脓毒症是一个高病死率的疾病,炎症因子风暴及微循环障碍导致多器官功能衰竭是脓毒症/脓毒性休克的重要病理生理过程.氢溴酸山莨菪碱可以保护内毒素所致的脏器损伤、抑制炎症反应、有效改善微循环障碍,在临床上主要应用于脓毒性休克的治疗.本文拟从脓毒症/脓毒性休克的治疗新理念、氢溴酸山莨菪碱在脓毒症/脓毒性休克治疗的研究进展等方面进行综述,为早期阻断与预防脓毒症/脓毒性休克提供新的思路.

目的 观察性研究提示脓毒症与心力衰竭关系密切,但由于受到各种混杂因素的影响,导致它们之间的关系仍不确定.因此,笔者使用双样本孟德尔随机化(MR)来探索脓毒症与心力衰竭风险之间的因果关系.方法 本研究从两项最广泛的全基因组关联研究中获得了脓毒症和心力衰竭的汇总统计数据.为了使结果更加稳健和可靠,使用了几种稳健的分析方法(逆方差加权、MR-Egger回归、MR-PRESSO、最大似然比、简单中位数和加权中位数)进行了补充分析.此外,本研究采用MR-Egger截距检验、Cochran's Q检验、漏斗图和"留一法"等对上述纳入的遗传变异工具变量的多效性和异质性水平进行评估.结果 笔者发现,脓毒症可能会增加心力衰竭发生的相对风险(OR=1.684,95％CI 1.587～1.786,P=0.001),而上述关系同样在加权中位数(OR=1.726,95％CI 1.585～1.881,P=0.001),MR-Egger回归(OR=1.768,95％CI 1.508～2.075,P=0.001),最大似然比(OR=1.686,95％CI 1.607～1.769,P=0.001),MR-PRESSO(OR=1.691,95％CI 1.590～1.799,P=0.001)中被证实.其次,MR-Egger截距检测(P=0.516)和检验显示,上述所纳入的遗传变异工具变量并不存在任何多效性.结论 脓毒症和心力衰竭发生的相对风险之间可能存在因果关系.

Objective:To investigate the relationship between serum ubiquitin C-terminal hydrolase-L1 (UCH-L1) and neuroglobin levels and the prognosis of neurological function in coma patients after cardiopulmonary resuscitation, and to analyze their value in predicting the prognosis of patients.Methods:From February 2018 to June 2020, 45 comatose patients admitted to the Chengdu Third People′s Hospital of Sichuan Province after successful cardiopulmonary resuscitation were prospectively selected as the coma group, and 62 patients admitted to the emergency intensive care unit during the same period after successful cardiopulmonary resuscitation with consciousness recovered within 24 hours were selected as the control group.Serum UCH-L1 and neuroglobin levels were detected within 24 hours after admission.Glasgow coma Scale (GCS)and cerebral performance category(CPC)were used to evaluate coma severity and neurological prognosis.Spearman rank correlation analyzed the correlation between UCH-L1 and neuroglobin levels and GCS and CPC scores.Logistic regression analyzed the factors affecting the prognosis of neurological function in coma patients after cardiopulmonary resuscitation.Receiver operating characteristic curve (ROC) was used to analyze the value of UCH-L1 and neuroglobin in predicting the prognosis of neurological function in coma patients after successful cardiopulmonary resuscitation.Results:In coma group, serum UCH-L1((0.63±0.21) μg/L) and the concentration of neuroglobin ((89.34±21.35) mg/L) was higher than that in the control group ((0.27±0.08) μg/L, (32.13±9.21) mg/L), the difference was statistically significant( t=12.338, 18.846; all P<0.001). The levels of UCH-L1 and neuroglobin in mild, medium and severe coma groups were increased in turn, and the differences between the groups were statistically significant( F=86.430, 26.958; all P<0.001). The serum levels of UCH-L1((0.72±0.06) μg/L)and neuroglobin ((100.35±5.79) mg/L)in the group with poor neurological prognosis were higher than those in the group with good neurological prognosis((0.52±0.08) μg/L, (75.58±6.91) mg/L), and the differences between the groups were statistically significant( t=9.585, 13.086; all P<0.001). UCH-L1 and neuroglobin were negatively correlated with GCS score(rs=-0.685, -0.669; all P<0.001), and positively correlated with CPC score (rs=0.688, 0.670; all P<0.001). Multivariate Logistic regression analysis showed that low GCS score( OR=0.552, 95% CI: 0.392-0.776, P<0.001), high UCH-L1 ( OR=1.881, 95% CI: 1.276-2.773, P<0.001)and neuroglobin( OR=1.677, 95% CI: 1.206-2.331, P=0.001)were independently associated with poor neurological outcomes in coma patients after cardiopulmonary resuscitation .The AUC of combining UCH-L1 and neuroglobin in predicting poor neurological outcomes in coma patients after cardiopulmonary resuscitation was 0.954, which was higher than that of UCH-L1 and neuroglobin alone (0.821, 0.790) ( Z=2.351, 2.649; all P<0.05). Conclusion:After successful cardiopulmonary resuscitation, the levels of UCH-L1 and neuroglobin in coma patients are increased.High levels of UCH-L1 and neuroglobin are associated with coma severity and neurological dysfunction, which can be used as a potential biological indicator for prognosis evaluation of neurological function.

