Prognostic factors and treatment effect of standard-volume plasma exchange for acute and acute-on-chronic liver failure: A single-center retrospective study

Patients with acute liver failure (ALF) and acute-on-chronic liver failure (ACLF) have a high risk of mortality. Few studies have reported prognostic factors for patients receiving plasma exchange (PE) for liver support. We conducted a retrospective analysis using data of 55 patients with severe ACLF (n?=?45) and ALF (n?=?10) who received standard-volume PE (1–1.5 plasma volume) in the ICU. Hepatitis B virus infection accounts for the majority of ACLF (87%) and ALF (50%) patients. PE significantly improved the levels of total bilirubin, prothrombin time and liver enzymes (P<0.05). Thirteen ACLF patients (29%) and one ALF patient (10%) underwent liver transplantation. Two ALF patients (20%) recovered spontaneously without transplantation. The overall in-hospital survival rates for ACLF and ALF patients were 24% and 30%, and the transplant-free survival rates were 0% and 20%, respectively. For the 14 transplanted patients, the one-year survival rate was 86%. Multivariate analysis showed that pre-PE hemoglobin (P?=?0.008), post-PE hemoglobin (P?=?0.039), and post-PE CLIF-C ACLF scores (P?=?0.061) were independent predictors of survival in ACLF. The post-PE CLIF-C ACLF scores ≥59 were a discriminator predicting the in-hospital mortality (area under the curve?=?0.719, P?=?0.030). Cumulative survival rates differed significantly between patients with CLIF-C ACLF scores ≤ 58 and those with CLIF-C ACLF scores ≥ 59 after PE (P< 0.05). The findings suggest that PE is mainly a bridge for liver transplantation and spontaneous recovery is exceptional even in patients treated with PE. A higher improvement in the post-PE CLIF-C ACLF score is associated with a superior in-hospital survival rate.     

三种常用指标体系在评估乙型肝炎病毒相关慢加急性肝衰竭患者短期预后中的应用比较

目的探讨预后营养指数（PNI）、抗凝血酶Ⅲ（AT-Ⅲ）、中国重症乙型肝炎研究学组-慢加急性肝衰竭评分（COSSH-ACLFs）模型在乙型肝炎病毒（HBV）相关慢加急性肝衰竭（ACLF）患者病情严重程度及短期预后中的价值。 方法回顾性分析2016年1月至2021年9月在南通大学附属南通第三医院诊治的277例HBV相关ACLF患者的临床资料,根据90 d预后情况,将患者分为好转组（108例）和恶化组（169例）。根据患者入院后24 h内血常规、肝肾功能、凝血功能、肝性脑病分级、平均动脉压、血氧饱和度、吸入氧流量,结合患者年龄,计算出PNI、慢性肝衰竭-慢加急性肝衰竭评分、COSSH-ACLFs。采用Logistic回归分析及受试者工作特征（ROC）曲线评估PNI、AT-Ⅲ、COSSH-ACLFs预测HBV相关ACLF患者90 d短期预后的价值。 结果恶化组COSSH-ACLFs明显高于好转组（Z = 11.189,P<0.001）,PNI、AT-Ⅲ水平均明显低于好转组（Z = 6.815、6.000,P均<0.001）。多因素回归分析结果提示PNI[比值比（OR）= 0.886,95%置信区间（CI）（0.815,0.963）,P = 0.004]、AT-Ⅲ [OR = 0.925,95%CI（0.893,0.958）,P<0.001]、COSSH-ACLFs[OR = 11.456,95%CI（5.700,23.023）,P<0.001]为HBV相关ACLF患者90 d预后的独立影响因素。PNI、AT-Ⅲ、COSSH-ACLFs预测HBV相关ACLF患者短期预后的曲线下面积（AUC）分别为0.737、0.720、0.893;三者联合预测模型的预测效能最佳,AUC达到0.926。 结论PNI、AT-Ⅲ、COSSH-ACLFs对预测HBV相关ACLF患者的短期预后具有良好的价值,联合应用预测价值更优。     

Hyponatremia influences the outcome of patients with acute-on-chronic liver failure: an analysis of the CANONIC study

Introduction

Hyponatremia is a marker of poor prognosis in patients with cirrhosis. This analysis aimed to assess if hyponatremia also has prognostic value in patients with acute-on-chronic liver failure (ACLF), a syndrome characterized by acute decompensation of cirrhosis, organ failure(s) and high short-term mortality.

Methods

We performed an analysis of the Chronic Liver Failure Consortium CANONIC database in 1,341 consecutive patients admitted to 29 European centers with acute decompensation of cirrhosis (including ascites, gastrointestinal bleeding, hepatic encephalopathy, or bacterial infections, or any combination of these), both with and without associated ACLF (301 and 1,040 respectively).

