恙虫病患者64例临床分析

目的探讨恙虫病的临床表现及多系统受损的严重性,提高临床诊疗水平,减少误诊。方法回顾2006年1月至2013年2月收治的64例恙虫病患者的临床资料。结果64例患者中,典型表现者63例,不典型1例;46例（71．8％）患者出现呼吸系统并发症,30例（46．1％）患者出现心肌损害,57例（88．5％）出现消化系统损害;患者院前均未能及时作出正确诊断,入院后3d内临床诊断正确52例（81．6％）;治愈出院61例（95．3％）,死亡3例（4．7％）。结论恙虫病临床表现多种多样,延误诊断和治疗易导致并发症发生,临床医师需要提高对恙虫病临床表现和并发症的认识,提高早期诊断正确率,减少误诊误治。     

胸部放线菌病五例临床分析及文献复习

目的探讨胸部放线菌病的临床特点,提高临床医师对该病的诊断和治疗水平。方法回顾性分析我院1995年1月-2008年3月确诊的5例胸部放线菌病患者的临床资料,并复习国内个案报道16例。结果胸部放线菌病患者21例,男性16例,女性5例,年龄11-59岁,病程4天-2年,咳嗽18例,咯血14例,胸痛6例,伴发热7例。胸部影像学表现无特异性,确诊依靠组织学或微生物学检查。CT引导下经皮肺穿刺活检组织病理确诊5例,纤支镜下活检组织病理诊断为肺放线菌病2例,手术切除肺组织确诊9例,1例合并颈淋巴结肿大,淋巴结活检确诊,仅1例3次痰涂片发现大量放线菌菌丝而且培养阳性,1例在痰中找到硫磺颗粒,2例胸水里发现放线菌菌落确诊。结论胸都放线菌病临床少见,容易误诊造成不必要的外科手术,应尽可能早期诊断,及时治疗。     

平板运动试验阴性的冠心病患者62例冠状动脉造影分析

目的 :为了解平板运动试验阴性的冠心病患者临床与冠脉病变特点 ,以提高诊断水平。方法 :对平静心电图正常及平板运动试验阴性而冠状动脉造影确诊为冠心病的 6 2例患者的临床资料及冠状动脉造影结果进行分析。结果 :冠心病危险因素 :高脂血症 40例 （6 5 %） ,高血压病 2 8例 （45 %） ,糖尿病 16例 （2 6 %） ,吸烟者 30例 （48%）。冠状动脉造影显示 2～ 3支血管病变占 6 5 %（40 / 6 2 ） ,包括左主干受累 4例 ;单支血管病变占 36 %（2 2 / 6 2 ）。 2～ 3支血管病变 40例中 34例 （85 %）血管狭窄部位相互对应。2支血管病变为前降支和右冠者多见 ,占 5 4%（14/ 2 6 ） ,单支血管病变以前降支者多见 ,占 5 9%（13/ 2 2 ）。73%（16 / 2 2 ）单支血管狭窄为 5 0 %～ 74%。结论 :对临床疑为冠心病的患者 ,即使平板运动试验阴性也应及早作冠脉造影检查以明确诊断。     

外科治疗儿童主动脉瓣病变的近中期结果及经验总结

【摘要】 目的 探讨外科治疗儿童主动脉瓣病变的近中期结果及经验总结。方法 2009年1月至2019年9月期间所收治的22例主动脉瓣病变的患儿。男13例,女9例,年 龄：1岁～16岁;体重：（12～46)kg,平均(29)kg;年龄分布：1～3岁9例,3～6 岁3例,6～12岁4例,12～16 岁6例。术前经心脏超声及心脏CTA明确诊断,先天性主动脉瓣病变16例,后天获得性主动脉瓣病变6例。手术在全麻、体外循环下进行,结合心脏超声、心脏CTA及术中情况决定手术方式。术后3个月、6个月、一年、以后每年复查心脏超声。 结果 行主动脉瓣机械瓣置换手术（AVR）6 例,主动脉瓣成形手术（AVP）5例,改良Ross手术5例,Ross 手术4 例, Bentall术2例。术后随访：长期随访20例,2例失访,其中AVR后2例跨瓣压差>40mmHg,1例Ross出现中量返流,处于随访观察状态,无二次手术。 结论 儿童主动脉瓣病变积极地外科治疗结果是令人鼓舞的,本文旨在为心外科医师在儿童主动脉瓣病变的治疗策略方面提供更多的临床经验,以及观察儿童主动脉瓣疾病治疗的近中期临床效果。     

