目的 研究微课结合PBL教学法在烧伤外科学教学中的应用.方法 选取南通大学医学院2017级临床医学本科生共120名,研究时间为2020年11月至2021年4月,采用随机数表法将其分为研究组(n=60)和对照组(n=60).对照组采用传统教学法,研究组则运用微课结合PBL教学法,每组配备5名相应师资的教师.比较两组学生的理论知识成绩、操作技能成绩、学生及教师的教学效果反馈.结果 研究组的理论知识、操作技能成绩显著优于对照组,差异有统计学意义(P<0.05).研究组学生对烧伤外科学的实践操作能力、临床思维能力、理解能力、交流合作能力、学习效率、学习积极性、学习兴趣、碎片时间利用率、自主学习能力等方面的反馈均优于对照组,差异有统计学意义(P<0.05).研究组教师在教学满意度、教学效率、教学压力减轻等方面的反馈均优于对照组,差异有统计学意义(P<0.05).结论 微课结合PBL的新型教学方法使教学活动变得更为灵活高效,使学习不再局限于固定的时间和地点,能够很好地促进学生对烧伤外科学的学习.

创面愈合后期瘢痕增生较为常见,而传统的治疗方式存在些许弊端.外泌体作为旁分泌因子参与细胞间的信号传导,并促进血管生成和细胞增殖.外泌体作为无细胞衍生物的研究热点之一,在创面修复领域备受关注.多种干细胞来源的外泌体可通过多种途径抑制瘢痕增生,甚至可成为促进创面无瘢痕修复的治疗工具.未来,外泌体联合生物支架、增强靶向能力、作为递药载体等方向都值得一步深入探索.总而言之,外泌体有望成为治疗病理性瘢痕的一个新方向.

目的 调查烧伤合并多重耐药革兰阴性菌(MDR-GNB)感染患者的患病率,并对感染相关危险因素进行logistic分析.方法 对南通大学附属医院烧伤整形科2014年10月至2019年10月间患者进行回顾性调查,选取80例发生多重耐药革兰氏阴性杆菌感染的患者作为病例组,80例未发生多重耐药革兰氏阴性杆菌感染的患者作为对照组.收集患者一般资料、疾病状态、感染情况等临床资料,采用logistic分析合并MDR-GNB感染的危险因素.结果 80例感染患者的感染部位主要位于创面(53例),其次为肺部(14例)、血流(9例)以及尿道(4例).感染病原菌主要为肺炎克雷伯氏菌(26例),其次依次为鲍氏不动杆菌(19例)、大肠埃希菌(17例)、铜绿假单胞菌(10例)、荧光假单胞菌(5例)、嗜麦芽窄食单胞菌(3例).单因素分析显示重症监护室入住时间、烧伤深度、烧伤面积、吸入性损伤、抗菌药使用合理情况、责任护士年资与烧伤患者合并MDR-GNB感染有关,logistic分析表明烧伤深度、烧伤面积、抗菌药使用合理情况、责任护士年资均是合并MDR-GNB感染的独立危险因素.结论 重症烧伤患者易发生MDR-GNB感染,其中烧伤深度、烧伤面积/抗菌药使用合理情况、责任护士年资均是MDR-GNB感染的独立危险因素,临床上应加强对重症患者的护理,从而有效预防和控制感染.

目的 分析切削痂植皮术结合术后银离子凝胶治疗对高龄深度烧伤人群恢复情况及急性C反应蛋白(CRP)、降钙素原(PCT)水平的影响.方法 63例老年深度烧伤患者随机分为对照组(n=32)和观察组(n=31).对照组患者在烧伤3～5d实施切削痂植皮术治疗,观察组在对照组切削痂植皮术的基础上使用银离子凝胶进行治疗.对比两组患者临床疗效,对血清CRP、PCT含量进行检测.结果 观察组患者创面清洁时间、创面愈合时间和住院时间均显著短于对照组(P<0.05).观察组患者疼痛程度显著轻于对照组(P<0.05).治疗后第3天和第7天,观察组血清CRP和PCT含量均显著低于对照组(P<0.05).观察组不良事件总发生率显著低于对照组(P<0.05).结论 切削痂植皮术结合术后银离子凝胶可有效治疗高龄深度烧伤,降低深度烧伤人群血清CRP和PCT,具有较好的临床应用前景.

