急诊快速诊断不典型急性主动脉夹层的临床结果分析

背景　急性主动脉夹层（AAD）临床上少见,如未及时发现将出现致命危险。以胸背部剧烈疼痛伴高危病史及体征的典型AAD不易被误诊和漏诊,而以不典型临床表现的AAD患者,极易被临床误诊或漏诊,因此,对不典型AAD的诊断研究日益凸显其重要性。目的 总结急诊快速诊断不典型AAD的诊治流程,并观察该流程对患者确诊时间及急诊科滞留时间的改善情况。方法　收集2012年1月—2018年12月由马鞍山市人民医院急诊科确诊和误诊的符合纳入标准的91例典型和不典型AAD患者的临床资料。依据临床表现和最终诊断结果将患者分为典型AAD组51例和不典型AAD组40例;再根据入院时间不同将不典型AAD组分为对照亚组（2012年1月—2015年12月入院）24例和观察亚组（2016年1月—2018年12月入院）16例。急诊诊断流程：自2012年发现并确诊第1例不典型AAD患者后不断探索和改进该类患者的急诊诊断流程。2016年前,由于对不典型AAD尚处于认识不充分阶段,并没有对疑似不典型AAD患者同时进行常规检查（血常规、C反应蛋白、心电图、肝肾功能、血电解质、血尿淀粉酶、凝血四项、心肌酶和肌钙蛋白I）和D-二聚体及必要时的CT检查,经过多年总结与深入学习主动脉疾病相关知识,并结合相关文献,逐渐加深对不典型AAD的认识,形成修改后的急诊流程,即上述检查同时进行,并对高度疑似患者、经CT平扫不能确诊的不典型AAD患者及时给予主动脉CT血管造影（CTA）检查。记录患者的一般资料、漏诊情况、误诊情况、确诊时间、急诊科滞留时间、转归情况,并进行比较。结果　典型AAD组、对照亚组、观察亚组患者性别（χ2=0.024,P=0.989）、年龄（F=2.594,P=0.080）比较,差异无统计学意义。急诊科诊断时,对照亚组和观察亚组各误诊1例患者,典型AAD组误诊5例。典型AAD组于急诊诊断正确的46例患者,其确诊时间为（27.6±16.8）min;对照亚组于急诊诊断正确的23例患者的确诊时间为（38.8±21.6）min;观察亚组于急诊诊断正确的15例患者的确诊时间为（19.1±7.4）min。三组于急诊诊断正确的患者的确诊时间比较,差异有统计学意义（F=6.180,P=0.003）。典型AAD组患者不存在急诊科滞留时间;对照亚组患者急诊科滞留时间为3.4（8.9）h,长于观察亚组的1.5（1.0）h（Z=-3.875,P<0.001）。91例AAD患者中,77例转至上级医院,11例在本院予药物治疗,1例在本院给予支架植入治疗,2例典型AAD患者死亡（均在确诊后的1 h内死亡）。结论　对有不典型症状的疑似不典型AAD患者,应尽可能在患者首次检查时考虑同时给予D-二聚体和CT及必要的CTA检查;加强一线临床医生对不典型AAD各种临床症状和影像学征象的学习,规范科室对不典型AAD的诊断流程,从而提高该类患者的诊断正确率,为其进一步救治赢得时间。     

细胞外组蛋白对ARDS早期诊断和预后评估的临床价值

目的 探究细胞外组蛋白对急性呼吸窘迫综合征（acute respiratory distress syndrome, ARDS）早期诊断和预后评估的临床价值。方法 选择2017年1月—2018年6月同济大学附属上海市肺科医院和北京市朝阳医院急诊重症监护病房（emergency intensive care unit, EICU）收治的ARDS患者67例,并以15名健康志愿者作为健康对照组。根据28d转归情况将ARDS患者分为生存组（38例）和死亡组（29例）。测定ARDS患者血清中细胞外组蛋白的水平,比较细胞外组蛋白在健康对照组和ARDS患者中的差异以及细胞外组蛋白与ARDS患者预后的相关性;受试者工作特征曲线（ROC）分析细胞外组蛋白对ARDS早期诊断及预后评估的价值。结果 和对照组相比,ARDS患者的血清细胞外组蛋白水平明显升高（P<0.0001）,且与患者的预后密切相关（P<0.01）。ROC曲线显示细胞外组蛋白（1d）对于ARDS的早期诊断的AUC为0.8985,细胞外组蛋白（3d）对于判断ARDS患者预后的AUC为0.8154。结论 细胞外组蛋白水平对ARDS的早期诊断和预后评估具有重要参考临床价值。     

