坏死性筋膜炎（NF）是一种临床罕见的炎症感染性疾病。主要侵及皮下组织及筋膜层,病死率极高,最典型的表现称为Fournier坏疽。早期诊断及积极的治疗,包括尽早清创、引流及广谱抗生素的使用是该病处理的关键。现报道1例我院收治的坏死性筋膜炎病例并进行相关文献复习。

ObjectiveTo investigate the distribution of HBV genotypes in Changchun, China, as well as the association of genotypes with virus replication level, serum markers, and liver impairment and its clinical significance. MethodsA total of 702 patients with HBV infection who visited The First Hospital of Jilin University from August 2013 to May 2016 were enrolled. Real-time PCR was used to determine HBV genotypes. HBV DNA load, serum markers, and liver function were measured, and the association between genotype and clinical test items was analyzed. The independent samples t-test was used for the comparison of means between groups, and the chi-square test was used for comparison of categorical data between groups. The Mann-Whitney U test was used to investigate the distribution of HBV genotypes in different diseases. ResultsOf all patients with HBV infection, 664 underwent successful genotyping, among whom 484 (72.9%) had genotype C, 168 (25.3%) had genotype B, and 12 (1.8%) had genotype B+C. There were no differences in the distribution of HBV genotypes between patients with different sexes or ages. Compared with those with genotype B HBV infection, the patients with genotype C HBV infection had significantly higher HBV DNA load (6.68±1.20 log10 copies/ml vs 5.15±1.37 log10 copies/ml, t=13.714, P＜0.001) and HBsAg(+)+HBeAg(+)+anti-HBc(+)(χ2=21.687, P＜0.001). There was no significant difference in HBsAg(+)+anti-HBe(+)+anti-HBc(+) between the two groups (χ2=2.124, P=0.145). The patients with genotype B had significantly higher levels of HBsAg and anti-HBe than those with genotype C (χ2=28.780, P＜0.001). Compared with those with genotype B, the patients with genotype C had significantly higher levels of alanine aminotransferase (ALT) and aspartate aminotransferase (AST) (ALT: 307.6±113.4 U/L vs 285.8±96.2 U/L, t=2.229, P=0.026; AST: 211.1±96.4 U/L vs 192.7±89.2 U/L, t=2.172, P=0.030), as well as a significantly lower level of albumin (37.6±9.1 g/L vs 39.9±10.6 g/L, t=2.701, P=0.007). Among the patients with genotype C HBV infection, 264 progressed to chronic hepatitis, 202 to liver cirrhosis, and 18 to liver cancer; among the patients with genotype B HBV infection, 142 progressed to chronic hepatitis, 20 to liver cirrhosis, and 6 to liver cancer. The patients with genotype C HBV infection had significantly greater liver injury compared with those with genotype B HBV infection (U=28 894.000, P＜0.001). ConclusionMost of the patients with HBV infection in Changchun have genotype C, followed by genotype B. HBV genotype is not associated with sex or age. The patients with genotype C HBV infection have active HBV DNA replication and show greater association with the severity of liver injury compared with those with genotype B HBV infection.

1临床资料<br>　　患儿男，3岁。因“腹胀、消瘦2个月，发热3天”入院。查体：体温38．5℃，心律98次／min，贫血貌，无皮肤巩膜黄染、牙龈出血及身体瘀斑等，肝脏肿大，肋下1 cm，脾肿大肋下3 cm，腋窝下及颈下淋巴结可触及。甲状腺体检未见异常，双下肢无水肿，饮食及大小便正常。否认糖尿病病史及家族史，排除误服降糖药的可能。血常规：白细胞420．8×109／L，幼稚细胞0．10，红细胞2．6×1012／L，血红蛋白70．0 g／L，血小板32．0×109／L。骨髓象诊断慢性粒细胞白血病（CML）。入院次日晨起空腹，抽取静脉血，肝功能：AST 36．4 U／L，ALT 5．8 U／L， ALP 198 U／L，GGT 11．4 U／L，CHE 4268 U／L， TBil 7．7μmol／L，DBil 2．3μmol／L，TP 51．6 g／L， ALB 32．6 g／L；肾功能：BUN 2．1 mmol／L，CRE 27．6μmol／L；血清离子均在参考范围内。空腹胰岛素2．81 mU／L，空腹 C肽1．29μg／L，抗胰岛素抗体阴性。促甲状腺素、皮质醇、促肾上腺皮质激素、生长激素、催乳素、性腺激素、促性腺激素均正常。静脉血糖0．59 mmol／L，操作人员复查后确认检测结果无误，与临床反复沟通，确认患儿无心慌、乏力、恶心、呕吐、出汗、腹痛、腹泻、意识障碍等低血糖表现，立即采集末梢血采用微量血糖仪检测血糖，结果为5．6 mmol／L。为验证此低血糖是否与标本采集后放置时间有关，于次日晨起空腹再次抽取血常规1管，有分离胶生化管2管，进行复查。血常规结果为：白细胞408．8×109／L，幼稚细胞0．09，红细胞2．7×1012／L，血红蛋白73．0 g／L，血小板35．0×109／L，生化管一管于采集血液后15 min迅速离心分离血清检测血糖，另一管采集血液后放置1．5 h后离心分离血清检测血糖，两管检测的血糖结果分别是4．92 mol／L和0．98 mmol／L，其他检测结果与第1天检测结果无明显差异。

