腹腔镜直肠癌根治术(Dixon)

在结肠系膜与后腹膜移行处切开后腹膜,分离系膜至肠系膜下动脉根部,清扫253组淋巴结,在距腹主动脉根部1 cm处夹闭并切断血管,切断肠系膜下静脉。由内侧向外侧分离结肠系膜至结肠旁沟,切开其左侧后腹膜,将降结肠及乙状结肠系膜从后腹壁游离。沿直肠固有筋膜与盆壁筋膜的间隙按照TME原则锐性分离直肠系膜,先游离后壁,再游离两侧壁及前壁,直至盆底。在肿瘤下方2 cm处用阻断夹夹闭肠管,冲洗远端直肠,用切割缝合器切断直肠。取脐部弧形切口。提出近端肠管,于肿瘤近端15 cm处离断肠管。近端置入管型吻合器抵钉座,还纳腹腔,重建气腹。经肛置入管型吻合器,在腹腔镜直视下作乙状结肠－直肠端端吻合,冲洗腹腔,置引流管,手术结束。     

Ethics of delivering the message of impending death]

Two questions are discussed: 1. our relation to death. Contrary to the saying "shadows of the death" and to it's modern concealment this contribution states: death gives light: it enables to be conscious of one's self and to bow to the inevitable, it shows the valuables of earthly and mortal beings, and even allows us to hope. 2. Solidarity in the situation of death. This situation means the experience of being abandoned and in the same time the challenge to release the other (and to allow him to live [respectively to go]). Against the ego-centralizing power of pain and dread especially the dying needs aid--only to face to (the "hour of") truth. The decisive help is the helper: his being there and remaining by under the common fate.     

Adrenal gland injury due to gunshot

Adrenal gland trauma is a rare phenomenon, due to the small size and retroperitoneal location of the organ. The majority of adrenal gland trauma is due to blunt force injury and is only rarely encountered due to the penetrating mechanisms. A 20-year-old male sustained a gunshot wound to the left abdomen. Upon exploration, he was found to have a through and through injury to the left adrenal gland, among other injuries. Injury to the adrenal gland due to penetrating trauma is exceptionally rare. The principles of management are to control bleeding from the gland with debridement and hemostasis rather than attempt to resect the entire organ. The management of a penetrating injury to the adrenal gland is straightforward and should not be a contributor to a patient''s morbidity or mortality.     

Rehabilitation of the communicatively impaired stroke patient

The stroke patient who has lost the ability to communicate has lost more than the ability to talk. To one degree or another, he has lost the ability to understand his environment, the ability to structure his thought process internally in a logical and meaningful order, and the ability to formulate language in a logical and meaningful order. The ability to structure one's thoughts and ideas internally, as well as the ability to communicate them to others, are intrinsic factors in an individual's ability to motivate himself to establish a goal and to pursue the acquisition of that goal. Therefore, the successful physical rehabilitation of the stroke patient with a communication disorder rests heavily upon an understanding and a resolution of his communication problem.     

Role of the pelvic floor in bladder neck opening and closure I: Muscle forces

The aim of the study was to identify the striated muscle forces hypothesized to assist bladder neck opening and closure in females. Cadaveric dissection was used to identify the levator plate (LP), the anterior portion of pubococcygeus muscle (PCM), the longitudinal muscle of the anus (LMA), and their relation to the bladder, vagina and rectum. X-ray video recordings were made during coughing, straining, squeezing and micturition in a group of 20 incontinent patients and 4 controls, along with surface EMG, urethral pressure and digital palpation studies. During effort, urethral closure appeared to be activated by a forward muscle force corresponding to PCM, and bladder neck closure by backward muscle forces corresponding to LP and LMA. During micturition the PCM force appeared to relax, allowing LP and LMA to pull open the outflow tract. The data appear to support the hypothesis of specific directional muscle forces stretching the vagina to assist bladder neck opening and closure.     

Aberrations in Hollander test response after incomplete vagotomy. Compensating effect of antral resection in the dog.