急性主动脉夹层诊治流程中的护理策略

目的：探讨急性主动脉夹层（AAD）早期诊断与救治流程中的护理策略。方法：分析江阴市人民医院2010年1月至2014年12月收治的56例急性主动脉夹层患者的临床资料，将其分为传统组和协定流程组，比较两组患者急诊滞留时间及急诊救治有效率的差异。结果：协定流程组患者急诊滞留时间明显短于传统组（1．53±0．61 vs 2．56±0．73）h，差异具有统计学意义（P ＜0．01）。协定流程组急诊救治有效率92．31％（24／26）高于传统组66．67％（20／30），差异具有统计学意义（P ＜0．05）。结论：制定多科协作诊治流程，应用早预警、早诊断、有效处理的护理策略，能提高救治AAD 的时效性。     

急性冠脉综合征的早期诊断及处理

目的 探讨急性冠脉综合症的早期诊断与处理方法.方法 急性冠状动脉综合征的患者建立急诊诊治的绿色通道,建立胸痛中心,对不同的病情采取不同的诊治措施,及早识别、及时诊断、危险评估、早期干预、有效的治疗手段、个体化治疗方案,将有利于降低不良的心血管事件发生,改善患者的远期预后.在急诊诊疗中要及时做出危险分层与危险评估,规范治疗与选择正确治疗方法,个体化治疗原则与合理有效的治疗措施非常重要和必要的.     

血浆D-二聚体水平对伴腹痛急性主动脉夹层的诊断价值

目的探讨血浆D-二聚体（D-dimer）在急诊鉴别诊断伴腹痛急性主动脉夹层（AAD）中的临床价值。方法选取伴腹痛的ADD患者（ADD组）、急性胰腺炎患者（胰腺炎组）及其他外科急腹症患者（急腹症组）各22例,检测血浆D-二聚体水平并进行比较。结果 AAD组的血浆D-二聚体水平（5678±459ng/ml）明显高于胰腺炎组（987±235ng/ml）和急腹症组（673±104ng/ml）（P〈0.01）。结论血浆D-二聚体水平有助于伴腹痛AAD患者的诊断。     

120例高血压性脑出血患者的急诊救治疗效分析

目的：探讨高血压性脑出血患者急诊救治的临床疗效。方法：回顾性分析笔者所在科室2004年3月～2009年3月收治的120例高血压性脑出血患者急诊救治的临床资料,并跟踪最终治疗效果。结果：120例患者均安全转送神经内科进一步检查治疗,其中恢复良好78例（65%）,死亡18例（15%）,致残6例（5%）,植物状态18例（15%）。结论：规范及时的急诊救治能显著降低患者的病死率和致残率,为后期进一步治疗奠定基础。早期正确处理能改善患者的预后,早期应控制血压、降低颅内压。     

整肠生治疗抗菌药物相关性腹泻临床观察

目的观察整肠生对抗菌药物相关性腹泻（AAD）的治疗效果及安全性。方法将60例抗菌药物相关性腹泻患者随机分为治疗组和对照组各30例,对照组给予营养支持治疗,治疗组在营养支持等综合治疗基础上加用整肠生。治疗2周后,对2组疗效、不良反应进行对比、分析。结果治疗组总体疗效评估明显优于对照组,差异有显著性（P〈0.05）,未发现明显不良反应。结论整肠生能显著改善AAD患者的临床症状并缩短病程,安全可靠,是治疗AAD较理想的药物。     

