铜绿假单胞菌和鲍曼不动杆菌临床感染和耐药性分析

目的探讨铜绿假单胞菌和鲍曼不动杆菌的筘床感染分布及其药敏情况,为临床合理使用抗菌药物和预防多重耐药菌株的产生提供依据。方法回顾性分析了642株铜绿假单胞茼和570株鲍曼不动杆菌感染科室分布及耐药情况。结果铜绿假单胞菌和鲍曼不动杆菌感染的科室主要集中在重症监护病房（ICU）、呼吸科、神经外科、神经内科;氨苄西林和头孢唑啉对铜绿假单胞菌和鲍曼不动杆茸的抗菌作用最差,耐药率大于95％;铜绿假单胞茴对亚胺培南、美洛培南、头孢哌酮／舒巴坦、多粘菌素敏感性最高;鲍曼不动杆菌对亚胺培南和美罗培南的敏感性有所降低,其耐药率在15％左右,对多粘菌素的敏感性最高。结论铜绿假单胞菌争鲍曼不动杆茼临床分离株多来自ICU病房;氨苄西林和头孢唑啉已经不适于铜绿假单胞菌和鲍曼不动杆菌感染的治疗,亚胺培南、芙洛培南、多粘茼素可作为临床经验性用药;临床应重视合理使用抗生素,加强对铜绿假单胞菌和鲍曼不动杆菌的耐药性监蒯,减少多重耐药菌的产生。     

鲍曼不动杆菌的感染分布及耐药性分析

目的了解贵州省人民医院鲍曼不动杆菌的感染分布和耐药情况,以指导临床合理用药。方法对2009年12月至2011年5月收集的贵州省人民医院临床上非重复分离的117株鲍曼不动杆菌,统计其科室分布和标本来源,采用K-B法测定14种抗菌药物的耐药性。结果鲍曼不动杆菌临床分布以重症监护病房(ICU)最多,42株(35.9%),其次是神经外科22株(18.8%),呼吸内科14株(11.9%)。分离标本以痰液最多,82株(70.0%),继之为伤口分泌物20株(17.1%)。117株鲍曼不动杆菌中对米洛环素的耐药率最低,为5.9%,其次为头孢哌酮/舒巴坦,为14.5%,对亚胺培南和美洛培南的耐药率分别为31.6%、34.2%,对氨曲南的耐药率最高,为94.9%,对左氧氟沙星、环丙沙星、庆大霉素、阿米卡星、氨曲南、头孢吡肟、头孢他啶、哌拉西林/他唑巴坦、莫西沙星、复方新诺明、四环素的敏感性在54.7%～72.7%。亚胺培南耐药组的耐药性明显高于敏感组,呈现出多重耐药和泛耐药现象。结论贵州省人民医院临床分离的鲍曼不动杆菌主要来自ICU、神经外科、呼吸内科,主要分离自痰液标本、伤口分泌物,对米洛环素和头孢哌酮/舒巴坦较敏感,存在泛耐药菌株。     

2004-2005年中国CHINET鲍曼不动杆菌耐药性分析

目的监测2004-2005年中国不同地区7所教学医院临床分离鲍曼不动杆菌的耐药性。方法收集从患者分离的非重复鲍曼不动杆菌1787株,在各监测点采用纸片扩散法测定菌株对头孢哌酮-舒巴坦等13种抗菌药物的敏感性,数据采用WHONET5.3软件分析。结果鲍曼不动杆菌对亚胺培南和美罗培南敏感率最高,分别为65.1%和56.8%。其次为头孢哌酮-舒巴坦和氨苄西林-舒巴坦,敏感率分别为43.5%和39.2%。其他抗菌药物的敏感率均在2.2%～34%。2种碳青霉烯类药物和2种含舒巴坦制剂的敏感性具有明显的一致性。特定药物在不同地区的敏感率有较大差异。对亚胺培南不敏感的菌株除对头孢哌酮-舒巴坦和氨苄西林-舒巴坦耐药率分别为52.1%和76.8%外,对其他药物耐药率均在80%以上。而对亚胺培南敏感的菌株,除对美罗培南、头孢哌酮-舒巴坦、氨苄西林-舒巴坦耐药率分别仅为11%、12.5%和29.1%,对其他抗菌药物的耐药率均在40%以上。结论碳青霉烯类抗生素仍是对鲍曼不动杆菌抗菌活性最高的药物,但对碳青霉烯类耐药的鲍曼不动杆菌(CRAB)已达43.1%,并在部分地区造成医院内流行。头孢哌酮-舒巴坦对鲍曼不动杆菌抗菌活性仅次于碳青霉烯类,且中介率较高,尤其对CRAB是敏感率最高的药物。     

