从湿论治慢性静脉功能不全刍见

慢性静脉功能不全是常见的周围血管疾病。文章在梳理历代中医辨证思路的基础上,结合现代医学的认识和临床观察,分别从湿的来源、湿在慢性功能不全疾病中的具体体现和治疗3个方面来探讨本类疾病与湿的关系。认为湿作为本病的重要致病因素和病理产物,贯穿于本病的始终,与本病的形成密不可分,在治疗上应注重对湿的辨析,明确其性质、来源、病证特点等,选用多法以祛湿。     

Analysis of early mortality and related risk factors in maintenance hemodialysis patients

Objective To analyze the early mortality and related risk factors of new hemodialysis patients in Zhejiang province, and provide basis for reducing the death risk of hemodialysis patients. Methods The early mortality and related factors of new hemodialysis patients from January 1, 2010 to June 30, 2018 were retrospectively analyzed using the database of Zhejiang province hemodialysis registration. The early mortality was defined as death within 90 days of dialysis. Cox regression model was used to analyze the related risk factors of the early mortality in hemodialysis patients. Results The mortality was the highest in the first month after dialysis (46.40/100 person year), and gradually stabilized after three months. The early mortality was 25.33/100 person year. The mortality within 120 days and 360 days were 21.40/100 person year and 11.37/100 person year, respectively. The elderly (≥65 years old, HR=1.981, 95%CI 1.319-2.977, P＜0.001), primary tumor (HR=3.308, 95%CI 1.137-5.624, P=0.028), combined with tumors (not including the primary tumor, HR=2.327, 95%CI 1.200-4.513, P=0.012), temporary catheter (the initial dialysis pathway, HR=3.632, 95%CI 1.806-7.307, P＜0.001), lower albumin (＜30 g/L, HR=2.181, 95%CI 1.459-3.260, P＜0.001), lower hemoglobin (every 0.01 g/L increase, HR=0.861, 95%CI 0.793-0.935, P=0.001), lower high density lipoprotein (＜0.7 mmol/L, HR=1.796, 95%CI 1.068-3.019, P=0.027) and higher C reactive protein (≥40 mg/L, HR=1.889, 95%CI 1.185-3.012, P=0.008) were the risk factors of early death for hemodialysis patients. Conclusions The early mortality of hemodialysis patients is high after dialysis, and gradually stable after 3 months. The elderly, primary tumor, combined with tumors, the initial dialysis pathway, lower albumin, lower hemoglobin, lower high density lipoprotein and higher C reactive protein are the risk factors of early death for hemodialysis patients.     

美托康注射液与都可喜联合治疗椎基底动脉供血不足的疗效观察

目的观察美托康注射液与都可喜联合治疗椎基底动脉供血不足的临床疗效。方法随机将87例病人分为治疗组（45例）和对照组（42例），治疗组应用美托康注射液250ml静滴，1a／d，同时加服都可喜1片，2次／d；对照组应用复方丹参注射液30m1加入5％葡萄糖注射液500ml静滴，1次／d；两组均连用10d，其余常规治疗相同。结果治疗组痊愈26例，有效18例，总有效率98％；对照组痊愈15例，有效24例，总有效率93％。治疗组疗效优于对照组（P〈0．05）。结论美托康注射液与都可喜联合治疗椎基底动脉供血不足有良好临床疗效，可于临床广泛应用。     

Pediatric valve replacement, 15 years experience in Oman

Background Despite improving surgical techniques, treatment of heart valve disease in children remains controversial. Somatic growth and adequate anticoagulation are of concern when children undergo valve replacement. We conducted this study to evaluate the performance of valves in this age group. Methods 42 children under the age of 13 years who underwent valve replacement were included in this study. Totally, 50 valves were implanted in 42 patients: 48 were mechanical prostheses, two were bioprosthetic both in pulmonary position. 37 (74%) valves were implanted in mitral position, 10 (20%) in aortic position, 1 (2%) in tricuspid position and 2 (4%) in pulmonary position. Preoperatively, 14 (33,3%) patients were in New York Heart Association (NYHA) class IV, while 27 (64.2%) were in NYHA class III. Results There were 2 (4.7%) hospital deaths and 2 (4.7%) late deaths while 2 (4.7%) patients were lost to follow up. The mean follow up period was 9.4 yrs. 35 (83.3%) patients are in NYHA Class I and free of all medications except warfarin. 3 (7.1%) patients have undergone 5 successful pregnancies. The median INR was 2.23. Major thrombo-embolic episode occurred in 1 (2.3%) patient. Conclusions In view of the problems of sizing, anticoagulation and need for re-operation at an early age, there is a reluctance to replace valves in children. This study shows that despite these problems, valve replacement can be undertaken safely and successfully in children, when repair has failed or not technically feasible.     

