胸部爆震伤致兔急性呼吸窘迫综合征模型的建立及相关因素分析

目的 构建室内胸部爆震伤致兔急性呼吸窘迫综合征(ARDS)模型并分析其发生机制及早期死亡原因,为研究肺爆震伤早期预警体系和治疗方法提供依据.方法 按照不同炸药量和致伤距离所产生的压强,将60只新西兰大白兔按随机数字表法分为5个致伤组和1个无致伤对照组.伤后观察存活率和组织病理学,并监测病理生理学指标、肺含水量.结果 冲击波压强低于1 210.5 mm Hg(1 mm Hg=0.133 kPa,A、B组)时,肺损伤较轻,表现为点状肺挫伤,肺简明损伤评定分级法(ALS)均在2级内,动物伤后24 h内全部恢复,长期存活无并发症.冲击波压强高于2 036.1 mm Hg(D、E组)时,肺损伤过重,表现为广泛的肺挫伤、肺门撕裂伤和肺内大血肿,AIS均大于5级,动物于伤后1 h内全部死亡.冲击波压强为1 917.3 mm Hg(C组)时,肺表现为广泛而恒定的挫伤,累及4个肺叶以上,AIS 4～5级,伤后6 h内出现动脉氧分压下降;肺组织可见肺泡壁水肿,部分肺泡壁断裂,肺泡融合;肺泡内充满大量炎性细胞,偶见透明膜形成.与对照组比较,C组兔致伤6 h肺湿/干重比值即显著升高(6.46±0.24比3.98±0.19,P＜0.01),血浆及支气管肺泡灌洗液(BALF)中肿瘤坏死因子-α(TNF-α)和白细胞介素-6(IL-6)即明显升高[血浆TNF-α(ng/L):328.89±6.26比62.12±2.98,BALF TNF-α(ng/L):164.87±4.59比29.51±1.12;血浆IL-6(ng/L):128.51±4.13比19.32±1.53,BALF IL-6(ng/L):94.97±1.14比22.72±0.19,均P＜0.05].结论 在1 917.3 mm Hg爆炸压强的密闭环境下,冲击伤可诱导兔发生ARDS;TNF-α及IL-6参与爆震伤致ARDS的形成与发展;特定环境下,肺脏破裂致气胸为早期死亡原因,而冲击波致循环系统功能紊乱也是引起早期死亡的重要原因.

Abstract：

Objective To reproduce acute respiratory distress syndrome (ARDS) model in rabbit induced by chest blast injury and to analyze the pathogenesis and causes of early death in order to provide the basis for the early diagnosis of lung blast injury and its early-warning system to facilitate an early treatment.Methods Sixty healthy New Zealand white rabbits were divided into six groups according to the different explosion distance with the random number table method. The survival rate and its resulting pathological changes were observed and patho-physiological indexes and lung fluid content were determined at sequential time points post-explosion. Results Shock wave pressure less than 1 210. 5 mm Hg (1 mm Hg=0. 133 kPa,group A, B) resulted in limited injury to the lung within grade-2 as assessed with the abbreviated injury scale (AIS). The rabbits in these groups recovered soon and survived without any complication. Shock pressure higher than 2 036. 1 mm Hg (group D, E) caused severe injuries to the lung, including deep laceration, disruption of lung hilus and large hematoma in the lung, and the injury severity of lungs was assessed above grade-5 as assessed with AIS. All rabbits died within 1 hour post-explosion. The groups described above failed to meet the demand of an ARDS model for the present study. Shock wave pressure at 1 917. 3 mm Hg (group C) produced extensive contusion from grade-4 to grade-5 as assessed with AIS. The rabbits survived in poor general condition, and arterial partial pressure of oxygen (PaO2) lowered within 6 hours. Pathological examination showed extensive and constant multi-focal bleeding involving more than four lobes. The alveolar wall was edematous, with partial rupture and alveolar fusion in lung tissues was observed in the group C. Alveoli were filled with inflammatory cells, and hyaline membrane was formed occasionally. Compared with control group, the wet to dry weight ratio (W/D) in lungs increased obviously (6.46±0. 24 vs. 3. 98±0. 19, P＜ 0. 01) in group C within 6 hours postinjury. The contents of tumor necrosis factor-α (TNF-α) and interleukin-6 (IL-6) in plasma and bronchoalveolar lavage fluid (BALF) were also increased distinctly compared with the control group [TNF-α (ng/L) in plasma: 328. 89± 6.26 vs.62.12±2. 98, TNF-α (ng/L) in BALF: 164.87±4.59 vs. 29. 51±1.12; IL-6 (ng/L) in plasma: 128. 51±4.13 vs. 19.32±1.53: IL-6 (ng/L) in BALF: 94.97±1.14 vs. 22.72±0. 19, all P＜0. 05]. Conclusion In an airtight environment, rabbit ARDS model can be reproduced successfully by blast injury with 1 917.3 mm Hg explosion pressure; TNF-α and IL-6 are involved in the pathogenesis and development of ARDS in blast injury. Pneumothorax as a result of lung rupture is the chief reason for early death and dysfunction of circulatory system is also an important reason in producing early death.     

