52例严重烧伤休克期血流动力学变化监测

目的观察休克期血流动力学监测对复苏的指导意义。方法采用血流动力学监测仪,对我科１９８５～１９９６年烧伤总面积在（６９９±２０１）％,Ⅲ度面积（６０４±１３６）％,且人院后均置入ＳｗａｎＧａｎｚ飘浮导管的５２例烧伤病人的右房压（ＲＡＰ）、肺动脉压（ＰＡＰ）、肺动脉楔嵌压（ＰＡＷＰ）、心率（ＨＲ）、心排量（ＣＯ）、心排指数（ＣＩ）、每搏指数（ＳＩ）,于入院时及伤后８,１６,２４,４８,７２,９６ｈ进行了动态监测。结果休克期实施有创血流动力学监测是安全的,无一例发生并发症;休克病人在烧伤后２４ｈ各项血流动力学指标基本恢复了正常。结论烧伤休克期实施有创血流动力学监测对指导复苏具有重要意义。     

延迟快速复苏对烧伤休克循环影响的临床研究

目的探讨在烧伤延迟复苏情况下,如何迅速纠正休克.方法通过对20例烧伤面积大于40%TBSA、因延迟复苏导致休克的患者,进行延迟快速复苏.观察休克期液体出入量、动咏压(BP)、肺动脉压(PAP)、肺动脉楔状压(PAWP)、中心静脉压(CVP)、心输出量(CO)、肺血管阻力(PVR)、外周血管阻力(SVR)、氧供应(DO2)、氧消耗(VO2)、氧摄取率(O2ext)、乳酸(LA)及碱缺失(BD)等血流动力学和氧代谢指标的变化.结果快速补液后2h内输入液体占“第一个24h公式计算量”的(38.8±6.1)%,如果加上院外补液量则占“第一个24h公式计算量”的(48.3±5.0)%.第一个24h实际补入量占“第一个24h公式计算量”的(131.4±14.3)%;第二个24h实际补入量占“第二个24h公式计算量”的(103.2±7.2)%.快速补液后,尿量大幅增加,CO显著升高,DO2增强,SVR、LA、BD大幅下降,PVR虽大幅升高,但PAWP、PAP和CVP并未超过正常.结论在严密血流动力学监护下,烧伤后延迟复苏初期加快补液速度是可行且有益的,烧伤休克的延迟复苏需要显著增加补液量.指导休克延迟快速复苏应以监护心输出量及PAP、PAWP、CVP等血流动力学指标为主,辅以血中LA、BD水平及尿量变化等临床指标的监测.     

心脏术后感染性休克早期优化目标导向治疗分析

目的通过漂浮导管(Swan-Ganz导管)监测外周血管阻力指数(SVRI)作为优化的心功能不全状态下感染性休克早期目标导向治疗(EGDT)的临床意义。方法 2012年1月至2014年1月第四军医大学附属西京医院心血管外科ICU收治体外循环心脏术后感染性休克患者8例,其中男7例、女1例,年龄(50.9±11.1)岁。以中心静脉压(CVP)为复苏目标行经验性容量复苏治疗,循环未见改善,则实施漂浮(Swan-Ganz)导管监测血流动力学指标,以外周血管阻力指数(SVRI)为优化目标复苏,观察Swan-Ganz导管复苏前及复苏6 h、24 h后的血流动力学及氧代谢指标,分析复苏达标所需时间。结果 8例患者平均住ICU时间(16.87±3.35)d,发生肺部并发症8例,急性肾功能衰竭5例,急性肝功能衰竭1例,消化道出血1例。6例28 d后病情好转存活,死亡2例。8例感染性休克患者经Swan-Ganz导管目标导向治疗6 h和24 h后平均动脉压(MAP)分别为(65.8±2.76)mm Hg、(67.8±3.79)mm Hg,中心静脉压(CVP)分别为(12.75±3.37)cm H2O、(9.75±2.86)cm H2O,心排血量指数(CI)分别为(2.36±0.12)L-·min1·m-2、(2.41±0.39)L·min-1·m-2,外周血管阻力指数(SVRI)分别为(1 892.60±2 294.62)dyn·s·m2·cm-5、(2 053.90±205.54)dyn·s·m2·cm-5,各项指标均较治疗前升高;治疗6 h和24 h后动脉血乳酸分别为(11.83±1.16)mmol/L、(6.47±2.59)mmol/L,较治疗前[(14.98±0.45)mmol/L]下降。结论采用Swan-Ganz导管监测SVRI作为优化目标导向治疗心功能不全状态下感染性休克可以提高6 h复苏成功率,改善患者预后。     

