Stanford A型主动脉夹层患者行改良象鼻主动脉弓置换术的护理

目的总结和探讨改良象鼻主动脉弓置换术治疗Stanford A型主动脉夹层患者的护理方法。方法方便性抽样对山东大学齐鲁医院18例主动脉夹层患者进行术前心理疏导、缓解镇痛、控制血压,术中加强脑保护,术后进行早期心血管系统处理、神经系统监护、呼吸道管理;预防肾功能不全、感染;防治出血、渗血等护理措施。结果除1例患者术后发生昏迷外,其余17例均获得成功。结论科学严谨的护理措施是提高Stanford A型主动脉夹层人造血管置换术成功率、减少术后并发症、促进患者康复的有效保障。     

Racial and Ethnic Disparities in Health: An Emergency Medicine Perspective

Significant disparities exist in health care based on race. Even when controlling for socioeconomic factors, minorities still have lower rates of utilization for certain procedures, higher mortality rates, and differences in usual source of care. There are a multitude of causes for these disparities, including differences based on access to care, the patient-doctor relationship, and insurance status. This article addresses possible factors that account for persistent disparities in health based on race and suggests approaches to remedying these disparities. Although many studies have been done on this topic, further research is needed to examine factors specifically in the emergency department setting.     

术中经食道超声心动图在急性Stanford A型主动脉夹层手术中的应用价值

目的 探讨术中经食道超声心动图（Transesophageal Echocardiography,TEE）在急性Stanford A型主动脉夹层（AAD）手术中的应用价值。 方法 选取经全主动脉CTA诊断为ADD的患者41例,术前行TEE检查,根据TEE检出主动脉根部受累情况分为三组：夹层未累及主动脉根部组（A组）16例,主动脉根部轻-中度受累组（B组）9例,主动脉根部重度受累组（C组）16例。均行术前TEE检查观察主动脉根部形态、夹层受累情况,包括主动脉瓣叶形态、功能,测量并比较各组主动脉瓣环内径、主动脉窦部内径、窦管交界内径及可显示升主动脉段的最大内径,观察冠状动脉起始段形态;术后TEE即刻观察手术效果。并将TEE结果与术中所见进行比较。结果 41例患者术前TEE对升主动脉内撕裂的内膜片显示阳性率为100%。B、C组主动脉窦部内径均大于A组,C组主动脉窦部内径大于B组,差异均有统计学意义（P＜0.05）;A、B、C三组患者主动脉瓣环及升主动脉内径比较差异均无统计学意义。经手术证实,术前TEE诊断夹层累及冠状动脉的特异性为62.5%,敏感性为56%。术后TEE可评估人工主动脉瓣或修复主动脉瓣形态、功能,以及人工血管、冠状动脉等吻合情况。结论 术前TEE能准确评估AAD主动脉根部及冠状动脉受累情况,术后TEE可即刻评估手术效果,具有重要的临床应用价值。     

Racial and Socioeconomic Disparities in Disabling Chronic Pain: Findings From the Health and Retirement Study

The U.S. National Pain Strategy calls for increased population research on “high-impact chronic pain” (ie, longstanding pain that substantially limits participation in daily activities). Using data from the nationally-representative Health and Retirement Study (HRS), we investigated the prevalence of high-impact chronic pain in U.S. adults older than age 50 overall and within population subgroups. We also explored sociodemographic variation in pain-related disability within specific activity domains. Data are from a subsample of HRS respondents (n = 1,925) who were randomly selected for a supplementary pain module in 2010. Our outcome was operationalized as pain duration of ≥7 months and a disability rating of ≥7 (0–10 scale) in at least 1 domain: family/home, leisure, social activities, work, or basic activities. Overall, 8.2% (95% confidence interval = 6.7–10.1%) of adults older than age 50 met criteria for high-impact chronic pain. This proportion rose to 17.1% (95% confidence interval = 12.3–23.4%) among individuals in the lowest wealth quartile. Prevalence differences according to education, race/ethnicity, and age were not significant. Arthritis and depression were significantly associated with high-impact pain in multivariable analysis. Among adults with any chronic pain, African American and individuals in the lowest wealth quartile reported more pain-related disability across activity domains.

