基层医院ICU与非ICU主要革兰阴性杆菌分布与耐药性差异

目的了解医院重症监护室(ICU)与非ICU主要革兰阴性(G-)杆菌的分布及耐药性,为临床合理使用抗菌药物提供依据。方法对某院2011—2013年住院患者送检标本中培养分离的G-菌标本来源及耐药性进行统计分析,比较ICU与非ICU的差异。结果 25 153份标本共分离G-菌3 875株,分离率15.41%;其中ICU1 121份标本中分离G-菌527株,分离率47.01%,非ICU24 032份标本分离G-菌3 348株,分离率13.93%,两者比较差异有统计学意义(χ2=899.32,P0.001)。大肠埃希菌和肺炎克雷伯菌产超广谱β-内酰胺酶(ESBLs)菌株检出率:ICU分别为56.00%(28/50)、70.65%(65/92),非ICU分别为52.81%(517/979)和40.37%(241/597)。ICU中铜绿假单胞菌、鲍曼不动杆菌、大肠埃希菌、肺炎克雷伯菌对亚胺培南的耐药率分别为36.59%、88.54%、10.00%、10.87%,均高于非ICU同类菌的耐药率,分别为20.21%、61.15%、1.74%、2.85%。结论 ICU主要G-杆菌的耐药率高于非ICU,且以多重耐药的非发酵菌为主。临床治疗应区别对待,以减少耐药菌的产生。     

The Effect of Lactobacillus plantarum 299v on the Incidence of Clostridium difficile Infection in High Risk Patients Treated with Antibiotics

Background: Lactobacillus plantarum 299v (LP299v) has been used in order to reduce gastrointestinal symptoms during antibiotic exposure. However, it remains controversial whether or not probiotics are effective in the prevention of Clostridium difficile infections (CDI) among patients receiving antibiotics. The aim of this study was to analyze the CDI among patients receiving antibiotics and hospitalized in the period before and after starting routine use of LP299v as a prevention of this infection. Methods: Among 3533 patients hospitalized in the nephrology and transplantation ward during a two-year period, 23 patients with CDI were diagnosed and enrolled in this retrospective study. Since November 2013, prevention of CDI with oral use of LP299v was performed in all patients treated with antibiotics and who were at a high risk of developing CDI. The observation period was divided into two twelve-month intervals before and after initiation of the use of LP299v as a prophylactic against CDI. Results: A significant (p = 0.0001) reduction of the number of cases of CDI was found after routinely using LP299v (n = 2; 0.11% of all hospitalized patients) compared with the previous twelve-month period of observation (n = 21; 1.21% of all hospitalized patients). Conclusions: Routine use of LP299v during treatment with antibiotics may prevent C. difficile infection in the nephrology and transplantation ward.     

微粒体环氧化物水解酶基因多态性与膀胱移行细胞癌发生的关系

目的 探讨微粒体环氧化物水解酶(mEH)基因型与膀胱移行细胞癌(BTCC)的相关性.方法 应用聚合酶链反应—限制性片段长度多态性分析方法检测BTCC患者(BTCC组,216例)和健康人群(对照组,300例)mEH基因型频率的分布.设计流行病学调查问卷进行面访调查.结果 BTCC组野生型、杂合型和变异型mEH第3外显子(mEH-exon3)分别占60.6％、27.3％和12.0％,对照组分别占46.3％、39.0％和14.7％ (P＜0.05);杂合型mEH-exon3为BTCC发生的保护性因素(OR=0.56,95％ CI=0.41-0.82).BTCC组野生型、杂合型和变异型mEH第4外显子(mEH-exon4)分别占85.6％、13.4％和0.9％,对照组分别占82.3％、15.0％和2.7％(P＞0.05).吸烟的mEH-exon3野生型人群的BTCC风险高于不吸烟者(P＜0.05).结论 mEH-exon3非野生型可能是BTCC发生、发展中的保护性因素之一;吸烟为BTCC发生的重要危险因素.而mEH-exon4基因多态性和BTCC的发生无明显相关性.     

