肝内胆管癌肝切除术后“教科书式结局”影响因素分析及预测模型建立

目的 分析肝内胆管癌（ICC）病人肝切除术后“教科书式结局”（TO）的影响因素，构建预测TO评分模型。方法 回顾性分析2011年1月至2017年1月东南大学附属中大医院和中国人民解放军东部战区总医院八一医院收治的261例行肝切除术的ICC病人临床病理资料，分析影响TO的独立危险因素，根据危险因素的权重构建预测TO的评分模型。结果 261例ICC病人中，67例（25.7%）术后发生TO。年龄、肝硬化、手术时间和T分期［第8版美国癌症联合委员会（AJCC）癌症分期］为术后TO的独立预测因素。依此4项因素构建的评分模型显示了较好的预测准确性，最佳截断值为-1.9分，其敏感度为67.2%，特异度为62.9%。一致性检验显示其预测概率和实际发生概率有着较好的一致性（χ2=1.350，P=0.853）。结论 基于年龄、肝硬化、手术时间、T分期4个因素建立的评分模型可较准确地预测ICC病人术后TO的可能性，即手术时间短、无肝硬化、肿瘤直径<5 cm的年轻ICC病人肝切除后获得TO的可能性更大。     

我国日间手术开展现状与前景展望

日间手术在国外已有上百年的发展历史，现已成为欧美国家重要手术模式。我国于20世纪初开始开展日间手术，但目前尚未普及，发展不平衡问题比较突出，存在认识不清、开展不规范、与医保支付对接不畅等问题。日间手术是一种使国家、医院和病人三方均受益的新型手术模式。近年来，国家相关管理部门积极引导，开展日间手术的医院明显增多，可以预见，我国日间手术即将进入快速发展的新阶段。因此，有条件的医院可以从简单、易操作的病种开始，落实临床路径，积累经验，再逐步稳妥展开。在保证质量的前提下，不断拓展日间手术范围，提高三、四级手术比例。同时，积极与医保支付政策对接，采取灵活的方式，获得医保的支持，更好地促进我国日间手术的快速发展。     

临床解惑

怎样选用中成药治疗中暑?答:中暑,为夏日常见病,在高温环境下劳动或工作,出现大量出汗、口渴、明显疲劳、四肢乏力、头昏眼花、胸闷、恶心、注意力不集中、四肢发麻等症状时,为先兆中暑。若伴有发热,体温高于38℃,面色潮红,皮肤灼热.或面色苍白,恶心呕吐,血压下降,皮肤湿冷,脉搏细弱者,为轻度中暑,若出现昏迷、痉挛、或皮肤干燥无汗、持续高热者,为重症中暑,应及时去医院治     

眼脉冲幅度增加提示动脉反流

目的:报道1例因双眼脉冲幅度(OPA)增加发现动脉反流的病例,而后者正是引起OPA增加的原因。设计:病例报道。方法:偶然发现双眼OPA增高,由此发现脉压增高和动脉反流。患者接受动脉瓣膜手术,待动脉脉压恢复正常后评价OPA。结果:动脉脉压高时的双眼OPA为9mmHg,动脉脉压恢复正常后的双眼OPA为3mmHg。结论:动脉脉压增高可以导致OPA增高。眼脉冲幅度增加提示动脉反流@McKee H.D.R.$Hull and East Yorkshire Eye Hospital, Fountain Street, Hull, Uni ted Kingdom @Saldaa M. @Ahad M.A. @张少娟…     

单纯型腺性唇炎2例

腺性唇炎（CG）是一种少见的唇部疾病。以往认为本病是以唇腺增生肥大为主要特征的，多累及下唇，或上下唇同时受累。但近年来文献报道CG的组织病理特征是以小涎腺硬化性炎症为主要特征。本文结合2例单纯型腺性唇炎患者，重点探讨其临床病理特征，现报道如下。     

Nuclear Factor κB and Anesthetic Preconditioning during Myocardial Ischemia-Reperfusion

Background: Volatile anesthetic preconditioning (APC) protects against myocardial ischemia-reperfusion (IR) injury, but the precise mechanisms underlying this phenomenon remain undefined. To investigate the molecular mechanism of APC in myocardial protection, the activation of nuclear factor (NF) [kappa]B and its regulated inflammatory mediators expression were examined in the current study.

