非体外循环下再次冠状动脉旁路移植术后早期监护

探讨20例在非体外循环下再次行冠状动脉旁路移植术后患者早期监护的要点.针对手术的致死危险因素如心律失常、左心室射血分数、糖尿病、机械通气时间延长等提出相应的护理措施.     

小肠原发性非霍奇金淋巴瘤34例临床分析

目的探讨小肠淋巴瘤的临床特点、治疗和预后。方法对1996年1月至2005年12月间收治的经组织病理学明确诊断、并作免疫学分型的原发性小肠淋巴瘤34例患者的临床资料进行分析。结果27例为B细胞淋巴瘤，7例为T细胞淋巴瘤。腹痛和肠梗阻是主要临床表现。用Ann Arbor分期，22例为Ⅰ～Ⅱ期，其中B细胞淋巴瘤20例（74．1％），T细胞淋巴瘤2例（2／7）；12例为Ⅲ～Ⅳ期，其中B细胞淋巴瘤7例（25．9％），T细胞淋巴瘤5例（5／7）；小肠B细胞淋巴瘤的分期低于T细胞淋巴瘤（P〈0．05）；27例行手术治疗，14例行6次化疗[方案为CHOP（环磷酰胺、阿霉素、长春新碱和强的松龙）]，8例同时加用抗CD20单克隆抗体Rituximab。T细胞淋巴瘤急诊手术率高于B细胞淋巴瘤（P〈0．05），B细胞淋巴瘤更易达到完全缓解（P〈0．05），累计生存率高于T细胞淋巴瘤（P〈0．05）。结论小肠B细胞淋巴瘤Ⅰ和Ⅱ期对手术和化疗效果佳，T细胞淋巴瘤的治疗效果和预后不满意。     

Reconstruction of the face and neck scar contractures using staged transfer of expanded "Super-thin flaps"

BACKGROUND: The authors introduced the "Super-thin flap" concept, which is sometimes called the subdermal vascular network (SVN) flap, in 1994. Since 1994, we have reconstructed face and neck scar contractures using various types of "Super-thin flaps." In this report, we introduce expanded "Super-thin flaps" for reconstruction of the face and neck for the first time in a patient. METHODS: Since 2000 we have used 21 expanded flaps to reconstruct 21 face or neck scar cases in nine males and 12 females. In the first operation, an expander was inserted on the fascia of the pectoralis major muscle, and then about 1,000 cc of saline was injected during a 2-month period. In the second operation, the flap was thinned primarily and applied to the recipient site. Three weeks after the second operation, the pedicle of the flap was cut down and sutured. RESULTS: Flap size ranged from 4 cm x 14 cm to 10 cm x 22 cm. Expanded volume ranged from 800 cc to 1,200 cc. All flaps survived completely and scar tissues were replaced with normal skin. Flaps did not shrink after the operations, and contractures did not recur. CONCLUSION: Advantages of the expanded flaps are presented: (1) Large flaps can be harvested because of the expander; (2) Extremely thin flaps can be safely employed; (3) Texture and color match are good; (4) Donor site can be closed primarily; and (5) Microsurgery is not required. However, the disadvantage of the method is the requirement for two or three operations.     

SUMO4 M55V variant is associated with diabetic nephropathy in type 2 diabetes

OBJECTIVE-SUMO4 mRNA was recently found to be mainly expressed in the kidney, and the methionine-to-valine substitution at codon 55 (M55V) variant of SUMO4 may induce higher nuclear factor-kappaB (NF-kappaB) activity. Because NF-kappaB is known to mediate the development of diabetic nephropathy, we examined the association between the SUMO4 M55V variant and the severity of diabetic nephropathy. RESEARCH DESIGN AND METHODS-We recruited a total of 430 patients with type 2 diabetes. The M55V (rs237025, 163A-->G) polymorphism of SUMO4 was genotyped by real-time PCR, and urine albumin concentration was measured by radioimmunoassay. RESULTS-The frequencies of SUMO4 AA, GA, and GG were 52.6, 40.7, and 6.7%, respectively, in the normoalbuminuric group; 45.5, 47.3, and 7.1% in the microalbuminuric group; and 36.9, 46.2, and 16.9% in the macroalbuminuric group. We detected a significant linear trend for SUMO4 genotype between the macroalbuminuric and normoalbuminuric groups. The mean urine albumin-to-creatinine ratio (42.3 +/- 108.82 mg/mmol) in the GG group was significantly higher than in the AA (14.9 +/- 51.49 mg/mmol) and GA (17.0 +/- 43.74 mg/mmol) groups. Multivariate logistic regression analysis showed the SUMO4 M55V variant to be independently associated with the severity of diabetic nephropathy. CONCLUSIONS-This study indicates that the SUMO4 gene M55V variant is associated with severity of diabetic nephropathy in patients with type 2 diabetes.     

