急诊手术的职业暴露及防护对策

目的:通过对医务人员在急诊手术中职业暴露的情况调查,了解急诊手术中标准预防现状,提出合理化建议和措施。方法:对2007年6月-2010年5月手术患者乙肝、丙肝、梅毒、艾滋病的阳性率进行比较,现场调查急诊手术中防护用品的使用情况。结果:手术患者乙肝、丙肝、梅毒、艾滋病的阳性率逐年上升,职业暴露的危险性越来越大;急诊手术中医务人员防护用品使用率的高低取决于血液、体液、分泌物的污染程度。结论:对医务人员要加强职业安全教育,强化标准预防,提高医务人员的整体防护水平,避免或减少职业暴露的危害,在救死扶伤的同时,保护好自身安全。     

Demonstration of the use of windows of operation to visualize the effects of fouling on the performance of a chromatographic step

The high resolution afforded by packed bed chromatography makes it an indispensable operation in the downstream processing of therapeutic molecules. Packed bed performance is however inherently susceptible to changes in feed stream characteristics and fouling processes. The impact of fouling is seldom considered during the early stages of bioprocess development which is concerned with the selection of purification conditions. Instead these are performed with rigorously clarified feeds. Under such conditions, chromatography is effectively treated as an isolated step, independent from its preceding unit operations. In this study, we demonstrate how windows of operation could be used to visualize the impact of changes in the preceding clarification step on the fouling response of a subsequent cation exchange capture step. Laboratory columns (2,5 and 12 cm height) were subjected to varying fouling challenges of Escherichia coli lysate containing different amounts of solids carried over from the previous step. Changes in trans‐column pressure drop and breakthrough of the target protein (Fab′) were monitored. The limits of operability of the resin were determined with respect to the process material's properties. This information was used to extract the parameters for the adsorption kinetics used in the general rate (GR) model to create windows of operation for manufacturing scale operation. © 2011 American Institute of Chemical Engineers Biotechnol. Prog., 2011     

多镜联合治疗胆总管结石合并胆囊结石的技术优势

目的探讨十二指肠镜、胆道镜、腹腔镜等多镜联合治疗胆总管结石合并胆囊结石的技术优势。方法采用腹腔镜胆总管探查术+腹腔镜胆囊切除术(LCBDE+LC)和内窥镜逆行胰胆管造影术+内窥镜下括约肌切开取石术+腹腔镜胆囊切除术(ERCP+EST+LC)两种术式治疗胆总管结石合并胆囊结石患者。结果有两组病例,其中LCBDE+LC组36例,本组术后胆道残余结石2例,后经T管窦道行胆道镜取石治愈。ERCP+EST+LC组54例,本组术后并发一过性高淀粉酶血症3例,发生急性轻型胰腺炎2例。结论多镜联合治疗胆总管结石合并胆囊结石具有创伤小、效果好、并发症少、恢复快的优点,多镜联合发挥出其独特技术优势,避免了因接受传统开腹手术而造成较大创伤的不合理治疗模式。     

重大手术术前律师见证的作用探讨

目的:探讨对于重大手术进行术前律师见证的积极作用。方法:对我院自2004年10月至2011年12月1478例非急症手术的术前签字所进行的律师见证进行回顾分析。结果:患者家属及医务人员对这种手术签字形式予以肯定,无一例因告知不足引发的医疗纠纷发生。结论:手术律师见证是手术风险的合理分担,有利于保护医患双方的合法权益,减少医疗纠纷的发生,促进医学发展。     

Evaluation of a self-assessed screening test for masticatory ability of Taiwanese older adults

doi: 10.1111/j.1741‐2358.2012.00632.x Evaluation of a self‐assessed screening test for masticatory ability of Taiwanese older adults Objectives: The aim of this study was to evaluate a screening test based on a food intake questionnaire to discriminate the masticatory ability of Taiwanese older adults with 20 and more natural teeth and at least 8 functional tooth units (FTUs) from the masticatory ability of those with fewer than 20 natural teeth and 8 FTUs. Materials and Methods: The subjects were 2244 patients (mean age, 60.4±10.0 years) recruited from 23 counties and cities in Taiwan. Information about their demographic data, dentition, and masticatory ability was collected. Masticatory ability was measured for 23 food groups comprising 35 common Taiwanese foods, and receiver operation characteristic curve analysis was performed. Results: The results showed that the final questionnaire included 14 food groups and a subject choosing ’difficult to eat‘ responses for 4 and more of these food groups had the same masticatory ability as individuals with fewer than 20 natural teeth and 8 FTUs. Conclusion: In conclusion, foods that are the most difficult to eat are not necessarily good discriminatory indicators. Hence, the 14‐food group questionnaire can be considered the best screening test for masticatory ability of Taiwanese older adults in terms of the presence of 20 and more natural teeth and at least 8 FTUs.     

异丙酚复合布托啡诺辅助腰硬联合麻醉用于妇科腹腔镜手术

目的探讨异丙酚复合布托啡诺辅助腰硬联合麻醉应用于妇科腹腔镜手术的安全性和优越性。方法将50例行妇科腹腔镜手术患者随机分为两组,B组为异丙酚复合布托啡诺辅助腰硬联合麻醉组,F组为异丙酚复合芬太尼辅助腰硬联合麻醉组。术中保证患者睡眠、无体动。观察两组术中有无呼吸抑制、舌后坠及恶心呕吐,记录各时段生命体征及气腹时间、苏醒时间、异丙酚总用量。结果两组患者各时段的MAP、HR、RR、SpO2变化均在正常范围内。B组呼吸抑制、舌后坠、寒战发生率显著低于F组（P〈0.05）,异丙酚总用量显著少于F组（P〈0.05）。结论异丙酚复合布托啡诺辅助腰硬联合麻醉能为妇科短时间腹腔镜手术提供安全满意的麻醉效果。     

