1例富血小板血浆治疗外阴Paget′s病术后创面感染的护理体会

总结1例外阴Paget’s病术后创面感染的护理体会,利用伤口评估三角工具对患者创面进行评估,通过使用液体伤口敷料联合银离子敷料控制感染,富血小板血浆技术促进伤口愈合,个体化健康教育提高患者治疗依从性的整体干预方案对伤口进行有效管理,结果显示伤口愈合效果良好。     

Exosome-cargoed microRNAs: Potential therapeutic molecules for diabetic wound healing

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Mechanism matters: A 10-year experience of ballistic injuries of the upper extremity

IntroductionUpper Extremity gunshot wounds represent a significant strain on community and hospital resources, and reports of their epidemiology are varied. We hypothesized that demographic and socioeconomic variables would be associated with variable injury patterns and management, and that two distinct populations would be affected by upper extremity ballistic injury based on violent versus accidental, self-inflicted mechanism.Materials & methodsRetrospective review of all adult patients sustaining ballistic injury to the upper extremity at a single urban Level I trauma center over 10 years (n = 797). Demographic, injury pattern, treatment, and outcomes data were collected. Comparisons between groups were conducted with unpaired t-tests and chi-square testing where appropriate.ResultsMost patients were male (89.1%) and mean age was 30.1 years (18-83). Violence accounted for 89.1% of injuries. Black individuals were disproportionately affected at 87% of patients. Shoulder injuries were most common (34%), and wrist least common (7%). Demographics and injury pattern varied significantly between patients sustaining violent injury and those with self-inflicted mechanisms. Patients sustaining violent injury were most often young, Black men more likely to be injured proximally, whereas patients with self-inflicted injuries were more likely to be older, Caucasian men with more comorbidities injured distally. Cumulatively, 35.3% of patients required operative intervention. Distal injuries were more likely operative. The most commonly injured structure across all levels was bone (53%), and 54.3% of fractures required operation. Median follow-up was 24.5 months. Complication rate was 13.6%.ConclusionsGunshot wounds of the upper extremity create complex patterns of injury which vary based on level of injury and mechanism. Violent and self-inflicted injuries occur in dissimilar populations and result in distinctive injury patterns.     

An analysis of the morbidity associated with abdominal wall resection and reconstruction after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC)

PurposeCRS/HIPEC has evolved as an effective method for management of selected patients with peritoneal metastatic disease. Abdominal wall resection (AWR) is often required, and may require complex reconstructions, such as component separation (CST) leading to wound dehiscence (WD) and wound complications (WC). The purpose of our study was to analyse factors contributing to wound complications and wound recurrence (WR).MethodsRetrospective review of a prospective database of 1074 patients undergoing CRS/HIPEC procedures from 1996 to 2017 at St George Hospital.ResultsAWR and reconstruction for abdominal wall metastases was performed in 197 (18.3%) patients. Tumour types included mesothelioma, appendiceal, colorectal and ovarian cancers. Grade III WC were found in 21 (10.6%). WD was found in 14 (7.1%) compared to 30 (3.4%) in 877 patients without AWR (p = 0.028). Midline WR was seen in 26 (13.3%) with AWR and mean time to recurrence of 18 months. Multivariable’ regression analysis showed age (OR 1.06, 95%CI 1.01–1.11, p = 0.022) and CST (OR 9.63, 95%CI 2.55–36.23, p = 0.001) were independent predictors of Grade III WC, and CST (OR 4.19, 95%CI 1.27–13.86, p = 0.019) was an independent predictor of WD after AWR. The presence of a higher prior surgical score (PSS) 2–3 (OR 2.74, 95%CI 1.16–6.49, p = 0.022) was an independent predictor of midline WR post AWR.ConclusionThis study demonstrates that patients undergoing AWR have a higher incidence of postoperative WD. CST was associated with an increased incidence of Grade III WC and WD. Patients with a higher PSS were more likely to develop midline wound recurrence.     

“A picture tells a thousand words” smartphone-based secure clinical image transfer improves compliance in open fracture management

BackgroundBOAST (British Orthopaedic Association Standards for Trauma) and NICE (National Institute of Clinical Excellence) guidelines recommend clinical photography of all open fractures on admission and at key stages of patient care for objective wound documentation and to avoid repeated examination. Recording and handling photographs in a compliant and confidential manner in the setting of acute trauma management can prove challenging. To facilitate clinical photography at our Major Trauma Centre (MTC) institution, a smartphone-based Secure Clinical Image Transfer (SCIT) app was introduced and integrated with the existing clinical photography database to allow clinicians to take photographs, which are saved directly to patient records.ObjectivesTo compare rates of information governance (IG)-compliant clinical photography of wounds of patients with open fractures before and after introduction of departmental smartphones loaded with the clinical photography app SCIT.MethodsAdmission lists were inspected retrospectively for patients admitted with open fractures between August and October 2016, before SCIT was introduced. The Trust clinical photography database was searched for corresponding patient images and where present, graded out of three for clarity, comprehensiveness and context. The procedure was repeated prospectively from August to October 2017 after rollout of SCIT. The uptake and quality of photography were statistically compared (Fisher’s exact test, significance level p < 0.05).Results42 open fractures were identified in the 2016 period and 40 in the 2017 period. None of the 42 patients in the 2016 cohort had records of IG-compliant clinical photography on admission. 16 of 40 patients in the 2017 cohort had IG-compliant clinical photography on admission. This was statistically significant (p < 0.0001). 5 of 42 patients in the 2016 cohort and 8 of 40 patients in the 2017 cohort had photographs after first debridement. This was statistically insignificant (p = 0.375). All five photographs in the 2016 cohort scored 3/3. 18 of 21 photographs in the 2017 cohort scored 3/3, one scored 2/3 and two scored 1/3.ConclusionsIntegrating commonplace smartphone technology with a secure platform for taking and storing photographs can improve rates of IG-compliant clinical photography of open fractures. This may improve documentation, communication and patient care.     

