乏脂肪肾血管平滑肌脂肪瘤的CT特征分析（附40例报告）

目的通过分析40例术前诊断为肾癌的乏脂肪肾血管平滑肌脂肪瘤的CT影像学特征,以期提高肾脏肿瘤的诊断准确率,减少过度治疗。方法回顾性分析40例术前影像学诊断为肾癌的乏脂肪血管平滑肌脂肪瘤,评价CT平扫及增强后三期扫描中肿瘤的大小、位置、强化模式、强化程度、是否伴有钙化等。结果肿瘤最大径1.6～7.9（3.48±1.68）cm;38例表现为实性占位,2例表现为囊实性占位（BosniakⅣ型）;1例肿瘤伴有钙化;就强化程度而言,13例表现为轻度强化,18例表现为中度强化,9例表现为明显强化;就强化模式而言,28例表现为延迟强化,12例表现为非延迟强化;10例表现为不均匀强化,30例表现为均匀强化。结论 CT强化程度,强化模式及特殊征象在乏脂肪肾血管平滑肌脂肪瘤的诊断中具有一定价值。     

便携式负压封闭吸引技术治疗压疮创面

目的：探索便携式负压封闭吸引技术治疗压疮创面的效果。方法：2009年9月～2010年9月利用便携式负压吸引瓶,治疗深度压疮创面19例。治疗方法：先将创面清创后,用负压封闭吸引技术覆盖伤口,给以持续创面冲洗,接便携式负压瓶家中持续冲洗引流。结果：本组19例中14例在1周内生长出新鲜的肉芽组织,一次手术修复成功。5例感染较重,负压吸引1周后生长出新鲜肉芽组织,更换泡沫海绵后继续负压吸引、封闭冲洗约7天左右肉芽组织完全覆盖创面,行游离植皮或皮瓣修复一次成活。结论：便携式负压封闭吸引技术治疗压疮创面,方法简便易行,无需医院专业中心负压设备,方便快捷,缩短住院日内待术日期,为患者节约治疗费用,效果可靠,值得临床推广应用。     

负压封闭引流治疗小鼠创面铜绿假单胞菌感染的效果及机制

目的 观察VSD对感染创面中铜绿假单胞菌生长的影响,并探讨其可能机制。 方法 选取健康成年雄性C57BL/6小鼠40只,按照随机数字表法分为对照组和治疗组,每组20只。无菌条件下切除各小鼠背部1 cm×1 cm的全层皮肤,将细菌荧光素酶目的基因luxCDABE标记的野生型铜绿假单胞菌菌株PAO1 -lux涂抹于创面,包扎创面24 h,制成铜绿假单胞菌感染小鼠模型。治疗组小鼠创面行VSD治疗（负压为-16.625 kPa）,对照组创面常规换药。分别于治疗前和治疗24 h时,用小动物活体成像系统检测2组小鼠创面PAO1-lux荧光强度,激光多普勒血流成像仪检测创面血流量,以实时荧光定量RT-PCR检测创缘组织IL-1β、血管内皮生长因子(VEGF)的mRNA表达水平。观察治疗24 h时2组小鼠创缘组织病理学特点。对实验数据行t检验。 结果(1)治疗前,治疗组小鼠创面PAO1 -lux荧光强度与对照组相近(t=0.03,P=0.98);治疗24 h时,治疗组的荧光强度为(2.69±0.75)光子·秒-1·厘米-2·单位角度-1(photons· s-1- cm-2·sr-1),明显低于对照组的(5.18±0.96)photons·s-1·cm-2·sr-1,t =3.54,P=0.02。(2)治疗前,治疗组小鼠创面血流量与对照组相似(t =0.50,P=0.64);治疗24 h时,治疗组创面血流量为(96±9)灌注单位,明显高于对照组的(70±11)灌注单位,t=3.13,P=0.04。(3)治疗前,2组小鼠创缘皮肤组织中IL-1β、VEGF mRNA表达水平接近（t=0.19,P=0.86;t=0.07,P=0.95）;治疗24h时,治疗组IL-1β、VEGF mRNA表达水平分别为4.72±0.37、2.68±0.39,均明显高于对照组的2.24±0.50、1.22±0.13,t值分别为6.90、6.12,P值均为0.00。(4)治疗24 h时,治疗组创缘皮肤组织内炎性细胞浸润数量较对照组增加约77％。 结论 与常规换药相比,VSD治疗在小鼠全层皮肤缺损早期即能明显降低创面铜绿假单胞菌含量。其机制可能与增加创面局部血流量、提高创面组织炎性细胞数量、促进IL-1β和VEGF的mRNA表达有关。     

