小儿肝脏局灶性结节样增生一例

肝脏局灶性结节样增生(focal nodular hyperplasia,FNH)是一种少见的肝细胞源性良性肿瘤,文献报道多见于中青年,罕有小儿FNH报道.近来四川省人民医院收治一例小儿FNH病人,在治疗过程中笔者有一些体会,现报告如下.     

12例肝脏局灶陛结节增生的治疗体会

目的 探讨肝脏局灶性结节增生(focal nodular hyperplasia,FNH)的诊断和治疗方法.方法 总结回顾我院2006年3月至2009年5月间收治的12例FNH患者临床资料,进行统计分析.结果 12例患者均行B超定位下穿刺活检明确,3例FNH患者肿瘤大于5 cm,且有肝区疼痛,故行手术治疗;另外9例给予临床随访.所有患者随访1年以上,手术患者未见复发,未手术者结节无明显增大.结论 常规的实验室和影像学检查对FNH的诊断率不高,肝穿刺活检可明确病变性质,有助于肿瘤治疗措施和手术方式的选择.     

12例肝脏局灶陛结节增生的治疗体会

目的 探讨肝脏局灶性结节增生(focal nodular hyperplasia,FNH)的诊断和治疗方法.方法 总结回顾我院2006年3月至2009年5月间收治的12例FNH患者临床资料,进行统计分析.结果 12例患者均行B超定位下穿刺活检明确,3例FNH患者肿瘤大于5 cm,且有肝区疼痛,故行手术治疗;另外9例给予临床随访.所有患者随访1年以上,手术患者未见复发,未手术者结节无明显增大.结论 常规的实验室和影像学检查对FNH的诊断率不高,肝穿刺活检可明确病变性质,有助于肿瘤治疗措施和手术方式的选择.     

肝脏局灶性结节性增生的临床病理分析

目的 探讨肝脏局灶性结节性增生( FNH)的临床病理学特征.方法 回顾性分析我院2002年6月至2010年6月收集的8例FNH的临床资料和病理学检查结果.结果 8例FNH病例病灶均呈孤立结节或分叶状肿块,均无明显包膜,中央有纤维瘢痕;其中可见厚壁血管及增生的小胆管.结论 FNH确诊主要依靠术后病理检查,手术切除是主要的治疗方法.     

四例不典型肝局灶性结节增生的影像学特点

目的 分析不典型肝局灶性结节增生（focal nodular hyperplasia, FNH）的影像学特点,提高对不典型FNH的确诊率。方法 通过回顾4例影像学表现不典型且经病理学证实为FNH的病例,分析不典型FNH的影像学表现及其组织病理学基础。结果 病例1为FNH合并腺瘤的混合型,MRI可见强化包膜;病例2超声显示中强回声,CT静脉期可见病灶周边有静脉血管包绕;病例3 CT静脉期呈等密度,周围静脉血管包绕;病例4超声显示内部血流不丰富,静脉期病灶结节样强化。其中病例1、3、4均无纤维瘢痕。结论 FNH可因组织病理学特点的多样性而出现影像学上的不典型性,需要结合多种检查方法综合分析,提高对不典型FNH的诊断率。     

肝脏局灶性结节样增生的诊断及治疗：附病例报告并文献综述

目的:探讨肝脏局灶性结节样增生(FNH)的临床特点、病理特征、影像学表现及鉴别诊断,以期对其进行准确诊断和合理治疗.方法:笔者回顾性总结近期收治的1例,结合患者临床资料进行文献综述.结果:随访8个月,患者恢复良好,复查肿瘤标志物、腹部CT未见异常.结论:FNH是一种少见的良性肿瘤性疾病,多数无特异性临床表现,CT和MRI增强扫描能提高对FNH的诊断率.对有症状者或与恶性病变难以鉴别者应积极行手术治疗.     

核素显像诊断肝局灶性结节增生1例

肝局灶性结节增生(focal nodular hyperplasia,FNH)是一种少见的肝脏良性占位性病变,多见于30～60岁女性.绝大多数患者无明显临床症状,多于腹部B超等查体时偶然发现.FNH极少发生恶变,一般无需外科手术治疗,而多主张随访观察[1,2,3].因此,准确的临床诊断尤为重要.本文报道1例FNH的影像学诊断过程,并对各种影像技术诊断FNH的价值进行分析和探讨.     

肝脏局灶性结节增生一例

正肝脏局灶性结节增生(focal nodular hyperplasia,FNH)是一种良性肿瘤,约占肝原发肿瘤的8%,发病率仅次于肝血管瘤[1]。FNH的确切病因仍不清楚,常被认为是肝细胞对局部血管异常产生的一种反应性增生性改变,临床上大多数无特异性症状,部分患者可出现腹痛、右上腹包块,甚至破裂出血等。由于目前对FNH缺乏足够的认识,常常被误诊为原发性肝癌、肝血管瘤,最终导致不恰当的外科治疗,增加患者心理及身体负担。通过本病例报道,结合     

超声造影在肝脏局灶性结节样增生诊断中的应用

目的探讨肝脏局灶性结节样增生(FNH)的超声造影表现,旨在提高超声造影对FNH诊断的认识。方法收集2007年5月至2009年2月期间在四川大学华西医院行超声造影检查并经病理检查证实的FNH患者12例,并复习有关文献。结果超声造影动脉期全部病灶均迅速强化,9/12例病灶动脉期可探及"轮辐状"增强,实质期有11/12例病灶呈稍高或等增强,1/12例病灶呈稍低增强。结论超声造影能动态显示FNH的血流灌注,特别是动脉期的"轮辐状"血流对FNH的诊断具有重要价值。     

�ξ����Խ����������������������

目的　探讨肝局灶性结节性增生 (FNH )的临床诊断与外科治疗指征。方法　回顾性分析 1995～1999年以来收治的 17例FNH并复习文献进行分析。结果　术前超声、CT检查均未确诊本病 ,2例经超声引导下穿刺活检而获得明确病理诊断。 15例行手术切除 ,术后恢复良好 ,无手术并发症。结论　FNH的发生可能与肝先天性血管畸形形成血流高灌注有关。FNH临床鉴别诊断极其困难 ,超声引导下穿刺活检可获明确病理诊断。无症状的FNH无须手术治疗 ,但当结节直径 >5cm ,病人有症状时 ,或结节位于中肝 ,压迫门静脉、下腔静脉时 ,或性质未明 ,不能排除肝细胞癌 (HCC)和肝腺瘤时应积极手术切除     

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.