Survival of Patients on the Kidney Transplant Wait List: Relationship to Cardiac Troponin T

Patients waiting for a kidney transplant have high mortality despite careful preselection. Herein, we assessed whether cardiac troponin T (cTnT) can help stratify risk in patients selected for kidney transplantation. cTnT levels were measured in all kidney transplant candidates but the results were not used for patient selection. Among 644 patients placed on the kidney waiting list from 9/2004 to 12/2006, 61% had elevated cTnT levels (>0.01 ng/mL). Higher levels related to diabetes, longer time on dialysis, history of cardiovascular disease and low serum albumin. High cTnT also related to cardiac anomalies, including left ventricular hypertrophy (LVH), wall motion abnormalities and stress‐inducible ischemia by dobutamine echo (DSE). However, 54% of patients without these cardiac findings had elevated cTnT. Increasing cTnT levels were associated with reduced survival (HR = 1.729, CI (1.25–2.39), p = 0.01) independently of low serum albumin (0.449 (0.24–0.83), p = 0.011) and history of stroke (3.368 (1.47–7.73), p = 0.0004). The results of the DSE and/or coronary angiography did not relate significantly to survival. However, high cTnT identified patients with abnormal echo findings and poor survival. Wait listed patients with normal cTnT have excellent survival irrespective of other factors. In contrast, high cTnT levels are strongly predictive of poor survival in the kidney transplant waiting list.     

Cardiac output measurement in children: comparison of Aesculon cardiac output monitor and thermodilution

Background: We compared cardiac output (CO) measurements by the non-invasiveelectrical velocimetry (Aesculon^®) monitor with the pulmonaryartery catheter (PAC) thermodilution method in children. Methods: CO values using the Aesculon^® monitor and PAC thermodilutionwere simultaneously recorded during cardiac catheterizationin children. Measurements were performed under general anaesthesia.To compare, three consecutive measurements for each patientwithin 3 min were obtained. The means of the three values werecompared using simple regression and Bland–Altman analysis.Data were presented as mean (SD). A mean percentage of <30%was defined to indicate clinical useful reliability of the Aesculon^®monitor. Results: A total of 50 patients with a median (range) age of 7.5 (0.5–16.5)yr were enrolled in the study. Mean CO values were 3.7 (1.5)litre min^–1 (PAC thermodilution) and 3.1 (1.7) litre min^–1(Aesculon^® monitor). Analysis for CO measurement showeda good correlation between the two methods (r=0.894; P<0.0001).The bias between the two methods was 0.66 litre min^–1with a precision of 1.49 litre min^–1. The mean percentageerror for CO measurements was 48.9% for the Aesculon^® monitorwhen compared with PAC thermodilution. Conclusions: Electrical velocimetry using the Aesculon^® monitor did notprovide reliable CO values when compared with PAC thermodilution.Whether the Aesculon^® monitor can be used as a CO trendmonitor has to be assessed by further investigations in patientswith changing haemodynamics.     

Monitoring level of sedation with bispectral EEG analysis: comparison between hypothermic and normothermic cardiopulmonary bypass

The level of sedation of 28 patients undergoing elective coronaryartery bypass grafting with fentanyl–propofol anaesthesiawas monitored with bispectral analysis (BIS), spectral edgefrequency, and band power of the electroencephalogram. Fourteenpatients underwent hypothermic cardiopulmonary bypass (CPB)(32°C, group H), and 14 normothermic CPB (group N). Thelevel of sedation was measured with Observer’s Assessmentof Alertness/Sedation Score and with Ramsay Sedation Score.BIS was the only EEG measurement that paralleled the clinicalcourse of the patients’ sedation level. Values (median,95% confidence intervals (CI)) changed significantly over timein both groups (P<0.0001). In group H, BIS decreased from97 (95, 99) the day before surgery to 48 (44, 52) after trachealintubation, to 46 (41, 52) before going off CPB, to 91 (85,97) immediately before extubation. In group N, values were 93(91, 97) the day before surgery, 53 (47, 59) after trachealintubation, 48 (43, 53) before going off CPB, and 90 (84, 96)before extubation. During CPB, BIS values were significantlydifferent between the two groups. Group H had a median of 41(95% CI, 39, 42), and group N had a median of 49 (95% CI, 48,51, P<0.0001). Peak values of all other processed EEG parametersduring anaesthesia and surgery overlapped with values from theday before, when patients had no sedating medication, and thesevalues did not correlate to the patients’ course of sedationduring the study. There was no explicit recall of the surgeryin either group. During the phases of anaesthesia and surgerywithout CPB, the progression of BIS levels was comparable withpreviously published data for non-cardiac surgery. During normothermicCPB, the highest BIS values were close to values representinginsufficient depth of sedation. It remains to be elucidatedwhether the much lower BIS values in the hypothermic group weresolely a result of brain cooling or if increased serum propofolconcentrations, because of slowed pharmacodynamics during hypothermia,also contributed. Br J Anaesth 2001; 86: 769–76     

