21例小口径头静脉血液透析患者前臂桡动脉头静脉内瘘制作体会

目的 通过21例头静脉内径小于2mm血液透析患者前臂桡动脉头静脉内瘘制作体会及通畅率的观察,探讨尿毒症维持性血液透析患者头静脉细小时如何制作前臂桡动脉头静脉内瘘.方法 采用头静脉液压扩张法与头静脉纵向剖开法相结合,对21例头静脉内径小于2mm的血液透析患者采取扩大头静脉口径后将头静脉与桡动脉行端端吻合或者端侧吻合术.结果 21例患者中19例（90.5%）取得一次性手术成功,成功率高于国内报告.19例手术成功患者中3例使用3-6月内瘘失功,1例使用9月内瘘失功,余患者内瘘使用良好,血流量充分.结论 采取头静脉液压扩张法与头静脉纵向剖开法相结合扩大头静脉口径后制作前臂桡动脉头静脉内瘘,成功率高于国内报告.但对于头静脉、桡动脉内径均细小且合并桡动脉硬化、钙化者,内瘘手术部位宁可选择肘部.     

超声检查在难建前臂动静脉内瘘血液透析患者中的应用

目的 分析彩色多普勒超声在较为困难建立的血液透析患者前臂动静脉内瘘中的作用.方法 分析总结 32例临床认为建立前臂动静脉造瘘较为困难的血液透析患者,超声在选择适宜的吻合动脉、静脉,确定吻合部位,造瘘术后评价动静脉内瘘血流情况与内瘘并发症中的作用.结果 受检者桡动脉几乎能满足手术需要,有时管壁粗糙,可有粥样硬化斑块形成.选择管腔比较清晰、管壁较为光滑、有血流充盈的前臂浅静脉进行造瘘手术,以静脉直径大于或等于2.5mm、动脉直径大于或等于2.0mm为符合做内瘘的标准,静脉需明确较大的分支走形,测定支数目,确定吻合部位.造瘘术后动脉平均内径(0.25±0.09)cm,静脉平均内径(0.31±0.1)cm,瘘口处内径(0.22±0.07)cm,静脉血流量为(255±67)mL/min.主要并发症为吻合口狭窄、血管腔内血栓形成、周围组织血肿压迫、血管扭曲、静脉瘤、假性动静脉瘤形成.结论 彩色多普勒超声在建立血液透析患者动静脉内瘘中,对术前血管的选择、吻合口部位的确定以及造瘘术后评价动静脉内瘘血流情况,分析内瘘并发症有重要作用.     

腕瘘失功能后在邻瘘口处行瘘成形术的临床研究

目的:总结维持性血液透析(MHD)患者腕瘘失功能后在邻瘘口处行瘘成形术的临床资料,为节约外周静脉提供一可行方法.方法:23例腕瘘失功能患者(A组),在邻瘘口处利用已扩张的头静脉与桡动脉再次行内瘘成形术;同期腕部桡动脉-头静脉瘘首次成形手术患者75例作为对照组(B组),比较其手术成功率、动脉及静脉内径、吻合口长度.结果:A组失功能部位82.61%在瘘口处,13.04%为头静脉血栓,其动、静脉内径明显比B组大[分别为(3.46±0.21)mm对(2.62±0.19)mm,(3.51±0.35)mm对(2.43±0.23)mm,P＜0.001];A组吻合口大小(4.14±0.49)mm、B组为(7.35±1.63)mm,A组吻合口明显比B组小(P＜0.001).A组手术均成功,B组手术成功率90.67%,但与A组相比差异无显著性(P＞0.05).A组术后1～2周内使用瘘,透析血流量＞300 ml/min,B组术后(5.19±1.19)周使用瘘.结论:腕瘘失功能的部位主要在瘘口;利用已扩张的头静脉行瘘成形术的成功率高、瘘成熟期短、血流充足,可节约MHD有限的外周静脉.     

