CAPD腹膜炎时白细胞、T细胞亚群及白蛋白之间的相关性

目的探讨持续性非卧床腹膜透析(continuous ambulatory peritoneal dialysis,CAPD)患者发生急性腹膜透析相关性腹膜炎时血和腹膜透析液白细胞计数、T淋巴细胞亚群和白蛋白的变化,以及相互之间的关系。方法对2006年1月至2008年3月期间因腹膜透析相关性腹膜炎住院的22例CAPD患者(男12例,女10例,平均62.6岁)进行研究,收集腹膜炎发生后第1、3、6、9、12d的血液和腹膜透析液标本,分别检测血液和腹膜透析液白细胞总数、分类、T淋巴细胞亚群及白蛋白。血T淋巴细胞亚群对照组为同期健康体检人群24例(男13例,女11例,平均60.2岁)。结果与对照组比较,CAPD相关性急性腹膜炎不同时间点血CD3CD8(+)%明显降低,血CD4/CD8明显增高,差异均有统计学意义(P0.05);血白细胞与腹膜透析液白细胞、血CD4/CD8与腹膜透析液CD4/CD8、腹膜透析液白细胞和腹膜透析液白蛋白均呈正相关(相关系数分别为0.404,0.976,0.434,均P0.01)。22例患者中腹膜透析液培养阳性17例(77.3%),其中革兰氏阴性杆菌9例(52.9%),革兰氏阳性球菌7例(41.2%),霉菌1例(5.9%)。结论CAPD相关性急性腹膜炎时腹膜透析液白细胞计数和中性粒细胞百分比升高与经腹腔白蛋白丢失增加呈正相关;腹膜炎时血CD4/CD8比值增高,提示患者细胞免疫被激活;革兰氏阴性杆菌已成为我院CAPD相关性腹膜炎的主要致病菌。     

临床路径在腹膜透析相关性腹膜炎治疗中的作用

[目的]了解实施临床路径在腹膜透析相关性腹膜炎治疗中的作用.[方法]2006年1月-2006年12月对腹膜透析相关性腹膜炎病人均要求责任护士按临床路径操作,具体包括腹膜透析液样本的留取、经验抗生素的使用、参照药物敏感试验结果选择抗生素类型及治疗疗程,复查腹膜透析液常规的时间和频度以及标准的腹膜炎诊治记录单的填写,收集腹膜炎诊治记录单并进行分析,包括资料收集情况(腹膜炎诊治记录情况、腹膜透析液送检率)、诊疗水平(细菌培养阳性率、腹膜炎发生率、住院率、复发性腹膜炎发生率)、治疗依从性(完成规定疗程比例)和经济花费(包括抗生素和肝素药费、腹膜透析液常规和细菌培养检查费).[结果]2006年共收治腹膜透析病人352例次,发生72例次腹膜炎,腹膜炎发生率为60个病人月1次.其中44例次(61.1%)按标准填写了腹膜炎诊治记录单,其中腹膜透析液送检43例次(97.73%);细茵培养阳性37例(84.09%),腹膜炎发生率60个病人月1次,住院2例(4.54%),发生复发性腹膜炎2例(4.55%),腹膜炎平均疗程17.77 d,按致病菌采取适当疗程43例(97.73%),治疗依从43例(97.73%),平均花费374.07元.[结论]通过在腹膜透析相关性腹膜炎诊治中应用临床路径,有效地保证了诊治水平.     

