Thymectomy by partial sternotomy for the treatment of myasthenia gravis

BACKGROUND: Myasthenia gravis is an autoimmune disease characterized by weakness and fatigue of voluntary muscles. Surgical treatment of choice for myasthenia gravis has been thymectomy. However, thymectomy indications and surgical approach are still controversial. The purpose of this study is to evaluate the efficacy of partial median sternotomy approach to the thymus. METHODS: From 1973 to 1999, 478 patients with myasthenia gravis underwent thymectomy through a partial median sternotomy. RESULTS: Sixty-one patients (12.7%) had complete remission of symptoms, 299 (62.5%) had a significant improvement, and 83 (17.4%), a mild improvement; whereas 35 patients (7.4%) had no improvement of clinical symptoms. CONCLUSIONS: Partial median sternotomy has shown to be a useful surgical approach to the thymus, as demonstrated by the good functional and aesthetic results, associated with low morbidity and no mortality.     

The risk of stroke following coronary revascularization -- a population-based long-term follow-up study

OBJECTIVE: To study the incidence and risk factors of stroke after coronary artery bypass grafting (CABG) or percutaneous transluminal coronary angioplasty (PTCA). DESIGN: During 1983-1992, coronary revascularization procedures (n = 2160) were recorded in patients aged 35-64 years as part of the population-based FINMONICA Myocardial Infarction Register. The FINMONICA Stroke Register and National Hospital Discharge Register were used to ascertain subsequent stroke events in such patients. RESULTS: During the average follow-up of 5.83 years, 155 patients (7.2%) had a stroke. The cumulative incidence of stroke was 1.55% in the first year after revascularization and varied between 0.8 and 1.4% during subsequent years. In Cox proportional hazard models the relative risk of stroke was 3.01 (p = 0.0007) for a previous stroke, 2.61 (p = 0.0001) for diabetes mellitus, 2.15 (p = 0.007) for low income (compared with high income), 2.06 (p = 0.03) for male sex, and 1.43 (p = 0.02) for a 10-year increment in age. CONCLUSION: The incidence of stroke during the first year after revascularization was five times higher than among the age- and sex-matched general population. Patients with a previous stroke, diabetes mellitus, advanced age, male sex and low socioeconomic status need special attention because of increased risk of stroke after CABG or PTCA.     

Isoniazid-related hepatic failure in children: a survey of liver transplantation centers

BACKGROUND: Isoniazid (INH) therapy for tuberculosis carries a known risk for hepatoxicity, and leads to hepatic failure in a small subset of patients. This incidence has been described for adults, but is uncertain in children. Our aim was to estimate the incidence of pediatric referrals for INH-related liver failure, and to describe the characteristics and outcomes of these patients. METHODS: The 84 U.S. centers performing pediatric liver transplants between 1987 and 1997 were surveyed regarding patients with INH-induced liver failure. Additional transplant statistics were obtained from the United Network for Organ Sharing. Estimates of the number of children taking preventive INH were derived from a nationwide public health database. RESULTS: Twenty cases of INH-related liver failure were found during a 10-year period. Four patients (20%) recovered spontaneously; 10 (50%) underwent orthotopic liver transplantation (OLT), while six (30%) died awaiting OLT. Mean age at presentation was 9.8 years (range 1.3-17). Mean length of INH therapy was 3.3 months (range 0.5-9). Notably, five patients seen for symptoms of hepatitis were initially told not to stop treatment. INH-associated liver failure accounted for 0.2% (8 of 4679) of all pediatric OLTs, and 14% (8/56) of transplants for drug hepatoxicity. The estimated incidence of liver failure was up to 3.2/100,000 for children on prophylactic INH. CONCLUSIONS: While INH-associated liver failure in children is rare, discontinuation at the onset of symptoms does not assure recovery. This indicates a need for increased awareness of hepatotoxicity risk, expanded biochemical monitoring for children receiving INH, and prompt withdrawal in symptomatic patients.     

