中心静脉压联合全心舒张末容积指数指导感染性休克患者容量治疗的效果

目的 评价中心静脉压(CVP)联合全心舒张末容积指数(GEDVI)指导感染性休克患者容量治疗的效果.方法 感染性休克患者23例,性别不煨,年龄18～64岁,休克时间＜6h,急性生理和慢性健康状况评分13～31分,采用随机数字表法,将其随机分为2组:CVP指导容量治疗组(Ⅰ组,n=12)和CVP联合GEDVI指导容量治疗组(Ⅱ组,n=11).2组均静脉输注生理盐水和6％羟乙基淀粉200/0.5,晶体液和胶体液的比例为1∶(0.5 ～ 1.0),输注速率800～ 1600 ml/h,容量治疗过程中Ⅰ组维持CVP8～ 12mmHg;Ⅱ组维持CVP＞8 mm Hg和GEDVI 600 ～ 750 ml/m2.分别于容量治疗前及容量治疗开始后6h时采集动脉及中心静脉的血样,测定血乳酸浓度和中心静脉血氧饱和度(ScvO2),计算乳酸和ScvO2的变化率.结果 与Ⅰ组比较,Ⅱ组乳酸变化率升高(P＜0.05),ScvO2变化率差异无统计学意义(P＞0.05).结论 与CVP指导容量治疗比较,CVP联合GEDVI指导感染性休克患者容量治疗时可增加组织灌注,其效果较好.     

咪达唑仑复合氯胺酮应用于小儿基础麻醉的临床探讨

 目的 探讨应用咪达唑仑复合氯胺酮不同给药方法在小儿基础麻醉中的优化方案.方法 200例1～6岁,ASAⅠ～Ⅱ级患儿随机分成以下五组:A组为口服咪达唑仑0.7 mg/kg;B组为口服氯胺酮8 mg/kg;C组为肌注氯胺酮5mg/kg;D组为口服咪达唑仑0.5 mg/kg和氯胺酮4 mg/kg;E组为先口服咪达唑仑0.5 mg/kg,再肌注氯胺酮4 mg/kg.观察各组诱导结果及呼吸循环变化、不良反应.结果 ①A组与B组比较,A组起效更快(P<0.01),合作更好,不良反应较少;②A组、B组均比C组更合作,但不如C组起效更快;③D组和E组相比,患儿更合作,不良反应更少,但起效更慢,两组诱导效果无显著差异(P>0.05).结论 咪达唑仑复合氯胺酮优于单独给药,对循环呼吸影响小;口服给药可行性更佳.     

Biomechanical evaluation of the less invasive stabilization system and the 95-degree angled blade plate for the internal fixation of distal femur Fractures in human cadaveric bones with high bone mineral density

BACKGROUND: The less invasive stabilization system (LISS) is an internal fixator that utilizes unicortical locked screws for fixation of distal femur fractures. A question is whether locked unicortical screw fixation is sufficient, when compared with a standard implant such as a blade plate. METHODS: Eight matched pairs of fresh-frozen cadaveric femora were instrumented with either the LISS or a 95-degree blade plate. A 4-cm supracondylar gap fracture model was created and all bone-implant constructs were tested to failure in axial loading. RESULTS: All constructs failed by plastic deformation of the implant. There was no significant difference between the LISS and the blade plate constructs with respect to load to failure. CONCLUSIONS: Despite unicortical fixation axial loading to failure of the LISS did not result in implant/screw pull-out neither proximally nor distally. However, there does not appear to be a biomechanical advantage of using the LISS as opposed to a blade plate in bones with high bone mineral density.     

Off pump coronary artery bypass (OPCAB) in critical left mainstem stenosis—Our experience

Background Beating heart surgery has now become the commonest technique of doing Coronary Artery Bypass Graft Surgery (CABG) in our country. It is being used even in such high risk situations like diffuse coronary disease and Critical Left Main stem Stenosis (LMCS) with good results. The aim of this study is to retrospectively review our results in Off-Pump Coronary Artery Bypass Surgery (OPCAB) in patients with critical left main stem stenosis. Methods This study is a retrospective analysis of the data of patients who underwent primary coronary artery bypass surgery. During the period from April 2003 to September 2005 a total of 64 patients underwent OPCAB procedure for critical LMCS. During the same period 10 patients underwent CABG on Cardio Pulmonary Bypass (CPB). The age range was 36–77yrs. The sex distribution was M: F 53∶10. Ten patients were done as emergency. 2 of them were on Intra Aortic Balloon Pump (IABP) support preoperatively. 10 patients were high risk with a Euro score of ≥5. Results Left Internal Mammary Artery (LIMA) was used in 78% of cases. Average grafts per patient was 2.96. The median ventilation time was 5.91 hrs. New IABP insertion in postoperative period was required in 1 patient. One patient was reexplored for bleeding. There was one perioperative myocardial infarction. 57% of patients did not need any blood transfusion. There was no conversion to CPB. There was no operative mortality. Inotropes were used in ten cases. Conclusions OPCAB is a safe method of revascularization in patients with critical LMCS. Preoperative IABP is useful in patients with cardiogenic shock. However, there is a place for CPB in patients needing additional procedures like Mitral Valve repair (MV repair) or Dor's procedure or when the vessels are very diffusely diseased. Those patients who are unstable despite IABP support may be managed by Beating heart On Pump (BHOP) technique.     

