Outcomes of laparoscopic bile duct exploration for choledocholithiasis with small common bile duct

BACKGROUNDLaparoscopic cholecystectomy (LC) combined with laparoscopic common bile duct (CBD) exploration (LCBDE) is one of the main treatments for choledocholithiasis with CBD diameter of larger than 10 mm. However, for patients with small CBD (CBD diameter ≤ 8 mm), endoscopic sphincterotomy remains the preferred treatment at present, but it also has some drawbacks associated with a series of complications, such as pancreatitis, hemorrhage, cholangitis, and duodenal perforation. To date, few studies have been reported that support the feasibility and safety of LCBDE for choledocholithiasis with small CBD.AIMTo investigate the feasibility and safety of LCBDE for choledocholithiasis with small CBD.METHODSA total of 257 patients without acute cholangitis who underwent LC + LCBDE for cholecystolithiasis from January 2013 to December 2018 in one institution were reviewed. The clinical data were retrospectively collected and analyzed. According to whether the diameter of CBD was larger than 8 mm, 257 patients were divided into large CBD group (n = 146) and small CBD group (n = 111). Propensity score matching (1:1) was performed to adjust for clinical differences. The demographics, intraoperative data, short-term outcomes, and long-term follow-up outcomes for the patients were recorded and compared.RESULTSIn total, 257 patients who underwent successful LC + LCBDE were enrolled in the study, 146 had large CBD and 111 had small CBD. The median follow-up period was 39 (14-86) mo. For small CBD patients, the median CBD diameter was 0.6 cm (0.2-2.0 cm), the mean operating time was 107.2 ± 28.3 min, and the postoperative bile leak rate, rate of residual CBD stones (CBDS), CBDS recurrence rate, and CBD stenosis rate were 5.41% (6/111), 3.60% (4/111), 1.80% (2/111), and 0% (0/111), respectively; the mean postoperative hospital stay was 7.4 ± 3.6 d. For large CBD patients, the median common bile duct diameter was 1.0 cm (0.3-3.0 cm), the mean operating time was 115.7 ± 32.0 min, and the postoperative bile leak rate, rate of residual CBDS, CBDS recurrence rate, and CBD stenosis rate were 5.41% (9/146), 1.37% (2/146), 6.85% (10/146), and 0% (0/146), respectively; the mean postoperative hospital stay was 7.7 ± 2.7 d. After propensity score matching, 184 patients remained, and all preoperative covariates except diameter of CBD stones were balanced. Postoperative bile leak occurred in 11 patients overall (5.98%), and no difference was found between the small CBD group (4.35%, 4/92) and the large CBD group (7.61%, 7/92). The incidence of CBDS recurrence did not differ significantly between the small CBD group (2.17%, 2/92) and the large CBD group (6.52%, 6/92).CONCLUSIONLC + LCBDE is safe and feasible for choledocholithiasis patients with small CBD and did not increase the postoperative bile leak rate compared with chole-docholithiasis patients with large CBD.     

Fostering a culture of engagement: a pilot study of the outcomes of training mental health nurses working in two UK acute admission units in brief solution-focused therapy techniques

It is widely acknowledged that there are major concerns about quality of care, ward atmosphere, the nature of nurse–patient interactions and patient outcomes in UK psychiatric acute admission units. Brief solution-focused therapy (SFT) is an approach which aims to shift the focus of interactions in professional care away from the traditional concentration on an individual's problems and weaknesses towards a more proactive identification of their strengths and positive coping mechanisms. This approach relies on a collaborative engagement with patients, in which the nurse or therapist using simple language aims to help the patient construct a plan to ensure their immediate safety while working to identify, focus on and reinforce their strengths and coping mechanisms in the achievement of identified future goals. This paper reports on a pilot study whose principal objective was to determine whether a short training in brief SFT for psychiatric nurses can produce measurable improvements in nurse–patient interactions in two psychiatric acute admission wards. In this study, 36 nurses undertook a 2-day training course in SFT and were followed up 3 months after training. Positive results were obtained on a number of measures indicating that nurses had acquired knowledge and skills and were applying SFT techniques in their clinical work.     