从ICU继发感染者不同标本中分离鲍曼不动杆菌耐药性分析

目的分析从ICU重症患者不同标本类型中分离出的鲍曼不动杆菌的耐药性差异,为有效预防和控制ICU内鲍曼不动杆菌感染提供依据。方法回顾性分析本院2010年1月至2014年12月住院ICU患者送检标本中分离的568株鲍曼不动杆菌临床资料。结果从ICU感染患者中分离的鲍曼不动杆菌主要来源为痰液(60.0%);药敏试验表明鲍曼不动杆菌对常用抗菌药物的耐药率呈普遍多重耐药,对替加环素、头孢哌酮/舒巴坦最敏感,耐药率小于40.0%;从痰液和无菌体液中分离的鲍曼不动杆菌对亚胺培南、美罗培南、头孢哌酮/舒巴坦、哌拉西林/他唑巴坦、环丙沙星、左氧氟沙星、阿米卡星的耐药率普遍高于血液和尿液,差异有统计学意义(P0.05)。结论鲍曼不动杆菌对常用抗菌药物多重耐药,在ICU中不同标本类型的耐药性存在差异,临床必须加强耐药性监测,治疗该菌感染时首选替加环素、头孢哌酮/舒巴坦。     

2010年中国CHINET鲍曼不动杆菌耐药性监测

目的了解2010年中国不同地区14所教学医院临床分离鲍曼不动杆菌的耐药性。方法收集14所教学医院临床分离的非重复不动杆菌属共5 523株,其中鲍曼不动杆菌4 949株,按照统一方案,在各监测点采用纸片扩散法进行药敏试验,试验结果按照CLSI 2010年版标准判读,采用WHONET 5.4软件进行数据分析。结果鲍曼不动杆菌对头孢哌酮-舒巴坦和米诺环素耐药率最低,分别为33.6%和35.4%。对碳青霉烯类抗生素亚胺培南和美罗培南的耐药率分别为62.1%和63.6%,对其他监测的抗菌药物的耐药率均达56.2%以上。不同医院分离菌对抗菌药物的耐药率不同,其中以ICU分离菌耐药率最高,急诊次之,内科最低。门诊与住院患者分离菌对亚胺培南和美罗培南的耐药率分别为48.3%/50.8%和62.3%/63.8%,且住院患者分离菌对抗菌药物的耐药率高于门诊患者(米诺环素除外)。全国14所教学医院药敏试验结果显示多重耐药(MDR)及泛耐药(PDR)鲍曼不动杆菌分别达55.0%(2 720/4 949)和21.4%(1 058/4 949)。2010年鲍曼不动杆菌耐药率与往年相比,呈上升趋势,尤以对头孢哌酮-舒巴坦、碳青霉烯类抗生素耐药率升高显著。结论鲍曼不动杆菌对各抗菌药物的耐药性仍呈上升趋势。头孢哌酮-舒巴坦和米诺环素对鲍曼不动杆菌仍具有较好的体外抗菌活性。不同医院、不同科室鲍曼不动杆菌对抗菌药物的耐药率存在显著差异。     

鲍曼不动杆菌的耐药特征及blaOXA_(23)基因分布

目的:分析丽水市中心医院鲍曼不动杆菌耐药特征及blaOXA23基因携带情况,指导临床合理应用抗生素.方法:经VITEK2-compact微生物系统鉴定,收集丽水市中心医院2008年3月至2009年6月从临床分离的鲍曼不动杆菌62株.统计其科室来源,以K-B法检测菌株对抗生素的耐药性,并利用PCR扩增法检碳青酶烯酶耐药基因blaOXA23.结果:鲍曼不动杆菌检出率前两位是脑外科和ICU病房,分别占32.3%和27.4%.多重耐药鲍曼不动杆菌阳性率最高的是ICU,为70.6%(12/17);其次为脑外科,为35.0%(7/20).亚胺培南、美洛培南、头孢他啶、头孢吡肟、替卡西林/克拉维酸、哌拉西林/他唑巴坦、头孢哌酮/舒巴坦、多粘菌素耐药率分别为33.9%、38.9%、61.3%、53.3%、56.1%、45.2%、16.9%和0.0%.blaOXA23总检出率35.5%,亚胺培南耐药鲍曼blaOXA23检出率100.0%,敏感鲍曼均未检出.结论:鲍曼不动杆菌分布广泛,并且多重耐药性严重;blaOXA23基因可能是耐碳青酶烯类抗生素的主要原因.建议加强鲍曼不动杆菌耐药性监测及耐药机制的研究.     