雄激素水平增龄变化对老年男性的影响

雄激素对机体的影响是多方面的。随着人体的衰老 ,雄激素水平会发生变化 ,这种变化对老年男性生理和心理会产生影响 ,如生殖功能、性功能、认知能力、情绪、骨骼肌肉等 ,老年男性雄激素水平的降低与临床表现之间的关系较为复杂 ,这方面的研究受很多因素的影响。对雄激素水平下降的老年男性可以给予激素替代治疗 ,但是也应对其副作用引起足够重视。     

The Effects of Hormone Resuscitation on Cardiac Function and Hemodynamics in a Porcine Brain-Dead Organ Donor Model

We compared the effects of hormone resuscitation (HR) with a norepinephrine-based protocol on cardiac function, hemodynamics and need for vasopressor support after brain death in a porcine model. Following brain death induction, animals were treated with norepinephrine and fluids for 3 h. In the following 3 h, they continued on norepinephrine and fluids (control) or received additional HR (triiodothyronine, methylprednisolone, vasopressin, insulin). Data were collected pre-brain death, 3 and 6 h post-brain death. At 6 h, median norepinephrine use was higher in controls (0.563 vs. 0 microg/kg/min; p < 0.005), with 6/8 HR animals weaned off norepinephrine compared with 0/9 controls. Mean arterial pressure was higher in HR animals at 6 h (74 +/- 17 vs. 54 +/- 14 mmHg; p < 0.05). Cardiac contractility was also significantly higher in HR animals at 6 h (stroke work index 1.777 vs. 1.494). After collection of 6 h data, all animals were placed on the same low dose of norepinephrine. At 6.25 h, HR animals had higher stroke work (3540 +/- 1083 vs. 1536 +/- 702 mL.mmHg; p < 0.005), stroke volume (37.2 +/- 8.2 vs. 21.5 +/- 9.8 mL; p < 0.01) and cardiac output (5.8 +/- 1.4 vs. 3.2 +/- 1.2 L/min; p < 0.005). HR in a porcine model of brain death reduces norepinephrine requirements, and improves hemodynamics and cardiac function. These results support the use of HR in the management of the brain-dead donor.     

