目的 探讨新生儿危重先心病手术治疗时机的选择及术前调整策略.方法 收集从阜外医院PICU入组2019年9月～2020年9月期间行小儿外科手术先心病新生儿53例,及未行手术治疗新生儿共60例.未手术的7例中,5例自动出院,2例患儿院内死亡),接受手术的新生儿中位日龄为14天,男性37例,女性16例.以14 d分组对比两组术后临床指标,比较两组临床预后情况.结果 行外科手术治疗的年龄14 d以内(含)新生儿27例,年龄14 d以上新生儿26例,对比两组新生儿术前体质量无明显差异(3.344±0.428 vs.3.631±0.622)kg,对比术前转入ICU调整例数,两组无明显差异(16vs.11),对比术前出现危重状态例数,两组无明显差异(9 vs.5).临床预后对比,年龄14 d以上组术后呼吸机使用时间明显少于年龄14 d以内组(318±330 vs.156±167)h(P＜0.05);ICU住院时间方面,14 d以上组明显少于14 d以内组新生儿(20±17 vs.11±6)d(P＜0.01);术后并发症对比:两组新生儿在术后死亡率、渗漏、二次插管、延迟关胸等方面均无明显差异.结论 新生儿年龄是否大于14天与院内死亡率、渗漏发生率、二次插管发生率、延迟关胸等方面无明显相关,危重先心病术前危重状态出现概率与年龄无相关,尽早外科手术治疗新生儿危重先天性心脏病并不能改善临床预后,推迟危重状态出现时间的ICU系统调整策略尤为重要.

目的 探讨新生儿危重先天性心脏病术前危重状态的识别及针对危重状态的治疗策略.方法 收集2019年9月至2020年9月我院的收治新生儿手术患儿60例,其中53例接受手术治疗,5例自动出院,2例死亡.手术新生儿中位年龄14 d,男37例,女16例.以术前出现危重状态分组,比较两组术后临床指标及预后情况.结果 53例接受手术治疗的新生儿中,术前出现危重状态14例,未出现危重状态39例.两组新生儿术前体重、手术年龄无明显差异,危重组新生儿术前调整时间显著多于非危重组新生儿[(3.5±2.2)d,(1.2±2.5)d].危重组术后呼吸机使用时间明显多于非危重组[(382.6±262.8)h,(187.0±260.2)h].危重组新生儿ICU住院时间明显高于非危重组[(23.5±12.8)d,(12.8±12.9)d].两组新生儿在术后死亡率、渗漏、二次插管等方面均无明显差异,危重组新生儿术后延迟关胸发生率明显多于非危重组.结论 新生儿危重先天性心脏病术前出现危重状态将影响预后,术前危重状态出现概率与年龄不相关,做好术前危重状态评估和系统调整策略尤为重要.

目的 评估小剂量右美托咪定在紫绀型先天性心脏病术后镇痛镇静的疗效和安全性.方法 选取2019年(7～12)月紫绀型先天性心脏病患儿(n=151)接受镇痛镇静治疗,分为常规组(瑞芬太尼+咪达唑仑治疗,n=81)和联合组(再加用右美托咪定治疗,n=70).观察两组镇痛满意程度、儿科重症监护室(pediatric intensive care unit,PICU)停留时间等指标.结果 与常规组相比,联合组镇痛效果更好(P＜ 0.05);联合组使用的瑞芬太尼[(46±7) μg/(kg.h)vs.(28±4) μg/(kg·h)]和苯二氮卓类中咪达唑仑[(206±54)μg/(kg·h) vs.(139±21)μg/(kg·h)]用量更低(P＜0.05);疼痛临时干预比例更低(P＜0.05).机械通气时间和PICU停留时间两组无明显差异.结论 小剂量右美托咪定在紫绀型先天性心脏病术后镇痛镇静中具有良好效果,还可降低阿片类和苯二氮卓类药物的用量,安全可靠.

目的 探究膈肌折叠术治疗先天性心脏病(先心病)术后膈肌麻痹的手术时机及疗效.方法 收集2013年1月至2019年2月于阜外医院行膈肌折叠术患儿30例,男17例、女13例,年龄19.5(3,72)个月,其中双侧膈肌麻痹(双侧组)6例,单侧膈肌麻痹(单侧组)24例,比较两组患者的临床资料.结果 双侧膈肌麻痹患者中2例行双侧膈肌折叠术,其余4例经单侧膈肌折叠后继续脱机锻炼.单侧组与双侧组比较,呼吸机使用时间较短[(266.77±338.34)h vs.(995.33±622.29)h,P=0.001],总ICU滞留时间较短[(33.21±23.97)d vs.(67.33±28.54)d,P=0.008],差异有统计学意义.双侧组死亡1例,两组差异无统计学意义(P=0.363).两组患者膈肌折叠术后ICU滞留时间差异无统计学意义[(11.68±10.28)d vs.(29.83±27.73)d,P＞0.05].结论 膈肌折叠术是先心病术后膈肌麻痹经保守治疗无效后的有效治疗手段,双侧膈肌麻痹经手术治疗其预后较单侧膈肌麻痹效果差,严格把握手术适应证有利于患儿早期康复.