Highly sensitive and specific novel biomarkers for the diagnosis of transitional bladder carcinoma

Transitional bladder carcinoma (BCa) is prevalent in developed countries, particularly among men. Given that these tumors frequently recur or progress, the early detection and subsequent monitoring of BCa at different stages is critical. Current BCa diagnostic biomarkers are not sufficiently sensitive for substituting or complementing invasive cystoscopy. Here, we sought to identify a robust set of urine biomarkers for BCa detection. Using a high-resolution, mass spectrometry-based, quantitative proteomics approach, we measured, compared and validated protein variations in 451 voided urine samples from healthy subjects, non-bladder cancer patients and patients with non-invasive and invasive BCa. We identified five robust biomarkers: Coronin-1A, Apolipoprotein A4, Semenogelin-2, Gamma synuclein and DJ-1/PARK7. In diagnosing Ta/T1 BCa, these biomarkers achieved an AUC of 0.92 and 0.98, respectively, using ELISA and western blot data (sensitivity, 79.2% and 93.9%; specificity, 100% and 96.7%, respectively). In diagnosing T2/T3 BCa, an AUC of 0.94 and 1.0 was attained (sensitivity, 86.4% and 100%; specificity, 100%) using the same methods. Thus, our multiplex biomarker panel offers unprecedented accuracy for the diagnosis of BCa patients and provides the prospect for a non-invasive way to detect bladder cancer.     

A Pilot Study Using Nominal Group Technique to Assess Residents’ Perceptions of Successful Attending Rounds

BACKGROUND  Ward attending rounds are fundamental for internal medicine residency training. An improved understanding of interns’ and residents’ perceptions of attending rounds should inform training programs and attending physicians. OBJECTIVES  The aim of this study was to assess residents’ perceptions of successful attending rounds. DESIGN  We convened two groups of interns and two groups of residents, to elicit their perceptions on attending rounds. SUBJECTS  Participants were recruited by e-mail and conference announcements from the 49 interns and 80 residents in the internal medicine and medicine-pediatrics residency programs. MEASUREMENTS  The nominal group technique (NGT) uses a structured group process to elicit and prioritize answers to a carefully articulated question. MAIN RESULTS  Seven interns (14%) identified 27 success factors and ranked attending approachability and enthusiasm and high quality teaching as most important. A second group of six (12%) interns identified 40 detractors and ranked having “mean attendings,” receiving disrespectful comments, and too long or too short rounds as the most significant detractors. Nine (11%) residents identified 32 success factors and ranked attention to length of rounds, house staff autonomy, and establishing goals/expectations as the most important success factors. A second group of six (8%) residents identified 34 detractors and ranked very long rounds, interruptions and time constraints, and poor rapport between team members as the most significant detractors). CONCLUSIONS  Although there was some overlap in interns’ and residents’ perceptions of attending rounds, interns identified interpersonal factors as the most important factors; whereas residents viewed structural factors as most important. These findings should assist attending physicians improve the way they conduct rounds targeting both interns and residents needs. Presented in part at the Southern Regional Meeting of the Society of General Internal Medicine in New Orleans, LA, in February 2005 and the Society of General Internal Medicine Annual Meeting in New Orleans, LA, in May 2005.     

Transitional care for patients with surgical pediatric hepatobiliary disease: Choledochal cysts and biliary atresia

Choledochal cysts (CDCs) and biliary atresia (BA) are rare pediatric hepatobiliary anomalies that require surgical intervention due to increased risk of malignancy and liver failure, respectively. The underlying disease and operative procedures place patients at risk for long‐term complications, which may continue to affect them into adulthood. Lack of a transitional care model in the health‐care system potentiates the challenges they will face following aging out of their pediatric providers' care. We sought to elucidate the long‐term complications and challenges patients with CDCs and BA face, review the current literature regarding transitioning care, and propose guidelines aiding adult providers in continued care and surveillance of these patients. A literature review was performed to assess short‐term and long‐term complications after surgery and the current standards for transitioning care in patients with a history of CDCs and BA. While transitional programs exist for patients with other gastrointestinal diseases, there are few that focus on CDCs or BA. Generally, authors encourage medical record transmission from pediatric to adult providers, ensuring accuracy of information and compliance with treatment plans. Patients with CDCs are at risk for developing biliary malignancies, cholangitis, and anastomotic strictures after resection. Patients with BA develop progressive liver failure, necessitating transplantation. There are no consensus guidelines regarding timing of follow up for these patients. Based on the best available evidence, we propose a schema for long‐term surveillance.     

Lessons learned from the management of adults who have undergone augmentation for spina bifida and bladder exstrophy: Incidence and management of the non‐lethal complications of bladder augmentation

