不同方式的全腔静脉—肺动脉连接术后的肿血分布

目的 评价不同方式的全腔静脉－肺动脉连接术（TCPC）术后的肺血分布特征,为选择最佳手术方式提供依据。方法 将23例TCPC术后的患者根据下腔静脉与肺动脉吻合方式的不同和有无左心腔静脉分为4组。所有患者均在术后30天内接受核素肺灌注显像检查,根据核素放射性计数在双侧肺内的分布,定性和定量分析上腔静脉、下腔静脉血液和全部肺血在左右肺内的分布特征。结果 组Ⅰ：下腔静脉血液全部或绝大多数回流到左肺;上腔静脉血液中绝大多数回流到右肺;全部静脉血液主要分布于左肺,左右肺血流量相比差别较大（P≤0．01）,与生理性肺血分布不符。组Ⅱ：上、下腔静脉血液及全部静脉血液比较均匀地分布于左右肺,左右肺血流量相比差别较小（P≥0．05）。组Ⅲ：下腔静脉血液大多数回流到右肺,左右肺血流量相比差别较大（P≤0．05）;上腔静脉血液比较均匀地回流至右肺,左右肺血流量相比差别较小（P≥0．05）;全部肺血主要回流至右肺,左右肺血流量相比差别较大（P≤0．05）,比较符合生理性肺血分布。组Ⅳ：右上腔静脉血液全部回流至右肺,左上腔静脉血液全部回流至左肺,左右肺血流量相比差别较大（P≤0．05）。结论 不同方式的TCPC可以导致不同的肺血分布;对于无左上腔静脉的患者,下腔静脉与右肺动脉端侧吻合并向右侧稍微偏移及向右扩大吻合口可能是最佳手术方式。     

非体外循环下改良全腔静脉-肺动脉连接术

目的：探讨非体外循环下行改良全腔静脉－肺动脉连接手术治疗功能性单心室技术。方法：3例功能性单心室病儿在非体外循环下施行了改良全腔静脉－肺动脉连接手术。术中先作上、下腔静脉插管并与右房插管连接，静脉血分流入右房，然后置右肺动脉侧壁钳，上腔静脉远心端与右肺动脉上缘行端侧吻合，吻合口尽量偏左；下腔静脉通过心外管道与右肺动脉下缘连接，吻合口尽量偏右。最后缝扎肺动脉口。结果：术后无早、晚期死亡，仅1例发生低心输出量综合征及胸腔渗出。动脉血氧饱和度0．94－0．97。术后随访1－3个月，心功能I级2例，Ⅱ级1例。结论：非体外循环下行改良全腔静脉－肺动脉连接术，是治疗功能性单心室的有效技术，可取得良好的手术效果。     

全腔静脉-肺动脉连接术的临床应用

目的探讨全腔静脉-肺动脉连接术（TCPC）的手术方法，总结其临床应用经验。方法回顾分析2004年11月～2006年8月我科施行心内隧道TCPC和心外管道TCPC治疗21例复杂紫绀型先天性心脏病患者的临床资料，比较两种术式间术前、术后的临床指标。结果全组共死亡2例，1例死于术后反复发生心室颤动，1例死于低心排血量综合征。术后发生并发症16例，其中胸腔积液或心包积液7例，乳糜胸5例，经行胸腔闭式引流或胸腔穿刺后治愈；心律失常、肺部感染各1例，均经保守治疗治愈。19例生存患者术后紫绀均得到有效改善；除心内隧道TCPC平均手术时间（288．5min vs．217．1min，P〈0．05），呼吸机平均使用时间（9．63h vs 65．8h，P〈0．05）长于心外管道TCPC外，两种手术方式术后中心静脉压（CVP）、血红蛋白（HGB）、红细胞压积（HCT）、动脉血氧饱和度（SaO2）、平均肺动脉压（MPAP）、上腔静脉吻合口压差（SVCPG）、下腔静脉吻合口压差（IVCPG）等均差异无统计学意义。随访16例，随访时间2个月～2年，无死亡患者。超声心动图、胸部x线片复查结果满意。结论TCPC是治疗复杂紫绀型先天性心脏病的有效方法，两种手术方法的疗效相似，但各有利弊，对婴幼儿患者选择心内隧道TCPC较为合适，对年龄较大的患者选择心外管道TCPC为佳。     

改良全腔静脉-肺动脉连接术治疗功能性单心室

目的 为了进一步改善全腔静脉－肺动脉连接手术的效果,探讨其经典手术方式的改良方法。方法 对１３例功能性单心室施行了改良全腔静脉－肺动脉妆手术 上腔静脉远心民右肺动脉上缘作端侧吻合,吻合口尽量偏左,近心端与右肺动脉下缘吻合,吻合口尽量偏右。其中５便在心脏不停跳下用Ｇｏｒｅ－Ｔｅｘ心外管道连接下腔静脉与右肺动脉下缘,８例采用心房内隧道。结果 术后早期死亡１例（７．７％）,１２例（９２．３％）存活者术后     

