住院结核病人死因死亡调查

本文对全国22个省、市68所结核病院(所)住院死亡的3284例结核病人,做了死因死亡调查。结果:1965、1975、1985年肺结核病死率(％;为2.3、5.0、2.8。年龄组肺结核病死率随年龄而增长。肺结核与肺外结核死亡所占比率各年分别为78.5、12.8、82.4、9.9、76.3、10.3;非结核性死亡占6.9、6.9、12.5。肺结核直接死因主要为慢性心肺功能不全,各年为(％)65.0、69.8、68.2。肺外结核死于结脑分别占70.0、86.5、89.2,其中儿童呈下降趋势,成人则有所上升。肺结核发现-死亡期间分别为5.3、6.3、6.3年,10年以上分别占(％)18.1、40.9、45.6。     

影响急性心肌梗死患者住院病死率的因素

目的 探讨影响急性心肌梗死（AMI）患者住院病死率的因素。方法 回顾分析AMI患者2 136例,比较出院时存活和住院期间死亡两组患者的临床特征和住院治疗,并应用Logistic回归分析筛选影响AMI患者住院病死率的因素。结果 与存活组相比,死亡组患者年龄较大［(71±10)岁 vs （62±11）岁,P<0.01］,男性和有吸烟史者较少（56.0% vs 71.5%,P<0.01;45.2% vs 54.2%,P<0.05）,高血压病、糖尿病和高脂血症患病率较高（分别为58.3% vs 43.2%,47.7% vs 21.1%,72.0% vs 58.8%,均P<0.01）,心功能Killip分级较高（2.0±1.1 vs 1.2±0.5,P<0.01）,急性期再灌注治疗率和住院期间β受体阻滞剂及硝酸酯类药物的使用率较低（分别为10.1% vs 30.3%,47.0% vs 71.1%,95.2% vs 98.6%,均P<0.01）。Logistic回归分析显示年龄、高血压病、糖尿病、高脂血症、心功能Killip分级、再灌注治疗、β受体阻滞剂和硝酸酯类药物的使用率为影响AMI患者住院病死率的独立危险因素。结论 年龄、高血压病、糖尿病、高脂血症、心功能Killip分级、再灌注治疗、β受体阻滞剂和硝酸酯类药物的使用率对AMI患者住院病死率有显著影响。     

中国各类疫源地鼠疫病死率对比分析

目的了解不同年代我国人间鼠疫的病死率,及疫源地类型、病型、年龄和性别对病死率的影响。方法运用卡方检验、Fisher确切概率法对鼠疫病死率进行比较分析。结果建国前病死率（78.00%）明显高于建国后（34.01%）。建国初期为35.26%,之后呈波浪式起伏,90年代后呈明显下降趋势。各疫源地建国前后的病死率也存在显著性差异,1945-1969年旱獭疫源地病死率（89.52%）最高,依次为黄鼠疫源地（83.00%）、长爪沙鼠疫源地（81.31%）、黄胸鼠疫源地（70.76%）。建国后肺型（78.04%）和败血型（77.08%）鼠疫病死率较高,腺型（26.99%）和皮肤型（15.00%）病死率较低;儿童病死率（48.78%）和中老年病死率（48.83%）高于青少年病死率（39.94%）;男女病死率无统计学差异。结论早期发现及时治疗可以大幅度降低鼠疫病死率;病型、疫源地类型与病死率有较高的相关性;青少年病死率较低,性别与病死率无关。     

在结核病人完成治疗疗程以前医生决定停止治疗的相关因素

目的:调查肺结核病的诊断和在结核病人完成疗程以前医生决定停止治疗的相关因素.设计:调查台湾地区台北市所有居民医疗档案中,在2003年已经接受治疗的肺结核病人.结果:1126例肺结核病人中,512例(45.5%)仅根据胸部x线检查结果立即开始治疗,214例(19.0 %)基于痰涂片检查发现抗酸杆菌阳性进行治疗,261例(23.2 %)基于其他检查结果,还有139例(12.3%)根据细菌培养阳性的结果.在1126例肺结核患者中,156例(13.9%)被临床医生改变了结核病的诊断.多因素分析显示,仅依靠x光胸片或其他方法、女性病人、中断治疗2个月的病人、在其他卫生机构(转诊)继续治疗的病人以及肺癌病人与其他组相比有更大的改变诊断可能性.结论:有一部分的病人基于单独的胸部x线检查结果给予抗结核治疗,其中相当比例在完成结核病治疗全疗程前被医生劝告停止治疗,调查表明对台湾结核病控制项目需要尽快引起关注.     

