目的:探讨严重多发伤患者伤后免疫紊乱与急性胃肠功能损伤（acute gastrointestinal injury, AGI）间的关系。方法:纳入同济医院创伤外科2018年4月至2019年10月收治的严重多发伤患者205例，选取23例健康志愿者作为对照组。依据AGI诊断标准将患者分为AGI组与不伴AGI组（N-AGI组）；AGI组根据严重程度又分为轻度AGI组（L-AGI组）与重度AGI组（S-AGI组）。收集患者临床资料，于伤后1、7、14 d采集患者外周血，检测淋巴细胞亚群比率及炎症因子水平。采用 t检验或 χ2检验比较各指标的组间差异，logistic回归分析AGI发生的免疫相关危险因素。 结果:79.5%的严重多发伤患者伴发AGI（163/205例）。与N-AGI组患者相比，AGI组在伤后1 d总T淋巴细胞（Tc）、辅助性T淋巴细胞（Th）比率；7 d的白细胞介素-6（IL-6）、肿瘤坏死因子-α（TNF-α）、白细胞介素-8（IL-8）及白细胞介素-10（IL-10）水平，抑制性T淋巴细胞（Ts）、Th/Ts与调节性T淋巴细胞（Treg）比率；14 d的IL-8与IL-10水平，Ts、Th/Ts及Treg比率方面均差异有统计学意义（ P<0.05）。与L-AGI组患者相比，S-AGI组在伤后1 d的Tc、Th比率，IL-6与TNF-α水平；7 d和14 d的Ts、Th/Ts与Treg比率，IL-8与IL-10水平方面均差异有统计学意义（ P<0.05）。Logistic回归分析显示：Ts 7 d（ OR=2.018，95% CI：1.105~5.364， P=0.013）、Treg 14 d（ OR=3.612，95% CI：1.375~8.476， P=0.006）、IL-6 7 d（ OR=1.824，95% CI：1.011 ~5.835， P=0.024）、IL-10 14 d（ OR=2.847，95% CI：1.241~6.216， P=0.014）、TNF-α 7 d（ OR=1.754，95% CI：1.215~5.441， P=0.018）是严重多发伤后伴发AGI的高危因素。 结论:严重多发伤后机体免疫紊乱易诱发AGI，且伴发AGI将导致伤后免疫紊乱的持续加重。

目的:研究多发伤患者伤后不同时期的休克发生类型及特征。方法:回顾性研究2020年6月至2021年12月间收治于多家创伤中心的多发伤患者，入选年龄>18岁多发伤患者；排除受伤到入组时间>48 h，及有恶性肿瘤史，慢性消耗性、代谢性或免疫性疾病史者。伤后48 h内为伤后早期，伤后48 h至14 d内为伤后中期。收集患者疾病史、临床表现、实验室检验、影像学检查、损伤严重度评分、格拉斯哥昏迷评分等资料，依据各休克类型的诊断标准，观察多发伤后不同时期休克的发生类型及特征。通过 t检验、 χ2检验或Mann-Whitney U检验比较组间差异。 结果:多发伤后早期、中期休克发生率分别为73.1%、36.4%，组间比较差异有统计学意义（ P<0.01）。在伤后早期、中期两组中，低血容量性休克（hypovolemic shock, HS）患者（83.6% vs. 28.4%）、分布性休克（distributed shock, DS）患者（13.7% vs. 80.9%）、心源性休克患者（3.5% vs. 6.6%）的占比，组间比较差异均有统计学意义（均 P<0.05）；梗阻性休克（obstructive shock, OS）患者占比（8.4% vs. 9.7%），差异无统计学意义（ P>0.05）；病因不明型休克占比分别为1.6%、1.2%。多因型休克在伤后早期、中期占比分别为9.5%与14.4%。伤后不同时期多因型休克共观察到7种病因组合，伤后早期以HS+DS最为常见（42.3%），其次为HS+OS（28.8%）；伤后中期以HS+DS最为常见（48.6%），其次为DS+OS（24.3%）。 结论:多发伤后休克发生率高，患者不同类型的休克可能同时存在或序贯发生，在制定休克复苏策略时应更加全面，以期提高多发伤的救治成功率。

