Tracheoesophageal fistula: New option in management

Tracheoesophageal fistula is a life threatening condition. Patients not managed surgically ultimately die of their disease. Surgical management is the treatment of choice. We present a case of a patient that developed a tracheoesophageal fistula after tracheostomy. Surgical repair was done which failed due to infection. The patient was managed with the help of an esophageal stent and Trichloroacetic Acid cautery. This approach can be used in selected patients, depending upon the size and site of TEE Larger fistulae and those situated lower down e.g. supra carinal cannot be managed by this technique.     

Pulmonary artery-bronchus fistula treated with coil embolization

Bronchopulmonary arterial fistula consists of an abnormal connection between the bronchus and the vascular tree and is a rare but serious complication associated with a variety of lung interventions. We present a case of a 61-year-old female with a history of metastatic breast cancer treated with lumpectomy and radiation 20 years prior, who was found to have a fistula between the right pulmonary artery and the right mainstem bronchus. Our patient was treated endovascularly with coil embolization in the setting of massive hemoptysis flooding the trachea, which was successful in controlling the acute bleed, although care was withdrawn in the following days following a discussion with the family given the presence of advanced metastatic disease. This case illustrates the use of endovascular techniques to treat an actively bleeding bronchopulmonary arterial fistulae, including a review of the existing literature regarding the optimal endovascular management strategy. Although our patient did not achieve the best outcome, endovascular intervention with stent-placement or embolization can serve to temporarily halt blood flow through the fistula, stabilizing the patient and allowing for more radical therapy after improvement.     

整体护理对冠心病患者冠脉内支架植入术围术期血脂水平的影响

目的观察整体护理对冠心病患者冠状动脉内支架植入术围术期血脂水平的影响。方法选择行经皮冠状动脉内支架植入术治疗的冠心病患者149例,随机分为整体护理组86例与传统护理组63例。对整体护理组实施整体护理干预,传统护理组被给予传统护理干预;分析、比较两组患者3个时间点（人院第2日、手术当日及出院当日）的状态焦虑水平、血脂含量变化以及术后并发症发生情况的差异。结果两组患者状态焦虑水平（分）整体护理组手术当日（51．64±7．78）分、出院当日（38．94±4．37）分与传统护理组（74．42±8．29）分、（59．97±5．76）分比较,差异有统计学意义（P〈0．05）。两组患者血脂水平（mmol／L）整体护理组手术当日、出院当日与传统护理组差异有统计学意义（P〈0．05）。两组患者术后并发症发生率（％）、整体护理组血肿或出血、桡动脉痉挛或闭塞、心律失常、发热以及迷走神经反射等并发症发生率明显低于传统护理组（P〈0．05）。结论整体护理可以降低冠心病患者冠脉内支架植入术围术期血脂水平与状态焦虑水平,减少术后并发症的发生,提高护理质量。     

Meta-Analysis of Short vs. Prolonged Dual Antiplatelet Therapy after Drug-Eluting Stent Implantation and Role of Continuation with either Aspirin or a P2Y12 Inhibitor Thereafter

Aim: The optimal duration of dual antiplatelet therapy (DAPT) after drug-eluting stent (DES) implantation is an ongoing debate and novel data has emerged. The aim of this meta-analysis was to assess outcomes of short vs. control DAPT duration. In addition, the role of single antiplatelet therapy (SAPT) after DAPT with either aspirin or P2Y₁₂ inhibitor monotherapy was analyzed. Methods: The authors searched MEDLINE and Cochrane databases and proceedings of international meetings for randomized controlled trials (RCT) comparing ≤ 3 months with ≥ 6 months DAPT after DES implantation. The primary and co-primary outcomes of interest were definite or probable stent thrombosis (ST) and bleeding. In addition, we performed an analysis on studies who continued with either aspirin or P2Y₁₂ monotherapy after DAPT. Results: 9 RCTs comprising 41,864 patients were included and we analyzed a short DAPT duration of median 1.5 months vs. 12.1 months in the control group. The risk for ST was similar with short vs. control DAPT duration (0.5 vs. 0.5%; hazard ratio 1.17[95% CI 0.89-1.54];p=0.26). Bleeding was significantly reduced with short vs. control DAPT duration (1.9 vs. 3.0%; 0.65[0.54-0.77];p＜0.0001). ST was not different between short vs. control DAPT duration in the analysis of the 4 RCTs who continued with aspirin after DAPT and the 5 P2Y₁₂ RCTs, respectively, and no heterogeneity was detected (p=0.861). Bleeding was also reduced with short vs. control DAPT in both the aspirin (1.2 vs. 1.7%; 0.71[0.51-0.99];p=0.04) and P2Y₁₂ inhibitor studies (2.1 vs. 3.4%; 0.62[0.47-0.80];p=0.0003) and no heterogeneity was detected (p=0.515). Conclusions: Our meta-analysis shows that short DAPT ≤ 3 months followed by SAPT reduces bleeding and is not associated with an increase in ST. The results were consistent within the aspirin and P2Y₁₂ SAPT studies.     

