Stevens-Johnson综合征1例

患者女,28岁。主诉:全身皮肤起红斑伴眼、口腔黏膜糜烂15d,体温38.5℃。患者因胃疼口服中药"摩罗丹"后,周身皮肤出现大小不等的红斑,自行"外用药物"治疗(药名具体不详),未见好转,皮疹逐渐增多,并起水疱、大疱,双     

硫糖铝联合法莫替丁治疗急性胃炎的疗效分析

对来我院诊治的88例患者入院资料进行分析,将其随机分为两组。对照组采用法莫替丁治疗,试验组联合硫糖铝治疗,比较两组治疗效果。结果试验组91%治疗效果较好,优于对照组(77.3%)(P0.05);试验组95.5%对我院总体比较满意,高于对照组(P0.05),试验组治疗12.8±6.7d后患者痊愈出院,短于对照组(P0.05);治疗组1例患者出现口干,后自行缓解。对照组1例患者出现便秘亦自行缓解。两组均无严重不良反应发生。急性胃炎发病率较高,临床上采用硫糖铝联合法莫替丁治疗效果较好,值得推广使用。     

甲巯咪唑致多关节炎1例报道

正1临床资料患者,男,67岁,因"间断多关节肿痛10d"于2015年7月2日入院。入院前10d患者无明显诱因出现右手第3远端指间关节肿痛伴局部皮肤轻度发红、皮温稍高,未治疗,3d后自行缓解。后关节症状逐渐累及双肘关节、右腕关节、右手第2远端指间、左膝关节、右足第2、5趾跖关节,症状均能1~3d后自行缓解,关节痛呈游走性。既往有阵发性心房颤动病史9     

CIK细胞治疗晚期恶性肿瘤27例临床护理

目的:探讨采用CIK细胞治疗晚期恶性肿瘤患者的护理方法。方法:为27例晚期恶性肿瘤患者合理选择和保护采血用静脉,做好采集外周血单个核细胞(PBMC)的护理和准备、CIK细胞采集时的护理、CIK细胞悬液回输时的护理、CIK细胞回输后不良反应护理。结果:本组患者均未出现过敏反应。1例输注后出现恶心、呕吐1次,未行特殊治疗,自行缓解。4例输注后1 h出现低热,指导患者适量饮用温开水后体温自行恢复正常。通过患者主诉得知20例患者一般状况、饮食、睡眠等均有不同程度好转。结论:精心的护理可保证治疗顺利进行,提高治疗效果,改善患者生存质量。     

梗阻型肥厚性心肌病合并感染性心内膜炎、房间隔缺损1例

患者男,33岁.因"活动后心悸、气短6年,间断发热1年,咳嗽1周"入院.患者自6年前间断出现心悸、气短,多于大量活动后出现,休息后数分钟即可自行缓解,一直未诊治.     

梗阻型肥厚性心肌病合并感染性心内膜炎、房间隔缺损1例

患者男,33岁.因"活动后心悸、气短6年,间断发热1年,咳嗽1周"入院.患者自6年前间断出现心悸、气短,多于大量活动后出现,休息后数分钟即可自行缓解,一直未诊治.     

梗阻型肥厚性心肌病合并感染性心内膜炎、房间隔缺损1例

患者男,33岁.因"活动后心悸、气短6年,间断发热1年,咳嗽1周"入院.患者自6年前间断出现心悸、气短,多于大量活动后出现,休息后数分钟即可自行缓解,一直未诊治.     

感康片引起腹膜透析患者幻视、幻听1例

1 临床资料 患者男性,34岁,该患者为慢性肾小球肾炎、慢性肾脏病5期患者,并已腹膜透析治疗1年,治疗方式为持续性不卧床腹膜透析( continuous ambulatory peritonealdialysis,CAPD)方式,治疗效果尚好,患者正常参加工作.于2010年10月26日着凉后出现鼻塞、流涕、喷嚏等症状,继续按常规进行腹膜透析治疗及相关药物治疗,并自行加服"感康片"2 粒,每日2次口服,应用3～4d,感冒症状好转.     