阵发性睡眠性血红蛋白尿症继发缺血性肠病的临床特点分析

目的 提高临床医师对阵发性睡眠性血红蛋白尿症(paroxysmal nocturnal hemoglobinuria, PNH)继发缺血性肠病的认识。方法 对我院1例及文献报道的15例PNH合并缺血性肠病的患者临床资料进行综合分析。结果 16例患者中，男7例，女9例，确诊年龄(41.0±9.6)岁(27～64岁),中位诊断用时42个月。病变分布方面，十二指肠及空回肠13例(81.3%),结肠3例(18.8%),胃2例(12.5%),盲肠1例(6.3%)。临床表现方面，表现为程度不一的腹痛(16/16),多因急腹症就诊，伴呕吐(9/16)、发热(4/16)等。单纯PNH继发缺血性肠病14例；AA-PNH综合征继发缺血性肠病2例。诊断以内镜检查为主，影像学及手术病理为辅。治疗方面，9例行手术治疗，其中3例术后复发，1例死亡；7例保守支持治疗，手术治疗复发率较保守治疗低。结论 PNH继发缺血性肠病罕见，临床表现主要为腹痛，内镜检查及病理有助于诊断，治疗后易复发，建议预防性抗凝治疗。     

肺放线菌病1例报道及误诊原因分析

目的 探讨放线菌病的临床特征、影像学表现及误诊原因.方法 报道1例胸型放线菌病,并结合文献,总结放线菌病的临床特征、影像学表现,对误诊原因进行系统分析.结果 胸型放线菌病发病率低,临床医师认知较少,极容易误诊,主要引起误诊的原因为临床表现普通,影像学表现多样,放线菌标本取材困难,疗效判断周期长.为此,应该提高临床医师对本病的认识,同医技科室多交流,进行厌氧菌培养及特殊染色,提高诊断正确率,减少误诊.结论 放线菌病是一种少见病,临床上容易误诊,如果能够做到早诊断并提高综合治疗方案,预后良好.     

烟雾病合并甲状腺功能亢进症患者的临床分析

目的探讨烟雾病合并甲状腺功能亢进症（简称甲亢）的临床特征、发病机制、手术及药物治疗的效果。方法回顾性分析11例烟雾病合并亢患者的临床资料,其中经DSA确诊烟雾病10例,MRA确诊1例;所有患者均符合甲亢的诊断标准。8例患者在甲亢稳定后,行脑硬膜颞浅动脉血管融通术,另外3例单纯给予药物控制甲亢。结果①11例患者中8,例为女性,10例有甲状腺功能异常,另一例在入院前,甲亢已被控制。基本上都表现为三碘甲状腺原氨酸（T3）、甲状腺素（T4）增高和促甲状腺激素（TSH）降低。②11例患者中9,例影像学表现为脑梗死,1例表现为脑室内出血,有1例的检查未发现异常（9.1%,1/11）。10例为双侧病变1,例为单侧病变。③对11例患者的随访时间为11～102个月,除1例遗留智力下降、反应慢等症状外,其余患者经治疗后,症状均减轻或消失。8例接受手术治疗的患者术后未出现手术并发症,对其中6例患者术后（10～26个月）进行了造影复查,均显示颅外已向颅内大量代偿供血。结论烟雾病合并甲亢以女性患者为多,临床症状主要表现为脑梗死。二者合并发病机制不明,可能与遗传及免疫等多种因素有关。控制甲亢症状后,行手术治疗能够建立有效的侧支循环。     

