吸入性损伤患者早期气管切开拔管时机及后期并发症分析

Objective To investigate the appropriate extubation time and treatment of late complications after early tracheotomy in patients with moderate or severe inhalation injury. Methods One hundred and fifty patients ( 105 males and 45 females) with inhalation injury were admitted to our hospital from January 2000 to January 2009. Among them, 109 out of 129 cases with moderate inhalation injury received early tracheotomy, and all 21 cases with severe inhalation injury received early tracheotomy. Data were collected for analysis as follows: ( 1 ) incidence of re-intubation due to suffocation and pneumonia incidence after extubation within 2 weeks or after 2 weeks post inhalation injury (PⅡ), and mortality rate within the first week after injury were recorded. (2) Conservative treatments including expectorant, oral antibiotics, and absolute bedrest were recommended for patients who had severe cough, hoarseness or poor pulmonary function after late extubation and closure of tracheostomy wound. Fiberoptic bronchoscopy findings ( tracheostenosis degree, granuloma formation rate, vocal cord paralysis rate) and pulmonary function index ( FEV1 ) data were collected and analyzed in 30 cases with moderate inhalation injury and 10 cases with severe inhalation injury within 3 months after injury for follow-up. Data were processed with t test or chi-square test. Results There was no obvious difference in the rate of re-intubation after extubation in patients with moderate inhalation injury between those done within 2 weeks PⅡ ( 15/70, 21.4% ) and those done after 2 weeks PⅡ (2/25, 8.0% ) ( x 2 = 1.52, P ＞ 0.05 ). Pneumonia incidence in patients of moderate inhalation injury with extubation within 2 weeks PⅡ (21/70, 30.0% ) was lower than those with extubation after 2 weeks PⅡ (15/25, 60.0% ) (x 2= 7.04, P ＜ 0.05). Levels of above-mentioned indexes in patients with severe inhalation injury extubated in diffferent stages were similar to those of patients with moderate inhalation injury.Within the first week after injury, mortality rate of patients with severe inhalation injury was higher than that of patients with moderate inhalation injury ( x 2 = 11.90, P ＜ 0.05 ). During follow-up, tracheostenosis rate in patients with moderate or severe inhalation injury was 100.0%; granuloma formation rate and vocal cord paralysis rate in patients with severe inhalation injury were higher than those of patients with moderate inhalation injury ( with x 2 value respectively 4.59, 13.47, P values all below 0.05 ). The FEV1 value of patients with moderate inhalation injury in the 1st, 2nd, 3rd month after injury was respectively higher than that of patients with severe inhalation injury ( with t value respectively 5.48, 12. 10, 6.25, P values all below 0.05). The values recovered to normal level in the 3rd month after injury. Conclusions Extubation time of tracheotomy for patients with moderate or severe inhalation injury within 2 weeks or after 2 weeks PⅡ has its own advantage and disadvantage, and it should be performed according to specific conditions of each patient. Conservative treatment is optional for late complications of respiratory system.     

全膝关节置换术多用途挡板设计与应用

[目的]介绍全膝关节置换术（total knee arthroplasty, TKA）多用途挡板设计与应用技术和初步临床结果。[方法]本多用途挡板结构包括相互连接的挡板、手柄与负压吸气器。挡板上设有圆形通透窗口、圆形通透窗口通道、矩形通透窗口。矩形通透窗口设置在挡板顶边的中部,圆形通透窗口设置在挡板的几何中心位置的一侧。手柄与挡板的下部连接;负压吸气器与手柄连接在挡板的下部,其前端开口延伸到挡板的中部形成吸气口,其后端开口连接外部负压抽气管道,将靠近挡板或附着在挡板表面上的血液、碎屑吸出。[结果]86例TKA患者术中应用多用途挡板,高效遮挡了飞溅的血液和碎骨渣,大大降低手术感染率,有效保护医护人员从而预防血源性职业暴露。86例患者均顺利完成手术,术后手术切口愈合良好。膝关节功能恢复良好,随访过程中未出现感染等严重并发症。[结论]本多用途挡板遮挡并吸附TKA手术过程中飞溅的血液和碎骨渣等污染物,降低了感染率,减少对医务人员的污染和伤害。     

