Volume 18 · Issue 05 · 2015

2013年，文森特等人¹为《柳叶刀》撰文呼吁重新定义脓毒症，引起了医学领域的激烈争论，也得到了相关学者非常积极的回应。为什么败血症能引起如此多的关注？是因为脓毒症可诱发多器官功能衰竭，严重影响患者预后。^2,3,4在1991年芝加哥共识会议上，⁵脓毒症被简单地定义为“对感染的全身反应被称为脓毒症。“不仅如此，诊断仅仅是基于是否存在感染和SIRS，但我们都知道，SIRS只是宿主对感染的一种基本反应，按照这个定义和诊断标准，几乎所有伴有全身炎症反应症状的感染都会被诊断为败血症，事实上，大多数都是很容易治愈的。”上述定义和诊断标准不能准确呈现脓毒症的本质，甚至有悖于关注脓毒症研究者的初衷。更有甚者，相关研究和讨论无法聚焦关键问题。严重脓毒症的定义（与器官功能障碍、低灌注或低血压相关的脓毒症)⁵和MODS（急性疾病患者器官功能改变，如不干预就无法维持体内平衡）更接近我们对脓毒症的定义。因此，临床实践中使用了几种不同的脓毒症诊断标准，导致本已明确的问题变得更加复杂和混乱。

脓毒症，本质上是指各种有害刺激因素对机体的过度刺激而引起的炎症损伤。自1991年脓毒症的现代概念提出以来，其定义不断修订，既有内涵又有外延。治疗策略和技术也得到了改进。然而，令人遗憾的是，到目前为止，脓毒症引起的死亡率并没有显著降低。^1,2

Inflammation plays a critical role in secondary brain damage after intracerebral hemorrhage (ICH). However, the mechanisms of inflammatory injury following ICH are still unclear, particularly the involvement of NLRP3 inflammasome, which are crucial to sterile inflammatory responses. In this study, we aim to test the hypothesis that NLRP3 signaling pathway takes a vital position in ICH-induced secondary inflammatory damage and detect the role of N-methyl-D-aspartic acid receptor 1 (NMDAR1) in this progress.

ICH was induced in mice by microinjection of hemin into the striatum. The protein levels of NMDAR1, NMDAR1 phosphorylation, NLRP3 and IL-1β were measured by Western blot. The binding of NMDAR1 to NLRP3 was detected by immunoprecipitation.

The expression of NMDAR1, NMDAR1 phosphorylation, NLRP3 and IL-1β were rapidly increased after ICH. Hemin treatment enhanced NMDAR1 expression and NMDAR1 phosphorylation, as well in cultured microglial cells treated by hemin. Hemin up-regulated NLRP3 and IL-1β level, which was reversed by MK801 (NMDAR antagonist) in vitro. Hemin also promoted the binding of NMDAR1 to NLRP3.

Our findings suggest that NMDAR1 plays a pivotal role in hemin-induced NLRP3-mediated inflammatory damage through synergistic activation.

确定后髁偏移（PCO）对使用高屈曲后稳定（PS）固定轴承假体进行全膝关节置换术（TKA）后临床结果的影响。

我们前瞻性研究了89例连续女性患者（89膝）的临床和影像学材料，这些患者因终末期骨关节炎接受了初次TKA。所有手术均由一名高级外科医生或在其监督下使用相同的手术技术进行。根据校正后的PCO变化，我们将所有病例分为两组：A组（校正后PCO变化≥0 mm，58膝）和B组（校正后PCO变化<0 mm，31膝）。术后一年，通过独立比较两组的临床和影像学变量t-测试。通过Pearson线性相关分析所有患者校正后的PCO变化与临床变量改善之间的相关性。

术后1年，膝关节学会评分、西安大略大学和麦克马斯特大学骨关节炎指数、非负重主动和被动膝关节屈曲范围、屈曲挛缩、伸肌滞后及其改善情况在两组间均无统计学差异（均p>0.05).校正后的PCO变化与任何临床变量的改善均无显著相关性（所有p>0.05).在主动负重过程中，A组表现出比B组更大的屈曲（p<0.05).

