肝门阻断对肝硬化大鼠肠黏膜屏障的影响

目的 探讨肝硬化大鼠肝门阻断后肠道黏膜屏障结构和功能的改变.方法 40 只肝硬化模型雄性SD 大鼠被随机分为假手术组、肝门阻断10 min、肝门阻断20 min、肝门阻断30min 组,每组各10 只.在行肝门阻断术后18 h 乳果糖、甘露醇混合液灌胃,6 h 后收集尿液,检测乳果糖和甘露醇排出率及比值（L/M）,并于术后24 h 取未段回肠行病理组织学和电镜检查.结果 肝硬化大鼠肝门阻断10 min 时即出现明显小肠病理损伤,电镜下可见小肠微绒毛肿胀、缩短,紧密连结变宽.阻断20 min 时,小肠微绒毛缺失、脱落,细胞器肿胀.阻断30 min 时,可见部分肠黏膜细胞坏死,微绒毛脱落以及紧密连结破坏.肝门阻断10 min 组大鼠的尿中L/M 比值（0.069 ±0.022）明显高于假手术组（0.047 ± 0.016）,并随肝门阻断时间延长增高越明显.结论 肝硬化大鼠肝门阻断后可导制肠道黏膜通透性增加,肠黏膜屏障功能受损.     

选择性肠道去污染对肝硬化大鼠肝门阻断细菌移位、内毒素血症的影响

目的探讨选择性肠道去污染对肝硬化大鼠肝门阻断后肠道细菌移位、内毒素血症的效果。方法将制成肝硬化模型的60只雄性SD大鼠随机分为假手术组、肝门阻断30rain组（阻断组）及通过选择性肠道去污染预处理组（预处理组）,各20只。在实验术后30min及24h时分别取肠系膜淋巴结、肝、肺及门、腔静脉血作细菌培养,并取门、腔静脉血作内毒素检测。结果阻断组大鼠手术后30min即出现门、腔静脉血内毒素浓度升高（P〈0．01）,在手术24h后升高更明显。并在术后24h肠系膜淋巴结、肝组织及门、腔静脉血细菌培养出现阳性,主要为大肠杆菌。预处理组大鼠无论是手术30min还是24h后,门、腔静脉内毒素水平升高均不明显,较阻断组明显降低（P〈0．01）,肠道外组织及门、腔静脉血细菌培养阳性率也明显降低。结论肝硬化大鼠肝门阻断30min后早期即可出现内毒素血症,并于手术24h后出现明显肠道细菌移位。选择性肠道去污染能减少肝硬化大鼠肝门阻断后肠道细菌移位及内毒素血症的发生。     

应对突发事件抽组机动卫勤力量决策支持系统研究

目的：解决应对突发事件抽组机动卫勤力量的决策问题,为军队卫生管理部门提供实用性强、可视化的辅助决策工具,以提高区域预编军队卫生资源配置决策水平。方法：在军队卫生资源宏观配置研究的基础上,通过分析区域中观层面上突发事件与机动卫勤力量之间的距离和符合程度,构建了应急抽组决策系统和抽组评估系统。结果：研发了应对突发事件抽组机动卫勤力量决策支持系统,包括应急抽组和抽组评估两个分系统。结论：系统设计开放友善,可针对各种突发事件提供抽组方案,既可为军队卫生管理部门提供决策支持,又可为培养军队卫生管理干部提供训练工具。     

Normal saline and lung recruitment with paediatric endotracheal suction (NARES): A pilot,factorial, randomised controlled trial

Background/objectiveEndotracheal suction is one of the most common and harmful procuedres performed on mechanically ventilated children. The aim of the study was to establish the feasibility of a randomised controlled trial (RCT) examining the effectiveness of normal saline instillation (NSI) and a positive end-expiratory pressure recruitment manoeuvre (RM) with endotracheal suction in the paediatric intensive care unit.MethodsPilot 2 × 2 factorial RCT.The study was conducted at a 36-bed tertiary paediatric intensive care unit in Australia.Fifty-eight children aged less than 16 years undergoing tracheal intubation and invasive mechanical ventilation.(i) NSI or no NSI and (ii) RM or no RM with endotracheal suction . The primary outcome was feasibility; secondary outcomes were ventilator-associated pneumonia (VAP), change in end-expiratory lung volume assessed by electrical impedance tomography, dynamic compliance, and oxygen saturation-to-fraction of inspired oxygen (SpO₂/FiO₂) ratio.Results/FindingsRecruitment, retention, and missing data feasibility criteria were achieved. Eligibility and protocol adherence criteria were not achieved, with 818 patients eligible and 58 enrolled; cardiac surgery was the primary reason for exclusion. Approximately 30% of patients had at least one episode of nonadherence. Children who received NSI had a reduced incidence of VAP; however, this did not reach statistical significance (incidence rate ratio = 0.12, 95% confidence interval = 0.01–1.10; p = 0.06). NSI was associated with a significantly reduced SpO₂/FiO₂ ratio up to 10 min after suction. RMs were not associated with a reduced VAP incidence (incidence rate ratio = 0.31, 95% confidence interval = 0.05–1.88), but did significantly improve end-expiratory lung volume at 2 and 5 min after suction, dynamic compliance, and SpO₂/FiO₂ ratio.ConclusionRMs provided short-term improvements in end-expiratory lung volume and oxygenation. NSI with suction led to a reduced incidence of VAP; however, a definitive RCT is needed to test statistical differences. A RCT of study interventions is worthwhile and may be feasible with protocol modifications including the widening of participant eligibility.     

