid reduces the blood transfusion requirement and need for emergency surgery in patients bleeding from a benign gastric or duodenal lesion.     

Effects of exercise and beta 2-agonists on lung function in chronic obstructive pulmonary disease.

The effects of inhaled bronchodilators at rest and during exercise were studied in 15 subjects with chronic obstructive pulmonary disease. In a crossover study against placebo, albuterol caused a significant increase in expiratory flow and reduced lung hyperinflation and dyspnea at rest, but this was not associated with differences in symptoms with exercise or any relevant parameter of physical performance. Dynamic hyperinflation occurred during exercise similarly after placebo or albuterol and was associated with a reduction of forced expiratory flows. This, in turn, was correlated with the bronchoconstrictor effect of deep inhalation determined at rest. In a parallel group study, expiratory flow was increased by 3-wk treatment with salmeterol (n = 9) but not with placebo (n = 6). However, in neither group was the response to exercise different from baseline. These results suggest that in chronic obstructive pulmonary disease effective pharmacological bronchodilation at rest may not be predictive of benefits of exercise tolerance. This may be related to the occurrence of airway narrowing during exercise, particularly when a deep inhalation at rest is followed by a decrease in expiratory flow.     

孤立肾多发结石患者超声引导微创经皮肾穿刺取石术治疗的效果分析

目的:分析孤立肾多发结石患者超声引导微创经皮肾穿刺取石术治疗的效果。方法:64例孤立肾多发结石患者随机均分为试验组和对照组。其中对照组患者均采用常规开放式取石术治疗,试验组患者则在超声引导下实施微创经皮肾穿刺取石术治疗。比较两组患者的手术时间和术中出血量以及术后取净率等临床资料。结果:两组患者的手术时间并无明显差异(t=1.942,P0.05)且试验组患者的术后取净率和术后两个月排净率均显著高于对照组患者(t=4.731,P0.05,t=4.288,P0.05);对照组患者的并发症发生率显著高于试验组患者(t=4.333,P0.05);试验组患者的术中出血量显著低于对照组(t=3.762,P0.01)。两组患者术前术后以及术后2个月的血肌酐水平比较均无明显差异(均P0.05),并且两组患者血肌酐水平组间比较亦无明显差异(均P0.05)。结论:超声引导下对孤立肾多发结石患者实施微创经皮肾穿刺取石术治疗具有较高的安全性和临床疗效。     

帕金森病伴抑郁患者DBS 术后帕罗西汀治疗疗效观察

目的:研究丘脑底核(STN)脑深部电刺激(DBS)治疗帕金森病(PD)合并抑郁障碍术后服用帕罗西汀治疗的疗效。方法:将38例合并抑郁障碍的PD患者随机分为三组,行丘脑底核脑深部电极植入术,术后空白对照组不服用任何抗抑郁药物,药物治疗组服用帕罗西汀每日一次,每次20mg,安慰剂组服用安慰剂。术前一周,术后1个月、2个月和3个月进行随访和临床评价。结果:抑郁患者术后抑郁障碍症状如焦虑、绝望和激越症状也有不同程度好转,应用安慰剂后,患者术后抑郁障碍程度好转程度大于空白对照组(P<0.05),而应用帕罗西汀后术后3个月汉密尔顿抑郁量表评分(HAMD)下降程度显著低于空白对照组及安慰剂组(P<0.05)。结论:表明STN-DBS术后PD患者的抑郁症状有所改善,辅助抗抑郁药物治疗效果更佳。     

