不同血液净化方式联合骨化三醇冲击治疗对维持性血液透析患者肾性骨病指标的影响及意义

目的 通过观察不同血液净化方式联合骨化三醇冲击治疗对维持性血液透析患者肾性骨病指标的影响,探讨肾性骨病合适的治疗方案.方法 将60例符合标准的患者按随机数字表法分为3组,每组20例.所有患者采用骨化三醇冲击治疗,使用低钙透析液.普通透析组患者采用常规透析,血液透析滤过组患者采用血液透析滤过治疗,每周透析3次,其中血液透析滤过治疗每周1次.血液透析灌流组患者采用血液透析联合血液灌流治疗,每周透析3次,其中血液透析联合血液灌流治疗每周1次.结果 3组患者使用不同透析方式联合药物治疗3个月后发现,治疗前3组患者血钙、血磷、血甲状旁腺激素水平比较差异无统计学意义(P＞0.05),治疗后1个月血液透析灌流组患者血磷与普通透析组患者比较差异有统计学意义(P＜0.05),而血液透析滤过组患者的血磷与普通透析组比较差异无统计学意义(P＞0.05);治疗后3个月血液透析滤过组和血液透析组患者的血甲状旁腺激素、血磷、血钙水平与普通透析组比较差异也有统计学意义(P＜0.05),而血液透析滤过组和血液透析灌流组间血甲状旁腺激素、血磷、血钙水平比较差异无统计学意义(P＞0.05).结论 对于维持性血液透析的患者存在高磷血症以及继发性甲状旁腺激素的升高等肾性骨病的指标异常,可以应用血液透析滤过以及血液透析联合血液灌流治疗,且安全可行.     

Clinical judgment analysis of the parameters used by consultant urologists in the management of prostate cancer

PURPOSE: We assessed which clinical parameters consultant urologists use to recommend treatment for early prostate cancer. MATERIALS AND METHODS: A total of 30 consultant urologists reviewed 70 paper representations of patients with prostate cancer. Each contained 7 commonly available cues, including prostate specific antigen, Gleason grade, rectal examination, magnetic resonance imaging/laparoscopic stage, medical history, patient choice and age, in addition to 2 cues not yet routinely available, that is predicted life expectancy and 10-year survival probability, as calculated using actuarial formulas based on noncancer comorbidity. Consultants indicated how strongly they would recommend radical prostatectomy, radiotherapy with or without hormones, or active surveillance/hormones. Judgment analysis was performed using multiple regression analysis with significance considered at p相似文献   

Perioperative management of the patient with rheumatoid arthritis

A multidisciplinary approach is required to care for patients with rheumatoid arthritis (RA) in the perioperative period. In preparation for surgery, patients must have a cardiovascular risk assessment performed due to the high risk of heart disease in patients with RA. Treatment of RA is with immunomodulatory medications, which present unique challenges for the perioperative period. Currently, there is no consensus on how to manage disease modifying antirheumatic drug (DMARD) therapy in the perioperative setting. Much of the data to guide therapy is based on retrospective cohort data. Choices regarding DMARDs require an individualized approach with collaboration between surgeons and rheumatologists. Consensus regarding biologic therapy is to hold the therapy in the perioperative period with the length of time dictated by the half-life of the medication. Special attention is required at the time of surgery for potential need for stress dose steroids. Further, there must be close communication with anesthesiologists in terms of airway management particularly in light of the risk for cervical spine disease. There are no consensus guidelines regarding the requirement for cervical spine radiographs prior to surgery. However, history and exam alone cannot be relied upon to identify cervical spine disease. Patients with RA who undergo joint replacement arthroplasty are at higher risk for infection and dislocation compared to patients with osteoarthritis, necessitating particular vigilance in postoperative follow up. This review summarizes available evidence regarding perioperative management of patients with RA.     

Biofeedback versus physiotherapy in patients with partial weight-bearing

Medical instructions for partial weight-bearing after lower limb surgery and fractures are commonly given. The techniques for instruction are mainly verbal cues. Our aim was to evaluate the efficiency of a new biofeedback device compared with traditional intervention for gait rehabilitation. After orthopedic surgery, 33 patients, randomly divided into a study group (n = 15) and a control group (n = 18), completed 10 days of a rehabilitation protocol. A significant difference (P<.05) was found between the groups. Study subjects were able to follow weight-bearing instructions better. We suggest that gait rehabilitation is more efficient when biofeedback is used to instruct patients regarding partial weight-bearing.     

