冠状动脉旋磨标签外使用的安全性

目的:探讨冠状动脉旋磨治疗在适应证标签外使用的安全性。方法:顺序入选2010-01至2015-12北京大学人民医院行旋磨治疗的112例患者,列出9项旋磨需注意的非标签适应证包括:静脉桥血管,大量血栓病变,无保护左主干病变,急性心肌梗死罪犯病变,大夹层病变,严重左心室功能不全(左心室射血分数30%),严重三支病变,长病变(≥25 mm),成角病变(≥45°)。具有上述≥1项非标签使用的患者,列入旋磨标签外组(67例,59.8%);无上述相对禁忌使用旋磨术的患者,列入标签内组(45例,40.2%)。比较两组患者旋磨相关并发症(慢血流/无复流、旋磨头坎墩、冠状动脉穿孔、导丝断裂)和住院期间不良事件(紧急外科搭桥、急性支架内血栓、心原性死亡)的发生率。结果 :(1)慢血流/无复流是最常见的旋磨并发症,标签外组与标签内组相比差异无统计学意义(4.5%vs 8.9%,P0.05)。1例患者发生旋磨头坎墩,发生于标签外组(1.5%vs 0%,P0.05)。(2)1例患者发生急性支架内血栓,位于标签内组(2.2%vs 0%,P0.05);1例患者发生心原性死亡,位于标签外组(1.5%vs 0%,P0.05)。结论:标签外使用旋磨并未增加慢血流/无复流发生率,其他严重并发症和住院期间不良事件罕见。     

冠状动脉血管内超声对严重钙化病变斑块旋磨术终点判断的评价研究

目的评价冠状动脉血管内超声(IVUS)对严重钙化病变斑块旋磨术终点的影响。方法回顾性分析2016年8月至2021年2月于北京大学人民医院行IVUS指导下冠状动脉斑块旋磨术治疗的54例患者。根据初次旋磨治疗后是否强化预处理方案(包括升级旋磨头或使用棘突/切割球囊进行扩张)或直接采用半顺应性/非顺应性球囊扩张进行分组,强化组11例,非强化组43例。比较两组患者临床资料、病变特点、手术情况及腔内影像学结果等情况。结果两组患者性别、年龄、既往病史(高血压病、糖尿病、高脂血症、心肌梗死、经皮冠状动脉介入治疗及冠状动脉旁路移植术)、左心室射血分数(LVEF)、估算的肾小球滤过率(eGFR)、旋磨靶血管、三支病变情况、旋磨头/血管直径比值、半顺应性或非顺应性球囊平均直径及最大扩张压力、手术时间、对比剂用量、X线辐射剂量、手术成功率等方面比较,差异均无统计学意义(均P0.05)。强化组患者旋磨头数量明显多于非强化组[2(1,2)个比1(1,1)个,P0.001],病变钙化弧度明显高于非强化组[(357.3±9.0)°比(339.1±41.7)°,P=0.011],差异均有统计学意义;而两组在钙化长度、钙化结节、旋磨后出现多重反射、最小支架面积及支架膨胀率等方面的差异均无统计学意义(均P0.05)。结论 IVUS提示钙化弧度为360°或接近360°的严重钙化病变需要更加积极的强化预处理策略,包括升级旋磨头或旋磨后使用棘突/切割球囊进行扩张;对于旋磨治疗后出现多重反射者需要给予更多关注。     

