残角子宫35例临床分析

目的提高对残角子宫临床特点、诊断及处理的认识。方法对2004年1月至2014年1月北京协和医院收治的35例经手术确诊的残角子宫患者的临床资料进行回顾性分析。结果 (1)35例患者中IIa型3例(8.6%),IIb型22例(62.9%),IIc型8例(22.9%),无IId型,分型不详2例(5.7%);临床表现为痛经者24例(68.5%),不孕者6例(17.1%),12例合并子宫内膜异位症(34.3%),12例合并泌尿生殖系统畸形(34.3%)。(2)所有患者术前均行超声检查,提示为残角子宫12例,双子宫5例,畸形子宫3例,未见异常15例;其中13例患者术前同时行核磁共振检查,提示为残角子宫5例,双子宫4例,纵隔子宫1例,畸形子宫1例,未见异常2例,与超声诊断基本符合,超声及核磁共振与手术诊断符合率均为38.5%(5/13)(P0.05);7例术前行子宫输卵管造影,双侧输卵管未显影1例,单侧未显影4例,双侧正常2例。(3)非妊娠时诊断者23例,妊娠时诊断者12例(其中4例为残角子宫妊娠)。(4)手术切除残角子宫共25例,其中腹腔镜16例,开腹9例。结论残角子宫的诊断和分型是治疗的依据,超声及核磁共振检查有助于残角子宫的诊断,子宫输卵管碘油造影有助于判断其分型,宫腹腔镜联合手术诊治残角子宫具有良好效果。     

糖尿病合并肾脏损害患者肾活检的临床意义

糖尿病肾脏疾病(DKD)是导致慢性肾衰竭的主要原因,其中2型糖尿病所致的肾脏病变占绝大多数。肾活检病理检查是诊断的"金标准",对患者治疗方案的选择及预后判断具有重要价值,对新药的开发具有重要意义,也是DKD流行病学调查、确定临床病理联系和开发无创诊断方法的重要依据。因此,对糖尿病尤其是2型糖尿病合并肾脏损害的患者积极开展肾活检病理检查具有重要的临床意义。     

Clinical analysis of fluid resuscitation in severe burned patients with or without inhalation injury]

The amount of fluid resuscitation, estimated according to crystal-colloid for formula, were retrospectively studied in 55 cases of severe burned patients with or without inhalation injury. These cases were divided into two groups. One group consisted of patients with inhalation injury, while the another there was no inhalation injury. The result showed that patients in the former required 13.5% additional amount of fluids over the latter in the first 24 hours postburn, and this amount was mainly due to the additional requirement in the first 8 hour period. We propose that the amount required in severe burned patients with inhalation injury in the first 24 hours postburn should be appropriately increased, and special attention should be paid to the harmful effect of inadequate fluid resuscitation in the first 8 hour period. The amount of fluids required for resuscitation in severe burned patients with inhalation injury, as estimated according to crystal-colloid formula, should be increased by 13.5% in the first 24 hours, and 2/3 of the addition amount should be given in the first 8 hours, with 1/3 of it in the second and third 8 hours postburn.     

200例医院获得性急性肾损伤病例临床分析

目的 探讨医院获得性急性肾损伤（Hospital-Acquired acute kidney injure,HA-AKI）的致病因素、高危因素及治疗方法,以改善HA-AKI患者预后.方法 回顾性分析200例（老年组120例,非老年组80例）HA-AKI患者的临床资料,对比分析两组患者的病因、高危因素、治疗方法及预后.结果 两组HA-AKI致病因素明显不同,且存在多种危险因素,老年组以未及时控制的原发病或慢性肾脏病基础急性加重（32％）、药物损伤（30％）、低血容量（25％）为主.非老年组以手术损伤（29、4％）、其他（29％）为主.非老年组肾损伤程度显著低于老年组（P＜0.05）;非老年组合并原发慢性病的百分率低于非老年组（P＜0.05）;老年组存在多器官功能障碍综合征（MODS）者显著高于非老年组（P＜0.05）;老年组需要肾脏替代治疗组显著高于非老年组（P＜0.05）;非老年组的预后显著好于老年组（P＜0.05）.结论 临床上HA-AKI非常多见,且逐渐增多,早期诊断和干预HA-AKI,可明显改善患者的预后和生活质量.     

