症状性脑血管痉挛血管内治疗的研究进展

症状性脑血管痉挛是蛛网膜下腔出血后死亡和致残的主要原因，治疗较困难。近年来应用介入神经放射技术进行血管内治疗取得了较满意疗效。现就基础和临床方面的研究进展作一综述。     

症状性脑血管痉挛血管内治疗的研究进展

症状性脑血管痉挛是蛛网膜下腔出血后死亡和致残的主要原因，治疗较困难。近年来应用介入神经放射技术进行血管内治疗取得了较满意疗效。现就基础和临床方面的研究进展作一综述     

经皮血管成形术治疗脑血管痉挛

综述了经皮血管成形术(PTA)治疗脑血管痉挛的发展史、操作方法、适应症和禁忌症、治疗时机及疗效、影响疗效的因素及治疗机制。     

血管内支架成形术在症状性脑血管狭窄治疗中应用的初步探讨

目的 探讨血管内支架成形术治疗症状性脑动脉狭窄的效果及安全性.方法 对33例症状性脑动脉狭窄患者进行了37处血管内支架成形术治疗,其中颈内动脉颅外段狭窄14处,颈内动脉颅内段狭窄3处,大脑中动脉狭窄3处,椎动脉颅外段狭窄13处,椎动脉颅内段2处,锁骨下动脉2处.结果 本组33例患者行37处支架置入术,其中成功置入35枚支架,手术成功率94.59%;1例手术中并发脑血管痉挛,1例手术中并发造影剂过敏,1例手术后并发高灌注综合征.结论 血管内支架成形术治疗症状性脑动脉狭窄是安全有效的,其远期疗效尚待进一步随访观察.     

犬脑血管痉挛经皮腔内血管成形术治疗

目的　探讨经皮腔内血管成形术 (PTA)治疗顽固性脑血管痉挛的可行性和效果。方法　成年杂种犬 2 0只 ,采用枕大池两次注血模型。应用扩张后直径为 1.5mm的硅胶球囊 ,扩张压力为 2个大气压、持续时间 10s,在痉挛的基底动脉近、远端分别扩张 1次。结果　 2 0只犬的基底动脉均发生痉挛 ,为其中的 14只进行了PTA治疗 ,成功13只、死亡 1只 ;另外的 6只犬 ,由于血管解剖原因 ,无法进行PTA操作。PTA治疗后 ,痉挛的基底动脉明显扩张 ,犬神经功能恢复明显加快。 2 0d后复查脑血管造影 ,接受PTA治疗犬的基底动脉显影基本正常 ,而未进行PTA治疗犬的基底动脉仍有明显的痉挛。结论　PTA是治疗顽固性脑血管痉挛的一种有效方法     

运用血管内超声比较切割球囊成形术和传统成形术扩张血管管腔的机制

以往的血管内超声(IVUS)研究显示,血管的负性重塑和内膜增殖在介入术后再狭窄中占主导地位。球囊扩张所致的严重损伤可引起血管内膜增生,切割球囊成形术(CBA)可减轻这种     

糖尿病足血管内介入治疗临床意义

对19例血管节段性狭窄者行介入治疗(13例经皮血管内球囊成形术，6例血管腔内支架植入术)，术后6月血管造影复查。结果：19例行血管内介入治疗者下肢动脉血供均得到明显改善，通过控制血糖、局部换药等治疗措施，糖尿病足部溃疡愈合较快，近期疗效令人满意。结论：DSA检查可以准确了解血管阻塞部位及程度，糖尿病足下肢动脉血管内介入治疗疗效满意，可以降低患者的病残率。     

椎基底动脉狭窄的血管内治疗

对于重度椎基底动脉狭窄药物治疗无效的患者，大脑后循环血管重建较前循环要困难得多。应用经皮腔内血管成形术加支架置入术的血管内治疗可增加后循环血流量、降低急性闭塞和血栓栓塞并发症的发生率，成为一种很有前景的临床治疗方法。文章详细介绍了椎基底动脉狭窄血管内治疗的发展现状、适应证、方法、并发症和预防策略。     