PCO的恢复在后路稳定TKA后负重条件下主动膝关节屈曲的优化中起着重要作用，而它对非负重膝关节屈曲或任何其他临床结果没有益处。

We once reported blast-induced traumatic brain injury (bTBI) in confined space. Here, bTBI was studied again on goats in the open air using 3.0 kg trinitrotoluene.

The goats were placed at 2, 4, 6 and 8 m far from explosion center. Trinitrotoluene (TNT) was used as the source of the blast wave and the pressure at each distance was recorded. The systemic physiology, electroencephalogram, serum level of S-100beta, and neuron specific enolase (NSE) were determined pre and post the exposure. Neuroanatomy and neuropathology were observed 4 h after the exposure.

Simple blast waveforms were recorded with parameters of 702.8 kPa-0.442 ms, 148.4 kPa-2.503 ms, 73.9 kPa-3.233 ms, and 41.9 kPa-5.898 ms at 2, 4, 6 and 8 m respectively. Encephalic blast overpressure was on the first time recorded in the literature by us at 104.2 kPa-0.60 ms at 2 m, where mortality and burn rate were 44% and 44%. Gross examination showed that bTBI was mainly manifested as congestive expansion of blood vessels and subarachnoid hemorrhage, which had a total incidence of 25% and 19% in 36 goats. Microscopical observation found that the main pathohistological changes were enlarged perivascular space (21/36, 58%), small hemorrhages (9/36, 25%), vascular dilatation and congestion (8/36, 22%), and less subarachnoid hemorrhage (2/36, 6%). After explosion, serum levels of S-100β and NSE were elevated, and EEG changed into slow frequency with declined amplitude. The results indicated that severity and incidence of bTBI is related to the intensity of blast overpressure.

Blast wave can pass through the skull to directly injure brain tissue.

Trauma is an inevitable part of the health burden in every country. Both the preventive and rehabilitative aspects of traumatic injuries are expensive. Since most of the injuries happen in low- and middle-income developing countries, a judicious allocation of the limited resources to the most costefficient strategies is necessary. The present study was designed to report the causes of trauma, injured body regions, trauma severity scores and the one year survival rate of a randomly selected sample of trauma patients in a major referral hospital in Tehran, Iran.

We chose and analyzed a random subgroup of traumatic patients admitted during the oneyear period of May 2012 to May 2013 to Shariati Hospital, a major University Teaching Hospital in Tehran, Iran. Patients who stayed at the hospital for less than 24 h were excluded. In total, 73 traumatic patients were registered. The mean age was (40.19 ± 20.34) years and 67.1% of them were male.

In general, the most common cause of injury was falls (47.9%), followed by road traffic crashes (RTCs, 40.8%). Assault and exposure to inanimate mechanical forces each were only associated with 5.6% of all injuries. The only cause of injury in ages of more than 65 years was fall. The most common cause of injury in ages between 15 and 45 years was RTCs. During the study, two deaths occurred: one was at ICU and the other was at home. The most commonly injured body region was the head (23.8%), followed by the elbow and forearm (19%), hip and thigh (15.9%), and multiple body regions (14.3%). The mean abbreviated injury score was 2.23 ± 1.02; injury severity index was 7.26 ± 7.06; and revised trauma score was 7.84, calculated for 38 patients.

Prevention strategy of traumatic injury should focus on falls and RTCs, which are respectively the most common cause of trauma in older aged people and young males.

Subtrochanteric fractures of the femur are being managed successfully with various intramedullary and extramedulary implants with reasonable success. However, these implants require precise placement under image intensifier guidance, which exposes the surgeon to substantial amount of radiation. It also restricts the management of these fractures at peripheral centers where facility of image intensifiers is not available. Keeping this in mind we designed this study to identify if contralateral reversed distal femoral locking plate can be used successfully without the use of image intensifier.