小儿原发性纵隔肿瘤和囊肿的诊治

目的 探讨小儿原发性纵隔肿瘤和囊肿的诊断及治疗.方法 回顾性分析79例小儿原发性纵隔肿瘤和囊肿的临床资料.所有病例均经手术和病理证实.结论 本组病例中,小儿原发性纵隔肿瘤和囊肿占同期我科收治的原发性纵隔肿瘤及囊肿的13.96%(79/566).其中神经源性肿瘤21.5%(18/79)、肠源性囊肿15.2%(12/79)、畸胎瘤17.7%(14/79),其他肿瘤和囊肿44.30%(35/79).无临床症状而于查体时发现12例,占15.19%.手术切除74例,手术切除率93.7%(74/79),经治疗后康复出院76例,死亡3例.结论 小儿纵隔肿瘤和囊肿的术前诊断依据胸部X线、CT扫描及超声检查,必要时可以结合MRI扫描判断病变范围,而确诊则依赖于术中所见及术后病理检查.其病情复杂,变化快,可危及患儿生命,除淋巴瘤外宜选手术治疗.

Abstract：

Objective To investigate the diagnosis and treatment of primary mediastinal tumors and cysts in children.Methods The data of 79 patients admitted from 1966 to 2009 with primary mediastinal tumors and cysts were retrospectively reviewed.All patients underwent surgery and pathological examination.Results The primary mediastinal tumors and cysts in children accounted for 13.96% of primary mediastinal tumors and cysts at the same period.In these 79 patients,neurogenic tumors were diagnosed in 18 (21.5%)patients,gastrointestinal cyst was 15.2%(12/79),teratoma was 17.7%(14/79),and the others were 44.30%(35/79).Twenty-two patients without clinical symptoms were diagnosed by health checkup,accounting for 15.2% in all cases.Tumors in 74 patients(93.7%)were resected,and the mortality rate was 3.8%(3/79).Conclusions The preoperative diagnosis of mediastinal tumors and cysts in children primarily bases on chest X ray,CT scan,ultrasonography,and MRI scan in some cases,but the final diagnosis depends on the intraoperative findings and pathologic examination.Except of lymphoma,primary mediastinal tumors and cysts should be treated by surgery appropriately.     

