急性冠脉综合征如何进行抗血小板治疗

急性冠脉综合征(acute coronary syndrome,ACS)是以冠状动脉粥样硬化斑块破裂或侵袭,继发完全或不完全闭塞性血栓形成为病理基础的一组临床综合征,包括急性ST段抬高型心肌梗死、急性非ST段抬高型心肌梗死和不稳定型心绞痛(UA)。血栓形成是ACS发病的病理基础。ACS的发病机制为长期冠脉血管内皮功能障碍及炎症反应导致斑块形成,急性发作期表现为斑块破裂或侵蚀,导致血小板聚集并形成血栓从而引起心肌细胞损伤。ACS在全球的发病率和死亡率高,无论在发达国家还是发展中国家,ACS都是导致死亡的重要原因之一。目前冠心病仍是人类,尤其是高龄患者致死的最主要原因,同时中青年人群中其发病率及死亡率也呈急剧上升趋势。针对急性冠脉综合征治疗,无论选择保守药物治疗还是选择PCI开通血管使心肌充分再灌注治疗,均以抗血小板聚集治疗为治疗基石。     

辽西地区急性ST段抬高型心肌梗死救治延迟影响因素分析

了解目前辽西地区急性ST段抬高型心肌梗死患者院前及院内救治延迟的状况和影响因素。连续入选就诊于锦州医科大学附属第一医院发病在12h内并行直接经皮冠状动脉介入治疗(PCI)的急性ST段抬高型心肌梗死患者82例。性别、交通情况、发病地点及对疾病的认知是症状入门(S2D)时间的影响因素。交通情况、对疾病的认知是S2D时间3h的独立预测因素。谈话时间、导管室人员到达时间及准备手术时间是入门球囊(D2B)时间的主要影响因素。建立急性心肌梗死救治项目是D2B时间90min的保护预测因素。建立急性心肌梗死救治项目前后比较,D2B时间明显缩短,说明该项目对缩短D2B时间有重要意义。     

导言:冠心病的抗血小板治疗越来越重要

正众所周知,各种类型冠心病的发病、并发症的发生以及动脉硬化的进展过程都有血小板的参与,因此冠心病的抗血小板治疗已成为冠心病尤其是急性冠脉综合征治疗的基石,抗血小板治疗的重点应是急性冠脉综合征的患者[不稳定型心绞痛(UA);非ST段抬高型心肌梗死(NSTEMI);ST段抬高型心肌梗死(STEMI)]、经皮冠状动脉介入治疗(PCI)围手术期治疗、STEMI溶栓治疗的辅助治疗、冠状动脉旁路移植术(CABG)术后的治疗结合个体参照     

急性心肌梗死患者院前延误的影响因素

急性心肌梗死(AMI)患者的治疗关键在于早期诊断和及时开通闭塞的冠状动脉,患者在发病后能否及早到院接受再灌注治疗,对患者的治疗效果和预后有重要影响.院前延误时间(PDT)即为从患者出现症状至到达医院接受治疗的时间.AMI患者就医大多是延迟的,主要原因是患者不能决定自己的症状是否需要治疗,也就是患者决定就医时间延长.本研究目的是分析造成急性心肌梗死患者院前延误的相关影响因素,为患者赢得最佳治疗时间提供理论依据.     

aVR导联ST段下移对急性下壁心肌梗死罪犯血管的预测价值

本研究选择急性下壁心肌梗死患者185例,回顾性分析其心电图改变及冠脉造影结果,以评估aVR导联ST段下移对急性下壁心肌梗死罪犯血管的预测价值.结果显示aVR导联ST段下移预测左冠状动脉回旋支闭塞的特异性88.0％,敏感性51.2％,阴性预测值85.6％,阳性预测值56.4％.提示aVR导联ST段下移可以用来预测急性下壁心肌梗死左冠状动脉回旋支闭塞,其预测特异性较高,敏感性一般.     

