492例臀位分娩临床分析

目的探讨臀位分娩的合理方式。方法回顾分析笔者所在医院2005年1月～2008年1月492例臀位分娩情况。结果 310例臀位阴道分娩与182例剖宫产新生儿窒息率和新生儿骨折率相比较差异无统计学意义（x2=0.23,P〉0.05）,两种分娩方式的产后出血率相比较差异有统计学意义（x2=4.73,P〈0.05）。结论臀位分娩有选择性的行阴道臀牵引助产分娩,并不会增加母儿的并发症,可以降低剖宫产率。     

不同植骨融合术治疗腰椎滑脱症的疗效比较分析

目的：比较3种不同植骨融合术治疗腰椎滑脱症的疗效。方法：自2006年1月至2008年12月共收治腰椎滑脱症患者85例,男36例,女49例;年龄38～65岁,平均51.8岁。采用3种手术方法：后外侧植骨融合术32例（A组）、后路椎体间植骨融合术28例（B组）、前路椎体间植骨融合术25例（C组）。疗效评定采用Nakai评分标准,骨性融合标准采用Suk标准判断。结果：所有患者均获得随访,随访时间均不少于2年。A组：优19例,良9例,中4例;B组：优16例,良9例,中3例;C组：优14例,良8例,中3例。A、B、C组的融合率分别为68.8%（22/32）、92.9%（26/28）、92.0%（23/25）。B、C组的椎间隙高度维持及融合率均优于A组（P〈0.05）。结论：对于治疗腰椎滑脱症,前路及后路椎体间植骨融合术在椎间隙高度维持及融合率优于后外侧植骨融合术,但腰椎滑脱症病情及伴随并发症多样化,应具体根据患者滑脱类型、程度、有无椎间盘突出及神经症状等做出相应的选择。     

Destiny of candidates for heart transplantation in the Eurotransplant heart allocation system

OBJECTIVE: We analyzed the prognosis of candidates for heart transplantation (HTx) after being listed with 'urgent status' for donor heart allocation or after ventricular assist device (VAD) implantation without application for urgent status. METHODS: Urgent status as used in this study refers to both the high urgency (HU) status awarded by Eurotransplant until August 31, 2005 and the urgent (U) status that replaced it from then on. Patients who underwent primary VAD implantation between January 2001 and December 2006 and who were listed as transplantable (T) (group VAD-prim, n=159), and patients listed primarily in urgent status before VAD implantation and/or HTx during the same period (group U-prim, n=168) were enrolled in the study. Group U-prim consists of subgroups: group U-HTx (n=123), who underwent primarily HTx in urgent status; group U-VAD (n=25), who underwent primarily VAD implantation in urgent status; patients who died in urgent status before HTx or VAD implantation (n=6); and patients in urgent status without HTx or VAD implantation (n=14). The survival rate in each group was studied. RESULTS: Survival rates after VAD implantation in group VAD-prim were comparable to those after urgent status listing in group U-prim (67.0% vs 68.5% for 1-year survival, 56.6% vs 65.8% for 2-year survival, respectively). Actuarial survival after listing for urgent status in group U-HTx was significantly better than that in group U-VAD (73.7% vs 46.0% for 1-year survival, p<0.05, log-rank test). Actuarial survival during mechanical circulatory support after the VAD implantation (censored at HTx or weaning from the device) in group VAD-prim was significantly better than that in group U-VAD (80.7% vs 56.2% for 3-month survival, p<0.001, log-rank test). CONCLUSIONS: In order to receive urgent HTx, HTx candidates may choose urgency listing without primary VAD implantation at the risk of failed donor heart allocation in urgent status. However, the prognosis of the patients in the latter situation is poor.     

