酒精性肝病合并弧菌性脓毒症的临床及病理学特点

目的：探讨酒精性肝病合并弧菌性脓毒症患者的临床病理特点。方法：自2002年8月至2004年8月问符合酒精性肝病合并弧菌性脓毒症早期临床诊断主要依据的患者6例，在应用抗菌药物、补液扩容、升压及1～2h内切开患肢以减压、引流、清创等外科治疗，在总结其临床特点同时，观察患者下肢的临床病理特点及超微结构改变。结果：患者首先出现下肢足背或小腿肿胀、剧烈疼痛、局部红斑、数小时内血疱增多、融合成大血疱、皮肤大片淤血斑，下肢病变迅速扩大并向大腿或躯体蔓延，患者同时出现休克、MODS表现。2例下肢皮肤苍白、肌肉色红。肌酸磷酸激酶(CPK)正常或轻度升高，经清创、植皮后保存了患肢。另4例见皮肤脂肪坏死，筋膜肌肉坏死范围广．小血管血栓形成，患者的CPK明显升高，其中2例下肢病变严重，行截去患肢治疗，2例切开患肢以减压、引流、清创等病情好转，因经济原因放弃进一步治疗。6例中4例患者治愈出院。作者通过光镜及电镜对弧菌感染患者下肢病变组织系统观察，包括皮肤、肌肉、脂肪、坐骨神经、股动脉、股静脉，结合大体表现发现创伤弧菌脓毒症患者下肢病变组织病理改变主要表现为炎症性改变。结论：及早正确认识下肢临床及病理改变特点对早期临床诊断及治疗十分重要，可有效提高患者生存率。     

下肢弧菌感染性脓毒血症患者行负压封闭引流术的护理

总结8例下肢弧菌感染性脓毒血症患者实施负压封闭引流术(vacuum sealing technique,VSD)治疗的护理.保持有效负压,负压20～60 kPa;准确记录引流液的颜色和量;做好并发症的预防与护理,防止引流管堵塞,因下肢弧菌感染性脓毒血症患者免疫力降低引起的感染,创面周围皮肤问题;患肢和创面的观察与护理;做好心理护理.3例经VSD治疗后,创面新鲜,肉芽组织生长良好,皆行Ⅱ期创面修复术;2例大腿中厚皮植皮,3例采用下腹部全厚皮植皮,创面愈合后皮肤表面平整、疤痕轻.     

预防性切开减压在急性下肢动脉栓塞取栓术中的应用

目的 观察预防性切开减压在急性下肢动脉栓塞取栓术中的应用效果。方法 回顾性分析2016年1月至2021年12月间皖南医学院附属弋矶山医院17例取栓术中行预防性切开减压处理急性下肢动脉栓塞患者的临床资料,观察其有效性和安全性。结果 17例患者均成功接受预防性切开减压,平均随访时间12个月,13例患者痊愈,2例轻度下肢感觉或运动功能障碍(不影响日常生活),2例重度下肢感觉或运动功能障碍(影响日常生活但未坏死),无坏死或截肢。切口愈合方面,1例自行愈合无需缝合,10例二期清创缝合,6例一期术中预留缝线,延期闭合减压切口,无患者需植皮或截肢。结论 对急性下肢动脉栓塞取栓患者预防性切开减压具有较好的安全性和有效性。     

Ilizarov外固定联合负压封闭引流修复四肢骨折合并骨筋膜室综合征

背景：目前治疗骨折合并骨筋膜室综合征常采用单边外固定架固定骨折,凡士林纱布覆盖减压创面,需长期、频繁敞开换药,增加了感染概率,不利于创面引流及肉芽组织培养,造成住院周期长、效果欠佳。
　　目的：探讨Ilizarov外固定联合负压封闭引流修复四肢骨折合并骨筋膜室综合征的临床效果。
　　方法：将32例四肢骨折合并骨筋膜室综合征患者按随机数字表法均分为2组,在进行相同切开减压和药物治疗的基础上,治疗组采用Ilizarov外固定架固定骨折,负压封闭引流覆盖创面;对照组采用单边外固定架固定骨折,凡士林纱布覆盖创面,比较两组骨折愈合、临床结局、住院时间及治疗费用。
　　结果与结论：治疗组治愈10例,肌挛缩4例,截肢2例;对照组治愈7例,肌挛缩6例,截肢3例,两组临床结局指标比较差异无显著性意义。治疗组骨折愈合率及治疗费用高于对照组(P<0.05),住院时间、植皮及感染发生率低于对照组(P <0.05)。表明在及时切开减压的基础上,采用Ilizarov外固定联合负压封闭引流修复四肢骨折合并骨筋膜室综合征保肢率高,可有效治疗骨折,提高骨折愈合率,降低感染率、植皮率,缩短住院时间,但费用较高。     

