The ultrasound‐assisted paraspinous approach to lumbar neuraxial blockade: a simplified technique in patients with difficult anatomy

Pre‐procedural ultrasound imaging of the spine to identify the interspinous and interlaminar space has been shown to facilitate subsequent performance of lumbar neuraxial blockade. However, adequate visualization of the vertebral canal can be challenging for less‐experienced operators, and particularly in subjects with difficult anatomy. In this case report, we describe a simplified technique of ultrasound‐assisted neuraxial blockade that addresses these limitations and may thus be a useful fallback option. A pre‐procedural scan is performed in which the main ultrasonographic landmarks to be identified are the neuraxial midline and the spinous processes, rather than the posterior and anterior complexes of the vertebral canal. Another key difference is the use of a paraspinous (or paramedian) needle approach rather than a midline approach that is advantageous where the interspinous spaces are narrowed by disease or suboptimal patient positioning. The anatomical basis and technical performance of this novel ultrasound‐assisted paraspinous approach are presented in detail.     

Bronchoscopy and Tuberculostearic Acid Assay in the Diagnosis of Sputum Smear-negative Pulmonary Tuberculosis: A Prospective Study with the Addition of Transbronchial Biopsy

A prospective study of the efficacy of bronchoscopy and tuberculostearicacid assay in the diagnosis of sputum smear-negative pulmonarytuberculosis (TB) was carried out in 39 patients with symptomsand radiographic changes suggestive of active pulmonary TB.The diagnosis of TB was confirmed in 15 patients, probable TBwas diagnosed in eight and 16 patients did not have TB. An earlydiagnosis of TB was made by bronchoscopy in six patients (40per cent). Culture of sputum obtained before bronchoscopy waspositive in nine patients (60 per cent) while combined withbronchoscopy specimens, a positive mycobacterial culture wasobtained in 12 patients (80 per cent). Mycobacteria were culturedfrom transbronchial biopsy specimens from five patients (33per cent) but none of these was exclusively positive. Histologicalexamination of transbronchial biopsy tissue was diagnostic ofTB in four patients and it was the exclusive means of earlydiagnosis in two. Transbronchial biopsy also provided an alternativediagnosis in four other patients. Tuberculostearic acid assayhad a sensitivity of 0.40 in bronchial aspirate, 0.80 in bronchoalveolarlavage fluid, and 0.27 in transbronchial biopsy specimens: thecombined result was 0.87. In nine patients with pulmonary TBin whom an early diagnosis could not be made, the tuberculostearicacid assay was positive in seven (78 per cent). We concludethat bronchoscopy with bronchoalveolar lavage and transbronchialbiopsy is helpful in providing early diagnosis and positiveculture results. Assay of tuberculostearic acid in bronchoalveolarlavage fluid is a useful adjunct to early diagnosis. However,mycobacterial culture and assay of tuberculostearic acid intransbronchial biopsy specimens have little diagnostic value.     

MDS clinical diagnostic criteria for Parkinson's disease

This document presents the Movement Disorder Society Clinical Diagnostic Criteria for Parkinson's disease (PD). The Movement Disorder Society PD Criteria are intended for use in clinical research but also may be used to guide clinical diagnosis. The benchmark for these criteria is expert clinical diagnosis; the criteria aim to systematize the diagnostic process, to make it reproducible across centers and applicable by clinicians with less expertise in PD diagnosis. Although motor abnormalities remain central, increasing recognition has been given to nonmotor manifestations; these are incorporated into both the current criteria and particularly into separate criteria for prodromal PD. Similar to previous criteria, the Movement Disorder Society PD Criteria retain motor parkinsonism as the core feature of the disease, defined as bradykinesia plus rest tremor or rigidity. Explicit instructions for defining these cardinal features are included. After documentation of parkinsonism, determination of PD as the cause of parkinsonism relies on three categories of diagnostic features: absolute exclusion criteria (which rule out PD), red flags (which must be counterbalanced by additional supportive criteria to allow diagnosis of PD), and supportive criteria (positive features that increase confidence of the PD diagnosis). Two levels of certainty are delineated: clinically established PD (maximizing specificity at the expense of reduced sensitivity) and probable PD (which balances sensitivity and specificity). The Movement Disorder Society criteria retain elements proven valuable in previous criteria and omit aspects that are no longer justified, thereby encapsulating diagnosis according to current knowledge. As understanding of PD expands, the Movement Disorder Society criteria will need continuous revision to accommodate these advances. © 2015 International Parkinson and Movement Disorder Society     

