Angio-Seal血管封堵器与人工压迫止血在脑血管介入诊疗术中的作用比较

目的观察Angio-Seal血管封堵器在脑血管介入诊疗术后的应用安全性及疗效。方法对592例经皮股动脉穿刺行血管介入诊断和治疗术后病人,分别进行血管封堵器封堵或人工压迫股动脉穿刺点止血,观察病人的止血时间、下肢制动时间和止血成功率、血管并发症。结果血管封堵组的止血时间(1.5±0.67)min、下肢制动时间(3.9±0.7)h、腹股沟血肿10.56%及迷走反射发生率较人工压迫组比较明显缩短,两组间的止血成功率(99.72%vs 99.14%)、假性动脉瘤发生率(0.56%vs 1.71%)比较无统计学意义。结论应用Angio-Seal血管封堵器封堵动脉穿刺口可以大大缩短病人止血时间及平卧时间,且安全、有效。     

标准化急救护理流程对急性ST段抬高型心肌梗死患者急诊抢救的影响分析

目的分析急性ST段抬高型心肌梗死(STEMI)患者急诊抢救过程中应用标准化急救护理流程的效果。方法将自2019年1-12月进行治疗的STEMI患者68例分成两组,分别予以对照组及干预组患者常规救治流程及标准化救治流程。结果两组对比,干预组分诊时间等急诊时间窗均明显更短,差异有统计学意义(P0.05)。两组对比,干预组救治成功率明显更高,差异有统计学意义(P0.05)。两组对比,干预组心肌再梗死等并发症发生率均较对照组低,差异有统计学意义(P0.05)。结论 STEMI患者应用标准化急救护理流程能够缩短急诊时间窗,提高急诊抢救效率及救治效果,对于降低患者死亡率及并发症发生率均有重要价值。     

区域协同体系对不具备急诊冠脉介入能力医院急性心肌梗死患者救治的影响

目的:总结以具备急诊冠状动脉介入治疗(PCI)能力医院(PCI医院)胸痛中心为核心的区域协同救治体系对未具备PCI能力医院(非PCI医院)救治急性ST段抬高型心肌梗死(STEMI)患者疗效的影响、目前现状及问题,以探索改进措施。方法:调取华中科技大学同济医学院附属同济医院胸痛中心数据库中2016年8月1日～2017年7月31日与2018年8月1日～2019年7月31日2个时间段的数据,分析比较区域协同救治体系建立前后,首诊于非PCI医院STEMI患者的诊治流程及治疗效果。结果:区域协同救治体系建立后,患者首次医疗接触(FMC)至首份心电图时间从(17.7±40.7)min缩短至(7.9±8.5)min (P0.01),10 min内完成心电图达标率从52.1%提高至72.1%(P0.01);FMC至负荷剂量双抗血小板聚集药时间明显缩短[(36.7±29.3)min vs(30.0±18.7)min,P0.05];FMC至抗凝给药时间虽有缩短趋势但差异无统计学意义[(92.8±79.7)min vs(71.0±55.6)min,P=0.20];FMC至溶栓时间有降低趋势但差异无统计学意义[(117.4±126.0)min vs(79.5±61.2)min,P=0.20];采取溶栓早期介入策略者比例由9.0%升至17.3%(P0.05);患者当地医院入门至转出时间未见统计学差异[(269.9±530.5)min vs(298.3±337.5)min,P=0.60];转诊患者绕行华中科技大学同济医学院附属同济医院急诊的比例从55.7%提高至75.8%(P0.01);转诊患者急诊PCI术前造影罪犯血管TIMI血流从0.29±0.82提高至0.93±1.23(P0.01),然而FMC至球囊扩张时间较前延长[(363.2±209.1)min vs(422.9±302.7)min,P0.05],转诊患者住院期间心力衰竭发生率(5.7%vs 4.0%,P=0.38)、死亡率(2.3%vs 0.9%,P=0.25)虽有下降,但均未见统计学差异。结论:基于胸痛区域协同救治体系,对首诊于非PCI医院STEMI患者的早期规范化救治有明显改进,带来疗效的改善,但转诊延迟仍然普遍。     

