目的:介绍应用彩色多普勒在术前对股前外侧皮瓣穿支血管进行精准定位后，切取不携带主干血管的短蒂单穿支股前外侧皮瓣游离移植修复四肢中小面积皮肤缺损的手术方法和临床效果。方法:自2017年12月至2019年9月，我科对15例四肢中小面积皮肤缺损患者应用短蒂股前外侧单穿支皮瓣游离移植修复，皮瓣供养动脉与受区动脉端侧吻合，皮瓣静脉与受区静脉端端吻合。皮瓣切取面积6 cm×5 cm~11 cm×7 cm，所有皮肤缺损创面均伴有肌腱或骨外露，皮瓣均为单穿支皮瓣，皮瓣的游离时间为30~40 min，平均切取时间为35 min。皮瓣供区一期缝合。结果:术后15例皮瓣全部存活，随访时间3~12个月，平均7.2个月，皮瓣外形满意，供区创面Ⅰ期愈合。结论:利用彩色多普勒在股前外侧的近中段对皮瓣穿支入皮点及穿支血管在皮下和肌肉内的行径进行精确定位，选择合适的穿支作为皮瓣的供养血管，应用"Free-style"理念切取短蒂股前外侧皮瓣，对供区损伤小，切取较传统方式简便，手术时间短，供区能直接缝合，是一种理想的应对血管变异的手术方法。对显微外科技术和彩色多普勒操作技术和要求较高。

Objective:To summarize the clinical application value of color Doppler ultrasound (CDU) in the nursing observation of flap vascular circulation after free flap transplantation.Methods:From September 2018 to November 2020, 18 patients with skin defect of limbs treated by free flap transplantation in the Second Affiliated Hospital of Wenzhou Medical University were monitored by skin color, skin temperature, skin tension, capillary reaction time and CDU. When the vascular circulation disorder was found, the patients should be treated with volume expansion, rehydration, local massage of the flap, anticoagulation and microcirculation improvement. Positive drainage under the flap to prevent infection, combined with hyperbaric oxygen treatment, accurate and timely exploration of vascular crisis to avoid flap necrosis.Results:Postoperatively, CDU monitoring found that 2 cases had regional vascular circulation disorder, 1 case had complete embolization of the main vessels and perforators in the flap, the flap was thinned and changed to full thickness skin grafting, the deep tissue exposed area was healed by dressing change, and 1 case had incomplete embolization of the flap′s reflowing vein. After operation, the venous crisis was relieved and the flap survived completely.Conclusions:Comprehensive observation is needed after free flap transplantation. Combined with four routine vascular circulation indexes, CDU monitoring of flap blood flow can provide more objective, accurate and detailed basis for vascular circulation status, and can accurately find the vascular circulation disorder after free flap transplantation in early stage, and understand the vascular flow status of the flap, so as to effectively avoid the continuous progress of vascular crisis, to avoid flap necrosis and improve the survival rate of flap.

目的 本研究旨在确立前列腺增生症患者尿流动力学检查后尿路感染的临床危险因素,并建立预测尿路感染风险的列线图模型.方法 以2014年1月至2019年9月间在我院完成尿流动力学检查的540名前列腺增生症患者为研究对象,采用多因素Logistic回归分析方法筛选临床危险因素,并建立预测前列腺增生症患者尿流动力学检查后尿路感染发生概率的列线图模型.通过受试者工作特征(ROC)曲线和重复1000次Bootstrap自抽样方法检验模型区分度,绘制校准曲线来评价模型一致性.结果 多因素Logistic回归分析显示年龄≥65岁、糖尿病、存在尿路感染史以及膀胱出口梗阻(均P＜0.05)是前列腺增生症患者尿流动力学检查后尿路感染发生的危险因素.运用ROC曲线及重复1000次Bootstrap自抽样方法计算的一致性指数(C?index)分别为0.754及0.735,表明模型具有良好的区分度;校正曲线接近45度斜线的理想曲线,提示该模型具有良好一致性.结论 基于上述4个危险因素构建的列线图具有良好的预测性能,是预测前列腺增生症患者尿流动力学检查后尿路感染的一种可靠、简便的临床工具.

