目的:探讨腰痹通胶囊联合阿仑膦酸钠片对骨质疏松症(OP)患者临床疗效及对骨代谢和细胞因子影响.方法:采用随机数字表法,将本院于2018年1月—2020年1月OP患者106例分为联合组与对照组各53例.对照组患者给予阿仑膦酸钠片口服,10 mg/次,1次/d;联合组在对照组基础上加用腰痹通胶囊,3粒/次,3次/d.两组治疗疗程24周.比较两组治疗24周总有效率,治疗前与治疗24周患者股骨颈和L2-4腰椎骨密度(BMD)、骨代谢[Ⅰ型胶原羧基端肽β特殊序列(β-CTX)、Ⅰ型原胶原N-端前肽(P1NP)和骨钙素(BGP)]和细胞因子[白介素-6(IL-6)、胰岛素生长因子-1(IGF-1)和肿瘤坏死因子-α(TNF-α)]变化.结果:联合组和对照组总有效率分别为94.34％和73.58％,差异有统计学意义(P<0.05).联合组OP患者治疗后股骨颈和L2-4腰椎BMD高于对照组(P<0.05).联合组OP患者治疗后血清β-CTX和P1NP水平低于对照组,而BGP水平高于对照组(P<0.05).联合组OP患者治疗后血清IL-6、IGF-1和TNF-α水平低于对照组(P<0.05).结论:腰痹通胶囊联合阿仑膦酸钠片对OP患者临床疗效明显,且可改善患者骨代谢,及减轻细胞炎性反应.

Objective To design and conduct objective structured clinical examination (OSCE) in professional postgraduates in obstetrics and gynecology, and to investigate the improvement measures for the teaching of professional postgraduates in obstetrics and gynecology by analyzing the performance of postgraduates in OSCE. Methods In October 2017, OSCE was performed for postgraduates in obstetrics and gynecology in the classes of 2016 and 2017 to evaluate their clinical ability. This OSCE consisted of the following four aspects: inquiry of standardized patients, basic practical skills in obstetrics and gynecology, utilization and interpretation of auxiliary examinations, and case analysis. The postgraduates were scored according to the following six items: doctor-patient communication skills, completeness of inquiry, basic practical skills in obstetrics and gynecology, utilization of auxiliary examinations, competence of clinical thinking, and mastery of medical knowledge. SPSS 18.0 was used for statistical analysis, and the t-test was used for comparison between groups . Results A total of 27 postgraduates participated in this OSCE . Among the six scoring items, completeness of inquiry had the lowest score (78 ±6), and utilization of auxiliary examinations had the highest score (85±3). Among the 27 postgraduates, 7 (25.9％) lacked doctor-patient communication skills, 6 (22.2％) showed serious problems in basic practical skills in obstetrics and gynecology, and 6 (22.2％) lacked the scientific thinking of clinical diagnosis. Conclusion In the training of professional postgraduate students in obstetrics and gynecology, doctor-patient communication skills and clinical thinking should be emphasized, and basic clinical skill training should be strengthened.

临床住院医师规范化培训(以下简称住培)作为毕业后医学教育的一个重要组成部分,是医院培养高素质医学人才的一条重要渠道.目前,妇产科住培临床教学中存在以下问题:医患关系紧张,实践机会难求;理论知识抽象,难以结合实践;重心偏重临床,科研能力欠缺.将多元化教学方法运用于妇产科住培临床教学中,能够帮助学员培养系统的临床思维,提高其临床技能水平,使其能够迅速适应并胜任临床工作.

近年来,随着经济水平的不断发展,交通运输业和建筑业发展迅速,随之而来的交通事故和高处坠落事故也频频发生,因此外伤性下颈椎骨折脱位的发生率也不断升高 [1].外伤性下颈椎骨折脱位的治疗方式主要是手术治疗,效果较好,但对于手术入路方式的选择仍有争议.现对我院收治的 180例外伤性下颈椎骨折脱位患者临床资料进行回顾性分析,对不同手术入路方式效果进行比较,报道如下.

妇产科住院医师规范化培训是培养妇产科专业医师的重要途径.由于目前的医疗环境及妇产科的特殊性,住院医师临床实践的机会减少.医学模拟教育具有可重复性、无风险的特点,弥补了医学教育资源相对缺乏的不足.我们将医学模拟教育如模型模拟、虚拟病人软件、虚拟病人及标准化病人等应用于妇产科住院医师分层次规范化培训中,针对不同基础的住院医师,因材施教,进行分层次的且具有针对性的能力训练,提高了妇产科规范化培训住院医师的临床技能、临床思维、团队协作能力及人文素质.医学模拟教育的充分灵活运用为高质量完成妇产科住院医师规范化培训提供了有力保障.

