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反复咳嗽伴鼻阻为首发表现的双侧鼻窦真菌球二例

Efficacy of Telbivudine Combined with Defovir Dipivoxil on Positive-HBeAg Chronic Hepatitis B Patients with Suboptimal Response to Adefovir Dipivoxil

目的　评估替比夫定与阿德福韦酯联合治疗优化阿德福韦酯单药治疗应答不佳的阳性慢性乙型肝炎患者的疗效。 方法　选择2008年6月－2009年8月间共26例阿德福韦酯治疗至少12个月且病毒学应答不佳的乙型肝炎病毒e抗原（HBeAg），阳性的慢性乙型肝炎患者，在10 mg阿德福韦酯治疗的基础上，加用600 mg替比夫定。肝功能和乙型肝炎病毒（HBV） DNA每3个月评估1次，乙型肝炎两对半和腹部B型超声每半年评估1次。 结果　在第1年的治疗期间，所有患者血清HBV DNA水平均呈进行性下降，其中24例（92.3%）血清HBV DNA水平在联合治疗12个月时低于检测值下限，有25例（96.2%）患者丙氨酸转氨酶水平复常。治疗6个月时，分别有7例（26.9%）和2例（7.7%）患者发生HBeAg消失和血清学转换；治疗12个月时，分别有11例（42.3%）和8例（30.8%）患者发生HBeAg消失和血清学转换。整个治疗期间，26例患者均未出现病毒学突破。 结论　阿德福韦酯单药治疗应答不佳时，加用替比夫定可有效控制病毒，使患者获得较好的病毒学、生化学和免疫学应答。Objective　To evaluate the curative efficacy of telbivudine combined with defovir dipivoxil on positive-HBeAg chronic hepatitis B patients with suboptimal response to adefovir dipivoxil. Methods　A total of 26 HBeAg-positive patients with suboptimal response to adefovir dipivoxil (treated with adefovir dipivoxil for more than 12 months) were treated with adefovir dipivoxil 10 mg in addition to telbivudine 600 mg between June 2008 and August 2009. Liver function and serum hepatitis B virus (HBV) DNA tests were assessed at the baseline and 3-month intervals, whereas HBV serological markers and abdominal ultrasonography were carried out every 6 months. Results　During the first year of treatment, all patients showed a progressive decline of serum HBV DNA levels; while undetectable serum HBV DNA and normalization of alanine aminotransferase was achieved in 24(92.3%) and 25 (96.2%) patients, respectively, at the end of the first year of treatment. The 6- and 12-month cumulative rates of HBeAg loss were 26.9% (7/26) and 42.3% (11/26), respectively; and corresponding cumulative rates of HBeAg/anti-HBe seroconversion were 7.7% (2/26) and 30.8 (8/26), respectively. During the observation period, no virological breakthrough was detected. Conclusion　Telbivudine combined with defovir dipivoxil may be a good choice for patients with suboptimal response to adefovir dipivoxil, which could induce effective viral inhibition and help patients obtain more virological, biochemical and immunological responses.

先天性心脏病合并气道异常的围术期处理

摘要： 目的 提高对先天性心脏病合并气道异常的认识，总结围术期处理经验。 方法 对中南大学湘雅二医院2006年1月至2008年1月收治的5例先天性心脏病合并气道异常患者的临床资料进行回顾性分析，其中男3例，女2例；年龄5个月~9岁，平均年龄27个月。气道异常包括：左主支气管狭窄2例，右侧气管化支气管、气管轻度软化和左主支气管狭窄、长段先天性气管狭窄各1例。行先天性心脏病矫治术加左主支气管成形术1例，仅行先天性心脏病矫治术3例，放弃手术治疗1例。 结果 围术期死亡1例，为先天性心脏病合并右侧气管化支气管，术后发生右肺上叶不张、肺部感染和呼吸衰竭死亡。1例先天性心脏病合并左主支气管狭窄，同期行左主支气管成形术后顺利出院；随访2年健康。1例行先天性心脏病矫治术后撤离呼吸机困难，发现合并先天性左主支气管狭窄伴轻度气管软化，经内科处理撤离呼吸机后仍有喘憋；随访6个月患者发育好，喘憋未再发作。1例混合型室间隔缺损致心脏扩大、肺动脉扩张压迫左主支气管导致狭窄，行先天性心脏病矫治术后左主支气管压迫症状缓解；随访1年健康。1例合并长段气管狭窄,家属放弃手术。 结论 先天性心脏病合并气道异常临床上很少见。应提高对该病的认识，做到术前确诊；采用最佳的手术方法，尽量与先天性心脏病同期手术纠治；术后加强呼吸道管理，以获得最佳的疗效。

Spinal Cord Protection During Aortic Operation

Spinal cord injury is one of severe complications after thoracic aortic surgery. The degree and time of spinal cord ischemia during surgery, reconstruction of the blood supply of spinal cord ,biochemistry factors ,ischemiareperfusion injury, etc. are considered as factors influence on the complication of spinal cord after surgery. At present, to improve the surgical technique, to increase the blood supply of spinal cord, such as the mechanical dynamic blood perfusion, arterial shunt and cerebrospinal fluid shunt, to degrade the metabolic rate of spinal cord using hypothermia, and to prevent the ischemia-reperfusion injury using drugs are the methods for spinal cord protection during the aortic surgery. The feature of blood circulation of spinal cord, mechanisms of spinal cord injury and the latest progress of spinal cord protection is reviewed in this article.

