年轻乳腺癌患者生育力保存现状与临床应对策略

尽管抗癌治疗可以提高年轻乳腺癌患者长期生存率,但也可能导致生育力降低。随着我国乳腺癌发病年轻化,年轻乳腺癌患者的生育需求获得更多关注,适用于癌症患者的生育力保存技术不断发展。但目前我国年轻乳腺癌患者生育力保存的实施仍然存在很多问题:患者和乳腺外科医师对生育力保存技术认识不足,且态度保守;治疗过程中缺少生殖科专家的意见;对保存生育力患者的长期随访和信息管理不完善等。为改善上述现状,首先应提高医师对生育力保存的了解,包括相关技术的进展和适用人群、介入时机,以及癌症治疗结束后何时妊娠、如何妊娠等;其次要加强对患者进行生育力保存相关的宣教,特别是癌症治疗期间科学避孕方法和意外怀孕的处理;最后,医院和相关单位应完善和规范乳腺癌多学科团队诊疗,加强年轻乳腺癌患者的综合管理,从而为年轻乳腺癌患者提供更科学的肿瘤治疗方案和更多的生育机会。     

年轻乳腺癌患者生育愿望和生育力保存认知调查

目的了解年轻乳腺癌患者在乳腺癌综合治疗后的生育愿望及生育力保存认知的情况。方法收集2018年3～11月在四川省肿瘤医院乳腺外科确诊为乳腺癌的281例患者为研究对象,采用问卷调查的方法,对患者年龄、婚姻情况、文化程度、子女数量、是否有生育愿望、对生育力保存认知等资料进行描述。结果 281例患者中,40岁以下者占40.2%(113/281),最终纳入113份有效问卷。113例患者的平均年龄(33.8±4.5)岁,考虑生育者29例(25.7%),文化程度大专以上者占44.2%,已婚者占79.6%。不同年龄、婚姻状况、文化程度、子女状况和家庭收入的患者对生育力保存的认知和生育意愿无明显差别;已婚患者的生育力保存意愿略高于未婚群体,年龄越大的患者对生育力保存的意愿越低,但尚无显著性差异(P0.05)。结论年轻的乳腺癌患者中有生育要求的患者仍占一定的比例,临床工作中要加大生育力保存的宣教,治疗前进行充分评估,让患者在知情同意后作出选择。     

基于共享决策的青少年与青年癌症患者生育力保存研究进展

癌症相关治疗会损害癌症幸存者的生育力。生育力保存可帮助癌症幸存者保护其生殖内分泌功能或保存生殖潜能。在青少年与青年癌症患者中开展生育力保存的共享决策,有助于患者做出最符合自己价值观和偏好的生育力保存决策,减少决策冲突和决策后悔。本文对青少年与青年癌症患者生育力保存的共享决策的相关概念、发展现状、决策模式、挑战及其对策进行综述,为促进青少年和青年患者生育力保存共享决策和提升生活质量提供参考。     

生育咨询及教育干预对年轻妇科恶性肿瘤患者生育忧虑的影响

目的 降低年轻妇科恶性肿瘤患者生育忧虑。方法 应用随机数字表法将50例年轻妇科恶性肿瘤患者分为对照组和干预组各25例，对照组接受基础健康教育，干预组给予多学科模式下的生育咨询及教育干预，于干预前、干预后1个月、干预后3个月采用生育忧虑量表及自制癌症育龄女性生育知识问卷进行评定。结果 两组癌症相关生育知识得分比较，组间效应、时间效应和交互效应差异有统计学意义；两组生育忧虑总分及备孕、配偶知情、接受度、怀孕能力、自身健康、子女健康维度得分比较，组间效应、时间效应和交互效应差异有统计学意义（均P<0.01）。结论 生育咨询及教育干预可提高年轻妇科恶性肿瘤患者癌症相关生育知识水平，减轻年轻妇科恶性肿瘤患者的生育忧虑。     

