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Preterm Birth

截止至2002年5月,現有早產治療的臨床證據如下: (1) 高危早產:在一些國家實施的RCT發現,在降低早產危險方面,加強產前保健與普通產前保健沒有明顯差異.包括5個RCT的1個系統評價發現,對有宮頸改變的婦女行宮頸環扎術有不同的結果,沒有明確的結論.1個大樣本的RCT發現,孕9～29周宮頸功能可能不全的婦女進行預防性宮頸環扎手術與不環扎相比,能明顯降低早產(＜33孕周),但也會明顯增加產褥感染的危險.另外4篇較小樣本的RCT發現,孕10～30周、具各種早產高危因素的婦女,進行預防性宮頸環扎手術與不環扎相比,并不能降低早產(＜34孕周).1篇系統評價的2個RCT報告,對有宮頸改變的婦女進行環扎術有不同的結果,其中1個RCT發現其并不能明顯降低早產(＜34孕周),而另外1個較小樣本的RCT卻發現宮頸環扎手術加臥床休息與單純臥床休息比較,能明顯降低34周前的早產.沒有1個RCT證實行環扎術加臥床休息與單純臥床休息相比,能降低圍生兒死亡率. (2) 胎膜早破:1個系統評價發現,對胎膜早破的婦女,抗生素較安慰劑能明顯延長孕周、降低新生兒發病率的危險,如新生兒感染、出生后氧療、腦部超聲異常等.阿莫西林加克拉維酸治療與新生兒壞死性小腸結腸炎的發生率明顯增加有關.一個基于1個RCT的系統評價發現,沒有充足的證據證實羊膜腔灌注與不灌注比較能改善胎膜早破后的新生兒結局. (3) 先兆早產的治療:①β-腎上腺素興奮劑:1個系統評價發現,β-腎上腺素興奮劑與安慰劑或不治療相比,并不能明顯降低圍生兒死亡率、呼吸窘迫綜合征及低體重兒(＜2 500 g)發生率,且與與安慰劑或不治療相比,β-腎上腺素興奮劑增加孕母副反應,如胸痛、心悸、呼吸困難、震顫、惡心、嘔吐、頭痛、高血糖、低鉀血癥.②鈣離子通道拮抗劑: 沒有關于鈣離子通道拮抗劑與安慰劑比較的系統評價或RCT.1個系統評價發現,鈣離子通道抑制劑與其它保胎藥(主要是β-腎上腺受體興奮劑)比較,能顯著降低48 h內的早產分娩,減少因孕母副反應退出治療和新生兒發病率.③硫酸鎂:1個系統評價發現,硫酸鎂與安慰劑比較,并不能明顯降低孕36周前的早產率、圍生兒死亡率、呼吸窘迫綜合征的發生率.另一個系統評價發現,硫酸鎂和其他宮縮抑制劑(β-腎上腺素興奮劑、鈣離子通道拮抗劑、前列腺素合成抑制劑、硝化甘油、酒精和葡萄糖注射劑)比較,并不能明顯降低48 h內早產率(盡管結果沒有差異).④垂體受體拮抗劑(阿托西班):1個系統評價納入 2個RCT,對阿托西班和安慰劑治療早產進行比較有不同的結果.較大樣本的RCT發現,阿托西班較安慰劑能延長孕周,但阿托西班增加了孕28周以下的胎兒死亡率.另一個RCT發現,阿托西班增加了48 h內的早產.⑤前列腺素抑制劑(消炎痛):1個系統評價發現,消炎痛與安慰劑比較,能明顯降低孕37周前的48 h和7天的早產率的證據有限.然而,同時發現消炎痛與安慰劑或不治療相比,并不能明顯降低圍生兒死亡率、新生兒呼吸窘迫綜合征、肺支氣管發育不良、壞死性小腸結腸炎、新生兒敗血癥或低體重兒.但這個系統評價樣本太小,尚不能發現有臨床意義的差異. (4) 擇期或非擇期剖宮產對早產婦女治療效果:1個系統評價結果發現,擇期剖宮產較非擇期剖宮產會增加孕母的發病率,卻不能降低新生兒的發病率和死亡率.但尚不能證明此效果是否對新生兒有臨床意義. (5) 改善早產妊娠結局的干預措施:①對早產者采用皮質類固醇:1個系統評價認為,對可能發生早產的婦女使用皮質激素較安慰劑或不處理能明顯降低早產兒出生后呼吸窘迫綜合征、新生兒死亡率和顱內出血的發生.②促甲狀腺激素釋放激素在早產中的運用:1個系統評價發現,在早產的高危婦女中,促甲狀腺激素釋放激素和類固醇激素聯合應用與單用皮質類固醇激素比較,對新生兒結局的影響無明顯差異,但會明顯增加孕母和胎兒的不良反應.③抗生素:1個系統評價發現,抗生素與安慰劑比較,不能延長孕周、降低新生兒死亡率,但可降低孕母感染率.

