子宫动脉化疗栓塞术对剖宫产瘢痕妊娠患者卵巢功能的影响

目的探讨子宫动脉化疗栓塞术(UACE)治疗剖宫产瘢痕妊娠(CSP)对患者卵巢功能的影响。方法选取2014年7月至2015年7月在我院计划生育科诊断为CSP并行UACE+刮宫术住院的患者共100例为研究对象,分别于术前及术后第1、3、6、12个月的月经周期第2~5天抽静脉血检查血清卵泡刺激素(FSH)、黄体生成激素(LH)、雌二醇(E2)、抗苗勒管激素(AMH)、抑制素B(INHB)水平,并随访月经情况及围绝经期症状。观察术前及术后不同时期的激素水平变化及月经变化。结果所有病例均成功清除瘢痕妊娠组织,均未出现围绝经期症状。72例(73.5%)在术后1~3个月月经复潮,经量正常,周期规律;16例(16.3%)术后4~6月月经来潮,规律,量正常;10例(10.2%)术后12个月内恢复月经,但曾出现过月经紊乱。术前与术后各时段血清FSH、LH、E_2、AMH、INHB水平比较均无显著性差异(P>0.05)。结论在具备准确熟练的手术操作技术基础上,UACE治疗对CSP患者卵巢内分泌功能及储备功能均无明显影响,是一种安全、有效的治疗方法。     

子宫动脉化疗栓塞术联合刮宫术治疗剖宫产瘢痕妊娠的临床疗效

目的探讨子宫动脉化疗栓塞术联合刮宫术治疗剖宫产瘢痕妊娠(CSP)的可行性和安全性。方法将82例CSP患者分为2组:A组39例,行氨甲蝶呤+刮宫术;B组43例,行子宫动脉化疗栓塞术+刮宫术。比较2组刮宫术成功率、术中出血量、β-HCG下降至正常的时间、住院时间及术后6个月性激素水平和月经周期恢复时间等。结果 A组中4例因无法控制的急性阴道出血而终止刮宫术,对其中2例行子宫切除手术,2例行子宫动脉栓塞术止血。B组无子宫切除患者。刮宫术成功率、术中出血量、β-HCG下降至正常的时间、住院时间在两组间差异均有统计学意义(P均0.05),但术后6个月性激素水平和月经周期恢复时间组间差异无统计学意义(P均0.05)。结论子宫动脉化疗栓塞术联合刮宫术治疗CSP安全、有效,可明显降低子宫切除风险。     

子宫动脉栓塞联合清宫术治疗早期瘢痕妊娠(附21例报道)

目的探讨对早期瘢痕妊娠(CSP)患者行双侧子宫动脉栓塞联合宫腔镜清宫治疗的可行性和安全性。方法回顾性分析2012年8月—2015年6月21例接受双侧子宫动脉化疗栓塞术后并于术后24~48h内接受宫腔镜清宫术的早期CSP患者资料。结果对21例患者双侧子宫动脉化疗栓塞术均操作成功,无严重并发症。栓塞术后清宫过程中出血量0~150ml。术前血HCG值为(41 866.71±26 374.59)U/L,术后3天血HCG值为(3 311.10±3 007.67)U/L。平均住院时间(6.95±1.86)天。术后平均随访时间(18.62±10.05)个月。术后2例月经量减少,1例月经量增多,1例表现为绝经前期改变,1例术后2年怀孕并正常分娩,余16例术后月经情况均无明显改变。结论对早期CSP患者行子宫动脉化疗栓塞联合宫腔镜清宫术安全、可行,可降低术后大出血风险并缩短住院时间。     