KiSS-1和E钙黏蛋白在贲门癌组织中的表达及临床意义

目的检测KiSS-1及上皮细胞E钙黏蛋白（E—cadherin）在贲门癌组织中的表达，探讨其临床意义及两者的相关性。方法采用免疫组织化学方法检测80例贲门癌、20例正常贲门组织中KiSS-1及E钙黏蛋白的表达情况。分析其与相关临床病理参数的关系以及两者表达的相关性。结果KiSS-1的表达与贲门癌的临床分期、淋巴结转移呈负相关（均P〈0．05），与分化程度无相关性（均P〉0．05）；E钙黏蛋白的表达与贲门癌的临床分期、淋巴结转移、分化程度均呈负相关（均P〈0．05）。Spearman等级相关分析显示，KiSS-1与E钙黏蛋白在贲门癌中的表达呈正相关（rs=0．722，P〈0．05）。结论KiSS-1与E钙黏蛋白可能在抑制贲门癌的侵袭和转移过程中起重要作用。     

增强抗原呈递功能的树突状细胞疫苗

树突状细胞（DC）疫苗的研究已成为当前肿瘤免疫治疗的一大热点。随着对DC的不断认识,其强大的功能可塑性为发展增强其抗原呈递功能的DC疫苗提供了新思路,现就DC疫苗增强其抗原呈递功能的种种途径进行综述。     

肱桡关节炎的超声诊断与综合治疗

[目的]探讨超声在诊断肱桡关节炎的价值和综合治疗的效果。[方法]应用高频超声探头对34例肱桡关节炎病人进行检查诊断，从超声表现上与“网球肘”相鉴别，并根据超声、临床表现和普通X线片进行临床分期，针对病情采用不同的方法进行治疗。[结果]制动、局部糖皮质激素封闭治疗5例，症状消失，复诊B超关节囊恢复正常。关节腔内注射玻璃酸钠10例，8例症状消失，关节内积液消失，B超检查关节间隙恢复正常。Ⅲ型在关节镜下手术2例，镜下手术包括病变滑膜切除，关节冲洗，病变软骨修整手术开放手术1例，滑膜切除、关节软骨修复桡骨小头切除。随访3个月-2年，开放手术治疗功能恢复效果不如关节镜手术。局部疼痛症状均消失，3例病人有5。左右的旋转功能受限。开放手术桡骨小头切除病例肘关节屈曲5。受限。[结论]超声作为一种无创、精确、简易、经济的检查手段对诊断肱桡关节炎有重要的作用。根据临床分型采取不同综合治疗方法治疗取得了良好的临床效果。     

A validation trial of subdermal injection compared with intraparenchymal injection for sentinel lymph node biopsy in breast cancer

Sentinel lymph node (SLN) biopsy is increasingly being used as an accurate and less morbid surrogate for axillary dissection. However, a standardized technique in the biopsy of SLNs is not used. Some authors propose subdermal injection to be as accurate as peritumoral intraparenchymal injection (IPI). Our objective is to determine whether the SLNs identified by subdermal injection truly represent SLNs and match those found with IPI. Specific end points of the study were 1) successful localization of the SLN by the IPI of isosulfan blue or the radiocolloid intradermal injection, 2) successful uptake of radiocolloid and isosulfan blue on individual SLN, and 3) determination of the frequency with which the radiocolloid injection detected the "gold standard" blue SLN. SLNs were found in 71 of 73 cases (success rate = 97%). Blue SLNs were identified in 64 patients (88%). SLNs in 61 patients (84%) were radioactive. A total of 112 SLNs were identified in 71 patients (1.6 nodes/patient). Seventy-six of 87 SLNs found with IPI were also radioactive (concordance of 87%). All SLNs harboring metastatic cancer (16 patients) were found by both techniques, being both blue and radioactive. Our results support the concept of shared lymphatic pathways in the breast with a high degree of communication between the subdermal lymphatics and the intraparenchymal lymphatics. The success in identification of the SLN is made simpler and improved by the addition of subdermal radiocolloid injection.     