冠状动脉严重钙化病变计划与非计划旋磨的安全性及有效性比较

目的比较冠状动脉严重钙化病变计划旋磨与非计划旋磨治疗的安全性及有效性。方法连续纳入2014年1月至2017年7月于北京大学人民医院行旋磨治疗的92例患者。根据启动旋磨治疗的时机,分别纳入计划旋磨组(72例)和非计划旋磨组(20例),比较两组患者临床资料、病变特点、手术特点及术后并发症等情况。结果两组患者基线资料匹配,性别、年龄、体重指数、心血管相关危险因素、心功能、既往病史(心肌梗死、经皮冠状动脉介入治疗及冠状动脉旁路移植术)、临床诊断比较,差异均无统计学意义(均P0.05)。两组患者均以多支病变为主,计划旋磨组(70.8%)与非计划旋磨组(75.0%)比较,差异无统计学意义(P=0.974)。计划旋磨组使用结合血管内超声(intravascular ultrasound,IVUS)和光学相干断层成像(optical coherence tomography,OCT)比例(26.4%比10.0%,P=0.030)显著高于非计划旋磨组,差异有统计学意义。两组患者旋磨靶血管、旋磨头使用情况比较,差异均无统计学意义(均P0.05)。两组患者支架置入个数及总支架长度比较,差异均无统计学意义(均P0.05)。但计划旋磨组预扩张球囊用量明显少于非计划旋磨组[1(1,2)个比2(1,3)个,P=0.004],而且手术时间[(81.4±22.7)min比(94.8±33.0)min,P=0.035]、X线照射量[600(492,939)m Gy比840(624,1294)m Gy,P=0.010]及对比剂用量[(227±46)ml比(260±87)ml,P=0.031]均显著低于非计划旋磨组,差异均有统计学意义。计划旋磨组手术即刻成功率显著高于非计划旋磨组(100.0%比85.7%,P=0.001)。术中相关并发症以慢血流、慢心率为主,虽然计划旋磨组并发症发生率(5.4%)低于非计划旋磨组(9.5%),但差异无统计学意义(P=0.493)。结论对于冠状动脉严重钙化病变,应积极应用IVUS和OCT等腔内影像学进行评估,并采取计划旋磨治疗,提高手术成功率,降低手术时间、X线照射量及对比剂用量。     

冠状动脉斑块旋磨术治疗冠状动脉弥漫钙化病变的长期安全性及有效性

目的 评估冠状动脉斑块旋磨术治疗冠状动脉弥漫钙化病变的长期安全性及有效性。方法 连续纳入2015年1月至2020年12月于北京大学人民医院因重度钙化病变行冠状动脉斑块旋磨术并符合研究入选标准的188例患者。根据旋磨靶病变长度分为弥漫病变（≥25 mm）旋磨组（98例）和标签内旋磨组（90例）,比较两组患者旋磨术中并发症（C型以上冠状动脉夹层、慢血流/无复流、冠状动脉破裂、旋磨导丝断裂、旋磨头嵌顿）、住院期间主要不良心血管事件（全因死亡、经皮冠状动脉介入治疗相关心肌梗死、靶血管再次血运重建、急性/亚急性支架内血栓形成）及随访期间主要不良心血管事件（全因死亡、非致死性心肌梗死、靶血管再次血运重建、支架内血栓形成）的发生率。结果 两组患者临床基线资料匹配,差异无统计学意义（均P>0.05）。弥漫病变旋磨组旋磨术中并发症发生率高于标签内旋磨组（7.1%比3.3%,P=0.247）,尤其是慢血流/无复流的发生率（5.1%比1.1%,P=0.121）,但差异均无统计学意义。两组患者住院期间主要不良心血管事件发生率的差异无统计学意义（7.8%比11.2%,P=0.923）,平均随访33.4个月...     

老年冠状动脉钙化患者冠状动脉旋磨术中并发症及术后短期主要不良心血管事件的影响因素

目的 探讨老年冠状动脉钙化(CAC)患者冠状动脉旋磨(RA)术中并发症及术后短期(12个月内)主要不良心血管事件(MACE)的影响因素。方法 收集2017年1月至2020年12月于宜宾市第三人民医院行RA的老年CAC患者188例,参照《冠状动脉内旋磨术中国专家共识》进行手术,随访术后12个月内MACE发生情况,按照12个月内是否发生MACE分为试验组和对照组。采用SPSS 25.0软件进行统计分析。根据数据类型组间比较采用t检验或χ²检验。采用多因素logistic回归分析术中并发症和术后12个月内MACE的影响因素。结果 术中并发症和术后12个月内MACE的发生率分别为17.02%(32/188)和18.62%(35/188),发生术中并发症组和未发生术中并发症组患者体质量指数、吸烟史、心力衰竭史、高血压史、既往心肌梗死史、病变血管、SYNTAX评分、凝血酶原时间、糖化血红蛋白(HbA1c)、最小管腔直径(MLD)、管腔横切面积和旋磨头血管内径比比较,差异均有统计学意义(P<0.05)。多因素分析显示：心力衰竭史、病变血管(双支、三支、左主干支相对于单支)...     