子宫动脉化疗栓塞术联合刮宫术治疗剖宫产瘢痕妊娠

目的探讨子宫动脉化疗栓塞术（UACE）联合刮宫术治疗剖宫产瘢痕妊娠（CSP）的安全性和有效性。方法对33例CSP患者行选择性双侧子宫动脉插管造影,灌注氨甲蝶呤（MTX）和明胶海绵颗粒栓塞后24-48h内进行刮宫术,评价术后疗效。结果对所有患者均成功完成UACE刮宫术中出血（24．62±12．53）ml。未见严重并发症发生。结论UACE联合刮宫术治疗CSP微创、安全、有效,可避免子宫切除,保留患者生育能力。     

子宫动脉化疗栓塞治疗剖宫产瘢痕妊娠的临床价值

目的探讨子宫动脉化疗栓塞(uterine arterial chemoembolization,UACE)治疗剖宫产瘢痕妊娠(cesarean scar pregnancy,CSP)的临床价值。方法 2012年2月～2017年9月我院采用UACE治疗16例CSP,双侧子宫动脉各灌注甲氨蝶呤40 mg,再用甲氨蝶呤20 mg浸泡的560～710μm明胶海绵颗粒及1 mm×2 cm明胶海绵条栓塞子宫动脉,UACE术后1～3 d终止妊娠。结果 16例均成功行UACE,UACE操作时间15～45 min,(26. 8±9. 0) min,曝光时间5～15 min,(8. 1±2. 8) min。UACE术后清宫8例,出血量10～200 ml,中位出血量50 ml;宫腔镜切除7例,出血量5～150 ml,中位出血量20 ml;1例因清宫大出血行急诊UACE,二次清宫时出血较多终止清宫,MRI提示胎盘植入,行开腹瘢痕妊娠组织切除(术中出血1000 ml)。介入术后3 d内β-h CG下降(204 72. 1±17 076. 4) U/L,恢复正常时间(37. 6±4. 3) d。住院6～28 d,(14. 1±6. 5) d。住院费用(15 750±5305)元。UACE术后出现轻微下腹部疼痛4例,低热2例,恶心、呕吐2例,未出现盆腔感染、子宫缺血坏死及异位栓塞等严重并发症。16例随访3～6个月,1～2个月后均月经恢复,月经恢复正常时间(44. 8±5. 7) d,2例半年后再次妊娠。结论 UACE治疗CSP安全、有效、微创。     

子宫动脉化疗栓塞术治疗剖宫产子宫瘢痕妊娠的疗效

目的探讨子宫动脉化疗栓塞术(UACE)治疗剖宫产子宫瘢痕妊娠(CSP)的疗效及安全性。方法对26例CSP患者UACE后行清宫术,观察并记录UACE和清宫术的并发症、血清β-HCG和月经恢复正常的时间,对UACE前和术后1天、4天、1周血清β-HCG进行对比;根据UACE前血清β-HCG水平将患者分为A组(血清β-HCG≥10 000mIU/ml)和B组(血清β-HCG10 000mIU/ml),对比组间孕周、前次剖宫产距今时间、清宫术中出血量的差异。结果 UACE技术成功率为100%;术后阴道出血均得到有效控制,清宫术中出血量5~400 ml,无严重并发症发生;UACE前和术后1天、4天、1周血清β-HCG差异有统计学意义,UACE术后血清β-HCG较术前显著下降;两组年龄、孕周、前次剖宫产距今时间、清宫术中出血量差异均无统计学意义(P均0.05),两组既往孕次、血清β-HCG降至正常的时间差异均有统计学意义(P均0.05)。结论 UACE在CSP的治疗中有较好的疗效及安全性,无论血清β-HCG水平高低,均可达到保留子宫和生育能力目的。     

