乳腺癌保乳手术的治疗及预后

目的探讨乳腺癌保乳手术的方式和预后。方法回顾性分析笔者所在2所医院10年间保乳治疗69例原发性乳腺癌患者的临床资料，包括保乳术不放疗和保乳术加放疗、化疗和激素治疗。随访12～140个月。结果保乳手术未放疗组3年复发率11．54％（3／26），显著高于手术加放疗组3．03％（1／33）（P〈0．05）。腋窝淋巴结阳性的保乳手术未化疗者，其5年远处转移率（50．0％）高于手术加化疗组（11．1％）（P〈0．05）。结论保乳术后应进行放疗；年轻、淋巴结阳 性、组织学分级Ⅲ级者应辅助化疗。     

Color Doppler Ultrasound Detection and Classification of the Tangential Hepatic Vein before Laparoscopic Cholecystectomy

Background: Unexpected fatal bleeding from the gallbladder bed during laparoscopic cholecystectomy is often associated with injury to the middle hepatic vein. This paper studies whether preoperative color Doppler ultrasound is effective in reducing the risk of injury. Also a venous classification is suggested. Methods: Between June 1999 and February 2004, 2,146 patients undergoing laparoscopic cholecystectomy by standard method received preoperative color Doppler ultrasound examinations. The closest distance between the hepatic vein and the gallbladder was studied. Also, cases of liver cirrhosis, number of conversions to open cholecystectomy, intraoperative blood loss, operative time, complications, and hospital stay were recorded (group D). At the end of the study, we retrospectively reviewed the same parameter of another 2,146 patients who received laparoscopic cholecystectomy without preoperative color Doppler ultrasound between the period of March 1995 and June 1999 (group ND). Results: In group D, 108 patients had cirrhosis. Four hundred and ninety-six patients (27 cases of cirrhosis) had a closest distance of 1 mm or less between the vein and the gallbladder. There were two conversions to open cholecystectomy, but none related to gallbladder bed bleeding. In group ND, there were five conversions, including four cases of gallbladder bed bleeding from the middle hepatic vein and one case of severe adhesion. The conversion rate was significantly higher. In group ND, the mean intraoperative blood loss in the cases of liver cirrhosis was significantly greater. Also, the operative time of patients with the closest vein and gallbladder distance of 1 mm or less in group D was significantly longer. Conclusions: Color Doppler ultrasound is an effective method for detecting the presence of potential bleeders. Although the operative time will be a bit longer, the operation can be done under meticulous care and complete preparation, so that the conversion rate and the risk of fatal hemorrhage can be reduced, especially in patients with liver cirrhosis.     

Prognostic value of acute physiology and chronic health evaluation II and organ system failure in patients with acute renal failure requiring dialysis

BACKGROUND: Despite advances in modern technology of dialysis, prognosis of patients with acute renal failure (ARF) remains poor. To give the clinicians the most useful information, a model that accurately predicts outcome early in the course of ARF is required. However, because ARF is a heterogeneous syndrome and occurs in patients with diverse etiologies and some coexisting diseases, predicting outcome early is hard. The aim of this study is to evaluate prospectively the Acute Physiology and Chronic Health Evaluation (APACHE II) and organ system failure (OSF) models, evaluated prior to dialysis, in predicting hospital mortality. METHODS: From June 2002 to March 2004, ARF patients requiring dialysis at Chang Gung Memorial Hospital, Chiayi, were prospectively recruited for this study. The worst clinical and laboratory data in the 24 hours before initiation of dialysis were prospectively evaluated, and the patients' APACHE II score and OSF number were assessed. RESULTS: A total of 61 patients (40 male and 21 female) were enrolled, of whom 38 (62.3%) died before discharge. By multivariate logistic regression, the APACHE II score (odds ratio 1.3 per increase in one score; P<0.001), or OSF number (odds ratio 1.9 per increase in one OSF; P<0.01) and oliguria (odds ratio 4.2; P=0.04), were found to be statistically significant prognostic factors for hospital mortality. Mortality increased progressively and significantly as OSF number (chi-square for trend; P=0.001) or the APACHE II score (chi-square for trend; P < 0.001) increased. By using Youden's index, the best cut-off value for APACHE II was 24, with 63% sensitivity and 96% specificity. The best cut-off value for OSF number was 2, with a sensitivity of 81.6% and a specificity of 60.9%. The areas under the receiver operating characteristic curves for APACHE II and OSF number were 0.847 (95% confidence interval (CI)=0.752-0.942; P<0.01) and 0.769 (95% CI=0.646-892; P<0.001), respectively, indicating good model discrimination. CONCLUSIONS: This study concludes that APACHE II and OSF number measured prior to initiation of dialysis reliably predict outcomes of ARF patients requiring dialysis. The mortality rates increase as the APACHE II score or OSF number increases. For predicting mortality, the APACHE II score > or = 24 was found to have 63% sensitivity and 96% specificity, and OSF number> or = 2 had 81.6% sensitivity and 60.9% specificity.     