高张氯化钠右旋糖酐液在犬烧伤休克延迟复苏中的作用

目的从血流动力学、心肌力学及代谢等方面探讨高张氯化钠右旋糖酐液(7.5%氯化钠 6%右旋糖酐70,HSD)在烧伤休克延迟复苏中的作用。方法采用犬35%TBSAⅢ度烧伤模型,伤后6 h 分别用乳酸林格液及 HSD 进行复苏,并以每 h 尿量为1.0ml/kg 及心输出量为伤前值的70%～80%来调整输液速度及输液量,观察 HSD 在复苏中容量负荷、左心室等容收缩期最大压力变化速率及左心室舒张期压力下降最大变化速率(±dp/dt_(max))、心脏指数(CI)、氧供给(DO_2)及氧消耗(VO_2)等的变化。结果 HSD 在烧伤休克延迟复苏伤后第一个24 h 输液量比乳酸林格液复苏少30.56%,其中复苏后4 h 的输液量比乳酸林格液少59.50%,在复苏后0.5～2 h, dp/dt_(max)、CI、DO_2及 VO_2的增加幅度明显高于乳酸林格液复苏。结论 HSD 在烧伤休克延迟复苏中具有容量负荷小、改善心肌功能及促进组织代谢等作用。     

评估Parkland公式治疗烧伤休克的实验研究

为了探讨按 Parkland 公式补液治疗烧伤休克的效果及其是否遗留缺氧性损害,将22只雄性杂种犬致50%Ⅲ度烧伤,随机分成两组,即伤后不输液组(14只),及伤后按 Parkland 公式立即输液组(8只)。致伤前以 Swan-Ganz 导管插入犬的肺动脉,分别于伤前,伤后2、6、12、18、24、36、48、60及72h 对其股动脉压、中心静脉压、肺动脉压、心排出量和血气分析进行监测,结果表明,不输液组犬均在伤后12 h 内死亡,而输液组犬均渡过休克期。但在这些生存犬中,伤后18 h 内仍有明显的心输出量和氧耗量降低。提示:按 Parkland 公式补液仍不能完全纠正组织灌流不足而遗留缺氧性损害。故仍需对烧伤休克的早期液体复苏和综合治疗加以改进,以提高心输出量和改善组织供氧不足。     

犬烧伤休克延迟复苏的实验研究

目的探讨应用林格液进行烧伤休克延迟复苏的效果.方法12只犬随机分为对照组(S组,6只)和治疗组(LR组,6只).LR组采用35%TBSAⅢ度烧伤模型,伤后6h以乳酸林格液进行复苏,并以尿量为1.0ml@kg-1@h-1及心输出量为伤前值的70%～80%来调整输液速度及输入量,观察其在伤后第一个24h复苏中的容量负荷、平均动脉压(MAP)、左心室收缩压(LVSP)、左室内压最大上升/下降速率(±dp/dtmax)、心脏排血指数(CI)、氧供给(DO2)及氧消耗(VO2)等的变化.结果乳酸林格液在烧伤休克延迟复苏后第一个24h的复苏中,每1%烧伤面积的输液量为(887±1.02)ml/kg,比采用Parkland公式复苏多1.2倍,其中在复苏后4h内的输液量为(3.63±0.99)ml/kg,为总入量的41%;MAP、LVSP、±dp/dtmax、CI、DO2及VO2等指标在复苏后2h即达到或接近对照组水平.结论乳酸林格液在烧伤休克延迟复苏中,比早期复苏需要更多的液体量才能满足需求,而血流动力学、心肌功能及氧动力学等在复苏后2h即有明显改善.     

