食管间质瘤与胃间质瘤的临床特点及内镜治疗

目的：探讨食管间质瘤和胃间质瘤的临床特点及内镜下治疗。方法回顾性分析经本院内镜治疗的30例食管间质瘤和146例胃间质瘤的临床资料。分析患者的基本情况、病变部位及起源、免疫组织化学特征、治疗情况以及术后随访结果。结果食管间质瘤30例,男22例,女8例。病变多位于食管下段,63.3%病变起源于固有肌层。胃间质瘤146例,男41例,女105例。病变多位于胃底部,98.0%病变起源于固有肌层。免疫组织化学检查示食管间质瘤 CD117,CD34,SMA,desmin 阳性率分别为93.3%,93.3%,73.3%,73.3%;胃间质瘤 CD117,CD34,SMA,desmin阳性率分别为94.5%,88.4%,21.9%,19.2%。22例食管间质瘤行内镜黏膜下剥离术(ESD),8例行内镜黏膜下隧道肿瘤切除术(STER),病灶均一次性完整切除,1例患者 ESD 术中发生穿孔。145例胃间质瘤行 ESD,1例行内镜下氩离子凝固术(APC),一次性完整切除率95.2%,术中穿孔39例,出血1例。所有穿孔及出血患者均经内镜下修复。术后随访3~50个月未发现肿瘤残留和复发。结论胃肠道间质瘤缺乏特异性临床表现,但食管间质瘤和胃间质瘤在肿瘤位置分布和起源、免疫组织化学方面各具特点,内镜下微创技术已发展为治疗胃肠道间质瘤新的手段之一。     

内镜黏膜下剥离术治疗胃间质瘤的临床效果及术后出血的危险因素分析

目的探讨内镜黏膜下剥离术(ESD)治疗胃间质瘤的临床疗效及术后出血的危险因素。方法选取2019年2月-2020年4月该院诊治的135例胃间质瘤作为研究对象,统计手术时间、术后进食时间、住院时间、术后出血、穿孔和感染发生率。根据患者ESD治疗后是否发生出血将患者进一步分为术后出血组(n=12)和术后无出血组(n=123)。采用Logistic回归分析胃间质瘤患者ESD术后出血的影响因素。结果135例患者手术时间为(46.23±8.79) min,术后进食时间为(3.05±0.98) d,住院时间为(6.11±0.95) d,术后出血发生率为8.89%,术中穿孔发生率为0.74%,术后穿孔发生率为1.48%,术后感染发生率为7.41%。胃间质瘤患者ESD术后出血的独立危险因素有:高血压、糖尿病、血清降钙素原(PCT)、C反应蛋白(CRP)、血小板计数(PLT)。结论高血压、糖尿病、PLT、血清PCT和CRP水平是胃间质瘤患者ESD术后出血的影响因素。     

单切口与常规腹腔镜胃楔形切除术治疗胃间质瘤的对比研究

目的通过胃间质瘤单切口腹腔镜和常规腹腔镜手术的对比研究,以评价单切口腹腔镜手术治疗胃间质瘤的临床效果、安全性和可行性。方法回顾性分析2008年4月~2012年2月,27例接受常规腹腔镜手术(常规腹腔镜组)与16例接受单切口腹腔镜手术(单切口腹腔镜组)的胃间质瘤患者的一般资料、术中经过及术后恢复情况等进行病例对照研究。结果单切口腹腔镜组在手术时间、术中出血量、术后胃肠功能恢复时间及术后住院时间等方面均能达到常规腹腔镜组的临床效果。两组病例中均无术中及术后并发症发生,随访期间未见复发病例。结论单切口腹腔镜胃楔形切除术治疗胃间质瘤安全、可行、有效性。     