胫骨上端骨折合并胭动脉损伤51例病例分析

目的探讨胫骨上端骨折后腘动脉损伤的诊断及治疗效果。方法选择胫骨上端骨折合并腘动脉损伤病例51例,本院首诊入院治疗44例,肢体损伤至血液循环重建时间6小时以内者19例,6~8小时25例;外院转入7例患者患肢缺血时间均超过14小时。结果本组51例中,41例恢复良好出院;因肌肉挫伤较重,致皮肤部分坏死,经2次手术,清创、换药或植皮后出院8例(其中2例出院后因腓总神经及胫后神经严重碾挫性损伤,患肢感觉丧失、运动障碍而截肢);因患肢肌肉广泛挫伤,创面较大,血运无法恢复截肢2例。本组5例截肢患者,均为受伤后14小时以上来院就诊患者。结论确定胫骨上端骨折后,详细的临床检查是早期诊断肢体血管损伤的必要手段,及时的手术治疗是修复血管损伤,挽救肢体功能的关键因素。     

自制串接法负压引流在1例盆腔脓肿伴深部软组织感染创口护理中的应用

总结1例盆腔脓肿伴右下肢软组织感染致全身脓毒血症患者的创口护理。在全身抗感染治疗的同时,右下肢深部软组织多处错层切开,盆腔脓肿在CT引导下行置管,采用盆腔高位冲洗、右下肢自制串接法低位负压引流,全身情况得到了有效的控制,创面逐渐好转直至愈合,并通过对患者疼痛、营养、心理、患肢功能等方面的评估及干预,加速了患者康复的时间。经36d治疗,患者感染控制,创面基本愈合,康复出院。     

sCD14-ST在脓毒血症早期诊断中的应用

目的探讨可溶性白细胞分化抗原14亚型(s CD14-ST)在脓毒血症早期诊断中的临床应用价值。方法采用前瞻性研究,选取2012年3月至2014年8月疑似脓毒血症患者共50例,正常对照者30名。根据美国胸内科医师学会和危症监护医学学会(ACCP/SCCM)共识会议及临床相关表现将入选患者分为脓毒血症组、细菌感染性全身炎症反应综合征(SIRS)组、局部细菌感染组。收集50例患者入院治疗前、使用抗菌药物24 h、使用抗菌药物72 h及30名正常对照者的血浆和/或血清,检测其s CD14-ST、降钙素原(PCT)及C反应蛋白(CRP)水平。采用受试者工作特征(ROC)曲线研究s CD14-ST在脓毒血症早期诊断中的应用价值。结果入院治疗前,3个病例组血s CD14-ST、PCT和CRP水平均显著高于正常对照组(P0.05),其中s CD14-ST水平在3个病例组之间差异有统计学意义(P0.05),而脓毒血症组PCT和CRP水平与细菌感染性SIRS组比较,差异无统计学意义(P0.05)。对脓毒血症组治疗前后的s CD14-ST、PCT和CRP的动态变化进行分析,s CD14-ST在入院治疗前、使用抗菌药物24 h和使用抗菌药物72 h 3个时间点的水平差异有统计学意义(P0.05)。s CD14-ST、PCT和CRP的ROC曲线下面积分别为0.956、0.939和0.848。结论 s CD14-ST与PCT和CRP相比,在诊断脓毒血症中具有明显优势,可为诊断早期脓毒血症提供重要的临床依据。     

地震灾害中挤压综合征患者的早期治疗与疗效分析

目的:探讨在地震灾害中挤压综合征患者的早期治疗方案及治疗效果.方法:对"5.12"四川大地震中收治我院32名挤压综合征患者的早期治疗方案及短期疗效进行分析.结果:1例患者死亡,22例患者患肢行筋膜室切开减压术后感觉运动功能不同程度恢复,保肢成功;5例患者行伤肢截肢手术;24例患者实验室检验指标恢复正常,7例患者实验室检验指标不同程度恢复.2例患者切口感染,经治疗后感染控制.结论:地震灾害中挤压综合征患者的早期治疗对预后有至关重要的影响,早期行筋膜室切开减压及血液透析治疗能够有效降低死亡率,改善预后.     

