骨水泥型单髋和全髋关节置换治疗老年股骨颈骨折的疗效比较

目的比较骨水泥型单髋和全髋关节置换治疗老年股骨颈骨折的疗效。方法将41例股骨颈骨折患者分为A组(采用单髋关节置换治疗,n=23)和B组(采用全髋关节置换治疗,n=18)。比较两组手术时间和术中出血量;术后6、12、24个月采用髋关节Harris评分评价疗效。结果患者均获得24个月随访。手术时间和术中出血量B组均多于A组(P 0. 05)。术后6、12、24个月Harris评分优良率B组均高于A组(P 0. 05)。结论治疗老年股骨颈骨折,单髋关节置换术具有手术时间短、出血量少等优点;而全髋关节置换患者术后功能恢复较好。     

全髋关节置换术治疗老年骨质疏松性股骨转子间骨折效果观察

目的总结全髋关节置换术治疗老年骨质疏松性股骨转子间骨折的临床效果。方法对30例老年骨质疏松性股骨转子间骨折患者实施全髋关节置换术进行治疗,观察手术时间、出血量、Harris关节评分、并发症发生率等指标。结果本组手术时间(105.42±10.31)min,术中出血量(305.92±15.37)m L。术后6个月Harris髋关节评分优良率86.67%(26/30)。随访6~24个月,未发生假体脱位、松动及下沉等并发症。结论运用全髋关节置换术治疗老年骨质疏松性股骨转子间骨折,髋关节功能恢复良好,并发症发生率低,效果满意。     

老年患者全髋关节置换术后急性肾损伤的危险因素分析及预测模型建立

目的探讨老年患者全髋关节置换术后急性肾损伤(AKI)的危险因素并建立风险预测模型。方法回顾性分析行全髋关节置换术老年患者633例,男243例,女390例,年龄65～96岁,ASAⅠ—Ⅲ级。根据改善全球肾脏病预后组织(KDIGO)指南中的诊断标准:48 h内血清肌酐值升高≥26.5μmol/L;血清肌酐值升高超过基础值的1.5倍及以上,且明确或经推断上述情况发生在7 d内,将患者分为AKI组(n=68)和非AKI组(n=565)。分别收集患者的人口学资料、基础疾病史、围术期一般情况及相关实验室检查。将组间差异有统计学意义的单因素纳入二元Logistic回归模型,分析老年患者全髋关节置换术后AKI的危险因素并建立风险预测模型。结果术后有68例(10.74%)患者发生AKI。单因素分析显示:年龄增加、高BMI、低蛋白血症、低预估肾小球滤过率(eGFR)、中重度贫血、术中低血压持续时间、出血量及血清高浓度胱抑素C与术后AKI有关(P0.05)。二元Logistic回归分析显示:年龄增加(OR=1.120,95%CI 1.063～1.180,P0.001)、高BMI(OR=1.283,95%CI 1.149～1.433,P0.001)、重度贫血(OR=24.688,95%CI 3.019～201.858,P=0.003)、血清高浓度胱抑素C(OR=1.749,95%CI 1.146～2.670,P=0.010)、低蛋白血症(OR=9.386,95%CI 4.798～18.359,P0.001)和低eGFR(OR=3.468,95%CI 1.213～9.913,P=0.020)是老年患者全髋关节置换术后AKI的独立危险因素,建立的风险预测模型受试者工作特征(ROC)曲线下面积为0.91(95%CI 0.87～0.94,P0.001),敏感性83.80%,特异性84.40%。结论年龄增加、高BMI、重度贫血、血清高浓度胱抑素C、低蛋白血症和低eGFR是老年患者全髋关节置换术后AKI的独立危险因素。     

