46例经皮球囊肺动脉瓣成形术后患儿运动功能的研究

目的经皮球囊肺动脉瓣成形术（percutaneous balloon pulmonary valvuloplasty,PBPV）已成为治疗肺动脉瓣狭窄的首选方法,本研究旨在应用平板运动试验观察PBPV后患儿运动耐量和运动心率、血压反应以及心电图变化,探讨相关因素对远期预后的影响。方法46例经皮球囊肺动脉瓣成形术后患儿采用Bruce方案进行平板运动试验,观察其运动耐量和运动心率、血压反应以及心电图变化。同期对294例健康儿童进行平板运动试验,测定各年龄组运动耐量均值,并从中随机选取46例年龄、性别相仿的儿童作为正常对照组。结果PBPV后患儿跨肺动脉瓣压差稳定在25mmHg（1mmHg=0．133kPa）以下,平均运动耐量可达正常同龄标准的90％左右,且运动所能达到的负荷量与PBPV前跨瓣压差无明显相关性。运动心率、血压反应正常。运动功能与术时年龄、PBPV所选用的球囊／瓣膜比值有关。5例患儿运动试验诱发室性心律失常,均为偶发室性早搏,运动试验过程中无一例出现ST段异常变化。结论早期解除右室流出道梗阻有利于远期运动功能的改善。PBPV时采用适度的球囊／瓣膜比值（1．2～1．4）值得推荐。但对于术后发生的肺动脉瓣反流仍应长期随访观察。     

法洛四联症根治术后远期肺动脉返流问题及处理对策

法洛四联症(tetralogy of Fallot，TOF)根治术临床应用至今已40余年，在术后远期并发症中，右室功能不全、运动能力下降、心律失常性猝死是不容忽视的问题，而以上并发症都与手术中的一个重要环节——肺动脉狭窄的解除、右室-肺动脉流出道的重建有密切关系。经典的右室流出道重建方式在远期发生肺动脉返流(pulmonary regurgitation，PR)的比率很高，对患者的远期预后产生许多不利影响。本文就TOF根治术后远期PR的后果及如何最大限度地减少PR的问题作一综述。     

法洛四联症根治术后远期肺动脉返流问题及处理对策

法洛四联症(tetralogy of Fallot,TOF)根治术临床应用至今已40余年,在术后远期并发症中,右室功能不全、运动能力下降、心律失常性猝死是不容忽视的问题[1],而以上并发症都与手术中的一个重要环节--肺动脉狭窄的解除、右室-肺动脉流出道的重建有密切关系.经典的右室流出道重建方式在远期发生肺动脉返流(pulmonary regurgitation,PR)的比率很高,对患者的远期预后产生许多不利影响.本文就TOF根治术后远期PR的后果及如何最大限度地减少PR的问题作一综述.     

婴幼儿法洛四联症1期根治术时机选择

目的:评价婴幼儿法洛四联症(TOF)早期根治术后效果。方法:2002年1月至2006年6月,我科共手术治疗<36个月婴幼儿TOF 87例,年龄(2~36)个月,平均(17.2±5.6)个月:<6个月14例(16.1%)、7~12个月34例(39.1%)、13~36个月39例(44.8%)。比较不同年龄组手术病死率、围手术期处理、术后并发症及随访结果。结果:2例(2.3%)死于术后低心排出量综合征,1例(1.2%)死于术后心律失常。不同年龄组术后并发症差异无统计学意义。术后6个月以下患儿更多需要升压药维持,但术后呼吸机通气时间、ICU停留时间、住院时间差异无统计学意义。回访时间2.0~6.0年,平均(3.5±1.6)年,56例(66.7%)例患儿存在不同程度肺动脉瓣反流,2例(2.3%)残余右心室流出道梗阻,3例(3.4%)室缺残余分流再次手术矫治。结论:对<6个月婴儿TOF一期根治手术病死率和术后并发症低,手术年龄不影响术后效果。     

