肾上腺隐匿性嗜铬细胞瘤诊断与治疗（附15例）

目的提高肾上腺隐匿性嗜铬细胞瘤诊断意识和治疗水平。方法回顾性分析15例肾上腺隐匿性嗜铬细胞瘤临床资料。既往无高血压病史。术前均行B超、CT及实验室检查,拟诊无功能肾上腺皮质腺瘤4例、肾上腺隐匿性嗜铬细胞瘤11例。结果15例均手术切除肿瘤,其中开放手术9例,后腹腔镜手术6例。术中出现血压波动10例,硝普钠控制高血压,去甲肾上腺素处理低血压;4例拟诊肾上腺皮质腺瘤术中均出现血压波动,余11例血压波动6例,其中服用酚苄明患者无明显血压波动。术后病理均为嗜铬细胞瘤。14例术后随访3个月～8年,血压正常,肿瘤无复发。结论综合分析实验室检查结果及影像学表现,可提高诊断意识;术前常规应用仅受体阻滞剂及扩容治疗,可提高手术安全性,减少并发症;后腹腔镜手术效果良好。     

嗜铬细胞瘤的术前准备

目的 提高嗜铬细胞瘤围术期治疗水平,降低病死率.方法 2003年11月-2008年11月收治92例嗜铬细胞瘤患者,应用嗜铬细胞瘤围术期管理方案,即在术前应用选择性al受体阻滞剂甲磺酸多沙唑嗪控释片(商品名可多华),最大剂量为12 mg/d,最小剂量为4 mg/d,同时在术中补充血容量.使术前准备时间明显缩短,中位时间为11 d,且术中血压稳定.结果 所有患者的血压稳定,收缩压≤140 mmHg(1 mmHg=0.133 kPa)及舒张压≤90 mmHg,无阵发性血压升高、心悸和多汗等现象,心率为80～90次/min,外周循环改善,肿瘤直径为2.5～13.0 cm,中位直径为4.5 cm,肿瘤大小与功能和用药时间长短无明显关系.85%的患者在麻醉诱导和术中挤压肿瘤时血压仍发生波动,但易控制,术后血压平稳.结论 嗜铬细胞瘤术前充分的准备是保证麻醉、术中及术后血压平稳控制、减少心血管并发症及降低病死率的关键.     

嗜铬细胞瘤术前准备的临床分析

目的探讨嗜铬细胞瘤术前准备的临床体会。方法收集2000-2004年收治58例嗜铬细胞瘤患者术前准备资料，术前使用酚苄明48例，使用压宁定10例，用药时间2-9周，平均6周，28％的患者术前加用β-受体阻滞剂控制心率。结果50例患者血压稳定在135／85mmHg左右，无阵发性血压升高、心悸、多汗等现象，体重呈增加趋势，心率80-85次／min，外周微循环明显改善。肿瘤大小（直径3～12cm，平均5．2cm）与功能和用药时间长短无明显关系，术前2周发生高血压危象7例，97％的患者麻醉诱导和术中挤压肿瘤时血压仍发生波动，最高时可达280／180mmHg，但较易控制。术后血压平稳。结论嗜铬细胞瘤术前充分的准备是保证麻醉、术中及术后血压平稳控制，减少心血管并发症和死亡率的关键。     

经肝动脉化疗栓塞治疗5例恶性嗜铬细胞瘤术后复发动脉

目的:评价经动脉化疗栓塞术(TACE)治疗恶性嗜铬细胞瘤术后复发的安全性和疗效性。方法:总结经TACE术5例恶性嗜铬细胞瘤的资料。4例血压升高者术前用α-肾上腺素能阻滞剂和β-受体阻滞剂调节血压和心率,按Seldinger技术经右侧股动脉插管至肾上腺或/和肝动脉内行TACE术。在行TACE术时均建立静脉通道滴注酚妥拉明,在术后2周内密切观察血压和心率等变化。结果:4例血压升高者通过术前准备后血压和心率均控制在正常范围内。在行TACE术时有4例血压升高,经过术中注入酚妥拉明后血压稳定,1例血压无明显波动。3例TACE术后2周内有低血压表现,通过扩容治疗后血压稳定,2例血压无明显变化。随访2月-2年3月,2例死亡,均非手术所致,3例在TACE术后7月-2年3月仍存活,血压稳定,未出现明显阵发性头晕,面色苍白等症状,实验室检查时香草扁桃酸基本正常。1月后原发肿瘤和转移肿瘤有不同程度缩小。结论:恶性嗜铬细胞瘤术后复发或转移而又不适再次手术者通过术前降压及术中和术后监测,TACE术治疗是安全、可行的,并有一定的疗效。     