兔油酸ARDS模型72h内炎性因子及凝血情况分析

目的 探讨兔油酸(OA)急性呼吸窘迫综合征(ARDS)模型72 h内NF-κB、IL-10、GR、PT、APTT、Fib含量变化的意义.方法 健康新西兰大耳白兔30 只随机分为5组,每组6只,实验组(n=24)耳缘静脉注射油酸(0.1 mL/kg)建立ARDS模型,对照组(n=6)注射等量生理盐水.分别检测对照组6 h和实验组6、24、48、72 h(n=6)血浆和支气管肺泡灌洗液(BALF)核因子(NF-κB)、白细胞介素-10(IL-10)、糖皮质激素受体(GR)含量与血浆凝血酶原时间(PT)、活化部分凝血酶原时间(APTT)、纤维蛋白原(Fib)的变化.结果 (1)注射油酸48 h内,实验组氧合指数PaO2/FiO2<200 mmHg达到ARDS的诊断标准;72 h后呼吸功能有所改善,PaO2/FiO2>200 mmHg达不到ARDS的诊断标准.(2)与对照组相比,各实验组血浆及支气管肺泡灌洗液NF-κB、IL-10、GR含量升高(P<0.05或P<0.01).肺泡灌洗液中NF-κB、IL-10、GR含量均比血浆中略低.(3)与对照组相比,OA 6、24 h 组PT明显增加(P<0.01);各实验组APTT均见明显升高(P<0.01),OA 6 h 组Fib明显降低(P<0.01).结论 兔油酸构建ARDS模型48 h内符合ARDS诊断标准,72 h后未能达到ARDS诊断标准.促炎/抗炎系统平衡可能影响ARDS的发展进程.ARDS时凝血功能下降.     

Poland综合征胸壁畸形的外科治疗（附三例报告）

Poled综合征是一种少见的先天性前胸壁及上肢畸形,又称胸大肌缺损并指综合征.2003年7月至2007年8月,我们行胸壁重建手术矫治Poland综合征胸壁畸形3例,疗效满意,现报告如下.     

下行性坏死性纵隔炎的诊断与治疗

下行性坏死性纵隔炎是由牙源性或颈部感染沿颈筋膜扩散侵及纵隔所致的急性纵隔炎,其临床特点为发病罕见、病情危重、进展迅速和病死率高,发病过程与颈、纵隔的解剖生理特点有密切的关系。早期诊断和有效的治疗可降低病死率,胸部CT检查是早期诊断该病的有效方法;早期、足量应用广谱抗生素,根据胸部CT分型采取个体化的及时切开引流、冲洗,彻底清除坏死组织是降低病死率的有效手段,必要时应会同各有关科室,如口腔、头颈外科、胸外科、重症监护、感染科等协同处理治疗;同时对易导致下行性坏死性纵隔炎发生和恶化的原有全身系统性疾病,如糖尿病以及体质不良者,应加以关注和治疗,以降低致死并发症的发生率,提高治疗效果。     

异体移植气管中骨形态发生蛋白诱导软骨再生的实验

目的:比较骨形态发生蛋白2在犬自体、异体、冷冻异体气管移植体内诱导软骨再生的作用。方法:实验于2004-03/10在第四军医大学唐都医院实验外科完成。21只杂种犬随机等分为3组,自体移植组、异体移植组、冷冻后的异体移植组。各组动物颈部切除4环气管段作为移植体,植入骨形态发生蛋白2后埋入腹腔大网膜中。骨形态发生蛋白2均以胶原溶液作为缓释载体,用注射器直接注入各软骨环间。术后5周处死实验动物,通过对标本组织学观察、碱性磷酸酶活性和钙含量测定,对各标本的新生软骨进行观察和定量分析。结果:各组实验犬均存活到预杀期。①定量组织学观察:各实验组骨形态发生蛋白2植入区均可见新生软骨细胞和软骨岛,HPLAS-1000病理图像分析系统计算各环间新生软骨的像素面积,自体移植组、异体移植组、冷冻后的异体移植组的新生软骨面积差异有显著性犤2573.6±738.4,1691.3±743.6,2482.9±827.5,F=5.711,P<0.05犦自体移植组和深低,而温冷冻后的同种异体移植组差异无显著性。②碱性磷酸酶活性和钙含量测定:自体移植组、冷冻后的异体移植组与异体移植组均差异有显著性犤体移植组:(7.00±0.50)μkat/g,(5.48±1.15)mg/g;冷冻后的异体移植自组:(7.00±0.83)μkat/g,(5.03±0.91)mg/g;异体移植组:(5.00±0.67)μkat/g,(3.57±0.98)mg/g,P<0.05犦,自体移植组与深低温冷冻后的同种异体移植组间无显著性差异(P>0.05)。结论:骨形态发生蛋白2能在气管移植体内有效地诱导出新生软骨,在冷冻后的异体气管移植体内的作用效果与自体气管移植体内相似,明显优于异体气管移植体。     

