胃食管折迭术治疗食管静脉曲张出血

本文报告1986～1991年,作者采用贲门周围血管离断加 Nissen 氏胃底成形术治疗门脉高压并食管静脉曲张出血40例。急症手术全部立即止血,出院的37例术后6～52个月随访.无再出血病例。3例作了术中食管压力测定.其包裹折迭部压力分别为3.47、3.87、4.27个 kPa。术后食管测压26例,食管下段压力范围为2.5～4.27kPa,平均3.52kPa。其中3例於术后17、19、21个月测压,食管下段静息压仍分别为3.88、3.64、3.46kPa。表明胃食管折迭术后食管下段腔内压明显增高。作者讨论了胃食管折迭术在食管静脉曲张出血病人的临床应用。认为:只要正确掌握折迭缝合的松紧度.本术式具有确定的近期止血作用且可以有效预防再出血。     

Antidepressant use during pregnancy and risk of postpartum hemorrhage: A systematic review and meta-analysis

Evidence about relationship between antidepressant use during pregnancy and the risk of postpartum hemorrhage (PPH) is conflicting. The aim of this meta-analysis was to systematically assess this relationship. To identify relevant studies, we conducted systematic searches in PubMed and Embase of articles published through May 2016. Random-effects models were adopted to estimate overall relative risk. In total, eight studies involving more than 40,000 PPH cases were included in our meta-analysis. After pooling the estimates, the odds for developing PPH were 1.32-fold higher (risk ratio, RR = 1.32; 95% confidence interval, CI = 1.17–1.48) in antidepressant users compared with individuals who had not taken antidepressants. In subgroup analyses, the associations still exist for women with exposure to non-SRI (RR = 1.31, 95% CI = 1.1–1.56), SRIs (RR = 1.23, 95% CI = 1.06–1.44), SSRIs (RR = 1.2, 95% CI = 1.04–1.38), and SNRIs (RR = 1.62, 95% CI = 1.41–1.85). Based on exposure window, we found an increased risk of PPH among current (RR = 1.37, 95% CI = 1.09–1.71) and recent users (RR = 1.32, 95% CI = 1.15–1.51), but not past users (RR = 1.08, 95% CI = 0.88–1.31). The findings of this meta-analysis support an increased risk of PPH in women exposure to antidepressant during late gestation.     

扁桃体术后出血的处理与预防

目的探讨扁桃体切除术后出血的原因和预防措施。方法总结113例扁桃体切除术后出血病例,从手术指征、麻醉方式、手术方法、术后止血等方面进行综合分析。结果扁桃体切除术后出血率为4.9%（113/2305）。Ⅰ°出血17例、Ⅱ°出血24例、Ⅲ°出血70例、Ⅳ°出血2例、无Ⅴ°出血病例。全组病例在止血后24h内创面伪膜形成,无高热、白细胞升高等感染现象,无再出血现象,无死亡病例。术后3～5d出院。结论严格掌握手术指征和手术时期,充分做好术前准备,熟练手术技巧和术后仔细检查,能有效控制术后出血。     

A Novel Percolation Method for Determining Solubilities of Pharmaceutical Agents in Semisolid Vehicles

A novel technique was developed to quantify the solubility of pharmaceutical actives in semisolid formulations. Ointments and emulsions of increasing potencies were sheared to disrupt their internal microcrystalline networks. These sheared materials were held in taut cheesecloth pouches, and the bleed that percolated out was collected and assayed for active potency. The solute concentration in the bleed was proportional to the concentration of the solute in solution in the formulation. Plots of bleed active potency against total formulation potency rose linearly to the point of formulation saturation. Above saturation, bleed potencies remained constant, producing plateaus on the solubility plots. The formulation potency at the onset of plateau quantified the saturation solubility of the active in each formulation. This technique was demonstrated with butylparaben in three ointment bases, and with hydrocortisone in an emulsion formulation. The solubility estimates thus obtained were confirmed experimentally by optical microscopy. This novel technique permits saturation solubilities to be determined for a range of semisolid formulations, with much greater accuracy than was previously possible.     

Validation of a power law model in upper extremity vessels: potential application in ultrasound bleed detection

Vascular ultrasound can provide quick and reliable diagnosis of arterial bleeding but it requires trained and experienced personnel. Development of automated sonographic bleed detection methods would potentially be valuable for trauma management in the field. We propose a detection method that (1) measures blood flow in a trauma victim, (2) determines the victim’s expected normal limb arterial flow using a power law biofluid model where flow is proportional to the vessel diameter taken to a power of k and (3) quantifies the difference between measured and expected flow with a novel metric, flow split deviation (FSD). FSD was devised to give a quantitative value for the likelihood of arterial bleeding and validated in human upper extremities. We used ultrasound to demonstrate that the power law with k = 2.75 appropriately described the normal brachial artery bifurcation geometry and adequately determined the expected normal flows. Our metric was then applied to three-dimensional (3-D) computational models of forearm bleeding and on dialysis patients undergoing surgical construction of wrist arteriovenous fistulas. Computational models showed that larger sized arterial defects produced larger flow deviations. FSD values were statistically higher (paired t-test) for arms with fistulas than those without, with average FSDs of 0.41 ± 0.12 and 0.047 ± 0.021 (mean ± SD), respectively. The average of the differences was 0.36 ± 0.12 (mean ± SD).     

