红霉素序贯疗法对小儿支原体肺炎患者免疫球蛋白、细胞因子的影响

目的研究红霉素序贯疗法对小儿支原体肺炎患者免疫球蛋白及细胞因子的影响。方法选取2013年1月~2013年12月就诊于我院儿科的支原体肺炎患儿80例,随机分为A组和B组,每组各40例,A组予红霉素进行序贯治疗,B组予红霉素单纯静脉续滴治疗;随机选取40名健康儿童作为对照组,于治疗前后抽取3组外周静脉血,比较A、B两组血清中Ig A、Ig M、Ig G、IL-6、IL-8等指标治疗前后的水平,并将其与对照组进行对比,对比两组的临床疗效。结果两组治疗后血清中Ig A、Ig M、Ig G、IL-6、IL-8的水平较治疗前均有所改善,且A组明显优于B组(P0.05);A组治疗有效率明显优于B组(72.50%vs 55.00%,Uc=2.11,P0.05),呼吸道症状消失时间及平均住院天数明显低于B组(P0.05);两组不良反应发生率A组明显低于B组(2.5%vs17.50%,P0.05)。结论相比于红霉素单纯静脉续滴治疗,红霉素序贯疗法在治疗小儿支原体肺炎中更有利于患儿血清中免疫球蛋白Ig A、Ig M、Ig G及细胞因子IL-6、IL-8水平的恢复,其疗效更优,值得在临床上推广。     

肺炎支原体感染儿童血清MCP-1与IL-10水平及临床意义

目的研究肺炎支原体(MP)感染儿童急性期血清单核细胞趋化蛋白-1(MCP-1)与白细胞介素-10(IL-10)水平,探讨其临床意义。方法将160例研究对象分为3组:MP肺炎组(A组,80例)、非MP肺炎组(B组,40例)和对照组(C组,40例)。A组按照重症支原体肺炎诊断标准,分成普通型组(52例)和重症组(28例);普通型组按有无蛋白尿分成蛋白尿组(30例)和无蛋白尿组(22例)。采用ELISA法检测MCP-l与IL-10水平。结果 1 A组MCP-1、IL-10水平均高于B组和C组(P0.05);2重症组MCP-1水平明显高于普通型组(t=9.9031,P0.05);3蛋白尿组与无蛋白尿组MCP-1水平差异无统计学意义(t=0.0605,P0.05)。结论 MP肺炎患儿血清MCP-1及IL-10水平均显著升高,且与其他原因所致肺炎差异明显,提示血清MCP-1及IL-10水平可作为早期诊断MP肺炎的依据之一。     

Electrophysiological study of pro-arrhythmogenic effects of erythromycin

Three cases of torsades de pointe induced by erythromycin have recently been reported. After observing a new case, the authors tried to demonstrate the possible mechanism of the arrhythmogenic action of this molecule. Twenty-two patients undergoing electrophysiological studies in the catheter laboratory to determine the cause of syncope were given an intravenous injection of 10 mg/Kg of erythromycin lactobionate. The drug was injected in 1 minute (bolus) in 11 patients (Group A). The other 11 patients (Group B) received the drug by slow intravenous infusion (20 minutes). Electrophysiological parameters were measured before and after erythromycin. A significant prolongation of the atrial refractory periods (+39 ms), ventricular refractory periods (+20 ms), QT (+20 ms) and QTC intervals (+42 ms) was observed in Group A. These electrophysiological effects could explain an arrhythmogenic action similar to that of antiarrhythmic drugs in Group I of Vaughan-Williams' classification. The slow intravenous infusion of erythromycin in Group B considerably reduced these undesirable secondary effects. This difference was directly related to serum concentrations of the molecule.     

Legionella micdadei pneumonia diagnosed by culture isolation and DNA-dNA hybridization from bronchial lavage fluid

An 80-year-old man was admitted because of dyspnea on effort. We suspected an acute exacerbation of chronic heart failure and idiopathic interstitial pneumonia caused by right-sided pneumonia. A nodular shadow in right upper lobe spread and consolidated into the airspace, and it failed to improve despite administration of meropenem trihydrate, vancomycin hydrochloride and clindamycin. A definitive diagnosis of Legionella micdadei pneumonia was made on the basis of this organism being isolated in culture from bronchial lavage fluid and subsequent identification of Legionella micdadei using DNA-DNA hybridization. The airspace consolidation gradually improved following treatment with intravenous erythromycin and minocycline hydrochloride.     

