Objective:To investigate the related factors that affect the timing and prognosis of early tracheostomy in patients with multiple rib fractures.Methods:A retrospective case series study was conducted on medical data of 222 patients with multiple rib fractures who underwent tracheostomy in Affiliated Hospital of Yangzhou University from February 2013 to October 2019，including 160 males and 66 females，with the age of 18 to 85 years ［（49.5 ± 16.3）years］. According to the practice management guidelines for tracheostomy timing and the use of propensity score matching technology，there were 118 patients with tracheostomy within 7 days of tracheal intubation （early group） and 104 patients with tracheostomy after 7 days of tracheal intubation （late group） before matching，and there were 87 patients in early group and 87 patients in late group after matching. Data were compared between groups including the gender，age，underlying disease，injury severity score （ISS），Glasgow coma score （GCS），number of fractured ribs，total number of rib fractures （NTRF），first rib fracture，flail chest，traumatic brain injury，combined injuries （spine，maxillofacial，sternum），acute respiratory distress syndrome （ARDS），volume fraction of pulmonary contusion（VPC），blood lactic acid （within 24 hours of admission），hemothorax，pneumothorax，mechanical ventilation time，duration of tracheostomy，time from tracheal intubation to incision，length of hospital stay，length of stay in ICU，closed thoracic drainage，number of fiberoptic bronchoscopy，multi-drug resistant bacteria infection，ventilator-associated pneumonia，antibiotic use time，duration of sedative and analgesic drugs used and 28-day mortality. The multivariate Logistic regression analysis was used to predict independent risk factors for early tracheostomy. The Pearson method was used to compare the relationship between multiple factors. The receiver operating characteristic （ROC） curve was used to predict indicators that affect the prognosis of patients with early tracheostomy，and calculate the best cut-off value. The Kaplan-Meier single factor and COX multivariate survival were used to analyze the relevant factors affecting the 28-day mortality of patients.Results:（1） In early group，the NTRF，ARDS and VPC were higher than those in late group，and the time from tracheal intubation to incision and 28-day mortality rate were lower than those in late group （ P < 0.05），while the two groups showed no significant differences in the gender，age，underlying diseases and ISS （ P > 0.05）. （2） The multivariate Logistic regression analysis showed that there was statistical significance in NTRF （ OR = 1.775，95% CI 1.439-2.188），ARDS（ OR = 3.740，95% CI 1.441-9.711），VPC （ OR = 1.087，95% CI 1.052-1.124） （ P < 0.05）； the Pearson method analysis showed a significant correlation between VPC and NTRF （ r = 0.369， P < 0.05） and a low degree of correlation between ARDS and VPC （ r = 0.179， P < 0.05），but there was no significant correlation between ARDS and NTRF （ r = 0.132， P > 0.05）. （3） The ROC curve analysis showed that the area under the curve （AUC） of the VPC and NTRF ［AUC = 0.832 （95% CI 0.770-0.893），AUC = 0.804 （95% CI 0.740-0.868）］ were significantly higher than those of the number of rib fractures ［AUC = 0.437（95% CI 0.352-0.523），GCS ［AUC = 0.519 （95% CI 0.432-0.605）］ and ISS ［AUC = 0.484 （95% CI 0.398-0.571）］ （ P < 0.05）. After calculating the Yorden index，the best cut-off value for VPC was 23.9，and the best cut-off value for NTRF was 8.5. （4） The Kaplan-Meier single factor and multivariate COX model survival analysis showed that the 28-day survival ratio of patients with early tracheostomy was significantly better than that of late tracheostomy （ P < 0.05）. Conclusions:The NTRF，ADRS and VPC are independent risk factors for the timing and prognosis of early tracheostomy. There is a significant correlation between VPC and NTRF. The VPC ≥ 23.9% and or NTRF ≥ 8.5 can be used to predict early tracheostomy in patients with multiple rib fractures. Early tracheostomy may benefit the 28-day survival of patients with multiple rib fractures.

目的 分析阿帕替尼联合肝动脉化疗栓塞术(TACE)治疗肝癌疗效及对患者血管内皮生长因子(VEGF)和甲胎蛋白(AFP)的影响.方法 选取2017年1月至2019年3月宿迁市人民医院介入科收治的肝癌患者80例,随机分为观察组(n=40,接受TACE联合阿帕替尼治疗)、对照组(n =40,行TACE).患者治疗后随访12个月,比较两组临床疗效、治疗前后血清VEGF与AFP水平及生化指标[总胆红素(TBIL)、丙氨酸转氨酶(ALT)、白蛋白(ALB)]变化,记录两组生存情况及不良反应.结果 观察组治疗后6个月客观缓解率高于对照组(P＜0.05),两组疾病控制率比较差异无统计学意义(P＞0.05).治疗后3个月、6个月,观察组血清VEGF、AFP水平较对照组低(P＜0.05);观察组治疗后6个月TBiL、ALT低于对照组,而ALB水平较对照组高,差异均有统计学意义(P＜0.05).治疗后6个月,两组生存率比较差异无统计学意义(P＞0.05);治疗后12个月,观察组生存率高于对照组(P＜0.05).两组栓塞后综合症发生率比较差异无统计学意义(P＞0.05),观察组高血压、手足综合征、蛋白尿发生率高于对照组(P＜0.05),所有不良反应予以对症治疗均缓解.结论 阿帕替尼联合TACE治疗肝癌疗效满意,可明显改善患者血清VEGF、AFP水平,提高12个月生存率,多数不良反应较轻微,不会导致治疗中断,安全可靠.