胃镜黏膜下剥离术治疗胃食管连接部黏膜病变30例临床分析

目的探讨胃镜黏膜下剥离术(endoscopic submucosal dissection,ESD)治疗胃食管连接部黏膜病变的疗效及安全性。方法回顾性分析30例胃食管连接部黏膜病变患者临床资料,分析病变特点及ESD治疗切除率和手术时间,随访观察术后并发症和复发情况。结果患者胃食管连接部黏膜病变直径(30±15)mm,ESD治疗完整切除率为100%,手术时间(45±16)min;术后1例有少量胃管内出血,未发生穿孔等并发症;组织病理确诊黏膜慢性炎症8例,萎缩性胃炎3例,增生性息肉6例,低级别上皮内瘤变9例,高级别上皮内瘤变3例,腺癌1例;平均随访18个月,无复发。结论 ESD治疗胃食管连接部黏膜病变的完整切除率高,安全。     

18例胃间质瘤临床病理分析

目的 探讨胃间质瘤的病理组织学特点、免疫表型特征、诊断标准、治疗原则及决定预后的因素.方法 对18例胃间质瘤患者的手术切除标本用10%甲醛固定,常规HE染色、光镜观察,SP染色后检测CD117、CD34、平滑肌肌动蛋白(SMA)、S100蛋白的表达.结果 18例胃间质瘤的病理形态呈梭形细胞样12例,上皮细胞样6例,CD117阳性+ 6例、++ 8例、+++ 4例,CD34 + 8例、++ 2例,+++ 6例、阴性2例,S100蛋白仅有1例散在阳性,SMA仅有2例散在阳性,其余均为阴性.结论 CD117、CD34是胃间质瘤的诊断标记物,病理检查及免疫组织化学是诊断胃间质瘤的可靠方法,肿瘤大小及核分裂是判断危险度的标准,手术切除是首选的治疗方法.术后密切随访、定期复查,必要时配合甲磺酸伊马替尼治疗对控制复发、转移,延长患者生命有重要意义.     

内镜黏膜下剥离术治疗胃肠道间质瘤的围手术期护理

目的总结内镜黏膜下剥离术(ESD)治疗胃肠道间质瘤的围手术期护理方法。方法回顾分析2007年1月-2011年8月符合内镜下治疗77例胃肠道间质瘤患者行ESD的临床资料和护理措施。结果 77例患者全部经内镜完整切除肿瘤,其中3例出现出血,5例发生穿孔,2例发生术后狭窄,经内科保守治疗、内镜下治疗以及围手术期精心护理,患者痊愈出院。结论 ESD治疗胃肠道间质瘤安全、有效,正确细致的各项护理措施是胃间质瘤患者手术获得成功、且身体早日康复的有力保障。     

胃间质瘤内镜黏膜下剥离术术后出血相关因素分析

目的 探讨胃间质瘤患者内镜黏膜下剥离术(ESD)术后出血情况并分析其相关危险因素.方法 回顾性分析2018年12月至2020年12月上海市徐汇区中心医院收治的110例接受ESD治疗的胃间质瘤患者的临床资料,分析ESD术后出血情况,并采用多因素Logistic回归分析影响ESD术后出血的危险因素.结果 110例患者中15...     

腹腔镜联合内镜手术治疗胃间质瘤患者的疗效及预后

目的与传统的开腹手术对比,探讨腹腔镜联合内镜手术治疗胃间质瘤患者的临床疗效及预后。方法选取60例胃间质瘤患者,按随机数字表法分为研究组30例和对照组30例。对照组给予传统的开腹手术,研究组采取腹腔镜联合内镜手术治疗,比较2组手术时间、术中出血量、术后胃肠功能恢复时间、平均住院时间、术后并发症及瘤体复发情况。结果研究组手术时间、术中出血量、术后胃肠功能恢复时间和平均住院时间明显短于或少于对照组(均P<0.05)。研究组并发症发生率为0(0/30),对照组并发症发生率为6.67%(2/30),2组手术并发症发生率比较差异无统计学意义(P=0.150)。术后随访3~36个月,研究组术后复发1例,复发率为3.33%;对照组复发3例,复发率为10.0%,2组随访期内复发率比较差异无统计学意义(P=0.301)。结论腹腔镜与内镜结合可实现优势互补,对胃间质瘤患者有良好的手术效果,且并发症和复发少,预后好。     

