26、27融合畸形1例

２６、２７融合畸形１例邵泽成，张玉峰，孙显瑞枣庄市中区医院（２７７１３７）李某，女，３２岁，左上颌后牙痛３ｄ，于１９８９年９月７日来诊。检查：２６、２７颊、腭向融合，２６探痛（＋＋），冷痛（＋＋＋），热痛（＋＋），叩痛（±），牙龈无肿胀。初诊：２６急...     

临床服务指南

临床服务指南是健康宝典的一个新的补充。十几年来，在临床实践中已先后出版了多种不同形式及版本。这些冠以不同名称、以不同形式出版的“临床服务指南”包括：状况描述、实践原则、临床常规、方案、实践指南。临床服务指南被视为解决一些医学相关问题(如医疗保健费用的普遍上涨，医疗行为的地区差异，医疗保健服务质量的评价等)的一个途径，同时，它旨在规范人们的医疗服务行为，尤其是减少那些对同一种情况所采取的不同诊疗措施情况的发生。其中，最重要的是应避免那些对病人无任何益处而徒增病人负担的医疗服务。对医生而言，通晓临床服务指南十分重要，医生应知道指南是如何开发的、关于指南的争议以及如何去评价和使用指南。     

Effect of etoposide on experimental testicular teratoma in 129/SvJ mice

To study the effects of etoposide on experimental testicular teratoma in 129/SvJ mouse we analysed the tumour growth, differentiation, apoptosis and the localisation of mdr₁ P-glycoprotein (mdr₁-Pgp). In this model the implanted gonadal ridges developed into testicular teratomas in 17 out of 56 implanted testes (30%) and in 14 out of 28 mice (50%). The tumour-bearing mice were treated with etoposide on 4 successive days either 4 weeks or 6 weeks after implantation, and killed 7 days after the last dose. The mice in the control groups did not receive etoposide. The teratomas consisted mainly of neural tissue. The etoposide-treated 4-week teratomas, but not the 6-week teratomas, were significantly smaller than those in the corresponding control groups. The density of apoptotic cells and the distribution of the mdr₁-Pgp were not altered by etoposide. The decreased proportion of immature neuroectodermal tissue components was observed in all treated teratomas, converting the histology towards that of a mature teratoma. In addition, a low proportion of immature tissue components was frequently combined with a low density of apoptotic cells. In conclusion, etoposide decreased the immature tissue components of teratomas, while mature tissues remained unaffected. These results may have clinical relevance in man, since they confirm that postchemotherapy mature teratomas cannot be treated with chemotherapy. Despite benign histology, the human residual tumours have a significant malignant potential and require complete surgical excision and close surveillance. Received: 20 August 1999 / Accepted: 20 January 2000     

Dermatan sulfate and LMW heparin enhance the anticoagulant action of activated protein C

Unfractionated heparin potentiates the anticoagulant action of activated protein C (APC) through several mechanisms, including the recently described enhancement of proteolytic inactivation of factor V. Possible anticoagulant synergism between APC and physiologic glycosaminoglycans, pharmacologic low molecular weight heparins (LMWHs), and other heparin derivatives was studied. Dermatan sulfate showed potent APC-enhancing effect. Commercial LMWHs showed differing abilities to promote APC activity, and the molecular weight of LMWHs correlated with enhancement of APC activity. Degree of sulfation of the glycosaminoglycans influenced APC enhancement. However, because dextran sulfates did not potentiate APC action, the presence of sulfate groups per se on a polysaccharide is not sufficient for APC enhancement. As previously for unfractionated heparin, APC anticoagulant activity was enhanced by glycosaminoglycans when factor V but not factor Va was the substrate. Thus, dermatan sulfate and LMWHs exhibit APC enhancing activity in vitro that could be of physiologic and pharmacologic significance.     