Results

Of the 301 patients with ACLF, 24.3% had hyponatremia at inclusion compared to 12.3% of 1,040 patients without ACLF (P <0.001). Model for end-stage liver disease, Child-Pugh and chronic liver failure-SOFA scores were significantly higher in patients with ACLF and hyponatremia compared to those without hyponatremia. The presence of hyponatremia (at inclusion or during hospitalization) was a predictive factor of survival both in patients with and without ACLF. The presence of hyponatremia and ACLF was found to have an independent effect on 90-day survival after adjusting for the potential confounders. Hyponatremia in non-ACLF patients nearly doubled the risk (hazard ratio (HR) 1.81 (1.33 to 2.47)) of dying at 90 days. However, when considering patients with both factors (ACLF and hyponatremia) the relative risk of dying at 90 days was significantly higher (HR 6.85 (3.85 to 12.19) than for patients without both factors. Patients with hyponatremia and ACLF had a three-month transplant-free survival of only 35.8% compared to 58.7% in those with ACLF without hyponatremia (P <0.001).

Conclusions

The presence of hyponatremia is an independent predictive factor of survival in patients with ACLF. In cirrhosis, outcome of patients with ACLF is dependent on its association with hyponatremia.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-014-0700-0) contains supplementary material, which is available to authorized users.     

Predictors of mortality in patients with bloodstream infection due to ceftazidime-resistant Klebsiella pneumoniae

Bloodstream infection (BSI) due to multidrug-resistant Klebsiella is associated with high rates of morbidity and mortality. The aim of this study was to identify predictors of in-hospital mortality among patients with BSI due to ceftazidime-resistant (CAZ-R) Klebsiella pneumoniae at a tertiary care medical center. Patients with CAZ-R K. pneumoniae BSI were identified by our microbiology laboratory between January 1995 and June 2003. Clinical data were collected retrospectively. Logistic regression was used to identify independent predictors of all causes of in-hospital mortality. Of 779 patients with K. pneumoniae BSI, 60 (7.7%) had BSI due to CAZ-R K. pneumoniae; 43 (72%) of these were nosocomial infections. Pulsed-field gel electrophoresis identified a single predominant strain in 17 (28%) patients. The in-hospital mortality rate was 43% (n = 26). Among patients with CAZ-R K. pneumoniae BSI, those who died were similar to survivors with respect to demographic, clinical, and antimicrobial susceptibility characteristics. Only 43 (72%) patients received effective therapy within 5 days of BSI. In bivariable analysis, delay in initiation of effective therapy for >72 h after diagnosis of BSI was associated with death (P = 0.03). Strain genotype was not predictive of outcome. In multivariable analysis, delay in initiation of effective therapy for >72 h after diagnosis of BSI was an independent predictor of death (odds ratio, 3.32; 95% confidence interval, 1.07 to 10.3). Thus, among patients with BSI due to CAZ-R K. pneumoniae, a delay in the initiation of effective therapy of greater than 72 h after BSI was associated with a >3-fold increase in mortality risk.     

GP73, a new marker for diagnosing HBV-ACLF in population with chronic HBV infections

Although Golgi protein 73 (GP73) has been widely evaluated for diagnosing hepatocellular carcinoma (HCC) and other liver diseases in recent decade, its serum profile of patients with hepatitis B virus (HBV)–associated acute-on-chronic liver failure (HBV-ACLF) is still unknown. This study was designed to evaluate the serum levels of GP73 in patients with HBV-ACLF. The participants included 200 apparently healthy controls; 200 patients with chronic hepatitis B (CHB); 200 patients with HCC; 210 patients with HBV-ACLF, in which 29 HBV-ACLF patients were followed up for 3 months. All patients were Hepatitis B virus surface antigen (HBsAg) positive. The concentrations of GP73 in patients with HBV-ACLF (285.3 ± 128.5 ng/mL) were markedly higher than those HCC patients (159.1 ± 105.8 ng/mL), CHB patients (64.65 ± 44.99 ng/mL), and healthy controls (35.37 ± 12.41 ng/mL). When the cut-off value was set at 182.1 ng/mL, the sensitivity and specificity of HBV-ACLF diagnosis were 77.62% (95% confidence interval [CI]: 71.37%–83.07%) and 95.50% (95% CI: 92.27%–98.26%), respectively. If serum GP73 concentration was still above 361.6 ng/mL after 14 days of follow-up, the patient's prognosis may be depressed. Serum GP73 may be used to diagnosis HBV-ACLF in population with chronic HBV infections.     

