磁共振成像在膀胱肿瘤分期中的应用

１９９３年９月～１９９６年１月对５０例膀胱肿瘤患者术前做ＭＲＩ检查，判断肿瘤的临床分期，并与术后病理分期结果进行比较。ＭＲＩ分期的总符合率为８４％，本组３８例开放手术符合率为７９％。认为ＭＲＩ对判断膀胱肿瘤临床分期很有价值，优于ＣＴ。但对低期肿瘤（Ｔａ、Ｔ１和Ｔ２期）的判断会出现分期偏高和偏低的明显错误，对淋巴结轻度受累的检出也还有困难     

磁共振成像对膀胱肿瘤分期的评价

从１９９２年８月至１９９４年８月，采用ＭＲ、ＣＴ、经尿道腔内超志和经腹部超声对２７例膀胱肿瘤患者的３３个肿瘤进行了检查，并分别与术后病理分期结果进行比较。ＭＲ判断肿瘤分期的准确率为９２．５％，ＣＴ为７３．３％，经尿道腔内超声为８８．９％，经腹部超声为６０．０％。结果认为，经腹部超声可用于对膀胱肿瘤的筛选检查，判断肿瘤分期不可靠，经尿道腔内超声对限于膀胱壁以内的肿瘤分期是准确的，而ＣＴ对浸润到膀胱壁     

动脉输注LAK细胞治疗晚期膀胱癌和前列腺癌

１９９３年４月到１０月、采用髂内动脉结扎，动脉内输注ＬＡＫ细胞，辅以淋巴结局注射ＩＬ－２治疗晚期膀胱癌４例和前列腺癌１例，病理分期均为Ｄ１期。经治疗，有效率１００％，３例存活〉１５个月，２例仍存活。该疗法全身毒性反应小，是将ＬＡＫ细胞直接向负癌器官内输注的过继性免疫疗法。     

膀胱移行细胞癌临床病理指标与外周血CK-20基因表达的相关研究

目的 探讨外周血角蛋白20（CK－20）基因表达在膀胱移行细胞癌微转移情况及其临床意义。方法 以逆转录多聚酶链反应（RT－PCR）检测91例膀胱癌不同临床分期及病理分级CK－20mRNA外周血表达情况。结果 91例膀胱癌外周血CK－20基因表达阳性47例(51.6%），外周血肿瘤细胞微转移与膀胱癌患者的临床分期密切相关（P＜0.05），而与病理分级无明显相关（P＞0.05），随访中未发现淋巴结转移的T1－2期患者，术后8个月2例复发且均为CK－20RNA表达阳性。结论 RT－PCR方法检测CK－20mRNA在外周血表达是判断膀胱癌微转移的重要标志，对准确分期及治疗有重要意义。     

膀胱癌根治术中的盆腔淋巴结清扫

目的 总结膀胱癌根治术盆腔淋巴结清扫的疗效. 方法 膀胱癌患者95例.男76例,女19例.年龄25～78岁.初发49例、复发46例.病理分类:尿路上皮癌87例、腺癌5例、鳞状细胞癌3例.病理分级:G117例、G2 39例、G3 31例.病理分期:Ta～T1 10例、T2 54例,T3 26例、T45例.95例均行膀胱癌根治术及标准的双侧区域盆腔淋巴结清扫术,清扫范围包括双侧髂内、髂外以及闭孔淋巴结. 结果 95例清扫手术平均时间20 min,平均出血量25 ml,术中未发生重要血管及神经损伤.清扫淋巴结数目1～20枚,平均10枚,淋巴结阳性率为17.9%(17/95).术后发生近期并发症12例(12.6%),包括盆腔淋巴瘘、盆腔感染、阴囊或下肢水肿.术后随访3～64个月,中位时间34个月,死亡16例,3年存活率84.5%. 结论 膀胱癌根治术中行标准的双侧区域盆腔淋巴结清扫能提高分期准确性和患者生存率,无严重并发症,是一种安全、有效的操作.     

