小儿肺炎旁胸腔积液40例分析

[目的]探讨小儿肺炎旁胸腔积液的病因、临床特征及治疗. [方法]回顾性分析滨州医学院附属医院儿科2006年1月-2009年5月肺炎旁胸腔积液患儿40例临床资料.[结果]1)40例胸腔积液患儿,支原体感染17例(42.5%),细菌感染12例(30%),混合感染(支原体合并细菌感染)7例(17.5),病原体不明确4例(10%);2)胸腔积液培养阳性5例,3例为肺炎链球菌,2例为β溶血链球菌;3)不同年龄组中胸腔积液不同病因比较差异无统计学意义.支原体感染有明显年龄特点,3岁和<3岁患儿相比有显著差异(χ2=4.13,P<0.05);4)对于支原体抗体阳性患儿大环内酯类药物单药治疗效果欠佳.8例脓胸患儿行脓胸廓清及纤维板剥除术.[结论]小儿胸腔积液病因以支原体和细菌感染为主.多发性包裹性积脓需行手术手术治疗.     

胸腔积液184例临床分析

[目的]探讨良恶性胸腔积液的病因及临床特点. [方法]对2003年7月-2004年6月收住院的胸腔积液患者的临床症状.影像学表现及实验室检查进行回顾性分析. [结果]良性胸腔积液中结核占第1位94例(51.09%),充血性心力衰竭16侧(8.70%),肺炎旁积液和脓胸15例(8.15%),肝硬化及肾功能不全10例(543%),病毒性胸膜炎5例(2.72%),麦格氏综合征3例(1.63%),恶性胸腔积液中以原发性支气管肺癌最多26例(14.13%),乳腺癌5例(2.71%),胸膜间皮瘤4例(2.17%).良恶性胸腔积液的pH值、ADA、CEA有较大差异. [结论]胸腔积液的主要发病原因为结核及肿瘤、胸水pH值、ADA、CEA有助于良恶性积液的鉴别.     

胸膜腔穿刺盲检在不明原因胸腔积液诊断中的临床应用

目的探讨胸膜腔穿刺盲检在不明原因胸腔积液诊断中的临床应用。方法对平片、痰细胞学、CT或MR,胸腔积液常规、生化免疫、细胞学等检查未能确诊的109例胸腔积液病人采用COPE活检针活检联合胸水生化、细菌培养及病理检查等方法检查,分析影响诊断阳性率的因素以及胸膜活检的并发症。结果本组患者采用COPE活检针活检,取材成功率为100%。较国内外文献报道87-97%为高。本组最后诊断为结核性胸膜炎的65例中,胸膜活检病理诊断为54例,占83.1%;最后诊断为恶性肿瘤的23例,胸膜活检诊断14例,占60.9%。本组13例,胸膜活检病理诊断为慢性炎症;其中6例抗炎治疗后胸水完全吸收,7例反复治疗1-3个月胸水未吸收,最后追踪诊断为肺癌6例,胸膜间皮瘤1例;横纹肌及纤维脂肪组织8例(7.3%)。术中并发出血2例(3.3%)、气胸3例(5%)、术后出现发热1例(1.6%)。结论胸膜腔穿刺活检结合胸穿胸水生化、细菌培养及病理检查等方法检查可使活检结果诊断阳性率达85%[1],接近于内科胸腔镜检查阳性率。     

胸液中的C-反应蛋白在胸液诊断中的价值

目的　本研究的目的为了分析C -反应蛋白 (CRP)是否能作为区别渗出液与漏出液的敏感指标 ,及可否能被用于区别肺炎旁与其他类型胸腔积液的指标。方法　我们对 190例胸腔积液病人的胸液采用免疫乳胶凝集法检测CRP水平 ,比较了漏出液与渗出液、肺炎旁与其他类型胸液的CRP水平。结果　根据以往划分漏出、渗出胸液的标准胸液 ,33例漏出液组的CRP水平 .4 79± 4 .91mg/L明显低于 15 7例渗出液组的CRP水平 12 .6 4± 9.35mg/L(P <0 .0 5 )。在渗出液组 ,5 9例为结核性胸腔积液 ;4 8例为恶性胸腔积液 ;2 7例为肺炎旁胸腔积液及 2 3例慢性非特异性胸腔积液 ,对这些亚组进行了比较 ,肺炎旁胸腔积液CRP水平 (2 2 .5± 9.5mg/L)明显高于其他类型亚组。结论　在对不同病因引起的胸腔积液诊断时 ,高水平的CRP可以作为区别肺炎旁与其他类型胸腔积液的一种快速、实用、较为可靠的指标     

