肺心病合并冠心病的临床特点与治疗体会

肺心病合并冠心病的临床特点与治疗体会湖南省永州市人民医院（４２５０００）张荣娣肺心病合并冠心病者于老年人并不少见，其发病率约为１４．４％～１８．４％，而在肺心病患者尸检发现伴有冠心病者占５０％～７０％，较临床诊断者为多。这由于临床上，两者症状互相掩盖...

Analysis of colonoscopic perforations at a local clinic and a tertiary hospital

AIM： To define the clinical characteristics, and to as- sess the management of colonoscopic complications at a local clinic. METHODS： A retrospective review of the medical re- cords was performed for the patients with iatrogenic colon perforations after endoscopy at a local clinic be- tween April 2006 and December 2010. Data obtained from a tertiary hospital in the same region were also analyzed. The underlying conditions, clinical presenta- tions, perforation locations, treatment types （operative or conservative） and outcome data for patients at the local clinic and the tertiary hospital were compared. RESULTS： A total of 10 826 colonoscopies, and 2625 therapeutic procedures were performed at a local clinic and 32 148 colonoscopies, and 7787 therapeutic proce-dures were performed at the tertiary hospital. The clinic had no perforations during diagnostic colonoscopy and 8 （0.3%） perforations were determined to be related to therapeutic procedures. The perforation rates in each therapeutic procedure were 0.06% （1/1609） in polyp- ectomy, 0.2% （2/885） in endoscopic mucosal resection （EMR）, and 3.8% （5/131） in endoscopic submucosal dis- section （ESD）. Perforation rates for ESD were significantly higher than those for polypectomy or EMR （P 〈 0.01）. All of these patients were treated conservatively. On the oth- er hand, three （0.01%） perforation cases were observed among the 24 361 diagnostic procedures performed, and these cases were treated with surgery in a tertiary hospi- tal. Six perforations occurred with therapeutic endoscopy （perforation rate, 0.08%; 1 per 1298 procedures）. Perfo- ration rates for specific procedure types were 0.02% （1 per 5500） for polypectomy, 0.17% （1 per 561） for EMR, 2.3% （1 per 43） for ESD in the tertiary hospital. There were no differences in the perforation rates for each therapeutic procedure between the clinic and the tertiary hospital. The incidence of iatrogenic perforation requiring surgical treatment was quite low in both the clinic and the tertiary hospital. No procedure-related mortalities occurred. Performing closure with endoscopic clipping reduced the C-reactive protein （CRP） titers. The mean maximum CRP titer was 2.9：1：1.6 mg/dL with clipping and 9.7 ＋ 6.2 mg/dL without clipping, respectively （P 〈 0.05）. An operation is indicated in the presence of a large perforation, and in the setting of generalized peritonitis or ongoing sepsis. Although we did not experience such case in the clinic, patients with large perforations should be immediately transferred to a tertiary hospital. Good relationships between local clinics and nearby tertiary hospitals should therefore be maintained. CONCLUSION： It was therefore found to be possible to perform endoscopic treatment at a local clinic when sufficient back up was available at a nearby tertiary hospital.

DIAGNOSIS AND TREATMENT OF PULMONARY HAMARTOMA

From 1970 to 1997, 67 patients with pulmonary hamartoma were operated on in our hospital. There were 38 men and 29 women with a M/F ratio of 1. 3: 1. The mean age was 47 years (range 21 to 82 years). The peak incidence was 40 to 60 years. 39% Patients had pulmonary symptoms: hemoptysis, cough, phlegm and chest pain. All were solitary. 68. 7% tumors were located in right lung and 64. 2% in upper or middle lobe. 80. 6% hamartomas were less than 3 cm in transverse diameter. On chest films, the opacity was homogeneous in 79.1% cases, heterogeneous in 20.9% and calcifications in 9.0%. The vast majority of shadows were heterogeneous on CT films. Operation is the best treatment for hamartomas. Postoperative mortality was 1. 5%. There was none recurrences and canceration during the follow-up (mean 14 years).

