基于网络数据库的脑膜炎诊断三联征研究

目的 应用网络数据库进行数据挖掘,探讨建立用3～5个关键的症状、体征组合来初步快速判断脑膜炎的社区辅助诊断方法.方法 用中国知网数据库收集近4年符合纳入标准的161例脑膜炎患者和161例非脑膜炎患者完整的病例资料,以脑膜炎患者的临床症状、体征为自变量,采用单因素方法 进行变量筛选后对有统计学意义的变量进行多元Logistic回归分析,拟定脑膜炎诊断三联征,以病例诊断为金标准,对研究得出的诊断三联征的诊断效果进行评价.结果 应用多元回归方程提取出的脑膜炎初筛三联征是发热、头痛和脑膜刺激征,以其做工具检测脑膜炎的灵敏度是71.4%,特异度是78.9%,阳性预测值是77.2%,阴性预测值是73.4%;与金标准的诊断符合率用调整一致性指标来评价,为75.2%.结论 以发热、头痛和脑膜刺激征组合的脑膜炎诊断三联征作为一种简单、方便、快速和有效的方法,可用于基层医疗单位初筛脑膜炎患者,成为鉴别诊断和转诊患者的参考依据.     

颞动脉炎24例临床分析

目的:总结颞动脉炎的神经系统临床特征。方法:对诊断为颞动脉炎的24例患者进行回顾性分析,根据临床表现、颞动脉活检、糖皮质激素治疗效果作为诊断标准,以1990年美国风湿病学会(ACR)制定的颞动脉炎诊断标准作为参考。结果:24例患者被诊断为颞动脉炎,8例经颞动脉活检证实7例。其中,头痛为主要症状,本组24例中有22例(91.7%);视力障碍及眼痛较常见,本组有3例(12.5%),其中有1例失明;低至中度发热10例(41.7%),体温37.2～39℃;合并肌炎6例;颞动脉均增粗,呈条索状,搏动减弱。经糖皮质激素治疗后其症状或体征常在数小时至数天消失。结论:颞动脉炎的神经系统症状与体征较为常见,可见严重的并发症,早期诊断及治疗可得到有效控制。     

The rational clinical examination. Does this adult patient have acute meningitis?

CONTEXT: Early clinical recognition of meningitis is imperative to allow clinicians to efficiently complete further tests and initiate appropriate therapy. OBJECTIVE: To review the accuracy and precision of the clinical examination in the diagnosis of adult meningitis. DATA SOURCES: A comprehensive review of English- and French-language literature was conducted by searching MEDLINE for 1966 to July 1997, using a structured search strategy. Additional references were identified by reviewing reference lists of pertinent articles. STUDY SELECTION: The search yielded 139 potentially relevant studies, which were reviewed by the first author. Studies were included if they described the clinical examination in the diagnosis of objectively confirmed bacterial or viral meningitis. Studies were excluded if they enrolled predominantly children or immunocompromised adults or focused only on metastatic meningitis or meningitis of a single microbial origin. A total of 10 studies met the criteria and were included in the analysis. DATA EXTRACTION: Validity of the studies was assessed by a critical appraisal of several components of the study design. These components included an assessment of the reference standard used to diagnose meningitis (lumbar puncture or autopsy), the completeness of patient ascertainment, and whether the clinical examination was described in sufficient detail to be reproducible. DATA SYNTHESIS: Individual items of the clinical history have low accuracy for the diagnosis of meningitis in adults (pooled sensitivity for headache, 50% [95% confidence interval [CI], 32%-68%]; for nausea/vomiting, 30% [95% CI, 22%-38%]). On physical examination, the absence of fever, neck stiffness, and altered mental status effectively eliminates meningitis (sensitivity, 99%-100% for the presence of 1 of these findings). Of the classic signs of meningeal irritation, only 1 study has assessed Kernig sign; no studies subsequent to the original report have evaluated Brudzinski sign. Among patients with fever and headache, jolt accentuation of headache is a useful adjunctive maneuver, with a sensitivity of 100%, specificity of 54%, positive likelihood ratio of 2.2, and negative likelihood ratio of 0 for the diagnosis of meningitis. CONCLUSIONS: Among adults with a clinical presentation that is low risk for meningitis, the clinical examination aids in excluding the diagnosis. However, given the seriousness of this infection, clinicians frequently need to proceed directly to lumbar puncture in high-risk patients. Many of the signs and symptoms of meningitis have been inadequately studied, and further prospective research is needed.     