Racial Disparities in Acute Outcomes of Life-Threatening Injury

PURPOSE: To critically analyze racial and ethnic disparities in acute outcomes of life-threatening injury in the United States (US). DESIGN: Integrative review of literature. METHODS: A search of Medline (1966-2005) and CINAHL (Cumulative Index to Nursing and Allied Health Literature; 1982-2002) scientific literature databases was undertaken to identify research aimed at correlating minority race and ethnicity to acute outcomes of life-threatening injury in the US. RESULTS: Although injury is the leading cause of death for adults 15 to 44 years of age, racial and ethnic health disparities in acute outcomes of life-threatening injury have been relatively unexplored: only seven of 352 (2%) studies. The findings from these studies were mixed. Four studies indicated significant relationships between race or ethnicity to acute outcomes in injury morbidity and mortality, but three studies showed no significant relationships between these variables. Other variables associated with health disparities, such as income and education, were rarely (income) or not (education) addressed. CONCLUSIONS: These inconclusive results indicate the need for more research aimed at investigating racial and ethnic disparities in acute outcomes of life-threatening injury.     

Hybrid aortic arch and frozen elephant trunk reconstruction: bridging the gap between conventional and total endovascular arch repair

Introduction: Novel endovascular techniques hope to offer patients aortic arch repair with reduced morbidity compared to conventional arch surgery; however, current endovascular strategies remain challenged by the proximal seal zone, higher stroke rates, long-term durability and select anatomy. Hybrid arch repair offers patients a less invasive alternative that can treat more distal aorta than conventional arch repair yet still be performed via standard sternotomy.

Areas covered: This review will discuss the current evidence and future development of hybrid aortic arch and frozen elephant trunk reconstruction. Several approaches to hybrid arch repair are summarized, including the off-label use of thoracic endovascular stent-grafts and commercially manufactured hybrid grafts. Technical considerations and clinical outcomes with each approach will be addressed along with advantages and disadvantages.

Expert commentary: Hybrid arch repair will undergo continued refinement as our ability to provide a less-invasive alternative to conventional open arch repair grows. Evolution to allow for improved head vessel branch sizing, improved frozen elephant trunk deployment accuracy, monitoring to prevent paraplegia and utilization of intraoperative image guidance in hybrid operating rooms is necessary. The potential exists for hybrid approaches to arch pathology to completely supplant conventional surgery, while avoiding the potential deleterious complications of total endovascular repair.     

Emergency Cesarean Section Due to Acute Aortic Dissection Type A (Debakey I) without Marfan Syndrome: A Case Report and Review of the Literature

Background

Acute aortic dissection during pregnancy is an uncommon but important emergency due to its lethal risk to both mother and child. The dissection usually involves the ascending aorta or the aortic arch. Although additional affection of the descending aorta up to bifurcation is possible, further increasing the risk of organ malperfusion, full-length aortic dissection (DeBakey I) is known to be very rare. Dissection during pregnancy has been reported predominantly in combination with Marfan syndrome. Acute aortic dissection Stanford type A (AADA) DeBakey I during pregnancy without signs of Marfan syndrome as a warning signal is very uncommon in the current literature.

Objectives

The etiology, diagnosis, differential diagnosis, and management of this rare disease are discussed in relation to the current literature.

Case Report

We report the case of an athletic 34-year-old woman in the third trimester of pregnancy, without history of previous diseases, who presented to our Emergency Department after collapsing. In the resuscitation department, an emergency cesarean section was performed due to the start of circulation failure in the mother. Computed tomography scan revealed a severe aortic dissection starting from 1 cm distal the aortic valve over the full length up to the iliac arteries, involving the brachiocephalic and carotid arteries up to the level of the larynx. Emergency replacement of the ascending aorta and the aortic arch was performed. Both the mother and baby survived and were doing well 1 year postoperatively.

Conclusion

This alarming result of AADA (DeBakey I) in late pregnancy without obvious warnings such as Marfan syndrome illustrates the importance of performing early imaging in similar cases.     

Acute Type A Aortic Dissection in a 37-Week Pregnant Patient: An Unusual Clinical Presentation

Background

Aortic dissection in pregnancy is relatively rare, but it is often fatal. The estimated incidence of aortic dissection in the general population is 2.9 per 100,000 person-years. Early recognition and treatment of aortic dissections are crucial for survival. Whereas the majority of patients who present with aortic dissection are older than 50 years of age and have a history of hypertension, younger patients with connective tissue disease, bicuspid aortic valves, or a family history of aortic dissection are also at increased risk for developing this condition.

