目的 依据头颅计算机断层扫描(CT)和CT灌注成像(CTP)评估颈内动脉颅内段钙化(I-ICAC)程度,探讨其与轻型缺血性脑卒中(MIS)患者转归的相关性.方法 回顾性分析MIS患者228例,获得根据CT和CTP结果评估的I-ICAC分值,并将患者分成I-ICAC轻症组152例和I-ICAC重症组76例.观察2组90 d缺血性脑卒中复发情况;观察2组90 d时美国国立卫生研究院卒中量表(NIHSS)评分、改良Rankin评分表(mRS)评分改善情况以及全因死亡率.结果 相较于I-ICAC轻症组,I-ICAC重症组的缺血性脑卒中复发率升高,NIHSS评分改善率降低,差异有统计学意义(P＜0.05);2组患者90 d mRS评分改善率及全因死亡率比较,差异无统计学意义(P＞0.05).结论 I-ICAC重症患者缺血性脑卒中复发风险更高,应重视对MIS患者的I-ICAC评估.

1病例资料 患者,男,55岁.2019年4月21日患者因A型主动脉夹层、肠系膜动脉夹层在市人民医院心胸外科行肠系膜上动脉夹层术,左肾动脉造影,支架植入术.术后发现对答不畅,左口角歪斜,左侧肢体活动不能,查头颅CT未见出血灶,右侧额颞顶枕叶低密度影.患者病情稍稳定后于2019年5月15日全麻体外循环下行升主动脉置换、全弓置换、术中主动脉支架置人,患者病情好转后为进一步康复治疗,于2019年5月29日转入我院治疗.

Objective:To understand the current situation of the head nurses of orthopedics department on bleeding risk assessment and management in the prevention of DVT, to provide a reference for future clinical practice of bleeding risk assessment.Methods:Using phenomenological research methods, five head nurses of orthopedics department were interviewed one-on-one and analyzed by Colaizzi ′s phenomenological analysis. Results:Four themes were refined for the awareness and management of bleeding risk assessment in DVT prevention, mainly focusing on risk assessment, choice of assessment timing, multiple risk assessment methods, and unclear grading attitudes.Conclusions:The bleeding risk assessment work needs to be further explored. It is necessary to further scientifically clarify the timing and methods of bleeding risk assessment, effectively guide clinical practice, strengthen nurses ′ awareness of bleeding risk classification, and promote clinical nursing practice, so as to better conduct bleeding assessment and Care.

目的:探究血尿素氮与肌酐比值(blood urea nitrogen to creatinine ratio,BUN/Cr)与急性心力衰竭(心衰)患者长期预后的相关性.方法:前瞻性分析2012年至2016年纳入本研究的462例因急性心衰发作于南京医科大学第一附属医院住院的患者.根据入院时BUN/Cr的四分位间距,将全部患者分为4组.Q1组(BUN/Cr＜17.00,114例)、Q2组(17.00≤BUN/Cr＜20.73,116例)、Q3组(20.73≤BUN/Cr＜ 25.08,116例)及Q4组(BUN/Cr≥25.08,116例),并随访至2018年12月,定义主要终点事件为全因死亡,评估4组患者之间长期病死率有无差异,并绘制Kaplan-Meier生存曲线.对所有影响患者预后的变量行单因素分析,并将P＜0.05的变量纳入Cox回归模型,对有可能影响患者预后的变量行亚组分析.结果:中位随访时间2.8[1.5,3.8]年,197例(42.6％)患者死亡,其中Q1组37例(18.8％),Q2组52例(26.4％),Q3组47例(23.9％),Q4组61例(31.0％).随BUN/Cr增加,全因死亡发生率增加,4组间累积生存率差异有统计学意义(Log-rank:P=0.001).多因素分析后,Cox回归模型显示,Q4组(BUN/Cr≥25.08)患者病死率是Q1组(BUN/Cr＜17.00)患者的2.30倍[HR=2.30(1.40～3.79),P=0.001].结论:BUN/Cr与急性心衰患者不良预后相关,是全因死亡的独立预测因素.

