孙氏手术与联合三分支支架血管术中置入治疗急性Stanford A型主动脉夹层对比

目的 探讨孙氏手术、联合三分支支架血管术中置入两手术方式治疗急性Stanford A型主动脉夹层的疗效.方法 2011年1月至2013年1月我院收治的急性Stanford A型主动脉夹层患者,以孙立忠教授主动脉细化分型中AC型为入选标准,选取患者24例.孙氏手术组患者12例,单纯行升主动脉及全弓替换加支架“象鼻”手术9例,同期主动脉根部替换手术（Bentall术）2例,主动脉瓣成形1例.联合三分支支架血管术中置入组患者12例,单纯三分支支架术中置入3例,同期升主动脉替换8例,主动脉根部替换手术（Bentall术）1例.出院前、术后3个月、术后每年复查主动脉全程重建CT.结果 孙氏手术组：平均手术时间（10.00±1.60）h,平均体外循环时间（253.33±49.33）min,平均心肌阻断时间（141.41±27.58）min,选择性脑灌注时间（39.67±10.28）min.住院死亡4例,死亡原因：多脏器衰竭2例,术后肾功能衰竭1例,术后呼吸功能衰竭1例.联合三分支支架血管术中置入组：平均手术时间（7.77±2.06）h,平均体外循环时间（168.25±32.05）min,平均心肌阻断时间（79.75±29.54）min,选择性脑灌注时间（24.33±6.53）min.住院死亡2例,死亡原因：术后呼吸功能衰竭死亡1例,1例术后一直未醒,术后第5天少尿,家属放弃治疗.孙氏手术组随访（11.09±6.87）个月,无死亡及需再次手术者.联合三分支支架术中置入组随访（18.40±8.03）个月,术后死亡2例,1例术后1年胸痛发作,心脏彩超提示升主动脉明显增宽,主动脉后壁分离为两层,当即死亡;1例术后2年随访主动脉全程重建CT提示无名动脉近端内漏.结论 孙氏手术和联合三分支支架血管术中置入术是治疗大多数急性Stanford A型主动脉夹层安全有效的方法.作为一种崭新的技术手段,联合三分支支架血管术中置入简化了手术步骤,术后内漏是高危因素,对该种手术方式患者选取应有一定针对性,根据患者信息订制更加个体化支架,并且需要长期随访.     

急性A型主动脉夹层患者手术死亡临床风险分析

目的探讨评估急性A型主动脉夹层老年患者手术死亡的风险因素。方法 2010年1月至2015年12月手术治疗的25例急性A型主动脉夹层老年患者,男19例,女6例,平均年龄57岁,根据手术结果分为生存组和死亡组,比较术前、术后各种临床资料。结果 5例(20%)住院期间死亡。单因素分析显示,手术死亡率的术前危险因素是炎症和肾功能不良,手术危险因素是体外循环时间、主动脉夹闭时间和最低肛温。多因素分析显示独立危险因素是术前肾功能不良(OR=1.020,95%CI 0.999~1.041,P=0.045)。结论急性A型主动脉夹层手术死亡率独立危险因素是术前肾功能不全。     

主动脉夹层急性期院内死亡相关因素的Logistic回归分析

目的：探讨急性主动脉夹层（AD）住院死亡的相关因素。方法：回顾性分析114例我院2007年8月~2011年8月AD住院患者的临床资料,对部分相关因素进行单因素及多因素Logistic回归分析。结果：114例主动脉夹层患者中Stanford A型主动脉夹层72例（63.16%）,StanfordB型主动脉夹层42例（36.84%）,平均年龄（59.41±12.59）岁,男女性别比2.8：1;急性期院内病死率25.44%;多因素Logistic分析显示,吸烟史（OR=11.156,P〈0.001）和入院舒张压偏低（OR=6.146,P=0.013）为主动脉夹层急性期死亡独立的危险因素,知晓患有高血压（OR=0.230,P=0.021）和手术或介入（OR=0.066,P=0.002）为主动脉夹层急性期死亡独立的保护因素。结论：吸烟史和入院舒张压偏低为主动脉夹层急性期死亡独立的危险因素,知晓患有高血压和主动脉弓置换手术或腔内介入隔绝术为独立的主动脉夹层急性期死亡保护因素。     

