大面积烧伤合并吸入性损伤机械通气治疗探讨

目的 探讨大面积烧伤合并吸入性损伤后机械通气治疗效果及撤机次数对预后的影响.方法 对61例大面积烧伤合并吸入性损伤患者的临床资料进行回顾性研究,依临床治疗结果分为一次撤机组47例与多次撤机组14例,对两组患者的机械通气时间、病死率、并发症进行比较.结果 多次撤机组机械通气时间明显长于一次撤机组,病死率以及机械通气相关性肺炎发病率均显著高于一次撤机组,两组间机械通气时间、病死率以及机械通气相关性肺炎发病率的差异均有统计学意义(均P<0.05).结论 应尽量减少大面积烧伤合并吸入性损伤机械通气撤机次数,在吸入性损伤明显好转的前提下,尽早撤机,有助于减少并发症,降低大面积烧伤合并吸入性损伤患者的病死率.     

中枢性呼吸衰竭患者早期机械通气治疗与延迟治疗的研究

目的比较早期机械通气与延迟机械通气对急性脑卒中伴中枢性呼吸衰竭患者的救治效果。方法将312例需机械通气的急性脑卒中合并中枢性呼吸衰竭患者,根据开始机械通气的时间先后,随机分为2组,观察组（n=178）,对照组（n=134）。对比研究2组患者的机械通气治疗时间、神经功能缺损程度评分、APACHEⅡ评分值、并发症、动脉血气指标的变化及预后情况。结果2组患者机械通气后PaO2、PaCO2、SaO2等血气指标均有改善,但观察组通气效果更好,通气时间更短,并发症更少,差异均有统计学意义（均P〈0．05）;极严重缺陷和严重缺陷占幸存者比例下降,轻度缺陷和自理占幸存者比例上升,差异均有统计学意义（均P〈0．05）。结论早期机械通气较延迟机械通气能更有效改善急性脑卒中伴中枢性呼吸衰竭患者呼吸和缺氧状态,缩短机械通气时间及改善预后。     

综合肺部物理治疗在成人机械通气中对预后的影响

目的 总结床边行肺部物理治疗对长时间机械通气患者的分泌物排出,增加肺廓清功能,从而减少呼吸机相关并发症,改善预后的作用.方法 将入选的58例患者随机分为试验组,对照组两组,试验组患者在机械通气期间给予综合胸部物理治疗,对照组则仅给予ICU常规胸部物理治疗即翻身、扣背、吸痰.比较两组之间呼吸机相关肺炎发生率,以及预后的差异.结果 两组之间一般临床资料无显著性差异.治疗组VAP发生率22.22%(6例),对照组VAP发生率48.39%(15例).机械通气时间分别为(9.7±8.3)d和(16.51±14.4)d.两组间差异有统计学意义.两组之间死亡率差异有统计学意义(P<0.05).住院时间差异无统计学意义(P>0.05).结论 保证质量的床边肺部理疗,能够有效降低VAP发生率和死亡率,改善预后.     

机械通气在老年脑血管病合并呼吸衰竭患者中应用的对照研究

目的研究机械通气在脑血管病合并呼吸衰竭中的作用。方法118例8年间连续进入急诊的36-99岁的脑血管合并呼吸衰竭患者接受机械通气，其中78例年龄≥65岁者用作通气组。以同期就诊于急诊的有机械通气指征但拒绝机械通气治疗的脑血管合并呼吸衰竭患者（均≥65岁）为对照组，比较两组的病情严重程度、APACHE Ⅱ评分、存活时间、费用、支付方式和预后等各方面的差异。结果①两组患者在年龄、性别分布和APACHE Ⅱ评分方面无显著差异（均P〉0．05），两组患者有可比性。②两组患者住院时间、病死率差异无统计学意义（P〉0．05）。③机械通气组医疗费用为（38659-78468）元，明显高于非机械通气组[（19863-48321）元，P〈0．05]。④通气组患者享受公费医疗的比例为96．2％（75／78），显著高于对照组（79％，93／118，P〈0．05）。结论需要机械通气辅助呼吸的脑血管患者预后极差，大于65岁患者组接受机械通气后仅延长住院时间，不能提高存活率，而且医疗费用明显增加。     