Gleich综合征一例

患者,男,25岁.因"周期性全身水肿22年"人院.患者从3岁起,每月周期性出现全身水肿伴少尿,体重增加,有时伴发热或出现分布全身的风团样皮疹,有瘙痒,上述症状每次一般持续5 d左右,其后自行消散,于当地医院行血常规检查示"嗜酸粒细胞升高",且发现其增高程度随症状出现和消失而变化.曾给予抗寄生虫治疗无效,8年前改用泼尼松口服,症状减轻,发作周期逐渐延长且不规则,2年前自行停药,患病以来患者无其他不适.     

超声诊断异位急性阑尾炎1例

患者男性,45岁,数月前劳累后右中上腹部疼痛,伴恶心、呕吐、白细胞增高,当时诊断"急性胆囊炎"抗炎治疗3 d后疼痛好转,白细胞降至正常。3天前又出现恶心,偶有呕吐、右上腹部疼痛,自行输液2 d未见好转,且右上腹部疼痛加剧伴低热,来院就     

Pathophysiology and therapy of diabetic ketoacidosis and of non-ketoacidotic hyperosmolar diabetic coma

Metabolic derangements in diabetic coma are the sequelae of insulin deficiency. These defects are aggravated by the actions of insulin counteracting ("diabetogenic") hormones and hypertonic dehydration, which both impair insulin action. Conversely, it has been shown that hypo-osmolar rehydration of a hyperosmolar, severely hyperglycaemic diabetic patient reduces insulin resistance and restores biological responsiveness of previously dehydrated insulin-dependent tissues towards insulin. Thus treatment of diabetic coma requires appropriate fluid and electrolyte replacement as a life-saving emergency action alongside insulin replacement. The use of proper rehydration during the past decade might also explain the reported fall in the insulin requirement for the treatment of diabetic coma from approximately 1,000 units per coma to low-dose insulin therapy. In order to guarantee proper treatment of severe hyperglycaemia and normalization of the hyperosmolar state, we feel that hypo-osmolar rehydration has to be initiated in parallel with low-dose insulin therapy (5 to 6 U/h) to restore the physiological response of the respective target tissues to insulin action and to ameliorate glucose utilization. This approach probably avoids a too rapid fall in plasma osmolarity, minimizes the risk of cerebral oedema and hypokalaemia, and improves survival. The development of severe diabetic ketoacidosis or of hyperosmolar non-ketotic diabetic coma should be prevented by advice to patients on the importance of metabolic monitoring, which can be done by proper self-monitoring of blood glucose. In addition, information should be provided on the detrimental metabolic effects of both dehydration and stress.     

Fulminant diabetes due to immune checkpoint inhibitors in the emergency department

Immune checkpoint inhibitors (ICIs) are of growing importance in new cancer therapies, exposing patients to various and potentially severe immune-related adverse events and placing emergency physicians on the front line when they occur. If endocrine toxicity is a well-known complication of ICIs, fulminant diabetes with diabetic ketoacidosis is exceptional. We present a case of fulminant diabetes after only two cycles of pembrolizumab in a 53-year-old man with a history of metastatic lung cancer who presented to our emergency department with coma and acidosis revealing diabetic ketoacidosis. The patient was rehydrated and treated with insulin and recovered quickly. Lung toxicity was also suspected on CT-scan findings. This rare and life-threatening complication that developed unusually early during the treatment course may be challenging in a cancer patient. Therefore, emergency physicians should investigate symptoms in patients treated with checkpoint inhibitors and consider toxicity when they present to the ED with complaints compatible with an immune-related adverse event.     

Combating diabetic ketoacidosis and other hyperglycemic-ketoacidotic syndromes.

Diabetic ketoacidosis is an acute medical emergency that requires immediate diagnosis and treatment. Diagnosis may be established rapidly by measurement of urinary glucose and ketones, arterial blood pH and blood gases, and serum ketones. Rapid infusion of large volumes of fluids and electrolytes, together with continuous infusion of low doses of insulin, provides effective restoration of fluid and electrolyte balance and correction of metabolic derangements. Hyperosmolar nonketotic coma is characterized by marked hyperglycemia in the absence of ketoacidosis and occurs usually in patients with mild adult-onset diabetes. Symptoms develop more slowly than in diabetic ketoacidosis. Treatment is the same for both conditions. In alcoholic ketoacidosis, hyperketonemia is present without hyperglycemia. The syndrome differs from diabetic ketoacidosis in that blood glucose levels are lower and glycosuria is absent. Treatment consists of intravenous administration of dextrose in water and, if necessary, of sodium bicarbonate. Insulin administration usually is not necessary.     