Objective To summarize the characteristics of Chinese coccidioidomycosis cases, improve the diagnosis and treatment of this disease and prevent misdiagnosis as well as therapeutic error.Methods Search in databases including Medline,Wanfang,and CNKI using "Coccidioidomycosis" and "China" as index words yielded 23 articles that reported a total of 32 Chinese coccidioidomycosis cases.In addition,one patient with disseminated coccidioidomycos was treated in our center in April 2016.The demographic data,site of infection,clinical manifestations,past medical history,exposure history,imaging and laboratory findings,and pathological features of these 33 patients were analyzed.Results Among these 33 patients,7(21.2%)had visited an epidemic area and 6(18.2%)were immunocompromised.The disease involved the respiratory system,skin,bone,central nervous system,cornea,and stomach in 24,6,3,2,1,and 1 patients,respectively.Eight patients (24.2%) had multiple system involvement,and three of them died.The imaging findings included pulmonary nodules(n=14),mediastinal lymphadenopathy(n=5),solid shadow(n=4),cavity(n=4),pleural effusion(n=3),multiple plaques(n=2)and masses(n=2).Coccidiolys cysts were detected in the affected tissues(n=28)or in pus,exudate or pleural smear(n=3);in addition,coccidioides mycelium and spores were found in the sputum,pus,and tissue cultures in 4 cases,among whom only 2 cases were confirmed by serological examination.The treatments included triazoles(n=20),systemic or local administration of amphotericin B(n=13),surgical resection of the lesion(n=8),and intravenous gamma globulin(n=1).Five patients died,among whom three had underlying diseases that caused immunosuppression and one was an infant.The prognoses were relatively good in the remaining patients.Conclusions Early diagnosis and proper treatment can achieve good prognosis in coccidioidomycosis patients.Multi-system involvement and immunosuppression are risk factors for poor prognosis of coccidioidomycosis.For these patients,adequate and full-course medication may prevent rapid disease progression.

Disseminated nontuberculous mycobacterial (NTM) infection occurs mostly in immunocompromised hosts.Penicilliosis marneffei (PM) is a unique dimorphic fungal infection endemic in Southeast Asia.It is one of the commonest opportunistic infections among human immunodeficiency virus (HIV)-positive patients.There are rare reports about NTM associated with PM infection in non-HIV-infected individuals.Peking Union Medical College Hospital diagnosed a 45-year-old male patient who came from Guangxi Province.He complained of abdominal pain,generalized lymphadenopathy,weight loss,fever,and upper limb pain at presentation.He was HIV-negative,blood culture was positive for NTM,and the result of humerus specimen culture was PM.After treatment with anti-NTM drugs and itraconazole,his clinical status was improved.He remained symptom-free during the 2-year follow-up.

患者女，47岁。因“发现肝占位1个月”于2015年5月入院。患者外院体检行腹部超声时发现肝内结节，进一步行腹部CT见肝脏多发占位，性质待定，遂就诊我院。查血常规：WBC 6.26×109／L，Hb 98 g／L，PLT 420×109／L；超敏C反应蛋白（ hsCRP ）76.23 mg／L；ESR 100 mm／1 h；酶联免疫斑点法结核感染T细胞检测（ T-SPOT.TB）：未检测到结核感染T细胞；肿瘤标记物：CA15-3为26.1 U／ml，组织多肽特异性抗原（ TPS）90.44 U／L，甲胎蛋白、癌胚抗原、CA19-9等均正常；凝血功能：APTT 42.0 s，凝血酶原时间（ PT）11.8 s（即刻、2h均可完全纠正）；卫氏并殖吸虫、肝包虫、囊虫、华支睾吸虫IgG抗体均阴性；免疫固定电泳、免疫球蛋白、补体、自身抗体均正常。颅脑MRI未见特异性改变。颈部超声见双侧颈部肿大淋巴结。既往史：胆囊多发息肉，青霉素过敏（用药后出现皮疹）。个人史：从事服装生意，经常多地出差。婚育、月经史：孕2产1，人工流产1次，否认冶游史。入院体检：生命体征平稳；左颈后可及1个花生粒大小的淋巴结，质韧，无压痛，边界清楚，活动度好；心、肺无异常；腹软未及包块，肝区叩痛（±）；双下肢不肿。

