吻合器痔上粘膜环切术的护理配合

为探讨吻合器痔上黏膜环切术（Procedure for Prolapse and Hemorrhoids,PPH）的护理配合经验,文章对医院2009年4月至2011年7月间施行的86例PPH术的护理配合进行分析和总结,包括术前对患者的心理护理和手术物品准备,术中巡回护士和器械护士应做的护理配合等,认为术前对患者充分的沟通交流,术中正确的体位摆放、严密的病情观察、及时准确的操作配合,是手术安全、顺利进行,避免并发症发生的重要保证。     

ICD-10 anaphylaxis algorithm and the estimate of vaccine-attributable anaphylaxis incidence in Medicare

BackgroundAnaphylaxis is a rare, serious allergic reaction. Its identification in large healthcare databases can help better characterize this risk.ObjectiveTo create an ICD-10 anaphylaxis algorithm, estimate its positive predictive values (PPVs) in a post-vaccination risk window, and estimate vaccination-attributable anaphylaxis rates in the Medicare Fee For Service (FFS) population.MethodsAn anaphylaxis algorithm with core and extended portions was constructed analyzing ICD-10 anaphylaxis claims data in Medicare FFS from 2015 to 2017. Cases of post-vaccination anaphylaxis among Medicare FFS beneficiaries were then identified from October 1, 2015 to February 28, 2019 utilizing vaccine relevant anaphylaxis ICD-10 codes. Information from medical records was used to determine true anaphylaxis cases based on the Brighton Collaboration’s anaphylaxis case definition. PPVs were estimated for incident anaphylaxis and the subset of vaccine-attributable anaphylaxis within a 2-day post-vaccination risk window. Vaccine-attributable anaphylaxis rates in Medicare FFS were also estimated.ResultsThe study recorded 66,572,128 vaccinations among 21,685,119 unique Medicare FFS beneficiaries. The algorithm identified a total of 190 suspected anaphylaxis cases within the 2-day post-vaccination window; of these 117 (62%) satisfied the core algorithm, and 73 (38%) additional cases satisfied the extended algorithm. The core algorithm’s PPV was 66% (95% CI [56%, 76%]) for identifying incident anaphylaxis and 44% (95% CI [34%, 56%]) for vaccine-attributable anaphylaxis. The vaccine-attributable anaphylaxis incidence rate after any vaccination was 0.88 per million doses (95% CI [0.67, 1.16]).ConclusionThe ICD-10 claims algorithm for anaphylaxis allows the assessment of anaphylaxis risk in real-world data. The algorithm revealed vaccine-attributable anaphylaxis is rare among vaccinated Medicare FFS beneficiaries.     

Technical skills and training of upper gastrointestinal endoscopy for new beginners

The incidence of gastric cancer remains high in SouthKorea.Upper gastrointestinal(GI) endoscopy,i.e.,esophagogastroduodenoscopy(EGD),has a higher diagnostic specificity and sensitivity than the upper GI series.Additionally,EGD has the ability to biopsy,through taking a tissue of the pathologic lesion.Successful training of EGD procedural skills require a few important things to be learned and remembered,including the posture of an examinee(e.g.,left lateral decubitus and supine) and examiner(e.g.,one-man standing method vs one-man sitting method),basic skills(e.g.,tip deflection,push forward and pull back,and air suction and infusion),advanced skills(e.g.,paradoxical movement,J-turn,and U-turn),and intubation techniques along the upper GI tract(e.g.,oral cavity,pharynx,larynx including vocal cord,upper and middle and lower esophagus,gastroesophageal junction,gastric fundus,body,and antrum,duodenal bulb,and descending part of duodenum).In the current review,despite several limitations,we explained the intubation method of EGD for beginners.We hope this will be helpful to beginners who wish to learn the procedure.     

The impact of long-term corticosteroid use on acute postoperative complications following lumbar decompression surgery

