耐碳青霉烯类肺炎克雷伯菌血流感染危险因素分析及列线图预测模型构建

[摘要]?目的?探究住院患者发生耐碳青霉烯类肺炎克雷伯菌（carbapenem-resistant Klebsiella pneumoniae, CRKP）血流感染的危险因素，并构建列线图模型。方法?选取2016年1月1日—2021年12月31日我院药学部收治的190例肺炎克雷伯菌（Klebsiella pneumonia, KP）所致血流感染患者作为研究对象，并根据是否耐碳青霉烯类抗菌药物，分为CRKP组（n=40）和碳青霉烯类敏感肺炎克雷伯菌（carbapenem-sensitive Klebsiella pneumonia, CSKP）组（n=150）。Logistic回归模型分析住院患者发生CRKP血流感染的危险因素，并绘制预测CRKP血流感染的列线图模型。使用ROC曲线、校准曲线及Hosmer-Lemeshow（H-L）检验对列线图模型进行验证。结果?感染前1个月内留置导尿管、留置中心静脉导管、使用免疫抑制剂、使用碳青霉烯类抗菌药物以及年龄≥65岁是影响住院患者发生CRKP血流感染的危险因素（P均＜0.05）。对列线图进行验证，校准曲线拟合良好，H-L检验χ2 =7.630，P=0.366，AUC为0.817（95% CI：0.739～0.895）。结论?感染前1个月内留置导尿管、留置中心静脉导管、使用免疫抑制剂、使用碳青霉烯类抗菌药物以及年龄≥65岁是住院患者发生CRKP血流感染的危险因素，据此构建的列线图模型对住院患者发生CRKP所致血流感染有较好预测价值，可为临床医护人员制定个体化防治策略提供参考。     

重症监护病房呼吸机相关性肺炎的危险因素及病原菌分析

目的分析重症监护病房(ICU)呼吸机相关性肺炎(VAP)的危险因素及病原菌分布。方法调查ICU接受呼吸机通气治疗患者中VAP发生率、危险因素、病原菌分布特点。结果 362例患者中确诊为VAP 114例,发生率为31.5%;机械通气时间>5 d,年龄>65岁,既往曾使用抑酸剂治疗,抗菌素联合应用≥2种,神志不清等均为VAP发生的危险因素;VAP的病原菌主要是乙酸钙鲍氏复合不动杆菌、铜绿假单胞菌、金黄色葡萄球菌等病菌。结论革兰阴性杆菌是ICU导致VAP的主要病原菌,对VAP发生的危险因素应实行重点监控并积极避免。     

超高龄肺部感染患者多重耐药菌感染风险Nomogram模型的建立和验证

目的 构建超高龄肺部感染患者多重耐药菌(MDR)感染风险Nomogram模型。方法 659例超高龄(≥80岁)肺部感染痰培养阳性的住院患者的临床资料,原始数据中随机抽取150例作为验证组,其余509例用于建模,分别使用单因素和Logistic回归多因素分析建模组超高龄肺部感染住院患者感染MDR的独立危险因素。构建Nomogram预测模型,并对模型的预测性及准确度进行验证。结果 抗生素使用时长≥2 w、气管插管、呼吸衰竭、脑血管疾病、营养不良是超高龄肺部感染患者感染MDR的独立危险因素。基于上述5项危险因素建立风险列线图预测模型,建模组和验证组AUC值分别为0.748、0.746,提示模型有良好的诊断能力;经Hosmer-Lemeshow检验(建模组P=0.991,验证组P=0.348),提示模型有良好的拟合优度;通过decision曲线分析显示,模型在较大的阈值内均有较高的获益性。结论 对于超高龄肺部感染患者应及时考虑抗生素使用时长、气管插管等综合因素,通过列线图模型个体化预测超高龄肺部感染患者发生MDR感染的概率,并尽早做好干预措施,从而改善患者预后。     