目的探讨酿脓链球菌导致毒素休克综合征的致病机制及患者死亡原因。方法研究2例侵袭性酿脓链球菌致坏死性筋膜炎并发毒素休克综合征患者临床资料,对其中1例患者的分离株进行emm基因分型及其超抗原毒素基因的测定。结果患者2感染酿脓链球菌（GAS）产生的emm89型M蛋白,并且同时产生多种超抗原毒素（speG、speI、speK/L、smeZ、ssa、spd1、spd3、spd4、sdn、prtF-15）;病例1患者因昏迷、休克,而放弃治疗,病例2患者因多器官功能脏器衰竭死亡。结论我国首例报道由emm89型酿脓链球菌所致严重的侵袭性感染,坏死性筋膜炎伴毒素休克综合征,emm89型酿脓链球菌引起的重症感染应引起有关部门的足够重视,避免形成暴发流行,早期的手术清创以及有效的抗感染、IVIG的使用,是挽救患者的有效手段。

Objective To investigate the antimicrobial resistance proifle in the clinical bacterial strains isolated from Peking Union Medical College Hospital during 2014.Methods A total of 8 295 nonduplicate clinical isolates were collected. Disc diffusion test (Kirby-Bauer method) and automated systems were employed to study the antimicrobial susceptibility. The data were analyzed by using WHONET 5.6 software according to CLSI 2014 breakpoints.Results Of the 8 295 isolates, 67.4% were gram-negative, and 32.6% were gram-positive. The top 10 most frequently isolated bacteria were:E. coli(18.1%),P. aeruginosa (10.8%),K. pneumoniae (10.2%),S. aureus (9.8%), <br> A. baumannii(9.2%),E. faecalis (6.3%),E. faecium (4.1%), coagulase-negativeStaphylococcus (4.1%),E. cloacae (3.1%) andS. maltophilia (2.9%). Methicillin resistant strains inS. aureus (MRSA) and coagulase negativeStaphylococcus (MRCNS) accounted for average of 28.4% and 66.5%, respectively. The resistance rates of MR strains to β-lactams and other antimicrobial agents were much higher than those MS strains. Overall, 81.3% of MRSA strains were still susceptible to trimethoprim-sulfamethoxazole, while 81.1% of MRCNS strains were susceptible to rifampin. No staphylococcal strains were resistant to vancomycin, teicoplanin or linezolid. The resistance rate ofE. faecalis strains to most of the drugs tested (except chloramphenicol) was much lower than those ofE. faecium. Several strains of bothE. faecium andE. faecalis were found resistant to vancomycin and teicoplanin, which were Van-A and Van-B types based on their phenotype. No linezolid resistant enterococcal strains were found. Data showed that 90.8% ofβ-hemolyticStreptococcus strains were susceptible to penicillin. ESBLs-producing strains accounted for 54.2%, 31.0% and 28.9% inE. coli,Klebsiella spp (K. pneumoniae andK. oxytoca) andP. mirabilis, respectively.Enterobacteriaceae isolates were still highly susceptible to carbapenems. Overall, no more than 3.3% of these strains were resistant to carbapenems. A few extensively drug-resistant strains ofK. pneumoniae (1.3%, 11/842) were identiifed. The resistance rates ofP. aeruginosa to imipenem and meropenem were 17.5% and 11.8%, respectively.P. aeruginosa isolates showed the lowest resistance rate (5.9%) to amikacin. And 69.0% and 67.4% ofA. baumanniiisolates were resistant to imipenem and meropenem.A. baumannii isolates showed the lowest resistance rates to cefoperazone-sulbactam and minocycline (47.8% and 28.7%), respectively. The prevalence of extensively drug-resistant strains was 32.3% inA. baumannii and 1.8% inP. aeruginosa. The prevalence of β-lactamase inH. inlfuenzae was 33.7%. More than 93.0% ofS. pneumoniae strains were resistant to erythromycin and clindamycin.Conelusions Bacterial resistance is still increasing in this hospital, especially carbapenem resistantEnterobacteriaceae. It is necessary to take effective hospital infection control measures and use antibiotics rationally.

