目的 探讨床旁优化便涂片检查在早期诊治重症肺炎患者出现抗生素相关性腹泻中的临床价值.方法 对天津市第四中心医院重症医学科2013年1月—2018年12月收治的重症肺炎继发腹泻的患者进行研究.根据病房内有无开展床旁便涂片检查将研究对象分为两组:无床旁便涂片组和有床旁便涂片组.动态记录床旁便涂片检查结果,记录两组患者抗生素使用时间、腹泻持续时间、ICU住院时间.结果 床旁便涂片检查可动态反应患者肠道菌群情况.与无床旁便涂片组比较,有床旁便涂片组患者抗生素使用时间(d:6.32±2.46:11.53±2.88)、腹泻持续时间(d:2.78±0.97:6.91±1.74)、ICU住院时间(d:6.91±1.49:11.90±2.40)明显缩短,差异有统计学意义(P<0.05).结论 优化的便涂片检查有助于早期诊治抗生素相关性腹泻,减少患者的抗菌药物暴露时间,缩短腹泻时间,减少ICU入住时间.

近日,医院重症医学科成功抢救了一例以喘息、大汗、心衰症状发病,实际为急性心肌梗死并发心衰的患者. 65岁的张先生,近三年来开始出现胸闷憋气症状,伴心前区压榨性疼痛,每次持续约10分钟,休息后症状能缓解,曾做过冠脉造影检查诊断为冠心病,但张先生未予以重视,未规律服用冠心病二级预防药物.

目的:探讨腹腔镜直肠癌根治术(total mesorectal excision,TME)中保留左结肠动脉术式的可行性,以及对围手术期相关指标和并发症的影响.方法:回顾性分析2017年1月至2019年6月于天津市第四中心医院收治的103例行TME患者的病例资料,其中保留左结肠血管52例(低位结扎组,观察组),不保留左结肠血管51例(高位结扎组,对照组),比较两组手术时间、术中出血量、胃肠道功能恢复时间、术后并发症、淋巴结清扫数量等.结果:两组患者均无中转开腹病例,围手术期无死亡病例.对比观察组与对照组手术时间、出血量、淋巴结清扫数量分别为[(188.2±9.0)min vs.(185.6±13.3)min,(53.9±4.1)mL vs.(54.4±4.1)mL,(18.5±1.8)枚vs.(19.4±2.1)枚],均差异无统计学意义(P>0.05).术后观察组肠鸣音恢复时间早于对照组[(21.2±2.0)h vs.(25.2±3.2)h,P<0.05],差异有统计学意义;两组术后吻合口瘘以及吻合口狭窄发生率无显著差异(P>0.05).两组术后2周膀胱残余尿比较,观察组少于对照组[(34.8±8.4)mL vs.(45.5±15.6)mL,P<0.05],差异有统计学意义.结论:保留左结肠动脉的低位结扎术,不会减少吻合口瘘以及吻合口狭窄发生率,不影响吻合口的血供,不会延长手术时间,不会增加术中出血量,而且清扫的淋巴结数量(包括253组淋巴结数量)不少于高位结扎组,可以减少由于盆腔自主神经功能损伤导致的膀胱残余尿量增加的情况,并且可以加快术后胃肠功能的恢复.

The flavonoid apigenin is common to many plants. Although the responsible mechanisms have yet to be elucidated, apigenin demonstrates tumor suppression in vitro and in vivo. This study uses an azoxymethane (AOM)/dextran sodium sulfate- (DSS-) induced colon cancer mouse model to investigate apigenin's potential mechanism of action exerted through its effects upon gut microbiota. The size and quantity of tumors were reduced significantly in the apigenin treatment group. Using 16S rRNA high-throughput sequencing of fecal samples, the composition of gut microbiota was significantly affected by apigenin. Further experiments in which gut microbiota were reduced and feces were transplanted provided further evidence of apigenin-modulated gut microbiota exerting antitumor effects. Apigenin was unable to reduce the number or size of tumors when gut microbiota were depleted. Moreover, tumor inhibition effects were initiated following the transplant of feces from mice treated with apigenin. Our findings suggest that the effect of apigenin on the composition of gut microbiota can suppress tumors.

呼吸机相关性肺炎(Ventilator-associated pneumonia,VAP)是常见的院内获得性感染,在ICU医院获得性感染中发生率最高.机械通气患者并发VAP会延长机械通气时间,延长住院时间,增加抗生素使用量,加重患者家属经济负担,且对患者的预后影响重大.特别是多重耐药(Multidrug-Resistant,MDR)病原菌的感染,治疗困难,抗生素治疗效果差,已成为影响重症患者预后的最大顽疾之一.随着人口的老龄化,老年机械通气患者越来越多.老年患者是一组特殊人群,机体各项机能衰退,故如何个体化的给予抗感染治疗方案尤为重要.