目的:探讨微创性磨削痂在面部深Ⅱ度烧伤创面中的治疗效果.方法:面部深Ⅱ度烧伤患者26例,在伤后2～4天使用水动力清创系统对创面进行微创性磨削痂,人体生物敷料覆盖磨削痂创面,观察术后创面感染发生率、愈合时间及愈合质量.结果:所有患者磨削痂术后创面均未发生感染,创面愈合时间9～23天,平均愈合时间为15.15±3.02天,愈合质量满意,温哥华瘢痕量表对创面愈合瘢痕评分为0.81±0.73分.结论:微创性磨削痂能减少创面感染,防止创面加深,缩短愈合时间,提高愈合质量,减少色素沉着及瘢痕增生、挛缩畸形的发生.

中国的新型冠状病毒肺炎疫情经过全国齐心协力,已经得到了较好的控制,但全球范围的疫情尚未得到有效遏制,未来的不确定性尚存,作为医疗系统仍不能掉以轻心.烧伤整形科作为医院主要面对急诊的科室,面对类似情况有较高的风险.故此,笔者结合国家发布的新型冠状病毒肺炎诊疗方案(第七版)及国内外最新文献资料,在门急诊患者及康复期患者的诊治、手术和住院患者的分类管理、医务人员的防护策略、病区管理等方面提出建议,以期为疫情期间烧伤整形患者的救治防控提供参考.

目的 探讨持续性血液净化(CRRT)联合乌司他丁治疗对烧伤并发脓毒症患者肺脏及肾脏功能的影响.方法 选择2014年1月～2017年4月南通大学附属医院烧伤科收治的30例烧伤并发脓毒症患者,按照随机数字表法将其分为两组,分别采用CRRT治疗(对照组)和CRRT治疗联合乌司他丁治疗(观察组),每组各15例.治疗期间两组均使用心排量监测(PICCO)监测血流动力学.在治疗前及治疗后第1、3、5、7天,分别同时监测两组患者的肺肾功能指标并进行相关性研究.结果 观察组治疗后第1天即出现胸腔内血容量指数(ITBVI)、血管外肺水指数(EVLWI)、全身血管阻力指数(SVRI)降低,氧合指数(PaO2/FiO2)显著改善(P＜0.05);对照组也有不同程度的改善,ITBVI及EVLWI第3天起下降,PaO2/FiO2治疗后第3天起上升,组内比较差异有统计学意义(P＜0.05),两组间比较差异有统计学意义(P＜0.05).两组患者治疗后血尿酸、肌酐均下降,24 h尿量均升高(P＜0.05);观察组治疗后不同时间点患者血尿酸、肌酐低于对照组,24 h尿量高于对照组(P＜0.05).结论 CRRT联合乌司他丁能改变重症脓毒症患者的血流动力学状况,显著改善脓毒症患者的肺、肾功能.

Objective To explore the curative effect of comprehensive nursing intervention in patients with burn sepsis with continuous renal replacement therapy. Methods A total of 34 patients with burned sepsis who underwent continuous renal replacement therapy were randomly divided into control group and intervention group, 17 cases of each group. Both groups of patients received routine hospital care before, during and after continuous renal replacement therapy.The intervention group received comprehensive nursing intervention on the basis of routine nursing. Results After 24 hours and 72 hours of operation, the body temperature, respiration and pulse recovery of the patients in the intervention group were better than those of the control group, and the differences were statistically significant (P<0.05). The satisfaction rate of the patients in the intervention group was higher than that in the control group, and the difference was statistically significant (P<0.05). The Barthel index of the patients in intervention group was higher than that of the control group at 1 month and 3 months after operation, and the difference was statistically significant (P<0.05). Conclusions Comprehensive nursing intervention has a positive effect on patients with burned sepsis who received continuous renal replacement therapy. Key words: Comprehensive nursing intervention; Burn sepsis; Continuous renal replacement therapy

对1例烧伤合并冲击伤感染耐碳青霉烯类肺炎克雷伯菌的患者进行了护理.要点包括实施高效气道管理方案,加强气道管理;积极有效应对抗生素和镇静药的不良反应;用胃肠双腔管行全面的营养支持;严格无菌操作的同时,注意保护创面,预防创面感染.患者半个月后创面愈合出院.

