胰腺癌病人围手术期营养支持要点

胰腺癌病人发生围手术期营养不良的风险极高,而围手术期营养不良的发生将严重影响病人预后。一方面,术前营养状态差将影响手术时机的抉择、增加术后并发症发生的风险;另一方面,术后短期内营养状态差可导致住院时间延长、术后并发症发生率及病死率增加。长期的营养不良对病人生存质量及生存时间带来巨大负面影响。因而建议：（1）当体重下降＞10%（血浆白蛋白＜30 g/L）时,考虑推迟手术,并给予强化营养支持治疗,同时动态监测营养状态。（2）当体重下降5%～10%时,仍建议营养支持先于手术的治疗策略,对可切除胰腺癌病人密切监测营养状态,选择最佳手术时机,实现R0切除。（3）术后可依据加速康复外科理念给予营养支持,以实现快速康复,帮助病人进入下一阶段治疗。（4）术后应重视对胰腺外分泌功能不全的诊断及治疗。     

急性基底动脉闭塞患者血管内支架机械取栓治疗的临床效果研究

目的　探讨急性基底动脉闭塞（ABAO）患者使用Solitaire AB型支架血管内机械取栓治疗的临床疗效和安全性,并分析影响临床预后的因素。方法　回顾性分析2015年3月—2017年12月于河北医科大学第二医院神经内科住院治疗的16例ABAO患者资料。其均使用Solitaire AB型支架系统进行血管内机械取栓治疗,分析血管内机械取栓治疗的血管再通率及并发症,评估治疗90 d临床预后,分析影响临床预后的因素。结果　16例患者中14例（14/16）顺利完成血管内机械取栓治疗。11例（11/16）患者的闭塞血管成功再通〔改良的脑缺血治疗分级（mTICI）3级或2b级〕。术中未发生症状性颅内出血事件,1例（1/16）取栓支架回收失败,1例（1/16）发生医源性夹层。术后90 d内随访共5例（5/16）患者死亡。存活患者改良Rankin量表（mRS）评分为（2.0±1.4）分。7例（7/16）患者预后良好（mRS评分≤2分）,9例（9/16）患者预后不良（mRS评分>2分或死亡）。预后良好与预后不良患者性别、术前美国国立卫生研究院卒中量表（NIHSS）评分、术前颅脑CT后循环急性卒中预后早期评分（pc-ASPECTS）、就诊时昏迷发生率、就诊时偏瘫发生率、发病至入院时间、发病至血管再通时间比较,差异均有统计学意义（P<0.05）。结论　使用Solitaire AB型支架进行的血管内机械取栓治疗ABAO患者,有较高的血管再通率,可改善临床预后。 椎底动脉供血不足;支架;血管内操作;机械溶栓     

The minimum test battery to screen for binocular vision anomalies: report 3 of the BAND study

Purpose

This study aims to report the minimum test battery needed to screen non‐strabismic binocular vision anomalies (NSBVAs) in a community set‐up. When large numbers are to be screened we aim to identify the most useful test battery when there is no opportunity for a more comprehensive and time‐consuming clinical examination.

Methods

The prevalence estimates and normative data for binocular vision parameters were estimated from the Binocular Vision Anomalies and Normative Data (BAND) study, following which cut‐off estimates and receiver operating characteristic curves to identify the minimum test battery have been plotted. In the receiver operating characteristic phase of the study, children between nine and 17 years of age were screened in two schools in the rural arm using the minimum test battery, and the prevalence estimates with the minimum test battery were found.

Results

Receiver operating characteristic analyses revealed that near point of convergence with penlight and red filter (> 7.5 cm), monocular accommodative facility (< 10 cycles per minute), and the difference between near and distance phoria (> 1.25 prism dioptres) were significant factors with cut‐off values for best sensitivity and specificity. This minimum test battery was applied to a cohort of 305 children. The mean (standard deviation) age of the subjects was 12.7 (two) years with 121 males and 184 females. Using the minimum battery of tests obtained through the receiver operating characteristic analyses, the prevalence of NSBVAs was found to be 26 per cent. Near point of convergence with penlight and red filter > 10 cm was found to have the highest sensitivity (80 per cent) and specificity (73 per cent) for the diagnosis of convergence insufficiency. For the diagnosis of accommodative infacility, monocular accommodative facility with a cut‐off of less than seven cycles per minute was the best predictor for screening (92 per cent sensitivity and 90 per cent specificity).

Conclusion

The minimum test battery of near point of convergence with penlight and red filter, difference between distance and near phoria, and monocular accommodative facility yield good sensitivity and specificity for diagnosis of NSBVAs in a community set‐up.

