67例疑似气性坏疽地震伤员院内交叉感染控制分析

目的探索地震伤员中疑似气性坏疽患者医院交叉感染控制途径。方法2008年5月14日至6月24日，华西医院通过预检分诊、科学分期，优化地震伤员的接诊收治流程，科学管理开放性伤口，筛选疑似气性坏疽患者，实施手术消毒隔离处理，将预防控制疫情前移：用3％过氧化氢溶液冲洗、湿敷；对已缝合的伤口，拆去缝线，彻底清创，再给予抗菌药物治疗。结果截至6月24日共收治疑似气性坏疽67例，其中高度疑似气性坏疽共32例，经暖氧细菌培养确诊气性坏疽5例，无1例凶气性坏疽死亡，也无1例气性坏疽病例发生院内交叉感染。32例中有26例已痊愈出院，尚有6例仍在住院治疗中。结论科学管理与治疗得当是控制疑似气性坏疽患者医院感染的良好途径。     

5.12汶川大地震气性坏疽感染伤员器械处置程序

目的探讨地震伤员气性坏疽感染伤员用后器械有效处理流程及方法。方法结合地震伤情特点，预见性制定了特殊感染器械的处理流程并严格实施。结果灭菌效果监测均达标，未发生医院感染病例。结论及时制定特殊感染器械处理流程，规范各环节操作，是控制发生气性坏疽医院交叉感染的有效措施。     

25例地震伤致气性坏疽伤员的救治与管理体会

目的：总结分析25例地震伤致气性坏疽伤员的救治经验,探讨救治方案,为临床工作提高参考。方法：回顾性研究25例地震伤致气性坏疽伤员的早期临床表现,诊断方法,隔离措施、1临床管理及其预后。结果：共收治25例气性坏疽伤员,无一例死亡。院外诊断7例,院内诊断18例。截肢18例,开放性截肢12例,非开放性截肢6例;扩创7例。发生急性肾功能衰竭2例,行血液透析治疗后肾功能恢复;无院内交叉感染的发生。结论：早期诊断、治疗、早期隔离及全面、系统护理可以提高临床救治水平,改善患者的预后,避免院内交叉感染的发生。     

汶川地震医疗救援中华西医院急诊预检分诊的管理

汶川地震医疗救援中，为应对大量污染或感染伤员入院带来的医院环境污染和预防病人间交叉感染，四川大学华西医院医院感染管理委员会立即启动应急预案，改进急诊预检分诊流程，组建多学科融合的医院感染控制组，加强伤员的检伤分流和预检分诊处的感染管理，同时规范医务人员的个人行为，采取正确的个人防护措施，从而有效保障了伤员和医务人员的医疗安全。     

汶川地震3周2621例急诊伤员分检流程分析

目的探讨汶川地震发生后，根据接诊地震伤员的特点动态调整分检流程的意义与要点，为建立在大型灾害事件中的分检处理流程，及时合理配置医疗资源，启动应急预案，提高医疗救援水平提供思路。方法以华西医院在震后不同时段接收地震伤员的诊治信息数据为基本资料，分析不同时段伤员特点，对流程变化进行归纳分析。结果震后3周，华西医院共收治地震伤员2621例，伤员的伤情特点在不同时段有所改变，皮肤软组织伤和肢体骨折占总就诊量的45％，挤压伤占4．3％，气性坏疽5例，无一例院内交叉感染。结论根据急诊人数及病情的变化，急诊流程动态改变和调整有助于伤员早检早治，提高生存率和治愈率，从而提高医疗救援水平及效果。     

地震伤并发气性坏疽患者2例手术过程中感染控制的做法

气性坏疽是由梭状芽孢杆菌侵入伤口引起的一种严重的特异性感染，以全身出现毒血症，局部出现产气、水肿、坏死、恶臭为其特征，是创伤后最严重的并发症之一。该病通过伤口接触传播，感染后若不及时救治，12h内可造成严重后果，甚至死亡。四川汶川大地震后，截至5月31日，我院手术救治地震伤员345例，其中2例并发气性坏疽。现将2例并发气性坏疽患者开放性骨折手术中的感染控制方法介绍如下。     

气性坏疽早期诊断9例分析

早期伤口分泌物涂片检查，对创伤性气性坏疽早期诊断起到很重要的作用。气性坏疽是由革兰阳性产气荚膜梭菌又名魏杆菌和诺梭菌A型，是属细菌引起的急性特异性软组织感染，侵入伤口后引起伤口急性感染。常继发于开放性的骨折，大块肌肉撕裂以及组织的严重坏死。多见于外伤，交通肇事及各种严重创伤之后。本病潜伏期一般为1～4d，也有短至6h者死亡。现将本院对这9例气性坏疽分析报道如下。     

