超声心动图对半旋转动脉干调转术治疗完全性大动脉转位合并室间隔缺损和肺动脉瓣狭窄的研究

目的应用超声心动图评价半旋转动脉干调转术治疗完全性大动脉转位合并室间隔缺损和肺动脉瓣狭窄的早期临床效果。方法我院自2006年2月至2009年10月,应用超声心动图对8例完全性大动脉转位(TGA)合并室间隔缺损(VSD)和肺动脉狭窄(PS)的先天性心脏病进行诊断并对施行半旋转动脉干调转术最新的手术方法进行临床研究。本组8例患者,男5例,女3例,年龄2m-22岁,平均6岁。8例中,5例TGA(SDD),3例右室双出口(DORV),其中2例SDD,1例ILL(镜像右位心)。8例均有VSD、PS。应用飞利浦公司IE33彩色多普勒超声心动图(CDFI),探头频率为2.5-3.75 MHz。选择经胸超声(TTE)切面:胸骨旁左心室长轴切面,胸骨旁右室,左室流入道长轴,胸骨旁大动脉短轴,心尖四腔心切面,剑突下腔静脉及肝静脉切面,剑突下右心室及左心室流出道切面,剑突下左心室至主动脉切面,剑突下右室流出道切面及剑突下四腔心切面,术后1个月用TTE复查两个大动脉关系,有无冠脉扭曲,有无主动脉瓣关闭不全(AI)及各瓣膜异常血流,左心室功能。结果应用TTE术前8例准确诊断,准确定出心房位、心室位、大动脉关系,心房与心室连接及心室与大动脉连接关系,其中5例TGA合并VSD均为围膜部,检出率为100%,而3例DORV合并VSD部位检出率为33%。半旋转动脉干调转术后用TTE复查5例。术后复查1个月～4年。5例患者大动脉关系正常,左、右心室功能正常,VSD修补完整,无AI及冠脉扭曲。2例PS(轻度),2例PI(轻度),2例TI(少量)。结论用TTE诊断及术后随诊半旋转动脉干调转术,是有重要临床价值,此手术临床效果是满意的。     

超声心动图对半旋转动脉干调转术治疗完全性大动脉转位合并室间隔缺损和肺动脉瓣狭窄的研究

目的应用超声心动图评价半旋转动脉干调转术治疗完全性大动脉转位合并室间隔缺损和肺动脉瓣狭窄的早期临床效果。方法我院自2006年2月至2009年10月,应用超声心动图对8例完全性大动脉转位(TGA)合并室间隔缺损(VSD)和肺动脉狭窄(PS)的先天性心脏病进行诊断并对施行半旋转动脉干调转术最新的手术方法进行临床研究。本组8例患者,男5例,女3例,年龄2m-22岁,平均6岁。8例中,5例TGA(SDD),3例右室双出口(DORV),其中2例SDD,1例ILL(镜像右位心)。8例均有VSD、PS。应用飞利浦公司IE33彩色多普勒超声心动图(CDFI),探头频率为2.5-3.75 MHz。选择经胸超声(TTE)切面:胸骨旁左心室长轴切面,胸骨旁右室,左室流入道长轴,胸骨旁大动脉短轴,心尖四腔心切面,剑突下腔静脉及肝静脉切面,剑突下右心室及左心室流出道切面,剑突下左心室至主动脉切面,剑突下右室流出道切面及剑突下四腔心切面,术后1个月用TTE复查两个大动脉关系,有无冠脉扭曲,有无主动脉瓣关闭不全(AI)及各瓣膜异常血流,左心室功能。结果应用TTE术前8例准确诊断,准确定出心房位、心室位、大动脉关系,心房与心室连接及心室与大动脉连接关系,其中5例TGA合并VSD均为围膜部,检出率为100%,而3例DORV合并VSD部位检出率为33%。半旋转动脉干调转术后用TTE复查5例。术后复查1个月～4年。5例患者大动脉关系正常,左、右心室功能正常,VSD修补完整,无AI及冠脉扭曲。2例PS(轻度),2例PI(轻度),2例TI(少量)。结论用TTE诊断及术后随诊半旋转动脉干调转术,是有重要临床价值,此手术临床效果是满意的。     