Objective To explore the feasibility of radical cholecystectomy for early gallbladder car cinoma found during or after laparoscopic cholecystectomy.Methods A retrospective study was conducted on patients who received laparoscopic cholecystectomy between January 2007 to August 2013 and were diagnosed to have gallbladder cancer during or after the operation.There were 34 patients.In 29 patients intraoperative frozen section diagnosed gallbladder carcinoma.In 5 patients postoperative histopathological study diagnosed stage Ⅰ or Ⅱ gallbladder carcinoma.Results Surgery was conducted successfully on these 34 patients.In 20 patients with stage Ⅰ,Ⅱ and Ⅲ,the tumor had invaded the serosa,or into the liver with a depth of less than 2 cm,laparoscopic cholecystectomy alone or radical/extended radical cholecystectomy were carried out.In 9 patients,the laparoscopic surgery was converted to open surgery and these patients underwent cholecystectomy with resection of the adjacent liver segments/sections.In 5 patients who were diagnosed to have gallbladder carcinoma after laparoscopic cholecystectomy,they were re-operated with laparoscopic radical cholecystectomy.Conclusions Stage Ⅰ,Ⅱ and Ⅲ gallbladder carcinoma with tumor invasion into serosa,or patients with tumor invasion into the liver with a depth of less than 2 cm should undergo radical or extended radical cholecystectomy.Laparoscopic assisted radical or extended radical cholecystectomy could achieve the same operation as with open surgery but with better short-term results.There were less pain,smaller incisions,better scars and shorter hospitalization stay.

患者女，75岁，因“脐部外生性肿物2个月”于2013年4月7日入院。入院查体：心肺无异常。脐部可见直径约4 cm外生肿物，质硬，活动度差，有压痛。腹部无明确阳性体征。实验室检查示：血常规：血红蛋白101 g／L，红细胞压积31．2％；癌胚抗原：53．23 ng／ml，余检查均未见明显异常。体表及腹部彩超显示：脐周腹壁内实质性低回声肿物，有丰富血管信号，直径约38 mm，厚径34 mm，深部达腹壁深层距壁层腹膜3．8 mm；肝右叶可见3．8 cm ×3．3 cm 低回声光团，界限清，形态欠规则，周边可见低回声晕。脐部肿物活组织检查（活检）病理示：（脐部）送检坏死组织内见少量异型腺体，符合腺癌形态，见图1。胸部CT未见异常。腹部及盆腔CT （平扫＋增强）示：肝右叶病变及结肠肝曲、横结肠管壁改变，考虑恶性占位性病变，见图2。纤维结肠镜检查示：距肛门约70 cm处见一增生型肿物，表面凹凸不平、污秽，黏膜充血、水肿，色暗红，质脆易出血，病变侵及肠管全周，致肠腔狭窄；活检病理示：结肠中分化腺癌。术前诊断：右半结肠癌、肝转移瘤、脐部转移癌。经术前评估及与家属沟通知情同意后，于4月13日行姑息性右半结肠切除及脐部转移癌切除术。术后脐部转移瘤大体标本见图3。术后病理示：右半结肠中分化腺癌，浸润肠壁全层，脉管内见有癌浸润，脐部内见癌转移，双切缘未见癌，大网膜内未见癌浸润，肠周围淋巴结（0／29）均未见癌转移。TNM分期为T4N0M1。患者病情平稳后，于4月24日出院。患者术后恢复良好，于5月8日再次入院治疗，给予口服替吉奥胶囊（20 mg／片，江苏恒瑞）3片／次、2次／d，口服2周休息1周，坚持4周期，肝脏转移瘤行咖玛刀照射治疗，转移瘤体积明显缩小。随访12个月，患者生活质量可，复查无腹部、盆腔内肿瘤复发、转移，肝脏无新发病灶，转移瘤体积未见明显增大。

