兔耳大神经植入颈肩部失神经皮瓣后感觉重建的量化研究

目的：客观评价感觉神经植入术用于失神经皮肤感觉重建的效果。方法：将兔耳大神经植入颈肩部失神经皮瓣，６～８个月用抗神经丝抗体免疫组化法显示再生的真皮神经网丛及感觉末梢，并用图像分析法测定其表面积密度。以神经单纤维放电引导技术对再生的放电纤维进行计数研究和特征观察。结果：实验组皮瓣中央区再生的真皮神经网丛密度达到正常组水平，而神经放电纤维数量显著超过正常。结论：提示感觉神经植入术具有良好效果。     

手与前臂皮神经伴行血管逆行岛状皮瓣的临床应用

目的：报道手、前臂皮神经伴行血管逆行岛状皮瓣的临床应用结果。方法：用桡神经拇指背尺侧支及前臂外侧皮神经前支伴行血管为蒂设计逆行岛状皮瓣，蒂部携带浅静脉及皮下组织，修复拇指缺损时皮神经与指神经缝合。结果：手部６例、前臂部２例皮瓣全部成活，伤指恢复良好感觉。结论：这两种皮瓣血供充分，不牺牲主干血管，前者可修复拇指指腹及指端缺损，后者可修复腕、掌背侧中、小面积皮肤缺损。     

URODYNAMIC AND CLINICAL EVIDENCE OF ACUTE INHIBITORY EFFECTS OF INTRAVESICAL NOCICEPTIN/ORPHANIN FQ ON DETRUSOR OVERACTIVITY IN HUMANS: A PILOT STUDY

PURPOSE: Management of neurogenic incontinence is complex and available treatments are not satisfactory. Nociceptin/orphanin FQ, a recently discovered neuropeptide, has been reported to inhibit the voiding reflex in the rat. These experimental results prompted us to investigate the urodynamic and clinical effects of intravesical instillation of nociceptin/orphanin FQ in humans. MATERIAL AND METHODS: Our study involved 5 normal subjects (group 1) with a mean age of 40.4 years (range 21 to 54) and 9 patients (group 2) 40.4 years (24 to 54). All patients in group 2 presented with detrusor hyperreflexia refractory to standard therapy. They were invited to undergo a filling cystometrogram with saline solution and after 30 minutes, a new one with a solution containing 1 microM. nociceptin/orphanin FQ. The urodynamic parameters that were recorded included bladder capacity, volume threshold for the appearance of detrusor hyperreflexia and maximum bladder pressure. Clinical and urodynamic followup was performed after 15 days. The data were statistically analyzed with 1-way analysis of variance followed by the Dunnett test for multiple comparison considered statistically significant with p <0.05. RESULTS: Intravesical instillation of 1 microM. nociceptin/orphanin FQ in group 1 did not produce significant functional changes. This infusion in group 2 produced a statistically significant increase in mean bladder capacity and volume threshold for the appearance of detrusor hyperreflexia from 164 plus or minus standard deviation (SD) 84 to 301 +/- 118 and 93 plus or minus SD 41 to 231 +/- 104 ml. (p <0.05, respectively). Mean maximum bladder pressure decreased from 79 plus or minus SD 25 to 54 +/- 44 cm. water but was not statistically significant (p = 0.19). After 15 days an absence of clinical improvement was noticed in group 2, and the urodynamic control did not show any significant changes compared to the values before nociceptin/orphanin FQ treatment. No severe symptomatic reactions were observed during infusion of 1 microM. nociceptin/orphanin FQ. CONCLUSIONS: Our results demonstrate that nociceptin/orphanin FQ is able to elicit a robust inhibitory effect on voiding reflex in group 2 but not 1. The ideal dosage, route of administration of nociceptin/orphanin FQ and treatment interval are not yet established.     