高频彩色多普勒超声在尿毒症患者动静脉内瘘并发症监测中的临床应用价值

目的探讨高频彩色多普勒超声在尿毒症患者动静脉内瘘术后并发症诊断中的价值。方法用高频彩色多普勒超声检查65例临床医师发现的血流量不足、瘘口震颤异常、穿刺困难以及穿刺局部包块等动静脉内瘘术后的尿毒症透析患者,通过高频超声观察桡动脉、头静脉及瘘口处的二维结构及血流情况,进而评估动静脉内瘘的功能状态。结果 65例动静脉内瘘患者中头静脉瘤样扩张29例,血栓18例,狭窄7例,穿刺局部血管壁增厚5例,血肿3例,内瘘不成熟2例,假性动脉瘤1例。结论高频彩色多普勒超声在诊断尿毒症患者动静脉内瘘并发症中具有重要的临床应用价值。     

改良动静脉内瘘术在150例慢性肾衰血液透析患者中的应用

目的：探讨动静脉内瘘的手术方法并观察其临床效果。方法：对150例慢性肾衰患者（其中糖尿病患者20例）和改良动静脉内瘘术：动脉做纵向梭形切口,静脉管腔用肝素盐水稍加压后冲洗,吻合后血管表面滴注罂粟碱。结果：本组150例患者均一次手术成功。术后血液透析中的平均血流量为252ml/min。内瘘平均启用时间为术后12d,对于30例因动静脉内瘘处形成血栓、利用原来的头静脉行二次手术的患者,手术后2d-3d开始启用,血液透析效果满意。结论：动脉做纵向梭形切口不易发生吻合口狭窄,静脉管腔用肝素盐水稍加压冲洗可以扩大管腔,吻合后血管表面滴注罂栗碱可缓解血管痉挛。改良后的动静脉内瘘术有利于提高手术成功率。     

小口径静脉液压扩张建立自体动静脉内瘘在血液透析通路中的应用研究

目的:探讨经液压扩张小口径头静脉后建立自体动静脉内瘘进行血液透析的临床效果.方法:将我院收治的确诊为尿毒症的患者140例,分为实验组78例(头静脉Φ1.5～2.0 mm),对照组62例(头静脉Φ2.0～2.5 mm).实验组先用液压扩张头静脉后,再行头静脉-桡动脉端侧内瘘吻合术,对照组行传统内瘘吻合手术.比较手术成功率...     

彩色多普勒超声联合血管CT成像监测动静脉内瘘成熟程度的临床应用

目的探讨彩色多普勒超声和血管CT成像技术在该领域的应用价值指导建立动静脉内瘘和术后监测尿毒症患者前臂动静脉瘘的应用价值。方法对56例尿毒症患者造瘘术前及术后行彩色多普勒超声监测,选择适宜吻合血管及对人工动静脉瘘功能评价,螺旋CT血管成像技术进行检查内瘘血管的狭窄部位情况。结果造瘘术前动脉平均内径1.8～2.9(2.2±0.8)mm,静脉平均内径2.2～3.9(1.0±0.4)mm。5例患者出现内瘘血栓,狭窄和瘤样扩张,53例患者人工动静脉瘘血流动力学稳定,2月左右成熟,术后内瘘内径,血流量和血流速度逐渐增加,适用于穿刺进行血液透析。对3例超声难以定位内瘘障碍部位的患者进行CT成像,可精确发现狭窄部位,详细描述中心静脉情况,如锁骨下静脉,头臂干,上腔静脉是否有狭窄或血栓形成。结论彩色多普勒超声联合CT血管成像对人工动-静脉内瘘患者进行术前造瘘血管的选择和术后血管通路监测有重要的临床应用价值。     

2种溶栓方法治疗动静脉内瘘血栓的疗效探讨

目的探讨2种溶栓方法对动静脉内瘘血栓的疗效。方法72例桡动脉头静脉内瘘血栓形成的患者随机分为2组,治疗组通过血栓形成部位的动、静脉端血管分别给予尿激酶50万U注入;对照组通过外周静脉血管给予尿激酶100万U滴注,通过观察动静脉内瘘再通率评价治疗效果并对血栓形成的原因进行分析。结果治疗组内瘘再通率为86.1%高于对照组的63.9%,差异有统计学意义(P<0.05)。溶栓效果与发现血栓形成时间呈负相关(均为P<0.05)。糖尿病血管病变、造瘘血管内径细小、透析后按压不当、高凝、透析后低血压、穿刺后血肿形成是动静脉内瘘血栓形成的常见原因。结论早期发现内瘘血栓并及时应用尿激酶是内瘘再通的关键,尿激酶通过血栓形成部位的动、静脉端血管内注入溶栓效果显著。     