Enteric Fever: A retrospective 6-year analysis of 82 paediatric cases in a teaching hospital

Objective: To evaluate the clinical and laboratory properties, to see the response to therapy, incidence of antimicrobial resistance and complications of Enteric Fever in children. Methods: This is a retrospective study of 82 cases of enteric fever admitted in department of pediatrics, Manipal Teaching hospital, Pokhara, Nepal .Study period was six years from (Jan 2000 to Dec 2005). Results: Total of 82 cases of Salmonella infections were admitted .There were 50 (60%) males and 32 (40%) females. Most of the patients were above the age of five. The leading clinical feature were Fever (100%) , GI symptoms (73%), followed by splenomegaly (60%), hepatomegaly (58%) , chills & rigor (41%), headache(33%),coated tongue(17%), lymphadenopathy (13%), Respiratory signs (13%) , toxic look (7%). The laboratory reports revealed leucopenia in 26% and leukocytosis in 16%. Widal test was positive in 83%, Blood culture was positive in 37 %.Bone marrow was done in 8 cases, out of which 5(62.5%) were culture positive. Out of 35 culture positive cases 32 were Salmonella typhi and 3 were Salmonella paratyphi A. Regarding the treatment 55% were treated with ciprofloxacin, 29 % with ceftriaxone , 7% with ampicillin , 6% with cefotaxime and 2.4 % with chloramphenicol . Response to therapy was assessed by day of defervescence after antibiotics. Best response was observed with ciprofloxacin (4.7 days) followed by ceftriaxone (5days), ampicillin (5.5 days), cefotaximee (6.4 days), chloramphenicol (10 days) respectively. In the antibiogram resistance was 43% with chloramphenicol, 37% with ampicillin, 31% with trimethoprim- sulfamethoxazole, 5.7%with ciprofloxacin and 4% with cefotaxime .Resistance was 0% with ceftriaxone, cefuroxime, and ofloxacin. Gentamycin was found to show high sensitivity (91%). The complications observed were anemia in 10%, 5% had neurologic signs like clouding of consciousness and 3.7% had CNS irritability. Conclusion: It is important to include Enteric fever in the differential diagnosis of febrile patients with abdominal symptoms. Though blood culture is the definite test, Widal test plays supportive role in diagnosis of enteric fever, especially when patients come after a course of antibiotics. Sometimes when both blood culture and Widal tests are negative Bone marrow can be the diagnostic tool for the diagnosis. Based on this analysis ciprofloxacin is still a good drug for the treatment of Enteric Fever. Ceftriaxone, Cefuroxime and Ofloxacin can be considered as first line treatment for Enteric fever since resistance was nil with these drugs on culture reports. Key words: Enteric fever, salmonella infections.     

脑干出血29例临床分析

目的：分析脑干出血的临床症状与体征,讨论其与预后的关系。方法：选择经头颅CT或MRI确诊的29例病例,对其病因、分型、临床表现、诊断、治疗与预后进行分析。结果：病死率48．27％,预后与出血部位及出血量、发病后的意识状态、眼征、发热、有无并发症、白细胞总数、血糖水平有密切关系。结论：高血压动脉硬化为本病的主要病因,出血部位及出血量是影响病人预后的最重要因素。而CT、MRI的表现及发病后意识状态、眼征、体温、白细胞数及血糖水平均有判断预后的重要价值。     

中医临床术语系统的“症状体征”分类探讨

目前尚无中医症状的分类标准,本文在分析中医症状体征分类的现状与研究进展的基础上,依据中医临床诊疗过程特点,将症状体征按照信息来源分：四诊类症状体征、中医仪器诊察类症状体征、体质诊察类体征三大类,以期为完善中医临床术语系统的分类奠定基础。     