“瓣中瓣”法二尖瓣置换术21例

目的 探讨保留全部二尖瓣结构置换二尖瓣的方法，即“瓣中瓣”方法的应用。方法 2002年1月至2005年2月，对21例二尖瓣病变患者采用“瓣中瓣”方法行二尖瓣置换术，术中保留全部二尖瓣结构，维持自然瓣下结构形态与位置，均采用2-0Prolene线进行连续缝合，将人工瓣膜置于二尖瓣口中央，同期行三尖瓣成形术15例。结果 全组均植入人工机械二尖瓣膜20枚和生物二尖瓣1枚，三尖瓣机械瓣2枚。主动脉阻断时间平均17．1min，体外循环时间平均38．1min。手术及体外循环停机顺利，无1例住院死亡和严重并发症发生。术后第7d，左心室舒张期末内径由76．1mm下降至60．1mm，左心房舒张期末内径由67mm下降至49ram，心胸比率由0．72下降至0．56，射血分数由0．47增至0．59。结论 采用“瓣中瓣”方法置换二尖瓣，保持了二尖瓣下装置的自然位置，操作简便，有利于对心肌的保护，并减少术后并发症的发生。

Bentall手术后早期并发症的发生原因及处理

目的总结Bentall手术后并发症发生的原因及早期处理经验。方法48例马方综合征（Marfan syndrome）或升主动脉瘤合并主动脉瓣关闭不全患者均行Bentall手术治疗。主动脉瓣置换采用连续缝合5例，其余患者采用间断缝合。冠状动脉开口直接吻合于人工血管上42例，游离成纽扣状后吻合6例，对动脉夹层采用三明治法缝闭。结果全组死亡3例，分别死于严重低心排血量不能脱离体外循环机、脑出血和心室颤动。存活的45例中，术后24h胸腔引流量280-1180ml，发生低心排血量12例，严重心律失常9例，肺功能不全11例，左侧胸腔积血7例等，均经强心、止血、扩张血管、呼吸机辅助呼吸等对症处理治愈。术后住院9～23d。出院时心功能Ⅰ级29例，Ⅱ级15例，无明显改善1例。结论改进手术方法和缝合技术，可减少心肌缺血和体外循环时间，有利于减少Bentall手术后并发症的发生。

连续缝合法行双瓣膜置换术

目的 总结连续缝合法行双瓣膜置换术的经验。方法 将40例风湿性心瓣膜病患者随机分为两组，每组20例。连续缝合组：二尖瓣置换术和主动脉瓣置换术均采用连续缝合法。对照组：二尖瓣置换术用连续缝合，主动脉瓣置换术用间断带垫片褥式缝合。结果 与对照组比较，连续缝合组平均主动脉阻断时间为55分钟，心肺转流时间为84分钟，较对照组缩短33.7%和34.3%，术后需正性肌力药物减少，呼吸机辅助时间缩短，并发症减少，住院时间缩短(P＜0.05)，均无瓣周、瓣缘漏发生。结论 双瓣膜置换术中采用连续缝合法可显著减少心肌缺血时间和心肺转流时间,减少心肌损伤和术后并发症发生，是一种简便有效的方法。

Research on the Curative Efficacy of Ademetionine in Treating Hyperbilirubinemia for Chronic Hepatitis B Patients

【摘要】　目的　分析腺苷蛋氨酸治疗慢性乙型肝炎高胆红素血症的临床疗效。　方法　回顾性分析2010年1-12月28例接受腺苷蛋氨酸（2 000 mg静脉滴注，1次/d）治疗慢性乙型肝炎高胆红素血症患者的临床资料，并对腺苷蛋氨酸治疗慢性重症乙型肝炎高胆红素血症后症状、体征及实验室检测指标的改变情况进行总结，利用多因素logistic回归分析方法探索与疗效相关的预测因素。根据相关症状、体征和实验室结果的不同，将疗效分为显效、有效和无效3类。　结果　28例患者使用腺苷蛋氨酸治疗4周后，显效20例（71.4%），有效4例（14.3%），无效4例（14.3%）。多因素logistic回归分析提示病程短、并发症少是影响腺苷蛋氨酸疗效的独立预测因素。　结论　腺苷蛋氨酸是治疗慢性乙型肝炎高胆红素血症有效，发病时间短及并发症少的患者退黄效果更好。【Abstract】　Objective　To investigate the curative efficacy of ademetionine in the treatment of hyperbilirubinemia for chronic hepatitis B patients. 　Methods　The clinical data of 28 chronic hepatitis B patients with intrahepatic cholestasis receiving intravenous ademetionine treatment (2 000 mg per day) were retrospectively analyzed. Patients’ symptoms, body signs and laboratory examination results were summarized, and predictors for efficacy were investigated using multiple regression analysis. In this study, the curative efficacy was classified into remarkable efficacy, efficacy and inefficacy, according to the clinical data.　Results　After one-month treatment with ademetionine, the percentage for remarkable efficacy, efficacy and inefficacy was 71.4%, 14.3%, and 14.3% respectively. Multivariate logistic regression analysis showed that short disease duration and fewer complications were independent predictors for remarkable efficacy of ademetionine treatment.　Conclusion　Ademetionine is an effective agent for the treatment of hyperbilirubinemia in chronic hepatitis B patients, and the result is especially good for patients with short duration and fewer complications.

