颅脑损伤所致人格改变的量化评估

目的：通过对颅脑损伤所致器质性人格改变的患者进行量化评估分析，以寻找一种最适合颅脑损伤后人格改变的量化评估方法。方法：全都病例来自2003-01-03／2005-01-31期间到深圳市康宁医院法医精神病司法鉴定所进行工伤鉴定的工伤所致颅脑损伤患者116例，所有病例首先由综合医院神经外科行头颅CT或MRI检查，并对颅脑损伤的部位、性质、严重程度等做出诊断和治疗。治疗终结后，由两名副高级主任医师及以上职称的精神医学鉴定专家对患者的精神状况进行评估，并分别做出有无人格改变的诊断。同时采用慢性脑器质性人格改变评定量表（包括10个条目）及自编脑外伤后人格改变评定量表（包括5个因子17个条目）对患者人格改变的情况进行量化评定。以专家诊断结果为效标，对两种量表对颅脑损伤所致人格改变的判定灵敏度和特异性以及两量表的内部条目进行分析。结果：①颅脑损伤所致人格改变专家评定及量表评定结果：经专家鉴定，116例颅脑损伤患者中诊断为颅脑损伤所致器质性人格改变的患者22例，占所有调查对象的19％，评估者的诊断一致性kappa值为0．86（P〈0．01）。以专家诊断为效标，慢性脑器质性人格改变评定量表对本组颅脑损伤患者所致人格改变诊断的假阳性率为0，假阴性率为50％；自编脑外伤后人格改变评定量表的假阳性率为2．4％，假阴性率为4．5％。②两种量表评定颅脑损伤所致人格改变的内部条目分析：慢性脑器质性人格改变评定量表各条目评分结果显示有人格改变与无人格改变的患者在情绪不稳、情感淡漠或不协调、社会功能减退、个性改变、行为障碍5个条目的差异显著（t=12．082-5．921,P〈0．01-0．05）。自编脑外伤后人格改变评定量表除认知偏离因子中的所有条目外，情感偏离因子中的情绪不稳，情感脆弱，易激惹．情感平淡、不关心人4个条目，意志行为偏离中的意志缺乏，欲望增强，行为冲动、不计后果。自我中心4个条日．人际关系偏离及原有人格变化及其所有条目上均有显著性差异（t=13．339-2．094,P〈0．01-0．05）。结论：自编脑外伤后人格改变评定量表提高了对颅脑损伤所致人格改变诊断的灵敏度，其各条目能更准确地反映颅脑损伤所致人格改变的临床特点，但其信度和效度还需进一步完善。     

颅脑损伤患者应激障碍与认知功能的关系

目的：探讨颅脑损伤患者创伤后应激障碍和认知功能的关系。方法：选择2003-01／2004—12在鹤壁矿务局总医院脑外科门诊及住院的76例颅脑损伤患者（符合颅脑损伤诊断标准，年龄≥18岁）为观察对象。排除严重并发症及其他严重躯体疾病。患者在发病后3个月采用创伤后应激障碍诊断标准进行是否合并创伤后应激障碍的确诊。创伤后应激障碍诊断标准包括4个方面的内容：①遭受异乎寻常的创伤性事件或处境。②参反复重现创伤性体验。③持续的警觉性增高。④对与刺激相似或有关的情境的回避。根据检测结果分出应激障碍组和无应激障碍组。选用湖南医科大学龚耀先修订的中国书氏成人智力测验量表对两组患者进行认知功能进行评估和调查，韦氏成人智力测验量表分语言（知识、领悟、算术、相似性和数字广度）和操作（词汇、数字符号、填图、木快、图形排列、图形拼凑）两部分11项分测验。评分越低，说明认知功能损害越严重。并与正常人常模比较。结果：参加测试的76例颅脑损伤患者，均进人结果分析。①76例颅脑损伤患者遭遇车祸事件后3个月时创伤后确诊成激障碍患者17例（应激障碍组），无应激障碍患者59例（无应激障碍组），患病率为22％。②应激障碍组患者与正常人常模韦氏成人智力测验量表智测成绩中，应激障碍患者的知识、领悟、算术、相似性、数字广度、词汇、数字符号、填图、木块图、图形排列、图形拼凑评分均明显低于正常人常模（t=2．65-8．25，P〈0.05）。（彭在韦氏成人智力测验培表智测成绩中应激障碍组患者的知识、算术、数字广度、数字符号、填图、木块图、图形排列、图形拼凑评分明显低于无应激障碍组（t=2.24-3．84，P〈0．05）。结论：颅脑损伤患者常伴有很高的应激障碍发病半及认知功能损害，颅脑损伤患者的应激障碍与认知功能密切相关.     

