高血压脑出血外科手术时机对临床预后的影响

目的评价高血压脑出血患者行颅内血肿清除手术的时机对临床效果的影响。方法136例高血压脑出血的患者，均行钻颅血肿清除术，按手术实施时间分为3组：A组，7小时内手术者46例；B组，8—24小时内手术者53例；C组，大于24小时手术者37例。比较3组患者术后一个月意识恢复、致残及死亡情况。结果A、B两组患者意识恢复良好者多于C组（P〈0．05）；A组患者致残率低于B、C组（P〈0．05），B组致残率低于C组（P〈0．05）；3组患者死亡事件发生率无显著差异。结论高血压脑出血患者应尽早争取手术时间，早期手术可提高救治成功率，降低术后患者致残率。     

Computer-assisted total knee arthroplasty versus the conventional technique: how precise is navigation in clinical routine?

Restoration of the mechanical leg axis and component positioning are crucial factors affecting long-term results in total knee arthroplasty (TKA). In a prospective study, 1,000 patients were operated on either using a CT-free navigation system or the conventional jig-based technique. Leg alignment and component orientation were determined on postoperative X-rays. The mechanical leg axis was significantly better in the computer-assisted group (95%, within ±3° varus/valgus) compared to the conventional group (74%, within ±3° varus/valgus) (P < 0.001). On average, the operating time was increased by 8 min in the computer-assisted group. No significant differences were seen between senior and younger surgeons regarding postoperative leg alignment and operating time. Computer-assisted TKA leads to a more accurate restoration of leg alignment and component orientation compared to the conventional jig-based technique. Potential benefits in long-term outcome and functional improvement require further investigation.     

肝脏撞击伤致心脏间接损伤后左心室功能变化的实验研究

目的 探讨肝脏撞击伤对猪左心室功能的影响.方法 14只健康家猪随机分为撞击组(10只)和对照组(4只).采用自制小型撞击器撞击组猪肝区,建立急性肝撞击伤动物模型.撞击前、撞击后即刻采用超声心动图评估左心室功能.剖杀实验动物,观察心脏大体损伤情况,取样浸泡,进行光镜和电镜检查.结果 撞击后即刻,8例左心室整体舒张和收缩功能较撞击前下降.对照组左心室功能无明显变化.大体标本显示撞击组8例发生不同程度的左心室心内膜下呈片状、点状出血,2例未见明显损伤.光镜下和电镜下可见心肌细胞发生不同程度的损伤.对照组未见明显异常改变.结论 肝脏撞击伤后导致心脏发生间接损伤,左心室收缩和舒张功能均下降,超声心动图检查能快速、准确评估心功能的变化,为临床救治提供有价值的信息.     

特发性脊柱侧凸不同固定术式疗效分析

目的 分析治疗特发性脊柱侧凸的不同手术方法和效果.方法 对1989年～2005年收治的34例特发性脊柱侧凸术前、术后临床资料进行分析,总结所采用不同术式的治疗效果.结果 34例分别采用了Harrington术式、联合Harrington-Luque(H-L)术式、Cotrel-Dubousset(C-D)双棍法及Texas Scottish-Rite Hospital(TSRH)三维矫正,平均矫正率分别为36.42%、45.18%、55.68%、63.28%,采用H-L、C-D和TSRH手术方法的矫正度均高于Harrington方法,其中以TSRH、C-D三维矫正系统效果最好.结论 手术矫正特发性脊柱侧凸效果是明显的,尤以近年运用的三维矫正系统效果更为优良.     

不同剂量罗哌卡因腰-硬联合麻醉用于下肢手术的效果比较

目的比较不同剂量低浓度罗哌卡因腰-硬联合麻醉用于下肢手术的麻醉效果。方法择期下肢手术患者136例,急诊下肢手术患者83例。按腰麻用药分为0.1%、0.15%和0.2%罗哌卡因3组,每组73例,各组剂量从3mg开始递增,顺序完成3mg各3例,4mg各10例,5、6、7mg各20例。硬膜外腔维持用药均为0.2%罗哌卡因。术前不用药。患者侧卧位,患侧在上,L2-3套针法穿刺,调整麻醉平面在T9-10。观察麻醉效果,BP、HR、SpO2、Bromage评分等。结果优良率6~7mg时为95%、5mg时为50%~55%、4mg时为30%,剂量为3mg时虽有镇痛平面,但不能行手术,均为麻醉失败,剂量为7mg时无失败病例。患者术中BP、HR、SpO2平稳,无恶心呕吐。头痛1例,尿潴留2例。术中患肢Bromage评分为2~3分,健肢为0~1分。结论0.1%~0.2%罗哌卡因6~7mg腰麻与0.2%罗哌卡因硬膜外阻滞联合麻醉,具有用药少,起效快,镇痛完善,BP、HR、SpO2平稳,副作用小,麻醉消退快,能早期活动,利于搬运转移患者等优点,不仅可用于无严重创伤性休克患者下肢不同部位手术的麻醉,而且可为战时手术方舱内的手术提供一种麻醉选择。     

创伤后横纹肌溶解症致急性肾功能衰竭的连续性肾脏替代治疗

目的 提高创伤后横纹肌溶解所致急性肾功能衰竭的诊治水平.方法 回顾性分析20例创伤后横纹肌溶解症致急性肾功能衰竭患者的临床表现、实验室检查和治疗.其中9例给予连续性肾脏替代治疗(CRRT)与11例未做CRRT者作对照.结果 9例创伤后横纹肌溶解症致急性肾功能衰竭给予CRRT,除2例死亡外,7例患者均获得临床治愈;11例未做CRRT者5例死亡,5例继发慢性肾功能不全,1例患者临床治愈.结论 早期诊断、连续性肾脏替代治疗、充分水化、支持治疗是提高治愈率的有效措施,出现肾功能不全须尽早进行连续性肾脏替代治疗.     

