农毒症大鼠结肠内容物CFA／Ⅰ、SpaBnRNA的动态变化及意义

目的：观察CFA／I、SpaB基因在脓毒症大鼠结肠内容物中的表达，探讨CFA／I、SpaB基因表达在脓毒症发病机制中的作用。方法：SD大鼠64只，随机分为假手术组和脓毒症组各32。假手术组和脓毒症组根据术后取标本的时间各自分为1周、2周、3周、4周四个亚组，每个亚组8只，制定脓毒症和假手术组模型，在规定的时间点内按要求取结肠内容物标本，实时荧光PGR法检测结肠内容物CFA／I、SpaB mRNA的表达。结果：脓毒症组大鼠结肠内容物CFA／I基因表达同期高于假手术组，SpaB基因表达低于同期假手术组（P〈0．05）：结论：脓毒症大鼠结肠内容物CFA／I基因表达增加，SpaB基因表达减弱与膝毒症发病机制有关。     

A retrospective analysis of deep sternal wound infections after longitudinal median sternotomy

Median sternotomy is the most commonly performed surgical procedure in the treatment of heart conditions in both adults and children. Deep sternal wound infections (DSWI) present a serious complication occurring after surgery, highly demanding both of patients and surgery departments. The present study is a retrospective analysis of 9110 patients who underwent a cardiac surgery at the Center of Cardiovascular Surgery and Transplantations, Brno, Czech Republic, in the years 2005–12, and as its objective it has a definition of risk factors of DSWI after median sternotomy.In this study, a multivariate analysis found sepsis to be the most serious risk factor, in addition to harvesting of the mammary artery (to be used as a graft for revascularisation), haemodynamic instability, reintubation and male sex.     

Can we back off using antibiotics in the NICU?

Antibiotics are extensively and inconsistently prescribed in neonatal ICUs, and usage does not correlate with rates of culture positive sepsis. There is mounting data describing the short and long-term adverse effects associated with antibiotic overuse in neonates, including the increased burden of multi-drug resistant organisms. Currently there is considerable variation in antibiotic prescribing practice among neonatologists. Applying the practice of antibiotic stewardship in the NICU is crucial for standardizing antibiotic use and improving outcomes in this population.Several approaches have been proposed to identify neonatal sepsis, with the hope of reducing antibiotic utilization. These strategies all have their limitations, and often include laboratory testing and treatment of well-appearing, non-septic, infants. A conservative “watch and wait” algorithm is suggested as an alternative method for when to initiate antibiotics. This observational approach relies on availability of trained personnel able to examine infants at specified intervals, without delaying antibiotics, should signs of sepsis arise.     

一起尿源性脓毒血症死亡案例的解析与改进*

对一起尿源性脓毒血症患者死亡案例进行解析，从明确诊断标准、制定规范举措、畅通绿色通道、促进患方参与等方面进行改进。改进后，尿源性脓毒血症患者诊断率提高，就诊至处理时间（DTN）从88.9min缩短至55.6min（P＜0.001），患者住院时间由7.9天缩短至4.9天，人均住院总费用减少8 105元，差异均有统计学意义（P＜0.05）。运用精益管理方法，优化专科急危重症诊治流程，能够缩短治疗时间，促进患者康复，节约住院费用，改善患者愈后     