不同个体表浅性膀胱癌灌注化疗药物敏感性的研究

为研究不同个体表浅性膀胱癌组织对化疗药物的敏感性，自１９９５年９月～１９９６年４月使用肿瘤细胞原代培养技术和ＭＴＴ比色法测定了２４例膀胱癌组织对灌注化疗药物的敏感性。结果显示：不同个体对不同化疗药物的敏感性存在明显差异，如阿霉素对不同个体膀胱癌细胞的抑制率差别为０％～９５．１％，丝裂霉素的抑制率为０％～８５．７％，且化疗药物敏感性与膀胱癌病理分期、分级、复发性、多发性均无显著性差异（Ｐ＞０．０５）。表明表浅性膀胱癌对灌注化疗药物的敏感性有明显的个体差异，提示对不同个体应选择最敏感的化疗药物进行治疗，以实现治疗的个体化。     

抑癌基因P53及其蛋白产物表达与膀胱癌发生及病理关系

以光敏生物素－金标链亲和素核酸原位杂交及免疫组化方法检测膀胱癌病理标本中Ｐ５３基因片段及其蛋白表达。１３例原位杂交阳性膀胱癌中，Ｐ５３蛋白表达阳性率５３．９％，提示约半数膀胱癌的发生可能与Ｐ５３基因突变有关；Ｐ５３蛋白表达与病理分级、临床分期无明显关系。     

保留女性生殖器官的根治性膀胱切除55例临床分析

目的 评价保留女性生殖器官的根治性膀胱切除术的长期疗效. 方法 回顾性分析1990 - 2010年保留女性生殖器官的根治性膀胱切除并且有完整随访结果的病例55例,年龄25～82岁,平均63岁.随访时间12个月-19年,平均55个月.单发肿瘤49例,多发6例.初发肿瘤39例,复发16例.病理类型:尿路上皮癌49例,鳞状细胞癌3例,腺癌2例,膀胱癌肉瘤1例.病理分期:原位癌1例,pT118例,pT2 16例,pT314例,pT4 4例,标本中未见到癌2例(pT0).盆腔淋巴结阳性9例,侵犯淋巴血管7例.对可能影响生存率的8项临床病理指标(年龄、吸烟史、初发与复发、单发与多发、肿瘤分级、分期、盆腔淋巴结状态及淋巴血管侵犯)进行单因素及多因素生存分析.结果 55例患者3、5、10年总生存率(overall survival,OS)分别为61％、54％和42％;3、5、10年癌特异生存率( cancer specific survival,CSS)分别为65％、61％和61％.病理分期≤pT2N0M0者的5年CSS和OS分别为84％和72％,病理分期≥pT3N0M0者分别为29％和29％;淋巴结阳性患者的3年CSS和OS分别为28％和28％.单因素分析显示年龄≥65岁、肿瘤病理分期≥PT3、盆腔淋巴结阳性、肿瘤多发、肿瘤侵犯神经血管与CSS显著相关,COX回归分析显示仅肿瘤的病理分期(HR=3.992,P=0.011)及盆腔淋巴结状态(HR=3.877,P=0.019)与CSS显著相关. 结论 保留女性生殖器官的根治性膀胱切除术后CSS与膀胱癌的病理分期及淋巴结状态显著相关,是遴选适宜此术式患者的最关键参考指标.保留女性生殖器官的根治性膀胱切除是治疗器官局限性膀胱癌(≤pT2N0M0)安全可靠的手术方式,在最大程度保留女性功能及生活质最的同时可以取得理想的肿瘤治疗效果,但对病理分期≥pT3N0M0(不包括侵犯子宫或阴道的T4期患者)及盆腔淋巴结阳性病例,尚需更多的临床病例来验证其合理性.     