心脏移植的临床实践(十)

4.3.2 对心房调转术(Senning手术和Mustard手术)后的心脏移植方法心房调转术是早年Senning和Mustard为完全性大动脉转位创造的在心房内静脉血流调转手术.完全性大动脉转位是一种严重的复杂先天性心脏病.     

新生儿复杂先天性心脏病外科治疗--一年经验回顾

目的回顾分析过去一年新生儿复杂先天性心脏病手术治疗结果.方法2004年5月～2005年5月我院新生儿手术临床资料.手术共完成21例,其中室间隔完整的大动脉转位(TGA/IVS)13例;合并室间隔缺损的大动脉转位(TGA/VSD)2例;右心室双出口(DORV、Taussing-Bing)1例;完全性肺静脉畸形引流(TAPVC)2例(心下型及心上型各1例);肺动脉闭锁(PAA)3例.分别行动脉调转术(ASO)16例,完全性肺静脉畸形引流矫治术2例,改良Blalock-Taussing手术3例(其中肺动脉瓣闭式扩张术2例).结果全组存活18例,死亡3例,死亡率14.3%.2例完全性大动脉转位,1例为冠状动脉壁内走行,术后死于低心排血量综合征,1例死于肺部感染.另1例为心上型完全性肺静脉畸形,术后因肺部感染导致肾功能衰竭死亡.结论准确认识新生儿复杂先天性心脏病的病理生理,是正确选择手术时机,提高围手术期治疗的关键.     

伴室间隔缺损的主动脉窦瘤破裂患者主动脉瓣反流外科技术探讨

目的:回顾性总结伴室间隔缺损的主动脉窦瘤破裂(RSVA)的手术治疗,对术前主动脉瓣反流(AR)及术后中期随访AR加重的危险因素进行分析。方法:全组94例患者,RSVA起源于右冠窦瘤91例,破入右心室流出道85例。所有患者均限期内行根治手术,术中行主动脉瓣置换(AVR)24例,补片修补破口基底部63例,直接缝合破口7例。结果:手术无死亡,术后晚期死亡1例系AVR患者。术前61例合并AR,经Logistic回归分析,主动脉瓣继发性改变和室缺直径为术前并发AR的危险因素。术后中期随访56例患者,9例AR加重,单因素分析显示术后合并AR者中期随访AR加重的比率显著高于未合并AR者。结论:早发现、早手术是避免术前AR的有效方法;RSVA术后合并有AR患者应密切随访。     

