糖尿病患者足溃疡减压指南(2023年更新版)——《国际糖尿病足工作组:糖尿病相关的足病预防与管理指南(2023)》的一部分

减轻组织的机械性压力在治愈糖尿病相关的足溃疡所需的多种干预措施中最为重要。本文是2023年国际糖尿病足工作组(IWGDF)发布的减压治疗促进糖尿病相关的足溃疡愈合的循证指南,也是对2019年IWGDF指南的更新。我们遵循推荐、评估、发展和评价分级(GRADE)方法学,以患者-干预-比较-结局(patient-intervention-control-outcome,PICO)模式设计临床问题和重要结果,进行系统评价和Meta分析,制定评判表汇总,为每个问题编写推荐和理由。每项推荐都是基于系统综述中发现的证据,在无证据情况下则采用专家意见,以及对判断项目的GRADE等级总结进行仔细权衡,包括可预期和不可预期的影响、证据的确定性、患者价值、所需资源、成本效益、公平性、可行性和可接受性。为了治愈糖尿病患者神经性前足底或中足底溃疡,要使用不可拆卸的齐膝高减压装置作为首选减压干预措施。如果患者存在对不可拆卸减压装置的禁忌证或不能耐受,考虑使用可拆卸齐膝(或踝)高减压装置作为减压干预措施的第二选择。如果无可用的减压装置,考虑使用合适的鞋具结合毡制泡沫作为减压干预措施的第三选择。如果这种非手术减压治疗不能治愈前足底溃疡,可以考虑跟腱延长术、跖骨头切除术、关节置换术或跖骨截骨术。为了治疗继发于屈趾畸形的神经性足底或小趾远端溃疡,可行趾屈肌腱切开术。为了促进后足、非足底或并发感染或缺血的溃疡的愈合,提出了进一步的推荐。所有推荐都已在减压临床路径中进行了总结,以帮助促进本指南在临床实践中的实施。这些减压推荐将帮助医务人员为糖尿病相关的足溃疡患者提供最佳的治疗和预后,降低患者感染、住院和截肢的风险。

糖尿病相关的足病的定义和标准(2023年更新版)

糖尿病相关的足病管理涉及多个学科,通用的专业词汇对于各学科间准确沟通交流至关重要。国际糖尿病足工作组(IWGDF)对相关文献进行了系统综述,构成了制定IWGDF指南的基础,并且明确了糖尿病相关的足病的一系列定义、标准及名词解释。本文介绍2023年IWGDF对这些定义和标准的更新,并建议在临床实践和研究中一致使用,以利于世界各地不同学科人员针对糖尿病相关的足病的专业性交流。

Spatial analysis of the osteoarthritis microenvironment: techniques, insights, and applications

Osteoarthritis(OA)is a debilitating degenerative disease affecting multiple joint tissues,including cartilage,bone,synovium,and adipose tissues.OA presents diverse clinical phenotypes and distinct molecular endotypes,including inflammatory,metabolic,mechanical,genetic,and synovial variants.Consequently,innovative technologies are needed to support the development of effective diagnostic and precision therapeutic approaches.Traditional analysis of bulk OA tissue extracts has limitations due to technical constraints,causing challenges in the differentiation between various physiological and pathological phenotypes in joint tissues.This issue has led to standardization difficulties and hindered the success of clinical trials.Gaining insights into the spatial variations of the cellular and molecular structures in OA tissues,encompassing DNA,RNA,metabolites,and proteins,as well as their chemical properties,elemental composition,and mechanical attributes,can contribute to a more comprehensive understanding of the disease subtypes.Spatially resolved biology enables biologists to investigate cells within the context of their tissue microenvironment,providing a more holistic view of cellular function.Recent advances in innovative spatial biology techniques now allow intact tissue sections to be examined using various-omics lenses,such as genomics,transcriptomics,proteomics,and metabolomics,with spatial data.This fusion of approaches provides researchers with critical insights into the molecular composition and functions of the cells and tissues at precise spatial coordinates.Furthermore,advanced imaging techniques,including high-resolution microscopy,hyperspectral imaging,and mass spectrometry imaging,enable the visualization and analysis of the spatial distribution of biomolecules,cells,and tissues.Linking these molecular imaging outputs to conventional tissue histology can facilitate a more comprehensive characterization of disease phenotypes.This review summarizes the recent advancements in the molecular imaging modalities and methodologies for in-depth spatial analysis.It explores their applications,challenges,and potential opportunities in the field of OA.Additionally,this review provides a perspective on the potential research directions for these contemporary approaches that can meet the requirements of clinical diagnoses and the establishment of therapeutic targets for OA.

