创伤骨科中责任制护理初探

本文复习了有关责任制护理的理论，从创伤骨科的角度，介绍了这一护理技术在创伤骨科中具体应用方法。通过对创伤骨科病人心理及临床特点的分析，提出了针对创伤病人的护理问题，订出护理计划，在阐述了责任制护理具体实施的优点时，对现存的问题也进行了分析，提出了改进措施。     

红细胞对创伤性脑内出血大鼠脑含水量及HO-1表达的影响

目的研究大鼠创伤性脑内出血(TICH)中红细胞对脑含水量和血红素氧合酶-1(HO-1)表达的影响,并分析二者的关系,以探讨红细胞在TICH后脑水肿形成中的作用机制。方法120只大鼠随机分为创伤性脑损伤组(TBI组),TBI加注全血组(WB组),TBI加注溶解红细胞组(LRBC组)和TBI加注压积红细胞组(PRBC组),每组30只。4组均采用自由落体打击法造成大鼠脑外伤。后3组借助立体定向仪分别向伤区脑皮质内注射全血、溶解红细胞或压积红细胞,造成TICH模型。每组于伤后1、3、5d分别处死10只大鼠,5只测伤区脑组织含水量,5只用免疫组化法检测HO-1的表达。结果4组组内比较:TBI、WB和PRBC3组第3d的脑含水量最高(分别为82.85%±0.60%,85.00%±1.12%,84.93%±1.21%),LRBC组第1d的含水量最高(84.44%±0.85%;4组间比较,1d时LRBC组含水量最高,3d时WB和PRBC组含水量最高。在WB、PRBC和LRBC组,HO-1阳性表达的强弱与脑含水量的高低变化相一致。结论红细胞在TICH后迟发性脑水肿的形成中有重要作用,其机制涉及红细胞的降解产物。     

小腿创伤性软组织缺损的显微外科修复

目的 探讨小腿创伤性软组织缺损的显微外科治疗效果。方法 临床上应用腓骨骨皮瓣、背阔肌皮瓣、股前内、外侧皮瓣和腹股沟皮瓣等12种外科皮瓣，对小腿创伤组织缺损进行修复99例。结果 术后皮瓣全部成活，随访6个月-10年，皮瓣质地良好，功能改善。结论 应用显微外科技术修复小腿创伤组织缺损，疗程短，疗效好。根据缺损的不同部位、范围以及术者的技术水平，选择不同的显微外科皮瓣进行修复，可获得满意的临床效果。     

女性服刑人员精神创伤的特征

目的调查女性服刑人员精神创伤的特征。方法在湖南新路职业学校中,采用多级随机整群抽样的原则抽取471个女性服刑人员,分青少年组（年龄≤25岁）和成年组（〉25岁）。运用创伤性生活事件问卷（TLEQ）和访谈相结合的技术评估她们的精神创伤经历。结果（1）90.4%的女性服刑人员至少经历1件创伤性事件,63.7%至少经历3件或以上的多重创伤。青少年组的事件数量多于成年组（平均为4和3件,P〈0.01）。暴力和毒品相关犯罪组的事件数量相当（平均4件）,都多于经济犯罪组（2件）;中学或相当教育程度者的事件数量最多（4件）,大专或以上者最少（2件）;未婚、离婚/丧偶2组经历的事件数量最多（4件）,已婚组最少（2件）,均差异有显著性（P〈0.05）。（2）最多见的创伤类型是机动车祸（46.9%）、目睹家庭暴力（46.1%）和被抢劫（38.9%）。16.7%的女犯在18岁以前遭遇过性虐待。与成年组相比,青少年组经历了更多的创伤类型为被抢劫、目睹被惨打、目睹家庭暴力,以及儿童期性虐待。结论我国文化背景下,女性服刑人员的精神创伤经历相当普遍,是精神创伤的潜在受害者。     

Predicting Survival after Trauma: a Comparison of TRISS and ASCOT in the Netherlands

Background: Evaluating the performance of a trauma system may be attempted by comparing outcome in different trauma populations. Controlling for injury severity is a necessity for such evaluations. We compare two current models for doing so: the “Trauma and Injury Severity Score” (TRISS) and “A Severity Characterization Of Trauma” (ASCOT). Material and Methods: This study of high-energy trauma victims took place in Leiden, the Netherlands, between 1993 and 1998. Using the Hosmer-Lemeshow (HL) test and receiver operator characteristic (ROC) analysis, the TRISS and ASCOT models were compared for calibration and discrimination. Results: 1,024 patients, with an average Injury Severity Score (ISS) of 13.5, were eligible for inclusion. Blunt trauma was the predominant cause of injuries. Both models gave accurate, though pessimistic, results in predicting the actual number of fatalities (n = 71). The HL test indicated a sufficient fit for the ASCOT model (p = 0.28) and an insufficient fit (p = 0.02) for TRISS. The ROC curves were nearly identical (0.97). Including age as a linear variable, instead of using the current age groups, resulted in an improved discriminative power of the models. Conclusions: The ASCOT model proved superior over TRISS in its accuracy to estimate of survival chances. This difference was most evident for victims with an estimated survival chance of 60–90%. Future national trauma researchers should therefore collect ASCOT data. Improved ASCOT models could be developed, with age as a linear variable. Received: April 25, 2002; revision accepted: September 17, 2002 Correspondence Address Prof. Arie B. van Vugt, MD, PhD, Department of General Surgery and Traumatology, Erasmus MC Rotterdam, Dr. Molewaterplein 40, Postbus 2040, 3000 CA Rotterdam, The Netherlands, Phone (+31/10) 463-5735, Fax -4757, e-mail: vanvugt@hlkd.azr.nl     

