Fetal stroke and cerebrovascular disease: Advances in understanding from lenticulostriate and venous imaging,alloimmune thrombocytopaenia and monochorionic twins

Fetal stroke is an important cause of cerebral palsy but is difficult to diagnose unless imaging is undertaken in pregnancies at risk because of known maternal or fetal disorders. Fetal ultrasound or magnetic resonance imaging may show haemorrhage or ischaemic lesions including multicystic encephalomalacia and focal porencephaly. Serial imaging has shown the development of malformations including schizencephaly and polymicrogyra after ischaemic and haemorrhagic stroke. Recognised causes of haemorrhagic fetal stroke include alloimmune and autoimmune thrombocytopaenia, maternal and fetal clotting disorders and trauma but these are relatively rare. It is likely that a significant proportion of periventricular and intraventricular haemorrhages are of venous origin. Recent evidence highlights the importance of arterial endothelial dysfunction, rather than thrombocytopaenia, in the intraparenchymal haemorrhage of alloimmune thrombocytopaenia. In the context of placental anastomoses, monochorionic diamniotic twins are at risk of twin twin transfusion syndrome (TTTS), or partial forms including Twin Oligohydramnios Polyhydramnios Sequence (TOPS), differences in estimated weight (selective Intrauterine growth Retardation; sIUGR), or in fetal haemoglobin (Twin Anaemia Polycythaemia Sequence; TAPS). There is a very wide range of ischaemic and haemorrhagic injury in a focal as well as a global distribution. Acute twin twin transfusion may account for intraventricular haemorrhage in recipients and periventricular leukomalacia in donors but there are additional risk factors for focal embolism and cerebrovascular disease. The recipient has circulatory overload, with effects on systemic and pulmonary circulations which probably lead to systemic and pulmonary hypertension and even right ventricular outflow tract obstruction as well as the polycythaemia which is a risk factor for thrombosis and vasculopathy. The donor is hypovolaemic and has a reticulocytosis in response to the anaemia while maternal hypertension and diabetes may influence stroke risk. Understanding of the mechanisms, including the role of vasculopathy, in well studied conditions such as alloimmune thrombocytopaenia and monochorionic diamniotic twinning may lead to reduction of the burden of antenatally sustained cerebral palsy.     

创伤性膈肌破裂的早期诊断和外科治疗

目的 :　总结创伤性膈肌破裂 (TDR)的早期诊断和外科治疗的临床经验 ,探讨早期明确诊断对病情转归的影响。　方法 :回顾性分析 1983年 1月至 2 0 0 3年 1月该院收治的 2 8例TDR患者的临床资料 ,对其发病原因、部位、合并伤及损伤严重程度评分、诊断经过及手术途径等分别进行分析。　结果 :2 8例患者均经外科手术治疗后痊愈出院。与早期诊断组相比 ,延迟诊断组的术后并发症发生率较高 ,平均住院时间显著延长 (P <0 .0 1)。　结论 :早期诊断和积极治疗合并伤是救治TDR的关键。     

外伤后诊疗失误医疗纠纷探析

患者外伤后因不良医疗因索的介入导致伤情恶化或死亡所引发的医疗纠纷案例在目前较多见。由于这种案例存在不同程度的死因和责任竞争，因而医疗纠纷的发生率和诉讼率高，已成为当前法医学鉴定和医疗事故技术鉴定的重点和难点，也是法院审判和调解的难点之一。文章对相关案例的诊疗失误原因、责任程度及鉴定进行了简要分析，并提出一些注意事项。     

四肢创伤围术期的脂肪栓塞综合征

目的:论述四肢创伤围术期脂肪栓塞综合征的病因、病理、临床表现及防治。方法:查阅关于四肢创伤围术期脂肪栓塞综合征方面的文献,进行总结。结果:脂肪栓塞综合征在四肢多发骨折中应引起临床医师认识和重视。结论:脂肪栓塞综合征防治的关键是防止应激反应发生、低血容量、组织缺氧、骨折早期固定、髓内钉手术进行减压处理及皮质类固醇的应用。     

儿童多发伤的ICU救治138例

目的总结儿童多发性创伤ICU的救治经验。方法对2005—2010年收治的138例多发伤患儿的伤情、诊断、治疗结果进行回顾性分析,总结多发伤的救治经验。结果本组病例138例患儿115例撤离呼吸机,休克纠正、循环稳定、凝血功能恢复正常、内环境稳定,病情平稳,无明显其它并发症后,转回原科室。死亡23例（16．67％）,死亡原因为脑疝及心脏与大血管损伤,如严重肝、脾、胰损伤、重度失血性休克和MODS等。结论损伤控制策略在ICU成功救治多发伤患儿的生命中起重要作用;严重多发伤患儿经外科处理后应转至ICU综合治疗,在整个抢救过程中,应严密监护,紧急处理休克、创伤、呼吸衰竭等主要问题,同时尽量兼顾全身情况,促进患儿康复。     

骨创伤微环境免疫调控机制的研究进展

创伤诱导免疫细胞在损伤部位浸润,并通过分泌多种细胞因子和炎症介质调节局部损伤的清除和修复.随着创伤免疫学的发展,免疫系统在骨愈合过程中的调节作用得到深入研究.骨折时,非特异性与特异性免疫细胞先后到达骨折区并参与骨折吸收与修复.若骨创伤微环境免疫失调,将导致成骨细胞与破骨细胞间协调作用紊乱,造成骨折延迟愈合或不愈合.因此...     