A型主动脉夹层术后急性肾损伤患者接受连续性肾脏替代治疗的预后因素

目的 分析Stanford A型主动脉夹层术后出现急性肾损伤（acute kidney injury, AKI）并接受连续性肾脏替代治疗（continuous renal replacement therapy, CRRT）的患者预后因素。 方法 筛选2015年4月 ~ 2018年3月西京医院收治A型主动脉夹层心脏手术后出现AKI并接受CRRT治疗的患者,记录患者术前、术中、术后临床资料,按患者是否存活分为2组:存活组(n = 32)和死亡组(n = 34)。 结果 最终纳入66例患者,年龄（49 ± 9）岁,男性占91%,术前血肌酐（144 ± 77）μmol/L。其中,34例患者死亡（52%）。多因素Logistic回归分析表明术中红细胞输注的量（HR = 3.169, 95% CI 1.180 -8.513;P < 0.05）和术后多脏器功能衰竭（HR = 3.575, 95% CI 1.196 -10.687;P < 0.05）是A型主动脉夹层术后出现AKI并接受CRRT的患者死亡独立危险因素。 结论 对于A型主动脉夹层术后需要CRRT治疗的AKI患者,术中输注红细胞量越多以及术后出现多脏器功能衰竭患者的死亡风险越大。     

急性Stanford A型主动脉夹层再手术治疗分析

摘要 目的：探讨急性A型主动脉夹层再手术治疗的效果,总结其外科治疗经验。方法 ：回顾分析2007年1月-2017年5月16例Stanford A型主动脉夹层再手术患者的临床资料。首次手术包括升主动脉替换术1例,Wheat手术 (升主动脉+主动脉瓣替换术)1例,升主动脉+次全弓替换+主动脉瓣成形术1例,升主动脉替换+孙氏手术（全弓替换及降主动脉支架象鼻人工血管置入）2例,升主动脉替换+孙氏手术+主动脉窦部成形术4例,Bentall手术(带瓣人工血管升主动脉替换替换术)3例,Bentall+孙氏手术4例。再次手术方式包括孙氏手术5例,全主动脉置换术1例,全胸腹主动脉替换2例,主动脉瓣周漏修补术1例,主动脉根部吻合口漏修补术2例（其中1例并行主动脉根部假性动脉瘤切除术）,主动脉覆膜支架腔内隔绝术7例。结果：1例患者在围术期死亡,术后并发症共8例。其中再次开胸2例,伤口感染2例,低心排综合症1例,神经系统并发症1例,肺部感染2例,以上并发症均于出院前治愈。结论：急性A型主动脉夹层再手术临床效果满意,因弓部病变再次行孙氏手术亦安全、有效;孙氏术后远端主动脉病变行常温非体外循环下全胸腹主动脉替换术亦是一种安全、有效的外科策略。     

A型主动脉夹层术后行连续性肾脏替代治疗患者死亡危险因素分析

目的:分析Stanford A型主动脉夹层患者深低温停循环(DHCA)手术后行连续性肾脏替代治疗(CRRT)的死亡危险因素。方法:回顾性研究2009年3月至2013年12月间,885例经DHCA下手术的A型主动脉夹层患者的临床资料,其中97例(10.96%)术后行CRRT治疗。CRRT治疗患者根据术后住院期间是否死亡分为:非死亡组(58例)及死亡组(39例),记录患者性别、年龄、相关病史、心功能、DHCA时间、出血量、输血量及术后并发症等临床资料,及CRRT前后SCr、乳酸、p H等数值,对术后死亡的相关危险因素进行单因素及多因素Logistic回归分析。结果:97例患者中住院死亡39例(40.21%),其中死于心力衰竭10例,多器官衰竭20例,多发性脑梗死4例,感染中毒性休克5例。单因素分析发现:年龄(P=0.011)、术前左心室舒末径(P=0.044)、术后急性呼吸功能不全(P=0.035)、术后低心排出量综合征(低心排)(P=0.012)、术后应用ECMO(P=0.037)、永久性神经功能障碍(P=0.025)、术后感染(P=0.012)、术后肢体缺血(P=0.047)、术后肝功能不全(P=0.045)、CRRT后血肌酐值(P=0.029)、CRRT前平均动脉压(P=0.016)、CRRT后平均动脉压(P=0.046)、CRRT后血乳酸值(P=0.014)及CRRT距离手术结束时间(P=0.032)是A型主动脉夹层手术后行CRRT治疗住院死亡的相关危险因素。多因素回归分析发现:术后低心排(P=0.028)、术后感染(P=0.037)、CRRT后血乳酸值(P=0.044)是其住院死亡的独立危险因素。结论:A型主动脉夹层手术后行CRRT治疗住院病死率较高,由多因素导致,应重视围术期脏器保护。     

