成人重症紫绀型先天性心脏病的体外循环管理

目的：回顾性总结20例成人重症紫绀型先天性心脏病矫治术的体外循环（CPB）管理方法、脑保护及血液保护措施。方法20例成人重症紫绀型心脏病矫治术患者采用深低温低流量CPB方法,适当血液稀释,提高胶体渗透压,应用超滤技术,加强脑、肺、肾保护。结果20例患者均顺利脱机。无1例院内死亡,无严重并发症。结论采用合理的CPB技术、围术期的良好的器官保护是成人紫绀型心脏病矫治手术成功和减少术后并发症的重要因素。     

青年胃癌136例临床病理特点及预后观察

目的：分析青年胃癌患者的临床病理特征,探讨影响预后的因素。方法：回顾性分析2000年5月—2005年1月间行胃癌手术治疗的年龄≤45岁的青年患者136例的临床资料。结果：青年人胃癌临床表现以腹上区疼痛不适最常见,占72.1%,男女之比为1∶1.66,肿瘤部位以胃窦部常见,肿瘤分期Ⅲ～Ⅳ期120例,占88.2%;患者原发灶穿透浆膜（T3-4）114例,占全组的83.8%;Borrmann分型以浸润型（Ⅲ型＋Ⅳ型）为主,共110例,占80.9%;全组平均生存期为28.81个月,全组1,3,5年生存率分别为57.3%,25.7%和20.5%。结论：青年胃癌以女性和弥漫型癌所占比例较高,临床分期晚,根治性手术切除率低。TNM分期、手术性质及术后辅助化疗是评价其预后的重要参考因素。     

成人斜视生存质量量表在斜视患者术前生存质量评估中临界值的研究

目的探讨成人斜视生存质量量表在成人斜视患者术前生存质量状况评估中的最佳临界值。方法对306例成人斜视患者,于入院第1天采用成人斜视生存质量量表及国家眼科研究视功能量表进行调查,以国家眼科研究视功能量表作为诊断"金标准",绘制受试者工作特征曲线,确定成人斜视生存质量量表的最佳临界值。结果成人斜视生存质量量表得分与国家眼科研究视功能量表得分呈正相关(r=0.481,P0.01);当成人斜视生存质量量表临界值为74.5时,受试者工作特征曲线在左上方离标准参照线最远,此时灵敏度、特异度、假阴性率及假阳性率分别为0.784、0.875、0.216、0.125。受试者工作特征曲线下面积为0.893,面积的标准误为0.038。由于量表采用Likert 5级评分,临界值取为整数74分。结论成人斜视生存质量量表在斜视患者术前生存质量状况评估中的最佳临界值为74分,是成人斜视患者术前生存质量状况评估的有效工具。     

糖皮质激素在重症医学科急性呼吸窘迫综合征中的应用

目的评价糖皮质激素(glucocorticoids,GCs)在重症监护室(intensive care unit,ICU)治疗急性呼吸窘迫综合征(acute respiratory distress syndrome,ARDS)中的作用。方法回顾性分析本院入住ICU的ARDS患者的临床资料,并根据致病因素在肺损伤中的作用,将所入选患者分为肺内源性ARDS(primarily from pulmonary diseases,ARDSp)和肺外源性ARDS(primarily from extra-pulmonary diseases,ARDSexp);ARDSp患者62例,ARDSexp患者101例。根据GCs的使用量各分为3组,分析ARDSp及ARDSexp应用GCs和未应用GCs患者的病情改善和病死率。结果 ARDSp及ARDSexp患者各组急性生理与慢性健康评分(Acute Physiology and Chronic Health EvaluationⅡ,APACHE-Ⅱ)相当(P0.05)。GCs治疗30mg/d组与≥30mg/d组比较,病情改善时间和呼吸机治疗时间明显缩短(P0.01),病死率也略低(P0.05);GCs治疗30mg/d组与非GCs治疗组比较差异有统计学意义(P0.01);≥30mg/d组与非GCs治疗组比较差异无统计学意义(P0.05)。ARDS患者总体病死率23.3%(38/163),其中使用GCs治疗组病死率22.8%(34/149),未使用GCs治疗组病死率28.6%(4/14)(P0.05)。结论低剂量(30mg/d)、早期应用(24h内)、长期疗程(7d)的GCs,可及时遏制炎性介质的"瀑布样效应",在一定程度上缩短病程,降低病死率。     

Day procedure intervention is safe and complication free in higher risk patients undergoing transradial angioplasty and stenting. The discharge study.