老年人下肺叶病变合并胸腔积液的影像诊断

目的分析老年人下肺叶病变合并胸腔积液的X线和CT表现的诊断意义。方法收集60岁以上,有下肺叶病变和胸腔积液及有完整影像学资料并经临床和病理证实的病例共35例。结果老年人下肺叶病变合并胸腔积液主要见于肺癌(19/35,占54.3%)、肺炎(10/35,占28.6%)和肺结核(4/35,占11.4%)。良性病变多为轻度胸腔积液(8/15,53%),恶性肿瘤多为中~重度胸腔积液(16/20,80%)。若以环状胸膜增厚、增厚胸膜>10mm、纵隔胸膜受累和结节状胸膜增厚作为恶性肿瘤的征象,诊断准确率为71%(12/17)。结论综合分析胸水程度、胸膜增厚和病灶的形态学特征,对提高诊断准确率有很大帮助。     

渗出性胸腔积液病因诊断综合分析

目的探讨基层医院渗出性胸腔积液的常见病因。方法64例渗出性胸腔积液患者均行PPD试验、胸部X线或CT、痰涂片找抗酸杆菌及癌细胞、胸膜活检、胸水癌胚抗原、胸水找抗酸杆菌及癌细胞。结果64例渗出性胸腔积液病因,41例为结核性胸膜炎,占64%;19例为肿瘤性胸腔积液,占29·7%;3例为类肺炎性胸腔积液;1例为系统性红斑狼疮。结论基层医院虽缺乏一些较先进的检验和设备,如ADA、肿瘤坏死因子、白细胞介素8、胸腔镜等,但通过常见的检查,耐心筛查,绝大部分患者仍可明确病因。     

小儿胸腔积液32例病因及治疗初探

目的:探讨小儿胸腔积液的病因及临床特点。方法:对32例胸腔积液患儿的临床资料进行回顾性分析。结果:32例胸腔积液患儿中肺炎27例,肺结核4例,肺囊肿合并感染1例。9例行胸腔穿刺液检查,渗出液改变9例(其中脓胸2例)。致病菌中细菌20例,肺炎支原体7例,结核4例,肺囊肿合并感染1例。春季11例(34.5%),夏季6例(18.6%),冬季15例(46.9%)。结论:肺部感染是小儿胸腔积液的主要病因,以细菌、支原体感染为主;肺炎合并胸腔积液主要以冬春季节为主。     

内科电子胸腔镜对胸腔积液的诊断价值

目的探讨内科电子胸腔镜对胸腔积液的诊断价值。方法对210例胸腔积液患者行内科电子胸腔镜检查,取胸膜结节或可疑胸膜行组织病理学检查。结果获得明确的病理结果204例。胸腔镜下表现大致可分为5种:①以包裹、粘连、纤维条索为主,53例病理检查全部为结核。②单发或多发结节,呈干酪样、菜花样、瘤样团块、乳突状等新生物134例,病理检查中结核占48例;肺癌占74例(以肺腺癌转移最多,占46例,肺鳞癌25例;肺小细胞癌占3例);恶性间皮瘤占9例;恶性肿瘤分型不清3例。③胸膜表面覆盖大量脓苔,诊断为脓胸8例,其中结核合并脓胸5例,细菌性脓胸2例,真菌1例。④胸膜充血水肿花斑样溃疡9例,病理检查为胸膜恶性间皮瘤3例,腺癌4例,慢性炎性病变2例,⑤胸膜基本正常6例,随机活检病理检查未见异常(后通过其他方法证实淋巴瘤3例,结缔组织病1例,心衰1例,未确诊1例)。结论内科胸腔镜检查对胸腔积液诊断是一种创伤小、费用低、诊断率高的安全有效的检测方法。     