围术期保温对老年患者止血功能的影响

目的 探讨研究围术期保温对老年患者的止血功能的影响.方法 选择60例腹腔镜下行直肠癌根治术老年患者,ASA Ⅰ～Ⅱ级,完全随机分为两组,每组30例,Ⅰ组为对照组,按常规手术进行；Ⅱ组为试验组,采用综合性保温.分别监测和记录两组患者在麻醉前及麻醉后30、60、90、120 min和术毕的鼻咽温度.麻醉前,术中30、60、90、120 min和术毕,术后24、48、72、120 h取外周静脉血测量两组老年患者凝血酶原时间(prothrombin time,PT)、活化部分凝血活酶时间(activated partial　thromboplastin time,APTT)、凝血酶时间(thrombin time,TT)、血小板计数(platelet,PLT)、D-二聚体(D-dimer,DD)、纤维蛋白原(fibrinogen,FBG)和血管性血友病因子(yon willebrand factor,vWF)的含量.结果 Ⅰ组麻醉后30、60、90、120 min及术毕时体温(℃)[分别为( 36.52±0.08)、(36.22±0.07)、(35.83±0.07)、(35.68±0.06)和(35.65±0.06)]较麻醉前(36.86±0.08)和Ⅱ组同时间体温(℃)[分别为(36.83±0.12)、(36.80±0.10)、(36.78±0.11)、(36.76±).10)和(36.80±0.11)]明显降低(P＜0.05).Ⅰ组在术中30、60、90、120 min和术毕时的PT(s)[分别为(16.12±0.31)、(16.32±0.51)、(16.21±0.33)、(16.320.42)和(16.32±0.32)]、APTT(s)[(39.3±3.3)、(39.2±3.2)、(42.2±3.1)、(43.4±3.2)和(44.4±3.3)]、TT(s)[(16.2±1.0)、(16.3±1.1)、(17.1±1.4)、(17.3±1.4)和(183±1.4)]较麻醉前的PT( 14.12±0.21)s、APTT(34.3±1.5)s和TT( 14.1±0.5)s以及Ⅱ组同时间的PT(s)[分别为(13.32±0.23)、(13.42±0.21)、(13.32±0.22)、(13.42±0.31)、(14.21±0.12)]、APTT(s)[分别为(35.3±1.4)、(35.2±1.3)、(34.2±1.4)、(34.2±1.4)、(34.1±1.3)]和TT(s)[分别为(14.0±0.4)、( 14.4±0.3)、(14.2±0.4)、(14.2±0.5)、(14.0±0.4)]明显延长(P＜0.05)；Ⅰ组在术中120 min,术毕和术后24、48、72 h时的PLT含量(×109/L)[分别为(178±13)、(121+15)、(131±34)、(123±35)、(166±14)]较麻醉前(213±12)×109/L和Ⅱ组同时间的PLT含量(×109/L)[分别为(209±14)、(192±13)、(198±17)、(203±18)、(216±15)]明显降低(P＜0.05)；Ⅰ组在术后24、48、72h的DD含量(mg/L)[分别为(1.01±0.11)、(0.82±0.13)、(0.71±0.12)]和vWF的含量(％)[分别为(220±23)、(183±20)、( 126±18)]较麻醉前DD含量(0.41±0.12) mg/L和vWF含量(92±12)％以及Ⅱ组同时间DD含量(mg/L)[分别为(0.44±0.12)、(0.45±0.22)、(0.45±0.21)]和vWF含量(％)[分别为(94±12)、(96±13)、(95±11)]明显升高(P＜0.01),同时间Ⅰ组FBG的含量(％)[分别为(1.5±0.3)、(1.6±0.3)、(2.1±0.3)]也较麻醉前(2.5±0.3)％和Ⅱ组(％)[分别为(2.5±0.4)、(2.5±0.4)、(2.5±0.5)]明显降低(P＜0.05).结论 围术期综合性保温能够部分减轻老年患者术后止血功能抑制程度,使患者早期康复.     

老年患者后腹腔镜术中高碳酸血症的监测方法及处理特点

背景 由于具备创伤小、术后恢复快等优点,后腹腔镜术在泌尿外科老年患者中的应用日益增多.然而后腹腔镜术本身的特点以及老年患者特殊的生理特点使得该类手术中患者更易发生较高程度的高碳酸血症,严重威胁老年患者围术期的安全及预后.目的 寻找术中对老年患者动脉血二氧化碳分压(arterial partial pressure of carbon dioxide,PaCO2)进行准确监测和对高碳酸血症进行实时监测和有效通气调控的方法.内容 就近年来关于老年患者后腹腔镜手术中高碳酸血症的产生机制及其对老年患者生理功能的影响以及监测、处理方法进行综述. 趋向 经皮二氧化碳分压监测(transcutaneous partialpressure of carbon dioxide,TcPCO2)已被证实可以用于成年人多种手术的血二氧化碳气连续监测并与PaCO2值有很好的相关性；呼气末正压(positive end-expiratory preassure,PEEP)也被证实在腹腔镜手术中对改善通气功能有一定作用.这些方法或可为老年患者后腹腔镜手术中的监测提供新的选择.     