Purpose::Intramedullary implants are well accepted fixation of all types of intertrochanteric (IT) fractures, both stable and unstable types. Intramedullary nails have an ability to effectively support the posteromedial part, but fail to buttress the broken lateral wall requiring lateral augmentation. The aim of this study was to evaluate the outcome of proximal femoral nail augmented with trochanteric buttress plate for broken lateral wall with IT fractures, which was fixed to the femur through hip screw and antirotation screw nail.Methods::Of 30 patients, 20 had Jensen-Evan type III and 10 had type V fractures. Patients with IT fracture of broken lateral wall and aged more than 18 years, in whom satisfactory reduction was achieved by closed methods, were included in the study. Patients with pathologic or open fractures, polytrauma, prior hip surgery, non-ambulatory prior to surgery, and those who refused to participate were excluded. The operative time, blood loss, radiation exposure, quality of reduction, functional outcome, and union time were evaluated. All data were coded and recorded in Microsoft Excel spread sheet program. SPSS 20.0 was used for data analysis and normality of the continuous data was checked using Kolmogorv Smirnov test.Results::The mean age of patients in the study was 60.3 years. The mean duration of surgery (min), mean intra-operative blood loss (mL) and mean number of exposures were 91.86 ± 12.8 (range 70 - 122), 144.8 ± 3.6 (range 116 - 208), and 56.6 (range 38 - 112), respectively. The mean union time was 11.6 weeks and the mean Harris hip score was 94.1.Conclusion::Lateral trochanteric wall in IT fractures is significantly important, and needs to be reconstructed adequately. Nail-plate construct of trochanteric buttress plate fixed with hip screw and antirotation screw of proximal femoral nail can be successfully used to augment, fix or buttress the lateral trochanteric wall giving excellent to good results of early union and reduction.

Total elbow arthroplasty as a treatment option for open elbow fracture is relatively rare described. We reported a 39 years old polytrauma patient with complex open elbow fracture (Gustilo-Anderson type IIIB). The patient presented with large soft tissues defect on dorsal part of the left elbow, ulnar palsy due to the irreparable loss of the ulnar nerve, distal triceps loss due to the complete loss of the olecranon, loss of both humeral condyles with collateral ligaments and complex elbow instability. Only few similar cases have been published. Reconstructive surgery included repetitive radical debridement, irrigation, vacuum assisted closure system therapy, external fixation, coverage of the soft tissue defect with fascia-cutaneous flap from the forearm. Four months after the injury, total elbow arthroplasty with autologous bone graft (from the proximal radius) inserted in the ulnar component, was performed. At 3 years postoperatively, the patient is able to perform an active flexion from 0° to 110° with full pronosupination. Only passive extension is allowed. The ulnar neuropathy is persistent. Patient has no signs of infection or loosening of the prosthesis.

Purpose::The median time from the event leading to the spinal cord injury (SCI) to the time of decompressive surgery is estimated to be 6.9 days in Iran, which is much longer than the proposed ideal time (less than 24 h) in published guidelines. The current qualitative study aimed to determine the reasons for the observed decompression surgery delay in Iran from the perspective of neurosurgeons.Methods::This qualitative study is designed to perform content analysis on the gathered data from face-to-face semi-structured interviews with 12 Iranian neurosurgeons.Results::The findings of the current study suggest that patient-related factors constitute more than half of the codes extracted from the interviews. Overall, the type of injury, presence of polytrauma, and surgeons' wrong attitude are the main factors causing delayed spinal cord decompression in Iranian patients from the perspective of neurosurgeons. Other notable factors include delay in transferring patients to the trauma center, delay in availability of necessary equipment, and scarce medical personnel.Conclusion::In the perspective of neurosurgeons, the type of injury, presence of polytrauma, and surgeons' wrong attitude are the leading reasons for delayed decompressive surgery of individuals with SCI in Iran.