动静脉内瘘动脉瘤形成的原因及预防措施

目的探讨维持性血液透析（MHD）患者自体动静脉内瘘（AVF）动脉瘤形成的原因及预防措施。方法选取AVF透析患者287例,其中前臂头静脉-桡动脉内瘘231例,鼻咽窝桡动脉-头静脉33例,肱动脉-头静脉20例,尺动脉-贵要静脉3例;内瘘穿刺方法为绳梯式和区域穿刺;内瘘止血方法主要为弹力绷带环扎止血法和指压法。结果 287例患者中形成动脉瘤51例,其中真性动脉瘤（动脉瘤样扩张）48例,假性动脉瘤3例;采用弹力绷带环扎止血49例,指压法2例;区域穿刺43例,绳梯穿刺8例;瘘口手术术式在桡动脉、肱动脉、鼻烟窝、尺动脉四处出现的动脉瘤分别为37例、8例、5例、1例。结论采用扣眼及绳梯穿刺法穿刺、指压法止血、瘘口吻合部位选择前臂头静脉-桡动脉等,可有效预防动脉瘤的形成,对内瘘的长期保护有重要意义。     

桡、头动静脉瘘手术改进

目的:研究提高头静脉较细的慢性血透患者前壁内瘘手术成功率的方法.方法:改进方式为桡、头动静脉侧侧吻合,吻合后经头静脉分支或吻合口远端头静脉置入3～4号Fogarty导管,至肘部后将前臂头静脉直径全程或阶段性扩张为3～4 mm;传统方式为桡、头动静脉端端吻合或(静脉)端(动脉)侧吻合.结果:自1996年2月至1999年9月间为61例慢性肾功能衰竭患者行桡、头动静脉内瘘术.传统方法26例,手术成功率为80.8%.其中头静脉直径＜2mm时的手术成功率为0;2～2.4mm时为57.1%;2.5～2.9 mm以上的成功率为88.9%;3 mm以上时为100%.改进术式35例.头静脉直径≥1.5 mm时手术成功率为100%.两组数据经Fisher's精确概率法计算的P值为0.011.结论:桡、头动静脉正常,头静脉直径不小于1.5 mm时,方可施行桡、头动静脉瘘;头静脉直径小于3 mm,尤其是小于2.5 mm,或头静脉因操作而痉挛时,应行前臂头静脉全程或阶段性扩张的改进造瘘方式,以提高手术成功率;鼻烟壹是作内瘘较理想的部位.     

Value of D-Dimers in patients with acute aortic dissection

Objective: To evaluatel the value of D-dimers in patients with acute aortic dissection (AAD). Methods: This study consisted of 16 patients with AAD and 27 non-AAD patients. Serum D-dimets were measured by Sta-Liatest D-DI immunoturbidimetric assay. Results: D-dimer level was higher (P ＜ 0.001) in patients with AAD(7.91 ± 5.52 μg/ml) than that in non- AAD group(1.57±1.24 μg/ml). D-dimer was positive (＞0.4 μg/ml) in all patients with AAD and in 10 control group patients (37%). Among patients with acute AAD, D-dimers tended to be higher in Stanford A than in Stanford B (8.67 ± 4.31 μg/ml vs. 3.24±1.27 μg/ml, P ＜0.01). D-dimer values tended to be higher in more extended disease(3.84 ± 1.65 μg/ml, 8.57 ± 3.58 μg/ml and 11.87 ± 5.69 μg/ml in thoracic aorta, thoracic and abdominal aorta, thoracic and abdominal aorta and iliacal arteries, respectively, P ＜ 0.05 for both 8.57 ± 3.58 and 11.87 ± 5.69 vs. 3.84 ± 1.65 ). Including the control group into the analysis, we found a sensitivity of 100%, a negative predictive value of 100%, and a specificity of 66% and a positive predictive value of 64% for D-dimer in diagnosis of AAD in our patients with suspected AAD. Conclusion: D-dimer was elevated in patients with AAD. A negative D-dimer test result could be useful in excluding AAD.     

Research of combined liver-kidney transplantation model in rats

Objective： To set up a simple and reliable rat model of combined liver-kidney transplantation. Methods： SD rats served as both donors and recipients. 4℃ sodium lactate Ringer＇s was infused from portal veins to donated livers,and from abdominal aorta to donated kidneys, respectively. Anastomosis of the portal vein and the inferior vena cava （IVC） inferior to the right kidney between the graft and the recipient was performed by a double cuff method, then the superior hepatic vena cava with suture. A patch of donated renal artery was anastomosed to the recipient abdominal aorta. The urethra and bile duct were reconstructed with a simple inside bracket. Results： Among 65 cases of combined liver-kidney transplantation, the success rate in the late 40 cases was 77.5%. The function of the grafted liver and kidney remained normal. Conclusion： This rat model of combined liver-kidney transplantation can be established in common laboratory conditions with high success rate and meet the needs of renal transplantation experiment.     