OBJECTIVES: To assess the timeframe of postprocedural complications following transradial percutaneous intervention in selected nonlow-risk risk patients as a feasibility study for same day discharge. BACKGROUND: Percutaneous coronary intervention (PCI) is traditionally performed as an inpatient procedure. Transradial access with its lower complication rate facilitates safe and same day discharge. We hypothesize that with current standards of pharmacotherapy and intervention, complications post transradial percutaneous coronary angioplasty even in a nonlow-risk patient cohort will be evident within 6 hr or occur more than 24 hr post procedure. Under these circumstances, overnight stay results in no improvement in patient safety. METHODS: 2,189 patients underwent transradial PCI at our institution between January 2005 and June 2006. Of these 1,174 were assessed as intermediate or high risk and admitted postprocedure. The remaining 1,015 were assessed as low risk and discharged the day of procedure. All 1,174 inpatients were entered into our study database. Information was collected on patient demographics, angiographic characteristics, post procedural complications, and timing of post procedural events. RESULTS: 1,543 ACC type B2 or C lesions were treated in 1,174 patients. All post-procedural complications were identified within 6 hr of the intervention or occurred more than 24 hr later when patients would have been discharged according to overnight admission protocols. CONCLUSIONS: Day case transradial percutaneous intervention with a 6-hr period of post procedure observation is a safe and feasible practice. The presence of higher-risk features should not be considered an absolute indication for overnight admission in patients considered clinically appropriate for discharge.     

Isolated central nervous system involvement in adult T-cell lymphoma/leukaemia

Central nervous system (CNS) presentation of adult T-cell lymphoma/leukaemia is rare, and almost invariably associated with systemic disease. We report an unusual manifestation of adult T-cell lymphoma/leukaemia, with isolated CNS involvement and unusual imaging findings. We also describe objective response to antiviral therapy. To our knowledge, this is the first report of such presentation and response.     

裸露DNA疫苗pCDSj32的构建、鉴定及在小鼠骨骼肌细胞的表达

应用基因工程技术，对本室已经克隆的日本血吸虫成虫３２ｋＤａ蛋白分子的ｃＤＮＡ片段进行ＰＣＲ扩增，扩增产物亚克隆入高效真核表达载体ｐＣＤ，构建成功裸露ＤＮＡ疫苗ｐＣＤＳｊ３２。ｐＣＤＳｊ３２在ＢＡＬＢ／ｃ小鼠骨骼肌细胞得到表达。表达产物可被小鼠抗３２ｋＤａ蛋白分子单抗识别。免疫荧光定位显示，表达产物不但存在于细胞浆，而且可结合于胞膜并被分泌至胞外。     

Are children just small adults? The differences between paediatric and adult sleep medicine

Several important physiological and maturational changes occur in sleep development during the paediatric age range, particularly during infancy and in early childhood. As the pathology of sleep apnoea is superimposed onto a developing and often plastic physiological system, children often show a different pathophysiology to their adult counterparts. These factors need to be incorporated into the evaluation of a child's sleep problems. Particular attention should be paid to the developmental stage of the child. Investigation, interpretation and subsequent management provide further unique challenges and during successive reviews predicted normal changes must also be taken into account. This review article discusses the important physiological and maturational changes that occur in sleep during childhood, some common paediatric sleep conditions and their presentation and the appropriate evaluation and management of these conditions. In the course of the discussion, we have stressed important differences between paediatric and adult sleep medicine.     

Clinical and echocardiographic correlates of health status in patients with acute chest pain

Objective  To assess the ability of echocardiographic data to predict important functional status outcomes in patients with chest pain. Design  Prospective cohort study. Setting  A large, urban teaching hospital. Patients  Three hundred thirty-three patients admitted from the Emergency Department for evaluation of chest pain. Measurements and Main Results  Patients underwent two-dimensional and Doppler echocardiography as well as a face-to-face interview during their initial hospitalization and a telephone interview 1 year thereafter. The interview included the Medical Outcomes Study 36-Item Short Form (SF-36) health inventory, a generic health status instrument with a physical function subscale. The relation between clinical and echocardiographic factors and functional status was explored by univariable and multivariable linear regression and logistic regression analyses. Multiple clinical and echocardiographic factors correlated significantly with functional status measures at 1 year. For the SF-36 score at 1 year, age, male gender, white race, the presence of rales, and a comorbidity score were independently predictors in multivariate analysis; echocardiographic findings of severe left ventricular dysfunction (parameter estimate [PE] −27.6; 95% confidence interval [CI] −43.1, −12.2) and aortic insufficiency (PE −16.7; 95% CI −26.4, −7.0) added independent predictive information. Explanatory power (r ²) for models using clinical and demographic variables was .27 and increased after inclusion of echocardiographic data to an r ² of .35. Results in the subset of patients (n=148) with acute coronary syndromes such as unstable angina or myocardial infarction were qualitatively similar. Selected factors (rales on examination, electrocardiographic changes suggestive of ischemia, and moderate to severe mitral regurgitation) also predicted which patients would die or have a decline in their functional status. In multivariate analysis, only rales remained an independent predictor of poor outcome (odds ratio 2.4; 95% CI 1.2, 4.5). Conclusions  Echocardiographic data are correlated with measures of functional status in patients with chest pain, but the ability to predict future functional status from clinical or echocardiographic information is limited. Because functional status cannot be predicted adequately from either patients’ characteristics or echocardiographic testing, it must be assessed directly. Dr. Fleischmann is the recipient of a Clinical Investigator Development Award (IK08HL02964-01) from the National Heart, Lung and Blood Institute.