Hematoma subdural intracraneal tras punción dural accidental: caso clínico

Intracranial subdural hematoma is a rare, but potentially lethal complication of neuraxial procedures. Considering the high frequency of neuraxial techniques in the obstetric population, parturients are more susceptible to this fearful complication. The diagnosis is often masked and delayed because it shares similar clinical characteristics with posdural puncture headache, with headache being the most common symptom. This case report describes a timely diagnosis and successful management of an intracranial subdural hematoma, after unintentional dural puncture during labour epidural analgesia. Postpartum headache following epidural analgesia, remains a clinical challenge for the caring team, requiring a close follow-up and awareness for non-benign causes that require prompt management, avoiding devastating consequences.     

经椎间孔入路经皮内窥镜下腰椎椎间盘切除术治疗腰椎椎间盘突出症的疗效及预后影响因素分析

目的探讨经椎间孔入路经皮内窥镜下腰椎椎间盘切除术(PETD)治疗腰椎椎间盘突出症(LDH)的临床疗效,并探讨影响患者预后的相关因素。方法采用前瞻性队列研究设计,纳入2015年8月—2016年9月诊断为LDH并行PETD治疗的102例患者。分别于术前1 d及术后1 d、3个月、6个月、12个月、36个月时评估疼痛视觉模拟量表(VAS)评分、Oswestry功能障碍指数(ODI)、日本骨科学会(JOA)评分,采用改良MacNab标准评估临床疗效。分析患者临床特征和影像学资料等因素对预后的影响。结果86例患者完成36个月及以上随访,其中男56例、女30例,年龄19~88(46.96±14.03)岁,随访36~46(40.91±3.21)个月。86例患者手术顺利完成,无术中转开放手术。并发症发生率为1.2%(1/86),复发率为5.8%(5/86)。术后1 d、3个月、6个月、12个月、36个月,腰痛和腿痛VAS评分及ODI均较术前下降,JOA评分较术前升高,差异均有统计学意义(P<0.05)。根据改良MacNab标准,术后36个月优良率为94.2%(81/86)。突出髓核(HNP)越大,术后腿痛VAS评分、ODI和JOA评分改善越明显,差异有统计学意义(P<0.05);与体质量指数(BMI)<25 kg/m^2的患者相比,BMI≥25 kg/m^2的患者JOA评分改善较小,差异无统计学意义(P>0.05)。结论PETD治疗LDH可取得满意疗效。HNP大小是影响患者预后的主要因素,BMI可能对预后也有一定影响,但尚需扩大样本量进一步研究。     

骨盆前环皮下内固定支架与微创经皮钢板内固定治疗骨盆前环骨折的疗效比较

目的 比较前环皮下内固定支架（INFIX）和微创经皮钢板内固定（MIPPO）治疗骨盆前环骨折的疗效。方法 回顾性分析2016年7月至2020年5月我院收治且符合标准的48例不稳定型骨盆骨折病人的临床资料,其中INFIX组22例,MIPPO组26例。INFIX组,男15例,女7例,年龄为（36.89±11.12）岁（21~58岁）。MIPPO组,男17例,女9例,年龄为（43.70±17.66）岁（21~71岁）。比较两组手术时间、术中出血量、骨折复位质量（Matta标准）、骨折愈合时间、骨折术后功能恢复情况（Majeed评分系统）,并记录并发症。结果 两组均获得随访,随访时间为5~17个月,平均为13个月。INFIX组手术时间[（75.41±15.25） min]低于MIPPO组[（85.62±17.92） min],差异无统计学意义（t=-5.154,P=0.101）;INFIX组术中出血量[（30.27±7.67） mL]明显低于MIPPO组[（111.15±24.30） mL],差异有统计学意义（t=-14.971,P=0.006）;两组负重时间[（16.00±2.06）周vs.（15.94±2.32）周]、Majeed评分[（81.90±7.73）分vs.（83.44±3.54）分]、骨折复位优良率[81.8% vs.84.6%]比较,差异均无统计学意义（P均＞0.05）,但MIPPO组能够达到更好的解剖复位。INFIX组1例病人出现股外侧皮神经损伤,两组病人未出现内固定失败情况。结论 治疗骨盆前环骨折,INFIX具有出血少、手术创伤小等优点,钢板能够达到更好的解剖复位,两组具有相似的术后功能恢复情况。可根据术者经验和病人具体情况选择适宜的固定方式。     

Percutaneous coronary angioscopy: methods, findings, and therapeutic implications

The development and clinical implementation of percutaneous coronary angioscopy represents an engineering triumph, blending the newest technologies and materials in the field of fiberoptics with the most advanced techniques of balloon angioplasty catheter materials and construction. Current devices provide a safe method for acquiring excellent quality images of the coronary arteries. This is due to major advances in catheter alignment techniques allowing coaxial positioning of the angioscope in the relatively tortuous coronary arteries. Additional development is needed to further refine the degree of operator control over the field of view, which would also reduce procedure duration. The percutaneous coronary angioscope is currently a functional device for investigators attempting to correlate the morphology of atherosclerotic lesions and clinical coronary artery disease. Confirmation of the value of the angioscope as a clinically useful device for routine application in the diagnosis and management of cardiovascular disease will depend upon the results of further studies.     

