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英国学者Smith在 2 0 0 2年Lancet上回顾近年研发获准上市的治疗乳腺癌的药物就有 15种之多。如 :细胞毒类药物 :紫杉醇 ,多西紫杉醇 ,长春瑞宾 ,希罗达 ;内分泌类药物 :阿那曲唑 ,来曲唑 ,依西美坦 ,法乐通 ,诺雷德 ,Fulves trant;二膦酸盐类药物 :骨膦 ,帕米膦酸二钠 ,唑来膦酸 ,伊班膦酸 ;信号传导抑制剂 :赫赛汀。除Fulvestrant之外 ,其余药物都已在我国批准面市应用 ,或正在进行进口前注册试验 ,或在做国产新药的Ⅱ期临床研究。　　新药的不断研制开发 ,大大增加医患双方选择用药的余地 ,给临床治疗带来希望。但是如何更加规范地进行…     

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对原发性肝癌治疗方法的临床评价指标一般包括：(1)局部疗效，即清除肿瘤的彻底程度。(2)远期疗效，即生存期和生存率。(3)侵袭性，即与治疗相关的合并症发生率及其病死率。(4)操作性，即治疗手段的获得和实施是简便容易还是繁琐困难。(5)经济性，即医疗成本/效果比或医疗费用的高低。治疗的首要目标是彻底地清除肿瘤，目前     

肝细胞癌靶向治疗研究进展

原发性肝癌是目前我国第四位常见恶性肿瘤及第二位肿瘤致死病因, 肝细胞癌占原发性肝癌的近90%。既往肝细胞癌主要采用以手术切除为主的综合治疗, 随着靶向治疗的蓬勃发展, 肝细胞癌患者有了更多的治疗选择。本文就近年来肝细胞癌的靶向药物在单药治疗、联合治疗、新辅助治疗、转化治疗、辅助治疗的应用作一综述。     

胰腺癌的综合治疗研究进展

胰腺癌的预后极差,手术是可切除性胰腺癌的首选方式,胰腺癌对化疗及放疗均不敏感,迄今仍未取得实质性的突破,于是综合治疗逐渐成为胰腺癌治疗的共识。近年来,围绕胰腺癌治疗开展的靶向治疗、免疫治疗方面的研究如火如荼,尤其是胰腺癌疫苗方面的研究,取得了一些令人激动的初步成果;中医药治疗作为胰腺癌综合治疗的一部分,也展现出了令人期待的一面。本文对胰腺癌综合治疗方面的文献作一梳理,展示胰腺癌研究的最新动态。     

乳腺癌手术治疗进展

手术是治疗乳腺癌的主要手段之一.随着医学基础研究的深入,新理论,新观念,新技术使乳腺癌的外科治疗向更科学、更合理的方向迈进.保乳手术广泛开展,前哨淋巴结活检技术亦开始在临床应用,同时新辅助化疗能够增加乳腺癌保乳治疗的机会.乳腺癌外科治疗的新进展使得我们必须重视乳腺癌的个体化手术治疗.     

胰腺癌外科治疗现状:争议与共识

现阶段胰腺癌的外科治疗,虽有共识但更有争议,也存在一些正在探索中的问题。手术技术的进步、新的有效药物的出现、更为严谨的临床研究的开展、治疗模式的优化以及观念的更新,是促成胰腺癌外科治疗取得突破性进展的重要因素。     

微创治疗在退行性腰椎管狭窄症中的应用

目的观察微创治疗对退行性腰椎管狭窄症的临床效果。方法45例腰椎管狭窄症的成年病人,按治疗方法分为三组,每组15例。Ⅰ组,传统口服药物加硬膜外腔注射类固醇;Ⅱ组,Ⅰ组疗法加黄韧带射频热凝;Ⅲ组,Ⅱ组疗法加椎间盘射频热凝和/或椎间盘外胶原酶溶盘。治疗前和治疗后1周、1、3和6个月对间歇性跛行疼痛行VAS评分。结果治疗前三组VAS评分差异无显著性(P>0·05);治疗后各时点各组的VAS评分均比术前低,其中Ⅰ组最高,Ⅲ组最低,各组间比较差异有极显著性(P<0·01)。6个月内腰腿痛复发22例,其中Ⅰ组11例(73·0%)、Ⅱ组7例(46·7%)、Ⅲ组4例(26·7%),组间比较差异有极显著性(P<0·01)。三组病人对治疗满意度的平均分为1·8、2·3和2·8分。并发症为下肢区域性皮肤感觉异常,分别发生在Ⅱ组和Ⅲ组(各1例)。结论微创治疗对退行性腰椎管狭窄症有较好的治疗效果。     