目的 通过回顾性分析非艾滋病患者感染马内菲蓝状菌病的临床特点提高对非HIV患者马内菲蓝状菌病的认识.方法 分析并总结9例马内菲蓝状菌感染患者的临床表现及实验室检查各项指标.结果 6例无基础疾病,3例有基础疾病,6例患者接受免疫抑制剂治疗.5例患者有骨损坏,2例有皮疹,淋巴结肿大7例,贫血7例,脾增大7例,肝大5例,体重下降5例,6例患者接受抗结核或非结核治疗.最后有6例患者治愈或好转,3例死亡.结论 激素或免疫抑制剂的使用是非艾滋病患者感染马内菲蓝状菌的主要原因.非艾滋病患者感染马内菲蓝状菌无特异性的临床表现,易误诊,早期诊断困难,尤其需与结核病等疾病相鉴别.抗真菌治疗与患者的预后有密切的相关性.

皮肤隐球菌感染在近年来逐渐受到重视，占隐球菌感染的10%~15%。长期使用糖皮质激素是皮肤隐球菌的主要病因之一[1]。但同时合并鼻疽奴卡菌感染少见。现报道1例新型隐球菌合并鼻疽奴卡菌皮肤感染的病例。经过氟康唑联合复方磺胺甲噁唑抗感染治疗，病情好转，出院后继续按医嘱巩固治疗。

Objective To investigate the profile of antimicrobial resistance in clinical isolates from the patients in Peking Union Medical College Hospital during2012.Methods A total of 6 662 nonduplicate clinical isolates were collected.Disc diffusion test or Kirby-Bauer method and automated systems were employed to study the antimicrobial resistance.The data were analyzed by WHONET5.6 software according to CLSI 2012 breakpoints.Results Of the 6 662 bacterial strains included in this analysis,gram negative organisms and gram positive cocci accounted for 66.7%(4 446/6 662)and 33.3%(2 216/6 662),respectively.The top 10 most frequently isolated microorganisms were E.coli(17%),P.aeruginosa(11.4%),A.baumannii(11.4%),S.aureus(11.2%),K.pneumoniae(9.2%),E.faecalis(8.4%),E.faecium(4.1%),coagulase negative Staphylococcus(3.3%),E.cloacae(3.1%)and S.maltophilia(3.1%).About 39.9%of the S.aureus strains and73.4%of the coagulase negative Staphylococcus were methicillin-resistant.No staphylococcal strains were found resistant to vancomycin,teicoplanin or linezolid.A few of vancomycin-or teicoplanin-resistant strains were identified in both E.faeciumand E.faecalis.No linezolid resistant strains were found.ESBLs-producing strains accounted for 53.0%,25.7% and 27.0%in E.coli,Klebsiella spp.(K.pneumoniae and K.oxytoca)and P.mirabilis,respectively.The Enterobacteriaceae strains were still highly susceptible to carbapenems.Overall,less than 2.6% of these strains were resistant to carbapenems.A few pan-resistant strains of K.pneumoniae(0.7%,4/615)were identified.About 20.3%and 13.6% of the P.aeruginosaisolates were resistant to imipenem and meropenem,respectively.P.aeruginosaisolates showed the lowest resistance rate(7.2%)to amikacin.And 72.8% and 75.2% of A.baumannii strains were resistant to imipenem and meropenem.A.baumanniiisolates showed relatively low resistance rate to cefoperazone-sulbactam(51.2%)and minocycline(30.2%).The prevalence of pan-resistant strains was 43.5%in A.baumannii and 1.4%in P.aeruginosa.Conclusions Bacterial resistance is still increasing,especially pan-resistant A.baumannii strains.It is mandatory to take effective measures to control hospital infections and improve rational antibiotic use.

Objective To investigate the antimicrobial susceptibilities of nosocomial multi-drug resistant Acinetobacter baumannii ( MDR-AB) and multi-drug resistant Pseudomonas aeruginosa ( MDR-PA) isolates. Methods MDR-AB and MDR-PA isolates were collected between August 2011 and July 2012 from 27 hospitals in China.All isolates were collected from high quality samples with definite infection diagnoses , whilst isolates from sputum and screen samples were strictly excluded .Minimum inhibitory concentrations ( MICs) of 12 com-monly used antimicrobial agents were tested by broth microdilution method in a microbiology laboratory .CLSI clinical breakpoints ( CBPs) of pre-and post-revision were applied and compared in determination of MDR .Re-sults A total of 664 MDR-AB and 268 MDR-PA isolates were collected .Pan-drug resistant ( PDR) was detec-ted in four Pseudomonas aeruginosa but not in Acinetobacter baumannii.The majority of isolates were collected from ICUs and surgical wards .Colistin and tigecycline were the most active agents against MDR-AB (96.8%and 72.6% susceptible , respectively ) , while no other drug exhibited activity of >55%susceptible .Only 72.4%of MDR-PA isolates remained susceptible to colistin , but amikacin was more active to MDR-PA ( 64.2%) than MDR-AB (16.7%).By applying revised CBPs , the susceptibility of MDR-AB isolates to imipenem and mero-penem decreased by 1.3% and 0.6%, respectively , whereas the susceptibility of MDR-PA to these two drugs decreased by 5.5%and 8.6%, respectively .The carbapenems susceptible rate of isolates collected from ICUs was lower than surgical and other wards .Isolates collected from different geographic regions showed varied resist -ant profiles .Conclusions Colistin and tigecycline are the most active drugs against MDR-AB, while colistin and amikacin have comparably good performance to MDR-PA.

