The effects of percutaneous nephrolithotomy on renal function in geriatric patients in the early postoperative period

Since percutaneous nephrolithotomy (PNL) is a surgical intervention, it may show deteriorative effects on renal function in the early postoperative period. In this study, the deteriorative effects of PNL on renal function were investigated in the geriatric population, and it was compared to the non-geriatric population. A total of 711 patients [64 in the geriatric group (female/male ratio: 33/31, mean age: 70.4 ± 4.2 years), 647 in the non-geriatric group (female/male ratio: 267/380, mean age: 40.9 ± 12.7 years)] were included in the study. Demographic data, biochemical parameters, stone diameters, duration of the operation and estimated glomerular filtration rates (eGFR) were recorded both preoperatively and postoperatively. The eGFR ratio (post-/preoperative) was 1.13 ± 1.00 in the geriatric group, 0.98 ± 0.20 in the non-geriatric group (P < 0.001). Although the mean stone diameter was larger in the geriatric group than the non-geriatric group (10.08 ± 6.5 mm, 8.28 ± 5.54 mm, P = 0.037), the mean duration of the operation was shorter in the geriatric group than in the non-geriatric group (55.7 ± 13.6 min, 61.3 ± 20.9 min, P = 0.036). Hematocrit, hemoglobin, urea levels, and grade of hydronephrosis were not different between the groups. Renal function impairment is expected to be common in the geriatric patient population since they already have lower basal renal function. In the present study, the ratio of postoperative to preoperative eGFR was higher in the geriatric group. Hematocrit, hemoglobin, and urea levels and degree of hydronephrosis of these two groups did not show a great difference. The relatively short duration of the operation in the geriatric group and the diversity of perioperative and postoperative care of these two groups may explain the difference.     

The profile of circulating metalloproteinases after PCI in patients with acute myocardial infarction or stable angina

The objective of this study was to investigate the time profiles of plasma matrix metalloproteinase-9 (MMP-9), tissue inhibitor of metalloproteinases (TIMP-1 and -2), and pregnancy associated plasma protein A (PAPP-A) in patients with acute myocardial infarction (AMI), compared to patients with stable angina pectoris (AP), all treated with percutaneous coronary intervention (PCI) with stent.

Methods

Twenty patients with ST-elevation AMI and 10 patients with AP were included. Serum levels of the selected markers were measured before (only in the AP group) PCI, and 3 and 12 hours, 1,3,5,7 and 14 days after PCI in all patients.

Results

The levels of MMP-9 and MMP-9/TIMP-1 ratio, being higher in the AMI group compared to the AP group at 3 hours, were significantly reduced 1 day after PCI (p < 0.01 for both), sustaining during the study period. A similar pattern was observed in PAPP-A levels with significant reduction after 12 hours (p < 0.01). In the AP group only smaller changes were observed, except from an increase in PAPP-A levels from before PCI to 3 hours (p < 0.001), followed by significant reduction.No significant correlations were found between any of the measured biomarkers and the infarct size, either evaluated in the acute phase or after 6 weeks.

Conclusion

AMI patients treated with PCI had an early significant reduction in MMP-9, MMP-9/TIMP-1 ratio and PAPP-A when compared to patients with stable angina pectoris treated with PCI. This indicates that the metalloproteinases may be involved in the early phase of the plaque rupture process, with limited influence of the PCI procedure.     

骨质疏松性椎体骨折经皮后凸成形术中伤椎和手术入路的选择

目的 探讨骨质疏松性椎体骨折经皮后凸成形术中伤椎定位和手术入路选择.方法 36例骨质疏松性椎体压缩性骨折患者,术前根据CT及MRI确定伤椎,根据伤椎椎弓根CT层面经椎弓根进针线确定单、双侧入路,采用球囊或Sky扩张器行椎体后凸成形术.术前、术后1周及随访时摄X线片测量椎体高度恢复率、后凸Cobb角及疼痛视觉类比评分(VAS).结果 36例50节骨质疏松性椎体压缩性骨折中,44节椎体行经皮椎体后凸成形术.术前计划单侧经椎弓根入路32节椎体,双侧经椎弓根入路12节椎体;术中单侧入路22节椎体,双侧入路22节椎体,其中10节椎体由单侧入路改为双侧入路.术后1周及最末随访时椎体高度恢复率分别为66.3%、65.2%;术前后凸Cobb角为23.4°,术后1周及最末随访时分别为9.2°、10.2°,较术前显著改善(P<0.01);术前VAS评分为8.9分,术后1周及最末随访时分别为1.9分、2.3分,较术前均改善(P<0.01).结论 术前CT伤椎体清晰的骨折线是椎体新鲜骨折的依据,陈旧性骨折需进一步检查MRI确定责任椎.大部分中胸椎及腰椎可以采用单侧经椎弓根入路行经皮椎体后凸成形术,部分下胸椎骨质疏松性骨折患者需行双侧经椎弓根入路.     

