Patch-based adversarial attacks were proven to compromise the robustness and reliability of computer vision systems. However, their conspicuous and easily detectable nature challenge their practicality in real-world setting. To address this, recent work has proposed using Generative Adversarial Networks (GANs) to generate naturalistic patches that may not attract human attention. However, such approaches suffer from a limited latent space making it challenging to produce a patch that is efficient, stealthy, and robust to multiple real-world transformations. This paper introduces a novel approach that produces a Dynamic Adversarial Patch (DAP) designed to overcome these limitations. DAP maintains a naturalistic appearance while optimizing attack efficiency and robustness to real-world transformations. The approach involves redefining the optimization problem and introducing a novel objective function that incorporates a similarity metric to guide the patch's creation. Unlike GAN-based techniques, the DAP directly modifies pixel values within the patch, providing increased flexibility and adaptability to multiple transformations. Furthermore, most clothing-based physical attacks assume static objects and ignore the possible transformations caused by non-rigid deformation due to changes in a person's pose. To address this limitation, a 'Creases Transformation' (CT) block is introduced, enhancing the patch's resilience to a variety of real-world distortions. Experimental results demonstrate that the proposed approach outperforms state-of-the-art attacks, achieving a success rate of up to 82.28% in the digital world when targeting the YOLOv7 detector and 65% in the physical world when targeting YOLOv3tiny detector deployed in edge-based smart cameras.

急性主动脉夹层(acute aortic dissection,AAD)是严重影响人类生命健康的大血管疾病,其临床治疗方案选择是住院医师培训的重点和难点.案例教学法(case-based learning,CBL)是指以案例为教材,在教师的指导下,运用多种方式启发学生独立思考,从而达到教学目的的一种教学方法.现从教学目标的确定、教案的设计、教学实施、教学评价及移动学习课程5个方面介绍了CBL教学法在AAD疾病教学工作中的初步探索过程.

主动脉夹层指主动脉腔内血液从主动脉内膜撕裂处进入主动脉中膜,使中膜分离,沿主动脉长轴方向扩展形成主动脉壁的真假两腔分离状态,发病时间<14 d为急性期.本病虽少见,但死亡率甚高[1].如不及时治疗,2周内死亡率达90％以上.急性主动脉夹层(AAD)临床表现多样,病情变化复杂,误诊率和漏诊率高,导致大多数患者得不到及时有效的治疗[2].

目的:探讨心外膜左心耳夹闭在心房颤动外科治疗中的安全和有效性,为心房颤动治疗提供临床选择.方法:回顾性分析2019年1月至2020年12月,首都医科大学宣武医院心脏外科收治的单组心心房颤动动病例的临床资料,其中男15例,女15例,年龄39～86岁,平均年龄(63.7±9.5)岁.阵发性心房颤动22例,持续性心房颤动8例,其中长期持续性心房颤动5例.入组患者中,孤立性心房颤动7例,合并冠心病18例,瓣膜病2例,房间隔缺损1例,同时合并冠心病和瓣膜病2例.所有患者均接受心外膜左心耳夹闭治疗及其他相应手术.患者出院前均行头颅磁共振及心脏CTA检查,以评估左心耳闭合效果、心耳夹移位情况以及有无心房颤动相关脑卒中.结果:所有患者行心外膜左心耳夹闭术,其中单纯行左心耳夹闭7例,同期联合单纯冠状动脉移植术18例,联合冠状动脉旁路移植术和二尖瓣置换术1例,联合冠状动脉移植术、二尖瓣成形和射频消融术1例,联合房间隔缺损修补和三尖瓣成形1例,联合二尖瓣成形和置换术各1例.16例患者采用传统胸骨正中切口,14例采用小切口技术,其中左侧肋间小切口 12例,胸骨倒"L"型小切口 2例.7例孤立性心房颤动患者采用电视胸腔镜下左侧肋间小切口技术,手术时间44～66 min,平均(56.0±7.9)min.围手术期死亡患者2例,死因均为心力衰竭继发多脏器衰竭.术后随访6～10个月,平均(6.8±1.4)个月;随访期间,1例患者因长期营养不良、肺部和手术切口感染并发呼吸衰竭和败血症死亡;所有随访患者无心房颤动相关卒中症状及体征,头颅磁共振检查未见新发脑梗死病灶;心脏CTA显示左心耳血流沟通及左心房血栓形成,无心耳夹移位、变形表现.结论:心外膜左心耳夹闭是治疗心房颤动安全可行的外科方案,可作为临床外科医师治疗心房颤动的新策略.

