DIAGNOSIS OF HEMORRHAGIC DISEASES—Evaluation of Procedures

Careful and complete history and physical examination are essential in the diagnosis of diseases characterized by hemorrhage and are more reliable than laboratory tests for the prediction of the tendency to bleed at the time of surgical operation. Specific questions should be asked about bleeding from various anatomical sites, allergic manifestations, diet, and exposure to poisons and chemical substances. Because hemorrhagic diseases may be hereditary, it is necessary to obtain a family history. If there is a personal or family history of abnormal bleeding, the examiner should obtain exact details about the events immediately preceding the bleeding episodes, the character and duration of the hemorrhage and the response to therapy.The history is particularly important in the case of patients who are to have operation. Failure to obtain a history of past bleeding episodes may be catastrophic. In patients with bleeding tendencies who require operation, the history is valuable in predicting the severity of the bleeding.Physical examination including examination of retina, breast and pelvic organs will often detect evidence of lesions that are helpful in the diagnosis of the primary diseases of which the hemorrhage is a manifestation. The location, distribution, character and number of hemorrhagic lesions are of value in diagnosis and in prognosis.     

DIAGNOSIS OF HEMORRHAGIC DISEASES—Evaluation of Procedures—Part II Preoperative Tests

Routine preoperative tests such as the determination of bleeding time and coagulation time are unnecessary and are not recommended. Rulings which require routine preoperative tests result in the adoption of inferior and unreliable time-saving methods in the laboratory. If the clinical staff insists that laboratory procedures to predict hemorrhage be performed on every patient scheduled for operation, approved methods of performing the tests should be employed.Preoperative procedures should include a personal and a family history, a careful and complete physical examination and screening laboratory tests such as urinalysis, hematocrit, leukocyte count and smear examination, including estimation of the number of thrombocytes.Special hemorrhagic studies are indicated on selected patients. These selected patients include those who have a history of abnormal bleeding, those who consider themselves “easy bleeders” or who have apprehension concerning hemorrhage at the time of operation, and those who have physical signs of hemorrhage. Special hemorrhagic studies should also be performed on patients who have diseases that are known to be associated with vascular and coagulation abnormalities, infants who have not been subjected to tests of trauma and on patients from whom a reliable history cannot be obtained.Extra precaution should be taken if operation is to be performed in hospitals or clinics that do not have adequate blood banking facilities and if the operation to be performed is one in which difficulty in hemostasis is anticipated.The preoperative tests that are indicated on selected patients should include as a minimum: The thrombocyte count, determination of the bleeding time by the Ivy method, determination of the coagulation time by the multiple tube method and the observation of the clot. Where facilities are available, the hemorrhagic study should also include the plasma and serum prothrombin activity tests.     

Hepatocerebral dysfunction

Routine preoperative tests such as the determination of bleeding time and coagulation time are unnecessary and are not recommended. Rulings which require routine preoperative tests result in the adoption of inferior and unreliable time-saving methods in the laboratory. If the clinical staff insists that laboratory procedures to predict hemorrhage be performed on every patient scheduled for operation, approved methods of performing the tests should be employed. Preoperative procedures should include a personal and a family history, a careful and complete physical examination and screening laboratory tests such as urinalysis, hematocrit, leukocyte count and smear examination, including estimation of the number of thrombocytes. Special hemorrhagic studies are indicated on selected patients. These selected patients include those who have a history of abnormal bleeding, those who consider themselves "easy bleeders" or who have apprehension concerning hemorrhage at the time of operation, and those who have physical signs of hemorrhage. Special hemorrhagic studies should also be performed on patients who have diseases that are known to be associated with vascular and coagulation abnormalities, infants who have not been subjected to tests of trauma and on patients from whom a reliable history cannot be obtained. Extra precaution should be taken if operation is to be performed in hospitals or clinics that do not have adequate blood banking facilities and if the operation to be performed is one in which difficulty in hemostasis is anticipated. THE PREOPERATIVE TESTS THAT ARE INDICATED ON SELECTED PATIENTS SHOULD INCLUDE AS A MINIMUM: The thrombocyte count, determination of the bleeding time by the Ivy method, determination of the coagulation time by the multiple tube method and the observation of the clot. Where facilities are available, the hemorrhagic study should also include the plasma and serum prothrombin activity tests.     