复杂性胸腔积液和脓胸诊治新进展

由细菌性肺炎、肺脓肿和支气管扩张感染等肺部炎症引起的渗出性胸腔积液称为肺炎旁胸腔积液,临床上可将其分为单纯性胸腔积液、复杂性胸腔积液和脓胸。一旦出现复杂性胸腔积液或脓胸,将严重影响患者肺功能和预后。近年来,复杂性胸腔积液和脓胸的诊治策略出现许多新进展,检查手段包括病原学检查、生化标志物检测以及影像学检查,治疗方法包括抗菌治疗、胸腔穿刺引流和胸腔内纤溶治疗、胸腔灌注治疗、激素治疗、手术以及全身支持治疗等。本文对其进行简要综述,以提高对复杂性胸腔积液和脓胸的认识。     

复方苦参注射液联合顺铂胸腔内注入治疗恶性胸腔积液的疗效观察

目的观察复方苦参注射液联合顺铂胸腔内注入治疗恶性胸腔积液的疗效。方法 70例恶性胸腔积液患者随机分为联合组(35例)、顺铂组(35例)。抽尽胸腔积液后,联合组向胸腔内注入复方苦参注射液加顺铂,顺铂组胸腔内只注入顺铂。观察两组患者治疗后的总有效率及胸水吸收情况。结果治疗后联合组总有效率82.8%,顺铂组68.6%,两组差异有统计学意义(P<0.05);治疗后联合组1个月内胸水吸收25例(71.4%),顺铂组11例(31.4%),两组差异有统计学意义(P<0.05)。结论复方苦参注射液联合顺铂胸腔内注入治疗恶性胸腔积液有确切疗效。     

Pediatric parapneumonic empyema, Spain

Pediatric parapneumonic empyema (PPE) has been increasing in several countries including Spain. Streptococcus pneumoniae is a major PPE pathogen; however, antimicrobial pretreatment before pleural fluid (PF) sampling frequently results in negative diagnostic cultures, thus greatly underestimating the contribution of pneumococci, especially pneumococci susceptible to antimicrobial agents, to PPE. The study aim was to identify the serotypes and genotypes that cause PPE by using molecular diagnostics and relate these data to disease incidence and severity. A total of 208 children with PPE were prospectively enrolled; blood and PF samples were collected. Pneumococci were detected in 79% of culture-positive and 84% of culture-negative samples. All pneumococci were genotyped by multilocus sequence typing. Serotypes were determined for 111 PPE cases; 48% were serotype 1, of 3 major genotypes previously circulating in Spain. Variance in patient complication rates was statistically significant by serotype. The recent PPE increase is principally due to nonvaccine serotypes, especially the highly invasive serotype 1.     

Clonal and clinical profile of Streptococcus pneumoniae serotype 19A causing pediatric invasive infections: a 2-year (2007-2009) laboratory-based surveillance in Madrid

Studies of clonality and clinical profile of serotype 19A invasive pneumococcal disease in children (IPD-19A) are worthy after PCV7 introduction. A prospective, hospital-based surveillance of IPD-19A, culture and/or PCR confirmed, was performed in 2007-2009 in Madrid (all 22 hospitals with pediatric departments). Sixty-two cases were found: 90.3% in children <5 years, 87.1% in <36 months, and 74.2% in ≤18 months. Clinical presentations: meningitis (22.6%), primary bacteremia (19.4%), secondary bacteremia to otic foci (SBOF; 17.7%), bacteremic pneumonia (17.7%), pediatric parapneumonic empyema (PPE; 17.7%) and others (4.8%). Presentations by age: meningitis (35.7%), SBOF (28.6%) and primary bacteremia (21.4%) in children <12 months, bacteremic pneumonia, PPE and primary bacteremia (26.3% each) in 12-23 months, and bacteremic pneumonia (33.3%) and PPE (26.6%) in ≥24 months. Sequence types ST276 and ST320 represented 83.0% isolates, all oral-penicillin/erythromycin non-susceptible. In nonmeningeal isolates, non-susceptibility to parenteral penicillin/cefotaxime was 0%/17.6% (ST276) and 93.8%/75.0% (ST320). Non-susceptibility in ST276 and ST320, prevalence of these STs among 19A isolates, and serotype 19A prevalence among IPDs, indicate the importance of 19A inclusion in PCV13 for IPD-19A prevention and for reducing 19A nasopharyngeal carriage, thus preventing 19A otitis (one-third of 19A bacteremia in this study were from otic origin).     

