超声测量舌骨-会厌距离对喉镜显露困难的预测价值

目的评估超声测量舌骨-会厌距离预测喉镜显露困难的有效性。方法选择择期行气管插管全身麻醉患者72例,男40例,女32例,年龄18～90岁,ASAⅠ—Ⅲ级。麻醉前测量张口度、甲颏距离,评估改良Mallampati分级,并在"嗅花位"下超声测量患者舌骨-会厌距离。患者麻醉后在相同体位下行气管插管,根据Cormack-Lehane分级分为两组:Ⅰ和Ⅱ级为喉镜显露容易组(n=53),Ⅲ和Ⅳ级为喉镜显露困难组(n=19)。比较常规评估气道方法和舌骨-会厌距离与喉镜显露困难的关系,采用受试者工作特征(ROC)曲线评估各项指标预测喉镜显露困难的效能。结果与喉镜显露容易组比较,喉镜显露困难组中男性比例、BMI值和改良Mallampati分级明显升高(P0.05),甲颏距离和舌骨-会厌距离明显缩短(P0.05)。BMI值、甲颏距离、张口度、Mallampati分极和舌骨-会厌距离曲线下面积(AUC)分别为0.74、0.63、0.71、0.67和0.84,舌骨-会厌距离临界值为1.4 cm其敏感性为79.0%,特异性为83.0%。结论超声测量舌骨-会厌距离可较好预测喉镜显露困难。     

超声在阻塞性睡眠呼吸暂停综合征患儿气管插管中的应用

目的 探讨超声在阻塞性睡眠呼吸暂停综合征(OSAS)患儿气管插管时选择合适导管型号、插管成功率、围术期气道相关并发症中的应用效果。方法 选择择期全麻下行扁桃体和(或)腺样体切除术的OSAS患儿123例,男59例,女64例,年龄3～8岁,身高92～141 cm,体重16～39 kg, ASAⅠ或Ⅱ级,MallampatiⅠ或Ⅱ级。采用随机数字表法将患儿分为两组：超声组(n=62)和常规组(n=61)。超声组通过测量环状软骨内空气-黏膜界面直径来选择导管型号,听诊法和气管超声检查定位导管深度;常规组采用年龄公式确定气管导管型号,听诊法确定插管深度。记录插管深度、首次插管成功例数、插管时间和气管导管置换、气管导管脱出、支气管内插管、咳嗽声嘶、拔管后喘鸣等围术期气道相关并发症发生情况。结果 与常规组比较,超声组插管深度明显增加(P<0.05),首次插管成功率明显升高(P<0.05),插管时间明显延长(P<0.05),气管导管置换发生率明显降低(P<0.05)。两组气管套管脱出、支气管内插管、咳嗽声嘶和拔管后喘鸣发生率差异无统计学意义。结论OSAS患儿术中通过气管超声选择...     

超声测量气道参数预测困难喉镜暴露的准确性

目的评价超声测量气道参数预测困难喉镜暴露的准确性。方法择期全麻手术患者104例,年龄18～70岁,ASA分级Ⅰ或Ⅱ级。麻醉诱导前行气道评估,记录患者BMI、颈围、张口度、甲颏间距及改良Mallampti分级,并采用超声测量颞下颌移动度、舌下表面深度、舌颏间距和会厌深度。测量结束后,行麻醉诱导,面罩加压通气后使用直接喉镜暴露声门,记录患者CL分级,以CL分级≥2b级作为困难喉镜暴露的标准。根据患者喉镜暴露的困难程度将其分为非困难喉镜暴露组(NDL)和困难喉镜暴露组(DL组)。将组间差异有统计学意义的因素,采用ROC曲线下面积(AUC)及其95%置信区间(95%CI)评价各指标预测困难喉镜暴露的准确性,结合约登指数确定预测喉镜暴露困难临界值,计算灵敏度和特异度。结果与NDL组比较,DL组BMI、会厌深度和改良Mallampti≥Ⅲ级比例升高,张口度和甲颏间距降低(P<0.05)。改良Mallampti分级和会厌深度预测困难喉镜暴露的AUC(95%CI)分别为0.728(0.619～0.836)和0.833(0.743～0.924)。会厌深度临界值为2.125 cm时,其预测困难喉镜暴...     