食管癌的治疗进展

近年来食管癌的治疗取得了很大的进展。综述相关的治疗进展主要可以归纳为３个方面：手术治疗、综合治疗和内镜治疗。一、手术治疗手术是食管癌的主要治疗方法。食管癌手术治疗最瞩目的进展就是降低了手术后的死亡率和并发症。４０年代，食管癌手术治疗死亡率为７２％；７０年代为２９％；８０年代已经降低为１３％；自１９９０年以来进一步降低为１１％，甚至低于５％。这些成就部分归因于合适的病例选择和良好的围手术期处理。手术入路和淋巴结清扫的范围历来存在着争论。最常用的手术入路包括经食管裂孔法（ｔｒａｎｓｈｉａｔａｌＴＨＥ…     

夜间遗尿症的诊治

遗尿的概念是指尿流的一种不随意改变。这一概念单独应用比较含糊,在此仅限于发生在夜间睡眠时的尿床,更确切的应称为夜间遗尿。 5岁儿童中大约有15％在夜间尿床。通常夜间遗尿持续到5岁或7岁左右才引起注意,它不是直到7岁父母才期望他不再尿床,而是与开始进入社会有关。夜间遗尿的自然缓解率大约为15％,     

肾病综合征的治疗

肾病综合征 (ＮＳ)不是一个独立的疾病 ,而是许多疾病过程中 ,损伤了肾小球毛细血管滤过膜的通透性而发生的一个症候群。其典型表现是大量蛋白尿 ( 2 4ｈ尿蛋白定量在 3.5 ｇ以上 )、低蛋白血症 (血浆白蛋白在 30 ｇ/Ｌ以下 )、高度水肿和高脂血症。ＮＳ的治疗不仅以减少或消除尿蛋白为目的 ,同时应当重视保护肾功能 ,减缓肾功能恶化的程度 ,预防合并症的发生。　　 1　一般治疗1 .1　休息　当ＮＳ发生时应以卧床为主 ,可以床边做适当活动。当ＮＳ缓解后可逐步增加活动 ,但应注意观察尿蛋白的情况 ,如果尿蛋白在活动后增加时 ,则应酌情减少…     

Vasopressor hormone response following mesenteric traction during major abdominal surgery

Background : We investigated the vasopressor hormone response following mesenteric traction (MT) with hypotension due to prostacyclin (PGI₂) release in patients undergoing abdominal surgery with a combined general and epidural anesthesia. Methods : In a prospective, randomized, placebo-controlled study we administered 400 mg ibuprofen (i.v.) in 42 patients scheduled for abdominal surgery. General anesthesia was combined with epidural anesthesia (T4-L1). Before as well as 5, 15, 30, 45, and 90 min after MT we recorded plasma osmolality, hemodynamics and measured 6-keto-PGFlα (stabile metabolite of PGI₂), TXB₂ (stabile metabolite of thromboxane A₂) active renin, and arginine vasopressin (AVP) plasma concentrations by radioimmunoassay. Catecholamine levels were assessed by high-pressure liquid chromatography (HPLC) with electrochemical detection. Results : Following MT, arterial hypotension occurred along with a substantial PGI₂ release. This was completely abolished by ibuprofen administration. Although plasma levels of 6-keto-PGF_1α (1133 (708) vs. 60 (3) ng/L, median (median absolute deviation), P=0.0001, placebo vs. ibuprofen) remained significantly elevated, blood pressure was restored within 30 min after MT in the placebo group. At the same point in time plasma concentrations of TXB² (164 (87) vs. 58 (1) ng/L, P=0.0001), epinephrine (46 (33) vs. 14 (6) ng/L, P=0.001), AVP (41 ± (18) vs. 12 (7) ng/L, P=0.0004), and active renin (27 (12) vs. 12 (4) ng/L, P = 0.001) were significantly higher in placebo-treated patients. Conclusion : Under combined general and epidural anesthesia arterial hypotension following MT due to endogenous PGI₂ release is associated with enhanced release of AVP, active renin, epinephrine and thromboxane A₂, presumably contributing to hemodynamic stability within 30 min after MT.     