VA Practice Patterns and Practice Guidelines for Treating Posttraumatic Stress Disorder

Little is known about how recent ISTSS practice guidelines (E. B. Foa, T. M. Keane, & M. J. Friedman, 2000) compare with prevailing PTSD treatment practices for veterans. Prior to guideline dissemination, clinicians in 6 VA medical centers were surveyed in 1999 (n = 321) and in 2001 (n = 271) regarding their use of various assessment and treatment procedures. Practices most consistent with guideline recommendations included psychoeducation, coping skills training, attention to trust issues, depression and substance use screening, and prescribing of SSRIs, anticonvulsants, and trazodone. PTSD and trauma assessment, anger management, and sleep hygiene practices were provided less consistently. Exposure therapy was rarely used. Additional research is needed on training, clinical resources, and organizational factors that may influence VA implementation of guideline recommendations.     

Patient Selection for Therapy in Prostate Cancer

The two major challenges in prostate cancer today are biochemical failure and hormone-refractory disease. Biochemical failure, manifested by a rising prostate-specific antigen (PSA) level following failure of local therapy, is the most common presentation of advanced prostate cancer. Hormonal therapy can produce dramatic but short-lived response rates in metastatic hormone-sensitive prostate cancer, while chemotherapy possesses the ability to induce significant response rates in refractory disease. Clinicians agree that patients with symptomatic advanced prostate cancer should receive immediate androgen ablation therapy; however, there is debate regarding treatment for asymptomatic patients with advanced disease. While there is no clear evidence to support the widespread use of aggressive interventions such as hormonal therapy with or without chemotherapy in men with biochemical failure, there are a number of studies indicating that early hormonal therapy may prolong the time to disease progression and survival for some patients, with this benefit being more pronounced in men with less tumor burden. Numerous questions remain for patients with advanced prostate cancer regarding optimal therapy, and until these questions are answered, the use of early hormonal therapy with or without chemotherapy for the management of locally advanced and metastatic disease is warranted.     

Sudden sensorineural hearing loss after spinal surgery under general anesthesia

Two patients, ages 72 and 71, who underwent lumbar decompressive surgery for spinal stenosis, were evaluated for postoperative sudden sensorineural hearing loss (SSHL). After two uncomplicated spinal procedures, both patients developed SSHL immediately after surgery. Hearing loss was moderate to profound in these two patients. None of the patients had a significant otologic history. Nitrous oxide administration, Valsalva maneuvers during general anesthesia, and transient drops in cerebrospinal fluid pressure stemming from spinal decompression may, in some combination, lead to an implosive force on the inner ear, causing SSHL. Further causes of postlumbar surgery SSHL may include microemboli or viral infections. SSHL is a rare but possible complication after nonotologic, noncardiac bypass surgery; only 26 cases of SSHL after this surgery have been reported. We encourage the continued reporting of sudden sensorineural hearing loss after spinal surgery.     

3D HD versus 2D HD: surgical task efficiency in standardised phantom tasks

Background  

Common video systems for laparoscopy provide the surgeon a two-dimensional image (2D), where information on spatial depth can be derived only from secondary spatial depth cues and experience. Although the advantage of stereoscopy for surgical task efficiency has been clearly shown, several attempts to introduce three-dimensional (3D) video systems into clinical routine have failed. The aim of this study is to evaluate users’ performances in standardised surgical phantom model tasks using 3D HD visualisation compared with 2D HD regarding precision and working speed.     