Objective To investigate the effect of continuous renal replacement therapy (CRRT) combined with ulinastatin on inflammatory factors,hemodynamic parameters and prognosis in patients with bum sepsis.Methods Thirty patients with bum sepsis enrolled from January 2014 to June 2017 in Affiliated Hospital of Nantong University were divided into observation group and control group,with 15 cases in each group.The control group was treated with CRRT;the observation group was treated with CRRT and intravenous administration of ulinastatin.Infection indexes,inflammatory factors and hemodynamic parameters were tested before and 1,3,5,7 d after treatment.Scores of acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) and multiple organ dysfunction syndrome (MODS) were recorded to evaluated the severity of sepsis.The mortality rate was analyzed.Results Levels of white blood cell count,procalcitonin (PCT) and C-reactive protein (CRP) in observation group were significantly lower than those in control group 3,5 d after treatment[3 d:(15.5 ± 1.7) ×109/L vs (18.6 ± 3.6) × 109/L,(10.3 ± 2.3) mg/L vs (13.3 ± 1.7) mg/L,(26 ± 13) mg/L vs (32 ± 10) mg/L;5 d:(13.3±2.4) ×109/L vs (15.5±2.2) × 109/L,(8.2±l.6)mg/L vs (10.2±2.2)mg/L,(20±8)mg/L vs (30 ± 8) mg/L] (P ＜ 0.05);PCT and CRP in observation group were significantly lower than those in control group7 daftertreatment[(4.7±l.7)mg/L vs (6.7 ±l.9)mg/L,(lO±8)mg/L vs (13 ±6)mg/L](P＜0.05).The level of tumor necrosis factor-α in observation group was significantly lower than that in control group 3,5 d after treatment [(56 ± 13) μg/L vs (62 ± 11) μg/L,(47 ± 10) μg/L vs (55 ± 13) μg/L] (P ＜ 0.05);interleukin-1 β,-6,-10 in observation group were significantly lower than those in control group 5 d after treatment [(59 ± 14) μg/L vs (67± 11) μg/L,(41 ±8) μg/L vs (46 ± 8) μg/L,(31.7 ±4.3) μg/L vs (33.6 ± 3.4) μg/L](P ＜ 0.05).The oxygenation index in observation group was significantly higher and the level of blood lactic acid was significantly lower than those in control group 3,5,7 d after treatment(P ＜ 0.05).Scores of APACHE Ⅱ and MODS significantly decreased 5,7 d after treatment and there were significant differences between observation group and control group[5 d:(14 ±4) points vs (18 ±4) points,(7.7 ± 3.4) points vs (10.7 ± 1.8) points;7 d:(12 ± 6) points vs (17 ± 5) points,(6.5 ± 3.2) points vs (9.8 ± 3.6) points] (P ＜ 0.05).The death rate in observation group was lower than that in control group[20.0％ (3/15) vs 33.3％ (5/15)] but the difference was not significant (P ＞ 0.05).Conclusion CRRT combined with ulinastatin treating burn sepsis can effectively improve hemodynamic status,lower inflammatory factors and improve the prognosis.

目的：观察负压封闭引流技术（VSD）对慢性创面修复的疗效。方法选取慢性创面患者62例，随机均分为VSD组及对照组。两组均予以抗感染，改善微循环治疗；VSD组早期应用VSD处理创面，对照组用凡士林及聚维酮纱布外敷。两组均在创面肉芽生长满意后再行后续治疗。比较两组二期创面闭合时间、住院时间、抗生素费用及不同时间点创缘毛细血管密度、血小板衍生因子（PDGF）水平。结果 VSD组二期创面闭合时间、住院时间及抗生素费用少于对照组（P＜0．01）。治疗后VSD组毛细血管密度及PDGF水平在不同时间点均高于对照组（P＜0．05）。结论 VSD对慢性创面的修复优于传统方法，其机制可能与促进毛细血管及组织细胞生成有关。

目的：对颈胸部烧伤患儿采取护理干预措施，研究其对治疗及预防瘢痕增生和挛缩的效果。方法：选取我院收治的44例颈胸部烧伤的患儿作为研究对象，针对创面进行清创换药等治疗，并为预防瘢痕增生和挛缩采取护理干预措施。结果：通过治疗配合整复手术及院外随访，治疗及随访时间不等，使得治疗后仅3例出现瘢痕增生，1例颈部瘢痕挛缩，其他患儿无功能障碍，均痊愈。结论：通过对颈部烧伤的患儿采取护理干预措施，能够避免瘢痕增生及挛缩，无须通过整复手术，具有临床研究价值。