单切口腹腔镜胃楔形切除术治疗胃间质瘤的护理体会

目的观察分析16例单切口腹腔镜下胃楔形切除术治疗胃间质瘤的临床效果和护理方法。方法回顾我院2008年4月-2012年3月16例接受单切口腹腔镜手术的胃间质瘤患者的一般资料和护理过程。结果单切口腹腔镜在手术时间、术中出血量、术后胃肠功能恢复时间、术后住院时间等方面得到了非常满意的效果，术后均无并发症发生，随访期间未见复发病例。结论单切口腹腔镜胃楔形切除术治疗胃间质瘤安全、可行，有效的护理方法对患者术后康复具有重要的作用。     

胃肠恶性间质瘤25例诊治分析

目的：探讨胃肠恶性间质瘤诊治方法。方法：回顾性分析我院1999—09／2005—12收治的25例胃肠恶性间质瘤临床及病理资料。结果：25例均行手术治疗。术后免疫组化CD117阳性25例，CD34阳性18例。随访1～3a，死亡9例。结论：胃肠恶性间质瘤临床表现无特异性，病理检查是确诊的惟一方法。完整局部手术切除是最有效的治疗手段。对无法切除或有肿瘤残余及术后复发的患者可应用格列卫进行治疗。     

Guns and Knives in New Mexico: Patterns of Penetrating Trauma, 1978–1993

Objective: To identify patterns of nonfatal and fatal penetrating trauma among children and adults in New Mexico using ED and medical examiner data.
Methods: The authors retrospectively sampled in 5-year intervals all victims of penetrating trauma who presented to either the state Level-1 trauma center or the state medical examiner from a 16-year period (1978–1993). Rates of nonfatal and fatal firearm and stabbing injury were compared for children and adults.
Results: Rates of nonfatal injury were similar (firearm, 34.3 per 100,000 person-years; stabbing, 35.1). However, rates of fatal injury were significantly different (firearm, 21.9; stabbing, 2.7; relative risk: 8.2; 95% confidence interval: 5.4, 12.5). From 1978 to 1993, nonfatal injury rates increased for children (p = 0.0043) and adults (p < 0.0001), while fatal penetrating injury remained constant. The increase in nonfatal injury in children resulted from increased firearm injury rates. In adults, both stabbing and firearm nonfatal injury rates increased.
Conclusions: Nonfatal injury data suggest that nonfatal violence has increased; fatal injury data suggest that violent death rates have remained constant. Injury patterns vary by age, mechanism of trauma, and data source. These results suggest that ED and medical examiner data differ and that both are needed to guide injury prevention programs.     

Interprofessional approaches to creating safe,high quality health care

Three supplementary perspectives are presented arguing that interprofessional collaboration is both necessary and desirable. Nonetheless, there are often too many serious intra-professional barriers and obstacles to interprofessional collaboration to make it successful. Some of these barriers, it is argued and illustrated, are found in the multiple ways in which professional identity is tacitly acquired and embodied in the practitioners' habitual, everyday practice. The paper then explores ways in which reflection, especially Second order reflection, can help to elucidate and overcome these obstacles, as well as increasing professional adaptability and competence.     

Systematic Reviews Published in the January 2011 Issue of The Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly as a DVD and monthly online. The January 2011 issue (first quarterly DVD for 2011) contains 4515 complete reviews, 1985 protocols for reviews in production, and 13,521 one-page summaries of systematic reviews published in the general medical literature. In addition, there are citations of 641,000 randomized controlled trials, and 14,018 cited papers in the Cochrane methodology register. The health technology assessment database contains over 9300 citations. One hundred and seven new reviews have been published in the last 3 months, of which five have potential relevance for practitioners in pain and palliative medicine.     