Objective To?discuss?the?biofeedback?electric?stimulator?with?solifenacin?tablets?in?the?treatment?of?post?prostatic?plasma?resection?lower?urinary?tract?symptoms(LUTS).?Methods 68?patients?with?post?prostatic?plasma?resection?LUTS?admitted?in?our?hospital?from?January?2017?to?January?2018?were?selected?as?the?subjects.?Sixty-eight?patients?were?divided?into?two?groups?according?to?the?difference?of?treatment?methods.?33?patients?treated?with?solinaceous?new?tablets?were?set?as?control?group,35?patients?treated?with?biofeedback?electrical?stimulation?apparatus?combined?with?solinaceous?new?tablets?were?set?as?experimental?group.?The?clinical?effects?of?the?two?groups?were?retrospectively?compared?and?analyzed.?Results After?treatment,the?prostate?symptom?score?of?the?experimental?group?was(8.76±1.25),which?was?lower?than?that?of?the?control?group(11.02±1.56), with?statistically?significant(P<0.05).?The?residual?urine?volume?in?the?experimental?group?was?lower?than?that?in?the?control?group,and?the?maximum?urine?flow?rate?was?greater?than?that?in?the?control?group,with?statistically?significant(P<0.05).?The?score?of?incontinence?questionnaire?in?the?experimental?group?was?lower?than?that?in?the?control?group,with?statistically?significant(P<0.05).?Conclusion The?biofeedback?electric?stimulator?combined?with?solifenacin?tablets?can?effectively?relieve?the?symptoms?of?the?prostate,improve?the?dynamics?of?urine?flow?and?alleviate?the?symptoms?of?urinary?incontinence?after?the?treatment?of?LUTS,have?the?value?to?choice.

To introduce the repairation procedure of composite distal soft tissue defect of thumb and finger with mini toenail flap. Methods From June, 2015 to June, 2018, 7 cases with composite tissue defect at 7 distal fingers, including 5 thumbs, 1 index finger and 1 middle finger, were reconstructed with mini toenail flap transfer.The flap sizes which were raised during the operation ranged from 4.5 cm×3.0 cm-3.0 cm×1.5 cm.The donor sites were covered by toe phalanx shortening, V-Y advancement flap and local pedicle flap. Microsurgical routine treatment was made after the operation, and followed-up regularly. Results Seven flaps of 7 cases completely sur-vived without any necrosis. All the wounds at the donor sites healed well. All patients were followed-up for 6-36 months. The motive, sensor and cosmetic result were satisfied. In sensory function, the two-point discrimination dis-tance could restore to be 4-6 mm. Conclusion The mini toenail flap transfer is a reliable and suggested method.It can anatomically restored the distal digit sensor function with cosmetic contour, and regain the motive, sensory func-tion and satisfied cosmetic appearance.

目的 总结大面积股前外侧皮瓣游离移植术后按血管蒂和皮瓣穿支位置分区域的血液循环观察方法与护理体会.方法 2017年9月-2019年3月, 对20例大面积股前外侧皮瓣游离移植术后按血管穿支分区对皮瓣进行血液循环监测,及时输血补液,局部按摩,抗凝、活血治疗,积极换药预防感染,配合高压氧治疗,早期发现血管危象和避免皮瓣坏死.结果 术后2例出现区域性血液循环障碍,2例出现皮瓣下感染,1 例出现供区近端植皮坏死,1 例出现皮瓣的穿支内增压区血供不足.经早期发现及处理后,本组皮瓣均成活.结论 大面积股前外侧皮瓣游离移植术后需全面观察,按血管穿支分区观察能在极早期发现血液循环障碍,有效避免血管危象发生,提高皮瓣成活率.