不同导电介质用于急诊PCI并发心室颤动电除颤疗效分析

目的探讨两种导电介质在急诊经皮冠状动脉介入治疗(PCI)并发心室颤动(室颤)患者中电除颤的安全性和有效性,从而提高电除颤的整体疗效。方法选取2010年1月~2016年12月于北京协和医院心脏导管室救治的急性心肌梗死行急诊PCI术中发生室颤的患者80例,随机分为对照组和观察组,每组各40例,对照组采用浆形电极板上涂导电糊为导电介质的方法进行电除颤,观察组用生理盐水浸泡纱布直接置于除颤部位进行电除颤,比较两组患者电除颤抢救的整体疗效。结果两组患者一次电除颤成功率比较,观察组与对照组相比无明显差异(60%vs.50%,P0.05)。观察组电除颤平均用时较对照组显著缩短(0.80±0.49 min vs.1.86±0.79 min),且差异具有统计学意义(P0.05)。观察组皮肤灼伤发生率显著低于对照组(5%vs.35%,P0.05),皮肤灼伤范围观察组低于对照组(中心局部印记5.0%vs.22.5%,P0.05)。结论对急诊PCI并发室颤患者,应用生理盐水纱布为电除颤导电介质,可显著缩短除颤时间、减少皮肤灼伤,电除颤成功率相似,显示出较好的安全性和有效性,利于室颤的抢救。     

经桡动脉、股动脉途径急诊介入治疗急性ST段抬高心肌梗死的对照研究

目的探讨经桡动脉行急诊经皮介入治疗(percutaneous coronary intervention,PCI)急性ST段抬高性心肌梗死(STEMI)的有效性和安全性。方法 2010年1月—2011年12月我院收治的409例诊断明确、有急诊PCI适应症的STEMI住院患者,分为桡动脉组(213例)与股动脉组(196例)。观察两组手术成功率、手术时间和术后血管并发症发生率。结果两组患者PCI成功率无统计学意义(96.71%vs 97.44%,P>0.05)。桡动脉组假性动脉瘤、迷走反射发生率显著低于股动脉组。结论经桡动脉途径急症PCI治疗STEMI患者是一种安全、有效和可行的方法,与股动脉途径比较,经桡动脉途径可减少并发症的发生。     

急性心肌梗死患者抢救中急诊护理流程的优化分析

目的探讨急性心肌梗死患者抢救中急诊护理流程的优化措施。方法选择2014年4月~2016年2月我院收治的急性心肌梗死患者75例,将收治的患者随机分为常规组和优化组。常规组行常规抢救护理;优化组抢救中实施急诊护理流程优化措施。对比抢救护理结果。结果 (1)优化组患者家属满意度明显高于常规组,院内再PCI率、院内AMI复发率显著比常规组低(P0.05);(2)优化组急诊球囊扩张时间、分诊时间、静脉通道建立时间、进出急诊室时间显著比常规组短(P0.05)。结论急性心肌梗死患者抢救中急诊护理流程的优化措施实施效果确切,可缩短急救时间,为患者赢得抢救时机,减少不良事件的发生,提升患者家属满意度,对规避医疗纠纷有益,值得推广。     

区域协同救治对急性ST段抬高型心肌梗死病人再灌注时间及预后的影响

目的观察区域协同救治模式对急性ST段抬高型心肌梗死(STEMI)救治的首次医疗接触至球囊扩张(FMC-to-B)时间、症状发作至球囊扩张(S-to-B)时间及其预后的影响。方法选择2013年1月—2015年3月首诊于太原市中心医院胸痛中心、发病时间在12 h内,行急诊经皮冠状动脉介入(PCI)治疗并完成6个月随访的STEMI病人230例,依据是否纳入区域协同救治模式分为区域救治组(138例)和常规流程组(92例)。比较两组FMC-to-B时间、S-to-B时间、入院和PCI术后6个月心功能指标有无差别,并随访病人6个月,观察主要不良心脏事件(MACE)发生率。结果区域救治组FMC-to-B时间、S-to-B时间[分别为(96.3±21.0)min、(410.8±208.9)min]均低于常规流程组[分别为(138.9±49.2)min、(461.3±215.4)min],其中FMC-to-B时间两组比较差异有统计学意义(P0.05),以FMC-to-B时间在90 min内为目标,区域救治组FMC-to-B时间达标率为30.4%(42/138),明显高于常规流程组的2.2%(2/92),差异有统计学意义(P0.05);两组病人入院时左室射血分数(LVEF)、左心室舒张末期内径(LVEDD)相似,出院后6个月区域救治组病人LVEF高于常规流程组[(54.12±6.72)%比(51.90±6.93)%],LVEDD小于常规流程组[(52.15±4.84)mm比(55.86±4.98)mm],差异有统计学意义(P0.05),且MACE发生率明显低于常规流程组[6.52%比17.4%,P0.05]。结论区域协同救治模式可明显缩短FMC-to-B时间,改善病人心功能及预后,减少MACE的发生。     