严重的顽固性便秘经长期药物治疗无效需行手术治疗。本文分析腹腔镜联合TEM器械保留回盲部及直肠壶腹部结肠次全切手术的老年顽固性便秘病人临床资料。

目的讨论肠内营养与肠外（静脉）营养对胃肠道恶性肿瘤患者术后营养状况、术后并发症、免疫功能、及住院时间的影响。方法针对我院2009-2011年间92例确诊胃肠道恶性肿瘤并行手术治疗患者随机分为:观察组50例（肠内营养组）和对照组42例（肠外营养组）,在术前1d及术后3d和7d抽取静脉血,检测淋巴细胞总数、T淋巴细胞亚群（CD3、CD4、CD8、CD4/CD8）和体重、血清白蛋白、前白蛋白等营养状况,并比较两组的并发症发生率、住院时间、发热时间等指标。结果观察组与对照组患者体重均有下降,但观察组患者的白蛋白和前白蛋白升高水平均高于对照组;两组患者术后的淋巴细胞总数、CD3+、CD4+、CD8+细胞、CD4+/CD8+比值降低,但是观察组的回升高于对照组;且观察组的并发症发生率明显低于对照组、发热时间及住院时间明显短于对照组。结论胃肠道恶性肿瘤术后早期肠内营养较肠外营养更具优越性,可降低术后并发症发生率,缩短住院时间,能提高患者的营养水平及免疫功能。

目地探讨原发性甲状腺功能亢进症(原发性甲亢)合并甲状腺癌(甲癌)的诊治方法。方法回顾性分析我院2009年7月～2013年2月经手术及病理证实的9例原发性甲亢合并甲癌临床资料,分析其诊断及治疗。结果在本组9例原发甲亢合并甲状腺癌的病例中,术前细针穿刺细胞学检查确诊2例,术前误诊、漏诊率高达77.8%(7/9)。术中快速病理明确诊断88.9%(8/9)。1例术后病理检查明确诊断。9例患者均行手术治疗,行患侧甲状腺全切除术+对侧甲状腺次切除术6例,甲状腺全切除术3例(其中1例为二次手术)。术后均服用左旋甲状腺素片进行内分泌治疗。所有患者均获随访,无一例复发、转移或死亡。结论原发甲亢合并甲状腺癌近年患者有所增多;术前诊断比较困难,术前应综合运用B超、细针穿刺细胞学等检查,本病的确诊有赖于病理学诊断,术前、术中明确诊断,避免患者行第二次手术。采取合理的手术方式,术后再根据甲功结果服用左旋甲状腺素片,患者术后疗效较好。

目的探讨桥本氏病(Hashimoto's disease,HD)合并甲状腺癌(Thyroid Cancer,TC)的诊断和手术治疗的适应症及其疗效。方法回顾性分析2008年9月～2012年03月经手术及病理证实的17例HD合并TC患者的临床资料,分析其诊断和治疗。结果在本组17例HD合并TC病例中,术前误诊、漏诊率高达88.2%(15/17)。术中快速病理明确诊断准确率为94.1%(16/17)。行患侧腺叶全切除+峡部切除+对侧次全切除13例,甲状腺全切除4例(其中1例为二次手术),加行中央组淋巴结清扫10例,术中见癌肿侵犯喉返神经的1例。术后均服用甲状腺素进行内分泌治疗。所有患者均获随访,无一例复发、转移或死亡。结论 HD合并TC术前明确诊断困难,漏诊率高,多数术中快速病理可确诊。对HD合并单发的甲状腺肿块有恶性可能、甲状腺肿大产生压迫症状、合并疼痛、内分泌治疗无效及短期内肿物明显增大的HD病人应积极手术治疗。术中根据快速病理结果决定具体手术方式,通过个体化的手术治疗联合术后内分泌治疗,预后良好。