Objective To evaluate dynamic contrast-enhancement combined with intravoxel incoherent motion ( IVIM) diffusion-weighted ( DW) MRI for differentiating benign from malignant breast lesions. Methods The clinical data of 60 cases of breast diseases confirmed by pathology in our hospital from October, 2016 to September, 2017 were retrospectively analyzed ( benign: 25 cases, malignant: 35 cases). Conventional MRI, dynamic contrast enhancement and IVIMDWI ( b = 0-1 200 s/mm～2) examination were performed in all patients. Lesion morphology, enhancement pattern, time signal curve and the relevant parameters of IVIM model were analyzed to evaluate the differential diagnostic value between breast benign and malignant lesions respectively. Results The irregular margin with or without spiculation and heterogeneous enhancement were mostly seen in breast cancer ( P = 0.003, 0.004, respectively). TIC type Ⅲ was mostly seen in breast cancer, TIC type Ⅰ and Ⅱ were mostly seen in breast benign ( χ～2= 19.272, P＜ 0.01). Except D*value, there were statistically significant differences among the IVIM related parameters ( t = 3. 301, -5. 247, 3. 899, all P＜ 0.05).ROC analysis showed that the AUC of D value was 0.873 which was the highest one. AUC was increased to 0.941 by combining D with f value for diagnosis. Conclusion Magnetic resonance dynamic contrast enhancement combined with IVIM model related parameter values can improve the value of differentiating benign from malignant breast lesions, and shows a higher diagnostic efficiency.

目的:研究分析对手术室腔镜器械应用精细化管理的效果.方法:选取2016年6月～2017年6月医院收治的300例行手术治疗患者,随机分为两组,每组150例,其中对照组手术室腔镜器械采取常规管理,观察组予以精细化管理,比较两组患者对护理质量的评分及患者满意度.结果:观察组患者的满意度,显著高于对照组(P＜0.01),观察组患者在无菌情况、护理记录、物品管理、基本护理及健康教育护理质量等方面的评分,均显著高于对照组(P＜0.01).结论:精细化管理应用于手术室腔镜器械中,能提高护理水平,有效提高患者对治疗的满意度,改善医患关系.

Objective To discuss the surgical method,treatment outcome and clinical significance of modified unilateral neurovascular V-Y flap for repair of skin defects in volar distal fingers.Methods From May 2016 to August 2017,28 cases (30 fingers) with skin defects in volar distal fingers were treated by modified unilateral neurovascular V-Y flap.The size of skin defects ranged from 1.5 to 2.0 cm2.The donor sites were closed straightly.Results All the flaps survived uneventfully.All the patients were follow-up for 6 to 12 months with an average of 9 months.The appearance of the flap was satisfactory and the two-point discrimination was 4 to 6 nn.Conclusion It is simple and reliable to repair the skin defects in volar distal fingers using modified unilateral neurovascular V-Y flap.While covering the wound,it can restore the appearance and sensation of the pulp at the same time.

Objective To discuss the operation method,treatment effects and clinical significance of sequential flap pedicled with the dorsal metacarpal artery for repair of the wound of donor site at the dorsum of the finger.Methods From August 2014 to August 2016,6 cases (6 fingers) with soft tissue defects at middle segment of the finger were treated with the proximal dorsal digital flap,and the donor site at dorsum of the middle segment of the finger was covered by sequential flap pedicled with the dorsal metacarpal artery.The donor sites of the dorsal metacarpal flaps were sutured directly.The flap sizes ranged from 3.0 cm×2.0 cm to 4.0 cm×2.5 cm.Results All the flaps survived uneventfully.The average hospitalization time was 10 days.All the patients were follow-up for 6 to 12 months postoperatively.The texture,color,plumpness and elasticity of the proximal dorsal digital flap were satisfactory,as well as the motor function of injured fingers.No tendon adhesion and joint stiffness occurred.The dorsal metacarpal donor sites achieved satisfactory appearance without scar hyperplasia.All the patients were satisfied with the appearance and function of injured fingers.Conclusion Application of sequential flap pedicled with the dorsal metacarpal artery for repair of the wound of donor site at the dorsum of the finger is beneficial to the early rehabilitation of the injured fingers because of good appearance and durability.The operation method is safe and simple,and has little damage to the donor site.Therefore,it is an improvement of repairing the donor site of digital arterial dorsal branch flaps.

Objective Through the adjustment of controllable factors, to improve the diffusion weighted imaging and dynamic enhanced imaging image quality. Methods 305 cases of female breast lesions were selected, and subjected to cross sectional T1WI, T2WI, diffusion weighted imaging with saturated fat technology, dynamic enhanced scan. Using GE with analysis software, we selacted ROI in abnormal strengthening lesions and drew the time signal intensity curve (TIC). The factors that affected image quality were compared and analyzed. Results 283 images had enough signal to noise ratio, the T1 perfusion time signal intensity curve resolution was reasonably good. Conclusion By optimizing the controllable factors, making the procedural breast magnetic resonance imaging technology can obtain higher quality of magnetic resonance imaging.

