动脉化静脉皮瓣移植术后临床表现分型及其护理对策

目的：对动脉化静脉皮瓣移植术后的不同临床表现进行分型,以便采取针对性护理干预,改善其成活状况,提高皮瓣成活率。方法：收集2010年6月至2019年3月温州医科大学附属第二医院采用动脉化静脉皮瓣游离移植修复的所有临床病例资料,根据其术后皮瓣颜色、皮瓣张力、肿胀程度、水泡形成以及淤血等情况,采用个体化护理干预措施,以皮瓣最终成活状况作为最主要的观察评价指标,进行系统总结分析。结果：共收集64例,68个动脉化静脉皮瓣,根据其术后表现情况分为正常生理皮瓣型（NPF型,25例,27个）、水泡形成型（BF型,18例,18个）和淤血肿胀型（CS型,21例,23个）。其中,NPF型皮瓣全部成活,BF型皮瓣仅1个部分坏死,CS型皮瓣虽经积极保守治疗,有1个完全坏死和2个部分坏死。结论：动脉化静脉皮瓣移植术后临床表现差异较大,需根据不同的临床分型,加强护理观察,采取针对性术后护理干预措施,以提高其整体成活状况。     

BI-RADS分类联合超微血管成像技术在乳腺实性结节鉴别诊断中的价值

目的 探讨数据系统分类标准（BI-RADS）联合超微血管成像（SMI）技术在乳腺实性结节鉴别诊断中的应用效果。方法 回顾性分析2018 年7 月～2019 年8 月收治的94 例乳腺结节患者临床资料。所有患者均行常规超声和SMI 检查,根据二维超声结果予以BI-RADS 分类,并经手术或穿刺病理活检。评估BI-RADS 分类、SMI 技术单独及联合诊断乳腺实性结节的诊断结果,计算诊断效能（准确度、敏感度、特异度、阳性及阴性预测值）,绘制ROC曲线比较不同诊断方法效能。结果 ①SMI 诊断乳腺结节良恶性灵敏度、阴性预测值高于BI-RADS 分类,特异度、准确率、阳性预测值低于BI-RADS 分类,联合检测灵敏度、特异度、准确率、阳性预测值、阴性预测值均高于BI-RADS 分类及SMI 单独诊断;②联合检查诊断曲线下面积（AUC）高于BI-RADS 分类和SMI,SMI 诊断AUC 高于BI-RADS 分类（P＜0.05）。结论BI-RADS 分类联合SMI 技术在乳腺实性结节鉴别诊断中效能较高,临床应用前景可观。     

老年肾病综合征临床和病理分析

目的 :了解老年肾病综合征的临床表现和病理特点。方法 :对我院住院的 34例老年肾病综合征病人进行临床表现和病理类型分析。结果 :34例老年性肾病综合征 ,原发病为原发性肾小球肾炎者 2 3例 ,占 6 7.6 %,糖尿病肾病 6例 ,占 17.6 %。临床表现以浮肿、血尿为主 ,贫血的发生率为 35 .3%,慢性肾衰竭为 17.6 %。肾活检发现 ,原发性肾病综合征中膜性肾病最常见。老年肾病综合征病人用激素或激素加免疫抑制剂治疗的缓解率为 5 2 .9%,有效率为 2 6 .5 %,未缓解率为 2 0 .6 %。合并感染者占 14.7%。结论 :在肾病综合征中老年人所占比例并不高 ,其临床表现与年轻人的肾病综合征相似 ,但合并贫血、慢性肾衰竭 (CRF)和感染的比例较高 ,最常见的病因是慢性肾小球肾炎 ,其病理类型以膜性肾病 (MN)最常见。老年肾病综合征患者对激素或激素加免疫抑制剂治疗的反应尚可。     

Late-Onset Radial Nerve Palsy Associated with Conservatively Managed Humeral Fracture. A Case Report and Suggested Classification System

Radial nerve palsy can occur with humerus fracture, either at the time of injury (primary) or during reduction (secondary). Late-onset radial nerve palsy (not immediately related to injury or reduction) has been very seldom reported in the English literature. We describe a case of late-onset radial nerve palsy, which developed 9 weeks after an attempted closed management of a midshaft humerus fracture. Exploration of the nerve was performed. The radial nerve was found to be stretched over the ends of the fracture. Open reduction and external fixation of the fracture with mobilization of the nerve from the fracture site lead to complete return of radial nerve function occurring by 3 months. We recommend exploration of cases of late-onset radial nerve palsy in contrast to primary or secondary radial nerve palsy, which can be treated conservatively. Our experience suggests that the cause of the palsy is a continuous ongoing pathology and not a single time event as in primary or secondary cases. Radial nerve palsies associated with humeral fracture should be classified as either primary (at the time of injury), secondary (at the time of reduction), or late onset (not related to either injury or reduction).     