The Role of Monitoring Procalcitonin in Comprehensive Evaluation during Diagnosis and Treatment of Community Acquired Pneumonia

ObjectiveTo investigate the role of dynamic monitoring procalcitonin (PCT) in the comprehensive evaluation during the diagnosis and treatment of community acquired pneumonia (CAP). MethodsFour hundred and sixty-eight patients with CAP were randomly assigned to a PCT-guided group (the research group) and a standard guideline group (the control group). The clinical symptoms,CURB-65 grade,blood leucocyte count and classification,and C-reactive protein (CRP)were compared between two groups. The PCT-guided application time of antibiotics,the hospitalization time,chest CT examination rate,the cure or the improvement rate were also estimated and commpared. ResultsThe hospitalization time [(9.6±1.7)days vs. (10.9±1.6)days],hospitalization cost [(6 957.11±1 009.46) yuan vs. (8 011.35±1 049.77) yuan],chest CT examination rate (56.96% vs. 89.40%),the application time of antibiotics [(16.5±2.3)days vs. (20.0±1.2)days],and the rate of required antibiotics upgrade (6.96% vs. 11.06%) in the research group were all significantly lower than the control group (P<0.05). There was no significant difference between two groups in the ratio of the adverse reaction of antibiotics (14.78% vs. 15.20%),the rate of transfer into ICU (2.61% vs. 3.69%) or the mortality (1.74% vs. 2.30%)(P>0.05). ConclusionOn the basis of CAP guidelines,the dynamic monitoring of PCT may shorten the time of antibiotic use and the hospitalization,reduce the cost of hospitalization and the rate of chest CT scan in patients with CAP.

Pay Attention to Management of Perioperative Antibiotic’ Application

The Analysis of the Application of Perioperative Antibiotics

【摘要】　目的　了解在圍手術期術前30 min應用抗生素的情況。　方法　根據2004年衛生部、國家中醫藥管理局、總后勤部發布的《抗菌藥物臨床應用指導原則》中圍手術期抗生素的使用原則，對四川大學華西醫院2010年4-6月500臺手術圍手術期抗生素的使用情況進行分析。　結果　抗生素在麻醉前輸：0臺；抗生素末在術前30 min輸2臺，占0.4%；抗生素末即用即配：0臺；抗生素與麻藥及其他禁忌藥混合輸:0臺；手術3 h后末及時追加抗生素：0臺；特殊患者使用抗生素的注意事項不清楚2臺，占0.4%。　結論　該院99.6%的手術實行在手術室術前30 min輸入抗生素，確保抗生素達到有效濃度，有效控制感染，保證手術的成功，保障患者安全。【Abstract】　Objective　To investigate the application of perioperative antibiotics half an hour before operation in West China Hospital of Sichuan University. 　Methods　According to Clinical Guidance of Antibiotics published by Ministry of Health, State Administration of Traditional Chinese Medicine and General Logistics Department in 2004, we investigated the application of perioperative antibiotics in 500 operations between April to June 2010 in our hospital.　Results　There was no operation with infusion of antibiotics before anesthesia, 2 operations without infusion of antibiotics half an hour before operation (0.4%), no operation without immediate infusion after preparation, no operation with mixed infusion of antibiotics and anesthesia and other contraindicated drugs, no operation without infusion of antibiotics 3 hours after operation, and 2 operations in which cautious items about the children, pregnancy and old patients were unclear (0.4%).　Conclusion　About 99.6% operations in our hospital have the infusion of antibiotics 30 minutes before the operation, which is the guarantee of antibiotics with effective concentration, inhibition of infection, success of the operation and safety of the patients.

枯草桿菌二聯活菌腸溶膠囊預防老年人抗生素相關性腸道菌群失調的臨床研究

目的　觀察枯草桿菌二聯活菌腸溶膠囊對老年人抗生素相關性腸道菌群失調的防治作用。 方法　選擇2011年7月－2012年5月80例老年重度下呼吸道感染患者隨機分配至A組（單用頭孢哌酮舒巴坦）和B組（頭孢哌酮舒巴坦+枯草桿菌二聯活菌腸溶膠囊），療程14 d，治療結束后判定療效和菌群失調的情況。 結果　頭孢哌酮舒巴坦對老年重度下呼吸道感染患者有理想效果，兩組有效率分別為70%和75%（P＞0.05）；B組患者腸道菌群失調的發生率、繼發真菌的發生率顯著低于A組（P＜0.05）。 結論　枯草桿菌二聯活菌腸溶膠囊能有效預防老年人抗生素相關性腸道菌群失調的發生。

