全膝关节置换术(TKA)是目前临床上最常见且最成功的骨科手术之一,其在恢复关节活动能力、缓解疼痛、改善患者生活质量方面发挥重要作用.然而,在TKA术后,多数患者仍存在功能损伤、步态异常和相当大的跌倒风险,这主要与术后本体感觉下降有关.目前国内外针对TKA术后患者本体感觉康复已有较多研究,但对本体感觉恢复机制尚不清楚,且现有锻炼方法多样,效果不一,因此本文将就膝关节本体感觉及TKA术后患者本体感觉康复治疗的研究进展进行综述.

To describe individual perspectives and reflections on unforgettable stories about dying over an eight-year period, in a mixed surgical and general intensive care unit (ICU) in China. The study was carried out at the Second Affiliated Hospital of Soochow University. The research was based on personal experience and reflection. Narrative and experiential reflection synthesis were performed for the data analysis. This was done to understand the current situation regarding dying, then to identify and analyze, and finally to put forward some suggestions regarding the experience. The discussion and preparation for death in the ICU may still require further discussion. For a better acceptance of hospice care and high quality and dignity of death and even the donation of organs, it is important that health care providers learn to talk about death with their patients, and to encourage the patients to participate in the decision-making process.

Objective:To investigate the effect of early ambulation time on lower limbs muscle strength and fear of falling in patients with total knee arthroplasty, so as to provide basis for promoting the postoperative rehabilitation of patients undergoing total knee arthroplasty.Methods:A total of 210 patients after unilateral total knee replacement from July 2018 to December 2019 in the Second Affiliated Hospital of Soochow University were included and assigned to experimental group 1, experimental group 2 and experimental group 3 by random digits table method, each group contained 70 cases, and the patients began ambulation at 16, 20, 24 hours after knee replacement, respectively. The peak torque (PT) of knee joints flexors and extensor as well as hamstrings quadriceps ratio (H/Q) were compared among three groups at 1 week, 1 month and 3 months after knee replacement. The fall efficiency was evaluted by Modified Fall Efficacy Scale (MFES), the fear of falling rate was conducted by single item method.Results:After 1 month of knee replacement, the PT of knee joints flexor and extensor and H/Q were (18.73±5.49) N·m, (37.56±7.76) N·m, (48.08±9.19)% and (18.44±5.27) N·m, (37.04±7.07) N·m, (47.49±9.30)% in the experimental group 1 and experimental group 2, which were higher than those in the experimental group 3(16.38±2.85) N·m, (33.75±6.75) N·m, (43.48±7.17)%, the differences were statically significant ( t values were 2.316-3.057, P<0.05). After 1 week of knee replacement, the fear of falling rate were 72.3%(47/65) and MFES scores were (3.14±0.58) points in the experimental group 1, 53.7%(36/67), (3.81±0.65) points and 50.8%(32/63), (3.87±0.74) points in the experimental group 2 and experimental group 3, the fear of falling rate significantly increased and MFES scores significantly decreased in the experimental group 1 compared to the experimental group 2 and experimental group 3, the differences were statistically significant ( χ2 values were 5.780, 4.878, t values were 6.221, 6.129, P<0.05). Conclusions:Twenty hours after knee replacement is the best time for ambulation, which can shortern the time for lower limbs muscle strength recovery and reduce the risk of fear of falling.

拔管后吞咽障碍是因气管插管导致的并发症,严重影响患者疾病预后和生存质量,本文主要对气管插管拔管后吞咽障碍的危险因素、筛查评估进行综述,为临床护理人员对此类患者拔管后吞咽障碍筛查评估及护理提供依据,从而提高该类患者的生存质量.

