72株阴沟肠杆菌的临床分布及其耐药性分析

目的分析阴沟肠杆菌在临床的感染和对常用抗生素的耐药性,以指导临床合理用药。方法对2007年7月至2009年7月从临床分离的阴沟肠杆菌的临床分布特点及耐药情况进行总结分析。结果72株阴沟肠杆菌标本主要源于痰液（32株,44.4%）和尿液（16株,22.2%）;菌株分布于多个病区;阴沟肠杆菌对碳青酶烯类、头孢吡肟、派拉西林/他唑巴坦的敏感性较高。结论阴沟肠杆菌主要引起呼吸道、尿路感染,其耐药率较高,亚胺培南仍为治疗阴沟肠杆菌严重感染的首选用药。     

Ⅳ期结直肠癌外科治疗方式的选择

目的评价不同手术切除方式对Ⅳ期结直肠癌预后的作用和意义。方法回顾性分析167例Ⅳ期结直肠癌的临床资料,将这167例患者分为两组：95例根治性切除组与72例姑息性切除或仅行造瘘术组。比较两组患者的手术并发症发生率、手术死亡率以及长期生存率。结果根治性切除组手术并发症发生率为15.2%,姑息性切除或仅行造瘘术组手术并发症发生率为27.9%（P〈0.05）;根治性切除组手术死亡率为3.1%,姑息性切除或仅行造瘘术组死亡率为5.5%（P〉0.05）;根治性切除的患者术后1、3、5年生存率为85.7%、63.2%、38.4%,姑息性切除术后1、3、5年的生存率分别为67.5%、41.3%、8.6%,仅行造瘘的患者术后1、3、5年的生存率分别为45.3%、0%、0%。结论对于Ⅳ期结直肠癌施行积极的根治性切除手术可改善患者的预后。     

不同浓度罗哌卡因复合布托啡诺患者自控硬膜外镇痛的临床比较

目的比较3种不同浓度罗哌卡因复合布托啡诺患者自控硬膜外镇痛（PCEA）的镇痛效果、胃肠动力、运动阻滞的影响,探讨罗哌卡因复合布托啡诺PCEA的最佳浓度。方法90例择期硬膜外麻醉行妇科手术的患者,术后PCEA随机接受0.075%、0.1%和0.125%罗哌卡因复合布托啡诺6mg、氟哌利多2.5mg,自控镇痛的设置为：总量120ml,初始负荷剂量5ml,背景剂量恒速2ml/h,自控2ml/次,间隔时间15min。镇痛效果、胃肠动力及下肢肌力的评估指标分别为：视觉模拟量表（VAS）、第1次肛门排气或者排便时间和修正Bromage分级。采集数据时间：手术当天17：00、术后第1天08：00、术后第1天17：00、术后第2天8：00。结果3组的镇痛效果、胃肠动力及运动阻滞比较无统计学意义。三组均能提供较好的镇痛效果,且无下肢运动的阻滞。结论0.075%罗哌卡因PCEA可以提供较好的镇痛效果,保护胃肠动力,无运动阻滞。     

抗生素在椎间盘髓核组织内药物动力学变化的实验研究--静脉和经皮穿刺椎间盘给药的比较

目的探讨抗生素在兔椎间盘髓核组织内药物动力学改变,比较静脉和经皮穿刺椎间盘给药2种方法的药代动力学差异,为临床治疗椎间盘炎的方法选择提供理论依据. 材料与方法将35只新西兰大白兔随机分为A、B、C 3组.A组为经皮穿刺椎间盘给药,共15只,随机再分为3组,并分别于用药后24h、48h、72h取髓核标本测定药物浓度;B组为静脉多次给药,共15只,随机再分为3组,并分别于用药24h、48h、72h后于次日取髓核标本测定药物浓度;C组为静脉单次给药,共5只,静脉给药后,每隔30min取1只动物的髓核样本测定药物浓度. 结果经皮穿刺椎间盘给药(A组)24h后检测髓核药物浓度最高峰达到1 180μg/g,平均值665μg/g,与静脉多次给药(B组)24h后检测髓核药物浓度的平均值4.04μg/g有显著差异(P＜0.05);与静脉单次给药(C组)2.5h内检测髓核药物浓度的平均值16.6μg/g亦存在显著差异.静脉单次给药组2.5h内检测髓核药物浓度随时间推移而有所降低,与静脉多次给药组24h后检测髓核药物浓度同样存在显著差异(P＜0.01).经皮穿刺椎间盘给药组48h、72h后检测髓核药物浓度明显降低,二者之间无显著差异(P＞0.05),但与24h检测结果均存在显著差异(P＜0.01).静脉多次给药组24h、48h、72h后检测髓核药物浓度之间无明显差异(P＞0.05). 结论静脉注射头孢唑啉,药物对椎间盘具有较强的渗透性,对预防椎间盘炎的发生及轻度椎间盘炎的治疗有一定价值;经皮穿刺椎间盘注射头孢唑啉,24h内髓核药物浓度维持在最小抑菌浓度的数百倍,是治疗椎间盘炎、特别是重度椎间盘炎的首选方法.     

