自上世纪90 年代以来, 多耐药非发酵革兰阴性杆菌开始成为医院感染的重要病原菌, 并迅速增加, 其中不动杆菌( Acinetobacter) 尤其令人关注。鲍曼不动杆菌( Acinetobacter baumannii) 或称鲍曼-醋酸钙不动杆菌复合群, 占不动杆菌的80% ～90% , 是不动杆菌中引起人类感染的主要菌群, 具有极强的环境适应能力、获得外源性耐药基因的能力及播散性, 因而被称为21 世纪革兰阴性菌中的“耐甲氧西林金黄色葡萄球菌( MRSA) ”, 值得引起临床医生的重视。
抗生素的降阶梯治疗（de-escalation therapy）是近年来提出的用于治疗重症肺部感染的一个策略，在临床研究和实践中能够有效地提高重症感染治疗的成功率，降低病死率，同时降低住院时间和费用，是感染治疗策略的一大进展。本文就这一策略的概念演变和应用时机作一介绍
In recent years, with the wide application of metagenomics next-generation sequencing, more and more rare pathogens have been detected in our clinical work, including non-tuberculous Mycobacterium, Corynebacterium, Fusarium, Cryptococcus pneumoniae, human herpes virus, torque teno virus, parvovirus, Tropheryma whipplei, Bartonella, Chlamydia psittaci, etc. It is difficult to determine whether these rare pathogens are clinically significant and need treatment. This article puts forward some suggestions and discussions on the diagnosis and treatment of pulmonary infections with some rare pathogens.
Objective To investigate changes of TLR2 mRNA expression in lung of a mouse model of Chlamydia Pneumoniae pneumonitis, and to explore the possible mechanism of signal transduction. Methods Ninety-six male C3H/HeJ mice were randomly divided into four groups as follows: a control group, a model group, a SB203580 intervened group, and a pyrrolidine dithiocarbamate( PDTC) intervened group. Chlamydia Pneumoniae pneumonitis was induced by intranasally inoculated with 4. 0 ×106 IFU/mL of C. Pneumoniae per mouse in the model group and two intervened groups. Then the intervened groups were intraperitoneally injected with the p38MAPK inhibitor SB203580 and nuclear factor kappa B ( NF-κB)inhibitor PDTC, respectively. Six mice in each group were randomly killed in 1st, 4th, 7th and 14th day. The expressional changes of TLR2 mRNA in the mice lung tissue were measured by semi-quantitative RT-PCR. The concentrations of TNF-α in the lung homogenate were measured by ELISA. Results TLR2 mRNA expression in the lung tissue significantly increased after C. Pneumoniae infection, peaking at 4th and 7th days, then decreased after 14th day. Tumor necrosis factor-α( TNF-α) was also elevated in the lung tissue after C. Pneumoniae challenging. Both SB203580 and PDTC treatment effectively inhibited TNF-αand TLR2 mRNA expressions in lung. The inhibitory effect was more obvious by SB203580 treatment. Conclusion C. Pneumoniae can upregulate the expressions of TLR2 and TNF-α in lung, and TLR2/MAPK and TLR2 /NF-κB signal pathways may be involved in Chlamydia Pneumoniae pneumonitis.
Objective To evaluate the efficacy and safety of colistin in the treatment of severe infections. Methods PubMed, ISI Web of Knowledge and Wanfang databases were searched. The initial literatures and references listed in the literature were manually searched. Controlled studies were analyzed using RevMan 5. 0 software.Results Eleven studies were enrolled, including five prospective studies and six retrospective studies. Pooled analysis showed that, compared with other therapies, treatment with colistin in severe infections did not improve 28 or 30-day mortality, clinical symptoms, or bacteria clearance,however, increased the risk of kidney damage. Subgroup analysis showed that colistin did not improve symptoms, mortality ( which was even higher in the patients with drug resistant bacteria infection) , or kidney damage in drug resistant bacteria infections and ventilator associated pneumonia ( VAP) compared with the other antibiotic group. Conclusions Colistin is not superior to the other antibiotics in severe infections.However, there are some shortcomings in our meta-analysis due to limited high-quality RCTs, thus welldesigned RCTs are still needed before final conclusion is made.
Objective To investigate the surgical treatment methods and effects for pulmonary atresia with ventricular septal defect (PAVSD) in elder children and adults in order to promote the treatment effects. Methods From October 1996 to October 2008, we performed stage1 or staged biventricular repair on 39 PAVSD patients including 21 males and 18 females, ranging from 8 to 27 years old with an average age of 13.43 years. There were 14 cases of type A, 11 cases of type B, and 14 cases of type C. Among them, 23 patients underwent stage1 radical repair in which either human blood vessel with valves or bovine jugular vein with valves were used to connect the pulmonary artery and the right ventricular outflow tract. In these 23 patients, 3 patients complicated with major aortopulmonary collaterals(MAPCAs) underwent unifocalization (UF) operation. The other 16 patients received staged repair, including 9 cases of systemic to pulmonary artery shunt and 7 of staged radical cure. Results There were 6 perioperative deaths with a total mortality of 15.38%(6/39), including 4 (17.39%) stage1 radical repair cases and 2 (12.50%) staged radical repair cases. The former 4 were all type C patients, dying from low cardiac output due to increased pulmonary arterial pressure. In the latter 2 deaths, 1 was a type B secondary shunt patient, and the other was a type C staged radical repair case, both of whom died of bleeding caused by aortic injury in the succeeding operations. Followup was done on 28 cases with a followup rate of 84.85%. The followup time ranged from 14.0 months to 9.2 years with 5 cases missing. No patient died during the followup, and 9 patients maintained their cardiac function at class Ⅰ, 13 at class Ⅱ, 5 at class Ⅲ and 1 at class Ⅳ. Three patients had aortic valve regurgitation of small to medium volume, the treatment of which included an administration of oral potassium diuretic medication and regular follow-up. Conclusion Pulmonary vessels of elder children and adults with PAVSD are usually injured severely and oftentimes it is complicated with MAPCAs. Standard for stage1 radical repair should be defined more strictly based on the present one.
