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.     

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.     

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.     

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.     

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.     

High-performance teams for current and future physician leaders: an introduction

The scope of patient management increasingly crosses the defined lines of multiple medical specialties and services to meet patient needs. Concurrently, many hospitals and health-care systems have adapted new multidisciplinary team structures that provide patient-centric care as opposed to the more traditional discipline-centered delivery of care. As health care continues to evolve, the use of teams becomes even more critical in allowing interdependence between multiple disciplines to provide excellent care delivery and ongoing patient management. The use of teams permeates the health-care industry (and has done so for many years), but confusion about the structure, role, and use of teams contributes to limited effectiveness. The health-care industry's underuse of the fundamentals of corporate teamwork has, in part, created ineffective team leadership at the physician level. As the first in a series of documents on teamwork, this article is intended to introduce the reader to the rudiments of team theory and to present an introduction to a model of teamwork. The role of current and future physician leaders in ensuring team effectiveness is emphasized in this discussion. By educating health-care professionals on the foundations of high-performance teamwork, we hope to accomplish two main goals. The first goal is to help create a common and systematic taxonomy that physician leaders and institutional management can agree on and refer to concerning the development of high-performance health-care teams. The second goal is to stimulate the development of future physician leaders who use proven teamwork principles as a powerful modality to achieve efficient and optimal patient care. Most importantly, we wish to emphasize that health care, both philosophically and practically, is delivered best through high-performance teams. For such teams to perform properly, the organizational environment must support the team concept tangibly. In concert, we believe the best manner in which to cultivate knowledge and performance of the health-care organizational mission and goals is by using such teams.     

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.     

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.     

天人合一理论在中医美容中的应用

天人合一是中医美容理论体系的特色之一，认为人的生命活动与大自然息息相关，强调人体必须与天地自然界保持高度的和谐、协调，才可能保持健康长寿，容颜晚衰。人体是一个小天地，是一个有机整体；同时人又生活在天地之间，是整个物质世界的一部分，人的生命活动与大自然息息相关，故防治损美性疾病既强调调节机体自身状况，又主张灵活顺应气候及地理环境变化，即三因制宜，从而改善人体机能，达到内外和谐统一，最终实现健康长寿、容颜晚袁。本文对天人合一的内涵及其损美性疾病治疗的指导进行了阐释。     

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     

Ethical issues in palliative care

The relief of suffering is one of the aims of health care. Pain relief is a moral obligation in health care, not an optional extra. Doctors have moral obligations to strive to relieve pain, to be competent in basic pain control, and to endeavour to give patients an adequate understanding of their illness and painkillers. The most common moral problem in pain control in terminally ill patients is the conflict between the obligation to relieve suffering and the obligation to prolong life. The law prohibits intentionally causing the death of another person. Debates follow as to what constitutes an intention to cause death, and what actually constitutes a cause of death. At present, doctors are legally permitted to give sedatives and analgesics to terminally ill patients with the intention of relieving suffering, even if life is shortened. The moral principle of the ‘double effect’ relates to this and is explained. It relies on a distinction between intended and foreseen effects of treatment. Some people dispute the distinction between intended and foreseen effects and claim that the principle of double effect allows doctors who intend euthanasia to carry it out under cover of the law. This debate is explored in the article. Finally, is it ever morally justifiable to end the patient’s life on the grounds that this is the only way to end pain? Even if it is, should euthanasia be legalised? A brief comment on these issues, and the roles of law and morality, are made.     

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.     

The problems in France created by the HIV/AIDS epidemic at the onset of the third millenium

UNANSWERED QUESTIONS: The HIV/AIDS epidemic represented a medical, social and political challenge to our society. It raises numerous questions, to which some replies have been partially proposed. In the context of less attention paid to AIDS, the epidemic continues to create problems in France and has led to the debates on medical and sanitary questions and other political, social and economical issues. FROM A THERAPEUTIC POINT OF VIEW: Among the issues concerning health management, those related to treatment are first-line: progress in therapeutic indications, choice of antiretroviral molecules and their combinations, particular aspects of treatments delivered in certain circumstances (pregnant women or primary-infection), difficulties in the assessment of the benefit/risk progress. The problems of compliance that occasionally induce severe side effects, provoke therapeutic failure in some patients and for whom rapid access to new antiretroviral molecules and new therapeutic strategies is mandated. THE CROSS-LINK WITH POLITICAL, SOCIAL AND ECONOMIC PROBLEMS: The resulting debates partly depend on the progress made in therapeutics. The latter have led to expectations of HIV-infected patients, who would like to benefit fully from the promise of a return to normal life (access to insurance and medically-assisted procreation). HIV/AIDS has led to new ethical debates on the rights of patients, such as those related to screening, clinical research or confidential access of under-aged patients to treatment. Some of these aspects involve political decisions: prevention measures to be taken against the possibility of a new epidemic, the risks and damages related to the use of drugs and the guarantee of access to treatment of patients living in under-developed countries.     