Accuracy in the clinical diagnosis of parkinsonian syndromes

This review of Parkinson's disease and related disorders emphasizes the difficulties of distinguishing between variants of the parkinsonian syndrome. Characteristic clinical features may remain absent for many months, but accuracy of diagnosis may be improved by considering certain presenting symptoms and signs. The main characteristics of various parkinsonian syndromes are reviewed and their major distinguishing features are emphasized. Future improvement in the precision of clinical diagnosis, especially early in the course of parkinsonian syndromes, will depend on selecting out patients with Parkinson's disease using positive diagnostic criteria.     

基于诊断标准心脏磁共振成像在致心律失常性右室心肌病诊断中的价值

摘 要: 【目的】 总结致心律失常性右室发育不良/心肌病(ARVD/C)的临床特征,分析其相应心脏磁共振成像(CMR)上心肌组织特征?右心室形态学和功能改变,探讨CMR在ARVD/C诊断中的应用价值? 【方法】 回顾性收集?分析已确诊ARVD/C且行CMR检查患者的临床资料?所有患者CMR图像由两名医师进行心脏容积和功能等定量评价,同时进行心室壁组织特性?形态学特征及心室壁运动的定性评估?定量测量指标包括右心室舒张末容积(RVEDV)?右心室收缩末容积(RVESV)?右心室每搏输出量(RVSV)及右心室射血分数(RVEF),其中RVEDV指标经体表面积(BSA)校正,获得右心室舒张末容积指数(RVEDVI)?定性评估包括脂肪浸润?“手风琴征”?延迟强化及心室壁运动等?【结果】共35例患者确诊为ARVD/C且行CMR检查,其中男22例(62.9%),女13例(37.1%),平均年龄(32.0 ± 11.8)岁,年龄范围(15 ~ 57)岁?常见的症状依次分别为心悸25例(71.4%)?胸闷10例(28.6%)和晕厥6例(17.1%)?所有患者均有室性心律失常?图像定量评估指标(RVEDV?RVEF)的观察者间一致性良好(组内相关系数为0.996-0.999, P < 0.001)?CMR评估RVEF为(33.51 ± 13.19)%,RVEDVI为(174.74 ± 64.36)mL/m2?依据2010年修订的ARVD/C诊断标准中CMR的定量参数分析显示:其中RVEDVI符合主要标准的为24例(88.9%),符合次要标准的为3例(11.1%); RVEF符合主要标准的为20例(57.1%),符合次要标准的为8例(22.9%)?21例(60.0%)可见脂肪浸润;19例(54.3%)出现“手风琴征”;29例(82.9%)CMR显示心室壁延迟强化,其中18例(51.4%)可及左心室壁延迟强化;28例(80.0%)出现室壁运动异常?【结论】 CMR可以全面评价ARVD/C患者心脏的解剖形态?心肌的组织学特性以及心室壁的运动情况,并准确评估右心室的功能,可在ARVD/C诊断中提供相应的信息,是ARVD/C诊断标准中的重要组成部分?     

小肠非霍奇金淋巴瘤的CT影像分析

目的探讨CT对小肠非霍奇金淋巴瘤(NHL)的诊断价值。方法选择25例经手术病理证实的小肠NHL患者,术前均行CT检查,分析其CT表现。结果10例CT表现为:肠腔扩大,类似瘤样扩张改变;6例表现为肠壁增厚,肠腔狭窄;9例显示夹心面包征。结论小肠NHL的CT征象具有一定的特征性,借助CT表现可对患者做出正确诊断和治疗。     

