完全性肺静脉异位引流围术期死亡危险因素分析

目的:单纯性完全性肺静脉异位引流(TAPVC)术后围术期死亡危险因素分析。方法:回顾性分析1996-10至2012-12,我院共收治仅包括房间隔缺损、室间隔缺损和动脉导管未闭的TAPVC患儿563例,男性219例(40.8%),平均年龄(4.6±9.0)岁,平均体重(13.2±14.6)kg。将患儿分为死亡组(n=34)和存活组(n=529),进行单因素分析和多因素Logistic回归分析。结果:全组死亡34例(6.0%),死亡组较存活组,年龄≤1岁的患儿较多(P=0.008)、择期手术的比例较高(P=0.002)、体外循环时间(P=0.000)和主动脉阻断时间较长(P=0.001),差异均有统计学意义。多因素Logistic回归分析结果显示,年龄≤1岁(比值比=3.802,P=0.013)是TAPVC围术期死亡的独立危险因素,择期手术(比值比=0.234,P=0.027)是TAPVC围术期死亡的保护性因素。结论:年龄≤1岁是TAPVC围术期死亡的独立危险因素,择期手术是围术期死亡的保护性因素。     

255例完全性肺静脉异位引流手术治疗的单中心回顾性研究

目的:分析单中心完全性肺静脉异位引流(TAPVC)手术治疗的早中期效果.方法:连续入组2009年1月至2019年10月首都医科大学附属北京儿童医院心脏外科收治并进行手术治疗的0～3岁TAPVC患儿共255例.按照年龄将患儿分为两组:0～6个月组(A组,n=195)和6个月以上～3岁组(B组,n=60),总结其临床特点,...     

单心室合并完全性肺静脉异位引流的外科治疗

目的:探讨单心室合并完全性肺静脉异位引流(TAPVC)的外科治疗效果。方法:2009-05至2011-09,我科共收治单心室合并TAPVC患儿11例,年龄(30.1±21.4)个月,体重(11.0±3.2)kg。例2行改良B-T分流术,例1、3～6、8、9、11行一侧或双侧双向腔肺分流术,例7、10行一期改良Fontan术。例1、6～9、11同期行TAPVC矫治术。结果:例6、10围术期死亡(18.2%,2/11),死亡原因分别为中枢神经系统感染和多器官功能衰竭。存活的患儿随访1～29个月,例4死亡,余患儿氧饱和度改善,未发现残余肺静脉梗阻,例5行二期改良Fontan术并顺利出院。结论:单心室合并TAPVC患儿仍具有较高早期死亡率,术前明确诊断TAPVC并制定合理的个体化治疗方案是提高手术疗效的关键。     

完全性肺静脉异位引流的外科治疗体会(附16例报告)

完全性肺静脉异位引流 ( TAPVC)为一种少见的先天性心脏畸型 ,发病率占先天性心脏病的 1 %～3% ,自然病程预后极差 ,其中 5 0 %于生后 3个月内死亡 ,80 %于 1岁以内死亡 ,存活至 1岁以上的患儿常合并较大的房间隔缺损。 1 995年 6月至 2 0 0 2年 6月 ,我院共实施 TAPVC矫正术 1 6例 ,取得较好的效果。现总结报告如下。1　资料与方法1 .1　临床资料　本组 TAPVC患儿 1 6例 ,男 7例 ,女 9例 ;年龄 3个月至 6岁 ,平均 1 .2岁。均经心脏超声和多普勒检查明确诊断 ,1例行心导管检查和心血管造影。按 Darling分类法均为心上型 ,均合并房间…     

单心室合并完全性肺静脉异位引流的外科治疗

目的:总结单心室合并完全性肺静脉异位引流(TAPVC)的外科治疗效果。方法:入选2008-09至2016-03期间,我院手术治疗的单心室合并TAPVC患儿25例,年龄5天~14岁,体重3.3~49.5kg,心上型TAPVC 22例,心下型TAPVC 1例,混合型TAPVC 2例;合并完全性房室间隔缺损17例,三尖瓣闭锁2例,二尖瓣闭锁2例;中度以上房室瓣反流4例,肺动脉闭锁5例,肺静脉梗阻9例。结果:院内早期死亡5例,死亡率20%(5/25),死亡原因均为低心排血量综合征。存活20例患儿随访1~65个月,7例再次手术,其中5例完成二期改良Fontan术,1例因重度房室瓣反流行房室瓣置换术,另1例因肺静脉梗阻及重度房室瓣反流行肺静脉狭窄矫治+房室瓣成形术;余13例患儿未再次手术。20例出院患者随访期间3例死亡,死亡原因分别为低心排血量综合征、蛋白丢失性肠病和神经系统损伤。余存活患儿一般情况好,未发现残余肺静脉梗阻。结论:单心室合并TAPVC常合并右心房异构,心内畸形复杂,手术治疗仍具有较高死亡率。     

