Laparoscopic Deployment of Biliary Self-Expandable Metal Stent (SEMS) for One-Step Palliation in 23 Patients with Advanced Pancreatico-Biliary Tumors—a Pilot Trial

Background Exploratory laparoscopy is commonly undertaken in patients with highly suspicious biliary and pancreatic lesions to facilitate diagnosis and staging cancer is present. If an unresectable tumor is identified, a second endoscopic procedure may be required do deploy a self-expandable metal stent (SEMS) for palliation. As endoscopic retrograde cholangio pancreatography (ERCP) may be unsuccessful in up to 20% of patients, we evaluated the feasibility and safety of deployment of self-expandable metal stents at the same time as the initial laparoscopy. Patients and Methods A total of 23 eligible patients (8 male and 15 female) with malignant obstruction of the common bile duct underwent deployment of SEMS at laparoscopy. Primary outcome measure was the successful laparoscopic deployment of stent and secondary outcome measure was complications rates. Results Indications for stent deployment were unresectable pancreatic cancer in 18, cholangiocarcinoma in two, neuroendocrine tumor in one and ampullary adenocarcinoma in two patients. The median age was 73 years (range 49–93). Twenty-two of 23 stents were deployed successfully: 17 stents were deployed transcystically and five via a choledochotomy. Median times for laparoscopic exploration and SEMS deployment were 165 min (range 105–230) and 20 min (range 10–50), respectively. Pre- and post-procedures median total bilirubin were 9.4 mg/dl (range 5.4–17.5) and 4.0 (range 2.6–7.1). The median size of the pancreatic mass was 3 cm (range 2–5 cm) and that of the common bile duct (CBD) from 9.2 mm (range 7.2–17.4). The mean duration of laparoscopy was 170 min (range 120–230 min) and that for stent deployment 23 min (range 10–50 min). Complications included bleeding, obstruction, and wound infection. Bleeding occurred on day 7 in two patients and on day 30 in one patient; bleeding occurred at the gastrojejunal anastomosis site and was successfully treated with endoscopic hemostasis. A total of three stent obstructions were identified: one each at 60, 90, and 120 days follow-up. All complications were successfully managed endoscopically. There were a total of seven deaths, six as a result of progressive cancer and one of surgical wound infection and ensuing complications. Conclusion This study demonstrates that laparoscopic deployment of self-expandable metal bile duct stents is feasible and safe. This option appears to be a reasonable option in patients with inoperable malignant obstruction of the distal common bile duct.     

MANAGEMENT TO PREVENT BLEEDING DURING ENDOSCOPIC SUBMUCOSAL DISSECTION USING THE FLUSH KNIFE FOR GASTRIC TUMORS

The gastric vasculature responsible for intraoperative bleeding in endosocpic submucosal dissection (ESD) is the ramified vascular network occupying the middle of the submucosal layer and large vessels penetrating the muscle layer. Appropriate management for these vessels must be addressed. The trimming of the ramified vascular network can be safely performed with coagulation mode following shallow mucosal cutting. A large penetrating vessel usually requires precoagulation prior to dissection. These procedures are effectively performed with the water jet short needle knife (Flush knife).     

Predicting work status following interdisciplinary treatment for chronic pain.

The effectiveness of interdisciplinary treatments for chronic pain is well established. In general, these treatments decrease psychosocial distress and increase physical abilities. Further, return to work rates following interdisciplinary treatment tend to be quite high. Previous studies have highlighted a number of factors that individually influence return to work rates; however, there is a need for more comprehensive and unified models that allow an evaluation of the inter-relations among these factors. The present investigation examined how demographic and treatment outcome variables interacted to influence post-treatment return to work rates in a sample of individuals with chronic pain following interdisciplinary treatment. Results indicated that patient age, lifting ability, pain duration, depression level, and reported disability were individually related to return to work; however, when these variables were evaluated relative to one another, level of depression and patient age had the best ability to predict post-treatment work status. These results add to the literature by specifically highlighting post-treatment factors that best discriminate patients who had returned to work from those that had not. Furthermore, they provide evidence that general emotional distress is perhaps the most important predictor of work status following treatment.     