Percutaneous endoscopic lumbar discectomy for migrated disc herniation: classification of disc migration and surgical approaches

Percutaneous endoscopic lumbar discectomy (PELD) for migrated disc herniations is technically demanding due to the absence of the technical guideline. The purposes of this study were to propose a radiologic classification of disc migration and surgical approaches of PELD according to the classification. A prospective study of 116 consecutive patients undergoing single-level PELD was conducted. According to preoperative MRI findings, disc migration was classified into four zones based on the direction and distance from the disc space: zone 1 (far up), zone 2 (near up), zone 3 (near down), zone 4 (far down). Two surgical approaches were used according to this classification. Near-migrated discs were treated with "half-and-half" technique, which involved positioning a beveled working sheath across the disc space to the epidural space. Far-migrated discs were treated with "epiduroscopic" technique, which involved introducing the endoscope into the epidural space completely. The mean follow-up period was 14.5 (range 9-20) months. According to the Macnab criteria, satisfactory results were as follows: 91.6% (98/107) in the down-migrated discs; 88.9% (8/9) in the up-migrated discs; 97.4% (76/78) in the near-migrated discs; and 78.9% (30/38) in the far-migrated discs. The mean VAS score decreased from 7.5 +/- 1.7 preoperatively to 2.6 +/- 1.8 at the final follow-up (P < 0.0001). There were no recurrence and no approach-related complications during the follow-up period. The proposed classification and approaches will provide appropriate surgical guideline of PELD for migrated disc herniation. Based on our results, open surgery should be considered for far-migrated disc herniations.     

Colorado 2~(TM)骶髂板治疗Tile C型骨盆骨折中骶髂关节骨折脱位的临床研究

目的探讨Colorado 2TM骶髂板在治疗Tile C型骨盆骨折中对骶髂关节骨折脱位稳定性重建的作用。方法 2009年2月-2011年1月,收治8例Tile C型骨盆骨折患者。男3例,女5例;年龄22～52岁,平均34.4岁。交通事故伤3例,高处坠落伤3例,重物挤压伤2例。按照Tile分型,C1-2型5例,C1-3型2例,C2型1例。受伤至手术时间5～10 d,平均7 d。经股骨髁上牵引,使骶髂关节骨折脱位复位后,采用Colorado 2TM骶髂板固定骶髂关节,选择性加用骨盆前环重建钢板或外固定支架固定。结果术后X线片复查示骶髂关节垂直和旋转移位均获满意复位,骶髂关节得到有效固定,骨盆后环获得即刻稳定性。术后切口均Ⅰ期愈合,未发生血管、神经损伤等严重并发症。8例均获随访,随访时间6～24个月,平均12个月。骶髂关节无再移位,螺钉无松动。骨折愈合时间6～12个月,平均9个月。末次随访时采用Majeed功能评价标准,获优5例,良2例,一般1例。结论 Colorado 2TM骶髂板固定可使骨盆后环获得有效的即刻稳定性并维持至骨折愈合,是治疗Tile C型骨盆骨折中骶髂关节骨折脱位的有效方法之一。     

Implantable ventricular assist device exchange with focused intravascular deairing techniques

As ventricular assist devices are increasingly adopted and widely implemented as a highly effective therapy for end-stage heart disease, extended utilization periods for destination therapy or bridge-to-transplantation have created the possibility of device failure, infection, or thrombosis, requiring challenging implant exchanges. A major problem in these operations is the risk of air embolization, particularly in a nonsternotomy approach that precludes access to the outflow aortic graft and to the ascending aorta. We report a minimally invasive, nonsternotomy HeartMate II implantable left ventricular assist device (LVAD) exchange, using peripheral cardiopulmonary support and a novel approach to continuous intravascular ascending aortic air removal.     

Primary complete repair of partial double aortic arch and Kommerell diverticulum

Tracheal and esophageal stenosis caused by double aortic arch and Kommerell diverticulum is a rare but important pathologic entity in adult patients. Clinical symptoms are caused by esophageal or tracheal stenosis, or both. The present article describes a surgical method of complete repair with division of the rudimentary left arch, resection of the diverticulum, and transposition of the left subclavian artery. This method was transferred from pediatric patients and led to excellent clinical results in 2 consecutive adult patients compared with the previous technique with division of the left arch alone.