Epidemiology and Outcome of Klebsiella Species Bloodstream Infection: A Population-Based Study

OBJECTIVE: To determine incidence rate, seasonal variation, and short- and long-term outcomes of Klebsiella species bloodstream infection (BSI) in a population-based setting.PATIENTS AND METHODS: We identified 127 unique patients in Olmsted County, Minnesota, from January 1, 1998, to December 31, 2007, who had Klebsiella spp BSI. Multivariable Poisson regression was used to examine temporal change and seasonal variation in incidence rate, and Cox proportional hazards regression was used to determine predictors of mortality.RESULTS: The age-adjusted incidence rate of Klebsiella spp BSI per 100,000 person-years was 15.4 (95% confidence interval [CI], 11.6-19.2) in men and 9.4 (95% CI, 7.0-11.8) in women. There was no linear increase in incidence rate of Klebsiella spp BSI during the study period (P=.55). The incidence rate of Klebsiella spp BSI increased at quadratic rate with age (P=.005). No significant difference was noted in incidence rate of Klebsiella spp BSI during the warmest 4 months compared to the rest of the year (incidence rate ratio, 0.97; 95% CI, 0.66-1.38; P=.95). The overall 28-day and 1-year all-cause mortality rates of Klebsiella spp BSI were 14% (95% CI, 9%-22%) and 35% (95% CI, 27%-44%), respectively. Respiratory source of BSI was associated with a higher 28-day mortality (hazard ratio, 4.90; 95% CI, 1.73-13.84; P=.003).CONCLUSION: The incidence rate of Klebsiella spp BSI increased with age. There was no temporal change or seasonal variation in incidence rate of Klebsiella spp BSI during the past decade. The 28-day all-cause mortality rate of Klebsiella spp BSI was relatively low; however, a respiratory source of BSI was associated with a poorer outcome.BSI = bloodstream infection; CI = confidence interval; HR = hazard ratio; REP = Rochester Epidemiology ProjectKlebsiella species are the second most common cause of gram-negative bloodstream infection (BSI).^1-5 Population-based studies that specifically address the epidemiology and outcome of Klebsiella spp BSI are lacking because most previous studies have been derived from referral tertiary care centers.^6-8 Therefore, we performed a population-based study to determine the incidence rate of Klebsiella spp BSI and to investigate for temporal changes and seasonal variation in the incidence rate of Klebsiella spp BSI. We estimated the 28-day and 1-year mortality rates and identified predictors of mortality of Klebsiella spp BSI among inhabitants of Olmsted County, Minnesota, from 1998 through 2007.     

慢性阻塞性肺疾病急性加重期患者急性胃肠损伤发生率及其预后研究

目的探讨慢性阻塞性肺疾病急性加重期（AECOPD）患者急性胃肠损伤（AGI）的发生率及其对预后的评价。 方法分析2009年1月至2015年12月在马鞍山十七冶医院重症医学科收治的146例AECOPD患者的临床资料,进行AGI诊断和分级,依据28 d内存活情况,将发生AGI的患者分为存活组（72例）和死亡组（17例）,比较两组患者年龄、性别、合并症以及急性病生理学和长期健康评价（APACHEⅡ）评分、临床肺部感染评分（CPIS）。依据APACHEⅡ评分分值将AECOPD患者分成四组,轻度组（39例）、重度组（53例）、危重度组（35例）和极危重度组（19例）;另依据CPIS评分分值分成三组,轻度组（71例）、中度组（53例）和重度组（22例）,比较各分组间AGI发生率和28 dAGI病死率。同时对不同AGI分级患者的28 d病死率也进行比较。 结果146例AECOPD患者中有89例发生AGI,发生率为60.96%,其中Ⅰ级53例（59.55%）、Ⅱ级19例（21.35%）、Ⅲ级11例（12.36%）、Ⅳ级6例（6.74%）。AECOPD合并AGI患者存活组和死亡组的年龄、性别、合并症等比较,差异均无统计学意义（P均> 0.05）;但存活组患者APACHEⅡ评分[（20 ± 5）分vs.（28 ± 5）分,t = 5.833,P< 0.001]、CPIS评分[（3.5 ± 1.5）分vs.（5.4 ± 1.6）分,t = 4.568,P< 0.001]均显著低于死亡组。APACHEⅡ评分分组中AGI发生率和28 dAGI病死率各组比较,差异均有统计学意义（χ² = 27.369、47.838,P均< 0.001）;而CPIS评分分组中AGI发生率和28 dAGI病死率各组比较,差异也均有统计学意义（χ² = 24.025、47.453,P均< 0.001）。不同AGI分级患者28 d病死率比较（1.89%、15.79%、63.64%和100.00%）,差异有统计学意义（χ² = 49.829,P < 0.05）。 结论AECOPD患者AGI发生率高,且AGI分级越高,预后越差,应当重视AECOPD患者AGI的诊治。     