Effectiveness of levofloxacin in enteric fever

This intervention study was conducted to determine the efficacy of Levofloxacin in the treatment of uncomplicated enteric fever. Among 100 patients, who were purposively selected for the study had presented sign and symptoms of enteric fever with blood culture positive salmonella in laboratory findings during the admission in the department of Medicine, Uttara Adhunik Medical College & Hospital, Dhaka. Patients who fulfilled the diagnostic criteria were enrolled in the study and divided into two groups. One group was treated with oral levofloxacin 750mg once daily (OD) and another was injected with Levofloxacin 500mg once daily for 7 days. All the patients were examined twice daily to observe the clinical cure or failure of levofloxacin. Study was conducted from January 2008 to December 2008. Statistical analysis was performed by using statistical software SPSS version 12. Among the 100 patients in the study, majority of them 46(92%) were aged between 15 to 25 years, the next group was between 25 to 35 years 26(52%) and only three patients were aged above 65 years. Significant number of the patients were male (67), and the rest of them were female. The patients were clinically examined specially for anaemia, jaundice, caecal gurgling, hepatosplenomegaly in both the groups and the relevant investigations were performed. It was found that 46 patients in group A, who took oral levofloxacin, were cured after seven days, whereas 48 patients in group B were fully cured by taking injectable levofloxacin by seven days. In this study, levofloxacin was found to be the most effective drug in both oral and injectable form in one-week treatment of uncomplicated typhoid.     

Profile of Culture Positive Enteric Fever from Bangalore

Background

Enteric fever is endemic in India. The aim of this study was to analyse the clinical, laboratory, antibiotic sensitivity profile and response to antibiotics of culture positive enteric fever patients from Bangalore.

Methods

In this retrospective study only culture positive enteric fever patients were taken and their clinical, laboratory, antibiotic sensitivity profile and the clinical response to antibiotics studied.

Result

Eighty one culture positive enteric fever patients were taken into the study. Presenting symptoms included fever, pain abdomen (18.5%), loose stools (25%), vomiting (33%) and headache (30%). Absolute bradycardia at admission was not found in any of our patients. Normal or low total leucocyte count was seen in 97.5%. Typhoid hepatitis was seen in 8.5%. Salmonella enterica subspecies enterica serovar typhi (S typhi) were isolated in 80% of cases; 83% of all cases showed nalidixic acid resistance. All isolates were sensitive to chloramphenicol and third generation cephalosporins. Ciprofloxacin resistance was found in 19% cases. The time to defervescence in patients treated with ceftriaxone was 4.3 days. There was no statistical difference in time to defervescence in nalidixic acid resistant and sensitive strains. Complications included gastro intestinal bleed and encephalopathy. Conclusion: Prevalence of nalidixic acid resistance is high, while clinical resistance to quinolones may be higher than that found in the laboratory which requires detailed study. Chloramphenicol sensitivity has returned and nalidixic acid resistant and sensitive isolates are uniformly sensitive to third generation cephalosporins with no difference in time to defervescence.Key Words: Enteric fever, Nalidixic acid resistance, Ciprofloxacin resistance, Time to defervescence     

652例临床诊断细菌性痢疾患者的流行病学特点

目的 探讨北京市近年来成人急性细菌性痢疾的流行病学和临床特点,为肠道传染病的防控提供科学依据.方法 以2007年4月至2007年10月北京大学第三医院肠道门诊652例临床诊断急性细菌件痢疾患者为研究对象,对患者年龄、职业分布、症状体征、病原检测等情况进行分析.结果 临床诊断急性细菌性痢疾患者以青壮年发病为多,职业构成以干部职员、学生为主,临床症状以腹泻、腹痛、发热为最常见症状,里急后重、左下腹压痛少见,大便细菌培养阳性率17.7%,细菌性痢疾确诊率8.9%.结论 临床诊断急性细菌性痢疾的患者临床和流行病学特点已经发生了一些变化,病原菌培养阳性率低,与其他感染性腹泻不易鉴别,易造成传播.     