中药对HIV患者肠道菌群结构及免疫影响的研究

目的：基于16SrRNA高通量测序,研究中医药对HIV患者肠道菌群丰度、多样性及免疫的影响。方法：纳入HIV患者36例,采用多中心、双盲、随机、安慰剂对照研究方法,分为试验组(Treat组)和对照组(Control组),其中试验组16例、对照组20例。试验组给予单纯中药,对照组给予相应中药安慰剂,连续治疗72周。利用16SrRNA高通量测序观察上述干预措施对HIV患者肠道菌群丰度和多样性的影响并检测治疗前后两组患者T淋巴细胞计数以观察患者免疫情况。结果：对比两组患者肠道菌群菌落结构及组成发现,对照组的梭菌在门、纲、目、科、属水平丰度均偏高(P<0.05);试验组瘤胃球菌属、塞内加尔厌氧菌属丰度偏高(P<0.05)。治疗前,两组患者CD4+T细胞计数、CD8+T细胞计数、CD4+/CD8+未见明显差异(P>0.05);经72周治疗,两组患者CD4+T细胞计数、CD4+/CD8+较治疗前均增加,CD8+T细胞计数较治疗前均减少,组间未见明显差异(P>0.05),组内前后比较中仅对照组CD4+/CD8+存在显著差异(P<0.05)。结论：两组HIV患者肠道菌群的...     

小儿手指掌侧瘢痕屈曲畸形矫正术后早期挛缩原因分析

目的 回顾性分析小儿手指掌侧瘢痕屈曲畸形矫正术后早期挛缩的原因. 方法 2002年1月-2006年1月,收治98例347指掌侧瘢痕屈曲畸形,行掌侧瘢痕切除松解中厚皮片植皮术.男52例185指,女46例162指.年龄9个月～6岁.病程3个月～2年,平均7个月.烫伤80例,火焰烧伤18例.每例为1～7个伤指不等.瘢痕切除后,采用1.2 cm×0.7 cm～6.0 cm×2.2 cm中厚皮片修复. 结果 术后5例12指伤口Ⅱ期愈合,余均Ⅰ期愈合.患儿获8～12个月随访,术后早期挛缩9例20指,发生率占患儿9.2%,占术指5.8%.发现早期挛缩后,积极加强防瘢痕处理及功能锻炼.余患儿皮片成活良好,手指活动正常. 结论 小儿手指掌侧瘢痕屈曲畸形一旦影响功能,应尽早手术.术前仔细准备,掌握手术要领和技巧,术后坚持长期有效的防瘢痕治疗及功能锻炼,有助于减少术后早期皮片挛缩的发生.     

PI3Kγ抑制剂AS605240对异丙肾上腺素诱导大鼠心肌肥厚和纤维化的拮抗效应

目的 研究磷脂酰肌醇3-激酶γ(PI3Kγ)小分子抑制剂AS605240对异丙肾上腺素(isoproterenol,ISO)诱导大鼠心肌肥厚和纤维化的治疗作用,并初步探讨其作用机制.方法 健康雄性Wistar大鼠30只,随机分为3组(n=10),分别为ISO模型组、AS605240治疗组和正常对照组(空白组).ISO模型组、AS605240治疗组皮下注射ISO 10 mg/(kg·d)×3 d,再5 mg/(kg·d)×11 d,复制大鼠心肌肥厚和纤维化模型,空白组注射相同体积的生理盐水;建模第2 d,AS605240治疗组给予AS605240 50 mg/(kg·d),ISO模型组和空白组给予等体积0.5%羧甲基纤维素,共给药14 d.末次给药后24 h,称取大鼠心脏质量和体质重,心脏HE染色观察组织学改变并评分,测量大鼠心重指数(Hw/BW)、心功能、胶原容积分数(CVF)等.结果 与正常对照组相比,ISO模型组大鼠Hw/BW增加(P＜0.05),心肌细胞间有大量胶原增生,心功能降低,胶原蛋白含量增加(P＜0.05).与ISO模型组大鼠相比,AS605240治疗组大鼠HW/BW降低(P＜0.05),心功能有明显改善,心肌细胞间胶原沉积减少(P＜0.05).结论 AS605240对ISO引起的大鼠心肌纤维化具有一定的改善作用.     

