儿童大叶性肺炎344例临床分析

目的分析儿童大叶性肺炎的临床特点及病原学变迁。方法对344例大叶性肺炎病例的临床及病原学特点进行回顾性分析。结果发病年龄平均6.1岁,〈1岁24例,1～3岁56例,〉3～6岁104例,〉6～18岁160例。344例患儿中咳嗽342例（99.4%）,多为刺激性干咳,发热267例（77.6%）,胸痛57例（16.7%）,气促45例;肺炎支原体抗体188例,80例病毒感染,14例痰培养阳性,混合感染46例。细菌感染多发生于≤3岁儿童,〉3岁儿童支原体感染发生率高。累及部位右肺多于左肺,均以下叶为主;经系统治疗后,大部分好转,2例放弃治疗后死亡。结论大叶性肺炎多好发于3岁以上儿童,由肺炎链球菌感染引起的大叶性肺炎逐渐减少,而由支原体、病毒及其他细菌感染引起的大叶性肺炎逐渐增多,大部分经治疗后预后良好。     

危重症甲型H1N1流感病毒肺炎的多层螺旋CT表现

目的：探讨危重症甲型H1N1流感病毒肺炎患者的多层螺旋CT的影像学特点。方法：回顾性分析21例确诊的危重症甲型H1N1流感患者的64层螺旋CT影像资料。结果：21例患者中,①所有病变均表现为双侧分布,且主要为弥漫性分布,多灶性病变以中下肺叶为主。其中累及右肺上叶9例,右肺中叶14例,右肺下叶19例,左肺上叶9例,左肺下叶19例。②病变形态表现为：支气管血管束增粗（21/21,100%）,小叶中心结节（12/21,57.1%）,小叶间隔增厚（9/21,42.9%）,网状结节（3/21,14.3%）,磨玻璃样密度影（14/21,66.7%）,斑片融合影（7/21,33.3%）,大片实变密度影（9/21,42.9%）,支气管气象（5/21,23.8%）。③胸膜腔积液（8/21,38.1%,其中5例单侧,3例双侧）;淋巴结肿大（9/21,42.9%,其中5例腋窝淋巴结肿大,3例纵隔淋巴结肿大,2例腋窝、纵隔均淋巴结肿大）;胸膜肥厚（12/21,57.1%）;心包积液（1/21,4.76%）。④9例复查危重症甲型H1N1流感患者中3例死亡者首诊MSCT见双肺中下叶斑片及实变密度影、磨玻璃密度影。复查见病变进展迅速,双肺实变明显,死于呼吸衰竭。6例好转者肺内病变明显吸收,仅遗留少许索条或小斑片状影。结论：危重症甲型H1N1流感病毒肺炎64层螺旋CT主要表现为双肺内弥漫分布的磨玻璃密度影及多灶性实变影,多同时累及肺实质及肺间质,可伴有胸膜腔积液、淋巴结肿大、胸膜肥厚等。病程进展以磨玻璃密度影及实变影范围扩大为主要标志。     

老年社区获得性肺炎118例临床诊疗分析

对2008年1月～2010年1月118例住院治疗的老年社区获得性肺炎患者的临床资料进行回顾性分析。结果118例CAP患者中有96例（81.36%）检测到病原体。检出肺炎支原体19例,肺炎衣原体4例,嗜肺军团菌3例。分离出流感嗜血杆菌26例,肺炎链球菌34例,卡他莫拉菌2例,肺炎克雷伯杆菌3例,金黄色葡萄球菌5例。混合感染26例。其中治愈91例（77.12%）,好转24例（20.34%）,死亡3例（2.54%）,总有效率为97.46%。流感嗜血杆菌和肺炎链球菌是CAP的主要致病菌。对老年社区获得性肺炎要掌握其规律,做到早期诊断,联合用药,疗程足够,以提高治愈率。     