目的 探究医院-社区团队干预应用于老年人工股骨头置换术后患者中对生活质量的影响.方法 选取2016年6月—2017年6月收治的给予常规干预的老年人工股骨头置换术后患者68例作为对照组,另选取2017年7月—2018年7月收治的给予医院-社区团队干预的老年人工股骨头置换术后患者68例作为观察组.比较两组并发症发生率、负性情绪及生活质量.结果 干预6个月后观察组并发症发生率低于对照组,差异有统计学意义(P<0.05);观察组干预6个月后焦虑自评量表(SAS)、抑郁自评量表(SDS)评分均低于对照组,差异有统计学意义(P<0.05);观察组干预6个月后心理功能、生理功能、环境适应能力及社会功能评分均高于对照组,差异有统计学意义(P<0.05).结论 将医院-社区团队干预应用于老年人工股骨头置换术后患者中,可显著降低其并发症发生率,缓解其负性情绪,并有效提高患者生活质量,值得推广.

目的 分析研究早期下床开始时间对全膝关节置换术患者功能恢复的影响.方法 收集2019年1-9月入住我院关节外科50～80岁的膝关节骨性关节炎患者共90例,其中每季度第1月入院者设为对照组共30例,每季度第2月入院者设为观察A组共30例,每季度第3月入院者设为观察B组共30例.观察A组在术后16 h开始下床活动,观察B组在术后20 h开始下床活动,对照组在术后24h开始下床活动.比较3组患者的一般临床资料,比较术后第3天、第5天膝关节最大屈曲、最大伸直角度及借助步行器行走距离;比较3组患者术后第7天、术后1月、术后3月膝关节评分和日常生活能力评分.结果 3组患者在术后第3天膝关节最大伸直角度、最大屈曲角度、借助步行器行走距离及术后第5天膝关节最大伸直角度差异无统计学意义(P>0.05),但术后第5天最大屈曲角度及借助步行器行走距离差异有统计学意义(P<0.05),其中观察A组屈曲角度最大,借助步行器行走距离最远.3组患者中观察A组在术后第7天、术后1月HSS评分最高(P<0.05),在术后第7天ADL评分最高(P<0.05).结论 全膝关节置换术后患者在术后16 h开始下床活动可更有效地恢复膝关节功能、改善生活质量,有助于患者早日康复.

Background: Radicular pain, caused by a lesion or autologous nucleus pulposus (NP) implantation, is associated with alteration in gene expression of the pain-signaling pathways. lncRNAs have been shown to play critical roles in neuropathic pain. However, the mechanistic function of lncRNAs in lumbar disc herniation (LDH) remains largely unknown. Identifying different lncRNA expression under sham and NP-implantation conditions in the spinal cord is important for understanding the molecular mechanisms of radicular pain. Methods: LDH was induced by implantation of autologous nucleus pulposus (NP), harvested from rat tail, in lumbar 5 and 6 spinal nerve roots. The mRNA and lncRNA microarray analyses demonstrated that the expression profiles of lncRNAs and mRNAs between the LDH and sham groups were markedly altered at 7 days post operation. The expression patterns of several mRNAs and lncRNAs were further proved by qPCR. Results: LDH produced persistent mechanical and thermal hyperalgesia. A total of 19 lncRNAs was differentially expressed (>1.5-folds), of which 13 was upregulated and 6 was downregulated. In addition, a total of 103 mRNAs was markedly altered (>1.5-folds), of which 40 was upregulated and 63 downregulated. Biological analyses of these mRNAs further demonstrated that the most significantly upregulated genes in LDH included chemotaxis, immune response, and positive regulation of inflammatory responses, which might be important mechanisms underlying radicular neuropathic pain. These 19 differentially expressed lncRNAs have overlapping mRNAs in the genome, which are related to glutamatergic synapse, cytokine-cytokine receptor interaction, and the oxytocin-signalling pathway. Conclusion: Our findings revealed the alteration of expression patterns of mRNAs and lncRNAs in the spinal cord of rats in a radicular pain model of LDH. These mRNAs and lncRNAs might he potential therapeutic targets for the treatment of radicular pain.