目的:探讨修复头皮缺损的方法、适应证及经验.方法:针对30例不同原因导致的头皮缺损伴颅骨外露的创面大小、深浅、血管条件、感染情况等特点,选用游离皮瓣移植修复3例、局部皮瓣转移修复19例、扩张头皮皮瓣转移修复1例及自体皮片移植修复7例.结果:30例患者头皮缺损伴颅骨外露创面均得到满意修复.自体皮片移植7例成活率超过90%,残余创面经换药愈合,无毛发生长;局部皮瓣及扩张头皮皮瓣转移修复的20例患者,皮瓣血供良好,12例患者切口瘢痕较宽,出现瘢痕性秃发;游离皮瓣转移的3例患者术后皮瓣定位良好,1例皮瓣皮缘有小部分坏死,后期自体皮片移植修复,3例患者均存在皮瓣臃肿及瘢痕性秃发.结论:对于中小面积头皮缺损伴颅骨外露的创面,局部皮瓣及扩张头皮皮瓣是最佳方法;对于大面积头皮缺损伴颅骨外露的创面,游离皮瓣是最佳方法;对于大面积头皮缺损伴颅骨外露、血管损伤严重的创面,游离皮片更为适宜.

目的 探讨人脐带间充质干细胞(UC-MSCs)移植修复烧伤皮肤的机制.方法 24只SD大鼠均分为UC-MSCs移植治疗组和对照组.分别收集烧伤后12 h、1、3、7d两组大鼠损伤局部的皮肤组织,抽提蛋白;ELISA法测定皮肤组织内细胞因子TNF-α、IL-1及IFN-γ的表达,Westernblot法检测大鼠皮肤中MCP-1及CCX-2蛋白的变化,免疫组化法检测烧伤后14d两组碱性成纤维细胞生长因子(bFGF)及血管内皮生长因子(VEGF)表达量.结果 烧伤后,大鼠烧伤皮肤细胞因子TNF-α和IL-1增加,IFN-γ表达下降;治疗组UC-MSCs移植后3d,TNF-α和IL-1下降,IFN-γ含量增加(P＜0.05);烧伤7d时,受损皮肤中趋化因子MCP-1及CCX-2的表达增加,而UC-MSCs移植治疗组在烧伤7d时受损皮肤中MCP-1及CCX-2的表达量下降(P＜0.05).烧伤14 d时,UC-MSCs移植治疗组的bFGF及VEGF表达量较对照组增加(P.＜0.05).结论 烧伤后,UC-MSCs移植治疗可能通过抑制皮损局部的炎症反应,减少淋巴细胞的浸润,促进血管的再生和成纤维细胞的生长来促进损伤皮肤的修复.

目的 总结难愈性伤口应用负压封闭引流(VSD)技术的效果和护理要点.方法 回顾性分析2009年2月至2012年3月对48例难愈性创面病人应用VSD技术后的疗效.结果 使用VSD较传统方法效果明显,且操作方便.结论 VSD技术能保证有效引流,加快创面愈合,减少换药次数,减轻病人痛苦,值得推广.

目的 探讨动态监测血C反应蛋白(C reactire protein,CRP)和Wnt5a水平的相关变化对脓毒症患者诊疗的临床意义.方法 选择2010-01/2014-02月作者科室收住的脓毒症患者15例,将15例脓毒症患者随机配对分为常规治疗组,常规治疗+胰岛素组,常规治疗+强化胰岛素组.在入科的第2,4,6,8天检测CRP及Wnt5a水平,同时行血培养,根据血培养结果分为血培养阳性组和血培养阴性组.结果 在脓毒症血培养阳性组第2,4,6,8天,Wnt5a水平及第6,8天的CRP水平明显高于血培养阴性组;=三组患者中CRP水平与Wnt5a随时间呈下降趋势,在ROC曲线中,Wnt5a有更好的敏感性和特异性.结论 脓毒症患者血清Wnt5a水平较CRP水平与脓毒症严重程度有着更明显的相关性,动态监测Wnt5a水平变化有助于脓毒症严重程度的判断及临床治疗.