Graded exercise testing early after myocardial revascularization surgery

The response to early graded exercise testing (GXT) was studied in 227 patients at a mean of 15.3 days after myocardial revascularization surgery (MRS). GXT followed a modified Bruce protocol without multiples of resting energy expenditure (MET) restrictions and a target heart rate (HR) of 90% of age-predicted maximal HR. The decision as to precisely when to administer the GXT after surgery was made on an individual case basis by the cardiovascular surgeon and the attending cardiologist. For the data analysis, patients were grouped according to the number of days the GXT was administered after surgery: group 1, 7 to 14 days (n = 164); group 2, 15 to 28 days (n = 46); and group 3, greater than 28 days (n = 17). The use of beta blockers was also determined on an individual case basis by the attending cardiologist rather than on a random basis. Ninety-seven of the 227 patients were on beta blockers. Ventricular ectopic activity (VEA), ST-segment changes (STTC), peak HR, peak systolic blood pressure (SBP), peak rate-pressure product (RPP), and peak METs were assessed during exercise. No major complications occurred during testing. Approximately two thirds (67.4%) of the tests were terminated voluntarily by the patient, and 22.5% were stopped by the attending physician. Only 10.1% of the subjects reached the target HR. Chi-square analysis failed to reveal any association between time of testing after surgery and either STTC or VEA. Analysis of variance failed to reveal any effects of group or beta blocker on peak METs attained during GXT; however, patients not using beta blocker medication attained higher peak HR, SBP, and RPP.(ABSTRACT TRUNCATED AT 250 WORDS)     

The impact of previous hospitalization in the preceding 90 days on the outcome in critically ill patients with gram-negative bloodstream infection

We conducted a retrospective cohort study to evaluate the impact of previous hospitalization in the preceding 90 days on mortality in critically ill patients with gram-negative bloodstream infection (BSI) and to identify the risk factors for 30-day mortality in these patients. Of 89 critically ill patients with gram-negative BSI, 42 patients had previous hospitalization in the preceding 90 days. Multivariate Cox regression analysis revealed previous hospitalization in the preceding 90 days as a significant predictor for 30-day mortality (hazard ratio [HR], 2.10; 95% confidence interval [CI], 1.11–3.94; P = 0.022), along with Acute Physiology and Chronic Health Evaluation II score at BSI onset (HR, 1.08; 95% CI, 1.04–1.12; P < 0.001), liver cirrhosis (HR, 3.61; 95% CI, 1.46–8.94; P = 0.006), and inappropriate definitive antimicrobial therapy (HR, 4.28; 95% CI, 2.17–8.45; P < 0.001). The effect of previous hospitalization in the preceding 90 days should be considered in evaluating the risk for 30-day mortality when treating such patients, and further study is required.     

红细胞分布宽度在慢加急性肝衰竭患者预后预测中的应用

目的 旨在探讨红细胞分布宽度（RDW）在慢加急性肝衰竭（ACLF）患者预测预后中的应用。方法 选取乙型肝炎病毒（HBV）相关性ACLF患者78例,根据预后分为生存及死亡组,检测患者外周血RDW水平及其他相关临床指标。结果 ACLF死亡患者外周血RDW水平高于生存患者（t=-3.568,P=0.004）。RDW与白细胞计数（WBC）、中性粒细胞绝对值/淋巴细胞绝对值（NLR）、总胆红素（TBIL）、终末期肝脏病评分（MELD）存在相关性（P值均<0.05）。受试者工作特征曲线（ROC）分析显示：RDW预测ACLF死亡率的ROC曲线下面积（AUC）为0.64,Cut off值为17.15%,灵敏度和特异度分别为54.2%和67.9%。多因素回归分析显示：RDW、NLR、国际标准化比值（INR）是ACLF患者短期死亡率的独立危险因素（OR值=1.444、1.305、1.891,P值均<0.05）,生存分析显示：RDW≥17.15%患者生存率低于RDW＜17.15%患者（P<0.05）。结论 外周血RDW是临床预测ACLF患者短期预后的简单、有效的指标。     