右外侧小切口剖胸行婴幼儿法洛四联症根治术治疗体会

目的:总结0～3岁婴幼儿经右外侧小切口剖胸行法洛四联症(TOF)根治手术的结果及治疗体会。方法:回顾性分析2011年1月至2011年12月完成的0～3岁TOF根治术142例,经右外侧小切口剖胸进行的TOF根治术47例,经正中剖胸进行的TOF根治术95例,对比2组患儿的术前血氧饱和度、血红蛋白、McGoon比值,术中体外循环时间和主动脉阻断时间以及术后当日胸腔引流量、左心房压、正性肌力药物评分、呼吸机使用时间,监护室停留时间和术后住院时间。结果:经右外侧小切口剖胸进行的TOF根治术47例,其中跨环补片15例(占32%)。本组平均年龄(13.34±6.41)个月(5～34个月),平均体质量(9.58±1.17)kg(6～14 kg),术前血氧饱和度(87.57±9.02)%(69%～99%),McGoon比值2.06±0.48(1.11～3.36),术中体外循环时间(95.95±26.31)min(40～170 min),主动脉阻断时间(67.95±17.57)min(30～117 min),术后当日胸腔引流量(10～850 mL),中位数胸腔引流量110(80,167)mL,左心房压(9.19±2.12)mmHg(3～14 mmHg),正性肌力药物评分8.57±3.97(2～19),呼吸机使用时间(4～165 h),中位数呼吸机使用时间21.5(14.2,36.5)h,监护室停留时间(2.86±1.94)d(0～9 d)。术后因胸腔引流过多二次开胸探查2例。残余分流2例(2 mm)。与同期相匹配95例正中剖胸TOF根治术相比,术前临床资料无差异,术中体外循环时间和主动脉阻断时间无差异,术后右外侧小切口剖胸组监护室停留时间明显短于正中剖胸组,正性肌力药物评分及术后左心房压明显低于正中剖胸组。其余各项均与正中剖胸组无差异。结论:在熟练掌握手术技巧,严格手术适应证选择的基础上,右外侧小切口剖胸可以在TOF根治手术中应用。     

肺动脉瓣狭窄合并房间隔缺损的介入治疗

目的　探讨肺动脉瓣狭窄合并房间隔缺损介入治疗的可行性、安全性及其疗效。方法选择临床诊断肺动脉瓣狭窄合并继发孔型房间隔缺损患者 11例 ,其中 ,男性 2例 ,女性 9例 ,年龄 4～38岁 ,平均 (2 2± 11)岁。 1例房水平双向分流和 2例右向左分流。 3例用双叶球囊和 8例用Inoue球囊行肺动脉瓣扩张成形术 ,3例用纽扣式补片和 8例用Amplatzer房间隔缺损封堵器关闭缺损。结果11例患者 10例经 1次导管术得到根治 ,1例肺动脉瓣扩张后诱发右室流出道痉挛 ,延迟 3个月后再行房间隔缺损关闭术成功 ;治疗后右室收缩压 (12 8± 72 )mmHg(1mmHg =0 133kPa)下降到 (5 6± 32 )mmHg(P <0 0 1) ,肺动脉瓣跨瓣压差 (113± 75 )mmHg降至 (2 5± 2 2 )mmHg(P <0 0 1) ,三尖瓣反流面积 (4 6± 2 0 )cm2 降至 (1 4± 0 9)cm2 (P <0 0 1) ,动脉血氧饱和度 0 92± 0 0 4上升到 0 96± 0 0 9(P <0 0 5 )。 3～ 6个月随访 ,有继发右室流出道心肌肥厚者右室压力继续下降到 (4 6± 14)mmHg(P >0 0 5 ) ,术中、术后未出现并发症。结论　先天性肺动脉瓣狭窄合并继发孔型房间隔缺损的法乐三联征介入治疗是可行的及安全的非外科根治方法 ,近期疗效肯定 ,远期效果有待随访。     

经皮腔内冠状动脉成形术对心肌梗塞患者心电图及运动耐量的影响

对23例心肌梗塞(MI)患者于发病后6±3周行经皮腔内冠状动脉成形术(PTCA),并于PTCA前(平均3±2d)、后(平均6±3d)记录心电图和行平板运动试验.结果显示,PTCA成功19例(管腔狭窄由93.5%±6.4%降至16.3%±11.1%).其运动耐量、时间、最大心率及心率与收缩压乘积明显增高,而QRS积分显著减低.提示,PTCA对MI恢复期患者心功能改善具有明显的有益作用.     

冠心病患者平板运动试验运动耐量测定的临床意义

目的对冠心病患者和年龄相当的正常健康人进行运动前、后的运动耐量连续测定并探讨其临床意义.方法应用Bruce方案在Quest型活动平板运动仪上进行次极量或症状限制性平板运动试验.结果(1)两组在运动的前3分钟内运动耐量相差不显著;(2)实验组最大运动耐量(7.01±0.11METs)明显低于对照组的(13.6±0.14METs),P<0.05;(3)多支冠脉病变者运动耐量<6.5METs.结论随着病情加重,冠心病患者运动耐量下降,运动耐量低于6.5METs时,可能有多支冠脉病变.     

