肝门部胆管癌ERCP前应用抗菌药物能否降低术后胆管炎发生率——附138例对照研究

目的验证逆行胰胆管造影（ERCP）前应用抗菌药物能否降低术后胆管炎发生率。方法选择肝门部胆管癌需行ERCP治疗的患者138例,随机分为试验组（67例）与对照组（71例）。试验组于ERCP治疗前30 min静脉注射头孢哌酮1.0g;对照组按常规操作,不应用抗菌药物。结果两组患者一般临床资料比较,差异无统计学意义（P〉0.05）,具有可比性。ERCP术后,试验组胆管炎发生率为34.33%（23/67）,对照组为26.76%（19/71）,两组胆管炎发生率差异无统计学意义（χ2=0.360,P=0.152）。结论对高感染率的病种行ERCP治疗,仅通过术前单剂量应用抗菌药物来降低ERCP治疗后胆管炎发生率,效果不甚理想。     

抗菌药物预防颅脑术后颅内感染的贝叶斯网状Meta分析

目的评价多种抗菌药物在预防颅脑术后颅内感染的效果,为开颅手术患者预防性使用抗菌药物提供参考。方法检索国内外数据库关于预防颅脑术后颅内感染的随机对照试验,根据纳入与排除标准各自筛选文献、提取数据和进行文献质量评价后,使用R软件GeMTC包调用JAGS进行贝叶斯网状Meta分析。结果最终纳入11个研究,共3 214例颅脑术后患者,术后颅内感染159例,其中使用抗菌药物组33例,对照组126例,文献质量较好,一致性检验显示直接比较与间接比较的结果无明显不一致性。贝叶斯网状Meta分析结果显示预防性使用抗菌药物可降低颅脑术后颅内感染发病率,但头孢菌素、克林霉素、夫西地酸、万古霉素与青霉素5种抗菌药物间无统计学差异。结论目前证据表明,不同抗菌药物术前静脉注射在预防颅脑术后颅内感染方面无统计学差异,故可选择低级别抗菌药物预防颅脑术后颅内感染,但仍需更多高质量、大样本研究进一步证实。     

鼻胆管引流术预防经内镜逆行胰胆管造影术后感染的临床分析

目的探讨鼻胆管引流术(ENBD)预防经内镜逆行胰胆管造影术(ERCP)后胆管感染的临床效果,旨在改善ERCP手术的临床预后。方法将2011年8月-2013年1月86例行ERCP术的病例随机分成观察组46例和对照组40例,观察组术后行ENBD,对照组术后未行ENBD,比较两组ERCP术后胆管感染情况,采用SPSS13.0软件进行统计分析。结果观察组和对照组患者ERCP术后胆管感染分别为2、4例,感染率分别为4.3%、10.0%,组间比较差异有统计学意义(P<0.05);观察组中2例单纯性胆管炎药物保守治疗后痊愈;对照组中单纯性胆管炎1例对症处理后好转,3例急性重症胆管炎(ACST)分别行开腹胆道引流术、经皮肝穿刺胆道引流术,其中2例治疗无效并发多器官功能衰竭(MOF)死亡。结论 ENBD能有效预防ERCP术后胆管感染,对于存在ERCP术后胆管感染危险因素的手术患者尤其必要。     

腹股沟疝无张力修补术中抗菌药物预防手术部位感染效果的荟萃分析

目的 系统评价腹股沟疝开放式无张力修补术中,预防性使用抗菌药物对防止手术部位感染的效果.方法 检索Cochrane Library临床对照试验资料库、PubMed、EMbase、中国生物医学文献数据库(CBM)和中国期刊全文数据库(CNKI);纳入预防性使用抗菌药物对手术部位感染发病率影响的随机对照试验,进行荟萃分析及系统评价.结果 筛选符合纳入标准的随机对照试验7项,共2569例;荟萃分析发现,与对照组相比,预防性使用抗菌药物组可以减少手术部位感染(OR=0.50,95％CI=0.32～0.78,P=0.002)、表浅手术部位感染(OR=0.49,95％CI=0.29～0.82,P=0.007)的发生;在预防深部手术部位感染方面的差异无统计学意义.结论 行开放式腹股沟疝无张力修补术的患者,术前预防性使用抗菌药物能有效降低手术部位感染率和表浅手术部位感染率,但并不能降低深部手术部位感染率.     

