目的 探讨院外延续性护理联合院内心理指导对重症烧伤患者创伤应激的影响。方法 选取2020年6月—2022年6月南开大学附属医院（天津市第四医院）重症烧伤科收治的86例重度烧伤患者为研究对象,应用随机数字表法将患者分为观察组与对照组,每组各43例。对照组采取常规护理,观察组在常规护理基础上增加院外延续性护理联合院内心理指导,评估患者的创伤应激指标[血清肿瘤坏死因子α（TNF-α）、白细胞介素6（IL-6）、β-内啡肽（β-ep）]、心理韧性程度、应对行为、创伤后成长水平,并分析患者创伤应激与心理韧性的相关性。结果 干预前,两组的TNF-α、IL-6、β-ep水平比较差异无统计学意义（P>0.05）;干预后,两组创伤应激相关指标水平均下降,且观察组降低幅度更大（P<0.05）。干预后,两组患者乐观性、力量性、坚韧性相关中文版创伤后成长评定量表（C-PTGI）评分均升高,且观察组更高（P<0.05）;Pearson相关性分析显示,TNF-α、IL-6、β-ep等创伤应激指标水平与心理韧性水平呈负相关（P<0.05）;干预后,两组患者积极应对特质应对方式问卷（TCSQ）评分均升高,观察组高于对照组,人消极应对评分均降低,观察组低于对照组（P<0.05）;干预后,两组患者人际关系、精神变化、生活欣赏、个人力量、新的可能相关C-PTGI评分分量表得分均升高,观察组高于对照组（P<0.05）。结论 对重度烧伤患者采取院外延续性护理联合院内心理指导能够降低患者的创伤后应激水平、消极应对评分,提升患者心理韧性程度、创伤后成长水平以及积极应对评分,且创伤后应激水平与心理韧性水平呈负相关。

Objective To explore the effect of out-hospital continuous nursing combined with in-hospital psychological guidance on traumatic stress in severe burn patients．Methods A total of 86 patients with severe burn treated in the Affiliated Hospital of Nankai University（Tianjin Fourth Hospital）from June 2020 to June 2022 were selected as the research objects．The patients were divided into observation group and control group by random number table method,with 43 cases in each group．The control group received routine care,and the observation group was supplemented with out-hospital continuous nursing and in-hospital psychological guidance on the basis of routine care．The traumatic stress indexes [serum tumor necrosis factor-α（TNF-α）,interleukin-6（IL-6）,β-endorphin（β-ep）],psychological toughness,coping behavior and post-traumatic growth level of the patients were evaluated．The correlation between traumatic stress and mental toughness was analyzed．Results Before intervention,the levels of TNF-α,IL-6 and β-ep were not significantly different between the two groups（P>0.05）．After intervention,the levels of traumatic stress-related indicators were decreased between the two groups,and the reduction was greater in the observation group（P<0.05）．After intervention,C-PTGI scores related to optimism,strength and fortitude were increased in both groups,which were higher in observation group（P<0.05）．Pearson correlation analysis showed that the levels of TNF-α,IL-6,β-ep and other traumatic stress indexes were significantly negatively correlated with the levels of mental toughness（P<0.05）．After intervention,the positive coping TCSQ scores of both groups were increased,the observation group was higher,and the negative coping scores were decreased,while the observation group was lower（P<0.05）．After the intervention,the scores of interpersonal relationships,mental changes,life appreciation,personal strength,and new possibly relevant C-PTGI score subscale were increased in both groups,and higher in the observation group（P<0.05）．Conclusions The combination of out-hospital continuous nursing and in-hospital psychological guidance for severe burn patients can reduce the level of post-traumatic stress and negative response score of patients,and improve the level of mental toughness,post-traumatic growth and positive score of patients,and the level of post-traumatic stress is significantly negatively correlated with the level of mental toughness．

严重烧伤后患者免疫功能的失调,易导致创面感染、全身炎症反应综合征、脓毒症、感染性休克等并发症,增加患者病死率。免疫细胞功能适度的活化将有助于烧伤患者抵御外界病原体的侵袭、促进创面的愈合,但功能过度激活或者功能低下,则会引发一系列严重的后果。本文旨在归纳严重烧伤后中性粒细胞、单核/巨噬细胞、肥大细胞、NK细胞及T淋巴细胞等免疫细胞的功能变化与炎症反应之间的关系,为完善烧伤患者诊疗、减少并发症、改善预后提供新的思路。

