青海省人民医院2010年—2012年常见病原菌耐药性变迁分析

目的：分析我院2010年—2012年前十位病原微生物的变迁及耐药趋势,为临床医生提供治疗依据。方法：用自动细菌生化分析仪（VITEK）进行菌种鉴定,用纸片扩散法作抗生素耐药试验。结果：标本分离细菌中主要以革兰阴性杆菌为主,占63%-87%,常见的革兰阴性杆菌是大肠埃希菌、不动杆菌属、克雷伯菌属、铜绿假单胞菌。大肠埃希菌对头孢他啶、头孢吡肟的耐药率都在30%左右,临床分离株对亚胺培南耐药率低于5%,对氨苄西林耐药率下降至65%,对哌拉西林耐药率高于85%;肺炎克雷伯氏菌临床分离株对阿米卡星的耐药率增加到5%。氨曲南耐药率增加到16%,对环丙沙星的耐药率稳定不变,对头孢类耐药率稳定在10%以下,对于亚胺培南耐药率低于1%;铜绿假单胞菌、不动杆菌耐药率较高,对哌拉西林、头孢他啶、头孢吡肟耐药率持续在30%以上,对于阿米卡星耐药率下降至2%,对亚胺培南耐药率高,超过30%;阴沟肠杆菌属对头孢他啶的耐药率由50.8%增至67.0%,增长较快。对氨苄西林的耐药率由82.3%降至0,对亚胺培南、氨曲南也很敏感,耐药率为0。结论：临床合理用药任重道远,耐药菌逐年有增多趋势,进一步提醒临床要合理用药,避免高档抗生素长期使用,才能真正做到抗菌药物分级使用。     

2007年我院病原菌的检测情况及耐药性分析

目的：分析临床分离的病原菌的菌种结构及其常用抗生素的耐药情况;为临床合理使用抗生素提供依据。方法：采用K—B法检测抗菌药物对常见致病菌的耐药性。结果：从住院患者中（1387人）分离出病原菌475株。位居前6位的分别是大肠埃希菌（19．8％）、凝固酶阴性葡萄球菌（16．2％）、白色念珠菌（6．5％）、金黄色葡萄球菌（6．1％）、克雷伯杆菌（5．7％）、铜绿假单胞菌（5．7％）。超广谱β-内酰胺酶（ESBLS）克雷伯菌及大肠埃希菌的检出率分别为29．6％和12．8％,耐甲氧西林凝固酶阴性葡萄球菌（MRCNS）和耐甲氧西林金葡菌（MRSA）的检出率分别为62．3％和44．8％。耐药性检测结果显示：凝固酶阴性葡萄球菌耐药率较低的药物有万古霉素、丁胺卡那霉素、硫酸庆大霉素、头孢西丁等。对金葡菌耐药性较低的药物有万古霉素、丁胺卡那霉素、头孢西丁、头孢唑啉等。大肠埃希菌的耐药率较低的药物有亚胺培南-西司他汀、头孢他定、阿米卡星。克雷伯菌耐药率较低的药物有亚胺培南-西司他汀、阿米卡星。铜绿假单胞菌耐药率较低的药物有亚胺培南-西司他汀、阿米卡星、哌拉西林、氧氟沙星、头孢他定等。到目前为止,没有发现对万古霉素、亚胺培南-西司他汀耐药菌株。结论：开展细菌药敏试验的检测,根据药敏试验结果合理选用抗生素,对于提高疗效、减少耐药菌株的发生具有重要意义。     

呼吸机相关肺炎的痰菌分布及耐药性分析

目的：了解呼吸机相关肺炎的痰菌分布及耐药性特征，方法：收集呼吸机相关肺炎的深部脓痰进行痰菌分离培养，并对其药敏试验情况进行分析。结果：主要是革兰氏阴性杆菌97．5％，前几位的革兰氏阴性杆菌分别为铜绿假单胞菌42．5％、肺炎克雷伯菌14．2％，不动杆菌12．5％，大肠埃希菌9．2％，阴沟杆菌5．8％等，青霉素、红霉素、头胞唑林对铜绿假单胞菌的耐药率为100％，亚胺培南，头孢他啶对铜绿假单胞菌的耐药率亦分别达19．6％和27．5％，肺炎克雷伯菌及大肠埃希菌对头胞三嗪、头孢哌酮亦有较高的耐药性。不动杆菌对所监测的抗生素广谱耐药，亚胺培南对不动杆菌的耐药率为7．1％，阴沟杆菌对亚胺培南，头孢他啶未发现耐药株，而对其他抗生素耐药性较高，结论：呼吸机相关肺炎的病理菌主要是革兰氏阴性杆菌，其均有严重的耐药性，加强耐药性监测，合理使用抗生素十分重要。     