食管癌术前分期评价：食管腔内超声,计算机断层扫描？…

比较食管腔内超声计算机断层扫描和临床分期对食管癌术前分期的价值。方法３６例食管癌患者，术前均进行ＥＵ检查，其中８例因管腔严重狭窄末获得全面评估。２１例进行了ＣＴ分期。ＥＵ、ＣＴ和传统临床分期结果分别与手术病理分期比较。结果传统临床分期确率仅为３６％，ＣＴ对肿瘤浸润程度，局部淋巴结受累及ＰＩＮＭ分期的准确率分别为３８．１％、５７．１％和４７．６％，ＥＵ为７７．８％、７２．２％和７０．２％，去除严重狭     

CT对肾癌的诊断和分期

根据ＣＴ扫描图像诊断为肾癌患者１３７例，经病理证实ＣＴ诊断者１３１例，诊断准确率９５．６％。按照Ｒｏｂｓｏｎ分期标准，ＣＴ分期与病理对照准确率８３．２％。对肾癌的ＣＴ诊断及分期标准进行了探讨，并分析了肾癌ＣＴ分期的失误原因。     

Endogenous nitric oxide in the airways of different animal species

Background: High amounts of endogenous nitric oxide (NO) have been demonstrated in the human upper airway, but the role of nasal NO is still unclear. The present study aims to describe nasal NO excretion in different animal species with special living conditions or anatomy.
Methods: Domestic animals (horse, cow, pig, sheep, dog, cat) and zoo-animals (Rhesus monkey, chimpanzee, gorilla, elephant, fur seal, alpaca, yak, dolphin, camel, capybara, bear, tiger, wolf, giraffe, alligator, Harris' hawk, kangaroo) were studied awake, resting or anaesthetised. NO concentrations were measured by chemiluminescence using different analysers and techniques, including measurements on mixed exhaled air, during continuous or intermittent gas sampling, and on single breaths.
Results: Rhesus monkeys (number of individuals N=5) and pigs (N=2) were compared and displayed quite different excretion patterns. Allowing NO to accumulate in the nose during timed occlusions yielded peak concentrations in monkeys of 0.46-CO.07 parts per million (ppm, meanzSEM), 0.590.08 ppm, 0.700.08 ppm and 1.020.05 pprn NO after 15, 30, 60 and 120 s of occlusion. In pigs, 0.012–0.021 ppm NO were recorded, independent of occlusion time. The chimpanzee was similar to the Rhesus monkey and the highest NO value, 2.9 ppm, was recorded after 4–5 min of occlusion. In single breaths from 3 elephants 0.031–0.082 ppm, from 1 gorilla 0.029 ppm, and from 1 chimpanzee 0.0690.003 pprn NO (8 observations) were recorded.
Conclusions: We found considerable species difference in nasal NO excretion with pronounced amounts only in primates and elephants. The physiological implications of these findings remain to be defined.     

Neurological consequences after long-term sedation in the ICU

Experiments performed in mammals, including non-human primates, have demonstrated an increase in neuronal death rates normally seen in normal brain development. Such an increase is encountered in diseases but also after exposure of the brain to various class of anaesthetics. In living animals, it can (but not always) result in persistent cognitive impairment. Most of the experiments have been conducted in animals which were never exposed to any pain, which questions their relevancy. On the clinical side, all data comes from retrospective studies. Given the multiple bias, they cannot definitely state that a protocol, if toxic, is more or less when compared to another. Until now, prospective follow-up of children exposed to anaesthetics in utero or during the first months of life do not suggest a major deleterious effect. Yet, a minor one, if existing, would be hard to detect among polluting variables (e.g. pathology requiring anaesthesia, long hospitalization after birth, preterm birth, environmental stress...). For sure, when surgery is mandatory during pregnancy, it is generally for maternal indication and should not be a motif strong enough for foetal extraction, especially in terms where the baby has few chances to survive. Second, it is known for years than anaesthesia before 1 year of age is much riskier than after 1 year, whatever the theorical neurotoxicity is. Third, this enforces the need to develop tools enhancing the precision of anaesthesia as much as possible. Meanwhile, when an infant has undergone numerous general anaesthesias, we strongly recommend a long-time neurological follow-up.     

