术前急性扩容血液稀释联合控制性降压用于脑膜瘤手术麻醉的临床研究

目的：观察急性扩容血液稀释联合控制性降压对脑膜瘤手术的血液保护效果。方法择期32例美国麻醉医师协会（American Society of Anesthesiologists,ASA）I～I级脑膜瘤手术患者,随机分成对照组和试验组(n=16)。常规麻醉诱导后,试验组快速输入羟乙基淀粉20mL/kg。术中静脉用硝酸甘油和艾司洛尔实施控制性降压,维持平均动脉压（mean arterial pressure,MAP）>65mmHg。记录麻醉诱导前(T1),血液扩容稀释后15min(T2),手术开始后60 min(T3)及手术结束(T4)时2组患者心率（heart rate,HR）、MAP、中心静脉压（central venous pressure,CVP）、血红蛋白（hemoglobin,Hb）和血球压积（hematocrit,Hct）。结果试验组T2时MAP显著高于对照组,术中T3时MAP显著低于对照组（P<0.05）。试验组中有9例患者接受输血,出血量显著低于对照组（P<0.05）;对照组中有15例患者术中接受了异体输血,输血量显著高于试验组（P<0.05）。结论急性扩容血液稀释联合控制性降压可以安全应用于脑膜瘤手术的麻醉,减少失血量。     

Longitudinal Recovery and Reduced Costs After 120 Sessions of Locomotor Training for Motor Incomplete Spinal Cord Injury

Objective

To determine the impact of long-term, body weight–supported locomotor training after chronic, incomplete spinal cord injury (SCI), and to estimate the health care costs related to lost recovery potential and preventable secondary complications that may have occurred because of visit limits imposed by insurers.

Hypovolemic Shock Caused by Angiotensin-Converting Enzyme Inhibitor-Induced Visceral Angioedema: A Case Series and A Simple Method to Diagnose this Complication in the Emergency Department

Background

Visceral angioedema is a rarely reported side effect of angiotensin-converting-enzyme inhibitors (ACEI). Because signs and symptoms tend to be nonspecific, the diagnosis is difficult to make, especially in the emergency department (ED).

The Evaluation and Management of Toxic Shock Syndrome in the Emergency Department: A Review of the Literature

Background

Toxic shock syndrome (TSS) is a severe, toxin-mediated illness that can mimic several other diseases and is lethal if not recognized and treated appropriately.

Randomized Trial of Ivabradine in Patients With Hyperadrenergic Postural Orthostatic Tachycardia Syndrome

BackgroundPostural orthostatic tachycardia syndrome (POTS) is a complex, multifaceted disorder that impairs functional status and quality of life. Current pharmacological treatments are limited.ObjectivesThis study investigated the effect of ivabradine (selective blocker of the I_funny channel in the sinoatrial node) on heart rate, quality of life (QOL), and plasma norepinephrine (NE) levels in patients with hyperadrenergic POTS defined by plasma NE >600 pg/ml and abnormal tilt table test.MethodsIn total, 22 patients with hyperadrenergic POTS as the predominant subtype completed a randomized, double-blinded, placebo-controlled, crossover trial with ivabradine. Patients were randomized to start either ivabradine or placebo for 1 month, and then were crossed over to the other treatment for 1 month. Heart rate, QOL, and plasma NE levels were measured at baseline and at the end of each treatment month.ResultsThe average age was 33.9 ± 11.7 years, 95.5% were women (n = 21), and 86.4% were White (n = 23). There was a significant reduction in heart rate between placebo and ivabradine (p < 0.001). Patients reported significant improvements in QOL with RAND 36-Item Health Survey 1.0 for physical functioning (p = 0.008) and social functioning (p = 0.021). There was a strong trend in reduction of NE levels upon standing with ivabradine (p = 0.056). Patients did not experience any significant side-effects, such as bradycardia or hypotension, with ivabradine.ConclusionIvabradine is safe and effective in significantly improving heart rate and QOL in patients with hyperadrenergic POTS as the predominant subtype.     

Cardiovascular Assessment of Falls in Older People

Falls in older people can be caused by underlying cardiovascular disorders, either because of balance instability in persons with background gait and balance disorders, or because of amnesia for loss of consciousness during unwitnessed syncope. Pertinent investigations include a detailed history, 12-lead electrocardiography, lying and standing blood pressure, carotid sinus massage (CSM), head-up tilt, cardiac electrophysiological tests, and ambulatory blood pressure and heart rate monitoring, which includes external and internal cardiac monitoring. The presence of structural heart disease predicts an underlying cardiac cause. Conversely, the absence of either indicates that neurally mediated etiology is likely. CSM and tilt-table testing should be considered in patients with unexplained and recurrent falls. Holter monitoring over 24 hours has a low diagnostic yield. Early use of an implantable loop recorder may be more cost-effective. A dedicated investigation unit increases the likelihood of achieving positive diagnoses and significantly reduces hospital stay and health expenditure.     

Treatment of severe orthostatic hypotension with the somatostatin analogue octreotide

The long-acting somatostatin analogue octreotide was used in a patient with severe orthostatic hypotension resistant to conventional treatment. 0.4 ug/kg octreotide given subcutaneously abolished the postural drop in systolic blood pressure for about four hours and was more effective than a combination of fludrocortisone and pindolol.     

Hemodynamic Instability during Carotid Angioplasty and Stenting-Relationship of Calcified Plaque and Its Characteristics

Purpose

During carotid angioplasty and stenting (CAS), hemodynamic instability (HDI) can occur, possibly causing post-procedural ischemic complications. The goal of this study was to investigate the risk factors of HDI focusing on characteristics of plaque.

Materials and Methods

Thirty nine CAS patients were retrospectively evaluated for HDI. Prolonged HDI that lasted over 30 minutes was analyzed in relation to characteristics of calcified plaque.

Results

Nineteen (48.7%) patients had HDI. Ten of the 19 had both bradycardia and hypotension, and nine had only bradycardia. All bradycardia was treated well with a transcutaneous temporary cardiac pacemaker. But eight patients presented with prolonged hypotension in spite of recovery of bradycardia. Calcified plaque was a related factor associated with HDI (odds ratio, 8.571; 95% confidence interval, 1.321-55.62; p=0.024). Extensive and eccentric type calcified plaques were associated with prolonged hypotension (p=0.04, and p=0.028, respectively).

Conclusion

The calcification of plaque is a predictable factor of HDI during CAS, and its extensive and eccentric calcified plaques may be related to prolonged HDI.     

中青年维持性血液透析患者轻度认知功能损害与透析间低血压的相关性分析

目的探讨中青年维持性血液透析患者轻度认知功能损害与透析间低血压的相关性。方法回顾性分析2018年6月至2019年6月78例维持性血液透析的中青年忠者的临床资料。采用MMSE和MoCA评估所有忠者的认知功能,根据是否发生轻度认知功能损害将其分为观察组和对照组,比较两组的临床资料及各项血液指标,观察损害认知功能的危险因素,并进行相关性分析。结果观察组患者的透析时间、合并糖尿病比例、透析间低血压的发生率、血清UA和CRP水平与对照组比较,差异有统计学意义(P<0.05)。透析间低血压、糖尿病以及血清UA水平是影响中青年维持性血液透析患者发生轻度认知损害的重要危险因素。维持性血液透析患者MoCA得分与透析间低血压的发生呈负相关(r=-0.542,P<0.001)。结论透析间低血压是中青年维持性血液透析患者发生轻度认知功能损害的重要危险因素,应引起临床重视。