慢性阻塞性肺疾病院内感染的病原菌分布及耐药性分析

目的了解慢性阻塞性肺疾病 (COPD)院内感染病原菌分布及耐药情况 ,为临床治疗COPD院内感染合理选用抗生素提供依据。方法对 4 3例COPD院内感染患者的痰培养及药敏结果进行分析。结果 4 3株细菌中革兰阴性杆菌感染占 81 4 % ,其中铜绿假单孢菌占 2 3 3% ,克雷伯杆菌占 18 4 % ,不动杆菌占 14 0 % ;药敏结果发现 :革兰阴性杆菌的耐药率分别为氨苄西林90 6 %、头孢唑啉 90 6 %、头孢他啶 15 6 %、头孢哌酮 2 1 9%、哌拉西林 9 4 %、阿米卡星 15 6 %、左氧氟沙星 18%、亚胺培南9 4 % ,铜绿假单孢菌对亚胺培南、哌拉西林敏感。结论COPD院内感染以革兰阴性杆菌为主 ,亚胺培南、哌拉西林、头孢他啶 ,阿米卡星、左氧氟沙星的抗菌活性最强 ,可作为COPD院内感染病人的经验性用药。临床应尽量开展药敏试验 ,根据当地耐药情况 ,合理选用或交替使用抗生素 ,尽量减少耐药菌的产生。     

2012年某医院革兰阴性杆菌耐药性分析

目的了解海洋石油总医院2012年临床分离的724株常见革兰阴性杆菌对各类抗菌药物的耐药状况,为临床合理使用抗菌药物提供依据。方法收集2012年该院临床标本中分离的革兰阴性杆菌,采用VITEK 2 compact进行鉴定和药敏试验。结果大肠埃希菌产ESBLs菌株占55.0%,头孢菌素和氟喹诺酮类药物耐药率高,碳青霉烯类是治疗首选;肺炎克雷伯杆菌产ESBLs占35.6%,哌拉西林/他唑巴坦、头孢替坦、亚胺培南敏感性较高;铜绿假单胞菌对头孢他啶、哌拉西林、哌拉西林/他唑巴坦具有良好的抗菌活性,哌拉西林/他唑巴坦耐药性低于碳青霉烯类;鲍曼不动杆菌对阿米卡星、左旋氧氟沙星、哌拉西林/他唑巴坦、亚胺培南、美洛培南的耐药率低于30%;嗜麦芽寡养单胞菌对复方新诺明、美洛培南、哌拉西林/他唑巴坦敏感性高。结论该院革兰阴性杆菌对常用抗菌药物耐药现象严重,必须加强病原菌耐药情况的监测,合理使用抗菌药物。     

鲍曼不动杆菌的临床分布与耐药性分析

目的了解鲍曼不动杆菌的临床分布及其耐药性。方法采用ATB Expression半自动微生物鉴定系统对51株鲍曼不动杆菌进行分离鉴定，K—B法进行药敏试验。结果51株鲍曼不动杆菌的标本分布以呼吸道分泌物为主，占82．35％；科室分布以神经外科（28株）、神经内科（10株）和肿瘤科（7株）为主；对阿米卡星、哌拉西林、头孢他啶、环丙沙星、头孢噻肟、头孢吡肟、复方新诺明、哌拉西林／他唑巴坦的耐药率均〉50．0％，亚胺培南、美罗培南的抗菌活性好，耐药率仅分别为3．92％、5．89％。结论鲍曼不动杆菌主要分布在神经外科、神经内科和肿瘤科等科室，耐药率高且具多重耐药性，临床应加强监测并根据药敏结果合理选用抗菌药物进行治疗。     

