咽成形术失败后再次手术后语音功能的评价

目的：客观评价咽成形术失败后语音障碍患者可以弥补治疗的方法。方法：对6例一期咽成形术后失败患者,再次实施咽后壁组织瓣转移术,术后进行详细观察和随访,并在术后4周开始吹气训练、行为疗法、语音治疗;对每例患者术前、语音治疗前后行汉语语音清晰度、吹气和冷镜检查,同时用CSL比较其音声特征的变化。结果：6例患者术后供区和受区伤口均一期愈合,聘咽闭合功能(VPC)明显改善,经语音治疗后,患者的语音清晰度达到或接近正常。结论：咽成形术失败后再次手术能补救一期咽成形术后失败的部分病例,除应该严格掌握咽成形术失败后再次手术的适应证外,术者熟练的操作技能也非常重要,同时术后语音治疗必不可少。     

鼻咽镜、阻塞器在治疗腭咽闭合不全中的应用

目的应用鼻咽纤维镜、腭咽阻塞器治疗腭裂术后腭咽闭合不全。方法腭咽闭合不全患者通过鼻咽镜检查，根据腭咽孔大小、形状制作腭咽阻塞器。结果４５例腭咽闭合不全患者经戴阻塞器治疗后，１００％腭咽闭合不全得到改善，其中１５例（３３％）２年后摘掉阻塞器发音正常。结论联合应用鼻咽镜与腭咽阻塞器是保守治疗腭咽闭合不全的好方法     

去氧孕烯炔雌醇片预处理联合氯米芬用于宫颈机能不全患者体外受精-胚胎移植的临床研究

目的 观察去氧孕烯炔雌醇片预处理联合氯米芬用于宫颈机能不全患者体外受精-胚胎移植的临床疗效,并分析其不良妊娠结局的影响因素。方法 将120例拟接受体外受精-胚胎移植的宫颈机能不全患者随机分为观察组和对照组,对照组给予氯米芬微刺激治疗,观察组给予去氧孕烯炔雌醇片预处理联合氯米芬微刺激治疗。比较两组患者的周期取消率、生化妊娠率及临床妊娠率、获卵数、正常受精卵数、早孕期流产率、血清胰岛素样生长因子1（IGF-1）、胰岛素样生长因子结合蛋白3（IGFBP-3）。结果 观察组患者的促性腺激素（GTH）用量、GTH刺激天数少于对照组,人绒毛膜促性腺素（HCG）注射日雌激素值小于对照组,周期取消率、早孕期流产率、晚期流产率、早产率低于对照组（P <0.05）,正常受精率、生化妊娠率、临床妊娠率、活产率、A型子宫内膜率高于对照组,获卵数、正常受精卵数多于对照组,扳机日子宫内膜厚度厚于对照组（P <0.05）。观察组患者刺激前后血清IGF-1、IGFBP-3水平的差值大于对照组（P <0.05）。一般Logistic回归分析结果显示,不孕年龄［O^R=0.882（95% CI：0.511,0.999）］、不同刺激方案［O^R=1.062（95% CI：1.001,2.112）］、GTH用量［O^R=0.712（95% CI：0.526,0.941）］、获卵数［O^R=1.122（95% CI：1.022,1.201）］、可利用胚胎数［O^R=2.012（95% CI：1.561,2.300）］是妊娠不良结局的危险因素（P <0.05）。结论 去氧孕烯炔雌醇片预处理联合氯米芬可显著改善患者的IGF-1、IGFBP-3水平及妊娠结局;且可利用胚胎数较多、GTH用量较少的患者,其妊娠结局较好、获卵数较多。     

The Effect of Maximum Heart Rate On Oxygen Kinetics and Exercise Performance at Low and High Workloads

The normal heart rate is lineurly related to oxygen consumption during exercise. The maximum heart rate of the normal sinus node is approximated by the formula: HR_max= (220-age) with a variance of approximately 15%. However, the nominal upper rate of most permanent pacemakers is 120 beats/min, a value that remains unchanged for many patients. As this nominal setting falls well below the maximum predicted heart rate for most patients, it is possible that the chronotropic response of rate adaptive pacemakers during moderate und maximal exercise workloads may be less than optimal. The purpose of this study was to determine the effect of the upper programmed rate on oxygen kinetics during submaximal exercise workloads and maximum exercise performance during symptom-limited treadmill exercise. Exercise performance with an upper rate programmed to 220-age was compared with an upper rate of 120 beats/min. Eleven patients (5 men and 6 women, mean age 54 ± 10 years) with complete heart block following catheter ablation of the atrioventricular junction for refractory atrial fibrillation who were implanted with permanent, rate-modulating VVIR pacemakers comprised the study population. The rate adaptive sensors were based on activity in 8 patients, minute ventilation in 2 patients, and mixed venous oxygen saturation in 1 patient. After performing a symptom-limited treadmill exercise test to determine maximum exercise capacity and to optimize programming of the rate adaptive sensor, each subject performed two treadmill exercise tests in random sequence with a rest period of at least 1 hour between tests. During one of the tests the upper rate was programmed to a value calculated by the formula: HR_max= (220-age). During the other exercise test the upper rate was programmed to 120 beats/min. Patients were blinded as to their programmed values and to the hypothesis of the study. A novel treadmill exercise protocol was used that consisted of a 6 minute, constant-workload phase at approximately 50% of maximum workload followed immedictely by incremental, symptom-limited exercise using a modified Chronotropic Assessment Exercise Protocol (CAEP) with 1 minute stages until peak exertion. Breath-by-breath analysis of expired gases was performed with subjective scoring of exertional difficulty at the end of the constant workload phase and during each stage of incremental exercise using the Borg Perceived Exertion Scale. Exercise duration was significantly longer (6.37 ± 47 vs 611 ±48 seconds. P < 0.005) with the higher programmed upper rate. Oxygen kinetics were also significantly improved with an age predicted upper rate with a lower O₂ deficit (258 ± 88 vs 395 ± 155 ml, P = 0.002) and higher VO₂ rate constant (3.6 ± 1.0 vs 2.4 ± 0.7. P < 0.001.). The V0_2maxduring peak exertion was higher with an age predicted upper rate than with an upper rate of 120 beats/min (1807 ± 751 vs 1716 ± 702 mL/min, P = 0.01). The mean Borg score was lower during the last common treadmill stage during maximum exercise with an age predicted upper rate than with an upper rate of 120 beats/min (15.7 ± 2.0 vs 16.5 ± 1.9. P = 0.04). The mean Borg score during submaximal. constant workload exercise was also lower with a higher upper rate (9.0 ±2.5 vs 9.6 ± 2.2, P = 0.10). Programming the upper rate of rate adaptive pacemakers based on the age of the patient improves exercise performance and exertional symptoms during both low and high exercise workloads as compared with a standard nominal value of 120 beats/min.     