Clinical analysis of 16 patients with brachial plexus injury

Brachial plexus injury is very rare in neurosurgical practice, so many neurosurgeons have never experienced this problem in Japan. This study describes a clinical analysis of 16 patients aged 5 to 62 years (mean 32.9 years) who presented at our institution with brachial plexus injuries. Nine patients presented with paralysis and seven with paresis. Head injury was the most common associated injury in eight of 16 patients. Six patients were managed conservatively. All patients with C8-T1 paresis spontaneously recovered to a useful level. Surgery was performed in 10 patients: six neurolysis, two neurotization, and three nerve grafting procedures. All six patients who underwent neurolysis of the brachial plexus attained useful recovery. Four of five patients achieved useful recovery after nerve repair. Nerve grafting achieved a better outcome than neurotization in this study. The difference of outcome was attributed to the graft length. The management of brachial plexus injury is a great challenge, but surgical outcome can be improved if the optimal repair procedure is selected for brachial plexus injury.     

Clinical characteristics of renal damage in patients with accidental hypothermia]

We have investigated the clinical characteristics of renal damage and associated complications of 79 patients with accidental hypothermia whom we encountered over the last 5 years. All patients were male, with an average age of 58.9 +/- 9.2 years. Most of these patients were homeless. Body temperature on admission was 29.3 +/- 3.0 degrees C. The most common clinical manifestations on admission were consciousness disturbance and severe hypotension. Complications, including increase in serum transaminase, alcoholism, pneumonia, liver cirrhosis, sepsis, diabetes mellitus, hypoglycemia, acidosis, and an increased level of serum CPK and amylase were found frequently on admission. Death within 48 hours after admission occurred in 23 cases (the death rate; 23/79 = 29%). Renal damage was found in 36 cases (36/79 = 46%), consisting of acute renal failure (ARF) in 27, and acute on chronic in 6. Urinary diagnostic indices suggested that the etiological factor for ARF was pre-renal, which responded well to passive rewarming and an appropriate fluid replacement therapy, resulting in full recovery in most of the cases (the recovery rate; 25/27 = 93%). Among patients with renal damage, there were no cases requiring dialysis. The present data suggest that accidental hypothermia is a fatal condition with an extremely high death rate. It also is associated with multiple complications including ARF. The main cause for ARF is pre-renal, possibly caused by cold diuresis or dehydration superimposed on the underlying diseases such as alcoholism, diabetes mellitus, liver cirrhosis. Such complications, independent of renal damage, determine the patient's prognosis.     

2型糖尿病患者肾脏损害的临床病理分析

糖尿病肾脏疾病(DKD)是糖尿病常见的三大微血管并发症之一,其主要临床表现为蛋白尿,但大量研究表明2型糖尿病合并蛋白尿并非均为DKD[1].2005年美国糖尿病协会(ADA)[2]和2007年美国肾脏病基金会的"肾脏病生存质量指导"(KDOQI)提出了临床诊断及排除DKD的标准[1].     

Clinical characteristics and prognosis of ANCA-associated vasculitis in patients with renal injury

Objective To investigate the characteristics and outcome of anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) in patients with renal injury. Methods AAV patients with renal injury diagnosed in the Department of Nephrology, Renmin Hospital of Wuhan University, from January 2012 to January 2017 were included into this study. Patients were divided into MPO-ANCA positive and PR3-ANCA positive groups for further study. The clinical characteristics, pathological and laboratory indexes, treatment and prognosis were retrospectively analyzed. Results A total of 68 cases were enrolled, among which 52 cases (76.5%) were MPO-ANCA positive and 16 cases (23.5%) were PR3-ANCA positive, and 41 patients (60.3%) were over 65 years old. The incidences of interstitial lung disease, digestive and nervous system damage in PR3-ANCA positive group were significantly higher than those MPO-ANCA positive group (P＜0.05). There were significant differences of hemoglobin, complement C3, complement C1q, IgE, 24 h urinary protein, erythrocyte sedimentation rate, procalcitonin, BVAS score and eGFR in two groups (P＜0.05). 19 cases had done renal biopsy,among them 14 cases were MPO-ANCA positive and 5 cases were PR3-ANCA positive. Incidence of crescentic necrotizing glomerulonephritis in PR3-ANCA positive group was significantly higher than that in MPO-ANCA positive group, and incidence of diffuse global glomerulosclerosis in MPO-ANCA positive group was significantly higher than that in PR3-ANCA positive group (all P＜0.05). At the median follow-up time of 32 months, the relapse rate at 6 month of MPO-ANCA-positive and PR3-ANCA-positive patients were 46.2% and 75.0%, respectively (P＜0.05). Multivariate logistic regression analysis showed that PR3-ANCA positive, age≥65 years old, baseline eGFR＜30 ml?min-1?(1.73 m2)-1, and combined with pulmonary interstitial lesions were all independent risk factors for relapse. And the incidence of ESRD were 42.3% and 75.0% during the follow-up period and 10 patients (14.7%) died. COX regression analysis showed that patients older than 65 years old, BVAS score≥18 points, eGFR＜30 ml?min-1?(1.73 m2)-1 and complicated with pulmonary interstitial disorders at the onset were independent risk factors causing ESRD or death. Conclusion The PR3-ANCA-positive patients had more severe renal injury than those with MPO-ANCA-positive patients, and the injury of extrarenal organs was more serious, recurrence rate was higher, and the prognosis was worse.     