急性右下肢深静脉血栓的临床治疗分析

目的:探讨右下肢深静脉血栓的临床治疗方法。方法:对我院2015年6月-2017年6月收治的63例右下肢深静脉血栓形成患者进行回顾性分析,从小腿周径差、彩超检查及造影3方面对疗效进行评价,并统计导管接触溶栓后患者复查肺部增强CT情况。结果:63例患者中,57例进行导管接触溶栓+下腔静脉滤器,6例进行导管接触溶栓+下腔静脉滤器+肺动脉碎栓、溶栓。治疗后,患者小腿周径差较治疗前明显降低,差异具有统计学意义(P0.05)。患者显效26例,有效28例,好转8例,无效1例,临床治愈率为85.7%。63例下腔静脉滤器,取出60例,3例留置为永久性滤器。新增肺栓塞12例,无致死性肺栓塞发生。结论:导管接触溶栓对右下肢深静脉血栓的治疗效果较好,但导管接溶栓时有较高肺栓塞发生率,应积极放置下腔静脉滤器。     

Dextran 70 in prophylaxis of thromboembolic disease after surgery: a clinically oriented randomized double-blind trial.

A randomized double-blind trial of prophylaxis of thromboembolism in surgical patients judged by clinical morbidity has been completed. Altogether 831 patients over 40 years of age who underwent elective surgery of the stomach, biliary system, or colon received either dextran 70 or normal saline before the operation. Thirteen of the 435 patients on saline and three of the 396 on dextran developed pulmonary embolism. Eight of these 16 patients died of pulmonary embolism--seven in the saline group and one in the dextran group. As detected either clinically or by 125I-fibrinogen scanning the incidence of deep vein thrombosis was similar in the two groups. There was no increased incidence of excessive bleeding in patients on dextran though clinical impression suggested that some patients on dextran bled excessively. This trial showed that dextran 70 administered by intravenous drip during operation is effective in preventing pulmonary embolism and, in particular, reducing mortality from this cause. It seems to be as effective as subcutaneous heparin but is easier to administer and places less of a burden on nursing services.     

Expectation Modulates the Effect of Deep Brain Stimulation on Motor and Cognitive Function in Tremor-Dominant Parkinson's Disease

Expectation contributes to placebo and nocebo responses in Parkinson''s disease (PD). While there is evidence for expectation-induced modulations of bradykinesia, little is known about the impact of expectation on resting tremor. Subthalamic nucleus (STN) deep brain stimulation (DBS) improves cardinal PD motor symptoms including tremor whereas impairment of verbal fluency (VF) has been observed as a potential side-effect. Here we investigated how expectation modulates the effect of STN-DBS on resting tremor and its interaction with VF. In a within-subject-design, expectation of 24 tremor-dominant PD patients regarding the impact of STN-DBS on motor symptoms was manipulated by verbal suggestions (positive [placebo], negative [nocebo], neutral [control]). Patients participated with (MedON) and without (MedOFF) antiparkinsonian medication. Resting tremor was recorded by accelerometry and bradykinesia of finger tapping and diadochokinesia were assessed by a 3D ultrasound motion detection system. VF was quantified by lexical and semantic tests. In a subgroup of patients, the effect of STN-DBS on tremor was modulated by expectation, i.e. tremor decreased (placebo response) or increased (nocebo response) by at least 10% as compared to the control condition while no significant effect was observed for the overall group. Interestingly, nocebo responders in MedON were additionally characterized by significant impairment in semantic verbal fluency. In contrast, bradykinesia was not affected by expectation. These results indicate that the therapeutic effect of STN-DBS on tremor can be modulated by expectation in a subgroup of patients and suggests that tremor is also among the parkinsonian symptoms responsive to placebo and nocebo interventions. While positive expectations enhanced the effect of STN-DBS by further decreasing the magnitude of tremor, negative expectations counteracted the therapeutic effect and at the same time exacerbated a side-effect often associated with STN-DBS. The present findings underscore the potency of patients'' expectation and its relevance for therapeutic outcomes.     

Low-molecular-weight heparin and prevention of postoperative deep vein thrombosis.

