呼吸内科不同区域下呼吸道感染耐药菌分布及耐药特征比较分析

目的：探索昆明医科大学第一附属医院呼吸内科不同区域[门诊、病房,呼吸重症监护病房（RIC U ）]下呼吸道感染耐药菌株的分布构成及耐药特征,为临床抗菌药物的合理应用提供依据。方法采用K‐B纸片扩散法和仪器法（VITEK‐TWO）,按照美国临床与实验室标准化研究所（CLSI）2010年版标准判读结果,对昆明医科大学第一附属医院呼吸科门诊、病房、RICU患者送检的痰液、肺泡灌洗液标本通过细菌培养鉴定及药敏试验分离出的480株耐药菌株,用WHONET5．6软件对检测数据进行分析。结果该医院呼吸门诊、病房、RICU下呼吸道感染耐药菌分布构成前4位均以革兰阴性菌为主。肺炎克雷伯菌对多数抗菌药物的耐药率大于30％,对庆大霉素、左氧氟沙星、氨苄青霉素的耐药率大于50％,RIC U与呼吸科门诊和病房相比差异有统计学意义（ P＜0．05）。亚胺培南、哌拉西林／他唑巴坦、头孢哌酮／舒巴坦、阿米卡星抗菌活性较强,其耐药率小于20％。大肠埃希菌对11种常用抗菌药物在呼吸科门诊、病房与RICU的耐药率相似。产超广谱β‐内酰胺酶（ESBLs）菌株的多重耐药率明显高于非产ESBLs菌株（P＜0．05）,产ESBLs菌株对亚胺培南耐药率小于10％。铜绿假单胞菌对头孢哌酮／舒巴坦、哌拉西林／他唑巴坦、头孢吡肟、喹诺酮类、氨基糖甙类在呼吸科门诊和病房仍保持较高的抗菌活性,但RIIU的耐药率大于54％（ P＜0．05）。鲍曼不动杆菌对亚胺培南的耐药率在RIC U和病房明显高于呼吸科门诊,分别为70．4％、64．6％和46．2％。RIC U检出的耐甲氧西林金黄色葡萄球菌（MRSA）对利福平耐药率明显高于呼吸科门诊和病房（P＜0．05）。结论呼吸科门诊、病房和RICU的耐药菌分布构成及耐药率均有明显差异,临床医师除了熟悉本地区耐药菌分布及耐药率监测情况外,还应掌握本单位各科室不同区域耐药菌的耐药率情况,才能正确有效合理应用抗菌药物。     

Predictive factors associated with long-term survival in patients with neuroendocrine tumors of the pancreas

Background Neuroendocrine tumors of the pancreas are rare tumors. We identified predictive factors that are associated with long-term survival (≥5 years). Methods Fifty patients with a diagnosis of neuroendocrine tumors of the pancreas were retrospectively evaluated. The following factors were evaluated for disease-specific mortality: age, sex, primary tumor location, functional status, type of primary tumor treatment, presence or absence of liver metastases, timing of liver metastases occurrence, and type of liver metastases treatment. Aggressive treatment of the liver metastases included surgery, chemoembolization, or intrahepatic arterial infusion chemotherapy. Results Twenty-three patients (47%) had tumor located in the head of the pancreas, and 29 patients (58%) had nonfunctioning tumor. Thirty-nine patients (78%) had liver metastases. The median follow-up for the entire group was 35 months (range, 76–206 months). The median survival for the entire group was 40 months, and the overall 1-, 2-, and 5-year survival rates were 84%, 69%, and 36%, respectively. Factors that had a significant favorable effect on survival included curative resection of the primary tumor, metachronous liver metastases, absence of liver metastases, and aggressive treatment of the liver metastases. Conclusions Definitive surgical resection of the primary tumor, absence of liver metastases, metachronous liver metastases, and aggressive treatment of the liver metastases were predictors of long-term survival in patients with neuroendocrine tumors of the pancreas. Presented as a poster presentation at the Society of Surgical Oncology 55th Annual Cancer Symposium, Denver, Colorado, March 14–17, 2002.     

Quality of life outcomes in 599 cancer and non-cancer patients with colostomies

BACKGROUND: A colostomy is known to impact negatively on a patient's quality of life (QOL). Concerns include incontinence, rectal discharge, gas, difficulties in returning to work, decreased sexual activity, and travel and leisure challenges. Reports have described QOL outcomes in cancer patients with colostomies and inflammatory bowel syndrome with colostomies, but little has been written regarding a comparison of cancer and non-cancer populations. The purpose of this study was to describe QOL issues of colostomy patients and compare these issues in cancer and non-cancer participants. MATERIALS AND METHODS: A QOL-ostomy questionnaire was mailed to 2455 California members of the United Ostomy Association. RESULTS: Of the 1457 respondents (59%), 599 had a colostomy. Most were results from cancer (517/599), with colorectal cancer being the most common diagnosis. The most common benign diagnoses were inflammatory bowel disease and diverticulitis. Demographics were similar, except for more females in the non-cancer group (76%), and increased length of time with colostomy from the cancer group (mean 135.9 versus 106.4 months, P = 0.03). Common QOL problems included sexual problems, gas, constipation, travel difficulties, and dissatisfaction with appearance. Overall, cancer patients had less difficulty adjusting to their colostomies. CONCLUSIONS: Results confirmed the negative impact of a colostomy on QOL. While patients with cancer had a better overall QOL than those with benign processes, concerns were common to all colostomy patients. These results provide health care practitioners with information useful in discussing QOL concerns during pre-operation treatment decisions and post operative teaching and follow-up care.     