乳腺浸润性导管癌的病理基础及X线分析

目的:研究浸润性导管癌的X线表现,分析其病理学基础,以提高乳腺癌手术前的诊断水平。方法:23例住院病例,术后病理诊断为浸润性导管癌,结合其病理学基础与生物学特性,回顾分析术前乳腺钼靶X线表现特点。结果:23例浸润性导管癌中,钼钯X线表现:约70%为边缘模糊肿块,70%有毛刺状边缘,而同时出现2~5个间接恶性征象者有20例,占87%。结论:乳腺钼靶X线成像是目前诊断乳腺癌有效的手段。正确识别各种乳腺癌钼靶X线的直接与间接征象是诊断的前提,同时结合临床体查,特别是触诊——对肿块的手感,对提高乳腺癌手术前的正确诊断率非常重要。     

侵袭性肺曲霉菌病的影像对比研究

目的：评价MRI和CT对侵袭性肺曲霉菌病诊断的准确性。方法：对38例在普通胸片上表现结节样浸润及临床拟诊侵袭性肺曲霉菌病患的MRI、CT表现进行对比研究。结果：早期病变（临床症状和体征小于10天）CT所见“日晕征”有较高的敏感性（16／22）和特异性（8／8）;而MRI也显示很高的敏感性（22／22）,但特异性很差（0／8）。尽管使用GD－DT－PA增强亦不能提高其特异性。病变后期（临床症状和体征大于10天）,MRI增强扫描T1WI显示边缘强化的靶样小结节的典型表现。结论：在侵袭性肺曲霉菌病早期阶段,MRI表现不如CT的“日晕征”具有特征性。但在病变后期,MRI增强后T1WI边缘明显强化及在T2WI上的“反向日晕征”是诊断侵袭性肺曲霉菌病的有力证据。     

The rational clinical examination. Does this patient have carpal tunnel syndrome?

CONTEXT: History taking and physical examination maneuvers, including Tinel and Phalen signs, are widely used for the diagnosis of carpal tunnel syndrome (CTS). OBJECTIVE: To systematically review the precision and accuracy of history taking and physical examination in diagnosing CTS in adults. DATA SOURCES: English-language literature was searched using MEDLINE (January 1966-February 2000) as well as bibliographies of relevant articles. STUDY SELECTION: Studies of patients presenting to clinicians with symptoms suggestive of CTS in which findings from clearly described physical examination maneuvers were independently compared with electrodiagnostic testing. Twelve of 42 initially identified articles met these criteria and were included in the review. DATA EXTRACTION: Two authors independently reviewed and abstracted data from all of the articles and reached consensus about any discrepancies. DATA SYNTHESIS: In patients presenting with hand dysesthesias, the findings that best distinguish between patients with electrodiagnostic evidence of CTS and patients without it are hypalgesia in the median nerve territory (likelihood ratio [LR], 3. 1; 95% confidence interval [CI], 2.0-5.1), classic or probable Katz hand diagram results (LR, 2.4; 95% CI, 1.6-3.5), and weak thumb abduction strength (LR, 1.8; 95% CI, 1.4-2.3). Findings that argue against the diagnosis of carpal tunnel syndrome are unlikely Katz hand diagram results (LR, 0.2; 95% CI, 0.0-0.7) and normal thumb abduction strength (LR, 0.5; 95% CI, 0.4-0.7). Several traditional findings of CTS have little or no diagnostic value, including nocturnal paresthesias; Phalen and Tinel signs; thenar atrophy; and 2-point, vibratory, and monofilament sensory testing. Other less commonly used maneuvers, including the square wrist sign, flick sign, and closed fist sign, require validation by other studies before they can be recommended. CONCLUSIONS: Hand symptom diagrams, hypalgesia, and thumb abduction strength testing are helpful in establishing the [corrected] electrodiagnosis of CTS. The utility of these results is limited, however, by problems inherent in using nerve conduction studies as a criterion standard. JAMA. 2000.     

