慢性肾功能不全对中老年非瓣膜性房颤患者全因死亡、心脑血管疾病死亡及血栓终点事件的影响

目的：探讨中老年非瓣膜性房颤患者全因死亡、心脑血管疾病死亡及血栓终点事件的危险因素及慢性肾功能不全是否为其独立危险因素。方法：纳入未应用抗凝药物的中老年非瓣膜性房颤患者825例,平均年龄为76.52±11.80岁,其中女性占18.91%,75岁以上患者占64.73%,记录基线特征及各终点事件发生情况。通过Cox生存分析,探讨肾功能不全对各终点事件的影响。结果：入选患者中位数随访时间为33.5个月,随访期间发生全因死亡209例、心脑血管疾病死亡61例及血栓终点事件139例。合并慢性肾功能不全的房颤患者各终点事件发生率均显著高于对照组,在校正CHA₂DS₂-VASc评分危险因素及其他传统危险因素后,慢性肾功能不全仍是全因死亡、心脑血管疾病死亡及血栓终点事件的独立危险因素。结论：慢性肾功能不全是未服用抗凝药物的中老年非瓣膜性房颤患者全因死亡、心脑血管疾病死亡及发生血栓事件的独立危险因素之一。     

PERFORATED PEPTIC ULCER—Selective Gastric Resection in Emergency Treatment

In a series of 240 cases of perforated peptic ulcer prior to 1952 there was a total mortality of 17 per cent. This included cases treated conservatively as a planned procedure or because of other morbid conditions and undiagnosed cases, all ending in death.In cases treated by simple suture, mortality was 2.6 per cent for patients under 50 years of age and 17 per cent for those over 50, the rate rising very steeply with each decade over 50.From 1953 through 1959 selective gastric resection was carried out, the operation being done in all cases of perforated gastric ulcers, of chronic duodenal ulcers and of perforations associated with hemorrhage.During this period 303 perforated ulcers were treated, with a mortality of 15.5 per cent. Patients with associated morbid conditions and those admitted moribund and died, or died undiagnosed were again included.In this series also the mortality increased steeply from age 50 onward.Gastric resection was carried out in 148 cases of perforated peptic ulcer with a mortality of 6 per cent. In 105 cases under 60 years of age there were no deaths but in those over 60 the mortality rate was 21.8 per cent. Results in the patients who had resection, as determined after three years of observation, compared favorably with the results in patients who were treated by suture.The mortality of perforated ulcers in females was higher than in males.Emergency gastric resection has a definite place in the treatment of perforated peptic ulcer.     

Autopsy in California

From information complied from death certificates registered in 1952 and 1962 an examination was made of California''s autopsy performance and the characteristics of deaths in which autopsy was done. The data indicated that California had an overall autopsy rate of 37 per cent of total deaths in 1962, probably higher than any other state. In the decade reviewed, there was a 62 per cent absolute increase in autopsies and a 7 per cent increase relative to total deaths.Substantial increases in the proportion of deaths in which autopsy was done were found for physician-certified deaths in both metropolitan and nonmetropolitan counties and for coroner-certified deaths in nonmetropolitan counties. For all but two of forty-five selected natural causes of death there were increases in the proportion of deaths in which autopsy was done.Seventy per cent of deaths occurred in some type of facility. About one-half of all deaths occurred in general hospitals, and autopsy was done in 42 per cent of such cases.The dual factors of a high autopsy rate and overrepresentation of deaths brought to autopsy in white males, ages 35-64, support the validity of a reported decline in California''s death rate for arteriosclerotic heart disease.     

Surgical Treatment of Mitral Insufficiency

Sixty-four patients with pure mitral insufficiency were operated upon. Thirty of them had torn chordae tendineae. It was possible to repair the mitral valve in 57 patients and there were five operative deaths. One patient had a femoral artery embolus and another had a cerebral embolus. The incidence of peripheral embolization was 4 per cent compared with 40 per cent reported for ball valve replacement.Forty-eight of the 57 patients with repair (84 per cent) were living and well with at most a grade II/VI apical systolic murmur up to seven and a half years after operation. There has been no evidence of recurrence in these patients.In approximately 90 per cent of patients with pure mitral insufficiency, repair should be performed. When feasible, repair is more satisfactory than valvular replacement, with not only excellent long-term results, but far less morbidity than is reported with ball valve replacement.     

