Predictors of postoperative myocardial ischemia in patients undergoing noncardiac surgery.The Study of Perioperative Ischemia Research Group.

OBJECTIVE--To identify predictors of postoperative myocardial ischemia in patients scheduled to undergo major noncardiac surgery. DESIGN--Historical, clinical, laboratory, and physiological data were obtained prospectively before and during surgery to identify potential univariate predictors of postoperative myocardial ischemia, which then were entered into multivariate logistic models. Continuous two-lead electrocardiograms before, during, and after surgery were used to identify episodes of myocardial ischemia. SETTING--Department of Veterans Affairs tertiary care hospital. PATIENTS--A consecutive sample of 474 men at high risk for or with coronary artery disease who were scheduled to undergo major noncardiac surgery (95% compliance rate). MAIN OUTCOME MEASURE--Significant variables identified by multivariate logistic models that are associated with postoperative myocardial ischemia. RESULTS--Five major preoperative predictors of postoperative myocardial ischemia were identified: (1) left ventricular hypertrophy by electrocardiogram; (2) history of hypertension; (3) diabetes mellitus; (4) definite coronary artery disease; and (5) use of digoxin. The risk of postoperative myocardial ischemia increased progressively with the number of predictors present: in 22% of patients with no predictors, in 31% with one predictor, in 46% with two predictors, in 70% with three predictors, and in 77% with four predictors. CONCLUSION--Patients subgroups who are at high risk for developing postoperative myocardial ischemia and who might benefit the most from intensive Holter monitoring in the postoperative period now can be identified preoperatively.     

急性心肌梗死患者外周血Th17细胞的检测及临床意义

目的探讨急性心肌梗死患者外周血Th17细胞的变化,了解其变化在急性心肌梗死及冠心病发病中的意义。方法将研究对象分为急性心肌梗死组（AMI组,10例）、不稳定性心绞痛组（Ua组,10例）及对照组（造影正常的胸痛患者10例）。应用流式细胞分析法和ELISA法检测外周血11117及其分泌的细胞因子IL-17A的表达。结果AMI患者外周血Th17百分率（0．99±0．18）％显著高于UA患者（0．63±0．11）％及对照组（0．35±0．08）％（P〈0．05）,UA组Th17百分比高于对照组（P〈0．05）。AMI患者IL-17A血浆浓度（182±23．68）pg／mL高于UA患者（114±14．36）pg／mL及对照组（49±10．74）pg／mL（P〈0．05）,UA组IL-17A血浆浓度高于对照组（P〈0．05）。结论随着动脉粥样硬化斑块不稳定的加剧,外周血Th17及IL一17A的表达显著增高。Th17可能与斑块的不稳定相关,促进AMI的进展。     

环磷酸腺苷与术中心肌缺血的研究

目的 研究环磷酸腺苷（商品名美心力）在术中预防和治疗心肌缺血中的价值。方法 86例存在心肌缺血或ECG证实有ST段下降的腹部外科手术病人，随机分为环磷酸腺苷组（M组，44例）和对照组（C组，42例）。M组在麻醉诱导前10min静脉注射环磷酸腺苷10mg，随后以1mg/kg加入100ml生理盐水中持续缓慢静滴；对照组静滴生理盐水。术中持续纪录各导联（Ⅱ、Ⅲ、Ⅴ5、aVF、aVR)ST段水平，纪录SBP、MBP、DBP、HR并计算心率收缩压乘积（Rate-pressure product,RPP)；同时抽取外周静脉血检测术前1d，术后12h、术后24h血清心肌酶指标。结果 术中C组出现明显的ST段下降和RPP升高，与M组有显著性的差异（P＜0.05)。M组的术后心肌酶指标的升高程度较C组为低，在CK、CK－MB两个酶上有显著性差异（P＜0.05)。术后C组有1例出现灶性心肌梗塞（local myocardial infarction)(2.3%)。结论 环磷酸腺苷在预防和治疗术中心肌缺血、心肌梗塞上具有较好的作用。     

