食管癌术后并发症及其处理

食管癌是我国一种常见的消化道恶性肿瘤,居世界癌症死因第7位,中国癌症死因第4位。其中以中段鳞状细胞癌多见,临床表现以晚期进行性吞咽困难为主,确诊主要以胃镜病理活检为金标准,其治疗方法主要有手术、放疗、化疗及分子靶向治疗等。但目前治疗上仍然以手术为主,术前术后放化疗为辅。然而,随着手术在食管癌治疗中适应症的不断扩大、根治性手术淋巴结的扩大清扫及拥有基础疾病高龄患者的增多,术后并发症的发生率不可避免的随之增加。本文将重点阐述吻合口瘘、吻合口狭窄、呼吸及心血管并发症、乳糜胸、胃排空障碍、膈疝、喉返神经损伤及单纯脓胸、严重腹泻、呕血等食管癌术后常见、严重并发症的病因、临床表现与诊断、治疗及其预防。通过对食管癌术后并发症的充分认识及有效预防,从而对食管癌手术成功率及患者术后生存质量的提高、肿瘤预后的改善起到了重要作用。     

Outcomes from engaging urban community groups in publicly funded vegetation restoration

Community‐based ecological restoration (CBR) has been encouraged by government funding schemes worldwide to help reverse ecosystem degradation, although many observers have questioned their longer‐term outcomes. We investigated the ecological and social outcomes of community‐based revegetation projects in an urban context, using the case study of all CBR groups located within 25 km of the Brisbane CBD which had been funded during 1997–2008 by the Australian Government's Natural Heritage Trust program to undertake revegetation works and which were also available for interview (N = 9 groups). First we reviewed the funding allocation within the region. Second, we conducted rapid on‐ground assessments of vegetation outcomes at 10 project sites several years after works were completed, which showed that the detectable area of established revegetation averaged 75% of the area planned, and the achieved revegetation areas varied greatly, both in total and in relation to cost. Third, we undertook thematic analysis of semi‐structured interviews with key group members, revealing that groups viewed the NHT scheme's short‐term funding and lack of administrative flexibility as being largely incompatible with both quantitative monitoring (which groups did not prioritise) and longer‐term maintenance of sites for successful vegetation establishment. Interactions with local governments were considered important to success, but internally‐conflicting policies of local and state governments, together with unforeseen site disturbances, acted to limit the achievement of projects' revegetation goals. Volunteer involvement and motivation were an important part of groups' activities. Overall, these CBR projects achieved modest short term environmental benefits together with a range of social benefits. There is a need for new CBR models aimed at maximising both environmental and social outcomes.     

Monitoring and evaluating large-scale, ‘open-ended’ habitat creation projects: A journey rather than a destination

Ecological restoration frequently involves setting fixed species or habitat targets to be achieved by prescribed restoration activities or through natural processes. Where no reference systems exist for defining outcomes or where restoration is planned on a large spatial scale, a more ‘open-ended’ approach to defining outcomes may be appropriate. Such approaches require changes to the definition of goals and the design of monitoring and evaluation activities. We suggest that in open-ended projects restoration goals should be framed in terms of promoting natural processes, mobile landscape mosaics and improved ecosystem services. Monitoring can then focus on the biophysical processes that underpin the development of habitat mosaics and the provision of ecosystem services, on the way habitat mosaics change through time and on species that can indicate the changing landscape attributes of connectivity and scale. Stakeholder response should be monitored since an open-ended restoration approach is unusual and can encounter institutional and societal constraints. Evaluation should focus on reporting changing restoration impacts and benefits rather than on achieving a pre-defined concept of ecological success.     

Recanalisation of coronary chronic total occlusions with new techniques including the retrograde approach via collaterals

Objective

Percutaneous treatment of coronary chronic total occlusions (CTO) remains one of the major challenges in interventional cardiology. The strategies of recanalisation in CTO have changed drastically due the development of new techniques such as the retrograde approach via collaterals. In this single-centre experience we sought to analyse the success rates with the use of different CTO techniques, the complication rates, and we evaluated predictors of failed CTO recanalisation attempts.

Methods and Results

In this single-centre observational study we analysed the prospectively entered data of 331 consecutive patients, undergoing percutaneous coronary intervention (PCI) for CTO in 338 lesions at the Heart Center Wuppertal between June 2007 and July 2010. Nineteen lesions were attempted twice and one lesion three times (=358 procedures). The lesion-related success rates were 81.1%. Single-wire usage was the predominant strategy used in 198 antegrade cases (65.6%) followed by parallel wire technique and see-saw technique in 94 cases (31.1%). In the retrograde procedures, the reverse CART technique was predominantly used (35.7%), followed by retrograde wire passage (17.9%), marker wire (17.9%) and CART (14.3%). The in-hospital complications were low and comparable with conventional PCI data. The presence of blunt stump, severe calcification, severe tortuosity and occlusion length >30 mm were independent predictors of procedural failure.

Conclusions

A high degree of success with low in-hospital complications comparable with conventional PCI data can be expected in the hands of experienced CTO operators. A second try with a retrograde approach after antegrade failure should be considered.     