SUPRACONDYLAR AMPUTATION IN THE AGED

Of 105 consecutive supracondylar amputations done at the San Diego County General Hospital during the five-year period, 1953-58, 88 were in patients more than 60 years of age. Occlusive arterial disease was the reason for operation in 85 of the 88 cases.Presenting complaints at the time of amputation were gangrene in 45 cases, pre-gangrene associated with severe pain in 34. Acute arterial occlusion as a cause of thigh amputation was infrequent.The average age of patients requiring thigh amputation from complications of arteriosclerosis obliterans was 78.3 years; for those with diabetic arteriosclerosis or embolism it was about seven and a half years less.Supracondylar amputation was considered the procedure of choice in the elderly debilitated patients with far-advanced occlusive diffuse arteriosclerosis, complicated by gangrene, ulcer and infection of the toes or feet. Sympathectomy and direct arterial operation if done early in the course of the disease may postpone or prevent subsequent amputation.The surgical mortality rate (first two weeks) for supracondylar amputation was 12.5 per cent. More than two-thirds of the deaths were due to bronchopneumonia.     

Relation of CuZnSOD activity with renal insufficiency in hypertensive diabetic patients

Diabetes and renal insufficiency are interrelated metabolic disorders closely associated with redox homeostasis disturbances. The aim of this study was to compare the activity of copper zinc superoxide dismutase (CuZnSOD) in the erythrocytes of hypertensive diabetic patients with or without renal insufficiency with normal healthy control subjects. In both groups of diabetic patients, blood glucose level and the content of glycosylated hemoglobin (HbA1c) were higher than in the control group. However, CuZnSOD activity was significantly higher than control only in hypertensive diabetic patients with renal insufficiency. Our results suggest that disturbances in superoxide homeostasis do correlate with long-term complication in diabetes, i.e. diabetic renal insufficiency and hypertension.     

应用锥颅置管引流手术治疗急性高血压脑出血

探讨应用锥颅置管引流术治疗急性高血压脑出血的临床治疗效果。方法：对62例应用锥颅置管引流术治疗的高血压脑出血病人进行了回顾性分析。对高血压脑出血的全组病例的发病年龄、性别、诱发病因、病史、常见发病部位、类型、手术方式以及临床效果进行了分析。结果：手术后2—6个月,按COS方法判定病人治疗效果。手术治疗结果：全组有痊愈者20例,中残者23例,重残者9例,植物生存者4例,死亡者6例（死亡率为10％）。结论：锥颅置管引流的手术方式,安全、医疗费用非常低廉,而且该手术后并发症和死亡率均降低。加之它简便,疗效确切,故值得临床广泛推广应用。     

Physicians' strike and general mortality: Croatia's experience of 2003

The aim of the study was to establish whether the physicians' strike, which took place in Croatia in 2003, had an impact on the mortality of the population. Mortality data from the National Bureau of Statistics relating to the strike period (15 January - 14 February 2003) were selected and compared with the previous and subsequent periods of the same duration in 2001, 2002 and 2004. Of the 52,575 deaths in 2003, Croatia recorded 4,682 (8.9%, 95% Confidence interval 8.4-9.4) in the strike period from the 15th of January to the 14th of February 2003 or 1.1 deaths per 1000. No deviations of the 15th of January to the 14th of February period's share of the death total in relation to other observation periods were noted. It is impossible to associate the strike based on the figures shown in this paper with either an increase or decrease in population mortality.     