BackgroundCorticosteroids have a negative impact on the human immune system’s ability to function at an optimal level. Studies have shown that patients on long-term corticosteroids have higher infection rates. However, the rates of infection and other complications following lumbar decompression surgery remains under-investigated. The aim of our study was to determine the impact of preoperative long-term corticosteroid usage on acute, 30-day postoperative complications in a subset of patients undergoing lumbar spine decompression surgery, without fusion or instrumentation. We hypothesize that patients on long-term corticosteroids will have higher rates of infection and other postoperative complications after undergoing lumbar decompression surgery of the spine.MethodsA retrospective cohort study was conducted using data collected from the National Surgical Quality Improvement Program database data from 2005 to 2016. Lumbar decompression surgeries, including discectomies, laminectomies, and others were identified using CPT codes. Chi-square analysis was used to evaluate differences among the corticosteroid and non-corticosteroid groups for demographics, preoperative comorbidities, and postoperative complications. Logistic regression analysis was done to determine if long-term corticosteroid use predicts incidence of postoperative infections following adjustment.Results26,734 subjects met inclusion criteria. A total of 1044 patients (3.9%) were on long-term corticosteroids prior to surgical intervention, and 25,690 patients (96.1%) were not on long-term corticosteroids. Patients on long-term corticosteroids were more likely to be older (p < 0.001), female (p < 0.001), nonsmokers (p < 0.001), and have a higher American Society of Anesthesiologist class (p < 0.001). Multivariate analysis demonstrated that long-term corticosteroid usage was associated with increased overall complications (odds ratio [OR]: 1.543; p < 0.001), and an independent risk factor for the development of minor complications (OR: 1.808; p < 0.001), urinary tract infection (OR: 2.033; p = 0.002), extended length of stay (OR: 1.244; p = 0.039), thromboembolic complications (OR: 1.919; p = 0.023), and sepsis complications (OR: 2.032; p = 0.024).ConclusionLong-term corticosteroid usage is associated with a significant increased risk of acute postoperative complication development, including urinary tract infection, sepsis and septic shock, thromboembolic complications, and extended length of hospital stay, but not with superficial or deep infection in patients undergoing lumbar decompression procedures. Spine surgeons should remain vigilant regarding postoperative complications in patients on long-term corticosteroids, especially as it relates to UTI and propensity to decompensate into sepsis or septic shock. Thromboembolic risk attenuation is also imperative in this patient group during the postoperative period and the surgeon should weigh the risks and benefits of more intensive anticoagulation measures.     

选择性痔上黏膜切除术与吻合器痔上黏膜环切术治疗Ⅲ度和Ⅳ度痔的疗效比较

目的 分析比较选择性痔上黏膜切除术与吻合器痔上黏膜环切术在Ⅲ、Ⅳ痔疮患者中的治疗效果.方法 收集2013年1月-2014年6月于上海交通大学医学院附属第九人民医院和上海交通大学医学院附属新华医院(崇明分院)普外科行选择性痔上黏膜切除术和吻合器痔上黏膜环切术手术的Ⅲ、Ⅳ痔疮患者,运用t检验比较两组患者在手术时间、术中出血、术后住院时间、恢复日常工作时间等围手术期相关变量的差异,术后的疼痛程度和出血、尿潴留、急便感、大便失禁、肛门狭窄及直肠阴道瘘的发病率和复发率则通过t检验或,检验进行比较,运用秩和检验比较两组患者满意度差异.结果 吻合器痔上黏膜环切术组手术时间、术中出血量评分、术后住院时间及恢复日常工作时间均显著高于选择性痔上黏膜切除术组(P=0.021,P=0.003,P=0.001,P＜0.001);吻合器痔上黏膜环切术组在术后第一次排便和术后24 h、72 h的疼痛评分均显著高于选择性痔上黏膜切除术组(均P ＜0.001);吻合器痔上黏膜环切术组术后1个月内存在急便感的患者比例(18.6％)明显高于选择性痔上黏膜切除术组(6.6％)(P=0.036);两组患者术后出血、尿潴留的发病率及复发率、患者满意度评价等方面差异无统计学意义(P＞0.05).结论 选择性痔上黏膜切除术在手术时间、术中出血量、术后疼痛及术后急便感的发病率等方面明显优于吻合器痔上黏膜环切术手术,且其长期疗效可达到与吻合器痔上黏膜环切术相当的水平.     

结直肠肿瘤内镜黏膜下剥离术(ESD)手术时间的影响因素分析

目的 分析ESD治疗结直肠肿瘤的手术时间的影响因素.方法 回顾性分析210例结直肠癌肿瘤患者ESD治疗的临床资料.将手术时间分为≥60 min和＜60 main两部分,采用逻辑回归分析对包括肿瘤部位、类型、病理诊断、非抬举征、术中严重出血等5个变量进行分析.结果 210例结直肠ESD平均手术时间(50.3-42.8) min,病灶平均大小(31.9 ±44.9)cm2,整块切除率为91.4％,R0切除率为90.5％,治愈性切除率为88.6％.穿孔发生率为5.2％(11/210),迟发性出血率为0.5％(1/210).多因素回归分析提示,肿瘤直径≥40 mm或跨结肠袋(OR 3.466;95％CI:1.594～7.538)、病变位于弯曲部(OR 2.270;95％ CI:0.175～9.227)是影响结直肠ESD手术时间的独立危险因素(时间≥60min).结论 结直肠肿瘤直径≥40mm或跨结肠袋,病变位于弯曲部可明显延长ESD手术时间,使手术难度增加.     

