《伤寒杂病论》中对咳喘的治法、用药浅述

咳喘为临床常见症状,不同病机治法不一,用药亦不尽相同。笔者从《伤寒杂病论》中找寻其治法及用药特点,并从解表散寒,宣降肺气、化痰祛饮、清泻热邪,祛瘀排脓、扶助正气四个方面进行论述,以期同道指正、并对临床有所启发。     

An optimization model for reducing typhoid cases in developing countries without increasing public spending

This article considers the investment case for using the Vi polysaccharide vaccine in developing countries from two perspectives: reducing typhoid cases and limiting new health care spending. A case study is presented using data from South and Southeast Asia. The purpose of the paper, however, is to draw broad implications that may apply to developing countries in general. Typical consumer demand functions developed from stated preference household surveys in South and Southeast Asia are used to predict probabilities of adults and children purchasing typhoid vaccinations at different prices. These functions are incorporated in a formal mathematical model. Using data from the recent literature for South and Southeast Asia for typhoid incidence, Vi vaccine effectiveness, public cost of illness, and vaccination program cost, three mass vaccination policy alternatives are evaluated: charging adults and children different (optimal) prices, charging uniform prices, and providing free vaccines. Assuming differential pricing is politically feasible, different vaccine prices for children and adults would maximize the number of typhoid cases avoided from a mass vaccination program if the public sector faces a budget constraint on spending for the vaccination program. However, equal prices for children and adults produce very similar results, and they might be more readily accepted by the community. Alternatively, if vaccines are free, the number of cases is not significantly reduced compared to either pricing policy, but a large external financial contribution from government or donors would be required. A Monte Carlo simulation explores the effects of uncertain parameters on vaccination program outcomes.     

Colonoscopic manifestations of typhoid fever with lower gastrointestinal bleeding

BACKGROUND: Intestinal bleeding in patients with typhoid fever usually occurs in the ileum. However, endoscopic findings in such patients are not well established. We examined the colonoscopic manifestations of intestinal lesions with bleeding in patients with typhoid fever. PATIENTS AND METHODS: The colonoscopic findings of seven patients who presented with haematochezia due to typhoid fever were reviewed retrospectively. Typhoid fever was diagnosed when the Salmonella typhi was isolated or when the Widal test showed strongly positive reactions. RESULTS: Clinical data and colonoscopic findings were reviewed in seven patients (four men and three women with an average age of 42 years). The most commonly involved area was the terminal ileum (100%), followed by the ileocecal valve (57%), the ascending colon (43%), and the transverse colon (29%). Left colon was intact in all cases. The most common colonoscopic finding was multiple variable-sized punched-out ulcers with slightly elevated margin, as found in five patients. In two patients, only several oedematous hyperaemic mucosal patches with haemorrhagic spots or shallow erosions were seen. Active bleeding was noticed only in one patient, who received endoscopic haemostasis twice. The remaining six patients were treated by conservative treatment including antibiotic therapy. There was no complication during or after the colonoscopic examination. CONCLUSIONS: Intestinal bleeding in typhoid fever usually occurs from the ulcers in the ileum or proximal colon, and the most common colonoscopic manifestations are multiple variable-sized punched-out ulcerations.     

小儿伤寒肠穿孔45例诊治体会

本文报告小儿伤寒肠穿孔４５例，其中男２９例，女１６例。年龄３－１４岁，平均９．８岁。入院前误诊１４例，治愈３９例，死亡６例，并发肠瘘６例。结果提示：小儿伤寒肠穿孔以学龄期儿童发病率最高，穿孔多发生在伤寒病病程的第２、３周，部位多在距回盲瓣５０ｃｍ内的回肠肠系膜对侧缘。     

Cases of typhoid fever imported into England, Scotland and Wales (2000-2003)

Although typhoid fever is no longer endemic in most of the developed world, it remains a major infectious disease in less developed regions and imported cases continue to occur in returning travellers, immigrants or migrant workers. We analysed all 692 isolates of Salmonella enterica subspecies enterica serovar Typhi from cases in England, Scotland and Wales that were sent to the Laboratory of Enteric Pathogens at the Health Protection Agency, Centre for Infections, London, UK between 2000 and 2003. The country of acquisition was known for 416 isolates (60%), and the majority of these (70%) came from India or Pakistan. Overall, 24 countries were listed, mainly in Asia and Africa. A total of 48 phage types were detected, 41% of which were Vi-phage type E1. Antimicrobial susceptibility testing revealed that 22% of isolates were multidrug resistant (MDR) (defined as resistance to chloramphenicol, ampicillin and co-trimoxazole) and 39% were quinolone resistant. A significant number of isolates (n=49) were sensitive to nalidixic acid by disk test but exhibited low-level ciprofloxacin resistance, suggesting a novel mechanism of resistance and reinforcing the need for minimum inhibitory concentration determination. Overall, 13% of isolates were both MDR and likely to show a poor response to a fluoroquinolone. A third-generation cephalosporin (e.g. ceftriaxone) should be considered as empirical therapy in regions of the Indian subcontinent where resistance is now at high levels as well as in patients returning from these areas. This study helps to describe the epidemiology of antimicrobial drug resistance in typhoid fever.     