心脏手术慢性术后疼痛发生及其危险因素的前瞻性队列研究

目的观察正中胸骨切开体外循环下心脏手术慢性术后疼痛(CPSP)的发生情况并分析其危险因素。方法本研究为单中心前瞻性观察性研究,纳入2017年7~9月在四川大学华西医院择期正中胸骨切开体外循环下心脏手术患者248例,其中男104例、女144例,年龄20~74岁。使用数字等级评分(NRS)评估患者急性术后疼痛,使用改良简明疼痛量表评估术后30 d疼痛及术后3个月、6个月CPSP情况。结果术后6个月CPSP发生率为45.2%(112/248),其中24.1%(27/112)为中-重度疼痛(NRS≥4分)。术后3个月CPSP发生率为60.9%(151/248),其中25.8%(39/151)为中-重度疼痛。术后30 d、3个月存在中-重度疼痛以及术中应用瑞芬太尼为术后6个月CPSP危险因素。结论正中胸骨切开体外循环下心脏手术术后6个月CPSP发生率较高。其危险因素为术中应用瑞芬太尼以及术后30 d、3个月存在中-重度疼痛。     

全髋关节置换与人工股骨头置换术治疗老年不稳定股骨颈骨折的疗效比较

目的探讨全髋关节置换与人工股骨头置换术治疗老年不稳定股骨颈骨折对患者髋关节功能恢复及术后并发症的影响。方法回顾性分析自2013-04—2015-04诊治的110例老年不稳定股骨颈骨折,55例采用全髋关节置换术治疗(全髋置换组),55例采用人工股骨头置换术治疗(股骨头置换组)。比较2组手术时间、术中出血量、术后引流量及住院总时间,术后12、24个月髋关节功能Harris评分,以及随访期间并发症情况。结果 110例均获得至少2年随访。股骨头置换组手术时间、术中出血量及术后引流量明显少于全髋置换组,而全髋置换组术后24个月髋关节功能Harris评分优于股骨头置换组,术后并发症发生率低于股骨头置换组,差异有统计学意义(P0.05)。2组住院总时间、术后12个月髋关节功能Harris评分比较差异无统计学意义(P0.05)。结论全髋关节置换与人工股骨头置换术治疗老年不稳定股骨颈骨折临床应用广泛,人工股骨头置换术具有创伤小、操作简便的优点,而全髋关节置换术能更有效维持患者远期良好的髋关节功能,并降低术后远期并发症发生的风险。     

老年股骨颈骨折患者微创全髋置换术治疗效果观察

目的探讨老年股骨颈骨折患者行微创全髋置换术的效果。方法选取2016-11-2018-11间收治的76例老年股骨颈骨折患者,按照手术方案不同分为2组,各38例。传统组采用传统后外侧入路全髋置换术,微创组采用微创全髋置换术。比较2组手术时间、术中出血量,以及术后引流量、并发症发生率和术后6个月的髋关节功能。结果微创组手术时间、术中出血量,以及术后引流量和术后6个月的髋关节功能优良率等指标,均优于传统组,差异均有统计学意义(P<0.05)。2组并发症发生率差异无统计学意义(P>0.05)。结论微创全髋置换术治疗老年股骨颈骨折,手术时间短,能有效减少术中出血量和术后引流量,有利于促进髋关节功能的恢复。     

脊髓神经鞘瘤切除术患者术后慢性疼痛的危险因素

目的 探讨脊髓神经鞘瘤切除术患者术后慢性疼痛（CPSP）的危险因素。
方法 选择2020年3月至2021年3月择期行脊髓神经鞘瘤切除术的患者161例,男75例,女86例,年龄≥18岁,ASA Ⅰ—Ⅲ级。采用数字评分量表（NRS）以及神经病理性疼痛量表（NPQ）评估患者术后3个月发生慢性疼痛及神经病理性疼痛的情况。根据NRS评分将患者分为两组：CPSP组（NRS≥1分）和无CPSP组（NRS=0分）。通过医院电子病历系统以及术后3个月电话随访收集临床资料,采用多因素Logistic回归分析脊髓神经鞘瘤切除术患者发生CPSP的独立危险因素。
结果 发生CPSP的患者有63例（39%）,其中中重度疼痛(NRS≥4分)40例（25%）。多因素Logistic回归分析结果显示,术前合并疼痛（OR=3.670,95%CI 1.034～13.025,P=0.044）以及术后应用阿片类药物（OR=2.357,95%CI 1.103～5.036,P=0.027）是发生CPSP的独立危险因素。
结论 术前合并疼痛以及术后使用阿片类药物是脊髓神经鞘瘤切除术患者发生CPSP的危险因素。     