西班牙抗结核药物所致严重肝毒性反应

目的：判定抗结核药物引起的严重肝毒性反应的发生频率及发生急性肝功能衰竭或死亡的预报指标.方法：西班牙肺科学会成员对1997-2001年18家医院的资料进行回顾性研究.严重肝毒性反应界定为,无临床症状者转氨酶有10倍升高或胆汁郁滞参数3倍增加;有肝炎症状者则为肝功能参数增加或发生肝功能衰竭.采用logistic回归分析计算比值比（OR）及其95%可信区间（CI）研究其预报因素.结果：3510例中共有166例发生肝毒性反应,其中90例（2.56%）为活动性结核病治疗所致.11例（10.3%）发生急性肝功能衰竭,其中3例进行了肝移植.总体病死率为4.7%（5例,其中3例与饮酒或肝毒性药物有关）.预后不良的预报指标为总胆红素＞2mg/dl（OR=9.4,95%CI：1.0-85.5）及血清肌肝＞1.5mg/dl（OR=32.1,95%CI：2.4-424.6）.结论：抗结核药物引起的严重肝毒性反应死亡率较高.必须进行经常性的临床检查及临床实验室观察,以预防其发生.     

结核病人呼吸道念珠菌分布特征与免除因素研究

近几年由于感染因素改变，人类感染的菌谱发生了很大变化。结核病人感染菌谱的特征如何？很少有国内外资料报道。作者经１年检测痰样９５２份，念珠菌检出率２１．６４％，高于肠杆菌科细胞１８．４６％，绿脓杆菌１１．２８％，其它非发酵菌１０．２５％，致病性球菌２．５６％，低于革兰氏阳性杆菌４０．００％，在常见致病性菌群组成中，其构成率３３．０６％，与非发酵菌３３．８４％近似，低于革兰氏阴性杆菌６２．９１，高于肠     

西班牙1991-1999年结核病疫情发展趋势的评价

背景:西班牙官方无可靠的结核病疫情资料。目的:确定西班牙 1991-1999年间结核病疫情的流行病学趋势。方法:在西班牙肺病和胸部外科联合会(SEPAR),结核和呼吸系感染(TRI)工作组实施的年度调查研究中,从两种途径收集了结核病的发病以及感染资料:1)17个自治地区(AR)的公共卫生服务资料;2)分布于西班牙不同地区的60个TRI成员收集的信息资料。结果:根据 AR途径的资料,结核病发病率从 1991年的 36.4/10万下降到1999年的 26.7/10万(平均年递降率为3.3％);根据TRI途径的资料,结核病发病率则从45.6/10万下降到 26.8/10万(平均年递降率为5.1％)。关于涂阳肺结核也有类似的观察结 果(AR途径的年递降率为3.0％;TRI途径的年递降率为5.6％)。两种来源的资料都说明6岁儿童的结核感染率也在下降(AR途径的结核感染率从1991年的0.87％下降到1998年的0.5％,年递降率为 6％;TRI途径的结核感染率则从 1991年的1.00％下降到 1997年的 0.71％,年递降率为 4.2％)。结论:本研究观察到的结核病发病率要高于官方公布的数据。尽管结核病发病率存在下降趋势,但递降率很低,西班牙仍然是工业化国家中结核病发病率最高的国家之一。     

1985-1998年昆士兰结核病人中的病人自身延误和医疗机构延误调查

地点:昆士兰结核病(TB)控制中心(QTCC)。 目的:调查昆士兰地区活动性肺结核诊断中的病人自身延误和医疗机构延误情况。 设计:对摘取自QTCC数据库的资料进行分析并作病历回顾。经细菌学或组织学诊断的有症状病人构成一个总体组和一个涂阳肺结核(PSP)病例组。 结果:病人自身延误的中位数是29天(总体组)和30天(PSP组)。医疗机构延误的中位数是22天(总体组)和11天(PSP组)。随着病例年龄增加以及移民定居时间的延长,医疗机构延误呈现明显上升趋势。45岁以上女性病人的医疗机构延误明显为长。与非土著澳人病例相比,来自高结核病发病率地区以及土著澳人病例的医疗机构延误要短。造成90天以上诊断延误的常见原因是未对病人进行适当的TB调查以及胸部X线检查误诊。 结论:医生在对老年病人以及来澳定居时间较长的移民病人进行鉴别诊断时应考虑结核病的可能。对于有持续性咳嗽症状的病人宜适当降低进行X线检查和痰菌检查的标准。     

活动性结核病人的鉴别

在最佳实践指南第二章陈述的最佳实践标准中，重点讲述了鉴别活动性结核的方方面面，目的是针对与病例发现相关的一些挑战。当就诊者属于结核菌感染高危人群时，开始即与其建立一种良好的关系是非常重要的。第一项标准重点讲述如何评价某人是否可能患有结核病，第二项标准详细阐述如何留取用于诊断的痰标本。这些标准主要针对医务人员，因为他们要判断到卫生医疗机构的就诊者是否患有结核病。因此，他们需要熟悉与结核病有关的体征、症状及危险因素。当就诊者为疑似结核病患者时，医务人员需要确保对就诊者进行了正确的检查，并遵循了适当的流程，从而使得质量最好的痰标本被送往实验室，且所有需要填写的资料清晰和正确。可以通过准确而及时的检查报告、对每例发现病人的登记和每例需要治疗病人的治疗依从性，来验证这些标准是否被成功地应用。     

Current status of treatment completion and fatality among tuberculosis patients in Spain.