不同部位克罗恩病的临床特点分析

目的 探讨不同部位（小肠、结肠、回结肠）克罗恩病的临床特点,以期提高对该病的认识。方法回顾性分析2000年至2008年1月住院诊断的103例患者,根据其发病部位的不同,对其一般资料、病程、临床表现、实验室检查、病理学改变等进行分析。结果103例患者中男性70例,女性33例,诊断时年龄12～70岁。以20～29岁为高峰期,30～39岁次之。病变部位位于小肠（L1）的39例（38％）,结肠（L2）的16例（16％）,回结肠（L3）的48例（46％）,发病年龄的性别差异无统计学意义,但L1型临床诊断年龄明显高于12型（P〈0．05）和L3型（P〈0．01）,且肠梗阻发生率远远高于L3（P〈0．05）。L1型中通过胶囊内镜协助诊断的占L1型的30．8％,结肠镜协助诊断的占44％;L2、L3临床表现结合结肠镜及病理检查明确诊断的分别占87．5％、83．3％,通过手术确诊的L1患者（9例）占手术确诊病例的47．3％,但与12、L3相比差异无统计学意义。参考简化CD活动指数（CDAI）评分,轻度23例（22．3％）,中度58例（56．3％）,重度22例（21．4％）,回结肠受累者（L3）重度患者13例,占59．0％,与L1比较差异有统计学意义（P〈0．05）。结论在克罗恩病患者中L1型较多以诊断延迟、急诊需手术治疗为特点;L3型则因病变范围较广,并发症及全身表现严重,重型多见。需重视发病早期胶囊内镜和回结肠镜检查的重要作用,减少手术发生率,延缓患者首次手术的时间。     

冠状动脉自发性夹层的临床特点与治疗策略

目的回顾分析冠状动脉自发性夹层（SCAD）患者的临床资料,探讨治疗策略。方法回顾分析2010年7月至2013年3月单中心冠状动脉造影患者4517例,检出SCAD13例,借用冠状动脉夹层分型系统对病变进行分类,分析不同类型SCAD的发生率、影像特点及随访临床事件。结果13例SCAD患者中,2例（2／13,15．4％）发生2处夹层,共存在15处夹层。12例（92．3％）发生临床事件,包括心肌梗死10例（76．9％）与心绞痛2例（15．4％）。发生于右冠状动脉夹层9处（9／15,60％）,前降支6处（6／15,40％）,左回旋支未见夹层。A型病变1处（6．7％）,B型2处（13．3％）,D型8处（53．3％）,E型2处（13．3％）,F型1处（6．7％）,壁间血肿1处（6．7％）。4例5处保守治疗,9例10处病变给予经皮冠状动脉介入治疗（PCI）,9处病变PCI治疗成功,1处未成功改为冠状动脉旁路移植术。1例D型夹层患者药物治疗6个月后复查冠状动脉造影,夹层无明显变化,无心绞痛发作;l例D型夹层患者药物治疗3个月,仍有心绞痛,给予PCI治疗;1例A型夹层患者PCI后12个月复查冠状动脉造影未见夹层复发,无再狭窄。其余患者电话随访6～12个月无临床事件。结论SCAD可以按照NHLB1分型。A、B、E型及壁间血肿采取PCI治疗相对容易。D型夹层占比例最高。D、F型治疗难度最大。关键在于早期确诊。可以根据病变的类型、长度,选择性地采取PCI治疗,保守治疗是否可以自愈仍需长期随访。     

双气囊内镜检查对小肠疾病的诊断价值

目的探讨小肠溃疡性病变的临床、内镜、病理等特点。方法临床怀疑小肠疾病者155例。按术者操作内镜并送镜,助手辅助进外套管的方法。结果155例患者中,125例发现病变,阳性率80．6％。检出的主要疾病为小肠溃疡（含克罗恩病）、慢性炎症、美克尔憩室、间质瘤、血管畸形、小肠癌等。其中92例怀疑小肠出血者,检查阳性84例（91．3％）;39例腹痛患者中,阳性24例（61．5％）;腹泻、腹胀、消瘦23例,阳性16例（69．6％）。病变位于胃及十二指肠9例,小肠病变115例,大肠病变1例,全消化道未发现病变30例。在155例接受双气囊内镜（DBE）检查的患者中,检出小肠溃疡性病变43例;病灶数为单个12例,多个（2个及以上）31例;病变位于空肠的18例,回肠20例,空肠和回肠都有病变的5例。DBE结合组织学检查对美克尔憩室、间质瘤、癌、血管病变、肠黏连的诊断与手术后诊断是完全相符的;而对溃疡性病变（主要是克罗恩病）的诊断与手术后诊断却相差较大,符合率57．1％（4／7）。发生小肠穿孔和急性肠梗阻并发症各1例。结论DBE目前是诊断小肠疾病安全、有效的方法,特别在发现病变方面,但对溃疡性病变的定性即使结合活检也未必是特异的,及时行外科处理对某些溃疡性病变的诊断和治疗都是有益的。     