冠状动脉介入术后血流与靶血管直径相关

目的:评价冠状动脉支架术后血流与血管直径的相关性。方法:对192例行冠状动脉介入(PCI)治疗患者的224支靶血管进行定量冠状动脉造影(QCA)分析和术前术后TIMI帧数分析。术前术后TIMI帧数差值进行三分位数分组,≤2为"慢血流组",3~9为"正常血流组",≥10为"快血流组"。同时根据参考血管直径分成大血管组(≥4 mm)、正常血管组(2.76~4.0 mm)、小血管组(≤2.75 mm)。对3组的冠状动脉病变特征和基线资料进行比较。比较不同直径血管的病变特征。对术后血流的相关危险因素进行多元线性回归分析。结果:慢血流组、正常血流组和快血流组患者靶血管参考血管直径分别为(3.4±0.7)mm、(3.2±0.7)mm和(3.2±0.7)mm,P0.05。大血管在慢血流组、正常血流组和快血流组的比率分别为29%(23/78)、10%(8/80)和14%(9/66),P0.01。≥4 mm血管组和4 mm血管组的斑块面积分别为(23±11)mm2和(15±8)mm2,P0.01。多元回归分析PCI术后血流状态的危险因素为年龄(P0.05)和参考血管直径(P0.01)。结论:PCI术后血流与冠状动脉血管直径相关。血管直径越大发生介入术后慢血流的几率越高。     

成角近段旋磨对严重钙化成角冠状动脉病变的治疗价值

目的:在严重钙化成角冠状动脉(冠脉)病变患者中,对比成角近段旋磨和全程旋磨的手术成功率、术中并发症及临床预后,评估成角近段旋磨对该类病变的治疗价值。方法:连续纳入我院2017年1月至2019年12月接受冠脉旋磨介入治疗且冠脉均存在严重钙化伴成角(≥45°)的患者共245例,依据旋磨手术策略分为全程旋磨组(n=179)和成角近段旋磨组(n=66)。比较两组手术成功率和术中并发症发生率,观察两组患者的临床转归,观察终点包括院内和1年主要不良心血管事件(MACE,包括心原性死亡、靶血管再次血运重建、支架内血栓)发生率。结果:成角近段旋磨组的手术成功率为97.0%,2例(3.0%)患者因术中球囊无法扩张而最终转换为全程旋磨;全程旋磨组的手术成功率为99.4%,1例(0.6%)患者因冠脉穿孔导致手术失败而行急诊冠脉旁路移植术。全程旋磨组发生旋磨头嵌顿和心包填塞各2例(1.1%)、冠脉穿孔4例(2.2%),而成角近段旋磨组未出现这些严重并发症;两组术中慢血流/无复流的发生率差异无统计学意义(P>0.05),但全程旋磨组术中冠脉夹层的发生率显著高于成角近段旋磨组(43.6%vs.19.7%,P<0.05)。两组的院内总MACE发生率相当,但全程旋磨组1年MACE发生率明显高于成角近段旋磨组(27.4%vs.13.6%,P<0.05)。结论:对于严重钙化伴成角的冠脉病变,成角近段旋磨联合球囊扩张的手术成功率和临床转归与全程旋磨相似,而术中并发症尤其严重并发症的发生风险明显低于后者,说明仅采用成角近段旋磨治疗此类病变是安全和有效的。     