Electric Acupuncture in the Treatment of 36 Cases of Female Urethral Syndrome

Since 1999, the authors have used electricacupuncture to treat 36 cases of female urethralsyndrome with good therapeutic effects as comparedto that of the routine treatment. The following is areport of it.

Nickel-Titanium swan-like memory connector: a new tool to treat humeral shaft nonunion

Objective: To explore a new strategy to treat humeral shaft nonunion efficiently. Methods: In the light of mechanical characteristics of Nickel Titanium memory and the anatomic morphology of humeral shaft, we designed the swan like shape memory alloy connector (SMC). SMC was clinically applied in treating 55 cases of humeral shaft nonunion. Success rate of nonunion repair, reinterventions, complications, range of motion, and patient satisfaction were evaluated. Results: Fifty five humeral shaft nonunion patients were treated with autogenous bone grafting and SMC internal fixation. The average follow up period was 32 months. In 50 patients with complete follow up data, 49 were recovered from nonunion by lamellar bone healing. The excellent and good rate was 98%; one patient suffering from re fracture in a fall refused further treatment. Neither infection nor re fracture after SMC extraction or joint dysfunction was found in the whole group. Conclusion: SMC facilitates safe internal fixation and bone grafting; its memory biomechanic properties promote osteosynthesis, resulting in accelerated and high quality healing of humeral shaft nonunion. SMC internal fixation with bone grafting is creative, efficient and promising in treating humeral shaft nonunion.

Diagnosis and Treatment of Primary Adult Renal Sarcoma

Objective To investigate the clinical characteristics of primary adult renal sarcoma.Methods A total of 1654 cases with adult renal tumors were treated during 1985 to 2009 in Peking Union Medical College Hospital.Of all,17 cases were diagnosed as primary renal sarcoma and underwent radical nephrectomy.The clinical features of 17 such patients were retrospectively analyzed.Results The first symptom of 10(59%) cases in all renal sarcomas was abdominal mass.The pathological diagnosis was leiomyosarcoma(7 cases),rhabdomyosarcoma(2 cases),malignant fibrous histiocytoma(2 cases),low-differentiated sarcoma(2 cases),chromophobe renal cell carcinoma coexisting with liposarcoma(1 case),fibrosarcoma(1 case),embryonic sarcoma(1 case) and leiomyosarcoma(1 case).One patient died of tumor thrombus of the inferior vena cava during surgery.Finally,15 cases were regularly followed up for 4 to 60 months.Till now,1 had tumor-free survival for 9 months,and the other 14 cases died 2-38 months after the operation with a median survival time of 18(range,5-60) months.The median survival time of leiomyosarcoma group was 28(range,11-60) months,and 2 cases of malignant fibrous histiocytoma died 4 and 8 months after the operation respectively.Conclusions The primary renal sarcoma has the clinical symptom similar with advanced renal cell carcinoma and has poor prognosis.Leiomyosarcoma might have relative good prognosis.