EV71型手足口病合并脑炎患儿母亲照顾体验的质性研究

目的 :了解EV71型手足口病合并脑炎患儿母亲在照顾患儿期间内心深处的感受,为临床护理提供依据。方法 :采用质性研究中的现象学研究法,深度访谈并收集18名患儿母亲的资料。结果 :运用Co1aizzi法通过阅读、分析、反思、分类和提炼,得出3个主题:过重的心理负荷,沉重的经济负担,渴望疾病相关的知识。结论 :深入了解EV71型手足口病合并脑炎患儿母亲的真实照顾体验,有利于护理人员对其提供专业照护知识指导及心理疏导,促进其身心健康和患儿康复。     

澳大利亚的老年社区卫生服务

澳大利亚共有人口2100万,2006年,老年人口(≥65岁)占总人口的13.1%,预计2021年,将上升到占总人口的18.0%以上.在澳大利亚,社区医疗服务是老年关怀的重要组成部分,是医疗服务和家庭服务联系的纽带.社区医疗服务站有完整的医疗队伍,对患者提供全方位的医疗服务.     

Leukemic transformation of hematopoietic progenitors by MLL-GAS7 in the absence of Hoxa7 or Hoxa9

Differential expression of Hox genes is associated with normal hematopoiesis, whereas inappropriate maintenance of Hox gene expression, particularly Hoxa7 and Hoxa9, is a feature of leukemias harboring mixed-lineage leukemia (MLL) mutations. To understand the pathogenic roles of Hox genes in MLL leukemias, we assessed the impact of Hoxa7 or Hoxa9 nullizygosity on hematopoietic progenitor compartments and their susceptibility to MLL-induced leukemias. Selective reductions in the absolute numbers of committed progenitors, but not of hematopoietic stem cells, distinguished Hoxa7- and Hoxa9-deficient mice. Megakaryocytic/erythroid progenitor (MEP) reductions in Hoxa7(-/-) mice correlated with reticulocytosis and thrombocytopenia without anemia. Conversely, Hoxa9(-/-) mice displayed marked lymphopenia and substantial reductions of common lymphoid progenitors (CLPs) and lymphoid precursors, in addition to significant reductions of common myeloid progenitors (CMPs) and granulocyte/monocyte progenitors (GMPs). In retroviral transduction/transplantation assays, Hoxa7- and Hoxa9-deficient progenitors remained susceptible to transformation by MLL-GAS7, which activates MLL through a dimerization-dependent mechanism. However, Hoxa7(-/-) or Hoxa9(-/-) progenitors were less efficient in generating transformed blast colony-forming units (CFUs) in vitro and induced leukemias with longer disease latencies, reduced penetrance, and less mature phenotypes. Thus, Hoxa7 and Hoxa9 contribute to hematopoietic progenitor homeostasis but are not necessary for MLL-GAS7-mediated leukemogenesis, yet they appear to affect disease latency, penetrance, and phenotypes consistent with their critical roles as downstream targets of MLL fusion proteins.     

HYPOFIBRINOGENEMIA DUE TO INCREASED FIBRINOLYSIS IN TWO PATIENTS WITH ACUTE PROMYELOCYTIC LEUKEMIA

Two patients with acute promyelocytic leukemia and severe bleeding associated with hypofibrinogenemia were studied. The markedly shortened whole blood clot lysis time and dilute clot lysis time suggested that the defect was an increase in fibrinolysis. Although disseminated intravascular coagulation could not be totally excluded as an alternative mechanism, excessive fibrinolysis was confirmed as the pathogenic cause by the prompt response to the administration of tranexamic acid. The low circulating plasminogen, α₂ plasmin inhibitor level and the presence of α₂ plasmin inhibitor-protease complex in both patients suggested that the increased fibrinolysis probably resulted from the liberation of plasminogen activator from the promyelocyte.     

食管癌组织血管内皮生长因子的表达与血管生成的关系

目的 探讨血管内皮生长因子(VEGF)对食管癌血管生成的影响.方法 应用SP法对90例食管鳞癌组织和34例癌旁正常黏膜进行VEGF和CD34免疫组化染色,检测VEGF表达和微血管密度(MVD),分析VEGF的表达、MVD以及食管癌临床病理特征之间的关系.结果 食管癌组织中VEGF的阳性表达率和MVD分别为71.1%和29.70±3.82,显著高于癌旁正常黏膜的11,76%和15.10±2.38(P＜0.01).VEGF表达及MVD均值与淋巴结转移、肿瘤TNM分期有关(P＜0.05和P＜0.01),与患者年龄、性别、分化程度、以及肿瘤组织学类型、肿瘤部位均无关(P＞0.05);VEGF表达与MVD均值呈显著正相关(P＜0.01).结论 VEGF异常表达在食管癌的血管生成中起重要作用,VEGF及其诱导的血管生成与食管癌的侵袭和转移密切相关.