“4.14”青海玉树高原地震伤员救治特点分析

目的:探讨青海玉树高原地震伤员救治特点,提高高原地震救援能力。方法:回顾性分析绵阳市医疗救援队赴青海玉树地震灾区进行现场救援、伤员转运、后勤保障、应对措施。结果:此次救援中绵阳市医疗救援队现场筛查及救治地震伤员共160余人次、查房会诊101人次、手术8台、转运伤员40人次、清洁消毒帐篷医院及生活区25000m2、心理辅导49人次、心理抚慰培训35人、发放地震宣传资料千余份;整个救援行动有序、有效、安全。结论:高原地震伤员救治应在注重高原特点重视后勤保障的前提下注重社会及地域现实情况,加强与当地政府、组织、居民合作。     

由执行抗震救灾任务引发的抢险救灾医疗救援问题思考

抢险救灾医疗救援主要是针对受灾地区人民群众以及救灾人员进行的救治和健康维护。该类任务发生紧急，短时间内面对大量伤病员，对医学救援的组织和救护效率提出了很高的要求。四川汶川地震，青海玉树地震发生后，我院两次抽组医疗队开赴灾区进行现场医疗救治和技术支援，圆满完成了任务。认真总结两次抗震救灾医疗救援工作的经验与教训，有利于高效组织突发事件医学救援，更好地履行救死扶伤使命。     

急性四肢动脉栓塞的外科治疗

目的：探讨急性肢体动脉栓塞的手术治疗效果和术后并发症的防治方法。方法：采用Fogarty球囊导管取栓治疗23例29条急性动脉栓塞肢体。术后所有患者均行溶栓、抗凝治疗。结果：本组无死亡。术后肢体存活23条，截肢3例、截趾3例；骨筋膜室综合征切开减压6例；术后出现急性心衰2例，脑梗塞3例，精神症状4例。23例均痊愈出院。随访1～6个月，23条成活肢体及6条残肢血供良好，功能正常。结论：早期诊断、及时手术治疗和术后对重要脏器功能的保护，是提高手术疗效、降低截肢率和死亡率的关键。     

尿毒症患者糖尿病足截肢术围手术期血液净化治疗方案的选择及护理

目的探讨尿毒症患者因糖尿病足而实施截肢手术围手术期血液净化治疗方案的选择及护理。方法回顾性分析解放军火箭军特色医学中心肾脏病科2016年10月至2019年10月收治的因糖尿病足而导致截肢手术的5例尿毒症患者临床资料,其中1例患者先行右小腿截肢术,后行右大腿截肢术;2例患者行左小腿截肢术;1例患者行右大腿截肢术;1例患者行双侧大腿截肢术。术前对所有患者均进行充分的血液透析,术后根据伤口面积、渗血渗液程度、血流动力学及容量负荷、经济因素等选择由连续性肾脏替代治疗(CRRT)过渡至维持性血液透析(MHD)治疗或直接行MHD治疗,选择合适的抗凝剂并做好患者的术后护理,包括病情观察、伤口护理及心理护理。统计患者术后行CRRT次数、平均伤口愈合时间及住院时间、术后伤口并发症发生情况。结果 5例患者平均伤口愈合时间为16 d,平均住院时间为22 d,住院期间共行9次CRRT,由于伤口面积比较大,伤口渗出严重,血流动力学不稳定,行双侧大腿截肢手术的患者术后给予3次CRRT后过渡为MHD治疗;行单侧大腿截肢手术的患者术后给予2次CRRT后过渡为MHD治疗;由于伤口面积相对较小、血流动力学比较稳定,3例行小腿截肢术的患者中1例术后给予1次CRRT后过渡为MHD治疗,2例因经济原因术后直接选择MHD治疗。但直接行MHD治疗的2例患者中,1例因伤口感染及伤口破裂,于右小腿截肢术后20 d再行右大腿截肢术,术后给予3次CRRT后过渡至MHD治疗。术后直接选择MHD治疗的患者平均伤口愈合时间为18 d、平均住院时间为24 d,均长于术后行床旁CRRT过渡至MHD患者(平均伤口愈合时间为14 d,平均住院时间为21 d)。术后由床旁CRRT过渡至MHD治疗的3例患者中2例为大腿截肢患者,虽然伤口面积比小腿截肢术患者大,但未出现伤口感染等并发症。结论尿毒症患者手术治疗风险较高,实施截肢手术创面比较大,而且糖尿病患者伤口不易愈合,故手术前应进行充分有效的透析治疗,术后建议首先给予床旁CRRT,而后逐渐过渡至MHD治疗。     