A clinical study of 50 cases of Legionnaires disease]

The clinical features and X-ray manifestations of 50 cases of legionnaires disease were analysed. 8 cases might be due to nosocomial infection through breathing in flying particles of the saliva or phlegm. According to the main clinical features, this disease could be divided into common pneumonia type; acute gastroenteritis type; encephalopathy type; shock type; acute renal insufficiency type. The differential diagnosis of legionnaires disease with mycoplasmal pneumonia, pneumococcal pneumonia and infiltrative pulmonary tuberculosis was also discussed. The first choice for treatment is erythromycin or erythromycin with rifampicin.     

氨溴索雾化及静滴联合用药与单独用药治疗小儿支气管肺炎的效果比较观察

目的探讨氨溴索雾化及静滴联合用药与单独用药治疗小儿支气管肺炎的效果。方法选择2011-09—2013-03该院收治的101例支气管肺炎患儿,按入院时间半随机分为A、B、C三组。在综合治疗的基础上,A组采用氨溴索氧化雾化联合静脉滴注治疗,B组采用氨溴索氧化雾化治疗,C组采用氨溴索静脉滴注治疗,比较三组总有效率、胸片改变情况、住院天数和症状改善时间。结果（1）三组疗效比较差异均无统计学意义（P〉0．05）;（2）三组临床指标（症状、体征消失时间和住院天数）比较差异均无统计学意义（P〉0．05）;（3）三组治疗后胸片情况比较差异均无统计学意义（P〉0．05）;（4）三组对C反应蛋白（CRP）、白细胞计数（WBC）的影响比较差异均元统计学意义（P〉0．05）。两种给药途径联合应用治疗后hs-CRP恢复正常的例数明显多于单独应用者（P〈0．05）。结论氨溴索氧化雾化联合静脉滴注治疗小儿支气管肺炎其疗效、临床指标、治疗后胸片、WBC与CRP的变化并不优于单用静脉滴注或氧驱动雾化吸入治疗,仅对hs-CRP的恢复存在优势,认为两种用药途经联合应用既浪费药源,增加病人负担,又浪费护士人力资源。     

3种临床用药方案治疗社区获得性肺炎的成本-效果分析

目的探讨3种不同的临床治疗方案用于社区获得性肺炎的经济效果。方法运用药物经济学成本-效果分析法对A组（左氧氟沙星静脉滴注）、B组（阿奇霉素静脉滴注）、C组（左氧氟沙星＋阿奇霉素静脉滴注）进行回顾性分析评价。结果3种药物治疗方案成本分别为46．2元、70．0元、81．2元；细菌清除率分别为84．6％、80．O％、92．6％（P〉0．05）；痊愈率分别为64．5％、58．1％、77．4％（P〉0．05）；成本-效果比分别为（细菌清除率）0．55、0．87、0．88；（痊愈率）0．40、0．72、0．63；有效率分别为87．1％、74．2％、93．5％（P〈0．05）；3种方案治疗社区获得性肺炎在痊愈率、细菌清除率上无显著差异，在有效率上有显著差异。结论综合考虑C方案为较佳方案。     

Comparison of amiodarone and quinidine in the conversion to sinusal rhythm of atrial fibrillation of recent onset

The effectiveness of amiodarone and quinidine in converting atrial fibrillation of recent onset (less than three weeks) to sinus rhythm was compared in a randomized, open-label study. Patients with signs of heart failure determining a NYHA class 3 or 4, acute myocardial infarction, unstable angina pectoris, sick sinus syndrome, Wolff-Parkinson-White syndrome, conduction disturbances, dysthyroidism, or undergoing concomitant therapy with antiarrhythmic drugs, were excluded from the study. Sixty-eight consecutive patients were randomized to receive amiodarone (group A) or quinidine (group B). Group A was treated with amiodarone intravenously as a bolus of 5 mg/Kg over a 20 min period followed by a 15 mg/Kg infusion during the first 24 hours and then orally at a dose of 0.4 g every 6 hours. Group B was treated with quinidine sulphate orally at a dose of 0.2 g every 6 hours during the first day; 0.4 g every 6 hours the second day and 0.6 g every 6 hours during the third day of therapy. Quinidine was preceded by rapid intravenous digitalization depending on the patient's clinical status so as to obtain a ventricular rate of about 100 beats/min, with subsequent oral digitalis administration in maintenance doses. Both treatments were continued until conversion or for a maximum of three days. If the sinus rhythm was not restored, patients underwent electrical cardioversion. Drug efficacy was assessed on the basis of conversion to sinus rhythm. Six patients converted to sinus rhythm with intravenous digitalization alone and were excluded from the comparison between the two groups.(ABSTRACT TRUNCATED AT 250 WORDS)     