乌司他丁对肺癌切除术患者的肺保护效应

目的 探讨乌司他丁对肺癌切除术患者的肺保护效应.方法 选择拟行肺叶切除术的Ⅲ期肺癌患者40例,年龄50～64岁,体重53～70 kg,ASA分级Ⅱ或Ⅲ级,随机分为2组(n=20):对照组(C组)和乌司他丁组(U组).均采用咪达唑仑-芬太尼-维库溴铵-异丙酚麻醉诱导,异丙酚-芬太尼-维库溴铵维持麻醉.麻醉诱导后单肺通气前,U组经30 min静脉注射乌司他丁10 000 U/kg(生理盐水稀释至20 ml),C组给予等容量生理盐水.于麻醉诱导前即刻(T0)、单肺通气0.5 h(T1)、1 h(T2)、术后4 h(T3)、24 h(T4)时采集动脉血样5 ml,行动脉血气分析,计算呼吸指数(RI),并测定血浆IL-6、IL-10和TNF-α浓度.结果 与T0时比较,C组T1～4时血浆TNF-α、IL-6浓度和RI升高,T1-3时血浆IL-10浓度升高(P＜0.05),U组T2,3时血浆TNF-α和IL-6浓度升高,T1～4时血浆IL-10浓度和RI升高(P＜0.05).与C组比较,U组血浆TNF-α、IL-6浓度和RI降低,血浆IL-10浓度升高(P＜0.05).结论 乌司他丁10 000 U/kg可通过减轻全身炎性反应从而对肺癌切除术患者产生肺保护效应.     

全麻手术患者LMAS喉罩和SLIPA喉罩气道管理的效果

目的 比较全麻手术患者LMAS喉罩和SLIPA喉罩气道管理的效果.方法 择期全麻手术患者80例,年龄18～70岁,体重45～80 kg,ASA分级Ⅰ或Ⅱ级,随机分为2组(n=40):LMAS喉罩组(L组)和SLIPA喉罩组(S组).麻醉诱导后置入喉罩,行机械通气.记录MAP和HR、喉罩置入情况、喉罩置入时间、气道密闭压、最高气道压、平均气道压、置入喉罩后返流和误吸的发生情况、拔除喉罩后粘血的发生情况及术毕和术后24 h内咽痛的发生情况.结果 两组MAP和HR差异无统计学意义(P＞0.05).两组喉罩全部置入成功,一次置入成功率差异无统计学意义(P＞0.05).与L组比较,S组喉罩置入时间延长,气道密闭压降低(P＜0.05),最高气道压和平均气道压差异无统计学意义(P＞0.05).两组均未发生返流和误吸.与L组比较,S组喉罩粘血和术毕咽痛的发生率升高(P＜0.05),术后24 h内咽痛的发生率差异无统计学意义(P＞0.05).结论 LMAS喉罩和SLIPA喉罩置入简单易行,气道密封效果好,可有效保证通气,不良反应少.LMAS喉罩用于全麻手术患者气道管理的效果更好.     

低流量七氟烷吸入麻醉时不同二氧化碳吸收剂环路中化合物A浓度的比较及其对患者肝肾功能的影响

Objective To investigate the influence of different carbon dioxide (CO2) absorbents (Dr(a)gersorb 800 plus , Sodasorb,Sodasorb LF) on the production of compound A during low-flow sevoflurane anesthesia.Methods Twenty-seven ASA Ⅰ or Ⅱ patients aged 20-64 years were randomly assigned to three groups according to different CO2 absorbents: Dr(a)gersorb 800 plus' group (group D, n = 10), Sodasorb group (group S, n = 10) and Sodasorb LF group (group LF, n = 7). Anesthesia was maintained with low-flow (500 ml/min) sevoflurane inhalation (with the end-tidal sevoflurane concentration of approximately 2% ). At 2 h after low-flow sevoflurane anesthesia, gas samples were taken from the expiratory limb of the circuit. Compound A was detected by gas chromatography. Serum alanine transaminase (ALT), aspartate aminotransferase (AST), bilirubin (BR), urea nitrogen (BUN) and creatinine (Cr) levels were measured before (T0 ) and 24 h after operation (T1).Results The three groups were comparable with respect to age, body weight and height. After 2 h of low-flow sevoflurane anesthesia, compound A concentrations in the expiratory limb of the circuit were 11.6 ± 5.8 (group D), 2.1 ± 1.9 (group S)and ＜ 0.1 ppm (group LF), respectively. There were no significant changes in the serum ALT, AST, BR, BUN and Cr levels at 24 h after operation as compared with the preoperative baseline values in the three groups.Conclusion After 2 h of low-flow (500 ml/min) sevoflurane anesthesia, compound A concentrations within the circuit with different CO2 absorbents ( Dr(a)gersorb 800 plus' , Sodasorb, Sodasorb LF) are less than 50 ppm, with the lowest in Sodasorb LF.However, they have no significant effects on hepatic or renal function.