人格障碍与精神分裂症患者凶杀案特征比较分析

目的探讨人格障碍与精神分裂症患者凶杀行为的犯罪学特征及刑事责任能力评定的特点。方法对98例鉴定为精神分裂症、16例鉴定为人格障碍者的鉴定资料进行回顾性对比分析。结果两组的病理性动机和现实性动机（x^2=5．27,P〈0．05）、作案对象（x^2=15．16,P〈0．01）、责任能力（x^2=92,P〈0．01）、作案后即刻表现（x^2=18．97,P〈0．01）差异均有显著性或极显著性。结论人格障碍与精神分裂症凶杀案具有不同的犯罪学特征,这些差别是刑事责任能力评定的重要依据。     

煤矿瓦斯爆炸后创伤性应激障碍群体的心理健康水平调查

目的 调查煤矿瓦斯爆炸后应激障碍的发生情况和影响因素。 方法 选择1985-01／2005-05平顶山平煤集团矿区井下发生过瓦斯爆炸井下从事煤矿生产的工人为调查对象，以井下工作队为单位随机抽取256名进行调查。根据DSM-IV中创伤后应激障碍的诊断标准，对256名井下工人中曾经经历瓦斯爆炸的80名进行诊断，按有无创伤性应激障碍分为患者组和正常组，应用症状自评量表及艾森克个性问卷进行评定和比较。结果 80名经历过瓦斯爆炸事故的工人均进入结果分析，符合创伤后应激障碍诊断30名。①患者组艾森克个性问卷内外向分明显低于对照组（P〈0．01），神经质分明显高于对照组（P〈0．01），精神质和掩饰度分差异无显著意义。②同正常组相比．患者组症状自评量表各因子分显著增高（P〈0．05）。结论 经历煤矿瓦斯爆炸的矿工是创伤后应激障碍的高危人群，创伤后应激障碍的发生可能和个性特征相关，应及时有效的进行心理干预避免不良的心理影响。     

急性颅脑损伤后抵抗素和精氨酸加压素动态变化的临床研究

目的研究急性颅脑损伤后血中抵抗素和精氨酸加压素（AVP）的动态变化,探讨抵抗素和AVP与急性颅脑损伤后继发性脑水肿及其预后的关系。方法采用酶联免疫吸附法（ELISA）检测抵抗素含量,采用放射免疫法检测AVP含量,分别测定110例急性颅脑损伤住院患者伤后12h,伤后第3、5d血中抵抗素和AVP含量,并结合临床表现、影像学检查及格拉斯哥预后评分（GOS）进行比较分析。结果本组110例急性颅脑损伤患者伤后早期（12h内）,血抵抗素和AVP含量随着格拉斯哥昏迷评分（GCS）下降,均有不同程度的升高。颅脑损伤越严重,抵抗素和AVP升高越明显,脑水肿程度越重,脑水肿高峰持续时间越长（P均〈0．01）。颅脑损伤早期,血抵抗素和AVP含量与脑水肿严重程度（r=0．68,0．65,P均〈0．01）和脑水肿高峰持续时间（r=0．69,0．64,P均〈0．01）呈正相关。此外,不同GOS组之间抵抗素和AVP差异亦有统计学意义,其中预后不良组血抵抗素和AVP水平在伤后5d仍持续在较高水平,而且显著高于预后良好组和正常对照组（P〈0．05或P〈0．01）。同时急性颅脑损伤后血抵抗素和AVP的含量呈正相关（r=0．72,P〈0．01）。结论急性颅脑损伤后血抵抗素和AVP的动态变化与急性颅脑损伤预后密切相关,抵抗素和AVP参与了颅脑损伤后继发性脑水肿形成的病理生理过程。     