急性ST段抬高型心肌梗死患者院前延误的相关因素

本研究的目的是评估急性心肌梗死患者院前延误的原因,包括社会经济学和个人因素等。选取327例急性ST段抬高型心肌梗死(STEMI)患者,详细记录患者人口学资料,受教育水平,婚姻状况,何种方式就诊于医院及院前延误时间。35.7%的患者在症状发作的2小时内到达医院,7.9%患者在症状发作24小时后到达医院。经多因素回归分析,已婚,高学历,既往有心肌梗死病史,将自己的症状归结为心脏原因,具有的疼痛症状和非疼痛症状数量多,发病时不在家,发病时有陪同者,发病后呼叫EMS是院前延误时间短的相关因素(P0.05)。增加患者对心血管症状和危险因素的认识,教育患者一旦出现症状,立即呼叫急救系统可能缩短院前延误时间。     

《黄帝内经》时间医学思想对急性心肌梗死时间节律的解释

《黄帝内经》“天人相应”理论比较完备地奠定了中医关于人体生物节律知识的基础,强调人体自然节律与四季日月昼夜节律之间的密切关系。在急性心肌梗死发病呈现显著的时间节律特征,以中医时间学理论进行解释,充分掌握急性心肌梗死发病的规律性,指导高危人群合理作息,减少急性心梗的发生。     

急性心肌梗死合并心源性休克的治疗进展

心源性休克(CS)是急性心肌梗死死亡的最主要原因。急诊再血管化治疗PCI或者冠状动脉旁路移植术(CABG)对于降低急性心肌梗死(AMI)合并CS的病死率有积极的意义。目前还没有哪个随机对照试验明确PCI或CABG哪种更好,但目前的治疗倾向于急诊PCI。合并CS的AMI患者直接多支血管PCI治疗获益增加。对于血压偏低的患者,去甲肾上腺素应该作为缩血管药物的一线选择。靶目标平均血压维持在65mmHg~70mmHg,因为更高的血压不增加临床获益。最佳的多器官功能不全综合征治疗是CS治疗的基石。经皮机械辅助装置临床应用逐渐广泛,可以提高冠状动脉的灌注,但也加剧炎症反应、出血等风险。     

《黄帝内经》时间医学思想对急性心肌梗死时间节律的解释

<黄帝内经>"天人相应"理论比较完备地奠定了中医关于人体生物节律知识的基础,强调人体自然节律与四季日月昼夜节律之间的密切关系.在急性心肌梗死发病呈现显著的时间节律特征,以中医时间学理论进行解释,充分掌握急性心肌梗死发病的规律性,指导高危人群合理作息,减少急性心梗的发生.     

冠状动脉造影术并发症的预防及护理

冠状动脉造影是观察冠状动脉血管病变为主体的心血管血液动力学和形态学的综合技术,作为冠心病的主要检查手段之一,已在临床上广泛应用与推广。因冠状动脉造影术是一种有创性诊断技术,因此术中可能会发生各种并发症甚至死亡。最常见的并发症有：心绞痛、急性心肌梗死、急性冠脉痉挛、血栓栓塞、心包填塞、低血压、心律失常（房颤、室颤、传导阻滞等）、穿刺部位血管损伤（出血、血肿、假性动脉瘤）、血管迷走神经反应等。现将其术中并发症的预防及护理报告如下：     

Attitudes to suffering: Parfit and Nietzsche

Abstract

In On What Matters, Derek Parfit argues that Nietzsche does not disagree with central normative beliefs that ‘we’ hold. Such disagreement would threaten Parfit’s claim that normative beliefs are known by intuition. However, Nietzsche defends a conception of well-being that challenges Parfit’s normative claim that suffering is bad in itself for the sufferer. Nietzsche recognizes the phenomenon of ‘growth through suffering’ as essential to well-being. Hence, removal of all suffering would lead to diminished well-being. Parfit claims that if Nietzsche understood normative concepts in Parfit’s objectivist sense, he would not disagree with the claim that suffering is bad in itself – that intrinsic facts about suffering count in favour of our not wanting it. I argue that Nietzsche would disagree. Suffering for Nietzsche is not merely instrumentally necessary for psychological growth, nor is it easy to construe it as something bad in itself that contributes value as part of a good whole. Suffering that can be given meaning through growth is something we have reason to want. Suffering that remains brute and uninterpreted is something we have reason not to want. But for Nietzsche, suffering as such has no invariant value across all contexts.     