Acid secretory and serum gastrin responses to 2-deoxy-D-glucose and insulin were compared in gastric fistula dogs before and after partial vagotomy and pyloroplasty or partial vagotomy and antrectomy. The acid response and serum gastrin curve were basically unaltered by partial vagotomy and pyloroplasty. Based on the data presented, the acid response to insulin hypoglycemia appears to be more dependent on the vagal release of antral gastrin than on direct vagal stimulation of the parietal cell. However, acid response to insulin was profoundly suppressed to only 4 per cent of control levels after partial vagotomy and antrectomy. Although acid response to 2-deoxy-D-glucose was also profoundly depressed to 33 per cent of control levels after partial vagotomy and antrectomy, it was seven times greater than that seen with insulin. Serum gastrin response was abolished after antrectomy to either insulin or 2-deoxy-D-glucose. Finally, the question to which we originally addressed ourselves appears to have been answered and, in terms of response to vagal stimulation, antrectomy appears to compensate for incomplete vagal denervation and may lead to aberrations and misinterpretations, raising serious questions as to the validity of the Hollander test in patients who have undergone distal gastric resection.     

Percent free prostate specific antigen in the total prostate specific antigen 2 to 4 ng./ml. range does not substantially increase the number of biopsies needed to detect clinically significant prostate cancer compared to the 4 to 10 ng./ml. range

PURPOSE: Percent free prostate specific antigen (PSA) is useful to select patients for prostate biopsy with total PSA 4 to 10 ng./ml. However, 20% of men with PSA between 2.6 and 4 ng./ml. harbor significant prostate cancer and percent free PSA has been suggested to aid in the decision to biopsy in this total PSA range as well. Concerns exist that the number of biopsies needed to detect 1 cancer in this range may be inappropriately high. In a prospective referral population we evaluated sensitivity and specificity of various percent free PSA cutoffs and determined the biopsy-per-cancer ratio in the PSA 2 to 4 ng./ml. range in men with a benign digital rectal examination, and report on the biological nature of the detected cancers based on Gleason score. Results were compared to those obtained from a reference group of patients (PSA 4 to 10 ng./ml., benign digital rectal examination) from the same prospective referral cohort. MATERIALS AND METHODS: Total PSA and free PSA were measured and percent free PSA was calculated. Of the initial 1,602 men 756 had a benign digital rectal examination and PSA 4 to 10 ng./ml., and 219 had a benign digital rectal examination and PSA 2 to 4 ng./ml. Sensitivity, specificity, the number of true positive (evidence of cancer) and false-positive (no evidence of cancer) biopsies were determined. The ratio of true positive biopsies-to-all biopsies performed was used to determine the biopsy-per-cancer ratio. Gleason score of the detected cancers was evaluated. The procedure was repeated for the PSA 4 to 10 ng./ml. range. RESULTS: In the PSA 4 to 10 ng./ml. range a sensitivity of 63.7% to 92.5% with a specificity of 57.5% to 18.7% was found when percent free PSA was 18% to 25%. On average 3 biopsies were needed to detect 1 cancer. When PSA was 2 to 4 ng./ml. sensitivity was 46.3% to 75.6% and specificity was 73.6% to 37.6% when the same percent free PSA cutoff was examined. Calculation of the biopsy-per-cancer ratio for various percent free PSA cutoffs revealed that 3 to 5 biopsies were needed to find 1 cancer. Of 41 cancers detected in the PSA 2 to 4 ng./ml. range 6 had a Gleason score 5. The majority (28 of 41) of cases had a Gleason score of 6. Gleason score was 7 in 5 patients and 8 in 1. CONCLUSIONS: In the PSA 4 to 10 ng./ml. range high sensitivity for prostate cancer detection is critical and 3 biopsies are needed to detect 1 cancer. In the PSA 2 to 4 ng./ml. range a percent free PSA cutoff of 18% to 20% detected about 50% of cancers while sparing up to 73% of unnecessary biopsies with a biopsy-to-cancer ratio of 3 to 4:1. Percent free PSA can be applied to the PSA 2 to 4 ng./ml. range to detect prostate cancer and only moderately increases the number of biopsies needed to detect 1 significant cancer compared to the greater than 4 to 10 ng./ml. range.     