小儿院内HAP产超广谱β-内酰胺酶细菌的耐药性及危险因素分析

目的探讨小儿院内获得性肺炎(HAP)产超广谱β-内酰胺酶(ESBLs)细菌的耐药性,并分析相关危险因素。方法对137例HAP患儿痰液行ESBLs菌检测,比较产ESBLs菌与非产ESBLs菌对抗生素体外耐药情况,对小儿HAP产ESBLs菌的危险因素进行Logistic多因素回归分析。结果产ESBLs菌对除亚胺培南外抗菌药物的耐药率明显高于非产ESBLs菌(P0.05);第3代头孢菌素使用时间≥3 d、气管插管、留置鼻饲管、反复口鼻腔吸痰和住ICU均为小儿HAP产ESBLs菌的危险因素(P0.01或P0.05)。结论小儿HAP产ESBLs菌感染应首选亚胺培南治疗,针对危险因素制定有效防治措施可降低小儿HAP产ESBLs菌感染的发生率。     

重症监护室老年患者下呼吸道感染多重耐药肺炎克雷伯杆菌的危险因素及预后

目的探讨重症监护室(ICU)老年患者下呼吸道多重耐药肺炎克雷伯杆菌(MDR-KPN)感染的危险因素及相关预后。方法 121例ICU老年患者下呼吸道肺炎克雷伯杆菌(KPN)感染的痰液标本,根据第一次KPN阳性细菌学培养药敏结果分为MDR-KPN组(n=69)和非MDR-KPN组(n=52),统计分析引起多重耐药菌感染的危险因素,并分析两组预后。结果两组性别、年龄及基础疾病差异无统计学意义(P0.05);两组ICU住院时间、入ICU时血糖水平≥7.8 mmol/L、痰培养KPN阳性前机械通气时间≥5 d、痰培养KPN阳性前碳青霉烯类抗生素连续使用≥5 d、头孢三代抗生素使用史、慢性肺部疾病史、30 d内ICU住院史方面差异有统计学意义(P0.001);多因素Logistic回归分析显示,痰培养KPN阳性前机械通气时间≥5 d、痰培养KPN阳性前碳青霉烯类抗生素连续使用≥5 d、既往30 d内ICU住院史是预测感染MDR-KPN的独立危险因素。MDR-KPN组患者的预后差、病死率高,两组病死率比较,差异有统计学意义(P0.05)。结论每日评估患者撤机条件,缩短机械通气时间,合理使用抗菌药物,控制碳青霉烯类抗生素疗程,可降低MDR-KPN的发生率,从而减少老年患者ICU住院时间,降低患者病死率,改善患者临床结局。     

成人革兰阴性杆菌社区获得性肺炎危险因素分析

目的研究成人革兰阴性杆菌社区获得性肺炎(CAP)的临床特征及危险因素,为正确诊断革兰阴性杆菌CAP和合理应用抗菌药物提供理论依据。方法收集2003年9月～2009年9月间的CAP患者共552例。收集病人发病时的临床资料,取患者痰标本进行常规细菌培养,应用SPSS12.0对CAP危险因素进行单因素和多因素Logistic分析。结果 CAP患者中革兰阴性杆菌感染57例,占10.3%(57/552);单因素分析筛选出年龄≥65岁、合并支气管扩张、合并心衰、合并神经系统疾病、3月内应用抗菌药、呼吸频率28次/min、中性粒细胞≥90%、BUN升高、PORT评分≥Ⅳ级等9个革兰阴性杆菌CAP可能危险因素。多因素分析筛选出合并支气管扩张症、合并神经系统疾病、呼吸频率28次/min、中性粒细胞≥90%、3月内应用抗菌药等5个变量,可视为革兰阴性杆菌CAP的独立危险因素。结论革兰阴性杆菌感染在CAP占有一定比例,合并支气管扩张症、合并神经系统疾病、呼吸频率28次/min、中性粒细胞≥90%、3月内应用抗菌药是革兰阴性杆菌CAP的独立危险因素。     

