Clinical features of diabetic patients with pulmonary tuberculosis admitted to a university hospital

Diabetes mellitus (DM) is a risk factor of tuberculosis (TB). We studied the clinical presentation of pulmonary TB among patients with DM in comparison with patients without DM who were admitted into the hospital of the University of the Ryukyus from 2006 to 2010. The clinical data were collected from medical records retrospectively. Ten cases (25%) of hospitalized patients with pulmonary TB had DM. The DM group showed lower Body Mass Index and higher incidence of chronic heart failure and chronic renal failure. The DM group also were more likely to have cavitary lesion, had longer period of hospitalization, and higher mortality. Their causes of deaths were mainly the co-morbidities and associated complications. Further studies are warranted in order to fully elucidate the relationships between pulmonary TB and DM.     

综合医院住院肺结核诊断现状分析

目的了解分析综合医院住院活动性肺结核患者的诊断现状。方法对2002年1月1日—2006年5月31日北京大学人民医院控感科登记的以“肺结核”为主要诊断出院的患者住院病历进行调查并进行回顾性分析,不包括陈旧性肺结核及结核性胸腔积液。结果共统计分析患者74例,其中呼吸内科报告最多,共53例(71.6%),其次为胸外科,共13例(17.6%)。有典型结核中毒症状者仅31例(41.9%),红细胞沉降率明显增快患者者占54.1%,PPD试验阳性仅54.1%。查痰率64.9%,涂阳率54.2%。患者入院至确诊时间平均为13.15 d,≤14 d者48例(64.9%),>14d者26例(35.1%)。确诊方法主要为痰抗酸杆菌阳性(共26例,占35.1%)。经各种活检确诊共27例(36.7%),其中纤维支气管镜下活检诊断8例(10.9%),经开胸肺活检确诊17例(23.0%),经肺穿刺活检确诊1例(1.4%),淋巴结活检确诊1例(1.4%),除纤维支气管镜下活检阳性率88.9%外,其余方式活检阳性率均为100%。临床诊断20例(27.0%)。结论综合医院呼吸内科处于结核病防治的第一线,目前北京大学人民医院对大部分肺结核患者在住院2周之内确诊。主要诊断方法仍为痰找抗酸杆菌阳性,但相当一部分患者通过各种方式的活检确诊。今后应进一步提高痰菌检查率和阳性率。对于诊断不清的病例应及时进行纤维支气管镜检查(包括镜下活检),必要时行肺穿刺甚至开胸肺活检。     

综合医院住院肺结核诊断现状分析

目的了解分析综合医院住院活动性肺结核患者的诊断现状。方法对2002年1月1日-2006年5月31日北京大学人民医院控感科登记的以“肺结核”为主要诊断出院的患者住院病历进行调查并进行回顾性分析，不包括陈旧性肺结核及结核性胸腔积液。结果共统计分析患者74例，其中呼吸内科报告最多，共53例（71，6％），其次为胸外科，共13例（17．6％）。有典型结核中毒症状者仅31例（41．9％），红细胞沉降率明显增快患者者占54．1％，PPD试验阳性仅54．1％。查痰率64．9％，涂阳率54．2％。患者入院至确诊时间平均为13．15d，≤14d者48例（64．9％），〉14d者26例（35．1％）。确诊方法主要为痰抗酸杆菌阳性（共26例，占35，1％）。经各种活检确诊共27例（36．7％），其中纤维支气管镜下活检诊断8例（10．9％），经开胸肺活检确诊17例（23．0％），经肺穿刺活检确诊1例（1．4％），淋巴结活检确诊1例（1．4％），除纤维支气管镜下活检阳性率88．9％外，其余方式活检阳性率均为100％。临床诊断20例（27．0％）。结论综合医院呼吸内科处于结核病防治的第一线，目前北京大学人民医院对大部分肺结核患者在住院2周之内确诊。主要诊断方法仍为痰找抗酸杆菌阳性，但相当一部分患者通过各种方式的活检确诊。今后应进一步提高痰菌检查率和阳性率。对于诊断不清的病例应及时进行纤维支气管镜检查（包括镜下活检），必要时行肺穿刺甚至开胸肺活检。     

