大面积脑梗塞患者鼻饲一周、二周引起消化道出血的相关因素分析

目的:探讨影响神经内科大面积脑梗塞患者鼻饲后消化道出血的影响因素,以使医护人员采取有效的护理措施预防患者消化道出血,为神经内科防控大面积脑梗塞患者鼻饲后消化道出血提供切实可行的依据。方法:选取2010年9月-2011年9月我院神经内科大面积脑梗塞住院患者400例,分为普通组与对照组,比较两组患者消化道出血的情况。针对消化道出血情况进行调查分析,找出引起大面积脑梗塞患者消化道出血的相关影响因素。结果:数据显示,鼻饲时间长短(一周、二周)与患者发生消化道出血有关联,鼻饲二周患者发生消化道出血机率高于鼻饲一周患者,两组间统计检验,x2=11.329,P<0.05,有显著差异。大面积脑梗塞患者发生消化道出血主要与以下几个因素相关:自身疾病及严重程度、年龄、置管位置、鼻饲技术。结论:护理人员可依据致使患者发生消化道出血的危险因素,有针对性的采取防控措施,降低神经内科患者鼻饲后消化道出血发生率,有效保障患者安全,提高护理质量。     

Laboratory and histopathologic comparative study of internal ultrasound-assisted lipoplasty and tumescent lipoplasty

Despite the advantages of using internal ultrasound-assisted lipoplasty instead of the classic tumescent lipoplasty, such as reduced bleeding and tissue damage, the authors found no objective or comparative study of these techniques in humans. For this reason, they conducted a clinical study to determine the amount of bleeding and tissue damage caused by each of the techniques. A simple clinical assay was accomplished at the Jalisco Plastic Surgery Institute on seven female patients scheduled for abdominal lipectomy. Two similar sections of the surgical area were marked for lipoplasty techniques: classic tumescent lipoplasty on one side and internal ultrasound-assisted lipoplasty on the other. Both areas were treated simultaneously by surgeons experienced in each technique. Laboratory tests and histologic studies were performed on the aspirated material and the manipulated tissue, respectively. The fluids sent to the laboratory were analyzed to determine the amount of bleeding and tissue damage. In the laboratory, the degree of lesion and tissue damage was evaluated in the dermis, nerves, blood vessels, and adipose cells. With internal ultrasound-assisted lipoplasty, indicators of tissue damage such as glutamic oxalacetic transaminase, pyruvic oxalacetic transaminase, cholinesterase, and myoglobin showed higher values than with tumescent lipoplasty. The same was found for hemoglobin levels and in the histologic data indicative of tissue damage; both values were statistically significant at < 0.001. Internal ultrasound-assisted lipoplasty was not demonstrated to be more innocuous or to have a selective effect in adipose cells, and it generally resulted in more tissue damage and bleeding than the classic tumescent technique.     

Extended somatostatin treatment of a patient with bleeding ulcer.

The results of a 67 hour cyclic somatostatin continuous infusion in a patient with a bleeding ulcer are reported. The subject was a 65 year old male with very heavy gastrointestinal bleeding on the 9th postoperative day following a high BI-resection. Endoscopy revealed the bleeding to be caused by two residual ulcers in the area of the anastomosis. Somatostatin treatment led to an immediate cessation of the bleeding after 1 hour. Gastric secretion as well as gastrin, insulin and growth hormone levels were significantly inhibited by somatostatin. Endoscopy at the end of the treatment period showed two ulcers in the process of healing. The raised blood glucose levels caused by somatostatin were easily controlled with max. 14 IU cristalline insulin daily. Except for dryness in the mouth, no adverse side effects were apparent. There was no evidence from laboratory investigations of hemostatic defects or bleeding tendency in the patient.     

Prospective comparison of double-contrast barium meal examination and fibreoptic endoscopy in acute upper gastrointestinal haemorrhage.

Fibre-optic endoscopy was compared prospectively with double-contrast radiology in 53 consecutive patients admitted with acute gastrointestinal haemorrhage. The bleeding site was correctly identified by endoscopy in 94% of patients and the final diagnosis was correctly given in 89%. The corresponding figures with radiology were 83% and 74%. Among the 50 patients with a final diagnosis of a bleeding site in the upper gastrointestinal tract endoscopy indicated the site of bleeding in all and radiology indicated it in 88%. Both investigations were well tolerated by patients. Endoscopy is the investigation of choice, but when it is not available double-contrast radiology will show the site of bleeding in 80-90% of patients.     

