套管式长针深层软组织松解术的临床特点与应用

套管式长针属古代“九针”中“长针”的范畴,可祛深邪久痹,通过松解神经根,刺激相应区域的肌肉,以调节机体生理功能。套管式长针深层软组织松解术依据中医学经筋理论和以痛为腧理论,属于古代针刺中的“经刺”“报刺”“恢刺”及“合谷刺”等范畴。通过针刺疏散瘀滞之气血,以通治痛。套管式长针弥补普通毫针刺激量小及松解类针具风险较大的不足,兼具针刺调衡、提插松解的双重作用。套管式长针深层软组织松解术对深层肌纤维紧张所导致的各类难治性疼痛类疾病疗效明显,为临床医生提供了新的治疗方式,具有较高的推广及应用价值。     

Idarucizumab for Intravenous Thrombolysis and Endovascular Thrombectomy in Acute Stroke: A Case Report

BackgroundNon–vitamin K antagonist oral anticoagulants (NOACs), such as dabigatran, are widely used to prevent ischemic stroke in patients with nonvalvular atrial fibrillation. Nonetheless, stroke occurs in 1–2% of patients, and the use of NOACs may increase the bleeding risk for patients who are receiving acute treatment of intravenous thrombolysis (IVT) or endovascular thrombectomy (EVT). Idarucizumab, a monoclonal antibody developed to bind dabigatran, has been proven safe and effective for patients with uncontrolled bleeding or for patients planning to receive emergent procedures. It is now accepted that patients taking dabigatran with recurrent stroke may benefit from IVT after idarucizumab. However, there are limited data regarding idarucizumab use in patients planning to have EVT.Case ReportWe present the case of a male patient taking dabigatran who had a stroke and who was treated with idarucizumab followed by combined IVT and EVT. The patient had immediate recanalization of the occluded vessel and near total recovery of function after 3 months.Why Should an Emergency Physician be Aware of This?Our case report supports the evidence that patients presenting with acute ischemic stroke (AIS) despite being under dabigatran therapy should be evaluated for reversal by idarucizumab which can contribute to the eligibility for IVT as well as EVT. It has also been proved to provide better outcomes for patients with AIS. The availabilities of specific reversal agents for NOACs will probably alter the current management of patients with AIS.     

Combined tumor plus nontumor interim FDG-PET parameters are prognostic for response to chemoradiation in squamous cell esophageal cancer

We have investigated the prognostic value of two novel interim ¹⁸F-fluorodeoxyglucose positron emission tomography (FDG-PET) parameters in patients undergoing chemoradiation (CRT) for esophageal squamous cell carcinoma (ESCC): one tumor parameter (maximal standardized uptake ratio rSUR) and one normal tissue parameter (change of FDG uptake within irradiated nontumor-affected esophagus ∆SUV_NTO). PET data of 134 European and Chinese patients were analyzed. Parameter establishment was based on 36 patients undergoing preoperative CRT plus surgery, validation was performed in 98 patients receiving definitive CRT. Patients received PET imaging prior and during fourth week of CRT. Clinical parameters, baseline PET parameters, and interim PET parameters (rSUR and ∆SUV_NTO) were analyzed and compared to event-free survival (EFS), overall survival (OS), loco-regional control (LRC) and freedom from distant metastases (FFDM). Combining rSUR and ∆SUV_NTO revealed a strong prognostic impact on EFS, OS, LRC and FFDM in patients undergoing preoperative CRT. In the definitive CRT cohort, univariate analysis with respect to EFS revealed several staging plus both previously established interim PET parameters as significant prognostic factors. Multivariate analyses revealed only rSUR and ∆SUV_NTO as independent prognostic factors (p = 0.003, p = 0.008). Combination of these parameters with the cutoff established in preoperative CRT revealed excellent discrimination of patients with a long or short EFS (73% vs. 17% at 2 years, respectively) and significantly discriminated all other endpoints (OS, p < 0.001; LRC, p < 0.001; FFDM, p = 0.02), even in subgroups. Combined use of interim FDG-PET derived parameters ∆SUV_NTO and rSUR seems to have predictive potential, allowing to select responders for definitive CRT and omission of surgery.     

Brain tissue oxygenation during transnasal endoscopic skull base procedures

PurposeWe aimed to study brain tissue oxygenation during the period of controlled reduction of arterial blood pressure – a maneuver often used in extended endoscopic skull base surgery for bloodless operative field.MethodsIntracranial pressure, arterial blood pressure and the resultant cerebral perfusion pressure were measured during extended endoscopic skull base surgery in 5 patients with diagnosed tumors of the skull base and arterial hypertension. Simultaneously, in those patients, we measured partial pressure of oxygen in the brain parenchyma (PbtO₂).ResultsValues of PbtO₂ lower than 15 mm Hg (risk of brain ischemia) were observed in 3 patients for periods of 40 min, 110 min and 123 min, respectively. In 2 of these patients, no hypotension (mean arterial pressure <65 mm Hg) was necessary for bloodless operative field. Another 2 patients had PbtO₂ above 30 mm Hg at the time when their mean arterial pressure was below 65 mm Hg. The time course of PbtO₂ followed that of cerebral perfusion pressure with a time lag of 40–60 s in all patients.ConclusionModerate reduction of arterial pressure, often used to obtain bloodless operative field during extended endoscopic skull base surgery, may in patients with the medical history of arterial hypertension be associated with critically low values of partial oxygen pressure in brain tissue.     