Physician Aid-in-Dying and Suicide Prevention in Psychiatry: A Moral Crisis?

Involuntary psychiatric commitment for suicide prevention and physician aid-in-dying (PAD) in terminal illness combine to create a moral dilemma. If PAD in terminal illness is permissible, it should also be permissible for some who suffer from nonterminal psychiatric illness: suffering provides much of the justification for PAD, and the suffering in mental illness can be as severe as in physical illness. But involuntary psychiatric commitment to prevent suicide suggests that the suffering of persons with mental illness does not justify ending their own lives, ruling out PAD. Since both practices have compelling underlying justifications, the most reasonable accommodation might seem to be to allow PAD for persons with mental illness whose suffering is severe enough to justify self-killing, but prohibit PAD for persons whose suffering is less severe. This compromise, however, would require the articulation of standards by which persons’ mental as well as physical suffering could be evaluated. Doing so would present a serious philosophical challenge.     

谁是最大的受害群体:群际受害者竞争

长期冲突的群体双方都致力于建构自己的最大受害者角色,他们认为自己比对方遭受了更多、更不公平、更不合理的伤害,这种现象称之为群际受害者竞争。群体通过强调冲突给自身造成的伤害后果的严重性与不公平性、伤害的处理方式等,努力声称内群体比对方遭受了更多的伤害。集体受害感、冲突责任归因、记忆的选择性、消除威胁的内在需要以及其他心理特点是群际受害者竞争的心理基础。通过构建"共同的受害者-侵犯者"认同以及增加群际接触等可以降低群际受害者竞争的水平,促进群际关系的和谐。今后的研究需要进一步完善群际受害者竞争的机制,深入探讨群际受害者竞争的其他影响因素,争取在干预策略上有所突破,关注非暴力冲突的群体情境中群际受害者竞争的特点,了解第三方群体对谁是最大受害者群体的认知和评价机制。     

The “Loving Parent” analogy

A crucial part of William Rowe’s evidential argument from evil implies that God, like a loving parent, would ensure that every suffering person would be aware of his comforting presence. Rowe’s use of the “loving parent” analogy however fails to survive scrutiny as it implies that God maximally loves all persons. It is the argument of this paper that no one could maximally love every person; and whatever variation there is in the divine love undercuts the claim that every suffering person would be aware of the divine presence.     

Assisted Suicide,Suffering and the Meaning of a Life

The ethical problems surrounding voluntary assisted suicide remain formidable, and are unlikely to be resolved in pluralist societies. An examination of historical attitudes to suicide suggests that modernity has inherited a formidable complex of religious and moral attitudes to suicide, whether assisted or not. Advocates usually invoke the ending of intolerable suffering as one justification for euthanasia of this kind. This does not provide an adequate justification by itself, because there are (at least theoretically) methods which would relieve suffering without causing the physical death of the suffering person. Carried to extremes, these methods would finish the life worth living, but leave a being which was technically alive. Such acts, however, would provide no moral escape, since they would create beings without meaning. Arguments seeking to justify ending the lives of others need some grounding in concepts of the meaning of a life. The euthanasia discourse therefore needs to take at least some account of the meaning we construct for our lives and the lives of others.     