严重烧伤抗休克时胃肠粘膜内缺血的研究

目的探讨烧伤早期胃肠缺血(pHi 降低)的发生规律。方法采用模拟临床的 TBSA30％Ⅲ度烧伤小型猪模型,从血流动力学、胃肠缺血、血液流变学等方面探讨烧伤早期胃肠缺血的发生规律及相关因素。伤后1小时开始复苏,按 Parkland 公式补充平衡液。结果烧伤后平均动脉压(MAP)无明显变化,但右房压(RAP)、平均肺动脉压(MPAP)、肺动脉楔压(PAWP)及心排指数(CI)等均显著下降,于伤后48小时降至谷值,经复苏后于24小时恢复正常。胃肠 pHi 于伤后1小时就迅速下降,并且恢复缓慢,伤后72小时仍未达到正常。门脉血流量也呈类似变化,并且与肠 pHi 呈显著正相关。门脉全血粘度及血浆粘度均在伤后有明显的提高。结论①胃肠缺血发生早、恢复慢。②与血流动力学变化不一致。③常规液体复苏疗法不易纠正。④门脉血液流变学变化可能加重胃肠缺血损伤。     

严重烧伤休克期大面积切痂对休克复苏的影响

目的 评价休克期大面积切痂对休克复苏的影响。方法 采用40％TBSAⅢ度烫伤犬模型,随机分为切痂组(E组)和非切痂组(C组)。两组动物于伤后1h按parkland公式补充复方乳酸钠溶液复苏,E组在伤后3h切除全部焦痂,立即植以新鲜异体皮。动态观察血流动力学、血液流变学、氧供、氧耗和血乳酸的变化。结果两组犬烫伤后30min均立即发生严重休克,心排出量(CO)、心脏指数(CI)、左心作功指数(LVWI)显著降低,全血粘度、血浆粘度、红细胞聚集指数、血浆乳酸含量明显增加。E组动物伤后3h切痂,CO、CI、血液流变学和乳酸含量较术前及C组均有明显改善。结论 烧伤后单纯补液不能较快纠正休克,休克期大面积切痂是安全可行的,并能有效纠正休克。     

内毒素休克时抑制NO对血流动力学的影响

目的:探讨内毒素休克时血流动力学的改变及其与一氧化氮的关系。方法:内毒素休克的小型猪模型,监测血流动力学的动态变化,结果:内毒素(LPS)持续泵入后1小时,平均动脉压(MAP)下降,心输出量(CO)增高,平均肺动脉压(MPAP)增高,全身血管阻力(SVRI)下降,肺血管阻力(PVRI)增高。应用NOS抑制剂左旋精氨酸甲酯(L-NAME)后,MAP、SVRI增高,CO降低,MPAP、PVRI进一步增高。结论:内毒素休克早期血流动力学的主要特征为高排低阻,同时存在肺动脉高压。NOS抑制剂L-NAME能提高血压,但心输出量降低,肺动脉高压进一步加重。NOS抑制剂在内毒素休克早期的治疗作用是可疑的。     

