Sonothrombolysis in ST-Segment Elevation Myocardial Infarction Treated With Primary Percutaneous Coronary Intervention

BackgroundPreclinical studies have demonstrated that high mechanical index (MI) impulses from a diagnostic ultrasound transducer during an intravenous microbubble infusion (sonothrombolysis) can restore epicardial and microvascular flow in acute ST-segment elevation myocardial infarction (STEMI).ObjectivesThis study tested the clinical effectiveness of sonothrombolysis in patients with STEMI.MethodsPatients with their first STEMI were prospectively randomized to either diagnostic ultrasound–guided high MI impulses during an intravenous Definity (Lantheus Medical Imaging, North Billerica, Massachusetts) infusion before, and following, emergent percutaneous coronary intervention (PCI), or to a control group that received PCI only (n = 50 in each group). A reference first STEMI group (n = 203) who arrived outside the randomization window was also analyzed. Angiographic recanalization before PCI, ST-segment resolution, infarct size by magnetic resonance imaging, and systolic function (LVEF) at 6 months were compared.ResultsST-segment resolution occurred in 16 (32%) high MI PCI versus 2 (4%) PCI-only patients before PCI, and angiographic recanalization was 48% in high MI/PCI versus 20% in PCI only and 21% in the reference group (p < 0.001). Infarct size was reduced (29 ± 22 g high MI/PCI vs. 40 ± 20 g PCI only; p = 0.026). LVEF was not different between groups before treatment (44 ± 11% vs. 43 ± 10%), but increased immediately after PCI in the high MI/PCI group (p = 0.03), and remained higher at 6 months (p = 0.015). Need for implantable defibrillator (LVEF ≤30%) was reduced in the high MI/PCI group (5% vs. 18% PCI only; p = 0.045).ConclusionsSonothrombolysis added to PCI improves recanalization rates and reduces infarct size, resulting in sustained improvements in systolic function after STEMI. (Therapeutic Use of Ultrasound in Acute Coronary Artery Disease; NCT02410330).     

体外肺膜氧合在急性冠脉综合征介入治疗中的临床应用与分析

目的 总结及分析体外肺膜氧合（Extracorporeal membrane oxygenation，ECMO）在急性冠状动脉综合征（Acute coronary syndrome,ACS）介入治疗中的临床应用及评价预后。方法 回顾性分析2015年8月至2018年8月因ACS入院，并在ECMO辅助下行冠状动脉造影术的20例患者的临床资料。采用SPSS 23.0软件进行统计分析，计量资料以x±s表示，采用COX回归分析相关因素与患者生存时长的关系，并用OR值与相关因素与生存时间长短之间的关系强度，采用寿命表达计算总数的生存率和绘制生存曲线图。结果 20例ECMO支持下行经皮冠状动脉介入治疗（Percutaneous transluminal coronary intervention，PCI）， 患者中16例成功置入冠状动脉支架，其年龄为43~76岁，平均年龄（61.4±9.1）岁，中位年龄为61岁；平均住院天数为（18.0±12.4）d；ECMO平均支持时间为（31.52±27.97）h，术后成功脱机16例（80%），生存出院16 例（80%），术后6个月生存率85.0%，平均住院时间为（18.0±12.4）d，术后并发症（OR=3.486，95%CI 1.266~9.599）、ECMO支持时间（OR=1.05，95%CI 1.010~1.106）、术后CK（OR=1.009，95%CI 1.001~1.017）是急性冠状动脉综合征ECMO辅助行PCI 预后的危险因素，其中死亡终点事件主要分布在术后30 d内，术后5例（71.4%）出现肺部感染，2例（28.6%）出现急性出血，1例（14.3%）出现心房颤动 ，1例（14.3%）出现肾功能不全、呼吸衰竭，给予CRRT及呼吸机辅助治疗，1例（14.3%）出现弥漫性血管内凝血，1例（14.3%）下肢缺血性坏疽。结论 ECMO辅助PCI为ACS提供了有效治疗方式，严格把握ECMO辅助时间对治疗危重症ACS远期预后有着重要的意义。     

氯吡格雷联合前列地尔对急性脑梗死患者疗效、血流动力学及凝血功能水平的影响

目的：探讨氯吡格雷联合前列地尔对急性脑梗死患者的疗效及对患者血流动力学、凝血功能水平的影响。方法：选取2015年6月-2017年6月某院收治的急性脑梗死患者90例，按照随机数字表法分为对照组与观察组，每组各45例。对照组患者在常规治疗基础上给予氯吡格雷治疗，观察组患者在对照组治疗基础上给予前列地尔治疗。比较2组患者临床治疗效果；检测治疗前、后2组患者血浆黏度（PV）、血浆纤维蛋白原（FIB）、血小板聚集率（PAR）、凝血酶原时间（PT）、活化部分凝血活酶时间（APTT）、D-二聚体（D-D）水平。结果：对照组患者治疗后临床总有效率为64.44%；观察组患者治疗后临床总有效率为86.67%。两者比较差异有显著性（P<0.05）。治疗前，2组患者血流动力学指标PV、FIB、PAR及凝血功能指标PT、APTT、D-D水平比较，差异无显著性（P>0.05）。治疗后，对照组及观察组患者PV、FIB、PAR及D-D水平均明显低于本组治疗前，PT、APTT水平均明显高于本组治疗前；观察组患者治疗后PV、FIB、PAR及D-D水平均明显低于对照组治疗后，PT、APTT水平均明显高于对照组治疗后，差异均有显著性（P<0.05）。结论：氯吡格雷联合前列地尔对急性脑梗死患者具有较好的临床疗效，可通过抑制血小板活性及降低血液黏度，起到改善患者血流动力学水平，调节患者凝血功能的作用。     