肝移植手术前后骨密度变化的临床研究

目的 通过双能X线吸收测量仪(DEXA)检测肝移植患者手术前骨密度变化特点，探讨与骨质疏松发生、发展的关系。方法 6例肝移植患者，平均年龄52y，其中重症肝功能衰竭患者3例。原发性肝细胞性肝癌3例。手术方式均为改良背驮式肝移植，术后患者均常规两联应用糖皮质激素及环孢素A抗排斥治疗。术后随访时阳16个月。DFXA仪测定患者左侧髋部骨密度(BMD），个体骨密度测定值以与正常成人骨密度峰值对照值的标准差。结果 手术前、手术后1个月及术后6个月的骨密度差异有非常显著性(P=0.002)。其中，3例肝功能衰竭患者的髋部骨密度从平均-2．7下降到3．1。而3例原发性肝癌患者的骨密度值平均-0．1下降到-1．2；术后6个月复查时发现，3例肝功能衰竭患者中有两例出现非外伤性脊柱压缩骨折。结论 肝移植患者术后骨质疏松症主要和原发病、长期卧床及手术后的免疫抑制有关；易并发骨质疏松性骨折，影响患者的生存质量。     

METASTATIC CARCINOMA IN THE NECK: A CLINICAL,COMPUTERIZED TOMOGRAPHY SCAN AND ULTRASOUND STUDY

Metastatic cervical lymph node involvement is a major determinant of treatment planning and prognosis of upper aerodigestive tract tumours. If the metastatic tumour invades the carotid artery wall then complete tumour excision is not possible unless carotid artery ligation or replacement is planned. A prospective study was performed to assess the role of palpation, computerized tomography (CT) and B-mode ultrasound scanning in the detection of metastatic cervical lymph node involvement in patients with upper aerodigestive tract tumours. In particular, detection of carotid artery wall invasion by tumour was examined. Thirty-two neck dissection specimens were available for histopathological confirmation of findings. Palpation under general anaesthesia was 87.5% sensitive and 87.5% specific in the detection of involved nodes. If a positive finding was defined as detection of a node greater than 15 mm in largest diameter, CT scanning was 78.6% sensitive and 93.8% specific, and the sensitivity of ultrasound was 81.3% and specificity was 84.6%. Ultrasound scanning was sensitive in excluding carotid artery wall invasion, identifying five out of five cases with one false positive and no false negative reports. The combination of palpation under general anaesthesia and B-mode ultrasound imaging provides a sensitive means of detecting the presence of metastatic cervical lymphadenopathy and invasion of the carotid artery wall.     

EFFECT OF MANUAL LYMPH DRAINAGE AS DESCRIBED BY VODDER ON OEDEMA OF THE HAND AFTER FRACTURE OF THE DISTAL RADIUS: A PROSPECTIVE CLINICAL STUDY

The aim of this study was to evaluate the efficacy of manual lymph drainage, as described by Vodder, in reducing oedema in the hand after a traumatic injury. During a period of 10 months in 1996-7, a total of 26 consecutive patients with a fracture of the distal radius that was treated by external fixation were included in the study. Patients were randomised into an experimental (n = 12) and a control group (n = 14). Treatment started 11 days after application of the external fixator. All patients had the same conventional treatment with exercises, movement, oedema control, and education. The experimental group was given 10 treatments of manual lymph drainage in addition. Oedema was measured four times with the volumeter, and the injured hand was always compared with the uninjured one. The first measurement was made three days after removal of the external fixation. The difference in hand volume showed that the experimental group had significantly less oedema in the injured hand. This result indicates that manual lymph drainage is a useful method for reducing post-traumatic oedema in the hand.     