Optimal duration of IV and oral antibiotics in the treatment of thoracic actinomycosis

STUDY OBJECTIVE: IV antibiotic therapy for 2 to 6 weeks followed by 6 to 12 months of oral antibiotic therapy is usually recommended for the treatment of thoracic actinomycosis. The objective of this study was to evaluate the duration of IV and oral antibiotic therapy for thoracic actinomycosis. METHODS: We present a retrospective case series of 28 patients with thoracic actinomycosis as confirmed by histopathology from October 1994 through December 2003. RESULTS: After diagnosis of actinomycosis, 54% (15 of 28 patients) received antibiotic therapy alone. The duration of IV antibiotic therapy ranged from 0 to 18 days (median, 2 days; interquartile range [IQR], 0 to 3 days), and the duration of oral antibiotic treatment ranged from 76 to 412 days (median, 167 days; IQR, 142 to 214 days) in patients who received antibiotics alone. Combination surgical and antibiotic therapy occurred in 46% (13 of 28 patients). The duration of IV antibiotic therapy ranged from 3 to 17 days (median, 8 days; IQR, 5 to 13 days), and the duration of oral antibiotic therapy ranged from 0 to 534 days (median, 150 days; IQR, 3.5 to 289 days) in these patients. Clinical cures were achieved in 96% (27 of 28 patients). There was no clinical evidence of recurrence during follow-up period at our hospital (median, 23 months; IQR, 9 to 44 months) in 21 patients, excluding 7 patients who were transferred to referring hospitals after completion of antibiotic therapy (n = 6) or during antibiotic therapy (n = 1). CONCLUSIONS: Thoracic actinomycosis is best treated with individualized therapeutic modalities, depending on factors such as the initial burden of disease, the performance of resectional surgery, and the clinical and radiologic responses to therapy. The traditional recommendation of IV antibiotic therapy for 2 to 6 weeks followed by oral antibiotic therapy for 6 to 12 months is not always necessary for all thoracic actinomycosis patients.     

Whipple's disease: the value of upper gastrointestinal endoscopy for the diagnosis and follow-up.

Due to the systemic nature of Whipple's disease the clinical presentation may be highly variable. The diagnosis may therefore be unduly delayed. If untreated, Whipple's disease is still potentially lethal. In contrast, the endoscopic findings as they are observed in the postbulbar small intestine and the light microscopic picture of small intestinal biopsies are almost pathognomonic. Out of a group of 18 patients (14 male, 4 female, mean age = 45 yrs), 12 patients were diagnosed using upper gastrointestinal endoscopy and duodenal biopsy, while six patients were diagnosed only by a small intestinal capsule biopsy. The clinical history prior to diagnosis lasted from 1 m to 22 yrs (mean = 3 yrs 6 m) in the first group and from 4 yrs to 21 yrs (mean = 12 yrs 6 m) in the second group. The endoscopic findings at the time of diagnosis were: oesophagitis (1/12), erosive gastritis (4/12), atrophic gastritis (2/12), severe erosive bulbitis (3/10), pathognomonic post-bulbar duodenal lesions (9/12). In 20% of the patients the endoscopic lesions had disappeared 6 m after antibiotics while the lesions had disappeared in all cases 9 m after therapy, despite the fact that PAS positive macrophages remained present in the endoscopic biopsies for years. All patients were treated with antibiotics (8 tetracycline alone, 4 tetracycline, streptomycin and penicillin, 6 trimethoprim). Five patients (27%-4 of the tetracycline group) relapsed within 2 to 20 yrs after the initial diagnosis. Three of these patients (3/5) had typical duodenal lesions on endoscopy at that time.     