脊柱侧弯矫形术患者术后慢性疼痛的危险因素

目的 探讨脊柱侧弯矫形术患者术后慢性疼痛（CPSP）的危险因素,并建立预测模型。
方法 回顾性分析2017年1月至2020年9月择期行后入路脊柱侧弯矫形术206例患者资料,男88例,女118例,ASAⅠ—Ⅲ级,根据术后3个月是否发生CPSP将患者分为两组：CPSP组（n=76）和无CPSP组（n=130）。收集术前、术中和术后资料,并通过电话随访获取患者CPSP以及术后3个月并发症（如内固定松动、连接棒断裂、螺钉拔出等）的发生情况。采用多因素Logistic回归分析CPSP的危险因素并建立预测模型。
结果 有76例（36.9%）患者发生CPSP。多因素Logistic回归分析显示：术前VAS疼痛评分＞3分（OR=5.794,95%CI 2.224～15.097,P＜0.001）、融合椎体数增加（每增加1个单位,OR=1.525,95%CI 1.256～1.853,P＜0.001）、术后72 h VAS疼痛评分＞3分（OR=3.022,95%CI 1.360～6.715, P=0.007）以及术后3个月内有并发症（OR=5.424,95%CI 1.058～27.800, P=0.043）是CPSP的危险因素,预测模型的受试者工作特征（ROC）曲线下面积为0.873（95%CI 0.822～0.925,P＜0.001）,敏感性85.5%,特异性79.2%。
结论 术前VAS疼痛评分＞3分、融合椎体数增加、术后72 h VAS疼痛评分＞3分以及术后3个月有并发症是脊柱侧弯矫形术患者发生CPSP的危险因素,建立的CPSP风险预测模型可以较好地预测脊柱侧弯患者矫形术CPSP发生的风险。     

老年股骨颈骨折半髋关节置换术后输血预测模型的建立

目的分析老年股骨颈骨折患者半髋关节置换术后输血的危险因素,建立老年股骨颈骨折患者半髋关节置换术后输血的列线图预测模型。 方法回顾性分析2016年1月至2020年6月江苏省苏北人民医院股骨颈骨折行半髋关节置换术的235例患者。纳入标准：年龄≥60岁,新发、单侧股骨颈骨折;手术方式为半髋关节置换术。排除标准：合并全身其他骨折;术前输血;合并凝血功能障碍或者其他血液系统疾病;身体状况较差无法耐受手术者;病历资料不完整者。根据术后是否输血,分为输血组和未输血组。收集其临床资料,包括性别、年龄、身体质量指数(BMI)、高血压、糖尿病、冠心病、脑卒中、吸烟、饮酒、术前血红蛋白(Hb)、术前血小板(PLT)、术前白蛋白、术前凝血功能、术前抗凝药使用、骨折Garden分型、受伤至手术时间、假体类型、术后是否引流、术后血钙浓度、美国麻醉师协会(ASA)分级、麻醉方式、手术时间、术中出血量等。应用单因素和多因素logistic回归模型筛选术后输血的独立危险因素;通过R软件构建列线图预测模型,并绘制出受试者工作特征(ROC)曲线及校准曲线来评价模型的区分度和准确度。 结果本研究共纳入235例研究对象,输血组60例,输血率为25.5%。两组患者在术前Hb(χ²＝62.831)、麻醉方式(χ²＝6.539)、手术时间(χ²＝79.392)、术中出血量(χ²＝74.515)、假体类型(χ²＝5.631)方面的组间差异有统计学意义(均为P<0.05)。多因素logistic回归模型分析显示：术前Hb水平(Hb<100 g/L)、手术时间延长(时间≥60 min)、术中出血量增多(出血量≥200 ml)是老年股骨颈骨折患者半髋关节置换术后输血的独立危险因素(均为P<0.05)。列线图预测模型曲线下面积AUC为0.95,校准曲线的斜率接近1,提示该预测模型具有良好的区分度和准确度。 结论基于术前血红蛋白、手术时间、术中出血量这3项独立危险因素构建的老年股骨颈骨折患者半髋关节置换术后输血预测的列线图模型具有良好的区分度和准确度,望为临床上早期甄别术后高风险输血患者提供指导意义。     