腹腔镜下输卵管妊娠手术治疗80例临床分析

目的 探讨腹腔镜下异位妊娠的手术方法、适应证、手术疗效及临床应用价值。方法 回顾分析确诊为输卵管妊娠、有手术指征的80例患者的腹腔镜手术情况和术后情况。结果 80例输卵管妊娠均在腹腔镜下完成，术中出血量为5-200ml，手术获得满意疗效。结论 腹腔镜手术具有创伤小、恢复快、术中出血少、住院时间短等优点，是治疗异位妊娠首选的手术方式。     

汶川地震救援官兵创伤后应激障碍患者的生存质量

本文就汶川地震救援官兵创伤后应激障碍(post-traumatic stress disorder,PTSD)患者的生存质量及相关因素进行研究。1对象与方法1.1对象对汶川地震重灾区直接从事一线救援军人创伤暴露半年后进行调查。按方便取样方法确定调查对象1125人。按照美国精神疾病与分类标准第4版创伤后应激障碍诊断标准入组PTSD患者63例,年龄18～31岁,平均(21±3)岁;军龄:1年29人,2年11人,≥3年23人;婚姻:未婚58人,已婚5人。     

胸腔镜治疗血胸25例体会

目的探讨电视胸腔镜手术处理血胸的适应证与禁忌证。方法对25例血胸在电视胸腔镜下进行手术治疗。其中19例为创伤性血胸,5例为自发性血胸,手术后血胸1例。结果手术时间（40-140）min,平均66min。手术中从胸内清除的血量（800-2200）ml,平均1310ml。术后留置胸腔闭式引流管2-5d,平均2.8d。全组无手术死亡。2例中转剖胸手术,未发生术后并发症。结论电视胸腔镜手术适应于自发性血胸、创伤性血胸、凝固性或包裹性血胸。     

伴有挤压伤的前臂离断再植的治疗研究

目的探讨伴有挤压伤的前臂离断再植的手术方法及功能重建效果。方法对6例患者离断前臂进行彻底清创、不同程度短缩骨骼，进行有效的内固定，尽可能修复上肢的主要神经、血管及肌肉（肌腱）组织，一期闭合创口。结果6例离断前臂中除1例再植肢体因感染、坏死截肢外，其余5例全部成活，术后随访2—4年，再植肢体功能恢复良好。结论在断肢再植手术中，必须熟练掌握前臂应用解剖，具备骨科、血管外科、整形外科的基本知识和技术，应用显微外科技术才能使再植的前臂和手获得良好的功能恢复。     

保留乳头改良根治术治疗乳腺癌中远期疗效分析

目的进一步评价保留乳头改良根治术治疗Ⅰ、Ⅱ期乳腺癌的疗效。方法2000年3月至2002年10月共实施该手术37例，其中Ⅰ期22例，Ⅱ期15例，35例符合作者制定的手术适应证，2例略超出手术适应证。结果37例病人中，术后发生乳头表皮部分坏死1例，1个月后乳头皮肤痂下愈合；皮下积液3例，经穿刺抽液治愈；33例切口甲级愈合，顺利出院。全部病例乳头基底部病理检查均无癌浸润。术后37例全部随访，最长随访时间93个月，中位随访时间59个月。37例病人均无局部复发和远处转移。结论保留乳头改良根治术可作为Ⅰ、Ⅱ期乳腺癌手术治疗的选择术式。     