持续质量改进在提高腹膜透析相关性腹膜炎致病菌培养阳性率中的应用

[目的]探讨持续质量改进(CQI)对提高腹膜透析相关性腹膜炎致病菌培养阳性率的作用。[方法]选择华中科技大学同济医学院附属同济医院肾内科实施CQI前(2013年)持续不卧床腹膜透析(CAPD)病人106例,分析18例次腹膜炎致病菌及特征,与采用CQI后(2014年)125例CAPD病人腹膜炎16例次致病菌培养阳性率情况进行比较。[结果]我科实施CQI后我科腹膜透析相关性腹膜炎致病菌培养阳性率明显提高,由2013年的50.00%提高至2014年的81.25%。[结论]我科实施CQI可以提高腹膜透析相关性腹膜炎致病菌培养阳性率。     

腹膜透析相关性腹膜炎的调查及护理

目的探讨腹膜透析相关性腹膜炎的发生情况,为有效预防腹膜炎提供参考。方法对第二军医大学长海医院腹膜透析中心2008年1月至2010年10月收治的156例次腹膜炎患者的临床资料进行回顾性分析,比较腹膜透析液标本培养阳性率、腹膜炎致病菌种等情况。结果腹膜透析相关性腹膜炎患者的人数在不断下降。病原菌培养的阳性率也在不断提高,且致病菌的种类在不断减少。结论规范的腹膜透析操作、反复多次的腹膜透析培训考核、扎实的腹膜透析护理水平以及适时的家访服务等能够有效降低腹膜炎的发生。肾科医生或腹膜透析护士及早介入、改进标本的培养技术、针对性的病原菌治疗等能有效提高腹膜炎的治愈率。     

改良腹膜透析液双联系统的制作与应用

目的制作改良腹膜透析液双联系统,并探讨其在腹膜透析患者中的应用效果。方法选择2018年1月—2019年12月在某三级甲等医院肾内科随访的156例腹膜透析患者为研究对象,用随机数字表法将患者分为试验组和对照组,分别使用改良腹膜透析液双联系统和传统腹膜透析液双联系统进行换液操作,比较两组的换液时间、腹膜炎发生率、平均每次透析成本、患者满意度。结果与对照组相比,试验组腹膜透析换液操作时间缩短、腹膜炎发生率降低,平均每次透析成本减少,患者满意度得分高,差异具有统计学意义(P<0.05)。结论相对传统腹膜透析液双联系统,改良腹膜透析液双联系统方便操作、缩短了换液操作时间、降低了腹膜炎发生率和透析成本,可提高患者满意度。     

腹膜透析相关性腹膜炎致病菌的耐药性分析

目的：探讨腹膜透析相关性腹膜炎的致病菌及其耐药性。方法：回顾性分析的93例腹膜透析相关性腹膜炎的致病菌及其耐药性。结果：34例培养阳性,透出液培养阳性率为36.6%,其中革兰阳性球菌14例,革兰阴性杆菌17例,真菌4例。革兰阴性杆菌对氨苄西林的耐药率最高,达83.3%,亚胺培南耐药性最低,达20.0%。革兰阳性球菌对青霉素、环丙沙星的耐药率高,分别为81.8%、71.4%。结论：提高腹膜透析液细菌培养阳性率有助于腹膜透析相关性腹膜炎的治疗;在经验用药基础上,应依据细菌培养、药敏,选择治疗腹膜透析相关性腹膜炎的敏感、有效抗菌素,真菌性腹膜炎治疗效果仍差,应尽早拔管。     