限制性液体复苏与常规液体复苏治疗胸部创伤失血性休克的疗效比较

目的 总结胸部创伤失血性休克患者液体复苏治疗策略.方法 回顾性分析符合研究标准的68例胸部创伤失血性休克患者液体复苏治疗的相关资料,限制性液体复苏组在彻底止血前,只给予少量的平衡液维持机体基本需求;常规液体复苏组入院后快速给予大量等张晶体液和(或)胶体液.用成组t检验、方差分析或卡方检验分析两种液体复苏方式对血红蛋白含量、血小板计数、红细胞比容、凝血酶原时间、血乳酸含量、碱缺失水平、机械通气率及病死率的影响.结果 限制性液体复苏组与常规液体复苏组术后血红蛋白、凝血酶原时间、血小板计数、红细胞比容、血乳酸和碱缺失两组间差异具有统计学意义(P＜0.05).常规液体复苏组病死率高于限制性液体复苏组病死率,差异有统计学意义(P＜0.05).机械通气率限制性液体复苏组低于常规液体复苏组,差异有统计学意义(P＜0.05).结论 限制性液体复苏能显著改善胸部创伤失血性休克患者凝血功能、组织和器官的灌注及乳酸酸中毒程度,降低机械通气率,效果优于常规液体复苏.     

序贯性机械通气抢救多发伤者呼吸衰竭的临床研究

目的 探讨改良格拉斯哥昏迷(GCS)评分15分为切换点行有创与无创序贯机械通气抢救多发伤者急性呼吸衰竭的临床治疗效果.方法 选择接受气管插管和机械通气的多发伤者急性呼吸衰竭患者,采用前瞻性对照研究方法,以2008年1月~2010年12月收治的20例为治疗组,采用同步间歇强制通气+压力支持方式(SIMV+PSV).待改良GCS评分达15分稳定2h的窗口期拔除气管导管,改用经鼻面罩PSV +呼气末正压(PEEP)通气,以后渐减压力支持(PS)水平直至脱离呼吸机.以2005年3月~2007年3月收治的23例患者作为对照组,按常规机械通气及传统的脱机方式脱离呼吸机.记录两组接受有创机械通气时间、总机械通气时间、总住院时间、重新插管例数,发生呼吸机相关性肺炎(VAP)的例数.结果 两组治疗前各指标相仿.治疗组和对照组有创通气时间分别为(3.2±1.0)d和(7.5±3.5) d(P<0.01);总机械通气时间分别为(4.8±2.4)d和(7.5±3.5)d(P<0.01);总住院时间分别为(18±4)d和(23±6) d(P<0.01);再插管例数分别为0例和1例;VAP发生例数分别为0例和4例,但无统计学意义(均P >0.05).结论 对多发伤急性呼吸衰竭患者,以改良GCS评分达15分标准稳定2h窗口期为时机早期拔管改用经鼻面罩无创通气,可以显著改善治疗效果.     