成角近段旋磨对严重钙化成角冠状动脉病变的治疗价值

目的:在严重钙化成角冠状动脉(冠脉)病变患者中,对比成角近段旋磨和全程旋磨的手术成功率、术中并发症及临床预后,评估成角近段旋磨对该类病变的治疗价值。方法:连续纳入我院2017年1月至2019年12月接受冠脉旋磨介入治疗且冠脉均存在严重钙化伴成角(≥45°)的患者共245例,依据旋磨手术策略分为全程旋磨组(n=179)和成角近段旋磨组(n=66)。比较两组手术成功率和术中并发症发生率,观察两组患者的临床转归,观察终点包括院内和1年主要不良心血管事件(MACE,包括心原性死亡、靶血管再次血运重建、支架内血栓)发生率。结果:成角近段旋磨组的手术成功率为97.0%,2例(3.0%)患者因术中球囊无法扩张而最终转换为全程旋磨;全程旋磨组的手术成功率为99.4%,1例(0.6%)患者因冠脉穿孔导致手术失败而行急诊冠脉旁路移植术。全程旋磨组发生旋磨头嵌顿和心包填塞各2例(1.1%)、冠脉穿孔4例(2.2%),而成角近段旋磨组未出现这些严重并发症;两组术中慢血流/无复流的发生率差异无统计学意义(P>0.05),但全程旋磨组术中冠脉夹层的发生率显著高于成角近段旋磨组(43.6%vs.19.7%,P<0.05)。两组的院内总MACE发生率相当,但全程旋磨组1年MACE发生率明显高于成角近段旋磨组(27.4%vs.13.6%,P<0.05)。结论:对于严重钙化伴成角的冠脉病变,成角近段旋磨联合球囊扩张的手术成功率和临床转归与全程旋磨相似,而术中并发症尤其严重并发症的发生风险明显低于后者,说明仅采用成角近段旋磨治疗此类病变是安全和有效的。     

冠状动脉内旋磨治疗失败患者的临床及病变特征分析

目的 探讨行冠状动脉内旋磨术（RA）失败患者的临床及病变特征。方法 回顾性分析复旦大学附属中山医院2015年3月至2019年12月558例因冠状动脉严重狭窄合并冠状动脉钙化行RA患者,结果发现14例治疗失败,对其临床资料及病变特点进行分析。结果 14例RA失败患者的平均年龄（69.9±10.3）岁,平均身体质量指数（BMI,22.78±3.17）kg/m2,男10例（10/14）,合并高血压病8例（8/14）、糖尿病9例（9/14）、吸烟6例（6/14）;以多支血管病变为主,靶血管左前降支病变10例（10/14）、慢性闭塞病变7例（7/14）,病变钙化角度>90o12例（12/14）,RA类型以补救性旋磨为主11例（11/14）;手术失败直接原因包括微导管不能通过旋磨导丝交换失败8例（8/14）,旋磨头不能通过病变3例（3/14）,术中合并严重并发症而终止手术3例（3/14）。结论 RA治疗失败的直接原因主要为旋磨导丝交换失败、旋磨头通过失败以及术中合并严重并发症,钙化合并严重狭窄、迂曲成角及低BMI可能是旋磨失败的预测因素。     

冠状动脉旋磨术联合药物洗脱支架治疗冠状动脉严重钙化病变的临床研究

目的:评价冠状动脉旋磨术(rotational atherectomy,ROTA)联合药物洗脱支架(drug eluting stent,DES)治疗冠状动脉严重钙化病变的疗效及中期随访结果。方法:对2009-01至2011-02连续的24例冠心病患者严重钙化病变行ROTA加DES治疗,其中经股动脉路径14例,经桡动脉路径10例,观察其旋磨特点、即刻造影成功率、临床成功率、院内事件发生率和平均随访12个月(6～24个月)的结果。结果:行ROTA的患者均为美国心脏病学会/美国心脏病协会(AHA/ACC)B2/C型严重钙化病变。旋磨头均成功通过狭窄病变,并完成DES置入术,91.7%(22/24)的病例最后使用≤1.5 mm旋磨头通过钙化病变,总成功率为100%,术中仅1例发生慢血流和心动过缓,院内无非Q波心肌梗死发生,无冠状动脉穿孔、急诊冠脉旁路移植术及死亡发生。随访期间无主要心脏不良事件(MACE)。结论:选用直径较小的旋磨头改变钙化病变的血管的顺应性后,可以顺利完成DES植入术,中期效果满意。     