Determination of creatine kinase isoenzyme MB activity in serum using immunological inhibition of creatine kinase M subunit activity. Activity kinetics and diagnostic significance in myocardial infarction.

This is a new method for the determination of creatine kinase isoenzyme MB activity in serum. The method uses direct activity measurement of creatine kinase B subunit activity after blocking of CK-M subunit activity by inhibiting antibodies. The test takes no longer than 15 min. The method yields an intra-serial C.V. of 2.0-12.9%, and a C.V. from day to day of 5.5%. The detection limit is 3.4 U/l creatine kinase MB. In the 95 cases with proven myocardial infarction several types of creatine kinase MB activity kinetics could be determined. The percentage of creatine kinase MB of peak CK-total is 6-25%, with a mean of 11.1%. The amount of creatine kinase MB with respect to total CK activity after reinfarction is higher than the amount after initial infarction.     

俯卧位通气对高海拔地区肺复张治疗无效急性呼吸窘迫综合征患者氧合的影响

目的 探讨俯卧位通气对高海拔地区肺复张术(RM)治疗无效急性呼吸窘迫综合征(ARDS)患者的治疗作用.方法 从海拔2260m的地区医院筛选RM治疗无效的41例ARDS患者[平均氧合指数( PaO2/FiO2)较RM前升高＜20％视为RM无效],依不同病因分为肺内源性ARDS组(ARDSp组)和肺外源性ARDS组(ARDSexp组),每组再按信封法随机分为俯卧位组和仰卧位组,即ARDSp俯卧位组(11例)、ARDSp仰卧位组(9例)、ARDSexp俯卧位组(10例)、ARDSexp仰卧位组(11例).在通气前及通气1、2、3、4h监测动脉血氧分压( PaO2)、PaO2/FiO2、静态顺应性(Cst)、气道阻力(Raw)的变化.结果 通气lh时,ARDSexp俯卧位组PaO2/FiO2( mm Hg,l mm Hg=0.133 kPa)即较通气前显著升高(157.4±40.6比129.3±48.7,P＜0.05),并随通气时间延长呈持续增高趋势,4h达峰值(219.1 ±41.1);且ARDSexp俯卧位组通气3h内PaO2/FiO2较其他3组显著增高,另3组间则差异无统计学意义.ARDSp俯卧位组、ARDSexp俯卧位组通气4h时PaO2/FiO2均较相应仰卧位组显著增高(208.8±39.7比127.4±47.1,219.1±41.1比124.9±50.8,均P＜0.05).4组通气前后Cst无显著改变,各组间差异也无统计学意义.ARDSp俯卧位组通气4h时Raw(cmH2O·L-1·s-1)较通气前显著降低(6.8±1.7比10.7±1.8,P＜0.05),且明显低于其他3组;其他3组各时间点Raw组内及组间比较差异均无统计学意义.结论 俯卧位通气作为ARDS机械通气重要策略之一,可以改善RM无效高原ARDS患者的氧合,为抢救患者赢得宝贵的时间.     

Digital imaging among medical facilities

The Department of Veterans Affairs (VA) in the USA operates a network of 172 medical centres which all utilize a hospital information system (HIS) which has been developed and is currently maintained by the VA. During the past several years, an image management and communication module has been developed, installed and clinically utilized at the Washington DC and Maryland VA Medical Centres. This image management and communication system, referred to as the decentralized hospital computer program (DHCP) imaging system, is fully integrated with a commercial picture archiving and communication system (PACS). The system is utilized to capture, archive, and display all images generated within the hospital including radiology, nuclear medicine, pathology, endoscopy, bronchoscopy, and dermatology, intraoperative photographs, ECG data, and a limited number of paper documents. The ultimate goal of the project is to have all patient text and image data available at any clinical workstation to any authorized user anywhere within the network of medical centres. Clinical requirements for an imaging workstation include ease of use, rapid and reliable access to the complete set of patient information, and images which are of acceptable quality to meet the requirements of the user and the subspecialty. Patient confidentiality and data security must be safeguarded at all times. Integration of the images with the remainder of the patient's database was found to be critical to the success of the project. The experience at the Washington and Maryland facilities suggests that an imaging system that is successfully integrated with a hospital information system can provide substantial clinical and economic benefits both within and among medical centres. Clinical acceptance and utilization of the system has been excellent, particularly in diagnostic radiology where DHCP Imaging has been interfaced to a commercial PAC system. Based upon this initial experience, the VA has begun to deploy the system throughout its large network of medical centres.     