ELISA中和(竞争)抑制法检测HBeAb试剂盒共系统检测HBeAg结果分析

目的 探讨用中和(竞争)抑制法检测HBeAb EIA[(预包被纯化乙肝e抗体(HBeAb]商品试剂盒共系统检测乙肝e抗原(HBeAg)的可行性及结果判定方法.方法 用中和(竞争)抑制法检测HBeAbELISA试剂盒共系统检测1000份随机血清(浆)标本HBeAb与HBeAg,并与常规ELISA双抗体夹心法检测HBeAg试剂盒检测HBeAg作平行对照.结果 ELISA共系统检测HBeAg,其阳性检测孔显色较HBeAg阴性参比对照孔明显加深,甚至比HBeAb阴性对照孔还深(或明显加深),易于目测;其比色判定临界值(COV)易于设定(或使用.HBeAg临界值血清或HBeAb阴性对照),与常规ELISA检测HBeAg比色判定无显著性差异(配对计数资料比较的x2检验:相关检验均为P＜0.005,v=1,a=0.05;优劣检验依次为HBeAg临界值血清①P＞0.900,v=1,a=0.05;HBeAb阴性对照②0.100＞P＞0.050,v=1,a=0.05;ELISA共系统检测HBeAgCOV③0.100＞P＞0.050,v=1,a=0.05;但x12＜x22＜x32).结论 用中和(竞争)抑制法检测HBeAbELISA商品试剂盒能够兼测HBeAg,在有优质现代酶标仪的实验室,可以省去常规ELISA双抗体夹心法检测HBeAg试剂盒,实用价廉,值得推广.     

腹腔镜胆总管探查取石术后胆管一期缝合与T管引流比较的系统评价

目的系统评价腹腔镜下胆总管探查取石后胆管一期缝合(LBEPS)与腹腔镜下胆总管探查取石后T管引流(LCHTD)治疗胆总管结石的效果,为医患双方合理选择术式提供证据。方法计算机检索Cochrane图书馆临床对照试验数据库(2010年第2期)、PubMed(1978～2010)、EMbase(1966～2010)、CBM(1978～2010)、CNKI(1979～2010)和中华医学会数字化期刊系统(1990～2010),并手工检索中、英文已发表的资料和会议论文并追索纳入文献的参考文献,查找比较LBEPS与LCHTD治疗胆总管结石的随机或半随机对照试验。在对纳入研究进行方法学质量评价后,采用RevMan 5.0软件进行Meta分析。结果共纳入3个随机对照试验和1个半随机对照试验,合计274例患者。Meta分析结果表明:与LCHTD相比,LBEPS能缩短手术时间[WMD=–17.11,95%CI(–25.86,–8.36)]、腹腔引流时间[WMD=–0.74,95%CI(–1.39,–0.10)]、术后住院天数[WMD=–3.30,95%CI(–3.67,–2.92)]和减少住院费用[WMD=–2998.75,95%CI(–4396.24,–1601.26)],而且还能降低由放置T管引起的脱管及拔管后胆漏、胆汁性腹膜炎等并发症的发生[RR=0.56,95%CI(0.29,1.09)]。结论 LBEPS治疗胆总管结石总体疗效优于与LCHTD,其前提是需严格掌握手术适应症。由于纳入研究质量普遍较低,上述结论尚需开展更多设计合理、执行严格的多中心大样本且随访时间足够的随机对照试验加以验证。     

双镜结合选择性术中胆道造影治疗胆囊炎急性发作65例临床分析

目的评价双镜结合选择性术中胆道造影治疗胆囊炎急性发作的疗效。方法回顾性分析本院2007年1月～2010年12月65例按腹腔镜联合胆道镜结合选择性术中胆道造影方法治疗胆囊炎急性发作的临床资料。结果 43例行腹腔镜下胆囊切除术,6例中转开腹行胆囊切除术,16例发现或证实胆总管内有结石,其中3例中转开腹行胆囊切除+胆总管切开取石,13例腔镜手术成功,其中1例胆道镜经胆囊管切开取石术,胆总管未放置T管;12例行腔镜下胆囊切除+胆总管切开胆道镜取石术,胆总管内放置T管,术后6～8周行纤维胆道镜检查,1例发现残余结石,拔除T管后经窦道取净,11例未发现胆总管残余结石,再次行胆道造影后未发现结石,拔除T管,术中出血30～130 mL,手术时间90～220 min,术后住院4～8 d,所有病例均无发生并发症。结论腹腔镜联合胆道镜结合选择性术中胆道造影治疗胆囊炎急性发作并胆总管结石,患者创伤小,康复快,胆管结石残留少,安全有效,减少不必要的阴性胆总管切开探查。术中不能取净胆总管结石者,术后可通过T管窦道行纤维胆道镜取石。     

青春期肥胖超重儿大、中动脉内中膜及血流动力学变化的超声研究

目的 分析青春期肥胖儿颈总动脉、足背动脉内中膜厚度,血流动力学变化与BMI指数之间的关系.方法 采用彩色多普勒超声分别测量40名肥胖青少年、37名超重青少年和42名正常体重青少年颈总、足背动脉内径、内中膜厚度（intimal-medial thickness,IMT）及血流动力学指标.生化分析法检测空腹血糖、空腹胰岛素,计算胰岛素抵抗指数.结果 与体重正常组相比,肥胖组和超重组的BMI、颈总及足背动脉IMT、空腹血糖（FBS）、空腹胰岛素（FINS）、胰岛素抵抗指数（IR）均明显升高,差异有显著性（P〈0.05）.足背动脉反应性充血前后血管内径变化百分率肥胖、超重组较正常对照组降低,差异有显著性（P〈0.05）.结论 肥胖超重组青少年普遍存在胰岛素抵抗;肥胖超重组青少年的颈总、足背动脉的内中膜厚度及血流动力学改变与肥胖程度有关,提示肥胖超重组青少年的血管内皮功能受损.     