超声测量舌体积和舌纵截面积预测困难气道的有效性

目的研究超声测量舌体积和舌纵截面积对喉镜暴露困难,以及气管插管困难的预测作用。方法选取需行气管插管全身麻醉的患者120例,男68例,女52例,年龄18~90岁,BMI 16~39 kg/m^2,ASAⅠ-Ⅲ级。麻醉前进行临床气道评估,并超声测量患者的舌纵截面积和舌横径,两者的乘积为超声舌体积。患者麻醉后进行喉镜暴露和气管插管,分析患者的超声舌体积、舌纵截面积和舌横径与喉镜暴露困难以及气管插管困难的关系,采用受试者工作特征(ROC)曲线结合约登指数得到各指标预测喉镜暴露困难和气管插管困难的临界值,根据临界值计算出各指标预测困难气道的准确率、灵敏性、特异性,阳性预测值和阴性预测值。结果本研究共纳入117例患者,喉镜暴露困难31例(26.5%),气管插管困难13例(11.1%)。患者的超声舌体积、舌纵截面积和舌横径均与喉镜暴露困难、气管插管困难相关(P<0.05)。舌纵截面积>18.7 cm^2和舌体积>82.1 cm^3在预测喉镜暴露困难的准确率、灵敏性、特异性、阳性预测值和阴性预测值方面差异均无统计学意义;超声舌纵截面积>19.2 cm^2在预测气管插管困难的准确率和特异性明显低于舌体积>97.4 cm^3(P<0.05),但两指标在灵敏性、阳性预测值和阴性预测值方面差异均无统计学意义。结论超声舌纵截面积和舌体积都能较好地预测喉镜暴露困难和气管插管困难,超声舌纵截面积有望替代舌体积用于预测喉镜暴露困难。     

超声测量气道参数预测困难面罩通气的准确性

目的评价超声测量气道参数预测困难面罩通气(DMV)的准确性。方法择期行气管插管全麻手术患者96例, 年龄18～90岁, BMI 16～39 kg/m2, ASA分级Ⅰ或Ⅱ级。术前1 d时行临床气道评估, 记录改良Mallampati分级、甲颏间距和上唇咬合试验分级。麻醉诱导前30 min采用超声测量髁状突活动度、舌纵截面积及舌横径, 计算舌体积(舌纵截面积与舌横径的乘积)。麻醉诱导后行面罩通气, 面罩通气困难分级≥Ⅲ级为DMV, 根据是否发生DMV分为2组:非DMV组 (NDMV组)和DMV组。将组间差异有统计学意义的临床气道评估指标和超声测量气道参数与DMV行Spearman相关分析;采用受试者工作特征曲线下面积(AUC)评价各指标预测DMV的准确性, 确定临界值, 计算准确率、灵敏度、特异度、阳性预测值和阴性预测值。结果改良Mallampati分级、上唇咬合试验分级、舌纵截面积、舌横径、舌体积与DMV呈正相关, 甲颏间距和髁状突活动度呈负相关(P<0.05)。超声测量髁状突活动度和舌体积预测DMV的AUC分别为0.898、0.862, 界值分别为1.19 cm、99.94 c...     

上腔静脉塌陷指数预测机械通气患者容量反应的可行性

目的探索上腔静脉塌陷指数(SVC-CI)对机械通气患者容量反应的预测效果。方法选择择期气管插管全麻机械通气下行腹部手术患者36例,男20例,女16例,年龄18～64岁,ASAⅠ或Ⅱ级,NYHAⅠ或Ⅱ级。所有患者在全麻诱导后至手术开始前,快速输注复方乳酸钠10 ml/kg,输注时间10～15 min。记录补液前后MAP、HR、CVP、心脏指数(CI)、每搏量变异度(SVV),利用经食管超声心动图测量上腔静脉(SVC)内径,并计算补液前后CI的变化值(ΔCI)以及SVC-CI。根据ΔCI将患者分为容量反应组(R组,ΔCI≥15%)和非容量反应组(NR组,ΔCI15%)。采用受试者工作特征(ROC)曲线评估SVC-CI和SVV预测容量反应的效能。结果有20例(56%)患者出现容量反应。R组SVC-CI明显高于NR组(P0.05)。SVC-CI预测容量反应的ROC曲线下面积为0.816(95%CI 0.673～0.958),敏感性85%,特异性75%。SVV预测容量反应的ROC曲线下面积为0.731(95%CI 0.567～0.895),敏感性55%,特异性88%。结论 SVC-CI和SVV均可预测机械通气患者容量反应,而SVC-CI的预测效能优于SVV。     