Mechanism of Ethanol-Enhanced Estradiol Permeation Across Human Skin in Vivo

The influence of ethanol on the permeation of 17-estradiol (estradiol) across viable human skin in vivo was investigated with the human skin sandwich flap model. Maintaining continuous delivery of a constant concentration of the solute in phosphate-buffered saline, pH 7.4 (PBS), or mixtures of ethanol in PBS to the skin surface revealed that steady-state flux of estradiol was achieved within 30–60 min and maintained throughout 4 hr. The 10-fold decrease in in vivo flux and permeability coefficient (K _p) of tracer estradiol solutions in ethanol or ethanol solutions compared with PBS vehicle reflected the 10-fold difference in the apparent partition coefficients (K _m) of estradiol from the respective vehicles into isolated human stratum corneum. Neither the stratum corneum thickness nor the diffusion coefficient of estradiol was significantly different among the vehicles tested. In vivo flux of estradiol in ethanol or ethanol solutions across viable human skin was increased with saturated solutions of estradiol. Further, in vivo flux of estradiol from vehicles such as PBS, ethanol, and ethanol mixtures, which minimally alter the rate-limiting barrier, can be successfully predicted with knowledge of only two physicochemical parameters, the estradiol concentration in the vehicle and the K _m of estradiol from the vehicle into isolated human stratum corneum.     

Percutaneous balloon aortic valvuloplasty in the treatment of congenital valvu lar aortic stenosis in children

Objective To assess the effect of the balloon valvuloplasty for congenital valvular aortic stenosis (AS) in children.Methods A total of 27 (mean age 6.09 years) children with AS accepted the treatment of percutaneous balloon aortic valvuloplasty (PBAV).The ratios of balloon/valve were 0.95±0.08 for 19 cases of typical AS and 1.00±0.11 for 8 cases of hyp oplastic AS.The patients were evaluated by the gradients across aotic valves i n pre- and post-PBAV and by echocardiogram during the follow-up period.Results Fifteen of 19 （78.9%）cases of typical AS had a better outcome and the gradien t of the remaining 4 cases (26.7%) had increased after follow-up (ΔP&gt;50 mm Hg).Four of 8 (50.0%) cases of hypoplastic AS had satisfactory responses and the gradient of the remaining 3 cases (75.0%) rose.There was no moderate to s evere aortic insufficiency (AI). Conclusion The balloon aortic valvuloplasty provides safe and significant hemodynamic and c linical improvement in pediatric patients.The outcome of PBAV for typical AS is better than for hypoplastic AS.     

PTCA及血管内支架术中冠脉循环血小板功能的变化

目的 探讨经皮腔内冠脉成形术（PTCA）及冠脉内支架术对冠脉循环中血小板功能的影响。方法 29例冠心病患者分成冠脉造影组（8例）和PTCA加支架组（21例）,分别于术前及术后即刻采集冠状静脉窦血,采用比浊法测定血小板最大聚集率（MPAR）,放免法测定血小板α-颗粒膜蛋白（GMP－140）及血栓素B2（TXB2）的浓度。并对PTCA及支架术中不同时间点血小板功能指标的变化情况进行了观察。结果 冠脉造影前后血小板功能指标无显著变化;PTCA及支架组在球囊预扩张即刻各血小板功能指标均轻度增高;支架后即刻显著升高（P＜0．05）,支架后10min有下降趋势。结论 冠脉造影对冠脉循环血小板功能无显著影响;PTCA及支架术中能使血小板功能激活。     

CT导引下经皮肺穿刺活检的临床应用

目的：探讨ＣＴ导引下经皮肺穿刺活检的技术、适应证的选择及临床应用价值。方法：通过对１０８例肺部病变病人进行ＣＴ扫描确定穿刺平面及穿刺路径（即定位）,局麻后进针,操作过程中ＣＴ监视穿刺针的走向,达预定位置后取材送病理检查。结果：１０８例病人穿刺活检后９９例确定病理诊断,９例未风瘤细胞,未能作细胞学分类,阳性诊断率９２％,并发症少且轻。结论：ＣＴ导引下经皮肺穿定位准确,安全可靠,操作简便,阳性诊断率高     

经皮肾镜去石术后出血的介入治疗

目的: 研究超选择性肾动脉栓塞在治疗经皮肾镜术后出血中的效果及失败原因。方法: 对65例伴有血液动力学改变的经皮肾镜术后出血患者行肾动脉造影,用微导管行超选择性插管,用微弹簧圈栓塞损伤动脉。若首次肾动脉造影无阳性发现,则采用以下措施以防止遗漏病灶:(1)腹主动脉造影;(2)重复肾动脉造影;(3)造瘘管走行区域肾动脉分支超选择造影;(4)保留穿刺通道,拔除肾造瘘管后造影。对肾动脉出血的造影表现进行总结,并对栓塞止血失败的原因进行分析。结果: 65例患者中,造影有阳性发现的60例(62个肾脏), 均经超选择性栓塞成功止血。肾动脉造影的阳性表现包括:假性动脉瘤形成、斑片状造影剂外溢、假性动脉瘤合并动静脉瘘、造影剂进入集合系统、造影剂弥散至肾被膜下。一次栓塞成功53例(55个肾脏), 成功率88.71%,两次栓塞成功率96.77%。首次栓塞失败的原因主要是遗漏病灶(4例,57.10%)和栓塞的受损血管再通(2例,28.57%)。5例患者肾动脉造影无阳性发现,经保守治疗血尿停止。所有患者介入治疗后3、6、12个月随访,均未再次出现血尿,且未发生持续、严重的肾功能损害。结论: 超选择肾动脉栓塞是治疗经皮肾镜术后出血的有效方法,肾动脉造影遗漏病灶是造成止血失败的主要原因。