阔筋膜皮瓣移植修复手前臂巨大创面

报道采用吻合血管的阔筋膜皮瓣移植，修复手、前臂巨大创面１１例，均获成功，其优点：①阔筋膜长而坚韧，内面光滑，覆盖关节、骨、肌腱粘连轻，尤其利于肌腱滑动，是修复手、前臂的最佳皮瓣。②皮肤与肌腱同时缺损时，利用阔筋膜修复肌腰，一期完成肌腱及皮肤的修复。③股外侧皮神经长而粗，分支多，适合手部感觉修复。④供区隐蔽，皮下组织簿，血运丰富，供皮及阔筋膜面积大。     

Immunologie bei Schwerverletzten

Zusammenfassung. Der klinische Verlauf bei polytraumatisierten Patienten wird durch das h?ufige Auftreten schwerwiegender immunologischer Komplikationen beeintr?chtigt. Die Immunantwort auf schweres Trauma kann durch die vermehrte Freisetzung proinflammatorischer Mediatoren über das „systemic inflammatory response syndrome (SIRS)“ zum Mehrorganversagen [„multisystem organ failure (MOF)“] führen, welches mit einer Letalit?t von bis zu 80 % behaftet ist. Charakteristisch für die Entwicklung des Multiorganversagens ist das Auftreten des „remote organ failure (ROF)“, eine Fehlfunktion von Organen, die durch das eigentliche Trauma keinen direkten Schaden erlitten haben. Diese Arbeit gibt einen kurzen überblick über die neueren Entwicklungen auf dem Gebiet der tierexperimentell-immunologischen Traumaforschung und geht eingehend auf den aktuellen Stand der klinisch-immunologischen Traumaforschung ein. Insbesondere wird die Bedeutung der sog. pro- und antiinflammatorischen Cytokine bei der Entstehung von SIRS, MOF und ROF er?rtert. Trotz der vielen Fortschritte auf dem Gebiet der klinischen Immunologie und der vielf?ltigen Informationen über die Trauma-induzierten Immunfunktionsst?rungen müssen jedoch noch viele offene Fragen gel?st werden, bevor die immunologischen Ver?nderungen nach schwerem Trauma durch immunmodulatorische Therapieans?tze nachhaltig positiv beeinflu?t werden k?nnen.      

Associations of Early Premenopausal Fractures with Subsequent Fractures Vary by Sites and Mechanisms of Fractures

In a retrospective population-based study we assessed whether and how self-reported former fractures sustained at the ages of 20–34 are associated with subsequent fractures sustained at the ages of 35–57. The 12,162 women who responded to fracture questions of the baseline postal enquiry (in 1989) of the Kuopio Osteoporosis Study, Finland formed the study population. They reported 589 former and 2092 subsequent fractures. The hazard ratio (HR), with 95% confidence interval (CI), of a subsequent fracture was 1.9 (1.6–2.3) in women with the history of a former fracture compared with women without such a history. A former low-energy wrist fracture was related to subsequent low-energy wrist [HR = 3.7 (2.0–6.8)] and high-energy nonwrist [HR = 2.4 (1.3–4.4)] fractures, whereas former high-energy nonwrist fractures were related only to subsequent high-energy nonwrist [HR = 2.8 (1.9–4.1)] but not to low-energy wrist [HR = 0.7 (0.3–1.8)] fractures. The analysis of bone mineral density (BMD) data of a subsample of premenopausal women who underwent dual x-ray absorptiometry (DXA) during 1989–91 revealed that those with a wrist fracture due to a fall on the same level at the age of 20–34 recorded 6.5% lower spinal (P= 0.140) and 10.5% lower femoral (P= 0.026) BMD than nonfractured women, whereas the corresponding differences for women with a former nonwrist fracture due to high-energy trauma were −1.8% (P= 0.721) and −2.4% (P= 0.616), respectively. Our results suggest that an early premenopausal, low-energy wrist fracture is an indicator of low peak BMD which predisposes to subsequent fractures in general, whereas early high-energy fractures are mainly indicators of other and more specific extraskeletal factors which mainly predispose to same types of subsequent fractures only. Received: 21 February 1996 / Accepted: 24 September 1996     

重度创伤患者外周血单个核细胞HLA-DR的表达与创伤后免疫功能障碍的关系

为了探讨创伤后机体细胞免疫、体液免疫及红细胞免疫功能障碍与外周血单个核细胞ＨＬＡ－ＤＲ表达率之间的关系，本文选择了３０例重度复合伤病人。在住院治疗期间，连续观察了患者受伤当日、伤后第３、１０、２０ｄ及出院前一天外周血单个核细胞ＨＬＡＤＲ表达率的变化及其与细胞免疫、体液免疫及红细胞免疫功能状况之间的相关性，发现创伤病人自受伤当日至出院前外周血单个核细胞膜上ＨＬＡ－ＤＲ表达率的变化无统计学意义（Ｐ＞０．０５），提示创伤后免疫功能障碍不是由于外周血单个核细胞ＨＬＡ－ＤＲ表达异常所致。