靶向药物联合介入封堵治疗动脉导管未闭合并艾森门格综合征5例效果观察

目的探讨动脉导管未闭（patent ductus arteriosus,PDA）合并艾森门格综合征（eisenmenger syndrome,ES）应用靶向药物联合介入封堵治疗的效果。方法选择2011年6月—2013年10月诊断为重度肺动脉高压（pulmonary arterial hypertension,PAH）的PDA患者5例,术前行右心导管检查肺循环血流量/体循环血流量在1.0～1.5。入院时行急性肺血管扩张试验和试封堵试验,阳性患者行介入封堵术,所有患者术后接受规范靶向药物治疗,治疗后6、12个月综合评估介入封堵治疗指征和治疗效果。结果本组随访12个月,无一例死亡,3例成功行介入封堵术,术后肺动脉压力及肺血管阻力均呈下降趋势,1例经靶向药物治疗6个月后仍无手术指征,但一般情况好转,1例接受靶向药物治疗1个月后放弃治疗,病情逐步恶化。结论经积极靶向药物、介入封堵治疗可使部分PDA合并ES患者获益。     

经胸超声心动图在ASD、VSD、PDA介入封堵中的应用

目的：探讨经胸超声心动图（TTE）在先心病房间隔缺损（ASD）、室间隔缺损（VSD）、动脉导管未闭（PDA）介入封堵术前、术中、术后的应用价值。方法：对ASD4例、VSD14例、PDA7例TTE检查条件符合而行Amplatzer封堵器封堵治疗。结果：24例封堵成功,1例VSD封堵失败。结论：TTE在先心病介入封堵术中对术前病例的选择、术中指导监测、封堵器型号的选择和术后随访疗效评价都有重要的价值。     

超声心动图在介入治疗小儿动脉导管未闭中的应用

目的：评价超声心动图在小儿动脉导管未闭（PDA）介入治疗中的作用。方法：51例动脉导管未闭患儿,男20例,女31例,年龄0.5个月~13岁,平均（5.5±4.0）岁。采用先键动脉导管封堵器行介入治疗。封堵前应用超声心动图测定PDA最小内径,并与X线造影测值比较,术中全程指导监测封堵器位置是否正常、有无残余分流,术后复查随访观察有无残余分流。结果：51例患儿中46例行主动脉弓降部造影。PDA最窄处直径造影测量为（5.5±1.6）mm,而超声心动图结果为（5.80±1.52）mm,二者差异无统计学意义（P〉0.05）。51例PDA中5例直接依据超声结果选择封堵器治疗。术后即刻造影17%（9/51）有微量残余分流。术后24~48h超声心动图仅5例有微量残余分流。术后3个月CDFI示大动脉水平无残余分流,患儿术后左心腔、肺动脉内径均明显减小,肺动脉压基本恢复正常。结论：超声心动图检查在PDA介入治疗前筛选合适患者、判断PDA的直径大小、选择合适的介入治疗方法,对术后治疗效果的评价方面具有重要的作用。     

早期非小细胞肺癌外科治疗进展

手术是非小细胞肺癌（NSCLC）的重要治疗手段。近几年电视辅助胸腔镜手术（VATS）和达芬奇机器人（Robotic VATS,RVATS）在胸外科广泛应用,传统开胸手术越来越少,而大量肺磨玻璃结节（GGN）的发现一方面促进了微创胸外科的发展,另一方面也对传统肺癌术式的选择提出了质疑。本文就早期NSCLC外科治疗在单孔VATS、RVATS及肺段切除的选择进行综述。     

婴幼儿左向右分流性先天性心脏病的外科治疗

目的探讨婴幼儿左向右分流性先天性心脏病的手术及围术期治疗的规律,分析影响其预后的因素。方法系统回顾1999年3月—2010年3月310例4个月～30个月左向右分流先天性心脏病手术治疗及转归。病种包括：VSD194例,ASD17例,VSD伴ASD23例,VSD伴PDA27例,VSD伴PDA及MS10例,VSD伴ASD及PDA27例,PDA8例,ASD伴丁APCV4例。术前肺动脉收缩压与体动脉收缩压之比〉0．75的81例（26．1％）。因难治性肺炎和心衰而急诊手术38例（12．2％）。采用中度低温体外循环下手术。结果住院死亡9倒。术后3个月和半年各死亡1例。病死率3．5％（11／310）。年龄小,畸形复杂矫治不完全,术后肺部感染（5例）、持续肺动脉高压（2例）、低心排（2例）、顽固性出血（1例）、营养不良（1例）等是导致死亡的主要因素。结论手术治疗是拯救婴幼儿高危先心病的积极有效手段,提高手术和体外循环技术,有效控制肺部感染是降低死亡率的主要环节。     

