用喹诺酮诱导铜绿假单胞菌获得耐药质粒的研究

目的探讨对喹诺酮敏感的铜绿假单胞菌经诱变后耐药质粒基因的变化。方法收集该院2011年1月至2013年12月从各种合格临床标本培养出的铜绿假单胞菌共31例,将其中16例用K-B药敏试验证明对喹诺酮敏感的细菌作为研究对象。挑选环丙沙星药敏纸片敏感圈外生长的铜绿假单胞菌进行连续转种诱变,直至铜绿假单胞菌对喹诺酮产生耐药。对新产生耐药性的铜绿假单胞菌进行质粒转化、提取质粒并确定其耐药质粒的存在,通过PCR扩增、基因序列分析,确定获得的耐药质粒类型。结果 16例对喹诺酮敏感的铜绿假单胞菌在喹诺酮诱变下连续转种第9次以后有2例发生突变产生qnrS耐药质粒。结论抗菌药物在抑菌浓度附近使用,细菌容易突变产生耐药质粒基因。     

铜绿假单胞菌mexA基因的克隆及其序列分析

目的克隆铜绿假单胞菌临床菌株mexA基因并进行序列分析。方法从临床分离多重耐药的铜绿假单胞菌抽提DNA,经PCR扩增出mexA基因与PUC18克隆载体连接,对重组质粒进行测序验证。结果成功地克隆了mexA基因,重组质粒(PUC/mexA)经测序与Genebank检索的mexA基因序列进行对比证实为99.9%同源。结论所构建的铜绿假单胞菌临床菌株mexA基因克隆适于进一步的克隆表达。     

运用PCR-RFLP技术研究耐喹诺酮类铜绿假单胞菌gyrA基因的突变

目的 研究临床分离的耐喹诺酮类铜绿假单胞菌(Pseudomonas aeruginosa.PA)gyrA基因突变情况.方法 以铜绿假单胞菌gyrA基因序列为靶序列,用PCR-RFLP、DNA测序等方法,对铜绿假单胞菌gyrA基因突变进行研究.结果 在57株耐喹诺酮类铜绿假单胞菌中,有35株(61.4%)菌gyrA基因的83位出现突变,其突变方式为Thr83(ACC)→Ile(ATC),其余22株(38.6%)耐喹诺酮类铜绿假单胞菌未发现基因位点突变.33株喹诺酮类敏感临床分离铜绿假单胞菌菌株未发现上述突变.gyrA基因的PCR扩增产物Sac Ⅱ酶切片段与它们测序结果一致.结论 gyrA基因83位氨基酸密码子突变(Thr-83→Ile)是临床分离铜绿假单胞菌耐喹诺酮类药物的主要机制之一.     

国内铜绿假单胞茵对喹诺酮类药物耐药机制的Meta分析

目的 系统评价我国铜绿假单胞菌对喹诺酮类药物的相关耐药机制。 方法 计算机检索CNKI、WanFang Data、CBM、VIP、PubMed、EMbase和The Cochrane Library数据库,检索时限均从建库至2012年12月,查找来自中国的有关铜绿假单胞菌对喹诺酮类药物耐药机制研究的相关文献。按照纳入与排除标准筛选文献后,采用RevMan 5.0软件进行Meta分析。 结果 共纳入19篇文献,合计723株耐喹诺酮类铜绿假单胞菌。统计分析结果显示：gyrA、gyrB、parC和parE基因检出率在淮河以北地区分别为88.0%、13.3%、31.4%和16.7%;在淮河以南地区分别为64.6%、50.0%、35.4%和11.5%。质粒介导的耐药基因aac（6’）-Ib-cr淮河以北地区检出率为0（0/66）,淮河以南地区检出率则为39%（25/64）,主动泵出系统表达率为68.1%。 结论 在我国,铜绿假单胞菌耐喹诺酮类药物的机制以gyrA基因突变为主,其主动泵出系统是重要的耐药机制,而DNA拓扑异构酶Ⅳ的异常及质粒介导的耐药是次要机制。     