留置静脉留置针患儿198例舒适护理

目的：探讨ICU重症颅脑损伤患者并发高钠血症的相关因素，以寻找有效的护理干预措施。方法：回顾ICU病房286例重症颅脑损伤有关资料，统计高钠血症的发生情况，将发生高钠血症56例作为观察组，未发生高钠血症230例作为对照组，以分析高钠血症对重症颅脑损伤患者预后的影响。结果：观察组56例，好转41例，死亡15例，病死率为26、79％；对照组230例，好转204例，死亡26例，病死率为11．30％。两组比较均有极显著性差异（P〈0．01）。结论：高钠血症是重症颅脑损伤死亡的重要影响因素，积极采取有效护理措施进行干预，可提高临床治疗效果。     

颅脑损伤患者的社会功能分析

目的比较有和无器质性损伤的颅脑损伤患者的社会功能,探讨其作为精神损伤鉴定的价值.方法采用社会功能缺陷筛查量表(SDSS)、大体评定量表(GAS)和功能大体评定量表(GAF)对56例无脑器质性损伤和55例有脑器质性损伤的颅脑损伤患者进行评估.结果用SDSS评定,无脑器质性损伤组患者的社会功能缺陷发生率为33.9%(19/56),有脑器质性损伤组为45.5%(25/55),两组间比较其差异无统计学意义(X2=1.544,P=0.214).两组的GAS评分结果无显著性差异(t=0.021,P=0.983);两组的GAF评分比较也无显著性差异(t=0.391,P=0.697).结论本研究提示,颅脑损伤患者的社会功能缺陷发生率较高,但有或无脑器质性损伤患者的社会功能损害发生率及社会功能受损程度间并无显著性差异.建议把社会功能受损程度作为评定精神损伤严重程度的重要指标之一.     

早期凝血功能障碍对评估急性颅脑损伤患者预后的价值探讨

目的探讨早期凝血功能障碍对评估急性颅脑损伤患者预后的临床价值。方法选择我院近年来收治的54例急性颅脑损伤患者,对其格拉斯哥昏迷评分（GCS）、凝血酶原时间（PT）、活化部分凝血活酶时间（APTT）、纤维蛋白原（FBG）、凝血酶时间（TT）、D-二聚体（DD）及血小板计数（PLT）7项指标进行检测,并与健康对照组比较,以判断其对格拉斯哥预后评分（GOS）的影响。结果急性颅脑损伤组与健康对照组比较,格拉斯哥昏迷评分（GCS）〉8分组FBG及DD差异有统计学意义（P〈0．01）,GCS≤8分组7项观察指标差异均有统计学意义（P〈0．01）。结论颅脑损伤患者早期凝血功能障碍主要由受伤脑组织释放凝血因子引起,因而能够反映脑组织受伤程度,对早期判断颅脑损伤患者的预后有重要的临床价值。     

143例精神损伤司法精神医学鉴定分析

目的探讨司法精神医学鉴定中精神损伤的评定标准。方法对143例精神损伤司法精神医学鉴定案例进行回顾性分析。结果精神损伤鉴定占鉴定总案例的7．5％。多发生于文化层次较低的青壮年及农民。心因性障碍、精神分裂症、癔症、神经症、脑震荡后综合征占精神损伤的81.8％。结论目前我国对精神损伤程度评定尚缺乏量化标准,制定全国统一的精神损伤评定标准刻不容缓。     

重型颅脑损伤患者血清及脑脊液胃泌素水平测定及其意义

目的探讨重型颅脑损伤患者血清及脑脊液胃泌素水平与颅脑损伤程度及其与消化道出血的关系,探讨血清与脑脊液胃泌素含量的相关性。方法对71例重型颅脑损伤患者,根据伤后是否合并消化道出血分为出血组及无出血组,用放射免疫法分别于入院时及第3、7、14天测定血清及脑脊液胃泌素含量并与正常对照组进行比较。结果重型颅脑损伤早期血清胃泌素含量均明显．高于正常对照组（P〈0．01）;3～7d达高峰,伤后1周内有、无出血组间差异显著（P〈0．01）;随着病情好转,血清胃泌素值逐渐下降,伤后2周,出血组血清胃泌素水平明显高于无出血组（P〈0．01）。脑脊液胃泌素不能检出。结论血清胃泌素水平与颅脑损伤程度及消化道出血呈正相关,脑脊液胃泌素水平测定与颅脑损伤程度及消化道出血无相关性,血清与脑脊液胃泌素含量无相关性,早期动态观察血清胃泌素含量变化对判断病情及预后有重要意义。     