外科治疗动脉导管未闭合并感染性心内膜炎

目的研究动脉导管未闭（PDA）合并感染性心内膜炎（IE）的诊断、手术指征、手术时机及手术方式的选择,观察手术效果,总结临床治疗经验。方法回顾性分析2000年1月至2012年9月接受手术治疗的36例PDA合并IE患者资料。所有患者均予血培养和超声心动图检查,并及时予外科手术治疗,术后充分地抗感染和心功能维护治疗。结果本组无围术期死亡。术后并发症主要有：低心排综合征2例,急性肾功能不全2例,肝功能损伤1例,短暂脑损伤1例。所有患者经积极治疗,均痊愈出院。结论 PDA合并IE这一严重的感染性疾病,血培养和超声心动图检查具重要的诊断价值;适时而彻底的外科手术治疗至关重要;术后继续充分地抗感染治疗和心功能维护治疗是取得良好疗效的保证。     

超声协助介入封堵治疗先天性心脏病4例

目的评价彩色超声多普勒在开胸及经心导管对房缺（ASD）、室缺（VSD）及动脉导管未闭（PDA）封堵术的应用价值。方法先天性心脏病共4例,ASD、VSD各1例,PDA2例。年龄7-30岁,术前采用超声确定诊断并分型,术中依据超声测值,协助临床医生进行封堵治疗。结果4例患者介入手术均获成功。结论超声多普勒血流检查作为一种安全、简便的方法,在介入封堵先天性心脏病的术前筛选,选择封堵器大小,术中及时评估封堵器效果及评价封堵术后的心脏功能状况等方面具有重要的临床价值。     

经皮穿刺行未闭动脉导管栓塞术的护理

经皮穿刺未闭动脉导管（PDA）栓塞术，是通过心导管技术，将聚乙烯醇泡沫（PAF）塞子栓塞于PDA，到永久关闭PDA的目的。与开胸直视手术相比，具有创伤小、疗效好、安全简便、康复快等优点，是目前治疗PDA的一项值得推广的治疗方法。1966年Porstmann首创非开胸经血管栓塞PDA成功。70年代初，日本很快开展了此项技术。1983年我国上海市儿童医院首次开展。我院于1998年以来共治疗19例，其中男4例、女15例；年龄最大54岁、最小6岁，均获成功，现将护理体会报告如下。     

Amplatzer封堵器治疗动脉导管未闭

动脉导管未闭（PDA）是常见的先天性心脏病,既往手术是惟一的治疗方法。随着介入医学的发展,已有若干种器械应用于PDA的介入治疗,Amplatzer封堵器是比较有代表性的一种。我院自2000年6月开始采用Amplatzer封堵器对PDA病人进行封堵治疗,共完成3例,现报道如下。1 资料与方法1.1 临床资料 例1:女,20岁。主因间断心悸,活动后气喘3年于2000年6月入院,查体于胸骨左缘第2肋间可闻及连续性机器样杂音。经胸超声心动图（TTE）示PDA直径11     

老年急性胆囊炎的手术治疗体会

目的探讨老年急性胆囊炎的临床特点及手术治疗经验。方法对110例老年急性胆囊炎的临床特点、治疗方法选择、手术时机、手术方式、治疗效果进行回顾性分析。结果治愈104例（94.5%）;好转2例（1.8%）;死亡4例（3.6%）。并发症27例,急诊手术8例,择期手术19例,切口感染（5例4.5%）,其它感染9例（8.2%）,电解质严重紊乱13例（11.8%）。结论根据老年人的临床特点,选择合理的手术时机和手术方式并注重围手术期处理,老年急性胆囊炎外科手术治疗是安全可行的。     

Cyclopamine treatment disrupts extracellular matrix and alleviates solid stress to improve nanomedicine delivery for pancreatic cancer

