罕见豚鼠耳炎诺卡菌多部位感染死亡患者个案报道

【摘要】豚鼠耳炎诺卡菌是人体罕见感染病原体,也是诺卡菌属中罕见的菌属之一,多存在于土壤或腐烂物中,常通过皮肤破损处进入人体而引发感染,罕见通过呼吸道感染人体,此菌毒力强,感染组织液化坏死化脓,可并发多脏器、多部位感染,常发生在免疫功能障碍、肿瘤、免疫缺陷患者肺部豚鼠耳炎诺卡菌感染是诺卡菌属常见感染部位,死亡率极高,预后差6-7],临床治疗手段有限,早期合理及时的治疗有助于患者预后的改善。但在临床诊疗中,持续进展、复发加重患者较为罕见,本文就我院收治1例复发性豚鼠耳炎诺卡菌所致重症肺炎、双下肢多发部位感染且经多家医院诊治病情复发、最终死亡的青年患者1例报告讨论如下,期望对此类罕见病原体感染患者的临床诊疗有所启示。     

豚鼠耳炎诺卡菌引起儿童颌下皮肤感染1例

正诺卡菌属(Nocardia)是革兰阳性、需氧丝状菌,寄生于土壤、腐物中,经呼吸道或皮肤伤口侵入人体造成感染。利用表型和分子生物学方法,诺卡菌属已被鉴定出89个种[1]。豚鼠耳炎诺卡菌(Nocardia otitidiscaviarum)引起人类感染的报道相对较少,可能与其致病力低、土壤中分布不广泛或病例漏报有关[2]。本院于2016年12月自1例儿童颌下脓肿     

诺卡菌分子鉴定方法的研究进展

正诺卡菌是一群需氧革兰阳性分枝杆菌,可存在于土壤、空气、水、动植物排泄物中,主要通过吸入或破损皮肤侵入人体引起感染,可引起局部或全身感染,好发于免疫功能低下患者(例如器官移植后,使用糖皮质激素,HIV感染等免疫抑制状态),也可见于健康人[1-2]。近年来国际上和我国有关诺卡菌感染的报道不断增多,日益受到关注[3-6]。     

非霍奇金淋巴瘤合并北京诺卡菌肺部感染1例

<正>肺诺卡菌病是由诺卡菌引起的肺部感染性疾病，其临床表现不典型，且易合并肺部其他感染，容易引起误诊、漏诊，已逐渐引起重视^[1]。近年来肺部诺卡菌感染多有报道，但由北京诺卡菌引起的肺部感染报道较少，非霍奇金淋巴瘤合并北京诺卡菌肺部感染罕见。现报道1例肺部诺卡菌感染合并非霍奇金淋巴瘤患者的临床病例，复习既往相关文献，以期进一步提高医务人员对该病的认识。     

脑脊液分离出皮疽诺卡菌1例

诺卡菌属于放线菌属,包含 50 余种[1].现阶段,诺卡菌属有 9 种类型,其中皮疽诺卡菌临床较为少见,作为兼性需氧菌,常引起急性或亚急性化脓性感染,多发生于免疫功能低下的患者[1-2],该菌感染后临床表现多样,且不具备特异性,易被临床忽视[2].2020 年 12 月,本院微生物室从 1 例患者脑脊液标本中分离获得皮疽诺卡菌,现将细菌分离及对患者的诊疗过程报道如下.     

血培养检出皮疽诺卡菌1例

诺卡菌感染通常由创伤相关细菌侵入或通过吸入方式导致,后者好发于免疫功能低下患者,并在肺部形成感染灶 [1].诺卡菌也可引起肺外各部位感染,肺外感染通常由肺部原发病灶经血行播散所致 [2].在我国,临床感染最常见的诺卡菌为星形诺卡菌,约占70％[3],皮疽诺卡菌引起的感染比较少见,在血液中培养出皮疽诺卡菌更是罕见,本文报...     

支气管扩张患者合并肺诺卡菌病2例

<正>支气管扩张症(支扩)是各种原因引起的支气管树的病理性、永久性扩张,导致反复发生化脓性感染的气道慢性炎症[1]。肺诺卡菌病是由需氧放线菌科诺卡菌属引起的少见的肺部细菌感染,常发生于免疫功能低下患者[2],近年来逐渐有文献报道发生于免疫功能正常的患者中。结合既往文献,关于支扩患者合并肺诺卡菌病的病例甚少,现回顾性分析2例支扩合并肺诺卡菌病的诊疗经过,并结合相关文献进行复习,以提高临床工作     

皮疽诺卡菌脑脓肿1例

诺卡菌病常见的为肺诺卡菌病和播散型诺卡菌病,半数以上肺诺卡菌病患者合并肺外疾病 [1].病原菌多由外伤进入皮肤或经呼吸道吸入引起感染 [2],常见于各种原因所致的机体免疫功能低下患者 [3],20％播散型诺卡菌病患者无明显肺部受累表现,脑是最常见的播散部位.多数诺卡菌病患者存在免疫缺陷.我院从1例脑脓肿患者穿刺液中分离...     

皮肤诺卡菌病1例

原发性皮肤诺卡菌感染在临床上比较罕见,主要表现为皮肤脓疱、脓皮病、脓肿、溃疡、肉芽肿或蜂窝织炎,主要由巴西诺卡菌感染所致 [1].本文报道1例由巴西诺卡菌合并荒尾诺卡菌感染所致的原发性皮肤感染病例,以供临床参考.     

皮肤巴西诺卡菌感染致蜂窝织炎1例并文献复习

正诺卡菌在自然界分布广泛,多为腐生寄生菌,是一种条件致病菌。临床多经呼吸道吸入或皮肤伤口侵入机体而引起感染,通常认为主要在免疫功能低下的患者中引起感染,免疫功能正常的患者也有感染的风险,但多伴有潜在的疾病和外伤等风险因素。诺卡菌的感染临床表现、病史无明显的特异性,极易引起误诊、漏诊,错过最佳治疗时期[1-3]。现报道1例免疫功能正常的中年男性皮肤巴西诺卡菌感染及治愈的过程,为临床诊治提供参考。     

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.     

Guns and Knives in New Mexico: Patterns of Penetrating Trauma, 1978–1993

Objective: To identify patterns of nonfatal and fatal penetrating trauma among children and adults in New Mexico using ED and medical examiner data.
Methods: The authors retrospectively sampled in 5-year intervals all victims of penetrating trauma who presented to either the state Level-1 trauma center or the state medical examiner from a 16-year period (1978–1993). Rates of nonfatal and fatal firearm and stabbing injury were compared for children and adults.
Results: Rates of nonfatal injury were similar (firearm, 34.3 per 100,000 person-years; stabbing, 35.1). However, rates of fatal injury were significantly different (firearm, 21.9; stabbing, 2.7; relative risk: 8.2; 95% confidence interval: 5.4, 12.5). From 1978 to 1993, nonfatal injury rates increased for children (p = 0.0043) and adults (p < 0.0001), while fatal penetrating injury remained constant. The increase in nonfatal injury in children resulted from increased firearm injury rates. In adults, both stabbing and firearm nonfatal injury rates increased.
Conclusions: Nonfatal injury data suggest that nonfatal violence has increased; fatal injury data suggest that violent death rates have remained constant. Injury patterns vary by age, mechanism of trauma, and data source. These results suggest that ED and medical examiner data differ and that both are needed to guide injury prevention programs.     

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.