甲氨蝶呤、明胶海绵动脉化疗栓塞治疗宫颈妊娠

目的探讨甲氨蝶呤(MTX)、明胶海绵子宫动脉化疗栓塞治疗宫颈妊娠的临床效果。方法 11例宫颈妊娠,4例刮宫后大出血急诊栓塞,7例刮宫前预防性化疗栓塞,选择性子宫动脉插管,用MTX灌注化疗并用医用明胶海绵颗粒及条块栓塞。所有患者术后联合刮宫术,复查血β-hCG及宫颈B超。结果 4例大出血立即停止,所有患者术后5~10 d行刮宫术,出血60~100 ml。术后1个月血β-hCG均降至正常范围,B超提示宫颈恢复正常大小,于45~60天月经复潮。未出现严重并发症。结论 MTX、明胶海绵子宫动脉化疗栓塞既能终止妊娠,又能防治大出血,是治疗宫颈妊娠一种安全有效的方法。     

不同剂量的MTX子宫动脉灌注化疗栓塞治疗瘢痕妊娠效果分析

目的评价不同剂量的MTX子宫动脉灌注化疗栓塞术(UACE)治疗剖宫产瘢痕妊娠(CSP)的疗效。方法将经临床确诊CSP患者90例根据在UACE中不同MTX用量将患者随机分为A、B、C 3组,各30例。A组MTX用量按体表面积50 mg/m2,B组30例MTX用量50 mg,C组30例MTX用量100 mg,3组在UACE中每侧子宫动脉各注入MTX总量的1/2,均在UACE治疗后48 h内行彩超引导下清宫术。以介入术后不良反应(腹痛、恶心、呕吐)、清宫术中出血量、人绒毛膜促性腺激素(HCG)恢复正常时间、月经恢复时间、二次治疗率作为疗效评估参数,比较3组间相关数据的差异。结果 A组、C组介入治疗后清宫手术均顺利,无子宫切除,治疗成功率均为100%,差异无统计学意义(P0.05)。2组患者术后阴道持续出血时间、月经复潮时间、HCG恢复正常时间、二次治疗率差异均无统计学意义(P0.05)。C组介入术后腹痛、恶心、呕吐明显,介入术后不良反应与A组及B组比较差异有统计学意义。结论 UACE后清宫为治疗CSP的安全有效方法,根据患者体表面积科学选择MTX的用量,可以减少MTX的不良反应,又能取得满意的临床效果。     

子宫动脉化疗灌注栓塞术联合宫腔镜治疗剖宫产术后子宫瘢痕妊娠的效果

目的分析对剖宫产术后子宫瘢痕妊娠(CSP)患者应用子宫动脉化疗灌注栓塞术联合宫腔镜治疗的临床效果。方法对本院收治的21例CSP患者予以双侧子宫动脉选择插管,灌注甲氨蝶呤后应用明胶海绵颗粒栓塞,经造影证实栓塞完全后拔管。术后适时实施宫腔镜妊娠组织清除术。对患者的手术效果进行评价,并观察患者术中出血量、术后住院时间和并发症等指标。在随访期间观察患者血β-HCG转阴时间及月经恢复正常时间。结果 21例患者均一次成功施行子宫动脉化疗灌注栓塞术。术后3～5 d内顺利完成宫腔镜妊娠组织清除术。术中出血量为(52.50±8.26)mL。无子宫穿孔、大出血等严重并发症出现。住院时间为(9.86±1.24)d。患者出院后均获6个月随访,血β-HCG转阴时间为(40.60±11.52)d。月经恢复正常时间为(43.86±13.60)d。超声复查子宫包块消失,子宫复旧良好,未发生闭经等并发症。结论对CSP患者应用子宫动脉化疗灌注栓塞术联合宫腔镜治疗,疗效确切,微创且安全性高。     

子宫动脉插管化疗栓塞术治疗产后胎盘植入伴感染

目的探讨子宫动脉插管化疗栓塞术(UACE)治疗产后胎盘植入伴感染的临床疗效。方法采用UACE治疗12例产后胎盘植入伴感染的患者,并评价治疗效果。结果 12例患者均顺利完成手术,术后彩色多普勒超声检查示胎盘植入区域血流灌注明显减少甚至消失,人绒毛膜促性腺激素(HCG)较入院时有显著下降(P0.002),其中6例患者7天内胎盘组织自行排出,5例患者接受辅助清宫术。术后随访3~34个月,所有患者均未出现介入治疗相关的远期并发症,患者均月经复潮,其中1例患者再次妊娠。结论 UACE是治疗产后胎盘植入伴感染的一种微创有效的治疗方法。     

