选择性血流阻断配合超声乳化吸引刀切除中央型肝肿瘤

目的 探讨选择性血流阻断配合超声乳化吸引刀切除中央型肝肿瘤的效果.方法 选择性阻断肿瘤所在肝叶的进出血流,超声乳化吸引刀解剖,行中央区肝段切除.结果 自2006年7月至2008年1月,采用这种外科技术治疗中央型肝肿瘤46例.本组患者术前肝功能Child A级43例,Child B级3例.39例患者一次性肝区域性全血流阻断8～33 min.术中出血量100～2400ml,平均490ml.43例术后在一周内肝功能恢复至A级;3例术后出现腹水,其中1例并发黄疸;2例发生胆瘘;1例胃瘫,1例术后第3天并发大面积心梗死亡.35例恶性肿瘤患者中位随访9个月,1例患者术后10个月因肿瘤腹腔及肝内转移死亡,34例患者至今无瘤生存.结论 肝区域性进出血流阻断能有效控制切肝时的出血;应用超声乳化吸引刀切肝,解剖清晰,综合应用这两种技术,能较安全地切除肝脏任何部位的肿瘤.     

Difficulties in diagnosing intrinsic spinal cord tumours

Thirteen children with intrinsic spinal cord tumours were seen between 1984 and 1995. In only one was this the presumptive diagnosis at referral, despite a high incidence of characteristic features. Eight had presented to their local paediatrician, four to local orthopaedic teams, and one to a general surgeon. Eleven had back pain. Eleven had either spinal curvature or change in gait. The interval between onset of symptoms and diagnosis ranged from one week to six years, with a mean of 17.5 months. In nine children symptoms had been present for four or more months. In nine, unrewarding investigations had been carried out. This paper highlights typical presenting features of these tumours and how earlier diagnosis can be achieved.     

Timing of intraventricular haemorrhage

The detection of the onset of intraventricular haemorrhage (IVH) during life is a necessary preliminary to understanding the cause of this condition. In 10 infants of very low birthweight treated with serial transfusions of adult blood the proportions of transfused cells circulating after each transfusion were compared with the proportion of transfused cells found in the intraventricular clot at necropsy. This allowed the timing of IVH to be restricted retrospectively to the period between consecutive blood transfusions. In addition, the proportional changes of transfused cells produced by infusion of a known red cell mass allow changes in the babies' original red cell mass to be followed during life. A fall in this value occurred in 8 infants dying with IVH and was taken to indicate haemorrhage. Comparison of the two methods in 9 infants suggested that, while in some cases intraventricular bleeding occurs rapidly, in others it takes place over a period of time. The interval between birth and the onset of haemorrhage was directly proportional to the gestational age of the infant.     

Significant changes in the surgical methods and length of hospital stay of hip fracture patients occurring over 10 years in Central Finland

BACKGROUND AND AIMS: The objective of this study is to determine the changes occurring in the treatment chain and mortality of hip fracture patients in Central Finland over a ten-year period. In order to cope with an aging population and increasing cutbacks in the health care system, health-center hospitals run by general practitioners have taken a more active role in the rehabilitation of elderly patients. MATERIAL AND METHODS: Patients with acute hip fracture admitted to Jyv?skyl? Central Hospital in 1982-1983 (n = 317) and in 1992-1993 (n = 351) were collected from the hospital discharge register and the medical records of these patients were studied retrospectively. RESULTS: The median length of central hospital stay diminished from 18 days to 5 days and the percentage of hip fracture patients discharged to cope on their own diminished from 22 % to only 7 %. The percentage of trochanteric fractures treated by osteosynthesis increased from 83 % to 96 % and the percentage of cervical fractures treated by hemiprosthesis increased from 35 % to 76 %. First-year mortality has remained almost unchanged. CONCLUSIONS: There has been a dramatic change in surgical methods, in the length of hospital stay on the traumatology ward, and in discharge patterns and no change in mortality during the last 10 years in Central Finland.     

The changing picture of hip fractures: dramatic change in age distribution and no change in age-adjusted incidence within 10 years in Central Finland

The objective of this study was to find out if the age-standardized incidence of hip fractures has changed in 10 years in Central Finland. Patients with acute hip fracture admitted to Jyv?skyl? Central Hospital in 1982-1983 (n = 317) and in 1992-1993 (n = 351) were selected from the hospital discharge register and from contemporaneous records of the Department of Anesthesiology and the ward of traumatology. Earlier studies in Finland have indicated that there has been an increase in incidence rates. The results of this study show no change in the age-standardized incidence of hip fractures of men and women during the last 10 years. However, because of the change in the age distribution of the population, the number of hip fractures has increased by 11%. The mean age of the hip fracture patients increased from 75.4 years in 1982-1983 to 78.4 years in 1992-1993. In 1982-1983, 18.0% of the patients were > or =85 years. The corresponding figure in 1992-1993 was 30.2%. Therefore, we summarize that there has been a dramatic change in age distribution and no change in age-adjusted incidence within the last 10 years in central Finland.     