OBJECTIVE:To investigate the significance of optimization of bedside Gram staining of sputum smear in the early diagnosis and antimicrobial treatment for ventilator-associated pneumonia (VAP) patients.METHODS:The data of patients with VAP undergoing mechanical ventilation over 48 hours in the Department of Critical Care Medicine of Tianjin Fourth Central Hospital from June 2009 to June 2014 were analyzed. The patients were divided into two groups according to whether or not bedside Gram staining of sputum smear was used or not. The sputum samples from lower respiratory tract of all VAP patients were collected daily with tracheal catheter. In empirical examination group (from June 2009 to December 2011, n=43), the patients received antibiotics at the time of onset of VAP, selection of antibiotics depended on the information of bacterial epidemiology of the intensive care unit (ICU), and also existence of high risk factors of multi-drug resistant bacteria. In target treatment group (from January 2012 to June 2014, n=43), the patients received antibiotics according to the results of bedside instant sputum smear examination and empirical antibiotic regime. The correlation between the results of sputum smear examination and culture result was analyzed. The levels of body temperature, white blood cell (WBC) count, procalcitonin (PCT) level,and high sensitivity C- reactive protein (hs-CRP) were measured on the 1st day and 3rd day. The length of antibiotics treatment, duration of mechanical ventilation, and the time of ICU stay were recorded for both groups.RESULTS:There were 512 qualified sputum specimens for culture, from which 336 pathogens were found, and 358 strains of pathogenic bacteria were found from microscopic examination of 512 qualified sputum smear. The coincidence rate of results of bedside examination of sputum smear and that of sputum culture was 78.32%(401/512). The diagnostic acumen of the former was 85.42% (287/336), specificity was 64.77% (114/176), positive predictive value was 80.17% (287/358), and negative predictive value was 74.03% (114/154). On the 1st day, no statistical differences in infection index between the two groups could be found, but on the 3rd day, the results were significantly improved in both groups. Compared with the empirical treatment group, the body temperature, WBC, PCT and hs-CRP in the target treatment group were significantly lower [body temperature (centigrade): 36.83 ± 0.69 vs. 37.64 ± 0.71, WBC (× 10⁹/L): 7.91 ± 2.75 vs. 9.66 ± 3.39, PCT (μg/L): 7.14 ± 3.89 vs. 10.14 ± 4.32, hs-CRP (mg/L): 12.24 ± 6.28 vs. 15.54 ± 5.94, P<0.05 or P<0.01]. Compared with the empirical treatment group, the time of antibiotics use(days: 6.00 ± 2.55 vs. 9.20 ± 3.46), the duration of mechanical ventilation (days: 5.00 ± 1.73 vs. 7.00 ± 1.94), and the length of ICU stay (days: 7.43 ± 1.72 vs. 12.57 ± 4.16) were significantly shortened (P<0.05 or P<0.01).CONCLUSIONS:The results of bedside sputum examination and sputum culture showed a good correlation, and the former is helpful in early diagnosis and treatment of VAP. The result of high quality sputum smear in significant in guiding the first choice of antibiotics, reduce the time of antibiotic use, shorten the duration of mechanical ventilation and the length of ICU stay, and improve the outcome of the patients.

Objective To investigate the association of insulin resistance and C-reactive protein with urinary albumin excretion rate(UAER)in patients with type 2 diabetes for 5 years. Methods The subjects(674 cases with type 2 diabetes for 5 years)were divided into the normal albuminuria group (296 cases, UAER20 μg/min), microalbuminuria group (242 cases, UAER: 20~200 μg/min)and clinical albuminuria group(136 cases, UAER200 μg/min), according to UAER levels. Oral glucose tolerance test and insulin release test were performed.The insulin resistance index (ISI), area under the insulin curve and ratio of the area under insulin curve(AUCI/AUCG)were used to assess the insulin resistance(HOMA-IR)for each patient. The levels of hs-CRP, HbA1C, LDL-C, HDL-C, SCr and BUN were measured for analyzing the relationship between UREA and hs-CRP or insulin resistance. Results The ISI in normal albuminuria group was -3.67±0.53, which was significantly higher than those(-4.27±0.42 and -4.39± 0.47)in microalbuminuria group and clinical albuminuria group (P0.05). HOMA-IR in normal albuminuria group was 3.41± 0.56, which was significantly lower than those (3.88±0.42 and 3.97±0.52)in microalbuminuria group and clinical albuminuria group(P0.05). AUCI/AUCG in normal albuminuria group was 2.89±0.62 which was significantly lower than those(2.93±0.84 and 2.97±0.53)in microalbuminuria group and clinical albuminuria group (P0.05). There was positive correlation between UAER levels and hs-CRP levels (r=0.319,P0.05). Multiple stepwise regression analysis showed that UAER was positively correlated with diabetes progress, hs-CRP and AUCI/AUCG (β were 0.643, 0.148 and 0.219, respectively, P0.05). Conclusion The increase of UAER in T2DM patients with normal renal function for 5 years might be associated with the development of insulin resistance and the increase of hs-CRP level.

Objective:To evaluate the reliability and effectiveness of application of bedside gastroscopy oncritically-ill patients. Methods:At the bedside, 108 Critilly-ill patients with upper gastrointernal tract bleedingwere examined and treated using the gastriscope. The heart rate, blood pressure, breath status and temperaturewere detected before and after gastroscopy check. Results:The physiological index of 108 Critilly-ill ill patientsafter gastroscopy check were as stable as before. Conclusion:The application of bedside gastroscope oncritically-ill patients is safe, reliable and effective, but it must be practiced by experienceal profssional and ingastroscopic center with the condition of rescue.

目的探讨危重症病人床旁胃镜应用价值及安全性.方法对我院109例危重症病人实施床旁电子胃镜检查,检查过程中观察病人在检查潜、检查后半小时的体温、心率、血压、呼吸等生命体征变化.结果该研究显示,病人各项生理指标术前、术后相近,无统计学差异.结论危重症病人床旁胃镜检查是安全可行的,但应在有经验的内镜医师实施和监控及有抢救条件的监护病房进行.