Extrapulmonary tuberculosis in chronic hemodialysis patients

BACKGROUND: The incidence of extrapulmonary tuberculosis is higher in dialysis than general population. The aim of the study was to characterize clinical picture in dialysis patients, who developed extrapulmonary tuberculosis. METHODS: We retrospectively investigated the hemodialysis patients with extrapulmonary tuberculosis. 2208 hemodialysis patients were reviewed for extrapulmonary tuberculosis from October 1986 to January 2001. RESULTS: Seventeen patients (10 male, 7 female) were enrolled. The mean age was 57.4 +/- 12.4 years. The sites for extrapulmonary tuberculosis were peritoneum (35.3%, 6/17), cervical lymph node (17.6%. 3/17), bone marrow (5.9%, 1/17), spine (5.9%, 1/17), knee (5.9%, 1/17), brain (5.9%, 1/17), pericardium (5.9%, 1/17), cutaneous tissue (5.9%, 1/17) and genitourinary system (5.9%, 1/17). Fourteen of 15 tissue-biopsy specimens from suspicious sites revealed granulomatous inflammation. There were low yield in mycobacteria culture (11.1%, 1/9) and PCR (33.3%, 2/6). Three patients died during the treatment of the disease. CONCLUSION: Extrapulmonary tuberculosis constitutes a major part of tuberculosis in dialysis patients. Tissue biopsy with invasive procedures, such as laparoscopy or laparotomy, may be necessary if clinical presentations are suspicious.     

腰椎手术中的移行椎问题

目的：探讨移位椎的定位方法和移行椎对腰椎手术的影响。方法：回顾性分析了52例腰椎疾患手术治疗的病例，其中腰椎间盘突出症26例，腰椎骨折15例，腰椎滑脱9例，腰椎结核2例，术前均经过X线摄片、CT或MRI检杳。结果：腰部疾患合并移行椎的病例并不少见，本组病例占同期腰椎手术病人的5．3％。腰椎出现移行椎，其定位则石L4—S1，L5—L6，L6—S1。结论：腰部疾患合并移行椎时，腰椎数量发生改变，定位诊断非常重要。要确定手术部位，X线定位片(包括术中X线透视定位)、CT或MRI片缺一不可，但必须注意的是，腰椎CT和MRI检查结果是以骶椎为基准定位，也就是从下往上定位，普通X线片是从上往下序列，两定位诊断的差异，手术时必须高度重视。     