骨质疏松患者就医选择的影响因素分析及干预研究

目的分析骨质疏松患者就医行为的影响因素,并对骨质疏松患者进行干预研究,为骨质疏松防治提供参考。方法选取2017年1月至2018年1月在崇左市天等县人民医院进行体检的骨质疏松患者218名,根据患者是否主动就医的行为,分为主动组(n=102)和非主动组(n=116)。采用多因素Logistic回归分析骨质疏松患者不主动就医的影响因素,并对主动组及非主动组进行干预治疗,随访1年,观察主动组与非主动组发生骨折的概率、骨密度及骨质疏松相关知识知晓情况。结果Logistic回归分析发现非事业单位人员、经济收入低、农村居民、文化程度低、合并癌症、无养老保险等是骨质疏松患者不主动就医的独立危险因素(P0. 05)。干预1年后,主动组发生骨折的概率为0. 98%,非主动组发生骨折的概率为1. 72%;干预前非主动组对骨质疏松相关知识知晓情况远低于主动组(P0. 05),而干预后非主动组的知晓情况与干预前相比大大提高(P0. 05);干预后两组骨密度高于干预前(P0. 05)。结论非事业单位人员、经济收入低、农村居民、文化程度低、合并癌症、无养老保险等是骨质疏松患者不主动就医的独立危险因素。医护人员应加强这类患者的健康宣教工作,必要时给予饮食、药物、运动等干预。     

年轻女性早期乳腺癌病人生育相关调查研究

目的 了解年轻女性乳腺癌病人的生育现状。 方法 以2018年11月至2021年1月在复旦大学附属妇产科医院乳腺外科门诊就诊的226例女性乳腺癌病人为研究对象,采用问卷调查对病人年龄、婚姻状况、生育史、生育计划及生育力保存等资料进行观察分析。 结果 226例病人中,≤40岁且无远处转移者占63.27%（143/226）,143例病人中,未婚未育乳腺癌病人更倾向于有生育意愿。年龄、婚姻状况、生育史、乳腺癌分子分型是乳腺癌诊断时“是否与医师讨论生育功能保留问题”、“是否担心药物治疗会影响生育功能”、“是否与医师讨论改变药物治疗方案”、“是否采取生育功能保留措施”的关键影响因素（P值均＜0.05）。 结论 未婚未育的年轻女性乳腺癌病人有更高的生育需求,乳腺外科医师要增加对癌症病人生育力保存的知识储备,抗癌治疗前充分了解病人的生育需求,及时启动乳腺癌病人生育力保存的多学科诊疗。     

湖南省年轻女性乳腺癌患者生育力保存实施方案专家共识

年轻乳腺癌患者的生育力保存一直是肿瘤生殖学科学研究和临床实践的热点。为更好地给患者提供科学有效的生育力保存医疗服务,湖南省来自乳腺科、生殖科、遗传科的专家,汇总国内外相关重要研究结果和指南,结合临床实践经验,通过充分讨论后,制定了年轻乳腺癌患者生育力保存实施方案共识。内容包括:阐述疾病及治疗与生育之间的关系;介绍目前可及的生育力保存方案;形成患者筛选、评估、适应证临床指南;建议实施跨学科就诊的临床流程。     

年轻女性鼻咽癌患者生育忧虑的研究进展

生育忧虑指患者对生殖能力、配偶和子女抚育方面的担忧。随着鼻咽癌患者生存率的提高及中国二胎政策的开放,许多育龄期的年轻女性鼻咽癌患者有孕育后代的愿望,但生育忧虑可能给她们带来巨大的心理压力,影响患者的治疗决策和生活质量。本文从癌症后生育忧虑的概念及特点、鼻咽癌的治疗及其对女性生殖功能与妊娠的影响、生育忧虑的现状、评估及相关影响因素等方面进行综述,以引起国内学者及医护人员对年轻女性鼻咽癌患者生育忧虑问题的关注。     

育龄期女性癌症患者生育力保存决策的研究进展

对育龄期女性癌症患者生育力保存决策现状及影响因素进行综述。影响因素包括社会人口学因素、信息支持、社会支持、生育力保存风险、经济负担、癌症类型、情绪状态、伦理因素、时间压力、文化宗教等。以期为开展决策支持干预提供依据，缓解患者不良情绪，减少决策冲突。     

