急诊选择性肾动脉栓塞治疗外伤性肾出血

目的 探讨外伤性肾出血的急诊选择性肾动脉栓塞治疗的效果和价值。方法 外伤性肾出血患者23例，临床症状：腹痛、血尿或酱黄色尿，心率快、血压低，11例出血性休克，其中5例血压测不出；12例伴多脏器伤。7例急诊科直接送导管室，5例手术室转送导管室，11例保守治疗3～75小时无效而行肾动脉栓塞治疗。采用seldinger法，经股动脉入路，选择性肾动脉血管造影和栓塞治疗，栓塞材料为明胶海绵。结果 23例经血管造影诊断：肾破裂13例、肾内血肿6例、肾横断3例、肾粉碎1例。出血肾动脉28支，其中：19例1支肾动脉、3例2支、1例3支。6例伴腹膜后巨大血肿者12支腰动脉及1支髂内动脉参与出血，给予栓塞，对伴骨盆骨折7例同时行10支髂内动脉栓塞。栓塞治疗后出血即刻停止，血压平均回升11／5kPa，血尿于术后0．5～3天停止，尿液变清。3例多脏器伤死于脏器衰竭。门诊随访，15例健康存活，3例经静脉肾盂造影证实，部分肾功能存在。5例失访。结论 外伤性肾出血采用急诊选择性肾动脉栓塞术，疗效显著，是一种积极、有效、简单、快速、安全的止血措施，而选择、超选择性插管栓塞治疗，能最大限度保留肾脏功能。     

盐酸氟桂利嗪对实验性脑出血大鼠体感诱发电位的影响

目的:观察钙拮抗剂盐酸氟桂利嗪对脑出血后神经功能缺失的修复作用。方法:用66只成年健康Wistar大鼠,分为正常对照组(6只)、脑出血组(30只)和治疗组(30只)三个组,对后两组运用胶原酶法建立大鼠脑出血模型,其中出血组仅制模不作处理,治疗组于制模前一天及制模后五天,按1 mg／kg体重腹腔注射盐酸氟桂利嗪,每日一次。此两组均于制模后分别于0．5、6、24、72、120 h五个时点各6只鼠作体感诱发电位(SEP)测定P1-N1蜂峰值、P1波潜伏期值、N1潜伏期及神经功能评定后处死。结果:脑出血后SEP波幅降低和潜伏期延长。治疗组脑出血后6 h波幅开始明显降低及潜伏期明显延长,持续约3天左右后逐渐恢复,SEP的P1-N1峰峰波幅升高及P1、N1波潜伏期缩短,治疗组与出血组结果比较差异有显著意义(P<0．01)。结论:盐酸氟桂利嗪对脑出血动物神经功能缺失有明显的修复作用,即具有脑保护作用。     

子宫动脉栓塞术在产科出血治疗中的应用

目的:探讨子宫动脉栓塞术在治疗胎盘植入等产科出血性疾病中的意义。方法:对20例因胎盘植入等各种病因发生产科大出血的患者,应用Seldinger技术行双侧子宫动脉造影并注入明胶海绵颗粒行栓塞术,其中8例胎盘植入和5例宫颈妊娠者栓塞前先行化疗药物灌注。结果:子宫动脉栓塞术后30 min内阴道流血量显著减少,栓塞术后病人仅表现轻微的疼痛和不同程度的发热,无严重并发症。20例均治愈并保留了生殖功能。结论:子宫动脉灌注栓塞术具有止血迅速、创伤小、并发症及副反应少的特点,且可同时药物灌注,是治疗产科大出血的有效方法。     

Role of brain acetylcholine in vasopressin release during osmotic stimulation and hemorrhage

Summary There is considerable evidence to suggest that there is a cholinergic link in the neural control of vasopressin release, but the precise role for this link has not been adequately demonstrated in the intact animal. We have, therefore, examined in conscious unrestrained rats the effects of central cholinergic blockade on the stimulation of vasopressin release by increased plasma osmotality (iv infusion of 2.5 M NaCl at 0.1 mg/kg body weight · min for 30 min) and by decreased blood volume (2 successive hemorrhages of 10% of blood volume each). The vasopressin responses to these stimuli were unaffected by either intracerebroventricular (icv) atropine (10 g; muscarinic blockade) or icv hexamethonium (10 g; nicotinic blockade) in doses which block the vasopressin responses to icv cholinergic agonists. The implications of these findings are discussed.On leave from the Second Department of Internal Medicine, Tohoku University School of Medicine, Sendai, JapanOn leave from the Third Department of Internal Medicine, University of Tokyo School of Medicine, Tokyo, Japan     

Time-dependent effect of sectioning carotid sinus nerves on the vagally mediated baroreflex

The purpose of the reported experiments was to examine whether the vagally mediated baroreflex system (V-system) increases its feedback gain with time after sectioning of the carotid sinus nerves (CSN). In 10 dogs anesthetized with Nembutal, we determined the overall open-loop gain (G) of the rapidly acting arterial pressure control system. G was assessed as (AP_I/AP_S)-1, where AP_I and AP_S represent the immediate and steady-state decreases in arterial pressure at the aortic arch following a fast step-wise reduction in blood volume. AP_I, AP_S and G_INTACT in the intact condition (30th min before sectioning of the CSN) were –1.8±0.1 kPa, –0.20±0.01 kPa and 8.4±0.3 (mean±SE), respectively. The mean values of AP_I, AP_S and G after sectioning of the CSN (G_V), first averaged within individual dogs and then averaged for ten dogs, were –2.53±0.07 kPa, –1.1±0.05 kPa, and 1.5±0.1, respectively. G_V did not change with time over about 4 h after sectioning of the CSN. It is concluded that the V-system cannot augment its ability to restore arterial pressure in compensation for the lost function of the carotid sinus baroreflex system over 4 h after sectioning of the CSN in the anesthetized dog.     

