静脉溶栓桥接Solitaire支架取栓治疗急性后循环梗死并文献复习

目的探讨静脉溶栓桥接Solitaire AB支架取栓治疗急性后循环梗死的效果及安全性。 方法回顾性分析2017年8至9月聊城市人民医院神经内科采用桥接模式接受血管内治疗的急性后循环梗死患者3例资料,均为基底动脉闭塞,分析血管开通情况、并发症情况、神经功能改善情况、随访3个月时改良Rankin量表评分(mRS)和Barthel指数(BI)评分情况。 结果3例静脉溶栓桥接Solitaire AB支架取栓均成功再通,第1例静脉溶栓症状好转,4 h后症状加重并进入昏迷,考虑血管再闭塞,紧急启动机械取栓,术后第1天患者清醒;另2例患者静脉溶栓同时联合机械取栓,术后5～7 d复查颅脑CT及CT血管造影(CTA)均显示基底动脉通畅,未见梗死灶扩大,未发生症状性颅内出血(SICH)。3例患者出院时美国国立卫生研究院卒中量表(NIHSS)评分较入院时降低16～27分,出院时mRS评分为3分1例,2分2例;3个月后mRS评分为2分1例,1分2例,BI评分均为95～100分。 结论颅内大血管闭塞患者可选择静脉溶栓桥接Solitaire AB支架取栓治疗,可提高血管再通率,有效改善预后。     

后循环颅内动脉粥样硬化狭窄急性闭塞血管内治疗的疗效分析

目的 探讨后循环颅内动脉粥样硬化狭窄急性闭塞血管内治疗的有效性和安全性。方法 回顾性分析2018年1月至2021年12月后循环急性大血管闭塞行血管内治疗患者87例,分为颅内动脉粥样硬化组（28例）和非颅内动脉粥样硬化组（59例）,分析两组患者血管再通时间、手术时间、血管再通程度（mTICI）、术后颅内出血、术后严重脑梗死、死亡率、术后3个月mRS评分等临床指标。结果 与非颅内动脉粥样硬化组比较,颅内动脉粥样硬化组年龄（P=0.017）、高血压（P=0.040）、吸烟史（P=0.020）、术前NIHSS评分（P=0.013）、侧支循环良好代偿（P=0.017）、术中行血管成形（P<0.001）、手术时间（P<0.001）差异有统计学意义。两组患者在血管再通时间、有效血管再通率、颅内出血发生率、术后严重梗死发生率、死亡率和90 d良好预后率差异无统计学意义。结论 高血压、吸烟史是后循环颅内动脉粥样硬化狭窄急性闭塞的高危因素,后循环颅内动脉粥样硬化狭窄急性闭塞患者术前血管代偿相对良好,症状相对较轻,及时有效的血管内治疗是安全有效的。     

替罗非班对急性缺血性脑卒中血管内治疗患者神经功能及术后出血转化的影响

目的探讨替罗非班对急性缺血性脑卒中(AIS)血管内治疗患者神经功能及术后出血转化的影响。方法我院收治的120例AIS患者,根据是否应用替罗非班分为对照组58例和观察组62例,对照组给予静脉溶栓桥接血管内治疗,观察组在对照组基础上加用替罗非班治疗,比较两组治疗14 d的神经功能美国国立卫生研究院卒中量表(NIHSS)、血小板功能指标(血小板聚集率、血小板黏附率及P-选择素)和炎症指标超敏C反应蛋白(hs-CRP)、白细胞介素-6(IL-6),治疗90 d的预后改良Rankin量表问卷(mRS)和日常生活能力(Barthel指数)、不良事件情况。结果治疗14 d内,两组NIHSS评分均降低,且观察组治疗24 h、7 d、14 d的NIHSS评分均低于对照组(P<0.05);治疗14 d后,两组血小板功能指标、炎症指标水平均降低,且观察组低于对照组(P<0.05);治疗90 d后,两组mRS评分降低,Barthel指数评分提高,且观察组治疗后的mRS评分低于对照组,Barthel指数评分高于对照组(P<0.05);治疗后90 d内,观察组血管再闭塞率低于对照组(P<0.05),两组症状性颅内出血转化、非症状性颅内出血转化、其他部位出血及死亡发生率比较差异无统计学意义(P>0.05)。结论AIS患者血管内治疗时应用替罗非班有助于的患者神经功能、血小板功能的改善及炎症状态的减轻,可改善患者预后、提高其日常生活能力,而对术后出血转化并无明显不良影响。     