Objective To make clinicians' awareness of diagnosis and treatment of chronic disseminated histoplasmosis,so to minimize misdiagnosis and optimize the prognosis.Methods To make a literature review about the clinical manifestations,pathological features,diagnosis,treatment of chronic histoplasmosis,according to 2 cases of clinical and follow-up data in our hospital from 1980 to 2012.Results Both two cases of patients have a long course,lack of early and specific symptom,multi-system involvement and no exposure history.One case has gastrointestinal,lung and adrenal gland involvement,and the other one has lung and peritoneal involvement.Both of them are misdiagnosed early,with diagnosis by pathology and good effect by the anti-fungal therapy,neither relapsed.Conclusions Chronic histoplasmosis is a rare disease and the clinical manifestations are not specific.Diagnosis depends on the typical pathological morphology and special stains,prognosis is good with active treatment.

奴卡菌感染引起的脑脓肿非常罕见,大约占所有脑脓肿的2％.在系统性奴卡菌感染中,并发脑脓肿的发生率为15％ ～ 40％.奴卡菌可从植物和土壤中分离,通过呼吸道和皮肤侵入人体并通过血行播散感染脑、肾、关节和眼等.奴卡菌脑脓肿的影像学表现并不特异,诊断困难,我院2007 - 2010年收治3例脑奴卡菌感染患者,现结合近10年来文献报告如下.

播散性放线菌病临床上不常见,同时合并结核分枝杆菌感染的更为罕见[1-2].现报道1例继发于流产术后年轻女性播散性放线菌病合并结核分枝杆菌感染的病例,经过积极的脓液引流、抗放线菌联合四联(异烟肼+利福平+乙胺丁醇+吡嗪酰胺)抗结核治疗痊愈.

病历摘要患者男,52岁,双眼进行性视力下降伴头痛2年入北京协和医院.体格检查:神清语利,查体合作.心肺腹(-).专科查体:视力视野检查示右眼颞上偏盲,鼻侧阈值降低小暗点,左眼颞侧偏盲,鼻侧及中心暗点,左眼视力0.8,右眼视力1.0.既往病史:高血压病6年,服用卡托普利及尼莫地平等降压药物控制良好.高血脂5年,白服血脂康控制,5年前诊断为陈旧性心肌梗死及多发腔隙性梗死,长期自服消心痛、丹参片.内分泌学检查:泌乳素25.7μg/L,睾酮147.0 μg/L,血总皮质醇、甲状腺功能正常。

报道1例由棕黑腐质霉属（Humicola fuscoatra）导致的真菌性腹膜炎。此菌分离自1名长期腹膜透析患者的腹水。腐质霉属在自然界广泛存在,棕黑腐质霉导致的人类感染罕见。现对棕黑腐质霉的真菌学特点进行研究,并进行分子测序。体外药物敏感性试验结果对伊曲康唑的MIC为0.008μg/mL,伏立康唑的MIC为0.016μg/mL,两性霉素B的MIC为1.5μg/mL。患者拔除腹透管,改行血液透析。口服伊曲康唑0.1 g/12 h,28 d后病情明显改善,出院。

A case of endocarditis caused by Microascus trigonosporus related was reported.The strain was isolated from the pacemaker surface and identified as Microascus trigonosporus by ITS analysis.Histopathology showed abundant septate hyphae and intercalary swollen chlamydospores in the vegetaion.Microascus trigonosporus widely spread in the natural world was anamorphs(asexual forms) of Scopulariopsis.Endocarditis caused by Microascus was rarely reported.Etest showed the MICs of itraconazole and amphotericin B were ≥32 μg/mL,while the MIC of voriconazole was 4 μg/mL.The patient improved by vegetation removal and itroconazole treatment.