重症监护病房非发酵菌的分布与耐药性分析

目的　了解重症监护病房（ ICU）患者非发酵菌的分布和耐药情况,给临床使用抗菌药物提供参考。方法　对浙江省温州医学院附属第二医院2007 年7 月至2008年9月ICU 感染患者细菌培养和药敏试验的结果进行回顾性分析和统计。结果　在4109 例标本中, 共分离出非发酵菌952 株，居前4位的非发酵菌分别是:洋葱伯克霍尔德菌243株（占25.5%），铜绿假单胞菌200株（占21.0%），鲍曼不动杆菌163株（占17.1%），嗜麦芽窄食单胞菌148株（占15.6%）。药敏结果显示:洋葱伯克霍尔德菌对派拉西林/他唑巴坦和复方新诺明的耐药率最低，分别为2.5%和9.5%；铜绿假单胞菌对各种抗菌药物的耐药率均大于20.0%，以对阿米卡星的耐药率（22.0%）为最低，对其他各种抗菌药物的耐药率在32.0%～95.0%之间；鲍曼不动杆菌对各种抗菌药物的耐药率均大于50%,许多菌株呈多重耐药；嗜麦芽窄食单胞菌对复方新诺明的耐药率最低,为4.1%，对除头孢他啶外的三、四代头孢菌素、氨基糖苷类、氨苄西林/舒巴坦和氨曲南的耐药率在79.7%～95.9 %之间,对亚胺培南天然耐药。结论　洋葱伯克霍尔德菌、铜绿假单胞菌、鲍曼不动杆菌、嗜麦芽窄食单胞菌是引起医院ICU感染的主要非发酵菌,对多种抗菌药物存在高耐药率,临床应引起高度重视并加强耐药性监测,根据药敏试验结果合理选用抗菌药物，以减少耐药菌株的产生。     

4850例痰标本洋葱伯克霍尔德菌分布与耐药分析

目的 了解该院洋葱伯克霍尔德菌感染的临床分布特征及耐药性,指导临床合理使用抗菌药物.方法 对该院2009年1月至2011年12月送检的4 850例痰标本中分离出的120株洋葱伯克霍尔德菌进行回顾性分析,并比较检出洋葱伯克霍尔德菌科室的分布及药敏结果.结果 4 850例痰标本共检出洋葱伯克霍尔德菌120株,检出率逐年增加,分别为2.0%、2.5%、2.8%;且多分布于ICU病房,占86.6%.洋葱伯克霍尔德菌对16种常用抗菌药物中的14种耐药,平均耐药率高达80.9%,仅对磺胺甲噁唑/甲氧苄啶和米诺环素敏感,敏感率分别为76.5%、93.9%.结论 洋葱伯克霍尔德菌耐药谱广,临床抗感染治疗应根据药敏选用抗菌药物.     

156株洋葱伯克霍尔德菌的临床分布及耐药性分析

目的了解2003--2006年我院临床分离的洋葱伯克霍尔德菌的标本来源、临床分布和耐药性。方法用MicroScanWalkAway-4-0全自动微生物鉴定和药敏系统对我院临床分离的洋葱伯克霍尔德菌进行鉴定和药敏试验，并分析结果。结果20032006年共分离出156株洋葱伯克霍尔德菌，痰标本中分离菌株数占84．0％（131／156），血液中占5．1％（8/156）。药敏试验结果显示，多数测试的抗菌药物耐药率均大于50％；耐药率小于50％有哌拉西林他唑巴坦（4．8％～21．4％）、复方磺胺甲嗯唑（5．6％～23．8％）和头孢他啶（17．2％～40．0％）。结论洋葱伯克霍尔德菌对多数抗菌药物具有较高的耐药性，临床抗感染治疗应以分离菌株的体外抗菌药物敏感性为依据。     