Pleural effusion and empyema as complications of pneumonia

Parapneumonic effusion is observed radiologically in approximately 40% of the patients with a bacterial pneumonia. In most cases the course of the disease is uncomplicated, and the parapneumonic effusion (PPE) resolves with antibiotic therapy. However, in 5-10% of the patients, PPE becomes more complicated (loculation) and the effusion eventually leads to the formation of an empyema if no drainage has been performed. In view of negative impact on morbidity and mortality, it is important to recognise and evaluate a PPE as soon as possible. Intrapleural pus is the only absolute indication for drainage. In all other cases, the risk of a complicated PPE has to be established in the early phase of the illness, based on radiological, biochemical and microbiological parameters of the effusion. Based on these findings one or more of the following therapeutic strategies can be chosen: tube installation with drainage, fibrinolytical therapy, video-assisted thoracoscopic surgery, thoracotomy with or without decortication, or open drainage. Although every PPE needs to be evaluated on an individual basis, an attempt has been made to formulate a strategy that can be used in clinical practice, based on recent literature and expert opinions.     

Increase in Streptococcus pneumoniae serotype 3 associated parapneumonic pleural effusion/empyema after the introduction of PCV13 in Germany

IntroductionPediatric pneumococcal pneumonia complicated by parapneumonic pleural effusion/empyema (PPE/PE) remains a major concern despite general immunization with pneumococcal conjugate vaccines (PCVs).MethodsIn a nationwide pediatric hospital surveillance study in Germany we identified 584 children <18 years of age with bacteriologically confirmed PPE/PE from October 2010 to June 2018. Streptococcus pneumoniae was identified by culture and/or PCR of blood samples and/or pleural fluid and serotyped.ResultsS. pneumoniae was identified in 256 of 584 (43.8%) children by culture (n = 122) and/or PCR (n = 207). The following pneumococcal serotypes were detected in 114 children: serotype 3 (42.1%), 1 (25.4%), 7F (12.3%), 19A (7.9%), other PCV13 serotypes (4.4%) and non-PCV13 serotypes (7.9%). Between October 2010 and June 2014 serotype 1 (38.1%) and serotype 3 (25.4%) were most prevalent, whereas between July 2014 and June 2018 serotype 3 (62.7%) and non-PCV13 serotypes (15.7%) were dominant. Compared to children with other pneumococcal serotypes, children with serotype 3 associated PPE/PE were younger (median 3.2 years [IQR 2.1–4.3 years] vs. median 5.6 years [IQR 3.8–8.2 years]; p < 0.001) and more frequently admitted to intensive care (43 [89.6%] vs. 48 [73.8%]; p = 0.04). Seventy-six of 114 (66.7%) children with pneumococcal PPE/PE had been vaccinated with pneumococcal vaccines. Thirty-nine of 76 (51.3%) had received a vaccine covering the serotype detected. Thirty of these 39 breakthrough cases were age-appropriately vaccinated with PCV13 and considered vaccine failures, including 26 children with serotype 3, three children with serotype 19A and one child with serotype 1.ConclusionFollowing the introduction of PCV13 in general childhood vaccination we observed a strong emergence of serotype 3 associated PPE/PE in the German pediatric population, including a considerable number of younger children with serotype 3 vaccine breakthrough cases and failures. Future PCVs should not only cover newly emerging serotypes, but also include a more effective component against serotype 3.     