Maternal mortality in Guinea-Bissau: the use of verbal autopsy in a multi-ethnic population

BACKGROUND: In developing countries with scanty resources it is very important to have reliable data to establish priorities for the health sector; e.g. to reduce maternal mortality it is necessary to determine the most important causes. The majority of deaths, however, occur without previous contact with the health system and consequently conventional analyses of death certificates are not feasible. Instead, studies have been carried out in some developing countries with various forms of post-mortem interviews, the so-called verbal autopsies (VA). METHODS: We developed a structured interview with filter questions, which was applied to all deaths of women of fertile age in a cohort of 10,000 women living in 100 clusters in Guinea-Bissau and followed over a period of 6 years. The cause of death was ascertained by means of a series of diagnostic algorithms for the most common causes of maternal mortality, including postpartum haemorrhage, antepartum haemorrhage, puerperal infection, obstructed labour, eclampsia, abortion, and ectopic pregnancy. RESULTS: Of the 350 deaths of women of fertile age, 32% were maternal and it seems unlikely that a significant proportion of maternal deaths have not been classified correctly. Using the diagnostic algorithm 70% could be given a specific diagnosis, the most important causes being postpartum haemorrhage (42% [29/69]), obstructed labour (19% [13/69]), and puerperal infection (16% [11/69]). We attempted to identify the factors that are critical for obtaining sufficient information to reach a diagnosis. In the univariate analyses, it was important whether the respondent had been present during the last illness (P = 0.04) and whether the death occurred more than one week after delivery (P = 0.04). The husband was a better respondent than a co-wife (P = 0.08), and men in general provided more specific information than women (P = 0.08). Furthermore, information appeared to be better if the woman had died in the rainy season (P = 0.08). The length of the recall period, parity, age of woman, place of death, rural/urban residence, and ethnic group were not decisive. In the multivariate analysis sex and presence of respondent and time after delivery were significantly associated with the risk of not reaching a specific diagnosis. Women are less likely to provide adequate information for a diagnosis than men (odds ratio [OR] 3.1; 95% confidence interval [CI]: 1.2-8.1). Respondents that did not reside in the village during the departed woman's illness/delivery carried equal risk of not reaching a conclusion (OR 3.1; CI: 1.1-9.1). Deaths occurring more than one week after delivery were also less likely to be classified (OR 6.1; CI: 1.7-22.0). CONCLUSION: The VA described in the present paper left 30% of the maternal deaths unclassified without a specific diagnosis. Had all interviews been with husbands, only 14% would have remained unclassified. If we had only asked people who were present during the terminal phase of the victim's illness the proportion of classified deaths would have risen from 70% to 75%. It is likely that delayed maternal deaths have not been adequately covered by the present algorithms, but they may also simply be more difficult to describe due to the duration of the disease episode. In contrast to methods by which cause of death is established by a panel of medical experts, the present VA should be economically and technically viable in areas where health workers have only minimal training.     

Effect of short-term hyperventilation on cerebral blood flow autoregulation in patients with acute bacterial meningitis

BACKGROUND AND PURPOSE: Cerebral blood flow (CBF) autoregulation is impaired in patients with acute bacterial meningitis: this may be caused by cerebral arteriolar dilatation. We tested the hypothesis that CBF autoregulation is recovered by acute mechanical hyperventilation in 9 adult patients with acute bacterial meningitis. METHODS: Norepinephrine was infused to increase mean arterial pressure (MAP) 30 mm Hg from baseline. Relative changes in CBF were concomitantly recorded by transcranial Doppler ultrasonography of the middle cerebral artery, measuring mean flow velocity (V(mean)), and by measurement of arterial to jugular oxygen content difference (a-v DO(2)). The slope of the regression line between MAP and V(mean) was calculated. Measurements were performed during normoventilation and repeated after 30 minutes of mechanical hyperventilation. RESULTS: At normoventilation (median PaCO(2) 4.4 kPa, range 3.5 to 4.9), MAP was increased from 68 mm Hg (60 to 101) to 109 mm Hg (95 to 126). V(mean) increased with MAP from 48 cm/s (30 to 61) to 65 cm/s(33 to 86) (P<0.01), and a-v DO(2) decreased from 2.2 mmol/L (1.0 to 2.7) to 1.4 mmol/L (0.8 to 1.8) (P<0.05). During hyperventilation (PaCO(2) 3.5 kPa, range 3.3 to 4.1), MAP was increased from 76 mm Hg (58 to 92) to 109 mm Hg (95 to 121). V(mean) increased from 45 cm/s (29 to 55) to 53 cm/s (33 to 78) (P<0.01), and a-v DO(2) decreased from 2.5 mmol/L (1.8 to 3.0) to 1.8 mmol/L (1.2 to 2.4) (P<0.05). Four patients recovered autoregulation completely during hyperventilation. The slope of the autoregulation curve decreased during hyperventilation compared with normoventilation (P<0.05). CONCLUSIONS: CBF autoregulation is partially recovered during short-term mechanical hyperventilation in patients with acute bacterial meningitis, indicating that cerebral arteriolar dilation in part accounts for the regulatory impairment of CBF in these patients.     

