| Mastitis is a common disease of women.According to the period of its occurrence,it can be roughly divided into two types: lactation mastitis and non-lactation mastitis.Lactation mastitis is a common disease of postpartum lactation women.It is an inflammation of breast tissue in lactation women.It is often accompanied by bacterial infection,which can occur in partial or whole breast.Generally,the common symptoms are pain at the onset of breast,with or without redness and swelling of breast.At the same time,it can have systemic infection symptoms such as temperature rise,shivering and general discomfort.According to past reports,the incidence rate of mastitis in lactation is as high as 20%.It is generally believed that the occurrence of lactation mastitis is related to bacterial infection,mainly including Staphylococcus aureus,Escherichia coli,Streptococcus and other infectious pathogens.Antibiotics are the main treatment of lactation mastitis.However,in recent years,with the widespread use of antibiotics,the pathogenic bacteria spectrum and the drug sensitivity of the pathogenic bacteria are also changing.To master the pathogenic bacteria and antibiotic sensitivity of mastitis during lactation is of great significance for rational selection of antibiotics in clinical practice.About3% of women with breast-feeding mastitis progress to breast-feeding abscess.Breast abscess in lactation will lead to prolonged course of disease,bring great pain to patients,and seriously affect the quality of life of patients.On the other hand,some patients stop breastfeeding because they can't insist on it,which is also one of the important reasons for the decrease of breastfeeding rate.The treatment principle of breast-feeding abscess is to drain the pus in time.In the past,the most commonly used method was abscess incision and drainage,but this method has obvious disadvantages such as large surgical trauma,long incision pain,long healing time,easy to affect the beauty of the breast and so on.In recent years,it is gradually replaced by new methods such as ultrasound-guided puncture and tube washing.In recent years,the incidence rate of non-lactation mastitis has increased year by year,and a large number of cases have been reported in many parts of the country.In the world,China,Iran,Turkey and other Asian countries are the high incidence areas of non-lactating mastitis.Most of the non-lactating mastitis cases reported in the world are concentrated here.According to different pathological characteristics,non-lactation mastitis can be divided into plasma cell mastitis(PCM)andgranulomatous lobular mastitis(GLM).GLM is a common type in clinic.The clinical manifestations of GLM are various,and the imaging manifestations are lack of typical characteristics,which makes the clinical diagnosis difficult and easy to be misdiagnosed.At the same time,it has a long course of disease,is easy to relapse,and often has a large range of pathological changes in the late stage,which causes great pain to patients and seriously affects their quality of life.At present,the treatment of GLM mainly includes surgical treatment and conservative drug treatment.However,these two methods have great problems.Surgical treatment has quick effect and low recurrence rate,but it needs complete removal of the focus.GLM usually develops rapidly after the onset of the disease,and the scope of the lesions is often large.The surgical treatment of complete removal of the focus will cause greater surgical trauma and have a serious impact on the breast beauty of the patients.Conservative drug therapy does not need surgery and has less trauma,but it has the problems of long treatment time and high recurrence rate.Therefore,it is an urgent problem for scholars and clinicians all over the world to explore a new effective and minimally invasive treatment plan.One of the main reasons for the lack of optimal treatment for granulomatous lobular mastitis is that the specific etiology and pathogenesis are not clear at present.The possible causes include autoimmunity,bacterial infection,trauma,imbalance of hormone level in the body,oral contraceptives,racial differences,etc.Among them,bacterial infection,especially Corynebacterium kroppenstedtii(Ck)infection,is widely suspected by many experts and clinicians.Ck is a kind of lipophilic bacteria,which grows slowly or even does not grow on the traditional culture medium without lipid supplement.Some studies have shown that adding lipid to the culture medium can improve the culture success rate of Ck.In addition,with the rapid development of biotechnology,the molecular identification based on bacterial genome sequence has