小儿腹腔镜阑尾切除术后疼痛的危险因素分析

目的:探讨小儿腹腔镜术后发生明显术后疼痛的影响因素,为患儿的适时镇痛治疗提供线索。方法:收集2012年1月~12月收治、确诊并行腹腔镜阑尾切除术(laparoscopic appendectomy,LA)的阑尾炎患儿57例,对发生明显术后疼痛的病例分布情况进行描述并对各时间点疼痛评估分数进行对比,同时对8个可能与LA术后明显疼痛的有关因素进行多因素logistic回归分析。结果:术后12 h明显术后疼痛人数最多,且其疼痛评估分数最高;术后12 h除与术后6 h相比P值为0.179,与其他时间点相比P值均<0.05。多因素logistic回归分析显示,影响LA明显术后疼痛的独立危险因素为CO2气腹特殊情况[即腹内压(intra-abdominal pressure,IAP)>16 mmHg和/或时间持续>1 h](OR为1.34,P<0.001)。结论:儿童LA术后发生明显术后疼痛与气腹条件异常有关,建议术中将气腹条件控制在适宜范围,术中经历气腹特殊情况的患儿应注重适宜的镇痛治疗。     

Small bowel obstruction in pregnancy is a complex surgical problem with a high risk of fetal loss

IntroductionSmall bowel obstruction (SBO) in pregnancy is rare and is most commonly caused by adhesions from previous abdominal surgery. Previous literature reviews have emphasised the need for prompt laparotomy in all cases of SBO because of the significant risks of fetal loss and maternal mortality. We undertook a review of the contemporary literature to determine the optimum management strategy for SBO in pregnancy.MethodsThe MEDLINE® and PubMed databases were searched for cases of SBO in pregnancy between 1992 and 2014. Two cases from our own institution were also reviewed.ResultsForty-six cases of SBO in pregnancy were identified, with adhesions being the most common aetiology (50%). The overall risk of fetal loss was 17% and the maternal mortality rate was 2%. In cases of adhesional SBO, 91% of cases were managed surgically, with 14% fetal loss. Two cases (9%) were managed conservatively with no complications. Magnetic resonance imaging (MRI) was used to diagnose SBO in 11% of cases.ConclusionsBased on our experience and the contemporary literature, we recommend that urgent MRI of the abdomen should be undertaken to diagnose the aetiology of SBO in pregnancy. In cases of adhesional SBO, conservative treatment may be safely commenced, with a low threshold for laparotomy. In other causes, such as volvulus or internal hernia, laparotomy remains the treatment of choice.     

Oral estrogen therapy in postmenopausal women is associated with loss of kidney function

Women are generally protected against progressive loss of kidney function; however, this advantage seems to diminish with menopause. Because of conflicting reports on the association between use of hormone therapy and kidney function we studied 5845 women (1459 on hormone therapy and 4386 non-users) who were over 66 years of age and had at least 2 serum creatinine measurements during the 2 year study period. After adjustment for covariates, hormone use (estrogen-only, progestin-only, or both) was associated with a significant loss of estimated GFR as the primary outcome along with an increased risk of rapid loss of kidney function as the secondary outcome compared to non-users. This increased rate of loss was associated with oral but not transvaginal estrogen use. An increased cumulative dose of estrogen was also associated with a greater decline in estimated GFR. Our study shows an independent association in a dose-dependent manner of estrogen use and loss of kidney function in this elderly population.     

Rate of bone loss is associated with mortality in older women: a prospective study.