The severity and duration of postoperative pain and analgesia requirements in children after tonsillectomy, orchidopexy, or inguinal hernia repair

Objectives: To provide parents of children with accurate information regarding postoperative pain, its management, and functioning following common surgical procedures. Background: The increasing prevalence of pediatric day‐case procedures demands a more thorough understanding of the recovery profiles associated with these operations. Aim: To document postdischarge pain profiles, analgesia requirements, and functional limitation in children following tonsillectomy, orchidopexy, or inguinal hernia repair (IHR). Methods: Following hospital discharge, parents were asked to record their children’s pain levels, analgesia consumption, and degree of functional limitation each day until complete recovery. Pain and functional limitation were measured using the Parents’ Postoperative Pain Measurement (PPPM) scale and Functional Activity Score, respectively. Significant pain was defined as PPPM ≥ 6. Results: One hundred and five patients (50, tonsillectomy; 24, orchidopexy; and 31, IHR) were recruited. Median PPPM was always <6 after IHR, ≥6 only on day 1 after orchidopexy and persisted through to day 8 after tonsillectomy. Mild or severe functional limitation was observed after all surgeries and persisted for 4, 5, and 4 days after median PPPM < 6 after IHR, orchidopexy, and tonsillectomy, respectively. Combination analgesia was commonly administered after orchidopexy and tonsillectomy but less so after IHR. The general practitioner consultation rate following tonsillectomy was 54%. Conclusions: After tonsillectomy, children experience significant pain and severe functional limitation for 7 days after surgery. For many children, pain and functional limitation persists throughout the second postoperative week. In children undergoing orchidopexy, paracetamol and ibuprofen provide adequate analgesia. Pain begins to subside after the first postoperative day, and normal activity resumes after 7 days. After IHR, children experience mild pain that can be treated with paracetamol and return to normal functioning after 4 days.     

Répercussions psychocomportementales en périopératoire chez l’enfant

The relevant literature since the 1940s has been collected from the Medline database, using the keywords: child, operation, anxiety, distress, postoperative complications, preparation, premedication, parental presence, prevention. Preoperative anxiety, emergence delirium, and postoperative behavior changes are all manifestations of psychological distress in children undergoing surgery. Preoperative anxiety is most prominent during anaesthesia induction. Emergence delirium is frequent and somewhat independent of pain levels. Postoperative behavior changes most often include separation anxiety, tantrums, fear of strangers, eating problems, nightmares, night terrors and bedwetting. These difficulties tend to resolve themselves with time but can last up to one year in some children. The major risk factors for postoperative behavior problems are young age, prior negative experience with hospitals or medical care, certain kinds of hospitalization, postoperative pain, parental anxiety, and certain personality traits of the child. Currently, tools exist for quantifying anxiety (m-YPAS) and postoperative behavior (PHBQ). It is possible to identify those children who are at risk for postoperative complications during the preanaesthesia consultation by paying close attention to children under six years with higher levels of emotionality and impulsivity and poorer socialization skills with anxious parents. Suggested strategies for reducing child distress include preoperative preparation, premedication, parental presence during anaesthesia induction, and interventions affecting the child's environment, such as hypnosis. There are numerous ways to provide preoperative preparation (information, modeling, role playing, encouraging effective coping) and their effectiveness is proven in the preoperative setting but not during anaesthesia induction or in the operating room. Midazolam has been shown to be an effective preoperative sedative for reducing anxiety. Parental presence during induction has been shown to effectively reduce preoperative anxiety in children in certain contexts (when the parent is calm and the child is anxious). It is worthwhile if it is integrated into a family-centered anxiety management program and remains one of several options offered to families. Overall, taking into account the child's psychological needs should be considered an essential part of paediatric anaesthesia. Tools and techniques are available for assessing and managing the perioperative distress experienced by children.     