静脉溶栓桥接血管内取栓的护理配合

目的:探讨静脉溶栓桥接Solitaire支架取栓治疗急性脑血管闭塞性疾病的护理配合要点。方法:对2014年6月~2015年10月我院收治的15例静脉溶栓桥接Solitaire支架取栓开通颅内闭塞大血管的患者的护理配合方法进行总结。结果:本组15例患者大血管成功获得开通,其中2例患者取栓3次后未能取出栓子,给予Solitaire支架成形获得满意效果。仅2例患者出现症状性的颅内出血。临床转归方面,死亡2例。90 d后随访临床结局优良患者9例。结论:快速的术前护理准备、术中积极而熟练地护理配合是协助介入医师治疗急性脑血管病的重要保障,提高治疗成功率,减轻患者严重并发症的保证。     

早期血管检查对急性脑梗死诊治的临床意义

目的通过回顾性分析静脉溶栓及血管内介入治疗急性脑梗死的临床实例,探讨早期血管检查对急性脑梗死诊治的临床意义。方法选取2015年8月至2018年8月该院收治的298例急性脑梗死患者作为观察对象,入院时间窗内给予静脉溶栓治疗,治疗过程中行头颈CTA检查,头颈CTA发现明确血管闭塞立即改用血管内介入治疗。结果 298例研究对象经头颈部CTA检查提示,138例(46.31%)存在颅内大血管狭窄/闭塞。其中颈内动脉狭窄18例;大脑中动脉M1段闭塞39例,狭窄33例;大脑中动脉M2段闭塞30例,大脑后动脉闭塞18例。160例不存在颅内大血管闭塞/狭窄事件。298例患者均行静脉溶栓治疗,治疗后症状好转212例,有效率为71.1%;86例静脉溶栓后疗效均不佳,时间窗内(6h)进行血管内介入治疗的患者46例,血管内治疗后有效人数32例,有效率为69.57%。结论急性脑梗死患者溶栓过程中,应尽早完善头颈部血管检查,明确是否存在大血管闭塞事件,以便于早期启动血管内介入治疗,保障患者预后。     

Solitaire支架取栓再通后经解脱 治疗医源性颈动脉夹层1例

<正>急性颅内大血管闭塞发病急、病情重,急诊血管内治疗能在有效时间内再通血管,挽救患者生命。本文报告1例急性大脑中动脉闭塞患者接受静脉溶栓桥接血管内治疗：首选直接抽吸技术取栓失败,采用Solitaire取栓支架补救性拉栓实现血管再通后,靶血管近端出现医源性夹层,而后解脱Solitaire支架实现夹层贴壁治疗,最终获得满意疗效。     

中青年前循环急性大血管闭塞性缺血性卒中患者血管内机械血栓切除术治疗效果及预后的影响因素

目的 观察中青年(年龄18～50岁)前循环急性大血管闭塞性缺血性卒中(LVO-AIS)患者行血管内机械血栓切除术(MT)治疗的效果，探讨术后90 d预后不良的影响因素。方法 2019年1月—2022年8月武汉大学中南医院诊治中青年前循环LVO-AIS患者52例，均于发病24 h内行MT,依据术后90 d改良Rankin量表评分(mRS)分为预后良好组(mRS≤2分)和预后不良组(mRS>2分)。比较2组性别、年龄、合并症(高血压、糖尿病、心房颤动、冠心病、高脂血症)、吸烟史、血管闭塞部位、血管闭塞数量、TOAST病因分型及入院时美国国立卫生研究院卒中量表评分(NIHSS)、Alberta脑卒中早期CT诊断评分(ASPECTS)、中性粒细胞与淋巴细胞比值(NLR);比较2组静脉溶栓比率、发病至穿刺时间、发病至再通时间、穿刺至再通时间、取栓次数、球囊和/或支架植入比率、血管再灌注成功率、术后并发症(颅内出血、症状性颅内出血、肺部感染、下肢深静脉血栓形成)发生率；多因素logistic回归分析中青年前循环LVO-AIS患者MT术后90 d预后不良的影响因素；绘制ROC曲线，评估合并高血...     