Construction of a predictive model for poorly differentiated adenocarcinoma in pulmonary nodules using CT combined with tumor markers

ObjectiveTo establish and validate a predictive model for solid and partially solid lung nodules as poorly differentiated adenocarcinoma based on CT imaging and tumor marker results. MethodsPatients who underwent lung nodule surgery at the Department of Thoracic Surgery, the Affiliated Brain Hospital of Nanjing Medical University in 2023 were selected and randomly divided into a training set and a validation set at a ratio of 7:3. Patient CT features, including average density value, maximum diameter, pleural indentation sign, and bronchial inflation sign, as well as patient tumor marker results, were collected. Based on postoperative pathological results, patients were divided into a poorly differentiated adenocarcinoma group and a non-poorly differentiated adenocarcinoma group. Univariate analysis and logistic regression analysis were performed on the training set to establish the predictive model. The receiver operator characteristic (ROC) curve was used to evaluate the model's discriminability, the calibration curve to assess the model's consistency, and the decision curve to evaluate the clinical value of the model, which was then validated in the validation set. ResultsA total of 299 patients were included, with 103 males and 196 females, with a median age of 57 (51.00, 67.25) years; 211 patients in the training set and 88 patients in the validation set. Multivariate analysis showed that carcinoembryonic antigen (CEA) value [OR=1.476, 95%CI (1.184, 1.983), P=0.002], cytokeratin 19 fragment antigen (CYFRA21-1) value [OR=1.388, 95%CI (1.084, 1.993), P=0.035], maximum tumor diameter [OR=6.233, 95%CI (1.069, 15.415), P=0.017], and average CT value [OR=1.083, 95%CI (1.020, 1.194), P=0.040] were independent risk factors for solid and partially solid lung nodules as poorly differentiated adenocarcinoma. Based on this, a predictive model was constructed with an area under the ROC curve of 0.896 [95%CI (0.810, 0.988)], a maximum Youden index corresponding cut-off value of 0.103, sensitivity of 0.936, and specificity of 0.750. Using the Bootstrap method for 1000 samplings, the calibration curve predicted probability was consistent with actual risk. Decision curve analysis indicated positive benefits across all prediction probabilities, demonstrating good clinical value. ConclusionFor patients with solid and partially solid lung nodules, preoperative use of CT to measure tumor average density value and maximum diameter, combined with tumor markers CEA and CYFRA21-1 values, can effectively predict whether it is poorly differentiated adenocarcinoma, allowing for early intervention.

Diagnosis and Treatment of Acute Stanford Type A Aortic Dissection during Pregnancy

Objective To summarize our diagnostic and treatment experience for patients with acute Stanford type A aortic dissection （AAAD） during pregnancy. Methods Clinical data of 3 AAAD gravida （age of 30，32，35） who received surgical treatment in Beijing Anzhen Hospital of Capital Medical University from May 2008 to July 2010 were retros-pectively analyzed. One gravida received Sun’s procedure （total arch replacement combined with stented elephant trunk implantation） 3 days after cesarean section，but the fetus died in the uterus. Another gravida successfully underwent Bentall procedure and Sun’s procedure immediately after cesarean section and hysterectomy. The third gravida received cesarean section with the uterus in situ followed by ascending aorta replacement and Sun’s procedure. Results All the 3 puerperasrecovered uneventfully，and the 2 newborns of the second and third puerperas also lived well. The 3 puerperas were followedup for 6 months after discharge. CT scan showed organized thrombus in the aortic false lumen. During follow-up，the 3 puerperas recovered well，and the 2 infants had normal growth and development. Conclusions Management principles of AAAD during pregnancy firstly include timely and accurate diagnosis，which is of prime importance. Secondly，gravidas’hemodynamics should maintain stable. Thirdly，intraoperative hemorrhage should be satisfactorily controlled. Lastly，multi-modality treatment is very important to improve the prognosis of both gravidas and fetuses.