attracted more and more attention.16 S r DNA is the most useful and commonly used molecular clock in the systematic classification of bacteria.It has a small species,a large content(about 80% of the bacterial DNA content),a moderate molecular size,and exists in all organisms.Its evolution has a good clock property and a high degree of conservation in structure and function.The 16 S r DNA sequence contains 9 variable regions and 10 constant regions.The conserved regions reflect the genetic relationship among species,while the highly variable regions reflect the differences among species.By sequencing 16 S r DNA and comparing the results with BLAST on NCBI website,we can get the known sequence with high homology,which provides the basis for species classification.Oxford Nanopore Technologies(ONT),also known as the fourth generation sequencing technology,is a new generation of sequencing technology emerging in recent years.It has the advantages of long reading,fast sequencing speed and high data accuracy.Using ONT to sequence 16 S r DNA of bacteria can quickly and accurately identify pathogens in samples.To sum up,in order to explore the best treatment of breast abscess in lactation and GLM,and to explore the etiology of GLM with a new strain identification method,this research is carried out from the following three parts:Part One: Treatment of breast abscess in lactation by ultrasound-guided catheterization and washingBackground: Lactation mastitis is a common disease of postpartum lactating women.When mastitis forms abscess,the treatment principle is to drain the pus in time.In the past,the most commonly used method was abscess incision and drainage,but this method has obvious disadvantages such as large surgical trauma,long incision pain,healing time,easy to affect the beauty of the breast,etc.In recent years,it is gradually replaced by new methods such as ultrasound-guided catheterization and washing.In order to evaluate the therapeutic effect of ultrasound-guided catheterization and washing on breast abscess in lactation,and to preliminarily understand the pathogenic bacteria of lactation mastitis in this area,the following research was carried out by our group.Methods: From January 1,2017 to December 31,2017,the patients with breast abscess in lactation in our hospital were collected.All the patients were treated by ultrasound-guided catheterization and washing in our hospital.The age,length of stay,pregnancy and delivery,whether there is damage to the nipple,white blood cell(WBC),pus culture results and other information of the patients were analyzed.Before the patients were treated with ultrasound-guided catheterization and washing,the patients were instructed to carry out visual simulation score P1 of pain degree and self-evaluation B1 of breast beauty;on the third day after the patients were treated with ultrasound-guided catheterization and washing,the patients were instructed to carry out visual simulation score P2 of pain degree again;before the patients were discharged from the hospital after treatment,the patients were instructed to carry out self-evaluation of breast beauty again score B2,the above scores were conducted by the same special nurse.After discharge,the patients were followed up by telephoneonce a week.After one month,the patients were followed up by telephone once a month.The recurrence was recorded.Results: A total of 21 cases of breast abscess in lactation were included in our hospital from January 1,2017 to December 31,2017.All of them received ultrasound-guided catheterization and washing in our hospital.The average length of stay was 5.95 ± 1.99 days and the median length of stay was 7 days.During the6-month follow-up period,no recurrence occurred in all patients,with a recurrence rate of 0%.In addition to one case of no bacterial growth,20 strains of pathogenic bacteria were detected,with a detection rate of 95.24%,including 12 strains of penicillin resistant Staphylococcus aureus,3 strains of methicillin resistant Staphylococcus aureus,4 strains of coagulase negative Staphylococcus and 1 strain of?