Primary graft dysfunction following lung transplantation:From pathogenesis to future frontiers

Lung transplantation is the treatment of choice for patients with end-stage lung disease.Currently,just under 5000 lung transplants are performed worldwide annually.However,a major scourge leading to 90-d and 1-year mortality remains primary graft dysfunction.It is a spectrum of lung injury ranging from mild to severe depending on the level of hypoxaemia and lung injury post-transplant.This review aims to provide an in-depth analysis of the epidemiology,pathophysiology,risk factors,outcomes,and future frontiers involved in mitigating primary graft dysfunction.The current diagnostic criteria are examined alongside changes from the previous definition.We also highlight the issues surrounding chronic lung allograft dysfunction and identify the novel therapies available for ex-vivo lung perfusion.Although primary graft dysfunction remains a significant contributor to 90-d and 1-year mortality,ongoing research and development abreast with current technological advancements have shed some light on the issue in pursuit of future diagnostic and therapeutic tools.

Ventricular Arrhythmia in the Fontan Circulation:Prevalence,Risk Factors and Clinical Implications

Objective:Sudden cardiac death(SCD)and malignant ventricular arrhythmia(VA)are increasingly recognized as important issues for people living with a Fontan circulation,but data are lacking.We sought to characterize the cohort who had sudden cardiac death,most likely related to VA and/or documented VA in the Australia and New Zealand Fontan Registry including risk factors and clinical outcomes.Methods:A retrospective cohort study was performed.Inclusion criteria were documented non-sustained ventricular tachycardia,sustained ventricular tachycardia,ventricular fibrillation,resuscitated cardiac arrest or SCD>30 days post-Fontan completion.Results:Of 1611 patients,20(1.2%)had VA;14(1.0%)had VA without SCD and 6(<1%)had SCD(6%of all deaths recorded in Registry;5 of those had documented VA at the time of arrest and 1 was presumed to be VA-associated).The median age at first VA was 20.5(14–32)years,10(50%)were females,and the median age at Fontan operation was 8(4–17)years.On univariable analysis,hypoplastic left heart syndrome(p=0.03)and older age Fontan operation(p<0.001)were associated with VA.Earlier Fontan era(p<0.003),atriopulmonary Fontan(p<0.001),pre-Fontan atrioventricular valve repair(p=0.013)pre-or post-Fontan atrial arrhythmia(p=0.010)were associated with SCD.Patients with VA had a 3 times higher risk of death or heart transplant(HR 3.27(1.19,8.98),p=0.02).Conclusions:A proportion of people living with a Fontan circulation have malignant VA.Routine VA screening in this cohort is essential.More data are needed to aid risk stratification.

腹主动脉瘤病因新探讨

目的 证实家族性因素和遗传性因素在腹主动脉瘤 ( abdominal aortic aneurysm,AAA)发病中的作用。方法 30 8例澳大利亚欧洲腹主动脉瘤病人和 110例健康对照组以及男女各 4 0例的新生儿对照组。对动脉壁四种重要结构蛋白基因进行等位基因分析。等位基因频率分析采用 Sham and Curtis方法。结果 50例 AAA病人至少有一例直系亲属患有 AAA。在 539例存活的同代亲属中 ,14例查出 AAA,其中 12例已施行了手术治疗。对 74例同代亲属筛选发现 4例患有轻度主动脉扩张 ,6例患有中到重度主动脉扩张。女性病人与对照组之间及女性病人与男性病人之间 ,COL 1A2基因的等位基因频率具有统计学差别。结论 在本组病例中遗传性因素在 AAA发病中起着重要作用。 COL 1A2在男女 AAA发病中作用不同 ,其详细机制有待进一步探讨。