瑞芬太尼用于骨科术中及术后静脉镇痛的效果观察

目的:观察瑞芬太尼用于骨科手术术中及术后静脉镇痛的效果。方法:选择择期在全身麻醉下行骨科手术患者80例均采用气管插管全凭静脉麻醉,术后行自控静脉镇痛。患者随机分为瑞芬太尼组(A组)和分太尼组(B组),每组40例。术中麻醉维持,A组:丙泊酚5 mg/(kg·h)泵注,瑞芬太尼0.15μg/(kg·min)泵注,维库溴铵2~4 mg/h;B组:丙泊酚5 mg/(kg·h)泵注,芬太尼2μg/kg/h泵注,维库溴铵2~4 mg/h。术后自控静脉镇痛配方为A组:瑞芬太尼1mg+托烷司琼5mg加生理盐水至100 ml,B组:芬太尼1 mg+托烷司琼5 mg加生理盐水至100 ml。观察并记录两组患者术后12、24 h PCA总按压次数和有效按压次数,1、3、6、12、24 h NRS和BCS评分,观察有无恶心呕吐、畏寒发热、头晕、嗜睡等不良反应。结果:A组术后12和24 h PCA总按压次数和PCA有效按压次数与B组比较均明显降低(P<0.05);A组术后3 h、6 h、12 h和24 h的NRS评分明显较低,而BCS评分明显偏高(P<0.05);两者间恶心呕吐、畏寒发热、头晕、嗜睡等不良反应发生率差异均无统计学意义(P>0.05)。结论:瑞芬太尼用于骨科术中和术后镇痛效果明显,是一种骨科手术术中和术后有效而安全的镇痛药物。     

术中超声辅助颅内血管性疾病的外科治疗研究

目的 探讨术中超声在颅内血管性疾病外科手术治疗中的应用价值.方法 对70例颅内动脉瘤患者、41例脑动静脉畸形患者分别行术中超声辅助下的外科手术治疗,并对手术前、手术中及术后复查的结果进行比较.结果 ①70例颅内动脉瘤患者术中超声清晰显示68例,合并血栓者49例.②41例脑动静脉畸形在超声引导下均快速找到病灶并准确定位.结论 术中超声能够对颅内血管性疾病进行术中准确定位和实时导航,确定病变边界,测量病变的血流动力学特征,及时发现病灶残留,具有很大的实用价值.     

老年非心脏手术围手术期的心肌缺血

作者对７０例老年普通外科手术患者围手术期的心肌缺血情况进行分析，结果表明（１）冠心病，高龄（〉７５岁）患者与术中心肌缺血有显著相关性（Ｐ〈０．０５）；（２）术中及术后心动过速（〉１００／ｍｉｎ）、血压升高（收缩压〉２１．３ｋＰａ）与ＳＴ段下降有显著相关性（Ｐ〈０．０５）；（３）牢冠患者围手术期心肌缺血主要表现为无症心状缺血；（４）术后４８ｈ内心肌梗死发生的高危期。     

两种液体治疗方案在直、结肠手术中的临床观察

目的比较肠道手术中常规输液和限制性输液对术后并发症、肠功能恢复的影响,为此类手术术中合理输液提供依据。方法将直、结肠手术患者分为常规输液组(A组)和限制性输液组(B组)各30例,术中分别以10ml/(kg.h)和4ml/(kg.h)的速度按1∶1的比例输入复方氯化钠溶液(Ringer's solusion)和羟乙基淀粉氯化钠注射液(HES 130/0.4)作为术中维持输液。结果:限制性输液组术中输入总液量、中心静脉压和尿量显著低于常规输液组(P<0.01),但仍在正常范围;限制输液组术后第一天保持较高的血红蛋白和血浆白蛋白含量(P<0.01),其术后并发症总体发生率较少(P<0.01);首次排气、排便较早(P值分别<0.05和0.01),术后住院时间短于常规输液组(P<0.05)。结论在直、结肠手术术中限制性液体治疗,有利于减少术后并发症及术后肠功能的恢复。     

Detection of transitory myocardial ischemia secondary to perinatal asphyxia

Transitory myocardial ischemia (TMI) is seen as a complication of severe asphyxia. Its presentation is variable, ranging from tachypnea to cardiogenic shock, and it is often masked by the predominant disease. The objective of this study was to detect TMI secondary to perinatal asphyxia in a population of asphyxiated newborns (NB) in comparison with asphyxiated NB with no evidence of TMI.From April 1996 to December 1997, 43 asphyxiated (stressed) NB were studied. Three were excluded. Patients were placed into two groups: Group A with TMI (n = 33) and Group B without TMI (n = 7).No significant differences were found in gestational age, birth weight, extrauterine age, Apgar score, or total creatine phosphokinase values between the two groups. Differences were found in CPK-MB levels and in ischemic electrocardiographic changes and blockages, especially for Group A. In this group, only 24 (72.7%) were cardiovascularly symptomatic.We conclude that TMI secondary to perinatal asphyxia is more frequent than has been reported. Thus, it would be useful in all asphyxiated NB to measure CPK-MB isoenzyme activity and patients can then be submitted to an electrocardiogram for detection in order to offer opportune treatment when required.     