The immunoneuroendocrine role of melatonin

Abstract: A tight, physiological link between the pineal gland and the immune system is emerging from a series of experimental studies. This link might reflect the evolutionary connection between self-recognition and reproduction. Pinealectomy or other experimental methods which inhibit melatonin synthesis and secretion induce a state of immunodepression which is counteracted by melatonin. In general, melatonin seems to have an immunoenhancing effect that is particularly apparent in immunodepressive states. The negative effect of acute stress or immunosuppressive pharmacological treatments on various immune parameters are counteracted by melatonin. It seems important to note that one of the main targets of melatonin is the thymus, i.e., the central organ of the immune system. The clinical use of melatonin as an immunotherapeutic agent seems promising in primary and secondary immunodeficiencies as well as in cancer immunotherapy. The immunoenhancing action of melatonin seems to be mediated by T-helper cell-derived opioid peptides as well as by lymphokines and, perhaps, by pituitary hormones. Melatonin-induced-immuno-opioids (MHO) and lymphokines imply the presence of specific binding sites or melatonin receptors on cells of the immune system. On the other hand, lymphokines such as -γ-interferon and interleukin-2 as well as thymic hormones can modulate the synthesis of melatonin in the pineal gland. The pineal gland might thus be viewed as the crux of a sophisticated immunoneuroendocrine network which functions as an unconscious, diffuse sensory organ.     

Changes in connexin43, the gap junction protein of astrocytes, during development of the rat pineal gland

Abstract: The abundance of gap junctions between rat pineal astrocytes formed by connexin43 (Cx43) was studied during development. Levels and distribution of Cx43 were measured by immunoblotting and indirect immunofluorescence, respectively. The amount of Cx43 in cells located within the gland was low until about the 7th postnatal day and increased to adult values between the 14th and 21st days postpartum. Although astrocytes, recognized by their vimentin immunoreactivity, were scarce before birth, they were abundant by the 7th postnatal day suggesting that the low levels of Cx43 found at this age corresponded to a low expression of this protein. Localization of the immunoreactivity to Cx43 and vimentin showed a close correlation, indicating that mature or immature pineal astrocytes form gap junctions made of Cx43. Since Cx43 levels attained their adult values at about the time the innervation and the functional state of the gland reached maturity (2–3 weeks after birth), it is proposed that astrocyte gap junctions are involved in the function of the adult rat pineal gland.     

Conservative management of perforated duodenal diverticulum： A case report and review of the literature

Duodenal diverticula are a relatively common condition. They are asymptomatic, unless they become complicated, with perforation being the rarest but most severe complication. Surgical treatment is the most frequently performed approach. We report the case of a patient with a perforated duodenal diverticulum, which was diagnosed early and treated conservatively with antibiotics and percutaneous drainage of secondary retroperitoneal abscesses. We suggest this method could be an acceptable option for the management of similar cases, provided that the patient is in good general condition and without septic signs.     

Response of rat pineal melatonin to calcium, magnesium, and lithium is circadian stage dependent

Abstract: Herein we documented the response of pineal melatonin production to electrolytes known to be effective on pineal function in view of a possible circadian stage dependence. We studied the release of melatonin by perifused rat pineal glands at 2 different circadian stages corresponding to the middle of the light and dark periods, i.e., respectively, 7 and 19 HALO (Hours After Light Onset, L:D = 12:12). The initial efflux rates were, as expected, much higher in the perifusates of glands removed from rats sacrificed during the dark phase than of those removed during the light phase. After 3 hr of perifusion, melatonin release reached similar levels which were found constant up to the 8th hr of perifusion, whatever the circadian stage. Perifusion of the glands with physiological concentrations for the rat of calcium (5.2 mmol/1) and magnesium (1.34 mmol/1) resulted in a stimulatory effect on the pineal glands removed from rats sacrificed in the middle of the dark period (19 HALO), whereas no effects were observed on the pineal glands removed from rats sacrificed during the light (7 HALO). Lithium (0.28 and 0.55 mmol/1) was ineffective on melatonin release in pineal glands removed 7 and 19 HALO. Our results show differences in the initial efflux rates of melatonin and in the response of perifused pineal glands to calcium and magnesium according to the circadian stage.     