小儿混合性完全型肺静脉异位引流的超声诊断经验

目的总结经胸超声心动图(TTE)在小儿混合型完全性肺静脉异位引流(TAPVC)术前诊断、术后随访的价值和经验。方法选择自2010年1月-2016年12月在中国医学科学院北京阜外医院小儿中心经手术证实为混合型TAPVC的22例患者,将术前术后超声资料与CT检查及手术结果对照进行回顾性研究。结果本组混合型TAPVC约占总体TAPVC的5.4%。22例患儿均成功接受了手术矫治,其中包括:心上型+心内型19例,心上型+心下型3例;其中合并肺静脉回流梗阻7例(含单侧肺静脉发育不良1例),共占约31.8%。超声术前准确探查全部回流途径的病例占(13/22)59.1%,误判为心上型TAPVC 2例,误判为心内型TAPVC 5例,术前漏诊1例为法鲁氏四联症合并肺静脉发育不良患儿。超声对肺静脉回流途径梗阻部位的诊断率为(8/13)61.5%。术前共12例患儿(54.5%)接受了增强螺旋CT检查,CT对各支肺静脉回流途径均判断准确,对肺静脉回流梗部位检出率约38.5%。所有患儿术后6个月内均接受至少一次超声复查,中位随访时间为4个月。截止最后一次超声随访资料显示有5例患儿术后仍存在肺动脉高压,其中3例出现肺静脉与左房吻合口或分支狭窄,发生于术后2个月-4个月。结论超声心动图可为儿童混合型TAPVC提供重要的诊断线索和随访信息,熟悉本病不同类型、了解少见的变异情况有助于提高超声诊断水平,有利于评估患儿手术风险及预后。     

完全性肺静脉异位引流患儿临床及尸检分析

目的 :探讨儿童完全性肺静脉异位引流 (TAPVC)的临床及尸检特征性改变。方法 :回顾性总结我院 1980～ 2 0 0 0年间收治的 2 3例TAPVC患儿的临床表现、心电图、胸片、心脏超声、心导管检查、手术及尸检资料。结果 :2 3例TAPVC患儿中属心上型 17例 (占 74 % ) ,心内型 6例 (占 2 6 % ) ,其中伴有动脉导管未闭 (PDA) 6例 ,房间隔缺损 (ASD) 11例 ,卵圆孔未闭 5例 ,室间隔缺损 (VSD) 2例 ,二尖瓣发育不良 1例。 2 3例患儿中 5例经内科保守治疗后好转出院 ,4例放弃治疗 ;3例施行纠治术 ,2例痊愈出院 ,1例死亡 ;死亡 12例 (5 2 % ) ,年龄均 <6个月 ,其中 10例尸检年龄为 2 4d～ 4个月 ,均发现有肺静脉梗阻性病变。结论 :TAPVC在先心病中并不少见 ,常伴发一些临床综合征及其他心脏畸形 ,大多在婴幼儿即有症状 ,本组病例中 5 2 %死于 6个月以内 ,特别是患肺血管梗阻性病变者 ,多于数日或 3～ 4个月内死亡 ,极易误诊为新生儿肺炎 ,尸检中才得以证实。心脏超声、心导管及选择性心血管造影术是常用的有效确诊手段     