480株铜绿假单胞菌耐药性分析

目的了解我院铜绿假瞥胞菌的耐药现状，为临床用药提供依据。方法将我院分离的铜绿假单胞菌的药敏试验结果，应用WHONET5．3软件进行统计学分析。结果铜绿假单胞菌对抗菌药物的敏感性逐年下降，三代头孢和喹诺酮类药物下降明湿。亚胺培南对铜绿假单胞菌仍保持着98．2％的敏感率，多粘菌素B对铜绿假单胞菌也保持着95．0％的敏感率。结论铜绿假单胞菌耐药严蓖，医院应加强对铜绿假单胞菌的监测，临床要依据药敏试验结果合理用药．     

2012～2014年534株铜绿假单胞菌的耐药率及变迁

目的：了解分析铜绿假单胞菌的耐药谱,为我院临床用药提供参考依据。方法用WHONET软件对分离的534株铜绿假单胞菌的药敏试验结果进行统计学分析。结果铜绿假单胞菌对抗菌药物的耐药性呈现逐年上升的趋势,头孢曲松和头孢唑肟一直处于高耐药状态,喹诺酮类药物上升不很明显,米诺环素、哌拉西林、庆大霉素、妥布霉素和氨曲南上升较快,炭青霉烯类对铜绿假单胞菌一直保持高度敏感性,达到了85％以上,阿米卡星的敏感性也达86．9％,多黏菌素对铜绿假单胞菌的敏感性也保持93％以上。结论铜绿假单胞菌耐药日趋严重,医院应加强对铜绿假单胞菌的耐药监测,临床也应依据药敏结果合理用药。     

呼吸科抗菌药物的使用与铜绿假单胞菌耐药率的宏观量化关系研究

目的探讨某三甲医院呼吸科2005～2009年抗菌药物使用与铜绿假单胞菌耐药水平变化之间的关系。方法统计呼吸科2005～2009年每半年的药物"类"和药物"种"的消耗情况,并监测铜绿假单胞菌临床耐药率,然后对两者进行相关分析。结果头孢三代药物使用2005～2009年呈整体下降趋势,且和铜绿假单胞菌对主要抗菌药物的耐药率呈正相关;喹诺酮类药物的使用2005～2009年呈整体上升趋势,且和铜绿假单胞菌对主要抗菌药物的耐药率呈负相关;加酶抑制剂类(包括头孢三代加酶抑制剂类和青霉素加酶抑制剂类等)药物的使用,均与铜绿假单胞菌对抗菌药物的耐药率无正相关关系。结论在用药结构中,适当减少头孢三代抗菌药物的比例,适当增加喹诺酮类、加酶抑制剂类抗菌药物的比例,有利于减少铜绿假单胞菌耐药性产生。     

铜绿假单胞菌耐药性及氟喹诺酮类耐药相关基因的研究

目的 了解医院临床分离的铜绿假单胞菌耐药情况及氟喹诺酮类相关耐药基因存在状况.方法 用BD Phoenix100全自动微生物分析仪进行细菌鉴定和药物敏感试验,用聚合酶链反应（PCR）检测parC、gyrA两种氟喹诺酮类耐药相关基因.结果 70株铜绿假单胞菌呈现多重耐药,对环丙沙星、左旋氧氟沙星的耐药率分别为51.4%、50.0%,其余11种的耐药率在10.0%～100.0%.在70株铜绿假单胞菌中,39（55.7%）株分离菌检出parC基因,18（25.7%）株分离菌检出gyrA基因.结论 临床分离的铜绿假单胞菌多重耐药严重,携带parC和gyrA基因是本组试验菌株对氟喹诺酮类抗生素耐药的重要机制.     