新型冠状病毒肺炎CT征象再讨论

目的寻找新型冠状病毒肺炎（NCP）的特征性CT征象,并从影像病理学角度探讨其临床意义。方法收集整理2020年1月26日至2月12日河北省确诊为NCP的40例病人的CT图像,对其72侧肺部,234个肺段,共459个病灶进行分析;同时与随机抽取的20例本院诊治的其他性质肺炎（非NCP）病人的28侧肺部,79个肺段,共258个病灶的CT图像进行比较研究。结果NCP组病灶多位于两肺下叶（分别为30个,23.44%）,多累及双侧（32例,80.00%）,且累及5个肺叶的比例较大,其在左、右侧肺分布上差异不大,伴有胸腔积液的仅为1例（2.50%）。NCP组与非NCP组在病灶累及肺叶数量、扇形分布、肺血增多或肺水肿、伴有血管增粗和支气管壁增厚上差异有统计学意义。18例有复查资料的患者中有进展的为13例（占72.22%）,其中8例有肺血增多或肺水肿（占62%）,11例累及双侧（约占85%）。结论NCP的CT表现有其特征性,而且其可能更容易侵犯血管引起血管炎,进而会导致肺水肿和心肺循环紊乱的发生,这对于预测患者病情发展可能具有提示作用。     

老年人社区获得性肺炎临床分析

目的：分析老年人社区获得性肺炎的临床特点及流行病学特征。方法：对上海市宝山区25家医院3502例老年人社区获得性肺炎患者的临床资料进行回顾性分析。结果：年龄60～105（75.03±8.42）岁,男性1831例（52.3%）,女性1671例（47.7%）。冬春季节发病2406例（68.7%）,夏秋季发病1096例（31.3%）。发热1578例（45.1%）,咳嗽或咳痰1986例（56.7%）,乏力伴纳差2001例（57.1%）。血白细胞数升高（≥10×109/L）708例（20.2%）,白细胞数正常而中性粒细胞升高1209例（34.5%）,白细胞数减少（≤4×109/L）88例（2.5%）,两者均正常1497例（42.7%）。双肺肺炎996例（28.4%）,左肺肺炎913例（26.1%）,右肺肺炎1593例（45.5%）。合并基础疾病1935例（55.3%）,出现并发症518例（14.8%）。患者住院天数8～47（18.3±2.4）d。住院费用为人民币1865～9892（4823.36±251.24）元。死亡291例（9.3%）。结论：老年人社区获得性肺炎临床表现不典型,双肺病变多见,合并基础疾病及并发症多,住院时间长,医疗费用较高。     

肺炎支原体感染致小儿大叶肺炎21例临床分析

摘要：目的 探讨肺炎支原体感染致小儿大叶性肺炎（肺炎支原体肺炎）的临床特点、诊疗方法。方法 总结21例肺炎支原体感染致小儿大叶性肺炎的临床资料及治疗与转归。结果 本组病例以年长儿多见，3~5岁3例，5~10岁18例，临床表现为发热、咳嗽，肺部体征少，可伴有肺外并发症；21例胸部X线均呈单侧大叶性肺炎，1例以腹痛、腹泻为首发症状，1例并少量胸腔积液；肺炎支原体特异性抗体IgM（MP-IgM）测定均阳性；所有病例阿齐霉素治疗有效。结论：肺炎支原体感染致小儿大叶性肺炎在临床和X线表现上与细菌性肺炎不易区分，尤其与肺炎链球菌感染的大叶性肺炎难以区分，血清学检测MP—IgM为诊断的主要手段；大环内酯类抗生素是治疗的有效药物。     