目的 探讨机械按压对急诊科非创伤心搏骤停患者自主循环恢复(ROSC)及预后的影响因素.方法 回顾性分析2018年6月1日—2019年12月31日在急诊抢救室使用机械按压治疗的急性非创伤性心搏骤停患者的临床资料,根据心搏骤停患者心肺复苏(CPR)后是否发生ROSC,分为ROSC组和非ROSC组,采用多因素logistic回归分析影响心搏骤停患者机械按压后ROSC及预后的影响因素.结果 单因素分析显示CPR持续时间≤30 min,肾上腺素用量≤5 mg,早期使用Lucas心肺复苏仪(≤4 min),入抢救室时pH>7.05,Lucas使用后15 min呼气末二氧化碳分压(PetCO2)是心搏骤停患者使用机械按压后ROSC的独立影响因素(P<0.05).经过多因素logistic回归分析校正混杂因素后最终显示CPR持续时间≤30 min(OR=283.489,95％CI 14.474～5552.565),早期使用Lucas(≤4 min)(OR=1.986,95％CI 0.298～13.223),入抢救室时pH>7.05(OR=0.054,95％CI 0.005～0.589),Lucas使用后15 min PetCO2>20 mm Hg(OR=0.005,95％CI 0.000～0.149)是机械按压后ROSC的保护因素(P<0.05).机械按压可以提高急诊科心搏骤停患者的ROSC率,早期使用Lucas(≤4 min)和晚期使用Lucas(>4 min)两组相比ROSC恢复后最终存活入院率相似,但早期组4h存活率较好.结论 对于急诊非创伤性心搏骤停患者,早期使用机械按压可能提高急诊科非创伤心搏骤停患者的ROSC率和4 h存活率.复苏时间,早期使用Lucas,入抢救室时pH和Lucas使用15 min后PetCO2值与ROSC密切相关.

高质量的胸外按压是高质量心肺复苏的核心.心肺复苏辅助装置和团队心肺复苏可改善人工胸外按压的低效能,因此在心搏骤停抢救中使用越来越广泛.现主要对心肺复苏辅助装置的原理、研究进展、应用前景和团队心肺复苏的发展理念进行综述.