Clinical Features and Treatment of Bronchogenic Cyst in Adults

Objective To investigate the clinical features and management of bronchogenic cyst in the adults. Methods We retrospectively reviewed 50 patients admitted to our hospital with histopathologically proved bronchogenic cyst from January 1983 to December 2007. Of all the patients, 28 were male and 22 were female, with an average age of 36.9 (range, 18 to 64) years. The symptoms, location of the cysts, imaging evaluation, surgical treatment manner, and outcome of these patients were analyzed. Results Symptoms were present in 33 of the 50 patients, and cough was the most common symptom. Thirteen patients presented with complications: hemoptysis, infected cyst, dysphagia, paralysis, and hoarseness. The locations of the cysts included the mediastinum (28 cases), pulmonary parenchyma (12 cases), hilar area (3 cases), visceral pleura (1 case), and some rare locations including the intestinal mesentery (1 case), retroperitoneum (1 case), adrenal gland (1 case), neck (2 cases), and dura matter of the cervical verte-brae (1 case). Chest X-ray was performed in 36 patients and computed tomography (CT) was performed in 41 patients. The bronchogenic cyst in CT was characterized as a round, well circumscribed, unilocular mass, with density ranging from that of water to high density (0-50 Hu). As for treatment, complete resection of the bronchogenic cyst was performed in 47 (94%) patients, subtotal resection was performed in 3 (6%) patients. Open surgery was performed in 45 (90%) patients, and thoracoscopy (video-assisted thoracic surgery) was performed in 5 (10%) paitients. Of the 12 patients with intrapulmonary cyst, 11 patients underwent lobectomy and 1 patient underwent wedge resection. Postoperative sequelae occurred in 2 patients, 1 with persistent air leakage and 1 with hoarseness. All patients were proved with bronchogenic cyst pathologically. The average follow-up period was 6.5 years (range, 4 months to 10 years), and no late sequelae or recurrence of the cyst occurred. Conclusions The clinical and imaging presentations of bronchogenic cyst in adults are variable. Surgical resection is the best way for diagnosis and treatment. Both open surgery and thoracoscopy are appropriate for the selected candidates.

Dignosis and Treatment of Primary Malignant Lymphoma of the Thyroid Gland

Primary malignant lymphoma of the thyroid gland is a rare disease comprising about 1%–3% of the thyroid malignancies, and this uncommon lymphoma represent less than 1% of all non-Hodgkinlymphomas (NHL). According to the modified Ann-Arbor-Classification primary thyroid lymphoma by definition is a lymphoma that is restricted to the thyroid gland (stage I E ) or involves the thyroid gland and supradiaphragmatic predominantly adjacent thyroid lymph nodes (stage II E ). Primary thyroid lymphoma is a heterogenous disease encompassing a wide variety of lymphoma entities. The diagnosis and treatment of this lymphoma are emphasis of this article. Key words thyroid gland - lymphoma - diagnosis - treatment

Clinical Characters of Gastrointestinal Lesions in Intestinal Behcet's Disease

Objective To investigate the clinical features,diagnosis methods,therapeutic principles of intestinal Behcet's disease.Methods The clinical data of 45 patients with confirmed intestinal Behcet's disease admitted to Peking Union Medical College Hospital from August 1998 to April 2010 were retrospectively analyzed.Results The clinical courses of patients with intestinal Behcet's disease were from 26 days to 33 years,and the average duration was 6.32±1.01 years.The appearance of extra-gastrointestinal symptoms was significantly earlier than that of gastrointestinal symptoms(7.35±1.39 years vs.3.24±0.82 years,P<0.05).The predominant gastrointestinal manifestations were right lower quadrant pain(95.56%) and hematochezia or melena(40.00%).Misdiagnosis occurred in 17 cases.In patients without systemic medicine therapy before surgery,the incidence of postoperative infection of incision site and abdominal cavity was significantly higher than that in those undergoing systemic medicine therapy(80.00% vs.0%,P<0.05).Conclusions Because of the diversity of gastrointestinal manifestations,intestinal Behcet's disease is easily misdiagnosed.The systemic medical therapy before surgery could decrease the incidence of infection of incision and abdominal cavity.

PREDICTION OF NON-SENTINEL LYMPH NODE METASTASES IN BREAST CANCER

Objective.To identify a subset of breast cancer patients in whom metastatic disease is confined on-ly to the sentinel lymph node(SLN).Methods.Sentinel lymph node biopsy is performed with the injecetion of Tc99m-SC,and a gamma probe.Sentinel node biopsy was compared with standard axillary dissection for its ability to reflect the fi-nal pathological status of the axillary nodes.The factors associated with non-SLN metastases were as-sessed in the univariate and multivariate analysis.Result.We successfully identified91out of95patients for SLN(95.8%).The accuracy of sentinel lymph node to predict the axillary lymph node status was93.4%.Clinical tumor size and tumor grade were proved to be the independent predictive factors for non-SLN metastases by logistic regression model.Conclusion.In most cases,the gamma probe guided method is technically feasible for detecting sentinel nodes,accurately predicting the axillary lymph node status.A subset of the patients identified who have a low risk of non-SLN metastases may not require axillary lymph node dissection.