背景:快速康复外科是指通过改良、优化和组合围术期处理的诸多措施,以缓解手术创伤应激反应,从而减少术后并发症发生,缩短住院时间,达到患者快速康复的目的.该理念在胃肠外科应用较为广泛成熟,而近年越来越受到骨科医师的重视,因此膝关节置换手术的快速康复管理成为近年来的焦点.目的:探讨围术期快速康复外科管理模式对全膝关节置换患者术后康复效果的影响.方法:选择2018年1至6月行全膝关节置换的患者30例作为快速康复组,围术期采用快速康复外科管理方案管理;同时收集2017年7至12月行全膝关节置换的患者30例作为传统组,围术期采用传统的诊疗护理常规方案管理.2组患者对治疗方案均知情同意,且得到医院伦理委员会批准.比较2组患者术后早期康复效果,包括主动屈膝角度、美国特种外科医院评分及静息状态、运动状态下的疼痛目测类比评分;记录2组患者术后30 d非计划性再入院率及满意度.结果 与结论:①快速康复组术后第3,5,7天主动屈膝角度及术后1,3个月美国特种外科医院评分均显著大于传统组,差异有显著性意义(P＜0.05);②快速康复组术后6,24,36 h静息状态、运动状态疼痛目测类比评分均显著低于传统组(P＜0.05);③2组患者术后30 d非计划性再入院病例均为0例;④满意度方面,快速康复围术期管理模式能够显著提高患者的满意度(P＜ 0.01);⑤提示全膝关节置换围术期快速康复外科管理模式不仅能够促进患者术后早期的康复进程,还可以提高患者的满意度及就医体验,提升医疗服务质效.

目的 探讨六西格玛管理应用于神经外科老年住院患者中对肺部感染及负性情绪的影响.方法 选取2016年3月 ～2017年3月我院神经外科收治行六西格玛管理的老年住院患者54例作为观察组,选取2015年2月 ～2016年2月我院神经外科收治行传统管理的老年住院患者54例作为对照组,对比两组肺部感染、 负性情绪、 服务质量等指标.结果 观察组肺部感染率、 总并发症发生率均低于对照组,差异有统计学意义(P<0.05);观察组管理后汉密尔顿焦虑量表(HAMA)、 汉密尔顿抑郁量表(HAMD)评分均低于对照组,差异显著,有统计学意义(P<0.001);观察组操作实施、 无菌意识、 宣教与沟通、 服务态度评分均高于对照组,差异显著,有统计学意义(P<0.001).结论 六西格玛管理应用于神经外科老年住院患者中效果显著,可有效预防肺部感染,缓解负性情绪,提高服务质量.

目的 探讨吞咽功能训练操应用于老年脑卒中吞咽障碍患者对其吞咽功能和依从性的影响.方法 选择我院2014年10月至2016年10月收治的老年脑卒中吞咽障碍患者98例,按数字随机表分为两组,每组49例.对照组行常规吞咽功能训练,观察组行吞咽功能训练操.观察并记录两组训练2周后吞咽障碍程度、训练依从性和训练前后生存质量变化,进行比较分析.结果 观察组训练2周后吞咽障碍程度轻于对照组,差异有统计学意义(P<0.05);观察组各项训练依从性均高于对照组,差异有统计学意义(P<0.05);观察组训练2周后各生存质量评分均优于对照组,差异有统计学意义(P<0.05).结论 吞咽功能训练操应用于老年脑卒中吞咽障碍患者可显著改善吞咽功能,提高训练依从性和生存质量,值得推广.

目的:探讨新生儿脐带严重水肿时,采用脉冲压迫方法断脐的效果.方法:将120例脐带水肿新生儿随机分为观察组和对照组各60例.观察组脐带脉冲压迫后断脐,对照组直接断脐.比较两组断脐时间、脐带残端意外断裂和血肿发生率、断脐质量及术者满意度.结果:观察组断脐时间短于对照组(P<0.01),断脐质量优于对照组(P<0.05),脐带残端意外断裂发生率少于对照组(P<0.01),术者满意度高于对照组(P<0.01).结论:脉冲压迫应用于严重水肿脐带新生儿断脐结扎中,快速、安全、术者操作满意.