呼吸机相关性肺炎病原学及感染耐碳青霉烯类革兰阴性菌危险因素与预后分析

目的:分析外科ICU术后患者中呼吸机相关性肺炎(VAP)的病原分布特点及耐药性,探讨感染耐碳青霉烯革兰阴性菌的危险因素。方法:回顾性分析2011年1月至2016年12月,北京安贞医院外科ICU收治的非心脏手术术后VAP患者临床资料。结果:VAP患者68例,检出病原菌173株,前三位依次为鲍曼不动杆菌、铜绿假单胞菌及肺炎克雷伯菌;检出病原菌中存在严重多重耐药情况;单因素分析显示感染耐碳青霉烯革兰阴性杆菌的危险因素:二次插管、多联抗生素使用、碳青霉烯类抗生素使用、低蛋白血症及合并脑血管病;Logistic回归分析显示二次插管、碳青霉烯类抗生素使用、低蛋白血症及合并脑血管病是感染耐碳青霉烯类革兰阴性杆菌的独立危险因素;感染耐碳青霉烯类革兰阴性菌组较未感染组死亡率明显增加(P=0.015)。结论:外科ICU中VAP主要病原菌为革兰阴性菌,多重耐药现象严重。二次插管、碳青霉烯类抗生素的使用、低蛋白血症及合并脑血管病为VAP患者感染耐碳青霉烯革兰阴性菌的独立危险因素。感染耐碳青霉烯革兰阴性菌会显著增加患者死亡率。     

老年卫生保健性肺炎多重耐药菌感染相关因素

目的分析老年卫生保健性肺炎(HCAP)患者多重耐药菌(MDRO)感染的相关因素。方法回顾性分析516例老年HCAP患者的临床资料,比较其中93例MDRO感染患者与423例非MDRO感染患者的差异,并进行多因素Logistic回归分析。结果 516例老年HCAP患者检出MDRO感染93例,MDRO感染率为21. 99%。单因素分析显示,年龄≥70岁、肺炎严重指数(PSI)分级高、90 d内住院天数≥15 d、入住ICU、30 d内抗菌药物使用时间7 d、30 d内联用抗菌药物≥3种、30 d内累计使用抗菌药物≥3种7个因素是HCAP患者MDRO感染的危险因素(P0. 05);多因素分析显示,30 d内联用抗菌药物(≥3种)、90 d内住院天数(≥15 d)、入住ICU、30 d内抗菌药物使用时间(7 d)、年龄≥70岁5个因素是老年HCAP患者MDRO感染的独立危险因素(P0. 05)。结论老年HCAP患者MDRO感染主要与环境MDRO定植交叉感染和抗菌药物的不合理应用有关。防控应首先减少不必要住院时间与入住ICU时间,减少MDRO的感染与定植;减少抗菌药物不合理的长期、反复及联合使用,根据微生物检测采取有针对性的抗感染方案。     

老年男性膀胱造瘘患者长期留置尿管的感染因素

目的探讨老年男性患者膀胱造瘘后长期留置尿管发生感染的相关危险因素。方法采用回顾性研究方法共纳入120例该院行膀胱造瘘后长期留置尿管的老年男性患者,入院后详细记录其基本信息及相关病史,如发生泌尿系感染为感染组,未感染为非感染组,采用多因素回归分析对发生感染的相关危险因素进行多因素分析。结果有20例(16.7%)发生泌尿系感染,共分离出24株病原菌,其中18株(75.0%)为革兰阴性杆菌,4株(16.7%)为革兰阳性球菌,2株(8.3%)为真菌,致病菌中以大肠埃希菌最多见,其次为表皮葡萄球菌等。两组留置尿管时间≥7 d、有糖尿病史、有抗生素使用、每日尿量、白蛋白水平、低密度脂蛋白水平、空腹血糖水平差异有统计学意义(P<0.05);多因素分析显示留置尿管时间≥7 d、糖尿病史、每日尿量少、白蛋白水平低下是膀胱造瘘后长期留置尿管感染发生的独立危险(P<0.05)。结论膀胱造瘘后长期留置尿管感染发生与留置尿管时间≥7d、糖尿病史、每日尿量少、白蛋白水平低下存在密切相关性,临床工作中要对上述危险因素加以控制及干预,从而降低感染率。     