目的 探讨磁敏感加权成像(SWI)在新生儿颅内出血的诊断价值,并比较早产儿与足月儿间的差别.方法 对115例怀疑脑损伤的新生儿行常规MRI、DWI和SWI检查,明确有无颅内出血并记录各序列出血灶个数,比较3种方法在颅内出血检出率、分布区域及病灶检出个数的差异,并比较早产儿与足月儿间颅内出血分布区域及病灶检出个数的差异.结果 115例新生儿中,SWI的颅内出血检出率高于常规MRI及DWI(检出率分别为32.2％、26.1％、12.2％,P＜0.05),常规MRI亦较DWI高(P＜0.05).37例颅内出血新生儿,常规MRI、DWI及SWI检出颅内出血灶分别为66、33、125个,SWI较常规MRI及DWI、常规MRI较DWI显示更多出血灶(均P＜0.05).出血灶主要位于生发基质-脑室、大小脑半球(分别为33、34、25个),SWI较常规MRI及DWI显示更多这些部位的出血灶(均P ＜0.05);常规MRI及SWI较DWI更敏感地显示蛛网膜下腔出血及硬膜下出血(P＜0.05),但常规MRI与SWI相仿.早产儿出血灶总数及生发基质-脑室出血灶数目均多于足月儿(P＜0.05),而其他部位出血灶数目差异无统计学意义(P＞0.05).结论 SWI对新生儿颅内出血检出优于常规MRI及DWI,但各序列显示不同部位颅内出血差异存在统计学意义,对怀疑有颅内出血的新生儿,应行上述序列检查以综合判断有无颅内出血及出血数目.上述结果可为新生儿颅内出血的临床诊断、治疗及预后评估提供重要依据.

目的:评价并分析在手术室护理管理中,应用护理安全风险管理的效果.方法:选取医院的282例手术室患者,随机分为观察组141例和对照组141例.观察组采用护理安全风险管理模式,对照组采用常规手术室护理模式,比较两组患者的风险事件发生率、纠纷投诉事件发生率及对护理的满意度评分.结果:与对照组比较,观察组的风险事件总发生率显著低于对照组(P＜0.05),纠纷和投诉事件发生率也较对照组有所降低,患者及其家属对护理满意度显著高于对照组(P＜0.05).结论:护理安全风险管理的应用,降低了手术室息者风险事件发生的概率,增加了患者的满意度.

Objective To study the diagnostic value of intravoxel incoherent motion (IVIM) diffusion-weighted MRI in differentiating benign from malignant breast lesions.Methods 50 female patients with lesions verified by pathology were included in this study,all of them underwent multi-b value (b=0-2000s/mm2) DWI scanning.Tissue diffusivity (D),pseudo-diffusivity (D*),perfusion fraction (f) and apparent diffusion coefficient (ADC) were acquired using IVIM model.The difference of these parameters in benign and malignant breast lesions was analyzed statistically.The diagnostic performance of these parameters was evaluated by ROC analysis.Results In benign lesions,D,D*,f and ADC value was (1.31±-0.47) ×10-3 mm2/s,(26.47±13.81) ×10-3 mm2/s,(17.35±3.78)％,(1.37±0.37)×10-3 mm2/s,respectively.In malignant lesions,D,D*,f and ADC value was(0.95±0.28)×10-3 mm2/s,(24.58±14.62)×10-3 mm2/s,(23.69±4.35)％,(1.03±0.14)×10-3 mm2/s,respectively.There were statistically significant differences between benign and malignant lesions in D,f and ADC value (t=3.203,-5.139,3.991,P＜0.05).There was no statisticaly significant difference in D* value (P＞0.05).ROC analysis showed that AUC of D value was 0.866,which was the highest one.AUC was increased to 0.934 by combining D with f value for diagnosis.Condusions The parameters acquired from IVIM model are useful to differentiate benign from malignant breast lesions.D value obtained from IVIM model may have relatively high sensitivity and specificity,D Combined with f value can obtain the best diagnostic performance.