心肺联合移植术后管理

20 0 0年 4月 ,我们对 1例 31岁 ,男性 ,先天性心脏病室间隔缺损、肺动脉高压病人施行了心肺联合移植手术 ,术后病人生存 83ｄ。现将此例心肺联合移植术后管理情况报告如下。术后心脏功能监测与处理　供心、肺与受体的血管吻合好以后 ,从受者的左颈内静脉放置Ａｒｒｏｗ 7Ｆｒ肺动脉导管监测血流动力学参数。病人的血流动力学参数为 :术毕到术后 60ｈ ,桡动脉血压 1 4 0 / 87～ 1 31 / 68ｍｍＨｇ(1ｍｍＨｇ =0 1 33ｋＰａ)、肺动脉压 40 / 2 6～ 39/ 1 7ｍｍＨｇ、肺动脉楔压 1 7～ 1 4ｍｍＨｇ,术后 60ｈ均正常。术毕时的心输出量 4 2 2…     

2015年乳腺癌辅助化疗进展

【摘要】〓乳腺癌是危害我国女性健康的头号杀手,尽管近年来辅助化疗的研究进展突飞猛进,但临床中仍有不少问题未能明确,如辅助化疗的合适人群、化疗的开始时间、蒽环及紫杉类的地位和用法、强化维持治疗的作用、疗效及预后的生物标志物等。本文结合乳腺癌辅助化疗在临床上的常见问题和2015年各大乳腺癌会议阐述乳腺癌辅助化疗的最新进展。     

Alterations in T-Cell Subset Frequency in Peripheral Blood in Obesity

Background: Obesity affects the regulation of immune and inflammatory responses. This study characterizes differences in peripheral blood lymphocyte phenotype in obese humans. Methods: Frequencies of lymphocyte subsets among peripheral blood mononuclear cells were compared between 10 obese (BMI ≥35) and 10 lean subjects, as determined by antibodies directed against cluster differentiation (CD) markers. Results: Obese patients demonstrated an increased frequency of CD3+CD4+ T-cells (mean difference 12%, P=0.004), a decreased frequency of CD3+CD8+ T-cells (mean difference 9.4%, P=0.016) and an increased frequency of CD3+CD8+CD95+ T-cells (mean difference 13.3%, P=0.032). No other differences among T-cell or monocyte subsets were noted. Conclusions: Obesity is associated with alterations in frequencies of peripheral CD4+ and CD8+ T-cells and aberrations in the expression of CD95 among CD8+ T-cells. These data suggest both CD4+ and CD8+ T-cell compartments, as well as the regulation of CD95 expression on CD8+ T-cells, as targets for further study into obesity's effects on the immune system.     

西宁地区烧伤病人动脉血气分析观察

对高海拔地区的27例烧伤病人动脉血气变化进行了分析和观察。结果证明:无论是存活病人还是死亡病人伤后均存在有低氧血症问题。并且在死亡病人和烧伤合并吸入性损伤病人其低氧血症的发生早于单纯烧伤病人。提示:吸入性损伤病人应立即行气管切开术以保障氧气供给,单纯烧伤病人可常规吸氧以维持正常血 PaO_2,ARDS 均发生在合并吸入性损伤的病人,高频喷射通气技术对纠正低氧血症有一定效果。     

Controversies in Fistula in Ano

Managing a complex fistula in ano can be a daunting task for most surgeons; largely due to the two major dreaded complications—recurrence & fecal incontinence. It is important to understand the anatomy of the anal sphincters & the aetiopathological process of the disease to provide better patient care. There are quite a few controversies associated with fistula in ano & its management, which compound the difficulty in treating fistula in ano. This article attempts to clear some of those major controversies.     

β-半乳糖苷酶在体内外成骨细胞中的表达

目的 研究β—半乳糖苷酶(β—gal)在成骨细胞中的表达状况，为阐明MorquioB综合征的发病机制提供依据。方法 裸鼠各器官和骨组织标本行X-gal染色检测。抽取羊和人骨髓行骨髓基质细胞(BMSCs)培养，分为4组：I：Adv-hBMP-2转染组；Ⅱ：Adv—β—gal转染组；Ⅲ：未转染组；Ⅳ：地塞米松诱导组。分别行X-gal染色和RT-PCR检测β—gal的表达。结果 裸鼠骺板两侧、骨膜内面及松质骨的成骨细胞和破骨细胞可见多量β—gal的表达。未转染BMSCs组有少量β—gal的表达，其他3组细胞的β—gal表达增高。结论成骨细胞和破骨细胞可表达多量β—gal，该两种细胞的β—gal缺乏可能是MorquioB综合征骨骼异常的直接原因。     