Long-term survival for spontaneous rupture of hepatocellular carcinoma treated with hepatectomy

Objective- To determine the prognostic factors of ruptured hepatocellular carcinoma （HCC） and report the management of patients with spontaneous rupture of HCC in a single center during a 5-year period and to evaluate one-stage hepatectomy Methods- A series of 4,209 patients with HCC were collected at Eastern Hepatobiliary Surgery Hospital from April 2002 to November 2006, of whom 200 patients （4.8%） with ruptured HCC were studied retrospectively regarding their clinical characteristics and prognostic factors. The one-stage therapeutic approach to manage ruptured HCC consisted of initial management by conservative method, transarterial embolization （TAE） or surgical hepatectomy. Results of various treatments were evaluated and compared in the randomly selected 202 patients with no history of rupture during the same study period. Results： A total of 200 patients with spontaneous rupture of HCC were studied who underwent surgical treatment （n=105）, TAE 33 and conservative treatment （ConT 62）. A multivariate analysis using the Cox hazard regression model （including all the patients n=200） identified surgical hepatectomy as the only independent factor determining a relatively long survival period （P〈0.0001） On the other hand, in a further analysis of the patients in whom surgical hepatectomy was successfully performed （n=105）, which identified a maximum tumor size exceeding 6 cm as significant determinants of a poor 12-month （P=0.036）, and a multivariate analysis did not identify as any inverse independent factor determining relatively long-term survival, only a maximum tumor size exceeding 6 cm exhibited a tendency toward being a determinant factor （P=0.083）. Conelusionz Considering the high propensity to spontaneous rupture, as long as preoperatively clinical evaluation meet surgery requirements, elective one-stage hepatectomy for patients with ruptured HCC is the first treatment option. Prolonged survival could be achieved in selected patients with hepatic resection, although the survival results were inferior to those of the patients who did not have the complication of rupture

Characteristics of small bowel tumors detected by double balloon endoscopy:A Chinese single-center study

Objective： Small intestinal tumors （SBTs） were difficult to be discovered before surgery. The emergence of dou- ble-balloon enteroscopy （DBE） and capsule endoscopy （CE） have greatly improved the evaluation of SBTs and facilitated a more precise preoperative diagnosis. Yet little data exist in China regarding clinical efficacy of DBE and clinical characteristics of SBTs. The aim of our study was to clarify the clinical characteristics of SBTs and analyze the efficacy of DBE examination in the detection and diagnosis of SBTs. Methods： We retrospectively reviewed patients who underwent DBE in our hospital between June 2011 and July 2014. Patients who were diagnosed with SBTs by DBE were included in the study. Results： A total of 316 patients underwent 321 DBE procedures, 80 （25.3%） of whom were suspected to have an SBT. And 59 of the 80 subjects were diagnosed with SBT finally. The majorities （59.3%, 35/59） of the patients diagnosed with SBT were males, whose average age was 61.8 years （SD _＋11.0 years）. DBE were frequently performed in patients with obscure gastrointes- tinal bleeding （66.1%）, abdominal pain （16.9%）. The common SBTs identified were： gastrointestinal stromal tumors （GISTs） （24/59, 40.7%）, adenocarcinomas （13/59, 22.0%）, lymphomas （6/59, 10.2%） and benign polyps （6/59, 10.2%）. Jejunum had the highest detection rate （47.5%, 29/61）. During the follow-up period （3 months to 3 years）, 14 patients were submitted to chemotherapy and two patients died of tumor. Conclusion： The most high frequency type and location of SBTs detected in our hospital were different from western countries. DBE is a valuable and safe examination for SBIs.

