Limb salvage after infrainguinal bypass graft failure

OBJECTIVE: The purpose of this study was to examine the outcome of patients in whom an infrainguinal bypass graft failed. METHODS: This was a retrospective analysis of consecutive patients undergoing infrainguinal bypass grafting in a single institution over 8 years. RESULTS: Six hundred thirty-one infrainguinal bypass grafts were placed in 578 limbs in 503 patients during the study period. The indication for surgery was limb-threatening ischemia in 533 patients (85%); nonautologous conduits were used in 259 patients (41%), and 144 (23%) were repeat operations. After a mean follow-up of 28 +/- 1 months (median, 23 months; range, 0-99 months), 167 grafts (26%) had failed secondarily. The rate of limb salvage in patients with graft failure was poor, only 50% +/- 5% at 2 years after failure. The 2-year limb salvage rate depended on the initial indication for bypass grafting: 100% in patients with claudication (n = 16), 55% +/- 8% in patients with rest pain (n = 49), and 34% +/- 6% in patients with tissue loss (n = 73; P <.001). The prospect for limb salvage also depended on the duration that the graft remained patent. Early graft failure (<30 days; n = 25) carried a poor prognosis, with 2-year limb salvage of only 25% +/- 10%; limb salvage was 53% +/- 5% after intermediate graft failure (<2 years, n = 110) and 79% +/- 10% after late failure (>2 years, n = 15; P =.04). Multivariate analysis revealed shorter patency interval before failure (P =.006), use of warfarin sodium (Coumadin) postoperatively (P =.006), and infrapopliteal distal anastomosis (P =.01) as significant predictors for ultimate limb loss. CONCLUSION: The overall prognosis for limb salvage in patients with failed infrainguinal bypass grafts is poor, particularly in patients with grafts placed because of tissue loss and those with early graft failure.     

Routine early postoperative duplex scanning is unnecessary following uncomplicated carotid endarterectomy

Although early postoperative duplex scanning has become routine after carotid endarterectomy (CEA), it is unclear whether the results of these scans alter clinical management. The purpose of this study was to critically examine the usefulness of early postoperative duplex scans in evaluating the ipsilateral carotid artery (for technical perfection) as well as the contralateral carotid artery (for potential velocity changes after improvements in ipsilateral flow). Consecutive patients undergoing CEA between January 1995 and June 1999 in a tertiary hospital setting were studied. Patients underwent early postoperative duplex scanning according to the discretion of the operating surgeon and the availability of the patient. In 212 patients 236 CEAs were performed with selective use of patch closure (49%), intraluminal shunting (19%), and intraoperative completion imaging studies (14%). Neurologic complications included 3 transient ischemic attacks (TIAs) (1.3%), 3 nondisabling strokes (1.3%), and 3 disabling strokes (1.3%). There was 1 30-day death from myocardial infarction. Patients were followed up for a median of 18 months (range 0-72 months). Sixty-five percent of patients undergoing uncomplicated CEA (147/227) underwent early duplex surveillance within 6 months of operation. Unsuspected sonographic abnormalities were discovered in 8 patients (5%), including 7 cases of mild internal carotid artery (ICA) stenosis (>50% by velocity criteria) and 1 case of common carotid artery (CCA) stenosis (intimal flap). None of the patients with ICA stenosis developed symptoms or required operation at any time. The CCA intimal flap was electively repaired without complication. Postoperative changes in velocity in the contralateral ICA were found in 8/48 (17%) cases. There were 3 cases of increased velocity, upgrading 1 from 0-49% to 50-79% stenosis and upgrading 2 from 50-79% to 80-99% stenosis. The latter patients both underwent uneventful contralateral CEA. There were 6 cases of decreased velocity, resulting in downgrading of stenoses from 50-79% to 0-49% (n=5) or from 80-99% to 50-79% (n=1). Only the latter patient underwent contralateral CEA; the remainder have been followed up without intervention. Early scanning appeared to offer no clinical benefit; survival and neurologic outcome were the same in the 135 patients scanned within the first 6 months as in the 68 patients whose first postoperative scan occurred later (4-year neurologic event rate 0% in both groups; patient survival with early duplex 98 +/- 1.5%, without early duplex 96 +/- 2.6%; = NS). Early ipsilateral duplex abnormalities following CEA are infrequent in asymptomatic patients and, even if found, rarely alter management. Patients with bilateral stenosis being considered for contralateral CEA should undergo repeat duplex scanning after the first operation, because of the significant rate (19%) of contralateral velocity changes induced by ipsilateral CEA.     

