原位大静脉动脉旁路术治疗下肢动脉硬化闭塞症

作者对１９８９年￣１９９４年运用自制瓣膜切除器开展原位大隐静脉动脉旁路术治疗下肢动脉硬化闭塞症２８例共３０条肢体的方法、疗效和治疗体会进行了总结。患者术前踝肱指数（ＡＢＩ）为０￣０．５７（平均０．４１），均经动脉造影证实。术后移植物均可门及搏动，有１８条肢体恢复足背或胫后动脉搏动。１７例同时行输入或输出道动脉重建术。溃疡清创术６例。３例于术后３天内出现移植物搏动消失，行第二次重建术。治疗结果，ＡＢ     

大隐静脉原位转流术重建下肢血液循环

目的:评价大隐静脉原位转流术治疗下肢动脉硬化闭塞症的疗效.方法:运用自制瓣膜切除器开展大隐静脉原位转流术治疗下肢动脉硬化闭塞症38例共40例肢体.患者术前踝肱指数(ABI)为0-0.58(平均0.29),均经动脉造影证实.术后移植物均可扪及搏动,有28条肢体足背或胫后动脉搏动恢复,17例同时行输入输出道动脉重建术,溃疡清创术6例,4例于术后3天内出现移植物搏动消失,行第2次重建术,结果:ABI平均值同术前0.29上升至0.84,严惩缺血肢体挽救率为100%,经寿命表统计分析,1-5年的血管累积通畅率分别为92%,87%,82%,72%和65%,结论:大隐静脉原位转流术是治疗下肢动脉硬化闭塞症的理想方法之一,同时行输入功输出道动脉重建术,对保证移植血管的通畅有着重要的意义.     

股腘动脉闭塞症的手术治疗

目的 探讨股腘动脉旁路移植术治疗下肢动脉硬化闭塞症(C、D级病变)的近中期疗效.方法 2005年1月至2009年2月,170例患者(191条肢体)行股动脉以远血管重建术.其中男性108例,女性62例;年龄45～85岁,平均67岁.症状包括间歇性跛行78例,静息痛62例,下肢缺血性溃疡19例,远端组织坏死11例.所有患者术前均行动脉造影检查,根据TASC Ⅱ分级:C级病变127条肢体,D级病变64条肢体.手术方法包括大隐静脉原位旁路移植术15条肢体,大隐静脉转位20条肢体,人工血管旁路移植术128条肢体,大隐静脉与人工血管组合旁路移植术28条肢体.结果 围手术期无死亡病例.术后随访6～36个月,平均(24±6)个月;76例失访,随访率57%(109/191).一期通畅率84.4%(92/109),其中人工血管旁路移植通畅率88.2%(75/85),大隐静脉(原位、转位、组合)旁路移植通畅率70.8%(17/24).二期通畅率89.9%(98/109).结论 人工血管旁路移植术是治疗严重股腘动脉闭塞症(TASC C和D级病变)的主要方法,手术疗效满意.     

微创技术结合外科手术治疗重症下肢缺血

目的 探讨术中血管微创治疗技术结合外科手术治疗重症下肢缺血的初步临床经验。方法 1999年7月至2000年10月,采用术中同时行髂动脉腔内微创治疗技术(球囊扩张和支架植入)结合肢体远端动脉重建术治疗广泛多节段动脉硬化闭塞症15例(20条肢体)。结果 术中17条髂动脉微创介入治疗均获成功,11条肢体同时行股-腘动脉人工血管旁路术,3条肢体行股-股-腘动脉人工血管旁路系列转流术,5条肢体行股深动脉成形术。其中有1条肢体股-腘动脉旁路术失败。本组患者无重要脏器并发症和手术死亡。平均随访时间8个月(1-16个月),髂动脉腔内支架通畅率100％,3条股-股动脉耻骨上人工血管转流均通畅,而股-腘动脉人工血管通畅率78．6％,截肢率10．0％。结论 术中髂动脉腔内微创介入治疗技术同时结合远端动脉重建术是治疗广泛多节段动脉硬化闭塞症的害全右特肯沸．     