     

三种双眼视功能障碍的鉴别诊断及处理方法

目前,集合不足、基本型外隐斜、假性集合不足三种双眼视功能障碍引发的视疲劳在视光学门诊中较为常见,由于这三种视功能障碍的症状和体征相似,视光师如果仅对单纯的某个指标进行分析往往会造成误诊,因此在对此类患者进行鉴别诊断时,需要对患者的远近眼位、调节反应、AC/A、正/负相对调节等各个体征进行综合分析以准确诊断和归类。根据诊断结果,提供合适的配镜处方、训练方法以及日常生活建议,才能最好地缓解视力疲劳,维持正常双眼视功能。     

单眼水平直肌后徙联合缩短术与内直肌斜向缩短术治疗集合不足型外斜视的疗效对比

目的：比较单眼水平直肌后徙联合缩短手术与内直肌斜向缩短术对集合不足型外斜视的治疗效果。方法：前瞻性研究。对2016年9月到2017年2月在郑州大学第一附属医院就诊的36例集合不足型外斜视患者行手术治疗,随访时间≥6个月。根据手术方式不同分为3组：单眼水平直肌后徙联合缩短手术组（A组,16例）、单眼内直肌斜向缩短术组（B组,9例）和双眼内直肌斜向缩短术组（C组,11例）。A组中外直肌按照看远斜视度数后徙,内直肌按照看近斜视度数缩短。B组和C组中内直肌肌止端上端按照看远斜视度数缩短,肌止端下端按照看近斜视度数缩短。术后正位的评价标准为看远斜视度在±10 △ 以内。采用Fisher精确概率检验、重复测量方差分析进行数据分析。结果：随访期末,A组正位占比为14/16例,显著高于B组（2/9例）和C组（4/11例）,差异具有统计学意义（均P < 0.05）。A组看近和看远斜视度均小于其他2组,差异具有统计学意义（均P < 0.05）。3组间手术后看近和看远斜视度的差异无统计学意义。结论：单眼水平直肌后徙联合缩短手术中外直肌按照看远斜视度数后徙,内直肌按照看近斜视度数缩短设计术式,可以有效治疗集合不足型外斜视,优于内直肌斜向缩短手术。     

Pregnancy following diagnosis of premature ovarian insufficiency: a systematic review

The aim of this review is to report the occurrence of pregnancies in women with premature ovarian insufficiency (POI), naturally or with different treatments (hormonal replacement therapy, IVF, in-vitro maturation and stem cell therapy). This study involved an exhaustive search of the electronic databases MEDLINE, PubMed and Embase covering the period January 2000 to January 2018. A combination of Medical Subject Heading and text words was used to generate a subset of citations, including studies involving POI (‘premature menopause’ or ‘premature ovarian failure’ or ‘POI’ or ‘hypergonadotrophic amenorrhoea’). This subset of citations was then combined with ‘AND’ to the Medical Subject Heading term ‘pregnancy’. Fifteen studies were included in this review. Two randomized controlled trials, two observational studies, and 11 interventional studies reporting cases of pregnancy in women with POI were included. This review reports pregnancy rates across studies ranging from 2.2% to 14.2%. Mean age in patients who achieved a pregnancy was 30 years, highlighting that oocyte quality in these patients is likely unaffected. No treatment has thus far shown its superiority in improving fertility in women with POI. Recent advances in options such as in-vitro maturation and stem-cell therapy, however, are likely to be the future of treatment and may generate new hope for these patients.     

Investigation of soluble anti-Müllerian hormone receptor type 2 as a biomarker for diagnosis of female fertility disorders

Research questionThe ectodomain of the anti-Müllerian hormone (AMH) type 2 receptor is shed by proteases under certain conditions, which makes it measurable in the blood. The aim of this study was to identify correlations of soluble anti-Müllerian hormone receptor type 2 (sAMHR2) with other sex hormone concentrations and to assess whether sAMHR2 may serve as a new biomarker in fertility disorders.DesignIn a retrospective cross-sectional study of women (n = 186) with different gynaecological–endocrinological disorders, mixed-effect models were used to analyse the correlation with established diagnostic hormone tests. Receiver operating characteristic curve analysis was performed to assess the diagnostic performance.ResultsThere was a strong correlation of sAMHR2 with LH (r = 0.898) and FSH (r = 0.846) and a moderate correlation of AMH with testosterone (r = 0.666) and androstenedione (r = 0.696) (all P < 0.001). In diagnoses of polycystic ovary syndrome (PCOS), AMH showed the best performance (area under the curve [AUC] 0.981, cut-off 4 ng/ml) with 96% sensitivity and 94% specificity. sAMHR2 concentrations and sAMHR2/AMH ratios were elevated in women with ovarian insufficiency, compared with all other study groups, including post-menopausal women on hormone replacement therapy. Highest sensitivity and specificity (100% and 98.2%, respectively) were achieved with sAMHR2/AMH ratio for the diagnosis of post-menopausal status (cut-off 68.85). The sAMHR2/AMH ratio (AUC 0.997) had a better performance than sAMHR2 (AUC 0.947), FSH (AUC 0.989) and LH (AUC 0.967).ConclusionsThe sAMHR2/AMH ratio may serve as a useful biomarker for infertility diagnostics to identify post-menopausal women.     

高流量湿化氧疗的临床应用研究进展

高流量湿化氧疗（HFNC）是一种新型的供氧装置,能够以最大流量60 L/min输送100％的加湿、加热氧气,与传统的氧气输送装置相比其存在诸多优势。越来越多的证据表明HFNC是成人早期呼吸衰竭的有效治疗方法。但也有研究指出,不适当使用HFNC可能会延迟气管插管并增加病死率,还有报道HFNC造成严重漏气事件,尽管缺乏一套指导HFNC使用的指南,但将其应用于不同疾病及临床环境已成为惯例。本文从HFNC的生理效应及其在临床中的一系列应用等方面进行综述,为HFNC的临床应用提供依据和参考。