造血干细胞移植后血流感染的临床分析

目的:分析造血干细胞移植(HSCT)患者血流感染的临床特征。方法:回顾性分析2013年1月至2020年6月在我科行HSCT的910例患者的临床特征、发生血流感染的病原菌分布及药敏情况。结果:910例患者中,111例在移植后100 d内确诊血流感染,98例的血流感染发生在粒细胞缺乏(粒缺)期。多因素分析显示,预处理方案含抗胸腺细胞球蛋白(ATG)、粒缺持续时间长、单个核细胞(MNC)输注量低是HSCT后血流感染的独立危险因素。分离出的121株病原菌中,革兰氏阴性(G-)菌76株(62.8%),革兰氏阳性(G+)菌40株(33.1%),真菌5株(4.1%)。病原菌前3位依次为大肠埃希菌、表皮葡萄球菌和铜绿假单胞菌。大肠埃希菌、肺炎克雷伯菌和铜绿假单胞菌对碳青霉烯类药物耐药率分别为14.3%、7.7%和66.7%。G+菌对万古霉素、利奈唑胺、替考拉宁的敏感率分别为97.5%、100%和100%。血流感染患者HSCT后100 d死亡率显著高于无血流感染患者(P<0.001)。结论:预处理方案含ATG、粒缺持续时间长、MNC输注量低是HSCT后血流感染的独立危险因素,移植后血流感染病原菌以...     

乙型肝炎病毒相关慢加急性肝衰竭患者血清miR-328-3p 表达水平及其与疾病严重程度及预后的相关性研究

目的 探究微小核糖核酸（microRNA,miR）-328-3p表达水平与乙型肝炎病毒相关慢加急性肝衰竭（hepatitis B virus-related acute-on-chronic liver failure,HBV-ACLF）严重程度及预后的关系。方法 选取 2018年 12月～2021年 12月陕西省人民医院收治的 HBV-ACLF患者 120例（HBV-ACLF组）、慢性乙型肝炎（chronic hepatitis B,CHB）患者 120例（CHB组）,另选取同期健康体检者 120例为健康组。比较三组一般资料及血清 miR-328-3p表达水平,比较不同分期 HBV-ACLF患者血清 miR-328-3p表达水平;分析 HBV-ACLF患者血清 miR-328-3p表达水平与终末期肝病模型（model for end-stage liver disease,MELD）评分的相关性;比较不同预后 HBV-ACLF患者基线资料及血清 miR-328-3p表达水平;评估血清 miR-328-3p和 MELD评分对 HBV-ACLF患者预后的预测价值; COX回归分析 HBV-ACLF患者预后的影响因素。结果 健康组、 CHB组和 HBV-ACLF组血清 miR-328-3p（1.03±0.34,1.85±0.62和 2.76±0.92）表达水平比较,差异有统计学意义（F=200.241,P＜ 0.05）;早期、中期、晚期组 HBV-ACLF患者血清 miR-328-3p（2.30±0.58,2.88±0.72和 3.63±0.91）表达水平逐渐升高,差异有统计学意义（F=28.023,P＜ 0.05）;HBV-ACLF患者血清 miR-328-3p表达水平与 MELD评分、血清天门冬氨酸氨基转移酶（aspartate aminotranferase,AST）、总胆红素（total serum bilirubin,TBIL）和丙氨酸氨基转移酶（alanine aminotransferase,ALT）呈正相关（r=0.598,0.418,0.375,0.339,均 P＜ 0.05）;死亡组 HBV-ACLF患者 MELD评分（28.62±5.72）和血清 miR-328-3p（3.34±0.67）表达水平均高于生存组（21.14±4.23,2.32±0.46）,差异有统计学意义（t=8.237,9.878,均 P＜ 0.05）;血清 miR-328-3p和 MELD评分预测 HBV-ACLF患者预后的曲线下面积（area under curve,AUC）分别为 0.861（95%CI:0.791～0.932）,0.853（95%CI: 0.781～0.925）,且二者联合预测 HBV-ACLF患者预后的 AUC为 0.945（95%CI:0.902～0.989）,高于 miR-328-3p和 MELD评分单独预测（Z=1.991,2.137,均 P＜ 0.05）,且其敏感度和特异度分别为 96.2%,86.8%;回归分析显示, MELD评分 [OR(95%CI)=2.532(1.635～3.920)]和 miR-328-3p[OR(95%CI)=2.928(1.836～4.668)]均是 HBV-ACLF患者死亡的危险因素（均 P＜ 0.05）。结论 HBV-ACLF患者血清 miR-328-3p表达水平较高,与 HBV-ACLF疾病严重程度和预后显著相关,且血清 miR-328-3p与 MELD评分联合能较为有效地预测 HBV-ACLF患者预后,有一定临床参考价值。     