Oncofetal protein IMP3, a new diagnostic biomarker to distinguish malignant mesothelioma from reactive mesothelial proliferation

The distinction of malignant mesothelioma from reactive mesothelial proliferation remains to be a major challenge for surgical pathologists. In this study, we investigated whether insulin-like growth factor II messenger ribonucleic acid-binding protein 3 (IMP3), an oncofetal protein, can be used as a biomarker to distinguish between malignant and reactive mesothelial cells. A total of 109 cases (mesothelioma, n=45; reactive mesothelial proliferation, n=64) were examined by immunohistochemistry for IMP3 expression. IMP3 showed strong cytoplasmic staining in 33 of 45 (73%) mesothelioma cases. In contrast, the expression of IMP3 was undetectable in all (64 cases) benign reactive mesothelial proliferations. Among the IMP3-positive mesotheliomas, 27 (82%) exhibited diffuse IMP3 expression. The vast majority of IMP3-positive subtypes of mesotheliomas showed IMP3 expression in >50% of malignant cells, as this diffuse staining pattern occurred in 17 (81%) cases of epithelial, 4 (100%) cases of sarcomatoid, and 6 (75%) cases of mixed types of mesothelioma. In addition, 2 cases, which were initially diagnosed as atypical mesothelial proliferations and later confirmed to be mesotheliomas, showed diffuse IMP3 expression. Our findings suggest that IMP3 is a new positive biomarker for malignant mesothelioma. IMP3 immunohistochemical staining can be used as an adjunct tool in the distinction of malignant mesothelioma from reactive mesothelial proliferations.     

HLA class I antibodies in patients awaiting kidney transplantation and the association with renal graft survival

The presence of alloantibodies against human leukocyte antigens (HLA) in the circulation of a transplant recipient shows a significant negative impact on the outcome of solid-organ transplantations. The aim of this study was to examine the impact on renal graft survival of various patterns of alloantibodies detected among patients awaiting kidney transplantation. Among more than 2000 patients awaiting kidney transplantations between July 1992 and March 2006, were 683 patients who displayed anti-HLA alloantibodies, 318 of whom were enrolled in this study. Each patient was followed for at least 9 months; the presence of HLA alloantibodies was checked every 3 months by an enzyme-linked immunosorbent assay. Among these 318 patients, 55 patients underwent kidney transplantations. Their median follow-up time was 69 (range, 9-129) months, including 267 (84%) who displayed persistent class I HLA alloantibodies. The intermittent presence of class I HLA alloantibodies was seen in 20 (6.3%) patients. Serum class I HLA antibodies which was positive at first then became undetectable in 4 (1.3%) patients. Three (0.9%) patients were unsensitized at first and then developed class I HLA alloantibodies later; & 24 (7.5%) patients had class I HLA alloantibodies only once during the follow-up period. Among these patients, 55 patients received renal transplantations. The median survival time was shortest in the patients with persistent class I HLA alloantibodies (59.9 months) and longest among patients who were positive at first and then became negative thereafter or in whom class I HLA alloantibodies was detected only once (132 months). There was a significant difference in graft survival times between patients who had persistent HLA alloantibodies and those in whom to have class I HLA alloantibodies were detected only once (P < .05). In this study, the persistent presence of class I HLA alloantibodies among pretransplantation patients was associated with poorer renal graft outcomes. Surveys of various patterns of sensitization to class I HLA antigen may help us to perform risk stratification. High-risk patients may need more aggressive approaches to deplete antibody or complement levels.     

可多华、戴芬联合治疗慢性前列腺炎/慢性盆底疼痛综合征

目的 探讨可多华和戴芬联合治疗慢性前列腺炎，慢性盆底疼痛综合征的疗效。方法 将123例慢性前列腺炎，慢性盆底疼痛综合征的患者，随机分成3组，即可多华组、戴芬组和可多华＋戴芬联合治疗组，每组均治疗12周。治疗前以及在治疗12周后分别检测慢性前列腺炎症状积分指数（NIH—CPSI）。结果 有115名患者完成了12周的治疗并最终接受评估，可多华组39例，NIH—CPSI总分由治疗前的24．1&#177;2．2下降到治疗后的18．51&#177;1．67，平均下降5．59分（23％）（P〈0．001）；戴芬组37例，NIH-CPSI总分由治疗前的23．95&#177;2．17下降到治疗后的18．14&#177;1．69，平均下降5．81（24％）（P〈0．001）；可多华＋戴芬组39例，NIH—CPSI总分由治疗前的23．82&#177;1．72下降到治疗后的16．77&#177;1．37，平均下降7．05分（30％）（P〈0．001）。结论 可多华、戴芬均能有效缓解慢性前列腺炎，慢性盆底疼痛综合征患者的症状，改善患者的生活质量，但可多华＋戴芬联合治疗组疗效优于单一治疗组。     