50株铜绿假单胞菌的耐药性及耐药基因分析

目的分析铜绿假单胞菌的耐药性及其耐药基因类型,指导临床合理应用抗生素。方法收集广州中医药大学第一附属医院临床送检标本中分离的50株铜绿假单胞菌,用K-B纸片扩散法进行抗生素敏感性试验;筛选出20株多重耐药铜绿假单胞菌,采用聚合酶链反应检测β-内酰胺酶基因类型。结果铜绿假单胞菌对临床常用抗生素存在不同程度的耐药现象,其中最常用的亚胺培南耐药率达96%,20株多重耐药铜绿假单胞菌中检出TEM(40%)、OXA-2群(5%)、OXA-10群(5%)、CARB(30%)4种β-内酰胺酶基因,未检出质粒型AmpC酶和金属β-内酰胺酶基因。膜孔蛋白编码基因oprD2均为缺失型。结论铜绿假单胞菌的耐药现象严重,其原因可能与铜绿假单胞菌多耐药基因表达有关。     

2015～2016年呼吸内科铜绿假单胞菌感染/定植情况调查及耐药性分析

目的：了解2015～2016年呼吸内科患者铜绿假单胞菌感染／定植状况及铜绿假单胞菌的耐药性,为铜绿假单胞菌医院感染预防与控制及临床合理使用抗菌药物提供依据。方法收集2015～2016年呼吸内科患者临床微生物检验报告,凡是临床微生物检验报告检出铜绿假单胞菌患者,均查阅临床资料。统计分析30株铜绿假单胞菌的感染／定植情况及耐药性。结果30株铜绿假单胞菌中16株为定植菌株,定植率为53.33％;14株为感染菌株,感染率为46.67％。30株铜绿假单胞菌多数为多重耐药菌,体外药敏试验结果显示对头孢类、氨基糖苷类、青霉素类、碳青霉烯类、喹诺酮类抗菌药物均产生不同程度耐药,耐药率分别为63.33％、53.33％、53.33、43.33％、13.33％。结论铜绿假单胞菌是引起医院感染的重要条件致病菌,常常引起呼吸系统疾病,并且具较强的耐药性。因此,临床应加强对多重耐药铜绿假单胞菌医院感染预防和控制。     

Guns and Knives in New Mexico: Patterns of Penetrating Trauma, 1978–1993

Objective: To identify patterns of nonfatal and fatal penetrating trauma among children and adults in New Mexico using ED and medical examiner data.
Methods: The authors retrospectively sampled in 5-year intervals all victims of penetrating trauma who presented to either the state Level-1 trauma center or the state medical examiner from a 16-year period (1978–1993). Rates of nonfatal and fatal firearm and stabbing injury were compared for children and adults.
Results: Rates of nonfatal injury were similar (firearm, 34.3 per 100,000 person-years; stabbing, 35.1). However, rates of fatal injury were significantly different (firearm, 21.9; stabbing, 2.7; relative risk: 8.2; 95% confidence interval: 5.4, 12.5). From 1978 to 1993, nonfatal injury rates increased for children (p = 0.0043) and adults (p < 0.0001), while fatal penetrating injury remained constant. The increase in nonfatal injury in children resulted from increased firearm injury rates. In adults, both stabbing and firearm nonfatal injury rates increased.
Conclusions: Nonfatal injury data suggest that nonfatal violence has increased; fatal injury data suggest that violent death rates have remained constant. Injury patterns vary by age, mechanism of trauma, and data source. These results suggest that ED and medical examiner data differ and that both are needed to guide injury prevention programs.     

Systematic Reviews Published in the January 2011 Issue of The Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly as a DVD and monthly online. The January 2011 issue (first quarterly DVD for 2011) contains 4515 complete reviews, 1985 protocols for reviews in production, and 13,521 one-page summaries of systematic reviews published in the general medical literature. In addition, there are citations of 641,000 randomized controlled trials, and 14,018 cited papers in the Cochrane methodology register. The health technology assessment database contains over 9300 citations. One hundred and seven new reviews have been published in the last 3 months, of which five have potential relevance for practitioners in pain and palliative medicine.     

Interprofessional approaches to creating safe,high quality health care

Three supplementary perspectives are presented arguing that interprofessional collaboration is both necessary and desirable. Nonetheless, there are often too many serious intra-professional barriers and obstacles to interprofessional collaboration to make it successful. Some of these barriers, it is argued and illustrated, are found in the multiple ways in which professional identity is tacitly acquired and embodied in the practitioners' habitual, everyday practice. The paper then explores ways in which reflection, especially Second order reflection, can help to elucidate and overcome these obstacles, as well as increasing professional adaptability and competence.     