ICU治疗的老年急性冠脉综合征患者行急诊经皮冠状动脉介入术后新发房颤的预测因素

目的评价在我院ICU行急诊经皮冠状动脉介入(PCI)手术治疗的老年急性冠脉综合征(ACS)患者术后新发房颤(NOAF)的预测因素.方法选取2016年5月至2019年4月在泉州市第一医院老年病科ICU进行急诊PCI手术治疗的老年ACS患者440例.根据患者术后是否发生NOAF将患者分为NOAF组与非NOAF组,收集并比较两组患者人口统计学资料、合并症、病史、超声与血管造影特征、治疗情况、术前实验室指标.对患者进行6个月隧访,比较两组患者预后指标.采用多变量分析评价患者发生NOAF及6个月死亡的独立预测因素.采用受试者工作特征(ROC)曲线分析相关预测因素敏感度、特异度.结果共有77例(17.5%)发生NOAF(NOAF组,n=77),363例(82.5%)未发生NOAF(非NOAF组,n=363).68例(15.5%)死亡.多变量Logistic回归分析表明,心肌梗死(MI)病史(OR=4.510,95%CI1.680~12.107,P=0.004)与单核细胞/高密度脂蛋白比值(MHR,OR=1.103,95%CI1.055~1.153,P<0.001)是老年ACS患者急诊PCI术后发生NOAF的独立预测因素.MHR的ROC曲线下面积为0.750,MHR预测NOAF的截断值为15.873,敏感度为75.98%,特异度为65.03%.多变量Cox比例模型分析表明,NOAF(HR=2.330,95%CI2.489~8.625,P=0.019)与Killip分级Ⅲ/Ⅳ级(HR=2.951,95%CI 1.219~7.137,P=0.017)是老年ACS患者急诊PCI术后6个月死亡的独立预测因素.结论MI病史和MHR是老年ACS患者急诊PCI术后发生NOAF的独立预测因素,NOAF与Killip分级Ⅲ/Ⅳ级是老年ACS患者急诊PCI术后6个月死亡的独立预测因素.     

Clinical impact of antimicrobial resistance in European hospitals: excess mortality and length of hospital stay related to methicillin-resistant Staphylococcus aureus bloodstream infections

Antimicrobial resistance is threatening the successful management of nosocomial infections worldwide. Despite the therapeutic limitations imposed by methicillin-resistant Staphylococcus aureus (MRSA), its clinical impact is still debated. The objective of this study was to estimate the excess mortality and length of hospital stay (LOS) associated with MRSA bloodstream infections (BSI) in European hospitals. Between July 2007 and June 2008, a multicenter, prospective, parallel matched-cohort study was carried out in 13 tertiary care hospitals in as many European countries. Cohort I consisted of patients with MRSA BSI and cohort II of patients with methicillin-susceptible S. aureus (MSSA) BSI. The patients in both cohorts were matched for LOS prior to the onset of BSI with patients free of the respective BSI. Cohort I consisted of 248 MRSA patients and 453 controls and cohort II of 618 MSSA patients and 1,170 controls. Compared to the controls, MRSA patients had higher 30-day mortality (adjusted odds ratio [aOR] = 4.4) and higher hospital mortality (adjusted hazard ratio [aHR] = 3.5). Their excess LOS was 9.2 days. MSSA patients also had higher 30-day (aOR = 2.4) and hospital (aHR = 3.1) mortality and an excess LOS of 8.6 days. When the outcomes from the two cohorts were compared, an effect attributable to methicillin resistance was found for 30-day mortality (OR = 1.8; P = 0.04), but not for hospital mortality (HR = 1.1; P = 0.63) or LOS (difference = 0.6 days; P = 0.96). Irrespective of methicillin susceptibility, S. aureus BSI has a significant impact on morbidity and mortality. In addition, MRSA BSI leads to a fatal outcome more frequently than MSSA BSI. Infection control efforts in hospitals should aim to contain infections caused by both resistant and susceptible S. aureus.     

