2018 Vol. 9, No. 2

Editorial
Abstract:
Anticoagulation therapy is highly effective in preventing thromboembolism in patients with atrial fibrillation, deep vein thrombosis, or genetic predisposition, etc. Despite this advantage, however, anticoagu-lation results in an elevated risk of bleeding that may sometimes be life-threatening. There is excess concern in patients and physicians about the risk of bleeding from anticoagulation, which leads to the use of anticoagulation reportedly much less than expected. It is crucial to assess the bleeding risk and balance the benefit and the risk in order to plan a proper therapeutic regimen. An optimal decision on the therapy is based on a good balance between anticoagulation and bleeding according to the patient condition, the choice of an appropriate evaluation scale, a comprehensive assessment of coagulation, the right selection of medicine and dosage, and the enforcement of the management of anticoagulation therapy.
Specialist Forum
Abstract:
During the clinical practice of anticoagulation therapy, some puzzles, including the choice between traditional anticoagulants and novel alternatives, options of anticoagulants in different phases of the therapy or under exceptional circumstances, the determination of anticoagulation course, and management of complications, cannot be solved by consulting guidelines or consensuses. The individual regimen should be worked out by physicians according to their knowledge and clinical experiences, or by reviewing the literature. Several opinions were given in this article, aiming to provide a further understanding of above questions.
Abstract:
Anticoagulation therapy is an important measure for the treatment and prevention of thromboembolic diseases, especially pulmonary embolism. Warfarin, as a classic anticoagulant drug, has been applied to thromboembolic diseases since the 1950s. Compared with warfarin, novel oral anticoagulants(NOACs) have the advantages of stable pharmacokinetics, fixed-dose usage, no need for frequent monitoring of coagulation function, less interaction with drugs and foods, and good drug safety. The emergence of NOACs has given clinicians more choice of drugs, and it also challenges warfarin's position in the field of anticoagulation. However, there is no medicine to replace warfarin yet in many clinical scenarios. Warfarin still has the value of its existence.
Abstract:
Cerebral microbleeds (CMBs), as hemorrhagic neuroimaging markers of cerebral small-vessel disease, are radiologically defined as small round or ovoid lesions of homogeneous signal intensity loss on T2*-gradient echo imaging and are believed to represent chronic hemosiderin deposition following microhemorrhage. Histopathological analysis of the vessels associated with CMBs have generally identified two main types of vascular pathological changes: hypertensive vasculopathy and cerebral amyloid angiopathy (CAA). CMBs with strictly lobar distribution are specific for CAA with deposition of β-amyloid in small arterial walls, while CMBs in the basal ganglia, white matter, and brainstem are related to hypertensive small arteries. Previous study showed that CMBs might increase the risk of bleeding. Especially, CMBs increase the risk of hemorrhagic complications in patients on antiplatelet, anticoagulation or thrombolytic therapy. However, whether the bleeding risk overweighs the clinical benefit of antithrombotic treatment remains unclear and warrants further investigations. Furthermore, controlling other risk factors, such as hypertension, alcoholism and renal function, is also an important part of clinical practice when considering the balance between the risks of bleeding and thrombus.
Abstract:
Both coronary artery disease and atrial fibrillation are common diseases. Ischemic stroke and systemic embolism are major adverse outcomes of atrial fibrillation, and antithrombotic treatment reduces the risk of thromboembolic events significantly. On the other hand, antiplatelet therapy is essential in patients with coronary artery disease. Combined antiplatelet-anticoagulant therapy is required to reduce the risk of recurrent ischemic cardiac events and stroke in patients with atrial fibrillation coexisting with coronary artery disease. However, this antithrombotic strategy is associated with an increased risk of bleeding complications. It is challenging in clinical practice to balance the risk of bleeding and thromboembolism, and to choose from oral anticoagulants and antiplatelet agents to establish an optimal strategy.
Opinion
Abstract:
Antiplatelet therapy is of proven benefit to arterial thrombotic diseases. Although antiplatelet agents are usually given on fixed dosages, there is great interindividual variability in pharmacodynamic response to antiplatelet medications. Patients with high on-treatment platelet reactivity are at increased risk for thrombotic events. On the contrary, low on-treatment platelet reactivity has been linked to a higher risk of bleeding. Personalized antiplatelet treatment strategies based on platelet function monitoring constitute a promising tool for the prevention of both thrombotic and bleeding events, but the conclusive evidence for improved clinical outcomes with such approaches is yet lacking. Up to now, whether routine laboratory monitoring of antiplatelet therapy is of clinical benefit is still controversial. This review discusses the causes of variability in the response to aspirin or clopidogrel and highlights the current position of platelet function testing in guiding personalized antiplatelet therapy.