腹腔镜治疗肾上腺嗜铬细胞瘤的疗效及安全性

目的:评价腹腔镜治疗肾上腺嗜铬细胞瘤的疗效及安全性.方法:采用腹腔镜治疗肾上腺嗜铬细胞瘤31例.其中经后腹膜途径23例,经腹膜途径8例.结果:所有患者手术均获成功.术后病理诊断皆为嗜铬细胞瘤.有4例出现血压、心率剧烈波动,血压最高达210/110 mmHg,最低达到85/55 mmHg,心率最高达121次/min.其余患者手术过程中血压和心率平稳.术中出血量约为40-210 ml,平均(70±21) ml,无1例患者输血,手术时间50-135min,平均(60±20) min.术后住院时间4-8 d,平均5.1d.所有患者无明显并发症,无切口感染.术前内分泌检查尿香草苦杏仁酸(VMA)、肾上腺素(N)、去甲肾上腺素(NE)增高者,术后3个月复查已经恢复正常.术后随访3-24个月,未见症状复发以及肿瘤局部复发.结论:腹腔镜治疗肾上腺嗜铬细胞瘤具有相当高的安全性,充分的术前准备是手术成功的关键,术者可根据经验和肿瘤大小选择经腹入路腹腔镜手术或腹膜后入路腹腔镜手术.     

后腹腔镜手术治疗肾上腺嗜铬细胞瘤19例临床分析

我们自2004年2月～2009年3月共对19例.当血压控制在150/90 mmHg以下时即进行手肾上腺嗜铬细胞瘤患者行后腹腔镜肾上腺嗜铬细胞瘤手术.手术前3天适当扩容,以防止术中术后出现低血压.     

儿童嗜铬细胞瘤的诊断与治疗（附6例分析及文献复习）

目的：提高儿童嗜铬细胞瘤的诊断和治疗水平。方法：回顾性分析1998年至２０１１年来6例患儿的临床资料及复习文献。结果：24 h尿香草苦杏仁酸（vanillylmandelic acid,VMA）增高4例;血儿茶酚胺（catecholamine,CA）增高6例;超声、CT、MRI检查均有阳性发现。肾上腺嗜铬细胞瘤4例,肾上腺外嗜铬细胞瘤2例。全部患儿均在全麻下手术成功切除肿瘤,术后病理检查均证实为嗜铬细胞瘤。术后随访1～13年,5例无瘤存活至今,1例复诊发现肿瘤多发转移,家长放弃进一步治疗,2月后死亡。结论：虽然术前充分准备如扩容、控制血压,术中减少对肿瘤的挤压避免术中突然出现恶性高血压、控制术后低血压是至关重要的,但手术切除肿瘤是根治方法;组织病理学鉴别肿瘤良恶性很困难;若儿童伴恶性高血压合并心律失常、心悸、视力障碍或腹痛,需警惕此病。     

腹腔镜治疗肾上腺嗜铬细胞瘤的围手术期的护理体会

目的 探讨后腹腔镜下肾上腺嗜铬细胞瘤切除术的护理.方法 对28例行后腹腔镜肾上腺嗜铬细胞瘤切除术的患者行术前的心理护理、术后的常规护理,密切观察血压以及心率,预防术中及术后并发症的护理和管道的护理等.结果 患者手术均获成功,术后一个月内血压恢复正常,肿瘤未见复发.结论 做好充分的术前准备、术前心理护理和术后密切观察、精心护理是提高手术成功的关键因素.     