A型主动脉夹层手术后早期并发症分析

目的:分析A型主动脉夹层手术后早期并发症发病情况,探讨与住院病死率的相关性,为制定预防和治疗措施提供依据。方法:2009年2月至2010年10月在我院行主动脉替换术的A型主动脉夹层患者252例的手术资料。手术方案依据细化分型原则制定。根据主动脉根部病变程度分为3型:A1主动脉窦部正常型;A2主动脉窦部轻度受累型;A3主动脉窦部重度受累型。根据主动脉弓部病变分为2型:S型单纯型;C型复杂型。C型采用主动脉弓替换加支架象鼻(孙氏手术)处理。结果:252例患者,平均年龄47岁,男性193例,女性59例。急性夹层187例(发病<2 w),慢性夹层65例。A1S型8例,A2S型7例,A3S型8例,A1C型42例,A2C型90例,A3C型97例。术后早期并发症包括吻合口出血(8例,3.2%);肝功能不全(8例,3.2%);肾功能衰竭(16例,6.3%);急性呼吸功能不全(32例,12.7%);神经系统并发症(37例,14.7%),包括脑部并发症一过性脑功能紊乱(29例,11.5%)、脑梗死(3例,1.2%)和脊髓损伤(5例,2.0%);住院死亡(16例,6.3%)。住院死亡组除吻合口出血外,其余术后并发症的发病率均明显高于非住院死亡组(P<0.05)。多元Logistic回归分析显示脊髓损伤,肾衰竭和肝功能不全是住院死亡的危险因素。结论:A3C型是A型主动脉夹层细化分型的主要类型。术后早期神经系统并发症最为常见。住院病死率与术后早期并发症发病率明显相关,其中脊髓损伤,肾功能衰竭和肝功能不全是导致住院死亡的独立危险因素。     

急、慢性降主动脉夹层腔内修复术的单中心对比分析

目的比较急性和慢性降主动脉夹层行腔内修复(endovascular aortic repair,EVAR)治疗的近、远期临床疗效。方法回顾性分析沈阳军区总医院2002年4月至2014年12月的456例(急性期342例,慢性期114例)诊断为降主动脉夹层,并行EVAR治疗的患者的临床特点及手术参数等临床资料,并对术后近、远期临床随访结果进行对比分析。同时,分析降主动脉夹层患者的临床特征与术后死亡的关系。结果与慢性期组比较,急性期组前胸及后背部疼痛、胸腔积液、急性肾功能不全、D-二聚体(0.5 ng/mL)的患者比例显著升高,差异均具有统计学意义(P均0.05)。急性期组入院收缩压、入院心率高于慢性期组,差异有统计学意义(P0.001)。两组间EVAR相关参数比较,差异均无统计学意义(P0.05)。术后近期结果(术后30 d内):两组间全因病死率,主动脉源性死亡、内漏、截瘫、再发夹层、主动脉夹层破裂、急性肾功能不全患者比例比较,差异均无统计学意义(P0.05)。远期随访结果(术后30 d以后):两组间病死率,内漏、再发夹层、主动脉夹层破裂的患者比例比较,差异均无统计学意义(P0.05)。Logistic回归分析显示人院胸腔积液(OR=39.793;95%aCI:12.540-126.269;P0.001)、冠状动脉粥样硬化性心脏病(冠心病)(OR=4.724;95%CI:1.921-11.617;P=0.001)与EVAR术后死亡存在独立相关性。结论 EVAR治疗Stanford B型主动脉夹层安全有效,但是急性期患者术后近期病死率较慢性期具有增高趋势,两组间远期病死率相近;胸腔积液、冠状动脉粥样硬化性心脏病为EVAR术后死亡的独立危险因素。     