Objective To report a case of atrial septal defect (ASD) with congenital fibrinogen deficiency (CFD), and review the literature. Methods A case of secondary ASD with CFD treatment in Xuanwu Hospital of Capital Medical University was reported, and the defect was repaired under CPB on beating heart. The management experience of cardiac surgery under CPB in patients with CFD was summarized by means of PubMed database and literature analysis. Results This patient was female, 30 years old. She was admitted to the hospital with the complaint that ASD was found for 8 months after physical examination. On admission, echocardiography showed that the atrial septum was interrupted by about 34 mm. Color Doppler flow imaging (CDFI) detection indicated systolic left to right shunt, the pressure difference of tricuspid regurgitation was 66 mmHg, systolic pulmonary artery pressure (SPAP) was 76 mmHg, ejection fraction (EF) was 64%. Coagulation function: Prothrombin time was >120 s, thrombin time >240 s, activated partial thrombin time >180 s, and fibrinogen 1.5 g. Three days later ASD repair was performed under CPB on beating heart. Infusion of fibrinogen 2 g was performed by venous injection during operation, and another fibrinogen 2 g was given after heparin was neutralized by protamine. Operation time was 3.5 hours, and CPB time was 45min. Fibrinogen 4 g per day was supplemented postoperatively for 5 days. At the 3rd day chest drainage tube was removed. The patient was discharged at the 7th day. There were no hemorrhage and thrombosis complications. After 3 months, outpatient follow-up showed the surgical incision healed well, echocardiography showed no residual shunt in the atrial septum, and EF value was 67%. A total of 8 English literatures were obtained after searching PubMed database and manually screening, including 875 patients with hypofibrinogenemia after CPB cardiac surgery. Among them, 604 were males (69.0%) and 271 were females (31.0%). There were 6 case reports, including 1 infant (5 days old, weight 2.5 kg) and 5 adult cases, and they were all male. Patients with abnormal afibrinogenemia may have both bleeding and thromboembolic symptoms. Patients with fibrinogen deficiency who undergo CPB cardiac surgery need to be supplemented with fibrinogen, cryoprecipitation or fresh frozen plasma during the perioperative period to prevent severe postoperative bleeding complications. Conclusion Patients with fibrinogen deficiency should be given a individualized perioperative management plan according to the quantitative and other coagulation indexes of fibrinogen in plasma for cardiac surgery under CPB. DOI: 10.11855/j.issn.0577-7402.2021.03.07

目的 分析14例三尖瓣机械瓣置换术的临床效果和患者生存情况,以提高三尖瓣疾病手术疗效.方法 分析2010年1月至2019年5月期间于北京安贞医院心脏外科十病房接受三尖瓣位机械瓣置换外科手术的14例患者的临床资料,其中女性9例(64.3％),男性5例(35.7％),平均年龄(51.2±8.3)岁;术前心功能(NYHA分级):Ⅱ级2例,Ⅲ级10例,Ⅳ级2例;术前经胸超声心动图显示,风湿性病变(8例),发育不全(3例),Ebstein畸形(2例),法洛四联症术后(1例).患者均接受三尖瓣机械瓣置换术,并对术后患者住院期间及远期情况进行随访总结.结果 14例患者住院期间2例死亡(住院死亡率14.2％),1例术后并发急性肾功能衰竭,术后97 d出院.随访11例,随访率91.7％,平均随访时间(54.3±15.2)月;随访患者术后心功能(NYHA分级)Ⅰ级1例(9.1％),Ⅱ级8例(72.7％),Ⅲ级2例(18.2％);1例术后3个月发生三尖瓣瓣周漏,再次行三尖瓣生物瓣置换;其余患者随访期间无死亡及瓣膜相关心血管事件.结论 尽管三尖瓣机械瓣置换手术适应症要求严格,手术风险高,但手术方式可行,术后效果理想;对于无法行三尖瓣修复或修复效果不理想的患者,三尖瓣机械瓣置换是可行的.