小儿卡波西型血管内皮瘤的个体化治疗分析

目的总结分析小儿卡波西型血管内皮瘤（KHE）的临床特点，探讨其个体化治疗策略。 方法回顾性分析2016年1月至2020年3月江西省儿童医院收治的20例KHE患儿的临床资料，总结病例的临床特征、肿瘤性状、是否合并卡萨巴赫-梅里特现象（KMP）、治疗策略及转归等特点。 结果20例KHE患儿中女6例，男14例。年龄<1岁的患儿16例（80.0%），其中13例（65.0%）出生时即发现。合并KMP的患儿有8例，合并KMP与不合并KMP患儿在瘤体大小（P=0.009）、是否侵犯深部肌肉（P=0.003）的差异有统计学意义。合并KMP患儿中3例病灶行网状缝扎治疗，5例口服西罗莫司治疗；1例网状缝扎治疗无效后联合口服西罗莫司治疗。不合并KMP的12例患儿中，7例行肿瘤完全切除，2例行肿瘤部分切除后联合口服激素，2例病灶行网状缝扎治疗，1例口服西罗莫司；1例网状缝扎治疗无效后联合口服西罗莫司治疗。随访2~5年，合并KMP的患儿中1例实现瘤体接近消失，7例带瘤生存；不合并KMP的患儿中7例肿瘤完全切除，未见复发，5例无症状带瘤生存。 结论大多数KHE为婴儿期发病，肿瘤大小、病灶累及深部肌肉情况与患儿是否合并KMP相关。对于合并KMP的患儿，初步予以激素冲击治疗或输注血液制品稳定病情，病灶合适病例可先单纯进行网状缝扎治疗；如病灶不适合网状缝扎术或治疗无效，可单用或联合口服西罗莫司治疗。     

Peri‐operative management of anti‐platelet agents

Background: Increasing numbers of patients treated with anti‐platelet agents are presenting for non‐cardiac surgery. We examined the peri‐operative management of anti‐platelet therapy in patients undergoing elective non‐cardiac surgery and the process by which patients received instructions. Methods: We interviewed and collected outcome data on 213 consecutive patients aged ≥45 years presenting for elective non‐cardiac surgery at our institution over a 6‐week period regarding the peri‐operative management of anti‐platelet and warfarin therapy. Results: Anti‐platelet therapy was prescribed in 22.5% and warfarin in 5.2% of the study subjects. Aspirin was stopped peri‐operatively in 55.3%, while clopidogrel was stopped in the sole patient treated with this. The frequency of anti‐platelet agent discontinuation was similar for major and minor surgery. Warfarin was discontinued prior to surgery in all cases. Only 54.2% of those treated with anti‐platelet therapy recalled being given instruction regarding pre‐operative management of their anti‐platelet therapy compared with 90.9% of patients treated with warfarin (P= 0.04). In the absence of instructions, a number of patients made their own decision to stop their aspirin pre‐operatively. Post‐operatively, only 37% recalled receiving instructions regarding restarting anti‐platelet therapy. As a result, three patients failed to do so. In contrast, all those treated with warfarin received clear post‐operative instructions. Conclusion: Peri‐operative anti‐platelet management and communication with patients appears to be sub‐optimal. There is a need for standardized processes whereby informed decisions regarding peri‐operative anti‐platelet therapy are made and communicated clearly to the patients.     

Are oxidative stress and ischemia significant causes of bladder damage leading to lower urinary tract dysfunction? Report from the ICI-RS 2019

Several studies indicate that pelvic ischemia and oxidative stress may play a significant role in lower urinary tract dysfunction (LUTD), including detrusor overactivity (DO)/overactive bladder (OAB) and detrusor underactivity (DU)/underactive bladder (UAB). The present article addresses proposal 1: “Are oxidative stress and ischemia significant causes of bladder damage leading to LUTD?” from the 2019 International Consultation on Incontinence—Research Society (ICI-RS) meeting. Bladder ischemia in animals and humans is briefly described, along with the proposed progression from ischemia to LUTD. Bladder ischemia is compared with ischemia of other organs, and the ongoing development of pelvic ischemia animal models is discussed. In addition, the distribution of blood within the bladder during filling and voiding and the challenges of quantification of blood flow in vivo are described. Furthermore, oxidative stress, including potential biomarkers and treatments, and challenges regarding antioxidant therapy for the treatment of LUTD are discussed. Finally, seven critical research questions and proposed studies to answer those questions were identified as priorities that would lead to major advances in the understanding and treatment of lower urinary tract symptoms (LUTS)/LUTD associated with pelvic ischemia and oxidative stress.     

Pathology,pathophysiology, and pathogenesis of painful bladder diseases

Conclusion Many unresolved questions remain regarding painful bladder disease. The etiology, pathogenesis and pathophysiology are not precisely known and therefore no rational therapy exist. One have to keep in mind that the lack of efficient therapy is the main problem for these, often very disabled and handicapped patients [64]. The goal for all future research regarding painful bladder patients has to be to find an efficient and rational therapy.     

