689例硅沉着病患者下呼吸道感染病原菌分布及耐药性分析

目的探究硅沉着病合并下呼吸道感染患者的病原菌种类分布及耐药性,以协助临床更加准确诊断及合理应用抗菌药物。方法对硅沉着病患者的痰标本进行采集和培养,培养出的病原菌进行分离、鉴定,并进行药敏测定。结果硅沉着病合并下呼吸道感染患者主要病原菌的分布以革兰阴性菌为主,其中肺炎克雷伯菌、铜绿假单胞茵、大肠埃希菌位于前3位。革兰阳性菌相对分布较少,其中金黄色葡萄球菌、肠球菌居前,革兰阴性杆菌对第二、三代头孢类抗菌药物耐药性较高,但对其复合酶制剂敏感性较好,对碳青霉烯类及第四代头孢类抗菌药物敏感性较好,其中铜绿假单胞菌耐药性最严重;革兰阳性球菌对第三、四代头孢菌素耐药率较高,对万古霉素高度敏感。结论硅沉着病患者下呼吸道感染的主要病原菌为革兰阴性杆菌,医师应监测细菌耐药性变化,合理使用抗菌药物。     

普外科手术患者常见病原菌及耐药性分析

目的了解我院普外科病原菌的菌种构成及对抗菌药物的耐药性,为预防性应用抗菌药物和术后抗感染治疗提供依据。方法采用ATB Expression自动细菌培养鉴定仪及配套板条对普外科分离的菌株进行鉴定及药敏试验,用WHONET 5.6软件进行统计学分析。结果普外科分离病原菌以革兰阴性杆菌为主,占83.3%。前四位病原菌依次是大肠埃希菌、肺炎克雷伯菌、铜绿假单胞菌和金黄色葡萄球菌。大肠埃希菌对一些常用抗菌药物如头孢菌素有一定的耐药性,对第三代头孢菌素和第Ⅱ代头孢菌素的耐药率也在47.2%-77.5%之间。葡萄球菌对青霉素和红霉素等表现出较高的耐药性,但对万古霉素仍然非常敏感。结论普外科的病原菌构成以革兰阴性杆菌占主导地位,临床在抗感染治疗时应根据药敏试验合理应用并及时调整抗菌药物。     

尘肺病合并下呼吸道感染患者的病原菌及菌株耐药情况的分析

目的探讨尘肺病合并下呼吸道感染患者的病原菌及菌株耐药情况,为指导临床合理用药提供参考。方法选择2013年1月至2014年12月该院收治的合并下呼吸道感染的尘肺病患者122例,采取口痰培养法收集相关标本后对其进行相关鉴定,采用K-B纸片扩散法进行药敏分析。结果 122例标本培养出病原菌82株,检出率67.21%(82/122),主要以革兰阴性杆菌为主,占70.7%,其中前3位依次为肺炎克雷伯菌(18.3%)、大肠埃希菌(15.9%)及铜绿假单胞菌(9.8%);革兰阳性球菌检出率为19.5%,其中肺炎链球菌(11.0%)、金黄色葡萄球菌(6.1%)及肠球菌(2.4%);真菌(白色念珠菌)检出率占9.8%;革兰阴性杆菌中对第二及第三代头孢菌素类药物有着较高的耐药性,其中以铜绿假单胞菌的耐药性最高,但对此类药物的复方制剂有着较高的敏感性,尤其对四代头孢类药物及碳青霉烯类的敏感性较高;革兰阳性球菌对第三及第四代头孢菌素类药物具有较高的耐药性,对替考拉宁、万古霉素具有较低的耐药性。结论尘肺病合并下呼吸道感染患者的主要病原菌为革兰阴性杆菌,且病原菌的耐药现象较为严重,临床给予持续耐药监测对于指导合理应用抗菌药物,提高治疗效果以及减缓耐药菌株的出现至关重要。     