Valsalva manoeuvre in patients with different Parkinsonian disorders

The valsalva manoeuvre (VM), used as an autonomic function test, can detect sympathetic and/or parasympathetic autonomic dysfunction. This study investigated the value of VM in patients with different Parkinsonian syndromes (PS). We continuously recorded blood pressure, ECG and respiration among 38 patients with multiple system atrophy (MSA), 32 patients with progressive supranuclear palsy (PSP), 26 patients with idiopathic Parkinson’s disease (PD) and in 27 healthy subjects matched in age and sex (Con). VM was performed in addition to metronomic breathing and tilt-table testing. VM could not be analysed in 26% of the ES patients. Valsalva ratio (VR), as a parameter of cardiovagal function, was pathologically decreased in all patient groups. Valsalva ratio (VR) was not able to discriminate parasympathetic dysfunction between patients and controls as well as E/I ratio of metronomic breathing. As a parameter of sympathetic dysfunction during VM, the physiological increase of blood pressure was more often missing during phase IV than phase II especially in PD and MSA patients. Correlation with orthostatic hypotension during tilt-table testing was only moderate. Although VM can demonstrate sympathetic and parasympathetic autonomic dysfunction, we cannot recommend VM as a first line autonomic test in PS patients. Metronomic breathing and tilt-table test seem more capable as parasympathetic resp. and sympathetic function tests to identify cardiovascular abnormalities in PS patients.     

Operative Mortality,Blood Loss and the Use of Pringle Manoeuvres in 526 Consecutive Liver Resections

INTRODUCTION

Centres with high volumes of high-risk surgery have significantly better outcomes than low-volume centres for pancreatic resection, oesophagectomy and pelvic exenteration. However, this has not to date been conclusively demonstrated for hepatic resection. With increased experience, operative practice can change. The use of the Pringle manoeuvre reduced substantially over a 12-year period in a single centre as it was felt anecdotally that its use increased the incidence of hepatic insufficiency and operative mortality. This study was designed to review 12 years of experience in a single hepatobiliary centre

PATIENTS AND METHODS

Data regarding 526 consecutive liver resections were prospectively recorded and retrospectively analysed in a high-volume referral unit over a 12-year period. Patients'' demographics, operative mortality and morbidity were analysed on an annual basis.

RESULTS

Overall peri-operative mortality was 1.9%. Operative mortality in the first 6 years compared to the latter 6 years was 4.1% and 1.2%, respectively (P = 0.13). The morbidity rate was 26.8% and 20.3% in the first and second halves of the study, respectively (P = 0.15). With increased experience, intra-operative blood loss and patients receiving blood transfusions decreased (P = 0.047 and 0.03, respectively) while the number of intra-operative Pringle manoeuvres also decreased (P < 0.0001). Hospital stay decreased significantly over the 12 years (P = 0.049).

CONCLUSIONS

High-volume centres are the safest environment for hepatic resection. With increased experience, it may be possible to reduce the intra-operative use of the Pringle manoeuvre without increasing the intra-operative blood loss. This may be associated with a decrease in hepatic insufficiency and peri-operative mortality.     

Relationship between the margin of manoeuvre and the return to work after a long-term absence due to a musculoskeletal disorder: an exploratory study

Purpose.?The application of the margin of manoeuvre (MM) concept in work rehabilitation is new. It allows for variations in both health status and work demands, and the interaction between the two, to be taken into account. The objective of this exploratory study was to document the relationship between the presence of an MM in the workplace and the return to work (RTW), after a long-term absence.

Methods.?This study used the data collected during an earlier study that sought to identify the dimensions and indicators of the MM. The data were analysed on three levels, and the convergences and divergences in the MM indicators and dimensions in relation to the RTW were grouped accordingly.

Results.?Eleven workers and five clinicians participated in this study. The results support the proposition that the presence of a sufficient MM in the workplace is associated with RTW of individuals at the end of a rehabilitation programme despite a long-term absence (n == 6), and conversely, that its absence would appear to be associated with a non-return to work (n == 4).

Conclusions.?A better understanding of this concept will help further the development of a tool to assist clinicians in their task of assessing a worker's capacity to return to a given job.     

Pneumocephalus – an unreported risk of Valsalva's manoeuvre following cochlear implantation

Abstract

We describe a case of pneumocephalus as an unusual early postoperative complication following cochlear implantation. The aetiology of this condition we attribute to the patient's habit of ‘ear popping’ using Valsalva's manoeuvre