急诊冠状动脉介入治疗患者经锁骨下静脉和股静脉路径置入临时起搏器的疗效对比

目的 对比急诊冠状动脉介入治疗(PCI)患者经锁骨下静脉和股静脉路径置入临时起搏器的疗效。方法 选择2012年6月—2013年6月我科收治的行急诊PCI的冠心病患者168例,均需要置入临时起搏器。将患者随机分为锁骨下静脉组和股静脉组,各84例。锁骨下静脉组患者经锁骨下静脉置入临时起搏器,股静脉组患者经股静脉置入临时起搏器,比较两组患者穿刺和置入临时起搏器时间(置入用时)及局部出血、迷走反射、排便困难、腰痛、睡眠障碍等并发症发生情况。结果 锁骨下静脉组患者临时起搏器置入用时短于股静脉组,局部出血、迷走反射、排便困难、腰痛、睡眠障碍发生率低于股静脉组(P<0.05)。结论 经锁骨下静脉路径置入临时起搏器较股静脉路径能为急诊PCI及时开通罪犯血管赢得宝贵时间,且能有效降低PCI患者围术期并发症发生率。     

优化急诊护理流程对急性心梗患者抢救效果的影响

目的探讨优化急诊护理流程对急性心肌梗死患者抢救效果的影响。方法抽取40例来我院急诊科进行急诊治疗的急性心肌梗死患者作为研究研究对象,患者的治疗时间在2015年6月到2016年6月,以对照实验要求为依据,随机将其分为观察组和对照组,每组均设置20例研究对象。观察组患者急诊抢救过程中实施优化急诊护理流程,对照组实施常规急诊护理流程。结果观察组患者院前急救时间、急诊抢救时间和住院时间,均明显比对照组患者短,组间比较差异存在统计学意义(P0.05)。观察组患者救治2h后的胸痛缓解率、ST段回落率、心肌酶谱回落率及抢救成功率,均明显比照组患者高,组间比较差异存在统计学意义(P0.05)。观察组患者的急诊护理满意度为89.5%,明显比对照组患者的66.7%高,组间比较差异存在统计学意义(P0.05)。结论优化急诊护理流程能够显著缩短患者的各项急诊抢救时间,从而显著提高患者的抢救效果和抢救成功率。     

冠心病急诊PCI的护理与观察

目的急诊PCI的护理与观察。方法本文研究对象为急诊PCI患者,研究例数一共200例,急诊PCI患者均采取抽签分组方式分为两组,收取时间在2016年10月1日至2017年5月1日之间,分为观察组(100例急诊PCI患者)、对照组(100例急诊PCI患者),分别实施全程护理、常规护理,将两组患者各项指标进行对比。结果观察组急诊PCI患者的并发症发生率4.00%(血管迷走神经反射患者1例、低血压患者2例、皮下出血患者1例)低于对照组患者(P0.05);观察组急诊PCI患者的生活质量评分(90.21±1.05)分和满意度评分(89.45±2.08)分高于对照组患者(P0.05)。结论通过对急诊PCI患者实施全程护理后,取得显著的效果。     