TRAIN-OF-FOUR FADE DURING ONSET AND RECOVERY OF NEUROMUSCULAR BLOCK: A STUDY IN NON-ANAESTHETIZED SUBJECTS

The actions of alcuronium, vecuronium and tubocurarine havebeen studied in the isolated forearms of six healthy, non-anaesthetizedvolunteers. The responses of adductor pollicis were measuredduring onset and recovery of neuro-muscular block for each agent.There was a drug-related disparity between mechanomyo-gram (MMG)and electromyogram (EMG) measurement of the first response ofthe train-of-four (T1) and of the ratio of the fourth (T4) tothe first response (TOF ratio). There were significantly higherT1 values for the EMG than for MMG during alcuronium blockade(P = 0.03). For tubocurarine, however, the relationship wasreversed. The relationship between T1 and TOF ratio during onsetand recovery of neuromuscular block was a hysteresis. The TOFratio at 50% T1 was significantly higher during onset than duringrecovery for all three drugs, measured by MMG or EMG (P <0.005). Analysis of variance of the differential fade loopsfailed to show a drug-related effect. We conclude that careshould be taken in assuming interchangeability between MMG andEMG measurement of T1. Relationships between T1 and TOF ratioderived during recovery do not necessarily apply during onsetand may lead to error in estimating the degree of muscle relaxation.     

EXTRADURAL AND PARENTERAL MORPHINE: KINETICS AND EFFECTS IN POSTOPERATIVE PAIN. A CONTROLLED CLINICAL STUDY

In a controlled clinical study of 20 patients undergoing arthrotomya single dose of morphine 0.05 mg kg^–1 administered extradurallyresulted in more pronounced and prolonged pain relief than morphine0.1 mg kg^–1 i.m. in the period immediately after operation.This difference was significant between 2 and 11 h after morphineadministration. The maximum analgesic effect for nine patientsin the extradural group was obtained about 2 h after injection.Two of 10 in the extradural group experienced urinary retention.Other side-effects were mild for both groups. Plasma concentrationsof morphine were measured in five patients in each group. Fourhours after administration, morphine was not detectable in plasmain any of the extradural group and in two of the i.m. group.Our study gives further support for the theory that extraduralmorphine acts on the spinal cord.     

腹部手术前后病人血清TNF和IgE水平变化及与感染的关系

对60例腹部疾病病人手术前后血清肿瘤坏死因子(TNF)和免疫球蛋白E(IgE)水平进行临床动态观察的结果表明,过高的IgE水平有发生严重感染的可能,增高的TNF值预示有感染发生、过高时感染严重可伴有器官功能损伤而可作为病情严重性和预后的观察指标。在术后感染的防治中,对二者的监测有助于对感染的发生、严重性和预后的早期判断。     

脾肾分流加断流联合术血流动力学变化的临床研究

本文利用彩色多普勒血流显象（ＤＣＦＩ）数字减影血管造影（ＤＳＡ）和术中门静脉压力测量，研究了脾肾分流加贲门周围血管离断联合术后门脉系统血流动力学变化。结果表明联合术后门静脉内径和压力较断流术明显减小和降低，但门静脉血流量的减少与断流术无显著差异（ｐ＞０．０５）；同时发现联合术后门静脉血流量仍维持正常高值水平，门静脉为向肝血流，脾静脉为逆肝血流，门静脉肝内灌注良好，门静脉头向侧枝全部消失，以上血流动力学变化与本组病例术后再出血及脑病发生率低，腹水消退和生活质量好有关。本研究表明，脾肾分流加贲门周围血管离断联合术是合理而可取的一种术式。     

左半结肠急性梗阻一期手术后应用新斯的明的实验与临床研究

通过对左半结肠一期切除吻合术后应用新斯的明，从组织学等指标观察对结肠吻合口的影响。结果提示：术后早期使用新斯的明可迅速排除肠道内容物，减轻吻合口炎症，促进吻合口愈合。进而提出了术后应用新斯的明的安全性及注意点，并且阐述了结肠吻合口漏发生的主要机理及预防措施     