1999～2003年鲍曼不动杆菌耐药性的变迁分析

目的 了解5a来鲍曼不动杆菌的耐药性变迁。方法 采用微量稀释法，测定549株鲍曼不动杆菌对亚胺培南等22种抗生素的敏感性。结果 5a中总敏感率居前4位的依次是亚胺培南(96.4％)、美罗培南(92．9％)、多粘菌素(93．0％)和哌拉西林／他唑巴坦(30．1％)，其余在0．0％～20．9％之间。5a间亚胺培南的抗菌活性最高，且数年不减，敏感率在95．0％以上；其次是多粘菌素E和美罗培南，敏感率分别大于88．0％和84．0％。到2002／2003年度对阿莫西林、阿莫西林，克拉维酸、哌拉西林、哌拉西林／他唑巴坦、替卡西林、替卡西林，克拉维酸、氨苄西林，舒巴坦、头孢噻吩、头孢噻肟、头孢曲松、头孢他啶、头孢吡肟、氨曲南、复方新诺明、氨基糖苷类、环丙沙星和磷霉素的耐药率在56．7％～100．0％之间。5a间耐药率上升最快的是阿莫西林，克拉维酸、头孢曲松、头孢噻肟、哌拉西林和哌拉西林，他唑巴坦。结论 5a间鲍曼不动杆菌对大多数常用广谱抗生素的耐药性在逐年增强，并且多重耐药状况相当严重。亚胺培南仍是抗多重耐药鲍曼不动杆菌感染最有效的抗生素。     

革兰阴性杆菌产AmpC酶和超广谱β-内酰胺酶的检测及耐药相关性

目的了解革兰阴性杆菌产AmpC酶和超广谱β-内酰胺酶（ESBLs）的情况及其耐药性，指导临床合理用药。方法K—B法检测184株革兰阴性杆菌对11种抗生素的耐药性；采用头孢西丁（FOX）药敏纸片进行AmpC酶的初筛，通过酶提取物三维试验方法确证产AmpC酶细菌；采用NCCLS推荐的纸片扩散确证试验检测184株革兰阴性杆菌中大肠埃希菌和肺炎克雷伯菌产ESBLs的情况。结果184株革兰阴性杆菌中，AmpC酶阳性率为23．3％主要产生菌为鲍曼不动杆菌57．7％，铜绿假单胞菌37．5％，AmpC酶阳性菌对头孢噻肟（CTX）、头孢曲松（CRO）、复方新诺明（SXT）、左旋氧氟沙星（LEV）、哌拉西林（PRL）、氨曲南（ATM）、头孢他啶（CAZ）、阿米卡星（AK）、头孢吡肟（FEP）、美洛培南（MEM）的耐药率分男11为94．7％、86．8％、84．2％、81．6％、71．0％、68．4％、68．4％、55．3％、50．O％、5．3％；38株大肠埃希菌和26株肺炎克雷伯菌中ESBLs阳性率分别为42．1％、23．1％，ESBLs阳性菌对头孢噻肟（CTX）、头孢曲松（CRO）、哌拉西林（PRL）、氨曲南（ATM）、复方新诺明（SXT）、头孢他啶（CAZ）的耐药率较高。对头孢吡肟（FEP）、阿米卡星（AK）、头孢西丁（FOX）、美洛培南（MEM）的耐药率较低，对左旋氧氟沙星（LEV）的耐药率大肠埃希菌则远高于肺炎克雷伯菌。结论在革兰阴性杆菌中，AmpC酶和ESBLs产生情况已相当严重，应重视对其的检测；产酶菌与非产酶菌对抗生素的耐药性有明显区别；临床用药以碳青霉烯类如美洛培南（MEM）为首选。     

养老院内获得性下呼吸道感染病原菌分布和耐药性分析

目的分析养老院内获得性下呼吸道感染的致病菌种类及药敏试验结果，指导临床用药。方法对28例在敬养老院内获得的下呼吸道感染者患者的48株致病菌资料进行回顾性分析。结果28例在养老院内获得的下呼吸道感染分离出48株致病菌，革兰阴性杆菌占70、8％，革兰阳性菌占16．7％，真菌占12．5％。革兰阴性杆菌中以铜绿假单胞菌（38．2％），大肠埃希菌（23.5％）、肺炎克雷伯菌（20．6％）和不动杆菌（11.8％）最为常见。亚胺培南总的药物敏感性最高，哌拉西林／他唑巴坦、阿米卡星次之。结论治疗养老院内获得性下呼吸道感染应首选亚胺培南；其次是哌拉西林／他唑巴坦＋阿米卡星：或头孢吡肟、头孢他啶。     