激素抵抗型婴幼儿Kasabach-Merritt综合征治疗中雷帕霉素的临床应用价值探讨

目的 初步评估临床上应用雷帕霉素治疗激素抵抗型婴幼儿Kasabach-Merritt综合征的临床疗效及安全性.方法 2015年2月至2016年4月共收集8例在我科接受治疗的Kasabach-Merritt综合征患儿,其中男5例,女3例,病灶位于颌面部3例、颈部1例、四肢2例,胸腹壁2例,8例患儿均表现为激素抵抗,对激素抵抗型Kasabach-Merritt综合征采用mTOR抑制剂雷帕霉素治疗.雷帕霉素服用方法为每次0.8 mg/m2,2次/d,间隔12h,血药浓度维持10～15 ng/ml.定期监测血常规、凝血功能、肝肾功能、血脂及雷帕霉素血药浓度等指标.根据血药浓度、血小板变化、凝血功能、瘤体缩小情况及副作用可适当调整用药计划.结果 8例患儿经雷帕霉素治疗后血小板均恢复正常,瘤体萎缩,并逐步撤离了激素,有效率达到100％.雷帕霉素平均起效时间(6.8±2.7)d,平均血小板稳定时间(19.1±8.5)d,目前雷帕霉素总的用药时间为4～10个月,平均(6.0±2.2)个月,开始雷帕霉素单药治疗时间为2～8个月,平均(4.5±1.9)个月.8例患儿仍在服药进行中,均无血小板下降和病灶复发.药物使用中不良反应主要为口腔黏膜炎及口腔溃疡(2例,GradeⅡ)、呕吐(1例,Grade工)、腹泻(2例,Grade Ⅰ/GradeⅡ)、发热(2例,GradeⅡ)、皮疹(1例,Grade Ⅰ)、疼痛(1例,Grade Ⅰ)、短暂性转氨酶及血脂异常(1例,Grade Ⅰ/GradeⅡ),予对症治疗后好转,无严重不良事件,无病例退出.结论 mTOR抑制剂雷帕霉素治疗激素抵抗型Kasabach-Merritt综合征具有一定的疗效及安全性,值得临床进一步推广应用.     

Acute Mediastinitis – Outcomes and Prognostic Factors of Surgical Therapy (A Single-Center Experience)

Purpose: The aims of this work were the retrospective analysis of a cohort of patients with acute mediastinitis treated at the authors’ worksite over a 15-year period and the identification of factors that significantly affect the outcomes of the therapy.Methods: During the period 2006–2020, 80 patients with acute mediastinitis were treated. Within the cohort, the following were observed: the causes and the type of acute mediastinitis, length of anamnesis, comorbidities, diagnostic methods, time from the diagnosis to surgery, types and number of surgical procedures, results of microbiological tests, complications, and outcomes of the treatment.Results: The most common type of acute mediastinitis was descending mediastinitis (48.75%). A total of 116 surgical procedures were performed. Ten patients in the cohort died (12.5%). Patients older than 60 years were at a 6.8 times higher risk of death. Patients with more than two comorbidities were at a 14.3 times higher risk of death. The presence of yeasts in the culture material increased the risk of death by 4.4 times.Conclusion: Early diagnosis, removal of the cause of mediastinitis, sufficient mediastinal debridement, and multiple drainage thereof with the possibility of continual postoperative lavage are essential for the successful treatment of acute mediastinitis.     