Prise en charge des entorses externes de cheville : étude clinique préliminaire sur l’efficacité du dispositif Myolux™

Ankle sprains are the most common injury of the musculoskeletal system and are associated with significant societal and economic impacts. It has been proven that classical therapeutic strategies may not be effective in preventing recurrent injuries: the recurrence rates reported in the literature can reach 73%. In order to provide an effective rehabilitation solution, a destabilizing orthosis was developed. This device is equipped with a mechanical articulator reproducing the subtalar mechanics and placed under the heel. In this paper, we present the main results of a preliminary clinical study conducted between 2004 and 2007. All subjects included in this study were treated with the abovementioned orthosis during 10 rehabilitation sessions of 30 minutes each. Data show a relatively low recurrence rate of 12% for the overall population. Moreover, it's of primary importance to note that this satisfactory ratio is largely reduced (3% of recurrence rate) for the 29 patients who performed one training session per month after the 10th initial rehabilitation sessions. Hence, the destabilizing orthosis appears to be an effective solution to prevent recurrent ankle sprains. However, joint protection requires long-term and regular training sessions. This result has motivated the development of a similar device allowing patients to perform training sessions at home. Finally, data obtained in this study are promising awaiting the final results of the comparative, multicentric and independent clinical trials currently managed by the Hospices Civils de Lyon.     

Determination of creatine kinase isoenzyme MB activity in serum using immunological inhibition of creatine kinase M subunit activity. Activity kinetics and diagnostic significance in myocardial infarction.

This is a new method for the determination of creatine kinase isoenzyme MB activity in serum. The method uses direct activity measurement of creatine kinase B subunit activity after blocking of CK-M subunit activity by inhibiting antibodies. The test takes no longer than 15 min. The method yields an intra-serial C.V. of 2.0-12.9%, and a C.V. from day to day of 5.5%. The detection limit is 3.4 U/l creatine kinase MB. In the 95 cases with proven myocardial infarction several types of creatine kinase MB activity kinetics could be determined. The percentage of creatine kinase MB of peak CK-total is 6-25%, with a mean of 11.1%. The amount of creatine kinase MB with respect to total CK activity after reinfarction is higher than the amount after initial infarction.     

俯卧位通气对高海拔地区肺复张治疗无效急性呼吸窘迫综合征患者氧合的影响

目的 探讨俯卧位通气对高海拔地区肺复张术(RM)治疗无效急性呼吸窘迫综合征(ARDS)患者的治疗作用.方法 从海拔2260m的地区医院筛选RM治疗无效的41例ARDS患者[平均氧合指数( PaO2/FiO2)较RM前升高＜20％视为RM无效],依不同病因分为肺内源性ARDS组(ARDSp组)和肺外源性ARDS组(ARDSexp组),每组再按信封法随机分为俯卧位组和仰卧位组,即ARDSp俯卧位组(11例)、ARDSp仰卧位组(9例)、ARDSexp俯卧位组(10例)、ARDSexp仰卧位组(11例).在通气前及通气1、2、3、4h监测动脉血氧分压( PaO2)、PaO2/FiO2、静态顺应性(Cst)、气道阻力(Raw)的变化.结果 通气lh时,ARDSexp俯卧位组PaO2/FiO2( mm Hg,l mm Hg=0.133 kPa)即较通气前显著升高(157.4±40.6比129.3±48.7,P＜0.05),并随通气时间延长呈持续增高趋势,4h达峰值(219.1 ±41.1);且ARDSexp俯卧位组通气3h内PaO2/FiO2较其他3组显著增高,另3组间则差异无统计学意义.ARDSp俯卧位组、ARDSexp俯卧位组通气4h时PaO2/FiO2均较相应仰卧位组显著增高(208.8±39.7比127.4±47.1,219.1±41.1比124.9±50.8,均P＜0.05).4组通气前后Cst无显著改变,各组间差异也无统计学意义.ARDSp俯卧位组通气4h时Raw(cmH2O·L-1·s-1)较通气前显著降低(6.8±1.7比10.7±1.8,P＜0.05),且明显低于其他3组;其他3组各时间点Raw组内及组间比较差异均无统计学意义.结论 俯卧位通气作为ARDS机械通气重要策略之一,可以改善RM无效高原ARDS患者的氧合,为抢救患者赢得宝贵的时间.     