Objective To compare the efficacy of one kind of modified De Vega technique and traditional De Vega technique. Methods From January 2002 to August 2005, 70 patients were treated with tricuspid valve plasty. These patients were divided into modified De Vega annuloplasty group and traditional De Vega annuloplasty group randomly before operation. The tricuspid regurgitation （TR） were functional and secondary in all patients. The grade of TR and New York Heart Association（NYHA） functional class of two groups were analyzed by Ridit analysis. The changes of right ventricular end-diastolic dimension of two groups were analyzed by paired-sample t test. Results There was no statistically difference between two groups about preoperative characteristics. The follow-up time of modified De Vega annuloplasty group was 12.91±8.84 months and that of traditional De Vega annuloplasty group was 13.61±11.21 months. There was no significant difference between two groups. The outcome of follow-up was satisfactory. In modified De Vega annuloplasty group, there were 12 patient with no TR, 17 patient with mild TR, and 6 patients with moderate TR. There was no patient with severe TR. In traditional De Vega annuloplasty group, 7 patients were observed with no TR, 19 patients mild TR, 7 patients moderate TR and 2 patients severe TR. In modified De Vega annuloplasty group, 32 patients were in NYHA class Ⅰ, 2 patients in NYHA class Ⅱ and only 1 patient in NYHA class Ⅲ. As for traditional De Vega annuloplasty group, 31 patients were in NYHA class Ⅰ, 2 patients in NYHA class Ⅱ and 2 patients in NYHA class Ⅲ. The Ridit analysis showed that there was no significant difference about NYHA class between two groups. However, the difference of TR between two groups was statistically significant （P〈0.05）. The outcome of modified De Vega annuloplasty was superior to that of traditional De Vega technique. Paired-sample t test demonstrated that the modified De Vega annuloplasty could reduce the right ventricular end-diastolic dimension significantly （P〈0.05）. However, the right ventricular end-diastolic dimension of traditional De Vega annuloplasty groups did not change significantly （P 〉 0.05）. Conclusion The efficacy of modified tricuspid De Vega technique is superior to that of traditional De Vega technique in patients with secondary TR.
Objective To describe the underlying conditions of chronic pulmonary aspergillosis (CPA). Methods A retrospective study was performed. Details of the clinical, imaging features, and the underlying conditions of CPA patients admitted to a tertiary university teaching hospital from January 2009 to December 2016 were extracted from clinical records. The classification distribution of CPA, and underlying conditions were analyzed. Results Among the 108 CPA patients, 87 cases had underlying conditions, 21 cases had no underlying conditions. Seventy two (66.7%) patients were engaged in agriculture, the proportion of which was significantly higher in the cases without underlying conditions (85.7% vs. 62.1%). Chronic necrotizing pulmonary aspergillosis (CNPA) was the most common type of these CPA cases. The cases without underlying conditions had significantly more proportion of CNPA than the cases with underlying conditions (85.7% vs. 62.1%). The cases with systemic underlying conditions had significantly more proportion of CNPA than the cases only with pulmonary underlying conditions (82.8% vs. 51.7%). Chronic cavity pulmonary aspergillosis (24/108, 22.2%) only existed in the cases with pulmonary underlying conditions. Underlying conditions were identified in 87 cases of CPA, with 85.1% (74/87) pulmonary and 33.3% (29/87) systemic underlying diseases. Previous tuberculosis mycobacterial infection, bronchiectasis and chronic obstructive pulmonary disease were the most common pulmonary underlying conditions (40.2%, 39.1% and 35.6%, respectively). Diabetes (16.1%) and glucocorticoid using (13.8%) were the most two common systemic underlying conditions. Conclusions CPA can occur in patients with and without underlying diseases. CNPA is the most common type of these CPA, the proportion of which is higher in cases without underlying conditions and cases with systemic underlying conditions. Farming maybe the risk factors of CPA. Chronic pulmonary primary diseases are the most common underlying conditions. The most common systemic factors are diabetes and glucocorticoid using.
Objective To assess the psychological status of patients with lung cancer in ward preliminarily for providing the theoretical support for further clinical treatment. Methods Lung cancer patients were enrolled in this study during the period from January 2016 to January 2017, when they were being treated in the respiratory ward of Nanjing General Hospital. Their psychological status was assessed by using Symptom Check List 90, and the results with their demographic information and somatic symptoms were combined. Data were analyzed by using SPSS 18.0 software. Results This study included 239 inpatients, out of them 161 patients were male (67.4%), and the average age was 60.7±9.9 years. Sixty patients had a positive psychological status. The incidence of depression was 11.3% (27/239), of anxiety 4.2% (10/239), and of the total psychological disorder 25.1%. The patients had more serious psychological problems, when they had a longer course, more autonomic symptoms, or a lower score of Karnofsky performance scale, etc. Conclusion More serious psychological problems exist in patients with lung cancer, so it has the clinical significance for their timely psychological assessment.