金属大头髋(ASRTM XL)的临床应用特点

目的 探讨金属大头髋(ASRTMXL)的临床应用特点.方法 对14例患者采用ASRTMXL金属大头髋进行全髋关节置换术(total hip arthroplasty,THA),其中强直性脊柱炎合并髋关节融合2髋,股骨头坏死3髋,继发性骨关节炎2髋,股骨颈骨折7髋.根据随访结果对金属大头髋的设计特点、临床特点进行分析.结果 本组患者术后1周开始扶拐行走,6周去拐行走,髋关节前屈、后伸、内旋、外旋、内收、外展显著改善,Harris评分术后平均90分(75～100分)、比术前平均30分(13～50分)显著提高.术后X线片示假体位置正确,外翻角、前倾角正常.无早期并发症发生.结论 金属大头髋早期随访效果好,假体设计具有磨损率低、活动范围大、脱位发生率低、臼杯变形小等特点.     

RETRACTED ARTICLE: Combined Interventional and Surgical Treatment for Acute Aortic Type A Dissection

Surgical repair and endovascular stent-graft placement are both therapies for thoracic aortic dissection. A combination of these two approaches may be effective in patients with type A dissection. In this study, we evaluated the prognosis of this combined technique. From December 2003 to December 2006, 15 patients with type A dissection were admitted to our institute; clinical data were retrospectively reviewed. Follow-up was performed at discharge and approximately 12 months after operation. Endovascular stent-graft placement by interventional radiology and surgical repair for reconstruction of aortic arch was performed in all patients. Total arch replacement for distal arch aneurysm was carried out under deep hypothermia with circulatory arrest; antegrade-selected cerebral perfusion was used for brain protection. Four patients concomitantly received a coronary artery bypass graft. Hospital mortality rate was 6.7%; the patient died of cerebral infarction. Neurological complications developed in two patients. Multi-detector-row computed tomography scans performed before discharge revealed complete thrombosis of the false lumen in six patients and partial thrombosis in eight patients. At the follow-up examination, complete thrombosis was found in another three patients, aortic rupture, endoleaks, or migration of the stent-graft was not observed and injuries of peripheral organs or anastomotic endoleaks did not occur. For patients with aortic type A dissection, combining intervention and surgical procedures is feasible, and complete or at least partial thrombosis of the false lumen in the descending aorta can be achieved. This combined approach simplified the surgical procedures and shortened the circulatory arrest time, minimizing the necessity for further aortic operation. Jin-Cheng Liu and Jin-Zhou Zhang contributed equally to this work.     

慢性心力衰竭患者血浆谷胱甘肽抗氧化系统的变化及意义

目的研究慢性心力衰竭（CHF）患者血浆谷胱甘肽抗氧化系统的改变及其临床意义。方法选择2006年1月至2006年9月收住我院心内科慢性心力衰竭的住院患者53例为观察组，门诊体检健康者25例为对照组。按NYHA心功能分级将CHF组分为心功能Ⅱ级组（n=11例），心功能Ⅲ级组（n=15例），心功能Ⅳ级组（n=27例）。所有患者均于入院后第2天采空腹静脉血，应用酶循环法测定血浆还原型谷胱甘肽（GSH）、氧化型谷胱甘肽（GSSG）浓度，根据Nemst公式计算氧化还原电位（EhGSH/GSSG）。结果①CHF组血浆GSH浓度较对照组明显下降（5．23±0．77）umol／L VS（6．52±1．02）umol]L，P〈0．05）；CHF组血浆GSSG浓度高于对照组（1．51±0．24）umol／L vs（1．16±0．53）umol／L，P〈0．05，CHF组EhGSH/GSSG值较对照组升高（-122．92±4．37）mV vs（-133．67±3．49）mV，P〈0．05。②CHF各亚组患者血浆GSH浓度、GSSG浓度、EhGSH/GSSG值在心功能Ⅱ级组与Ⅲ、Ⅳ级组之间有显著性差异（P〈0．05），Ⅲ、Ⅳ级组之间无差异。结论心衰时存在氧化应激，机体的抗氧化作用减弱；血浆GSH浓度、GSSG浓度及EhGSH/GSSG值均与心功能存在相关性，可作为反映心功能的指标。     

曲美他嗪联合培哚普利治疗慢性充血性心力衰竭疗效观察

目的观察曲美他嗪（TMZ）联合培哚普利治疗慢性充血性心力衰竭（CHF）患者的临床疗效。方法72例CHF患者随机分为研究组和对照组，均给予内科常规抗心衰治疗。对照组加服培哚普利，初始剂量2mg，每日1次，逐渐加至靶剂量4mg，每日1次；研究组在对照组的基础上接受曲美他嗪20mg／次，3次/d。治疗12周。结果治疗12周，两组心功能较治疗前有明显改善，治疗组临床总有效率为93．4％，较对照组（80．6％）显著提高（P〈0．05）；超声心动图LVEF均较治疗前有明显改善（P〈0．01或P〈0．051．但治疗组较对照组改善更为显著（P〈0．05）。治疗组LVEDD、LVESD、LADD均较治疗前改善，差异有显著性（P〈0．01或P〈0．05），而对照组无改善；两组均未发现有明显的不良反应。结论TMZ联合培哚普利治疗CHF是一种安全有效的方法。