急性缺血性卒中血管内治疗联用标准剂量 替罗非班的安全性研究

目的:探讨替罗非班对急性缺血性卒中(AIS)血管内治疗患者颅内出血转化(ICH)的影响。方法:回顾性研究,连续收集我科实施血管内治疗的AIS患者106例,依据是否静脉应用标准剂量替罗非班分为替罗非班组和非替罗非班组,分析2组ICH类型并观察90 d预后转归。结果:106例AIS患者,1例(0.9%)发生替罗非班相关血小板减少症,替罗非班组的高血压、吸烟患者显著高于非替罗非班组(P<0.05),而心房颤动患者远低于非替罗非班组(P<0.001);但2组症状性颅内出血转化(sICH)发生率分别为8.5%(5/59)与10.6%(5/47),差异无统计学意义(P>0.05)。结论:标准剂量替罗非班不增加AIS患者血管内治疗的sICH风险。     

静脉溶栓治疗急性脑梗死大血管闭塞患者的血管再通情况及其影响因素分析

目的:分析静脉溶栓治疗急性脑梗死(ACI)大血管闭塞患者的血管再通情况及其影响因素。方法:接受静脉溶栓治疗的急性脑梗死大血管闭塞患者128例纳入研究,根据溶栓后血管再通情况分为血管再通组(97例)和血管未通组(31例),比较2组临床资料并分析血管再通的影响因素。结果:静脉溶栓血管再通率为75.78%;溶栓前美国国立卫生院脑卒中量表(NIHSS)评分、心源性脑栓塞和发病到静脉溶栓治疗时间是静脉溶栓后血管再通的独立影响因素(均P<0.05);血管再通组发生非症状性颅内出血(NSICH)的比例明显低于血管未通组,24 h神经功能恢复良好、7 d早期临床转归良好、90 d预后良好和生活自理患者的比例均显著高于血管未通组(均P<0.05);2组7 d和90 d的死亡率差异无统计学意义(P>0.05)。结论:ACI患者静脉溶栓的血管再通率较高,可显著改善患者预后;溶栓前NIHSS评分、心源性脑栓塞和发病到静脉溶栓治疗时间是静脉溶栓后血管再通的独立影响因素。     

多模式桥接治疗急性缺血性卒中临床疗效及安全性

目的:评估多模式桥接治疗急性缺血性卒中(AIS)的疗效及安全性。方法:回顾性分析2015年1月到2016年8月广东省中山市人民医院神经内科收治的AIS患者100例的临床资料,根据病情选择适当的再通血管方式:对起病4.5 h小时内、有静脉溶栓指征者,立刻予静脉溶栓治疗,同时送介入室行全脑血管造影,了解病变血管情况,如血管已再通则结束手术;对前循环在6小时内、后循环在24小时内无静脉溶栓指征,且无全脑管造影禁忌症者,均予急诊行全脑血管造影术,了解病变血管情况,若血管已再通则结束手术;对血管仍有闭塞或狭窄,则考虑予动脉溶栓或支架成型术或支架取栓术等多模式桥接开通血管,评价治疗后NIHSS评分改善率,3个月后随mRS评分。结果:100例AIS患者接受多模式桥接治疗,平均年龄62.72±14.16岁,入院时平均NIHSS评分8.49±4.48分,发病到我院时间平均为3.59±2.37小时,所有患者均获得血管再通,术后残余狭窄程度(25.27±19.77)%;术后死亡3例,1例死于肺部严重感染,2例死于术后高灌注出血,余97例术后NIHSS评分3.63±4.3分,3个月后随访87例mRS2分,NIHSS 2.16±2.01分。结论:多模式联合治疗急性缺血性卒中能够有效地再通血管,可有效提高治疗效果,改善神经功能,促进患者恢复,值得临床推广应用。     

Guns and Knives in New Mexico: Patterns of Penetrating Trauma, 1978–1993

Objective: To identify patterns of nonfatal and fatal penetrating trauma among children and adults in New Mexico using ED and medical examiner data.
Methods: The authors retrospectively sampled in 5-year intervals all victims of penetrating trauma who presented to either the state Level-1 trauma center or the state medical examiner from a 16-year period (1978–1993). Rates of nonfatal and fatal firearm and stabbing injury were compared for children and adults.
Results: Rates of nonfatal injury were similar (firearm, 34.3 per 100,000 person-years; stabbing, 35.1). However, rates of fatal injury were significantly different (firearm, 21.9; stabbing, 2.7; relative risk: 8.2; 95% confidence interval: 5.4, 12.5). From 1978 to 1993, nonfatal injury rates increased for children (p = 0.0043) and adults (p < 0.0001), while fatal penetrating injury remained constant. The increase in nonfatal injury in children resulted from increased firearm injury rates. In adults, both stabbing and firearm nonfatal injury rates increased.
Conclusions: Nonfatal injury data suggest that nonfatal violence has increased; fatal injury data suggest that violent death rates have remained constant. Injury patterns vary by age, mechanism of trauma, and data source. These results suggest that ED and medical examiner data differ and that both are needed to guide injury prevention programs.     