Smear-positive pulmonary tuberculosis diagnosed in a general hospital

In Japan, patients with smear-positive pulmonary tuberculosis (SPTB) are hospitalized in a sanatorium because of the law for the prevention of tuberculosis, and not in a general hospital. According to our experience, however, some of the patients with SPTB are hospitalized in a general hospital. In order to study if it is possible to prevent the admission of patients with SPTB to a general hospital, we retrospectively reviewed and compared the medical records of pulmonary TB patients whose sputum was smear-positive for Mycobacterium tuberculosis at our outpatient clinic (Group B; n = 61), and patients whose sputum was smear-positive after the admission to our hospital (Group A; n = 17). The Group A patients were significantly older than the Group B patients [mean age, Group A, 67 years vs Group B, 56 years; (p = 0.01)]. Compared with the Group B patients, the Group A patients more often suffered from underlying diseases [percentage of patients with underlying disease, Group A, 88.2% vs Group B, 37.7%; p < 0.001]; more often showed atypical infiltrative patterns of pulmonary tuberculosis [percentage of cases showing atypical chest roentgenograms, 70.6% vs 19.7%; p < 0.001]; and were in a more serious condition [percentage of deaths during treatment, 47.1% vs 1.7%; p < 0.001]. We conclude that hospitalization of SPTB patients in general hospitals is inevitable, because SPTB can not always be accurately diagnosed before admission, and because it is sometimes difficult to send severely ill SPTB patients to a sanatorium which is inconveniently located in the countryside. We propose to provide facilities for the treatment of SPTB at all general hospitals in Japan.     

综合医院住院病人中诊断的活动性肺结核132例分析

目的了解综合医院住院活动性肺结核病人入院前后诊疗情况,探讨肺结核病人诊断延误的原因,以提高综合医院医生对不典型肺结核的诊断水平。方法回顾性分析2002年1月—2006年12月各科活动性肺结核转、出院的132例病例的临床资料,包括临床症状,辅助检查,诊治情况等。结果(1)门诊误诊为其他疾病而收入院29例占22%,以肺炎、肺部阴影待查及肺脓疡为主;因其他疾病收入院而发现合并肺结核的103例占78%,以慢性喘息性支气管炎、胸膜炎为主。(2)以老年人及外地打工或外地农民比例较高。(3)临床症状以发热、咳嗽、纳差、咳痰喘、头痛、憋气、胸痛、咯血、乏力为常见症状,分别占43.9%、37.1%、21.2%、19.7%、11.4%、10.6%、10.6%、9.1%、8.3%。(4)单纯肺结核病例11例,合并其他疾病病例121例,常见合并疾病为脑血管疾病、营养不良、慢性喘息性支气管炎、糖尿病等,2种以上基础疾病的51例。合并肺外结核共21例,占15.9%,以结核性脑膜炎、颅内结核、肠结核多见。(5)入院后CT检查103例,肺结核89例,提示肺结核可能的14例,诊断率86.4%。(6)入院前100%未作痰涂片抗酸杆菌检查,入院后痰涂片检查82例占62.1%,阳性31例占37.8%。结论综合医院门诊是肺结核诊查的第一线,应进一步加强门诊病人结核病的排查工作,怀疑不典型肺结核病人门诊应该进行痰涂片及肺CT检查。     

Bacteriology in acute exacerbation of chronic obstructive pulmonary disease in patients admitted to hospital