肾上腺外和双侧肾上腺嗜铬细胞瘤的手术治疗

探讨肾上腺外和双侧肾上腺嗜铬细胞瘤的诊治方法.方法:12例肾上腺外和双侧肾上腺嗜铬细胞瘤患者,在充分术前准备后, 经腹行肿瘤切除术.结果:12例均手术成功,无并发症出现,术后症状消失,尿香草基杏仁酸降至正常.结论:经腹手术是治疗肾上腺外和双侧肾上腺嗜铬细胞瘤的有效途径,囊内剜除术可减少损伤和出血,膀胱镜检对膀胱嗜铬细胞瘤的诊断价值有限.     

嗜铬细胞瘤的外科治疗

目的：探讨嗜铬细胞瘤的外科治疗方法及临床效果。方法：通过外科手术的方法治疗52例嗜铬细胞瘤患者．观察其疗效。结果：术后7例（13．5％）患者发生低血压。病理提示良性嗜铬细胞瘤50例（96．2％）,恶性嗜铬细胞瘤2例（3．8％）。出院时血压恢复正常42例（80．8％）。2例恶性嗜铬细胞瘤患者中．5年内均死于肿瘤转移。良性嗜铬细胞瘤者复发3例（5．8％）,均复发于肾上腺区。结论：嗜铬细胞瘤的手术效果好。但手术风险大;良好的术前准备、术中及术后的监护可以降低手术死亡率。     

Value of D-Dimers in patients with acute aortic dissection

Objective: To evaluatel the value of D-dimers in patients with acute aortic dissection (AAD). Methods: This study consisted of 16 patients with AAD and 27 non-AAD patients. Serum D-dimets were measured by Sta-Liatest D-DI immunoturbidimetric assay. Results: D-dimer level was higher (P ＜ 0.001) in patients with AAD(7.91 ± 5.52 μg/ml) than that in non- AAD group(1.57±1.24 μg/ml). D-dimer was positive (＞0.4 μg/ml) in all patients with AAD and in 10 control group patients (37%). Among patients with acute AAD, D-dimers tended to be higher in Stanford A than in Stanford B (8.67 ± 4.31 μg/ml vs. 3.24±1.27 μg/ml, P ＜0.01). D-dimer values tended to be higher in more extended disease(3.84 ± 1.65 μg/ml, 8.57 ± 3.58 μg/ml and 11.87 ± 5.69 μg/ml in thoracic aorta, thoracic and abdominal aorta, thoracic and abdominal aorta and iliacal arteries, respectively, P ＜ 0.05 for both 8.57 ± 3.58 and 11.87 ± 5.69 vs. 3.84 ± 1.65 ). Including the control group into the analysis, we found a sensitivity of 100%, a negative predictive value of 100%, and a specificity of 66% and a positive predictive value of 64% for D-dimer in diagnosis of AAD in our patients with suspected AAD. Conclusion: D-dimer was elevated in patients with AAD. A negative D-dimer test result could be useful in excluding AAD.     

Research of combined liver-kidney transplantation model in rats

Objective： To set up a simple and reliable rat model of combined liver-kidney transplantation. Methods： SD rats served as both donors and recipients. 4℃ sodium lactate Ringer＇s was infused from portal veins to donated livers,and from abdominal aorta to donated kidneys, respectively. Anastomosis of the portal vein and the inferior vena cava （IVC） inferior to the right kidney between the graft and the recipient was performed by a double cuff method, then the superior hepatic vena cava with suture. A patch of donated renal artery was anastomosed to the recipient abdominal aorta. The urethra and bile duct were reconstructed with a simple inside bracket. Results： Among 65 cases of combined liver-kidney transplantation, the success rate in the late 40 cases was 77.5%. The function of the grafted liver and kidney remained normal. Conclusion： This rat model of combined liver-kidney transplantation can be established in common laboratory conditions with high success rate and meet the needs of renal transplantation experiment.     