脓毒血症患儿血浆肝素结合蛋白、降钙素原和C-反应蛋白与病情严重程度的关系

目的探讨腺毒血症患儿血装肝素结合蛋白(heparin-binding protein,HBP)、血清降甸素原(procalcitonin,PCT)和C反应蛋白(C-reactive protein,CRP)与病情严重程度的关系。方法选取2017年1月-2019年3月在西安交通大学医学院第一附属医院接受治疗的113例脓毒血症患儿为观察组,选取同期在本院体检的健康志愿者35例为对照组。根据病情程度将观察组分为脓毒症组,严重脓毒症组,感染性休克脓毒症组。根据预后情况不同分为存活组和死亡组。比较各组HBP、PCT、CRP、慢性健康状况评分Ⅱ(APACHEⅡ)、序贯器官衰竭估计评分(SOFA),并分析其与病情严重程度和预后的关系。分析HBP、PCT和CRP与APACHEⅡ、SOFA的相关性。采用受试者工作曲线(ROC)分析血浆HBP、PCT和CRP诊断膝毒血症的临床效能。结果①113例脓毒血症患儿,脓毒症34例,严重脓毒症36例,感染性休克脓毒症43例;经规范治疗后,生存82例,死亡31例。②观察组患儿入院时血浆HBP、血清PCT和CRP水平比对照组显著升高(P<0.05)。感染性休克脓毒症组患儿入院时血浆HBP、血清PCT和CRP水平最高,严重脓毒症组次之,脓毒症最低(P<0.05)。Pearson分析表明,入院时血浆HBP、血清PCT和CRP水平与脓毒血症严重程度均呈正相关(r分别为0.804、0.732、0.605,均P<0.05)。③存活组患儿入院时血浆HBP、血清PCT和CRP水平均低于死亡组(P<0.05)。Pearson分析显示:入院时血浆HBP、血清PCT和CRP水平均与预后呈正相关(r分别为0.813、0.756,、0.674,均P<0.05)。④血浆HBP、血清PCT和CRP水平与APACHEⅡ评分、SOFA评分显著相关,均呈正相关。其中血浆HBP水平与APACHEⅡ评分及SOFA评分的相关性较好(r分别为0.741和0.811,均P<0.001)。⑤入院时血浆HBP的评估脓毒血症的曲线下面积(AUC)和95%CI分别为0.885和(0.854~0.973),当截断点为27.99ng/mL时,灵敏度、特异度分别为80.4%和88.5%。血清PCT的评估脓毒血症的AUC和95%CI分别为0別5和(0.749~0.882),当截断点为0.16ng/mL时,灵敏度、特异度分别为81.9%和68.7%。血清CRP的评估脓毒血症的AUC和95%CI分别为0.731和(0.653~0.809),当截断点为2.3 mg/L时,灵敏度、特异度分别为54.3%和87.0%。结论脓毒血症患儿血浆HBP、PCT和CRP显著上升,与患儿病情严重程度和预后有关,用于早期监测和评估脓毒症患者的病情具有重要临床意义。     

Sepsis after elective neurosurgery: Incidence,outcomes, and predictive factors

Sepsis is a life-threatening condition resulting from systemic infection, with mortality rates approaching 30%. Most neurological surgeries are now performed electively, which permits medical optimization preoperatively. We performed a retrospective cohort analysis of 122,466 adult elective neurosurgical patients from 2012 to 2018 in the National Surgical Quality Improvement Program database. To select for a medically optimized population, patients were included if they arrived from home on the day of surgery, were not pregnant or puerperium, and had no documented evidence of preexisting infection. We analyzed demographic, comorbidity, and operative information; performed multivariate logistic regression to explore factors predictive of postoperative sepsis; and evaluated outcomes for patients who developed sepsis. Overall, 0.87% of patients developed postoperative sepsis (n = 1,067). The rate of sepsis was higher in the cranial subpopulation (1.21%; n = 330) and lower in the spinal subpopulation (0.77%; n = 733). The overall sepsis cohort was older, had more males, was more functionally dependent, had longer operation durations, and had higher rates of medical comorbidities. Minority race and smoking were not associated with sepsis. The sepsis cohort fared worse than the control cohort across all outcome measures, including prolonged length-of-stay (≥90^th percentile), discharge anywhere but home, 30-day readmission, 30-day reoperation, and 30-day mortality. Results for the cranial and spine subpopulations follow similar trends. In summary, sepsis in the elective neurosurgical population is an uncommon but devastating cause of excess morbidity and mortality.     

The preterm gut microbiota: changes associated with necrotizing enterocolitis and infection

Aim: To describe gut colonization in preterm infants using standard culture and 16S gene rRNA profiling, exploring differences in healthy infants and those who developed NEC/late onset sepsis (LOS). Methods: Ninety‐nine stools from 38 infants of median 27‐week gestation were cultured; 44 stools from 27 infants had their microbial profiles determined by 16S. Ordination analyses explored effects of patient variables on gut communities. Results: Standard microbiological culture identified a mean of two organisms (range 0–7), DGGE 12 (range 3–18) per patient. Enterococcus faecalis and coagulase negative staphylococci (CONS) were most common by culture (40% and 39% of specimens). Meconium was not sterile. No fungi were cultured. Bacterial community structures in infants with NEC and LOS differed from healthy infants. Infants who developed NEC carried more CONS (45% vs 30%) and less Enterococcus faecalis (31% vs 57%). 16S identified Enterobacter and Staphylococcus presence associated with NEC/LOS, respectively. Conclusions: Important differences were found in the gut microbiota of preterm infants who develop NEC/LOS. The relationship of these changes to current practices in neonatal intensive care requires further exploration.