后腹腔镜肾上腺切除术36例报告

目的 探讨后腹腔镜。肾上腺切除术的适应证及手术方法。方法应用后腹腔镜肾上腺切除术治疗肾上腺疾病36例37侧，其中原发性醛固酮增多症12例，皮质醇增多症11例12侧，嗜铬细胞瘤9例，无功能腺瘤4例。结果36例手术均获得成功，手术时间平均90(70～210)min。术中出血平均40(20～100)ml，均未输血。患者术后1～2d恢复进食，并可下床活动。术后住院时间平均6(4～12)d。结论与开放手术相比，后腹腔镜手术具有创伤小，疼痛轻，康复快等优点，应成为肾上腺良性疾病的首选手术方法。     

下肢截肢水平对主动脉血流动力学影响的数值研究EI北大核心CSCD

已有研究发现,下肢截肢患者心血管疾病发病率显著高于正常人,但少有学者从血流动力学角度研究下肢截肢与心血管疾病之间的关系。本文采用数值仿真,通过改变外周阻抗和电容模拟不同截肢水平,研究截肢对主动脉血流动力学环境的影响。结果发现,截肢后主动脉血压升高,肾下腹主动脉时均壁面切应力降低,且左右侧壁振荡剪切指数呈不对称分布;截肢侧髂动脉时均壁面切应力降低且振荡剪切指数增大;同时随截肢水平提高,上述变化更加显著,增加了截肢者患动脉粥样硬化与腹主动脉瘤的风险。本文初步揭示了下肢截肢对心血管疾病的影响规律,为截肢后康复训练设计与心血管疾病治疗方案优化提供理论指导。     

Repeated regeneration of the German cockroach legs

Two series of repeated-regeneration experiments were carried out on each fore-, mid- and hindleg of both sexes during the entire postembryonic development period. One was autotomy at trochanterofemoral articulation; the other was amputation from basal coxa. In both experiments, one of the six legs was operated on before the regeneration critical period in the 1st instar. If a regenerate appeared in the following instar, it was repeatedly operated on; if not, operation was postponed until a regenerate appeared. The number of instars required to reach the adult stage increased in both autotomy and amputation experiments. Total larval duration was also prolonged in both experiments. In autotomy regenerates repeatedly appeared almost every instar until the adult stage, while in amputation no regenerates were present just after postoperative molts. Regenerated femur and tibia developed well after autotomy, whereas those after amputation were considerably smaller. All the regenerated legs had tetramerous tarsi. Regenerated legs from autotomized stumps showed incomplete homoeotic regeneration as to the kind of legs. Regenerates from foreleg stumps showed intermediate tibia/femur ratios between normal foreleg and midleg, and those from the hindlegs, intermediate between normal hindleg and midleg. After amputation, the tibia/femur ratios of regenerates were variable. Possible modifiers were suggested for the homeotic and tetramerous regeneration.     

Actin fiber patterns detected by Alexafluor 488 phalloidin suggest similar cell migration in regenerating and nonregenerating rodent toes

Although mammals do not regenerate most appendages, they are able to regenerate toetips if the amputation occurs through the nail bed. The reasons for different outcomes following amputation at different levels are not understood. It is possible that cells at regenerating and nonregenerating sites migrate from fundamentally different tissues. If so, different migratory pathways could be detected. To identify putative migrating cells, microscope slides were made from both regenerating and nonregenerating toes of rats and mice on successive days after amputation. Fluorescent-labeled phalloidin, which binds polymerized f-actin, was used to identify actin filaments and fibers. Cells containing prominent actin bundles were distinguishable from those containing diffuse fibrils and those in which visible fibers were absent. Phalloidin labeling was similar in regenerating and nonregenerating digits after amputation. As early as 2 days after amputation at either proximal or distal levels, many cells of the hypodermis adjacent to the wound became labeled with phalloidin. The number and intensity of labeled hypodermal cells containing stress fiber-like bundles increased rapidly with time, and at successive times cells were seen progressively further distally. By approximately 7 days, they occupied the wound site immediately distal to bone of both regenerating and nonregenerating digits. Most dermal cells were unlabeled and endosteal and marrow cells contained only fibrillar actin. Phalloidin labeling does not support the concept of migration from different tissues in regenerating and nonregenerating amputation sites.     