Severe Colonic Bleeding

Patients requiring emergency operation for severe acute colonic hemorrhage usually arrive in the operating room inadequately studied and the point of bleeding not known. A well planned procedure for making an operative diagnosis is lacking.The fact that diverticular disease is the most common cause of massive colonic bleeding, dominates the surgical management of this problem. A critical interpretation of the color and the consistency of the stools must be made by the surgeon. Since the bleeding lesion is usually otherwise clinically silent, the character of the stools may be the only indication of the level of bleeding and the rate and the amount of the blood loss. A proctoscopic examination, followed by an emergency barium enema study if possible, is always done before subjecting a patient to laparotomy.The indications for emergency operation include acute exsanguinating hemorrhage, less severe but persistent colonic bleeding and recurrent colonic bleeding. The steps for the operative diagnosis and the surgical procedure utilized for a specific situation are discussed.     

Hemoptysis: Diagnosis and Management

Hemoptysis is one of the most important symptoms of cardiopulmonary disease—first, because bleeding even in small amounts may indicate the presence of such serious diseases as bronchogenic carcinoma or active tuberculosis, and second, because untreated massive hemorrhage is associated with a high mortality rate. The cause of hemoptysis may be suggested by the history, physical examination or chest x-ray findings, but often diagnostic procedures such as bronchoscopy, bronchography and pulmonary angiography are needed for definitive diagnosis. The importance of early localization of the bleeding site and surgical intervention in patients with massive hemoptysis is stressed.     

磁共振磁敏感加权成像在颅脑疾病中的应用研究

目的探讨磁敏感加权成像在脑部疾病中的临床应用价值。方法对65例临床疑是脑血管病变患者行常规T1WI、T2WI、DWI、SWI序列及增强T1WI、MRA,探讨SWI序列在显示小出血灶、小静脉及含铁血黄素、钙化等顺磁性物质的优越性。结果①海绵状血管瘤,SWI能鉴别出血与血管,发现更多的小出血灶;②动静脉畸形,SWI能够发现更多的细小静脉向大静脉引流;③急性脑梗死,SWI可发现小的出血灶;④脑肿瘤,SWI显示出小的引流静脉;⑤帕金森病,SWI能显示脑内多发异常低信号铁沉积。结论 SWI对低流量血管畸形、小静脉结构、多发细小出血以及铁钙沉积十分敏感,为常规MRI的重要补充,应用于中枢神经系统疾病的诊断和鉴别诊断。     

Bleeding varices: 1. Emergency management.

The aim of the emergency management of bleeding varices is to stop the hemorrhage nonoperatively if possible, avoiding emergency shunt surgery, an operation that has a higher mortality than elective shunt surgery. Patients with an upper gastrointestinal hemorrhage should undergo endoscopy immediately to verify the diagnosis of bleeding varices. They can then be categorized according to whether they stop bleeding spontaneously (group 1), continue to bleed slowly (group 2) or continue to bleed rapidly (group 3). Group 1 patients are discussed in the second part of this two-part series. Group 2 patients are initially treated with vasopressin given intravenously; those who fail to respond should undergo emergency angiography and receive vasopressin intra-arterially. If this fails, patients at low surgical risk should undergo urgent shunt surgery; those at high risk do better with endoscopic sclerotherapy. Group 3 patients are also given an intravenous infusion of vasopressin. Patients at low surgical risk who continue to bleed then receive tamponade with a Sengstaken--Blakemore tube. If this fails, they undergo emergency creation of an H-shaped mesocaval shunt. Patients at high surgical risk who fail to respond to vasopressin given intravenously are next treated intra-arterially. If this fails they are given either endoscopic or transhepatic sclerotherapy.     