Objective:To identify the impact of extracorporeal cardiopulmonary resuscitation (ECPR) on neurological outcome and survival in adults with cardiac arrest (CA).Methods:Totally 31 adult patients with ECPR were enrolled from March 2015 to June 2019 in Emergency Department of the First Affiliated Hospital of Nangjing Medical University (Jiangsu People Hospital). Patients were divided to the survival group ( n=12) and death group ( n=19). Duration of conventional cardiopulmonary resuscitation (CCPR) and extracorporeal membrane oxygenation (ECMO) and other mechanical support were compared between groups. Cerebral performance category (CPC) and hospital survival were also evaluated according to the duration of CCPR before ECPR. Results:The duration of CCPR before ECPR was significantly shorter in the survival group than that in the death group ( P=0.002). Duration of ECMO had no significant difference between the two groups ( P=0.478). The location of CA occurrence had no impact on the hospital survival rate ( P=0.716). ECPR in combination with intra-aortic balloon pump (IABP) also had no impact on the hospital survival rate ( P=0.174), and patients received continuous renal replacement therapy (CRRT) had higher hospital survival than patients without CRRT ( P = 0.032). Patients with CCPR duration ≤ 60 min had higher rates of ROSC and hospital survival ( P <0.001). CPC evaluation showed no difference between the two groups. Conclusions:ECMO can provide effective life support to CA patients, and improve their survival rates. It is recommended to initiation of ECMO implantation within 60 min after CCPR.

目的 介绍急性缺血性脑卒中绿色通道信息化建设及其在脑卒中救治工作流程改进中的应用.方法 分析急性缺血性脑卒中绿色通道信息系统设计、构成、特点和应用方法,同时采用便利抽样法选取2017年7月—2018年12月在我院急诊科治疗的急性缺血性脑卒中绿色通道患者作为研究对象,观察组患者应用传统人工流程模式,对照组患者应用信息化流程模式,比较两组流程模式患者入院至溶栓时间.结果 急性缺血性脑卒中绿色通道信息化流程模式优于传统人工流程模式,患者入院至溶栓时间由(48.66±27.12)min缩短至(35.76±16.37)min,差异具有统计学意义(P<0.05).结论 急性缺血性脑卒中绿色通道信息化建设是优化脑卒中绿色通道救治工作流程的有效方法,值得推广和应用.

目的 依据碱缺失(BE)情况探讨创伤性失血性休克早期液体复苏策略.方法 选取创伤性失血性休克患者60例,其中急诊术后无代谢性酸中毒6例,48 h内未纠正代谢性酸中毒13例,48 h内纠正代谢性酸中毒41例.将纠正代谢性酸中毒41例依据BE≤-6 mmol/L、BE＞-6 mmol/L分为重度代谢性酸中毒组29例(A组)、轻度代谢性酸中毒组12例(B组),回顾性分析2组创伤严重程度(ISS)评分、就诊时间、血小板计数、代谢性酸中毒实际纠正时间、输血占比、液体输入速率.结果 A组与B组在补液速率、BE方面比较有显著差异(P＜0.05).结论 对于创伤性失血性休克患者,在损伤出血控制情况下,依据BE值快速选择补液速率可尽早纠正代谢性酸中毒,提高抢救成功率.

目的 分析失效模式与效应分析(FMEA)在急诊静脉血标本质量控制中的应用价值.方法 成立FMEA小组,确定标本采集送检流程,并对失效后果的严重度、失效模式发生概率及可检测程度进行评估;通过分析标本不合格原因,制定相应改进措施.结果 改进后前5项高风险因子失效模式总风险优先指数(RPN)从改进前的1050降至200.改进后,标本不合格率为0.18％(25/14023),明显低于改进前的0.65％(67/10369)(P<0.01).结论 在急诊静脉血标本质量控制中应用FMEA能节约人力资源,缩短标本转运时间,提高标本合格率.

Objective:To explore the treatment effect and the possible protective mechanism of hyperbaric oxygen(HBO) and the ginkgo biloba extract(EGB761) in Alzheimer disease(AD).Methods: One hundred and twenty patients were randomly divided into 4 groups including control group, HBO group, EGB761 group and HBO+EGB761 group.All patients were estimated by MMSE,ADL and ADAS-Cog.The levels of TGF-β1, IL-1β, SOD, MDA and GSH-PX were detected before and after treatment.Results: In our research, the scale assessment had been improved in the treatment of HBO and EGB761, and the combination showed the better.The activities of SOD, GSH-PX and TGF-β1 were increased in HBO, EGB761 and HBO + EGB76l group, compared with the control group, and the levels of MDA and IL-1β were reduced(P<0.05).Further, the combination of HBO and EGB761 showed the better compared with the HBO group and EGB761 group, respectively.Conclusion: The ability of cognition and daily life in AD patients can be improved by combination of HBO and EGB761 in our study, which may be association with the inhibition of oxygen free radical and inflammatory factors by HBO and EGB761 inducing the excessive damage.