综合重症监护病房老年患者多重耐药菌感染危险因素分析及预测模型建立

目的 探讨综合重症监护病房（ICU）老年患者多重耐药菌感染危险因素,构建ICU老年患者感染多重耐药菌的预测模型。方法 回顾性分析2019年1月—2019年12月入住复旦大学附属中山医院吴淞医院ICU共613例老年患者的临床资料,采用单因素和Logistic多因素回归模型,分析ICU老年患者多重耐药菌感染的独立危险因素,并根据Logistic回归分析结果构建预测模型,通过受试者工作特征曲线（ROC）检验拟合优度。结果 留置中心静脉导管（OR=3.205,95%CI:1.204～8.533）、气管插管（OR=4.259,95%CI:2.008～9.034）、留置导尿管（OR=7.542,95%CI:1.335～42.615）以及住院天数≥7d(OR=18.534,95%CI:6.576～52.239)是ICU老年患者多重耐药菌感染的危险因素。ROC曲线下面积为0.963 (95%CI:0.948～0.978),模型拟合度较好。结论 根据留置中心静脉导管、气切插管、留置导尿管以及住院天数≥7d构建的预测模型对预判ICU老年患者多重耐药菌感染有较好的效果,对于指导医院公共卫生防控和临床工作,降...     

胰岛素瘤的解剖分布特点分析

目的胰岛素瘤是最常见的胰腺神经内分泌肿瘤，因其临床表现多样，导致诊断困难。影像学诊断尤其是超声内镜(EUS)在胰岛素瘤的诊断中起着重要作用，拥有较高的敏感性和特异性。本研究拟通过明确胰岛素瘤的解剖分布特点，以期有助于提高影像学的诊断准确率和降低漏诊率，尤其是在教育和培训实践中对于EUS的学习者更具有指导价值。 方法回顾性分析解放军总医院第一医学中心病案资料数据库1993年1月至2019年11月经外科手术、病理确诊为胰岛素瘤的患者的临床资料，检索方法采取搜索术后病理诊断为"胰岛素瘤"的病例，通过查阅病例的方法，提取出胰岛素瘤的大小和解剖分布等数据，进一步分析其特点。 结果共检索到确诊为胰岛素瘤的患者116例，其中，男45例、女71例，年龄13～76岁，平均年龄(44.4±14.85)岁。胰岛素瘤单发110例(94.8%)、多发6例(5.2%)。位置分布：头颈部46例(39.7%)，单发45例、多发1例；体尾部68例(58.6%)，单发65例、多发3例；全胰腺多发2例(1.7%)。病变大小特点：最大径0.4～3.4 cm，平均大小(1.53±0.58)cm。≤1 cm 29例、>1 cm而≤1.5 cm41例、>1.5 cm而≤2.0 cm28例，≤3 cm 15例，>3 cm 3例。年龄与肿瘤的大小相关，≤44岁患者肿瘤平均大小为(1.36±0.51)cm、>44岁患者肿瘤平均大小为(1.70±0.60)cm，P<0.05。头颈部的肿瘤大于体尾部的肿瘤，头颈部肿瘤平均大小(1.66±0.63)cm，体尾部(1.42±0.52)cm，P<0.05。 结论胰岛素瘤在胰腺体尾部较头颈部更好发；绝大多数单发，但可以全胰腺多发；多数小于1.5 cm，肿瘤的大小与患者年龄和肿瘤的解剖分布相关。     

Pathogenesis of carcinoma of the papilla of Vater

Most adenomas and carcinomas of the small intestine and extrahepatic bile ducts arise in the region of the papilla of Vater. In familial adenomatous polyposis (FAP) it is the main location for carcinomas after proctocolectomy. In many cases symptoms due to stenosis lead to diagnosis at an early tumor stage. In about 80%, curative intended resection is possible. Operability is the most relevant prognostic factor. Most ampullary carcinomas resp. carcinomas of the papilla of Vater develop from adenomatous or flat dysplastic precursor lesions. They can be sited in the ampulloduodenal part of the papilla of Vater, which is lined by intestinal mucosa. They also can develop in deeper parts of the ampulla, which are lined by pancreaticobiliary duct mucosa. Intestinal-type adenocarcinoma and pancreaticobiliary-type adenocarcinoma represent the main histological types of ampullary carcinoma. Furthermore, there exist unusual types and undifferentiated carcinomas. Many carcinomas of intestinal type express the immunohistochemical marker profile of intestinal mucosa (keratin 7?, keratin 20+, MUC2+). Carcinomas of pancreaticobiliary type usually show the immunohistochemical profile of pancreaticobiliary duct mucosa (keratin 7+, keratin 20?, MUC2?). Even poorly differentiated carcinomas, as well as unusual histological types, may conserve the marker profile of the mucosa they developed from. These findings underline the concept of histogenetically different carcinomas of the papilla of Vater which develop either from intestinal- or from pancreaticobiliary-type mucosa of the papilla of Vater. Molecular alterations in ampullary carcinomas are similar to those of colorectal as well as pancreatic carcinomas, although they appear at different frequencies. In future studies, molecular alterations in ampullary carcinomas should be correlated closely with the different histologic tumor types. Consequently, the histologic classification should reflect the histogenesis of ampullary tumors from the two different types of papillary mucosa.     