不明原因发热的临床综合诊断

不明原因发热是临床常见疑难疾病,其定义随着疾病种类的不断变化及诊断流程的进步而逐步完善。不明原因发热(feverof unknown origin,FUO)病因包括感染性疾病、风湿免疫性疾病及肿瘤性疾病三大类,三大病因各自具有不同临床特征。详细病史采集、全面体格检查及常规实验室检查对诊断FUO至关重要,必要时应及时进行相关影像学及病理学检查,疾病的最终诊断应综合分析病史及实验室检查。     

Hemorrhage During Long-Term Anticoagulant Drug Therapy—Part I: Intracranial Hemorrhage

Intracranial hemorrhage was the most serious hemorrhage as measured by death and disability, occurring during long-term anticoagulant drug therapy of 1,626 patients. Among 95 hemorrhagic episodes considered life-threatening or potentially crippling, 30 were intracranial and 56 were gastrointestinal. Over two-thirds of the patients with intracranial hemorrhage died, as against one-tenth of those with gastrointestinal hemorrhage.The incidence of intracranial hemorrhage is increased among hypertensive patients, but the results of a controlled study indicate that the incidence of intracranial hemorrhage is not affected by whether or not the hypertensive patient is receiving anticoagulant therapy. Hypertension is the important precipitating factor, not the prothrombin level. Even at excessively low prothrombin levels only one intracranial hemorrhage occurred in 337 instances.In this series, reducing coagulability to a desirable range did not increase the probability of intracranial hemorrhage. Once bleeding occurred, however, it increased the risk of death and disability.     

Determining carrier probabilities for breast cancer-susceptibility genes BRCA1 and BRCA2.

Breast cancer-susceptibility genes BRCA1 and BRCA2 have recently been identified on the human genome. Women who carry a mutation of one of these genes have a greatly increased chance of developing breast and ovarian cancer, and they usually develop the disease at a much younger age, compared with normal individuals. Women can be tested to see whether they are carriers. A woman who undergoes genetic counseling before testing can be told the probabilities that she is a carrier, given her family history. In this paper we develop a model for evaluating the probabilities that a woman is a carrier of a mutation of BRCA1 and BRCA2, on the basis of her family history of breast and ovarian cancer in first- and second-degree relatives. Of special importance are the relationships of the family members with cancer, the ages at onset of the diseases, and the ages of family members who do not have the diseases. This information can be elicited during genetic counseling and prior to genetic testing. The carrier probabilities are obtained from Bayes's rule, by use of family history as the evidence and by use of the mutation prevalences as the prior distribution. In addressing an individual's carrier probabilities, we incorporate uncertainty about some of the key inputs of the model, such as the age-specific incidence of diseases and the overall prevalence of mutations. There is some evidence that other, undiscovered genes may be important in explaining familial breast cancer. Users of the current version of the model should be aware of this limitation. The methodology that we describe can be extended to more than two genes, should data become available about other genes.     

Association of Dengue Hemorrhagic Fever With Multiple Risk Factors for Pituitary Apoplexy