Injury to the head and face in patients with cervical spine injury

The charts of 81 patients with acute cervical spine fracture and/or subluxation were reviewed to determine the incidence of injury to the soft tissue and bone of the head or face in these patients. Motor vehicle accidents accounted for over 69% of these injuries. Only 33 patients had concomitant soft tissue injury to the head or face, and only five had facial and/or skull fractures. Injuries of the skull and face do not usually accompany cervical fractures, and our findings do not support the restriction of post-traumatic cervical spine radiography in the emergency department to patients with obvious head or facial trauma.     

Identification of Intra-abdominal Injuries in Children Hospitalized Following Blunt Torso Trauma

OBJECTIVE: To determine the utility of the ED physical examination and laboratory analysis in screening hospitalized pediatric blunt trauma patients for intra-abdominal injuries (IAIs). METHODS: The authors reviewed the records of all patients aged <15 years who sustained blunt traumatic injury and were admitted to a Level 1 trauma center over a four-year period. Patients were considered high-risk for IAI if they had any of the following at ED presentation: decreased level of consciousness (GCS < 15), abdominal pain, tenderness on abdominal examination, or gross hematuria. Patients without any of these findings were considered moderate risk for LAI. The authors compared moderate-risk patients with and without IAIs with regard to physical examination and laboratory findings obtained in the ED. RESULTS: Of 1,040 children with blunt trauma, 559 (54%) were high-risk and 481 (46%) were moderate-risk for IAI. 126 (23%) of the high-risk and 22 (4.6%) of the moderate-risk patients had IAIs. Among moderate-risk patients with and without IAIs, those with IAIs were more likely to have abdominal abrasions (5/22 vs 34/459, p = 0.008), an abnormal chest examination (11/22 vs 86/457, p = 0.01), higher mean serum concentrations of aspartate aminotransferase (AST) (604 U/L vs 77 U/L, p < 0.001) and alanine aminotransferase (ALT) (276 U/L vs 39 U/L, p = 0.002), higher mean white blood cell (WBC) counts (16.3 K/mm3 vs 12.8 K/mm3, p < 0.001), and a higher prevalence of >5 RBCs/hpf on urinalysis (7/22 vs 54/427, p = 0.02). There was no significant difference (p > 0.05) between moderate-risk patients with and without IAIs in initial serum concentrations of amylase, initial hematocrit, drop in hematocrit >5 percentage points in the ED, or initial serum bicarbonate concentrations. CONCLUSION: In children hospitalized for blunt torso trauma who are at moderate risk for IAI, ED findings of abdominal abrasions, an abnormal chest examination, and microscopic hematuria as well as elevated levels of AST and ALT, and elevated WBC count are associated with IAI.     

Chronic post-traumatic neck and head pain

OBJECTIVE: This is a review of current concepts of chronic post-traumatic neck and head pain. In this article, I will emphasize the physiological and sociological aspects of these disorders. BACKGROUND: The pathophysiology of chronic post-traumatic neck and head pain has not been well understood. Some have emphasized the organic factors and others the psychogenic aspects of these conditions. Only in recent years have this dichotomy been integrated with sociocultural concepts. METHODS: The history of chronic post-traumatic head and neck pain is reviewed. Paradoxes are discussed, ie, the great differences in prevalence around the world, the inconsistent relationship of symptoms to degree of trauma, the curious phenomena of structural disease without symptoms, and symptoms without structural disease. The organic and pathophysiologic factors are reviewed, then those factors that modulate pain in these conditions are discussed. CONCLUSION: Chronic post-traumatic neck and head pain is rarely either organic or psychogenic. Rather physiological, social, and cultural factors play major roles in modulating pain and either perpetuate or ameliorate these chronic pain conditions.     

Myocardial contusion in blunt chest trauma: A ten-year review

A retrospective review was undertaken of 169 patients admitted to an Intensive Therapy Unit with a major chest injury to determine the incidence, clinical features and outcome of patients with myocardial contusion. This injury occurred in 29 (17%) patients, of whom 24 (83%) had significant cardiovascular complications and five died as a direct result of the injury. The interval between injury and diagnosis was 3.2±2.3 days (mean±SD) from injury and in six patients the diagnosis was made only at necropsy. Increased awarenness of myocardial contusion is required for earlier diagnosis and prevention of complications.     