下呼吸道感染鲍曼不动杆菌的临床分布及耐药性分析

目的了解医院鲍曼不动杆菌下呼吸道感染的临床分布及耐药状况,为临床合理使用抗生素提供依据。方法采用纸片扩散(K-B)法进行药物敏感试验,并对169株鲍曼不动杆菌的药物敏感试验进行回顾性分析。结果 169株鲍曼不动杆菌主要来源以重症监护室(ICU)为主,占36.1%。其次为神经外科(25.4%)。药敏试验结果显示该菌对美罗培南和亚胺培南耐药率最低,分别为7.1%和9.5%,其次为头孢哌酮/舒巴坦(14.8%),哌拉西林/他坐巴坦16.6%,对其他抗生素均有不同程度的高耐药性、多重耐药性。结论鲍曼不动杆菌主要分布于ICU和神经外科。碳青霉烯类抗生素仍是敏感性最高的药物,β-内酰胺类/β-内酰胺酶抑制剂酶的抗生素次之,临床应根据药物敏感性结果合理用药,以便及时有效地控制感染并延缓耐药株的产生。     

477株鲍曼不动杆菌耐药性分析

目的分析477株鲍曼不动杆菌临床分布特征及耐药性,为临床合理使用抗菌药物提供依据。方法对按常规送检的患者的各类标本进行培养、分离、鉴定。对分离出的477株鲍曼不动杆菌的药敏结果进行分析。结果 477株鲍曼不动杆菌（非重复菌株）的标本分布以呼吸道分泌物为主。重症监护（ICU）病房216株鲍曼不动杆菌对亚胺培南、美罗培南、头孢哌酮-舒巴坦、哌拉西林-他唑巴坦的耐药率分别为28.9%、32.7%、25.5%、61.9%,对3类或以上抗菌药物多重耐药菌45株。非ICU病房261株鲍曼不动杆菌对亚胺培南、美罗培南、头孢哌酮-舒巴坦、哌拉西林-他唑巴坦的耐药率分别为17.9%、19.0%、11.3%、35.0%,多重耐药菌6株。结论自ICU病房分离的菌株对大部分抗菌药物的耐药性比非ICU分离株高,多重耐药菌株多。     

鲍曼不动杆菌临床分布及耐药性分析

目的了解鲍曼不动杆菌的临床分布特征及耐药性,为临床经验性选择抗菌药物及控制感染提供依据。方法收集2008年1月至2011年12月从临床分离所得鲍曼不动杆菌519株,均采用VITEK-32自动微生物分析系统进行细菌鉴定和药敏试验。结果分离的519株鲍曼不动杆菌主要集中在重症监护病房和呼吸内科、神经外科等科室;该菌对头孢哌酮/舒巴坦的耐药率最低为18.0%,对阿米卡星、亚胺培南的耐药率最低分别为52.3%和28.4%;其他药物则有较高的耐药率。结论临床在合理使用抗菌药物的同时应对鲍曼不动杆菌的耐药性监测,减少多重耐药鲍曼不动杆菌的传播和暴发流行;对于多重耐药鲍曼不动杆菌的治疗,可经验性的选择头孢哌酮/舒巴坦。     

下呼吸道感染患者中分离鲍曼不动杆菌的耐药性分析

目的 了解鲍曼不动杆菌医院下呼吸道感染的分布及耐药状况,为临床合理用药提供依据.方法 收集我院2005年1月-2007年12月住院患者下呼吸道感染的356株鲍曼不动杆菌,采用纸片扩散法测定菌株对抗菌药物的敏感性,数据用WHONET 5.0及SPSS 13.0软件进行统计分析.结果 鲍曼不动杆菌感染以下呼吸道感染为主,临床分离率逐年升高,多重耐药菌株占77.2%.主要分布于ICU.药敏试验结果 显示该菌对亚胺培南和美罗培南敏感率最高,分别为76.7%和74.2%,其次为头孢哌酮-舒巴坦67.1%,对其他所测抗菌药物的敏感率均小于30%.碳青霉烯类抗生素耐药的菌株除头孢哌酮-舒巴坦外,对常用抗菌药物的耐药率超过80%.结论 鲍曼不动杆菌多重耐药严重,集中分布于ICU.碳青霉烯类抗生素仍是敏感性最高的药物,头孢哌酮-舒巴坦次之,其他抗菌药物耐药率高,宜根据药敏试验结果 选用.     