急性主动脉夹层时间分布规律

目的 研究急性主动脉夹层时间分布规律.方法 回顾性研究我院2000年1月-2010年12月所有急性主动脉夹层患者的时间资料,分析其月份、季节、周以及时刻分布特点.结果 急性主动脉夹层月份分布高峰点为1月4日,高峰段为9月21日～次年4月19日(P＜0.05);季节分布以冬春季较多(P＜0.05);周分布无高峰点及高峰段...     

Acute aortic dissection in women: challenges and opportunities

Acute aortic dissection (AAD) is a severe and potentially fatal disease which requires rapid diagnosis and appropriate treatment in order to improve survival. The variable and sometimes non-specific presentation of this rare condition makes it a continued diagnostic challenge for even the best of clinicians. Multiple clinical factors have been studied for their role in increasing the risk of AAD. While the complete pathophysiology of the condition is not known, contemporary research has shed light on many important factors that might lead to the development of aortic aneurysms and AAD. Despite continued research in this area, there is scant research looking at gender-related differences in the epidemiology, presentation, treatment and outcomes of patients with AAD. This review first revisits lessons about gender-related differences seen in various cardiovascular diseases, and then critically examines the data on gender-related differences in AAD diagnosis, management and outcomes. A summary of the pathophysiology and possible reasons for gender-specific differences in the development of aneurysms and dissections is also provided.     

Type A aortic dissection developed after type B dissection with the presentation of shoulder pain: A case report

BACKGROUNDAortic dissection (AD) is a life-threatening condition with a high mortality rate without immediate medical attention. Early diagnosis and appropriate treatment are critical in treating patients with AD. In the emergency department, patients with AD commonly present with classic symptoms of unanticipated severe chest or back pain. However, it is worth noting that atypical symptoms of AD are easily misdiagnosed.CASE SUMMARYA 51-year-old woman was first diagnosed with scapulohumeral periarthritis due to left shoulder pain. After careful examination of her previous medical history and contrast-enhanced computed tomography angiography, the patient was diagnosed with a new type A AD after chronic type B dissection in the ascending aorta. The patient was successfully treated with surgical replacement of the dissected aortic arch and remains in good health.CONCLUSIONNew retrograde type A AD after chronic type B dissection is relatively rare. It is worth noting that a physician who has a patient with suspected AD should be vigilant. Both patient medical history and imaging tests are crucial for a more precise diagnosis.     

急性Stanford A型主动脉夹层的外科治疗策略及其进展

急性Stanford A型主动脉夹层在临床上是一种极度危险的疾病,一旦发作大多患者都会在急性期死亡,很少有患者会迁延到慢性期,所以临床处理颇为棘手。目前该疾病的发病原因及机理尚不明确,临床最有效的治疗手段是积极采取外科手术治疗,虽然外科治疗手段一直在不断地改进、提高,但是患者的死亡率依然很高。本文就急性Stanford A型主动脉夹层的外科处理策略及目前的现状作一综述,以期为今后的研究提供有价值的参考。     

术中置入新型三分支主动脉弓覆膜支架治疗急性Stanford A型主动脉夹层临床研究

目的应用新型三分支型主动脉弓覆膜支架治疗急性Stanford A型主动脉夹层,总结其临床应用经验,并评价其安全性和疗效。方法 2009年12月至2011年1月7例急性Stanford A型主动脉夹层患者在我科接受新型三分支主动脉弓覆膜支架手术治疗。结果全组手术时间(259.2±53.6)分钟,体外循环时间(136.4±28.5)分钟,心肌血运阻断时间(85.3±11.7)分钟,深低温停循环选择性脑灌注时间(17.6±8.2)分钟。术中死亡1例,系术中主动脉开放后主动脉根部后壁大出血无法止血;其余6例患者术后及时清醒,循环稳定,无严重并发症发生。随访2～15个月,主动脉血管成像显示患者主动脉弓部及分支动脉内支架扩张贴壁满意,相应部位假腔消失,远端假腔内血栓填充;无与覆膜支架相关的并发症发生;患者心功能改善,生活质量良好。结论 采用新型三分支主动脉弓覆膜支架治疗急性Stanford A型主动脉夹层,可以简化主动脉弓部操作,降低手术风险,提高手术成功率,适合于大多数Stanford A型主动脉夹层患者的治疗。     