改良早期预警评分与国家早期预警评分对老年急诊患者病情评估的比较

目的 利用改良早期预警评分（MEWS）和国家早期预警评分（NEWS）对老年急诊患者进行病情评估,比较其应用价值,探讨更适合老年急诊患者的评分方法。方法 收集2013年10月-2014年3月中国人民解放军总医院急诊科抢救室收治的老年患者（≥60岁）361例,根据其实际转归情况,分为普通病房组和监护病房组;并以30d为终点观察患者预后,分为死亡组和存活组。对患者均进行NEWS和MEWS评估,使用ROC曲线比较两种评分方法预测老年急诊患者转归和预后的能力。结果 普通病房组239例,监护病房组122例。监护病房组NEWS、MEWS、呼吸频率、心率均高于普通病房组,血氧饱和度低于普通病房组（P＜0.01）。NEWS与MEWS评估老年急诊患者转归的ROC曲线下面积分别为（0.970±0.011）和（0.831±0.025）,两者比较,差异有统计学意义（Z=6.950,P＜0.010）。观察终点30d时,存活组323例,死亡组38例。死亡组NEWS、MEWS、呼吸频率、心率均高于存活组,血氧饱和度低于存活组（P＜0.05）。NEWS与MEWS评估老年急诊患者30d预后的ROC曲线下面积为（0.861±0.039）和（0.789±0.045）,两者比较,差异有统计学意义（Z=2.250,P=0.023）。结论 NEWS可更准确、有效反映老年急诊患者呼吸和心率的实际情况,与MEWS评分比较,更适合评估老年急重症患者的转归和预后。     

心脏标志物在急性期心肌梗死的临床意义

急性心肌梗死（AMI）是急性心肌缺血性坏死的严重类型的冠心病.近几年,随着溶栓治疗,急性经皮冠脉腔内球囊成形术（PTCA）以及急诊冠脉旁路移植术（CABG）的广泛应用,使得早期诊断显得尤为重要.现常用的3种快速床边检测血清酶学指标可及时准确的诊断急性心肌梗死.通过2007年NACB（美国临床生化科学院）医疗实践指南就ACS（急性冠脉综合征）生化标志物的临床特性和应用,提出以下指导性建议,有助于早期发现AMI,及时检测病情的变化,评估患者的预后.     

脓毒症性急性肾损伤诊断和预后评估相关生物标志物的研究进展

急性肾损伤（AKI）是由多种病因导致并涉及多个临床学科的临床症候群。脓毒症致多脏器衰竭是引起AKI的重要原因之一,同时AKI也导致脓毒症患者病死率显著增加,究其原因是临床对AKI干预措施的滞后。通过相关生物标志物早期诊断脓毒症性AKI（SIAKI）,并及时完成预后评估是改善患者预后的关键。随着对SIAKI发生机制的不断深入,多种新的生物标志物不断发现,其在AKI发生及发展中的作用及对治疗、预后的指导价值逐渐阐明。本文对SIAKI的发生机制进行了探讨,并介绍了对SIAKI早期诊断和预后评估具有潜在价值的生物标志物。     

Value of D-Dimers in patients with acute aortic dissection

Objective: To evaluatel the value of D-dimers in patients with acute aortic dissection (AAD). Methods: This study consisted of 16 patients with AAD and 27 non-AAD patients. Serum D-dimets were measured by Sta-Liatest D-DI immunoturbidimetric assay. Results: D-dimer level was higher (P ＜ 0.001) in patients with AAD(7.91 ± 5.52 μg/ml) than that in non- AAD group(1.57±1.24 μg/ml). D-dimer was positive (＞0.4 μg/ml) in all patients with AAD and in 10 control group patients (37%). Among patients with acute AAD, D-dimers tended to be higher in Stanford A than in Stanford B (8.67 ± 4.31 μg/ml vs. 3.24±1.27 μg/ml, P ＜0.01). D-dimer values tended to be higher in more extended disease(3.84 ± 1.65 μg/ml, 8.57 ± 3.58 μg/ml and 11.87 ± 5.69 μg/ml in thoracic aorta, thoracic and abdominal aorta, thoracic and abdominal aorta and iliacal arteries, respectively, P ＜ 0.05 for both 8.57 ± 3.58 and 11.87 ± 5.69 vs. 3.84 ± 1.65 ). Including the control group into the analysis, we found a sensitivity of 100%, a negative predictive value of 100%, and a specificity of 66% and a positive predictive value of 64% for D-dimer in diagnosis of AAD in our patients with suspected AAD. Conclusion: D-dimer was elevated in patients with AAD. A negative D-dimer test result could be useful in excluding AAD.     

Research of combined liver-kidney transplantation model in rats

Objective： To set up a simple and reliable rat model of combined liver-kidney transplantation. Methods： SD rats served as both donors and recipients. 4℃ sodium lactate Ringer＇s was infused from portal veins to donated livers,and from abdominal aorta to donated kidneys, respectively. Anastomosis of the portal vein and the inferior vena cava （IVC） inferior to the right kidney between the graft and the recipient was performed by a double cuff method, then the superior hepatic vena cava with suture. A patch of donated renal artery was anastomosed to the recipient abdominal aorta. The urethra and bile duct were reconstructed with a simple inside bracket. Results： Among 65 cases of combined liver-kidney transplantation, the success rate in the late 40 cases was 77.5%. The function of the grafted liver and kidney remained normal. Conclusion： This rat model of combined liver-kidney transplantation can be established in common laboratory conditions with high success rate and meet the needs of renal transplantation experiment.     