目的 探讨血浆成纤维细胞生长因子23(FGF23)、血管生成素2(Ang2)水平对急性呼吸窘迫综合征(ARDS)患者并发急性肾损伤(AKI)的预测价值.方法 选择2018年9月—2020年10月成都市第三人民医院收治ARDS患者210例,其中合并AKI 86例(AKI组),未合并AKI 124例(NAKI组).检测患者血浆FGF23、Ang2水平,Pearson相关或Spearman秩相关分析血浆FGF23、Ang2与AKI分期及肾功能相关性,Logistic回归分析ARDS并发AKI的危险因素,受试者工作特征曲线(ROC)分析血浆FGF23、Ang2预测ARDS患者并发AKI的价值.结果 AKI组血浆FGF23、Ang2水平高于NAKI组(t/P=25.182/0.000、10.331/0.000),AKI 3～5期亚组患者血浆FGF23、Ang2水平高于AKI 1～2期亚组(t/P=36.032/0.000、46.870/0.000).血浆FGF23、Ang2水平与AKI分期、尿素氮(BUN)、血肌酐(SCr)、胱抑素C(CysC)水平呈正相关(FGF23:r/P=0.639/0.000、0.515/0.005、0.603/0.000、0.534/0.002;Ang2:r/P=0.647/0.000、0.521/0.005、0.657/0.000、0.559/0.000),与肾小球滤过率(eGFR)水平呈负相关(r/P=-0.705/0.000、-0.683/0.000).Logistic回归分析显示,高血压、ARDS分级重度及高水平FGF23、Ang2是ARDS并发AKI的危险因素[OR(95％CI)=1.702(1.652～1.832)、1.828(1.765～1.943)、1.790(1.653～1.837)、1.824(1.718～1.936)].ROC分析显示,血浆FGF23联合Ang2预测ARDS患者并发AKI的AUC为0.934,高于单独FGF23和Ang2检测的0.709、0.771(Z/P=2.698/0.002、2.302/0.009).结论 血浆FGF23、Ang2水平升高与ARDS并发AKI密切相关,可作为肾损伤的预测指标,联合血浆FGF23和Ang2可提高诊断AKI的效能.

腹痛是急诊常见疾病,疼痛得不到及时控制可使患者身心受损.传统医学认为镇痛可能延误诊断,目前早期镇痛的观念尚未普及,且临床实施存在不足之处.对急诊腹痛快速诊断,合理的疼痛评估,选择适当的镇痛药物和用药方式,有利于改善患者体验和预后.本文针对早期镇痛的意义及镇痛方式等研究进展进行综述.

由于颌面外科手术的特殊性及其培养体制的限制,口腔颌面外科学生普遍不能较好掌握颌面外科相关手术及其应用,达不到培养的目的和要求.近年来,随着计算机三维模拟技术的发展,数字化外科逐渐成熟.在口腔颌面外科教学中结合计算机三维模拟技术,将其与传统的教学方式有机结合,才能更好地培养更多优秀的颌面外科医师.笔者近年来,在口腔颌面外科教学培养中应用了Dolphin软件系统,取得了较好的效果.

3D printing technique, a rapid prototyping technique, which is developing fast, has already been used in oral and maxillofacial clinical surgery. At the same time, 3D printing model is playing a more and more important role in the education field. This review focuses on the application of 3D printing to oral and maxillofacial surgery education.

Objective:To investigate the primary cause of coma in emergency internal medicine and to establish a standard process for diagnosis and treatment of coma.Method:A total of 164 patients with coma were randomly divided into routine group (n=60) and experimental group (n =104) in the experimental group a established standard procedure for diagnosis and treatment of coma will be applied to clarify its clinical benefit and health economics benefit.Result:There were significant differences in the rate of recovery of consciousness,the time needed for diagnosis,and the cost of examination and medication compared with the routine group (P＜0.05).Conclusion:Standard coma diagnosis and treatment process can improve the recovery rate,reduce the time required for clear diagnosis,the cost.