Digital imaging among medical facilities

The Department of Veterans Affairs (VA) in the USA operates a network of 172 medical centres which all utilize a hospital information system (HIS) which has been developed and is currently maintained by the VA. During the past several years, an image management and communication module has been developed, installed and clinically utilized at the Washington DC and Maryland VA Medical Centres. This image management and communication system, referred to as the decentralized hospital computer program (DHCP) imaging system, is fully integrated with a commercial picture archiving and communication system (PACS). The system is utilized to capture, archive, and display all images generated within the hospital including radiology, nuclear medicine, pathology, endoscopy, bronchoscopy, and dermatology, intraoperative photographs, ECG data, and a limited number of paper documents. The ultimate goal of the project is to have all patient text and image data available at any clinical workstation to any authorized user anywhere within the network of medical centres. Clinical requirements for an imaging workstation include ease of use, rapid and reliable access to the complete set of patient information, and images which are of acceptable quality to meet the requirements of the user and the subspecialty. Patient confidentiality and data security must be safeguarded at all times. Integration of the images with the remainder of the patient's database was found to be critical to the success of the project. The experience at the Washington and Maryland facilities suggests that an imaging system that is successfully integrated with a hospital information system can provide substantial clinical and economic benefits both within and among medical centres. Clinical acceptance and utilization of the system has been excellent, particularly in diagnostic radiology where DHCP Imaging has been interfaced to a commercial PAC system. Based upon this initial experience, the VA has begun to deploy the system throughout its large network of medical centres.     

Myocardial elastography at both high temporal and spatial resolution for the detection of infarcts

Myocardial elastography is a novel method for noninvasively assessing regional myocardial function, with the advantages of high spatial and temporal resolution and high signal-to-noise ratio (SNR). In this paper, in-vivo experiments were performed in anesthetized normal and infarcted mice (one day after left anterior descending coronary artery [LAD] ligation) using a high-resolution (30 MHz) ultrasound system (Vevo 770, VisualSonics Inc., Toronto, ON, Canada). Radiofrequency (RF) signals of the left ventricle (LV) in longitudinal (long-axis) view and the associated electrocardiogram (ECG) were simultaneously acquired. Using a retrospective ECG gating technique, 2-D full field-of-view RF frames were acquired at an extremely high frame rate (8 kHz) that resulted in high-quality incremental displacement and strain estimation of the myocardium. The incremental results were further accumulated to obtain the cumulative displacements and strains. Two-dimensional and M-mode displacement images and strain images (elastograms), as well as displacement and strain profiles as a function of time, were compared between normal and infarcted mice. Incremental results clearly depicted cardiac events including LV contraction, LV relaxation and isovolumetric phases in both normal and infarcted mice, and also evidently indicated reduced motion and deformation in the infarcted myocardium. The elastograms indicated that the infarcted regions underwent thinning during systole rather than thickening, as in the normal case. The cumulative elastograms were found to have higher elastographic SNR (SNR(e)) than the incremental elastograms (e.g., 10.6 vs. 4.7 in a normal myocardium, and 6.0 vs. 2.4 in an infarcted myocardium). Finally, preliminary statistical results from nine normal (m = 9) and seven infarcted (n = 7) mice indicated the capability of the cumulative strain in differentiating infracted from normal myocardia. In conclusion, myocardial elastography could provide regional strain information at simultaneously high temporal (>/=0.125 ms) and spatial ( approximately 55 microm) resolution as well as high precision ( approximately 0.05 microm displacement). This technique was thus capable of accurately characterizing normal myocardial function throughout an entire cardiac cycle, at the same high resolution, and detecting and localizing myocardial infarction in vivo.