小儿右侧颈动、静脉体外膜肺氧合致颅脑损伤多因素分析

目的 了解小儿右颈动静脉体外膜肺氧合(extracorporeal membrane oxygenation,ECMO)致颅脑损伤的高风险因素.方法 回顾性分析自2009年7月至2015年11月19例严重心肺衰竭患儿行右颈总动脉和右颈内静脉插管,并结扎相应远端血管转ECMO的临床资料.本组男12例,女7例;年龄1d～13岁,新生儿2例;体重3.7～61.0 kg,平均(22.7±15.2)kg.本组行ECMO前低灌注13例(68.4％),伴有高乳酸血症10例(52.6％),少尿10例(52.6％),心肺复苏胸外按压同时ECMO(E-CPR)7例(36.8％),低氧和/或酸中毒16例(84.2％).采用静脉-动脉转流ECMO(VA-ECMO) 18例,静脉-静脉转流ECMO(VV-ECMO)1例.结果 能在1h内建立有效循环并在随后24h内获得明显组织灌注改善17例,不能改善2例.ECMO支持时间65～572 h,平均(172.0±141.0)h.19例中脱机14例(73.7％),存活13例(68.4％),死亡6例(31.6％).发生颅脑损伤4例(21.0％,颅脑损伤组),其中心搏骤停3例(院外心搏骤停史1例,E-CPR 2例),插管困难且不能在24h获得内环境和组织灌注改善2例,ECMO前长时间严重低氧血症1例,最终死亡2例(50.0％).行E-CPR 7例的存活率为71.4％(5/7),病死率为28.6％(2/7);颅脑损伤发生率为28.6％(2/7),明显高于总体平均水平.本组2例新生儿,存活1例为新生儿膈疝,1例为胎粪吸入综合征死于严重溶血、肝衰竭,这2例均无颅脑损伤.存活13例出院后随访时间1个月～6年不等,无颅脑损伤后遗症12例,能正常生活学习,有明显颅脑损伤后遗症1例(7.7％).存活13例中有10例在ECMO撤离后行颈部血管超声检查,均提示右颈总动脉及颈内静脉结扎远端血管充盈,血流正常;7例行脑MRI检查,2例行脑部CT检查,发现颅内出血2例.新生儿中存活1例脑干听觉诱发电位测定提示双耳正常.结论 ECMO能治疗严重心肺衰竭患儿.预防ECMO所致颅脑损伤的关键在于密切关注EC-MO术前、术中各个相关危险因素,把握ECMO置入时机.对于小儿ECMO颈部血管入路是比较好的选择.结扎颈部血管并不增加颅脑损伤的发生.     

成人自身免疫性肝炎二线药物治疗选择的Meta分析

目的通过自身免疫性肝炎二线药物相关文献的系统性回顾及Meta分析探讨药物的有效性和安全性。方法计算机检索PubMed、EMBASE、Cochrane Library、Web of Science、中国知网、中国生物医学文献数据库、万方数据库及维普数据库等公开发表的关于自身免疫性肝炎二线药物治疗的研究文献,时间截至2019年12月31日。对纳入的文献采用纽卡斯尔-渥太华量表进行文献质量评价,提取相关数据,采用Meta-Analyst统计软件进行Meta分析。结果纳入22篇文献,共计636例患者。Meta分析结果显示,吗替麦考酚酯(MMF)、他克莫司(TAC)、环孢素(CsA)及布地奈德(BUD)的汇总应答率分别为56.1%、76.0%、62.7%、57.3%,汇总的不良反应发生率分别为22.5%、47.4%、48.4%、33.0%。将应用MMF的患者按照一线治疗不耐受和一线治疗无应答进行分组比较,相对危险度为1.965,95%可信区间为1.181～3.269,异质性检验I2=0.665,P=0.014。结论对于成人自身免疫性肝炎患者的二线药物治疗选择,结合应答率及不良反应发生率,MMF和TAC均是较好的选择,而对一线治疗无应答的患者,TAC可能是更优的选择。     

胃pH监测对残胃黏膜泌酸功能的应用价值

目的研究胃远端部分切除术后患者泌酸功能及其与黏膜病理改变、胆汁反流和幽门螺杆菌（Hp）感染的相关性。方法采用24hpH监测仪测定51例残胃患者空腹胃内pH值，根据24h胃内平均pH值分为低泌酸组（pH≥3）和正常泌酸组（pH〈3）。胃镜观察残胃黏膜以及Hp检测。结果低泌酸组患者35例，其中29例黏膜呈重度萎缩；正常泌酸组16例，其中4例呈重度黏膜炎症（P=0．0061。胆汁反流率在低泌酸组和正常泌酸组分别为37．4％和18、7％（P=0．014）。两组间Hp感染率差异无统计学意义。62．7％的患者胃酸分泌减少．但却接受了抑酸药物药物治疗。结论24h动态胃pH监测可有效评价残胃患者胃黏膜泌酸功能。胆汁反流和残胃炎程度与黏膜泌酸功能有明显相关性。     

