颗粒复位法治疗后半规管良性阵发性位置性眩晕的临床分析

目的:探讨颗粒复位法治疗后半规管良性阵发性位置性眩晕(PC-BPPV)的临床疗效。方法:将42例PC-BPPV患者随机分为药物治疗组22例,颗粒复位组(Epley法、Semont法)20例。药物治疗组采用苯海拉明、胃复安肌肉注射,20%甘露醇及复方丹参20 mL+生理盐水250 mL静滴,颗粒复位法首先Semont法、其次选Epley法,比较两组治疗效果。结果:颗粒复位组与药物组疗效比较差异有统计学意义(P<0.05)。颗粒复位组随访至今复发4例(20%),复发者再行Semont法或Epley法治疗仍有效。结论:颗粒复位法治疗PC-BPPV有效、简便、安全,可作为PC-BPPV的首选治疗方法。     

Efficacy of the barbecue manoeuvre in benign paroxysmal vertigo of the horizontal canal

Five to ten percent of benign paroxysmal positional vertigo are caused by the horizontal semi-circular variant (h-BPPV). In this study, we reviewed the efficacy of the Barbecue repositioning manoeuvre in h-BPPV, and we assessed the possible effect of different factors on the outcome. Barbecue manoeuvre consists in turning the supine patient around his longitudinal axis toward the unaffected side until 360° are accomplished. After every 90° step the patient is maintained in the new position for 30 s. We reviewed 46 patients with h-BPPV, treated by barbecue rotation from 2003 to 2005. After the first Barbecue manoeuvre, the patients were followed-up at intervals of approximately 1 week and the rotation was repeated if h-BPPV persisted (up to three rotations). Factors assessed were age, gender, duration of symptoms before treatment and type of h-BPPV (canalolithiasis vs. cupulolithiasis). Fisher’s exact test was used for the analysis. Results: 85% of patients (39/46) were cured after a maximum of 3 rotations. 74% (34/46) were cured after the first manoeuvre and 80% (37/46) after the second one. None of the evaluated factors did significantly affect the efficacy (P > 0.05). The Barbecue manoeuvre is an efficient treatment of h-BPPV demonstrating 85% cure rate after a maximum of three sessions. 74% of the patients are healed after one manoeuvre. The efficacy is not affected by the evaluated factors.     

Influence of negative intrathoracic pressure on right atrial and systemic venous dynamics

To investigate the effect of a sustained fall in intrathoracicpressure (Mueller manoeuvre) on blood flow through the rightheart and on systemic venous dynamics, 16 patients were studiedusing thermodilution, cinevenograms and simultaneous pressurerecordings with two micromanometric transducers. The reductionsin airway pressure (median [rangeI) during two graded Muellermanoeuvres were 25 (20–30) and 42 (22–52) mmHg.Right atrial mean pressure decreased by 17 (2–25) mmHgduring the former and 38 (0–49) mmHg during the latter,and simultaneously, pressure gradients of 23 (1–32) and45 (1–82) mmHg developed between the inferior vena cavaand right atrium (P<0.003 for all). Internal jugular venouspressure decreased by 16 (4–25) and 24 (4–43) mmHg(P<0.03 for both), respectively, and no pressure gradientdeveloped between internal jugular and superior caval veins.The minimum diameter of the proximal inferior vena cava decreasedby 69 (–49–84)% (P = 0.002) during the greater manoeuvre.Cardiac index tended to increase by 26 (–17–40)%(P<0.066) during the lesser manoeuvre but did not changestatistically significantly during the greater. In conclusion,during negative intrathoracic pressure caused acutely by theMueller manoeuvre, right atrial pressure decreases and the inferiorvena cava collapses partially at or below the diaphragm. Despitea significant venous obstruction between the lower body andright atrium, blood flow through the right heart increases orremains constant.     

Computational optimal control of the terminal bunt manoeuvre—Part 1: minimum altitude case

This two‐part paper studies trajectory shaping of a generic cruise missile attacking a fixed target from above. This guidance problem is reinterpreted using optimal control theory resulting in two formulations: (1) minimum time‐integrated altitude (part 1) and (2) minimum flight time (part 2). Each formulation entails non‐linear, two‐dimensional (vertical plane) missile flight dynamics, boundary conditions and path constraints, including pure state constraints. The focus here is on informed use of the tools of computational optimal control, rather than their development. Each of the formulations is solved using a three‐stage approach. In stage 1, the problem is discretized, effectively transforming it into a non‐linear programming problem, and hence suitable for approximate solution DIRCOL and NUDOCCCS. The results are used to discern the structure of the optimal solution, i.e. type of constraints active, time of their activation, switching and jump points. This qualitative analysis, employing the results of stage 1 and optimal control theory, constitutes stage 2. Finally, in stage 3, the insights of stage 2 are made precise by rigorous mathematical formulation of the relevant two‐point boundary value problems (TPBVPs), using the appropriate theorems of optimal control theory. The TPBVPs are then solved using BNDSCO and the results compared with the appropriate solutions of stage 1. For each formulation (minimum altitude and minimum time) the influence of boundary conditions on the structure of the optimal solution and the performance index is investigated. The results are then interpreted from the operational and computational perspectives. Copyright © 2007 John Wiley & Sons, Ltd.     