Laminin isoforms in fetal and adult human adrenal cortex

Laminin has been proposed to influence the function of human adrenal cortex. We have studied the distribution of laminin (Ln) chains using immunofluorescence in human fetal and adult adrenal cortex. In the fetal gland Ln alpha2- and alpha5-chains were weakly expressed in the definitive zone, whereas Ln alpha4-, beta1-, and gamma1-chains occurred around vessels. In the adult gland, Ln alpha2-, alpha5-, and gamma1-chains were found in epithelial basement membranes (BM) in all cortical zones, Ln alpha4-chain in vessels, Ln beta1-chain in outer zone, and Ln beta2-chain in the two inner zones of the cortex, respectively. Among the integrins in adult gland, integrin alpha(3)-subunit was confined to basal surfaces of cortical cells, alpha(6) to vessels, alpha(1) to the stroma, and alpha(2) diffusely to epithelial cells. Lutheran glycoprotein and dystroglycan occurred in the fetal gland diffusely in the definitive zone and throughout the epithelium in the adult. The isoform composition of BM of the adult adrenal gland is distinct, with Ln-2 and -10 in BM of the outer zone and Ln-4 and -11 in BM of the two inner zones. The results suggest that integrin alpha(3)beta(1) and Lutheran are candidate receptors for Ln-10 and -11, whereas dystroglycan probably binds Ln-2 and -4.     

Activated protein C and inflammation in human myocardium after heart surgery

To assess possible interactions between inflammation and activation of the anticoagulant protein C system during post-ischemic reperfusion protein C, APC, neutrophil L-selectin expression and myocardial myeloperoxidase activity (MPO) were measured in 19 patients undergoing cardiopulmonary bypass. After reperfusion for 10 min, APC to protein C ratio (APC/PC) increased from pre-reperfusion value 1.43 +/- 0.12 (mean +/- SEM) to 2.25 +/- 0.29, p = 0.015. Negative correlations were observed between APC/PC and MPO activity (Spearman r -0.64, p = 0.007) and APC/PC and neutrophil L-selectin expression (r = -0.7, p = 0.007, demonstrating that post-ishemic protein C activation was associated with decreased neutrophil tissue sequestration. Thus, physiological protein C activation may be involved in regulation of the inflammatory injury during reperfusion of human ischemic coronary circulation.     

切开复位与闭合复位交锁髓内钉内固定治疗股骨干骨折效果观察

目的 对比分析切开复位交锁髓内钉内固定与闭合复位交锁髓内钉内固定治疗股骨干骨折的效果。方法 选取2015年1月至2018年6月收治的78例股骨干骨折患者随机分为观察组和对照组,观察组给予闭合复位交锁髓内钉内固定治疗,对照组给予切开复位交锁髓内钉内固定治疗,比较手术情况、骨折愈合时间、术前及术后6个月HSS评分、术后12个月膝关节功能评价、并发症发生情况、术后12个月综合疗效。结果 观察组术中出血量(165.78±29.34)mL较对照组(451.26±30.02)mL显著减少,骨折愈合时间为(19.36±5.24)周较对照组(31.33±4.48)周显著缩短,差异具有统计学意义(P＜0.05),两组手术时间无统计学差异(P＞0.05),术前两组HSS评分无统计学差异(P＞0.05),术后两组HSS评分均显著提高,且观察组HSS评分提高更显著(P＜0.05),观察组并发症发生率为5.13%较对照组23.08%显著降低,差异具有统计学意义(P＜0.05),术后12个月观察组、对照组综合疗效、膝关节功能优良率分别为94.87%vs87.18%、94.87%vs89.74%,差异无统计学意义(P＞0.05)。结论 切开复位交锁髓内钉内固定与闭合复位交锁髓内钉内固定治疗股骨干骨折疗效相当,但是闭合复位可减轻对患者创伤,缩短骨折愈合时间,降低术后并发症的发生率,促进膝关节功能的恢复,值得在临床上推广。