患者40岁，男性，因机器压伤致左手4 h 入院，患者表现为左第一腕掌关节和掌指关节毁损，左拇指由掌指关节平面不全离断，拇指指体完整；左示指的远节毁损，左示指近节、中节开发骨折并伴桡侧血管神经束断裂；左腕桡背侧创面皮肤软组织大面积缺损，拇指无法一期原位再植（图1）。臂丛加连续硬膜外麻醉下行创面清创，左示指末节截指，同时左示指近节、中节骨折复位后用克氏针固定，修复左示指桡侧的指动脉及指神经；左腕桡侧清创后缺损背面积为10 cm ×8 cm，用尺动脉腕上支皮支皮瓣覆盖，皮瓣供区取对侧大腿中厚皮片植皮。离断拇指异位寄养在同侧股外侧区（图2）。拇指尺侧指动脉与旋股外侧动脉降支的1条穿入股外侧肌的分支吻合，拇指的指背静脉与穿支血管的伴行静脉端－端吻合，术后寄养指成活，术后2周出院。

目的 探讨MRI在老年宫颈癌患者术前诊断及病理分期中的价值.方法 回顾性分析温州市中心医院2013年8月～2016年8月收治并经宫颈活检证实为宫颈癌的90例老年患者的临床资料及影像学资料,依据肿瘤在MRI图像上的位置、大小、信号特点及浸润范围等情况进行分期,并与术后病理分期结果进行比较.结果 本组90例宫颈癌患者除3例Ⅰa期在MRI上未被检测出,其余87例均被检出,即术前检出率为96.7％(87/90),且肿瘤形状为类圆形(64例)或不规则形(23例),在T1WI呈等信号者71例,呈稍低信号者16例,全部肿瘤在T2WI呈稍高信号,增强扫描后均出现不同程度强化.60例手术患者的肿瘤平均大小为(1.95±1.12)cm,术后病理测量标本平均大小为(1.94±1.11)cm,差异无统计学意义(P＞0.05).以术后病理分期结果为金标准,临床分期的准确率为61.7％(37/60),MRI分期的准确率为86.7％(52/60),差异有统计学意义(P＜0.05).结论 MRI对老年宫颈癌患者的术前诊断准确率较高,且MRI分期准确率明显高于临床分期,能够提供出客观准确的诊疗依据,应作为影像学检查的最佳方法进一步推广与应用.

Objective To compane and explore the magnetic sensitive weighted imaging ( SWI) in the diagnosis of premature infant brain damage value .Methods 50 cases of clinical examination of premature infant brain injury patients (1 w after birth), line T1 WI, T2 WI, FLAIR, DWI and SWI axis can scan , assessment record low signal on the sequences of different parts and the number and area .Results In 50 cases of premature infants , T1 WI, T2 WI, FLAIR, DWI, SWI can find the number of lesions , respectively 108, 82, 123, 82, 204, SWI was more sensitive than conventional sequence to display hemorrhage stove , difference was statistically significant.In the same place for displaying the lesion size range , SWI was best (0.72 ±0.58), compared with T1 WI, T2 WI, (0.50~0.48) was clearly apparent , difference was statistically significant .Conclusion SWI sequence is easier to find lesions than others micro hemorrhage stove , SWI can also detect premature deep brain marrow venous duct , incomparable advantages with other methods .

Objectives: To understand the present situation of core self evaluation and work flow of the nurses in operation room in tertiary hospials and to discuss the relationship between core self evaluation and the work flow among nurse. Method: A total of 1988 operating room nurse in three level hospitals in Zhejiang were selected by the Nurse's Core Self-evaluations Scale and work-related Flow. Results: There is a positive correlation among nursing core self-evaluations and work flow. Conclusions: It is considered to pay attention to the core self-evaluation and the work flow which is beneficial to improve medical care quality.