糖尿病足截肢术预后影响因素分析及预后能力评估

目的　探索相关实验室指标对糖尿病足截肢术预后的影响,评估对其不良预后的预测价值。 方法　回顾性选取2016年1月到2018年3月于本院行糖尿病足截肢术且完成术后随访1年的69例患者资料,将随访期间发生病情恶化的患者定义为不良预后组,病情无恶化、伤口愈合良好者为预后良好组,绘制Kaplan-Meier生存曲线观察1年预后不良率;单因素及多因素分析筛选导致不良预后的独立影响因素;ROC曲线评价其对糖尿病足截肢术后发生不良事件的预测能力;在预后良好组内依据清创次数进行亚分组,筛选影响截肢术前清创次数的独立危险因素。 结果　单因素分析提示糖尿病足截肢术不良预后组其血清白蛋白（ALB）、中性粒细胞/淋巴细胞比值（NLR）、C反应蛋白（CRP）、血沉（ESR）及D-二聚体（D-dimer）相比预后良好组有统计学差异（P<0.05）,多因素分析显示D-dimer、CRP及NLR为影响重症糖尿病足截肢术预后的独立危险因素。生存曲线提示1年不良预后率为40.6%。ROC三者联合诊断的曲线下面积为0.902,高于D-dimer,Delong检验显示其与D-二聚体有统计学差异（P<0.05）。在预后良好组内,CRP是影响截肢术前清创次数的独立危险因素（P<0.05）。 结论　D-dimer、CRP、NLR及三者联合诊断对糖尿病足截肢术预后均有较好的预测能力,其联合诊断效率高于D-dimer,但不优于CRP或NLR;CRP为预后良好组内影响截肢术前的独立危险因素。     