盲探气管插管装置联合呼气末二氧化碳监测用于困难气道患者经鼻气管插管的效果

目的 评价盲探气管插管装置联合呼气末二氧化碳监测用于困难气道患者经鼻气管插管的效果.方法 择期经鼻气管插管的口腔颌面外科手术患者60例,性别不限,年龄35-64岁,体重55-75 kg,ASA分级Ⅰ或Ⅱ级,张口度＜3 cm,颈部后仰度＜30°,Mallampati分级Ⅲ或Ⅳ级,甲颏间 距＜6.5 cm,预计为困难气道.采用随机数字表法,将患者随机分为2组(n=30):盲探气管插管装置组(Ⅰ组)和盲探气管插管装置联合呼气末二氧化碳监测(Ⅱ组).Ⅰ组采用盲探气管插管装置进行气管插管;Ⅱ组采用肓探气管插管装置结合呼气末二氧化碳监测进行气管插管.记录气管插管情况、气管插管时间、气管插管期间(鼻衄、心动过速、高血压和低氧血症)和术后(咽痛和声音嘶哑)不良反应的发生情况.结果 2组患者气管插管成功率均为100％.2组均未见心动过速、高血压、低氧血症和声音嘶哑的发生.与Ⅰ组比较,Ⅱ组首次气管插管成功率升高,气管插管时间缩短,鼻衄和咽痛的发生率降低(P＜0.05).结论 盲探气管插管装置联合呼气末二氧化碳监测用于困难气道患者经鼻气管插管时可缩短气管插管时间,提高气管插管成功率,减少不良反应的发生.     

呼气末正压抬高期间肱动脉峰流速差值对患者术中容量反应性的预测作用

目的评估呼气末正压(PEEP)抬高期间肱动脉峰流速差值对患者术中容量反应性的预测作用。方法择期全麻下行胃肠手术患者67例,男45例,女22例,年龄40～72岁,BMI 18～25 kg/m~2,ASAⅠ或Ⅱ级,心功能Ⅰ或Ⅱ级。麻醉诱导后所有患者均先后进行PEEP抬高试验和容量负荷试验。将扩容后每搏量增加≥15%的患者纳入有反应组(R组,n=35),扩容后每搏量增加15%的患者纳入无反应组(NR组,n=32)。分别在PEEP抬高前、PEEP抬高时记录HR、MAP、中心静脉压(CVP)、每搏量(SV),同时超声测量肱动脉峰流速记录肱动脉峰流速最大值(Vp_(max))、肱动脉峰流速最小值(Vp_(min))、肱动脉峰流速变异度(ΔVp),计算上述指标的差值(Δ)。采用受试者工作特征曲线(ROC曲线)评估ΔVp_(min)、ΔΔVp预测容量反应性的效能。结果 PEEP抬高期间R组ΔVp_(min)、ΔΔVp明显高于NR组(P0.05)。ΔVp_(min)、ΔΔVp预测容量反应性的ROC曲线下面积(AUC)分别为0.887(95%CI 0.808～0.965)和0.817(95%CI 0.710～0.924)。讨论 PEEP抬高期间肱动脉峰流速差值可有效预测术中容量反应性,其中ΔVp_(min)有较好的预测作用。     

不同血浆靶浓度瑞芬太尼对患儿吸入七氟烷诱导气管插管最低肺泡有效浓度的影响

目的 评价不同血浆靶浓度瑞芬太尼对患儿吸入七氟烷诱导气管插管最低肺泡有效浓度(MAC)的影响.方法 择期全麻患儿126例,年龄3～8岁,ASAⅠ或Ⅱ级,随机分为4组,对照组(C组,n=30);R1组(n=30)、R2组(n=30)和R3组(n=36)瑞芬太尼血浆靶浓度分别为1、2、3 ng/ml.均吸入5%七氟烷行麻醉诱导,睫毛反射消失后鼻腔置入导管连接气体分析仪,建立静脉通路,注射阿托品0.01 mg/kg,R1-3 组靶控输注瑞芬太尼.C组注射阿托品、R1-3组瑞芬太尼血浆浓度与效应室浓度达平衡后,采用改良序贯法进行试验,初始呼气末七氟烷浓度均为3.0%,相邻浓度比值为1.2,七氟烷呼气末浓度达到预定值并维持10 min后行气管插管.气管插管条件满意的标准:气管插管条件评分为6分.计算每组七氟烷MAC,并观察不良反应的发生情况.结果 C组、R1-3组患儿吸入七氟烷诱导气管插管的MAC分别为5%、3%、2%、1%,依次降低(P<0.01);所有患儿均无心动过缓、低血压等发生,R2组3例、R3组8例患儿因下颌松弛度差致喉镜无法置人或声门关闭,静脉注射罗库溴铵完成气管插管.结论 瑞芬太尼1 ng/ml可降低患儿吸入七氟烷诱导气管插管的最低肺泡有效浓度,且不良反应少.     

