多发伤患者血清胆碱酯酶与急性期蛋白的相关性

目的 探讨多发伤患者血清胆碱酯酶(ChE)与急性期蛋白(APP)变化的相关性,比较它们在反映病情严重度和判断预后中的价值. 方法 为前瞻性观察研究.选择2005年10月至2007年10月在伤后24 h内收住浙江大学医学院附属第二医院急诊监护室的多发伤患者共81例.排除标准:(1)有慢性肝病、有机磷接触、活动性肺结核或肿瘤病史;(2)伤前有主要脏器感染;(3)存在肝脏损伤;(4)年龄<18周岁者.其中男57例,女24例;年龄(46±18)岁,损伤严重度评分(34.0±11.9).另选择76例本院健康体检者作为对照,其中男53例,女23例;年龄(44±16)岁.排除标准同患者组.2组性别、年龄构成均具可比性.患者组在伤后第1、3,7天抽取静脉血常规方法检测血清ChE活性、血清白蛋白(ALB)、前白蛋白(PAB)、转铁蛋白(TRF)、C反应蛋白(CRP),同时记录急性生理和慢性健康评分Ⅲ(APACHEⅢ).对照组以同样方法测定血清ChE、ALB、PAB、TRF、CRP,并采用t检验或秩和检验分别与患者组各时点相比较.采用单因素重复方差分析患者组血清ChE及各APP指标在伤后的动态变化情况,采用Pearson相关分析法分析血清ChE与各APP的相关性及它们与APACHEⅢ的相关性.根据患者转归分为存活和死亡2组,采用t检验或秩和检验比较组间各指标的差异,通过Logistic回归分析比较它们在预后判断中的价值. 结果 患者伤后各时点血清ChE、ALB、PAB、TRF均比各对照组显著降低,CRP则明显升高,其中血清ChE活性都比对照组下降超过25%(42.3%～50.2%),并与PAB、TRF一样呈下降趋势;血清ChE活性在各时点与ALB、PAB、TRF都显著正相关,与CRP第3、7天负相关.患者APACHEⅢ在各时点与血清ChE、TRF均显著负相关,与ALB仅第1天负相关,与PAB仅第1、7天负相关,与CRP仅第7天正相关;各时点死亡组血清ChE活性和TRF都显著低于存活组,而死亡组ALB仅在第7天、PAB仅在第1天和第7天显著低于存活组,CRP仅在第7天显著高于存活组,Logistic回归分析提示仅血清ChE和PAB是判断预后的独立因素. 结论 血清ChE可视为负急性期蛋白的一种,在反映多发伤病情严重度和预测患者转归中的综合价值要优于其他主要APP.     

危重患者胸腔积液超声测量新方法的建立与应用

目的 探索危重患者胸腔积液超声精确测量的新方法 .方法 选择收住急诊ICU的危重患者46例,应用超声在平卧位、呼气末测定胸腔积液的高度(H)、中间层积液的面积(S)和在后背正中线、腋后线处的厚度(T1、T2),以H×S估算胸腔积液量(Vc),胸腔置管充分引流获取实际积液量.分析胸腔积液实际量与积液高度、厚度、面积及估算量的相关性,比较不同指标和方法 估算积液量的准确性.结果 在总组和各亚组中,胸腔积液实际量与S、(H和S)、Vc的相关性明显好于T1、T2和H.超声测量新方法 获取的估算量与实际积液量有较好的相关性(r=0.778,P＜0.001),而且非常接近实际积液量(平均相差56 ml),尤其在积液量＜500 ml时两者的差别无统计学意义[(417±94)ml对(402±95)ml,t=1.095,P=0.285].Logistic逐步回归分析和受试者工作特征曲线(ROC)分析均表明,以H、S、T1、T2预测实际积液量＞500 ml、400 ml和300 ml,其中以S最为可靠,其阈值分别为30.3 cm2、28.3 cm2和23.1cm2,相应的敏感性和特异性分别为0.77和0.88,0.72和1.0,0.95和1.0.结论 基于积液面积测定基础上建立的胸腔积液超声新测量方法 较传统方法 更可靠和精确,具有重要的临床价值,且测定技术简单,值得推广应用.

Abstract：

Objective To develop a new method to measure pleural effusion volume by ultrasound in critically ill patients. Methods Forty-six critically ill patients admitted to emergency ICU were involved.The height of effusion (H),area of effusion at the middle section (S), thickness of effusion at middle-back line (T1) and posterior axillary line (T2) were measured by ultrasound in supine position at the end of expiration. The measured volume of pleural effusion (Vc) was calculated by H×S,and the actual volume of drainage (V) within 2 hours was also recorded. The correlation of actual volume of pleural effusion (V)with effusion height (H) ,thickness (T1, T2), area (S) and the calculated volume (Vc) were analyzed to decide the most accurate index and method. Results There was much better correlation between actual volume of effusion and S, (H & S), Vc, than these between V and T1 ,T2, H in all patients and subgroup, Vc had good correlation with V and very close to V(the average difference was 56 ml) when the actual volume was less than 500 ml,there was no difference[(417 ± 94)ml vs (402±95)ml, t = 1.095, P = 0. 285]. Both Logistic regression analysis and receiver operating characteristic (ROC) curve showed S was the most reliable index to predict the actual volume to exceed 500 ml,400 ml,and 300 ml when compared with H,S,T1 and T2. The corresponding threshold was 30.3 cm2 , 28.3 cm2 and 23. 1 cm2 , with the sensitivity and specificity of 0. 77 and 0. 88,0.72 and 1.0,0.95 and 1.0, respectively. Conclusions This new method based on measuring the area of effusion by ultrasound is more efficient and reliable than those traditional ones to measure the volume of pleural effusion. It's clinically valuable and easy to perform, and deserves broad application.     