目的:探究TBL联合CBL教学法在口腔颌面外科临床教学中的应用效果.方法:将60名实习生随机分为对照组和实验组.分别采用传统教学法和TBL联合CBL教学法进行教学,对比分析两种教学法的教学效果.结果:出科考核实验组技能及理论成绩均高于对照组,差异具有统计学意义;问卷调查显示TBL-CBL联合教学法更受学生们的认可.结论:TBL联合CBL教学法有利于提高口腔颌面外科的临床教学质量,值得在颌面外科教学中进行推广.

数字化切片库的建立打破了传统组织切片的局限,将其引入传统的口腔组织病理教学中,应用于从本科教育、住院医师规范化培训到网络教育、继续教育等各个层次的教学,可以充分发挥学生在教学中的主体作用,激发学生的学习热情,提高学生自主学习和创新能力.

目的 评价医患沟通课程效果并为医患沟通人文医学类课程的设置和内容作进一步探寻.方法 将2010、2011级的口腔医学本科实习学生就有无选修医患沟通类课程为基础将其分为A医、B医两组,临床实习对应接诊处理的患者分为A患、B患两组,对两组双向分别进行问卷调查以评价实习医学生医患沟通行为及人文执医的能力.应用SPSS 17.0软件进行数据分析,组间各项比较采用卡方检验.结果 87.91％的医学生具有良好的职业认同感,仅17.58％的患者认为他们的接诊医生具有较好的职业感.学生自我评价和患者评价共同表示,在“制定治疗方案能否与患者共同选取方案”、“操作过程中能否运用适当的肢体语言关怀患者情绪”两项中,A组的评价均高于B组(P＜0.05),仅34.07％的学生认为自己有较好的处理特殊患者的能力.结论 我院医患沟通类课程取得一定的课程效果,但在学生形象管理、心理管理、早期社会医患接触方面的工作需给予关注并加强.

目的：通过分析成都市第三人民医院急诊科就诊的自杀患者的流行病学特点，为建立自杀防控网络提供理论依据。方法回顾性统计1999～2013年我院急诊科就诊的391例自杀患者的临床资料，分析其流行病学特点。结果391例患者共自杀485次，年龄（45．85±12．65）岁。其中男97例（24．81％）124次（25．57％），女294例（75．19％）361次（74．43％）。未成年组43例（10．99％），青年组270例（69．05％），中年组54例（13．81％），老年组24例（6．14％）。自杀方式依次为服用药物（47．07％）、割腕（24．54％）、跳楼（11．13％）、自缢（5．98％）、吞异物（3．71％）、淹溺（2．47％）、煤气中毒（2．62％）、电击（1．03％）。自杀成功死亡人数42例（占总人数的10．74％），2009年为自杀人数最低点，其后有逐渐上升的趋势；反复自杀者26例，自杀成功率达到34．62％。结论在我科就诊的自杀人数近年来有上升趋势，建立完善的自杀防控网络势在必行。

目的 探讨急诊胃镜检查在急性上消化道出血诊断与治疗中的价值.方法 对546例急性上消化道出血患者的急诊胃镜诊治结果及其转归情况进行回顾性分析,描述急诊胃镜对上消化道出血病因的诊断率和内镜下治疗的成功止血率.结果 本组546例中,消化性溃疡占46.1％,食管/胃底静脉曲张破裂出血占26.0％,急性胃黏膜病变占12.3％,食管贲门黏膜撕裂占9.2％,恶性肿瘤占3.5％,Dieulafoy病占1.6％,原因不明者占1.3％,病因确诊率为98.7％.共258例行内镜下治疗,占47.3％,内镜止血成功率为95.3％.结论 急诊胃镜对急性上消化道出血的病因诊断和止血治疗安全有效.