ObjectiveTo describe pituitary apoplexy that developed during the course of dengue hemorrhagic fever.MethodsWe describe the clinical findings, laboratory test results, imaging findings, and clinical course of the study patients.ResultsPatient 1 was a 40-year-old man who developed clinical signs and symptoms of dengue, which was confirmed by serologic testing. He presented with thrombocytopenia and developed severe headache and vomiting. During hospitalization, acromegaly was suspected because of the characteristic disease phenotype. Magnetic resonance imaging confirmed the diagnosis of pituitary apoplexy. Subsequently, the biochemical diagnosis of acromegaly was confirmed, and the patient underwent transsphenoidal surgery. Histopathologic examination showed signs of recent bleeding. Patient 2 was a 38-year-old man with a macroprolactinoma, who had been treated with cabergoline for 10 weeks and had shown improvement on laboratory testing and imaging. The patient then presented with clinical symptoms of dengue (confirmed serologically) and thrombocytopenia. He developed bilateral hemianopsia, and magnetic resonance imaging showed enlargement of the pituitary adenoma with signs of intratumoral bleeding. The patient underwent transsphenoidal surgery, and histopathologic examination documented a pituitary adenoma diffusely infiltrated by blood cells.ConclusionsWe describe dengue as a probable novel condition for pituitary apoplexy because it may be associated with multiple risk factors for pituitary infarction or bleeding. Physicians should suspect pituitary apoplexy in patients with dengue hemorrhagic fever who develop a rapid onset of severe headache and vision defects, even in those without known pituitary adenomas. (Endocr Pract. 2012;18:e97-e101)     

Subperitoneal hemorrhage

Clinical diagnosis of subperitoneal hemorrhage can be made in a substantial percentage of cases by recognition of a quite constant syndrome-provided the possibility of bleeding is considered. Progressive anemia, as indicated by repeated counts of erythrocytes in the blood or by hematocrit determinations, is confirmation of the diagnosis. The majority of patients recover spontaneously under conservative management.Surgical intervention is indicated if repeated episodes of hemorrhage occur or if the volume of circulating blood cannot be maintained by repeated transfusions of whole blood.     

Pathology associated with Cryptobia infection in a summer flounder (Paralichthys dentatus)

A laboratory-held summer flounder (Paralichthys dentatus) became moribund and presented gross ulcerative and hemorrhagic lesions, concomitant with a space-occupying lesion in the abdominal cavity and a prolapsed rectum. Edema, hemorrhage, and necrosis of the intestine and edema of the stomach wall were noted upon post-mortem examination. Microscopic examination revealed large numbers of Cryptobia in the submucosa of the gut and in the liver.     

Estimating the power of a proposed linkage study: a practical computer simulation approach.

I describe a simulation method to estimate the power to detect linkage given a set of pedigrees of known structure and for which family history data may be available. This method can be applied to autosomal and X-linked dominant diseases; depending on the pedigrees under consideration, it will often be applicable for autosomal and X-linked recessive diseases. This power calculation can most usefully be undertaken after family history data are gathered, but prior to examination and testing of pedigree members to obtain marker information. Of key importance, the power calculation is straightforward to carry out and not too time-consuming; it is practical even on a microcomputer. The result of the power calculation is an objective answer to the question: Will my families be sufficient to demonstrate linkage?     

Ischemic Colitis

Twenty cases of ischemic colitis are reviewed; 19 were obtained from autopsy files and the diagnosis in one was made from a surgical specimen. The majority of the patients were elderly with generalized arteriosclerosis. In approximately two-thirds of the patients the ischemic colitis was precipitated by preceding trauma, operation or congestive heart failure. Clinically, ischemic colitis is characterized by abdominal pain, distension and bleeding per rectum. Perforation of large bowel may occur. The lesions tend to be localized around the splenic flexure and junction of the descending and sigmoid colon, and in cases following aortic graft surgery the rectum is involved. Microscopically, there is necrosis, hemorrhage and ulceration. In less severe cases the mucosa only is affected. Cases with perforation show necrosis of all layers. It is considered that ischemic colitis is comparatively frequent and should be distinguished from other inflammatory conditions of the colon.     

肺隐球菌病12例临床分析

目的 提高对隐球菌病的认识.方法 对确诊为肺隐球菌病的12例病例的临床资料进行回顾性分析.结果 12例病例中,男性8例,女性4例,年龄31～68岁,平均年龄(51.8±12.6)岁,6例伴有基础疾病,但无1例有鸟类接触史;有临床症状者10例,其中咳嗽8例,咯痰3例,胸痛4例,发热2例,有体征者仅2例;胸部影像表现为:1...     