BLOOD PRESSURE CHANGE WITH AGE IN SALT-SENSITIVE TEENAGERS

Objective To observe blood pressure change with age in salt-sensitive teenagers whose salt sensitivity were determined by repeated testing.Methods Salt sensitivity was determined through intravenous infusion of normal saline combined with volume-depletion by oral diuretic furosemide in 55 teenagers. After five years, salt sensitivity was re-examined and subject blood pressure was followed up. Blood pressure changes in salt-sensitive teenagers were compared to that of non-salt sensitive teenagers over five years.Results After 5 years, the repetition rate of salt sensitivity determined by intravenous saline loading is 92.7%. In teenagers with salt sensitivity on the baseline, both the systolic blood pressure increments and increment rates were much higher than non-salt sensitive teenagers (12.7±12.1 mmHg vs. 2.8±5.2 mmHg, P＜ 0.01; 12.2%± 12.0% vs. 2.5% ±4.4%, P＜ 0.001,respectively). There was a similar trend for diastolic blood pressure (8.4 ± 6.4 mmHg vs. 3.7 ± 6.4 mmHg, P = 0.052; 13.2% ±10.6 % vs. 6.8%± 10.1%, P = 0.053, respectively).Conclusions Salt sensitivity determined by intravenous saline loading showed good reproducibility. Blood pressure increments with age were much higher in salt-sensitive teenagers than non-salt sensitive teenagers, especially in terms of systolic blood pressure.     

安心颗粒对急诊经皮冠状动脉介入术后生活质量影响的研究

目的：评价使用安心颗粒对急诊经皮冠状动脉介入术（PPCI）术后生活质量的影响.方法：将160例接受PPCI的急性ST段抬高型心肌梗死患者随机分为安心颗粒组（术前顿服安心颗粒8.8g,术后安心颗粒4.4 g/次,每日2次）和对照组（仅接受基础药物治疗）.所有患者均服用阿司匹林、氯吡格雷和阿托伐他汀.分别在入院时、出院前1d、出院后180 d时,应用心肌梗死多维度量表（MIDAS）、中文版SF-36评价量表对患者生活质量评分.并观察术后30 d以内的出血并发症、血小板减少症发生情况.结果：入院时和出院前1d,两组患者的心肌梗死MIDAS、SF-36量表评分比较无差异（P＞0.05）;出院后180 d时,与对照组比较,安心颗粒组MIDAS、SF-36评分明显减低（P＜0.05）;组内与入院时比较,两组出院前1d、出院后180 d时,MIDAS、SF-36评分均降低（P＜0.05）.两组患者在随访期间均无大量出血、少量出血、重度和极重度血小板减少症发生,安心颗粒组有4例、对照组有7例发生不明显出血（P＞0.05）.两组发生轻度血小板减少症的患者数比较无差异（P＞0.05）.结论：PPCI使用安心颗粒,能改善急性ST段抬高型心肌梗死患者的生活质量,且不增加出血风险.     

The comparative studies of the influences of Urapidil and Nicardipine on sino-atrial node function, atrio-ventricular node function and hemodynamics

Objective:To investigate the influences of urapidil and nicardipine on rabbit sinus function,atrio-ventricular node function and hemodynamics.Methods:Thirty-two Angora's rabbits were selected and randomly divided into four groups.U1 group:urapidil 0.25 mg/kg;U2 group:urapidil 0.5 mg/kg;N1 group:nicardipine 10 μg/kg;N2 group:nicardipine 20 μg/kg.All these medicine were administrated within 30 seconds.Measurements were taken before and after the administration of urapidil or nicardipine for the following data:mean blood pressure(MAP),heart rate(HR),sino-atrial conduction time(SACT),maximal sinoatrial recovery time(SNRTmax)corrected sinus node recovery time(CSNRT),index of sinus node recovery time(SNRTI),Wenckebach A-V conduction frequency (WB),and P-R interval.Results:Significant MAP and HR changes were identified in all of the four groups before and after administration of both urapidil and nicardipine.No significant changes could be found in the rest of the parameters.Intergroup analysis showed that SACT and CSNRT of N1 and N2 groups were shorter than those of the U2 group(P＜0.01);the MAP decreased(P＜0.01)and the HR increased drastically(P＜0.01).Conclusions:Neither urapidil(0.25 mg/kg,0.5 mg/kg)nor nicardipine(10μg/kg,20μg/kg)has any significant influence on rabbit sinus function or rabbit atrio-ventricular node function.Nicardipine could be a better choice than urapidil for parafunctional sinus node patients.     