Wound ballistics is a model of the pathophysiology of all blunt and penetrating trauma

The tissue factors important in wound ballistics provide a useful insight into the pathophysiology of organ injury in all trauma. Wound ballistics includes penetrating and blunt trauma mechanisms. Blunt trauma takes the form of tissue stretch (temporary cavitation). The varied ability of different types of tissue to tolerate the physical displacement of tissue stretch in gunshot wounds, and the inability of any tissue to survive being crushed by a bullet, is a model for the relative abilities of different tissues to tolerate blunt trauma and penetrating trauma of all types. As in gunshot wounds, the extent of tissue injury from any type of trauma is directly related to both the characteristics of the tissue injured and the mechanism of injury. Penetrating trauma can be a feature of blunt trauma (and vice versa), such as when a rib fracture fragment is displaced into the spleen, lacerating it. Although the mechanism of a traumatic event may be pure blunt or penetrating trauma, the mechanism of tissue injury may be mixed.     

颈部血管损伤的诊断与救治(附23例报告)

目的分析颈部血管损伤的诊断和治疗特点,提高治疗成功率,降低死亡率。方法通过回顾性总结我院8年来颈部血管损伤23例的诊治经过,总结出颈部血管损伤的现场急救要点和临床诊治的特征。结果本组23例中18例痊愈,2例死亡,3例有程度不等的后遗症。结论现场急救要及时,诊断要正确。不同类型的颈部血管损伤要采取不同的治疗方法。     

严重创伤后氧对T细胞功能的影响

目的 探讨严重创伤后病人T淋巴细胞转化活性及CD4 T、CD8 T细胞活性变化,CTLA-4分子水平在严重创伤转归、干预治疗等方面的意义.方法 将133例病人分为创伤对照组46例、高流量吸氧组44例、高压氧组43例,创伤对照组患者入院后给予常规治疗;高流量吸氧组患者辅以5 L/min,120 min/d吸氧治疗;高压氧组患者辅以高压氧治疗(压力2 ATA,60 min/d).于3、7 d时间点,对各组分别进行T淋巴细胞转化活性、T淋巴细胞亚群及CTLA-4分子水平的测定.结果 与创伤对照组比较,高流量吸氧组和高压氧组患者的T淋巴细胞转化活性增高,CD4 T细胞数明显增多(P＜0.01),CD4 /CD8 细胞比值明显增加(P＜0.01),T细胞表面和总CTLA-4分子表达明显降低(P＜0.01);与高流量吸氧组相比,高压氧组患者的T淋巴细胞转化活性增高,CD4 T细胞数明显增多(P＜0.05),CD4 /CD8 细胞比值明显增加(P＜0.01),T细胞表面和总CTLA-4分子表达降低(P＜0.05).结论 氧能够明显提高T淋巴细胞转化活性,使CD4 T细胞增多,CD4 /CD8 细胞比值明显增加,并且明显降低T细胞表面和总CTLA-4分子的表达.     

长途转诊161例ICU严重创伤患者临床分析

目的分析长途转诊入ICU创伤患者的临床特点,探讨严重创伤患者的救治对策。方法回顾性分析161例长途转诊入ICU的创伤患者入住ICU的原因、院前是否手术、入ICU时是否休克、是否建立人工气道、是否呼吸停止、是否建立中心静脉、转诊途中是否抢救、入院后是否手术、治疗后是否死亡等临床资料。并且对颅脑外伤中脑血肿类型转诊前是否手术以及是否休克进行分组分析。结果转诊的创伤患者以致命部位分类病例构成依次为重型颅脑外伤、严重腹部外伤、胸部外伤、四肢外伤、大面积烧伤。死亡病例的构成依次为重型颅脑外伤、大面积烧伤、腹部外伤、胸部外伤。有手术指征的颅内血肿患者转诊前手术组与未手术组、入ICU时休克组与非休克组死亡率存在显著差异。结论有手术指征的重型颅脑外伤患者、创伤后出现任何的休克患者均不适合长途转诊。主张建立社会急诊医疗服务体,制定高级创伤生命支持计划,建立上下级医院创伤救治联动及远程会诊机制,就近抢救严重创伤患者。