金属离子沉积症是全髋关节置换术(total hip arthro-plasty, THA)术后严重的并发症,源于金属与金属异常接触,产生金属磨损颗粒在髋关节周围聚集、浸染,触发炎症细胞释放细胞因子,加剧金属腐蚀,导致骨溶解、假体松动、软组织纤维化和坏死[1].随着髋关节假体材料工艺和摩擦界面的研究进展,特别是高交联聚乙烯、陶瓷假体的广泛应用,极大地减少了金属离子沉积症的发生率[2].

目的探讨经后侧入路手术治疗胫骨平台后髁骨折手术方法的临床疗效。方法回顾性分析并选取采用后内侧入路、后外侧入路及后内侧、后外侧双切口联合入路切开复位内固定治疗的胫骨平台单纯后髁骨折患者15例。部分有关节面塌陷的病例骨刀撬拨复位后用同种异体骨填充植骨,术中使用"T"型或"L"型支撑钛板内固定。结果 15例均获随访,随访时间9～26个月,平均13.5个月。术后1个月膝关节屈伸70～100°,平均75°;术后3个月膝关节屈伸70～115°,平均86.2°;术后9个月膝关节屈伸100～125°,平均108.6°。术后12个月膝关节HSS评分85～92分,平均90.5分。无一例发生术区皮瓣坏死、感染或内固定失效。结论采用后外侧或后内侧入路或双切口入路可充分暴露胫骨后平台后髁,减少软组织损伤,有利于骨折的复位内固定及膝关节早期康复训练。

Objective To explore the effect of pedicel screw or screw-rod fixation in lateral mass through posterior approach in the treatment of traumatic unstable type Ⅱ odontoid fracture. Methods 20 patients with traumatic unstable type Ⅱ odontoid fracture were treated with pedicel screw or screw-rod fixation in lateral mass through posterior approach. Results All cervical symptoms disappeared after operation and the neurological function of cervical spinal cord were significantly improved. 20 patients were followed up for 3 ~ 55( 11 ± 3. 1) months. The sequence of recovered cervical vertebras were stable in all patients,without looseness,crack of interior fixation or displacement of grafting bone; fracture healing was well and grafting bone was gradually fused. Conclusions The effect of pedicle screw or screw-rod fixation in lateral mass through posterior approach in the treatment of traumatic unstable type Ⅱ odontoid fracture is well.

目的 探讨颈后路椎弓根钉技术治疗寰枢椎创伤性失稳临床效果及操作技巧.方法 对17例创伤性寰枢椎失稳患者行颈后路椎弓根钉.棒复位固定、椎板后弓植骨.结果 随访3 ～43(9 ±3.1)个月,未发生并发症,复位良好,序列稳定；无内固定松动、断裂、植骨块移位；骨折愈合好,植骨渐进融合.术后颈部症状完全消失,受损颈髓神经功能明显改善.结论 经寰枢椎椎弓根钉内固定是治疗寰枢椎创伤性失稳的一种安全有效的方法.

Objective To explore the therapeutic effect on treatment of traumatic instability of cervical vertebra by pedicel screw through posterior approach or screw-rod fixation in lateral mass.Methods 30 patients of traumatic cervical vertebra instability were treated with grafting in cervical spinal lamina or between small joints by posterior transpedicular screw through posterior approach or screw-rod fixation in lateral mass.Results All cervical symptoms disappeared after operation and the damaged neurological function of cervical spinal cord were significantly improved.No complication was found in the follow up visits for 3~52(10±3.2) months.The recovered cervical vertebra of all patients was of well fused and stable without looseness,fracture of interior fixation or displacement of grafting bone;the fracture was well healing and grafting bone was gradually fused with flexion range of extensible 105°±10.5°,lateral 80°±7.2°,and axial rotation 96°±9.3°.Conclusions The treatment of the traumatic cervical vertebra by posterior transpedicular screw through posterior approach or screw-rod fixation in lateral mass reveals good reconstructed stability.