慢性难愈合创面住院患者回顾性调查

目的 了解慢性难愈合创面形成原因及患者相关情况,为该类创面的治疗、研究提供方向,为国家相关部门制定健康保障策略提供依据.方法收集2008年武汉市第三医院全院共12 161例次住院患者病历资料.以皮肤组织缺损经1个月治疗未愈合为判定标准,筛选出慢性难愈合创面患者病历,回顾性调查患者创面形成原因、性别、年龄、治疗情况、平均住院日.对数据行x2检验和方差分析.结果 12 161例次住院患者中,慢性难愈合创面患者397例次占3.3%.(1)创面的主要形成原因为烧伤占59.9%(238/397)、糖尿病占15.6%(62/397)、压疮占10.8%(43/397),其次为手术、感染、静脉曲张等.各种原因引起慢性难愈合创面患者例次比较,差异有统计学意义(x2=136.21,P=0.001).(2)慢性难愈合创面患者男、女比例为2.0∶1.0;年龄(44±23)岁,高发年龄段为大于或等于70岁,各年龄段创面患者例次比较,差异有统计学意义(x2=24.12,P=0.025).各种原因引起的慢性难愈合创面患者各年龄段例次比较,差异均有统计学意义(x2值为7.86～28.31,P值均小于0.05).(3)分别有60.5%(240/397)和86.4%(343/397)的慢性难愈合创面患者接受了手术与抗生素治疗,所有患者均采用传统敷料治疗.(4)慢性难愈合创面患者平均住院日为(38±27)d,较同期所有住院患者明显延长[(15±7)d,F=22.82,P=0.012].烧伤引起的慢性难愈合创面患者平均住院日[(47±27)d]最长,各种原因引起的慢性难愈合创面患者平均住院日比较,差异有统计学意义(F=24.06,P=0.036).结论烧伤及糖尿病引起的慢性难愈合创面较多,创面患者老龄化明显、住院时间明显长于其他疾病患者.有必要加大转化医学研究力度,促进国家相关政策制定,使慢性难愈合创面得到科学合理的治疗.

Abstract：

Objective To investigate cause of chronic wounds and related status of patients so as to provide strategy for study and treatment of chronic wounds and establish ment of health policy. Methods A total of twelve thousand one hundred and sixty-one cases hospitalized in our hospital in 2008 were enrolled in the study. A chronic wound was defined as skin tissue defect which could not heal after one month of treatment. Medical records were thus screened. Then a retrospective study was performed on patients with chronic wounds with analysis of age, gender, injury cause, therapy, and average length of hospital stay. Data were processed with chi-square test and one-way analysis of variance. Results Investigation showed:397 out of 12 161 cases ( accounting for 3.3% ) were recognized as having chronic wounds. ( 1 ) The main causes for chronic wound were burn, diabetes, and pressure ulcer, accounting for 59.9% (238/397),15.6% (62/397), 10.8% (43/397), respectively. The other causes were operative injury, infection,varicosity, etc. There was statistical difference among the numbers of patients with chronic wounds with regard to various causes of injury (x 2 = 136.21, P = 0. 001 ). (2) Among patients with chronic wound, the patients older than 70 years. There was significant difference in the numbers of patients with chronic wound among different age groups (x2 = 24.12, P =0. 025). There was statistical difference among the numbers of patients with chronic wound in different age groups with each cause of injury ( with x 2 values from 7.86 to 28.31, P values all below 0.05 ). ( 3 ) All patients with chronic wounds received traditional dressing. In 60. 5% (240/397) and 86.4% (343/397) of patients, operative treatment or antibiotics were given. (4)The average length of hospital stay in patients with chronic wound [( 38 ± 27 ) d] was longer as compared with that of all the inpatients in the same period [(15 ± 7) d, F = 22.82, P = 0. 012]. There was obvious difference in the average length of hospital stay among patients with chronic wound caused by different reasons ( F = 24.06, P = 0. 036) , in which burn injury resulted in the longest length of hospital stay [(47 ±27) d]. Conclusions Chronic wounds are mainly caused by diabetes and burn, and characterized by old age and longer length of hospital stay. It is necessary to strengthen translational research and related policy making, so that more rational treatment can be applied for patients with chronic wounds.     