DIASPORIC GENERATIONS. MEMORY,POLITICS AND NATION AMONG CUBANS IN SPAIN

Both national and international studies of education often show that the performance of immigrant students is substantially lower than that of non-immigrant students. This article investigates the contribution of socio-economic, sociocultural and school factors to the relative performance of first- and second-generation immigrant students in twenty countries using data from the OECD's 2000 Program for International Student Assessment. In most countries, socio-economic factors substantially account for the weaker performance of immigrant students, whereas sociocultural factors contribute little and school factors are important in only a limited number of instances. Altogether, these factors account for the bulk of the difference in achievement between immigrant and non-immigrant students in almost all the countries examined.     

Do soundscape indices predict landscape‐scale restoration outcomes? A comparative study of restored seabird island soundscapes

Measuring restoration outcomes is essential, but challenging and expensive, particularly on remote islands. Acoustic recording increases the scale of monitoring inexpensively; however, extracting biological information from large volumes of recordings remains challenging. Soundscape approaches, characterizing communities using acoustic indices, rapidly analyze large acoustic datasets and can be used to compare restoration sites against reference conditions. We tested this approach to measure nocturnal seabird recovery following invasive predator removal in the Aleutian Islands. We used recordings of nocturnal seabird soundscapes from six islands with varied histories of predators, from never invaded (one island) to 9–34 years post‐predator removal (four islands) and currently invaded (one island). We calculated 10 indices of acoustic intensity and complexity, and two pairwise indices of acoustic differences. Three indices reflected patterns of seabird recovery. Acoustic richness (measuring temporal entropy and amplitude) increased with time since predator removal and presence of historical predator refugia (r² = 0.44). These factors and moonlight accounted for 30% of variation in cumulative spectral difference from the reference island. Over 10% of acoustic richness and temporal entropy was explained by Leach's Storm‐petrel (Oceanodroma leucorhoa) calls. However, indices characterized the soundscape of rat‐invaded Kiska Island like a never invaded island, likely due to high abiotic noise and few seabird calls. Soundscape indices have potential to monitor outcomes of seabird restoration quickly and cheaply, if confounding factors are considered and controlled in experimental design. We suggest soundscape indices become part of the expanding acoustic monitoring toolbox to cost‐effectively measure restoration outcomes at scale and in remote areas.     

Perinatal mental health: a review of progress and challenges

Perinatal mental health has become a significant focus of interest in recent years, with investment in new specialist mental health services in some high‐income countries, and inpatient psychiatric mother and baby units in diverse settings. In this paper, we summarize and critically examine the epidemiology and impact of perinatal mental disorders, including emerging evidence of an increase of their prevalence in young pregnant women. Perinatal mental disorders are among the commonest morbidities of pregnancy, and make an important contribution to maternal mortality, as well as to adverse neonatal, infant and child outcomes. We then review the current evidence base on interventions, including individual level and public health ones, as well as service delivery models. Randomized controlled trials provide evidence on the effectiveness of psychological and psychosocial interventions at the individual level, though it is not yet clear which women with perinatal mental disorders also need additional support for parenting. The evidence base on psychotropic use in pregnancy is almost exclusively observational. There is little research on the full range of perinatal mental disorders, on how to improve access to treatment for women with psychosocial difficulties, and on the effectiveness of different service delivery models. We conclude with research and clinical implications, which, we argue, highlight the need for an extension of generic psychiatric services to include preconception care, and further investment into public health interventions, in addition to perinatal mental health services, potentially for women and men, to reduce maternal and child morbidity and mortality.     

Comparing the efficacy of pain managements after total hip arthroplasty: A network meta-analysis

The aim of our current study is to compare efficiency of various interventions implemented for pain management after total hip arthroplasty (THA). PubMed and EMBASE were searched for randomized clinical trials (RCTs) reporting the pain scales for evaluate the efficacy of pain control after THA including at least one pair of direct control groups. Pain scale values and the associated 95% credible interval (CrI) were used to describe efficacy. Surface under the cumulative ranking curve (SUCRA) of each means of pain control was calculated to compare the relative ranking of different interventions. Thirty-five eligible literatures were involved in data analysis. The interventions for postoperative pain management we examined were psoas compartment block (PCB), posterior nerve block (PNB), fascia iliaca block (FIB), periarticular injection (PAI), femoral nerve block (FNB), lumbar plexus block (LPB), spinal anesthesia (SA), epidural analgesia (EPI), intrathecal morphine (IA), intravenous patient-controlled analgesia (IV-PCA), patient-controlled analgesia (PCA), onsteroidal anti-inflammatory drug (NSAID), local infiltration analgaesia (LIA), and reverse LIA (rLIA). In 0 to 6 hours analysis, patients under SA were found to have significantly lower pain score and SA was ranked the best. In 6 to 12 hours analysis, SA was found to be significantly more effective than other interventions and its SUCRA was the highest. No intervention showed a significant effect on reducing pain score for 12 to 24 hours and 24 to 48 hours after THA. SA is the best intervention to reduce THA postoperative pain in the first 24 hours. LPB is a better choice to reduce pain 12 to 48 hours after THA.