锁骨下静脉塌陷指数对剖宫产产妇腰麻后低血压的预测价值

目的探讨超声测量锁骨下静脉直径(dSCV)及锁骨下静脉塌陷指数(SCV-CI)对剖宫产产妇腰麻后低血压的预测价值。方法纳入择期剖宫产单胎产妇101例,年龄18～40岁,ASAⅠ或Ⅱ级,孕37～42周。于腰麻前后采用超声测量最大dSCV (dSCVmax)和SCV-CI。根据产妇腰麻后是否发生低血压分为两组:未发生低血压组(N组)和发生低血压组(H组)。采用Pearson相关分析dSCVmax、SCV-CI与腰麻后低血压之间的关系,并采用受试者工作特征(ROC)曲线评价dSCVmax、SCV-CI对腰麻后低血压的预测价值。结果腰麻后有44例(43.6%)产妇发生低血压。与N组比较,H组腰麻前后dSCVmax明显降低,SCV-CI明显升高(P0.01)。腰麻前后dSCVmax预测腰麻后低血压的ROC曲线下面积(AUC)分别为0.806、0.903,临界值分别为8.0 cm、6.5 cm,敏感性分别为80.84%、75.00%,特异性分别为57.89%、94.74%(P0.01)。腰麻前后SCV-CI预测腰麻后低血压的AUC分别为0.871、0.914,临界值分别为38.24%、37.68%,敏感性分别为70.45%、93.18%,特异性分别为96.49%、98.25%(P0.01)。结论腰麻前和腰麻后SCV-CI在预测剖宫产产妇腰麻后低血压具有一定价值,且腰麻后SCV-CI更具有临床意义。     

2015年乳腺癌辅助化疗进展

【摘要】〓乳腺癌是危害我国女性健康的头号杀手,尽管近年来辅助化疗的研究进展突飞猛进,但临床中仍有不少问题未能明确,如辅助化疗的合适人群、化疗的开始时间、蒽环及紫杉类的地位和用法、强化维持治疗的作用、疗效及预后的生物标志物等。本文结合乳腺癌辅助化疗在临床上的常见问题和2015年各大乳腺癌会议阐述乳腺癌辅助化疗的最新进展。     

Alterations in T-Cell Subset Frequency in Peripheral Blood in Obesity

Background: Obesity affects the regulation of immune and inflammatory responses. This study characterizes differences in peripheral blood lymphocyte phenotype in obese humans. Methods: Frequencies of lymphocyte subsets among peripheral blood mononuclear cells were compared between 10 obese (BMI ≥35) and 10 lean subjects, as determined by antibodies directed against cluster differentiation (CD) markers. Results: Obese patients demonstrated an increased frequency of CD3+CD4+ T-cells (mean difference 12%, P=0.004), a decreased frequency of CD3+CD8+ T-cells (mean difference 9.4%, P=0.016) and an increased frequency of CD3+CD8+CD95+ T-cells (mean difference 13.3%, P=0.032). No other differences among T-cell or monocyte subsets were noted. Conclusions: Obesity is associated with alterations in frequencies of peripheral CD4+ and CD8+ T-cells and aberrations in the expression of CD95 among CD8+ T-cells. These data suggest both CD4+ and CD8+ T-cell compartments, as well as the regulation of CD95 expression on CD8+ T-cells, as targets for further study into obesity's effects on the immune system.     

西宁地区烧伤病人动脉血气分析观察

对高海拔地区的27例烧伤病人动脉血气变化进行了分析和观察。结果证明:无论是存活病人还是死亡病人伤后均存在有低氧血症问题。并且在死亡病人和烧伤合并吸入性损伤病人其低氧血症的发生早于单纯烧伤病人。提示:吸入性损伤病人应立即行气管切开术以保障氧气供给,单纯烧伤病人可常规吸氧以维持正常血 PaO_2,ARDS 均发生在合并吸入性损伤的病人,高频喷射通气技术对纠正低氧血症有一定效果。     

Controversies in Fistula in Ano

Managing a complex fistula in ano can be a daunting task for most surgeons; largely due to the two major dreaded complications—recurrence & fecal incontinence. It is important to understand the anatomy of the anal sphincters & the aetiopathological process of the disease to provide better patient care. There are quite a few controversies associated with fistula in ano & its management, which compound the difficulty in treating fistula in ano. This article attempts to clear some of those major controversies.     