Management of the open abdomen using negative pressure wound therapy with instillation in severe abdominal sepsis: A review of 48 cases in Hospital Mexico,Costa Rica

IntroductionDespite the numerous advances in recent years, severe abdominal sepsis (with associated organ failure associated with infection) remains a serious, life-threatening condition with a high mortality rate. OA is a viable alternative to the previously used scheduled repeat laparotomy or continuous peritoneal lavage. The use of Negative Pressure Wound Therapy (NPWT) has been described as a successful method of management of the open abdomen. Adding instillation of saline solution to NPWT in a programmed and controlled manner, could offer the clinician an additional tool for the management of complex septic abdomen.ObjectivesTo explore if the concept of active two-way therapy (Negative pressure wound therapy with instillation or NPWT-I) yields superior control of underlying, life-threatening abdominal infections and its effects on survival and morbidity in patients with severe abdominal sepsis when management with an open abdomen is required.MethodsA retrospective review of 48 patients with severe abdominal sepsis, who were managed with and open abdomen and NPWT-I was performed. NPWT-I was initiated utilizing the same parameters on all patients, this consisted of cycles of instillation of saline solution, which was removed through negative pressure after a short dwell period. We observed the effects on primary fascia closure rate, mortality, hospital and SICU length of stay and associated complications.ResultsOur patient group consisted of 20 (42%) males and 28 (58%) females. Average age was 48 years. Mortality in these patients was attributed to pulmonary embolism (n = 1), acute renal failure (n = 2) and cardiopulmonary arrest (n = 1). Average total hospital stay was 24 days, and stay in the SICU (n = 26) averaged 7.5 days.No acute complications related to the NPWT-I. All patients presenting with abdominal compartment syndrome resolved after initiation of the NPWT-I. A total of 46 patients (96%) patients achieved fascia closure after NPWT-I therapy after an average of 6 days. Four patients (8%) died during the course of treatment of causes unrelated to NPWT-I.ConclusionThis therapy showed added benefits when compared to traditional methods such as ̈Bogota bag̈, Wittmann patch, or NPWT traditional in the management of the open abdomen pertaining to severe abdominal sepsis.NPWT-I in patients with severe abdominal sepsis had promising results, since we obtained higher fascia closure rates, lower mortality and reduced hospital and ICU length of stay with no complications due to this therapeutic approach.     

不同肌松程度对脊柱手术皮层体感诱发电位的监测

目的：了解新型肌肉松弛药顺式阿曲库铵用于脊柱外科手术,肌松程度对皮层体感诱发电位（CSEP）监测的影响。方法：选择ASAI～II级,择期脊柱外科手术病人60例,随机分为6组。在首次推注插管剂量的顺式阿曲库铵后,连续监测T1,以肌松监测反馈调控输注模式调整不同剂量进行输注,维持各分组所要求的不同肌松程度,观察6组病例术中CSEP的P40波的波幅及潜伏期。同时对肌松分级进行主观评定。结果：在不同的肌松程度下,IV组、V组及VI组患者的波幅与基准值比较有统计学差异（P〈0.05）;I组、II组、III组患者的波幅与基准值比较无统计学差异（P〉0.05）。肌松主观评定,V组、VI组患者肌松评价差的例数与I组、II组、III组、IV组比较有统计学差义（P〈0.05）。结论：能满足CSEP监测的要求,同时也能满足手术及运动诱发电位监测需要的肌松程度是T1值在0～15%。     

Negative pressure wound therapy using gauze and foam: histological, immunohistochemical and ultrasonography morphological analysis of the granulation tissue and scar tissue. Preliminary report of a clinical study

Negative pressure wound therapy (NPWT) is becoming routine for the preparation of wounds prior to grafting for wound closure. We have been using both foam- and gauze-based NPWT to prepare wounds for closure prior to skin grafting and have obtained similar proportions of closed wounds; 7/7 for wounds treated with gauze-based NPWT and 11/11 for wounds treated with foam-based NPWT. In our follow-up consultations we observed that skin grafts on the foam-treated patients were less pliable than those on the gauze-treated patients. To assess what the mechanism of this effect might be, we compared the specific details of the treatments of both 11 foam and 7 gauze patients, including depth, location, patients' age and co-morbidity; biopsies of granulation and scar tissue were taken and stained with haematoxylin-eosin and by Masson's trichrome staining and conducted ultrasound analysis of the closed wounds, to see if there were features which explained those effects. All foam patients were treated at -125 mm Hg for an average of 25·9 days before skin grafts were applied. All gauze patients were treated at -80 mm Hg for an average of 24·7 days before skin grafts were applied. Biopsies of granulation tissue prior to skin grafting from five foam and four gauze-based NPWT patients did not reveal any obvious histological differences between the treatments. Ultrasound analysis of the skin-grafted wounds showed an average depth of scar tissue of 18 mm in the wound beds of the foam-treated wounds and 7 mm in the gauze-treated ones. Biopsies taken on the scar tissue after treatment with the gauze showed a minor tissue thickness and disorganisation and less sclerotic components. The findings of this preliminary analysis suggest that foam-based NPWT may induce a thicker layer of scar tissue beneath skin grafts than gauze-based NPWT which might explain a reduced pliability of the reconstructed bed. At present it is unclear which mechanism might be responsible for the difference in pressure (-125 versus -80 mm Hg), either the length of the time taken to reconstruct the wound bed or the intrinsic nature of the foam or gauze on the tissue surface. Prospective studies are necessary to investigate whether these preliminary observations are confirmed and to investigate what the mechanism might be.     

