Laparoscopic repair of a diaphragmatic hernia through the foramen of Morgagni

A 78-year-old woman is described who presented with a diaphragmatic hernia through the foramen of Morgagni. A definitive diagnosis was confirmed by a sagittal view on magnetic resonance imaging prior to surgery. The hernia was repaired laparoscopically under an abdominal wall lifting technique without pneumoperitoneum, and her symptoms completely resolved postoperatively with no evidence of recurrence. The laparoscopic repair was considered a suitable and safe procedure for the treatment of a Morgagni hernia. Received: 3 April 1996/Accepted: 3 May 1996     

艾滋病相关卡波西肉瘤32例尸检材料病理学研究

目的：概况艾滋病相关卡产波西肉瘤（ＫＳ）病理特征，并探讨其两全是学分型、来源与性质。方法：所有病例均按常规尸检及制片，光镜观察，并复习资料。结果：ＫＳ累及皮肤２３例，呼吸系统２０例，消化道１７例，淋巴结１２例，２６例为播散性。肿瘤肉眼表现为斑型和结节型，镜下主要同增生的血管和梭形细胞构成。并常见胶原分、淋这扩张、嗜性小体、炎细胞浸浸、出血及含铁务黄素沉积等特征性病变。结论：ＫＳ是一种颇具特征的病变     

Bilateral continuous paravertebral block used for postoperative analgesia in an infant having bilateral thoracotomy

We describe the successful postoperative pain management in an 11-month-old infant who underwent bilateral thoracotomy, using continuous infusions of bupivacaine into two directly placed paravertebral catheters. Haemodynamic parameters and pain scores were measured 1–2 h for 60 h while the infusions were continued and, intermittently, blood samples were taken for subsequent measurement of serum bupivacaine concentrations. The technique provided effective pain relief and the infant required no other analgesia postoperatively. There were no adverse haemodynamic consequences or complications relating to either catheter placement or drug infusions. Serum concentrations of bupivacaine remained below toxic levels throughout the study period, though accumulation did occur.     

An uncommon cause of acute right ventricular failure and high mixed venous oxygen saturation

Ruptured sinus of Valsalva aneurysms are rare. We report a case in which the usual clinical manifestations were not present and the patient was initially treated as an acute pulmonary embolus. Despite three negative echocardiograms an intra-cardiac shunt was suspected because of a persistently elevated mixed venous oxygen saturation. Cardiac catheterisation confirmed the diagnosis. Surgical repair was performed and post operative recovery was uneventful.     

多普勒超声心动图食道调搏负荷试验对冠心病左室功能的评价

本文对１９例冠心病患者和１３例健康人进行了经食道心房调搏负荷多普勒超声心动图检查，旨在观察此法对冠心病患者的诊断价值。结果表明：（１）静息状态下多普勒超声心动图各项心功能指标二组之间无显著差异（Ｐ＞０．０５）；（２）在经食道心房调搏试验中左心室收缩指标Ｖｍａｘ、Ｖｍｅａｎ、ＶＴＩ、ＳＶ、ＣＯ等与对照组比较有显著差异（Ｐ＜０．００ｌ），以此几项指标进行二类判别分析，符合率达９３．７５％。结论认为经食道心房调搏负荷多普勒超声心动图是诊断冠心病的一项较敏感、无创易行的方法。     

Hyperglycaemia compensates for the defects in insulin-mediated glucose metabolism and in the activation of glycogen synthase in the skeletal muscle of patients with Type 2 (non-insulin-dependent) diabetes mellitus

Summary Insulin resistance and a defective insulin activation of the enzyme glycogen synthase in skeletal muscle during euglycaemia may have important pathophysiological implications in Type 2 (non-insulin-dependent) diabetes mellitus. Hyperglycaemia may serve to compensate for these defects in Type 2 diabetes by increasing glucose disposal through a mass action effect. In the present study, rates of whole-body glucose oxidation and glucose storage were measured during fasting hyperglycaemia and isoglycaemic insulin infusion (40 mU·m^–2min^–1, 3 h) in 12 patients with Type 2 diabetes. Eleven control subjects were studied during euglycaemia. Biopsies were taken from the vastus lateralis muscle. Fasting and insulin-stimulated glucose oxidation, glucose storage and muscle glycogen synthase activation were all fully compensated (normalized) during hyperglycaemia in the diabetic patients. The insulin-stimulated increase in muscle glycogen content was the same in the diabetic patients and in the control subjects. Besides hyperglycaemia, the diabetic patients had elevated muscle free glucose and glucose 6-phosphate concentrations. A positive correlation was demonstrated between intracellular free glucose concentration and muscle glycogen synthase fractional velocity insulin activation (0.1 mmol/l glucose 6-phosphate: r=0.65, p<0.02 and 0.0 mmol/l glucose 6-phosphate: r= 0.91, p<0.0001). In conclusion, this study indicates an important role for hyperglycaemia and elevated muscle free glucose and glucose 6-phosphate concentrations in compensating (normalizing) intracellular glucose metabolism and skeletal muscle glycogen synthase activation in Type 2 diabetes.     