世界卫生组织和国际疼痛研究协会(IASP)定义疼痛为：现存或潜在组织损伤引起的不愉快感觉和情感体验。美国疼痛学会主席James Campell提出将疼痛列为“第5大生命体征”，术后的剧烈疼痛加重了膝关节术后深静脉栓塞发生的概率，往往导致患者睡眠不足、情绪低落，影响切口愈合。“无痛病房”是以患者为中心，在患者就诊住院手术期间，合理评估疼痛，制定有效治疗方案，将疼痛最小化，减少各种并发症，更舒适的度过围手术期。

Objective To explore the correlation between femoral head bone iron content,serum ferritin (SF) and bone mineral density of postmenopausal women with femoral neck fragility fracture.Methods From June 2010 to March 2013,156 postmenopausal women with femoral neck fragility fractures aged from 56 to 92 years old,with an average age of 72.40±8.97 years,were divided into 5 groups based upon the stratification of 10-year age intervals (≤60,61-70,71-80,81-90 and ≥91).Blood samples were collected to determine iron metabolism and bone metabolic markers after overnight fasting.Bone specimens were obtained for detecting bone iron contents and performing iron stain respectively after hip arthroplasty surgery.BMD was measured by dual energy X-ray absorptiometry(DXA)at hip and lumbar spine from L1 to L4 ten days after surgery.Results There were significant differences in the values of bone iron content,SF,transferrin,total iron binding capacity,serum procollagen type Ⅰ N-terminal propeptide,β-carboxy terminal telopeptide of collagen type Ⅰ and BMD at hip and L1 to L4 in all groups.BMD at hip and L1 to L4 decreased while bone iron content and SF increased with age; the peaks of bone iron content and SF were both in 81-90 years group; the average of bone iron content and SF was 96.81 μg/g and 235.66 μg/L respectively.There were 100 patients (100/156,64.1％) whose SF was over 200 μg/L.Bone iron content combined with SF,age and BMI could be put into the regression models of BMD at various proximal femur sites (femoral neck R2=0.443,Wards triangle R2=0.397,greater trochanter R2=0.322 and total femur R2=0.379).After adjustment of age,weight,BMI and other factors,we found that bone iron content and SF were negatively correlated with BMD at proximal femur,but had no significant correlation with BMD at lumbar spine.Conclusion Iron accumulation is prevalent in postmenopausal women with hip fragility fractures.High bone iron content and SF are independent risk factors for low BMD at proximal femur.These results provide clinical evidences that iron accumulation is associated with postmenopausal osteoporosis.

目的：探讨髋部骨折高龄患者的呼吸系统管理，以防止并发症的发生。方法对58例髋部骨折高龄患者，加强呼吸系统的管理和护理。结果患者术后出现呼吸道并发症9例，包括肺部感染、肺不张、Ⅱ型呼吸衰竭，发生率为15．5％。结论髋部骨折高龄患者应尽早入院接受正规治疗，术前积极治疗合并症，改善肺功能，可减少围手术期呼吸系统并发症的发生。

Objective Detecting the femoral head bone iron contents of femoral neck fracture patients (postmenopausal women), and further contacting of bone mineral density(BMD),serum ferritin(FER)and serum bone metabolic markers to explore the potential values of the iron contents of bone tissue in osteoporosis patients. Methods 10 elderly women aged 56～87 years old(an average of 72.6 years old)as the older age group with the brittle femoral neck fracture (6 cases with walking falls, while 4 cases with sprains fell); Meanwhile 6 cases of young female violence femoral neck fracture(traffic accidents in 4 cases, rider fell 1 cases, falls 1 case)as the control group aged 19～43 years with mean 31 years; Both cases were hospitalized, single, non-open fracture with no inflammation abnormal indicators and no previous pathological history of iron overload. The serum specimens were measured for iron metabolism and bone metabolic markers were detected, the biopsy specimens were performed in both groups by a special require to detect the bone iron contents and bone iron were stained after operation and BMD considered of lumbar vertebras and hips were undertook after surgeries. Results Hip and L1-L4 BMD values, FER and 25-OH-VD,of elderly women were outside the reference range; while the control group were within it. The bone iron contents, FER, β-CTX and TRAP5b of postmenopausal group were significantly higher than those of the control group (88.9±47.2 μg/g vs 32.5±12.7 μg/g,234.3±91.70 ng/mL vs 69.6±42.5 ng/mL, 643.4±284.3 pg/mL vs 254.3±129.9 pg/mL,3.4±0.73 U/L vs 2.3±0.45 U/L; P<0.05), while hip and L1-4 BMD values were less than the control group(0.63±0.11 g/cm2vs 0.88±0.67 g/cm2, 0.87±0.10 g/cm2 vs 1.06±0.18 g/cm2; P<0.05). HE staining covered by Prussian showed iron was seen as blue-staining lines at the bone trabecular structures in old age group, and no obvious blue staining structures of control group were appeared; Specific iron deposition (blue staining areas) also could be showed outside of the trabecular bone structures in both groups. A significant phenomenon was found that bone iron contents and FER showed a positive correlation (r =0.966), and were negatively correlated with hip BMD values (r=-0.820)among postmenopausal women.Conclusion Postmenopausal women often had abnormal iron and bone metabolism. When bone iron contents increased, bone mass reduced. Iron contents of bone tissue may be a potential risk factor for osteoporosis in postmenopausal women.