辛伐他汀局部注射对大鼠骨质疏松性骨折愈合的影响

目的： 研究辛伐他汀局部注射对去势大鼠骨折愈合的影响。方法: 2月龄雌性SD大鼠采用去势方法模拟人绝经后骨质疏松症,模型成立后进一步建立胫骨骨折髓内钉内固定模型,实验组于骨折端皮下注射辛伐他汀(10 mg·kg^-1·d^-1,5 d),另一组仅注射无辛伐他汀的溶剂作为空白对照组。骨折后1、2、4周取标本,通过X片、生物力学、组织病理学以及组织形态计量学等方法评价两组骨折愈合质量。结果: 与空白对照组相比,实验组骨痂横截面积在骨折后1周、2周分别增加21.3% (P<0.05) 和21.5% (P<0.05);骨痂最大载荷在骨折后2周、4周分别增加57.5% (P<0.05) 和31.4% (P<0.05);组织学显示实验组新生编织骨较对照组多且排列致密;组织形态计量学测量结果表明辛伐他汀可明显增加矿化宽度(MLW)、矿化容积(MLV) 以及矿化率(MAR)。结论: 局部应用辛伐他汀可促进去势大鼠骨折愈合。     

螺旋CT早期快速诊断多发伤合并的颈椎损伤

多发性创伤合并颈椎损伤的发生率为2%～12%[1].未被发现的颈椎损伤可能在后续诊治过程中发生骨折移位,造成或加重颈髓损伤而导致严重后果.     

改良哈氏棒治疗胸腰椎骨折脱位

目的 报告应用改良哈氏棒治疗胸腰椎骨折的体会，探讨发言奶哈氏棒的优缺点。方法 以椎弓根螺钉替代哈氏棒的下钩，棒钉组合治疗胸腰椎骨折４３例。结果 本组病人术后骨折复合满意，术后半年３４例随访，２５ Ｆｒａｎｋｅｌ分级有１～２级提高，１例脑脊液漏和后期１例１侧断钉外，无其它并发症。结论 改良哈氏棒可增加对前、中柱的作用，提高抗旋转和水平作用力，操作方便省时，可减少并发症，尤其适合于中上胸椎的治疗。     

螺旋CT早期快速诊断多发伤合并的颈椎损伤

多发性创伤合并颈椎损伤的发生率为2%～12%[1].未被发现的颈椎损伤可能在后续诊治过程中发生骨折移位,造成或加重颈髓损伤而导致严重后果.     

Early period of fracture healing in ovariectomized rats

Objective. To evaluate the effect of osteoporosis on fracture healing through observing the hlstomorphological changes, bone mineral density of callus and expression and distribution of transforming growth factor beta 1 (TGF-β1 ), basic fibroblast growth factor (bFGF)and bone morphogenetic protein.2 (BMP-2) in ovariectomized rats. Methods. Sixty female Sprague-Dawley rats ( aged 12 weeks and weighing 235 g on average ) were randomly divided into an ovariectomized (OVX) group (n =30) anda sham-operated (SO) group ( n = 30). Ovariectomy was performed in the OVX rats and same incision was made in the SO rats. Three months later, fracture of femoral shaft was made on all the rats. Then they were killed at different time points. Callus formation was observed with histological and imethods. Results: A reduction in callus and bone mineral density in the healing femur and a decrease of osteoblasts expressing TGF-β1 near the bone trabecula were observed in the OVX rats 3-4 weeks after fracture.Histomorphological analysis revealed a higher content of soft callus in the OVX rats than that in the SO rats.Immunohistochemistry results showed that no remarkable difference in expression and distribution of BMP-2 and bFGF between the OVX and SO groups was found. Conclusions: Osteoporosis influences the quantity and quality of callus during the early period of fracture healing. The effect of osteoporosis on fracture healing has no relationship with the expression of BMP-2 or bFGF. The decreased expression of TGF-I31 in osteoblasts may cause a decrease in quality of facture healing after osteoporosis.     

下肢骨关节术后持续被动活动效果的临床初步观察

骨关节术后持续被动活动是关节外科的一大进展。本文通过对６３例下肢骨关节术后早期进行持续被动活动情况的观察与随访，认为持续被动活动对下肢骨关节术后有功能恢复快、相对无痛、不影响组织愈合等优点，值得临床推广应用。     

螺旋CT早期快速诊断多发伤合并的颈椎损伤

多发性创伤合并颈椎损伤的发生率为2%～12%[1].未被发现的颈椎损伤可能在后续诊治过程中发生骨折移位,造成或加重颈髓损伤而导致严重后果.