目的:探讨在多发创伤患者中采用多层螺旋CT一次性扫描检查多个部位的应用价值。方法:收集2023年1—11月多发创伤患者60例，采用随机数表法将患者分为试验组和对照组，每组30人，试验组患者为头颅、颈椎、胸部和腹部一次性扫描，对照组为各部位分开扫描。记录两组图像的噪声、信噪比(SNR)、对比信噪比(CNR)，比较两组患者图像主观评价、客观评价、CT容积剂量指数(CTDI vol)、有效剂量( E)、扫描时间及扫描范围的差异。 结果:试验组头颅SNR小于对照组，胸部SNR和CNR大于对照组( t＝－5.47、－5.95、－6.15， P<0.05)。试验组 E从18.53 mSv降低至13.81 mSv( t＝3.29， P<0.001)；CTDI vol从15.77 mGy降低至10.59 mGy( t＝4.48， P<0.001)；扫描时间从31.68 s缩短至10.97 s( t＝6.95， P<0.001)；扫描范围从64.92 cm缩短至45.21 cm( t＝9.05， P<0.001)。 结论:多发创伤患者采用多部位一次性CT扫描在保证图像质量的同时，降低了有效剂量，缩短了扫描时间，优化了扫描范围，值得临床推广。

Purpose::The human-wildlife conflicts (HWCs) causing nuisances and injuries are becoming a growing public health concern over recent years worldwide. We aimed to study the demographic profile, mode of injury, pattern of injury, and outcome of wild animal attack victims presented to the emergency department.Methods::This retrospective cross-sectional study was conducted in the emergency department of a tertiary-care hospital in Eastern India. Data were retrieved from the medical records from May 2017 to May 2021. Patients of all ages and genders attacked by wild animals and secondary injuries were included in this study. Patients with incomplete data, injuries due to the attack of stray and domestic animals and trauma due to other causes were excluded. Demographic profile, mode of injury, the pattern of injury, injury severity score (ISS), radiological pattern, and outcome were recorded. Statistical analysis with R (version 3.6.1.) was conducted.Results::A total of 411 wild animal attack victims were studied, of which 374 (90.9%) were snakebite injuries and 37 (9.1%) were wild mammalian (WM) attack injuries. The mean age of WM attack victims was 46 years, and the male-to-female ratio was 4:1. Elephant attack injury (40.5%) was the most common WM attack injury reported. Most WM attacks (43.2%) occurred between 4:00 a.m. to 8:00 a.m. The median ISS was 18.5 (13-28), where 54.2% of patients had polytrauma (ISS>15). Elephant attack was associated with a higher ISS, but the difference was not significant compared to other animal types ( p= 0.2). Blunt trauma was common pattern of injury in the elephant attack injury cases. Lacerations and soft tissue injuries were common patterns in other animal attacks. Among snakebites, neurotoxic was the most common type (55.4%), and lower extremity was the most common site involved. Conclusion::The young male population is the major victim of HWCs; and elephant is the most common animal involved. There is a need to design scientifically sound preventive strategies for HWCs and to strengthen the preparedness in health establishments to manage victims effectively.