Objective To investigate the effection of gastric bypass surgery on the non-obese type 2 diabetic rat islet β-cells' apoptosis.Methods 72 8-week-old GK rats were randomly divided into operation group(O group),sham operation group(S group),diet control group(F group) and control group(C group),measured fasting,postprandial blood glucose and insulin in preoperative periond and postoperative 1,2,4,8 W.At postoperative 2 w,4 w,8 w,after measuring postprandial blood glucose,the rats were killed randomly in batches,6 were sacrificed in each batch of each group,then we separated the pancreas for subsequent experiments,analysised islet β-cells' apoptosis through TUNEL method.Results In O group at the postoperative 4,8 weeks,fasting,postprandial blood glucose decreased,the difference was statistically significant(P0.01),fasting,postprandial insulin significantly increased,the difference was statistically significant(P0.01);Through TUNEL assay,we found rat islets in the O group with the extension of time,gradually reduced the number of apoptotic cells,apoptosis rate was decreased,the difference was statistically significant(P0.01).Conclusion gastric bypass surgery can effectively control blood glucose of the non-obese type 2 diabetic rats,can reduce the islet β-cell apoptosis.

正>肝脏缺血再灌注损伤防护是目前肝脏外科的研究热点。本研究应用大鼠肝脏缺血再灌注损伤模型,探讨术前应用乌司他丁（ulinastain UTI）对肝脏缺血再灌注损伤的保护及其可能机制。1材料与方法1.1实验动物健康雄性Wistar大鼠,体重150-

目的 总结探讨分析腹腔镜胆囊切除治疗急性胆囊炎的疗效.方法 本院2006年7月至2009年7月间的急性炎症期胆囊炎有选择性行腹腔镜胆囊切除术共269例.结果 本组269例急性炎症期胆囊炎患者均采用腹腔镜胆囊切除术,有2例中转开腹,无并发症发生.结论 急性炎症期胆囊炎行腹腔镜胆囊切除术的临床分析,认为急性炎症期胆囊炎行腹腔镜胆囊切除术是完全可行的、安全的,可靠的,疗效显著,值得临床借鉴.

Objective To investigate the relationship between tumor metastasis-related Rac1 mRNA expression levels and gastric carcinomas metastasis, and to investigate the significance of Rac1 as a tumor marker for the evaluation of gastric carcinomas metastasis and distinguish between benign and malignant lesions. Methods This experiment used fluorescence quantitative RT-PCR TaqMan probe technology, chose Rac1 target gene fragment, which was cloned into the pET-20b (+) vector, constructed recombinant plasmid, and established the Rac1 mRNA fluorescence quantitative RT-PCR standard curve. And then the Rac1 mRNA levels were detected in 52 cases of gastric carcinoma tissues,52 cases of para-carcinoma tissues and 12 cases of benign gastric disease tissues. Its association with the metastasis of gastric carcinomas was analyzed. Results The positive rates and levels (median, P25-P75) of Rac1 mRNA were 100. 0% ,7.41 ×105 (3. 50 × 105-4. 36 × 106) copies/μl in gastric carcinomas, 46. 2% ,0(0-1.73 × 104) copies/μl in parscarcinoma tissues, 33. 3%, 0(0-3.55 × 103) copies/μl in benign tissues. The positive rates and leves(x2 =43.16,x2Xk-w = 64. 19, P ＜0. 01)among the three groups were significantly different. When the critical value of Rac1 mRNA level was 1.73 × 104 copies/μl determined by ROC, the sensitivity and specificity were 88. 5% and 100% respectively. When the critical value of Rac1 level was 7.49 × 105 copies/μl, the sensitivity and specificity were 57.9% and 78. 6% respectively. ConclusionThe Rac1 mRNA level detected with fluorescence quantitative RT-PCR has reference value to distinguish between benign and malignant lesions and evaluate gastric carcinoma metastasis.

目的 探讨胆固醇结石与肝脏SRBI基因表达关系.方法 选取20例胆囊胆固醇结石患者和20例健康者作为试验组和对照组.分别测定血清HDL,胆汁总脂.胆汁总脂中各成分含量以及胆汁胆固醇饱和指数.对测量结果进行对比分析.结果 实验组患者血清HDL.和胆汁总脂显著低于对照组(P<0.05),其它各项测量指标值则均显著高于对照组(P<0.05).结论 肝脏SRBI过表达,可能与胆汁胆固醇过饱和有关,是胆固醇结石病的重要遗传因素.

