医学院校沟通技能教学现状的量化评估

目的 调查医学院校沟通技能教学现状,为医学沟通课程改革提供依据.方法 采用Dalhousie医学院研制的医学院校沟通技能教学评估问卷对260名医学学生进行调查.结果 91.5%学生认为沟通技能很重要;85.0%认为沟通课程应贯穿在整个医学教育过程中;86.6%认为需要通过更多与患者接触来提升沟通技能;70.7%认为角色扮演有助于提升沟通技能教学效果;71.5%认为教师反馈不充分;76.1%认为需要更多地学习沟通技能,以提升自我沟通能力.结论 需要尽早对学院课程进行改革,采用合理科学的方法对教师和学生进行沟通技能培训,能提高教师及学生的沟通技能.     

2009“第四届新西兰-中国-亚太区微创妇科论坛”在奥克兰获圆满成功

由以国内外著名的微创妇科专家,澳大利亚新南威尔士大学Felix Wong教授为主席的“论坛专家委员会”（Forum Expert Committee,FEC）和《中国微创外科杂志》编辑部联合主办的“第四届新西兰-中国-亚太区微创妇科论坛”予2009年8月28日～9月4日在新西兰奥克兰CophthorneHotel成功举行。来自北京、     

Steroid-Free Immunosuppression Since 1999: 129 Pediatric Renal Transplants with Sustained Graft and Patient Benefits

Despite early promising patient and graft outcomes with steroid-free (SF) immunosuppression in pediatric kidney transplant recipients, data on long-term safety and efficacy results are lacking. We present our single-center experience with 129 consecutive pediatric kidney transplant recipients on SF immunosuppression, with a mean follow-up of 5 years. Outcomes are compared against a matched cohort of 57 concurrent recipients treated with steroid-based (SB) immunosuppression. In the SF group, 87% of kidney recipients with functioning grafts remain corticosteroid - free. Actual intent-to-treat SF (ITT-SF) and still-on-protocol SF patient survivals are 96% and 96%, respectively, actual graft survivals for both groups are 93% and 96%, respectively and actual death-censored graft survivals for both groups are 97% and 99%, respectively. Unprecedented catch-up growth is observed in SF recipients below 12 years of age. Continued low rates of acute rejection, posttransplant diabetes mellitus (PTDM), hypertension and hyperlipidemia are seen in SF patients, with sustained benefits for graft function. In conclusion, extended enrollment and longer experience with SF immunosuppression for renal transplantation in low-risk children confirms protocol safety, continued benefits for growth and graft function, low acute rejection rates and reduced cardiovascular morbidity.     

硝酸甘油预防ERCP术后胰腺炎及高淀粉酶血症的临床应用研究

目的 探讨硝酸甘油对经内镜逆行胰胆管造影(ERCP)术后胰腺炎(PEP)和高淀粉酶血症的预防作用.方法 选择2008年1～12月在山东省交通医院肝胆外科住院治疗、经CT或MRI证实为胆总管结石、拟实施ERCP、经内镜乳头括约肌切开术(EST)及经内镜取石的患者100例,按照随机数字表法随机分为硝酸甘油组(n=50)与对照组(n=50),检测2组患者术前、术后3 h和24 h血清淀粉酶水平以及术后高淀粉酶血症和PEP的发生情况.结果 2组患者术前血清淀粉酶水平的差异无统计学意义(P＞0.05),2组患者术后3 h和24 h血清淀粉酶水平均高于术前水平(P＜0.01),但硝酸甘油组术后3 h及24 h血清淀粉酶水平[(108.88±152.07) U/L,(97.02±113.38) U/L]均分别显著低于对照组术后3 h及24 h血清淀粉酶水平[(196.30±244.41) U/L,(234.22±406.05) U/L],P＜0.05.硝酸甘油组ERCP术后的高淀粉酶血症发生率(12.00%,6/50)和PEP发生率(2.00%,1/50)均分别显著低于对照组[高淀粉酶血症30.00%(15/50),PEP 14.00%(7/50)],P＜0.05.结论 舌下含化硝酸甘油可降低ERCP术后血清淀粉酶水平,对PEP及高淀粉酶血症均有预防作用.     

