黄疸

本文报告了一例44岁男性黄疸病人的诊治经过与分析。该病人因黄疸、食欲差,先被诊断为“黄疸型肝炎”,用中药治疗无效。后经B超检查诊断为“胆囊、胆管多发结石”建议手术治疗。术前,结合病史、体检及多种影像学检查手段复查,诊断确定为“下段胆管癌、梗阻性黄疸、肝及胆囊淤滞性肿大”。手术探查中,因发现胰腺头部肿物,考虑胰头癌可能,遂行胰十二指肠切除术。术后病理检查报告为胆总管下段低分化腺癌伴胰腺头部癌组织侵犯。结合此病例的特点及诊治过程,对表现为黄疸,容易与胆总管下段癌混淆的各种良、恶性肝、胆、胰疾病作了有针对性的分析与鉴别。     

黄疸

本文报告了一例44岁男性黄疸病人的诊治经过与分析.该病人因黄疸、食欲差,先被诊断为"黄疸型肝炎",用中药治疗无效.后经B超检查诊断为"胆囊、胆管多发结石"建议手术治疗.术前,结合病史、体检及多种影像学检查手段复查,诊断确定为"下段胆管癌、梗阻性黄疸、肝及胆囊淤滞性肿大".手术探查中,因发现胰腺头部肿物,考虑胰头癌可能,遂行胰十二指肠切除术.术后病理检查报告为胆总管下段低分化腺癌伴胰腺头部癌组织侵犯.结合此病例的特点及诊治过程,对表现为黄疸,容易与胆总管下段癌混淆的各种良、恶性肝、胆、胰疾病作了有针对性的分析与鉴别.     

胰头癌根治性手术的淋巴结清扫

胰头恶性肿瘤以手术治疗为主要治疗方式，其淋巴结清扫问题近年来受到热议。本文比较扩大淋巴结清扫与标准根治对患者生存的影响。讨论最新制定的胰头癌标准淋巴结清扫范围。认识淋巴结转移数目、淋巴结转移率作为预后判断因素的作用。介绍腹主动脉旁淋巴结活检以及最小淋巴结检测数研究的进展。最终认为胰头癌根治性手术的淋巴结清扫因手术方式多...     

胰十二指肠切除术后C级胰瘘防治

随着现代医学的发展以及手术技术的进步,胰十二指肠切除手术(PD)的围手术期死亡率不断下降,大部分胰腺中心甚至已经达到小于2%,但术后并发症,比如胰瘘、术后出血、腹腔感染、胃排空障碍等居高不下。其中术后出血和腹腔感染会导致病情危重,有时需要紧急处理,否则危及生命;术后胰瘘是最常见并发症。胰腺术后胰瘘(POPF)发生率3%~45%,可能导致术后出血和腹腔感染,也是导致术后死亡的主要原因。如何防治胰瘘,尤其是防治C级胰瘘,是所有胰腺外科医生共同面临的难题。本文结合临床实践与文献,对胰瘘发生危险因素,以及预防和治疗胰瘘进行探讨。     

胰十二指肠切除术治疗严重胰头、十二指肠损伤的体会

急诊胰十二指肠切除手术(PD)是腹部手术难点之一,风险极大,死亡率高。本文通过5年来我院实行的急诊5例PD手术,探讨该手术的适应证,并对胰肠、胆肠吻合进行改进,提出了一期完成手术的可能性及安全性,并对手术改进做了较详细说明。     

肝圆韧带在胰腺损伤中的应用

自2002年1月以来,我们有选择性利用肝圆韧带修补胰腺缺损处11例,获得满意效果。现报告如下。1临床资料1.1一般资料11例病人中6例男性,5例女性,年龄49岁~79岁,肝圆韧带应用情况见表1。表1肝圆韧带应用情况n术式修补部位胰漏结果胆总管中段癌2除胆总术管癌切楔胆总型切管除远处端     