Addressing the structural drivers of HIV: a luxury or necessity for programmes?

The social, economic, political and environmental structural factors that increase susceptibility to HIV infection and undermine prevention and treatment efforts continue to pose a challenge. The papers in this series highlight the importance of sustaining those efforts to address the structural drivers of the HIV epidemic, and that initiatives to achieve HIV elimination will only come about through a comprehensive HIV response, that includes meaningful responses to the social, political, economic and environmental factors that affect HIV risk and vulnerability. In the context of declining resources for HIV/AIDS, the papers speak to the need to integrate responses to the structural drivers of HIV/AIDS into future HIV investments, with both initiatives to integrate HIV into broader gender and development initiatives, as well as adaptations of current service models, to ensure that they are sensitive to and able to respond to the broader economic and social responsibilities that their clients face.     

计算机辅助下颌骨截骨的三维显微结构模型建立

目的 探索计算机重建下颌骨三维显微结构模型及下颌角截骨手术的三维仿真操作方法 ,以减少手术操作中的组织损伤. 方法 利用螺旋CTA数据重建包含血管神经束的下颌骨三维模型并进行测量分析,使用Freeform雕刻刀及其布尔运算的切割方法 对模型进行保护血管的手术模拟.结果 利用计算机辅助技术可以精确的重建包含下牙槽动脉的下颌骨三维模型:血管从下颌孔进入下颌支.依照下颌支外缘弧度走行,下颌孔距下颌支前缘距离为(19.13±0.66)mm,孔距下颌支后缘距离为(18.96±0.64)mm,下颌角的角度为(109.70±4.67)°,下颌支的安全截骨范围和角度是平行下颌支外缘(12.62±0.28)mm宽、与下颌底成角(22.30±4.67)°;根据模型与数据,Fredorm可以模拟安全的下颌角截骨的手术操作. 结论 下颌骨显微结构的三维模型重建和测量分析技术,是增加手术安全性的一条新途径.     

A laboratory training model for interhemispheric-transcallosal approach to the lateral ventricle

Laboratory training models are essential for developing and refining surgical skills before clinical application of microneurosurgery. Our aim is to train residents of neurosurgery to be familiar with a basic microneurosurgical technique in access to the lateral ventricle via a transcallosal approach. The training material consists of a 2-year-old fresh cadaveric cow cranium. A four-step approach was designed to simulate microneurosurgical dissection along the falx to visualize cingulated gyri, callosomarginal and pericallosal arteries in order to perform callosotomy and access to the lateral ventricle, and finally to the foramen of Monroe. We conclude that the model perfectly simulates standard microneurosurgical steps in interhemispheric-transcallosal approach to the lateral ventricle and to the area of the foramen of Monroe.     

Crystalloids,colloids, blood,blood products and blood substitutes

Understanding the physiology of fluid distribution within the human body is fundamental to the practice of anaesthetists and intensivists of all grades. There is a necessity to recognize the range of actions and consequences of the commonly infused intravenous fluids if safe patient care is to be provided. There are many historical and on-going trials surrounding fluid therapy and it is important for the physician to keep up to date with current guidelines.There is a continued drive to improve the safety of donor blood and prevent transfusion errors. Knowledge of how blood products are collected separated and stored is essential to prevent harm to patients through transfusions. Work in producing blood substitutes is progressing, but to date, trials have failed to market a product in Europe and the USA with an acceptable risk profile.     