Metastasis of Prostate Adenocarcinoma to Testis

Metastatic carcinoma to the testis is very rare. Metastasis of prostate adenocarcinoma to testis was detected incidentally after bilateral orchiectomy for hormonal management of metastatic prostate carcinoma. The metastatic lesion was not identified in physical examination or in macroscopic dissection of the testis after surgery. Microscopy revealed an adenocarcinoma which, given the history of the patient and a positive immunohistochemical stain for PSA, was identified as metastatic prostatic adenocarcinoma.     

654─2在小儿急性脑水肿及中枢性呼吸衰竭中的应用探讨

感染性脑水肿病儿在感染得到有效控制，应用654—2（山莨菪碱）后未再用脱水剂，笔者认为．654—2具有解除脑血管痉挛及微循环障碍的作用。急性脑水肿在脱水剂应用后，用654—2有利于脑水肿液的吸收和回流。目前，治疗小儿捂热综合征（IMS）之细胞内水肿仍没有有效的方法，研究结果表明654—2能改善脑细胞供氧．其还能通过解除呼吸中枢血管痉挛而治疗中枢性呼吸衰竭。     

Comparison of the APACHE III, APACHE II and Glasgow Coma Scale in acute head injury for prediction of mortality and functional outcome

Objectives: This study examines the efficacy of the predicting power for hospital mortality and functional outcome of three different scoring systems for head injury in a neurosurgical intensive care unit (NICU). Design: On the day of admission, data were collected from each patient to compute the Acute Physiology, Age, and Chronic Health Evaluation (APACHE) II and III, and Glasgow Coma Scale (GCS) scores. Hospital mortality was defined as the deaths of patients before discharge from hospital. Early mortality was defined as death before the 14th day after admission. Late mortality was defined as death after the 15th day from admission. Functional outcome was evaluated by Index of Independence in Activities of Daily Living (Index of ADL). Setting: An 8-bed NICU in a 1270-bed medical center in Taichung Veterans General Hospital. Patients and participants: Two hundred non-selected patients with acute head injury were included in our study in a consecutive period of 2 years. Patients less than 14 years old were not included. Interventions: None. Measurements and results: Sensitivity, specificity and correct prediction outcome were measured by the chi-square method in three scoring systems. The Youden index was also obtained. The best cut-off point in each scoring system was determined by the Youden index. The difference in Youden index was calculated by Z score. A difference was also considered if the probability value was less than 0.05. The area under Receiver Operating Characteristic (ROC) curve was computed. Then the area under ROC of each scoring system was compared by Z score. There was statistical significance if p was less than 0.05. For prediction of hospital mortality, the best cut-off points are 55 for APACHE III, 17 for APACHE II and 5 for GCS. The correct prediction outcome is 82.4% in APACHE III, 78.4% in APACHE II and 81.9% in the GCS. The Youden index has best cut-off points at 0.68 for APACHE III, 0.59 for APACHE II, and 0.56 for GCS. The area under Receiver Operating Characteristic (ROC) curve is 0.90 in the APACHE III, 0.84 in the APACHE II and 0.86 in the GCS. There are no statistical differences among APACHE III and II, and GCS in terms of correct prediction outcome, Youden Index and the area under the ROC curve. Other physiological variables excluding GCS in APACHE III and II (AP III-GCS, AP II-GCS) have less statistical value in the determination of mortality for acute head injury. For the prediction of late mortality, APACHE III and II yield significantly better results in the area under the ROC curve, correct prediction and Youden index than those of GCS. Other physiological variables (AP III-GCS and AP II-GCS) play an important role in the prediction of late mortality in APACHE scores. For prediction of the functional outcome of surviving patients with acute head injury, the APACHE III yields the best results of correct prediction outcome, Youden index and the area under the ROC curve. Conclusion: The APACHE III and II may not replace the role of GCS in cases of acute head injury for hospital or early mortality assessment. But for prediction of the late mortality, the APACHE III and II have better accuracy than GCS. Other physiological variables excluding GCS in the APACHE system play a crucial contribution for late mortality. GCS is simple, less time-consuming and economical for patients with acute head injury for the prediction of hospital and early mortality. The APACHE III provides better prediction for severe morbidity than GCS and APACHE II. Therefore, the APACHE III provides a good assessment not only for hospital and late mortality, but also for functional outcome. Received: 22 May 1995 Accepted: 2 September 1996