反应停对急性肝衰竭的的预防作用

目的探讨反应停(Thal)对急性肝衰竭的预防作用.方法用D-半乳糖胺(D-GalN,600mg/kg,ip)和细菌脂多糖(LPS,5μg/只,H)复制大鼠急性肝衰竭模型,观察Thal对急性肝衰竭死亡率、细胞因子、转氨酶、肝组织形态学和单个核细胞TNFαmRNA表达的影响.结果Thal可降低急性肝衰竭的死亡率、TNFα和转氨酶的水平(P＜0.05),减轻肝细胞坏死的程度,抑制单个核细胞TNFαmRNA的表达.结论 Thal对实验性肝衰竭的预防和治疗有重大的意义.     

The Tourniquet Gap: A Pilot Study of the Intuitive Placement of Three Tourniquet Types by Laypersons

Background

The “Stop the Bleed” campaign in the United States advocates for nonmedical personnel to be trained in basic hemorrhage control and that “bleeding control kits” be available in high-risk areas. However, it is not clear which tourniquets are most effective in the hands of laypersons.

剖宫产术中出血的预防及技术探讨

剖宫产术中出血是产科常见且严重的手术并发症，严重威胁产妇的生命安全。近年来，随着科学技术的不断发展和进步，各种辅助检查方法日渐增多，一些高危因素的检出率随之增高。由于优生优育知识的普及，人们对高危妊娠认识的提高，加之人为因素及社会因素，使剖宫产率居高不下，尤其在大城市。然而，就剖宫产手术而言，其出血量、并发症及其风险远高于阴道分娩。为了更好地掌握手术指征，降低母婴风险，预防术中出血过多，本文对剖宫产术中出血的原因、预防及技术操作做一探讨。     

顽固性后鼻孔部出血的治疗

目的 提高对顽固性后鼻孔出血的高度重视，使临床医生掌握顽固性鼻出血的治疗步骤及原则。快速准确的对其进行合理治疗，耳鼻喉科医生对其做到胸中有数，防止低血容量性休克及并发症的发生。方法 对顽固性后鼻孔出血进行临床分析，从解剖学上了解鼻腔血液供应动脉，对临床上顽固性后鼻孔出血的部位、应对措施进行详细阐述，结合我科病例及目前国际上的最新治疗现状进行临床讨论。结果 顽固性鼻出血大多发生在鼻腔的后部，行鼻腔填塞不易止血，出血为反复发作，出血点不易找到。提前做好血管造影检查以确定出血动脉。在非利特氏区出血的情况下，首次处置即应行前、后鼻孔同时纱条、纱球填基为宜。动态观察血色素的变化，随时纠正贫血。结论 （1）住院治疗；（2）作前、后鼻孔的纱条、纱球填塞；（3）掌握动态血色素变化，及时纠正贫血；（4）提前做好血管造影检查确定出血动脉，为手术法不成功时选择性动脉栓塞术做好准备工作；（5）对高龄患者行鼻饲供给营养；（6）对填塞法、手术法不能奏效时在严格掌握适应证情况下行选择性动脉栓塞术。     

Predictors and outcomes of bleed after sleeve gastrectomy: an analysis of the MBSAQIP data registry

BackgroundBleeding after laparoscopic sleeve gastrectomy (LSG) is an important complication associated with significant morbidity and a drastic increase in healthcare resources. Multiple strategies have been developed to minimize bleeding, including varying bougie size, line reinforcement, and intra-operative tranexamic acid. These techniques, however, have been implemented without a clear understanding of the pre-, intra-, and postoperative predictors of bleeding in patients undergoing SG.ObjectivesThe purpose of this study was to examine predictors and outcomes associated with postoperative bleeding in patients undergoing LSG.SettingThe Metabolic and Bariatric Surgery Accreditation and Quality Improvement data registry.MethodsWe identified Metabolic and Bariatric Surgery Accreditation and Quality Improvement patients who underwent LSG in 2015 and 2016. Primary outcomes of interest include identifying the prevalence, impact, and predictors of bleeding in LSG patients. Our secondary outcomes of interest include characterizing overall complication rates in LSG patients. Univariate analysis of pre-, intra-, and postoperative variables was performed using Χ² tests for categorical data and independent sample t test for continuous data. A nonparsimonious multivariable logistic regression model was then developed to determine predictive factors for development of postoperative bleed.ResultsA total of 175,353 patients underwent LSG from 2015 to 2016. The majority of patients were female (79.0%), with a mean age of 44.4 ± 12.0 years and a mean body mass index of 45.2 kg/m² ± standard deviation of 7.9 kg/m². A total of 1116 (.6%) patients had a postoperative bleed. Bleeding was associated with a mortality of 1.0% versus .1% among patients without bleeding. The mean operative time was 74.0 ± 36.6 minutes with a mean bougie size of 36.9 ± 2.9 Fr, and a mean pylorus distance of 4.80 ± 1.1 cm. Staple-line reinforcement was used in 67.8% of patients while 22.4% were oversewn. Bleeds were associated with a statistically significant increase in all complications, readmission, reoperation, and mortality rates at 30 days. The following statistically significant independent predictors of bleed after LSG were identified using multivariable logistic regression analysis: bougie size, age, prior cardiac procedure, hypertension, renal insufficiency, therapeutic anticoagulation, diabetes, obstructive sleep apnea, and operative length. Staple-line reinforcement, staple-line oversewing, and higher body mass index were found to be protective for bleed after adjusting for confounders and interactions. An increase in pylorus distance did show a signal toward a protective effect; however, this was not statistically significant.ConclusionBleeding after LSG is associated with increased complications, readmission and reoperation rates, and mortality at 30 days. Staple-line reinforcement techniques independently predict a lower risk of postoperative bleeding after LSG. Adoption of these techniques may therefore have an important role in reducing morbidity and mortality for patients who undergo LSG.