Incidence trends of parapneumonic pleural effusions/empyema in children 2009 to 2018 from health insurance data: Only temporal reduction after the introduction of PCV13

BackgroundRecently, emergence of a higher proportion of serotype 3 in children with parapneumonic pleural effusion/empyema (PPE/PE) were observed in Germany despite general immunization with 13-valent pneumococcal conjugate vaccine (PCV13) since 2009. The impact of PCV13 on the overall incidence of PPE/PE in children is unclear.MethodsAnnual incidence of PPE/PE in children were determined using secondary health care data for 2009–2018, provided by the Barmer statutory health insurer, serving about 11% of the German population. Temporal trends of the annual incidence were modelled applying generalized additive models.ResultsOverall incidence of PPE/PE in children ( ≤18 years) in the ten-year observation period was 18.17 per 100,000. The 0–1 year olds showed the highest incidence (43.09 per 100 000). PPE/PE incidence decreased from 2009 until 2013 (nadir 2013 was 15.36; 95% CI: 13.41–17.31). Since 2013, the data show an annual increase. The nadir of incidence for the 2–5 year olds (15.85; 95% CI: 11.27–20.43) and the 6–18 year olds (12.29; 95% CI: 10.23–14.36) was also in 2013, whereas for the 0–1 year olds it was found in 2014 (32.66; 95% CI: 23.79–41.54). The GAM across all age groups showed a nearly U-shaped curve between time and incidence of PPE/PE by calendar year (p-non-linear = 0.0017). The model confirms the nadir in the year 2013.DiscussionWe found a nonlinear temporal trend of PPE/PE incidence in children with a decrease from 2009 to 2013 and a subsequent increase until 2018. The former might be explained by a quasi elimination of serotype 1, the latter by an increase in the proportion of serotype 3 as demonstrated in German surveillance data of pediatric PPE/PE cases generated during the same observation period.     

Significant impact of pneumococcal conjugate vaccination on pediatric parapneumonic effusion: Italy 2006–2018

Etiology and serotyping of parapneumonic effusion (PPE) and the impact of vaccination was evaluated over a 12-year period, before and after the PCV13 introduction (2011) for Italian children From 0 to 16 years of age.Five hundred and two children were evaluated; 226 blood and 356 pleural fluid samples were obtained and tested using Realtime-PCR and culture. In the pre-PCV13 era S. pneumoniae was the most frequent pathogen identified (64/90; 71.1%) with a large predominance of serotypes 1 (42.4%), 3 (23.7%), 7F (5.1%) and 19A (11.9%).The impact of vaccination, calculated on children 0–8 years of age, demonstrated a significant reduction of PPE: with an incidence rate of 2.82 (95%CL 2.32–3.41) in the pre-PCV13 era and an age-standardized rate (ASR) of 0.66 (95% CL 0.37–1.99) in the post-PCV13 era, p < 0.0001. No increase in non-PCV13 serotypes was recorded. S. pneumoniae remained the most frequent pathogen identified in the post-PCV13 era in unvaccinated children with an unchanged serotype distribution: respectively 26/66 (39.4%), 25/66 (37.9%), 5/66 (7.6%), and 4/66 (6.1%) for 1, 3, 7F and 19A. On the other hand 7F and 19A disappeared in vaccinated children and serotype 1 and 3 decreased by 91.8% and 31.5%, respectively. Realtime PCR was significantly more sensitive than culture both in pleural fluid (79.7% vs 12.5%) and in blood (17.8% vs 7.4%).In conclusion, our findings indicate that routine immunization with PCV13 has significantly reduced the burden of childhood PPE in vaccinated children, without increasing PPE due to other bacteria and without serotype shift. Moreover, the impact of PCV13 may be underestimated due to the increase in pneumococcal surveillance in Italy. Data has also shown that Real-time PCR is an essential tool to better define the etiology of PPE and to monitor vaccination plans. Longer studies will be necessary to evaluate the role of herd protection in PPE prevention.     