巨噬细胞移动抑制因子在大鼠急性坏死性胰腺炎模型中的作用研究

目的初步探讨巨噬细胞移动抑制因子（MIF）在大鼠急性坏死性胰腺炎（ANP）发病中的作用。方法健康雄性SD大鼠60只,随机分成三组,分别为对照组（腹腔注射生理盐水）、ANP组（腹腔注射左旋精氨酸）和干预组（腹腔注射左旋精氨酸＋单克隆抗MIF抗体）,每组20只。采用左旋精氨酸改良方法建立ANP模型,分别于3、6、12、24h四个不同时点处死5只大鼠,剖腹后从肠系膜上静脉取血,ELISA法测定血清MIF、TNF-α、IL-1、IL-6和IL-8水平 碘比法测定血淀粉酶 切取胰腺组织依据Kusske标准行胰腺病理学评分 Western blot法测定胰腺组织NF-κBp65蛋白的表达。结果ANP组血淀粉酶及胰腺组织病理学评分各时点㈦对照组相比均显著升高,干预组㈦ANP组相比均显著降低（P〈0.01） 胰腺组织NF-κBp65蛋白的表达于造模后3h开始呈持续性上调,与对照组相比其表达显著增多,在干预组其表达水平㈦ANP组相比明显下调（P〈0.01） 血清MIF、TNF-α、IL-1、IL-6各时点在ANP组与正常对照组相比其水平均有明显升高,在干预组其水平㈦ANP组相比显著降低（P〈0.05） 血清IL-8在6、12、24h不同时点水平变化同上述因子,但在3h时点其水平无明显升高 MIF、胰腺组织病理学评分及胰腺组织NF-κBp65蛋白的表达,两两之间均成正相关（P〈0.05）。结论腹腔注射左旋精氨酸建立ANP的模型是稳定的 MIF可能通过调控核因子NF-κB的途径影响血清TNF-α、IL-1、IL-6及IL-8水平而在大鼠急性胰腺炎发病过程中起一定的作用。     

Surgical Strategy for Hepatocellular Carcinoma Patients with Portal Vein Tumor Thrombus Based on Prognostic Factors

Rationale  Surgical strategy for patients with hepatocellular carcinoma and portal vein tumor thrombus (PVTT) remains to be established. Methods  From 1990 to 2008, 48 hepatocellular carcinoma patients with PVTT detected by preoperative imaging underwent hepatic resection, and their clinical data were retrospectively analyzed. Possible prognostic factors for survival were analyzed with postoperative survival curves, and significant factors were determined by univariate and multivariate analysis. The frequency of postoperative severe complications was investigated for each prognostic factor. Results  Significant prognostic factors included patient age <60 years, serum total bilirubin (T-Bil) >0.8 mg/dl, serum aspartate aminotransferase >30 IU/L, serum alkaline phosphatase (ALP) >300 IU/L, tumor size >4 cm, PVTT in the main trunk (Vp4), and a surgical margin <1 mm by univariate analysis, and independent prognostic factors were serum T-Bil, ALP, and Vp4. No patient with Vp4 survived for more than 400 days after surgery, and frequency of postoperative severe complications in these Vp4 patients was significantly higher than in other Vp1–3 patients. Conclusion  Hepatic resection as a first-choice treatment should be carefully selected in patients with Vp4 unless emergent removal of the PVTT is required.     

Accurate Preoperative Localization of Insulinomas Avoids the Need for Blind Resection and Reoperation: Analysis of a Single Institution Experience with 17 Surgically Treated Tumors over 19 Years