大连市医患双方对年轻癌症患者生育力保存认知现状的调查研究

目的通过调查大连市部分医患双方对年轻癌症患者生育能力保存的认知现状,初步探讨在大连市内建立"年轻癌症患者生育能力保存"医疗协作网络体系的可行性。方法 2016年1~12月在大连市5所三级甲等医院通过问卷调查40岁以下年轻癌症患者61人(3例18岁以下患者由父母回答调查问卷),医生125人(肿瘤科医生32人、妇产科医生21人、生殖科医生22人、放射线科医生3人、泌尿科医生3人、血液科医生32人、儿科医生14人)。制作《年轻癌症患者生殖保护调查问卷》进行问卷调查,并分析问卷填写情况。结果患者对于生殖保护的态度:对生殖保护非常感兴趣的患者30人(49%);手术之后再考虑生殖保护的患者27人(44%);想听肿瘤医生建议的患者3人(3%);只想先手术,暂时不考虑生殖保护的患者1人(2%)。医生对于生殖保护的认知程度:125人(100%)都会为患者解释癌症治疗后存在性腺机能低下或早衰的可能,解释治疗后存在不孕症的可能。关于生殖保护的精子、卵母细胞冷冻保存技术:非生殖医生中有14人(13.6%)不知道,89人(86.4%)知道,89人(86.4%)向患者解释了该技术;关于胚胎冷冻保存技术:非生殖医生中94人(91.3%)表示不知道,9人(8.7%)知道,103人(100%)均未向患者解释过该技术;关于卵巢组织保存:非生殖医生中99人(96.1%)表示不知道,4人(3.9%)知道,103人(100%)均未解释过该技术。而22名生殖医生均非常清楚卵母细胞、精子冷冻和胚胎冷冻技术,均会向患者解释该技术;关于卵巢组织冷冻技术:18人(81.8%)知道该技术,4人(18.2%)非常清楚该技术,均会向患者解释该技术。结论非生殖医生和年轻癌症患者对生育力保护的认知尚存在不足。建立大连市"癌症与生育能力保存"医疗协作网络体系存在一定必要性。     

Vasopressor hormone response following mesenteric traction during major abdominal surgery

Background : We investigated the vasopressor hormone response following mesenteric traction (MT) with hypotension due to prostacyclin (PGI₂) release in patients undergoing abdominal surgery with a combined general and epidural anesthesia. Methods : In a prospective, randomized, placebo-controlled study we administered 400 mg ibuprofen (i.v.) in 42 patients scheduled for abdominal surgery. General anesthesia was combined with epidural anesthesia (T4-L1). Before as well as 5, 15, 30, 45, and 90 min after MT we recorded plasma osmolality, hemodynamics and measured 6-keto-PGFlα (stabile metabolite of PGI₂), TXB₂ (stabile metabolite of thromboxane A₂) active renin, and arginine vasopressin (AVP) plasma concentrations by radioimmunoassay. Catecholamine levels were assessed by high-pressure liquid chromatography (HPLC) with electrochemical detection. Results : Following MT, arterial hypotension occurred along with a substantial PGI₂ release. This was completely abolished by ibuprofen administration. Although plasma levels of 6-keto-PGF_1α (1133 (708) vs. 60 (3) ng/L, median (median absolute deviation), P=0.0001, placebo vs. ibuprofen) remained significantly elevated, blood pressure was restored within 30 min after MT in the placebo group. At the same point in time plasma concentrations of TXB² (164 (87) vs. 58 (1) ng/L, P=0.0001), epinephrine (46 (33) vs. 14 (6) ng/L, P=0.001), AVP (41 ± (18) vs. 12 (7) ng/L, P=0.0004), and active renin (27 (12) vs. 12 (4) ng/L, P = 0.001) were significantly higher in placebo-treated patients. Conclusion : Under combined general and epidural anesthesia arterial hypotension following MT due to endogenous PGI₂ release is associated with enhanced release of AVP, active renin, epinephrine and thromboxane A₂, presumably contributing to hemodynamic stability within 30 min after MT.     