Presence of immunoreactive growth hormone and prolactin in the ovine pineal gland

Abstract: The use of antisera raised against bovine growth hormone (GH) and ovine prolactin (PRL) enabled the detection of related immunoreactive (ir) sequences of proteins in ovine pineal tissue. The isolation of PRL-like ir-material was accomplished using a 0.25 M ammonium sulphate (pH 5.5) extraction followed by ethanol precipitation, whereas the resulting 2.0 M ammonium sulphate (pH 7.0) precipitate contained a GH-like immunoreactivity. Gel chromatography of the GH-like immunoreactivity (Sephadex G-100) indicated the presence of several GH-like fragments ranging in the M_r range of 7,000 to 55,000. Analyses of the PRL-like ir-material found in pineal tissue on HPLC using a TSK 545-DEAE column led to the resolution into a single peak of immunoreactivity. A single peak of activity was also observed following chromatofocusing and hydrophobic interaction chromatography of the ir-peak from the TSK 545-DEAE column. The PRL-like ir-material inhibited the binding of [¹²⁵I]ovine PRL-S14 to anti-ovine PRL antibodies without showing an affinity for binding to anti-rat PRL or anti-bovine GH antibodies. Scatchard analysis of the binding of pineal PRL-like ir-material and pituitary ovine PRL-S14 to liver membranes from day-20 pregnant rats revealed similar affinity constants (K_a of 4.7 ± 0.2 × 10⁹ M^-1). In addition, the replication of Nb 2 Node rat lymphoma cells was stimulated by pineal PRL-like ir-material, an effect known to be specific for lactogenic hormones. The pineal PRL-like immunoreactivity appeared on sodium dodecyl sulfate polyacrylamide gels as a single major band of M_r 24,000. The functional status of PRL-and GH-like ir-material in the ovine pineal remains to be determined, but evidence is presented that the overall protein synthesis rate of the rat pineal responded to circulating concentrations of PRL.     

Microbiology of human immunodeficiency virus anorectal disease

PURPOSE: Individuals who are seropositive for the human immunodeficiency virus are at high risk for opportunistic infection and anorectal disorders. Little prospective information is available regarding anorectal pathogens in these patients. METHODS: One hundred sixty-three HIV-seropositive patients presented to the colorectal clinic between 1989 and 1992. Forty-seven (29 percent) patients were thought to have an infectious process and were prospectively studied using a standardized multiculture protocol. RESULTS: Mean age was 33 (range, 19–59) years. All were male; high-risk behavior accounted for 87 percent of HIV transmissions. Presenting complaints included anorectal pain (79 percent), pus per anum (28 percent), and blood per anum (26 percent). Examination revealed perianal tenderness (60 percent), condyloma (38 percent), perianal ulcers (38 percent), and anal fissures (34 percent). Sixty-six sets of cultures were performed; 28 patients had one set, 15 had two sets, and 4 had three sets. Thirty-two of these 47 patients (68 percent) had positive cultures including herpes (50 percent), cytomegalovirus (25 percent),Neisseria gonorrhoeae (16 percent), chlamydia (16 percent), acidfast bacilli (2 percent), and others (9 percent). Six of 32 patients with positive cultures had more than one organism cultured. Sixteen (50 percent) patients with positive cultures were treated medically, 8 (25 percent) were treated surgically and 8 (25 percent) were treated with both modalities. Sixty-one procedures were performed on 17 patients for condylomata. Eighteen patients had 20 procedures for abscesses, 50 percent of whom had positive cultures for other than common bowel flora; all improved. Fourteen patients underwent 33 procedures for perianal fistulas.Mycobacterium fortuitum was cultured from one patient who required 13 procedures for abscesses and fistulas. Forty-five (96 percent) patients were followed for an average of 12.5 months ±2.9 SEM (range, 1–94 months). Symptoms were improved or resolved in 22 of 32 (69 percent) patients with positive cultures and in 11 of 13 (84 percent) with negative cultures. CONCLUSIONS: Specific pathogens may often be identified in human immunodeficiency virus-seropositive patients with anorectal disorders if aggressively sought. Although patients without specific pathogens identified may be expected to improve with planned empiric treatment, positive identification allows more directed therapy.