依达拉奉联用降纤酶治疗急性脑梗死临床研究

目的研究依达拉奉联用降纤酶治疗急性脑梗死的临床疗效及安全性。方法选择2005—2007年复旦大学附属上海市第五人民医院急诊科发病12h内的急性脑梗死患者93例,随机分为A组46例和B组47例。A组患者使用依达拉奉注射液(30mg加入生理盐液100mL静脉滴注,每日2次,共14d)和降纤酶(首剂量为15U,以后隔日5U,共4次,均加入生理盐液250mL,2～3h内静脉滴注);B组仅使用降纤酶治疗。治疗前后对患者进行欧洲脑卒中量表(ESS)神经功能缺损程度评分、日常生活能力(ADL)、APACHEⅡ评分及C-反应蛋白(CRP)的测定,治疗后进行疗效评定,进行为期3个月的随访。结果在治疗后14d,两组患者的ESS、ADL、A-PACHEⅡ和CRP较治疗前有显著改善,A组的各项指标优于B组;A组有效率(67.4%)高于B组(40.4%)(P<0.05);两组的3个月病死率没有显著差异(P>0.05);两组患者均无颅内出血发生,少数患者发生颅外出血,两组没有显著差异,所有病例无严重不良反应发生。结论依达拉奉联用降纤酶能够安全有效的治疗急性脑梗死患者。     

左氧氟沙星治疗老年糖尿病合并社区获得性肺炎疗效观察

目的评价左氧氟沙星400mg每天1次治疗老年糖尿病合并社区获得性肺炎的安全性和有效性。方法本研究采用对照研究的方法，实验组采用左氧氟沙星400mg／次，每天1次静脉滴注；对照组采用左氧氟沙星200mg／次，每天2次静脉滴注，总疗程均为10～14d。观察两组治疗老年糖尿病合并社区获得性肺炎的临床疗效和安全性。结果本研究共入选患者74例，可作临床疗效评价患者70例，实验组和对照组分别为36例和34例，实验组和对照组的基本情况、疾病类型、用药天数无显著性差异（P〉0．05）；两组临床有效率、痊愈率、细菌清除率，无统计学差异（P〉0．05）；两组不良反应率亦无显著性差异（P〉0．05）。结论左氧氟沙星400mg每天1次静脉滴注治疗老年糖尿病合并社区获得性肺炎疗效良好，不良反应程度较低，患者可耐受，每天1次给药，方便临床治疗。     

A case of Legionella pneumonia complicated with acute respiratory distress syndrome treated with methylprednisolone and sivelestat sodium in combination with intravenous erythromycin and ciprofloxacin]

A 64-year-old man was referred to us because of pneumonia refractory to panipenem/betamipron. His chest radiography showed patchy consolidations in the lower lobe of the right lung and in the middle field of the left lung, and severe hypoxia was present. He was diagnosed as having acute respiratory distress syndrome due to severe pneumonia, and was treated with pulse methylprednisolone and sivelestat sodium in combination with intravenous erythromycin and ciprofloxacin. The patient recovered with this treatment. Serological examination using blood samples collected on the 12th and 28th hospital days revealed elevation of anti-L. pneumophila serogroup I antibody. It is suggested that administration of methylprednisolone and sivelestat sodium in combination with intravenous erythromycin and ciprofloxacin in a case of severe Legionella pneumonia complicated with acute respiratory distress syndrome is effective, and may be of use in similar cases.     