Bile leakage after hepatectomy for hepatolithiasis: risk factors and management

BACKGROUND: Bile leakage remains a major postoperative complication after liver resection. Bile leakage after hepatectomy for liver neoplasms has been well studied. However, the risk factors and management of this complication after liver resection for intrahepatic lithiasis has not been investigated. METHODS: From January 1992 to June 2004, 312 consecutive patients with intrahepatic lithiasis underwent hepatic resections Sun Yet-san University. Perioperative risk factors pertaining to the development of bile leakage were identified using univariate and multivariate analysis. The management and outcome of these patients with bile leakage were evaluated. RESULTS: Bile leakage developed in 23 (7.4%) of 312 patients. The multivariate logistic regression analysis identified that left hepatectomy (P=.024, odds ratio [OR]=3.695, 95% confidence interval [CI]: 1.185 to 11.517) and the period greater than 1 month between operative time and the latest acute cholangitis attack (P=.02, OR=4.144, 95% CI: 1.248 to 13.757) were the independent risk factors for development of bile leakage after hepatectomy for hepatolithiasis. The septic complications were higher in the patients with bile leakage than in those without bile leakage (ie, wound infection: 56.5% vs 13.5%, P=.001; subphrenic abscess: 21.7% vs 4.8%, P=.01; septicemia: 8.7% vs 0.7%, P=.029). Percutaneous drainage or combined endoscopic naso-biliary drainage was the first choice of treatment for bile leakage; 20 (87.0%) of 23 patients were treated by this method. One patient underwent re-operation for diffuse peritonitis due to withdrawal of T tube inadvertently at postoperative day 1. Two patients with bile leakage were re-operated due to uncontrollable hemobilia at postoperative day 5 and 12, respectively. CONCLUSIONS: Patients who underwent hepatectomy at the period less than 1 month after the latest attack of acute cholangitis carry high risk for the development of bile leakage. Preoperative cholangiography to identify the aberrant hepatic duct for high risk patients and avoidance of hepatectomy at the acute phase of cholangitis are of critical importance to prevent bile leakage after hepatectomy. Percutaneous drainage is the primary and effective treatment for bile leakage.     

Treatment of osteonecrosis of the femoral head with hBMP-2-gene-modified tissue-engineered bone in goats

The efficacy of beta-tricalcium phosphate (beta-TCP) loaded with bone morphogenetic protein-2 (BMP-2)-gene-modified bone-marrow mesenchymal stem cells (BMSCs) was evaluated for the repair of experimentally-induced osteonecrosis of the femoral head in goats. Bilateral early-stage osteonecrosis was induced in adult goats three weeks after ligation of the lateral and medial circumflex arteries and delivery of liquid nitrogen into the femoral head. After core decompression, porous beta-TCP loaded with BMP-2 gene- or beta-galactosidase (gal)-gene-transduced BMSCs was implanted into the left and right femoral heads, respectively. At 16 weeks after implantation, there was collapse of the femoral head in the untreated group but not in the BMP-2 or beta-gal groups. The femoral heads in the BMP-2 group had a normal density and surface, while those in the beta-gal group presented with a low density and an irregular surface. Histologically, new bone and fibrous tissue were formed in the macropores of the beta-TCP. Sixteen weeks after implantation, lamellar bone had formed in the BMP-2 group, but there were some empty cavities and residual fibrous tissue in the beta-gal group. The new bone volume in the BMP-2 group was significantly higher than that in the beta-gal group. The maximum compressive strength and Young's modulus of the repaired tissue in the BMP-2 group were similar to those of normal bone and significantly higher than those in the beta-gal group. Our findings indicate that porous beta-TCP loaded with BMP-2-gene-transduced BMSCs are capable of repairing early-stage, experimentally-induced osteonecrosis of the femoral head and of restoring its mechanical function.     

