腹腔镜门静脉高压症贲门周围血管离断术的风险评估

目的 探讨腹腔镜在外科治疗门静脉高压症手术风险及手术技巧.方法 自 2011 年 6 月以来,46 例诊断为肝炎肝硬变、门静脉高压症、食管胃底静脉曲张,肝功能分级 Child A 级 32 例,B 级 14 例.术前胃镜检查了解食管胃底静脉曲张;门静脉彩超,了解门静脉有无血栓;上腹部 CT 增强扫描,了解脾脏大小,脾动、静脉走行,二级脾蒂分叉部位,脾门以及胃底、贲门周围曲张静脉分布情况.采用 4 孔法,取脐上 10 mm 戳孔为腹腔镜观察孔,左锁骨中线约与脐平线 12 mm 戳孔,为主操作孔;剑突左侧肋缘下 2 cm 处 5 mm 戳孔、左腋前线约与脐平线 12 mm 戳孔为辅操作孔,术者、一助均位于患者右侧.LS 技术操作我们采用前入路与侧入路结合方法,离断脾动脉、胃短血管时用前入路,游离脾肾、脾膈韧带,离断脾蒂时运用侧入路;贲门周围血管离断采用前入路.结果 全腹腔镜成功实施 38 例肝硬化门静脉高压症脾切除加贲门周围血管离断术,7 例术中出现不可控出血中转,1 例慢性胰腺炎术中无法分离出脾动脉中转.手术时间 142 ～ 218 min,平均（ 167 ± 44 ） min,术中出血80 ～ 280 ml,平均（ 113 ± 76 ） ml.采用预先结扎脾动脉,Endo Cut 闭合切割一级脾蒂或二级脾蒂,无出血、胰漏并发症,无死亡病例.术后第 2 天拔除胃管,第 3 天拔除腹腔引流管,术后 7 ～ 12 d 出院.结论 通过上腹部 CT,谨慎进行贲门周围血管离断术手术风险评估,正确的操作步骤,准确的分离层面,娴熟的腹腔镜下分离技巧,处理脾蒂血管动作精细,预防出血,保持视野清晰,尽管风险很大,腹腔镜手术治疗门静脉高压症还是安全、可行的.     

“I Wasn't Alone”—A Study of Group Prenatal Care in the Military

The military has recognized that health and quality of life for service members are closely tied to the resources for their families, including how they are cared for during pregnancy and childbirth. However, there has been little examination of women's experience with different models of prenatal care (PNC) in military settings. The purpose of this article is to describe the results of a qualitative study of women's experiences with the CenteringPregnancy model of group PNC compared to individual PNC in two military health care settings. This clinical trial enrolled 322 women who were randomized into group or individual PNC at two military treatment facilities. Qualitative interviews were completed with 234 women during the postpartum period. Interpretative narrative and thematic analysis was used to identify three themes: 1) “I wasn't alone”—the experience with group PNC; 2) “I liked it but…”—recommendations to improve group PNC; and 3) “They really need to listen”—general concerns across the sample about PNC. Greatest concerns of women in individual PNC included lack of continuity and time with the provider. Our military families must be assured that their health care system meets their needs through personal and family‐centered care. Group PNC offers the potential for continuity of provider while also offering community with other women. In the process, women gain knowledge and power as a health care consumer.     

应用密度梯度离心结合免疫磁珠法富集孕妇外周血中胎儿NRBC的实验研究

目的研究利用不连续密度梯度离心结合免疫磁珠方法,分选孕妇外周血中的胎儿有核红细胞(NRBC)。方法采集21名孕周在12-28周的孕妇外周血10ml,经不连续密度梯度离心后,再用免疫磁珠法分选和富集胎儿NRBC,同时对富集前后的孕妇外周血进行瑞氏染色和胎儿血红蛋白(fetal hemoglobin,HbF)特异性抗体标记、识别。结果未经分选、富集,21名孕妇外周血有核细胞层涂片经瑞氏染色检查均未发现NRBC;梯度离心富集后21名孕妇中有11例外周血有核细胞涂片找到1～8个NRBC;再经免疫磁珠分离后有12例涂片发现1～7个NRBC,同时进行HbF特异性抗体标记,证实其NRBC阳性涂片中均存在胎源性NRBC。结论本研究初步建立了分选、富集胎儿NRBC的实验方法,通过进一步的方法学改进,有望用于产前基因筛查的研究。