足跟部软组织缺损的修复

足跟部软组织缺损临床上较常见,修复困难,修复方法较多。本文回顾分析了近年来有关足跟部软组织缺损修复的相关文献,对各种修复方法的适应证、疗效及优缺点进行综述如下。     

头皮扩张器扩张头皮治疗秃发的手术配合

使用头皮扩张器扩张头皮治疗秃发是上世纪末国内外美容整形外科的一项新进展。这项技术的应用，使得患者的秃发区得以被正常头皮完全或部分覆盖，改善了患者形象，增强了患者信心。1995年1月-2005年12月，我科利用扩张术修复头部秃发患者57例，取得了比较满意的效果，现报道如下。     

参附注射液对二尖瓣置换术患者围术期心肌酶及血流动力学的影响

目的 探讨参附注射液对体外循环二尖瓣置换术（MVR）患者围手术期心肌酶及血流动力学的影响。方法 将40例行MVR的患者随机分为实验组（n=20）和对照组（n=20），实验组于麻醉诱导后手术开始前、术后12、36和60h经静脉滴注参附注射液（1ml／kg）和250ml生理盐水；对照组输入等量的生理盐水。于术前、术后2、8、24、48和72h取静脉血检测两组血浆肌酸激酶（CK）、肌酸激酶同工酶（CK—MB）含量，并观察血流动力学指标变化及术中、术后血管活性药物的用量。结果术后2、8、24、48和72h对照组血浆CK和CK—MB值均高于实验组（P〈0.05）。主动脉阻断前、心脏复跳后30min、手术结束时实验组平均动脉压（MAP）均高于对照组（P〈0.05）。术中和术后住ICU期间实验组多巴胺和氨力农的用量均低于对照组（P〈0．05）。结论 参附注射液能减轻心内直视手术患者的心肌损伤，对心功能有一定的保护作用。     

肌皮瓣转移修复骶尾部难治性压疮分期手术治疗19例报告☆

目的：研究表明难治性压疮采用肌皮瓣或筋膜皮瓣修复远期效果好，观察采用肌皮瓣转移修复骶尾部难治性压疮分期手术的治疗效果。 方法：选择2000-01/2006-01四川大学华西医院整形外科收治的采用分期手术肌皮瓣转移修复骶尾部难治性压疮患者19例，患者对治疗方案均知情同意。手术分两期进行：一期行清创切痂术，二期根据患者年龄、压疮部位、范围等选择肌皮瓣类型行肌皮瓣转移术。全部采用局部肌皮瓣修复，臀大肌皮瓣修复21处，皮瓣范围13 cm×11 cm~17 cm×14 cm；股二头肌长头肌皮瓣修复8处，皮瓣范围10 cm×6 cm~13 cm×6 cm。术后睡翻身床14 d，定期随访。 结果：术后皮瓣均成活，18例切口Ⅰ期愈合；1例尿毒症患者皮瓣下积血，经换药后创面愈合。随访5个月~3年，原手术部位无压疮复发，皮瓣质地柔软，外形满意。 结论：应用分期手术肌皮瓣转移方法治疗骶尾部难治性压疮效果明显，手术成功率高。     

绝经后妇女骨质疏松症的循证治疗

目的:评价绝经妇女骨质疏松治疗手段的疗效及安全性。方法:检索The Cochrane Library、Pubmed、NEngl J Med和NGC(national guideline clearinghouse)网站有关绝经后妇女骨质疏松的系统评价和随机对照实验。结果:检索到27项结果,共评估了基础治疗与药物治疗绝经妇女骨质疏松的疗效及安全性。结论:钙与维生素D是绝经后妇女骨质疏松的基础治疗;降钙素能有效缓解绝经妇女骨质疏松性骨痛;阿仑膦酸钠能有效降低绝经后妇女骨质疏松骨折的发生率。