肺癌全基因组测序

肺癌是全球肿瘤发病率和病死率的主因,且预后很差。加强对肿瘤生物学的认识对肺癌研究至关重要。被誉为"下一代测序技术"的NGS技术(next-generation sequencing)是一种针对全基因组鉴定的有力工具,可以对致癌体细胞突变进行全面检测。大多数的NGS技术是基于平台特异性DNA文库进行多重聚合酶链反应(polymerase chain reaction,PCR),从而对目的基因扩增后测序。这种技术适用于高通量测序,可以检测出肿瘤中出现的全部基因组变异。缺点是这种技术需要在时间、实验设备、计算机数据分析、生物信息技术等各方面的大量投入。NGS技术已广泛应用于全基因组、外显子组、转录组和表观基因组的研究中,为肺癌研究和医疗模式带来改变。这项新技术的开展将转变当前对致癌信号通路的认识,可为癌症诊疗提供新的分子靶点。肺癌体细胞突变已有NGS技术的分析报道,但大规模基因组研究仍在进行中。个体化治疗策略将改善那些潜在获益患者的治疗方式,避免"无辜"患者受无效治疗带来的高额费用和不良反应。NGS的组织化、计算机化和生物信息化技术推动了科技的进步,同时,患者知情权和数据发布的相关伦理问题也浮现出来。信号通路中,驱动基因(driver gene)突变和传递基因(passenger gene)突变的区别,需要对测序结果进行细致解读。解读准确与否取决于DNA提取的样本类型、样本处理技术和样本含量。肿瘤异质性也会降低肿瘤基因突变的检测效能。NGS技术将推动对肿瘤基因突变的基础和临床研究,而且,也可应用于单细胞和游离的循环DNA,未来还将用于从体液和肿瘤亚群中获取的DNA样本。如果能进一步降低费用、提高检验速度和精度,NGS技术无疑将会成为肺癌研究的绝佳选择。

国际糖尿病足工作组:糖尿病足溃疡减压指南——《国际糖尿病足工作组:糖尿病足防治国际指南(2019)》的一部分

1999年,国际糖尿病足工作组(IWGDF)根据循证医学证据发表了采用减压治疗促进糖尿病足溃疡愈合的预防和管理指南,这一版指南是在此基础上的更新。我们遵循GRADE方法学,采用患者-干预-比较-结果(PICO)模式设计临床问题和关键的重要结局,对医学科学文献进行系统评价分析后撰写了建议并阐述其理由。这些建议是基于系统评价、专家意见(尚无有效证据时)的基础上建立,并在患者依从性、可行性、实用性以及干预的成本等方面进行了利弊权衡。针对糖尿病患者前足或中足底的溃疡愈合,我们建议不可拆卸齐膝高减压装置作为减压治疗的首选。若出现禁忌或患者不耐受不可拆卸减压装置,则可拆卸齐膝高和齐踝高减压装置可作为二线或三线减压治疗方法。合适的鞋袜结合泡沫毡垫可被视为四线减压治疗选择。如果非外科手术减压失败,我们建议通过外科减压干预以促进跖骨头和足趾溃疡愈合。我们还增加了采用减压治疗促进合并感染、缺血的复杂足溃疡和足跟溃疡愈合的新的推荐意见。减压是促进糖尿病神经性足底溃疡愈合诸多干预措施中最重要的手段。遵循这些建议将帮助医务人员和团队,为那些具有感染、住院和截肢风险的糖尿病足溃疡患者提供更好的治疗。

Volar locking distal radius plates show better short-term results than other treatment options: A prospective randomised controlled trial

AIM To compare the outcomes of displaced distal radius fractures treated with volar locking plates and with immediate postoperative mobilisation with the outcomes of these fractures treated with modalities that necessitate 6 wk wrist immobilisation.METHODS A prospective, randomised controlled single-centre trial was conducted with 56 patients who had a displaced radius fracture were randomised to treatment either with a volar locking plate(n = 29), or another treatment modality(n = 27; cast immobilisation with or without wires or external fixator). Outcomes were measured at 12 wk. Functional outcome scores measured were the Patient-Rated Wrist Evaluation(PRWE) Score; Disabilities of the Arm, Shoulder and Hand and activities of daily living(ADLs). Clinical outcomes were wrist range of motion and grip strength. Radiographic parameters were volar inclination and ulnar variance.RESULTS Patients in the volar locking plate group had significantly better PRWE scores, ADL scores, grip strength and range of extension at three months compared with the control group. All radiological parameters were significantly better in the volar locking plate group at 3 mo. CONCLUSION The present study suggests that volar locking plates produced significantly better functional and clinical outcomes at 3 mo compared with other treatment modalities. Anatomical reduction was significantly more likely to be preserved in the plating group. Level of evidence: Ⅱ.