对临床分离革兰阴性菌连续4年耐药性监测

目的 对深圳市人民医院临床分离常见革兰阴性菌进行耐药变迁监测，以指导临床合理使用抗菌药。方法 采用Kirby—Bauer纸片琼脂扩散法检测2002—2005年深圳市人民医院分离的2060株革兰阴性菌对各种抗菌药的敏感性，作统计分析。结果连续4年对肠杆菌科细菌体外抗菌活性最强的是亚胺培南和曼罗培南（敏感率94．1％．100％），最差的是哌拉西林（敏感率19．0％．43．5％），产ESBL大肠埃希菌和肺炎克雷伯检出率分别为42．9％-54．9％和37．7％-49．2％。肠杆菌属细菌对头孢曲松、头孢他啶、氨曲南的耐药率高达37.0％，60％。2005年监测对铜绿假单胞菌抗菌活性最强的是阿米卡星（敏感率78．0％），其次为哌拉西林／他唑巴坦、亚胺培南、荚罗培南、哌拉西林（敏感率72．0％-77．0％），4年中对鲍曼不动杆抗菌活性最高的是亚胺培南和蔓罗培南（71．0％-91．0％）。氨苄西林／舒巴坦对鲍曼不动杆菌的抗菌活性明显下降，对嗜麦芽窄食单胞菌和洋葱伯克霍尔德抗菌活性最高的是复方新诺明，敏感率分别为76．0％-92．0％和95．0％-100％％。结论 细菌对药仍是临床面临的严重问题，应继续加强对细菌耐药的监测q     

Value of D-Dimers in patients with acute aortic dissection

Objective: To evaluatel the value of D-dimers in patients with acute aortic dissection (AAD). Methods: This study consisted of 16 patients with AAD and 27 non-AAD patients. Serum D-dimets were measured by Sta-Liatest D-DI immunoturbidimetric assay. Results: D-dimer level was higher (P ＜ 0.001) in patients with AAD(7.91 ± 5.52 μg/ml) than that in non- AAD group(1.57±1.24 μg/ml). D-dimer was positive (＞0.4 μg/ml) in all patients with AAD and in 10 control group patients (37%). Among patients with acute AAD, D-dimers tended to be higher in Stanford A than in Stanford B (8.67 ± 4.31 μg/ml vs. 3.24±1.27 μg/ml, P ＜0.01). D-dimer values tended to be higher in more extended disease(3.84 ± 1.65 μg/ml, 8.57 ± 3.58 μg/ml and 11.87 ± 5.69 μg/ml in thoracic aorta, thoracic and abdominal aorta, thoracic and abdominal aorta and iliacal arteries, respectively, P ＜ 0.05 for both 8.57 ± 3.58 and 11.87 ± 5.69 vs. 3.84 ± 1.65 ). Including the control group into the analysis, we found a sensitivity of 100%, a negative predictive value of 100%, and a specificity of 66% and a positive predictive value of 64% for D-dimer in diagnosis of AAD in our patients with suspected AAD. Conclusion: D-dimer was elevated in patients with AAD. A negative D-dimer test result could be useful in excluding AAD.     

Research of combined liver-kidney transplantation model in rats

Objective： To set up a simple and reliable rat model of combined liver-kidney transplantation. Methods： SD rats served as both donors and recipients. 4℃ sodium lactate Ringer＇s was infused from portal veins to donated livers,and from abdominal aorta to donated kidneys, respectively. Anastomosis of the portal vein and the inferior vena cava （IVC） inferior to the right kidney between the graft and the recipient was performed by a double cuff method, then the superior hepatic vena cava with suture. A patch of donated renal artery was anastomosed to the recipient abdominal aorta. The urethra and bile duct were reconstructed with a simple inside bracket. Results： Among 65 cases of combined liver-kidney transplantation, the success rate in the late 40 cases was 77.5%. The function of the grafted liver and kidney remained normal. Conclusion： This rat model of combined liver-kidney transplantation can be established in common laboratory conditions with high success rate and meet the needs of renal transplantation experiment.     