Diagnosis and Treatment for Diabetes Mellitus with Pyogenic Liver Abscess

目的總結糖尿病并細菌性肝膿腫(DPHA)的臨床特點和診治經驗。方法回顧性分析我院2002年3月至2010年12月期間出院的DPHA與無DPHA(NDPHA)患者的臨床資料。結果細菌性肝膿腫患者共22例，其中DPHA患者11例。DPHA組人口學特征、臨床表現、白細胞計數與NDPHA組比較差異均無統計學意義(Pgt;0.05); DPHA組血白蛋白低于NDPHA(P=0.006)，而ALT高于NDPHA(P=0.006)。DPHA組病灶個數多于NDPHA組(P=0.032)，且病灶直徑也大于NDPHA組(P=0.006)。膿培養: 2組大腸桿菌均為3例; DPHA組克雷伯桿菌4例，而NDPHA組無克雷伯桿菌。DPHA組發生切口感染7例、腹腔感染2例，NDPHA組發生切口感染3例。 DPHA組抗生素使用時間、住院時間及住院費用均高于NDPHA組(Plt;0.05)。2組均分別治愈6例、好轉5例，2組均無死亡患者。結論DPHA有其特殊的臨床特征，并發癥多，住院費用高，但預后與NDPHA差別不大。

Treatment of antibiotic associated diarrhea by Bifidobacterium tetravaccine in infants in China: a Meta-analysis

Objective To systematically evaluate the clinical effect and safety of Bifidobacterium tetravaccine tablets in the treatment of antibiotic associated diarrhea (ADD) in infants in China. Methods Randomized controlled trials (RCTs) of treatment of AAD by Bifidobacterium tetravaccine in infants were searched by computer from China Knowledge Resource Integrated Database, VIP and Wanfang Data from their inception to November 2016. Meta-analysis of the data was carried out by RevMan 5.3 software. Results Twelve RCTs were chosen, which included 1 761 infant patients. The Meta analysis showed that the effects of treatment of ADD were significantly superior to those of the control group [OR=5.74, 95%CI (4.14, 7.96),P<0.000 01]. Among the 12 RCTs, 8 had no adverse reactions, while the rest4 articles did not mention adverse reactions. Conclusions Based on the present clinical evidences, treatment of ADD by Bifidobacterium tetravaccine in infants is effective and safe. But due to the small number and different quality of RCTs, this conclusion still needs to be confirmed by large sample, multicenter, and high-quality clinical RCTs.

腹膜透析相關性腹膜炎致病菌的耐藥性分析

目的:探討腹膜透析相關性腹膜炎的致病菌及其耐藥性。方法:回顧性分析的93例腹膜透析相關性腹膜炎的致病菌及其耐藥性。結果:34例培養陽性, 透出液培養陽性率為36.6%, 其中革蘭陽性球菌14例, 革蘭陰性桿菌17例, 真菌4例。革蘭陰性桿菌對氨芐西林的耐藥率最高,達83.3%,亞胺培南耐藥性最低,達20.0%。革蘭陽性球菌對青霉素、環丙沙星的耐藥率高,分別為81.8%、71.4%。 結論:提高腹膜透析液細菌培養陽性率有助于腹膜透析相關性腹膜炎的治療;在經驗用藥基礎上,應依據細菌培養、藥敏,選擇治療腹膜透析相關性腹膜炎的敏感、有效抗菌素,真菌性腹膜炎治療效果仍差,應盡早拔管。

大環內酯類抗生素在支氣管擴張癥中的應用

SIMPLE CHOLECYSTECTOMY AND USING ANTIBIOTIC IN PERIOPERATIVE PERIOD(ANALYSIS OF 642 CASES)

目的 了解單純膽囊切除術圍手術期應用預防性抗生素的作用。方法 對我院普外一科1998年1月至1999年12月2年間所施行的642例擇期單純膽囊切除術圍手術期抗生素的使用、細菌培養結果和切口感染情況進行回顧性分析。結果 642例根據其抗生素應用情況分為未用抗生素組(n＝220)、術前30分鐘一次性給藥組(n＝200)和術后3天持續用藥組(n＝222) 3組，3組患者之性別、年齡構成情況、全身狀況及發生術后切口感染情況間的差異均無顯著性意義(Ｐ＞0.05)； 對642例中隨機選擇52例行術中膽囊膽汁培養，結果47例無細菌生長。結論 對單純膽囊切除術患者術前無感染前提下，不用或僅術前30分鐘一次性使用抗生素是安全可行的，這對縮短患者住院日，減少其醫療費用具有積極的意義。