Lack of correlation of degree of villous atrophy with severity of clinical presentation of coeliac disease

BACKGROUND AND AIM: Both the clinical presentation and the degree of mucosal damage in coeliac disease vary greatly. In view of conflicting information as to whether the mode of presentation correlates with the degree of villous atrophy, we reviewed a large cohort of patients with coeliac disease. PATIENTS AND METHODS: We correlated mode of presentation (classical, diarrhoea predominant or atypical/silent) with histology of duodenal biopsies and examined their trends over time. RESULTS: The cohort consisted of 499 adults, mean age 44.1 years, 68% females. The majority had silent coeliac disease (56%) and total villous atrophy (65%). There was no correlation of mode of presentation with the degree of villous atrophy (p=0.25). Sixty-eight percent of females and 58% of males had a severe villous atrophy (p=0.052). There was a significant trend over time for a greater proportion of patients presenting as atypical/silent coeliac disease and having partial villous atrophy, though the majority still had total villous atrophy. CONCLUSIONS: Among our patients the degree of villous atrophy in duodenal biopsies did not correlate with the mode of presentation, indicating that factors other than the degree of villous atrophy must account for diarrhoea in coeliac disease.     

Demonstration of the mechanism of action of biguanides

Summary Palmitic acid oxidation in rat diaphragm homogenate is depressed by biguanide concentrations that are still incapable of inhibiting oxidative phosphorylation. Glucose oxidation is not directly effected by the same biguanide concentrations: however, the inhibitory effect of palmitic acid on glucose oxidation is partly removed by biguanides. Inhibition of fatty acid oxidation, which accounts for most of the metabolic effects caused by these drugs, can be regarded as the fundamental mechanism of action of biguanides. There is some evidence suggesting that these drugs might interact with carnitine, thus preventing long-chain fatty acids from being transported across the mitochondrial membrane to the site of oxidation. Traduzione a cura degli AA.     

血吸虫童虫生长发育及其机制的研究进展

血吸虫童虫是宿主免疫系统攻击的重要靶标,包括皮肤型、肺型和肝门型童虫。宿主分子对童虫生长发育具有重要作用。童虫生长发育机制包括免疫调节、信号转导、性别发育及凋亡等。肌动蛋白、组织蛋白酶、烯醇化酶和葡萄糖基转移酶等分子为血吸虫童虫生长发育的重要分子。本文对血吸虫童虫生长发育及其机制的研究进展做一综述。     

124例耐多药结核分枝杆菌基因突变特征分析

目的对临床分离的耐多药结核分枝杆菌相关基因的突变特征进行分析。方法对124例耐多药结核分枝杆菌以及50株敏感株的耐药相关基因(包括异烟肼inh A、kat G、oxyR-ahp C间隔区以及利福平rpo B)进行序列测定,分析其基因突变情况。结果异烟肼耐药inh A基因突变率为14.5%;kat G基因突变率为70.2%(87/124),主要位于315位;oxyR-ahp C间隔区突变率为15.3%;inh A、kat G两种基因同时突变率75.0%,三种基因同时突变率为89.5%。利福平rpo B基因突变的检出率高达95.2%,突变主要发生在531、526、516位点。结论我省耐多药菌异烟肼耐药相关基因最常见突变为kat G 315、inh A C-T(-15)、axyR-ahp C间隔区(-10)C-T,利福平为rpo B531、526、516。结合MDR-TB耐药相关基因的特征分析,可以建立一种快速、准确、特异的适合于我省的检测结核菌耐多药性的新方法。     

Assessment of quality of life of parents of children with juvenile chronic arthritis