Planned cesarean section versus planned vaginal delivery: comparison of lower urinary tract symptoms

We compared the prevalence and risk of lower urinary tract symptoms in healthy primiparous women in relation to vaginal birth or elective cesarean section 9 months after delivery. We performed a prospective controlled cohort study including 220 women delivered by elective cesarean section and 215 by vaginal birth. All subjects received an identical questionnaire on lower urinary tract symptoms in late pregnancy, at 3 and 9 months postpartum. Two hundred twenty subjects underwent elective cesarean section, and 215 subjects underwent vaginal delivery. After childbirth, the 3-month questionnaire was completed by 389/435 subjects (89%) and the 9-month questionnaire by 376/435 subjects (86%). In the vaginal delivery cohort, all lower urinary tract symptoms increased significantly at 9 months follow-up. When compared to cesarean section, the prevalence of stress urinary incontinence (SUI) after vaginal delivery was significantly increased both at 3 (p < 0.001) and 9 months (p = 0.001) follow-up. In a multivariable risk model, vaginal delivery was the only obstetrical predictor for SUI [relative risk (RR) 8.9, 95% confidence interval (CI) 1.9–42] and for urinary urgency (RR 7.3 95% CI 1.7–32) at 9 months follow-up. A history of SUI before pregnancy (OR 5.2, 95% CI 1.5–19) and at 3 months follow-up (OR 3.9, 95% CI 1.7–8.5) were independent predictors for SUI at 9 months follow-up. Vaginal delivery is associated with an increased risk for lower urinary tract symptoms 9 months after childbirth when compared to elective cesarean section.     

前列腺切除术后静脉自控镇痛的疗效观察

目的：探讨前列腺切除术后简便、安全、有效的镇痛方法。方法：104例BPH术后病人随机分为两组,A组46例采用静脉自控镇痛（PCIA）,B组58例按常规方法止痛。通过VAS评分、控制膀胱痉挛效果等指标进行综合评价。结果：A组在止痛效果和控制膀胱痉挛方面明显优于B组（P＜0．01）,膀胱冲洗时间较B组缩短（P＜0．05）,差别有显著性意义。结论：BPH术后应用PCIA镇痛及防止膀胱痉挛效果确切,有利于术后康复。     

Plasma exchange before surgery for left ventricular assist device implantation

Abstract:  Left ventricular assist device (LVAD) implantation in end-stage heart failure patients is frequently associated with hemorrhagic complications requiring reoperation. The preoperative coagulopathic profile includes prolonged prothrombin time (PT), partial thromboplastin time (PTT), and bleeding time; platelet dysfunction; decreased coagulation factor activity; and increased inflammatory markers. We compare outcomes in LVAD patients treated with preoperative plasma exchange with concurrent, nonrandomized control patients. We reviewed data from 68 consecutive elective patients who received LVADs at our institution. Thirty-five received LVADs after preoperative plasma exchange (replacement of one plasma volume of fresh frozen plasma), and 33 received LVADs without plasma exchange. Groups were comparable in age, sex, body weight, New York Heart Association class, intra-aortic balloon pump insertion, cardiac index, pulmonary capillary wedge pressure, creatinine, total bilirubin, hemoglobin levels, PT, international normalized ratio, PTT, and platelet count. Early mortality was lower in the plasma exchange group (0% [0/35] vs. 18% [6/33], P  = 0.026), and postoperative chest tube drainage decreased by 33% ( P  = not significant). Blood transfusion requirements were similar.Perioperative mortality decreased in patients treated with plasma exchange before LVAD implantation.     

心脏移植前采用体外膜肺氧合循环支持过渡二例

目的：探讨等待心脏移植患者发生心源性休克时采用体外膜肺氧合（ECMO）循环支持过渡的可行性和有效性。方法：2例患者在等待心脏移植期间发生心源性休克，1例为限制型心肌病，另1例为扩张型心肌病，并发肝功能异常，药物治疗均无法控制心力衰竭和呼吸衰竭，遂紧急使用ECMO支持，等待心脏移植。使用Medtronic成人ECMO系统，采用股动脉、股静脉插管，ECMO系统使用肝素涂层表面和离心泵，流量30～50ml·kg^-1·min，激活全血凝固时间维持在160s左右，血温维持在36～37℃。流量随心肺功能改善情况进行调整，支持期间监测动脉血气、血浆游离血红蛋白、血小板、出血及凝血指标，以及股动脉插管侧下肢血液循环情况。结果：经ECMO支持后，患者的血流动力学稳定，血气各指标改善，循环、呼吸平稳，X线显示双肺清晰，肝功能异常的1例肝功能好转。ECMO支持期间未发生严重的并发症。2例患者分别支持了5d和3d，均顺利过渡到心脏移植，术后心功能Ⅰ级，未发生排斥反应，患者痊愈出院。结论：等待心脏移植患者发生心源性休克时，可采用ECMO循环支持过渡，安全、有效。     