法乐四联症完全矫治术后影响心室大小恢复状况的因素

本文应用多普勒超声心动图随访法乐四联症完全矫治术后1～10年的患者63例。探讨法乐四联症畸形特点等对其远期予后的影响。结果认为:木前肺动脉分支发育好者的右室与左室内径比值(RVD/LVD)为0.98±0.19,肺动脉分支发育不好者为1.071±0.14,P<0.01,说明肺动脉发育是影响远期予后的主要因素。手术后长期存在的肺动脉瓣返流,(RVD/LVD 1.093±0.17对0.990±0.15,P<0.05),三尖瓣返流(RVD/LVD 1.153±0.12对1.013±0.13,P<0.01)亦影响手术远期心室大小的恢复。相反。手术前室缺的大小、部位,肺动脉瓣狭窄的程度、部位等对远期心室大小的恢复无明显影响。     

婴幼儿法乐四联症的外科治疗(附102例报告)

近年来 ,法乐四联症 (TOF)的外科治疗方法发生了较大变化 ,一期根治术逐渐取代了早期 TOF姑息性手术。 1 995～ 2 0 0 2年 ,我们对 1 0 2例 TOF患儿行一期根治术治疗 ,现报告如下。1　资料与方法1 .1　临床资料　本组男 6 9例 ,女 3 3例 ;年龄 4～ 3 5个月 ,平均 (1 6± 6 .2 )个月 ;体重 4.5～ 1 4kg,平均(8.9± 2 .8) kg。患儿均有不同程度紫绀 ,3 2例(3 4 .78% )曾发生过 1～ 7次晕厥。血细胞压积 0 .4～0 .86 ,平均 (0 .5 3± 0 .1 2 ) ;心电图均示右心室肥大 ;X线胸片示靴型心 ,心胸比率 0 .3 9～ 0 .5 4 ,均有肺血减少 ;超声心动…     

胰岛素瘤的解剖分布特点分析

目的胰岛素瘤是最常见的胰腺神经内分泌肿瘤，因其临床表现多样，导致诊断困难。影像学诊断尤其是超声内镜(EUS)在胰岛素瘤的诊断中起着重要作用，拥有较高的敏感性和特异性。本研究拟通过明确胰岛素瘤的解剖分布特点，以期有助于提高影像学的诊断准确率和降低漏诊率，尤其是在教育和培训实践中对于EUS的学习者更具有指导价值。 方法回顾性分析解放军总医院第一医学中心病案资料数据库1993年1月至2019年11月经外科手术、病理确诊为胰岛素瘤的患者的临床资料，检索方法采取搜索术后病理诊断为"胰岛素瘤"的病例，通过查阅病例的方法，提取出胰岛素瘤的大小和解剖分布等数据，进一步分析其特点。 结果共检索到确诊为胰岛素瘤的患者116例，其中，男45例、女71例，年龄13～76岁，平均年龄(44.4±14.85)岁。胰岛素瘤单发110例(94.8%)、多发6例(5.2%)。位置分布：头颈部46例(39.7%)，单发45例、多发1例；体尾部68例(58.6%)，单发65例、多发3例；全胰腺多发2例(1.7%)。病变大小特点：最大径0.4～3.4 cm，平均大小(1.53±0.58)cm。≤1 cm 29例、>1 cm而≤1.5 cm41例、>1.5 cm而≤2.0 cm28例，≤3 cm 15例，>3 cm 3例。年龄与肿瘤的大小相关，≤44岁患者肿瘤平均大小为(1.36±0.51)cm、>44岁患者肿瘤平均大小为(1.70±0.60)cm，P<0.05。头颈部的肿瘤大于体尾部的肿瘤，头颈部肿瘤平均大小(1.66±0.63)cm，体尾部(1.42±0.52)cm，P<0.05。 结论胰岛素瘤在胰腺体尾部较头颈部更好发；绝大多数单发，但可以全胰腺多发；多数小于1.5 cm，肿瘤的大小与患者年龄和肿瘤的解剖分布相关。     