目的 分析急性肠炎、急性呼吸道感染、急性病毒性脑炎患儿血清单项肌酸激酶同工酶(CK-MB)增高的原因.方法 选取临床明确诊断患儿793例,分为急性肠炎组、急性呼吸道感染组、急性病毒性脑炎组,采用速率法检测血清肌酸激酶(CK),免疫抑制法检测同工酶CK-MB,对CK-MB升高的患儿同时全部采用45 ℃灭活后再检及电泳法复检并行ECG及心脏彩色多普勒超声.结果 793例患儿中CK-MB单项升高者314例(39.6%),45 ℃灭活后仍有303例升高,电泳法复检并确诊心肌炎者24例,发病率为3.03%.结论 采用免疫抑制法检测CK-MB单项升高的3种感染性疾病患儿应采用电泳方法来鉴定CK同工酶,确定有无CK-BB或巨CK的干扰,为临床诊断提供准确的依据.

小儿腹泻是由多病原、多因素引起的以腹泻为主的一组疾病,轮状病毒(rotavirus,RV)是引起小儿腹泻主要的致病原,儿童RV感染除了出现腹泻等消化道症状外,还可引起其他脏器的损害.我们发现其中部分患儿血清CK-MB异常增高,无心肌损伤的临床症状和心电图改变,肌酸激酶(CK)的活性正常或仅轻度增高,给临床诊断造成困惑.为此,我们检测了我院2008年收治的274例RV感染腹泻患儿的心肌酶,报道如下.

目的评价血清肿瘤标志物癌胚抗原（CEA）、糖类抗原125（CA125）、糖类抗原19-9（CA19-9）、M2-丙酮酸激酶（M2-PK）和胃蛋白酶原Ⅰ（PGⅠ）联合检测对胃癌诊断的价值。方法采用酶联免疫法测定69例胃癌患者、40例良性胃病患者以及30例健康人血清中CEA、CA19-9、CA125、M2-PK和PGⅠ的水平,比较3组间的差异。结果胃癌组患者血清中CEA、CA19-9、CA125、M2-PK和PGⅠ的阳性率均显著高于良性胃病组及对照组（P＜0.01）。5项标志物联合检测的敏感性为80.1%,与单项检测相比差异有显著性（P＜0.01）。结论CEA、CA125、CA19-9、M2-PK和PGⅠ对胃癌具有较高的辅助诊断价值,5项标志物联合检测有助于提高胃癌诊断的敏感性。

急性胰腺炎(Acute pancreatitis,AP)是临床常见的急腹症,并发症多,死亡率高,其发病机制尚未完全阐明.

Objective To investigate the correlation between TAP levels in plasma and urine and severity in patients with acute pancreatitis and their clinical significances.Methods the plasma and urinary TAP levels were measured with ELISA methods in 53 patients with acute pancreatitis(AP) and 30 normal subjects.Results the plasma and urinary TAP levels in AP patients were significantly higher than that in healthy people(P0.01).the plasma and urinary TAP levels in patients with severe acute pancreatitis were significantly higher than in those with mild acute pancreatitis(P0.01).Conclusion The plasma and urinary TAP levels are related to the development of acute pancreatitis,The measurement of plasma and urinary TAP may contribute to predict the severity of AP and guide clinical treatment.

To investigate expressions of osteopontin(OPN)and matrix metalloproteinase-2(MMP-2)in hepatocellular carcinoma and their clinical significance.The expression of OPN in the liver of 42 patients with primary hepatocellular car- cinoma and 4 normal controls was detected using SP Immunohistochemical technique.The positive expression rates of OPN and MMP-2 in hepatocellular carcinoma tissue were 71.4%(30/42)and 66.7%(28/42)respectively.And the expres- sion of OPN was significantly correlated with the expression of MMP-2(P＜0.01 ).The expressions of OPn and MMP-2 were related to the tumor grade and clinical stage(P＜0.05).OPN might play an important role in the progression of hepatocellular carcinoma and be a potential marker for invasion and metastasis of hepatoellular carcinoma.OPN and MMP -2 might play synergetic roles in hepatocellular carcinogenesis.