单中心腹膜透析相关性腹膜炎的临床分析

目的探讨腹膜透析相关性腹膜炎的发病原因、致病菌及转归预后情况,为腹膜炎的防治提供依据。方法回顾性分析首都医科大学附属北京潞河医院腹膜透析中心2013年1月~2015年12月接受腹膜透析治疗并发生腹膜炎患者的临床资料。分析发生腹膜炎的发病原因、致病菌、转归预后情况。结果共收治发生腹膜透析相关性腹膜炎的患者96例次。腹膜炎发生的主要原因包括:换液操作不规范35例(36.5%),肠道感染27例(28.1%)。腹膜透析液培养阳性63例,阳性率65.6%。革兰阳性球菌38例(60.3%),革兰阴性杆菌18例(28.6%),真菌4例(6.3%),混合菌3例(4.8%)。培养阳性者行致病菌耐药分析,革兰阳性球菌中,对万古霉素、利奈唑胺均敏感,主要对红霉素(69.2%)和青霉素(68.4%)耐药率高。头孢西丁(46.7%)和头孢唑啉(45.9%)耐药率也较高。革兰阴性杆菌中,对亚胺培南均敏感,对头孢唑林(53.8%)和头孢他啶(38.5%)的耐药率较高。革兰阳性球菌性腹膜炎治愈率较高,明显高于革兰阴性杆菌(χ~2=5.661,P=0.017)、真菌(χ~2=26.526,P0.001)、混合菌的腹膜炎(χ~2=11.907,P=0.001);真菌性腹膜炎的退出率较高,明显高于革兰阳性球菌(χ~2=26.526,P0.001)、革兰阴性杆菌(χ~2=4.390,P=0.036)、培养阴性的腹膜炎(χ~2=11.485,P=0.010);真菌性腹膜炎的死亡率较高,明显高于革兰阳性球菌(χ~2=26.526,P0.001)、革兰阴性杆菌(χ~2=6.016,P=0.010)、培养阴性的腹膜炎(χ~2=32.918,P0.001)。结论本中心腹膜透析患者发生腹膜透析相关性腹膜炎的主要原因为换液操作不规范和肠道感染,致病菌主要为革兰阳性球菌。培养阳性的致病菌对国际腹膜透析协会指南推荐的头孢唑林和头孢他啶有不同程度的耐药。革兰阳性球菌性腹膜炎治愈率较高,预后好;真菌性腹膜炎退出率及死亡率较高,预后差。     

腹膜透析液的细菌培养及耐药性分析

目的了解持续不卧床腹膜透析(CAPD)腹膜炎患者腹膜透析液的主要致病菌及其耐药性,为临床预防腹膜炎及合理使用抗菌药物提供依据。方法腹膜透析液标本在血培养仪中培养阳性后分离培养出纯菌落,用法国生物梅里埃公司ATB微生物分析系统进行种属鉴定及药敏试验。结果 39例标本中,培养阳性有24例,细菌检出率为61.5%,其中检出革兰阳性菌12株,革兰阴性菌9株,真菌3株。药物敏感试验结果表明,革兰阳性菌对万古霉素、喹奴普汀-达福普汀敏感,对青霉素、红霉素耐药率较高;革兰阴性菌对美诺培南、亚胺培南、环丙沙星敏感,对青霉素类抗菌药物、头孢类抗菌药物耐药率较高。结论 CAPD腹膜炎患者以凝固酶阴性葡萄球菌、大肠杆菌、肠球菌为主要致病菌,致病菌对某些常用抗菌药物耐药严重,应引起临床医师的高度重视。     

糖尿病腹膜透析患者发生腹膜炎的临床特征及预后分析

目的比较糖尿病患者腹膜透析相关性腹膜炎与非糖尿病患者腹膜透析相关性腹膜炎的临床特征、病原学特点及预后。方法回顾性分析行腹膜透析置管并行持续性不卧床腹膜透析(CAPD)治疗的患者临床资料,根据发生第1次腹膜透析相关性腹膜炎时患者是否合并糖尿病分为非糖尿病组和糖尿病组。结果非糖尿病患者108例,其中33例至少发生过1次腹膜炎,占30.8%;糖尿病患者共30例,14例至少发生过1次腹膜炎,占46.7%,两组比较差异有统计学意义(P0.01)。糖尿病组患者置管时平均年龄高于非糖尿病组,分别为(63.21±11.75)岁和(48.36±15.37)岁,差异有统计学意义(P0.05)。糖尿病组患者超敏C反应蛋白(hs-CRP)高于非糖尿病组,差异有统计学意义(P0.05)。糖尿病组血浆白蛋白(ALB)、血浆前白蛋白(PAB)、血红蛋白(HGB)、血钾(K+)低于非糖尿病组,差异有统计学意义(P0.05)。糖尿病组革兰阴性杆菌及真菌所占比例较非糖尿病组增高,且糖尿病组拔管率及死亡率增加,但差异无统计学意义(P0.05)。结论糖尿病腹膜透析患者较非糖尿病腹膜透析患者更容易发生腹膜炎,且常合并更为严重的营养不良、贫血、全身炎症等表现;两组致病菌仍以革兰阳性球菌为主,但糖尿病组患者透析液培养革兰阴性杆菌及真菌比例增高,拔管及死亡率相对增加,预后不良。     