从腹腔镜胰腺手术谈成立“微创胰胃外科学”之必要

胰腺和胃在解剖上紧密相连，腹腔镜胰胃手术技术上相辅相成。成立“微创胰胃外科学”，让富有创新精神的外科医师同时开展腹腔镜胃癌手术和胰腺手术，并进行认真的临床研究，必将有助于进一步提高腹腔镜胃癌根治术和腹腔镜胰腺手术的水平，使更多患者从现代高新技术中获益。     

78例鼻颅底肿瘤经鼻内镜下手术治疗的临床观察

对78例鼻颅底肿瘤患者经鼻内镜下行微创手术治疗,考察其治疗效果、围术期并发症,并总结可供临床参照的手术操作要点。回顾性分析2012年1月~2014年6月笔者所在医院收治的78例鼻颅底肿瘤患者的临床资料。患者均经鼻内镜下行手术治疗。术后经病理活检确诊,如为恶性肿瘤,患者还需术后接受放射治疗。考察手术完成、肿瘤切除情况(切除率)、围术期并发症的发生及持续随访的结果。78例患者全部顺利完成手术。肿瘤全切率80.8%(63/78),次全切除率14.1%(11/78),大部分切除率5.1%(4/78)。术后病理结果显示良性肿瘤占53.8%(42/78),恶性肿瘤占46.2%(36/78)。围术期并发症的发生率为5.1%(4/78)。无致死病例。持续随访,术后1年良性肿瘤复发率11.9%(5/42),恶性肿瘤复发率25.0%(9/36)。术后3年恶性肿瘤复发率52.8%(19/36),病死率44.4%(16/36)。经鼻内镜下微创手术切除鼻腔、鼻窦侵犯至颅底或颅底的原发良、恶性肿瘤是简便、有效、安全的治疗方法。只要掌握好适应证,制定合理的手术路径,则鼻内镜下微创术切除或部分切除鼻颅底的肿瘤在临床是切实可行的。     

肝胰十二指肠系膜概念的基础与临床思考

全直肠系膜切除术、完整结肠系膜切除术术式的提出给患者带来了术后生存率的提高。近期笔者于术中以及间接的临床证据推测肝胰十二指肠系膜的存在,并结合胚胎学和解剖学提出假设及概念。笔者认为胰腺前后有完整的筋膜包绕,向上延续至肝十二指肠,向下终结于横结肠系膜前叶,向左至十二指肠,向右至脾,形成以腹腔干血管为核心的筋膜组织。并希望由此带来临床术式的改变及肿瘤患者生存率的提高。     

对“胰十二指肠及肾一期联合移植”成功的哲学思考

对“胰十二指肠及肾一期联合移植”成功的哲学思考浙江医科大学（杭州３１００３１）万慧进黄书孟赖瑞南一、在合规律与合目的的统一中追求医学科学的创新一项重大医学科学成果的取得,首先表征着创造者在把握医学科学规律上的成功,即合规律性。合规律性反映的是人对真理...     

Impaired sequential and partially compensated probabilistic skill learning in Parkinson's disease

The striatal dopaminergic dysfunction in Parkinson's disease (PD) has been associated with deficits in skill learning in numerous studies, but some of the findings remain controversial. Our aim was to explore the generality of the learning deficit using two widely reported skill learning tasks in the same group of Parkinson's patients. Thirty-four patients with PD (mean age: 62.83 years, SD: 7.67) were compared to age-matched healthy adults. Two tasks were employed: the Serial Reaction Time Task (SRT), testing the learning of motor sequences, and the Weather Prediction (WP) task, testing non-sequential probabilistic category learning. On the SRT task, patients with PD showed no significant evidence for sequence learning. These results support and also extend previous findings, suggesting that motor skill learning is vulnerable in PD. On the WP task, the PD group showed the same amount of learning as controls, but they exploited qualitatively different strategies in predicting the target categories. While controls typically combined probabilities from multiple predicting cues, patients with PD instead focused on individual cues. We also found moderate to high correlations between the different measures of skill learning. These findings support our hypothesis that skill learning is generally impaired in PD, and can in some cases be compensated by relying on alternative learning strategies.     