2型糖尿病合并脑卒中患者肠内营养期间血糖控制方案的探讨

目的探讨2型糖尿病合并脑卒中患者进行持续滴注胃肠内营养期间的血糖控制方案。方法选取52例2型糖尿病合并脑卒中需进行营养泵胃肠内营养的患者,随机分为两组：胰岛素静脉泵入组26例,采用持续静脉胰岛素泵入,胰岛素剂量根据随机血糖进行调整;甘精胰岛素组：26例,采用每日1次甘精胰岛素皮下注射,根据空腹血糖调整用量。两组随机血糖目标值为7．8—10．0mmol／L。其他治疗措施基本相同。结果入院第3日,胰岛素静脉泵入组血糖控制明显优于甘精胰岛素组（P〈0．05）,入院第7日两组日均血糖值已无明显差异,均能达到控制目标,但胰岛素静脉泵入组的血糖波动性（血糖标准差和最大血糖波动幅度）明显大于甘精胰岛素组（P〈0．05）。结论在2型糖尿病合并脑卒中患者进行持续滴注胃肠内营养期间,先使用静脉胰岛素泵2～3天有效控制过高的血糖,而后过渡为甘精胰岛素治疗是相对安全、有效的治疗方案。     

吸入性糖皮质激素增加哮喘患者肺炎风险

目的 探讨哮喘患者长期吸入激素(ICS)是否增加肺炎发生风险.方法 选择上海市杨浦区市东医院07年1月～ 07年12月哮喘患者共300例,其中使用ICS者156例(A组),未使用者144例(B组),并选择同期健康志愿者150例(C组).结果 随访6、12、18、24个月结束时,A组患者ICS使用总量分别为28.50 g、50.10 g、61.30 g、69.10 g,发生肺炎分别为10、23、37、53例次；B组发生肺炎分别为7、14、22、29例次；C组发生肺炎分别为9、16、26、33例次.B组和C组比较差异无统计学意义(P＞0.05).A组和B组、C组比较差异有统计学意义(P＜0.05).结论 长期使用ICS增加肺炎风险,随着剂量和时间增加,肺炎发病机会增高,但预后良好.     

Case of macrolide-ineffective Mycoplasma pneumoniae pneumonia successfully treated with intravenous ciprofloxacin]

A 18-year-old man complaining of remittent fever and nonproductive cough visited a nearby clinic. He did not recover despite treatment of oral azithromycin. We admitted him because his chest radiograph showed consolidation in the left upper lung field. We diagnosed his pneumonia as co-infection by non-bacterial and bacterial pathogens, and initiated treatment with intravenous ampicillin and oral clarithromycin. On the 3rd day after admission his symptom had not improved, so his treatment was changed to intravenous panipenem/betamipron and erythromycin. Ciprofloxacin was administered intravenously because consolidative shadows with atelectasis increased on the chest radiograph on the 6th day. Clinical symptoms such as fever, CRP and chest radiograph findings were rapidly improved after the start of ciprofloxacin treatment. He was discharged on the 22nd hospital day. Since serum antibody titer against Mycoplasma pneumoniae was elevated to x 20,480 on the 13th hospital day, it is confirmed that causative pathogen was macrolide-ineffective Mycoplasma Pneumoniae.     

Azithromycin vs cefuroxime plus erythromycin for empirical treatment of community-acquired pneumonia in hospitalized patients: a prospective, randomized, multicenter trial

OBJECTIVE: To compare the efficacy and safety of azithromycin dihydrate monotherapy with those of a combination of cefuroxime axetil plus erythromycin as empirical therapy for community-acquired pneumonia in hospitalized patients. METHODS: Patients were enrolled in a prospective, randomized, multicenter study. The standard therapy of cefuroxime plus erythromycin was consistent with the American Thoracic Society, Canadian Community-Acquired Pneumonia Consensus Group, and Infectious Disease Society of America consensus guidelines. The doses were intravenous azithromycin (500 mg once daily) followed by oral azithromycin (500 mg once daily), intravenous cefuroxime (750 mg every 8 hours), followed by oral cefuroxime axetil (500 mg twice daily), and erythromycin (500-1000 mg) intravenously or orally every 6 hours. Randomization was stratified by severity of illness and age. Patients who were immunosuppressed or residing in nursing homes were excluded. RESULTS: Data from 145 patients (67 received azithromycin and 78 received cefuroxime plus erythromycin) were evaluable. Streptococcus pneumoniae and Haemophilus influenzae were isolated in 19% (28/145) and 13% (19/145), respectively. The atypical pathogens accounted for 33% (48/145) of the etiologic diagnoses; Legionella pneumophila, Chlamydia pneumoniae, and Mycoplasma pneumoniae were identified in 14% (20/ 145), 10% (15/145), and 9% (13/145), respectively. Clinical cure was achieved in 91% (61/67) of the patients in the azithromycin group and 91% (71/78) in the cefuroxime plus erythromycin group. Adverse events (intravenous catheter site reactions, gastrointestinal tract disturbances) were significantly more common in patients who received cefuroxime plus erythromycin (49% [30/78]) than in patients who received azithromycin (12% [8/67]) (P<.001). CONCLUSIONS: Treatment with azithromycin was as effective as cefuroxime plus erythromycin in the empirical management of community-acquired pneumonia in immunocompetent patients who were hospitalized. Azithromycin was well tolerated.     

