2-8℃低温干预结合金银花口腔喷雾在甲状腺术后气管拔管患者中的应用研究

[摘要]目的：探讨纳米炭在分化型甲状腺癌（DTC）中不同注射时机下对患者术后低钙血症、甲状旁腺功能及中央区淋巴结清扫质量的影响，力求构建标准化操作路径。方法：将行甲状腺切除联合中央区清扫的DTC患者按1∶1∶1随机分为三组：术前超声引导注射组（POI）、术中直视注射组（IOI）及对照组（C）。比较三组术后48h校正血钙<2.1 mmol/L发生率、PTH水平、甲状旁腺误切率及淋巴结检出数，并以外渗评分、等待时间达标率评估操作规范性。结果：POI组术后低钙血症及甲状旁腺误切发生率最低，PTH水平下降幅度最小，中央区淋巴结及微小淋巴结检出数最多；IOI组次之；对照组最差。POI组外渗率为0，等待时间及分区送检一致性显著优于IOI组（均P<0.05）。三组均无严重并发症。结论：术前超声引导纳米炭注射能有效降低术后低钙风险，保护甲状旁腺功能，并提高清扫质量。结合过程指标构建的标准化路径，为临床推广提供了可复制的优选策略。

目的 探讨不同剂量左甲状腺素钠联合二甲双胍治疗妊娠期糖尿病（GDM）并发甲状腺功能减退症（简称“甲减”）患者的临床疗效，并分析其对甲状腺激素水平、妊娠结局的影响。方法 选取2023年1月～2025年1月于本院诊治的92例GDM并发甲减患者为研究对象，依据治疗方案不同将其分为2组，对照组采用左甲状腺素钠、二甲双胍治疗，观察组采用维生素D联合左甲状腺素钠、二甲双胍治疗。比较2组临床疗效及治疗前后甲状腺激素[促甲状腺激素（TSH）、游离三碘甲状腺原氨酸（FT3）、游离甲状腺激素（FT4）]、糖脂代谢指标[空腹血糖、胰岛素抵抗指数（HOMA-IR）、总胆固醇（TC）、甘油三酯（TG）、低密度脂蛋白胆固醇（LDL-C）]、血管内皮功能[一氧化氮（NO）、内皮素-1（ET-1）、一氧化氮合酶（NOS）、非对称性二甲基精氨酸（ADMA）]、病情进展相关指标[成纤维细胞生长因子-21（FGF-21）、视黄醇结合蛋白4（RBP4）、脂蛋白相关磷脂酶A2（Lp-PLA2）]。比较2组妊娠结局。结果 观察组总有效率高于对照组（P＜0.05）；观察组治疗后TSH水平低于对照组，FT3、FT4水平高于对照组（P＜0.05）；观察组治疗后空腹血糖水平、TC、TG、LDL-C水平及HOMA-IR低于对照组（P＜0.05）；观察组治疗后NO、NOS水平高于对照组，ET-1、ADMA水平低于对照组（P＜0.05）；观察组治疗后血清FGF-21、RBP4、Lp-PLA2水平低于对照组（P＜0.05）；2组流产、胎盘早剥、新生儿窒息发生率比较无明显差异（P＞0.05），观察组早产发生率低于对照组（P＜0.05）。结论 维生素D联合左甲状腺素钠、二甲双胍治疗GDM并发甲减患者的效果显著，可更好地维持甲状腺功能正常，纠正糖脂代谢，改善血管内皮功能，控制疾病进展，并可在一定程度上改善妊娠结局。