Plasma estriol levels after intramuscular injection of estriol and two of its esters

Twelve female volunteers from Berlin and 9 from Stockholm, all using a contraceptive pill (30 micrograms ethinyl estradiol and 150 micrograms levonorgestrel), received an intramuscular injection of estriol (E3; 1 mg in oil) on day 5 of withdrawal bleeding. Blood samples were collected at increasing time intervals during 4 weeks. Three months later, on day 5 of their withdrawal bleeding, 6 women were given intramuscularly (in oil) estriol 3,17-dipropionate (E3-prop) and 15 women estriol 3,17-dihexanoate (E3-hex). The doses were equivalent to 5 mg of estriol, i.e. 6.94 and 8.90 mg, respectively. Blood samples were collected during a period of 9 weeks. Estriol was analyzed by radioimmunoassay in all plasma samples. The average half-life of E3 ranged from 1.5 to 5.3 h after the administration of E3. It was 12.7 h and between 187 and 221 h after the administration of E3-prop and E3-hex, respectively. The average areas under the curve (in nmol.l-1.h) of E3 were between 82.5 and 161 after the administration of E3-prop or E3-hex, and between 27.1 and 37.9 when E3 had been given. As E3 was administered in a 5-fold lower dose than the esters, the areas under curve appeared to be comparable. Thus, the total exposure to E3 seemed to be almost independent of the type of E3 derivatization, while the time and intensity of exposure were very different.     

Support Immersion Endoscopy in Post-Extraction Alveolar Bone Chambers: A New Window for Microscopic Bone Imaging In Vivo

Using an endoscopic approach, small intraoral bone chambers, which are routinely obtained during tooth extraction and implantation, provide visual in vivo access to internal bone structures. The aim of the present paper is to present a new method to quantify bone microstructure and vascularisation in vivo. Ten extraction sockets and 6 implant sites in 14 patients (6 men / 8 women) were examined by support immersion endoscopy (SIE). After tooth extraction or implant site preparation, microscopic bone analysis (MBA) was performed using short distance SIE video sequences of representative bone areas for off-line analysis with ImageJ. Quantitative assessment of the microstructure and vascularisation of the bone in dental extraction and implant sites in vivo was performed using ImageJ. MBA revealed bone morphology details such as unmineralised and mineralised areas, vascular canals and the presence of bleeding through vascular canals. Morphometric examination revealed that there was more unmineralised bone and less vascular canal area in the implant sites than in the extraction sockets.     

"Haemostasis time", a modified bleeding time test and its comparison with the Duke and Ivy/template bleeding times. I. Normal values, application in thrombocytopenic patients and evaluation of heparin and aspirin effects

The occlusion time ("haemostasis time" - HT) of a thin, short cannula inserted into the cubital vein, was compared with the skin bleeding times of the Duke and Ivy/template techniques. 25 male and 25 female volunteers without a history of bleeding were divided into 5 equally large age groups ranging from 10 to over 50 years of age. They exhibited a range of 46 s-6 min 38 s (95% tolerance interval), while the Duke and Ivy/template bleeding times, which were simultaneously determined, corresponded to values given by other authors. HT is different from the skin bleeding times in that endothelium is replaced by a standard foreign surface which allows better standardization of the method. Similar results were obtained with HT compared to the skin bleeding times. These and a similar, non-significant heparin response with all three techniques suggest that HT is not more influenced by clotting factors than the Duke and Ivy/template bleeding times and, indeed, may be regarded as a bleeding time modification. HT, like both of the skin bleeding times, reflected lowered platelet counts and is even more sensitive in this respect. As tested in a group of 20 male and 20 female volunteers, HT showed a significant prolongation two hours after ingestion of 1 g aspirin. While male individuals exhibited longer bleeding times than females with the Ivy/template technique (sex-related difference p = 0.01), no male to female differences were found both with HT and the Duke bleeding time. HT is easy to perform, inexpensive, leaves no scars and is safe even for the patient with severe bleeding. Moreover, compared to the skin bleeding times, it permits a differential evaluation of vessel wall and tissue effects.     

The morphological basis of proestrus endometrial bleeding in canines

Endometrial bleeding during proestrus is a well-known phenomenon in the bitch. However, the exact events on the cellular level have not been studied. In the present investigation, immunohistochemical methods and transmission electron microscopy were employed to obtain more information about this cyclic event in canines. Long, stretched blood vessels were seen in H&E stained sections during proestrus. These vessels showed mitotic activity, as evidenced by Ki67 immunostaining. Although the endothelial lining and basement membrane of endometrial blood vessels seemed continuous, as indicated by immunohistochemical staining for laminin and Von Willebrand factor, transmission electron microscopy showed an extreme thinning and even interruption of the vascular wall in endometrial venules. Platelets were frequently seen in those areas, and also detected by immunohistochemistry. Interestingly, all endometrial capillaries examined by electron microscopy had an intact wall. We therefore postulate the endometrial venules to be the blood vessels that are mainly responsible for proestrus endometrial bleeding, rather than subepithelial capillaries.     