Microspheres Based Detoxification System: A New Method in Convective Blood Purification

Abstract: A variety of protein-bound or hydrophobic substances, accumulating as a result of pathologic conditions such as exogenous or endogenous intoxications, are removed poorly by conventional detoxification methods because of low accessibility (hemodialysis), insufficient adsorption capabilities (hemosorption), low efficiency (peritoneal dialysis), or economic limitations (high-volume plasmapheresis). Combining advantages of existing methods with microspheric technology, a module-based system was designed. Major operating parameters of the latter can be modified to allow for adjustment to individual clinical situations. An extracorporeal blood circuit including a plasmafilter is combined with a secondary high-velocity plasma circuit driven by a centrifugal pump. Different microspheric adsorbers can be combined in one circuit or applied in sequence. Thus, a prolonged treatment can be tailored using specially designed selective adsorber materials. Comparing this system with existing methods (high-flux hemodialysis, molecular adsorbent recycling system), results from our in vitro studies and animal experiments demonstrate the superior efficiency of substance removal.     

Bariatric Surgery in Some "Central and East-European (former Eastern bloc)"Countries - Current Status and Prediction for the Next Millennium

Background: Obesity is increasing globallly, including in the formerly "Eastern Bloc" countries. Methods: A survey was made of obesity and bariatric surgery. Results: In the 8 East and Central European countries studied, with total population 300 million, roughly 43% of the population was overweight (BMI 25-30), 23% obese (BMI > 30), with about 15 million people morbidly obese (BMI > 40). From 0-10 morbidly obese individuals/100,000/year undergo bariatric surgery. Conclusion: Most countries were found to provide inadequate treatment for obesity.The majority of the morbidly obese are not treated effectively. However, health-care awareness of obesity and bariatric surgeons are slowly increasing.     

Synergistic interaction between the effects of propofol and midazolam with fentanyl on phrenic nerve activity in rabbits

Background: It has been shown that the depressive effects of both propofol and midazolam on consciousness are synergistic with opioids, but the nature of their interactions on other physiological systems, e. g. respiration, has not been fully investigated. The present study examined the effect of propofol and midazolam alone and in combination with fentanyl on phrenic nerve activity (PNA) and whether such interactions are additive or synergistic. Methods: PNA was recorded in 27 anaesthetised and artificially ventilated rabbits. In three groups, propofol, fentanyl and midazolam were administered intravenously in incremental doses to construct dose-response curves for the depressant effects of each one on PNA. In another two groups, the effect of pretreatment with either fentanyl 1 μg · kg^?1 i. v. or midazolam 0.05 mg · kg^?1 i. v. on the effects of propofol and fentanyl respectively on PNA were studied. Results: Propofol and fentanyl caused a dose-dependent depression of PNA with complete abolition at the highest total doses of 16 mg · kg^?1 i. v. and 32 μg · kg^?1 i. v., respectively. In contrast, midazolam in incremental doses to a total of 0.8 mg · kg^?1 reduced mean PNA by 63%, but approximately 12% of PNA remained at a total dose as high as 6.4 mg · kg^?1. The mean ED₅₀s, calculated from dose-response curves, were 5.4 mg · kg^?1, 3.9 μg · kg^?1 and 0.4 mg · kg^?1 for propofol, fentanyl and midazolam, respectively. Initial doses of either fentanyl 1 μg · kg^?1 i. v. or midazolam 0.05 mg · kg^?1 i. v. acted synergistically with subsequent doses of either propofol or fentanyl to abolish PNA at total doses of 8 mg · kg^?1 and 8 μg · kg^?1, respectively. Conclusion: Fentanyl has a synergistic interaction with both propofol and midazolam on PNA and hence potentially on respiration.     

Influence of dopexamine hydrochloride on haemodynamics and regulators of circulation in patients undergoing major abdominal surgery