Pathogenesis of carcinoma of the papilla of Vater

Most adenomas and carcinomas of the small intestine and extrahepatic bile ducts arise in the region of the papilla of Vater. In familial adenomatous polyposis (FAP) it is the main location for carcinomas after proctocolectomy. In many cases symptoms due to stenosis lead to diagnosis at an early tumor stage. In about 80%, curative intended resection is possible. Operability is the most relevant prognostic factor. Most ampullary carcinomas resp. carcinomas of the papilla of Vater develop from adenomatous or flat dysplastic precursor lesions. They can be sited in the ampulloduodenal part of the papilla of Vater, which is lined by intestinal mucosa. They also can develop in deeper parts of the ampulla, which are lined by pancreaticobiliary duct mucosa. Intestinal-type adenocarcinoma and pancreaticobiliary-type adenocarcinoma represent the main histological types of ampullary carcinoma. Furthermore, there exist unusual types and undifferentiated carcinomas. Many carcinomas of intestinal type express the immunohistochemical marker profile of intestinal mucosa (keratin 7?, keratin 20+, MUC2+). Carcinomas of pancreaticobiliary type usually show the immunohistochemical profile of pancreaticobiliary duct mucosa (keratin 7+, keratin 20?, MUC2?). Even poorly differentiated carcinomas, as well as unusual histological types, may conserve the marker profile of the mucosa they developed from. These findings underline the concept of histogenetically different carcinomas of the papilla of Vater which develop either from intestinal- or from pancreaticobiliary-type mucosa of the papilla of Vater. Molecular alterations in ampullary carcinomas are similar to those of colorectal as well as pancreatic carcinomas, although they appear at different frequencies. In future studies, molecular alterations in ampullary carcinomas should be correlated closely with the different histologic tumor types. Consequently, the histologic classification should reflect the histogenesis of ampullary tumors from the two different types of papillary mucosa.     

Demonstration of the mechanism of action of biguanides

Summary Palmitic acid oxidation in rat diaphragm homogenate is depressed by biguanide concentrations that are still incapable of inhibiting oxidative phosphorylation. Glucose oxidation is not directly effected by the same biguanide concentrations: however, the inhibitory effect of palmitic acid on glucose oxidation is partly removed by biguanides. Inhibition of fatty acid oxidation, which accounts for most of the metabolic effects caused by these drugs, can be regarded as the fundamental mechanism of action of biguanides. There is some evidence suggesting that these drugs might interact with carnitine, thus preventing long-chain fatty acids from being transported across the mitochondrial membrane to the site of oxidation. Traduzione a cura degli AA.     

Lack of correlation of degree of villous atrophy with severity of clinical presentation of coeliac disease

BACKGROUND AND AIM: Both the clinical presentation and the degree of mucosal damage in coeliac disease vary greatly. In view of conflicting information as to whether the mode of presentation correlates with the degree of villous atrophy, we reviewed a large cohort of patients with coeliac disease. PATIENTS AND METHODS: We correlated mode of presentation (classical, diarrhoea predominant or atypical/silent) with histology of duodenal biopsies and examined their trends over time. RESULTS: The cohort consisted of 499 adults, mean age 44.1 years, 68% females. The majority had silent coeliac disease (56%) and total villous atrophy (65%). There was no correlation of mode of presentation with the degree of villous atrophy (p=0.25). Sixty-eight percent of females and 58% of males had a severe villous atrophy (p=0.052). There was a significant trend over time for a greater proportion of patients presenting as atypical/silent coeliac disease and having partial villous atrophy, though the majority still had total villous atrophy. CONCLUSIONS: Among our patients the degree of villous atrophy in duodenal biopsies did not correlate with the mode of presentation, indicating that factors other than the degree of villous atrophy must account for diarrhoea in coeliac disease.     

血吸虫童虫生长发育及其机制的研究进展

血吸虫童虫是宿主免疫系统攻击的重要靶标,包括皮肤型、肺型和肝门型童虫。宿主分子对童虫生长发育具有重要作用。童虫生长发育机制包括免疫调节、信号转导、性别发育及凋亡等。肌动蛋白、组织蛋白酶、烯醇化酶和葡萄糖基转移酶等分子为血吸虫童虫生长发育的重要分子。本文对血吸虫童虫生长发育及其机制的研究进展做一综述。     

124例耐多药结核分枝杆菌基因突变特征分析

目的对临床分离的耐多药结核分枝杆菌相关基因的突变特征进行分析。方法对124例耐多药结核分枝杆菌以及50株敏感株的耐药相关基因(包括异烟肼inh A、kat G、oxyR-ahp C间隔区以及利福平rpo B)进行序列测定,分析其基因突变情况。结果异烟肼耐药inh A基因突变率为14.5%;kat G基因突变率为70.2%(87/124),主要位于315位;oxyR-ahp C间隔区突变率为15.3%;inh A、kat G两种基因同时突变率75.0%,三种基因同时突变率为89.5%。利福平rpo B基因突变的检出率高达95.2%,突变主要发生在531、526、516位点。结论我省耐多药菌异烟肼耐药相关基因最常见突变为kat G 315、inh A C-T(-15)、axyR-ahp C间隔区(-10)C-T,利福平为rpo B531、526、516。结合MDR-TB耐药相关基因的特征分析,可以建立一种快速、准确、特异的适合于我省的检测结核菌耐多药性的新方法。     