Stress and marital discord: Some sex differences

The general importance of stress reduction techniques in sexual and marital therapy is examined in the light of findings that sexual dysfunction is an important factor in marital discord for men, but not for women. The implications of this finding for treatment are examined, and it is concluded that, while stress reduction may have a role to play in the treatment of specific sexual dysfunctions in men, a more global approach to change is needed for sex therapy in women.     

Surveillance and medical therapy following endovascular treatment of chronic cerebrospinal venous insufficiency

The debate regarding the possible link between chronic cerebrospinal venous insufficiency and multiple sclerosis (MS) is continuously becoming more and more contentious due to the current lack of level 1 evidence from randomized trials. Regardless of this continued uncertainty surrounding the safety and efficacy of this therapy, MS patients from Canada, and other jurisdictions, are traveling abroad to receive central venous angioplasty and, unfortunately, some also receive venous stents. They often return home with few instructions regarding follow-up or medical therapy. In response we propose some interim, practical recommendations for post-procedural surveillance and medical therapy, until further information is available.     

Endoscopic therapy for gastroesophageal reflux disease

There are many options regarding the treatment of gastroesophageal reflux disease (GERD). This report reviews the safety, efficacy, and early results of the various treatment options, with a focus on endoscopic therapy for GERD. This approach, which is still in its infancy, is viewed as cost-effective without the associated morbidity of surgery and the necessity of long-term compliance with medical therapy.     

Laser Therapy for Genitourinary Syndrome of Menopause

Purpose of Review

The purpose of this article is to review the available data regarding the application and therapeutic outcomes of laser therapy for the treatment of genitourinary syndrome of menopause (GSM).

Recent Findings

There have been several studies regarding the use of laser therapy for the treatment of GSM. Most of these studies show a trend toward safe and effective treatment in the short term (less than or equal to 12 weeks). However, these studies are lacking in randomization, blinding, placebo, and comparison groups.

Summary

Although laser therapy for the treatment of the symptoms of GSM appears promising, there is currently a lack of high-level and long-term evidence regarding its safety and efficacy. There is also a lack of professional guidelines in the USA regarding this modality of treatment, specifically for GSM. Opportunities exist for future research in this area, specifically to determine safety and long-term outcomes of therapy.

     

Localized ureteral fibrosis: an unrecognized complication of radiation therapy for prostatic carcinoma.

Complications of radiation therapy for prostatic carcinoma are frequent but usually minor. A patient is described in whom localized ureteral fibrosis developed following curative radiation therapy, which subsequently required a reconstructive operation. An analogous situation regarding patients with carcinoma of the cervix is examined and possible etiologies are discussed. This complication should be recognized so that proper management can be instituted.     

Binaural interactions in primary auditory cortex of the awake macaque

The functional organization of primary auditory cortex in non-primates is generally modeled as a tonotopic gradient with an orthogonal representation of independently mapped binaural interaction columns along the isofrequency contours. Little information is available regarding the validity of this model in the primate brain, despite the importance of binaural cues for sound localization and auditory scene analysis. Binaural and monaural responses of A1 to pure tone stimulation were studied using auditory evoked potentials, current source density and multiunit activity. Key findings include: (i) differential distribution of binaural responses with respect to best frequency, such that 74% of the sites exhibiting binaural summation had best frequencies below 2000 Hz; (ii) the pattern of binaural responses was variable with respect to cortical depth, with binaural summation often observed in the supragranular laminae of sites showing binaural suppression in thalamorecipient laminae; and (iii) dissociation of binaural responses between the initial and sustained action potential firing of neuronal ensembles in A1. These data support earlier findings regarding the temporal and spatial complexity of responses in A1 in the awake state, and are inconsistent with a simple orthogonal arrangement of binaural interaction columns and best frequency in A1 of the awake primate.     

Management of radiation failure for localized prostate cancer

Due to the historically large number of patients with localized prostate cancer (CAP) treated by radiation therapy, an increasing number of patients are presenting local failure. The currently available concepts regarding its definition as well as management options are reviewed. The literature regarding radiation failure for localized prostate cancer was reviewed. Emphasis was made on articles concerning definition of radiation failure, patient evaluation and restaging and definitive as well as palliative management options. There is definitely a subset of patients with locally recurrent prostate cancer without evidence of metastasis that could potentially benefit from aggressive local therapy. A treatment algorithm is proposed but it should be emphasized that treatment options should be individualized to suit the need of a particular patient.