A comparison of the inhibitory effects of four volatile anaesthetics on the metabolism of chlorzoxazone, a substrate for CYP2E1, in rabbits

Background: Halothane inhibits in vitro and in vivo activity of cytochrome P-450 (CYP) 2E1. There are several fluorinated volatile anaesthetics besides halothane, and most of them are defluorinated by CYP2E1. It is unclear whether other fluorinated anaesthetics inhibit the in vivo activity of CYP2E1.
Methods: We compared the inhibitory effects of therapeutic concentrations of four inhalational anaesthetics, halothane, enflurane, isoflurane, and sevoflurane, on chlorzoxazone metabolism in rabbits receiving artificial ventilation.
Results: All four inhalational anaesthetics decreased arterial blood pressure and increased plasma chlorzoxazone concentration. However, no significant differences in the plasma chlorzoxazone concentration were found between the four anaesthetics. The estimated chlorzoxazone clearance increased after beginning inhalation with all four agents, but no significant difference in clearance was noted between agents.
Conclusions: At therapeutic concentrations, the in vivo inhibitory effect on chlorzoxazone metabolism was similar for all four inhalational anaesthetics examined, even though their chemical characteristics and extent of hepatic metabolism differ considerably.     

A Teaspoon Pump for Pumping Blood with High Hydraulic Efficiency and Low Hemolysis Potential

Abstract: Virtually all blood pumps contain some kind of rubbing, sliding, closely moving machinery surfaces that are exposed to the blood being pumped. These valves, internal bearings, magnetic bearing position sensors, and shaft seals cause most of the problems with blood pumps. The original teaspoon pump design prevented the rubbing, sliding machinery surfaces from contacting the blood. However, the hydraulic efficiency was low because the blood was able to "slip around" the rotating impeller so that the blood itself never rotated fast enough to develop adequate pressure. An improved teaspoon blood pump has been designed and tested and has shown acceptable hydraulic performance and low hemolysis potential. The new pump uses a nonrotating "swinging" hose as the pump impeller. The fluid enters the pump through the center of the swinging hose; therefore, there can be no fluid slip between the revolving blood and the revolving impeller. The new pump uses an impeller that is comparable to a flexible garden hose. If the free end of the hose were swung around in a circle like half of a jump rope, the fluid inside the hose would rotate and develop pressure even though the hose impeller itself did not "rotate"; therefore, no rotating shaft seal or internal bearings are required.     

Microspheres Based Detoxification System: A New Method in Convective Blood Purification

Abstract: A variety of protein-bound or hydrophobic substances, accumulating as a result of pathologic conditions such as exogenous or endogenous intoxications, are removed poorly by conventional detoxification methods because of low accessibility (hemodialysis), insufficient adsorption capabilities (hemosorption), low efficiency (peritoneal dialysis), or economic limitations (high-volume plasmapheresis). Combining advantages of existing methods with microspheric technology, a module-based system was designed. Major operating parameters of the latter can be modified to allow for adjustment to individual clinical situations. An extracorporeal blood circuit including a plasmafilter is combined with a secondary high-velocity plasma circuit driven by a centrifugal pump. Different microspheric adsorbers can be combined in one circuit or applied in sequence. Thus, a prolonged treatment can be tailored using specially designed selective adsorber materials. Comparing this system with existing methods (high-flux hemodialysis, molecular adsorbent recycling system), results from our in vitro studies and animal experiments demonstrate the superior efficiency of substance removal.     

Tissue perfusion in relation to cardiac output during continuous positive-pressure ventilation and administration of propranolol or verapamil