可吸收冠脉支架耐疲劳评价体系的研究

目的:建立可吸收支架耐疲劳测试的评价体系,为可吸收冠脉支架的安全性和有效性评价提供测试手段.方法:模拟人体血管内的受力、温度和腐蚀环境,在1.2 Hz频率下,对可吸收冠脉支架进行18662400次脉动的疲劳实验,相当于植入人体6个月.实验结束后对支架的整体情况和微观形态进行观测.结果:支架在疲劳实验后,未出现移位、弯曲...     

药物洗脱支架在后循环动脉狭窄治疗中的应用

目的 研究在后循环动脉狭窄治疗中应用药物洗脱支架的安全性和疗效性.方法 经常规造影证实椎动脉狭窄者30例,接受支架置入治疗者19例.局麻或全麻下经右股动脉以Seldinger技术置入6 F导管鞘,在相应导丝辅助下使导引导管进入锁骨下动脉或椎动脉,血管造影后沿导引导管插入0.014英寸、300 cm或205 cm导丝至狭窄远端,经此微导丝交换置入相应规格球囊扩张式CypherTM支架(10例)或TAXUSTM支架(9例).结果 19例患者手术均成功,无死亡和并发症,置入支架贴壁良好,血流明显改善,狭窄远端分支血管(小脑后下动脉等)充盈明显改善,狭窄率由原来的平均87.5%降至平均5.2%.15例表现为眩晕症状的患者术后症状消失12例(80%),改善3例.表现为共济失调的6例患者术后共济运动基本正常4例,明显改善2例,表现为小脑性语言障碍的1例患者术后明显改善.完成至少1次造影随访的患者15例,经DSA证实无再狭窄发生.所有患者门诊随访,最长18个月.结论 药物洗脱支架在后循环动脉狭窄的治疗中安全、有效,在短期内能防止术后再狭窄,长期疗效需进一步观察,需要大样本的随机对照研究进一步证实.     

Evaluation of in-stent stenosis by magnetic resonance phase-velocity mapping in nickel-titanium stents

PURPOSE: To evaluate different grades of in-stent stenosis in a nickel-titanium stent with MRI. MATERIALS AND METHODS: Magnetic resonance phase velocity mapping (MR-PVM) was used to measure flow velocity through a 9-mm NiTi stent with three different degrees of stenosis in a phantom study. The tested stenotic geometries were 1) axisymmetric 75%, 2) axisymmetric 90%, and 3) asymmetric 50%. The MR-PVM data were subsequently compared with the velocities from computational fluid dynamic (CFD) simulations of identical conditions. RESULTS: Good quantitative agreement in velocity distribution for the 50% and 75% stenoses was observed. The agreement was poor for the 90% stenosis, most likely due to turbulence and the high-velocity gradients found in the small luminal area relative to the pixel resolution in our imaging settings. CONCLUSION: The accuracy of the MRI velocities inside the stented area renders MRI a modality that may be used to assess moderate to severe in-stent restenosis (ISR) in medium-sized vascular stents in peripheral vessels, such as the iliac, carotid, and femoral arteries. Advances in MR instrumentation may provide sufficient resolution to obtain adequate velocity information from smaller vessels, such as the coronary arteries, and allow MRI to substitute for invasive and expensive catheterization procedures currently in clinical use.     

理阿诺碱对雷帕霉素诱导的内皮生长晕细胞功能抑制的保护作用

目的 探讨理阿诺碱对雷帕霉素诱导的内皮生长晕细胞（EOCs）功能抑制的影响.方法 密度梯度离心法分离脐血单个核细胞,培养并扩增EOCs,免疫组化法、荧光染色法鉴定其内皮细胞特性.分别加雷帕霉素、理阿诺碱、理阿诺碱预处理1h再加雷帕霉素,与EOCs作用24h,CCK8检测细胞增殖能力,Transwell小室检测细胞迁移能力,并在倒置显微镜下检测细胞的黏附能力.结果 雷帕霉素抑制EOCs的增殖、迁移、黏附能力（P＜0.05）.理阿诺碱预处理1h能改善雷帕霉素对EOCs的增殖、迁移、黏附的抑制作用（P＜0.05）,理阿诺碱单独作用对EOCs的增殖、迁移、黏附无影响（P ＞0.05）.结论 雷帕霉素抑制EOCs的增殖、迁移、黏附能力 理阿诺碱可以改善雷帕霉素诱导的对体外培养的EOCs增殖、迁移、黏附的抑制作用.