颏下岛状皮瓣解剖和临床应用进展

综述颏下岛状皮瓣在头颈部软组织缺损修复中的应用价值,此皮瓣旋转弧度大,供皮面积大,术后皮瓣易成活,功能与外观满意,是修复头颈部缺损的一种理想的选择。     

Comparable Outcome of Out‐of‐Hospital Cardiac Arrest and In‐Hospital Cardiac Arrest Treated With Extracorporeal Life Support

Extracorporeal life support (ECLS) has shown benefits in the management of refractory in‐hospital cardiac arrest (IHCA) by improving survival. Nonetheless, the results concerning out‐of‐hospital refractory cardiac arrests (OHCA) remain uncertain. The aim of our investigation was to compare survival between the two groups. We realized a single‐center retrospective, observational study of all patients who presented IHCA or OHCA treated with ECLS between 2011 and 2015. Multivariate analysis was realized to determine independent factors associated with mortality. Over the 4‐year period, 65 patients were included, 43 in the IHCA group (66.2%), and 22 (33.8%) in the OHCA group. The duration of low flow was significantly longer in the OHCA group (60 vs. 90 min, P = 0.004). Survival to discharge from the hospital was identical in the two groups (27% in the OHCA group vs. 23% in the IHCA group, P = 0.77). All surviving patients in the OHCA group had a cerebral performance categories score of 1–2. In multivariate analysis, we found that the initial lactate level and baseline blood creatinine were independently associated with mortality. We found comparable survival and neurological score in patients who presented IHCA and OHCA treated with ECLS. We believe that appropriate selection of patients and optimization of organ perfusion during resuscitation can lead to good results in patients with OHCA treated with ECLS.     

术前心功能检查在胸部肿瘤外科手术治疗中的意义

目的分析胸部肿瘤患者术前心功能的状况及其对术后恢复的影响。方法前瞻性随机抽取166例胸部肿瘤患者,进行术前左心室射血分数(leftventricularejectionfraction,LVEF)检查并分析其特点。同时,采用Logistic回归分析LVEF对术后发热≥38℃天数、术后行气管镜吸痰、住院天数,并发症发生情况和出院时状况的影响。结果①左心室各部位射血分数(ejectionfraction,EF)由大到小依次为:下壁、侧壁、心尖部、间壁和下间壁。②除间壁外,其他各部位EF及LVEF,运动后较运动前值均有显著增加(P<0.05)。③心电图显著异常组和合并心脏疾病史患者,运动后LVEF无显著提高(P>0.05)。④心率越慢,LVEF值越大(P<0.05)。⑤运动前LVEF、FEV1%和年龄对术后发热天数(≥38℃)影响最大。运动前LVEF对术后肺并发症的发生影响最大。⑥LVEF与术后其他并发症发生、术后吸痰、住院时间和出院时状况无明显相关性。结论①心脏异常时,LVEF增加困难。②LVEF仅影响术后肺并发症和发热天数,对术后吸痰、住院时间、出院时状况等其他术后恢复情况影响不大。     

Prediction of the Postoperative Pulmonary Function and Complication Rate in Elderly Patients

We analyzed the risk factors predisposing elderly patients to develop postoperative respiratory complications (PRCs) and investigated the possibility of predicting the postoperative pulmonary function and PRC rate. The postoperative pulmonary functions were predicted according to a simplified system, which we developed using plain chest roentgenograms from patients with primary lung cancer. Both univariate and multivariate analyses of PRCs were performed in 39 elderly patients with lung cancer from July 1982 to March 1991 (the early period). Based on the results obtained, the permissible extent of lung resection to achieve a predicted postoperative % forced expiratory volume in 1 s (ppo%FEV_1.0) and a predicted postoperative % vital capacity (ppo%VC) of more than 55% was selected as the basic criteria for undergoing such an operation after April 1991 (the recent period). A ppo%FEV_1.0 and/or ppo%VC of 55% or less was the most significant risk factor for developing PRCs. The PRC rate decreased from 33.3% to 9.8% (P = 0.0251) and the operative mortality rate decreased from 10.3% to 0%. The survival rates for stage I, II, and III cases were not significantly different between the early and recent periods. Decisions made on the operability and the permissible extent of lung resection based on our system using plain chest roentgenograms therefore appeared to reduce the PRC rate and operative mortality rate in elderly patients. Received: September 20, 2000 / Accepted: May 15, 2001     