目的探讨自制疼痛评估表在全膝关节置换围术期多模式镇痛管理中的作用。方法对153例全膝关节置换术后患者,使用疼痛评估表进行镇痛护理。结果疼痛评估表较好的反映了围术期疼痛的变化。结论疼痛评估表对准确了解患者围术期疼痛、及时给予镇痛处理可以起着重要的作用。

Background and objectives: Symptomatic ASD after lumbar spinal fusion surgery occurs most commonly in the cranial segment. The surgery for ASD contains anterior lumbar interbody fusion, posterior lumbar interbody fusion, decompression alone (laminotomy) and so on. But coblation nucleoplasty for ASD has not been reported previously. In this study, a case of coblation nucleoplasty after posterolateral fusion surgery at L4-L5 for adjacent segment degeneration (ASD) was reported and the clinical results were examined.Material and method: A 32-year-old male patient who had discectomy and fusion on the L4-L5 level seven years ago complained of chronic back pain for four months with numbness on his right leg for a month. X-ray revealed mild lumbar instability on L3-L4 segment. Magnetic resonance imaging confirmed a right-sided L3-L4 herniated disc compressing the L4 nerve root. He underwent L3-L4 coblation nucleoplasty. The visual analog scale (VAS) was adopted to assess the relief of back pain, leg pain and numbness.Results: The operation was performed successfully and the symptoms were relieved significantly at the follow-up of more than twenty-four months.Conclusion: Although coblation nucleoplasty is not a regular therapy for ASD, the excellent outcome of this case suggests that this technique might be an option before a complicated revision surgery.

目的 降低高危药物用药错误,提高患者用药的安全性.方法 分析2007年至2008年高危药物不良事件报告,应用SHEL模式归类分析,针对原因提出相应对策:S-soft软件部分,加强护士素质培训和风险意识培训,合理使用人力资源如APN排班及分组护理;H-hard硬件部分,设立高危药物放置屏障及明显警示标志、添加配药车;E-environment临床环境,改善工作流程、设定高危操作等;L-1itigant当事人及他人,高危药物双人核对等.结果 2009年至2010年高危药物用药失误发生情况较2007年至2008年显著减少.结论 应用SHEL模式分析差错,能客观找出差错原因,并制订相应各项措施,减少高危药物差错发生,提高患者用药安全性。

目的探讨多模式镇痛在骨科术后管理中的作用。方法观察335例全关节置换和股骨干、胫腓骨骨折内固定术后患者多模式镇痛效果及疼痛管理的作用。结果患者术后6h时疼痛评分升高(P<0.001),经及时处理后,疼痛评分均显著下降(P<0.001);使用不同镇痛方法,其副作用的发生率亦不同。结论围手术期多模式镇痛的实施中,疼痛管理起着重要的作用。

<正>人工髋关节置换术作为一种有效也较为成熟的治疗方法,既可改善关节功能,又可早期下床活动,提高生活质量,但针对高龄患者来说其创伤仍较大,术后并发症发生也较多,一旦发生并发症,可导致手术失败,甚至危及生命。我院骨关节中心2006年1月～2010年1月对181例高龄患者施行人工髋关节置换术,经过系统的并发症预防及进行有效的护