超声引导下穿刺置管引流治疗妊娠期合并高位肛周脓肿的疗效观察

目的探讨超声引导下穿刺置管引流治疗妊娠期合并高位肛周脓肿的疗效。方法选取2016年1月至2017年10月沧州市中心医院诊治的100例妊娠期合并肛周脓肿患者作为研究对象。将其随机分为两组,每组50例患者。观察组50例患者采用超声引导下穿刺置管引流,对照组50例患者采用高位切开挂线术。对两组患者疼痛程度和肛门括约肌功能进行评分,评价治疗效果,并记录患者住院时间、住院费用、创面愈合时间等情况,随访观察患者复发和并发症发生。结果观察组患者痊愈率为98.0%,对照组患者痊愈率为94.0%,其差异无统计学意义(P0.05);观察组患者创面愈合时间、住院时间和住院费用均少于对照组患者,其差异均具有统计学意义(均P0.05);两组患者术后疼痛评分和肛门括约肌功能评分均明显降低,观察组患者相关评分均低于对照组患者,其差异均具有统计学意义(均P0.05);观察组患者并发症发生率(2.0%)低于对照组患者并发症发生率(22.0%),其差异具有统计学意义(P0.05);观察组患者复发率(0%)低于对照组患者复发率(16.0%),其差异具有统计学意义(P0.05)。结论对妊娠期合并高位肛周脓肿患者采用超声引导下穿刺置管引流治疗,疗效肯定,对患者损伤小,并发症少,复发率低,值得临床推广应用。     

颅脑损伤合并多发伤患者气管切开的护理

多发伤是指在同一致伤因素作用下，人体同时或相继遭受两个或两个以上解剖部位或器官的严重损伤。颅脑外伤合并多发伤后出现的呼吸系统并发症是影响患者预后的重要因素[1]。开放性气管切开术在临床应用中最早且最为广泛嘲，是治疗、解决颅脑损伤患者呼吸道阻塞，迅速改善通气功能的重要措施。对急诊颅脑损伤合并多发伤患者留置气管切开套管的原则是早期切开，早期拔除。     

早期无创正压通气治疗连枷胸合并急性肺损伤疗效观察

目的探讨无创正压通气在连枷胸合并急性肺损伤中的疗效。方法随机选择42例符合ALI标准连枷胸合并肺挫伤患者并分为两组,一组早期使用无创正压通气,对照组为早期面罩吸氧。比较两组间发展到ARDS的例数、呼吸机通气天数、气管插管例数,以及治疗48h的呼吸频率、心率、动脉血氧分压和氧合指数。结果早期无创正压通气组相对对照组在发展到ARDS例数、呼吸机通气天数、气管插管数及48h后呼吸频率、心率、动脉血氧分压、氧合指数改善优于对照组,差异有统计学意义（P〈0．05）。结论急性肺损伤是连枷胸合并肺挫伤低氧血症早期阶段,大部分会发展到ARDS,早期无创正压通气治疗可以明显逆转此进程,连枷胸合并肺挫伤的患者一旦有急性肺损伤应尽早实施无创正压通气。     

不同人工气道在院外救护车内的应用

目的 探讨院外急救车上心肺复苏(CPR)建立人工气道通气的最佳方法和对复苏成功率的影响.方法 对院外急救车上发生心跳呼吸骤停患者318例,根据当时CPR时对患者随机建立人工气道的3种不同方法,将其分为3组,进行回顾性分析,A组68例,常规行气管导管插管;B组140例,盲插喉罩通气;C组110例,食管气管联合导管通气.结果 B组建立人工通气需(26±11.3)s,显著短于A组和C组[分别为(146±14.7)s和(81±16.5),均P＜0.05].A组建立人工通气所需时间显著长于C组(P＜0.05).盲插喉罩通气时间最短,其次是食管气管联合导管插管术,气管插管术最慢.B组一次插管成功率为100％,显著高于A组(60.3％,P＜0.05),与C组的差异无显著性(98.2％,P＞0.05).B组与C组之间差异无统计学意义(P＞0.05).A、B、C组三组复苏成功率分别为26.5％,25.7％和27.3％,相互间的差异无无统计学意义(均P＞0.05).结论院外急救车上最好早期应用盲插喉罩或食管气管联合导管.     

