中心静脉压联合全心舒张末容积指数指导感染性休克患者容量治疗的效果

目的 评价中心静脉压(CVP)联合全心舒张末容积指数(GEDVI)指导感染性休克患者容量治疗的效果.方法 感染性休克患者23例,性别不煨,年龄18～64岁,休克时间＜6h,急性生理和慢性健康状况评分13～31分,采用随机数字表法,将其随机分为2组:CVP指导容量治疗组(Ⅰ组,n=12)和CVP联合GEDVI指导容量治疗组(Ⅱ组,n=11).2组均静脉输注生理盐水和6％羟乙基淀粉200/0.5,晶体液和胶体液的比例为1∶(0.5 ～ 1.0),输注速率800～ 1600 ml/h,容量治疗过程中Ⅰ组维持CVP8～ 12mmHg;Ⅱ组维持CVP＞8 mm Hg和GEDVI 600 ～ 750 ml/m2.分别于容量治疗前及容量治疗开始后6h时采集动脉及中心静脉的血样,测定血乳酸浓度和中心静脉血氧饱和度(ScvO2),计算乳酸和ScvO2的变化率.结果 与Ⅰ组比较,Ⅱ组乳酸变化率升高(P＜0.05),ScvO2变化率差异无统计学意义(P＞0.05).结论 与CVP指导容量治疗比较,CVP联合GEDVI指导感染性休克患者容量治疗时可增加组织灌注,其效果较好.     

改良颈腮腺入路切除咽旁间隙高位良性肿瘤

目的 探讨改良颈腮腺入路在高位咽旁间隙良性肿瘤手术中的应用疗效。 方法 7例咽旁间隙良性肿瘤患者,术前影像学检查提示为高位、肿瘤巨大、哑铃型且边界欠清,采用改良颈腮腺入路术式,解剖辨认面神经总干及颞面干后,于外耳道软骨前方、腮腺的后缘以及颞面干的上方间隙向深部分离至肿瘤上极,剥离子分离并下压肿瘤与下方常规颈部自下而上肿瘤游离会师后,从颌下区取出肿瘤。腮腺浅叶不切除,面神经分支不做过多解剖。 结果 所有患者均一次性完整切除肿瘤;术后病理示多形性腺瘤6例,神经鞘瘤1例;术中出血均少于300 mL;1例患者出现术后同侧眼睑轻度闭合障碍,两周后完全正常;所有患者面容美学保存理想。 结论 对于高位咽旁间隙良性肿瘤采用改良颈腮腺入路术式,不仅可以安全完整地切除肿瘤,同时由于减少了面神经及腮腺浅叶的处置,术后相关神经并发症及腮腺区凹陷性改变的发生率下降。     

Cystic fibrosis and the phenotypic expression of autosomal dominant polycystic kidney disease

Recent experiments in cultured cyst epithelial cells from kidneys of patients with autosomal dominant polycystic kidney disease (ADPKD) have shown that the cystic fibrosis (CF) transmembrane conductance regulator (CFTR) is present in the apical surface of these cells and mediates chloride (Cl-) and fluid secretion in vitro. To determine whether the presence of CF with the expression of mutated CFTR proteins modifies cyst formation in ADPKD, we studied a large family with both inherited diseases. ADPKD in this family is linked to PKD1. The family is composed of 26 members; 11 members with ADPKD, 4 members with CF, and 2 members with both diseases. Renal volumes measured by computerized tomography (CT), calculated creatinine clearances, and other clinical parameters in the family members with ADPKD and CF were compared with those in the family members with ADPKD alone, as well as to a large population of patients with ADPKD. The patients with CF and ADPKD, but not the CF heterozygote carriers with ADPKD, had less severe polycystic kidney and liver disease, as indicated by normal renal function; smaller renal volume, even when corrected for height and body surface area; and the absence of hypertension and liver cysts. These observations suggest that the coexistence of CF may reduce the severity of ADPKD.     

Predictors of Completion Axillary Lymph Node Dissection in Patients with Positive Sentinel Lymph Nodes