ERCP术后胆管炎的相关因素分析

对131例行内镜下逆行胰胆管造影术(ERCP)的住院患者进行回顾性调查,18例发生ERCP术后胆管炎。将患者按是否发生ERCP术后胆管炎分为术后胆管炎组和非胆管炎组,分析相关因素(年龄、性别、术中操作、梗阻部位)对ERCP术后胆管炎发生的影响,结果显示梗阻部位与术后胆管炎有关。18例ERCP术后胆管炎患者10例送检病原学检查,胆汁培养共获得菌株9株,以革兰氏阴性杆菌为主。     

抗感染导管预防导管相关性血流感染效果的系统评价

目的系统评价肿瘤患者使用抗感染导管预防导管相关性血流感染(CRBSI)的效果。方法计算机检索Cochrane图书馆、中文、英文数据库中关于肿瘤患者使用抗感染导管的随机对照试验,同时筛检纳入文献的参考文献;对文献质量进行严格评价和资料提取,对符合质量标准的RCT进行荟萃分析。结果共纳入6个RCT;显示抗感染导管能显著降低CRBSI的发生率(P0.001),1个RCT显示涂抗菌药物的导管能有效预防CRBSI的发生(P=0.01),5个RCT显示涂消毒剂的导管能有效预防CRBSI的发生(P=0.02)。结论由于纳入研究少,均存在方法学上的不足,没有足够证据认为抗感染导管能够有效预防肿瘤患者发生CRBSI。     

神经外科清洁手术预防用药及手术部位感染分析

目的分析神经外科清洁手术预防用药时间与手术部位感染(SSI)发生率的关系,以降低SSI发生率。方法以2012年1月-2013年6月收治的386例开颅手术患者为研究对象,参照原卫生部颁布的《抗菌药物临床应用指导原则》和《医院感染诊断标准》,采用统计方法分析围手术期抗菌药物预防使用与SSI发生率。结果 386例开颅手术患者抗菌药物使用率为100.00%,其中三代头孢菌素中的头孢曲松占83.42%,一、二代头孢菌素占15.80%,均为单联使用,选择范围合理;术前和术后给药时间不合理的分别占41.45%和74.61%;在术后不同时间用药的SSI发生率差异无统计学意义。结论术前合理时间内预防用药可以有效降低SSI发生率,术前精心准备、术后精心护理、严格无菌技术、规范手术操作是避免过度依赖抗菌药物,降低SSI发生率的有效措施。     

ERCP术后并发症的预防与护理对策

通过对156例ERCP术后病人的护理,总结ERCP术后并发症(包括急性胰腺炎、急性胆管炎、术后出血、胃肠穿孔)的预防及护理对策,要求助手熟练的配合技术、精心的护理能力、有效预防和减少ERCP术后并发症的发生.     