肝移植术后患者预后不良的独立危险因素分析

目的 了解肝移植手术患者术后的预后情况,并阐明与预后相关的危险因素.方法 回顾性分析上海交通大学医学院附属仁济医院首次接受原位经典尸体肝移植手术成人患者,收集患者术前、术中和术后临床资料.运用急性肾损伤网络(AKIN)定义的急性肾损伤(AKI)诊断和分期标准观察肝移植手术患者术后AKI的发生情况;应用Kaplan-Meier生存曲线分析患者术后28 d和1年的预后情况,采用Cox风险回归模型分析患者死亡危险因素,重点观察AKI对患者预后的影响.结果 符合人选标准的病例共193例,年龄(48.07±10.02)岁,男女比例4∶1,术后共有116例(占60.1%)患者发生了AKI.AKI患者术后28 d病死率明显高于非AKI患者(15.5%(18/116)比0,P＜0.053,1年存活率明显低于非AKI患者(70.7%(82/116)比90.9%(70/77),P＜0.053;Kaplan-Meier生存分析显示,非AKI患者(77例)和术后AKI 1、2、3期(分别为58、25、33例)患者1年生存率分别为90.9%、81.0%、84.0%、42.4%,术后28 d死亡患者均发生术后AKI,Cox回归显示,术前高血压及术后AKI、感染、急性生理学与慢性健康状况评分系统Ⅱ(APACHEⅡ)评分≥10分是术后1年患者死亡的独立危险因素;术前高血压死亡危险度(HR)为4.398,95%可信区间(CI)为1.535～12.604;术后AKI的HR为12.100,95%CI为1.565～93.540;术后感染的HR为4.709,95%CI为1.813～12.226;术后APACHEⅡ评分的HR为3.627,95%CI为1.244～10.573(P＜0.05或P＜0.01).结论 AKI是肝移植患者术后预后不良的独立危险因素,预防AKI的发生可能有助于提高患者的生存率.     

Development of subsequent bloodstream infection in patients with positive Hickman catheter blood cultures and negative peripheral blood cultures

There are limited data on the incidence of subsequent bloodstream infection (BSI) and the effect of systemic antibiotics in patients who had positive catheter-drawn blood cultures (CBC) and negative peripheral blood cultures (PBC). We retrospectively reviewed all paired blood cultures from patients with Hickman catheter in the hematology-oncology ward between January 1997 and December 2008. There were 112 episodes with positive CBC and negative PBC. Nine episodes (8.0%; 95% CI, 3.0-13.1%) led to subsequent BSI within 28 days. Subsequent BSI developed in 6 of 31 episodes (19%) where empiric antibiotics were inappropriate but in 3 of 81 episodes (4%) where empiric antibiotics were appropriate (P = 0.01). Subsequent candidemia (50%, 2 of 4) was more common than subsequent bacteremia (6%, 7 of 108) (P = 0.03). In conclusion, for patients with positive CBC and negative PBC, the overall incidence of subsequent BSI was 8.0%, and inappropriate empiric antibiotics was associated with subsequent BSI.     

Predictive Value of High-Sensitivity C-Reactive Protein in Patients with Idiopathic Dilated Cardiomyopathy

We analyzed the serum concentrations of high-sensitivity C-reactive protein (hsCRP) at the time of diagnostic cardiac catheterization in 198 patients with idiopathic dilated cardiomyopathy (IDC) to evaluate its prognostic value. Patients were dichotomized according to a median value of hsCRP of 2 mg/dL. Predefined study endpoints over 69 ± 33 months of follow-up included major arrhythmic events and transplant-free survival. Major arrhythmic events during follow-up occurred in 20 of 98 patients (20%) with low, compared to 22 of 100 patients (22%) with high hsCRP (ns). By multivariate analysis, a depressed left ventricular ejection fraction (LVEF) was the only significant predictor of arrhythmic risk. Death or cardiac transplantation was observed in 36% of patients with high, versus 22% of patients with low hsCRP (P < 0.05). By multivariate analysis, hsCRP and LVEF were independent predictors of transplant-free survival. Thus, in this patient population with IDC, hsCRP had independent prognostic value with regard to transplant-free survival, but did not contribute in the stratification with regard to arrhythmic risk.     

HBV相关慢加急性肝衰竭患者血清细胞因子水平与疾病预后的关系研究

目的观察乙型肝炎病毒(HBV)相关慢加急性肝衰竭(ACLF)患者血清细胞因子水平的变化,探讨细胞因子在疾病预后中的作用。方法收集HBV相关ACLF患者24例(治愈者13例,死亡者11例)、慢性乙型肝炎(CHB)患者30例和正常对照者15名,采用Luminex液相芯片技术检测血清白细胞介素IL-2、IL-4、IL-6、IL-8、IL-10、粒细胞-巨噬细胞刺激因子(GM-CSF)、γ干扰素(IFN-γ)和肿瘤坏死因子α(TNF-α)等细胞因子水平,并结合临床指标进行相关分析。结果 ACLF组IL-6、IL-8和TNF-α水平高于CHB组和对照组(P0.01),CHB组亦高于对照组(P0.05);ACLF死亡组IL-6、TNF-α水平和终末期肝病模型(MELD)评分明显高于治愈组(P0.05);TNF-α、IL-6与凝血酶原活动度(PTA)之间呈明显负相关(r=-0.712,P0.001;r=-0.521,P=0.009);TNF-α、IL-6与MELD评分之间呈明显正相关(r=0.491,P0.015;r=0.379,P=0.048)。细胞因子与HBV DNA和乙型肝炎表面抗原(HBsAg)之间无明显相关性。结论 HBV相关ACLF患者血清中多种细胞因子明显升高,其中IL-6和TNF-α水平随疾病严重程度的增加而增加,检测其血清细胞因子水平有助于疾病严重程度和预后转归的判断。     