糖尿病大鼠心肌缺血再灌注损伤中聚(腺苷二磷酸)聚合酶的表达及意义

目的探索高血糖状态下缺血再灌注损伤（IRI）诱导的在体心肌细胞凋亡的变化；通过PARP表达的检测．希望发现糖尿病心肌IRI机制的特异性。方法TUNEL法检测糖尿病大鼠IRI心肌细胞凋亡的程度与分布，应用免疫组化染色、WesternBlot技术检测PARP表达。结果TUNEL结果显示，DM组凋亡细胞数目呈逐渐上升趋势，未见明显坏死区；NDM组凋亡细胞数目呈先上升再下降的趋势，再灌注24h呈现心肌细胞坏死的表现。免疫组化结果显示，再灌注6h内，NDM组PARP表达阳性细胞明显多于DM组，再灌注24h，NDM组PARP表达阳性细胞明显少于DM组。PARP的阳性表达率与AI值呈正相关。Western blot证明DM组和NDM组随着再灌注时间的延长116kD的PARP表达逐渐减少，24kD的PARP蛋白表达逐渐增加，相同时相，DM组116kD的PARP表达明显强于NDM组，24kD的PARP表达明显弱于NDM组。结论一定病程糖尿病大鼠，心肌IRI过程中．心肌细胞损伤明显轻于非糖尿病大鼠；PARP在糖尿病心肌细胞IRI细胞凋亡中亦发挥着重要作用；心肌细胞坏死的机制可能与PARP无关。     

液体治疗对老年腹部手术患者术中状况和术后康复的影响

目的 观察手术期间输入不同液体对老年腹部手术患者术中和术后生理状况的影响。方法 择期老年腹部手术患者,随机分为晶体组(组Ⅰ,n=33,输入乳酸林格液)、胶体组(组Ⅱ,n=32,输入佳乐施)和晶胶组(组Ⅲ,n=31,乳酸林格液和佳乐施各半),麻醉手术期间均以5mL/（kg·h）匀速输入目标液体。对三组术中循环参数、动脉血气、手术前后血液学和凝血指标、术后各类并发症以及康复指标进行比较。结果 三组术中HR、MBP变化趋势相似,组ⅡCVP增高尤为明显（P＜0.05）;组Ⅰ和组Ⅱ的pH和PaCO2呈降低趋势（P＜0.05及P＜0.001）,其变化幅度与组Ⅲ对比存在显著差异（P＜0.05）;三组术后WBC显著增高,组Ⅱ与组Ⅰ和组Ⅲ对比差异显著（P＜0.05）。术后三组的Hct、PLT和ALB均呈降低,以组Ⅱ为明显,与组Ⅰ组对比差异显著（P＜0.05）。三组的PT、INR和APTT均略增加,组Ⅱ与组Ⅰ及组Ⅲ对比存在显著统计学差异（P＜0.05）。胶体组术后并发症总发生率比晶体组显著增高（P＜0.05）。三组术后康复各指标对比均未见统计学差异。结论 老年腹部手术中按5 mL/（kg·h）输入晶体液、胶体液或1:1晶体和胶体液,均能较好维持术中循环功能,但晶胶组可维持更好动脉pH;单纯胶体组术中CVP呈持续增高,术后并发症发生率也较高;而晶体组术后白细胞增高反应更为显著,但三组术后的康复时间均无不同。 【关键词】老年;液体治疗;腹部手术;术中状态;术后康复     

慢性冠状动脉供血不足患者PTCA术前后外周血心肌酶和白细胞的变化及意义

目的探讨经皮腔内冠状动脉成形术（ＰＴＣＡ）是否对慢性冠状动脉供血不足产生缺血及再灌注损伤。方法　选择行ＰＴＣＡ的慢性冠心病患者１８例为观察组（ＰＴＣＡ组）,怀疑有冠心病行选择性冠状动脉造影（ＳＣＡ）患者２０例作对照组（ＳＣＡ组）,观察血清心肌酶ＣＫ－ＭＢ、ＬＤＨ、外周血白细胞计数（ＷＢＣ）及中性粒细胞百分比（ＰＭＮ％）在手术前后的变化。结果　所有ＰＴＣＡ均成功,术后残余狭窄均小于１５％。手术后上述指标与术前相比两组均有明显升高（Ｐ＜０．０５）,但术后两组间比较,尽管ＰＴＣＡ组ＣＫ－ＭＢ、ＷＢＣ、ＰＭＮ％较对照组有升高趋势,但无统计学差异（Ｐ＞０．０５）。结论　ＰＴＣＡ对慢性冠状动脉供血不足不产生显著的缺血及再灌注损伤,但不能排除轻微的损伤作用,这种损伤不仅与ＰＴＣＡ中球囊扩张的时间,球囊的压力及基础病变有关,还与心肌组织的病理生理状态有关,对不稳定性心绞痛病人ＰＴＣＡ可能增加缺血及再灌注损伤的机会和程度。     