肾脏替代治疗在地震伤挤压综合征患者保肢中的应用

目的 分析肾脏替代治疗在汶川大地震后挤压综合征患者保肢治疗中的作用和预后,探讨肾脏替代治疗与手术相结合的模式和优点.方法 对31例挤压综合征合并急性肾功能衰竭患者行床旁透析治疗,其中30例行急诊手术治疗.结果 死亡4例,1例在1肢截肢平面上再截肢.其余患者采用肾脏替代治疗后肾功能在7～23天恢复,切开减压创面经换药、二期缝合或植皮愈合,患肢得以保存.结论 肾脏替代治疗能快速、有效地改善患者肾脏功能,纠正高血钾及代谢性酸中毒,合理地与手术相结合,能为保存患者生命和肢体提供重要的保障.     

急性胆管炎合并脓毒血症危险因素临床研究

[目的]探讨急性胆管炎合并脓毒血症的危险因素.[方法]回顾性分析本院消化内科从2009年1月至2016年4月行逆行胰胆管造影(ERCP)治疗的227例急性胆管炎患者的临床资料.根据入院时血培养结果分成两组(A组:血培养阳性,B组:血培养阴性),探讨急性胆管炎合并脓毒血症的危险因素.[结果]单因素分析结果显示患者年龄、发病时间、恶性肿瘤及既往乳头切开是急性胆管炎发生脓毒血症的危险因素;多因素Logistic分析结果显示恶性肿瘤、既往乳头切开是急性胆管炎发生脓毒血症的独立危险因素.[结论]恶性肿瘤、既往乳头切开是急性胆管炎合并脓毒血症的独立危险因素,对高危患者应采取相应及时有效的治疗措施,预防脓毒血症、脓毒性休克、多脏器功能衰竭的发生.     

乌司他丁联合血必净治疗脓毒血症的疗 效

目的 探讨乌司他丁联合血必净治疗脓毒血症的临床疗效和安全性.方法 将60例脓毒血症患者按人院的先后顺序分为观察组和对照组,每组30例.2组均根据细菌培养及药敏试验结果应用抗生素进行抗感染治疗,根据患者的血液生化检测指标及血气分析结果及时调整水、电解质紊乱及酸碱平衡.同时,给予肠内营养支持和肠外营养支持治疗.在此基础上,观察组采用乌司他丁和血必净注射液治疗.观察2组治疗前后肺组织中IL-6、TNF-α水平、住院时间、康复及死亡的情况,并对2组治疗前后进行急性生理学与慢性健康状况评分Ⅱ（APACHEⅡ）评分.结果 观察组治疗后肺组织中IL-6、TNF-α水平、APACHEⅡ得分、住院时间和病死率均明显低于对照组（P＜0.05或P＜0.01）,康复率明显高于对照组（P＜0.05）.结论 乌司他丁联合血必净治疗脓毒血症疗效显著,并能改善免疫功能.     

早期连续血液滤过治疗慢性肾衰竭并脓毒血症效果

目的探讨早期连续血液滤过治疗慢性肾衰竭并发严重脓毒血症的效果。方法对12例慢性肾衰竭并发严重脓毒血症病人均在常规治疗的基础上实施早期连续血液滤过治疗。结果 12例病人均存活,入院前APACHEⅡ评分与出院时比较,差异有显著性（t′=17.82,P〈0.05）;多脏器功能障碍综合征、呼吸衰竭、休克及低氧血症基本得到纠正。结论慢性肾衰竭并发严重脓毒血症病人通过早期连续血液滤过治疗,可改善其长期预后,降低病死率。     

降钙素元结合SOFA评分在小儿脓毒症的诊断及预后的应用研究

目的 探讨血清降钙素元(PCT)及SOFA评分动态监测对小儿脓毒症的早期诊断并判断预后效果.方法 55例脓毒症患儿入院后24h内进行血常规、痰培养、外周血培养和X线胸片等常规检测;测定肝、肾功能,电解质,动脉血气;体温、白细胞计数、中性粒细胞计数、中性粒细胞比例;测定血清C反应蛋白(CRP)、PCT;进行SOFA评分.并于入院后第4、7天同样采集上述指标,并随访28d.对照组患儿均来自PICU危重患儿.结果 入院后三组患儿相关炎症指标比较可见死亡组及存活组的WBC,中性粒细胞,CRP及PCT均显著高于对照组,但死亡组及存活组两组间差异均无统计学意义.存活组在第4天及第7天较死亡组炎症指标及SOFA评分均明显下降,差异有统计学意义(P<0.05).结论 在早期小儿脓毒症中,PCT的大小与病情的轻重相关;在判断预后方面,需结合PCT及SOFA评分才能得到更准确的结果.     