第三代头孢菌素使用情况分析

目的分析我院第三代头孢菌素使用情况分析。方法随机选取我院2017年4月～2019年3月使用400张头孢菌素类抗菌药物使用处方为研究对象,对头孢菌素类抗菌药物的使用方式、不良反应、剂量及药物名称等进行分析,并提出合理用药方案。结果在使用频度上,第三代头孢菌素类抗菌药物高于第一、二代头孢菌素类抗菌药物,差异有统计学意义(P<0.05)。肌肉注射/静脉滴注例数及使用金额中,最高的为第二代头孢菌素类抗菌药物,最低为第一代头孢菌素类抗菌药物。第三代头孢菌素类抗菌药物使用频率较高药物主要有头孢噻肟钠、头孢曲松及头孢地嗪钠,用药方式主要以肌肉注射和静脉注射为主,使用频率通常为1～2次/d,使用剂量均未超过4g/d。400张处方中对应用药发生不良反应24例,总发生率为6.00%,其中过敏占8.33%,消化系统占79.17%,血液系统占4.17%、泌尿系统占8.33%。消化系统不良反应和其它相比,差异有统计学意义(P<0.05)。结论我院第三代头孢菌素类抗菌药物使用情况较为合理,需要了解和熟知临床相关药物的药理,进而继续保持用药的合理性。     

665株鲍曼不动杆菌耐药性变化与用药频度相关性分析

目的:调查鲍曼不动杆菌的耐药现状,分析抗菌药物用药频度与细菌耐药性的相关性,促进临床更加合理使用抗菌药物。方法:回顾性分析临床分离的665株鲍曼不动杆菌的耐药性,并结合抗菌药物使用频度分析其与鲍曼不动杆菌耐药性的相关性。结果:鲍曼不动杆菌对多种常用抗菌药物的耐药性均较高,且呈现广泛耐药的趋势。对头孢菌素类、碳青霉烯类等药物的耐药率明显上升。鲍曼不动杆菌的耐药率与抗菌药物的使用频度有一定的相关性,对庆大霉素、哌拉西林/他唑巴坦的耐药率与其用药频度呈显著正相关(r=0.87、0.98,P0.01);对头孢他啶的耐药率与其用药频度呈正相关(r=0.75,P0.05);对头孢西丁的耐药率与其用药频度呈负相关(r=-0.74,P0.05);鲍曼不动杆菌对头孢哌酮/舒巴坦的耐药率与氨基糖苷类药物的使用频度呈负相关(r=-0.84,P0.05);对阿米卡星的耐药率与头孢菌素的使用频度呈显著正相关(r=0.98,P0.01)。结论:鲍曼不动杆菌对常用抗菌药物的耐药性较为严重,抗菌药物的用药频度和细菌耐药率之间存在一定的相关性。     

2014-2018年某院ICU感染目标病原菌分布及耐药性分析

目的了解该院重症监护病房(ICU)感染目标病原菌的分布及耐药性,为ICU病原菌的有效控制及合理选择抗菌药物提供依据。方法回顾性分析该院ICU 2014年1月至2018年12月送检标本所分离的病原菌,锁定目标病原菌,分析其耐药性。结果送检标本共5339份,分离病原菌3364株,其中革兰阴性杆菌占62.2%,革兰阳性球菌占23.0%,真菌占14.8%。革兰阴性杆菌分离数量居前3位的分别为鲍曼不动杆菌、铜绿假单胞菌和肺炎克雷伯菌;革兰阳性球菌分离数量居前3位的分别为屎肠球菌、金黄色葡萄球菌和粪肠球菌。目标病原菌药敏试验结果和多重耐药性分析显示:鲍曼不动杆菌对各类抗菌药物耐药率均偏高,最高达89.4%;肺炎克雷伯菌对第三、四代头孢菌素类药物耐药率均>50.0%;耐碳青霉烯铜绿假单胞菌构成比总体呈下降趋势,耐碳青霉烯肺炎克雷伯菌和耐碳青霉烯鲍曼不动杆菌构成比5年变化不大;未发现耐万古霉素的金黄色葡萄球菌,耐甲氧西林金黄色葡萄球菌2014-2017年构成比≥69.0%。结论该院ICU感染病原菌主要为革兰阴性杆菌,以鲍曼不动杆菌耐药尤为突出,年份不同,病原菌耐药性略有不同,应定期对ICU感染病原菌的分布及耐药性进行监测,指导临床合理应用抗菌药物。     

武汉地区61株鼠伤寒沙门菌的耐药性分析

目的了解本地区门诊腹泻患者鼠伤寒沙门菌（STM）的耐药性。方法采用商用培养基及沙门菌诊断血清分离、鉴定细菌；抗菌药物敏感性试验采用琼脂稀释法检测MIC。结果STM检出率为0．6％（61／10464），其对氨苄西林、氯霉素、四环素、复方磺胺甲嗯唑、阿莫西林-克拉维酸、环丙沙星和庆大霉素耐药率达71．2％～100％。第三代和第四代头孢菌素对STM仍维持较好的抗菌活性，耐药率均低于3．3％。未检出亚胺培南耐药株。61株STM中，多重耐药菌占88．5％。结论本地区腹泻患者粪便标本中STM对亚胺培南和第三代、第四代头孢菌素较敏感，对氨苄西林、氯霉素、四环素、复方磺胺甲嗯唑、庆大霉素和阿莫西林-克拉维酸等耐药性较严重，应加强其耐药性监测和防治。     