室间隔缺损远离两大动脉开口右心室双出口的术后早中期随访结果报道

目的:对近13年来124例7岁以下室间隔缺损远离两大动脉开口的右心室双出口(室间隔缺损远离型右心室双出口)患儿进行了术后早中期随访,以期为优选手术方式提供资料.方法:1996-03至2008-08共有124例7岁以下室间隔缺损远离型右心室双出口患儿在我院接受了外科手术,男80例,女44例,年龄3个月～7岁,平均(3.1±2.1)岁,体重4～20 kg,平均(12.2±4.5)kg.手术方法有双心室矫治、单心室矫治和姑息手术.随访依据门诊复查结果(包括病史、体格检查、心电图、X线胸片和超声心动图检查)及电话随访.结果:124例患儿双心室矫治59/124例(47.6%),单心室矫治51/124例(41.1%),姑息手术14/124例(11.3%).住院生存患儿107例,随访期限为术后1～134个月,平均(27±31)个月.有近期随访资料77例,占72.0%.晚期死亡9/107例(8.4%).Kaplan-Meier生存分析,术后2个月、1年、2年、5年和10年生存率分别为98.9%、93.5%、89.0%、86.0%和81.0%.Cox回归分析表明合并复杂畸形(完全性心内膜垫缺损、完全性肺静脉异位引流、主动脉弓缩窄、三房心)和二尖瓣或共同房室瓣中量以上反流是影响生存的独立危险因素.Log rank分析表明姑息手术生存时间与单、双心室矫治差异均有统计学意义(P均<0.05).单、双心室矫治术后早中期生存曲线差异无统计学意义(P>0.05);合并复杂畸形和二尖瓣或共同房室瓣中量以上反流患儿术后早中期生存曲线明显较未合并复杂畸形及无房室瓣反流和少量反流患儿差(P均<0.01),差异均有统计学意义.结论:室间隔缺损远离型右心室双出口无论是双心室还是单心室矫治,术后早中期生存率高.而一期只能做姑息手术的患儿术后早中期生存率低.合并完全性心内膜垫缺损和共同房室瓣中大量反流的患儿无论选择何种术式手术效果都较差.合并复杂畸形的患儿术后早中期生存率也较低.     

自制三瓣叶Goretex管道在先天性心脏病患儿右心室流出道重建中的近期结果

目的:总结自制三瓣叶Goretex管道在先天性心脏病(先心病)患儿右心室流出道重建中的近期结果。方法:2016-12至2017-06期间采用自制三瓣叶Goretex管道重建右心室流出道患儿19例,平均年龄(5.9±3.6)岁,平均体重(20.2±8.2)kg。根据患者年龄和体重,制定右心室流出道的直径目标值,将0.1 mm Goretex膜剪裁三片相同大小的椭圆形作为瓣叶,6/0 prolene线单纯连续缝合至Goretex管道,自制成三瓣叶Goretex管道。采集患儿出院时超声心动图评价带瓣管道内瓣口狭窄和反流程度情况,出院后1个月门诊超声心动图复查随访观察。结果:右心室双出口6例,矫正型大动脉转位4例,肺动脉闭锁4例,大动脉转位2例,共同动脉干1例,双根部调转术后外管道狭窄1例,主动脉瓣狭窄1例。单纯Rastelli术8例,Rastelli+Senning术1例,Rastelli+半Mustard术2例,Rastelli+上腔静脉右心房连接术(Glenn take down)2例,Rastelli+双侧双向Glenn例1例,右心室肺动脉外管道置换术3例,Ross术1例,共同动脉干矫治术1例;其中二次手术12例(63.2%)。手术均在体外循环下完成,术后常规阿司匹林(3 mg/kg口服QD)抗栓,全组患者无院内死亡和严重并发症发生,出院及随访时间1个月时超声心动图显示所有患者肺动脉瓣口均无狭窄,2例(10.5%)患者肺动脉瓣轻度反流,其余患者无反流。结论:自制三瓣叶Goretex管道重建先心病右心室流出道近期结果满意,但中远期结果需要进一步随访。     

动脉调转手术后中期生存结果及其影响因素分析

目的:探讨完全型大动脉转位(TGA)合并室间隔缺损(VSD)及TGA型右心室双出口(Taussig-Bing)患者行动脉调转手术(ASO)后的中期生存结果及其影响因素.方法:回顾性研究2001-01-01至2007-12-31期间来我院行动脉调转手术并存活出院的115例TGA合并VSD及Taussig-Bing患者的临床资料,并对所有患者进行了电话随访及院内随诊复查.结果:115例存活患者均完成了随访,随访时间1～8年(平均3.1年).其中10例患者随访过程中院外死亡(死亡率8.7%,10/115).Kaplan-Meier法分析中期生存率6个月、1年、5年、8年分别为94.8%,92.2%,89.3%,89.3%.Cox回归分析显示手术年龄>3岁(相对危险度10.644,P=0.002)及术后1个月复查超声心动图,提示残存肺动脉高压(相对危险度4.864,P=0.047)是此类患者预后的重要影响因素.结论:TGA合并VSD及Taussig-Bing患者行动脉调转手术中期结果满意,死亡率及再手术率低.证实了手术年龄>6个月的TGA合并VSD及Taussig-Bing患者依然有手术适应证,但手术年龄>3岁者,术后1年死亡率高,故一定要做到定期随访,避免肺动脉高压危象发生.     

