measures for post-transplant infection(Vaccinations for pneumococci and hepatitis B are typically given prior to transplant to ensure an adequate immune response)
Post-transplant measures
Monitoring for the following infections:
・CMV viral loads in blood monthly for a minimum of 12 months
・EBV viral loads in blood for a minimum of 12 months
Universal prophylaxis
・PCP prophylaxis with ★trimethoprim-sulfamethoxazole for a minimum of 6–12 months
・CMV prophylaxis with ganciclovir or valganciclovir for 12–14 weeks transplantationsurgeryUWorld step2CK HirotoShishido
Indication for operative management of Intussusception発症後時間が経過して壊死が疑われるまたは腹膜炎を伴う場合や，高圧浣腸で整復されない場合は，Hutchinson手技（開腹して内筒を押し出す整復法）を用いる． pediatricssurgery卒試 HirotoShishido
treatment of chylothorax乳び胸の治療は胸腔ドレナージと栄養管理が基本である．胸腔ドレナージにより貯留した乳びを排出し，肺の圧迫を解除する．栄養管理では☆絶食＋中心静脈栄養とし，乳びの産生を抑制する．このとき，胸管を介さずに門脈系に取りこまれる中鎖脂肪酸（MCT）の割合を増やすことで，乳びを減らす方法も試みられる．また，近年,オクトレオチド（ソマトスタチンアナログ）が有効であるとの報告もある．
treatment of pneumothorax■ stable, small (<2 cm between lung and chest wall on x-ray), minimal symptoms: observation + O2
■ symptomatic or large (>2 cm): aspiration
■ unstable/tension pneumothorax: needle decompression then chest tube, and VATS if unsuccessful
(25-50%) respiratorysurgery卒試 HirotoShishido
penile fracture陰茎折症
① 性交中など陰茎の勃起時に強力な外力が加わって，☆陰茎海綿体白膜が断裂したもの．陰茎海綿体に損傷が及ぶこともある．
② 受傷時には断裂音を伴い，激痛が生じる．血腫のため対側に屈曲する．
③ 治療は，血腫除去と白膜断裂部の縫合を速やかに行う． urologysurgery国試過去3回 HirotoShishido
definition of massive hemoptysis, and management for thatbleeding more than 600 mL/24hr or 100 mL/hr
secure airway first,and treat cause; persistent bleeding treated via ★bronchoscopic interventions, embolization, or resection
★Urgent thoracotomy and surgical intervention are reserved for patients with unilateral bleeding who continue to bleed despite initial bronchoscopy and/or pulmonary artery embolization. respiratorysurgeryUWorld step2CK HirotoShishido
treatment for large bowel obstruction (LBO)•supportive management: IV fluids, gastrointestinal decompression; 75% require surgical intervention
•surgical correction of obstruction
•volvulus: ☆initial decompression with flexible sigmoidoscopy, operative reduction or sigmoid resection dependent on severity
•mechanical obstruction: ostomy alone(fecal diversion), colectomy with primary anastomosis or Hartmann procedure. May pursue stenting as bridging (follow with another intervention) or palliation gastrointestinalsurgery国試過去3回 HirotoShishido
laparotomy is mandatory in the patient with penetrating abdominal trauma if★Hemodynamic instability
Peritonitis
Evisceration
Impalement
Peritoneal penetration & significant organ injury
Free air in abdomen
Blood in NG tube, Foley catheter, or on
DRE(digital rectal exam) gastrointestinalsurgeryUWorld step2CK HirotoShishido
renal pelvic, ureteral cancer 好発部位、診断、治療、予後尿管癌は尿管の下1/3に好発し，再発が多いのが特徴である
signs of complicated SBO(small bowel obstruction)changes in the character of the pain, fever, hemodynamic instability (hypotension, tachycardia), guarding, leukocytosis, and significant metabolic acidosis (low bicarbonate in this patient)
Delay in surgery (★urgent surgical exploration)may lead to perforation and significant risk of mortality.
when is the pain worsened in the patients with plantar fasciitisintense pain when walking from rest that subsides as patient continues to walk, worse at end of day with prolonged standing
Leriche syndromeThigh claudication is suggestive of occlusive disease of the ipsilateral external iliac artery or its more distal branches (ie, common femoral, superficial femoral, profunda femoris arteries).
Accompanying ☆★impotence and/or ☆gluteal claudication suggests ☆more proximal aortoiliac occlusion (so-called Leriche syndrome), which, in addition to affecting the external iliac artery, also diminishes blood flow to the internal pudendal and gluteal branches of the internal iliac artery. cardiologysurgeryUWorld step2CK HirotoShishido
thracentesis
locationThoracentesis is typically performed between
①the 6th and 8th ribs along the midclavicular line,
②☆the 8th and 10th ribs along the midaxillary line (above image),
③and the 10th and 12th ribs along the paravertebral line.
This allows pleural fluid to be drained without risking lung injury (which can occur at higher insertion sites). However, insertion of a needle ☆below the 9th rib still risks penetrating abdominal structures. surgeryUWorld HirotoShishido
disinfectant and antiseptic that is used for skin disinfection before surgery and to sterilize surgical instrumentschlorhexidine (chlorhexidine gluconate,CHG) surgerypharmacology HirotoShishido
