门诊肝硬化腹水合并自发性腹膜炎的临床分析

目的探讨门诊肝硬化腹水患者自发性腹膜炎(SBP)的发病情况及特点。方法门诊或住院6h内肝硬化患者行诊断性腹穿,抽取腹水20ml,计数腹水中中性粒细胞数,并查腹水总蛋白及细菌培养,同时查血总胆红素、丙氨酸转氨酶(ALT)、白蛋白及凝血酶原时间(PT)。结果共检出典型SBP32例,占6.15%;无症状型SBP12例,占2.31%;细菌性腹水3例,占0.58%。典型SBP组血浆总胆红素、PT、腹水中中性粒细胞数及腹水总蛋白较无症状SBP组有显著性差异,30天内死亡率(15.6%)高于无症状SBP组(8.3%)。结论门诊肝硬化患者SBP的发生率低于文献报道的住院患者,约2.31%为无症状型,无症状型SBP患者的肝功能状态及预后较典型SBP为好。     

肝硬化并结核性腹膜炎与肝硬化并自发性腹膜炎患者间临床特征比较

目的:探讨肝硬化并结核性腹膜炎(tuberculous peritonitis,TBP)与肝硬化并自发性腹膜炎(spontaneous bacterial peritonitis,SBP)患者间临床特征差异。方法:收集2000年1月至2010年6月间温州医学院附属第一医院住院资料完整的肝硬化患者共102例。其中肝硬化并TBP患者28例,肝硬化并SBP患者74例。回顾性比较两组患者间年龄、性别、肝硬化病因、Child-Pugh分级、既往结核病史、实验室检查等。结果:TBP主要发生于病毒性肝硬化患者(57.1%),Child-Pugh分级主要分布在B级(75.0%),既往常有结核病史(71.4%),而SBP患者主要发生于酒精性肝硬化患者(52.7%);Child-Pugh分级主要分布在C级(77.0%);与肝硬化并SBP患者比较:肝硬化并TBP患者肝功能损害较轻,腹水白细胞计数较低,并且以淋巴细胞为主,腹水腺苷脱氨酶水平较高。余指标无差异。结论:肝硬化并TBP患者与肝硬化并SBP患者在年龄、性别分布上无差异,而导致肝硬化的病因、Child-Pugh分级、既往有无结核病史、肝功能、腹水白细胞计数及各种白细胞比例、腺苷脱氨酶可作为鉴别两者的重要参考依据。     

Predictors of digoxin use and risk of mortality in ED patients with atrial fibrillation

Objectives

The aim of this study was to evaluate factors of digoxin use and its relation to mortality in ED patients with atrial fibrillation (AF).

自发性腹膜炎腹水细菌潜生体形成及其生物学特性研究

目的：观察自发性腹膜炎患者腹水中细菌潜生体（CGC）的生物学特性。方法：用细菌形态学检测方法观察腹水细菌CGC的形成;用细菌显微培养技术、细菌遗传稳定性试验和最小抑菌浓度（MIC）测定并观察CGC的生物学特点。结果：自发性腹膜炎患者腹水中CGC具有传代生长、繁殖方式多样,活动能力强和抗生素耐受力强的特点。结论：自发性腹膜炎患者腹水CGC有很强的繁殖能力、运动能力和抗生素耐受力,从而具有极强的侵袭力。     

Thyroid stimulating hormone testing in ED evaluation of patients with atrial fibrillation and various psychiatric diagnoses