肝门部胆管癌术前胆汁引流方式选择的Meta分析

目的探讨肝门部胆管癌患者不同术前胆汁引流方式术后并发症发生率情况及引流减黄疗效,以期为临床决策提供参考。方法计算机检索2007年1月-2018年6月在中国知网(CNKI)、维普(VIP)和PubMed、EMbase等数据库中关于肝门部胆管癌患者术前胆汁引流的文献,采用NOS评分评估纳入文献的质量,并采用RevMan 5.3软件对纳入文献进行Meta分析。结果本次Meta分析最终共纳入11篇文献。分析结果显示:行经内镜逆行胰胆管造影(ERCP)的患者术后胆管炎的发生率高于行经皮肝穿刺胆道引流(PTBD)的患者(RR=0.64;95%CI:0.42～0.98;P=0.040 0);行PTBD的患者术后引流减黄疗效优于行ERCP的患者(RR=2.12;95%CI:1.41～3.20;P=0.000 3);行ERCP的患者术后胰腺炎的发生率高于行PTBD的患者(RR=0.29;95%CI:0.15～0.57;P=0.000 3);而行PTBD与ERCP的患者其术后出血情况的差异无统计学意义(RR=1.24;95%CI:0.62～2.46;P=0.540 0)。行经内镜鼻胆道引流(ENBD)与行经内镜胆道支架置入术(EBS)的患者术后并发胆管炎的差异无统计学意义(RR=0.51;95%CI:0.25～1.04;P=0.060 0),且行ENBD与EBS的患者术后并发胰腺炎的差异亦无统计学意义(RR=0.62;95%CI:0.29～1.32;P=0.210 0)。结论对于诊断明确,需行胆汁引流的肝门部胆管癌患者,可选择行PTBD术。PTBD与ERCP相比,不但具有更高的胆汁淤积改善率,而且术后胆道感染、胰腺炎的发生率均更低,是术前胆汁引流、减黄的首选方式。     

抗菌药物对骨科围术期预防感染的影响

目的探究抗菌药物对骨科围术期预防感染的影响。方法选择2016年1月-2019年1月瑞安市人民医院骨科收治的手术患者82例,随机数表法分为对照组和研究组,每组各41例,其中对照组围术期给予常规应用抗菌药物,研究组围术期给予干预性应用抗菌药物,观察两组抗菌药物使用情况、抗菌药物费用,并对抗菌药物使用的合理性进行评价。结果研究组住院时间、手术部位感染、治疗各项费用均低于对照组,差异有统计学意义(P<0.05);两组体温异常情况比较,无统计学差异;两组围术期抗菌药物使用均主要以单一用药为主,研究组单一用药多于对照组,二联用药低于对照组,差异有统计学意义(P<0.05);研究组在抗菌药物品种选择、预防用药时机、术后用药时间等围术期抗菌药物使用合理率均高于对照组,差异有统计学意义(P<0.05);两组治疗前肿瘤坏死因子-α(TNF-α)、白细胞介素-6(IL-6)、IL-8、C-反应蛋白(CRP)各项血清炎性因子水平比较,无统计学差异;治疗后,两组血清炎性因子水平均下降,差异有统计学意义(P<0.05)。结论干预性应用抗菌药物对骨科围术期预防感染效果显著,在降低手术部位感染发生率的同时,提高抗菌药物使用合理性、缩短住院时间、降低住院费用。     

Antimicrobial prophylaxis in clean surgery with special focus on inguinal hernia repair with mesh

Until recently, antimicrobial prophylaxis was thought to be unnecessary for clean surgery except when a foreign body is implanted or the presence of infection poses a significant risk to patients. However, the results of several trials support extending the administration of antimicrobial prophylaxis to other types of clean surgery such as inguinal hernia repair or breast surgery. A recent Cochrane meta-analysis concluded that antimicrobial prophylaxis for inguinal hernia repair with or without mesh cannot be recommended or discarded. Resolution of this problem is important because inguinal hernia repair with mesh is one of the most common procedures in general surgery, and antibiotic consumption for preventive purposes is becoming a serious problem due to the risk of contribution to development of bacterial resistance and the significant increase in healthcare costs. This review will document clinical trials and meta-analyses on clean surgery, and will focus on inguinal hernia repair with mesh.     