Liver transplant in patients with hepatocellular carcinoma

Liver transplant in patients with cirrhosis and hepatocellular carcinoma is indicated in the early stages of the disease, which can be achieved with early detection programs using liver ultrasound. Dynamic imaging techniques (ultrasound with contrast, magnetic resonance and tomography) are essential in the diagnosis of this tumour, being able to type the lesion clearly, and, in the majority of cases, lead to the therapy to follow. Surgery is the treatment of choice in these patients, and liver transplant, from a theoretical point of view, is the best. Currently, the size and number of nodes play an important role in the indication of a transplant. The best liver transplant results are obtained in these patients using the Milan criteria, with survivals that exceed 70% and recurrence indices of 15%, at 5 years. Nowadays we have the possibility of using neo-adjuvant treatments to transplant, such as arterial chemoembolisation, percutaneous ablation techniques, and even liver resection as a bridging technique. The survival of patients transplanted due to liver cancer is similar to that obtained for other non-tumour diseases. In Spain it is 1, 3 and 5 years and 82%, 70% and 60%, respectively. The recurrence is between 6.4% and 16%, micro- and macrovascular invasion being its highest risk variable.     

Total Intravenous Anesthesia with Midazolam, Remifentanil, Propofol and Cisatracurium in Morbid Obesity

Background: According to physical impairments of massive obesity, cardiac, respiratory and gastrointestinal physiology must be considered as much as pharmacokinetic behavior. Anesthetic management of morbidly obese patients has to be carefully planned, in order to minimize the increased risks of aspirative pneumonitis, hemodynamic instability and delay in recovery.The ideal anesthesia should provide a smooth and quick induction, allowing rapid airway control, prominent hemodynamic stability, and rapid emergence from anesthesia.To approach these ideal conditions,aTotal Intravenous Anesthesia (TIVA) with midazolam, remifentanil, propofol and cisatracurium was designed and analyzed. Methods: 10 consenting morbidly obese patients scheduled for elective Laparoscopic Adjustable Gastric Banding participated in the study.TIVA with midazolam, remifentanil, propofol and cisatracurium was used in all cases.Time to loss of consciousness, tracheal intubation, perianesthetic physiological parameters and complications, incidence of awareness with recall, recovery times, postoperative analgesia and costs of drugs were evaluated. Results:The analyzed data showed adequate time and physiological conditions for induction and tracheal intubation, stable maintenance with easy handling of deepness, low incidence of perianesthetic complications, excellent recovery performance and institutional efficiency. Conclusions: TIVA with midazolam, remifentanil, propofol and cisatracurium was found to be effective, secure, predictable and economic for the anesthetic management of morbidly obese patients.     

Evidenzbasiertes diagnostisches Vorgehen bei Verdacht auf stumpfes HWS-Trauma

ZusammenfassungHintergrund Ziel dieser Arbeit war einerseits die Darstellung der bisher publizierten, unterschiedlichen diagnostischen Vorgehensweisen bei Verdacht auf stumpfe HWS-Verletzung, sowie andererseits deren evidenzbasierte Berücksichtigung bei der Entwicklung einer Empfehlung zum adäquaten diagnostischen Vorgehen.Material und Methoden Mittels systematischer Literaturrecherche in Medline, Embase, National Guideline Clearinghouse, Cochrane Library sowie manueller Referenzrecherche sichteten wir relevante Veröffentlichungen zwischen 1966 und Juli 2004. Suchbegriffe waren: Cervical Spine, Cervical Vertebrae, Spinal, Spinal Cord, Injury, Trauma, Fracture, Dislocation, Imaging, Radiography, Flexion, Extension, Fluoroscopy, Computed Tomography, Computed Scanning und Magnetic Resonance Imaging. Evidenzbasiert selektierten wir die Suchergebnisse und klassifizierten sie entsprechend ihrem Evidenzgrad.Ergebnisse Aus insgesamt >10.000 Veröffentlichungen sichteten wir mit stringenten Kriterien 137 relevante Artikel. Der Evidenzgrad ist aufgrund mangelnder Datenlage insgesamt eingeschränkt. Wegen fehlender Klasse-I-Daten sind nur Stufe-II- bis -III-Empfehlungen möglich. Wir entwickelten einen Algorithmus für das diagnostische Vorgehen bei Verdacht auf HWS-Trauma. Dieser klinische Algorithmus setzt die komplexe Diagnostik potentieller HWS-Verletzungen in einen übersichtlichen, logisch aufgebauten und systematischen Prozess um.Schlussfolgerungen Der nach reproduzierbaren, evidenzbasierten Kriterien entwickelte diagnostische Algorithmus erfüllt aktuelle geforderte Standards, um die Behandlungsqualität frisch Verletzter zu maximieren. Auch durch seine nachvollziehbare Transparenz bietet er eine wesentliche Entscheidungshilfe in der Auswahl des adäquaten diagnostischen Vorgehens.     