输入性2019-nCoV肺炎的临床和CT特征初步观察

目的：初步探讨输入性2019-nCoV肺炎的临床和CT表现特点。方法：回顾性分析12例输入性2019-nCoV肺炎患者的临床及CT资料，初步分析该病的CT特征。结果：12例患者（100%）均有流行病学史，最常见的症状是发热（12/12,100%）和咳嗽（8/12,66.7%）,9例（75%）患者白细胞计数正常，7例（58.3%）淋巴细胞计数减少，C反应蛋白升高5例（41.7%）。CT影像所见病变发生一侧肺者2例（左肺），双侧肺者10例。病变局限于1个肺叶2例，两个肺叶3例，3个以上肺叶7例。病灶主要在两肺外周胸膜下分布10例，单纯毛玻璃结节（GGO）2例，GGO伴有实性成分6例，GGO伴有实性结节4例，病灶形态斑片影10例，类圆形病灶2例，6例可见空气支气管征，4例可见小叶间隔增粗，3例可见纤维灶。12例患者均未见胸腔积液和淋巴结肿大。结论：患者有发热和或咳嗽症状，实验室检查白细胞计数正常，粒细胞计数减低，CT影像所见两下肺外周多发GGO病变，同时有流行病学史时高度提示输入性2019-nCoV肺炎可能。     

变应性支气管肺曲霉菌病的影像学表现

目的分析变应性支气管肺曲霉菌病(ABPA)的影像学表现。方法回顾性分析6例ABPA病例的直接数字化X线摄影(DR)胸片和胸部高分辨率CT(HRCT)的影像特点。结果 6例病人DR胸片和HRCT均可见支气管扩张和肺内实变病灶,其中1例为单发实变病灶,5例为多发实变;5例可见中心性支气管扩张,1例中心性支气管和外周支气管均可见扩张。HRCT示实变共累及上叶10个肺叶,中叶(或舌叶)8个肺叶,下叶5个肺叶;6例HRCT均可见磨玻璃密度影,2例可见树芽征;6例病人HRCT均见上叶支气管扩张,其中2例为一侧上叶支气管扩张,4例为多叶、多段支气管扩张。上叶支气管扩张共累及10个肺叶,中叶(或舌叶)支气管扩张共累及8个肺叶,下叶支气管扩张共累及6个肺叶;静脉曲张样扩张为主4例,囊状扩张和柱状扩张为主各1例。扩张支气管内见黏液崁塞2例,形成"指套"征,增强扫描无强化。扩张支气管内见钙化和软组织密度影者各1例。内见气液平面者2例。肺门淋巴结肿大1例。结论对于有长期哮喘病史,HRCT显示有肺内实变病灶和中央支气管扩张,特别是扩张支气管内有黏液崁塞、钙化或软组织密度影且病变主要分布在中上肺者应考虑ABPA的诊断。     

儿童坏死性肺炎支原体肺炎的影像学表现

目的探讨儿童坏死性肺炎支原体肺炎的影像学特点。方法回顾性分析经临床确诊的17例坏死性肺炎支原体肺炎患儿的临床资料和影像学表现。结果 17例坏死性肺炎支原体肺炎影像学均表现为肺内实质浸润及液性坏死,9例为单一肺叶受累,8例2个及以上肺叶受累;9例肺内有空腔形成;15例合并胸膜改变。随访中17例肺内实质浸润及液化坏死区范围缩小或者明显吸收,2例局部残留支气管扩张。结论儿童坏死性肺炎支原体肺炎表现为肺内实质浸润及液性坏死,可有空腔形成及胸腔积液、胸膜增厚。     

枣庄地区小儿大叶性肺炎流行病学调查及病原学研究

目的：探讨大叶性肺炎病原学特点及流行规律。方法：山东枣庄地区2006年1月—2008年11月住院患儿296例,于入院当日给予吸痰做痰培养,查结核杆菌,查肺炎支原体、衣原体DNA以及呼吸道合胞病毒、腺病毒、流感病毒、副流感病毒和柯萨奇病毒。结果：296例患儿中病原阳性数共179例（60.5%）,其中支原体DNA阳性76例（占病原阳性数的42.5%）。流行季节支原体以11月至次年4月为主;病毒及细菌以6～8月为主。发病年龄1～7岁为主,占59.7%。结论：枣庄地区小儿大叶性肺炎病原种类多,以支原体为主,在临床诊治中应加强实验室检查;流行季节集中于寒冷及高温季节。     