Expanded endonasal approach: vidian canal as a landmark to the petrous internal carotid artery

The purpose of this study was to describe the technique used to safely identify the petrous carotid artery during expanded endonasal approaches to the skull base. A series of 20 cadaveric studies was undertaken to isolate the vidian artery and nerve and to use them as landmarks to the petrous internal carotid artery (ICA). Twenty-five consecutive paraclival endoscopic cases were also reviewed to determine the consistency of the vidian artery in vivo as an intraoperative landmark to the ICA. These data were then correlated with results from a separate study in which computed tomography scans from 44 patients were evaluated to delineate the course of the vidian canal and its relationship to the petrous ICA. In all 20 cadaveric dissections and all 25 surgical cases, the vidian artery was consistently identified and could be reliably used as a landmark to the ICA. The correlation between anatomical and clinical data in this paper supports the consistent use of the vidian artery as an important landmark to the petrous ICA.     

EMLA cream as a topical anaesthetic for ulcer debridement and simultaneous split-skin grafting

Summary The object of the study was to investigate the effect of EMLA cream when used as an anaesthetic for the debridement of ulcers and wounds. The cream was applied to a fresh, standardized wound caused by a dermatome, to an ulcer which was to be revised and for simultaneous split-skin grafting to both donor site and recipient area to be debrided. The effect on wound healing, the plasma concentrations of lidocaine and prilocaine and the analgesic effect following the application of EMLA to the ulcer and to both ulcer and donor site were studied. The study showed that EMLA cream when topically applied has a sufficient analgesic effect for revision of an open ulcer and can be used concomitantly for both revision of the ulcer and cutting of the split-skin graft. The application of EMLA cream to the fresh wound, or to the recipient area prior to cleaning, did not cause any clinical signs of a delayed healing at the applied areas compared to the control sites. Correspondence to: L. Ohlsén     

Role of glutathione in cisplatin resistance in osteosarcoma cell lines

This study was designed to examine whether and how glutathione and catalase increase the resistance of osteosarcoma cells to the toxicity of cisplatin. Eight osteosarcoma cell lines were exposed to varying concentrations of cisplatin. and a [³H]thymidine incorporation study then estimated their drug sensitivity. Cells were pretreated with aminotriazole and buthionine sulfoximine to depress catalase and glutathione activities and then entered into the same protocol to assess their sensitivity to cisplatin. Intracytoplasmic levels of catalase and glutathione were measured before and after the treatments. Cisplatin-glutathione conjugates were created to examine how glutathione might depress the toxicity of cisplatin. Although the cell lines differed in the magnitude of their response to cisplatin, there was a statistical correlation between intrinsic glutathione content and cisplatin resistance. Pretreatment with aminotriazole reduced catalase activity by 84% but did not change the sensitivity to cisplatin. Depletion of glutathione activity by 70% increased the sensitivity of the cells to the cytotoxicity of cisplatin. In addition, cisplatin was detoxified following conjugation with glutathione. The increased sensitization to cisplatin toxicity caused by the depletion of glutathione and cisplatin detoxification after the in vitro reaction of glutathione to cisplatin indicated that the formation of the glutathione-cisplatin conjugate was an important mechanism in the cellular resistance to cisplatin. These data also demonstrated that catalase activity did not contribute to resistance to cisplatin and suggested that H₂O₂-induced oxidative stress did not significantly contribute to the cytotoxicity of cisplatin in osteosarcoma cells.     

Editorial Commentary: Back to Work After Shoulder Biceps Tenodesis!!

Assessing the time and factors influencing return to work after any procedure is very important. It helps in both preoperative counseling of patients and gives them a clear picture of the time needed to get back to work. Very few studies have commented on return to work after shoulder biceps tenodesis. In most patients, average time to return to work approximates 5 months; however, for a specific patient, the time to return to work is quite variable and multifactorial. It is important that future studies also analyze the factors and the time to return to preinjury work status.     