As one of the most intractable tumours, pancreatic ductal adenocarcinoma (PDA) has a dense extracellular matrix (ECM) which could increase solid stress within tumours to compress tumour vessels, reduce tumour perfusion and compromise nanomedicine delivery for PDA. Thus, alleviating solid stress represents a potential therapeutic target for PDA treatment. In this study, cyclopamine, a special inhibitor of the hedgehog signalling pathway which contributes a lot to ECM formation of PDA, was exploited to alleviate solid stress and improve nanomedicine delivery to PDA. Results demonstrated that cyclopamine successfully disrupted ECM and lowered solid stress within PDA, which increased functional tumour vessels and resulted in enhanced tumour perfusion as well as improved tumour nanomedicine delivery in PDA-bearing animal models. Therefore, solid stress within PDA represents a new therapeutic target for PDA treatment.     

Identifying pancreatic cancer patients for targeted treatment: the challenges and limitations of the current selection process and vision for the future

Recent preclinical data have demonstrated that pancreatic adenocarcinoma (PDA) cells with defects in the Fanconi anemia/BRCA2 pathway are hypersensitive to interstrand crosslinking agents. The challenge is to efficiently identify patients who will benefit from these therapies. Patients were chosen for this study by evaluating personal history, ethnic background and family history of pancreatic malignancy. Molecular assays were performed on tissue samples. Patient A developed PDA in the context of a known BRCA2 frameshift mutation (2157delG), suspected because of her personal and multigenerational family history of breast cancer. She was treated with surgical resection, and targeted chemotherapy. Patient A continues to be disease free 32 months after her diagnosis and treatment. Patient B developed PDA in the context of a strong family history of PDA and Ashkenazi Jewish heritage. Genetic analysis on critical DNA repair genes revealed no alterations. This patient did not receive a tailored treatment regimen. This study highlights the challenge of treating PDA patients and selecting those eligible for targeted therapy. The current targeted treatment options for PDA are reviewed. A new multidisciplinary approach for stratifying PDA patients for promising targeted adjuvant therapy and familial risk counseling is proposed.     

Patent ductus arteriosus in premature neonates

Persistent patency of the ductus arteriosus is a major cause of morbidity and mortality in premature infants. In infants born prior to 28 weeks of gestation, a haemodynamically significant patent ductus arteriosus (PDA) can cause cardiovascular instability, exacerbate respiratory distress syndrome, prolong the need for assisted ventilation and increase the risk of bronchopulmonary dysplasia, intraventricular haemorrhage, renal dysfunction, cerebral palsy and mortality. We review the pathophysiology, clinical features and assessment of haemodynamic significance, and provide a rigorous appraisal of the quality of evidence to support current medical and surgical management of PDA of prematurity. Cyclo-oxygenase inhibitors such as indomethacin and ibuprofen remain the mainstay of medical therapy for PDA, and can be used both for prophylaxis as well as for rescue therapy to achieve PDA closure. Surgical ligation is also effective and is used in infants who do not respond to medical management. Although both medical and surgical treatment have proven efficacy in closing the ductus, both modalities are associated with significant adverse effects. Because the ductus does undergo spontaneous closure in some premature infants, improved and early identification of infants most likely to develop a symptomatic PDA could help in directing treatment to the at-risk infants and allow others to receive expectant management.     

Pharmacologic management of patent ductus arteriosus

The incidence, pathophysiology, and clinical findings of symptomatic patent ductus arteriosus (PDA) are reviewed, and the pharmacologic management of symptomatic PDA is discussed. Spontaneous closure of the ductus arteriosus (DA) usually occurs within four days after birth in most premature and full-term infants. The incidence of PDA is related to birth weight in premature infants and has been shown to decrease with an increase in birth weight. Clinical findings are reviewed. Prophylactic treatment in the first few hours after birth may not be needed in most premature infants. Treatment should be considered only if the ductus becomes symptomatic. Medical management consists of respiratory support, fluid restriction, diuretics, digoxin, and indomethacin. Respiratory support, fluid restriction, and diuretics are used as first-line treatment of symptomatic PDA. Digoxin cannot be recommended as part of first-line therapy, since its risks seem to outweigh the benefits in preterm infants. Indomethacin should be used only if other standard measures including fluid restriction and diuretic treatment fail. The mechanism of action, pharmacokinetics, adverse effects, and drug interactions of indomethacin are discussed. Symptomatic PDA can increase morbidity and mortality, especially in very low birth weight infants. Treatment of symptomatic PDA may decrease the morbidity associated with this condition.     