髋关节置换术后并发症及其危险因素分析

目的:探讨影响髋关节置换术后并发症的危险因素。方法:收集2016 年2 月—2018 年7 月在我院行髋关节置换术的114 例患者的临床资料,根据患者术后临床结局分为并发症组29 例、无并发症组85 例。比较两组患者的一般临床资料及术后并发症。采用多元逐步Logisitic 回归分析筛选影响患者临床结局的独立危险因素,并构建列线图预测模型进行验证。结果:两组性别、吸烟史、饮酒史差异无统计学意义(P ＞ 0.05),两组年龄、体质指数(BMI)、糖尿病、高血压、手术时间、住院时间、术后搬运不当、长期应用激素、输血、术后C 反应蛋白(CRP)差异有统计学意义(P ＜ 0.05)。多元逐步Logistic 分析结果显示,年龄≥ 60 岁、BMI ≥ 24 kg/m2、糖尿病、手术时间≥ 2 h、住院时间≥ 15 d、术后搬运不当、输血过多、术后CRP ≥ 10 mg/L 是影响髋关节置换术后发生并发症的独立危险因素(P ＜ 0.05)。列线图预测模型经Bootstrap法重复抽样进行内部验证和外部验证,C 指数分别为0.817 和0.795,区分度较好。结论:年龄大、BMI 大、有糖尿病、手术时间长、住院时间长、术后搬运不当、输血过多、术后CRP 大是影响髋关节置换术后发生并发症的独立危险因素。预测术后并发症发生风险的列线图模型具有良好的区分度与准确度,临床工作中应考虑对这些因素进行针对性防控,以降低髋关节置换术后并发症的发生率。     

Reduction of Plasma Fibrinogen, Immunoglobulin G, and Immunoglobulin M Concentrations by Immunoadsorption Therapy with Tryptophan and Phenylalanine Adsorbents

Abstract Immunoadsorption (1A) therapy with tryptophan (TR-350) or phenylalanine (PH-350) adsorbents has been used to reduce the concentration of serum antibodies in human lymphocyte antigen (HLA)-immunized patients. Other forms of plasma purification have been reported to reduce the level of fibrinogen, which affects the blood properties. In this study we investigated the effects of IA therapy using both adsorbents on plasma fibrinogen and immunoglobulins G and M in 13 patients (8 patients were treated with TR-350, and 5 patients were treated with PH-350). During each session 1 plasma volume (2.8 ± 0.4 L of plasma) was processed through the immunocolumn and then returned to the patient together with the blood cells. Compared with the pretreatment values, the plasma fibrinogen, IgG, and IgM concentrations were significantly reduced after IA therapy (p < 0.01 for TR-350; p < 0.04 for PH-350). There was a positive correlation between the degree of reduction of plasma proteins and the number of IA treatments given. A nonpara-metric test (Wilcoxon's signed-rank test or the Mann-Whitney test) was used for statistical analysis. We conclude from our study that IA therapy effectively lowers the plasma levels of fibrinogen, IgG, and IgM and thus can be considered a valuable alternative to other blood purification methods.     

Is the recovery profile of mivacurium independent of the rate of decay of its plasma concentration in patients with normal plasma cholinesterase activity?

Background: The duration of action of muscle relaxants is poorly correlated to the rate of decay of their plasma concentration. The plasma concentration of mivacurium may rapidly decrease below its active concentration because of the extensive hydrolysis of mivacurium. By inflating a tourniquet on one upper limb for 3 min after the administration of atracurium, mivacurium or vecuronium, we studied the influence of the initial decline of their plasma concentration on their effect. Methods: In 50 patients anaesthetised with thiopental, isoflurane and fentanyl, the effect of bolus doses of 0.15 or 0.25 mg . kg^?1 mivacurium (MIV 15, MIV 25), 0.3 or 0.5 mg . kg^?1 atracurium (ATR 30, ATR 50) and 0.06 or 0.1 mg . kg^?1 vecuronium (VEC 06, VEC 10) were measured on both arms (evoked response of the adductor pollicis to train-of-four stimulation every 12 s), a tourniquet being applied on one arm just before and during 3 min after the muscle relaxant bolus. Results: Tourniquet inflation of 3 min almost abolished the neuromuscular effect of mivacurium. In the vecuronium groups and in the ATR 50 group, tourniquet inflation did not modify the maximum degree of depression of the twitch response. Also, the duration of action of vecuronium was unaffected by the tourniquet. In the ATR 30 group, times to return of the twitch response to 25% (duration 25%) and 75% (duration 75%) of control response were significantly shorter in the cuffed arm, 23 min vs 27 min, and 41 min vs 45 min, respectively. In the ATR 50 group, only duration 25% was significantly shorter in the cuffed arm (41 min vs 45 min). Conclusion: The results suggest that the rate of decline of the plasma concentration of mivacurium is so rapid, that a very low and almost clinically ineffective concentration is present as soon as 3 min after its administration. The results also indicate that the recovery from a mivacurium-induced neuromuscular blockade is not influenced by the rate of decay of its plasma concentration in patients with genotypically normal plasma cholinesterase.     