Atrial Synchronized Ventricular Pacing: Contribution of the Chronotropic Response to Improved Exercise Performance

In contrast to asynchronous ventricular pacing (VOO, VVI), alrial synchronized ventricular pacing (VAT, VDD, DDD) maintains the normal sequence of cardiac chamber activation and permits a chronotropic response to exercise. thereby improving exercise performance. To assess the separate contributions of these two factors to improved work capacity. 14 patients with implanted programmable VAT pacemakers were exercised according to the Bruce protocol, in three different pacing modes, selected in a random orderand on a double blind basis: (a) VAT: (b) chest wall stimulation triggered ventricular (V-CWS-T) pacing, during which the pacemaker was programmed to VAT mode but driven externally using chest wall stimulation at rates fractionally above the patients'atrial rate, thereby providing a chronotropic response to exercise without atrioventricular synchronization; and (c) VOO mode at 70 beats per minute. There was a significant improvement in exercise performance in all patients during both VAT and V-CWS-T pacing as compared to VOO mode; the average increase in work capacity being similar: VAT: 44 ± 31, (range, 12 to 140) percent and V-CWS-T; 40 ± 24 (range, 5 to 85) percent. It is concluded that in patients with adaptive pacing systems, the chronotropic response is the major determinant of any improvement in exercise performance.     

Effect of nasal speaking valve on speech intelligibility under velopharyngeal incompetence: a questionnaire survey

Velopharyngeal incompetence is known as a contributing factor to speech disorders. Suwaki et al. reported that nasal speaking valve (NSV) could improve dysarthria by regulating nasal emission utilising one‐way valve. However, disease or condition which would be susceptible to treatment by NSV has not been clarified yet. This study aimed to evaluate the effect of NSV by questionnaire survey using ready‐made NSV. Subjects were recruited through the internet bulletin, and NSV survey set was sent to the applicant. Sixty‐six participants, who agreed to participate in this study, used NSV and mailed back the questionnaire which included self‐evaluation and third‐party evaluation of speech intelligibility. Statistical analysis revealed that the use of NSV resulted in significant speech intelligibility improvement in both self‐evaluation and third‐party evaluation (P < 0·01). Regarding the type of underlying disease of dysarthria, significant effect of NSV on self‐evaluation of speech intelligibility could be observed in cerebrovascular disease and neurodegenerative disease (P < 0·01) and that on third‐party evaluation in neurodegenerative disease (P < 0·01). Eighty‐six percent of subjects showed improvement of speech intelligibility by shutting up nostrils by fingers, and the significant effect of NSV on both self‐evaluation and third‐party evaluation of speech intelligibility was observed (P < 0·001). From the results of this study, it was suggested that NSV would be effective in cerebrovascular disease and neurodegenerative disease, as well as in subjects whose speech intelligibility was improved by closing nostrils.     

宫颈环扎术并发症

宫颈环扎术是治疗宫颈机能不全的唯一有效方法,其并发症发生率低,相关报道少,严重并发症罕见。最常见的并发症包括胎膜早破、绒毛膜羊膜炎、子宫内膜炎、围手术期出血、宫颈裂伤、环扎线或环扎带移位等,少见的并发症有膀胱宫颈瘘、输尿管宫颈瘘等,经阴道环扎的并发症较经腹环扎多。并发症的发生率因宫颈环扎的时机及适应证的不同而异。并发症常随孕周的增加及宫颈的扩张而增多,当胎膜破裂或宫颈扩张时行环扎术会增加并发症的发生风险。故应严格掌握适应证与禁忌证,选择适合的手术时机。已证明宫颈环扎的穿刺点和环扎带的位置直接影响妊娠结局,环扎带越接近宫颈内口效果越好。宫颈环扎后一般要限制体力活动,适当卧床休息,若子宫的敏感性增高给予孕酮和保胎药物,有感染病史及感染迹象者给予抗生素,重视阴道感染的筛查与治疗,密切监测母胎情况,关注宫颈环扎可能出现的并发症。开腹或腹腔镜环扎需剖宫产分娩,如有产兆,应即刻施术,避免发生宫颈裂伤或子宫破裂。