重症监护病房洋葱伯克霍尔德菌爆发感染的分子流行病学分析

目的 分析重症监护病房（ICU）分离的洋葱伯克霍尔德菌耐药性和分子流行病学特点。方法 对2012年12月至2013年2月金华市中心医院ICU患者分离出的13株洋葱伯克霍尔德菌进行耐药性分析,同时应用聚合酶链反应法进行recA基因检测,扩增产物进行测序并通过基于局部比对算法的搜索工具（BLAST）进行同源性比对。结果 ICU分离的13株洋葱伯克霍尔德菌耐药模式完全一致,除头孢他啶、头孢吡肟、哌拉西林,他唑巴坦、复方新诺明外,洋葱伯克霍尔德菌对氨苄西林、氨曲南、头孢唑林、头孢曲松、头孢替坦、亚胺培南、氨苄西林／舒巴坦、阿米卡星、庆大霉素、妥布霉素、环丙沙星、左氧氟沙星、呋喃妥因等13种常用抗菌药物均表现为耐药。测序结果显示：ICU来源的13株菌株均为同一基因型（Ⅲ 型基因）,同源性100％;BLAST比对显示,13株菌株recA基因序列与GenBank中洋葱伯克霍尔德菌recA基因序列片段的同源性为99％。结论本院ICU洋葱伯克霍尔德菌爆发感染为同一基因型克隆株所致,该克隆菌株对常用抗菌药物的耐药性强,应用分子流行病学技术追溯其来源对感染的控制和治疗具有重要意义。     

重症监护病房感染洋葱伯克霍尔德菌62例耐药分析

为了解我院ICU中洋葱伯克霍尔德菌医院感染的分布特征及耐药情况,指导临床医师合理使用抗生素,笔者对本院2008—12—2009—12引起ICU医院感染的62株洋葱伯克霍尔德菌进行分析,现报告如下。     

洋葱伯克霍尔德菌86株的分布与耐药性

目的：调查洋葱伯克霍尔德菌分布及其对22种常用抗菌药物耐药性，旨在指导临床合理选用抗菌药物。方法：采用ATB全自动鉴定及药敏测试仪检测86株洋葱伯克霍尔德菌，并进行抗菌活性测定。结果：药敏试验结果表明细菌对下列药物的敏感性为：复方磺胺甲口恶唑96.5％、哌拉西林-三唑巴坦93.0％、哌拉西林75.6％、头孢他啶73.3％。对阿莫西林、阿莫西林-克拉维酸、替卡西林、头孢噻吩、妥布霉素、庆大霉素、头孢磺啶、磷霉素、多粘菌素E安全耐药。结论：洋葱伯克霍尔德菌耐药现象严重，治疗可选择复方磺胺甲口恶唑、哌拉西林-三唑巴坦、哌拉西林和头孢他啶等抗菌耐药物。     

洋葱伯克霍尔德菌感染的临床分布和耐药性分析

目的 分析医院洋葱伯克霍尔德菌感染的临床分布及耐药情况,指导临床合理使用抗菌药物.方法 回顾性分析2012年1月至2014年12月405株洋葱伯克霍尔德菌的标本来源、科室分布及药敏结果 .结果 该菌株主要来源于呼吸道标本(占92.35%),科室分布为ICU及神经外科,分别为77.04%、11.85%;该菌对米诺环素、甲氧苄啶-磺胺甲口恶唑、美罗培南、头孢他啶、哌拉西林/他唑巴坦耐药率低,分别为2.48%、7.43%、9.90%、11.98%.结论 洋葱伯克霍尔德菌抗菌活性三年基本保持稳定,治疗应根据药敏结果 合理选用抗菌药物,同时应加强重点科室的预防和控制.     