Hypothalamic knife cuts alter vasopressin induced recovery of blood pressure following hemorrhage

Summary Effects of knife cuts posterior to the paraventricular nucleus (PVN) alone or to both the PVN and the supraoptic nucleus (SON) on vasopressin dependent restoration and maintenance of blood pressure following hemorrhage were tested in the rat. Conscious, unrestrained animals were hemorrhaged a volume equivalent to 1.8% of body weight from a femoral arterial catheter. Blood pressure was monitored for 30 min with no treatment, 30 min following iv injection of a specific antagonist to the pressor action of vasopressin, and 15 min during iv infusion of the competitive blocker of angiotensin II, saralasin. Restoration of blood pressure and the decrease in blood pressure with vasopressin blockade in rats with knife cuts posterior to the PVN alone were similar to that of control-operated animals. However, if knife cuts extended to the level of the SON, blood pressure was not restored, and vasopressin blockade did not result in a reduction of blood pressure. Saralasin infusion produced a similar decrease in blood pressure in all groups of animals. These data show that when knife cuts are confined to the area posterior to the PVN, vasopressin contributes to the restoration of blood pressure following hemorrhage. However, when cuts extend into the ventral hypothalamus, the contribution of vasopressin is eliminated.     

Effects of hemorrhage on vasopressin secretion and arterial blood pressure during experimental diabetes insipidus in goats

The effect of hypotensive hemorrhage on plasma vasopressin (AVP) concentration and carotid blood pressure before and after induction of experimental diabetes insipidus (DI) was studied in the conscious goat. Bleeding to the point of blood pressure fall (blood loss 15–25% of the estimated blood volume) caused an immediate, approximately hundred fold, increase in the plasma AVP concentration in the normal animal. Hemorrhage to the same extent during DI did not affect the plasma AVP levels. A rather transient hypotensive response to bleeding was seen before disruption of the pituitary stalk, but during DI the recovery of the hemorrhage-induced hypotension was less effective. However, the normalization of the blood pressure after bleeding was slightly more efficient during the permanent than during the temporary phase of DI. It is concluded that an intact hypothalamoneurohypophysial connection is necessary for the massive release of AVP normally seen in response to hypotensive hemorrhage. It is also confirmed that the lack of this hormonal response to bleeding is accompanied by an increased susceptibility to the hypotensive effect of hemorrhage.     

食管胃底静脉曲张破裂出血预后的队列研究

目的探讨影响食管胃底静脉曲张破裂出血患者长期生存的预后因素,评价手术、内镜硬化剂或套扎治疗、经颈静脉肝内门体静脉分流术(TIPS)治疗及联合治疗等干预措施对病人长期生存的影响.方法以回顾性队列研究方式分析了1992～1999年202例以食管胃底静脉曲张破裂出血入院的患者.首次接受干预措施时或因食管胃底静脉曲张破裂出血首次入院为研究起点,死亡、发生肿瘤或研究截止日为终点.平均随访时间34个月.按接受干预措施的不同分为未干预组、手术组、内镜组、TIPS组及联合干预组,比较各组生存曲线;评价影响肝硬化食管静脉曲张破裂出血病人长期生存的预后因素.结果生存率曲线(Kaplan-Meier曲线)分析显示,联合干预组和手术组病人预后明显优于内镜治疗组和无干预组(P<0.05),而内镜治疗组和未干预组无明显差异(P>0.05),联合干预组与手术组也无明显差异.采用Child-Pugh分级分层后显示对于ChildA或ChildB级者,结果相似.而ChildC级病人由于病例数较少无法比较各组之间的差异.Cox比例风险模型的多因素分析显示,4个变量和预后独立相关凝血酶原时间、HBV-DNA、腹水、手术治疗.结论手术治疗或者手术联合其他措施的预防食管静脉曲张治疗能明显改善肝硬化食管静脉曲张破裂出血病人的预后.凝血酶原时间、HBV-DNA、腹水、手术分流与肝硬化食管静脉曲张破裂出血病人的预后有关.     

脑出血CT改变与预后关系的探讨（附360例分析）

目的探讨脑出血CT改变与预后的关系.方法对360例脑出血患者的CT和临床资料进行回顾性分析.结果血肿≥30cm3和＜30cm3病死率无显著差异(P＞0.05);破入脑室和非破入脑室者预后无显著差异(P＞0.05),但闭塞型和非闭塞型有显著差异(P＜0.01);中线移位＜5mm,5～10mm,＞10mm生命预后存在显著差异(P＜0.05).结论生命预后与血肿大小无肯定关系;合并脑室出血预后良好者不少,中线移位常严重影响生命预后.     

Lengthening of Massive Intercalary Cortical Allograft After Successful Graft Incorporation in Skeletally Immature Bone with Critical-Sized Defect: A Case Report with 6-year Follow-up

Bone allograft serves as an alternative to overcome the limitation of autograft. Some concerns, such as graft rejection, infection, and low union rate, arise from the use of bone allograft since the graft is a non-living and foreign material. We reported a case of critical-sized bone defect in a skeletally immature patient treated with massive intercalary allograft that not only did it show union but also graft incorporation that allowed for subsequent bone lengthening at the site of the incorporated massive allograft. To our knowledge, there has been a report of lengthening of free-vascularized fibular autograft but not the nonvascularized one. Massive intercalary allograft that incorporates well to the host could be an option to treat critical-sized bone defect.