目的 探究改良Miccoli手术治疗单侧甲状腺癌（TC）患者的效果及其对机体创伤应激反应的影响。方法 选取新密市中医院200例单侧TC患者（2021年3月—2023年3月）,按随机数字表法分两组。A组100例接受改良Miccoli手术治疗,B组100例接受开放根治术（OT）治疗。对比两组围术期指标、喉返神经损伤发生情况、美学效果、手术前后肿瘤指标[细胞角蛋白19片段抗原（Cyfra21.1）、半乳糖凝集素3（Gal-3）、可溶性白细胞介素-2受体（sIL-2R）]、创伤应激反应指标[去甲肾上腺素（NE）、肾上腺素（E）、皮质醇（Cor）]水平。结果 A组切口长度为（2.05±0.13）cm,短于B组的（7.11±0.49）cm,住院及手术用时分别为（3.12±0.44）d、（53.48±7.52）min,均短于B组的（5.22±0.81）d、（76.81±11.39）min,术中失血量、引流量分别为（19.24±2.66）mL、（21.47±3.41）mL,均少于B组的（45.08±5.75）mL、（64.82±7.24）mL,组间比较差异有统计学意义（P<0.05）;A组喉返神经损伤总发生率为2.00%（2/100）,低于B组的12.00%（12/100）,组间比较差异有统计学意义（P<0.05）;A组美容总满意度为97.00%（97/100）,高于B组的73.00%（73/100）,差异有统计学意义（P<0.05）;A组术后3个月血清Cyfra21.1、Gal-3水平分别为（1.78±0.26）ng/mL、（6.14±1.64）ng/mL,均高于B组的（1.55±0.21）ng/mL、（5.39±1.28）ng/mL,血清sIL-2R水平为（375.36±20.12）μg/mL,低于B组的（427.13±23.18）μg/mL,组间比较差异有统计学意义（P<0.05）;A组术后1 d血清NE、E、Cor水平分别为（0.73±0.17）mmol/L、（0.49±0.10）mmol/L、（185.46±22.95）μg/L,均低于B组的（0.96±0.19）mmol/L、（0.81±0.22）mmol/L、（272.53±32.41）μg/L,组间比较差异有统计学意义（P<0.05）。结论 相较于OT治疗单侧TC患者,经改良Miccoli手术治疗更有助于提升美学效果,减少喉返神经损伤,优化围术期指标,抑制肿瘤进展,且机体产生的创伤应激反应更轻微。

Objective To investigate the effect of modified Miccoli surgery on patients with unilateral thyroid cancer（TC）and its impact on the body’s traumatic stress response．Methods The data of 200 patients with unilateral TC in Xinmi City Hospital of Traditional Chinese Medicine from March 2021 to March 2023 were retrospectively collected and divided into two groups according to different surgical protocols．A hundred patients treated with modified Miccoli surgery were classified as group A and 100 patients treated with open radical surgery（OT）were classified as group B．The perioperative indicators,incidence of recurrent laryngeal nerve injury,aesthetic effect,as well as tumor indicators [cytokeratin 19 fragment antigen（Cyfra21.1）,galectin-3（Gal-3）,soluble interleukin -2 receptor（sIL-2R）] and trauma stress response indicators [norepinephrine（NE）,epinephrine（E）,and cortisol（Cor）] before and after surgery were compared between the two groups．Results The incision length of group A was（2.05±0.13）cm,which was shorter than that of group B [（7.11±0.49）cm]．The duration of hospitalization and operation of group A were（3.12±0.44）d and（53.48±7.52）min,respectively,which were shorter than those of group B [（5.22±0.81）d and（76.81±11.39）min]．The intraoperative blood loss and drainage volume were（19.24±2.66）mL and（21.47±3.41）mL,respectively,which were lower than those in group B [（45.08±5.75）mL and（64.82±7.24）mL],and the difference was statistically significant（P<0.05）．The total incidence of recurrent laryngeal nerve injury in group A was 2.00%（2/100）,lower than that in group B [12.00%（12/100）],and the difference was statistically significant（P<0.05）．The total satisfaction of group A was 97.00%（97/100）,higher than that of group B [73.00%（73/100）],and the difference was statistically significant（P<0.05）．Serum Cyfra21.1 and Gal-3 levels in group A were（1.78±0.26）ng/mL and（6.14±1.64）ng/mL,respectively,higher than those in group B [（1.55±0.21）ng/mL and（5.39±1.28）ng/mL]．Serum sIL-2R level was（375.36±20.12）μg/mL,lower than that of group B [（427.13±23.18）μg/mL],and the difference was statistically significant（P<0.05）．The serum levels of NE,E and Cor in group A were（0.73±0.17）mmol/L,（0.49±0.10）mmol/L and（185.46±22.95）μg/L,respectively．They were lower than（0.96±0.19）mmol/L,（0.81±0.22）mmol/L and（272.53±32.41）μg/L in group B,and the differences were statistically significant（P<0.05）．Conclusions Compared to OT treatment for unilateral TC patients,the modified Miccoli surgery is more helpful in improving aesthetic effects,reducing damage to the recurrent laryngeal nerve,optimizing perioperative indicators,inhibiting tumor progression,and producing less traumatic stress response to the body．