MEBO治疗烧伤后感染创面的体会

通过MEBO对烧伤感染创面的治疗,显示了MEBO在止痛、抗感染、清除异物、滋润创面、祛腐生肌、缩短疗程,减少植皮面积等方面的特点与优势,说明MEBT在烧伤感染治疗中优于传统的疗法。     

Is post-sternotomy percutaneous dilatational tracheostomy a predictor for sternal wound infections?

OBJECTIVE: Early post-sternotomy tracheostomy is not infrequently considered in this era of percutaneous tracheostomy. There is, however, some controversy about its association with sternal wound infections. METHODS: Consecutive patients who had percutaneous tracheostomy following median sternotomy for cardiac operation at our institution from March 1998 through January 2007 were studied, and compared to contemporaneous patients. We identified risk factors for tracheostomy, and investigated the association between percutaneous tracheostomy and deep sternal wound infection (mediastinitis) by multivariate analysis. RESULTS: Of 7002 patients, 100 (1.4%) had percutaneous tracheostomy. The procedure-specific rates were: 8.6% for aortic surgery, 2.7% for mitral valve repair/replacement (MVR), 1.1% for aortic valve replacement (AVR), and 0.9% for coronary artery bypass grafting (CABG). Tracheostomy patients differed vastly from other patients on account of older age, severe symptoms, preoperative support, lower ejection fraction, more comorbidities, more non-elective and complex operations and higher EuroScore. Risk factors for tracheostomy were New York Heart Association class III/IV (OR 6.01, 95% CI 2.28-16.23, p<0.0001), chronic obstructive pulmonary disease (OR 1.84, 95% CI 1.01-3.37, p=0.05), preoperative renal failure (OR 3.57, 95% CI 1.41-9.01, p=0.007), prior stroke (OR 3.08, 95% CI 1.75-5.42, p<0.0001), ejection fraction<0.30% (OR 2.73, 95% CI 1.23-6.07, p=0.01), and bypass time (OR 1.008, 95% CI 1.004-1.012, p<0.0001). The incidences of deep (9% vs 0.7%, p<0.0001) and superficial sternal infections (31% vs 6.5%, p<0.0001) were significantly higher among tracheostomy patients. Multivariate analysis identified percutaneous tracheostomy as a predictor for deep sternal wound infection (OR 3.22, 95% CI 1.14-9.31, p<0.0001). CONCLUSIONS: Tracheostomy, often performed in high-risk patients, may further complicate recovery with sternal wound infections, including mediastinitis, therefore, patients and timing should be carefully selected for post-sternotomy tracheostomy.     

小鼠全层皮肤创伤愈合过程中基质细胞衍生因子-1及其受体CXCR4基因表达的研究

目的：研究小鼠全层皮肤创伤愈合过程中创面基质细胞衍生因子-1（stroma-cell derived factor-1,SDF-1）及其受体CXCR4的基因表达情况。方法：建立小鼠背部皮肤正中近颈侧1.5cm×1.5cm的正方形皮肤全层缺损模型,分别于伤后1、2、3、4、5、7、10和14d获取创缘组织,应用半定量逆转录-聚合酶链反应检测损伤后各时间点创面SDF-1及CXCR4的mRNA表达,并观察组织病理学变化。结果：伤后1～3d创面有大量炎症细胞浸润,4d时有肉芽组织形成,5d可见上皮细胞覆盖创面,7d时创面周围明显上皮化,14d创面基本完全愈合。SDF-1及CXCR4在创面愈合过程均呈双峰表达,SDF-1基因表达于伤后1d明显增高（P〈0.01）,随后下降,于伤后3d达最低,随后再次升高,于伤后5d达峰值（P〈0.01）,然后下降,14d时接近伤前值。CXCR4基因表达于伤后1d升高,然后继续升高,至伤后5d达峰值,随后下降,于伤后10d表达最少（P〈0.01）,伤后14d表达再次增加（P〈0.01）。结论：SDF-1/CXCR4轴参与了创伤愈合的炎症反应期和增殖期的愈合过程,在皮肤组织创伤愈合过程中起着重要作用。