BLOOD PRESSURE CHANGE WITH AGE IN SALT-SENSITIVE TEENAGERS

Objective To observe blood pressure change with age in salt-sensitive teenagers whose salt sensitivity were determined by repeated testing.Methods Salt sensitivity was determined through intravenous infusion of normal saline combined with volume-depletion by oral diuretic furosemide in 55 teenagers. After five years, salt sensitivity was re-examined and subject blood pressure was followed up. Blood pressure changes in salt-sensitive teenagers were compared to that of non-salt sensitive teenagers over five years.Results After 5 years, the repetition rate of salt sensitivity determined by intravenous saline loading is 92.7%. In teenagers with salt sensitivity on the baseline, both the systolic blood pressure increments and increment rates were much higher than non-salt sensitive teenagers (12.7±12.1 mmHg vs. 2.8±5.2 mmHg, P＜ 0.01; 12.2%± 12.0% vs. 2.5% ±4.4%, P＜ 0.001,respectively). There was a similar trend for diastolic blood pressure (8.4 ± 6.4 mmHg vs. 3.7 ± 6.4 mmHg, P = 0.052; 13.2% ±10.6 % vs. 6.8%± 10.1%, P = 0.053, respectively).Conclusions Salt sensitivity determined by intravenous saline loading showed good reproducibility. Blood pressure increments with age were much higher in salt-sensitive teenagers than non-salt sensitive teenagers, especially in terms of systolic blood pressure.     

安心颗粒对急诊经皮冠状动脉介入术后生活质量影响的研究

目的：评价使用安心颗粒对急诊经皮冠状动脉介入术（PPCI）术后生活质量的影响.方法：将160例接受PPCI的急性ST段抬高型心肌梗死患者随机分为安心颗粒组（术前顿服安心颗粒8.8g,术后安心颗粒4.4 g/次,每日2次）和对照组（仅接受基础药物治疗）.所有患者均服用阿司匹林、氯吡格雷和阿托伐他汀.分别在入院时、出院前1d、出院后180 d时,应用心肌梗死多维度量表（MIDAS）、中文版SF-36评价量表对患者生活质量评分.并观察术后30 d以内的出血并发症、血小板减少症发生情况.结果：入院时和出院前1d,两组患者的心肌梗死MIDAS、SF-36量表评分比较无差异（P＞0.05）;出院后180 d时,与对照组比较,安心颗粒组MIDAS、SF-36评分明显减低（P＜0.05）;组内与入院时比较,两组出院前1d、出院后180 d时,MIDAS、SF-36评分均降低（P＜0.05）.两组患者在随访期间均无大量出血、少量出血、重度和极重度血小板减少症发生,安心颗粒组有4例、对照组有7例发生不明显出血（P＞0.05）.两组发生轻度血小板减少症的患者数比较无差异（P＞0.05）.结论：PPCI使用安心颗粒,能改善急性ST段抬高型心肌梗死患者的生活质量,且不增加出血风险.     

The comparative studies of the influences of Urapidil and Nicardipine on sino-atrial node function, atrio-ventricular node function and hemodynamics

Objective:To investigate the influences of urapidil and nicardipine on rabbit sinus function,atrio-ventricular node function and hemodynamics.Methods:Thirty-two Angora's rabbits were selected and randomly divided into four groups.U1 group:urapidil 0.25 mg/kg;U2 group:urapidil 0.5 mg/kg;N1 group:nicardipine 10 μg/kg;N2 group:nicardipine 20 μg/kg.All these medicine were administrated within 30 seconds.Measurements were taken before and after the administration of urapidil or nicardipine for the following data:mean blood pressure(MAP),heart rate(HR),sino-atrial conduction time(SACT),maximal sinoatrial recovery time(SNRTmax)corrected sinus node recovery time(CSNRT),index of sinus node recovery time(SNRTI),Wenckebach A-V conduction frequency (WB),and P-R interval.Results:Significant MAP and HR changes were identified in all of the four groups before and after administration of both urapidil and nicardipine.No significant changes could be found in the rest of the parameters.Intergroup analysis showed that SACT and CSNRT of N1 and N2 groups were shorter than those of the U2 group(P＜0.01);the MAP decreased(P＜0.01)and the HR increased drastically(P＜0.01).Conclusions:Neither urapidil(0.25 mg/kg,0.5 mg/kg)nor nicardipine(10μg/kg,20μg/kg)has any significant influence on rabbit sinus function or rabbit atrio-ventricular node function.Nicardipine could be a better choice than urapidil for parafunctional sinus node patients.     