螺旋CT血管造影诊断肺动脉栓塞的临床价值

目的:探讨肺动脉栓塞(PE)的螺旋CT血管造影(CTA)的诊断价值。方法:对22例临床疑为PE的患者行螺旋CT血管造影,其中8例在溶栓治疗后进行复查。结果:22例患者累及62处肺动脉及其分支。PE的CT直接征象为:血管腔内充盈缺损,包括部分充盈缺损、附壁充盈缺损、完全阻塞及中心性充盈缺损(轨道征)。其中轨道征提示急性PE,其余3种提示亚急性、慢性PE的征象,对指导临床治疗有重要意义。PE的间接征象为:肺动脉高压、肺梗塞灶及右心室增大。结论:螺旋CT血管造影是一种快速、有效、无创伤性检查肺栓塞的方法,对指导临床正确诊断及治疗后随访均有重要意义。     

婴儿肥厚性幽门狭窄的临床诊断与影像检查对照分析

目的:探讨临床、超声及X线检查三者对肥厚性幽门狭窄(HPS)诊断的符合率。方法:通过手术证实的14例HPS的临床症状和体征、超声检查以及X线上消化道钡餐造影检查结果进行比较。结果:通过不含胆汁呕吐、右上腹深部触到橄榄状肿块等症状和体征的临床依据诊断HPS其符合率为42.9%。超声检查幽门肌厚度≥4mm、幽门管长度≥15mm的依据诊断HPS其符合率为85.7%。X线检查上消化道钡餐造影"幽门管延长"、"线样征"、"肩征"、"蕈征"等征象的依据可诊断HPS,符合率为92.9%。结论:通过临床、超声及X线检查对照分析,HPS的诊断以X线检查诊断率最高,其次为超声检查,仅靠临床对HPS的诊断符合率较低,但三者结合可以进一步提高HPS的诊断率。     

肝泡性包虫病的影像学诊断

目的 探讨肝泡性包虫病在B超、CT和磁3共振成像（MRI）影像学检查中的图像特征,以提高术前诊断率。方法 收集1984年1月至2000年12月经手术治疗的46例肝泡性包虫病患者的术前影像学检查资料（均行B超和CT检查,12例行MRI检查）,对照手术病理所见进行分析。结果 基于泡球蚴的基本病理形态、组织结构与病程发展演变的特殊影像学征象,可归纳为病灶浸润（41例,89.1%）、钙化（39例,84.8%）、液化空洞（37例,80.4%）3种类型,这3种类型可以并存。在3处类型中共发现9项具有特异性诊断意义的图像特征,即晕带征、钙化征、年轮征、内陷征、空腔征、岩洞征、半岛征、小泡征与地图征。结论 肝泡性包虫病具有特异性影像学征象,在9项具有特异性诊断意义的图像特征中,只要确认其中1项,即可确认。     

肝郁证候宏观辨证标准的文献计量学研究

目的初步建立异病同证中肝郁证候的宏观辨证标准.方法采用文献研究与临床研究相结合的方法,通过文献研究筛选出频次高的症状体征作为参考诊断标准及症状观察量表,通过两个专家同时诊断作为肝郁证诊断的"金标准"与参考标准对77例患者进行诊断,比较计算符合率、Kappa值及R值.结果通过文献研究得出肝郁证参考诊断标准:①胸胁作胀或痛;②精神抑郁;③烦躁易怒;④口苦;⑤胸闷;⑥善太息;⑦脉弦.以上7条同时具备4条或4条以上即可诊断.该标准与临床专家诊断结果比较,Kappa值为0.71,符合性较好.结论经肝郁证和非肝郁证临床对照研究,得出以下症状、体征在肝郁证与非肝郁证比较具有显著差异:胸胁作胀或痛、精神抑郁、烦躁易怒、口苦、胸闷、善太息、嗳气、脘腹胀痛、少腹胀闷、腹胀、症状因精神紧张而诱发、咽部异物感、舌红.结合中医理论,舌苔薄白、脉弦可作为进一步研究的肝郁证症状条目.     

203例原发性肝癌临床分析

原发性肝癌起病隐匿，临床表现复杂，易引起误诊。临床上对非典型肝癌、亚临床肝癌可疑病例应及时进行ＡＦＰ、ｒ－ＧＴ、ＡＬＰ，以及Ｂ超等检查，并密切观察临床症状和体征变化，以提高诊断率。本文对部分肝癌病例进行肝癌特异蛋白检测，其诊断率达８３．０８％，表明对可疑肝癌病例，采用肝癌特异蛋白普察，可提高早期诊断率，以达到早期治疗，改善预后的目的。