Development of a highly sensitive search strategy for the retrieval of reports of controlled trials using PubMed

OBJECTIVE: To develop, through revision of the Cochrane Collaboration search strategy for OVID-MEDLINE, a highly sensitive search strategy to retrieve reports of controlled trials using PubMed. METHODS: The original highly sensitive Cochrane strategy was revised to take into account additional Medical Subject Headings (MeSH) and other terminology as well as the current unique features of PubMed. We compared the retrieval of the revised strategy with that of the original Cochrane strategy before and after translation of the strategies into PubMed format. Finally, we used a gold standard database of reports of controlled trials identified by electronic and hand search of selected journals to test the revised strategy in PubMed format. RESULTS: The revised strategy included a search statement modified for increased precision, and added 'Cross-over Studies' as a MeSH term and the term 'latin square' as a text word. Compared to the original Cochrane strategy, the revised strategy identified 53 additional reports of controlled trials accessing MEDLINE through OVID. When the revised strategy and original Cochrane strategy were translated into PubMed format, the revised strategy retrieved 90 reports of controlled trials not identified by the original strategy. Finally, the revised strategy in PubMed format retrieved all of the reports of controlled trials in the gold standard database. Ninety-eight per cent of the gold standard reports of controlled trials were retrieved by Phase 1 of the optimal PubMed search strategy. CONCLUSIONS: Failure to identify all relevant trials for systematic review could result in bias. We developed a highly sensitive search strategy for the retrieval of reports of controlled trials for use with PubMed that retrieves more relevant citations (greater sensitivity) and fewer non-relevant citations (greater precision) than the original Cochrane search strategy.     

Comparative analysis of two regimens of antibiotic prophylaxis in elective colorectal surgery

BACKGROUND: Antibiotic prophylaxis has greatly reduced the rate of postoperative infectious complications since its utilization in the elective colorectal surgery in the last several decades. Although the need of its application is indisputable, the optimal duration of antibiotic prophylaxis is still on debate. AIM: The aim of the present study was to compare two regimens of antibiotic prophylaxis with different duration. MATERIALS AND METHODS: A retrospective clinical study was conducted of 190 patients that underwent elective surgery for colorectal carcinoma in the Clinic between January 1997 and June 2000. The patients were divided into two groups according to the regimen of antibiotic prophylaxis. Group 1 (n = 92) patients received a 24-hour antibiotic prophylaxis and Group 2 (n = 98) had a prolonged antibiotic cover that lasted 5 days. The antibiotic prophylaxis was conducted with a third generation cefalosporin and metronidazole. RESULTS: Of all 190 patients 92 were in Group 1 and 98 in Group 2. Postoperative infectious wound complications were found in 14 (15.2%) patients from Group 1 and in 25 (25.5%) patients from Group 2. The difference did not reach statistical significance (P > 0.05). CONCLUSION: The results of the study show no advantage of the prolonged over short-term antibiotic prophylaxis. Based on the study findings the authors suggest that a 24-hour antibiotic prophylaxis should be recommended for the lower rate of side effects and lower cost.     

乳腺癌手术预防应用抗菌药物对降低手术部位感染的作用

目的 明确预防应用抗菌药物对乳腺癌手术后手术部位感染发病率的影响.方法 通过检索Medline、Embase和Cochrane图书馆数据库,筛选2011年12月之的公开发表的文献,无语言限制；选择标准为乳腺癌患者接受围手术期抗菌药物的随机对照试验、研究结局为手术部位感染；数据收集和分析由作者审查检索的所有研究的标题和摘要,然后评估研究质量,并从符合纳入标准的研究中提取数据.结果 共纳入了8项研究,所有研究干预组均为抗菌药物,对照组为安慰剂或空白对照,而且均为高质量随机对照研究；研究结果表明,乳腺癌手术患者围手术期预防应用抗菌药物可显著降低手术部位感染率(RR=0.71,95％CI:0.55～0.92);经过Begg's检验(z=0.12,P-0.90)和Egger's检验(t=0.16,P=0.88),该研究不存在明显的发表偏倚.结论 预防应用抗菌药物可降低乳腺癌手术后手术部位感染发病率,但需权衡考虑感染引起的潜在风险如伤口愈合或延迟质量和用药引起的不良后果如成本、药物反应或增加细菌耐药性等.     