The imbalance of immune function in severely burned patients can easily lead to wound infection,systemic inflammatory response syndrome,sepsis,septic shock and other complications,which increase the mortality of patients. Moderate activation of immune cell function will help burned patients to resist the invasion of external pathogens and promote wound healing,but excessive activation or low function can lead to a series of serious consequences. The purpose of this paper is to summarize the relationship between the functional changes of immune cells such as neutrophils,monocytes/macrophages,mast cells,NK cells,T lymphocytes and inflammatory reaction after severe burns,and to provide new ideas for improving the diagnosis and treatment of burned patients,reducing complications and improving the prognosis.

       目的   分析重症烧伤患者血培养标本中检测出念珠菌的临床分布，探究重症烧伤患者血流念珠菌感染的病原学特征。方法   选取2012—2023年在广州市红十字会医院住院治疗的重症烧伤患者血培养标本1 148份，分析分离出念珠菌的非重复患者病死率、菌种分布、同时送检的其他类型标本念珠菌培养结果及患者念珠菌血流感染的检出时间与季节分布、抗菌药物使用情况及对常用抗真菌药物的耐药情况。结果  1 148份血培养标本中77份检出真菌，阳性率为6.71%。检出念珠菌感染的非重复患者27例，其中近平滑念珠菌13例，构成比为48.15%、白念珠菌8株，构成比为29.63%。血与静脉导管培养均检出念珠菌的有22例（81.48%）；血与伤口分泌物培养圴检出念珠菌的有10例（37.04%）；血、静脉导管、伤口分泌物培养圴检出念珠菌的有4例（14.81%）。静脉导管检出念珠菌高于其他类型标本。27例重症烧伤患者血流感染检出念珠菌的时间主要分布在入院后第2~3周、季节主要分布在春夏季。近平滑念珠菌、白念珠菌、热带念珠菌对氟康唑敏感率分别为83.33%、87.50%和75.00%。结论   重症烧伤患者血流近平滑念珠菌检出率最高，发生血流感染时间主要在春夏季及烧伤入院后第2~3周，静脉导管留置是增加重症烧伤患者念珠菌血流感染的因素。我院念珠菌对抗真菌药物具有较高敏感性。

      Objective  To retrospective analyze the clinical distribution of Candida species detected in blood cultures of patients with severe burns and to investigate the etiological characteristics of Candida bloodstream infections in these patients．Methods  A total of 1 148 blood culture specimens were collected from patients with severe burns hospitalized at an institution between 2012 and 2023．Patients data with Candida bloodstream infections isolated from 1 148 blood culture specimens were analyzed，including mortality rates，species distribution，Candida culture results from other simultaneously collected specimen types，and the timing and seasonal distribution of Candida bloodstream infections，the use of antibiotics and  resistance to commonly-used antifungal drugs．Results  A total of 1 148 blood culture samples，77 fungi were separated，resulting in a positive rate of 6.71%．Among the 27 patients with Candida infections，13 cases（48.15%）were caused by Candida parapsilosis and 8 cases（29.63%）by Candida albicans．Candida was isolated from both blood and intravenous catheter cultures in 22 cases，with a positivity  rate of 81.48%．Candida was isolated from both blood and wound secretion cultures in 10 cases（positivity rate of 37.04%），and 4 cases from blood，intravenous catheter and wound secretion cultures（positivity rate of 14.81%）．The detection rate of Candidafrom intravenous catheters was higher than that from other specimen types．Candida bloodstream infections were most commonly observed during the 2nd and 3rd week after admission，with a seasonal peak in spring and summer．The  susceptibility  rates of Candida parapsilosis、Candida albicans and Candida tropicalis to fluconazole were 83.33%、87.50% and 75.00%，respectively．Conclusions  The detection rate of Candida parapsilosis in bloodstream infections among patients with severe burns was the highest．These infections predominantly occur during the spring and summer and in the 2nd and 3rd week post-admission．The presence of intravenous catheters significantly contributes to Candida infections．The Candida in the hospital has high sensitivity to antifungal drugs．