小隐静脉原位旁路术治疗下肢动脉缺血症

为探讨下肢动脉缺血症旁路重主新的移植材料,笔者于１９９２年５月至１９９７年５月,应用小隐静脉原位旁路术治疗下肢动脉闭塞严重缺血症１８例２４条肢体并监测随访１－５年。结果：１８例近期缺血症状均显著改善,临床有效率达８８．８％,远期疗效优良率达８３．３％,经寿命青法统计分析,移植物１,３,５年通畅率分别为９５．８％,７９．６％和７０．０％,认为以小隐静脉移植材料重建因肢体循环具有不受长度限制,我需预破     

血管腔内介入联合外科手术治疗下肢多节段动脉硬化闭塞症

目的：探讨下肢多节段动脉硬化闭塞症的治疗手段及临床疗效。方法：采用下肢动脉球囊扩张、支架植入结合动脉旁路术、股深动脉成形及原位大隐静脉动脉化,治疗下肢多节段动脉硬化闭塞症31例（36条患肢）,行髂动脉支架植入球囊扩张术33条患肢;股总动脉支架植入球囊扩张术3条患肢,23条患肢行股一胭动脉人工血管旁路术,12条患肢行股深动脉成形术,6条行原位的大隐静脉动脉化。结果：手术均获得成功,未出现严重并发症。术后踝肱指数（0．65±0．18）与术前（0．25±0．11）相比较有明显提高（P〈0．05）。平均随访14个月（2～24个月）,与术前相比,患者术后症状明显好转,跛行距离加大（〉1000m）。结论：下肢动脉腔内介入结合动脉旁路术、股深动脉成形术、大隐静脉动脉化等是治疗多节段多平面下肢动脉硬化闭塞症的有效方法。     

显微外科静脉瓣膜切除在下肢静脉动脉化手术中的应用

为探索静脉动脉化重建缺血下肢血循环的新途径，根据大隐静脉瓣膜的解剖观察和抗逆向压力测试结果，应用显微外科技术切除大隐静脉的主要瓣膜，一期完成原位大隐静脉动脉化，以重建严重缺血下肢的血循环。临床治疗重症血栓闭塞性脉管炎、动脉硬化性闭塞所致下肢广泛动脉闭塞共４３例，经随访１～４年，４１例效果满意。文章重点介绍大隐静脉瓣膜的解剖、定位、切除和原位大隐静脉转流的手术要点，并就术式评价、指征等进行讨论。     

主髂动脉闭塞症的重建术术式选择

为探索主髂动脉闭塞重建手术方式选择的规律，作者对３１例不同类型的主髂动脉闭塞症患者分别采用动脉硬化内膜切除术、主－髂或主－股动脉旁路术、解剖外途径动脉旁路术和顺序动脉旁路术治疗。手术死亡率为３．２％。五年通畅率为８４．２％；二期五年通畅率为９６．５％。作者认为踝／肱指数对正确掌握动脉重建术指征有肯定意义。     

股深动脉血流重建治疗下肢动脉硬化闭塞症

目的总结股深动脉血流重建治疗下肢动脉硬化闭塞症的经验。方法选择FontaineⅢ、Ⅳ期下肢动脉硬化闭塞症共23例。入选标准：膝上无理想的用于旁路术的流出道，股深动脉主干长度达到或超过股骨干中点且与胭动脉间有侧支血管，近端动脉病变导致股深动脉内无正常动脉血流。采用旁路术、取栓术及股深动脉成形术重建股深动脉血流。结果全部FontaineⅢ期病例于术后肢体静息痛消失；9例FontaineⅣ期病例中术后肢体静息痛消失7例，6例于术后10d行截足（趾）术，1例于术后1周行膝上截肢术。手术后踝／肱血压指数显著增加（P〈0．01）。术后22例随访2个月至6年，移植血管3年通畅率为82％。结论股深动脉血流重建治疗严重肢体缺血简单、安全、有效。     