The aim of the study was to assess the quality of life (QOL) and the psychological status of parents of children with juvenile chronic arthritis (JCA). The QOL, anxiety and depression of the parents of 28 children with JCA were evaluated and compared to those of the parents of 28 healthy children. Mothers of JCA children and mothers of healthy children reported similar QOL. The reported anxiety and depression levels were similar for mothers and fathers in both groups. The parents of children with pauciarticular-type JCA reported lower QOL and higher levels of anxiety and depression than the parents of children with other types, namely polyarticular and systemic JCA. These findings may be explained by the fact that the pauciarticular patients had shorter disease duration and were less frequently seen in the outpatient clinic. The QOL of mothers of children with JCA was found to be slightly impaired in the group of children with pauciarticular JCA. Future larger studies are needed to confirm these results, as the number of subjects in the three groups was rather low. Received: 26 September 2001 / Accepted: 8 February 2002     

Numerical Simulation of the Effect of Rate of Change of Glucose on Measurement Error of Continuous Glucose Monitors

Background

A 5-day in-patient study designed to assess the accuracy of the FreeStyle Navigator® Continuous Glucose Monitoring System revealed that the level of accuracy of the continuous sensor measurements was dependent on the rate of glucose change. When the absolute rate of change was less than 1 mg•dl⁻¹•min⁻¹ (75% of the time), the median absolute relative difference (ARD) was 8.5%, with 85% of all points falling within the A zone of the Clarke error grid. When the absolute rate of change was greater than 2 mg•dl⁻¹•min⁻¹ (8% of the time), the median ARD was 17.5%, with 59% of all points falling within the Clarke A zone.

Method

Numerical simulations were performed to investigate effects of the rate of change of glucose on sensor measurement error. This approach enabled physiologically relevant distributions of glucose values to be reordered to explore the effect of different glucose rate-of-change distributions on apparent sensor accuracy.

Results

The physiological lag between blood and interstitial fluid glucose levels is sufficient to account for the observed difference in sensor accuracy between periods of stable glucose and periods of rapidly changing glucose.

Conclusions

The role of physiological lag on the apparent decrease in sensor accuracy at high glucose rates of change has implications for clinical study design, regulatory review of continuous glucose sensors, and development of performance standards for this new technology. This work demonstrates the difficulty in comparing accuracy measures between different clinical studies and highlights the need for studies to include both relevant glucose distributions and relevant glucose rate-of-change distributions.     

氯硝柳胺悬浮剂的毒性评价

目的评价氯硝柳胺悬浮剂的毒性，为现场大规模应用灭螺提供依据。方法按照中华人民共和国国家标准GB 15670-1995《农药登记毒理学试验方法》和鱼类毒性试验方法进行。结果经口、经皮肤的LDso雌、雄性大鼠均>5 000 mg/kg，经呼吸道的LCso雌、雄性大鼠均>5 000mg/m3，该药经口、经皮肤、经呼吸道毒性均属微毒类药物；兔眼用药后，观察期内无不良反应，对眼无刺激性；皮肤用药后对皮肤无刺激性。与氯硝柳胺原药、氯硝柳胺乙醇胺盐原药和氯硝柳胺乙醇胺盐可湿性粉剂相比，氯硝柳胺悬浮剂对鱼急性毒性最低。结论氯硝柳胺悬浮剂属微毒类药物，对鱼的毒性低于其乙醇胺盐可湿性粉剂，适合于现场应用。     

Study of constancy of hydrogen-consuming flora of human colon

The constancy of the hydrogen consuming flora of the human colon was studied in 15 healthy subjects via two measurements obtained 18 to 36 months apart. Hydrogen disappearance rate and the major products of H₂-consuming bacteria, methane and sulfide, were measured during incubation of fecal homogenates with excess hydrogen and sulfate. In 11/15, the hydrogen consumption rate and the predominant hydrogen-consuming pathway (methanogenesis, sulfate reduction, or neither) remained constant. However, major shifts in these pathways were observed in four subjects, with two losing and two gaining the ability to produce methane. Methanogenesis was associated with the highest hydrogen consumption rate. This study demonstrates that clinically unrecognizable, major alterations of the colonic flora occur in healthy subjects. Understanding of the factors responsible for these alterations might allow for therapeutic manipulation of the colonic flora.Supported in part by the Department of Veterans Affairs and NIDDKD RO1 DK 13309-25.