Clinical Study on Therapeutic Effect of Acupuncture on Behcet's Disease

Forty-six cases of Behcet's disease were randomly divided into two groups. The 26 cases in the treatmentgroup were treated by acupuncture and the 20 cases in the control group with the drugs. The level ofL-chain (κ) of IgM and the level of the trace element Zn were determined before and after treatment inthe treatment group. The results showed that the recurrence rate in the treatment group was significantlylower than that in the control group (P＜0.01), and the differences in the level of L-chain (κ) of IgM andlevel of Zn in the treatment group before and after treatment were very significant (P＜0.01). These twoindexes tended to become normal after treatment.

Analysis of 610 cases inpatients with chronic heart failure

Objective： To analyze the clinical characteristics and medical treatment of hospitalized patients with chronic heartfailure, and provide medication for the patients. Methods： According to medical records of inpatients, demographicinformation, etiology, clinical features and treatment information were collected. Results： A total of 610 cases withheart failure from our hospital between July 2010 and June 2016 were analyzed. The average age of all the patientswas 63. Males accounted for 50.49%. There were 82.7% patients with NYHA functional classification at III-IV.31.3% patients with coronary artery disease, 28.4% with rheumatic heart diseases and 21.8% with expansion ofheart disease. 27.4 percent of the patients with the left ventricular ejection fraction lower than 40%. There were78.9% patients received aldosterone antagonist treatment, 63.4% received ACEI/ARB, 62.1% received digoxin,59.8% received beta blockers, and 75.4% patients received decoction, and 80.8% received Chinese patent medicine.Conclusion： The study has shown that high utilization of traditional Chinese medicine is to highlight theadvantages of the combination of traditional Chinese and western medicine in the treatment of heart failure. Theusage of spironolactone, ACEI/ARB, beta blockers in our hospital was lower than the ratio reported, higher thanthat of the national average. However, the use of diureticis is lower than that of national average, which may relateto the use of damp-clearing herbs. Clinicians should pay attention to the high utilization rate of digoxin. Patientswith the left ventricular ejection fraction 〉 50% accounted for 61.1%, which required more attention should be paidto the diagnosis and treatment of patients with heart failure of the ejection fraction remains.

DIAGNOSIS AND SURGICAL TREATMENT OF BRONCHOGENIC CYSTS

Between 1974 and 1993, 22 patients with bronchogenic cysts were operated on in our hospital; there were 14 men and 8 women, ranging in age from 11 to 62 years. The cyst locations were mediastinal in 13 (59.1%) and intrapulmonary in 9 (40. 9%). There were symptoms (chest pain and recurrent bronchiolits) in 20 patients (91%). The preoperative complications included infection in the lung and in the cyst and dysphagia due to esophageal compression. Chest pain was the main symptom in mediastinal cyst and recurrent infection of lung in intrapulmonary cyst. Plain chest radiograms showed that a round shadow, occasional air-fluid levels, and peripheral calcification may be found in cysts. An operation is the best treatment for cysts. All cysts were completely excised. No postoperative cornphcations. late complications, or recurrence developed in our patients.

Juvenile Myasthenia Laryngis Treated by Acupuncture and TCM Medication

Myasthenia laryngis, or laryngoparalysis, oftenoccurs in juvenile teachers, actors or actresses, andmusical school students.