支气管扩张症辨证模式初探

目的:探讨支气管扩张症的中医辨证分型规律及证候特点.方法:通过对563例支气管扩张症的临床流行病学调查,采集以症状、体征、舌、脉及相关理化检测为变量的基本信息,以频数分析、聚类分析、方差分析等方法,提炼支气管扩张症的证候分布规律及证候特点.结果:临床上支气管扩张症多见4种证候类型,分别为痰热壅肺证(45.65%)、肝火犯肺证(24.51%)、肺脾气虚证(22.38%)、气阴两虚证(7.46%).结论:较大样本的临床流行病学调查为研究支气管扩张症辨证分型规律提供了科学依据,并可以通过主症判别分析法建立证候识别模式,为临床实践提供依据.     

化痰通络法治疗脊髓炎后遗症

介绍魏品康教授治疗脊髓炎后遗症一则,以化痰通络法贯穿始终。     

Supporting insensitive mothers: the Vilnius randomized control trial of video-feedback intervention to promote maternal sensitivity and infant attachment security

Objective   This randomized control trial examined the effects of a short-term, interaction-focused and attachment-based video-feedback intervention (VIPP: video-feedback intervention to promote positive parenting).
Design   VIPP effect on mothers' sensitive responsiveness and infant–mother attachment security was evaluated in a sample ( n  = 54) of low sensitive, non-clinical, middle class Lithuanian mothers.
Methods   Maternal sensitivity was assessed in a free play session with the Ainsworth's sensitivity scale, and attachment security was observed using the Attachment Q sort for home observations.
Results   We found that the intervention mothers indeed significantly improved their sensitive responsiveness through participation in our VIPP. The effect size was large according to Cohen's criteria, d  = 0.78. VIPP enhanced maternal sensitive responsiveness even when maternal age, educational level, depression, daily hassles, efficacy, infant gender, and infant negative and positive affect were controlled for. However, attachment security in the VIPP infants was not enhanced after the intervention, compared with the control infants, and the infants did not seem to be differentially susceptible to the increase in maternal sensitivity dependent on their temperamental reactivity.
Conclusion   We suggest that a relatively brief and low-cost programme can provide effective support for mothers who lack sensitivity in the interactions with their infants.     

枕骨大孔区腹侧脑膜瘤的显微手术技术探讨

目的探讨远外侧入路在治疗枕骨大孔区腹侧脑膜瘤中的应用。方法对14例脑膜瘤患者采用远外侧入路显微手术治疗,其中枕髁后入路8例,经部分枕髁入路3例,经C1、2关节面侧方联合部分枕髁入路2例,经完整枕髁入路1例。结果肿瘤全切11例,次全切除3例;1例行枕颈融合,无手术死亡病例。所有患者术后均未出现寰枕关节不稳定的症状,手术并发症主要是后组颅神经损伤、椎动脉损伤、脑脊液漏以及脑干缺血。结论远外侧入路是手术治疗下斜坡区和上段颈髓腹侧、腹外侧病变的理想入路,可以理想显露肿瘤及其基底部并减少术中出血,但手术操作比较复杂且具有一定的风险。     

Milgram and Tuskegee—Paradigm Research Projects in Bioethics

This paper discusses the use of the Milgram obedience experiments and the Tuskegee syphilis study in the bioethical literature. The two studies are presented and a variety of uses of them identified and discussed. It is argued that the use of these studies as paradigms of problematic research relies on a reduction of their complexity. What is discussed is thus often constructions of these studies that are closer to hypothetical examples than to the real studies.     

Immunoblotting human C4 bound to human erythrocytes in vivo and in vitro.

A study of C4 bound to human erythrocytes in vitro and in vivo has been made by immunoblotting with mouse monoclonal anti-C4c and anti-C4d and human polyclonal anti-C4d (Rodgers and Chido) following SDS-PAGE. Multi-banded patterns differentiated between C4A and C4B isotypes. Treatment of EC4b with trypsin eliminated immunoblotting but not agglutination reactions. Serum inactivation (factor I) of EC4b resulted in banding patterns similar to those obtained from patients' EC4d. Treatment of EC4b membranes with NH2OH affected many of the bands, two were lost, one was markedly reduced and others had altered SDS-PAGE mobility. Interpretation of the bands has been made in terms of C4-acceptor complexes and inactivation fragments of C4. A distinct difference in the banding of C4A and C4B isotypes has been detected.