Older women with low bone density have an increased risk of fracture, cardiovascular disease, and mortality. However, it is not known whether this association is caused by ongoing bone loss or by lower bone mass earlier in life. To determine whether rate of bone loss is associated with total and cause-specific mortality, we prospectively studied 6046 women aged 65 years or older who had serial bone mineral density (BMD) measurements as a part of the Study of Osteoporotic Fractures. Rates (mean +/- SD) of loss of BMD at the heel (for a mean of 5.7 years) and hip (for a mean of 3.5 years) were estimated. Cause-specific mortality was ascertained from death certificates and hospital records. BMD loss at the heel was 5.9 +/- 6.0 mg/cm2 per year (1.5 +/- 1.5%) and BMD loss at the hip was 4.1 +/- 10.2 mg/cm2 per year (0.6 +/- 1.4%). During an average follow-up of 3.2 years after the second measurement of BMD, 371 deaths occurred. Each SD increase in BMD loss at the hip was associated with a 1.3-fold (95% CI, 1.1-1.4) increase in total mortality, adjusted for age, baseline BMD, diabetes, hypertension, incident fractures, smoking, physical activity, health status, weight loss, and calcium use. In particular, hip BMD loss was associated with increased mortality from coronary heart disease (relative hazard [RH] = 1.3 per SD; 95% CI, 1.0-1.8) and pulmonary diseases (RH = 1.6 per SD; 95% CI, 1.1-2.5). The findings were similar for bone loss at the heel, except there was no significant association with pulmonary mortality. These results raise the possibility that bone loss may share common etiologies with coronary and pulmonary diseases.     

Transumbilical laparoscopic-assisted appendectomy is associated with lower costs compared to multiport laparoscopic appendectomy

Background/Purpose

Single-incision laparoscopic appendectomy has been associated with improved cosmetic benefits, and decreased postoperative pain. Less is known about costs and other outcomes. Our aim was to evaluate the costs and outcomes between transumbilical laparoscopic-assisted appendectomy (TULAA) and multiport laparoscopic appendectomy (MLA).

Methods

IRB-approved retrospective review (September 2010–July 2013) of institutional medical records identified 372 pediatric patients undergoing laparoscopic appendectomy. Outcomes included costs, LOS and readmission. Costs were fully loaded operating costs from the hospital’s cost accounting database. Generalized linear regression was used to assess costs of MLA and TULAA. A subgroup analysis was performed using only patients with non-perforated appendicitis.

Results

There were 132 patients (35.5%) that underwent TULAA while 240 patients (65.5%) underwent MLA. Compared to MLA, TULAA was associated with decreased operative time (0.6 vs. 1.0 h, p < 0.0001), used in comparable proportions of interval appendectomies, but was performed less often for perforated appendicitis (9.8% vs. 22.9%, p = 0.002). Readmission and postoperative complications were similar between both groups. In the setting of non-perforated appendicitis, TULAA was associated with lower costs of $1378 relative to MLA (p = 0.009).

Conclusions

In non-perforated appendicitis, TULAA is associated with lower costs and comparable rates of readmission and postoperative complications.     

Clinical outcomes compared between laparoscopic and open appendectomy in pregnant women

Background

Despite the initial absolute or relative contraindication of laparoscopic surgery during pregnancy, in the last decade, laparoscopic appendectomy (LA) has been performed in pregnant women. But few studies compare the outcomes of LA compared with open appendectomy (OA). We investigated clinical outcomes to evaluate the safety and efficacy of LA compared with OA in pregnant women.

Methods

We recruited consecutive pregnant patients with a diagnosis of acute appendicitis who were undergoing LA or OA between May 2007 and August 2011 into the study.

Results

Sixty-one patients (22 LA and 39 OA) enrolled in our study. There were no significant differences in duration of surgery, postoperative complication rate and obstetric and fetal outcomes, including incidence of preterm labour, delivery type, gestation age at delivery, birth weight and APGAR scores between the 2 groups. However, the LA group had shorter time to first flatus (2.4 ± 0.4 d v. 4.0 ± 1.7 d, p = 0.034), earlier time to oral intake (2.3 ± 1.6 d v. 4.1 ± 1.9 d, p = 0.023) and shorter postoperative hospital stay (4.2 ± 2.9 d v. 6.9 ± 3.7 d, p = 0.043) than the OA group.

Conclusion

Laparoscopic appendectomy is a clinically safe and effective procedure in all trimesters of pregnancy and should be considered as a standard treatment alternative to OA. Further evaluation including prospective randomized clinical trials comparing LA with OA are needed to confirm our results.     