Aspirin and bleeding peptic ulcers in the elderly.

A case-control study was performed to determine whether aspirin confers a similar risk of bleeding from gastric or duodenal ulcers in the elderly as non-aspirin, non-steroidal anti-inflammatory drugs. The intake of analgesics in 230 patients with bleeding ulcers aged 60 and over and in hospital and community controls matched for age and sex was examined. Those who had taken aspirin were between two and three times more likely to be admitted to hospital with bleeding ulcers. This increased risk was not accounted for by aspirin taken for indigestion or by concurrent use of non-aspirin, non-steroidal anti-inflammatory drugs. A similar effect was not seen for paracetamol. When aspirin and other non-steroidal anti-inflammatory drugs were considered together the overall risk attributed to the drugs suggested that these drugs may be responsible for over a third of admissions for bleeding peptic ulcers in the elderly.     

Predictive value of rectal bleeding in screening for rectal and sigmoid polyps.

Overt rectal bleeding is a common symptom of colorectal cancer and polyps but also occurs in apparently healthy people. It is not known how often this represents bleeding from an undiagnosed rectal or sigmoid polyp or cancer. Three hundred and nineteen apparently healthy men aged over 50, selected by random sampling, were interviewed and underwent flexible sigmoidoscopy to at least 30 cm. Polyps of 10 mm or more in diameter were diagnosed in 12, one of whom also had an adenocarcinoma. Rectal bleeding during the previous six months was reported by 48, four of whom were found to have polyps; seven polyps and one cancer were diagnosed among the 271 who reported no rectal bleeding. Rectal bleeding had a specificity of 86%, a sensitivity of 33%, and a positive predictive value of 8% for rectal or sigmoid polyps or cancer. Restricting the analysis to those subjects who regularly inspected their stools did not improve the predictive value. Sigmoidoscopy in apparently healthy subjects with rectal bleeding will not result in the diagnosis of appreciable numbers of rectal and sigmoid polyps or cancers.     

Patient Delay in Colorectal Cancer Patients: Associations with Rectal Bleeding and Thoughts about Cancer

Rectal bleeding is considered to be an alarm symptom of colorectal cancer. However, the symptom is seldom reported to the general practitioner and it is often assumed that patients assign the rectal bleeding to benign conditions. The aims of this questionnaire study were to examine whether rectal bleeding was associated with longer patient delays in colorectal cancer patients and whether rectal bleeding was associated with cancer worries. All incident colorectal cancer patients during a 1-year period in the County of Aarhus, Denmark, received a questionnaire. 136 colorectal cancer patients returned the questionnaire (response rate: 42%). Patient delay was assessed as the interval from first symptom to help-seeking and was reported by the patient. Patients with rectal bleeding (N = 81) reported longer patient intervals than patients without rectal bleeding when adjusting for confounders including other symptoms such as pain and changes in bowel habits (HR = 0.43; p = 0.004). Thoughts about cancer were not associated with the patient interval (HR = 1.05; p = 0.887), but more patients with rectal bleeding reported to have been wondering if their symptom(s) could be due to cancer than patients without rectal bleeding (chi² = 15.29; p<0.001). Conclusively, rectal bleeding was associated with long patient delays in colorectal cancer patients although more patients with rectal bleeding reported to have been wondering if their symptom(s) could be due to cancer than patients without rectal bleeding. This suggests that assignment of symptoms to benign conditions is not the only explanation of long patient delays in this patient group and that barriers for timely help-seeking should be examined.     

电子阴道镜在诊断妊娠期阴道出血的价值

探讨应用电子阴道镜在寻找妊娠期阴道出血原因方面的价值。方法:对我院2004年5月-2006年11月64例非产科原因孕期阴道流血的孕妇,进行电子阴道镜检查及颈管分泌物培养和镜下定位活检。结果:阴道镜下发现宫颈赘生物12例,其中2例坏死,10例明显充血水肿;宫颈炎伴活动性出血2例,宫颈炎无活动性出血18例;正常宫颈16例;宫颈上皮内瘤样病变图象15例;宫颈分泌物培养阳性23例。结论:妊娠期不规则阴道出血原因复杂,阴道镜检查能较快排除与查明宫颈及阴道病变所导致的出血。     

A New Coronary Retroinfusion Technique in theRat Infarct Model: Transjugular Cardiac Vein Catheterization