Interprofessional approaches to creating safe,high quality health care

Three supplementary perspectives are presented arguing that interprofessional collaboration is both necessary and desirable. Nonetheless, there are often too many serious intra-professional barriers and obstacles to interprofessional collaboration to make it successful. Some of these barriers, it is argued and illustrated, are found in the multiple ways in which professional identity is tacitly acquired and embodied in the practitioners' habitual, everyday practice. The paper then explores ways in which reflection, especially Second order reflection, can help to elucidate and overcome these obstacles, as well as increasing professional adaptability and competence.     

Systematic Reviews Published in the January 2011 Issue of The Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly as a DVD and monthly online. The January 2011 issue (first quarterly DVD for 2011) contains 4515 complete reviews, 1985 protocols for reviews in production, and 13,521 one-page summaries of systematic reviews published in the general medical literature. In addition, there are citations of 641,000 randomized controlled trials, and 14,018 cited papers in the Cochrane methodology register. The health technology assessment database contains over 9300 citations. One hundred and seven new reviews have been published in the last 3 months, of which five have potential relevance for practitioners in pain and palliative medicine.     

Determination of creatine kinase isoenzyme MB activity in serum using immunological inhibition of creatine kinase M subunit activity. Activity kinetics and diagnostic significance in myocardial infarction.

This is a new method for the determination of creatine kinase isoenzyme MB activity in serum. The method uses direct activity measurement of creatine kinase B subunit activity after blocking of CK-M subunit activity by inhibiting antibodies. The test takes no longer than 15 min. The method yields an intra-serial C.V. of 2.0-12.9%, and a C.V. from day to day of 5.5%. The detection limit is 3.4 U/l creatine kinase MB. In the 95 cases with proven myocardial infarction several types of creatine kinase MB activity kinetics could be determined. The percentage of creatine kinase MB of peak CK-total is 6-25%, with a mean of 11.1%. The amount of creatine kinase MB with respect to total CK activity after reinfarction is higher than the amount after initial infarction.     

俯卧位通气对高海拔地区肺复张治疗无效急性呼吸窘迫综合征患者氧合的影响

目的 探讨俯卧位通气对高海拔地区肺复张术(RM)治疗无效急性呼吸窘迫综合征(ARDS)患者的治疗作用.方法 从海拔2260m的地区医院筛选RM治疗无效的41例ARDS患者[平均氧合指数( PaO2/FiO2)较RM前升高＜20％视为RM无效],依不同病因分为肺内源性ARDS组(ARDSp组)和肺外源性ARDS组(ARDSexp组),每组再按信封法随机分为俯卧位组和仰卧位组,即ARDSp俯卧位组(11例)、ARDSp仰卧位组(9例)、ARDSexp俯卧位组(10例)、ARDSexp仰卧位组(11例).在通气前及通气1、2、3、4h监测动脉血氧分压( PaO2)、PaO2/FiO2、静态顺应性(Cst)、气道阻力(Raw)的变化.结果 通气lh时,ARDSexp俯卧位组PaO2/FiO2( mm Hg,l mm Hg=0.133 kPa)即较通气前显著升高(157.4±40.6比129.3±48.7,P＜0.05),并随通气时间延长呈持续增高趋势,4h达峰值(219.1 ±41.1);且ARDSexp俯卧位组通气3h内PaO2/FiO2较其他3组显著增高,另3组间则差异无统计学意义.ARDSp俯卧位组、ARDSexp俯卧位组通气4h时PaO2/FiO2均较相应仰卧位组显著增高(208.8±39.7比127.4±47.1,219.1±41.1比124.9±50.8,均P＜0.05).4组通气前后Cst无显著改变,各组间差异也无统计学意义.ARDSp俯卧位组通气4h时Raw(cmH2O·L-1·s-1)较通气前显著降低(6.8±1.7比10.7±1.8,P＜0.05),且明显低于其他3组;其他3组各时间点Raw组内及组间比较差异均无统计学意义.结论 俯卧位通气作为ARDS机械通气重要策略之一,可以改善RM无效高原ARDS患者的氧合,为抢救患者赢得宝贵的时间.     