We investigated the bacterial flora and antimicrobial sensitivity in sputum from patients admitted to hospital with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) in order to recommend the best empirical treatment for these patients. The survey was a retrospective study of all patients admitted to Hvidovre hospital with the diagnosis AECOPD during 2004. A total of 118 patients were included. Microscopy, culture and sensitivity testing investigated their sputums. Clinical and paraclinical features were collected from the patients' files. Among the 118 patients, 59 (50%) had a positive sputum culture. The group with positive cultures had a higher blood neutrophil count (p=0.03). There were no other clinical differences between the groups with and without positive sputum culture. The majority of patients with positive sputum cultures were infected with bacteria other than S. pneumonia, mostly H. influenzae and Moraxella catarrhalis. Patients with low FEV(1)<1.0 litre were more likely to be infected with Pseudomonas aeruginosa (p=0.03). The sensitivity patterns of the bacteria showed that the majority were resistant to penicillin. If antibiotics are initiated empirically for AECOPD we recommend either cefuroxime for intravenous treatment or amoxicillin-clavulanate for oral treatment.     

Iodine contamination in subjects admitted to a general hospital.

Urinary iodine excretion was measured in 300 consecutive patients admitted to a general hospital for nonthyroidal disease. Iodine contamination (values greater than 300 micrograms l/g creatinine) was found in 29.3% of cases, mostly due to amiodarone and iodinated contrastographic agents. The source of iodine contamination was not detected in 23% of cases.     

Predictors of risk in patients with unstable angina admitted to a district general hospital.

OBJECTIVE--To observe the long-term prognosis of patients with unstable angina and select simple criteria to identify high and low risk subgroups. DESIGN--A six month prospective survey with three year follow up. SETTING--One eleven bed coronary care unit. PATIENTS--All patients admitted with chest pain in whom no infarct was confirmed by subsequent electrocardiographic or enzyme changes and for whom no alternative cause of chest pain was found were studied. Unstable angina was also diagnosed if there was evidence of myocardial ischaemia in the form of previous effort angina, previous myocardial infarction, or if transient electrocardiographic changes accompanied the pain. When none of the above were present, chest pain without a known cause, was diagnosed. INTERVENTIONS--No routine intervention. Angiography and revascularisation for persistent symptoms despite medical treatment. OUTCOME MEASURES--Death or non-fatal infarction. RESULTS--In the 141 patients with unstable angina there were eight deaths and five non-fatal infarctions during the first eight weeks. Symptoms of increasing angina before admission were similar in all three groups and did not help predict early complications. Recurrence of pain in hospital, a rise in cardiac enzymes to less than twice the upper limit of normal, and transient electrocardiographic changes were all associated with an increased risk of early events. The presence of either abnormal enzyme activity or more than five episodes of pain in hospital identified a group of 49 in whom 11 of the 13 early events occurred. After three years, 29 of the 141 patients had died and eight had had infarctions (overall event rate 26%). Seventeen had undergone revascularisation (12%) and 51 (36%) were on antianginal treatment. Thirty six (26%) were still alive, without new myocardial infarction, and were free of angina. In the 29 patients with chest pain without a known cause there were no early events and only one non-fatal infarction during the three year follow up. CONCLUSION--When patients are admitted to the coronary care unit with chest pain not due to myocardial infarction, the history, electrocardiography and measurement of cardiac enzymes are sufficient to identify high and low risk subgroups.     

Predictors of risk in patients with unstable angina admitted to a district general hospital.