目的 探讨超声弹性成像联合高频超声在甲状腺乳头状癌诊断中的应用价值。方法 2022年1月—2023年6月选择在中国人民解放军联勤保障部队第九九〇医院诊治的疑似甲状腺乳头状癌患者82例,所有患者均给予超声弹性成像联合高频超声检查,记录超声特征。所有患者均行病理检查,并以病理检查作为判断的金标准。结果 在82例患者中,病理诊断为甲状腺乳头状癌48例（癌性组）,占比58.54%;甲状腺良性结节34例（良性组）,占比41.46%。癌性组的形态异常、后方回声衰减、钙化、晕环征、边界不清晰、内部低回声等超声征象占比为81.25%、83.33%、83.33%、83.33%、81.25%、81.25%,高于良性组的52.94%、47.06%、47.06%、41.18%、47.06%、52.94%（P<0.05）。癌性组的收缩期最高流速低于良性组（P<0.05）,阻力指数、搏动指数与良性组相比有提高（P<0.05）。癌性组的弹性成像评分多为3~4分,良性组多为2分,两组比较差异有统计学意义（P<0.05）。超声弹性成像联合高频超声判断为甲状腺乳头状癌47例,诊断中的灵敏度与特异度分别为97.92%（47/48）和100.00%（34/34）。结论 甲状腺乳头状癌在超声上多表现为血流信号异常、钙化、后方回声衰减、晕环征等特征,超声弹性成像评分多为3~4分,超声弹性成像联合高频超声在其诊断中具有较高的应用价值。

Objective To explore the application value of ultrasound elastography combined with high-frequency ultrasound in the diagnosis of papillary thyroid cancer（PTC）．Methods From January 2022 to June 2023,82 patients with suspected PTC were treated at Chinese People’s Liberation Army Joint Logistics Force 990 Hospital．All patients were given ultrasound elastography combined with high-frequency ultrasound examination to record ultrasound features．All cases were given pathological examination,and the pathological examination were used as the gold standard for diagnosis．Results Among the 82 patients,48 were PTC（cancerous group）,accounting for 58.54%;and the other 34 were benign thyroid nodules（benign group）,accounting for 41.46%．The proportion of morphological abnormalities,posterior echo attenuation,calcification,halo ring signs,unclear boundary and internal hypoechoics in cancerous group were 81.25%,83.33%,83.33%,83.33%,81.25% and 81.25%,which were significantly higher than 52.94%,47.06%,47.06%,41.18%,47.06% and 52.94% in the benign group（P<0.05）．The highest systolic flow velocity in the cancerous group was significantly less than that in the benign group（P<0.05）,and the resistance index and pulse index were also significantly higher compared with the benign group（P<0.05）．The elastography score were mostly 3~4 in the cancerous group and 2 in the benign group,with a significant difference between the two groups（P<0.05）．Forty-seven cases of PTC were diagnosed by ultrasound elastography combined with high frequency ultrasonography,and the sensitivity and specificity in diagnosis were 97.92%（47/48）and 100.00%（34/34）,respectively．Conclusions PTC is often characterized by abnormal blood flow signals,calcification,posterior echo attenuation,halo sign and so on．The ultrasound elastography score is usually 3~4 points．Ultrasonic elastography combined with high frequency ultrasound has high value in diagnosis of PTC．