隐球菌性脑膜炎26例临床分析

目的 总结隐球菌性脑膜炎的资料,提高对隐球菌性脑膜炎的认识。方法 回顾性总结近20年（1981年10月至2001年9月）隐球菌性脑膜炎的一般资料,诊断及治疗情况。结果 共26例患者,其中男12例,女14例,年龄5－62岁,平均35．6岁,有基础疾病者16例,其中系统红斑狼疮（SLE）9例,人类免疫缺陷病毒感染或艾滋病（HIV／AIDS）4例,其他疾病3例;有明确鸽子接触史者12例;误诊结核性脑膜炎者5例,狼疮脑病者6例;墨汁染色找到隐球菌者23例（23／26）,乳胶凝集试验抗原阳性20例（20／20）。颅内压明显增高＞300mm H2O者15例,脑室扩大行侧脑室引流者9例;12例给予两性霉素B（AmpB) 5氟胞嘧啶,6例又同时加氟康唑治疗,5例AmpB 氟康唑,1例单纯应用AmpB治疗。AmpB最大用量：AmpB10.05g 脂质体两性霉素B20g,平均用量2.6g;治愈17例,好转4例,死亡或自动出院5例。同时发现近5年隐球菌性脑膜炎病例数明显增多。结论 近年来,隐球菌性脑膜炎发病率明显增高,可能和免疫抑制剂和糖皮质激素的应用及HIV／AIDS增多有关,减少病死的关键在于提高早期诊断率,治疗仍首选AmpB加5氟胞嘧啶,侧脑室引流可减少AmpB的用量,提高治愈率,缩短疗程。     

Early responses to H7N9 in southern Mainland China

Background

There have been few studies of pulmonary actinomycosis, which is an uncommon anaerobic infection. Consequently, the optimal therapeutic regimen, appropriate duration of treatment, long-term prognosis, and factors predicting prognosis are not well established.

Methods

We retrospectively reviewed the medical records of histopathologically confirmed cases of pulmonary actinomycosis seen between November 2003 and December 2012.

Results

The study included 68 patients with a mean age of 58.4?±?11.6 years. Of the 68, initial surgery was performed in 15 patients (22.1%), while the remaining 53 (77.9%) received antibiotic therapy initially. In the initial antibiotic group, 45/53 (84.9%) were cured without relapse (median antibiotic duration 5.3 months). 5/53 (9.4%) patients were refractory medically (median antibiotic duration 9.7 months), and 3/53 (5.7%) experienced a recurrence (median time to relapse 35.3 months). In the initial surgery group, 14/15 (93.3%) were cured and treatment failure occurred in one (6.7%). In the multivariate analysis, the absence of an antibiotic response at 1 month was the only independent factor associated with a poor treatment outcome, with an adjusted odds ratio of 49.2 (95% CI, 3.34–724.30). There was no significant difference in treatment outcome based on the size of the parenchymal lesion, comorbidities, whether intravenous antibiotics were used, antibiotic therapy duration, or whether the initial treatment was surgical.

Conclusions

Antibiotic treatment with or without surgery was effective for treatment of pulmonary actinomycosis. Nevertheless, treatment failure or recurrence occurred in a considerable proportion of patients, especially those resistant to the initial antibiotic treatment.     

Treatment of hypertrophic cardiomyopathy with nifedipine and propranolol in combination

Fifteen patients (14 males and 1 female) with hypertrophic cardiomyopathy, ranging from 22 to 67 years of age (mean: 45.5 years) were treated with oral nifedipine and propranolol for 6 to 24 (mean: 18) months. Twelve of the patients had been pretreated with a mean oral dose of 560 mg verapamil for 60 to 93 (mean 78.5) months, showing slight subjective and objective improvement. Treatment with nifedipine and propranolol was terminated in five cases, due to deterioration or side effects after 6 and 12 months, respectively. During combined therapy, two patients reported improvement, whereas in five cases there was no change and eight patients reported deterioration. There was no change in the Sokolow index. The radiologically determined heart volume increased in 10 out of 15 patients and in the total group from 887 +/- 214 to 938 +/- 248 ml/1.73 m2. Echocardiographic measurements showed a significant increase in left atrial diameter from 40.0 +/- 9 to 44.0 +/- 11 mm, whereas ventricular wall thickness remained unchanged. Thus, high-dose verapamil therapy seems superior to nifedipine-propranolol therapy in patients with hypertrophic cardiomyopathy.     