Membranes in Artificial Organs

Abstract: Membrane processes play a pivotal and enabling role in modern replacement therapy for acute and chronic organ failure and in the management of immunologic diseases. In fact, virtually all contemporary extracorporeal blood purification methods employ membrane devices, and the next generation of artificial organs and tissue engineering therapies are almost certain to be similarly grounded in membrane technology. In this short essay, we comment on the similarities and differences among synthetic membranes and their natural counterparts and also provide a critical overview of the demographics and technology of hemodialysis, hemofiltration, apheresis, oxygenation, and emerging membrane technologies and applications.     

The multiply injured child

Blunt trauma is the principal cause of childhood death in many developed countries. This review outlines the differences between adults and children with respect to resuscitation and treatment of orthopaedic injuries in a child with polytrauma. Recent advances in techniques of fracture stabilization are reported.     

Dilemma of Membrane Biocompatibility and Reuse

Abstract: Numerous articles have been published on the multiple use of dialyzers and on the effect of different reprocessing chemicals and techniques on the dialyzer biocompatibility and performance. The results often appear contradictory, especially those comparing standard biocompatibility parameters. Despite this confusion, a discerning review of the published works allows certain limited conclusions to be drawn. Reprocessing of used hemodialyzers changes the biocompatibility profile of a dialyzer as defined by the parameters complement activation. leukopenia, and cytokine release. The effect of reprocessing depends on the chemicals and reprocessing technique applied and also on the type of membrane polymer being subjected to the reprocessing procedure. Reports of pyrogenic reactions indicate that the flux of the membrane also influences how suitable it is for safe reuse. An increased risk of allergic and pyrogenic reactions appears to be associated with dialyzer reuse. Furthermore, there has been a lack of investigations into the immunologic effect of the layer of adsorbed and chemically altered proteins that remains on the inner surface of reprocessed dialyzers. We conclude that the clinical benefit of dialyzer reuse cannot be generally accepted from a biocompatibility point of view.     

The analgesic effect of racemic ketamine in patients with chronic ischemic pain due to lower extremity arteriosclerosis obliterans

Background : Ketamine in sub-dissociative doses has been shown to have analgesic and phantom-Limb pain, where conventional treatment has often failed. Chronic ischemic pain due to lower extremity arteriosclerosis obliterans often responds poorly to analgesics, and the pain-generating mechanisms are not well understood.
Methods : Eight patients with rest pain in the lower extremity due to arteriosclerosis obliterans were given sub-dissociative doses of 0.15, 0.30, or 0.45 mg/kg racemic ketamine and morphine 10 mg as a 5-min infusion on four separate days in a cross-over, double-blind, randomised protocol. Plasma levels of (S)- and (R)-ketamine and their nor-metabolites were analysed with an enantioselective high-performance liquid chromatography (HPLC) method. Pain levels were evaluated with a visual analogue scale (VAS).
Results : Individual pain levels were highly variable during and after all the infusions but the pooled pain levels showed a dose-dependent analgesic effect of ketamine with a transient but complete pain relief in all patients at the highest dose (0.45 mg/ kg). Side-effects, mainly disturbed cognition and perception, were pronounced and dose-dependent. Morphine 10 mg had an analgesic peak at 20 min and 5/8 patients had complete pain relief. The remaining 3 patients also had high baseline pain scores, indicating a higher analgesic potency for the 0.30 and 0.45 mg/ kg ketamine doses than for morphine 10 mg.
Conclusion : We have demonstrated a potent dose-dependent analgesic effect of racemic ketamine in clinical ischemic pain. Due to a narrow therapeutic window, this analgesic effect is probably best utilised in combination with other analgesics.     