2018, 9(2): 127-143. doi: 10.3969/j.issn.1674-9081.2018.02.007
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Abstract:
Abstract:
Lu Zhang
2018, 9(2): 190-192. doi: 10.3969/j.issn.1674-9081.2018.02.016
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Abstract:
Guideline Interpretation
Abstract:
Venous thromboembolism (VTE) is one of the common perioperative complications. The Guidelines for Prevention and Management of Perioperative Venous Thrombosis in General Surgery in China was released in 2016, which makes a lot of pertinent suggestions on VTE risk assessment in patients with general surgery, implementation of prophylactic measures, and perioperative management with anticoagulant medications. It also standardizes and promotes the practice of thrombosis management in the perioperative period of general surgery in China. Based on the interpretation of the guidelines and our own clinical practice, we analyzed in detail the influence of the ethnic differences, different surgical methods, and the type of disease on the incidence of VTE, as well as the selection of risk model and anticoagulation preventive measures for VTE. We hope to provide a further understanding of the clinical perioperative prevention and management of VTE.
Abstract:
Non-traumatic hemorrhage, as one of the most common acute emergencies with a wide range, high risk, and multiple disciplines, requires emergency physicians to have a higher clinical ability. The first edition of Experts' Consensus/Opinion on the Emergency Treatment for Non-traumatic Hemorrhage was formulated in 2017 by Chinese College of Emergency Physician, which consists of definitions, classifications, clinical management strategies and emergency anticoagulation haemostatic treatment for patients with non-traumatic hemorrhage. Based on the clinical practice of emergency care, the consensus emphasizes life saving as the first priority. The principle is Firstly guarantee basic vital signs and then find out the source of bleeding and give pertinent treatments. The consensusalso emphasizes the importance of evaluation and management of air, breath, and circulation, as well as the importance of stopping the bleeding and coagulation for these patients. Based on the experts' consensus/opinion, this article focuses on interpretation so that physicians can grasp the emergency approach and methods more comprehensively to improve the efficiency of clinical treatment.
Original Contributions
Abstract:
  Objective   The aim of this study was to explore the clinical characteristics and prognosis of thrombotic thrombocytopenic purpura (TTP).  Methods   Clinical manifestations, laboratory examinations, diagnosis, therapeutic methods, and prognosis of 60 TTP patients diagnosed between 2012 and 2017 in Peking Union Medical College Hospital were retrospectively analyzed. Risk factors of prognosis were analyzed by single factor and multivariate Logistic regression analysis, and the influence of therapeutic strategieson prognosis was analyzed by Kruskal-Wallis test and Mann-Whitney U test.   Results   Among 60 TTP patients, 17 were males (28.3%, 17/60) and 43 were females (71.7%, 43/60), aged (41±15) years old. Twenty-eight patients (46.7%, 28/60) had Triad Syndrome including fever, microangiopathic hemolytic anemia, and thrombocytopenia; 23 patients (38.3%, 23/60) had Quinary Syndrome including fever, microangiopathic hemolytic anemia, thrombocy-topenia, renal insufficiency, and neurological symptoms; and the other 9 patients (15.0%, 9/60) have neither the typical Triad Syndrome nor the Quinary Syndrome. Twenty-eight patients received the measurement for ADAMTS13 activity and 23 (82.1%, 23/28) was < 10% among whom; ADAMTS13 inhibitor was tested in 20 patients with 18 (90.0%, 18/20) of them being positive; 20 patients received these both tests and the double positive rate was 90% (18/20). Different treatments, which included plasma exchange, glucocorticoids, rituximab, immunosuppresors, and intravenous immunoglobulin, were given based on patients' financial situation and blood fountain; 42 patients (70.0%, 42/60) were relieved and 18 patients died (30.0%, 18/60). The combined immunosuppressive therapy on the basis of plasma exchange and glucocorticoids improved the remission rate from 57.1% to 85.2% (P=0.032). No risk factor was found between the dead group and the remission group.   Conclusions   Most of TTP patients manifest the Triad Syndrome or the Quinary Syndrome. The decline of ADAMTS13 activity and its inhibitor have high positive rates in TTP. Immunosuppressive therapy can improve the prognosis.