Objective:To investigate the relationship between the complete right bundle branch block (CRBBB) patterns and long-term mortality of heart failure (AHF) in Chinese patients.Method:We enrolled 346 patients who had been hospitalized for AHF in cardiovascular department of the First Affiliated Hospital of Nanjing Medical University,from March 2012 to February 2015.The Primary endpoint was all-cause mortality during 18-months follow up.Result:①Thirty-nine participants (i1.3％) dropped out,73 patients (23.8％) dead at the end of this study.②Among the 307 patients,CRBBB was present in 35 patients (11.4％),including 18 patients in the death group and 17 patients in the survivor group,which was statistically significant (P＜0.01).③Kaplan-Meier analysis revealed that patients with CRBBB were at higher risk of death when compared with patients without CRBBB (P＜0.01).④The calculation shows that the specificity of CRBBB for predicting the prognosis of patients with AHF was up to 92.7 ％ (95 ％ CI 88.6 ～ 95.7),and the sensitivity was 24.7 ％ (95 ％ CI 15.3 ～ 36.1).⑤ In COX stepwise regression analysis (forward),after multivariable adjustment,CRBBB was associated with over two-fold increase in mortality[hazard ratio (HR) =3.912,95％CI 2.208～6.933].Conclusion:CRBBB seems to be a promising predictor of long-term mortality in AHF with Chinese patients.

目的:研究脂蛋白相关磷脂酶A2(Lp-PLA2)联合改良版ABCD2评分与轻型缺血性卒中早期神经功能恶化(END)的相关性.方法:本研究共收集148例急性轻型缺血性卒中患者为研究对象,应用改良版ABCD2评分进行风险分层,ELISA法检测患者血浆Lp-PLA2水平.结果:END和无END 2组轻型缺血性卒中患者进行比较,END组Lp-PLA2水平显著升高(P＜0.05).Lp-PLA2与改良版ABCD2评分显著相关(P＜0.05).多因素Cox回归分析结果显示ABCD2评分(≥4分)、大动脉狭窄(≥75％)及Lp-PLA2(＞200 ng/mL)是轻型脑缺血卒中END复合终点事件的预测因素(P＜0.05).结论:Lp-PLA2联合改良版ABCD2评分可提高轻型缺血性卒中END事件的风险预测能力.

目的：探讨脑梗死合并糖尿病患者在磁共振指导下溶栓治疗效果及其预后的影响因素。方法回顾选取溶栓患者109例,根据是否合并糖尿病分为糖尿病组(21例)和非糖尿病组(88例),接诊后对其进行美国国立卫生院卒中量表(NIHSS)评分,进行头颅 MRI 检查；给予 rt-PA 静脉溶栓治疗,溶栓后24 h 及第7 d 进行 NIHSS 评分；3个月后对存活患者进行改良 Rankin 量表(mRS)评定。结果2组患者发病时 NIH-SS 评分无显著统计学差异,糖尿病组患者纤维蛋白原水平较高(3.44±0.86VS 2.88±0.87,P =0.048),3个月预后良好比例(mRS 评分为0-1分)低于非糖尿病组(P =0.013),相关分析显示预后与病情及空腹血糖具有相关性。结论急性脑梗死合并糖尿病患者经头颅 MRI 评价后溶栓治疗较为安全有效,但预后较非糖尿病患者差。

Objective To explore the blood uric acid level in the patients with multiple system atrophy-cerebellar type ( MSA-C) and to discover the relationship between blood uric acid level and the course of MSA. Methods Twenty-one pa-tients with MSA-C in the neurological ward of our hospital from June 2011 to April 2013 were enrolled as observation group. Twenty-two healthy people were enrolled as control group in the same period. The fasting bloods were collected from the elbow venous in the morning and the blood uric acid level was detected. The relationship of blood uric acid level with the course of MSA-C was analyzed. Results The blood uric acid level (279?19±71?48 mmol/L) of the patients with MSA-C was signifi-cantly lower than that of health people (340?96±58?02 mmol/L)(P<0?05). The blood uric acid level was not significantly related with the course of MSA-C ( r=0?041, P=0?859) . Conclusions MSA-C may be influenced by oxidative stress and induce the decrease of blood uric acid level, but the blood uric acid level has no relations with the course of MSA-C.

