胰腺浆液性微囊性腺瘤临床病理学观察

目的 探讨胰腺浆液性微囊性腺瘤(serous microcystic adenoma,SMA)的临床与病理学特点.方法 对12例SMA进行临床病理、特殊染色及免疫组化观察并随访.结果 ①临床:12例SMA中,男3例、女9例,35～70岁,平均51.5岁;7例因体检发现,5例因上腹不适或疼痛就诊;肿瘤直径2.0～13 cm,平均6.0 cm,切面均呈蜂窝状,囊内含清亮液体或灰红色液体.②镜下:瘤组织由多量小囊腔构成,囊壁内衬单层立方或扁平上皮,胞浆透亮,富含糖原,部分嗜酸,核小而圆,深染,大小一致,无明显异型性,核分裂像极少或无.③特殊染色:瘤细胞PAS(+),AB-PAS(-).④免疫组化:AEl/AE3及EMA(+),CEA、Vimentin、CgA、Syn、CD34、P53及S-100均(-).10例病人随访12～71个月,均未见复发.结论 SMA为胰腺罕见的肿瘤,临床上多无明显症状,依据其特有的病理组织学形态及免疫组化染色可明确诊断.其具体生物学行为有待进一步研究.     

胰腺浆液性微囊性腺瘤临床病理学观察

目的 探讨胰腺浆液性微囊性腺瘤(serous microcystic adenoma,SMA)的临床与病理学特点.方法 对12例SMA进行临床病理、特殊染色及免疫组化观察并随访.结果 ①临床:12例SMA中,男3例、女9例,35～70岁,平均51.5岁;7例因体检发现,5例因上腹不适或疼痛就诊;肿瘤直径2.0～13 cm,平均6.0 cm,切面均呈蜂窝状,囊内含清亮液体或灰红色液体.②镜下:瘤组织由多量小囊腔构成,囊壁内衬单层立方或扁平上皮,胞浆透亮,富含糖原,部分嗜酸,核小而圆,深染,大小一致,无明显异型性,核分裂像极少或无.③特殊染色:瘤细胞PAS(+),AB-PAS(-).④免疫组化:AEl/AE3及EMA(+),CEA、Vimentin、CgA、Syn、CD34、P53及S-100均(-).10例病人随访12～71个月,均未见复发.结论 SMA为胰腺罕见的肿瘤,临床上多无明显症状,依据其特有的病理组织学形态及免疫组化染色可明确诊断.其具体生物学行为有待进一步研究.     

胰腺浆液性小囊性腺瘤临床与病理分析:附四例

目的 分析胰腺浆液性小囊性腺瘤(serous microcystic adenoma,sMA)的临床、病理特点及治疗.方法 回顾性分析4例sMA的临床表现、病理特征及治疗结果 .行PAS染色及CK7、CK20、AE1/AE3、EMA、CA19-9、CEA、34βE12、P63、SMA、Vim、S-100、CgA、Syn、NSE、ER、PR等免疫组织化学检测.结果 病人平均年龄66岁,因体检发现肿块或因其它疾病人院.巨检肿块呈蜂窝状,镜下见大小不等囊腔,囊内衬单层立方或扁平上皮,胞质透亮或嗜酸性.小囊间为胶原纤维分隔.肿瘤无包膜.上皮PAS染色及CK7、EMA、AE1/AE3均全部弥漫阳性.病人均出现手术并发症.结论 胰腺sMA好发于老年人,多为偶然发现.肉眼观呈蜂窝状,镜下小囊内衬一致性富于糖原的上皮,无包膜.免疫组化检测CK7、EMA、AE1/AE3全部阳性.肿块局部彻底切除是最佳治疗方案,但对于无症状的手术耐受力差的病人建议明确诊断后行保守治疗.     

胰腺浆液性微囊性腺瘤临床病理学观察

目的 探讨胰腺浆液性微囊性腺瘤(serous microcystic adenoma,SMA)的临床与病理学特点.方法 对12例SMA进行临床病理、特殊染色及免疫组化观察并随访.结果 ①临床:12例SMA中,男3例、女9例,35～70岁,平均51.5岁;7例因体检发现,5例因上腹不适或疼痛就诊;肿瘤直径2.0～13 cm,平均6.0 cm,切面均呈蜂窝状,囊内含清亮液体或灰红色液体.②镜下:瘤组织由多量小囊腔构成,囊壁内衬单层立方或扁平上皮,胞浆透亮,富含糖原,部分嗜酸,核小而圆,深染,大小一致,无明显异型性,核分裂像极少或无.③特殊染色:瘤细胞PAS(+),AB-PAS(-).④免疫组化:AEl/AE3及EMA(+),CEA、Vimentin、CgA、Syn、CD34、P53及S-100均(-).10例病人随访12～71个月,均未见复发.结论 SMA为胰腺罕见的肿瘤,临床上多无明显症状,依据其特有的病理组织学形态及免疫组化染色可明确诊断.其具体生物学行为有待进一步研究.     