经皮穿刺椎体成形术及综合治疗骨质疏松性椎体压缩性骨折

目的 探讨经皮穿刺椎体成形术(PVP)联合药物及康复训练法治疗老年骨质疏松性椎体压缩性骨折的疗效.方法 32例骨质疏松性椎体压缩性骨折患者接受PVP术后,给予鲑鱼降钙素、活性维生素D、补钙等药物治疗,同时指导患者适当进行康复锻炼.结果 根据日常生活能力5级分类法.治疗前:4级12例,5级20例;治疗后3个月:1级8例,2级18例,3级6例.无因手术或长期卧床而引起的并发症.结论 PVP联合药物及康复训练等综合治疗是老年人骨质疏松性椎体压缩性骨折的有效治疗方法,可减少患者因长期卧床所带来的并发症,提高患者的生活质量.     

中药配合经皮肾镜超声气压弹道碎石术治疗肾输尿管结石

目的：探讨中药配合经皮肾镜超声气压弹道碎石术治疗复杂肾输尿管结石的可行性和安全性。方法：对200例复杂肾输尿管结石采用经皮肾镜超声气压弹道碎石术碎石,术后口服八正化石胶囊1~2周。结果：结石1次取净率95%,无肾输尿管穿孔、大出血及尿瘘等并发症。结论：中药配合经皮肾镜超声气压弹道碎石术治疗复杂肾输尿管结石,具有创伤小、操作安全、结石取净率高等优点。但要选择病例适当,熟练手术技巧。     

经皮椎体成形术中椎体内压力的测定与分析

目的　从生物力学的角度来分析椎体成形术(PVP)中并发症发生的可能性缘由,并提出科学的预防性建议。方法　对16例具有脊柱椎体骨质疏松症临床诊断的老年尸体腰椎（14具）有椎体压缩性骨折的椎体（其椎体骨密度值T<-2.5）予以C-arm透视机的动态监测下达到临床评价要求的椎体成形术,采用unisensor AG公司生产的直径为2.0mm的微型压力传感器(5mv/bar)和Peekel Instruments GmbH生产的载频放大器及其附属配套软件－SignaSoft6000 (PICAS & SIGNALOG 6000)测定每个椎体的椎体成形术术中椎体内压力的动态变化,采用描述性的统计和非参数统计方法进行统计学上的描述和分析,并就并发症发生的可能性进行临床意义上的分析。结果　每个椎体的椎体成形术均达到临床评价要求,每次推杆（美国Kypho公司提供标准椎体成形术中Yamshi-Nadel套系中推注骨水泥入椎体的器具,每具推杆可容纳骨水泥约1.5mL）推注骨水泥入椎体时所产生的椎体内的压力P(下标 max)不是很高,多数在0.50 bar以下,其所导致的效应具有显著的统计学差异(P<0.01),而每次推杆推注骨水泥入椎体时的椎体内压力面积值P(下标 ares)也不是很高,多数在10.00 Unit以下,其所导致的效应具有显著的统计学差异(P<0.01),两者均呈偏态分布;而且,对每例椎体的第一、二、三、四杆之间两两予以统计学上的分析,在总体存在差异有统计学意义的基础上还发现除第一和二杆、第三和四杆之间外,其他各杆之间存在着差异(a<0.0083)。结论　对骨质疏松性腰椎椎体压缩性骨折行椎体成形术(PVP)时,其在推注骨水泥入病椎时一般3推杆（约4.5ml骨水泥）即可达到推注骨水泥的临床评价要求,已无必要予第四杆等再次将骨水泥推注入病椎,既不作无意义的行为,又减少发生手术并发症的风险。     

经皮肾镜气压弹道联合超声碎石术治疗复杂性肾结石150例报告

目的探讨经皮肾镜气压弹道联合超声碎石取石术治疗复杂性肾结石的疗效。方法全麻下经膀胱镜先向患侧逆行插入输尿管导管,俯卧位,在B超或X线引导下,向目标肾盏穿刺,建立皮肾通道,肾镜下用气压弹道联合超声腔内碎石机碎石取石。结果单通道取石137例,双通道取石11例,三通道取石2例;一次取石119例,二次取石27例,三次取石4例。手术时间（88±34）min。1例术后当晚发生感染性休克,经抗休克治疗后缓解;2例术后2周继发出血,保守治疗后缓解。术后3个月结石取净率为84.7%（127/150）;23例残余结石中,术后10例行ESWL治疗,其中7例结石排净,余13例口服排石药,术后6个月随访结石排净率为89.3%（134/150）。结论经皮肾镜气压弹道联合超声碎石取石术治疗复杂性肾结石效率高,安全有效,损伤小,可以解决开放手术难以处理的复杂性肾结石。     