Torture and judgments of guilt

Although torture can establish guilt through confession, how are judgments of guilt made when tortured suspects do not confess? We suggest that perceived guilt is based inappropriately upon how much pain suspects appear to suffer during torture. Two psychological theories provide competing predictions about the link between pain and perceived blame: cognitive dissonance, which links pain to blame, and moral typecasting, which links pain to innocence. We hypothesized that dissonance might characterize the relationship between torture and blame for those close to the torture, while moral typecasting might characterize this relationship for those more distant from it. Accordingly, this experiment placed participants into one of two different roles in which people may be exposed to torture. Participants in the proximal role of prison staffer saw suffering torture victims as relatively more guilty, while participants in the relatively distant role of a radio listener saw suffering victims as more innocent.     

Adapted motivational interviewing for women with binge eating disorder: a randomized controlled trial

In this randomized controlled trial, 108 women with binge-eating disorder (BED) recruited from the community were assigned to either an adapted motivational interviewing (AMI) group (1 individual AMI session + self-help handbook) or control group (handbook only). They were phoned 4, 8, and 16 weeks following the initial session to assess binge eating and associated symptoms (depression, self-esteem, quality of life). Postintervention, the AMI group participants were more confident than those in the control group in their ability to change binge eating. Although both groups reported improved binge eating, mood, self-esteem, and general quality of life 16 weeks following the intervention, the AMI group improved to a greater extent. A greater proportion of women in the AMI group abstained from binge eating (27.8% vs. 11.1%) and no longer met the binge frequency criterion of the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; American Psychiatric Association, 2000) for BED (87.0% vs. 57.4%). AMI may constitute a brief, effective intervention for BED and associated symptoms.     

暴食症的诊断、治疗及其疗效

暴食症已成为目前世界上广泛流行的三大进食障碍之一,我国患者亦不在少数并有增加之势,但对暴食症的研究与治疗尚属起步阶段。文章回顾了暴食症的表征及其诊断技术,简要介绍了常见的三种治疗方法（即行为疗法、认知疗法及伴随症状改善法）,并讨论了影响暴食症疗效的诸个体因素。暴食症的诊断主要是根据美国精神疾病诊断与统计手册第四版（DSM-IV）、进食障碍检测评估表（EDE）（治疗者用）和患者用进食障碍检测问卷（EDE-Q）（患者用）,并结合过往病史和伴随症状。三类治疗方法在理论与操作层面各有倚重,均可收到一定治疗效果。但各疗法的效果与预后会因患者而异甚或迥乎相异,这是因为暴食症疗效还受到患者自身人格、社会和认知诸因素的影响,治疗者应根据特定患者选择适合该患者的疗法。     

The problem of evil: skeptical theism leads to moral paralysis

Natural disasters would seem to constitute evidence against the existence of God, for, on the face of things, it is mysterious why a completely good and all-powerful God would allow the sort of suffering we see from earthquakes, diseases, and the like. The skeptical theist replies that we should not expect to be able to understand God’s ways, and thus we should not regard it as surprising or mysterious that God would allow natural evil. I argue that skeptical theism leads to moral paralysis: accepting skeptical theism would undermine our ability to make any moral judgments whatsoever. Second, and more briefly, I argue that skeptical theism would undercut our ability to accept any form of the argument from design, including recent approaches based on fine-tuning.     

Is Religious Coping Related to Better Quality of Life Following Acute Myocardial Infarction?

Although few studies have examined the extent to which religiousness is related to better well-being following acute myocardial infarction (AMI), studies from the broader literature suggest that positive religious coping may be helpful while more negative forms of religious coping may be related to poorer well-being. To assess the relationship between positive and negative religious coping and depressive symptoms in patients with AMI, we collected data twice over a 1-month period from 56 patients hospitalized with a first AMI. Controlling for demographic variables and social support, both positive and negative religious coping were independently related to higher levels of depressive symptoms both in hospital and at a one-month follow-up. Further, even when controlling for baseline depressive symptoms, religious coping predicted higher subsequent depressive symptoms. These results suggest that religious coping appears to be maladaptive in dealing with acute MI, perhaps because this type of recovery requires more active forms of coping.