胰腺浆液性囊腺瘤57例临床分析及治疗探讨

目的 探讨胰腺浆液性囊腺肿瘤的临床诊断及治疗.方法 回顾性分析57例术后病理确诊为胰腺浆液性囊腺瘤患者的临床资料.结果 57例患者中,男13例(22.8％),女44例(77.2％),平均年龄56.8岁.术前无临床症状者31.6％,CT的正确诊断率为70.6％.57例均为经手术治疗的患者,其中胰十二指肠切除术17例(29.8％),保留或不保留脾脏的胰腺远端切除术38例(66.7％),姑息术1例,肿瘤剥除术1例.术后出现并发症6例(10.5％).术后病理为微囊型浆液性囊腺瘤50例(87.7％),寡囊型浆液性囊腺瘤7例(12.3％).包括微囊型浆液性囊腺癌1例.随访12个月至15年,除1例浆液性囊腺癌患者于术后13个月死亡外,均获得长期生存.按术后病理分型及肿瘤大小分组行统计分析,寡囊型患者的术后平均住院日大于微囊型[(17.39±7.61)d比(19.43±0.98)d,P=0.002],肿瘤最大径≥4 cm组患者临床症状发生率高于＜4 cm组(76.1％比23.9％,P=0.03),其余临床指标差异无统计学意义.结论 胰腺浆液性囊腺瘤是一种少见的胰腺囊性肿瘤,多发于中老年女性.笔者认为,有症状的、肿瘤直径大于4 cm的、有恶性生物学行为倾向或无法排除其他潜在恶性肿瘤的患者是手术切除的适应证.无症状且肿瘤小于4 cm者如随诊发现肿瘤进行性增长证据也应手术切除.     

胰腺浆液性囊腺瘤的临床分析（附19例报道）

目的总结胰腺浆液性囊腺瘤的临床特点、诊治及预后情况。方法对我院2003年6月至2013年6月期间收治的19例胰腺浆液性囊腺瘤患者的临床资料进行回顾性分析。结果胰腺浆液性囊腺瘤好发于中老年女性（本组男女比例为1：3．75，发病平均年龄56．7岁）。患者首发症状：腹部疼痛不适12例，发现腹部包块2例，无特殊症状因体检发现5例。肿瘤部位：胰头及胰颈部8例，胰体部6例，胰尾部5例。肿瘤平均直径5．4cm。CT及MRI术前诊断率分别为60．0％（9／15）、80．0％（8／10）。19例患者均成功手术并行病理检查，其中浆液性微囊性腺瘤15例，浆液性寡囊性腺瘤4例。有4例患者术后出现胰漏，其中l例合并腹腔感染，经内科治疗后痊愈。术后随访4～124个月，平均55个月，未见肿瘤复发。结论胰腺浆液性囊腺瘤的临床表现无特异性，CT及MRI术前诊断价值较高。手术为最有效的治疗方法，预后良好。     

乳腺腺样囊性癌6例及文献回顾

探讨乳腺腺样囊性癌的临床病理特征、免疫组化特点、诊断及鉴别诊断。对6例乳腺腺样囊性癌的临床表现、组织学形态、免疫组化特点、诊断及鉴别诊断要点、治疗和预后进行分析,并复习相关文献。6例患者均为女性,发病年龄47～60岁,平均52.8岁。大体上,肿瘤与周围乳腺组织分界清楚。镜下可见筛状、小管-小梁状及实体结构模式。肿瘤由腺上皮、肌上皮及基底样细胞构成。腺上皮细胞表达CK7、CK5/6和CD117;肌上皮细胞表达SMA、Calponin和P63,基底样细胞不同程度表达CK5/6、P63和CD117。肿瘤细胞不表达ER、PR和Her-2。乳腺腺样囊性癌是一种罕见的具有形态学异质性的肿瘤,具有独特的组织病理学和免疫组化特点,预后良好。     