Venoarterial extracorporeal membrane oxygenation resuscitation in diabetic ketoacidosis with hypothermic cardiocirculatory instability

Diabetic ketoacidosis with hypothermia is underrecognized, and the mortality rate is high at between 30% and 60%. The cause of hypothermia in diabetic ketoacidosis patients is speculative and has multiple factors. Insulin deficit is the most important factor that leads to a lack of substrate for cellular heat production. Water depletion and low environment temperature may also be contributing factors, especially in patients with a severe diabetic coma. Hypothermia may also aggravate uncontrolled diabetes mellitus and complicate treatment because insulin secretion is impaired and exogenous administered insulin is less effective at low temperatures. We present a case, the first in the literature, of severe diabetic ketoacidosis with marked hypothermia and cardiovascular instability that was successfully resuscitated by venoarterial extracorporeal membrane oxygenation support. Based on this report, we suggest that portable venoarterial extracorporeal membrane oxygenation should be considered to treat patients with severe diabetic ketoacidosis and hypothermic cardiocirculatory instability.     

The diabetic child in the emergency room

The WHO announced diabetes mellitus as one of the main threats to human health in the 21st century. In children and adolescents the prevalence of both the autoimmune type 1 and the obesity-related type 2 diabetes is increasing. Common to all types of diabetes is an absolute or relative lack of insulin to keep glucose homeostasis under control. Thus children and adolescents with newly diagnosed diabetes present with hyperglycemia which is often accompanied by ketoacidosis bearing the risk of cerebral edema. Children and adolescents with known diabetes treated with insulin or orale antidiabetic agents may also suffer from hyperglycemia or even ketoacidosis during times of non-compliance with diet and drugs or during concomitant illnesses. Hyperglycemia with ketoacidosis is an emergency situation for which patients need to be admitted to the next hospital for administration of insulin, fluids and potassium. In contrast, insulin treatment in diabetic patients may also lead to a hypoglycemia, the sudden drop in blood glucose, at any moment. Thus recognition and correction of mild hypoglycemia should be familiar to every diabetic child and their caretaker. Severe hypoglycemia with or without seizures may bring the diabetic child in a sudden emergency situation for which the administration of glucagon intramuscularly or glucose intravenously is mandatory. After every severe hypoglycemia the insulin and diet regimen of the diabetic child or adolescent must be reviewed with the diabetes specialist. For unexplained hypoglycemia or major treatment adjustments the diabetic child or adolescent may need to be readmitted to the diabetic ward of a hospital to avoid repeat, potentially life-threatening hypoglycemia.     

Diabetic emergencies.

Diabetic emergencies include diabetic ketoacidosis, insulin-induced hypoglycemia, hyperosmolar coma and lactic acidosis. By determining the blood pressure, observing for evidence of dehydration or sweating and making a rapid qualitative assessment of blood glucose and ketonemia, the physician can usually identify the condition promptly. When adequate facilities are available, continuous intravenous insulin infusion is preferred for treatment of diabetic ketoacidosis. The nonketotic hyperosmolar state should be corrected gradually, not rapidly, in order to avoid cerebral edema.     

Metabolic emergencies

All patients in stupor or coma should undergo blood chemistry studies, including blood gases. The anion gap and serum osmolality must be calculated in all patients. An indwelling catheter to monitor urine content and volume is essential. Electrocardiogram monitoring is indicated in all significant metabolic acidosis, especially for evaluation of intracellular potassium effect and arrhythmias. Repeated arterial monitoring of blood gases and electrolytes is essential with the use of flow sheets. Sodium lactate and Ringer's solution should never be given in an emergency care area. Large doses of insulin (100+ units intravenously) are not necessary or indicated in diabetic ketoacidosis and may be contraindicated and dangerous especially in HHNKC. Intravenous or intramuscular regular insulin after urine tests for glucose and ketones alone should not be given. Urine dilution of serum ketones is useless, and serum dilution may be grossly misleading and contraindicated: arterial studies are much more reliable.     