Effect of Surgical Stress on Immune Function in Patients with Urologic Cancer

Background: To determine the immunosuppressive effect of surgery for urologic cancers, multiple variables of immune function were measured serially before and after operation in patients with urologic cancer.
Methods: Peripheral blood was obtained before operation and at postoperative day 7 and 14 from 20 patients with bladder cancer, renal pelvic, or ureteral cancer, or renal cell carcinoma.
Results: In patients with bladder cancer who were undergoing radical cystectomy with use of intestine for urinary diversion, the serum level of immunosuppressive acidic protein (IAP) increased, and serum levels of immunoglobulin (Ig)A, IgG, and IgM decreased after operation. In contrast, the number of CD25+ lymphocytes significantly increased. Transurethral resection of bladder cancer also resulted in an increase in serum IAP level, however, the number of CD4+ and human leukocyte-associated HLA-DR+ lymphocytes increased. In patients with renal pelvic or ureteral cancer undergoing nephroureterectomy with cuff, the level of serum IAP increased and serum IgG level decreased after operation. By contrast, the number of CD3+ lymphocytes increased. In patients with renal cell carcinoma, radical nephrectomy led to a significant increase in the number of CD8+ lymphocytes.
Conclusions: These findings suggest that surgical stress in patients with urologic cancer may result in both suppression and stimulation of host immunity.     

IIEF分析93例ED病人老龄化与性功能的关系

目的 :研究老龄化对于男性性功能的影响。　方法 :用国际勃起功能评分量表 (IIEF)对泌尿男科门诊的93例排除器质性疾病的勃起功能障碍 (ED)病人从性功能的 5个方面进行分析。　结果 :在 2 3～ 6 4岁的 5个年龄组中 ,中重度ED的比例由 16 .6 7%升高到 5 7.14 % ;勃起功能积分由 (19.5 0± 4 .6 4 )分下降到 (15 .2 7± 5 .6 4 )分 ;达到性高潮能力积分由 (6 .93± 2 .86 )分下降到 (5 .6 2± 2 .94 )分 ;性欲积分由 (6 .33± 1.6 3)分下降到 (4.5 0± 2 .94 )分 ;性交满意度积分由 (10 .17± 1.94 )分下降到 (6 .93± 2 .90 )分 ;总体满意度积分由 (5 .0 0± 0 .89)分下降到 (3.15±1.84 )分。　结论 :老龄化与男性性功能呈明显负相关 ,老龄化是男性ED的危险因子。应用IIEF研究ED的流行病学是可行的     

全腔静脉肺动脉连接手术对降钙素基因相关肽分泌的影响

目的　研究全腔静脉肺动脉连接术 (TCPC)术后降钙素基因相关肽 (calcitonin gene relatedpeptide,CGRP)的变化情况及肺循环内无搏动血流对其分泌的长期影响。　方法　实验组为 1 3例心外管道TCPC术后患者 ,对照组为 1 3例房间隔、室间隔缺损心内修复术患者 ,对 2组患者分别于术前、术后第 1天、第 5天、第 4周和术后 6个月测量血CGRP含量。实验组患者术后经右心导管测量心脏指数 (cardiacindex ,CI)及肺血管阻力 (pulmonaryvascularresistance ,PVR)。　结果　术前实验组CGRP含量显著低于对照组 (t=3 1 2 ,P <0 0 1 ) ;术后 2组CGRP均出现一过性升高 ,第 4周对照组恢复正常 ,而实验组仍显著高于对照组 (t=3 1 4 ,P <0 0 1 ) ,且术后 6个月仍保持高水平 (t=2 32 ,P <0 0 5)。CGRP含量与PVR呈显著负相关 (r=- 0 99,t=9 82 ,P <0 0 5) ,与CI呈显著正相关 (r =0 98,t=6 95 ,P <0 0 5)。　结论　TCPC手术完全旷置右心后 ,肺循环无搏动血流会刺激肺组织CGRP分泌增加 ,由此所引起的肺血管阻力降低 ,可能对手术患者的早期恢复有利