43例严重糖尿病足治疗的临床分析

目的分析和总结糖尿病足的临床特点和治疗体会。 方法回顾性分析2013年6月至2017年8月北京朝阳急诊抢救中心烧伤整形科收治的43例严重糖尿病足患者的临床资料,根据患者截肢(趾)与否,将43例患者分为截肢组、截趾组、截肢(趾)组和非截肢(趾)。对患者年龄、糖尿病病程、住院时间、血浆白蛋白浓度、血红蛋白水平、白细胞计数、糖化血红蛋白水平、血糖值、Wagner分级、有无糖尿病周围神经病变、视网膜病变、糖尿病肾病、坏死性筋膜炎等进行分析。数据进行单因素方差分析、多因素非条件Logistic回归分析、独立样本t检验和χ²检验。 结果截肢组患者的住院时间为(80.7 ± 39.3)d,长于非截肢(趾)组(58.4 ± 14.2)d,差异有统计学意义(t＝－2.27, P＝0.03);截肢(趾)组、截肢组和截趾组的年龄分别为(58.7 ± 9.8)、(55.7 ± 11.2)、(62.2 ± 6.7)岁,与非截肢(趾)组(59.0 ± 8.4)岁相比,差异均无统计学意义(t＝0.12、0.96、－1.07,P＝0.91、0.35、0.29);截肢(趾)组、截肢组和截趾组的糖尿病病程分别为(13.4±6.4)、(12.3±7.1)、(14.6±5.5)年,较非截肢(趾)组(15.4±6.3)年,差异均无统计学意义(t＝1.03、1.29、0.32,P＝0.31、0.21、0.75);截肢(趾)组和截肢组的血浆白蛋白浓度均分别为(21.9±3.0)、(20.9±2.4)g/L,明显低于非截肢(趾)组的(25.0±4.5)g/L,差异均有统计学意义(t＝2.80、3.04,P＝0.01、P<0.05);截肢(趾)组、截肢组和截趾组的血红蛋白水平分别为(93.1±14.2)、(91.8±13.5)、(94.6±15.5)g/L,与非截肢(趾)组(101.4±14.9)g/L相比,差异均无统计学意义(t＝1.86、1.85、1.19,P＝0.07、0.07、0.25);截肢(趾)组、截肢组和截趾组的白细胞计数分别为(23.1±4.3)、(23.7±4.8)、(22.4±3.9)×10⁹/L,与非截肢(趾)组(21.8 ± 3.6)×10⁹/L相比,差异均无统计学意义(t＝－1.08、－1.30、－0.46, P＝0.29、0.20、0.65);3组的糖化血红蛋白水平分别为(9.8±1.2)、(10.1±1.3)、(9.6±1.1)mg/dl,与非截肢(趾)组(9.4±1.5)mg/dl相比,差异均无统计学意义(t＝－0.98、－1.21、－0.28,P＝0.16、0.03、0.98);43例患者中,13例截肢,截肢率为30.23%,截肢切口一期愈合2例,11例截趾,截趾率25.58%,截肢(趾)率55.81%。截肢(趾)组与截肢组的患者多为高Wagner分级,其中4级以上分别有11、19例,与非截肢(趾)组的7例相比,差异均有统计学意义(χ²＝7.91、9.73,P<0.05、P＝0.02);截肢(趾)组合并周围神经病变、下肢血管病变、视网膜病变、糖尿病肾病和坏死性筋膜炎的患者分别有12、10、6、7、21例,截肢组合并这5种疾病的患者分别有8、7、4、4、12例,截趾组合并这5种疾病的患者分别有4、3、2、3、9例,与非截肢(趾)组的3、5、3、6、14例比较,差异均无统计学意义(χ²＝2.57、3.07、1.05,P＝0.63、0.55、0.90)。 结论严重糖尿病足有较高的截肢伤残率,局部严重的感染是导致截肢(趾)的重要原因,病灶彻底的清创引流是治疗糖尿病足的关键措施。     

An animal model for evaluation of antigen-specific dialyzable leukocyte extracts therapy of osteosarcoma

The effects of human osteosarcoma (OS)-specific dialyzable leukocyte extracts (DLE) in hamsters bearing human OS were investigated. The DLE used in this investigation was prepared from rabbits immunized with human osteosarcoma-associated antigens (DLE-OSAA). Tuberculin (DLE-PPD) and control DLE were prepared from rabbits injected with tuberculin or 0.85% NaCl (DLE-NaCl). DLE was administered subcutaneously into inbred hamsters (each injection contained DLE derived from 10(7) rabbit leukocytes). Four groups of animals were studied: group 1, amputation alone; group 2, amputation plus DLE-OSAA; group 3, amputation plus DLE-PPD; group 4, amputation plus DLE-NaCl. Of the DLE-OSAA-treated animals (group 2), 60% were still alive at 300 days postamputation; whereas in animals in groups 1, 3, and 4, all died within 90 days postamputation. In separate experiments, we found that 100% of the animals in groups 1, 3, and 4 developed pulmonary metastases within 30-60 days postamputation, whereas only 20% of the animals in group 2 developed metastases at the same time; indeed 40% of the DLE-OSAA-treated animals were free of metastases in 240-300 days postamputation. Both the leukocyte adherence inhibition assay (LAI) and lymphocyte DNA synthesis assay (LDS) were used to monitor the transfer of antigen-specific cell-mediated immunity in each group of tumor-bearing hamsters. All surviving hamsters in group 2 had high LAI and LDS activity. Our results suggest that DLE-OSAA is effective in preventing pulmonary metastases and death of OS-bearing hamsters (after amputation) as compared with amputation alone, amputation plus DLE-NaCl, and amputation plus DLE-PPD, and that its effect is via an antigen-specific mechanism.     