Effects of cyclic vs. daily treatment with human parathyroid hormone (1-34) on murine bone structure and cellular activity

Previously, we demonstrated that the human parathyroid hormone (1-34) fragment (hPTH(1-34)) increased bone strength in proportion to its effects on BMD and cortical bone structure in the murine femur by comparing cyclic vs. daily administration of hPTH(1-34). Both cyclic and daily regimens increased vertebral BMD similarly at 7 weeks. Here, we have examined the effects of daily and cyclic PTH regimens on bone structure and cellular activity by static and dynamic histomorphometry. Twenty-week-old, intact female C57BL/J6 mice were treated with the following regimens (n=7 for each group): daily injection with vehicle for 7 weeks [control]; daily injection with hPTH(1-34) (40 microg/kg/day) for 7 weeks [daily PTH]; and daily injection with hPTH(1-34) (40 microg/kg/day) and vehicle alternating weekly for 7 weeks [cyclic PTH]. At days 9 and 10, and 2 and 3 prior to euthanasia, calcein (10 mg/kg) was injected subcutaneously. At the end of study, the lumbar vertebrae 1-3 and the left femora were excised, cleaned, and processed for histomorphometry. In the lumbar vertebrae, daily and cyclic PTH regimens significantly increased cancellous bone volume (BV/TV), trabecular number, trabecular osteoclast and osteoblast perimeters, trabecular mineral apposition rate (MAR) and bone formation rate (BFR), and periosteal MAR and BFR compared to control, with no significant difference between the two PTH-treated groups. Increased trabecular tunneling was observed in both PTH-treated groups. Both regimens tended to increase vertebral cortical bone formation parameters with the effects at the periosteum site being more marked than those at the endosteum site, resulting in a significant increase in cortical width. In the femur, the effects of cyclic PTH on BV/TV, trabecular width and number, trabecular and endocortical osteoblast and osteoclast perimeters, cortical width, and trabecular and periosteal BFR were less marked than those of daily PTH. A cyclic PTH regimen was as effective as a daily regimen in improving cancellous and cortical bone microarchitecture and cellular activity in the murine vertebra.     

腹腔镜直肠前切除术后吻合口漏的预防和处理

目的探讨腹腔镜下直肠癌前切除术术后吻合口漏的预防和治疗对策。方法回顾2001年9月至2006年11月对227例直肠癌患者行腹腔镜直肠前切除术的临床资料。前期（90例）主要通过保护性造口预防和治疗吻合口漏,后期（137例）采用充分的引流、留置肛管、使用生物蛋白胶等预防措施和保守治疗方法。计量资料采用t检验,计数资料采用χ^2检验。结果227例中12例（5.28%）术后发生吻合口漏。前期和后期手术后吻合口漏发生率分别为5.6%（5/90）、5.1% （7/137）,χ^2=0.022,P=0.88,但前期5例吻合口漏中有4例行腹腔镜再手术并预防性造口,后期手术中6例（占6/7）吻合口漏经保守治疗后愈合,另1例因术后早期发生吻合口漏而接受再手术。5例再手术均于腹腔镜下完成,无中转开腹病例,后期再手术1例未行保护性造口。结论腹腔镜下再手术是治疗直肠手术后吻合口漏的有效方式,腹腔镜于术预防吻合口漏的一系列措施增加了保守治疗的成功率。     

Height outcome of patients with congenital adrenal hyperplasia due to 21-hydroxylase deficiency

Objective:To retrospectively investigate the height outcome of patients with congenital adrenal hyperplasia(CAH)due to 21-hydroxylase deficiency(21-OHD).Methods:The 135 CAH patients with 21-OHD diagnosed in our hospital from Jan 1980 to Oct 2006 were retrospectively analyzed.The investigated parameters included final height(FH),FH standard deviation score(FH SDS),target height SDS(TH SDS),difference between TH and FH(TH-FH),FH SDS-TH SDS,the age of onset of sexual development,and the difference between bone age and chronological age(BA-CA)when patients got the FH.Results:Among the 135 patients,female/male=108/27.Mean FH was(156.8±5.4)cm(n=14)and(150.8±6.8)cm(n=76)for males and females,respectively.Mean FH SDS was(-0.6±0.8)(n=13)and(0.2±1.2)(n=54)for males and females,respectively.Sexual development began at(5.2±1.7)years old(y/o)(n=13)and(7.9±3.2)y/o(n=43)in males and females,respectively.Conclusions:The FH of CAH patients with 21-OHD was lower than that of the normal range.Effect of the disease on the height growth in male patients was more severe than that in females.All patients began sexual development much earlier than the normal age-matched group.Male patients began their sexual development even earlier.