Objective To investigate the application value of multi-detector computed tomography (MDCT) examination in the preoperative assessment of adenocarcinoma of esophagogastric junction (AEG).Methods The retrospective cross-sectional study was conducted.The clinicopathological data of 91 AEG patients who were admitted to the Second Affiliated Hospital of Wenzhou Medical University between January 2011 and December 2015 were collected.All the patients received plain and enhanced scans of MDCT,and they underwent operation under the consent of patients and his family members after preoperative relevant examinations and then received postoperative pathological examination.Follow-up using outpatient examination and telephone interview was performed to detect tumor recurrence and metastasis up to December 2015.Observation indicators included:(1) imaging features of MDCT,(2) comparison between preoperative MDCT examination and postoperative pathological examination,(3) treatment and prognosis.Measurement data with normal distribution were represented as x ± s.Consistency analysis between stage of MDCT examination and pathological stage was done using the chi-square test.Results (1) Imaging features of MDCT:MDCT findings in 91 AEG patients were heterogeneously thickened wall at esophagogastric junction and cauliflower-like local soft tissue mass,and enhanced scan findings were obviously heterogeneous enhancement,clear periphery fat gap and most of lymph nodes enlargement between liver and stomach.(2) Comparison between preoperative MDCT examination and postoperative pathological examination:preoperative MDCT examination in 91 AEG patients showed that invasion of the esophagus was found in 88 patients,with a infiltration length of (3.1 ± 1.1) cm.Postoperative pathological examination in 91 AEG patients showed that invasion of the esophagus was found in 68 patients,with a infiltration length of (3.5 ± 1.3) cm.The sensitivity,specificity and accuracy of invasion of the esophagus were respectively 95.6％,85.0％ and 92.0％,and these of invasion of the serosa were 96.8％,84.2％ and 95.5％,with aκ=0.9.Preoperative enhanced scans of MDCT of gastric wall showed that the single-layer structure was detected in 22 patients and multi-layer structure in 69 patients (double-layer structure in 34 patients and 3-layer structure in 35 patients).Detection rate of AEG through preoperative MDCT examination was 96.7％ (88/91).One,18,53 and 16 patients was in T1,T2,T3 and T4 stages and 3 had false negative results.Postoperative pathological examination showed that 2,17,55 and 17 patients were in T1,T2,T3 and T4 stages.Accuracy of T stage through preoperative MDCT examination was 85.4％,with a κ =0.7.N0,N1,N2,and N3 stages were respectively detected in 25,43,18,5 patients through preoperative enhanced scans of MDCT and in 29,32,22,8 patients through postoperative pathological examination.Accuracy of N stage through preoperative MDCT examination was 58.0％ and κ was 0.4.Preoperative Siewert type of 91 patients:Siewert type Ⅰ,Ⅱ and Ⅲ were detected in 5,46 and 40 patients,respectively.Postoperative pathological examination:4 and 87 patients were respectively in the early and advanced AEG by Borrmann type (4 in Borrmann type Ⅰ,15 in Borrmann type Ⅱ,54 in Borrmann type Ⅲ and 14 in Borrmann type Ⅳ).(3) Treatment and prognosis:of 91 AEG patients,5 in Siewert type Ⅰ underwent the lower esophageal and proximal gastrectomy via chest wall approach,46 in Siewert type Ⅱ underwent gastrectomy via transabdominal esophageal hiatus approach (28 using epigastric midline incision approach,15 using left thoracic incision approach and 3 using thoracoabdominal incision approach),and 40 in Siewert type Ⅲ underwent transabdominal total gastrectomy.All the 91 patients were followed up for 5-6 months with a median time of 4 months.During the follow-up,there was no death,and lymph node metastases were respectively detected in 3 of 5 patients with Siewert type Ⅰ AEG,6 of 46 patients with Siewert type Ⅱ AEG and 24 of 40 patients with Siewert type Ⅲ AEG.Conclusion Result of preoperative MDCT examination for AEG is highly consistent with postoperative pathological result,and MDCT examination can also improve the diagnostic rate of AEG and accuracy of T stage.

目的 探讨尺动脉腕上支逆行岛状皮瓣修复手部皮肤缺损的护理.方法 分析我院2014年3月 -2015年3月收治的11例手掌(背)皮肤缺损伤患者的临床资料 ,总结出有效护理方法 及重点.结果 2例皮瓣因动脉供血不足远端部分坏死 ,经换药后创面愈合 ;其余皮瓣均完全成活 ,手部功能与外观均满意.结论 手掌(背)皮肤缺损伤行尺动脉腕上支逆行岛状皮瓣修复的患者除常规护理外 ,还应了解穿支皮瓣的解剖特点 ,全方位观察皮瓣血运 ,及时发现并处理并发症 ,早期功能锻炼.