重症监护病房的病原菌分布及药物敏感性分析

目的了解本院重症监护病房（ICU）感染病原菌的分布及对抗菌药物的敏感性。方法对本院ICU住院患者因感染而分离出的403株细菌用Phoenix-100全自动微生物鉴定和药敏系统进行菌种鉴定、药敏分析和耐药机制检测。采用WHONET软件进行统计分析。结果从ICU620例住院患者的标本中共分离出403株细菌。分离率排在前6位的细菌分别是鲍曼不动杆菌占19．4％,铜绿假单胞菌占18．1％,肺炎克雷伯菌占17．9％,金黄色葡萄球菌占15．4％,大肠埃希菌占7．7％,嗜麦芽寡养单胞菌占5．5％。药物敏感试验提示所分离到的病原菌绝大多数呈现多重耐药。特别是对临床上最常使用的头孢三代和氟喹诺酮类抗茵药物有较高的耐药率。结论从本院ICU病房分离到的病原菌来看,其耐药问题相当严重,应加强细菌耐药性监测,指导临床合理使用抗菌药物,有效的预防和控制感染。     

重症监护病房患者感染的非发酵革兰阴性杆菌耐药趋势分析

目的：了解重症监护病房（ICU）分离的非发酵革兰阴性杆菌的分布和耐药谱的变化趋势,为临床合理使用抗菌药物提供依据。方法从该院ICU住院患者的可能感染部位收集标本进行细菌分离培养,培养出的非发酵革兰阴性杆菌采用纸片扩散法进行药敏试验,参照临床实验室标准化委员会（CLSI）制定的标准进行结果判读,用 WHONET5．6软件进行统计分析。结果5年共分离出非发酵革兰阴性杆菌624株,占革兰阴性杆菌的72．8％（624/857）;非发酵革兰阴性杆菌中铜绿假单胞菌占43．4％（271/624）,鲍曼不动杆菌占42．6％（266/624）,嗜麦芽窄食单胞菌占6．4％（40/624）,洋葱伯克霍尔德菌占3．3％（21/624）;鲍曼不动杆菌对其耐药率较低的抗菌药物包括米诺环素（31．2％）、头孢哌酮/舒巴坦（48．1％）、阿米卡星（64．8％）;铜绿假单胞菌对其耐药率较低的抗菌药物包括头孢哌酮/舒巴坦（23．5％）、阿米卡星（26．6％）、哌拉西林/他唑巴坦（31．8％）、嗜麦芽窄食单胞菌;洋葱伯克霍尔德菌对临床实验室标准化协会（CLSI）推荐的抗菌药物敏感率在80％以上。鲍曼不动杆菌耐药率逐年上升,其对碳青霉烯类抗菌药物的耐药率在2009年前低于11％,2010年以后达到80％以上;铜绿假单胞菌的耐药率有逐年下降的趋势,其对碳青霉烯类抗菌药物的耐药率在2008年高于80％,在2012年低于34％。结论非发酵革兰阴性杆菌发生多重耐药的情况严重,医院应重视耐药监测以及抗菌药物的合理应用。     

临床分离142株洋葱伯克霍尔德菌分布特征及耐药性分析

目的了解南海区第三人民医院和佛山市第一人民医院洋葱伯克霍尔德菌医院感染的分布及耐药谱,为临床治疗及医院感染的控制提供依据。方法 2010年1月至2012年6月临床分离142株菌株,细菌鉴定和大多数药敏试验利用Vitek-compact全自动微生物分析仪,少数利用ATB Expression半自动微生物分析仪,个别药敏试验采用K-B法。药敏数据分析用WHONET5.4软件。结果痰液标本分离洋葱伯克霍尔德菌的阳性率最高,达到78.2%。洋葱伯克霍尔德菌对多种抗菌药物耐药,但对头孢吡肟、哌拉西林/他唑巴坦、左氧氟沙星、头孢他啶、复方磺胺甲噁唑敏感率较高,敏感率分别为83.1%、87.2%、87.3%、90.3%、90.9%。结论洋葱伯克霍尔德菌已成为医院分离的常见病原菌之一,医院应重视其耐药性监测,指导临床合理使用抗菌药物。     

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.