Neural substrates of cognitive skill learning in Parkinson's disease

While cognitive skill learning is normally acquired implicitly through frontostriatal circuitry in healthy individuals, neuroimaging studies suggest that patients with Parkinson's disease (PD) do so by activating alternate, intact brain areas associated with explicit memory processing. To further test this hypothesis, 10 patients with PD and 12 healthy controls were tested on a modified, learning version of the Tower of London task while undergoing positron emission tomography at four different time points over the course of learning. Despite having less accurate problem solving abilities than controls, PD patients were able to acquire the skill learning task. However, as compared to controls, they maintained higher levels of cerebral blood flow activity in the dorsolateral prefrontal cortex and hippocampus and showed an increase in activity in the frontopolar cortex and posterior cingulate over the course of learning. These findings reflect a shift to the explicit memory system in PD patients, enabling them to learn this cognitive skill, which is normally acquired by control subjects using implicit learning strategies and frontostriatal circuitry.     

Motor deficits in Parkinsonian reaching: dopa-sensitivity influenced by real-world task constraint

Parkinson's disease (PD) patients can perform many daily activities, but movement deficits are evident. Those deficits may be increased when the required movement is constrained in accuracy. Variable improvements in performance with PD medication have been demonstrated, and sensitivity to task constraint has been evident in some studies. The authors quantified both specific movement deficits and improvements for PD patients in a reaching task. PD patients (N=8) both on and off medication showed a need for greater ongoing control in movements with higher task-accuracy constraints. Increased task-accuracy constraints further compromised movement timing and structure among PD patients who were off medication, suggesting that unmedicated PD patients may typically compensate by using more conscious control of movement, resulting in increased slowing and segmentation of components when higher task accuracy is required.     

Exploring the role of sexual experiences in on‐again/off‐again dating relationships

As an important dimension of romantic relationships, sexual activity has received little attention in research on on‐again/off‐again (on–off) relationships. Study 1 assessed the prevalence and perceptions of sexual experiences in on–off relationships as compared to non‐cyclical relationships (those without a history of breakups and renewals); furthermore, current and post‐dissolution (PD) relationships were assessed. Findings showed that on–off partners were four times more likely to engage in sex after breakups than non‐cyclical partners (55 vs. 13%). Results also suggested that on–off partners' perceptions of PD sexual experiences were more satisfying, more compatible, and less stressful than were non‐cyclical partners'. Using longitudinal data, Study 2 showed that PD sex was linked with reconciling the relationship. Conclusions from these findings and future directions are discussed.     

Role of the striatum and the cerebellum in motor skill acquisition

Motor skill acquisition was investigated in patients with Parkinson's disease (PD) or cerebellar dysfunction using two sensory-guided tracking tasks. The subjects had to learn to track a visual target (a square) on a computer screen by moving a joystick under two different conditions. In the unreversed task, the horizontal target movements were semi-predictable and could be anticipated. In the reversed task, the horizontal movements of a pointer which had to be kept within the target square were mirror-reversed to the joystick movements. PD patients showed intact learning of the semi-predictable task and reduced learning of the mirror-reversed task; patients with cerebellar dysfunction showed the opposite pattern. These findings are discussed in relation to the differential contribution of the cerebellum and the striatum to motor skill acquisition: the cerebellum appears to participate in the implementation of anticipatory movements, whereas the striatum may be critically involved in types of motor learning which require a high degree of internal elaboration.     

Role of the striatum and the cerebellum in motor skill acquisition

Motor skill acquisition was investigated in patients with Parkinson's disease (PD) or cerebellar dysfunction using two sensory-guided tracking tasks. The subjects had to learn to track a visual target (a square) on a computer screen by moving a joystick under two different conditions. In the unreversed task, the horizontal target movements were semi-predictable and could be anticipated. In the reversed task, the horizontal movements of a pointer which had to be kept within the target square were mirror-reversed to the joystick movements. PD patients showed intact learning of the semi-predictable task and reduced learning of the mirror-reversed task; patients with cerebellar dysfunction showed the opposite pattern. These findings are discussed in relation to the differential contribution of the cerebellum and the striatum to motor skill acquisition: the cerebellum appears to participate in the implementation of anticipatory movements, whereas the striatum may be critically involved in types of motor learning which require a high degree of internal elaboration.     