目的 探讨高龄因素对冠状动脉旁路移植术(CABG)治疗安全性的影响及围术期管理.方法 收集2016年1月至2019年2月于首都医科大学宣武医院接受CABG治疗冠状动脉(冠脉)病变70岁以上高龄患者共71例,其中男性48例,女性23例,发病年龄为(70～83)岁,平均为(74.23±6.8)岁.按照手术方法的不同,分为停跳和不停跳两组,比较两组患者的术前、围手术期以及住院死亡的情况.结果 高龄患者中,53例实施了停跳CABG治疗,18例实施了不停跳CABG治疗.高血压和糖尿病病史多见于停跳CABG治疗的患者,差异有显著统计学意义(P<0.01),其他合并症两组间均无统计学差异(P>0.05).冠脉三支病变患者接受停跳CABG治疗比例高于不停跳CABG患者,差异有统计学意义(P<0.01).在CABG中,使用左侧乳内动脉和完全血管重建多见于停跳CABG治疗中,差异有统计学意义(P<0.01).胸腔积液多见于不停跳CABG治疗后的患者,差异有统计学意义(P<0.05),其他术后并发症两组之间均无统计学差异(P>0.05).总住院时间为(19.1±7.3)d,住院死亡率为5.6％,两组之间均无统计学差异(P>0.05).结论 术前全面详尽检查,术中严密监测生命体征、维持血流动力学稳定,及早发现并处理并发症,对于高龄患者行CABG具有重要意义.

Objective To improve the diagnosis and treatment of coronary heart disease with carotid stenosis, explore synchronous hybrid treatment for coronary heart disease with severe carotid stenosis and review of literature. Methods A case of one-stop carotid artery stenting (CAS) and coronary artery bypass grafting (CABG) hybrid surgical treatment of coronary heart disease with severe carotid stenosis was reported in present paper. Searching the China National Knowledge Infrastructure (CNKI) and PubMed databases, several literatures were retrieved and analyzed to summarize the experience of diagnosis and treatment of coronary heart disease with severe carotid stenosis. Results A 64-year-old male patient was admitted to our hospital due to intermittent chest tightness for more than one month. Imaging examination, including coronary angiography, carotid ultrasound and cerebral vessel angiography, showed that severe coronary heart disease with bilateral carotid stenosis and obvious cerebral ischemia in the right brain hemisphere. Operation for right carotid artery was first performed under local anesthesia, and then the off-pump CABG was carried on under general anesthesia. Operation procedure was going well, and the recovery was good. The patient was followed up 3 months after operation, and there was no chest tightness and head-neck discomfort. Fourteen articles were obtained through database retrieval, and a total of 590 patients were reported including 427 male cases (72.4%) and 163 female cases (27.6%). All of them were treated at same stage with first CAS and sequential CABG. The interval between CAS and CABG was less than 24 hours. Findings indicated that postoperative stroke in 21 cases (3.5%), perioperative myocardial infarction in 11 cases (1.8%) and in-hospital death in 26 cases (4.4%). The follow-up results were satisfactory. Conclusion One-stop CAS and CABG hybrid treatment is one of good therapeutic options for patients with coronary heart disease and carotid stenosis, but this operation needs to be carried out in the hybrid operation room, and the technical requirements for the surgeons are relatively high. DOI: 10.11855/j.issn.0577-7402.2019.11.10