Guns and Knives in New Mexico: Patterns of Penetrating Trauma, 1978–1993

Objective: To identify patterns of nonfatal and fatal penetrating trauma among children and adults in New Mexico using ED and medical examiner data.
Methods: The authors retrospectively sampled in 5-year intervals all victims of penetrating trauma who presented to either the state Level-1 trauma center or the state medical examiner from a 16-year period (1978–1993). Rates of nonfatal and fatal firearm and stabbing injury were compared for children and adults.
Results: Rates of nonfatal injury were similar (firearm, 34.3 per 100,000 person-years; stabbing, 35.1). However, rates of fatal injury were significantly different (firearm, 21.9; stabbing, 2.7; relative risk: 8.2; 95% confidence interval: 5.4, 12.5). From 1978 to 1993, nonfatal injury rates increased for children (p = 0.0043) and adults (p < 0.0001), while fatal penetrating injury remained constant. The increase in nonfatal injury in children resulted from increased firearm injury rates. In adults, both stabbing and firearm nonfatal injury rates increased.
Conclusions: Nonfatal injury data suggest that nonfatal violence has increased; fatal injury data suggest that violent death rates have remained constant. Injury patterns vary by age, mechanism of trauma, and data source. These results suggest that ED and medical examiner data differ and that both are needed to guide injury prevention programs.     

Interprofessional approaches to creating safe,high quality health care

Three supplementary perspectives are presented arguing that interprofessional collaboration is both necessary and desirable. Nonetheless, there are often too many serious intra-professional barriers and obstacles to interprofessional collaboration to make it successful. Some of these barriers, it is argued and illustrated, are found in the multiple ways in which professional identity is tacitly acquired and embodied in the practitioners' habitual, everyday practice. The paper then explores ways in which reflection, especially Second order reflection, can help to elucidate and overcome these obstacles, as well as increasing professional adaptability and competence.     

Prospects for the control of neglected tropical diseases by mass drug administration

The prospects for the control of neglected tropical diseases, including soil-transmitted helminthiasis, shistosomiasis, lymphatic filariasis, onchocerciasis and trachoma, through mass drug administration, are exemplified by the elimination of the trachoma as a public-health problem in Morocco. In spite of this and other striking successes, mass drug administration programs are faced with major challenges resulting from suboptimal coverage and lack of efficacy. At current suboptimal coverage rates, programs may need prolongation for an extended period, increasing costs and undermining sustainability. Community participation through health education and information appears to be crucial to improve coverage and to achieve sustainability. Implementation of complementary measures, such as vector control, improved hygiene and environmental sanitation, are important to further control transmission and to prevent re-emergence of the infection and, again, may only be achieved effectively through community-based initiatives. To reduce costs and to relieve pressure on the health system, combining neglected tropical disease programs in areas where diseases coexist and integration with existing control programs for malaria, tuberculosis and HIV/AIDS is advocated. The risk of developing drug resistance is of particular concern in view of the lack of alternative drugs, and reduced treatment efficacy due to emerging resistance is evident for the soil-transmitted helminths and onchocerciasis. Given the risk for the development of drug resistance and the need for a high degree of participation, close attention should be paid to the monitoring of the coverage and efficacy of the different program components.     

Bacterial meningitis: an update of new treatment options

The outcome of bacterial meningitis critically depends on the rapid initiation of bactericidal antibiotic therapy and adequate management of septic shock. In community-acquired meningitis, the choice of an optimum initial empirical antibiotic regimen depends on the regional resistance patterns. Pathogens resistant to antibacterials prevail in nosocomial bacterial meningitis. Dexamethasone is recommended as adjunctive therapy for community-acquired meningitis in developed countries. In comatose patients, aggressive measures to lower intracranial pressure <20 mmHg (in particular, external ventriculostomy, osmotherapy and temporary hyperventilation) were effective in a case–control study. Although many experimental approaches were protective in animal models, none of them has been proven effective in patients. Antibiotics, which are bactericidal but do not lyse bacteria, and inhibitors of matrix metalloproteinases or complement factor C5 appear the most promising therapeutic options. At present, vaccination is the most efficient method to reduce disease burden. Palmitoylethanolamide appears promising to enhance the resistance of the brain to infections.     