Mechanical Testing of Seven Fixation Methods for Generation of Compression Across a Midtarsal Osteotomy: A Comparison of Internal and External Fixation Devices

The purpose of this study was to assess 7 methods of fixation for a midtarsal osteotomy. Polyurethane foam models (N = 6) and cadaver specimens (N = 4-7) were used to examine the force generated by the different constructs of fixation. A midtarsal osteotomy was performed on each specimen in the test groups. The osteotomies were fixated either with 2 parallel 0.062-in Kirschner wires and 40-mm-long, 4-mm partially threaded, cancellous, cannulated titanium screws, an external ring fixator (frame), a frame with wires tensioned (tension), a frame with wires tensioned and compressed toward the osteotomy (tension and compression), a frame with tension, compression, and parallel Kirschner wires, or a frame with tension, compression, and two 4.0 cannulated parallel screws, respectively. Each model was fixated, and the force generated by the construct across the osteotomy was recorded via the use of pressure-sensitive film. Statistical analysis of the data in the polyurethane foam group determined that the use of frame with tension, compression, and two 4.0 parallel cannulated screws was statistically superior to 1) frame, 2) frame with tension, 3) 2 parallel Kirschner wires, 4) two 4.0 cannulated parallel screws, and 5) frame with tension and compression. A cadaver study determined that the frame with tension, compression, and 2 parallel Kirschner wires was statistically superior to 1) frame and 2) two parallel Kirschner wires. These findings suggest that there is a difference in the force generated by the type of fixation construct across a midtarsal osteotomy.     

Postmarketing safety of biologics and biological devices

Background contextRegardless of study design, the approval process of biologics and biological devices cannot identify every possible safety concern. Postmarketing safety surveillance can provide information based on real-world use of medical products in heterogeneous populations and is critical for identifying potentially serious adverse events, events that are too rare to be detected during premarketing studies, late complications, and events involving individuals or uses that were not evaluated in clinical trials.PurposeTo review why adverse event reporting is important and how the information is used, with emphasis on the points that are most applicable for surgeons and other spine professionals.MethodsThis is an overview of postmarketing safety surveillance.ResultsReview of adverse event reports has resulted in safety notifications, label changes, and publications regarding the safety of biologics and biological devices, such as the risk of airway compromise after the use of recombinant human bone morphogenetic protein in cervical spine fusion, the occurrence of a fatal air embolism after the use of a fibrin sealant that had been applied with a spray device, and infections after allograft transplantation of human tissues.ConclusionsIn light of the rapid development of new biologics, postmarketing surveillance is imperative for ensuring that these products are as safe as possible. By reporting adverse events, surgeons and other health care professionals play a key role in improving and refining our understanding of the safety of biologics.     

血管外科技术创新的意义与趋势

血管外科的发展与技术的创新发展密切相关。血管外科治疗范围主要包括主动脉疾病、外周动脉疾病及静脉疾病,近年的治疗方法已明显侧重于血管腔内治疗技术,且随着技术的不断创新发展,既往以开放手术治疗为主的许多复杂疑难病例,如累及升主动脉、主动脉弓的主动脉夹层或瘤样扩张疾病,近肾或累及肾动脉等重要内脏动脉分支的腹主动脉瘤等,亦逐渐采用开窗支架、分支支架等新型血管腔内技术治疗,未来内脏动脉及主动脉弓上重要分支动脉的腔内重建将成为血管腔内技术发展的主要方向。外周动脉病变的血管腔内治疗方法与治疗理念均处于改进阶段,各新型开通装置增加了血管腔内治疗成功率,涂药球囊和减容装置较传统支架置入术的远期效果有明显优势,同时能达到不遗留异物的目的,但现阶段还不能完全取代支架置入术。