住院老年高血压患者死亡相关因素的分析

目的：调查和分析1993～2012年19年间住院的老年高血压患者的死亡原因及影响因素,为北京地区老年高血压防治中靶器官的保护和并发症的减少提供重要临床依据。方法：回顾性分析我院1993～2012年19年间住院死亡的2866例1〉60岁老年高血压患者,通过病历采集,收集性别、年龄、并发症及死亡原因等临床资料,按性别、年龄及高血压分期和危险程度将病人分组。采用卡方检验的方法比较各组病人的死亡原因。结果：①按疾病：与死亡相关性最高的疾病为心脏病1294例（45．15％）,脑卒中985例（34．37％）,肾功能衰竭340例（11．88％）,感染性疾病131例（4．58％）,恶性肿瘤116例（4．06％）,心脏病是导致老年高血压患者死亡的首要原因;②按性别：男性占老年高血压死亡的53．31％,女性占46．69％,差异具有统计学意义（P〈0．01）。而心脏病（男性46．73％比女性43．35％]和脑卒中（男性37．04％比女性31．32％）均占据高血压死亡原因构成比的前两位;③按年龄：90岁以上高血压患者因心脏病（43．02％）、肾功能衰竭（20．54％）和感染（6．59％）死亡的比例低于其他各年龄组。因脑卒中死亡的比率低于60—69岁组（38．71％）和70～79岁组（33．37％）。因恶性肿瘤死亡的老年高血压患者在70～79岁组最高（4．80％）;④按高血压分期和危险程度：I．Ⅱ期高血压患者因心脏病（49．70％）和恶性肿瘤（7．55％）死亡的比例高于Ⅲ期高血压患者（分别为43．78％和2．99％）,而Ⅲ期高血压患者因脑卒中（35．84％）和肾功能衰竭（12．79％）死亡的比例高于I．Ⅱ期高血压患者（分别为29．45％和8．76％）。高危组的老年高血压患者因心脏病（38．15％）死亡的比例低于其他三组（低危组51．05％、中危组47．64％和极高危组47．38％）,而其因肾功能衰竭（19．54％）死亡的比例则高于其他三组（低危组1．63％、中危组3．07％和极高危组11．69％）,但中危组的老年高血压患者因脑卒中死亡的比例最高（42．69％）。结论：男性患者、60～79岁患者在老年高血压的根本死亡原因中所占的比率较高。不同的高血压分期和危险分层对根本死亡原因有不同的影响。     

OPERATING ROOM DEATHS—An Analysis of Mortality in a Veterans Administration Hospital Over a Ten-Year Period

A study of operating room and recovery room deaths which occurred during a ten-year period from 1948 through 1957 at one hospital revealed that there were 59 deaths associated with 57,132 surgical procedures.Factors which directly influenced the rate of operating room and recovery room death were the age of the patient and the length of operating time. Seventy-five per cent of the deaths occurred in cases in which the operation took longer than one hour. Combined anesthesia techniques may have indirectly contributed to death in some cases.Complications of operation requiring another surgical procedure sometimes occur. In this series, reoperation proved to be more hazardous in terms of mortality rate than did single operations. This is not surprising for most complications occur in the poorer risk patients.The operating room death rate steadily increased during the ten-year period studied. This increasing death rate can largely be attributed to the more intricate operations which are being done on poorer risk patients. The use of the curariform drugs had no influence on the increasing death rate.     

Operating room deaths; an analysis of mortality in a Veterans Administration hospital over a ten-year period

A study of operating room and recovery room deaths which occurred during a ten-year period from 1948 through 1957 at one hospital revealed that there were 59 deaths associated with 57,132 surgical procedures. Factors which directly influenced the rate of operating room and recovery room death were the age of the patient and the length of operating time. Seventy-five per cent of the deaths occurred in cases in which the operation took longer than one hour. Combined anesthesia techniques may have indirectly contributed to death in some cases. Complications of operation requiring another surgical procedure sometimes occur. In this series, reoperation proved to be more hazardous in terms of mortality rate than did single operations. This is not surprising for most complications occur in the poorer risk patients. The operating room death rate steadily increased during the ten-year period studied. This increasing death rate can largely be attributed to the more intricate operations which are being done on poorer risk patients. The use of the curariform drugs had no influence on the increasing death rate.     

Donation of kidneys. Medical Services Study Group of the Royal College of Physicians.

A survey of deaths from medical causes among hospital inpatients aged under 50 years in three health regions provided details of 1168 such deaths not caused by renal failure. Kidneys for transplantation were obtained from only 20 of these patients. In another 18 cases permission was refused or donation was impracticable. Ninety-eight of the deaths were due to subarachnoid haemorrhage and 38 to primary cerebral tumour, yet kidneys were obtained from only 11 and one of these patients respectively. Patients dying from subarachnoid haemorrhage are particularly suitable for donating their kidneys, but there is still a shortage of kidneys for transplantation because they are not harvested efficiently. Doctors seem to be reluctant to ask relatives'' permission to remove kidneys, and the arrangement of a donation is time consuming. Because transplant surgery is recognised as a specialist sphere, surgeons in other specialties may be reluctant to remove kidneys and come to rely on one transplant team covering a wide area. In an area such as Grampian, where a small population is served by one hospital containing all the major units, including accident and emergency and renal departments, it may be easier to arrange prompt donation and transplantation.     

Isolation of purified populations of T- and B-lymphocytes under clinical conditions]

The authors present comparative characteristics of the methods of isolation of T- and B-lymphocytes in patients with chronic renal insufficiency. T-lymphocytes were obtained on columns with neilon cotton wool. B-cells were fractionated by repeated centrifugation in the gradient of phycol-urotrast density after staging E-rosette formation with the total lymphocyte pool. Methodical peculiarities of single-stage and two-stage B-lymphocyte fractionation were revealed.     