β-半乳糖苷酶在体内外成骨细胞中的表达

目的 研究β—半乳糖苷酶(β—gal)在成骨细胞中的表达状况，为阐明MorquioB综合征的发病机制提供依据。方法 裸鼠各器官和骨组织标本行X-gal染色检测。抽取羊和人骨髓行骨髓基质细胞(BMSCs)培养，分为4组：I：Adv-hBMP-2转染组；Ⅱ：Adv—β—gal转染组；Ⅲ：未转染组；Ⅳ：地塞米松诱导组。分别行X-gal染色和RT-PCR检测β—gal的表达。结果 裸鼠骺板两侧、骨膜内面及松质骨的成骨细胞和破骨细胞可见多量β—gal的表达。未转染BMSCs组有少量β—gal的表达，其他3组细胞的β—gal表达增高。结论成骨细胞和破骨细胞可表达多量β—gal，该两种细胞的β—gal缺乏可能是MorquioB综合征骨骼异常的直接原因。     

Smoking-Attributable mortality in Spain in 2016

IntroductionSmoking-attributable mortality (SAM) is a valuable indicator that can be used to characterize the course and health burden of the smoking epidemic. The aim of this paper was to estimate SAM in Spain in 2016 in the population aged 35 and over, using the best available evidence.MethodsA smoking prevalence-dependent analysis based on the estimation of population-attributable fractions was performed. Smoking prevalence (never, former, and current smokers) was calculated from a combination of the Spanish Health Survey (2016) and the European Health Survey (2014); the relative risk of death among current and former smokers was taken from the follow-up of various cohorts; and mortality rates were obtained from National Center for Statistics data. SAM estimates are presented globally, and by sex, age groups, and major disease categories: cancer, cardiometabolic diseases and respiratory diseases.ResultsIn 2016, 56,124 deaths were attributed to tobacco consumption, 84% in men (47,000), and 50% in the population aged over 74 (27,795). Overall, 50% of SAM was due to cancer (28,281), 65% of which was lung cancer. One in 4 attributable deaths (13,849) occurred before the age of 65.ConclusionsOne in 7 deaths in Spain in 2016 were attributable to smoking. This estimation of SAM clearly highlights the great impact of smoking on mortality in Spain, mainly due to lung cancer and chronic obstructive pulmonary disease.     

MicroRNAs in hepatic pathophysiology in diabetes

MicroRNAs(miRNAs or miRs) are small approximately 22 nucleotide RNA species that are believed to regulate diverse metabolic and physiological processes.In the recent past,several reports have surfaced that demonstrate the role of miRNAs in various biological processes and numerous disease states.For a disease as complex as diabetes,the emergence of miRNAs as key regulators leading to the disease phenotype has added a novel dimension to the area of diabetes research.On the other hand,the liver,a metabolic hub,contributes in a major way towards maintaining normal glucose levels in the body as it can both stimulate and inhibit hepatic glucose output.This equilibrium is frequently disturbed in diabetes and hence,the liver assumes special significance considering the correlation between altered hepatic physiology and diabetes.While the understanding of the mechanisms behind this altered hepatic behavior is not yet completely understood,recent reports on the status and role of miRNAs in the diabetic liver have further added to the complexities of the knowledge of hepatic pathophysiology in diabetes.Here,we bring together the various miRNAs that play a role in the altered hepatic behavior during diabetes.     

Fluid-phase transcytosis in the primate epididymis in vitro and in vivo

Ligated tubules from the corpus epididymidis of men and monkeys were incubated in medium containing horseradish peroxidase (HRP) as a marker for fluid-phase endocytosis. HRP was localized by light and electron microscopy after 0, 15, 30 and 60 min of incubation. Movement between the cells was prevented by tight junctions, but bypass of this barrier was apparently achieved by an intracellular vesicular mechanism leading to a time-dependent appearance of HRP in the lumen. Uptake of HRP into basal cells and capture by the lysosomal apparatus of principal cells were also observed. HRP-filled vesicles also appeared in the basal, mid and apical cytoplasm of epithelial cells in the caput 1 h after injection of the tracer into the epididymal circulation of the monkey, suggesting that this pathway also operates in vivo.