不同年龄急性主动脉夹层患者发病时间的比较

目的比较不同年龄的急性主动脉夹层(acute aortic dissection,AAD)患者的发病时间,以期为因人、因时施护提供客观依据。方法回顾性分析2002年1月至2011年12月在扬州大学临床医学院确诊治疗的、有明确发病时间记载的287例AAD患者的临床资料。根据患者的年龄分为中青年组(65岁)和老年组(≥65岁),对其发病时间进行圆形分布图分析。结果中青年组AAD患者发病存在明显的月份集中趋势,集中月份在9月29日至次年2月18日,高峰月在12月9日;同时存在明显的时间集中趋势,集中时间在6:49至16:19,高峰时间在11:34。老年组AAD患者发病无月份集中趋势,发病呈均匀分布,但存在明显的时间集中趋势,集中时间在6:06至14:43,高峰时间在10:25。不同年龄组患者的发病时间的差异有统计学意义(F=6.197,P0.05)。结论中青年AAD患者的发病时间与老年患者不同,防治侧重不一样,有针对性地做好中青年与老年患者的时间护理,有助于更好地防范AAD的发生。     

A Systematic Review Exploring Racial Disparities,Social Determinants of Health,and Sexually Transmitted Infections in Black Women

ObjectiveTo explore and describe racial disparities, the role of social determinants of health, and individual risk behaviors among Black women as related to sexual health and/or sexually transmitted infections (STIs).Data SourcesElectronic resource databases used were PubMed, CINAHL, and Google Scholar. Peer-reviewed articles published during 2010 to 2020 were considered.Study SelectionThirty-two studies met the criteria and included data for a total of 18,904 Black women.Data ExtractionData were extracted from each study using the subheadings author (year), purpose, design, sample demographics and setting, key measures, key findings, and quality assessment. In addition, PRISMA-E and PROGRESS-Plus guided data extraction to illustrate health inequity.Data SynthesisBlack women who were more likely to report having an STI over the course of their lifetime engaged in behaviors associated with greater risk, the most common of which were unprotected sex, disproportionate partner power, and substance abuse. The primary social determinants of health associated with increased risk were lower income and lower levels of education. Black women were less likely to discuss or feel comfortable discussing their sexual health with health care providers. By contrast, engagement in safe sexual practices stemmed from internal, social, and relationship factors.ConclusionIdentifying Black women who are at risk of contracting an STI is essential in driving clinical decision-making. Health care providers should be cognizant of the long-standing mistrust that Black women have of health care providers and, therefore, work to establish positive respectful and trusting relationships with open communication.     

Total endovascular repair of an intraoperative stent-graft deployed in the false lumen of Stanford type A aortic dissection: A case report

BACKGROUND A 46-year-old male underwent ascending aortic replacement,total arch replacement,and descending aortic stent implantation for Stanford type A aortic dissection in 2016.However,an intraoperative stent-graft was deployed in the false lumen inadvertently.This caused severe iatrogenic thoracic and abdominal aortic dissection,and the dissection involved many visceral arteries.CASE SUMMARY The patient had pain in the chest and back for 1 mo.A computed tomography scan showed that the patient had secondary thoracic and abdominal aortic dissection.The ascending aortic replacement,total arch replacement,and descending aortic stent implantation for Stanford type A aortic dissection were performed 2 years prior.An intraoperative stent-graft was deployed in the false lumen.Endovascular aneurysm repair was performed to address this intractable situation.An occluder was used to occlude the proximal end of the true lumen,and a covered stent was used to direct blood flow back to the true lumen.A three-dimensional printing technique was used in this operation to guide prefenestration.The computed tomography scan at the 1stmo after surgery showed that the thoracic and abdominal aortic dissection was repaired,with all visceral arteries remaining patent.The patient did not develop renal failure or neurological complications after surgery.CONCLUSION The total endovascular repair for false lumen stent-graft implantation was feasible and minimally invasive.Our procedures provided a new solution for stent-graft deployed in the false lumen,and other departments may be inspired by this case when they need to rescue a disastrous stent implantation.