主动脉夹层主动脉弓替换术后肾功能损伤分析

目的 分析体外循环下主动脉弓替换术患者肾功能损害的原因及治疗方法。方法 回顾性分析2008年1月至2014年7月宜昌市第一人民医院22例外循环下主动脉弓替换术的临床资料,其中男性17例、女性5例,年龄（49.53±9.64）岁。结果 术后血肌酐与术前相比有所增高,总体平均值之间的差别具有统计学意义［（174.00±111.61）μmol/L比（87.90±43.44）μmol/L,t=4.137,P=0.000］,手术加重肾功能损害;体外循环时间≥180 min与体外循环术时间＜180 min相比,肾功能损害的差异有统计学意义（χ2=3.884, P=0.035）,提示术中长时间体外循环加重肾功能损害。术后肾功能损害与术后无肾功能损害患者相比较,术前肾功能损害是术后肾功能损害的危险因素（χ2=7.246,P=0.011）;血液净化后血肌酐与血液净化前血肌酐相比有所降低,总体平均值之间的差别具有统计学意义［（84.00±113.62）μmol/L比（174.00±111.00）μmol/L,t=6.335,P=0.000］。结论 主动脉夹层主动脉弓替换术后肾功能损伤与体外循环时间过长及术前肾功能损害有关。肾功能损伤患者在重症监护室进行血液净化治疗,疗效满意。     

复发性心脏瓣膜病再次外科治疗效果及其相关因素

目的:回顾性分析对二尖瓣闭式扩张术、瓣膜成形术、瓣周漏、人工机械瓣功能障碍、生物瓣衰坏等原因引起的复发性瓣膜病变进行再次手术的效果和相关因素。方法: 复发性瓣膜病患者331（男143,女188）例,年龄12～73(46±12)岁,两次手术间隔时间2月～25(17±8)年。其中二尖瓣闭式扩张术后再狭窄143例,二尖瓣或主动脉瓣成形术后瓣膜病变复发53例,生物瓣衰坏32例,瓣周漏26例,换瓣术后其它瓣膜病21例,人工瓣膜替换或瓣膜成形术后心内膜炎17例, Ebstein畸形矫治术后三尖瓣关闭不全15例,人工瓣膜机械功能故障9例,室间隔缺损修补术并行瓣膜成形术后心内膜炎7例,完全或部分性心内膜垫缺损和矫正性大动脉转位术后二尖瓣或三尖瓣关闭不全6 例,二尖瓣球囊扩张术2例。再次手术方式为二尖瓣替换术,主动脉瓣替换术,二尖瓣和主动脉瓣替换术,三尖瓣替换术,瓣周漏修补术及三尖瓣成形术等。结果: 全组共死亡27例,占8.2％,早期主要死亡原因为低心排出量综合征、室性心律失常、多脏器功能衰竭、左心室破裂、感染性心内膜炎、肾功能衰竭。随访259例,随访期6月～21（10±7）年,心功能恢复至Ⅰ～Ⅱ级189例。复发性心脏瓣膜病再次手术的危险因素包括术前心功能差、重要脏器功能不全、急诊手术、主动脉阻断时间和体外循环时间长等。结论: 针对再手术相关的危险因素进行积极防治,适时而妥善的外科手术和围手术期处理仍可获良好效果。     