胰腺囊性肿瘤35例诊治分析

目的 探讨胰腺囊性肿瘤的诊断和治疗.方法 对35例胰腺囊性肿瘤病例资料进行回顾性分析.结果 术前诊断率:B超为28.6%(10/35),CT为44.4%(12/27),MRI为70%(7/10).28例行手术治疗,并为术后病理确诊,其中浆液性囊腺瘤2例,黏液性囊腺瘤9例,囊腺癌7例,胰腺导管内乳头状黏液性肿瘤3例,胰腺实性假乳头状瘤7例.获得随访23例:胰腺囊腺瘤术后5年存活率为62.5%(5/8),无复发病例;胰腺囊腺癌完整切除者最长存活5年8个月,未能完整切除者最长存活6个月;胰腺实性假乳头状瘤4例,均健在,最长已存活4年.结论 胰腺囊性肿瘤术前诊断较困难,CT及MRI对本病的诊断帮助较大.外科切除是最有效的治疗手段.加强各科医师之间的交流与合作、及早发现、恰当的手术方法,有助于提高本病的诊治效果.     

胰腺囊性肿瘤13例诊治体会

目的 探讨胰腺囊性肿瘤的诊断与治疗方法.方法 对13例胰腺囊性肿瘤患者的临床资料进行回顾性分析.结果 浆液性囊腺瘤4例,黏液性囊腺瘤7例,黏液性囊腺癌2例.B超和CT诊断胰腺囊性肿瘤的正确率分别为85%(11/13)和92%(12/13).采取胰十二指肠切除术6例,胰体尾部切除3例,胰腺局部切除3例,囊壁大部切除1例....     

肾囊性病变临床病理分析（附3例报告）

目的 探讨肾囊性病变的临床病理学特点、免疫表型和鉴别诊断。方法 采用常规HE和免疫组织化学染色,观察3例肾囊性病变组织学形态,并复习有关文献。结果 3个病例临床症状均为腰痛或血尿,最后经病理确诊为囊性肾瘤2例和多房性囊性肾癌1例。囊性肾瘤为多房囊腔组织,囊壁薄,内衬单层上皮。免疫表型：上皮细胞角蛋白（CK）、上皮细胞膜抗原(EMA)均呈阳性表达;间质成分波形蛋白阳性。多房性囊性肾癌囊壁被覆单层或多层胞浆透明的细胞,间隔内含聚集的透明细胞巢。免疫表型：透明细胞CK和EMA阳性,CD68阴性。结论 囊性肾瘤和多房性囊性肾癌均是少见的肾脏肿瘤。两种病变临床症状和影像学改变极为相似,确诊需依赖病理检查。两种病变均预后良好。     

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.     

Dilemma of Membrane Biocompatibility and Reuse

Abstract: Numerous articles have been published on the multiple use of dialyzers and on the effect of different reprocessing chemicals and techniques on the dialyzer biocompatibility and performance. The results often appear contradictory, especially those comparing standard biocompatibility parameters. Despite this confusion, a discerning review of the published works allows certain limited conclusions to be drawn. Reprocessing of used hemodialyzers changes the biocompatibility profile of a dialyzer as defined by the parameters complement activation. leukopenia, and cytokine release. The effect of reprocessing depends on the chemicals and reprocessing technique applied and also on the type of membrane polymer being subjected to the reprocessing procedure. Reports of pyrogenic reactions indicate that the flux of the membrane also influences how suitable it is for safe reuse. An increased risk of allergic and pyrogenic reactions appears to be associated with dialyzer reuse. Furthermore, there has been a lack of investigations into the immunologic effect of the layer of adsorbed and chemically altered proteins that remains on the inner surface of reprocessed dialyzers. We conclude that the clinical benefit of dialyzer reuse cannot be generally accepted from a biocompatibility point of view.     

The analgesic effect of racemic ketamine in patients with chronic ischemic pain due to lower extremity arteriosclerosis obliterans

Background : Ketamine in sub-dissociative doses has been shown to have analgesic and phantom-Limb pain, where conventional treatment has often failed. Chronic ischemic pain due to lower extremity arteriosclerosis obliterans often responds poorly to analgesics, and the pain-generating mechanisms are not well understood.
Methods : Eight patients with rest pain in the lower extremity due to arteriosclerosis obliterans were given sub-dissociative doses of 0.15, 0.30, or 0.45 mg/kg racemic ketamine and morphine 10 mg as a 5-min infusion on four separate days in a cross-over, double-blind, randomised protocol. Plasma levels of (S)- and (R)-ketamine and their nor-metabolites were analysed with an enantioselective high-performance liquid chromatography (HPLC) method. Pain levels were evaluated with a visual analogue scale (VAS).
Results : Individual pain levels were highly variable during and after all the infusions but the pooled pain levels showed a dose-dependent analgesic effect of ketamine with a transient but complete pain relief in all patients at the highest dose (0.45 mg/ kg). Side-effects, mainly disturbed cognition and perception, were pronounced and dose-dependent. Morphine 10 mg had an analgesic peak at 20 min and 5/8 patients had complete pain relief. The remaining 3 patients also had high baseline pain scores, indicating a higher analgesic potency for the 0.30 and 0.45 mg/ kg ketamine doses than for morphine 10 mg.
Conclusion : We have demonstrated a potent dose-dependent analgesic effect of racemic ketamine in clinical ischemic pain. Due to a narrow therapeutic window, this analgesic effect is probably best utilised in combination with other analgesics.     