Access to kidney transplantation: the limitations of our current understanding

Since kidney transplantation (KTX) is the preferred means of treating kidney failure, ensuring that all patients who may benefit from KTX have equal access to this scarce resource is an important objective. Studies focusing on this issue will become increasingly important as the gap between the demand and supply of organs continues to increase, and changes to the United Network of Organ Sharing organ allocation policy are actively debated. However, it is clear that current methods used to study access to KTX have serious limitations. This review highlights the shortcomings of the methods currently used to assess access to KTX, and the limitations of registry data and national wait-list data as information sources to study patient access to KTX. The review also provides suggestions for research and analytical approaches that might be utilized to improve our future understanding of patient access to KTX. The information provided will aid the reader to critically assess issues related to patient access to KTX.     

Working together as a team: adolescent transplant recipients and nurse practitioners

Nurse practitioners are a critical part of the transplant team, enhancing the quality of patient care with their knowledge and skill with respect to disease-specific populations of patients. Adolescent transplant recipients are a vulnerable population and require specific considerations. Nurse practitioners can successfully tailor care to the adolescent developmental stages in order to promote quality of life, adherence to the medical regimen, and successful transition to adult transplant centers and to minimize risk-taking behaviors. Teamwork between the patient's family and the entire transplant team is important to optimize not only the patient's health but also to ensure quality of life after transplant. Adolescents can be especially challenging after transplant, given their complex and evolving psychosocial and cognitive development. Nurse practitioners are in a unique position to be central in adolescents' successful adaptation to their medical condition. Facilitating identification and management of medication-related side effects, awareness of emotional health and quality of life, adherence to the medical regimen, and eventual transition to adult caregivers all remain critically important steps in care that are ideally suited for advance practice leadership.     

How to stich? 90 degrees: The perfect angle

ObjectiveThis is a discussion about correct suturing techniques and implications that follow inappropriate suturing. We deconstruct the suturing needle angles and methods to be adopted to acquire the perfect needle angle to the tissue being sutured. A study of angles confirms that 90° is perceptible to the naked eye and easy to identify, making it an appropriate foundation to explain, communicate and teach the concepts in the wet-lab and the operating room.BackgroundThere is a lack of robust teaching regarding entry of the needle orthogonal to the tissue planes. In addition, objective methods of assessing angles of the needle relative to the tissue and consequences of inaccuracy are lacking. The authors aim to deconstruct the steps of suturing with the aim of demonstrating ninety degrees is the perfect suturing angle.Study designWe conducted a study to identify 90° (the perfect suturing angle) as an angle easy to identify with the naked eye. Angles from 86° to 94° and 41° to 49° were printed and presented to volunteers with the instruction to identify the angles of 90° and 45°.ResultsFifty-one volunteers replied to the 90° angle study and sixty-five volunteers replied to the 45° study. 92% correctly identified at least one 90° angle and 72% identified both the 90° angles. 63% identified at least one 45° angle and only 27% identified both the 45° angles presented to them. This supported our hypothesis that 90° is an angle that is readily identifiable to the human eye.ConclusionsObjective assessment of surgical skills and training should focus on the basic needle skills with particular emphasis on suturing angles, progressing to higher skills using low and intermediate fidelity models and correlating practice alongside the trainees' operative progress.     

Psychosocial, socio-cultural, and environmental influences on mental health help-seeking among African-American men

The social determinants unique to African-American men's health contribute to limited access and utilization of health and mental health care services and can have a deleterious effect on their overall health and well-being. There is a need to examine the complex issues concerning African-American men's help-seeking behaviors relative to mental health concerns. Current research estimates that African-American men are approximately 30% more likely to report having a mental illness compared to non-Hispanic Whites and are less likely to receive proper diagnosis and treatment. There is an extensive body of research that supports the view that women are more likely to seek help for psychological problems than African-American men. This review explores the psychosocial, environmental and socio-cultural factors that influence mental health help-seeking behavior among African-American men and explains the urgency to engage various stakeholders to pursue effective behavioral strategies. Research literature concerning the relationships between social determinants of health and their mental health help-seeking behaviors is reviewed and discussed in this paper. The article illustrates the need for mental health providers and researchers to establish feasible, culturally competent prevention and intervention strategies to increase help seeking behavior among African-American men, thereby contributing to the reduction of mental health disparities.