术中髂动脉支架结合股动脉旁路术治疗多节段动脉硬化闭塞症

目的 探讨术中髂动脉腔内成形及支架植入结合股-Guo动脉旁路术治疗多节段动脉硬化闭塞症的初步临床经验。方法 采用术中同时行髂动脉腔内成形和支架植入结合股-Guo动脉旁路术治疗多节段动脉硬化闭塞症10例（12条肢体）。结果 术中11条髂动脉行腔内成形和支架植入均获成功,9条肢体行股-Guo动脉人工血管旁路术,3条肢体行股-股-Guo动脉人工血管旁路系列转流术;1条肢体股-Guo动脉旁路术失败,本组患者无重要脏器并发症和手术死亡。平均随访时间6个月（1-12个月,髂动脉腔内支架通畅率100%;3条股-股动脉耻骨上人工血管转流均通畅;而股-Guo动脉人工血管通畅率83.3%;截肢率8.3%。结论 术中髂动脉腔内支架结合股-Guo动脉旁路术是治疗多节段动脉硬化闭塞症的安全、有效方法。     

Comparison of 27-gauge (0.41-mm) Whitacre and Quincke spinal needles with respect to post-dural puncture headache and non-dural puncture headache

BACKGROUND: The incidence of headache after spinal anaesthesia has varied greatly between studies. We compared the incidence of postoperative headache in general and postdural puncture headache (PDPH) when using 27-gauge (G) (outer diameter 0.41 mm) Quincke and Whitacre spinal needles in ambulatory surgery performed under spinal anaesthesia. Methods: In a prospective, randomized study, 676 ASA physical status I-II day-case outpatients were given a spinal anaesthetic through either a 27-G (0.41 mm) Quincke or a 27-G (0.41 mm) Whitacre spinal needle. The incidence of any type of postoperative headache was assessed and the type of headache defined using a standardized questionnaire including PDPH criteria. The severity of the headache was defined using a 100-mm visual analogue scale. Results: For the final analysis, 529 patients were available (259 patients in the Quincke group and 270 patients in the Whitacre group). The overall incidence of postoperative headache was 20.0%, but the incidence of true PDPH was very low (1.51%). The incidence of PDPH in the Quincke group was 2.70%, while in the Whitacre group it was only 0.37% (P < 0.05). The overall incidence of non-dural puncture headache was 18.5% and did not differ between the study groups. Conclusions: True PDPH seldom occurs when a 27-G (0.41 mm) spinal needle is used, although postoperatively a non-specific headache is common. Using the 27-G (0.41 mm) Whitacre spinal needle further reduced the incidence of PDPH. Thus, we recommend routine use of the 27-G (0.41 mm) Whitacre spinal needle when performing spinal anaesthesia.     

Strength and sensation after epidural ropivacaine in men and women

We injected 15 ml epidural ropivacaine in 30 men and 30 women to determine the median dose required to impair a straight‐leg raise. We started at a concentration of 0.425%, increasing the concentration by 0.025% after an ineffective injection and decreasing the concentration by 0.025% after an effective injection. The median (95% CI) concentration of ropivacaine that prevented straight‐leg raise within 30 min of injection was 0.43% (0.41–0.45%) in men and 0.40% (0.39–0.41%) in women, p = 0.001. There were no differences in dermatome levels for loss of pinprick and cold sensation between men and women.     

微循环监测方法在皮瓣断蒂前的应用

目的监测腹股沟外侧皮瓣微循环血流动态变化及其规律,为选择最佳断蒂时间提供可靠客观量化指标.方法应用激光多普勒血流计(LDF)对12例腹股沟外侧皮瓣移转面中点逐日进行微循环监测,皮瓣移植后第4 d起记录皮瓣蒂部阻断前、后LDF的灌注单位(perfusion units,PU)值变化情况.结果腹股沟外侧皮瓣微循环血流变化可分为两期,即术后前6 d的骤升期,PU值分别为2.83±0.46、3.21±0.41、3.66±0.43、4.77±0.71、7.08±0.37;术后6～11 d的平台期,PU值分别为7.53±0.41、7.57±0.62、7.70±0.44、7.60±0.26、7.58±0.17.本组断蒂时间为术后8～11 d. 结论腹股沟外侧皮瓣移转用以修复手背及腕部缺损,其微循环血流变化在平台期稳定期时,在阻断皮瓣蒂部后其PU值恢复到或超过阻断前水平的50%时进行断蒂,皮瓣全部成活.     