Ampullary cancer of intestinal origin and duodenal cancer-A logical clinical and therapeutic subgroup in periampullary cancer

Periampullary cancers include pancreatic, ampullary, biliary and duodenal cancers. At presentation, the majority of periampullary tumours have grown to involve the pancreas, bile duct, ampulla and duodenum. This can result in difficulty in defining the primary site of origin in all but the smallest tumors due to anatomical proximity and architectural distortion. This has led to variation in the reported proportions of resected periampullary cancers. Pancreatic cancer is the most common cancer resected with a pancreaticoduodenectomy followed by ampullary(16%-50%), bile duct(5%-39%), and duodenal cancer(3%-17%). Patients with resected duodenal and ampullary cancers have a better reported median survival(29-47 mo and 22-54 mo) compared to pancreatic cancer(13-19 mo). The poorer survival with pancreatic cancer relates to differences in tumour characteristics such as a higher incidence of nodal, neural and vascular invasion. While small ampullary cancers can present early with biliary obstruction, pancreatic cancers need to reach a certain size before biliary obstruction ensues. This larger size at presentation contributes to a higher incidence of resection margin involvement in pancreatic cancer. Ampullary cancers can be subdivided into intestinal or pancreatobiliary subtype cancers with histomolecular staining. This avoids relying on histomorphology alone, as even some poorly differentiated cancers preserve the histomolecular profile of their mucosa of origin. Histomolecular profiling is superior to anatomic location in prognosticating survival. Ampullary cancers of intestinal subtype and duodenal cancers are similar in their intestinal origin and form a logical clinical and therapeutic subgroup of periampullary cancers. They respond to 5-FU based chemotherapeutic regimens such as capecitabine-oxaliplatin. Unlike pancreatic cancers, KRAS mutation occurs in only approximately a third of ampullary and duodenal cancers. Future clinical trials should group ampullary cancers of intestinal origin and duodenal cancers together given their similarities and their response to fluoropyrimidine therapy in combination with oxaliplatin. The addition of anti-epidermal growth factor receptor therapy in this group warrants study.

Management of infected pancreatic necrosis in the setting of concomitant rectal cancer:A case report and review of literature

BACKGROUND Pancreatitis with infected necrosis is a severe complication of acute pancreatitis and carries with it high rates of morbidity and mortality. The management of infected pancreatic necrosis alongside concomitant colorectal cancer has never been described in literature.CASE SUMMARY A 77 years old gentleman presented to the Emergency Department of our hospital complaining of ongoing abdominal pain for 8 h. The patient had clinical features of pancreatitis with a raised lipase of 3810 U/L, A computed tomography(CT) abdomen confirmed pancreatitis with extensive peri-pancreatic edema. During the course of his admission, the patient had persistent high fevers and delirium thought secondary to infected necrosis, prompting the commencement of broad-spectrum antibiotic therapy with Piperacillin/Tazobactam. Subsequent CT abdomen confirmed extensive pancreatic necrosis(over 70%). Patient was managed with supportive therapy,nutritional support and gut rest initially and improved over the course of his admission and was discharged 42 d post admission. He represented 24 d following his discharge with fever and chills and a repeat CT abdomen scan noted gas bubbles within the necrotic pancreatic tissue thereby confirming infected necrotic pancreatitis. This CT scan also revealed asymmetric thickening of the rectal wall suspicious for malignancy. A rectal cancer was confirmed on flexible sigmoidoscopy. The patient underwent two endoscopic necrosectomies and was treated with intravenous antibiotics and was discharged after 28 d.Within 1 wk post discharge, the patient commenced a course of neoadjuvant radiotherapy and subsequently underwent concomitant chemotherapy prior to undergoing a successful Hartmann's procedure for treatment of his colorectal cancer.CONCLUSION This case highlights the efficacy of endoscopic necrosectomy, early enteral feeding and targeted antibiotic therapy for timely management of infected necrotic pancreatitis. The prompt resolution of pancreatitis permitted the patient to undergo neoadjuvant treatment and resection for his concomitant colorectal cancer.