Objective To explore the influence of prognosis indicators of multiple indicators and their interactionat hospital admission in patients with brain injury. Methods We analyzed the clinical data of 130 patients with craniocerebral trauma who were admitted to the Department of Critical Care Medicine of the Affiliated Hospital of Yangzhou University from January 2013 to August 2017. We performed a mathematical model to identify the correlation between data at hospital admission and outcome. The clinical data of 26 patients with craniocerebral trauma from October 2017 to December 2018 were collected for external validation. Results Sedation score (RASS) squared item, Grasse coma (GCS) score and RASS score interaction item, age and acute physiology and chronic health status (APACHEⅡ) score interaction item, heart rate and lactic acid (LAC) interaction term were significantly associated with outcome. Conclusion Mathematical models can be used to assess prognostic indicators in patients with brain injury. Key words: Brain injury; Admission indicators; Prognosis indicators; Mathematical model

目的 评估多学科合作护理模式在血液透析通路失功围手术期中的应用价值.方法 将血液透析通路失功的患者34例,分为多学科合作组(实验组)和常规护理组(对照组),实验组患者18例,对照组16例.对照组患者采用常规治疗护理,实验组给予多学科合作护理.结果 实验组患者住院天数、并发症、通畅情况、再干预与对照组比较,差异无统计学意义(P＞0.05).实验组满意度与对照组比较,差异有统计学意义(P＜0.05).实验组出院前SAS、SDS评分与对照组比较,差异有统计学意义(P＜ 0.05).纵向比较实验组术前SAS与出院前SAS相应评分,差异有统计学意义(P＜0.05),但SDS差异无统计学意义(P=0.080).对照组术前SAS与出院前SAS相应评分比较差异无统计学意义(P=-0.569,0.209).结论 在血液透析通路失功围手术期中应用多学科合作护理模式,可以提高患者满意度,改善患者焦虑及抑郁.

Objective To explore the predictive value of dynamic changes of postoperative neutrophil lymphocyte ratio (NLR) in patients with craniocerebral trauma secondary intracranial infection. Methods One hundred sixteen patients with craniocerebral trauma secondary intracranial infection admitted to the Department of Critical Care Medicine, the Affiliated Hospital of Yangzhou University from January 2012 to December 2018 were included in the study. Patients were divided into a high NLR group (NLR≥3) and a low NLR group (NLR<3) based on the NLR measured on the third day after surgery. The difference in clinical outcome between the two groups was compared. Results NLR values were significantly higher in the high NLR group on the third postoperative day, and there was a significant statistical difference compared with the low NLR group (2.24±0.68 vs 4.72±1.21, P<0.05). In the high NLR group, 10 patients (19%) had intracranial infection, and 4 patients (6%) in the low NLR group. There was a significant statistical difference between the two groups (P=0.033). NLR: area under the curve (AUC)=0.894, 95%CI: 0.795-0.993; PCT: AUC=0.895, 95%CI: 0.764-1.027; CRP: AUC=0.898, 95%CI: 0.814-0.981. The ICU staying time and mechanical ventilation time were higher in the high NLR group than in the low NLR group. There was a statistical difference between the two groups (18.4±8.7 vs 13.2±5.4, P=0.000; 10.3±4.7 vs 5.3±4.1, P=0.000). The difference in mortality between the two groups was statistically significant. The mortality rate was higher in the high NLR group than in the low NLR group (P=0.026). Conclusion The elevated neutrophil lymphocyte ratio after surgery has a good clinical predictive value for the occurrence of intracranial infection in patients with craniocerebral trauma. The elevated NLR value is closely related to the poor prognosis. Key words: Neutrophil lymphocyte ratio; Craniocerebral trauma; Intracranial infection

目的 研究不同能量密度肠内营养制剂对重型颅脑损伤患者预后的影响.方法 本研究回顾分析了2015年01月～2018年12月于我院综合ICU及SICU住院的GCS评分≤8分的颅内出血的患者的临床资料,分析采用不同能量密度肠内营养制剂对患者预后、肠内营养不耐受等不良反应及营养支持达标情况的影响.结果 本研究共纳入病例288例.其中1.3Kcal组95例,1.0 Kcal组193例.两组的基线人口统计学和临床特征平衡,无明显统计学差异.1.3Kcal组与1.0 Kcal组患者90天死亡率无明显统计学差异(25.3％vs23.8％,P=0.906),90天GOS评分也无明显统计学差异(2.46±1.77vs2.41±1.83,P=0.485).但住院期间肠内营养支持所致的胃肠道不耐受反应(如腹泻及胃潴留)1.3 kcal组明显高于1.0 kcal组,有统计学差异(腹泻P=0.030,胃潴留P=0.034).结论 通过高能量密度肠内营养增加能量摄入并未影响GCS评分≤8分成人颅内出血患者的生存情况.

目的 研究超声引导下中心静脉置管术并发症发生率,以探讨胸片作为超声引导下中心静脉置管术后常规检查的必要性.方法 选取我院2016年1月～2018年6月于我院ICU行超声引导下中心静脉置管术患者的临床资料,我们计算了超声引导下中心静脉导管置入术后气胸及导管位置错误的发生率,以探讨胸片作为超声引导下中心静脉置管术后常规检查的必要性.结果 2057例超声引导下中心静脉置管术中发生气胸的共9例,发生率为0.44％(95％CI,0.15～0.72％).其中左侧锁骨下静脉穿刺置管气胸发生率最高,明显高于右侧锁骨下静脉、右颈内静脉及左颈内静脉置管(P值分别为0.025、0.000、0.512).发生导管位置错误共41例,发生率为1.99％(95％CI,1.39％～2.60％).其中,右侧颈内静脉置管导管位置错误发生率最低,与右侧锁骨下静脉、左侧锁骨下静脉及左颈内静脉置管比较,皆有明显统计学差异(P值分别为0.000、0.000、0.000).结论 超声引导下中心静脉置管尤其是右颈内静脉置管术后无需常规行胸部DR检查.