BLOOD PRESSURE CHANGE WITH AGE IN SALT-SENSITIVE TEENAGERS

Objective To observe blood pressure change with age in salt-sensitive teenagers whose salt sensitivity were determined by repeated testing.Methods Salt sensitivity was determined through intravenous infusion of normal saline combined with volume-depletion by oral diuretic furosemide in 55 teenagers. After five years, salt sensitivity was re-examined and subject blood pressure was followed up. Blood pressure changes in salt-sensitive teenagers were compared to that of non-salt sensitive teenagers over five years.Results After 5 years, the repetition rate of salt sensitivity determined by intravenous saline loading is 92.7%. In teenagers with salt sensitivity on the baseline, both the systolic blood pressure increments and increment rates were much higher than non-salt sensitive teenagers (12.7±12.1 mmHg vs. 2.8±5.2 mmHg, P＜ 0.01; 12.2%± 12.0% vs. 2.5% ±4.4%, P＜ 0.001,respectively). There was a similar trend for diastolic blood pressure (8.4 ± 6.4 mmHg vs. 3.7 ± 6.4 mmHg, P = 0.052; 13.2% ±10.6 % vs. 6.8%± 10.1%, P = 0.053, respectively).Conclusions Salt sensitivity determined by intravenous saline loading showed good reproducibility. Blood pressure increments with age were much higher in salt-sensitive teenagers than non-salt sensitive teenagers, especially in terms of systolic blood pressure.     

安心颗粒对急诊经皮冠状动脉介入术后生活质量影响的研究

目的：评价使用安心颗粒对急诊经皮冠状动脉介入术（PPCI）术后生活质量的影响.方法：将160例接受PPCI的急性ST段抬高型心肌梗死患者随机分为安心颗粒组（术前顿服安心颗粒8.8g,术后安心颗粒4.4 g/次,每日2次）和对照组（仅接受基础药物治疗）.所有患者均服用阿司匹林、氯吡格雷和阿托伐他汀.分别在入院时、出院前1d、出院后180 d时,应用心肌梗死多维度量表（MIDAS）、中文版SF-36评价量表对患者生活质量评分.并观察术后30 d以内的出血并发症、血小板减少症发生情况.结果：入院时和出院前1d,两组患者的心肌梗死MIDAS、SF-36量表评分比较无差异（P＞0.05）;出院后180 d时,与对照组比较,安心颗粒组MIDAS、SF-36评分明显减低（P＜0.05）;组内与入院时比较,两组出院前1d、出院后180 d时,MIDAS、SF-36评分均降低（P＜0.05）.两组患者在随访期间均无大量出血、少量出血、重度和极重度血小板减少症发生,安心颗粒组有4例、对照组有7例发生不明显出血（P＞0.05）.两组发生轻度血小板减少症的患者数比较无差异（P＞0.05）.结论：PPCI使用安心颗粒,能改善急性ST段抬高型心肌梗死患者的生活质量,且不增加出血风险.     

The comparative studies of the influences of Urapidil and Nicardipine on sino-atrial node function, atrio-ventricular node function and hemodynamics

Objective:To investigate the influences of urapidil and nicardipine on rabbit sinus function,atrio-ventricular node function and hemodynamics.Methods:Thirty-two Angora's rabbits were selected and randomly divided into four groups.U1 group:urapidil 0.25 mg/kg;U2 group:urapidil 0.5 mg/kg;N1 group:nicardipine 10 μg/kg;N2 group:nicardipine 20 μg/kg.All these medicine were administrated within 30 seconds.Measurements were taken before and after the administration of urapidil or nicardipine for the following data:mean blood pressure(MAP),heart rate(HR),sino-atrial conduction time(SACT),maximal sinoatrial recovery time(SNRTmax)corrected sinus node recovery time(CSNRT),index of sinus node recovery time(SNRTI),Wenckebach A-V conduction frequency (WB),and P-R interval.Results:Significant MAP and HR changes were identified in all of the four groups before and after administration of both urapidil and nicardipine.No significant changes could be found in the rest of the parameters.Intergroup analysis showed that SACT and CSNRT of N1 and N2 groups were shorter than those of the U2 group(P＜0.01);the MAP decreased(P＜0.01)and the HR increased drastically(P＜0.01).Conclusions:Neither urapidil(0.25 mg/kg,0.5 mg/kg)nor nicardipine(10μg/kg,20μg/kg)has any significant influence on rabbit sinus function or rabbit atrio-ventricular node function.Nicardipine could be a better choice than urapidil for parafunctional sinus node patients.     