The present review provides clinical insights and makes recommendations regarding patient management garnered by the long‐term follow up of patients undergoing enteric bladder augmentation for the management of congenital anomalies. A prospectively maintained database on 385 patients that have experienced an enteric bladder augmentation, using either the ileum or colon, was reviewed. Evaluations included methods used to prevent bladder calculi formation and recurrence, the incidence and etiology of renal calculi development, the incidence and treatment of vitamin B₁₂ deficiency, and the complications and need for surgical revisions for continent catheterizable stomas. A significantly increased risk for continent catheterizable stomal complications occurred after Monti–Yang tube formation, 70% (21/30 patients), compared with appendicovesicostomy, 41% (27/66 patients), P = 0.008. Both procedures had significantly more complications than continent catheterizable stomas using tapered ileum with a reinforced ileal–cecal valve, 21% (13/63 patients), P < 0.0001 and P < 0.013, respectively. Approximately 50% of the patient population developed a body mass index ≥30 during adulthood. The onset of obesity resulted in significantly more complications developing in patients with a Monti–Yang tube (87%; 13/15 patients) or appendicovesicostomy (55%; 18/33 patients) compared with a tapered ileum with a reinforced ileal‐cecal valve (27%, 8/30 patients), P < 0.00015 and P < 0.025, respectively, with a median follow‐up interval of 16 years, range 10–25 years. Long‐term follow‐up evaluations on patients undergoing an enteric bladder augmentation are necessary to prevent the long‐term sequela of this procedure. The key to improving patient prognosis is the nutritional management of the patient as they mature, especially if a continent abdominal stoma is going to be carried out.     

An implementation model for managing cloud-based longitudinal care plans for children with medical complexity

ObjectiveWe aimed to iteratively refine an implementation model for managing cloud-based longitudinal care plans (LCPs) for children with medical complexity (CMC).Materials and MethodsWe conducted iterative 1-on-1 design sessions with CMC caregivers (ie, parents/legal guardians) and providers between August 2017 and March 2019. During audio-recorded sessions, we asked participants to walk through role-specific scenarios of how they would create, review, and edit an LCP using a cloud-based prototype, which we concurrently developed. Between sessions, we reviewed audio recordings to identify strategies that would mitigate barriers that participants reported relating to 4 processes for managing LCPs: (1) taking ownership, (2) sharing, (3) reviewing, and (4) editing. Analysis informed iterative implementation model revisions.ResultsWe conducted 30 design sessions, with 10 caregivers and 20 providers. Participants emphasized that cloud-based LCPs required a team of owners: the caregiver(s), a caregiver-designated clinician, and a care coordinator. Permission settings would need to include universal accessibility for emergency providers, team-level permission options, and some editing restrictions for caregivers. Notifications to review and edit the LCP should be sent to team members before and after clinic visits and after hospital encounters. Mitigating double documentation barriers would require alignment of data fields between the LCP and electronic health record to maximize interoperability.DiscussionThese findings provide a model for how we may leverage emerging Health Insurance Portability and Accountability Act–compliant cloud computing technologies to support families and providers in comanaging health information for CMC.ConclusionsUtilizing these management strategies when implementing cloud-based LCPs has the potential to improve team-based care across settings.     

A British Dilemma Too

Abstract

Goal: Evidence-based guidelines exist for the prevention and treatment of patients with cerebral ischemia. Despite these guidelines, there are gaps in clinical practice. Our study aimed to determine if a physician-directed, nurse-case-management program could reduce individual patient vascular risk factors. Methods: Patients hospitalized with atherosclerotic cerebral ischemia with ≥ 1 major uncontrolled risk factor for stroke (hypertension, tobacco use, dyslipidemia, diabetes) were eligible to enroll in our study. Patients were randomized to management by the nurse-prevention program or usual care. Patients in the usual-care group received their initial risk-factor assessment and a scheduled follow-up at 1 year. Patients in the usual-care group underwent further follow-up by primary care and/or neurology as recommended during their hospitalization or outpatient visit. Patients assigned to the prevention group received individualized education, motivational interviewing, and were aided in setting up their risk-factor modification goal plan. Additional education was tailored to each patient based on individualized risk factors. Prevention-group patients also underwent consultation with a registered dietitian and an exercise physiologist. The primary endpoint of the study was improvement of ≥ 1 major patient risk factor for occurrence of stroke to goal at 1 year. Results: At 1-year post-hospitalization, patients in the nurse-care-management group were 42% more likely to have met the primary endpoint (n = 18; 61% nurse-managed patients) compared with 33% (n = 18) of patients undergoing usual care (P = 0.09). There was no significant reduction in minor risk factors for either patient group. Patients in the prevention group had greater reductions in low-density lipoprotein cholesterol levels (?38 vs ?4; P = 0.0083), changes in cardiovascular risk score (?5.2 vs 1.3; P = 0.0033), and had a greater reductions in systolic blood pressure (?12.2 vs ?0.105; P = 0.07) than their usual-care counterparts (changes shown respectively). Patients in the prevention group were more likely to follow a prescribed diet than those in the usual-care group (50%) vs 7%, respectively; P = 0.0070) and maintain an exercise program (83% vs 33%, respectively; P = 0.0018). Summary: A physician-directed, nurse case-management system for patients post-hospitalization for cerebral ischemia is feasible and may help improve long-term control of major patient risk factors for stroke. A larger trial is needed to verify trends noted in our study.