Twenty-four consecutive patients (18 men and 6 women) with a mean age of 28 years (range 19-47 years) suffering subtrochanteric fractures of the femur underwent open reduction and internal fixation with reversed contralateral distal femoral locking plate. The outcome was assessed at the mean follow-up period of 3.2 years (range 2-4.6 years) using the Harris hip score.

Twenty-one fractures united with the primary procedure, with a mean time of consolidation being 11 weeks (range, 9-16 weeks). One patient developed superficial suture line infection, which resolved with oral antibiotics. Another patient had a fall 3 weeks after surgery and broke the plate. Repeat surgery with reversed distal femoral locking compression plate was performed along with bone grafting and the fracture united. Two cases had nonunion, which went in for union after bone grafting. The mean Harris hip score at the time of final follow-up was 90.63 (range 82-97).

The reversed contralateral distal femoral plate is a biomechanically sound implant, which when used for fixation of the subtrochanteric fractures with minimal soft tissue stripping shows results comparable to those achieved by using other extramedullary implants as well as intramedullary devices. The added advantage of this implant is its usability in the absence of an image intensifier.

Nowadays pediatric femoral fractures are more commonly managed with operative treatment rather than conservative treatment because of more rapid recovery and avoidance of prolonged immobilization. Children between the ages of 5-13 years are treated either by traction plus hip spica and flexible/elastic stable retrograde intramedullary nail, or external fixators in the case of open fractures. The aim of this study is to evaluate the outcome of pediatric femoral shaft fractures treated by stainless steel flexible intramedullary nail in children between 5 and 13 years of age.

There were 32 cases of femoral shaft fractures which were all fixed with stainless steel flexible intramedullary nail under fluoroscopy. Long leg cast was applied at the time of fixation. Partial weight bearing was started 2 weeks after surgery. Patients were evaluated in follow-up study to observe the alignment of fracture, infection, delayed union, nonunion, limb length discrepancy, motion of knee joint, and time to unite the fracture.

We were able to follow up 28 out of 32 patients. The patients were 8.14 years of age on average. The mean hospital stay after operation was 4 days and fracture union time was 9.57 weeks. There were 3 cases of varus angulation, 2 cases of anterior angulation, and 4 cases of limb lengthening.

Patients aged between 5 and 13 years treated with flexible intramedullary nail for closed femoral shaft fracture have rapid union and recovery, short rehabilitation period, less immobilization and psychological impact, and cost-effective.

To evaluate the functional and radiological outcome of comminuted radial head fractures, which were not amenable for classical open reduction with internal fixation, treated by on-table reconstruction and fixation using low profile plates.

We reviewed 6 patients of Mason type III radial head fractures treated by on-table reconstruction technique between 2011 and 2013. There were 5 men and 1 woman with a mean age of 35 years (range 25-46 years). All surgeries were carried out at our tertiary care level 1 trauma centre within a mean of 3 days (range 1-8 days) from date of injury using on-table reconstruction technique. The functional outcome was measured using elbow functional rating index described by Broberg and Morrey and the patient-based Disabilities of the Arm, Shoulder and Hand (DASH) outcome measure.

The mean follow-up period was 25 months. The average elbow flexion was 135^° (range 125^°-140^°) and the average flexion contracture was 5^° (range 0-10^°). The average supination and pronation was 75^° (range 70^°-80^°) and 70^° (range 65^°-82^°) respectively. According to Broberg and Morrey scoring system, the average score was 90 points (range 75-100). The mean DASH score was 2.49 points.

On-table reconstruction and fixation of comminuted radial head fractures using low profile plates is a reasonable option. The reconstructed radial head acts as spacer and provides reasonably good results and no surgical intervention is required for asymptomatic nonunion of these fractures regardless of the radiological findings.