OBJECTIVE--To observe the long-term prognosis of patients with unstable angina and select simple criteria to identify high and low risk subgroups. DESIGN--A six month prospective survey with three year follow up. SETTING--One eleven bed coronary care unit. PATIENTS--All patients admitted with chest pain in whom no infarct was confirmed by subsequent electrocardiographic or enzyme changes and for whom no alternative cause of chest pain was found were studied. Unstable angina was also diagnosed if there was evidence of myocardial ischaemia in the form of previous effort angina, previous myocardial infarction, or if transient electrocardiographic changes accompanied the pain. When none of the above were present, chest pain without a known cause, was diagnosed. INTERVENTIONS--No routine intervention. Angiography and revascularisation for persistent symptoms despite medical treatment. OUTCOME MEASURES--Death or non-fatal infarction. RESULTS--In the 141 patients with unstable angina there were eight deaths and five non-fatal infarctions during the first eight weeks. Symptoms of increasing angina before admission were similar in all three groups and did not help predict early complications. Recurrence of pain in hospital, a rise in cardiac enzymes to less than twice the upper limit of normal, and transient electrocardiographic changes were all associated with an increased risk of early events. The presence of either abnormal enzyme activity or more than five episodes of pain in hospital identified a group of 49 in whom 11 of the 13 early events occurred. After three years, 29 of the 141 patients had died and eight had had infarctions (overall event rate 26%). Seventeen had undergone revascularisation (12%) and 51 (36%) were on antianginal treatment. Thirty six (26%) were still alive, without new myocardial infarction, and were free of angina. In the 29 patients with chest pain without a known cause there were no early events and only one non-fatal infarction during the three year follow up. CONCLUSION--When patients are admitted to the coronary care unit with chest pain not due to myocardial infarction, the history, electrocardiography and measurement of cardiac enzymes are sufficient to identify high and low risk subgroups.     

A study of case findings in pulmonary tuberculosis patients

The incidence of tuberculosis patients increased again recently and many outbreaks of pulmonary tuberculosis (PTB) patients were reported. The purpose of this study is to investigate the present situation of the delay in case finding of PTB patients. 1) Of 236 PTB patients who were admitted to our hospital for treatment in 1997, 118 patients, who were detected by their symptomatic visits, were enrolled in to this study. 50 percentile patient's delay was 21.0 days, and 50 percentile doctor's delay was 7.2 days. 50 percentile total delay was 42.0 days, which was longer than about 28 days obtained by summing up the 50 percentile patient's delay and doctor's delay. The number of cases detected within 28 days was only 39 cases (33.1%). Doctor's delay was mainly attributable to the performing the examination. Regarding the relationship between the period of total delay and sputum smear positive rate, the positive rate was less than 50% when total delay was less than 4 weeks, and came to more than 60% when the delay exceeded 4 weeks. 2) Of 236 PTB patients admitted to our hospital for treatment in 1997, 49 patients had been treated at medical institutions for other diseases. The majority of the cases were diagnosed as PTB in the routine examination, but early case findings was not made, with 9.5 weeks on an average and 50 percentile total delay was 5.5 weeks. The duration of doctor's delay in undergoing examination directly related to PTB diagnosis was accountable for doctor's delay. 3) The case finding of far-advanced cavitary PTB (bI3) patients was studied. Eighty-four patients were detected by symptomatic visits, 10 patients were detected during medical treatments of other disease, and 1 patients was detected by accident. The duration of patient's delay was 5.5 months on an average, while doctor's delay was 0.3 month on an average. The bI3 patients included many social and economical weak people. The body status on admission of bI3 patients were very severe. Twenty percentile of bI3 patients died of PTB, and 14 cases of 19 dead cases died within 1 month from admission. 4) The duration of case finding of tracheobronchial tuberculosis patients was studied. 50 percentile patient's delay was 14 days, while 50 percentile doctor's delay was 145 days. The delay in examination was considered accountable for doctor's delay, with 12 cases (57%) which were treated as bronchial asthma and 6 cases (29%) in which the sputum examination for tuberculosis bacilli was not performed after the detection of chest abnormal shadows on chest X-rays. 5) The present situation of case findings in Japan was studied. Patient's delay did not improve in recent years, while doctor's delay was improve in 2000, after Declaration of State of Emergency concerning tuberculosis. 6) As the countermeasures against patient's delay, it appears necessary to continue enlightenment on PTB, and selective detection by health examination for high risk groups is necessary. As the countermeasures against doctor's delay, it appears important to recommend to all doctors to pay attention to the patients with cough and sputum and undergo sputum examination.     