Point-of-Care Ultrasound Assists Diagnosis of Spontaneously Passed Common Bile Duct Stone

BackgroundCholedocholithiasis complicates approximately 10% of gallstone disease. Spontaneous stone migration out of the common bile duct (CBD) may occur in as many as 20% of choledocholithiasis cases. A decrease in CBD caliber occurs in the setting of spontaneous stone passage, but to our knowledge, this finding has not been appreciated using point-of-care ultrasound (POCUS) in the emergency medicine setting.Case ReportA 49-year-old woman presented to our Emergency Department (ED) with a complaint of epigastric pain radiating to the left shoulder. On examination she was found to have epigastric tenderness to palpation, but no guarding or rebound. POCUS demonstrated a dilated common bile duct, and her liver function tests were abnormally high. She was admitted to Medicine with concern for choledocholithiasis and plan for endoscopic retrograde cholangiopancreatography (ERCP), but her pain had resolved shortly after ED arrival. A repeat ultrasound examination demonstrated a normal-caliber common bile duct approximately 3 h after the initial scan.Why Should an Emergency Physician Be Aware of This?Choledocholithiasis often requires admission and invasive testing. Using POCUS in conjunction with liver function tests and patient assessments may obviate a need for ERCP.     

Proactive delivery of nicotine replacement therapy to families of hospitalized infants in a NICU: A randomized controlled pilot trial

Neonatal ICU (NICU) hospitalizations provide opportunities to engage individuals/families who smoke with evidence-based cessation treatments to protect infants from tobacco smoke exposure. The aim of this pilot study was to establish the feasibility and potential efficacy of providing motivational advice and NRT (MA + NRT) to families of NICU infants. RCT methodology equally allocated participants who reported ≥1 household smoker (N = 32) from a large NICU to MA + NRT or referral to a Quitline. The primary outcome was accepting NRT patches (MA + NRT) and use of NRT. Bayesian analyses modeled NRT use as a function of treatment group. Most MA + NRT participants (81.3%; n = 13) accepted the patches. No Quitline participants called the Quitline. NRT use differed across groups, indicating a 0.907 posterior probability that a positive effect for MA + NRT exists (RR = 2.32, 95% CI = [0.68–11.34]). This study demonstrated feasibility and acceptability for offering NRT and motivational advice to NICU parents and supports further intervention refinement with NICU families.     

Ultrasound measurements of carotid intima–media thickness by two semi‐automated analysis systems

Increased carotid intima–media thickness (cIMT) is associated with an increased risk of cardiac events and stroke. Several semi‐automated edge‐detection techniques for measuring cIMT are used for research and in clinical practice. Our aim was to compare two currently available semi‐automated techniques for the measurement of cIMT. Carotid ultrasound recordings were obtained from 99 subjects (mean age 54·4 ± 8·9 years, range 33–69) without known cardiovascular diseases using a General Electric (GE) Vivid 7 ultrasound scanner, 8‐MHz transducer. The far‐wall cIMT was evaluated 1–2 cm proximal to the carotid bulb. Three diastolic images (ECG R‐wave) from the left and three images from the right common carotid arteries were analysed using GE and Artery Measurement System (AMS) semi‐automated softwares. Mean systolic and diastolic blood pressures were 120 ± 13 and 76 ± 8 mmHg, respectively. The cIMT_mean (left + right)/2 by GE and cIMT_mean (left + right)/2 AMS were highly correlated (r = 0·92, P<0·001). Higher values were measured by GE (0·72 ± 0·12 mm) compared with AMS (0·69 ± 0·12 mm), and this was significant (P<0·001). The coefficients of variation for the intra‐observer variability of cIMT_mean (left + right)/2 were 1·0% (GE) and 2·2% (AMS). cIMT_mean measured by GE's semi‐automated edge‐detection method correlated well with that measured by AMS. However, there were small but significant systematic differences between the cIMT_mean values measured by the two techniques. Thus, the use of only one type of measurement program seems favourable in follow‐up studies and when evaluating treatment effects.     

Development and Psychometric Evaluation of a Fatigability Index for Full-Time Wheelchair Users With Spinal Cord Injury

Objective

To develop and evaluate psychometrically a self-reported instrument assessing physical fatigability (PF) and mental fatigability (MF) in adults with spinal cord injury (SCI).