Digital imaging among medical facilities

The Department of Veterans Affairs (VA) in the USA operates a network of 172 medical centres which all utilize a hospital information system (HIS) which has been developed and is currently maintained by the VA. During the past several years, an image management and communication module has been developed, installed and clinically utilized at the Washington DC and Maryland VA Medical Centres. This image management and communication system, referred to as the decentralized hospital computer program (DHCP) imaging system, is fully integrated with a commercial picture archiving and communication system (PACS). The system is utilized to capture, archive, and display all images generated within the hospital including radiology, nuclear medicine, pathology, endoscopy, bronchoscopy, and dermatology, intraoperative photographs, ECG data, and a limited number of paper documents. The ultimate goal of the project is to have all patient text and image data available at any clinical workstation to any authorized user anywhere within the network of medical centres. Clinical requirements for an imaging workstation include ease of use, rapid and reliable access to the complete set of patient information, and images which are of acceptable quality to meet the requirements of the user and the subspecialty. Patient confidentiality and data security must be safeguarded at all times. Integration of the images with the remainder of the patient's database was found to be critical to the success of the project. The experience at the Washington and Maryland facilities suggests that an imaging system that is successfully integrated with a hospital information system can provide substantial clinical and economic benefits both within and among medical centres. Clinical acceptance and utilization of the system has been excellent, particularly in diagnostic radiology where DHCP Imaging has been interfaced to a commercial PAC system. Based upon this initial experience, the VA has begun to deploy the system throughout its large network of medical centres.     

Myocardial elastography at both high temporal and spatial resolution for the detection of infarcts

Myocardial elastography is a novel method for noninvasively assessing regional myocardial function, with the advantages of high spatial and temporal resolution and high signal-to-noise ratio (SNR). In this paper, in-vivo experiments were performed in anesthetized normal and infarcted mice (one day after left anterior descending coronary artery [LAD] ligation) using a high-resolution (30 MHz) ultrasound system (Vevo 770, VisualSonics Inc., Toronto, ON, Canada). Radiofrequency (RF) signals of the left ventricle (LV) in longitudinal (long-axis) view and the associated electrocardiogram (ECG) were simultaneously acquired. Using a retrospective ECG gating technique, 2-D full field-of-view RF frames were acquired at an extremely high frame rate (8 kHz) that resulted in high-quality incremental displacement and strain estimation of the myocardium. The incremental results were further accumulated to obtain the cumulative displacements and strains. Two-dimensional and M-mode displacement images and strain images (elastograms), as well as displacement and strain profiles as a function of time, were compared between normal and infarcted mice. Incremental results clearly depicted cardiac events including LV contraction, LV relaxation and isovolumetric phases in both normal and infarcted mice, and also evidently indicated reduced motion and deformation in the infarcted myocardium. The elastograms indicated that the infarcted regions underwent thinning during systole rather than thickening, as in the normal case. The cumulative elastograms were found to have higher elastographic SNR (SNR(e)) than the incremental elastograms (e.g., 10.6 vs. 4.7 in a normal myocardium, and 6.0 vs. 2.4 in an infarcted myocardium). Finally, preliminary statistical results from nine normal (m = 9) and seven infarcted (n = 7) mice indicated the capability of the cumulative strain in differentiating infracted from normal myocardia. In conclusion, myocardial elastography could provide regional strain information at simultaneously high temporal (>/=0.125 ms) and spatial ( approximately 55 microm) resolution as well as high precision ( approximately 0.05 microm displacement). This technique was thus capable of accurately characterizing normal myocardial function throughout an entire cardiac cycle, at the same high resolution, and detecting and localizing myocardial infarction in vivo.     

Prise en charge des entorses externes de cheville : étude clinique préliminaire sur l’efficacité du dispositif Myolux™

Ankle sprains are the most common injury of the musculoskeletal system and are associated with significant societal and economic impacts. It has been proven that classical therapeutic strategies may not be effective in preventing recurrent injuries: the recurrence rates reported in the literature can reach 73%. In order to provide an effective rehabilitation solution, a destabilizing orthosis was developed. This device is equipped with a mechanical articulator reproducing the subtalar mechanics and placed under the heel. In this paper, we present the main results of a preliminary clinical study conducted between 2004 and 2007. All subjects included in this study were treated with the abovementioned orthosis during 10 rehabilitation sessions of 30 minutes each. Data show a relatively low recurrence rate of 12% for the overall population. Moreover, it's of primary importance to note that this satisfactory ratio is largely reduced (3% of recurrence rate) for the 29 patients who performed one training session per month after the 10th initial rehabilitation sessions. Hence, the destabilizing orthosis appears to be an effective solution to prevent recurrent ankle sprains. However, joint protection requires long-term and regular training sessions. This result has motivated the development of a similar device allowing patients to perform training sessions at home. Finally, data obtained in this study are promising awaiting the final results of the comparative, multicentric and independent clinical trials currently managed by the Hospices Civils de Lyon.