自身免疫性胰腺炎的诊断

自身免疫性胰腺炎（AIP）是一类特殊的慢性胰腺炎，其临床上依据组织学分为Ⅰ型和Ⅱ型。我国以Ⅰ型为主，是 IgG4相关性疾病的一部分，常表现为梗阻性黄疸或胰腺实质的肿块。组织学上表现为病变组织大量淋巴浆细胞的浸润及慢性纤维化。虽然国际胰腺病协会围绕其影像学、血清学、组织学及激素治疗的反应制定了诊断标准，但 AIP的临床表现较为隐匿和多样，其诊断仍然具有挑战性，特别是表现为胰腺肿块的患者，需要时刻警惕胰腺癌的风险。本文从影像学、组织学角度对文献进行了概述，重点是这种复杂疾病的诊断及误诊的风险，以期提高本病的鉴别诊断水平。     

Bradicardia grave e assistolia associadas ao sugamadex: relato de caso

Background and objectives

Sugamadex is a modified gamma‐cyclodextrin, the first selective agent for reversal of neuromuscular blockade induced by steroidal non‐depolarizing muscle relaxants, with greater affinity for rocuronium. In this article we present a case of severe bradycardia and asystole following sugammadex administration.

Acute penetrating atherosclerotic ulcer of the ascending aorta

A 67‐year‐old man presented with chest pain. Clinical examination revealed hypertension (160/90 mm Hg). Electrocardiogram indicated no acute coronary syndrome and cardiac enzymes were normal. Catheterization was performed owing to the patient’s continuing chest pain and ascending aortogram revealed irregular aortic wall. A computed tomography image showed the shape of penetrating ulcer. The patient was taken to the operating room and intraoperative examination confirmed the diagnosis of penetrating atherosclerotic ulcer (PAU). Coronary artery bypass graft and bovine pericardial patch repair of PAU was performed. A bovine pericardial patch was done as aortic root was heavily calcified and was easy to handle and more hemostatic.     

A short bout of high-intensity exercise alters ipsilesional motor cortical excitability post-stroke

Background: Acute exercise can increase motor cortical excitability and enhance motor learning in healthy individuals, an effect known as exercise priming. Whether it has the same effects in people with stroke is unclear.

Objectives: The objective of this study was to investigate whether a short, clinically-feasible high-intensity exercise protocol can increase motor cortical excitability in non-exercised muscles of chronic stroke survivors.

Methods: Thirteen participants with chronic, unilateral stroke participated in two sessions, at least one week apart, in a crossover design. In each session, they underwent either high-intensity lower extremity exercise or quiet rest. Motor cortical excitability of the extensor carpi radialis muscles was measured bilaterally with transcranial magnetic stimulation before and immediately after either exercise or rest. Motor cortical excitability changes (post-exercise or rest measures normalized to pre-test measures) were compared between exercise vs. rest conditions.

Results: All participants were able to reach the target high-intensity exercise level. Blood lactate levels increased significantly after exercise (p < .001, d = 2.85). Resting motor evoked potentials from the lesioned hemisphere increased after exercise (mean 1.66; 95% CI: 1.19, 2.13) compared to the rest condition (mean 1.23; 95% CI: 0.64, 1.82), p = .046, d = 2.76, but this was not the case for the non-lesioned hemisphere (p = .406, d = 0.25).

Conclusions: High-intensity exercise can increase lesioned hemisphere motor cortical excitability in a non-exercised muscle post-stroke. Our short and clinically-advantageous exercise protocol shows promise as a potential priming method in stroke rehabilitation.     

Assessing the CT findings and clinical course of ED patients with first-time versus recurrent acute pancreatitis

Study objectives

The primary objective of this study was to compare Emergency Department patients with first-time versus recurrent acute pancreatitis.

参麦注射液联合阿替普酶静脉溶栓治疗45例急性缺血性脑卒中患者的疗效观察

目的:探究参麦注射液联合阿替普酶静脉溶栓治疗急性缺血性脑卒中(AIS)患者疗效及安全性。方法:选取某院90例AIS患者,按照治疗方案不同分为对照组和观察组,各45例。对照组采用阿替普酶静脉溶栓治疗,观察组在对照组基础上加用参麦注射液治疗,观察分析两组临床疗效及不良反应发生情况。结果:观察组治疗总有效率高于对照组(P<0.05),观察组总不良反应发生率低于对照组(P<0.05)。结论:参麦注射液联合阿替普酶静脉溶栓治疗AIS可提升疗效,提高临床安全性。