慢加急性肝衰竭患者血清Clusterin 和CCR5 表达水平及其对预后预测价值研究

目的 探讨血清丛生蛋白(Clusterin）及趋化因子受体5（CCR5）在慢加急性肝衰竭（acute-on-chronic liverfailure，ACLF）患者中的表达以及两者联合检测对ACLF 患者预后的预测价值。方法 选取2018 年1 月～ 2020 年12月唐山市传染病医院收治的84 例ACLF 患者作为观察组，同期选择在该院体检的80 例健康体检者作为对照组。采用酶联免疫吸附试验(ELISA）法测定患者血清中Clusterin 和CCR5 水平；根据患者预后28 天情况，将其分为存活组（n=48）和死亡组（n=36）。采用受试者工作特征曲线（receiver operating characteristic curve，ROC）分析血清Clusterin 与CCR5联合检测对ACLF患者预后的预测价值；Spearman 相关性分析血清Clusterin 和CCR5水平与终末期肝病模型(modelfor end-stage liver disease，MELD) 评分、慢性肝衰竭- 序贯器官衰竭评分(chronic liver failure-sequential organ failureassessment，CLIF-SOFA) 的相关性；采用多因素Logistic 回归分析ACLF 患者预后的影响因素。结果 与对照组相比，观察组Clusterin（87.37±9.99μg/ml vs 104.85±15.14μg/ml） 及CCR5（11.55±2.86μg/ml vs 15.68±3.01μg/ml） 水平降低，差异具有统计学意义（t=8.767，9.010，均P<0.05）。与存活组相比，死亡组Clusterin（77.40±9.26μg/ml vs94.85±10.54μg/ml）及CCR5（8.58±1.98μg/ml vs 13.78±3.52μg/ml）水平降低，差异具有统计学意义（t=7.904，7.962，均P<0.05）。ROC 曲线显示，血清Clusterin 与CCR5 联合预测的曲线下面积（area under curve，AUC）（0.927）最大，其敏感度和特异度分别为88.90% 和83.30%。经Spearman 相关性分析Clusterin 与MELD，CLIF-SOFA 评分呈负相关（r=-0.524，-0.457，均P<0.05），CCR5 与MELD，CLIF-SOFA 评分呈负相关（r=-0.611，-0.358，均P<0.05）。多因素Logistic 回归分析显示，血清Clusterin，CCR5 及IL-6 为ACLF 患者预后不良的影响因素（均P ＜ 0.05）。结论 Clusterin 及CCR5 在ACLF 患者血清中表达下调，且联合检测二者在预测ACLF 患者短期预后方面具有良好的参考价值。     

Low hemoglobin levels are associated with direct antiglobulin test positivity in patients with acute-on-chronic liver failure

BackgroundMultiple factors contribute to anemia in patients with Hepatitis B virus (HBV)related acute-on-chronic liver failure (ACLF); however, the mechanism is unclear. The purpose of this study was to evaluate the clinical significance of the direct antiglobulin test (DAT) in patients with HBV related ACLF.MethodsDAT was used to detect immunoglobulins and/or complement proteins on the surface of erythrocytes.ResultsWe recruited 78 HBV-associated ACLF patients, 30 chronic hepatitis B(CHB)patients and 40 healthy people between October 2015 and May 2016. In HBV related ACLF patients, the hemoglobin concentration, number of erythrocytes, and hematocrit value were significantly lower, while the erythrocyte distribution width was significantly higher, compared to patients with CHB and healthy controls (HCs) (P < 0.001). The rates of DAT positivity in HBV related ACLF patients, CHB patients, and HCs were 62.8 %, 13.3 %, and 0%, respectively. DAT-positive ACLF patients exhibited lower Hb levels, older average age, as well as higher total bilirubin, alanine aminotransferase, and complement component 3 levels compared to DAT-negative patients.ConclusionsHBV related ACLF patients showed significant alterations in erythrocyte parameters, possibly reflecting disease development and severity. The high presence of erythrocyte autoantibodies suggested that immunologic clearance of erythrocytes contributed to multifactorial anemia in HBV related ACLF patients.