葛根临床应用举隅

葛根味甘、平、性凉,归脾、胃经,历代医家在临床运用中,使葛根用途日趋广泛.现就葛根的应用举例如下. 1 伤寒 沈某,女,40岁,2006年4月22日初诊.     

复方甘正浸膏对非酒精性脂肪性肝炎CYP2E1和PPARα表达的影响

目的观察复方甘正浸膏对高脂饮食建立的非酒精性脂肪性肝炎大鼠模型肝脏细胞色素P4502E1(CYP2E1)和过氧化物酶体增殖物激活受体(PPARα)表达的影响。方法大鼠随机分为正常组(不处理)、模型组、治疗组(予复方甘正浸膏),检测大鼠肝匀浆超氧化物歧化酶(SOD)活性、丙二醛(MDA)水平、甘油三酯(TG)含量及肝组织CYP2E1和PPARα的表达。结果模型组SOD活性较正常组明显降低,治疗组SOD活性较模型组显著增高,但仍低于正常;模型组MDA较正常组显著增高,治疗组MDA较模型组显著降低,但仍高于正常组;模型组TG含量明显高于正常组,治疗组与正常组无显著差异。模型组CYP2E1在肝组织中央静脉周围腺泡区肝细胞胞浆表达阳性率70%,正常组几乎无表达,治疗组阳性率20%,较模型组明显减少,与正常组相近。PPARα在正常组主要分布于肝组织汇管区周围肝细胞胞核内呈棕黄色表达,模型组较正常组表达细胞数明显减少,治疗组较模型组表达细胞数明显增多。结论复方甘正浸膏具有清除脂质过氧化和氧自由基的作用。     

肝硬化病人肾血流变化的临床研究

目的研究肝硬化患者肾脏血液动力学的变化.方法对49例肝硬化病人采用彩色多普勒超声测定肾叶间动脉及弓形动脉搏动指数(PI)、阻力指数(RI)及收缩期最高峰值/舒张期最低峰值(PS/PD)等指数,并同时监测患者的血内皮素情况.结果肝功能越差,搏动指数和阻力指数越高,尤以RI为著;随腹水量的增加,肝硬化病人的PI、RI等亦有明显增高.肝硬化血内皮素(ET)的增高与PI及RI增高密切相关.结论通过多普勒超声发现肝硬化患者肾血流与肝功能有直接相关性,肝硬化腹水和肾血流亦有相关性,而顽固性腹水PI、RI的演变可能有助于早期发现肝肾综合征(HRS);血内皮素水平在肝硬化病人中明显增高,且与肾血管阻力的增加呈正相关,因而内皮素可能是参与肝硬化病人肾血管收缩的重要活性因子.     

《黄帝明堂灸经》与《西方子明堂灸经》的灸法学术思想对比

《黄帝明堂灸经》与《西方子明堂灸经》均是唐宋时期灸法专著。该文通过对两书的研读比较,发现两书在灸治腧穴、灸治方法、灸治思想、灸治范围等方面各有异同。该文主要从载穴分部、取穴定位、灸疗内容、灸法禁忌4方面加以论述,以期抛砖引玉,求教同道。     