Dopaminergic modulation of prospective memory in Parkinson's disease

Growing interest is present in literature on the study of prospective memory functioning in Parkinson's disease (PD). Current data indicate that prospective memory may be impaired in PD and a relationship with general executive dysfunctioning has been suggested. However, although the dopamine dependency of cognitive dysfunction in PD has been widely investigated, poor is known on the dopaminergic modulation of PM. In the present study we explored the effect of acute administration of levodopa on the performance of a PD sample (n=20) in a time-based prospective memory task. PD patients were evaluated in the morning after a 12-hour therapy wash-out in two experimental conditions: i) after levodopa assumption ("on"); ii) without drug administration ("off"). The experimental task required to execute three uncorrelated actions after 10' for three consecutive trials. Distinct scores for the spontaneous recall of the intention to perform the actions (prospective component) and for the correct execution of the actions (retrospective component) have been computed. Results showed that in the "off" condition PD patients were selectively impaired on the prospective component of the task. However, L-dopa administration significantly improved PD patients' performance actually restoring the prospective memory deficit. These results support a critical role of dopaminergic modulation in prospective memory processes in PD patients, possibly through the replacement of dopamine levels in fronto-striatal pathways.     

Impaired awareness of movement disorders in Parkinson’s disease

Background

This study analyzed the presence of awareness of movement disorders (dyskinesias and hypokinesias) in 25 patients with Parkinson’s disease (PD) and motor fluctuations (dyskinesias, wearing off, on–off fluctuations). Of the few studies that have dealt with this topic, none have analyzed the differences in the awareness of motor deficits by comparing the on and off states using motor scales and an extensive battery of tests to assess cognitive and behavioral functioning.

Methods

PD patients were compared on three different scales that we have devised to measure awareness of movement disorders: Global Awareness of Movement (GAM) Disorders, dyskinesia/hypo-bradykinesia rating scales.

Results

Data showed that PD patients had greater awareness and psychological suffering in the off state than in the on state. In particular, they were troubled by motor disabilities related to hypokinesias and had mood-related symptoms and a perception of disability in activities of daily living. Interestingly, patients only showed a selective reduction of awareness of movement disorders associated with executive functions and related to dyskinesias in the on state, compared to a preserved awareness of hypokinesias in the off state. On the contrary, no association with executive functions was found in the off state.

Conclusion

Our findings suggest that the dopaminergic overstimulation of mesocorticolimbic pathways may cause a dysfunction of prefrontal–subcortical connections related to the impaired insight.     

Analysis and Discrimination of Surface Electromyographic Features for Parkinson’s Disease during Elbow Flexion Movements

Abstract

Parkinson’s disease (PD) is the second most common neurodegenerative disorder. Early intervention/treatment relies on early diagnosis of PD. There is increasing interest in methods based on electromyography measurements of PD patients because of its noninvasiveness. Thus, this study was to investigate electromyographic (EMG) characteristics of the upper limb between PD patients and healthy control subjects using EMG, and to distinguish PD patients from healthy control subjects according to the EMG information using a support vector machine (SVM) classifier. Sixteen right-handed PD patients and 25 right-handed healthy subjects participated in experiments involving elbow flexion movement. The frequency power, duration, skewness, recurrence rate, and correlation dimension of EMG signals and success rate for the right hand and the skewness of EMG signals for the left hand were found to be significantly different between the two groups. This information was subsequently used to distinguish PD patients from healthy control subjects using the SVM classifier to obtain a mean accuracy of 87.02%. Although the results may not be immediately available to use in clinical applications, the safety, simplicity and speed of the system still merits further consideration. Enhancing performance accuracy and examining PD patients in different stages of disease are anticipated in future investigations.