腹腔镜胆囊切除临床路径的持续改进

目的 探讨利用戴明环对腹腔镜胆囊切除的临床路径进行持续改进的效果。方法 总结分析2008年3月—2010年12月北京某三级甲等医院腹腔镜胆囊切除临床路径的数据。在路径实施过程中使用戴明环的原理遵照既定的临床路径方案实施,在实施方案过程中发现路径的问题,并进行分析和总结,解决问题,修正路径后继续实施。结果 近3年共1 861例患者进行筛选,1 539例进入路径,1 408例完成路径,共131例退出路径,退出率8.5%。在戴明环原理的指导下,逐步改进流程,退出率由14.5%逐步降至1.4%。 结论 按照戴明环的原理持续改进腹腔镜胆囊切除临床路径,可以使之更加符合临床实际,促进路径发展。

     

Orthotopic Small Bowel Transplantation in Rats

Small bowel transplantation has become an accepted clinical option for patients with short gut syndrome and failure of parenteral nutrition (irreversible intestinal failure). In specialized centers improved operative and managing strategies have led to excellent short- and intermediate term patient and graft survival while providing high quality of life ^1,3. Unlike in the more common transplantation of other solid organs (i.e. heart, liver) many underlying mechanisms of graft function and immunologic alterations induced by intestinal transplantation are not entirely known^6,7. Episodes of acute rejection, sepsis and chronic graft failure are the main obstacles still contributing to less favorable long term outcome and hindering a more widespread employment of the procedure despite a growing number of patients on home parenteral nutrition who would potentially benefit from such a transplant. The small intestine contains a large number of passenger leucocytes commonly referred to as part of the gut associated lymphoid system (GALT) this being part of the reason for the high immunogenity of the intestinal graft. The presence and close proximity of many commensals and pathogens in the gut explains the severity of sepsis episodes once graft mucosal integrity is compromised (for example by rejection). To advance the field of intestinal- and multiorgan transplantation more data generated from reliable and feasible animal models is needed. The model provided herein combines both reliability and feasibility once established in a standardized manner and can provide valuable insight in the underlying complex molecular, cellular and functional mechanisms that are triggered by intestinal transplantation. We have successfully used and refined the described procedure over more than 5 years in our laboratory ^8-11. The JoVE video-based format is especially useful to demonstrate the complex procedure and avoid initial pitfalls for groups planning to establish an orthotopic rodent model investigating intestinal transplantation.     

Relations between doses cumulated in bone marrow and dose delivery techniques during radiation therapy of cervical and endometrial cancer

PurposeTo compare normal tissue complication probability (NTCP) and average doses in the bone marrow (BM), obtained for five different radiotherapy delivery and planning strategies of cervical and endometrial cancer.Material/methods50 patients were taken to analysis. For each case, 3 different dose delivery techniques were used: 4-field, X15MV, 3DCRT; 7-field, X6MV, IMRT; and 2-arc, X6MV, VMAT. Two optimization scenarios were used for the IMRT and VMAT plans generation: with (+) and without (−) the inclusion of the BM as an optimized structure. Average doses and dose-volume histogram parameters for the PTV, BM, bladder, rectum, bowels and femoral heads were compared. In addition, the BM doses were analyzed with respect to the PTV and/or volume of the BM, and NTCP for the BM were computed.ResultsThe dose in PTV for evaluated plans was similar. The worst doses in organs at risk were obtained for 3DCRT. Using the BM during the optimization of IMRT and VMAT reduces an average dose in BM without increasing the doses in the bladder, rectum and bowels. Differences between doses in BM for IMRT(+) and VMAT(+) plans were similar while NTCP was lower for VMAT(+). A correlation between average dose in BM and the volume ratio of BM and PTV was found for each technique.ConclusionUsing the BM during the optimization of the IMRT and VMAT plans effectively reduces the dose in BM without increasing the dose in the bladder, rectum and bowels. The VMAT(+) plans were characterized by the lowest NTCP.     

宫颈癌患者行根治性子宫切除术且保留盆腔自主神经的效果观察

目的:探讨宫颈癌患者行保留盆腔自主神经的根治性子宫切除术的临床效果。方法:按照随机数字表法将入选的48例宫颈癌患者随机分为对照组和试验组两组,每组患者各24例,其中对照组患者均采用传统的宫颈癌根治手术治疗,而试验组患者则采用保留盆腔自主神经的根治性子宫切除术进行治疗,比较两组患者的术中情况和术后恢复情况等。结果:两组患者的子宫切除出血量和术中总出血量以及术中输血率均无明显差异(均P0.05),但是试验组患者的子宫切除时间和手术总时间显著长于对照组患者(t=2.934,P0.05;t=3.121,P0.05)。两组患者之间的术后排气、排便时间均无明显差异(均P0.05),提示两组患者术后直肠功能无明显差异;对照组患者的术后残余尿量100ml时间与术后残余尿量50ml时间均显著高于试验组患者(t=2.891,P0.05;t=3.092,P0.05)。术后试验组患者的首次排尿感和急迫排尿感以及最大腹压等均显著低于对照组患者(t=4.283,P0.05;t=4.027,P0.05;t=3.137,P0.05);而最大膀胱压和最大尿流量以及最大逼尿肌压等则显著高于对照组(t=3.192,P0.05;t=2.938,P0.05;t=3.572,P0.05)。结论:采取保留盆腔自主神经的根治性子宫切除术能够较好地减少宫颈癌患者临床并发症的出现,具有较好的治疗效果,值得加以推广和运用。