78例动脉调转手术在复杂先天性心脏病治疗中的临床应用

目的:回顾总结近年来动脉调转术(ASO)治疗心室大动脉连接异常复杂先天性心脏病(先心病)的手术疗效,探讨手术适应证。方法:2000年1月至2004年12月,对78例患儿行动脉调转术,其中室间隔完整型[或含小的室间隔缺损(VSD)]大动脉转位(TGA),为室间隔完整型组30例;<6个月的VSD型TGA和右心室双出口合并肺动脉瓣下VSD(简称TaussigBing畸形),为<6个月VSD型组20例;>6个月合并中～重度肺动脉高压的VSD型TGA和TaussigBing畸形,为>6个月VSD型组24例;矫正型TGA为矫正型TGA组4例。平均年龄(8.55±14.84)个月(2天～11岁)。合并主要畸形:左心室流出道狭窄7例,肺动脉瓣轻～中度狭窄7例,肺动脉瓣重度狭窄1例,主动脉弓中断1例,肺动脉瓣下隔膜1例,主动脉瓣下隔膜1例,镜面右位心1例。在全麻、低温(18～22℃)、低流量[50ml/(kg·min)]体外循环下完成动脉调转术,合并畸形者同期矫治。结果:全组病死率为14.1%(11/78)。其中室间隔完整型组、<6个月VSD型组、>6个月VSD型组和矫正型TGA组病死率分别是13.3%(4/30)、15.0%(3/20)、12.5%(3/24)、25.0%(1/4)。67例患者痊愈出院。平均随诊13.5±7.9(0.5～56)个月,心功能明显改善,紫绀消失,活动量增加,发育正常,无死亡和远期并发症发生。结论:动脉调转术是解剖矫治TGA、TaussigBing畸形及矫正型TGA的首选术式。对年龄较大(>6个月)、合并中～重度肺动脉高压、合并复杂畸形同期矫治以及一期姑息术后的二期动脉调转术患儿,手术疗效及中期随访结果满意。     

复杂完全性大动脉转位行动脉调转术治疗分析

目的对复杂完全性大动脉转位行动脉调转术的治疗效果进行观察。方法选择复杂完全性大动脉转位患者,共计17例,2014年1月~2017年1月是此次研究的时间选择段落,对所有患者均进行动脉调转术治疗,分析患者的住院时长、转流时间、呼吸机使用时长,并对患者进行为期1年的随访。结果患者的住院时长、转流时间、呼吸机使用时长分别为:(25.33±5.11)d、(261.11±70.22)min、(251.33±100.22)h;出现了3例死亡病例,其中术后12小时内死于肺高压危象1例、术后死于低心排综合症2例;其余患者治疗1年后的生长发育情况均相对良好。结论行动脉调转术治疗复杂完全性大动脉转位患者,可以获得相对较优的临床治疗效果,掌握合适的手术时机,冠脉移植的质量是手术成败的关键。     