The influence of native aortic valve calcium and transcatheter valve oversize on the need for pacemaker implantation after transcatheter aortic valve insertion

Objective

Native aortic valve calcium and transcatheter aortic valve oversize have been reported to predict pacemaker implantation after transcatheter aortic valve insertion. We reviewed our experience to better understand the association.

p21WAF1/CIP1 gene is inactivated in metastatic prostatic cancer cell lines by promoter methylation

INTRODUCTION: p21WAF1/CIP1 may act as a tumour suppressor gene (TSG) and loss of the p21WAF1/CIP1 gene has been reported in several solid tumours. The aim of this study was to see whether p21WAF1/CIP1 was expressed in metastatic prostate cancer cell lines and to determine if there was methylation of the p21WAF1/CIP1 promoter. METHOD: PC3, LNCaP and DU145 metastatic prostate cancer cell lines, 1542NP normal prostate, and RD rhabdomyosarcoma cell lines were cultured in the demethylating agent 5-Aza-2 deoxycytidine (5-Aza-CdR). p21WAF1/CIP1 mRNA expression was analysed by RT-PCR. DNA from untreated cell lines was modified with sodium bisulphite and promoter sequencing was performed. RESULTS: p21WAF1/CIP1 was expressed at low or undetectable levels in metastatic prostate cancer cell lines but expression was reactivated by treatment with 5-Aza-CdR. Sequence analysis of the promoter region revealed several sites of methylation at the 5' end of a CpG island in the PC3, LNCaP and DU145 cell line DNA but not in the normal prostate control DNA. Most notably the Sis-inducible element (SEI)-1-a STAT1-binding site, was methylated. CONCLUSIONS: In this study, we show that p21WAF1/CIP1 expression in metastatic prostate cancer cell lines is enhanced as a result of demethylation of the DNA. Furthermore, several cytosine residues in the promoter region are methylated, including critical binding sites. The inhibition of the STAT1-signalling pathway by methylation of the promoter may inactivate the p21WAF1/CIP1 TSG in prostate cancer.     

Inguinal hernias associated with a single strenuous event

Introduction

There is debate regarding the role of physical activity and, in particular, a single strenuous event (SSE) in the development of inguinal hernia. This study aims to identify the incidence and associated features of hernias perceived to be due to a single strenuous event and to compare their features with published guidelines.

Materials and methods

All consecutive patients surgically treated for primary inguinal hernia at a single NHS trust between April 2010 and April 2011 were identified and contacted to participate in a questionnaire. Clinical details from operative records and case notes were compared with patients’ responses to identify features of their presentation attributable to a single strenuous event according to previously published guidelines.

Results

Three hundred and thirty five eligible patients were contacted with a response rate of 292 (87 %). 41/292 (14 %) of patients reported an SSE associated with the onset of their hernia. Only 2 of 41 (5 %) patients reporting a hernia associated with SSE met published criteria for association of the hernia with SSE, and this represented less than 1 % of all patients treated for inguinal hernia at a single centre in a 1-year period.

Conclusion

The relationship between physical activity and development of inguinal hernia is under debate; however, we find that inguinal hernia that can be attributed to SSE is a rare event, despite the fact that many patients present with acute symptoms. Updated guidelines for the assessment of ‘cause’ in industrial claims for the association of hernia with workplace activity are required.

     

Unresolved priapism secondary to tamsulosin

Tamsulosin is the most potent adrenergic alpha-1 antagonist used for the treatment of benign prostatic hyperplasia. Priapism has been reported rarely in patients taking Prazosin, Doxazosin and Terazosin. We describe an otherwise healthy man with recurrent and then persistent unresolved priapism after the use of tamsulosin. Initial treatment consisted of aspiration and intracavernosal irrigation of iced saline and vasoconstrictive agent, but in vain. We then performed Winters procedure but that too failed and the priapism persisted. Health-care professionals should inform all patients taking such medications about rare but possible serious adverse effects.     

Does the presence of an upper extremity injury affect outcomes after major trauma?

BACKGROUND: There is a paucity of information about the impact of upper extremity (UE) injuries on patient outcomes, particularly after major trauma. METHODS: Data were obtained from a statewide trauma registry. Cases were defined as major trauma cases (Injury Severity Score > 15) with (UE group) and without (no-UE group) an associated upper extremity injury. Multivariate analysis was performed to identify independent predictors of outcome. RESULTS: Major trauma patients with UE injury were 1.5 times (p = 0.011) more likely than the no-UE group to have a length of stay greater than 7 days. After adjusting for age, mechanism of injury, and Injury Severity Score, UE injury was not an independent predictor of discharge destination. CONCLUSION: In major trauma patients, the presence of an upper extremity injury is a significant predictor of length of stay, indicating a greater complexity and cost of care associated with this group of major trauma patients.