Intravenous endotoxin does not increase tissue extravasation of albumin in rats

Background : It is unclear whether activation of the inducible nitric oxide synthase (iNOS) increases or decreases the extravasation of plasma.
Methods : Chloralose anaesthetised male Wistar rats received E. coli lipopolysacharide (LPS), 3 mg kg^-1 i.v., or the corresponding volume of saline, 3 or 5 h before the end of the experiment. Mean arterial pressure (MAP) and heart rate (HR) were recorded. Tissue clearance of radio-labelled albumin, during the last 2 h of each experiment, was determined by a double-isotope method. In separate animals, the serum concentration of nitrite and nitrate was determined, 5 h after LPS or the solvent.
Main Results : LPS initially decreased MAP and lastingly increased HR. In the 3-h LPS animals (n=8), tissue plasma clearance was lower in the heart and calf muscle and increased only in diaphragm, compared to corresponding control animals (n=8). In the 5-h LPS rats, clearance was lowered (n=8) in the entire gastrointestinal tract and in testes, compared to controls (n=8). The serum nitrite/nitrate concentration was higher in animals given LPS (n=6) than in controls (n=6).
Conclusion : After LPS, tissue clearance of albumin was not increased in any major tissue, in spite of increased serum levels of NO end products. Apparently, after activation of iNOS, the augmented release of NO is not necessarily associated with increased albumin extravasation.     

Adrenaline markedly improves thoracic epidural analgesia produced by a low-dose infusion of bupivacaine, fentanyl and adrenaline after major surgery: A randomised, double-blind, cross-over study with and without adrenaline

Background: Basic pharmacological research indicates that there are synergistic antinociceptive effects at the spinal cord level between adrenaline, fentanyl and bupivacaine. Our clinical experience with such a mixture in a thoracic epidural infusion after major surgery confirms this. The objectives of the present study were to evaluate the effects on postoperative pain intensity, pain relief and side effects when removing adrenaline from this triple epidural mixture. Methods: A prospective, randomised, double-blind, cross-over study was carried out in 24 patients after major thoracic or abdominal surgery. Patients with only mild pain when coughing during a titrated thoracic epidural infusion of about 10 ml · h^?1 of bupivacaine 1 mg · ml^?1, fentanyl 2 μg · ml^?1, and adrenaline 2 μg · ml^?1 were included. On the 1^st and 2^nd postoperative days each patient was given a double-blind epidural infusion, at the same rate, with or without adrenaline. The effect was observed for 4 h or until pain when coughing became unacceptable in spite of a rescue analgesic procedure. Rescue analgesia consisted of up to two epidural bolus injections per hour and i.v. morphine if necessary. All patients received rectal paracetamol 1 g, every 8 h. Fentanyl serum concentrations were measured with a radioimmunoassay technique at the start and end of each study period. Main outcome measures were extent of sensory blockade and pain intensity at rest and when coughing, evaluated by a visual analogue scale, a verbal categorical rating scale, the Prince Henry Hospital pain score, and an overall quality of pain relief score. Results: The number of hypaesthetic dermatomal segments decreased (P <0.001) and pain intensity at rest and when coughing increased (P <0.001) when adrenaline was omitted from the triple epidural mixture. This change started within the first hour after removing adrenaline. After 3 h pain intensity when coughing had increased to unacceptable levels in spite of rescue analgesia (epidural bolus injections and i.v. morphine). Within 15–20 min after restarting the triple epidural mixture with adrenaline, pain intensity was again reduced to mild pain when coughing. Serum concentration of fentanyl doubled from 0.22 to 0.45 ng · ml^?1 (P <0.01), and there was more sedation during the period without adrenaline. Conclusions: Adrenaline increases sensory block and improves the pain-relieving effect of a mixture of bupivacaine and fentanyl infused epidurally at a thoracic level after major thoracic or abdominal surgery. Serum fentanyl concentrations doubled and sedation increased when adrenaline was removed from the epidural infusion, indicating more rapid vascular absorption and systemic effects of fentanyl.     

Utilisation des médicaments prokinétiques en réanimation : indications et limites ?