目的 探讨暴露喉返神经的甲状腺手术后患者发生声音嘶哑的原因。方法 选取于2019年1月—2020年12月间在我院接受甲状腺手术且在术中暴露喉返神经的患者,对出现术后声音嘶哑的19例患者进行为期12个月的临床随访,观察研究对象术后声音嘶哑的发生特点、持续时间并进行直接喉镜及颈部超声检查。结果 发生声音嘶哑的19例患者中,5例存在术中喉返神经损伤情况,其余14例患者术中喉返神经暴露及保护良好。直接喉镜检查示,该14例患者中,4例存在声带充血水肿现象,1例发生勺状软骨半脱位。术后1周左右的超声检查显示,该14例患者中有11例存在不同程度的创腔内积液。结论 虽常规暴露喉返神经减少了术后声嘶的发生率,但术中喉返神经损伤仍然是造成患者术后声嘶的原因之一。此外,术后创腔积液、麻醉插管导致的声带损伤及其他插管相关并发症等非直接手术因素也是造成这些患者术后声嘶的重要原因,应引起临床重视。

Objective To explore the cause of hoarseness of voice in patients after thyroidectomy with recurrent laryngeal nerve exposure. Methods The patients from January 2019 to December 2020 underwent thyroidectomy with exposure of recurrent laryngeal nerve during operation were selected. There were 19 cases of hoarseness of voice after operation followed up for 12 months. Postoperative observations included the characteristics of the hoarseness of voice, duration, and direct laryngoscope neck ultrasonography. Results A total of 19 patients had voice hoarseness, only 5 of them had recurrent laryngeal nerve injury during operation, the other 14 patients had good exposure and protection of recurrent laryngeal nerve. Direct laryngoscope showed that 4 of 14 patients had vocal cord edema and 1 had subluxation of arytenoid cartilage. About 1 week after operation, ultrasound examination showed that 11 of 14 patients had varying degrees hydrops of wound cavity. Conclusions Although the routine exposure of recurrent laryngeal nerve reduces the incidence of postoperative hoarseness of voice, the injury of recurrent laryngeal nerve is still a cause of postoperative hoarseness of voice. In addition, non-operative direct factors, such as fluid accumulation in the operative field, vocal cord injury caused by anesthetic intubation and other intubation related complications, are also important reasons for postoperative hoarseness of voice in these patients, which we should pay more attention to.

目的 基于随机森林方法构建甲状腺功能减退（简称甲减）患病风险预测模型。方法 从MIMIC-IV数据库纳入5 735名甲减患者为病例组,4 803名非甲减患者为对照组,基于随机森林模型进行建模。同时利用逻辑回归、贝叶斯正则化神经网络、XGBoost作为比较模型。最后用准确率、F1分数、精确率、召回率、特异性以及AUC值评价四个机器学习模型性能。结果 随机森林模型准确率为0.85,F1分数为0.84,精确率为0.84,召回率为0.84,特异性为0.86,AUC值为0.91。在该模型中,促甲状腺激素、年龄、绝对淋巴细胞计数、血液中红细胞数、中性白细胞、性别、碱性磷酸酶、丙氨酸氨基转移酶、嗜酸性粒细胞绝对计数、尿素氮为甲减患者诊断重要性排前10的指标。结论 采用随机森林方法构建的甲减患病预测模型为甲减的早期诊断有潜在应用价值。

Objective To construct a risk prediction model for hypothyroidism based on the random forest model．Methods A total of 5 735 hypothyroidism patients were included from the MIMIC-IV database as the case group, and 4 803 non-hypothyroidism patients were included as the control group．Random forest models were constructed for both groups, and logistic regression, Bayesian regularized neural network, and XGBoost were used as comparative models．The performance of the four machine learning models was evaluated using accuracy, F1 score, precision, recall, specificity, and AUC value．Results The random forest model had an accuracy of 0.85, an F1 score of 0.84, a precision of 0.84, a recall of 0.84, a specificity of 0.86, and an AUC value of 0.91．In this model, thyroid-stimulating hormone, age, absolute lymphocyte count, red blood cell count in blood, neutrophil, gender, alkaline phosphatase, aspartate aminotransferase, absolute eosinophil count, and blood urea nitrogen were the top 10 indicators for diagnosing hypothyroidism patients．Conclusions The hypothyroidism disease prediction model constructed using the random forest method has potential application value for the early diagnosis of hypothyroidism．