Expression of OPGmRNA and ODFmRNA in the patients of hip fracture due to osteoporosis

Objective：To investigate the gene expression of osteoprotegerin（OPG） and osteoclast differentiation factor（ODF） in the bone tissue of patients with hip fracture due to osteoporosis. Methods：OPGmRNA and ODFmRNA in the bone tissue in 50 cases of osteoporosis sufferers（over 50 years old） with hip fracture（Observer Group） and 30 cases of hip facture sufferers with no osteoporosis（Control group） were analyzed with the Semi-Quantitative RT-PCR method. Results：The mRNA expressed of ODF, OPG were both high in the patients with hip fracture. In the control group, the expression of OPG mRNA was observed, while the expression of ODF mRNA was very slight. Conclusion：Aged patients contained all signals including OPG, ODF that are essential for inducing osteoclastogenesis and promoting bone resorption.     

Dynamic Changes in Serum Estradiol and Progesterone levels in Patients of Premenstrual Syndrome with Adverse Flow of Liver-qi

Objective:To probe into the influence of changes of ovarian hormones on the pathogenesis of the specific sub-type premenstrual syndrome(PMS)and reveal partial microcosmic mechanisms of adverse flow of liver-qi.Methods:Estradiol(E2)and progesterone(P)levels in serum were determined at different phases of menstrual cycle by radioimmunoassay.Results:In the group of PMS with adverse flow of liver-qi.the secretive peak value Of E2 and P at the follicular phase significantly decreased,and the secretive peak value at the luteal phase did not come into being.Conclusions:Low E2 and P secretive peak at the follicular phase and absence of secretive peak at the luteal phase is one of the microcosmic mechanisms of PMS with adverse flow of liver-qi.One of the pathophysiologic mechanisms of specific sub-type PMS is probably the continuous low level of E2and P.     

Real-time Three-dimensional Echocardiography in Assessment of Left Ventricular and Right Ventricular Volumes

Real-time three-dimensional echocardiography (RT3DE)is a new ultrasound technique that enables dynamic threedimensional visualization and quantification of the heart in real time. Investigation of feasibility and methodology of RT3DE in determining left ventricular (LV) and right ventricular (RV) volumes, RT3DE was performed in 35 normal adults using Philips SONOS 7500 system with a 2-4 MHz matrix array transducer. The 60°×60° "pyramid" volume database was obtained and analyzed on a TomTec echo workstation. Both LV and RV volumes were calculated with four 3DE methods (i.e. apical 2, 4, 8, and 16-plane) through manually tracing ventricular endocardial borders in end diastole and end systole. Stroke volumes were then calculated. LV volume was also measured by 2DE Simpson's rule using GE VIVID 7 ultrasound machine.     

SCREENING FOR A 21-CHROMOSOME ABNORMALITY IN PREIMPLANTED EMBRYOS OF ELDERLY WOMEN

Increasing maternal age is the only etiological factor unequivocally linked to Down's syndrome in humans. The occurrence rate of newborns with Down's syndrome is about 1/220 in women over 35 years old. However, the occurrence rate in embryos fertilized in vitro, of the elder woman is unclear. Using FISH we screened the number of chromosome 21 in preimplanted embryos of 5 elderly women (average age, 38.4 years) to study the feasibility and necessity of screening trisomy 21 in embryos in patients over 35 years old at the in vitro fertilization (IVF) center.     

Scientific principles and rigorous processes should be followed in developing clinical guidelines for therapeutic interventions of integrative medicine

A clinical guideline for the therapeutic interventions of integrative medicine may be defined as a written document which states a series of recommendations on therapeutic interventions of integrative medicine for a special disease or condition. The guideline may provide assistance to medical professionals in making clinical decisions aimed at improving the clinical outcome of patients and reducing the costs of medical care（~＇4~. Recommendations issued by a guideline should be based on the best available evidence in both Western and Chinese medicine. For fulfilling this purpose, the development of clinical guidelines for therapeutic interventions in the field of integrative medicine should follow scientific principles and undergo a rigorous processes.