病理在肺癌治疗中的关键角色

在过去的十年中,我们对于肺癌生物学和治疗的认识取得了显著进步。识别肺癌发生的关键驱动事件对其靶向治疗的发展作出了贡献,预示着肺癌的个性化医疗时代的到来。因此,病理分型和分子检测变得至关重要,而日益增加的检测需求往往是基于小的诊断标本。这使得国际肺癌研究学会/美国胸科学会/欧洲呼吸学会[The International association for the study of cancer(IASLC)/American thoracic society(ATS)/European respiratory society(ERS)]对小活检/细胞学肺癌标本的第一次结构分类进行了审视和推动,并且提出了肺腺癌的新分类。这些都提高了病理诊断的临床相关性,强调了现代外科病理学家作为多学科团队中成员的作用,在肺癌患者的临床试验和确定适当和及时的治疗中发挥了决定性作用。

Effect of obesity on post-operative outcomes following colorectal cancer surgery

BACKGROUND Colorectal cancer(CRC)resection is currently being undertaken in an increasing number of obese patients.Existing studies have yet to reach a consensus as to whether obesity affects post-operative outcomes following CRC surgery.AIM To evaluate the post-operative outcomes of obese patients following CRC resection,as well as to determine the post-operative outcomes of obese patients in the subgroup undergoing laparoscopic surgery.METHODS Six-hundred and fifteen CRC patients who underwent surgery at the Prince Charles Hospital between January 2010 and December 2020 were categorized into two groups based on body mass index(BMI):Obese[BMI≥30,n=182(29.6%)]and non-obese[BMI<30,n=433(70.4%)].Demographics,comorbidities,surgical features,and post-operative outcomes were compared between both groups.Postoperative outcomes were also compared between both groups in the subgroup of patients undergoing laparoscopic surgery[n=472:BMI≥30,n=136(28.8%);BMI<30,n=336(71.2%)].RESULTS Obese patients had a higher burden of cardiac(73.1%vs 56.8%;P<0.001)and respiratory comorbidities(37.4%vs 26.8%;P=0.01).Obese patients were also more likely to undergo conversion to an open procedure(12.8%vs 5.1%;P=0.002),but did not experience more postoperative complications(51.6%vs 44.1%;P=0.06)or high-grade complications(19.2%vs 14.1%;P=0.11).In the laparoscopic subgroup,however,obesity was associated with a higher prevalence of post-operative complications(47.8%vs 39.3%;P=0.05)but not high-grade complications(17.6%vs 11.0%;P=0.07).CONCLUSION Surgical resection of CRC in obese individuals is safe.A higher prevalence of post-operative complications in obese patients appears to only be in the context of laparoscopic surgery.

Value of multi-disciplinary input into laparoscopic management of rectal cancer-An observational study

AIM To assess the impact of multi-disciplinary teams(MDTs)management in optimising the outcome for rectal cancers.METHODS We undertook a retrospective review of a prospectively maintained database of patients with rectal cancers(defined as tumours≤15 cm from anal verge)discussed at our MDT between Jan 2008 and Jan 2011.The data was validated against the national database to ensure completeness of dataset.The clinical course and follow-up data was validated using the institution’s electronic patient records.The data was analysed in terms of frequencies and percentages.Significance of any differences were analysed usingχ2 test.A Kaplan-Meier analysis was performed for overall survival and disease free survival.RESULTS Following appropriate staging,one hundred and thirtythree patients were suitable for potentially curative resections.Seventy two(54%)were upper rectal cancer(URC)-tumour was>6 cm from the anal verge and 61(46%)were lower rectal cancers(LRC)-lower extent of the tumour was palpable≤6 cm.Circumferential resection margin(CRM)appeared threatened on preoperative MRI in 19/61(31%)patients with LRC requiring neo-adjuvant therapy(NAT).Of the 133 resections,118(89%)were attempted laparoscopically(5%conversion rate).CRM was positive in 9(6.7%)patients;Median lymph node harvest was 12(2-37).Major complications occurred in 8(6%)patients.Median follow-up was 53 mo(0-82).The 90-d mortality was 2(1.5%).Over the followup period,disease related mortality was 11(8.2%)and overall mortality was 39(29.3%).Four(3%)patients had local recurrence and 22(16.5%)patients had distant metastases.CONCLUSION Management of rectal cancers can be optimized with multidisciplinary input to attain acceptable long-term oncological outcomes even when incorporating a laparoscopic approach to rectal cancer resection.