目的 探讨不同贫血类型患者铁蛋白水平、甲状腺功能检测结果对比分析。方法 前瞻性选取2018年11月—2021年11月我院收治的240例贫血患者作为研究对象。将患者分为小细胞低色素性贫血组（n=75）,正细胞性贫血组（n=100）和大细胞性贫血组（n=65）。检查患者甲状腺功能[甲状腺素（TSH）、游离三碘甲腺原氨酸（FT₃）、游离甲状腺素（FT₄）]和铁蛋白（SF）表达水平。采用Spearman检验进行相关性分析;采用Logistics回归模型进行回归分析。结果 3组患者红细胞（RBC）、血红蛋白（Hb）、平均红细胞容积（MCV）、红细胞平均血红蛋白浓度（MCHC）、平均红细胞血红蛋白含量（MCH）、血清肌酐（Scr）间存在差异（P<0.05）;大细胞性贫血组TSH、FT₃和SF低于正细胞性贫血组和小细胞低色素性贫血组（P<0.05）,而FT₄高于正细胞性贫血组和小细胞低色素性贫血组（P<0.05）;贫血类型与TSH、FT₄、FT₃和SF呈正相关（P<0.05）;多因素Logistics回归分析结果显示,TSH、FT₄、FT₃和SF在3个模型中均为独立危险因素（P<0.05）。结论 不同贫血类型患者间甲状腺功能和铁蛋白表达水平存在显著差异,大细胞性贫血组TSH、FT₃和SF低于正细胞性贫血组和小细胞低色素性贫血组,而FT₄更高,甲状腺功能指标和铁蛋白均是各种类型贫血发生的危险因素。

Objective To explore the comparative analysis of ferritin level and thyroid function detection results in patients with different types of anemia．Methods A total of 240 anemia patients admitted to our hospital from November 2018 to November 2021 were prospectively selected as research objects．The patients were divided into microcytic hypochromic anemia group（n=75）,normocytic anemia group（n=100）,and macrocytic anemia group（n=65）．The expression levels of thyroid function[thyroxine（TSH）,free triiodothyronine（FT₃）,free thyroxine（FT₄）]and ferritin（SF）were examined．Correlation analysis was performed by Sperman test．The logistic regression model was adopted for regression analysis．Results There were significant differences in red blood cell,hemoglobin,mean corpuscular volume,mean corpuscular hemoglobin concentration,mean corpuscular hemoglobin content and serum creatinine among three groups（P<0.05）．TSH,FT₃ and SF in macrocytic anemia group were significantly lower than those in normocytic anemia group and microcytic hypochromic anemia group（P<0.05）,while FT₄ was significantly higher than that in normocytic anemia group and microcytic hypochromic anemia group（P<0.05）．The type of anemia was positively correlated with TSH,FT₄,FT₃ and SF（P<0.05）．The results of multi-factor logistics regression analysis showed that TSH,FT₄,FT₃ and SF were independent risk factors in the three models（P<0.05）．Conclusions There were significant differences in thyroid function and ferritin expression levels among patients with different types of anemia．Macrocytic anemia group TSH,FT₃ and SF were lower than those in normocytic anemia group and microcytic hypochromic anemia group,while FT₄ was higher．Both thyroid function indexes and ferritin were risk factors for various types of anemia．