The immunoneuroendocrine role of melatonin

Abstract: A tight, physiological link between the pineal gland and the immune system is emerging from a series of experimental studies. This link might reflect the evolutionary connection between self-recognition and reproduction. Pinealectomy or other experimental methods which inhibit melatonin synthesis and secretion induce a state of immunodepression which is counteracted by melatonin. In general, melatonin seems to have an immunoenhancing effect that is particularly apparent in immunodepressive states. The negative effect of acute stress or immunosuppressive pharmacological treatments on various immune parameters are counteracted by melatonin. It seems important to note that one of the main targets of melatonin is the thymus, i.e., the central organ of the immune system. The clinical use of melatonin as an immunotherapeutic agent seems promising in primary and secondary immunodeficiencies as well as in cancer immunotherapy. The immunoenhancing action of melatonin seems to be mediated by T-helper cell-derived opioid peptides as well as by lymphokines and, perhaps, by pituitary hormones. Melatonin-induced-immuno-opioids (MHO) and lymphokines imply the presence of specific binding sites or melatonin receptors on cells of the immune system. On the other hand, lymphokines such as -γ-interferon and interleukin-2 as well as thymic hormones can modulate the synthesis of melatonin in the pineal gland. The pineal gland might thus be viewed as the crux of a sophisticated immunoneuroendocrine network which functions as an unconscious, diffuse sensory organ.     

Changes in connexin43, the gap junction protein of astrocytes, during development of the rat pineal gland

Abstract: The abundance of gap junctions between rat pineal astrocytes formed by connexin43 (Cx43) was studied during development. Levels and distribution of Cx43 were measured by immunoblotting and indirect immunofluorescence, respectively. The amount of Cx43 in cells located within the gland was low until about the 7th postnatal day and increased to adult values between the 14th and 21st days postpartum. Although astrocytes, recognized by their vimentin immunoreactivity, were scarce before birth, they were abundant by the 7th postnatal day suggesting that the low levels of Cx43 found at this age corresponded to a low expression of this protein. Localization of the immunoreactivity to Cx43 and vimentin showed a close correlation, indicating that mature or immature pineal astrocytes form gap junctions made of Cx43. Since Cx43 levels attained their adult values at about the time the innervation and the functional state of the gland reached maturity (2–3 weeks after birth), it is proposed that astrocyte gap junctions are involved in the function of the adult rat pineal gland.     

Response of rat pineal melatonin to calcium, magnesium, and lithium is circadian stage dependent

Abstract: Herein we documented the response of pineal melatonin production to electrolytes known to be effective on pineal function in view of a possible circadian stage dependence. We studied the release of melatonin by perifused rat pineal glands at 2 different circadian stages corresponding to the middle of the light and dark periods, i.e., respectively, 7 and 19 HALO (Hours After Light Onset, L:D = 12:12). The initial efflux rates were, as expected, much higher in the perifusates of glands removed from rats sacrificed during the dark phase than of those removed during the light phase. After 3 hr of perifusion, melatonin release reached similar levels which were found constant up to the 8th hr of perifusion, whatever the circadian stage. Perifusion of the glands with physiological concentrations for the rat of calcium (5.2 mmol/1) and magnesium (1.34 mmol/1) resulted in a stimulatory effect on the pineal glands removed from rats sacrificed in the middle of the dark period (19 HALO), whereas no effects were observed on the pineal glands removed from rats sacrificed during the light (7 HALO). Lithium (0.28 and 0.55 mmol/1) was ineffective on melatonin release in pineal glands removed 7 and 19 HALO. Our results show differences in the initial efflux rates of melatonin and in the response of perifused pineal glands to calcium and magnesium according to the circadian stage.     

Conservative management of perforated duodenal diverticulum： A case report and review of the literature

Duodenal diverticula are a relatively common condition. They are asymptomatic, unless they become complicated, with perforation being the rarest but most severe complication. Surgical treatment is the most frequently performed approach. We report the case of a patient with a perforated duodenal diverticulum, which was diagnosed early and treated conservatively with antibiotics and percutaneous drainage of secondary retroperitoneal abscesses. We suggest this method could be an acceptable option for the management of similar cases, provided that the patient is in good general condition and without septic signs.     