Atypical Subglenoid Inferior Glenohumeral Dislocation Clinically Mimicking Anterior Dislocation

Abstract Inferior shoulder dislocation is a rare form of shoulder dislocation. A subglenoid subtype of an inferior glenohumeral dislocation is described which clinically mimicked anterior dislocation, as the pathognomonic upright arm posture was conspicuous by its absence. An awareness of associated potential axillary artery injury, brachial plexus complications and rotator cuff tears is important in this rare entity and should be excluded with a high index of suspicion.     

Haemostasis in head and neck surgical procedures: Valsalva manoeuvre versus Trendelenburg tilt

INTRODUCTION

The aim of the study was to identify whether Trendelenburg position helps detect any further bleeding points following Valsalva manoeuvre in order to achieve adequate haemostasis in head and neck surgery.

PATIENTS AND METHODS

Fifty consecutive patients undergoing major head and neck surgical procedures were included. The protocol consisted in performing Valsalva manoeuvre to check haemostasis and treated any bleeding points identified. The operating table was tilted 30° and haemostasis was checked again and treated accordingly. The number of vessels identified and the treatment was recorded.

RESULTS

Twelve male and 38 female patients were included. The median age was 53 years and 74% had an ASA of 1. Twelve patients had complicating features such as retrosternal extensions or raised T4 levels pre-operatively. Thyroid resections were the most common operations performed. The total number of bleeding vessels identified in Trendelenburg tilt was significantly greater than when using Valsalva manoeuvre (P < 0.0001). All bleeding points found on Valsalva manoeuvre were minor (< 2 mm) and dealt with using diathermy. In Trendelenburg position, 11% of bleeding vessels required ties or stitching. The time taken during Valsalva manoeuvre was 60 s on average and 360 s in Trendelenburg position.

CONCLUSIONS

The results show that the Trendelenburg position is vastly superior to the Valsalva manoeuvre in identifying bleeding vessels at haemostasis. It has become our practice to put patients in Trendelenburg tilt routinely (we have discontinued the Valsalva manoeuvre), to check its adequacy before closing the wound. We have not noticed any intracranial complications using a tilt angle of 30°.     

Double liver hanging manoeuvre for central hepatectomy

We describe a modification of Belghiti''s liver hanging manoeuvre (LHM) using two small tubes placed in the cut planes, the first between the left lateral and medial sections, and the second along the right hepatic vein, to achieve complete anatomic central hepatectomy for a large tumour compressing surrounding vessels. Using this technique, a large central hepatocellular carcinoma compressing hilar vessels and the right hepatic vein was easily and safely resected in a 57-year-old man.     

Patterns of Doppler recordings and its relationship to varicocele in infertile men

Incompetence of the testicular vein appears to be the basic pathology of testicular dysfunction in varicocele. Doppler recording is a very sensitive method for detecting this reflux even when varicocele is not evident clinically. One hundred and seventy-eight men with infertility were studied. The presence of reflux in the pampiniform plexus as demonstrated by Doppler recording was compared with clinical varicocele. Reflux patterns were recorded on graph paper and various grades of reflux were observed. The three grades of reflux identified varied between a momentary reflux during vigorous Valsalva manoeuvre to significant reflux on minimal increase in intra-abdominal pressure brought about by normal respiration and deep breathing. Ninety-four per cent of the patients with clinical signs of varicocele had refluxes of grade 2 and 3 on Doppler study. Forty per cent of the patients without clinical evidence of varicocele were found to have reflux of grade 1 and 2 in the testicular veins.     

Autonomic responses to the Valsalva manoeuvre in healthy subjects

Summary. To assess normal autonomic haemodynamic responses to the Valsalva manoeuvre, 158 healthy unmedicated subjects, aged 25–60 years, were examined. For measurement of beat-to-beat blood pressure on a finger, the Finapres instrument was used. Phase-to-phase changes in instantaneous blood pressure and heart rate and the latency response between the end of a Valsalva manoeuvre and points on the resultant blood pressure and heart rate were calculated, and the reference limits for various indices were determined. Sex had no or only marginal effect on blood pressure or heart rate responses or latencies. Ageing was accompanied by a smaller decrease and smaller partial recovery of blood pressure during the strain, with attenuation of reflectory bradycardia, and lengthening of the latencies. It is concluded that age-related reference values should be applied in the interpretation of the Valsalva responses. The following responses should be analysed: mean blood pressure decrease and partial recovery during the strain (adrenergic vasoconstrictor function), reflectory bradycardia after the strain (parasympathetic function), and the latencies (sympathetic and parasympathetic function).