Introduction  Presently, the need for and choice of preoperative localization tests for insulinomas remain controversial. We report the results from a single institution experience whereby the management policy adopted was that of accurate preoperative localization before surgical exploration. Materials and Methods  From 1990 to 2008, 17 patients with a clinical and biochemical diagnosis of an insulinoma who underwent surgery were retrospectively reviewed. The diagnosis of all insulinomas were confirmed pathologically. Results  All tumors were localized preoperatively and an average of 2.2 preoperative localization studies including 1.4 noninvasive studies and 0.8 invasive studies were utilized per patient. Invasive localization modalities were more sensitive (92%) than noninvasive modalities in localizing insulinomas (71%). Intra-arterial calcium stimulation with hepatic venous sampling was the most sensitive invasive modality (100%), whereas magnetic resonance imaging was the most sensitive noninvasive modality (63%). Fifteen of 17 tumors (88%) were localized intraoperatively via inspection/palpation and/or intraoperative ultrasonography. Both insulinomas which were not localized intraoperatively were localized correctly to the distal pancreas via preoperative transhepatic portal venous sampling. None of the patients required a blind resection or surgical reexploration for failed localization. All 17 patients underwent complete surgical resection which included eight enucleations and nine distal pancreatectomies with a cure rate of 94% (16/17) at a median follow-up of 35 (range, 1–217) months. The postoperative morbidity and long-term outcome of enucleation was similar to distal pancreatectomy despite a higher rate of microscopic margin involvement. Conclusion  Accurate preoperative localization of insulinomas is useful as it eliminates the need for blind distal pancreatectomy and avoids reoperation. Complete surgical resection is the treatment of choice, and whenever possible, a pancreas-sparing approach such as enucleation should be adopted.     

经尿道电切术治疗女性膀胱颈梗阻12例

目的探讨经尿道电切治疗女性膀胱颈梗阻的疗效。方法对12例女性膀胱梗阻患者行径尿道膀胱颈电切术治疗,年龄51±13岁,病程3个月-5年,尿流率3.8±11.4ml／s,残余尿200-800ml术后随诊6个月以上。结果手术均获成功,手术时间15-50min,平均25min,术中出血〈20ml。12例患者排尿症状评分,最大尿流率平均18ml／s,残余尿均〈50ml。最大尿流率、残余尿量等均较术前显著改善,随访无尿失禁、尿瘘发生。结论经尿道电切术治疗女性膀胱颈梗阻疗效显著,并发症少。     

小隐静脉-腓肠神经营养血管逆行岛状皮瓣修复儿童足部软组织缺损

目的 探讨小隐静脉-腓肠神经营养血管逆行岛状皮瓣在修复儿童足部软组织缺损中的应用特点.方法 2006年7月至2008年6月,应用小隐静脉一腓肠神经营养血管逆行岛状皮瓣修复儿童足背、足跟及足踝部软组织缺损8例,皮瓣切取范围6 cm×5 cm～9 cm×7 cm,除2例足踝部外,6例修复足背、足跟,皮瓣上界超过小腿中上1/3交界处,其中1例接近胭窝横纹.结果 8例皮瓣全部成活良好.经1-17个月的随访,皮瓣外观满意,感觉功能有部分恢复,足跟处亦未出现溃烂,供区无功能障碍,双小腿发育未见明显差异,外观稍受影响.皮瓣上界可超过小腿中上1/3交界处达胭窝横纹,皮瓣旋转点位于外踝尖后上方4～6 cm.结论 儿童小隐静脉一腓肠神经营养血管逆行岛状皮瓣存活的范围与成人相比差异不大,操作简单,对小腿发育未见明显影响.是修复足部软组织缺损的较好方法.     

胸腔镜下胸腰段疾病的前路手术及内固定

目的回顾胸腔镜下前路减压、植骨内固定治疗胸腰椎骨折、结核和椎间盘突出症的经验,评价胸腔镜技术在脊柱前路手术中的应用价值。方法收集12例接受胸腔镜下前路手术患者的临床资料,分析操作技术、手术时间、出血量以及功能恢复情况。结果胸腰椎骨折8例;结核3例;椎间盘突出症l例。平均手术时间210min,平均出血量600ml,平均住院时间12d。1例结核患者因严重骨质疏松而放弃内固定,仅作病灶清除植骨术。所有患者随访3—10个月,神经功能恢复与普通开胸前路手术近似,骨折复位良好,植骨块和内固定未发现移位,活动基本恢复正常。结论胸腔镜下脊柱前路手术创伤小,并发症及出血量少,术后恢复快,为胸腰椎前路手术提供了一种安全、有效的操作技术。