Prophylaxis of gastrointestinal tract bleeding with magaldrate in patients admitted to a general hospital ward.

A randomized, placebo-controlled trial was performed to assess the effect of magaldrate (800 mg every 4 h) in reducing the rate of upper gastrointestinal tract bleeding among 100 consecutive patients with severe diseases admitted to a general hospital ward. Upper gastrointestinal tract bleeding occurred in 11 of 48 placebo-treated patients and in only 1 of 52 magaldrate-treated patients (p less than 0.01). Endoscopic examination of these patients showed gastric ulcer (two cases), multiple gastric mucosa ulcerations (nine), and no lesions (one). In three patients who received placebo the hemorrhage was clinically relevant and required transfusion of two or more blood units. Patients with two or more risk factors showed a higher rate of gastrointestinal hemorrhage (p less than 0.05). Respiratory failure and treatment with a high dose of corticosteroids were associated with the highest incidence of bleeding (p less than 0.05 for both). The only adverse reaction associated with magaldrate was a mild and self-limiting diarrhea in two cases. We conclude that patients seriously ill admitted to a general hospital ward should be treated with a prophylactic agent against stress-induced ulcer bleeding. Magaldrate is an effective and safe antacid to prevent gastrointestinal tract bleeding in such patients.     

Characteristics associated with inappropriate hospital use in elderly patients admitted to a general internal medicine service

Our objective was to identify patient characteristics associated with inappropriate hospital days in a cohort of elderly medical inpatients. This prospective cohort study included a total of 196 patients aged 75 years and older, who were consecutively admitted over eight months to the internal medicine service of a regional, non-academic public hospital located in a rural area of Western Switzerland. Patients with severe cognitive impairment, terminal disease, or previously living in a nursing home were excluded. Data on demographics, medical, physical, social and mental status were collected at admission. A blinded hospitalization review was performed concurrently using a modified version of the Appropriateness Evaluation Protocol (AEP). Subjects' mean age was 82.4 years; 63.3% were women. Median length of stay was 8 days. Overall, 68 patients (34.7%) had at least one inappropriate day during their stay, including 18 patients (9.2%) whose hospital admission and entire stay were considered inappropriate. Most inappropriate days were due to discharge delays (87.10%), primarily to nursing homes (59.30%). Univariate analysis showed that subjects with inappropriate days were more likely to be living alone (69.1 vs 48.4%, p=0.006), and receiving formal in-home help (48.5 vs 32.8%, p=0.031). In addition, they were more impaired in basic and instrumental activities of daily living (BADLs, and IADLs, p<0.001 and p=0.015, respectively), and more frequently had a depressed mood [29.4 vs 10.9%, p=0.001 with a score > 6 at the Geriatric Depression Scale (GDS), short form]. Using multivariate analysis, independent associations remained for patients living alone (OR 2.6, 95%CI 1.2-5.8, p=0.016), those with a depressed mood (OR 2.8, 95%CI 1.1-7.3, p=0.032), with BADL dependencies (OR 1.5, 95%CI 1.2-1.8, p=0.001), and IADL dependencies (OR 1.3, 95%CI 1.0-1.6, p=0.032). Cardiovascular (OR 0.2, 95%CI 0.1-0.7, p=0.008) and pulmonary admission diagnoses (OR 0.1, 95%CI 0.0-0.7, p=0.022) were inversely associated with inappropriate hospital days. In conclusion, patients living alone, functionally impaired and showing depressive symptoms were at increased risk for inappropriate hospital days. These characteristics might permit better targeting for early discharge planning in these at-risk subjects, and contribute to avoiding premature discharge of other vulnerable elderly patients. Whether these interventions for at-risk patients will also result in prevention of hospitalization hazards, such as deconditioning and related functional decline, will require further study.