Ciprofloxacin therapy for typhoid fever needs reconsideration

Outbreaks of multidrug-resistant Salmonella enterica serotype Typhi in the Indian subcontinent in the late 1980s resulted in the failure of conventional drugs, and ciprofloxacin became the firstline drug to treat enteric fever. However, reduced susceptibility to ciprofloxacin, reported widely since 1994, has posed a therapeutic difficulty. The aim of the present work was to review the situation of drug resistance among S. enterica serotype Typhi in central India from 1988 to 2005. A minimum inhibitory concentration (MIC) study for ciprofloxacin was carried out by the agar dilution method on 314 stock cultures preserved since 1988. The MIC for ciprofloxacin was ≤0.125 mg/l for the 50 isolates isolated during 1989–1994, but during 1998–1999, 60% of the 50 isolates showed MIC > 0.125 mg/l, while in 2002–2003, 82.5 % of the 97 isolates had MIC > 0.125 mg/l and 35% had MIC > 1 mg/l (high-level resistance). In 2004–2005, 88.2% of the 77 isolates had MIC > 0.125 mg/l and 15% had MIC > 1 mg/l (high-level resistance). Sixty-four isolates showing MIC > 1 mg/l with the agar dilution method were also checked by Epsilometer test (E-test, AB Biodisk, Solna, Sweden). Based on the data, it is suggested to withdraw ciprofloxacin as a therapeutic agent for enteric fever. Fortunately, multiple drug resistance, with concurrent resistance to chloramphenicol, cotrimoxazole, and ampicillin, which had reached more than 90% in 1990–1991, started declining over the years and was as low as 5.6% in 2004–2005. According to these observations, older drugs such as chloramphenicol, cotrimoxazole, and ampicillin could be recalled to treat enteric fever.     

陈泽东论太阳病

近代天津名医陈泽东所著《国医伤寒课义》论太阳病,以表里轻重提纲挈领,如他论＂太阳病＂重视表里轻重之病,以求＂条目清晰,俾令读者易记易明,而适用也＂。太阳在表之病分列中风、伤寒、温病,并有轻重之分,不仅分述了仲景治中风与伤寒之正方桂枝汤、麻黄汤,而且还补充了温病治法与处方。太阳在里之病分列蓄水为轻证、蓄血为重证,蓄水之证治以五苓散、茯苓甘草汤及猪苓汤,蓄血之证治以桃核承气汤与抵当汤。     

伤寒并发中毒性肝炎的肝功能分析

目的 :探讨伤寒杆菌对肝脏的损害和对肝功能的影响。方法 :对 35 0例伤寒患者肝功能及乙型肝炎病毒(HBV)标记物的检测结果进行分析。结果 :2 30例 (6 5 .7% )出现ALT和AST升高 ,其中 83例 (36 .1% )伴有血清总胆红素 (STB)升高 ;32 0例进行HBV标记物检测 ,发现HBV感染 4 5例 ,伤寒重叠HBV感染率为14 .1% ,重叠感染组的ALT ,AST及STB均值比单纯感染组显著升高 (P <0 .0 5 )。结论 :伤寒患者中肝损害较常见 ,其中重叠HBV感染者肝损害程度更重 ,但重叠HBV感染者中肝损害的发生率并无明显升高。     

临沂市1956～2000年伤寒流行病学分析

目的 探讨伤寒在临沂市的流行规律,制定有效的防制措施。方法 收集我市1956～2000年伤寒疫情报告及流行病学调查资料,并进行汇总分析。结果 1956～2000年临沂市共发生伤寒病9 344例,死亡70例,年平均发病率为2.23/10万,病死率0.75％;发病具有明显的周期性和季节性;年龄主要集中在10～35岁年龄段,占68.40％;农民和中小学生是主要的发病人群,占81.13％;平原伤寒发病率高于山区;临床特征由典型转为不典型,近几年流行菌株主要有M_1、D_2 2个噬菌体。结论 改善饮用水卫生、保护饮用水源,是预防伤寒发生的重要措施。