The immunoneuroendocrine role of melatonin

Abstract: A tight, physiological link between the pineal gland and the immune system is emerging from a series of experimental studies. This link might reflect the evolutionary connection between self-recognition and reproduction. Pinealectomy or other experimental methods which inhibit melatonin synthesis and secretion induce a state of immunodepression which is counteracted by melatonin. In general, melatonin seems to have an immunoenhancing effect that is particularly apparent in immunodepressive states. The negative effect of acute stress or immunosuppressive pharmacological treatments on various immune parameters are counteracted by melatonin. It seems important to note that one of the main targets of melatonin is the thymus, i.e., the central organ of the immune system. The clinical use of melatonin as an immunotherapeutic agent seems promising in primary and secondary immunodeficiencies as well as in cancer immunotherapy. The immunoenhancing action of melatonin seems to be mediated by T-helper cell-derived opioid peptides as well as by lymphokines and, perhaps, by pituitary hormones. Melatonin-induced-immuno-opioids (MHO) and lymphokines imply the presence of specific binding sites or melatonin receptors on cells of the immune system. On the other hand, lymphokines such as -γ-interferon and interleukin-2 as well as thymic hormones can modulate the synthesis of melatonin in the pineal gland. The pineal gland might thus be viewed as the crux of a sophisticated immunoneuroendocrine network which functions as an unconscious, diffuse sensory organ.     

Changes in connexin43, the gap junction protein of astrocytes, during development of the rat pineal gland

Abstract: The abundance of gap junctions between rat pineal astrocytes formed by connexin43 (Cx43) was studied during development. Levels and distribution of Cx43 were measured by immunoblotting and indirect immunofluorescence, respectively. The amount of Cx43 in cells located within the gland was low until about the 7th postnatal day and increased to adult values between the 14th and 21st days postpartum. Although astrocytes, recognized by their vimentin immunoreactivity, were scarce before birth, they were abundant by the 7th postnatal day suggesting that the low levels of Cx43 found at this age corresponded to a low expression of this protein. Localization of the immunoreactivity to Cx43 and vimentin showed a close correlation, indicating that mature or immature pineal astrocytes form gap junctions made of Cx43. Since Cx43 levels attained their adult values at about the time the innervation and the functional state of the gland reached maturity (2–3 weeks after birth), it is proposed that astrocyte gap junctions are involved in the function of the adult rat pineal gland.     

Response of rat pineal melatonin to calcium, magnesium, and lithium is circadian stage dependent

Abstract: Herein we documented the response of pineal melatonin production to electrolytes known to be effective on pineal function in view of a possible circadian stage dependence. We studied the release of melatonin by perifused rat pineal glands at 2 different circadian stages corresponding to the middle of the light and dark periods, i.e., respectively, 7 and 19 HALO (Hours After Light Onset, L:D = 12:12). The initial efflux rates were, as expected, much higher in the perifusates of glands removed from rats sacrificed during the dark phase than of those removed during the light phase. After 3 hr of perifusion, melatonin release reached similar levels which were found constant up to the 8th hr of perifusion, whatever the circadian stage. Perifusion of the glands with physiological concentrations for the rat of calcium (5.2 mmol/1) and magnesium (1.34 mmol/1) resulted in a stimulatory effect on the pineal glands removed from rats sacrificed in the middle of the dark period (19 HALO), whereas no effects were observed on the pineal glands removed from rats sacrificed during the light (7 HALO). Lithium (0.28 and 0.55 mmol/1) was ineffective on melatonin release in pineal glands removed 7 and 19 HALO. Our results show differences in the initial efflux rates of melatonin and in the response of perifused pineal glands to calcium and magnesium according to the circadian stage.     

Conservative management of perforated duodenal diverticulum： A case report and review of the literature

Duodenal diverticula are a relatively common condition. They are asymptomatic, unless they become complicated, with perforation being the rarest but most severe complication. Surgical treatment is the most frequently performed approach. We report the case of a patient with a perforated duodenal diverticulum, which was diagnosed early and treated conservatively with antibiotics and percutaneous drainage of secondary retroperitoneal abscesses. We suggest this method could be an acceptable option for the management of similar cases, provided that the patient is in good general condition and without septic signs.     