用于移植气管局部的表皮生长因子明胶微球的研究

目的制备可用于移植气管局部的表皮生长因子（epidermal growth factor，EGF）明胶微球（gelatin microspheres，GMs），研究其生物学活性。方法采用改良双相乳化冷凝法制备表皮生长因子明胶微球（epidermal growth factor gelatin microspheres，EGF-GMs），计算其溶胀率，观测微球分散度、粒径及外观形态。采用BALB／c3T3作为效应细胞，分为3组，A组（EGF-GMs组）、B组（游离EGF组）、C组（空白GMs组），进行细胞计数并应用流式细胞仪观测细胞周期评估表皮生长因子明胶微球生物学活性。结果制得的明胶微球大小均匀，平均粒径为107μm。细胞计数：第1、3天时。B组＞A组＞C组，且差异有统计学意义（P＜0．05）；第7天时，A、B组高于C组，差异有统计学意义（P＜0．05），但A、B两组间无统计学意义（P＞0．05）；第11天时，A组＞B组＞C组，且差异有统计学意义（P＜0．05）。第11天，流式细胞分析结果：A组增殖指数和S期细胞比例均大于B、C组，三组间差异有统计学意义（P＜0．05）。结论表皮生长因子明胶微球粒径大小适合局部应用，能够在较长时间缓释具有生物学活性的表皮生长因子。     

日达仙联合泰能治疗肺切除术后难治性肺部感染45例分析

肺切除术后患者免疫力低下,易发生常规抗生素治疗难以奏效的难治性肺部感染,2000-01~2006-06我科采用日达仙联合泰能治疗45例,效果较好,报道如下。1临床资料1.1一般资料本组男29例,女16例,年龄45~78(平均54)岁。均有肺部感染的临床表现,且符合下列条件:(1)肺切除患者术后;(2)术后10 d以上;(3)均经过正规、合理抗生素治疗;(4)T>38℃;(5)白细胞计数>1×109/L;(6)胸片示:肺部存在感染。其中合并支气管胸膜瘘5例,胸腔少量积液11例。气管切开5例,呼吸机辅助呼吸9例。治疗前共行89例次痰培养,共培养出13种细菌44株,6例合并真菌感染。1.2方法在加…     

支气管袖状切除治疗支气管肺癌

目的：总结分析支气管袖状切除术治疗肺癌的经验及疗效。方法：回顾性总结支气管肺癌手术治疗128例．采用支气管袖状切除、肺动脉成形术。结果：随访87例，1．3、5年生存率分别为81．6％（71／87）、54.0％（47／87）、32．2％（28／87）。结论：支气管袖状切除、肺动脉成形术治疗支气管肺癌既能全部切除肿瘤，又最大限度保护了肺功能，改善了患者的生存质量，远期疗效良好。     

普胸术后血胸再次手术止血21例临床分析

目的探讨普胸外科术后胸腔内出血再手术的处理，分析术后胸内出血的原因及其处理方法和预防。方法同顾性分析小院1981年1月～1997年1月焚实施各类普胸手术2988例，术后血胸再次手术止血21例，发牛率0．7％（21／2988），对陔组病例进行回顾性临床分析。结果本组21例再手术，治愈18例，死亡3例，死亡占二次手术的14．3％（3／21），并有更多的并发症。结论积极、准确地处理和正确的预防术后血胸是手术成功的关键。