Clinical experience of spontaneous pneumomediastinum: diagnosis and treatment

Background

Spontaneous pneumomediastinum (SPM) is a benign disease with a variety degree of severity but definite treatment modality is not clearly identified with its rarity. The purpose of this study was to review our experience and discuss the management of SPM according to the severity of disease.

Methods

From March 1996 to December 2012, total 64 patients were enrolled and classified as mild, moderate and severe groups and subsequent clinical courses were analyzed retrospectively.

Results

Fifty-one were males and 13 were females (M:F =3.9:1) with a mean age of 18 years old (range: 10-30 years old). Thirty-six patients were in mild, 22 in moderate and 6 in severe group. Chief complaints were chest pain (50 cases; 78.1%), neck pain (35 cases; 54.7%), dyspnea (18 cases; 28.1%), odynophagia (9 cases; 14.1%) and precipitating factors were coughing in 12 cases, feeding problems in 9 cases, and vomiting in 7 cases; however, 34 patients (53.1%) had no precipitating signs. All patients received oxygen therapy (100%), prophylactic antibiotics in 57 patients (89.1%), and pain medications in 47 patients (73.4%). The mean hospital stay was 4.6 days (range: 1-10 days). There was an increased linear trend according to time to visit (P=0.023) but clinical course demonstrated no significant trend between groups.

Conclusions

These data demonstrated that there was no difference in symptom, clinical course and SPM was adequately treated with conservative management regardless of the degree of severity of SPM.     

A survey of thoracic actinomycosis

We have reviewed the case notes of 19 patients with thoracic actinomycosis. The median age at presentation was 42 (range 9-66) years, 15 were male and 12 were urban residents. Cough, sputum production, chest pain and weight loss were the commonest symptoms. Six patients reported haemoptysis. In contrast with the classical appearances of thoracic actinomycosis, only four patients had cutaneous abnormalities, and only one patient had radiological evidence of bone involvement. The provisional diagnosis was bronchial carcinoma in nine patients, and in seven patients the diagnosis of actinomycosis was only made after resection of the lesion, in two cases by pneumonectomy. The median delay between presentation and diagnosis was 3.5 (range 1-24) weeks. Two patients developed extrathoracic complications, but all patients made a full recovery after receiving antibiotic therapy for a median of 6 (range 1-24) weeks. Thoracic actinomycosis is rare, but should still be considered in the differential diagnosis of a pulmonary lesion thought to be malignant.     

Acute myocardial infarction in patients with angiographically normal coronary arteries: clinical features and medium term follow-up

BACKGROUND: Acute myocardial infarction (MI) in patients with normal coronary arteries has been recognized for several years. In most cases its etiology is unknown. The objective of the present study was to describe clinical features and medium term follow-up of those patients. PATIENTS AND METHODS: Between April 1991 and December 1996, 9860 coronary angiographies were performed in our hospital. During this period 17 patients with documented myocardial infarction and completely normal coronary arteries were identified. Acute myocardial infarction was defined as the clinical event with acute angina pectoris, ST-elevation typical for myocardial infarction, and an increase in serum creatinine phosphokinase (CPK) above 125 U/l. RESULTS: The mean peak CPK was 675 U/l (range: 129-1760 U/l). All 17 patients revealed significant ST-segment elevation. According to the ECG criteria there was no predilection for a specific location of MI (9 anterior MIs and 8 inferior MIs). Thrombolytic therapy was performed in 9 patients. In 12 patients areas of localized hypo- or akinesia were shown on left ventricular cineangiography. The mean ejection fraction was 61.5+/-10.3%. The age and sex distribution revealed a bimodel character: there was a younger age group of 9 patients, all men with a mean age of 35.9 years (31-43) and all strong cigarette smokers (mean 28 cigarettes/day) and there was an older group of 7 patients (1 man, 6 women) with a mean age of 56,4 years (47-68) and no significant association with cigarette smoking. During a mean follow-up period of 48.6 months (31-85 months) no patient died and no patient suffered from recurrent chest pain and used nitroglycerin occasionally. CONCLUSION: Patients with acute MI and angiographically normal coronary arteries show a bimodal sex and age distribution: a younger age group, all men and uniformly strong cigarette smokers and an older group predominantly women with no significant association with cigarette smoking. Both groups seem to have a favorable prognosis.