Maternal and fetal complications in pregnant women with systemic lupus erythematosus

Recent studies provide important insights into maternal complications in patients with systemic lupus erythematosus (SLE) established before onset of pregnancy. Exacerbations or relapse occur during the course of pregnancy and immediately postpartum in 25% to 60% of pregnancies. However, the likelihood of increased clinical activity of SLE during pregnancy is influenced by signs of activity present at onset of pregnancy. In the absence of signs of clinical activity for at least 6 months before conception, relapses occur in about one third, whereas in patients with clinical activity at onset of pregnancy, persistent activity or exacerbations occur in approximately two thirds. Fetal survival in these patients parallels the incidence of SLE activity: 85% to 95% in the group with inactive disease at conception and 50% to 80% in subjects with active disease at onset of pregnancy. The introduction of an assay for anticardiolipids has led to a new concept for the pathogenesis of autoimmune disease, namely immune-related thrombosis. Recent studies suggest that this mechanism may play an important role in clinical episodes in SLE, involving late fetal death and maternal arterial and venous thrombosis.     

短肽型肠内营养在胎儿生长受限孕妇中的应用

目的探讨短肽型肠内营养在胎儿生长受限(FGR)孕妇中的应用及护理的效果。方法对孕32～33周FGR初产、单胎、无其他合并症的孕妇69例,按照入院时间单号分为观察组(n=35),双号为对照组(n=34);在常规治疗基础上,对照组予正餐和加餐饮食,观察组予正餐和短肽型肠内营养液750mL/d口服。观察治疗前后两组孕妇的宫高、腹围、体质量及胎儿双顶径、头围、腹围、股骨长、体质量等指标情况。结果观察组各项指标增长值显著优于对照组(P<0.05,P<0.01)。结论短肽型肠内营养有利于FGR孕妇的治疗,正确的健康教育和饮食指导是治疗效果的保障。     

Height loss in elderly women is preceded by osteoporosis and is associated with digestive problems and urinary incontinence

Summary  

This study explores risk factors for height loss and consequences in terms of health and wellbeing, in older women. Osteoporosis, low body-mass index, being born in Europe and using medications for both sleep and anxiety were risk factors for height loss. Height loss was associated with digestive problems; excessive height loss was also associated with urinary stress-incontinence and a decline in self-rated health.     

Incidental appendectomy with cholecystectomy: is the increased risk justified?

To evaluate the advisability of incidental appendectomy relative to patient age, a retrospective chart review of 905 patients undergoing elective cholecystectomy between 1979 and 1983 was undertaken. A total 377 of these patients underwent incidental appendectomy. The overall complication rate in the two groups was the same. Wound infection occurred in 1.5 per cent of patients undergoing cholecystectomy alone, compared with 3.7 per cent in those patients undergoing incidental appendectomy as well. Patients over the age of 50 who underwent incidental appendectomy had a wound infection rate of 5.9 per cent, compared with 0.9 per cent in those patients over 50 who underwent cholecystectomy alone, a difference found to be statistically significant (P less than .05). Therefore, incidental appendectomy cannot be recommended for patients over the age of 50.     

Postmenopausal bilateral oophorectomy is not associated with increased fracture risk in older women.

We studied whether oophorectomy performed after menopause is associated with an increased risk of hip or vertebral fractures in 6295 Study of Osteoporotic Fractures participants. There was no association between postmenopausal oophorectomy and the risk of hip or vertebral fractures. INTRODUCTION: Bilateral oophorectomy after natural menopause has been associated with an increased risk of osteoporotic fractures, potentially because of a decline in serum estradiol and testosterone levels after the oophorectomy. We prospectively tested this hypothesis in the Study of Osteoporotic Fractures (SOF). MATERIALS AND METHODS: We studied 6295 white women 65 years of age participating in the SOF who were not taking estrogen therapy at baseline. Hip fracture analyses included 708 hip fractures; vertebral fracture analyses included 267 incident vertebral fractures. Baseline serum estradiol and free testosterone values were available in a small subset of participants. RESULTS AND CONCLUSION: There were no significant differences in age, weight, or BMD between the women who underwent postmenopausal oophorectomy (n = 583) and those who did not (n = 5712). Free testosterone levels were significantly lower among women who had a postmenopausal oophorectomy. A history of postmenopausal oophorectomy was not associated with an increased risk of hip (hazard ratio [HR] = 1.1; 95% CI = 0.9-1.5) or vertebral fracture (HR = 0.7; 95% CI = 0.5-1.2). The relationship between oophorectomy and hip fracture was not altered by adding serum estradiol level (HR = 1.3; 95% CI = 0.5-3.2) or serum free testosterone level (HR = 1.7; 95% CI = 0.8-3.7) to the model. In summary, postmenopausal oophorectomy was not associated with an increased risk of hip or vertebral fracture in this cohort. These results are in contrast to previous findings, suggesting that the relationship between postmenopausal oophorectomy and fractures is not fully elucidated and that incidental oophorectomy after menopause should still be considered carefully in each potential patient.     