BLOOD PRESSURE CHANGE WITH AGE IN SALT-SENSITIVE TEENAGERS

Objective To observe blood pressure change with age in salt-sensitive teenagers whose salt sensitivity were determined by repeated testing.Methods Salt sensitivity was determined through intravenous infusion of normal saline combined with volume-depletion by oral diuretic furosemide in 55 teenagers. After five years, salt sensitivity was re-examined and subject blood pressure was followed up. Blood pressure changes in salt-sensitive teenagers were compared to that of non-salt sensitive teenagers over five years.Results After 5 years, the repetition rate of salt sensitivity determined by intravenous saline loading is 92.7%. In teenagers with salt sensitivity on the baseline, both the systolic blood pressure increments and increment rates were much higher than non-salt sensitive teenagers (12.7±12.1 mmHg vs. 2.8±5.2 mmHg, P＜ 0.01; 12.2%± 12.0% vs. 2.5% ±4.4%, P＜ 0.001,respectively). There was a similar trend for diastolic blood pressure (8.4 ± 6.4 mmHg vs. 3.7 ± 6.4 mmHg, P = 0.052; 13.2% ±10.6 % vs. 6.8%± 10.1%, P = 0.053, respectively).Conclusions Salt sensitivity determined by intravenous saline loading showed good reproducibility. Blood pressure increments with age were much higher in salt-sensitive teenagers than non-salt sensitive teenagers, especially in terms of systolic blood pressure.     

安心颗粒对急诊经皮冠状动脉介入术后生活质量影响的研究

目的：评价使用安心颗粒对急诊经皮冠状动脉介入术（PPCI）术后生活质量的影响.方法：将160例接受PPCI的急性ST段抬高型心肌梗死患者随机分为安心颗粒组（术前顿服安心颗粒8.8g,术后安心颗粒4.4 g/次,每日2次）和对照组（仅接受基础药物治疗）.所有患者均服用阿司匹林、氯吡格雷和阿托伐他汀.分别在入院时、出院前1d、出院后180 d时,应用心肌梗死多维度量表（MIDAS）、中文版SF-36评价量表对患者生活质量评分.并观察术后30 d以内的出血并发症、血小板减少症发生情况.结果：入院时和出院前1d,两组患者的心肌梗死MIDAS、SF-36量表评分比较无差异（P＞0.05）;出院后180 d时,与对照组比较,安心颗粒组MIDAS、SF-36评分明显减低（P＜0.05）;组内与入院时比较,两组出院前1d、出院后180 d时,MIDAS、SF-36评分均降低（P＜0.05）.两组患者在随访期间均无大量出血、少量出血、重度和极重度血小板减少症发生,安心颗粒组有4例、对照组有7例发生不明显出血（P＞0.05）.两组发生轻度血小板减少症的患者数比较无差异（P＞0.05）.结论：PPCI使用安心颗粒,能改善急性ST段抬高型心肌梗死患者的生活质量,且不增加出血风险.     

The comparative studies of the influences of Urapidil and Nicardipine on sino-atrial node function, atrio-ventricular node function and hemodynamics

Objective:To investigate the influences of urapidil and nicardipine on rabbit sinus function,atrio-ventricular node function and hemodynamics.Methods:Thirty-two Angora's rabbits were selected and randomly divided into four groups.U1 group:urapidil 0.25 mg/kg;U2 group:urapidil 0.5 mg/kg;N1 group:nicardipine 10 μg/kg;N2 group:nicardipine 20 μg/kg.All these medicine were administrated within 30 seconds.Measurements were taken before and after the administration of urapidil or nicardipine for the following data:mean blood pressure(MAP),heart rate(HR),sino-atrial conduction time(SACT),maximal sinoatrial recovery time(SNRTmax)corrected sinus node recovery time(CSNRT),index of sinus node recovery time(SNRTI),Wenckebach A-V conduction frequency (WB),and P-R interval.Results:Significant MAP and HR changes were identified in all of the four groups before and after administration of both urapidil and nicardipine.No significant changes could be found in the rest of the parameters.Intergroup analysis showed that SACT and CSNRT of N1 and N2 groups were shorter than those of the U2 group(P＜0.01);the MAP decreased(P＜0.01)and the HR increased drastically(P＜0.01).Conclusions:Neither urapidil(0.25 mg/kg,0.5 mg/kg)nor nicardipine(10μg/kg,20μg/kg)has any significant influence on rabbit sinus function or rabbit atrio-ventricular node function.Nicardipine could be a better choice than urapidil for parafunctional sinus node patients.     