Imaging choices in occult hip fracture

Background: Hip fracture is a common injury, with an incidence rate of > 250,000 per year in the United States. Diagnosis is particularly important due to the high dependence on the integrity of the hip in the daily life of most people. Objectives: In this article we review the literature focused on hip fracture detection and discuss advantages and limitations of each major imaging modality. Discussion: Plain radiographs are usually sufficient for diagnosis as they are at least 90% sensitive for hip fracture. However, in the 3–4% of Emergency Department (ED) patients having hip X-ray studies who harbor an occult hip fracture, the Emergency Physician must choose among several methods, each with intrinsic limitations, for further evaluation. These methods include computed tomography, scintigraphy, and magnetic resonance imaging. Conclusion: We present an evidence-based algorithm for the evaluation of a patient suspected to have an occult hip fracture in the ED. Also outlined are future directions for research to distinguish more effective techniques for identifying occult hip fractures.     

Systematic Reviews Published in the April 2012 Issue of the Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly as a DVD but monthly online. The April 2012 issue (second DVD for 2012) contains 5045 complete reviews, 2182 protocols for reviews in production, and 17,084 short summaries of systematic reviews published in the general medical literature. In addition, there are citations of 674,000 randomized controlled trials, and 15,400 cited papers in the Cochrane methodology register. The health technology assessment database contains just over 11,000 citations. One hundred and seventeen new reviews have been published in the last 3 months of which 12 have potential relevance for practitioners in pain and palliative medicine. The impact factor of the Cochrane Library stands at 6.186. Readers are encouraged to access the full report for any articles of interest as only a brief commentary is provided.     

Platelets,thrombosis, coagulation,and atherosclerosis

When I first got the invitation to join a medical delegation going to Moldova, I thought for a moment that our destination was the fictional country in the old Marx Brothers movie Duck Soup. On further checking, it turns out that entertaining place was called Freedonia. I now know that Moldova is indeed a real country, bordered on the west by Romania and on the other three sides by the Ukraine. It is a proud country, rich with traditions, and its people are warm, giving, eager to learn ways to improve their healthcare system, and deeply appreciative of our attempts to help them in the task.     

Spiritual Dimensions of Nursing Practice. edited by V. B. Carson

The Cochrane Library of Systematic Reviewsis published quarterly. Issue one for 2004 of the library was published in February 2004. This issue contains 3,329 reviews and protocols of which 1,921 are fully published reviews. The trials database now stands at over 400,000 records with an additional 4,427 one-page summaries of non-Cochrane reviews in the NHS database of reviews of effectiveness (DARE). This version of the library contains the results of an extensive search for RCTs on EMBASE. The latest library contains 84 new reviews, seven are considered relevant to practitioners in pain and palliative care. References are published in the same format as the citation for Cochrane reviews.     

Advance Care Planning

Predictors of patient wishes and influence of family and clinicians are discussed. Research findings on patient decision-making relating to preferences in end-of-life care are described. Advance directives and durable powers of attorney are defined and differentiated. Most patients have not participated in advance care planning and the need for more effective planning is documented. Appropriate times for discussions of such planning are described. Scenarios discussed include terminal cancer, chronic obstructive pulmonary disease, AIDS, stroke, and dementia. Patient satisfaction is discussed, as is a structured process for discussions about patient preferences. Results of patient responses to hypothetical scenarios are described. Invasiveness of interventions, prognosis and other factors that favor or discourage patient preferences for treatment are discussed. Findings resulting from research funded by the Agency for Healthcare Research and Quality (AHRQ) are discussed. This research can help providers offer end-of-life care based on preferences held by the majority of patients under similar circumstances.     

Évaluation,par l’imagerie ultrasonore,du recrutement musculaire,de la force motrice et de la détente verticale du quadriceps après électromyostimulation (cas de 15 étudiants de l’INJS)

The increase of strength seems to be an element of performance in some sports.