Renal allograft rejection: the temporal relationship and predictive value of plasma TNF (alpha and beta), IFN-gamma and soluble ICAM-1

Recently, close interactions have been described between the tumour necrosis factors alpha and beta (TNF-alpha and beta), interferon-gamma (INF-gamma) and intercellular adhesion molecule-1 (ICAM-1) in T-cell mediated immune activation. During the process of renal graft rejection, the properties of these cytokines to act as powerful stimulators of macrophages, to upregulate class II MHC expression and to stabilise cell-to-cell binding make them of great potential interest. The aim of the present study was to determine the plasma levels of each cytokine and soluble ICAM-1 in 16 renal allograft recipients. We examined plasmas of patients for the first 2 weeks after transplantation and correlated results with the clinical pattern of rejection. Our data suggest an immunopathologic involvement of TNF-alpha, TNF-beta and slCAM-1 in renal allograft rejection and showed that there was a significant elevation in plasma concentrations of these parameters 2 or 3 days prior to the diagnosis of clinical rejection. Rises in INF-gamma did not appear to be significant with regard to rejection as very high levels were found in patients showing no evidence of clinical rejection.     

血浆凝血因子VIII水平与IgA肾病患者临床病理改变及预后的关系

目的探讨血浆凝血因子VIII(factor VIII,FVIII)水平与IgA肾病(IgAN)患者临床参数及预后的关系。方法收集2016年1月至2016年12月中南大学湘雅二医院确诊的IgAN患者的临床资料。按照时间依赖的受试者工作特征曲线(ROC)得出的血浆FVIII预测IgAN预后的临界值,将患者分为高FVIII组(FVIII>140.50%)和低FVIII组(FVIII≤140.50%),比较两组患者肾活检时基线临床参数的差异。以估算肾小球滤过率(eGFR)下降≥30%或进入终末期肾脏病(ESRD)为终点事件,采用Kaplan-Meier生存曲线及Cox回归方程法分析血浆FVIII水平对IgAN患者预后的影响。结果共93例IgAN患者纳入本研究,中位随访时间为35.15(33.77,36.76)个月,12例(12.90%)患者发生终点事件。高FVIII组患者年龄、血肌酐、尿素氮、血三酰甘油、血总胆固醇、血浆纤维蛋白原、D-二聚体、24 h尿蛋白量、蛋白C、蛋白S和eGFR下降速率高于低FVIII组(均P<0.05);eGFR、血白蛋白、中位随访时间低于低FVIII组(均P<0.05)。Kaplan-Meier生存分析结果显示,与低FVIII组比较,高FVIII组患者肾脏累积生存率降低(χ2=5.635,P=0.018)。在校正收缩压、eGFR、尿蛋白、肾小管萎缩/间质纤维化程度等因素后,多因素Cox回归分析结果显示,高血浆FVIII水平是IgAN患者肾脏预后不良的独立危险因素(HR=4.147,95%CI 1.055~16.308,P=0.042)。结论血浆FVIII水平与IgAN患者临床指标及预后相关,高血浆FVIII水平是IgAN患者肾脏预后不良的独立危险因素。     

Perioperative clopidogrel and postoperative events after hip and knee arthroplasties

Background  

Hip and knee arthroplasties are widely performed and vascular disease among patients having these procedures is common. Clopidogrel is a platelet inhibitor that decreases the likelihood of thrombosis. It may cause intraoperative and postoperative bleeding, but its discontinuation increases the risk of vascular events. There is currently no consensus regarding the best perioperative clopidogrel regimen that balances these concerns.     