Injury to nerves and the initiation of amphibian limb regeneration

The possibility has been investigated that nerves, which promote mitotic activity during the growth phase of limb regeneration, may also release factors upon injury to stimulate the cellular events during the initiation of regeneration. These events have been compared in control, innervated limb stumps and in limbs denervated for various periods before amputation. Wound closure occurred in an essentially normal manner in limbs denervated at the time of amputation but frequently occurred at reduced rates or not at all in limb stumps denervated 5 days before amputation. Tissue loss and various degrees of morphological regression were seen in many of the predenervated limb stumps, including all of those denervated for 6 days or more before amputation. Evidence is presented which suggests that regression may result from a combination of the denervated state and disturbance to the limb ' vascular system. Limbs predenervated 2-10 days before amputation were fixed 7 days after amputation and examined histologically. All limb stumps, including those involved in regression, showed tissue dissociation and cellular dedifferentiation. Autoradiography revealed that the dedifferentiation involved DNA synthesis in both denervated and innervated limbs. Seven days after amputation, DNA-labeling indices in limb stumps predenervated 2 or 4 days were similar to those of control limbs, but labeling indices were significantly reduced in limbs predenervated 6 or more days. The results are assessed in light of the state of nerve degeneration in the limbs at the time of amputation and are discussed in terms of what is known regarding nerve-derived growth-promoting substances.     

Psychiatric and emotional sequelae of surgical amputation

The prevalence of posttraumatic stress symptoms after the experience of amputation is not well established. The current study gathered data on the prevalence of posttraumatic stress disorder (PTSD) and other psychiatric disorders after amputation. Participants were recruited from a large Northeastern rehabilitation hospital and were assessed with structured clinical interviews. The data suggest that planned surgical amputations resulting from chronic illness do not frequently lead to PTSD symptoms. In contrast, data suggest that amputation resulting from accidental injury may lead to a higher prevalence of PTSD, in part because of the emotional stress surrounding the accident.     

人参皂甙对应激免疫抑制小鼠模型中枢神经肽Y和儿茶酚胺类递质的影响

本文观察了人参总甙对截肢应激免疫抑制小鼠模型中枢神经肽Y 和儿茶酚胺类递质的影响。结果表明人参皂甙可以拮抗应激造成的中枢神经肽Y、高香草酸的升高和去甲肾上腺素的下降,同时纠正应激所致的免疫功能抑制。结果提示人参皂甙的这一中枢神经系统作用可能与其抗应激所致免疫抑制的效应有关。     

Supra-vaginal uterine amputation vs. abdominal hysterectomy: The effects on urinary symptoms with special reference to pollakisuria, nocturia and dysuria

Post-operative symptoms of hysterectomy have received relatively little attention in the literature. In the present study the first author has personally interviewed and examined 105 abdominal hysterectomy patients and 107 patients with supravaginal uterine amputation pre-operatively and thrice post-operatively. At one year the follow-up percentage was 99.5 (211/212). In the statistical analysis McNemar's test of symmetry and Fisher's exact test were used. Loglinear models were developed where applicable.

A number of patients had urinary symptoms pre-operatively: 27.6% of the abdominal hysterectomy and 48.6% of the supra-vaginal amputation patients suffered from pollakisuria; preoperative nocturia and dysuria were present in about 10% of patients in each group. These urinary symptoms disappeared more frequently in patients who underwent supra-vaginal amputation; with regard to pollakisuria the difference is statistically significant. Twelve months post-operatively pollakisuria was present in 10.3% of supra-vaginal amputation and 13.5% of hysterectomy patients.

The advantage of supra-vaginal amputation over abdominal hysterectomy with regard to these symptoms may result from the considerably less extensive manipulation of the bladder during supravaginal amputation. Possibly the support provided by the remaining stump and the round ligaments fixed to it also help to reduce urinary symptoms in these patients. However, further urodynamic studies are needed.