The efficacy of low-molecular-weight heparin as a prophylactic agent was assessed in 150 consecutive patients over the age of 40 undergoing major abdominal surgery. Fifty of these patients received 1250 activated partial thromboplastin time (APTT) units of low-molecular-weight heparin every 12 hours: three developed isotopic deep vein thrombosis, which was confirmed by phlebography in two cases. The other 100 patients received a single injection of 1850 APTT units of low-molecular-weight heparin. Three of them developed isotopic deep vein thrombosis; phlebography failed to confirm the presence of thrombi in each case. None of the 150 patients studied died from fatal or contributory pulmonary emboli. Low-molecular-weight heparin was not associated with any increase in preoperative or postoperative bleeding. The effect of equal amounts of postoperative bleeding. The effect of equal amounts of low-molecular-weight heparin and unfractionated heparin on the coagulation mechanism during surgery was investigated in another 30 patients. The clotting assays and results of in-vivo platelet function tests indicated that both preparations produced similar effect. Intragroup comparisons, however, showed significant differences in the anti-factor Xa activity, lipoprotein lipase release, and plasma prekallikrein concentrations. A single injection of low-molecular-weight heparin daily is a convenient way of preventing deep vein thrombosis in high-risk patients undergoing major abdominal surgery.     

Fibrinolysin Therapy of Thrombophlebitis and Pulmonary Embolism: A Double-Blind Study

Thrombophlebitis and pulmonary embolism are major causes of disability and death in both medical and surgical patients. Etiological factors are still poorly understood. Preventive measures as currently practised are non-specific and based on questionable premises. Diagnostic measures to predict the silent fatal embolus are inadequate. Currently accepted treatment measures are designed to prevent extension of the thrombus but have no effect on the existing clot. Theoretically, thrombolytic preparations now being marketed offer some hope for dissolution of preformed thrombi. An experimental study was carried out on artificially induced thrombi in jugular and femoral veins of mongrel dogs. Human fibrinolysin (Actase, Ortho) was infused locally and systemically in varying doses. No thrombi were successfully lyzed by either method. Thirty-six cases of acute deep thrombophlebitis in the leg, one of axillary thrombosis, three of chronic postphlebitis of a lower limb with massive edema and eight of pulmonary emboli were observed and carefully documented clinically. All these patients received anticoagulants unless there was a contraindication. Fibrinolysin infusions in varying dosages were administered to 27 patients; 10 served as controls. The observers were unaware of the identity of those receiving the actual drug or of those given the placebo until completion of the study. Progress of the disease was judged by the rate of dis-appearance of symptoms and signs. No significant benefit could be noted in the treated as compared to the control group, in terms of rate of recovery or incidence of embolus.     

New technique of plication for miniabdominoplasty

The authors present a new method of plication of abdominal fascia performed in 42 patients who underwent surgery for miniabdominoplasty between September of 1998 and February of 2000. The design consisted of a horizontal half-moon on the infraumbilical fascia with high lateral tension, similar to the one that is performed on the skin, achieving an improvement in the muscle-aponeurotic tension of the whole abdomen without requiring a supraumbilical dissection or undermining. All patients (n = 42) had a superficial and a deep conventional liposuction of the abdomen, flanks, and posterior trunk with the wet technique. The rate of minor complications was 59.5 percent. Twenty patients had seromas, three patients had dog-ears and one had cutaneous ischemia (epidermolysis). There were no cases of major complications such as tissue necrosis, infections, deep venous thrombosis, pulmonary emboli, or fat embolus syndrome. Patients received follow-up examination between 6 months and 2 years after surgery (average, 15 months). The results were excellent, and the patients were completely satisfied.     