65例腹膜透析患者腹膜透析液细胞学和病原学分析

目的分析65例腹膜透析患者腹膜透析液常规及细菌培养结果。方法取腹膜透析液两管,一管行常规分析,包括有核细胞计数和沉渣细胞分类,另一管做细菌培养。结果 65例患者中37例表现为腹膜透析相关感染性腹膜炎,占56.9%;45例患者送检细菌培养,阳性率为62.2%,主要为凝固酶阴性葡萄球菌,占20.0%,其次为链球菌和革兰阴性杆菌,分别占17.8%和15.6%;35例腹膜炎患者有8例表现为顽固性腹膜炎,2例出现腹膜透析液性质改变,其转归情况明显差于其他患者(P0.05)。结论腹膜透析相关感染性腹膜炎是腹膜透析最常见的严重并发症,以细菌性感染多见,因此对腹膜透析液进行细胞学常规和病原学相结合的分析,能及时了解透析情况和变化,更好地为临床服务。     

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.     

Dissociable correlates of two classes of retrieval processing in prefrontal cortex

Although substantial evidence suggests that the prefrontal cortex (PFC) implements processes that are critical for accurate episodic memory judgments, the specific roles of different PFC subregions remain unclear. Here, we used event-related functional magnetic resonance imaging to distinguish between prefrontal activity related to operations that (1) influence processing of retrieval cues based on current task demands, or (2) are involved in monitoring the outputs of retrieval. Fourteen participants studied auditory words spoken by a male or female speaker and completed memory tests in which the stimuli were unstudied foil words and studied words spoken by either the same speaker at study, or the alternate speaker. On "general" test trials, participants were to determine whether each word was studied, regardless of the voice of the speaker, whereas on "specific" test trials, participants were to additionally distinguish between studied words that were spoken in the same voice or a different voice at study. Thus, on specific test trials, participants were explicitly required to attend to voice information in order to evaluate each test item. Anterior (right BA 10), dorsolateral prefrontal (right BA 46), and inferior frontal (bilateral BA 47/12) regions were more active during specific than during general trials. Activation in anterior and dorsolateral PFC was enhanced during specific test trials even in response to unstudied items, suggesting that activation in these regions was related to the differential processing of retrieval cues in the two tasks. In contrast, differences between specific and general test trials in inferior frontal regions (bilateral BA 47/12) were seen only for studied items, suggesting a role for these regions in post-retrieval monitoring processes. Results from this study are consistent with the idea that different PFC subregions implement distinct, but complementary processes that collectively support accurate episodic memory judgments.     

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.     

Clinical Pharmacokinetics of Morphine

Morphine, the most widely used mu-opioid analgesic for acute and chronic pain, is the standard against which new analgesics are measured. A thorough understanding of the pharmacokinetics of morphine is required in order to safely and effectively use this analgesic in a wide variety of patients with different levels of organ function. A MEDLINE search was conducted to identify literature published between 1966 and January 2002 relevant to the pharmacokinetics of morphine. These publications were reviewed and the literature summarized regarding unique and clinically important elements of morphine disposition relative to its parenteral administration (including intravenous, intramuscular, subcutaneous, epidural and intrathecal administration), absorption profile (immediate release, controlled release, and sublingual/buccal, and rectal administration), distribution, and its metabolism/ excretion. Special populations, including infants, elderly, and those with renal/liver failure, have a unique morphine pharmacokinetic profile that must be taken into account in order to maximize analgesic efficacy and reduce the risk of adverse events.