Detection of hepatocellular carcinoma cells in peripheral venous blood and its significance

Primary hepatocellular carcinoma (PHC) is a major cause of death in patients with chronic liver disease. One of the difficulties in the management of PHC is its extensive character: intrahepatic metastasis, venous invasion and distant metastasis. In the process of metastasis, tumor cells are scattered from the original site, spread hematogenously and arrested at small vessel. Thus, detection of tumor cells in the circulation might predict metastasis of tumor.1 However, the number of cells in circulation could be much too small to be detected morphologically.     

心先安防治心肌缺血老年病人围术期心肌梗死的效果观察

目的研究环磷酸腺苷葡胺(心先安,McAMP)围术期对心肌缺血老年病人心肌梗死的预防和治疗作用。方法40例有心肌缺血基础的老年病人随机分为治疗组和对照组,每组各20例。治疗组在麻醉诱导前10min静脉注射心先安20mg,随后160mg加入100ml0.9%氯化钠注射液中持续缓慢静脉滴注;对照组静脉滴注0.9%氯化钠注射液。术中纪录心电图各导联ST段水平、MAP和HR,并计算HR与SBP的乘积(RPP);同时抽取外周静脉血检测术前、术毕、术后24h血清心肌肌钙蛋白I(cTnI)水平。结果术中对照组出现明显的ST段下降和RPP升高,与治疗组比较差异有统计学意义(P<0.05);治疗组术后cTnI水平的升高程度较对照组为低(P<0.05)。术后对照组有2例出现灶性心肌梗死。结论心先安预防和治疗老年患者围术期心肌缺血、心肌梗死具有较好的作用。     

Detection of reversible platelet aggregates in the blood of smokers and ex-smokers with peripheral vascular disease.

OBJECTIVE: To demonstrate that smoking increases platelet aggregation in vivo, that smoking cessation reverses platelet aggregation and that this explains, in part, why smoking perpetuates the development of peripheral vascular disease. DESIGN: Prospective case-control study involving three groups of patients: smokers with peripheral vascular disease, ex-smokers with peripheral vascular disease and smokers with peripheral vascular disease who quit smoking during the study. SETTING/PARTICIPANTS: Fourteen smokers and seven ex-smokers, new patients with confirmed peripheral vascular disease, attending the vascular clinic at Fremantle Hospital between February and November, 1988. INTERVENTIONS: Blood samples taken weekly from all subjects for five weeks. Week 1 was taken as the baseline before smoking cessation in the six smokers who were assigned to stop smoking during the study. MAIN OUTCOME CRITERIA: Platelet aggregate ratio, an indicator of in-vivo platelet aggregability where an increase in platelet aggregate ratio suggests a decrease in platelet function. RESULTS: Only three of six smokers stopped smoking for the duration of the study. Median platelet aggregate ratios were: smokers = 0.85 (range, 0.79-0.92) v. non-smokers = 0.93 (range, 0.91-1.00). The difference was statistically significant P less than 0.0002. The difference in platelet aggregate ratios between smokers and quitters was not statistically significant. CONCLUSIONS: This study demonstrated an increase in platelet aggregability in smokers compared to ex-smokers but there was no clear evidence that platelet function was fully reversed after only four weeks cessation of smoking. The data suggested that platelet function of the ex-smokers had fully reversed to normal over a longer period. This could explain the decreased incidence of complications of peripheral vascular disease in ex-smokers. The small number of patients able to quit smoking impeded this study.     

心肌桥的检出率及其临床意义

目的探讨冠状动脉(冠脉)造影时心肌桥的检出率及临床意义。方法回顾性分析2165例冠脉造影中检出的66例心肌桥患者的临床资料。结果心肌桥检出率为3·0%,分布在左前降支62例。孤立性心肌桥患者58例,其中24例无明显临床症状,34例表现为心绞痛等临床症状;根据冠脉管腔收缩期狭窄程度分成A、B、C3组,结果显示心肌桥下血管管腔狭窄程度与临床表现有显著相关性(P<0·05)。结论提高心肌桥的检出率有助于减少误诊,正确治疗。