BackgroundPrevious studies of thyroid stimulating hormone (TSH) levels in Emergency Department (ED) patients largely have centered on patients with atrial fibrillation (AF). In our ED patients with AF as well as patients with Psychiatric diagnoses (psych) are screened. The purpose of the present study was to compare TSH levels in the 2 groups. Our hypotheses were that an abnormal TSH and/or AF predicted the need for hospital admission and that TSH is more likely decreased in AF and increased in psych patients.MethodsOur goal in the study was to compare the use of TSH testing in two ED populations, AF vs. psych patients. The study was a cross sectional cohort of AF vs. psych patients who had TSH levels drawn in the ED over a two year period. Our laboratory ranges were used to determine high vs. low TSH. Two chart examiners collected data after a training process. Charts were reviewed extracting demographic data, TSH levels, outcome (admit vs. discharge), history of AF, thyroid disease, psych diagnoses, presence of CHF, diabetes, hypertension. We compared AF vs. Psych groups using chi square and t-tests for parametric data. Odds ratios were calculated for comparisons between the 2 groups. For non-parametric data Mann Whitney U was used. A logistic regression was performed with the outcome of admission vs. discharge to find predictors of hospital admission. Kappa was calculated for inter-rater agreement. An a priori power analysis showed 80% power with 2 groups of 100 with an absolute difference of 20% between the 2 groups.Results252 patients were included, 101 with AF and 152 Psych. Demographics differed in age only with AF patients being older. Mean TSH for AF vs. 2.4 for AF, 2.9 for psych (NS) with no differences in percentages with high or low TSH in the 2 groups. Fifty-three patients had abnormal TSH levels (21%), 27% of AF and 17% of Psych patients (NS). There were significant differences in incidence of CHF, DM, HTN, and tachycardia with more in the AF group (P < 0.001). Significantly more of the psych patients had a history of hypothyroidism (OR 2.28). Our logistic regression showed that taking into account demographics including age, the only predictors of admission were the presence of CHF (aOR 18.6) and having a diagnosis of AF (aOR 4.0).ConclusionThere were no differences in TSH levels between the 2 groups. Twenty-one percent had an abnormal level. CHF and AF predicted hospital admission on regression analysis. Many with these AF or Psych diagnoses had abnormal ED TSH levels that could be useful in diagnosis, maintenance, or continuous treatment for their conditions diagnoses.     

Long-term prophylaxis of spontaneous bacterial peritonitis in patients with cirrhosis

OBJECTIVE: To review the literature regarding long-term prophylaxis of spontaneous bacterial peritonitis (SBP) in patients with cirrhosis. DATA SOURCES: A MEDLINE (1967-September 2004) and bibliographic search of the English-language literature was conducted using the search terms spontaneous bacterial peritonitis, cirrhosis, antimicrobial, and prophylaxis. DATA SYNTHESIS: Long-term antimicrobial prophylaxis has been shown to decrease recurrent SBP in cirrhotics with a prior episode. Prophylaxis in patients with low ascitic fluid protein has also been shown to reduce the incidence of SBP; however, studies are too in-homogeneous to identify subgroups that benefit the most. CONCLUSIONS: Long-term antimicrobial therapy should be considered for secondary prophylaxis of SBP. Studies should be done to confirm this benefit and identify subsets of patients with low ascitic fluid protein who clearly benefit.     

Complement and immunoglobulin levels in serum and ascitic fluid of patients with spontaneous bacterial peritonitis,malignant ascites,and tuberculous peritonitis

BACKGROUND: We determined complement and immunoglobulin levels in ascitic fluid and serum of 47 patients with spontaneous bacterial peritonitis, malignant ascites, or tuberculous ascites. METHODS: Paracentesis was done to confirm the underlying cause of ascites. Biochemical, hematologic, and microbiologic investigations were also done. RESULTS: The highest serum and ascitic fluid C3 and C4 levels and ascitic fluid IgM, IgA, and IgG levels were found in patients with tuberculosis. Ascitic fluid C3 level was found to be higher in the tuberculous group than in the patients with spontaneous bacterial peritonitis or malignant ascites. Ascitic fluid C4 levels were higher in patients with tuberculosis than in those with spontaneous bacterial peritonitis. CONCLUSION: We believe that further studies of the in vivo kinetics of immunoglobulins and complement in ascitic fluid of various causes are necessary for a better understanding of the host defense mechanisms of these fluids.     