Myocardial elastography at both high temporal and spatial resolution for the detection of infarcts

Myocardial elastography is a novel method for noninvasively assessing regional myocardial function, with the advantages of high spatial and temporal resolution and high signal-to-noise ratio (SNR). In this paper, in-vivo experiments were performed in anesthetized normal and infarcted mice (one day after left anterior descending coronary artery [LAD] ligation) using a high-resolution (30 MHz) ultrasound system (Vevo 770, VisualSonics Inc., Toronto, ON, Canada). Radiofrequency (RF) signals of the left ventricle (LV) in longitudinal (long-axis) view and the associated electrocardiogram (ECG) were simultaneously acquired. Using a retrospective ECG gating technique, 2-D full field-of-view RF frames were acquired at an extremely high frame rate (8 kHz) that resulted in high-quality incremental displacement and strain estimation of the myocardium. The incremental results were further accumulated to obtain the cumulative displacements and strains. Two-dimensional and M-mode displacement images and strain images (elastograms), as well as displacement and strain profiles as a function of time, were compared between normal and infarcted mice. Incremental results clearly depicted cardiac events including LV contraction, LV relaxation and isovolumetric phases in both normal and infarcted mice, and also evidently indicated reduced motion and deformation in the infarcted myocardium. The elastograms indicated that the infarcted regions underwent thinning during systole rather than thickening, as in the normal case. The cumulative elastograms were found to have higher elastographic SNR (SNR(e)) than the incremental elastograms (e.g., 10.6 vs. 4.7 in a normal myocardium, and 6.0 vs. 2.4 in an infarcted myocardium). Finally, preliminary statistical results from nine normal (m = 9) and seven infarcted (n = 7) mice indicated the capability of the cumulative strain in differentiating infracted from normal myocardia. In conclusion, myocardial elastography could provide regional strain information at simultaneously high temporal (>/=0.125 ms) and spatial ( approximately 55 microm) resolution as well as high precision ( approximately 0.05 microm displacement). This technique was thus capable of accurately characterizing normal myocardial function throughout an entire cardiac cycle, at the same high resolution, and detecting and localizing myocardial infarction in vivo.     

Prise en charge des entorses externes de cheville : étude clinique préliminaire sur l’efficacité du dispositif Myolux™

Ankle sprains are the most common injury of the musculoskeletal system and are associated with significant societal and economic impacts. It has been proven that classical therapeutic strategies may not be effective in preventing recurrent injuries: the recurrence rates reported in the literature can reach 73%. In order to provide an effective rehabilitation solution, a destabilizing orthosis was developed. This device is equipped with a mechanical articulator reproducing the subtalar mechanics and placed under the heel. In this paper, we present the main results of a preliminary clinical study conducted between 2004 and 2007. All subjects included in this study were treated with the abovementioned orthosis during 10 rehabilitation sessions of 30 minutes each. Data show a relatively low recurrence rate of 12% for the overall population. Moreover, it's of primary importance to note that this satisfactory ratio is largely reduced (3% of recurrence rate) for the 29 patients who performed one training session per month after the 10th initial rehabilitation sessions. Hence, the destabilizing orthosis appears to be an effective solution to prevent recurrent ankle sprains. However, joint protection requires long-term and regular training sessions. This result has motivated the development of a similar device allowing patients to perform training sessions at home. Finally, data obtained in this study are promising awaiting the final results of the comparative, multicentric and independent clinical trials currently managed by the Hospices Civils de Lyon.