Physiologic analysis of cardiac cycle in an implantable impeller centrifugal left ventricular assist device

The purpose of this study was to determine the physiologic relationship between the cardiac cycle and the nonpulsatile impeller centrifugal Taita No.1 left ventricular assist device (T-LVAD) in a chronic animal study. The relationship of the cardiac cycle, pump flow, aortic pressure, left ventricle pressure, and pump power were analyzed by 5 phases in 4 stages. The isovolumetric ventricular phase is from mitral valve closure (MVC) to aortic valve opening (AVO) and is called Stage 1. The ejection phase is from AVO to aortic valve closure (AVC) and is called Stage 2. The isovolumetric relaxation phase is from AVC to MVC and is called Stage 3. The passive filling and atrial contraction phase is from MVC to mitral valve opening (MVO) and called Stage 4. Based on evidence from the physiologic volume change of the left ventricle, the change of pump flow of the T-LVAD in a cardiac cycle by variable voltages of pump control was evaluated using animal models. After left posteriolateral thoracotomy via the fifth intercostal space under general anesthesia, the nonpulsatile centrifugal T-LVAD was implanted into 2 healthy calves. The inflow of the T-LVAD was inserted into the left ventricle through the mitral valve via the left atrial appendage. The arterial blood pressure waveform was measured and recorded on the outflow of the T-LVAD. The 4 phases of a cardiac cycle were defined as MVC-AVO (Stage 1), AVO-AVC (Stage 2), AVC-MVO (Stage 3) and MVC-MVO (Stage 4) according to the outflow pressure of the outflow of the T-LVAD and differential pressure between the outflow and inflow of the T-LVAD. We carried out the real-time waveform measurement for electrocardiogram, the outflow pressure, the T-LVAD flow and the speed, as well as open loop and constant voltage (V). In a cardiac cycle, the sensing current of the T-LVAD was inverse to the speed. The flow of the T-LVAD at the 4 stages was measured individually and analyzed with different control voltages from 10 to 18 V. The highest flow ratio of MVC-AVC/AVC-MVC was noted when the T-LVAD worked on 14 V. By using analysis methodology of the flow ratio of a cardiac cycle, the optimal physiologically effective control of the T-LVAD might be achieved.     

Case report: Management of immediate post-car-diopulmonary bypass massive intra-cardiac thrombosis

PURPOSE: To describe the management of severe acute intracardiac thrombosis in a patient who underwent redo multiple valve replacement and valvular repair. The diagnostic features, associated risk factors, and anesthetic management are reviewed. CLINICAL FEATURES: A 67-yr-old woman undergoing redo mitral and aortic mechanical valve replacement and tricuspid annuloplasty under aprotinin prophylaxis exhibited severe refractory hypotension that began immediately after protamine reversal of intraoperative heparin anticoagulation following separation from cardiopulmonary bypass. Intraoperative transesophageal echocardiography revealed severe thrombosis in the right atrium, right ventricle and pulmonary artery. The patient was managed by immediate reheparinization and return to cardiopulmonary bypass (CPB), surgical thrombectomy, and intraoperative administration of recombinant tissue-plasminogen activator. After removal of the thrombi, and separation from CPB, no further protamine was given. One hundred units of blood products and two surgical re-explorations were required to manage subsequent massive postoperative bleeding. Acute heparin-induced thrombocytopenia (HIT) was ruled out using sensitive assays for HIT antibodies. After 16 days in the intensive care unit and 30 more days in hospital, the patient was subsequently transferred to a chronic care facility and succumbed several weeks later. CONCLUSION: Acute intraoperative thrombosis is a rare and potentially fatal complication of cardiac surgery. Intraoperative transesophageal echocardiography was essential for rapid diagnosis in this case. Multiple interacting prothrombotic factors (e.g., aprotinin use, acquired antithrombin deficiency, long pump time, post-protamine status, transfusion of blood components) were likely contributing factors related to this rare complication.     

计算机体层成像多平面重建在评价椎间融合中的作用

目的 探讨计算机体层成像多平面重建(CTMPR)在评价椎间融合中的作用,寻找定量评价椎间融合的新方法.方法 13例行腰椎间融合的患者术后1周、3个月、6个月行CTMPR,行椎间融合器(Cage)内植骨CT值定量测量.结果 术后1周Cage内植骨CT值为(619.52±26.97)Hu,术后3个月为(628.69±42.60)Hu,术后6个月为(657.77±37.43)Hu.术后1周与术后3个月相比无显著性差异,与术后6个月相比有显著性差异.结论 CT值的测量在椎间融合的判断中具有高准确性.