【摘要】 目的 探讨活动期感染性心内膜炎（infectiue endocarditis，IE）患者心脏手术的最佳时期。 方法 回顾分析1999年9月-2009年9月行外科治疗的92例IE患者的临床资料。IE诊断标准为修订的Duke标准。采用SPSS 12.0软件包，分析了年龄、性别、是否是院内感染IE、合并症（糖尿病、慢性阻塞性肿疾病、癌症）、病原菌、手术时间等因素与手术并发症及6个月病死率的关系。 结果 56例患者在确诊为IE后7 d内手术，36例患者在确诊7 d后，并抗生素治疗完成后手术。葡萄球菌为主要感染菌株，与栓塞、脓肿及感染性休克显著相关。最常见的手术指征是重度的瓣膜关闭不全合并心功能不全。6个月的病死率为12%。早期手术与晚期手术比较，病死率增高。单因素分析显示，与6个月病死率相关的因素包括葡萄球菌感染和感染性休克。多因素分析显示感染性休克为6个月内死亡的预测因子。感染性休克的患者尽管行了早期手术，病死率仍为67%。严重瓣膜关闭不全的患者，若未出现心衰，无手术（早期或晚期）死亡。 结论 手术患者的预后由是否发生过感染性休克决定。晚期手术组患者结果好于早期手术组，但结果的差异可能并不是手术的时期不同，而是感染性心内膜炎的严重程度不同造成的。对于有重度瓣膜返流但无心衰的患者，早期手术可能在缩短住院时间，预防心衰发生上有帮助。【Abstract】 Objective To discuss the optimal time of cardiac operations in patients with infective endocarditis (IE). Methods We analyzed the clinical data of 92 patients with IE diagnosed by the modified Duke criteria between September 1999 and September 2009. SPSS 12.0 was used to analyze predictors of 6-month mortality, including age, sex, nosocomial origin of infection, comorbid conditions (diabetes, chromic obstructive pulmonary disease, cancer), the causative microorganisms, the timing of cardiac operation, and the complications. Results Fifty-six patients underwent operation within the first 7 days after diagnosis of infective endocarditis, and 36 received operation at the completion of antibiotic treatment 7 days after the diagnosis. Staphylococci predominated and were significantly associated with embolism, abscess, and septic shock. The most frequent indication for operation was severe regurgitation with heart failure. The 6-month mortality was 12%. Early operation showed an increased mortality compared with late operation. Univariate analysis showed that factors associated with 6-month mortality included staphylococci infection and septic shock. Multivariate analysis revealed that septic shock was a predictor of 6-month mortality. Despite early operation for patients with septic shock, 67% of them died. No death occurred to patients with severe regurgitation but without heart failure after undergoing (early or late) operations. Conclusions The prognosis for surgically treated patients is determined by the occurrence of septic shock. The outcome in patients undergoing late operations is favorable compared with patients undergoing early operations. This difference is probably not due to the timing of the surgical intervention but to the severity of infective endocarditis. In patients with severe regurgitation without heart failure, early operation may offer benefits in shortening the length of hospitalization and preventing development of heart failure.
