The surgical learning curve for artificial urinary sphincter procedures compared to typical surgeon experience

Background

The artificial urinary sphincter (AUS) is a well-established treatment for male stress urinary incontinence.

Objective

We aimed to characterize the surgical learning curve for reoperation rates after AUS implantation.

Design, setting, and participants

The study cohort consisted of 65 602 adult males who received an AUS between 1988 and 2008, constituting close to 90% of all operations conducted during that time. Data on reoperations were obtained from the manufacturer, which requires documentation for warranty coverage.

Measurements

Surgeon experience was calculated as the number of original AUS implants performed prior to the index patient's surgery. Multivariable logistic regression models were used to examine the association between experience and reoperative rates, adjusted for case mix.

Results and limitations

There was a slow but steady decrease in reoperative rates with increasing surgeon experience (p = 0.020), showing no plateau through 200 procedures. The risk of reoperation for a surgeon with five prior cases was 24.0%, which decreased to 18.1% for a surgeon with 100 prior implants (absolute risk difference [ARD]: 5.9%; 95% confidence interval [CI], 1.3–10.1%) and to 13.2% for a surgeon with 200 prior implants (ARD: 10.7%; 95% CI, 2.6–16.6%). Two-thirds of contemporary patients (having AUS procedure between years 2000 and 2008) saw a surgeon who had done ≤25 prior AUS implants; only 9% saw a surgeon with ≥100 prior procedures.

Conclusions

The learning curve for AUS surgery appears to be very long and without an obvious plateau. This is in contrast to typical surgeon experience, suggesting a considerable burden of avoidable reoperations. Efforts to flatten the learning are urgently needed.     

瓣叶切除与人工腱索治疗单纯二尖瓣后叶脱垂的病例对照研究

目的 比较单纯二尖瓣后叶脱垂应用瓣叶切除或人工腱索技术行二尖瓣成形术的手术效果。 方法 2010年12月至2013年12月, 384例患者病因单纯二尖瓣后叶脱垂导致的二尖瓣反流于我科行二尖瓣成形术,其中单纯人工腱索者33例（8.6%）、单纯瓣叶切除者258例（67.2%）。应用倾向评分匹配进行配对,分为人工腱索组（n=32）与瓣叶切除组（n=32）,并进行比较。回顾性分析两组围手术期情况及术后随访结果。结果 倾向评分匹配后人工腱索组和瓣叶切除组的各项术前指标无统计学差异。两组均顺利完成手术,无围手术期死亡。两组体外循环时间、主动脉阻断时间均有统计学差异（P=0.009、0.013）。人工腱索组使用较大二尖瓣成形环更多（P=0.019）。两组出院前左室射血分数（LVEF）、舒张期二尖瓣跨瓣峰值压差（TMG）均无统计学差异。平均随访（31.8±11.9）个月,两组患者生存、再次手术、≥中度二尖瓣反流、舒张期二尖瓣跨瓣峰值压差、再次手术均无统计学差异,但人工腱索组LVEF为（66.0±4.1）%,瓣叶切除组LVEF为（61.5±5.9）%,两组间有统计学差异（P=0.007）。 结论 人工腱索技术和瓣叶切除技术都可以有效地修复二尖瓣后叶脱垂。人工腱索技术与瓣叶切除技术相比更有利于术后左室功能,但两种技术在术后生存及二尖瓣反流情况上并无差异。     

Automatic point correspondence using an artificial immune system optimization technique for medical image registration

In this paper, an automatic method for determining pairs of corresponding points between medical images is proposed. The method is based on the implementation of an artificial immune system (AIS). AIS is a relatively novel, population based category of algorithms, inspired by theoretical immunologic models. When used as function optimizers, AIS have the attractive property of locating the global optimum of a function as well as a large number of strong local optimum points. In this work, AIS has been applied both for the extraction of an optimal set of candidate points on the reference image and the definition of their corresponding ones on the second image. The performance of the proposed AIS algorithm is evaluated against the widely used Iterative Closest Point (ICP) algorithm in terms of the accuracy of the obtained correspondences and in terms of the accuracy of the point-based registration by the two correspondence algorithms and the Mutual Information criterion, as an intensity-based registration method. Qualitative and quantitative results involving 92 X-ray dental and 10 retinal image pairs subject to known and unknown transformations are presented. The results indicate a superior performance of the proposed AIS algorithm with respect to the ICP algorithm and the Mutual Information, in terms of both correct correspondence and registration accuracy.     

吸痰对人工气道套囊内压力的影响

目的 通过观察吸痰时及吸疾后30min人工气道套囊压力的变化,探讨吸痰对人工气道套囊压力的影响.方法 吸痰前用测压表调整人工气道套囊压力为30CMH2O,持续监测吸痰时的套囊最高压力、患者有无咳嗽,以及吸痰后5min、10min、15min、30min的压力,并记录吸痰后套囊压力降至25cmH2O时所需时间.结果 在吸痰过程中81.25%(78/96)患者发生咳嗽.本组套囊内压力平均明显升高至(89.42±31.37)cmH20,咳嗽者套囊内平均压力为(96.00±25.99)cmH2O,高于无咳嗽者套囊内平均压力(60.89±37.14)cmH2O,差异有统计学意义(P<0.01).吸痰时套囊内压力升高者较保持者更易下降至正常低限(25cmH2O),差异有统计学意义(P<0.01).结论 患者吸痰过程中容易发生咳嗽,人工气道套囊内压力波动明显,建议临床上在吸痰后30min内调整套囊内压力,必要时应立即调整,避免囊内压力过低或过高对患者的伤害.     