Objective To evaluate the effect of external fixator on the treatment of comminuted distal radius fracture.Methods A retrospective study was conducted in 21 patients who had been treated with external fixator.Wrist movement range and radiographic index were measured and wrist function was evaluated by the Gartland-Werley criteria 1-3 years after the operation.Results There was no significant difference in the movement range of pronation,supination and radial deviation,and no significant difference in the radial height and ulnar inclination between the treated wrist joint and the normal hand(P0.05).Nevertheless,the recovery of the wrist flexion,extension,ulnar deviation and volar tilt angle was limited,significantly smaller than the normal(P0.05).By the Gartland-Werley criteria,the excellence rate was 85.7%.Conclusion The external fixator is an effective way to treat comminuted distal radius fracture.

目的 探讨带肌腱的尺动脉腕上皮支游离皮瓣修复手指复合组织缺损的临床疗效.方法 2007年3月-2009年9月,采用带尺侧腕屈肌腱的尺动脉腕上皮支游离皮瓣修复手指指腹皮肤软组织合并屈肌腱缺损15例.结果 15例皮瓣全部成活,术后随访6～18个月,皮瓣色泽、质地、外形满意,两点分辨觉为8～10 mm.手指屈曲功能按中华医学会手外科分会手部肌腱修复后功能评定标准(TAM 法)评定:优3例,良6例,可4例,差2例.结论 采用带尺侧腕屈肌腱的尺动脉腕上皮支游离皮瓣修复手指指腹皮肤软组织合并屈肌腱缺损是一种理想的术式.

目的:探讨围手术期综合救治对颈椎后路手术并发症的预防作用。方法:对15例颈椎创伤致骨折脱位失稳患者进行围手术期综合救治并实施后路减压、钉棒固定、植骨融合术。结果:随访3～30个月,未发生与手术相关并发症;术后受损脊髓神经功能均不同程度恢复;骨折脱位复位良好,相应颈椎椎体节段稳定,序列良好;内固定无松动、移位、断裂,固定位置好;无植骨块移位,植骨节段有不同程度骨融合。结论:围手术期综合救治对实施颈椎后路手术、恢复颈髓神经功能、防止并发症发生具有重要作用。

目的 总结采用尺动脉腕上皮支皮瓣游离移植修复手指皮肤缺损,并利用其手背尺侧皮支重建手指末梢血运的临床疗效. 方法 2007年5月-2009年5月,收治6例6指中末节指腹皮肤缺损伴末梢血运障碍患者.男4例,女2例;年龄21～56岁,平均31岁.电锯伤4例,其中中指2例,示指1例,环指1例;合并屈肌腱断裂2例.热压伤2例,示、中指各1例.采用尺动脉腕上皮支皮瓣游离移植修复缺损,手背尺侧皮支与远端指动脉吻合重建末梢血运.结果术后6例皮瓣及患指均顺利成活,创面Ⅰ期愈合,无血管危象及感染发生.供区植皮成活,切口Ⅰ期愈合.4例获随访,随访时间6～15个月,平均8个月.皮瓣无明显臃肿及瘢痕挛缩,患指功能恢复正常,远端指体感觉及皮瓣感觉恢复满意,两点辨别觉8～12 mm. 结论 采用带手背尺侧皮支的尺动脉腕上皮支皮瓣既可修复患指皮肤缺损,又可重建末梢血运,疗效满意.

目的总结以足底内侧动脉浅支蒂皮瓣游离移植修复指掌侧皮肤缺损并重建远端血运的手术方法和临床效果。方法 2008年3月-2009年10月,收治6例指掌侧皮肤缺损伴指动脉节段性缺损、远端血运障碍者。男4例,女2例;年龄18～39岁,平均27岁。冲床轧伤4例,电刨损伤2例。示指2例,中指2例,环指1例,小指1例。皮肤软组织缺损范围为4.0cm×2.5cm～6.0cm×4.0cm。受伤至手术时间2～8h,平均3.5h。术中应用大小为4.5cm×3.0cm～6.5cm×4.5cm的足底内侧皮瓣游离移植修复缺损,同时以足底内侧动脉浅支桥接指动脉重建手指远端血运,皮瓣隐神经终末支与指神经吻合。供区植皮修复。结果术后6例皮瓣及植皮均成活,供、受区切口均Ⅰ期愈合。患者均获随访,随访时间6～18个月。皮瓣质地良好,外形无明显臃肿。两点辨别觉为7～9mm。术后6个月手指功能按中华医学会手外科学分会上肢功能评定试用标准进行评定,优2例,良3例,可1例。结论足底内侧动脉浅支蒂皮瓣厚度适中且耐磨,血管解剖恒定,管径与指动脉相近,血管蒂长,是修复手指掌侧皮肤缺损并重建远端血运的一种较好方法 。