Ochronosis: a report of a case and a review of literature

A patient with alkaptonuria and ochronotic pigment deposited in articular cartilage and sclerae clinically manifested a serious osteoarthritis of the peripheral and axial joints and synchondrosis, typically involved in long lasting cases of this hereditary defect of homogentisic acid oxidase. This is the first patient with this disorder reported, where a non-cemented total knee prosthesis (PCAR) was applied on both knees. This was possible due to the good quality of the bone stock, which did not seem to be impaired by ochronosis. Our patient had no cardiac symptoms or murmurs, but had a slight calcification in the annulus of aorta observed with echocardiography, a useful new method for screening this disease manifestation. A third new aspect reported is the immunopathology of the synovial tissue. Small pieces of torn-off cartilage were seen embedded in the synovial stroma. This was associated with a slight hyperplasia of the C3bi-receptor positive and proline hydroxylase positive type A and B synovial lining cells. Perivenular infiltrates contained CD2 positive T lymphocytes, mostly belonging to the CD4 subset, and some C3bi-receptor positive monocytes. Activated CD25 positive and immunoglobulin light chain positive T and B lymphocytes were absent or few. Because modern medicine has much to offer to those suffering from this ancient inborn error of metabolism in the form of new specific diagnostic methods and new surgical modes of treatment, such as endoprosthesis surgery and cardiac valve replacement, we also present a literature overview of this interesting condition.     

Charge of a quasiparticle in a superconductor

Nonlinear charge transport in superconductor–insulator–superconductor (SIS) Josephson junctions has a unique signature in the shuttled charge quantum between the two superconductors. In the zero-bias limit Cooper pairs, each with twice the electron charge, carry the Josephson current. An applied bias V_SD leads to multiple Andreev reflections (MAR), which in the limit of weak tunneling probability should lead to integer multiples of the electron charge ne traversing the junction, with n integer larger than 2Δ/eV_SD and Δ the superconducting order parameter. Exceptionally, just above the gap eV_SD ≥ 2Δ, with Andreev reflections suppressed, one would expect the current to be carried by partitioned quasiparticles, each with energy-dependent charge, being a superposition of an electron and a hole. Using shot-noise measurements in an SIS junction induced in an InAs nanowire (with noise proportional to the partitioned charge), we first observed quantization of the partitioned charge q = e*/e = n, with n = 1–4, thus reaffirming the validity of our charge interpretation. Concentrating next on the bias region eV_SD ～ 2Δ, we found a reproducible and clear dip in the extracted charge to q? ～ 0.6, which, after excluding other possibilities, we attribute to the partitioned quasiparticle charge. Such dip is supported by numerical simulations of our SIS structure.Excitations in superconductors (Bogoliubov quasiparticles) can be described according to the Bardeen–Cooper–Schrieffer (BCS) theory (1) as an energy-dependent superposition of an electron with amplitude u(ε), and a hole with amplitude v(ε), where the energy ε is measured relative to the Fermi energy (2). Evidently, the expectation value of the charge operator (applied to the quasiparticle wave function), which we address as the quasiparticle charge e* = q(ε)e, is smaller than the charge of an electron, q(ε) = |u(ε)|² ? |ν(ε)|² (3). Solving the Bogoliubov–de Gennes equations, one finds that |u(ε)|2=1/2[1+(ε2−Δ2/ε)] and |v(ε)|2=1/2[1−(ε2−Δ2/ε)], with the expected charge evolving with energy according to q(ε)=ε2−Δ2/ε––vanishing altogether at the superconductor gap edges (3). Note, however, that the quasiparticle wave function is not an eigenfunction of the charge operator (3, 4). Properties of quasiparticles, such as the excitation spectra (5), lifetime (6–10), trapping (11), and capturing by Andreev bound states (12, 13), had already been studied extensively; however, studies of their charge are lagging. In the following we present sensitive shot-noise measurements in a Josephson junction, resulting in a clear observation of the quasiparticle charge being smaller than e, q(eV_SD∼2Δ) < 1, and evolving with energy, as expected from the BCS theory.To observe the BCS quasiparticles in transport we study a superconductor–insulator–superconductor (SIS) Josephson junction in the nonlinear regime. The overlap between the wave functions of the quasiparticles in the source and in the drain is expected to result in a tunneling current of their effective charge. This is in contrast with systems which are incoherent (14, 15) or with an isolated superconducting island, where charge conservation leads to traversal of multiples of e – Coulomb charge (16). As current transport in the nonlinear regime results from “multiple Andreev reflections” (MAR), it is prudent to make our measurements credible by first measuring the charge in this familiar regime.In short, the MAR process, described schematically in Fig. 1, carries a signature of the shuttled charge between the two superconductors (SCs), being a consequence of n traversals through the junction (as electron-like and hole-like quasiparticles), with n an integer larger than 2Δ/eV_SD. A low transmission probability t (via tunneling through a barrier) in the bias range 2Δ/n < eV_SD < 2Δ/(n ? 1) assures dominance of the lowest order MAR process (higher orders are suppressed as tⁿ), with the charge evolving in nearly integer multiples of the electron charge. Although there is already a substantial body of theoretical (3, 17–23) and experimental (24–29) studies of the MAR process, charge determination without adjustable parameters is still missing. An important work by Cron et al. (27) indeed showed a staircase-like behavior of the charge using “metallic break junctions;” however, limited sensitivity and the presence of numerous conductance channels some of which with relatively high transmission probabilities did not allow exact charge quantization. Our shot-noise measurements, performed on a quasi-1D Josephson junction (single-mode nanowire) allowed clear observation of charge quantization without adjustable parameters. To count a few advantages: (i) the transmission of the SIS junction could be accurately controlled using a back-gate; (ii) this, along with our high sensitivity in noise measurements, enabled us to pinch the junction strongly (thus suppressing higher MAR orders); and (iii) with the Fermi level located near the 1D channel van Hove singularity, a rather monoenergetic distribution could be injected (SI Appendix, section S7).Open in a separate windowFig. 1.MAR. Illustrations of the leading processes contributing to the current as function of bias. In general, for 2Δ/(n ? 1) > eV_SD > 2Δ/n the leading charge contribution to the current is ne. An electron-like quasiparticle is denoted by a full circle, whereas a hole-like quasiparticle is denoted by an empty circle. (A) When the bias is larger than the energy gap, eV_SD > 2Δ, the leading process is a single-path tunneling of single quasiparticles from the full states (Left) to the empty states (Right). This current is proportional to the transmission coefficient t. Higher-order MAR process (dashed box), being responsible for tunneling of Cooper pairs, is suppressed as t². (B) For 2Δ > eV_SD > Δ, the main charge contributing to the current is 2e with probability t². (C) For Δ > eV_SD > 2Δ/3, the main charge contributing to the current is 3e with probability t³.     