-hemolytic streptococcus.The score of pain after treatment was lower than that before treatment,and the difference was statistically significant.There was no significant difference in the self-evaluation of breast beauty before and after treatment.Conclusion: Drug resistant Staphylococcus aureus has become an important pathogen of breast abscess in lactation in this area,and should be alert to the spread of methicillin-resistant Staphylococcus aureus.Under the guidance of ultrasound,the treatment of breast abscess in lactation can shorten the cure time,relieve the patients' pain quickly and effectively,and has little effect on the beauty of breast.Part Two: Minimally invasive comprehensive treatment of granulomatous lobular mastitisBackground: Granulomatous lobular mastitis(GLM)is a non-lactation mastitis with unknown etiology.At present,no consensus has been reached regarding the optimal first-line treatment for GLM.The purpose of this study was to describe a minimally invasive comprehensive treatment of GLM and to compare its effect with the existing methods,particularly in terms of its recurrence rate and esthetic outcomes.Methods: From January 1,2017 to December 31,2017,69 patients with granulomatous lobular mastitis who received minimally invasive comprehensive treatment were analyzed.Patient information,including age,clinical features,image characteristics,histopathology findings,previous mastitis,treatment process,operative technique,recurrence,and esthetic effect,was evaluated.Results: All patients were female with a median age of 32(range 17 ? 55)years.All patients underwent minimally invasive comprehensive treatment.Hospital stays ranged from 2 to 34 days,with a median of 6 days.The shortest time for complete rehabilitation was 2 days and the longest time was 365 days,with a median of 30 days.After a median follow-up of 391 days(range 162 ? 690),7 patients(10.14%)had disease recurrence.The average cosmetic score was 2.62±0.57 points and was mainly related to the past treatment process,especially the surgical history.Conclusion: Minimally invasive comprehensive treatment is a new method for the treatment of GLM,and it can ensure a therapeutic effect while maintaining the beauty of the breast.Part Three: Bacteriological study of granulomatous lobular mastitisBackground: The specific etiology and pathogenesis of granulomatous lobular mastitis(GLM)are not clear at present.The possible causes include autoimmunity,bacterial infection,trauma,imbalance of hormone level in vivo,oral contraceptives,racial differences,etc.Among them,bacterial infection,especially Corynebacterium kroppenstedtii(Ck)infection,is widely suspected by many experts and clinicians.Ck is a kind of lipophilic bacteria,which grows slowly or even does not grow on the traditional culture medium without lipid supplement.The research shows that adding lipid to the culture medium can improve the culture success rate of Ck.Oxford Nanopore Technologies(ONT),also known as the fourth generation sequencing technology,is a new generation of sequencing technology emerging in recent years.It has the advantages of long reading,fast sequencing speed and high data accuracy.Using ONT to sequence 16 S r DNA of bacteria can quickly and accurately identify pathogens in samples.Methods: 23 patients with GLM admitted to our hospital from September 2018 to June 2019 were included in the study,and 3 patients with acute lactating mastitis abscess formation admitted to our hospital at the same time were included in the control group.Pus or tissue samples of all cases were collected,and bacterial culture and ONT were used to detect bacterial 16 S r DNA sequence and identification of strains.Results: In 23 patients with GLM,2 cases of Ck and 1 case of Mycobacterium abscessus were detected by bacterial culture.The 16 S r DNA sequence of bacteria in the samples was determined by ONT and the strains were identified.5 cases(21.74%)of mixed bacterial infection,4 cases(17.39%)of Ck,1 case(4.35%)ofStaphylococcus aureus,1 case(4.35%)of Corynebacterium stearate,1 case(4.35%)of Pandora and 1 case(4.35%)of Escherichia coli were detected in 23 patients with GLM.In addition,1 case(4.35%)of fungus was found,which Candida tropicalis was.Of the 5 cases of mixed bacterial infection,4 contained Ck,and other bacteria included rare colorless bacteria,copper resistant bacteria,M.cheloni abscess complex,Prevotella nigrum,Acinetobacter yoelii,Brevibacterium casei,Staphylococcus epidermidis and Bifidobacterium brevium.Staphylococcus aureus was detected in the pus samples of 3 patients with acute lactation mastitis abscess.The 16 S r DNA sequence of bacteria in the samples was determined by ONT,and the strains were identified.Staphylococcus aureus was also detected in three samples,and no other strains or fungi were detected.Conclusion: Using ONT to sequence the 16 S r DNA sequence of bacteria can quickly and accurately identify the species of pathogenic bacteria in the samples,without relying on bacterial culture,which has unique advantages for the identification of mixed infection.Corynebacterium,especially Ck,is closely related to GLM.Mixed infection may be an important cause of GLM. |
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