Of mites and men: reference bias in narrative review articles: a systematic review

BACKGROUND: Citations in scientific articles may tend to favor the views presented. We studied whether there is such reference bias in narrative review articles that discuss interventions against house dust mites for people with asthma. DESIGN: Systematic review of reviews identified in a Medline search that expressed an opinion about the clinical effects of physical or chemical intervention methods. MAIN OUTCOME MEASURE: Positive bias was judged to have occurred if the reference list contained a higher proportion of trial references with significant results than among all trials available to the authors (published 2 years or more prior to the review). RESULTS: Seventy reviews were included, of which 63 (90%) recommended physical interventions. Forty-six reviews had trial references, 4 of these only to chemical interventions. In the remaining 42 reviews, reference bias was detected (P=2 x 10-8). The most quoted trial had only 7 patients per group, its claimed significant result was probably erroneous, and it did not report a clinical outcome. Intervention recommendations were often based on nonrandomized evidence, and the most quoted nonrandomized controlled study had included only 10 patients per group but claimed very positive results. CONCLUSION: The narrative review articles were severely biased, and their positive intervention recommendations are at variance with the systematic Cochrane Review on this topic and a recent very large trial of physical intervention, both of which failed to find an effect.     

独活寄生汤治疗类风湿性关节炎临床疗效的meta分析

目的系统评价独活寄生汤治疗类风湿性关节炎（RA）的有效性,为临床应用和进一步研究提供参考依据。方法在万方医学网、重庆维普网和中国知网数据库,以＂独活寄生汤＂和＂类风湿关节炎＂为并列检索词,检索应用独活寄生汤治疗RA的随机对照临床试验文献,时间区间设定为1999年1月—2014年4月。按照Cochrane系统评价手册推荐的简单评价法,评价纳入研究的方法学质量,软件版本为Rev Man 5.2,采用优势比指标进行meta分析。结果共有7个应用独活寄生汤治疗RA的随机对照临床试验文献,文献中累计观察类风湿关节炎患者542例。meta分析结果显示,OR值为4.29,95%CI为（2.55,7.20）,整体效果检验Z为5.51,P〈0.01。结论与对照组相比,独活寄生汤治疗RA在治疗效果方面较好,是一种比较安全的药物。受到纳入研究的文献数量和质量的限制,效果评定可能存在小部分偏倚,尚需要高质量的随机双盲试验继续验证。     

Is antibiotic prophylaxis for bacterial endocarditis cost-effective?

BACKGROUND: Antibiotic prophylaxis for bacterial endocarditis is recommended by the American Heart Association (AHA) before undergoing certain dental procedures. Whether such antibiotic prophylaxis is cost-effective is not clear. The authors' objective is to estimate the cost-effectiveness of predental antibiotic prophylaxis in patients with underlying heart disease. METHODS: The authors conducted a cost-effectiveness analysis using a Markov model to compare cost-effectiveness of 7 antibiotic regimens per AHA guidelines and a no prophylaxis strategy. The study population consisted of a hypothetical cohort of 10 million patients with either a high or moderate risk for developing endocarditis. RESULTS: Prophylaxis for patients with moderate or high risk for endocarditis cost $88,007/quality-adjusted life years saved if clarithromycin was used. Prophylaxis with amoxicillin and ampicillin resulted in a net loss of lives. All other regimens were less cost-effective than clarithromycin. For 10 million persons, clarithromycin prophylaxis prevented 119 endocarditis cases and saved 19 lives. CONCLUSION: Predental antibiotic prophylaxis is cost-effective only for persons with moderate or high risk of developing endocarditis. Contrary to current recommendations, our data demonstrate that amoxicillin and ampicillin are not cost-effective and should not be considered the agents of choice. Clarithromycin should be considered the drug of choice and cephalexin as an alternative drug of choice. The current published guidelines and recommendations should be revised.