Bone mineral content, gender, body posture, and build in relation to back pain in middle age

In 575 55-year-old residents of Malm?, Sweden, the authors studied the interrelationships between back pain and bone mineral content, degree of kyphosis and lordosis, height, and weight, and in women also the age of menarche and menopause, and number of childbirths. Men with back pain tended to be heavier than those without back pain. Back pain was not related to body height nor to degree of kyphosis or lordosis. In women, a positive correlation was found between the degree of kyphosis and lordosis and body weight. Body height in women also was correlated to degree of kyphosis, but not to the degree of lordosis. In men, the authors found no such relationships. Bone mineral content was not related to the occurrence of back pain but to body height and weight in men and in women. Back pain in women was not related to the age at menarche or menopause, nor to the number of children to whom they had given birth.     

Radiosurgery for pituitary tumors and craniopharyngiomas

Standard techniques of conventional radiation therapy have been used for many years to treat pituitary adenomas and craniopharyngiomas. These techniques are not always effective and carry with them morbidity in the form of damage to the normal pituitary gland, damage to the hypothalamus, the potential of damage to the visual system and to intellectual functions of the brain and a small but real risk of the development of secondary malignancies. In an effort to avoid these complications and to provide more effective adjunctive radiation therapy, techniques of stereotactic delivery of high-dose radiation to the pituitary region have been developed, known as radiosurgery. The history of the development of radiosurgery and its application to pituitary problems are recounted in this article, as are a number of the controversies that currently exist and need to be considered as these modalities of stereotactic radiosurgery are applied more frequently and to better effect in the future.     

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.     

Treating work-injured patients in Europe. The Italian experience

According with to International Labor Office, the European Union gave the directions to improve the life of workers not only by regulating care, but also safety and return to work. Each European country is conforming to this. In Italy, INAIL, an independent body under the control of the Department of Labor and the Ministry of Health, covers the workers for occupational accidents and is funded by an insurance premium, obligatory paid by the employer. INAIL has the medicolegal task of assessment of injuries, supply of prostheses, physical therapy, and various compensation according to the degree of disability and the type of work. The specific treatment of the injured workers is carried out by the SSN, which is in charge of the outpatient treatment and hospitalization; however, INAIL contributes to the costs according to agreements made with each region. Although on one hand the injured worker is fully protected by the regulations, on the other hand, he or she is obliged to abide to the laws of security and to undergo treatment offered. In returning to work, certain factors are taken into account, such as percentage of disability, type of work, and discomfort that disability produces in carrying out work. Should the type or severity of the disability not allow complete return to work, support is given to assess and integrate the reduced working ability of the injured worker with regards to the workplace, even by adapting the latter to solve structural and environmental problems. INAIL, in accordance with the European Council, is committed to the total care of the worker and not only worker meaning "work force." In fact, health care and economic aid are integrated with the safety and rehabilitation of the worker and his or her return to family, social, and working life.     

Anatomy of the posterolateral aspect of the goat knee.

The purpose of this study was to determine the anatomy of the posterolateral aspect of the goat knee for future in vivo studies using a goat model to examine the natural history of posterolateral knee injuries. Twelve non-paired, fresh-frozen, adult goat knees were dissected to determine the anatomy of the posterolateral corner. The main posterolateral structures identified in the goat knee were the lateral collateral ligament, the popliteus muscle and tendon, popliteomeniscal fascicles, and the lateral gastrocnemius muscle. The lateral collateral ligament was extra-articular and coursed from its proximal attachment, located posterior and proximal to the lateral epicondyle, to its distal attachment on the lateral aspect of the fused proximal tibiofibula. The popliteus muscle attached to the medial edge of the posterodistal tibia, traveled anterolaterally, became intra-articular at its musculotendinous junction, and attached to the lateral femur just distal to the lateral epicondyle. Distinct popliteomeniscal fascicles attached the lateral meniscus to the popliteus muscle and tendon, and a fascial attachment from the musculotendinous junction of the popliteus muscle coursed to the lateral tibial plateau. This study provided information on the structures present in the posterolateral aspect of the goat knee and enhanced our understanding of their relationships to analogous structures in the human knee. This information is important to enable future development of potential models of the natural history of posterolateral knee injuries and also to test surgical techniques and the in vivo effects of these injuries on cruciate ligament reconstructions.