重症监护专用压力性损伤风险评估工具(COMHON指数)的汉化

目的将重症监护专用压力性损伤风险评估工具(COMHON Index)翻译为中文。方法COMHON指数的翻译采用了四步法:①由3名独立的中英文双语者进行英语-中文正向翻译;②由另外2名独立中英文双语者进行中文-英语回译;③对比正向翻译和回译,识别不同翻译版本差异,并将所需修改返回至第一步;④初步测试翻译后的量表。COMHON指数的初步测试研究在中国外科重症监护病房进行,共有20名护士参与。采用5级计分法(1=非常难;5=非常容易)评估该工具的易用性和理解难度;当得分中位数≥4时,表明量表的使用和理解均容易或非常容易,采用中文翻译。结果为了在初步测试量表之前确定翻译的一致性,步骤①至③反复进行了5次,并对量表的原始英语版本进行了2处修改。大部分初步测试评估都记录了亚量表评分、总分和风险分类(≥80%),但3个总分计算不正确。整个工具和所有亚量表都易于使用和理解(中位数≥4),大多数护士(16/20)完成测试的时间少于5 min。因此,中文版翻译达成一致,可以采用,但对评分和风险分类的说明进行了细微修改。结论通过跨文化翻译,引入了一种易于使用的中文版重症监护专用压力性损伤风险评估工具。然而,尚需进一步测试评估者间可靠性和一致性。本研究提供了一个严格的量表翻译和报告范例,为今后的工具翻译提供参考。

Feasibility and oncological outcomes of laparoscopic rectal resection following neo-adjuvant chemo-radiotherapy: A systematic review

AIM: To study the feasibility and oncological outcomesfollowing laparoscopic total mesorectal excision(LTME) in patients who have received Neo-adjuvant long course chemo-radiotherapy(LCRT). METHODS: A protocol driven systematic review of published literature was undertaken to assess the feasibility and oncological outcomes following LTME in patients receiving LCRT. The feasibility was assessed using peri-operative outcomes and short term results. The oncological outcomes were assessed using local recurrence, disease free survival and overall survival.RESULTS: Only 8 studies-1 randomized controlled trial, 4 Case Matched/Controlled Studies and 3 Case Series were identified matching the search criteria. The conversion rate was low(1.2% to 28.1%), anastomotic leak rates were similar to open total mesorectal excision(0%-4.1% vs 0%-8.3%). Only 3 studies reported on local recurrence rates(5.2%-7.6%) at median 34 mo follow-up. A single study described disease free survival and overall survival at 3 years as 78.8% and 92.1% respectively. CONCLUSION: LTME following LCRT is feasible in experienced hands, with acceptable short term surgical outcomes and with the usual benefits associated with minimally invasive procedures. The long term oncological outcomes of LTME after LCRT appear to be comparable to open procedures but need further investigation.

Extra-corporeal membrane oxygenation in aortic surgery and dissection: A systematic review

BACKGROUND Very little is known about the role of extracorporeal membrane oxygenation(ECMO)for the management of patients undergoing major aortic surgery with particular reference to aortic dissection.AIM To review the available literature to determine if there was any evidence.METHODS A systematic literature search through PubMed and EMBASE was undertaken according to specific key words.RESULTS The search resulted in 29 publications relevant to the subject:1 brief communication,1 surgical technique report,1 invited commentary,1 retrospective case review,1 observational study,4 retrospective reviews,13 case reports and 7 conference abstracts.A total of 194 patients were included in these publications of whom 77 survived.CONCLUSION Although there is no compelling evidence for or against the use of ECMO in major aortic surgery or dissection,it is enough to justify its use in this patient population despite current adverse attitude.

血小板-单核细胞聚集可预测经皮冠状动脉介入后肌钙蛋白增高,且可被阿昔单抗抑制

Platelet-monocyte aggregates and other markers of platelet activation were investigated before and after percutaneous coronary intervention(PCI) with abciximab therapy. The study sought to assess the relationship between the level of platelet-monocyte aggregation and increases in cardiac troponin I post coronary intervention. Methods: Blood samples were collected from 40 patients before PCI and 10 min after abciximab administration. These were tested for platelet activation markers by flow cytometry. Cardiac troponin I levels were assayed at baseline and at 24 h post PCI. Results: Compared to healthy controls, patients with coronary artery disease had elevated markers of platelet activation including platelet-monocyte aggregates, P-selectin and PAC- 1(a marker specific for activated glycoprotein IIb/IIIa) prior to PCI. Increased levels of platelet-monocyte aggregates before PCI were associated with increased expression of P-selectin on the platelet surface. Abciximab therapy reduced platelet-monocyte aggregate levels but had no effect on P-selectin expression. The high levels of expression of activated glycoprotein IIb/IIIa(PAC-1) on platelets prior to PCI was reduced with abciximab therapy. Patients with higher levels of platelet-monocyte aggregates prior to PCI were more likely to develop an elevation of cardiac troponin I during the 24 h after PCI. Conclusions: Increased levels of platelet-monocyte aggregates may predict patients at risk for troponin elevation following PCI and identify those most likely to benefit from abciximab.