Regional anesthesia for orthopedic procedures: What orthopedic surgeons need to know

Regional anesthesia is an integral component of successful orthopedic surgery. Neuraxial anesthesia is commonly used for surgical anesthesia while peripheral nerve blocks are often used for postoperative analgesia. Patient evaluation for regional anesthesia should include neurological, pulmonary, cardiovascular, and hematological assessments. Neuraxial blocks include spinal, epidural, and combined spinal epidural. Upper extremity peripheral nerve blocks include interscalene, supraclavicular, infraclavicular, and axillary. Lower extremity peripheral nerve blocks include femoral nerve block, saphenous nerve block, sciatic nerve block, iPACK block, ankle block and lumbar plexus block. The choice of regional anesthesia is a unanimous decision made by the surgeon, the anesthesiologist, and the patient based on a risk-benefit assessment. The choice of the regional block depends on patient cooperation, patient positing, operative structures, operative manipulation, tourniquet use and the impact of post-operative motor blockade on initiation of physical therapy. Regional anesthesia is safe but has an inherent risk of failure and a relatively low incidence of complications such as local anesthetic systemic toxicity (LAST), nerve injury, falls, hematoma, infection and allergic reactions. Ultrasound should be used for regional anesthesia procedures to improve the efficacy and minimize complications. LAST treatment guidelines and rescue medications (intralipid) should be readily available during the regional anesthesia administration.     

Isobolographic analysis of epinephrine with bupivacaine, dextromethorphan, 3-methoxymorphinan, or dextrorphan on infiltrative anesthesia in rats: dose-response studies

BACKGROUND AND OBJECTIVES: The aims of this study were to establish the potencies of epinephrine, bupivacaine, dextromethorphan, 3-methoxymorphinan, and dextrorphan and evaluate interactions of epinephrine with bupivacaine, dextromethorphan, 3-methoxymorphinan, or dextrorphan as an infiltrative anesthetic. Bupivacaine, a common and long-acting local anesthetic, was used as control. METHODS: Dose-dependent responses of epinephrine, dextromethorphan, 3-methoxymorphinan, and dextrorphan on cutaneous analgesia were compared with bupivacaine in rats. The interactions of drugs were evaluated via an isobolographic analysis. RESULTS: We found that epinephrine, bupivacaine, dextromethorphan, 3-methoxymorphinan, and dextrorphan produced a dose-dependent local anesthetic effect as infiltrative cutaneous analgesia. Relative potencies were epinephrine > bupivacaine > dextromethorphan > 3-methoxymorphinan > dextrorphan (P < .01 for each comparison). Coadministration of bupivacaine with epinephrine produced a synergistic effect, and coadministration of dextromethorphan, 3-methoxymorphinan, or dextrorphan with epinephrine produced an additive effect. CONCLUSIONS: Epinephrine, dextromethorphan, 3-methoxymorphinan, and dextrorphan are known to have local anesthetic effects as infiltrative cutaneous analgesia in rats. Epinephrine increased the potency of bupivacaine, but not dextromethorphan, 3-methoxymorphinan, or dextrorphan as an infiltrative anesthetic. The cutaneous analgesic effects of adding epinephrine to dextromethorphan, 3-methoxymorphinan, or dextrorphan, are similar to combinations of 2 local anesthetics.