不同剂量布洛芬治疗动脉导管未闭极低出生体质量儿效果及安全性

目的:探究不同剂量布洛芬治疗动脉导管未闭(PDA)极低出生体质量儿的效果及安全性,为布洛芬治疗PDA极低出生体质量儿提供参考。方法:选取2017年2月30日至2019年4月30日我院收治的180例胎龄<37周且体质量<1500 g的PDA患儿,根据随机数字表法分为高剂量组90例和低剂量组90例。高剂量组患儿接受第1天20 mg/kg、第2天10 mg/kg、第3天10 mg/kg布洛芬治疗,低剂量组患儿接受第1天10 mg/kg、第2天5 mg/kg、第3天5 mg/kg布洛芬治疗,第一疗程失败患儿接受第二疗程治疗,治疗方法同第一疗程。观察两组患儿治疗后PDA关闭率、治疗期间不良反应发生率、病死率、治疗前后肺动脉端内径变化情况。结果:两组患儿治疗期间病死率及不良反应发生率比较差异均无统计学意义(P>0.05)。治疗第一疗程结束后高剂量组PDA治疗成功率高于低剂量组,PDA治疗失败率低于低剂量组(P<0.05)。第二疗程两组患儿PDA治疗成功率差异无统计学意义(P>0.05)。两组患儿两个疗程累计PDA治疗成功率比较差异有统计学意义(P<0.05)。治疗两个疗程后两组患儿动脉导管重新开放率比较差异无统计意义(P>0.05)。治疗前,两组患儿肺动脉端内径比较差异无统计学意义(P>0.05),治疗后两组患儿肺动脉端内径均低于治疗前(P<0.05),治疗第一、二个疗程后,高剂量组肺动脉端内径均低于低剂量组,差异有统计学意义(P<0.05)。结论:高剂量布洛芬治疗PDA极低出生体质量儿的效果优于低剂量,且安全性高。     

成人动脉导管未闭的外科治疗

目的:总结成人动脉导管未闭(PDA)的外科治疗经验。方法:1998年10月-2005年4月,纠治成人动脉导管未闭13例中男3例,女10例。全组均在深低温低流量(DHLF)体外循环(CPB)下行手术。结果:全组无死亡,术后并发低心排综合征3例,心包积液2例,经治疗均痊愈。结论:在深低温低流量体外循环下行成人动脉导管缝合术是一种安全有效的方法。     

Comparative evaluation for the use of oral ibuprofen and intravenous indomethacin in Korean infants with patent ductus

Ductus arteriosus is a normal connecting blood vessel between the pulmonary artery and aorta in the fetus. However, if the ductus arteriosus is not closed and maintained as the open state even after 72 h of the birth, this is called a patent ductus arteriosus (PDA). Intravenous indomethacin is the conventional treatment for PDA in immature infants, but remains controversial in mature infants. The purpose of this study was to compare intravenous indomethacin and oral ibuprofen with regard to efficacy and safety for treatment of PDA. 78 neonates treated for PDA were included and classified into immature (n = 49) and mature (n = 29) groups. Ductal closure occurred in immature infants treated with indomethacin (74.1%) and ibuprofen (90.9%). Ductal closure occurred in mature infants treated with indomethacin (66.7%) and ibuprofen (92.9%). Platelet counts were increased in immature infants treated with ibuprofen (p = 0.027). Hyponatremia occurred in immature infants treated with ibuprofen (p = 0.002) and in both groups of mature infants (p = 0.001 for both groups). Serum creatinine values were lowered in mature infants treated with ibuprofen (p = 0.032). Bleeding occurred in 5 immature infants treated with indomethacin. Administration of furosemide for urine output was more frequent in the mature groups than in the immature group. In conclusion, oral ibuprofen was as effective as intravenous indomethacin in the immature groups and more effective in the mature groups. Adverse effects of oral ibuprofen were less severe than intravenous indomethacin.     