Expression of OPGmRNA and ODFmRNA in the patients of hip fracture due to osteoporosis

Objective：To investigate the gene expression of osteoprotegerin（OPG） and osteoclast differentiation factor（ODF） in the bone tissue of patients with hip fracture due to osteoporosis. Methods：OPGmRNA and ODFmRNA in the bone tissue in 50 cases of osteoporosis sufferers（over 50 years old） with hip fracture（Observer Group） and 30 cases of hip facture sufferers with no osteoporosis（Control group） were analyzed with the Semi-Quantitative RT-PCR method. Results：The mRNA expressed of ODF, OPG were both high in the patients with hip fracture. In the control group, the expression of OPG mRNA was observed, while the expression of ODF mRNA was very slight. Conclusion：Aged patients contained all signals including OPG, ODF that are essential for inducing osteoclastogenesis and promoting bone resorption.     

The clinicopathological and immuohistochemical analysis of solid-pseudopapillary tumor of the pancreas： report of 9 cases

Objective：To investigate the clinical features, pathological characteristics and immunophenotype of solid-pseudopapillary tumor of the pancreas（SPTP）. Methods：Nine surgically treated cases of SPTP were retrospectively reviewed. Hematoxylin and Eosin（HE） staining and immunohistochemical staining were used to analyze all cases, and the general clinical data was collected. Results：Six patients were asymptomatic except for a palpable mass. Two patients complained of vague-epigastric pain. One patient appeared jaundice. The tumor was encapsulated and solid tissues alternately with cystic tissues. Histologically, the histological structure of solid portion was pseudopapillary with a fibrovascular core. Tumor cells were uniform and medium-sized which were arranged in sheets ets or nests or pseudopapillary patterns. Immunohistochemical studies demonstrated that SPTP proved positive in vimentin（9/9 cases）, AAT（9/9 cases）, NSE（9/9 cases）, ACT（7/9 cases）, CK20（2/9 cases）, CgA（1/9 cases）, S-100（3/gcases）, PR（4/gcases）, Syn（3/9 cases） and CD56（5/9cases）, negative in CEA and ER. Conclusion：SPTP is a tumor predominantly occurring in young women frequently without special symptoms. This tumor has various characteristical histological patterns with different immunophenotype.     

Dynamic Changes in Serum Estradiol and Progesterone levels in Patients of Premenstrual Syndrome with Adverse Flow of Liver-qi

Objective:To probe into the influence of changes of ovarian hormones on the pathogenesis of the specific sub-type premenstrual syndrome(PMS)and reveal partial microcosmic mechanisms of adverse flow of liver-qi.Methods:Estradiol(E2)and progesterone(P)levels in serum were determined at different phases of menstrual cycle by radioimmunoassay.Results:In the group of PMS with adverse flow of liver-qi.the secretive peak value Of E2 and P at the follicular phase significantly decreased,and the secretive peak value at the luteal phase did not come into being.Conclusions:Low E2 and P secretive peak at the follicular phase and absence of secretive peak at the luteal phase is one of the microcosmic mechanisms of PMS with adverse flow of liver-qi.One of the pathophysiologic mechanisms of specific sub-type PMS is probably the continuous low level of E2and P.     

Real-time Three-dimensional Echocardiography in Assessment of Left Ventricular and Right Ventricular Volumes

Real-time three-dimensional echocardiography (RT3DE)is a new ultrasound technique that enables dynamic threedimensional visualization and quantification of the heart in real time. Investigation of feasibility and methodology of RT3DE in determining left ventricular (LV) and right ventricular (RV) volumes, RT3DE was performed in 35 normal adults using Philips SONOS 7500 system with a 2-4 MHz matrix array transducer. The 60°×60° "pyramid" volume database was obtained and analyzed on a TomTec echo workstation. Both LV and RV volumes were calculated with four 3DE methods (i.e. apical 2, 4, 8, and 16-plane) through manually tracing ventricular endocardial borders in end diastole and end systole. Stroke volumes were then calculated. LV volume was also measured by 2DE Simpson's rule using GE VIVID 7 ultrasound machine.     

SCREENING FOR A 21-CHROMOSOME ABNORMALITY IN PREIMPLANTED EMBRYOS OF ELDERLY WOMEN

Increasing maternal age is the only etiological factor unequivocally linked to Down's syndrome in humans. The occurrence rate of newborns with Down's syndrome is about 1/220 in women over 35 years old. However, the occurrence rate in embryos fertilized in vitro, of the elder woman is unclear. Using FISH we screened the number of chromosome 21 in preimplanted embryos of 5 elderly women (average age, 38.4 years) to study the feasibility and necessity of screening trisomy 21 in embryos in patients over 35 years old at the in vitro fertilization (IVF) center.