Abstract:
  Objective  This study aimed to investigate the clinical results of the method of direct lateral structure release in the treatment of severe valgus knee deformity with total knee arthroplasty(TKA).  Methods  Twenty-eight patients(30 knees) with severe valgus knee deformity underwent TKA with the method of direct lateral soft tissue release with posterior stabilized implants from January 2007 to December 2014. There were 8 males and 20 females, with the ages ranging from 41 to 80 years[mean(66.7±11.1)years]. There were 23 knees of osteoarthritis, 5 knees of rheumatoid arthritis, 2 knees of patella dislocation, and 1 knee of medial instability. Lateral collateral ligament(LCL) and iliotibial band(ITB) were released in all patients, only 2 popliteus(Pops) were released. Clinical and radiographic evaluations including range of motion(ROM), the Hospital for Special Surgery(HSS) knee score, and the tibia and femur angle(T-F angle) were performed at follow-up.  Results  The duration of follow-up ranged 2 to 8 years. The average HSS score improved from 20.4±14.3 points preoperatively to 89.5±9.4 points at the final follow-up, P < 0.001. The average T-F angle was corrected from 32.6±4.3 to 7.6±3.7, P =0.001. We cured 1 case of lateral instability by using articular branches. 4 patients with palsy of peroneal nerve recovered after 3 months. There had been no complications, such as infection, DVT, or component loosening.  Conclusions  The techniques of direct lateral soft tissue release(LCL+Pop+ITB) with posterior stabilized implants can correct a sever valgus deformity very successfully in patients undergoing primary total knee arthroplasty, and provide excellent results.
Complicated and Rare Disease
Abstract:
Rare diseases have a wide variety, complicated manifestations, and genetic and clinical heterogeneity, which make the diagnosis highly challenging.Moreover, many of the diseases lack effective therapies.The research in medical informatics technologies, such as clinical semantic system, genomic data analysis, imaging data analysis, and multi-omics data fusion analysis, has been greatly improved with the development of precision medical informatics, which is gradually breaking the restrictions of rare disease in data sharing and scientific research of rare diseases. Integrating and studying the shared data of rare diseases from different sources is conducive to the discovery of more pathogenic loci and the development of orphan drugs, which will promote the diagnosis and treatment of rare diseases. This review aims to introduce recent research progresses and applications of medical informatics technologies on rare diseases, in order to promote the development of medical informatics in the diagnosis and treatment of rare disease.
Clinical Biobank
Abstract:
A biobank is one of the important sources and key links in the realization of translational medicine and precision medicine. The initiation of "Precision Medicine" and "Healthy China 2030" Plan has created an extremely rare opportunity for the development of biobanks. At the same time, it also highlights the problems existing in the biobanks in China, including relevant national standards have not yet been published, implementation of standardized processes and quality control need to be pushed forward, sharing-application mechanism needs to be improved, low-level redundant construction is more serious, self-restoration ability is generally weak, a sustainable development mechanism needs to be explored, and so on. In the past ten years, a lot of pioneering work on the standardization, sharing applications, intensification and sustainable development of biobanks has been done to promote the full application of bio-specimens in biopharmaceutical industry. We have initiated a new era of constructing the standardization of biobanks in China.
Clinical Research and Evidence Based Medicine
Abstract:
The emergence of electronic health records (EHRs) provides a good opportunity for clinical studies to be carried out on large samples with high efficiency and at low costs. However, misunderstanding and inappropriate application of EHRs in clinical research are common. This paper brings us back to the essentials of epidemiology. We use a number of examples to discuss: the characteristics of EHRs, the relationship of data domains of EHRs with their corresponding variables (exposure, outcomes, and covariates) in epidemiological research, and how to use EHRs to estimate prevalence and incidence and to evaluate the effectiveness of treatment and policy. We also focus on the selection bias and confounding controls, especially unmeasured confounding controls. Hopefully, this paper would contribute to the integration of EHRs and clinical research and to the improvement of efficiency and quality of clinical research.