血液肿瘤患儿深部真菌感染诊断和治疗的临床分析

目的 探讨血液肿瘤患儿深部真菌感染的临床特征及其诊断和治疗.方法 回顾性分析2006年1月～2011年10月210例血液肿瘤经微生物学检查证实深部真菌感染患儿的相关诱因、临床特点、真菌培养结果和治疗方案并进行分析.结果 210例患儿从血或深部分泌物中共分离出168株菌种,其中念珠菌134株,占79.7％,包括白色念珠菌102株,热带念珠菌株23,近平滑念珠菌9株;曲霉菌27株,占16.1％;假丝酵母菌5株,占3.0％;毛霉菌2株,占1.2％.其余42例根据典型的影像学改变和治疗效果诊断为真菌感染.感染部位以肺部最常见,占69.5％,主要表现为咳嗽、咯痰、气促、喘憋,CT可见大片结节状或团块状高密度影;其次为肠道和泌尿系统,分别占14.9％和10.1％,其他还有败血症和皮肤感染.210例患儿全部行抗真菌药物治疗,同时加强对症支持治疗,其中单用氟康唑者83例,单用伊曲康唑者56例,单用两性霉素B者38例,其余33例联合或先后应用上述药物治疗.治愈66例,好转78例,恶化死亡42例,24例因原发病未缓解自动出院.结论 血液肿瘤患儿深部真菌感染诊断困难,最常见的感染部位为肺部,最常见的病原菌为念珠菌和曲霉菌.对于粒细胞减少发热患者抗生素治疗无效时,应及早行肺部CT检查.     

北仑区229株结核分枝杆菌的耐药性分析

目的分析结核病患者的耐药性和患者特征为临床治疗提供依据。方法回顾分析宁波市北仑区人民医院2017年7月1日-2018年6月30日送检的984例疑似结核病患者的痰液样本,进行MGIT320结核分枝杆菌液体培养,并对结核分枝杆菌分离培养阳性者采用结核液体药敏试验,对4种抗结核药物:链霉素(SM)、异烟肼(INH)、利福平(RFP)、乙胺丁醇(EMB)进行药物敏感性试验,分析其耐药性,为临床合理选用抗结核药物提供依据。结果全部敏感为183株,占79.9%;单耐药为23株,占10.0%;耐多药率为17株,占7.4%;耐INH为31株,占13.5%;耐RFP为17株,占7.4%;耐SM为38株,占16.6%;耐EMB为15株,占6.5%。结论结核病的耐药率相对较低,INH和SM是结核病一线药物中耐药性较高的药物。     

湖南省新型冠状病毒肺炎临床特征分析

目的 分析湖南省新型冠状病毒肺炎(简称新冠肺炎,COVID-19)病例临床特征,为病例的发现、治疗和预防提供科学依据。 方法 回顾性分析湖南省 2020年1月21日—2月13日的所有新型冠状病毒肺炎确诊病例临床资料。比较不同年龄段、不同临床分型病例的临床表现、实验室检查及胸部CT检测结果 的差异。 结果 918 例患者高发年龄为 15～64 岁,小于15岁的病例28例(仅占3.05%),轻型病例318例(占34.64%),普通型病例523例(占56.97%),重型70例(占7.63%),危重型7例(占0.76%);有一种以上基础疾病的240例(占26.14%)。主要临床表现有发热(占67.54%),干咳(占42.59%),部分患者出现乏力、咳痰、咳嗽、头痛症状;血常规表现白细胞总数以降低或正常为主(占97.37%),淋巴细胞下降(占43.93%),中性粒细胞百分比降低或正常(占66.46%);95%患者胸部CT检查有肺炎影像学特征。 结论 新型冠状病毒肺炎病例临床表现不典型,以发热和干咳为主要临床表现。患者的血象有改变,胸部CT检查有肺炎影像学特征。胸部CT检查是一种较好的辅助诊断方法。     

新冠肺炎隔离病房个人防护用品使用中面临的问题与应对

 

新型冠状病毒肺炎是一种新发的传染病,某院作为新型冠状病毒肺炎疑似病例和确诊病例的收治场所,为确保医务人员的安全,个人防护用品的正确使用尤为重要。在临床实际操作中,医务人员在个人防护用品使用中面临很多的困惑,本文探讨医务人员穿脱个人防护用品过程中遇到的问题及困惑,对该院采取的相应措施进行梳理和总结。