维生素A棕榈酸酯凝胶治疗白内障超声乳化人工晶状体植入术后干眼疗效观察

目的 探讨人工泪液联合维生素A棕榈酸酯凝胶治疗白内障超声乳化人工晶状体植入术术后干眼的临床疗效.方法 对2009年1月至2011年12月在河北省廊坊市香河县人民医院就诊并诊断为白内障超声乳化人工晶状体植入术后干眼症的患者68例(68只眼),随机分为治疗组和对照组.治疗组采用人工泪液和维生素A棕榈酸酯凝胶滴眼,对照组单用人工泪液.两组在治疗前、治疗后2周和治疗后4周采用裂隙灯下观察泪膜破裂时间(BUT),泪液分泌试验(SIt),角膜荧光素染色(FL)的情况评价治疗效果.结果 共计入组患者68例(68只眼),治疗组和对照组各34例(34只眼).所有患者均按计划完成相应治疗和检查.治疗组和对照组BUT、SIT、FL三项检查的初始评分均无明显差别,在治疗组接受人工泪液联合维生素A棕榈酸酯凝胶治疗白内障超声乳化人工晶状体植入术治疗后,2周、4周的三项检查的评分均好于对照组,差异显著有统计学意义(P ＜0.0001).结论 人工泪液联合维生素A棕榈酸酯凝胶滴眼治疗白内障超声乳化人工晶状体植入术术后干眼疗效优于单用人工泪液,效果显著.     

A novel plasma filtration therapy for hepatic failure: preclinical studies

There is a need to develop artificial means of liver replacement and/or assistance with the aim of either supporting patients with borderline functional liver cell mass until their liver regenerates, or until a donor liver becomes available for transplantation. Selective plasma filtration is a novel approach to blood purification therapy designed to reduce the level of circulating toxins of hepatic and renal failure, mediators of inflammation and inhibitors of hepatic regeneration. The results of preclinical studies indicate that treatment of pigs with experimentally-induced fulminant hepatic failure is safe and effective in extending survival time and arresting brain swelling. In addition, the amount of ammonia, aromatic amino acids, IL6, TNFalpha and C3a removed during the 6-h treatment in the present study was higher by 34% to 175% than the total plasma content of those substances at the start of therapy.     

Sorbent suspensions vs. sorbent columns for extracorporeal detoxification in hepatic failure

Hepatic failure is a significant medical problem which has been unsuccessfully treated by hemodialysis. However, similar therapies using recirculated dialysate regenerated by sorbents in place of single-pass dialysate have been beneficial in treating acute-on-chronic liver failure. The advantages of sorbent-based treatments include some selectivity of toxin removal and improved removal of protein-bound toxins. Activated carbon has been extensively used in detoxification systems, but has often had insufficient toxin capacity. Powdered activated carbon, because of its large surface area, can provide greater binding capacity for bilirubin and other toxins than granular carbon commonly used in detoxifying columns. Methods of using powdered carbon in extracorporeal blood treatment devices are reviewed in the present paper, including liver dialysis and a new sorbent suspension reactor (SSR); and the abilities and limitations of the SSR and columns to process protein solutions are discussed.     

聚酸酐-氨基葡聚糖作为干细胞载体的研究

研究聚酸酐-氨基葡聚糖三维载体材料对胎儿肝干细胞黏附及增殖的影响,寻找胎儿肝干细胞新的载体材料。采用改进的两步胶原酶灌注消化法加Percoll液不连续密度梯度离心的方法,分离胎儿肝干细胞。选取胎儿肝干细胞的传代细胞,种植于聚酸酐-氨基葡聚糖三维载体材料上。倒置显微镜下观察细胞的黏附和生长状况;计算细胞贴壁率;MTT法检测各组细胞的吸光度值(OD值);收集载体支架上细胞并计数。取细胞载体进行组织学切片,HE染色光镜下观察。在细胞培养第7 d进行免疫荧光化学染色和流式细胞仪检测。结果表明,聚酸酐-氨基葡聚糖三维载体能促进肝干细胞在材料内黏附并保持其在机体内的形态;载体材料内的肝干细胞功能活跃;在材料表面和三维空间内部培养的肝干细胞均能持续增殖;经过连续40 d共同培养聚酸酐-氨基葡聚糖三维载体对干细胞无毒性,人胎儿肝干细胞可以很好的贴附于聚酸酐-氨基葡聚糖三维载体支架上,细胞增殖活力良好,标志物持续表达,培养7 d得到的细胞数量增多19.7%。聚酸酐-氨基葡聚糖三维载体能促进肝干细胞的增殖,可作为肝干细胞的载体应用于肝脏组织工程。     

青春期功能失调性子宫出血的调经治疗研究

目的:探讨人工周期调经对青春期功能失调性子宫出血(青春期功血)的临床效果及其安全性。方法:回顾性分析85例患者,经人工周期调经(50例,观察组)和口服复合避孕药调经(35例,对照组)6个周期治疗后,两组撤药性岀血时间及不良反应,以及治疗结束后第3月末和第6月末临床总有效率。结果:治疗期间两组撤药性岀血时间及不良反应发生率差异无统计学意义(P0.05),治疗结束后第3月末和第6月末复查临床总有效率,观察组明显高于对照组(P0.05)。结论:在调理青春期功血中人工周期调经效果较复合避孕药效果好。     

Cardiac resynchronization therapy for left ventricular dysfunction induced by chronic right ventricular pacing in a child

Cardiac resynchronization therapy (CRT) has been proven its value in adult patients with congestive heart failure of low ejection fraction and wide QRS duration. Contrast to adult patients, CRT has been rarely applied for young patients. We report on a 9-yr-old boy with progressive left ventricular (LV) dilatation and dysfunction following chronic VVI pacemaker therapy for congenital complete atrioventricular block associated with maternal anti-SSA/Ro and SSB/La antibody. His LV dysfunction was improved after epicardially established CRT.