Background: Catecholaminergic support is often used to improve haemodynamics in patients undergoing major abdominal surgery. Dopexamine is a synthetic vasoactive catecholamine with beneficial microcirculatory properties. Methods: The influence of perioperative administration of dopexamine on cardiorespiratory data and important regulators of macro- and microcirculation were studied in 30 patients undergoing Whipple pancreaticduodenectomy. The patients received randomized and blinded either 2 μg · kg^?1 · min^?1 of dopexamine (n=15) or placebo (n=15, control group). The infusion was started after induction of anaesthesia and continued until the morning of the first postoperative day. Endothelin-1 (ET-1), vasopressin, atrial natriuretic peptide (ANP), and catecholamine plasma levels were measured from arterial blood samples. Measurements were carried out after induction of anaesthesia, 2 h after onset of surgery, at the end of surgery, 2 h after surgery, and on the morning of the first postoperative day. Results: Cardiac index (CI) increased significantly in the dopexamine group (from 2.61±0.41 to 4.57±0.78 1 · min^?1 · m^?2) and remained elevated until the morning of the first postoperative day. Oxygen delivery index (DO₂I) and oxygen consumption index (VO₂I) were also significantly increased in the dopexamine group (DO₂I: from 416±91 to 717±110 ml/m² · m²; VO₂I: from 98±25 to 157±22 ml/m² · m²), being significantly higher than in the control group. pHi remained stable only in the dopexamine patients, indicating adequate splanchnic perfusion. Vasopressive regulators of circulation increased significantly only in the untreated control patients (vasopressin: from 4.37±1.1 to 35.9±12.1 pg/ml; ET-1: from 2.88±0.91 to 6.91±1.20 pg/ml). Conclusion: Patients undergoing major abdominal surgery may profit from prophylactic perioperative administration of dopexamine hydrochloride in the form of improved haemodynamics and oxygenation as well as beneficial influence on important regulators of organ blood flow.     

Systemic analgesia adapted to the children's condition

A concept of balanced analgesia using nonsteroidal anti-inflammatory drugs (NSAIDs), paracetamol (acetaminophen), opioids, and corticosteroids can also be used in patients with pre-existing illnesses. NSAIDs are the most effective treatment for acute pain of moderate intensity in children; however, these drugs should be avoided in patients at increased risk for serious side effects, e.g. patients with renal impairment, bleeding tendency, or extreme prematurity. NSAIDs can be given with minimal risks to the younger child with mild to moderate asthma, and, in these patients, the use of steroids can be encouraged; in addition to their antiemetic and analgesic action, a beneficial effect on asthma symptoms can be expected. In the non-intubated child with cerebral trauma, exaggerated sedation caused by opioids and increased bleeding tendency caused by NSAIDs must be avoided. In neonates and small infants, the oral administration of sucrose or glucose is helpful to minimize pain reaction during short uncomfortable interventions.     

Intraoperative autotransfusion is associated with modest reduction of allogeneic transfusion in prosthetic hip surgery

Background: The efficacy of intraoperative salvage and washing of wound blood and the predictors of allogeneic red cell transfusions in prosthetic hip surgery are insufficiently known.
Methods: In 96 patients, undergoing primary or revision surgery, salvaged and washed red cells and, if necessary, allogeneic blood were used to keep haematocrit not lower than 33%. The bleeding of red cells during hospital stay was calculated from the red cell balance. The preoperative red cell reserve (millilitres of red cells in excess of a haematocrit of 33%) was estimated and the difference between this volume and the total bleeding of red cells was retrospectively used to classify patients with regard to the need for red cells. Stepwise regression analysis was used to define patient-related variables associated with allogeneic blood transfusion.
Results: Preoperative knowledge of the type of operation (primary, revision), the preoperative red cell reserve, and the body mass could predict roughly half of the need for banked blood (r²=0.45). Only one-third of the total bleeding of red cells was retransfused. For complete avoidance of allogeneic blood, autotransfusion was most effective in patients with a moderate need (0–4 u). However, 32% of such patients required allogeneic blood.
Conclusions: Autotransfusion has a limited efficacy to decrease the need for allogeneic blood, and other blood-saving methods should be added for this purpose. It is difficult to predict the need for allogeneic blood preoperatively.     