Presence of immunoreactive growth hormone and prolactin in the ovine pineal gland

Abstract: The use of antisera raised against bovine growth hormone (GH) and ovine prolactin (PRL) enabled the detection of related immunoreactive (ir) sequences of proteins in ovine pineal tissue. The isolation of PRL-like ir-material was accomplished using a 0.25 M ammonium sulphate (pH 5.5) extraction followed by ethanol precipitation, whereas the resulting 2.0 M ammonium sulphate (pH 7.0) precipitate contained a GH-like immunoreactivity. Gel chromatography of the GH-like immunoreactivity (Sephadex G-100) indicated the presence of several GH-like fragments ranging in the M_r range of 7,000 to 55,000. Analyses of the PRL-like ir-material found in pineal tissue on HPLC using a TSK 545-DEAE column led to the resolution into a single peak of immunoreactivity. A single peak of activity was also observed following chromatofocusing and hydrophobic interaction chromatography of the ir-peak from the TSK 545-DEAE column. The PRL-like ir-material inhibited the binding of [¹²⁵I]ovine PRL-S14 to anti-ovine PRL antibodies without showing an affinity for binding to anti-rat PRL or anti-bovine GH antibodies. Scatchard analysis of the binding of pineal PRL-like ir-material and pituitary ovine PRL-S14 to liver membranes from day-20 pregnant rats revealed similar affinity constants (K_a of 4.7 ± 0.2 × 10⁹ M^-1). In addition, the replication of Nb 2 Node rat lymphoma cells was stimulated by pineal PRL-like ir-material, an effect known to be specific for lactogenic hormones. The pineal PRL-like immunoreactivity appeared on sodium dodecyl sulfate polyacrylamide gels as a single major band of M_r 24,000. The functional status of PRL-and GH-like ir-material in the ovine pineal remains to be determined, but evidence is presented that the overall protein synthesis rate of the rat pineal responded to circulating concentrations of PRL.     

Microbiology of human immunodeficiency virus anorectal disease

PURPOSE: Individuals who are seropositive for the human immunodeficiency virus are at high risk for opportunistic infection and anorectal disorders. Little prospective information is available regarding anorectal pathogens in these patients. METHODS: One hundred sixty-three HIV-seropositive patients presented to the colorectal clinic between 1989 and 1992. Forty-seven (29 percent) patients were thought to have an infectious process and were prospectively studied using a standardized multiculture protocol. RESULTS: Mean age was 33 (range, 19–59) years. All were male; high-risk behavior accounted for 87 percent of HIV transmissions. Presenting complaints included anorectal pain (79 percent), pus per anum (28 percent), and blood per anum (26 percent). Examination revealed perianal tenderness (60 percent), condyloma (38 percent), perianal ulcers (38 percent), and anal fissures (34 percent). Sixty-six sets of cultures were performed; 28 patients had one set, 15 had two sets, and 4 had three sets. Thirty-two of these 47 patients (68 percent) had positive cultures including herpes (50 percent), cytomegalovirus (25 percent),Neisseria gonorrhoeae (16 percent), chlamydia (16 percent), acidfast bacilli (2 percent), and others (9 percent). Six of 32 patients with positive cultures had more than one organism cultured. Sixteen (50 percent) patients with positive cultures were treated medically, 8 (25 percent) were treated surgically and 8 (25 percent) were treated with both modalities. Sixty-one procedures were performed on 17 patients for condylomata. Eighteen patients had 20 procedures for abscesses, 50 percent of whom had positive cultures for other than common bowel flora; all improved. Fourteen patients underwent 33 procedures for perianal fistulas.Mycobacterium fortuitum was cultured from one patient who required 13 procedures for abscesses and fistulas. Forty-five (96 percent) patients were followed for an average of 12.5 months ±2.9 SEM (range, 1–94 months). Symptoms were improved or resolved in 22 of 32 (69 percent) patients with positive cultures and in 11 of 13 (84 percent) with negative cultures. CONCLUSIONS: Specific pathogens may often be identified in human immunodeficiency virus-seropositive patients with anorectal disorders if aggressively sought. Although patients without specific pathogens identified may be expected to improve with planned empiric treatment, positive identification allows more directed therapy.