Incomplete distal renal tubular acidosis affects growth in children.

BACKGROUND: Incomplete distal renal tubular acidosis (idRTA) is recognized as an underlying aetiology in recurrent nephrolithiasis. Until the recently reported high prevalence of idRTA in adults with osteoporosis, the effect of idRTA on skeletal parameters was not known. We hypothesize that idRTA has a potential to affect height in the paediatric population. METHODS: In a cross-sectional study, the children with posterior urethral valves (PUV), with normal estimated glomerular filtration rates, were evaluated for idRTA and complete dRTA. The idRTA evaluation was done by short ammonium chloride acidification test. The height standard deviation scores (SDS) in the idRTA group were compared with PUV children without dRTA, with complete dRTA, and to age and gender matched controls with no renal issue (n = 50). RESULTS: The idRTA group (n = 17) manifested a significantly lower mean height SDS (-1.94 +/- 0.41 vs -0.46 +/- 0.28; P < 0.001) and a higher short stature prevalence (height SDS below 2) (18% vs 0; P = 0.06) as compared with those without dRTA (n = 23). The matched controls showed a significantly higher height SDS as compared with the idRTA group (-0.39 +/- 0.25 vs -1.94 +/- 0.41; P < 0.001). As compared with the complete dRTA group (n = 9), the children with idRTA did have significantly higher height SDS (-1.94 +/- 0.41 vs -5.31 +/- 1.95; P = 0.002), and a lower short stature prevalence (18% vs 78%; P = 0.001). On multivariate analysis, dRTA was significantly associated with the height SDS (= -0.88; P < 0.001). CONCLUSIONS: Incomplete dRTA affects height in children. This observation needs validation in longitudinal studies.     

Hemorrhage causes interalveolar perfusion maldistribution in the lungs of anesthetized rats

BACKGROUND: Lung injury often occurs following hemorrhage and we hypothesized that this might be due to the effects of hemorrhage on perfusion distribution among alveoli. To test this, we measured interalveolar perfusion distribution in anesthetized, spontaneously breathing rats subjected to blood losses of 0%, 10%, 20%, or 30% of calculated blood volume. METHODS: We measured interalveolar perfusion distribution by analyzing trapping patterns of 4-mum diameter fluorescent latex particles infused into the pulmonary circulation. The particles (2 x 10) were infused 1 hour after each animal had been bled, and the lungs were then removed and air-dried. Using a confocal fluorescence microscope, we collected images of the particles in eight sections of each lung. Each image encompassed 3,360 x 3,360 x 100 microm (approximately 5,000 alveoli), and included 3-4,000 particles. Particle distributions in the images were measured using the method of dispersion index (DI) analysis. A DI value of zero corresponds to a statistically random distribution; the more DI exceeds zero, the more the distribution is clustered or inhomogenous. RESULTS: The largest DI values for the four groups were: 0%, 0.69 +/- 0.41; 10%, 0.57 +/- 0.58; 20%, 0.72 +/- 0.34; 30%, 1.38 +/- 0.41. The 30% blood loss group had a max DI value approximately twofold greater than those of the other three (p < 0.0001). CONCLUSIONS: Our results suggest that interalveolar perfusion distribution becomes markedly maldistributed at blood losses of 30%. This contributes to ventilation-perfusion mismatching, and may be a precipitating event for lung injury following hemorrhage.     

Quantification of the Learning Curve for Arthroscopic Os Trigonum Excision

The purpose of the present study was to quantify the learning curve for arthroscopic os trigonum excision using the log-linear model. Twenty-three consecutive feet underwent arthroscopic os trigonum excision and release of the flexor hallucis longus. The required time from the beginning of shaving of the soft tissue until completion of os trigonum excision and release of the flexor hallucis longus (van Dijk time) was recorded. Regression analysis was applied to predict the required time on the basis of the cumulative case volume after logarithmic transformation of both statistics. The mean required time was 35.2 (range 9 to 90) minutes. After logarithmic transformation, a significant linear correlation was observed between the required time and the cumulative case volume (p?=?.0043). The best-fit linear equation was calculated as log (y, estimated required time)? = ?0.41 log (x, case volume) + 1.86, resulting in an estimated learning rate of 75.3% (= 2^?0.41). The results showed an overall time reduction in arthroscopic os trigonum excision in support of a learning curve effect with an ~75% learning rate, indicating that the required time for arthroscopic os trigonum excision can decrease by ≤25% when the cumulative volume of cases has doubled.     