Background : Our objective was to determine whether administration of propranolol or verapamil modifies the hemodynamic adaptation to continuous positive-pressure ventilation (CPPV), in particular the regional distribution of cardiac output (CO).
Methods : General hemodynamics and regional blood flows assessed by microsphere technique (15 (μm) were recorded in 16 anesthetized pigs during spontaneous breathing (SB) and CPPV with 8 cm H₂O end-expiratory pressure (CPPV8) before and after intravenous administration of propranolol (0.3 mg · kg⁻¹ followed by 0.15 mg · kg⁻¹ · h⁻¹, n=8) or verapamil (0.1 mg · kg⁻¹ followed by 0.3 mg · kg⁻¹ · h⁻¹, n=8).
Results : CPPV8 depressed CO by 25% without shifts in its relative distribution with the exception of a noteworthy increase in adrenal perfusion. Propranolol increased arterial blood pressure, and due to a fall in heart rate, CO dropped by 25%. The kidneys and, to a lesser extent, the splanchic region and central nervous system received increased fractions of the remaining CO at the expense of skeletal muscle flow. Similar patterns were seen during SB and CPPV8 such that the combination of propranolol and CPPV8 depressed CO by 50%. The circulatory effects of verapamil were less evident but myocardial perfusion tended to increase.
Conclusions : The combination of propranolol or verapamil with CPPV does not result in any specific hemodynamic interaction in anesthetized pigs, except that the combined effect of propranolol and CPPV may severely reduce CO.     

Volatile anaesthetics reduce adhesion of blood platelets under low-flow conditions in the coronary system of isolated guinea pig hearts

Background : Inhibitory effects of volatile anaesthetics on platelet aggregation have been demonstrated in several studies. However, the influence of volatile anaesthetics on intracoronary platelet adhesion has not been elucidated so far.
Methods : Isolated hearts of guinea pigs were perfused with buffer in the absence or presence of volatile anaesthetics (0.5 and 1 MAC) at constant coronary flow rates of 5 ml/min for 25 min, then 1 ml/min for 30 min and again 5 ml/min for 10 min. Before, during and after low-flow perfusion, a bolus of human platelets was applied into the coronary system. To simulate thrombogenic conditions, 0.3 U/ml human thrombin was infused during low-flow perfusion and reperfusion. The number of platelets sequestered to the endothelium was calculated from the difference between coronary in- and output of platelets. The myocardial production of lactate and consumption of pyruvate and coronary perfusion pressure were also determined.
Results : At a flow rate of 5 ml/min only about 3% of the applied platelets did not emerge from the coronary system, in any group. In contrast, 13.1±1.2% (mean±SEM) of infused platelets became adherent in low-flow perfusion in the control group without anaesthetic. The adherence was reduced with each 1 MAC isoflurane (to 6.2±1.2%), sevoflurane (to 4.4±0.9%) or halothane (to 3.2±1.5%) (each P <0.05 vs. control). Volatile anaesthetic, 0.5 MAC, did not inhibit platelet adhesion to a statistically significant extent in any case. Perfusion pressure and metabolic parameters were not statistically different between the control and the hearts exposed to anaesthetics.
Conclusion : Volatile anaesthetics in a concentration of 1 MAC can reduce the adhesion of platelets in the coronary system under reduced flow conditions. This action does not arise from vasodilation or inhibition of ischaemic stress.     

Bariatric Surgery in Some "Central and East-European (former Eastern bloc)"Countries - Current Status and Prediction for the Next Millennium

Background: Obesity is increasing globallly, including in the formerly "Eastern Bloc" countries. Methods: A survey was made of obesity and bariatric surgery. Results: In the 8 East and Central European countries studied, with total population 300 million, roughly 43% of the population was overweight (BMI 25-30), 23% obese (BMI > 30), with about 15 million people morbidly obese (BMI > 40). From 0-10 morbidly obese individuals/100,000/year undergo bariatric surgery. Conclusion: Most countries were found to provide inadequate treatment for obesity.The majority of the morbidly obese are not treated effectively. However, health-care awareness of obesity and bariatric surgeons are slowly increasing.     

Is the recovery profile of mivacurium independent of the rate of decay of its plasma concentration in patients with normal plasma cholinesterase activity?