68例急诊气性坏疽手术的管理与配合

[目的]加强手术室感染的预防与管理,防止气性坏疽引起院内交叉感染,提高手术护理配合质量。[方法]选取68例气性坏疽感染病人作为观察目标,对其手术配合进行回顾性分析,建立气性坏疽手术的隔离和感染控制的管理流程和制度,实施严格的感染控制处理措施。[结果]术前细菌检查结果梭状芽孢杆菌均为阳性,术中实施严密隔离措施,顺利完成68例急诊气性坏疽手术病人的救治工作,有效地预防与控制了医院感染。[结论]有效地落实手术室气性坏疽手术消毒隔离措施是防止医院感染、提高医疗护理安全的重要保证。     

19例地震伤员气性坏疽的护理探讨

目的探讨地震伤员气性坏疽的护理规律。方法对19例气性坏疽患者制定详细的护理计划,局部创面换药和高压氧治疗,严格消毒隔离,预防压疮、肺炎、尿路感染等并发症,加强心理护理,增强患者康复的信心。结果19例地震伤员气性坏疽中除1例因多器官功能衰竭死亡之外,18例患者均有不同程度的康复。结论对气性坏疽患者应制定严密的治疗及护理计划,早期隔离消毒,早发现,早治疗,预防并发症的发生,才能达到治疗和抢救的目的。     

早期伤口分泌物涂片检查对创伤性气性坏疽早期诊断的作用

目的探讨早期伤口分泌物涂片检查对创伤性气性坏疽早期诊断的作用。方法回顾性分析2003年4月至2006年4月本院收治的受伤后超过1 h的10 881例开放性创伤患者的资料,对其伤口分泌物早期常规作革兰染色涂片检查。结果本组创伤患者发生气性坏疽11例,发病率为0．10%。其中车祸伤5例,机器压伤3例,石头压伤2例,枪伤1例。受伤部位在上肢7例(63．6%),下肢3例(27．3%),下颌部合并头颈部伤1例(9．09%)。发病时间(3．3±2．2)d,均全部治愈。7例合并粉碎性骨折、已丧失肢体功能的患者均行伤肢截肢,3例肢体创伤没有骨折的患者及1例下颌部合并头颈部伤气性坏疽立即行外科清创、联合选用抗菌谱广(包括革兰染色阳性和阴性)的头胞菌素和高压氧治疗后均治愈。结论气性坏疽发生率少但比较致命,医生诊断时应提高警惕。清洗和清创术对预防感染是关键,高压氧是一种有益的辅助治疗。早期伤口分泌物涂片查找革兰染色粗大杆菌对早期诊断创伤性气性坏疽有一定的作用,且快速简便。     

Instruments for quality assurance in centers for medical rehabilitation

In 1994, the German statutory pension insurance scheme started to develop a quality assurance programme in rehabilitation clinics, involving scientists giving support to the project. Established as a routine in 1998, the programme is based on the integrated use of different instruments relating to structural, procedural as well as outcome quality. Analysis and evaluation of data follow a concept of clinic comparisons, assessing particular groups of clinics of similar structure. The specific instruments used are described, their development is outlined and their application explained.     

A Role for Residential Treatment in Preparation for Adoption

No abstract available for this article.     

Advances in drug development for targeted therapies for glioblastoma

Glioblastoma is the most aggressive primary brain tumor in adults. The prognosis of patients with primary glioblastoma treated with the current standard of care, tumor resection followed by radiation therapy and auxiliary temozolomide, remains poor. Integrative genomic analyses have identified essential core signaling pathways and frequent genetic aberrations, which provide potential drug targets for glioblastoma treatment. Drugs against these therapeutic targets have been developed rapidly in recent years. Although some have shown promising effects on models in preclinical studies, many have shown only modest efficacy in clinical trials. New therapeutic strategies and potent drugs are urgently needed to improve the prognosis of patients with glioblastoma. The goal of this review is to summarize the current advances in drug development for targeted glioblastoma therapies and to reveal the major challenges encountered in clinical trials or treatment. This study will provide new perspectives for future studies of targeted therapeutic drug development and provide insights into the clinical treatment of glioblastoma.     

Screening for dysglycemia in overweight youth presenting for weight management

OBJECTIVE

To examine the performance of current screening recommendations for detecting dysglycemia in children and adolescents with obesity.