2010～2011年重症手足口病呼吸机相关性肺炎的病原学调查及耐药性分析

目的:分析重症手足口病并发呼吸机相关性肺炎(VAP)的病原菌构成及其耐药性,为临床合理使用抗菌药物提供科学依据。方法:回顾性分析2010年1月～2011年12月我院重症病房收治的重症手足口病发生VAP 31例患儿的痰培养分离病原菌及药敏结果。结果:VAP感染率为31.31%,分离出的54株病原菌均为革兰氏阴性菌,31例患儿VAP感染前三位的菌是铜绿假单胞菌、非发酵革兰氏阴性杆菌、鲍曼不动杆菌。结论:重症手足口病合并VAP致病以革兰氏阴性杆菌为主,可将第3代头孢菌素、磺胺类作为临床治疗手足口病并发VAP铜绿假单胞菌感染的首选药物;单环β-内酰胺类、磺胺类、第三代头孢菌素可作为非发酵革兰氏阴性杆菌感染的首选药物;单环β-内酰胺类、第三代头孢菌素可作为鲍曼不动杆菌感染的首选药物。     

2018—2020年某三甲医院成人社区获得性肺炎病原菌分布及耐药率变迁

摘要 目的 探讨成人社区获得性肺炎(CAP)病原菌分布及耐药性变迁,为临床经验性治疗提供科学依据。方法 收集某三级甲等医院2018年1月—2020年12月期间诊断为CAP患者的病原菌及药敏试验结果,分析其病原菌分布和耐药性差异。结果 CAP分离病原菌在不同年份和不同季节构成比差异有统计学意义(P＜0.001);铜绿假单胞菌对哌拉西林他唑巴坦和头孢哌酮舒巴坦的耐药率呈上升趋势(P＜0.05);肺炎克雷伯菌对亚胺培南、美罗培南、头孢哌酮舒巴坦、左氧氟沙星、替加环素、氨曲南、环丙沙星和阿米卡星的耐药率均有上升趋势(P＜0.05);鲍曼不动杆菌对常用抗菌药物的耐药率均无明显变化趋势(P＞0.05),对碳青霉烯类抗菌药物耐药率均大于50%;大肠埃希菌对亚胺培南、头孢哌酮舒巴坦和妥布霉素的耐药率有升高趋势(P＜0.05);金黄色葡萄球菌对万古霉素和利奈唑胺100%敏感。结论 CAP患者分离病原菌分布及耐药性随时间的变迁和季节的不同而有差异,细菌耐药性形势严峻,临床应加强CAP病原菌分布及耐药性监测,合理使用抗菌药物。     

2017—2019年临床药师持续干预骨科清洁手术预防性使用抗菌药物的效果分析

目的通过临床药师对医院骨科清洁手术前预防性使用抗菌药物的持续干预,规范骨科清洁手术前抗菌药物的预防性使用。方法通过临床药师参与医院抗菌药物的管理与考核,建立医嘱点评与考核系统,收集持续性干预3年(2017-2019年)的医院骨科清洁手术出院病历4430份,对清洁手术抗菌药物的预防性使用率、人均抗菌药物费用、抗菌药物的种类选择及使用疗程进行分析与点评。结果临床药师持续干预期间,人均抗菌药物费用由2017年的(2073.6±26.7)元下降至2019年的(255.3±8.2)元,差异有统计学意义(P<0.05);抗菌药物预防性使用率由2017年的70.72%下降至2019年的58.33%,差异有统计学意义(P<0.05);第3代头孢菌素(头孢曲松)的选用比例逐年下降,第1代头孢菌素(头孢唑啉)的选用比例逐年升高。2017—2019年,抗菌药物预防性使用疗程<24 h的例数逐年增加,使用疗程>48 h的例数逐年下降,2017年与2019年比较,差异有统计学意义(P<0.05)。结论临床药师干预医院骨科清洁手术抗菌药物的预防性使用可明显促进骨科抗菌药物的合理应用。     

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.     

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.     

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.     

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.     

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.