Formalizing the Austrian Procedure Catalogue: A 4-step methodological analysis approach

ObjectivesDue to the lack of an internationally accepted and adopted standard for coding health interventions, Austria has established its own country-specific procedure classification system – the Austrian Procedure Catalogue (APC). Even though the APC is an elaborate coding standard for medical procedures, it has shortcomings that limit its usability. In order to enhance usability and usefulness, especially for research purposes and e-health applications, we developed an ontologized version of the APC. In this paper we present a novel four-step approach for the ontology engineering process, which enables accurate extraction of relevant concepts for medical ontologies from written text.MethodsThe proposed approach for formalizing the APC consists of the following four steps: (1) comparative pre-analysis, (2) definition analysis, (3) typological analysis, and (4) ontology implementation. The first step contained a comparison of the APC to other well-established or elaborate health intervention coding systems in order to identify strengths and weaknesses of the APC. In the second step, a list of definitions of medical terminology used in the APC was obtained. This list of definitions was used as input for Step 3, in which we identified the most important concepts to describe medical procedures using the qualitative typological analysis approach. The definition analysis as well as the typological analysis are well-known and effective methods used in social sciences, but not commonly employed in the computer science or ontology engineering domain. Finally, this list of concepts was used in Step 4 to formalize the APC.ResultsThe pre-analysis highlighted the major shortcomings of the APC, such as the lack of formal definition, leading to implicitly available, but not directly accessible information (hidden data), or the poor procedural type classification. After performing the definition and subsequent typological analyses, we were able to identify the following main characteristics of health interventions: (1) Procedural type, (2) Anatomical site, (3) Medical device, (4) Pathology, (5) Access, (6) Body system, (7) Population, (8) Aim, (9) Discipline, (10) Technique, and (11) Body Function. These main characteristics were taken as input of classes for the formalization of the APC. We were also able to identify relevant relations between classes.ConclusionsThe proposed four-step approach for formalizing the APC provides a novel, systematically developed, strong framework to semantically enrich procedure classifications. Although this methodology was designed to address the particularities of the APC, the included methods are based on generic analysis tasks, and therefore can be re-used to provide a systematic representation of other procedure catalogs or classification systems and hence contribute towards a universal alignment of such representations, if desired.     

宫颈环形电切术阻断宫颈癌的临床研究

[目的]探讨使用高频电波刀作宫颈环形电切术切除宫颈癌前病变组织对阻断官颈癌发生的作用。[方法]选择本院阴道镜下活检病理诊断为CIN的病例351例,行电波刀宫颈环形切除术,术后2个月及1年行阴道镜复查并作细胞学追踪。[结果]术后2个月阴道镜检查图像正常的有332例,占94．6％,另19例为颈口柱状上皮团、新上皮见少部分白色上皮或官颈表面出现红色斑,再行活检均为炎症或正常宫颈组织;细胞涂片阴性314例(89．5％),细胞核肥大或轻度核异质37例(10．5％)予局部处理或上药。1年后复查288例阴道镜下均无CIN图像,细胞学正常的277例(96．2％),细胞核肥大8例(2．8％),不典型鳞状上皮3例(1．0％)。[结论]只要对宫颈癌前病变切除的范围够大、够深、够彻底,就不会出现CIN的残留和复发。LEEP是阻断宫颈癌发生的有效手段。     

Feasibility of Surgical Treatment for Laryngomalacia Using the Spontaneous Respiration Technique

Objectives.In this study, we review our institutional experience with pediatric laryngomalacia (LM) and report our experiences of patients undergoing supraglottoplasty using the spontaneous respiration using intravenous anesthesia and high-flow nasal oxygen (STRIVE Hi) technique.Methods.The medical records of 29 children with LM who visited Seoul National University Hospital between January 2017 and March 2019 were retrospectively reviewed. Surgical management was performed using the STRIVE Hi technique. Intraoperative findings and postoperative surgical outcomes, including complications and changes in symptoms and weight, were analyzed.Results.Of the total study population of 29 subjects, 20 (68.9%) were female. The patients were divided according to the Onley classification as follows: type I (n=13, 44.8%), II (n=10, 34.5%), and III (n=6, 20.7%). Twenty-five patients (86.2%) had comorbidities. Seventeen patients (58.6%) underwent microlaryngobronchoscopy under STRIVE Hi anesthesia. Four patients with several desaturation events required rescue oxygenation by intermittent intubation and mask bagging during the STRIVE Hi technique. However, the procedure was completed in all patients without any severe adverse effects. Overall, 15 children (51.7%) underwent supraglottoplasty, of whom 14 (93.3%) showed symptom improvement, and their postoperative weight percentile significantly increased (P=0.026). One patient required tracheostomy immediately after supraglottoplasty due to associated neurological disease.Conclusion.The STRIVE Hi technique is feasible for supraglottoplasty in LM patients, while type III LM patients with micrognathia or glossoptosis may have a higher risk of requiring rescue oxygenation during the STRIVE Hi technique.