MORPHOLOGICAL ANALYSIS OF ILEAL GRAFTING FOLLOWING ILEOCYSTOPLASTY IN THE RAT: A KINETIC AND ULTRASTRUCTURAL STUDY OF THE INTESTINAL EPITHELIUM

lleocystoplasty was performed in rats and the morphological and cell-kinetic changes occurring in the ileal grafts were determined at intervals up to 18 months postoperatively. The intestinal mucosa underwent no progressive changes but included villous and avillous regions associated with crypts of various sizes at all time intervals. Newly appearing and densely packed epithelial cells, shaped like petals, were always present in the lower parts of the villi associated with crypts showing no elongation, but seldom present in those with elongated crypts in the villous mucosa. Bromodeoxyuridine studies showed that the petal-shaped cells interfered with cell migration. No petal-shaped cells were observed in avillous mucosa in which the rate of cell turnover depended on crypt size. Fine-structural changes in absorptive epithelial cells in both types of mucosa included features of prematurity or hypermaturity in the cytoplasm and close adherence to the basal portions of adjacent cells and to the basal lamina. These changes may possibly contribute to the prevention of reabsorption of urine. However, some of the mechanisms responsible for adherence of the basal parts might incidentally interfere with the normal cell kinetics of the intestinal epithelium, resulting in dense packing of cells and the formation of multiple types of mucosa in ileal grafts.     

肾脏病患者血清脂蛋白,载脂蛋白变化及血透对其影响的临床观察

本实验测定了３４例慢性肾衰（ＣＲＦ）、２７例肾病综合征（ＮＳ）患者和１００例正常人血清脂质、脂蛋白（Ｌｐ）和载脂蛋白（Ａｐｏ）的含量，并观察了血透（ＨＤ）和非透析（ＮＤ）患者血清脂质、Ｌｐ、Ａｐｏ的浓度变化。结果显示：（１）与正常组比较，ＮＳ和ＣＲＦ患者血清脂质、Ｌｐ及Ａｐｏ的绝大多数指标有明显异常（Ｐ＜０．０１或０．０２或０．００１）；（２）比较ＨＤ和ＮＤ组，ＮＤ对ＣＲＦ血清脂质、Ｌｐ、Ａｐｏ含量的影响无显著意义（Ｐ＞０．０５）。     

套式聚合酶链反应扩增胆固醇结石中细菌DNA及其临床意义研究

为探讨细菌在胆固醇结石发病机理中的作用，从３０例胆汁细菌培养阴性的胆囊胆固醇结石中提取ＤＮＡ，应用套式聚合酶链反应扩增细菌１６ＳｒＲＮＡ基因片段作为有细菌存在的分子证据。结果显示，２６例胆固醇结石中有细菌ＤＮＡ存在。提示细菌可能在胆固醇结石的形成中具有一定的作用。     

EARLY AND LATE RESULTS AFTER BIRD'S NEST FILTER PLACEMENT IN THE INFERIOR VENA CAVA: CLINICAL AND DUPLEX ULTRASOUND FOLLOW UP

From February 1989 to November 1992, 61 Bird's Nest filters were placed in the infrarenal vena cava in 61 patients (36 men and 25 women; mean age ± s.d., 63 ± 15, range (16–83). In 27 (44.3%). the filter was inserted because of contraindication to anticoagulation, in 19 (31.1%) for anticoagulation failure and in 15 (24.6%) as prophylaxis against pulmonary embolism in high risk patients. All the filters were introduced by percutaneous puncture of the femoral vein after preliminary screening venography demonstrated that the iliac vein was free of thrombus. Two deaths occurred within 24 h of filter placement (periprocedure mortality 3.3%) while five other patients died within 1 month (30 day cumulative mortality 11.5%). At follow up, 2–40 months later (mean ± s.d., 17 ± 9), a further 13 patients had died (cumulative mortality 32.8%). At 36 months, the probability of survival, calculated by the Kaplan-Meier Product Limit Method, was 55% (95% confidence intervals 37–74%). Apart from the two patients dying within 24 h, none of the early or late deaths were attributable to the procedure and there were no recurrent pulmonary emboli. Thirty-seven of the surviving 41 patients were recalled for clinical examination and Duplex ultrasound interrogation of the vena cava and the lower limb veins. No new venous thromboses in the legs were observed and no increase or onset of leg swelling was reported. The vena cava patency was 100% in these 37 patients. Considering that the annual attack rate for deep venous thrombosis in New South Wales, Australia is 60 per 100000, and for pulmonary embolism 45 per 100000, vena caval filter placement is an effective but underused resource.     

