天津地区耐亚胺培南铜绿假单胞菌整合子的检测及其耐药机制研究

目的 调查天津地区临床分离的耐亚胺培南铜绿假单胞菌(imipenem-resistant Pseudomonas aeruginosa,IRPA)的整合子流行情况,探讨耐亚胺培南铜绿假单胞菌的耐药机制.方法 收集天津地区60株临床分离的耐亚胺培南铜绿假单胞菌,检测其耐药情况.应用PCR限制片段长度多态性(PCR-RFLP)初筛整合子并分型,用PCR扩增整合子的可变区并测序.结果 60株耐亚胺培南铜绿假单胞菌中有11株检出整合子(18.3%);PCR-RFLP结果显示均为Ⅰ类整合子,未检出Ⅰ类和Ⅱ类整合子.IRPA对多数药物均有较高的耐药率.结论 Ⅰ类整合子为天津地区耐亚胺培南铜绿假单胞菌携带的主要类型,整合子中包括多种耐药基因.     

携带新型耐药基因盒组合形式Ⅰ类整合子的铜绿假单胞菌耐药特性分析

目的分析1株临床分离携有多重耐药基因盒整合子的铜绿假单胞菌的耐药特性。方法应用PCR-限制性片段长度多态性（PCR—RFLP）对整合子进行检测及分型，用长片段PCR（Long—PCR）扩增整合子的可变区并进行DNA测序，分析整合子可变区含有的耐药基因。同时应用PCR扩增金属酶基因和oprD2基因。结果该株铜绿假单胞菌PA27携带Ⅰ类整合子，其可变区大小为3.0kb，含有编码对氨基糖苷类、氯霉素和β内酰胺类抗生素耐药的基因，经与GenBank数据库进行同源性分析（BLAST），确定为一种新型基因盒组合形式：aac（6’）-Ⅱ-cm1A8-OXA-10，GenBank登录号为EU708817。oprD2基因检测阳性，未检出IMP-1、VIM-2和IMP-2型金属酶基因。结论该地区首次报道携带新型基因盒组合形式的Ⅰ类整合子的铜绿假单胞菌，并携有多重耐药基因，应引起临床高度重视。     

广东地区医院分离铜绿假单胞菌整合子及其携带耐药基因的研究

目的研究广东地区医院分离铜绿假单胞菌整合子携带现状及其耐药基因与菌株耐药的关系。方法采用基因扩增法,对广东省5所医院临床分离的铜绿假单胞菌三类整合子及耐药基因进行了检测,并检测阳性菌株整合子可变区。结果在30株铜绿假单胞菌中检出23株携带Ⅰ类整合子,有7株携带Ⅱ类整合子,有1株携带Ⅲ类整合子的基因。随机选取三类整合子携带菌各1株进行测序及序列分析,Ⅰ类整合子得到aac-3+aad2的组合形式;Ⅱ类整合子得到CmlA耐药基因盒;Ⅲ类整合子得到bla-MAP耐药基因盒。结论广东地区医院分离铜绿假单胞菌Ⅰ类整合子的检出率最高,检出1株携带Ⅲ类整合子基因。     

铜绿假单胞菌整合子分布及基因盒携带情况分析

目的 了解烟台地区临床分离铜绿假单胞菌整合子的分布及耐药基因盒携带情况,探讨整合子与菌株耐药的相关性.方法 菌株鉴定及药敏试验采用VITEK 2全自动细菌分析仪.整合子及可变区检测采用PCR法,并采用限制性片段长度多态性分析和测序分析进一步确定可变区耐药基因盒类型.结果 在100株铜绿假单胞菌中38株(38%)检出Ⅰ类整合子,未检出Ⅱ、Ⅲ类整合子.Ⅰ类整合子常见基因盒类型为aac(6′)Ⅱ-aadA13-clmA8-oxA10a和aac(6′)Ⅱ-aadA13-oxA10a,其中aac(6′)Ⅱ-aadA13-oxA10a基因盒为首次出现的新基因盒排列方式,并已登录Genbank:JN118546.结论 烟台地区铜绿假单胞菌整合子类型分布为Ⅰ类整合子,整合子携带菌株与铜绿假单胞菌耐药密切相关.     