Clinical analysis on 149 old patients with craniocerebral injury

OBJECTIVE: To study the clinical features of craniocerebral injury (CI) in the aged. METHODS: The data of 149 old patients with CI hospitalized in t he department from July 1991 to May 2000 were studied retrospectively in this study. The causes of injury, traumatic pathology, clinical manifestation and cause s of death were analyzed, too. RESULTS: Automobiles were the main victim-makers, and falls we re the second. And there was no significant difference between the first two kin ds of victim-makers. The patients suffered mainly from cerebral contusion, intracerebral hematomas and subdural hematomas, and relatively fewer from epidural hematomas. The scores of Glasgow Coma Scale (GCS) were related closely to the prognosis when hospitalized or before surgical treatment. The total mortality rate was 37.5% in this study. The main cause of death was brain injury. CONCLUSIONS: The old patients with CI have a high mortality rat e. And the causes of injury, traumatic pathology and clinical manifestation are peculiar in the aged.     

132例动脉粥样硬化性肾动脉狭窄临床分析

目的探讨动脉粥样硬化性肾动脉狭窄(ARAS)患者的临床特点,评价介入治疗和单纯药物治疗对肾功能预后的影响。方法分析本院经肾动脉造影确诊的ARAS患者132例的临床资料。88例单侧ARAS按年龄≤70岁和>70岁分组及按基础GFR≥60 ml／min和GFIR< 60 ml／min分组,比较介入治疗和药物治疗对GFR的影响。44例双侧ARAS按行双侧、单侧、非介入治疗分组,比较3组差异。结果单侧ARAS、年龄≤70岁者,介入治疗1年后GFR变化值优于药物治疗组(P<0．05);基础GFR≥60 ml／min者,介入治疗1年后GFR变化值优于药物治疗组(P<0．05);年龄>70岁,GFR<60 ml／min者,介入治疗与药物治疗相比,GFR变化值无显著性差异。双侧ARAS者双侧介入治疗GFR变化值优于单侧介入,单侧介入优于非介入治疗组。Logistic回归分析示基础GFR≥60 ml／min,进行介入治疗的单侧AKAS者,肾功能(GFR)的预后较好。结论单侧ARAS年龄≤70岁,介入治疗前GFR≥60 ml／min者,介入治疗后肾功能 (GFR)预后较好;年龄大于70岁的患者,介入前应仔细评估,慎重选择介入治疗。     

Effect of exercise on rats with renal injury]

Effect of exercise on rats with renal injury was studied. Nephritis was induced in rats by injection of anti-GBM antibody followed by ligation of a branch of the left renal artery after nephrectomy of the right kidney. Moderate daily treadmill exercise was forced on these experimental rats for ten weeks. Sedentary nephritic rats that received the same treatment described above served as controls. The sedentary nephritic rats suffered progressively increasing proteinuria during the time course of the experiment, whereas the nephritic rats with daily treadmill exercise experienced less proteinuria. Mild proteinuria was induced by daily treadmill exercise forced on non-nephritic rats that had received only nephrectomy of the right kidney, but no NTS injection. Light microscopy and immunofluorescence microscopy revealed severe glomerular injury in the sedentary nephritic rats, however, less glomerular injury was seen in nephritic rats with treadmill exercise. Serum cholesterol level was higher in the sedentary rats than in the rats with daily treadmill exercise. The results suggest that daily exercise by nephritic rats will not aggravate renal injury.     

A case with arteriovenous fistula from renal injury]

We report on a 58-year-old male treated with transcatheter embolization for arteriovenous fistula due to renal injury. The patient was transferred to our hospital on December 10, 1989, with left renal injury and left temporal bone fractures. Enhanced CT revealed parenchymal fracture with peri-renal hematoma in the left kidney. Antibiotics were prescribed to prevent bacterial infection of the injured kidney. Urine cleared and pain in the left loin area disappeared 17 days later. However, on December 28, gross hematuria and pain in the left flank suddenly reappeared. He was given a blood transfusion and was diagnosed with re-bleeding from the injured kidney. Renal angiography performed on January 10, 1990, revealed arteriovenous fistula of the kidney. Transcatheter embolization was done using a metal coil to close the arteriovenous fistula. The patient has had no further problems or complaints. Excretory pyelogram showed no hydronephrosis in the left kidney. TcDMSA renoscintiscan showed a defect in the mid-portion of the kidney. These results suggest that transcatheter embolization can be useful to alleviate arteriovenous fistula in cases of renal injury.     