Early experience with laparoscopic appendectomy in women

Summary Experience and the surgical technique of laparoscopic appendectomy in 70 female patients over a period of more than three years is described. Three women were pregnant. Complications occurred in one case.     

Major trauma in pregnant women: maternal/fetal outcome

One regional trauma center's experience with a large number of seriously injured pregnant women was reviewed to identify factors affecting maternal and fetal outcome after injury. Of 318 pregnant women who suffered trauma from January 1984 through December 1988, 25 (8%) were severely injured and would have required hospital admission even in the absence of pregnancy. Physical examination, except for the inappropriate absence of fetal heart tones, was a poor predictor of fetal status. Sonography proved to be the most accurate modality for acutely assessing fetal status. There was one (4%) maternal death, consistent with predicted mortality (TRISS methodology). Four pregnancies were lost and one neonate died because of injuries sustained, not because of surgery or anesthesia. There was significant difference between the ISS (average, 9) and CTS (average, 16) of women with surviving pregnancies or successful deliveries and the ISS (average, 30) and CTS (average, 12) of women who lost pregnancies or witnessed neonatal death. Fetal outcome relates to direct fetal injury and to the acute hemodynamic insult associated with maternal trauma. Maternal evaluation and treatment should occur in a stepwise and organized fashion following the general principles of trauma care (ATLS guidelines) in conjunction with perinatal specialists. Uterine ultrasonography should be an integral component of the initial evaluation. With expedient resuscitation, evaluation, and intervention, maternal and fetal survival can be expected.     

Estrogen receptor α CA dinucleotide repeat polymorphism is associated with rate of bone loss in perimenopausal women and bone mineral density and risk of osteoporotic fractures in postmenopausal women

Summary The association between a newly identified CA repeat polymorphism of the estrogen receptor alpha gene (ESR1) with osteoporosis was investigated. Postmenopausal women with <18 CA repeats had low BMD, increased rate of bone loss and increased fracture risk. Introduction Studies have shown that intronic dinucleotide repeat polymorphisms in some genes are associated with disease risk by modulating mRNA splicing efficiency. D6S440 is a newly identified intronic CA repeat polymorphism located downstream of the 5’-splicing site of exon 5 of ESR1. Methods The associations of D6S440 with bone mineral density (BMD), rate of bone loss and fracture risk were evaluated in 452 pre-, 110 peri- and 622 postmenopausal southern Chinese women using regression models. Results Post- but not premenopausal women with less CA repeats had lower spine and hip BMD. The number of CA repeats was linearly related to hip BMD in postmenopausal women (β = 0.008; p = 0.004). Postmenopausal women with CA repeats <18 had higher risks of having osteoporosis (BMD T-score<−2.5 at the spine: OR 2.46, 95% CI 1.30–4.65; at the hip: OR 3.79(1.64–8.74)) and low trauma fractures (OR 2.31(1.29–4.14)) than those with ≥18 repeats. Perimenopausal women with <18 CA repeats had significantly greater bone loss in 18 months at the hip than those with ≥18 repeats (−1.96% vs. −1.61%, p = 0.029). Conclusions ESR1 CA repeat polymorphism is associated with BMD variation, rate of bone loss and fracture risk, and this may be a useful genetic marker for fracture risk assessment. Funding Source: This project is supported by CRCG Grant, Bone Health Fund, Matching Grant and Osteoporosis and Endocrine Research Fund of the University of Hong Kong.     