Fluid-phase transcytosis in the primate epididymis in vitro and in vivo

Ligated tubules from the corpus epididymidis of men and monkeys were incubated in medium containing horseradish peroxidase (HRP) as a marker for fluid-phase endocytosis. HRP was localized by light and electron microscopy after 0, 15, 30 and 60 min of incubation. Movement between the cells was prevented by tight junctions, but bypass of this barrier was apparently achieved by an intracellular vesicular mechanism leading to a time-dependent appearance of HRP in the lumen. Uptake of HRP into basal cells and capture by the lysosomal apparatus of principal cells were also observed. HRP-filled vesicles also appeared in the basal, mid and apical cytoplasm of epithelial cells in the caput 1 h after injection of the tracer into the epididymal circulation of the monkey, suggesting that this pathway also operates in vivo.     

Surgical management of ductal carcinoma in situ in Australia in 1995

Background: In the present paper we describe the presentation and management of ductal carcinoma in situ (DCIS) of the breast in women in Australia in 1995. This representative, national data set provides a historical comparator for studies examining DCIS management that follow. Methods: Surgeons identified by population‐based cancer registries as having treated a new diagnosis of DCIS between 1 April and 30 September 1995 completed a questionnaire on the presentation and management of each case. Results: Two hundred and five surgeons supplied treatment details on 418 DCIS tumours in 415 women . Half of all tumours were detected at BreastScreen clinics and a further 25% were detected at other mammography centres. Twenty‐six percent of tumours were palpable at presentation, 33% were multifocal and 55% were high grade (including comedocarcinoma). Breast conserving therapy (BCT) rather than mastectomy was utilized in 260 (62%) of cases. Tumours that were of low grade, small in size and not multifocal were more likely to be treated by BCT. Surgeons seeing six or more DCIS cases in the 6‐month period were more likely to utilize BCT. Of the conservatively treated cases, 22% were referred for a radiation oncology consultation. The most common reasons for treating DCIS with mastectomy were that the tumour was too extensive or multifocal (63%), it extended to margins of the specimen (42%), or patient concerns about recurrence (34%). Conclusions: In 1995 the majority of DCIS was treated with breast conserving surgery alone. Surgeons treating more DCIS cases were more likely to perform conservative surgery than surgeons treating only one DCIS case in the study period.     

Smoking-Attributable mortality in Spain in 2016

IntroductionSmoking-attributable mortality (SAM) is a valuable indicator that can be used to characterize the course and health burden of the smoking epidemic. The aim of this paper was to estimate SAM in Spain in 2016 in the population aged 35 and over, using the best available evidence.MethodsA smoking prevalence-dependent analysis based on the estimation of population-attributable fractions was performed. Smoking prevalence (never, former, and current smokers) was calculated from a combination of the Spanish Health Survey (2016) and the European Health Survey (2014); the relative risk of death among current and former smokers was taken from the follow-up of various cohorts; and mortality rates were obtained from National Center for Statistics data. SAM estimates are presented globally, and by sex, age groups, and major disease categories: cancer, cardiometabolic diseases and respiratory diseases.ResultsIn 2016, 56,124 deaths were attributed to tobacco consumption, 84% in men (47,000), and 50% in the population aged over 74 (27,795). Overall, 50% of SAM was due to cancer (28,281), 65% of which was lung cancer. One in 4 attributable deaths (13,849) occurred before the age of 65.ConclusionsOne in 7 deaths in Spain in 2016 were attributable to smoking. This estimation of SAM clearly highlights the great impact of smoking on mortality in Spain, mainly due to lung cancer and chronic obstructive pulmonary disease.