目的 探讨胰岛素对脓毒症患者血清Wnt5a及超氧化物歧化酶(SOD)活性的影响.方法 将15例脓毒症患者随机均分为常规治疗组(A组)、常规治疗+胰岛素组(B组)和常规治疗+强化胰岛素组(C组).入院治疗后第2、4、6、8天,采用黄嘌呤氧化酶法检测血浆SOD活性,ELISA法检测血清Wnt5a水平.结果 三组Wnt5a和SOD的水平均呈时间依赖性下降.与A组相比,B、C组Wnt5a水平降低,SOD活性升高(P＜0.05),C组变化过程较B组更为明显(P＜0.05).血培养阳性患者治疗后Wnt5a水平及SOD活性均高于血培养阴性患者(P＜0.05).结论 使用胰岛素严格控制血糖能降低患者的病死率,改善预后;动态监测Wnt5a及SOD水平变化有助于脓毒症严重程度的判断及临床治疗.

To investigate the changes of expression of Wnt5a in intestinal mucosa of rats during the early stage after severe burn injury. Scald models were set up in 48 healthy SD rats, which were randomly divided into control group, scald group and scald + insulin group (treatment group). The intestinal mucosa tissue samples were extracted separately at 6 th, 12 th, 24 th, and 48 th hours after scald injury. The pathological changes of the intestinal mucosa tissue of each group were observed, and the expression of Wnt5a in the intestinal mucosa was detected with immunohistochemical methods and analyzed by a micro-image analysis system. In the scald group, the expression of Wnt5a was higher than that in control group at the same time (P < 0.05). In the first 12 hours post-scald injury, the Wnt5a expression in control group was increasing, and then decreased obviously from the 12th hour, and after 24 hours, it was return to increase. In treatment group, the expression reached the peak at the 48 th hour post-scald injury. The pathological changes were milder in treatment group than in control group in each time points. In the early phase of severe burn injury, the intestinal mucosa tissue injury is very severe. Wnt5a may take part in the procession of burn sepsis which may be one of factors protecting the intestinal mucosa tissue.

Objective To investigate the efficacy of umbilical core mesenchymal stem cells(UC-MSCs)in treatment of burn in rats.Methods UC-MSCs were isolated and identified in vitro.Twenty-four burned rats were egually randomized into two groups of A(locally transplanted with UC-MSCs seeding)and B(dropped with PRMI 1640culture solution as control).The pathological structure of wounded tissues was observed by HE staining.The wound healing rate was compared.Rusults UC-MSCs were obtained successfully and identified by morphology,flow cytometry and cell differentiation.The wound healing time was shorter in group A than that in group B[(22.0±3.1)d vs.(27.0±3.1)d](P<0.05).On the 14th day after treatment,the wound healing rate was higher in group A than that in group B [(56.3±9.8)% vs.(47.2±8.3)%](P<0.05).Conclusion Local transplantation of UC-MSCs can promote the skin wound healing in rats with burn injury.

Objective: To investigate the changes of the expressions of Wnt5a in intestinal mucosa of rats during the early stage after severe burn Injury and its sigficance.Methods: 48 healthy SD rats were set upscalded models,which were randomly divided into control group,scald group and scald+insulin group(treatment group).The intestinal mucosa tissue sample separately after 6,12,24,48 hours were posted scald injury.In the treatment group,subcutaneous injection of 3 U/kg insulin after scald injury.The expression of Wnt5a in the intestinal mucosa was detected with immunohistochemistry methods and analyzed by a micro-image analysis system,and at the same time we observed the pathological changes of the intestinal mucosa tissue of each groups.Results: In the scalded group,the expression of Wnt5a was higher than that in control group at the same time(P<0.05),6-12 hours post scald injury the expression was increased.Following the expression of Wnt5a decreased obviously 24 hours post scald injury,48 hours post scald injury the expression was increased.The expression of Wnt5a in the treatment group was significantly smaller than that in scalded group at most time points at the same time(P<0.05).Conclusions: In the early phase of severe burns injury,the intestinal mucosa tissue injury is very severe.Wnt5a may take part in the procession of burn sepsis.Insulin can deduce its expression,which may be one of factors protecting the intestinal mucosa tissue.