完全性肺静脉异位引流矫治术后肺静脉梗阻的治疗探讨

目的:总结完全性肺静脉异位引流(TAPVC)矫治术后肺静脉梗阻的治疗经验。方法:回顾性分析2011-01至2015-12于青岛市妇女儿童医院心脏中心施行TAPVC矫治术后发生肺静脉梗阻16例患儿的临床资料,其中男性10例。所有患儿均出院前、术后1个月、3个月、6个月、12个月、24个月回院复诊,包括经胸心脏超声多普勒、心电图、X线胸部正侧位片。以经胸心脏超声多普勒检查肺静脉流速2 m/s为梗阻标准,诊断肺静脉梗阻。结合患儿临床表现(反复心力衰竭、生长发育迟缓)确定二次手术时机。二次手术采用sutureless缝合技术和常规补片扩大技术。结果:术后发生肺静脉狭窄16例患儿无失访,其中7例吻合口周围狭窄(混合型1例,心下型3例,心上型2例,心内型1例);7例单支肺静脉狭窄,2例双支肺静脉狭窄,无三支及以上肺静脉狭窄。按术前Darling类型分:混合型2例,心下型5例,心上型5例,心内型4例。11例(68.8%)术后肺静脉狭窄流速增快发生在术后3~6个月。5例二次手术患儿中,4例采用sutureless缝合技术,1例采用常规补片扩大技术,均为吻合口周围梗阻狭窄,2例死亡,3例患儿随访中。结论:TAPVC矫治术后吻合口周围狭窄为主要二次手术适应证,并且需早期即行手术。     

69例小儿心上型完全性肺静脉异位引流超声诊断与临床分析

目的:总结心上型完全性肺静脉异位引流(TAPVC)超声心动图的诊断特点及对围术期临床转归的指导意义。方法:对2010年6月至2015年6月5年间我院儿童心脏中心收治的心上型TAPVC患儿的超声心动图及临床资料进行回顾性分析。结果:经超声心动图诊断并外科手术证实为心上型TAPVC 69例,男性46例,女性23例,中值年龄5.0个月(21d~180个月)。69例术前超声心动图诊断均与手术诊断一致,符合率100%。设定超声测量房间隔交通≤5mm为限制性房间隔交通(限制性房水平分流)。本组研究提示限制性房间隔交通组就诊年龄(P=0.005)、体表面积(P=0.015),经皮血氧饱和度(P=0.039),房间隔交通直径指数(P0.001)等均明显低于房间隔交通直径5mm患儿组(非限制性分流);而肺动脉收缩压(P=0.002),右心室舒张末径指数,右心室与左心室前后径比值则明显高于非限制性分流组(P0.001),且术后ICU时间明显长于非限制性分流组(P=0.01)。结论:超声心动图是诊断心上型TAPVC首选且准确的方法。心上型TAPVC尽早诊断手术预后良好。房水平分流大小,引流血管是否梗阻,术前右心室与左心室内径比值与心上型TAPVC患儿围术期转归密切相关。     

99Tcm-MIBI 心肌灌注显像及18F-FDG PET心肌代谢显像探测左心室室壁瘤心肌存活性的临床价值

目的 评估99锝m-甲氧基异腈(99Tcm-MIBI)单光子发射计算机断层(SPECT)心肌灌注显像及18F-脱氧葡萄糖(FDG)正电子发射断层(PET)心肌代谢显像探测左心室室壁瘤(室壁瘤)心肌存活性的临床价值.方法 46例确诊为室壁瘤合并左心功能不全[左心射血分数(LVEF)36%±7%],行99Tcm-MIBI SPECT+18F-FDG PET显像,并接受血运重建术的患者,随访(80±27)个月.根据室壁瘤是否有存活心肌[灌注-代谢不匹配分(MMS)≥2.0分]以及是否行室壁瘤切除术,将患者分为4个小组:室擘瘤无存活心肌(A组):血运重建术为Al组(n=8),血运重建术+瘤切除术为A2组(n=15);窒壁瘤有存活心肌(B组):血运重建术为B1组(n=10),血运重建术+瘤切除术为B2组(n=13).结果 A1、A2、B1、B2 4个组心脏事件发生率分别为25%(2/8),40%(6/15).20%(2/10)和31%(4/13)(P＞0.05).除A1组外,其他各组的术后左心功能均得到明显改善(P＜0.05).多因素logistic回归分析筛选出与术后LVEF改善相关的独立影响因素,为左心室的MMS(OR=2.34,95% CI 1.08～5.06,P＜0.05),非室壁瘤部位的心肌灌注分(OR=0.24.95% CI 0.07～0.85,P＜0.05)和远端血管病变(OR=0.008,95% CI 0.001～0.560.P＜0.05).结论 室壁瘤接受血运重建术的患者,长期预后良好.室壁瘤部位有存活心肌的患者,单纯的血运重建术也可以明显改善左心功能,且与心肌存活的量相关.     

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.