丙种球蛋白静脉滴注辅助治疗小儿糖尿病合并重症肺炎的临床分析

目的分析丙种球蛋白静脉滴注辅助治疗小儿糖尿病合并重症肺炎的临床治疗效果。方法选取该院2018年3月—2019年11月期间收治的小儿糖尿病合并重症肺炎92例进行研究分析,将其分为实验组和对照组,对照组采取常规治疗,实验组在对照组治疗基础上采取丙种球蛋白静脉滴注辅助治疗,对比两组患儿的治疗有效率、各项指标改善情况。结果实验组患儿采取丙种球蛋白静脉滴注治疗后,患儿机体FPG、2 hPG、HbAlc等指标的改善程度明显优于对照组,两组患儿机体血糖指标对比差异有统计学有意义(P<0.05)。实验组采取丙种球蛋白静脉滴注辅助治疗后,治疗有效率明显高于对照组,对比差异有统计学意义(P<0.05)。实验组采取丙种球蛋白静脉滴注治疗后,出现1例肠胃不适、1例恶心呕吐、1例过敏,对照组治疗后出现3例肠胃不适、4例恶心呕吐、3例过敏,治疗后不良反应率数据对比差异有统计学意义(P<0.05)。结论为小儿糖尿病合并重症肺炎采取丙种球蛋白静脉滴注辅助治疗后,在提高治疗有效率的基础上,有效改善患儿的血糖指标和症状改善情况,降低不良反应,提高治疗的安全性,促进患儿机体的康复。     

Treatment of community-acquired pneumonia in adults

Appropriate antibiotic treatment reduces the duration of symptoms associated to pneumonia, the risk of complications and mortality. In most cases, it is not possible to identify the etiologic agent so antibiotic treatment is empirically prescribed. In Chile, one third of Streptococcus pneumoniae strain isolates has diminished susceptibility to penicillin; in-vitro erythromycin resistance is about 10-15% and cefotaxime resistance 2-10%. It is recommended to classify patients with community acquired pneumonia in four risk categories: Group 1: patients under 65 years without co-morbidities, in ambulatory attendance. Treatment: oral amoxicillin 1 g TID, 7 days. Group 2: patients over 65 years and / or co-morbidities, in ambulatory attendance. Treatment: oral amoxicillin/clavulanate 500/125 mg TID or 875/125 mg BID, or cefuroxime 500 mg BID, 7 days. Group 3: patients admitted to general wards with criteria of moderate severity. Treatment: ceftriaxone 1-2 g once a day or cefotaxime 1 g TID, IV, 7-10 days. Group 4: patients with severe CAP that must be interned into ICU. Treatment: ceftriaxone 2 g once a day or cefotaxime 1 g TID, IV, associated to erythromycin 500 QID, levofloxacin 500-1.000 mg once a day, or moxifloxacin 400 mg/once a day, IV, 10-14 days. In the presence of allergy to or treatment failure with betalactam drugs and/or positive serology for Mycoplasma, Chlamydia or Legionella sp it is recommended to add: erythromycin 500 mg QID, IV or oral, oral clarithromycin 500 mg BID, or oral azythromycin 500 mg once a day.     

