问题 多项选择题 案例分析题

患儿,男,2个月,体重5.8kg。出生后即发现皮肤紫绀,近2周来紫绀加重入院。已行超声心动图检查,提示:主动脉发自右心室,位于前方,主动脉瓣环0.98cm。肺动脉发自左心室,位于后方,肺动脉瓣及瓣下狭窄。肺动脉总干0.76cm,左肺动脉内径0.52cm,右肺动脉内径0.61cm。见一膜周室间隔缺损0.85cm,双向分流。卵圆孔未闭0.31cm,左向右分流。动脉导管未闭,0.12cm,左向右分流。入院后见患儿反应可,呼吸40次/分,无吸气相三凹征,听诊双肺呼吸音清,心音有力,心率136次/分,胸骨左缘3~4肋间可闻及3/6级收缩期杂音。测经皮氧饱和度72%,血气分析:pH7.36,PaO238mmHg,PaCO244mmHg,BE-1mmol/L。

(提示患儿行Ⅰ期姑息术后,缺氧状况明显改善,不吸氧经皮氧饱和度86%。随访2年后,又出现紫绀加重,测经皮氧饱和度78%。行超声心动图提示:改良B-T分流束宽0.12cm,左向右分流速度3.15m/s。行心导管检查测得肺动脉平均压16mmHg。)则下一步治疗可选用的方案是()

A.拆除原B-T分流,行Switch手术

B.拆除原B-T分流,Rastelli手术

C.重新行改良B-T分流手术(采用4#人工血管)

D.重新行改良B-T分流手术(采用5#人工血管)

E.保留原B-T分流,加行肺动脉瓣交界切开术

F.拆除原B-T分流,行Fonxan类手术

G.拆除原B-T分流,Nikaidoh手术(主动脉移位术)

答案

参考答案:B, G

单项选择题
单项选择题

In most parts of the world, climate change is a worrying subject. Not so in California. At a recent gathering of green luminaries--in a film star’s house, naturally, for that is how seriousness is often established in Los Angeles--the dominant note was self-satisfaction at what the state has already achieved. And perhaps nobody is more complacent than Arnold Schwarzenegger. Unlike A1 Gore, a presidential candidate turned prophet of environmental doom, California’s governor sounds cheerful when talking about climate change. As well he might: it has made his political career.

Although California has long been an environmentally-conscious state, until recently greens were concerned above all with smog and redwood trees. "Coast of Dreams", Kevin Starr’s authoritative history of contemporary California, published in 2004, does not mention climate change. In that year, though, the newly-elected Mr. Schwarzenegger made his first tentative call for western states to seek alternatives to fossil fuels. Gradually he noticed that his efforts to tackle climate change met with less resistance, and more acclaim, than just about all his other policies. These days it can seem as though he works on nothing else.

Mr. Schwarzenegger’s transformation from screen warrior to eco-warrior was completed last year when he signed a bill imposing legally-enforceable limits on greenhouse--gas emissions--a first for America. Thanks mostly to its lack of coal and heavy industry, California is a relatively clean state. If it were a country it would be the world’s eighth- biggest economy, but only its 16th-biggest polluter. Its big problem is transport--meaning, mostly, cars and trucks, which account for more than 40% of its greenhouse-gas emissions compared with 32% in America as a whole. The state wants to ratchet down emissions limits on new vehicles, beginning in 2009. Mr. Schwarzenegger has also ordered that, by 2020, vehicle fuel must produce 10% less carbon: in the production as well as the burning, so a simple switch to corn-based ethanol is probably out.

Thanks in part to California’s example, most of the western states have adopted climate action plans. When it comes to setting emission targets, the scene can resemble a posedown at a Mr. Olympia contest. Arizona’s climate-change scholars decided to set a target of cutting the state’s emissions to 2000 levels by 2020. But Janet Napolitano, the governor, was determined not to be out-muscled by California. She has declared that Arizona will try to return to 2000 emission levels by 2012.

California has not just inspired other states; it has created a vanguard that ought to be able to prod the federal government into per national standards than it would otherwise consider. But California is finding it easier to export its policies than to put them into practice at home. In one way, California’s self-confidence is fully justified. It has done more than any other state--let alone the federal government--to fix America’s attention on climate change. It has also made it seem as though the problem can be solved. Which is why failure would be such bad news. At the moment California is a beacon to other states. If it fails, it will become an excuse for inaction.

According to the author, Mr. Arnold Schwarzenegger is cheerful chiefly because()

A. climate change is not worrying California anymore

B. even film stars become serious about environmental protection

C. he has benefited personally from California’s achievements

D. his style of administration is always dominated by self-satisfaction