缺氧对肾小管上皮细胞分泌外泌体的影响

目的    观察缺氧对肾小管上皮细胞分泌外泌体的影响,探讨外泌体在缺氧致肾脏损伤中的作用及机制。 方法    （1）常氧（21% O₂）及缺氧（1% O₂）分别处理大鼠肾小管上皮细胞（NRK-52E）48 h,收集细胞上清液并使用高速梯度离心法分离外泌体。采用透射电镜、纳米示踪分析、Western印迹、蛋白浓度定量鉴定并比较两组外泌体的基本特性。（2）在共培养实验中,以不同浓度（1、10、50、100、300 mg/L）的常氧外泌体、缺氧外泌体分别干预脂多糖（LPS）诱导的大鼠原代腹腔巨噬细胞,使用实时荧光定量PCR与酶联免疫吸附试验（ELISA）法分别检测巨噬细胞白细胞介素6（IL-6）、肿瘤坏死因子α（TNF-α）、诱导型氮氧化物合酶（iNOS）水平;使用Western印迹法检测巨噬细胞磷酸化（p）STAT/STAT及细胞因子信号传导抑制蛋白1（SOCS1）的蛋白表达;最后,使用实时荧光定量PCR法检测常氧外泌体与缺氧外泌体中炎性反应相关微RNA（microRNA,miR）的表达差异。 结果    （1）离心得到的囊泡具有外泌体典型的结构,粒径小于150 nm,表达外泌体标志蛋白CD63,说明分离得到外泌体。缺氧对肾小管上皮细胞分泌的外泌体形态、粒径分布比例无明显影响,但提高了外泌体的分泌量。（2）缺氧外泌体相比于常氧外泌体促进了LPS诱导的M1型巨噬细胞IL-6、TNF-α、iNOS 的表达和分泌（均P＜0.01）,同时提高STAT的磷酸化水平并减少SOCS1的蛋白表达（均P＜0.01）;对炎性反应相关microRNA检测发现缺氧外泌体中miR-155、miR-27a表达量较常氧外泌体明显升高（P＜0.05）。 结论    缺氧可改变外泌体的生物学功能,表现为协同促进LPS诱导的M1型巨噬细胞的表型转化,这可能是慢性肾脏病微炎性反应状态持续的原因之一。     

In Vitro Function and Durability Assessment of a Novel Polyurethane Heart Valve Prosthesis

Abstract While flexible-leaflet, central-flow prosthetic heart valves promise relief from anticoagulation therapy, they continue to be restricted by inadequate durability. In consequence, a novel trileaflet valve, made entirely from polyurethane, has been developed. A batch of 6 consecutively manufactured polyurethane valves was subjected to hydrodynamic function and accelerated fatigue testing. Computerized data acquisition and control systems have been introduced to improve valve testing methodologies. In terms of hydrodynamic function, the polyurethane valve demonstrates transvalvular pressure gradients similar to those for a bioprosthetic valve (Carpentier-Edwards) and levels of retrograde flow significantly less than those for either the bioprosthetic valve or a bileaflet mechanical valve (St Jude Medical). The equivalent of 10 years of cycling without failure has been exceeded by all 6 polyurethane valves in accelerated fatigue tests with 2 valves remaining intact after 674 million cycles (equivalent to approximately 17 years) in continuing tests. Highspeed photography revealed considerable differences in leaflet motion between valves cycled at accelerated and physiological rates.     

Negative pressure ventilation vs. spontaneous assisted ventilation during rigid bronchoscopy: A controlled randomised trial

Background: Ventilation during interventional rigid bronchoscopy (IRB) under general anaesthesia (jet ventilation, positive pressure ventilation and spontaneous assisted ventilation) may offer some difficulties. This study compares the effectiveness during IRB of intermittent negative pressure ventilation (INPV) and spontaneous assisted ventilation (SAV). Methods: Thirty-eight patients submitted to IRB were randomised into two groups: SAV or INPV. All patients received a total intravenous anaesthesia; INPV patients were paralysed. Pre-and intra-operative arterial blood gases and O₂ flow through a rigid bronchoscope were assessed. The endoscopist applying a subjective score evaluated the operating conditions. Results: Patients of the INPV group, as compared to the SAV group, required a lower dosage of fentanyl (2.6 ± 1.8 (μg · kg^?1· h^?1 vs. 6.6 ± 4.8 μg · kg^?1· h^?1), a lower O₂ supply (3.3 ± 2.8 1/min vs. 11.6 ± 3.4 1/min), a shorter recovery time (5.4 ± 2.9 min vs. 9.8 ± 7.1 min) and no manually assisted ventilation (0 ± 0 vs. 1 ± 1.1 nd?/procedure). Intraoperative PaCO₂ was higher in the SAV (8.1 ± 1.3 kPa) than in the INPV group (5.0 ± 1.6 kPa) and intraoperative pH differed in the two groups (7.26 ± 0.05, SAV vs. 7.47 ± 0.08, INPV). Operating conditions, as assessed by a subjective score, were considered better with INPV than with SAV (4.9 vs. 4.3). Conclusions: As compared to SAV, INPV in paralysed patients during IRB reduces administration of opioids, shortens recovery time, prevents respiratory acidosis, excludes the need for manually assisted ventilation, reduces 02 need and affords optimal surgical conditions. INPV appears a safe, non-invasive and effective ventilatory management during IRB.