Free tissue transfer in patients with renal disease

Several authors have cited renal disease as a risk factor for free flap failure. The authors performed a retrospective analysis of all patients who underwent free tissue transfer with concomitant renal disease, including acute renal failure, end-stage renal disease, chronic renal insufficiency, and functional kidney transplants, to determine what effect renal disease has on flap survival and overall reconstructive outcome. More than 1053 free flaps were examined. Renal disease was identified in 32 patients who underwent 33 free tissue transfers. Average patient age was 57 years (range, 36 to 80 years). Twelve patients (38 percent) were on chronic dialysis (end-stage renal disease), 18 patients (56 percent) had chronic renal insufficiency, and three patients (9 percent) had the diagnosis of acute renal failure at the time of surgery. Three patients in the chronic renal insufficiency group had a functioning renal transplant. Average follow-up was 16 months. Immediate postoperative complications occurred in 14 patients (42 percent of the 33 flaps). Overall perioperative mortality was 3 percent. Within the first 30 days there were two cases (6 percent) of primary flap failure; an additional four legs were lost as the result of complications related to their bypass grafts. There were no primary flap failures after 30 days; however, within the first year after surgery an additional seven limbs were lost as the result of progressive ischemia or infection, and an additional three patients died. This resulted in a 52 percent incidence of major morbidity or mortality during the first year and a 55 percent reconstructive success rate in survivors at 1 year. No significant difference was seen in postoperative morbidity or mortality when comparing the end-stage renal disease group to the chronic renal insufficiency group; however, patients with renal disease and diabetes tended to have poorer outcomes. Renal disease, especially renal disease associated with diabetes and peripheral vascular disease, can be a strong indicator of possible reconstructive failure. The surgeon and patient should be aware of the medical and surgical complications associated with this procedure at the outset.     

Alterations in central and peripheral adrenergic receptors in deoxycorticosterone/salt hypertensive rats

The treatment of uninephrectomized rats with deoxycorticosterone (DOCA) and salt for 6 weeks caused a significant systolic hypertension and cardiac and renal hypertrophy. There was a significant decrease in the density of cardiac α₁- and β-, and renal α₁-adrenoceptors in DOCA/salt hypertensive rats, as compared to uninephrectomized salt loaded control rats. In contrast, the cerebral cortex, corpus striatum, hippocampus and hypothalamus/thalamus of hypertensive rats showed a significant increase in adrenoceptor binding in these hypertensive rats. In contrast, muscarinic cholinergic receptors and [³H]yohimbine binding sites were not altered in most tissues of the hypertensive rats. The present study suggests an important role for central and peripheral α₁- and β-adrenoceptors in the pathogenesis of hypertension.     

Acute renal function in chronically sympathectomized deoxycorticosterone acetate-treated miniature swine

We recently validated a swine model in which chronic treatment with 6-hydroxydopamine (6-OHDA) produced an effective sympathectomy. These sympathectomized swine demonstrated a significantly attenuated hypertensive response when treated with deoxycorticosterone acetate (DOCA). Because renal nerve activity is elevated and important in controlling renal function and blood pressure in the DOCA swine model, we wanted to study the effect of chronic sympathectomy on acute renal hemodynamics and tubular function. Kidney function was assessed in 14 DOCA-treated miniature swine, 8 of which were sympathectomized by chronic treatment with 6-OHDA, while 6 served as controls. Effective renal sympathectomy in this model has been previously confirmed by a significant reduction (97%) of norepinephrine in renal cortical tissue. When anesthetized, mean arterial pressure and renal blood flow were similar between the two groups. Glomerular filtration rate was lower by 43%, urine flow rate by 71%, sodium excretion by 66%, and potassium excretion by 48% in the 6-OHDA DOCA animals. All of these parameters were significantly different from the intact DOCA controls. These results indicate that anesthetized, chronically sympathectomized swine exhibit decreased renal excretory function. The changes in renal function may have been due to the development of a tubular or glomerular supersensitivity to circulating antinatriuretic factors, since the 6-OHDA group had a 28% greater pressor response to the alpha-agonist phenylephrine and a significantly greater fall in mean arterial pressure in response to alpha-blockade with prazosin when compared with the controls. These changes in renal function may also explain why the 6-OHDA animals demonstrated a slight increase in mean arterial pressure in response to DOCA. Because acute renal denervation in DOCA-treated swine produces a diuresis and natriuresis, this study affirms that there may be important functional differences in acutely versus chronically denervated kidneys for which the implications under normal physiologic conditions are unknown.     