预制破片致兔胸部爆炸伤的实验研究

目的：研究预制破片铝制雷管致兔胸部爆炸伤的伤情特点及规律，为制定胸部爆炸伤的救治原则提供实验依据。方法：用电启动方式引爆预制破片铝制雷管，将32只家兔置于距雷管5，8，10，12，15cm处，致伤前后常规观察生命体征及破片，冲击波对胸壁，肺脏和周围组织脏器的损伤情况，结果：伤后即刻死亡率为46．9％，各组死亡率有明显差异，冲击波主要靶器官为肺脏，破片伤发生率为62．5％，以盲管伤为主，常合并肋骨折及肋间血管损伤，心肌挫伤，肝脾，胃肠破裂。结论：胸部爆炸伤伤情复杂，死亡率高，伤后易致以肺功能衰竭（ARDS）为主的多脏器功能衰竭，破片伤致失血性休克和冲击伤致急性肺功能损伤是伤后早期死亡的主要原因。     

不同时相下颌面部破片+冲击波复合伤特点研究

目的　研究爆炸破片及冲击波在不同时相下作用于颌面部时的损伤特点并探讨其致伤机制。方法　利用颌面部高速破片 冲击波复合致伤模型模拟爆炸伤 ,由同步系统控制不同致伤时相。按不同时相将重庆当地成年犬 15只随机分为 3组 ,A组为破片先与冲击波到达目标 ,B组为二者同时到达 ,C组为冲击波先于破片到达。破片对犬咬肌区致伤 ,记录致伤参数 ,观察动物伤情特点。结果　在其它致伤条件相同时 ,B组致伤冲击波为双波峰形态。致伤后A组颌面部皮肤与肌肉分离明显 ,污染严重 ,创面最大 ,B组次之 ,C组最小。B组局部组织坏死及挫伤范围均较其它两组明显 ,并有心、肺、脑等脏器的损伤。结论　颌面部爆炸伤伤情严重 ,高速破片与冲击波具有协同致伤作用 ,不同组织对冲击波的反应不同是局部伤情不同的原因     

The Effect of Concussion History on Lower Extremity Injury Risk in College Athletes: A Systematic Review and Meta-Analysis

IntroductionCollegiate athletes who suffer a concussion may possess prolonged impairments even after clearance for return-to-participation, which may place them at an increased risk of lower extremity injury.ObjectiveTo conduct a systematic review and meta-analysis of studies examining risk of lower extremity musculoskeletal injury following a concussion in collegiate athletes.MethodsA literature search was performed using the following databases: PubMed, CINAHL, SPORTDiscus. The following search terms were used to identify relevant articles, [“concussion” OR “brain injury” OR “mild traumatic brain injury” OR “mTBI”] AND [“lower extremity injury” OR “musculoskeletal injury”]. Articles were included if they were published between January 2000 and July 2021 and examined collegiate athletes’ risk of sustaining a lower extremity musculoskeletal injury following a concussion. Methodological quality of included studies was performed with a modified Downs and Black Checklist. The primary outcome of interest was the risk of sustaining a lower extremity musculoskeletal injury following a concussion. A random effects meta-analysis was conducted in which a summative relative risk (RR) for sustaining a lower extremity injury in athletes with and without a history of concussion was calculated.ResultsSeven studies met the eligibility criteria to be included in the systematic review. There were 348 athletes in the concussion group and 482 control athletes in the included studies. Most of the studies were of good or excellent quality. Five of the seven studies were able to be included in the meta-analysis. College athletes who suffered a concussion possessed a 58% greater risk of sustaining a lower extremity musculoskeletal injury than those who did not have a history of a concussion (RR = 1.58[1.30, 1.93]).ConclusionsLower extremity injury risk is potentially increased in college athletes following a concussion compared to those without a history of a concussion. Further research is needed to investigate the mechanism behind this increased risk. Clinical assessments throughout the concussion return-to-play protocol may need to be improved in order to detect lingering impairments caused by concussions.Level of Evidence1