一种新型全腔静脉肺动脉吻合术动物模型的建立

目的 建立一种与临床术式相近的全腔静脉肺动脉吻合术实验动物模型。方法 选用成年杂交犬10条。根据下腔静脉吻合口的位置不同分为两组：1组为下腔静脉与右肺动脉吻合;2组为下腔静脉与主肺动脉吻合。两组动物模型中的上腔静脉全部与右肺动脉吻合。全腔静脉肺动脉吻合术模型在非体外循环下通过心外管道建立。结果 两组动物术后30min、1h及2h血液循环指标稳定,两组犬血流动力学指标差异无显著性（P＞0．05）。上腔静脉压维持在12mmHg(1mmHg=0.133kPa) 以上时才能维持 正常的血液循环。全腔静脉肺动脉吻合术后,肺血管阻力随静脉压的升高而下降。所有动物在手术结束后都能进行2h以上的实验数据监测 和观察。结论 犬心外管道全腔静脉肺动脉吻合术动物模型与临床实际术式相接近,是一种可靠的急性动物实验模型;全腔静脉肺动脉吻合术后,静脉压维持到合适水平是维护循环稳定的重要特征。     

心房内管道行全腔静脉─肺动脉连接术

自１９９０年１月至１９９５年１月共施行全腔静脉—肺动脉连接术３２例，其中单心室２例，三尖瓣闭锁１例。应用心房内管道行全腔静脉—肺动脉连接术。该手术方法常规将上腔静脉远心端与右肺动脉行端侧吻合，然后选用直径＞ｌ．５ｃｍ人工血管，将下腔静脉与主肺动脉吻合，方法简便，易于操作。其优点是：右房组织损伤小；血流动力学合理；更适用于伴共同心房和（或）共同房室瓣等复杂畸形；选用直径１．５ｃｍ以上人工血管无需再更换；术后心律紊乱明显减少。     

左向右分流所致肺动脉高压大鼠模型的建立及其肺血管结构的变化

目的：建立左向右分流所致肺动脉高压模型，了解高肺血流量对肺血管结构的影响。方法：对大鼠行腹主动脉－下腔静脉分流术。术后6周和11周，以右心导管法测定肺动脉平均压（PAMP）。检测右心室（RV）／左心室＋室间隔（LV＋S）比值，并且观测肺血管结构的变化。结果：6周分流大鼠肺动脉平均压明显增高，右心室肥厚。光镜下，肺小血管肌化程度增强，肺动脉中膜增厚；电镜下，内皮细胞增生变性，平滑肌细胞肥厚，向合成表型转化。结论：以腹主动脉－下腔静脉分流术制备大鼠肺动脉高压模型是可行的.     

全腔静脉肺动脉连接术的疗效与术式评价

目的 探讨全腔静脉肺动脉连接术（TCPC）的外科治疗效果并对相关术式进行评价。方法 1998年2月至2006年6月，对51例复杂先天性心脏病病儿采用TCPC予以纠治，15例采用心内隧道术式、29例采用心外管道术式、7例采用主肺动脉与下腔静脉直接吻合术式。结果 手术死亡4例（7.8％）。此外，术后低心排出量综合征6例（12．8％）、心律失常14例（29．8％）。80．1％术后24h内撤离呼吸机。术后48．9％留置胸引流管超过7d。随访1个月至8年，9例（19．1％）术后6个月后仍需长期或间断服用强心、利尿剂，7例（14．7％）有房性心律失常。结论 全腔静脉肺动脉连接术可取得满意的外科治疗效果。应用主肺动脉下腔静脉直接吻合术式，在部分病例中可望成为理想术式。     

腔静脉主动脉转流下的全腔静脉肺动脉连接术

全腔静脉肺动脉连接术(TCPC)是将体循环静脉血直接引流到肺动脉的一种右心旁路手术,目前报道的TCPC基本方法有低温心脏停跳、常温不停跳及非体外循环(OPCAB)3种.2006年8月至2008年3月,我们运用腔静脉主动脉转流(CAB)的方法,对7例复杂先天性心脏病病儿实施TCPC术,取得了良好的临床效果.     

腔静脉主动脉转流下的全腔静脉肺动脉连接术

全腔静脉肺动脉连接术(TCPC)是将体循环静脉血直接引流到肺动脉的一种右心旁路手术,目前报道的TCPC基本方法有低温心脏停跳、常温不停跳及非体外循环(OPCAB)3种.2006年8月至2008年3月,我们运用腔静脉主动脉转流(CAB)的方法,对7例复杂先天性心脏病病儿实施TCPC术,取得了良好的临床效果.     