阴道镜检查在宫颈疾病诊断中的应用

目的:探讨阴道镜检查在宫颈病变诊断中的应用价值。方法:对我院2010年7月至2010年10月150例患者进行阴道镜检查,对镜下可疑宫颈病变110例患者病变处取活检送病理检查,将结果行分析总结。结果:110例宫颈病变中,阴道镜检查诊断慢性宫颈炎83例,不典型增生21例,宫颈癌6例;病理诊断慢性宫颈炎77例,不典型增生25例,宫颈癌8例。阴道镜下诊断与病理诊断符合率最高可达92.77%。结论:阴道镜检查联合病理活检能及时发现宫颈癌前病变和宫颈癌,提高宫颈癌及癌前病变的早期检出率。     

Lower body negative pressure as a model to study progression to acute hemorrhagic shock in humans.

Hemorrhage is a leading cause of death in both civilian and battlefield trauma. Survival rates increase when victims requiring immediate intervention are correctly identified in a mass-casualty situation, but methods of prioritizing casualties based on current triage algorithms are severely limited. Development of effective procedures to predict the magnitude of hemorrhage and the likelihood for progression to hemorrhagic shock must necessarily be based on carefully controlled human experimentation, but controlled study of severe hemorrhage in humans is not possible. It may be possible to simulate hemorrhage, as many of the physiological compensations to acute hemorrhage can be mimicked in the laboratory by applying negative pressure to the lower extremities. Lower body negative pressure (LBNP) sequesters blood from the thorax into dependent regions of the pelvis and legs, effectively decreasing central blood volume in a similar fashion as acute hemorrhage. In this review, we compare physiological responses to hemorrhage and LBNP with particular emphasis on cardiovascular compensations that both share in common. Through evaluation of animal and human data, we present evidence that supports the hypothesis that LBNP, and resulting volume sequestration, is an effective technique to study physiological responses and mechanisms associated with acute hemorrhage in humans. Such experiments could lead to clinical algorithms that identify bleeding victims who will likely progress to hemorrhagic shock and require lifesaving intervention(s).     

Viral hemorrhagic fevers of South America

This paper reviews the epidemiology and distinguishing features of three viral hemorrhagic fevers (dengue hemorrhagic fever, yellow fever and arenaviral hemorrhagic fever) that have emerged as important public health problems in South America. Although the etiology, natural history and control of the three diseases are different, their clinical manifestations and histopathology findings are similar and can be difficult to differentiate. Consequently, early recognition and correct diagnosis are essential for effective control measures to be initiated.     

小脑后下动脉瘤经微血管多普勒超声辅助下的显微外科治疗

目的：探讨小脑后下动脉瘤（PICA）的微血管多普勒超声（MVD）辅助下显微外科治疗。方法：回顾性分析31例患者的显微外科手术的临床症状,影像特点,外科治疗方法及相关预后。结果：头颅CT表现主要为幕下为主的蛛网膜下腔出血或脑室出血或二者兼有（除1例未破裂）。其中经全脑数控减影血管造影术（DSA）和/或CT血管造影（CTA）检查确诊。其中手术路径为枕下旁正中16例,枕下正中入路14例,枕下乙状窦后入路1例。在MVD的辅助下行脉瘤夹闭术27例,动脉瘤包裹术1例,动脉瘤夹闭并动静脉畸形切除术2例,动脉瘤夹闭术并小脑血肿清除术1例。术后出现并发症10例,其中3例意识障碍致死亡或自动出院,其余患者术后无神经功能损伤或并发症,恢复良好。结论：小脑后下动脉瘤的治疗选择合适的手术入路行显微外科手术,辅助MVD下,能够降低手术风险,提高完全夹闭动脉瘤的成功率,降低手术并发症的发生。