Enteral feeding is often limited by gastric and intestinal motility disturbances in critically ill patients, particularly in patients with shock. So, promotility agents are frequently used to improve tolerance to enteral nutrition. This review summaries the pathophysiology, presents the available pharmacological strategies, the clinical data, the counter-indications and the principal limits. The clinical data are poor. No study demonstrates a positive effect on clinical outcomes. Metoclopramide and erythromycin seems to be the more effective. Considering the risk of antibiotic resistance, the first line use of erythromycin should be avoided in favor of metoclopramide.     

Anesthésie générale chez l’enfant : quid des pratiques en 2010 ?

Introduction

The practice of pediatric anesthesia requires a regular update of scientific knowledge and technical skills. To provide the most adequate Continuing Medical Education programs, it is necessary to assess the practices of pediatric anesthesiologists. Thus, the objective of this survey was to draw a picture of the current clinical practices of general anesthesia in children, in France.

Material and methods

One thousand one hundred and fifty questionnaires were given to anesthesiologists involved in pediatric cases. These questionnaires collected information on various aspects of clinical practice relative to induction, maintenance, recovery from general anaesthesia and also classical debated points such as children with Upper Respiratory Infection (URI), emergence agitation, epileptoid signs or anaesthetic management of adenoidectomy. Differences in practices between CHG (general hospital), CHU (teaching hospital), LIBERAL (private) and PSPH (semi-private) hospitals were investigated.

Results

There were 1025 questionnaires completed. Fifty-five percent of responders worked in public hospitals (CHG and CHU); 77% had a practice that was 25% or less of pediatric cases. In children from 3 to 10 years: 72% of respondents used always premedication and two thirds performed inhalation induction in more than 50% of cases. For induction, 53% used sevoflurane (SEVO) at 7 or 8%. Respondents from LIBERAL used higher SEVO concentrations. Tracheal intubation was performed with SEVO alone (37%), SEVO and propofol (55%) and SEVO with myorelaxant (8%), 93% of respondents used a bolus of opioid. For maintenance, the majority of respondents used SEVO associated with sufentanil; desflurane and remifentanil were more frequently used in CHU. Two thirds of respondents used N₂O. Depth of anesthesia was commonly assessed by hemodynamic changes (52%), end tidal concentration of halogenated (38%) or automated devices based on EEG (7%). In children with URI, 98% of respondents used SEVO for anesthesia. To control the airway 42% used a tracheal tube, 30% a laryngeal mask and 20% a facial mask. Emergence agitation was an important concern for two thirds of respondents, while epileptoid signs were considered as important by only 20%. Eighty-nine percent of respondents practiced anesthesia for adenoidectomy. Anesthesia was induced by inhalation of SEVO 7–8% (41%), 6% (39%) or 4% (12%), 66% put an intravenous line (less frequently in LIBERAL). 67% of the responders managed adenoidectomy without any device to control the airway (more frequently in LIBERAL), 32% administrated a bolus of opioid (less frequently in LIBERAL).

Discussion

This survey demonstrated that the practices regarding general anesthesia in children are relatively homogenous. Most of the differences appeared between LIBERAL and the others structures; the anaesthetic management for adenoidectomy illustrates these findings.     

Intérêt d’une rééducation précoce pour les patients neurologiques

Rehabilitation improves the functional prognosis of patients after a neurologic lesion, and tendency is to begin rehabilitation as soon as possible. This review focuses on the interest and the feasibility of very early rehabilitation, initiated from critical care units. It is necessary to precisely assess patients’ impairments and disabilities in order to define rehabilitation objectives. Valid and simple tools must support this evaluation. Rehabilitation will be directed to preventing decubitus complications and active rehabilitation. The sooner rehabilitation is started; the better functional prognosis seems to be.     

Risiko Schlaganfall — Öffentlichkeitsarbeit und Aufklärung dringend erforderlich

Zusammenfassung Das wesentliche — und zugleich noch wenig ausgeschöpfte — Potenzial der Schlaganfallmedizin liegt in der langfristigen Prophylaxe. Durch Beeinflussung von Lifestylefaktoren wie Ernährungsgewohnheiten, Zigarettenkonsum und körperlichem Training durch entsprechende Aufklärung ließe sich ein erheblicher Teil an zerebralen Ereignissen vermeiden. Ein weiterer in Deutschland noch zu wenig beachteter Faktor ist die konsequente Blutdruckeinstellung. Breitgestreute Aufklärung könnte außerdem potenziellen Patienten helfen, bereits auftretende Warnsymptome wie die transiente ischämische Attacke richtig einzuschätzen, um eine rechtzeitige Behandlung zu ermöglichen.