运用血管内超声比较切割球囊成形术和传统成形术扩张血管管腔的机制

以往的血管内超声 (ＩＶＵＳ)研究显示 ,血管的负性重塑和内膜增殖在介入术后再狭窄中占主导地位。球囊扩张所致的严重损伤可引起血管内膜增生 ,切割球囊成形术 (ＣＢＡ)可减轻这种对血管的损伤。然而ＣＢＡ扩张狭窄血管的机制尚未明了。本文作者通过ＩＶＵＳ探讨ＣＢＡ引起血管管腔扩张的机制 ,并与传统球囊成形术进行对比。对 65例行ＣＢＡ或传统球囊成形术的患者进行了研究 ,其中ＣＢＡ组 ( 40例 ) ,传统球囊成形术组 ( 2 5例 )。这些患者均在自身冠脉内有长度小于 10ｍｍ的未加处理的病变。两组患者手术前后均进行定量冠脉造影 (ＱＣＡ)…     

Experimental and clinical study on effect of endovascular dilation on symptomatic cerebral vasospasm

Objective To undertake animal experimentation and clinical study on the safety and efficacy of percutaneous transluminal angioplasty (PTA) and intraarterial papaverine (IAP) infusion for treatment of refractory symptomatic cerebral vasospasm (CVS). Methods In the experimental study, vasospasm was induced in rabbits by double injections of blood into the cisterna magMa, IAP infusion was given on either the 4th day or the 7th day after occurrence of subarachnoid hemorrhage (SAH), and then neurological observation, angiography, light and electron microscopy were done, In the clinical study, since September 1996, 22 patients with refractory symptomatic CVS involving 50 vascular territories received dilation therapy by PTA and IAP within 24 hours of clinical neurological deterioration. Results In the experimental study, all the rabbits except two in the ‘the 4th day‘ group showed angiographic dilation in all of the spastic basilar arteries, and neurological improvement; in the ‘the 7th day‘ group angiographic dilation appeared in 4 (57. 1% ) out of 7 rabbits. After 24 hours, 1 rabbit in each group had recurrence of neurological deficits and angiographic constriction. In the clinical study after aneurysm clipping or endovascular coil embolization was done, within 72 hours of SAH all patients underwent endovascular treatment: PTA alone in 3 cases, IAP alone in 14 cases, PTA and lAP in the remaining 5 cases. All vessel segments were dilated satisfactorily after endovascular treatment. Clinical improvement was significant in 13 eases,moderate in 7, minimal or none in 2; 2 cases died on the 7th day after endovascular dilation treatment. Conclusion Endovascular dilating techniques, namely, PTA, IAP and a combination of PTA and IAP, are safe and effective for treatment of symptomatic CVS refractory to medical therapy.     

动脉瘤性蛛网膜下腔出血后脑血管痉挛的药物治疗

动脉瘤性蛛网膜下腔出血后脑血管痉挛( cerebral vasospasm,CVS)的发生是一个多因素参与的过程,其发生机制复杂,临床表现和影像学检查结果并不一致.理论上,通过阻断钙通道、抑制Rho激酶、清除氧自由基和拮抗内皮素受体等措施能防治CVS,但各类药物的实际临床效果却不尽如人意,尤其是在改善临床转归方面.3H治疗的临床应用因存在诸多潜在并发症而受到限制,而动脉内介入治疗则受到技术、设备、适应证等因素的影响.因此,CVS的防治仍然面临着许多挑战.     