移植肾丢失患者维持性血液透析的临床分析

目的 探讨移植肾丢失后维持性血液透析患者的治疗策略.方法 选择2013年5月在山西省第二人民医院肾移植透析中心接受维持性血液透析治疗的26例慢性移植肾丢失患者作为移植组,选择同期年龄、性别及透析维持时间相匹配的26例普通透析患者作为对照组.两组患者原发病均以不明原因的慢性肾小球肾炎为主.记录移植组患者移植肾状况,记录两组患者维持性血液透析的治疗情况.两组间计量资料比较采用t检验,率的比较采用x2检验或Fisher精切概率法.结果 移植组再次进入维持性血液透析的中位时间为39个月（1～186个月）,对照组维持性血液透析的中位时间为37个月（1 ～192个月）.移植组患者留存1个移植肾者20例,留存2个移植肾者2例,完全移植肾切除4例.留存移植肾的22例患者中,6例完全停用免疫抑制剂,16例维持小剂量免疫抑制剂.移植组患者再次进入维持性血液透析前,主要表现为不同程度的蛋白尿和/或“爬行肌酐”、重度水肿,血浆白蛋白平均值为（34 ±6） g/L,与对照组比较低蛋白血症程度更严重（t=-2.420,P ＜0.05）;平均血清肌酐（654±272） μmol/L,低于对照组（t=-3.979,P＜0.05）;用MDRD公式计算的肾小球滤过率（GFR）低于对照组（t=2.656,P ＜0.05）,但用血清胱抑素C计算的GFR两组差异无统计学意义（t=1.395,P＞0.05）.至2013年5月,移植组和对照组患者体质量指数分别为（20.1±2.3）kg/m2和（22.6±4.2）kg/m2,血浆白蛋白分别为（41 ±6） g/L和（45 ±4） g/L,两组比较差异均有统计学意义（t=-2.645和-2.512,P均＜0.05）.与对照组比较,移植组血红蛋白水平较低,促红细胞生成素（EPO）用量和EPO抵抗指数（ERI）较高.移植组和对照组血红蛋白分别为（100±17） g/L和（115 ±18） g/L,血红蛋白达标的患者分别为9例和17例,两组差异均有统计学意义（t=-3.028,x2=4.923,P均＜0.05）;平均每周EPO用量?     

抗磷脂综合征并发急性肾衰竭22例临床分析

抗磷脂综合征(APS)是指临床表现为反复的动脉和(或)静脉血栓形成、自发性流产和血小板减少症,并伴有狼疮抗凝物(LA)和(或)抗磷脂抗体(APL)阳性的综合征~([1]).我们曾报道过91例APS患者的肾脏损害~([2]).APS引起急性肾衰竭(ARF)临床少见,其主要病因包括肾动脉或肾静脉血栓形成、血栓性微血管病~([3]),其他罕见情况包括肾皮质坏死~([4]).有关APS并发ARF的文献报道国内罕见.我们收集了本院22例APS并发ARF患者的临床资料,分析其临床特点、治疗以及预后情况,以增进对该疾病诊治的认识.     

Clinical study of parathyroidectomy of secondary hyperparathyroidism in patients with chronic renal failure]

We performed parathyroidectomy for renal osteodystrophy due to secondary hyperparathyroidism on 16 patients with chronic renal failure who were refractory to medical management; subtotal parathyroidectomy on one patient and total parathyroidectomy with autotransplantation on 15 patients. Postoperative clinical improvement, i.e., bone and/or joint pain, pruritus and radiographic signs of renal osteodystrophy, was marked. After the operation, serum calcium decreased rapidly and adequate calcium replacement therapy was necessary. The levels of intact parathyroid hormone decreased rapidly and serum concentration of alkaline phosphatase gradually decreased for a few months postoperatively. Recurrence was diagnosed in one patient, who underwent excision of the transplanted parathyroid tissue. Osteomalasia due to hypoparathyroidism was not seen clinically in this series. In preoperative image diagnosis, ultrasonotomogram (US) showed the highest detective rate of the enlarged parathyroid glands. However, combination of US, computerized tomography and 99mTcO4(-)-201T1C1 scintigram can be recommended as a localizing diagnostic method for compensating the disadvantages of each method. Clinical results after parathyroidectomy for secondary hyperparathyroidism are considered to be good. However, long-term followup is mandatory for early detection of persistent hyperparathyroidism or hypoparathyroidism.     