Expression of OPGmRNA and ODFmRNA in the patients of hip fracture due to osteoporosis

Objective：To investigate the gene expression of osteoprotegerin（OPG） and osteoclast differentiation factor（ODF） in the bone tissue of patients with hip fracture due to osteoporosis. Methods：OPGmRNA and ODFmRNA in the bone tissue in 50 cases of osteoporosis sufferers（over 50 years old） with hip fracture（Observer Group） and 30 cases of hip facture sufferers with no osteoporosis（Control group） were analyzed with the Semi-Quantitative RT-PCR method. Results：The mRNA expressed of ODF, OPG were both high in the patients with hip fracture. In the control group, the expression of OPG mRNA was observed, while the expression of ODF mRNA was very slight. Conclusion：Aged patients contained all signals including OPG, ODF that are essential for inducing osteoclastogenesis and promoting bone resorption.     

Dynamic Changes in Serum Estradiol and Progesterone levels in Patients of Premenstrual Syndrome with Adverse Flow of Liver-qi

Objective:To probe into the influence of changes of ovarian hormones on the pathogenesis of the specific sub-type premenstrual syndrome(PMS)and reveal partial microcosmic mechanisms of adverse flow of liver-qi.Methods:Estradiol(E2)and progesterone(P)levels in serum were determined at different phases of menstrual cycle by radioimmunoassay.Results:In the group of PMS with adverse flow of liver-qi.the secretive peak value Of E2 and P at the follicular phase significantly decreased,and the secretive peak value at the luteal phase did not come into being.Conclusions:Low E2 and P secretive peak at the follicular phase and absence of secretive peak at the luteal phase is one of the microcosmic mechanisms of PMS with adverse flow of liver-qi.One of the pathophysiologic mechanisms of specific sub-type PMS is probably the continuous low level of E2and P.     

Real-time Three-dimensional Echocardiography in Assessment of Left Ventricular and Right Ventricular Volumes

Real-time three-dimensional echocardiography (RT3DE)is a new ultrasound technique that enables dynamic threedimensional visualization and quantification of the heart in real time. Investigation of feasibility and methodology of RT3DE in determining left ventricular (LV) and right ventricular (RV) volumes, RT3DE was performed in 35 normal adults using Philips SONOS 7500 system with a 2-4 MHz matrix array transducer. The 60°×60° "pyramid" volume database was obtained and analyzed on a TomTec echo workstation. Both LV and RV volumes were calculated with four 3DE methods (i.e. apical 2, 4, 8, and 16-plane) through manually tracing ventricular endocardial borders in end diastole and end systole. Stroke volumes were then calculated. LV volume was also measured by 2DE Simpson's rule using GE VIVID 7 ultrasound machine.     

SCREENING FOR A 21-CHROMOSOME ABNORMALITY IN PREIMPLANTED EMBRYOS OF ELDERLY WOMEN

Increasing maternal age is the only etiological factor unequivocally linked to Down's syndrome in humans. The occurrence rate of newborns with Down's syndrome is about 1/220 in women over 35 years old. However, the occurrence rate in embryos fertilized in vitro, of the elder woman is unclear. Using FISH we screened the number of chromosome 21 in preimplanted embryos of 5 elderly women (average age, 38.4 years) to study the feasibility and necessity of screening trisomy 21 in embryos in patients over 35 years old at the in vitro fertilization (IVF) center.     

Scientific principles and rigorous processes should be followed in developing clinical guidelines for therapeutic interventions of integrative medicine

A clinical guideline for the therapeutic interventions of integrative medicine may be defined as a written document which states a series of recommendations on therapeutic interventions of integrative medicine for a special disease or condition. The guideline may provide assistance to medical professionals in making clinical decisions aimed at improving the clinical outcome of patients and reducing the costs of medical care（~＇4~. Recommendations issued by a guideline should be based on the best available evidence in both Western and Chinese medicine. For fulfilling this purpose, the development of clinical guidelines for therapeutic interventions in the field of integrative medicine should follow scientific principles and undergo a rigorous processes.