颅内静脉窦血栓形成血管内治疗的麻醉管理

目的探讨颅内静脉窦血栓形成(CVST)患者血管内治疗的麻醉管理方法。方法回顾性分析首都医科大学宣武医院介入诊断治疗科2009年1月—2011年12月血管内治疗(包括溶栓、支架置入、碎栓)CVST患者的麻醉资料,纳入接受喉罩全身麻醉(18例)和气管插管全身麻醉(26例)的患者共44例,对危险因素、术中监测数据、镇痛药物的使用、并发症等资料进行比较分析。结果 44例患者术毕拔管30例,其中气管插管组拔管率为50.0%(13/26),低于喉罩组的94.4%(17/18),两组比较差异有统计学意义,χ2=9.675,P<0.01。①对昏迷(2例)和脑出血(6例)的8例患者,均采用气管插管麻醉。伴有多发性静脉窦血栓危险因素的患者采用气管插管的比率为76.0%(19/25),高于采用喉罩全身麻醉的比率(24.0%,6/25),差异有统计学意义(P<0.01)。伴有局灶症状的患者采用喉罩全身麻醉的比率为69.2%(18/26),高于采用气管插管麻醉的30.8%(8/26),差异有统计学意义(P<0.05)。②麻醉诱导后,气管插管组的平均动脉压(MAP)降低,术中升高,与患者的基础水平比较,差异有统计学意义(P<0.05);喉罩组MAP各时点两两比较的差异无统计学意义(P=0.077)。两组各阶段的呼气末二氧化碳分压差异无统计学意义,血氧饱和度在拔除气管插管后均出现下降,与拔管前比较,差异有统计学意义(P<0.05)。气管插管组麻醉后的体温与基础体温比较,差异有统计学意义(P<0.05),喉罩组体温有下降趋势,但与诱导前比较差异无统计学意义(P=0.068)。③气管插管组患者的镇痛药芬太尼用量[(3.49±0.66)μg/kg]高于喉罩组[(2.53±0.50)μg/kg],差异有统计学意义(P=0.038),瑞芬太尼的用量两组差异无统计学意义(P=0.718)。④气管插管组无肺栓塞和颅内出血并发症,喉罩组有颅内出血1例,咽痛2例,体动反应1例。结论在CVST患者接受血管内治疗的麻醉管理中,对伴有高危因素的CVST患者宜选择气管插管全身麻醉;需要密切监测生命体征以及完善的镇痛,维持血压在基础水平,维持脑灌注压。     

动脉瘤性蛛网膜下腔出血患者出血后脑血管痉挛的介入治疗

本临床实践标准述及动脉瘤性蛛网膜下腔出血患者出血后脑血管痉挛(posthemorrhagic cerebral vasospasm,PHCV)的介入治疗.这些结论基于神经介入外科学学会的标准委员会的评估,包括使用由美国心脏协会卒中委员会和牛津大学循证医学中心提出的循证医学指南进行的文献回顾.特别关注现有介入治疗方法的安全性和有效性,包括腔内球囊血管成形术(transluminal balloon angioplasty,TBA)和动脉内血管扩张药物输注治疗(intra-arterial vasodilator infusion therapy,IAVT).评估结果显示,这些侵袭性介入治疗可能有益,并可考虑用于PHCV,如伴有脑缺血症状和最佳的药物治疗无效的患者的治疗.概括起来,IAVT对累及近端和(或)远端颅内脑循环的PHCV 可能有益,而TBA则可能对累及近端颅内脑循环的PHCV有益.评估结果显示,对于上述适应证,根据美国心脏协会指南可将TBA和IAVT归为Ⅱb级推荐和B级证据,根据牛津大学循证医学中心指南则可归为4级推荐和C级证据.     

Critical appraisal of the guidelines for the management of ankylosing spondylitis: disease-modifying antirheumatic drugs

Surprisingly, little data are available for the use of disease-modifying antirheumatic drugs in ankylosing spondylitis. Sulfasalazine has been the best studied. Efficacy data for individual agents (including pamidronate) and combinations of agents are detailed in this review. Intriguingly, these agents continue to be used with some frequency, even in the absence of efficacy data. To answer these questions, additional systematic studies of these agents in ankylosing spondylitis are needed and will likely need to be done by interested collaborative groups such as SPARTAN.     