Purpose::To explore the epidemiological and clinical profile of patients admitted to the trauma and emergency department (TED) of a tertiary care hospital due to tropical cyclone Fani and highlight the challenges faced by the hospital in this natural disaster.Methods::A retrospective study was conducted in the TED in the affected zone. Data of all victims affected by the cyclone Fani on May 3, 2019 were obtained from disaster records and medical case sheets. All patients except death on admission were included. Clinical variables included anatomical sites and severity of injuries which was assessed by revised trauma score (RTS) and injury severity score (ISS). Trauma injury severity score (TRISS) was also calculated.Results::Of 75 patients, 74 were included and the other one was brought dead and thus excluded. The age, median ± interquartile range (IQ), was 41.0 (27.7-53.0) years. The male to female ratio was 2:1. Most of the wounded were transported by the police control room vans on day 1: first 10 h, 50.0%; 10-24 h, 20.3%. The median ± IQ range of RTS, ISS and TRISS were 20 (14-28), 7.84 (7.841-7.841), and 97.4 (91.6-98.9), respectively. Simple external injury was the dominant injury type. Polytrauma (ISS >15) was seen in 67% cases and spine injury in 14% cases (7% cervical and 7% thoracolumbar). Injury causes included sharp flying objects (broken pieces of glasses and asbestos) in 31% cases, followed by fall of trees in 20.3%. Twenty-four patients were discharged after primary treatment, 30 admitted to the indoor-trauma ward or intensive care unit and 20 deferred or transferred to another center. There was no in-house mortality. Challenges were related to electricity failure, mobile network breakdown, infrastructure collapse, and delay in expertise repair from outside due to airport/railway closure.Conclusion::In cyclonic storm like Fani, sharp flying objects, fall of trees/poles and collapsing walls constitute the common mode of injuries causing harm to more than one body regions. Polytrauma was seen in the majority of patients though external injury was the commonest. The affected hospital had the uphill task of treating hospitalized patients as well as disaster victims.

多发伤是一种涉及机体多部位的严重创伤，危害大，病死率高。目前其诊断主要由各不同解剖部位创伤性疾病组合的“疾病集”构成。多发伤具有明确的病因、特征性病理生理改变，救治措施不同于单发创伤。笔者呼吁将其视为一种独立的“疾病”类型，而非“疾病集”。依照“柏林定义”的多发伤是完全符合现阶段关于独立“疾病”的分类标准，笔者探讨将多发伤确认为一种独立“疾病”类型对其预防、救治及创伤外科学科发展的重要意义。

目的:研究多发性创伤患者伤后黄疸的发生情况、预后及可能的早期高危因素。方法:本研究为单中心、前瞻性研究，同济医院创伤中心2020年10月至2023年1月期间收治的年龄>18岁的多发伤患者，排除伴发肝、胆道或胰腺外伤，以及既往慢性肝脏病史等。收集患者临床资料，实验室检验结果、影像学检查结果及损伤严重度评分（injury severity score, ISS）、格拉斯哥昏迷评分及急性生理与慢性健康评分等。分析多发伤后黄疸发生率、黄疸分类、伴黄疸患者的病死率，以及伤后早期黄疸的危险因素。采用 t检验或 χ2检验比较各指标的组间差异，Logistic回归分析黄疸发生的相关危险因素。 结果:本研究纳入多发性创伤患者742例，34.09%多发伤患者伤后伴发黄疸，且中度与重度黄疸的比率高达32.41%，黄疸的主要类型为肝内胆汁淤积性黄疸（47.03%）。伴黄疸的多发伤患者病死率高于不伴黄疸多发伤患者（12.25% vs. 3.47%， P <0.001）。经Logistic回归分析发现，ISS评分（ OR=3.405，95% CI: 1.962~7.438， P=0.026）、血乳酸（ OR=2.216，95% CI:1.203~4.862， P=0.017）、白介素6水平（ OR=2.431，95% CI:1.424~3.793， P=0.007）、肠外营养支持时间（ OR=3.011，95% CI:1.624~5.041， P=0.022）与机械通气时长（ OR=3.572，95% CI:1.497~4.601， P=0.031）为多发伤患者伤后早期伴发黄疸的独立危险因素。 结论:多发伤患者伤后易伴发黄疸，其危害较大，特别是对伤后肝内胆汁淤积性黄疸临床应予高度关注。应加强对伤后伴发黄疸的高风险因素的早期识别与早期干预。