舒普深联合左氧氟沙星治疗哮喘并发肺部感染的疗效分析

目的:研究舒普深联合左氧氟沙星治疗哮喘并发肺部感染的临床疗效。方法:选取2012年6月到2016年6月来我院治疗的哮喘合并肺部感染患者80例,按照患者入院时间将患者随机分为观察组(n=40)和对照组(n=40)。对照组采用舒普深治疗,观察组采用舒普深和左氧氟沙星联合治疗,两组患者均治疗2周,观察比较两组患者的治疗疗效、病原菌清除率以及肺功能的恢复情况。结果:观察组患者的总效率、病原菌清除率均较对照组总有效率显著提高,差异具有统计学意义(P0.05)。与治疗前相比,两组患者治疗后的肺功能指标均显著提高,且观察组患者的肺功能指标较治疗组改善更显著。结论:舒普深联合左氧氟沙星治疗哮喘并发肺部感染临床疗效显著,可显著改善患者肺功能。     

Ursodeoxycholic acid (UDCA) in the treatment of chronic cholestatic diseases.

Several studies suggest that UDCA treatment has beneficial effects in chronic cholestatic diseases. We designed a controlled trial to assess the efficacy and tolerance of UCDA in primary biliary cirrhosis (PBC): 73 patients received UDCA (13-15 mg/kg per day) and 73 a placebo. One side-effect required interruption of therapy in each group. The relative risk of treatment failure (doubling of the bilirubin level or occurrence of a severe complication of cirrhosis) was 3 times higher in the placebo group. Pruritus resolved in 40% of the patients of UDCA group vs 19% in placebo group. Biological and histological parameters significantly improved in the patients receiving UDCA. Unexpectedly, immune parameters, including IgM levels and anti-mitochondrial antibody titers, also improved. The Mayo risk score was significantly different between the two groups at one and two years, suggesting that UDCA could prolong survival in PBC. Recent studies suggest that UDCA could have immunoregulating properties. Abnormal MHC class I expression by hepatocytes, observed in PBC, was dramatically reduced by UDCA treatment. Cholestasis itself induces hepatic MHC expression: hepatocyte MHC class I expression was present in 6/6 cholestatic patients vs 0/8 control subjects. Experimental cholestasis in the rat induced MHC class I expression. Cyclosporin or corticosteroids had no effect on this overexpression, suggesting that an immune mechanism is not involved in this phenomenon. To assess the effect of bile acids on MHC expression, human hepatocytes were incubated with bile acids. Chenodeoxycholic acid (CDCA) (an endogenous bile acid) but not UDCA induced a dose-dependent MHC class I hyperexpression. UDCA suppressed the CDCA-induced MHC hyperexpression.(ABSTRACT TRUNCATED AT 250 WORDS)     

Pilot study of losartan for pulmonary hypertension in chronic obstructive pulmonary disease

Background

Morbidity in COPD results from a combination of factors including hypoxia-induced pulmonary hypertension, in part due to pulmonary vascular remodelling. Animal studies suggest a role of angiotensin II and acute studies in man concur. Whether chronic angiotensin-II blockade is beneficial is unknown. We studied the effects of an angiotensin-II antagonist losartan, on haemodynamic variables, exercise capacity and symptoms.

Methods

This was a double-blind, randomized, parallel group, placebo- controlled study of 48 weeks duration. Forty patients with COPD and pulmonary hypertension (Tran tricuspid pressure gradient (TTPG) = 30 mmHg) were randomised to losartan 50 mg or placebo. Changes in TTPG were assessed at 3, 6 and 12 months.

Results

There was a trend for TTPG to increase in the placebo group (baseline 43.4 versus 48.4 mmHg at endpoint) and stay constant in the losartan group (baseline 42.8 versus 43.6 mmHg). More patients in the losartan group (50%) than in the placebo group (22%) showed a clinically meaningful reduction in TTPG at any timepoint; these effects seemed more marked in patients with higher baseline TTPG. There were no clear improvements in exercise capacity or symptoms.

Conclusion

In this 12-month pilot study, losartan 50 mg had no statistically significant beneficial effect on TTPG, exercise capacity or symptoms in pulmonary hypertension secondary to obstructive disease. A sub-group of patients with higher TTPG may benefit.     