Objective To explore the prognostic value of BNP in patients with CPR. Methods A total of 98 patients with sudden cardiac arrest were divided into 3 groups according to the effect of Cardiopulmonary Resuscitation. 42 patients were all died in group A after CPR for half an hour. 21 patients in group B were all died during this hospitalization after the return of spon-taneous circulation for 24 hours. 35 patients in group C were all survival to hospital discharge. Group D, ased the control group, were composed of 20 healthy peoples. In group A, B, and/C, peripheral venous blood(2ml)were taken to measure the BNP con-centration at the time of 0h、0. 5h、4h、8h、12h and 24h after CPR Blood samples(2ml) of the control group were taken at early morning on an empty stomachall. Results Compared with control group D, the BNP level in Group A, B and C were all statisti-cally significant higher(P<0. 05)at the time of 0h. The BNP level in Group B expressed continuing ascending during 24h. The BNP level in Group C expressed continuing ascending and reached the peak at 8h, then declined gradually during 8~24h. Con-clusion During CPR, the expression of BNP showed dynamic changes. Higher BNP level indicateed poor prognosis.

医学研究生的职业素质水平直接关系到医疗卫生服务的整体质量和医疗卫生事业的发展,而当前我国医学研究生的就业选择期望严重脱离了社会需求,该现象造成了研究生就业率低,偏远落后地区医学人才匮乏,人民群众“看病难,看病贵”等一系列问题.合理调整研究生教育,优化医疗卫生资源的配置是解决这些问题的首要措施.

In order to guide students to apply regional anatomy knowledge to clinical skill manipulation and help them enhance their manipulation ability and theory learning , we conducted research and practice of integrating surgical simulation with head-and-neck anatomy teaching .Evaluation of teaching results after the course was over shows that this teaching reform can promote students 'grasping anatomical knowledge and improve surgical manipulation and clinical thinking abilities .Applying the teaching approach in the reform of anatomy teaching has achieved good teaching results and upgraded teaching quality .

虚拟仿真技术在医学教育领域的应用已日益广泛.该文结合四川大学华西口腔医学院虚拟仿真实验教学中心建设情况,对中心的数字化3D虚拟口腔解剖实习平台、穆格数字化虚拟口腔技能培训系统及口腔医学仿真机器人实习机等虚拟仿真实验平台作一介绍,并对虚拟仿真技术在口腔医学教育领域的应用作一展望.

Background: Paraquat is one of the most commonly used herbicides in the world.Since liver, kidney, heart and CNS,especially lung are affected after intoxiation,the use of paraquat is controversial.Once it is mistakenly taken by a person ,lung damage resulting to pulmonary fibrosis is the usual cause of deaths in the cases with intoxication. The mechanism of paraquat toxicity is not clear but probably includes the induction of lipid peroxidation of unsaturated fatty acids. Lisinopril, an angiotensin-converting enzyme inhibitor (ACEI), has beneficial effects on the treatment of fibrosis in oversea reports. however the antifibrotic effect and mechanism of lisinopril on lung fibrosis caused by paraquat has been rarely reported . my research aims to approach antifibrotic effect and mechanism of ACE-Ⅰ on paraquat-induced lung fibrosis. Method 50 Male albino Wistar rats were used in the experiments (weighing 150~300 g). The animals were divided into 5 groups: group Ⅰ received saline, group Ⅱ received lisinopril (1 mg/kg; po), group Ⅲ was given a single ip. dose of 20 mg/kg paraquat, group IV (treatment group) received lisinopril after single a ip. dose of 20 mg/kg paraquat, and group Ⅴ (pre-treatment group) received lisinopril before a single ip. dose of 20 mg/kg paraquat. After 21 days of treatment, the level of hydroxyproline and the degree of lipid peroxidation were determined in the lung tissue of the animals and the lungs were examined histologically for fibrosis. Result Paraquat caused a significant increase in hydroxyproline content and lisinopril significantly decreased the amount hydroxyproline(P<0.001) in the lung tissue of the rats. The histological examination also indicated that lisinopril can effectively protect the paraquatinduced lung fibrosis. The lipid peroxidation levels in the lung were not significantly changed when compared to the control group. Conclusion The antifibrotic effect of lisinopril may be due to inhibition of angiotensin II or proline moiety, which is a common structural in all ACEI, drugs.