Report of a case of a giant phytobezoar in a patient with a duodenal bulb ulcer.

A case of a large phytobezoar (750 g weight and with the length of 29 cm) due to Khormalou (Persimmon) is being reported in a young patient with chief complaint of abdominal pains and concomitant duodenal ulcer. Review of the literature in this subject shows that bezoars of this size and weight are relatively rare in healthy individuals.     

Hemoptysis in a patient with a previous surgical correction of a tetralogy of Fallot

Aorto-bronchial fistula is a rare but associated with a height rare of mortality. Although most reported cases are secondary to infectious aneurysms, cases arising after surgery to correct congenital cardiovascular abnormalities have recently been described. We report the case of a 41-year-old patient with recurrent hemoptysis and a history of Fallot's tetralogy corrected in childhood. Given such a case of hemoptysis in a patient with a history of cardiovascular surgery, the correct diagnostic approach includes fiberoptic bronchoscopy, helicoidal CAT and/or NMR, and aortography. Diagnostic confirmation should be followed soon by corrective surgery.     

Fate of a mutation in a fluctuating environment

Natural environments are never truly constant, but the evolutionary implications of temporally varying selection pressures remain poorly understood. Here we investigate how the fate of a new mutation in a fluctuating environment depends on the dynamics of environmental variation and on the selective pressures in each condition. We find that even when a mutation experiences many environmental epochs before fixing or going extinct, its fate is not necessarily determined by its time-averaged selective effect. Instead, environmental variability reduces the efficiency of selection across a broad parameter regime, rendering selection unable to distinguish between mutations that are substantially beneficial and substantially deleterious on average. Temporal fluctuations can also dramatically increase fixation probabilities, often making the details of these fluctuations more important than the average selection pressures acting on each new mutation. For example, mutations that result in a trade-off between conditions but are strongly deleterious on average can nevertheless be more likely to fix than mutations that are always neutral or beneficial. These effects can have important implications for patterns of molecular evolution in variable environments, and they suggest that it may often be difficult for populations to maintain specialist traits, even when their loss leads to a decline in time-averaged fitness.Evolutionary trade-offs are widespread: Adaptation to one environment often leads to costs in other conditions. For example, drug resistance mutations often carry a cost when the dosage of the drug decays (1), and seasonal variations in climate can differentially select for certain alleles in the summer or winter (2). Similarly, laboratory adaptation to specific temperatures (3, 4) or particular nutrient sources (5, 6) often leads to declines in fitness in other conditions. Related trade-offs apply to any specialist phenotype or regulatory system that incurs a general cost to confer benefits in specific environmental conditions (7). Despite the ubiquity of these trade-offs, it is not always easy to predict when a specialist phenotype can evolve and persist. How useful must a trait be on average to be maintained? How regularly does it need to be useful? How much easier is it to maintain in a larger population compared with a smaller one?The answers to these questions depend on two major factors. First, how often do new mutations create or destroy a specialist phenotype, and what are their typical costs and benefits across environmental conditions? This is fundamentally an empirical question, which depends on the costs and benefits of the trait in question, as well as its genetic architecture (e.g., the target size for loss-of-function mutations that disable a regulatory system). In this paper, we focus instead on the second major factor: given that a particular mutation occurs, how does its long-term fate depend on its fitness in each condition and on the details of the environmental fluctuations?To address this question, we must analyze the fixation probability of a new mutation that experiences a time-varying selection pressure. This is a classic problem in population genetics, and has been studied by a number of previous authors. The effects of temporal fluctuations are simplest to understand when the timescales of environmental and evolutionary change are very different. For example, when the environment changes more slowly than the fixation time of a typical mutation, its fate will be entirely determined by the environment in which it arose (8). On the other hand, if environmental changes are sufficiently rapid, then the fixation probability of a mutation will be determined by its time-averaged fitness effect (9, 10). In these extreme limits, the environment can have a profound impact on the fixation probability of a new mutation, but the fluctuations themselves play a relatively minor role. In both cases, the effects of temporal variation can be captured by defining a constant effective selection pressure, which averages over the environmental conditions that the mutation experiences during its lifetime. This result is the major reason why temporally varying selection pressures are neglected throughout much of population genetics, despite the fact that truly constant environments are rare.However, this simple result is crucially dependent on the assumption that environmental changes are much slower or much faster than all evolutionary processes. When these timescales start to overlap, environmental fluctuations can have important qualitative implications that cannot be summarized by any effective selection pressure, even when a mutation experiences many environmental epochs over its lifetime. As we will show below, this situation is not an unusual special case, but a broad regime that becomes increasingly relevant in large populations. In this regime, the fate of each mutation depends critically on its fitness in each environment, the dynamics of environmental changes, and the population size.Certain aspects of this process have been analyzed in earlier studies. Much of this earlier work focuses on the dynamics of a mutation in an infinite population (11–24). However, these infinite-population approaches are fundamentally unsuitable for analyzing the fixation probabilities of mutations that are neutral or deleterious on average (and even for mutations that are beneficial on average, population sizes must often be unrealistically large for this infinite population size approximation to hold). Another class of work has focused explicitly on finite populations, but only in the case where the environment varies stochastically from one generation to the next (25–31). Later work has extended this analysis to fluctuations on somewhat longer timescales, but this work is still restricted to the special case where selection cannot change allele frequencies significantly during an individual environmental epoch (9, 32, 33).These studies have provided important qualitative insights into various aspects of environmental fluctuations. However, we still lack both a quantitative and conceptual understanding of more significant fluctuations, where selection in each environment can lead to measurable changes in allele frequency. This gap is particularly relevant because significant changes in allele frequency are the most clearly observable signal of variable selection in natural populations.In this work, we analyze the fate of a new mutation that arises in an environment that fluctuates between two conditions either deterministically or stochastically on any timescale. We provide a full analysis of the fixation probability of a mutation when evolutionary and environmental timescales are comparable and allele frequencies can change significantly in each epoch. We find that even in enormous populations, natural selection is often very inefficient at distinguishing between mutations that are beneficial and deleterious on average. In addition, substitution rates of all mutations are dramatically increased by variable selection pressures. This can lead to counterintuitive results. For instance, mutations that result in a trade-off but are predominantly deleterious during their lifetime can be much more likely to fix than mutations that are always neutral or even beneficial. Thus, it may often be difficult for populations to maintain specialist traits, even when loss-of-function mutations are selected against on average. This can lead to important signatures on the genetic level, e.g., in elevated rates of nonsynonymous to synonymous substitutions (dN/dS) (34).