目的：探讨脑梗死合并心房颤动患者溶栓治疗效果及其预后的相关性。方法回顾性选取溶栓患者78例,根据是否合并房颤分为房颤组(1 8例),非房颤组(60例),接诊后对其进行美国国立卫生院卒中量表(NIHSS)评分,评价头颅 MRI；给予 rt-PA 静脉溶栓治疗,评价24 h及7 dNIHSS 评分；3个月后对存活患者进行改良 Rankin 量表(mRS)评定。结果房颤组发病时病情较重(NIHSS 评分高,(12.8±6.33)分 VS (9.39±4.32)分,P =0.023),血管狭窄发生率较高(66.7% VS 33.3%,P =0.013),继发性出血率较高(27.7% VS 3.33%,P =0.006),2 组 3个月 mRS 评分无显著差异。结论脑梗死合并房颤患者经头颅 MRI评价后溶栓治疗较为安全,预后与非房颤患者无显著差异。

目的探讨颅内静脉窦血栓形成的临床表现和影像学特点以提高该病的诊断。方法对60例颅内静脉窦血栓形成患者的临床特点和影像学检查等客观资料进行总结,并结合文献对其临床特点、发病机制、诊断及鉴别诊断进行分析。结果本组患者多为急性、亚急性起病,临床表现复杂,多有头痛,可伴有恶心、呕吐、癫痫、偏瘫、视力障碍等症状。影像学既可表现为出血也可表现为缺血,49例(49/54)头颅MRV检查示颅内静脉窦血栓形成,27例患者头颅DSA检查均示一处或多处静脉窦狭窄、充盈缺损和显示不良。脑脊液多压力升高,脑电图可有轻度异常。予抗凝等对症支持治疗,预后良好。结论颅内静脉窦血栓形成临床表现复杂多变,头痛是其主要表现,影像学MRV及DSA检查有助于该病诊断,及时治疗预后良好。

对186例化疗置经外周静脉置入中心静脉导管(PICC)病人实施积极有效的护理,积极预防并发症,结果186例病人中发生并发症64例。

Objective To investigate the features of cerebrovascular lesions in patients with posterior circulation ischemia(PCI).Methods CT angiography(CTA) was detected in 74 PCI patients,and the location,nature and extent of the vascular lesions were analyzed.Results There were 61 cases(82.4%) with vascular disease proved by CTA.In which,the vascular atherosclerosis were 8 cases(10.8%),the vascular stenosis were 38 cases(51.4%),the vascular slender were 22 cases(29.7%) and the vascular dysplasia were 12 cases(16.2%);the purely anterior circulation lesions were 7 cases(9.5%),the purely posterior circulation lesions were 21 cases(28.4%) and the vascular lesions with anterior circulation and posterior circulation were 33 cases(44.6%);the main anterior circulation lesion was extracranial internal carotid artery stenosis,and the main posterior circulation lesions were lesions in the ectracranial vertebral artery and posterior cerebral artery;the stenosis degree was most severe in the vascular lesions with anterior circulation and posterior circulation.Conclusions The main locations of vascular lesions in PCI patients are ectracranial vertebral artery and posterior cerebral artery,and then is extracranial internal carotid artery.The main natures of vascular lesions in PCI patients are vascular atherosclerosis and vascular stenosis,and the severe degree is the most.

Objective:To evaluate the predicting value of the marker of endothelial injury:plasma matrix metalloproteinase-9(MMP-9) level on the progression of acute anterior circulating territory infarction progressing to malignant middle cerebral artery infarction(m-MCA). Methods:Eighty-five patients with acute anterior circulating territory infarction,in which 45 patients progressed to m-MCA,were collected and sampled consecutively. The plasma MMP-9 and C-reactive protein(CRP) of all patients were determined by means of ELISA and immunoturbidimetry,respectively,at admission. And the clinical characters and cranial CT features of the patients were analysed. Results:At admission,the plasma MMP-9 level in the patients with m-MCA(230.0 ± 60.5 ng/ml) was significantly higher than that in the patients with non m-MCA(174.0 ± 56.0 ng/ml)(P 0.001),while the plasma CRP levels between m-MCA and non m-MCA patients had no significant difference(8.8 ± 3.8 ng/ml vs 8.5 ± 4.0 ng/ml,P 0.05). The sensitivity and specificity of serum MMP-9≥220 ng/ml to predict m-MCA were 89% and 95%, respectively. Conclusion:The increased level of plasma MMP-9 may be a predictor to the m-MCA proceeding.