Cell delivery via the retrograde coronary route boasts less vessel embolism, myocardial injury, and arrhythmogenicity when compared with those via antegrade coronary administration or myocardial injection. However, conventional insertion into the coronary sinus and consequent bleeding complication prevent its application in small animals. To overcome the complication of bleeding, we described a modified coronary retroinfusion technique via the jugular vein route in rats with myocardial infarction (MI). A flexible wire with a bent end was inserted into the left internal jugular vein and advanced slowly along the left superior vena cava. Under direct vision, the wire was run into the left cardiac vein by rotating the wire and changing the position of its tip. A fine tube was then advanced along the wire to the left cardiac vein. This modified technique showed less lethal hemorrhage than the conventional technique. Retroinfusion via transjugular catheter enabled efficient fluid or cell dissemination to the majority areas of the free wall of the left ventricle, covering the infarcted anterior wall. In conclusion, transjugular cardiac vein catheterization may make retrocoronary infusion a more safe and practical route for delivering cell, drug, and gene therapy into the infarcted myocardium of rats.     

Compartmentalization of massive vascular malformations

A total of 18 patients with massive vascular malformations of the head and neck region were treated with compartmentalization using nonabsorbable sutures followed by injection of a sclerosant agent into each compartment. The indication for compartmentalization was either to stop potentially uncontrollable, life-threatening hemorrhage during the dissection of the lesion or to reduce its vascularity to allow a less dangerous subsequent resection. Compartmentalization was used in both high-flow and low-flow vascular malformations. In this technique, large nonabsorbable sutures are placed deeply in multiple areas within the lesion. The aim is to divide the malformation into multiple compartments by changing the direction of the suturing; in this way the sclerosing agent is provided with a more effective environment. The sclerosant used was either sodium tetradecyl sulfate 3%, absolute alcohol, or both. The total amount of infiltrate varied from 3 to 35 cc, according to the size of malformation. After compartmentalization, swelling was the most noticeable complication. With this technique, it was possible to treat what were considered untreatable malformations using standard techniques and to control the inevitable serious bleeding.     

Shortened bleeding time in acute myocardial infarction and its relation to platelet mass.

The bleeding time, using the Simplate method, horizontal incision, and venostasis, was measured in a study of 51 patients admitted to a coronary care unit within 12 hours of the onset of chest pain. The bleeding time was significantly shorter in the 28 patients who were found to have definite myocardial infarction compared with the 23 others with chest pain but no definite infarction (p less than 0.0005). A bleeding time of less than 212 seconds correctly classified 84% of patients (sensitivity for definite myocardial infarction 89%) presenting to the coronary care unit with chest pain. Multiple regression analysis showed the bleeding time in all patients to be determined independently (and with high significance) by the following variables in order of importance: diagnostic group, platelet mass (platelet count X mean volume), and age. Packed cell volume was not a significant determinant. In the group with definite myocardial infarction considered alone the same order of variables was observed in predicting bleeding time, but none of them was significant. A major variable reducing bleeding time in acute myocardial infarction remains to be determined. There was no association between bleeding time and creatine phosphokinase activity or infarct size in the group with definite myocardial infarction.     

Bleeding time in patients with hepatic cirrhosis.

OBJECTIVE--To determine the frequency of an abnormal bleeding time in patients with cirrhosis and to relate this to known factors that affect primary haemostasis and to the severity of liver disease. DESIGN--Prospective clinical and laboratory study in patients admitted for complications or investigations of liver disease. SETTING--Royal Free Hospital hepatobiliary and liver transplantation unit. SUBJECTS--100 Consecutive inpatients aged 17-74 with various forms of cirrhosis, including alcoholic, biliary, autoimmune, viral, and cryptogenic. At least 10 days had elapsed since any episodes of bleeding, resolution of sepsis, or alcohol intake. No patient was taking any drug known to affect primary haemostasis. MAIN OUTCOME MEASURES--Bleeding time as measured with the Simplate double blade template device. A bleeding time longer than 10 minutes was considered abnormal. Other measures were platelet count, prothrombin time, partial thromboplastin time, packed cell volume, and blood urea, serum bilirubin, and serum albumin concentrations, all measured on each subject at the same time by standard laboratory methods. RESULTS--A weak but significant correlation existed between the bleeding time and the platelet count (rs = 0.483; p less than 0.001). There were significantly lower platelet counts, longer prothrombin times, and higher blood urea and serum bilirubin concentrations in the 42 patients with bleeding times of 10 minutes or more compared with the 58 patients with bleeding times less than 10 minutes. Multiple linear regression analysis showed that the bilirubin concentration as well as the platelet count was independently correlated with the bleeding time. The combination of a platelet count greater than 80 x 10(9)/l and a prothrombin time less than 17 seconds (usually taken as safe limits for performing routine liver biopsy) did not predict a normal bleeding time. Ten of 39 patients fulfilling these criteria had a prolonged bleeding time. CONCLUSIONS--Prolonged bleeding time is common in patients with cirrhosis, even in those with prothrombin times and platelet counts within "safe limits" for invasive procedures. The severity of liver disease as assessed by the bilirubin concentration plays an important part in determining the bleeding time in cirrhosis. The bleeding time should be measured when assessing patients for invasive procedures who have a raised bilirubin concentration or poor hepatic function, even if the platelet count and prothrombin time are considered adequate.     