Use of radiography and ultrasonography for nasal fracture identification in children under 18 years of age presenting to the ED

Purpose

To compare the diagnostic value of ultrasonography (USG), which is rapid, inexpensive, simple, and does not involve radiation, with that of direct radiography for identifying fractures in the nasal bones of pediatric patients presenting in the emergency department with nasal trauma.

Point of care ultrasound is associated with decreased ED length of stay for symptomatic early pregnancy

IntroductionEmergency physicians (EP) can accurately rule out ectopic pregnancy with pelvic point of care ultrasound (PPOCUS). Multiple studies have suggested that PPOCUS may decrease length of stay (LOS) for emergency department (ED) patients presenting with early symptomatic pregnancy compared to comprehensive ultrasound (CUS). This systematic review and meta-analysis examines the association between the use of PPOCUS vs CUS and ED LOS.MethodsA systematic review of the literature was performed. Patients with symptomatic early pregnancy receiving EP-performed PPOCUS were compared to patients receiving CUS without PPOCUS. Keywords and search terms were generated for PPOCUS, ED LOS and CUS. Two independent reviewers screened abstracts for inclusion. A third reviewer was used when conflicts arose to gain consensus. Formal bias assessment was performed on included studies. Meta-analysis was carried out, pooling the mean differences between studies using a random-effects model.Results2980 initial articles were screened, 32 articles underwent detailed review, 8 underwent bias assessment, and 6 were included in the final meta-analysis. There were 836 patients in the study group and 1514 in the control group. All studies showed a decreased LOS in the PPOCUS group with a mean decrease of 73.8 min (95% CI 49.1, 98.6). Two studies not included in the meta-analysis also showed significantly decreased LOS with PPOCUS.ConclusionUse of PPOCUS in the evaluation of patients with symptomatic early pregnancy is associated with decreased LOS in patients ultimately diagnosed with intrauterine pregnancy. This review suggests that this finding is generalizable to a variety of practice settings.     

Peritoneal fluid concentrations of gentamicin in patients with spontaneous bacterial peritonitis.

Simultaneous peritoneal fluid and serum gentamicin assays were performed at 1- or 4-h intervals after the intravenous administration of gentamicin (3 to 5 mg/kg per day) during nine episodes of spontaneous bacterial peritonitis in cirrhotic patients. Mean peritoneal fluid levels were 4.2 micrograms/ml, whereas simultaneous mean serum levels were 6.1 micrograms/ml (mean percent diffusion into ascites of 67.8%). Three additional patients with uninflamed ascites demonstrated lower levels of diffusion. Regression analysis revealed a positive correlation between simultaneous serum and peritoneal fluid levels. We conclude that diffusion of gentamicin from serum into peritoneal fluid during spontaneous peritonitis is therapeutically adequate if sufficient serum levels are maintained.     

血浆D-二聚体检测在诊断肝硬化腹腔积液患者自发性细菌性腹膜炎中的应用

目的了解血浆D-二聚体(D-D)浓度在肝硬化腹腔积液患者自发性细菌性腹膜炎(SBP)诊断中的应用价值。方法留取肝硬化腹腔积液患者137例,分为SBP组和非自发性细菌性腹膜炎(NSBP)组,另选取慢性肝病患者30例(慢性肝病组)及30例健康者(健康对照组),分别测定各组D-D和C反应蛋白(CRP)浓度。结果 SBP组、NSBP组、慢性肝病组、健康对照组D-D浓度分别为(7.82±5.68)、(5.55±4.55)、(0.45±0.26)、(0.06±0.04)mg/L;血清CRP分别为(30.0±29.6)、(16.4±20.5)、(5.3±1.8)、(2.1±0.9)mg/L。SBP组和NSBP组D-D、CRP浓度均明显高于慢性肝病组和健康对照组(P<0.01)。SBP组D-D、CRP浓度高于NSBP组,差异也有统计学意义(P<0.05)。ROC曲线分析显示,D-D诊断SBP的曲线下面积、灵敏度、特异度分别为0.650、0.604、0.709;CRP分别为0.705、0.792、0.582。结论检测D-D有助于肝硬化腹腔积液患者SBP的早期诊断。     