氯硝柳胺悬浮剂的毒性评价

目的评价氯硝柳胺悬浮剂的毒性，为现场大规模应用灭螺提供依据。方法按照中华人民共和国国家标准GB 15670-1995《农药登记毒理学试验方法》和鱼类毒性试验方法进行。结果经口、经皮肤的LDso雌、雄性大鼠均>5 000 mg/kg，经呼吸道的LCso雌、雄性大鼠均>5 000mg/m3，该药经口、经皮肤、经呼吸道毒性均属微毒类药物；兔眼用药后，观察期内无不良反应，对眼无刺激性；皮肤用药后对皮肤无刺激性。与氯硝柳胺原药、氯硝柳胺乙醇胺盐原药和氯硝柳胺乙醇胺盐可湿性粉剂相比，氯硝柳胺悬浮剂对鱼急性毒性最低。结论氯硝柳胺悬浮剂属微毒类药物，对鱼的毒性低于其乙醇胺盐可湿性粉剂，适合于现场应用。     

Assessment of quality of life of parents of children with juvenile chronic arthritis

The aim of the study was to assess the quality of life (QOL) and the psychological status of parents of children with juvenile chronic arthritis (JCA). The QOL, anxiety and depression of the parents of 28 children with JCA were evaluated and compared to those of the parents of 28 healthy children. Mothers of JCA children and mothers of healthy children reported similar QOL. The reported anxiety and depression levels were similar for mothers and fathers in both groups. The parents of children with pauciarticular-type JCA reported lower QOL and higher levels of anxiety and depression than the parents of children with other types, namely polyarticular and systemic JCA. These findings may be explained by the fact that the pauciarticular patients had shorter disease duration and were less frequently seen in the outpatient clinic. The QOL of mothers of children with JCA was found to be slightly impaired in the group of children with pauciarticular JCA. Future larger studies are needed to confirm these results, as the number of subjects in the three groups was rather low. Received: 26 September 2001 / Accepted: 8 February 2002     

Numerical Simulation of the Effect of Rate of Change of Glucose on Measurement Error of Continuous Glucose Monitors

Background

A 5-day in-patient study designed to assess the accuracy of the FreeStyle Navigator® Continuous Glucose Monitoring System revealed that the level of accuracy of the continuous sensor measurements was dependent on the rate of glucose change. When the absolute rate of change was less than 1 mg•dl⁻¹•min⁻¹ (75% of the time), the median absolute relative difference (ARD) was 8.5%, with 85% of all points falling within the A zone of the Clarke error grid. When the absolute rate of change was greater than 2 mg•dl⁻¹•min⁻¹ (8% of the time), the median ARD was 17.5%, with 59% of all points falling within the Clarke A zone.

Method

Numerical simulations were performed to investigate effects of the rate of change of glucose on sensor measurement error. This approach enabled physiologically relevant distributions of glucose values to be reordered to explore the effect of different glucose rate-of-change distributions on apparent sensor accuracy.

Results

The physiological lag between blood and interstitial fluid glucose levels is sufficient to account for the observed difference in sensor accuracy between periods of stable glucose and periods of rapidly changing glucose.

Conclusions

The role of physiological lag on the apparent decrease in sensor accuracy at high glucose rates of change has implications for clinical study design, regulatory review of continuous glucose sensors, and development of performance standards for this new technology. This work demonstrates the difficulty in comparing accuracy measures between different clinical studies and highlights the need for studies to include both relevant glucose distributions and relevant glucose rate-of-change distributions.     

治疗高血压药物的经济学评价

重视高血压治疗中的经济学评价,对利用我国有限的卫生资源来遏制高血压对人民群众的危害有着重要的现实意义。药物经济学对于药物治疗的成本和治疗的结果给予同样的关注。因为治疗高血压的费用,不仅涉及药物价格,还包括患者的危险水平,降压疗效和对临床终点事件的影响,以及治疗的依从性和安全性。因此药物经济学更强调整体成本和价-效比。低危病人,若非药价低廉,治疗的价-效比不够理想。而在高危的患者,价-效比越小越经济而不是药费越便宜越好。