Cognitive decline is associated with an accelerated rate of bone loss and increased fracture risk in women: a prospective study from the Canadian Multicentre Osteoporosis Study

Cognitive decline and osteoporosis often coexist and some evidence suggests a causal link. However, there are no data on the longitudinal relationship between cognitive decline, bone loss and fracture risk, independent of aging. This study aimed to determine the association between: (i) cognitive decline and bone loss; and (ii) clinically significant cognitive decline (≥3 points) on Mini Mental State Examination (MMSE) over the first 5 years and subsequent fracture risk over the following 10 years. A total of 1741 women and 620 men aged ≥65 years from the population-based Canadian Multicentre Osteoporosis Study were followed from 1997 to 2013. Association between cognitive decline and (i) bone loss was estimated using mixed-effects models; and (ii) fracture risk was estimated using adjusted Cox models. Over 95% of participants had normal cognition at baseline (MMSE ≥ 24). The annual % change in MMSE was similar for both genders (women −0.33, interquartile range [IQR] −0.70 to +0.00; and men −0.34, IQR: −0.99 to 0.01). After multivariable adjustment, cognitive decline was associated with bone loss in women (6.5%; 95% confidence interval [CI], 3.2% to 9.9% for each percent decline in MMSE from baseline) but not men. Approximately 13% of participants experienced significant cognitive decline by year 5. In women, fracture risk was increased significantly (multivariable hazard ratio [HR], 1.61; 95% CI, 1.11 to 2.34). There were too few men to analyze. There was a significant association between cognitive decline and both bone loss and fracture risk, independent of aging, in women. Further studies are needed to determine mechanisms that link these common conditions. © 2021 American Society for Bone and Mineral Research (ASBMR).     

Rate of forearm bone loss is associated with an increased risk of fracture independently of bone mass in postmenopausal women: the OFELY study.

BMD is a major determinant of the risk of fragility fractures, but the role of the rate of postmenopausal bone loss is still unclear. In 671 postmenopausal women from the OFELY cohort, we found that the rate of bone loss was significantly associated with fracture risk independently of other well-known predictors including BMD and previous fractures. INTRODUCTION: The level of BMD is a major determinant of the risk of fragility fractures, but the role of the rate of postmenopausal bone loss is still unclear. MATERIALS AND METHODS: In the OFELY study, we analyzed the risk of fracture in 671 postmenopausal women (mean age, 62.2 +/- 9 years), according to the rate of bone loss. BMD was measured annually by DXA at the forearm, with a mean number of measurements of 10.3 +/- 2.6. Peripheral fractures, all confirmed by radiographs, were prospectively registered, and vertebral fractures were evaluated with spine radiographs every 4 years. RESULTS: During a median (interquartile range [IQ]) of 11.2 years (11-12.3 years) of follow-up, 183 incident fragility fractures including 53 vertebral and 130 nonvertebral fractures were recorded in 134 women. The annual median +/- IQ rate of bone loss, calculated from the slope, was -0.30 +/- 0.76% at the mid-radius, -0.55 +/- 0.79% at the distal radius, and -0.40 +/- 0.96% at the ultradistal radius. Women with incident fracture had a rate of bone loss (before fracture) higher by 38-53% than those without fracture (p = 0.0003-0.016). Using multivariate Cox regression models, we found that bone loss in the highest tertile at the mid-radius, distal radius, and ultradistal radius was associated with a significant increased risk of all fractures with an hazard ratio from 1.45 to 1.70 (p = 0.02 to p = 0.009 after adjusting for age, previous fractures, maternal history of fracture, physical activity, grip strength, falls, and baseline BMD). CONCLUSIONS: The rate of bone loss in postmenopausal women is significantly associated with fracture risk independently of other well-known predictors such as BMD and history of fractures.     

胎儿异常孕妇自我同情现状及影响因素分析

目的了解胎儿异常孕妇终止妊娠前自我同情现状及其影响因素,为护理人员进行针对性心理干预,改善胎儿异常孕妇心理应激提供依据。方法使用自我同情量表对211例因胎儿异常需引产的孕妇进行调查。结果胎儿异常孕妇自我同情总分为85.19±10.75。多元线性回归结果显示,查出胎儿异常到入院引产时间、不良妊娠史、文化程度是胎儿异常孕妇自我同情的影响因素(P<0.05,P<0.01)。结论胎儿异常孕妇自我同情处于中等水平。护理人员应加强对文化程度低及有不良妊娠史等胎儿异常孕妇的心理疏导,指导其提高自我同情水平,以有效应对心理危机。