Low agreement among 24 doctors using the Neer-classification; only moderate agreement on displacement,even between specialists

Twenty-four orthopaedic surgeons classified 42 pairs of radiographs according to the Neer system for proximal humeral fractures. Mean kappa value for inter-observer agreement was 0.27 (95% CI 0.26-0.28) with no clinically significant difference between orthopaedic residents ( n=9), fellows ( n=6) and specialists ( n=9). Mean kappa for agreement of displacement versus non-displacement was 0.41 (95% CI 0.39-0.43) overall, and 0.50 (95% CI 0.45-0.56) within the specialist group. The agreement found in our study is unsatisfactory from a clinical perspective.     

Visual assessment of train-of-four and double burst-induced fade at submaximal stimulating currents

The influence of current intensity on visual assessment of fade in response to train-of-four (TOF) and two modes of double-burst stimulation (DBS) was determined to assess the utility of low-current neurostimulation. Each of 150 sets of assessments (in 51 patients) included a mechanographic TOF at 60 mA followed by visual assessments of TOF, DBS3,3 (two minitetanic bursts of three stimuli each), and DBS3,2 (a burst of three followed by a burst of two impulses) at 20, 30, 50, and 60 mA in random order. For the range of mechanographic TOF ratios between 0.41 and 0.70, visual assessment of TOF fade failed to identify fade in 33%, 36%, 44%, and 58% of cases at 20, 30, 50, and 60 mA, respectively. Corresponding false-negative rates for DBS3,3 were 11%, 17%, 36%, and 33%, and for DBS3,2 they were 6%, 6%, 17%, and 28%. Within each method, P less than 0.05 (by Mantel-Haenszel analysis) for a linear trend of increasing accuracy as current decreased. For the range between 0.41 and 0.70, quantitative assessment overestimated the actual ratio at all currents for TOF, at 30, 50, and 60 mA for DBS3,3, and at 50 and 60 mA for DBS3,2 (P less than 0.05 by Wilcoxon signed rank test). At each current tested, DBS was more sensitive in detecting fade visually than TOF. The accuracy of visual fade detection was not influenced significantly by level of observer training. In conclusion, visual assessment of fade by novice and expert observers is improved by testing at low currents.     

Effect of precision error on T-scores and the diagnostic classification of bone status.

We quantified confidence intervals (CIs) for T-scores for the lumbar spine and hip and determined the practical effect (impact on diagnosis) of variability around the T-score cutpoint of -2.5. Using precision data from the literature for GE Lunar Prodigy dual-energy X-ray absorptiometry (DXA) systems, the 95% CI for the T-score was +/-0.23 at the lumbar spine (L1-L4), +/- 0.20 at the total hip, and +/-0.41 at the femoral neck. Thus, T-score variations of +/-0.23 or less at the spine, +/-0.20 at the total hip, and +/-0.41 at the femoral neck are not statistically significant. When diagnosing osteoporosis, T-scores in the interval -2.3 to -2.7 for spine or total hip (after rounding to conform to guidelines from the International Society for Clinical Densitometry) and -2.1 to -2.9 for femoral neck are not statistically different from -2.5. Better precision values resulted in smaller 95% CIs. This concept was applied to actual clinical data using Hologic DXA systems. The study cohort comprised 2388 white women with either normal or osteopenic spines in whom the densitometric diagnosis of osteoporosis would be determined by hip T-scores. When evaluating actual patient T-scores in the range -2.5+/-95% CI, we found that the diagnosis was indeterminate in approximately 12% of women when T-scores for femoral neck were used and in 4% of women when T-scores for total hip were used, with uncertainty as to whether the classification was osteopenia or osteoporosis. We conclude that precision influences the variability around T-scores and that this variability affects the reliability of diagnostic classification.