Ofloxacin versus standard therapy in treatment of community-acquired pneumonia requiring hospitalization. Pneumonia Study Group.

Community-acquired pneumonia occurs 3 to 4 million times per year in the United States, accounting for about 500,000 hospitalizations annually. Empiric treatment is usually instituted because of a lack of early organism-specific diagnostic tests. This study compared empiric therapy with ofloxacin to standard antibiotic regimens (usually a beta-lactam with or without a macrolide) for patients hospitalized for community-acquired pneumonia. Therapy was administered to 298 patients (146 receiving ofloxacin and 152 receiving standard therapy); 227 patients (ofloxacin, 109; standard treatment, 118) were evaluable for treatment efficacy. The most common pyogenic respiratory pathogens were Haemophilus influenzae (30 isolates) and Streptococcus pneumoniae (24 isolates). There was evidence of infection with either Mycoplasma pneumoniae (38 patients), Chlamydia pneumoniae (40 patients), or a Legionella sp. (8 patients) in a total of 79 patients (35%). The clinical success rates were similar in both groups among evaluable patients (92%, ofloxacin; 87%, standard therapy) and among patients with atypical respiratory pathogens (88%, ofloxacin; 81%, standard therapy). The mean numbers (+/- the standard deviations) of intravenous doses of antibiotics were 7.5 +/- 8.0 in the ofloxacin group and 18.4 +/- 18.5 in the standard therapy group (P < 0.001); the mean number of oral doses of ofloxacin per patient was 19.7 +/- 11.2, compared with 30.2 +/- 16.0 oral antibiotic doses in the standard therapy group (P < 0.001). All treatments were well tolerated and associated with no significant clinical or laboratory abnormalities. The findings of this study indicate that ofloxacin is active against traditional bacterial pathogens as well as the major atypical respiratory pathogens. When given as monotherapy for the empiric treatment of community-acquired pneumonia, ofloxacin is as effective as standard antimicrobial therapy.     

Erythema nodosum in patients with tinea pedis and onychomycosis.

To document association between erythema nodosum and concomitant fungus infection, we studied seven white women seen during a six-year period in our office practice. Five patients are presented. Unilateral erythema nodosum occurred in three patients on the same side as unilateral tinea. Tests with potassium hydroxide (KOH), cultures of nodules on Sabouraud agar and dermatophyte test medium (DTM), skin biopsy, and clinical examination ruled out nodular granulomatous perifolliculitis of Wilson. Lesions simulating erythema nodosum were produced when Trichophyton antigen was injected subcutaneously in the lower legs. All nodose and fungal lesions cleared after griseofulvin therapy. Fungus infection of feet or nails should be considered a possible cause of erythema nodosum when no other cause is apparent.     

Lyme arthritis

Evanescent arthralgias and myalgias are common early symptoms of Lyme disease. Transient, intermittent episodes of monoarticular, oligoarticular, or sometimes migratory polyarticular arthritis, lasting weeks to months, with disease-free intervals, are frequently observed in untreated patients with erythema chronicum migrans. A minority of patients develop chronic joint involvement, most commonly affecting the knee. Antibiotic therapy given during erythema chronicum migrans is often protective with regard to late joint manifestations. In chronic Lyme arthritis, however, the response to antibiotics is variable.     

Electrocardiographic findings in children with erythema migrans

OBJECTIVE: To assess electrocardiographic findings in children with erythema migrans and to compare them with findings obtained in a healthy control group of comparable age and with a similar proportion of boys and girls. METHODS: Electrocardiograms were carried out in 147 children under the age of 15 years before treatment with antibiotics for erythema migrans (solitary 68 patients, multiple 79 patients) and in the control group of 148 healthy children. RESULTS: Abnormal electrocardiographic findings were detected more often in healthy children than in patients (14% versus 5%; P = 0.0303) and among patients more often in boys than in girls (10% versus 0%; P = 0.0107). Electrocardiographic abnormalities characteristic for Lyme borreliosis, such as atrioventricular blocks, were rare: in patients with erythema migrans only one child had first-degree atrioventricular block; in the control group one child had first-degree and another had second-degree atrioventricular block. Patients with erythema migrans had shorter PR and RR intervals and lower R and S wave voltages in V1 than the healthy children. Comparison among patients with solitary and multiple erythema migrans did not reveal significant electrocardiographic differences. The frequency of electrocardiographic abnormalities in patients with erythema migrans was not associated with the presence of systemic symptoms, or with the presence of meningitis or the isolation of Borrelia burgdorferi sensu lato from the blood. CONCLUSIONS: Electrocardiographic abnormalities in children with erythema migrans are mild, nonspecific and rare. The presence of clinical signs and symptoms indicative or suggestive of disseminated Lyme borreliosis is not associated with higher frequency of such abnormalities. Comparison of findings in patients with erythema migrans and healthy children revealed several distinctions, some of which might have been interpreted as a result of altered activity of the autonomic nervous system.     