Sympathetic-renal interaction in chronic arterial pressure control

The effects of neonatal sympathectomy of donors or recipients on posttransplantation arterial pressure were investigated in spontaneously hypertensive rats (SHR) by renal transplantation experiments. Conscious mean arterial pressure (MAP) and renal vascular resistance were 136 +/- 1 mmHg and 15.5 +/- 1.2 mmHg x ml(-1) x min x g in sympathectomized SHR (n = 8) vs. 158 +/- 4 mmHg (P < 0.001) and 20.8 +/- 1.1 mmHg x ml(-1) x min x g (P < 0.05) in controls (n = 10). Seven weeks after transplantation of a kidney from neonatally sympathectomized SHR donors, MAP in SHR recipients (n = 10) was 20 mmHg lower than in controls transplanted with a kidney from hydralazine-treated SHR (n = 10) (P < 0.05) associated with reduced sodium sensitivity of MAP. Neonatal sympathectomy also lowered MAP in F1-hybrids (F1H; SHR x Wistar-Kyoto rats). Within 6 wk after transplantation, renal grafts from untreated SHR increased MAP by 20 mmHg in sympathectomized F1H (n = 10) and by 35 mmHg in sham-treated F1H (n = 8) (P < 0.05). Neonatal sympathectomy induces chronic changes in SHR kidney function leading to a MAP reduction even when extrarenal sympathetic tone is restored. Generalized reduction in sympathetic tone resets the kidney-fluid system to reduced MAP and blunts the extent of arterial pressure rise induced by an SHR kidney graft.     

Role of the baroreceptor reflex in the early phases after removing the renal artery constriction in conscious renal hypertensive rats

Hemodynamic studies in unanesthetized rats with chronic one-kidney-Goldblatt hypertension showed a 25% increase in cardiac output and a 42% increase in peripheral resistance. Removal of renal artery constriction under either anesthesia and minor surgical trauma produced an immediate 20% drop in arterial pressure. At the end of the 6 observation period the pressure dropped 30% but still remained at a moderate hypertensive level. The hemodynamic measurement at that time suggested that the pressure drop was the result of a decrease in cardiac output. However, the data obtained 1 hour after removal of the constriction suggested that a vasodilating mechanism may also contribute to pressure normalization in the early phase of reversal of renal hypertension. In the sham-operated hypertensive rats the pressure remained unchanged, while the cardiac output dropped due to compensation by a proportional increase in peripheral resistance. In contrast, in the unclipped animals the same drop in cardiac output produced an equivalent fall in pressure because no change in peripheral resistance occurred. This was not due to an insufficiency of the baroreceptor reflex since bilateral splanchnicectomy performed at that time produced a striking hypotensive response, indicating an overactivity of the sympathetic system possibly due to the baroreceptor still reset to operate at a hypertensive level.     

Variation in virulence of Coxsackie virus B3 in the hearts of mice. I. Comparison of mortality and virus growth in the heart and other organs

Virulence of Coxsackie virus B3 (CB3) was compared in mice between strain SK-74 isolated from a patient and strain T-70 isolated from a healthy child as well as between prototype strain Nancy and its mouse-passaged derivative strain PMH. Strain SK-74 showed a high mortality (40-80%), while strain T-70 did not induce deaths in mice (mortality: 0%). Strain PMH showed a high mortality (65-85%), but strain Nancy did not cause deaths in the mice. In agreement with the mortality trend, virus titers in the heart and other organs of mice inoculated with strain SK-74 and PMH were higher than those in mice inoculated with T-70 and Nancy strains. Since virus titers in the heart remained higher than those in other organs, the heart was regarded as the main organ in which CB3 could replicate and induce cell degeneration. The present results suggest that a marked variation in virulence in the hearts of mice among CB3 strains occurred and that passage through the hearts of mice enhances the virulence of CB3 in the hearts of mice.     

UNILATERAL RENAL DISEASE AND HYPERTENSION

Cure is obtained in about 20 per cent of patients with unilateral renal disease and hypertension who have nephrectomy primarily for relief of hypertension. Carrying out urologic studies on a larger number of hypertensive patients might result in tracing the condition to renal disease in more cases. Renal angiography more accurately indicates renal origin of hypertension than any other diagnostic study. When it can reasonably be established that hypertension is of renal origin, nephrectomy should be performed unless there is some general contraindication to an operative procedure.