Intravenous endotoxin does not increase tissue extravasation of albumin in rats

Background : It is unclear whether activation of the inducible nitric oxide synthase (iNOS) increases or decreases the extravasation of plasma.
Methods : Chloralose anaesthetised male Wistar rats received E. coli lipopolysacharide (LPS), 3 mg kg^-1 i.v., or the corresponding volume of saline, 3 or 5 h before the end of the experiment. Mean arterial pressure (MAP) and heart rate (HR) were recorded. Tissue clearance of radio-labelled albumin, during the last 2 h of each experiment, was determined by a double-isotope method. In separate animals, the serum concentration of nitrite and nitrate was determined, 5 h after LPS or the solvent.
Main Results : LPS initially decreased MAP and lastingly increased HR. In the 3-h LPS animals (n=8), tissue plasma clearance was lower in the heart and calf muscle and increased only in diaphragm, compared to corresponding control animals (n=8). In the 5-h LPS rats, clearance was lowered (n=8) in the entire gastrointestinal tract and in testes, compared to controls (n=8). The serum nitrite/nitrate concentration was higher in animals given LPS (n=6) than in controls (n=6).
Conclusion : After LPS, tissue clearance of albumin was not increased in any major tissue, in spite of increased serum levels of NO end products. Apparently, after activation of iNOS, the augmented release of NO is not necessarily associated with increased albumin extravasation.     

Adrenaline markedly improves thoracic epidural analgesia produced by a low-dose infusion of bupivacaine, fentanyl and adrenaline after major surgery: A randomised, double-blind, cross-over study with and without adrenaline

Background: Basic pharmacological research indicates that there are synergistic antinociceptive effects at the spinal cord level between adrenaline, fentanyl and bupivacaine. Our clinical experience with such a mixture in a thoracic epidural infusion after major surgery confirms this. The objectives of the present study were to evaluate the effects on postoperative pain intensity, pain relief and side effects when removing adrenaline from this triple epidural mixture. Methods: A prospective, randomised, double-blind, cross-over study was carried out in 24 patients after major thoracic or abdominal surgery. Patients with only mild pain when coughing during a titrated thoracic epidural infusion of about 10 ml · h^?1 of bupivacaine 1 mg · ml^?1, fentanyl 2 μg · ml^?1, and adrenaline 2 μg · ml^?1 were included. On the 1^st and 2^nd postoperative days each patient was given a double-blind epidural infusion, at the same rate, with or without adrenaline. The effect was observed for 4 h or until pain when coughing became unacceptable in spite of a rescue analgesic procedure. Rescue analgesia consisted of up to two epidural bolus injections per hour and i.v. morphine if necessary. All patients received rectal paracetamol 1 g, every 8 h. Fentanyl serum concentrations were measured with a radioimmunoassay technique at the start and end of each study period. Main outcome measures were extent of sensory blockade and pain intensity at rest and when coughing, evaluated by a visual analogue scale, a verbal categorical rating scale, the Prince Henry Hospital pain score, and an overall quality of pain relief score. Results: The number of hypaesthetic dermatomal segments decreased (P <0.001) and pain intensity at rest and when coughing increased (P <0.001) when adrenaline was omitted from the triple epidural mixture. This change started within the first hour after removing adrenaline. After 3 h pain intensity when coughing had increased to unacceptable levels in spite of rescue analgesia (epidural bolus injections and i.v. morphine). Within 15–20 min after restarting the triple epidural mixture with adrenaline, pain intensity was again reduced to mild pain when coughing. Serum concentration of fentanyl doubled from 0.22 to 0.45 ng · ml^?1 (P <0.01), and there was more sedation during the period without adrenaline. Conclusions: Adrenaline increases sensory block and improves the pain-relieving effect of a mixture of bupivacaine and fentanyl infused epidurally at a thoracic level after major thoracic or abdominal surgery. Serum fentanyl concentrations doubled and sedation increased when adrenaline was removed from the epidural infusion, indicating more rapid vascular absorption and systemic effects of fentanyl.