Methods: Hearts from male rats were isolated, Langendorff perfused, and randomly assigned to one of three groups: (1) the control group: hearts were continuously perfused for 130 min; (2) the IR group: 30 min of equilibration, 15 min of baseline, 25 min of ischemia, 60 min of reperfusion; and (3) the APC + IR group: 30 min of equilibration, 10 min of sevoflurane exposure and a 5-min washout, 25 min of global ischemia, 60 min of reperfusion. Tissue samples were acquired at the end of reperfusion. NF-[kappa]B activity was determined by electrophoretic mobility shift assay. The NF-[kappa]B inhibitor, I[kappa]B-[alpha], was determined by Western blot analysis. Myocardial inflammatory mediators, including tumor necrosis factor [alpha], interleukin 1, intercellular adhesion molecule 1, and inducible nitric oxide synthase, were also assessed by Western blot analysis.

Results: Nuclear factor [kappa]B-DNA binding activity was significantly increased at the end of reperfusion in rat myocardium, and cytosolic I[kappa]B-[alpha] was decreased. Supershift assay revealed the involvement of NF-[kappa]B p65 and p50 subunits. APC with sevoflurane attenuated NF-[kappa]B activation and reduced the expression of tumor necrosis factor [alpha], interleukin 1, intercellular adhesion molecule 1, and inducible nitric oxide synthase. APC also reduced infarct size and creatine kinase release and improved myocardial left ventricular developed pressure during IR.     

Morphine Enhances Pharmacological Preconditioning by Isoflurane: Role of Mitochondrial KATP Channels and Opioid Receptors

Background: Adenosine triphosphate-regulated potassium channels mediate protection against myocardial infarction produced by volatile anesthetics and opioids. We tested the hypothesis that morphine enhances the protective effect of isoflurane by activating mitochondrial adenosine triphosphate-regulated potassium channels and opioid receptors.

Methods: Barbiturate-anesthetized rats (n = 131) were instrumented for measurement of hemodynamics and subjected to a 30 min coronary artery occlusion followed by 2 h of reperfusion. Myocardial infarct size was determined using triphenyltetrazolium staining. Rats were randomly assigned to receive 0.9% saline, isoflurane (0.5 and 1.0 minimum alveolar concentration [MAC]), morphine (0.1 and 0.3 mg/kg), or morphine (0.3 mg/kg) plus isoflurane (1.0 MAC). Isoflurane was administered for 30 min and discontinued 15 min before coronary occlusion. In eight additional groups of experiments, rats received 5-hydroxydecanoic acid (5-HD; 10 mg/kg) or naloxone (6 mg/kg) in the presence or absence of isoflurane, morphine, and morphine plus isoflurane.

Results: Isoflurane (1.0 MAC) and morphine (0.3 mg/kg) reduced infarct size (41 +/- 3%; n = 13 and 38 +/- 2% of the area at risk; n = 10, respectively) as compared to control experiments (59 +/- 2%; n = 10). Morphine plus isoflurane further decreased infarct size to 26 +/- 3% (n = 11). 5-HD and naloxone alone did not affect infarct size, but abolished cardioprotection produced by isoflurane, morphine, and morphine plus isoflurane.     

Eliminating Intensive Postoperative Care in Same-day Surgery Patients Using Short-acting Anesthetics

Background: A multidisciplinary effort was undertaken to determine whether patients could safely bypass the postanesthesia care unit (PACU) after same-day surgery by moving to an earlier time point evaluation of recovery criteria.

Methods: A prospective, outcomes research study with a baseline month, an intervention month, and a follow-up month was designed. Five surgical centers (three community-based hospitals and two freestanding ambulatory surgical centers) were utilized. Two thousand five hundred eight patients were involved in the baseline period, and 2,354 were involved in the follow-up period. Outcome measures included PACU bypass rates and adverse events. Intervention consisted of a multidisciplinary educational program and routine feedback reports.

Results: The overall PACU bypass rate (58%) was significantly different from baseline (15.9%, P < 0.001), for patients to whom a general anesthetic was administered (0.4-31.8%, P < 0.001), and for those given other anesthetic techniques (monitored anesthesia care, regional or local anesthetics; 29.1-84.2%, P < 0.001). During the follow-up period, the average (SD) recovery duration for patients who bypassed the PACU was significantly shorter compared to that for patients who did not bypass, 84.6 (61.5) versus 175.1 (98.8) min, P < 0.001, with no change in patient outcome. Patients receiving only short-acting anesthetics were 78% more likely (P < 0.002) to bypass the PACU after adjusting for various surgical procedures.