微导管系统在原发性肝癌介入治疗中的临床应用

目的研究微导管系统在原发性肝癌化疗栓塞中的应用价值。方法应用研制的微导管系统对常规导管不能超选择的23例原发性肝癌患者行肝动脉化疗栓塞术。结果23例患者使用微导管系统32次，操作成功30次，失败2次，成功率93．8％。治疗后3周复查肿瘤缩小大于50％者7例(30．4％)，肿瘤缩小小于50％但大于25％者12例(52．2％)，肿瘤无明显变化者4例(17．4％)。血清AFP下降大于50％者17例(85％)，肝功能损害轻，全部患者术后无严重并发症。结论微导管系统操作简单、方便、超选择成功率高、疗效好、副反应少，具有十分重要的临床应用价值。     

瑞芬太尼预防丙泊酚注射痛

目的:探讨输注瑞芬太尼是否能有效地预防丙泊酚注射痛。方法:93例择期手术的病人随机分为A、B、C3组,每组31例。A组用药为瑞芬太尼0.3μg/kg;B组用药为2%利多卡因40mg;C组为对照组用生理盐水2ml。用VAS法对各组丙泊酚注射痛进行评分。观察各组对丙泊酚注射痛的影响。结果:C组注射痛的发生率为70.9%,与C组相比A组(25.8%;P<0.01)及B组(29.0%;P<0.01)注射痛的发生率明显减少。与C组相比A组及B组的疼痛评分差异显著(P<0.01),A与B两组间差异不显著。结论:瑞芬太尼与利多卡因一样可有效地预防注射痛,与丙泊酚配合使用可成为一种新的静脉麻醉方法。     

Uterine artery pulsatility index and serum BMP-9 predict resistance to methotrexate therapy in gestational trophoblastic neoplasia: A cohort study

Background: Methotrexate is the most common first-line chemotherapy for low-risk gestational trophoblastic neoplasia (GTN). Uterine artery pulsatility index (UAPI) is an ultrasound marker for tumor vascularity that has been associated with an increased risk of methotrexate resistance. The combination of circulating angiogenic factor levels with UAPI data may improve the capacity of this model to predict chemoresistance. Methods: This was a single-center cohort study of women newly diagnosed between January 2008 and June 2012 with low-risk GTN during postmolar surveillance and treated with single-agent methotrexate at Charing Cross Hospital, a UK national center for treatment of gestational trophoblastic disease. Two hundred seventeen women underwent an ultrasound for UAPI measurement prior to initiation of chemotherapy. To examine serologic markers of methotrexate resistance among this cohort, we performed a case-control study using archived serum from 76 patients who could be matched based on prognostic risk score. Serum samples were examined by immunoassay to measure 8 different angiogenic factors (VEGF-A, FGF-basic, PLGF-1, PDGF-BB, EGF, ANGPT2, BMP-9, and ENG). Receiver-operator characteristic area under the curve (AUC) values were calculated for the ability of each analyte to correctly classify patients as methotrexate sensitive (MTX-S) or resistant (MTX-R). Results: Total human chorionic gonadotropin levels were similar between the MTX-S and MTX-R groups. UAPI values were significantly higher in MTX-S (median 1.30 [interquartile range {IQR} = 0.80-1.90]) compared to MTX-R patients (median 0.875 [IQR = 0.60-1.30]; P < 0.0001) with AUC 0.68 (95% confidence interval 0.61-0.76; P < 0.0001). In univariate analysis, only BMP-9 concentrations were significantly different between groups, lower among MTX-S (median of 225 ng/L, IQR = 170-287) compared to MTX-R patients (median 280 ng/L [IQR = 200-339]; P= 0.03). Combining UAPI with BMP-9 concentration improved prediction for chemoresistance with AUC 0.77 (95% confidence interval 0.66-0.88; P < 0.0001). Conclusion: Circulating levels of BMP-9 are elevated in newly diagnosed women with low-risk GTN destined to fail primary methotrexate therapy. A combined test using serum BMP-9 plus UAPI might improve prediction of MTX-R in low-risk GTN.     

Magnetic resonance imaging criteria of immune checkpoint inhibitor-induced hypophysitis

Autoimmune hypophysitis is a rare complication of immune checkpoint inhibitors. Immune checkpoint inhibitors have been used for advanced stages of melanoma, renal cell carcinoma, and lung cancer. Multiple endocrinopathies, among them hypophysitis, could result as a reverse event from this therapy. MRI is the imaging modality of choice and usually demonstrates pituitary gland hypertrophy, irregular thickening of the pituitary infundibulum, and diffuse enhancement. We present a case of stage IV metastatic renal cell carcinoma complicated with hypophysitis secondary to combined nivolumab and ipilimumab therapy.     

密闭式浅层吸痰在机械通气中的应用效果研究

[目的]探讨实施不同的吸痰方式和吸痰深度对机械通气病人的效果,为临床选择安全、有效的吸痰方式提供依据。[方法]将40例行机械通气的病人随机分成两组,观察组采用密闭式浅层吸痰（吸痰管超过气管导管前端1 cm）,对照组采用临床常规开放式吸痰（即吸痰管插入气管遇到阻力后上提0.5 cm ~1.0 cm 后吸引）,比较两组病人吸痰前后血氧饱和度（SpO 2）、心率（HR）、呼吸频率（R）、潮气量（VT）、平均气道压（Pmean）的变化以及对气道黏膜的损伤等并发症的影响。[结果]观察组病人采用密闭式浅层吸痰后引起呼吸循环变化幅度及气道黏膜损伤程度明显优于对照组,差异有统计学意义（P 〈0.05）。[结论]病人机械通气期间行密闭式浅层吸痰能降低机体的应激反应,减少对气道的刺激及吸痰并发症,是一种安全有效的吸痰方式。