行经皮冠状动脉介入的患者应用阿昔单抗和大剂量替罗非班的比较研究

Background: The TARGET study has been criticised for suboptimal platelet inhib ition with tirofiban. We aimed to compare a high-dose bolus regimen of tirofiba n(hd-tirofiban) to standard dose of abciximab for patients undergoing percutane ous coronary intervention(PCI). Methods: We assessed consecutive patients who re ceived either hd-tirofiban(25 mcg/kg bolus followed by 0.15 mcg/kg/min infusion for 18 h) or standard dose abciximab. In-hospital and 6-month outcomes were o btained in all cases. Results: Over an 18-month period, 109 patients who receiv ed hd-tirofiban were compared with 110 patients who received abciximab. Both hd -tirofiban and abciximab groups had acute coronary syndromes in 86%and 80%and diabetes in 10%and 13%respectively. Most patients had coronary stent implanta tion(96%vs. 98%). Thrombocytopenia(platelet count< 100,000) developed in 0.9% of patients receiving hd-tirofiban and 2%of patients receiving abciximab(p=0.5 66). Bleeding requiring transfusion occurred in 7.3%and 3%of patients respecti vely(p=0.118). Peri-procedural troponin rise was 0.9%in patients receiving hd -tirofiban and 5.5%in patients receiving abciximab(p=0.07). MACE(Myocardial in farction, Stroke, Revascularisation and Death) at 6 months was 23%in the hd-ti rofiban group and 20%in the abciximab group(p=0.711). The pharmaceutical costs were AUD 322 for hd-tirofiban(one ampoule) and AUD 1350 for abciximab(3 ampoule s). Conclusion: There was a small increase in bleeding requiring transfusion and a lower rate of peri-procedural troponin rise in the hd-tirofiban group howev er, the overall 6-month MACE rates were similar in both groups. There was a con siderable cost-saving with the use of hd-tirofiban. A prospective randomized t rial of hd-tirofiban vs. abciximab is warranted.

Should we resect colorectal cancer in patients over the age of 85?

BACKGROUND The prevalence of colorectal cancer in the elderly is rising,with increasing numbers of older patients undergoing surgery.However,there is a paucity of information on the surgical outcomes and operative techniques used in this population.AIM To evaluate the post-operative outcomes for patients≥85 years old following colorectal cancer resection as well as evaluating the outcomes of laparoscopic resection of colorectal cancer in patients over 85.METHODS Patients who underwent colorectal cancer resection at our institution between January 2010 and December 2018 were included.The study was divided into two parts.For part one,patients were divided into two groups based on age:Those age≥85 years old(n=48)and those aged 75-84 years old(n=136).Short term surgical outcomes and clinicopathological features were compared using appropriate parametric and non-parametric testing.For part two,patient’s over 85 years old were divided into two groups based upon operative technique:Laparoscopic(n=37)vs open(n=11)colorectal resection.Short-term postoperative outcomes of each approach were assessed.RESULTS The median length of stay between patients over 85 and those aged 75-85 was eight days,with no statistically significant difference between the groups(P=0.29).No significant difference was identified between the older and younger groups with regards to severity of complications(P=0.93),American Society of Anaesthesiologists grading(P=0.43)or 30-d mortality(2%vs 2%,P=0.96).Patients over 85 who underwent laparoscopic colorectal resection were compared to those who underwent an open resection.The median length of stay between the groups was similar(8 vs 9 d respectively)with no significant difference in length of stay(P=0.18).There was no significant difference in 30-d mortality rates(0%vs 9%,P=0.063)or severity of complication grades(P=0.46)between the laparoscopic and open surgical groups.CONCLUSION No significant short term surgical differences were identified in patients≥85 years old when compared to those 75-85 years old.There is no difference in short term surgical outcomes between laparoscopic or open colorectal resections in patients over 85.