OBJECTIVES: To determine treatment completion among patients with tuberculosis (TB), and to analyse factors associated with treatment default and fatality. METHODS: A prospective cohort study of patients who began treatment between 1 June 1999 and 31 May 2000 in areas where members of the SEPAR Tuberculosis and Respiratory Infections Group work. Factors associated with treatment default and fatality were studied using logistic regression, calculating odds ratios (OR) and their 95% confidence intervals (95%CI). RESULTS: The study involved 142 physicians from 76 different hospitals who provided information on 1515 cases. Eighty-two per cent of the patients completed treatment correctly, 14% defaulted, 5% died, 0.5% failed, and 8.7% interrupted treatment due to transfer or other reasons. The variables associated with default were intravenous drug use (IVDU) (OR 6.00, 95%CI 2.59-13.89) and immigration (OR 8.57, 95%CI 3.78-19.45); sex, age, homelessness, incarceration, directly observed treatment (DOT) or hospitalisation were not associated with default. Variables found to be predictive of fatality were alcoholism (OR 6.38, 95%CI 2.09-19.48), human immunodeficiency virus (HIV) infection (OR 7.08, 95%CI 2.08-29.15) and age >64 years (OR 10, 95%CI 2.9-34.07), whereas sex, IVDU, homelessness, DOT and hospitalisation were not. CONCLUSIONS: In industrialised countries, IVDU patients and immigrants should be targeted for DOT, while to reduce fatality rates stricter monitoring is required for patients who are alcoholic, HIV-infected, or aged >64 years.     

DOT and timely treatment completion among Asian-born immigrant tuberculosis patients.

SETTING: A large urban tuberculosis (TB) control program. OBJECTIVES: To identify factors associated with directly observed therapy (DOT) participation and to quantify how early use of DOT affected treatment duration. DESIGN: A retrospective study of 731 Asian-born patients with drug-susceptible Mycobacterium tuberculosis isolates who were verified in New York City between 1993 and 1997 and completed treatment. RESULTS: Overall, 297 (41%) of 731 patients in the study participated in DOT for some or all of their TB treatment. DOT participation was significantly associated with TB disease in a pulmonary site (adjusted odds ratio [aOR] 2.85, 95% CI 1.86-4.35), more recent year of diagnosis (aOR 1.70, 95% CI 1.50-1.94) and male sex (aOR 1.86, 95% CI 1.30-2.66). Patients who received > or = 70% of their TB treatment at a health department chest clinic were also significantly more likely to participate in DOT (aOR 3.83, 95% CI 2.55-5.74). Among 297 DOT patients, those who completed treatment by 9 months received a greater amount of treatment by DOT during the first 4 months of treatment than those who took longer to complete treatment. CONCLUSION: Earlier DOT participation can lead to overall shorter treatment duration. Health care providers should encourage TB patients to participate in DOT as early as possible in their TB treatment.     

Does antiretroviral treatment reduce case fatality among HIV-positive patients with tuberculosis in Malawi?

SETTING: Thyolo district, Malawi. OBJECTIVES: To report on 1) case fatality among human immunodeficiency virus (HIV) positive tuberculosis (TB) patients while on anti-tuberculosis treatment and 2) whether antiretroviral treatment (ART) initiated during the continuation phase of TB treatment reduces case fatality. DESIGN: Retrospective cohort analysis. METHODS: Comparative analysis of treatment outcomes for TB patients registered between January and December 2004. RESULTS: Of 983 newly registered TB patients receiving diagnostic HIV testing, 658 (67%) were HIV-positive. A total of 132 (20%) patients died during the 8-month course of anti-tuberculosis treatment, of whom 82 (62%) died within the first 2 months of treatment when ART was not provided (cumulative incidence 3.0, 95%CI 2.5-3.6 per 100 person-years). A total of 576 TB patients started the continuation phase of anti-tuberculosis treatment, 180 (31%) of whom were started on ART. The case-fatality rate per 100 person-years was not significantly different for patients on ART (1.0, 95%CI 0.6-1.7) and those without ART (1.2, 95%CI 0.9-1.7, adjusted hazard ratio 0.86, 95%CI 0.4-1.6, P = 0.6) CONCLUSIONS: ART provided in the continuation phase of TB treatment does not have a significant impact on reducing case fatality. Reasons for this and possible measures to reduce high case fatality in the initial phase of TB treatment are discussed.     