输尿管镜下气压弹道碎石术近期并发症的预防及处理

目的总结输尿管镜下气压弹道碎石术并发症的处理经验。方法回顾性分析2002年5月～2007年12月660例经尿道输尿管镜取石术中发生25例并发症的临床资料。结果输尿管穿孔22例：13例顺利将结石击碎并将双J管越过穿孔处一端置入肾盂内;4例手术取石并修补输尿管;5例拒绝开放手术,术后出现不同程度的发热、腰痛、血尿等症状,3例经皮肾穿刺造瘘后症状好转,2例经皮穿刺肾造瘘失败待病情稳定后行开放手术治疗。输尿管撕断2例,术中开放行输尿管端端吻合术。输尿管下段穿孔至盆腔卵巢静脉血管出血1例,术中开放手术结扎破裂的血管。25例经积极对症处理后均痊愈出院。术后2个月顺利拔除双J管,术后1年行静脉肾盂造影检查无输尿管狭窄、梗阻。结论输尿管镜下气压弹道碎石术后近期输尿管损伤通过输尿管内支架引流管或经皮穿刺肾造瘘改道处理,可降低再次手术发生率;果断及时的开放手术可以避免更为严重并发症的发生。     

经皮微波热凝固联合^125I放射性粒子植入治疗晚期肺癌

目的探讨经皮微波凝固治疗（percutaneous microwave coagulation therapy,PMCT）联合^125I放射性粒子植入治疗晚期肺癌的临床疗效及可行性。方法22例晚期肺癌（鳞癌15例,腺癌7例）,瘤体最大径5-12 cm,在CT引导下行PMCT联合^125I放射性粒子植入治疗。病灶位于胸壁上或大血管、大气道周围的部分划为粒子治疗区域,其他病灶的大部分区域为PMCT区域。结果22例PMCT均为1次手术、多点治疗,共植入^125I粒子712颗,平均每例植入32.4颗粒子。术后2个月并发症包括少量咯血（7例）、气胸（4例）、PMCT术后发热（17例）、肺部炎症（11例）、少量胸腔积液（6例）及粒子移位（2例）。PR 15例,SD 5例,PD 2例,有效率68.2%（15/22）。15例术前疼痛者治疗后疼痛完全消失（11例）或明显减轻（4例）。22例随访4-18个月,平均7个月,PR、SD的病灶均未见增大。结论PMCT联合^125I粒子植入治疗病灶≥5 cm的晚期肺癌疗效肯定、微创、安全。     

A new self-expanding aortic stent valve with annular fixation: in vitro haemodynamic assessment

Objective: Balloon-expandable stent valves require flow reduction during implantation (rapid pacing). The present study was designed to compare a self-expanding stent valve with annular fixation versus a balloon-expandable stent valve. Methods: Implantation of a new self-expanding stent valve with annular fixation (Symetis^®, Lausanne, Switzerland) was assessed versus balloon-expandable stent valve, in a modified Dynatek Dalta^® pulse duplicator (sealed port access to the ventricle for transapical route simulation), interfaced with a computer for digital readout, carrying a 25 mm porcine aortic valve. The cardiovascular simulator was programmed to mimic an elderly woman with aortic stenosis: 120/85 mmHg aortic pressure, 60 strokes/min (66.5 ml), 35% systole (2.8 l/min). Results: A total of 450 cardiac cycles was analysed. Stepwise expansion of the self-expanding stent valve with annular fixation (balloon-expandable stent valve) resulted in systolic ventricular increase from 120 to 121 mmHg (126 to 830 ± 76 mmHg)*, and left ventricular outflow obstruction with mean transvalvular gradient of 11 ± 1.5 mmHg (366 ± 202 mmHg)*, systolic aortic pressure dropped distal to the valve from 121 to 64.5 ± 2 mmHg (123 to 55 ± 30 mmHg) N.S., and output collapsed to 1.9 ± 0.06 l/min (0.71 ± 0.37 l/min* (before complete obstruction)). No valve migration occurred in either group. (* = p < 0.05). Conclusions: Implantation of this new self-expanding stent valve with annular fixation has little impact on haemodynamics and has the potential for working heart implantation in vivo. Flow reduction (rapid pacing) is not necessary.