目的 总结68例二尖瓣成形术的临床经验，评估其术后临床效果。 方法 回顾分析2001年12月－2011年12月进行二尖瓣成形术治疗的68例二尖瓣关闭不全患者的临床资料。成形术的方法为：人工瓣环植入、双孔成形、后瓣矩形切除、赘生物切除及心包补片修复、腱索转移等。术中采用注水实验和经食管超声心动图检查评估成形效果。 结果 68例患者中手术死亡2例，二次开胸止血1例，肺部感染3例。全部患者术中注水实验和食管超声心动图检查显示成形效果满意。存活66例患者随访6个月，术后10 d、6个月彩色多普勒超声心动图检查：左心房内径、左心室舒张末内径缩小。术后6个月彩色多普勒超声心动图检查：无或微量反流33例，轻度反流27例，轻～中度反流5例，中度反流1例。 结论 根据二尖瓣关闭不全的特征，选择相应的二尖瓣成形技术，可以取的较好的临床效果。
【摘要】 目的 探讨主动脉窦瘤破裂（RSVA）的临床特点、诊断及外科治疗方法。 方法 2004年1月-2009年12月对28例RSVA患者在体外循环下行RSVA修补术，同期行室间隔缺损修补术18例，房间隔缺损修补术4例，主动脉瓣成形术2例，主动脉瓣置换术4例。术后随访3个月～6年，平均32.4个月。 结果 28例患者均无手术死亡和残余分流。失访4例。心功能Ⅰ级20例，Ⅱ级4例；复查心脏彩色超声心动图无主动脉窦瘤复发或残余分流，主动脉瓣轻-中度反流2例。 结论 外科手术是RSVA的最有效治疗方法，窦瘤破口直径gt;0.5 cm者宜用补片修补。伴有中或重度主动脉瓣关闭不全时需根据主动脉瓣病变程度以及手术者经验决定，必要时需放宽换瓣指征。【Abstract】 Objective To evaluate the clinical characteristics, diagnosis, and surgical treatment of ruptured sinus of Valsalva aneurysm (RSVA). Methods Twenty-eight patients with RSVA were treated surgically in extracorporeal circulation. Repair of RSVA with patch were taken in all patients while closure of ventricular septal defect (VSD) in 18 patients, closure of atrial septal defect (ASD) in four patients, aortic angioplasty (AA) in two patiens and replacement of aortic valve in four patients. Results There was no death and no residue leak after operation. The patients were followed-up for 24 patients, ranged from three months to six years, with the average 32.4 months. The cardiac function of 20 patients was found to be of NYHA classⅠand four patients of classⅡ. Review the heart colour echocardiography, there was no residual tumor or sinus and aortic regurgitation light-moderate in two patients. Conclusions Surgery is the most effective treatment for RSVA, the breaches of sinus tumor in diametergt;0.5 cm is used to repair. When the patients with moderate or severe aortic regurgitation, whether it is necessary to relax in disc indications depends on the degree of aortic disease and performer’s experience.
ObjectiveTo systematically evaluate the changes in placental protein expressions in gestational diabetes mellitus (GDM) and their correlations with maternal insulin resistance (IR). Methods PubMed, Cochrane Library, Scopus, Web of Science, Embase, China National Knowledge Infrastructure, VIP database, Wanfang Database and CBMdisc were searched for case-control studies published from January 2009 to November 2021, which reported the placental protein expressions in GDM and their correlations with IR. Two researchers independently reviewed the literature, extracted data and evaluated the literature quality. RevMan 5.4 software was used for meta-analysis, and descriptive analysis was performed on data that cannot be combined. ResultsA total of 19 studies were included, comprising 2 012 patients. The results of meta-analysis showed that: the expression level of retinol binding protein 4 (RBP4) [standard mean difference=2.11, 95% confidence interval (CI) (1.64, 2.58), P<0.000 01] and the positive rate of protein tyrosine phosphatase-1B (PTP1B) [relative risk (RR)=1.56, 95%CI (1.29, 1.88), P<0.000 01] were up-regulated, and the positive rate of insulin receptor substrate 1 (IRS-1) [RR=0.69, 95%CI (0.60, 0.78), P<0.000 01] was down-regulated. The protein expression levels of RBP4 (P<0.000 01) and PTP1B (P<0.000 01) were positively correlated with homeostasis model assessment of insulin resistance (HOMA-IR), while the protein expression levels of IRS-1 (P<0.000 01) and APN (P=0.002) were negatively correlated with HOMA-IR, and glucose transporter 4 (GLUT 4) was not correlated with HOMA-IR (P=0.79). Descriptive analysis found that the expression levels or positive rates of adipocytokines (leptin, resistin), oxidative stress markers (xanthione oxidase, malondialdehyde, 8-isoprostaglandin),inflammatory factors (tumor necrosis factor α, Toll-like receptor 4, Galectin-3, Galectin-2, migration inhibitory factor),fetuin-A, forkhead box transcription factor 1, forkhead box transcription factor 3a and estrogen receptor α in GDM placenta were up-regulated and all were positively correlated with HOMA-IR. The expression levels or positive rates of insulin signaling pathway proteins [phosphoinositide 3-kinase (PI3K), protein kinases B (AKT), phospho-protein kinases B (p-AKT), GLUT 4] were down-regulated, PI3K and AKT were negatively correlatedwith HOMA-IR, while p-Akt had no correlation with HOMA-IR. ConclusionsThe dysregulation of placental protein expressions may mediate maternal IR exacerbation, thus promote the occurrence and development of GDM and other pregnancy complications. The causal relationship and regulatory mechanism are still unclear, which need to be further studied.