Expression of OPGmRNA and ODFmRNA in the patients of hip fracture due to osteoporosis

Objective：To investigate the gene expression of osteoprotegerin（OPG） and osteoclast differentiation factor（ODF） in the bone tissue of patients with hip fracture due to osteoporosis. Methods：OPGmRNA and ODFmRNA in the bone tissue in 50 cases of osteoporosis sufferers（over 50 years old） with hip fracture（Observer Group） and 30 cases of hip facture sufferers with no osteoporosis（Control group） were analyzed with the Semi-Quantitative RT-PCR method. Results：The mRNA expressed of ODF, OPG were both high in the patients with hip fracture. In the control group, the expression of OPG mRNA was observed, while the expression of ODF mRNA was very slight. Conclusion：Aged patients contained all signals including OPG, ODF that are essential for inducing osteoclastogenesis and promoting bone resorption.     

Dynamic Changes in Serum Estradiol and Progesterone levels in Patients of Premenstrual Syndrome with Adverse Flow of Liver-qi

Objective:To probe into the influence of changes of ovarian hormones on the pathogenesis of the specific sub-type premenstrual syndrome(PMS)and reveal partial microcosmic mechanisms of adverse flow of liver-qi.Methods:Estradiol(E2)and progesterone(P)levels in serum were determined at different phases of menstrual cycle by radioimmunoassay.Results:In the group of PMS with adverse flow of liver-qi.the secretive peak value Of E2 and P at the follicular phase significantly decreased,and the secretive peak value at the luteal phase did not come into being.Conclusions:Low E2 and P secretive peak at the follicular phase and absence of secretive peak at the luteal phase is one of the microcosmic mechanisms of PMS with adverse flow of liver-qi.One of the pathophysiologic mechanisms of specific sub-type PMS is probably the continuous low level of E2and P.     

Real-time Three-dimensional Echocardiography in Assessment of Left Ventricular and Right Ventricular Volumes

Real-time three-dimensional echocardiography (RT3DE)is a new ultrasound technique that enables dynamic threedimensional visualization and quantification of the heart in real time. Investigation of feasibility and methodology of RT3DE in determining left ventricular (LV) and right ventricular (RV) volumes, RT3DE was performed in 35 normal adults using Philips SONOS 7500 system with a 2-4 MHz matrix array transducer. The 60°×60° "pyramid" volume database was obtained and analyzed on a TomTec echo workstation. Both LV and RV volumes were calculated with four 3DE methods (i.e. apical 2, 4, 8, and 16-plane) through manually tracing ventricular endocardial borders in end diastole and end systole. Stroke volumes were then calculated. LV volume was also measured by 2DE Simpson's rule using GE VIVID 7 ultrasound machine.     

SCREENING FOR A 21-CHROMOSOME ABNORMALITY IN PREIMPLANTED EMBRYOS OF ELDERLY WOMEN

Increasing maternal age is the only etiological factor unequivocally linked to Down's syndrome in humans. The occurrence rate of newborns with Down's syndrome is about 1/220 in women over 35 years old. However, the occurrence rate in embryos fertilized in vitro, of the elder woman is unclear. Using FISH we screened the number of chromosome 21 in preimplanted embryos of 5 elderly women (average age, 38.4 years) to study the feasibility and necessity of screening trisomy 21 in embryos in patients over 35 years old at the in vitro fertilization (IVF) center.     

Scientific principles and rigorous processes should be followed in developing clinical guidelines for therapeutic interventions of integrative medicine

A clinical guideline for the therapeutic interventions of integrative medicine may be defined as a written document which states a series of recommendations on therapeutic interventions of integrative medicine for a special disease or condition. The guideline may provide assistance to medical professionals in making clinical decisions aimed at improving the clinical outcome of patients and reducing the costs of medical care（~＇4~. Recommendations issued by a guideline should be based on the best available evidence in both Western and Chinese medicine. For fulfilling this purpose, the development of clinical guidelines for therapeutic interventions in the field of integrative medicine should follow scientific principles and undergo a rigorous processes.