Objective:To investigate the causes of prolonged second stage of labor and the high risk factors of neonatal asphyxia.Methods:All of the cases with prolonged second stage of labor in our hospital from Jan 2002 to Jan 2008 were retrospectively reviewed.Results:The total cases of prolonged second stage of labor were 133 and the incidence was 2.07%.The four major causes were abnormal fetal position(35.34%),uterine atony(19.55%),abnormality of umbilical cord(15.04%)and abnormality of birth canal(8.27%).The incidence of neonatal asphyxia were significantly higher in the patients with fetal distress or abnormality of umbilical cord than the patients without those factors(P<0.05).The incidence of neonatal asphyxia were also higher in the patients with vaginal midwifery than the patients with cesarean section and vaginal delivery(P<0.05).The incidence of neonatal asphyxia was no difference between the patient with abnormal fetal position,uterine atony,preterm delivery,pregnant complication,fetal gender and the patients without those factors(P>0.05).Conclusions:The major causes of prolonged second stage of labor are abnormal fetal position,uterine atony,abnormality of umbilical cord and abnormality of birth canal.The high risk factors of the neonatal asphyxia after the prolonged second stage of labor include fetal distress,abnor-mality of umbilical cord and vaginal midewifery.

目的探讨胫骨平台后方剪力骨折的分型、手术入路及手术效果。方法 2004年6月至2009年2月,采用后内侧或后外侧以及后内侧+后外侧双切口入路治疗胫骨平台后方剪力骨折11例。后内侧入路经由半腱肌、半膜肌和腓肠肌内侧头间隙,后外侧入路自肌和比目鱼肌间隙分离显露后外侧髁。骨折块直视下复位,用3.5 mm"T型"锁定钢板或有限接触加压钢板于胫骨后内或后外侧固定骨块,必要时结合拉力螺钉一起固定骨块。侧副韧带、半月板损伤一期修复,前交叉韧带损伤二期修复。结果 11例患者全部获得8个月以上的随访,随访时间8～26个月,平均12.5个月。术后1.5个月60°～100°,平均65°;术后3个月70°～115°,平均85.2°;术后6个月膝关节屈伸范围:95°～125°,平均100.6°。术后12个月膝关节HSS评分80～92分,平均90.5分。无一例发生手术区皮肤坏死、感染或内固定松动。结论将此分型加入Schatzker分型法中,使之更加完善.本组所采用的后外侧或后内侧入路或双切口入路可充分暴露胫骨后平台,减少前方大范围剥离所带来的软组织并发症,直视下复位和固定骨折块可以充分防止力线的改变和骨折的再移位,有利于患者良好的膝关节功能恢复。

Objective To evaluate clinical outcome of repairing finger skin defect by the innervated reverse island flaps based on the dorsal branches of the digital proper artery.Methods From January 2005 to June 2008,thinty six cases with finger skin defect were treated with the reverse island flaps from the dorsum of the middle and third phalanx based on the dorsal branch of the digital artery used as the pedicle.Meanwhile,the sense was reconstructed with the proper branches of the digital dorsal nerves.The largest flap was 1.5 cm × 3.0 cm.Results The 36 flaps survived completely and followed up for 6 to 12 months,all flaps had satisfactory appearances,soft texture.The two-point discrimination ranged between 6 and 8 mm.And the movements of interphalangteal joints were satisfactory.Conclusions This kind of flap has the advantages of simplicity,non-invasion to the collateral digital artery and nerve,in addition,the sense is regained successfully.It is an ideal alternative for reconstruction of finger skin defects.

目的:探讨髋部骨折并存糖尿病的围手术期治疗血糖控制以及并发症的预防.方法:对32例髋部骨折并存糖尿病的围手术期的血糖控制、胰岛素使用、并发症的处理及麻醉方式选择进行分析.结果:32例中,2例术后内固定松动,I例应激性胃溃疡,2例下肢静脉栓塞,未发生感染和其他并发症.术后患者症状体征均明显改善,肢体功能恢复良好.结论:糖尿病患者经正确的围手术期处理,将血糖控制至理想水平,可安全度过手术期.

跟骨骨折在临床上多见,占全身骨折的1%～2%,约占足部骨折的75%.跟骨骨折中约75%为关节内骨折,这种骨折可引起长期疼痛、功能受损等后遗症,很多患者难以完全恢复健康.跟骨关节内骨折损伤机制和骨折类型复杂,治疗困难,过去大多采取非手术治疗.