二维超声心动图对主动脉瓣关闭不全病变鉴别诊断价值

本文报道用二维超声心动图对主动脉瓣关闭不全124例进行病变鉴别诊断。就其图象特征结合X线所见,心音图等进行了鉴别诊断的探讨。其中,有风湿性心脏病111例;感染性心内膜炎4例;冠状动脉粥样硬化性心脏病5例;马凡氏综合征2例;左室假腱索2例。认为此项检查对主动脉瓣关闭不全病变鉴别诊断有一定的价值。     

Heart insufficiency in traumatic arteriovenous fistulas

Objective: To analyse the incidence, clinical presentation, and outcome of heart insufficiency in patients with chronic arteriovenous fistulas (AVF). Methodology: From 1991 to 2000 we treated 49 patients with traumatic AVF. The present study included 19 patients with AVF present for 6 months or longer, as it was presumed that these AVF will have an impact on cardiac overload. There were 16 male and three female patients with a mean age of 36 years (17–59). The time from injury to admission varied from 6 months to 33 years. Cardiological examination checked for dyspnoea and palpitation. ECG, chest X‐ray and ECHO‐cardiography were also performed. All AVF were deleted, magistral vessels reconstructed, non‐magistral obliterated, either surgically or by percutaneous embolization. Results: Mean follow up was 44.2 months (3–93). Serious heart insufficiency was seen in two patients only, with AVF in the subclavial vessels. Both suffered from serious heart disease prior to the therapeutic procedures that resulted in iatrogenic AVF, so it was difficult to connect heart insufficiency to the AVF alone. Despite surgical closure of AVF and intensive medical treatment, signs of heart insufficiency remained in both patients. Signs of cardiac overload were seen in six patients with long‐standing AVF in major vessels. Except for one patient who refused surgical closure of femoral AVF, the remaining five were symptom free for cardiac overload during the follow‐up period. Conclusion: In our series, heart insufficiency was an infrequent complication in long‐standing AVF, even when major vessels were involved.     

盐酸丁咯地尔治疗椎-基底动脉供血不足的效果

①目的　观察盐酸丁咯地尔对椎 基底动脉供血不足的治疗作用。②方法　将 82例椎 基底动脉供血不足病人随机分为两组 ,治疗组 4 2例 ,给予盐酸丁咯地尔 2 5 0mL静滴 ,每日 1次 ;对照组 4 0例 ,给予维脑路通0 .5g、胞二磷胆碱 0 .5 g静滴 ,每日 1次 ,均治疗 7d。检测两组治疗前后血液流变学和血流动力学指标的变化。 ③结果　治疗后治疗组全血高切黏度明显低于对照组 ,椎动脉平均血流速度 (VA)明显快于对照组 ,差异均有显著性(t=3.96 0 ,P <0 .0 1 ;t=2 .0 92 ,P <0 .0 5 )。治疗组治疗后全血高切、低切和血浆黏度明显低于治疗前 ,差异有显著性 (t=2 .74 6～ 2 .95 1 ,P <0 .0 1 ) ;VA、基底动脉平均血流速度 (BA)和外周血管阻力指数 (PI)高于治疗前 ,差异有显著性 (t=2 .732～ 5 .1 0 4 ,P <0 .0 1 )。对照组治疗后血浆黏度、PI明显低于治疗前 ,VA高于治疗前 ,差异均有显著性 (t=2 .1 6 8～ 2 .732 ,P <0 .0 5 ) ;全血高切、低切黏度、BA治疗前后差异无显著性 (t=0 .346～ 2 .0 0 8,P >0 .0 5 )。④结论　盐酸丁咯地尔对椎 基底动脉供血不足有良好的改善作用 ,其疗效明显优于维脑路通加胞二磷胆碱的治疗效果     

干下漏斗部室间隔缺损的外科治疗

４６例干下漏斗部室间隔缺损，占同期室缺手术治疗的２３．２％（４６／１９８）。缺损位于肺动脉瓣下３４例，漏斗部１２例。用带垫片褥式缝合修补２１例，补片修补２５例。全组无死亡。术后直接缝合组有主动脉关闭不全２例、残余分流２例，残留杂音３例。笔者认为，适时手术，选择适当的进路、应用补片修补、正确判断和处理主动脉瓣病变及对合并肺动脉狭窄者予以流出道补片加宽，是提高本病手术疗效的关键。     

Carbohydrate metabolism in children receiving growth hormone for 5 years

Carbohydrate metabolism was evaluated by fasting and postprandial glucose, insulin, and hemoglobin (Hb)A_1c levels in children with chronic renal insufficiency and various other growth disorders treated with growth hormone. Mean fasting and postprandial glucose remained unchanged throughout the 5-year study period in all four study groups. Median fasting insulin levels rose from lownormal levels into the normal range after 5 years of growth hormone. Average fasting insulin level after 5 years was 10 mU/l. Median postprandial insulin values also rose, yet remained within the normal range at the 5-year mark. Mean Hb A_1c levels remained within low to middle end of the normal range in the patients with growth hormone deficiency, Turner syndrome, and idiopathic short stature. Mean Hb A_1c levels at the 5 years were slightly elevated to 6.3% for the patients with chronic renal insufficiency.