Critical assessment of the current guidelines for the management and treatment of morbidly obese patients

An interdisciplinary panel of specialists met in Mallorca in the first European Symposium on Morbid Obesity entitled; "Morbid Obesity, an Interdisciplinary Approach". During the two and half days of the meeting, the participants discussed several aspects related to pathogenesis, evaluation, and treatment of morbid obesity. The expert panel included basic research scientists, dietitians and nutritionists, exercise physiologists, endocrinologists, psychiatrists, cardiologists, pneumonologists, anesthesiologists, and bariatric surgeons with expertise in the different weight loss surgeries. The symposium was sponsored by the Balearic Islands Health Department; however, this statement is an independent report of the panel and is not a policy statement of any of the sponsors or endorsers of the Symposium. The prevalence of morbid obesity, the most severe state of the disease, has become epidemic. The current recommendations for the therapy of the morbidly obese comes as a result of a National Institutes of Health (NIH) Consensus Conference held in 1991 and subsequently reviewed in 2004 by the American Society for Bariatric Surgery. This document reviews the work-up evaluation of the morbidly obese patient, the current status of the indications for bariatric surgery and which type of procedure should be recommended; it also brings up for discussion some important real-life clinical practice issues, which should be taken into consideration when evaluating and treating morbidly obese patients. Finally, it also goes through current scientific evidence supporting the potential effectiveness of medical therapy as treatment of patients with morbid obesity.     

蛛网膜下腔出血后脑血管痉挛机制的研究进展

SAH后脑血管痉挛（cerebrovascular spasm，CVS）分为早期痉挛和迟发痉挛。前者多发生在SAH后0．5-1h，发生迅速，可以起到生理止血的作用。后者是指始发于SAH后24-72h，5-14d达高峰，2-4周后消退。后者对患者的预后影响较大，是目前研究的重点。CVS的发病机制非常复杂，     

Critical incidents of nonadherence with standard precautions guidelines among community hospital-based health care workers

OBJECTIVE: To identify, categorize, and assess critical incidents of nonadherence to standard precautions. DESIGN: Qualitative and quantitative analysis of a written, mail-out survey. SETTING: Community hospitals. PARTICIPANTS: Statewide stratified random sample of community hospital-based health care workers at risk for blood exposure. MAIN VARIABLE: Responses to the question: "Think of an incident during the past year when you didn't adhere to universal precautions. Please describe the situation and why you didn't adhere." RESULTS: Reasons given for not using precautions included: belief that stopping to use standard precautions would have put the patient at risk (22%); using precautions would have interfered with patient care (20%); precautions were not warranted in a specific situation (14%); did not anticipate the potential for exposure (14%); and high job demands that had caused respondent to be in a hurry (11%). Less often, equipment was not available (7%), respondent forgot (6%), respondent thought that the patient did not pose a risk (4%), or the available equipment was not effective (3%). In terms of overall exposure rates, 34% of those who described an incident had experienced a sharps injury during the previous 3 months and 42% had experienced a mucocutaneous exposure. In terms of overall nonadherence, 44% wore gloves less than 100% of the time, while 61% washed their hands less than 100% of the time. Needlestick injuries were lowest among those who had forgotten to use precautions, while mucocutaneous exposures were highest among those who had not anticipated potential exposure while performing the task. Failure to wear gloves routinely was highest among those who said that following precautions interfered with their ability to provide care and among those who believed a particular patient to be low risk; failure to wash hands routinely was also highest among the latter group and lowest among those who said necessary equipment was not available. CONCLUSIONS: Using specific information about local incidents of nonadherence to standard precautions may enhance training, especially if the program identifies incidents of unanticipated exposure and helps workers plan for them in the future. Closer examination of job demands and responsibilities that interfere with standard precautions may increase the likelihood of adherence.