Bacterial peritonitis in a patient with malignant ascites caused by pancreatic carcinoma: Case report and review of literature

Bacterial peritonitis, an infection of the ascitic fluid, can be classified etiologically as spontaneous or secondary bacterial peritonitis. The former is mainly caused by portal hypertension and its subsequent effects, whereas the latter is caused by the direct dissemination of bacteria into the peritoneal cavity. Previous reports have described some distinguishing features of these two entities. Here, we report the first known case of bacterial peritonitis with Aeromonas hydrophilia and Escherichia coli in a patient with malignant ascites associated with pancreatic carcinoma who exhibited features of both spontaneous and secondary peritonitis. Our report suggests that clinicians should also consider bacterial peritonitis in patients with malignant ascites who present with ostensibly cancer-related symptoms.     

Peritoneal catheter for continuous drainage of ascites in advanced cancer patients

INTRODUCTION: Advanced cancer patients with refractory ascites do not often respond to dietary sodium restriction and diuretics. While paracentesis is effective, the condition invariably recurs, necessitating repeated procedures. A continuous peritoneal drainage by an indwelling catheter has been reported to be hugely beneficial symptomatically, avoiding the hazards and disadvantages of multiple repeated procedures and direct and indirect costs. MATERIALS AND METHODS: Forty patients with advanced cancer patients admitted to an acute pain relief and palliative care unit, who presented symptomatic ascites, were recruited for continuous drainage of peritoneal fluid. A central venous catheter set for Seldinger technique was used. Technical failure was defined as an unsuccessful drainage of fluid through the catheter. Immediate and late complications, including hypotension, haemorrhage, tube blockage, dislodgment and sepsis were recorded. Record of daily drainage during admission were noted. At time of discharge, patients were asked to rate their global symptom burden as improved, unchanged or worsened. The follow-up was performed with frequent phone contacts or day-hospital admission in case of problems. RESULTS: The mean patients' age was 68 years, and 21 were men. Patients were receiving unsuccessfully a mean dose of furosemide of 32 mg/day. The technique was not painful and was easily accepted by patients. Insertion was technically successful in almost all patients. Mean admission time was 5.5 days (range 2-14), and the mean drained volume during admission was 8,499 ml (range 800-20,700), 2,850 ml (300-4,200) being drained on the first 24 h. No immediate complications were recorded. Six patients died during admission. The mean survival was 38.9 days (range 1-120). Of the 34 patients who were discharged home, 22 patients stated that symptom burden had improved, while in 10 patients symptom burden did not change or worsened, probably due to the advanced status of diseases and multiple contributing factors. Five, two, and one patients required skin sutures at 1, 2 and 3 months, respectively. About one third of patients had mechanical problems, some of them requiring a catheter replacement. No infection was recorded. CONCLUSION: In conclusion, a permanent peritoneal catheter was a valuable method to remove abdominal fluids and reduce symptom burden attributable to ascites and was also easy to use at home. Complication rate was acceptable and balanced by the benefits of the technique which avoided frequent paracentesis and associated complications.     

Rapid detection of causative pathogen of peritonitis using in-situ hybridization in a patient with continuous ambulatory peritoneal dialysis

Continuous ambulatory peritoneal dialysis (CAPD) peritonitis is a common problem in patients on peritoneal dialysis, and the bacteriological diagnosis is important for the treatment of this condition. We used Hybrizep (a method for detecting the genes of bacteria ingested in phagocytes), to detect the causative bacterium in a 50-year-old woman receiving peritoneal dialysis who was admitted our hospital with bacterial peritonitis. The test, using peritoneal dialysis fluid, was positive for Streptococcus epidermidis. Vancomycin administration led to a good outcome for this patient. The Hybrizep method (which is available on the Japanese National Health system only for the diagnosis of septicemia) was a useful diagnostic approach for a patient on peritoneal dialysis who had peritonitis.     