RESEARCH DESIGN AND METHODS

In a cross-sectional study, an oral glucose tolerance test and demographic (age, sex, family history of diabetes, and ethnicity), clinical (BMI z score, waist circumference, and pubertal stage), and laboratory variables used in current pediatric screening criteria for type 2 diabetes mellitus were measured in 259 overweight or obese youth aged 5–17 years. Glycemic status was based on American Diabetes Association (ADA) thresholds. The performance (sensitivity and specificity) of current screening criteria and newly developed models to identify isolated IGT were compared.

RESULTS

Dysglycemia was present in 20.8% of the cohort. Of the 54 participants with dysglycemia, 68% had a normal fasting glucose and were identified with the 2-h glucose test. Current ADA criteria had low sensitivity (41.7% [95% CI 25.6–57.8]) and moderate specificity (69.5% [63.5–75.6]) to identify IGT. In receiver operating characteristic (ROC) analysis, the addition of hemoglobin A_1c (HbA_1c) or FPG did not improve the ROC area under the curve (AUC) (HbA_1c: 0.64 vs. 0.63; P = 0.54; HbA_1c + FPG: 0.66; P = 0.42), but adding triglyceride level did (AUC 0.72 vs. 0.63; P = 0.03). A simple model with fasting triglyceride level >1.17 mmol/L improved AUC compared with ADA screening criteria (0.68 vs. 0.57; P = 0.04).

CONCLUSIONS

The prevalence of IGT is high among obese children and youth. Current screening criteria have low sensitivity to detect isolated IGT. Although adding nonfasting laboratory values to history and physical measures does not improve diagnostic accuracy, adding fasting lipid profile improves predictive value.Obesity-related metabolic abnormalities are common in children and adolescents with obesity. Impaired glucose tolerance (IGT), an important predictor of progression to type 2 diabetes mellitus (T2DM) in youth (1), is identified in overweight and obese children, although the prevalence varies considerably with the population studied. Although 20–25% of overweight youth presenting to a weight management program in the northeastern U.S. were diagnosed with IGT (2), clinical cohorts in other countries have had much lower prevalence (5–17%) (3–5). In adults, IGT is a strong predictor for progression to T2DM (6) and increased risk of cardiovascular disease, independent of the development of T2DM (7). Randomized controlled trials of lifestyle or medication interventions in adults with IGT have demonstrated that T2DM can be prevented (8,9). Because the detection of IGT requires the performance of a cumbersome oral glucose tolerance test (OGTT), strategies to minimize the number of people requiring such a test have been studied in adults (10,11). Few such studies have been done in children and adolescents.Current American Diabetes Association (ADA) guidelines recommend screening high-risk populations with a fasting plasma glucose (FPG) test (12,13), although they acknowledge that the best screening test and the population of obese children and youth that should be screened require further investigation (14). The majority of children with IGT have a normal fasting glucose (2), suggesting that FPG alone may be inadequate to identify prediabetes and that an OGTT be considered for screening in at-risk youth. Because the OGTT is costly, it should be performed on those at highest risk only, but little evidence evaluating the risk prediction properties of current screening criteria is available.This study examines the clinical usefulness of current screening recommendations in identifying dysglycemia (T2DM, impaired fasting glucose [IFG], or IGT) in a cohort of 259 children and youth (aged 5–17 years) presenting to a weight management program and identifies a potential new screening tool for identification of obese youth with dysglycemia.     

Targets for intervention in dyslipidemia in diabetes

Treatment for dyslipidemia in diabetes reduces cardiovascular events. Diabetes is associated with major abnormalities in fatty acid metabolism. The resulting disturbance results in an abnormal lipoprotein cascade from the large chylomicron through to the small HDL particle. This suggests that drugs that alter formation of the chylomicron particle might have a very important role in diabetic dyslipidemia. Achieving normal glycemia will reverse the abnormalities in fatty acid metabolism, but this is difficult, particularly as the disease progresses. Genes that regulate cholesterol absorption and excretion have been described (Niemann Pick C1-like 1 [NPC1-L1] and ATP binding cassette proteins [ABC] G5 and G8). An effective NPC1-L1 inhibitor (ezetimibe) improves the reduction in cholesterol caused by statins. Agonists of ABCG5 and G8 may become important in the treatment of dyslipidemia. Microsomal triglyceride transfer protein (MTP) is responsible for the assembly of the chylomicron and VLDL particles. New MTP inhibitors, acting only on the intestine, are exciting possible treatments. The advisability of sitosterol-enriched foods to lower cholesterol may have to be reassessed for patients with diabetes, since these products may lead to an increase in chylomicron sitosterol in diabetic patients. More successful treatment of diabetic dyslipidemia is essential if we are to reduce the burden of cardiovascular disease so commonly found in diabetes.