糖尿病患者围手术期用胰岛素泵控制血糖的临床观察

目的：探讨胰岛素泵对糖尿病患者围手术期控制血糖的疗效。方法：对78例择期手术的糖尿病患者分别应用胰岛素泵持续皮下输注胰岛素（CSII组,37例）和常规皮下注射胰岛素（对照组,41例）控制血糖。另外13例急诊手术者均行CSII控制血糖。结果：择期手术中,CSII组入院时空腹血糖（FBG）15.3±2.4mmol.L^-1,餐后2h血糖（PG2h）19.6±4.1mmol.L^-1,糖化血红蛋白（HbA1c）9.02±2.12%。对照组入院时FBG14.3±2.68mmol.L^-1,PG2h19.2±3.2mmol.L^-1,HbA1c8.93±1.98%。两组方法均能显著降低空腹以及餐后血糖,与对照组比较,CSII组血糖达标时间、胰岛素用量均有显著性差异（P〈0.05）,CSII组能更迅速控制血糖。另外还有13例急诊手术者通过随时血糖监测调整基础率以及临时给予大剂量冲击后,血糖在数小时内由18.13±3.56mmol.L^-1下降到可接受手术的血糖水平（8～10mmol.L^-1）。除2例出现低血糖先兆经对症处理后缓解外,无一例发生低血糖昏迷、酮症酸中毒、高渗性昏迷等严重并发症。结论：与常规皮下注射胰岛素相比,胰岛素泵治疗对围手术期糖尿病患者具有平稳、快速、安全降低血糖的作用。     

Management of diabetic ketoacidosis.

Diabetic ketoacidosis is an emergency medical condition that can be life-threatening if not treated properly. The incidence of this condition may be increasing, and a 1 to 2 percent mortality rate has stubbornly persisted since the 1970s. Diabetic ketoacidosis occurs most often in patients with type 1 diabetes (formerly called insulin-dependent diabetes mellitus); however, its occurrence in patients with type 2 diabetes (formerly called non-insulin-dependent diabetes mellitus), particularly obese black patients, is not as rare as was once thought. The management of patients with diabetic ketoacidosis includes obtaining a thorough but rapid history and performing a physical examination in an attempt to identify possible precipitating factors. The major treatment of this condition is initial rehydration (using isotonic saline) with subsequent potassium replacement and low-dose insulin therapy. The use of bicarbonate is not recommended in most patients. Cerebral edema, one of the most dire complications of diabetic ketoacidosis, occurs more commonly in children and adolescents than in adults. Continuous follow-up of patients using treatment algorithms and flow sheets can help to minimize adverse outcomes. Preventive measures include patient education and instructions for the patient to contact the physician early during an illness.     

Does bicarbonate therapy improve the management of severe diabetic ketoacidosis?

OBJECTIVE: The use of bicarbonates in the treatment of severe diabetic ketoacidosis remains controversial, especially regarding the benefit/risk ratio. The aim of this study was to assess the efficacy of bicarbonate therapy during severe diabetic ketoacidosis (pH <7.10). DESIGN: Retrospective study. SETTING: The emergency unit of a teaching hospital. PATIENTS: The records of 39 patients consecutively admitted for severe diabetic ketoacidosis were analyzed (pH <7.10).The patients were divided into two groups: group 1 (n = 24; patients with bicarbonate treatment) and group 2 (n = 15; patients without bicarbonate treatment). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We compared two groups of patients presenting with severe diabetic ketoacidosis (pH values between 6.83 and 7.08) treated with or without bicarbonate. A group of 24 patients received 120+/-40 mmol sodium bicarbonate. The two groups were similar at admission with regard to clinical and biological parameters. No difference could be demonstrated between the two groups concerning the clinical parameters or the normalization time of biochemical parameters. If the number of patients with hypokalemia was comparable between the two groups, the potassium supply was significantly more important in group 1 compared with group 2 (366+/-74 mmol/L vs. 188+/-109 mmol/L, respectively; p < .001). CONCLUSIONS: Data from the literature and this study are not in favor of the use of bicarbonate in the treatment of diabetic ketoacidosis with pH values between 6.90 and 7.10.