Hypotension and myocardial metabolism

This study investigated the effect of hypotension produced by nitroprusside or halothane on haemodynamics and myocardial metabolism. It is postulated that halothane might influence the balance of supply and demand of oxygen to the heart more favourably than nitroprusside. The results in six open-chested dogs do not support this view. Despite the fact that the two drugs lowered the mean arterial pressure by radically different mechanisms, the reduction in demand for oxygen by the heart seemed to be matched by a similar reduction in supply with both drugs. No evidence of anaerobic metabolism or increased a-v O₂ content differences was found. It is concluded that the reduction in mean arterial pressure to these levels by either method is not likely to impair myocardial energetics in healthy hearts with normal coronary anatomy.     

Osteoporosis and obesity: Role of Wnt pathway in human and murine models

Studies concerning the pathophysiological connection between obesity and osteoporosis are currently an intriguing area of research.Although the onset of these two diseases can occur in a different way,recent studies have shown that obesity and osteoporosis share common genetic and environmental factors.Despite being a risk factor for health,obesity has traditionally been considered positive to bone because of beneficial effect of mechanical loading,exerted by high body mass,on bone formation.However,contrasting studies have not achieved a clear consensus,suggesting instead that excessive fat mass derived from obesity condition may not protect against osteoporosis or,even worse,could be rather detrimental to bone.On the other hand,it is hitherto better established that,since adipocytes and osteoblasts are derived from a common mesenchymal stem cell precursor,molecules that lead to osteoblastogenesis inhibit adipogenesis and vice versa.Here we will discuss the role of the key molecules regulating adipocytes and osteoblasts differentiation,which are peroxisome proliferators activated receptor-γand Wnts,respectively.In particular,wewill focus on the role of both canonical and non-canonical Wnt signalling,involved in mesenchymal cell fate regulation.Moreover,at present there are no experimental data that relate any influence of the Wnt inhibitor Sclerostin to adipogenesis,although it is well known its role on bone metabolism.In addition,the most common pathological condition in which there is a simultaneous increase of adiposity and decrease of bone mass is menopause.Given that postmenopausal women have high Sclerostin level inversely associated with circulating estradiol level and since the sex hormone replacement therapy has proved to be effective in attenuating bone loss and reversing menopause-related obesity,we hypothesize that Sclerostin contribution in adipogenesis could be an active focus of research in the coming years.     