急性有机磷农药中毒120例的救治

0　引言　近年来 ,我科在救治急性有机磷农药 (organophos-phorus,OP)中毒方面 ,积累了一些经验 ,现报告如下 .1　对象和方法1 .1　对象　本组 1 2 0例符合《急诊急救学》中的诊断标准 [1 ](男 2 9例 ,女 91例 ) ,年龄 1 .5～ 70岁 ,平均 2 8.6岁 .经口中毒 99例 ,经皮肤中毒 2 1例 .轻度中毒 1 5例 ,中度中毒 42例 ,重度 (含极重度 )中毒 6 3例 . 1 996年 39例 ,1 997年 43例 ,1 998年 38例 . DDV 79例 ,乐果 2 0例 ,混合性中毒 1 0例 ,水胺磷 3例 ,氧化乐果、 391 1、 1 0 5 9、对硫磷各 2例 ,敌百虫 1例 ,药名不详 1 0例 .服毒量 >2 5 …     

Chronic pancreatitis: ultrasonic features

A retrospective analysis of 84 ultrasound examinations (in 77 patients) was performed to assess the frequency of sonographic findings in chronic pancreatitis. The findings included: inhomogeneously increased echogenicity in 53% of these examinations, focal or diffuse enlargement in 41%, focal dense echoes in 40%, pseudocyst formation in 21%, and a hypoechoic head mass in 7%. Thirteen per cent of our patients had a normal sonogram. Several presentations of chronic pancreatitis not previously described in the sonographic literature included: pancreatic or common bile duct enlargement or pseudocyst formation with otherwise normal-appearing glands. There was no direct relationship between the presence of focal high-intensity echoes within the pancreatic parenchyma and the presence of radiographic calcification. There was no difference in the frequency of ultrasonic abnormalities between patients with and without clinical evidence of pancreatic insufficiency. These results indicate that the sonographic findings in chronic pancreatitis are significantly more varied than previous reports would indicate.     

T1N0M0 bronchogenic carcinoma: assessment by CT

We reviewed medical records and conventional chest radiographs that showed a solitary T1N0M0 nodule in 23 patients who had non-oat-cell bronchogenic carcinoma. No patient had evidence of metastases, either on the chest radiograph or clinically. All patients underwent computed tomography (CT) examination of the thorax, including the adrenal glands. Only one patient (4%) had mediastinal lymph nodes greater than 1 cm in diameter accessible to mediastinotomy; anterior mediastinotomy confirmed metastatic spread in this patient, which precluded curative resection. Three patients each had a mildly enlarged (2 cm or less) adrenal gland; however, follow-up study suggested that metastasis was not the cause of adrenal enlargement in these patients. This study reinforces concern over whether CT is warranted in the preoperative assessment of T1N0M0 bronchogenic carcinoma.     

子宫颈妊娠1例

１　病例报告　患者,２８岁,因“停经３ｍｏ余,不规则阴道流血２ｍｏ余,于１９９９－０６－３０入院．患者１９９３年足月妊娠剖宫产一男婴．末次月经１９９９－０３－１２,０６－１４始阴道少量流血,无腹痛．０４－２８当地医院Ｂ超提示“不全流产”,未行清宫术．...     

神经节苷脂GM1对乙醇引起的神经膜磷脂脂肪酸参入变化的影响

研究神经节苷脂ＧＭ１对乙醇引起的神经膜磷脂的脂肪酸参入变化的影响。使用同位素标记的脂肪酸测定其对神经膜磷脂不同组分的参入率，比较ＧＭ１和乙醇对参入率的影响。慢性乙醇暴露发迹了不饱和脂肪酸「油酸，亚油酸，花生四烯酸和二十二碳六烯酸」参入到旨酰肌醇，磷脂酰丝氨酸和磷脂酰胆碱。     

LATE-ONSET GM2 GANGLIOSIDOSIS PRESENTING AS BURNING DYSESTHESIAS

Peripheral polyneuropathy is the most frequent complication of diabetic mellitus. In spite of many clinical trials of different specific interventions for diabetic polyneuropathy, intensive glycemic control remains the only effective specific therapy currently available for this troublesome complication. This systematic overview reports the status of current clinical trials in diabetic polyneuropathy with an emphasis on those interventions directed towards specific pathophysiological derangements. A discussion of clinical trials of agents directed towards relieving painful symptoms of diabetic polyneuropathy concludes this overview.