布洛芬治疗早产儿动脉导管未闭失败的影响因素分析

目的：探究布洛芬治疗胎龄小于37周且出生体质量<1 500 g早产儿动脉导管未闭（PDA）失败的影响因素,寻找PDA布洛芬治疗失败的危险因素。方法：选取2017年1月30日至2019年3月30日于我院就诊的400例胎龄<37周且出生体质量<1 500 g的PDA早产儿,均接受布洛芬治疗和床旁心电图检查。根据动脉导管是否封闭分为动脉导管未封闭组和动脉导管封闭组,分析早产儿PDA治疗失败的影响因素。结果：400例PDA患儿在接受布洛芬治疗后,140例导管未封闭,治疗失败率为35.0%,导管封闭260例,封闭率为65.0%。动脉导管未封闭组胎龄小于动脉导管封闭组,出生体质量低于动脉导管封闭组,动脉导管两端压差、宫内窘迫、窒息史、合并感染、呼吸支持、新生儿临床危险指数评分、左心房与主动脉根部内径比高于动脉导管封闭组,首次治疗日龄大于动脉导管封闭组,差异有统计学意义（P<0.05）。多因素回归分析结果显示,出生体质量、呼吸窘迫综合征、新生儿临床危险指数评分、窒息史、动脉导管两端压差、呼吸支持、合并感染是布洛芬治疗PDA失败的独立影响因素。结论：出生体质量低、合并宫内窘迫、呼吸窘迫综合征、感染、动脉导管两端压差较大、呼吸支持、新生儿临床危险指数评分>5分是出生体质量小于1 500 g PDA早产儿布洛芬治疗失败的危险因素。     

Therapygenetics: 5-HTTLPR genotype predicts the response to exposure therapy for agoraphobia

This study was intended to assess the extent to which the low-expression allele of the serotonin transporter gene promoter predicts better response to exposure-based behavior therapy in patients with panic disorder with agoraphobia (PDA). Ninety-nine patients with PDA underwent a 1-week in vivo exposure-based behavior therapy program and provided saliva samples to extract genomic DNA and classify individuals according to four allelic forms (S_A, S_G, L_A, L_G) of the 5-HTT-linked polymorphic region (5-HTTLPR). We determined whether the 5-HTTLPR genotype predicted change in avoidance behavior in PDA following treatment. After controlling for pre-treatment avoidance behavior, the 5-HTTLPR low-expression genotypes showed a more favorable response to exposure therapy two weeks following treatment, compared to the other patients. This study suggests a genetic contribution to treatment outcome following behavior therapy and implicates the serotonergic system in response to exposure-based treatments in PDA.     

Standardization of the perchlorate discharge assay for thyroid toxicity testing in rats

The perchlorate discharge assay (PDA) is potentially of high diagnostic value to distinguish between direct and indirect thyroid toxicity mechanisms, provided that standard treatment times are established and positive controls yield reproducible results. Therefore the PDA was evaluated after 2 and/or 4 weeks of treatment with positive control compounds in rats. Phenobarbital, Aroclor 1254 and beta-naphthoflavone (indirect toxic mechanism) enhanced thyroidal radioiodide accumulation, and the administration of potassium perchlorate had no effect on thyroid: blood (125)I ratio. Phenobarbital caused follicular cell hypertrophy and hyperplasia in the thyroid and centrilobular hypertrophy in the liver, without effects on serum triiodotyronine (T(3)), thyroxine (T(4)) levels. Thyroid-stimulating hormone (TSH) levels were moderately increased. Propylthiouracil (direct toxic mechanism) caused severe thyroid follicular cell hypertrophy and hyperplasia, reduced serum T(3) and T(4) levels and increased serum TSH levels, and reduced thyroidal radioiodide accumulation; perchlorate administration significantly reduced thyroid: blood (125)I ratio, demonstrating an iodide organification block. Potassium iodide (direct toxic mechanism) virtually blocked thyroidal radioiodide accumulation, without significant effects on serum T(3), T(4), and TSH levels and a microscopic correlate for higher thyroid weights. Thus, positive controls yielded reproducible results and we conclude that both the 2- and 4-week PDA is suitable to distinguish between direct and indirect thyroid toxicity mechanisms.