血清降钙素原定量检测在儿科血流感染诊断中的应用价值

目的：探讨血清降钙素原（PCT）定量检测在儿科血流感染诊断中的价值。方法回顾性分析某院183例同时送检血液培养和 PCT 检测的结果,以血培养为金标准,把患者分为非血流感染组和血流感染组,比较两组间血清 PCT 浓度的差异。两组间 PCT 值差异比较采用 Mann-WhitneyU 检验,P ＜0．05为差异有统计学意义。结果非血流感染组血清 PCT 浓度为0．15（0．065～0．55）ng/mL,血流感染组血清 PCT 水平为1．11（0．505～8．975）ng/mL,两组间的血清 PCT 浓度差异有统计学意义（P ＝0．000）;以0．50 ng/mL 为界点,PCT 诊断的灵敏度为77．8％、特异度为73．3％,阳性预测值和阴性预测值分别为24．1％和96．8％。结论定量检测 PCT 可辅助快速排除或诊断血流感染,为避免抗菌药物的过度使用或早期抗感染治疗提供参考。     

Renal abscess: early diagnosis and treatment

The purpose of this study was to identify initial clinical characteristics that can lead to early diagnosis of renal abscess in the emergency department and predict poor prognosis. A retrospective review of 88 renal abscess patients, from April 1979 through January 1996, was conducted. Patients were categorized into two groups. In group 1, renal abscess was diagnosed by an emergency physician, whereas in group 2 renal abscess was not diagnosed by an emergency physician. Clinical characteristics included demographic data, predisposing medical problems, duration of illness before diagnosis, time spent in hospital diagnosis, initial signs and symptoms, laboratory tests, and radiology studies that may have been useful in the early diagnostic regimes. Clinical factors were also analyzed for their value in predicting poor prognosis. The mean age of 88 patients with renal abscess was 59.8 years. The most common predisposing disorder was diabetes mellitus, followed by renal calculi and ureteral obstruction. The duration of diagnosis by emergency physicians was shorter for group 1 patients (1.2 +/- .4 v group 2, 2.8 +/- 2.9 days; P < .01) and the blood urea nitrogen level was higher in group 1 (55.7 +/- 42.2 mg/dL, v group 2, 33.5 +/- 33.5 mg/dL; P = .02). In the early diagnosis of renal abscess, emergency physicians should focus on patients who have predisposing disorders, ie, diabetes mellitus, renal stones, immunosuppression, longer duration of symptoms of urinary tract infection, and renal failure, who should promptly be investigated with ultrasound in the emergency department. The cure rate after treatment with routine antibiotics plus percutaneous drainage was 64%. This therapy is recommended for initial treatment. Poor prognosis is associated with elderly patients with lethargy and with elevation of the serum blood urea nitrogen level.     

Utility and limitations of serodiagnostic tests in monitoring the response to treatment of leprosy patients

Simple measures that can facilitate early recognition of leprosy complications are still lacking. We therefore evaluated a lateral flow-based rapid diagnostic test and fast enzyme-linked immunosorbent assay measuring anti-LID-NDO antibody responses among leprosy cases in Cebu, Philippines. Responses were measured at diagnosis, then during and after the provision of standard multidrug therapy. Our data indicate that both platforms are highly sensitive tools for the primary diagnosis of, in particular, multibacillary leprosy. A gradual, quantifiable decline in both magnitude of response and percent positive responders was observed during and after treatment. As a group, patients that developed erythema nodosum leprosum (ENL) had a significantly higher response at diagnosis than patients that either developed reversal reactions or did not develop reactions. Although higher initial anti-NDO-LID responses were a risk factor for ENL, neither platform, however, could reliably predict the time of emergence of reactional episodes.