维生素D受体在糖尿病肾病足细胞损伤及蛋白尿缓解中的作用

目的探讨维生素D受体(VDR)在糖尿病肾病(DKD)足细胞中的表达水平及在足细胞损伤及蛋白尿缓解中的作用。方法(1)本研究纳入了65例诊断患有2型糖尿病(伴或不伴蛋白尿)的患者,并纳入了25例年龄和性别相匹配的健康体检者为对照组。根据白蛋白/肌酐(ACR)的尿排泄比例对2型糖尿病患者进行分组,分别为无蛋白尿(ACR<30 mg/g,n=24)、微量白蛋白尿(ACR 30~300 mg/g,n=18)和临床蛋白尿(ACR>300 mg/g,n=23)。另选择25例经肾活检确诊的DKD患者作为DKD组。正常肾脏组织标本均取自泌尿外科同一时期肾脏肿瘤切除患者10例。将各组检测指标进行对比,同时采用实时定量PCR、ELISA法和免疫组化法检测VDR在各组患者的血液、尿液样本和肾脏组织中的表达情况,以及使用Pearson相关分析分析VDR与尿蛋白的相关性。(2)在2型糖尿病肾病小鼠模型中对上述结果进行验证,将遗传背景均为C57BLKs/J的雄性db/db小鼠及同窝出生的db/m小鼠,随机分为正常对照组(A组)、DKD对照组(B组)、DKD二甲基亚砜处理组(C组)、DKD帕立骨化醇(VDR激动剂)处理组(D组),C、D组连续腹腔注射处理8周,对照组不做任何处理。小鼠10周龄时开始连续干预8周,在小鼠22周龄(开始干预后12周)检测各组小鼠体重、血、尿生化指标对比;Western印迹法检测β⁃catenin、VDR的变化;免疫荧光观察足细胞标志蛋白podocin及足细胞损伤蛋白α⁃SMA的表达变化。结果(1)与正常健康对照组相比,无蛋白尿组、微量白蛋白尿组和临床蛋白尿组的糖尿病患者血浆中VDR的mRNA和蛋白水平均较低(均P<0.05);与无蛋白尿组的糖尿病患者相比,微量白蛋白尿组和临床蛋白尿组的糖尿病患者血浆中VDR的mRNA和蛋白水平均较低(均P<0.05)。(2)与正常健康对照组相比,无蛋白尿糖尿病组和DKD组患者血浆中VDR的mRNA和蛋白水平均较低(均P<0.05);与无蛋白尿糖尿病组患者相比,DKD组患者血浆中VDR的mRNA和蛋白水平亦较低(均P<0.05)。(3)免疫组化结果显示,DKD组肾组织中VDR的表达明显少于正常对照组。(4)DKD患者血浆中VDR mRNA相对水平与ACR呈负相关(r=-0.342,P<0.05)。(5)各组尿液上清液中VDR的水平与血浆中的水平呈相反趋势。(6)Western印迹结果显示,B组、C组肾小球足细胞β⁃catenin蛋白表达高于D组(均P<0.05),VDR蛋白的表达低于D组(均P<0.05);免疫荧光结果显示,B组、C组肾小球足细胞podocin的表达低于D组(均P<0.05),α⁃SMA的表达高于D组(均P<0.05)。结论VDR高表达缓解DKD足细胞损伤及蛋白尿。     

Anaesthesia, recovery and postoperative nausea and vomiting after breast surgery. A comparison between desflurane, sevoflurane and isoflurane anaesthesia

BACKGROUND: Whereas induction and recovery will occur more rapidly with the new low soluble anaesthetics than with isoflurane, the quality of anaesthesia and recovery with special emphasis on postoperative nausea and vomiting (PONV) is not well known. METHODS: In an open (peroperatively), double-blinded (postoperatively), randomised controlled study, we assessed anaesthesia characteristics, recovery and 24 h PONV after breast surgery comparing isoflurane, desflurane and sevoflurane. RESULTS: There were no significant quality differences between the three agents during anaesthesia and recovery except for the incidence of PONV in the postanaesthesia care unit (PACU). The PONV rate (24 h in PACU and ward) was higher in the desflurane group (67%) than in the isoflurane group (22%), (P<0.01). The corresponding PONV rate for sevoflurane was 36%. CONCLUSION: The quality of anaesthesia, time to opening of eyes and influence on respiration was similar with all three anaesthetics. As the emergence from anaesthesia did not differ significantly between the three agents, the choice of agent could be based on PONV rate and price. Desflurane had a significantly higher 24 h PONV rate than isoflurane. Early PACU PONV rate was significantly (P<0.05) lower for the more soluble isoflurane (4%) than for the low soluble gases, desflurane and sevoflurane together (28%). The result of this study does not give a rationale for a transition to the new low soluble agents in breast cancer surgery.     

移植肾IgA肾病临床病理及预后分析

目的探讨移植肾IgA肾病(IgAN)复发或新发的诱因及移植肾生存的危险因素。方法选取2012年11月至2018年12月浙江大学医学院附属第一医院经肾活检确诊为移植肾IgAN的患者,按照血肌酐(Scr)增高水平、估算肾小球滤过率(eGFR)下降率分为稳定组(Scr升高值<20μmol/L,eGFR下降率<10%)和进展组(Scr增高但未达翻倍值,30%相似文献