1株携带新型耐药基因盒Ⅰ类整合子的铜绿假单胞菌分析

目的对1株临床分离的多重耐药铜绿假单胞菌进行基因盒整合子分析。方法利用PCR-限制性片段长度多态性(PCR-RFLP)对整合子进行检测及分型,用长片段PCR(Long-PCR)扩增整合子的可变区并进行DNA测序,分析整合子可变区含有的耐药基因。结果该株铜绿假单胞菌PA27携带Ⅰ类整合子,其可变区大小为3.0kb,含有编码对氨基糖苷类、氯霉素和β-内酰胺类抗生素耐药的基因,经与gene bank数据库进行同源性分析(BLAST),确定为一种新型基因盒组合形式:aac(6′)-Ⅱ—cmlA8—OXA-10,gene bank登录号为EU708817。结论本菌株携带新型基因盒组合形式的Ⅰ类整合子为天津地区首次报道。     

铜绿假单胞菌金属酶及整合酶的检测

目的：了解哈尔滨医科大学附属第二医院铜绿假单胞菌（Pa）株中金属β-内酰胺酶及整合酶携带情况。方法采用改良 Hodge法、双纸片协同法、组合纸片法进行金属酶表型检测,PCR法检测金属酶基因型以及整合酶Ⅰ、整合酶Ⅱ和整合酶Ⅲ。将 IMP金属酶全基因PCR产物进行纯化,测序再进行Blast比对分析。结果62株 Pa经金属β-内酰胺酶改良 Hodge法检出3株、双纸片协同法检出4株,组合纸片法检出4株,PCR法检测出4株（6.45％,4／62）金属酶阳性菌株,经全基因测序结果为 IMP-1型,且全部为亚胺培南耐药菌株10％（4／40）;未检测出 VIM,SPM和 GIM型金属酶;PCR检测整合酶Ⅰ在亚胺培南耐药菌株中阳性率为40％（16／40）,在亚胺培南敏感菌株中检出率为22.73％（5／22）;所有菌株均未检出整合酶Ⅱ,Ⅲ。结论哈尔滨医科大学附属第二医院存在 IMP-1型金属酶阳性的Pa,这些菌株多为多重耐药细菌,且携带Ⅰ类整合子,该院应做好防范工作,防止金属酶和整合子的传播。     

多重耐药铜绿假单胞菌整合子中发现2种新基因盒组合形式

目的研究多重耐药铜绿假单胞菌携带整合子的类型及耐药基因组合。方法 PCR检测多重耐药铜绿假单胞菌整合酶基因intI 1、intI 2、intI 3,Ⅰ类整合子恒定区基因qacEΔ1-sul1及可变区基因,扩增产物经胶回收、限制性片段长度多态性(RFLP)分析及基因测序分析。结果 30株临床分离铜绿假单胞菌中16株(53.3%)Ⅰ类整合酶基因及恒定区qacEΔ1-sul1基因扩增阳性,未检出Ⅱ、Ⅲ类整合酶基因。Ⅰ类整合子可变区共检出5种不同的耐药基因组合形式,含有对氨基糖苷类、β-内酰胺类和喹诺酮类抗菌药耐药的基因,其中有2种为新型基因盒组合形式,包括aacA4-VIM2和aadA2-OXA10-aacA4-blaIMP-9-aatI1,GenBank登录号分别为GQ890658和GU122165,另外3种与GenBank登录号分别为FJ917747、FJ817423、GU367339的序列基本吻合。结论多重耐药铜绿假单胞菌携带的整合子主要为Ⅰ类整合子,在Ⅰ类整合子上首次发现2种新型基因盒组合形式。     

铜绿假单胞菌整合子基因盒的相关研究

目的对北京大学人民医院不同年度临床分离的铜绿假单胞菌进行整合子基因盒检测,分析其变化趋势及其与细菌耐药性的相关性。方法应用PCR对2006—2008年临床分离的420株铜绿假单胞菌进行整合子检测,对阳性PCR产物采用HinfⅠ内切酶作限制片段多态性(RFLP)分析进行整合子分类,并对整合子阳性株进行耐药基因盒的扩增与测序。结果 420株铜绿假单胞菌中116株(27.6%)检出Ⅰ类整合子,未检出Ⅱ、Ⅲ类整合子。对2006年及2008年的整合子阳性菌株可变区基因盒扩增得到7种不同的基因盒图谱,片段大小在710～2526bp,基因盒为介导氨基糖苷类抗生素耐药的aadB、aadA族和介导甲氧苄啶耐药的dfrA1和dhfrXVB。结论该院铜绿假单胞菌中整合子检出率随年度呈上升趋势,携带的基因盒与其耐药表型有相关性。     