Presence of immunoreactive growth hormone and prolactin in the ovine pineal gland

Abstract: The use of antisera raised against bovine growth hormone (GH) and ovine prolactin (PRL) enabled the detection of related immunoreactive (ir) sequences of proteins in ovine pineal tissue. The isolation of PRL-like ir-material was accomplished using a 0.25 M ammonium sulphate (pH 5.5) extraction followed by ethanol precipitation, whereas the resulting 2.0 M ammonium sulphate (pH 7.0) precipitate contained a GH-like immunoreactivity. Gel chromatography of the GH-like immunoreactivity (Sephadex G-100) indicated the presence of several GH-like fragments ranging in the M_r range of 7,000 to 55,000. Analyses of the PRL-like ir-material found in pineal tissue on HPLC using a TSK 545-DEAE column led to the resolution into a single peak of immunoreactivity. A single peak of activity was also observed following chromatofocusing and hydrophobic interaction chromatography of the ir-peak from the TSK 545-DEAE column. The PRL-like ir-material inhibited the binding of [¹²⁵I]ovine PRL-S14 to anti-ovine PRL antibodies without showing an affinity for binding to anti-rat PRL or anti-bovine GH antibodies. Scatchard analysis of the binding of pineal PRL-like ir-material and pituitary ovine PRL-S14 to liver membranes from day-20 pregnant rats revealed similar affinity constants (K_a of 4.7 ± 0.2 × 10⁹ M^-1). In addition, the replication of Nb 2 Node rat lymphoma cells was stimulated by pineal PRL-like ir-material, an effect known to be specific for lactogenic hormones. The pineal PRL-like immunoreactivity appeared on sodium dodecyl sulfate polyacrylamide gels as a single major band of M_r 24,000. The functional status of PRL-and GH-like ir-material in the ovine pineal remains to be determined, but evidence is presented that the overall protein synthesis rate of the rat pineal responded to circulating concentrations of PRL.     

Microbiology of human immunodeficiency virus anorectal disease

PURPOSE: Individuals who are seropositive for the human immunodeficiency virus are at high risk for opportunistic infection and anorectal disorders. Little prospective information is available regarding anorectal pathogens in these patients. METHODS: One hundred sixty-three HIV-seropositive patients presented to the colorectal clinic between 1989 and 1992. Forty-seven (29 percent) patients were thought to have an infectious process and were prospectively studied using a standardized multiculture protocol. RESULTS: Mean age was 33 (range, 19–59) years. All were male; high-risk behavior accounted for 87 percent of HIV transmissions. Presenting complaints included anorectal pain (79 percent), pus per anum (28 percent), and blood per anum (26 percent). Examination revealed perianal tenderness (60 percent), condyloma (38 percent), perianal ulcers (38 percent), and anal fissures (34 percent). Sixty-six sets of cultures were performed; 28 patients had one set, 15 had two sets, and 4 had three sets. Thirty-two of these 47 patients (68 percent) had positive cultures including herpes (50 percent), cytomegalovirus (25 percent),Neisseria gonorrhoeae (16 percent), chlamydia (16 percent), acidfast bacilli (2 percent), and others (9 percent). Six of 32 patients with positive cultures had more than one organism cultured. Sixteen (50 percent) patients with positive cultures were treated medically, 8 (25 percent) were treated surgically and 8 (25 percent) were treated with both modalities. Sixty-one procedures were performed on 17 patients for condylomata. Eighteen patients had 20 procedures for abscesses, 50 percent of whom had positive cultures for other than common bowel flora; all improved. Fourteen patients underwent 33 procedures for perianal fistulas.Mycobacterium fortuitum was cultured from one patient who required 13 procedures for abscesses and fistulas. Forty-five (96 percent) patients were followed for an average of 12.5 months ±2.9 SEM (range, 1–94 months). Symptoms were improved or resolved in 22 of 32 (69 percent) patients with positive cultures and in 11 of 13 (84 percent) with negative cultures. CONCLUSIONS: Specific pathogens may often be identified in human immunodeficiency virus-seropositive patients with anorectal disorders if aggressively sought. Although patients without specific pathogens identified may be expected to improve with planned empiric treatment, positive identification allows more directed therapy.