高龄维持性血液透析患者的临床分析

目的 评估高龄肾衰竭患者维持性血液透析（maintenance hemodialysis,MHD）的临床特点.方法 分析82例高龄肾衰竭患者（高龄组）行血液透析治疗前基线情况,包括血压、体质量指数、血红蛋白（haemoglobin,Hb）、尿素氮（BUN）、血肌酐（SCr）、血白蛋白（serum albumin,Alb）;同期进行血液透析治疗的156例非高龄患者设为对照组,定期监测2组患者透析阶段一般治疗情况、透析充分性、血红蛋白（haemoglobin,Hb）、血白蛋白（serum albumin,Alb）、甲状旁腺素、C反应蛋白、心功能测定、营养状况等,透析中合并症和治疗阶段心脑血管并发症的发生情况,统计分析高龄透析患者临床治疗特点.通过生存率和死亡原因分析,总结影响高龄患者透析生存质量的主要因素.结果 高龄组与对照组相比,病因以继发性（高血压、糖尿病）为主、整个透析阶段Alb和SGA低于对照组（P＜0.05）,Kt/V值低于对照组（P＜0.05）、心功能指标左心室舒张末内径、左心室射血分数低于对照组（P＜0.05）,透析中并发症发生率（40.8％）高于对照组（29.3％）,死亡原因1年内主要为脑血管意外及心血管疾病,超过1年的死亡原因主要为脑血管意外、感染、心血管疾病及严重营养不良,比较不同生存时间（3年以内和超过3年）的临床特征,影响高龄患者生存率的主要因素是糖尿病、低血压、透析前SCr水平高,Kt/V值不达标,贫血,营养不良.增加透析频次,联合采用血液透析滤过（hemodiafiltration,HDF）、血液灌流（hemoperfusion,HP）组合治疗有助于延长透析存活时间.结论 高龄MHD患者营养不良较为普遍,并伴随贫血程度重,心功能差,易感染,从而导致了患者并发症、合并症的发生率增加,生存时间减少,通过改善营养、纠正贫血、采取个体化的透析方案,组合治疗,可以减少高龄透析患者的并发症,提高生存率.     

危重烧伤合并腹腔间隙综合征的临床诊治特点分析

目的总结危重烧伤合并腹腔间隙综合征(ACS)的临床诊治特点。方法2001年1月—2005年4月笔者单位收治12例特重度烧伤合并ACS的患者,其中3例予以非手术治疗(胃肠减压、肛管排气),4例行腹壁减张,5例开腹减压。统计、分析本组患者的治疗结果。予以腹壁减张或开腹减压术者,监测其术后24 h尿量、膀胱内压、中心静脉压、动脉收缩压、动脉血氧分压(PaO2),并与术前比较。结果本组患者病死率为41．7％,9例手术患者死亡3例。多数患者术前24 h尿量偏少,膀胱内压、中心静脉压、动脉收缩压和PaO2表现异常,手术患者术后各项指标较术前明显好转(P<0．01)。结论危重烧伤合并ACS的患者及时给予腹壁减张和开腹减压是治疗的关键。     

Clinical analysis of seven patients of crushing head injury

BACKGROUND: Crushing head injuries (CHI) are caused by static loading. This static force slowly deforms a cranium and damages some intracranial components. Severe CHI is usually fetal but substantial brain damage may not be recognized in some patients. In this article, we report seven patients who sustained CHI and analyzed clinical and radiological findings. METHODS: In seven patients who sustained CHI, the following factors were analyzed: epidemiological features, neurological findings, and neuroradiological findings. RESULTS: The present series included three males and four females. Mean age was 5.9 years. Six patients had the heads run over by automobiles. One patient had the head crushed by press machine. Epistaxis in six patients and otorrhagia in five patients was recognized. Mean Glasgow coma scale at admission was 8.1. Multiple linear fractures were recognized in four patients and skull base fractures in six patients. Pneumocephalus in five patients and cerebrospinal fluid leakage in seven patients was recognized. One patient underwent evacuation of ASDH and dural plasty. Four patients died and three survived and had only cranial nerve palsies, which recovered completely. CONCLUSION: This injury actually has seldom been countered in daily practice and clinical manifestation and neuroimaging have characteristic features. The prognosis of CHI may be polarized to fatal or excellent, and depends on whether the cranium and brain itself can tolerate the applied force.