Congenital bronchoesophageal fistula in adults

AIM: To study the clinical characteristics, diagnosis and surgical treatment of congenital bronchoesophageal fi stulae in adults. METHODS: Eleven adult cases of congenital bronchoesophageal fistula diagnosed and treated in our hospital between May 1990 and August 2010 were reviewed. Its clinical presentations, diagnostic methods, anatomic type, treatment, and follow-up were recorded. RESULTS: Of the chief clinical presentations, nonspecific cough and sputum were found in 10 (90.9%), recurrent bouts of cough after drinking liquid food in 6 (54.6%), hemoptysis in 6 (54.6%), low fever in 4 (36.4%), and chest pain in 3 (27.3%) of the 11 cases, respectively. The duration of symptoms before diagnosis ranged 5-36.5 years. The diagnosis of congenital bronchoesophageal fistulae was established in 9 patients by barium esophagography, in 1 patient by esophagoscopy and in 1 patient by bronchoscopy, respectively. The congenital bronchoesophageal fistulae communicated with a segmental bronchus, a main bronchus, and an intermediate bronchus in 8, 2 and 1 patients, respectively.The treatment of congenital bronchoesophageal fistulae involved excision of the fistula in 10 patients or division and suturing in 1 patient. The associated lung lesion was removed in all patients. No long-term sequelae were found during the postoperative follow-up except in 1 patient with bronchial fistula who accepted reoperation before recovery. CONCLUSION: Congenital bronchoesophageal fistula is rare in adults. Its most useful diagnostic method is esophagography. It must be treated surgically as soon as the diagnosis is established.

DIAGNOSIS AND TREATMENT OF THE MIRIZZISYNDROME

Objectives. The aim of this paper is to describe the clinical characteristics, diagnostic procedure and operative management of Mirrizi syndrome. Methods. Sixteen cases of Mirrizi syndrome were selected and reviewed from 1987 to 1997. Results. In the 16 cases, 6 cases were male, 10 cases were female, the average age was 62.7 years old. Ten cases were diagnosed to be Mirrizi syndrome preoperatively(62.5%); 3 cases were considered to bile duct tumor, the other 3 cases were emergency, they were confirmed the diagnosis after the operation. Conclusions. Ultrasound is recommended as the first choice of screening method, while ERCP may confirm the diagnosis. Surgical approach is considered to be the choice and technical procedures are suggested to prevent intraoperative injury and to repair defects of the common bile duct.

Research progress in triple-negative breast cancer

Triple-negative breast cancer (TNBC) is a unique subgroup defined by a lack expression of ER (estrogen receptor), PR(progesterone receptor) and HER2 (human epidermal growth factor receptor 2), which has distinctly biological, clinical and pathological characteristics. This subgroup has close relationship with basal-like and BRCA1 (breast cancer susceptibility gene-1) breast cancers. Since endocrine and HER2-targered therapy can not be applied, chemotherapy is the major mean of therapy. Some studies show that TNBC is sensitive to taxol, platinum and anthracycline-based chemotherapy. Furthermore, targeted therapy to EGFR (epidermal growth factor receptor), c-kit (stem cell factor receptor) and PARP (poly ADP-ribose polymerase) inhibitor may show better anticancer activity. We will review this subgroup of breast cancer as the following three aspects, biological characteristics, clinicopathology characteristics and therapy strategy.

THYMIC CARCINOMA(REPORT OF 14 CASES)

This paper reports of 14 cases of thymic carcinoma. Most of them with symptoms of chest pain, cheststuffy and discomfort, but without combined with extrathoracic syndromes, The tumors always were largein size and frequently invaded adjacent organs, hence with low resection rate. ln this series, complete re-section of tumor only 2 cases, partial resection in 7 cases, exploratory thoracotomy in 5 cases. Thymic car-cinoma was an extremely malignant tumor with extensive invasion intrathoracally and early metastasis ex-trathoracally. The common sites of metastasis were bone, liver,lung and extrathoracic lymph nodes. Adju-vant therapy postoperatively was given to all patients. Follow-up of lbo 8 years showed 1O cases death,ofwhich 5 cases died within the first year after surgery,3 cases within the second year. Four patients werestill alive so far, in which 3 patients were within 1. 5 years postoperatively. Pathological studies revealed 9cases of squamous epithe1ial cell thymic carcinoma, 3 of lymphoepithelioma - like thymic carcinoma and 2 ofsmall cell undifferentiate thymic carcinoma.