Large-Bore Aspiration Thrombectomy versus Catheter-Directed Thrombolysis for Acute Pulmonary Embolism: A Propensity Score–Matched Comparison

PurposeTo compare effectiveness and safety of large-bore aspiration thrombectomy (LBAT) with catheter-directed thrombolysis (CDT) for treatment of acute massive and submassive pulmonary embolism (PE).Materials and MethodsThis retrospective review included patients with acute PE treated with LBAT or CDT using tissue plasminogen activator (tPA) between December 2009 and May 2020. A propensity score based on Pulmonary Embolism Severity Index class and PE severity (massive vs submassive) was calculated, and 26 LBAT cases (age 60.2 y ± 17.1, 14/26 women) were matched with 26 CDT cases (age 59.7 y ± 14.2, 14/26 women).ResultsThe CDT group had 22.1 mg ± 8.1 tPA infused over 21.2 h ± 6.6. Both groups demonstrated similar initial and final systolic pulmonary artery pressure (PAP) (LBAT: 54.5 mm Hg ± 12.9 vs CDT: 54.5 mm Hg ± 16.3, P = .8, and LBAT: 42.5 mm Hg ± 14.1 vs CDT: 42.6 mm Hg ± 12.1, P = .8, respectively) and similar reductions in heart rate (LBAT: −5.4 beats/min ± 19.2 vs CDT: −9.6 beats/min ± 15.8, P = .4). CDT demonstrated a higher reduction in Miller score (−10.1 ± 3.9 vs −7.5 ± 3.8, P = .02). LBAT resulted in 1 minor hemorrhagic complication and 2 procedure-related mortalities, and CDT resulted in 1 minor and 1 major hemorrhagic complication.ConclusionsLBAT and CDT resulted in similar reductions of PAP and heart rate when used to treat acute PE. CDT reduced thrombus burden to a greater degree. Although hemorrhagic complications rates were not significantly different, the LBAT group demonstrated a higher rate of procedure-related mortality. Larger studies are needed to compare the safety of these techniques.     

胫前动脉踝上穿支皮瓣修复足踝部软组织缺损19例

目的探讨胫前动脉踝上穿支皮瓣修复足踝部软组织缺损的临床疗效。方法回顾性研究2018年4月至2019年6月采用胫前动脉踝上穿支皮瓣修复足踝部软组织缺损19例的资料,其中男11例,女8例;年龄为21~75岁,平均39岁。根据前踝上穿支皮瓣解剖学基础,按照足踝部软组织缺损大小和形状,在小腿下端前外侧设计并切取皮瓣转位修复创面。切取胫前动脉踝上穿支皮瓣面积为6.0 cm×5.0 cm^14.0 cm×8.0 cm,均为带蒂皮瓣转位。根据皮瓣成活、感染控制、弹性色泽、外观形态、供区瘢痕、皮肤感觉、患者认可等情况,对患者足踝部软组织缺损的修复情况进行综合评价。结果本组19例皮瓣全部成活,软组织缺损、肌腱、骨质及钢板外露均得以修复。供区均I期愈合。术后门诊随访2~16个月,皮瓣血运良好,颜色接近周围正常皮肤,臃肿不明显,患者对外观表示满意;供区皮片愈合良好,无明显增生、挛缩及溃疡,踝关节功能良好。结论胫前动脉踝上穿支皮瓣是修复足踝部软组织缺损较为理想的方法之一,手术操作简便,穿支较恒定,血供可靠,具有一定的临床应用价值。     

Ocular and adnexal anomalies in craniofacial microsomia: a systematic review

Ocular anomalies may occur in craniofacial microsomia (CFM). The aim of this systematic review was to review the literature on ocular anomalies and their incidence, in order to estimate the need for ophthalmological screening in CFM patients. Online databases were searched, and data on the number of patients, type and incidence of ocular anomalies, and visual acuity were extracted. Four subgroups of ocular and adnexal anomalies were identified, to provide an overview of the different anomalies. Twenty-five papers analysing 1419 patients in total were included. Ocular anomalies were documented in 6.7–100% of patients. The most reported type I ocular anomalies were eyelid coloboma, lipodermoids, and orbital dystopia. The most reported type II ocular anomalies were epibulbar dermoid, microphthalmia, and anophthalmia. Ptosis and strabismus were the most reported type III anomalies, and irregular astigmatism was the most reported type IV ocular anomaly. Visual impairment in general was reported in 8–71.4% of patients, with severe visual impairment in 11.1–71.4% and amblyopia in 16.3%. This study provides a detailed overview of ocular anomalies in CFM and their prevalence. Furthermore, we propose a new classification to organize ocular anomalies into four clinically relevant subtypes. Finally, the high prevalence of ocular anomalies and visual impairment in this study suggests that CFM patients should undergo ophthalmological screening at least once during the sensitive period.