Presenteeism and Absenteeism Before and After Total Hip and Knee Arthroplasty

BackgroundAbsenteeism is costly, yet evidence suggests that presenteeism—illness-related reduced productivity at work—is costlier. We quantified employed patients’ presenteeism and absenteeism before and after total joint arthroplasty (TJA).MethodsWe measured presenteeism (0-100 scale, 100 full performance) and absenteeism using the World Health Organization’s Health and Work Performance Questionnaire before and after TJA among a convenience sample of employed patients. We captured detailed information about employment and job characteristics and evaluated how and among whom presenteeism and absenteeism improved.ResultsIn total, 636 primary, unilateral TJA patients responded to an enrollment email, confirmed employment, and completed a preoperative survey (mean age: 62.1 years, 55.3% women). Full at-work performance was reported by 19.7%. Among 520 (81.8%) who responded to a 1-year follow-up, 473 (91.0%) were still employed, and 461 (88.7%) had resumed working. Among patients reporting at baseline and 1 year, average at-work performance improved from 80.7 to 89.4. A Wilcoxon signed-rank test indicated that postoperative performance was significantly higher than preoperative performance (P < .0001). The percentage of patients who reported full at-work performance increased from 20.9% to 36.8% (delta = 15.9%, 95% confidence interval = [10.0%, 21.9%], P < .0001). Presenteeism gains were concentrated among patients who reported declining work performance leading up to surgery. Average changes in absences were relatively small. Combined, the average monthly value lost by employers to presenteeism declined from 15.3% to 8.3% and to absenteeism from 16.9% to 15.5% (ie, mitigated loss of 8.4% of monthly value).ConclusionAmong employed patients before TJA, presenteeism and absenteeism were similarly costly. After, employed patients reported increased performance, concentrated among those with declining performance leading up to surgery.     

The German emergency and disaster medicine and management systemdhistory and present

As well for optimized emergency management in individual cases as for optimized mass medicine in disaster management, the principle of the medical doctors approaching the patient directly and timely, even close to the site of the incident, is a long-standing marker for quality of care and patient survival in Germany. Professional rescue and emergency forces, including medical services, are the “Golden Standard” of emergency management systems. Regulative laws, proper organization of resources, equipment, training and adequate delivery of medical measures are key factors in systematic approaches to manage emergencies and disasters alike and thus save lives. During disasters command, communication, coordination and cooperation are essential to cope with extreme situations, even more so in a globalized world. In this article, we describe the major historical milestones, the current state of the German system in emergency and disaster management and its integration into the broader European approach.     

Differences in Osteocyte Density and Bone Histomorphometry Between Men and Women and Between Healthy and Osteoporotic Subjects

Bone defects related to osteoporosis develop with increasing age and differ between males and females. It is currently thought that the bone remodeling process is supervised by osteocytes in a strain-dependent manner. We have shown an altered response of osteocytes from osteoporotic patients to mechanical loading, and osteocyte density is reduced in osteoporotic patients, which might relate to imperfect bone remodeling, leading to lack of bone mass and strength. Hence, information on osteocyte density will contribute to a better understanding of bone biology in males and females and to the assessment of osteoporosis. Osteocyte density as well as conventional histomorphometric parameters of trabecular bone were determined in cancellous iliac crest bone of healthy postmenopausal women and men and of osteoporotic women and men. Osteocyte density was higher in healthy females than in healthy males and lower in osteoporotic females than in healthy females. Bone mass was reduced in osteoporotic patients, both male and female. In females, trabecular number was reduced, whereas in males, trabecular thickness was reduced and eroded surface was increased. There were no correlations between the parameter groups bone architecture, bone formation, bone resorption, and osteocyte density. These results are consistent with impaired osteoblast function in osteoporotic patients and with a different mechanism of bone loss between men and women, in which osteocyte density might play a role. The reduced osteocyte numbers in female osteoporotic patients might relate to imperfect bone remodeling leading to lack of bone mass and strength. M. G. Mullender and S. D. Tan contributed equally to this work.     

肝内胆管囊腺瘤和囊腺癌的CT、MRI及病理表现

目的探讨肝内胆管囊腺瘤和囊腺癌的CT、MRI和病理特点。方法回顾性分析经手术病理证实的6例肝内胆管囊腺瘤和2例肝内胆管囊腺癌的影像及临床病理资料，将病变的影像表现与其病理大体形态及组织学表现作对照分析。结果6例肝内胆管囊腺瘤，女4例、男2例；2例肝内胆管囊腺癌均为女性病人；8例病人平均年龄55岁。所有病灶均表现为多房囊性肿块，肿瘤囊腔各分房内常为多种液体成分，在CT上可表现为不同密度、在MRI上可表现为不同信号强度。囊内出现多发大小不等的壁结节在胆管囊腺癌内更常见，囊内有分隔但无壁结节只见于胆管囊腺瘤。在7例CT扫描中，4例胆管囊腺瘤和1例胆管囊腺癌可见囊壁或分隔上钙化，囊壁、囊内分隔及囊内结节均为轻、中度延迟增强。肿瘤中出现卵巢样间质见于3例胆管囊腺瘤和1例胆管囊腺癌，且均为女性病人。结论肝内胆管囊腺瘤和囊腺癌是肝脏不常见的囊性肿瘤，影像上多房、囊内有分隔且各分房囊内密度或信号不一致，高度提示肝内胆管囊腺瘤或囊腺癌的诊断，如囊内伴有多发大小不等的结节，则进一步提示囊腺癌的可能。但影像学表现不能区分肿瘤中有无卵巢样间质。