含乌司他丁肺保护液在心肺转流术中的肺保护作用

Objective To evaluate protective effects of hypothermic pulmonary protective solution with uli-nastatin on lung function during cardiopulmouary bypass (CPB) in the patients with congenital heart disease(CHD) and pulmonary hypertenion. Method Fifty-four children,who had CHD of left-to-fight shunts with moderate-se-rious pulmonary hypertension, were enrolled. They had been performed with the radical operation under CPB from September 2005 to December 2006 in the Department of Cardiovascular Surgery, Children' s Hospital of Zhejiang University. Moderate-serious pulmonary hypertension was defined as pulmonary-to-systolic pressure ratio > 0.45(Pp/Ps > 0.45). Fifty-four children were randomly divided into three groups. Patients in group A (n = 18)didn't receive pulmonary protective solution, and scrved as control; patients in group B (n = 18) were adminis-tered with pulmonary protective solution without ulinastatin;patients in group C (n = 18) were administered with pulmonary protective solution with ulinastatin. The serum concentrations of MDA and MPO were measured at five different time points:pre-operation, 0 h, 3 h, 6 h and 24 h in the intensive care unit (ICU) (T1～5). Patients'lung functions were monitored at T1 - T4. The time of mechanical ventilation was recorded. Results No one died in this study. The mean time of mechanical ventilation was shorter in the group B and group C than that in the group A. The MDA and MPO levels were lower in group B compared with group A at T4. The MDA level at T3-T5 and the MPO level at T4 was lower in group C than those in group A. There were no significant in MDA and MPO levels between group B and group C at five time point.A-aDO2 was lower in groups B and C than those in group A at T3 and T4, whereas at T4, A-aDO2 was lower in group C than that in group B. Cdyn was higher in group B at T3and group C at T3 - T4 than those in group A. Cdyn was lower in groups C than that in group B at T4.Condusions Lung perfusion with hypothermic protective solution during CPB can all lung injury and promote recovery after operation, especialy with ulinastatin.     

以癫痫为首发症状的老年急性脑血管病32例临床分析

1996年 6月至 1999年 10月住院的 6 40例老年急性脑血管病中以癫痫为首发症状者 32例 ,其中男 18例 ,女 14例 ,年龄 6 0～ 88岁 ,平均年龄 74岁 ,蛛网膜下腔出血 8例 ,脑出血 10例 ,脑梗死 14例。病变部位 :蛛网膜下腔出血 8例脑出血 10例中 ,额叶出血 2例 ,出血量 2 4ｍＬ、40ｍＬ ;顶叶出血 1例 ,出血量 2 8ｍＬ ;颞叶出血 2例 ,出血量 2 8ｍＬ、36ｍＬ。枕叶出血 1例 ,出血量 32ｍＬ ;基底结区出血 4例 ,其中 1例出血 36ｍＬ。余 3例破入脑室。脑梗死 14例。额颞叶 2例 ,颞顶叶 1例 ,额颞顶 1例 ,颞叶 3例 ,枕叶 2例 ,基底结区 2例。脑室…     

评价多重连接探针扩增法诊断染色体22q11.2微缺失结果研究

目的 对多重连接探针扩增(multiplex ligation-dependent probe amplification,MLPA)诊断染色体22q11.2微缺失结果进行评价.方法 应用MLPA及荧光原位杂交(fluorescence in situ hybridization,FISH)两种方法分别检测了32份儿童(男16例,女16例;年龄1～13岁,平均3.6±3.1岁)血样本,其中16例为染色体22q11.2微缺失患儿组(阳性对照组),16名为体检正常儿童组(阴性对照组).采用灵敏度、特异度及Kappa分析来评估结果.结果 MLPA检测32份样本中,16例阳性对照样本均有染色体22q11.2微缺失,且缺失片段长度约3-Mb;16名对照样本中未发现22号染色体缺失.FISH证实16例22q11.2微缺失患儿均存在缺失,16名对照样本不存在缺失.因此,MLPA诊断染色体22q11.2微缺失的灵敏度及特异度高.结论 MLPA是一种快速、可靠、高通量及相对经济的诊断染色体22q11.2微缺失的有效方法,弥补了FISH技术的不足,可用于临床实验室快速诊断染色体22q11.2微缺失,具有较高的临床诊断价值.

Abstract：

Objective To evaluate multiplex ligation-dependent probe amplification (MLPA) assay detection in analysis of chromosome 22q11.2 microdeletion. Methods Between March 2008 and September 2009, thirty-two patients including 10 males and 16 females aged between years (3.6±3.1) were selected and evaluated by history, physical examination and medical records. Of these patients, sixteen patients who were previous diagnostic as 22q11.2 microdeletion were in positive control group, the other 16 healthy children were in negative control group. All the patients were detected by MLPA and fluorescence in situ hybridization (FISH) for the presence of a 22q1 1.2 microdeletion after informed consent. Diagnostic efficacy was assessed by sensitivity, specificity and Kappa analysis. Results We have applied the two assays of detection of chromosome 22q11.2 microdeletion in 32 patients. Sixteen patients in positive control group were found to have a 22q11. 2 deletion and, with the deletion size of 3-Mb. However, as expected,chromosome 22q11.2 deletion was not found in negative control group. The MLPA results were in good agreement with that by FISH. Therefore, MLPA has high sensitivity and specificity. Conclusion MLPA is a rapid, reliable, high-throughput and relatively economical alternative to FISH technology for the diagnosis of 22q11.2 microdeletion. It can provide reliable and helpful information for clinical diagnosis of 22q11.2 microdeletion syndrome.