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.     

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.     

手转胎头术失败的原因与分娩结局临床分析

目的 探讨手转胎头术失败的原因与分娩结局.方法 选择2008年1月至2010年12月于我院住院分娩的持续性枕横位、枕后位产妇198例,根据行手转胎头术后结果分为成功组126例、失败组72例.比较两组分娩结局,对比分析失败原因.结果 失败组胎儿体质量≥3500 g的发生率[76.4％(55/72)]明显高于成功组[31.7％(40/126)],差异有统计学意义(x2=30.177,P=0.001)、失败组宫缩乏力发生率[58.3％(42/72)]高于成功组[38.1％ (48/126)],差异有统计学意义(x2=7.569,P=0.006)、失败组骨盆临界或轻度狭窄发生率[38.9％ (28/72)]高于成功组[23.8％(30/126)],差异有统计学意义(x2 =5.030,P=0.002)、失败组手转胎头时机不当(宫口开大＜6 cm、胎头位于坐骨棘上及宫口开大8～10 cm、胎头位于坐骨棘下≥2 cm)发生率[61.1％(44/72)]高于成功组[38.9％(49/126)],差异有统计学意义(x2=9.084,P=0.003).失败组母儿并发症(产后出血、产褥病率、胎儿窘迫、新生儿窒息)发生率高于成功组(x2 =9.586,P=0.002、x2=9.334,P=0.002、x2=5.910,P=0.015、x2=5.240,P=0.022)、失败组剖宫产发生率[72.2％(52/72)]明显高于成功组[34.1 ％(43/126),x2=26.641,P=0.001)].结论 手转胎头术能使难产变顺产,降低剖宫产率,减少母儿并发症,但须积极预防、处理导致手转胎头术失败的原因,对矫正失败后继续矫正及试产应慎重.     

Evidence-Based Pain Management and Palliative Care in Issue Four for 2009 of The Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly. Issue 4 for 2009 contains 4027 complete reviews, 1906 protocols for reviews in production, and 11447 one-page summaries of systematic reviews published in the general medical literature. In addition, there are citations of 600,000 randomized controlled trials, and 12,200 cited papers in the Cochrane methodology register. The health technology assessment database contains over 7500 citations. This edition of the Library contains 90 new reviews, of which 19 have potential relevance for practitioners in pain and palliative medicine.     

Wie zuverlässig sind Angaben zu nichtentzündlichen ausgedehnten Schmerzen?

ZusammenfassungFragestellung Es wurde geprüft, wie sich der Differenziertheitsgrad zweier Schmerzmessmethoden auf Angaben zur Ausgedehntheit klinischer Schmerzen auswirkt. Zugleich wurde der Referenzzeitraum variiert, über den die Patienten berichten sollten.Methode Erfasst wurde der Einfluss zu Lasten der Befragungsdifferenziertheit durch den Vergleich zweier Körperschema-Bildvorlagen. Drei Referenzzeiträume (Schmerz aktuell, letzte Woche, letztes halbes Jahr) wurden vorgegeben.Ergebnisse Patienten mit ausgedehnten Schmerzen gaben bei differenzierter Befragung um so mehr Schmerzen an, je weiter die Schmerzen zurück lagen und je größer der Berichtszeitraum war. Patienten mit gelenknahen Schmerzen gaben bei hoch differenzierter Befragung weniger ausgedehnte Schmerzen in der Vergangenheit an als bei globaler Einschätzung. Patienten mit Rückenschmerzen berichteten bei differenzierter Befragung zum aktuellen Schmerz über weniger ausgedehnte Schmerzen als bei globaler Befragung.Schlussfolgerung Die Angaben zur Schmerzausdehnung variieren vor allem bei Patienten mit ausgedehnten Schmerzen in Abhängigkeit von der Differenziertheit der Befragung. In diesen Fällen ist die Wahrscheinlichkeit erhöht, dass sich die Beschwerdesymptomatik zumindest teilweise erst in der Reaktion auf die situativen Befragungsbedingungen konstituiert und daher nicht auf andere Befragungsbedingungen generalisiert werden kann.