Outcomes and adverse effects of ablative vs nonablative lasers for skin resurfacing: A systematic review of 1093 patients

It is generally believed that ablative laser therapies result in prolonged healing and greater adverse events when compared with nonablative lasers for skin resurfacing. To evaluate the efficacy of ablative laser use for skin resurfacing and adverse events as a consequence of treatment in comparison to other modalities, a PRISMA‐compliant systematic review (Systematic Review Registration Number: 204016) of twelve electronic databases was conducted for the terms “ablative laser” and “skin resurfacing” from March 2002 until July 2020. Studies included meta‐analyses, randomized control trials, cohort studies, and case reports to facilitate evaluation of the data. All articles were evaluated for bias. The search strategy produced 34 studies. Of 1093 patients included in the studies of interest, adverse events were reported in a total of 106 patients (9.7%). Higher rates of adverse events were described in nonablative therapies (12.2% ± 2.19%, 31 events) when compared with ablative therapy (8.28% ± 2.46%, 81 events). 147 patients (13.4%) reported no side effects, 68 (6.22%) reported expected, transient self‐resolving events, and five (0.046%) presented with hypertrophic scarring. Excluding transient events, ablative lasers had fewer complications overall when compared with nonablative lasers (2.56% ± 2.19% vs 7.48% ± 3.29%). This systematic review suggests ablative laser use for skin resurfacing is a safe and effective modality to treat a range of pathologies from photodamage and acne scars to hidradenitis suppurativa and posttraumatic scarring from basal cell carcinoma excision. Further studies are needed, but these results suggest that ablative lasers are a superior, safe, and effective modality to treat damaged skin.     

New fillers for the new man

ABSTRACT:  Two new collagen-based lidocaine-containing dermal fillers, ArteSense™/ArteFill™ (Artes Medical, San Diego, CA) and Evolence® (Colbar LifeScience Ltd., Herzliya, Israel), have proved to be of particular interest to men, many of whom seek a long-lasting or permanent correction. ArteFill™ has been available in the United States since 2006, and it is expected that Evolence® will reach the American market in 2008. The properties of the two products will be described, and experience based on the administration of many hundreds of syringes of both products by a Canadian dermatologist will be detailed here, with tips and precautions to optimize patient outcomes.     

Multiple New-Onset Subcutaneous Nodules of the Upper Extremity Digits: Giant Cell Tumor of Tendon Sheath and Lipoma

A black woman with the concurrent onset of two subcutaneous nodules located on the digits of her upper extremities is described. Initially, a single systemic disorder was considered; yet, the lesions differed in morphology and consistency. Microscopic examination of the nodules showed a giant cell tumor of tendon sheath and a lipoma. Although Occam's “razor” suggests that multiple lesions in the same person are more likely to represent variable manifestations of a single disorder than several different diseases in that individual, the simultaneously appearing lesions in this patient represented two different conditions.     

Genetic alterations in RAS‐regulated pathway in acral lentiginous melanoma

Studies integrating clinicopathological and genetic features have revealed distinct patterns of genomic aberrations in Melanoma. Distributions of BRAF or NRAS mutations and gains of several oncogenes differ among melanoma subgroups, while 9p21 deletions are found in all melanoma subtypes. In the study, status of genes involved in cell cycle progression and apoptosis was evaluated in a panel of 17 frozen primary acral melanomas. NRAS mutations were found in 17% of the tumors. In contrast, BRAF mutations were not found. Gains of AURKA gene (20q13.3) were detected in 37.5% of samples, gains of CCND1 gene (11q13) or TERT gene (5p15.33) in 31.2% and gains of NRAS gene (1p13.2) in 25%. Alterations in 9p21 were identified in 69% of tumors. Gains of 11q13 and 20q13 were mutually exclusive, and 1p13.2 gain was associated with 5p15.33. Our findings showed that alterations in RAS‐related pathways are present in 87.5% of acral lentiginous melanomas.     

Medición del impacto psicológico en pacientes con psoriasis en tratamiento sistémico

Background and objectives

The negative impact of psoriasis on patient quality of life can be as important as the physical consequences of the disease. We could assume that clearance of the disease would also lead to an improvement in its psychosocial impact. The present study assesses the psychological state of patients with psoriasis receiving systemic treatment in a psoriasis unit, especially those with mild or no disease involvement.