鲍曼不动杆菌的耐药性与Ⅰ类整盒子的相关研究

目的了解该院鲍曼不动杆菌的流行趋势以及鲍曼不动杆菌与Ⅰ类整合子的耐药关系。方法用该院临床常用22种抗菌药物来检测临床分离的鲍曼不动杆菌的敏感性。用PCR检测鲍曼不动杆菌Ⅰ类整合子酶基因,再扩增部分Ⅰ类整合子酶基因的可变区,对整合子可变区进行基因测序分析。结果鲍曼不动杆菌的耐药现象十分严重,呈多重耐药性。鲍曼不动杆菌对CPZ/SB耐药率为1.2%,对替加环素、左旋氧氟沙星、亚胺培南、比阿培南、阿米卡星等几种抗菌药物的耐药率为15.4%~69.5%,对其他抗菌药物均在71%以上。102株中有72株菌株含Ⅰ类整合子(阳性率为70.2%),Ⅰ类整合子阳性株的耐药性均高于阴性株,对Ⅰ类整合子可变区采用双酶切分析产生类似的酶切条带,说明该院鲍曼不动杆菌具有同源性。Ⅰ类整合子基因盒序列分析表明该院鲍曼不动杆菌Ⅰ类整合子携带aacA4、catB8和aadA1 3种耐药基因。结论该院2010~2013年,鲍曼不动杆菌对头孢菌素类、广谱青霉素、氨基糖苷类和氟喹诺酮类呈高度耐药及严重的多重耐药现状,说明治疗鲍曼不动杆菌所致感染的抗菌药物选择已十分有限。Ⅰ类整合子与鲍曼不动杆菌多重耐药性密切相关。     

20株亚胺培南耐药肺炎克雷伯菌耐药机制及分子流行病学研究

目的对20株亚胺培南耐药肺炎克雷伯菌耐药机制和分子流行病学进行研究。方法改良Hodge试验检测碳青霉烯酶表型;PCR法检测碳青霉烯酶、Amp C酶和超广谱β-内酰胺酶(ESBLs)耐药基因及整合子,并进行测序及BLAST比对确定基因型;脉冲场凝胶电泳(PFGE)和多位点序列分型(MLST)分析菌株同源性和遗传相关性;并进行药敏试验结果分析。结果20株菌均携带KPC-2、TEM-1、SHV和CTX-M型基因,未检测到IMP、VIM、OXA和NDM碳青霉烯酶基因和amp C酶基因;20株菌均有I类整合子,其中18株的整合子整合有耐药基因盒,主要整合基因是aad A2。20株菌中19株被PFGE分型为13个型别,其中P1型和P7型各有3株,P2和P 10型各有2株;20株菌中17株为ST11型,其余3株分别为ST290、ST147和ST967型;20株菌呈多重耐药或泛耐药。结论携带KPC-2是20株肺炎克雷伯菌耐亚胺培南的主要原因,多重耐药或泛耐药与其他β-内酰胺酶和整合子有关;院内存在克隆株流行;检出ST290和ST967型别产KPC肺炎克雷伯菌。     

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.     

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.     

Molecular characterization of virulence and antimicrobial resistance profile of Shigella species isolated from children with moderate to severe diarrhea in northeastern Brazil

Molecular characterization of virulence and antimicrobial resistance profiles were determined for Shigella species isolated from children with diarrhea in Fortaleza, Brazil. Fecal specimens were collected along with socioeconomic and clinical data from children with moderate to severe diarrhea requiring emergency care. Shigella spp. were isolated by standard microbiological techniques, and we developed 4 multiplex polymerase chain reaction assays to detect 16 virulence-related genes (VRGs). Antimicrobial susceptibility tests were performed using disk diffusion assays. S. flexneri and S. sonnei were the predominant serogroups. S. flexneri was associated with low monthly incomes; more severe disease; higher number of VRGs; and presence of pic, set, and sepA genes. The SepA gene was associated with more intense abdominal pain. S. flexneri was correlated with resistance to ampicillin and chloramphenicol, whereas S. sonnei was associated with resistance to azithromycin. Strains harboring higher numbers of VRGs were associated with resistance to more antimicrobials. We highlight the correlation between presence of S. flexneri and sepA, and increased virulence and suggest a link to socioeconomic change in northeastern Brazil. Additionally, antimicrobial resistance was associated with serogroup specificity in Shigella spp. and increased bacterial VRGs.     

护理干预对面部中重度寻常型痤疮的临床疗效影响分析

目的研究护理干预对面部中重度寻常型痤疮的临床疗效影响。方法选取本院在2014年4月~2016年7月诊治的136例面部中重度寻常型痤疮患者,随机分为研究组与对照组,每组68例;所有患者均依据其情况给予对应的治疗,其中对照组在治疗期间给予常规护理,研究组在对照组的基础上再给予综合性护理干预,比较两组的治疗效果及护理满意度情况等。结果患者在接受治疗和护理后,研究组中度与重度患者的治疗效果较对照组均明显提高(P0.05),研究组护理满意度较对照组明显增高(P0.05)。结论对面部中重度寻常型痤疮患者在其治疗期间给予综合性护理干预,具有良好的效果。