1962名男性新兵人格诊断问卷(PDQ-4~+)结果分析

目的了解部队新兵人格倾向特征。方法采用人格诊断问卷(PDQ-4+)对某部队1 962名男性新兵进行抽样调查,并与大学生样本进行比较。结果 (1)除表演型、反社会型分量表外,新兵其他各分量表及总量表得分均显著低于大学生(P<0.05);新兵人格倾向亚型的阳性检出率在7.25%~36.07%。(2)低年龄组新兵在偏执型、分裂型、自恋型、边缘型、反社会型、依赖型分量表及总量表的得分均高于高年龄组新兵(P<0.05);父母关系和睦的新兵各个人格倾向亚型(除强迫型外)得分均显著低于父母关系不和睦新兵的得分(P<0.05);农村与城市新兵的偏执型、分裂型、表演型、自恋型、边缘型、反社会型和被动攻击型分量表得分,差异有统计学意义(P<0.05),且城市新兵人格障碍得分更高(P<0.05);除分裂样型、自恋型、强迫型分量表外,独生子女新兵其他分量表及总量得分均高于非独生子女新兵(P<0.05)。结论新兵的人格倾向问题好于大学生样本,低龄、父母关系不和睦、居住在城市和独生子女新兵有更多的人格倾向问题。     

难治性胆石病的外科手术经验

目的 探讨难治性胆石病的手术方式与技巧.方法 回顾性分析1990年1月至2007年12月湖南省人民医院肝胆外科收治的521例难治性胆石病患者的临床资料.结果 全组均行手术治疗,3例术后围手术期内并发肝肾功能衰竭死亡,其余518例无严重并发症发生,痊愈出院.经B超和CT复查有结石残留者78例,占15.1%.423例获随访,随访5个月至17年,平均随访时间7.5年,随访率81.7%.效果良好率达90.1%(381/423).结论 大部分难治性胆石病患者可以根治;根据患者的具体情况,采用相匹配的个体化手术方案、精细规范的手术操作是保证疗效的关键.     

关节镜下同种异体肌腱双束法重建前交叉韧带

目的探讨同种异体肌腱移植重建关节内韧带,双束韧带即前内束（AM）、后外束（PL）重建前交叉韧带（ACL）,完善韧带修补重建的条件,以期达到ACL重建后膝关节的生物力下曲率运动的均衡和对膝关节回旋稳定的调控。方法对67例ACL患者应用同种异体肌腱重建ACL。股骨髁侧椭圆形隧道,应用Arthrax公司提供的横钉固定肌腱法固定;胫骨侧建立ACL—AM和ACL—PL双隧道,挤压钉固定。结果67例均获随访,时间12—36（18．4±3．8）个月,Lysholm评分：术前（34．47±1．5）分,术后3个月（78．35±3．4）分,术后6个月（81．88±3．3）分,术后12个月（87．76±2．1）分,术后18个月（89．70±3．5）分。有关节软骨损伤者,影响术后Lysholm评分。结论同种异体肌腱可以满足韧带受区的要求,双束ACL重建符合膝关节韧带4连杆曲率生物运动模式,膝关节回旋稳定度高。手术操作简单,效果良好。     

Caffeine in children with obstructive sleep apnea

BACKGROUND: Children with obstructive sleep apnea (OSA) have a higher rate of adverse post-extubation respiratory events, such as laryngospasm, upper airway obstruction, apnea, desaturation and/or need for re-intubation. They are overly sensitive to sedatives and narcotics. Although the etiology of OSA is primarily obstruction (mechanical or neuromuscular), a central element may contribute to OSA. Caffeine citrate has been shown to be effective in treating apnea of prematurity. This study evaluated whether the administration of caffeine benzoate to children with OSA decreases the number of children who experience adverse post-extubation respiratory events. METHODS: In a randomized, double-blind and placebo-controlled study, children with OSA scheduled for adenotonsillectomy (T&A) received either caffeine benzoate, 20 mg/kg IV, (caffeine group, n = 36) or saline (placebo group, n = 36). The primary outcome evaluated the number of children who developed adverse post-extubation respiratory events, and the secondary outcome was the incidence of those events. RESULTS: The results demonstrated the two groups differed in the number of children who developed adverse post-extubation respiratory events (p = 0.032). The overall incidence of adverse postoperative respiratory events was less in the caffeine group than the placebo group (p = 0.0196). CONCLUSION: In children with OSA scheduled for T&A, administration of caffeine benzoate, 20 mg/kg IV, decreased the number of children who developed adverse post-extubation respiratory events and decreased the overall incidence of adverse post-extubation respiratory events. PACU duration, hospital discharge time and postoperative delirium did not differ between groups.