四所结核病专科医院对肺结核患者的转诊及治疗现况分析

目的了解4所结核病专科医院对住院肺结核患者的报告、转诊以及抗结核治疗方案,为加强结核病专科医院参与结核病防治工作提供科学依据。方法采用横断面调查研究设计,通过调查问卷收集住院肺结核患者相关数据,并使用4个评价指标进行分析:报告率、转诊率和治疗方案不正确率。结果对4家结核病专科医院中的597例住院肺结核患者进行了病案和随访调查,医院对这些患者的总体报告率为93.5%、总体转诊率为54.4%;初治肺结核患者中仅有65例被采用国家结核病防治规划所推荐的标准化疗方案,86.4%初治患者的抗结核治疗方案不正确;结论尽管结核病专科医院的数量不多,但他们对结核病控制工作的影响不容忽视,亟待规范专科医院对结核病患者的诊疗行为。     

Acceptance of screening and completion of treatment for latent tuberculosis infection among refugee claimants in Canada.

SETTING: Primary care clinic for refugee claimants, Montreal, Canada. OBJECTIVES: To identify factors linked to the acceptance of the tuberculin skin test (TST), and assess completion of treatment for latent tuberculosis infection (LTBI). DESIGN: Asylum seekers consulting for a medical complaint or medical immigration examination between February and October 1999 were assessed for eligibility. Personal and clinical information was gathered prospectively by questionnaire. Hospital files were reviewed to assess completion of LTBI treatment. RESULTS: In our study, 296 subjects (72.4% of 409 eligible) were offered TST, of whom 227 accepted (76.7%). Of these, 49 (24.9%) had a TST > or = 10 mm and 24 (49%) completed 6 months of LTBI treatment. Logistic regression models showed that patients who had never had a TST (OR 3.2, 95%CI 1.34-7.6) or had no temporary exclusion criteria (OR 4.0, 95%CI 1.6-9.9) were more likely to accept TST. Perceiving tuberculosis as a severe disease (OR 0.29, 95%CI 0.09-0.91) and consulting for an immigration examination (OR 0.42, 95%CI 0.18-0.98) was associated with refusal of TST. Increasing age was found to be independently associated with a positive TST (OR 1.06, 95%CI 1.01-1.12). Variability in the proportion of positive results was found between TST readers. CONCLUSION: This study supports the feasibility of screening refugee claimants for LTBI during medical consultation and of developing organizational links to ensure completion of LTBI treatment.     

耐药肺结核全口服治疗方案研究的现状和展望

结核病是严重的公共卫生问题,是全球十大死亡疾病之一。相对于敏感肺结核的高治愈率,耐药肺结核治疗成功率低、死亡率高。近年来,以抗结核新药为核心的全口服治疗方案获得了巨大的成功,克服了二线注射剂不良反应发生率高、患者治疗依从性差等缺点,提高了耐药肺结核的治疗成功率。但如何选用抗结核药物组成安全有效的全口服方案,以及如何开展相关治疗方案的研究是我们需要思考的问题。笔者通过梳理耐药肺结核化学治疗药物、含注射剂方案向全口服方案过渡以及目前国内外正在开展的短程、超短程全口服方案的相关研究及其制定的依据,结合我国国情,做出了相应的评论、提出了相关的思考及启发,以期为临床科研人员更好的认识和开展相关研究提供参考。     

Predicting completion of treatment among foreign-born adolescents treated for latent tuberculosis infection in Los Angeles.

SETTING: Two health clinics in Los Angeles County, California. OBJECTIVE: To identify factors associated with completion of care among foreign-born adolescents treated for latent tuberculosis infection (LTBI). DESIGN: A total of 766 low-income adolescents (79% participation rate), including 610 foreign-born, were recruited. In prospective face-to-face interviews, data were obtained on socio-demographic and lifestyle characteristics, psychosocial factors and clinic-related variables. Medical chart data were abstracted regarding clinic appointment keeping and completion of treatment. Univariate and multivariate logistic regression analyses were performed to identify factors associated with completion of care. RESULTS: Foreign-born adolescents were more likely to complete care than US-born adolescents, with 82% completion of care rate. In logistic regression analyses after controlling for age, medication taking behavior (OR 1.26, 95%CI 1.15-1.39), living with both parents (OR 1.74, 95%CI 1.02-2.97), sexual intercourse (OR 0.66, 95%CI 0.36-1.19) and speaking mostly or only English with parents (OR 0.39, 95%CI 0.15-1.03) were independently associated with completion of care. CONCLUSION: These findings contribute to our understanding of the factors that may explain why some adolescents complete care whereas others do not. They provide supportive evidence that tailored intervention programs should be developed to support the screening and completion of treatment of foreign-born adolescents.