Background: The duration of action of muscle relaxants is poorly correlated to the rate of decay of their plasma concentration. The plasma concentration of mivacurium may rapidly decrease below its active concentration because of the extensive hydrolysis of mivacurium. By inflating a tourniquet on one upper limb for 3 min after the administration of atracurium, mivacurium or vecuronium, we studied the influence of the initial decline of their plasma concentration on their effect. Methods: In 50 patients anaesthetised with thiopental, isoflurane and fentanyl, the effect of bolus doses of 0.15 or 0.25 mg . kg^?1 mivacurium (MIV 15, MIV 25), 0.3 or 0.5 mg . kg^?1 atracurium (ATR 30, ATR 50) and 0.06 or 0.1 mg . kg^?1 vecuronium (VEC 06, VEC 10) were measured on both arms (evoked response of the adductor pollicis to train-of-four stimulation every 12 s), a tourniquet being applied on one arm just before and during 3 min after the muscle relaxant bolus. Results: Tourniquet inflation of 3 min almost abolished the neuromuscular effect of mivacurium. In the vecuronium groups and in the ATR 50 group, tourniquet inflation did not modify the maximum degree of depression of the twitch response. Also, the duration of action of vecuronium was unaffected by the tourniquet. In the ATR 30 group, times to return of the twitch response to 25% (duration 25%) and 75% (duration 75%) of control response were significantly shorter in the cuffed arm, 23 min vs 27 min, and 41 min vs 45 min, respectively. In the ATR 50 group, only duration 25% was significantly shorter in the cuffed arm (41 min vs 45 min). Conclusion: The results suggest that the rate of decline of the plasma concentration of mivacurium is so rapid, that a very low and almost clinically ineffective concentration is present as soon as 3 min after its administration. The results also indicate that the recovery from a mivacurium-induced neuromuscular blockade is not influenced by the rate of decay of its plasma concentration in patients with genotypically normal plasma cholinesterase.     

Membranes in Artificial Organs

Abstract: Membrane processes play a pivotal and enabling role in modern replacement therapy for acute and chronic organ failure and in the management of immunologic diseases. In fact, virtually all contemporary extracorporeal blood purification methods employ membrane devices, and the next generation of artificial organs and tissue engineering therapies are almost certain to be similarly grounded in membrane technology. In this short essay, we comment on the similarities and differences among synthetic membranes and their natural counterparts and also provide a critical overview of the demographics and technology of hemodialysis, hemofiltration, apheresis, oxygenation, and emerging membrane technologies and applications.     

Influence of dopexamine hydrochloride on haemodynamics and regulators of circulation in patients undergoing major abdominal surgery

Background: Catecholaminergic support is often used to improve haemodynamics in patients undergoing major abdominal surgery. Dopexamine is a synthetic vasoactive catecholamine with beneficial microcirculatory properties. Methods: The influence of perioperative administration of dopexamine on cardiorespiratory data and important regulators of macro- and microcirculation were studied in 30 patients undergoing Whipple pancreaticduodenectomy. The patients received randomized and blinded either 2 μg · kg^?1 · min^?1 of dopexamine (n=15) or placebo (n=15, control group). The infusion was started after induction of anaesthesia and continued until the morning of the first postoperative day. Endothelin-1 (ET-1), vasopressin, atrial natriuretic peptide (ANP), and catecholamine plasma levels were measured from arterial blood samples. Measurements were carried out after induction of anaesthesia, 2 h after onset of surgery, at the end of surgery, 2 h after surgery, and on the morning of the first postoperative day. Results: Cardiac index (CI) increased significantly in the dopexamine group (from 2.61±0.41 to 4.57±0.78 1 · min^?1 · m^?2) and remained elevated until the morning of the first postoperative day. Oxygen delivery index (DO₂I) and oxygen consumption index (VO₂I) were also significantly increased in the dopexamine group (DO₂I: from 416±91 to 717±110 ml/m² · m²; VO₂I: from 98±25 to 157±22 ml/m² · m²), being significantly higher than in the control group. pHi remained stable only in the dopexamine patients, indicating adequate splanchnic perfusion. Vasopressive regulators of circulation increased significantly only in the untreated control patients (vasopressin: from 4.37±1.1 to 35.9±12.1 pg/ml; ET-1: from 2.88±0.91 to 6.91±1.20 pg/ml). Conclusion: Patients undergoing major abdominal surgery may profit from prophylactic perioperative administration of dopexamine hydrochloride in the form of improved haemodynamics and oxygenation as well as beneficial influence on important regulators of organ blood flow.