目的 探究超声检查对于甲状腺囊性结节随访中的作用和临床价值,探讨其临床应用意义。方法 以2018年1月—2019年1月在本院就诊,经过临床金标准诊断为甲状腺囊实性结节的83名患者作为研究对象,采用历史性队列研究方法对患者进行为期18个月的随访观察,对患者在随访期内,使用超声检查所得知的甲状腺囊实性结节的大小、形态、边界、内部回声、钙化及血流信号等特征进行记录,并与患者初次就诊时的记录进行对比分析。结果 根据随访记录得知,83例患有甲状腺囊实性结节的患者当中,75例患者在随访后发现具有甲状腺恶性结节症,其余8例患者不具有甲状腺恶性结节特征。随访后83例患者的甲状腺囊实性结节均呈现好转,主要表现为:甲状腺囊实性结节出现不同程度的吸收;结节体积减小,个数无变化;结节吸收后在超声下显示在同一部位的结节表现为低或极低回声结节;囊性液体成分明显减少,部分原结节较小的患者,囊性成分出现消失。根据对随访前后患者甲状腺囊实性结节的平均体积对比有统计学差异(P<0.05),随访后的结节半径明显小于随访前。甲状腺囊实性结节体积有效缩小率为68%～88%。结论 通过对甲状腺囊实性结节定期进行超声复查可以实现对甲状腺结节的动态观察,有助于对患者的病情进行掌握,且由于甲状腺囊实性结节患者在后期结节吸收过程中常常出现恶性结节特征。通过使用超声检查对患者进行长期随访不仅可起到早期诊断甲状腺恶性肿瘤的意义,还可以避免,因过度诊断为甲状腺恶性结节,而使用细胞穿刺检查等有创检查对患者造成的不便。

目的 探讨影响先天性甲状腺功能减低症患儿不同转归的早期因素。 方法 选取2013年12月—2017年3月期间在本中心筛查并确诊的先天性甲状腺功能减低症患儿共80例,经左旋甲状腺激素钠治疗2~3年后停药评估再随访1年以上者,根据疾病转归将患儿分为持续性甲低组(29例)与暂时性甲低组(51例)。对2组患儿的临床情况进行回顾性分析,寻求影响结局的早期因素。结果 持续性甲低与暂时性甲低患儿初筛促甲状腺激素值[ 63.89 (43.89, 114.25) vs 38.54 (27.27, 60.00) mIU/L]、促甲状腺激素恢复正常所需剂量[(4.29±1.46) vs (3.38±1.34) μg/(kg·d)]、早期甲状腺超声正常比例[58.6%(17/29)vs 90.2%(46/51)]差异有统计学意义(P<0.05)。其中初筛促甲状腺激素值(最佳临界值:37.825 mIU/L,AUC=0.745,灵敏度0.897,特异度0.490)和出生后第8个月左旋甲状腺激素钠给药剂量[最佳临界值3.38 μg/(kg·d),AUC=0.759,灵敏度 0.586,特异度 0.843]可早期区别持续性甲低与暂时性甲低患儿。结论 初筛促甲状腺激素值和出生后左旋甲状腺激素钠给药剂量对先天性甲状腺功能减低症患儿临床转归有早期预测作用。

Objective To investigate the early factors affecting different outcomes of children with congenital hypothyroidism (CH). Methods A total of 80 children with CH screened and diagnosed at Meizhou Maternal and Child Health Care and Family Planning Service Center between December 2013 and March 2017, who were treated with levothyroxine sodium for 2~3 years and then discontinued for assessment and followed up for over 1 year, were selected and divided into the permanent CH group (29 cases) and transient CH group (51 cases) according to disease outcomes. The clinical conditions of the children were retrospectively analysed to seek early factors affecting outcome. Results The initial screening thyroid hormone values [ 63.89 (43.89, 114.25) vs 38.54 (27.27, 60.00) mIU/L ], the required dose to restore normal thyroid hormone in permanent and transient CH group [(4.29±1.46) vs (3.38±1.34) μg/(kg·d)], and the proportion of early normal thyroid ultrasound [58.6% (17/29) vs 90.2% (46/51)] had significant differences(P<0.05). The initial screening thyroid hormone value (optimal threshold: 37.825 mIU/L, AUC=0.745, sensitivity 0.897 and specificity 0.490) and the levothyroxine sodium dosage at eighth month of age [optimal threshold 3.38 μg/(kg·d), AUC=0.759, sensitivity 0.586 and specificity 0.843] could early distinguish permanent and transient CH children. Conclusions Initial screening thyroid hormone values and postnatal levothyroxine sodium dosage had an early predictive effect on clinical outcome in children with CH.