Continuous pH monitoring in wounds using a composite indicator dressing — A feasibility study

PurposeModern burn care strives for new means to guarantee optimised wound healing. Several studies have shown a correlation between the pH value in a (burn) wound and successful wound healing. A multitude of devices to monitor pH is available, all requiring direct wound contact and removal of the dressing for pH monitoring. The aim of this feasibility study was to create a sterile and easy to handle method for pH monitoring while simultaneously using an advanced wound dressing.Materials and methodsDressing sheets of biotechnologically generated nanofibrillar cellulose (epicite^hydro) were chemically functionalised with the indicator dye GJM-534. pH-donors with increasing pH were subsequently applied to the created indicator dressing. To investigate temporal resolution and continuous monitoring we used circular pH-donors with different pH (7 and 10) and decreasing diameters that were placed on another dressing sheet. Clinically relevant spatial resolution was checked by a wound bed simulation with small areas (8 mm) of higher pH (10) on a field of lower pH (7) and vice versa.ResultsThe indicator dressing showed a gradual colouring from yellow to dark orange with increasing pH in steps of 0.3. After conversion of digital pictures to greyscale values, a sigmoidal distribution with a pK_a-value of 8.4 was obtained. A ring-like pattern with alternating colour change corresponding to the pH was observed in the continuous monitoring experiment and the wound bed simulation delivered excellent local resolution.ConclusionSince the pH of a (burn) wound can have a significant influence on wound healing, a pH indicator was successfully linked to an advanced, temporary, alloplastic wound dressing material. We were able to show the possibility of pH monitoring by the dressing itself. Additional testing, including studies with large case numbers for optimisation are necessary before clinical implementation.     

罗哌卡因切口浸润联合羟考酮静脉输注对剖宫产术后宫缩痛和早期恢复的影响

目的观察罗哌卡因切口浸润联合羟考酮静脉术后镇痛对剖宫产术后宫缩痛和产妇早期恢复的影响。方法择期行剖宫产手术产妇60例,年龄22～35岁,ASAⅠ或Ⅱ级,随机均分为三组:羟考酮组(O组),罗哌卡因组(R组)和羟考酮联合罗哌卡因组(OR组)。O组患者于手术缝皮前静脉注射羟考酮0.1 mg/kg,R组患者于手术缝皮前皮下注射0.5%罗哌卡因15 ml浸润麻醉,OR组患者于手术缝皮前静脉注射羟考酮0.1 mg/kg联合皮下给予0.5%罗哌卡因15 ml浸润麻醉。术后VAS评分4分者静脉注射曲马多50 mg作为补救镇痛。比较三组产妇术后4、8、16、24、48 h的切口痛和宫缩痛的VAS评分和Ramsay镇静评分、术后48 h曲马多补救镇痛例次、术后恢复情况、术后皮肤瘙痒和恶心呕吐等不良反应发生情况。结果术后16、24 h O组和OR组宫缩痛VAS评分明显低于R组(P0.05),O组和R组切口痛VAS评分明显高于OR组(P0.05),术后曲马多补救镇痛例次明显大于OR组(P0.05)。O组和R组恶心呕吐发生率明显高于OR组(P0.05)。三组其他不良反应和术后恢复情况差异无统计学意义。结论剖宫产手术应用羟考酮静脉术后镇痛联合罗哌卡因切口浸润为基础的多模式镇痛,能对产妇的切口痛和宫缩痛达到良好的镇痛效果,其中羟考酮在减轻宫缩痛方面作用明显,且不增加术后不良反应。     

The efficacy of negative pressure wound therapy for diabetic foot ulcers: A systematised review

AimThis review investigated the current state of knowledge on negative pressure wound therapy (NPWT) used to treat diabetic foot ulceration (DFU), its clinical effectiveness and any current issues in the research. NICE have recommended research into the clinical effectiveness of different dressing types for DFUs since 2015.MethodsA systematic search of the British Nursing Index, CINAHL, Cochrane Central and PubMed was undertaken. Only primary studies were included and studies investigating a combination of NPWT and other therapies were excluded. All the included studies were published in English between 2008 and 2018 and were peer reviewed.ResultsThe search yielded seven studies for inclusion in the qualitative analysis. The studies included a variety of methodologies specifically; 3 randomized controlled trials, 2 case series’, 1 non-controlled trial and 1 randomized case-control study. Three main themes were identified and formed the focus of the qualitative synthesis.DiscussionAll the included studies reported that NPWT led to better clinical outcomes when compared to standard treatment. However, the studies had numerous methodological flaws such as the absence of validated tools for the measurement of outcomes such as wound area and depth; a lack of statistical power calculations to determine adequate sample sizes or the significance of outcome measures. Additionally, there was little consistency in the pressures used for the NPWT devices. Finally, many of the controlled trials did not conform to the standard of reporting trials stipulated by the CONSORT statement.