Late diagnosis of a neglected cervical carcinoma in an elderly woman: a case report

We report the case of an 88-year-old, Greek patient who was referred to our department with a bleeding mass that occupied her entire vagina. This exophytic tumor had extensive ulcerated areas and originated from the cervix. The biopsies taken from the mass confirmed it to be squamous cell carcinoma. Despite the giant size of the tumor, the parametria and middle and lower vagina were not infiltrated. Rather, the neglected mass created a severe septic condition that was progressing to disseminated intravascular coagulation DIC status. Because of the patient's advanced age and critical condition, we performed a "toilet" operation to remove the tumor mass. We subsequently administered radical radiation therapy with satisfactory results.     

Leech bite: a rare gynecologic emergency

Vaginal bleeding as the result of a leech bite is a rare occurrence. We report 2 cases of vaginal bleeding in young girls that resulted from a leech bite and required treatment. Clinical presentation and management for young girls is described. Health professionals working in rural areas where leech infestation is common should be aware that children are at risk for leech bites in the genital region; a high index of suspicion is of great help to make an early diagnosis and ensure prompt treatment.     

内镜下喷洒蛇毒血凝酶与金属钛夹治疗不明原因消化道出血的临床疗效比较

目的:探讨内镜下喷洒蛇毒血凝酶与金属钛夹治疗不明原因消化道出血的临床疗效。方法:选取2013年8月至2015年12月本院收治的不明原因消化道出血患者82例,随机分为对照组和实验组,每组41例。对照组给予内镜下喷洒蛇毒血凝酶治疗,实验组给予金属钛夹止血治疗。观察两组患者经止血治疗后即时止血时间、外科手术率、输血量、症状消失时间和临床疗效、再出血率和出血量。结果:实验组即时止血率明显高于对照组,输血量低于对照组(P0.05);实验组呕血消失时间、潜血转阴时间和引流液变清时间均小于对照组(P0.05);实验组痊愈率、总有效率高于对照组(P0.05);两组之间再出血率和出血量比较差异无统计学意义(P0.05)。结论:金属钛夹较内镜下喷洒蛇毒血凝酶对不明原因消化道出血具有更好的临床疗效,且再出血率较低。     

Short-term,medium-term,and long-term risks of nonvariceal upper gastrointestinal bleeding after dengue virus infection

Dengue patients have an increased risk of acute gastrointestinal (GI) bleeding. However, whether dengue virus (DENV) infection can cause an increased long-term risk of GI bleeding remains unknown, especially among elderly individuals who commonly take antithrombotic drugs. A retrospective population-based cohort study was conducted by analyzing the National Health Insurance Research Databases. Laboratory-confirmed dengue patients from 2002 to 2012 and four matched nondengue controls were identified. Multivariate Cox proportional hazard regression was used to evaluate the acute (<30 days), medium-term (31–365 days), and long-term (>365 days) risks of nonvariceal upper GI bleeding after DENV infection. Stratified analyses by age group (≤50, 51–64, ≥65 years old) were also performed. In total, 13267 confirmed dengue patients and 53068 nondengue matched controls were included. After adjusting for sex, age, area of residence, comorbidities, and medications, dengue patients had a significantly increased risk of nonvariceal upper GI bleeding within 30 days of disease onset (adjusted HR 55.40; 95% CI: 32.17–95.42). However, DENV infection was not associated with increased medium-term and long-term risks of upper GI bleeding overall or in each age group. Even dengue patients who developed acute GI bleeding did not have increased medium-term (adjusted HR; 0.55, 95% CI 0.05–6.18) and long-term risks of upper GI bleeding (adjusted HR; 1.78, 95% CI 0.89–3.55). DENV infection was associated with a significantly increased risk of nonvariceal upper GI bleeding within 30 days but not thereafter. Recovered dengue patients with acute GI bleeding can resume antithrombotic treatments to minimize the risk of thrombosis.