肝硬化腹水并发自发性细菌性腹膜炎86例临床分析

目的 分析肝硬化并发自发性细菌性腹膜炎（SBP）的临床特点。方法对86例肝硬化并发SBP患者的临床资料进行回顾性分析。结果86例患者中,发热65例（75．6％）,腹胀71例（82．6％）,腹痛55例（64．0％）,腹水多形核白细胞（PMN）〉／0．50者75例（87．2％）,腹水培养阳性31例（36．0％）。结论肝硬化并发SBP临床表现不典型,腹水常规可早期诊断,腹水PMN比值是诊断SBP的可靠参数。大肠杆菌为主要病原菌,对第三代头孢菌素和第三代喹诺酮类药敏感。     

Blood glucose reagent strip tests in the operating room: Influence of hematocrit,partial pressure of oxygen,and blood glucose level - a comparison of the BM-test 1-44, BM-accutest,and satellite G reagent strip systems

Objective. The objective of our study was to assess the influence of hematocrit (HCT), partial pressure of oxygen (PO₂), and blood glucose level upon results obtained with three different blood glucose reagent strip tests used in conjunction with the appropriate meter: BM-Test 1-44, BM-Accutest, and Satellite G.Methods. Our study was designed as a consecutive sample study of patients undergoing coronary artery surgery. The setting was the hospital theater and intensive care unit. We conducted blood analysis for HCT, PO₂ and blood glucose on 20 consecutive patients undergoing coronary artery surgery using three blood glucose reagent strip testing systems and a laboratory analysis of plasma glucose.Results. All three blood glucose reagent strip tests showed a significant bias when compared with plasma glucose: BM-Test 1-44, 0.89 mmol/L; BM-Accutest, –1.27 mmol/L; Satellite G, 0.75 mmol/L (p < 0.05). The error found when using the Satellite G system was worse than that of either of the other two systems. Results obtained with the BM-Accutest strips were unaffected by PO₂ (p = 0.745). Blood glucose value and HCT both had an influence on the results of all three blood glucose strip systems.Conclusions. Caution must be taken when using reagent strip systems in the operating room or intensive care setting because, of the three systems tested, all showed a significant bias, all were influenced by blood glucose level and HCT, and only the BM-Accutest reagent strips used with the Accutrend meter was unaffected by PO₂.     

Diagnostic accuracy of laboratory and ultrasound findings in patients with a non-visualized appendix

Ultrasound (US) and laboratory testing are initial diagnostic tests for acute appendicitis. A diagnostic dilemma develops when the appendix is not visualized on US. Objective: To determine if specific US findings and/or laboratory results predict acute appendicitis when the appendix is not visualized. Methods: A prospective study was conducted on children (birth-18?yrs) presenting to the pediatric emergency department with suspected acute appendicitis who underwent right lower quadrant US.Children with previous appendectomy, US at another facility, or eloped were excluded. US findings analyzed: inflammatory changes, right lower quadrant and lower abdominal fluid, tenderness during US exam and lymph nodes. Diagnoses were confirmed via surgical pathology. Results 1252 subjects were enrolled, 60.8% (762) had appendix visualized and 39.1% (490) did not. In children where the appendix was not seen, 6.7% [33] were diagnosed with appendicitis. Among patients with a non-visualized appendix, the likelihood of appendicitis was significantly greater if: inflammatory changes in the RLQ (OR 18.0, 95% CI 4.5–72.1), CRP >0.5?mg/dL (OR 2.64, 95% CI 1.0–6.8), or WBC?>?10 (OR 4.36, 95% CI 1.66–11.58). Duration of abdominal pain >3?days was significantly less likely associated with appendicitis in this model (OR 0.34, 95% CI 0.003–0.395). Combined, the absence inflammatory changes, CRP?<?0.5?mg/dL, WBC?<?10, and pain, ≤3?days had a NPV of 94.0%. Conclusion When the appendix is not visualized on US, predictors for appendicitis include the presence of inflammatory changes in the RLQ, an elevated WBC/CRP and abdominal pain <3?days.