Effects of single-dose steroid usage on edema, ecchymosis, and intraoperative bleeding in rhinoplasty

To examine the effects of single-dose dexamethasone use on edema, ecchymosis, and intraoperative bleeding in rhinoplasty, a double-blind, randomized trial with placebo control was planned. A total of 55 consecutive patients were included in the study. The dexamethasone (10 mg) was given intravenously just before surgery (preoperative group, n=18) or at the end of surgery (postoperative group, n=20). In the placebo group, 17 patients received saline preoperatively or postoperatively. Intraoperative blood loss was recorded for each patient. Postoperative scoring of eyelid swelling and ecchymosis was begun after approximately 24 hours and lasted into postoperative day 9. Only for the first 2 days was the difference between steroid groups (preoperative and postoperative) and the placebo group statistically significant for a decrease in eyelid edema (p < 0.05). A statistically significant difference in upper eyelid ecchymosis for both preoperative and postoperative steroid groups versus the placebo group also existed in the first 2 days (p < 0.05). Preoperative or postoperative steroid administration had no influence on the ecchymosis of the lower eyelid. When the results of the preoperative and postoperative steroid groups were compared, no significant difference was detected between the two groups in either edema or ecchymosis. To determine whether steroid use shortened the recovery period, the days on which edema and ecchymosis reached a minimum level were compared among the groups; no statistically significant difference was found among them. Using single-dose dexamethasone preoperatively did not alter intraoperative blood loss. Use of single-dose dexamethasone (either preoperatively or postoperatively) in rhinoplasty has a significant effect in decreasing upper and lower eyelid edema and upper eyelid ecchymosis for the first 2 days when compared with a placebo group. However, the effect of dexamethasone was lost after the first 2 days, and its use did not shorten the recovery period.     

Robot-assisted therapy using the MOTOmed letto 2 for the integrated early rehabilitation of stroke patients admitted to the intensive care unit

In this study, we aimed to assess the effects of early robot-assisted rehabilitation using the MOTOmed letto 2 on neurological recovery, disease severity, the rate and severity of multiple organ dysfunction syndrome, and the rate of venous thromboembolism in acute stroke patients in the intensive care unit (ICU), including patients requiring mechanical ventilation. This case-control study included 66 patients (49 men and 17 women; median age, 59 years) with acute ischemic stroke and cerebral hemorrhage admitted to the ICU. Patients were divided into two comparable groups, the intervention group (n = 33) and the control group (n = 33), and monitored from admission to day 21. After admission, both groups received standard rehabilitation, and patients in the intervention group also received robot-assisted arm and leg therapy. The groups had similar median Glasgow coma scale (GCS), National Institutes of Health Stroke Scale (NIHSS), APACHE II, and multiple organ dysfunction scale (MODS) scores on admission. There were no significant differences in neurological and medical outcomes on day 21 between the intervention and control groups (median GCS: 15 vs. 15, p = 0.32; median NIHSS 11 vs. 15, p > 0.05; median APACHE II: 6 vs. 9, p > 0.05; median MODS: 0 vs. 1, p > 0.05). The prevalence of multiple organ dysfunction syndrome and deep venous thrombosis (DVT) on day 21 was also similar in the intervention and control groups (60% vs. 67%, p > 0.05, and 58% vs. 45%, p > 0.05, respectively). However, the prevalence of severe multiple organ dysfunction syndrome, the incidence of pulmonary embolism, and the mortality rate were lower in the intervention group compared with the control group (14% vs. 41%, p < 0.05; 12% vs. 33%; p < 0.05; 12% vs. 39%, p < 0.05, respectively). Our results indicate that early robot-assisted therapy in patients with severe stroke admitted to the ICU reduces the rate of pulmonary embolism, the incidence of severe multiple organ dysfunction, and mortality on day 21, but does not influence neurological outcomes or the rate of deep vein thrombosis.