Background  Completion axillary lymph node dissection (CALND) is routinely performed in breast cancer patients with positive sentinel lymph nodes (SLN). We sought to determine the sociodemographic, pathologic, and therapeutic variables that were associated with CALND. Methods  From 7/1997 to 7/2003, 1,470 patients with invasive breast cancer were SLN positive by intraoperative frozen section or final pathologic exam by hematoxylin–eosin and/or immunohistochemistry (IHC). A comorbidity score was assigned using Adult Comorbidity Evaluation-27 system. Fisher’s exact, Wilcoxon tests, and multivariate logistic regression analysis were used. Results  CALND was performed less often in patients with age ≥ 70 years compared with age < 70 years, moderate or severe comorbidities compared with no or mild, IHC-only positive SLN and breast conservation therapy (BCT compared with mastectomy. Patients who did not undergo CALND were less likely than CALND patients to have grade III disease, lymphovascular invasion multifocal disease, tumor size > 2 cm or to receive adjuvant chemotherapy. However, they were more likely to undergo axillary radiotherapy (RT). On multivariate analysis, age ≥ 70 years [odds ratio (OR) 0.4, 95% confidence interval (CI) 0.26–0.63], IHC-only positive SLN (OR 0.13, 95%CI 0.09–0.19), presence of moderate to severe comorbidities (OR 0.64, 95%CI 0.41–0.99), tumor size ≤ 2 cm (OR 0.44, 95%CI 0.29–0.66), axillary RT (OR 0.39, 95%CI 0.20–0.78), and BCT (OR 0.54, 95%CI 0.37–0.79) were all independently associated with lower odds of CALND. Conclusions  The decision to perform CALND following positive SLN biopsy was multifactorial. Patient factors were a primary determinant for the use of CALND in our study. The decreased use of CALND in the BCT patients probably reflects reliance on the radiotherapy tangents to maintain local control in the axilla.     

咪达唑仑复合氯胺酮应用于小儿基础麻醉的临床探讨

 目的 探讨应用咪达唑仑复合氯胺酮不同给药方法在小儿基础麻醉中的优化方案.方法 200例1～6岁,ASAⅠ～Ⅱ级患儿随机分成以下五组:A组为口服咪达唑仑0.7 mg/kg;B组为口服氯胺酮8 mg/kg;C组为肌注氯胺酮5mg/kg;D组为口服咪达唑仑0.5 mg/kg和氯胺酮4 mg/kg;E组为先口服咪达唑仑0.5 mg/kg,再肌注氯胺酮4 mg/kg.观察各组诱导结果及呼吸循环变化、不良反应.结果 ①A组与B组比较,A组起效更快(P<0.01),合作更好,不良反应较少;②A组、B组均比C组更合作,但不如C组起效更快;③D组和E组相比,患儿更合作,不良反应更少,但起效更慢,两组诱导效果无显著差异(P>0.05).结论 咪达唑仑复合氯胺酮优于单独给药,对循环呼吸影响小;口服给药可行性更佳.     

“The Stork Lift”: A Circumoccipital Extended Neck-Lift

Background  The goal of the lower face- and neck-lift is restoration of a sharp cervicomental angle. However, standard cervical rhytidectomy for the patient with extensive excess skin of the neck often leaves the patient with objectionable vertical or diagonal skin folds of the lateral neck, a large hair-step deformity, or both. To remove extensive excess skin of the neck and to avoid vertical/diagonal folds and a stepped hairline, the authors “walk” the excess skin posteriorly along the hairline, often from ear to ear along the inferior posterior hairline. Methods  Patients with extensive excess skin of the neck underwent neck-lift procedures using the circumocciput incision technique during a 1-year period. With the patient in a sitting position, a postauricular face-lift incision is extended along the inferior hairline from ear to ear. The flap is “walked” posteriorly to and along the occiput on either side of the midline. It is closed using a divide and close technique. Flaps are created, and the wound is closed in a multilayered fashion with a posterior midline A-to-T flap. Results  During a 1-year period, 25 patients (22 women and 3 men) underwent a cheek/neck-lift, and 2 patients (1 man and 1 woman) underwent isolated neck-lift procedures using the circumocciput incision technique. The average patient age was 64.8 years (range, 49–79 years). There were no instances of obvious lateral neck folds. Complications included hematoma (1 patient), Candida wound infection (1 patient), and a widened scar revised secondarily (1 patient). All the patients were satisfied with their cosmetic result 6 months after the operation. None of the patients stated that their final scar was noticeable or objectionable. Conclusions  The patients in this study who presented with excessive redundant skin of the neck were treated with the “stork lift,” which provided excellent lifting of the anterior, lateral, and posterior neck as well as excellent cervicomental angles without postoperative sequelae of lateral neck folds or stepped hairlines.     

The dilemma of DCIS

The increasingly frequent diagnosis of ductal carcinoma in situ (DCIS) presents a major clinical dilemma. Our inability to predict which DCIS will progress to invasive cancer or the time interval in which recurrent DCIS or invasive cancer will occur has resulted in treatments ranging from mastectomy to excision and observation being offered to patients. Four randomized trials have demonstrated that the use of radiation reduces the risk of local recurrence by about 50% in women with DCIS. Prospective attempts to duplicate retrospective findings that wide excision results in high rates of local control have been unsuccessful. Patient attitudes towards risks and benefits of treatment are an important component of treatment choice in the absence of predictors of biologic behavior.