Cerebral amyloid angiopathy in a 95+ cohort: complement activation and apolipoprotein E (ApoE) genotype

There is growing evidence that in Alzheimer's disease (AD) amyloid beta-protein (Abeta) triggers a chronic inflammatory reaction in cerebral amyloid plaques, including complement proteins. Abeta also accumulates cerebrovascularly in age- and AD-associated cerebral amyloid angiopathy (CAA). We investigated complement proteins in CAA in a population-based series using histological and immunohistochemical staining methods. The 74 subjects, aged 95 years or more, had undergone clinical neurological examination and apolipoprotein E (ApoE) genotyping. The brains had been studied for AD post-mortem, allowing us to relate the histopathological findings to clinical and genetic conditions. CAA with congophilic amyloid was found in 36/74 individuals (48.6%). The vascular amyloid deposits immunoreacted with antibodies to Abeta and complements 3d (C3d) and 9 (C9). The positivity in complement stains increased with growing severity of CAA (P = 0.001). The presence of CAA associated with ApoE epsilon4 (P = 0.0005) and overrepresentation of epsilon4 among those with moderate or severe vs. mild CAA (P = 0.03) was demonstrated. The presence of CAA associated with dementia (P = 0.01), which was contributed by both epsilon4+ (P = 0.02) and epsilon4- (P = 0.06) subjects. Our study shows that complement proteins are deposited in the affected vessels in Abeta-associated CAA. They may solely represent the cerebral Abeta- burden associated to inflammatory stimuli, or signal a contribution in the clearance of cerebral Abeta, thereby contributing to the events associated with evolution of clinical dementia. Our results demonstrate a strong association between CAA and ApoE epsilon4 as well as dementia and suggest that the contribution of CAA to dementia is largely independent of ApoE epsilon4.     

Apolipoprotein E, cognitive function, and dementia in a general population aged 85 years and over

We examined 510 subjects representing 83.2% of all citizens of a Finnish city aged 85 years or over. Mini-Mental State Examination (MMSE) scores, diagnosis of dementia by DSM-III-R criteria, and Apo-E genotype were determined. The prevalence of dementia was 38.6%. The odds ratio (OR) of the Apo-E epsilon4 carriers (with the reference population of people with the genotype epsilon3/epsilon3) for dementia was 2.36 (95% CI 1.58 - 3.53). There was a significant sex difference: The OR in women was 3.23 (95% CI 2.02 - 5.17) whereas among men it was insignificant. The mean MMSE score (+/- SD) among the Apo-E epsilon4 carriers (15.0 +/- 10.0) and noncarriers (18.7 8.6) (p < .001) differed among the whole population, but not within the demented or nondemented subjects analyzed separately. This study does not support the hypothesis that the Apo-E epsilon4 allele impairs cognitive functions of nondemented elderly, at least in those surviving to very old age.     

Delirium in elderly people without severe predisposing disorders: etiology and 1-year prognosis after discharge

BACKGROUND: The etiologic factors of delirium have been frequently studied in hospitalized elderly patients who usually have an underlying disorder, i.e., hip fracture or dementia predisposing to delirium. The etiologic factors of delirium and prognosis in healthy elderly remain unstudied. The aim of our study was to detect the primary and additional etiologic factors contributing to delirium among community-dwelling healthy elderly people without predisposing disorders to delirium and to evaluate 1-year prognosis after discharge to home. METHOD: The study subjects consisted of 51 community-dwelling people over 65 years of age, without severe underlying disorders predisposing to delirium, admitted consecutively to the hospital because of a delirious state. The diagnosis of delirium was based on the DSM-III-R criteria. After discharge to home, the subjects were followed up for 1 year. RESULTS: The most important primary causes of delirium were infections in 22 cases (43%) and cerebrovascular attacks in 13 cases (25%). After the 1-year follow-up period, 10 patients (20%) had been taken into long-term care and 5 patients (10%) had died. DISCUSSION: The plausible etiologic factor of delirium was detected in all cases. Among healthy elderly people, infections and cerebrovascular attacks were the most important etiologic factors for delirium. After discharge to home, 30% of the patients had to be taken into long-term care or had died within 1 year of the delirium.     

APOE epsilon4 does not predict mortality, cognitive decline, or dementia in the oldest old

OBJECTIVE: To examine the effect of the epsilon 4 allele on cognitive decline in the oldest old. METHODS: We studied all 601 citizens of the city of Vantaa age 85 years and older in 1991. A total of 553 subjects (92%) took part in the study, which used the Mini-Mental State Examination (MMSE) and assessment of dementia according to the Diagnostic and Statistical Manual of Mental Disorders, third ed., revised (DSM-III-R) criteria. The survivors were re-examined 3 years later. APOE genotype was determined in 510 subjects, representing 83.2% of the original population. RESULTS: Approximately one-half of the subjects (n = 250) died before the follow-up, and 253 subjects (97.3% of the survivors) were re-examined. The occurrence of the APOE epsilon 4 allele did not have any significant effect on survival. Of the 187 previously nondemented subjects, 58 (31%) had developed dementia. The OR for the epsilon 4 carriers to develop dementia was not significant: OR = 1.78; 95% CI = 0.88 to 3.60. In individuals with a follow-up MMSE score (n = 222), the mean decline in the score was 3.1 points. APOE epsilon 4 carrier status did not have a significant effect on the mean MMSE change except in the previously demented subjects, among whom the drop was larger in the APOE epsilon 4 carriers. CONCLUSIONS: The lack of association between APOE epsilon 4 carrier status and mortality, or development of dementia, or cognitive decline in these very elderly people, whether analyzed in the whole population or among the nondemented subjects only, suggests that the APOE epsilon 4 effect in younger subjects is age-dependent, and that it is no longer present in very old age.