ANATOMICAL REASONS FOR PROBLEMS AFTER NEURECTOMY FOR BLEPHAROSPASM: A STUDY IN CADAVERS

The purpose of this study is to clarify the mechanisms of the problems that develop after neurectomy for blepharospasm. The left facial nerves in 10 Japanese cadavers were dissected under a surgical microscope. The temporal, zygomatic, and buccal branches innervated to the orbicularis oculi muscle. These three groups formed a well-communicating plexus posterior to the orbicularis. The most inferior buccal branch curved in the deep layer in the lower part of the cheek. In the cheek, both the buccal and the temporal branches had ramifications of other facial muscles. The information given in previous anatomical textbooks did not specifically define the denervation of the orbicularis. When neurectomy was done in the past, the inferior buccal branch may have been kept intact, or other facial muscles as well as the orbicularis may have been denervated which caused the blepharospasm to recur and complications to develop after neurectomy.     

ANTAGONISM OF THE HYPNOTIC EFFECT OF MIDAZOLAM IN CHILDREN: A RANDOMIZED, DOUBLEBLIND STUDY OF PLACEBO AND FLUMAZENIL ADMINISTERED AFTER MIDAZOLAM-INDUCED ANAESTHESIA

In a randomized, double-blind study, we administered placeboand flumazenil to 40 healthy Chinese boys, aged 3–12 yr,undergoing circumcision. The children received midazolam 0.5mg kg^–1 orally for premedication and 0.5 mg kg^–1i.v. during induction. After operation the patients were given0.1 ml kg^–1 of a blinded solution followed by 0.05 mlkg^–1 min^–1 until either they awoke or the 10-mlampoule of solution was empty. Efficacy of antagonism of midazolamwas assessed by times to eye opening and self identification,modified Steward coma scale, a post-box toy completion-timeratio and qualitatively by an independent observer. The differencebetween flumazenil and placebo was both clinically and statisticallydifferent in the first 2h. Children receiving flumazenil awokeapproximately four times faster and identified themselves nearlythree times sooner; 65% of this group could complete the post-boxtoy at 10 min, compared with none of the placebo group. Therewere no cases of resedation, but one child did not awaken for30 min after i.v. administration of flumazenil 1.0 mg. The meantotal dose of flumazenil administered was 0.024 (SD 0.019) mgkg^–1. Flumazenil rapidly antagonized midazolam-inducedhypnosis in children and was associated with minimal changein cardio-respiratory variables.     

VEIN TO ARTERY GRAFTS: A MORPHOLOGICAL AND HISTOCHEMICAL STUDY OF THE HISTOGENESIS OF INTIMAL HYPERPLASIA

Failure of vein to artery grafts has been associated with intimal thickening (hyperplasia) and atherosclerosis. Current theories of intimal development, derived from arterial studies, show that smooth muscle cells migrate from the media to the intima after endothelial damage, where they proliferate and produce intimal hyperplasia. However, little is known of the histogenesis of these lesions in vein grafts. Experimental ilio-lumbar vein to iliac artery autografts were placed in 52 rats and analysed by light microscopy and histochemistry from 2 to 140 days after surgery. On day 2 the grafts and adjacent artery were severely damaged. Regeneration of damaged arterial tissue occurred by day 5, and thickening was already evident in the arterial intima. The intimal cells had histochemical characteristics of smooth muscle. By day 15, this hyperplastic intima was continuous across the anastomosis from the artery into the graft. After day 28 a wedge of densely packed cells was present in the vein graft intima for approximately 2 mm into the graft. By day 140, all the grafts were fully re-endothelialized. Intimal hyperplasia was present in all grafts and varied in thickness from 3 to 20 cells. Histochemical staining of these cells showed them to be of smooth muscle origin.