氟比洛芬酯用于胸部创伤镇痛的临床观察

目的观察静脉滴注氟比洛芬酯对胸部创伤患者的镇痛效果及安全性。方法 60例以多发肋骨骨折(3根以上)为主的胸部创伤患者随机分为A、B两组,A组给予氟比洛芬酯注射液(凯纷)50 mg加入生理盐水50 ml静脉滴注,B组给予曲马多注射液100 mg肌肉注射。比较起效时间、维持时间及用药前、用药后2、6、24 h疼痛视觉模拟评分(VAS)值,以及副反应观察。结果 A组药物起效时间及持续时间与B组比较差异有统计学意义(P<0.01);两组给药后6 h VAS评分差异有显著性(P<0.01);给药前、给药后2、24 h两组VAS评分比较差异无统计学意义(P>0.05);两组用药后不良反应:A组不良反应率为3.33%,B组不良反应发生率为16.67%。结论氟比洛芬酯用于胸部创伤镇痛效果确切,且副作用少。     

A three-day course of intravenous omeprazole plus antibiotics for H. pylori-positive bleeding duodenal ulcer.

BACKGROUND/AIMS: This prospective trial aimed to test the efficacy of 3-day intravenous omeprazole plus antibiotics for Helicobacter pylori (H. pylori) eradication rate, and to see whether individualized response to omeprazole in intragastric pH elevation will alter the success of eradication. METHODOLOGY: One hundred and thirty-eight cases with H. pylori-positive duodenal ulcer bleeding were randomized into four therapy groups: Group 1 (n = 32) received a 3-day course of intravenous omeprazole (80 mg loading then 40 mg q 9 am & 9 pm) plus ampicillin/salbactum (1.5 gm i.v. loading then 750 mg q 9 am, 3 pm, & 9 pm); Group 2 (n = 35) followed protocol as for Group 1 except the antibiotics were metronidazole and erythromycin (both 500 mg i.v. q 9 am, 3 pm, & 9 pm). Group 3 (n = 31) followed protocol as for Group 1 and further added with erythromycin (both 500 mg i.v. q 9 am, 3 pm, & 9 pm). Group 4 served as a control group (n = 40) receiving oral dual therapy after leaving the emergency room (omeprazole 20 mg and amoxycillin 1 g bid x 2 weeks). In each case, three gastric biopsies were done for total histologic density of H. pylori (THPD) (range: 0-15) before, 1 day and 6 weeks after completion of therapy. Except for the control group, the 24-hour ambulatory intragastric pH meter (MIC Inc, Gastrograph Spark III, Swiss) was inserted as possible on the 2nd day of therapy. RESULTS: The 3-day intravenous regimens achieved high clearance rates of H. pylori (Group 1: 93.8%; Group 2: 93.9%; Group 3: 100%). The eradication rates of H. pylori in Groups 1-4 were 43.8%, 57.1%, 58.1%, and 72.8%, respectively. In Groups 1-3, the H. pylori-eradicated cases had lower pre-treatment THPD than non-eradicated cases (6.01 vs. 9.24, p < 0.001). Among 72 cases with pH meter insertion, the percentage of intragastric pH > 5.3 during 24-hour was not different among 35 H. pylori non-eradicated and 37 eradicated cases (78.7 vs. 76.7%, p > 0.05). CONCLUSIONS: The 3-day intravenous regimens may achieve clearance of H. pylori quickly. However, they were not so effective for eradication, especially in cases with higher bacterial loads. The interindividual response to omeprazole in intragastric pH elevation under the study dosage had insignificant variations to alter the success of eradication.     

2型糖尿病合并肺结核患者治疗方案的选择与评估

目的探讨2型糖尿病合并肺结核应用胰岛素加口服二甲双胍联合抗结核治疗的临床疗效。方法对216例2型糖尿病合并肺结核病人随机分成三组,三组患者均在有效控制血糖的基础上,规律抗结核治疗。A组单纯口服二甲双胍0.5/次,3次/d,B组单纯应用胰岛素。C组应用胰岛素加口服二甲双胍,胰岛素剂量12～60 U不等,根据FGB检测随时调整剂量。抗结核治疗方案为3HRZE(S)/9HR。结果肺结核疗效:治疗3月末、6月末及疗程结束病灶吸收率、空洞闭合率、痰菌阴转率:B组68.5%、83.6%、97.3%;C组78.1%、90%、98.6%。均高于A组41.1%、56.2%、68.5%;B、C组与A组比较均有显著差异(P<0.01)。结论应用胰岛素加口服降糖药疗效好于胰岛素组,胰岛素组好于口服降糖药组;控制血糖是治疗糖尿病合并肺结核的关键。